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ОглавлениеChapter 3 Dental plaque‐induced gingivitis
Learning outcomes
By the end of this chapter you should be able to:
1 Define dental plaque‐induced gingivitis (and inflammation), and describe its primary and secondary causes.
2 Explain the difference between signs and symptoms, and list the signs and symptoms of dental plaque‐induced gingivitis.
3 Explain how to treat this common condition.
DENTAL PLAQUE‐INDUCED GINGIVITIS
Dental plaque‐induced gingivitis (Figures 3.1, 3.2, and 3.3) describes the inflammation of the gums as defined in the 2017 Classification of Periodontal Diseases. (It was formerly referred to as chronic gingivitis under the previous classification of periodontal diseases.)
Who does it affect?
Dental plaque‐induced gingivitis is the condition that the oral health educator (OHE) will probably encounter most frequently in both children and adults.
In the UK Adult Dental Health Survey (2009), gingival bleeding on probing (a sign of active gingival disease) was found in 54% of dentate adults [1]. In the same survey, 59% of dentate adults aged 45–54, and 49% of dentate adults aged 65–74, showed gingival bleeding [1].
Since, initially, the condition rarely causes pain and affected gums can appear relatively normal, many sufferers are unaware that anything is wrong, and often will tell the educator that their gums have bled when brushing for years. OHEs will hear comments, such as: ‘I thought it was normal for my gums to bleed,’ or, ‘My gums always bleed when I have a new toothbrush’.
Figure 3.1 Localised marginal gingivitis.
Source: Professor Nicola West, Bristol University. Reproduced with permission of Professor Nicola West.
Figure 3.2 Generalised marginal gingivitis.
Source: Alison Chapman.
Figure 3.3 Gingivitis in a neglected mouth.
Source: Alison Chapman.
The OHE should promote the message that, ‘healthy gums do not bleed’, and in order to do this the educator needs to understand gingivitis and its causes, and have a basic knowledge of the body’s inflammatory process.
Primary cause of dental plaque‐induced gingivitis
The primary cause of dental plaque‐induced gingivitis is simply poor oral hygiene; the bacterial by‐products (i.e. enzymes and toxins) produced by mature plaque have the potential to directly damage the gingival tissue and also initiate inflammatory and immunological reactions in the tissues.
Secondary causes of dental plaque‐induced gingivitis
Secondary factors increase the risk of the dental plaque, causing disease to the gingival tissues. They can be local (i.e. increasing plaque retention in a specific area), or systemic (whole body) conditions that alter the body’s response to inflammation.
Local factors include:
Malpositioned teeth.
Overhanging fillings.
Ill‐fitting crowns, bridges, or dentures.
Implants.
Orthodontic appliances.
Calculus.
Lip apart posture (mouth breathing). The dryness of the attached gingivae in people whose lips are naturally parted when relaxed increases the likelihood of plaque retention.
Systemic factors include:
Hormone changes during:Pregnancy (pregnancy gingivitis) – swollen papilla, may progress to a pregnancy epulis (see Chapter 20).Puberty (puberty gingivitis) – caused by testosterone, for example.Menopause.
Drug‐induced:Anticonvulsants (for epilepsy) – e.g. phenytoin and phenobarbital.Figure 3.4 Drug‐induced gingival growth (immunosuppressants for rheumatoid arthritis).Source: Alison Chapman.Immunosuppressants (anti‐rejection medication for transplant patients) – e.g. cyclosporine (Figure 3.4).Certain calcium channel blockers (for high blood pressure) – e.g. nifedipine, verapamil, and diltiazem.Deep overbite causing direct gingival trauma.
Inflammation
The OHE needs a basic knowledge of the body’s inflammatory process in order to explain gingivitis to patients who need to deal with the condition. When a word ends in ‘itis’, it usually describes an inflammatory condition of a body tissue. For example, tonsillitis is inflammation of the tonsils.
Inflammation is the response of a tissue to injury, and is the first process by which the body defends itself against attack from:
Physical sources (e.g. a blow to the mouth or a scratch from a toothbrush bristle).
Chemical sources (e.g. an aspirin burn or a reaction to chemicals used in dentistry).
Microorganisms (e.g. invasion by bacteria, viruses, or fungi).
Stages of inflammation (also signs of gingivitis)
The four stages of inflammation are also signs of gingivitis that the dental professional may notice:
1 Redness (rubor) – due to increased blood flow.
2 Swelling (tumor) – tissue fluid accumulates.
3 Heat (calor) – tissue temperature increases.
4 Pain (dolor) – rare in gingivitis, but some patients may complain of sore gums.
The words in brackets are Latin and they may help in remembering these stages by association (ruby from rubor; tumour from tumor; calories from calor, and doleful from dolor).
Other signs and symptoms of gingivitis
Signs are what the dental professional notices on examination, symptoms are what the patient may complain of. Both signs and symptoms of gingivitis are reversible and will disappear if inflammation is resolved by improved oral hygiene.
Signs
The dental professional may notice:
Loss of stippling – the orange peel appearance seen in healthy attached gingivae, caused by bundles of collagen fibres beneath the epithelium. The inflammatory process damages these bundles and stippling disappears.
Rounding of the gingival margin.
False pocketing – caused by swelling of the marginal gingivae. There is no breach of the junctional epithelium, so the periodontal ligament remains intact.
Loss of contour – gingivae lose their pointed shape due to swelling.
Loss of consistency – gingivae lose their firmness and become soft and spongy.
Symptoms
The patient may complain of:
Red, swollen gums.
Bleeding on brushing – this is often the first thing that patients notice. They may also mention that their gums bleed when eating crisp foods, such as apples, or they may find blood on their pillow in the morning.
Halitosis (fetor oris) – ‘My breath smells’. May be caused by bleeding, but more likely to be noticed in periodontitis when debris becomes trapped in pockets (see Chapter 4).
Itching or pain (rarely) – usually from trauma of vigorous brushing with a stiff brush, or when another factor is present, such as hormonal changes during pregnancy.
Remember! Signs are what the professional notices, symptoms are what the patient complains of.
Treatment of gingivitis
Treatment should include:
Oral hygiene instruction, encouragement, and motivation.
Removal/good care of potential plaque‐retentive sites.
Fluoride – antibacterial effect, and can be applied via toothpaste or mouthwash.
Chemical (chlorhexidine mouthwash).
Regular monitoring, including scaling, polishing, and reinforcement of oral health instruction.
REFERENCE
1 1. The Health and Social Care Information Centre (2011) Disease and Related Disorders – A Report from the Adult Dental Health Survey 2009. The Health and Social Care Information Centre, Leeds.
