Chronic Gingivitis

Gingivitis is an inflammatory condition of the gingival tissue most commonly caused by

bacterial infection. Unlike periodontitis, there is no attachment loss and therefore no
migration of the junctional epithelium. The condition is restricted to the soft-tissue area of the
gingival epithelium and connective tissue. Among all the periodontal diseases, gingivitis is
considered to be the most common. There are various forms of gingivitis based on clinical
appearance, duration of infection, severity, and etiology. However, the chronic form of
gingivitis that is caused by plaque is considered to be the most frequent variant. Gingivitis
seldom generates spontaneous bleeding and is commonly painless, therefore many patients do
not recognize the disease and fail to seek attention. (Rathee & Jain, 2023)

https://www.ncbi.nlm.nih.gov/books/NBK557422/

Plaque-induced gingival disease is the result of an interaction between the microorganisms

found in the dental plaque biofilm and the tissues and inflammatory cells of the host. The
plaque-host interaction can be altered by the effects of local factors, systemic factors,
medications and malnutrition, all of which can influence the severity and duration of
response.

- Carranzas clinical periodontology 11th ed chapter 4 page 34

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Etiology

Gingivitis is caused by the microbial plaque deposits located in or close to the gingival sulcus.
The microorganisms more strongly associated with the etiology of gingivitis include species
of gram positive microorganisms: Streptococcus, Actinomyces and peptostreptococcus
micros. Also gram negative microorganisms such as Fusobacterium, Treponema, Prevotella
intermedia, Capnocytophaga and V.parvula. There may be other local or systemic etiologic
factors that intensify plaque deposition or the vulnerability of the tissue to the microbial
attack.

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Some local factors can contribute to the formation of plaque, such as crowding of teeth due to
which plaque removal becomes difficult. As misaligned teeth often require orthodontic
correction, cleaning difficulty increases accumulating more plaque. Furthermore, a dental
prosthesis that does not have an adequate fit or is not properly finished can also act as a nidus
for plaque accumulation.
- https://www.ncbi.nlm.nih.gov/books/NBK557422/

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Histopathology
Histopathology of chronic gingivitis associated with dental plaque reveals characteristic
changes in the gingival tissues that help identify and understand the inflammatory response
caused by the presence of dental plaque.

1. Epithelial Changes:
- Thickening of the oral epithelium (the outermost layer of the gingival tissue) is
often observed. This is known as acanthosis.

2. Inflammatory Infiltrate:
- Chronic inflammatory infiltrate consisting primarily of lymphocytes and
plasma cells is a hallmark of chronic gingivitis. This infiltrate is typically
found in the lamina propria, the connective tissue layer beneath the epithelium.

3. Capillary Proliferation:
- Increased vascularity and capillary proliferation (angiogenesis) are commonly
seen as a response to the inflammation. These blood vessels supply nutrients
and oxygen to the inflamed tissues.

4. Fibrosis:
- Chronic inflammation can lead to the deposition of collagen fibers in the
gingival connective tissue, resulting in fibrosis. This fibrotic tissue can
contribute to gingival tissue changes and may lead to gingival recession in
severe cases.

5. Plasma Cells:
- Plasma cells are immune cells that produce antibodies. They are often
prominent in the inflammatory infiltrate and can be a characteristic feature of
chronic gingivitis.

6. Neutrophils:
- While neutrophils are more common in acute gingivitis, they can still be
present in chronic gingivitis, especially during periods of exacerbation.

7. Elongated Rete Pegs:

- As part of the tissue response to chronic inflammation, rete pegs may
become elongated, extending deeper into the connective tissue.

8. Ulceration (in severe cases)

- In severe chronic gingivitis or if there is associated trauma, ulceration or
breakdown of the epithelial surface may occur.

- Chapter 8 page 81

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Chronic gingivitis
We have different stages.
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 Super healthy “pristine gingiva” which histologically has little or no inflammatory
infiltrate
 Initial lesion of gingivitis is within 24 hours of plaque accumulation – vasodilation of
various arterioles, capillaries and venules in the dentogingival plexus, and an increase
in GCF. Few lymphocytes and macrophages appear. Clinically gingiva looks healthy
 Early lesion develops approx. 1 week after plaque accumulation. Increase in
lymphocytes and neutrophils and very few plasma cells. Early loss of gingival collages
is seen in the infiltrated area. Rete peg proliferation occurs to try and maintain the
epithelial barrier function. Vessels remain dilated  contributing to the redness seen
 Established lesion, the neutrophils predominate, increased migration. Plasma cells
form 10-30% of the infiltrate. Loss of gingival collagen continues laterally and
apically, allowing more space for the infiltrating cells in inflammatory infiltrate. Rete
pegs extend further into CT. Junctional epithelium is no longer attached closely to the
tooth and has transformed into a pocket epithelium, this allows the subgingival plaque
to extend more apically. Clinical features are seen like redness, swelling and bleeding.
This stage may remain stable or may become active and progress to advanced lesion
which is classified as periodontitis.

- Semester 5 periodontology lecture slides “etiology and pathogenesis of periodontal

pathologies” Dr. Zane Laurina

- Chapter 7 page 74-75

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Patients complaints

The most common complaint is bleeding gums. The patient usually notices this when
toothbrushing or flossing. Also swelling, redness, tenderness and a shiny surface is noticed.

Classification

Gingival index – GI

Its based on the combination of visual assessment and mechanical stimulation of the marginal
periodontal tissues by probing gently along the soft tissue wall of the gingival pocket.
Technically, to stimulate the gingival tissues the probe engages approximately 1 to 2 mm of
the gingival margin with the probe at a 45-degree angle with moderate axial pressure. GI
scores are assigned on a 4-point scale:
0 = absence of inflammation;
1 = mild inflammation – slight change in color and little change in texture;
2 = moderate inflammation – moderate glazing, redness, edema and hypertrophy; bleeding on
pressure;
3 = severe inflammation – marked redness and hypertrophy, ulceration with tendency to
spontaneous bleeding.

- https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.17-0576

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Diagnostics

The teeth and gums are examined in detail for evidence of the early stages of tooth decay and
plaque. The dentist checks the shape and color of gingival tissue on the buccal side and
lingual side of each tooth. Swollen, painful, red or peeling gums and the presence of any
ulcers or abscesses is noted, as is the amount of plaque and tartar present. The dentist will also
check how sensitive the teeth are, whether there is any teeth movement and whether the teeth
are correctly aligned. Tooth mobility is a strong indicator that bone loss has occurred.

A detailed account of the patient’s medical history is taken to check for any past or present
gum disease or underlying conditions that could contribute to the development of
periodontitis. The dentist also asks about oral hygiene routines, any medications the patient is
taking, dietary habits and lifestyle habits such as drinking and smoking.

One of the complications of gingivitis is trench mouth, which describes the formation of
infective ulcers on the gums. A swab may be used to take a sample of discharge from the
ulcers, which can then be examined under a microscope to identify the causal bacteria. An
appropriate antibiotic can then be selected for treating the condition.

- https://www.news-medical.net/health/Gingivitis-Diagnosis.aspx

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Prognosis

Untreated chronic gingivitis will progress into periodontitis and eventually results in tooth
loss. After an initial cleaning and scaling in its early stages, gingivitis usually is reversible
with good dental hygiene. Gingivitis generally responds well to appropriate treatment.

- https://emedicine.medscape.com/article/763801-overview

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Treatment:

To treat gingivitis, people must maintain good oral hygiene. There are several techniques that
can be used to deep clean the teeth and these include scaling, where tartar is removed from
below and above the gum line; root planing, which smoothes any rough areas and removes
infected parts of the tooth and laser treatment, which is a less painful way of removing tartar
than root planing or scaling.

Several medications are also available to help treat the condition including time-release
antiseptic chips which are inserted into gum pockets after root planing; antibiotic
microspheres, which are inserted after either scaling or root planing and oral antibiotics,
which are used to treat persistent inflammation. An antibiotic mouthwash that contains
chlorhexidine can also be used to clear the mouth of infection.
Severe gum disease may require surgery. Flap surgery may be performed, where the gums are
folded back so that plaque can be removed. The gums are then fixed back in place snugly
around the tooth.

- https://www.news-medical.net/health/Gingivitis-Diagnosis.aspx

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Next visit:

Check if the inflammation is still there, the dentist will help the patient with an effective at-
home program to improve oral hygiene. Also schedule of regular professional checkups and
cleaning.

Gingival hyperplasia

Gingival hyperplasia is an overgrowth of gum tissue around the teeth. There are a number of
causes for this condition, but it’s often a symptom of poor oral hygiene or a side effect of
using certain medications.

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Etiology and histopathology:

Chronic inflammatory gingival enlargements show the exudative and proliferative features of
chronic inflammation. Lesions that are clinically deep red or bluish red are soft and friable
with a smooth, shiny surface, they bleed easily. They also have a preponderance of
inflammatory cells and fluid, with vascular engorgement, new capillary formation, and
associated degenerative changes. Lesions that are relatively firm, resilient and pink have a
greater fibrotic component with an abundance of fibroblasts and collagen fibers.

The histological appearance is characterized by proliferation of the gingival epithelium, CT,

and fibroblasts. Ulceration of the sulcular epithelium, changes in blood vessels withing
gingival tissue, including dilation and increase in vascularity. Elongated rete pegs and
presence of nodules of hyperplastic areas.

Book ch 9 sid 85

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Causes:
Chronic inflammatory changes are common in cases of gingival overgrowth. This may be a
result of prolonged exposure to dental plaque or localised trauma.
Clinical examination frequently reveals poor oral hygiene. This may be secondary to tooth
displacement, anatomical anomalies or dental work including prostheses, poorly contoured
restorations and orthodontic appliances, which favour the accumulation and retention of
plaque.

Poor dental hygiene resulting in bacterial plaque, gingivitis and periodontitis, also smoking,
mouth breathing and overcrowded teeth are contributing factors.

Gingival overgrowth is often caused by inflammation. It can also be drug-induced, as a side

effect of prescribed medications. Common medications that can cause this overgrowth
include:

 calcium channel blockers, or drugs used to treat high blood pressure and other heart-
related conditions

This condition often resolves once a person stops taking the prescribed medication.

Systemic causes:

- HIV
- Diabetes
- Chrohn´s disease

- https://dermnetnz.org/topics/gingival-enlargement

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Complaints:

 tender gums
 inflammation
 pain
 bad breath
 Plaque buildup on teeth

Diagnostic

1. Clinical examination: the dentist will conduct a visual and tactile examination of the
gums. They will look for signs of gingival hyperplasia, including excessive gum
tissue, changes in color or texture and the presence of any nodules of growth.
2. Medical and dental history: to identify the underlying factors or conditions that may
contribute to gingival hyperplasia. This includes asking about medications your
taking, hormonal changes, systemic diseases and oral hygiene practices.
3. Measurement of gingival dimensions: dentist will use periodontal probe to measure
the dimensions of gingival tissue, including its thickness and extent of overgrowth.
Helps determine the severity of hyperplasia.
 4. Radiographic imaging: in some cases, dental x-rays may be taken to assess the
underlying bone structure and rule out other dental or periodontal conditions that
could contribute to gingival overgrowth.
5. Biopsy (in needed): in situations where diagnosis is uncertain or if there are
suspicious lesions of nodules, a biopsy can be recommended. A small sample of
gingival tissue is then removed and sent to laboratory.

Prognosis:

1. Early intervention: the prognosis is often better when its diagnosed and treated in
early stages.
2. Underlying cause: the prognosis can be influenced by the underlying cause of the
hyperplasia.
3. Treatment approach: the choice of treatment and its success can impact the
prognosis.
4. Patient compliance: patient compliance with recommended treatments and ongoing
oral hygiene practices is crucial for a favorable prognosis.
5. Recurrence: in some cases, gingival hyperplasia may recur even after successful
treatment.
6. Complications: severe cases of gingival hyperplasia can lead to functional and
aesthetic issues, including difficulty in chewing, speaking and maintaining proper oral
hygiene.

No mortality is associated with gingival enlargement. Morbidity can be severe in some cases
because of gross overgrowth of gingival tissue, which can lead to gingival bleeding, pain,
teeth displacement, and periodontal disease. The prognosis is better if patients maintain
regular oral hygiene and plaque control. If you floss correctly and practice proper oral
hygiene, the condition usually goes away.

- https://www.nature.com/articles/sj.bdj.2017.71

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Treatment:
1. Removal of bacterial plaque by thorough tooth brushing and flossing.
2. Antiseptic mouthwashes such as chlorhexidine.
3. Ultrasonic treatments.
4. Courses of antibiotics to reduce oral bacterial load
In many cases, improved oral hygiene can prevent or improve symptoms and resolve this
condition.

However if gum overgrowth is a product of medication or disease, doctors may recommend

surgery.

Gingival hyperplasia can be a recurrent condition despite improvements in oral hygiene,

professional treatment, and drug substitutions. In such cases, overgrown gums may need to be
surgically removed.
Some procedures used to remove overgrown gums include:

 Laser excision.
 Electrosurgery.
 Periodontal flap surgery.
 Gingivectomy.

- https://www.healthline.com/health/gingival-hyperplasia