Dental Plaque Induced Gingival Diseases

Medical word for gum bleeding is “gingivitis”. Gingivitis  is inflammation of the gingiva. Plaque induced gingivitis is the most common form of gingival disease. This may occur on a periodontist with no attachment loss or on a periodontist with a previous attachment loss that is stable and not progressing. Plaque induced gingival disease is the result of plaque bacteria and defence cells of the host

What are the features of the healthy gingiva?

• The healthy gingiva fits snugly around the teeth, filling each interproximal space between the teeth to the contact area.
• The gingiva ends in a thin delicate edge called the free gingiva, which s adherent to the tooth. A jet of air from a syringe will blow the free gingiva away from the tooth surface, but the gingiva settles back into place quickly.
• The colour of the normal gingiva is pale, cool coral pink
• In adults, the tissue is dense, firm and insensitive to maderate pressure, it does not bleed easily and it has a stipples orange peel surface
• The free and attached gingiva blends smoothly with the redder, glossy, unstippled alveolar mucosa of the vestibule and floor of the mouth.
• In children , the gingiva is not stipples and appears redder and more delicate.
• Attached gingiva is firmly bound down to the underlying one to form a tough mucoperiosteum.

Which age group is affected by Gingival Diseases?

It is generally accepted that periodontal disease is world wide in distribution and that there is no age group except in very young infants in which it does not occur. Although all races are affected, there is some difference in incidence between diff races and different countries. Men were affected more frequently than women.

This Bactria and host interaction is modified by local and systemic factors.

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Local Factors:-

1. Microorganisms
2. calculus
3. food impaction
4. Faulty or irritating restorations or appliances
5. mouth breathing
6. tooth malposition

systemic Factors:-

1. Nutritional deficiencies
2. drug action
3. Endocrine changes associated with puberty, pregnancy, menstrual cycle, and diabetes mellitus
4. Allergy
5. Heredity
6. Psychic phenomena
7. Specific granulomatoud infections
8. Neutrophil dysfunction
9. Immunopathies

Microorganisms:-

Many varieties of microorganisms usually grows as biofilm or plaque, for the most part, on the self cleansing areas of the teeth, particularly below the cervical convex it you of the crown and in the cervical areas. Smears of the material taken from the normal gingival sulcus, the gingival sulcus in a case of marginal periodontitis or from the gingival pocket in advanced periodontal disease will reveal several microorganisms of many different types. Prominent among these will be Cocci, various types of bacilli, fusiform organisms, spirochetes, and in advanced periodontitis, amoebas and trichomonads.

The normal oral flora is so vast, however and is made up of so many varieties of microorganisms that it has never been possible to prove conclusively that any one type of microorganisms is of greater importance than others as far as periodontal diseases are conserved. The plaque associated with gingivitis and early periodontitis is complex. In the early stages of gingivitis the Actinomyces group of organisms is the dominant genus in the supragingival plaque.

Plaque or plaque derived endotoxins may act as irritants or antigens in both nonspecific acute inflammatory responses and immune mechanisms of defence. One of the prime functions of the immune response is to activate the inflammatory system.

Specific microorganisms sometimes cause an inflammatory reaction of the gingiva, although the clinical appearance may be entirely nonspecific.

calculus:-

Calculus, whether in a supragingival or subgingival position, causes irritation of the contracting gingival tissue. This irritation is probably caused by the byproduct’s of the microorganisms, although the mechanical friction resulting from the hard, rough surface of the calculus may play a role.

Food impaction and General Oral Neglect:-

The impaction of the food and accumulation of debris on the teeth because of oral neglect result in gingivitis through irritation of the gingiva by toxins of microorganisms growing in this medium. The degradation of food debris may also prove irritating to the gingival tissues.

Faulty or irritating Restorations or Appliances:-

Faulty restorations may act as irritants to gingival tissues and thereby induce gingivitis. Overhanging margins of proximal restorations may directly irritate the gingiva and in addition allow the collection of food debris and organisms that further injure these tissues. Improperly contoured restorations may also produce gingival irritation by causing food packing or abnormal excursions of food against the gingiva during mastication.

Mouth breathing:-

Drying of the oral mucous membrane because of breathing with the mouth open, because of an environment of excessive heat, or from excessive smoking, will result in gingival irritation, with accompanying inflammation or sometimes hyperplasia.

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Tooth malposition:-

Teeth which have erupted or which have been moved out of physiologic occlusion, where they are repeatedly subjected to abnormal forces during mastication, are apparently very susceptible to the development of periodontal disease. Calculus may be deposited on the surface of malposed tooth; the bacteria present attack the tissue around this tooth.

Chemical or Drug application:-

Many drugs are potentially capable of inducing gingivitis, particularly an acute case of gingivitis, owing to a direct local or systemic irritating action. For example, phenol, silver nitrate, the volatile oils, or aspirin, if applied to the gingiva, will provoke an inflammatory reaction.

Nutritional Disturbances:-

Nutritional imbalance is frequently manifested in changes n gingiva and deeper underlying periodontitis. An adequate intake, absorption and utilisation of the various vitamins, minerals and other food stuffs are essential to the maintenance of a normal periodontitis.

Pregnancy:–

The gingiva undergoes certain changes during pregnancy which have been termed

Pregnancy gingivitis. The appearance of the gingiva in the pregnant women varies from an unchanged to a smooth, shiny, deeply reddened gingiva with frequent focal enlargement and intense hyperaemia of the interdental papilla. Occasionally, a single tumour like mass will develop, the pregnancy tumour which is histologically identical with the pyogenic granuloma. Pregnancy induces a hypersensitive response to a mild injury which otherwise would have been innocuous. This gingivitis clinically nonspecific in appearance, may occur near the end of the first trimester and may regress or even completely disappear at the termination of the pregnancy.

Diabetes Mellitus:-

Diabetes has been repeatedly reported in association with severe periodontal disease, especially in younger people. It has not been proven that diabolical a specific cause of severe periodontal disease,  since many patients with diabetes have normal periodontal structures. However in uncontrolled diabetes, many metabolic processes are affected including those which make up resistance to infection or trauma. The effectiveness of the healing process is decreased possibly as a result of a disturbance i cellular carbohydrate metabolism. Therefore considering the periodontist located in the oral cavity with its many predisposing factors including calculus, bacteria and trauma, it is not surprise that this structure appears to be break down more readily in persons with uncontrolled diabetes than in normal people.

Other Endocrine Dysfunctions:-

Gingivitis is reported to occur with some frequency in puberty as the so called puberty gingivitis. The gingiva appears hyperaemic and edematous. The fact that many adolescents are chronic mouth breathers as a result of lymphoid hyperplasia of the tonsils and adenoids has suggested that the endocrine basis is relatively unimportant, while the mouth breathing being the actual cause of the condition.

Gingivitis associated with menstruation has been reported by many. In addition a nonspecific gingivitis with gingival bleeding, vicarious menstruation may occur sometimes. This phenomenon is rare.

Psychiatric Phenomena:-

Psychiatric disturbances appear to have a definite influence upon the severity of periodontal disease. The severity of periodontal disease significantly greater in psychiatric patients. The severity of periodontal disease increased significantly as the degree of anxiety increased. The severity of periodontal disease decreased significantly in both normal and psychiatric patients as the educational level of the patient increased.

What ere the symptoms of the Gingivitis?

The most common form of gingival disease is Chronic gingivitis. The clinical features of Chronic gingivitis are

• Gingivitis may be localized or generalised. It sometimes involves only the marginal gingiva, known as marginal gingivitisor interdental papilla, papillary gingivitis.when hyperaemia and swelling of the marginal gingiva are confined to a localized area of the gingiva, the affected area sometimes assumes a crescent shape and has been termed a ‘traumatic crescent’
• Slight alterations in colour of the free or marginal gingiva from a light to a deeper hue of pink, progressing to red or reddish blue as the hyperemia  and inflammatory infiltrate become more intense.
• Bleeding from gingival sulcus following even mild irritation such as tooth brushing or probing is also an early feature of gingivitis.
• Edema which invariably accompanies the inflammatory response as it causes a slight swelling of the gingiva and loss of stippling
• Inflammatory swelling of interdental papillae often produces a somewhat bulbous appearance of these structures. This increase in the size of the gingiva favours the collection of more debris with increased bacteria accumulations which in turn induce more gingival irritation.
• when there is marked enlargement due to edema and fibrosis as a result of chronic, the process is called hyperplasia gingivitis.
• Pus from the gingival sulcus by pressure may occur in advanced Chronic gingivitis.

Radiological Features:-

Chronic gingivitis in which the inflammation is limited strictly to the gingiva, does not manifest changes in the underlying bone. When bony changes become evident, the condition is termed periodontitis.

What is the treatment for the Gingivitis?

Most cases of Chronic gingivitis are due to local irritation. If the irritants are removed at this stage, the inflammation with its attendant swelling due to hyperaemia, edema will disappear within a matter of hours or a few days, leaving no permanent damage.

• Recovery usually follows the removal of the irritants.
• Early treatment followed up by proper brushing of teeth and frequent prophylaxis.
• Brush your teeth more effectively.Make sure you brush for 2 minutes, 2 times every day. Consider an electric toothbrush that will give you a more thorough cleaning than a manual brush. Pay special attention to the gum line, as that is where a lot of toxic plaque bacteria can build up, and a healthier mouth starts at the gums.
• Dental scaling should be done to remove the calculus, plaque
• Chemical plaque control methods such as using mouthwashes are recommended.
• Floss daily. Flossing is a great tool for the treatment of gingivitis, as it removes food particles that can feed plaque that your toothbrush could miss.
• If there is poor response to good local therapy, a search should be made for systemic factors, which might be complicating.