gingiva gingivitis

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					                                                                    Outline
                  Gingivitis and
               Periodontal Disease
                                                                   I. Introduction
                                                                II. Gingival Disease
                                                              III. Periodontal Disease
                           報告者 : 許 修 銘
                                                          IV. Extrinsic Stains & Calculus
                           日 期 : 93/07/20                           V. Summary

                                               1                                                     2




           I. Introduction (1)                               I. Introduction (2)
Free Gingiva                                       Gingiva of childhood
• Coronal to the bottom                            • Color: more reddish
  of the gingival sulcus                           • Surface: less stippled
                                                   • Probing depths around primary teeth
Attached Gingiva                                      - 2mm
• Extend apically where                               - Proximal > facial & lingual
  the free gingiva ends                            • Alveolar bone in primary dentition
  at the mucogingival
                                                      - Trabeculae , Calcification
  junction
                                                      - Marrow space
                                               3                                                     4




           I. Introduction (3)                               I. Introduction (4)

  Gingivitis                                       Bacterial Plaque
  • An inflammation involving only gingival        • Soft bacterial deposits that firmly adhere
    tissues next to the tooth                        to the teeth
  • Pediatric p’t: mild, reversible type           • Sequence of plaque formation (after brushing)
  • Major etiologic factors:                         - ~ 2 hrs: plaque begins to form
    uncalcified & calcified bacterial plaque                   (coccus on thin pellicle)
                                                     - ~ 5 hrs: plaque develop by cell division
                                                     - ~ 24 hrs: rod-shaped bacteria appear
                                                     - ~ 48 hrs: a mass of rods & filaments
                                               5                                                     6
        II. Gingival Disease                                        II-1. Simple Gingivitis

II-1. Simple Gingivitis                                       Eruption Gingivitis (1)
II-2. Acute Gingival Disease                                  • Absence of coronal contour protection of tooth
                                                                 during early stage of active eruption
II-3. Chronic Nonspecific Gingivitis                          • Impingement of food on the gingiva causes the
II-4. Chlorhexidine – Plaque-control agent                       inflammatory process

II-5. Gingival Diseases
      Modified by Systemic Factors
II-6. Scorbutic Gingivitis
                                                          7                                                      8




       II-1. Simple Gingivitis                                      II-1. Simple Gingivitis

Eruption Gingivitis (2)                                       Gingivitis Associated with Poor
• Treatment:                                                    Oral Hygiene
  Mild eruption gingivitis                                    • Early gingivitis
   → improved oral hygiene                                      - quickly reversible
  Painful pericornitis
   → counterirritant (Peroxyl)                                • Treatment:
  Pericornitis + swelling                                       good oral prophylaxis +
  & lymph node involvement                                      oral hygiene instruction
   → antibiotic therapy
                                                          9                                                      10




       II-1. Simple Gingivitis                                  II-2. Acute Gingival Disease

Allergy vs. Gingival Inflammation                             Herpes Simplex Virus Infection (1)
• In the allergic children:                                   • Primary infection occurs in
  gingival inflammation↑                                        a child under 6 y/o
  during pollen seasons
                                                              • 99% are subclinical
• P’ts with complex allergies
  who have symptoms for longer periods
  may be at higher risk for
  more adverse periodontal changes
                               (Matsson & Moller, 1990)

                                                      11                                                         12
  II-2. Acute Gingival Disease                               II-2. Acute Gingival Disease

Herpes Simplex Virus Infection (2)                         Herpes Simplex Virus Infection (3)
• Acute herpetic gingivostomatitis                         • Acute herpetic gingivostomatitis
  - Active symptoms: fiery red gingiva, malaise,             - Palliative treatment:
            irritability, headache, pain when eating           mild topical anesthetic
  - Run a course of 10~14 days                                 vitamin supplement
  - Characteristic oral finding:                             - Definitive therapy:                      1 wk later
    ↓vesicles                                                  analgesics
      (yellow/white liquid-filled)                            (acetaminophen, ibuprofen)
    ↓ulcers (painful, Ø 1~3mm)                                antiviral drug
      + whitish gray membrane                                 (acyclovir, famciclovir, valacyclovir)   2 wks later
                                                      13                                                       14




  II-2. Acute Gingival Disease                               II-2. Acute Gingival Disease

Herpes Simplex Virus Infection (4)                         Recurrent Apthous Ulcer (RAU) (1)
• Recurrent herpes labialis (RHL)                          • Recurrent apthous stomatitis (RAS)
  - Emotional stress,                                        Canker sore
    lowered tissue resistance,
    excessive exposure to sunlight                         • School aged children and adults
  - Treatment:            Cereals, Seeds,                  • Persist for intervals of 4~12 days
    antiviral drug        Nuts, Chocolate                  • Recurrent painful ulcerations
    lysine therapy (daily lysine doses of                    - On the moist mucous
     1000mg / avoid eating arginine-rich                     - Round to oval crateriform base
     foods)        (Griffith, Norins & Kagan, 1978)          - Raised reddened margins                 5 days later
                                                      15                                                       16
                        Dairy products, Yeast




  II-2. Acute Gingival Disease                               II-2. Acute Gingival Disease

Recurrent Apthous Ulcer (RAU) (2)                          Recurrent Apthous Ulcer (RAU) (3)
• Cause is unknown                                         • Treatment:
  - Delayed hypersensitivity                                 - Topical application of tetracyclines
  - Autoimmune responses                                     - Chlorhexidine mouthwash
  - Precipitating factors:                                   - Kenalog in orabase
    mirror trauma, stress                                    - Acyclovir
  - Nutritional deficiency                                   - 5% Amlexanox oral paste (Aphthasol)
    (iron, vit. B12, folic acid)

                                                      17                                                       18
    II-2. Acute Gingival Disease                               II-2. Acute Gingival Disease

Acute Necrotizing Ulcerative Gingivitis (1)                  Acute Necrotizing Ulcerative Gingivitis (2)
•   Vincent infection                                        • Borrelia vincentii, fusiform bacilli,
•   Young adult                                                spirochetes
•   Rapid onset                                              • Treatment:
•   Characterized by                                           - Subgingival curettage,
                                      ↓local tx + OHI
    painful necrotic ulcerative                                  debridement
    gingival lesions and                                       - Mild oxidizing sol’n (H2O2)
    affected interdental papilla                               - Antibiotic therapy

                                                        19                                                    20




    II-2. Acute Gingival Disease                               II-2. Acute Gingival Disease

Acute Candidiasis                                            Acute Bacterial Infections
• Thrush, Candidosis, Moniliasis                             • Acute streptococcal gingivitis
• Raised, furry, white patches (removed easily                 - Painful, vivid, red gingivae
  →bleeding underlying surface)
                                           ALL p‘t
                                                               - Enlarged papillae & gingival abscesses
                                               p‘
• Treatment:                                                 • Treatment:
  - Topical use of                                             - Broad-spectrum antibiotics
    antifungal agent                                           - Improved oral hygiene
    (Nystatin)                                                 - Chlorhexidine mouthrinses
                                                        21                                                    22




II-3. Chronic Nonspecific Gingivitis                         II-3. Chronic Nonspecific Gingivitis

• Prevalence                                                 • Etiology:
  - Commonly seen during                                       - Hormonal imbalance
    the pre- & teenage period                                  - Inadequate oral hygiene
• Features:                                                    - Vitamin deficiency
  - Rarely painful                                             - Malocclusion
  - long periods                                               - Faulty restoration
                                                               - Mouth breathing
                                                9 Ms later
                                                             • Thorough daily oral hygiene
                                                                                                       6 Ms later

                                                        23                                                    24
        II-4. Chlorhexidine –                                     II-4. Chlorhexidine –
              Plaque-control agent                                      Plaque-control agent
• Chlorhexidine (CH) is                                   • Adverse side effects:
  a chlorophenyl biguanide                                  - Mouth dryness & burning sensations
  with broad antimicrobial activity                         - Desquamative lesions
• Usage in dentistry:                                       - Calculus & extrinsic stain accumulation
  - Control of smooth-surface caries                        - Negative systemic effect
  - Denture disinfectant                                  • Sound conventional plaque control
  - Plaque-control agent                                    measure + adjunctive use of CH as
    (0.12% CH gluconate mouthrinse)                         therapeutic mouthrinse
                                                     25                                                   26




        II-5. Gingival Diseases                                  II-5. Gingival Diseases
      Modified by Systemic Factors                             Modified by Systemic Factors
Endocrine System                                          Genetic origin
  -Puberty Gingivitis                                         -Hereditary gingival fibromatosis (HGF) (1)
• 11~14 y/o,      with age                                •   Elephantiasis gingivae
• Bulbous interproximal                                   •   Hereditary hyperplasia of the gums
  papillae (ant. segment)            ↓local tx
                                                          •   Autosomal dominant (chromosome 2p21)
• Treatment:
  -   Improved oral hygiene                               •   Gingiva:
  -   Removing local irritants                                normal (at birth)
  -   Adequate nutrition                                       →distinctive enlargement
  -   Gingivoplasty (severe case)   ↓gingivoplasty               (primary teeth erupt)
                                                     27                                                   28




        II-5. Gingival Diseases                                  II-5. Gingival Diseases
      Modified by Systemic Factors                             Modified by Systemic Factors
Genetic origin                                            Phenytoin-
                                                          Phenytoin-Induced Gingival Overgrowth (1)
  - HGF (2)                                               (PIGO)
• Slow, progressive,                                      • Dilantin Hyperplasia
  benign enlargement of                                   • Features:
  the gingivae                                                - Painless enlargement of
• Treatment:                                                    interdental papillae & marginal gingiva
  - Quadrant surgical removal of hyperplastic                 - Does not occur in edentulous areas
    tissue (recur within a few months)                        - Interdental lobulations coalesce
  - Apically positioned flap + CO2 laser                        at the midline→pseudopockets
                                                     29                                                   30
     II-5. Gingival Diseases                                      II-5. Gingival Diseases
   Modified by Systemic Factors                                 Modified by Systemic Factors
Phenytoin-
Phenytoin-Induced Gingival Overgrowth (2)
                                                        • Drugs reported to cause
• Treatment:                                              gingival enlargement:
  - Professional prophylaxis &
    rigorous home care                                    - Phenytoin (Dilantin, anti-epileptic)
  - Antiplaque rinses                                     - Cyclosporin (anti-rejection)
    (0.12% CH gluconate)                                  - Nifedipine (calcium channel blocker)
  - Surgical removal (severe-2/3)                         - Valproic acid
     gingivectomy                     ↓surgical           - Phenobarbital
     internal bevel flap surgery
  - Positive-pressure appliance
  - Folic acid therapy
                                                  31                                                              32




    II-6. Scorbutic Gingivitis                                   II-6. Scorbutic Gingivitis

• Vit. C deficiency                                    16 m/o

• Features:
  - Involving marginal tissues & papillae
  - Severe pain                                                                                 →
  - Spontaneous hemorrhage                             ↓ascorbic acid 400mg/day            improved diet
                                                                                              + OHI
• Treatment:                                                                      13 y/o        →
  - Complete dental care
  - Improved oral hygiene
  - Vit. C supplements                                                                                     2 wks later

                                                  33                                                              34




     III. Periodontal Disease                            III-1. Periodontitis in Children

III-1. Periodontitis in Children                        • Periodontitis is an inflammatory disease
                                                          of the gingival and deeper tissues of the
III-2. Premature Bone Loss                                periodontium characterized by pocket
III-3. Papillon-Lefèvre Syndrome                          formation and destruction of supporting
III-4. Gingival Recession                                 alveolar bone
III-5. Self-Mutilation                                  • Alveolar bone crest (ABC)      CEJ
                                                          - Normal: 1 ± 0.5 mm
III-6. Abnormal Frenum Attachment                         - Questionable bone loss: 2~3 mm
                                                          - Definite bone loss: >3 mm
                                                  35                                                              36
III-1. Periodontitis in Children                       III-1. Periodontitis in Children

Early-
Early-Onset Periodontitis (EOP)                       Pre-
                                                      Pre-pubertal Periodontitis (PP) (1)
• Otherwise healthy                                   • Can be localized but usually occurs in
• Categorized under                                     generalized form
  Aggressive Periodontitis                            • Onset is unknown but 4 y/o is when
• Three different categories:                           bone loss seen around molars and / or
  - Localized juvenile periodontitis                    incisors
  - Generalized juvenile periodontitis                • Onset to alveolar destruction is rapid
  - Pre-pubertal periodontitis
                                                 37                                                          38




III-1. Periodontitis in Children                       III-1. Periodontitis in Children
                                                                4.5 y/o
Pre-
Pre-pubertal Periodontitis (PP) (2)                   PP (3)
• Etiology:
  - Leukocyte chemotactic defect                                                       →
                                                                             dietary counseling +
  - Gingival pockets                                                        excellent oral hygience
     Actinobacillus actinomycetemcomitans
     Porphyromonas (Bacteroides) gingivalis
• Treatment:
  - Early Dx, dental curettage & prophylaxis,
    OHI, extraction of hopeless primary teeth
  - Antibiotic: Amoxicillin or Tetracycline                                                           8 yrs later
                                                 39                                                          40




III-1. Periodontitis in Children                       III-1. Periodontitis in Children

Localized juvenile periodontitis (LJP) (1)            Localized juvenile periodontitis (LJP) (2)
• Features:
  - Localized bone loss around permanent
                                                      12 y/o
    incisors & first molars
  - Little or no plaque or tissue inflammation
  - Progression is 3-4 times faster than adult
• Etiology:
  - Aa is the etiologic microbial species
  - Neutrophil chemotactic defect
                                                 41                                                          42
 III-1. Periodontitis in Children                           III-1. Periodontitis in Children

Generalized Juvenile Periodontitis (GJP)                    EOP Treatment
• Severe periodontitis                                      • General rules
  Rapidly progressive periodontitis                           - Early Dx, antibiotics, infection-free
• Occurs around puberty                                     • Treating LJP (Keyes technique/1985)
• Features:                                                   - Scaling & root planing + irrigation with
  - Rapid affects the entire periodontium                       saturated salt sol’n & 1% chloramine-T
  - Plaque deposition & marked inflammation                   - Systemic tetracycline (1g/day) for 14 D
• Etiology:                                                   - Home care:
  - Porphyromonas gingivalis                                     soda/3% H2O2 + salt irrigations
  - Neutrophil chemotactic defect                           • Treating GJP: less predictable
                                                       43                                                  44




     III-2. Premature Bone Loss                             III-3. Papillon-Lefèvre Syndrome

• Systemic– but rare in the primary dentition               • Precocious Periodontosis
• Local factors: trauma, periodontitis                      • Genetic disorder: chromosome 11q14-q21
• Related systemic disease
                           - Leukemias                      • Features:
   - Hypophosphatasia
   - Papillon-Lefèvre      - Diabetes mellitus                - Palmar & plantar hyperkeratosis
      syndrome             - Scleroderma                      - Premature loss of primary
   - Histiocytosis X       - Fibrous dysplasia                  & permanent teeth
   - Agranulocytosis       - Acrodynia                      • Treatment:
   - Leukocyte adherence   - Down syndrome                    - Antibiotic therapy
      deficiency           - Chdiak-Higashi                   - Extraction of affected teeth
   - Neutropenias             syndrome
                                                       45                                                  46




 III-3. Papillon-Lefèvre Syndrome                                  III-4. Gingival Recession
2.5 y/o                         17.5 y/o
                                                            • Etiology:
                                                              -   Narrow band of attached gingiva
                                                              -   Alveolar bony dehiscence
                                                              -   Impinging frenum attachment
                                                              -   Tooth prominence
                                                              -   Toothbrush trauma
                                                              -   Orthodontic tooth movement
             3 y/o
                                                              -   Oral habits
                                                              -   Periodontitis
                                                              -   Pseudorecession (extrusion of teeth)
                                 3~6 y/o: tetracyclines
                                       for ear infections
                                                            • Elimination of the stimulus & f/u 4~8 wks
                                                       47                                                  48
                                               III-6. Abnormal Frenum
          III-5. Self-Mutilation
                                                      Attachment
• Etiology - Local dental factors        • Normal frenum attachment usually
           - Emotional problem             terminating at the mucogingival junction
  6 y/o
                                         • Abnormal/high frenum: inadequate attached
                                           gingiva in the insertion area

                                         • Seldom has there been
                                           any correlation between
                                           a maxillary frenum problem
                                           and recession
                                    49                                                 50




          III-6. Abnormal Frenum               III-6. Abnormal Frenum
                 Attachment                           Attachment
                                         Frenectomy & Frenotomy
                                         • Indications:
                                           - Persistent gingival inflammation
                                           - Progressive gingival recession
                                           - Midline diastema after 3│3 eruption
                                           - Inhibit tongue touching 1│1 .



                                    51                                                 52




IV. Extrinsic Stains & Calculus          IV-1. Extrinsic Stains & Deposits

                                         • Extrinsic staining – readily removed and
                                           have no effect on the enamel
IV-1. Extrinsic Stains & Deposits        • Pigmentation is associated with an
                                           active chemical change in tooth
IV-2. Calculus                             structure
                                           e.g. 8% SnF2
                                                → light brown ~ black


                                    53                                                 54
IV-1. Extrinsic Stains & Deposits                   IV-1. Extrinsic Stains & Deposits

Green Stain                                         Orange Stain
• Result of the action of chromogenic               • Occurs less frequently and is easier to
  bacteria on the enamel cuticle.                     remove than green stain
• Gingival third of labial surface                  • Associated with poor oral hygiene
• Roughened surface                                 • Gingival third
  → recurrence


                                               55                                               56




IV-1. Extrinsic Stains & Deposits                                IV-2. Calculus

Black Stain                                         • Calcified dental plaque=Dental Calculus
•   Less common                                     • Caries↓→Calculus↑
•   Difficult to remove                             • Supragingival calculus
•   A line following the gingival contour             - M│M buccal surfaces
•   Relatively free from caries                       - 21│12 lingual surfaces
                                                            amelogenesis imperfecta




                                               57                                               58




               V. Summary
                                                                Thanks for
• The predominant form of periodontal
  disease in pediatric p’t is nonspecific                      Your Attention
  gingivitis
• Development of EOP:
  genetic factor, bacteria, systemic disease
• Plaque & calculus is an important factor
  in the development of gingival &
  periodontal disease                                                                 The End

                                               59                                               60

				
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Description: gingiva gingivitis