Gingival ProblemsGingival ProblemsDr Erry Mochamad AriefDr Erry Mochamad Arief

Senior Lecturer in PeriodonticsSenior Lecturer in Periodontics13 Sept 200713 Sept 2007

Contents Contents

Chronic gingivitisChronic gingivitis

Gingival enlargementGingival enlargement

Gingival recessionGingival recession

Objectives Objectives

To know the differential diagnosis of the To know the differential diagnosis of the various forms of gingivitisvarious forms of gingivitisTo describe etiology and treatment options for To describe etiology and treatment options for the various forms of gingival enlargementthe various forms of gingival enlargementTo describe appropriate therapy of gingivitis To describe appropriate therapy of gingivitis and gingival enlargementand gingival enlargementTo explain etiology, clinical relevance and To explain etiology, clinical relevance and treatment for gingival recessiontreatment for gingival recession

Healthy Healthy PeriodontiumPeriodontium

0 - 3 mm sulcus depth

No suppuration

No bleedingB C C T S S

Chronic GingivitisChronic Gingivitis

Clinical and Clinical and histopathologicalhistopathological feature of Chronic gingivitisfeature of Chronic gingivitis

Clinical Clinical featurefeature

HealthyHealthy GingivitisGingivitis HistopathologyHistopathology

Fluid flowFluid flow MinimalMinimal IncreasedIncreased Increased vascular permeabilityIncreased vascular permeability

BBleeding on leeding on probingprobing

NoNo YesYes VascularityVascularity increasedincreasedDilatation and engorgement of the capillariesDilatation and engorgement of the capillariesEpithelium degenerated and thinned with capillaries Epithelium degenerated and thinned with capillaries

closer to surfacecloser to surface

CColor olor PinkPink Red to bluish red Red to bluish red ((erythemaerythema))

Result of:Result of:Vascular proliferationVascular proliferationReduction of Reduction of keratinizationkeratinizationVenous Venous statisstatis cause bluish redcause bluish red

CConsistency onsistency Firm, Firm, resilientresilient

Soggy, puffy, pits Soggy, puffy, pits on pressure on pressure (edema), flaccid(edema), flaccid

Infiltration by fluid and cells into the inflamed regionInfiltration by fluid and cells into the inflamed regionFlaccidity result of loss gingival fibersFlaccidity result of loss gingival fibers

Clinical and Clinical and histopathologicalhistopathological feature of Chronic gingivitisfeature of Chronic gingivitis

Clinical Clinical featurefeature

HealthyHealthy GingivitisGingivitis HistopathologyHistopathology

TTextureexture Stippling (not Stippling (not always)always)

Loss of stippling, Loss of stippling, smooth and shinysmooth and shiny

Thinning or atrophy of the epitheliumThinning or atrophy of the epitheliumDegeneration associated with edema and Degeneration associated with edema and

leucocyticleucocytic infiltration into the connective infiltration into the connective tissuetissue

SSizeize KnifeKnife--edge marginsedge marginsPapilla fills Papilla fills intedentalintedental spacespaceSulcusSulcus depth depth ≤≤ 3 3 mmmm

Swollen or Swollen or balloningballoning of of interdentalinterdental papilla papilla and/or gingival and/or gingival marginmarginFalse pocket False pocket formationformation

Result of:Result of:EdemaEdemaNew capillary formationNew capillary formationVascular engorgementVascular engorgement

SShape/ hape/ ContourContour

ScallopedScalloped--troughs in troughs in marginal areas rise marginal areas rise to peaks in to peaks in interdentalinterdental areasareas

Blunts the marginal Blunts the marginal and papillary tissuesand papillary tissues

EdemaEdemaNew capillary formationNew capillary formationVascular engorgementVascular engorgement

Remember B C C T S S

STIPPLINGSTIPPLING

GINGIVAL MARGIN NOT STIPPLED

Distribution of gingivitisDistribution of gingivitis

Localized Localized ≤≤ 30%30%Generalized Generalized ≥≥ 30%30%MarginalMarginalPapillaryPapillaryDiffuse Diffuse

Classification of Periodontal DiseasesClassification of Periodontal Diseases

I. Diseases of the Gingival Unit: GingivitisI. Diseases of the Gingival Unit: Gingivitis1- Plaque-induced gingivitis.2- Non-plaque-induced gingivitis

II. Diseases of the Supporting Structures: II. Diseases of the Supporting Structures: PeriodontitisPeriodontitis

I. Gingival DiseasesI. Gingival Diseases

Dental plaqueDental plaque--induced gingival diseaseinduced gingival diseaseassociated with dental plaqueassociated with dental plaquemodified by systemic factorsmodified by systemic factorsmodified by medicationsmodified by medicationsmodified by nutritionmodified by nutrition

Characteristics of Plaque-Induced Gingivitis

Plaque present at gingival marginDisease begins at the gingival marginChange in gingival colorChange in gingival shape/contourSulcular temperature change

Characteristics of PlaqueCharacteristics of Plaque--Induced GingivitisInduced Gingivitis

Increased gingival exudatesIncreased gingival exudatesBleeding upon provocationBleeding upon provocationAbsence of attachment lossAbsence of attachment lossAbsence of bone lossAbsence of bone lossHistological changesHistological changes

Reversible with plaque removalReversible with plaque removal

Reversible with plaque removalReversible with plaque removal

Characteristics of PlaqueCharacteristics of Plaque--Induced GingivitisInduced Gingivitis

Microbial plaque is the Microbial plaque is the DIRECTDIRECT cause of gingivitis.cause of gingivitis.LoeLoe et al, 1965 study: (classic evidence)et al, 1965 study: (classic evidence)

12 individuals Abstained from all oral hygiene measures.12 individuals Abstained from all oral hygiene measures.All individuals developed All individuals developed gingivitisgingivitis within 10within 10--21 days.21 days.All individuals returned to healthy All individuals returned to healthy gingivagingiva within one week of within one week of resuming oral hygiene measuresresuming oral hygiene measures

Epidemiology gingivitisEpidemiology gingivitis

Is ubiquitous in population of children and adults Is ubiquitous in population of children and adults globallyglobally>82% of adolescent in US have overt gingivitis and >82% of adolescent in US have overt gingivitis and signs of gingival bleeding signs of gingival bleeding AlbandarAlbandar et.alet.al, 1996), 1996)Similar or higher prevalence in other parts of the Similar or higher prevalence in other parts of the worldworld>75% of adults in US have gingival bleeding and >75% of adults in US have gingival bleeding and dental calculus (Kingman and dental calculus (Kingman and AlbandarAlbandar, 2002), 2002)

Epidemiology CIPD: adultsEpidemiology CIPD: adults (MOH Malaysia, 1990, 2000)(MOH Malaysia, 1990, 2000)

Gingivitis (CPITN 1); Calculus (CPITN 2); Moderate pocketing (CPGingivitis (CPITN 1); Calculus (CPITN 2); Moderate pocketing (CPITN 3); Deep pocketing (CPITN 4)ITN 3); Deep pocketing (CPITN 4)

Periodontal Status 1990(%) 2000(%)

Subjects examined having periodontal diseases

92.8 90.2

Gingivitis (CPITN 1) 4.6 4.2

Calculus (CPITN 2) 65.1 56.9

Moderate Pocketing (CPITN 3) 17 20.8

Deep Pocketing (CPITN 4) 6.0 5.5

I. Gingival DiseasesI. Gingival Diseases

Dental plaque-induced gingival diseaseassociated with dental plaquemodified by systemic factors

associated with endocrine systemPuberty-associated gingivitisPregnancy-associated:

gingivitispyogenic granuloma

Diabetes mellitus-associated gingivitisassociated with blood dyscrasia

leukemia-associated gingivitis

modified by medicationsmodified by nutrition

Clinical signs of gingivitis intensified.Clinical signs of gingivitis intensified.↑↑serum level of testosterone (boys) or serum level of testosterone (boys) or estradiolestradiol(girls) results in:(girls) results in:

↑↑ level of level of PrevotelaPrevotela intermediaintermedia and P. and P. nigrescensnigrescens

Puberty-associated gingivitis

PregnancyPregnancy--Associated GingivitisAssociated Gingivitis

↑↑ prevalence of gingivitis.prevalence of gingivitis.Prevalence range 30Prevalence range 30--100%100%

Gingivitis Caused by Hormonal ChangesGingivitis Caused by Hormonal Changes

Puberty

Pregnancy

REF: Color Atlas of Periodontology

Characteristics of PregnancyCharacteristics of Pregnancy--Associated Associated PyogenicPyogenic GranulomaGranuloma

Plaque present at gingival marginPlaque present at gingival marginPronounced inflammatory response of Pronounced inflammatory response of gingivagingivaCan occur anytime during pregnancyCan occur anytime during pregnancyMore common in maxillaMore common in maxillaMore common More common interproximallyinterproximallySessile or Sessile or pedunculatedpedunculated protuberant massprotuberant massNot a neoplasm; has Not a neoplasm; has histologichistologic appearance of a appearance of a pyogenicpyogenic granulomagranulomaRegresses following parturitionRegresses following parturition

Characteristics of LeukemiaCharacteristics of Leukemia--Associated GingivitisAssociated Gingivitis

Pronounced inflammatory response of Pronounced inflammatory response of gingivagingiva in relation to the plaque present; in relation to the plaque present; however, plaque is not a prerequisite for oral lesionshowever, plaque is not a prerequisite for oral lesionsGingival lesions are primarily found in acute Gingival lesions are primarily found in acute leukemiasleukemiasChange in gingival colorChange in gingival colorChange in gingival contour with possible modification of gingivaChange in gingival contour with possible modification of gingival sizel sizeEnlargement first observed at the Enlargement first observed at the interdentalinterdental papillapapillaBleeding upon provocation (may be one of the initial oral signs)Bleeding upon provocation (may be one of the initial oral signs)Reductions in dental plaque can limit the severity of lesionReductions in dental plaque can limit the severity of lesion

Characteristics of Diabetes Characteristics of Diabetes MellitusMellitus--Associated GingivitisAssociated Gingivitis

Plaque present at gingival marginPlaque present at gingival marginPronounced inflammatory response of Pronounced inflammatory response of gingivagingivaChange in gingival colorChange in gingival colorChange in gingival contourChange in gingival contourIncreased gingival Increased gingival exudateexudateBleeding upon provocationBleeding upon provocationMost commonly associated in children with poorly controlled TypeMost commonly associated in children with poorly controlled Type--1 diabetes mellitus1 diabetes mellitusAbsence of bone lossAbsence of bone lossAbsence of attachment lossAbsence of attachment lossReversible with control of diabetic stateReversible with control of diabetic stateReduction of dental plaque can limit severity of lesionReduction of dental plaque can limit severity of lesion

(A) Gingival(A) Gingival DiseasesDiseases

modified by medicationsmodified by medicationsdrugdrug--influenced gingival enlargementinfluenced gingival enlargementdrugdrug--influenced gingivitis:influenced gingivitis:

oral contraceptiveoral contraceptive--associated gingivitisassociated gingivitis

Gingival Disease Modified by Gingival Disease Modified by MedicationsMedications

DRUGDRUG--INDUCED ENLARGEMENTSINDUCED ENLARGEMENTSdilantindilantin, , nifedipinenifedipine, , verpamilverpamil, , cyclosporincyclosporinfree free gingivagingiva increases in size and thicknessincreases in size and thicknessdecrease in collagen turnover, increase decrease in collagen turnover, increase interstitial ground substanceinterstitial ground substance

Characteristics of DrugCharacteristics of Drug--Influenced Gingival Influenced Gingival EnlargementEnlargement

Variation in inter patient and intra patient patternVariation in inter patient and intra patient patternPredilection for anterior Predilection for anterior gingivagingivaHigher prevalence in childrenHigher prevalence in childrenOnset within 3 monthsOnset within 3 monthsChange in gingival contour leading to modification of gingival sChange in gingival contour leading to modification of gingival sizeizeEnlargement first observed at the Enlargement first observed at the interdentalinterdental papillapapillaChange in gingival colorChange in gingival color

Characteristics of DrugCharacteristics of Drug--Influenced Gingival Influenced Gingival EnlargementEnlargement

Increased gingival Increased gingival exudateexudateBleeding upon provocationBleeding upon provocationFound in Found in gingivagingiva with or without bone loss but is not associated with or without bone loss but is not associated with attachment losswith attachment lossPronounced inflammatory response of Pronounced inflammatory response of gingivagingiva in relation to the in relation to the plaque presentplaque presentReductions in dental plaque can limit the severity of lesionReductions in dental plaque can limit the severity of lesionMust be using Must be using phenytoinphenytoin, cyclosporine A, or certain calcium , cyclosporine A, or certain calcium channel blockerschannel blockers

Gingival enlargementGingival enlargementClinical conditionsClinical conditions Clinical featureClinical feature HistophatologyHistophatology

Clinical enlargementClinical enlargement(hyperplasia) associated with(hyperplasia) associated withDilantinDilantin ((PhenytoinPhenytoin),),Cyclosporine and CalciumCyclosporine and CalciumChannel Blockers (Channel Blockers (NefedipineNefedipine,,VerapamilVerapamil, , NitredipineNitredipine,,FelodipineFelodipine, , DiltiazemDiltiazem,,OxodipineOxodipine

Increased amount of gingival Increased amount of gingival tissue, tissue usuallytissue, tissue usuallyfirmfirm

Hyperplasia of Hyperplasia of connective tissue. connective tissue. IncreasedIncreasedresponse of response of gingivagingiva to to plaqueplaque

PyogenicPyogenic graulomagrauloma (pregnancy(pregnancytumor) (gingivitis in pregnancy)tumor) (gingivitis in pregnancy)

Red, soft Red, soft gingivagingiva. May be . May be prominent enlargementprominent enlargementinterproximallyinterproximally

Typical inflammatory Typical inflammatory response. Increasedresponse. Increasedresponse of response of gingivagingiva to to plaqueplaque

Gingival enlargement in a patient taking phenytoin

Various forms of gingival enlargementVarious forms of gingival enlargement

Gingival enlargementGingival enlargement

May be sign of an underlying systemic May be sign of an underlying systemic disorderdisorderA full medical history should always be takenA full medical history should always be takenCareful Careful extraoralextraoral and and intraoralintraoral examinations examinations are necessary to determine the nature and are necessary to determine the nature and extent of the lesion, additional signs and extent of the lesion, additional signs and predisposing or traumatic factors.predisposing or traumatic factors.Referral to a specialist centre for additional Referral to a specialist centre for additional investigations may be appropriate.investigations may be appropriate.

Chronic Chronic hyperplastichyperplastic gingivitisgingivitis

Chronic Chronic hyperplastichyperplastic gingivitis may occur following gingivitis may occur following prolonged accumulation of dental plaque.prolonged accumulation of dental plaque.It is frequently associated with concomitant systemic It is frequently associated with concomitant systemic medications, though predisposing factors may not be medications, though predisposing factors may not be identifiable. There is firm, pink identifiable. There is firm, pink gingivagingiva, enlargement, , enlargement, particularly at particularly at interdentalinterdental sites, although an sites, although an inflammatory component may also be present. The inflammatory component may also be present. The gingivagingiva may partially cover the crowns of teeth, may partially cover the crowns of teeth, resulting in aesthetic problems and cleaning resulting in aesthetic problems and cleaning difficulties.difficulties.Treatment: OHI, scaling and Treatment: OHI, scaling and gingivectomygingivectomy..

EpulidesEpulides

LocalisedLocalised hyperplastichyperplastic lesions arising from the lesions arising from the gingivagingiva..Caused by trauma and chronic irritation from Caused by trauma and chronic irritation from plaque and calculus plaque and calculus invoke a chronic invoke a chronic inflammatory response inflammatory response continued continued inflammation and repair occur concurrently inflammation and repair occur concurrently excessive production of granulation tissue excessive production of granulation tissue epulisepulis..

EpulidesEpulides

Fibrous Fibrous epulisepulisVascular Vascular epulisepulisPeripheral giant cell Peripheral giant cell granulomagranuloma

a) Fibrous a) Fibrous epulisepulis

firm, pink, firm, pink, pedunculatedpedunculated mass that may be mass that may be ulcerated if traumatized.ulcerated if traumatized.histology: chronically inflamed, histology: chronically inflamed, hyperplastichyperplasticfibrous tissue which may be richly cellular or fibrous tissue which may be richly cellular or densely densely collagenouscollagenous..metaplasticmetaplastic bone and/or foci of dystrophic bone and/or foci of dystrophic calcification are common.calcification are common.

b) Vascular b) Vascular epulisepulis

Include Include pyogenicpyogenic granulomagranuloma and pregnancy and pregnancy epulisepulis..Characteristic : soft, purple/red swelling, Characteristic : soft, purple/red swelling, frequently ulcerated which bleeds readily.frequently ulcerated which bleeds readily.Histology : proliferation of richly vascular tissue Histology : proliferation of richly vascular tissue supported by a fibrous supported by a fibrous stromastroma, with a thin and , with a thin and often extensively ulcerated epithelium.often extensively ulcerated epithelium.Pregnancy Pregnancy epulisepulis occuringoccuring in pregnant women.in pregnant women.

c) Peripheral giant cell c) Peripheral giant cell granulomagranuloma (GCG)(GCG)

Dark reddish/purple, ulcerated swelling, frequently Dark reddish/purple, ulcerated swelling, frequently arising interdentally and often extending arising interdentally and often extending buccallybuccally and and linguallylingually. . May cause superficial erosion of May cause superficial erosion of crestalcrestal alveolar bone.alveolar bone.Radiographs are essential to differentiate from a central Radiographs are essential to differentiate from a central GCG that has perforated the cortex to present as a GCG that has perforated the cortex to present as a peripheral swelling.peripheral swelling.Histology : contains multiple foci of Histology : contains multiple foci of osteoclastosteoclast--like giant like giant cells supported by a richly vascular and cellular cells supported by a richly vascular and cellular stromastroma..

Treatment for Treatment for epulidesepulidesSurgical excision.Surgical excision.Pregnancy Pregnancy epulisepulis can be prevented by the can be prevented by the removal of plaque and calculus, as well as OHI.removal of plaque and calculus, as well as OHI.In pregnancy, surgical excision without complete In pregnancy, surgical excision without complete elimination of local irritants, can be recurrenceelimination of local irritants, can be recurrence

Iatrogenic gingival enlargementIatrogenic gingival enlargement

Denture induced enlargementDenture induced enlargementOrthodonticallyOrthodontically induced enlargementinduced enlargement

Denture induced enlargementDenture induced enlargementchronic trauma from illchronic trauma from ill--fitting dentures + poor fitting dentures + poor OH OH hyperplasia of gingival tissues.hyperplasia of gingival tissues.Sign: edematous, Sign: edematous, erythematouserythematous and bleed readily.and bleed readily.treatment : OHI, denture hygiene, SRP, and treatment : OHI, denture hygiene, SRP, and replacement of defective prostheses.replacement of defective prostheses.

OrthodonticallyOrthodontically induced enlargementinduced enlargementresults in the results in the ‘‘heapingheaping--upup’’ of gingival soft tissues of gingival soft tissues in the direction of tooth movement.in the direction of tooth movement.More often with removal appliancesMore often with removal appliancesResolve on completion of orthodontic treatment.Resolve on completion of orthodontic treatment.Treatment : OHITreatment : OHI

Cystic lesionsCystic lesions

Gingival cystsGingival cystsDevelopmental lateral periodontal cystsDevelopmental lateral periodontal cysts

Cystic lesionsCystic lesionsGingival cysts Gingival cysts

< 1% of cysts of the jaws.< 1% of cysts of the jaws.common in neonates, tend to resolve common in neonates, tend to resolve spontaneously in early life.spontaneously in early life.in adults, it is asymptomatic and found by chance in adults, it is asymptomatic and found by chance in histological sections from in histological sections from gingivectomygingivectomyspecimens.specimens.probably probably odontogenicodontogenic in origin, arising from in origin, arising from remnants of dental lamina.remnants of dental lamina.

Developmental lateral periodontal cystsDevelopmental lateral periodontal cystsproduces localized destruction of the periodontal tissues along produces localized destruction of the periodontal tissues along a a lateral root surface.lateral root surface.may present with expansion of alveolar bone, but most are may present with expansion of alveolar bone, but most are incidental findings on radiographs.incidental findings on radiographs.resemble gingival cysts if arising near the alveolar bone crest.resemble gingival cysts if arising near the alveolar bone crest.radiographicallyradiographically, appear as a , appear as a radiolucencyradiolucency with wellwith well--defined bony defined bony margins.margins.Treatment for cystic lesions : surgical excisionTreatment for cystic lesions : surgical excision

Clinical and Clinical and histopathologichistopathologic feature of ANUGfeature of ANUG

Clinical conditionsClinical conditions Clinical featureClinical feature HistophatologyHistophatologyAcute Necrotizing Acute Necrotizing ulcerative gingivitisulcerative gingivitis

Fetid odor, painful Fetid odor, painful gingivagingiva, sudden onset, , sudden onset, punchedpunched--out out interdentalinterdentalpapillae, marginal and papillae, marginal and interdentalinterdental papilla papilla affected. affected. PseudomembranousPseudomembranousslough. Local slough. Local lymphadenopathylymphadenopathy and and slight elevation in slight elevation in temperature might be temperature might be presentpresent

Surfaces epithelium degenerated Surfaces epithelium degenerated and replace by and replace by pseudomembranepseudomembrane. . The connective tissue is The connective tissue is hyperemic with numerous hyperemic with numerous capillaries and a dense infiltration capillaries and a dense infiltration of PMN. The layer between of PMN. The layer between necrotic and living tissue contains necrotic and living tissue contains numerous number of numerous number of fusiformfusiformbacilli and spirochetes in addition bacilli and spirochetes in addition to to leucocyteleucocyteSpirochetes has been show to Spirochetes has been show to invade the underlying living tissueinvade the underlying living tissue

Necrotizing Ulcerative Gingivitis Necrotizing Ulcerative Gingivitis

Pain and (spontaneous) bleedingPain and (spontaneous) bleedingFetor Fetor exorisexorisPunched out papillaePunched out papillaeGrey pseudoGrey pseudo--membranemembraneFusospirochetalFusospirochetal infectioninfection

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

MicrobiologyMicrobiologyFusobacteriumFusobacterium sp. (spirochetes)sp. (spirochetes)TreponemaTreponema sp.sp.PorphyromonasPorphyromonas gingivalisgingivalisPrevotellaPrevotella intermediusintermedius

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Secondary EtiologySecondary EtiologyImpaired Impaired ChemotaxisChemotaxisPoor Oral HygienePoor Oral HygieneAlcoholAlcoholSmokingSmokingMalnutritionMalnutritionStressStress

Necrotizing Necrotizing UlcerariveUlcerarive GingivitisGingivitis(Healing)(Healing)

NonNon--plaqueplaque--induced gingival lesionsinduced gingival lesions

Gingival diseases of specific bacterial origin Gingival diseases of specific bacterial origin e.ge.g N.gonorrheaN.gonorrhea , , T.pallidumT.pallidum and Streptococcal speciesand Streptococcal speciesGingival diseases of viral origin Gingival diseases of viral origin e.ge.g primary herpetic primary herpetic lesion,recurrentlesion,recurrentoral herpes ,oral herpes ,vericellavericella--zosterzosterGingival diseases of fungal origin Gingival diseases of fungal origin e.ge.g generalized gingival generalized gingival candidosiscandidosis, , linear gingival linear gingival erythemaerythema, , histoplasmosishistoplasmosisGingival lesion of genetic origin Gingival lesion of genetic origin e.ge.g hereditary gingival hereditary gingival fibromatosisfibromatosisGingival manifestations of systemic conditions Gingival manifestations of systemic conditions e.ge.g mucocutaneousmucocutaneousdisorders,allergicdisorders,allergic reactions to metals and dentifricesreactions to metals and dentifricesTraumatic lesions of Traumatic lesions of chemical,physicalchemical,physical, and thermal origin, and thermal originForeign body reactionForeign body reactionNot otherwise specified (NOS)Not otherwise specified (NOS)

Clinical and Clinical and histopathologichistopathologic feature of Acute Herpetic feature of Acute Herpetic GingivostomatitisGingivostomatitis

Clinical conditionsClinical conditions Clinical featureClinical feature HistophatologyHistophatology

Acute Herpetic Acute Herpetic gingivostomatitisgingivostomatitis

Involvement of Involvement of gingivagingiva and may and may include mucosa and lips. Appear include mucosa and lips. Appear vesicular, vesicular, erythemathouserythemathous, shiny , shiny with varying degree of edema with varying degree of edema and gingival bleeding, After 24 and gingival bleeding, After 24 hours vesicles may rupture hours vesicles may rupture forming painful ulcers with a forming painful ulcers with a hellohello--like margin and depressed like margin and depressed grayish white central portion. grayish white central portion. More often in children with a More often in children with a duration on of 7duration on of 7--10 days10 days

EtiologyEtiology--Herpes Simplex. Herpes Simplex. Ulceration that result from Ulceration that result from rupture of vesicles rupture of vesicles resulting in a central resulting in a central portion of acute portion of acute inflammation with inflammation with purulent exudates purulent exudates surrounded by a zone rich surrounded by a zone rich a blood vesselsa blood vessels

HIVHIV--associated gingivitisassociated gingivitis

Linear Gingival Linear Gingival ErythemaErythema::Persistent, linear, Persistent, linear, erythematouserythematousgingivitis.gingivitis.Localized/generalizedLocalized/generalizedErythematousErythematous gingivagingiva may be: may be:

Limited to marginal Limited to marginal gingivagingiva..Extend into attached Extend into attached gingivagingiva and/or and/or alveolar mucosa.alveolar mucosa.

Gingival Gingival fibromatosisfibromatosisis an uncommon condition with is an uncommon condition with autosomalautosomal dominant dominant inheritance pattern.inheritance pattern.There is There is generalisedgeneralised fibrous enlargement of the fibrous enlargement of the gingivagingiva as a result of the accumulation of bundles of as a result of the accumulation of bundles of collagen collagen fibresfibres..It is frequently associated with fibrous enlargement of It is frequently associated with fibrous enlargement of the maxillary the maxillary tuberositiestuberosities..Treatment is usually not required, unless access for Treatment is usually not required, unless access for cleaning is impaired or aesthetics are compromised. It cleaning is impaired or aesthetics are compromised. It tends to recur following surgical excision.tends to recur following surgical excision.

Clinical and Clinical and histopathologichistopathologic feature of feature of DesquamativeDesquamativeGingivitis and Gingivitis and PericoronitisPericoronitis

Clinical conditionsClinical conditions Clinical featureClinical feature HistophatologyHistophatology

DesquamativeDesquamative GingivitisGingivitis Intense redness and desquamation of Intense redness and desquamation of the epithelium. the epithelium. GingivaGingiva and mucosa and mucosa involvedinvolved

Disruption of the epithelialDisruption of the epithelial--connective tissue with the connective tissue with the formation of formation of subepithelialsubepithelialbullaebullae. These lesions . These lesions characteristically have characteristically have immunoglobulinsimmunoglobulins bound bound

Treatment for chronic gingivitisTreatment for chronic gingivitis

TreatmentTreatment

THERAPEUTIC GOALSTHERAPEUTIC GOALSThe therapeutic goal is to establish gingival The therapeutic goal is to establish gingival healthhealththrough the elimination of the etiologic factors: through the elimination of the etiologic factors: plaque, calculus, and other plaqueplaque, calculus, and other plaque--retentive retentive factors factors

TreatmentTreatment

TREATMENT CONSIDERATIONSTREATMENT CONSIDERATIONSContributing systemic risk factors may affect Contributing systemic risk factors may affect treatment and therapeutic outcomes for plaquetreatment and therapeutic outcomes for plaque--induced gingivitis. These may include diabetes, induced gingivitis. These may include diabetes, smoking, and certain periodontal bacteria, aging, smoking, and certain periodontal bacteria, aging, gender, genetic predisposition, systemic diseases and gender, genetic predisposition, systemic diseases and conditions (conditions (immunosuppressionimmunosuppression), stress, nutrition, ), stress, nutrition, pregnancy, substance abuse, HIV infection, and pregnancy, substance abuse, HIV infection, and medications medications

TreatmentTreatment

A treatment plan for active therapy should be developed A treatment plan for active therapy should be developed that may include the following:that may include the following:Patient education and customized oral hygiene Patient education and customized oral hygiene instruction.instruction.DebridementDebridement of tooth surfaces to remove supra and of tooth surfaces to remove supra and subgingivalsubgingival plaque and calculus.plaque and calculus.Antimicrobial and Antimicrobial and antiplaqueantiplaque agents or devices may agents or devices may be used to augment the oral hygiene efforts of be used to augment the oral hygiene efforts of patients who are partially effective with traditional patients who are partially effective with traditional mechanical methods.mechanical methods.

TreatmentTreatmentCorrection of plaqueCorrection of plaque--retentive factors such as overretentive factors such as over--contoured contoured crowns, open and/or overhanging margins, narrow embrasure crowns, open and/or overhanging margins, narrow embrasure spaces, open contacts, illspaces, open contacts, ill--fitting fixed or removable partial fitting fixed or removable partial dentures, caries, and tooth dentures, caries, and tooth malpositionmalposition..In selected cases, surgical correction of gingival In selected cases, surgical correction of gingival deformities/enlargement that hinder the patientdeformities/enlargement that hinder the patient’’s ability to s ability to perform adequate plaque control may be indicated.perform adequate plaque control may be indicated.Following the completion of active therapy, the patientFollowing the completion of active therapy, the patient’’s s condition should be evaluated to determine the course of future condition should be evaluated to determine the course of future treatment.treatment.

Treatment Treatment

Santos A: Evidence-based control of plaque and gingivitis. J Clin Periodontal 2003; 30 (Suppl. 5): 13–16. Blackwell Munksgaard,2003.

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Treatment for gingival enlargementTreatment for gingival enlargement

A strict A strict programmeprogramme of OHI and plaque control of OHI and plaque control must be implemented. Overgrown tissues must be implemented. Overgrown tissues should be surgically excised should be surgically excised

Gingival recessionGingival recession

POSITIONPOSITION

Level of the gingival margin which is attached Level of the gingival margin which is attached to the toothto the toothAbnormality Abnormality –– gingival recessiongingival recession

GINGIVA RECESSIONGINGIVA RECESSION

GINGIVAL RECESSIONGINGIVAL RECESSION

Recession is exposure of the root surface by an Recession is exposure of the root surface by an apical shift in the position of the apical shift in the position of the gingivagingivaActual position Actual position –– level of the epithelial level of the epithelial attachment on the toothattachment on the toothApparent position Apparent position –– level of the crest of the level of the crest of the gingival margingingival marginSeverity of the recession is determined by the Severity of the recession is determined by the actual position not apparent positionactual position not apparent position

APPARENT & ACTUAL LENGTHAPPARENT & ACTUAL LENGTH

ETIOLOGYETIOLOGY

Faulty tooth brushing technique (Faulty tooth brushing technique (gingivagingivaabrasion)abrasion)Tooth Tooth malpositionmalpositionFriction from soft tissue (Friction from soft tissue (gingivagingiva ablation)ablation)Gingival inflammationGingival inflammationAbnormal Abnormal frenumfrenum attachmentattachmentUsage of a particular abrasive Usage of a particular abrasive dentrificedentrifice

ETIOLOGYETIOLOGY

Traumatic incisor relationshipTraumatic incisor relationshipHabits such as rubbing Habits such as rubbing gingivagingiva with a finger with a finger nail or end of a pencilnail or end of a pencilOrthodontic movement in labial directionOrthodontic movement in labial directionSmokingSmokingAging Aging -- not due to physiological shift of the not due to physiological shift of the gingival epithelium but cumulative effect of gingival epithelium but cumulative effect of minimal pathologic involvementminimal pathologic involvement

CLINICAL FEATURESCLINICAL FEATURES

Exposed root surface due to apical migration Exposed root surface due to apical migration of the gingival complexof the gingival complexStillmanStillman’’ss cleft cleft –– an incipient lesion, a narrow, an incipient lesion, a narrow, deep and slightly curved cleft extending deep and slightly curved cleft extending apicallyapically from the free gingival marginfrom the free gingival marginMcCallMcCall’’s festoon s festoon –– rolled, thickened band of rolled, thickened band of gingivagingiva

STILLMANSTILLMAN’’S CLEFT & MCCALLS CLEFT & MCCALL’’S S FESTOONFESTOON

Stillman’s Cleft

McCall’s festoon

PREDISPOSING FACTORSPREDISPOSING FACTORS

Natural defects in labial alveolar plates Natural defects in labial alveolar plates --DehiscencesDehiscences (clefts) or (clefts) or fenestrationsfenestrations(windows)(windows)

CLINICAL SIGNIFICANCECLINICAL SIGNIFICANCE

Exposed root surface is susceptible to cariesExposed root surface is susceptible to cariesAbrasion or erosion of the Abrasion or erosion of the cementumcementum which which subsequently cause hypersensitivity due to subsequently cause hypersensitivity due to exposed dentinal tubulesexposed dentinal tubulesHyperemia of the pulp Hyperemia of the pulp InterproximalInterproximal recession causes plaque recession causes plaque accumulationaccumulation

TREATMENTTREATMENT

Record the magnitude of recession to assess Record the magnitude of recession to assess progression or stability (clinically or on study progression or stability (clinically or on study models)models)Eliminate etiological factorsEliminate etiological factorsOral Hygiene InstructionOral Hygiene InstructionTopical Topical desensitisingdesensitising agent / agent / flourideflouride varnishvarnishGingival veneer to cover exposed roots / Gingival veneer to cover exposed roots / embrasure spacesembrasure spaces

TREATMENTTREATMENT

Crown teeth with extreme caution to prevent Crown teeth with extreme caution to prevent exposure of coronal pulp at level of exposure of coronal pulp at level of radicularradicularpreparationpreparationMucogingivalMucogingival surgery to correct the recession surgery to correct the recession either a lateral pedicle graft, double papilla either a lateral pedicle graft, double papilla flap or flap or coronallycoronally repositioned flaprepositioned flapMucogingivalMucogingival surgery to provide a wider and surgery to provide a wider and functional zone of attached functional zone of attached gingivagingiva using free using free gingivagingiva flapflap

MUCOGINGIVAL SURGERY MUCOGINGIVAL SURGERY USING FREE GINGIVAL FLAPUSING FREE GINGIVAL FLAP

BEFORE AFTER

REFERENCESREFERENCES

Newman Takei Newman Takei CarranzaCarranza, , CarranzaCarranza’’ss Clinical Clinical PeriodontologyPeriodontology, 2003;15, 2003;15--33, 27533, 275--277277Peter Peter HeasmenHeasmen, Master Dentistry , Master Dentistry –– Restorative Restorative Dentistry, Dentistry, PaediatricPaediatric Dentistry and Dentistry and OrthodonticsOrthodontics