Gingivitis is a non-destructive disease that causes

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

of the

gums The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lin ...

. The most common form of gingivitis, and the most common form of

periodontal disease Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main caus ...

overall, is in response to bacterial

biofilms A biofilm comprises any syntrophic consortium of microorganisms in which cells stick to each other and often also to a surface. These adherent cells become embedded within a slimy extracellular matrix that is composed of extracellular po ...

(also called

plaque Plaque may refer to: Commemorations or awards * Commemorative plaque, a plate or tablet fixed to a wall to mark an event, person, etc. * Memorial Plaque (medallion), issued to next-of-kin of dead British military personnel after World War I * Pl ...

) that is attached to tooth surfaces, termed ''plaque-induced gingivitis''. Most forms of gingivitis are plaque-induced. While some cases of gingivitis never progress to

periodontitis Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cau ...

, periodontitis is always preceded by gingivitis. Gingivitis is reversible with good oral hygiene; however, without treatment, gingivitis can progress to periodontitis, in which the inflammation of the

results in tissue destruction and

bone resorption Bone resorption is resorption of bone tissue, that is, the process by which osteoclasts break down the tissue in bones and release the minerals, resulting in a transfer of calcium from bone tissue to the blood. The osteoclasts are multi-nuclea ...

around the teeth. Periodontitis can ultimately lead to

tooth loss Tooth loss is a process in which one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth (baby teeth), when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of inju ...

Signs and symptoms

The symptoms of gingivitis are somewhat non-specific and manifest in the gum tissue as the classic signs of inflammation: *Swollen gums *Bright red gums *Gums that are tender or painful to the touch *Bleeding gums or bleeding after brushing and/or flossing *Bad breath (

halitosis Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant breath odour is present. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder. ...

) Additionally, the

stippling Stippling is the creation of a pattern simulating varying degrees of solidity or shading by using small dots. Such a pattern may occur in nature and these effects are frequently emulated by artists. Art In printmaking, stipple engraving is ...

that normally exists in the gum tissue of some individuals will often disappear and the gums may appear shiny when the gum tissue becomes swollen and stretched over the inflamed underlying connective tissue. The accumulation may also emit an unpleasant odor. When the gingiva are swollen, the

epithelial Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercell ...

lining of the gingival crevice becomes

ulcer An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...

ated and the gums will bleed more easily with even gentle brushing, and especially when flossing.

Complications

* Recurrence of gingivitis * Periodontitis * Infection or abscess of the gingiva or the jaw bones * Trench mouth (bacterial infection and

ulceration An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...

of the gums) *

Swollen lymph nodes Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...

* Associated with

premature birth Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 2 ...

and low birth weight

Alzheimer's and dementia

A new study from 2018 found evidence that gingivitis bacteria may be linked to Alzheimer's disease. Scientists agree that more research is needed to prove a cause and effect link. "Studies have also found that the bacteria ''

P. gingivalis ''Porphyromonas gingivalis'' belongs to the phylum ''Bacteroidota'' and is a nonmotile, Gram-negative, rod-shaped, anaerobic, pathogenic bacterium. It forms black colonies on blood agar. It is found in the oral cavity, where it is implicated i ...

'' – which are responsible for many forms of gum disease – can migrate from the mouth to the brain in mice. And on entry to the brain, ''P. gingivalis'' can reproduce all of the characteristic features of Alzheimer’s disease."

Cause

The cause of plaque-induced gingivitis is bacterial plaque, which acts to initiate the body's host response. This, in turn, can lead to destruction of the gingival tissues, which may progress to destruction of the periodontal attachment apparatus. The

accumulates in the small gaps between teeth, in the gingival grooves and in areas known as ''plaque traps'': locations that serve to accumulate and maintain plaque. Examples of plaque traps include bulky and overhanging restorative margins, clasps of

removable partial denture A removable partial denture (RPD) is a denture for a partially edentulous patient who desires to have replacement teeth for functional or aesthetic reasons and who cannot have a bridge (a fixed partial denture) for any reason, such as a lack of ...

s and

calculus Calculus, originally called infinitesimal calculus or "the calculus of infinitesimals", is the mathematical study of continuous change, in the same way that geometry is the study of shape, and algebra is the study of generalizations of arithm ...

(tartar) that forms on teeth. Although these accumulations may be tiny, the bacteria in them produce chemicals, such as degradative enzymes, and toxins, such as

lipopolysaccharide Lipopolysaccharides (LPS) are large molecules consisting of a lipid and a polysaccharide that are bacterial toxins. They are composed of an O-antigen, an outer core, and an inner core all joined by a covalent bond, and are found in the outer ...

(LPS, otherwise known as

endotoxin Lipopolysaccharides (LPS) are large molecules consisting of a lipid and a polysaccharide that are bacterial toxins. They are composed of an O-antigen, an outer core, and an inner core all joined by a covalent bond, and are found in the outer m ...

) or lipoteichoic acid (LTA), that promote an inflammatory response in the gum tissue. This inflammation can cause an enlargement of the gingiva and subsequent formation. Early plaque in health consists of a relatively simple bacterial community dominated by

Gram-positive In bacteriology, gram-positive bacteria are bacteria that give a positive result in the Gram stain test, which is traditionally used to quickly classify bacteria into two broad categories according to their type of cell wall. Gram-positive bact ...

cocci A coccus (plural cocci) is any bacterium or archaeon that has a spherical, ovoid, or generally round shape. Bacteria are categorized based on their shapes into three classes: cocci (spherical-shaped), bacillus (rod-shaped) and spiral ( of whi ...

and rods. As plaque matures and gingivitis develops, the communities become increasingly complex with higher proportions of

Gram-negative Gram-negative bacteria are bacteria that do not retain the crystal violet stain used in the Gram staining method of bacterial differentiation. They are characterized by their cell envelopes, which are composed of a thin peptidoglycan cell wa ...

rods, fusiforms, filaments, spirilla and spirochetes. Later experimental gingivitis studies, using culture, provided more information regarding the specific bacterial species present in plaque. Taxa associated with gingivitis included '' Fusobacterium nucleatum'' subspecies ''polymorphum'', '' Lachnospiraceae'' -2species HOT100, '' Lautropia'' species HOTA94, and ''

Prevotella oulorum ''Prevotella'' is a genus of Gram-negative bacteria. ''Prevotella'' spp. are members of the oral, vaginal, and gut microbiota and are often recovered from anaerobic infections of the respiratory tract. These infections include aspiration pneu ...

'' (a species of ''

Prevotella ''Prevotella'' is a genus of Gram-negative bacteria. ''Prevotella'' spp. are members of the oral, vaginal, and gut microbiota and are often recovered from anaerobic infections of the respiratory tract. These infections include aspiration pn ...

'' bacterium), whilst '' Rothia dentocariosa'' was associated with periodontal health. Further study of these taxa is warranted and may lead to new therapeutic approaches to prevent periodontal disease including systemic health.

Risk factors

Risk factors associated with gingivitis include the following: *age * osteoporosis *low dental care utilization *poor oral hygiene *overly aggressive oral hygiene such as brushing with stiff bristles *

mouth breathing Mouth breathing, medically known as chronic oral ventilation, is long-term breathing through the mouth. It often is caused by an obstruction to breathing through the nose, the innate breathing organ in the human body. Chronic mouth breathing ma ...

during sleep *Orthodontic braces *medications and conditions that dry the mouth *

cigarette smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...

*genetic factors *stress *mental health issues such as depression *pre-existing conditions such as

diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...

Diagnosis

Gingivitis is a category of periodontal disease in which there is no loss of bone but inflammation and bleeding are present. Each tooth is divided into four gingival units (mesial, distal, buccal, and lingual) and given a score from 0–3 based on the gingival index. The four scores are then averaged to give each tooth a single score. The diagnosis of the periodontal disease gingivitis is done by a dentist. The diagnosis is based on clinical assessment data acquired during a comprehensive periodontal exam. Either a registered dental hygienist or a dentist may perform the comprehensive periodontal exam but the data interpretation and diagnosis are done by the dentist. The comprehensive periodontal exam consists of a visual exam, a series of radiographs, probing of the gingiva, determining the extent of current or past damage to the periodontium and a comprehensive review of the medical and dental histories. Current research shows that activity levels of the following enzymes in saliva samples are associated with periodontal destruction:

aspartate aminotransferase Aspartate transaminase (AST) or aspartate aminotransferase, also known as AspAT/ASAT/AAT or (serum) glutamic oxaloacetic transaminase (GOT, SGOT), is a pyridoxal phosphate (PLP)-dependent transaminase enzyme () that was first described by Arthur ...

(AST),

alanine aminotransferase Alanine transaminase (ALT) is a transaminase enzyme (). It is also called alanine aminotransferase (ALT or ALAT) and was formerly called serum glutamate-pyruvate transaminase or serum glutamic-pyruvic transaminase (SGPT) and was first character ...

(ALT),

gamma glutamyl transferase Gamma-glutamyltransferase (also γ-glutamyltransferase, GGT, gamma-GT, gamma-glutamyl transpeptidase; ) is a transferase (a type of enzyme) that catalyzes the transfer of gamma- glutamyl functional groups from molecules such as glutathione t ...

(GGT), alkaline phosphatase (ALP), and acid phosphatase (ACP). Therefore, these enzyme biomarkers may be used to aid in the diagnosis and treatment of gingivitis and periodontitis. A dental hygienist or dentist will check for the symptoms of gingivitis, and may also examine the amount of plaque in the oral cavity. A dental hygienist or dentist will also look for signs of

using

X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

s or periodontal probing as well as other methods. If gingivitis is not responsive to treatment, referral to a

periodontist Periodontology or periodontics (from Ancient Greek , – 'around'; and , – 'tooth', genitive , ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting ...

(a specialist in diseases of the gingiva and bone around teeth and dental implants) for further treatment may be necessary.

Classification

1999 Classification

As defined by the 1999 World Workshop in Clinical Periodontics, there are two primary categories of

gingival The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lini ...

diseases, each with numerous subgroups: # Dental plaque-induced gingival diseases. ## Gingivitis associated with plaque only ## Gingival diseases modified by systemic factors ## Gingival diseases modified by medications ## Gingival diseases modified by malnutrition # Non-plaque-induced gingival lesions ## Gingival diseases of specific bacterial origin ## Gingival diseases of viral origin ## Gingival diseases of fungal origin ## Gingival diseases of genetic origin ## Gingival manifestations of systemic conditions ## Traumatic lesions ## Foreign body reactions ## Not otherwise specified

2017 Classification

As defined by the 2017 World Workshop, periodontal health, gingival diseases/ conditions have been categorised into the following: # Periodontal health and gingival health ## Clinical gingival health on an intact periodontium ## Clinical gingival health on a reduced periodontium ### Stable periodontitis patient ### Non-periodontitis patient # Gingivitis – dental biofilm-induced ## Associated with dental biofilm alone ## Mediated by systemic or local risk factors ## Drug-influenced gingival enlargement # Gingival diseases – non-dental biofilm induced ## Genetic/ developmental disorders ## Specific infections ## Inflammatory and immune conditions ## Reactive processes ## Neoplasms ## Endocrine, nutritional & metabolic diseases ## Traumatic lesions ## Gingival pigmentation

Prevention

Gingivitis can be prevented through regular

oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried out ...

that includes daily brushing and flossing.

Hydrogen peroxide Hydrogen peroxide is a chemical compound with the formula . In its pure form, it is a very pale blue liquid that is slightly more viscous than water. It is used as an oxidizer, bleaching agent, and antiseptic, usually as a dilute solution (3%� ...

, saline, alcohol or

chlorhexidine Chlorhexidine (CHX) (commonly known by the salt forms chlorhexidine gluconate and chlorhexidine digluconate (CHG) or chlorhexidine acetate) is a disinfectant and antiseptic that is used for skin disinfection before surgery and to sterilize surgi ...

mouth washes may also be employed. In a 2004 clinical study, the beneficial effect of hydrogen peroxide on gingivitis has been highlighted. The use of oscillation type brushes might reduce the risk of gingivitis compared to manual brushing. Rigorous plaque control programs along with periodontal scaling and curettage also have proved to be helpful, although according to the American Dental Association,

periodontal scaling Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus (scaling or debridement) and then smoothing, or planing, o ...

and root planing are considered as a treatment for periodontal disease, not as a preventive treatment for periodontal disease. In a 1997 review of effectiveness data, the U.S.

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respon ...

(FDA) found clear evidence showing that toothpaste containing

triclosan Triclosan (sometimes abbreviated as TCS) is an antibacterial and antifungal agent present in some consumer products, including toothpaste, soaps, detergents, toys, and surgical cleaning treatments. It is similar in its uses and mechanism of ac ...

was effective in preventing gingivitis. In 2017 the FDA banned triclosan in many consumer products but allowed it to remain in toothpaste because of its effectiveness against gingivitis. In 2019, Colgate, under pressure from health advocates, removed triclosan from the last toothpaste on the market containing it, Colgate Total.

Treatment

The focus of treatment is to remove

. Therapy is aimed at the reduction of oral bacteria and may take the form of regular periodic visits to a dental professional together with adequate oral hygiene home care. Thus, several of the methods used in the prevention of gingivitis can also be used for the treatment of manifest gingivitis, such as scaling, root planing,

curettage Curettage ( or ), in medical procedures, is the use of a curette (French, meaning scoop Mosby's Medical, Nursing & Allied Health Dictionary, Fourth Edition, Mosby-Year Book 1994, p. 422) to remove tissue by scraping or scooping. Curettages are ...

, mouth washes containing

hydrogen peroxide Hydrogen peroxide is a chemical compound with the formula . In its pure form, it is a very pale blue liquid that is slightly more viscous than water. It is used as an oxidizer, bleaching agent, and antiseptic, usually as a dilute solution (3%� ...

, and flossing. Interdental brushes also help remove any causative agents. Powered toothbrushes work better than manual toothbrushes in reducing the disease. The active ingredients that "reduce plaque and demonstrate effective reduction of gingival inflammation over a period of time" are

, chlorhexidine digluconate, and a combination of

thymol Thymol (also known as 2-isopropyl-5-methylphenol, IPMP), , is a natural monoterpenoid phenol derivative of ''p''-Cymene, isomeric with carvacrol, found in oil of thyme, and extracted from ''Thymus vulgaris'' (common thyme), ajwain, and vari ...

, menthol,

eucalyptol Eucalyptol is a monoterpenoid. A colorless liquid, it is a bicyclic ether. Eucalyptol has a fresh mint-like smell and a spicy, cooling taste. It is insoluble in water, but miscible with organic solvents. Eucalyptol makes up ~70% - 90% of eucal ...

, and

methyl salicylate Methyl salicylate (oil of wintergreen or wintergreen oil) is an organic compound with the formula C8H8O3. It is the methyl ester of salicylic acid. It is a colorless, viscous liquid with a sweet, fruity odor reminiscent of root beer, but often a ...

. These ingredients are found in toothpaste and mouthwash. Hydrogen peroxide was long considered a suitable over-the-counter agent to treat gingivitis. There has been evidence to show the positive effect on controlling gingivitis in short-term use. A study indicates the fluoridated hydrogen peroxide-based mouth rinse can remove teeth stain and reduce gingivitis. Based on a limited evidence, mouthwashes with essential oils may also be useful, as they contain ingredients with anti-inflammatory properties, such as thymol, menthol and eucalyptol. The bacteria that causes gingivitis can be controlled by using an

oral irrigator An oral irrigator (also called a dental water jet, water flosser or, by the brand name of the best-known such device, Waterpik) is a home dental care device which uses a stream of high-pressure pulsating water intended to remove dental plaque a ...

daily with a mouthwash containing an antibiotic. Either

amoxicillin Amoxicillin is an antibiotic medication used to treat a number of bacterial infections. These include middle ear infection, strep throat, pneumonia, skin infections, and urinary tract infections among others. It is taken by mouth, or less c ...

, cephalexin, or

minocycline Minocycline, sold under the brand name Minocin among others, is a tetracycline antibiotic medication used to treat a number of bacterial infections such as pneumonia. It is generally less preferred than the tetracycline doxycycline. It is also ...

in 500 grams of a non-alcoholic fluoride mouthwash is an effective mixture.

WebMD WebMD is an American corporation known primarily as an online publisher of news and information pertaining to human health and well-being. The site includes information pertaining to drugs. It is one of the top healthcare websites. It was fou ...

br>Treatments for Gum Disease
/ref> Overall, intensive oral hygiene care has been shown to improve gingival health in individuals with well-controlled type 2 diabetes. Periodontal destruction is also slowed due to the extensive oral care. Intensive oral hygiene care (oral health education plus supra-gingival scaling) without any periodontal therapy improves gingival health, and may prevent progression of gingivitis in well-controlled

References

External links

{{Authority control Inflammations Periodontal disorders