What is gingivitis?

Causes and Symptoms

Healthy pink gingiva (gums) end at tooth bases in epithelium-covered connective tissue, detached from teeth for 0.15 to 0.30 millimeter. This free gingiva is demarcated from the next gum portion, attached gingiva, by a gingival groove. The space between free gingiva and a tooth is the gingival sulcus. Attached gingiva is bound to the bone that it covers and is 3 to 6 millimeters deep. Free gingiva between teeth, interdental papillae, extend upward in the front of teeth and make the gums look scalloped. All gingival epithelium covers connective tissue holding collagen fibers. Gingival sulcus epithelium holds oral crevicular and junctional epithelium (JE). JE forms a tooth collar, which is joined to tooth surfaces. Each collar girdles the neck of a tooth and prevents marginal gingivitis and periodontitis.

Gingivitis
begins when plaque and calculus irritate free gingiva, causing inflammation and bleeding.
Unchecked, it leads to the more serious periodontitis, which can result in tooth loss, cardiovascular
disease, and diabetes. Plaque starts as aggregates of bacteria and their capsules on tooth surfaces. It forms in a protein film deposited on the surfaces and thickens as bacteria become established in a growing matrix of protein and capsule polysaccharide, extending into attached gingiva. Plaque and bacterial toxins damage tissue, producing gingivitis by irritating free gingiva, loosening collars around teeth, and causing the detachment of attached gingiva. Plaque is best identified via disclosing solutions of dyes (such as erythrosin). Many view it as the main factor in initial gingival inflammation. Plaque calcification produces calculus, which is most problematic when it causes irritation if gingiva push up against it.

Acute gingivitis of several types is short term and of minor interest. Nonspecific acute gingivitis occurs with colds and influenza. It causes diffuse redness, swelling, and discomfort but resolves quickly upon recovery. Localized acute gingivitis arises from gingival trauma (such as hard food). Removing its causes promotes rapid healing. Ulcerative acute gingivitis, called trench mouth, occurs widely, mostly in one's teens or twenties. Patients report soreness, difficulty eating, facile gum bleeds, and headache. It also occurs in heavy smokers as a result of chemical and thermal irritation.

Chronic marginal gingivitis, which accounts for most cases, begins with the reddening and swelling of interdental papilla and/or the gingival margin. Attempts to explore a sulcus cause bleeding. Enlargement, as a result of edema or hyperplasia, may be extensive and followed, after years of disease, by chronic periodontitis where supporting bone is lost. The initial symptoms of chronic marginal gingivitis reported most often are gingival bleeding, either spontaneous or caused by brushing or chewing; gingival margin recession; gums coming away from teeth; gingival enlargement; and color change to red or reddish-purple.

Three types of chronic marginal gingivitis are associated with sex hormones in people who do not practice good oral hygiene: chronic marginal gingivitis of puberty, pregnancy, and menopause. In the puberty type, the hormone changes that come with approaching adulthood are causative. Puberty gingivitis
is often accompanied by hyperplasia of interdental papillae. Pregnancy gingivitis
occurs in women whose chronic marginal gingivitis worsens after the first trimester. The culprits here, changed blood-vessel permeability and increased inflammation, are the result of hormone changes. The condition produces severe inflammation, marked edema, gingival enlargement, and loose teeth. With good oral hygiene, these problems disappear by the third trimester or birth. Menopausal
chronic marginal gingivitis, which can occur at and after the menopause, causes blotchy, reddened attached gingiva, starting as blisters. It may be immunological, the result of patients developing antibodies to their own epithelia.

Treatment and Therapy

Trench mouth is treated with bacteria-killing penicillin or peroxide. The key to treating chronic marginal gingivitis begins by determining gum health from gingival sulcus depth. To obtain this measurement, a metal probe is inserted into the gingiva at several mouth sites until slight resistance is felt. Sulcus depths under 0.30 millimeter indicate healthy gums. Greater depths indicate chronic marginal gingivitis. The deeper the sulcus, the more serious is the gingivitis. The first gingivitis-related dental visit begins with sulcus examination.

When chronic marginal gingivitis is apparent, most plaque and calculus is removed, and the patient is quizzed on oral hygiene habits. The information gained is used to plan several more visits to prove that the patient practices good oral hygiene and to remove any remaining plaque and calculus. The larger and deeper the deposits and the longer exposure to poor hygiene, the more visits required.

Most chronic marginal gingivitis disappears after dental cleaning and ensuing good oral hygiene. Calculus and plaque removal eliminates the source of irritation and causes healing. Gums become healthy in a few weeks. Mild periodontitis requires more extensive treatment: Bacterial pockets are cleaned out, and antiseptic mouthwash or toothpaste is prescribed. Severe periodontitis may require surgery.

Perspective and Prospects

The best current way to treat gingivitis is preventing it via good oral hygiene, which consists of regular brushing and periodic dental cleaning to prevent plaque and calculus buildup. It is best to brush all teeth and gums with a soft-bristled brush and fluoride toothpaste. Brushing should be done at least twice daily, in the morning and at bedtime. Daily flossing is also recommended. Floss is used to scrape the underside of each tooth, just below the gum line, to remove interdental plaque and to massage the gums. In addition to good daily oral hygiene, annual or semiannual dental visits for cleaning and checkup are valuable.

Curing chronic marginal gingivitis and preventing periodontitis are now thought to diminish the risk of heart disease and stroke, as research has found a relationship between oral bacteria and clogged arteries. A relationship also exists between diabetes mellitus and chronic marginal gingivitis or periodontitis: Diabetes increases the risk of developing periodontitis, and oral infection makes blood glucose harder to control. People having serious periodontitis and lung problems may inhale mouth bacteria and develop pneumonia. It is believed that susceptibility to gingivitis differs between individuals.

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