basic features of gingivitis which can be correlated to underlying tissues

1. Clinical features of gingivitis

2. Contents
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Course and duration
Description
Clinical findings
Gingival bleeding
Local factors
Systemic factors
Changes in gingiva
Colour
Contour
Consistency
Position
texture

3. Gingivitis

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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.

5. 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.

6. chronic marginal gingivitis

8.  Gingival diseases in individual cases can be described using the
following terms.
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Localised marginal gingivitis
Localised diffuse gingivitis
Localised papillary gingivitis
Generalised marginal gingivitis
Generalized diffuse gingivitis.

9. 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 )

10. • 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.

11. 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.

12. 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

13. aftermath…?
damaged vessels
hemostasis
Vessel walls contract
Diminished
Blood flow
Platelet adhesion
Clot contraction
Edges approximate.
But…
bleeding recurs…
with the slightest stimuli..

14. 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.

15. 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

16. 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 )

17. metallic piGmentation
Heavy metals absorbed systemically…
occupational
therapeutic
household
…discolor the gingiva.
bismuth
lead
Hg
Ag

18. 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…

19. Treatment…?
simply TREAT the Inflammation…
CoLor Changes – systemiC faCtors
- Non specific
- Further diagnostic efforts
- Referral to specialist
Endogenous pigmentations
MELANIN
BILIRUBIN
IRON

20. 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

21. exogenous
• Tobacco --- hyperkeratosis, increase in melanin pigmentation
• Metal dust… coal.
• Coloring agents. In foods , lozenges
•
Amalgam implantation – localised bluish black areas

22. 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

23. 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.

24. 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

25. 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…)

26. 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.

27. 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.

28. Recession
Tooth
Visible
Apparent
Hidden
Actual

29. recession refers to position of the gingiva
- NOT the condition of the gingiva.
May be
- localised.
- generalised

30. 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.

31. 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

32. 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

33. clinical significance.
1)
2)
3)
4)
Caries
Sensitivity ( erosion of the cementum)
Hyperemia of pulp.
Oral hygiene problems .
(interproximal recession))

34. gingival contour.
Stillman’s clefts.
McCall’s festoons
peculiar inflammatory changes….
generally found in gingival enlargements