CLINICAL EXAMINATION OF GINGIVA

1. DR. K.S. STELIN (HOD) DR. MARIYAM MOMIN
DR. PARUL ANEJA I YEAR PG
DEPARTMENT OF PERIODONTOLOGY & ORAL
IMPLANTOLOGY.

2.  INTRODUCTION
 COLOR
 SIZE
 CONSISTENCY
 CONTOUR
 SURFACE TEXTURE
 POSITION
 COCLUSION
 REFERENCES

3. • The gingiva is the part of the oral mucosa that covers the
alveolar processes of the jaws and surrounds the necks of the
teeth –Carranza.
• It is divided anatomically into marginal, attached and
interdental areas.
• All gingival changes must be described as being localized or
generalized & also in relation to the part of gingiva being affected
as papillary, marginal or diffuse.

4.  Normal color of gingiva – coral pink.
Factors responsible for the color
1. Vascular supply
2. Thickness of epithelium
3. Degree of keratinization
4. Pigmentation .

5. The changes in the color of gingival inflammation are:
 Reddish pink – Acute gingivitis/ acute exacerbation of
chronic gingivitis.
 Bluish red – Chronic gingivitis.

6. At times, localization of these changes in color helps in
diagnosis:
• ANUG – marginal involvement
• Herpetic gingivostomatitis – diffuse
• Chemical irritation – patchlike
• HIV – localized erythema along the marginal gingiva
known as linear gingival erythema.

7. ANUG HERPETIC GINGIVOSTOMATITIS
CHEMICAL IRRITATION LINEAR GINGIVAL ERYTHEMA

8. Endogenous causes:
 Melanin is increased in the following systemic
conditions:
- Addison’s disease (adrenal dysfunction)
- Peutz Jegher’s syndrome (intestinal polyposis)
- Albright’s syndrome (fibrous dysplasia)
- Von Recklinghausen’s disease (neurofibromatosis)
 Bilirubin (jaundice)
 Iron (hemochromatosis)

9. Melanin pigmentation
Bilirubin pigmentation Iron pigmentation

10. Exogenous causes:
 Metallic pigmentation due to bismuth, arsenic, lead,
mercury & silver.
 Tobacco
 Coloring agents in food and lozenges
 Amalgam tattoo or implantation of amalgam into the
gingiva.

11. Burtonian line (Lead poisoning) Smoker’s melanosis
Amalgam tattoo
Heavy metal pigmentation on
gingiva

12. Dummett (1946), described the distribution of melanin
in black individuals as:
 Palate – 61%
 Gingiva – 60%
 Mucous membrane – 22%
 Tongue – 15%

13.  The removal of gingival pigmentation can be achieved
by a procedure called depigmentation.

14. Technique Advantages Disadvantages
Surgical/ Scalpel technique: the
gingival epithelium is scraped away
from the underlying connective tissue.
Simple
inexpensive
instruments
Intraoperative bleeding is greater
than in some other techniques
Use of rotary burs: Diamond finishing
burs are used in a sweeping motion.
Simple
inexpensive
instruments
Intraoperative bleeding is greater
than in some other techniques
Electrosurgery: A loop electrode is
used and the tip is kept moving. The
heat produced volatizes the cells.
Good
hemostasis
Unpleasant odor injudicious use
can lead to tissue damage,
delayed healing can’t be used in
patients with poorly shielded
pacemakers. Expensive
equipment is necessary
Laser: The most commonly used
lasers for soft tissue procedures are
CO2, Nd: YAG & diode.
Decreased
bleeding and
pain
Expensive equipment is
necessary
Gingival grafting: Free gingival grafts
taken from the palate or maxillary
tuberosity can be placed over the
concerned area.
Less
incidence of
repigmentati
on
Technique sensitive procedure
Two surgical sites. Color wil not
match adjacent tissue
PROCEDURES FOR DEPIGMENTATION

15. Gingival
Depigmentation
Scalpel technique
Use of rotary bur

17. Lasers

18. Free gingival graft

20. Repigmentation is the reappearance of melanin pigment
after a period of clinical depigmentation of the oral
mucosa resulting from chemical, thermal, surgical,
pharmacologic or idiopathic factors.

21. The size of any matter depends on what it is made up of;
the size of the gingiva is determined by the sum total of:
• Cells
• Intercellular substances
• Vascular supply

22. Increase in the size of gingiva is called gingival
enlargement

23. Gingival enlargement is classified based on its etiology as:
 Inflammatory:
- Acute: Abscess
- Chronic: Plaque induced gingivitis
 Drug induced:
- Antiepileptic agents: Phenytoin
- Calcium channel blockers: Nifidipine
- Immunosuppresants: Cyclosporine
 Associated with systemic conditions/ systemic disease:
- Systemic condition: Pregnancy, puberty, plasma cell gingivitis, pyogenic
granuloma & scurvy.
- Systemic disease: Leukemia, Wegener’s granulomatosis or sarcoidosis.
 Neoplastic :
- Benign: Fibroma, papilloma, giant cell granuloma
- Malignant: Carcinoma, malignant melanoma
 False enlargement:
- Due to underlying bone lesion: Tori, Paget’s disease, fibrous dysplasia,
cherubism, osteoma, osteosarcoma.
- Due to underlying dental tissue: prominence of enamel during tooth
eruption.

24. Abscess
Plaque induced
gingivitis

25. Cyclosporin
induced
enlargement
Phenytoin induced
enlargement

26. Pyogenic granulomaScurvy
Puberty gingivitis Plasma cell gingivitis

27. Leukemic gingival
enlargement
Wegener’s
granulomatosis

28. NEOPLASTIC
Benign
Papilloma Fibroma
Giant cell
granulom
a

29. Carcinoma
Malignant
melanoma

30. False enlargement
Due to underlying bone lesion
Tori Cherubism
Osteosarcoma Fibrous dysplasia f jaw

31. Prominence of enamel
during tooth eruption

32. Inflammatory gingival enlargement has been graded by
Bokencamp et al (1994) as:
 Grade 0 – No sign of enlargement
 Grade I – Enlargement of interdental papilla
 Grade II – Enlargement of papilla and marginal gingiva
 Grade III – Enlargement covering three quarters
Grade O
Grade I
Grade II Grade III

33.  Inflammatory enlargement usually subsides after scaling if it is
edematous in nature; if fibrotic it may need to be surgically
excised (gingivectomy).
 For drug induced enlargement the offending drug should be
substituted by another drug by the physician.
 In case of pregnancy induced enlargement, removal of local
irritating factors by scaling & root planing is of prime
importance.
 Leukemic gingival enlargement:
- Estimation of bleeding time, clotting time & platelet count is a
must before periodontal therapy.
- administration of prophylactic antibiotics from the evening
before to 48 hours after treatment.
- Scaling and root planing is carried out in stages & oral hygiene
instructions are given including the use of chlorhexidine.

34. Inflammatory enlargement
Scaling
Gingivectomy

35.  Offending drug should be substituted with another drug by the physician.
For eg:
- Phenytoin Carbemazipine/ valproic acid
- Nifidipine Diltiazem/ verapamil
- Cyclosporin Tarcolimus
Scaling
Gingivectomy
Flap surgery

36. Scaling and root
planing
Excision of
pregnancy
tumor
(2nd trimester)

37. Bleeding time,
clotting time&
platelet count
Antibiotics
(evening before to
48 hours after
treatment)
Scaling and root
planing
Oral hygiene
instructions Chlorhexidine

38. Normal consistency of gingiva is firm and resilient due
to:
- Collagenous nature of the lamina propria
- Contiguity with the mucoperiosteum of the alveolar
bone.

39. In gingivitis, the consistency may be soft and edematous
due to edema, inflammatory cell infiltration and
degeneration of connective tissue elements.

40. Fibrous consistency of gingiva is seen in drug induced or
idiopathic gingival enlargement.

41. Contour of gingiva is scalloped with knife edge margins.
 Gingival contour depends upon the following factors:
- Shape of the teeth
- Alignment of the teeth in the arch
- Proximal contact
- Dimension of gingival embrasure.

42. Contour is accentuated in labially placed teeth and
gingiva is thickened in lingually placed teeth.

43. In areas of diastema the interdental papilla is missing
and the gingiva is firmly adherent to underlying bone.

44. In gingivitis, the knife edge is lost.

45.  Stillman’s cleft
 McCall’s festoon

46. The attached gingiva and central portion
of the interdental papilla show an orange
peel appearance called stippling.

47. Cause of stippling:
- Alternate rounded protruberances and depressions in
the gingival surface due to projection of connective
tissue papilla into the epithelium.
Function of stippling: functional adaptation of the
gingiva.

48. Increased : drug induced
gingival enlargement
Reduced : inflammation
STIPPLING

49. Other changes in surface texture:
Peeling off – desquamative gingivitis Leathery texture – hyperkeratosis
Nodular texture – drug
induced gingival
enlargement.

50. Position of the gingiva may be described as coronal,
apical or normal.
 Coronal – level of gingival margin above the CEJ
(Pseudo pockets)
 Apical – level of gingival margin below the CEJ
(Recession)
 Normal – level of gingival margin at CEJ.

51. At CEJ
Apical to CEJ Above CEJ

52. Recession is defined as “the exposure of the root surface
due to apical migration of the gingival margin.”

53. 1. Sullivan and Atkins (1968)

55. Causes of
Recession
Improper
brushing
habits
Inflammation
Abnormal
frenal
attachment
Labially
placed teeth
Congenital
defects
Pressure from
denture
clasps
Pressure from
orthodontic
bands
Following
periodontal
surgery
Overhanging
restorations

56.  Pedicle grafts:
- Coronally positioned flap including Tarnow’s technique
- Lateral pedicle flap
- Double papilla flap
 Free grafts:
- Free gingival graft
- Subepithelial connective tissue graft.

57. Good in Class I and Class II recession as the interdental
bone and soft tissue are intact.

58.  Earlier, greater importance was given to the width of
attached gingiva in the etiology of gingival recession.
However, thickness of the gingiva is of great
importance in the development of recession.
 In 1989, Seibert and Lindhe, gave 2 periodontal
biotypes – thin scalloped and thick flat biotype.
Inflammation causes pocket formation in thick
biotype and gingival recession in the thin biotype.
(Kao et al., 2008).

59.  Establish a proper diagnosis based on clinical findings.
 Proper management.

60.  Carranza’s Clinical Periodontology- 10th Edition.
 Essentials of Periodontology – (Sahitya Reddy S)
 Case History Recording In Periodontics – Divya Bhat
(2nd Edition).
 Clinical Periodontology and Implant dentistry- Lindhe
4th Edition.