Necrotising gingivitis: intense pain and a characteristic odour are the picture to recognise

The necrotising forms are the only periodontal condition presenting as an emergency, and they must be recognised because their management differs from everything else.

The picture has three elements appearing together, and their combination is characteristic: intense pain, necrotic interdental papillae with a punched-out appearance, and spontaneous bleeding.

The pain is what immediately distinguishes this form from ordinary periodontitis, which is typically painless. A patient presenting with acute gingival pain most probably has this picture.

The papillae appear decapitated, with an ulcerated surface covered by a greyish pseudomembrane that lifts away leaving a bleeding surface.

The odour is characteristic and recognised by anyone who has met it before, but on its own it is not a sufficient diagnostic criterion.

The predisposing factors are consistent and should all be explored. Intense stress, heavy smoking, neglected oral hygiene, malnutrition, immunosuppression and sleep deprivation.

The typical combination is a student in exam season or a worker in a period of exceptional load, who smokes more, sleeps less and has stopped attending to hygiene.

Immunosuppression should always be considered. In cases that do not respond to treatment or that recur, further investigation of immune status is appropriate.

Management of the acute phase involves gentle removal of necrotic tissue and deposits, with ultrasonic instrumentation at low power and copious irrigation.

It is one of the few situations in which immediate instrumentation is indicated despite acute inflammation, because removing the bacterial substrate is what interrupts the process.

Systemic antibiotics are reserved for cases with systemic involvement, fever or lymphadenopathy, and are not the primary therapy: instrumentation is.

Review should be scheduled in days rather than months, because the acute phase resolves quickly but the interdental tissue defects remain and require management of their own.

In summary: intense pain, necrotic papillae and spontaneous bleeding together identify the picture, predisposing factors including immunosuppression should all be explored, immediate instrumentation is indicated, antibiotics are reserved for systemic involvement, and review is in days.