Gingival Health and Plaque Induced Gingivitis

Question 1

What are the 4 levels of periodontal health?

Answer 1

1) pristine periodontal health with a structurally sound and uninflammed periodontium
2) well-maintained clinical periodontal health with a structurally and clinically sound (intact) periodontium
3) periodontal stability, with a reduced periodontium
4) periodontal disease remission/control, with a reduced periodontium
3/4 have the ability to control modifying factors and therapeutic response

Question 2

Periodontal health ( __ of clinical signs and symptoms of inflammation) can exist ____ disease commences BUT can be restored to an anatomically ____ periodontium as well.

Answer 2

absence
before
reduced

Question 3

what are the microbiological determinants of clinical periodontal health?

Answer 3

• supra gingival plaque composition

- sub gingival biofilm composition

Question 4

What are the host determinants of clinical periodontal health?

Answer 4

Local predisposing factors:
 - periodontal pockets
 - dental restorations
 - root anatomy
 - tooth position and crowding 
Systemic modifying factors:
 - host immune function
 - systemic health
 - genetics

Question 5

What are predisposing factors?

Answer 5

any agent or condition that contributes to the accumulation of dental plaque

Question 6

what’s modifying factors?

Answer 6

any agent or condition that alters the way in which an individual responds to subgingival plaque accumulation

Question 7

What’s plaque induced gingivitis?

Answer 7

• an inflammatory response of the gingival tissues resulting from bacterial plaque accumulation located at and below the gingival margin
• a loss of symbiosis between the biofilm and the host’s immune-inflammatory response, and development of incipient dysbiosis
• various systemic factors, including endocrinopathies, hematologic conditions, diet, and drugs can modify the immune-inflammatory response

Question 8

What are some common clinical changes from health to gingivitis?

Answer 8

• color
• texture/edema
• bleeding
• exudate
• plaque

Question 9

What are the color changes in the gingiva?

Answer 9

• normal gingival color: coral pink+ pigmentation
  (tissue’s vascularity and overlying epithelial layers)
• inflamed gingiva: red
  (increased vascularization and decreased epithelial keratinization)
• severely inflamed gingiva: red and cyanotic) vascular proliferation and reduction in keratinization + venous stasis)
• changes start at interdental papilla and gingival margin and spread to the attached gingiva

Question 10

When does gingival bleeding occur?

Answer 10

• with increasing inflammation:
  
  • dilation and engorgement of the capillaries
  • thinning or ulceration of the sulcular epithelium
• chronic or recurrent bleeding, provoked by trauma
• spontaneous bleeding occurs in acute/severe gingival disease and may be related to systemic health problems

Question 11

What are the changes in the consistency of the gingiva that can occur?

Answer 11

• health gingiva is firm and resilient
• with inflammation:
  
  • increase in extracellular fluid and exudate
  • degeneration of connective tissue and epithelium
  • engorged connective tissue and thinning of epithelium
• soft, swollen (edema), friable
• in severe gingival disease:
  
  • sloughing with grayish flake-like debris (necrosis)
• chronic inflammation can induce fibrosis and epithelial proliferation
  
  • firm, leathery gingival tissue consistency

Question 12

what are the changes in surface texture of the gingiva that can occur?

Answer 12

• healthy gingiva - dull surface texture with stippling present in some cases
• with inflammation:
  
  • loss of stippling
  • smooth and shiny (if exudate changes occur)
  • firm and nodule (if fibrotic changes occur)

Question 13

What is the shape of the gingival margin?

Answer 13

• in health gingiva
  
  • scalloped with gingiva filling interdental scallops (presence of papilla)
• with inflammation
  
  • knife edge gingival adaptation or loose gingival margins
  • in some cases, clefts (stillman’s) or festoons (McCall’s) may develop

Question 14

What’s gingival enlargement?

Answer 14

• enlargement: increase in size
• chronic inflammatory response characteristic with exudative and proliferative features
• clinically deep red lesions with soft, friable, smooth, shiny surface and bleeding tendency
• also, relatively firm, resilient and pink lesions with greater fibrotic component, abundant fibroblasts and collagen fibers

Question 15

what are the characteristics common to all dental plaque induced inflammatory gingival conditions?

Answer 15

1) signs and symptoms limited to gingiva
2) reversibility of the disease by removing the etiology
3) the presence of high dental plaque
4) systemic modifying factors which can alter the severity of inflammation
5) stable (non-changing) attachment levels on a periodontium which may or may not experience a loss of attachment or alveolar bone

Question 16

what are some characteristics of plaque-induced gingivitis?

Answer 16

1) plaque present at gingival margin
2) disease begins at the gingival margin (inflammation confined to the free and attached gingiva and doesn’t extend beyond MGJ)
3) reversible with plaque removal
4) change in color
5) change in gingival contour
6) sulcular temperature change
7) increased gingival exudate
8) bleeding upon provocation
9) absence of attachment loss
10) absence of bone loss
11) histological changes
4/8 varies among individuals
9-11 - stable (unchanging) attachment levels on a periodontium, which may or may not have experienced a loss of attachment or alveolar bone

Question 17

What’s the classification of plaque-induced gingivitis?

Answer 17

A. associated with dental biofilm only 
B. potential modifying factors for plaque-induced gingivitis
  1)  systemic conditions
        - sex steroids 
            * puberty
            * menstrual cycle
            * pregnancy
            * oral contraceptives
        - hyperglycemia
        - leukemia 
        - smoking
        - malnutrition
   2) oral factors enhancing plaque accumulation
       - prominent sub gingival restoration margins
       - hypo salivation 
C. drug-influenced gingival enlargements

Question 18

What can cause gingival diseases caused by non-dental biofilm-induced?

Answer 18

• genetic/development disorders
• specific infections
• inflammatory and immune conditions
• reactive processes
• neoplasms
• endocrine, nutritional and metabolic diseases
• traumatic lesions
• gingival pigmentation

Question 19

what’s peri-mucositis?

Answer 19

gingivitis around implants (inflammation limited to mucosa)

Question 20

What can be the severity and extent of inflammation?

Answer 20

• mild inflammation: minor change in color and little change in the texture of the tissue
• moderate inflammation: glazing, redness, edema, enlargement and bleeding upon probing
• severe inflammation: overt redness and edema with a tendency toward bleeding when touched rather than probed.
• generalized: >_30% of the sites with clinical signs of gingival inflammation
• incipient gingivitis: only a few sites are affected with mild signs of gingival inflammation can be considered “gingival health” having high risk of developing “gingivitis”

Question 21

what can be the severity and extent of enlargement?

Answer 21

• mild gingival enlargement: gingival papilla
• moderate gingival enlargement: gingival papilla and marginal gingiva
• severe gingival enlargement: gingival papilla, gingival margin and attached gingiva
• generalized gingival enlargement: >_30% of the sites with clinical signs of gingival inflammation
• localized gingival enlargement: limited to the gingiva in relation to a single tooth or group of teeth, while generalized enlargement involves the gingiva throughout the mouth

Question 22

What is plaque-induced gingivitis on a reduced periodontium characterized by?

Answer 22

its characterized by the return of bacterially induced inflammation to the gingival margin on a reduced periodontium with no evidence of progressive attachment loss (no indication of active diseases). The common clinical and microbial findings are the same as plaque-induced gingivitis on a full periodontium except for the presence of pre-existing attachment loss and therefore a higher risk of periodontitis, unless professional, tailored supportive care regimes are in place.

Question 23

what’s plaque-induced gingivitis on a reduced periodontium?

Answer 23

• reduced periodontium following active periodontal treatment and the resolution of inflammation from periodontitis is a common finding

Question 24

what’s the cause of gingivitis?

Answer 24

• primary etiologic factor = bacterial plaque (not enough data to support specific bacterial phenotypes associated with gingivitis)
• secondary etiological factors = local factors
  
  • calculus
  • marginal deficiencies in restoration and rough surfaces
  • malocclusion
  • tooth/root anomalies

Question 25

Does periodontitis start with gingivitis?

Answer 25

Yes, but gingivitis don’ts always progress into periodontitis

• progression of the inflammatory process to the underlying connective tissue attachment and periodontal ligament
• the return of inflammation to sites treated for periodontitis is common
• the recurrent inflammation may be confined to the gingival tissues and may not cause further attachment loss

Question 26

plaque-induced gingivitis ___ directly cause tooth loss

Answer 26

does not

Question 27

managing gingivitis is a primary _______ for periodontitis

Answer 27

preventative strategy

Question 28

plaque-induced gingivitis is the most common form ____

Answer 28

periodontal disease

Question 29

What are some examples of biologic changes in the transcription of genes from non-inflammated to inflamed gingival units?

Answer 29

• host-bacterial interactions (ex: microbial pattern recognition molecules)
• host cell chemotaxis
• phagocytosis and degranulation
• novel cellular/molecular pathway signaling (ex: cytokine signaling and cell adhesion)
• T lymphocyte response
• angiogenesis
• epithelial immune response

Question 30

what can plaque-induced gingivitis be exacerbated by?

Answer 30

sex steroid hormones (androgens, estrogen’s and progestins)

• plaque bacteria in conjunction with elevated steroid hormone levels are necessary to produce a gingival inflammation
  1) puberty
  2) pregnancy
  3) oral contraceptives

Question 31

how are gingivitis and puberty related?

Answer 31

an increase in gingival inflammation in circumpubertal age and in both genders w/o a concomitant increase in plaque levels

• localized and host response mediated by high levels of hormones (estrogen and testosterone)
• mouth breathing can be a secondary factor

Question 32

how are gingivitis and menstrual cycle related?

Answer 32

• modest inflammatory changes that may be observable during ovulation
• increase in gingival crevicular fluid flow by at least 20% during ovulation in over 75% of women tested
• a modest change in women with pre-existing periodontal conditions
• most women with menstrual cycle -associated gingival inflammation will present clinically non-detectable conditions.