Clinical features of gingivitis

Contents• Course and duration

• Description

• Clinical findings

• Gingival bleeding

a. Local factors

b. Systemic factors

• Changes in gingiva

a. Colour

b. Contour

c. Consistency

d. Position

e. texture

Gingivitis

• In general, clinical features of gingivitis may be characterized by presence of any of the following clinical signs:

a. Redness and sponginess of the gingival tissue

b. Bleeding on provocation

c. Changes in contour

d. Presence of plaque or calculus with no evidence of bone loss.

• Histological examination reveals ulcerated epithelium.

Classification Of Gingivitis

Course and duration Acute gingivitis - can occur with sudden onset and short duration. Recurrent gingivitis – reappears after treatment Chronic gingivitis – slow in onset and of long duration

Distribution Localised – confined to single tooth or a groupGeneralized – involves entire mouth• Marginal – involves gingival margin• Papillary – involves interdental papilla and extends into gingival

margin. Earliest signs of gingivitis occur in the papillae.• Diffuse – affects marginal, attached gingiva and interdental

papillae.

chronic marginal gingivitis

Gingival diseases in individual cases can be described using the following terms.

• Localised marginal gingivitis

• Localised diffuse gingivitis

• Localised papillary gingivitis

• Generalised marginal gingivitis

• Generalized diffuse gingivitis.

Clinical findings

• Systematic approach is required.

• An orderly examination of gingiva for colour, contour, consistency, position, and ease and severity of bleeding and pain.

BLEEDING ON PROBING

2 earliest signs of gingival inflammation preceding established gingivitis.

• Gcf production increased

• Bleeding on probing ( easily detectable )

• Bleeding varies in severity, duration, and ease of provocation.

• Easily detected clinically and therefore is of value for early diagnosis and prevention of advanced gingivitis

• Bleeding appears earlier than other visual signs of inflammation.

• It is a more objective sign that requires less subjective estimation by the examiner

• It is widely used to measure disease prevalance and progression, to measure outcome of the treatment, and to motivate patients with home care.

• Interestingly numerous studies show that smoking suppresses the gingival inflammatoryresponse.

Gingival bleeding caused by local factors

Contributing factors to plaque retention like

• Anatomic and developmental tooth variations, caries, frenum pull, iatrogenic factors, mal positioned teeth, mouth breathing, overhangs, partial dentures, lack of attached gingiva, and recession.

Chronic and recurrent bleeding

causes

long standing inflammation

Bleeding provoked …

Mechanical trauma.. Eg: tooth brushing, food impaction

Histopathologically…

dilated engorged capillaries 1)

2) Thinned out ulcerated gingiva

aftermath…?

damaged vessels

hemostasisVessel walls contract

DiminishedBlood flow

Platelet adhesion

Clot contractionEdges approximate.

But…

bleeding recurs… with the slightest stimuli..

ACUTE BLEEDING … -Injury or acute gingival disease Laceration of the gingiva - biting on sharp pieces of food. - toothbrush trauma - toothpicks - burns from hot foods or chemicals • Acute necrotizing ulcerative gingivitis

blood vessels exposed to the surface by necrosed epithelium so spontaneous bleeding or bleeding on slight provocation occurs.

Bleeding associated with systemic changes

Spontaneous or after irritation… -varied etiology and manifestations… -underlying cause “haemostatic system failure” bleeding in the skin , internal organs other

Tissues…. vascular abnormalities platelet disorders hypoprothrombinemia coagulation defects multiple myeloma other causes … administration of anticoagulants, harmonal replacement therapy,

oral contraceptives, pregnancy and menstrual cycle

Color changes Normally… coral pink effected by

• vascularity

• Keratinisation

Chronic

increased vascularity. --- Red or pale pink

reduced keratinisation.

venous stasis --- bluish hue

Acute

Colour changes differ in nature and distribution

• Marginal (acute necrotising ulcerative ging)

• Diffuse (herpetic gingivostomatitis)

• Patchlike (chemical reactions )

metallic pigmentation

Heavy metals absorbed systemically… occupational therapeutic household …discolor the gingiva. bismuth lead Hg Ag

Pigmentation can be seen as

• Black or bluish line ( gingival contour )• Isolated blotches (interdentally marginal or attached gingiva )

Metal pigments … Systemically absorbed.

Perivascular accumulation

Vessel rupture ( inflammatory)

Increased vascular permeability

Seepage of metal into surrounding tissue ( sub epithelial c.t.) …NOT DUE TO TOXICITY…

Treatment…?

simply TREAT the Inflammation…

CoLor changes – systemic factors - Non specific

- Further diagnostic efforts

- Referral to specialist

Endogenous pigmentations

MELANIN

BILIRUBIN

IRON

Melanin Physiologic pigmentation. Pathologies… Addison’s disease Peutz-Jegher’s disease Albright’s syndromeBile pigment. Yellowish color oral mucosa ( apart from sclera)Other causes.. Diabetes Pregnancy Blood dyscrasias Anemia Polycythemia etc

Exogenous

• Tobacco --- hyperkeratosis, increase in melanin pigmentation

• Metal dust… coal.

• Coloring agents. In foods , lozenges

• Amalgam implantation – localised bluish black areas

CONSISTENCY

Normally..

Firm and Resilient.• In chronic gingivitis the consistency of the gingiva is

determined by the relative predominance of the following changes

-Oedematous (destructive )

-Fibrotic (reparative)

- Combination of either

Clinical and Histopathological Correlations

Soggy puffiness that pits on pressure

Infiltration of Inflammatory exudate

Marked softness & friability with ready fragmentation on exploration with probe & pinpoint surface areas of redness and desquamation

Degeneration, inflammation & inflammatory exudatesEpithelium- thinned, degenerated, edema, leukocyte invasion.C.T- inflamed, engorged Elongated retepeges

Firm, leathery Fibrosis, epithelial proliferation with long standing chronic inflammation.

Chronic Gingivitis

Diffuse puffiness and softening Diffuse edema, fatty infiltration in xanthomatosis

Sloughinfgwith grayish, flakelike particles of debris adhering to eroded surface

Necrosis, pseudomembrane composed of bacteria, PMNs & degenerated epithelial cells in fibrinous network

Vesicle formation Intercellular & intracellular edemaDegeneration of nucleus and cytoplasmaRupture of vessel wall

Acute forms of Gingivitis

calcified masses… - isolated - groups traumatically lodged.. substances derived from the tooth. root remnants, calculus cementum fragments cementicles. Associated with… chronic inflammation fibrosis foreign body reaction

crystalline substances in the gingiva seen at times (origin not known…)

surface texture

Loss of stippling (… early sign )

in chronic inflammation… 1) Smooth , shiny 2) Firm and nodular ( also found in drug induced

gingival enlargement) - “peeling off” of the surface occurs in the

desquamative gingivitis. - leathery texture … hyperkeratosis.

Position of the gingiva. Recession

-actual position -apparent position.

Actual : position of the epithelial attachment. Apparent : level of the crest of the gingival margin. 2 types of recession … -visible clinically visible. -hidden can only be estimated by insertion of a

probe.

Recession

Visible

Hidden

Apparent

Actual

Tooth

recession refers to position of the gingiva

- NOT the condition of the gingiva.

May be

- localised.

- generalised

ETIOLOGY OF RECESSION. Age: physiologic process…? (8% incidence in children. 100% in persons aged 50 and above) No convincing evidence… - gradual apical shift : cumulative effect of minor

pathologic involvement and repeated direct trauma.

Factors responsible….

-Faulty tooth brushing -Tooth malposition -Friction from soft tissues ( gingival ablation) -Gingival inflammation -Frenal pull.

Faulty Tooth brushing.

brushing - gingival health vigorous tooth brushing - adverse effects to the position of

the gingiva.. Tooth Position

Most prominently placed teeth. e.g. Canine. Root bone angle higher the root : bone angle … less recession and vice versa. Mesio-distal curvature of the tooth… e.g . Canine

Gingiva “rests” or takes the support of the bone

rotated or tilted teeth labially placed

thinned out cortical plate

unsupported gingiva

gingival recession

mild masticatory stresses e.g. tooth brushing.

clinical significance.

1) Caries

2) Sensitivity ( erosion of the cementum)

3) Hyperemia of pulp.

4) Oral hygiene problems . (interproximal recession))

Gingival contour. Stillman’s clefts.

McCall’s festoons

peculiar inflammatory changes….

generally found in gingival enlargements