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Nigerian Journal of Dental and Maxillofacial Traumatology
Volume 2 Issue 1 & 2 December 2019
7
Trauma to the gingiva
Thermal traumatic injuries (TTI) to the gingival
tissue can be caused iatrogenically by the use of
overheated handpieces and ultrasonic scalers.
Ideally, no portion of the devices is expected
touch the gingiva while in use. However,
thermal burns have been documented as one of
the possible adverse events that may be
associated with the use of ultrasonic scalers
(Athmarao and Rekha, 2015). TTI can also be
self-inflicted through consumption of extremely
hot or cold food or beverages. This form of injury
is usually mild since it should be expected that
any hot food accidentally ingested should be
immediately expelled. However, severe forms of
intraoral and laryngopharyngeal burn caused by
hot foods or drinks have been reported in
patients with psychiatric disorders (Iyama et al.,
2016).
Chemical traumatic injuries (CTI) to the gingival
tissue can be caused by topical contact with
some drugs or chemical agents. The extent of
the CTI is dependent on the such factors as the
type, concentration, and quantity of the
chemical as well as the duration of the contact
of the injurious chemical agent with the soft
tissue (Ozcelik, 2005; Dayakar, 2012). Some
potentially injurious chemicals are used during
restorative procedures as cavity varnish, dentine
bonding agent, phosphoric etching solutions,
astringent for gingival retraction, porcelain and
metal etchant, root canal irrigants, and
devitalizing agents (Girish, 2015). Some of these
chemicals are used as antiseptics and
mouthwashes (phenol, chromic acid, iodine,
hydrogen peroxide) while some are medications
such as analgesic (Aspirin) and antipsychotic
agents (Chlorpromazine) (Girish, 2015).
ED Odai*, and AO Ehizele**
*Department of Oral and Maxillofacial Surgery,
University of Benin, Benin City
**Department of Periodontics, University of Benin,
Benin City
This review dealt only with trauma that can result from thermal, chemical
or mechanical assault to the soft tissues of the periodontium, namely the
gingiva and the periodontal ligaments. These forms of trauma may be
accidental, iatrogenic or self-inflicted (factitious). When trauma is
accidental and iatrogenic, the nature of the damage to the tissues is
usually acute and self-limiting. However, it is more chronic when trauma
is self-inflicted. This review is important to highlight potential non-plaque
related sources of damage to the tooth supporting structures which may
be unintended, unplanned or self-inflicted but nonetheless, of grave
consequences.
ABSTRACT
Key words: Trauma, periodontium, accidental, iatrogenic, self-inflicted
Correspondence: Dr. AO Ehizele
Department of Periodontics,
University of Benin, Benin-City, Nigeria
Email: Adebola.ehizele@uniben.edu
TRAUMA TO THE SOFT TISSUES OF THE PERIODONTIUM: A REVIEW
Citation: Odai ED, and Ehizele AO (2019): Trauma to the Soft
Tissues of the Periodontium: A Review; 2(1&2):7-14.
Nigerian Journal of Dental and Maxillofacial Traumatology
Volume 2 Issue 1 & 2 December 2019
8
Tetracycline hydrochloride was also reported to
cause chemical burn of the gingiva and oral
mucosa when used inappropriately (Dayakar,
2012). Recreation drugs, such as cocaine, can
cause serious chemical trauma when rubbed on
the gingiva (Girish, 2015).
Mechanical traumatic injuries (MTI) to the
gingival tissue can result from accidents,
assaults or falls during sports, play and seizures.
Malocclusions such as deep bite or increased
overbite have also been reported to cause
trauma to the gingiva (Ustun, 2008; Gupta,
2012). Iatrogenic mechanical trauma can occur
in cases of improperly fabricated dental
appliances and defective dental restorations
(Meeran, 2013; Asal and Abdel Fattah, 2017).
MTI could also be self-inflicted during improper
flossing or toothbrushing as well as in digit
sucking or biting of fingernail and hard sharp
objects (Dilsiz and Aydin, 2009).
The most widely documented self-inflicted MTI
to the gingival tissue is referred to as gingivitis
artefacta (Chalkoo et al., 2016)). Both minor and
major variants of gingivitis artefacta have been
reported (Dilsiz and Aydin, 2009; Mazumdar et
al., 2011; Chalkoo et al., 2016). Gingivitis
artefacta minor is reported to be more common
while gingivitis artefacta major is more severe,
spreading to the deeper tissues of the
periodontium (Mazumdar et al., 2011). There is
usually a preceding source of irritation such as
finger biting habit or consumption of abrasive
food in gingivitis artefacta minor. This makes
the condition amenable to basic removal of
underlying source of irritation. Gingivitis
artefacta major on the other hand requires
special treatment modalities because there may
be some emotional and extraoral component of
the condition (Mazumdar et al., 2011). Injuries
sustained from self-inflicted physical trauma to
the gingiva were categorized by Stewart and
Kernohan (1972) into three types: Type A-
injuries superimposed upon a pre-existing lesion
(or irritation) where the patient continues to
damage the site, Type B- injuries secondary to
an established habit such as fingernail biting or
finger sucking and Type C- injuries of unknown
and/or complex aetiology which are usually
based on some emotional disturbance.
Another self- inflicted MTI to the oral soft tissues
is oral piercing which is becoming a common
form of body modification because of the
increasing need for self-expression (Khalia et al.,
2013). A systematic review revealed that the
prevalence of oral and peri-oral piercings in
young adults varied from 0.8% to 12%
(Hennequin-Hoenderdos et al., 2012). In oral
piercing. oral and peri-oral tissues are punctured
to insert jewelries on different parts of the face
such as the tongue, lips, cheek and labial
frenum. Complications may however occur
post-operatively (Bone et al., 2008; Hickey et al.,
2010; Gill et al., 2012; Hennequin-Hoenderdos et
al., 2012). The primary post-operative
periodontal complications may include
increased plaque and calculus formation and
eventually, gingival inflammation (Gill et al.,
2012; Hennequin-Hoenderdos et al., 2012).
Secondary post-operative periodontal
complications may result from chronic poor oral
hygiene, especially in heavy smoking. It has also
been reported that where the jewelry material is
porous, there can be a shift in the bacteria
population and the pathogenic potential of the
periodontopathogenic bacteria becomes
higher. These secondary post-operative
periodontal complications may include gingival
recession and gingiva enlargement,
periodontitis, and periodontal abscesses (Gill et
al., 2012; Hennequin-Hoenderdos et al., 2012).
While the sole motivation for oral piercing may
be to make a style statement, to identify with a
group, to denote beauty or to demonstrate
virility (Khalia et al., 2013; Mishra et al., 2015),
other forms of self-inflicted MTI to the gingival
tissue may be due to potentially harmful oral
habits. These oral habits were classified into
neuroses, occupational habits and
Nigerian Journal of Dental and Maxillofacial Traumatology
Volume 2 Issue 1 & 2 December 2019
9
miscellaneous habits (Bathla et al., 2011).
Neuroses include lip biting, cheek biting,
pencil/pen biting and fingernail biting,
occupational habits include holding of nails in
the mouth by upholsterers and carpenters and
thread biting by tailors and miscellaneous
include habits such as pipe or cigarette smoking,
thumb sucking, mouth breathing and incorrect
methods of toothbrushing (Bathla et al., 2011).
Iatrogenic trauma to the gingiva can result
during any dental procedures that result in the
violation of the biological width, the use of
excessive digital force, improperly finished
restoration margins or improperly fitted
prosthesis/ appliance. Examples are the use of
wrong dimension of gingival retraction cord for
a wrong duration, the use of excessive digital
force during impression taking, improper use of
disks, burs and stones, unpolished and
imperfect margins,
Improper use of matrix band resulting into
improperly contoured interdental contacts and
gingival overhangs, Improperly designed
denture clasps and ill-fitting orthodontic bands
and wires (Shenoy and Rodrigues, 2007).
Clinical presentations and management of
trauma to the gingiva
There are many possible clinical presentations
because of the various aetiologies already
outlined. The history elicited will differ from
case to case depending on the peculiarities of
each case. In patients with self‑injurious
behaviors, there may be history of persistent
gingival irritation with resultant scratching or
picking of the gingiva and history suggestive of
emotional disturbance or psychological
imbalance (Mazumdar et al., 2011; Chalkoo et
al., 2016; Caliskan et al., 2018). History taking
may also reveal chronic habits such as finger nail
biting, digit sucking, or sucking on potentially
injurious objects, compulsive toothbrushing or
contact with other mechanical, chemical and
thermal injurious objects.
On examination, there may be painful burns,
scalding and bleeding, extensive ulcerative
lesion involving the gingival oral mucosa, lips
and tongue (Chalkoo et al., 2016). In some cases,
the ulcer may present as coagulative necrosis
covered by slough. In factitious injuries, nail
marks may be seen on the gingival as well as bite
marks on the lips (Mazumdar et al., 2011). There
may also be other self‑inflicted injuries in the
form of linear excoriations and areas of
crustation in other parts of the body (Chalkoo et
al., 2016). There is usually gingival recession
which may be severe and extensive, spanning
across many teeth. There may be limitation of
mouth opening and difficulty with food intake,
depending on the affected site. There may be no
radiologic or laboratory evidence of any
underlying systemic disorder.
The treatment goals include complete re-
epithelization of the gingival tissue, complete or
significant coverage of the previously denuded
roots and increase in the zone of attached
gingiva (Griffin et al., 2007). It is also important
to prevent recurrence by removing any
identified causative agent. Therefore, proper
treatment starts with correction of any
improper oral hygiene practices and removal of
any potentially harmful agent. Gentle
mechanical oral hygiene measure is
professionally instituted to remove the
accumulated plaque and this may be done with
topical or local anesthetic agents, if necessary.
Chemical plaque control may be prescribed as
the only oral hygiene measure in the affected
site while regular toothbrushing is maintained in
the other parts. This is sustained until clinical
improvement is observed. Chlorhexidine mouth
rinses may be prescribed twice a day. Regular
gaggle with warm saline mouth wash and
Betadine has also been found helpful (Girish et
al., 2015; Goncalves et al., 2017).
Supportive and symptomatic treatment is given
to maintain the general wellness of the patient
and this include prescription of non-spicy soft
Nigerian Journal of Dental and Maxillofacial Traumatology
Volume 2 Issue 1 & 2 December 2019
10
and cold diet as well as multivitamins and topical
application of the triamcinolone acetate and
benzocaine to reduce pain (Goncalves et al.,
2017). In cases of severe tissue damage, it has
been recommended that the topical
triamcinolone should be applied along with
carboxymethyl cellulose (Girish et al., 2015).
Antibiotic therapy may be necessary to prevent
the infection of the ulcerated area in very
extensive cases (Girish et al., 2015). Professional
psychological care may be necessary in
factitious cases and this may include the use of
antidepressant and antianxiety drugs
(Mazumdar et al., 2011). Where gingival tissue
loss is extensive, there may be a need to correct
the defect with a free gingival graft (Dilsiz and
Aydin, 2009). In all cases, regular recall visits are
mandatory to institute maintenance therapy.
Trauma to periodontal ligaments
The other soft tissue component of the
periodontium is the periodontal ligament. It is
the soft complex, vascular, highly cellular and
specialized connective tissue serving as an
interface which joins the cementum covering
the roots to the inner wall of the alveolar bone
(Mc Culloch, 2000; Lindhe et al., 2012).
Conditions that cause excessive bilateral
opposing vector forces may cause
overextension and inflammation of the
periodontal ligaments. This is referred to in
some quarters as Sprained Tooth Syndrome
(STS.). STS can result when an individual
accidentally bites on a hard object, in cases of
underfilling or overfilling of a tooth, when there
is drifting of teeth and in cases of common,
sinusitis or allergies. The STS reported in upper
respiratory tract infection has been attributed to
the abnormal outward lateral pressure from the
tongue to the teeth which creates temporary
orthodontic pressure and outward movement
outward, leading to abnormal tooth mobility.
Accidental mechanical/traumatic injuries to the
periodontal ligament can be classified based on
the extent of the injury into, concussion,
subluxation, lateral luxation, intrusive luxation
and extrusive luxation. Severe forms of
extrusive luxation may result in avulsion of the
tooth (Bakland and Andreasen, 2004; Brüllmann
et al., 2011). The clinical outcome of the
management of accidental trauma to the
periodontal ligament will depend on the
emergency measures instituted both in and
outside the dental office. The general populace
must therefore be vast in emergency steps to
take to improve the outcome of luxation injuries
while dental practitioners must be vast in the
various management options that may be
required in the varying degrees of luxation
injuries for favourable outcomes (Bakland and
Andreasen, 2004; Brüllmann et al., 2011)
Thermal injury to periodontal ligaments is also a
possibility especially with the advent of
ultrasonic devices and thermoplasticised
obturation method used in endodontics
effectively to remove fillings, paste, cements,
posts, dislodged or broken instrument tips or
any other obstructions from the root canal.
(Gluskin et al., 2005; Kwon et al., 2013). This
important use of ultrasonic devices can however
lead to intraradicular heat transfer where
cooling of the ultrasonic tip is not optimal
(Gluskin et al., 2005; Kwon et al., 2013). These
heat generating devices are more likely to
generate more temperature increase in the
periodontal ligament than the pulp because the
supporting periodontal tissue is not limited by
space and have a higher blood supply than the
pulp (Kwon et al., 2013).
Every effort must be made to avoid iatrogenic
forms of trauma to the periodontal ligament
because its attempts at healing may have
unpredictable outcomes. Periodontal ligament
may heal favourably without resorption or with
repair related surface resorption and it can also
heal unfavourably with osseous replacement
resorption (ankylosis) or with inflammatory
resorption (Goswami, 2011).
Nigerian Journal of Dental and Maxillofacial Traumatology
Volume 2 Issue 1 & 2 December 2019
11
Clinical presentations and management of
trauma to the periodontal ligament
In sprained tooth syndrome, there may be
history of bruxism, nail biting, recent defective
dental procedures. tooth infection, trauma from
small objects, such as bone and sinus problems,
such as allergies or a cold (Anthony, 2018). The
initial symptom of excessive force on
periodontal ligament is pain which can be dull or
sharp and localised to a tooth (Mortazavi and
Baharv, 2016)
The treatment of sprained tooth is essentially
based on correction of opposing vector forces
that brought about the strain (Anthony, 2018).
However, a sprained tooth can wait a few days
to see if it heals on its own. The treatment of a
sprained tooth involves rest because putting the
affected tooth under function, such as chewing
and speaking, increases the pain from the tooth.
There may be a need to prescribe analgesic for
the pain as well as to place ice stick in the
affected part. A protective mouth guard may be
needed in cases of bruxism.
The clinical presentation of traumatic injuries to
periodontal ligament is essentially varying
degree of mobility of the affected tooth or
teeth. In concussion, the injury may not result to
increased mobility or displacement but there
will be marked tenderness to percussion of the
affected tooth or teeth, subluxation presents
with increased mobility without marked
displacement of the tooth, lateral luxation may
have displacement of tooth labially, lingually,
mesially or distally, extrusive luxation presents
with increased mobility in the coronal direction
while in intrusion, the apical displacement of the
tooth is accompanied with fracture of the
alveolar bone (Bakland and Andreasen, 2004;
Brüllmann et al., 2011). In avulsion, a bleeding
socket will be seen and there may also be
damage to local soft tissues (My Hanh et al.,
2018). Radiographic assessment may reveal
thickening or increase of the periodontal
ligament space in many cases of traumatic injury
to the periodontal ligament but there may also
be a complete absence of periodontal space
(Panzarini et al., 2008). Fracture of alveolar bone
and periapical radiolucency are also common
radiographic features (Panzarini et al., 2008).
The treatment plan for the management of
intrusive luxation should include radiographic
examination, tooth repositioning, surgical or
orthodontic extrusion of the affected tooth,
splinting, occlusal adjustment, antibiotic
therapy, endodontic treatment and follow up
(Pedrini et al., 2011). Lateral luxation and
extrusive luxation will also require all the above
except extrusion of the tooth. Subluxation will
require only radiographic examination, splinting
and follow up while concussion will require only
radiographic evaluation and follow up to
observe the tooth over time (Pedrini et al, 2011).
An avulsed tooth may be reimplantable only if
there is no contamination and if transportation
and storage of the tooth was good enough to
ensure the viability of the periodontal
ligaments. Reimplantation will be followed by
immobilization of the tooth, adjunctive
antibiotic and anti-tetanus therapy and
eventually, a root canal treatment of the tooth
(Trope, 1995).
The harmful effects of increased temperature
on periodontal ligament have been documented
(Özkoçak et al., 2015). Thermal injury to
periodontal diseases may give rise to clinical
features suggestive of protein denaturation in
periodontal ligaments, interruption of blood
supply to the periodontal ligament as well as
tooth ankylosis (Gluskin et al., 2005; Özkoçak et
al., 2015). The management of thermal injuries
are largely preventive. Clinical guidelines have
been formulated to reduce the occurrence of
thermal injuries during dental procedures and
these include using sufficient cooling water for
tooth preparation or where dry cutting is
needed, using light pressure and limiting the
bur-contact time to less than 20seconds at a
time, using a 2-step curing or ramp curing
Nigerian Journal of Dental and Maxillofacial Traumatology
Volume 2 Issue 1 & 2 December 2019
12
technique for light curing composite resin, using
the refrigerated putty matrix as a heat sink in the
fabrication of provisional crowns, limiting
exposure to the heat source for
thermoplasticised root canal obturation to
3seconds and the contact time for the tip of
ultrasonic devices must be limited to 60seconds
(Kwon et al., 2013).
Conclusion
There is a possibility of the soft tissues of the
periodontium to be damaged accidentally,
iatrogenically and factitiously and this can lead
to greater and undesirable periodontal
destruction. Patients should therefore be
educated to discourage self-inflicted injuries
among them. More importantly, dentist should
be more aware on possible management
options for accidental injuries and also always
put necessary precautions in place to avoid
iatrogenic injuries as much as possible.
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