eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat
Gingivitis
Updated: Oct 15, 2008
Introduction
Background
Gingivitis is an inflammatory process limited to the mucosal epithelial tissue surrounding the cervical portion of the teeth and the alveolar processes. Gingivitis has been classified by clinical appearance (eg, ulcerative, hemorrhagic, necrotizing, purulent), etiology (eg, drug-induced, hormonal, nutritional, infectious, plaque-induced), and duration (acute, chronic). The most common type of gingivitis is a chronic form induced by plaque.
Moderate chronic gingivitis. Note that the papillae are edematous and blunted. They may bleed with brushing. Note areas of edema overlying some of the root areas. Pallor is seen in these areas. Image courtesy of Robert J. Lindberg, DMD.
Acute necrotizing ulcerative gingivitis (ANUG, ie, trench mouth) is an acute infectious gingivitis. The term trench mouth was coined in World War I when ANUG was common among trench-bound soldiers.
Pathophysiology
The most common type of gingivitis involves the marginal gingiva and is brought on by the accumulation of microbial plaques in persons with inadequate oral hygiene. Gingivitis proceeds through an initial stage to produce early lesions, which then progress to advanced disease.
The initial stage of an acute exudative inflammatory response begins within 4 or 5 days of plaque accumulation. Both gingival fluid and transmigration of neutrophils increase. Deposition of fibrin and destruction of collagen can be noted in the initial stage. At approximately 1 week, transition to early lesions is marked by the change to predominately lymphocytic infiltrates. Monocytes and plasma cells also may be present. With time, lesions become chronic and are characterized by the presence of plasma cells and B lymphocytes. As chronic local inflammation progresses, pockets develop where the gingiva separates from the tooth. These pockets deepen and may bleed during tooth brushing, flossing, and even normal chewing. As this persistent inflammation continues, periodontal ligaments break down and destruction of the local alveolar bone occurs. Teeth loosen and eventually fall out.
ANUG is a completely different syndrome caused by acute infection of the gingiva with organisms such as Prevotella intermedia, alpha-hemolytic streptococci, Actinomyces species, or any of a number of different oral spirochetes. ANUG may result in accelerated destruction of affected tissues, as well as local or systemic spread of infection.
Noma (cancrum oris) is a syndrome in which ANUG spreads beyond the gingiva. The infection invades local tissues of the mouth and face.
Frequency
United States
Frequency is difficult to determine because of the lack of agreement on measurement criteria. Many people believe that gingivitis begins in early childhood and that 9-17% of children aged 3-11 years have gingivitis. At puberty, prevalence rises to 70-90%. In recent years, periodontal disease, the endpoint of chronic gingivitis, slowly has decreased among adult Americans.
ANUG may be a clinical problem in immunocompromised patients during chemotherapy. Gingivitis and resulting periodontal disease are seen more frequently in patients with either diabetes or HIV.
International
Studies in Australia, Sweden, England, and Switzerland report gingivitis in 48-85% of children aged 3-6 years, but whether this range reflects population differences or whether it is due to different criteria used to define the disease is difficult to know. In adolescence, incidence around the world is comparable to US data (70-90%). ANUG may be found in areas where those at risk, particularly children, face poor living conditions. Recent publications show several cases in areas such as Nigeria, where ANUG and noma were observed in children younger than 14 years.1
Mortality/Morbidity
Periodontal disease has been shown in some studies to be an associated factor in coronary artery disease (CAD) and cerebrovascular disease/ischemic stroke.2,3,4 This association with CAD has not been shown in all studies. Periodontal disease in pregnancy has been associated with an increase in preterm birth.5 Periodontitis in a person with diabetes has been associated with exacerbation of both conditions.6,7
- Severe periodontal disease may occur.
- Chronic gingivitis leads to tooth loss.
- ANUG may progress into the local soft tissues of the mouth, resulting in noma or cancrum oris, or may spread hematogenously to any other part of the body.
Sex
- Gingivitis is slightly more prevalent in males than in females because females tend to have better oral hygiene.
Age
- Adults are most commonly affected.
- Children from sub-Saharan regions of Africa may be at risk for ANUG because of poor living conditions.
Clinical
History
Historical findings depend on whether the patient has chronic gingivitis or ANUG.
- Chronic gingivitis
- The most common complaint is bleeding gums. The patient usually notices this when toothbrushing or flossing.
- Bleeding may be associated with eating, especially foods with a hard consistency, such as apples or crusted bread. These foods may rub against gums.
- Acute necrotizing ulcerative gingivitis
- Apparently spontaneous bleeding or bleeding in response to very minimal local trauma may occur.
- ANUG also may produce local pain, malaise, and alterations in taste, such as a metallic flavor.
- ANUG may produce foul breath.
Physical
- Chronic gingivitis
- Patients have minimal physical findings aside from local findings at the dental-gingival margins.
- Gingival pockets may be detected with a periodontal probe. However, the pocket depth may be overestimated when periodontitis is present and underestimated in healthy gums.
- Mild bleeding from the gum margins may occur with any manipulation.
- Acute necrotizing ulcerative gingivitis
- Fever, halitosis, marked gingival edema, and ulceration, especially in the interdental papillae, may be present.
- A grey pseudomembrane may be present.
- Infection may spread to adjacent soft tissues of the mouth, with noticeable erythema, edema, tenderness, and induration of affected areas.
- Reaction to oral contraceptives (see Causes)
Causes
- Although bacteria play a role in all forms of gingivitis, the primary cause of chronic gingivitis is inadequate oral hygiene.
- Risk factors
- Use of tobacco or ethanol is thought to be a risk factor.
- Immune incompetence is observed more frequently in HIV-infected children. As their CD4 counts decline, incidence of gingivitis may increase. Diabetes mellitus increases the risk of gingivitis and periodontitis.
- Drug-induced causes
- The list of drugs that cause gingivitis and gingival bleeding is extensive.
- Gingival bleeding may occur with the use of anticoagulants and fibrinolytic agents.
- Phenytoin, oral contraceptive agents, and calcium channel blockers may cause gingival hyperplasia.
- Gingivitis has been observed with use of protease inhibitors (eg, saquinavir, ritonavir), vitamin A and analogues, danazol, pentamidine, misoprostol, methotrexate, and gold compounds.
- Gingivostomatitis has been observed in exposure to arsenic, gold, bismuth, mercury, nickel, sulfur dioxide, lead, thallium, zinc, methyl violet, and topical chlorhexidine.
- Acute necrotizing ulcerative gingivitis
- Acute necrotizing infection may occur as a complication of chronic gingivitis in situations in which hygiene is abandoned completely or host defenses are weakened.
- ANUG is the result of soft tissue invasion by ubiquitous organisms and is not believed to be contagious.
- It is a risk wherever poor sanitation, diet, or oral hygiene is present.
- Living near livestock is an additional risk factor.
- Other causes
- Inadequate plaque removal
- Blood dyscrasias
- Allergic reactions
- Chronic debilitating disease
- Poor nutrition
- Lack of periodic dental examinations
Differential Diagnoses
Adrenal Insufficiency and Adrenal Crisis
HIV Infection and AIDS
Other Problems to Be Considered
Gingivitis, desquamative
Gingivitis, diabetes mellitus
Gingivitis, phenytoin
Gingivitis, pregnancy
Glossitis
Noma (cancrum oris)
Pericoronitis
Periodontitis
Vincent angina (trench mouth)
Workup
Laboratory Studies
- Laboratory testing is not helpful in diagnosing gingivitis.
- If systemic disease or toxin exposure is suspected, laboratory tests should be requested.
- A smear to identify the causative agent may be helpful.
Imaging Studies
- Imaging studies are not indicated.
Treatment
Emergency Department Care
- In simple chronic gingivitis, ED intervention is not needed.
- Proper oral hygiene (including brushing and flossing) should be stressed. The patient should be referred to a dentist or periodontist.
- General measures
- Remove irritating factors such as plaque, calculus, and faulty dentures.
- Use a warm saline rinse.
Consultations
- Dentist
Medication
In chronic gingivitis, brushing with a fluoride dentifrice will slow disease progression and may help resolution. Most electric toothbrushes have additional benefit over manual brushing. Daily flossing in addition to brushing will reduce plaque and bacterial counts. Recent studies show that brushing followed by rinsing with chlorhexidine or other solutions may have even better results over brushing and flossing.8,9 Gum-care–specific preparations that show benefit are available.10 Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to speed the resolution of inflammation when teeth are being cleaned and scaled to remove plaque.11,12
In patients with ANUG, treatment involves antibiotics, NSAIDs, and topical Xylocaine for pain relief. Saline rinses can help to speed resolution, and oral rinses with a hydrogen peroxide 3% solution also may be of benefit.
Antibiotics
These agents are used to eradicate the bacterial infection that is the hallmark of ANUG. In the future, antibiotics also may be used to treat simple chronic gingivitis, but no current evidence exists to justify this practice. Treatment of gingivitis may be warranted if dental surgery is planned.
Penicillin VK (Veetids)
DOC in patients with ANUG who are not allergic to penicillin.
Dosing
Adult
500 mg PO qid for 10 d
Pediatric
<12 years: 25-50 mg/kg/d PO divided q6-8h; not to exceed 3 g/d (250 mg = 400,000 U)
>12 years: Administer as in adults
Interactions
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment
Erythromycin (EES, Ery-Tab, Erythrocin)
Alternative DOC for patients allergic to penicillin.
Dosing
Adult
1-2 h before the procedure: 1 g PO
6 h after initial dose: 500 mg PO
250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) q6h 1 h ac, or 500 mg q12h
Alternatively, 333 mg q8h; increase, depending on infection severity, up to 4 g/d
Pediatric
2 h prior to procedure: 20 mg/kg PO
6 h after initial dose: 10 mg/kg PO
Age, weight, and severity of infection determine proper dosage
30-50 mg/kg/d (15-25 mg/lb/d) in divided doses; double the dose for severe infection
Interactions
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Contraindications
Documented hypersensitivity; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Minocycline microspheres (Arestin)
Used as an adjunct to scaling and root planing procedures for reduction of pocket depth in patients with adult periodontitis. May be used as part of a periodontal maintenance program that includes good oral hygiene and scaling and root planing.
Dosing
Adult
Insert a unit-dose cartridge into base of pocket and then press the thumb ring in the handle mechanism to expel the powder while gradually withdrawing the tip from the base of the pocket; the handle mechanism should be sterilized between patients; minocycline microspheres do not have to be removed, as they are bioresorbable, and no adhesive or dressing is required
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Discoloration of teeth may occur in last half of pregnancy, infancy, and childhood to age 8 y (do not use unless benefits outweigh risks); photosensitivity may occur; use of minocycline microspheres in acutely abscessed periodontal pocket has not been studied and is not recommended; use of minocycline microspheres may result in overgrowth of nonsusceptible microorganisms, including fungi; effect of treatment for > 6 mo has not been studied; use minocycline microspheres with caution in patients with history of predisposition to oral candidiasis; safety and efficacy of minocycline microspheres has not been established for treatment of periodontitis in patients with coexistent oral candidiasis; use of microspheres has not been clinically tested in patients with immunocompromise (eg, diabetes, chemotherapy, radiation therapy, HIV infection)
Doxycycline (Periostat)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. However, some studies have shown that doxycycline reduces elevated collagenase activity in gingival crevicular fluid of patients with adult periodontitis. Clinical significance of these findings is not known.
Dosing
Adult
Following scaling and root planing: 20 mg PO bid as an adjunct for <9 mo; safety beyond 12 mo and efficacy beyond 9 mo have not been established
Pediatric
Not established
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Clindamycin (Cleocin)
Alternative for penicillin-allergic patients, a popular choice for severe infections or those recalcitrant with penicillin.
Dosing
Adult
300 mg PO tid
Pediatric
6-8 mg/kg/d PO divided tid/qid
Interactions
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Antiseptic
This is shown to decrease bacterial counts in oral flora. It probably speeds resolution of gingivitis when combined with brushing and flossing.
Chlorhexidine 0.12% oral rinse (PerioGard)
Has bactericidal activity.
Dosing
Adult
15 mL (1 tablespoon); swish in mouth for 30 s and expectorate bid
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May stain tooth enamel
Analgesics
Patients with ANUG should be given a strong analgesic along with topical anesthetics and NSAIDs because pain control is very important in allowing the patient to eat and carry out toothbrushing, flossing, and other oral hygiene maneuvers necessary to eradicate the disease. NSAIDs also help to decrease pain. Although effects of NSAIDs in the treatment of pain tend to be patient-specific, ibuprofen usually is the DOC for initial therapy.
Acetaminophen with codeine (Tylenol #3)
Narcotic analgesic well tolerated by most patients; it may induce severe nausea and vomiting in patients particularly sensitive to the drug.
Dosing
Adult
1-2 tab PO q6h prn pain
Pediatric
0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose PO based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Interactions
Toxicity increases with CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Ibuprofen (Ibuprin, Advil, Motrin)
Used for pain relief and to decrease gingival inflammation. Use with care in patients with history of asthma or peptic ulcer disease.
Dosing
Adult
600 mg PO q6-8h
Pediatric
5 mg/kg PO q6-8h
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Topical anesthetics
These agents are helpful in providing pain control, which is very important in allowing the patient to carry out toothbrushing, flossing, and other oral hygiene maneuvers.
Lidocaine viscous 2% (Dilocaine)
An adjunctive therapy for pain control that decreases the permeability to sodium ions in neuronal membranes. This results in inhibition of depolarization, blocking the transmission of nerve impulses.
Dosing
Adult
15 mL rinse PO and expectorate q6-8h prn
Pediatric
>12 years: 15 mL rinse PO and expectorate q6-8h prn
Interactions
None reported
Contraindications
Documented hypersensitivity; Adams-Stokes syndrome and Wolff-Parkinson-White syndrome
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For external or mucous membrane use only; do not use in eyes
Follow-up
Further Outpatient Care
- Patients with simple chronic gingivitis should be given nonurgent dental referral.
- Patients with ANUG should be seen within 24-48 hours for reevaluation because of risk of local or systemic spread of infection.
- In addition to antibiotic therapy, physical and mental stressors should be eliminated. Good oral hygiene is mandatory.
Deterrence/Prevention
- Good oral hygiene: The use of a power toothbrush with rotating/oscillating motion is better than a manual brush.
- Regular dental check-ups
Complications
- Gingivitis is not a direct significant threat to the health of a healthy individual, but it can contribute to illness and cause local and systemic complications.
- ANUG that progresses to noma is associated with a mortality rate as high as 70% without proper antibiotics and debridement.
- The most common complication of chronic gingivitis is progression to periodontal disease and tooth loss. Areas of chronic gingivitis may predispose the individual to the development of odontogenic abscesses by allowing a route of bacterial invasion into the periodontal space from the gingival pocket. ANUG may be locally destructive and may result in local spread of infection into the surrounding tissues (Vincent angina and noma [cancrum oris]). Potential also exists for systemic spread of infection.
- Osteomyelitis of alveolar bone may arise but is uncommon.
- Any dental procedures involving manipulation that causes bleeding may result in endocarditis. The presence of gingivitis increases this risk by making the gingiva more likely to bleed with simple manipulation (eg, dental scaling). Bacteria containing plaque accumulation in the gingival pockets are in direct proximity to the areas of disrupted gingiva, increasing the likelihood of bacteria escaping into the general circulation.
Prognosis
- Untreated chronic gingivitis eventually results in tooth loss.
- After an initial cleaning and scaling in its early stages, gingivitis usually is reversible with good dental hygiene.
- ANUG responds to treatment if host defenses are intact. Noma requires aggressive treatment with antibiotics and local debridement.
- The usual course is acute, relapsing, intermittent, and chronic.
- Gingivitis generally responds well to appropriate treatment.
Patient Education
- Good oral hygiene, including brushing and flossing, treats and prevents chronic gingivitis. If flossing is too much of a bother, then plaque-reducing rinses, used daily, have proven benefit.
- Studies show electric toothbrushes to be more effective than manual brushes in preventing gingivitis.13,14
- Certain toothpastes, both herbal and nonherbal, have additional benefit.
- For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Gingivitis, Periodontal (Gum) Disease, and When to Visit the Dentist.
Miscellaneous
Medicolegal Pitfalls
- If mistaken to be Dilantin effect, ANUG may be overlooked.
- ANUG may be mistaken as leukemic infiltrate, prompting an involved workup.
Multimedia
Media file 1: Healthy mouth and gingiva. Note the healthy light pink color of the gingiva. The intradental papillae are sharp and fill the intradental space. No local edema is present. Image courtesy of Robert J. Lindberg, DMD.
Media file 2: Moderate chronic gingivitis. Note that the papillae are edematous and blunted. They may bleed with brushing. Note areas of edema overlying some of the root areas. Pallor is seen in these areas. Image courtesy of Robert J. Lindberg, DMD.
Media file 3: Severe periodontal disease. Loss of the gingival tissue is seen, making the teeth appear long. Even more effacement of the papillae is present. Heaped up ridges are observed in the areas overlying the roots. Image courtesy of Robert J. Lindberg, DMD.
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Keywords
gingivitis, gum swelling, swollen gums, bleeding gums, gum disease, acute necrotizing ulcerative gingivitis, periodontal disease, ANUG, trench mouth, inflammation of the gingiva, plaque, bacterial plaque, gum swelling, gingival tissue, gingiva, acute infectious gingivitis, Prevotella intermedia, alpha-hemolytic streptococci, Actinomyces species, noma, cancrum oris, chronic gingivitis, blood dyscrasias, inadequate oral hygiene, halitosis, gingival hyperplasia, gingivostomatitis
Contributor Information and Disclosures
Author
James M Stephen, MD, FAAEM, FACEP, Assistant Professor, Tufts University School of Medicine; Attending Physician and Director of Medical Informatics, Department of Emergency Medicine, Associate Director, Kiwanis Pediatric Trauma Service, Tufts Medical Center
James M Stephen, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.
Medical Editor
Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.
CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.