Gingivitis

# Overview
Gingivitis ("inflammation of the gums") is a terminology referring to the gingival inflammation caused by bacterial biofilms adherent to tooth surfaces which is also known as plaque. It is characterized by a site-specific reversible dental plaqueinduced inflammation of the gingiva without detectable bone loss or clinical attachment loss. It is commonly prevalent among people of all ages from children, adolescents to adults which is readily seen during the dental practices. The etiology of gingivitis is multifactorial which usually shows synergistic effect by more than one factor acting together from poor oral hygiene, genetic, socioeconomic, demographic, iatrogenic, to behavioral factors. These plethora of factors seem to influence the staging process; thus, making it complicated to identify the risk factors. It is initiated by substances derived from microbial plaque accumulating at or near the gingival sulcus; where, all other suspected local and systemic etiologic factors either enhance plaque accumulation or retention, or enhance the susceptibility of the gingival tissue to microbial attack. This results in an inflammatory reaction that were initially edematous and become more fibrotic as the condition persists. The earliest clinical sign of gingival inflammation is the transudation of gingival fluid. This thin cellular transudate is gradually superseded by a fluid consisting of serum plus leucocytes. The redness of the gingival margin arises partly from the aggregation and enlargement of blood vessels in the immediate sub-epithelial connective tissue; and the loss of keratinization of the facial aspects of gingiva. However, gingivitis is commonly painless which rarely leads to spontaneous bleeding; thus, often associated with subtle clinical changes making most patients unaware of the disease or unable to recognize it. However, gingivitis has a clinical significance because it is considered the precursor of periodontitis, a disease characterized by gingival inflammation combined with connective tissue attachment and bone loss. Although, it is a reversible disorder and therapy is aimed primarily at controlling the causative or risk factors to reduce or eliminate inflammation and hence repairing the gingival tissues. Appropriate supportive periodontal maintenance through personal and professional care is important to prevent recurrences. Simple gingivitis is controlled by adequate oral hygienic measures with or without an antibacterial mouth rinse and thorough scaling via professional cleaning with hand or ultrasonic instruments.

# Classification
The gingival disease terminology and classification has been upgraded several times over the last decades. In 2017, the American Academy of Periodontology and the European Federation of Periodontology co-sponsored the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions with an objective to update the previous disease classification established at the 1999 International Workshop for Classification of Periodontal Diseases and Conditions. This workshop concluded the gingivitis case by the presence of gingival inflammation at one or more sites and bleeding on probing as the primary parameter for it's diagnosis.
Table 1: Classification of the gingivitis

# Stages
- It undergoes through four different stages which were first elaborated by Page and Schroeder in 1976 before final progression to periodontitis in cases of no timely treatment.
Table 2: Progression of the gingivitis through different level of stages

# Pathophysiology
- Gingivitis usually originates from the bacterial plaque that accumulates in the spaces between the gums and the teeth, and visible calculus (tartar) formed on the teeth.
- When the teeth are not adequately cleaned by regular brushing and flossing, bacterial plaque accumulates, and gets mineralized by calcium and other minerals in the saliva which transform them into a hard material called calculus harboring bacteria and irritating the gingiva.
- As the bacterial plaque biofilm becomes thicker, an anoxygenic environment develops which allows more pathogenic bacteria to flourish and release toxins and initiates gingival inflammation.
- Alternatively, excessive injury to the gums caused by very vigorous brushing may further lead to a cycle of recession, inflammation and infection.
- The superseded infection usually begins when the immune system of the body gets weakened due to some local or systemic conditions.
- Over the years, this inflammation and infection can cause deep pockets between the teeth and gums, and subsequent bone loss around the teeth thereby resulting in a periodontitis.

## Local factors
- Crowding of teeth makes the plaque difficult to remove completely.
- Malaligned teeth which often require orthodontic correction further adds on to the difficulty in cleansing.
- A dental prosthesis that is inadequately fitted or improperly finished can act as a nidus for the plaque accumulation.
- Eruptive gingivitis: In children, tooth eruption is also frequently associated with gingivitis, as plaque accumulation tends to increase in the area where primary teeth are exfoliating, and moreover, an oral hygiene is difficult to be maintained in the areas where permanent teeth are erupting.

## Infectious gingivitis 
- A low-grade injury to the local tissues such as fractured teeth, overhanging restorations, overextended flanges of the denture, and faulty fixed dental prosthesis with poor pontic design (saddle pontic) or over contoured margins act as a predisposing factor to it.

## Hypersensitive reaction 
- An allergens in the form of chewing gum, toothpaste, cinnamon, mint, red pepper, etc. can trigger the plasma cells infiltration in the gingiva, and causes plasma cell gingivitis.

## Nutritional gingivitis
- Dietary habits with a higher intake of refined carbohydrates and an increased ratio of omega-6 to omega-3 fatty acids can initiate the inflammatory process through activation of NFkB and oxidative stress.  

## Hormonal gingivitis
- This form of gingivitis occurs during pregnancy, puberty, or steroid therapy even without the presence of plaque.
- Pregnancy: An increase in the circulating female sex hormones causes pregnancy gingivitis. 
- Puberty: During adolescence, gingivitis observed to appear earlier in girls (eleven to thirteen years) in comparison to boys (thirteen to fourteen years). 
It has been found that the receptors in the cytoplasm of the gingival cells have a high affinity for both estrogens and testosterone. The receptors for estrogen are specifically present in the basal and spinous layers of the epithelium; whereas in the connective tissue, such receptors are found deeper in the fibroblasts and endothelial cells of small vessels. Hence, the gingiva is considered as an easy target organ for these steroid hormones resulting in gingivitis.  

## Drug induced gingivitis 
- An ability of the drug metabolites to induce the proliferation of fibroblasts is held responsible for the gingival inflammation.
- Additionally, an imbalance between the synthesis and the degradation of the extracellular matrix leads to the accumulation of immature proteins in the extracellular matrix, particularly collagen which subsequently results in gingivitis.

# Causes
- The etiology of gingivitis is multifactorial which includes from local, systemic, genetic to behavioral factors giving synergistic effect in most cases. The most common cause is an inadequate oral hygiene that leads to dental plaque formation.
Table 3: System wise causative factors of the gingivitis
Table 4: Alphabetical presentation of the causative factors of the gingivitis

# Differentiating Gingivitis from other Diseases
Table 5: Enumerate the conditions mimicking the gingivitis

# Epidemiology and Demographics

## Age
- Gingivitis is the commonest periodontal disease seen in all age groups prevailing worldwide. 
- Gingivitis occurs in half the population by the age of 4 or 5 years, and the incidence continues to increase with age.
- The prevalence peaks at close to 100% at puberty; however it declines slightly after puberty and shows constant rate into adulthood. 

## Gender predilection:
Gingivitis is more prevalent in males as compared to females as females been found to follow better oral care regimes and thus maintaining oral hygiene.
- Women: Pregnant women develops more severe form of gingivitis as compared to non-pregnant women. 
- Socioeconomic status: It is more commonly seen among low socioeconomic status as people with high social status tend to show a more positive attitude towards the maintenance of oral hygiene and have better access to health care.

# Risk Factors
- Common risk factors in the development of  gingivitis include
Table 6: List the risk factors for gingivitis 

# Complications
- Recurrence of gingivitis
- Periodontitis
- Infection or abscess of the gingiva or the jaw bones
- Trench mouth

## Acute Necrotizing Ulcerative Gingitivitis (ANUG or Trench mouth)
- Chronic gingivitis can progress to ANUG if not treated timely, oral hygiene neglected by the patient or the immune system gets compromised.
- The condition is commonly seen in developing countries where the living conditions are poor.
- Risk factors: Smoking, debilitated patients under stress, poor oral hygiene, nutritional deficiencies, immunodeficiency (eg, HIV/AIDS, use of immunosuppressive drugs), and sleep deprivation.
- Etiopathogenesis: An overgrowth of a particular type of pathogenic bacteria (fusiform-spirochete variety) which gets exacerbated in association with other risk factors.
- Clincal features: It is a severe form of gingivitis associated with pain, ulceration, marked gingival edema, spontaneous bleeding, or bleeding in response to minimal local trauma. It may be associated with altered taste (metallic taste mostly), and halitosis. Ulcerations, which are pathognomonic, are present on the dental papillae and marginal gingiva. They have a characteristically punched-out appearance and are covered by a gray pseudomembrane. Swallowing and talking may be painful. Regional lymphadenopathy often is present.
- Treatment: Debridement, rinses (eg, hydrogen peroxide, chlorhexidine) and improved oral hygiene. If debridement is delayed, oral antibiotics (eg, amoxicillin 500 mg every 8 hours, erythromycin 250 mg every 6 hours, or tetracycline 250 mg every 6 hours) may help to provide relief and can be continued until 72 hours after symptoms resolve. 

# Prognosis
- Gingivitis can easily be resolved in its early stages if identified and treated timely.
- However, if left untreated; chronic cases can progress to periodontitis which thereby results in bone destruction and tooth loss.

# Clinical presentation
- The clinical manifestations are usually episodic phenomenal characterized by discontinuous bursts of acute inflammation which are mostly transient or persistent.
- Onset: It can be acute or chronic, and can be either localized or generalized which is categorized as follows: 
Marginal gingivitis: An inflammation confined to the gingival margin.
Papillary gingivitis: It involves an inflammation of an interdental papillae.
Diffuse gingivitis: It has extensive involvement of the gingival margin, attached gingiva, and interdental papillae.
- Marginal gingivitis: An inflammation confined to the gingival margin.
- Papillary gingivitis: It involves an inflammation of an interdental papillae.
- Diffuse gingivitis: It has extensive involvement of the gingival margin, attached gingiva, and interdental papillae.

## Clinical symptoms
The symptoms of gingivitis are as follows:
- Swollen gums
- Mouth sores
- Bright-red, or purple gums
- Shiny gums
- Gums that are painless, except when pressure is applied
- Gums that bleed easily on gentle brushing and flossing
- Gums that itch with varying degrees of severity
- Receding gumline

## Clinical signs
Table 7: Elaborates the clinical signs of gingivitis seen on the physical examination  

# Diagnosis
- A detailed history review and physical examination (Table 7) should be performed.
- Clinical evaluation: Finding erythematous and friable tissue at the gum margins confirm the diagnosis. To detect early gingival disease, the depth of the pocket around each tooth should be measured. Depths < 3 mm are normal; however, the deeper pockets are at high risk of gingivitis and periodontitis. 
- Laboratory test: Not routinely required.
- Radiographs: As gingivitis is a soft tissue disease, radiographic evaluation is not helpful. However, it should be done to rule out periodontitis or other differential disorder. 

# Treatment
- Treatment approach: An interprofessional approach is required to identify the causes of gingivitis and to intervene at an early stage to stop the progression to periodontitis.
- Aim: To restore the inflamed tissues to clinical health, and then to maintain clinically healthy gingivae, and subsequently preventing periodontitis.
- Stepwise approach: 
A dentist or dental hygienist will perform a thorough cleaning of the teeth and gums, and remove localized factors promoting the inflammatory response. This includes scaling to thoroughly remove biofilm and deposits on the tooth structure, and laser decontamination of the sulcus if possible. The removal of plaque is usually not painful, and the inflammation subsides by one and two weeks.
Ensure oral hygiene reinforcement by twice daily tooth brushing; and once daily interdental cleaning with an interdental brush or dental floss; and adjunctive chemical plaque control agents (such as chlorhexidine or essential oil-containing mouthwash).
Address the modifiable systemic or local factors by changing the medication if drug induced; prescribing supplements in case of nutritional deficiency; and an identification of faulty prosthesis should be done and replaced.
In severe cases, patients can also be prescribed oral antibiotics.
- A dentist or dental hygienist will perform a thorough cleaning of the teeth and gums, and remove localized factors promoting the inflammatory response. This includes scaling to thoroughly remove biofilm and deposits on the tooth structure, and laser decontamination of the sulcus if possible. The removal of plaque is usually not painful, and the inflammation subsides by one and two weeks.
- Ensure oral hygiene reinforcement by twice daily tooth brushing; and once daily interdental cleaning with an interdental brush or dental floss; and adjunctive chemical plaque control agents (such as chlorhexidine or essential oil-containing mouthwash).
- Address the modifiable systemic or local factors by changing the medication if drug induced; prescribing supplements in case of nutritional deficiency; and an identification of faulty prosthesis should be done and replaced.
- In severe cases, patients can also be prescribed oral antibiotics.

# Prevention
- Oral hygiene: Maintaining a good oral hygiene can prevent the formation of plaque and gingivitis. Patients should be taught about the correct brushing technique, frequency of brushing (twice daily) and the use of floss. 
Brushing: Brushing after meals including the tongue helps to remove food debris and plaque trapped between your teeth and gums.
Floss: Flossing at least once a day helps remove food particles and plaque between teeth and along the gum line that toothbrush cant quite reach.
Swish with mouthwash: Mouthwash and gel containing antiseptic and anti-inflammatory properties can also be advised to the patient.
- Brushing: Brushing after meals including the tongue helps to remove food debris and plaque trapped between your teeth and gums.
- Floss: Flossing at least once a day helps remove food particles and plaque between teeth and along the gum line that toothbrush cant quite reach.
- Swish with mouthwash: Mouthwash and gel containing antiseptic and anti-inflammatory properties can also be advised to the patient.
- Balanced diet: An importance of a balanced diet should be emphasized.
- Dentist visit: A routine cleaning by a dentist or hygienist at 6-month to 1-year intervals can help minimize gingivitis. Patients with systemic disorders predisposing to gingivitis require more frequent professional cleanings (from every 2 weeks to every 3 months). 
- Know your risk: Age, smoking, diet, drugs, and genetics can all increase the risk for gingival disease.