Gingivitis

Gingivitis is reversible inflammation of the gingiva without loss of periodontal attachment. The dental plaque biofilm at the gingival margin is the cause of plaque induced disease, which affects most of the population at some point; moderate to severe gingivitis affects about 50 percent of adults. Inflammation appears within 10 to 21 days of plaque accumulation (experimental gingivitis) and resolves within 1 week of restored hygiene.

Modifying factors are hormonal changes (puberty, pregnancy, oral contraceptives), medicines (phenytoin, nifedipine, amlodipine and ciclosporin cause gingival overgrowth), systemic diseases (diabetes, leukaemia, vitamin C deficiency, HIV), smoking (suppresses the bleeding sign), mouth breathing, calculus, overhanging restorations and crowded teeth.

Non-plaque-induced gingival lesions include viral infection (primary herpetic gingivostomatitis), fungal infection, desquamative gingivitis from lichen planus or pemphigoid, and allergic reactions. Untreated plaque gingivitis progresses to periodontitis in susceptible persons.

• Red, swollen, shiny gingival margin and interdental papillae, loss of stippling.
• Bleeding on brushing, flossing or probing; spontaneous bleeding in severe cases.
• Halitosis, altered taste, minimal pain.
• Gingival enlargement (generalised in pregnancy, drug induced, or leukaemic), pyogenic granuloma (localised pregnancy epulis).
• Linear gingival erythema in HIV (a red band along the margin disproportionate to plaque).
• Probing depths normal (3 mm or less) with no attachment loss or bone loss.
• Red flags: marked gingival infiltration with purpura (leukaemia), widespread painful ulceration, rapid onset in a young patient, and fever.

• Clinical diagnosis: bleeding on probing at 10 percent or more of sites without attachment loss; localised (10 to 30 percent) or generalised (over 30 percent).
• Plaque index and gingival index scoring; probing depth and attachment level to exclude periodontitis.
• Bitewing radiographs: normal crestal bone level.
• Investigations for severe, persistent or atypical gingivitis: full blood count with film, fasting glucose or HbA1c, HIV test, vitamin C and iron studies, and drug history review.
• Biopsy for persistent desquamative or plaque independent lesions.
• Exclude periodontitis, necrotising gingivitis, leukaemic gingival infiltration, herpetic gingivostomatitis, candidiasis, and mucous membrane pemphigoid.

• Mechanical plaque removal is the treatment: professional scaling and polishing, removal of calculus and plaque retentive factors (overhangs, defective restorations), and oral hygiene training (brush twice daily for 2 minutes with fluoride toothpaste, interdental cleaning daily).
• Chlorhexidine gluconate 0.12 to 0.2 percent mouthwash 10 to 15 mL rinsed for 1 minute twice daily for 14 days as an adjunct, avoiding use within 30 minutes of toothpaste; main adverse effects are tooth staining, taste disturbance and mucosal desquamation.
• Essential oil mouthwash twice daily for long term use as an alternative to chlorhexidine.
• Drug induced overgrowth: improve hygiene; with ciclosporin or phenytoin, ask the prescriber to consider substitution (azithromycin 500 mg orally once daily for 3 days has been used to reduce ciclosporin overgrowth); gingivectomy for fibrotic overgrowth that is unresponsive.
• Pregnancy gingivitis: hygiene care and scaling in any trimester; epulis is excised after delivery if it persists.
• Systemic modifiers: control glucose, treat vitamin C deficiency (ascorbic acid 500 mg orally once daily for 4 weeks), and HIV care with antiretroviral therapy.
• Review at 2 to 4 weeks; return of bleeding on probing to under 10 percent denotes health.
• Prevention: 6-monthly dental review (3-monthly if high risk), fluoride toothpaste, and sugar reduction.
• Counselling: gingivitis is fully reversible; failure to improve implies another diagnosis or modifier.