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Chapter 12
The Gingiva
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The true test of successful treatment, the real evaluation of the effects of scaling and related
instrumentation, is the health of the periodontal tissues. The objective of all treatment is to bring
the diseased periodontal tissues to a state of health that can be maintained by the patient. To do
this, the first objective is to learn to recognize normal healthy tissue; to observe certain
characteristics of color, texture, and form; to test for bleeding; and to apply this knowledge to the
treatment and supervision of the patient's gingiva until health is attained.
An outline of the clinical features of the periodontal tissues in health and disease is included in this
chapter. Key words are defined in Box 12-1.

Box 12-1 Key Words


Key Words: Gingiva and Periodontium
Attachme nt appa ratus: the c ementu m, peri odonta l liga ment, and t he alv eolar bone.
Clinica l atta chment level: the p robin g dept h meas ured f rom a f ixed point, such as th e
cemento enamel junc tion.
Desmosom e: cel l junc tion; consi sts of a de nse pl ate n ear th e cell surfa ce th at rel ates t o a
similar struc ture o n an a djace nt cel l, bet ween which are th in lay ers of extra cellu lar
materia l.
Diaste ma: a s pace betwee n two natur al adj acent teeth . Plur al, di astema ta. Se e also
Primate space , pag e 287 .
Epithel ium
O ral: t he ti ssue s erving as a liner for t he int raoral mucosa l surf aces.
S quamous: compo sed of a la yer of flat, scale like c ells; or may be st ratifi ed.
Fibrobla st: fi ber-pro ducin g cell of th e con nectiv e tis sue; a flatt ened, irreg ularly branc hed
cell wi th a large oval n ucleu s that is re spons ible i n part for t he pro ducti on and remod eling
of the extra cellu lar mat rix.
Fibrosi s: a f ibrous chang e of the mu cous me mbrane , espe cially the gingiv a, as a res ult of
chroni c infl ammatio n; fib rotic gingiv a may appear outwa rdly h ealth y, thu s mask ing
underl ying d iseas e.
Hemides mosome: half of a d esmoso me that forms a sit e of a ttach ment be tween junct ional
epithe lial c ells a nd th e toot h sur face.
Hyperk eratos is: ab normal thicke ning of the kerat in la yer (st ratum corneu m) of t he
epithe lium.
Hyperpl asia: abnor mal inc rease in vol ume of a tis sue o r orga n caus ed by format ion an d
growth of ne w norma l cell s.
Hypertr ophy: i ncreas e in s ize o f tiss ue or organ cause d by a n inc rease in siz e of i ts
consti tuent cells .
Kerati nizatio n: deve lopmen t of a horn y laye r of f latten ed ep itheli al cel ls con taini ng
kerati n.
Marker : iden tifier ; sympt oms or signs by wh ich a partic ular c ondit ion ca n be r ecogn ized;
for ex ample, clinic al an d micro biolog ic mark ers a re use d to i dentif y gin gival and

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p eriod ontal infect ions.


Ma stica tion: ac t of chewin g.
N onkera tinized mucosa : linin g muco sa in which the s tratif ied sq uamous epith elial cells
r etain their nucle i and cytop lasm.
P eriodon tium: ti ssues surrou nding and suppor ting t he te eth; i n two sectio ns ar e the
g ingiv al uni t, comp osed of the free and a ttach ed gin giva a nd th e alve olar mucosa, and the
a ttach ment ap parat us, wh ich in clude s the cement um, per iodon tal lig ament, and alveol ar
p roces s.
P robing d epth: t he dis tance from t he gin gival margin to th e loca tion of the perio donta l
p robe tip in serted for g entle probi ng at the a ttachme nt.
P us: a fluid produc t of inflamma tion t hat c ontain s leu kocyte s, de genera ted ti ssue
e lement s, tis sue fl uids, and mi croorg anisms .
S harpey 's fi bers: penet rating conn ective tissu e fibe rs by which the t ooth i s att ached to
t he ad jacent alve olar b one; t he fi ber bu ndles penet rate c ementu m on o ne sid e and alveo lar
b one o n the other .
S tippling : the pitted , ora nge-pe el app earan ce fre quent ly see n on the su rface of th e
a ttach ed gin giva.
S uppurati on: for mation of pu s.
T aste bu d: rece ptor o f tas te on tongu e and oroph arynx; gobl et-sha ped ce lls o riente d at
r ight a ngles to th e surf ace o f the epith elium.

Objectives
The ultimate objective is to apply knowledge and skill in examination and assessment of the
periodontal tissues to patient care so that each patient attains and maintains optimum oral health.
The dental hygienist must know when the treatment provided by dental hygiene services is definitive
in restoring health and when additional treatment is needed. The patient can be properly informed so
that complete treatment can be provided.
Specific objectives are to be able to

Recognize normal periodontal tissues.

Know the clinical features of the periodontal tissues that must be examined for a complete
assessment.
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Recognize the markers that are the basic signs of periodontal infections and classify them by
type and degree of severity.

Identify the dental hygiene treatment and instruction needed.

Outline the patient's preventive program.

The Treatment Area


The treatment procedures are applied directly to the teeth, the gingiva, and the gingival sulcus.
Detailed knowledge and understanding of the anatomy and normal clinical appearance of the hard
and soft oral tissues are prerequisite to meaningful examination and treatment.

I. The Teeth

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A. Clinical Crown
The part of the tooth above the attached periodontal tissues. It can be considered the part of the
tooth where clinical treatment procedures are applied (Figure 12-1).

B. Clinical Root
The part of the tooth below the base of the gingival sulcus or periodontal pocket. It is the part of the
root to which periodontal fibers are attached.

C. Anatomic Crown
The part of the tooth covered by enamel.

D. Anatomic Root
The part of the tooth covered by cementum.

FIGURE 12-1 Clinical Crown. The part of the tooth that is above the attached
periodontal tissue. Left, When the periodontal pocket depth is increased, the clinical
crown extends to a position at which the clinical crown length is greater than the clinical
root length. The clinical root is that part of the tooth with attached periodontal tissues.
Right, When the clinical attachment level is at the cementoenamel junction, the clinical
crown and the anatomic crown are the same.

II. Oral Mucosa


The lining of the oral cavity, the oral mucosa, is a mucous membrane composed of connective tissue
covered with stratified squamous epithelium. There are three divisions or categories of oral mucosa.

A. Masticatory Mucosa
1.

Covers the gingiva and the hard palate, the areas used most during the mastication of food.

2.

Except for the free margin of the gingiva, the masticatory mucosa is firmly attached to
underlying tissues.

3.

The epithelial covering is generally keratinized.

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B. Lining Mucosa
1.

Covers the inner surfaces of the lips and cheeks, the floor of the mouth, the under side of the
tongue, the soft palate, and the alveolar mucosa.

2.

These tissues are not firmly attached to underlying tissue.

3.

The epithelial covering is not generally keratinized.

C. Specialized Mucosa
1.

Covers the dorsum (upper surface) of the tongue. It is composed of many papillae; some
contain taste buds.

2.

The distribution of the four types of papillae is shown in Figure 12-2.


a.

Filiform. Threadlike keratinized elevations that cover the dorsal surface of the tongue;
they are the most numerous of the papillae.

b.

Fungiform. Mushroom-shaped papillae interspersed among the filiform papillae on the


t i p a n d s i d e s o f t h e t o n g u e . O n c l i n i c a l e x a mi n a t i o n t h e y a p p e a r r e d d e r t h a n t h e f i l i f o r m
papillae and contain
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variable numbers of taste buds. The inset enlargement in Figure 12-2 shows the
comparative shape and size of the filiform and fungiform papillae.

FIGURE 12-2 Papillae of the Tongue. Dorsal surface of a human tongue


shows the four types of papillae. Inset enlargement shows the shape of
filiform and fungiform papillae.

c.

Circumvallate (vallate). The 10 to 14 large round papillae arranged in a V between the


body of the tongue and the base. Taste buds line the walls.

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d.

Foliate. Vertical grooves on the lateral posterior sides of the tongue; also contain taste
buds.

III. The Periodontium


The periodontium is the functional unit of tissues that surrounds and supports the tooth. The four
parts are the gingiva, periodontal ligament, cementum, and bone; the last three make up the
attachment apparatus.

A. Periodontal Ligament

The periodontal ligament is the fibrous connective tissue that surrounds and attaches the
roots of teeth to the alveolar bone.

The ligament is located in the periodontal space between the cementum and the alveolar
bone.

It is composed of connective tissue cells and intracellular substance.

The fibers that are inserted into the cementum on one side and the alveolar bone on the other
are called Sharpey's fibers.

B. Periodontal Ligament Fiber Groups


The two general groups of fibers are the gingival groups (around the cervical area within the
gingival tissues) and the principal fiber groups (surrounding the root).1

1.

Gingival Fiber Groups (Figure 12-3)

Dentogingival fibers (free gingival). From the cementum in the cervical region into the
free gingiva to give support to the gingival.

Alveologingival fibers (attached gingival). From the alveolar crest into the free and
attached gingiva to provide support.

Circumferential fibers (circular). Continuous around the neck of the tooth to help to
maintain the tooth in position.

Dentoperiosteal fibers (alveolar crest). From the cervical cementum over the alveolar
crest to blend with fibers of the periosteum of the bone.

Transseptal fibers. From the cervical area of one tooth across to an adjacent tooth (on
the mesial or distal only) to provide resistance to separation of teeth (Figure 12-4).

2.

Principal Fiber Groups (Figure 12-4)

The five principal groups of collagen fibers are named for their location on the root and for their
direction. They are also called the dentoalveolar fiber groups.

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FIGURE 12-3 Gingival Fiber Groups. Cross section of the gingiva shows the relation of
the gingival fiber groups to the gingival sulcus, the free gingiva, the cementum, and the
alveolar bone.

Apical fibers. From the root apex to adjacent surrounding bone to resist vertical forces.

Oblique fibers. From the root above the apical fibers obliquely toward the occlusal to resist
vertical and unexpected strong forces.

Horizontal fibers. From the cementum in the middle of each root to adjacent alveolar bone to
resist tipping of the tooth.

Alveolar crest fibers. From the alveolar crest to the cementum just below the cementoenamel
junction to resist intrusive forces.

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FIGURE 12-4 Principal Fiber Groups of the Periodontium. The five principal
groups (apical, oblique, horizontal, alveolar crest, and interradicular) are shown.
The transseptal fibers of the gingival fiber groups are also shown as they span
across from the cervical area of one tooth to the neighboring tooth.

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Interradicular fibers. From cementum between the roots of multirooted teeth to the adjacent
bone to resist vertical and lateral forces.

C. Cementum
The cementum is a thin layer of calcified connective tissue that covers the tooth from the
cementoenamel junction to, and around, the apical foramen.

1.

2.

Functions

To seal the tubules of the root dentin.

To provide attachment for the periodontal fiber groups.

Characteristics

Thickness is 50 to 200 m about the apex; 30 to 60 m about the cervical area.

Vascular and nerve connections are missing; therefore, cementum is insensitive.

Relationship of enamel and cementum at the cervical area is shown in Figure 14-2 (page 257).

D. Alveolar Bone

The alveolar bone consists of the lamina dura, which surrounds the tooth socket, and the
supporting bone.

When teeth are lost, the alveolar bone is resorbed.

The bone functions to support the teeth and provide attachment for the periodontal ligament
fibers.

E. Gingiva
The part of the masticatory mucosa that surrounds the necks of the teeth and is attached to the
teeth and the alveolar bone.

The Gingiva and Related Structures


The gingiva is made up of the free gingiva, the attached gingiva, and the interdental gingiva or
interdental papilla.

I. Free Gingiva (Marginal Gingiva)


In health, the free gingiva is closely adapted around each tooth. It connects with the attached
gingiva at the free gingival groove and attaches to the tooth at the coronal portion of the junctional

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epithelium (Figure 12-5).

A. Free Gingival Groove

The free gingival groove is a shallow linear groove that demarcates the free from the attached
gingiva. Generally, about one-third of the teeth show a visible gingival groove when the
gingiva is healthy.2

FIGURE 12-5 Parts of the Gingiva. Cross-sectional diagram shows the parts of the
gingiva and adjacent tissues of a partially erupted tooth. Note that the junctional
epithelium is on the enamel.

In the absence of inflammation and pocket formation, the gingival groove runs somewhat
parallel with and about 0.5 to 1.5 mm from the gingival margin,3 and it is approximately at the
level of the bottom of the gingival sulcus.

B. Oral Epithelium (outer gingival epithelium, Figure 12-6)

Covers the free gingiva from the gingival groove over the gingival margin.

Composed of keratinized stratified squamous epithelium.

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FIGURE 12-6 The Gingival Tissues. Cross-sectional diagram shows the histologic
relationships of the oral, sulcular, and junctional epithelia and the connective
tissue.

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C. Gingival Margin (gingival crest, margin of the gingiva, or free


margin, Figure 12-5)

This is the edge of the gingiva nearest the incisal or occlusal surface.

Marks the opening of the gingival sulcus.

II. Gingival Sulcus (Crevice)


A. Location
The crevice or groove between the free gingiva and the tooth.

B. Boundaries (Figure 12-6)


1.

Inner. Tooth surface. May be the enamel, cementum, or part of each, depending on the
position of the junctional epithelium.

2.

Outer. Sulcular epithelium.

3.

Base. Coronal margin of the attached tissues. The base of the sulcus or pocket is also called

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the probing depth, the depth of the sulcus, or the bottom of the pocket.

C. Sulcular Epithelium
The continuation of the oral epithelium covering the free gingiva. Sulcular epithelium is not
keratinized.

D. Depth of Sulcus

Healthy sulci are shallow and may be only 0.5 mm.

The average depth of the healthy sulcus is about 1.8 mm.4

E. Gingival Sulcus Fluid (sulcular fluid, crevicular fluid)

A serum-like fluid that seeps from the connective tissue through the epithelial lining of the
sulcus or pocket.

FIGURE 12-7 Tooth Eruption and the Gingiva. (A) Before eruption, the oral
epithelium covers the tooth. (B) As the tooth emerges, the reduced epithelium
joins the oral epithelium as the gingival sulcus is formed. (C) Partial eruption with
the junctional epithelium along the enamel. (D) Eruption complete, with junctional
epithelium at the cementoenamel junction. (E) From disease or other cause, the
attachment migrates along the root surface, exposing the cementum.

Occurrence is slight to none in a normal sulcus; increases with inflammation. It is part of the
local defense mechanism and is able to transport many substances, including endotoxins,
enzymes, antibodies, and certain systemically administered drugs.

III. Junctional Epithelium (Attachment Epithelium)


A. Description

The junctional epithelium is a cuff-like band of stratified squamous epithelium that is

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continuous with the sulcular epithelium and completely encircles the tooth.

It is triangular in cross section, is widest at the junction with the sulcular epithelium, and
narrows down to the width of a few cells at the apical end.

The junctional epithelium is not keratinized. It has two basement membranes: one adjacent to
the connective tissue and one adjacent to the tooth surface.

B. Size

The junctional epithelium may be up to 15 or 20 cells in thickness where it joins the sulcular
epithelium and tapers down to 1 or 2 cells in thickness at the apical end.

The length ranges from 0.25 to 1.35 mm.

C. Position

As the tooth erupts, the attachment is on the enamel; during eruption, the epithelium migrates
toward the cementoenamel junction (Figure 12-7).

At full eruption, the attachment is usually on the cementum, where it becomes firmly attached
(Figure 12-7D).

With wear of the tooth on the incisal or occlusal surface and with periodontal infections, the
attachment migrates along the root surface (Figure 12-7E).

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D. Relation of Crest of Alveolar Bone to the Attached Gingival Tissue

The distance between the base of the attachment and the crest of the alveolar bone is
approximately 1.0 to 1.5 mm.

This distance is maintained in disease when the epithelium moves along the root surface and
bone loss occurs.

E. Attachment of the Epithelium to the Tooth Surface

The junctional epithelium or attachment epithelium provides a seal at the base of the sulcus.

The attachment, or connecting interface between the tooth and the tissue, is accomplished by
hemidesmosomes and the basal lamina of the junctional epithelium.

IV. Interdental Gingiva (Interdental Papilla)


A. Location

In health, the interdental gingiva occupies the interproximal area between two adjacent teeth.

The tip and lateral borders are continuous with the free gingiva, whereas other parts are

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attached gingiva.

An interproximal area is also called an embrasure. In Type 1 embrasure the gingival tissue
fills the area; in Type 2 embrasure there is slight to moderate recession of the interdental
gingiva; in Type 3 embrasure there is extensive recession or complete loss of the of the
papilla as shown in Figure 26-1 (page 431).

B. Shape
1.

Varies With Spacing or Overlapping of the Teeth. The interdental gingiva may be flat or
saddle-shaped when wide spaces are between the teeth, or it may be tapered and narrow
when the teeth are crowded or overlapped.

2.

Between Anterior Teeth. Pointed, pyramidal.

3.

Between Posterior Teeth

Flatter than anterior papillae because of wider teeth, wider contact areas, and flattened
interdental bone.

Two papillae, one facial and one lingual, connected by a col, are found when teeth are
in contact.

C. Col
1.

A col is the depression between the lingual or palatal and facial papillae that conforms to the
proximal contact area (Figure 12-8).

2.

The center of the col area is not usually keratinized and thus is more susceptible to infection.
Most periodontal infection begins in the col area.

FIGURE 12-8 Col. A col is the depression between the lingual or palatal and the facial
papillae under the contact area. The contact area is represented by the striped lines. (A)
Mesial of mandibular molar to show wide col area. (B) Mesial of mandibular incisor to
show a narrow col. The col deepens when gingival enlargement occurs.

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V. Attached Gingiva
A. Extent

The attached gingiva is continuous with the oral epithelium of the free gingiva and is covered
with keratinized stratified squamous epithelium.

Maxillary palatal gingiva is continuous with the palatal mucosa.

The attached gingiva of the mandibular facial and lingual gingiva and maxillary facial gingiva
is demarcated from the alveolar mucosa by the mucogingival junction.

B. Attachment
Firmly bound to the underlying cementum and alveolar bone.

C. Shape
Follows the depressions between the eminences of the roots of the teeth.

VI. Mucogingival Junction


A. Appearance

The mucogingival junction appears as a line that marks the connection between the attached
gingiva and the alveolar mucosa.

The anterior line is scalloped, but it is fairly straight posterior to the premolars.

A contrast can be seen between the pink of the keratinized, stippled, attached gingiva and the
darker alveolar mucosa.

B. Location

A mucogingival line is found on the facial surface of all quadrants and on the lingual surface
of the mandibular arch.
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There is no alveolar mucosa on the palate. The palatal tissue is firmly attached to the bone of
the roof of the mouth.

The three mucogingival lines are facial mandibular, lingual mandibular, and facial maxillary.

I n F i g u r e 1 2 - 9 , t h e f a c i a l m a x i l l a r y a n d m a n d i b u l a r m u c o g i n gi v a l j u n c t i o n s a r e s h o w n i n
relation to the attached gingiva and the alveolar mucosa.

VII. Alveolar Mucosa


A. Description

Movable tissue loosely attached to the underlying bone.

It has a smooth, shiny surface with nonkeratinized, thin epithelium. Underlying vessels may be

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seen through the epithelium.

B. Frena (singular: frenum or frenulum)

Description. A frenum is a narrow fold of mucous membrane that passes from a more fixed to
a movable part, for example, from the attached gingiva at the mucogingival junction to the lip,
cheek, or undersurface of the tongue. A frenum serves to check undue movement.

Locations
a.

Maxillary and mandibular anterior frena. At midlines between central incisors. Figure
12-9 shows diagrammatically the location of the anterior frena.

b.

Lingual frenum. From undersurface of the tongue.

c.

Buccal frena. In the caninepremolar areas, both maxillary and mandibular.

Attachment of Frena in Relation to the Attached Gingiva


a.
b.

Closely associated with the mucogingival junction.


When the attached gingiva is narrow or missing, the frena may pull on the free gingiva
and displace it laterally. A tension test is used to locate frenal attachments and check
the adequacy of the attached gingiva (page 239).

FIGURE 12-9 Parts of the Gingiva. The mucogingival junction for each arch
is shown in relation to the attached gingiva, alveolar mucosa, and labial
anterior frena.

The Recognition of Gingival and Periodontal Infections


I. The Clinical Examination
The recognition of normal gingiva, gingival infections, and deeper periodontal involvement depends
on a disciplined, step-by-step examination.
It is necessary to know the extent of the disease. Gingival infections are confined to the gingiva,
whereas periodontal infections include all parts of the periodontium, namely, the gingiva,
periodontal ligament, bone, and cementum.

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A basic examination performed to recognize the signs and effects of inflammation includes
information about at least the following markers:

Gingival tissue changes (color, size, shape, surface texture, position).

Bleeding and exudates.

Mucogingival involvement (adequate width of attached gingiva).

Probing depths; pocket formation (attachment levels).

Furcation involvement.

Dental biofilm (and calculus) present.

Mobility of teeth.

Radiographic evidence.

II. Signs and Symptoms

Patients may or may not have specific symptoms to report because periodontal infections are
insidious in development.

Symptoms the patient notices or feels may include bleeding gingiva, sometimes only while
brushing, sometimes with drooling at night, or sometimes spontaneously.

Other possible symptoms are sensitivity to hot and cold, tenderness or discomfort while eating
or pain after eating, food retained between the teeth, unpleasant mouth odors, chronic bad
taste, or a feeling that the teeth are loose. Most of these are symptoms of advanced disease.

III. Clinically Normal


The terms clinically normal or clinically healthy may be used to designate gingival tissue that is
characterized by the following:

A shade of pale or coral pink varied by complexion and pigmentation.

A knife-edged gingival margin that adapts closely around the tooth.

Stippling; firmness; and minimal sulcus depth with no bleeding when probed.

Although normal varies with anatomic, physiologic, and other factors, general characteristics form
a baseline for a contrast in the recognition of inflammation.
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IV. Causes of Tissue Changes

Disease changes produce alterations in color, size, position, shape, consistency, surface
texture, bleeding readiness, and exudate production.

To understand the changes that take place in the gingival tissues during the transition from
health to disease, it is necessary to have a clear picture of what dental biofilm is, the role of
biofilm microorganisms in the development of disease, and the inflammatory response by the
body.

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When the products of the biofilm microorganisms cause breakdown of the intercellular
substances of the sulcular epithelium, injurious agents can pass into the connective tissue,
where an inflammatory response is initiated.

An inflammatory response means that there is increased blood flow, increased permeability of
capillaries, and increased collection of defense cells and tissue fluid.

The changes produce the tissue alterations, such as in color, size, shape, and consistency,
that are described in the next section.

V. Descriptive Terminology
The degree of severity and distribution of a change should be noted when examining the gingiva.
When a deviation from normal affects a single area, it can be designated by the number of the
adjacent tooth and the surface of the tissue involved, namely, facial, lingual, mesial, or distal.

A. Severity
Severity is expressed as slight, moderate, or severe.

B. Distribution
Terms used for describing distribution are as follows:

1.

Localized: The gingiva is involved only about a single tooth or a specific group of teeth.

2.

Generalized: The gingiva is involved about all or nearly all of the teeth throughout the mouth.
A condition may also be generalized throughout a single arch, the maxillary or mandibular.

3.

Marginal: A change that is confined to the free or marginal gingiva. This is specified as either
localized or generalized.

4.

Papillary: A change that involves a papilla but not the rest of the free gingiva around a tooth.
A papillary change may be localized or generalized.

5.

Diffuse: Spread out, dispersed; affects gingival margin, attached gingiva, and interdental
papillae; may extend into alveolar mucosa. A diffuse condition is more frequently localized,
rarely generalized.

VI. Early Recognition of Tissue Changes

Marked changes, such as moderate to severe generalized redness, enlargement, sponginess,


deep pockets, and definite mobility, are relatively easy to detect even with limited experience,
provided there is good light and accessibility for vision.

In contrast, when changes are subtle, localized about one or a few teeth, and of a lesser
degree of severity, more skillful application of knowledge is needed.

Early recognition and treatment of gingival and periodontal infections prevents neglect of
conditions that can develop into severe disease. Treatment is less complicated, and the
success of treatment and recovery to healthy tissue is predictable when early recognition
makes early treatment possible.

The Gingival Examination


The examination of the gingiva includes evaluation of color, size, shape, consistency, surface

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texture, position, mucogingival junctions, bleeding, and exudate. These are summarized in Table 121, which is a clinical reference chart.

I. Color
A. Signs of Health
1.

Pale Pink. Darker in people with darker complexions.

2.

Factors Influencing Color


a.

Vascular supply.

b.

Thickness of epithelium.

c.

Degree of keratinization.

d.

Physiologic pigmentation: melanin pigmentation occurs frequently in African Americans,


Asians, Indians, and Caucasians of Mediterranean countries.

B. Changes in Disease
1.

In Chronic Inflammation. Dark red, bluish red, magenta, or deep blue.

2.

In Acute Inflammation. Bright red.

3.

Extent. Deep involvement can be expected when diffuse color changes extend into the
attached gingiva, or from the marginal gingiva to the mucogingival junction, or through into
alveolar mucosa.

II. Size
A. Signs of Health
1.

Free Gingiva. Flat, not enlarged; fits snugly around the tooth.

2.

Attached Gingiva
a.

Width of attached gingiva varies among patients and among teeth for an individual, from
1 to 9 mm.5

Table 12-1 Examination of the Gingival Clinical Markers


CHANGES IN
DISEASE
APPEARANCE IN CLINICAL
HEALTH
APPEARANCE
Color

Uniformly pale
pink or coral
pink

Acute: bright
red

CAUSES FOR
CHANGES
Inflammation
Capillary
dilation
Increased
blood flow

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Variations in
pigmentation
related to
complexion,
race

Chronic:
bluish pink,
bluish red

Vessels
engorged
Blood flow
sluggish
Venous return
impaired
Anoxemia
Increased
fibrosis

Attached
gingiva: color
change may
extend to the
mucogingival
line

Deepening of
pocket,
mucogingival
involvement

Size

Not enlarged
Fits snugly
around the
tooth

Enlarged

Edematous:
inflammatory
fluid, cellular
exudate,
vascular
engorgement,
hemorrhage
Fibrotic: new
collagen
fibers

Shape
(contour)

Marginal
gingiva: knifeedged, flat,
follows a curved
line about the
tooth

Marginal
gingiva:
rounded
rolled

Inflammatory
changes:
edematous or
fibrous

Papillae:
(1)normal
contact: papilla
is pointed and
pyramidal; fills
the
interproximal
area

Papillae:
bulbous
flattened
blunted
cratered

Bulbous with
gingival
enlargement
(see
edematous
and fibrotic,
above)

(2)space
(diastema)
between teeth;
gingiva is flat or
saddle shaped

Cratered in
necrotizing
ulcerative
gingivitis

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Consistency

Surface
Texture

Position of
Gingival
Margin

Firm
Attached
gingiva firmly
bound down

Soft, spongy:
dents readily
when
pressed with
probe
Associated
with red
color, smooth
shiny
surface, loss
of stippling,
bleeding on
probing

Edematous:
fluid between
cells in
connective
tissue

Firm, hard:
resists probe
pressure
Associated
with pink
color,
stippling,
bleeding only
in depth of
pocket

Fibrotic:
collagen
fibers

Free gingiva:
smooth

Acute
condition:
smooth,
shiny gingiva

Inflammatory
changes in
the
connective
tissue;
edema,
cellular
infiltration

Attached
gingiva: stippled

Chronic:
hard, firm,
with stippling,
sometimes
heavier than
normal

Fibrosis

Fully erupted
tooth: margin is
12 mm above
cementoenamel
junction, at or
slightly below
the enamel
contour

Enlarged
gingiva:
margin is
higher on the
tooth, above
normal,
pocket
deepened
Recession:

Edematous or
fibrotic
Junctional
epithelium
has migrated
along the
root; gingival
margin
follows

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margin is
more apical;
root surface
is exposed
Position of
Junctional
Epithelium

During eruption
along the
enamel surface
(Figure 12-7)
Fully erupted
tooth: the
junctional
epithelium is at
the
cementoenamel
junction

Position
determined
by use of
probe, is on
the root
surface

Apical
migration of
the epithelium
along the root

Mucogingival
Junctions

Make clear
demarcation
between the
pink, stippled,
attached
gingiva and the
darker alveolar
mucosa with
smooth shiny
surface

No attached
gingiva:
(1) Color
changes may
extend full
height of the
gingiva;
mucogingival
line
obliterated
(2) Probing
reveals that
the bottom of
the pocket
extends into
the alveolar
mucosa
(3) Frenal
pull may
displace the
gingival
margin from
the tooth

Apical
migration of
the junctional
epithelium
Attached
gingiva
decreases
with pocket
deepening
Inflammation
extends into
alveolar
mucosa

Bleeding

No
spontaneous
bleeding or
upon probing

Spontaneous
bleeding
Bleeding on
probing:
bleeding
near margin
in acute
condition;
bleeding
deep in

Degeneration
of the sulcular
epithelium
with the
formation of
pocket
epithelium
Blood vessels
engorged
Tissue

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Exudate

No exudate
expressed on
pressure

pocket in
chronic
condition

edematous

White fluid,
pus, visible
on digital
pressure
Amount not
related to
pocket depth

Inflammation
in the
connective
tissue
Excessive
accumulation
of white blood
cells with
serum and
tissue makes
up the
exudate (pus)

P.221
P.222
b.

W i d e r i n m a x i l l a t h a n m a n d i b le ; b r o a d e s t z o n e r e l a t e d t o i n c i s o r s , n a r r o w e s t a t t h e
canine and premolar regions.

B. Changes in Disease
1.

Free Gingiva and Papillae. Become enlarged. May be localized or limited to specific areas or
generalized throughout the gingiva. The col deepens as the papillae increase in size.

2.

Attached Gingiva. Decreases in amount as the pocket deepens.

C. Enlargement From Drug Therapy


Certain drugs used for specific systemic therapy cause gingival enlargement as a side effect.
Examples of such drugs are phenytoin, cyclosporine, and nifedipine.

III. Shape (Form or Contour)


A. Signs of Health
1.

Free Gingiva
a.

Follows a curved line around each tooth; may be straighter along wide molar surfaces.

b.

The margin is knife-edged or slightly rounded on facial and lingual gingiva; closely
adapted to the tooth surface.

2.

Papillae
a.

Teeth with contact area. Facial and lingual gingiva are pointed or slightly rounded
papillae with a col area under the contact (Figure 12-8).

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b.

Spaced teeth (with diastemata). Interdental gingiva is flat or saddle shaped.

B. Changes in Disease
1.

Free Gingiva. Rounded or rolled.

2.

Papillae. Blunted, flattened, bulbous, cratered (Figure 12-10).

3.

Festoon (McCall's festoon). An enlargement of the marginal gingiva with the formation of a
lifesaver-like gingival prominence. Frequently, the total gingiva is very narrow, with
associated apparent recession, as shown in Figure 12-10D.

4.

Clefts
a.

Stillman's cleft (Figure 12-11). A localized recession may be V-shaped, apostropheshaped, or form a slitlike indentation. It may extend several millimeters toward the
mucogingival junction or even to or through the junction.
P.223

b.

Floss cleft. A cleft created by incorrect floss positioning appears as a vertical linear or
V-shaped fissure in the marginal gingiva.6 It usually occurs at one side of an interdental
papilla. The injury can develop when dental floss is curved repeatedly in an incomplete
C around the line angle so the floss is pressed across the gingiva.

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FIGURE 12-10 Gingival Shape or Contour. (A) Blunted papillae. (B) Bulbous papillae.
(C) Cratered papillae. (D) Rolled, lifesaver-shaped McCall's festoons.

IV. Consistency
A. Signs of Health
1.

Firm when palpated with the side of a blunt instrument (probe).

2.

Attached gingiva is bound down firmly to the underlying bone.

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B. Changes in Disease
1.

To Determine Consistency. Gently press side of probe on free gingiva. Soft, spongy gingiva
dents readily; firm, hard tissue resists.

2.

Soft, Spongy Gingiva. Related to acute stages of inflammation with increased infiltration of
fluid and inflammatory elements. The tissue appears red, may be smooth and shiny with loss
of stippling, has marginal enlargement, and bleeds readily on probing.

3.

Firm, Hard Gingiva. Related to chronic inflammation with increased fibrosis. The tissue may
appear pink and well stippled. Bleeding, when probed, usually occurs only in the deeper part
of a pocket, not near the margin.

4.

Retraction of the Margin Away From the Tooth. Normally, the free gingiva fits snugly about the
tooth. When the margin tends to hang slightly away or is readily displaced with a light air
blast, the gingival fibers that support the margin have been destroyed (Figure 12-3).

V. Surface Texture
A. Signs of Health
1.

Free Gingiva. Smooth.

2.

Attached Gingiva. Stippled (minutely pebbled or orange peel surface).

3.

Interdental Gingiva. The free gingiva is smooth; the center portion of each papilla is stippled.

B. Changes in Disease
1.

Inflammatory Changes. May be loss of stippling, with smooth, shiny surface.

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FIGURE 12-11 Gingival Clefts. (A) V-shaped Stillman's cleft. (B) Slit-like Stillman's
clefts of varying degrees of severity in relation to the mucogingival junction.

P.224
2.

Hyperkeratosis. May result in a leathery, hard, or nodular surface.

FIGURE 12-12 Gingival Recession. Left, Clinically visible recession of the gingival
margin with root surface apparent to the eye. Right, The actual recession exposes
the root surface as the periodontal attachment migrates along the root surface.

3.

Chronic Disease. Tissue may be hard and fibrotic, with a normal pink color and normal or
deep stippling.

VI. Position
The actual position of the gingiva is the level of the attached periodontal tissue. It is not directly
visible but can be determined by probing.
The apparent position of the gingiva is the level of the gingival margin or crest of the free gingiva
that is seen by direct observation.

A. Signs of Health
For the fully erupted tooth in an adult, the apparent position of the gingival margin is normally at the
level of, or slightly below, the enamel contour or prominence of the cervical third of a tooth.

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FIGURE 12-13 Localized Recession. A single tooth may show narrow or wide, deep or
shallow recession. (A) Wide, shallow. (B) Wide, deep, with narrow attached gingiva. (C)
Narrow, deep, with missing attached gingiva.

B. Changes in Disease
1.

Effect of Gingival Enlargement. When the gingiva enlarges, the gingival margin may be high
on the enamel, partly or nearly covering the anatomic crown.

2.

Effect of Gingival Recession


a.

Definition. Recession is the exposure of root surface that results from the apical
migration of the junctional epithelium (Figure 12-12).

b.

Actual recession. The actual recession is shown by the position of the attachment level.
The receded area is from the cementoenamel junction to the attachment.

c.

Visible recession. The visible recession is the exposed root surface that is visible on
clinical examination. It is seen from the gingival margin to the cementoenamel junction.

d.

Localized recession (Figure 12-13). A localized recession may be narrow or wide, deep
or shallow. The root surface is denuded, and the visible recession may extend to or
through the mucogingival junction.

e.

Measurement. Both actual and visible recession can be measured with a probe from the
cementoenamel junction. Total recession is the actual and visible positions added
together.

VII. Bleeding
A. Signs of Health
1.

No bleeding spontaneously or on probing.

2.

Healthy tissue does not bleed.

B. Changes in Disease
1.

Bleeding occurs spontaneously or when probed.

2.

Sulcular epithelium becomes diseased pocket epithelium. The ulcerated pocket wall bleeds

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readily on gentle probing.

P.225

VIII. Exudate
A. Signs of Health
There is no exudate except slight gingival sulcus fluid. Gingival sulcus fluid cannot be seen by
direct observation.

B. Changes in Disease
1.

Increased gingival sulcus fluid.

2.

Amount of exudate is not an indicator of the extent of disease or the depth of the periodontal
pockets.

The Gingiva of Young Children7 , 8


I. Signs of Health
A. Primary Dentition
1.

Color. Pink or slightly red.

2.

Shape. Thick, rounded, or rolled.

3.

Consistency. Less fibrous than adult gingiva; not tightly adapted to the teeth; may be easily
displaced with a light air jet.

4.

Surface Texture. May or may not have stippling; high percentage of patients has shiny
gingiva.

5.

Attached Gingiva. Width of attached gingiva in children aged 3 to 5 years: between 1 and 6
mm.5

6.

Interdental Gingiva
a.
b.

Anterior: diastemata are frequently present and the papillae are flat or saddle shaped.
Posterior: col between facial and lingual papillae when teeth are in contact (Figure 128).

E veryda y Ethi cs
Britain and Nicholas were first-year dental hygiene students just beginning to practice on each
other as student partners in the preclinic program. During the oral examination, Britain noticed
that Nicholas had some areas of bleeding and changes in the contour of the marginal gingiva. In
general, the soft tissue seemed more sponge-like and loose, but Britain was not sure she clearly
understood what is considered normal, remembering that the clinical instructor often referred
to a range of normal.
Britain decided to focus on and document the areas that were pale pink, firm, and pointed in the
interproximal areas. She carefully recorded this information with great detail and then signaled
for her instructor to verify the findings. When the instructor sat down and reviewed the

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examination she was pleased with Britain's thoroughness. The instructor provided positive
feedback and quickly moved on to the next pair of students. Britain began to feel uneasy that
she hadn't pointed out the gingival tissues that she thought were possibly inflamed.

Q uestion s for C onsider ation


1.

Explain how the ethical principles of autonomy, beneficence, and veracity apply to this
situation.

2.

Indicate how Nicholas is the center of this dilemma both from the perspective of Britain, a
student, and the clinical instructor who finds out from another faculty member that he or
she thinks Nicholas has definite signs of periodontal disease.

3.

Ethically, what alternatives or actions can Britain take at this time to address the uneasy
feeling she has about Nicholas' gingival status?

B. Mixed Dentition

Constant state of change related to exfoliation and eruption.

Free gingiva may appear rolled or rounded, slightly reddened, shiny, and with a lack of
firmness.

The gingiva covers a varying portion of the anatomic crown, depending on the stage of
eruption (Figure 12-7).

II. Changes in Disease


Examination of the periodontal tissues of a child is not different from that of an adult. A complete
examination is necessary, including probing around each tooth.
Gingivitis occurs frequently in children but is usually reversible without leaving permanent damage.
Although relatively rare, periodontitis can occur in primary dentition.
Mucogingival problems occur in children.9,10 The recognition of deficiencies of attached gingiva has
particular significance for the child who will need orthodontic treatment.

The Gingiva after Periodontal Surgery


The characteristics of normal healthy gingiva take on different dimensions for the patient who has
completed treatment for pockets, bone loss, and other signs of a periodontal infection. The
junctional epithelium is apical to the cementoenamel junction. After healing, the sulcus
P.226
depths may be within normal range and no bleeding occurs when probed.
Depending on the exact treatment performed, examination shows changes from the initial
evaluation. For example, where the initial examination showed a deficiency of attached gingiva with
frenal pull, mucogingival surgery may have been designed and treatment satisfactorily completed to
create new attached gingiva. With each maintenance appointment, a thorough, careful examination
is necessary to control factors that may permit recurrence of disease.

Factors To Teach The Patient

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C haract eristi cs of normal healt hy gin giva.

Th e sig nifica nce o f blee ding; healt hy tis sue d oes no t ble ed.

R elatio nship of fi ndings durin g a g ingiva l exam inatio n to t he pe rsonal daily care
p rocedu res f or inf ection contr ol.

Th e spe cial a ttent ion ne eded for an area of gi ngival reces sion t o pre vent a brasio n,
i nflamma tion, and fu rther involv ement.

H ow the metho d of b rushin g, sti ffnes s of t oothb rush f ilament s, ab rasive ness o f a
d entifr ice, a nd pr essure appli ed du ring b rushin g can be fa ctors in gin gival reces sion.

References
1. Avery, J.K. and Steele, P.F.: Essentials of Oral Histology and Embryology: A Clinical
Approach. St. Louis, Mosby, 1992, pp. 131134.

2. Ainamo, J. and Le, H.: Anatomical Characteristics of Gingiva: A Clinical and Microscopic
Study of the Free and Attached Gingiva, J. Periodontol., 37, 5, JanuaryFebruary, 1966.

3. Orban, B.: Clinical and Histologic Study of the Surface Characteristics of the Gingiva, Oral
Surg. Oral Med. Oral Pathol., 1, 827, September, 1948.

4. Bhaskar, S.N., ed.: Orban's Oral Histology and Embryology, 11th ed. St. Louis, Mosby, 1991,
pp. 323325.

5 . B o w e r s , G . M .: A S t u d y o f t h e W i d t h o f A t t a c h e d G i n g i v a , J . P e r i o d o n t o l . , 3 4 , 2 0 1 , M a y , 1 9 6 3 .

6. Hallman, W.W., Waldrop, T.C., Houston, G.D., and Hawkins, B.F.: Flossing Clefts: Clinical
and Histologic Observations, J. Periodontol., 57, 501, August, 1986.

7. Duperon, D. and Takei, H.H.: Gingival Diseases in Childhood, in Newman, M.G., Takei, H.H.,
Klokkevold, P.R., and Carranza, F.A.: Carranza's Clinical Periodontics, 10th ed. St Louis,
Saunders/Elsevier, 2006, pp. 404410.

8. Casamassimo, P.S.: Periodontal Conditions, in Pinkham, J.R., ed.: Pediatric Dentistry:


Infancy Through Adolescence, 2nd ed. Philadelphia, W.B. Saunders Co., 1994, pp. 353357,
607615.

9. Maynard, J.G. and Ochsenbein, C.: Mucogingival Problems, Prevalence and Therapy in
Children, J. Periodontol., 46, 543, September, 1975.

10. Andlin-Sobocki, A., Marcusson, A., and Persson, M.: 3-Year Observations on Gingival
Recession in Mandibular Incisors in Children, J. Clin. Periodontol., 18, 155, March, 1991.

Suggested Readings

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Ainamo, A., Ainamo, J., and Poikkeus, R.: Continuous Widening of the Band of Attached
Gingiva From 23 to 65 Years of Age, J. Periodont. Res., 16, 595, November, 1981.

Fedi, P.F., Vernino, A.R., and Gray, J.L.: The Periodontic Syllabus, 4th ed. Baltimore,
Lippincott Williams & Wilkins, 2000, pp. 113.

G r a n t , D . A ., S t e r n , I . B . , a n d L i s t g a r t e n , M . A . , e d s . : P e r i o d o n t i c s , 6 t h e d . S t . L o u i s , M o s b y ,
1988, pp. 375.

Hassell, T.M.: Tissues and Cells of the Periodontium, Periodontol. 2000, 3, 9, 1993.

Hempton, T.J., Wilkins, E., and Lancaster, D.: Evaluation of Attached Tissue Aids in Treatment
of Recession, RDH, 16, 34, June, 1996.

Mariotti, A.: The Extracellular Matrix of the Periodontium: Dynamic and Interactive Tissues,
Periodontol. 2000, 3, 39, 1993.

Melfi, R.C. and Alley, K.E.: Permar's Oral Embryology and Microscopic Anatomy, 10th ed.
Philadelphia, Lippincott Williams & Wilkins, 2000, pp. 237251.

Serino, G., Wennstrm, J.L., Lindhe, J., and Eneroth, L.: The Prevalence and Distribution of
G i n g i v a l R e c e s s i o n i n S u b j e c t s W i t h a H i g h S t a n d a r d o f O r a l H y g i e n e , J . C l i n . P e r i o d o n t o l ., 2 1 ,
57, January, 1994.

Vacek, J.S., Gher, M.E., Assad, D.A., Richardson, A.C., and Giambarresi, L.I.: The Dimensions
of the Human Dentogingival Junction, Int. J. Periodont. Restorative Dent., 14, 155, Number 2,
1994.

Gingiva of Children
American Academy of Periodontology, Committee on Research, Science and Therapy:
Position Paper: Periodontal Diseases of Children and Adolescents, J. Periodontol., 67, 57,
January, 1996.

Andlin-Sobocki, A.: Changes of Facial Gingival Dimensions in Children: A 2-year Longitudinal


Study, J. Clin. Periodontol., 20, 212, March, 1993.

Andlin-Sobocki, A. and Bodin, L.: Dimensional Alterations of the Gingiva Related to Changes
of Facial/Lingual Tooth Position in Permanent Anterior Teeth of Children: A 2-year Longitudinal
Study. J. Clin. Periodontol., 20, 218, March, 1993.

Bimstein, E. and Eidelman, E.: Longitudinal Changes in the Width of Attached Gingiva in
Children, Pediatr. Dent., 10, 22, March, 1988.

Bimstein, E., Machtei, E., and Eidelman, E.: Dimensional Differences in the Attached and

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Keratinized Gingiva and Gingival Sulcus in the Early Permanent Dentition: A Longitudinal
Study, J. Pedod., 10, 247, Spring, 1986.

Bimstein, E., Matsson, L., Soskolne, A.W., and Lustman, J.: Histologic Characteristics of the
Gingiva Associated With the Primary and Permanent Teeth of Children, Pediatr. Dent., 16, 206,
May/June, 1994.

Keszthelyi, G.: The Width of Plaque-Free Zones on Primary Molars With Attachment Loss, J.
Clin. Periodontol., 18, 94, February, 1991.

Saario, M., Ainamo, A., Mattila, K., and Ainamo, J.: The Width of Radiologically Defined
Attached Gingiva Over Permanent Teeth in Children, J. Clin. Periodontol., 21, 666, November,
1994.

Saario, M., Ainamo, A., Mattila, K., Suomalainen, K., and Ainamo, J.: The Width of
Radiologically Defined Attached Gingiva Over Deciduous Teeth, J. Clin. Periodontol., 22, 895,
December, 1995.

Tenenbaum, H. and Tenenbaum, M.: A Clinical Study of the Width of the Attached Gingiva in
the Deciduous, Transitional and Permanent Dentitions, J. Clin. Periodontol., 13, 270, April,
1986.

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