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Gingivitis: An Overall View for Undergraduate

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 https://orcid.org/0000-0002-4928-6500

Gingivitis: An overall review

for undergraduates
Mohammed A. Alawadh.
General Dentist, Qassim University, Qassim, Saudi Arabia 24 Nov. 2018

KEYWORDS: Gingival diseases. Classi cation. Gingival hemorrhage. Gingivitis. Periodontitis. Diabetes
Mellitus. Hypersensitivity. Infections. Medications.

ABSTRACT INTRODUCTION
Gingivitis is a non-destructive disease that causes The gingiva is a part of the soft tissue lining of the
inflammation of the gingiva. mouth. It surrounds the teeth and provide a seal
around them. Unlike the soft tissue linings of the
The most common form of gingivitis, and the most lips and cheeks, most of the gingiva is tightly
common form of periodontal disease overall, is in bound to the underlying bone which helps resist
response to bacterial plaque that is attached to tooth the friction of food passing over them. Thus when
surfaces, termed plaque-induced gingivitis. healthy, it presents an effective barrier to the
barrage of periodontal insults to deeper tissue.
Gingivitis is reversible with good oral hygiene; Healthy gums are usually coral pink in light-
however, without treatment, gingivitis can progress to skinned people but may be naturally darker with
Periodontitis, in which the inflammation of the gums melanin pigmentation.
results in tissue destruction and bone resorption
around the teeth. Periodontitis can ultimately lead to The gingiva is divided anatomically into marginal,
tooth loss.(1) attached, and interdental areas.

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 Periodontal disease is a major public health exacerbate the in ammatory reaction to
problem, particularly in low-income settings like commensal bacteria (11). The two main features of
sub-Saharan Africa (2). Aside from irreversible periodontal disease are gingival in ammation
tooth loss, chronic periodontitis may also increase (gingivitis) and the formation of periodontal
the risk of adverse systemic conditions (3), such as pockets (periodontitis).
cardiovascular disease (4) and preterm birth;
however for preterm birth, different studies have
reported con icting results (5). While it is clear that gingivitis always precedes
periodontitis (12), gingivitis does not always
The association between periodontitis and progress to periodontitis (13), suggesting that these
systemic disease may be due to both increased conditions may not simply represent different
systemic in ammation and to translocation of stages of a continuous spectrum of disease. While
bacteria into the bloodstream (6). there is some evidence that a steady continuous
progression may be expected (14), most models
Despite its importance, the microbial ecology of involve acute bursts of exacerbation and longer
periodontal disease in different oral habitats periods of remission (15, 16).
remains incompletely understood. Studies of the
oral microbiome in periodontal disease typically CLINICAL FEATURES
Most cases of gingivitis occur from a lack of
proper oral hygiene, which leads to the
accumulation of dental plaque and calculus;
however, many other factors can affect the
gingiva’s susceptibility to the oral ora. The
frequency of gingivitis is high in all age groups,
but its true prevalence is dif cult to determine
because of the lack of a standardized method of
measurement. Clinically detectable in ammatory
changes of the gingiva begin in childhood and
increase with age. With similar amounts of dental
plaque, the severity of gingivitis is greater in
adults than in prepubertal children. Around the
time of puberty, there is a period of increased
Di erence between Periodontitis (Upper image) susceptibility to gingivitis (puberty gingivitis),
and Gingivitis (Lower image). with the peak prevalence of involvement occurring
between the ages of 9 and 14 years. Between the
focus on small populations in developed countries ages of 11 and 17 years, the frequency declines;
with advanced dental health care systems, which then a slow increase is seen until the prevalence
may not be representative of the natural history of approaches 100% in the sixth decade of life.
periodontal disease in the absence of treatment (7).
In most age groups, females demonstrate a lower
In periodontal disease, the immune system frequency of gingivitis than males (although
responds with in ammation to oral bio lms (8). females have periods of increased susceptibility).
After an initial focus on identifying particular This may be due more to better oral hygiene in
periodontal pathogens (9), it is now widely females than to a physiologic difference between
accepted that oral bacterial communities undergo a the sexes. In addition to the years of puberty (17).
shift or dysbiosis (10) and that the presence of
particular disease-associated species may
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 destruction of the periodontal attachment
FACTORS ASSOCIATED WITH apparatus (18).
GINGIVITIS The plaque accumulates in the small gaps between
teeth, in the gingival grooves and in areas known
1. Hormonal changes as plaque traps: locations that serve to accumulate
2. Stress and maintain plaque. Examples of plaque traps
3. Poor nutrition
include bulky and overhanging restorative
margins, claps of removable partial dentures and
4. Certain medications: calculus that forms on teeth.
● Phenytoin
Although these accumulations may be tiny, the
● Calcium channel blockers
bacteria in them produce chemicals, such as
● Cyclosporine
degradative enzymes, and toxins, such as
5. Diabetes mellitus lipopolysaccharide (LPS, otherwise known as
endotoxin) or lipoteichoic acid (LTA), that
6. Immune dysfunction promote an in ammatory response in the gum
7. Local trauma tissue.
8. Dental caries
This in ammation can cause an enlargement of the
9. Tooth crowding with overlapping gingiva and subsequent formation. Early plaque in
health consists of a relatively simple bacterial
community dominated by Gram-positive cocci and
rods.
TYPES OF GINGIVITIS As plaque matures and gingivitis develops, the
communities become increasingly complex with
• Plaque-induced gingivitis higher proportions of Gram-negative rods,
fusiforms, laments, spirilla and spirochetes. Later
• Necrotizing ulcerative gingivitis (NUG) experimental gingivitis studies, using culture,
provided more information regarding the speci c
• Medication-in uenced gingivitis bacterial species present in plaque.(19)

• Allergic gingivitis

• Speci c infection-related gingivitis

• Systemic diseases gingivitis

• Plaque-induced gingivitis
The cause of plaque-induced gingivitis is bacterial
plaque, which acts to initiate the body's host Plaque-induced gingivitis
response. This, in turn, can lead to destruction of
the gingival tissues, which may progress to

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• Necrotizing ulcerative gingivitis (NUG) • Medication-in uenced gingivitis
Has a distinctive pattern of gingival pathologic Refers to abnormal growth of the gingival tissues
changes that have been recognized for hundreds of secondary to the use of systemic medication. The
years. Until recently, the name of this process has term is a misnomer because neither the epithelium
been preceded by the term acute (i.e., ANUG); nor the cells within the connective tissue exhibit
however, several investigators have discontinued either hyperplasia or hypertrophy.
the use of this word because there is no chronic
form of the disease.
The increased gingival size is due to an increased
The infection frequently occurs in the presence of amount of extracellular matrix, predominantly
psychologic stress. decreased neutrophilic collagen. Therefore, several authors designate the
chemotaxis and phagocytic response seen in alteration as medication-associated gingival
patients with NUG. Stress-related epinephrine may enlargement.
result in localized ischemia, which pre- disposes
the gingiva to NUG. These designations are further supported by
In addition to stress, other factors have been investigators who have suggested the gingival
related to an increased frequency of NUG: changes arise from interference with normal
intracellular collagen degradation.
● Immunosuppression
● Smoking It is known that gingival collagen constantly
● Local trauma undergoes physiologic remodeling, and the process
must be tightly controlled to maintain a constant
● Poor nutritional status volume of the gingival tissues.
Although the association with bacteria is strong,
controversial research has suggested that viruses Investigators have suggested that cyclosporine,
such as cytomegalovirus, Epstein- Barr virus, and phenytoin, and nifedipine are all associated with
herpes simplex may contribute to the onset and calcium deregulation, which disrupts the normal
progression of the process (20, 21). collagen phagocytosis and remodeling process. If
this is true, then the increased collagen does not
occur from hyperplasia but from impaired collagen
degradation and remodeling. (22, 23, 24)

Necrotizing ulcerative gingivitis (NUG).

Gingiva is hemorrhagic with necrosis of the interdental
papillae.

Cyclosporine-related gingival hyperplasia.

Gingiva is brotic and erythematous.

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 • Speci c infection-related gingivitis • Allergic gingivitis
๏ Bacterial infections: A distinctive pattern of gingival in ammation,
Bacterial infections can affect patients with and plasma cell gingivitis, was brought to the attention
w i t h o u t i m m u n o d e c i e n c y. N e i s s e r i a of health care practitioners during the late 1960s
gonorrhoeae, Treponema pallidum, streptococci, and early 1970s. A rash of cases occurred during
Mycobacterium chelonae, are the most common that time, and most appear to have been related to
bacterial infections that give rise to gingival a hypersensitivity to a component of chewing gum.
lesions. Since that time, the number of cases has dwindled,
but similar gingival alterations are reported
They can manifest as ery red, edematous, and occasionally. (28)
painful ulcerations, asymptomatic chancres,
mucous patches or atypical non-ulcerated, highly
in amed gingiva.(25) Although the association with chewing gum has
decreased, allergy still is responsible for many
๏ Viral infections: reported cases. A brand of herbal toothpaste, a
The most common viral infections are herpes speci c type of mint candy, and peppers used for
simplex virus type1(HSV-1) and 2 (HSV-2) and cooking have all been implicated in more recent
varicella-zoster virus. reports.
HSV is the most common viral infection of the
oral/facial area. It has two subtypes: type 1, which
affects the oral cavity; and type 2, which affects The list of allergens appears to be variable, and a
the genitals. Primary herpetic gingivo-stomatitis is thorough evaluation often is required to rule out an
most commonly observed in children from 7 allergic cause. (29)
months to 4 years of age but can also be found in
adolescents or young adults. Children are often
infected with HSV by their own parents if these
have recurrent herpes lesions.

The primary infection may be asymptomatic but

can manifest as severe gingivostomatitis, in which
the gingiva are painful, in amed and ulcerated.
Fever and lymphadenopathy are classic features
and affected individuals experience dif culty in
chewing. (26)

๏ Fungal infections:
Gingival in ammation can also be caused by
fungal infections such as candidosis, linear
gingival erythema, and histoplasmosis. (27)

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 • Systemic diseases gingivitis
Other systemic diseases with gingival Diabetes mellitus
manifestations include gastrointestinal diseases Diabetes mellitus is characterized by disorders in
(e.g., Crohn´s disease), leukemia, and diabetes insulin production, the metabolism of
mellitus. carbohydrates, fats, and proteins and in the
functioning and structure of blood vessels.
Crohn´s disease
An in ammatory disease of the intestines that can Patients with type I diabetes are at greater risk of
involve any part of the gastrointestinal tract, developing gingivitis. Both children and adults
causing a wide variety of symptoms. It primarily with poor metabolic control show a greater
causes abdominal pain, diarrhea (which may be tendency towards more severe gingivitis.
bloody if the in ammation is severe), vomiting, or
weight loss.
The prevalence of gingivitis in children and
adolescents with diabetes is nearly twice that
The oral lesions in Crohn´s disease are similar to observed in children and adolescents without this
those of the gastrointestinal tract, including large disease. The association between diabetes and
ulcerations. The oral lesions are sometimes the gingivitis in children and adolescents is so widely
rst signs of the disease. Typical oral accepted that diabetes mellitus– associated
manifestations are folds in the labial or buccal gingivitis appears as a speci c entity in the most
sides of the sulcus.(30) recent classi cation of periodontal diseases. Adults
with type II diabetes may show higher rates of
Leukemia gingival in ammation versus adults without
diabetes.
A malignant hematological disorder characterized
by an abnormal increase in white blood cells.
Almost 64% of diabetics are estimated to have
Oral manifestations have been reported in patients gingival in ammation, in comparison to 50% of
with acute monocytic leukemia, chronic myeloid non-diabetics.(32)
leukemia, acute lymphocytic leukemia, and
chronic lymphocytic leukemia. Gingival
in ltration is the initial presenting complication in
5% of acute monocytic leukemia cases.(31)

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 decrease the dental plaque responsible for the
MANAGEMENT in ammatory alterations. Most self-administered
plaque control programs are ineffective unless
Gingivitis can be prevented through regular oral periodic professional reinforcement also is
hygiene that includes daily brushing and ossing. provided. (17)
(33) Hydrogen peroxide, saline, alcohol, or

chlorhexidine mouthwashes may also be The discussion of periodontitis presents a further

employed. In a 2004 clinical study, the bene cial discussion of dental plaque and its relationship to
effect of hydrogen peroxide on gingivitis has been gingival in ammation. Research has shown that
highlighted.(34) The use of oscillation-type brushes few individuals have the physical skills and
might reduce the risk of gingivitis compared to motivation necessary to obtain and maintain
manual brushing.(35) ultimate oral hygiene.
Rigorous plaque control programs along with
periodontal scaling and curettage also have proved Mechanical removal of dental plaque can be aided
to be helpful, although according to the American by the use of numerous chemical agents, such as
Dental Association, periodontal scaling and root mouth rinses with chlorhexidine or essential oils,
planing are considered as a treatment for or dentifrices containing triclosan with 2.0%
periodontal disease, not as a preventive treatment Gantrez copolymer. In this vein, studies have
for periodontal disease.(36) In a 1997 review of evaluated the addition of these chemo-preventative
effectiveness data, the U.S. Food and Drug agents to typical oral hygiene efforts and shown a
Administration (FDA) found clear evidence statistically signi cant positive response to these
showing that toothpaste containing triclosan was products in controlling plaque and gingivitis.
effective in preventing gingivitis.(37)
On occasion, hyperplastic and brotic gingiva may
have to be re-contoured surgically to allow total
TREATMENT AND PROGNOSIS resolution of the pathosis after improved hygiene.
If the gingivitis does not resolve after improved
plaque control and elimination of obvious
Although periodontitis always is preceded by contributing factors, then the patient should be
gingivitis, most areas of gingivitis remain stable evaluated for underlying systemic disorders that
for years, and the number of affected sites that could be contributing to the process. (38)
convert to periodontitis is small. In spite of this,
optimal gingival health should be the goal of all
clinicians and their patients. In a 26-year study of a
cohort receiving state-of-the-art dental care, the
prevalence of localized tooth loss increased 46
CONCLUSION
times in areas associated with gingiva that
consistently bled on probing during routine Gingivitis can have multiple origins and can be the
examinations. Even when attachment loss is not manifestation of a wide range of systemic diseases.
evident and the alterations appear restricted to the Gingival tissue in ammation is one of the most
gingival soft tissues, proactive interventions are common lesions encountered in the clinical setting
recommended to eliminate these areas of persistent and may be the rst symptom in many types of
pathosis during the early stages of disease. disease. Gingivitis may therefore have important
diagnostic relevance, and it is vital for clinicians to
be aware of its different possible causes to ensure a
Treatment of gingivitis consists of elimination (if
correct diagnosis and treatment.
possible) of any known cause of increased
susceptibility and improvement in oral hygiene to

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