Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

necrotising gingivitis (NG)

1st line – debridement + dental hygiene

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ACUTE
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necrotising gingivitis (NG)
1st line – 

debridement + dental hygiene

Treatment involves irrigation and professional debridement of necrotic areas and tooth surfaces, oral hygiene instructions, and counselling to improve nutrition, oral care, fluid intake, and smoking cessation.

To remove plaque on a daily basis, soft or moderately soft toothbrushes should be used in a small circular motion with the bristles directed towards the junction between the gums and tooth on the facial and lingual surfaces of all teeth.

Use of dental floss or other means of removing dental plaque from tooth surfaces inaccessible to tooth brushing is essential.

Tooth cleaning or debridement of the tooth surfaces by a dental hygienist or a dentist can remove plaque and dental calculus above and below the gum line.

Plus – mouthwash

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ACUTE
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necrotising gingivitis (NG)
Plus – 

mouthwash

Treatment recommended for ALL patients in selected patient group

Most patients achieve symptomatic relief in a few days with oral rinsing with chlorhexidine or hydrogen peroxide rinses and tooth brushing.

Primary options

chlorhexidine oropharyngeal: (0.12% to 0.2%) rinse mouth with 15 mL for about 30 seconds twice daily

OR

hydrogen peroxide: (3%) rinse mouth with 10 mL for about 1 minute up to four times daily; rinse should contain equal portions of hydrogen peroxide and warm water

Consider – antibiotics

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ACUTE
|
necrotising gingivitis (NG)
Consider – 

antibiotics

Additional treatment recommended for SOME patients in selected patient group

Antibiotics can be considered in the presence of fever or temperature elevation of ≥38°C (101°F), or in the presence of significant cervical lymphadenopathy.

Primary options

metronidazole: 250 mg orally three times daily for 7-10 days

OR

phenoxymethylpenicillin: 500 mg orally four times daily for 7-10 days

OR

erythromycin base: 250 mg orally four times daily for 7-10 days

OR

tetracycline: 250 mg orally four times daily for 7-10 days

Consider – analgesics

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ACUTE
|
necrotising gingivitis (NG)
Consider – 

analgesics

Additional treatment recommended for SOME patients in selected patient group

If pain is a significant feature, a non-steroidal anti-inflammatory drug (NSAID) may be used for pain relief. Pain often subsides or disappears within a few days of professional debridement. Prolonged courses of pain medicine are usually not necessary.

Primary options

aspirin: 300-900 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg every 4-6 hours when required, maximum 2400 mg/day

OR

paracetamol: 500-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: 250-500 mg twice daily when required, maximum 1250 mg/day

Consider – correction of plaque-retentive factors

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ACUTE
|
necrotising gingivitis (NG)
Consider – 

correction of plaque-retentive factors

Additional treatment recommended for SOME patients in selected patient group

Poorly fitting or constructed dental fillings, crowns, and prosthetic dental appliances may retain dental plaque and compromise the ability to remove dental plaque. Correction of such dental restorations and prosthetic devices requires services of a dentist.

non-necrotising gingivitis

1st line – dental hygiene

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ACUTE
|
non-necrotising gingivitis
1st line – 

dental hygiene

To remove plaque on a daily basis, soft or moderately soft toothbrushes should be used in a small circular motion with the bristles directed towards the junction between the gums and tooth on the facial and lingual surfaces of all teeth.

Use of dental floss or other means of removing dental plaque from tooth surfaces inaccessible to tooth brushing is essential.

Tooth cleaning or debridement of the tooth surfaces by a dental hygienist or a dentist can remove plaque and dental calculus above and below the gum line.

Dental calculus may act as a physical irritant causing inflammation and, because it also serves as a reservoir for dental plaque that causes gingivitis, it must be removed. Removal is accomplished by a dentist or dental hygienist who uses various hand- and power-driven debridement devices (e.g., ultrasonics) in a tooth-cleaning procedure that is often termed a dental prophylaxis.

Consider – topical antimicrobial and antiplaque agents

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ACUTE
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non-necrotising gingivitis
Consider – 

topical antimicrobial and antiplaque agents

Additional treatment recommended for SOME patients in selected patient group

First-line treatments are oral rinses with the active ingredient being chlorhexidine, essential oils, amine fluoride/stannous fluoride, delmopinol hydrochloride, or triclosan.[67][73][70][71][74] [ Cochrane Clinical Answers logo ]

Second-line treatment is stannous fluoride toothpaste.[75][76]

All these treatments have varying availability and concentrations. The product literature should be consulted for guidance on dose.

Consider – correction of plaque-retentive factors

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ACUTE
|
non-necrotising gingivitis
Consider – 

correction of plaque-retentive factors

Additional treatment recommended for SOME patients in selected patient group

Poorly fitting or constructed dental fillings, crowns, and prosthetic dental appliances may retain dental plaque and compromise the ability to remove dental plaque. Correction of such dental restorations and prosthetic devices requires services of a dentist.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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