History and exam
Key diagnostic factors
common
presence of risk factors
bleeding on tooth brushing
Transient bleeding when tooth brushing, resulting in blood on the toothbrush and on expectoration during tooth brushing.
dental plaque
Bacterial plaque (biofilm) accumulates on the teeth, but because dental plaque is white and translucent, it is not visible on the teeth unless there is very heavy accumulation.
necrosis and ulcers in free gingiva
Absent in common plaque-induced gingivitis; they represent the most relevant clinical findings in necrotising gingivitis, frequently found in the interdental papilla.
Other diagnostic factors
common
halitosis
Halitosis that is not associated with specific foods may be obvious to the clinician. However, this is an inconsistent finding, as common halitosis is more often associated with the accumulation of bacterial and food debris on the posterior portion of the tongue.
Halitosis is especially prominent in NG, although it is not a sign of this disease exclusively.
redness, swelling, and puffy gingiva
Although patients may notice increased signs of gingival inflammation such as redness and swelling, they are often unaware that these signs are present. Depending on normal pigmentation, non-inflamed gingiva in people with white skin is uniformly light pink; in people with black and brown skin, the gingiva may have varying amounts of pigmentation, making it difficult to observe colour changes due to inflammation.
pseudomembrane formation
Absent in common plaque-induced gingivitis; it may occur over the necrotic area in NG.
uncommon
cervical lymphadenopathy
Absent in common plaque-induced gingivitis; it may occur in necrotising gingivitis but is generally only evident in advanced cases and in children.
fever
Absent in common plaque-induced gingivitis; moderate fever may be present in necrotising gingivitis, but it is not a consistent finding.
malaise
Absent in common plaque-induced gingivitis; may be present in necrotising gingivitis, but it is not a consistent finding.
pain
Common plaque-induced gingivitis is not accompanied by pain. However, pain, especially on tooth brushing and eating, is a primary complaint in necrotising gingivitis.
Risk factors
strong
poor oral hygiene
Dental plaque (biofilm) is the primary aetiological agent for gingivitis. Poor oral hygiene leads to accumulation of dental plaque on the teeth, resulting in gingivitis within a few days.[23] Plaque accumulates on the teeth if it is not removed from the teeth by tooth brushing and use of dental floss or other mechanical methods. Many local risk factors can increase plaque formation and retention, thus contributing to the onset of gingivitis (e.g., tooth position, caries, rough-surfaced and overhanging dental restorations, orthodontic appliances). In patients suffering from necrotising gingivitis, poor oral hygiene is a strong risk factor.
tobacco
The precise mechanism is unknown, but may be related to the noxious agents and toxins in tobacco, vascular effects of nicotine, impaired leukocyte function, and the influence of smoking on the composition of dental plaque. Tobacco consumption is also a strong risk factor for necrotising gingivitis.[30]
diabetes mellitus
Depending on the level of glucose control, diabetes mellitus can be a strong risk factor for gingival inflammation. The mechanism for this may be related to exaggerated monocyte response to plaque antigens, impaired neutrophil chemotactic response, and up-regulation of cytokines mediated by advanced glycation end-products.[31]
pregnancy
Severity and incidence can increase during pregnancy.[32] This is likely related to the effects of oestrogen and progesterone on the gingiva.[33] Oestrogen and progesterone also act as growth factors for certain components of the subgingival microbiota, and thereby alter its composition. Maintaining good oral hygiene and controlling dental plaque minimise gingivitis during pregnancy. Following delivery, gingivitis returns to levels found before pregnancy.
severe malnutrition or marginal nutritional deficiencies
Severe malnutrition is a strong risk factor in necrotising gingivitis.[30] More marginal deficiencies in nutrition are linked to common plaque-induced gingivitis. A severe vitamin C deficiency (scurvy) may induce generalised gingival overgrowth with spontaneous haemorrhage (scorbutic gingivitis). Mucosal ulceration and increased severity of periodontitis can also occur. These manifestations are related to abnormal collagen synthesis. People who misuse alcohol, older edentulous people, chronically ill people (including those with concomitant gastrointestinal disease or psychiatric illness leading to poor nutrition), and young children whose diet consists entirely of milk can develop scorbutic gingivitis. A diet-related vitamin D deficiency may also enhance susceptibility to gingival inflammation.
HIV/AIDS (in necrotising gingivitis [NG])
HIV infection with a low CD4 count (<200) and a detectable viral load is associated with the occurrence of NG.[30]
stress (in necrotising gingivitis [NG])
Increased levels of personal stress may be associated with NG.[30] Psychological stress and inadequate sleep are important predisposing factors, as they may impair host immunity.
severe (viral) infections (in necrotising gingivitis [NG])
Severe (viral) infections, such as measles, herpes viruses, chicken pox, malaria, and febrile illness, are predisposing conditions for necrotising periodontal diseases in chronically, severely compromised children.[18]
previous history of necrotising gingivitis (NG)
A previous history of NG is shown to be a predisposing factor.[18]
weak
stress (in plaque-induced gingivitis)
May be a risk factor because of less attention to oral hygiene during times of high stress.[34]
xerostomic medicines
Medicines that cause xerostomia (dry mouth) are a predisposing factor for common plaque-induced gingivitis because xerostomia may result in increased formation and retention of bacterial plaque on the teeth.[35]
male sex
Males, particularly adolescent males, are more at risk for common plaque-induced gingivitis than females of the same age. This is attributed to generally poorer oral hygiene among males compared with females.[36]
extreme living conditions (necrotising gingivitis [NG])
May occur in people who live in certain conditions, such as those with limited access to potable water, those who live in close proximity to livestock, or those living in substandard accommodations.[18] NG is not transmissible from one person to another.
high alcohol intake
People who misuse alcohol are more at risk for developing gingivitis because they are more likely to have poorer oral hygiene.[37] Alcohol consumption has also been associated with the physiological (e.g., malnutrition, inadequate oral hygiene) and psychological factors favouring necrotising gingivitis.
substance use
Marginal dietary and oral hygiene behaviours associated with substance abuse may increase gingivitis risk by enhancing dental plaque accumulation.[38]
Use of this content is subject to our disclaimer