Classification of Gingival Diseases

There has been much in the news lately about the relationship between gum disease and systemic health. Research has shown that gum disease can lead to increased levels of inflammation, poor diabetic control, and even certain types of cancer. However, did you know that there are many different types of gum disease? This article discusses the difference between a mild gum infection (gingivitis) and a more severe gum condition called periodontitis or periodontal disease.

Gingivitis has been traditionally defined as the presence of clinical signs of inflammation that are confined to the gingiva and associated with teeth showing no attachment loss. Gingival diseases are classified into two categories: dental plaque induced gingival diseases and non-plaque induced gingival lesions.

Dental plaque induced gingival diseases is the most common form of gingival disease. It has been concluded that plaque-induced gingivitis may occur on a periodontium with no attachment loss or on a periodontium with previous attachment loss that is stable and not progressing. Further classification of dental plaque induced gingival disease is present. Gingivitis associated with dental plaque only is the result of an interaction between the microorganisms found in the dental plaque biofilm and the tissues and inflammatory cells of the host.

Gingival diseases modified by systemic factors may be exacerbated by dental plaque. Gingival disease modified by medications have become more prevalent due to increased use of anticonvulsants, immunosuppressive drugs, calcium channel blockers, etc and show increased effect in the presence of dental plaque. Gingival diseases modified by malnutrition with plaque accumulation show increased effect in the condition known as scurvy (vitamin C deficiency).

Non plaque induced gingival lesions are oral manifestations of systemic conditions that produce lesions in the tissues without plaque formation. Again further categories have been established. Gingival diseases of specific bacterial origin have become increasingly prevalent as a result of sexually transmitted diseases. Gingival diseases of viral origin may be caused by DNA and RNA viruses for example herpes. Disease of fungal origin is common in immunocompetent individuals. The most common pathogen of this disorder is Candida Albicans which is a normal inhabitant of the oral cavity however takes advantage of the altered oral flora.

Genetic disorders such as hereditary gingival fibromatosis have been linked to non-plaque induced gingival lesions. Gingival manifestations of systemic conditions may appear as desquamative conditions, ulcerations or both. Allergy to certain restorative materials, toothpastes, mouthwashes, etc. has also been shown to cause gingivitis in the absence of plaque. Traumatic lesions may be factitial or iatrogenic but nevertheless be a causative factor in gingivitis. Foreign body reactions lead to localized inflammatory conditions of the gingiva. Common sources include amalgam which are embedded in gingiva or retained sutures.

Periodontitis is defined as an inflammatory disease of the supporting tissues resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession or both. Three main categories exist: chronic periodontitis, aggressive periodontitis, and periodontitis as a manifestation of systemic diseases. Minor classifications include necrotizing periodontal disease, abscesses and periodontal disease due to other factors.

Chronic periodontitis is the most common form of periodontitis. It is most prevalent in adults but can occur in children. The amount of destruction is most consistent with local factors. Subgingival calculus is frequently found as well as a variable microbial pattern. Slow to moderate rate of progression are common with possible periods of rapid progression. It can also be modified by systemic disease such as HIV, diabetes as well as local factors such as smoking.

Aggressive periodontitis is otherwise seen in a clinically healthy patient. Rapid attachment loss and bone destruction are present. The amounts of microbial deposits are inconsistent with disease severity and a familial aggregation of diseased individuals is sometimes seen. Some diseased sites are infected with a bacterial species called Actinobacillus actinomycetemcomitans. There is an abnormality in phagocyte function as well as hyper-responsive macrophages. In some cases the disease will be self-arresting however most will require surgical intervention as well as antibiotic therapy.

Periodontitis as a manifestation of systemic diseases can be seen in hematologic, genetic and other non-specified conditions. Hematologic disorders include but are not limited to acquired neutropenia and leukemias. Genetic disorders include familial and cyclic neutropenia, down syndrome, leukocyte adhesion deficiency syndromes, papillon-lefevre syndrome, etc. These forms of periodontal disease are extremely difficult to treat and diagnose. Most cases require intervention from both the medical as well as dental practitioner.

Another area of periodontal diseases includes the necrotizing periodontal diseases. The clinical characteristics of these conditions may include ulcerated and necrotic papillary and marginal gingiva, blunting and cratering of papillae, bleeding on provocation, pain and halitosis. Two major conditions exist: acute necrotizing ulcerative gingivitis (ANUG) and acute necrotizing ulcerative periodontitis (ANUP). The major difference which distinguishes these entities is that of attachment loss. ANUG will not display loss however ANUP will demonstrate attachment as well as alveolar loss. Fortunately, both ANUG and ANUP are not commonly seen in today's population. There is controversial evidence that links the decline of both diseases to the increasing amount of antibiotics placed in the food supply. Although this may be true, most periodontists will agree that the decrease in ANUG and ANUP is due to the public's increased knowledge in oral hygiene and home care products.

Abscesses of the periodontium can be classified into three categories. Endodontic-periodontal lesions are primary pulpal in nature with the infection spreading to the surrounding periodontium. Periodontal-endodontic lesions are the exact reverse with disease originating within the periodontium and subsequently affecting the dental pulp. A combined lesion occurs when pulpal necrosis and a periapical lesion occur in a periodontally involved tooth. Periodontal abscesses are extremely painful in nature and should be treated immediately by a dentist or periodontist.

Other factors also contribute to periodontitis. Conditions such as malformations of teeth, faulty dental restorations or ill-fitting appliances, root fractures, cervical root resorption and cemental tears all contribute to periodontal disease. These modes of periodontal disease are not as common and can generally be corrected.

It is of utmost importance that every individual receive an examination for periodontal disease by a dental healthcare professional at least twice a year. Gingivitis can be easily treated if diagnosed at an early stage by routine cleanings and oral hygiene instruction. If left untreated however, gingivitis will progress to periodontitis. Periodontitis is not reversible and must be treated with utmost care otherwise teeth will ultimately be lost.