presentation for clinical features of gingivitis

2. Clinical Features of Gingivitis
Dr. Haddadi

3. Reference:
• Carranza clinical periodontology, 2015, chapter 15.

4. What does gingivitis mean?
Clinical features of gingivitis may be characterize by the presence of
any of the following clinical signs:
• Redness and sponginess of the gingival tissue,
• Bleeding on provocation,
• Changes in contour,
• Presence of calculus or plaque with no radiographic evidence of
crestal bone loss.

5. 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.

6. 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.

7. • 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.

8. • 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

9. 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
Easily detected clinically, is of value for the early diagnosis and prevention
of more advanced gingivitis.
Appears earlier than a change in color or other visual signs of
inflammation
More 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

10. • 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.
• Gingival 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.
• Smoking => a strong, chronic, dose-dependent suppressive effect on
gingival bleeding with probing.
• Increase in gingival bleeding with probing in patients who quit
smoking.

11. 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

12. • 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:
 Decrease of MMP-14 activity at 7 days of inflammation.
 Immediate 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.
 Extracellular matrix remodeling was regulated with MMP-2 and
MMP-9 production and activation by the host inflammatory
response.

13. Gingival Bleeding Associated with Systemic Changes
• Hemorrhagic disorders in which abnormal gingival bleeding is encountered:
1. vascular abnormalities (vitamin C deficiency),
2. platelet disorders (thrombocytopenic purpura),
3. hypoprothrombinemia (vitamin K deficiency),
4. 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

14. • 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.

15. 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”.

16. • 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.

17. • The color changes may be marginal, diffuse, or patch like, depending
on the underlying acute condition.
• Acute necrotizing ulcerative gingivitis, the involvement is marginal
• Herpetic gingivostomatitis, it is diffuse;
• Acute reactions to chemical irritation, it is patch like or diffuse.

18. 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.

19. • 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. • 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.

26. • 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.

27. • 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

28. • Etiologic 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 ???

29. 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.

30. • 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

31. Any question..?