Approach

The clinical appearance may range from a barely perceptible increase in redness, puffiness, or swelling of the gingival tissues (gums) to severely inflamed reddened and swollen gingiva. A common clinical symptom reported by patients is transient bleeding during tooth brushing and use of various mechanical means of cleaning between the teeth, such as dental floss and tooth picks.[46] Gingivitis is accompanied by the accumulation of bacterial plaque (biofilm) on the teeth, but because dental plaque is white and translucent, it is not visible on the teeth unless there is very heavy accumulation. Gingivitis may also be characterized by the presence of calculus, and other plaque-retentive factors (e.g., dental fillings with open and/or overhanging margins, poorly fitting partial dentures, over-contoured crowns, cervical caries).[1] There is no radiographic evidence of loss of the adjacent supporting bone. Purulent exudates (pus) can occasionally be seen at sites with gingivitis, although it is most often detected at sites with chronic periodontitis. Halitosis is a common finding in gingivitis.[46]

Plaque-induced gingivitis

Common plaque-induced gingivitis is not accompanied by any symptoms of general malaise such as fever or lymphadenopathy.

Necrotizing gingivitis (NG)

NG is perceived by the patient as having a sudden onset and is often associated with ≥1 of the following: heavy smoking, increased personal stress, increased alcohol intake, poor nutrition, and substance abuse. It is characterized by a chief complaint of moderate to profuse bleeding on tooth brushing. Necrosis and ulceration of the tips of the interdental papillae or gingival margin are pathognomonic clinical features of NG. Also, pain will always be felt, especially with oral hygiene procedures such as tooth brushing. Pseudomembrane formation over the necrotic area is a less common finding.[47] Halitosis, often associated with NG, is not pathognomonic of this form of gingivitis as it can also be found in other pathologic conditions of the oral cavity, including chronic periodontitis. There can also be fever, lymphadenopathy, and a general feeling of malaise. NG is now rare in developed countries and may occur as a complication of HIV in severely immunocompromised patients with low CD4 T-lymphocyte counts. It is much more prevalent among children in countries where severe malnutrition, extreme living conditions, and severe viral infection/malaria are common.[17][18]

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