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Gingivitis

- Pathology - Acute or chronic inflammation - Hyperemic capillaries - Polymorphonuclear infiltration - Papillary projections in subepithelial tissue - Fibroblasts

- 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

- 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)

- 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

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

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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 diseaseSynergistic infection with fusiform bacillus (Fusobacterium spp.) and spirochete (Borrelia vincentii)
  • PathologyAcute or chronic inflammationHyperemic capillariesPolymorphonuclear infiltrationPapillary projections in subepithelial tissueFibroblasts

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 gingivitisStressLack of sleepMalnutritionViral illnessTypically teens and young adults
  • Bronchial asthma and other respiratory diseases (2,3)[B]
  • Rheumatoid arthritis (4)[B]

GENERAL PREVENTION

  • Good oral hygieneAdultsRegular 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]PediatricsRegular 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 gingivitisAlso called linear gingival erythemaNarrow band of bright red inflamed gum surrounding neck of toothPainfulBleeds easilyRapid destruction of gingival tissue and can progress to periodontitis with destruction of underlying support tissues (periodontal ligament, supporting alveolar bone)
  • Vincent diseaseUlcersFeverMalaiseRegional lymphadenopathyPainMouth 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)
  • AntibioticsPenicillin V: pediatric dose, 25 to 50 mg/kg/day divided q6h; adult dose, 250 to 500 mg q6h, ORMetronidazole: pediatric dose, 30 mg/kg/day PO/IV divided q6h; maximum 4 g/day; adult dose, 500 mg BID or TID for 10 days ORAmoxicillin/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 daysErythromycin: pediatric dose 30 to 40 mg/kg/day divided q6h; adult dose, 250 mg q6hDoxycycline: adult dose, 100 mg BID 1st day, then QD for 10 days
  • Topical corticosteroidsTriamcinolone 0.1% in Orabase (spray or ointment), applied locally TID, QIDContraindicationsAllergy to specific medication
  • PrecautionsErythromycin 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.