Gingivitis

Gingivitis
Classification and external resources
File:Gingivitis before and after.jpg Severe gingivitis before (top) and after (bottom) a thorough mechanical debridement of the teeth and adjacent gum tissues. (N.B. The apparent change in tooth color is due entirely to metamerism; its effect on the color of the gums must therefore be taken into consideration.)
ICD-10	K05.0-K05.1
ICD-9	523.0-523.1
DiseasesDB	34517
MedlinePlus	001056
MeSH	D005891

Gingivitis ("inflammation of the gum tissue") is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms (also called plaque) adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease. In the absence of treatment, gingivitis may progress to periodontitis, which is a destructive form of periodontal disease.

While in some sites or individuals, gingivitis never progresses to periodontitis, data indicates that gingivitis always precedes periodontitis.

Definition

In health, the gum and bone tissues that surround teeth are attached to the root surface by connective tissue fibers called the gingival fibers. This functional unit, called the periodontium, is made up of four types of tissue:

1. cementum, which exists on the tooth root surface
2. alveolar bone, which surrounds and supports the teeth in the jaw
3. gingiva, or gum tissue, which is made up of epithelium and a lamina propria of connective tissue
4. periodontal ligament fibers, which run from the alveolar bone and insert into the cementum

In addition to the periodontal fibers that attach the tooth to the surrounding bone, there are also two types of connection between the tooth and the surrounding gum tissue. There is the more apical gingival fiber attachment and the more coronal junctional epithelium attachment. Together, these two are referred to as the gingival attachment apparatus and, in health, they keep the gingival tissue snug around the necks of the teeth.

In gingivitis, an inflammatory process in the gum tissue may cause a transient loss of this gingival attachment apparatus that is completely reversible if the inflammatory process is reversed. Gingivitis is therefor termed non-destructive periodontal disease because it does not entail loss of periodontal ligament fibers or alveolar bone. Once the inflammatory process initiates loss of periodontal fibers and/or bone, the gingivitis is deemed to have progressed to periodontitis.

Classification

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

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

Signs and symptoms

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

• Swollen gums
• Bright red or purple gums
• Gums that are tender or painful to the touch.

Additionally, the stippling that normally exists on 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.

Cause

Because plaque-induced gingivitis is by far the most common form of gingival diseases, the following sections will deal primarily with this condition.

The etiology, or 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. 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, claps 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 degrative 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 pseudopocket formation.

Diagnosis

It is recommended that a dental hygienist or dentist be seen after the signs of gingivitis appear. 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.

Hypervitaminosis A, otherwise known as excess Vitamin A in the diet, has also been linked to gingivitis in cats and dogs. Whether this is applicable to humans remains unclear.

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.

Prevention

File:Chlorhexidine mouthrinse.png

OTC anti-gingivitis mouthwash containing chlorhexidine from Mexico.

Gingivitis can be prevented through regular oral hygiene that includes daily brushing and flossing. Mouthwash or Hydrogen Peroxide can be helpful, usually using peroxide or saline solutions (water and salt), alcohol or chlorhexidine. 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 to periodontal disease, not as a preventive treatment for periodontal disease. In a 1997 review of effectiveness data the FDA found clear evidence which showed that toothpaste containing triclosan was effective in preventing gingivitis.

In many countries, such as the United States, mouthwashes containing chlorhexidine are available only by prescription.

Researchers analyzed government data on calcium consumption and periodontal disease indicators in nearly 13,000 U.S. adults. They found that men and women who had calcium intakes of fewer than 500 milligrams, or about half the recommended dietary allowance, were almost twice as likely to have gum disease, as measured by the loss of attachment of the gums from the teeth. The association was particularly evident for people in their 20s and 30s.

Research says the connection between calcium and gum disease is likely due to calcium’s role in building density in the alveolar bone that supports the teeth.

Preventing gum disease may also benefit a healthy heart. According to physicians with The Institute for Good Medicine at the Pennsylvania Medical Society, good oral health can reduce risk of cardiac events. Poor oral health can lead to infections that can travel within the bloodstream.

Treatment

The focus of treatment for gingivitis is removal of the etiologic (causative) agent, 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.

• Metronidazole
• Antiseptic Mouthwash
• Floss
• Hydrogen Peroxide Rinse
• Gum Surgery
• Cleaning
• Curettage
• ProxaBrush

Complications

• Tooth loss
• Recurrence of gingivitis
• Periodontitis
• Infection or abscess of the gingiva or the jaw bones
• Trench mouth (bacterial infection and ulceration of the gums)

See also

• Periodontist
• Periodontitis

External links

• Good Oral Health Can Help Your Heart, The Institute for Good Medicine at the Pennsylvania Medical Society
• Gingivitis - Medline plus

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