gingival enlargement in periodontology

1. GINGIVAL ENLARGEMENT
Dr. shabeer Ahamed, Professor
Malabar Dental College

2. • Increase in size of the gingiva is a common
feature of the gingival disease
• Accepted terminology for this condition is
‘gingival overgrowth or gingival
enlargement’
• Earlier was called as ‘hypertrophic
gingivitis or gingival hyperplasia’

3. CLASSIFICATION
Based on etiologic factors and pathologic changes
1.Inflammatory enlargement
a) Acute
b) Chronic
2.Drug induced enlargement
3.Enlargement associated with systemic disease or conditions
a) conditioned enlargement b) systemic disease
Pregnancy Leukemia
Puberty Granulomatous diseases
Vitamin c deficiency
Plasma cell gingivitis
Non – specific conditioned enlargement
4. Neoplastic tumors:
a) Benign
b) Malignant
5. False enlargement

4. Using the criteria of location and distribution,
gingival enlagement is designated as follows:
Localised: limited to the gingiva adjacent to a
single tooth or group
Generalised : Invoving the gingiva throughout
the mouth
Marginal: confined to marginal gingiva
Papillary : confined to interdental pappila
Diffuse: Involving the marginal and attached
gingivae and papillae
Discrete : An isolated sessile or pedunculated,
tumour like enlargement

5. The degree of gingival enlargement
BOKEN KAMP
• 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
quarters or more of the crown

6. Inflammatory enlargement

7. Acute inflammatory enlargement
Gingival Abscess:
Etiology:
when bacteria carried deep into the tissues when a foreign substance (eg:
tooth brush bristle, piece of apple core , lobster shell fragment ) is forcefully
embedded in the gingiva
clinical features :
 Localised , painful , rapidly expanding swelling of sudden onset
 Limited to marginal gingiva or interdental papilla
 Red swelling with a smooth , shiny surface
 It becomes fluctuant and pointed with a surface orifice with purulent
exudate
Treatment:
 immediate removal of etiology
 Scaling and root planing- removal of debris and to drain the abscess
 Large abscess : local anaesthesia fluctuant area incised with #15 blade
area is cleansed with warm saline
 Recall after 24 hrs

8. Periodontal ( lateral/ parietal) Abscess
A localized purulent infection within the tissue adjacent to the
periodontal pocket that may lead to the destruction of
periodontal ligaments and alveolar bone
Etiology:
 Tortuous periodontal pockets
 Closure of margins of periodontal pockets may lead to
extension of the infection into the surrounding tissue
 Impaction of foreign bodies
 After procedures like scaling, where calculus is dislodged
and pushed into the soft tissue
 Perforation of the lateral wall of a tooth by an endodontic
instrument

9. Classification:
Abscess in the supporting periodontal tissue
along the lateral aspect of the root
Abscess in the soft tissue wall of a deep
periodontal pocket
Treatment
1.Drainage through pocket retraction or incision
2. Scaling and root planing
3. Periodontal surgery
4. Systemic antibiotics
5. Tooth removal

10. Chronic inflammatory enlargement
Etiology:
Prolonged exposure to dental plaque, irritation by anatomic
abnormalities, improper restorative and orthodontic appliance
clinical features :
• Ballooning of interdental papilla and marginal gingiva
• It increases in size until it covers part of the crown
• It can be discrete sessile or pedunculated mass resembling a
tumor
• Lesions are slow growing masses and painless.
• Lesions are clinically red or bluish red and soft and friable
• Smooth, shiny surface & they bleed easily

11. Gingival changes associated with
mouth breathing
• Often seen in mouth breathers
• Appears red and edematous with a diffuse surface
shininess of the exposed area
• Maxillary anterior region is the common site
• Altered gingiva is well demarcated from unexposed
normal gingiva
• It is due to irritation from surface dehydration

12. Treatment
• SCALING AND ROOT PLANING -
• SURGICAL REMOVAL-
Gingivectomy
Flap operation

13. Drug induced gingival enlargement

14. • Anti convulsants:
Phenytoin, ethotoin, mephenytoin,
Ethosuccinamide
• Immunosuppressants: Cyclosporine
• Calcium channel blockers:
Amlodipine , felodipine ,
nicardipine, diltiazem

15. Category Pharmacologic Agent Prevalence
Anticonvulsants Phenytoin
Sodium valproate
Phenobarbitone
Vigabatrin
Carbamazepine
50%
Rare
<5%
Rare
None reported
Immunosuppressants Cyclosporin Adults 25-30%
Children >70%
Calcium channel blocker Nifedipine
Isradipine
Felodipine
Amlodipine
Verapamil
Diltiazem
6-15%
None reported
Rare
Rare
<5%
5-20%
Estimated Prevalence of Drug-Associated Gingival Enlargement
According to the Most Frequently Reported Prevalence Rates

16. Characteristic of drug induced enlargement
Variation in
inter/ intra
pt. pattern
Ant. gingiva
 Children
Change in
contour, size
Enlargement first
IDP
Change in ging
color
Exudate
BOP
Inflamm to
plaque
Bone loss ±/
CAL
Drug use

17. Clinical Features
• It starts as a painless beadlike enlargement of the interdental
papilla & extends to the facial & lingual gingival margins
• When condition progresses, the marginal and papillary
enlargements unite
• The lesion is mulberry shaped, firm, pale pink, & resilient,
with a minutely lobulated surface & no tendency to bleed
• Generalized throughout the mouth but is more severe in the
maxillary & mandibular anterior regions, occurs in areas in
which teeth are present

18. COLOUR
• Usually pale pink
• Erythematous in cyclosporine induced Enlargement
CONSISTENCY
A.Firm , fibrotic
B.Based on the inflammatory component may be
edematous
SITES INVOLVED
 Usually marginal and papillary gingiva is involved
 Enlargement appears to project from beneath the
gingival margin

19. SURFACE TEXTURE
In phenobarbitone, the gingiva is enlarged
uniformly without lobulations of the
interdental papilla; more common in
posteriors.
Cyclosporine – pebbly or papillary lesions
appear on the surface of large lobulations.

20. Anticonvulsants
• First drug-induced gingival enlargements reported
was phenytoin (Dilantin) for the treatment of epilepsy
• Gingival enlargement occurs in about 50% of
patients receiving the drug
• Occurs more in younger patients

21. • Analogues 1-allyl 5-phenylhydantoinate and
5-methyl 5-phenylhydantoinate- stimulate fibroblasts
• stimulates proliferation of fibroblast-like cells and epithelium
• Phenytoin may induce a decrease in collagen degradation as a
result of the production of an inactive fibroblastic collagenase
• Gingival enlargement may result from the genetically determined
ability or inability of the host to deal effectively with prolonged
administration of phenytoin.

22. Immuno-suppressants
• Cyclosporine a potent immunosuppressive agent
• Used to prevent organ transplant rejection
• Selectively & reversibly inhibit helper T cells
• Administered intravenously or by mouth & dosages greater
than 500 mg/day have been reported to induce gingival
overgrowth
• More frequent in children
• Enlargement is a hyper-sensitivity response to the
cyclosporine, more vascularized enlargement

23. • TACROLIMUS has been used effectively,
it is also nephrotoxic, but it results in
much less severe hypertension,
hypertricosis, & gingival overgrowth
• Differs chemically from cyclosporine and
binds to a different receptor

24. Calcium Channel Blockers
• Used for the treatment of cardiovascular conditions such
as hypertension, angina pectoris, coronary artery spasms
• They inhibit calcium ion influx across the cell membrane
of heart & smooth muscle cells, blocking intracellular
mobilization of calcium
• Nifedipine ,Diltiazem, felodipine, nitrendipine &
verapamil induce gingival enlargement
• Nifedipine is also used with cyclosporine in kidney
transplant recipients & the combined use of both drugs
induces larger overgrowths

26. Treatment Options
• First-possibility of discontinuing the drug or
changing medication
• It is important to allow for a 6- to 12-month period
of time to elapse between discontinuation of the
offending drug & resolution of gingival
enlargement
• Alternative medications to phenytoin include
carbamazepine & valproic acid

27. Idiopathic Gingival Enlargement

28. Etiology
unknown, hereditary basis ,
begins with the eruption of the primary or
secondary dentition , presence of bacterial plaque
Clinical Features
• Attached gingiva, as well as the gingival margin&
interdental papillae
• Facial & lingual surfaces of the mandible &
maxilla are generally affected
• Enlarged gingiva is pink, firm, leathery in
consistency & has a characteristic minutely
pebbled surface

29. Enlargement associated with
systemic disease or conditions

30. Diseases and/or conditions can affect the
periodontium by two different mechanisms:
1. Magnification of an existing inflammation
initiated by dental plaque.
 Conditioned Enlargements/ includes hormonal conditions (e.g.
pregnancy & puberty), Nutritional diseases such as vitamin C
deficiency
 Nonspecific conditioned enlargement; in which the systemic
influence is not identified.
2. Manifestation of the systemic disease
independently of the inflammatory status of the
gingiva.
 Systemic Diseases Causing Gingival Enlargement
 Neoplastic Enlargement (Gingival Tumors)

31. Conditioned Enlargement
When the systemic condition of the patient
exaggerates or distorts the usual gingival response
Types
Hormonal (pregnancy, puberty)
Nutritional (associated with vitamin C deficiency)
Allergic to dental plaque

32. Enlargement in Pregnancy
• Marginal & generalized or may occcur as single
or multiple tumor-like masses
• hormonal changes induce changes in vascular
permeability leading to gingival edema & an
increased inflammatory response to dental plaque.
MARGINAL ENLARGEMENT
• Results from the aggravation of previous
inflammation

33. Clinical Features
• Generalized & tends to be more prominent
interproximally
• Gingiva is bright red or magenta,
soft ,friable& has a smooth,
shiny surface
• Bleeding occurs spontaneously

34. TUMOR-LIKE GINGIVAL
ENLARGEMENT
• The so-called pregnancy tumor is an
inflammatory response to bacterial plaque
Clinical features
• discrete, mushroomlike, flattened spherical
mass that protrudes from the gingival margin
• It has a smooth, glistening surface , the mass is
usually semifirm, painless

35. Treatment of gingival enlargement in
pregnancy
• It requires elimination of all local irritants , is a
preventive measure against gingival disease
• Marginal , interdental gingival inflammation &
enlargement are treated by scaling & curettage
•
• Treatment of tumorlike enlargements - surgical
excision & scaling & planing of the tooth
surface

36. • Lesions should be removed surgically during
pregnancy only if it interfere with mastication
or produce an esthetic disfigurement that the
patient wishes to be removed.
• In pregnancy, the importance should be on
1) preventing gingival disease before it occurs
2) treating existing gingival disease before it
worsens.

37. ENLARGEMENT IN PUBERTY
• occurs in both male and female
adolescents
• appears in areas of plaque accumulation.
CLINICAL FEATURES
• It is marginal & interdental, is characterized by
prominent bulbous interproximal papillae
• After puberty, the enlargement undergoes
spontaneous reduction but does not disappear until
plaque& calculus are removed
• Capnocytophaga sp. in the initiation of pubertal
gingivitis.

38. TREATMENT:
• It is treated by scaling & curettage, removing
all sources of irritation, &controlling plaque.
• Surgical removal may be required in severe
cases due to poor oral hygiene.

39. ENLARGEMENT IN VITAMIN C
DEFICIENCY
• a conditioned response to bacterial plaque
• acute vitamin C deficiency & inflammation produces
the massive gingival enlargement in scurvy
CLINICAL FEATURES
• Marginal
• Gingiva is bluish red, soft
• Friable & has a smooth, shiny surface.
• Hemorrhage, surface necrosis with pseudomembrane
formation

40. PLASMA CELL GINGIVITIS
• Mild marginal gingival enlargement
that extends to the attached gingiva.
CLINICAL FEATURES:
• Gingiva appears red, friable, sometimes
granular& bleeds easily
• Located in the oral aspect of the attached gingiva
• Allergic in origin, elated to components of
chewing gum, dentifrices, or various diet
components

41. NONSPECIFIC CONDITIONED ENLARGEMENT
(PYOGENIC GRANULOMA)
An exaggerated conditioned response to minor trauma.
CLINICAL FEATURES:
• A discrete spherical, tumorlike mass with a pedunculated
attachment to a flattened, keloid like enlargement with a broad
base.
• Bright red or purple& cither friable or firm, depending on its
duration
• Mostly presents with surface ulceration & purulent exudation
TREATMENT
Removal of the lesions plus
Elimination of irritating local factors.

42. Systemic Diseases Causing
Gingival Enlargement
LEUKEMIA
clinical features
• Enlargement may be diffuse or marginal,
localized or generalized.
• Gingiva is bluish red & has a shiny surface.
The consistency is moderately firm, there is a
tendency toward friability & hemorrhage
• Occurs in acute leukemia , subacute leukemia

43. TREATMENT OF LEUKEMIC
GINGIVAL ENLARGEMENT
• Oral hygiene procedures are extremely important in
these cases & should be performed if neccesary
• Progressively deeper scalings are carried out at
subsequent visits. Treatments are confined to a small
area of the mouth to facilitate control of bleeding.
• Antibiotics are administered systemically the evening
before & for 48 hours after each treatment to reduce the
risk of infection.

44. Granulomatous Diseases
WEGENER'S GRANULOMATOSIS
Clinical Features:
• Granulomatous papillary enlargement is reddish purple &
bleeds easily on stimulation.
• Cause of Wegener's granulomatosis is unknown, but the
condition is an immunologically mediated tissue injury
(Cotran, Kumar & Robbins 1989)
SARCOIDOSIS:
• unknown etiology.
• affects predominantly blacks
• Gingiva is red, smooth, painless enlargement may appear.

45. NEOPLASTIC ENLARGEMENT
(GINGIVAL TUMORS)
Benign Tumors of the Gingiva
EPULIS:
• All discrete tumors & tumorlike masses of the gingiva
•
FIBROMA:
• Arise from the gingival connective tissue or from the
periodontal ligament. They are slowgrowing, spherical tumors
that tend to be firm,nodular but may be soft,
vascular,pedunculated
PAPILLOMA:
• Gingival papillomas appear as solitary, wartlike or
"cauliflower"-like protuberances & may be small & discrete or
broad, hard elevations with minutely irregular surfaces.

46. PERIPHERAL GIANT CELL GRANULOMA
• Arise interdentally or from the gingival margin,
occur most frequently on the labial surface& may be
sessile or pedunculated.
• Lesions are painless, vary in size, may be firm or
spongy& the color varies from pink to deep red or
purplish blue
• Causes destruction of the underlying bone
LEUKOPLAKIA:
• “White patch or plaque that does not rub off
& cannot be diagnosed as any other disease”
• Tobacco, Candida albicans, HPV-16, HPV-18, &trauma
• Grayish white, flattened, scaly lesion to a thick,
irregularly shaped keratinous plaque

47. GINGIVAL CYST
• As localized enlargements that may involve the
marginal & attached gingiva.
• Occur in mandibular canine & premolar areas,
most often on the lingual surface.
• Painless, but with expansion,cause erosion of the
surface of the alveolar bone
• Microscopically, a cyst cavity is lined by a thin,
flattened epithelium with or without localized
areas of thickening

48. Malignant Tumors of the Gingiva
Carcinoma
• Gingiva is not a frequent site of oral malignancy
(6% of oral cancers).
• Squamous cell carcinoma is the most common
malignant tumor of the gingiva. It may be
exophytic, presenting as an irregular outgrowth, or
ulcerative, which appear as flat, erosive lesions.
• Locally invasive, involving the underlying bone &
periodontal ligament of adjoining teeth & adjacent
mucosa

49. MALIGNANT MELANOMA
• Flat or nodular ,rapid growth & early metastasis.
• Arises from melanoblasts in the gingiva, cheek, or
palate. Infiltration into the underlying bone &
metastasis to cervical & axillary lymph nodes
SARCOMA:
• Kaposi's sarcoma often occurs in the oral cavity of
patients with acquired immunodeficiency
syndrome (AIDS), particularly in the palate ,
gingiva.

50. FALSE ENLARGEMENT
• Are not true enlargements but appear as such as a
result of increases in size of the underlying
osseous or dental tissues
UNDERLYING OSSEOUS LESIONS
• Tori & exostoses, occur in Paget's disease, fibrous
dysplasia, cherubism, central giant cell
granuloma, ameloblastoma, osteoma, &
osteosarcoma
• Gingival tissue appear normal or may have
unrelated inflammatory changes.

51. UNDERLYING DENTAL TISSUES
• Labial gingiva may show a bulbous marginal
distortion caused by superimposition of the
bulk of the gingiva on the normal prominence
of the enamel in the gingival half of the crown.
• Developmental gingival enlargements are
physiologic
• Treatment- alleviate marginal inflammation

52. Conclusion
• Adverse aesthetics & impaired function are associated
with the presence of drug-induced gingival
enlargement.
• Comprehensive treatment of these cases is
multidisciplinary in nature, & dentists ,physicians
should first consider the nonsurgical approach ,then
only periodontal surgery in form of the gingivectomy or
periodontal flap procedures.
• Surgical retreatment of recurrence areas needs to be
periodically reconsidered