Introduction
The gingival exam is an aspect of the head and neck regional examination, which is a critical component of oral health care. This section will describe the gingival structures, their normal clinical appearances, disease processes that may involve the gingiva, the components of a gingival exam, and present a patient with a disease involving the gingiva.
The patient in this case has lichen planus (LP). LP is an immune‐mediated disorder that can manifest in the oral cavity. Patients may be asymptomatic, have mild to moderate discomfort, or complain of intense pain. This disease has a predilection for middle‐aged females, but can be seen in any segment of the population. The clinical findings in the oral cavity may include white striations, white plaques, erythematous erosions, and ulcerations anywhere on the oral soft tissues, with the buccal mucosa and the gingiva being among the most common sites (Neville et al. 2015). The diagnosis is established by combining clinical findings with histopathological examination of biopsied tissue. It is important for the oral health‐care practitioner to be familiar with LP as it can clinically mimic several other oral diseases, but requires specific management. Cases of malignant transformation to oral squamous cell carcinoma are documented in the scientific literature, further necessitating knowledge of this disease entity (Cheng et al. 2016).
Medical History
Celiac disease, managed by a gluten‐free diet.
Medications
Denies.
Review of Systems
All systems within normal limits.
Social History
Ten cigarettes per day for 10 years (five‐pack/year smoking history).
Dental History
Regular restorative dental work.
Moderate‐to‐severe chronic periodontitis.
Poor oral hygiene.
Regional Head and Neck Exam
Extraoral Exam
No palpable nodules, asymmetry, or other grossly visible signs of pathology are identified in the head and neck or craniofacial region. The examination is negative for clinically detectible cervical lymphadenopathy.
Intraoral Exam
Soft Tissue
Multiple erosions on the bilateral facial and buccal aspects of the maxillary and mandibular gingiva ranging from 0.1 × 0.1 cm to 0.3 × 0.3 cm (see Figures 1.5.1–1.5.3).
Multiple white striated plaques on the bilateral facial and buccal aspects of the maxillary and mandibular gingiva ranging from 0.1 × 0.1 cm to 0.5 × 1.5 cm (see Figures 1.5.1–1.5.3).
All other oral mucosal surfaces appear healthy with no visible signs of inflammation, infection, neoplasia, or other pathology.
Hard Tissue
Multiple occlusal restorations.
Moderate plaque and calculus accumulation.
Examination Findings and Problem List
- Multiple erosions of the gingiva.
- Multiple white striated plaques on the gingiva.
- Sensitivity to spicy and acidic foods.
- Tobacco use.
- Poor oral hygiene.
Differential Diagnosis
Based on the clinical examination, patient symptoms and history, the following entities were considered as possible diagnoses:
- LP
- Epithelial dysplasia
- Squamous cell carcinoma
The color and surface texture support any of the three entities mentioned. The long history of tobacco use places the patient at an elevated risk for epithelial dysplasia and squamous cell carcinoma. The generalized involvement (bilaterality, maxillary, and mandibular locations of lesions) favored a diagnosis of oral LP.
Arrival at a definitive diagnosis required a tissue biopsy to be performed.
Treatment
Written and oral consent were obtained to biopsy the patient’s gingiva. A biopsy of the gingiva adjacent to tooth #14 was performed under local anesthetic. Hemostasis was achieved within five minutes by applying local pressure with wet gauze. The specimen was submitted to an oral and maxillofacial pathology service for histopathological review.
Histopathological Description
The histopatholgical section (see Figure 1.5.4) showed a stratified squamous epithelial layer exhibiting hyperparakeratosis, saw‐toothing of the rete ridges, lymphocytic infiltration, and degeneration of the basal layer. The underlying connective tissue demonstrated a band‐like infiltrate of lymphocytic cells in the lamina propria. These features are characteristic of LP.
Figure 1.5.4: Histopathology of biopsied specimen demonstrating hyperparakeratosis, lymphocytic infiltration of the epithelium, degeneration of the basal layer, saw‐toothing of the rete ridges and a band‐like infiltrate of lymphocytes.
Definitive Diagnosis
Lichen planus.
Clinical Management
The patient was contacted and the diagnosis was disclosed and explained. A prescription was written for a 30‐g tube 0.05% fluocinonide gel (topical cortical steroid) to be applied to the affected areas three times per day. Smoking cessation counseling was provided. A follow‐up appointment was made to evaluate therapy and observe disease activity at four weeks.
Discussion
The gingiva is defined as the portion of the oral mucosa that covers the alveolar bone and the cervical aspects of the teeth. It is divided into three distinct anatomic regions: the marginal gingiva, the attached gingiva, and the interdental gingiva. The marginal gingiva is the terminal end of soft tissue at the tooth and forms a collar around it. The terminating position of the marginal gingiva is at the cementoenamel junction of the tooth in health. The gingival sulcus is the shallow space between the tooth and the marginal gingiva. The attached gingiva extends from the marginal gingiva to the mucogingival junction and is tightly bound to the underlying alveolar bone. The interdental gingiva is comprised of the mucosa occupying the embrasure space between adjacent teeth (Newman et al. 2012).
Healthy gingiva is of a firm consistency upon palpation. The surface texture of the attached gingiva bears multiple small depressions. This characteristic is termed stippling and is similar to the peel of an orange. Stippling is best viewed by drying the gingiva (Newman et al. 2012). A “salmon‐pink color” has often been included in the classical description of a healthy gingiva. In actuality the color of the gingiva in health can vary significantly from individual to individual. This variation depends on several factors. For instance, patients with darker skin often have a darker hue to their gingiva, or may have areas of scattered hyperpigmentation, known as physiologic or racial pigmentation (Neville et al. 2015).
The list of diseases that may involve the gingiva is extensive. The general categories include reactive, inflammatory and immune‐mediated, infectious, nutritional and metabolic, and neoplastic (benign and malignant). Please see Table 1.5.1 for examples of these categories of disorders.
Table 1.5.1: Examples of disease processes involving the gingiva.
| Category | Disease | Etiology | Clinical Features | Clinical Management |
| Reactive | Frictional hyperkeratosis | Repetitive mechanical habit | Homogenous white patch |
|
| Hematoma | Trauma and subsequent extravasation of blood under mucosa | Dark red to purple, fluctuant nodule |
|
|
| Inflammatory and Immune‐Mediated | Plaque –induced gingivitis |
|
Erythematous, swollen tissue with absence of stippling |
|
| Pyogenic Granuloma | Local reaction to accumulation of plaque and calculus | Pedunculated or sessile, nodule; color may be that of mucosa or more erythematous with or without ulceration |
|
|
| Peripheral Ossifying Fibroma | Local reaction to accumulation of plaque and calculus | Pedunculated or sessile, nodule; color may be that of mucosa or more erythematous with or without ulceration |
|
|
| Peripheral Giant Cell Granuloma | Local reaction to accumulation of plaque and calculus | Pedunculated or sessile, nodule; color may be that of mucosa or more erythematous with or without ulceration and occasionally exhibit a purple hue |
|
|
| Fibroma | Trauma | Pedunculated or sessile, nodule; color may be that of mucosa, paler or more erythematous with or without ulceration | ||
| Lichen Planus |
|
White striations, erythema, erosions and ulcerations |
|
|
| Mucous Membrane Pemphigoid | Autoantibodies directed at components of the basement membrane‐epithelial junction | Erythema, erosions and ulcerations with occasional identification of bullae |
|
|
| Infectious | Primary Herpetic Gingivostomatitis | Infection by herpes simplex virus | Erythema, edema, absence of stippling, purulence from the gingival sulcus and occasional vesicle formation (frequently accompanied by malaise, fever and lymphadenopathy) |
|
| Nutritional | Ascorbic Gingivitis (Scurvy) | Vitamin C deficiency | Swelling, ulceration and hemorrhage |
|
| Neoplastic‐ Benign | Peripheral odontogenic tumors (e.g., peripheral ameloblastoma, peripheral odontoma, peripheral odontogenic fibroma) | Genetic mutations in some cases and unknown etiology in others | Mucosa‐colored, smooth surfaced nodule |
|
| Neoplasti‐ Premalignant | Epithelial Dysplasia | Genetic mutations in epithelial cells | Leukoplakia, erythroleukoplakia, erythroplakia |
|
| Neoplastic‐ Malignant | Squamous Cell Carcinoma | Genetic mutations in epithelial cells | Leukoplakia, erythroleukoplakia, erythroplakia, ulcerations and ulcerative masses |
|
| Lymphoma | Genetic mutations in lymphocytic cells | Mucosa‐colored or erythematous broad based mass, often compressible |
|
|
| Leukemia | Genetic mutations in white blood cells | Generalized enlargement or broad based mass with compressible consistency and a range of color from that of mucosa to erythematous to dark green; may bleed with minimal provocation |
|
|
| Melanoma | Genetic mutations in melanocytic cells | Darkly pigmented nodule or mass that may exhibit ulceration |
|
|
| Metastatic Tumor | Genetic mutations in primary tumor | Often an ulcerative mass; great variety of appearance that may fit description of any of the above |
|
Many gingival diseases include a degree of inflammation. Inflammation of the gingiva is termed gingivitis. It is characterized by bright erythema (redness), swelling and loss of stippling. The swelling may be edematous or fibrotic. Inflamed gingival tissues may bleed with minimal provocation (e.g., palpation, brushing). Hence, in disease the clinical appearance of the gingival tissues change from those associated with health. Forms of gingivitis include plaque‐related, necrotizing ulcerative gingivitis, medication‐influenced, allergic, specific infection related, and dermatosis‐related gingivitis. There are also several systemic factors that are associated with gingivitis, including hormonal changes, stress, poor nutrition, and substance abuse (Neville et al. 2015).
Examination of the gingiva should be performed in a systematic, thorough, and repeatable manner. Attention must be paid to any changes in color, surface architecture, size, position of the gingiva on the teeth, or any other abnormality. Please see Table 1.5.2 for a suggested stepwise methodology in performing a gingival exam.
Table 1.5.2: Suggested stepwise methodology for performing a gingival exam.
| Step | Instruction |
| 1 | Retract the right buccal mucosa to allow visualization of the facial aspect of the upper right quadrant (URQ) |
| 2 | Beginning from the distal aspect of the most distal tooth, run the tip of your second digit along the surface of the gingiva applying moderate pressure |
| 3 | Dry the gingiva of the facial aspect of the upper right quadrant (URQ) with an air syringe or cotton tip applicator |
| 4 | Beginning from the distal aspect of the most distal tooth visualize the facial gingival surface; follow the above steps for the facial aspect of the upper left quadrant (ULQ) |
| 5 | Complete the above steps for the palatal surface of the ULQ and URQ, using indirect vision with a dental mirror as necessary; complete the above steps for the mandibular arch, retracting the tongue as necessary |
| 6 | Write a detailed description of any abnormalities in the patient chart and depict on a diagram if available |
Reviewing Figures 1.5.1–1.5.3 and applying the steps of the gingival exam in Table 1.5.2 to the patient in this case, one can rapidly identify features in this patient not associated with gingival health. These would include the atypical white striations, deeply erythematous areas of erosion, and an absence of stippling. Furthermore, application of moderate pressure through digital palpation would induce bleeding. Once these features are noted, the clinician would formulate a differential diagnosis and recommend biopsy. As noted above, the definitive diagnosis was LP based on the clinical and histopathological data.
Oral LP has an estimated worldwide prevalence of 2.2% (Cheng et al. 2016) with a 3:2 female‐to‐male ratio with most cases occurring in middle‐aged patients. The disease is considered to be an immune disorder with damage to the tissues primarily mediated by T lymphocytes (Kurago 2016).
The disease can take many forms in the oral cavity including white striations, white plaques, erythematous erosions, and ulcerations. Any surface of the oral mucosa may be involved in the disease process. Common locations include the buccal mucosa, gingiva, lateral tongue, palate, and labial mucosa and vermilion (Neville et al. 2015). Patients occasionally present with oral and cutaneous lesions. While LP may be completely asymptomatic, common symptoms include mild sensitivity to spicy or acidic foods. Certain patients may even report intense pain with minimal tissue manipulation.
Several diseases may have a similar clinical appearance to oral LP. Diseases that mimic oral LP include plaque‐induced gingivitis, lupus, epithelial dysplasia, mucous membrane pemphigoid, and pemphigus vulgaris (Cheng et al. 2016). A definitive diagnosis is made based on histopathological review of biopsied material.
Oral LP is an immune‐mediated disorder, therefore plaque control and attention to oral hygiene alone is not sufficient to manage the disease process. Several treatments are available, the most common of which include cortical steroid derivatives. While medications can help to manage the disease, and some patients experience spontaneous resolution, there is no known cure for oral LP.
There are several documented cases in the scientific literature of oral LP transforming to oral squamous cell carcinoma. Therefore it is imperative that oral health‐care providers become familiar with the clinical findings of this disease in order to make appropriate referrals to ensure adequate patient management and follow‐up.
Take‐Home Hints
- Develop a systematic approach to examining the gingiva.
- The list of diseases that can involve the gingiva is extensive and ranges from minimally symptomatic to life threatening.
- LP has several clinical manifestations and may appear similar to other oral diseases.
- Patients with LP must receive timely referrals to ensure appropriate clinical management of disease and long‐term follow‐up.
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