before proceeding please make sure to subscribe dental maniac and turn on the bell icon for upcoming videos you can always support my work with your likes comments and shares for latest updates you can join me on facebook and instagram at dental media for images and transcripts please visit my patreon page the link for which is given here above so let's begin the word gingivitis literally means inflammation of the gums gum disease is an infection caused by the harmful bacteria that live in our mouths the human mouth is full of numerous types of bacteria these include beneficial and harmful bacteria with improper oral hygiene maintenance the harmful bacteria combine with sugars and salivary proteins to form a coating on the teeth and the edges of the gums the coating is known as plaque and if this plaque is left to accumulate bacteria will use it to stage attacks on the gums the resulting infection is known as gum disease or gingivitis some known factors that can contribute to gum disease are listed as poor oral hygiene a dry mouth resulting from factors like medication and breathing issues crowded or crooked teeth hormonal shifts and a diet that is rich in carbohydrates and low in vitamins smoking may also increase the risk of gum disease the sequence of events involved in the development of gingivitis can occur in four different stages stage one is known as the initial stage stage two known as the early legion stage 3 known as the established lesion and stage 4 known as the advanced lesion before proceeding with these four stages of gingivitis it's really important to recap the histoanatomy of gingival epithelium so that we can have a great understanding of the disease process in gingivitis gingiva consists of a central core of connective tissue covered by stratified squamous epithelium three types of epithelium exist in the gingival tissue these are the oral or outer epithelium which has keratinized and lines the free gingival margin the circular epithelium which lines the sulcus and the junctional epithelium surrounds the earth in a collar-like fashion and attaches to the enamel of the turret at its inner end and to the connective tissue at its outer end amongst these three epithelia the epithelium which has the main role in the disease process of gingivitis is the junctional epithelium the length of the junctional epithelium ranges from 0.25 to 1.35 mm the cells of the junctional epithelium on a closer view are joined with each other through hemidismosomes hemidismosomes in the junctional epithelium possess wider intercellular junctions hence allowing movement of fluids and immune cells from the underlying connective tissue into the gingival sulcus the cells of the junctional epithelium also allow movement of bacteria and their toxins from the dental plaque to reach the underlying connective tissue hence initiating a disease process now let's zoom in this area to look at the stages of gingivitis stage one of gingivitis is initiated two to four days after considerable plaque accumulation during this stage bacteria present in the accumulated plaque at the base of the teeth release toxins that make their way into the underlying connective tissue through the intercellular gaps present in between the cells of the junctional epithelium here the bacterial toxins initiate an inflammatory process by stimulating immune cells within the connective tissue these immune cells are the mast cells and neutrophils the stimulated immune cells release pro-inflammatory cytokines or inflammatory mediators like histamine tnf alpha and some mental requiems these mediators in turn increase vascular permeability and allow extravasation of plasma fluids or exudate into the gingival sulcus the exudate within the gingival sulcus is referred to as the gingival clavicular fluid or gcf the neutrophils are also observed leaving the blood vessels through the process of diabetes and entering the junctional epithelium and beyond it within the gingival sulcus through chemothexis this first stage of gingivitis is known as the subclinical stage because no obvious changes are detected on a clinical level there are no obvious signs and symptoms of the disease process in this initial stage only histological changes can be seen under a microscope these histological changes are mild vasodilation of blood vessels subjection to the junctional epithelium which is then followed by extravasation of plasma fluids and inflammatory cells within the gingival sulcus hence increasing the gingival crevicular fluid the early lesion develops about one week after continual clock accumulation at the initial stage this stage is characterized by an exaggeration of all those events that started in the initial stage the vascular permeability is increased even more which causes migration of more inflammatory cells in the site of insult the inflammatory cells in this second stage are the neutrophils the t lymphocytes and macrophages with the predominant cells being the t lymphocytes and neutrophils a huge number of neutrophils are observed in the connective tissue within the junctional epithelium and within the gingival sulcus the neutrophils release cytotoxic enzymes in an attempt to kill the invading bacteria which along with killing bacteria destruct some nearby tissues like the collagen fiber bundles of the gingiva the fiber bundles destructed mainly are the dento gingival and the circular fibers the spaces left behind by the destruction of collagen fibers of the gingiva are soon filled by the proliferation of the junctional epithelium the junctional epithelium forms epithelial reti ridges which are the finger-like projections of the junctional epithelium within the underlying connective tissue fibroblasts also show alterations in structure with a decreased capacity for collagen production in addition lymphocytes and macrophages produce growth factors that promote angiogenesis which has the development of new blood vessels hence at this stage the gingiva becomes slightly swollen and arithmetic and the patient will have bleeding with probing due to increased blood vessel proliferation the gingival sulcus becomes slightly deeper resulting from the destruction of gingival fibers stage 3 or the established lesion begins 14 to 21 days after the early lesion this stage is characterized by a huge number of infiltrating immune cells within the gingival tissue these immune cells are the plasma cells b lymphocytes and neutrophils however the predominant cells are the plasma cells and b lymphocytes the cells are condensed all over the gingival tissues right from the sulcus to the junctional epithelium to the underlying lemon or propria and within the gingival fibers the neutrophils as they migrate through the dense collagen fiber bundles release matrix metalloproteins and collagenase enzymes these enzymes causes further destruction of the collagen fiber bundles the continuous leakage of plasma proteins from the blood vessels causes an increased viscosity of the blood hence reducing the blood flow in the region the reduction in the blood flow causes anoxemia in the region which gives the marginal gingiva a bluish hue in this established stage the destruction of gingival collagen fibers and intense accumulation of immune cells within the junctional and circular epithelium forms a pocket epithelium that is not firmly attached to the tooth surface that contains a large number of immune cells and that is more permeable to the passage of substances into or out of the underlying connective tissue remember that all these three stages of gingivitis we have just mentioned are totally reversible if proper oral hygiene maintenance is established again the advanced lesion is a stage of the periodontal breakdown which we will discuss in our upcoming next video thank you for watching you