Chapter 12 The Ging iva The true test of successful treatment, the real evaluation of the effects of scaling and related instrumentation, is the health of the periodontal tissues. The objective of all treatment is to bring the diseased periodontal tissues to a state of health that can be maintained by the patient. To do this, the first objective is to learn to re cognize normal healthy tissue; to observe certain characteristics of color, texture, and form; to test for bleeding; and to apply this knowledge to the treatment and supervision of the patient's gingiva until health is attained. An o u tl ine o f the clini c a l f e ature s o f t he p e r io d o ntal t issu e s in he a l th a nd dis e a se is i ncl u d e d i n t his chapter. Key words are defined in Box 12-1. Box 12-1 Key Words Key Words: Gingiv a and Periodonti um A t t a c h m e n t ap p a r a t us: the cementum, periodontal ligament, and the alveolar bone. Clinical attachment level: the probing depth measured from a fixed point, such as the cementoenamel junction. Desmosome: cell junction; consists of a dense plate near the cell surface that relates to a similar structure on an adjacent cell, between which are thin layers of extracellular material. Diastema: a space between two natural adjacent teeth. Plural, diastemata. See also Primate space, page 287. Epithelium Oral: the tissue serving as a liner for the intraoral mucosal surfaces. Squamous: composed of a layer of flat, scalelike cells; or may be stratified. Fibroblast: fiber-producing cell of the connective tissue; a flattened, irregularly branched cell with a large oval nucleus that is responsible in part for the production and remodeling of the extracellular matrix. Fibrosis: a fibrous change of the mucous membrane, especially the gingiva, as a result of chronic inflammation; fibrotic gingiva may appear outwardly healthy, thus masking underlying disease. Hemidesmosome: half of a desmosome that forms a site of attachment between junctional epithelial cells and the tooth surface. Hyperkeratosis: abnormal thickening of the keratin layer (stratum corneum) of the epithelium. Hyperplasia: abnormal increase in volume of a tissue or organ caused by formation and growth of new normal cells. Hypertrophy: increase in size of tissue or organ caused by an increase in size of its constituent cells. Keratinization: development of a horny layer of flattened epithelial cells containing keratin. Marker: identifier; symptoms or signs by which a particular condition can be recognized; for example, clinical and microbiologic markers are used to identify gingival and P.213 Page 1 of 31 11/2/2010 http://pt.wkhealth.com/pt/re/9780781763226/bookContentPane_frame.htm;jsessionid=MQ ...
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The part of the tooth above the at tached per i odontal t issues. I t can be considered the part of the
tooth where c l in ical t reatment procedures are appl ied (Figure 12-1 ) .
B. C l in ica l Root
The part of the tooth below the ba se of the gingival sulcus or per iodontal pocket . I t is the part of the
root to which per iodontal f ibers are at tached.
C. Anatomic Crown
The part of the tooth covered by ename l.
D. Anatom ic Root
The part of the tooth covered by cementum.
I I . Oral Mucos a
The l in ing of the oral cavi ty , the oral mucosa, is a mucous membrane composed of connect ive t issue
covered with st rat i f ied squamous epi thel ium. Ther e are three div is ions or categor ies of oral mucosa.
A . Mas t i cato r y Mucosa
1 . C ov er s t he gingiva and the hard palate , the areas used most dur ing the mast icat ion of food.
2 . Except fo r the f ree marg in o f the g ing iva , the mas t ica tory mucosa is f i rm ly a ttached to
under ly ing t issues.
3 . The ep i the l ial cover ing is genera l ly kera t in ized.
FIGURE 12-1 Clinical Crown. The part of the tooth that is above the attachedperiodontal tissue. Left, When the periodontal pocket depth is increased, the clinicalcrown extends to a position at which the clinical crown length is greater than the clinicalroot length. The clinical root is that part of the tooth with attached periodontal tissues.Right, When the clinical attachment level is at the cementoenamel junction, the clinicalcrown and the anatomic crown are the same.
1 . C ov er s t he inner surfaces of the l ips and cheeks, the f loor of the mouth, the under s ide of the
tongue, the sof t palate, and the alveolar mucosa .
2 . These tissues are not f i rm ly a t tached to under ly ing t issue.
3 . The epi the l ia l covering is no t genera l ly kerat in ized.
C. Spec ia l ized Mucosa
1 . C ov er s t he dorsum (upper sur face) of the tongue . I t is composed of many papi l lae; some
contain taste buds.
2 . The d is tr ibu t ion o f the four t ypes o f pap i l lae is shown in F igure 12-2 .
a. Fi l i form. Threadl ike kerat in ized elevat ions that cover the dorsal sur face of the tongue;
they are the most numerous of the papi l lae.
b. Fungiform. Mushroom-shaped papi l lae interspersed among the f i l i form papi l lae on thet ip and s ides of the tongue. On c l in ical examinat ion they appear redder than the f i l i form
papi l lae and contain
var iable numbers of taste buds. The inset en largement in Figure 12-2 shows the
comparat ive shape and s ize of the f i l i form and fungiform papi l lae.
c. Circumval late (val late) . The 10 to 14 large round papi l lae arranged in a “V” between the
body of the tongue and the base. Taste b uds l ine the wal ls .
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FIGURE 12-2 Papillae of the Tongue. Dorsal surface of a human tongueshows the four types of papillae. Inset enlargement shows the shape offiliform and fungiform papillae.
A p i c al f i b er s . From the root apex to adjacent surrounding bone to res is t ver t ical forces.
O b l i q u e f i b e r s . From the root above the apical f ibers obl iquely toward the occlusal to res is t
ver t ical and unexpected st rong forces.
Hor i zon t a l f i be r s . From the cementum in the mi ddle of each root to adjacent alveolar bone to
resis t t ipping of the tooth.
A l v eo l ar c r es t f i b er s . From the alveolar crest to the cementum just below the cementoenamel
junct ion to res is t int rus ive forces.
FIGURE 12-3 Gingival Fiber Groups. Cross section of the gingiva shows the relation ofthe gingival fiber groups to the gingival sulcus, the free gingiva, the cementum, and thealveolar bone.
I n t e r rad i cu la r f i be r s . From cementum between the roots of mult i rooted teeth to the adjacent
bone to res is t ver t ical and lateral forces.
C. Cementum
The cementum is a th in la yer of calc i f ied connect ive t issue that covers the tooth f rom the
cementoenamel junct ion to, and around, the apical foramen.
1. Funct ions
To seal the tubules of the root dent in.
To provide at tachment for the per iodontal f iber groups.
2. Character is t ics
Thickness is 50 to 200 µm ab out the apex; 30 to 60 µm about the cerv ical area.
Vascular and nerve connect ions are miss ing; therefore, cementum is insensi t ive.
Relat ionship of enamel and cementum at the cerv ical area is shown in Figure 14-2 (page 257).
D. Alveol ar Bone
The alveolar bone consists of the la mina dura, which surrounds the tooth socket , and the
support ing bone.
When teeth are lost , the alveolar bone is resorbed.
The bone funct ions to support the teeth and provide at tachment for the per iodontal l igam ent
f ibers.
E. Gingi va
The part of the mast icatory mucosa that surround s the necks of the teeth and is at tached to the
teeth and the alveolar bone.
The Gingi va and Related Struc tures
The gingiva is made up of the f ree gingiva , the at tached gingiva , and the interdental gingiva or
interdental papi l la.
I . Free Gingi va (Margin al Gingi va)
In health, the f ree gingiva is c losely adapted around each tooth. I t connects with the at tached
gingiva at the f ree gingival groove and at taches to the tooth at the coronal por t ion of the junct ional
FIGURE 12-4 Principal Fiber Groups of the Periodontium. The five principalgroups (apical, oblique, horizontal, alveolar crest, and interradicular) are shown.The transseptal fibers of the gingival fiber groups are also shown as they spanacross from the cervical area of one tooth to the neighboring tooth.
The f ree gingival groove is a shal low l inear groove that demarcates the f ree f rom the at tached
gingiva. General ly , about one-third of the teeth show a v is ib le gingival groove when the
gingiva is healthy.2
In the absence of inf lammat ion and pocket format ion, the gingival groove runs somewhat
paral le l wi th and about 0.5 to 1.5 mm f rom the gingival margin,3 and i t is approximately at the
level of the bot tom of the gingi val sulcus.
B. Oral Ep i the l ium (outer g ing iva l ep i the l ium, Figure 12-6)
Covers the f ree gingiva f rom the gingival groove over the gingival margin.
Composed of kerat in ized st rat i f ied squamous epi thel ium.
FIGURE 12-5 Parts of the Gingiva. Cross-sectional diagram shows the parts of thegingiva and adjacent tissues of a partially erupted tooth. Note that the junctionalepithelium is on the enamel.
C. Gingiv al Margi n (g ingi val c res t , margin of th e g ingiv a, or f reemargin, Figure 12-5)
This is the edge of the gingi va nearest the inc isal or occlusal sur face.
Marks the opening of the gingival sulcus.
I I. Gingiv al Sulcu s (Crevice)
A . Locat ion
The crevice or groove between the f ree gi ngiva and the tooth.
B. Bound ar ies (Figure 12-6)
1. Inner. Tooth sur face. May be the enamel, cem entum, or par t of each, depending on the
posi t ion of the junct ional epi thel ium.
2. Outer. Sulcular epi thel ium.
3. Base. Coronal margin of the at tached t issues. The base of the sulcus or pocket is a lso cal led
FIGURE 12-6 The Gingival Tissues. Cross-sectional diagram shows the histologicrelationships of the oral, sulcular, and junctional epithelia and the connectivetissue.
the “probing depth, ” the “depth of the sulcus, ” or the “bot tom of the pocket . ”
C. Sulcular Epi thel ium
The cont inuat ion of the oral epi thel ium cover ing the f ree gingiva. Sulcular epi thel ium is not
kerat in ized.
D. Depth of Sulcu s
Healthy sulc i are shal low and may be only 0.5 mm.
The average depth of the healthy sul cus is about 1.8 mm.4
E. Ging iva l Su lcus F lu id (su lcu la r f lu i d , c rev icu la r f lu id )
A serum-l ike fl u id that seeps f ro m the connect ive t issu e through the epi th e l ia l l in ing of the
sulcus or pocket .
Occurrence is s l ight to none in a n ormal sulcus; increases with inf lammat ion. I t i s par t of the
local defense mechanism and is abl e to t ransport many substances, inc luding endotoxins,enzymes, ant ibodies, and certain systemical ly administered drugs.
I II . Junc t ion al Epi th el ium (At tachment Epi thel iu m)
A . Desc r ip t i on
The junct ional epi thel ium is a cuf f - l ike band of s t rat i f ied squamous epi thel ium that is
FIGURE 12-7 Tooth Eruption and the Gingiva. (A) Before eruption, the oralepithelium covers the tooth. (B) As the tooth emerges, the reduced epithelium joins the oral epithelium as the gingival sulcus is formed. (C) Partial eruption withthe junctional epithelium along the enamel. (D) Eruption complete, with junctionalepithelium at the cementoenamel junction. (E) From disease or other cause, theattachment migrates along the root surface, exposing the cementum.
An interproximal area is also cal led an embrasure. In Type 1 embrasure the gingi val t issue
f i l ls the area; in Type 2 embrasure there is s l ight to moderate recession of the interdental
gingiva; in Type 3 embrasure there is extensive recession or complete loss of the o f the
papi l la as shown in Figure 26-1 (page 431).
B. Shape
1. Varies With Spacing or Over lapping of the Teeth. The interdental g ingiva may be f lat or
saddle-shaped when wide spaces are between the teeth, or i t may be tapered and narrow
when the teeth are crowded or over lapped.
2. Between Anter ior Teeth . Pointed, pyramidal .
3. Between Poster ior Teeth
Flat ter than anter ior papi l lae because o f wider teeth, wider contact areas, and f lat tened
interdental bone.
Two papi l lae, one fac ial and one l ingual, connected by a col , are found when teeth are
in contact .
C. Col
1. A co l is the depress ion between the l ingua l o r pa la ta l and facia l pap i l lae tha t conforms to the
proximal contact area (Figure 12-8 ) .
2 . The center o f the co l a rea is no t usua l ly kera t in ized and thus is more suscept ib le to in fec t ion .
Most per iodontal infect ion begins in the col area.
FIGURE 12-8 Col. A col is the depression between the lingual or palatal and the facialpapillae under the contact area. The contact area is represented by the striped lines. (A)Mesial of mandibular molar to show wide col area. (B) Mesial of mandibular incisor toshow a narrow col. The col deepens when gingival enlargement occurs.
Descr ipt ion. A f renum is a narrow fold o f mucous membrane that passes f rom a m ore f ixed to
a movable part , for example, f rom the at tached gingiva at the mucogingival j unct ion to the l ip,
cheek, or undersurface of the tongue. A f renum serves to check undue movement .
Locat ions
a . Max i l lary and mandibu lar an ter io r f rena. A t m id l ines between cent ral inc isors . F igure
12-9 shows diagrammat ical ly the locat ion of the anter ior f rena.
b . L ingual f renum. From undersurface o f the tongue.
c . Buccal f rena. In the can ine–premolar areas , both max i l la ry and mandibular .
At tachme nt of Frena in Rela ti on to the At tach ed Gingiva
a . C lose ly assoc ia ted w i th the mucog ing iva l junc t ion .
b . When the a ttached g ing iva is narrow or m iss ing, the f rena may pu l l on the f ree g ing ivaand displace i t lateral ly . A “ tension test ” is used to locate f renal at tachments and check
the adequacy of the at tached gingiva (page 239).
The Recogn i t i on of Gingiv al and Per iod ontal Infect ion s
I . The Cl in ical Examinat io n
The recognit ion of normal gingiva, g ingival infect ions, and deeper per iodontal involvement depends
on a disc ipl ined, s tep-by-step examinat ion.
I t is necessary to know the extent of the disease. Gingival infect ions are conf ined to the gingiva,
whereas per iodontal infect ions inc lude al l par ts of the per iodont ium, namely, the gingiva,
per iodontal l igament , bone, and cementum.
FIGURE 12-9 Parts of the Gingiva. The mucogingival junction for each archis shown in relation to the attached gingiva, alveolar mucosa, and labialanterior frena.
b. Spaced tee th (w i th d ias temata) . In terdenta l g ing iva is f la t o r saddle shaped.
B. Changes in Disease
1. Free Gingiva. Rounded or ro l led.
2. Papi l lae. B lunted, f lat tened, bulbous, cratered (Figure 12-10 ) .
3. Festoon (“McCal l 's festoon”) . An enlargement of the marginal g ingiva with the format ion of a
l i fesaver- l ike gingival prominence. Frequent ly , the total g ingiva is very narrow, with
associated apparent recession, as shown in Figure 12 -10D.
4. Clef ts
a . “ St i ll m an 's cl e ft ” (Figure 12-11 ) . A local ized recession may be V-shaped , apostrophe-
shaped, or form a s l i t l ike indentat ion. I t may extend several mi l l imeters toward the
mucogingival junct ion or even to or through the junct ion.
b . F loss c lef t . A c le ft c reated by incor rec t f loss pos i t ioning appears as a ver t ica l l inear or
V-shaped f issure in the marginal g i ngiva.6 I t usual ly occurs at one s ide of an i nterdentalpapi l la. The in jury can develop when dental f loss is curved repeatedly in an incomplete
“C” around the l ine angle so the f loss is pressed across the gingiva.
2. Hyperkeratosis. May resul t in a leathery, hard , or nodular sur face.
3. Chronic Disease. Tissue may be hard and f ibrot ic , wi th a normal pink color and normal or
deep st ippl ing.
VI. Posi t ion
The actual posi t ion of the gingiva is the level of the at tached per iodontal t issue. I t is not d irect ly
v is ib le but can be determined by probing.
The apparent posi t ion of the gingiva is the level of the gingival margin or crest of the f ree gingiva
that is seen by direct observat ion.
A . Signs o f Heal thFor the fu l ly erupted tooth in an adult , the apparent posi t ion of the gi ngival margin is normal ly at the
level of , or s l ight ly below, the enamel contour or prominence of the cerv ical th ird of a tooth.
FIGURE 12-11 Gingival Clefts. (A) V-shaped Stillman's cleft. (B) Slit-like Stillman'sclefts of varying degrees of severity in relation to the mucogingival junction.
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FIGURE 12-12 Gingival Recession. Left, Clinically visible recession of the gingivalmargin with root surface apparent to the eye. Right, The actual recession exposesthe root surface as the periodontal attachment migrates along the root surface.
1. Effect of Gingival Enlargement . When the gingiva enlarges, the gingival margin may be highon the enamel, par t ly or near ly cover ing the anatomic crown.
2. Effect of Gingival Recession
a . Def in it ion . Recess ion is the exposure o f roo t surface that resu l ts f rom the ap ica l
migrat ion of the junct ional epi thel ium (Figure 12-12 ) .
b . Ac tual recession. The ac tua l recess ion is shown by the pos i tion o f the a t tachment leve l .
The “receded area” is f rom the cementoenam el junct ion to the at tachment .
c . V is ib le recess ion. The v is ib le recession is the exposed root sur face tha t is v is ible on
cl in ical examinat ion. I t is seen f rom the gingival margin to the cementoenamel junct ion.
d . L oc al i ze d r ec es si on (Figure 12-13 ) . A local ized recession may be narrow or wide, deep
or shal low. The root sur face is denud ed, and the v is ib le recession may extend to or
through the mucogingival junct ion.
e . Measurement . Both ac tual and v is ib le recess ion can be measured w i th a probe f rom the
cementoenamel junct ion. Total recession is the actual and v is ib le posi t ions added
together.
VII. Bleeding
A . Signs o f Heal th
1 . No b leed ing s pont aneous l y o r on p rob ing .
2 . Heal t hy t i ss ue does no t b leed.
B. Changes in Disease
1. B leed ing occurs spontaneous ly or when probed.
2 . S u lc u la r ep i the l ium becom es d i s eas ed pocket epi thel ium. The ulcerated pocket wal l b leeds
FIGURE 12-13 Localized Recession. A single tooth may show narrow or wide, deep orshallow recession. (A) Wide, shallow. (B) Wide, deep, with narrow attached gingiva. (C)Narrow, deep, with missing attached gingiva.
examinat ion she was pleased with Br i ta in 's thoroughness. The inst ructor provided posi t ive
feedback and quick ly moved on to the ne xt pair of s tudents. Br i ta in began to feel uneasy that
she hadn't pointed out the ging ival t issues that she thought were possibly inf lamed.
Q u es t i o n s f o r C o n s id e ra t i o n
1. Exp la in how the e th ica l p r inc iples o f au tonomy, benef icence, and verac i t y apply to th is
s i tuat ion.
2 . Ind icate how Nicholas is the center o f th is di lemma both f rom the perspec t ive o f Br i ta in , a
student , and the c l in ical inst ructor who f inds ou t f rom another facul ty member that he or
she thinks Nicholas has def in i te s igns of per iodontal d isease.
3 . E th ica l ly , what a l te rnat ives or ac t ions can Br i ta in take a t th is t ime to address the “uneasy”
feel ing she has about Nicholas ' g ingival s tatus?
B. Mixed Dent i t ion
Constant s tate of change related to exfol iat ion and erupt ion.
Free gingiva may appear rol led or rounded, s l ight ly reddened, shiny, and with a lack of
f i rmness.
The gingiva covers a vary ing p ort ion of the anatomic crown, depending o n the stage of
erupt ion (Figure 12-7) .
I I . Changes in Disease
Examinat ion of the per iodontal t issues of a chi ld is not d i f ferent f rom that o f an adult . A complete
examinat ion is necessary, inc luding probing around each tooth.
Gingiv i t is occurs f requent ly in chi ldren but is usual ly revers ible without leaving permanent damage.
Al though relati vely rare, per iodont i t is can occur in pr imary denti ti on.
Mucogingival problems occur in chi ldren.9 ,10 The recognit ion of def ic iencies of at tached gingiva has
part icular s igni f icance for the chi ld who wi l l need or thodont ic t reatment .
The Gingi va af ter Per iodon tal Surgery
The character is t ics of “normal healthy gingiva” take on di f ferent d imensions for the pat ient who has
completed t reatment for pockets, bone loss, and other s i gns of a per iodontal infect ion. The
juncti onal epi th el ium is apica l to the cementoenamel junct ion. Aft er he al ing, th e sulcus
depths may be with in normal range and no bleeding occurs when probed.
Depending on the exact t reatment performed, examinat ion shows changes f rom the in i t ia levaluat ion. For example, where the in i t ia l examinat ion showed a def ic iency of at tached gingiva with
f renal pul l , mucogingival surgery may have been designed and t reatment sat is factor i ly completed to
create new at tached gingiva. With each maintenance appointment , a thorough, careful examinat ion
is necessary to control factors that may permit recurrence of d isease.
The signif icance of bleeding; healthy t issue does not bleed.
Relat ionship of f indings during a gingival examinat ion to the personal dai ly care
procedures for infect ion control.
The special at tent ion needed for an area of gingival recession to prevent abrasion,
inf lammation, and further involvement.
How the method of brushing, st i f fness of toothbrush f i laments, abrasiveness of adent i f r ice, and pressure appl ied during brushing can be factors in gingival recession.
References
1. Av er y , J .K . and Steele, P.F. : Essent ials of Oral Histology and Embryology: A Cl in i cal
Approach. St . Louis, Mosby, 1992, pp. 131–134.
2. A i n am o , J . and Löe, H. : Anatomical Character is t ics of Gingiva: A Cl in ical and Microscopic
Study of the Free and At tached Gingiva, J. Per iodontol . , 37 , 5, January–February, 1966.
3. Orban , B . : Cl in ical and Histologic Study of the Surface C haracter is t ics of the Gingiva, Oral