My Favorite Tissue :)

We have been told since we were very young to always brush our teeth! However what we may not realize when it comes to taking action for our oral hygiene is the importance of having healthy gum tissue which surrounds our pearly whites! This blog is an attempt to get a better understanding of gum tissue, or gingiva, as well as the unfortunate consequences that can result if proper precautions are not taken. This is a very important issue and I hope that both the information......and the images yet to come will help!!

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Classification and Organization of the Gingiva

The tissues which surround the teeth are collectively called the periodontum. Although a number of components of the periodontum have been defined, they do not work in isolation as each part is important in overall function. One of these major components, the gingiva (or gums) is a soft, mucosa-type tissue held firmly around each individual tooth carrying out two main functions:

1. Providing structural support to the teeth during the stress of mechanical processes
2. Providing protection to the underlying layers of bone and connective tissue from infectious bacteria that can be found in the mouth(1).

However, with a more in-depth consideration, this simple definition of gingival tissue becomes increasingly complex. The gingival tissues can be divided and categorized using several different classifications:

Its position in relation to the tooth

In general, the gingival tissues, based on their position around the tooth can be divided into two categories:
· Free (or unattached) Gingiva
· Attached Gingiva

Free Gingiva (B)

This is the gingival tissue that is found surrounding the tooth where it surfaces. This tissue is not directly connected or attached to the tooth or other bone in the jaw, and is lies on the crown, about 1 to 1.2 mm (2). This creates a small gap between the gum and the tooth, called the gingival crevice, or gingival sulcus.

Without any scientific knowledge, many people can relate to this small crevice which is where food that gets stuck remains…no matter how hard you try to get that stubborn popcorn out!!

Attached Gingiva (D)

This crevice then leads to the attached gingiva. As its name suggests it is firmly attached to the underlying bone which makes up the tooth and jaw, called the alveolar process. This bone is composed of a matrix of spongy bone trabecullae and cortical bone plates (1).

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Its position in the mouth

This divides the gingiva into two categories: (3)

· Labial Maxillary Gingiva: tissues which surround the teeth of the upper jaw
· Labial Mandibular Gingiva: tissues which surround the teeth of the lower jaw

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Histological Composition of the Gingiva

The composition of the oral mucosa of both the free and attached gingiva is very similar,
composed of:

· Stratified epithelial layer
· Lamina propria connective tissue

These components are separated by a boundary
referred to as the basement membrane, mainly composed of reticular fibers. (1).

EPITHELIUM

The epithelium is a stratified squamous layer, which generally is covered by a protective keratin layer. However in some cases it may lack this keratinized layer. The layer found closest to the basement membrane consist of cuboidal cells called the basal cell layer of stratum germinativum. This layer contains melanocytes which secrete the pigment melanin, which gives the gums its characteristic pink color.
On top of this are several layers of polyhedral cells called the stratum spinosum. It is in this layer where most mitotic divisions occur, allowing the tissue to continue to grow and remain healthy. The cells in each layer become increasingly flattened in the transition to the surface. These outmermost layers contain basoplhilic granules which secrete the materials which become the keratin. The tissue layer which contains these keratohyaline granules is called stratum granulosum. (1).

LAMINA PROPRIA

The lamina propria is the connective tissue layer which lies below the epithelium layer, providing structural support (1). In the gingiva, it is composed mainly of bundles of dense collagen fibers. These bundles are found to have a highly organized arrangement in the connective tissue layer, specifically in three different orientations. They may extend from the tooth surface into the gums, wrap around the tooth in a circular fashion or extend from the bone of the alveolar process into the gingiva (1). This third orientation may be observed by the naked eye when examining the external gum tissue as having a rough, orange-peel appearance. This is known as stippling. (3)

As well as its supporting function, the lamina propria is vascularized, containing a rich supply of blood and lymphatic vessels, as well as nerves. Therefore this connective tissue layer plays an important role in fighting infection that may occur as the oral mucosa comes in contact with harmful bacteria and other pathogens.

Interesting Fact:

Did you know that the collagen fibers that compose the gingival connective tissue has been found to be much denser in males than in females?? (1)

Assessment of risk of periodontal disease

Considering all the important information associated with oral functioning, it is quite clear that taking good care of our gums is very essential. We need to educate ourselves on any risk factors or preventative strategies that can ensure our gums remain healthy and reduce the chances of developing any problems with our oral health, such as periodontal diseases. Being able to recognize changes or associated symptoms is also very important so possible interventions can take place before the problem persists.
A thorough examination of the gingiva can help in the assessment of the health of the tissue through the consideration of several specific characteristics:

1. Color
As commonly seen, the color is subject to individual differences, similar to individual differences in skin pigmentation. However, healthy gum tissue is usually found to have a uniform coloration within a range from pale to a darker pink (1). However, if gums are found to be dark red or purple and if accompanied by swelling, this may cause reason for concern (4).

2. Shape
As mentioned above, healthy gingival tissue is found to tightly surround each individual tooth as well as fill in the interdental spaces that exist between them. An individual may be at risk for a periodontal disease if gums appear to be receding, making the teeth seem longer than before, or newly developed spaces appear between the teeth (4).

3. Texture
Compared to healthy gums, which are normally of a moderate hardness and quite resilient, gums which may be in the early stages of periodontal disease often appear swollen and very soft (4).

4. Reaction to everyday oral stresses
As we all know, our gums, when healthy are highly resistant to many everyday stresses that existing such as eating tough foods, or brushing and flossing our teeth. Gums which experience bleeding or appear to have small lacerations may be at risk. Also the development of pus between the teeth, or bad breath, both of which may be associated with infection are reasons for concern (4).



It is very important to recognize all the above symptoms when considering the chances you may have a periodontal disease. However, it is just as important to understand that in early stages, many of these symptoms may not be prevalent, and may not be recognized until later stages.

Serious pathological concerns can be associated with unhealthy oral practices and their consequences. One of the most common condition associated with unhealthy gingiva is Gingivitis, which can then lead to Periodontitis.

A litttle humor to catch your attention....about a very serious issue!

WHAT IS PERIODONTAL DISEASE?

Periodontal disease is a condition that results in the inflammation of the periodontum, including the gingival tissues (4). Generally, there are a number of consecutive stages that occur resulting in the progression and worsening of the condition. One commonly known stage of periodontal disease, gingivitis, may later develop into a more severe form, periodontitis. The disease is characterized by a number of symptoms, some which have been mentioned above, which can change as the disease makes its transition though its stages.

Causes and Possible Risk Factors

Periodontal disease has been found to be caused by a bacterial infection where a number of species have been identified. One of the most common species studied is Porphyromonas gingivalis. In the transition from healthy to unhealthy gingival tissue, the bacteria which normally occupy the gingiva between the teeth, generally gram positive species, are displaced by the invasion of gram negative species, such as P.gingivalis. The accumulation of these microbes may result in Gingivitis, which may the progress to become Periodontitis (6).














Porphyromonas gingivalis (6)

P. gingivalis invasion of gram positive bacteria
normally found between the teeth (6)

Although the mechanisms of how the disease develops in not clear, periodontal disease is today referred to as an “eco-genetic” disease, with both environmental and genetic implications.
Research in the past has provided supporting evidence that individual genetic differences may influence the chances or disease development as well as its progression. Individual differences may be observed in both infection susceptibility or in differences in the host immune system reaction.
As also made clear in the “eco-genetic” concept, environmental factors play a major in the development of periodontal disease. Through extensive research a number of factors have been found to play a role:

• Tobacco use: both smoking and chewing tobacco greatly increase chances of disease, playing a role in decreasing the immune response and creating a favourable environment for harmful bacteria.
• Use of various medications/drugs: any drug, whether illegal, prescription or over-the-counter that may cause a decrease in saliva production can play a role. Saliva has an important function in removing plaque and inhibition of bacterial growth.
• Diet: diet with low calcium or low Vitamin C and B levels can be harmful as they are important in gingival growth and repair (4).
  
  Researchers continue to search for risk factors that may be associated with periodontal diseases and have suggested other factors such as diabetes, incidence of pregnant women passing it on to unborn children, or hormonal changes (4).
  

Stages of Gingivitis-Periodontitis

The general transition from Gingivitis to Periodontitis occurs in a number of specific stages:

1: Gingivitis
As it is the earliest stage of gum disease, it is seldomly associated with pain and shows minor symptoms. The gums may appear swollen, red, or may experience bleeding. However, through proper practices, it can be reduced. If symptoms persist, this leads to periodontitis.

2: Early-Moderate Periodontitis
The major difference from gingivitis is that the inflammation that initially affected just the gingial tissues also affects deeper supporting structures, such as the surrounding bone. This may result in damage to the periodontal ligament, which secures each individual tooth in its socket and keeps the gingival tightly surrounding the exterior. When damage occurs, the gums begin to recede, causing problems such as excessive bleeding around the gumline.

3. Advanced Periodontitis
As the damage to the gingival tissues continues, the concentration of bacteria continues to increase. As the infection worsens, many major problems result including extreme pain, loss of teeth as they no longer are able to remain in sockets and loss of bone in the jaw (7). In the long-term, this can lead to many other complications including:

• Diabetes


• Increased risk of heart disease


• Complications during pregnancy


• Pneumonia and other lung infections (as bacteria in the mouth are inhaled into the lung (7).

Treatment and Prevention

Dentists have suggested a number of healthy oral hygiene practices that can reduce the risk of developing a periodontal disease.

Good oral hygiene practices should start very early in life. Parents should ensure that their children are both brushing and flossing regularly at an early age. It has been found that flossing is often much less carried out than brushing, yet equally important in maintaining healthy gums. In addition, parents should also practice the same, providing model guidance.

• A proper toothbrush and proper mechanism for brushing is also important. Using a soft brush and replacing it every three months is a good idea to reduce any irritation. Proper brushing includes both short back-forth and up-down movements with a brushing action that ensures the maximum amount of plaque is removed
  
• Regular visits to your dentist will ensure that your oral hygiene is at its best!
  
• Eat a healthy diet that is great sources of Vitamins C and B, as well as calcium. Some examples include citrus fruits, broccoli, cantaloupe, berries as well as many other fresh fruit and vegetables (4).

Conclusion

In conclusion, I hope that everyone has learned something by reading this blog. Through the construction of this blog, I know that I have learned a lot! Taking care of your teeth is very important, but taking care of the gingiva as well as all the surrounding tissue is just as important, as they just won't stay in place without them! It’s up to each and everyone one of us to take control and reduce our chances of periodontal disease and the consequences that can arise if we don’t take our oral health seriously! Keep brushing…..AND don’t forget to floss!!! It is through these and many other simple practices that we can all keep smiling! :)

References (non-alphabetical):
1: Integrated Publishing’s Reference Archive-Medical: Oral Histology and Tissues of the Teeth.
Retrieved on February 15, 2008 from
http://www.tpub.com/

2: Bhaskar, S.N. (1962). Synopsis of Oral Histology. Saint Louis: C.V Mosby Co.

3: Zwemer, Thomas, Stocking, Scott, and Gubili, Jyothimai. (2004). Mosby’s Dental
Dictionary (online). Saint Louis: Mosby Publications.

4: Oral and Dental Health Basics: Periodontitis.
Retrieved on February 15, 2008 from
http://www.colgate.com/
Colgate-Palmolive Co.

5: Bartold, P.Mark. (2006). Periodontal tissues in health and disease: introduction.
Periodontology 2000, 40, 7-10.

6: Duncan, Margaret, Dewhirst, Floyd, and Chen, Tsute. (2002). Forsyth Institute
Porphyromonas gingivalis Genome Project.
Retrieved on February 15, 2008 from
http://www.pgingivalis.org/

7: Jaworski, Marie, Klippenstein, Mary Ann, Anania, Francesca, and Chambers, Robin.
The Wisdom Tooth Page: School of Dental Hygiene, University of Manitoba.
Retrieved on February 15, 2008 from
http://www.umanitoba.ca/outreach/wisdomtooth/stagesof.htm