Gingivitis (Gum Disease): Symptoms, Causes, Risks, Complications, Diagnosis, Treatment and Prevention

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women with gingiva with pain expression

1Overview

Gingivitis is, clinically, an inflammation of the gingiva. The gingiva is the soft tissue of the oral cavity that surrounds each tooth. It consists of connective and epithelial tissues and they function to support the teeth in the mandibular or maxilla bone. The other structure that supports teeth is the periodontium, which is made up of alveolar bone and connective tissue attachments.

It occurs mainly due to the accumulation of plaque. The factors that are responsible for plaque formation are poor oral and dental hygiene. Gingivitis is a reversible disease in its early stages. In this disease, the gums redden, bleed, and become swollen when provoked, such as when brushing the teeth or touching. It is a mild form of gum disease that is reversible with tooth brushing and dental cleaning by a dentist, along with proper medication. There is no tissue or bone loss in gingivitis. If left untreated, however, gingivitis can lead to periodontitis, which is the inflammation of the periodontium.

2Symptoms

The signs and symptoms of gingivitis include red and puffy gums. Gums should never be this color because it indicates inflammation. Bleeding gums are another sign of gingivitis. Gums should never bleed, even when they are brushed vigorously or when dental floss is used. Persistent bad breath, caused by the accumulation of bacteria in the mouth, is another sign. New spacing between teeth is caused by bone loss, while loose teeth are caused by bone loss or weak periodontal fibers. If there is pus around the teeth and gums, then a more serious infection is present. Receding gums are also another sign of gingivitis, as is tenderness and discomfort. 

3Causes

Not all gingival diseases are caused by plaque formation. Non-plaque induced gingival diseases may be caused by viruses, bacteria, or fungal infections. They may also be caused by genetic disorders and mucocutaneous disorders. Other possible causes are tooth brushing and allergic reactions to drugs.

Plaque-induced gingival diseases, on the other hand, reflect the person’s inflammatory and immune responses to the bacteria. The clinical features of this disease are bleeding on the gums, redness, and swelling. There are modifying factors that affect the development of gingivitis when it is caused by plaque. Tooth anatomy is one of them. The position of the tooth, root proximity, open contacts, root abnormalities, tooth restorations, and effects of restorative materials all impact the gums and determine whether a person will get gingivitis.

Endogenous hormones may also cause gingivitis as modifying factors. Periodontal tissues are affected by progestins, estrogens, and androgens. Gingival disease increases when estrogen levels fluctuate even when oral hygiene remains the same.

Enlargement of the gingiva is associated with certain drugs. These include anticonvulsants, immunosuppressive agents, and calcium channel blockers.

Oral contraceptives are another modifying factor. Studies suggest that combined oral contraceptives that have high doses of estrogen are associated with gingivitis. Other studies have reported that the extent of gingival inflammation increases with the length of oral contraceptive use.

4Risk Factors

There are multiple risk factors for developing gingivitis. One of these is poor oral hygiene. Not brushing teeth properly or regularly can cause the build-up of plaque. If the plaque is not removed, it can harden and form calculus, otherwise known as tar. Tar sticks firmly to the tooth and can only be usually removed by dentists. The non-mineralized plaque on the surface of the tooth is the principal irritant. However, the underlying calcified portion is a significant contributory factor. Calculus is a significant pathogenic factor in gingivitis. The bacteria that accumulate in plaque irritate the gums, causing soreness and inflammation.

Smoking and chewing tobacco are also risk factors for gingivitis. The chemicals inhaled from smoke interfere with the body’s ability to repair tissue. In addition, smoking is a vasoconstrictor and thus cuts down on the body’s blood supply. Nicotine is toxic to fibroblasts which are responsible for the production of new connective tissue in the gingiva.

Genetic factors may also play a role in the disease. Up to 30% of the population may be susceptible to the disease. Some people with gingivitis have genes that code for damages immune factor interleukin-1, which is a cytokine that is involved in the inflammatory response. These individuals are 20 times more likely to develop gum disease.

People with diabetes are more likely to have gum disease. It is estimated that 1 in 3 diabetics suffer from gingivitis. When diabetes is poorly managed, it can lead to periodontitis. Diabetes alters the blood flow to the connective tissue surrounding the tooth, weakening the bones and gums and making them more prone to infection. An above average concentration of glucose in the mouth makes bacterial growth more rapid, leading to gingivitis. 

5Complications

If left untreated, gingivitis progresses to periodontitis. Periodontitis can lead to remote inflammatory responses via three mechanisms. First, it can cause bacteremia. Second, it can cause immune responses in the presence of oral pathogens. Third, there may be a hematogenous spread of the components of the infection/immune cascade.

Bacteremia is explained based on the spread of bacterias from the sub-gingival film and supragingival film into the bloodstream via the ulcerated epithelia of the lesion in the gums. Aside from invasive procedures such as dental extractions and sub-gingival scaling, daily activities such as chewing and brushing may lead to the spread of bacteria and bacterial products into the bloodstream.

The response of the host to oral pathogens may also explain why periodontal diseases lead to systemic disorders.

Another complication of periodontal disease is cardiovascular disease. One reason for this is that both diseases share similar risk factors, such as smoking, sedentary lifestyle, and gender. However, periodontal disease is a risk factor for heart disease, although causation has not yet been proven.

Adverse pregnancy outcomes have also been reported with periodontal diseases. The presence of inflammation in any part of the body accounts for the majority of cases of preterm births. In most cases, inflammation is associated with intrauterine infections. However, remote infections can also cause premature births. The dissemination of inflammatory by-products into the bloodstream may cause preterm births. Then, maternal and fetal responses to these products may further cause preterm births, as well as the hematogenous spread of oral bacteria.

6Diagnosis

Gingivitis can be diagnosed using a couple of methods. Although histological evidence of inflammation is the most reliable method of diagnosing gingivitis, performing biopsies on all patients is not practical. Therefore, a less invasive method is needed. The measurement of GCF is used to assess gingivitis.

Scales are used by dentists to assess gingivitis. They combine visual aspects and the presence of marginal bleeding after being stimulated. GCF results from the interaction between the periodontal tissue cells and the bacterial biofilm. It is a complex mixture of substances derived from blood serum, leukocytes, and oral microorganisms. Several methods have been developed to collect GCF for evaluation, such as the gingival washing method.

Visual criteria can be used to assess gingivitis. Some gingival indices have been used as bases for assessing the clinical features of inflammation. The visual signs of gingivitis are redness of the gingival margin and an increase of the vascular sub-units in the connective tissue surrounding the tooth.

Periodontal problems have been used to assess marginal bleeding. Some dentists, however, use dental floss or tape to assess. Variations in probing depth and angulation may change the results by stimulating bleeding. They may also cause injury, thus hindering the diagnostic value of the probe.

7Treatment

Therapy for patients with chronic gingivitis caused by plaques is to initially reduce the level of bacteria in the oral cavity. In addition, the associated calcified and noncalcified deposits should also be reduced. Improved personal hygiene alone may be the best treatment for most people with uncomplicated gingivitis in its early stages. However, while it is possible to maintain a plaque-free state, most patients do not have the skill or motivation to do so. Thus, professional removal of plaque in conjunction with personal hygiene is recommended and is deemed to be safe according to clinical trials. Dental calculus can be removed by dental scaling using ultrasonic, sonic, or hand instruments. The objective of this method is to reduce the level of calculus to reduce the level of bacteria on the teeth.

8Prevention

The best way to prevent gingivitis is to take care of gums by brushing teeth regularly and flossing. In addition, refraining from smoking will also help prevent the disease. Brushing the teeth twice or thrice a day will remove plaque from the tooth surface. Regular visits to the dentist are also important because the dentist will be able to check is gingivitis is already developing. The dentist will also be able to remove plaques that have built up over months or years. Maintaining good eating patterns and oral and dental hygiene is the key to preventing gingivitis. Aside from this, ensuring that the diet is sufficient in nutrients such as calcium and phosphorous will also help prevent the disease.