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4. The symptoms a patient may report include: a. Bleeding gums (metallic/altered taste) b. Pain (soreness) c. Halitosis d. Difficulty eating e. Appearance (swollen red gums) f. Reduced oral health–related quality of life 5. Radiographs cannot be used to diagnose gingivitis.
e. Elevations in sex steroid hormones – at puberty, during preg- nancy, or following medication with first generation oral con- traceptives may modify the gingival inflammatory response. Complex biological reactions within the gingival tissues result from such elevated sex steroid levels and generate more than expected inflammation, in response to relatively small levels of plaque. However, modern oral contraceptive dosages have been reduced and there is little evidence for exaggerated gin- gival inflammatory responses to plaque with such drugs. 21 f. H ematological conditions – particular blood malignancies such as leukemia or pre‐malignant conditions such as myelodyspla- sia are associated with signs of excess gingival inflammation in the absence of excessive plaque biofilm accumulation. Signs include swollen, purple or occasionally pale gingiva due to leukemic cell infiltration, gingival bleeding that is inconsis- tent with levels of dental plaque biofilm accumulation, due to thrombocytopenia and/or clotting‐factor deficiencies. 22 What are the diagnostic criteria for a gingivitis case? Given the “spectrum” of presentation of gingival health and gingival inflammation in terms of severity and extent of gingival involvement, it is important to define the features of a universally accepted case of gingivitis. Current epidemiological data on the prevalence of gingivitis suf- fer from the lack of a universally adopted case definition and vary as widely as 6% to 94%, due to the use of indices that measure gingival inflammation at individual sites rather than considering the patient's mouth as a whole. Therefore, mild localized clinical inflammation is reported to affect almost 95% of the population, a figure that would incorrectly suggest gingivitis as being a variation of “normality” and thus consistent with the spectrum of “clinical health” rather than being a disease. By contrast, the more extensive the manifestation of disease employed in a case definition, the lower the reported prevalence. A universally agreed case definition should be based upon a pragmatic appraisal of the evidence base derived from longi- tudinal observation and intervention studies.
Should we classify dental plaque biofilm‐induced gingivitis? There is utility in defining the severity of gingivitis as a patient commu- nication tool, but there are no objective clinical criteria for defining se- verity. Thus, in this context alone, the extent of gingivitis can be used to communicate “mild, moderate, and severe” gingivitis. Moreover, emerging evidence suggests that the contained gingivitis lesion may have systemic inflammatory consequences. 23,24 There is no robust evidence to clearly differentiate mild, moder- ate, and severe gingivitis, and definitions remain a matter of profes- sional opinion. Methods of defining gingivitis may include: Defining percentages (e.g. mild = < 10%, moderate = 10%‐30%, se- vere = > 30% sites) Grading (e.g. grade 1 to 5 in 20% quintiles for % sites bleeding on probing). How do we define a case of dental plaque‐induced gingivitis on an intact and a reduced periodontium for epidemiological purposes? For epidemiological purposes, gingivitis on an intact periodontium and gingivitis on a reduced periodontium in a patient without a history of periodontitis, is defined as ≥10% bleeding sites 4,5 with probing depths ≤3 mm. Localized gingivitis is defined as 10%‐30% bleeding sites; gen- eralized gingivitis is defined as > 30% bleeding sites. For epidemiological purposes alone, a periodontitis case cannot simultaneously be defined as a gingivitis case. Therefore, a patient with a history of periodontitis, with gingival inflammation is still a periodontitis case. How do we classify a patient with dental plaque‐ induced gingivitis on an intact and a reduced periodontium for clinical practice? In clinical practice, a case of gingivitis on an intact periodontium, or a reduced periodontium in a patient without a history of periodonti- tis, would be a patient with signs of gingival inflammation as defined above (Table 1). In clinical practice, periodontitis patients, if successfully treated can achieve a reduced and stable periodontium where probing pocket depths are ≤4 mm 27 and there is an absence of clinical inflammation
Clinical, radiological, and biological signs and symptoms
1. Gingivitis is a clinical diagnosis. While emerging technologies are starting to shed light on the microbiological, molecular, and pathophysiological characteristics of gingivitis, definitive knowledge is not sufficient to supersede current clinical parameters. 7 2. The clinical signs of inflammation are erythema, edema, pain (soreness), heat, and loss of function. 3. These may manifest clinically in gingivitis as: a. Swelling, seen as loss of knife‐edged gingival margin and blunting of papillae b. Bleeding on gentle probing c. Redness d. Discomfort on gentle probing
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