drg. Ade Ismail A. K., MDSc. Sp.

Perio

12 Mei 2017 KulPak,,blok 13, 2017 1

 Color
Size
Position of margin
Shape of margins and papillae
Texture and consistency
Bleeding and/or exudate
12 Mei 2017 KulPak,,blok 13, 2017 2
 Tissue fits snugly around the tooth
Pointed papillae fill embrasure spaces
Firm and resilient
Little or no gingival crevicular fluid (GCF)

12 Mei 2017 KulPak,,blok 13, 2017 3

 1. Healthy gingiva in the person
young

2. Healthy lightly pigmented

gingiva•AG is stippled•This
pigmentattion results from the
synthesis of melanin by
melanocytes located in the basal
layer of the epithelium (brown
spots)

3. Healthy, deeply pigmented

12 Mei 2017 KulPak,,blok 13, 2017 4
 Acute inflammation = increased blood
flow = RED tissue

Chronic inflammation = bluish-red or

purplish – red

12 Mei 2017 KulPak,,blok 13, 2017 5

 ACUTE CHRONIC
INFLAMMATION INFLAMMATION

12 Mei 2017 KulPak,,blok 13, 2017 6

12 Mei 2017 KulPak,,blok 13, 2017 7
12 Mei 2017 KulPak,,blok 13, 2017 8
12 Mei 2017 KulPak,,blok 13, 2017 9
12 Mei 2017 KulPak,,blok 13, 2017 10
12 Mei 2017 KulPak,,blok 13, 2017 11
12 Mei 2017 KulPak,,blok 13, 2017 12
 Both chronic and acute inflammations produce
changes in the normal firm and resilient
consistency of the gingiva.
Chronic gingivitis = edematous – (destructive)
and fibrotic – (repairative) changes coexist
The consistency of the gingiva is determined by
their relative predominance.

12 Mei 2017 KulPak,,blok 13, 2017 13

12 Mei 2017 KulPak,,blok 13, 2017 14
 The surface of normal gingiva usually
exhibits numerous small depressions
and elevations = stippling
In chronic inflammation the surface is
either smooth and shiny or firm and
nodular
(This depends on whether the dominant changes are
exudative or fibrotic)

12 Mei 2017 KulPak,,blok 13, 2017 15

 Can be:
Exudative

Epithelial atrophy in atrophic

gingivitis

Chronic desquamative gingivitis can

also have peeling of the surface

12 Mei 2017 KulPak,,blok 13, 2017 16

12 Mei 2017 KulPak,,blok 13, 2017 17
 Hyperkeratosis results in a leathery texture
(example = chronic gingival disease in a smoker)
Fibrotic = firm nodular
Drug induced gingival overgrowth also produces
a nodular surface

12 Mei 2017 KulPak,,blok 13, 2017 18

 Color
Size
Position of gingival margin
Shape of margins and papillae
Use air and probe to determine texture
Consistency
Check for bleeding

12 Mei 2017 KulPak,,blok 13, 2017 19

12 Mei 2017 KulPak,,blok 13, 2017 20
􀂄 Necrotizing Ulcerative Gingivitis (NUG)
􀂄 Necrotizing Ulcerative Periodontitis (NUP)

12 Mei 2017 KulPak,,blok 13, 2017 21

 An infection characterized by gingival
necrosis presenting as “punched-out”
papillae, with gingival bleeding and pain

12 Mei 2017 KulPak,,blok 13, 2017 22

 SYNONYM
VINCENT’S INFECTION
TRENCH MOUTH ACUTE
ULCEROMEMBRANEOUS GINGIVITIS
FUSOSPIROCHETAL GINGIVITIS

12 Mei 2017 KulPak,,blok 13, 2017 23

 It frequently occur in an epidemic pattern.
Especially apparent during World War I-and
the term ‘trench mouth’ originated.
Sporadic outbursts also occurred in World
War II
Global increase associated with HIV infection
More common among young and middle aged
adults,15-35 years old.

12 Mei 2017 KulPak,,blok 13, 2017 24

12 Mei 2017 KulPak,,blok 13, 2017 25
 Trench Construction diagram from 1914
British Army Manual

12 Mei 2017 KulPak,,blok 13, 2017 26

Sanitary conditions in the trenches were quite poor, and
common infections included dysentery, typhus, and cholera.
Many soldiers suffered from parasites and related infections.
Poor hygiene also led to fungal conditions, such as trench
mouth and trench foot.

12 Mei 2017 KulPak,,blok 13, 2017 27

Medical services were primitive and life-saving antibiotics had not yet been
discovered. Relatively minor injuries could prove fatal through onset of
infection and gangrene. The Germans recorded that 12% of leg wounds and
23% of arm wounds resulted in death, mainly through infection.

12 Mei 2017 KulPak,,blok 13, 2017 28

 Most investigators believe that it’s caused by a
fusiform bacillus and Borrelia vincentii
-a spirochete.
Some workers also included vibrio and coccal
forms as agents in the etiology of this disease.
Frequently occurs in the presence of
psychologic stress.

12 Mei 2017 KulPak,,blok 13, 2017 29

 Stress-related corticosteroids are thought to
alter T4/T8 lymphocyte ratios and may cause
the decreased neutrophilic chemotaxis and
phagocytic response.
Immunosuppresion.
Smoking.
Local trauma.
Poor nutritional status.
Poor oral hygeine.
Inadequate sleep.

12 Mei 2017 KulPak,,blok 13, 2017 30

 Mild/ Early stage
 Advanced/ Acute stage

 Severe

12 Mei 2017 KulPak,,blok 13, 2017 31

 Terjadi pada IP (Ulserasi dan Nekrosis)
Perdarahan + pd tekanan.
Sakit. ±

12 Mei 2017 KulPak,,blok 13, 2017 32

 Sakit
Onset tiba-tiba
Hemorrhage (merah terang dan titik perdrhan).
Hipersalivasi
Pseudomembrane
Halitosis (kecap metalik)
Meliputi bag.labial dan lingual MG (blm sp AG)

12 Mei 2017 KulPak,,blok 13, 2017 33

 Advanced/ acute stage

stage:

12 Mei 2017 KulPak,,blok 13, 2017 34

 Lympadenitis
Kerusakan sp Faring (Vincent’s Angina)
Ulserasi pada bibir dan lidah
Necrosi sp AG & tdp krskn tl di bwhnya
Interdental crater (tjd kerusakan meluas)
Demam & malaise.

12 Mei 2017 KulPak,,blok 13, 2017 35

 Severe :

12 Mei 2017 KulPak,,blok 13, 2017 36

 Primary Herpetic Gingivostomatitis
Lichen Planus
Difteri
DM tidak terkontrol

12 Mei 2017 KulPak,,blok 13, 2017 37

12 Mei 2017 KulPak,,blok 13, 2017 38
 Increase in tissue fluid causes enlargement of the
marginal and interproximal gingival tissues
(Edema)
Change can be localized to a few areas or affect the
whole mouth (generalized)
Gingival Enlargement or gingival overgrowth are
the current terms used to discribe an increase in the
size of the gingiva
“hypertrophic gingivitis” or “gingival hyperplasia”
may have erroneous pathologic connotations
Gingival enlargement is a purely clinical term
12 Mei 2017 KulPak,,blok 13, 2017 39
 I. Inflammatory enlargement
A. Chronic
B. Acute
II. Drug-induced enlargement
III. Enlargements associated with systemic
diseases or conditions
IV. Neoplastic enlargement (gingival tumors)
V. False enlargement
12 Mei 2017 KulPak,,blok 13, 2017 40
 Localized: limited to the gingiva adjacent to a
sengle tooth or group of teeth.
Generalized: involving the gingiva through out
the mouth
Marginally: confined to the marginal gingiva
Papillary: Confined to the interdental papillae
Diffuse: Involving the marginal and attached
gingivae and papillae.
Discrete: An isolated sessile or pedunculated,
tumorlike enlargement.

12 Mei 2017 KulPak,,blok 13, 2017 41

 LOCALIZED GENERALIZED

MARGINALIS
12 Mei 2017 KulPak,,blok 13, 2017
DISCRETE 42
 The two earliest signs of ginigval inflamma tion
preceding established gingivitis are:
1. Increased gingival crevicular fluid production
rate
GCF = inflammatory exudate
Recently – development of tests for the detection or
prediction of periodontal disease using the
components, origin, and function of GCF
Drugs in GCF – tetracycline and Metronidazole
2. Bleeding from the gingival sulcus on gentle
probing

12 Mei 2017 KulPak,,blok 13, 2017 43

 In gingival inflammation, histopathologic alterations
that result in abnormal gingival bleeding include
dilation and engorgement of the capillaries and
thinning or laceration of the sulcular epithelium.
Because the capillaries are engorged and closer to the
surface, and the thinned, degenerated epithelium is
less protective, stimuli that are normally innocuous
cause rupture of the capillaries and gingival
bleeding.
The severity of the bleeding and the ease of its
provocation depend on the intensity of the
inflammation.
In cases of moderate or advanced periodontitis, the
presence of bleeding on probing is considered a sign
of active tissue destruction.

12 Mei 2017 KulPak,,blok 13, 2017 44

 Gingival
Acute abscess
inflammatory
enlargement Periodontal
Inflammatory (lateral) abscess
enlargement
Chronic
Mouth
inflammatoy
breathing
enlargement

12 Mei 2017 KulPak,,blok 13, 2017 45

 Clinical features
Slight ballooning IP and MG
Early stage : a life-preserver-shaped bulge around
the teeth.
The bulge covers part of the crown
Localized/generalized, progress slowly and
painless (unless it is complicated by acute infection
or trauma)
Occurs as a dicrete sessile/pedunculated mass=
tumor (interproximal/marginal/attached gingiva)
12 Mei 2017 KulPak,,blok 13, 2017 46
12 Mei 2017 KulPak,,blok 13, 2017 47
 Histopathology
Shows the exudative and proliferative features of
chronic inflam.
Lession that are clinically deep red or bluish red
soft and friable with smooth, shiny surface, bleed
easily. And have inflammatory cells and fluid ,
vascular engorgement, new cappilary formation,
associated degeneratif changes.
Lession that are relatively firm, resilient, pink
have a greater fibrotic component with abundance of
fibroblalst and coolagen fibers.

12 Mei 2017 KulPak,,blok 13, 2017 48

 Etiology
Caused by prolonged exposure to dental plaque.
Factors that favor plaque accumulation and
retention :
Poor oral hygiene
irritation by anatomyc abnormalities
improver restorative
orthodontic appliances.

12 Mei 2017 KulPak,,blok 13, 2017 49

12 Mei 2017 KulPak,,blok 13, 2017 50
 Is localized, painful, rapidly expanding lesion
(sudden on set)
Limited, MG and IP
Early stage : red swelling with a smooth shiny surface
24 – 48 hrs : lesion become fluctuant and pointed
with surface orifice (purulant exudate may be
expressed)
Sensitif to percussion on the adjacent teeth
Permitted to progress : lesion generaly ruptures
spontaneously)

12 Mei 2017 KulPak,,blok 13, 2017 51

 Histopathology
 Consist of purulent focus in the connective tissue,
surrounded by a diffuse infiltration of polymorphonuclear
leucocyts/PMNs, edematous tissue, and vascular
engorgement.
 The surface ephitelium has varying degrees of intracelluler
and extracelluler edema, invasion by leucocyt, some time
ulceration.
 Etilology
 From bacteria carried deep into the tissue when a foreign
substance (e.g. toothbrush bristle, piece of apple core, lobster
shell fragment)m is forcefully embedded into the gingiva.
 The lesion is confined to the gingiva.

12 Mei 2017 KulPak,,blok 13, 2017 52

12 Mei 2017 KulPak,,blok 13, 2017 53
 Generally produce enlarge
ment of gingiva and perio
dontal tissue.
There is a greater increase risk
for diabetic patients to develop
periodontal abscesses due to
increased gingival reaction to
plaque and increased risk of
periodontal disease. The arrow
points to the abscess.

12 Mei 2017 KulPak,,blok 13, 2017 54

 Problem in:
1. Anticonvulsant 1. Speech
Gingival 2. Mastication
2. Immuno-suppressants Enlargement
3. Calcium channel blockers 3. Tooth eruption
4. aesthetic

12 Mei 2017 KulPak,,blok 13, 2017 55

 Clinical feature
 The growth start painless, beadlike enlargement of IP facial
and lingual MG progess Marginal and papilarry
margin unite.
 massive tissue fold covering of crown and may interfere
with occlusion
 When uncomplicated by inflammation, the lesion is mulberry shaped,
fimr, pale pink and resilience with a minutely lobulated surface and no
tendency to bleed.
 The enlargement appears from beneath MG, seperated by a linear groove
Difficult control plaque secundary inflammation
Combination enlargement (drug and inflammation)

12 Mei 2017 KulPak,,blok 13, 2017 56

12 Mei 2017 KulPak,,blok 13, 2017 57
12 Mei 2017 KulPak,,blok 13, 2017 58
A. Condition enlargement
1. Pregnancy
2. Puberty
3. Vitamin C deficiency
4. Plasma cell gingivitis
5. Non specific conditioned enlargement
B Systemic disease causing gingival enlargement
1. Leukemia
2. Granulomatous disease (e.g.,Wegener’s
granulomatosis, sarcoidosis)
12 Mei 2017 KulPak,,blok 13, 2017 59
12 Mei 2017 KulPak,,blok 13, 2017 60
12 Mei 2017 KulPak,,blok 13, 2017 61