GINGIVAL DISEASESInduced Gingival Diseases -Dental Plaque

Gingivitis that is associated with dental plaque formation' is the most common form of gingival disease characterized by the presence of clinical signs of inflammation that are confined to the gingiva and associated with teeth showing no attachment loss

Gingivitis associated with Dental Plaque Only:

is the result of an interaction between the microorganisms found in the dental plaque biofilm and the tissues and inflammatory cells of the host.

The plaque-host interaction can be altered by the effects of

*Local factors

*Systemic Factors

*Medications

*Malnutrition

Gingival Diseases Modified by Systemic Factors

*endocrine changes

*leukemia

gingival enlargement

bleeding

swollen, spongy

Gingival Diseases Modified by Medications

anticonvulsant drugs phenytoin

immunosuppressive drugs

cyclosporine

calcium channelblockers

nifedipine

Oral contraceptive pills

Gingival Diseases Modified by Malnutrition

bright red, swollen, and bleeding gingiva associated with severe ascorbic acid (vitamin C) deficiency or scurvy.

Nutritional deficiencies are known to affect immune function and may have an impact on the host's ability to protect itself against some of the detrimental effects of cellular products such as oxygen radicals.

Induced Gingival Lesions-Plaque-Non

They are observed in lower socioeconomic groups, developing countries, and immunocompromised individuals

Gingival Diseases of Specific Bacterial Origin:

Streptococcal gingivitis or gingivostomatitis is a rare condition that may present as an acute condition with fever, malaise, and pain associated with acutely inflamed, diffuse, red, and swollen gingiva with increased bleeding and occasional gingival abscess formation.

preceded by tonsillitis and have been associated with group A hemolytic streptococcal infections.

Gingival Diseases of Viral Origin:

the most common being the herpes viruses-Primary herpetic gingivostomatitis Clinically appear as: Multiple tiny vesicles that progress to form painful ulcers. Painful erythematous swollen gingival. Fever, malaise, cervical lymphadenopathy.

Gingival Diseases of Fungal Origin:

under prosthetic devices

in individuals using topical steroids

in individuals with decreased salivary flow

increased salivary glucose

decreased salivary pH.

A generalized candidal infection may manifest as white patches on the gingiva, tongue or oral mucous membrane that can be removed with gauze, leaving a red, bleeding surface.

In HIV-infected individuals, candidal infection may present as erythema of the attached gingiva and has been referred to as linear gingival erythema or HIV-associated gingivitis

Diagnosis of candidal infection can be made by culture, smear.

hereditary gingival fibromatosisthat exhibits autosomal dominant or (rarely) autosomal recessive modes of inheritance. The gingival enlargement may completely cover the teeth, delay eruption, and present as an isolated finding or be associated with several more generalized syndromes.

Gingival Diseases of Genetic Origin:

Traumatic Lesions:

factitial

as in the case of tooth brush trauma resulting in gingival ulceration, recession both;

iatrogenic

as in the case of preventive or restorative care that may lead to traumatic injury of the gingiva

as in the case of damage to the gingiva through minor burns from hot foods and drinks.

accidental

Foreign Body Reactions:

Foreign body reactions' lead to localized inflammatory conditions of the gingiva and are caused by the introduction of foreign material into the gingival connective tissues through breaks in the epithelium. Common examples are the introduction of amalgam into the gingiva during the placement of a restoration or extraction of a tooth, leaving an amalgam tattoo, or the introduction of abrasives during polishing procedures.

PERIODONTITIS

Periodontitis is defined as "an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both." The clinical feature that distinguishes periodontitis from gingivitis is the presence of clinically detectable attachment loss.

Chronic Periodontitis

Chronic periodontitis is the most common form of periodontitis Chronic periodontitis is most prevalent in adults but can be observed in children therefore the age range of >35 years previously designated for the classification of this disease has been discarded. Chronic periodontitis is associated with the accumulation of plaque and calculus and generally has a slow to moderate rate of disease progression

Local factors may influence plaque accumulation systemic diseases such as diabetes mellitus and HIV infection may influence the host defenses; environmental factors such as cigarette smoking and stress also may influence the response of the host to plaque accumulation

Chronic periodontitis may occur as a localized disease wherein <30% of evaluated sites demonstrate attachment and bone loss, or as a more generalized disease wherein >30% of sites are affected. The disease also may be described by the severity of disease as slight, moderate, or severe based on the amount of clinical attachment loss.

Aggressive Periodontitis

Aggressive periodontitis differs from the chronic form primarily by the rapid rate of disease progression seen in an otherwise healthy individual, an absence of large accumulations of plaque and calculus, and a family history of aggressive disease suggestive of a genetic trait.

early onset periodontitis

usually affect young individuals at or after puberty and may be observed during the second and third decade of life (i.e., 10 to 30 years of age). The disease may be localized (LJP) or generalized (GJP)

NECROTIZING PERIODONTAL DISEASES

of necrotizing periodontal disease may features Clinical include necrosis and/or punched out ulceration of the interdental papillae ("punched-out papillae") or gingival margin, pseudomembranous formation painful, bright red marginal gingiva that bleed upon gentle manipulation, halitosis

Necrotizing Ulcerative Gingivitis

Treatment*irrigation *and debridement of necrotic areas

•oral hygiene instruction and the uses of mouth rinses

•* pain medication.•* As these diseases are often

associated with systemic medical issues, proper management of the systemic disorders is appropriate

Necrotizing Ulcerative Periodontitis

NUP" differs from NUG in that loss of clinical attachment and alveolar bone is a consistent feature.

Several case reports have described extensive destruction leading to exfoliation of teeth within 3-6 months of onset, with sequestration of necrotic alveolar bone and necrotic involvement of the adjacent mandible and maxilla. Patients may present with concomitant malnutrition resulting from inability to take food by mouth.

*Chlorhexidine gluconate rinse (0.12%) twice daily after brushing and flossing*Antibiotic therapy Metronidazole is the drug of choice, 500 mg for 7-10 days.

Treatment*Removal of plaque and debris from the site of infection and inflammation* Debridement of necrotic hard and soft tissues

PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESIONS

Endodontic-Periodontal Lesions

In endodontic-periodontal lesions, pulpal necrosis precedes periodontal changes. A periapical lesion originating from pulpal infection and necrosis may drain to the oral cavity through the periodontal ligament, resulting in destruction of the periodontal ligament and adjacen alveolar bone. This may present clinically as a localized deep, periodontal pocket extending to the apex of the tooth. Pulpal infection also may drain through accessory canals, especially in the area of the furcation, and may lead to furcal involvement through loss of clinical attachment and alveolar bone.

Periodontal-Endodontic Lesions

In periodontal-endodontic lesions, bacterial infection from a periodontal pocket associated with loss of attachment and root exposure may spread through accessory canals to the pulp, resulting in pulpal necrosis. In the case of advanced periodontal disease, the infection may reach the pulp through the apical foramen.

Scaling and root planing removes cementum and underlying dentin and may lead to chronic pulpitis through bacterial penetration of dentinal tubules.

Combined Lesions

Combined lesions occur when pulpal necrosis and a periapical lesion occur on a tooth that also is periodontallyinvolved. A radiographically evident infrabony defect is seen when infection of pulpal origin merges with infection of periodontal origin

Diagnostic Methods

*Initially a detailed medical and dental history must be obtained from the patient. *The clinical examination should include inspection of the gingival and mucosal tissues, palpation, mobility testing, percussion*Periodontal probing is essential to identify and determine the depth of periodontal pockets and the degree of loss of attachment. *Pulp testing should be carried out with both carbon dioxide (dry ice) and an electric pulp tester*Radiographs are an essential tool to the diagnosis of any endodontic or periodontal condition.

Treatment

periodontal disease *scaling*root planing*oral hygiene instructions follow-up maintenance therapy, including surgery in some cases.

Diseased pulp tissue or infected root canals *cleaning* shaping* medicating * filling of the root canal system

DEVELOPMENTAL OR ACQUIRED DEFORMITIES AND CONDITIONS

Tooth Anatomic FactorsAnatomic factors such as* cervical enamel projections and enamel pearls have been associated with clinical attachment loss, especially in furcation areas. *Palatogingival grooves, found primarily on maxillary incisors* Proximal root grooves on incisors and maxillary premolars

Enamel pearl

Cervical enamel projection

Dental Restorations or Appliances

Dental restorations or appliances are frequently associated with the development of gingival inflammation, especially when they are located subgingivally. This may apply to subgingivally placed onlays, crowns, fillings and orthodontic bands.

Root Fractures

Root fractures caused by traumatic forces or restorative or endodontic procedures may lead to periodontal involvement

Cervical Root Resorption and Cemental Tears

Cervical root resorption and cemental tears may lead to periodontal destruction when the lesion communicates with the oral cavity and allows bacteria to migrate subgingivally