Gingivitis
Gingivitis: Excerpt from The 5-Minute Pediatric Consult
Shannon Connor Phillips, MD
Gingivitis - BASICS
Gingivitis - description
Reversible or chronic inflammation of the gum tissue margin surrounding the teeth. Symptoms may include bleeding, swelling, ulceration, and pain. Gingivitis is usually mild and asymptomatic. Some degree of gingivitis is usually associated with the onset of puberty. An intact gingival epithelium and salivary secretions that continuously flush the crevices with serum components that protect against infection are the oral cavity’s best defense against gingivitis and early periodontal disease.
Gingivitis - general prevention
- Consistent daily oral hygiene:
- Infants: Gum massage, washcloth to remove plaque
- Young children: Assistance with brushing with a small amount of fluoridated toothpaste
- School-aged children: Supervise brushing and assist if necessary.
- Fluorides: Supplements are appropriate if the water supply is not fluoridated.
- Sealants: Adherent plastic coating may be applied to the pits and fissures of the permanent teeth to provide a mechanical barrier.
- Begin regular dental checkups every 6 months when child is 3 years of age. Children with gingival overgrowth, HIV, or ongoing chemotherapy need visits to the dentist every 3 months to ensure good hygiene. Routine daily care may be inconsistent and often impossible in children with motor and cognitive limitations; these children also need more frequent visits to the dentist.
- Children with fixed appliances (orthodontic): Careful brushing and flossing is critical, fluoride or cetylpyridinium mouth rinses are used for some patients (under dentist’s care).
- Mouth guards for competitive sports
Establishing a consistent daily oral care routine prevents and treats gingivitis.
Gingivitis - epidemiology
Gingivitis - incidence
- Affects >90% of children between the ages of 4 and 13 years, although it is generally low grade.
- Between 13% and 40% of children 6–36 months of age have eruption gingivitis, which commonly resolves after teeth break through the gum.
- Boys have more severe and prevalent gingivitis than girls until the early teen years.
- Peak incidence is in adolescence, probably due to hormonal influences and inconsistent dental hygiene.
- Intraoral piercings contribute to poor dental hygiene and gingivitis.
Gingivitis - risk factors
- Behavioral factors: Smoking, stress, alcohol consumption
- Medications (antiepileptics, cyclosporine, calcium channel blockers)
- Pregnancy
- Diabetes mellitus
- Chronic renal failure
- Immunologic deficiency (HIV, Chediak-Higashi, cyclic neutropenia)
- Histiocytosis X
- Scleroderma
- Secondary hyperparathyroidism
- Neurologic problems: Cerebral palsy, mental retardation, seizures, and other conditions where routine dental care is difficult.
Gingivitis - pathophysiology
- Bacteria and food deposits adherent to the teeth (plaque) may accumulate, eroding the area where the gum and teeth meet.
- Incomplete or improper dental care over time may result in inflammation of the gum margin, with loss of vascular membrane integrity, increased bleeding, and low-grade infections.
- Inflammation may be more severe in children with altered or suppressed immune function.
- If allowed to progress, the inflammation may involve the connective tissue attachment of the teeth and the root surface, and result in irreversible periodontal disease.
- Microscopic changes include edema, exudate, ulceration, and proliferation of the epithelium surrounding the tooth.
Gingivitis - etiology
- Poor dental hygiene
- Caries
- Bacterial plaque, calcified and noncalcified
- Mouth breathing
- Orthodontic appliances
- Malocclusion
- Crowded teeth
- Erupting teeth margins
- Poor nutrition: Vitamin deficiencies (e.g., vitamin C deficiency), diet low in coarse detergentlike foods (e.g., raw carrots, celery, apples), high prevalence of anaerobic microflora
- Infections: Herpes simplex virus (HSV) type I, Candida albicans, HIV, bacterial pathogens
- Drugs: Phenytoin, cyclosporine, nifedipine, exogenous hormones (e.g., oral contraceptive pills)
- Trauma
Gingivitis - DIAGNOSIS
Gingivitis - signs & symptoms
- Bleeding at gum line
- Spontaneous bleeding
- Pain near the gingival margin
Gingivitis - history
- Dental appliances worn by patient:
- Orthodontic equipment makes gingiva more difficult to clean, and reactive tissue growth is more common.
- Regular medications taken by patient:
- Phenytoin may result in gingival hyperplasia, and chemotherapeutic agents, exogenous hormone therapy, and calcium channel blockers may result in gingivitis.
- Review significant medical history, asking about bleeding disorders and immunodeficiency.
- Review the diet of the child to assess for nutritional deficiencies.
- Review the frequency of dental care visits and the home dental hygiene regimen.
Gingivitis - physical exam
- Examine the face and neck for signs of swelling, erythema, and warmth, which may be signs of more extensive bacterial infection.
- Evaluate the gingival tissue for erythema, swelling, ulceration, fluctuance, or drainage.
- Evaluate the teeth for caries, fractures, looseness, malocclusion, pain, and plaque.
- Tanner staging: Normal pubertal changes seem to aggravate gingival inflammation.
- Assess the patient’s oral hygiene technique in the office. This is the single largest contributor to gingivitis.
Gingivitis - tests
Gingivitis - lab
- Most patients will not need laboratory evaluation.
- CBC with differential: With concern for excess bleeding, which may be due to thrombocytopenia or pancytopenia
- Blood culture: With concern for sepsis complicating the picture
- Direct fluorescent antibody testing for HSV-1: If herpes is suspected (stomatitis is usually present); swab the base of a stoma/vesicle and smear on a slide. HSV culture is the gold standard.
- Biopsy is rarely necessary.
Gingivitis - imaging
Panoramic or individual tooth radiographic imaging is important to assess the bones for evidence of periodontal extension of the gingivitis in the more significant cases.
Gingivitis - differencial diagnosis
- Infectious:
- Traumatic:
- Food impaction
- Orthodontic appliances
- Self-inflicted minor injury
- Hematologic:
- Gingival bleeding due to hemophilia (factor VIII or IX deficiency)
- Thrombocytopenia
- Immunologic:
- Neutrophil disorders
- Leukemia
- HIV
- Graft-versus-host disease (infiltrative gingivitis)
- Miscellaneous:
- Gingival hyperplasia due to medications (i.e., phenytoin and nifedipine)
Gingivitis - TREATMENT
Gingivitis - general measures
Gingivitis - activity
A daily oral care routine including brushing and flossing is essential to preventing gingivitis. Sonic toothbrushes are more adept at removing plaque and maintaining good gum hygiene effective than manual brushing.
Gingivitis - special therapy
- Mild gingivitis:
- Mechanical plaque and calculus removal by scaling or root planning
- Careful daily dental hygiene, including meticulous brushing and flossing
- Moderate to severe gingivitis:
- Care as outlined for mild gingivitis
- Should be evaluated by a pedodontist (if available) or by a general dentist
- Mouth rinses for plaque inhibition (e.g., 0.12% chlorhexidine or 0.075% or 0.1% cetylpyridinium chloride)
- Irrigation devices
- Sonic toothbrushes
- Gingivectomies in cases of overgrowth to permit better cleaning
- Antibiotics to cover mouth flora in more severe cases when bacterial superinfection is suspected
Gingivitis - medication
Gingivitis - first line
Mouth rinses for plaque inhibition (e.g., 0.12% chlorhexidine or 0.075% or 0.1% cetylpyridinium chloride) can be used to augment daily oral care routine.
Gingivitis - surgery
Only the most severe cases require gingivectomy.
Gingivitis - FOLLOW UP
- Routine dental care with professional cleaning and plaque removal is recommended for all children and adults.
- Appliances to restrict gingival growth may be used in select cases.
Gingivitis - disposition
Gingivitis - issues for referral
When gingival inflammation is noted, referral to a dentist is suggested. Routine dental examination, cleaning and patient education will control most gingivitis. If the extent of involvement is great or the underlying disease of the patient requires more aggressive care, a periodontist should be consulted.
Gingivitis - prognosis
- Good oral hygiene may reverse mild to moderate gingivitis within several months.
- Periodontal disease is not reversible; therefore, prevention is essential.
Gingivitis - complications
- Periodontal disease
- Osteomyelitis
- Tooth decay
- Sepsis, particularly in patients who are immunocompromised
Gingivitis - patient monitoring
Routine dental exam and cleaning should be performed every 6 months to monitor for signs of inflammation.
Gingivitis - bibliography
American Academy of Pediatric Dentistry. Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children. Available at: http://www.aapd.org/media/Policies_Guidelines/ G_Periodicity. pdf. Accessed October 3, 2007.American Academy of Periodontology. Treatment of plaque-induced gingivitis, chronic periodontitis and other clinical conditions. Available at: http://www.aapd.org/media/Policies_Guidelines/ E_Plaque.pdf. Accessed October 3, 2007.- Jenkins WM, Papapanou PN. Epidemiology of periodontal disease in children and adolescents. Periodontology 2000. 2001;26:16–32.
- Kallio PJ. Health promotion and behavioral approaches in the prevention of periodontal disease in children and adolescents. Periodontology 2000. 2001;26:135–145.
- Mankodi S, Bauroth K, Witt JJ, et al. A 6-month clinical trial to study the effects of a cetylpyridinium chloride mouthrinse on gingivitis and plaque. Am J Dent. 2005;18:9A–14A.
- Shyama M, Honkala E, Honkala S, et al. Effect of xylitol candies on plaque and gingival indices in physically disabled school pupils. J Clin Dent. 2006;17:17–21.
- Stocokey GK, Beiswanger B, Mau M, et al. A 6-month clinical study assessing the safety and efficacy of two cetylpyridinium mouthrinses. Am J Dent. 2005;18:24A–28A.
Gingivitis - CODES
Gingivitis - icd9
523.1 Chronic gingivitis
Gingivitis - PATIENT TEACHING-MED
Gingivitis - diet
- Avoid high sugar content food and beverages.
- Xylitol-containing chewing gum can improve oral hygiene by reducing plaque adherence to the gum line.
Gingivitis - activity
Spend time establishing good brushing and flossing techniques in early childhood.
Gingivitis - prevent
- Establish a daily mouth care routine.
- Brushing and flossing each morning and at bedtime will reduce plaque formation.
- Mouth rinses, if recommended by your dentist, can also reduce plaque formation.
- See the dental health professional every 6 months beginning at your child’s 1st birthday for examination and cleaning.
Gingivitis - FAQ
- Q: Are there differences among toothpastes and prevention of gingivitis?
- A: Yes. A study demonstrated that stabilized stannous fluoride toothpaste is effective in preventing gingivitis. When essential-oil mouthwashes (e.g., Listerine) are added, there is additional reduction in the amount of gingivitis noted.
- Q: What dietary changes may improve gingival health?
- A: Avoiding frequent carbohydrate intake may reduce gingivitis. Carbonated beverages, sugared chewing gum, and candy often adhere to teeth. When daily dental care is inconsistent, plaque formation is increased and gingivitis is much more likely.
- Q: Why do children generally not have the significant periodontal disease that adults get?
- A: No one knows for sure; however, it is known that the gingiva of the primary dentition is rounder and thicker and contains more blood vessels and less connective tissue than the gingival seen later in life. Whether these differences mask disease or are helpful is unclear.
- Q: How do intraoral piercings impact gum health?
- A: In addition to fractured teeth, gingival recession and gingivitis are complications of the trauma inflicted by a foreign body in the oral cavity.
- Q: Why is smoking associated with gingival disease?
- A: Nicotine inhibits phagocyte and neutrophil function, reduces bone mineralization, impairs vascularization, and reduces antibody production. Smokers do not respond as well as nonsmokers to surgical and nonsurgical treatment.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Gingivitis
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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