Diagnosis of Gingivitis: State of the Art

Special Article - Gingivitis

J Dent & Oral Disord. 2016;2(3): 1017.

Diagnosis of Gingivitis: State of the Art

Grellmann AP* and Zanatta FB

Department of Stomatology, Dental School, Federal University of Santa Maria, Brazil

*Corresponding author: Grellmann AP, Department of Stomatology, Dental School, Federal University of Santa Maria, Brazil

Received: April 12, 2016; Accepted: May 16, 2016; Published: May 18, 2016


Gingivitis is a disease caused by accumulation of supragingival biofilm. Considering the fact that gingivitis always precedes periodontitis, the diagnosis of marginal inflammation allows monitoring the quality of at-home plaque control. Moreover, several inflammatory and/or autoimmune conditions are associated with oral mucosal manifestations. The aim of this review is to present, compare, and discuss the main methods for the diagnosis of gingivitis and autoimmune conditions associated with gingivitis. The autoimmune diseases may be diagnosed by various methods including histological examination, direct and indirect immune fluorescence microscopy, immunoblotting and quantitative immunoassay. Some gingival indices evaluate visual aspects and the presence of marginal bleeding after mechanical stimulation whereas other indices just evaluate visual aspects. In addition, some use only the extent, the length, or just the presence or absence of bleeding. Despite the fact that the collection and analysis of gingival crevicular fluid are suitable for scientific research, the diagnosis of gingivitis made by marginal bleeding is easier, faster, cheaper and, therefore, more widely applicable to routine clinical practice and epidemiological studies. The clinical diagnosis of gingivitis can thus be done by different methods. In the clinical setting, dichotomous scoring of bleeding seems to be simpler, faster, and less subjective. In the research setting, visual criteria associated with the presence of bleeding seem to more clearly detect small changes in gingival tissues, increasing the sensitivity of the selected method. The various gingival indices available share similarities and differences, but none of them is universally applied or accepted, and their selection depends on what will be evaluated.

Keywords: Inflammation; Diagnosis; Periodontics; Indice


GCF: Gingival crevicular fluid


Gingivitis is the first sign of imbalance in the periodontal health-disease process. Plaque-induced gingivitis is caused by the accumulation of supragingival plaque around the gingival margin and is triggered between 10 and 21 days according to inter individual differences [1]. Plaque control rebalances the health-disease process and promotes the restoration of gingival health between 7 and 10 days [1-4]. Gingivitis is confined to the tissues that protect the teeth and, while not causing irreversible damage, its presence is a prerequisite for the establishment of a subgingival biofilm, which eventually leads to periodontitis [5-8]. Advanced periodontitis and dental caries are the most common causes of tooth loss in adults [9,10]. In addition, they are associated with greater impacts on quality of life for causing halitosis, pathologic tooth migration, gingival recession, bleeding, among others [11]. Besides the fact that gingivitis precedes periodontitis, the diagnosis of gingival inflammation helps the dentist to monitor sites where plaque control should be improved, i.e., the presence or absence of gingivitis is directly related to the frequency of appropriate at-home care [1]. Therefore, the diagnosis, prevention, and treatment of gingivitis are needed.

Oral lesions may be the first and occasionally the only manifestation for a number of immune-mediated diseases that affect the skin and mucosal surfaces. Autoantibodies directed against structural compounds of the skin and oral mucosa and/or inflammatory infiltrates cause tissue damage. An accurate diagnosis can be reached by utilizing a number of diagnostic tools such as direct immunofluorescence microscopy of a perilesional biopsy and serological testing for circulating autoantibodies in conjunction with histopathological analysis. An early and precise diagnosis of autoimmune and inflammatory diseases with oral involvement is a prerequisite for their effective treatment. That being considered, the present review aims to present and discuss the different methods for the diagnosis of gingivitis described in the literature.

Literature Review

Epidemiological studies have shown a high prevalence of gingivitis and periodontitis in the general population [12, 13]. Among periodontal diseases, gingivitis is the most prevalent one, affecting almost 100% of individuals [14]. High rates of supragingival biofilm accumulation have also been observed, denoting failure in oral hygiene self-care, especially in the cleaning of proximal surfaces [15,16]. Consequently, gingivitis is quite frequent at these sites [17]. Visual signs (redness, swelling, and change in texture) and/or presence of marginal bleeding have been included as components of different indices used for the diagnosis of gingivitis [18-31]. Muhlemann& Son (1971) reported that a gingival index should be able to detect the earliest sign of gingivitis. However, there is still no consensus in the literature about the chronology of visual and inflammatory events in the pathophysiological course of gingivitis.

Diagnosis of gingivitis

Gingivitis can be diagnosed by various methods. Although histological evidence of inflammation is an accurate method to assess gingivitis, biopsies are impracticable. Therefore, a less invasive method is required [32]. The measurement of GCF has proven to play an important role in the assessment of gingivitis [33-36].

Categorical scores have been used by different indices. Such indices combine visual aspects and the presence of marginal bleeding after mechanical stimulus [26,27,29]. Other indices only evaluate visual aspects [25,31]. Also, some use only the extent of bleeding [23,28], bleeding time [19,30], or just the presence or absence of bleeding [18, 20-22, 24]. It is difficult to determine which criteria (GCF volume, visual signs, or gingival bleeding) best indicate the inflammatory condition of the gingiva given that some evidence has shown weak correlations between clinical criteria/gingival fluid and inflammatory status observed histologically [35,37-40]. Thus, comparisons between different diagnostic methods could be inaccurate.

According to Carter & Barnes (1974), a good index for evaluating gingivitis must have well-established validity in order to assess what actually needs to be assessed and enough sensitivity to detect slight changes. Moreover, its reproducibility by the same or different examiners is also crucial. Finally, an index should be simple to use, require few tools, and be as free as possible from subjective interpretation.

Several methods for stimulation of marginal bleeding have been used: periodontal probe [18,19,26,28-30], wooden interdental cleaner [21,27], dental floss [20], dental tape [22], toothbrush [23], and interdental brush [24]. Table 1 shows the main features of the indices used to date.

Citation:Grellmann AP and Zanatta FB. Diagnosis of Gingivitis: State of the Art. J Dent & Oral Disord. 2016; 2(3): 1017. ISSN:2572-7710