Patients frequently ask about dental problems for a variety of reasons, and some doctors find this tiresome. The patient may attend with some medical condition and then ask a 'while I am here' question about a dental problem.
It may be that the patient does not have a dentist, and the GP is easier to access. Or the cynic may say it is because advice and treatment for a simple dental problem from a GP is free, but for many patients, seeing a dentist means payment.
Whatever the situation, the patient should be examined and advised, and not just dismissed.
There are good reasons for at least taking a look in a patient's mouth if they complain of gum disease. Bleeding or swollen gums may mean nothing more than over-zealous brushing or gingivitis, or more seriously, a bleeding diathesis or leukaemia.
Gingivitis may progress to periodontal disease, and this can lead to the serious condition acute necrotising ulcerative gingivitis (sometimes referred to as Vincent's angina or trench mouth).
Once a diagnosis is made, interim advice and an informed routine can be given or urgent referral to a dentist or dental specialist made.
2. Gingivitis and periodontitis
Gingivitis is usually caused by a build up of plaque on the teeth. Adequate brushing usually keeps plaque down, but if it builds up, bacteria can irritate the gums and cause inflammation and swelling.
Periodontitis is a more severe form of gum disease, where the inflammation affects not only the gums, but also involves the periodontal ligament and may cause destruction of the adjacent alveolar bone.
A space may develop between the tooth and the gum, making the tooth feel loose and may lead to a loss of teeth.
Acute necrotising ulcerative gingivitis is a painful bacterial infection of the gums associated with marked swelling and ulceration of the mucosa.
The patient with gingivitis needs advice about good oral hygiene, including brushing the teeth adequately at least twice a day (morning and last thing at night), flossing three times a week or using interdental brushes regularly and stopping smoking if necessary.
Chlorhexidine mouthwashes are often suggested as an adjunct to these measures.
Patients who have gingivitis and build-up of plaque will benefit from regular dental advice, and they should be encouraged to see their dentist. Poorly motivated patients and more severe cases need regular dental attention and may need interventions including scaling, polishing and root planing.
Antibiotics can play a part in treatment of troublesome cases, and might be prescribed by a GP if there are genuine reasons why an early dental appointment is unlikely to be possible.
Co-amoxiclav, tetracycline and metronidazole are commonly used, but ideally the responsible bacteria should be identified, although isolating a specific pathogen can prove difficult.
4. When to refer
Some cases require direct referral to an appropriate specialist, and this would include acute necrotising ulcerative gingivitis, unexplained tooth mobility for more than three weeks, unexplained ulceration of the oral mucosa or mass persisting for more than three weeks, and suspected lichen planus or leukoplakia.
Unexplained or atypical enlargement of the gums, often with bleeding, can be indicative of leukaemia.
5. Associated systemic disease
There is a well recognised association between gum diseases and systemic diseases, and much research has been done. The connection between periodontal disease and subacute bacterial endocarditis has long been known, but there are also significant associations between periodontal disease and cardiovascular disease (CVD), diabetes mellitus, preterm low birthweight and osteoporosis.1
Systemic disease resulting from infectious oral pathogens is generally recognised to occur in patients with immunological and nutritional deficiencies, such as when individual host defences are compromised.
Recent studies that examined the relationship of oral and dental infections and chronic CVD and other systemic illnesses have confirmed that it is not only immunologically or nutritionally compromised patients that are affected. CVD, diabetes mellitus, low birthweight and osteoporosis have all been shown to have an association with dental disease.
More specific evidence is required, but the GP needs to be aware that a simple case of sore gums may mean something more than an indifferent attitude to oral hygiene.
- Dr Barnard is a former GP from Fareham, Hampshire
1. Kim J, Amar S. Periodontal disease and systemic conditions: a bidirectional relationship. Odontology 2006; 94: 10-21.