Documente Academic
Documente Profesional
Documente Cultură
Correspondencia:
Dr. D. Antonio Bascones Martnez
Dpto. Estomatologa III
Facultad de Odontologa
Universidad Complutense de Madrid
Ciudad Universitaria
28040 Madrid Indexed in:
-Index Medicus / MEDLINE / PubMed
609.17 75 82-91 394 20 19 -EMBASE, Excerpta Medica
E-mail: Antbasco@arrakis.es -Indice Mdico Espaol
-IBECS
INTRODUCCION
El trmino infeccin se emplea para referirse a la presencia y
multiplicacin de microorganismos en el cuerpo (1). Las in-
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- Cuantiosa
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Enfermedades gingivales inducidas por placa los 2 cm. Su etiologa es desconocida, pero se han implicado
El trmino enfermedades gingivales se emplea para definir factores traumticos, higinicos y hormonales (13).
el patrn de signos y sntomas de diferentes enfermedades lo- En la gingivitis asociada a diabetes mellitus el nivel de con-
calizadas en la enca. Todas ellas se caracterizan por presentar trol diabtico es ms importante que el control de placa en la
placa bacteriana que inicia o exacerba la severidad de la lesin, severidad de la inflamacin gingival. Este tipo de gingivitis
ser reversibles si se eliminan los factores causales y por tener suele presentarse en nios con una diabetes mellitus tipo I mal
un posible papel como precursor en la prdida de insercin controlada.
alrededor de los dientes. La gingivitis asociada a leucemia se caracteriza por presen-
Clnicamente se aprecia una enca inflamada, con un contorno tar unos tejidos gingivales inflamados y esponjosos con una
gingival alargado debido a la existencia de edema o fibrosis, coloracin que vara entre el rojo y el morado. El sangrado
una coloracin roja o azulada, una temperatura sulcular eleva- gingival es frecuente y puede ser la primera manifestacin de
da, sangrado al sondaje y un incremento del sangrado gingival. una leucemia aguda o crnica en un 17,7 % y un 4,4% de los
Todos estos signos estn asociados a periodontos con niveles de casos, respectivamente.
insercin estables sin prdidas de insercin, o estables aunque Los agrandamientos gingivales estn asociados a la ingesta de
en periodontos reducidos (8) (Fig. 3). anticonvulsivantes (fenitona), inmunosupresores (ciclosporina A)
La gingivitis inducida por placa es una inflamacin de la y bloqueantes de los canales del calcio (nifedipino, verapamilo,
enca debida a la localizacin de bacterias en el margen gingi- diltiazem, valproato sdico). Existen variaciones inter e intrapa-
val, y que posteriormente se puede extender a toda la unidad cientes, aunque se suelen producir en la porcin anterior de la
gingival. Los hallazgos clnicos caractersticos son el eritema, enca, con mayor prevalencia en pacientes jvenes. Suele aparecer
edema, sangrado, sensibilidad y agrandamiento. Su severidad a los tres meses de uso del frmaco, normalmente a nivel de la
puede verse influenciada por la anatoma dentaria as como papila y no se asocia a prdida de insercin (Figs.4-7).
por las situaciones restauradoras o endodnticas de cada caso Se han observado otros casos de agrandamientos gingivales
(9) (Fig.1). asociados a la ingesta de anticonceptivos orales, donde apa-
La gingivitis asociada a la pubertad comparte la mayor parte rece una mayor inflamacin del tejido gingival con presencia
de los signos clnicos de la gingivitis inducida por placa pero de cantidades relativamente pequeas de placa.
su principal diferencia se basa en la propensin elevada a desa- Los sujetos malnutridos presentan un compromiso en su siste-
rrollar signos francos de inflamacin gingival en presencia de ma inmune, lo que puede afectar a la susceptibilidad individual
cantidades relativamente pequeas de placa bacteriana durante a la infeccin, exacerbando la respuesta gingival a la presencia
el perodo circumpuberal. Durante la pubertad se produce una de placa bacteriana. La deficiencia nutricional ms estudiada ha
serie de cambios endocrinos caracterizados por la elevacin de sido la de vitamina C, o escorbuto, en la cual la enca aparece
los niveles de hormonas esteroideas en sangre y que van a ser de color rojo brillante, inflamada, ulcerada y con tendencia a
los responsables del estado de la inflamacin de la enca (9). la hemorragia.
La gingivitis asociada al ciclo menstrual se caracteriza por una
respuesta inflamatoria moderada de la enca previa a la fase de Enfermedades gingivales no inducidas por placa (15).
ovulacin, con un incremento del exudado gingival en un 20%, Las enfermedades gingivales de origen bacteriano son aqu-
debido a la elevacin de los niveles de hormonas luteinizantes llas que estn inducidas por infecciones bacterianas exgenas
(>25 mU/ml) y/o de estradiol (>200 pg/ml) (9). diferentes de las que forman parte de la placa dental, tales como
La gingivitis asociada al embarazo es una inflamacin Neisseria gonorrhoeae, Treponema pallidum, Streptococcus y
proliferativa, vascular e inespecfica con un amplio infiltrado otros microorganismos. Clnicamente se manifiestan como ulce-
inflamatorio celular. Clnicamente se caracteriza por una enca raciones edematosas dolorosas, mculas mucosas o encas muy
intensamente enrojecida que sangra fcilmente, engrosamiento inflamadas no ulceradas atpicas, que pueden estar acompaadas
del margen gingival, hiperplasia de las papilas interdentales o no de lesiones en otras partes del cuerpo.
que pueden dar lugar a la aparicin de pseudobolsas (10). Le Las enfermedades gingivales de origen viral son manifes-
y Silness (11), en 1963, describen que los primeros sntomas taciones agudas de infecciones virales en la mucosa oral que
aparecen en el segundo mes de embarazo y continan hasta el cursan con la aparicin de mltiples vesculas que se rompen
octavo, momento a partir del cual se observa cierta mejora fcilmente dando lugar a la aparicin de lceras dolorosas. Las
para estabilizarse finalmente tras el parto. Los estudios clnicos ms importantes son las asociadas a los virus del herpes simple
muestran una prevalencia que vara entre el 35 y el 100% (11) (VHS) tipo 1 y 2 y al virus varicela-zoster. La primera manifes-
de las embarazadas. tacin del VHS-1 se conoce con el nombre de gingivoestomatitis
El granuloma gravdico, tambin llamado tumor del emba- primaria. Suele aparecer en nios y cursa con una gingivitis
razo, es una reaccin inflamatoria proliferativa fibrovascular severa y dolorosa junto con la formacin de vesculas que se
exagerada en relacin a un estmulo ordinario (12) localizada transforman en lceras recubiertas por una capa de fibrina. Se
fundamentalmente en la enca. Se describe como una masa lo- puede acompaar de fiebre y linfadenopatas. La reactivacin del
calizada roja o roja-amoratada, nodular o ulcerada que sangra virus se produce en un 20-40% de los casos asociada a episodios
fcilmente y que aparece frecuentemente en mujeres (0,5-5%) de fiebre, trauma o radiacin ultravioleta, entre otros. Aparecen
(13,14) en torno al segundo trimestre de embarazo y crece a lo pequeas lceras dolorosas agrupadas en racimos en la zona de
largo del mismo alcanzando un tamao que no suele superar la enca adherida. En cuanto a la varicela, se caracteriza por la
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autoanticuerpos se dirigen contra los desmosomas del epitelio juegan un papel fundamental en su patognesis (Figs. 8 y 9).
apareciendo una ampolla acantoltica o intraepitelial, que puede
llegar a comprometer la vida del sujeto. El eritema multiforme Periodontitis agresiva
es una enfermedad vesculo-ampollosa que afecta tanto a piel Los rasgos comunes de las formas de periodontitis agresiva son:
como a mucosas. Posee dos formas de aparicin: menor y mayor pacientes que salvo por la presencia de la infeccin periodontal
(sndrome de Stevens-Johnson). Los pacientes presentan los son clnicamente sanos, rpida prdida de insercin y destruc-
labios inflamados con amplias costras en la zona del bermelln, cin sea y antecedentes familiares (17).
aunque la lesin bsica es la ampolla que se rompe apareciendo Otros rasgos que tambin se presentan de forma general pero no
extensas lceras. El lupus eritematoso es una enfermedad auto- universal son: cantidad de depsitos microbianos inconsistentes
inmune del tejido conectivo donde los autoanticuerpos se dirigen con la severidad de destruccin tisular presente, proporciones
contra diferentes elementos celulares ejerciendo su efecto en los elevadas de Actinobacillus actinomycetemcomitans o Por-
riones, corazn, sistema nervioso central, sistema vascular y phyromonas gingivalis; anomalas en los fagocitos; fenotipo
mdula sea. La lesin tpica presenta una zona central atrfica de macrfagos con hiper-respuesta con niveles elevados de
con punteado blanquecino rodeada por una fina estriacin. Se prostaglandina E2 e interleuquina-1; la progresin de prdida
clasifica en lupus eritematoso discoide y sistmico. sea y de insercin puede ser llamativa (18).
Las reacciones alrgicas no son muy comunes en la mucosa Existen dos formas de periodontitis agresivas:
oral debido a que se necesitan concentraciones de alergenos a. Localizada. De inicio circumpuberal y con una respuesta
mayores que en la piel para que se produzcan. Pueden ser reac- elevada de anticuerpos frente a los agentes infecciosos. Clni-
ciones tipo I (inmediatas) mediadas por la inmunoglobulina E camente se caracterizan por prdidas de insercin interproximal
o tipo IV (retardada) mediada por clulas T. en primeros molares e incisivos o al menos en dos dientes per-
Las lesiones traumticas en la mucosa oral se pueden producir manentes, uno de los cuales es un primer molar y no incluye ms
de forma accidental, yatrognica o facticia. Pueden presentar- de dos dientes que no sean primeros molares e incisivos.
se en forma de recesiones gingivales localizadas, abrasiones, b. Generalizada. Se suele presentar en pacientes menores de 30
ulceraciones o quemaduras. Pueden tener una apariencia ede- aos, pero puede aparecer en edades superiores. La respuesta de
matosa, eritematosa o blanquecina, o una combinacin de las anticuerpos es pobre. Existen episodios de prdida de insercin,
anteriores. que afecta a tres dientes permanentes diferentes de primeros
Las reacciones a cuerpo extrao aparecen debido a la exis- molares e incisivos.
tencia de una ulceracin epitelial que permite la entrada de una
material extrao en el tejido conectivo gingival. A veces pueden Enfermedades periodontales necrotizantes
presentar una inflamacin gingival aguda o crnica asociada La gingivitis ulcerativa necrotizante (GUN) se diferencia
o pueden producir tatuajes. En algunos casos puede aparecer del resto de enfermedades gingivales por presentar necrosis
supuracin. interdental gingival, con papilas ulceradas, sangrado gingival
y dolor. Este dolor es la principal caracterstica de esta entidad
Periodontitis crnica y su elevada intensidad lleva al paciente a buscar tratamiento.
Los signos clnicos caractersticos de la periodontitis incluyen Otros signos y sntomas tambin asociados a la GUN, aunque
prdida de insercin clnica, prdida de hueso alveolar, formacin no patognomnicos, son la presencia de linfadenopatas, fiebre,
de bolsas periodontales e inflamacin gingival. A esto se puede halitosis y malestar general (Fig. 10) Los episodios se resuelven
asociar un sobrecrecimiento o recesin gingival, sangrado al en unos das tras recibir el tratamiento adecuado.
sondaje, movilidad dentaria aumentada, supuracin, pudiendo Existen una serie de factores que predisponen la aparicin
llegar a la prdida dentaria. En los casos de periodontitis crnica de esta infeccin tales como el estrs, la inmunosupresin, la
la infeccin progresa de forma continua o en picos de actividad malnutricin, el tabaco, traumatismo, o la existencia de una
(16). gingivitis previa (19).
Segn su extensin puede clasificarse en: La periodontitis ulcerativa necrotizante (PUN) es una in-
- Localizada, si estn afectadas menos de un 30% de las loca- feccin caracterizada por una necrosis del tejido gingival, del
lizaciones. ligamento periodontal y del hueso alveolar. Suele presentarse en
- Generalizada, si ms del 30% de las localizaciones estn sujetos con condiciones sistmicas que conduzcan a un estado
afectadas. de inmunosupresin (20).
Segn su severidad se define: Puede ser que la GUN y la PUN sean dos estados diferentes de la
- Periodontitis suave: cuando las prdidas de insercin clnica misma infeccin y an no existen suficientes datos para separar
son de 1 a 2 mm. ambas entidades en dos categoras diferentes. La nica diferencia
- Periodontitis moderada: si las prdidas de insercin se encuen- entre ambas se basa en que la GUN se limita a la enca, mientras
tran entre 3 y 4 mm. que la PUN incluye todo el aparato de insercin.
- Periodontitis severa: ante prdidas de insercin clnica mayores
o iguales a 5 mm. Abscesos periodontales
Los conceptos actuales demuestran que la infeccin bacteriana Un absceso periodontal es una infeccin purulenta localizada
es la primera causa de la enfermedad, siendo la placa el factor en los tejidos periodontales que puede ser una manifestacin
iniciador de la misma, sin embargo, los mecanismos de defensa clnica en pacientes con periodontitis moderada o severa. Se
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caracterizan por inflamacin, supuracin, enrojecimiento, ex- Por lo que a la hora de tratarlas, sabiendo de antemano que el
trusin del diente implicado y diente sensible a la percusin. raspado y alisado radicular por s solo no siempre consigue
A veces aparece una ligera elevacin de la temperatura (21) eliminar los patgenos periodontales, ser necesario el empleo
(Fig. 11 y 12). de antimicrobianos de manera coadyuvante (26-29).
Los abscesos pueden ser clasificados en: La seleccin de los antimicrobianos se basa en los criterios mi-
- Absceso gingival. Lesin localizada, dolorosa, rpidamente crobiolgicos de la enfermedad (espectro de accin) as como
expansiva que afecta al margen gingival o a la papila interden- en las caractersticas farmacocinticas del agente concreto se-
tal. Suele ser una respuesta inflamatoria aguda de la enca a un leccionado, evitando en cualquier caso los efectos adversos del
cuerpo extrao introducido en la enca. mismo (30,31). El empleo de antimicrobianos de forma local
- Absceso periodontal. Acumulacin localizada de pus en la pa- permite conseguir niveles de frmaco que no podran ser alcan-
red gingival de una bolsa periodontal que origina la destruccin zados de forma sistmica, o incluso la utilizacin de agentes
de la insercin de fibras colgenas y la prdida del hueso alveolar demasiados txicos para ser empleados de forma sistmica (32).
adyacente. Suele estar asociado a la existencia de bolsas perio- Sin embargo, por otro lado, los antibiticos sistmicos ejercen
dontales tortuosas, furcas afectadas o defectos infraseos. su efecto en todas las zonas de la cavidad oral, no estando slo
- Absceso pericoronal. Acumulacin localizada de pus sobre limitados a su zona de aplicacin (1, 32-34).
el tejido gingival que rodea la corona de un diente que no ha Por ello, se recomienda la utilizacin sistmica de amoxicilina,
erupcionado completamente, generalmente en la zona del tercer amoxicilinacido clavulnico y metronidazol como primera
molar inferior. El tejido gingival aparece rojo e inflamado y los opcin para el tratamiento de las enfermedades periodontales
pacientes pueden encontrar dificultades para tragar. agresivas. En caso de pacientes alrgicos a amoxicilina o me-
tronidazol, se sugiere el empleo de clindamicina, azitromicina
Lesiones periodontales-endodnticas o claritromicina (35).
Las infecciones de origen periodontal o endodntico pueden cur-
sar con un incremento en la profundidad de sondaje de los dien-
tes adyacentes, inflamacin, sangrado al sondaje, supuracin,
formacin de fstula, sensibilidad a la percusin, incremento en
la movilidad del diente, prdidas seas angulares y dolor. Estos
signos y sntomas suelen aparecer en periodontitis asociadas a
placa que comienzan en el margen gingival y progresan apical-
mente. Sin embargo, tambin pueden estar causadas por infec-
ciones endodnticas que alcanzan al ligamento periodontal a
travs del foramen apical o a travs de los canales laterales o
accesorios y avanzan coronalmente (22).
CONCLUSION
La revisin expuesta permite tener una idea global de los di-
ferentes cuadros clnicos de las enfermedades periodontales.
Se ha visto como en todos ellos las bacterias juegan un papel
importante en el inicio y posterior desarrollo de las mismas.
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bone resorption, tooth mobility and ultimately leading to the CLASSIFICATION OF PERIODONTAL DISEA-
loss of the tooth. SES
When they interact with connective tissue, the bacteria provoke For many years, the American Association of Periodontics has
a series of inflammatory and immunological reactions in the classified periodontal disease into two categories, i.e., gingivi-
host that are translated into an accumulation of cells associated tis and periodontitis (slight, moderate, severe and refractory),
with the activation of periodontal destruction processes. Longi- according to the area of the gum involved.
tudinal studies suggest that the disease progresses episodically At the World Workshop in Clinical Periodontics held in 1989, a
and is characterized by dormant phases followed by exacerba- new classification was established that set itself apart thanks to
tion, resting during the dormant periods and subsequent tissue the incorporation of new descriptive categories (Table 3).
destruction during active stages. These periods of periodontal
destruction are associated with various changes in the cell A. GINGIVITIS
population that confirms the inflammatory infiltrate located in a. Dental plaque-induced gingival diseas
the subepithelial connective tissue (neutrophiles, macrophages, b. Acute necrotizing ulcerative gingivitis (ANUG).
lymphocytes, plasma cells, etc.) (7). c. Steroid hormone-induced gingivitis.
Starting in the 90s, the hypothesis has been put forth that predis- d. Drug-induced gingival enlargements.
e. Gingivitis associated with blood disorders, nutri-
posing factors in the host (such as the lack of oral hygiene, age,
tional dcits, tumors, genetic factors, viral
systemic factors such as smoking, diabetes, genetic vulnerability, infections.
immunological alterations, etc.) play a key role in the patho- f. Gingivitis descamativa.
genesis of periodontal illness, as well as microbial factors that B. PERIODONTITIS
influence the periodontal pathogenicity of the germs involved a. Adult periodontitis.
(such as specific bacterial adhesion factors). b. Early-onset periodontitis:
At birth, the oral cavity is sterile, although bacterial coloniza- i. Prepuberal periodontitis:
tion quickly begins, creating the so-called oral microbial flora 1. Localized
or microbiota, where aerobic, strictly anaerobic (65%), sapro- 2. Generalized
phytic and pathogenic species all coexist. The natural balance ii. Juvenile periodontitis
(eubiosis) can be upset by exogenous or endogenous factors, 1. Localized
2. Generalized
thereby leading to disease (dysbiosis). Bacterial plaque located
c. Periodontitis associated with systemic diseases
in the gingival margin (supra and subgingival) is what triggers d. Necrotising ulcerative periodontitis
the illness; subgingival plaque is responsible to a greater degree e. Refractory periodontitis
since it has greater contact with the tissues that support the too-
Table 3. Classification of the World Workshop, 1989
th. Subgingival plaque is made up of anaerobic, gram-negative
bacteria, mobile forms and spirochetes, located in an area with
optimal conditions (pockets, anaerobic environments, Ph, oxido-
A. PRIMARY DESCRIPTORS
reduction potential, less self-cleaning action, etc). Microbiota
a. Adult periodontiti
is therefore polymicrobial and mixed and the resulting illnesses b. Early-onset periodontitis
are often the consequence of complex bacterial associations c. Necrotising ulcerative periodontitis
(Table 2). B. SECONDARY DESCRIPTORS
a. Tooth distribution.
b. Rate of progression.
c. Treatment response.
d. Associated with systemic diseases.
FLORA e. Microbiological characteristics.
HIGHLY COMPLEX f. Ethnicity.
- Heterogeneous g. Other factors.
- Multiple species ~ 300 species Table 4. Classification European Workshop, 1993
- Different ecosystems
- Abundant
- Specific
- Dynamic Later on, during the course of the First European Workshop on
OPPORTUNISTIC Periodontology (1993) a more straightforward classification of
Table 2. Oral Flora Characteristics periodontal disease was proposed based largely on the associated
causal factors and on the different host response (Table 4).
These classifications have been widely used by both clinicians,
as well as by researchers, although they present a series of shor-
tcomings. For example, in the classification of the Internatio-
nal Workshop, celebrated in 1989, there is an overlap between
different categories, gingival disease is conspicuously absent,
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inappropriate emphasis is placed on the age of onset of the following delivery. Clinical studies present prevalence rates of
disease, as well on the rates of progression and the presence of between 35 and 100% (11) of all pregnant women.
inadequate classification criteria. On the other hand, the 1993 Granuloma gravidarum, also known as pregnancy tumours,
European classification lacks details that are needed to properly is an exaggerated proliferative fibrovascular inflammatory res-
identify the broad spectrum of periodontal illnesses encountered ponse to an ordinary stimulus (12) mainly located in the gum.
in clinical practice. In light of all these deficiencies, the 1996 It is described as a nodular or ulcerated localized mass that is
World Workshop on Periodontology underscores the need to red or purplish red, that bleeds easily and that frequently ap-
revise the existing classifications and to create a new one. In pears in females (0.5-5%) (13, 14) around the second trimester
1997, the American Association of Periodontics decided to set of pregnancy that grows throughout the pregnancy, reaching
up a committee to take charge of this task; the classification sizes that tend to not exceed 2 cm. It is of unknown aetiology,
proposed by this committee was approved at the International although trauma, hygiene and hormonal factors have been in-
Workshop for a Classification of Periodontal Diseases and volved (13).
Conditions (1999) (Table 5). In gingivitis associated with diabetes mellitus, diabetic con-
trol is of greater relevance than plaque control insofar as the
Dental Plaque-Induced Gingival Diseases severity of the gingival inflammation is concerned. This type
The term gingival diseases is used to define the pattern of signs of gingivitis tends to present in children with poorly controlled
and symptoms of various illnesses located in the gum. They all diabetes mellitus type I.
share the following characteristics: they present bacterial pla- Gingivitis associated with leukaemia is characterised by
que that cause or exacerbate the severity of the lesion; they are inflamed, spongy gingival tissues that vary between red and
reversible if the causative factors are eliminated and they may purple in colour. Bleeding is common and may be the first sign
be the precursor to loss of attachment around the tooth. of acute leukaemia in 17.7% and of chronic leukaemia in 4.4%
Clinical manifestations include inflammation of the gum, with of the cases, respectively.
elongated gingival contour due to oedema or fibrosis, red or Gingival enlargement is associated with the use of anticonvul-
bluish in colour, elevated sulcular temperature, bleeding on sants (phenytoin), immunosuppressants (cyclosporin A) and cal-
probing and increased gingival bleeding. All of these signs are cium channel blockers (nifedipine, verapamil, diltiazem, sodium
associated with periodontia with stable attachment and without valproate). Although it varies from one patient to another and even
loss of attachment or stable albeit in shrunken periodontia (8) within the same individual, enlarged gums are generally located
(Fig. 3). in the anterior portion of the gingiva, with a greater prevalence
Dental plaque-induced is an inflammation of the gum due in young patients. It tends to appear three months after initiating
to the location of bacteria along the gingival margin that may drug treatment, generally at the level of the papilla and it is not
later spread to the entire gingiva. Characteristic clinical findings associated with attachment loss (Figs. 4 - 7).
include erythema, oedema, bleeding, tenderness and enlarge- Other cases of swollen gums have been observed in association
ment. The severity of the disease can be influenced by dental with the use of oral contraceptives, wherein the gingiva are more
anatomy, in addition to the restorative or endodontic status in inflamed in the presence of relatively small amounts of plaque.
each case (9) (Fig.1). Malnourished individuals are immunocompromised and this
Gingivitis associated with puberty shares the majority of the can affect the persons susceptibility to infection, which would
clinical signs encountered in plaque-induced gingivitis, but the exacerbate the gingival response to the presence of bacterial
main distinction between the two has to do with the high pro- plaque. The most widely studied nutritional deficit has been lack
pensity to develop overt signs of gingival inflammation with of vitamin C, or scurvy, in which the gum is bright red, swollen,
relatively small amounts of bacterial plaque around puberty. ulcerated and presents a tendency to bleed.
During puberty, a host of endocrine changes take place charac-
terised by increased steroid hormone plasma levels that will be Non-Plaque-Induced Gingival Diseases (15).
responsible for the inflammatory status of the gum (9). Gingival disease of bacterial origin are those that are caused
The hallmark of gingivitis associated with the menstrual cycle is by exogenous bacterial infections produced by germs other
a moderate inflammatory response of the gum prior to ovulation, than those that are typical components of dental plaque, such
with a 20% increase in the amount of gingival exudate, resulting as Neisseria gonorrhoeae, Treponema pallidum, Streptococcus
from the elevation of luteinizing hormone levels (>25 mU/ ml) and other microorganisms. They manifest clinically as painful
and/ or estradiol (>200 pg/ ml) (9). oedematous ulcerations, mucosal maculae or very swollen, non-
Pregnancy-related gingivitis is a proliferative, vascular and ulcerated, atypical gums that may or may not be accompanied
non-specific inflammation of the gingiva with significant infla- by lesions located elsewhere on the body.
mmatory cell infiltrate. Clinically, it presents as bright red gums Viral gum diseases are acute manifestations of viral infections
that bleed easily, the gingival margin is thickened, and the inter- in the oral mucosa that evolve with the appearance of multiple
dental papilla are hyperplasic which can lead to the appearance vesicles that break easily, leading to painful ulcerations. The
of pseudopockets (10). In 1963, Le and Silness (11) stated that most important ones are associated with the herpes simplex
the first symptoms appear in the second month of pregnancy and virus (HSV) types 1 and 2 and with the varicella zoster virus.
continue until the eighth month, at which time a certain degree The first manifestation of HSV-1 receives the name of primary
of improvement is seen, before the disease finally stabilizes gingival stomatitis. It tends to appear in children and progres-
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Infecciones orofaciales / Orofacial infections Enfermedades periodontales / Periodontal diseases
ses with severe, painful gingivitis, along with the formation of Foreign body reactions occur as a consequence of epithelial
blisters that go on to become fibrin-coated ulcerations. It may ulceration that allows foreign material to enter the gingival
be accompanied by fever and lymphadenopathies. The virus connective tissue. They sometimes present associated acute or
reactivates in 20-40% of the cases associated with fever, trauma chronic inflammation of the gums or they may cause tattoos. In
or ultraviolet radiation, amongst others. Small, painful clusters of some cases, they may become infested.
blisters appear in the area of the attached gum. Chickenpox ge-
nerally appears as small ulcers on the tongue, palate and gum, in Chronic Periodontitis
addition to fever, general malaise and skin rash. The subsequent The characteristic clinical signs of chronic periodontitis include
reactivation of the varicella zoster virus results in the appearance loss of clinical attachment, alveolar bone loss, periodontal pocket
of herpes zoster, with irregular, unilateral vesicles-ulcers. formation and inflammation of the gums. Gingival hypertrophy
Fungal gingival diseases include aspergillosis, blastomycosis, or recession, bleeding on probing, increased tooth mobility and
candidiasis, coccidioidomycosis, criptococcosis, histoplasmo- suppuration may also be associated; symptoms may even lead
sis, mucormycosis and paracoccidioidomycosis, although can- to tooth loss. In chronic periodontitis, the infection progresses
didiasis and histoplasmosis are the most common. Candidiasis, steadily or in bursts of activity (16).
predominantly caused by Candida albicans, is rarely seen in the Depending on its extension, it can be classified as:
gums of healthy individuals, although in immunocompromised - Localized, if fewer than 30% of the sites are involved.
subjects, it may lead to linear gingival erythema. Other forms of - Generalized, if more than 30% of the sites are involved.
presentation are plaques or nodular pseudomembranous, erythe- Based on severity, it is defined as:
matous candidiasis. Histoplasmosis is a granulomatous disease - Slight periodontitis: when clinical attachment loss is between
that is produced by Histoplasma capsulatum found in bird and 1 and 2 mm.
bat faeces. They begin as nodular lesions that later become ul- - Moderate periodontitis: if attachment loss is between 3 and 4 mm.
cerous and painful and may imitate a malignant tumour. - Severe periodontitis: when clinical attachment loss is 5 mm
Gingival manifestations of disorders of the skin or mucosa tend or greater.
to present as erosions, vesicles, blisters, ulcers or scaly lesions. Currently held concepts hold that bacterial infection is the lea-
Lichen planus presents in between 0.1 and 4% of the population ding cause of the disease and plaque is the factor that serves as
in two basic ways: white lichen planus and lichen planus ruber. a trigger; however, defence mechanisms play a key role in its
It is characterized by white, reticular lesions, known as Wickham pathogenesis (Figs. 2 - 9).
striae. Penfigoide is a group of disorders in which autoimmune
antibodies are produced against the components of the basement Aggressive Periodontitis
membrane, causing subepithelial blisters containing clear, yello- The common features of all forms of aggressive periodontitis are:
wish or bloody fluid to appear that later rupture, leading to painful, patients who, except for the presence of the periodontal infection,
fibrin covered ulcerous lesions. In pemphigus, the autoimmune are otherwise clinically healthy; rapid loss of clinical attachment
antibodies are directed against epithelial desmosomes, causing and bone destruction, and a positive family history (17).
an acantholytic or intraepithelial pustule to appear that may be- Other features that generally present, albeit they are not universal
come life threatening for the patient. Erythema multiforme is an to all patients, are: microbial deposits that are inconsistent with
illness producing pustules and blisters that affects both the skin the severity of tissue destruction present, high proportions of
and mucosa. There are two forms of the disease: minor and major Actinobacillus actinomycetemcomitans or Porphyromonas gin-
(Stevens-Johnson Syndrome). Patients present swollen lips with givalis, phagocytic anomalies and an abnormal hyperresponsive
large scabs in the area of the vermillion, although the basic lesion macrophage phenotype with high levels of prostaglandin E2 and
is a vesicle that ruptures and is followed by extensive ulcerous interleukin-1; the progression of bone loss and attachment may
lesions. Lupus erythematosus is an autoimmune illness of the be dramatic (18).
connective tissue in which autoimmune antibodies are directed There are two types of aggressive periodontitis:
against various cell elements, affecting the kidneys, heart, central a. Localized. Onset is around puberty with a high antibody
nervous system, vascular system and bone marrow. The typical response to infectious agents. Clinically it is characterized by
lesion consists of an atrophic central area with a whitish lacy interproximal attachment loss in the first molars and incisors
appearance surrounded by fine striae. It is classified as discoid or in at least two permanent teeth, one of which is a first molar
and systemic lupus erythematosus. and no more than two teeth other than first molars and incisors
Allergic reactions are not terribly common in oral mucosa, are involved.
since higher concentrations of allergens are needed to provoke b. Generalized. Generalized aggressive periodontitis tends to
a reaction in the mouth as opposed to the skin. Type I immuno- manifest in patients over 30 years of age, although it can appear
globulins E-mediated reactions (immediate) or Type IV T-cell at older ages. Antibody response is poor. There are periods du-
mediated reactions (delayed) may develop. ring which attachment is lost, involving three permanent teeth
Traumatic lesions of the mucosa of the mouth may be acci- other than first molars and incisors.
dental, iatrogenic or factitious. They may manifest as localized
gingival recessions, abrasions, ulcerations or burns. They may Necrotising Periodontal Diseases
be oedematous, erythematous or whitish in appearance or a Necrotising ulcerative gingivitis (NUG) is distinguished from
combination of all three.
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Med Oral Patol Oral Cir Bucal 2004;9 Suppl:S75-91. Enfermedades periodontales / Periodontal diseases
Table 5. Classication of Periodontal Diseases and Conditions of the International Workshop (1999)
105
Infecciones orofaciales / Orofacial infections Enfermedades periodontales / Periodontal diseases
other gingival diseases by the presence of gingival necrosis bet- Acquired Deformities and Conditions
ween the teeth, with ulcerated papilla, bleeding gums and pain. A number of tooth-related factors exist that may predispose
This pain is the hallmark of this entity and its intensity is what the individual to the development of periodontal illnesses. Thus,
leads the patient to seek treatment. Other signs and symptoms although the aetiology of periodontal illnesses is bacterial, any
that are also associated with NUG, although not pathognomonic, factor that favours bacterial accumulation or allows bacteria to
include the presence of lymphadenopathies, fever, halitosis and enter the periodontia must be taken into account (23).
general malaise (Fig. 10); episodes resolve within a few days Mucogingival deformities, alterations of the morphology, size
following proper treatment. and interrelationships between the gum and the alveolar mucosa.
A series of factors exist that predispose the individual to de- This abnormality may be associated with deformities of the
veloping this infection including stress, immunosuppression, underlying alveolar bone (24).
malnutrition, smoking, trauma or pre-existing gingivitis (19). Occlusal trauma: damage resulting from tissue changes in the
Necrotising ulcerative periodontitis (PUN) is characterized by attachment apparatus as a consequence of occlusal force.
necrosis of the gingival tissue, periodontal ligament and alveolar Occlusal trauma may be primary, when excessive occlusal for-
bone. It typically appears in subjects with systemic conditions ces are exerted on a tooth with normal support; it can also be
that lead to a state of immunosuppression (20). secondary, when the damage is the consequence of excessive
It is possible that NUG and PUN actually represent two different or normal occlusal forces exerted on a tooth or teeth with dimi-
states of the same infection; there is insufficient data at this nished periodontia (25).
point in time to be able to separate both entities into different
categories. The only difference between the two is that NUG CONCLUSION
is confined to the gum, whereas PUN includes the entire atta- The revision presented here offers an overview of the different
chment apparatus. clinical syndromes encompassed within the spectrum of perio-
dontal illnesses. Bacteria have been seen to play a leading role
Periodontal Abscesses in the onset and subsequent development of these illnesses.
A periodontal abscess is a purulent infection located in the pe- Therefore, when it comes to treatment of these diseases, coad-
riodontal tissues that may be a clinical manifestation in patients juvant antimicrobial treatment will be needed, since we already
with moderate or severe periodontitis. The most salient features know that scaling and root planing alone will be insufficient to
are inflammation, suppuration, reddening, extrusion of the tooth eliminate the periodontal pathogens (26-29).
involved and the tooth is tender on percussion. The patient may Antimicrobial selection is made on the basis of the microbio-
at times present a low-grade fever (21) (Fig. 11 and 12). logical criteria of the illness (spectrum of action), as well as on
Abscesses can be classified as: the pharmacokinetic profile of the selected drug in particular, at
- Gingival abscess. A localized, painful and rapidly spreading all times avoiding drug-related adverse effects (30, 31). The use
lesion that affects the gingival margin or interdental papilla. It of locally applied antimicrobial treatment enables drug levels
is generally an acute inflammatory response of the gingiva to a to be attained that would not be possible by means of systemic
foreign body that has entered the gum. administration; it can even make it possible to use drugs that are
- Periodontal abscess. A localized accumulation of pus in the too toxic for systemic use (32). Nonetheless, on the other hand,
gingival wall of a periodontal pocket that provokes the des- systemic antibiotics exert their effect throughout the entire oral
truction of collagen fibre attachment and the subsequent loss cavity and are therefore not limited to the site of application
of adjacent alveolar bone. It tends to be related to the presence (1, 32 - 34).
of tortuous periodontal pockets, furcation involvement or in- Systemic use of amoxicillin, amoxicillin-clavulanic acid and
fraosseous defects. metronidazole are recommended as the first line treatment op-
- Pericoronal abscess. A pericoronal abscess is a localized accu- tion in aggressive periodontal illnesses. If the patient is allergic
mulation of pus on the gingival tissue surrounding the crown of to amoxicillin or metronidazole, clindamycin, azithromycin or
a tooth that has not fully erupted and is generally located in the clarithromycin are suggested (35).
area of the third inferior molar. The gingival tissue appears red
and inflamed and patients have difficulty swallowing. BIBLIOGRAFIA / REFERENCES
1. Mombelli A. Periodontitis as an infectious disease: specific features and their
Periodontic-Endodontic Lesions implications. Oral Dis;9:6-10.
Periodontal or endodontic infections may evolve with increased 2. Socransky SS, Haffajee AD. Dental biofilms: difficult therapeutic targets.
Periodontol 2000 2002;28:12-55.
probing depth of the adjacent teeth, inflammation, bleeding on 3. Marsh PD. Plaque as a biofilm: pharmacological principles of drug delivery
probing, suppuration, fistula formation, sensitivity to percussion, and action in the sub- and supragingival environment. Oral Dis 2003;9:16-22.
increased tooth mobility, angular bone loss and pain. These signs 4. Trombelli L, Tatakis DN. Periodontal diseases: current and future indications
and symptoms are usually observed in plaque-induced periodon- for local antimicrobial therapy. Oral Dis 2003;9:11-5.
5. Le H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol
titis that begins at the gingival margin and progresses towards 1965;36:177-87.
the root. However, they may also be the result of endodontic 6. Lindhe J, Hamp SE, Le H. Experimental periodontitis in the beagle dog.
infections that reach the periodontal ligament through the api- Int Dent J 1973;23:432-7.
cal foramen or by means of the lateral or accessory canals and 7. Gamonal J, Bascones A, Silva A. Las quimioquinas en la patognesis de la
periodontitis. Av Periodoncia Implantol Oral 1999;11:89-95.
advance towards the crown (22).
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