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GINGIVAL

ENLARGEMENT

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CONTENTS

INTRODUCTION

CLASSIFICATION

ETIOLOGY

CLINICAL FEATURES

DIFFERENTIAL DIAGNOSIS

MANAGEMENT

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INTRODUCTION GINGIVA:-

It is defined as that part of oral

mucous membrane that covers the alveolar

bone and surrounds the necks of all the

teeth.

gingiva can be divided into

1.marginal

2.interdental .

3.attached

NORMAL CHARACTERISTICS OF HEALTHY

GINGIVA

1.colour:-colour is coral pink and may vary as

darker in people with darker complexions.

2.contour/shape:-shape of free gingiva is knife

edged &closely adapted to tooth surface.

3.consistency:-firm in consistency.

4.Surface texture:-free gingiva is smooth in

texture. Attached gingiva exhibits surface

stippling.

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5.size:-free gingiva is flat& fits snugly around

the teeth.

GINGIVAL ENLARGEMENT

DEFINITION:-

It is defined as increase in size of gingiva so

that soft tissue overfills the interproximal

spaces, balloons out over the teeth

&protrudes into the oral cavity.

CAUSES:-

1.poor oral hygiene.

2.food impaction.

3.mouth breathing.

4.harmonal changes.

5.drug therapy.

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CLASSIFICATION

According to the etiologic factors and

pathologic changes.

I) Inflammatory enlargement

a). Chronic

b). Acute

II) Drug induced enlargement

III) Enlargements associated with systemic

diseases

A). Conditioned enlargement

1). Pregnancy

2). Puberty

3). Vitamin C4). Plasma cell gingivitis

5). Nonspecific conditioned enlargement

B). Systemic diseases causing gingival

enlargement

1). Leukemia

2). Granulomatous diseases (Wegeners

granulomatosis, sarcodiosis)

IV) Neoplastic enlargement

A). Benign tumors

B). Malignant tumors

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a se en argemen

On the basis of location and distribution

A). Localized: Limited to the gingiva adjacent to

a single tooth or group of tooth.

eg. The gingival enlargement localized in thecanine region

B). Generalized involving the gingiva

throughout the mouth.

C). Diffuse; Involving the marginal and attached

gingiva and papillae

D). Papillary: Confined to the interdental papilla

E).Marginal: confined to marginal papilla.

f).Discrete: an isolated tumour like enlargement

Scoring of gingival enlargement

Grade 0: No signs of gingival enlargement

Grade I: Enlargement confined to interdental

papilla

Grade II: Enlargement involves papilla and

marginal gingiva.

Grade III: Enlargement covers three quarters or

more of the crown

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INFLAMATORY ENLARGEMENT

Gingival enlargement may result from chronic

or acute changes.

Chronic inflammatory enlargement

Etiology:

.Prolonged exposure to dental plaque

.poor oral hygiene

.irritation by anatomic abnormalities

.improper restorative & orthodontic

appliances.

.Mouth breathing habit

Clinical features :

y

Site - interdental, marginal, attachedgingiva

y Shape - slight ballooning to life

preserver shaped bulge

y slow progressing and painless

y painful ulceration sometimes

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cu e n amma ory en argemen -

Gingival abscess

Etiology:

y Bacteria carried deep into the tissues

by toothbrush bristles, piece of apple

coat etc.

Clinical features:

y site - marginal and interdental gingiva

y localized, painful, rapidly expanding.

y Within 24 to 28 hrs lesion becomesfluctuant & purulent exudate

expressed as surface orifice &

rupture spontaneously

DRUG INDUCED GINGIVAL

ENLARGEMENT.

Anticonvulsants

Immunosuppressant's

Calcium channel blockers

affects the speech, mastication, tooth

eruption, and aesthetics problems

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General clinical features:

y site - interdental papilla, facial and lingual

gingival margins

y Starts as a bead massive tissue fold

covering the crown.

y mulberry shaped , firm , pale pink,

resilient.

y no tendency to bleed.

yappears to project frombeneaththe

gingivalmarginseparated by alinear

groove.

y Plaque control becomes difficult.

secondary inflammation .

y red, bluish colored lobulated

demarcations, increased bleeding.

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1).Anticonvulsants

y First gingival enlargement reported

y Introduced by Merritt and Putnam in

1938.

y Drugs used for the treatment of

epilepsyy Phenytoin, ethotoin, mephenytoin,

succinimides etc.

y 50% of the patients

y younger patients more prone

y appears in saliva

y

in systemic administration acceleratesthe healing of gingival wounds in non-

epileptic humans.

MECHANISM

PHENYTOINstimulates fibroblast production of an

proliferation inactive fibroblastic

collagenase

gingival overgrowth

increase in the sulfated decrease in the

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g ycosam nog ycans n co agen egra a on

vitro.

2). Immunosuppressants

y Cyclosporine's used to prevent organ

transplant rejection & to treat

autoimmune origin

y if dosage > 500mg/day reported to

induce gingival enlargement.

y 30% patient.

y More vascularised

y associated with nephrotoxicity,

hypersensitivity, hypertension,

hyperthricosis.

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3).Calcium channel blockers

y used for CVS disorders, hypertension,

angina pectoris, coronary artery spasm

& cardiac arrhythmia.

y Drugs like nifedipine,diltiazem,

felodipine, nitrendipine and verapamil.

y Nifidipine induces enlargement in 20%

cases

y Nifidipine + cyclosporine (for kidney

transplant)

y larger overgrowth

y dose dependent growth

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Idiopathic gingival enlargement

y termed as gingivostomatitis,

elephantiasis, idiopathic fibromatosis,hereditary gingivalhyperplasia &

congenitalfamilialfibromatosis.

Etiology:-

y unknown

y

hereditary basis (autosomal dominant orrecessive)

y begins with primary & secondary

dentition eruption.

Clinical features:

y Site - attached gingiva, gingival margin,

and interdental papilla

y pink, firm and leathery with pebbled

appearance

y Severe cases jaw appears distorted due

to bulbous enlargement

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ENLARGEMENT ASSOCIATED WITH

SYSTEMIC DISEASES

y Many systemic diseases can develop

oral manifestations that may affect the

periodontium by two different

mechanisms

1). Magnification of existing inflammation

initiated by dental plaque Conditioned

enlargement

a). Hormonal conditions(pregnancy &puberty)

b). Nutritional (vitamin C deficiency)

c). Non- specific conditioned enlargement

secondary inflammation

2). Manifestation of systemic disease

independent of the inflammatory status of

the gingiva. This group described as

Systemic diseases causing gingivalenlargement

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Conditioned enlargement

y systematic condition of the patient

exaggerates the usual gingival response

to dental plaque

bacterial plaque is necessary for its initiation

3 types

a) Enlargement in pregnancy

b) Enlargement in puberty

c) Enlargement in vitamin C deficiency

A) Enlargement in pregnancyMarginal and generalized

y Etiology-

y increase in progesterone and

estrogen till 3rd trimester

y increased vascular permeability and

gingival edema.

Marginal enlargement

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n ca ea ures :-

y generalized and interproximal

y bright red, soft friable and

bleeds spontaneously.

B) Enlargement in Puberty

y In both male & female adolescents

y Clinical features :

y -marginal & interdental

y

-chronic gingival diseasey -reduces after puberty

y -Capnocytophagasp.. & P. intermedia

C)enlargementinVitaminCdeficiency

Clinical features :

y Marginal gingivitis

y hemorrhage on slight provocation

and surface necrosis with

pseudomembrane formation

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Plasma cell gingivitis

Referred to as atypical gingivitis and

plasma cell gingivostomatitis

site- marginal and attached gingiva

Clinical features :

-red, friable, bleeds easily-oral aspect of attached gingiva

Non specific conditioned

enlargement (pyogenic

granuloma)

Tumor like gingival enlargement

conditioned response to minor trauma

Clinical features:

y discrete spherical tumor like mass

y pedunculated, keloid like

y red friable with ulceration

yfibro epithelial papilloma

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Systemic diseases causing

gingival enlargement :-

LeukemiaClinical features:y -diffuse or marginal

y localized or generalized tumor like

mass in interproximal spaces

y red, friable, firm and hemorrhagic

y

painful necrotizingy ulcerative inflammation

Granulomatous diseases :-

Wegeners granulomatosisEtiology: cause unknown (immunologically

mediated tissue injury)

y Characterized by acute granulomatous

necrotizing lesion of respiratory tract

involving the orofacial region

Clinical features:

y reddish purple bleeds easily.

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arco os s :-

Etiology:-

y unknown

y red, smooth, painless enlargement

NEOPLASTIC ENLARGEMENT (GINGIVALTUMORS) :-

A).Benign tumors of gingiva

Epulis all discrete tumors & tumor like

masses of gingiva

considered inflammatory growth of gingiva & hard palate

1)Fibroma:- arises from connective tissue

or PDL

y slow growing, firm, nodular, soft,

vascular, pedunculated.

2). Papilloma:

y proliferation of surface

epithelium associated with

human papilloma virus(HPV)

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y cau ower e pro u erances

broad, hard.

Human Papilloma Virus(HPV) :-

Histopathology:

y Finger like projections of stratified

squamous epithelium, often

hyperkeratotic.

yfibrovascular core.

3)Peripheral giant cell granuloma

Clinical features

y interdentally, gingival marginy pedunculated, smooth,

multilobulated,ulcerations

y painless, firm , spongy

locally invasive destroys underlying

bone

Central giant cell granuloma :-

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y w n e aw an pro uce cen ra

cavitations.

Leukoplakia

y

Defined as a white plaque that cannotbe diagnosed as any other etiology

other than that associated with

tobacco chewing.

Etiology- C. albicans, HPV-16, trauma.

Clinical features - white, flattened, scaly,

thick keratinous plaque.

Gingival cyst :-

y Localized, marginal& attached

mandibular canine & premolar areas

painless& erodes the bone

y Cyst developers from odontogenic

epithelium

2).Malignant tumors

Carcinomas

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y 3% of all malignant tumors in the body.

y squamous cell carcinoma- common.

clinical features :-

y Exophytic, irregular growth, ulcerative,

flat, erosive lesions.y symptomless initially then painful

invades the bone .

Malignant melanoma

y site - hard palate& maxillary gingiva

localized pigmentation

yflat or nodular

y rapid growth with early metastasisy arises from melanocytes from the

gingiva

Sarcoma

Fibrosarcoma, lymphosarcoma& reticulumcell sarcoma of gingiva

Kaposis sarcoma.

False enlargement :-

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Appear as a result of increase in size of

underlying osseous or dental tissues.

A.UNDERLYING OSSEOUS LESIONS:-

y

Enlargement of bone subjacent tothe gingival area occurs, most

often in tori & exostosis & can also

occur in pagets disease, fibrous-

dysplasia,cherubism,osteoma,ost

eos-arcoma.

B. Underlying dental tissues

y during stages of eruption

particularly primary dentition.

y labial gingiva may show a bulbousmarginal distortion.

This enlargement is called developmental

enlargement.

Syndromes associated with

gingival enlargement :-

1.Cross syndrome:- gingival enlargement,

hypopigmentation,

microopthalmos,

athetosis,

oligophrenia

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. u er or syn rome:- g ng va

enlargement ,corneal dystrophy.

3.Robinow syndrome:- gingival

enlargement, foetal face.

4.Sturge-webersyndrome:- gingival

angiomas , Enchephalofacial angoimatosis.

5.Cowdens syndrome:-generalized

papillomatosis.

6.Murray-Puretic- Dresher syndrome:-gingival fibromatosis with multiple fibromas.

DIFFERENTIAL DIAGNOSIS:-

1.Fibrotic gingival enlargement tissue is

firm,hard,fibrous in consistency.do not bled

readily.

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. umour e g ng va en argemen :- es ons ar

discrete mushroom like spherical masses with

deep red pinpoint margins.

3.Inflammatory gingival enlargement :- involved

tissues are glossy,smoth, oedematous and

bleed readily.

4.Idiopathic gingival enlargement :- gingiva is

pink ,firm,leatherywith pebbled appearance.

5.enlargement in pregnancy :-gingiva is bright

red,soft friable& bleeds spontaneously.

6.Enlargement in vitamin c deficiency :-gingivais bluish red,soft, shiny surface.

7.Non specific condiotioned enlargement:-

discrete spherical ,tumour like masseswith

pedunculated attachment.

8.Leukaemia :- lesions are red,friable,firm&necrotizing.

9.Wegners granulomatosis :-reddish purple

lesion.

10.Sarcoidosis :- lesion is smooth,red ,painless.

MANAGEMENT

1). CHRONIC INFLAMMATORY ENLARGEMENT

Enlargements which are soft ,discolored are

treated by scaling and root planning.

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n argemen s w c are rous are rea e y

surgical removal.

Surgical removal involves 2 techniques

1.GINGIVECTOMY.

2.FLAP OPERATION.

2).TUMORLIKE INFLAMMATORY

ENLARGEMENT :-

These are treated by gingivectomy as follows,

Local anaesthesia is given to the patient and

tooth surfaces beneath the mass arescaled toremove calculus and debris.

Lesion is separated from the mucosa at its

base with a number 12 bard parker blade.

The involved tooth surfaces are scaled &the

area is cleansed with warm water.

A periodontal pack is applied and removed

after a week.

3). PERIODONTAL ABSCESSES :-

These are treated by following steps,

1.Drianage through pocket retraction or

incision.

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.sca ng an roo p ann ng.

3.Periodontal surgery.

4.Systemic antibiotics.

5.Tooth removal.

4).GINGIVAL ABSCESSES :-

y Scaling and root planning leads to removal

of microbial deposits.

y In acute situations,flctuant area is incised

with a 15 scalpel blade,exudates isexpressed by gentle pressure.

y The area is irrigated with warm water and

covered with moist gauze

5).DRUG ASSOCIATED GINGIVALENLARGEMENT :-

y Primary consideration should be possibility

of discontinuing the drug or changing

medication.

ANTICONVULSANT ALTERNATIVE DRUG

Phenytoin Carbamazepine

Valproic acid

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CALCIUM CHANNEL ALTERNATIVE DRUG

BLOCKERS

Nifedipine Diltiazem

Verapamil

IMMUNOSUPPRESANTS ALTERNATIVE DRUG

Cyclosporine Tacrolimus

y Secondarily plaque control is emphasized.

y Tertiarily persisting gingival enlargements

are treated with gingivectomy and flap

surgery

y Recurrence of drug induced enlargement isseen in surgically treated cases.

y Chlorhexidine gluconate rinses,professional

cleanings can decrease the speed & degree

of recurrence.

LEUKAM IC GINGIVAL ENLARGEMENT :-

y Scaling and root planning under local

anesthesia.

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y n a rea men cons s s o remov ng a

loose accumulations with cotton pellets,

performing superficial scaling

y Progressively deeper scaling is carried

out at subsequent levels.

y

Antibiotics are administeredsystemically the evening before and for

48 hrs after each treatment to reduce

risk of infection.

GINGIVAL ENLARGEMENT IN

PREGNANCY:-

y Elimination of all local irritants.

y

Marginal and interdental gingivalenlargement are treated by scaling

and curettage.

y Good preventive dental programme

consisting of nutritional

counseling,plaque control measures.

y

Lesions should be removed surgicallyduring pregnancy only if they

interfere with mastication or it is

unaesthetic.

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GINGIVAL ENLARGEMENTS IN

PUBERTY :-

y Scaling and curettage.

y Removal of al sources of irritation

and controlling plaque.

y Anti microbial mouth

washes,antibiotic therapy in

severe cases.

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REFERENCE BOOKS

*BURKITTS ORAL MEDICINE

*CARRANZA-TEXTBOOK OF

PERIODONTOLOGY

*SHAFFERS ORAL PATHOLOGY

*CRISPY AND SCULLY

*INTERNET