Radiographic Examination
A full‐mouth set of radiographs was ordered (G). (See Figure 1.2.5 for the patient’s bitewing radiographs.)
Diagnosis
After reviewing the history and both the clinical and radiographic examinations, a differential diagnosis was generated (H).
Treatment Plan
The treatment plan of the periodontal problems for this patient included an initial phase of scaling with polishing and a six‐week reevaluation.
Treatment
The patient received a scaling and polishing. At the six‐week reevaluation, the clinical signs and symptoms had not improved, even though the patient claimed to be practicing excellent oral hygiene as per the instructions (I).
Figure 1.2.4 Probing pocket depth measurements.
Figure 1.2.5 Bitewing radiographs depicting the interproximal bone levels.
Discussion
In dental plaque‐induced gingivitis, the inflammation is confined to the gingiva without attachment or bone loss, making it a reversible condition (with treatment). Gingivitis can also occur on a reduced but healthy periodontium. Reduced but healthy periodontium is when there is attachment loss due to past non‐periodontitis cause (e.g. gingival recession) or due to past history of periodontitis and/or its treatment but currently exhibiting shallow sulci (J). A thorough history and periodontal examination must be completed to arrive at a diagnosis. Other characteristic features associated with dental plaque‐induced gingivitis include the presence of plaque at the gingival margin, increased gingival exudate, and bleeding on probing (K). With good plaque control, the condition should resolve [1]. If there is a medical concern, it is typically identified by obtaining a thorough medical history. Conditions such as diabetes and leukemia have a profound effect on gingival health, and therefore the patient must be evaluated accordingly. In women, hormonal changes, such as those that occur during the onset of puberty, pregnancy, or menstruation, have a transient effect on the gingival inflammatory status of these patients [2], which when combined with poor plaque control will lead to severe gingivitis [3,4]. After a diagnosis is reached, the treatment plan will include oral hygiene instructions, an initial phase of treatment (scaling or scaling and root planing) with a four‐ to six‐week reevaluation. If the symptoms persist at this visit (despite an improvement in the patient’s oral hygiene), the patient should be referred to a physician to rule out any potential systemic conditions that might cause bleeding.
Self-Study Questions
1 How are gingival diseases classified in the 2017 Periodontal Disease Classification?
2 What are the “ideal” brushing/flossing habits and techniques for a patient?
3 What effects can smoking have on the periodontium? On the oral cavity?
4 How would you perform an oral cancer screening?
5 What are the components of a periodontal examination?
6 What information should be recorded on a periodontal or soft tissue charting?
7 What kind of radiographs should be ordered for a periodontal examination?
8 What are the components that make one diagnose a case as gingivitis versus periodontitis?
9 What should a practitioner do in the case where gingival/periodontal symptoms have not resolved despite the prescribed dental care?
10 What are the different clinical situations gingivitis can manifest?
11 What are the common signs and symptoms of dental plaque-induced gingivitis?
Answers located at the end of the chapter.
References
1 1. Mariotti A. Dental plaque‐induced gingival diseases. Ann Periodontol 1999; 4:7–17.
2 2. Mariotti A. Sex steroid hormones and cell dynamics in the periodontium. Crit Rev Oral Biol Med 1994; 5:27–53.
3 3. Hugoson A. Gingivitis in pregnant women. A longitudinal clinical study. Odontologisk Revy 1971; 22:25–42.
4 4. Löe H. Periodontal changes in pregnancy. J Periodontol 1965; 36:209–216.
5 5. Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Periodontol 2018; 89(Suppl 1):S74–S84.
6 6. Moran JM, Addy M, Newcombe RG. A comparative study of stain removal with two electric toothbrushes and a manual brush. J Clin Dent 1995; 6(4):188–193.
7 7. Tritten CB, Armitage GC. Comparison of a sonic and a manual toothbrush for efficacy in supragingival plaque removal and reduction of gingivitis. J Clin Periodontol 1996; 23:641–648.
8 8. Grossi SG, Zambon JJ, Ho AW, et al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994; 65:260–267.
9 9. Mullally B, Breen B, Linden GJ. Smoking and patterns of bone loss in early‐onset periodontitis. J Periodontol 1999; 70:394–401.
10 10. Rose LF, Mealy BL (eds). Periodontics: Medicine, Surgery, and Implants. St. Louis, MO: Mosby, 2004:871.
11 11. Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancers. Cancer Res 1988; 48:3282–3287.
12 12. Neville BW, Damm DD, Allen C, Bouquot J. Oral and Maxillofacial Pathology, 2nd edn. Philadelphia, PA: Lippincott, 2005:356–362.
TAKE‐HOME POINTS
A. Based on the 2017 periodontal disease classification, gingival diseases are broadly classified into those that are dental plaque induced and those that are not [5].
Dental plaque‐induced gingival diseases
1 Associated with plaque alone
2 Mediated by systemic or local risk factorsSystemic factors (e.g. smoking, diabetes, puberty, pregnancy, hematologic conditions)Local factors (e.g. plaque‐retentive restorative margins, dry mouth)
3 Medication‐induced gingival enlargement
Non‐plaque‐induced gingival diseases
1 Genetic disorders (hereditary gingival fibromatosis)
2 Infections (e.g. herpes simplex, Neisseria gonorrhoeae, human papillomavirus, candidosis)
3 Inflammatory and immune conditions (contact allergy, pemphigus, lichen planus, sarcoidosis)
4 Reactive processes (epulis, peripheral giant cell granuloma)
5 Neoplasms: