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Gingivitis

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Iqra Mazhar

Overview

Gingivitis is defined as an inflammation of the gingiva (gums), most commonly due to a bacterial infection. 
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Gingivitis is derived from the Latin words gingivae (gums) and -itis (inflammation). Thus, it translates to inflammation of the gums. It is most commonly caused by a bacterial infection and usually occurs before periodontitis. If left untreated, gingivitis can lead to periodontitis and tooth loss. According to the American Dental Association, periodontitis and gingivitis are the major causes of tooth loss in adults <a href="#accordion">[8]</a>. 
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Poor oral hygiene is the most common cause of gingivitis. A buildup of plaque increases the growth of bacteria in the gums. Thus, causing them to become inflamed and easily bleed during brushing. 
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Gingivitis is a very common condition and affects people of all ages. However, many individuals believe that gingivitis originates in childhood. An estimated 9-17% of children aged 3-11 years have gingivitis<a href="#accordion">[2]</a>. At puberty, the prevalence jumps to 70-90%<a href="#accordion">[2]</a>. A study conducted among schoolchildren in Hyderabad, Pakistan found that 70.4% of the students were suffering from gingivitis<a href="#accordion">[10]</a>. 
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Almost half of all adults aged older than 30 years suffer from some kind of gum disease<a href="#accordion">[5]</a>. Adults are most commonly affected, with females having a lower incidence than males. This is likely because women tend to practice better oral hygiene<a href="#accordion">[2]</a>. Furthermore, gingivitis is more common in pregnant women than non-pregnant women, with more severe types of gingivitis being reported among them<a href="#accordion">[1]</a>. A study conducted among pregnant females in Mardan, Pakistan reported 57.1% of the patients as suffering from gingivitis, with the severe form being the most common<a href="#accordion">[11]</a>. 
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According to studies, gingivitis is more common in low socioeconomic classes<a href="#accordion">[3]</a>. Contrastingly, higher socioeconomic classes have an increased awareness &nbsp;about the importance of&nbsp; maintaining oral hygiene. Also, various healthcare options are easily accessible and affordable. 
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Gingivitis is classified into several categories based on its etiology. 
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Plaque-Induced Gingivitis: This is the most common cause of the disease. It results from the accumulation of dental plaque on the teeth, leading to inflammation of the gums. Along with poor dental hygiene, the crowding of teeth also leads to the formation of plaque. Moreover, in children, tooth eruption makes it difficult to maintain oral hygiene in areas where permanent teeth are erupting. Thus, leading to plaque accumulation and gingivitis.&nbsp; 
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Nutritional Gingivitis: This is caused by the lack of certain nutrients, such as vitamin C, that are important for gum health. A diet composed of refined carbohydrates and an increased ratio of omega-6 to omega-3 fatty acids are often linked to nutritional gingivitis. 
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Hormonal Gingivitis: This is related to hormonal changes in the body, often observed during pregnancy or in menopausal women. The hormonal changes contribute to an increased inflammatory response by the gingival tissue to even small quantities of plaque accumulation. During puberty, these hormonal changes can lead to puberty gingivitis. 
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Drug-Induced Gingivitis: This is caused by certain medications, such as phenytoin, that cause an overgrowth of gum tissues. Other medications include calcium channel blockers, oral contraceptives, anticoagulants, and vitamin A and analogs. 
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Signs and Symptoms

Healthy gums should be pink, firm, and connected to the bottom ends of the teeth they support. Moreover, healthy gums do not bleed when brushed. The symptoms of gingivitis include: 
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<ul>
	<li>Red Swollen Gums: Gums may appear swollen, and may bleed while consuming hard foods, brushing, or flossing.</li>
	<li>Tender Or Painful Gums: Gums may be sensitive to the touch and may be painful when eating or talking. Moreover, people may have sensitivity to hot or cold foods.</li>
	<li>Receding Gums: Gums may shrink away from teeth, leaving more of the tooth exposed.</li>
	<li>Bad Breath (Halitosis): Chronic bad breath can be a sign of gingivitis.</li>
	<li>Pus Around The Gums And Teeth: Pus is a sign of infection that can occur in advanced cases of gingivitis.</li>
	<li>Changes In The Way Dentures Fit: Dentures may become loose or uncomfortable as a result of gum disease.</li>
	<li>Changes In The Appearance Of Gums: Gums may become discolored or have a shiny appearance. 
	&nbsp;</li>
</ul>

Not everyone with gingivitis will experience all these symptoms, and some individuals may have no symptoms at all. 
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Causes

Gingivitis is most commonly caused by bacterial plaque accumulation between and around the teeth. Over time this plaque can harden and form calculus or tar. A buildup of plaque and tar leads to the immune system destroying the gingival tissue. Thus, causing inflammation, which can lead to further complications. 
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The following microorganisms are strongly associated with causing gingivitis:

<ul>
	<li>Streptococcus</li>
	<li>Fusobacterium</li>
	<li>Actinomyces</li>
	<li>Veillonella</li>
	<li>Treponema 
	&nbsp;</li>
</ul>

The pathogenesis of the illness may also be related to Bacteroides, Capnocytophaga, and Eikenella. Several other factors can also lead to plaque deposition or increase the gums&rsquo; vulnerability to bacterial infection. 
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Diagnosis

A dentist will typically assess for signs of gingivitis during a dental exam. This includes a visual assessment of the gums and teeth to check for any inflammation and plaque build-up. A periodontal probe is used to assess gingival pockets. The probe is placed beside the tooth beneath the gum line, generally at multiple locations across the mouth. In a healthy mouth, the picket depth is normally between 1 and 3 millimeters (mm). A depth of more than 4mm typically indicates gum disease. 
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In some cases, a dental X-ray may be ordered to check for any bone loss. Moreover, a medical evaluation may also be advised to check for any underlying health conditions. 
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The gingival swelling in gingivitis can be classified into four grades<a href="#accordion">[3]</a>:

<ul>
	<li>Grade 0: There are no signs of gingival swelling.</li>
	<li>Grade I: The swelling is confined to the interdental papilla region.</li>
	<li>Grade II: Both the interdental papilla and the marginal gingiva are involved.</li>
	<li>Grade III: More than three-fourths of the crown structure is affected. 
	&nbsp;</li>
</ul>

Treatment

The aim of treatment in gingivitis is to control infection and restore healthy gums and teeth. During a routine dental cleaning, the doctor will try to remove bacteria, plaque, and tartar buildup from the teeth. Other common treatments include: 
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<ul>
	<li>Scaling And Root Planing - This process is similar to a regular dental cleaning. However, it reaches deeper beneath the gums. Tarter and bacteria are removed by scaling, while planing smooths the surface of the teeth roots, preventing bacteria from sticking to it. 
	&nbsp;</li>
	<li>Improving Oral Hygiene Practices - Proper oral hygiene techniques and regular dental checkups help monitor and maintain gum health. 
	&nbsp;</li>
	<li>Oral Antibiotics - In severe cases, an oral antibiotic may be used to treat chronic gingivitis 
	&nbsp;</li>
	<li>Antiseptic Mouthwash - Rinsing with an antiseptic mouthwash can help kill bacteria responsible for causing gingivitis. 
	&nbsp;</li>
	<li>Dental restoration - In some cases, dentists may need to fix misaligned teeth or poorly fitted crowns and bridges as these may irritate the gums and make it more difficult to remove plaque during brushing.&nbsp; 
	&nbsp;</li>
</ul>

In severe cases, especially if the inflammation has caused bone tissue loss, surgery may be required. The following procedures may be conducted:

<ul>
	<li>Flap Surgery - The gums are lifted back to remove plaque and tartar from the deeper pockets. They are then sutured back in place around the tooth. 
	&nbsp;</li>
	<li>Bone And Tissue Grafts - This is usually used in cases where the jaw and teeth are severely damaged. 
	&nbsp;</li>
	<li>Dental Crown Lengthening - In people with excess gum tissue, a periodontist may reshape the gum and bone tissue so more of the teeth are exposed. 
	&nbsp;</li>
</ul>

If left untreated, gingivitis can lead to the following complications.

<ul>
	<li>Periodontitis (advanced gum disease)</li>
	<li>Tooth loss</li>
	<li>Receding gums</li>
	<li>Difficulty controlling blood sugar in individuals with <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes</a></li>
	<li>Complications in pregnancy</li>
	<li>Poor oral health and related quality of life issues. 
	&nbsp;</li>
</ul>

Necrotizing ulcerative gingivitis (NUG), also called trench mouth, is a severe form of gingivitis. Although rare in developed nations, in developing countries, poor nutrition and living conditions can contribute to the disease. It can result in painful, infected, bleeding gums with ulceration. 
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The following factors can increase plaque formation or the risk of gum inflammation in people. 
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<ul>
	<li>Poor Oral Hygiene: Lack of regular brushing and flossing can lead to the buildup of plaque and tartar, which can cause gingivitis.</li>
	<li>Tobacco Use: Smoking or using tobacco products increases the risk of gum disease.</li>
	<li>Hormonal Changes: Hormonal changes, such as those observed in pregnancy or puberty, can make gums more susceptible to inflammation.</li>
	<li>Genetics: Some people may be genetically predisposed to gum disease. People with a family history of gingivitis are at a higher risk.</li>
	<li>Illnesses: Chronic diseases, such as diabetes, cancer, and HIV can lead to a higher risk of gingivitis.</li>
	<li>Medications: Certain medications reduce saliva production and increase plaque formation. Whereas, angina drugs and epilepsy medications can lead to abnormal growth of gingival tissue.</li>
	<li>Stress: Stress can weaken the immune system, making it more difficult to fight off gum disease.</li>
	<li>Poor Nutrition: A diet lacking essential nutrients, such as vitamin C, can increase the risk of gum disease.</li>
	<li>Alcohol And Drug Use: Alcohol and drug use can weaken the immune system and increase the risk of gum disease.</li>
	<li>Aging: As people age, their gums may become less resilient and more susceptible to gum disease.</li>
	<li>Bruxism (Teeth Grinding): Bruxism can cause injury to the gums and increase the risk of gum disease. 
	&nbsp;</li>
</ul>

Here are some ways to prevent gingivitis: 
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<ul>
	<li>Brush Teeth Twice A&nbsp;Day: Brushing teeth twice a day with fluoride toothpaste can help remove plaque and prevent gum disease.</li>
	<li>Floss Daily: Flossing helps remove plaque from areas where a toothbrush can&#39;t reach.</li>
	<li>Use An Antiseptic Mouthwash: Using an antiseptic mouthwash can help kill bacteria and freshen your breath.</li>
	<li>Eat A&nbsp;Healthy Diet: A balanced diet rich in nutrients and low in sugar can help maintain healthy gums.</li>
	<li>Stop Smoking Or Using Tobacco Products: Smoking or using tobacco products can increase the risk of gum disease.</li>
	<li>Use A&nbsp;Soft-Bristled Toothbrush: A soft-bristled toothbrush can help prevent injury to the gums.</li>
	<li>Replace Toothbrushes Frequently: Toothbrushes should be replaced every three to four months to ensure effective cleaning.</li>
	<li>Practice Stress Management Techniques: Stress can weaken the immune system and make it more difficult to fight off gum disease. Practicing stress management techniques can help maintain healthy gums.</li>
	<li>Good Health Practices: Managing blood sugar in case of diabetes is important for maintaining gum health.</li>
	<li>Regular Dental Visits: Visiting a dentist or dental hygienist every 6-12 months can help decrease the risk of gum disease. Moreover, people who smoke or take certain medications may require more frequent regular professional cleaning. 
	&nbsp;</li>
</ul>
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Anti-inflammatory diet (AID) has been linked to significantly reducing gingival inflammation, despite the presence of dental plaque. Recently, a study investigated the role of serum fatty acids in the effects of an anti-inflammatory diet (AID) on gingival inflammation. 30 participants with gingivitis followed either a pro-inflammatory diet (PID) or AID for 4 weeks. 
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The AID protocol reduced gum inflammation effectively but did not change fatty acid levels in patients with gingivitis. Some fatty acids showed limited associations with inflammation but no strong connection was found over the 4-week study. Researchers believe that other factors like carbohydrates or micronutrients may have contributed to the short-term improvement in gingivitis with AID<a href="#accordion">[9]</a>. 
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Key Points

<ul>
	<li>Gingivitis is derived from the Latin words gingivae (gums) and -itis (inflammation). Thus, it translates to inflammation of the gums. It is most commonly caused by a bacterial infection and usually occurs before <a href="https://merisehat.pk/disease/periodontitis">periodontitis</a>.</li>
	<li>Gingivitis is more common in men than in women, owing to the fact that women prefer to practice better oral hygiene.</li>
	<li>Healthy gums should be pink, firm, and connected to the bottom ends of the teeth they support. When the teeth are brushed regularly, there should be no bleeding. However, in gingivitis, the gums are rather swollen, bleeding, and painful. You might experience bad breath along with other symptoms.</li>
	<li>Gingivitis is classified into several categories based on its etiology such as plaque-induced gingivitis, nutritional gingivitis, hormonal gingivitis, and drug-induced gingivitis. The most common type is plaque-induced gingivitis.</li>
	<li>Gingivitis is diagnosed through a dental examination, including a visual assessment of the gums and teeth to check for any inflammation and plaque build-up. Dental probing is also used to measure the pocket depth of the groove between the gums and the teeth.</li>
	<li>Gingivitis is typically treated with proper oral hygiene and professional dental cleaning that involves scaling &amp; root planing. 
	&nbsp;</li>
</ul>
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[1] Kashetty M, Kumbhar S, Patil S, Patil P. Oral hygiene status, gingival status, periodontal status, and treatment needs among pregnant and nonpregnant women: A comparative study. J Indian Soc Periodontol. 2018;22(2):164-170. doi:10.4103/jisp.jisp_319_17

[2] James M Stephen MD. Gingivitis. Background, Pathophysiology, Epidemiology.

[3] StatPearls. Gingivitis. StatPearls.

[4] Gingivitis: Causes, symptoms, and treatment. Medical News Today.

[5] Gingivitis: Symptoms and how to treat it. Cleveland Clinic.

[6] Gum disease (gingivitis & periodontitis): Symptoms, causes, treatment. WebMD.

[7] Gingivitis. Mayo Clinic.

[8] Hersh E. Gum disease (gingivitis and periodontitis). Healthline.

[9] Kruse AB, Gärtner M, Vach K, et al. An exploratory study on the role of serum fatty acids in the short-term dietary therapy of Gingivitis. Scientific Reports. 2022;12(1). doi:10.1038/s41598-022-07989-510.

[10] Memon, S. ., Memon, F. ., Shahid, H. ., Khatri, D. R. ., & Memon, S. A. . (2016). Prevalence of Gingivitis in School Children at Different Government Schools of District Hyderabad. Journal of Bahria University Medical and Dental College, 6(4), 236–240.

[11] Hussain M, Naeem M, Khattak I, Zaman R, Raziq S. Frequency of gingivitis in pregnancy in patients reporting to Bacha Khan Dental College, Mardan. Pakistan Journal of Public Health. 2021;10(2):108-112. doi:10.32413/pjph.v10i2.484