Chapter 39. Gingivitis and Periodontal Disease

A 35-year-old woman presents to clinic for a routine physical examination. She says that for the last 6 months her gums bleed when she brushes her teeth. She reports smoking 1 pack of cigarettes per day. The oral examination finds generalized plaque and red swollen intradental papilla (Figure 39-1). The physician explains to her that she has gingivitis and that she should brush twice daily and use floss daily. The physician tells her that smoking is terrible for her health in all ways, including her oral health. The physician offers her help to quit smoking and refers her to a dentist for a cleaning and full dental examination.

Gingivitis is the inflammation of the gingiva (gums). Gingivitis alone does not affect the underlying supporting structures of the teeth and is reversible (Figure 39-1).

Periodontitis (periodontal disease) is a chronic inflammatory disease, which includes gingivitis along with loss of connective tissue and bone support for the teeth. It damages alveolar bone (the bone of the jaw in which the roots of the teeth are connected) and the periodontal ligaments that hold the roots in place. It is a major cause of tooth loss in adults (Figures 39-2, 39-3, and 39-4).

• Gingivitis and periodontal diseases are the most common oral diseases in adults.
• It is estimated that 35% of adults 30 years of age or older in the United States have periodontal disease: 22% have a severe form and 13% have a moderate-to-severe form.1
• Homeless persons are a very high-risk group for gingivitis, periodontitis, and all dental disease (Figure 39-4).
• Periodontal disease has been shown in some studies to be an associated factor in coronary heart disease and chronic kidney disease.2
• Periodontal disease in pregnancy is associated with an increase in preterm birth.3,4

• Periodontal diseases are caused by bacteria in dental plaque that create an inflammatory response in gingival tissues (gingivitis) or in the soft tissue and bone supporting the teeth (periodontitis).
• The normal healthy gingival attachments form the gingival cuff around the tooth to help protect the underlying bone and teeth from the bacteria of the mouth.
• Gingivitis is caused by a reversible inflammatory process that occurs as the result of prolonged exposure of the gingival tissues to plaque and tartar (Figure 39-2).
• Gingivitis may be classified by appearance (e.g., ulcerative, hemorrhagic), etiology (e.g., drugs, hormones), duration (e.g., acute, chronic), or by quality (e.g., mild, moderate, or severe).
• A severe form, acute necrotizing ulcerative gingivitis (ANUG) (Figure 39-5), also known as Vincent disease or trench mouth, is associated with α-hemolytic streptococci, anaerobic fusiform bacteria, and nontreponemal oral spirochetes. The term trench mouth was coined in World War I when ANUG was common among soldiers in the trenches. Predisposing factors now include diabetes, HIV, and chemotherapy.2
• The most common form of gingivitis is chronic gingivitis induced by plaque (Figure 39-1). This type of gingivitis occurs in half of the population 4 years of age or older. The inflammation worsens as mineralized plaque forms calculus (tartar) at and below the gum surface (sulcus). The plaque that covers calculus causes destruction of bone (an irreversible condition) and loose teeth, which result in tooth mobility and tooth loss.
• Gingivitis may persist for months or years without progressing to periodontitis. This suggests that host susceptibility plays an important role in the development of periodontal disease.5

Risk factors that contribute to the development of periodontal disease include poor oral hygiene, smoking, alcohol dependence, environmental factors (e.g., crowded teeth and mouth breathing), and comorbid conditions, such as a weakened immune status (e.g., HIV, steroids, or diabetes), low educational attainment, and low income.6-8

Clinical Features

• Simple or marginal gingivitis first cause swelling of the intradental papillae and later affect the gingiva and dental interface (see Figures 39-1, 39-2, 39-3, and 39-4).
• Mild gingivitis is painless and may bleed when brushing or eating hard foods.
• ANUG (Figure 39-5) is painful, ulcerative, and edematous, and produces halitosis and bleeding gingival tissue. Patients with ANUG may have systemic symptoms such as myalgias and fever.

Typical Distribution

Gingivitis begins at the gingival and dental margins and may extend onto the alveolar ridges.

Laboratory Studies and Imaging

Radiographs of the mouth are used to evaluate for bone loss in periodontal disease.

• Gingivitis can be from poor dental hygiene only or secondary to conditions that affect the immune system such as diabetes, Addison disease, HIV, and pregnancy.
• Gingival hyperplasia is an overgrowth of the gingiva with various etiologies, including medications such as calcium channel blockers, phenytoin, and cyclosporine. This can occur with or without coexisting gingivitis (see Chapter 40, Gingival Hyperplasia).

• Recommend smoking cessation for all patients who smoke.7 SOR A Offer help to support the patients' smoking cessation efforts with behavioral counseling and pharmacologic methods (see Chapter 236, Tobacco Addiction). SOR A
• Recommend alcohol cessation for patients with alcoholism and refer to Alcoholics Anonymous (AA) or another resource. For patients in whom alcohol use is heavy but addiction has not been diagnosed, at least recommend a decrease in alcohol use (see ­Chapter 237, Alcoholism).8 SOR B
• Dental experts recommend tooth brushing twice a day and flossing daily. SOR C However, a Cochrane systematic review failed to show a benefit for daily flossing on plaque and clinical parameters of gingivitis.9 SOR A
• Some experts suggest that electric toothbrushes may have additional benefit over manual brushing, but this remains unproven. SOR C In fact, one study of dental students showed that one electric toothbrush was no better than two different manual toothbrushes with respect to plaque control.10 SOR B
• Systematic reviews indicate that there is strong evidence supporting the efficacy of chlorhexidine as an antiplaque, antigingivitis mouthrinse.11 SOR A Mouthwashes should not be used as a replacement for tooth brushing. Chlorhexidine oropharyngeal 0.12% is available as a generic mouthrinse. Recommended dosing is 15 mL to swish (for 30 seconds) and spit twice daily.
• The treatments with chlorhexidine (gel and spray) achieved a significant reduction in plaque and gingival bleeding in children with special needs. The parents/caregivers preferred the administration of chlorhexidine in spray form.12 SOR B
• In patients with ANUG, treatment involves antibiotics, NSAIDs, and topical 2% viscous lidocaine for pain relief. Oral rinses with saline, hydrogen peroxide 3% solution, or chlorhexidine 0.12% may be of benefit. SOR C
• Antibiotics recommended for ANUG include penicillin VK, erythromycin, doxycycline, and clindamycin. SOR C
• Everyone should receive ongoing care from a dental professional for prevention and treatment of periodontal disease.

• No smoking or tobacco use at all.
• Avoid alcohol and drug abuse.
• Good oral hygiene with tooth brushing and flossing.
• Dental visits at least twice yearly even during pregnancy.

• There is no safe level of smoking. Quitting is crucial to good health.
• Drink alcohol in moderation or not at all.
• Practice good oral hygiene to remove plaque (i.e., brush twice a day and use floss daily).
• Consider use of chlorhexidine-containing mouthrinse.
• Consult a dentist for regular check-ups, especially when the condition does not improve after using good oral hygiene.
• Pregnancy is not a contraindication for dental visits and cleaning.

Follow up patients with ANUG closely. All patients need regular dental care and follow-up with their dentist.

Patient Resources

• PubMed Health. Gingivitis—http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002051/.
• The American Academy of Periodontology. Types of Gum Disease—http://www.perio.org/consumer/2a.html.

Provider Resources

• Stephen JM. Gingivitis—http://emedicine.medscape.com/article/763801.