Clinical Features of GingivitisClinical Features of Gingivitis

byby

Dr. Marcel HallareDr. Marcel Hallare

The Role of Inflammation in Gingival The Role of Inflammation in Gingival DiseaseDisease

Gingivitis is the most common form of Gingivitis is the most common form of gingival diseasegingival disease

Inflammation is almost always present in Inflammation is almost always present in all forms of gingival disease because all forms of gingival disease because bacterial plaque, which causes bacterial plaque, which causes inflammation, and irritating factor, which inflammation, and irritating factor, which favor plaque accumulation, are often favor plaque accumulation, are often present in the gingival environmentpresent in the gingival environment

All cases of gingivitis are not necessarily All cases of gingivitis are not necessarily the same because they exhibit the same because they exhibit inflammatory changes, and it is often inflammatory changes, and it is often necessary to differentiate between necessary to differentiate between inflammation and other pathologic inflammation and other pathologic processes that may be present in the processes that may be present in the gingival diseasegingival disease

The role of inflammation in individual The role of inflammation in individual cases of gingivitis varies as follows:cases of gingivitis varies as follows:

1.1. Inflammation may be the primary and Inflammation may be the primary and only pathologic change (most prevalent only pathologic change (most prevalent type)type)

2.2. Inflammation may be a secondary Inflammation may be a secondary feature, superimposed on systemically feature, superimposed on systemically caused gingival diseasecaused gingival disease

3.3. Inflammation may be the precipitating Inflammation may be the precipitating factor responsible for clinical changes factor responsible for clinical changes in patients with systemic conditions that in patients with systemic conditions that of themselves do not produce clinically of themselves do not produce clinically detectable gingival diseasedetectable gingival disease

TYPES OF GINGIVAL DISEASESTYPES OF GINGIVAL DISEASES

Most common type of gingival disease is Most common type of gingival disease is the simple inflammatory involvement the simple inflammatory involvement caused by bacterial plaque attached to the caused by bacterial plaque attached to the tooth surfacetooth surface

This type of gingivitis, called This type of gingivitis, called chronic chronic marginal gingivitis marginal gingivitis oror simple gingivitis, simple gingivitis, may may remain stationary for indefinite periods of remain stationary for indefinite periods of time or may proceed to destruction of the time or may proceed to destruction of the supporting structuressupporting structures

COURSE, DURATION, AND COURSE, DURATION, AND DISTRIBUTION OF GINGIVITISDISTRIBUTION OF GINGIVITIS

COURSE AND DISTRIBUTIONCOURSE AND DISTRIBUTION Acute gingivitisAcute gingivitis is a painful condition that is a painful condition that

comes on suddenly and is of short durationcomes on suddenly and is of short duration Subacute gingivitis Subacute gingivitis is a less severe phase of is a less severe phase of

the acute conditionthe acute condition Recurrent gingivitis Recurrent gingivitis reappearsreappears after having after having

been eliminated by treatment or disappears been eliminated by treatment or disappears spontaneously and then reappearsspontaneously and then reappears

Chronic gingivitis Chronic gingivitis comes on slowly, is of long comes on slowly, is of long duration, and is painless unless complicated duration, and is painless unless complicated

DISTRIBUTION DISTRIBUTION OF GINGIVITISOF GINGIVITIS

Localized gingivitisLocalized gingivitis is confined to the is confined to the gingiva in relation to a single tooth or gingiva in relation to a single tooth or group of teethgroup of teeth

GeneralizedGeneralized gingivitisgingivitis involves the entire involves the entire mouthmouth

Marginal gingivitisMarginal gingivitis involves the gingival involves the gingival margin but may include a portion of the margin but may include a portion of the contiguous attached gingivacontiguous attached gingiva

Papillary gingivitisPapillary gingivitis involves the involves the interdental papillae and often extends interdental papillae and often extends into the adjacent portion of the gingival into the adjacent portion of the gingival marginmargin

Diffused gingivitisDiffused gingivitis affects the gingival affects the gingival margin, the attached gingiva, and the margin, the attached gingiva, and the interdental papillaeinterdental papillae

The distribution of gingival disease in The distribution of gingival disease in individual cases is described by combining individual cases is described by combining the preceding terms, as follows:the preceding terms, as follows:

Localized marginal gingivitis Localized marginal gingivitis is confined to one or is confined to one or more areas of the marginal gingivamore areas of the marginal gingiva

Localized diffuse gingivitisLocalized diffuse gingivitis extends from the extends from the margin to the mucobuccal foldmargin to the mucobuccal fold

Localized papillary gingivitisLocalized papillary gingivitis is confined to one or is confined to one or more interdental spaces in a limited areamore interdental spaces in a limited area

Generalized marginal gingivitisGeneralized marginal gingivitis involves the involves the gingival margins in relation to all of the teethgingival margins in relation to all of the teeth

Generalized diffuse gingivitisGeneralized diffuse gingivitis involves the entire involves the entire gingivagingiva

CLINICAL FINDINGS IN CLINICAL FINDINGS IN GINGIVITISGINGIVITIS

In evaluating the clinical features of In evaluating the clinical features of gingivitis it is necessary to be gingivitis it is necessary to be systematicsystematic

Attention should be focused on subtle Attention should be focused on subtle tissue alterationstissue alterations

Systematic clinical approach requires an Systematic clinical approach requires an orderly examination of the gingiva for the orderly examination of the gingiva for the following features: color, size and shape, following features: color, size and shape, consistency, surface texture, position, consistency, surface texture, position, ease and severity of bleeding, and painease and severity of bleeding, and pain

Gingival BleedingGingival Bleeding

Two earliest symptoms of gingival Two earliest symptoms of gingival inflammation, which precede established inflammation, which precede established gingivitis:gingivitis: Increase gingival fluid production rateIncrease gingival fluid production rate Bleeding from the gingival sulcus on gentle probingBleeding from the gingival sulcus on gentle probing

Bleeding on probing is clinically easily Bleeding on probing is clinically easily detectable and therefore of great value for detectable and therefore of great value for early diagnosis and prevention of a more early diagnosis and prevention of a more severe casesevere case

Use of bleeding rather than color changes Use of bleeding rather than color changes to diagnose early gingival inflammation to diagnose early gingival inflammation has the advantage that bleeding is a more has the advantage that bleeding is a more objective sign, requiring less subjective objective sign, requiring less subjective estimation by the clinicianestimation by the clinician

Gingival bleeding varies in severity, Gingival bleeding varies in severity, duration, and the ease with which it is duration, and the ease with which it is provokedprovoked

Gingival Bleeding caused by Local Gingival Bleeding caused by Local FactorsFactors

Chronic and Recurrent BleedingChronic and Recurrent Bleeding Most common cause of abnormal gingival Most common cause of abnormal gingival

bleeding is chronic inflammationbleeding is chronic inflammation Is provoked by mechanical trauma such as Is provoked by mechanical trauma such as

improper brushing, toothpick, or food improper brushing, toothpick, or food impaction, by biting into solid food, and by impaction, by biting into solid food, and by grinding teeth (bruxism)grinding teeth (bruxism)

In gingival inflammation, the following In gingival inflammation, the following histopathologic alterations result in histopathologic alterations result in abnormal gingival bleeding:abnormal gingival bleeding: Dilation and engorgement of the capillaries Dilation and engorgement of the capillaries

and thinning or ulceration of the sulcular and thinning or ulceration of the sulcular epithelium epithelium

Because the capillaries are engorged and Because the capillaries are engorged and closer to the surface and the thinned, closer to the surface and the thinned, degenerated epithelium is less protective, degenerated epithelium is less protective, stimulation that are ordinarily innocuous stimulation that are ordinarily innocuous cause rupture of the capillaries and gingival cause rupture of the capillaries and gingival bleedingbleeding

Sites that bleed on probing have a greater Sites that bleed on probing have a greater area of inflamed connective tissue (cell area of inflamed connective tissue (cell rich, collagen poor) than do sites that do rich, collagen poor) than do sites that do not bleednot bleed

Cellular infiltrate of sites that bleed on Cellular infiltrate of sites that bleed on probing is predominantly lymphocytic (a probing is predominantly lymphocytic (a characteristic of Stage II or early gingivitis)characteristic of Stage II or early gingivitis)

Severity of the bleeding and the ease with Severity of the bleeding and the ease with which it is provoked depends on the which it is provoked depends on the intensity of the inflammationintensity of the inflammation

In cases of moderate or advanced In cases of moderate or advanced periodontitis the presence of bleeding on periodontitis the presence of bleeding on probing is considered a sign of active probing is considered a sign of active tissue destructiontissue destruction

Acute BleedingAcute Bleeding Gingival bleeding is Gingival bleeding is caused by injury or caused by injury or

occur spontaneously in acute gingival occur spontaneously in acute gingival diseasedisease

Laceration of the gingiva by toothbrush Laceration of the gingiva by toothbrush bristles during aggressive brushing bristles during aggressive brushing

Sharp piece of hard food cause gingival Sharp piece of hard food cause gingival bleeding even in the absence of gingival bleeding even in the absence of gingival diseasedisease

Gingival burns from hot foods or chemicals Gingival burns from hot foods or chemicals increase the case of gingival bleedingincrease the case of gingival bleeding

GINGIVAL BLEEDING GINGIVAL BLEEDING ASSOCIATED WITH SYSTEMIC ASSOCIATED WITH SYSTEMIC

DISTURBANCESDISTURBANCES

There are systemic disorders in which There are systemic disorders in which gingival hemorrhage, unprovoked by gingival hemorrhage, unprovoked by mechanical irritation, occur mechanical irritation, occur spontaneously, or in which gingival spontaneously, or in which gingival bleeding following irritation is excessive bleeding following irritation is excessive and difficult to controland difficult to control

Hemorrhage may be due to failure of one Hemorrhage may be due to failure of one or more of the hemostatic mechanismsor more of the hemostatic mechanisms

Hemorrhagic disorders in which abnormal Hemorrhagic disorders in which abnormal gingival bleeding is encountered include gingival bleeding is encountered include the following:the following: Vascular abnormalities (Vit. C deficiency or Vascular abnormalities (Vit. C deficiency or

allergy such as Schallergy such as Schöönlein-Henoch purpura)nlein-Henoch purpura) Platelet disorders (idiopathic Platelet disorders (idiopathic

thrombocytopenia purpura or thrombocytopenia purpura or thrombocytopenic purpura caused by diffuse thrombocytopenic purpura caused by diffuse injury to bone marrow)injury to bone marrow)

Hypoprothrombinemia (Vit. K deficiency Hypoprothrombinemia (Vit. K deficiency resulting from liver disease or sprue)resulting from liver disease or sprue)

Coagulation defects (hemophilia, leukemia, Coagulation defects (hemophilia, leukemia, Christmas disease)Christmas disease)

Deficient platelet thromboplastic factor (PF3) Deficient platelet thromboplastic factor (PF3) resulting from uremia, multiple myeloma and resulting from uremia, multiple myeloma and post-rubella purpurapost-rubella purpura

Bleeding may follow the administration of Bleeding may follow the administration of excessive amounts of drugs such as excessive amounts of drugs such as salicylates and the administration of salicylates and the administration of anticoagulants such as dicumarol and anticoagulants such as dicumarol and heparinheparin

Cyclic episodes of abnormal bleeding are Cyclic episodes of abnormal bleeding are occasionally associated with the menstrual occasionally associated with the menstrual period period

COLOR CHANGES IN THE COLOR CHANGES IN THE GINGIVAGINGIVA

Color changes in Chronic GingivitisColor changes in Chronic Gingivitis Chronic inflammation intensifies the red or Chronic inflammation intensifies the red or

bluish red color, this is caused by vascular bluish red color, this is caused by vascular proliferation and reduction of keratinization proliferation and reduction of keratinization due to epithelial compression by the inflamed due to epithelial compression by the inflamed tissuetissue

Venous stasis will add a bluish hueVenous stasis will add a bluish hue

Color changes in Acute GingivitisColor changes in Acute Gingivitis Color changes vary with the intensity of the Color changes vary with the intensity of the

inflammationinflammation In all instances there is an initial bright red In all instances there is an initial bright red

erythemaerythema

METALLIC PIGMENTATIONMETALLIC PIGMENTATION

Heavy metals absorbed systemically from Heavy metals absorbed systemically from therapeutic use or occupational therapeutic use or occupational environments may discolor the gingiva and environments may discolor the gingiva and other areas of the mucosaother areas of the mucosa

This is different from tattooing produced by This is different from tattooing produced by the accidental embedding of amalgam or the accidental embedding of amalgam or other metal fragmentsother metal fragments

Bismuth, arsenicBismuth, arsenic, and , and mercury mercury produce produce a black line in the gingiva, which follows a black line in the gingiva, which follows the gingival contour of the marginthe gingival contour of the margin

LeadLead results in a bluish red or deep blue results in a bluish red or deep blue linear pigmentation of the gingival margin linear pigmentation of the gingival margin (burtonian line)(burtonian line)

Silver Silver (argyria) (argyria) causes a violet marginal causes a violet marginal line, often accompanied by a diffuse bluish line, often accompanied by a diffuse bluish gray discoloration throughout the mucosagray discoloration throughout the mucosa

COLOR CHANGES ASSOCIATED COLOR CHANGES ASSOCIATED WITH SYSTEMIC FACTORSWITH SYSTEMIC FACTORS

Endogenous Endogenous oral oral pigmentation can be due pigmentation can be due to melanin, bilirubin, or to melanin, bilirubin, or ironiron

Melanin oral pigmentation Melanin oral pigmentation can be normal physiologic can be normal physiologic pigmentation and is pigmentation and is commonly found in darker commonly found in darker racesraces

Diseases that increase melanin Diseases that increase melanin pigmentation include the following:pigmentation include the following:

Addison’s diseaseAddison’s disease which is caused by which is caused by adrenal dysfunction and produces isolated adrenal dysfunction and produces isolated patches of discoloration varying from patches of discoloration varying from bluish black to brownbluish black to brown

Peutz-Jeghers syndromePeutz-Jeghers syndrome which produces which produces intestinal polyposis and melanin intestinal polyposis and melanin pigmentation in the oral mucosa and lipspigmentation in the oral mucosa and lips

Albright’s syndromeAlbright’s syndrome (polyostotic fibrous (polyostotic fibrous dysplasia)dysplasia)

Von Recklinghausen’s diseaseVon Recklinghausen’s disease (neurofibromatosis) (neurofibromatosis)

Skin and mucous membrane can also be Skin and mucous membrane can also be stained by stained by bile pigmentsbile pigments

Jaundice Jaundice is best detected by examination is best detected by examination of the sclera, but the oral mucosa may of the sclera, but the oral mucosa may also acquire a yellowish coloralso acquire a yellowish color

Iron Iron in hemochromatosis may produce a in hemochromatosis may produce a blue-gray pigmentation of the oral mucosablue-gray pigmentation of the oral mucosa

Exogenous factorsExogenous factors are capable of are capable of producing color changes in the gingiva producing color changes in the gingiva include atmospheric irritants, such as coal include atmospheric irritants, such as coal and metal dust, and coloring agents in and metal dust, and coloring agents in food and lozengesfood and lozenges

Tobacco causes gray hyperkeratosis of Tobacco causes gray hyperkeratosis of the gingiva the gingiva

Localized bluish black areas of pigment Localized bluish black areas of pigment are commonly due to amalgam implanted are commonly due to amalgam implanted in the mucosain the mucosa

Smoker’s MelanosisSmoker’s Melanosis

Changes in the Consistency of the Changes in the Consistency of the GingivaGingiva

Both chronic and acute inflammation Both chronic and acute inflammation produce changes in the normal firm, produce changes in the normal firm, resilient consistency of the gingivaresilient consistency of the gingiva

Chronic gingivitis is a conflict between Chronic gingivitis is a conflict between destruction and reparative changes, and destruction and reparative changes, and consistency of the gingiva is determined consistency of the gingiva is determined by the relative balance between the twoby the relative balance between the two

Changes in the Surface Texture of the Changes in the Surface Texture of the GingivaGingiva Loss of surface stippling is an early sign of Loss of surface stippling is an early sign of

gingivitisgingivitis In chronic inflammation the surface is either In chronic inflammation the surface is either

smooth and shiny or firm and nodular, smooth and shiny or firm and nodular, depending on whether the dominant changes depending on whether the dominant changes are exudative or fibroticare exudative or fibrotic

Smooth surface texture is produced by epithelial Smooth surface texture is produced by epithelial atrophyatrophy

Peeling of the surface occurs in desquamative Peeling of the surface occurs in desquamative gingivitisgingivitis

Hyperkeratosis results in a leathery textureHyperkeratosis results in a leathery textureNon-inflammatory gingival hyperplasia Non-inflammatory gingival hyperplasia

produces a minute nodular surfaceproduces a minute nodular surface

THANK YOU FOR THANK YOU FOR NOT SLEEPINGNOT SLEEPING