Periodontal Disease and Overall Health: A Clinician's Guide

CHAPTER 2 Overview of Periodontal Disease:CHAPTER 2 Causes, Pathogenesis, and Characteristics 7suppressive drugs (e.g., cyclosporine), andcalcium channel blockers (e.g., diltiazem)can cause severe gingival enlargement andpseudo-periodontal pocketing (i.e., increasedprobing depths with no associated attachmentor bone loss). 8 Medication-associatedgingival conditions are often reversed afterdiscontinuation of the offending agents.Malnutrition: The host immune systemcan be diminished when malnutritiondevelops, resulting in excessive gingival inflammation.Severe ascorbic acid (vitamin C)deficiencies (i.e., scurvy) can produce brightred, swollen, and bleeding gingival tissues. 1 Inthe case of vitamin C deficiency, gingivitis isassociated with a suppressed synthesis ofboth connective tissue collagens (e.g., TypesI and III) and basement membrane collagen(Type IV). Treatment with vitamin C supplementscan reverse this condition.Nonplaque-Induced Gingival LesionsThese types of lesions usually are rareand mainly due to systemic conditions. Bacteria,viruses, or fungi can cause these typesof gingival lesions. Sexually transmitted diseasessuch as gonorrhea (Neisseria gonorrhoeae)and syphilis (Treponema pallidum)can cause lesions in the tissues of the periodontium.9 Primary streptococcal gingivitisis an acute inflammation of the oral mucosa.It is associated with pain and fever, as wellas red swollen gingival tissues with bleedingor abscess formation, and can be treated withroutine periodontal scaling and root plan ingin addition to antibiotic therapy. Herpessimplex virus Type I is a common virus thatcan cause gingival lesions. 10 In children andyoung adults, herpes infections can be primaryand usually without symptoms, but insome cases pain and fever are reported. Inthese cases, the gingival tissues appear redand swollen, and are followed by the formationof small blisters, which eventuallybreak down to form shallow, painful ulcers.These lesions are usually self-limiting andheal within one to two weeks. After a primaryinfection, the herpes virus becomes latentand will be preserved in the ganglion ofthe trigeminal nerve. The virus may be reactivatedlater in life by reduced immunefunction or stress, resulting in recurrent herpeslabialis, gingivitis, and stomatitis. Gingivallesions of fungal origin usually occur inpeople with diabetes or other immunocompromisedstates. A shift in the normal oralflora related to the long-term use of systemicallyadministered antibiotics can also leadto lesions of fungal origin. 11 The most commonfungal infection is candidiasis, causedby Candida albicans, often seen in patientswearing removable prosthetic devices (e.g.,dentures) and in patients with dry mouthdue to multiple medications or salivary glanddysfunction. Clinical manifestations includewhite patches on the gingiva, tongue, or oralmucous membranes that can be removedwith a cotton swab or gauze, leaving behinda bright red bleeding surface. Treatment withantifungal agents is often necessary to resolvethese conditions.Gingival lesions can also be caused bygenetic systemic mucocutaneous disorders,allergic reactions, trauma, or foreign-bodyreactions. One of the most common geneticconditions associated with gingival lesionsis autosomal-dominant hereditary gingivalfibromatosis. 12 It is a benign condition affectingboth arches. The gingival tissues areenlarged and asymptomatic. It may be anisolated finding or associated with othersyndromes. Treatment is gingivectomy andrecurrence is possible. Systemic conditionssuch as pemphigoid, pemphigus vulgaris,erythema multiforma, and lupus erythematosuscan cause desquamative lesions andulceration. 10,13 Gingival changes due to allergicreactions to certain restorative ma -terials, dentifrices, or mouthrinses are rare,but have been observed. 10 Traumatic lesionsare usually produced unintentionally. 10 Aggressivetooth brushing and flossing can