description about introduction etilogy and various type of gingival enlargement

1. Sagar Dhital
Chitwan Medical College

2. Content
• Introduction
• Classification
• Chronic inflammatory enlargement
• Acute inflammatory enlargement
• Drug induced gingival enlargement

3. • Idiopathic gingival enlargement
• Systemic disease causing gingival
enlargement
• Neoplastic enlargement
• Treatment plan

4. Introduction
• Increase in size of gingiva is called gingival
enlargement.
• Also called gingival overgrowth.

5. Classification:
• According to etiologic factors &
pathologic changes:
Inflammatory enlargement:
 Chronic
 Acute
Drug induced enlargement:
 General information
 Anti-convulsants
 Immunosuppresants
 Ca-channel blockers

6. Enlargement associated with systemic
disease or conditions:
a) Conditioned enlargement:
 Pregnancy
 Puberty
 Vitamin C deficiency
 Plasma cell gingivitis
 Non-specific conditioned enlargement(pyogenic
granuloma)

7. b) Systemic diseases causing enlargement:
 Leukemia
 Granulomatous diseases (sarcoidosis, Wegener’s
granulomatosis)
 Neoplastic enlargements (gingival tumors):
 Benign tumors
 Malignant tumors
 False enlargement

8. • According to location & distribution:
Localized: limited to gingiva adjacent to single tooth
or group of teeth.
Generalized: involving gingiva throughout mouth
Marginal: confined to marginal gingiva
Papillary: confined to interdental papilla
Diffuse: involving marginal, attached & papillae
Discrete: an isolated sessile or pedunculated tumor
like enlargement

10. • According to degree of gingival
enlargement:
Grade 0: no signs of gingival enlargement
Grade I: enlargement confined to inderdental
papilla
Grade II: enlargement involves papilla & marginal
gingiva
Grade III: enlargement covers three quarters or
more of the crown

12. Chronic inflammatory enlargement:
• Clinical features:
• Originates as a slight ballooning of interdental papilla &
marginal gingiva
• Produces bulge around involved teeth
• Bulge increases in size until it covers part of
crown
• Painless
• Occasionally occurs as discrete sessile or
pedunculated mass resembling a tumor
• May be interproximal, marginal or attached
gingiva
• Slow growing mass
• Painful ulceration sometimes occur

13. Chronic inflammatory gingival enlargement
localized to anterior region

14. • Etiology:
 Prolonged exposure to dental plaque. Factors that
favor plaque accumulation & retention include poor
oral hygiene, Irritation by anatomic abnormalities &
improper restortative & orthodontic appliances.

15. Acute inflammatory enlargement:
• Gingival abscess:
o Clinical features:
• Localized, painful, rapidly expanding lesion that
usually has a sudden onset.
• Generally limited to marginal or interdental gingiva
• In early stage, appears as red swelling with smooth,
shiny surface
• Within 24-48 hrs, lesion becomes fluctuant &
pointed with surface orifice from which purulent
exudates may be expressed.
• Adjacent teeth is often sensitive to percussion
• If permitted to progress, lesion generally ruptures
spontaneously

16. Gingival abscess on facial gingival surface, in space
between cuspid & lateral incisor,unrelated to gingival
sulcus area.

17. o Etiology:
 Bacteria carried deep into the tissues when a foreign
substance( e.g. toothbrush bristle, piece of apple core
etc) is forcefully embedded into gingiva

18. • Periodontal (Lateral)abscess:
 Involve the supporting periodontal tissues &
generally produce enlargement of gingiva.

19. Drug induced gingival
enlargement:
• Clinical features:
 Growth starts as a painless, bead like enlargement of
interdental papilla & extends to the facial and lingual
gingival margins
 Marginal & papillary enlargements unite and may
develop into a massive tissue fold covering
considerable portion of the crowns

21. • When uncomplicated by inflammation, the lesion is
mulberry shaped, firm, pale pink and resilient with a
minutely lobulated surface and no tendency to bleed
• Appears to project from beneath gingival margin
• Usually generalized but more severe in maxillary &
mandibular anterior teeth
• Occurs in areas in which teeth are present, not in
edentulous spaces
• Drug induced enlargement may occur in mouths with
little or no plaque & may be absent in mouths with
abundant deposits.

22. Gingival enlargement associated with phenytoin
therapy. A.Facial view; prominent papillary lesions &
firm, nodular surface. B, Occlusal view of upper jaw

23. • Idiopathic gingival enlargement:
• Designated by such terms as gingivostomatitis,
elephantiasis, idiopathic fibromatosis, hereditary
gingival hyperplasia
• Clinical features:
• Affects attached gingiva as well as gingival margin &
interdental papillae
• Facial & lingual surfaces of mandible & maxilla are
generally affected
• Enlarged gingiva is pink, firm & almost leathery in
consistency
• Has a characteristic minutely pebbled surface

24. Idiopathic gingival enlargement in 14 year old white male pt.
A,facial view;gingiva is firm with nodular,pebbled surface &
partially covers crowns of teeth.B, occulual view

25. • Enlargement associated with systemic
disease or conditions:
• These disease and conditions affect the
periodontium by two different mechanisms:
• Magnification of an existing inflammation initiated
by dental plaque (conditioned enlargement)
• Manifestation of systemic disease independently of
the inflammatory status of gingiva (neoplastic
enlargement)

26. • Conditioned enlargement:
• Bacterial plaque is necessary for the initiation of this
type of enlargement.
• Three types of conditioned enlargements are
 Hormonal (pregnancy, puberty)
 Nutritional (associated with Vitamin C deficiency)
 Allergic

27. • Enlargement in pregnancy:
• May be marginal & generalized or may occur as a
single or multiple tumor like masses
• During pregnancy, there is increase in levels of
progesterone & estrogen.
• These hormonal changes induce changes in vascular
permeability, leading to gingival edema & increased
inflammatory response to dental plaque.

28. • Marginal enlargement:
• Clinical features:
• Results from aggravation of previous inflammation
• Usually generalized
• More prominent interproximally than on facial
&lingual surfaces
• Enlarged gingiva is bright red or mageneta, soft &
friable & has smooth, shiny surface
• Bleeding occurs spontaneously or on slight
provocation

29. • Tumor like gingival enlargement:
o Clinical features:
• Also called pregnancy tumor
• Inflammatory response to bacterial plaque
• Appears after 3rd month of pregnancy, may occur
earlier
• Appears as mushroom like, flattened spherical
mass that protudes from gingival margin
• Dusky red, smooth, glistening surface
• Usually painless

30. Enlargement in puberty:
o Clinical features:
• Appears in areas of plaque accumulation
• Occurs both in male & female adolescents
• It is marginal & inter-dental
• Characterized by prominent bulbous inter-
proximal papillae
• Often, only facial gingiva are enlarged
• Has all c/f associated with chronic inflammatory
gingival disease with distinction degree of
enlargement & recurrence in presence of relatively
scant plaque deposits

31. Enlargement in vitamin C deficiency:
o Clinical features:
• Generally included in classic description of scurvy
• Enlargement is marginal
• Gingiva is bluish red, soft& friable & has a smooth
shiny surface
• Hemorrhage occur either spontaneously or on slight
provocation
• Surface necrosis with pseudo membrane formation

33. • Plasma cell gingivitis:
• Referred to as atypical gingivitis and plasma cell
gingivostomatitis
• Gingiva appears red, friable, sometimes granular &
bleeds easily;usually it does not induce a loss of
attachment
• Mild marginal gingival enlargement that extends to
attached gingiva
• An associated cheilitis & glossitis have been
reported.
• Thought to be allergic in origin, possibly related to
components of chewing gum, dentrifices or various
diet components.

35. • Non-specific conditioned enlargement
(pyogenic granuloma)
 Tumor like gingival enlargement that is
exaggerated in response to minor trauma
 Similar to conditioned gingival enlargement seen
in pregnancy
 Treatment consists of removal of the lesions plus
the elimination of irritating local factors.
 Recurrence is about 15%

36. Pyogenic granuloma

37. • Systemic diseases causing gingival
enlargement:
Leukemia:
o Clinical features:
• May be diffuse or marginal & localized or generalized
 Gingiva is generally bluish red, has shiny surface,
friable , hemorrhagic
• Acute painful necrotizing ulcerative inflammatory
involvement may occur
• Pt may have simple chronic inflammation without
involvement of leukemic cells
• True leukemic enlargement occurs in acute leukemia,
sub-acute leukemia but seldom occurs in chronic
leukemia

38. Leukemic Gingival Enlargement

39. • Neoplastic enlargement(gingival tumors):
 Benign tumors of the gingiva:
o Fibroma:
 arise from the gingival CT or from the periodontal
ligament.
 Slow growing, spherical tumors that tend to be
firm & nodular, may be soft & vascular
 Usually pedunculated

40. • The so-called giant cell fibroma contains
multinucleated fibroblasts
• In another variant, mineralized tissue(bone,
cementum like material) may be found called as
peripheral ossifying fibroma.

41. • Papilloma:
 Benign proliferations of surface epithelium
 Not all cases associated with HPV
 Appear as solitary wart like or cauliflower like
protuberances
 Small & discrete or broad, hard elevations with
minutely irregular surfaces

42. Papilloma

43. • Peripheral giant cell granuloma:
• Arise interdentally or from gingival margin
• Occur most frequently on labial surface, may be
sessile or pedunculated
• Smooth, regularly outlined masses to irregularly
shaped, multilobulated protuberances with surface
indentations
• Ulcerations of margin occasionally seen
• Painless,vary in size, may cover several teeth
• Firm or spongy,color varies from pink to deep red
or purplish blue

44. Peripheral giant cell
granuloma

45. • Central giant cell granuloma:
 Giant cell lesions arise within the jaws and
produce central cavitation
 They occasionally create a deformity of jaws that
makes the gingiva appear enlarged
• Leukoplakia:
 A white patch or plaque that does not rub off &
cannot be diagnosed as any other disease –WHO
 Associated with use of tobacco. Other factors are
Candida albicans,HPV-16 & HPV-18 & trauma
 Leukoplakia of gingiva varies in apperance from
grayish white, flattened, scaly lesion to thick
irregularly shaped keratinous plaque

46.  Most leukplakias (80%) are benign; the remaining
20% aremalignant or pre-malignant

47. • Gingival cyst:
• Appear as localized enlargement that may involve
marginal & attached gingiva.
• Cysts occur in mandibular canine & premolar areas,
most often on lingual surface
• Painless
• Should be differentiated from lateral periodontal cyst
which arises within alveolar bone, adjacent to root &
is devepmental in origin.

48. • Other benign masses:
 Nevus, myoblastoma,
hemangioma,neurilemoma,neurofibroma, mucus-
secreting cyst (mucocele), ameloblastoma

49. • Malignant tumors of the gingiva:
o Carcinoma:
• Gingiva is not a frequent site of oral malignancy(6%
of oral cancers)
• Squamous cell Ca is the most common malignant
tumor of the gingiva
• May be exophytic, presenting as irregular
outgrowth, ulcerative, apperaing as flat erosive
lesions

50. • Malignant melanoma:
• Rare oral tumor that tends to occur in hard palate &
maxillary gingiva of older persons
• Usually darkly pigmented
• May be flat or nodular & characterized by rapid
growth & early metastasis

51. • Sarcoma:
• Fibrosarcoma, lymphosarcoma & reticulum cell
sarcoma of gingiva are rare
• Kaposi’s sarcoma occurs often occurs in oral cavity
of pts with AIDS, particularly in palate & gingiva

52. • False enlargement:
• Are not true enlargements of gingival tissues
• May appear as such as a result of increase in size of
underlying osseous or dental tissues
• Gingiva usually presents no abnormal clinical
features except massive increase in size of the area
o Underlying osseous lesions:
o Enlargement of bone sub adjacent to gingival area
occurs most often in tori & exostoses, can occur in
pagets disease, fibrous dysplasia, cherubism,
osteoma etc
o Gingival tissues can appear normal or may have
unrelated inflammatory changes

53. o Underlying dental tissues:
 During various stage of eruption, particularly of
primary dentition, labial gingiva may show a
bulbous marginal distortion caused by
superimposition of bulk of gingiva on normal
prominence of enamel in gingival half of crown.
This enlargement called as developmental
enlargement.
 This enlargement is physiologic & usually present
no problems

54. Treatment plan

55. Introduction
• Treatment of gingival enlargement is based on
understanding of the cause and underlying
pathology changes.

56. Chronic inflammatory enlargement
• Chronic inflammatory enlargement, which are
soft and erythematous and are caused
principally by edema and cellular infiltration are
treated by scaling and root planning, provided
the size of enlargement doesnot interfere with
complete removal of deposit from the involved
tooth surfaces.
• When these inflammatory enlargement include
a fibrotic component ,surgical removal is the
treatment of choice.

57. Periodontal and gingival abscess
• Treatment options are:
1. Drainage through pocket retraction or
incision.
2. Scaling and root planning.
3. Periodontal surgery.
4. Systemic antibiotics.
5. tooth removal.

58. Drug induced gingival enlargement
• Treatment of drug induced gingival enlargement
should be based on the medication being used and
the clinical features of the case.
• First, discontinuing the drug of changing the
medication:
 It is important to allow for 6-12 months to elapse
between discontinuation of the offending drug and
the possible resolution of gingival enlargement
before surgical intervention.
 Alternative medications.

59. Contd.
 Phenytoin-carbamazepine and valproic acid.
 Nifedipine-44%, diltiazem-20%, and verapamil-4%
and other hypertensive.
 Cyclosporin-tacrolimus.
 Antibiotic azithromycin may aid in decreasing the
severity of cyclosporin induced gingival
enlargement.

60. Contd.
• Second, non-surgical treatment options:
Plaque control
Good oral hygiene and frequent professional
removal of plaque decreases the degree of
the gingival enlargement present.
• Third, surgical treatment:
Gingivectomy
Periodontal flap

61. Fig: Decision tree for
treatment of drug

62. Gingivectomy
• A surgical procedure in which gingival
pockets are eliminated by removal of
gingiva.
Principle of operation:
1. Continuous incision at 45 degree angle at
the base of the pocket
2. Sharp dissection of tissues in the inter-
dental areas
3. Smoothing of the incisal edge
4. Contouring of the gingival surface

63. 5. Scaling and root planning
6. Wound coverage
Instruments:
1. Mouth mirror and probe
2. Pocket Marker
3. Kirkland and Orban inter-dental
gingivectomy knife
4. Surgical blade
5. BP handle

64. 7. Surgical currette, Gracey curette, tissue
forceps and scissors
8. Periodontal dressings

67. STEPS IN SURGICAL
GINGIVECTOMY
• Start apical to point marking of the course
of periodontal pocket and is directed
coronally to a point between the base of
the pocket and the crest of the bone.
• The incision should be beveled at
approximately 45 degree to the tooth
surface to follow the normal festooned
pattern of the gingiva.
• Should not leave diseased pocket wall.
• The incision should pass completely

68. REMOVE RESECTED-GINGIVA
• Remove the marginal and inter-dental
gingiva starting from distal surface of last
tooth,detach gingiva at the line of incision
with the help of surgical hoes and scalers.
• Remove the granulation tissue
• The curettes are used for this purpose.
The curette is guided along the tooth
surface and under the granulation tissue.

69. • Remove calculus:
The remaining calculus and necrotic cementum
are to be removed using scalers and
curettes.Check each surface of every tooth for
calculus and soft tissue remnants.
Wash area several times with saline and cover
with gauze sponge.
• Place periodontal pack
After the bleeding is control and hemostatis
achieved,the gingivectomy wound is covered
with periodontal pack.

70. Periodontal flap
• A section of gingiva and/or mucosa
surgically separated from the underlying
tissue to provide visibility and access to
the bone and root surface.

71. Leukemic gingival
enlargement
• Bleeding and clotting times and platelet count of
the patient should be checked and the
hematologist consulted before the periodontal
treatment.
• The enlargement is treated by scaling and root
planning carried out in stages under topical
anesthesia.
• The initial treatment consists of gently removing
all loose accumulation with cotton pellets.

72. Contd.
• Progressively deeper scaling are carried
out at subsequent visits.
• Antibiotics are administered systemically
the evening before and for 48 hrs after
each treatment to reduce the risk of
infection.

73. Gingival enlargement in
pregnancy
• Treatment requires elimination of all local
irritants responsible for precipitating the
gingival changes in pregnancy.
• Marginal and interdental gingival
inflammation and enlargement are treated
by scaling and curettage.
• Treatment of tumor like gingival
enlargement consists of surgical excision

74. Contd.
• In pregnancy, the emphasis should be on :
1. Preventing gingival disease before it
occurs.
2. Treating existing gingival disease before
it worsens

75. Gingival enlargement in
puberty
• Gingival enlargement in puberty is treated
by performing scaling and curettage,
removing all sources.
• The use of escharotic drugs has been
recommended in the past for the removal
of gingival enlargement of irritation and
controlling plaque.

76. CONCLUSION
• Gingival enlargement are multi-factorial
and complex in nature,which may be in
response to various interaction between
host and environment.
• Gingival overgrowth considerably reduce
the quality of life and may result in serious
emotional and social problems hence the
prevention and treatment based on the
underlying the cause and underlying
pathologic changes.

77. • The treatment of gingival enlargement
depends on the type of clinical
enlargement encountered.
• In recent years, flap surgery have been
used more often to treat gingival
enlargement than gingivectomy.