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Gingivitis

BASICS

  • Reversible inflammation of gingiva; mild periodontal disease.
  • Classified as plaque-induced or non-plaque induced (bacterial, viral, fungal, medication-induced, systemic factors).
  • Affects gastrointestinal, ENT, dental systems.
  • More frequent in elderly; common in children (usually requires improved hygiene only).
  • Very common during pregnancy (hormonal influence).

EPIDEMIOLOGY

  • Predominant in children, teenagers, and young adults.
  • ~42% of US adults have periodontal disease.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Inflammation of marginal gingiva; may progress to periodontitis if untreated.
  • Caused by inadequate plaque removal, medications (oral contraceptives, antiepileptics), nutritional deficiencies, vasoconstrictors (nicotine, methamphetamine), endocrine changes (pregnancy, menses).
  • Necrotizing ulcerative gingivitis (Vincent disease) caused by fusiform bacillus and Borrelia vincentii.
  • Possible genetic link (~30% population); rare hereditary gingival fibromatosis.

RISK FACTORS

  • Poor dental hygiene/plaque formation
  • Pregnancy
  • Uncontrolled diabetes
  • Malocclusion, dental crowding
  • Smoking, mouth breathing
  • Xerostomia
  • HIV/AIDS
  • Vitamin C, Coenzyme Q10 deficiency
  • Dental appliances (dentures, braces)
  • Stress, lack of sleep, malnutrition
  • Viral illness, respiratory diseases, rheumatoid arthritis, epilepsy

GENERAL PREVENTION

  • Twice-daily brushing with fluoride toothpaste (powered oscillating brushes better).
  • High-quality flossing, interdental brushes, water jets.
  • Chlorhexidine use in acute phase.
  • Regular dental cleanings (every 6 months or as indicated).
  • Essential oil mouthwashes (e.g., Listerine) adjunctively.
  • Pediatric brushing under parental supervision until ~8 years old.

COMMONLY ASSOCIATED CONDITIONS

  • Periodontitis
  • Glossitis
  • Pyogenic granuloma (pedunculated growths)

DIAGNOSIS

HISTORY

  • Gingival redness, swelling, bleeding (especially on brushing/flossing).
  • Usually painless but tender on touch.
  • Assess for risk factors: HIV, pregnancy, diabetes, smoking, nutritional deficiencies.

PHYSICAL EXAM

  • Normal gums: pink, firm, stippled, scalloped.
  • Gingivitis: edematous marginal gingiva, blunted papilla, bright red or red-purple, bleeds on manipulation.
  • Presence of soft plaque and calcified calculus.
  • HIV gingivitis: linear gingival erythema, painful, rapid tissue destruction.
  • Vincent disease: ulcers, fever, lymphadenopathy, halitosis.

DIFFERENTIAL DIAGNOSIS

  • Periodontitis (deeper tissue destruction).
  • Glossitis.
  • Desquamative gingivitis (painful, persistent).
  • Pericoronitis (common in adolescents).
  • Gingival ulcers (aphthous, herpetic, malignancy, TB, syphilis).

DIAGNOSTIC TESTS

  • Usually clinical diagnosis; no routine tests needed.
  • Smear or culture if infection suspected (HIV gingivitis includes anaerobes, yeast).
  • Labs to evaluate contributing systemic diseases (HIV, diabetes, nutritional).
  • Elevated CRP may be present.

TREATMENT

GENERAL MEASURES

  • Stop offending medications.
  • Remove plaque, calculus, faulty restorations, dentures.
  • Promote good oral hygiene and regular dental visits.
  • Smoking cessation.
  • Special needs: tray-applied carbamide peroxide gels.

MEDICATION

  • First line: chlorhexidine rinses or varnishes (short-term; may cause tongue staining, taste changes).
  • Essential oil mouthwashes as alternative/equal.
  • Antibiotics only for necrotizing ulcerative gingivitis (Vincent disease): penicillin V, metronidazole, amoxicillin-clavulanic acid, erythromycin, clindamycin, doxycycline.
  • Topical corticosteroids (e.g., triamcinolone in Orabase).
  • Pain relief: acetaminophen, ibuprofen.
  • Adjunctive: Decapinol oral rinse for bacterial reduction (not for pregnant women/children <12).

ISSUES FOR REFERRAL

  • Dental care for acute and chronic gingivitis.
  • Periodontitis requires deep root scaling, root planing, antibiotics.
  • Surgery for medication-induced or hereditary gingival hyperplasia.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Bilberry (anti-inflammatory, collagen stabilizer).
  • Coenzyme Q10 topical application.
  • Correct nutritional deficiencies (vitamins A, B12, C).

ONGOING CARE

  • Follow-up dental visits until resolution and for prevention.
  • Promote balanced diet with fruits, vegetables, vitamin C.
  • Avoid sugary foods and drinks.

PATIENT EDUCATION

  • Oral hygiene: twice daily brushing (prefer circular oscillating electric brush), daily flossing.
  • Regular dental checkups.
  • Patient education resources: American Dental Association, American Academy of Periodontology, National Institute of Dental and Craniofacial Research websites.

PROGNOSIS

  • Generally favorable with treatment.
  • Can be acute, relapsing, or chronic.
  • Untreated gingivitis may progress to periodontitis, increasing risk of tooth loss and systemic inflammation.

COMPLICATIONS

  • Severe periodontal disease associated with bone loss, tooth loss, cardiovascular disease, diabetes, dementia, preterm birth.

REFERENCES

  1. Kumar S. Evidence-based update on diagnosis and management of gingivitis and periodontitis. Dent Clin North Am. 2019;63(1):69-81.
  2. Karamani I, Kalimeri E, Seremidi K, et al. Chlorhexidine mouthwash for gingivitis control in orthodontic patients: a systematic review and meta-analysis. Oral Health Prev Dent. 2022;20(1):279-294.
  3. Figuero E, Roldán S, Serrano J, et al. Efficacy of adjunctive therapies in patients with gingival inflammation: a systematic review and meta-analysis. J Clin Periodontol. 2020;47(Suppl 22):125-143.

CODES

  • ICD10: K05.10 Chronic gingivitis, plaque induced
  • ICD10: K05.11 Chronic gingivitis, non-plaque induced
  • ICD10: K05.00 Acute gingivitis, plaque induced

CLINICAL PEARLS

  • Prevent and treat gingivitis with good oral hygiene, regular dental cleanings, and mouth rinses such as chlorhexidine or essential oils.
  • Untreated gingivitis may progress to periodontitis, which contributes to systemic inflammation and related diseases.
  • Consider other causes in new or refractory gingivitis: pregnancy, HIV, diabetes, medications, vitamin deficiencies.