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Chapter 15 Clinical Examination: Gingival Assessment (Table 15-1 (Clinical…
Chapter 15 Clinical Examination: Gingival Assessment
Key Words
Bleeding on probing
Bleeding that occurs when the gingival crevice is probed
Gingival assessment
Evaluation of the gingiva for inflammation
Inflammatory periodontal diseases
A group of inflammatory diseases of the peridontium including gingivitis and periodontitis
Key Points
Purpose of performing a gingival evaluation is to determine the status of the gingiva and the presence or absence of gingival inflammation and/or gingival enlargement
Steps involved in a gingival evaluation include assessing for gingival color, contour, consistency, surface texture, size, and bleeding
Gingival enlargement can be due to an inflammatory response to dental plaque or to certain drugs
Absence of bleeding indicates periodontal stability
Rapid Dental Hint
When assessing the color of the gingival tissues, compare these tissues with adjacent areas
Determine the cause when gingival inflammation and enlargement are recognized
Bleeding on probing indicates clinical inflammation. This is similar to getting a splinter in your finger. The same inflammatory process occurs.
The easiest way to record bleeding is either the site bleeds(+) or it doesn't
Table 15-1
Clinical and Histologic Changes Seen in Health and Gingivitis
Three C's and S
Clinical Features
Histologic Features
Figure
Color
In health, the gingiva is salmon pink
Presence of keratin
Salmon pink gingiva
Color
Pigmentation
Indicates the production of melanin by melanocytes; this does not indicate the presence of inflammation or disease
Pigmented gingiva
Color
In acute
Inflammation
, the tissues exhibit various shades of red (fiery red); in
chronic inflammation
, the gingiva may be a bluish red (cyanotic or magenta) or pale white
Redness is due to increased vasodilation (engorged blood vessels) resulting in locally increased blood flow. As the condition worsens, the bluish red color is due to stagnation of blood in the vessels. The pale white color is due to the repair process with excessive collagen formation
Inflamed gingiva
Free gingival margin
Contour
Knife-edged
Intact gingiva fibers brace the gingiva to the teeth
Knife-edged free gingiva
Contour
Rolled or rounded
Destruction of gingival fibers
Rolled free gingival margins
Contour
Gingival cleft
Narrow slit in the gingiva starting at the gingival margin; probably associated with tooth position in the arch or the beginning of pocket formation; not related to occlusal forces, as once thought
Gingival Cleft
Interdental Papillae
Contour
Pyramidal or pointed (flatter in posterior)
Papillae completely fill in gingival embrasure; no tissue destruction
Pyramidal papillae
Contour
Bulbous
Enlarged papillae due to accumulation of fluid in the tissue; the papilla is not tucked in the gingival embrasure but partly covers the enamel
Bulbous papillae
Contour
Blunted
Destruction of the tip of the papilla
Blunted papillae
Contour
Absent
Destruction of the entire papilla; occurs where there is a diastema
Absent papillae
Contour
Cratered
Destruction of the tissue between the papillae; a "concavity"
Cratered papillae
Consistency
Firm and resilient
Intact collagen fibers in the lamina propria give the gingiva its firm consistency.
Firm gingiva
Consistency
Edematous
Loss of collagen and vascular permeability resulting in fluid accumulation in the surrounding tissue
Edematous gingiva
Consistency
Fibrotic
Reparative process whereby the fibroblasts in tissue in an attempt to heal produce and secrete excessive collagen. Tissue becomes hard and non-resilient. Tissue is not compressible
Fibrotic gingiva
Consistency
Retractable
Loss of collagen fibers. Papillae and margins are easily retracted by a blast of air.
Retractable gingiva
Surface Texture
Stippling
Stippling results from the intersecting epithelial ridges on the under-surface of the epithelium. An excessive amount of stippling is seen in chronic inflammation
Stippling
Surface Texture
Shiny and smooth
Can occur in health or disease. In disease, loss of stippling occurs because of accumulation of fluid in the underlying gingival connective tissue
Introduction
Traditional diagnostic procedures
2 components
Detection of inflammation
Assessment of damage to periodontal tissues
Practitioners state tissue:
Normal
Diseased
No in-between stage
In medicine and dentistry
Range of normality
Slight deviations from the healthy norm can fall within the range of normality for an individual
Objectives of a Gingival Assessment
Purpose of gingival assessment
To evaluate the condition of the gingival tissues
To determine inflammatory and non-inflammatory changes
Essential step in identify
Inflammatory periodontal diseases
Accurate recording of initial examination findings is essential in formulating an appropriate treatment plan
Baseline comparison with future clinical findings
And subsequent periodontal maintenance visits
Risk Factors for gingival diseases
Inflammation is the host's response to the irritation
Additional risk factors predispose a host to gingival or periodontal disease
Consider host susceptibility
Inflammation is not resolved after treatment
Knowledge of all the potential risk factors
Important in providing the appropriate treatment
Risk Factors of gingival inflammation/gingival enlargement
Poor home care
Changes in hormone levels, as seen in pregancy, menopause, puberty, or use of oral contraceptives
Systemic diseases, such as diabetes mellitus, leukemia, or human immunodeficiency virus (HIV) infection
Eruption of the permanent dentition
Certain drugs, including phenytoin, valproate, cyclosporine, and calcium channel blockers
Clinical assessment procedures
Color
In healthy, the gingiva is salmon pink
Determined by:
Degree of vascularity
Epithelial keratinization
Presence of melanin
Thickness of the epithelium
In disease, tissues are variations of red or light to whitish pink
Not sole indicator of disease
Tissue may be healthy visually and diseased deep within the tissue
Melanin pigmentation or amalgam tattoos are both considered to be in health
Contour
Marginal gingiva and interdental papillae
In health, Knifed-edge
In disease, rolled margins due to destruction of circular fibers
In healthy tucked into embrasures and pyramidal
In disease, bulbous and enlarged due to edema or cratered or blunted
Also, caused by overuse or misuse of interdental aids
Gingival clefts
Made by incorrect tooth brushing, flossing, or a break in the gingiva
Psedocleft made by gingival enlargement no destruction of gingival fibers
Due to medication taken by pt, crowding, or pt with severely large gingiva
Determined by
Location and size of the contact area
Size of the gingival embrasure
Alignment of the teeth
Soft-tissue inflammation
Shapes and position of teeth
Will vary anterior to posterior and between individual teeth
Consistency
Confirmed by pressing perio probe against gingiva
Refers to firmness of connective tissue
In health, firm and resilient and rebounds quickly to pressure
Not seen in health with fibrotic tissue
In disease, edema will be present and tissue will not rebound quickly to pressure
Tissue will pit when pressed against
Interdental papillae, gingival margin, and adjacent areas
First areas that are affected clinically by inflammation
Presence of inflammation
Follow 5 cardinal signs:
Redness (rubor)
Swelling (tumor)
Heat (calor)
Pain (dolor)
Loss of function (functio laesa)
May not present until advance stages of perio disease
If inflammation not resolved
Inflammatory infiltrate will proceed into the attached gingiva and alveolar mucosa
Inflammatory infiltrate travels more quickly through loose connective tissue (alveolar mucosa)
My experience is this is where we make our money as Dental Hygienist. Being able to recognize and identify disease verse health prior to treatment. Providing us with the ability to provide the necessary and accurate treatment for each pt.
A most recent pt was generalized healthy in all sextants but also had generalized melanin pigmentation in all sextants so it was some what difficult to describe the color and health of the gingiva in some areas