Gngival enlargement

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Gngival enlargement

  1. 2. DEFINITION <ul><li>Increase in the size of the gingiva is termed as gingival enlargement or gingival overgrowth. </li></ul>
  2. 3. CLASSIFICATION <ul><li>According to the etiologic factors and pathologic changes. </li></ul><ul><li>I) Inflammatory enlargement </li></ul><ul><li>a). Chronic </li></ul><ul><li>b). Acute </li></ul><ul><li>II) Drug induced enlargement </li></ul><ul><li>III) Enlargements associated with systemic diseases </li></ul><ul><li>A). Conditioned enlargement </li></ul><ul><li>1). Pregnancy </li></ul><ul><li>2). Puberty </li></ul>
  3. 4. <ul><li>3). Vitamin C </li></ul><ul><li>4). Plasma cell gingivitis </li></ul><ul><li>5). Nonspecific conditioned enlargement </li></ul><ul><li>B). Systemic diseases causing gingival enlargement </li></ul><ul><li>1). Leukemia </li></ul><ul><li>2). Granulomatous diseases (Wegener’s granulomatosis, sarcodiosis) </li></ul><ul><li>IV) Neoplastic enlargement </li></ul><ul><li>A). Benign tumors </li></ul><ul><li>B). Malignanttumors </li></ul><ul><li>V) False enlargement </li></ul>
  4. 5. On the basis of location and distribution <ul><li>A). Localized: Limited to the gingiva adjacent to a single tooth or group of tooth. </li></ul><ul><li>eg. The gingival enlargement localized in the canine region </li></ul>
  5. 6. B). Generalized involving the gingiva throughout the mouth.
  6. 7. <ul><li>C). MARGINAL : Confined to the marginal gingiva. </li></ul>
  7. 8. <ul><li>D). Papillary : Confined to the interdental papilla </li></ul>
  8. 9. <ul><li>E). Discrete : An isolated sessile or pendunculated tumor like enlargement </li></ul>
  9. 10. <ul><li>F). Diffuse ; Involving the marginal and attached gingivae and papillae </li></ul>
  10. 11. <ul><li>Scoring of gingival enlargement </li></ul><ul><li>Grade 0 : No signs of gingival enlargement </li></ul><ul><li>Grade I : Enlargement confined to interdental papilla </li></ul><ul><li>Grade II : Enlargement involves papilla and marginal gingiva. </li></ul><ul><li>Grade III : Enlargement covers three quarters or more of the crown </li></ul>
  11. 12. <ul><li>Grade 0 Grade I </li></ul><ul><li>Grade II Grade III </li></ul>
  12. 13. INFLAMATORY ENLARGEMENT <ul><li>Gingival enlargement may result from chronic or acute changes. </li></ul><ul><li>Chronic inflammatory enlargement Etiology : </li></ul><ul><li>Prolonged exposure to dental plaque </li></ul><ul><li>poor oral hygiene </li></ul><ul><li>irritation by anatomic abnormalities </li></ul><ul><li>improper restorative & orthodontic appliances. </li></ul><ul><li>Mouth breathing habit </li></ul>
  13. 14. <ul><li>Clinical features : </li></ul><ul><li>Site - interdental, marginal, attached gingiva </li></ul><ul><li>may be localized or generalised. </li></ul><ul><li>Shape - slight ballooning to life preserver shaped bulge </li></ul><ul><li>slow progressing and painless </li></ul><ul><li>painful ulceration sometimes </li></ul>
  14. 15. <ul><li>Chronic inflammatory enlargement in a 27 year old woman </li></ul>
  15. 16. <ul><li>Chronic inflammation associated with mouth breathing in a 16 year old child </li></ul>
  16. 17. <ul><li>Histology : </li></ul><ul><li>chronic inflammatory cells (Lymphocytes, macrophages, plasma cells etc.) </li></ul><ul><li>lesions deep red, soft, friable, smooth </li></ul><ul><li>bleeds easily due to vascular engorgement </li></ul><ul><li>abundant fibroblasts & collagen fibers </li></ul>
  17. 18. <ul><li>Acute inflammatory enlargement </li></ul><ul><li>Gingival abscess </li></ul><ul><li>Etiology: </li></ul><ul><li>Bacteria carried deep into the tissues by toothbrush bristles, piece of apple coat etc. </li></ul><ul><li>Clinical features: </li></ul><ul><li>site - marginal and interdental gingiva </li></ul><ul><li>localized, painful, rapidly expanding. </li></ul><ul><li>Within 24 to 28 hrs lesion becomes fluctuant & purulent exudate expressed as surface orifice & rupture spontaneously. </li></ul>
  18. 19. <ul><li>Gingival enlargement in the case of acute necrotising gingivitis </li></ul>
  19. 20. <ul><li>Gingival abscess </li></ul>
  20. 21. <ul><li>Histopathology: </li></ul><ul><li>epithelium - varying degree of intra& extracellular oedema. </li></ul><ul><li>Leukocytic invasion & ulceration </li></ul><ul><li>connective tissue- purulent focus surrounded by PMNs. </li></ul><ul><li>edematous tissue </li></ul><ul><li>vascular engorgement. </li></ul><ul><li>Periodontal abscess : </li></ul><ul><li>involves the supporting periodontal tissues. </li></ul>
  21. 22. <ul><li>DRUG INDUCED GINGIVAL ENLARGEMENT . </li></ul><ul><li>Anticonvulsants </li></ul><ul><li>Immunosuppressants </li></ul><ul><li>Calcium channel blockers </li></ul><ul><li>affects th speech, mastication, tooth eruption, and aesthetics problems </li></ul><ul><li>General clinical features: </li></ul><ul><li>site - interdental papilla, facial and lingual gingival margins </li></ul>
  22. 23. <ul><li>Starts as a bead massive tissue fold covering the crown </li></ul><ul><li>mulberry shaped , firm , pale pink, resilient </li></ul><ul><li>no tendency to bleed </li></ul><ul><li>appears to project from beneath the gingival margin separated by a linear groove . </li></ul><ul><li>Plaque control becomes difficult </li></ul><ul><li>secondary inflammation </li></ul><ul><li>red, bluish colored lobulated demarcations, increased bleeding </li></ul>
  23. 24. <ul><li>Regress spontaneously within few months after discontinuation of the drug. </li></ul><ul><li>Histopathology : </li></ul><ul><li>Epithelium - acanthosis, elongated rete pegs </li></ul><ul><li>conn. Tissue - densely arranged collagen bundles, fibroblasts, neovascularisation </li></ul><ul><li>abundance of amorphous ground substance </li></ul><ul><li>cyclosporins - Highly vascularised & foci of chronic inflammatory cells </li></ul><ul><li>phenytoin - fibroblast to collagen ratio normal, oxytalan fibers are numerous </li></ul>
  24. 25. <ul><li>1).Anticonvulsants </li></ul><ul><li>First gingival enlargement reported </li></ul><ul><li>Introduced by Merritt and Putnam in 1938. </li></ul><ul><li>Drugs used for the treatment of epilepsy </li></ul><ul><li>Phenytoin, ethotoin, mephenytoin, succinimides etc. </li></ul><ul><li>50% of the patients </li></ul><ul><li>younger patients more prone </li></ul><ul><li>appears in saliva </li></ul><ul><li>in systemic administration accelerates the healing of gingival wounds in non- epileptic humans. </li></ul>
  25. 26. <ul><li>Mechanism: PHENYTOIN </li></ul><ul><li>stimulates fibroblast production of an </li></ul><ul><li>proliferation inactive fibroblastic </li></ul><ul><li>collagenase </li></ul><ul><li>gingival overgrowth </li></ul><ul><li>increase in the sulfated decrease in the </li></ul><ul><li>glycosaminoglycans in collagen degradation </li></ul><ul><li>vitro. </li></ul>
  26. 27. <ul><li>Phenytoin gingival enlargement on the facial surface </li></ul><ul><li>Phenytoin gingival </li></ul><ul><li>enlargement on the </li></ul><ul><li>occlusal surface </li></ul>
  27. 28. <ul><li>Phenytoin enlargement in the posterior region </li></ul><ul><li>Phenytoin gingival </li></ul><ul><li>enlargement - </li></ul><ul><li>close-up view of </li></ul><ul><li>anteriors. </li></ul>
  28. 29. <ul><li>2). Immunosuppressants </li></ul><ul><li>Cyclosporines used to prevent organ transplant rejection & to treat autoimmune origin </li></ul><ul><li>if dosage > 500mg/day reported to induce gingival enlargement. </li></ul><ul><li>30% patient. </li></ul><ul><li>More vascularised </li></ul><ul><li>associated with nephrotoxicity, hypersensitivity, hypertension, hyperthricosis. </li></ul>
  29. 30. <ul><li>Cyclosporine induced gingival enlargement </li></ul><ul><li>in a 14yr old boy </li></ul>
  30. 31. <ul><li>3).Calcium channel blockers </li></ul><ul><li>used for CVS disorders, hypertension , angina pectoris, coronary artery spasm & cardiac arrhythmia. </li></ul><ul><li>Drugs like nifedipine,diltiazem, felodipine, nitrendipine and verapamil. </li></ul><ul><li>Nifidipine induces enlargement in 20% cases </li></ul><ul><li>Nifidepine + cyclosporines (for kidney transplant) </li></ul><ul><li>larger overgrowth </li></ul><ul><li>dose dependent growth </li></ul>
  31. 32. <ul><li>Nifedipine induced gingival enlargement </li></ul>
  32. 33. <ul><li>Idiopathic gingival enlargement </li></ul><ul><li>termed as gingivostomatitis, elephantiasis, idiopathicfibromatosis, hereditary gingival hyperplasia & congenital familial fibromatosis. </li></ul><ul><li>Etiology : </li></ul><ul><li>unknown </li></ul><ul><li>hereditary basis (autosomal dominant or recessive) </li></ul><ul><li>begins with primary & secondary dentition eruption. </li></ul>
  33. 34. <ul><li>Clinical features: </li></ul><ul><li>Site - attached gingiva, gingival margin, and interdental papilla </li></ul><ul><li>pink,firm and leathery with pebbled appearance </li></ul><ul><li>Severe cases jaw appears distorted due to bulbous enlargement </li></ul><ul><li>secondary inflammation </li></ul>
  34. 35. <ul><li>Histopathology: </li></ul><ul><li>epithelium -thickened & acanthosis elongated rete pegs. </li></ul><ul><li>Conn. Tissue- highly vascular, densely arranged collagen bundles & numerous fibroblasts </li></ul>
  35. 36. <ul><li>ENLARGEMENT ASSOCIATED WITH SYSTEMIC DISEASES </li></ul><ul><li>Many systemic diseases can develop oral manifestations that mayaffect the periodontium by two different mechanisms </li></ul><ul><li>1). Magnification of existing inflammation initiated by dental plaque “Conditioned enlargement” </li></ul><ul><li>a). Hormonal conditions (pregnancy & puberty) </li></ul><ul><li>b). Nutritional (vitamin C deficiency) </li></ul><ul><li>c). Non- specific conditioned enlargement </li></ul>
  36. 37. <ul><li>2). Manifestation of systemic disease independent of the inflammatory status of the gingiva.This group described as “ Systemic diseases causing gingival enlargement”. </li></ul>
  37. 38. <ul><li>Conditioned enlargement </li></ul><ul><li>systematic condition of the patient exaggerates the usual gingival response to dental plaque </li></ul><ul><li>bacterial plaque is necessary for its initiation </li></ul><ul><li>3 types </li></ul><ul><li>a) Enlargement in pregnancy </li></ul><ul><li>b) Enlargement in puberty </li></ul><ul><li>c) Enlargement in vitamin C deficiency </li></ul>
  38. 39. A) Enlargement in pregnancy <ul><li>Marginal and generalized </li></ul><ul><ul><li>Etiology - increase in progesterone and estrogen till 3rd trimester </li></ul></ul><ul><ul><li> - increased vascular permeability and gingival edema. </li></ul></ul><ul><ul><li>Marginal enlargement </li></ul></ul><ul><ul><li>Clinical features </li></ul></ul><ul><ul><li>-generalized and interproximal </li></ul></ul><ul><ul><li>- bright red, soft friable and bleeds spontaneously. </li></ul></ul>
  39. 40. Tumor like gingival enlargement <ul><li>Also called pregnancy tumor </li></ul><ul><li>inflammatory response to bacterial plaque </li></ul><ul><li>clinical features </li></ul><ul><li>-lesions are discrete, mushroom like, flattened spherical masses </li></ul><ul><li>-sessile, pedunclated </li></ul><ul><li>-exibits deep red pin point margins. </li></ul><ul><li>-Painful ulcerations </li></ul>
  40. 41. <ul><li>- histopathology : </li></ul><ul><li>- called angiogranuloma . </li></ul><ul><li>- central mass of connective tissue </li></ul><ul><li>- neovascularisation lined by cuboidal endothelial cells. </li></ul><ul><li>-varying degree of edema & chronic inflammatory infiltrate </li></ul><ul><li>- epithelium thickened, prominent retepegs. </li></ul><ul><li>Preventable by removal of plaque & calculus. </li></ul>
  41. 42. B) Enlargement in Puberty <ul><li>In both male & female adolescents </li></ul><ul><li>Clinical features : </li></ul><ul><li>-marginal & interdental </li></ul><ul><li>-chronic gingival disease </li></ul><ul><li>-reduces after puberty </li></ul><ul><li>-Capnocytophaga sp.. & P. intermedia </li></ul><ul><li>Histopathology </li></ul><ul><li>-chronic inflammation with edema </li></ul>
  42. 43. C) enlargement in Vitamin C deficiency <ul><li>Clinical features : </li></ul><ul><li>- Marginal gingivitis </li></ul><ul><li>- hemorrhage on slight provocation and suface necrosis with pseudomembrane formation </li></ul><ul><li>Histopathology: </li></ul><ul><li>- chronic inflammatory cellular infiltrate with superficial acute response </li></ul><ul><li>- scattered hemorrhage </li></ul><ul><li>- diffuse edema, collagen degeneration & scarcity of collagen </li></ul>
  43. 44. <ul><li>Gingival englargement with ulceration due to severe deficiency of vit C </li></ul>
  44. 45. Plasma cell gingivitis <ul><li>Referred to as atypical gingivitis and plasma cell gingivostomatitis </li></ul><ul><li>site- marginal and attached gingiva </li></ul><ul><li>Clinical features : </li></ul><ul><li>-red, friable, bleeds easily </li></ul><ul><li>-oral aspect of attached gingiva </li></ul>
  45. 46. <ul><li>Histopathology: </li></ul><ul><li>-epithelium- spongiosis and infiltrated with chronic inflammatory cells. </li></ul><ul><li>-lower spinous layer and basal layer damaged </li></ul><ul><li>-plasma cells infiltrate </li></ul>
  46. 47. Non specific conditioned enlargement (pyogenic granuloma) <ul><li>Tumor like gingival enlargement </li></ul><ul><li>conditioned response to minor trauma </li></ul><ul><li>Clinical features: </li></ul><ul><li>-discrete spherical tumor like mass </li></ul><ul><li>-pedunclated, keloid like </li></ul><ul><li>-red friable with ulceration </li></ul><ul><li>-fibroepithelial papilloma </li></ul>
  47. 48. <ul><li>Histopathology: </li></ul><ul><li>-chronic inflammation with granulation tissue </li></ul><ul><li>-vascular spaces & epithelial atrophy </li></ul><ul><li>Treatment - removal of lesion and local irritating factors </li></ul><ul><li>gingival mass at the mass regress 3 time of pregnancy months after pregnancy </li></ul>
  48. 49. Systemic diseases causing gingival enlargement <ul><li>Leukemia </li></ul><ul><li>Clinical features : </li></ul><ul><li>-diffuse or marginal </li></ul><ul><li>-localized or generalized tumor like mass in interproximal spaces </li></ul><ul><li>-red, friable, firm and hemorrhagic </li></ul><ul><li>-painful necrotising </li></ul><ul><li>-ulcerative inflammation </li></ul>
  49. 50. <ul><li>Leukaemic gingival enlargement </li></ul>
  50. 51. <ul><li>Histopathology: </li></ul><ul><li>Epithelium - varying degree of leukocytic infiltration & edema </li></ul><ul><li>Psuedomembranous meshwork of fibrins, necrotic epithelial cells, PMNS & bacteria. </li></ul><ul><li>Conn.. Tissue - infiltrated with a dense mass of immature & proliferating leukocytes </li></ul><ul><li>engorged capillaries </li></ul>
  51. 52. Granulomatous diseases <ul><li>Wegener’s granulomatosis </li></ul><ul><li>Etiology : cause unknown (immunologically mediated tissue injury) </li></ul><ul><li>Characterized by acute granulomatous necrotising lesion of respiratory tract involving the orofacial region </li></ul><ul><li>Clinical features : </li></ul><ul><li>reddish purple bleeds easily </li></ul><ul><li>Histopathology: </li></ul><ul><li>chronic inflammatory giant cells & foci of acute inflammation, microabscesses </li></ul>
  52. 53. <ul><li>Red hemorrhagic mass surrounding gingiva </li></ul>
  53. 54. Sarcoidiosis <ul><li>Etiology unknown </li></ul><ul><li>red, smooth, painless enlargement </li></ul><ul><li>histopathology discrete, noncaseating whorls of epitheloid cells & multinucleated </li></ul><ul><li>foreign-body-type giant cells </li></ul>
  54. 55. NEOPLASTIC ENLARGEMENT (GINGIVAL TUMORS) <ul><li>A).Benign tumors of gingiva </li></ul><ul><li>Epulis all discrete tumors & tumor like masses of gingiva </li></ul><ul><li>considered inflammatory </li></ul><ul><li>growth of gingiva & hard palate </li></ul><ul><li>1) Fibroma - arises from connective tissue or PDL </li></ul><ul><li>slow growing, firm, nodular, soft, vascular, pedunculated. </li></ul>
  55. 56. <ul><li>Histopathology: </li></ul><ul><li>Bundles of well formed collagen fibers. </li></ul><ul><li>Multinucleated fibroblasts in Giant cell fibroma </li></ul>
  56. 58. <ul><li>2). Papilloma : </li></ul><ul><li>proliferation of surface epithelium associated with human papilloma virus(HPV) </li></ul><ul><li>cauliflower like protuberances </li></ul><ul><li>broad, hard </li></ul>
  57. 59. <ul><li>Human Pappilloma Virus(HPV) </li></ul><ul><li>histopathology: </li></ul><ul><li>Finger like projections of stratified squamous epithelium, often hyperkeratotic </li></ul><ul><li>fibrovascular core </li></ul>
  58. 60. 3)Peripheral giant cell granuloma <ul><li>Clinical features </li></ul><ul><li>interdentally, gingival margin </li></ul><ul><li>pedunclated, smooth, multilobulated, ulcerations </li></ul><ul><li>painless, firm , spongy </li></ul><ul><li>locally invasive destroys underlying bone </li></ul><ul><li>Histopathology : </li></ul><ul><li>Numerous foci of multinucleated giant cells & hemosiderin particles </li></ul><ul><li>chronic infiltration </li></ul>
  59. 61. <ul><li>Peripheral giant cell granuloma </li></ul>
  60. 62. <ul><li>Hyperplastic epithelium </li></ul><ul><li>ulceration </li></ul><ul><li>Central giant cell granuloma </li></ul><ul><li>within the jaw and produce central cavitation . </li></ul><ul><li>Leukoplakia </li></ul><ul><li>Defined as “a white plaque that cannot be diagnosed as any other etiology other than that associated with tobacco chewing”. </li></ul><ul><li>Etiology - C, albicans, HPV-16, trauma </li></ul><ul><li>Clinical features - white, flattened, scaly, </li></ul><ul><li>thick keratinous plaque </li></ul>
  61. 63. <ul><li>Histopathology </li></ul><ul><li>hyperkeratosis acanthosis </li></ul><ul><li>premalignant cahnges with atypical epithelium </li></ul><ul><li>dysplastic changes </li></ul><ul><li>carcinoma in situ </li></ul><ul><li>inflammatory infiltration </li></ul>
  62. 64. Gingival cyst <ul><li>Localized, marginal& attached </li></ul><ul><li>mandibular canine & premolar areas </li></ul><ul><li>painless& erodes the bone </li></ul><ul><li>Cyst developers from odontogenic epithelium </li></ul><ul><li>Histopathology </li></ul><ul><li>flattened, localized thickening of epithelium </li></ul><ul><li>Other benign tumors- Nevus, Myoblastoma, hemangioma, neurilemmoma, neurofibroma, ameloblastoma </li></ul>
  63. 65. 2).Malignant tumors <ul><li>Carcinomas </li></ul><ul><li>3% of all malignant tumors in the body. </li></ul><ul><li>squamous cell carcinoma- common </li></ul><ul><li>clinical features </li></ul><ul><li>Exophytic, irregular growth, ulcerative, flat, erosive lesions </li></ul><ul><li>symptomless initially then painful </li></ul><ul><li>invades the bone </li></ul>
  64. 67. <ul><li>Malignant melanoma </li></ul><ul><li>site - hard palate& maxillary gingiva </li></ul><ul><li>localized pigmentation </li></ul><ul><li>flat or nodular </li></ul><ul><li>rapid growth with early metastasis </li></ul><ul><li>arises from melanocytes from the gingiva </li></ul><ul><li>Sarcoma </li></ul><ul><li>Fibrosarcoma, lymphosarcoma& reticulum cell sarcoma of gingiva </li></ul><ul><li>Kaposi’s sarcoma. </li></ul>
  65. 68. FALSE ENLARGEMENT <ul><li>Not true enlargement but appear as an increase in size of underlying osseous or dental tissues. </li></ul><ul><li>A). Underlying osseous lesions </li></ul><ul><li>Enlargement of bone - exostosis or tori </li></ul><ul><li>paget’s disease, fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma osteoma, osteosarcoma . </li></ul>
  66. 69. <ul><li>B). Underlying dental tissues </li></ul><ul><li>during stages of eruption particularly primary dentition </li></ul><ul><li>labial gingiva- bulbous marginal distortion </li></ul><ul><li>Enlargement called developmental enlargement </li></ul><ul><li>& persists until junctional epithelium has migrated enamel to CEJ </li></ul><ul><li>Physiologic </li></ul><ul><li>complicated by marginal inflammation </li></ul>

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