Sit Dolor Amet

• “Health is a state of complete physical, mental and social well-being

and not merely an absence of disease or infirmity.”WHO 1948: 19456
No 2:1

• Thus, periodontal health should be defined as a state free from

inflammatory periodontal disease that allows an individual to
function normally and avoid physical or mental consequences due to
current or past disease.
Clinical
Features
A systematic clinical approach requires an orderly
examination of the gingiva for:
• Colour
• Contour
• Consistency
• Surface texture
• Position
• Bleeding (on probing)
• Pain
 Hallmarks of Gingivitis
Normal Colour Changes in the disease with condition
Coral Pink In chronic gingivitis: Varying shades of red, reddish pink, reddish
(sometimes associated with melanin pigmentation) blue, deep blue.

Normal contour Changes in the disease with conditions

Marginal gingiva: Scalloped and knife edged Chronic gingivitis: Marginal gingiva becomes rolled or rounded.
Interdental papilla becomes blunt and flat.
Interdental papilla:
Anterior- Pyramidal Necrotizing gingivitis: Punched out or crater-like depressions at the
Posterior- tent shaped crest of the interdental papilla extending to the marginal gingiva.

Stillman’s cleft: Apostrophe-shaped indentations extending from

and into the gingival margins for varying distances on the facial
surfaces.

McCall’s festoons: Lifesaver like enlargements of the marginal

gingiva.
Normal Consistency Changes in the disease with conditions

Firm and resilient Soft and edematous, Fibrotic, Fibro-

edematous.

Normal Size Changes in the disease with conditions

Appears normal without any alterations Gingival enlargement: The size of the gingiva is
enlarged, could be inflammatory or
noninflammatory.
Mostly associated with pseudo- pockets.

Normal surface texture Changes in the disease with conditions

Stippling present (orange peel appearance) Gingivitis: Loss of Stippling

Normal Healthy Gingiva Inflamed Gingival Unit - Changes in
Color, Contour and Consistency

A B

A. Stillman’s cleft B. McCall’s Festoon Gingival Enlargement

 Necrotizing
Gingivitis

• Necrotizing gingivitis: Punched out or

crater-like depressions at the crest of the
interdental papilla extending to the marginal
gingiva.
 Bleeding on
Probing (BOP)

• Normally, gingival bleeding is not evident.

• The insertion of a probe to the bottom of the
pocket elicits bleeding if the gingiva is inflamed and
the pocket epithelium is atrophic or ulcerated.
• Bleeding may occur spontaneously or delayed by
30 to 60 seconds after probing.
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Gingival Bleeding on Probing
 The two earliest signs of gingival inflammation that precede
established gingivitis are
 increased gingival crevicular fluid production and
 bleeding from the gingival sulcus on gentle probing.

 Gingival bleeding varies in severity, duration, and ease of

provocation.

 Bleeding on probing (BOP) is easily detected clinically and therefore

is of value for early diagnosis and for prevention of more advanced
gingivitis.

 BOP appears earlier than a change in color or other visual signs of

inflammation.

 The use of bleeding rather than color changes to diagnose early

gingival inflammation is advantageous, in that bleeding is a more
objective sign that requires less subjective estimation by the
examiner.
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Effect of smoking on BOP

 Numerous studies have shown that current cigarette smoking suppresses

the gingival inflammatory response, and smoking was found to exert a
strong, chronic, dose-dependent suppressive effect on gingival BOP.

 Research has revealed an increase in gingival BOP in patients who quit

smoking, and people who are committed to a smoking cessation program
should be informed about the possibility of an increase in gingival bleeding
associated with smoking cessation.
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Gingival Bleeding caused by local factors

 Factors that contribute to plaque retention and may

lead to gingivitis include anatomic and developmental
tooth variations, caries, frenum pull, iatrogenic factors,
malpositioned teeth, mouth breathing, overhangs, partial
dentures, lack of attached gingiva, and recession.

 Orthodontic treatment and fixed retainers are associated

with increased plaque retention and increased BOP.

 The most common cause of abnormal gingival BOP is

chronic inflammation.

 Chronic or recurrent bleeding in inflamed gingiva can be

provoked by mechanical trauma (e.g., toothbrushing,
toothpicks, food impaction) or by biting into solid foods
(e.g., apples).
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Medications and gingival bleeding

 Drugs such as antiplatelet medications (e.g., aspirin) or

anticoagulants (e.g., warfarin) that are prescribed for specific medical
indications also increase the bleeding tendencies of gingival tissues.

 Women taking oral contraceptives are significantly more prone to

gingivitis and therefore to gingival bleeding.
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Gingival bleeding associated with systemic
changes
Hemorrhagic disorders in which abnormal gingival
bleeding is encountered include,

 vitamin C deficiency

 Platelet disorders (e.g., thrombocytopenic purpura),

 Hypoprothrombinemia (e.g., vitamin K deficiency)

 Other coagulation defects (e.g., hemophilia, leukemia,

Christmas disease),

 Multiple myeloma,
 The effects of hormonal replacement
therapy, oral contraceptives, pregnancy,
and the menstrual cycle are also reported
to affect gingival bleeding.

Pregnancy Gingivitis

 Pregnancy gingivitis affects many

pregnant women and is primarily caused
by the hormonal imbalances associated
with pregnancy. It is characterized by mild
to severe gingival inflammation along with
pain and, in some cases, significant
hyperplasia and bleeding.

Pregnancy
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 Diabetes is an endocrine condition with a well-characterized effect on

gingivitis.

 In diabetes, marked inflammation affects both epithelial and connective

tissues, leading to degeneration of the dermal papilla, an increase in the
number of inflammatory cells, the destruction of reticulin fibers, and an
accumulation of dense collagen fibers that causes fibrosis.
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Color changes in the gingiva

The color of the gingiva is determined by several factors, including

 the number and size of blood vessels,

 the epithelial thickness,

 the quantity of keratinization, and

 the pigments in the epithelium.

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Color changes in the gingiva

 Change in color is an important clinical sign of gingival disease.

 The normal gingival color is coral pink, and it is produced by the tissue's
vascularity and modified by the overlying epithelial layers.

 The gingiva becomes red when vascularization increases or the degree

of epithelial keratinization is reduced or disappears. The color becomes
pale when vascularization is reduced (in association with fibrosis of the
corium) or epithelial keratinization increases.

 Chronic inflammation intensifies the red or bluish red color as a result

of vascular proliferation and a reduction of keratinization. Venous stasis
contributes a bluish hue.

 The changes start in the interdental papillae and gingival margin and
then spread to the attached gingiva.
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Color changes associated with systemic
factors
 Endogenous oral pigmentation can be caused by melanin, bilirubin, or
iron.

 Diseases that increase melanin pigmentation:

 Addison disease is caused by adrenal dysfunction, and it produces isolated
patches of discoloration that vary from bluish black to brown.
 Peutz–Jeghers syndrome produces intestinal polyposis and melanin
pigmentation in the oral mucosa and lips.
 Albright syndrome (i.e., polyostotic fibrous dysplasia) and von
Recklinghausen disease (i.e., neurofibromatosis) produce areas of oral
melanin pigmentation.
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Metallic Pigmentation

 Heavy metals (i.e., bismuth, arsenic,

mercury, lead, and silver) that are
absorbed systemically as a result of
therapeutic use or occupational or
household exposures can discolor the
gingiva and other areas of the oral
mucosa.

 These changes are rare, but they should

be ruled out in suspected cases.

 Metals typically produce a black or bluish

line in the gingiva that follows the
contour of the margin. The pigmentation
may also appear as isolated black
blotches involving the interdental
marginal and attached gingiva.

 This is different from the tattooing

produced by the accidental embedding
of amalgam or other metal fragments.
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Changes in gingival consistency
 Chronic and acute inflammations
produce changes in the normal
firm and resilient consistency of
the gingiva.

 In patients with chronic gingivitis,

destructive (i.e., edematous) and
reparative (i.e., fibrotic) changes
coexist, and the consistency of
the gingiva is determined by their
relative predominance.
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Changes in gingival surface texture

Stippling and Its Clinical Importance

 Healthy, attached gingiva has a pitted orange-peel appearance on its

surface. This surface feature, called stippling, is an external reflection of
the underlying connective tissue projections into the overlying epithelium.

 Stippling is restricted to the attached gingiva and is predominantly

localized to the subpapillary area, but it extends to various degrees into
the interdental papilla.

 Presence of stippling in the attached gingiva is indicative of gingival health,

and this surface feature is usually lost when the tissue is edematous.
+
Changes in gingival position
Gingival recession

 By clinical definition, recession is exposure of

the root surface by an apical shift in the
position of the gingiva.

 To understand recession, it helps to distinguish

between the actual and apparent positions of
the gingiva.

 The actual position is the level of the coronal

end of the epithelial attachment on the tooth,
whereas the apparent position is the level of
the crest of the gingival margin.

 The severity of recession is usually determined

by the apparent position of the gingiva.

 However, the actual gingival position is used to

determine the clinical attachment loss.
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The following etiologic factors have been implicated in gingival recession:

 Faulty toothbrushing technique (i.e., gingival abrasion),

 Tooth malposition,

 Friction from the soft tissues (i.e., gingival ablation),

 Gingival inflammation,

 Abnormal frenum attachment, and

 Iatrogenic dentistry.
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Clinical Significance

 Several aspects of gingival recession make it clinically significant.

 Exposed root surfaces are susceptible to caries.

 Abrasion or erosion of the cementum exposed by recession leaves an

underlying dentinal surface that can be sensitive.

 Hyperemia of the pulp and associated symptoms can result from excessive
exposure of the root surface.

 Interproximal recession creates oral hygiene problems results in plaque

accumulation.
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Changes in gingival contour

 Changes in gingival contour are primarily associated

with gingival enlargement, but changes may also occur
with other conditions.

 The term Stillman cleft has been used to describe a

specific type of gingival recession that consists of a
narrow, triangular-shaped gingival recession. As the
recession progresses apically, the cleft becomes
broader, thereby exposing the cementum of the root
surface.

 The term McCall festoon has been used to describe a

rolled, thickened band of gingiva that is usually seen
adjacent to the cuspids when recession approaches the
mucogingival junction.
 PERIODONTAL DISEASES & CONDITIONS
 PERIODONTAL HEALTH AND GINGIVAL DISEASES AND CONDITIONS.
 Periodontal health and gingival health.
 Gingivitis: Dental Biofilm Induced.
 Gingivitis: Non Dental Biofilm Induced.
 PERIODONTITIS.
 Necrotizing Periodontal Diseases.
 Periodontitis.
 Periodontal manifestation of systemic diseases and conditions.
 OTHER CONDITIONS AFFECTING PERIODONTIUM
 Systemic diseases or conditions affecting periodontal supporting tissues.
 Periodontal abscess and endodontic periodontal lesions
 Mucogingival deformities and conditions.
 Traumatic occlusal forces.
 Tooth and prosthesis related factors.
 PERI-IMPLANT DISEASES AND CONDITIONS.
 Pristine health:
FREE GINGIVAE
Gingival Does it exist? Is it
margin
Sulcular
natural?
epithelium
(
SE)
Gingival
crevice/
sulcus Gingivae
Junctional
epithelium
Alveolar Periodontal
(JE)
bone ligament

Neuro- Alveolar
bone
vascular
bundle
Periodontal Cementum
ligament
(PDL)
 SPECTRUM OF CLINICAL PERIODONTAL HEALTH

 Absence of bleeding on probing, erythema and edema, patient symptoms

and attachment and bone loss. Physiological bone level range from 1.0 to
3.0 mm apical to CEJ.

 Clinical gingival health is generally associated with an inflammatory

infiltrate and a host response consistent with homeostasis.

32
 Reduced periodontium
• Stable periodontitis patient:
– successfully treated periodontitis patient
• Non periodontitis patient:
– ( e.g., recession, crown lengthening).

 In presence of reduced clinical attachment and bone level.

 Successfully treated, stable periodontitis patient remain at increased risk

of recurrent progression.

22
 34

 Gingivitis on an intact periodontium.

 Gingivitis on a reduced periodontium in a non

periodontitis patient ( e.g., recession, crown
lengthening).

 Gingival inflammation on reduced peridontium in a

successfully treated periodontitis patient (recurrent
periodontitis cannot be ruled out).
 SCENARIOS FOLLOWING TRANSITION FROM HEALTH

Patient with
Gingivitis Periodontitis
periodontal
Patient Patient
health

Periodontal
therapy

Periodontitis Periodontitis
Patient: Periodontitis Patient:
Stable case Patient: Unstable
of Case with case of
periodontal some gingival recurrent
health periodontitis
inflammation

35
 Health and gingivitis on an intact periodontium and
on a reduced periodontium: underpinning principles
Classification

Patient with Gingivitis patient Periodontitis

periodontal health patient

Periodontal therapy

Periodontitis Periodontitis Periodontitis

patient: patient: patient:
Diagnosis Periodontal
Gingivitis Stable Remission Unstable
Health
BoP <10% BoP ≥ 10% PPD ≥ 5mm or
PPD ≤ 4mm PPD ≤ 4mm PPD ≥ 4mm & BoP
No BoP at 4mm sites No BoP at 4mm sites
What are the diagnostic criteria for a gingivitis case?

Clinical , radiological, and biological signs and symptoms

1. Gingivitis is a clinical diagnosis. While emerging technologies are

starting to shed light on the microbiological, molecular, and
pathophysiological characteristics of gingivitis, definitive knowledge is not
sufficient to supersede current clinical parameters.

2. The clinical signs of inflammation are erythema, edema, pain

(soreness), heat, and loss of function.

3. These may manifest clinically in gingivitis as:

a. Swelling, seen as loss of knife-edged gingival margin and blunting of

papillae

b. Bleeding on gentle probing

c. Redness

d. Discomfort on gentle probing

What are the diagnostic criteria for a gingivitis case?

Clinical , radiological, and biological signs and symptoms

4. The symptoms a patient may report include:

a. Bleeding gums (metallic/altered taste)

b. Pain (soreness)

c. Halitosis

d. Difficulty eating

e. Appearance (swollen red gums)

f. Reduced oral health–related quality of life

5. Radiographs cannot be used to diagnose gingivitis.

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