Periodontal Health, Gingivitis and Gingival Conditions

Based on the World Health Organization’s definition that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,”6 Working group 1 defined periodontal health as a “State free from inflammatory periodontal disease that allows an individual to function normally and avoid consequence (mental or physical) due to current or past disease.”10 This state of periodontal health should be determined by the clinical absence of disease associated with gingivitis, periodontitis or other periodontal conditions. The absence of disease may include those successfully treated who were previously diagnosed with gingivitis, periodontitis or other periodontal conditions who are able to maintain a state free from inflammation.10 However, it is important to recognize that the stable periodontitis patient is at higher risk for recurrent disease than those patients with previous gingivitis or those continuously healthy. From a Precision Medicine standpoint, these patients require ongoing surveillance and individual risk assessment for optimal patient management.10 It is important to recognize that clinical periodontal health encompasses the physiological state of homeostasis, both immunologically and microbiologically.

A case definition of patients who fall into the category of Periodontal Health is as follows:

Table 2. Periodontal Health.
Clinical Gingival Health on an Intact Periodontium Clinical Gingival Health on a Reduced Periodontium:
Stable Periodontitis Patient
Clinical Gingival Health on a Reduced Periodontium:
Non-periodontitis Patient (i.e., recession; crown lengthening, etc.)
Bleeding on Probing <10%
Pocket Probing depths ≤3mm
Probing Attachment Loss - No
Radiological Bone Loss - No
Bleeding on Probing <10%
Pocket Probing depths ≤4mm
  (no site ≥4mm with BOP)
Probing Attachment Loss - Yes
Radiological Bone Loss - Yes
Bleeding on Probing <10%
Pocket Probing depths ≤3mm
Probing Attachment Loss - Yes
Radiological Bone Loss - Possible
Chapple et al. 2018.10

Gingivitis Biofilm Induced

Cases of dental plaque-induced gingivitis whether they occur on an intact periodontium or a reduced periodontium, regardless of cause, are patients with signs of gingival inflammation as measured by bleeding on probing (BOP). The same three categories described for Periodontal Health in Table 2 are applied in Table 3 more specifically defining biofilm-induced gingivitis.

Table 3. Biofilm-induced Gingivitis.
Intact Periodontium Reduced Periodontium:
Stable Periodontitis Patient
Reduced Periodontium:
Non-periodontitis Patient (i.e., recession; crown lengthening, etc.)
Bleeding on Probing ≥10%
Pocket Probing depths ≤3mm
Probing Attachment Loss - No
Radiological Bone Loss - No
Bleeding on Probing ≥10%
Pocket Probing depths ≤3mm
Probing Attachment Loss - Yes
Radiological Bone Loss - Yes
Bleeding on Probing ≥10%
Pocket Probing depths ≤3mm
Probing Attachment Loss - Yes
Radiological Bone Loss - Possible
Localized gingivitis is >10% and <30% BOP/Generalized Gingivitis is >30% BOP.
Adapted from Chapple et al. 2018.10

Please note from the above table that for stable periodontitis patients with a reduced periodontium, if they have BOP in periodontal pockets that are either equal to or deeper than 4mm, they would automatically revert back to being an active periodontitis case and would not be classified as gingivitis on a reduced periodontium. However, as long as pocket depths of 4mm do not display signs of inflammation (BOP), then the case would remain as gingivitis.

There are three distinct categories of Biofilm-induced gingivitis:10

  1. Associated with biofilm alone
  2. Gingivitis Mediated by either Systemic Risk Factors or Local Risk Factors
    1. Systemic Risk Factors (modifying factors)
      Smoking
      Hyperglycemia
      Nutritional factors
      Pharmacological factors
      Sex steroids hormones (Puberty, menstrual cycle, pregnancy, oral contraceptives)
      Hematological conditions
    2. Local Risk Factors (predisposing factors)
      Dental plaque biofilm retaining factors
      Oral dryness
  3. Drug-influenced gingival enlargement

Gingival Diseases Non-biofilm Induced

It is well recognized that there are numerous oral conditions that are interrelated with systemic health. Some conditions may be further exacerbated by local factors such as plaque or oral dryness, however are not caused by plaque biofilm and usually do not resolve following plaque removal. These conditions may be manifestations of systemic conditions or they may be localized to the oral cavity.10

Table 4. Gingival Diseases Non-dental Plaque-induced.
Category Conditions
Genetic/Developmental Disorders Hereditary gingival fibromatosis
Specific Infections Bacterial Origin:
  • Neisseria gonorrhoeae
  • Treponema pallidum
  • Mycobacterial tuberculosis
  • Streptococcal gingivitis
Viral Origin:
  • Coxsackie virus (Hand-foot-and-mouth disease)
  • Herpes simplex I & II (Primary or recurrent)
  • Varicella zoster (Chicken Pox & Shingles)
  • Molluscum contagiosum
  • Human papilloma virus (squamous cell papilloma; condyloma acuminatum; verruca vulgaris; focal epithelial dysplasia
Fungal Origin:
  • Candidosis
  • Other mycoses (e.g., histoplasmosis, aspergillosis)
Inflammatory & Immune Conditions Hypersensitivity reactions:
  • Contact allergy
  • Plasma cell gingivitis
  • Erythema multiforme
Autoimmune diseases (skin & mucous membranes)
  • Pemphigus vulgaris
  • Pemphigoid
  • Lichen planus
  • Lupus erythematosis
    • Systemic lupus erythematosis
    • Discoid lupus erythematosis
Granulomatous Inflammatory Lesions (orofacial granulomatoses)
  • Crohn’s disease
  • Sarcoidosis
Reactive Processes Epulides
  • Fibrous epulis
  • Calcifying fibroblastic granuloma
  • Vascular epulis (pyogenic granuloma)
  • Peripheral giant cell granuloma
Neoplasms Premalignancy
  • Leukoplakia
  • Erythroplakia
Malignancy
  • Squamous cell carcinoma
  • Leukemic cell infiltration
  • Lymphoma
    • Hodgkin
    • Non-Hodgkin
Endocrine, Nutritional & Metabolic Diseases Vitamin Deficiencies
  • Vitamin C deficiency (Scurvey)
Traumatic Lesions Physical
  • Frictional Keratosis
  • Mechanically-induced gingival ulceration
  • Factitious injury (self-harm)
Chemical
  • Toxic burn
Thermal
  • Burns to gingiva
Gingival Pigmentation Melanoplakia
  • Smoker’s melanosis
  • Drug-induced pigmentation (antimalarials, minocycline)
  • Amalgam tattoo
Adapted from Chapple et al.10
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