Clinical Features of Gingivitis

by Dr. Marcel Hallare

The Role of Inflammation in Gingival Disease

Gingivitis is the most common form of

gingival disease Inflammation is almost always present in all forms of gingival disease because bacterial plaque, which causes inflammation, and irritating factor, which favor plaque accumulation, are often present in the gingival environment

 All cases of gingivitis are not necessarily

the same because they exhibit inflammatory changes, and it is often necessary to differentiate between inflammation and other pathologic processes that may be present in the gingival disease The role of inflammation in individual cases of gingivitis varies as follows:

1. Inflammation may be the primary and

only pathologic change (most prevalent type) 2. Inflammation may be a secondary feature, superimposed on systemically caused gingival disease 3. Inflammation may be the precipitating factor responsible for clinical changes in patients with systemic conditions that of themselves do not produce clinically detectable gingival disease

TYPES OF GINGIVAL DISEASES

Most common type of gingival disease is

the simple inflammatory involvement caused by bacterial plaque attached to the tooth surface This type of gingivitis, called chronic marginal gingivitis or simple gingivitis, may remain stationary for indefinite periods of time or may proceed to destruction of the supporting structures

COURSE, DURATION, AND DISTRIBUTION OF GINGIVITIS

COURSE AND DISTRIBUTION Acute gingivitis is a painful condition that comes on suddenly and is of short duration Subacute gingivitis is a less severe phase of the acute condition Recurrent gingivitis reappears after having been eliminated by treatment or disappears spontaneously and then reappears Chronic gingivitis comes on slowly, is of long duration, and is painless unless complicated

DISTRIBUTION OF GINGIVITIS
Localized gingivitis is confined to the

gingiva in relation to a single tooth or group of teeth Generalized gingivitis involves the entire mouth Marginal gingivitis involves the gingival margin but may include a portion of the contiguous attached gingiva

 Papillary

gingivitis involves the interdental papillae and often extends into the adjacent portion of the gingival margin Diffused gingivitis affects the gingival margin, the attached gingiva, and the interdental papillae

 The distribution of gingival disease in

individual cases is described by combining the preceding terms, as follows:

Localized marginal gingivitis is confined to one or

more areas of the marginal gingiva Localized diffuse gingivitis extends from the margin to the mucobuccal fold Localized papillary gingivitis is confined to one or more interdental spaces in a limited area Generalized marginal gingivitis involves the gingival margins in relation to all of the teeth Generalized diffuse gingivitis involves the entire gingiva

CLINICAL FINDINGS IN GINGIVITIS

In evaluating the clinical features of

gingivitis it is necessary to be systematic Attention should be focused on subtle tissue alterations Systematic clinical approach requires an orderly examination of the gingiva for the following features: color, size and shape, consistency, surface texture, position, ease and severity of bleeding, and pain

Gingival Bleeding
Two earliest symptoms of gingival

inflammation, which precede established gingivitis:

Increase gingival fluid production rate Bleeding from the gingival sulcus on gentle probing

Bleeding on probing is clinically easily

detectable and therefore of great value for early diagnosis and prevention of a more severe case

 Use of bleeding rather than color changes

to diagnose early gingival inflammation has the advantage that bleeding is a more objective sign, requiring less subjective estimation by the clinician Gingival bleeding varies in severity, duration, and the ease with which it is provoked

Gingival Bleeding caused by Local Factors

Chronic and Recurrent Bleeding Most common cause of abnormal gingival bleeding is chronic inflammation Is provoked by mechanical trauma such as improper brushing, toothpick, or food impaction, by biting into solid food, and by grinding teeth (bruxism)

 In gingival inflammation, the following histopathologic alterations result in abnormal gingival bleeding:
Dilation and engorgement of the capillaries and thinning or ulceration of the sulcular epithelium Because the capillaries are engorged and closer to the surface and the thinned, degenerated epithelium is less protective, stimulation that are ordinarily innocuous cause rupture of the capillaries and gingival bleeding

 Sites that bleed on probing have a greater

area of inflamed connective tissue (cell rich, collagen poor) than do sites that do not bleed Cellular infiltrate of sites that bleed on probing is predominantly lymphocytic (a characteristic of Stage II or early gingivitis) Severity of the bleeding and the ease with which it is provoked depends on the intensity of the inflammation

 In

cases of moderate or advanced periodontitis the presence of bleeding on probing is considered a sign of active tissue destruction

Acute Bleeding Gingival bleeding is caused by injury or occur spontaneously in acute gingival disease

Laceration of the gingiva by toothbrush bristles during aggressive brushing Sharp piece of hard food cause gingival bleeding even in the absence of gingival disease Gingival burns from hot foods or chemicals increase the case of gingival bleeding

GINGIVAL BLEEDING ASSOCIATED WITH SYSTEMIC DISTURBANCES

There are systemic disorders in which

gingival hemorrhage, unprovoked by mechanical irritation, occur spontaneously, or in which gingival bleeding following irritation is excessive and difficult to control Hemorrhage may be due to failure of one or more of the hemostatic mechanisms

 Hemorrhagic disorders in which abnormal

gingival bleeding is encountered include the following:

Vascular abnormalities (Vit. C deficiency or allergy such as Schnlein-Henoch purpura) Platelet disorders (idiopathic thrombocytopenia purpura or thrombocytopenic purpura caused by diffuse injury to bone marrow) Hypoprothrombinemia (Vit. K deficiency resulting from liver disease or sprue)

 Coagulation defects (hemophilia, leukemia, Christmas disease) Deficient platelet thromboplastic factor (PF3) resulting from uremia, multiple myeloma and post-rubella purpura Bleeding may follow the administration of excessive amounts of drugs such as salicylates and the administration of anticoagulants such as dicumarol and heparin Cyclic episodes of abnormal bleeding are occasionally associated with the menstrual period

COLOR CHANGES IN THE GINGIVA

Color changes in Chronic Gingivitis Chronic inflammation intensifies the red or bluish red color, this is caused by vascular proliferation and reduction of keratinization due to epithelial compression by the inflamed tissue Venous stasis will add a bluish hue

 Color changes in Acute Gingivitis Color changes vary with the intensity of the inflammation In all instances there is an initial bright red erythema

METALLIC PIGMENTATION
Heavy metals absorbed systemically from

therapeutic use or occupational environments may discolor the gingiva and other areas of the mucosa This is different from tattooing produced by the accidental embedding of amalgam or other metal fragments

 Bismuth, arsenic, and mercury produce

a black line in the gingiva, which follows the gingival contour of the margin Lead results in a bluish red or deep blue linear pigmentation of the gingival margin (burtonian line) Silver (argyria) causes a violet marginal line, often accompanied by a diffuse bluish gray discoloration throughout the mucosa

COLOR CHANGES ASSOCIATED WITH SYSTEMIC FACTORS

Endogenous oral

pigmentation can be due to melanin, bilirubin, or iron Melanin oral pigmentation can be normal physiologic pigmentation and is commonly found in darker races

 Diseases that increase melanin

pigmentation include the following: Addisons disease which is caused by adrenal dysfunction and produces isolated patches of discoloration varying from bluish black to brown Peutz-Jeghers syndrome which produces intestinal polyposis and melanin pigmentation in the oral mucosa and lips Albrights syndrome (polyostotic fibrous dysplasia)

 Von Recklinghausens disease

(neurofibromatosis) Skin and mucous membrane can also be stained by bile pigments Jaundice is best detected by examination of the sclera, but the oral mucosa may also acquire a yellowish color Iron in hemochromatosis may produce a blue-gray pigmentation of the oral mucosa

 Exogenous factors are capable of

producing color changes in the gingiva include atmospheric irritants, such as coal and metal dust, and coloring agents in food and lozenges Tobacco causes gray hyperkeratosis of the gingiva Localized bluish black areas of pigment are commonly due to amalgam implanted in the mucosa

Smokers Melanosis

Changes in the Consistency of the Gingiva

Both chronic and acute inflammation

produce changes in the normal firm, resilient consistency of the gingiva Chronic gingivitis is a conflict between destruction and reparative changes, and consistency of the gingiva is determined by the relative balance between the two

Changes in the Surface Texture of the Gingiva

Loss of surface stippling is an early sign of

gingivitis In chronic inflammation the surface is either smooth and shiny or firm and nodular, depending on whether the dominant changes are exudative or fibrotic Smooth surface texture is produced by epithelial atrophy Peeling of the surface occurs in desquamative gingivitis

 Hyperkeratosis results in a leathery texture

Non-inflammatory gingival hyperplasia

produces a minute nodular surface

THANK YOU FOR NOT SLEEPING