What are the symptoms and treatment options for gingivitis?

Gingivitis: Symptoms and Treatment

Symptoms of Gingivitis

Gingivitis presents with redness and swelling of the gums, accompanied by bleeding upon probing or brushing. 1

• Gingival bleeding is the hallmark sign, occurring spontaneously or during mechanical cleaning 1, 2
• Red, swollen gingival tissues with visible inflammation around the gum line 1, 2
• Exudation from the gingival sulcus may be present 2
• Plaque accumulation at or near the gingival sulcus is the underlying cause 3, 2

The condition is episodic, characterized by discontinuous bursts of acute inflammation, and most lesions are transient or persistent but not progressive 3. However, untreated gingivitis can progress to irreversible periodontitis in some cases 4, 5.

Treatment Algorithm

Step 1: Professional Mechanical Plaque Removal

The American Dental Association recommends professional mechanical plaque removal through scaling and root planing as the primary treatment. 6

• Thorough dental prophylaxis including scaling and polishing should be performed at baseline 6
• This removes existing plaque and calculus that cannot be eliminated by home care alone 6

Step 2: Daily Oral Hygiene Protocol

All patients should brush their teeth twice daily for at least 2 minutes with fluoridated toothpaste. 4

• Use a soft toothbrush after meals and before sleep, replacing it monthly 7
• Employ the Bass or modified Bass brushing technique 7
• Clean with a mild fluoride-containing, non-foaming toothpaste 7
• Rechargeable power toothbrushes provide small but statistically significant additional reductions in gingival inflammation and plaque 4

Step 3: Interdental Cleaning

Interdental brushes (IDBs) are the device of choice for interproximal plaque removal. 4

• Use once daily for patients with gingivitis 4
• Flossing should only be used at sites where interdental brushes will not pass through without trauma 4
• If not previously using interdental cleaners, do not initiate during active cancer therapy due to risk of epithelial barrier disruption 7

Step 4: Adjunctive Chemical Plaque Control

The American Dental Association recommends 0.2% chlorhexidine mouthwash used twice daily for 60 seconds to reduce plaque and gingival inflammation. 6, 1

• Wait 30 minutes after toothbrushing before using chlorhexidine to avoid inactivation by toothpaste ingredients 6
• Use 15 mL of alcohol-free mouthwash for approximately 1 minute, gargle, then spit out 7
• Rinse at least four times daily upon awakening and after brushing 7
• Avoid eating or drinking for 30 minutes after rinsing 7

Alternative Natural Product-Based Mouthwashes

For patients concerned about chlorhexidine side effects, natural alternatives show comparable efficacy: 6

• 0.1% turmeric mouthwash (10 mL twice daily for 21 days) 7, 6
• Triphala mouthwash (10 mL twice daily for 2 weeks) - cost-effective with no reported side effects 7, 6
• 0.25% green tea catechin or lemongrass oil mouthwash 7, 6
• 100% aloe vera mouthwash 6

These alternatives avoid the tooth staining, taste alteration, and increased calculus formation associated with prolonged chlorhexidine use 6.

Step 5: Reassessment

Reassessment of gingival health after 2-4 weeks is crucial for adjusting the treatment plan. 6

• Evaluate bleeding index, modified gingival index, and plaque scores 6
• Adjust treatment intensity based on response 6

When to Consider Antibiotics

Antibiotics are generally NOT recommended for routine gingivitis treatment. 6

• Only consider antibiotics if there is systemic involvement such as fever, malaise, or lymphadenopathy 6
• Amoxicillin is the first choice when antibiotics are necessary, with amoxicillin-clavulanic acid as a second option 6
• Antibiotics may be considered if the infection extends into facial spaces 6

Critical Pitfalls to Avoid

• Do not use antibiotics unnecessarily for routine gingivitis - this is the most common error 6
• Do not rinse with chlorhexidine immediately after brushing - wait 30 minutes to prevent inactivation 6
• Do not discontinue treatment prematurely before complete resolution of inflammation 6
• Do not use chronic vaseline/white paraffin on lips as this promotes mucosal dehydration and occlusion leading to secondary infection risk 7

Expected Timeline for Improvement

• Gingival bleeding and inflammation reduction can be observed as early as 2 weeks with stannous fluoride toothpaste 5
• Significant improvements in bleeding index (29-33% reduction) and plaque scores (15-16% reduction) occur by 3 weeks 5
• 71% of patients can achieve less than 10% bleeding sites (clinical periodontal health) after 24 weeks of proper treatment 8