GINGIVOPATHIES
I- Introduction :
The term periodontal disease is used in a general sense that encompasses all diseases of the periodontium. Anatomically, the periodontium is divided into:
– superficial covering tissues: mucous membranes and gums
– deep tissues: deep periodontium: alveolar bone, cementum and periodontium.
Periodontal diseases are subdivided into:
– Gingivopathies: which affect the superficial periodontium
– Periodontolysis: diseases that affect the deep periodontium
From an anatomopathological point of view, periodontal diseases will be linked to one of the following processes:
– Inflammatory process
– Degenerative process
– Tumor process
II- Definition
Gingivopathies are inflammatory processes that only affect the superficial periodontium (the gingival epithelium and the underlying connective tissue) without reaching and/or destroying the deep periodontal structures: there is therefore no loss of attachment in gingivitis. They are observed in both children and adults. Their causes are local and general.
Gingivitis can be:
– true when only the gum is affected,
– it can extend beyond the gingival framework and spread to the entire oral mucosa, in which case we speak of gingivostomatitis.
III- Classification of gingivopathies:
1999 ARMITAGE International Workshop: specifies the class of “gingival diseases”
A- Plaque-induced gingival diseases
1- Associated only with the plate
- Without local cofactors
- With local cofactors
2- Gingival diseases modified by systemic factors
- Endocrine
- Haematological
3- Gum diseases modified by drug treatments
- Anti-epileptic medications
- Oral contraceptives
4- Gum diseases modified by malnutrition
- Vitamin deficiency
- Other deficiency
B- non-plaque induced gum diseases
1- Specific bacterial origin
- Neisseria gonorrhea
- Treponema
- Steptococcus
2- Viral origin
- Herpetic gingivostomatitis
- Herpes
- Shingles
- Other
3- Fungal origin
- Candidiasis
- Linear gingival erythema
- Other
4- Genetic origin: gingival fibroma
5- Systemic origin
- Mucocutaneous disorders
- Allergic reaction
6- Traumatic injuries
7- Reaction to foreign bodies
8- Other origins, for example Rendu Osler’s disease.
GINGIVOPATHIES
C- Acute necrotizing gingivitis
Acute ulcerative-necrotic gingivitis is an infection caused by poor oral hygiene, stress, nutritional deficiencies, smoking or lack of sleep. It can occur at any time in life, but it generally affects people under 35 who have weak immunity or who eat an unbalanced diet. It can also affect patients who already have gingivitis and who have suffered a major emotional shock.
VI- Evolution and duration of gingivitis:
1- acute gingivitis : painful, appears suddenly and lasts very short
2- chronic gingivitis : sets in and progresses slowly, without pain, unless complicated by subacute flare-ups. It is a marginal, slow and progressive gingivitis. It is mainly related to poor hygiene. Clinically, significant bleeding is observed after exploration of the sulcus, with obvious erythema and loss of gingival granite.
Histologically, in this case, there is a rearrangement of the relationships: epithelium-connective tissue.
The epithelium proliferates and the epithelial digitations elongate into the connective tissue.
Chronic gingivitis is a permanent conflict between the destructive and reparative processes.
• On the one hand, persistent local irritants damage the gingiva, prolonging inflammation and causing abnormal vascular permeability and exudation, leading to tissue degeneration.
• On the other hand, new connective tissue cells and fibers and numerous blood vessels are formed in a constant effort of tissue repair (granulation tissue).
The reciprocal actions of destruction and repair therefore affect the color, volume, texture, contour and consistency of the gingiva.
3- subacute gingivitis: this is a less severe form than acute gingivitis.
4- recurrent gingivitis : (recurrent) reappears after having been eliminated, or after spontaneous disappearance
V- Distribution of gingivitis:
Gingivitis, depending on its distribution, can be:
– Localized: limited to the gum of one or a group of teeth
– Generalized: affecting the entire oral cavity
– Papillary: affects the papillae (the first signs of gingivitis most often appear at the level of the papillae)
– Marginal: affects the marginal gingiva
– Diffuse: affects both the marginal gingiva, the papillary gingiva and the attached gingiva. These terms can then be combined, for example: marginal gingivitis localized to the lower insisivo-canine block.
VI- Pathological variations of the gingival mucosa
A rigorous clinical examination of the gum should specify changes in color, volume, consistency, contour, texture, as well as the existence or absence of gingival bleeding.
1- Change in color of the gum:
The change in color is a very important and even determining clinical sign in gingivopathies. It varies according to the evolution and intensity of the inflammation:
a- In chronic inflammation : it begins with a slight redness, turns red, dark red, purplish red and sometimes dark blue.
b- In acute inflammation : the change in color may be marginal, localized or diffuse depending on whether the damage is more or less acute:
– it is marginal in acute necrotizing gingivitis (GUNA)
– it is diffuse in herpetic gingivostomatitis
– it is localized or diffuse in the acute reaction to chemical irritants.
Generally, and depending on the intensity, a bright red erythema is noted at the beginning, then when the acute inflammation becomes more severe, it becomes bright slate gray, to gradually become dull whitish gray. Erythema is the first reaction to irritation, produced by a dilation of the capillaries and an increase in blood flow.
C- color change due to other local or general causes:
Certain colorations of the gingival mucosa can direct the examination towards the search for a general condition:
– Paleness will suggest anemia
– Cyanosis will suggest leukemia
– The purple will evoke diabetes
– Diffuse red spots will suggest desquamative gingivitis or gingivostornatitis of menopause.
GINGIVOPATHIES
2- Volume change :
It can be increased and we speak of gingival growth. This more or less significant increase in volume, localized or generalized, can be located on the marginal gingiva, on the papillary gingiva, or be diffuse and extend to the attached gingiva. The increase in the volume of the gingiva can be due to:
– Edema: this is an inflammatory exudate from the vessels towards the inflammatory region, which manifests clinically by a more or less significant increase in the volume of the gum.
– Gingival hypertrophy
– Gingival hyperplasia
– A gum abscess
Let us recall that on the histological level, hyperplasia is an increase in the volume of a tissue or an organ due to the increase in the number of these component cells, whereas hypertrophy causes an increase in size through the increase in volume of these cellular components.
Gingival growths can be of inflammatory or non-inflammatory origin, inflammatory or result from the combination of these two phenomena.
– In the stage of hypertrophy, the gum may present an edematous, hyperthermic, soft appearance and a purplish-red color, bleeding easily, with a smooth and shiny surface.
– Hyperplasia is characterized, on the contrary, by firm, dense, slightly painful gums, whose color is almost normal.
Examples of hyperplastic and hypertrophic gingivitis:
a – Drug-induced gingival hyperplasia
a-1 – Gingival hyperplasia associated with Di-hydan (sodium diphenyl hydantoin or phenytoin)
Medicine used in the treatment of epilepsy.
Clinically: there is generalized hyperplasia of the marginal and interdental gingiva; the hyperplasia can progress to the point of covering the teeth and even interfering
With occlusion.
a-2 – Cyclosporine A-related hyperplasia
Used since 1984 to prevent organ transplant rejection reactions, and in certain autoimmune diseases. The gingival connective tissue undergoes growth.
-3 – Hyperplasia linked to calcium antagonists
In particular nifedipine (adalate R) used in the treatment of angina pectoris and high blood pressure.
b – Hyperplastic gingivitis of pregnancy (pregnancy gingivitis)
Linked to the physiological pituitary-ovarian complex, the hyperplasia is marginal or generalized papillary.
The gum is red in color, soft in consistency, smooth and shiny in appearance with a tendency to hemorrhage.
It appears in the 3rd month of pregnancy and regresses after childbirth.
c – Gingival hypertrophy linked to a vitamin C deficiency: (Scurvy)
d – Idiopathic gingival hyperplasia or gingival fibromatosis Gingival hyperplasia can be considerable, covering more or less completely the crowns of the teeth. The gingiva is dense, firm and painless.
This phenomenon can occur before the appearance of teeth, sometimes even at birth, and considerably hinder their eruption. The etiology is unknown. Affecting several members of the same family, a genetic component is suggested
e – Gingival epulis
Clinically, epulis refers to a localized hyperplastic gingival outgrowth, appearing on the marginal gingiva or the alveolar processes, especially at the level of the anterior or molar sector. A distinction is made between vascular epulis, fibrous epulis and giant cell epulis.
3- Change of surface texture of consistency:
A loss of graininess of the gingival surface is a precursor sign of gingivitis.
Chronic inflammation results in a smooth, shiny or firm, nodular surface.
Chronic desquamative gingivitis results in peeling of the gingival surface.
4- Alterations of the gingival contour:
The gingival contour becomes more or less irregular depending on the extent of the inflammation, and there are in particular two signs often linked to occlusal trauma which are:
– Stillmann fissures: These are apostrophe-shaped root denudations extending from the gingival margin in an apical direction at variable distances.
– MacCall’s festoons: “Lifebuoy” shaped hypertrophy on the marginal gingiva.
GINGIVOPATHIES
5- Gingivitis
It is the abnormal bleeding of the gums that can be spontaneous (during phonation, chewing or at night during sleep) or caused by brushing and probing the sulcus. Gingivorrhagia varies, depending on its severity, duration and the ease with which it is caused. Bleeding is the most constant sign of inflammatory gingivitis.
VII- Gingival changes during certain general syndromes:
Certain general factors modify the individual’s reaction possibilities:
– hormonal factors: bright red gums are observed which bleed at the slightest contact with an increase in volume in pregnancy (gravid), pubertal and menopausal gingivitis.
– Gingivitis in leukemia: marginal or diffuse localized or generalized increase in volume, with a purplish tint, a shiny surface and a strong tendency to hemorrhage.
– Vitamin C deficiency (scurvy): this deficiency is unable to trigger gingivopathy, but facilitates the action of local irritants by modifying healing capacities.
VIII- Main clinical pictures of acute and subacute gingivopathies :
To diagnose gingivitis, you must first look for:
The basic lesion:
1- Erythema:
The gum is soft and intensely red. The erythema is either localized or generalized. The characteristic sign of this lesion is given by the digital pressure test which makes the color disappear and reappears a few moments after the pressure stops (pit sign).
2- Erosion: These are losses of substances limited to the epithelium.
3- Ulceration: These are losses of substances reaching the basement membrane. The bottom of the lesion is often a poorly adherent “pseudo-membranous coating”.
4- Necrosis:
Tissue portion affected by mortification. The removal of necrotic tissue leaves an irregular crateriform lesion, bleeding at the slightest touch.
5- The vesicle: Epidermal elevation, as big as a pinhead, filled with a clear liquid.
6- The pustule: Vesicle whose contents are purulent.
7- The bubble: Epidermal lifting with damage to the basal. It contains a liquid and can reach a diameter of 5mm.
IX- Clinical study of some acute gingivitis:
1- Case of erythematous gingivitis: (the elementary lesion is erythema)
A red border is observed at the neck of the teeth accompanied by sometimes hyperplastic edema .
Functional signs: discreet. Pruritus, induced gingival bleeding.
2- Case of ulcerative gingivitis: (the elementary lesion is ulceration.)
The entire gingival mucosa may be affected. The papillae are decapitated, the gum is covered with bloody coatings masking the ulcerations .
Functional signs: are constant with spontaneous gingival pain or caused by chewing and/or spicy foods. There is hypersalivation, fetid breath and constant adenopathy.
GINGIVOPATHIES
3- Case of acute necrotizing gingivitis (ulcerative necrotic gingivitis): (Elementary lesions: ulceration and necrosis): This is a loss of crateriform substance bleeding at the slightest contact. The lesions: can be more or less extensive to the oral mucosa and the form will be more or less severe
Functional signs: are clearly marked with spontaneous diffuse pain, resistant to analgesics, chewing is painful with fetid breath. Adenopathy is the rule.
General signs: hyperthermia, insomnia and asthenia.
4 – Case of viral gingivitis (example: herpetic): (the elementary lesion being the vesicle): Occurs most often in children after an infectious disease (example of primary herpetic infection)
X- Conclusion
The evolution of gingivitis of local origin is towards healing by simple symptomatic treatment, that is to say, by the suppression of the cause and the establishment of suitable oral hygiene.
In the absence of complete treatment, neglected gingivitis recurs and can become complicated by gingivostomatitis or become chronic and develop into periodontitis.
v GINGIVOPATHIES
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.