 Gingivitis can develop with sudden onset and have a

short duration, and it can be painful. A less severe

phase of this condition can also occur.
 Chronic gingivitis develops slowly and has a long
duration. It is painless, unless it is complicated by acute
or subacute exacerbations, and it is the type that is
most often encountered.
 Recurrent gingivitis reappears after having been
eliminated by treatment or after disappearing
spontaneously.
 Localized gingivitis is confined to the gingiva of a
single tooth or group of teeth. Generalized
gingivitis involves the entire mouth.
 Marginal gingivitis involves the gingival margin, and
it can include a portion of the contiguous attached
gingiva. Papillary gingivitis involves the interdental
papillae, and it often extends into the adjacent portion
of the gingival margin. Diffuse gingivitis affects the
gingival margin, the attached gingiva, and the
interdental papillae.
 Gingival disease in individual cases is described by
combination of the above.
 Localized marginal gingivitis is confined to one or
more areas of the marginal gingiva
 Localized diffuse gingivitis extends from the
margin to the mucobuccal fold in a limited area
 Localized papillary gingivitis is confined to one or
more interdental spaces in a limited area
 Generalized marginal gingivitis involves the
gingival margins in relation to all the teeth. The
interdental papillae are usually affected
 Generalized diffuse gingivitis involves the entire
gingiva. Because the alveolar mucosa and
attached gingiva are affected, the mucogingival
junction is sometimes obliterated.
A systematic clinical approach requires an orderly
examination of the gingiva for :
 Color

 Contour

 Consistency

 Position

 Ease and severity of bleeding

 Pain
 Gingiva Bleeding on Probing

The two earliest signs of gingival inflammation that

precede established gingivitis are increased gingival
crevicular fluid production and bleeding from the
gingival sulcus on gentle probing
Gingival bleeding can also be caused by Local
Factors or it can be associated with Systemic
Changes

 Local Factors: Anatomic and developmental

tooth variations, caries, frenum pull, iatrogenic
factors, malpositioned teeth, mouth breathing,
overhangs, partial dentures, lack of attached
gingiva, and recession. Orthodontic treatment
and fixed retainers are associated with
increased plaque retention and increased BOP
(bleeding on probing)
 Systemic Changes: Hemorrhagic disorders in which
abnormal gingival bleeding is encountered include
vascular abnormalities (e.g., vitamin C deficiency),
platelet disorders (e.g., thrombocytopenic purpura),
hypoprothrombinemia (e.g., vitamin K deficiency),
other coagulation defects (e.g., hemophilia, leukemia),
deficient platelet thromboplastic factor as a result of
uremia,multiple myeloma. The effects of hormonal
replacement therapy, oral contraceptives, pregnancy,
and the menstrual cycle are also reported to affect
gingival bleeding
 Color Changes
 Change in color is an important clinical sign of gingival
disease. The normal gingival color is coral pink. The
gingiva becomes red when vascularization increases or
the degree of epithelial keratinization is reduced or
disappears. The color becomes pale when
vascularization is reduced (in association with fibrosis
of the corium) or epithelial keratinization increases.
 Heavy metals (i.e., bismuth, arsenic, mercury, lead, and
silver) that are absorbed systemically as a result of
therapeutic use or occupational or household
exposures can discolor the gingiva and other areas of
the oral mucosa.
 Bismuth gingivitis

 Discoloration cause by amalgam

 Changes in Gingival Consistency
In Chronic Gingivitis: Swelling, loss of stippling and
discoloration occurs when exudate and edema are
predominant. The gingiva is soft, friable and bleeds easily.

Firm Gingiva is produces when fibrosis

predominates
 Changes in Gingival Position
Recession is exposure of the root surface by an apical shift
in the position of the gingiva. The actual position is the
level of the coronal end of the epithelial attachment on the
tooth, whereas the apparent position is the level of the crest
of the gingival margin.

Stillman Cleft
 Terminology
Gingival enlargement and gingival overgrowth are terms
used interchangeably with hyperplasia, hypertrophy,
and fibrosis. Hyperplasia is an increase in the number of
cells in tissues that results in increased tissue
volume. Hypertrophy refers to increased tissue size and
volume resulting from increased cell size. Fibrosis refers
to a pathologic process in which disrupted wound healing
is associated with defective cell proliferation.
 Classification

 Inflammatory enlargement due to chronic

gingivitis
 Drug-induced enlargement
 GO associated with systemic conditions
 GO associated with systemic diseases
 Gingival fibromatosis
 Inflammatory enlargement due to chronic
gingivitis

Chronic inflammatory gingival enlargement

Gingival Abscess is a localized, painful and
rapidly expanding lesion due to Acute
inflammatory enlargement.

Gingival Enlargement in mouth breathers

Plasma cell gingivitis sometimes manifests as a
mild marginal gingival enlargement that extends
to the attached gingiva. The gingiva appears red,
friable, and sometimes granular, and it bleeds
easily.
 Drug-Induced Overgrowth of Gingiva
Most common forms of DIGO are caused by the use of
anticonvulsants, calcium channel blockers, and
immunosuppressants prescribed to patients for serious
health concerns.
 Phenytoin
 Gingival Overgrowth Associated with Systemic
Conditions

Changes in systemic conditions can lead to

gingival enlargement. These gingival pathologies
are referred as conditioned enlargements and
include lesions associated with hormonal and
nutritional etiologic factors.
 Pregnancy (localized GO)

 Pyogenic Granuloma (often seen in pregnancy)

 Enlargement of the gingiva is sometimes seen
during puberty. The lesions are not specific to
female gender; they can occur in both males
and females.
 Malnutrition has been historically associated
with several oral lesions. GO has been
observed in cases of chronic vitamin C
deficiency in patients with scurvy.
 Gingival Overgrowth Assosiated with Systemic
Diseases
 Leukemia-Associated Gingival Overgrowth
Leukemic gingival enlargement can be diffuse or marginal and
localized or generalized

 Wegener Granulomatosis
Wegener granulomatosis is a rare disease that is characterized by
acute granulomatous necrotizing lesions of the respiratory tract,
including nasal and oral defects
 Gingival Fibromatosis
Gingival fibromatosis can be hereditary or idiopathic. The
enlargement affects the attached gingiva, the gingival
margin, and the interdental papillae.
 Necrotizing Ulcerative Gingivitis

 Primary Herpetic Gingivostomatitis

 Pericoronitis
 Necrotizing Ulcerative Gingivitis
Necrotizing ulcerative gingivitis (NUG) is a microbial
disease of the gingiva that most often occurs in an
impaired host. It manifests with the characteristic clinical
signs of necrosis and sloughing of the gingival tissues and
may be accompanied by systemic symptoms.
 Oral Signs
Characteristic lesions are punched-out, craterlike
depressions at the crest of the interdental papillae
that subsequently extend to the marginal gingiva and
rarely to the attached gingiva and oral mucosa. The
surface of the gingival crater is covered by a gray,
pseudomembranous slough that is demarcated from
the remainder of the gingival mucosa by a
pronounced linear erythema
A) Typical punched-out papilla between mandibular canine and
lateral incisor is covered by grayish white pseudomembane
B) More advance case shows the destruction of the papillae, which
resilts in an irregular marginal contour
C) Typical lesions with spontaneous hemorrhage
D) Generalized involvement of the papillae and the marginal gingiva
with whitish necrotic lesions
 Primary Herpetic Gingivostomatitis
Primary herpetic gingivostomatitis is an infection of the oral cavity
caused by herpes simplex virus (HSV) type 1. It occurs most often
among infants and children who are younger than 6 years of age, but
it is also seen in adolescents and adults. It occurs with equal
frequency in male and female patients.

Primary herpetic gingivostomatitis appears as a diffuse,

erythematous, shiny involvement of the gingiva and the adjacent oral
mucosa, with various degrees of edema and gingival bleeding.
During its initial stage, it is characterized by discrete, spherical, gray
vesicles, which can occur on the gingiva, labial and buccal mucosae,
soft palate, pharynx, sublingual mucosa, and tongue. After
approximately 24 hours, the vesicles rupture and form painful small
ulcers with red, elevated, halo-like margins and depressed yellowish
or grayish white central portions.
 Pericoronitis
The term pericoronitis refers to inflammation of the gingiva in
relation to the crown of an incompletely erupted tooth. The partially
erupted or impacted mandibular third molar is the most common site
of pericoronitis. The space between the crown of the tooth and the
overlying gingival flap (i.e., operculum) is an ideal area for the
accumulation of food debris and bacterial growth.

The resultant clinical picture is a red, swollen, suppurating lesion that

is exquisitely tender, with radiating pains to the ear, throat, and floor
of the mouth. The patient is extremely uncomfortable as a result of
pain, a foul taste, and an inability to close the jaws.
THE END