GINGIVAL ENLARGEMENT

Gingival enlargement or gingival overgrowth

Increase in the size of gingiva

Old terminology gingival hyperplasia (not used more)

Management depends on origin of enlargement

Classified according to :
Etiologic factors and pathologic change
According to location and distribution
According to the degree of enlargement
 CLASSIFICATION
Based on etiologic factors and pathologic changes

I. Inflammatory Enlargement
Acute
Chronic

II. Drug-induced enlargement

Conditioned enlargement

1. Pregnancy
2. Puberty
3. Vitamin C deficiency
4. Plasma cell gingivitis
5. Nonspecific conditioned enlargement
 CLASSIFICATION

Systemic diseases causing gingival enlargement

1. Leukemia
2.Granulomatous diseases (Wegener's
granulomatosis, sarcoidosis)

Genetic gingival enlargement

Hereditary gingival fibromatosis

Neoplastic enlargement (gingival tumors)

Benign tumors
Malignant tumors

False enlargement
 Based on distribution
localized or generalized
.
I- Localized

A- Isolated” enlargements : limited to single or two teeth

Sessile
Pedunculated
Tumor-like enlargements (e.g., fibroma/pyogenic granuloma). “

B-Regional” enlargements : around three or more teeth in one or multiple areas of the
mouth
(e.g., inflammatory enlargement associated with mouth breathing in maxillary anterior
region).

II- Generalized :
Enlargement refers to involvement of gingiva adjacent to almost all the teeth (e.g., drug
influenced gingival overgrowth
SEVERITY OF GINGIVAL ENLARGEMENT

Degree 0 - No gingival enlargement

Degree 1 - Enlargement located on interdental papilla

Degree 2 - Enlargement involved papilla and marginal gingiva

Degree 3- Enlargement that covers ¾ or more of the tooth crown

(Bokenkamp, 1994, DeAngelo, 2007, Douzgou and Dallapicolla,2011).

1. INFLAMMATORY ENLARGEMENT

Gingival
abscess
ACUTE

Periodontal
INFLAMMATORY abscess

CHRONIC
 Inflammatory enlargement
Most common form of gingival enlargement
Chronic inflammatory response to local irritant associated with gingiva

Poor oral
hygiene

Plaque
Malocclusion accumulation Improper
restoration
& retention

Orthodontic
appliances
 Inflammatory enlargement
CLINICAL PICTURE
Smooth , edematous enlarged gingival tissue Ballooning of interdental papilla
& marginal gingiva
appear bluish or deep red
Bleed easily
Localized / generalized
Discrete sessile or pedunculated
(tumor like mass)
Progress- slowly and painlessly
Pseudopockets
Occasionally, chronic inflammatory enlargement may also present as firm,
resilient, pink and fibrotic enlargement
Treatment
Non –surgical treatment
Oral hygiene instructions
Supra- and subgingival scaling followed by reevaluation at 4 weeks
Correcting local factors
Treating underlying systemic diseases and controlling predisposing conditions
Surgical phase : Gingivectomy and gingivoplasty technique
 Enlargements associated with systemic diseases
or conditions
Two mechanisms
Conditioned enlargement
Magnification of an existing inflammation initiated by dental plaque
1. Hormonal – Pregnancy , Puberty
2. Nutritional – Vitamin C deficiency
3. Allergic
4. Non specific conditioned

Systemic disease causing enlargement

Enlargement as manifestations of systemic diseases independently of
presence of dental plaque

1. Leukemia
2. Wegeners granulomatosis
 b. Enlargement in puberty

• Male and female adolescents

• Areas of plaque accumulation

• Facial surface

• Marginal and interdental

Hormonal changes
Prevotella intermedia &
Prevotella nigrescens.

After puberty – spontaneous reduction

 a. Enlargement in pregnancy

1. Marginal , Interdental
2. Localized or generalized enlargement
3. Single or multiple tumor like masses

Prevalence of 30% and even ranging up to 100%

ETIOLOGY AND PATHOGENESIS :

Hormonal changes
(ESTROGEN AND PROGESTERON )

Subgingival microbiota – increase proportion of P.

intermedia
 Enlargement in Pregnancy
CLINICAL FEATURES

- Bright red or light purplish red color

- Friable , smooth & shiny surface

- Bleeding – spontaneously or on slight provocation

- PLAQUE MUST PRESENT

2. Tumor like gingival enlargement

Pregnancy tumor
Not a neoplasm , it is an inflammatory response to bacterial plaque and
modified patients condition

localized, Tumor-like growth

Most Common :
labial aspect of the anterior maxillary region

Etiology
Local factors :
Chronic trauma ,
irritation from calculus or restorations
CLINICAL FEATURES

- Soft , friable , discrete mushroomlike or flattened

- Doesn't invade underlying bone

- Bleed easily

- May have ulcerated surface

- Painless unless its size and shape

Treatment
Removal of plaque and calculus
Surgical excision and SRP
Recurrence
Spontaneous reduction – termination of pregnancy
 c. Enlargement in vitamin C deficiency

Scurvy
Acute deficiency
collagen degeneration ,
Modify response to plaque

Clinical features
- Bluish red , soft , friable smooth & shiny surface
- edema
- Haemorrhage – Spontaneous / slight provocation
- Surface necrosis with pseudomembrane formation
 MOUTH BREATHING

The exact mechanism is not clear

It is thought to be due to alternate wetting and drying of the gingival
surface
The gingiva appears red and edematous with diffuse shiny surface

Affects Mainly the anterior maxillary gingiva

Incomplete lip closure

Short upper lip
Class II malloclusion
Proclined incisors
Rhinitis
 d. Plasma cell gingivitis
Allergic in origin

Clinical features

Edematous and inflammed gingiva

facial aspect of attached gingiva
Bleeds easily
Differs from plaque induced gingivitis(NO local
factor)

HISTOPATHOLOGY
-Epithelium – mild hyperplsia
-Connective tissue – dense infiltrate of plasma cells
 Systemic Disease That Cause Gingival
Leukemia: Enlargement
Malignant neoplasia of WBC precursors
Acute myeloid leukemia
Gingival enlargementd due to the massive infiltration of immature WBCs
(leukemic cells) in the gingival connective tissue

Clinically:

it may mimic inflammatory origin.

Localized OR Generalized

Bluish red , shiny surface

EASELY bleed (even spontaneously)
Ulceration of gingiva

Secondary Inflammatory enlargement due to plaque accumulations

 Leukemia:
It can be associated with signs and symptoms of:
Bone marrow failure, such as ecchymoses, Petechiae

Night sweats, and lethargy

Recent infections ( Candidal infection)

Diagnosis can be made by a simple full blood count

Wegener’s Granulomatosis: “Strawberry gingivitis”,
-Granulomatous disease
-Acute necrotising vasculitis lesions of respiratory tract , nasal and oral defects

Etiology
-Unknown
-Immunologically mediated tissue injury

Reddish-purple exophytic gingival swelling with patechial haemorrhages, is a

characteristic sign of Wegener’s granulomatosis.

Help in EARLY diagnosis of this potentially fatal condition, because they APEAR for a
long time before multi-organ involvement occurs

At least two conditions to diagnose :

(1) ulcerative lesions of oral mucosa or nasal bleeding or inflammation;
(2) nodules, fixed infiltrates or cavities in chest radiograph;
(3) abnormal urinary sediment
(4) granulomatous inflammation on biopsy
 Neoplastic Enlargement
Benign tumors of gingiva
Epulis
Generic term refers to any solitary/discrete, pedunculated or sessile swellings
of the gingiva with no histologic characterization of a particular lesion

Fibrous epulis/peripheral fibroma

Firm, pink, uninflammed mass

Smooth surfaced
Grow slowly
Painless

Pain may be associated due to

secondary trauma
e. Nonspecific conditioned enlargement
Pyogenic granuloma
Tumorlike mass , pedunculated
Smooth surfaced , often ulcerated
Reddish/bluish color mass are highly vascular

Bleed readily
Rapid grow within first few weeks
and then slowly

The mass may penetrate interdentally and present

as bilobular
(buccal and lingual) mass
Bone not affected

Painless
 Gingival Cyst:

Unusual cysts of odontogenic source

Most common on :
The labial attached gingiva of the mandibular Canine and
premolar

Presence of fluid may give them a bluish hue

May cause resorption of the labial bone due to pressure

Excisional biopsy is the best management for these lesions

Malignant lesions of gingiva

Squamous cell carcinoma:

• Most common malignant tumor of gingiva
• Invasion to alveolar bone
• 90% of all Oral cancer
Melanoma:

From melanocytes
Maxillary attached gingiva , Hard palate

Rapid growth, early metastasis

Infiltration into underlying bone

Metastasis to lymph nodes
 Genetic disorders associated with gingival enlargement
Hereditary gingival fibromatosis
Rare fibrotic gingival enlargement
Autosomal dominant

Fibrotic firm consistency

pseudo-pockets

localized or generalized

It may present as a specific entity or as a part of syndrome

(mental retardation, epilepsy)

Diagnosis :

Positive family history of gingival enlargement.

Clinical picture
It usually begins with the eruption of the primary or permanent
dentition
Buccal and lingual surfaces involved
Most Common Effects

Diastema, spacing

Malpositioning of teeth

Prolonged retention of primary

teeth

Cover the dental crowns

The alveolar bone is not affected

unless periodontal diseases
progressed
 False enlargement
Enlargement of bone subjacent to gingival area
Gingival tissue appear normal

Underlying osseous lesions

Commonly  Tori, Exostosis
Also seen in  Paget’s disease, Fibrous dysplasia,
Cherubism,, Ameloblastoma, Osteoma and Osteosarcoma
 Drug induced gingival enlargement

Drugs associated with gingival overgrowth

Calcium channel
Anticonvulsants Immunosuppressants
blockers

Cyclosporin Nifedipine
Phenytoin
Amlodipine

Verapamil
Prevalence
50 % - phenytoin
30% - Cyclosporine Diltiazem
10% - Nifedipine
 Characteristics Of Drug-induced Gingival Enlargement
Esthetic Problem
Interfere masticatory function, speech, oral hygiene
Higher prevalence in children

Signs and symptoms are seen within 2-4 months of initiation of drug intake.

The enlargement starts in the interdental papilla and eventually may involve
marginal gingiva.

Found in gingiva with or without bone loss but is not associated with
attachment loss

More prominent in maxillary and mandibular anteriors, may involve the

gingiva around all teeth

It will be absent in edentulous areas and will disappear in areas where teeth
are extracted

.
 Clinical features
Gingival enlargement Without inflammation

The enlargement looks like mulberry Shape

lobulated surface
Firm, fibrotic resilient
Pink
No bleeding on probing

Enlargement with inflammation

Increase in the size of existing enlargement and adds characteristic
features of inflammatory enlargement

Red or bluish red discoloration

Increased bleeding tendency
Treatment
Changing to alternate drug by physician
Discontinuation of drug – spontaneous reduction

Maintenance of good oral hygiene

Plaque control , Mouthwashes

Periodontal debridement

Surgical excision of gingival overgrowth (gingivictomy)