The most common complaint of patients with gingivitis is the bleeding gums, which he notices while eating, brushing or flossing. In patients with ANUG, spontaneous bleeding is observed even after minimal local trauma. ANUG also causes local pain, malaise and altered taste with bad breath.

• Pain

  You can also decrease the inflammation and pain of gingivitis while helping your body fight the infection. [livestrong.com]

  NSAIDs and topical xylocaine for pain relief are also prescribed for patients with chronic gingivitis and ANUG. [symptoma.com]

  Swollen, painful, red or peeling gums and the presence of any ulcers or abscesses is noted, as is the amount of plaque and tartar present. [news-medical.net]

  Salt water may also: soothe inflamed gums help ease pain reduce bacteria remove particles of food relieve bad breath To use a salt water rinse: Add 1/2 to 3/4 teaspoon of salt to a glass of lukewarm water and mix well. [healthline.com]

• Bleeding Gums

  PUBLISHED: PUBLISHED: 11:01, Sat, Jun 3, 2017 GETTY Bleeding gums: It's not always gum disease Gum disease is a common condition where the gums become swollen, sore of infected. Symptoms include - famously - bleeding gums, and bad breath. [express.co.uk]

  RECOGNIZE THE SYMPTOMS Red, swollen gums are an indication that gingivitis is present. Other symptoms include bleeding gums and a noticeable change in the color of your gums (pink to red). [dovedentalcentres.com]

  […] on the gums or insides of cheeks What to do if you have painful or bleeding gums Don’t be tempted to assume that your gums are bleeding because you brushed a little too hard. [dentaly.org]

  Healthy gums are pale pink in colour, firm, and they never bleed. Gum inflammation is relatively common. The main symptoms are red, swollen and bleeding gums. [schwabingzahnarzt.de]

  What Do Bleeding Gums Mean Bleeding gums are caused by inadequate plaque removal. Plaque contains germs which attack the healthy tissue around the teeth. [bleedinggums.com]

• Halitosis

  Halitosis (bad breath) Halitosis is the medical name for bad breath. The most common cause of bad breath is tiny food particles trapped in your teeth and mouth. [healthdirect.gov.au]

  VSCs emit indole, skatole, and polyamines, which results in halitosis. [therabreath.com]

  Halitosis ( bad breath ), in which the breath begins to take on a foul odor, may be present in more severe forms of gingivitis. When Should Someone Seek Medical Care for Gingivitis? For simple gingivitis, work with a dentist. [emedicinehealth.com]

• Gingival Recession

  Subjects with advanced periodontal disease, excessive gingival recession, and heavy deposits of calculus or rampant decay were excluded from the study. [ncbi.nlm.nih.gov]

  In addition we compared the width of attacked gingiva in the subjects with less than 2 sites of gingival recession(Re≤2) and the subjects with more than 3 sites of gingival recession(Re≥3) to study the relationship between the gingival recession and the [ir.ymlib.yonsei.ac.kr]

  Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol. 1999 Jan;70(1):30-43. https://doi.org/10.1902/jop.1999.70.1.30 [ Links ] 12. [scielo.br]

• Gingival Hypertrophy

  Some patients with Crohn disease have a cobblestone area of granulomatous gingival hypertrophy when intestinal flare-ups occur. [msdmanuals.com]

• Oral Bleeding

  Patients reported decreased tooth and gingival pain, decreased oral bleeding, and increased motivation to maintain proper oral hygiene over the course of the study. [ncbi.nlm.nih.gov]

Laboratory testing does not help to diagnose gingivitis. However, if a systemic disease or toxin is suspected, laboratory tests are recommended. Generally, imaging studies are not indicated in patients with gingivitis [6].

• Capnocytophaga

  The genera Porphyromonas, Treponema, and Tannerella showed higher relative abundance in the subjects with gingivitis, while the genera Capnocytophaga showed higher proportions in health controls. [ncbi.nlm.nih.gov]

  Bacteria involved in the etiology of gingivitis include specific species of Streptoccous, Fusobacterium, Aclinomyces, VeiUonella, and Treponema and possibly Bacteroides, Capnocytophaga, and Eikenella. [onlinelibrary.wiley.com]

  Phylogenetic tree based on 16S rRNA gene comparisons showing the relationship between Capnocytophaga _HS5_2W_I24 and members of the genus Capnocytophaga. [doi.org]

Intervention from emergency department (ED) is generally not called for in patients with chronic gingivitis. Pain management is the requirement for patients with ANUG in the ED. In rare cases, fever and sepsis following the destruction of the soft tissue are observed in the patients with gingivitis. In such patients, intravenous antibiotics therapy is initiated.

The dentist must stress on the importance of oral care. The dentists remove the plaque, and calculus to avoid progression of the disease. He may advise to clean the mouth with warm saline water. Use of fluoride dentifrice, electric toothbrush and regular flossing will slow the progression of the disease. Some studies have concluded that brushing followed by rinsing with chlorhexidine also yield good results.

Some of the medications used in the management of gingivitis are non-steroidal anti-inflammatory drugs (such as ibuprofen, acetaminophen with codeine), local anesthetics and antibiotics. Antibiotics eradicate the bacterial infections in the patients with ANUG. NSAIDs and topical xylocaine for pain relief are also prescribed for patients with chronic gingivitis and ANUG. Penicillin V, erythromycin, minocycline (used as an adjunct to scaling), doxycycline, and clindamycin are some of the common antibiotics that are used to manage ANUG. Chlorhexidine has bactericidal activity and is helpful in combating the progression of the disease. Topical anesthetics such as lidocaine can help in controlling the pain and allows the patient to brush and floss without trauma [7] [8] [9].

If gingivitis is not treated, it can lead to tooth loss; however, with initial cleaning and scaling, gingivitis can be reverse and the patients respond well with appropriate treatment. Management of patients with ANUG requires the aggressive treatment with antibiotics. Patient with intact host defenses often respond well to treatment.

Inadequate oral hygiene is the primary cause of the chronic gingivitis. Other risk factors of this disease are smoking, use of tobacco, alcohol, patients with compromised immune system (diabetes, HIV/AIDS), and periodontitis. Diabetes mellitus, blood dyscrasias, inadequate removal of plaque, allergic reactions, poor nutrition, and lack of dental examination increases the chance of gingivitis several fold.

Gingivitis can also be caused by some drugs such as anticoagulants, fibrinolytic agents, oral contraceptives, phenytoin, danazol, vitamin A and its analogues, calcium channel blockers and protease inhibitors. Acute necrotizing ulcerative gingivitis (ANUG) is a complication of chronic gingivitis with poor or abandoned hygiene and weak host defenses. ANUG is not contagious and is caused as a result of invasion by ubiquitous organisms of the soft tissue [2].

In developed countries such as Australia, Sweden, Switzerland and England 48 to 85% of the children (ages between 3 and 6 years) have reported gingivitis. Among adolescents, the incidence of gingivitis across the world range between 50% and 90%. ANUG is common in regions which face poor living conditions. Gingivitis can cause health-issues in the patients. In some studies, the periodontal disease may be one of the factors of coronary artery disease or ischemic stroke.

The elevated levels of the markers of the chronic inflammation (C-reactive protein) fall after the treatment of the periodontal disease. Chronic gingivitis may lead to tooth loss. In patients with type-2 diabetes, gingivitis can be managed well by improved glycemic control. During pregnancy, periodontal disease is often associated with preterm birth and adverse pregnancy outcomes. Gingivitis is relatively more prevalent in males than females [3] [4] [5].

Accumulation of the microbial plaque due to inadequate oral hygiene, leads to the development of gingivitis. The initial stages of gingivitis (which begins within 4 or 5 days of formation of plaque) manifest as lesions which later progresses to advanced disease. With time, gingival fluid and increase of migration of neutrophils to the site is seen. In the initial stage itself, there is a deposition of fluid and the destruction of the collagen.

After 1 week, the infiltration of lymphocytes to the site occurs. With time, the lesions become chronic and are often characterized by the presence of the B lymphocytes and plasma cells. Bleeding during brushing or even chewing is also observed. Persistent inflammation leads to the breakdown and destruction of the local alveolar bone, loosening the teeth.

ANUG, on the other hand, is caused by the acute infection of the gingiva with Actinomyces species, alpha-hemolytic streptococci or Prevotella intermedia. ANUG leads to accelerated destruction of the affected tissues [1] [2].

Gingivitis and ANUG can be prevented by having a good oral hygiene, and regular dental check-up.

Inflammation which is limited to the mucosal epithelial tissues and which surrounds the cervical portion of the teeth and the alveolar processes is referred to as gingivitis. Depending on the clinical appearance, etiology and duration, gingivitis is classified. The most common chronic gingivitis is caused by plaque. [1]

Definition

Gingivitis is the inflammation of the gums due to bacteria which is present in the deposition of plaque buildup. Irritation and gum bleeding is common in patients with gingivitis.

Cause

Gingivitis is caused due to poor oral hygiene. Other risk factors of gingivitis are smoking, alcohol and diseases such as diabetes and HIV/AIDS (which impairs the immune system). Some medications such as anticoagulants, fibrinolytic agents, phenytoin and oral contraceptives can also contribute to the progression of gingivitis.

Symptoms

Symptoms of gingivitis are gum-bleeding, pain and swelling of the gums. 

Diagnosis

Diagnosis of gingivitis can be done by observing the oral cavity by a dentist. If the systemic disease is suspected, laboratory tests are recommended.

Treatment

Treatment of gingivitis involves use of painkillers such as ibuprofen and local anesthetics (lidocaine). The patient must also be advised about the advantages of having proper oral hygiene to combat the bacteria. 

1. Robinson PJ. Gingivitis: a prelude to periodontitis? J Clin Dent. 1995;6 Spec No:41-5. 
2. Prasad D, Kunnaiah R. Punica granatum: A review on its potential role in treating periodontal disease. J Indian Soc Periodontol. 2014 Jul;18(4):428-32.
3. Dorfer CE, Becher H, Ziegler CM, et al. The association of gingivitis and periodontitis with ischemic stroke. J Clin Periodontol. May 2004;31(5):396-401.
4. Lockhart PB, Bolger AF, Papapanou PN, et al. Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an Independent Association?: A Scientific Statement From the American Heart Association. Circulation. Apr 18 2012
5. Mealey BL. Periodontal disease and diabetes: A two-way street. J Am Dent Assoc. Oct 2006;137 Suppl 2:26S-31S.
6. Ranney RR. Diagnosis of periodontal diseases. Adv Dent Res. Dec 1991;5:21-36
7. Zimmer S, Kolbe C, Kaiser G, et al. Clinical efficacy of flossing versus use of antimicrobial rinses. J Periodontol. Aug 2006;77(8):1380-5. 
8. Johnson RH, Armitage GC, Francisco C, Page RC. Assessment of the efficacy of a nonsteroidal anti-inflammatory drug, Naprosyn, in the treatment of gingivitis. J Periodontal Res. Jul 1990;25(4):230-5.
9. Gehlen I, Netuschil L, Georg T, et al. The influence of a 0.2% chlorhexidine mouthrinse on plaque regrowth in orthodontic patients. A randomized prospective study. Part II: Bacteriological parameters. J Orofac Orthop. 2000;61(2):138-48.
10. Haas AN, Pannuti CM, Andrade AK, et al. Mouthwashes for the control of supragingival biofilm and gingivitis in orthodontic patients: evidence-based recommendations for clinicians. Braz Oral Res. 2014 Jul 11;28(spe):1-8.