Clinical features of gingivitis

presentation for clinical features of gingivitis

1. Clinical Features of Gingivitis Dr. Haddadi

2. Reference: Carranza clinical periodontology, 2015, chapter 15.

3. What does gingivitis mean? C linical features of gingivitis may be characterize by the presence of any of the following clinical signs : R edness and sponginess of the gingival tissue, B leeding on provocation , Changes in contour , P resence of calculus or plaque with no radiographic evidence of crestal bone loss.

4. Course and Duration Acute gingivitis can occur with sudden onset and short duration, and it can be painful. Chronic gingivitis is slow in onset and of long duration. It is painless , unless it is complicated by acute or subacute exacerbations, and it is the type that is most often encountered. Recurrent gingivitis reappears after having been eliminated by treatment or disappearing spontaneously.

5. Description Localized gingivitis is confined to the gingiva of a single tooth or group of teeth, whereas generalized gingivitis involves the entire mouth. Marginal gingivitis involves the gingival margin, and it may include a portion of the contiguous attached gingiva. Papillary gingivitis involves the interdental papillae, and it often extends into the adjacent portion of the gingival margin. Papillae are involved more frequently than the gingival margin, and the earliest signs of gingivitis often occur in the papillae . Diffuse gingivitis affects the gingival margin, the attached gingiva, and the interdental papillae.

6. 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 in a limited area. Localized papillary gingivitis is confined to one or more interdental spaces in a limited area.

7. Generalized marginal gingivitis involves the gingival margins in relation to all the teeth. The interdental papillae are usually affected. Generalized diffuse gingivitis involves the entire gingiva. The alveolar mucosa and the attached gingiva are affected, so the mucogingival junction is sometimes obliterated

8. Clinical Findings Gingival Bleeding on Probing: The two earliest signs of gingival inflammation that precede established gingivitis: (1) increased gingival crevicular fluid production rate (2) bleeding from the gingival sulcus on gentle probing E asily detected clinically, is of value for the early diagnosis and prevention of more advanced gingivitis . A ppears earlier than a change in color or other visual signs of inflammation M ore objective sign BOP is widely used by clinicians and epidemiologists to measure disease prevalence and progression, to measure outcomes of treatment, and to motivate patients to perform necessary home care

9. In general, gingival bleeding on probing indicates an inflammatory lesion both in the epithelium and in the connective tissue that exhibits specific histologic differences as compared with healthy gingiva. G ingival bleeding on probing may not be a good diagnostic indicator for clinical attachment loss,but its absence is an excellent negative predictor of future attachment loss. Persistent gingivitis => risk factor for periodontal attachment loss that may lead to tooth loss . S moking => a strong, chronic, dose-dependent suppressive effect on gingival bleeding with probing. I ncrease in gingival bleeding with probing in patients who quit smoking.

10. Gingival Bleeding Caused by Local Factors anatomic and developmental tooth variations, caries , frenum pull, iatrogenic factors, malpositioned teeth , mouth breathing , overhangs , partial dentures, lack of attached gingiva, and recession . orthodontic treatment and fixed retainers

11. Histologic evaluations of animal specimens revealed that, during the early stages of gingivitis, the expression of the cytokines responsible for connective tissue breakdown—(MMPs )—is ubiquitous. Different MMPs play a role in breakdown at different stages: D ecrease of MMP-14 activity at 7 days of inflammation . I mmediate increase in MMP-2 , especially with fibroblastic stimulation. MMP-9 expression peaked 5 days after gingivitis occurrence, which was also regulated by macrophages and neutrophils. E xtracellular matrix remodeling was regulated with MMP-2 and MMP-9 production and activation by the host inflammatory response .

12. Gingival Bleeding Associated with Systemic Changes Hemorrhagic disorders in which abnormal gingival bleeding is encountered: vascular abnormalities (vitamin C deficiency), platelet disorders (thrombocytopenic purpura ), hypoprothrombinemia (vitamin K deficiency ), other coagulation defects (hemophilia, leukemia, Christmas disease ). The effects of hormonal replacement therapy, oral contraceptives, pregnancy, and the menstrual cycle reported to affect gingival bleeding. In women, long-term depression-related stress exposure may increase concentrations of interleukin-6 in gingival crevicular fluid and worsen periodontal conditions with elevated gingival inflammation and increased pocket depths

13. Among pathologic endocrine changes, diabetes is an endocrine condition with a well-characterized effect on gingivitis . Several medications found to have adverse effects on the gingiva. For example, anticonvulsants, antihypertensive calcium channel blockers, and immunosuppressant drugs are known to cause gingival enlargement, secondarily cause gingival bleeding. It is important to consider aspirin’s effect on bleeding.

14. Color Changes in the Gingiva The color of the gingiva is determined by several factors, including the number and size of blood vessels, the epithelial thickness , the quantity of keratinization, and the pigments within the epithelium . Change in color is an important clinical sign of gingival disease. The normal gingival color is “coral pink”.

15. Chronic inflammation intensifies the red or bluish color as a result of vascular proliferation and a reduction of keratinization . Venous stasis will contribute a bluish hue . The changes start in the interdental papillae and the gingival margin and then spread to the attached gingiva.

16. The color changes may be marginal, diffuse, or patch like , depending on the underlying acute condition . A cute necrotizing ulcerative gingivitis, the involvement is marginal H erpetic gingivostomatitis, it is diffuse; A cute reactions to chemical irritation, it is patch like or diffuse.

17. Metallic Pigmentation Heavy metals (bismuth , arsenic, mercury, lead, and silver) that are absorbed systemically as a result of therapeutic use or occupational or may discolor the gingiva and other areas of the oral mucosa. Metals typically produce a black or bluish line in the gingiva that follows the contour of the margin. The pigmentation may also appear as isolated black blotches involving the interdental marginal and attached gingiva.

18. Gingival pigmentation is not a result of systemic toxicity. It occurs only in areas of inflammation in which the increased permeability of irritated blood vessels permits the seepage of the metal into the surrounding tissue. In addition to inflamed gingiva, mucosal areas that are irritated by biting or abnormal chewing habits (e.g., inner surface of lips, cheek at level of occlusal line, lateral border of tongue) are common sites of pigmentation . Pigmentation can be eliminated by treating the inflammatory changes without necessarily discontinuing the metal containing medication.

19. Color Changes Associated with Systemic Factors Many systemic diseases may cause color changes in the oral mucosa, including the gingiva. In general, these abnormal pigmentations are nonspecific, and they should stimulate further diagnostic efforts or referral to the appropriate specialist.

20. Changes in the Consistency of the Gingiva Both chronic and acute inflammations produce changes in the normal firm and resilient consistency of the gingiva. Calcified Masses in the Gingiva : Calcified microscopic masses may be found in the gingiva. These can occur alone or in groups, and they vary with regard to size, location, shape, and structure. Such masses may be calcified material that has been removed from the tooth and traumatically displaced into the gingiva during scaling, root remnants, cementum fragments, or cementicles .

21. Tooth brushing Tooth brushing has various effects on the consistency of the gingiva, such as promoting keratinization of the oral epithelium, enhancing capillary gingival circulation, and thickening alveolar bone. This process may repair small breaks in the junctional epithelium and prevent direct access to the underlying tissue by periodontal pathogens.

22. Changes in the Surface Texture of the Gingiva The surface of normal gingiva usually exhibits numerous small depressions and elevations that give the tissue an orange-peel appearance referred as stippling . Stippling is restricted to the attached gingiva and predominantly localized to the subpapillary area, but it extends to a variable degree into the interdental papilla. The loss of stippling is an early sign of gingivitis. In patients with chronic inflammation, the gingival surface is either smooth and shiny or firm and nodular, depending on whether the dominant changes are exudative or fibrotic.

23. Changes in the Position of the Gingiva Traumatic Lesions: Traumatic lesions—whether they are chemical, physical, or thermal—are among the most common lesions in the mouth. Sources of chemical injuries include aspirin, hydrogen peroxide, silver nitrate, phenol, and endodontic materials . Physical injuries can include lip, oral, and tongue piercings, which can result in gingival recession. Thermal injuries can result from hot drinks and foods.

24. In acute cases, the appearance of slough (necrotizing epithelium), erosion, or ulceration and the accompanying erythema are common features. In chronic cases, permanent gingival defects are usually present in the form of gingival recession. The localized nature of the lesions and the lack of symptoms readily eliminate them from the differential diagnosis of systemic conditions that may be present with erosive or ulcerative oral lesions.

25. Gingival Recession: Gingival recession is a common finding. The prevalence, extent, and severity of gingival recession increase with age, and this condition is more prevalent among males. Recession is the exposure of the root surface by an apical shift in the position of the gingiva. Recession refers to the location of the gingiva rather than to its condition. Gingival recession increases with age; the incidence varies from 8% in children to 100% after the age 50 of years.

26. The actual position is the level of the coronal end of the epithelial attachment on the tooth, whereas the apparent position is the level of the crest of the gingival margin. The severity of recession is determined by the actual position of the gingiva and not by its apparent position

27. E tiologic factors in gingival recession : faulty tooth brushing technique (gingival abrasion ), tooth malposition, friction from the soft tissues (gingival ablation ), gingival inflammation, abnormal frenum attachment, iatrogenic dentistry Trauma from occlusion ???

28. Changes in Gingival Contour Stillman’s clefts : has been used to describe a specific type of gingival recession that consists of a narrow, triangular-shaped gingival recession. As the recession progresses apically, the cleft becomes broader, thereby exposing the cementum of the root surface. When the lesion reaches the mucogingival junction, the apical border of oral mucosa is usually inflamed because of the difficulty with maintaining adequate plaque control at this site.

29. McCall festoons: has been used to describe a rolled, thickened band of gingiva that is usually seen adjacent to the cuspids when recession approaches the mucogingival junction . Initially , Stillman’s clefts and McCall festoons were attributed to traumatic occlusion, and the recommended treatment was occlusal adjustment. However, this association was never proved, and these indentations merely represent peculiar inflammatory changes of the marginal gingiva

30. Any question..?