para>More frequent in this age group (due more to additive effects than to increased susceptibility) á
Pediatric Considerations
Mild cases common in children (most common form of pediatric periodontal disease) and usually require no specific interventions other than improved oral hygiene
á
Pregnancy Considerations
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EPIDEMIOLOGY
- Predominant age: children, teenagers, and young adults. Predominant sex: slightly more males than female
- Prevalence ~50% of children
- ~90% of adolescents and adult population
- ~30-75% of pregnant women
ETIOLOGY AND PATHOPHYSIOLOGY
Inflammation of gingiva. This can progress to deeper, destructive inflammation. If involving supporting bone, will be classified as periodontitis, not gingivitis. á
- Usually noncontagious
- Inadequate plaque removal
- Blood dyscrasias (pregnancy)
- Oral contraceptives
- Allergic reactions
- Nutritional deficiencies
- Vasoconstriction (nicotine, methamphetamine)
- Endocrine/hormonal variations
- Chronic debilitating disease
- Vincent disease
- Synergistic infection with fusiform bacillus (Fusobacterium spp.) and spirochete (Borrelia vincentii)
- Pathology
- Acute or chronic inflammation
- Hyperemic capillaries
- Polymorphonuclear infiltration
- Papillary projections in subepithelial tissue
- Fibroblasts
Genetics
Possible genetic link (up to 30% of population); rare condition called hereditary gingival fibromatosis associated with hirsutism á
RISK FACTORS
- Poor dental hygiene/plaque formation
- Pregnancy
- Uncontrolled diabetes mellitus
- Malocclusion or dental crowding
- Smoking
- Mouth breathing
- Xerostomia
- Faulty dental restoration
- HIV-positive; AIDS
- Stress
- Hospitalization (1)[A]
- Vitamin C deficiency; coenzyme Q10 deficiency
- Dental appliances (dentures, braces)
- Eruption of primary or secondary teeth
- Necrotizing ulcerative gingivitis
- Stress
- Lack of sleep
- Malnutrition
- Viral illness
- Typically teens and young adults
- Bronchial asthma and other respiratory diseases (2,3)[B]
- Rheumatoid arthritis (4)[B]
GENERAL PREVENTION
- Good oral hygiene
- Adults
- Regular twice-daily brushing with fluoride toothpaste and increased benefit of using circular oscillating electric brush rather than regular brush or sonic/vibration (5,6)[A]
- Daily "high-quality"Ł flossing (studies show that flossing only helps when it is done correctly) (7)[A]
- Chlorhexidine with oral hygiene better than other oral rinse agents (8,9)[A]
- Use in acute phase sparingly (10)[B]
- Pediatrics
- Regular twice-daily brushing with fluoride toothpaste under parental supervision until full manual dexterity (~8 years of age)
- Regular flossing if no spaces between teeth
- Cleaning by a dentist or hygienist every 6 months or more frequently, if indicated
- Mouth rinse with essential oils (menthol, thymol, eucalyptol; e.g., Listerine) combined with brushing (11)[B]
- Caution: Long-term use of alcohol-based mouth rinse may be associated with an increased risk of oral cancer (12)[B].
COMMONLY ASSOCIATED CONDITIONS
- Periodontitis
- Glossitis
- Pedunculated growths (pyogenic granulomata)
DIAGNOSIS
HISTORY
- Gum erythema, swelling, and edema
- Gums are tender when touched but otherwise painless.
- Bleeding of gums when brushing, flossing, or eating
- Inquire about HIV risk, pregnancy, nutritional deficiencies, diabetes, and other risk factors as indicated (see "Risk Factors"Ł).
- Smoking history
- Oral hygiene, dental visit history
PHYSICAL EXAM
- Normal gums should appear pink, firm, stippled, and scalloped.
- Gingivitis-marginal gum swelling and edema (usually painless, except to touch)
- Gum erythema: bright red or red-purple appearance
- Bleeding with manipulation of gums
- Change of normal gum contours
- Plaque (soft) and calculus (not easily removed)
- Edema of interdental papillae
- HIV gingivitis
- Also called linear gingival erythema
- Narrow band of bright red inflamed gum surrounding neck of tooth
- Painful
- Bleeds easily
- Rapid destruction of gingival tissue and can progress to periodontitis with destruction of underlying support tissues (periodontal ligament, supporting alveolar bone)
- Vincent disease
- Ulcers
- Fever
- Malaise
- Regional lymphadenopathy
- Pain
- Mouth odor
DIFFERENTIAL DIAGNOSIS
- Periodontitis (deeper inflammation, causing destruction to connective tissue, ligaments, and alveolar bone)
- Glossitis
- Desquamative gingivitis (painful, persistent, usually middle-aged women)
- Pericoronitis (gum flap traps food and plaque over partially erupted third molar), common in adolescence
- Gingival ulcers (aphthous, herpetic, malignancy, TB, syphilis)
- Specific forms of gingivitis: See "Description,"Ł including acute necrotizing ulcerative gingivitis (Vincent disease) and HIV gingivitis (linear gingival erythema).
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- No tests usually needed
- Possible smear or culture to identify causative agent (HIV gingivitis includes gram-negative anaerobes, enteric strains, and Candida)
- Labs for contributing conditions (HIV, pregnancy, diabetes, nutritional deficiencies)
TREATMENT
GENERAL MEASURES
- Stop any contributing medications.
- Remove irritating factors (plaque, calculus, faulty dental restorations, or partial dentures).
- Good oral hygiene (see "General Prevention"Ł)
- Regular dental checkups (for scaling and polishing if plaque and/or tartar are present)
- Smoking cessation
- Warm saline rinses BID
- Special care needs patients: use of tray-applied 10% carbamide peroxide gels (13)[C]
MEDICATION
First Line
- Chlorhexidine rinses or varnishes may be used (14)[B].
- Mouth rinses with essential oils (EOMW) may be equally effective to chlorhexidine for reduction of gingival inflammation (while EOMW is not as effective for plaque control) (15)[A].
- Both chlorhexidine and EOMW rinses are as clinically effective as oral prophylaxis and oral hygiene instruction at 6-month recall (16)[B].
- Antibiotics indicated only for acute necrotizing ulcerative gingivitis (Vincent disease)
- Antibiotics
- Penicillin V: pediatric dose, 25 to 50 mg/kg/day divided q6h; adult dose, 250 to 500 mg q6h, OR
- Metronidazole: pediatric dose, 30 mg/kg/day PO/IV divided q6h; maximum 4 g/day; adult dose, 500 mg BID or TID for 10 days OR
- Amoxicillin/clavulanic acid: pediatric dose, 30 mg/kg/day PO divided q12h; info: use 125 mg/ 31.25 mg/5 mL susp; adult dose, 875 mg/ 125 mg PO BID for 10 days
- Erythromycin: pediatric dose 30 to 40 mg/kg/day divided q6h; adult dose, 250 mg q6h
- Doxycycline: adult dose, 100 mg BID 1st day, then QD for 10 days
- Topical corticosteroids
- Triamcinolone 0.1% in Orabase (spray or ointment), applied locally TID, QID
- Contraindications
- Allergy to specific medication
- Precautions
- Erythromycin frequently causes GI issues.
Second Line
- Acetaminophen or ibuprofen for any pain (rare)
- Other antibiotics or antifungal rinses or systemic according to culture or smear
- Decapinol oral rinse (surfactant that acts as a physical barrier, making it harder for bacteria to stick to tooth and mucosal surfaces) to reduce bacteria (not recommended for pregnant women or children <12 years); should be used in conjunction with other oral hygiene practices when those practices alone are not enough
ISSUES FOR REFERRAL
- Dental referral for cleanings and further treatment, as needed
- If gingivitis becomes periodontitis, deep root scaling, planing, and antibiotics may be indicated.
SURGERY/OTHER PROCEDURES
- D ębridement for acute necrotizing gingivitis
- Minor surgery may be necessary to correct tissue overgrowth for gingivitis caused by medicines.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Bilberry: potentially helpful in reducing inflammation and stabilizing collagen tissue
- Coenzyme Q10: topically, to restore coenzyme Q10 deficiency
- Replace any other deficiencies (e.g., vitamin C).
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Outpatient
- No restrictions
Patient Monitoring
Until clear; dental follow-up for continued cleanings and secondary prevention á
DIET
- Well-balanced diet that includes fruits, vegetables, vitamin C; avoid sugary snacks and drinks, which contribute to plaque formation.
- Soft foods during flare, if significant inflammation/bleeding
PATIENT EDUCATION
- Good oral hygiene, including twice-daily brushing with circular oscillating electric brush, fluoridated toothpaste, and daily flossing; regular dental visits
- Printable and viewable patient information available under "gum diseases"Ł from the American Dental Association at http://www.mouthhealthy.org/en/ and the American Academy of Periodontology under "patient resources"Ł at http://www.perio.org/
PROGNOSIS
- Usual course: acute, relapsing, intermittent; chronic
- Prognosis: generally favorable, responds well to appropriate treatment
- Left untreated, may progress to periodontitis (controversial), which is a major cause of tooth loss
COMPLICATIONS
Severe periodontal disease (which is associated with heart disease, diabetes, and preterm birth) á
REFERENCES
11 Terezakis áE, Needleman áI, Kumar áN, et al. The impact of hospitalization on oral health: a systematic review. J Clin Periodontol. 2011;38(7):628-636.22 Stensson áM, Wendt áLK, Koch áG, et al. Oral health in pre-school children with asthma-followed from 3 to 6 years. Int J Paediatr Dent. 2010;20(3):165-172.33 Widmer áRP. Oral health of children with respiratory diseases. Paediatr Respir Rev. 2010;11(4):226-232.44 Keles áZP, Keles áGC, Avci áB, et al. Analysis of YKL-40 acute-phase protein and interleukin-6 levels in periodontal disease. J Periodontol. 2014;85(9):1240-1246.55 Yaacob áM, Worthington áHV, Deacon áSA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev. 2014;(6):CD002281.66 Klukowska áM, Grender áJM, Conde áE, et al. A 12-week clinical comparison of an oscillating-rotating power brush versus a marketed sonic brush with self-adjusting technology in reducing plaque and gingivitis. J Clin Dent. 2013;24(2):55-61.77 Sambunjak áD, Nickerson áJW, Poklepovic áT, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011;(12):CD008829.88 Van Strydonck áDA, Slot áDE, Van der Velden áU, et al. Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review. J Clin Periodontol. 2012;39(11):1042-1055.99 Babu áJP, Garcia-Godoy áF. In vitro comparison of commercial oral rinses on bacterial adhesion and their detachment from biofilm formed on hydroxyapatite disks. Oral Health Prev Dent. 2014;12(4):365-371.1010 Eliot áMN, Michaud áDS, Langevin áSM, et al. Periodontal disease and mouthwash use are risk factors for head and neck squamous cell carcinoma. Cancer Causes Control. 2013;24(7):1315-1322.1111 Cortelli áSC, Cortelli áJR, Shang áH, et al. Gingival health benefits of essential-oil and cetylpyridinium chloride mouthrinses: a 6-month randomized clinical study. Am J Dent. 2014 Jun;27(3):119-126.1212 McCullough áM, Farah áCS. The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Aust Dent J. 2008;53(4):302-305.1313 Lazarchik áDA, Haywood áVB. Use of tray-applied 10 percent carbamide peroxide gels for improving oral health in patients with special-care needs. J Am Dent Assoc. 2010;141(6):639-646.1414 Puig Silla áM, Montiel Company áJM, Almerich Silla áJM. Use of chlorhexidine varnishes in preventing and treating periodontal disease. A review of the literature. Med Oral Patol Oral Cir Bucal. 2008;13(4):E257-E260.1515 Van Leeuwen áMP, Slot áDE, Van der Weijden áGA. Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review. J Periodontol. 2011;82(2):174-194.1616 Osso áD, Kanani áN. Antiseptic mouth rinses: an update on comparative effectiveness, risks and recommendations. J Dent Hyg. 2013;87(1):10-18.
SEE ALSO
- Dental Infection; Glossitis
- Algorithm: Bleeding Gums
CODES
ICD10
- K05.10 Chronic gingivitis, plaque induced
- K05.11 Chronic gingivitis, non-plaque induced
- K05.00 Acute gingivitis, plaque induced
- K05.01 Acute gingivitis, non-plaque induced
- A69.1 Other Vincent's infections
ICD9
- 523.10 Chronic gingivitis, plaque induced
- 523.11 Chronic gingivitis, non-plaque induced
- 523.00 Acute gingivitis, plaque induced
- 523.01 Acute gingivitis, non-plaque induced
- 101 Vincent's angina
SNOMED
- 66383009 Gingivitis (disorder)
- 72621003 Chronic gingivitis (disorder)
- 31642005 Acute gingivitis (disorder)
- 172697005 Acute ulcerative gingivitis
- 409865002 Vincent's disease (disorder)
CLINICAL PEARLS
- Gingivitis may be prevented and treated with regular dental cleanings, good oral hygiene, and use of certain mouth rinses including chlorhexidine.
- Untreated, gingivitis may progress to periodontitis, a possible contributor to systemic inflammation and its consequences (e.g., coronary artery disease and uncontrolled diabetes).
- New-onset or difficult-to-treat gingivitis, consider differential of etiology: pregnancy, HIV, diabetes, medications, and vitamin deficiencies.