Is gingivitis really reversible?
Dr. Richard Nagelberg explains that how we think about gingivitis is hugely important. If we think of gingivitis as a non-reversible disease, patients are more likely to benefit from our efforts to educate them about the critical importance of biofilm reduction and professional monitoring.
By Richard H. Nagelberg, DDS
As dental providers we know that gingivitis is the early, reversible phase of periodontal disease. If it is not controlled, it can progress to full-blown perio disease. It is most commonly caused by inadequate biofilm control, with the remedy being improved home care. The standard of care for gingivitis does not include professional intervention.
But is gingivitis truly a reversible condition? There is a school of thought that gingivitis is not reversible but rather, similar to periodontitis, controllable. Periodontal disease is a chronic, non-curable bacterial infection, with the damage to perio tissue being caused by the body’s immuno-inflammatory response to the perio pathogens. When patients respond favorably to any treatment we provide, they are healed, not cured. When we stabilize periodontitis, bone resorption ceases, although the damage to the bone that has already happened does not repair. The bone is gone for good. The soft tissue responds by reductions in pocket depth, swelling, redness, bleeding, and bacterial levels. If the patients’ biofilm control efforts are inadequate and they fail to present for perio maintenance appointments every three months, the disease returns.
Gingivitis is also caused by the body’s response to bacteria, manifesting as redness, swelling, and bleeding gums, without pocketing or bone loss. Addressing gingivitis by providing prophylaxis, along with improved biofilm control, causes reductions in swelling, redness, and bleeding. Failure to continue effective home care and professional care will return the patient to gingivitis in a short period of time.
So what is the difference between gingivitis and its more serious sequelae, periodontitis? Is it merely one of degree? There are some important differences. Gingivitis can be caused by the body’s response to the early biofilm colonizing bacteria, not the later colonizing perio pathogenic bacteria. The early colonizers are less pathogenic. So is this a matter of degree as well? Another important difference is that periodontitis requires a lifetime of disease management in the form of perio maintenance intervals every three months. Gingivitis is managed by twice yearly prophys. Another matter merely of degree?
In what ways are the two diseases the similar? Both are bacterial infections with tissue damage being the result of the immuno-inflammatory response. Both respond to biofilm reduction and/or addressing the host response. Both conditions will return if biofilm control is inadequate and patients fail to present for their respective professional visits.
Progression of gingivitis to periodontitis is not automatic; it does not happen in every patient or in every site. So sometimes gingivitis stays as gingivitis, sometimes it improves and returns the patient to health, and sometimes it worsens and progresses to periodontitis. If it does not progress, does this mean it is a different disease state? Can gingivitis be an independent disease entity? Perhaps it is, since gingivitis does not automatically worsen in every patient.
The differences seem to be a matter of degree — most glaringly, attachment and bone loss, which is no small matter to the patient who has suffered bone loss and requires office visits every three months as opposed to every six months for the gingivitis patient.
How we think about gingivitis, however, is hugely important. If we consider and approach it clinically as a non-worrisome, reversible condition, many more of our patients will progress to periodontitis. If we think of gingivitis as a non-reversible disease, our patients are more likely to benefit from our efforts to educate them about the critical importance of biofilm reduction and professional monitoring.
The main difference between the two is that periodontitis increases the risk for heart attack, stroke, premature low birth weight babies, diabetes complications, rheumatoid arthritis, and other systemic conditions as well.
Preventing the progression of gingivitis to periodontitis is the single most important thing we can do for our patients as dental providers, because by doing so, we prevent a lifetime of disease management and the increased risk for life-changing and life-threatening systemic conditions. Thinking of gingivitis as a non-reversible condition and addressing it in a more proactive manner will safeguard the oral and general health of our patients. Let us never forget that we are treating people, not oral cavities.
Dr. Richard Nagelberg has been practicing general dentistry in suburban Philadelphia for more than 27 years. He has international practice experience, having provided dental services in Thailand, Cambodia, and Canada. Dr. Nagelberg has served on many boards and advisory panels. He is co-founder ofPerioFrogz, an information services company, and is a speaker, clinical consultant, and key opinion leader for several dental companies and organizations. He is also a recipient of Dentistry Today’s Top Clinicians in CE, 2009. A respected member of the dental community, Dr. Nagelberg lectures extensively around the country on a variety of topics centered on understanding the impact dental professionals have, beyond the oral cavity.