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Gingivitis
Hugh Silk, MD, MPH, FAAFP
Sheila O. Stille, DMD
Nerissa P. Duchin, MD
image BASICS
DESCRIPTION
Gingivitis is a reversible form of inflammation of the gingiva. It is a mild form of periodontal disease. Classification includes the following:
  • Plaque-induced
  • Not plaque-induced (bacterial, viral, or fungal; e.g., acute necrotizing gingivitis, Vincent disease [“trench mouth”], denture-related)
  • Modified by systemic factors (e.g., pregnancy, puberty, HIV, diabetes, smoking, leukemia)
  • Modified by medications (calcium channel blockers, antipsychotics, antiepileptics, antirejection medications, hormones)
  • Modified by malnutrition (vitamin deficiencies)
  • System(s) affected: gastrointestinal; ears, nose, throat; dental
  • Synonym(s): mild periodontal disease; gum disease
Geriatric Considerations
More frequent in this age group (due more to additive effects than to increased susceptibility)
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
Pregnancy Considerations
  • Very common in pregnant women; hormonal effect
  • Self-limited
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.
  • Usually noncontagious
  • Inadequate plaque removal
  • Blood dyscrasias (pregnancy)
  • Oral contraceptives
  • Allergic reactions
  • Nutritional deficiencies
  • Vasoconstriction (nicotine, methamphetamine)
  • Endocrine/hormonal variations
    • Pregnancy
    • Menses
    • Menarche
  • 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
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” 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)
image DIAGNOSIS
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,” 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)
P.409

image TREATMENT
GENERAL MEASURES
  • Stop any contributing medications.
  • Remove irritating factors (plaque, calculus, faulty dental restorations, or partial dentures).
  • Good oral hygiene (see “General Prevention”)
  • 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
  • Débridement 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).
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Outpatient
  • No restrictions
Patient Monitoring
Until clear; dental follow-up for continued cleanings and secondary prevention
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” from the American Dental Association at http://www.mouthhealthy.org/en/ and the American Academy of Periodontology under “patient resources” 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
REFERENCES
1. Terezakis E, Needleman I, Kumar N, et al. The impact of hospitalization on oral health: a systematic review. J Clin Periodontol. 2011;38(7):628-636.
2. Stensson M, Wendt LK, Koch G, 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.
3. Widmer RP. Oral health of children with respiratory diseases. Paediatr Respir Rev. 2010;11(4):226-232.
4. Keles ZP, Keles GC, Avci B, et al. Analysis of YKL-40 acute-phase protein and interleukin-6 levels in periodontal disease. J Periodontol. 2014;85(9):1240-1246.
5. Yaacob M, Worthington HV, Deacon SA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev. 2014;(6):CD002281.
6. Klukowska M, Grender JM, Conde E, 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.
7. Sambunjak D, Nickerson JW, Poklepovic T, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011;(12):CD008829.
8. Van Strydonck DA, Slot DE, Van der Velden U, 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.
9. Babu JP, Garcia-Godoy F. 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.
10. Eliot MN, Michaud DS, Langevin SM, 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.
11. Cortelli SC, Cortelli JR, Shang H, 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.
12. McCullough M, Farah CS. The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Aust Dent J. 2008;53(4):302-305.
13. Lazarchik DA, Haywood VB. 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.
14. Puig Silla M, Montiel Company JM, Almerich Silla JM. 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.
15. Van Leeuwen MP, Slot DE, Van der Weijden GA. Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review. J Periodontol. 2011;82(2):174-194.
16. Osso D, Kanani N. Antiseptic mouth rinses: an update on comparative effectiveness, risks and recommendations. J Dent Hyg. 2013;87(1):10-18.
See Also
&NA;
  • Dental Infection; Glossitis
  • Algorithm: Bleeding Gums
Codes
&NA;
ICD10
  • K05.10 Chronic gingivitis, plaque induced
  • K05.11 Chronic gingivitis, non-plaque induced
  • K05.00 Acute gingivitis, plaque induced
Clinical Pearls
&NA;
  • 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.