DESCRIPTION

• Periodontal health is defined as the absence of clinical inflammation associated with gingivitis, periodontitis, or any other periodontal conditions.
• Gingivitis and periodontitis are both classified under periodontal disease—defined as inflammation of the periodontal tissues (gingiva, periodontal ligament, and supporting bone).
• Gingivitis is inflammation limited to the gingiva not resulting in clinical attachment loss. It is considered one of the most common human inflammatory diseases.
• Periodontitis is inflammation of the gingiva and adjacent connective tissue attachment, resulting in clinical attachment loss and, if progressive, alveolar bone loss, loose teeth, and eventual tooth loss.
• Patient symptoms may include bleeding gums, metallic/altered taste, pain/soreness, halitosis, difficulty eating, appearance of swollen red gums, and reduced oral health-related quality of life.
• Depending on etiology, gingivitis can be localized to a limited area or generalized (involving the entire gingiva). It can also manifest acutely or as a chronic condition.

EPIDEMIOLOGY

ETIOLOGY

Plaque-induced gingivitis most often occurs in response to bacterial plaque accumulation at the gingival margin resulting from:

• Inconsistent brushing and flossing
• Local areas that are difficult to access and clean
• Decreased saliva/xerostomia
• Increased inflammatory response to bacterial plaque

RISK FACTORS

• Factors increasing plaque accumulation leading to gingival inflammation:
  • Inconsistent brushing and flossing
  • Frequent carbohydrate intake
  • Localized areas of plaque accumulation—erupting teeth, crowded teeth, poor restoration margins, orthodontic appliances/bands/brackets, poor brushing technique
  • Decreased saliva (self-cleaning effect) or dry mouth/xerostomia leading to rapid plaque accumulation—mouth breathing, asthma medications, psychiatric medications, many other pediatric medications
• Factors increasing gingival inflammatory response:
  • Medications: antiepileptics, cyclosporine, calcium channel blockers
  • Hormonal changes: puberty, pregnancy
  • Immunologic deficiencies: HIV, Chédiak-Higashi syndrome, cyclic neutropenia
  • Chronic illnesses: diabetes mellitus, chronic renal failure, histiocytosis X, scleroderma, secondary hyperparathyroidism
  • Behavioral factors: smoking, stress, alcohol consumption
  • Miscellaneous: malnutrition, viral illnesses

GENERAL PREVENTION

• Prevention of gingivitis is directed toward effective removal of dental plaque on a consistent basis, thereby controlling gingival inflammation.
• Infants: washcloth to remove plaque after feeding; toothbrush using baby toothpaste (nonfluoridated)
• Children: assistance with brushing with a small amount of toothpaste after meals
• Older children and adolescents: gentle brushing toward the gumline after meals with fluoridated toothpaste in addition to daily flossing
• Children/adolescents with high-risk factors must brush and floss consistently after every meal.
• The American Academy of Pediatrics (AAP) recommends that children at high risk for dental caries should establish routine dental care by their first birthday. Children should then continue routine dental checkups at a minimum of every 6 months.

PATHOPHYSIOLOGY

Gingivitis (gingival inflammation) is the result of accumulation of bacterial plaque at the gingival margin (gingiva covering the necks of the teeth).

COMMONLY ASSOCIATED CONDITIONS

Nonplaque-induced gingival conditions are based on the etiology of the lesion:

• Genetic/developmental disorders (e.g., hereditary gingival fibromatosis)
• Specific infections of bacterial (e.g., necrotizing periodontal diseases, streptococcal gingivitis), viral (e.g., hand, foot, and mouth disease, primary herpetic gingivostomatitis), and fungal (e.g., candidiasis) origins
• Inflammatory and immune conditions and lesions (e.g., hypersensitivity reactions, autoimmune disease of skin, and mucous membranes)
• Reactive processes (e.g., epulides)
• Premalignant neoplasms (e.g., leukoplakia)
• Malignant neoplasms (e.g., leukemia, lymphoma)
• Traumatic lesions (e.g., physical, chemical, thermal insults)
• Endocrine, nutritional, and metabolic diseases (e.g., vitamin deficiencies)
• Gingival pigmentation (e.g., amalgam tattoo)
• Medications promoting gingival overgrowth (e.g., phenytoin, cyclosporine, nifedipine, oral contraceptive pills)

HISTORY

• Assess medical history for chronic illnesses, bleeding disorders, immunodeficiencies, etc.
• Assess home oral hygiene practice, focusing on brushing/flossing timing, frequency, and technique.
• Assess the diet, including carbohydrate intake/frequency, and possible nutritional deficiencies.
• Review medications, taking note of any that may increase risk of gingival inflammation/enlargement.
• Review any intraoral complaints:
  • Bleeding gums on brushing or spontaneously
  • Gingival pain on brushing, eating, or spontaneous
  • Gingival swelling
  • Review symptomology—when the condition arose, how often, etc.

PHYSICAL EXAM

• Mild signs are usually gingival erythema and bleeding with brushing or flossing.
• Moderate to severe signs include swelling (loss of knife-edge gingival margin and blunting of papillae), redness, and bleeding and discomfort on gentle probing.
• Examine the head and neck for signs of swelling, erythema, warmth, enlarged maxillary lymph nodes, as well as right/left symmetry.
• Examine the gingival tissue for erythema, swelling, ulceration, fluctuance, or drainage.
• Assess whether gingival inflammation is localized to an area (local factor) or generalized, involving the entire upper and lower gingiva (systemic factor/medication).
• Assess for pain or sensitivity on palpation.
• Assess oral hygiene, noting plaque buildup, crowding, carious teeth, fillings/crowns, or abscesses.
• Take note of any orthodontic appliances that may decrease effectiveness of brushing and flossing.
• Evaluate the teeth for caries, fractures, looseness, malocclusion, pain, and plaque.

DIFFERENTIAL DIAGNOSIS

• Localized gingivitis
  • Poor hygiene technique: Review home routine.
  • Food impaction: Review diet.
  • Orthodontic appliances
  • Pregnancy tumor (pyogenic granuloma)
  • Abscess: Check for caries.
  • Trauma: Check for history of trauma.
  • Self-inflicted injury—unusual location and history
• Generalized gingivitis—healthy presentation
  • Extremely poor or no oral hygiene
  • Diet high in carbohydrates
• Generalized gingivitis—systemic manifestations
  • Herpetic gingivostomatitis—fever; malaise
  • Neutrophil disorders
  • Leukemia
  • HIV
  • Graft-versus-host disease (infiltrative gingivitis)
  • Vitamin C deficiency
  • Behçet disease
• Generalized gingivitis—bleeding
  • Hemophilia (factor VIII or IX deficiency)
  • Thrombocytopenia
• Generalized gingivitis—overgrowth
• Gingival hyperplasia due to medication
• Gingival hyperplasia due to hormone fluctuation
• Generalized gingivitis—severe, rapid
  • Acute necrotizing ulcerative gingivitis (ANUG)—painful gingivitis associated with rapid onset and tissue ulceration and necrosis. Peaks in adolescence and young adulthood
  • Related to high oral concentrations of spirochetes and/or Prevotella intermedia

DIAGNOSTIC TESTS & INTERPRETATION

GENERAL MEASURES

• A consistent oral hygiene regime directed at minimizing plaque buildup is essential to prevent or manage gingivitis.
• Brushing after breakfast and prior to bedtime allows for consistent clearance of food and keeps plaque manageable.
• Mechanical/sonic toothbrushes allow for more effective plaque removal.
• Toothpaste with fluoride when child can expectorate
• Flossing if teeth are in tight contact and not spaced apart
• Regular visits to a pediatric dentist for examination and thorough cleaning/scaling every 4 to 6 months
• For moderate to severe gingivitis, possible risk factors should be assessed and additional measures implemented.
• Mouth rinses for plaque inhibition using 0.12% chlorhexidine gluconate oral rinse
• More frequent dental visits for reassessment and thorough cleanings/scalings
• Gingivectomy to allow for more access and control of plaque
• Antibiotics to cover mouth flora in more severe cases when bacterial superinfection is suspected

MEDICATION

ISSUES FOR REFERRAL

• It is important for providers to evaluate the oral health of all children. When gingival inflammation is noted, the patient should be referred to a pediatric dentist for assessment and management. Frequency of follow-up is based on the severity of inflammation.
• For severe cases of gingivitis, a pediatric dentist may consult a periodontist to provide timely assessment and aggressive management. Follow-up is at least every 3 months until the case is well controlled and then every 6 months to 1 year.
• Generalized cases of gingivitis may need referral to a pediatric medical specialist to assess systemic causes or medications that may be manifesting orally. The medical specialist and dentist should collaborate to determine etiology and follow-up management.

ADDITIONAL THERAPIES

None

SURGERY/OTHER PROCEDURES

• In cases of gingival hypertrophy, gingivectomy (partial surgical removal of overgrown gingiva) by a periodontist may be necessary to remove excess gingival tissue, allowing for more effective plaque access, removal, and control.
• Gingivectomy can be done in multiple office visits with local anesthesia or in one visit under general anesthesia. Recovery can take weeks, with follow-up gingivectomies if there is recurrence.

COMPLEMENTARY & ALTERNATIVE THERAPIES

If brushing and flossing is not practical after meals, xylitol-containing chewing gum has been shown to help minimize plaque accumulation.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

It is rare that a patient is admitted for mild to moderate gingivitis. Admission may be necessary for patients with suspected primary herpetic gingivostomatitis due to suspected dehydration and need for effective pain control.

FOLLOW-UP RECOMMENDATIONS

DIET

A balanced diet, minimizing the amount and frequency of high sugar content foods and beverages

PATIENT EDUCATION

• Establish a daily oral hygiene routine involving a moderate diet and timely brushing and flossing.
• Brushing after breakfast and prior to bedtime allows for consistent clearance of food and keeps plaque manageable.
• Mechanical/sonic toothbrushes allow for more effective plaque removal.
• Toothpaste with fluoride when child can expectorate
• Flossing if teeth are in tight contact and not spaced apart
• Regular visits to a pediatric dentist reassessment and thorough cleaning/scaling every 4 to 6 months

PROGNOSIS

• Timely assessment, management, and consistent home oral hygiene should lead to control of mild to moderate gingivitis within several months.
• Periodontal disease may not be reversible; therefore, prevention is essential.

COMPLICATIONS

• Pain leading to detrimental changes in hygiene, diet, behavior, and daily routine
• Irreversible periodontitis, bone loss, and premature tooth loss
• Osteomyelitis
• Subacute bacterial endocarditis (SBE)

ICD 10

• K05.10 Chronic gingivitis, plaque induced
• K05.00 Acute gingivitis, plaque induced
• A69.1 Other Vincent’s infections