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Rare indeed is the day in which a dental professional spends time at the chair and does not see at least one case of gingivitis. It is so common that we seldom give it much thought. Recommendations are commonly limited to encouraging the patient to increase his or her home-care efforts. After all, clinical intervention is not the standard of care; gingivitis is a reversible condition, and we have more severe disease states to address. The reversible nature of gingivitis has been dental dogma as long as anyone can remember, and may in fact be one of the most widely accepted facts in the profession.
Or is it? Is gingivitis truly a reversible disease entity, or is it irreversible like periodontitis? Does “reversed” imply cured? On a clinical level, patients with gingivitis due to inadequate biofilm control commonly return to gingival health by improving their home-care regimen.
When this occurs, the bacterial biofilm is reduced to a level with which their immune systems can cope. Clinical manifestations of gingivitis such as redness, swelling, and bleeding reduce, then cease. What happens when the patient’s home care reverts to the earlier, inadequate regimen?
The gingivitis recurs as evidenced by the return of redness, swelling, and bleeding. We see this every day in our offices. Standard-of-care treatment protocols dictate that gingivitis patients receive a prophy twice a year. Prophy is a nontherapeutic procedure for the maintenance of a healthy mouth.
This bears repeating: prophylaxis is nontherapeutic, meaning it is not intended to address a pathological condition. Even the prophy insurance code, 1110, establishes a diagnosis of health. From a clinical standpoint, however, the patient has diseased gingiva.
Think about other conditions such as diabetes. When an individual is diagnosed as prediabetic, he or she is commonly put on dietary control with frequent monitoring, not a regimen of oral medications and/or insulin. Intervention in the form of treatment and medications are not usually necessary at this point; however, if there is a lack of compliance, development of Type II diabetes may occur, requiring more aggressive approaches to achieve adequate glycemic control. Most importantly, a casual approach to prediabetes would be inappropriate and would increase the likelihood of disease progression and the development of serious diabetic complications.
There are important differences in the body’s response during gingivitis and periodontitis. Numerous studies have demonstrated that periodontitis involves predominantly B cells and plasma cells, while gingivitis is primarily a T cell-mediated response. Progression from gingivitis to periodontitis involves the interplay of inflammatory mediators, DNA expression, and periodontal pathogens. Progression to full-blown perio disease, however, does not occur automatically, in every patient, or in every site.
Gingivitis is not really an early form of periodontitis; it is the gatekeeper to it. The inflammatory processes associated with gingivitis act as a switch to turn on the patient’s DNA, which may or may not dictate expression of periodontitis. The presence of gingivitis is a necessary prelude to periodontitis.
This disease progression will occur in some cases, and not in others. Most importantly, a casual approach to gingivitis is inappropriate and may increase the likelihood of developing periodontitis in susceptible individuals.
The tissue damage typically seen in periodontitis — most notably bone loss — is irreversible even when the disease is well-controlled. The clinical signs of gingivitis are reversible when there is sufficient biofilm control. In both cases, however, the well-controlled patient is not cured, simply healed. The tissue-damaging processes can be reignited.
Rather than being an issue of semantics, how we view and approach gingivitis will have significant implications for our patients. A casual approach, in which we merely say, “Bump up your home care” or “You need to floss more” does little to educate and motivate our patients about the importance of returning to ideal gum tissue health.
Recognizing the noncurable nature of gingivitis and addressing it proactively will increase the predictability of achieving ideal gingival health. A proactive approach may include recommending power toothbrushes, frequent monitoring, antimicrobial rinses, DNA testing, and conservative treatment protocols.
Failure to help the gingivitis patient return to health may lead to periodontitis, requiring a lifetime of disease management. Among the most important things we can do for patients is prevent gingivitis from progressing to periodontitis by offering appropriate treatments and concern.
Dr. Richard Nagelberg 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 protected].
