See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/267763405

Gingival Enlargement: Revisited: A case series

Article · August 2014

CITATIONS READS
0 567

5 authors, including:

Atul Bajoria Medha Babshet

Kalinga Institute of Dental Sciences Sri Hasanamba Dental College
18 PUBLICATIONS   36 CITATIONS    24 PUBLICATIONS   132 CITATIONS   

SEE PROFILE SEE PROFILE

Preeti Patil Piyush Sukhija

Dayanand Sagar College of Dental Sciences, Bangalore Sri Hasanamba Dental College
15 PUBLICATIONS   22 CITATIONS    7 PUBLICATIONS   13 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

PERIPHERAL ADENOMATOID ODONTOGENIC TUMOR OF THE ANTERIOR MAXILLARY GINGIVA: A RARE CASE REPORT WITH CBCT FINDINGS View project

All content following this page was uploaded by Atul Bajoria on 05 November 2014.

The user has requested enhancement of the downloaded file.

 Case Report
1 1
2 2
3
4
Gingival Enlargement: Revisited: A Case Series 3
4
5 5
6 Atul Anand Bajoria1, M L Asha2, Medha Babshet3, Preeti Patil3, Piyush Sukhija1 6
7 1
Post-graduate, Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India, 2Professor and 7
8 Head, Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India, 3Assistant Professor, 8
Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India
9 9
10 10
Gingival enlargement can be hereditary or acquired. More than 20 prescription medications are associated with gingival overgrowth. A detailed
11 11
review on the risk factors and pathogenesis from various peer reviewed journals has been discussed in this article. The aim was to discuss the
12 role of drugs causing gingival enlargement, the hereditary gingival fibromatosis (HGF) and its possible pathogenesis. The following case series 12
13 highlights four cases of gingival enlargement, one being a case of HGF and the other three being drug-induced gingival enlargement. Variable 13
14 etiopathogenesis such as age, genetic predisposition, pharmacokinetic variables, tissue homeostasis, inflammation and growth factors have 14
15 been associated with this disease. Inflammatory changes that occur within the gingival tissues appear to orchestrate the interaction between 15
the “modified fibroblast” and the drug. Alternatively, these drugs influence directly the inflammatory response in the form of enlargement.
16 16
This information is valuable for the clinician as it will have implication to treat the patient effectively.
17 17
18 Keywords: Drug induced, Fibroblasts, Gingival overgrowth 18
19 19
20 20
21 21
22
INTRODUCTION categories: Anticonvulsants, calcium channel blockers and
immunosuppressant’s.4 22
23 23
Increase in size of gingiva is a common feature of
24 24
gingival disease. This is clinically designated as gingival The following case series highlights four cases of gingival
25 25
enlargement or gingival overgrowth. The terms overgrowth enlargement, one being a case of hereditary gingival
26 26
or enlargement are descriptive terms. Hyperplasia is a fibromatosis (HGF) and the other three being drug-induced
27 27
histologic term used to describe the increase in a number of gingival enlargement.
28 28
cells. It should be distinguished from hypertrophy, which
29 29
is an overgrowth due to increased size of the cells. Gingival CASE REPORTS
30 30
31 enlargement is a gingival dimorphism associated with
31
multiple factors. It is characterized by evident growth of Case 1
32 32
the gingiva vertically toward the incisal edge of the clinical A 22-year-old female patient came with a chief complaint of
33 33
crown and horizontally toward the buccal-lingual area and forwardly placed teeth in the upper front region. Patient gave
34 34
is more prevalent in the buccal surfaces of the anterior teeth.1 a history of gingival enlargement since childhood. Family
35 35
history revealed patient’s mother having similar gingival
36 36
Various researchers have described multiple indices to presentation. The medical history of the patient was not
37 37
evaluate gingival enlargement of which the Miranda and relevant. On examination, generalized enlargement of the
38 38
Brunet index had a better sensitivity in evaluating the interdental, marginal and a ached gingiva was seen in both
39 39
40 gingival enlargement.1 the arches, more pronounced on the buccal aspect. Surface
40
41 was lobulated in the posterior aspect and the anterior aspect
41
42 Classification of gingival enlargement is based on the degree was smooth. Stippling was maintained. Gingiva was covering
42
43 of overgrowth as: Grade 0: No signs of gingival enlargement; the cervical third of the anteriors, middle third of the canine
43
44 Grade I: Enlargement confined to interdental papilla; and premolars and unto the occlusal aspect of the molars.
44
45 Grade II: Enlargement involving papilla and marginal Displacement was seen in the posterior teeth in both the arches. 45
46 gingiva; and Grade III: Enlargement covering three-quarters On palpation, the gingiva was firm in consistency, non-tender 46
47 or more of the crown.2 with pus discharge from the gingival sulcus of the lower 47
48 posterior teeth. All complement of teeth was present except 48
49 Gingival enlargement can be hereditary or acquired. 18 and 28. There were root stumps in relation to 37, 38 and 49
50 More than 20 prescription medications are associated 48. Based on these clinical findings a provisional diagnosis of 50
51 with gingival overgrowth. 3 Drugs associated with HGF was given and a differential diagnosis of inflammatory 51
52 gingival enlargement can be broadly divided into three gingival enlargement was considered (Figures 1 and 2). 52
53 53
54 Corresponding Author: Dr. Atul Anand Bajoria, Department of Oral Medicine and Radiology, Sri Hasanamba Dental College and Hospital, Hassan, 54
55 Karnataka, India. Mobile: +91-9964837056. E-mail: atultink@gmail.com 55

IJSS Case Reports & Reviews | August 2014 | Vol 1 | Issue 3 1

 Bajoria, et al.: Gingival enlargement: Revisited

1 Case 2 Case 3 1
2 A 30-year-old female patient complained of swelling in A 49-year-old female patient complained of bleeding from the 2
3 the upper and lower teeth region since 6 weeks. Patient gums while brushing the teeth. Patient also had a complaint 3
4 gave a history of epilepsy from past 15 years and was of mobility of upper and lower front teeth since many days. 4
5 under medication ever since. Currently, the patient was on 5
6 100 mg tablets of phenytoin once in the morning, followed 6
7 by a combination of 50 mg of phenobarbitone and 100 mg 7
8 8
phenytoin tablet during night time. On examination,
9 9
generalized enlargement involving the interdental,
10 10
marginal and a ached gingiva was seen in both the arches,
11 11
covering approximately full length of the clinical crown
12 12
both buccally and palatally/lingually. The surface of the
13 13
gingiva appeared to be granular/pebbly. There was loss of
14 14
15 stippling and loss of gingival architecture also displacement 15
16 of the maxillary and mandibular anterior teeth were seen. 16
17 On palpation, tenderness was present over the maxillary 17
18 and mandibular labial gingiva. The consistency of the 18
19 gingiva was firm and fibrotic in both the arches. On 19
20 probing, there were pseudo pockets involving all the teeth. 20
All complement of teeth was present except 38 and 48. Figure 3: Phenytoin induced gingival enlargement (Case 2) anterior view
21 21
22 Based on these clinical findings a provisional diagnosis 22
23 of drug induced (phenytoin) gingival enlargement was 23
24 given and a differential diagnosis of inflammatory gingival 24
25 enlargement and idiopathic gingival fibromatosis was 25
26 considered (Figures 3-5). 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35 35
36 36
Figure 4: Lower arch of the patient having phenytoin induced gingival
37 enlargement (Case 2) 37
38 38
39 39
40 40
41 Figure 1: Hereditary gingival fibromatosis (Case 1) anterior view 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
54 Figure 2: Panoramic radiograph of a patient with hereditary gingival fibromatosis. Figure 5: Upper arch of the patient having phenytoin induced gingival 54
Arrows indicating the extent of gingiva covering the teeth enlargement (Case 2)
55 55

2 IJSS Case Reports & Reviews| August 2014 | Vol 1 | Issue 3

 Bajoria, et al.: Gingival enlargement: Revisited

1 She was a known hypertensive from past 10 years and under 1

2 medication for the same (atenolol 50 mg and amlodipine 2
3 5 mg combination tablet in the morning). On examination 3
4 generalized enlargement involving the interdental, marginal 4
5 and a ached gingival, covering approximately full length 5
6 of the clinical crown both buccally and palatally/lingually 6
7 in the posterior aspect of both the arches. Both the buccal 7
8 and palatal/lingual gingiva was enlarged on the right side, 8
9 whereas only the buccal gingiva was enlarged on the left 9
10 side. Stippling was present. On palpation, tenderness was 10
11 present over the maxillary and mandibular labial gingiva. 11
12 The overall consistency of the gingiva was firm and fibrotic. 12
13 There was pus discharge from the gingival sulcus in relation 13
14 to 12, 38 and 45. Teeth present were 15, 14, 12, 24, 25, 26, 14
Figure 6: Amlodipine induced gingival enlargement (Case 3) anterior view
15 27, 38, 35, 34, 32, 42, 43, 44, 45 and 46 of which 12, 32 and 15
16 42 were Grade II mobile. Based on these clinical findings, a 16
17 provisional diagnosis of drug induced (amlodipine) gingival 17
18 enlargement was given and a differential diagnosis of 18
19 inflammatory gingival enlargement and idiopathic gingival 19
20 fibromatosis was considered (Figure 6). 20
21 21
22 Case 4 22
23 A 45-year-old female patient came with a chief complaint 23
24 of swelling in the right lower back tooth region from past 24
25 1 week. Patient was a known hypertensive from past 2 years 25
26 and was under medication for the same (amlodipine 5 mg 26
27 tablet once daily). Patient was also a known diabetic from past 27
28 2 years and taking metformin 1000 mg daily. On examination, 28
29 generalized enlargement of the interdental and the marginal 29
30 gingiva of both the arches were present, more pronounced in 30
31 the lower arch having a pebbly surface. Stippling was present 31
32 and the normal gingival architecture was lost in the lower Figure 7: Amlodipine induced gingival enlargement (Case 4) anterior view 32
33 arch. Midline diastema in relation to 11 and 21 was also seen 33
34 with a high frenal a achment. On palpation, the gingiva was 34
35 firm and fibrotic in consistency. Tenderness was present over The mechanism behind drug-induced gingival hyperplasia 35
36 the gingiva in relation to 46. Pus discharge from the gingival involves inflammatory and non-inflammatory pathways 36
37 sulcus was observed in relation to 46, with Grade II mobility (Figure 8).6-8 37
38 of 45 and 46. Apart from the upper canines, all complement 38
39 of teeth was present with over retained deciduous canine Kimball in 1939 reported the first case of phenytoin induced 39
40 bilaterally in the upper arch. Based on these clinical findings, gingival enlargement.9 40
41 a provisional diagnosis of drug induced (amlodipine) 41
42 gingival enlargement was given and a differential diagnosis Phenytoin induced gingival hyperplasia has a higher 42
43 of inflammatory gingival enlargement and idiopathic prevalence rate of 50% when compared to cyclosporine and 43
44 gingival fibromatosis was considered (Figure 7). calcium channel blockers.10 Amlodipine is a third generation 44
45 dihydropyridine calcium channel blocker used for the 45
46 DISCUSSION management of hypertension and angina.11 46
47 47
48 HGF is a rare benign, asymptomatic, non-hemorrhagic and Phenytoin and amlodipine inhibit the intracellular calcium 48
49 non-exudative proliferative lesion of the gingival tissue, ion uptake which stimulates the gingival fibroblasts. 49
50 which may manifest either as a nodular or symmetric form However, only in those patients who are diagnosed with 50
51 resulting in uniform enlargement of the gingiva. It may occur drug-induced gingival enlargement has fibroblasts with 51
52 alone or as a part of syndrome, which include autosomal- an abnormal susceptibility to the drug. The presence of 52
53 dominant (Laband and Rutherford) or autosomal-recessive this differential proportion of fibroblasts in these patients’ 53
54 syndromes (Cross, Murray–Puretic–Dresher and Ramon).5 exhibits an abnormal fibrogenic response.12 Histologically 54
55 55

IJSS Case Reports & Reviews | Vol 1 | Issue 3 3

 Bajoria, et al.: Gingival enlargement: Revisited

1 elevated expression of transforming growth factor beta (integrin αvβ6, fibronectin, tenascin-C, TGF-β and 1
2 (TGF-β) has been reported in lamina propria of phenytoin connective tissue growth factor [CTGF]), and molecules that 2
3 induced gingival hyperplasia.13 play a role in the organization and homeostasis of the ECM 3
4 (Type I procollagen and the small leucine-rich proteoglycans 4
5 Phenytoin also up regulates B-chain of platelet derived decorin, biglycan, fibromodulin and lumican)20 (Figure 9). 5
6 growth factor - BB which acts as a mitogen and chemo- 6
7 a ractant for fibroblasts14-16 which increases the secretion First, various immunohistochemical staining studies 7
8 of basic fibroblast growth factor leading to increased have demonstrated the presence of cytokeratin 19 and 8
9 proliferation of gingival fibroblasts.13 integrin αvβ6 in the interdental papilla. In addition, the 9
10 immunostaining intensities of biglycan, fibromodulin 10
11 Elevated levels of interleukin 1 beta and interleukin 6 and lumican were more in the interdental papilla oral 11
12 have been reported in drug induced hyperplasia. They epithelium compared with marginal gingiva. This molecular 12
13 target the fibroblasts that trigger the proliferation of composition of the interdental papilla is distinct from that 13
14 fibroblasts and exert the positive regulation on collagen of the marginal gingiva, suggesting that the cells in the 14
15 and glycosaminoglycans synthesis.17 interdental papilla are in an activated state.20 This might 15
16 be the reason to explain the increased susceptibility of the 16
17 In cyclosporine, gingival enlargement reduced levels of interdental papilla to nodullary enlargement compared with 17
18 matrix metalloproteinases one and three have been found, 18
other parts of the gingiva, in the initial stages of gingival
19 which leads to accumulation of extra cellular matrix (ECM) 19
overgrowth.
20 component.18 20
21 21
Second, molecules such as integrin αvβ6 participate in the
22 Elevated levels of TGF-β have been found in the gingival 22
modulation of the inflammatory response by activating
23 crevicular fluid (GCF) of patients diagnosed with 23
immunosuppressive TGF-β, which can further induce CTGF
24 cyclosporine-induced gingival enlargement, which 24
expression. This was proved by the increased immunological
25 increases the accumulation of ECM.19 25
staining for TGF-β and Type I procollagen, which was found
26 26
to be significantly increased in fibroblasts.20
27 Csiszar et al. studied the expression of molecules that are 27
28 not normally expressed in gingiva (integrin αvβ6 and 28
Age is also considered to be an important risk factor for
29 fibronectin), molecules that are upregulated during wound 29
drug-induced gingival overgrowth.10 There is minimal
30 healing and regulate tissue development and regeneration 30
influence of gender and age in drug-induced gingival
31 31
hyperplasia. 21 However the relationship between the
32 32
extent and severity of gingival overgrowth and various
33 33
drug variables such as dose duration, serum and salivary
34 34
concentration is still an area of controversy. The salivary
35 35
36 concentration of phenytoin and cyclosporine are important 36
37 determinants of gingival overgrowth.10 The concentration of 37
38 certain drugs such as cyclosporine in dental plaque may also 38
39 play an important role in gingival enlargement.22 Reports 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
54 Figure 8: The non-inflammatory and the inflammatory mechanism for drug Figure 9: Various molecules expressed in gingiva during wound healing and 54
induced gingival enlargement inflammation
55 55

4 IJSS Case Reports & Reviews| August 2014 | Vol 1 | Issue 3

 Bajoria, et al.: Gingival enlargement: Revisited

1 of high local concentration of amlodipine and phenytoin in influence directly the inflammatory response in the form of 1
2 the GCF of patients having gingival enlargement have been enlargement. This information is valuable for the clinician 2
3 demonstrated,23,24 but it does not appear to be related to the as it will have implication to treat the patient effectively. 3
4 extent of gingival overgrowth.25 An increased enlargement Newer molecular approaches are required to establish the 4
5 of the gingiva was observed in organ transplant patients pathogenesis of gingival overgrowth thus aiding in novel 5
6 receiving a combination of nifedipine and cyclosporine.26 preventive and therapeutic modalities. 6
7 Patients having high plaque score and gingival inflammation 7
8 have a higher risk of developing drug-induced gingival ACKNOWLEDGMENTS 8
9 enlargement than in patients having a good oral hygiene.27 9
10 The fibroblast heterogeneity till date remains the key factor We express our deep sense of gratitude and profound thanks 10
11 for drug-induced gingival enlargement.10 to my respected teacher Dr. Asha ML, Professor and Head 11
12 of the Department of Oral Medicine and Radiology, Sri 12
13 There are mainly six risk factors responsible for drug- Hasanamba Dental College and Hospital, Hassan for her 13
14 induced gingival overgrowth (Table 1).17 constant encouragement, guidance and support in every 14
15 aspect of this study. We are grateful to Dr. S Ravindra, 15
16 CONCLUSION Principal, Sri Hasanamba Dental College and Hospital, 16
17 Hassan for providing us with all the college facilities to 17
18 Gingival overgrowth is disfiguring, and can interfere in carry out this study successfully. 18
19 mastication and speech; hence a thorough understanding 19
20 of the pathogenesis is essential. It is possible that REFERENCES 20
21 the specific phenotype is inherent to the cells in the 21
22 gingiva based on its anatomical location or that the 1. Miranda J, Brunet L, Roset P, Farré M, Mendieta C. Reliability of 22
23 cells are activated because of the presence of mild two measurement indices for gingival enlargement. J Periodontal 23
24 Res 2012;47:776-82. 24
localized inflammation, even in clinically healthy tissue.
2. Inglés E, Rossmann JA, Caffesse RG. New clinical index for drug-
25 Furthermore, the reason for the presence of a distinct cell 25
induced gingival overgrowth. Quintessence Int 1999;30:467-73.
26 phenotype in the interdental papilla oral epithelium and 3. Rees TD, Levine RA. Systematic drugs as a risk factor for 26
27 the function of the differentially expressed molecules are periodontal disease initiation and progression. Compendium 27
28 not clear. 1995;16:20, 22. 28
29 4. Dongari-Bag oglou A, Research, Science and Therapy Commi ee, 29
30 American Academy of Periodontology. Drug-associated gingival
Inflammatory changes that occur within the gingival tissues 30
enlargement. J Periodontol 2004;75:1424-31.
31 appear to orchestrate the interaction between the “modified 31
5. Bi encourt LP, Campos V, Moliterno LF, Ribeiro DP, Sampaio RK.
32 fibroblast” and the drug. Alternatively, these drugs Hereditary gingival fibromatosis: Review of the literature and a 32
33 case report. Quintessence Int 2000;31:415-8. 33
34 6. Nyska A, Shemesh M, Tal H, Dayan D. Gingival hyperplasia 34
Table 1: Multifactorial nature of drug induced gingival
35 induced by calcium channel blockers: Mode of action. Med 35
overgrowth Hypotheses 1994;43:115-8.
36 Factors Mechanism 36
7. Marshall RI, Bartold PM. A clinical review of drug-induced
37 Age Children and adolescents unique fibroblast gingival overgrowths. Aust Dent J 1999;44:219-32. 37
38 phenotype increased androgen metabolism 8. Lafzi A, Farahani RM, Shoja MA. Amlodipine-induced gingival 38
39 Genetic Functional heterogeneity of fibroblasts hyperplasia. Med Oral Patol Oral Cir Bucal 2006;11:E480-2. 39
40 predisposition 9. Pradhan S, Mishra P. Gingival enlargement in antihypertensive 40
41 Pharmacokinetic Threshold concentration of the drug medication. JNMA J Nepal Med Assoc 2009;48:149-52. 41
variables Concentration of the drug in serum, saliva, 10. Seymour RA, Ellis JS, Thomason JM. Risk factors for drug-induced
42 gingival crevicular fluid and plaque 42
gingival overgrowth. J Clin Periodontol 2000;27:217-23.
43 Drug induced Increased collagen production 11. Joshi S, Bansal S. A rare case report of amlodipine-induced 43
44 alteration in gingival Increase in non-sulfated gingival enlargement and review of its pathogenesis. Case Rep 44
45 connective tissue glycosaminoglycans of the non-collagenous Dent 2013;2013:138248. 45
homeostasis matrix
46 12. Seymour RA. Calcium channel blockers and gingival overgrowth. 46
Decreased collagenase activity
47 Br Dent J 1991;170:376-9.
Increased synthesis of TIMPs 47
13. Saito K, Mori S, Iwakura M, Sakamoto S. Immunohistochemical
48 Histopathology, Active protein synthesis 48
localization of transforming growth factor beta, basic fibroblast
49 ultrastructural Reduced degenerative changes 49
factors and Mononuclear and poly morphonuclear cell growth factor and heparan sulphate glycosaminoglycan in gingival
50 inflammatory change infiltrate hyperplasia induced by nifedipine and phenytoin. J Periodontal 50
51 Increased prostaglandin E2 Res 1996;31:545-55. 51
52 Drug induced action Increased expression of EGF and PDGF 14. Iacopino AM, Doxey D, Cutler CW, Nares S, Stoever K, 52
on growth factors Fojt J, et al. Phenytoin and cyclosporine A specifically regulate
53 53
TIMPs: Tissue inhibitors of metalloproteinases, EGF: Epidermal growth factor, macrophage phenotype and expression of platelet-derived
54 PDGF: Platelet derived growth factor growth factor and interleukin-1 in vitro and in vivo: Possible 54
55 55

IJSS Case Reports & Reviews | Vol 1 | Issue 3 5

 Bajoria, et al.: Gingival enlargement: Revisited

1 molecular mechanism of drug-induced gingival hyperplasia. 22. Niimi A, Tohnai I, Kaneda T, Takeuchi M, Nagura H. 1
2 J Periodontol 1997;68:73-83. Immunohistochemical analysis of effects of cyclosporin A on 2
3 15. Dill RE, Miller EK, Weil T, Lesley S, Farmer GR, Iacopino AM. gingival epithelium. J Oral Pathol Med 1990;19:397-403. 3
Phenytoin increases gene expression for platelet-derived growth 23. Ellis JS, Seymour RA, Monkman SC, Idle JR. Gingival sequestration
4 4
factor B chain in macrophages and monocytes. J Periodontol of nifedipine in nifedipine-induced gingival overgrowth. Lancet
5 1993;64:169-73. 1992;339:1382-3. 5
6 16. Sporn MB, Roberts AB. Polypeptide Growth Factors and Their 24. Seymour RA, Ellis JS, Thomason JM, Monkman S, Idle JR. Amlodipine- 6
7 Receptors. New York: Springer-Verlag; 1991. induced gingival overgrowth. J Clin Periodontol 1994;21:281-3. 7
8 17. Seymour RA, Thomason JM, Ellis JS. The pathogenesis of drug- 25. McLaughlin WS, Ball DE, Seymour RA, Kamali F, White K. The 8
induced gingival overgrowth. J Clin Periodontol 1996;23:165-75. pharmacokinetics of phenytoin in gingival crevicular fluid and
9 9
18. Sonmez S, Cavdar C, Gunduz C, Nizam N, Biray C, Atila K, et al. plasma in relation to gingival overgrowth. J Clin Periodontol
10 Do MMP-1 levels of gingival fibroblasts have a role in the gingival 1995;22:942-5. 10
11 overgrowth of cyclosporine-treated patients? Transplant Proc 26. Bökenkamp A, Bohnhorst B, Beier C, Albers N, Offner G, Brodehl 11
12 2008;40:181-3. J. Nifedipine aggravates cyclosporine A-induced gingival 12
13 19. Cotrim P, de Andrade CR, Martelli-Junior H, Graner E, hyperplasia. Pediatr Nephrol 1994;8:181-5. 13
Sauk JJ, Cole a RD. Expression of matrix metalloproteinases 27. Seymour RA, Jacobs DJ. Cyclosporin and the gingival tissues.
14 14
in cyclosporin-treated gingival fibroblasts is regulated by J Clin Periodontol 1992;19:1-11.
15 transforming growth factor (TGF)-beta1 autocrine stimulation.
15
16 J Periodontol 2002;73:1313-22. 16
How to cite this article: Bajoria AA, Asha ML, Babshet M, Patil P, Sukhija P.
17 20. Csiszar A, Wiebe C, Larjava H, Häkkinen L. Distinctive molecular Gingival enlargement: Revisited - A case series. IJSS Case Reports & Reviews 17
18 composition of human gingival interdental papilla. J Periodontol 2014;1(3):1-6. 18
19 2007;78:304-14. 19
21. Hassell TM. Epilepsy and the oral manifestations of phenytoin
20 Source of Support: Nil, Conflict of Interest: None declared. 20
therapy. Monogr Oral Sci 1981;9:1-205.
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35 35
36 36
37 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
54 54
55 55

6 IJSS Case Reports & Reviews| August 2014 | Vol 1 | Issue 3

View publication stats