Photo Rounds

Swollen, bleeding gums

A 35-year-old woman visited her family physician (FP) for a routine physical examination. She indicated that for the last 6 months, her gums had bled when she brushed her teeth. She also said that she smoked a pack of cigarettes a day. On examination, the FP found generalized plaque and red, swollen interdental papilla.

What's your diagnosis?


 

The FP explained to the patient that she had gingivitis.

Gingivitis—a reversible inflammation of the gingiva--occurs when gingival tissue is exposed to plaque and tartar for a prolonged period of time. Gingivitis may be classified by appearance (eg, ulcerative, hemorrhagic), etiology (eg, drugs, hormones), duration (eg, acute, chronic), or quality (eg, mild, moderate, or severe). Acute necrotizing ulcerative gingivitis (ANUG)—also known as trench mouth—is a severe form of gingivitis associated with α-hemolytic streptococci, anaerobic fusiform bacteria, and nontreponemal oral spirochetes. Predisposing factors include diabetes, human immunodeficiency virus, and chemotherapy.

The most common form of gingivitis is chronic gingivitis induced by plaque, which occurs in one-half of the population. The inflammation worsens as mineralized plaque forms tartar at and below the gum line. The plaque that covers tartar causes destruction of bone (an irreversible condition) and loosens teeth, which can result in tooth loss.

Gingivitis by itself does not affect the underlying supporting structures of the teeth and may persist for months or years without progressing to periodontal disease (periodontitis). Periodontitis is a chronic inflammatory disease that includes gingivitis and a loss of connective tissue and bone support for the teeth. Periodontitis is a major cause of tooth loss in adults.

All patients should receive ongoing care from a dental professional to prevent periodontal disease. Dental experts recommend that patients brush their teeth twice a day and floss daily. Some experts suggest that powered toothbrushes offer advantages over manual brushing, but this remains unproven. Strong evidence from systematic reviews supports the efficacy of chlorhexidine as an antiplaque, antigingivitis mouth rinse. Mouthwashes should not, however, be used as a replacement for brushing one’s teeth.

In this case, the FP told the patient that she should brush her teeth twice a day and floss daily. He offered her help to quit smoking and referred her to a dentist for a cleaning and full dental examination.

Photo courtesy of Gerald Ferreti, DMD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Gonsalves W. Gingivitis and periodontal disease. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:236-239.

To learn more about the Color Atlas of Family Medicine, see: http://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking this link: http://usatinemedia.com/

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