Gingival Disease Flashcards
What are the classes of periodontal health?
Periodontal health and gingival health
Gingivitis induced by dental biofilm
Gingival diseases not induced by dental biofilm
What are the causes of gingivitis induced by dental biofilm?
Associated with dental biofilm alone
Mediated by systemic or local risk factors
Drug influenced gingival enlargement
What are the types of periodontal and gingival health?
Clinical gingival health on an intact periodontium
Clinical gingival health on a reduced periodontium (stable or non-periodontitis patient)
What are the causes of gingival diseases not induced by dental biofilm?
Genetic/developmental disorders
Specific infections
Inflammatory and immune conditions
Reactive processes
Neoplasms
Endocrine, nutritional, and metabolic diseases
Traumatic lesions
Gingival pigmentation
What are the risk factors to periodontal and gingival diseases/conditions?
Local:
Plaque-retention factors
Oral dryness
Systemic:
Smoking
Hyperglycaemia
Low antioxidant micronutrient intake
Drugs - Especially immune-modulating drugs
Sex steroids - elevated levels
Haematological disorders
What is gingivitis defined as?
Dental plaque biofilm-induced gingivitis is defined as an inflammatory lesion resulting from itneractions between the dental plaque biofilm and the host’s inflammatory-immune response which remains contained within the gingiva and does not extend to the periodontal attachment.
This inflammation does not extend beyond the mucogingival junction and is reversible by reducing levels of dental plaque at and apical to the gingival margin.
What can gingivitis be classified as?
Gingivitis on an intact periodontium
Gingivitis on a reduced periodontium
Gingival inflammation on a reduced periodontium in a successfully treated periodontitis patient.
What causes gingival inflammation?
CHANGES ASSOCIATED TO PRESENCE OF MICROORGANISMS
PRODUCT RELEASE (COLLAGENASE, PROTEASE, SULPHATASE ENDOTOXINS, HYALURONIDASE)
POTENTIAL DAMAGE TO EPITHELIUM AND CONNECTIVE TISSUES
BACTERIA OR BACTERIAL PRODUCTS GAIN ACCESS TO CONNECTIVE
ACTIVATION OF MONOCYTES/MACROPHAGES
RELEASE OF VASOACTIVE SUBSTANCES PGE2, IFN, TNF, IL-1
What are the histopathological classifications of gingival and periodontal inflammation?
Pristine gingiva
Initial (clinically healthy gingiva)
Early gingivitis
Established gingivitis
Advanced periodontitis
What does pristine gingiva look like?
Histological perfection
Continuous neutrophil migration
Coronal part of JE
What happens in initial lesions?
Vascular changes, dilated capillaries and increased blood flow
Microbial activation of resident leukocytes and stimulation of endothelial cells
Clinically not apparent response
Subclinical gingivitis
No manifestation of tissue damage
Light or ultrastructureal SEM
Not pathological
Subtle changes in JE and perivascular connective tissue
Increased migration of PMNs
Increase in gingival fluid
Intensity resolves rapidly
What are the clinical features of an early lesion?
Occurs 1 week after plaque accumulation
Clinically appears as early gingivitis
Follows the initial lesion
Clinical signs of erythema appear
Bleeding on probing may be evident
Increased GCF
What are the histological features of an early lesion?
Capillary proliferation
Increased capillary loops between rete pegs and rete ridges
Maximum number of migrating PMNs at 6 - 12 days of gingivitis
Increased collagen destruction 70% around infiltrate
Circular and dentogingival fibers affected
Blood vessel morphology alteration
PMNs migrating to JE and phagocytosis of bacteria
Cytotoxic alteration of fibroblasts
Decreased collagen production
What are the clinical features of an established lesion?
Chronic gingivitis 2- 3 weeks of plaque accumulation
Blood vessels enlarged and congested
Blood flow slow
Venous return impaired
Anoxemia reddness or bluish gingiva
Moderate to severely inflamed gingiva
Haemoglobin breakdown
What are the physiological changes seen in established lesions?
Predominate plasma cells and B lymphocytes
B cells of G1 and G3 (IG1 and IG3)
Venous return impaired
Blood flow slowed down
Extravasation of erythrocytes and breakdown of haemoglobin
Increase in collagenolytic activity thus creating an inverse relationship between collagen and inflammatory cells
Collagenase enzyme from bacteria
Neutral mucopolysaccharides are reduced
Reversible reduction in plasma cells and increase in lymphocytes
What is an advanced lesion?
Extension of lesion into alveolar bone
A phase of periodontal breakdown
Fibrisis of gingiva
What happens to gingiva in an advanced lesion?
Plasma cells dominate infiltrate
Neutrophils dominate JE
Gingivitis progresses to periodontitis but not known if this is ALWAYS the case. It has been shown to do so in dogs but unknown in humans.
What are the clinical features of gingivitis induced by dental biofilm?
Plaque removal results in resolution of gingivitis
Redness, sponginess, bleeding, contour change, calculus, and plaque presence
Ulcerated epithelium
Altered epithelial function
What is the course and duration of gingivitis?
Acute sudden onset
Short duration
May be acute and painful
Recurrent gingivitis
Chronic gingivitis slow onset long duration (most common)
Painless
What is the difference between localized and generalized gingivitis?
Localized involves 10 to 30% of the teeth
Generalized involves more than 30% of teeth or entire dentition
What are the types of gingivitis in terms of location?
Marginal gingivitis
Diffuse gingivitis
Papillary gingivitis
What does Bleeding on Probing indicate?
EARLY SIGNS OF INFLAMMATION: GCF FLUID INCREMENT AND BLEEDING FROM GENTLE PROBING
BOP EARLIEST SIGN THAN COLOUR CHANGE
BOP WIDELY USED TO MEASSURE PREVALENCE, PROGRESSION TREATMENT OUTCOME
SUGGEST INFLAMMATORY LESION OF EPITHELIUM AND CONNECTIVE
BOP NOT GOOD PREDICTOR OF ATTACHMENT LOSS
ABSENCE OF BOP EXCELLENT NEGATIVE PREDICTOR OF ATTACHMENT LOSS (STABILITY)
AIM FOR ABSENCE ON BOP AND IMPLY LOW RISK FOR CAL
What kind of metals can cause pigmentation on gingiva?
Heavy metals
Bismuth
Arsenic
Mercury
Lead
Silver
What does metal staining look like on periodontium?
Black bluish line following the margin contour
Isolated black path on interdental or attached gingiva
Perivascular precipitation of metal sulphide into subepithelial connective tissue
Tattoing is different localised
What factors can cause colour changes in periodontium?
ADDISON’S DISEASE ADRENAL DYSFUNCTION ISOLATED PATCHES
PEUTZ-JEGHERS SYNDROME MELANIN PIGMENTATION
ALBRIGHT’S SYNDROME ORAL MELANIN PIGMENTATION
BILE PIGMENTS ON MUCOSA
IRON DEPOSITION BLUE-GRAY COLORATION
TOBACCO HYPERKERATOSIS AND MELANIN AREAS
AMALGAM IMPLANTED BLUISH-BLACK
What is the consistency of normal gingiva? What changes in gingivitis?
Normal is firm and resilient
Becomes:
Edematous and fibrotic
Soggy puffiness pits on pressure
Soft and friable
firm and leathery on fibrosis
What is the texture of diseased gingiva like?
ORANGE PEEL APPEARANCE STTIPLING (ATTACHED GINGIVA)
CHRONIC INFLAMMATION SMOOTH AND SHINING SURFACE
HYPERKERATOSIS LEATHERY
DRUG INDUCED OVERGROWTH NODULAR SURFACE
What can cause gingival recession?
Brushing technique hard technique or hard bristles
Lacerations, abrasions, keratosis and recession
Tooth malposition with excessive buccal orientation
Friction from tissues
Gingival inflammation
Abnormal frenum attachment
Iatrogenic dentistry dentrure clasps and overhangs
Smoking by reduction in irrigation to gingival sulcus
What are the features of a gingival contour?
Gingival enlargement
Stillman’s cleft and mccall festoons
Particular inflammatory changes
What local factors cause gingivitis?
Plaque retention by tooth crowding, caries, overhangs, partial dentures, mouth breathing, recession, and frenum attachment
Chronic inflammation or mechanical trauma
Acute bleeding from injury or burn.
What systemic factors can cause gingivitis?
Some cases are caused by spontaneous bleeding
Platelet disorders, thrombocytopaenia
Haemophilia, leukemia
Vitamin K deficiency, liver disease
Multiple myeloma
Hormonal changes estrogen/progesterone levels
What are the features of drug-induced gingival enlargement?
Increase in the size of the gingiva, gingival enlargement or overgrowth
Localized generalized, marginal papillary, diffuse and discrete
What are the grades of gingival enlargement?
Grade 0 No enlargement
Grade 1 Enlargement confined to interdental papilla
Grade 2 Enlargement involves papilla and margin
Grade 3 Enlargement covers 3/4 of the crown
What are the types of enlargement of the gingiva?
Inflammatory enlargement: Can be acute or chronic
Drug induced enlargement: Associated with systemic conditions
Neoplastic enlargement: Both benign and malignant
False enlargement
What are the features of chronic inflammatory enlargement?
Ballooning of interdental papilla and marginal gingiva
Discrete sessile or pedunculated mass
Slow growing masses
Painless
Caused by prolonged exposure to dental plaque
Mouth breathers from dehydration
What are the features of acute inflammatory enlargement?
Gingival abscesses
Periodontal or lateral abscess
What kind of drugs cause gingival enlargement?
Anticonvulsivants
Immunosuppressants
Calcium channel blockers
What kind of growth is induced by drugs?
Extends facially and lingually at joint of marginal and papilla.
Massive tissue fold covering the crowns
Uncomplicated muldberry shape firm, pale pink.
What are the complications that can arise from drug induced gingival growth?
Enlargement can complicate oral hygieve
Secondary inflammation due to plaque buildup
Inflammation can lead to red bluish discolouration
Hyperplasia of connective tissue can occur
What drug was first reported to cause drug induced gingival overgrowth?
Phenytoin: An epilepsy drug.
Other hydantoins also cause gingival overgrowth such as ethotoin and mephenytoin
50% of users develop gingival overgrowth
Pathogenesis is not known
What do immunosuppressants usually do?
Cyclosporine is used as an agent to prevent transplant rejection
Reversibly inhibit Th cells
What kind of enlargement do immunosuppressants such as cyclosporins and calcium channel blockers lead to?
> 500mg/day leads to more vascularized enlargement than phenytoin
What percentage of users of immunosuppressants such as cyclosporins and calcium channel blockers end up with gingival overgrowth?
25 - 70%
What alternative drug is used to suppress the immune system?
tacrolimus
What are calcium channel blockers used for?
CVD treatment (Hypertension, angina, coronary artery spasm, and arrhythmias)
What is the mechanism of action of calcium channel blockers?
Block intracellular mobilization of calcium
What are some examples of calcium channel blockers?
Diltiazem
Verapamil
Amlopdipine
Nifedipine
Felodipine
Nicardipine
Which calcium channel blocker has a 20% chance of causing gingival overgrowth?
Nifedipine
Nifedipine is used in conjunction with cyclosponine for a kidney transplant; what happens to gingiva as a result?
A larger overgrowth results
Which systemic conditions involving gingival overgrowth become magnified by plaque?
Enlargement in pregnancy
Enlargement in puberty
Vitamin C deficiency
Plasma cell gingivitis
Pyogenic granuloma
Which systemic diseases commonly result in gingival overgrowth?
Granulomatous diseases
Leukemia
What are the types of benign tumours of the gingiva?
Fibroma
Papilloma
Peripheral giant cell granuloma
Central giant cell granuloma
Leukoplakia
Gingival cyst
What are the malignant tumours of the gingiva?
Carcinoma
SCC
Malignant melanoma
What is idippathic gingival enlargement?
Rare condition with an unknown cause assocaited with congenital familial fibromatosis.
Enlargement occurs in both the facial and lingual direction up to the attached gingiva, margin and papilla.
What does idiopathic gingival enlargement look like typically?
Pink firm enlargement with leathery consistency
Severe cases crowns are completely crowded
What causes idiopathic gingival enlargement
Hereditary and can be complicated by presence of bacterial plaque.
What are the common gingival diseases seen in childhood?
Chronic marginal gingivitis (Most prevalent)
Acute gingival infections
What are the features and causes of chronic marginal gingivitis?
It is the most prevalent form of gingivitis of childhood called also puberty gingivitis and is caused by hormonal changes in males and females.
It is caused and amplified by plaque
What are common acute gingival infections?
Primary herpetic gingivo stomatitis (viral)
Candidiasis (antibiotics and immunodeficiencies)
Necrotizing ulcerative gingivitis (Malnutrition)
What are the features of desquamative gingivitis?
Intense erythema
Desquamation
Ulceration of free and attached gingiva
May be asymptomatic and causes mild burning or intense pain when symptomatic
What causes desquamative gingivitis?
75% by dermatological genesis
Cicatrical pemphigoid and lichen planus in 95% of cases
What are the differential diagnoses for desquamative gingivitis?
Bacterial infections
Fungal infections
Viral infections
How is desquamative gingivitis diagnosed?
Clinical history
Clinical examination
Biopsy
Microscopic examination
Immunofluorescence
Management and treatment
What is lichen planus?
A type of desquamative gingivitis that is an inflammatory mucocutaneous disorder of the mucosa and skin.
Reticular, atrophic, erosive, path and bullous
It is an ulcerative condition
How is lichen planus identified?
Immunofluorescence fibrin identification of basement membrane
How is lichen planus treated?
High potency steroids (Bethamethasone 0.05%)
What is pemphigoid?
Cutaneous immune mediated subepithelial bullous diseases
Basal membrane separation
What are the complications of pemphigoid?
Mucous membrane pemphigoid
Cicatrical pemphigoid
Desquamative gingivitis
Ocular lesions
How is pemphigoid treated?
Topical steroids
What is pemphigus vulgaris?
Autoimmune bullous disorder
Forms cutaneous and mucous blisters
Potentially lethal
Causes damage to cell to cell adhesion (desmosomes)
How is pemphigoid vulgaris treated?
Systemic steroids
How is lupus erythematosus identified and diagnosed?
Affects kidneys heart and skin
Causes ulceration of oral mucosa
Causes rash on malar area
It is systemic and is chronic mucocutaneous
Diagnosed by histopathology
How is lupus erythematosus treated?
Systemic or topical steroids
How is erythema multiforme identified and diagnosed?
ACUTE BULLOUS AND MACULAR MUCOCUTANEOUS DISEASE
IMMUNE COMPLEX VASCULITIS
ISCHEMIC NECROSIS OF EPITHELIUM
DESTRUCTION OF VASCULAR WALLS
NECROSIS OF EPITHELIUM AND CONNECTIVE TISSUES
LARGE ERYTHEMATOUS PAINFUL LESIONS IN THE MOUTH
What causes erythema multiforme?
Herpes simplex virus
Antibiotics
Mycoplasma infection
