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Gums

The gums, also known as the gingiva, are the soft, pink mucosal tissues that line the upper and lower jaws and surround the base of the teeth, forming a protective seal around their necks.^[1] Composed primarily of keratinized epithelium and underlying connective tissue, the gums anchor the teeth to the alveolar bone via the periodontal ligament and serve as a critical barrier against bacteria, food particles, and mechanical trauma in the oral cavity.^[2] Healthy gums are firm, stippled, and coral-pink in color (though pigmentation varies by ethnicity), with a marginal portion that hugs the tooth surface and an attached portion that binds firmly to the underlying bone.^[2] As an essential component of the periodontium—the supportive structures of the teeth—the gums play a vital role in maintaining oral health by preventing the ingress of pathogens into deeper tissues, facilitating mastication, and contributing to speech and aesthetics.^[3] They are richly vascularized and innervated, receiving blood supply from branches of the maxillary and facial arteries, which ensures rapid healing but also makes them susceptible to inflammation from plaque accumulation.^[2] Common conditions affecting the gums include gingivitis, characterized by reversible inflammation due to bacterial biofilms, and periodontitis, a progressive disease that can lead to tooth loss if untreated.^[2] Maintaining gum health involves daily oral hygiene practices such as brushing, flossing, and professional cleanings, as poor care can exacerbate systemic links to conditions like cardiovascular disease and diabetes.^[4] Research highlights the gums' microbiome as a dynamic ecosystem influenced by diet, genetics, and hygiene, underscoring their broader implications for overall health.^[2]

Anatomy

Gross anatomy

The gingiva, commonly known as the gums, consists of the soft mucosal tissue that covers the alveolar processes of the maxilla and mandible and surrounds the necks of the teeth, forming a protective collar around each tooth.^[2] This structure is part of the periodontium and serves as a barrier between the oral environment and the underlying periodontal tissues.^[5] The gingiva is divided into three main components based on its attachment and position relative to the teeth. The marginal gingiva, also called free gingiva, forms a collarette or collar around the cervical portion of each tooth, typically measuring about 1 mm in width, and is separated from the tooth surface by the gingival sulcus.^[6] The attached gingiva extends from the marginal gingiva to the mucogingival junction and is firmly bound to the underlying alveolar bone and tooth surfaces via the periosteum and connective tissue fibers.^[2] Between adjacent teeth, the interdental gingiva fills the spaces apical to the contact points, forming pyramidal or scalloped papillae that occupy the interdental embrasures.^[5] Anatomically, the gingiva is delineated by the mucogingival junction, which marks the boundary between the attached gingiva and the more mobile, non-keratinized alveolar mucosa, while the attached gingiva extends laterally toward the vestibule, the space between the alveolar ridge and the lips or cheeks.^[2] It relates intimately to the teeth at the cementoenamel junction (CEJ), where the enamel meets the root cementum, and is contiguous with the alveolar bone crest and the periodontal ligament, which anchors the teeth to the bone.^[5] These relationships ensure stability and protection of the periodontal structures. Structural variations exist between the maxillary and mandibular gingiva. In the maxilla, the attached gingiva is generally wider and thicker, ranging from 1 to 9 mm, particularly in the incisor regions, compared to the mandible, where it measures 1 to 8 mm and is narrowest on the incisors and canines (about 1.9 mm) but broader on the molars (up to 4.7 mm).^[5]

Microscopic anatomy

The gums, or gingiva, consist of a superficial epithelium overlying a connective tissue lamina propria. The epithelium is a stratified squamous type, varying in keratinization based on location: it is typically keratinized or parakeratinized in the attached and marginal regions, providing mechanical protection, while remaining non-keratinized in the sulcular area.^[7] The underlying lamina propria is composed primarily of collagen fibers (types I and III), fibroblasts, and ground substance, with cellular elements making up about 5% of its volume.^[2] The oral epithelium of the attached gingiva exhibits orthokeratinization, featuring a well-defined stratum corneum without retained nuclei, along with rete ridges that interdigitate with the connective tissue for enhanced attachment. In contrast, the marginal gingiva often displays parakeratinization, where the stratum corneum retains pyknotic nuclei, contributing to a slightly less robust barrier. Keratinocytes predominate throughout the epithelium, forming layers from cuboidal basal cells to flattened surface cells, while melanocytes in the basal layer produce melanin for pigmentation, with a melanocyte-to-keratinocyte ratio of approximately 1:10 to 1:15.^[7]^[8] The sulcular epithelium, lining the gingival sulcus, is a non-keratinized stratified squamous layer of 10 to 20 cells thick, serving as a semi-permeable barrier without direct attachment to the tooth. Adjacent to it, the junctional epithelium forms a specialized, non-keratinized collar around the tooth neck, consisting of 15 to 30 cell layers coronally tapering to 1 to 3 apically; it adheres to the enamel via hemidesmosomes and an internal basal lamina, spanning 0.25 to 1.35 mm in height.^[8]^[9] In the lamina propria, immune cells such as T lymphocytes, B cells, macrophages, and mast cells reside among the collagen bundles, supporting local immune surveillance. Fibroblasts maintain the extracellular matrix, including elastin and fibronectin.^[9]^[7] A dense capillary network permeates the papillary layer of the lamina propria, facilitating nutrient exchange and crevicular fluid production, while arterioles from branches of the maxillary and facial arteries supply the tissue. Innervation arises from trigeminal nerve branches, including the inferior alveolar, lingual, and buccal nerves in the mandible, and posterior superior alveolar nerves in the maxilla, providing sensory and vasomotor functions.^[2]^[7]

Development

Embryonic origins

The gingiva, or gums, originate from distinct embryonic germ layers during early fetal development. The oral epithelium, which forms the surface layer of the gingiva, derives from the ectoderm of the stomodeum, the primitive oral cavity.^[2] In contrast, the underlying connective tissue arises from neural crest-derived mesenchyme, specifically cranial neural crest cells that migrate to form ectomesenchyme in the orofacial region.^[10] These dual origins establish the foundational structure of the gingival tissues, with the ectodermal epithelium providing a protective barrier and the mesenchymal component contributing to the supportive stroma. Gingival formation occurs during weeks 6 to 7 of gestation, coinciding with the broader development of the oral cavity. This process involves the fusion of the primary palate, formed by the merger of the medial nasal and maxillary processes, and the mandibular prominences, which delineate the future gingival margins.^[11] By week 5, ectodermal thickenings from the stomodeum initiate the oral lining, progressing to a multilayered epithelium by week 10, with gingival regions beginning to specialize.^[2] Epithelial-mesenchymal interactions drive this differentiation, where signaling between the ectodermal oral epithelium and neural crest mesenchyme induces patterned growth and tissue specification essential for gingival architecture.^[12] The development of the gingiva is intimately linked to odontogenesis, arising concurrently with the formation of the dental lamina and enamel organ. Around week 6, the dental lamina—a band of ectodermal thickening—emerges along the oral epithelium, giving rise to tooth buds that include the enamel organ, which interacts with underlying mesenchyme to form dental structures.^[13] These events position the nascent gingival tissues adjacent to developing teeth, establishing the dentogingival junction through reciprocal inductive signals that promote gingival epithelial attachment to the enamel organ.^[5] Embryonic anomalies in gingival formation often stem from disruptions in these fusion and interactive processes. Incomplete fusion of the maxillary and mandibular processes or primary palate can result in orofacial clefts that extend to gingival clefts or defects, altering the continuity of the gingival tissue and potentially affecting tooth eruption sites.^[11] Such malformations, observed in conditions like cleft lip and palate, highlight the critical timing of weeks 6 to 7 for proper gingival morphogenesis.^[14]

Postnatal changes

During the primary dentition phase, the gingiva initially forms a protective collar around the erupting deciduous teeth, with the marginal gingiva adapting through coronal migration to accommodate tooth emergence. This process is often accompanied by localized gingival redness due to the mechanical irritation and inflammatory response during eruption, though significant swelling is typically absent.^[15] The width of the attached gingiva increases progressively with each successive tooth eruption, establishing a stable mucogingival junction that supports the primary teeth.^[16] As the permanent dentition emerges during childhood and adolescence, the marginal gingiva undergoes an apical shift relative to the cemento-enamel junction, allowing for the exposure of a greater clinical crown length while maintaining periodontal health. This migration facilitates the establishment of a broader zone of attached gingiva, which typically measures 1-3 mm in width around permanent incisors and increases further with maturation.^[17] The attached gingiva develops through epithelial differentiation and connective tissue remodeling, providing firmer adherence to the underlying periosteum compared to the primary dentition phase.^[18] With advancing age into adulthood and senescence, the gingiva exhibits progressive thinning of the epithelial layer and increased susceptibility to recession, particularly in the elderly where up to 88% of individuals over 65 years show exposure of root surfaces on at least one tooth. Concurrently, keratinization of the gingival epithelium intensifies with maturity, enhancing surface durability but contributing to a smoother, less stippled texture in older age.^[19] These alterations reflect cumulative effects of reduced cellular turnover and vascular changes in the gingival connective tissue.^[20] Hormonal fluctuations exert transient influences on gingival morphology, notably during puberty where elevated estrogen and progesterone levels provoke generalized enlargement of the interdental papillae and marginal gingiva in response to plaque accumulation. This puberty-associated gingival overgrowth resolves post-adolescence with normalization of hormone levels and improved hygiene.^[21] Similarly, pregnancy induces gingivitis in 60-75% of cases, characterized by heightened vascular permeability and inflammatory exudate due to progesterone surges, leading to edematous and erythematous gingival changes that typically subside postpartum.^[22] Environmental factors prompt adaptive gingival remodeling, as seen in orthodontic tooth movement where applied forces induce collagen reorganization and transient gingival inflammation on the pressure side, followed by tissue adaptation without permanent recession in most cases. Trauma, such as from injury or excessive occlusal loading, triggers a phased response involving inflammation, proliferative repair, and matrix remodeling to restore gingival integrity, often resulting in heightened keratinized tissue formation.^[23]^[24]

Functions

Protective mechanisms

The gums, or gingiva, serve as a primary barrier against microbial invasion through their keratinized epithelium, which forms a tough, protective layer on the outer surface exposed to the oral environment. This stratified squamous epithelium, particularly in the masticatory mucosa, provides mechanical resilience and prevents pathogens from penetrating into the underlying connective tissue and periodontal structures. The keratinization process involves the production of keratin proteins that strengthen the epithelial cells, creating an impermeable shield that resists abrasion and bacterial adhesion.^[25]^[26] A critical sealing role is fulfilled by the junctional epithelium and the gingival sulcus, which together form a tight, non-keratinized cuff around the tooth necks, effectively blocking bacterial entry into the periodontal ligament and alveolar bone. The junctional epithelium adheres directly to the tooth surface via hemidesmosomes and internal basal lamina, maintaining a dynamic seal that accommodates minor movements while excluding oral biofilms. The gingival sulcus, a shallow V-shaped crevice approximately 0.5–3 mm deep in health, further enhances this barrier by containing the initial microbial challenge without allowing deeper invasion.^[27]^[28] Mechanically, the attached gingiva contributes to protection by its firm, collagen-rich structure that anchors to the periosteum and absorbs masticatory forces, thereby preventing recession and exposure of root surfaces. This immobile portion of the gingiva, distinguished by its stippled appearance and keratinized surface, dissipates shear and compressive stresses during chewing, safeguarding the underlying bone from trauma and maintaining gingival contour integrity. Studies on oral mucosa biomechanics highlight the superior tensile strength of attached gingiva compared to other mucosal regions, underscoring its role in load distribution.^[29]^[7]^[30] Immune defense in the gingiva involves resident immune cells, such as Langerhans cells and neutrophils, alongside antimicrobial peptides secreted into the gingival crevicular fluid (GCF). These peptides, including human beta-defensins (hBDs) and cathelicidin LL-37, exhibit broad-spectrum activity against bacteria, fungi, and viruses by disrupting microbial membranes and modulating inflammation. GCF, an exudate rich in immunoglobulins and cytokines, flows continuously into the sulcus, delivering these effectors to neutralize threats at the tooth-gingiva interface and recruit additional immune responses when needed.^[31]^[32]^[33] The gums demonstrate robust wound healing capacity through rapid epithelial turnover and efficient collagen synthesis, enabling quick repair after injury or surgical intervention. Gingival epithelial cells exhibit a turnover rate of approximately 4–6 days, far exceeding that of skin, which facilitates swift re-epithelialization and barrier restoration with minimal scarring. Fibroblasts in the connective tissue rapidly upregulate collagen type I production, driven by growth factors like TGF-β1, to rebuild structural integrity within weeks, supporting overall periodontal stability.^[34]^[35]^[24]^[36]

Sensory and supportive roles

The gingiva receives sensory innervation primarily from the superior and inferior alveolar nerves, which are branches of the maxillary (V2) and mandibular (V3) divisions of the trigeminal nerve (cranial nerve V), enabling detection of pain, touch, and temperature in the oral mucosa.^[37]^[38]^[39] These nerves form a dense plexus within the gingival connective tissue, providing fine tactile discrimination essential for oral sensory processing.^[39] Mechanoreceptors located in the periodontal ligament and gingival tissues play a key role in proprioception, facilitating the regulation of bite force during occlusion and mastication by relaying mechanical stimuli to the central nervous system.^[40]^[41] These receptors, including Ruffini-like endings, respond to low-threshold forces as small as 1 N, contributing to precise control of jaw movements and preventing excessive loading on teeth.^[42] Gingival mechanoreceptors specifically enhance tactile feedback, supporting adaptive responses in dynamic oral activities.^[43] The attached gingiva serves a critical supportive function by firmly anchoring the teeth through its collagenous fibrous connections to the underlying alveolar bone and cementum, thereby stabilizing the dentition against mechanical stresses.^[44] This firm attachment, typically 3-12 mm in width, helps distribute occlusal loads across the periodontium, dissipating forces during biting and chewing to maintain structural integrity.^[45]^[46] During mastication, the gingiva provides a cushioning effect that absorbs and redirects chewing forces, reducing the risk of trauma to the underlying mucosal and periodontal structures.^[44] This resilient tissue layer, in conjunction with the periodontal ligament, modulates impact to protect against injury while enabling efficient food breakdown.^[47] Gingival sensitivity contributes to sensory feedback that supports coordinated movements in swallowing and speech, integrating tactile cues from the oral cavity to refine motor patterns.^[48] This proprioceptive input aids in bolus positioning and articulation precision, ensuring smooth transitions between oral phases of these functions.^[49]

Healthy characteristics

Appearance and color

The normal color of healthy gingiva typically ranges from coral pink to salmon pink in individuals with light skin tones, while it can vary to shades of brown or black in those with darker complexions due to the presence of melanin produced by melanocytes in the gingival epithelium.^[50]^[51] This pigmentation arises from the deposition of melanin granules, which contribute to the tissue's protective function against environmental factors.^[52] Gingival pigmentation is influenced by genetic factors, such as racial and ethnic differences, which determine the baseline melanin content and distribution.^[53] Physiological factors, including hormonal variations, can also modulate melanin production and lead to temporary increases in pigmentation intensity without indicating pathology.^[2] In healthy gingiva, the attached portion often exhibits a stippled or speckled uniformity, resulting from microscopic projections of connective tissue into the overlying epithelium that create a textured, orange-peel-like surface.^[2] This stippled appearance is smoother or absent in the marginal and sulcular regions, where the epithelium forms a more uniform barrier around the teeth.^[54] Gingival thickness can be visually assessed through translucency: thin biotypes appear delicate and translucent, allowing underlying structures like tooth roots to show through, whereas thick biotypes present an opaque, robust look.^[55]^[56] Variations in gingival color also occur with gender and age; males tend to have slightly darker pigmentation, often with more blue undertones in color coordinates, compared to females.^[57] Gingival pigmentation tends to increase with age as melanin levels rise.^[50]

Texture and contour

The healthy gingiva presents a firm and resilient texture, primarily attributable to the dense collagen fiber network within its connective tissue, which provides structural support and elasticity. This firmness is most evident in the attached gingiva, which adheres tightly to the underlying periosteum and resists deformation under normal oral forces.^[45] A characteristic feature of the attached gingiva is its stippled surface, resembling the texture of an orange peel, caused by small, rounded projections of the epithelium into the subjacent connective tissue.^[45] This stippling is typically more pronounced in the attached portion and interdental regions, contributing to the gingiva's overall resilience and indicating robust epithelial-connective tissue integration. In terms of contour, the marginal gingiva forms a thin, knife-edge margin that follows a scalloped outline, adapting closely to the curvature of the cemento-enamel junction without visible gaps.^[45] The interdental papillae adopt a pyramidal shape, filling the embrasures between adjacent teeth to maintain tight interproximal seals. This precise contour ensures effective coverage of the alveolar bone and root surfaces. The gingiva demonstrates high adaptability by forming a close apposition to tooth surfaces, with the gingival sulcus maintaining a shallow depth of 0-3 mm in health. During clinical probing, healthy gingiva resists penetration beyond this depth without bleeding or signs of recession, reflecting its intact attachment apparatus.^[45] Regional variations in texture are notable, with the labial gingiva often exhibiting more stippling compared to the lingual aspects, influenced by differences in epithelial keratinization and functional demands.^[58]

Response to stimuli

In healthy gums, gentle probing or brushing does not induce hemorrhage, distinguishing normal tissue from inflamed states where bleeding readily occurs.^[59] This absence of bleeding reflects the integrity of the gingival sulcular epithelium and underlying connective tissue, which resist minor mechanical disruptions without vascular compromise.^[60] Healthy gums exhibit a high pain threshold to routine mechanical pressures, such as those encountered during chewing, remaining painless under normal functional loads.^[59] While mild sensitivity may arise from extreme stimuli like intense thermal or chemical exposure, the gingival tissues tolerate everyday oral activities without discomfort, owing to their dense innervation and robust somatosensory adaptation.^[61] The inflammatory resilience of healthy gums ensures rapid resolution of minor trauma, such as superficial abrasions, without persistent swelling or redness.^[24] This controlled response involves transient neutrophil and macrophage recruitment to clear debris, followed by swift subsidence of any initial inflammation, preventing progression to chronic changes.^[62] Gingival crevicular fluid (GCF) in healthy gums serves as a baseline low-volume exudate, typically a few microliters per hour, with inherent antimicrobial properties that flush bacteria and deliver defensive agents like lactoferrin and myeloperoxidase into the sulcus.^[63] Upon mild stimulation, such as mastication or gentle irritation, GCF secretion increases slightly to enhance this protective barrier without eliciting inflammation.^[64] Healing dynamics in healthy gums feature efficient epithelial migration, where keratinocytes from the wound margins advance as a cohesive sheet to close small incisions within 2-3 days.^[24] This process, initiated within 12-24 hours post-injury, restores the epithelial barrier through proliferation and remodeling, supported by granulation tissue formation beneath the migrating layer.^[65]

Pathology

Inflammatory diseases

Inflammatory diseases of the gums encompass a range of conditions characterized by localized immune responses to microbial or autoimmune triggers, leading to tissue damage without initial involvement of deeper periodontal structures. These disorders primarily affect the soft gingival tissues and are distinguished from healthy states by excessive redness, edema, and disrupted epithelial integrity, deviating from the baseline mild inflammatory response to mechanical stimuli observed in normal gums. The most common forms include plaque-induced inflammation and more severe acute or chronic variants. Gingivitis represents the most prevalent inflammatory condition, manifesting as a reversible inflammation confined to the marginal gingiva due to the accumulation of bacterial plaque biofilm along the gumline. This biofilm, composed of diverse microbial communities, triggers an inflammatory cascade that results in clinical signs such as gingival redness, swelling, and spontaneous or provoked bleeding upon brushing or probing. Unlike deeper infections, gingivitis does not involve attachment loss and fully resolves with effective plaque removal, highlighting its superficial and host-responsive nature.^[3] Periodontitis is a destructive inflammatory disease that develops as an extension of untreated gingivitis, where pathogenic bacteria invade the subgingival area, eliciting a chronic immune response that affects the periodontal ligament and alveolar bone. Clinical features include probing depths greater than 4 mm, clinical attachment loss, radiographic evidence of bone resorption, and potential tooth mobility. Unlike gingivitis, periodontitis is irreversible and can progress to severe stages leading to tooth loss if not managed through scaling, root planing, and possibly surgical interventions.^[66] Acute necrotizing ulcerative gingivitis (ANUG), also known as trench mouth, is a rapidly progressive form of gingival inflammation marked by tissue necrosis, severe pain, and the formation of a grayish pseudomembrane covering ulcerated interdental papillae. Etiologically, ANUG arises from a polymicrobial invasion dominated by Fusobacterium and spirochetal species, often exacerbated by predisposing factors like psychological stress, poor oral hygiene, and immunosuppression. Symptoms include fetid halitosis, fever, and lymphadenopathy, with lesions presenting as punched-out craters that can lead to rapid tissue sloughing if untreated. Desquamative gingivitis constitutes a chronic inflammatory variant characterized by episodic sloughing of the gingival epithelium, resulting in painful erosive lesions, erythema, and fragile bullae that rupture to form denuded areas. This condition is frequently autoimmune-mediated, with mucous membrane pemphigoid being a primary culprit, where autoantibodies target hemidesmosomal proteins, leading to subepithelial separation and persistent gingival fragility. Unlike bacterial forms, desquamative gingivitis often requires immunosuppressive therapy to halt the cycle of epithelial desquamation and secondary infection. The progression of these inflammatory diseases typically begins with dysbiosis in the subgingival biofilm, where shifts in microbial composition—favoring pathogenic species—elicit an exaggerated host immune response. This dysbiosis prompts the release of pro-inflammatory cytokines, including interleukin-1 (IL-1) and tumor necrosis factor (TNF), from gingival fibroblasts, macrophages, and neutrophils, amplifying local inflammation and tissue breakdown. Such cytokine-mediated pathways underscore the interplay between microbial ecology and innate immunity in driving gingival pathology. Epidemiologically, gingivitis affects over 90% of adults worldwide, reflecting its near-ubiquitous association with inadequate plaque control, while smoking elevates the risk and severity of inflammatory progression by impairing immune surveillance and vascular responses in the gingiva.

Non-inflammatory conditions

Gingival recession refers to the apical displacement of the gingival margin, resulting in exposure of the root surface and potential dentin hypersensitivity. Non-inflammatory causes include mechanical trauma, such as aggressive toothbrushing, and anatomical factors like a thin gingival biotype, where the gingival tissue thickness is less than 1.1 mm, predisposing individuals to recession due to reduced tissue resilience.^[67] This condition leads to root sensitivity from exposure to thermal, tactile, or chemical stimuli, and may contribute to root caries or aesthetic concerns, particularly in anterior teeth.^[68] The severity of gingival recession is commonly assessed using the Miller classification system, proposed in 1985, which evaluates the extent of recession relative to the mucogingival junction and interdental bone or soft tissue loss to predict root coverage outcomes. Grade I involves marginal tissue recession not extending to the mucogingival junction with no interdental bone or soft tissue loss, offering a good prognosis for complete root coverage. Grade II features recession extending to or beyond the mucogingival junction but without interdental loss, with a moderate prognosis. Grade III includes recession beyond the mucogingival junction with partial interdental bone or soft tissue loss less than 50% of the recession depth, resulting in a poor prognosis for full coverage. Grade IV denotes severe recession beyond the mucogingival junction with interdental loss exceeding 50% of the recession depth, yielding a very poor prognosis.^[67] Hyperplastic conditions of the gingiva, characterized by fibrous overgrowth without primary inflammatory drivers, often arise from drug-induced mechanisms. Phenytoin, an anticonvulsant, cyclosporine, an immunosuppressant, and calcium channel blockers like nifedipine are the most common culprits, with phenytoin showing the highest prevalence among users. These drugs promote excessive collagen accumulation in gingival connective tissue, leading to firm, non-bleeding enlargements that primarily affect the interdental papillae and may interfere with mastication or aesthetics. The overgrowth typically develops within months of initiating therapy and is more pronounced in areas of plaque accumulation, though not directly caused by inflammation.^[69] Gingival neoplasms encompass both benign and malignant growths, with benign lesions being far more prevalent. Benign fibromas, often irritation fibromas arising from chronic trauma, present as firm, pedunculated or sessile masses on the gingiva, commonly in adults and twice as frequent in females; they consist of fibrous connective tissue and require excision if symptomatic. Malignant neoplasms, such as squamous cell carcinoma, are rare in the gingiva compared to other oral sites like the tongue, accounting for a small fraction of oral cancers; however, tobacco use, including smoking and smokeless forms, significantly elevates risk, with up to 80% of cases linked to tobacco exposure acting synergistically with alcohol. Early detection is crucial, as gingival squamous cell carcinomas may mimic benign overgrowths.^[70]^[71] Genetic disorders like hereditary gingival fibromatosis represent a rare cause of non-inflammatory gingival overgrowth, with a prevalence of approximately 1 in 175,000 and autosomal dominant inheritance in most cases, though 20% are sporadic. This condition manifests as a benign, slowly progressive, fibrous enlargement of the attached gingiva, often pink with marked stippling, beginning at birth or during the eruption of primary/permanent teeth, and covering teeth partially or completely without inflammation or bone involvement. It may occur in isolation or as part of syndromes like Zimmerman-Laband; treatment involves surgical gingivectomy, preferably after permanent tooth eruption to minimize recurrence.^[72] Systemic conditions can also produce non-inflammatory gingival changes, such as in leukemia, where leukemic cell infiltration leads to gingival swelling or hyperplasia without primary immune-mediated inflammation. This manifestation is most common in acute monocytic (M5) and myelomonocytic (M4) leukemias, affecting up to 66.7% of M5 cases, presenting as soft, edematous enlargements prone to bleeding that regress with chemotherapy. Such gingival involvement may precede systemic diagnosis, highlighting the importance of biopsy in unexplained overgrowths.^[73]

Risk factors and prevention

Poor oral hygiene, characterized by inadequate plaque removal, is a primary modifiable risk factor for gum diseases such as gingivitis and periodontitis, as bacterial accumulation leads to inflammation and tissue destruction.^[4] Smoking significantly increases susceptibility to periodontal disease by impairing immune responses, vascular function, and healing processes, with meta-analyses reporting odds ratios ranging from approximately 2 to 6 for smokers compared to non-smokers.^[74] Diabetes mellitus, particularly when poorly controlled, elevates risk through impaired neutrophil function and hyperglycemia-induced inflammation, making individuals two to three times more prone to severe periodontitis.^[75] Genetic predispositions, such as polymorphisms in the IL-1 gene cluster (e.g., IL-1A -889 and IL-1B +3954), contribute to heightened inflammatory responses and disease severity in susceptible individuals.^[76] Hormonal fluctuations during pregnancy or menstrual cycles can exacerbate gum susceptibility by altering vascular permeability and immune modulation, often leading to pregnancy gingivitis in up to 60-75% of cases or menstrual-related gingival inflammation.^[4] Vitamin C deficiency impairs collagen synthesis in gingival tissues, worsening conditions like scurvy-associated gingivitis with symptoms including bleeding and swelling.^[77] Effective prevention of gum diseases emphasizes modifiable risk reduction through daily oral hygiene practices, including brushing twice daily with fluoride toothpaste and flossing to disrupt plaque formation.^[4] Professional dental cleanings every six months remove calculus and monitor early signs, substantially lowering disease progression rates.^[4] Short-term use of antimicrobial rinses like 0.12% chlorhexidine gluconate, as an adjunct to mechanical cleaning, reduces plaque and gingival inflammation in mild cases.^[78] Public health initiatives promoting fluoride incorporation in toothpaste and water supplies help remineralize exposed root surfaces, thereby reducing gum recession risk.^[79] Smoking cessation programs, integrated into dental care, yield significant benefits by halving periodontitis risk within years of quitting and improving treatment outcomes.^[80]

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Mechanical properties of human oral mucosa tissues are site ... - NIH
Jul 2, 2020 · The highest mechanical properties found in the attached gingiva group showed that the fibres can withstand higher loads compared to the tissues ...
[30]
[PDF] 9 Attached Giniva- A Reliable Factor to Cling-To: Review Article
7 Rose and App found that the width of the attached gingiva is more in permanent dentition when compared to deciduous dentition and increases with age due to ...
[31]
Antimicrobial peptides in periodontal innate defense - PMC - NIH
Analysis of neutrophil-derived antimicrobial peptides in gingival crevicular fluid suggests importance of cathelicidin ll-37 in the innate immune response ...
[32]
Defensins and LL-37: A review of function in the gingival epithelium
Defensins and LL-37 have antimicrobial effects, protect from dental plaque, recruit immune cells, enhance phagocytosis, and act as chemoattractants.
[33]
Salivary Antimicrobial Peptides in Early Detection of Periodontitis
Gingival defensins and cathelicidins are small cationic antimicrobial peptides that play an important role in innate immune response. However, their ...
[34]
Investigating wound healing characteristics of gingival and skin ...
This study explored the contrasting healing efficiencies of gingival and skin keratinocytes, alongside their differential gene expression patterns.
[35]
Distinct Molecular Mechanisms in Oral Mucosal Wound Healing
Additionally, the oral mucosa's rapid healing is facilitated by its high epithelial turnover, the presence of salivary growth-promoting factors such as ...
[36]
Role of Fibroblast Populations in Periodontal Wound Healing and ...
Apr 23, 2019 · After gingival wounding, a fibroblast sub-type (myofibroblast) arises, which is centrally involved in collagen synthesis and fibrillar remodeling.Missing: turnover | Show results with:turnover
[37]
Anatomy, Head and Neck, Mandibular Nerve - StatPearls - NCBI - NIH
The inferior alveolar nerve supplies motor innervations to the mylohyoid and anterior belly of digastric muscles and sensory innervation to the teeth and ...
[38]
Anatomy, Head and Neck, Maxillary Nerve - StatPearls - NCBI - NIH
Jun 5, 2023 · The posterior superior alveolar nerve can supply the region usually innervated by the buccal nerve. The zygomatic nerve can pass through the ...
[39]
Innervation and blood supply of the teeth - Kenhub
The mandibular teeth are primarily supplied by the inferior alveolar nerve which is a branch of the mandibular nerve (third division of the trigeminal nerve).
[40]
The role of periodontal mechanoreceptors in mastication
The primary function of these receptors appears to be in regulating the forces applied by the teeth in occlusion, mastication, and biting (Türker et al., 2007).
[41]
Exploring the mechanical and biological interplay in the periodontal ...
Apr 2, 2025 · The periodontal ligament (PDL) plays a crucial role in transmitting and dispersing occlusal force, acting as mechanoreceptor for muscle activity during chewing.
[42]
[PDF] From periodontal mechanoreceptors to chewing motor control
Periodontal mechanoreceptors are known to be receptors in the periodontal ligament that respond to surprisingly low contact force levels (<1 N) (Newton) applied ...
[43]
The role of gingival mechanoreceptors in the tactile function of ...
Mar 23, 2022 · The aim of this study was to investigate the role of gingival mechanoreceptors in dental-implant osseoperception at the cortical-response level.
[44]
The Role of Attached Gingiva in Implant Therapy
May 9, 2017 · It provides a physical barrier to oral biofilm, dissipates masticatory forces, and protects the periodontium from injury. ... It also mitigates ...Missing: protection | Show results with:protection
[45]
Anatomy of the Periodontium - Dentalcare.com
Attached gingiva – This tissue is adjacent to the free gingiva and is keratinized and firmly attached to the bone structure. It can range from 3-12 mm in ...
[46]
Normal anatomy and clinical significance of attached gingiva: A review
May 13, 2021 · Attached gingiva is a part of keratinized gingiva which aids in periodontium to increase resistance to external injury and contribute in stabilization of ...
[47]
Periodontal Ligament - an overview | ScienceDirect Topics
The periodontal ligament (PDL) is the dense fibrous tissue which attaches the tooth to the alveolar bone. It is continuous coronally with the gingival ...
[48]
Somatosensory innervation of the oral mucosa of adult and aging mice
Jul 2, 2018 · Oral mechanoreception is implicated in fundamental functions including speech, food intake and swallowing; yet, the neuroanatomical ...
[49]
Loss of oral sensation impairs feeding performance and consistency ...
The aim of this study was to quantify the impact of loss of oral somatosensation on feeding performance, 3D tongue kinematics and tongue‐jaw coordination.
[50]
Reconnoitering the Association of Gingival Melanin Pigmentation ...
Oct 26, 2022 · The ideal color of normal gingiva is coral pink in adults and reddish pink in children. The color of the gingiva is varied among different ...
[51]
Gingival pigmentation index proposal of a new index with a brief ...
Sep 25, 2019 · The normal physiologic color of gingiva is coral pink or salmon pink, with physiological variations of melanin pigmentation.
[52]
Gingival pigmentation (cause, treatment and histological preview)
It varies from light to dark brown or black. The skin tone, texture and color differ in various races and regions [3].
[53]
Relationship of skin complexion with gingival tissue color and ... - NIH
Apr 13, 2024 · The study concluded that gender, skin color, and individual location are significantly associated with gingival melanin pigmentation.
[54]
Understanding the Link Between Hormonal Changes and Gingival ...
Jun 3, 2025 · During puberty, elevated levels of estrogen and progesterone enhance blood circulation to the gingival tissues, increasing their sensitivity to ...
[55]
Periodontal Anatomy – Stippling
Because the connective tissue projections within the gingival tissue create microscopic depressions and elevations, stippling occurs. The presence or prominence ...
[56]
Gingival biotype and its clinical significance – A review - ScienceDirect
Thin gingival biotypes are delicate, highly scalloped and translucent in appearance (Fig. ... biotype and to convert the thin biotype to a thick biotype.Missing: opaque | Show results with:opaque
[57]
Gingival Biotype: A Secret for Esthetic Success - Thieme Connect
Jun 14, 2021 · Thin biotype is characterized by thin gingival tissues. It is almost translucent in appearance and possess minimal zone of attached gingiva. It ...Missing: opaque | Show results with:opaque
[58]
Explaining the colour of natural healthy gingiva | Odontology
Feb 25, 2024 · It is influenced by race [15,16,17,18,19,20], the intensity of melanin pigments [21,22,23], sex [17, 24, 25], age [25], location [10, 26, 27], ...Missing: normal | Show results with:normal
[59]
Gingivitis - StatPearls - NCBI Bookshelf - NIH
Clinically, gingivitis presents with redness, swelling, bleeding on probing, tenderness, and occasionally bad breath. ... On periodontal probing, healthy gingiva ...Missing: stimuli | Show results with:stimuli
[60]
The Influence of Toothpaste Containing Australian Melaleuca ... - NIH
Nov 13, 2017 · All patients were described as “healthy gingiva, no bleeding on probing” upon the third examination. However, this trend did not demonstrate ...
[61]
Acute and Chronic Pain from Facial Skin and Oral Mucosa
The heat pain threshold is also higher in the gingiva, while the mechanical pain and vibration detection thresholds are lower in the tongue than other tissues.2.1. Somatosensation Of Oral... · 3.3. Neuropathic Pain · 3.3. 1. Trigeminal Neuralgia...
[62]
https://doi.org/10.1177/0022034514563750
[63]
Gingival Crevicular Fluid: An Overview - PMC - NIH
Gingival crevicular fluid is an inflammatory exudate derived from the periodontal tissues. It is composed of serum and locally generated materials.Missing: properties | Show results with:properties
[64]
https://doi.org/10.4103/JPBS.JPBS_56_19
[65]
[PDF] Healing Following Simple Gingivectomy. A Tritiated Thymidine ...
Epithelial migration appeared to be occur- ring beneath this altered layer, with the epi- thelial cells moving as a sheet of loosely at- tached cells which ...Missing: gum | Show results with:gum
[66]
Treatment of Gingival Recession: When and How? - PMC - NIH
Miller's classification system depends on the mucogingival junction (MGJ), the presence or absence of keratinised tissue (KT), and the interdental bone/soft ...
[67]
Prevalence of gingival recession and its correlation with gingival ...
Jul 1, 2021 · Gingival recession is associated with dentin hypersensitivity, unesthetic appearance, and carious or noncarious cervical lesions.
[68]
Drug-Induced Gingival Overgrowth - StatPearls - NCBI Bookshelf - NIH
Sep 19, 2022 · Phenytoin, cyclosporin, and nifedipine are the most common causes of gingival overgrowth, and phenytoin has the highest prevalence. There is ...
[69]
An Unusually Large Irritation Fibroma Associated with Gingiva ... - NIH
Fibroma is a benign tumor of oral cavity, with usually the tongue, gingiva, and buccal mucosa being the most common sites. Females are twice more likely to ...Missing: neoplasms | Show results with:neoplasms
[70]
Oral cancer: MedlinePlus Medical Encyclopedia
Dec 31, 2023 · Most oral cancers are a type called squamous cell carcinoma. These cancers tend to spread quickly. Smoking and other tobacco use are linked to most cases of ...
[71]
Hereditary gingival fibromatosis: Characteristics and treatment ...
Hereditary gingival fibromatosis (HGF) is a rare disorder characterized by a benign, non-hemorrhagic, fibrous gingival overgrowth that can appear in isolation ...
[72]
Gingival Hyperplasia as an Early Diagnostic Oral Manifestation in ...
Gingival infiltration of leukemic cells is most commonly seen in acute monocytic leukemia (M5) and acute myelomonocytic leukemia (M4)., Dreizen et al evaluated ...
[73]
Gum (Periodontal) Disease | NIDCR
Other risk factors include hormonal changes in girls and women; certain illnesses, such as diabetes or AIDS and their medications; and genetics. Back to top ...Overview · Causes · Symptoms · Diagnosis
[74]
Effect of Smoking on Periodontitis: A Systematic Review and Meta ...
Pooled adjusted risk ratios estimate that smoking increases the risk of periodontitis by 85% (risk ratio=1.85, 95% CI=1.5, 2.2).
[75]
Periodontitis and diabetes: a two-way relationship - PMC
The majority of research has focused on type 2 diabetes mellitus as a risk factor for periodontitis, probably because both diseases have historically tended to ...
[76]
Interleukin-1 Genotype in Periodontitis - PMC - NIH
Jul 19, 2019 · This paper presents the current knowledge concerning the role of polymorphisms of IL1A and IL1B genes in periodontitis.
[77]
Vitamin C Deficiency - StatPearls - NCBI Bookshelf
Nov 12, 2023 · [9] Subsequently, patients with scurvy experience oral and skin symptoms such as bleeding gums, easy bruising, skin rashes, fragility, delayed ...
[78]
Chlorhexidine in Dentistry: Pharmacology, Uses, and Adverse Effects
Mar 12, 2022 · Therefore, if CHX mouthwash is used, it must be used for the control of gingival inflammation as an adjunct to toothbrushing and interdental ...
[79]
Fluoride - an adjunctive therapeutic agent for periodontal disease ...
Oct 1, 2009 · The severity of periodontal disease was significantly associated with fluoride levels, with cases of loss of attachment gradually decreasing when moving from ...
[80]
Impact of Smoking Cessation on Periodontal Tissues - PMC - NIH
Feb 27, 2021 · Results demonstrated that there is convincing evidence to support the benefits of tobacco cessation in reducing the risk of periodontitis and tooth loss.