Carranza 2015

1. Clinical Features of Gingivitis

2. Chapter Outline
 Course and Duration
 Description
 Clinical Findings
 Gingival Bleeding on Probing
 Gingival Bleeding Caused by Local Factors
 Gingival Bleeding Associated with Systemic Changes
 Color Changes in the Gingiva
 Color Changes Associated with Systemic Factors
 Changes in the Consistency of the Gingiva
 Changes in the Surface Texture of the Gingiva
 Changes in the Position of the Gingiva
 Changes in Gingival Contour

3. Introduction
 Etiologic factors:
 Microbial plaque (the primary cause)
 Host response (important role in development and degree of inflammation)
 clinical signs:
 redness
 sponginess
 bleeding on provocation
 Changes in contour
 presence of calculus or plaque
 no radiographic evidence of crestal bone loss (?)
 histologic examination reveals ulcerated epithelium.

4. Course and Duration
 Acute gingivitis:
 sudden onset and short duration,
 it can be painful but a less severe phase of this condition can also occur.
 Chronic gingivitis
 slow in onset and of long duration.
 painless, unless it is complicated by acute or subacute exacerbations
 most often encountered
 Fluctuating
 Recurrent gingivitis
 reappears after having been eliminated by treatment or disappearing
spontaneously

5. Description
 Localized gingivitis: confined to the gingiva of a single tooth or group of teeth
 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
 Diffuse gingivitis affects the gingival margin, the attached gingiva, and the
interdental papillae.
 Papillae are involved more frequently than the gingival margin, and the earliest
signs of gingivitis often occur in the papillae.

6. Description
 Localized marginal gingivitis is confined to one or more areas of the marginal
gingiva
 Localized papillary gingivitis is confined to one or more interdental spaces in
a limited area.

7. Description
 Localized diffuse gingivitis extends from the margin to the mucobuccal fold in
a limited area.

8. Description
Generalized marginal gingivitis involves the gingival margins in relation to all the
teeth. The interdental papillae are usually affected

9. Description
Generalized papillary gingivitis

10. Description
Generalized marginal and papillary gingivitis

11. Description
 Generalized diffuse gingivitis involves the entire gingiva. The alveolar mucosa
and the attached gingiva are affected, so the mucogingival junction is
sometimes obliterated.
 Systemic conditions can be involved in the cause of generalized diffuse
gingivitis

12. Clinical Findings

13. Gingival Bleeding on Probing
 The two earliest signs of gingival inflammation that precede established
gingivitis are as follows:
 (1) increased gingival crevicular fluid production rate
 (2) bleeding from the gingival sulcus on gentle probing
 Advantages of BOP as a sign of ginigivitis:
 Early
 Objective
 Therefore, bleeding on probing is widely used to measure disease prevalence
and progression, to measure outcomes of treatment, and to motivate patients
to perform necessary home care.

14. Gingival Bleeding on Probing
 Even though gingival bleeding on probing may not be a good diagnostic
indicator for clinical attachment loss, its absence is an excellent negative
predictor of future attachment loss.
 In cases of moderate or advanced periodontitis, the presence of bleeding on
probing is considered a sign of active tissue destruction.
 Persistent gingivitis can be considered as a risk factor for periodontal
attachment loss that may lead to tooth loss

15. Gingival Bleeding on Probing
 The most common cause of abnormal gingival bleeding on probing is chronic
inflammation.
 The severity of bleeding and the ease of its provocation depend on the intensity
of the inflammation.
 In gingival inflammation, histopathologic alterations that result in abnormal
gingival bleeding include dilation and engorgement of the capillaries and thinning
or ulceration of the sulcular epithelium
 Smoking was found to exert a strong, chronic, dose-dependent suppressive effect
on gingival bleeding with probing.
 Recent research reveals an increase in gingival bleeding with probing in patients
who quit smoking.

16.  During the early stages of gingivitis, the expression of the cytokines
responsible for connective tissue breakdown—matrix metalloproteinases
(MMPs)—is ubiquitous.
 Decrease of MMP-14 activity at 7 days of inflammation
 Immediate increase of MMP-2
 MMP-9 expression peaked 5 days after gingivitis occurrence.

17.  Acute episodes of gingival bleeding are caused by injury, and they can occur
spontaneously in patients with gingival disease.
 Spontaneous bleeding or bleeding on slight provocation can occur with acute
necrotizing ulcerative gingivitis

18. Gingival Bleeding Associated with Systemic Changes
 Hemorrhagic disorders in which abnormal gingival bleeding is encountered
include
 vascular abnormalities (vitamin C deficiency, allergy [e.g., Henoch–Schönlein
purpura]),
 platelet disorders (thrombocytopenic purpura),
 hypoprothrombinemia (vitamin K deficiency),
 other coagulation defects (hemophilia, leukemia, Christmas disease),
 deficient platelet thromboplastic factor as a result of uremia,
 multiple myeloma
 postrubella purpura

19. Gingival Bleeding Associated with Systemic Changes
 Hormonal replacement therapy, oral contraceptives, pregnancy, and the
menstrual cycle are also 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.
 androgenic hormones and fluctuating estrogen and progesterone levels affect
on the periodontium, starting as early as puberty.

20. Gingival Bleeding Associated with Systemic Changes
 In diabetes, marked inflammation affects both the epithelial and connective
tissues, which leads to
 an increase in the number of inflammatory cells,
 the destruction of reticulin fibers,
 an accumulation of dense collagen fibers that causes fibrosis

21. Gingival Bleeding Associated with Systemic Changes
 anticonvulsants,
 antihypertensive calcium channel blockers,
 and immunosuppressant drugs
 are known to cause gingival enlargement which secondarily can cause gingival
bleeding.
 It is important to consider aspirin’s effect on bleeding during a routine dental
examination to avoid false-positive readings.

22. 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,
 the pigments within the epithelium.

23. Color Changes in the Gingiva
 The normal gingival color is “coral pink,” and it is produced by
 the tissue’s vascularity
 and modified by
 the overlying epithelial layers
 For this reason, the gingiva becomes red
 When vascularization increases
 or when the degree of epithelial keratinization is reduced or disappears.
 The color becomes pale
 when vascularization is reduced (in association with fibrosis of the corium)
 or when epithelial keratinization increases.

24. Color Changes in the Gingiva
 Chronic inflammation intensifies the red or bluishred 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

25. Color Changes in the Gingiva
 Color changes in acute gingival inflammation differ with regard to both nature
and distribution from those in patients with chronic gingivitis.
 With acute necrotizing ulcerative gingivitis, the involvement is marginal;
 With herpetic gingivostomatitis, it is diffuse;
 And with acute reactions to chemical irritation, it is patchlike or diffuse.

26. Color Changes in the Gingiva
 Initially, there is an increase in erythema.
 With severe acute inflammation, the red color gradually becomes a dull,
whitish gray.
 The gray discoloration produced by tissue necrosis is demarcated from the
adjacent gingiva by a thin, sharply defined erythematous zone.

27. Color Changes in the Gingiva
 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

28. Color Changes in the Gingiva
 Gingival pigmentation from systemically absorbed metals results from the
perivascular precipitation of metallic sulfides in the subepithelial connective
tissue.
 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.

29. Color Changes in the Gingiva
 Endogenous oral pigmentations can be caused by melanin, bilirubin, or iron.
 Melanin oral pigmentations can be normal physiologic pigmentations, and they are
often found in highly pigmented ethnic groups.
 Addison’s disease is caused by adrenal dysfunction, and it produces isolated
patches of discoloration that vary from bluish black to brown.
 Peutz-Jeghers syndrome produces intestinal polyposis and melanin pigmentation in
the oral mucosa and the lips.
 Albright’s syndrome (polyostotic fibrous dysplasia) and von Recklinghausen’s
disease (neurofibromatosis) produce areas of oral melanin pigmentation.

30. Color Changes in the Gingiva
 The skin and the mucous membranes can also be stained by bile pigments.
Jaundice is best detected via the examination of the sclera, but the oral
mucosa may also acquire a yellowish color.
 The deposition of iron in hemochromatosis may produce a blue-gray
pigmentation of the oral mucosa.

31. Color Changes in the Gingiva
 Tobacco causes hyperkeratosis of the gingiva, and it may also induce a
significant increase in melanin pigmentation of the oral mucosa.
 More recently, lasers have been used to ablate cells that produce the melanin
pigment; a nonspecific laser beam destroys the epithelial cells, including
those at the basal layer. In addition, selective ablation with the use of a laser
beam with a wavelength that is specifically absorbed in melanin effectively
destroys the pigmented cells without damaging the nonpigmented cells.

33. Changes in the Consistency of the Gingiva
 Calcified microscopic 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.
 Chronic inflammation and fibrosis, an occasional foreign body, and giant cell
activity occur in relation to these masses.
 They are sometimes enclosed in an osteoid-like matrix.

34. Changes in the Consistency of the Gingiva
 Toothbrushing
 promoting keratinization of the oral epithelium,
 enhancing capillary gingival circulation
 thickening alveolar bone.
 In animal studies, mechanical stimulation by toothbrushing was found to increase
the proliferative activity of the junctional basal cells in dog gingiva by 2.5 times as
compared with the use of a scaler.
 Toothbrushing causes an increased turnover rate and desquamation of the
junctional epithelial surfaces. This process may repair small breaks in the
junctional epithelium and prevent direct access to the underlying tissue by
periodontal pathogens.

35. Changes in the Surface Texture of the Gingiva
 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.
 In patients with chronic inflammation,
 smooth and shiny = the dominant changes are exudative
 firm and nodular = the dominant changes are fibrotic
 Smooth surface texture = epithelial atrophy in atrophic gingivitis.
 peeling of the surface = chronic desquamative gingivitis.
 leathery texture = Hyperkeratosis
 nodular surface = drug induced gingival overgrowth

36. Changes in the Position of the Gingiva
 Trauma:
 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.

37. Changes in the Position of the Gingiva
 Gingival Recession
 By clinical definition, recession is the exposure of the root surface by an
apical shift in the position of the gingiva.
 The prevalence, extent, and severity of gingival recession increase with age
(100% after the age 50 of years). The gradual apical shift is most likely the
result of the cumulative effect of minor pathologic involvement and repeated
minor direct trauma to the gingiva. In some populations without access to
dental care, however, recession may be the result of increasing periodontal
disease.
 This condition is more prevalent among males.

39. Changes in the Position of the Gingiva
 Etiologic factors
 Although toothbrushing is important for gingival health, faulty toothbrushing
technique or brushing with hard bristles may cause significant injury. This
type of injury may present as lacerations, abrasions, keratosis, and recession,
with the facial marginal gingiva being the most affected.

40. Changes in the Position of the Gingiva
 On rotated, tilted, or facially displaced teeth, the bony plate is thinned or
reduced in height.
 Pressure from mastication or moderate toothbrushing damages the
unsupported gingiva and produces recession.
 The effect of the angle of the root in the bone with recession is often
observed in the maxillary molar area.

41.  Pressure from a poorly designed partial denture, such as an ill-fitting denture
clasp, can cause gingival trauma and recession.
 Overhanging dental restorations have long been viewed as a contributing factor to
gingivitis because of plaque retention.
 In addition, there is general agreement that placing restorative margins within the
biologic width frequently leads to gingival inflammation, clinical attachment loss,
and, eventually, bone loss.
 Clinically, the violation of biologic width typically manifests as gingival
inflammation, deepened periodontal pockets, and gingival recession.

42.  Clinical Significance.
 Exposed root surfaces are susceptible to caries.
 Abrasion or erosion of the cementum exposed by recession leaves an
underlying dentinal surface that can be sensitive.
 Hyperemia of the pulp and associated symptoms may also result from the
excessive exposure of the root surface.
 Interproximal recession creates oral hygiene problems and resulting plaque
accumulation.

43. Changes in Gingival Contour
 Changes in gingival contour are primarily associated with gingival
enlargement
 The term 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.

44.  The term 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.

45. Your attention is appreciated