gingival and periodontal diseses.pdf

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GINGIVAL AND
PERIODONTAL DISEASES
By : DR/ Hamdy M. Badreldin
BDS., MDS., PhD.
Lecturer in Department of Paediatric and Community Dentistry
Faculty of Dental Medicine – Al-Azhar university
The gingiva is the mucous membrane that extends from the cervical
portion of the tooth to the mucobuccal fold. The gingiva is divided into:
1- Papillary portion:
2- Marginal portion:
3- Attached portion:
Character of periodontal tissues During childhood:
A) Gingiva:
1- More reddish:
2- Lack of stippling:
3- Flabbier
4- Rounded and rolled margins
5- Greater sulcular depth.
b) Cementum:
Thinner and less dense.

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C) Periodontal membrane:
1- Wider.
2- Fiber bundles less dense with less fibers per unit area.
3- Increased hydration, greater blood supply and lymph drainage.
D) Alveolar bone:
1- Thinner lamina dura (radiographically).
2- Fewer trabculation.
3- Wider marrow spaces.
4- Low degree of mineralization.
5- Greater blood and lymph supply.
6- Flatter alveolar crest associated with primary teeth.
GINGIVAL DISEASE
acute gingival lesions
chronic gingival lesions
Conditioned gingival enlargement

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I- ACUTE LESIONS
1) Eruption cyst or eruption Hematoma:
Definition: A type of dentigerous cyst
associated with erupting primary primary
teeth. Occurs in all ages including new
born.
Etiology: Unknown or due to mechanical
trauma resulting in hemorrhage and
accumulation of blood in the detailed
space above the crown of an erupting tooth.
Clinical Features: Bluish fluctuant swelling over an erupting tooth.
Treatment: Usually unnecessary but if it causes delayed eruption or if
parents are excessively worried, surgical excision can be done to expose the
crown.
2) Eruption gingivitis:
Appears between 6 to 7 year age when
permanent teeth begin to erupt. Food debris,
materia alba, and bacterial plaque collect
around and beneath the free tissue, partially
cover the crown of the erupting tooth, and
cause development of an inflammatory
process.
Treated by /improvement of the oral hygiene
3) Pericoronitis:
Clinically:
Operculum is red, swollen, and painful and with gentle pressure, purulent
exudate may be discharged. May be traumatized by opposing teeth. Regional
lymphadenopathy, fever and malaise in severe cases.
Treatment:
• Gentle debridement under the inflamed operculum.
• Warm saline rinses.
• Antibiotic if there is fever and lymphadenopathy and surgical removal
may be needed.

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4) Acute gingival problem associated with exfoliation of primary
teeth:
•Uneven root resorption may cause tooth mobility, which encourage
accumulation of food.
•Mechanical irritation and deposits accumulation cause gingival
enlargement, bleeding and discomfort.
•Removal of primary tooth eliminates the pathological condition.
5) Recurrent aphthous ulcer (Recurrent aphthous stomatitis,
Canker sore):
It is painful ulceration on the mucous membrane that occurs in school-aged
children and adults.
Clinically:
•Round or oval with crateriform base, raised reddened margins and painful.
•Appear in the form of attacks of single or multiple lesions.
•Persist for interval of 4-12 days and heal without scar.
Etiology
It may be caused by:
• autoimmune reaction of the oral epithelium.
• Minor trauma is a common predisposing factor.
• Nutritional deficiencies of iron, vitamin B12, folic acid.
• Gastrointestinal disorders.
• Stress.
• varicella zoster virus.
6)Acute Herpetic Infection
a) Primary herpetic gingivostomatitis:
Caused by: herpes virus.
Transmitted by: droplet infection.
Incubation period: one week.
Clinical manifestations :
• Prodromal symptoms : Headache, malaise, mild dysphagia and
cervical lymphadenopathy are common symptoms that accompanying
the fever and precede the onset of sever edematous gingivitis.

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• Oral Lesion development
1. Yellowish fluid filled vesicles appear on the gingiva and alveolar
mucosa, 1-3 mm in diameter.
2. Vesicles rupture spontaneously after that leaving extremely painful
yellowish ulcers with red inflamed margins.
3. Ulceration occur anywhere in the mouth except tips of interdental
papillae. It is self-limiting disease resolves within 10-14 days.
Treatment :
- Bed rest, soft diet and topical anesthesia.
- Pyrexia is reduced by paracetamol suspension.
- 2ry infection of ulcers may be prevented by chlorohexidine spray or
solution applied using sponge swab in young children < 6 years.
- Mouth rinse is used in older children.
- Acyclovir is active against herpes virus but unable to eradicate it
completely, effective only when given at the onset of infection.
b) Recurrent herps labialis
Attenuated intraoral form of the primary infection or as herpes labialis on
mucocutaneous border of the lips. May be due to emotional stress. Or
lowering tissue resistance from various type of trauma. Or excessive exposure
to sunlight.
May appear after routinedental work or post-common cold.
Treatment: Acyclovir ( antiviral ) cream 5 times daily for 5 days.
c) Herpetic whitlow :
form of herpitic infection can transmitted to the dentist and dental uxiliaries
hand and fingers in absence of barrier protection.
Figure 2 yellowish vesichle
after rupture
Figure 1 ulcertion

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6- Acute Necrotizing Ulcerative
Gingivitis (ANUG):
Infectious disease commonly referred to as Vincent infection.
Caused by / Treponema Vincenti and gram -ve fusiform bacilli.
In developed countries, it is reported in children from 6-12 years old.
Predisposing factors:
✓ •Malnourished children with history of debilitating diseases e.g. viral
diseases, measles and chicken pox.
✓ •Local irritation from plaque and calculus
Clinical Picture:
- Rapid destruction of interdental
papillae with pain and bleeding.
- Gingival margin is covered by
pseudomembrane necrotic covering.
- Punched out interdental papillae with
an erythromatous line below the
necrosed tissue.
- Characterisitic foul odour and excessive salivation.
✓ Acute stage enters the chronic phase of remission after 5-7 days.
Treatment
• Oral hygiene measurement
• Deep scaling and gingival curettage
• In severe cases of ANUG 3 days course of metronidazole alleviates
the symptoms.
7-Acute candidiasis (candidosis, thrush):
Candida (moniliasis) albicans is a common inhabitant of the oral cavity but
may multiply rapidly and cause a pathogenic state when tissue resistance is
lowered due to:
- Prolonged broad-spectrum antibiotic therapy especially topical oral
use.
- Repeated trauma to the oral soft tissue.
- Xerostomia.
- Following radiation.
- Malnutrition and malabsorption.

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Clinical picture
- Raised bluish white creamy
patches which can be wiped
off easily leaving bleeding
painful underlying surface.
- site : It may appear on cheek,
lip, palate and tongue. It can
affect other body sites and
external genitals.
Treatment : Antifungal
Mycostatin suspension may be dropped into the mouth and should be held in
mouth before swallowed for local action 4 times a day.
9-Gingival diseases of specific bacterial
origin: (acute streptococcal
gingivitis):
The gingiva is red, vivid, and painful and bleeds easily. The papillae had
enlarged and gingival abscess may develop.
Treatment:
• Improvement of the oral hygiene.
• Broad-spectrum antibiotic.
II- CHRONIC GINGIVITIS:
Etiology: May be due to:
Local Factors e.g. Plaque, Calculus, Maloccusion, Sharp irritating tooth
margins, Over hanging restorations and mouth breathing.
Systemic Predisposing Factors e.g. Nutritional deficiency, Hormonal
disturbances and Diabetes Mellitus.
Clinical Picture:
- Gingivitis may be localized to anterior region or generalized.
- Gingival margin is red, swollen with loss of stippling and bleeds on slight
touch or on eating on moderately rough food.

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- Pseudopockets are formed due to gingival enlargement.
Treatment:
- Correct predisposing factors (Local and Systemic).
- Improve oral hygiene.
III- Conditioned ginigival enlargement
(1) Puberty gingival enlargement:
- Develops in children in the prepubertal and pubertal period. It is related
to hormonal changes on sub-clinical nutritional deficiencies or local
irritation.
- Enlargement of gingival tissue is confined to the anterior region and
may appear only in one arch.
- Lingual gingival tissue generally remains unaffected.
- Interdental papillae are bulbous, gingival margins are red and bleed on
slight touch.
2) Familial gingival enlargement (gingival fibromatosis):
- It’s cause may be idiopathic but generally follows a familial pattern.
- Referred as elephantiasis gingiva or hereditary hyperplasia.
- Gingival tissues appear normal at birth but begin to enlarge with the
eruption of the primary teeth.

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- Gingival tissues continue to enlarge with eruption of permanent teeth
until tissues cover the clinical crown of the teeth being traumatized
during mastication.
3) Drug influenced gingival enlarge
[Phenytoin induced gingival overgrowth (PIGO)]
Phenytoin (Dilantin) is the major anticonvulsant agent used in treatment of
epilepsy. One of the most side effects of phenytoin therapy is varying degree
of gingival hyperplasia. There is a relationship between the serum and
salivary level of phenytoin and severity of PIGO.
4) Gingival disease modified by malnutrition
• Gingivitis associated with vitamin C deficiency.
• Limited to marginal tissues and papillae.
• Patient suffers from gingival enlargement, severe pain and
spontaneous bleeding.

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• The gingiva is bluish red, soft and has smooth shiny surface. It is a
capillary disease in which endothelium swells and degenerate. The
vessel wall become weakened and pours resulting in hemorrhage.
• The enlargement is a conditioned response to bacterial plaque
PERIODONTAL DISEASE
Gingivitis and periodontitis, are serious infections that, left untreated, can
lead to tooth loss. The word periodontal literally means "around the tooth".
Signs of Periodontal Disease:
• Bleeding: bleeding gums during tooth brushing, flossing or any other
time.
• Puffiness: swollen and bright red gums.
• Recession: gums have receded away from the teeth, sometimes
exposing the roots.
• Bad breath: constant bad breath that does not clear up with brushing
and flossing.
• Bone loss : alveolar bone loss

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(A) Localized aggressive periodontitis in primary dentition
• Localized attachment loss and alveolar bone loss only in the primary
dentition in an otherwise healthy child
- Appears around or before 4 years of age,bone loss is usually seen on
radiographs around the primary molars and/or incisors.
B) Generalized aggressive periodontitis in primary dentition
Characterized by:
•Severe generalized alveolar bone loss.
•Affects all deciduous teeth.
•Affects marginal and attached gingiva.
•Gingiva is severely inflamed and firry red in color.
•Premature exfoliation of teeth.
•Age of onset: tooth eruption.
It often affects the entire dentition. Alveolar bone destruction proceeds
rapidly, and the primary teeth may be lost by 3 years of age.
C) Localized aggressive periodontitis in permanent dentition (Localized
juvenile periodontitis).
The term for the previously described condition of localizedjuvenile
periodontitis has also been replaced by the term localized aggressive
periodontitis.
- This condition presents a classic pattern and occurs in otherwise healthy
children and adolescents without clinical evidence of systemic disease.
Aggressive periodontitis
Primary dentition
localized
generalized
Permanent dentition
Localized
Generalized

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- It is characterized by the rapid and severe loss of alveolar bone around
more than one permanent tooth, usually the first molars and incisors.
- It appears self-limiting.
Clinically, LAP patients have less tissue inflammation and very little
supragingival dental plaque or calculus.
D) Generalized aggressive periodontitis in permanent dentition :
Generalized Early Onset Periodontitis: (Generalized Juvenile
Periodontitis).
• It occurs at or around puberty. It affects the entire periodontium of the
dentition.
• The generalized form is also known by generalized juvenile
periodontitis(GJP), severe periodontitis, and
• rapidly progressive periodontitis.
• It is caused by nonmotile, facultative, anaerobic, gram negative rods
(especially Pro Phyromonas gingivalis ).
• Treatment of LPP or GPP depends on early diagnosis, dental curettage,
prophylaxis, oral hygiene instruc-tion and removal of the primary teeth
that have lost bony support. Use of antimicrobial agent. (chlorhexidine
mouth wash ) and broad- spectrum antibiotics.

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Periodontal diseases as a manifestation of
systemic disease
➢ Papillon-Le fevre syndrome:
Etiology:
- It is a rare genetic condition inherited as an autosomal recessive trait.
- It is associated with severe gingival inflammation and exfoliation of both
the primary and permanent dentition.
- Hyperkeratosis of the palms and soles are present.
- The periodontal involvement and alveolar bone loss start between second
and third year and progress till the fifth year of age (complete primary teeth
loss).
- The same cycle is repeated with the permanent teeth.
- Prognosis is bad and a complete denture is inserted at an early age.