Gingival Enlargement

An increase in size of the gingiva

The accepted current terms for this condition are
gingival enlargement and gingival overgrowth.

Dr Aicha Sid Ahmed

 Gingival enlargement can be transient and reversible or can
be chronic and irreversible
As in other pathologic processes, inflammation of the
periodontal tissues typically results in three outcomes:
✓ Complete resolution of inflammation and restoration of
tissue integrity (i.E., Homeostasis),
✓ Destruction of periodontal tissues and loss of attachment
(i.E., periodontitis),
✓ Fibrosis
 Fibrosis is a component of the defense mechanism against
progression of periodontal inflammation.
 During this process, fibroblasts play a major role by
generating excessive amounts of collagen and
noncollagenous proteins of the extracellular matrix.
Increased matrix .
 Deposition is not sufficiently balanced by the enzymatic
degradation of the matrix composition (e.g., collagen),
resulting in fibrotic changes in soft tissues.
 Gingival enlargement and gingival overgrowth are terms used
interchangeably with hyperplasia, hypertrophy, and fibrosis.

 Hyperplasia is an increase in the number of cells in tissues that

results in increased tissue volume.

 Hypertrophy refers to increased tissue size and volume resulting

from increased cell size.

 Hyperplastic, hypertrophic, and fibrotic changes are observed

during gingival enlargement and cannot be accurately
differentiated.
GO cases are classified as follows:
• Inflammatory enlargement due to gingivitis.
• Drug-induced enlargement.
• GO associated with systemic conditions.
• GO associated with systemic diseases
• Gingival fibromatosis.
 Other Forms of Gingival Enlargement
I. Inflammatory enlargement
A. Chronic
B. Acute
II. Drug-induced enlargement
A. General information
B. Anticonvulsants
C. Immunosuppressants
D. Calcium channel blockers
III. Enlargements associated with systemic diseases or conditions
A. Conditioned enlargement
1. Pregnancy
2. Puberty
3. Vitamin C deficiency
4. Plasma cell gingivitis
5. Nonspecific conditioned enlargement (pyogenic
granuloma)
B. Systemic diseases that cause gingival enlargement
1. Leukemia
2. Granulomatous diseases (e.g., Wegener’s granulomatosis,
sarcoidosis)
IV. Neoplastic enlargement (gingival tumors)
A. Benign tumors
B. Malignant tumors
V. False enlargement
 Diagnosis
 One of the most serious
pathologies in periodontal
medicine,

 Requires a meticulous
differential diagnosis for
selecting a therapeutic
approach tailored to the
patient’s systemic status.

 Accurate diagnosis requires a

thorough review of the medical
history of the patient.
 Based on distribution they can be
localized or generalized.
“Isolated” enlargements are those limited to gingiva
adjacent to single or two teeth

“Discrete” lesions are isolated sessile or pedunculated, tumor-

like enlargements

“Regional” enlargements refer to

involvement of gingiva around
three or more teeth in one
or multiple areas of the mouth

“Generalized” enlargement refers to

involvement of gingiva adjacent
to almost all the teeth present
Diagnosis :
 Various indices have been proposed.
 For example, the degree of gingival enlargement can be
scored as follows:
• 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-fourths or more of the
crown
 A more accurate assessment of GO can be made by models cast
on the impressions : A technique developed by Seymour and
colleagues has been validated by others and can be a valuable tool
for precise determination of the severity and extent of GO,
especially for research purposes and long-term follow-up.

 Other indices : Three-dimensional scanning can be used to

measure GO and compare the treatment outcomes with baseline
values .
Inflammatory Enlargement of Gingiva
Due to Gingivitis
In some cases, gingival enlargement is a direct outcome
of gingivitis without any complicating factors or
involvement of systemic conditions.
Initial assessment
is made by:
 Careful visual examination of abnormalities of gingival
contours, texture, and color, which are compared with
normal standards.
 Detailed medical history to exclude potential systemic
factors and conditions.
 Dental irregularities, dysfunctional habits, and oral care
efficiency should be considered in the evaluation,
 Clinical measurements should be recorded.
Clinical Manifestations
 Originates as a slight ballooning of the interdental papilla and
marginal gingiva.
 In the early stages, it produces a life-preserver–shaped bulge
around the involved teeth.
 This bulge can increase in size until it covers part of the
crowns.
 The enlargement may be localized or generalized;
 Progresses slowly and painlessly, unless it is complicated by
acute infection or trauma
Etiology.
 Prolonged exposure to dental plaque.
 Factors that favour plaque accumulation and retention
include : poor oral hygiene, irritation by anatomic
abnormalities, and improper restorative and orthodontic
appliances.
 Gingival Changes Associated with
Mouth Breathing.
 Often seen in patients who are mouth breathers.
 The gingiva appears red and edematous,with a diffuse surface shininess of the exposed area.
 The maxillary anterior region is the common site of such involvement.
 In many cases, the altered gingiva is clearly demarcated from the adjacent unexposed normal gingiva .
 Irritation from surface dehydration is attributed to mouth breathing.
-BUT comparable changes could not be reproduced by air-drying the gingiva of experimental animals, suggesting that
the pathogenesis of mouth breathing–associated gingival changes is far more complex.
Treatment
 Chronic enlargement of the gingiva due to gingivitis is
reversible
 Can be resolved by removal of the etiologic factors, including
the biofilm,
 Correction of environmental factors.
 In severe forms of inflammatory enlargement, surgical
approaches may be required.
Drug-Induced Overgrowth of Gingiva

• Major dental problem

• Poses a risk for the general health of these patients.
• The condition may create speech, mastication, tooth
eruption, and aesthetic problems
Drug-Induced Overgrowth of Gingiva
 Most common form

 Caused by the use of anticonvulsants, calcium channel blockers,

and immunosuppressants

 Prescribed to patients for serious health concerns.

 The degree of fibrosis and inflammation depend on :

 The dose, duration, and type of drug;
 Oral hygiene;
 Individual susceptibility, including genetic factors; and environmental
influences.
Clinical features :
 Develop fast and become chronic
over time

 Observed as localised nodular

enlargement of the interdental
papilla.

 The lesions expand and in some

cases cover the crowns of the teeth.

 Dental biofilm and bacterial

infection lead to inflamed tissues
characterized by edema and
bleeding.
 Anticonvulsants
 Phenytoin (diphenylhydantoinate) is the drug of choice for the
treatment of grand mal, temporal lobe, and psychomotor
seizures,

 Linked to GO for more than 70 years.

 The estimated prevalence is about 50%.

 Clinical onset occurs as early as 1 month, and increasing severity

is seen in 12 to 18 months.

 lesions frequently occur on the anterior buccal maxilla and

mandible, and the entire dentition can be covered in severe cases.
 Anticonvulsants
Phenytoin-induced GO is characterized by :
 Enlargement of interdental papillae and increased thickening of
the marginal tissues,
 Causing aesthetic and functional problems, such as malpositioning
of teeth, difficulty in speech, and impaired oral hygiene.
 Calcium Channel Blockers
 Calcium channel blockers are a group of drugs commonly used
to treat hypertension, angina pectoris, coronary artery spasm,
and cardiac arrhythmia.
 The first case was reported in 1984.
 the prevalence of nifedipine-induced GO is highly
variable,ranging from 6% to 83
 Clinically, interdental papillae are affected, and overgrowth is
limited to attached and marginal gingiva, which usually is
observed on the anterior segments.
 Nifedipine induced GO can coexist with periodontitis and
attachment loss that is different from other forms of DIGO.
 Immunosuppressants
 Cyclosporin A has been the immunosuppressant of choice for
preventing rejection of solid organ and bone marrow transplants
and for treatment of autoimmune conditions.
 The prevalence of cyclosporin A–induced GO has been reported to
be about 30%
 Clinically, the lesions are more inflamed and bleed more than other
forms of DIGO, and they commonly are limited to buccal surfaces.
 Severity of the lesions can be similar to those of phenytoin and
nifedipine.
 They affect the entire dentition and interfere with occlusion,
mastication, and speech.
 Pathogenesis of Drug-Induced Gingival Overgrowth
collectively the findings suggest that DIGO-associated
medications affect the extracellular matrix metabolism by
decreasing collagenase activity and increasing the production of
matrix proteins.

Gingival fibroblasts from Gingival Cyclosporin

phenytoin-induced GO
are characterized
by elevated levels of collagen
synthesis.
fibroblasts from nifedipine-
induced GO
Through interference with Cyclosporin A decreases
calcium metabolism, calcium expression of matrix
channel blockers decrease metalloproteinase-1
calcium levels in gingival (MMP-1) and MMP-3.12
fibroblasts and T cells, thereby
affecting T-cell proliferation
or activation and collagen
biosynthesis.
Treatment
 DIGO cannot be prevented, but it can be ameliorated by
elimination of local factors, plaque control, and regular
periodontal maintenance.
 The most effective treatment for drug-induced gingival
overgrowth is withdrawal or substitution of the medication.
 Nonsurgical treatment results in elimination of the
inflammatory component of DIGO. Surgical elimination of
DIGO lesions involves gingivectomy and gingivoplasty.
 The recurrence rate is high.
 Maintenance should include oral hygiene instructions,
periodontal prophylaxis, and removal of calculus as needed.
Gingival Overgrowth Associated With
Systemic Conditions
These gingival pathologies are referred as conditioned
enlargements and include
lesions associated with hormonal and nutritional
etiologic factors.
Gingival inflammation due to microbial factors is a
prerequisite that hormonal and nutritional changes
modify,
 Pregnancy-Associated Gingival
Overgrowth
 GO is a common pathology in pregnancy.
 Single mass or multiple tumor-like masses at the gingival margin.
 Marginal gingival enlargement during pregnancy results from the
aggravation of previous inflammation
 The incidence has been reported : 10% to 70%.
 single enlargements, which are referred to as pregnancy tumors.
 Clinical features
 A highly varied clinical picture.
 Enlargement is usually generalized, more prominent interproximally than on
the facial and lingual surfaces
 Bright red , soft, and friable, and it has a smooth, shiny surface.
 Bleeding occurs spontaneously or on slight provocation.
 Appears as a discrete,mushroom-like, flattened spherical mass that protrudes
from the gingival margin or, more often, from the interproximal space, and it is
attached by a sessile or pedunculated base
 Aetiology
 Hormonal changes have always been linked to pathology in periodontal tissues.

 Progesterone and estrogen levels increase 10 to 30 times by the end of the third trimester
compared with the menstrual cycle.
 Hypothesis : these hormonal changes induce an increased vascular permeability => to
gingival edema and an increased inflammatory response to dental plaque.
 During this process, the impaired vascular response and inflammatory milieu can lead to
modification of the subgingival microbiota.
 An increased presence of prevotella intermedia, prevotella melaninogenica, and porphyromonas
gingivalis has been linked to pregnancy-associated go in vivo and in vitro demonstrating
that the lesions have strong infectious associations
 Treatment:
GO LESIONS CAN BE PREVENTED BY GOOD ORAL HYGIENE.
 Oral care in pregnant women should be meticulous
 Patients should be treated by removal of plaque and calculus.
 Severe cases may require removal during the second trimester;
 Spontaneous reduction in the size of gingival enlargement typically
follows the termination of pregnancy,
 Complete elimination of the residual inlammatory lesion and GO
requires removal of all plaque deposits, elimination of factors that
favour its accumulation, and in some fibrotic cases, surgical
intervention.
 Puberty-Associated Gingival
Overgrowth
 Enlargement of the gingiva is sometimes seen during puberty.
 Not specific to female gender;
 Occur in male and female adolescents.
 Clinically, there is a strong association with plaque
accumulation. The lesions are usually marginal and interdental,
and they are characterized by prominent bulbous
interproximal papillae.
 Often, only the facial gingivae are enlarged, and the lingual
surfaces are relatively unaltered.
 Relatively scant plaque deposits distinguish puberty-
associated GO from purely gingivitis-associated lesions,
 The incidence of puberty-associated lesions decline with age,
further supporting the role of hormonal changes during
puberty.
 Studies of the subgingival microbiota of children between the ages of
11 and 14 years and their association with clinical parameters
implicated Capnocytophaga species in the initiation of pubertal
gingivitis.
 Other studies have reported that hormonal changes coincide with an
increase in the proportion of Prevotella intermedia and Prevotella
nigrescens.
 Treatment

 After puberty, enlargement undergoes spontaneous reduction,

 Does not disappear completely until the plaque and calculus
are removed.
 Nutrition-Associated Gingival
Overgrowth
 Malnutrition has been historically
associated with several oral lesions.

 Clinical Manifestations
 The gingiva is bluish red, soft, and
friable, and it has a smooth, shiny
surface.
 Hemorrhage that occurs
spontaneously or on slight
provocation and surface necrosis
with pseudomembrane formations
are common features.
Treatment

 Nutrition-associated GO lesions are rare.

 Changes in nutrition accompanied by nonsurgical treatment
and good oral hygiene usually result in complete resolution
of the pathology.
 In rare cases, surgical removal may be indicated.
 Plasma cell gingivitis.
 Manifests as a mild marginal gingival enlargement that extends to the
attached gingiva.
 The gingiva appears red, friable, and sometimes granular, and it bleeds
easily;
 Thought to be allergic in origin
 Possibly a reaction to components of chewing gum, dentifrices, or
various dietary items.
 Cessation of exposure to the allergen brings resolution
 Gingival overgrowth associated
with systemic diseases

GO may be linked to various systemic diseases.

Although uncommon and occurring with different
etiopathogenetic mechanisms, the GO associated
with systemic diseases can be linked to serious
issues in clinical management. These lesions
should be carefully diagnosed.
Leukemia-Associated Gingival
Overgrowth
Leukemia-Associated Gingival
Overgrowth
 It can appear as a diffuse enlargement of the gingival
mucosa, an oversized extension of the marginal gingiva or
a discrete tumor-like interproximal mass.
 The gingiva is bluish red, and it has a shiny surface.
 The reduced number of immunocompetent lymphocytes
in the periodontal tissues is associated with increased
edema, erythema, and bleeding of the gingiva as well as
gingival enlargement that may be associated with the
swollen, spongy gingival tissues caused by the excessive
infiltration of malignant blood cells
 Hemorrhage occurs spontaneously or with slight irritation.
 True leukemic enlargement often occurs with acute
leukemia,
TREATMENT
After acute symptoms subside, attention is directed to correction of the gingival
enlargement.
The rationale is to remove the local irritating factors to control the inflammatory
component of the enlargement, and this is achieved by scaling and root planing.
The initial treatment steps consist of gently removing all loose debris with cotton pellets,
performing superficial scaling, and instructing the patient in oral hygiene for biofilm
control.
This hygiene should include, at least initially, the daily use of chlorhexidine mouthrinses.
Oral hygiene procedures are extremely important for these patients and, if necessary, may
require the assistance of a nurse.
Definitive scaling and root planing are carried out at subsequent visits using local
anesthesia.
Treatment sessions are confined to a small area of the mouth if hemostasis poses a
challenge.
Antibiotics are administered systemically the evening before and for a week after each
treatment to reduce the risk of infection.
 Wegener Granulomatosis
 can involve the orofacial region
 oral mucosal ulceration,
gingival enlargement, abnormal
,tooth mobility, exfoliation of
teeth, and a delayed healing
response.
 The granulomatous papillary
enlargement is reddish purple
and bleeds easily on stimulation.
Sarcoidosis
 Granulomatous disease of
unknown etiology.
 It starts in individuals during
their 20s or 30s,
 It predominantly affects
blacks,
 And it can involve almost any
organ, including the gingiva,
in which a red, smooth,
painless enlargement may
appear.
Gingival Fibromatosis
 Can be hereditary or idiopathic.
 Rare and occur in highly fibrotic forms of go.
 Hereditary is the most common form, and it has been linked to
several genetic loci.
 The enlargement affects the attached gingiva, the gingival margin,
and the interdental papillae.
 The facial and lingual surfaces of the mandible and maxilla usually
are affected, but the involvement may be limited to either jaw.
 The enlarged gingiva is pink, firm, and almost leathery in
consistency, and it has a characteristic minutely pebbled surface .
 Idiopathic gingival enlargement is a rare condition of
undetermined cause.
In severe cases, the teeth are almost completely covered, and the enlargement
projects into the oral vestibule.
The jaws appear distorted because of the bulbous enlargement of the gingiva.
ETIOLOGY
 The genetic basis of hereditary gingival fibromatosis is well
established.
 In some families, gingival enlargement is linked to
impairment of physical development.
 Idiopathic forms of gingival fibromatosis have not been linked
to any specific genes.
Treatment

 Treatment of GO lesions manifesting as gingival fibromatosis

requires gingivectomy and gingivoplasty.
 Clinical management is difficult because of the high
recurrence rate, and the severity of lesions usually results in
extreme crowding and misalignment of teeth.
 After removal of the fibromatosis lesions, patients may
require orthodontic treatment.
Other Forms of Gingival
Enlargement
the gingiva can be enlarged due to increases in the size of the
underlying osseous and dental tissues.
Squamous cell carcinoma
 Squamous cell carcinoma is the most common malignant tumor of the
gingiva.
 It may be exophytic, manifesting as an irregular outgrowth, or
ulcerative, appearing as a flat, erosive lesion.

 It is often symptom free, going unnoticed until complicated by

inlammatory changes that can mask the neoplasm but cause pain;

 It sometimes becomes evident after tooth extraction.

 Metastasis is usually confined to the region above the clavicle;

however, involvement that is more extensive can include the lung,
liver, or bone.
Malignant melanoma
 Malignant melanoma is a rare oral tumor that tends to
occur in the hard palate and maxillary gingiva of older
persons
 Usually darkly pigmented, and it is often preceded by
localized pigmentation .
 It can be flat or nodular
 Characterized by rapid growth and early metastasis.
The low incidence of oral
malignancy should not mislead
the clinician. Ulcerations that do
not respond to therapy in the
usual manner and all gingival
tumor sand tumor-like lesions
must be biopsied
and submitted for microscopic
diagnosis.
Gingival enlargements can often be
diagnosed :
 By a careful history (e.G., Drug influenced or hormonal
influenced gingival enlargement),
 By location (e.G., Mouth-breathing enlargement around
anterior teeth)
 Or by the clinical presentation (e.G., Strawberry gingivitis).
 Presence of local irritants (plaque and calculus) could be
primary or associated cause of gingival enlargements.
 Hence, plaque control is an essential aspect of management in
all the patients.
 An excisional/incisional biopsy and/or
hematologic/histologic examination may be needed
occasionally to correctly diagnose the uncommon cases of
gingival enlargement.
 The clinician should have an open mind and consider all
possibilities before coming to the final diagnosis of the
condition at hand.
Periodontal abscess