Plaque Induced Gingival Inflmmation Question And Answers

Plaque Induced Gingival Inflammation

Plaque-induced gingival inflammation occurs as an inflammatory response to supragingival bacterial accumulation. As the accumulation of plaque and the tissue reaction to it is a time-bound process, the gingival inflammation in response to plaque is always chronic in nature. This differs from the pathogenic mechanisms that are involved in acute gingival infections that have been described elsewhere in this book.

Question 1. Describe the staging of gingival inflammation.
Answer:

Page and Schroeder have identified four stages of gingivitis as follows:

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Stage 1: Initial lesion

Stage 2: Early lesion

Stage 3: Established lesion

Stage  4: Advanced lesion

Stage 1: Gingivitis—The Initial Lesion

This stage is “subclinical gingivitis” as there are no visible clinical changes in the gingiva, on examination.

Microscopic Changes

• At the microscopic level, the gingiva shows classic acute inflammatory changes characterized by: Vasodilatation and increased GCF flow, the predominant inflammatory cell in the junctional epithelium is the neutrophil—the first line of defense.
• These cells marginate and then emigrate out of the vessel walls. This phase lasts for 2–5 days. There is early evidence of loss of collagen in perivascular areas.

Stage 2: Gingivitis—The Early Lesion

Initial clinical changes begin to appear with marginal erythema. There may also be bleeding on probing.

Microscopic Changes:

In this stage, a vascular response is in the form of proliferation with increased capillary loops, while the principal inflammatory cell is the T-lymphocytes. Collagen destruction occurs in the dentogingival/circular fier groups around cell infiltrate which consists of increased neutrophilic infiltration in the junctional epithelium.

Stage 3: Gingivitis—The Established Lesion

Clinical changes in the gingiva are well established with changes in color, contour, consistency, size and shape, and texture of the gingiva.

Microscopic Changes

• The chronic inflammatory breakdown of gingival connective tissue is more obvious at this stage.
• The principal inflammatory cell is the plasma cells in the connective tissue, that are capable of producing antibodies.
• The junctional epithelial cells extend into connective tissue and basal lamina becomes discontinuous. There is extensive loss of collagen around the cellular infiltrate at this stage.

Stage 4: Gingivitis—The Advanced Lesion

The uncontrolled gingival lesion generally progresses to the alveolar bone and the periodontal ligament and is therefore characterized as “Periodontitis” rather than “stage IV gingivitis”.

Question 2. Classify gingivitis. Describe its clinical features.
Answer:

Clinical Features of Chronic Gingivitis The clinical features differ according to the nature and extent of the inflammation. It is therefore necessary to appreciate the various clinical presentations of gingivitis before understanding their clinical features.

Classifiation of Gingivitis

Classification is based on the course of the disease and duration concerning its onset.

• Acute gingivitis: Inflammatory changes in the gingiva that occur suddenly and in a short course.
• Chronic gingivitis: Plaque-induced gingivitis that may undergo progression or remain at this stage for a long time.
• Classification based on distribution.
• Localized gingivitis: It is usually limited to one or a few teeth, for example, lower anterior.
• Generalized gingivitis: Present in the entire or most of the dentition. Classification based on site affected.
• Marginal gingivitis: Gingival inflammation is limited to the gingival margin.
• Papillary gingivitis: Gingival inflammation is limited to the interdental papilla.
• Diffse gingivitis: Gingival inflammation involves marginal, papillary, and attached gingiva. A complete classification combines a couple or more of the above: For example, localized marginal gingivitis, generalized diffuse gingivitis, localized papillary gingivitis, etc.

Question 3. Describe the clinical features of gingivitis.
Answer:

Changes in Color

The normal color of the gingiva is pale pink with a grayish or blackish hue due to the presence of melanin pigmentation. In gingival inflammation, the color of the gingiva may change to red due to the increased vascularity and ulceration of epithelium leading to the superficial presence of blood vessels. Chronic inflammation may lead to venous stasis and as a result, the color of the gingiva may turn bluish-red.

Changes in Contour

In gingival inflammation, the scalloped contour of healthy gingiva is altered, with blunting of the interdental papilla, as a result of the inflammatory edema.

Changes in Consistency

• The consistency of gingiva in health is firm and resilient, attributed to the presence of collagen fibers and its adhesion to the underlying periosteum.
• In gingival inflammation, the gingiva becomes soft and edematous, owing to the infiltration of inflammatory exudate in the interstitial spaces.

Changes in the Size and Shape

Gingival inflammation can result in bulbous and enlarged interdental and marginal gingiva, and roundening of marginal gingiva due to the inflammatory exudate invading the interstitial spaces.

Changes in Surface Texture

The normal surface texture of healthy gingiva, characterized by the orange—peel or stippled appearance is lost due to obliteration of the intercellular space by the inflammatory exudate and flattening of the rete ridges.

Bleeding on Probing

Bleeding on probing is a characteristic clinical sign of gingival inflammation.  Gingival inflammation is characterized by an increased number of blood vessels, thinning, and ulceration of epithelium, resulting in superficial localization of the underlying blood vessels.

• This histological change leads to the most objective sign of gingivitis—bleeding on probing.
• The cardinal sign that distinguishes gingivitis from periodontitis is loss of attachment.
• The clinical signs that have been described above indicating gingivitis, may or may not be present in periodontitis lesions, but periodontitis is always accompanied by evidence of loss of attachment.

Write a note on the management of plaque-induced gingivitis.

Plaque-induced gingivitis is primarily of bacterial origin, the objective of therapy is to remove the local irritants, as a result of which inflammation resolves. Chronic gingivitis is reversible as a result complete resolution is possible, following through debridement (for debridement refer to the chapter on scaling and root planing).

• However, in some cases, there may be altered gingival contour following gingival shrinkage, which may require gingivoplasty/gingivectomy procedures. (for details of gingivectomy refer later…..).