Gingivitis

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Gingivitis
Gingivitis (crop).jpg
A severe case of gingivitis
Specialty Dentistry
Complications Periodontal disease

Gingivitis is a non-destructive disease that causes inflammation of the gums; [1] ulitis is an alternative term. [2] The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also called plaque) that are attached to tooth surfaces, termed plaque-induced gingivitis. Most forms of gingivitis are plaque-induced. [3]

Contents

While some cases of gingivitis never progress to periodontitis, [4] periodontitis is always preceded by gingivitis. [5]

Gingivitis is reversible with good oral hygiene; however, without treatment, gingivitis can progress to periodontitis, in which the inflammation of the gums results in tissue destruction and bone resorption around the teeth. Periodontitis can ultimately lead to tooth loss. [6]

Signs and symptoms

Gingivitis Gingivitis.png
Gingivitis

The symptoms of gingivitis are somewhat non-specific and manifest in the gum tissue as the classic signs of inflammation:

Additionally, the stippling that normally exists in the gum tissue of some individuals will often disappear and the gums may appear shiny when the gum tissue becomes swollen and stretched over the inflamed underlying connective tissue. The accumulation may also emit an unpleasant odor. When the gingiva are swollen, the epithelial lining of the gingival crevice becomes ulcerated and the gums will bleed more easily with even gentle brushing, and especially when flossing.

Complications

Alzheimer's and dementia

A study from 2018 found evidence that gingivitis bacteria may be linked to Alzheimer's disease. Scientists agree that more research is needed to prove a cause and effect link. [8] "Studies have also found that the bacteria P. gingivalis – which are responsible for many forms of gum disease – can migrate from the mouth to the brain in mice. And on entry to the brain, P. gingivalis can reproduce all of the characteristic features of Alzheimer's disease." [9]

Cause

The cause of plaque-induced gingivitis is bacterial plaque, which acts to initiate the body's host response. This, in turn, can lead to destruction of the gingival tissues, which may progress to destruction of the periodontal attachment apparatus. [10] The plaque accumulates in the small gaps between teeth, in the gingival grooves and in areas known as plaque traps: locations that serve to accumulate and maintain plaque. Examples of plaque traps include bulky and overhanging restorative margins, clasps of removable partial dentures and calculus (tartar) that forms on teeth. Although these accumulations may be tiny, the bacteria in them produce chemicals, such as degradative enzymes, and toxins, such as lipopolysaccharide (LPS, otherwise known as endotoxin) or lipoteichoic acid (LTA), that promote an inflammatory response in the gum tissue. This inflammation can cause an enlargement of the gingiva and subsequent formation. Early plaque in health consists of a relatively simple bacterial community dominated by Gram-positive cocci and rods. As plaque matures and gingivitis develops, the communities become increasingly complex with higher proportions of Gram-negative rods, fusiforms, filaments, spirilla and spirochetes. Later experimental gingivitis studies, using culture, provided more information regarding the specific bacterial species present in plaque. Taxa associated with gingivitis included Fusobacterium nucleatum subspecies polymorphum, Lachnospiraceae [G-2] species HOT100, Lautropia species HOTA94, and Prevotella oulorum (a species of Prevotella bacterium), whilst Rothia dentocariosa was associated with periodontal health. [11] Further study of these taxa is warranted and may lead to new therapeutic approaches to prevent periodontal disease including systemic health.

Risk factors

Risk factors associated with gingivitis include the following:

Diagnosis

Gingivitis is a category of periodontal disease in which there is no loss of bone but inflammation and bleeding are present.

Each tooth is divided into four gingival units (mesial, distal, buccal, and lingual) and given a score from 0–3 based on the gingival index. The four scores are then averaged to give each tooth a single score.

The diagnosis of the periodontal disease gingivitis is done by a dentist. The diagnosis is based on clinical assessment data acquired during a comprehensive periodontal exam. Either a registered dental hygienist or a dentist may perform the comprehensive periodontal exam but the data interpretation and diagnosis are done by the dentist. The comprehensive periodontal exam consists of a visual exam, a series of radiographs, probing of the gingiva, determining the extent of current or past damage to the periodontium and a comprehensive review of the medical and dental histories.

Current research shows that activity levels of the following enzymes in saliva samples are associated with periodontal destruction: aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and acid phosphatase (ACP). Therefore, these enzyme biomarkers may be used to aid in the diagnosis and treatment of gingivitis and periodontitis.

A dental hygienist or dentist will check for the symptoms of gingivitis, and may also examine the amount of plaque in the oral cavity. A dental hygienist or dentist will also look for signs of periodontitis using X-rays or periodontal probing as well as other methods.

If gingivitis is not responsive to treatment, referral to a periodontist (a specialist in diseases of the gingiva and bone around teeth and dental implants) for further treatment may be necessary.

Classification

1999 Classification

As defined by the 1999 World Workshop in Clinical Periodontics, there are two primary categories of gingival diseases, each with numerous subgroups: [15]

  1. Dental plaque-induced gingival diseases.
    1. Gingivitis associated with plaque only
    2. Gingival diseases modified by systemic factors
    3. Gingival diseases modified by medications
    4. Gingival diseases modified by malnutrition
  2. Non-plaque-induced gingival lesions
    1. Gingival diseases of specific bacterial origin
    2. Gingival diseases of viral origin
    3. Gingival diseases of fungal origin
    4. Gingival diseases of genetic origin
    5. Gingival manifestations of systemic conditions
    6. Traumatic lesions
    7. Foreign body reactions
    8. Not otherwise specified

2017 Classification

As defined by the 2017 World Workshop, periodontal health, gingival diseases/ conditions have been categorised into the following: [16]

  1. Periodontal health and gingival health
    1. Clinical gingival health on an intact periodontium
    2. Clinical gingival health on a reduced periodontium
      1. Stable periodontitis patient
      2. Non-periodontitis patient
  2. Gingivitis – dental biofilm-induced
    1. Associated with dental biofilm alone
    2. Mediated by systemic or local risk factors
    3. Drug-influenced gingival enlargement
  3. Gingival diseases – non-dental biofilm induced
    1. Genetic/ developmental disorders
    2. Specific infections
    3. Inflammatory and immune conditions
    4. Reactive processes
    5. Neoplasms
    6. Endocrine, nutritional & metabolic diseases
    7. Traumatic lesions
    8. Gingival pigmentation

Prevention

Gingivitis can be prevented through regular oral hygiene [17] that includes daily brushing and flossing. [18] Hydrogen peroxide, saline, alcohol or chlorhexidine mouth washes may also be employed. In a 2004 clinical study, the beneficial effect of hydrogen peroxide on gingivitis has been highlighted. [19] The use of oscillation type brushes might reduce the risk of gingivitis compared to manual brushing. [20]

Rigorous plaque control programs along with periodontal scaling and curettage also have proved to be helpful, although according to the American Dental Association, periodontal scaling and root planing are considered as a treatment for periodontal disease, not as a preventive treatment for periodontal disease. [21] In a 1997 review of effectiveness data, the U.S. Food and Drug Administration (FDA) found clear evidence showing that toothpaste containing triclosan was effective in preventing gingivitis. [22] In 2017 the FDA banned triclosan in many consumer products but allowed it to remain in toothpaste because of its effectiveness against gingivitis. [23] In 2019, Colgate, under pressure from health advocates, removed triclosan from the last toothpaste on the market containing it, Colgate Total. [24]

Treatment

Gingivitis before (top) and after (bottom) a thorough mechanical debridement of the teeth Gingivitis-before-and-after-3.jpg
Gingivitis before (top) and after (bottom) a thorough mechanical debridement of the teeth
Analgesic and antiseptic gum paint with applicator buds used in treatment of gingivitis Gum paint.jpg
Analgesic and antiseptic gum paint with applicator buds used in treatment of gingivitis

The focus of treatment is to remove plaque. Therapy is aimed at the reduction of oral bacteria and may take the form of regular periodic visits to a dental professional together with adequate oral hygiene home care. Thus, several of the methods used in the prevention of gingivitis can also be used for the treatment of manifest gingivitis, such as scaling, root planing, curettage, mouth washes containing chlorhexidine or hydrogen peroxide, and flossing. Interdental brushes also help remove any causative agents.

Powered toothbrushes work better than manual toothbrushes in reducing the disease. [25]

The active ingredients that "reduce plaque and demonstrate effective reduction of gingival inflammation over a period of time" are triclosan, chlorhexidine digluconate, and a combination of thymol, menthol, eucalyptol, and methyl salicylate. These ingredients are found in toothpaste and mouthwash. Hydrogen peroxide was long considered a suitable over-the-counter agent to treat gingivitis. There has been evidence to show the positive effect on controlling gingivitis in short-term use. A study indicates the fluoridated hydrogen peroxide-based mouth rinse can remove teeth stain and reduce gingivitis. [19]

Based on a limited evidence, mouthwashes with essential oils may also be useful, as they contain ingredients with anti-inflammatory properties, such as thymol, menthol and eucalyptol. [26]

The bacteria that causes gingivitis can be controlled by using an oral irrigator daily with a mouthwash containing an antibiotic. Either amoxicillin, cephalexin, or minocycline in 500 grams of a non-alcoholic fluoride mouthwash is an effective mixture. [27]

Overall, intensive oral hygiene care has been shown to improve gingival health in individuals with well-controlled type 2 diabetes. Periodontal destruction is also slowed due to the extensive oral care. Intensive oral hygiene care (oral health education plus supra-gingival scaling) without any periodontal therapy improves gingival health, and may prevent progression of gingivitis in well-controlled diabetes.

See also

Related Research Articles

<span class="mw-page-title-main">Periodontal disease</span> Medical condition

Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cause of tooth loss for adults worldwide. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Halitosis may also occur.

<span class="mw-page-title-main">Calculus (dental)</span> Form of hardened dental plaque

In dentistry, calculus or tartar is a form of hardened dental plaque. It is caused by precipitation of minerals from saliva and gingival crevicular fluid (GCF) in plaque on the teeth. This process of precipitation kills the bacterial cells within dental plaque, but the rough and hardened surface that is formed provides an ideal surface for further plaque formation. This leads to calculus buildup, which compromises the health of the gingiva (gums). Calculus can form both along the gumline, where it is referred to as supragingival, and within the narrow sulcus that exists between the teeth and the gingiva, where it is referred to as subgingival.

<span class="mw-page-title-main">Necrotizing gingivitis</span> Non-contagious, painful bacterial infection of the gums

Necrotizing gingivitis (NG) is a common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of interdental papillae. This disease, along with necrotizing periodontitis (NP) and necrotizing stomatitis, is classified as a necrotizing periodontal disease, one of the three general types of gum disease caused by inflammation of the gums (periodontitis).

<span class="mw-page-title-main">Gums</span> Soft tissue surrounding the roots of the teeth

The gums or gingiva consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

Dental plaque is a biofilm of microorganisms that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is often brown or pale yellow. It is commonly found between the teeth, on the front of teeth, behind teeth, on chewing surfaces, along the gumline (supragingival), or below the gumline cervical margins (subgingival). Dental plaque is also known as microbial plaque, oral biofilm, dental biofilm, dental plaque biofilm or bacterial plaque biofilm. Bacterial plaque is one of the major causes for dental decay and gum disease.

<span class="mw-page-title-main">Gingival sulcus</span> Space between tooth and gums

The gingival sulcus is an area of potential space between a tooth and the surrounding gingival tissue and is lined by sulcular epithelium. The depth of the sulcus is bounded by two entities: apically by the gingival fibers of the connective tissue attachment and coronally by the free gingival margin. A healthy sulcular depth is three millimeters or less, which is readily self-cleansable with a properly used toothbrush or the supplemental use of other oral hygiene aids.

<span class="mw-page-title-main">Gingival and periodontal pocket</span>

Gingival and periodontal pockets are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth.

Bleeding on probing (BoP) which is also known as bleeding gums or gingival bleeding is a term used by dentists and dental hygienists when referring to bleeding that is induced by gentle manipulation of the tissue at the depth of the gingival sulcus, or interface between the gingiva and a tooth. BoP is a sign of periodontal inflammation and indicates some sort of destruction and erosion to the lining of the sulcus or the ulceration of sulcular epithelium. The blood comes from lamina propria after the ulceration of the lining. BoP seems to be correlated with Periodontal Inflamed Surface Area (PISA).

<span class="mw-page-title-main">Scaling and root planing</span> Dental procedure

Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus and then smoothing, or planing, of the (exposed) surfaces of the roots, removing cementum or dentine that is impregnated with calculus, toxins, or microorganisms, the agents that cause inflammation. It is a part of non-surgical periodontal therapy. This helps to establish a periodontium that is in remission of periodontal disease. Periodontal scalers and periodontal curettes are some of the tools involved.

<span class="mw-page-title-main">Gingival enlargement</span> Human disease

Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medications. The treatment is based on the cause. A closely related term is epulis, denoting a localized tumor on the gingiva.

Gingivectomy is a dental procedure in which a dentist or oral surgeon cuts away part of the gums in the mouth.

<span class="mw-page-title-main">Oral hygiene</span> Cleaning the mouth by brushing the teeth and cleaning in between the teeth

Oral hygiene is the practice of keeping one's oral cavity clean and free of disease and other problems by regular brushing of the teeth and adopting good hygiene habits. It is important that oral hygiene be carried out on a regular basis to enable prevention of dental disease and bad breath. The most common types of dental disease are tooth decay and gum diseases, including gingivitis, and periodontitis.

Gingival disease is a term used to group the diseases that affect the gingiva(gums). The most common gingival disease is gingivitis, the earliest stage of gingival-related diseases. Gingival disease encompasses all the conditions that surround the gums, this includes plaque-induced gingivitis, non-dental biofilm plaque-induced gingivitis, and periodontal diseases.

<span class="mw-page-title-main">Plasma cell gingivitis</span> Medical condition

Plasma cell gingivitis is a rare condition, appearing as generalized erythema (redness) and edema (swelling) of the attached gingiva, occasionally accompanied by cheilitis or glossitis. It is called plasma cell gingivitis where the gingiva (gums) are involved, plasma cell cheilitis, where the lips are involved, and other terms such as plasma cell orifacial mucositis, or plasma cell gingivostomatitis where several sites in the mouth are involved. On the lips, the condition appears as sharply outlined, infiltrated, dark red plaque with a lacquer-like glazing of the surface of the involved oral area.

<span class="mw-page-title-main">Debridement (dental)</span> Removal of plaque and calculus from teeth

In dentistry, debridement refers to the removal by dental cleaning of accumulations of plaque and calculus (tartar) in order to maintain dental health. Debridement may be performed using ultrasonic instruments, which fracture the calculus, thereby facilitating its removal, as well as hand tools, including periodontal scaler and curettes, or through the use of chemicals such as hydrogen peroxide.

<span class="mw-page-title-main">Periodontal abscess</span> Medical condition

A periodontal abscess, is a localized collection of pus within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, and is different from the more common periapical abscess, which represents the spread of infection from a dead tooth. To reflect this, sometimes the term "lateral (periodontal) abscess" is used. In contrast to a periapical abscess, periodontal abscesses are usually associated with a vital (living) tooth. Abscesses of the periodontium are acute bacterial infections classified primarily by location.

Chronic periodontitis is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by the accumulation of profuse amounts of dental plaque. Periodontitis initially begins as gingivitis and can progress onto chronic and subsequent aggressive periodontitis according to the 1999 classification.

In dentistry, numerous types of classification schemes have been developed to describe the teeth and gum tissue in a way that categorizes various defects. All of these classification schemes combine to provide the periodontal diagnosis of the aforementioned tissues in their various states of health and disease.

References

  1. ↑ The American Academy of Periodontology. Proceedings of the World Workshop in Clinical Periodontics. Chicago:The American Academy of Periodontology; 1989:I/23-I/24.
  2. ↑ Ireland R (2010). "Ulitis". A Dictionary of Dentistry. Oxford / New York: Oxford University Press. p. 357. ISBN   978-0-19-953301-5.
  3. ↑ Darby ML, Walsh M. Dental Hygiene - E-Book: Theory and Practice. p. 318.
  4. ↑ Ammons WF, Schectman LR, Page RC (1972). "Host tissue response in chronic periodontal disease. 1. The normal periodontium and clinical manifestations of dental and periodontal disease in the marmoset". Journal of Periodontal Research. 7 (2): 131–143. doi:10.1111/j.1600-0765.1972.tb00638.x. PMID   4272039.
  5. ↑ Page RC, Schroeder HE (March 1976). "Pathogenesis of inflammatory periodontal disease. A summary of current work". Laboratory Investigation; A Journal of Technical Methods and Pathology. 34 (3): 235–249. PMID   765622.
  6. ↑ "Parameter on plaque-induced gingivitis. American Academy of Periodontology". Journal of Periodontology. 71 (5 Suppl): 851–852. May 2000. doi: 10.1902/jop.2000.71.5-S.851 . PMID   10875689.
  7. ↑ Saini R, Saini S, Saini SR (July 2010). "Periodontitis: A risk for delivery of premature labor and low-birth-weight infants". Journal of Natural Science, Biology, and Medicine. 1 (1): 40–42. doi: 10.4103/0976-9668.71672 . PMC   3217279 . PMID   22096335.
  8. ↑ Singhrao SK (January 30, 2019). "Alzheimer's is linked to gum disease – but bad oral health is not the only culprit". theconversation.com.
  9. ↑ Lee KH, Choi YY (October 2019). "Association between oral health and dementia in the elderly: a population-based study in Korea". Scientific Reports. 9 (1): 14407. Bibcode:2019NatSR...914407L. doi:10.1038/s41598-019-50863-0. PMC   6783535 . PMID   31594986.
  10. ↑ Research, Science and Therapy Committee of the American Academy of Periodontology (December 2001). "Treatment of plaque-induced gingivitis, chronic periodontitis, and other clinical conditions". Journal of Periodontology. 72 (12): 1790–1800. doi: 10.1902/jop.2001.72.12.1790 . PMID   11811516.
  11. ↑ Kistler JO, Booth V, Bradshaw DJ, Wade WG (14 August 2013). "Bacterial community development in experimental gingivitis". PLOS ONE. 8 (8): e71227. Bibcode:2013PLoSO...871227K. doi: 10.1371/journal.pone.0071227 . PMC   3743832 . PMID   23967169.
  12. ↑ "Gingivitis and braces". Orthodontics Australia. 2021-05-02. Retrieved 2021-05-19.
  13. ↑ Neff JA, Kelley ML, Walters ST, Cunningham TD, Paulson JF, Braitman AL, et al. (December 2015). "Effectiveness of a Screening and Brief Intervention protocol for heavy drinkers in dental practice: A cluster-randomized trial". Journal of Health Psychology. 20 (12): 1534–1548. doi:10.1177/1359105313516660. PMID   24423575. S2CID   206711510.
  14. ↑ Kim E (August 2014). 비만과 치주염 및 치아우식증과의 연관성 [Association between obesity, periodontitis and dental caries] (Ph.D. thesis) (in Korean). 서울대학교 대학원 (Seoul National University Graduate School).
  15. ↑ Armitage GC (December 1999). "Development of a classification system for periodontal diseases and conditions" (PDF). Annals of Periodontology. 4 (1): 1–6. doi:10.1902/annals.1999.4.1.1. PMID   10863370. Archived from the original (PDF) on 2010-06-12. Retrieved 2010-05-12.
  16. ↑ Caton JG, Armitage G, Berglundh T, Chapple IL, Jepsen S, Kornman KS, et al. (June 2018). "A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification". Journal of Clinical Periodontology. 45 Suppl 20 (S20): S1–S8. doi: 10.1111/jcpe.12935 . hdl: 2027.42/144587 . PMID   29926489.
  17. ↑ "How to Get Rid of Puffy Gums with Braces". Orthodontics Australia. 2021-05-02. Retrieved 2021-07-21.
  18. ↑ Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV (December 2011). Johnson TM (ed.). "Flossing for the management of periodontal diseases and dental caries in adults". The Cochrane Database of Systematic Reviews (12): CD008829. doi:10.1002/14651858.CD008829.pub2. PMID   22161438. S2CID   70702223.
  19. 1 2 Hasturk H, Nunn M, Warbington M, Van Dyke TE (January 2004). "Efficacy of a fluoridated hydrogen peroxide-based mouthrinse for the treatment of gingivitis: a randomized clinical trial". Journal of Periodontology. 75 (1): 57–65. doi:10.1902/jop.2004.75.1.57. PMID   15025217.
  20. ↑ Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, Shaw WC (December 2010). "Different powered toothbrushes for plaque control and gingival health". The Cochrane Database of Systematic Reviews. 2010 (12): CD004971. doi:10.1002/14651858.cd004971.pub2. PMC   8406707 . PMID   21154357.
  21. ↑ "American Dental Hygienists' Association Position Paper on the Oral Prophylaxis". Archived from the original on 2012-06-26. Approved by the ADHA Board of Trustees April 29, 1998
  22. ↑ "FDA Triclosan: What Consumers Should Know". U.S. Food and Drug Administration. Retrieved 2010-08-12.
  23. ↑ Kary T (15 January 2019). "FDA - 5 Things to Know About Triclosan". U.S. Food and Drug Administration. Retrieved 2021-04-08.
  24. ↑ "Colgate Total Toothpaste to Relaunch Without Controversial Chemical". Bloomberg. 15 January 2019. Retrieved 2021-04-08.
  25. ↑ Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, Glenny AM (June 2014). "Powered versus manual toothbrushing for oral health". The Cochrane Database of Systematic Reviews. 2014 (6): CD002281. doi:10.1002/14651858.CD002281.pub3. PMC   7133541 . PMID   24934383.
  26. ↑ Stoeken JE, Paraskevas S, van der Weijden GA (July 2007). "The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review". Journal of Periodontology. 78 (7): 1218–1228. doi:10.1902/jop.2007.060269. PMID   17608576.
  27. ↑ Brennan D, ed. (29 January 2023). "Treatments for Gum Disease". WebMD .
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