AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Gingivitis is an inflammatory process limited to the mucosal epithelial tissue surrounding the cervical portion of the teeth and the alveolar processes. Gingivitis has been classified by clinical appearance (eg, ulcerative, hemorrhagic, necrotizing, purulent), etiology (eg, drug-induced, hormonal, nutritional, infectious, plaque-induced), and duration (acute, chronic). The most common type of gingivitis is a chronic form induced by plaque.

Acute necrotizing ulcerative gingivitis (ANUG, ie, trench mouth) is an acute infectious gingivitis. The term trench mouth was coined in World War I when ANUG was common among trench-bound soldiers.

Pathophysiology

The most common type of gingivitis involves the marginal gingiva and is brought on by the accumulation of microbial plaques in persons with inadequate oral hygiene. Gingivitis proceeds through an initial stage to produce early lesions, which then progress to advanced disease.

The initial stage of an acute exudative inflammatory response begins within 4 or 5 days of plaque accumulation. Both gingival fluid and transmigration of neutrophils increase. Deposition of fibrin and destruction of collagen can be noted in the initial stage. At approximately 1 week, transition to early lesions is marked by the change to predominately lymphocytic infiltrates. Monocytes and plasma cells also may be present. With time, lesions become chronic and are characterized by the presence of plasma cells and B lymphocytes. As chronic local inflammation progresses, pockets develop where the gingiva separates from the tooth. These pockets deepen and may bleed during tooth brushing, flossing, and even normal chewing. As this persistent inflammation continues, periodontal ligaments break down and destruction of the local alveolar bone occurs. Teeth loosen and eventually fall out.

ANUG is a completely different syndrome caused by acute infection of the gingiva with organisms such as Prevotella intermedia, alpha-hemolytic streptococci, Actinomyces species, or any of a number of different oral spirochetes. ANUG may result in accelerated destruction of affected tissues, as well as local or systemic spread of infection.

Noma (cancrum oris) is a syndrome in which ANUG spreads beyond the gingiva. The infection invades local tissues of the mouth and face.

Frequency

United States

Frequency is difficult to determine because of the lack of agreement on measurement criteria. Many people believe that gingivitis begins in early childhood and that 9-17% of children aged 3-11 years have gingivitis. At puberty, prevalence rises to 70-90%. In recent years, periodontal disease, the endpoint of chronic gingivitis, slowly has decreased among adult Americans.

ANUG may be a clinical problem in immunocompromised patients during chemotherapy. Gingivitis and resulting periodontal disease are seen more frequently in patients with either diabetes or HIV.

International

Studies in Australia, Sweden, England, and Switzerland report gingivitis in 48-85% of children aged 3-6 years, but whether this range reflects population differences or whether it is due to different criteria used to define the disease is difficult to know. In adolescence, incidence around the world is comparable to US data (70-90%). ANUG may be found in areas where those at risk, particularly children, face poor living conditions. Recent publications show several cases in areas such as Nigeria, where ANUG and noma were observed in children younger than 14 years.¹

Mortality/Morbidity

Periodontal disease has been shown in some studies to be an associated factor in coronary artery disease (CAD) and cerebrovascular disease/ischemic stroke.^{2, 3, 4} This association with CAD has not been shown in all studies. Periodontal disease in pregnancy has been associated with an increase in preterm birth.⁵ Periodontitis in a person with diabetes has been associated with exacerbation of both conditions.^{6, 7}

• Severe periodontal disease may occur.
• Chronic gingivitis leads to tooth loss.
• ANUG may progress into the local soft tissues of the mouth, resulting in noma or cancrum oris, or may spread hematogenously to any other part of the body.

Sex

• Gingivitis is slightly more prevalent in males than in females because females tend to have better oral hygiene.

Age

• Adults are most commonly affected.
• Children from sub-Saharan regions of Africa may be at risk for ANUG because of poor living conditions.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

Historical findings depend on whether the patient has chronic gingivitis or ANUG.

• Chronic gingivitis
• • The most common complaint is bleeding gums. The patient usually notices this when toothbrushing or flossing.
  • Bleeding may be associated with eating, especially foods with a hard consistency, such as apples or crusted bread. These foods may rub against gums.
• Acute necrotizing ulcerative gingivitis
• • Apparently spontaneous bleeding or bleeding in response to very minimal local trauma may occur.
  • ANUG also may produce local pain, malaise, and alterations in taste, such as a metallic flavor.
  • ANUG may produce foul breath.

Physical

• Chronic gingivitis
• • Patients have minimal physical findings aside from local findings at the dental-gingival margins.
  • Gingival pockets may be detected with a periodontal probe. However, the pocket depth may be overestimated when periodontitis is present and underestimated in healthy gums.
  • Mild bleeding from the gum margins may occur with any manipulation.
• Acute necrotizing ulcerative gingivitis
• • Fever, halitosis, marked gingival edema, and ulceration, especially in the interdental papillae, may be present.
  • A grey pseudomembrane may be present.
  • Infection may spread to adjacent soft tissues of the mouth, with noticeable erythema, edema, tenderness, and induration of affected areas.
• Reaction to oral contraceptives (see Causes)

Causes

• Although bacteria play a role in all forms of gingivitis, the primary cause of chronic gingivitis is inadequate oral hygiene.
• Risk factors
• • Use of tobacco or ethanol is thought to be a risk factor.
  • Immune incompetence is observed more frequently in HIV-infected children. As their CD4 counts decline, incidence of gingivitis may increase. Diabetes mellitus increases the risk of gingivitis and periodontitis.
• Drug-induced causes
• • The list of drugs that cause gingivitis and gingival bleeding is extensive.
  • Gingival bleeding may occur with the use of anticoagulants and fibrinolytic agents.
  • Phenytoin, oral contraceptive agents, and calcium channel blockers may cause gingival hyperplasia.
  • Gingivitis has been observed with use of protease inhibitors (eg, saquinavir, ritonavir), vitamin A and analogues, danazol, pentamidine, misoprostol, methotrexate, and gold compounds.
  • Gingivostomatitis has been observed in exposure to arsenic, gold, bismuth, mercury, nickel, sulfur dioxide, lead, thallium, zinc, methyl violet, and topical chlorhexidine.
• Acute necrotizing ulcerative gingivitis
• • Acute necrotizing infection may occur as a complication of chronic gingivitis in situations in which hygiene is abandoned completely or host defenses are weakened.
  • ANUG is the result of soft tissue invasion by ubiquitous organisms and is not believed to be contagious.
  • It is a risk wherever poor sanitation, diet, or oral hygiene is present.
  • Living near livestock is an additional risk factor.
• Other causes
• • Inadequate plaque removal
  • Blood dyscrasias
  • Allergic reactions
  • Chronic debilitating disease
  • Poor nutrition
  • Lack of periodic dental examinations

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Other Problems to be Considered

Gingivitis, desquamative
Gingivitis, diabetes mellitus
Gingivitis, phenytoin
Gingivitis, pregnancy
Glossitis
Noma (cancrum oris)
Pericoronitis
Periodontitis
Vincent angina (trench mouth)

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Lab Studies

• Laboratory testing is not helpful in diagnosing gingivitis.
• If systemic disease or toxin exposure is suspected, laboratory tests should be requested.
• A smear to identify the causative agent may be helpful.

Imaging Studies

• Imaging studies are not indicated.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Emergency Department Care

• In simple chronic gingivitis, ED intervention is not needed.
• Proper oral hygiene (including brushing and flossing) should be stressed. The patient should be referred to a dentist or periodontist.
• General measures
• • Remove irritating factors such as plaque, calculus, and faulty dentures.
  • Use a warm saline rinse.

Consultations

• Dentist

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

In chronic gingivitis, brushing with a fluoride dentifrice will slow disease progression and may help resolution. Most electric toothbrushes have additional benefit over manual brushing. Daily flossing in addition to brushing will reduce plaque and bacterial counts. Recent studies show that brushing followed by rinsing with chlorhexidine or other solutions may have even better results over brushing and flossing.^{8, 9} Gum-care–specific preparations that show benefit are available.¹⁰ Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to speed the resolution of inflammation when teeth are being cleaned and scaled to remove plaque.^{11, 12}

In patients with ANUG, treatment involves antibiotics, NSAIDs, and topical Xylocaine for pain relief. Saline rinses can help to speed resolution, and oral rinses with a hydrogen peroxide 3% solution also may be of benefit.

Drug Category: Antibiotics

These agents are used to eradicate the bacterial infection that is the hallmark of ANUG. In the future, antibiotics also may be used to treat simple chronic gingivitis, but no current evidence exists to justify this practice. Treatment of gingivitis may be warranted if dental surgery is planned.

Drug Category: Antiseptic

This is shown to decrease bacterial counts in oral flora. It probably speeds resolution of gingivitis when combined with brushing and flossing.

Drug Category: Analgesics

Patients with ANUG should be given a strong analgesic along with topical anesthetics and NSAIDs because pain control is very important in allowing the patient to eat and carry out toothbrushing, flossing, and other oral hygiene maneuvers necessary to eradicate the disease. NSAIDs also help to decrease pain. Although effects of NSAIDs in the treatment of pain tend to be patient-specific, ibuprofen usually is the DOC for initial therapy.

Drug Category: Topical anesthetics

These agents are helpful in providing pain control, which is very important in allowing the patient to carry out toothbrushing, flossing, and other oral hygiene maneuvers.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Outpatient Care

• Patients with simple chronic gingivitis should be given nonurgent dental referral.
• Patients with ANUG should be seen within 24-48 hours for reevaluation because of risk of local or systemic spread of infection.
• In addition to antibiotic therapy, physical and mental stressors should be eliminated. Good oral hygiene is mandatory.

Deterrence/Prevention

• Good oral hygiene: The use of a power toothbrush with rotating/oscillating motion is better than a manual brush.
• Regular dental check-ups

Complications

• Gingivitis is not a direct significant threat to the health of a healthy individual, but it can contribute to illness and cause local and systemic complications.
• ANUG that progresses to noma is associated with a mortality rate as high as 70% without proper antibiotics and debridement.
• The most common complication of chronic gingivitis is progression to periodontal disease and tooth loss. Areas of chronic gingivitis may predispose the individual to the development of odontogenic abscesses by allowing a route of bacterial invasion into the periodontal space from the gingival pocket. ANUG may be locally destructive and may result in local spread of infection into the surrounding tissues (Vincent angina and noma [cancrum oris]). Potential also exists for systemic spread of infection.
• Osteomyelitis of alveolar bone may arise but is uncommon.
• Any dental procedures involving manipulation that causes bleeding may result in endocarditis. The presence of gingivitis increases this risk by making the gingiva more likely to bleed with simple manipulation (eg, dental scaling). Bacteria containing plaque accumulation in the gingival pockets are in direct proximity to the areas of disrupted gingiva, increasing the likelihood of bacteria escaping into the general circulation.

Prognosis

• Untreated chronic gingivitis eventually results in tooth loss.
• After an initial cleaning and scaling in its early stages, gingivitis usually is reversible with good dental hygiene.
• ANUG responds to treatment if host defenses are intact. Noma requires aggressive treatment with antibiotics and local debridement.
• The usual course is acute, relapsing, intermittent, and chronic.
• Gingivitis generally responds well to appropriate treatment.

Patient Education

• Good oral hygiene, including brushing and flossing, treats and prevents chronic gingivitis. If flossing is too much of a bother, then plaque-reducing rinses, used daily, have proven benefit.
• Studies show electric toothbrushes to be more effective than manual brushes in preventing gingivitis.^{13, 14}
• Certain toothpastes, both herbal and nonherbal, have additional benefit.
• For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Gingivitis, Periodontal (Gum) Disease, and When to Visit the Dentist.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• If mistaken to be Dilantin effect, ANUG may be overlooked.
• ANUG may be mistaken as leukemic infiltrate, prompting an involved workup.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Special thanks to Robert J. Lindberg, DMD, for images and excellent dental care.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Healthy mouth and gingiva. Note the healthy light pink color of the gingiva. The intradental papillae are sharp and fill the intradental space. No local edema is present. Image courtesy of Robert J. Lindberg, DMD.
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Media file 2:  Moderate chronic gingivitis. Note that the papillae are edematous and blunted. They may bleed with brushing. Note areas of edema overlying some of the root areas. Pallor is seen in these areas. Image courtesy of Robert J. Lindberg, DMD.
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Media type:  Photo

Media file 3:  Severe periodontal disease. Loss of the gingival tissue is seen, making the teeth appear long. Even more effacement of the papillae is present. Heaped up ridges are observed in the areas overlying the roots. Image courtesy of Robert J. Lindberg, DMD.
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Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

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Article Last Updated: Oct 15, 2008