dcp2 lect1 2011

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Year 2

Lecture 1

GINGIVITIS

11-9-2011 1Classification of gingivitis- lecture 1

GINGIVITISModule Introduction

In Module 1, you gained an insight into the form and function of the periodontal tissues. The natural defence mechanisms of the gingival tissues were described and the role of commensal bacteria explained. It is assumed that you will carry forward this knowledge and build upon it, as more of the Modules in periodontics are presented.

slide 211-9-2011 Classification of gingivitis- lecture 1

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Review of aspects of Module 1Sequence of developing gingivitisq p g g g

Increased gingival crevicular fluid flow

Bleeding on probing

Colour changeg

Changed gingival contours

Retractability of the gingival tissues


GINGIVITISWhen you have completed Module 2, you are expected to y p , y p

be able to:

♦ Describe the anatomy and physiology of the gingival tissues in detail.

♦ Understanding the microbiology, etiology and pathogenesis of chronic gingivitis

♦ Have an overview of the many different gingival diseases and conditions.

♦ Be able to recognise chronic and acute forms of gingivitis and know the i t t t t f th ditiappropriate treatment for these conditions

♦ Understand the medical conditions that can cause modified/exaggerated gingival responses to dental biofilm.


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GINGIVITIS

Gingival health represents a balance between biofilm and host resistance factors. Gingivitis most often occurs as a CHRONIC disease and is present over many years/decades. It is reversible, meaning that gingiva can return to clinical and histological health when biofilm and calculus is removed.

slide 5Classification of gingivitis- lecture 1

GINGIVITIS


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Gingival Diseases

These diseases may occur on a periodontium with noy p

attachment loss or on a periodontium with attachment loss that is stable and not progressing.

I. Gingivitis associated with dental plaque only

II. Non‐plaque‐Induced Gingival Lesions


Dental Plaque‐Induced Gingival Diseases Gingivitis has been previously characterized by the presence of

clinical signs of inflammation that are confined to the gingiva and associated with teeth showing no attachment loss.

It h b l d d th t l i d d i i iti It has been concluded that plaque‐induced gingivitis may occur on a periodontium with no attachment loss or on a periodontium with previous attachment loss that is stable and not progressing.

I. Gingivitis associated with dental plaque only

II. Gingival diseases modified by systemic factors

III. Gingival diseases modified by medications

IV Gingival diseases modified by malnutritionIV. Gingival diseases modified by malnutrition


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Gingivitis

Non‐specific Inflammation Response

of the gingival tissues towards a Non‐specific Plaque Challenge


The most common type of gingivitis is

Plaque induced gingivitis caused by biofilm.

h ’ h Chronic’ means that gingivitis is present for a long time… usually years or decades.

Plaque induced gingivitis caused by biofilm

Plaque induced gingivitis is Plaque induced gingivitis is the most common periodontal disease you will be treating.


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I Gingivitis associated with dental plaque only:I. Gingivitis associated with dental plaque only:

A. Without local contributing factors

B. With local contributing factors


B. With local contributing factors

Local factors that may contribute to gingivitis, in addition to y g g ,plaque‐retentive calculus formation on crown and root surfaces.

Localized tooth‐Related Factors That can differ or

Predispose to Plaque‐Induced Gingival Diseases

1. Tooth anatomic factors

2. Dental restorations or appliances

R t f t3. Root fractures

4. Cervical root resorption and cemental tears


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II. Gingival diseases modified by systemic factors

A. Associated with endocrine system

1. Puberty‐associated gingivitis

2. Menstrual cycle–associated gingivitis

3. Pregnancy associated

a. Gingivitis

b. Pyogenic granuloma

4. Diabetes mellitus–associated gingivitis

B Associated ith blood d scrasiasB. Associated with blood dyscrasias

1. Leukemia‐associated gingivitis

2. Other


Plaque‐induced gingival di i h l f disease is the result of an inter‐action between the microorganisms found in the dental plaque biofilmand the tissues and inflarnmatory cells of the host.

Modified by factors which can influence the severity yand duration of the response:

Systemic factors. Medications Malnutrition.

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Systemic factors contributing to gingivitis, such as they g g g ,

endocrine changes associated with puberty, the menstrual

cycle, pregnancy, and diabetes, may be exacerbated

because of alterations in the gingival inflammatory response

to plaque.

• This altered response appears to result from the effects of

systemic conditions on the host's cellular and immunologic

functions.


Puberty‐associated gingivitis

The incidence of marginal gingivitis g g gpeaks at 11 to 13 years of age, then decreases slightly after puberty.

The most frequent manifestations in adolescents is bleeding and inflammation in the interproximal areas. This is usually the result of hormonal changes that magnify the tissue inflammatory response to dental plaque.

It occurs in both males and females and reduces in severity after puberty, it resolves as the person matures.


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Gingival Disease in Pregnancy

Pronounced ease of bleeding is the most striking clinical feature.

The gingiva is inflamed and varies in color from a bright red to bluish

The marginal and i t d t l i i interdental gingiva are edematous, pit on pressure, appear smooth , shiny and are soft.


The extreme redness results from marked vascularity, and there is an increased tendency to bleed.

Gingivitis in pregnancy is caused Gingivitis in pregnancy is caused by bacterial plaque, just as it is in nonpregnant women.

Pregnancy accentuates the gingival response to plaque and modifies the resultant clinical picture .

Pregnancy affects the severity of Pregnancy affects the severity of previously inflamed areas; it does not alter healthy gingiva.


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Tumor‐like Gingival Enlargement The so‐called pregnancy tumor is not a neoplasm; it is an inflammatory response to bacterial plaque and is modified by the patient's condition.


Diabetes mellitus–associated gingivitis

Gingivitis caused by biofilm, modified by poorly g y , y p ycontrolled diabetes

Diabetes may be first picked up by the oral health practitioner because of the unusual response of the gingival tissues to plaque.


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The most striking The most striking changes in uncontrolled diabetes are the reduction in defense mechanisms and the increased susceptibility to susceptibility to infections, leading to destructive periodontal disease.


Diabetes: What to look for?

Severe gingival g ginflammation

Deep periodontal pockets,

Rapid bone loss,

Frequent periodontal abscesses.

Slow resolution of gingivitis after conventional treatment.


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Blood dyscrasias such as leukemia may alter immune function y yby disturbing the normal balance of immunologically

competent white blood cells supplying the periodontium. Gingival enlargement and bleeding are common findings and may be associated with swollen, spongy gingival tissues caused by excessive infiltration of blood cells.


III. Gingival Diseases Modified by Medications

A. Drug‐influenced gingival diseasesA. Drug influenced gingival diseases

1. Drug‐influenced gingival enlargements

2. Drug‐influenced gingivitis

a. Oral contraceptive–associated gingivitis

b. Other.


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Gingival diseases modified by medications are increasingly

prevalent because of the increased use of anti‐convulsantp

drugs known to induce gingival enlargement, such as phenytoin, immunosuppressive drugs such as cyclosporine , and calcium channel blockers such as nifedipine.

The development and severity of gingival enlargement in response to medications are patient specific and may be influenced by uncontrolled plaque accumulation.

The increased use of oral contraceptives by premenopausal The increased use of oral contraceptives by premenopausal women has been associated with a higher incidence of gingival inflammation and development of gingival enlargement, which may be reversed by discontinuation of the oral contraceptive


Phenytoin Anticonvulsant drug used in

h f ilthe treatment of epilepsy.


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Cyclosporine

Potent immunosuppresive ppdrug used to prevent organ rejection following transplantation.


Nifedipine

Are drugs developed to treat g pseveral cardiac diseases such as hypertension, angina pectoris, coronary artery spasms.

In patients of Kidney transplant it is used in combination of both Cyclosporin and nifedipine leading to larger enlargements of the gingiva.


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IV. Gingival diseases modified by malnutrition

A. Ascorbic acid deficiency gingivitisB. Others.

Gingival diseases modified by malnutrition have received attention because of clinical descriptions of bright‐red, swollen, and bleeding gingiva associated with severe ascorbic acid ( vitamin C) deficiency or scurvy.

Nutritional deficiencies are known to affect immune function and may affect the host's ability immune function and may affect the host s ability to protect itself against some of the detrimental effects of cellular products, such as oxygen radicals.



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Non—Plaque‐Induced Gingival Lesions

I. Gingival diseases of specific bacterial originI. Gingival diseases of specific bacterial origin

II. Gingival diseases of viral origin

III. Gingival diseases of fungal origin

IV. Gingival lesions of genetic origin

V. Gingival manifestations of systemic conditions

VI. Traumatic lesions (factitious, iatrogenic, or gaccidental)

VII. Foreign body reactions

VIII. Not otherwise specified Gingival Diseases


I. Gingival Diseases of Specific Bacterial Origin

A. Neisseria gonorrhoeae

B Treponema pallidumB. Treponema pallidum

C. Streptococcus species

D. Other Gingival diseases of specific bacterial origin are increasing in prevalence,

especially as a result of sexually transmitted diseases such as gonorrhea (Neisseria gonarrhoeae) and to a lesser degree, syphilis (Treponenra pallidum).’

Oral lesions may be secondary to systemic infection or may occur y y y ythrough direct infection. Streptococcal gingivitis or gingivostomatitis is a rare condition that may present as an acute condition with fever, malaise, and pain associated with acutely inflamed, diffuse, red, and swollen gingiva with increased bleeding and occasional gingival abscess formation.


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II. Gingival diseases of viral origin

A. Herpesvirus infections

1. Primary herpetic gingivostomatitis

2 Recurrent oralherpes2. Recurrent oralherpes

3. Varicella zoster

B. Other.

Gingival diseases of viral origin may be caused by a variety of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) viruses, the most common b i h h i L i f l being the herpesviruses. Lesions are frequently related to reactivation of latent viruses, especially as a result of reduced immune function.


Types of gingivitis

Acute gingivitis Acute Viral

•Viral

gingivitis

slide 34

Herpes virus-induced gingivitis

Classification of gingivitis- lecture 1

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III. Gingival diseases of fungal origin

A Candida species infections: generalized gingival A. Candida species infections: generalized gingival candidiasis

B. Linear gingival erythema

C. Histoplasmosis

D. Other


Types of gingivitis

•Auto-immune•notbiofilm

slide 36

biofilm-related

Lichen PlanusClassification of gingivitis- lecture 1

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IV. Gingival lesions of genetic origin

A Hereditary gingival fibromatosisA. Hereditary gingival fibromatosis

B. Other. Gingival diseases of genetic origin may involve the tissues of the

periodontium. One of the most clinically evident conditions is hereditary gingival fibromatosis, which exhibits autosomal dominant or (rarely) autosomal recessive modes of inheritance. The gingival enlargement may completely cover the teeth, delay eruption, and present as an isolated finding or may be associated with several more generalized syndromes.


V. Gingival manifestations of systemic conditionsA. Mucocutaneous lesions

1 Lichen planus

B. Allergic reactions

1 Dental restorative materials1. Lichen planus

2. Pemphigoid

3. Pemphigus vulgaris

4. Erythema multiforme

5. Lupus erythematosus

6. Drug induced

7. Other

1. Dental restorative materials

a. Mercury

b. Nickel

c. Acrylic

d. Other

2. Reactions attributable to:

a. Toothpastes or dentifrices

b M th i th hb. Mouth rinses or mouthwashes

c. Chewing gum additives

d. Foods and additives

3. Other.


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Gingival manifestations of systemic conditions may appear

as desquamative lesions, ulceration of the gingiva, or both.

Allergic reactions that manifest with gingival changes

are uncommon but have been observed in association with

several restorative materials, tooth‐pastes, mouthwashes,

chewing gum, and foods .


Non plaque‐induced gingival lesionsVI. Traumatic lesions (factitious, iatrogenic, or accidental)

A. Chemical injury

B. Physical injury

C. Thermal injuryj y

Traumatic lesions may be factitious (produced by artificial

means; unintentionally produced), as in the case of

toothbrush trauma resulting in gingival ulceration, recession,

or both; iatrogenic (trauma to the gingiva induced by

the dentist or health professional), as in the case of

preventive or restorative care that may lead to traumatic

injury of the gingiva; or accidental, as in the case ofinjury of the gingiva; or accidental, as in the case of

damage to the gingiva through minor burns from hot foods

And drinks.


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VII. Foreign body reactions

Foreign body reactions lead to localized inflammatory conditions of the gingiva and are caused by the introduction of foreign material the gingiva and are caused by the introduction of foreign material into the gingival connective tissues through breaks in the epithelium.

Common examples are the introduction of amalgam into the gingiva during the placement of a restoration or extraction of a tooth, leaving an amalgam tattoo, or the introduction of abrasives during polishing procedures.

VIII. Not otherwise specified


11-9-2011 Classification of gingivitis- lecture 1 slide 42

dcp2 lect1 2011

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