It's time to revisit gingivitis - rdh
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It's time to revisit gingivitis
Gingivitis is a diagnosis, not a health condition
by Heidi Arndt, RDH, BS, and Richard H. Nagelberg, DDS
As dental providers, we know that gingivitis is the reversible precursor to periodontal disease. If it is not controlled, it canprogress to full-blown perio disease. It is most commonly caused by inadequate biofilm control, with the remedy beingimproved home care. The standard of care for gingivitis does not include professional intervention other than a prophy.
These facts are so widely accepted that they amount to dental dogma, but are they accurate? Have we, as a profession,been addressing our gingivitis patients properly? Perhaps it is time to revisit our assumptions.
Is gingivitis truly a reversible condition, or is it noncurable but controllable like periodontitis? Periodontal disease is a chronic,
noncurable bacterial infection, with the damage to perio tissue being caused by the body’s immuno-inflammatory response tothe perio pathogens. When periodontitis patients respond favorably to any treatment we provide, they are healed, not cured.
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When we stabilize periodontitis, bone resorption ceases, although the damage to the bone that has already occurred doesnot repair on its own. The bone is gone for good, unless regenerative procedures are undertaken. The soft tissue responds
by reductions in pocket depth, swelling, redness, and bleeding. If the patient’s biofilm control efforts are inadequate and theyfail to present for perio maintenance appointments every three months, active disease and tissue destruction returns.
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Gingivitis is also caused by the body’s response to bacteria, manifesting as redness, swelling, and bleeding, without
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pocketing or bone loss. Addressing gingivitis by providing prophylaxis, along with improved biofilm control efforts, causesreductions in swelling, redness, and bleeding. Failure to continue effective home care and professional care will return the
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patient to gingivitis in a short period of time.
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So what is the difference between gingivitis and its more serious sequelae, periodontitis? Is it merely one of degree? Thereare some important differences. Gingivitis can be caused by the body’s response to the early biofilm colonizing bacteria, not
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the later colonizing perio pathogenic bacteria. The early colonizers are less pathogenic. So is this a matter of degree as well?Another important difference is that periodontitis requires a lifetime of disease management in the form of perio maintenance
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intervals every three months. Gingivitis is most commonly addressed professionally by twice yearly prophies. Another mattermerely of degree?
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In what ways are the two diseases similar? Both are bacterial infections with tissue damage being the result of the immuno-
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inflammatory response. Both respond to biofilm reduction and/or addressing the host response. Both conditions will return if
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biofilm control is inadequate and patients fail to present for their respective professional visits.
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Gingivitis is not really an early, mild form of periodontitis, as is commonly assumed. We know this from several lines ofevidence. From a host response perspective, there are important differences in the body’s response during gingivitis and
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periodontitis. Numerous studies have demonstrated that periodontitis is primarily a B cell and plasma cell response, whilegingivitis is primarily a T cell mediated response. From a genetic perspective, we know that progression from gingivitis toperiodontitis involves the interplay of inflammatory mediators, DNA expression, and periodontal pathogens. For disease
progression to occur, the patient must be genetically susceptible to periodontitis. The inflammatory processes associated withgingivitis act as a switch to turn on the patient’s DNA, which may or may not dictate expression of periodontitis. If the patientis genetically susceptible to periodontal disease, when his or her DNA is ignited by the gingivitis switch, the tissue becomesmore susceptible to reinfection by the perio pathogens, which are programmed to take advantage of this situation, potentiallyleading to periodontitis.
From a clinical perspective, we know that progression to full-blown perio disease does not occur automatically, does notoccur in every patient, and does not occur in every site. Gingivitis is not really an early form of periodontitis; it is thegatekeeper to it. The presence of gingivitis is a necessary prelude to periodontitis. This disease progression will occur insome cases, but not in others. Most importantly, a casual approach to gingivitis is inappropriate and may increase thelikelihood of developing periodontitis in susceptible individuals.
How we think about and approach our patients who have gingivitis is perhaps among the most important decisions we makeas clinicians. The concept that no therapeutic intervention is required to address gingivitis minimizes its importance.
Prophylaxis is the standard of care and prophy is defined as a nontherapeutic procedure for the maintenance of a healthypatient. Is a nontherapeutic protocol at six-month intervals appropriate? From an insurance standpoint, the code for prophy —1110 — establishes a diagnosis of health. From a clinical standpoint, however, the patient has diseased gingiva.
Modifying our philosophy regarding the manner in which we address gingivitis is perhaps in order. It lies somewhere betweenperiodontitis and health, yet there is no treatment protocol that prevents gingivitis patients from falling through the cracks, toooften progressing to full-blown periodontal disease.
Gingivitis is a very pervasive disease, affecting 50% to 90% of adults worldwide.1
How often are we giving our patients a diagnosis of gingivitis?
What should we be doing differently for these patients?
If we are not treating our gingivitis patients differently than our healthy and periodontal patients, then modification of ourcurrent philosophy of care and treatment protocols is in order for the practice.
The clinical findings of gingivitis as described by the Academy of Periodontology are: pocketing <3 mm, bleeding on probing,with no attachment loss present. How many patients do you see daily who fit these criteria? We may be amazed at thenumber of patients who fit the gingivitis diagnosis.
The frequency is so large that it is easy to become desensitized and limit recommendations to “Bump up your home care,” or“You need to floss more.” Pausing to consider the reasons why an individual has gingivitis and developing a treatment plan toaddress the etiology will have enormous benefits for our patients.
So, what would a treatment protocol look like for the gingivitis patient? Here are some recommendations:
1. Patient education and motivation is the key to successful management of gingivitis
. The patient must
understand the gingivitis diagnosis and the importance of managing it. As mentioned earlier, gingivitis is thegatekeeper to periodontal disease. The mismanagement of gingivitis increases the potential for progression tononreversible periodontitis in susceptible individuals, requiring a lifetime of disease control.
2. Frequent dental hygiene appointments
. The most conservative professional approach to managing gingivitis is to
provide prophylaxis for the patient on a one-to-three-month interval until gingival health is restored.
3. Personalize oral hygiene instructions
. Review the patient’s risk factors and oral hygiene habits in order to create a
home-care regimen that works for them. Let’s face it; not all patients will floss and use a mouthrinse daily.
Personalized home care is the key to the long-term success of patient follow-through and oral health. Recommend orprovide the tools necessary to enhance each individual patient’s bacterial removal efforts. Utilize the wide variety ofitems at our disposal including interdental cleaners such as the Proxabrush, rubber tip stimulators, oral irrigators, andtongue cleaners. Recommending a power toothbrush such as the Philips Sonicare to your patients will improve biofilmremoval at home. Powered toothbrushes have been proven to remove biofilm and improve gingival health better thanmanual toothbrushes.
4. Incorporate antimicrobial mouth rinses
. Antimicrobial mouth rinses should be incorporated into your patients’
home-care regimen. At-home antimicrobials such as chlorhexidine, essential oils, cetylpyridinium chloride (CPC),triclosan, and stannous fluoride have all been proven to support the control of gingivitis by decreasing biofilmgrowth.2,3,4
5. Oral DNA testing
. Have you ever had a patient who has exceptional oral hygiene and follows all treatment
recommendations, but presents visit after visit with gingivitis? The underlying reasons for this clinical presentation aredetermined by Oral DNA salivary testing. The Oral DNA test (www.oraldna.com) will help you identify the type ofbacteria, the amounts present, and antimicrobial recommendations for eradicating the pathogenic bacteria. The testresults then determine the proper treatment protocol. For example, gingivitis patients with high levels of bacteria willbenefit from an antimicrobial treatment plan. This may take the form of a thorough prophy, irrigation with 10%povidone iodine (Betadine) or chlorhexidine, and the use of systemic antibiotics such as amoxicillin, metronidazole, orclindamycin. Patients with low bacterial levels require a completely different approach, such as the implementation ofa host modulatory treatment plan utilizing 20 mg doxycycline (Periostat). Without the information provided by salivaryDNA testing, we don’t know the bacteriological status underlying the gingivitis in patients with excellent home care.
Treatment decisions would be an educated guess at best.
Gingivitis is a diagnosis, and should be treated differently than our healthy or periodontal patients. Preventing theprogression of gingivitis to periodontitis is the single most important thing we can do for our patients. Thinking of gingivitis asa nonreversible condition and addressing it in a more proactive manner will safeguard the oral and general health of ourpatients.
Heidi Arndt, RDH, BSDH, is the general manager of Focus Practice Consultants as well as the director of dental
hygiene development for American Dental Partners Inc (ADPI). ADPI is a business partner to group dental
practices throughout the country. Heidi has 16 years of dental experience. She started her dental career working
as a dental assistant and practice manager before going to dental hygiene school. Her dental hygiene experience
includes working as a clinical instructor at two dental hygiene schools, a periodontal dental hygienist at Mayo
Clinic, and most recently as a dental hygiene mentor and coach to hundreds of dental hygienists across the
country. Heidi is an expert at training dynamic teams that deliver high-quality patient care and increased
profitability. You can reach Heidi at firstname.lastname@example.org.
Richard H. Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 27 years. He is
a speaker, advisory board member, consultant, and key opinion leader for several dental companies and
organizations. He lectures extensively on a variety of topics centered on understanding the impact dental
professionals have beyond the oral cavity. Contact him at email@example.com.
1. Albandar JM, Rams TE. Global epidemiology of periodontal diseases: an overview. Periodontal 2000. 2002;29:7-10.
2. Lorenz K, Bruhn G, Heumann C, Netuschil L, Brecx M, Hoffmann T. Effect of two new chlorhexidine mouthrinses on thedevelopment of dental plaque, gingivitis, and discoloration. A randomized, investigator-blind, placebo-controlled, 3-weekexperimental gingivitis study. J Clin Periodontol. 2006;33:561-567.
3. Cortelli SC, Cortelli JR, Holzhausen M, et al. Essential oils in one-stage full-mouth disinfection: double-blind, randomizedclinical trials of long-term clinical, microbial and salivary effects. J Clin Periodontol. 2009;36:333-342.
4. Kozak KM, Gibb R, Dunavent J, White DJ. Efficacy of a high bioavailable cetylpyridinium chloride mouthrinse over a24-hour period: a plaque imaging study. Am J Dent. 2005;18(Spec No):18A-23A.
5. Barnes CM. The bottom line on toothbrushes. Dimensions of Dental Hygiene; Feb./March 2003;1(1):32-33,35, 37.
The following articles are the RDH editorial staff's recommended reads:
The Medicine Cabinet --
June 2011The tongue: A window to other organs
-- May 2011D110 and D4910
-- April 2011'I hate probing'
-- May 2011Sonicare AirFloss: No string attached
-- July 2011A soaring dream
-- January 2011Ultrasonic techniques
-- May 2011Dental Radiography
-- January 2011Exercise needs of hygienists
-- March 2011Electronic health records
-- February 2011The clock is king
-- June 2011The challenges of diversity
-- April 2011
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