Gingivitis (063)

Periodontitis • Gum Disease • Trench Mouth

The Facts

Gingivitis is an inflammation of the gums (known to doctors as the gingiva) caused by bacteria. Eventually the bacteria can get into the bones at the root of the teeth and eat them away. This latter stage is called periodontitis. It's a leading cause of tooth loss in the overall population and the number one cause in seniors.

Causes

The bacteria that cause gingivitis lurk in the gum line, at the point where the teeth emerge. Many species of bacteria are involved, but they go by the universal name of plaque. Plaque is made of bacteria, mucus, and small particles of food. New bacteria are arriving constantly, and if they're not brushed off within about 2 days, they form a rock-hard layer called tartar. Toothbrushes and dental floss can't remove tartar, only a dentist can.

Some people are more prone to getting gingivitis than others. Gingivitis is particularly likely to occur in people with diabetes, AIDS, or leukemia. Other factors linked to an elevated risk of gingivitis include:

• puberty
• pregnancy
• menopause
• smoking
• poor-fitting fillings and crowns (also known as caps)
• mouth breathing
• genetics
• allergic reaction (e.g., cinnamon gum)
• vitamin C deficiency (scurvy)
• niacin (vitamin B3) deficiency (pellagra)
• medications (e.g., use of the female contraceptive pill)
• poorly aligned teeth or poorly fitted mouth appliances (such as retainers or crowns)
• exposure to heavy metals (e.g., lead, bismuth)

Pregnant people frequently have gum problems. Hormonal changes and tartar can combine to provoke an excess growth of gum tissue. Sometimes, a lump forms that may bleed easily. It's called a pregnancy tumour, though it has nothing to do with cancer. This lump can obstruct areas of gum line from brushing, letting bacteria prosper in safety.

Postmenopausal people can develop a painful condition called desquamative gingivitis. For unknown reasons, the outer layers of the gums come away from the teeth and lose their solidity. This disease can be very painful, as nerve endings are often exposed.

Some medications are also associated with gingivitis, including:

• cyclosporine* (used to treat rheumatoid arthritis and other autoimmune diseases)
• phenytoin (used to control epilepsy and other seizures)
• calcium channel blockers such as nifedipine (used treat high blood pressure and other heart conditions)

Some viruses can also infect the mouth. The one most likely to attack the gums is the herpes virus. It causes tiny ulcers and holes to appear in the gums and other parts of the mouth. This disease is called acute herpetic gingivostomatitis (stoma is a medical term for "hole"). It only strikes people who have just caught herpes for the first time. Some genetic disorders or allergic reactions may also lead to gingivitis.

Symptoms and Complications

Typical bacterial gingivitis is usually a painless condition, even when the gums are bleeding. They become bright red and swell up. They are less firm than usual and may even be movable. They are likely to bleed during brushing and perhaps eating. Sometimes they bleed at night.

Herpetic gingivostomatitis also turns the gums bright red, but it can be easily distinguished because it's usually quite painful. There are dozens of tiny white or yellow sores visible in the gums and inner cheeks.

The tartar that can be seen at the gum line may be the tip of the iceberg. It generally spreads between the teeth and gums, forcing the 2 apart and living in the newly created pocket. There, the bacteria release chemicals that can eat away at the bones that hold the roots of the teeth. These same chemicals cause bad breath. Eventually the teeth are no longer firmly fixed in position; they get loose and either fall out or have to be pulled out. This advanced form of gingivitis is called periodontitis. Surprisingly, it often causes no pain and the patient becomes aware of the disease due to bleeding gums or loose teeth.

Trench mouth, also known as Vincent's infection, is a particularly severe form of gingivitis caused by a combination of 2 bacteria. Your dentist may refer to it by its other name, acute necrotizing ulcerative gingivitis (or ANUG). This disease causes a rapid onset of swelling, bleeding, severe pain, and terrible bad breath. The gums are grey in colour, and are often misshapen. The papillae (the pointed part of the gum between the teeth) often become flat and have an area of dead tissue. The disease is usually found to affect those in times of severe stress (e.g., students during exam sessions) and smokers. Its name dates back to the First World War when it often developed among soldiers in the trenches.

Gum disease has been linked to various health concerns such as premature birth, lung disease, heart disease, stroke, and heart attack.

Making the Diagnosis

Gingivitis is easily diagnosed by the appearance of the gums. The appearance of the inflammation will help your doctor or dentist distinguish a bacterial infection from the herpes virus. Scrapings could yield information on the species of bacteria involved, but it's rarely relevant to treatment, so it's not generally done. Your dentist may look at the depth of the pockets around each tooth: depths greater than 3mm have a high risk of gingivitis.

Occasionally, gingivitis is the first sign of some other disease such as diabetes or leukemia. A doctor may want to give someone with gingivitis a more thorough examination if there is severe gum disease for no apparent reason.

Treatment and Prevention (5,6)

Thorough flossing and brushing can prevent gingivitis. Tartar control toothpaste, though not scientifically evaluated, may also help with prevention.

Some types of antibacterial mouthwash may also be helpful. The most effective ones contain the ingredient chlorhexidine (e.g., Perichlor®, Denti-Care®). Most traditional mouthwashes contain high amounts of alcohol, which may cause alcohol burn. These mouthwashes can be very irritating to already inflamed gums. They also do not get rid of sulphur-containing compounds (bacteria toxins) that cause bad breath. Mouthwashes containing chlorhexidine or chlorine dioxide will control bacterial growth.

Electric toothbrushes are also more effective than manual toothbrushes in removing the plaque that causes gingivitis. If you have a severe infection, your dentist may prescribe an antibiotic.

Studies have shown that brushing can prevent gingivitis in adults and children. Flossing appears not to help in children, though it's a good habit for them to form. However, people with diseases that make gingivitis more likely (such as diabetes) shouldn't rely on good oral hygiene alone to prevent it. Treating the disease itself is very important in preventing gingivitis.

Once plaque has turned to tartar, only a dentist can remove it. Dentists recommend having your teeth professionally cleaned every year or every 6 months. Some people with predisposing disorders gingivitis may need a professional cleaning every 3 months or even as frequently as every 2 weeks.

Plaque and tartar removal can also be the treatment for early gingivitis. Once the plaque and tartar are gone, the inflammation tends to subside quickly.

If the disease develops into periodontitis, periodontal deep cleaning or periodontal surgery may be needed. This involves opening up the gums to get at the infected area. Infected tissue is removed, and the root of the threatened tooth is scaled (the tartar is scraped off). Sometimes this can be done without actually cutting the gum (periodontal deep cleaning). Really severe disease might even require bone grafts.

Acute herpetic gingivostomatitis can't be cured, but it goes away on its own after about 2 weeks. Pregnancy tumours can be removed by a dentist.

Trench mouth, or acute necrotizing ulcerative gingivitis (ANUG), can be treated with appropriate antibiotics and thorough tooth and gum cleaning by a dental professional. Early treatment by your dentist is recommended.

Postmenopausal people who have desquamative gingivitis may benefit from hormone replacement therapy.

*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.

[references]

1. CMA what works for gingivitis/periodontitis? http://www.cma.ca/cmaj/vol-149/1409tab1.htm
2. Merck Manual. http://www.merck.com/pubs/mmanual/section9/chapter106/106e.htm
3. Medlineplus medical encyclopedia. Gingivitis. http://www.nlm.nih.gov/medlineplus/ency/article/001056.htm. Accessed October 5, 2004.
4. Ontario Dentist, Dr. Hurd Stein. Jan./Feb. 1999. 16-20. Journal of Periodontology, February 2001.
5. Columbia University College of Dental Medicine. Pregnancy tumor. http://www.simplestepsdental.com/SS/ihtSS/r.WSIHW/st.32219/t.32782/pr.3.html. Accessed April 21, 2010.
6. Merck Manual Online (Home Edition). Trench mouth. http://merck.com/mmhe/sec08/ch115/ch115d.html. Accessed April 21, 2010.
7. Gary C. Armitage, Ann Periodontol 1999;4:1-6.
8.  Ubertalli J. Gingivitis. Merck Manual. Last revised May 2019. Available at: https://www.merckmanuals.com/en-ca/professional/dental-disorders/periodontal-disorders/gingivitis. Accessed 20200130.
9. Wilder RS. Moretti AJ. Overview of gingivitis and periodontitis in adults. UpToDate. Last updated Oct 16, 2019. Accessed 20200130.