Published on March 8, 2014
Clinical features of gingivitis
Contents • • • • a. b. • a. b. c. d. e. Course and duration Description Clinical findings Gingival bleeding Local factors Systemic factors Changes in gingiva Colour Contour Consistency Position texture
• a. b. c. d. • In general, clinical features of gingivitis may be characterized by presence of any of the following clinical signs: Redness and sponginess of the gingival tissue Bleeding on provocation Changes in contour 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 group Generalized – 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 Mechanical trauma.. Eg: tooth brushing, food impaction Bleeding provoked … Histopathologically… 1) 2) dilated engorged capillaries Thinned out ulcerated gingiva
aftermath…? damaged vessels hemostasis Vessel walls contract Diminished Blood flow Platelet adhesion Clot contraction Edges 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 syndrome Bile 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 Chronic Gingivitis 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 exudates Epithelium- thinned, degenerated, edema, leukocyte invasion. C.T- inflamed, engorged Elongated retepeges Firm, leathery Fibrosis, epithelial proliferation with long standing chronic inflammation.
Acute forms of 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 edema Degeneration of nucleus and cytoplasma Rupture of vessel wall
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 Tooth Visible Apparent Hidden Actual
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 mild masticatory stresses e.g. tooth brushing. gingival recession
clinical significance. 1) 2) 3) 4) Caries Sensitivity ( erosion of the cementum) Hyperemia of pulp. Oral hygiene problems . (interproximal recession))
gingival contour. Stillman’s clefts. McCall’s festoons peculiar inflammatory changes…. generally found in gingival enlargements
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