Diagnosis and Treatment Plan for Gingival Diseases and Conditions

The prevalence of gingival and periodontal disease is manifold and has not been highlighted much due to its asymptomatic and milder symptoms. It is usually given its due importance when the gingival disease progresses to advanced periodontal disease, displays symptoms of dull pain and tooth mobility, and is associated with pus discharge. The starting point of periodontal disease is usually gingival disease which is a reversible condition. It is therefore necessary to diagnose gingival diseases at an early stage to prevent its progression to irreversible periodontal disease. The diagnosis of gingival disease becomes cumbersome due to its similarity in the presentation of signs and symptoms. Gingival diseases can occur due to microbial attack from the plaque biofilm which is usually bacterial in nature. There are other viral, fungal, and immune-mediated mechanisms which can result in gingival diseases. Some systemic conditions also influence the gingiva which allows for diagnosing systemic diseases and treating these conditions appropriately. It is said that oral cavity is the mirror of the body, and in that sense the gingiva is the biggest surface where any changes or manifestations could be observed.


Introduction
The gingiva or commonly referred to as gums surround and protect the teeth (Figure 1). Gingival diseases by namesake denote to the diseases affecting the gingival tissues. These diseases have burdened the human race since the early civilization, and this is proof enough to gauge the importance of diagnosing gingival diseases and treating them. Gingival disease if left untreated can progress to periodontal tissues and result in periodontal disease which is easier to diagnose probably due to its chronic and severe nature as compared to gingival disease. No wonder periodontal disease has been mentioned in the literature of ancient Egypt and a step toward preventing it by means of oral hygiene practices deserves its mention in the ancient scriptures [1].

Gingival disease terminology
The gingival disease terminology and classification has undergone many changes, and the current classification given at the World Workshop in 2017 classifies gingival condition in health and disease under three broad categories of health, dental biofilm-induced gingivitis, and non-dental biofilm-induced gingival disease [3] (Table 1).

Figure 1.
The diagnosis of any disease is based on a proper documentation of case history which requires precise identification of signs and symptoms of disease and also any underlying medical disease/condition which may influence the same. The next step is to correlate clinical, pathological, laboratory and radiological findings. This sequence of steps also holds true for gingival diseases. This chapter attempts to focus on the minute differences in the diagnosis of gingival diseases which becomes cumbersome due to a simple fact that any infection or inflammation usually results in swelling up of the gingiva, bleeding, or formation of ulcers or vesicles. Such symptoms could be due to a single to multiple etiologic agents corresponding to varied diagnoses and treatment regimens [2].

Diagnosis of plaque-induced gingivitis
Gingivitis per se refers to the inflammation of the gingival tissues and is labeled with different diagnostic terms based on the etiology and clinical presentation to aid in formulation of the best-suited treatment. As mentioned above, the broad etiologic factors which result in gingival disease is the dental biofilm, which contain microbes, causing a microbial attack on the gingiva resulting in a dysbiosis amounting to a host response manifested in the form of the inflammatory disease called plaque-induced gingivitis. The plaque microbes have an influence on the gingiva depending upon its quantity and quality of pathogens present. Although the increased plaque burden is almost always associated with gingivitis, there are instances where paucity of plaque can again result in gingivitis due to the effect of modifying factors which make the host response more accentuated and exaggerated as they tend to have a more systemic affect than a local one [2,4]. These modifying factors include few systemic conditions, factors which increase plaque accumulation and influence of drugs on gingiva. How these factors can affect gingivitis is summarized in Table 2

Tools used for gingival diagnosis
The crude tools used are a questionnaire/interview to collect important aspects of the patient demographics, medical history, current medications, and habits. The next step involves patient examination starting from extraoral structures to any abnormal intraoral findings to specific examination of the gingiva. The gingival disease is visually examined for clinical signs and symptoms using a mouth mirror under ambient lighting of the dental chair, cotton/gauze to dry the tissues, and sometimes the use of three-way air water syringe to wash way the debris for better inspection. Changes in color, contour, consistency, texture, size, position, etc. are  noted. This is followed by palpation of the gingiva for any spontaneous bleeding, pain, discharge, blanching, consistency (by checking the resiliency of tissues on applying pressure), and pitting edema. The UNC-15 or the Michigan O periodontal probe with William's marking is used to check for bleeding on probing, subgingival faulty restorative margins, and the presence of deeper than 5-mm pockets which is the critical probing depth to differentiate between gingivitis and periodontitis. Apart from these traditional tools used, advanced diagnostic aids have been introduced to further confirm the presence of gingival disease (Table 3) [5,6].

Diagnosis of non-plaque-induced gingival diseases
Apart from plaque-induced gingivitis, it is imperative to diagnose and differentiate the non-plaque-induced gingival diseases and conditions to provide appropriate treatment and to avoid overtreatment. The etiology of non-plaque-associated gingival disease is usually related to some genetic defect or systemic disorder. In many instances the oral lesions precede the extraoral findings and can help in diagnosing a disease which could affect the full body. Therefore, while diagnosing these conditions, we need to look for other associated conditions to arrive at a correct diagnosis.

Treatment of gingival disease
The treatment of gingival disease is based on resolving the etiologic factors and maintaining the systemic status of the individual. In the case of plaque-induced gingivitis, the main treatment plan involves removal of plaque and calculus by scaling and root planning, followed by oral hygiene instruction which includes modified bass method of brushing and the use of chemical plaque control agents like 0.2% or 0.02% chlorhexidine gluconate or essential oil mouthwash. In cases of gingival enlargement, initial therapy is focused on removing plaque and calculus, followed by a review on the gingival condition; only if the condition does not improve the drug substitution may be considered, followed by gingivectomy to remove the enlarged gingival tissue. Plaque-induced gingival disease influenced by modifying factors is controlled by reducing the exposure of the modifying factor in addition to removal of plaque and calculus to maintain oral hygiene. The details of the treatment have been mentioned in Table 2. Non-plaque-induced gingival diseases are treated depending on the etiology of the gingival disease. For example, viral lesions are treated by providing antiviral medications in addition to oral hygiene instruction. The details of treatment in brief are mentioned in Table 4. Diagnosis is essential for providing the proper treatment plan and updating recent research which might help prevent undue treatment [8].

Conclusions
Gingival diseases are an initial starting point of the advanced periodontal disease and in some cases depict the manifestation of an underlying undiagnosed systemic condition. Therefore, the early diagnosis of gingival disease and its treatment are warranted.