This document discusses clinical features of gingivitis and chronic periodontitis. It describes the signs and symptoms of gingivitis such as color changes, consistency changes, and bleeding. It also discusses the progression of inflammation from the gingiva to the supporting periodontal tissues. Finally, it outlines the characteristics, disease distribution, risk factors, and prevalence of chronic periodontitis.

1. Prof Dr.Eman Abd - Elsattar Tella
Faculty of Dentistry, Umm Al
Qurra University,Makka.

2. I. Clinical Features of Gingivitis
II. Extension of inflammation from
the gingiva in the supporting
periodontal tissue.
III. Chronic periodontitis

3. Clinical Features of
Gingivitis

4. COURSE AND DURATION
Acute gingivitis is of sudden onset and short duration
and can be painful.
Recurrent gingivitis reappears after having been
eliminated by treatment.
Chronic gingivitis is slow in onset and of ', long
duration, and is painless
Chronic gingivitis is a fluctuating disease in which
inflammation persists or resolves.

5. DISTRIBUTION
• Localized gingivitis is confined to the gingiva of a
sin-gle tooth or group of teeth while generalized
gingivitis involves the entire mouth.
• Marginal gingivitis involves the gingival margin and
may include a portion of the contiguous attached
gingiva.
• Papillary gingivitis involves the interdental papillae
and often extends into the adjacent portion of the
gingival margin.
• Diffuse gingivitis affects the gingival margin, the
attached gingiva, and the interdental papille.

6. DISTRIBUTION
• Localized marginal gingivitis is confined to one or
more areas of the marginal gingiva.
• Localized diffuse gingivitis extends from the margin to
the mucobuccal fold but is limited in area.
• Localized papillary gingivitis is confined to one or
more interdental spaces in a limited area
• Generalized marginal gingivitis involves the gingi-val
margins in relation to all the teeth.
• Generalized diffuse gingivitis involves the entire
gingiva. The alveolar mucosa and attached gingiva are
affected.

7. DISTRIBUTION
• Localized gingivitis is confined to the gingiva of a
single tooth or group of teeth while generalized
gingivitis involves the entire mouth.

8. DISTRIBUTION
• Marginal gingivitis involves the gingival margin and
may include a portion of the contiguous attached
gingiva.
• Papillary gingivitis involves the interdental papillae
and often extends into the adjacent portion of the
gingival margin.

9. DISTRIBUTION
• Diffuse gingivitis affects the gingival margin, the
attached gingiva, and the interdental papille.

10. Healthy gingiva Mild gingivitis
Pale pink & stippled. Narrow Localized mild erythema & slight
distinguishable free gingival edema. Some stippling is lost.
margin. No bleeding on probing Minimal bleeding after probing.

11. Moderate gingivitis Severe gingivitis
Fiery redness, edematous &
Obvious erythema & edema. hyperplastic swelling, complete
No stippling, bleeding on absence of stippling, bleeding on
probing probing & spontaneous
hemorrhage.

12. Mild gingivitis in anterior area:
Mild erythema in maxilla. Slight
edematous swelling & erythema.
In mandible, slight edematous
swelling & erythema.
Papilla Bleeding Index: Grade 1
&2
Stained plaque: Small plaque
accumulations arounds the necks
of the teeth & in interdental areas.

13. Gingival Bleeding on Probing
• The two earliest symptoms of gingival inflammation
preceding established gingivitis are:
1. increased gingival crevicular fluid production rate and
2. bleeding from the gingival sulcus on gentle probing
• shown that bleeding on probing appears earlier
than a change in color or other visual signs of
inflammation.

14. Moderate gingivitis in
anterior teeth :Erythema
& enlargement of gingiva
pronounced in mand than
in maxilla.
Papilla Bleeding Index :
grade 3 & 4
Stained plaque : Moderate plaque
accumulation in maxilla. Heavier plaque in mandible.
Radiographically, no destruction of interdental bony septa.

15. Gingival Bleeding Caused by Local Factors
• Chronic and Recurrent Bleeding
• The most common cause of abnormal gingival
bleeding on probing is chronic inflammation. The
bleeding is chronic or recurrent and is provoked by
mechanical trauma (e.g., from toothbrushing,
toothpicks, or food impaction) or by biting into solid
foods such as apples.
• In cases of moderate or advanced periodontitis, the
presence of bleeding on probing is considered a sign of
active tissue destruction.

16. Acute bleeding.
• Acute episodes of gingival bleeding are caused by
injury or occur spontaneously in acute gingival
disease.
• Spontaneous bleeding or bleeding on slight
provocation can occur in acute necrotizing ulcerative
gingivitis. In this condition, engorged blood vessels in
the inflamed connective tissue arc exposed by
ulceration of the necrotic surface epithelium.

17. Gingival bleeding Associated with
Systemic Changes
• In some systemic disorders, gingival hem-orrhage
occurs spontaneously or after irritation and is excessive
and difficult to control.
• A hemostatic mechanism failure and result in
abnormal bleeding (vitamin C deficiency or allergy
such as Schonlein-Hchoch purpura), platelet disorders
(thrombocytopcnic purpura), hypopro-thrombincmia
(vitamin K deficiency), other coagulation defects
(hemophilia, leukemia, Christmas disease)

18. Color Changes in the Gingiva
Color Changes in Chronic Gingivitis.
• The normal gingival color is "coral pink" .
• Thus chronic inflammation intensifies the red or
bluish red color, because of vascular proliferation and
reduction of keratinization.
Color Changes in Acute Gingivitis.
• The color changes may be marginal, diffuse, or
patchlike, depending on the underlying acute
condition.
• In acute necrotizing ulcerative gingivitis the
involvement is marginal; in herpetic gingivostomatitis,
it is diffuse.
• Color changes vary with the intensity of the
inflammation. Initially, there is an increasingly red
erythema.

19. Metallic Pigmentation
• Heavy metals (bismuth, arsenic, mercury, lead, silver)
absorbed systemically from therapeutic use or
occupational or household environments may discolor
the gingiva and other areas of the oral mucosa.

20. Color Changes Associated with Systemic
Factors
Addison's disease
• caused by adrenal dysfunction and pro-duces isolated
patches of discoloration varying from bluish black to
brown

21. Changes in the Consistency of the Gingiva
• Both chronic and acute inflammation produce changes
in the normal firm, resilient consistency of the gingiva.
• As noted in the preceding discussion, in chronic
gingivitis, both destructive (edematous) and reparative
(fibrotic) changes coexist and the consistency of the
gingiva is determined.
Changes in the Surface Texture of the
Cingiva
• Loss of surface stippling is tin early sign of gingivitis. In
chronic inflammation the surface is either smooth and
shiny or firm and nodular, depending on whether the
dominant changes are exudative or fibrotic.

23. Changes in the Position of the Gingiva
• Actual and Apparent Positions of the Gingiva.
Recession is exposure of the root surface by an apical
shift in the position of the gingiva.
• The actual position is the level of the epithelial
attachment on the tooth, whereas the apparent
position.
• The severity of recession is determined by the actual
position of the gingiva, not its apparent position.

25. Changes in Gingival Contour
• Changes in gingival contour are for the most part
associated with gingival enlargement

26. II- Extension of
inflammation from the
gingiva in the supporting
periodontal tissue

27. Histologically
• Interproximally, inflammation spreads to the loose
connective tissue around the blood vessels, through the
fibers, and then into the bone through vessel channels
that perforate the crest of the interdental septum at the
center of the crest toward the side of the crest or at the
angle of the septum and it may enter the bone through
more than one channel.
• Less frequently, the inflammation spreads from the
gingiva directly into the periodontal ligament and
from there into the interdental septum.
• Facially and lingually, inflammation from the gingiva
spreads along the outer periosteal surface of the bone
and penetrates into the marrow spaces through vessel
channels in the outer cortex.

29. III- Chronic
periodontitis

30. • Chronic periodontitis is most frequently observed in
adults, it i an occur in children and adolescents in
response to chronic plaque and calculus accumulation.
• Chronic periodontitis has recently been defined as "an
infectious disease resulting in inflammation within the
supposing tissues of the teeth, progressive attachment
loss and bone loss.
• Microbial plaque formation, periodontal
inflammation, and loss of attachment and alveolar
bone.

31. CLINICAL FEATURES
General Characteristics
• Characteristic clinical findings in patients with chroni
periodontitis include supragingival and subgingiva
plaque accumulation that is frequently associated with
calculus formation, gingival inflammation, pocket
formation, loss of periodontal attachment and loss of
alveolar bone.
• The gingiva ordinarily is slightly to moderately
swollen and exhibits alterations in color ranging from
pale red to magenta.

32. General Characteristics
• Loss of gingival stip pling and changes in the surface
topography may in elude blunted or rolled gingival
margins and flattened of cratcred papillae.
• Gingival bleeding, either spontaneous or in response
to probing, is frequent and inflammation-related
exudates of cervicular fluid and suppuration from the
pocket also may be found.
• Pocket depths are variable, and both horizontal and
vertical bone loss can be found. Tooth mobility often
appears in advanced cases when bone loss has been
considerable.

33. General Characteristics
• Chronic periodontitis can be clinically diagnosed by
the detection of chronic inflammatory changes in the
marginal gingiva, presence of periodontal pockets, and
loss of clinical attachment.
• It is diagnosed radiographically by evidence of bone
loss.

34. Chronic
Periodontitis
General Clinical
Features: (cont.’)
• Periodontal
pocket formation
with variable
depth.
• Bleeding upon
probing (BOP)

38. Disease Distribution
• Chronic periodontitis is considered a site-specific
disease.
Localized periodontitis :
• Periodontitis is considered localized when <30% of the
sites assessed in the mouth demonstrate attachment
loss and bone loss.
Generalized periodontitis :
• Periodontitis is considered generalized when >30% of
the sites assessed In the mouth demonstrate
attachment loss and bone loss.

39. Disease Severity
Slight (mild) Periodontitis :
• Periodontal destruction is generally considered slight
when no more than 1 to 2 mm of clinical attachment
loss has occurred.
Moderate Periodontitis :
• Periodontal destruction is generally considered
moderate when 3 to 4 mm of clinical attachment loss
has occurred.
Severe Periodontitis :
• Periodontal destruction is considered severe when 5
mm or more of clinical attachment loss has occurred.

40. Symptoms
• Because chronic periodontitis is usually painless,
patients may be less likely to seek treatment and accept
treatment recommendations.
• Occasionally, pain may be present in the absence of
caries due to exposed roots that an sensitive to heat,
cold, or both.
• The presence of areas of food impaction may add to the
patient's discomfort.

41. Disease Progression
• The rate of disease progression is usually slow but may be
modified by systemic and/or environmental and behavioral
factors.
• Onset of chronic periodontitis can occur at any time, and the
first signs may be detected during adolescence in the
presence of chronic plaque and calculus accumulation.
• Chronic periodontitis does not progress at an equal rate in
all affected sites throughout the mouth. Some involved
areas may remain static for long periods of time/ whereas
others may progress more rapidly.
• More rapidly progressive lesions occur most frequently in
interproximal areas and are usually associated with areas of
greater plaque accumulation and inaccessibility to plaque
control measures

42. Prevalence
• Chronic periodontitis increases in prevalence and
severity with age, generally affecting both sexes
equally.

43. RISK FACTORS FOR DISEASE
Prior History of Periodontitis
Local Factors
• Claque accumulation on tooth and gingival surfaces at
the dentogingival junction is considered the primary
initiating agent in the etiology of chronic periodontitis.
• Attachment and bone loss are associated with an
increase i n the proportion of gram-negative organisms
in the sub-gingival plaque biofilm.
• Bacteroides gingivals, Bacteroids forsythus and
Teponema denticola.

44. • These microorganims and their virulence factors.
• But these bacteria may impart a local effect on
the cells of the inflammatory response and the
cells and tissues of the host, resulting in a local,
site-specific disease process.
• Calculus is considered the most important plaque
retentive factor, because of its ability to retain
and harbor plaque bacteria on its rough surface

45. • Other factors
• Overhanging margins of
restorations.
• carious legions.
• Furcations.
• crowded and malaligned teeth.
• root grooves and concavities

46. Systemic Factors
• The rate of periodontal destruction may be
significantly increased. Diabetes is a systemic
condition that can increase the severity and extent if
periodontal disease in an affected patient.

47. Environmental and Behavioral
Factors
• Smoking has been shown to increase the severity and
extent of periodontal disease.
• When combined with plaque-induced chronic
periodontitis, an increased in the rate of periodontal
destruction.
• Emotional stress.
• Suggests that emotional stress also may influence the
extent and severity of chronic periodontitis.

48. Genetic Factors
• Periodontal destruction is frequently seen among
family members and across different generations
within a family, suggesting the possibility of a genetic
basis to the susceptibility to periodontal disease.
• Recurrent studies have demonstrated a familial
aggregation of localized and generalized aggressive
periodonlitis.