This document discusses gingival enlargement (GO), also known as gingival overgrowth. It begins by defining key terms like hyperplasia, hypertrophy, and fibrosis. It then classifies GO into different categories such as inflammatory enlargement, drug-induced enlargement, and GO associated with systemic conditions or diseases. For each category, it provides examples, descriptions, pictures when relevant, and discusses treatment approaches. In particular, it focuses on common causes of drug-induced GO like phenytoin, nifedipine, and cyclosporine, as well as discussing pregnancy-associated GO and nutrition-associated GO in patients with scurvy.

1. Gingival Enlargement
Dr. Mahmoud Mudalal
B.Sc. Dental surgery
M.Sc. Periodontology
Ph.D. Periodontology and Implantology
Asst. Professor at Arab American university
Member of ADEE.
Research fellow at Jilin Provincial Experimental School.
Google scholar. Mahmoud MUDALAL 64 citations.
Research Gate Ref #: 11.9.

2. Terminology and Classification
• 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. Although their pathogenetic mechanisms
are different, hyperplasia and hypertrophy usually occur
simultaneously when cellular involvement in hyperplasia most
likely triggers the overgrowth.
• Fibrosis refers to a pathologic process in which disrupted wound
healing is associated with defective cell proliferation, cell-to-cell
interactions, cell-to-matrix interactions, and matrix deposition and
with an impaired immune system response.

3. • In this regard, fibrosis can be defined as a pathologic lesion,
whereas hyperplasia and hypertrophy can be viewed as
pathologic processes.

4. GO cases are classiied as follows:
• Inflammatory enlargement due to chronic gingivitis.
• Drug-induced enlargement.
• GO associated with systemic conditions.
• GO associated with systemic diseases.
• Gingival fibromatosis.

5. • In periodontal tissues, indices are important for quantification
of the extent and severity of GO. 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

6. Inflammatory Enlargement of Gingiva Due to
Gingivitis
• All changes in gingival tissues manifest with some degree of inflammation.
• In some cases, gingival enlargement is a direct outcome of gingivitis
without any complicating factors or involvement of systemic conditions.
• When a patient with gingival enlargement is seen, the initial assessment is
made by careful visual examination of abnormalities of gingival contours,
texture, and color, which are compared with normal standards.
• Visual inspection is accompanied by a detailed medical history to exclude
potential systemic factors and conditions.
• Dental irregularities, dysfunctional habits, and oral care efficiency should
be considered in the evaluation, and clinical measurements should be
recorded.

8. • Treatment
• Chronic enlargement of the gingiva due to gingivitis is
reversible and can be resolved by removal of the etiologic
factors, including the biofilm, and correction of environmental
factors. In severe forms of inflammatory enlargement, surgical
approaches may be required.

9. Drug-Induced Overgrowth of Gingiva
• Most common forms of DIGO are caused by the use of
anticonvulsants, calcium channel blockers, and
immunosuppressants prescribed to patients for serious health
concerns.
• Three drugs associated with DIGO are phenytoin, nifedipine,
and cyclosporine. About 20 other medications have been
linked to DIGO.
• An estimated 30% to 80% of the patients using these
medications are at risk for overgrowth lesions. Genetic factors,
drug dosage, and local factors can affect the development and
severity of DIGO.

10. • Anticonvulsants, calcium channel blockers, and
immunosuppressants are prescribed to patients with serious
health concerns such as epilepsy, hypertension, and solid organ
transplantation, respectively.
• Drug-induced GO is a major dental problem due to impaired
oral hygiene, biofilm accumulation, and gingival inflammation,
and it poses a risk for the general health of these patients.

11. • Gingival enlargement associated with phenytoin therapy. (A)
Facial view. (B) Occlusal view of the maxillary arch.

12. • Treatment
• DIGO cannot be prevented by conventional approaches, but it
can be ameliorated by elimination of local factors, plaque
control, and regular periodontal maintenance.
• The most effective treatment of DIGO is withdrawal or
substitution of medications.
• A case report showed resolution of gingival lesions in 1 to 8
weeks after discontinuing the medication. For example,
changing nifedipine to another antihypertensive drug,
isradipine, caused regression of gingival enlargement.
Tacrolimus, used as an alternative for cyclosporin, resulted in
regression of gingival enlargement. However, most alternatives
have also been linked to DIGO in recent years.

13. • In addition to withdrawal or substitution of medication, scaling
and root planing have given relief to patients with GO.
Nonsurgical treatment can eliminate the inflammatory
component of DIGO, which can account for 40% of tissue
enlargement.

14. Gingival Overgrowth Associated With Systemic
Conditions
• Pregnancy-Associated Gingival Overgrowth
GO is a common pathology in pregnancy. Clinically, it manifests
as a single mass or multiple tumor-like masses at the gingival
margin. Marginal gingival enlargement during pregnancy results
from the aggravation of previous inflammation, and its incidence
has been reported as 10% to 70%.

15. • Pyogenic granuloma due to pregnancy.

16. • Treatment
• Similar to other forms of gingival changes associated with
hormonal variations during pregnancy, GO lesions can be
prevented by good oral hygiene.
• Oral care in pregnant women should be meticulous, and
patients should be treated by removal of plaque and calculus.
• Severe cases may require removal during the second trimester;
however, removal of the GO lesions without establishment of
an optimal oral hygiene regimen ensures recurrence of gingival
enlargement.

17. • Nutrition-Associated Gingival Overgrowth
Malnutrition has been historically associated with several oral
lesions.
GO has been observed in cases of chronic vitamin C deficiency in
patients with scurvy.
These lesions are no longer common, but GO is still considered a
part of the classic description of scurvy.

18. • 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.

19. Gingival Overgrowth Associated With Systemic
Diseases
1. Leukemia-Associated Gingival Overgrowth
2. Sarcoidosis
3. Wegener Granulomatosis
4. Gingival Fibromatosis

20. • 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 ibromatosis
lesions, patients may require orthodontic treatment.25