Clinical Features of Gingivitis

Overview of the clinical manifestations of gingivitis, emphasizing its progression, distribution patterns, and tissue alterations essential for accurate diagnosis and classification.

1. Course and Duration

Gingivitis is categorized based on its onset and persistence:

Acute Gingivitis: Rapid onset, short duration, may cause discomfort.
Subacute Gingivitis: A milder, less symptomatic variant of acute presentation.
Recurrent Gingivitis: Reappearance after resolution, either spontaneously or following treatment.
Chronic Gingivitis: The most common form. It progresses slowly, is often painless, and may exhibit cyclical exacerbations and remissions, affecting both previously involved and uninvolved sites.

2. Distribution

Inflammation is classified by location and extent:

Localized: Limited to one tooth or a specific group.
Generalized: Affects gingiva throughout the dentition.
Marginal: Confined to the gingival margin.
Papillary: Involves interdental papillae, often the earliest site of inflammation.
Diffuse: Involves marginal, attached gingiva, and papillae, sometimes masking the mucogingival junction.

Examples of Combined Distribution:

Localized Marginal Gingivitis
Localized Diffuse Gingivitis
Localized Papillary Gingivitis
Generalized Marginal Gingivitis
Generalized Diffuse Gingivitis: May indicate systemic involvement.

3. Clinical Findings

Diagnosis is based on systematic evaluation of:

Color
Contour
Consistency
Position
Bleeding
Pain

3.1 Gingival Bleeding on Probing

Earliest sign of gingival inflammation, along with increased gingival crevicular fluid.
Appears before visible changes and is an objective diagnostic marker.
Severity and ease of bleeding vary, making it a key parameter in several gingival indices.

3.2 Bleeding Due to Local Factors

Chronic Bleeding: Caused by chronic inflammation, aggravated by brushing, flossing, or hard foods.
Acute Bleeding: Due to trauma or conditions like ANUG, where ulcerated epithelium exposes capillaries.

3.3 Color Changes in Gingiva

Chronic Gingivitis: Red or bluish-red due to vascular dilation, reduced keratinization, and venous stasis.
Acute Gingivitis: Color varies (e.g., gray necrotic areas in ANUG or diffuse redness in herpetic infections).
Metallic Pigmentation: Heavy metals (e.g., lead, bismuth) cause bluish-black lines along the margin.

3.4 Color Changes from Systemic Factors

Endogenous Pigments:
- Melanin: Common in darker-skinned individuals.
- Bilirubin: Jaundice.
- Iron: Hemochromatosis.
Pathologic Pigmentations:
- Addison’s disease
- Peutz-Jeghers syndrome
- Albright’s and von Recklinghausen’s diseases
Exogenous Influences: Tobacco, food dyes, atmospheric irritants, and amalgam tattoos.

3.5 Changes in Consistency

Consistency varies with the balance of inflammatory exudate and fibrotic repair:

Clinical Appearance	Microscopic Change
Soggy, pitting edema	Fluid and exudate infiltration
Friable tissue	Degeneration of connective tissue
Firm, leathery	Fibrosis with epithelial proliferation
Nodular	Fibrosis with focal inflammation

Calcified deposits (e.g., calculus, cementicles) may be palpable within fibrotic tissues.

3.6 Surface Texture Changes

Loss of stippling: Early indicator.
Smooth/shiny: Exudative or atrophic tissue.
Firm/nodular: Fibrotic tissue.
Peeling/Desquamative: Often in chronic desquamative gingivitis.
Leathery/Nodular: Seen in drug-induced overgrowth or hyperkeratosis.

3.7 Changes in Gingival Position (Recession)

Recession involves apical migration of the gingival margin:

Actual Position: Attachment level on the tooth.
Apparent Position: Visible margin.
Total Recession = Visible + Hidden

Etiological Factors:

Aging: Not truly physiologic—cumulative trauma or pathology.
Toothbrushing Abrasion: Common, especially with hard bristles.
Tooth Malposition: Thinner bone makes gingiva more susceptible.
Frictional Trauma, Chronic Inflammation, Abnormal Frenum, Anatomic Root Prominences, Orthodontic Movement, and possibly smoking.

Clinical Implications:

Root caries
Hypersensitivity
Pulpal symptoms
Aesthetic concerns
Oral hygiene difficulty, especially interdentally

3.8 Changes in Gingival Contour

Most commonly associated with enlargement, but also includes:
- Stillman’s Clefts: Narrow indentations of the margin.
- McCall’s Festoons: Rolled, swollen marginal contours.
Previously linked to occlusal trauma, but now understood as inflammatory changes.

Conclusion

The clinical features of gingivitis offer valuable diagnostic insights based on a comprehensive assessment of the tissue’s appearance, texture, and response to provocation. Recognizing these subtle but significant changes ensures early intervention, preventing progression to more severe periodontal disease.