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GINGIVA IN HEALTH AND DISEASE

BY- ANUBHUTI SABHLOK ORAL MUCOSA NON KERATINIZED MUCOSAKERATINIZED MUCOSA MASTICATORY MUCOSALINING MUCOSA SPECIALIZED MUCOSA The oral mucosa consist of the following three zones:1)The gingiva and the covering of the hard palate, termed the masticatory mucosa.2)The oral mucosa membrane lining the remainder of the oral cavity is covered by lining mucosa.3)The dorsum of the tongue, covered by specialized mucosa.

GINGIVA DEFINITION It is the part of oral mucosa that covers the alveolar processes of the jaws & surrounds the neck of the teeth. Anatomically

MARGINAL GINGIVAThe marginal or unattached gingiva surrounds the teeth in collar like fashion. It is demarcated from the adjacent attached gingiva by a shallow linear depression, the free gingival groove .It may be separated from the tooth surface with a periodontal probe.

ATTACHED GINGIVA

The attached gingiva is continuous with the marginal gingiva.It is firm, resilient and tightly bound to the underlying periosteum of alveolar bone.The attached gingiva extends to loose and movable alveolar mucosa and is demarcated by the mucogingival junction.

The width of the attached gingiva differsIt is generally greatest in the incisor region (3.5 to 4.5 mm in maxilla, 3.3 to 3.9 mm in mandible) narrower in the posterior segments(1.9mm in maxillary and 1.8mm in mandibular 1st premolar) The demarcation (mucogingival line) (arrows) between the attached gingiva and the alveolar mucosa.

INTERDENTAL GINGIVA The interdental gingiva occupies the gingival embrasure, which is the interproximal space beneath the area of tooth contact. In a three dimensional view the interdental papilla. -in the anterior teeth is pyramidal. -in the posterior teeth is tent shaped, in this the oral and vestibular corners are high, whereas the central part is like a valley and this central area fits below the contact point and is called the COL.Col and pyramidal interdental gingiva

GINGIVAL SULCUS The gingival sulcus is the shallow crevice or space around the tooth bounded by the surface of the tooth on one side and the epithelium lining the free margin of the gingiva on the other side.

Under absolutely normal or ideal condition, the depth of the gingival sulcus is 0mm.

The so-called probing depth of a clinically normal gingival sulcus in humans is 2 to 3mm.

MICROSCOPIC FEATURES The gingiva is composed of (a) Epithelium (b) Connective tissue.

The gingival epithelium consist of a continuous lining of stratified squamous epithelium and the three different areas-

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ORAL (OUTER) EPITHELIUM.

The oral or outer epithelium covers the crest and outer surface of the marginal gingiva and the surface of the attached gingiva. The oral epithelium is 0.2 to 0.3 mm in thinkness. It is keratinized or parakeratinized. Oral epithelium is composed of four layers: 1)Stratum basale (basal layer)2)Stratum spinosum ( prickle cell layer)3) Stratum granulosum ( granular layer)4)Stratum corneum (cornified layer)

Three types of epithelial surface layers are :-Keratinized- in this the superficial cells form keratin and lose their nuclei -statum granulosum is present. Parakeratinized-in this the superficial cells retain pyknotic nuclei and show some sign of being keratinized . - statum granulosum is absent.Nonkeratinized-in this the superficial cells are nucleated and show on sign of keatinization.

SULCULAR EPITHELIUM

The sulcular epithelium lines the gingival sulcus.It is a thin, non keratinized stratified squamous epithelium without rete pegs.It extends from the coronal limit of the junctional epithelium to the crest of the gingival margin.It acts as a semipermeable membrane through which injurious bacterial products pass into the gingival and tissue fluid from the gingiva seeps into the sulcus.

JUNCTIONAL EPITHELIUMIt joins the tooth on one side and to the oral epithelium on the other.The junctional epithelium consist of a collar like band of stratified non keratinizing epithelium .These cells can be grouped in 2 strata; (a)the basal layer facing the connective tissue (b)the suprabasal layer extending to the tooth surface. The length of the junctional epithelium ranges from 0.25 to 1.35mm. PMNs are found routinely in the junctional epithelium.

It is attached to the tooth by means of an internal basal lamina and to the gingival connective tissue by an external basal lamina The attachment of the junctional epithelium to the tooth is reinforced by the gingival fibers.For this reason, the junctional epithelium and the gingival fibers are considered a functional unit, referred to as the dentogingival unit.

The junctional epithelium exhibits several unique structural and functional features-(1) It is firmly attached to the tooth surface, forming an epithelium barrier against plaque bacteria. (2) It allow access of gingival fluid, inflammatory cells, and components of the immunologic host defense to the gingival margin. (3) Junctional epithelial cells exhibit rapid turnover , which contributes to the host- parasite equilibrium and rapid repair of damaged tissues.

GINGIVAL CONNECTIVE TISSUE The connective tissue of the gingival is known as the lamina propria.The major components of the gingival connective tissue are- collagen fibers (60%), fibroblasts ( 5%) , vessels, nerves, and matrix (35%). It consists of two layers (1) A papillary layer which consists of palliary projection between the epithelial rete pegs ( 2) A reticular layer contiguous with the periosteum of the alveolar bone. Lamina propria consists of cells, fibers, blood vessels embedded in amorphous ground substances.

1)CELLS- a)Fibroblast b)Mast cells c)Macrophages d)Inflammatory cells

2)FIBERS- a)Collagen Fibers b)Reticulin Fibers c)Oxytalan Fibers d)Elastin Fibers

The function of gingival fibres are as follows- a) It braces the marginal gingiva firmly against the tooth.b)It help to withstand the forces exerted by mastication.c)It unites the free gingiva with cementum of the root and the adjacent attached gingiva.The arrangement of gingival fibres are grouped into two-Principal group of fibresSecondary group of fibres

Principal group of fibres are-

Dentogingival fibersAlveolar gingival fibers.Dentoperiosteal fibers.Circular fibersTrans-septal fibers.

Fibers of the secondary group are-

Periosteogingival fibersInterpapillary fibersTransgingival fibersIntercircular fibersIntergingival fibersSemicircular fibersOxytalan fibersElastin fibers

Blood supply Three major sources of blood supply to the gingiva are-: 1 ) Supraperiosteal arterioles. 2) Vessel of the periodontal ligament.3) Arterioles emerging from the crest of the interdental septa.

Lymphatics Lymphatic drainage of the gingiva brings in the lymphatics of the connective tissues papillae. It progresses to the periosteum of the alveolar process and then to regional lymph nodes.Nerve supply Nerve supply to gingiva is derived from fibers arising from nerves in the periodontal ligament and from the labial, buccal & palatal nerves.

Gingival features In health In diseaseClinical changesDisease conditions colour

Coral pink

Varying shades of red, reddish blue ,deep blue.

Colour changes from bright red erythema -shiny slate gray-dull whitish gray

Black line following the contour of margin

Bluish red or deep blue linear pigmentation

Chronic gingivitis

ANUGHerpetic gingivostomatits

Bismuth,arsenic and mercury pigmentation

Lead pigmentation CHRONIC GINGIVITIS

Anug

BISMUTH GINGIVITIS

contourMarginal gingiva is scalloped & knife edged

Interdental papilla 1)anterior-pyramidal2)Posterior-tent shaped

Marginal gingiva becomes rolled and interdental papilla becomes blunt and flat

Punched out crater like depression

irregularly shaped denuded appearance

Exaggerated scalloping

Chronic gingivitis

ANUG

Chronic desquamative gingivitis

Gingival recession

Gingival recession

Consitency Firm and resilient (except free margins)Soggy puffiness that pits on pressure

Marked softens and friability

Firm leathery &Diffuse puffiness and softening

Sloughing: graying flake like particle of debris vesicle formation

Chronic gingivtis

Exudative

Fibrotic

Acute gingivitisSize Normal Increased Gingival enlagement

Position 1mm above the CEJApically placed

Coronally placed Gingival recession

Pseudo pocketsBleeding on probing absentPresnt i.e chronic recurrent spontanous bleeding or bleeding on slight provocationChronic gingivitis

ANUG

Systemic diseases

GINGIVAL ENLARGEMENT GINGIVAL RECESSION BLEEDING ON PROBING

Surface texture Stippling is present Loss of stippling Smooth & shinny

Firm & nodular

Peeling of surface

Leathery texture

Minutely nodular surface

Gingivitis

Exudative chronic gingivitis

Fibrotic chronic gingivitis

Chronic desquamative gingivitis

Hyperkeratosis

Non inflammatory gingival hyperpalsia

chronic Gingivitis

Showing loss of stippling THANK YOU