GINGIVAL ENLARGEMENT,ORAL MEDICINE AND RADIOLOGY,PERIODONTOLOGY

1. GINGIVAL ENLARGEMENT
PREPARED BY:
KIRTHANA MUTHU
IV BDS
DEPARTMENT OF OMR

2. CONTENTS
• INTORDUCTION
• DEFINITION
• CLASSIFICATIONS
• INFLAMMATORY ENLARGEMENTS
• DRUG INDUCED ENLARGEMENTS
• ENLARGEMENTS ASSOCIATED WITH
SYSTEMIC DISEASES
• NEOPLASTIC ENLARGEMENT
• FALSE ENLARGEMENT

3. GINGIVA
• It is that part of the
oral mucosa which
surround the neck of
the teeth and covers
the alveolar process
of maxilla and
mandible

4. GINGIVAL ENLARGEMENT
• Gingival overgrowth
• Accepted terminology for the increase in
size of the gingiva

5. CLASSIFICATION
• ACCORDING TO ETIOLOGY & PATHOLOGIC
CHANGES

6. • ACCORDING TO THE DEGREE OF
GINGIVAL ENLARGEMET
Grade 0 : No sign of gingival enlargement
Grade I : Enlargement confined to the
interdental papilla
Grade II:Enlargement involves papilla &
marginal gingiva
Grade III:Enlargement covers three quartes
or more of the crown

7. • ACCORDING TO THE LOCATION &
DISTRIBUTION
Localized : Gingival enlargement limited to
one or more(group) teeth
Generalized : Entire mouth, the gingiva is
enlarged
Marginal : Limited to the marginal gingiva
Papillary : Confined to the interdental papilla
Diffuse : Involves all the part of gingiva
Discrete : Isolated sessile or pedunculated
tumor like enlargement

8. INFLAMMATORY ENLARGEMENT
• 2 Types :Acute inflammatory enlargement
Chronic inflammatory
enlargement

9. ACUTE INFLAMMATORY
ENLARGEMENT (GINGIVAL ABSCESS)
• Etiology :
From bacteria carried deep into the tissue
When foreign object like a toothbrush or lobster shell
fragment is forcefully embedded into the gingiva
• C/f:
-Location & Distribution : papillary/marginal gingiva
-Painful rapidly lesion of sudden onset.
-Within 24-48 hours, it becomes fluctuant & pointed
with a surface orrifice through which purulent exudate
comes out.

10. - Gingiva appears to be red,
swollen,extremely painful &
sometimes the impacted
foreign object may still be in
the gingiva.
• R/f:No bone loss is evident

11. • Diagnosis
Clicical:Red swelling with shiny surface associated with pain
Lab:Consist of purulent focus in the connective tissue,
surrounded by a diffuse infiltration of PMNL,edematous tissues
& vascular engorgement.
• TREATMENT
- Remove the cause of the abscess
- Incision
Apply topical LA-->incise the fluctuant area of the lesion with a
blade--> Widen the incision to permit drainage-->Clean the
area with warm water--> Cover it with a gauze pad-->After
bleeding stopped--> Instruct the patient to gargle every 2
hours with a glassful of water.

12. CHRONIC INFLAMMATORY
ENLARGEMENT• Etiology :
Prolonged exposure to plaque & the factors that favour plaque retention.
• Types:Localized
Generalised
Discrete/tumour like
Localized/Generalised
C/f:It originates as a slight balloning of the interdental papilla or marginal gingiva.
In early stages produces, life preserver like bulge around the involved tooth & this
bulge increase until it covers part of crown.
Progression : slow,painless unless secondarily infected
Color:Deep red/bluish red
Soft & friable with a smooth shiny surface & tendency to bleed.
Disrete/tumour like
C/f:Site: interdental/marginal/attached gingiva
Occurs as a discrete mass which is sessile or pedunculated mass resembling a
tumour.
Slow growing & usually painless
May undergo spontaneous reduction in size, followed by exacerbatian & continued
enlargement

13. • Treatment
- Scalling & curettage:if the size of the enlargement does
not interfere with the complete removal of deposits, the
enlargement caused due to inflammation is treated by
scalling & curettage.
-Surgical removal: It is indicated for 2 reasons :
a. If enlargement with significant fibrotic component does not
undergo shrinkage following scalling & curettage.
b.If the size of the enlargement interferes with the access to
the root surface deposits
Surgical techniques include:
a.Gingivectomy technique: the incision should be made at
least 1-2mm coronal to the mucogingival line
b.Flap operation

15. DRUG-INDUCED GINGIVAL ENLARGENT
• Seen with administration of:
- Anticonvulsant: - phenytoin(50%)
- valproic acid
- phenobarbitol
- vigabatrin
- CCB : Nifedipinne & diltiazam (5-20%)
- Immunosupressant: Cyclosporine (25-30
% in adults & 70% in children).

16. • The extent of inflamation,fibrosis &
cellularity depends on:
-dose and identity of the drug
-quality of oral hygiene
-individual susceptibillity
• Pathogenesis : The drug is said to be
exert their influence by dysregulation of
CK and GF.

17. • C/f:
- After approx 1 month of the drug use,
interdental papillae enlargement begins
usually in the anterior region.
- Attached gingiva gingiva are generally
involved although the enlargement can
become more extensive leading to
-Gingival disfigurement
-Associated aesthetic &functional
complications

18. • DIAGNOSIS
-H/o chronic drug use
-clinical appearance
• TREATMENT
- Withdrawal or change of medication
- A variety of new generation of drugs are available.Ex:
tacrolimus is said to be effective replacement of
cylosporine & does not seem to cause gingival
enlargement.
- Non-surgical treatment such as professional gingival
debridement & topical or systemic antimicrobials may
ameliorate gingival enlargement

19. -Surgical management
reserved for severe cases & doesn't provide long term
efficacy.
Methods used:
a.Conventional gingivectomy(most commonly used)
b.Laser ablation gingivectomy vs CG
- faster procedures
- improve hemostasis
- more rapid healing
c.Periodontal flap surgery
-if osseous recountouring is needed
-mucogingival considerations
-pediatric patients inwhom tooth eruption is affected.

21. HEREDITARY GINGIVAL FIBROMATOSIS
• Syn: Idiopathic gingival fibromatosis, hereditary gingival
hyperplasia, congenital familial
fibromatosis,elephantiasis gingiva.
• Etiology:Autosomal dominant & autosomal recessive
pattern of inheritance is recognized.
Enlargement develop irrespective of effective plaque
control
• C/f :
- Enlargement may present at birth/may become
apparent only with the eruption of the decideous and
permanent dentition.
- Appearance:dense, smooth, diffuse or nodular
overgrowth of gingiva of one or more arches.It has a
characteristic pebbled surface.
-Color:Pale pink
-Consistency:Firm,leathery & dense that it prevent the
normal eruption of teeth.

22. -Enlargement may completely cover the crown of
the teeth ->> difficulty in mastication, speaking &
poor esthetics
-Some problems associated:
-Tooth migration
-Prolonged retention of the primary dentition
-Diastemata
• Management
- Surgical: surgical removal of excessive tissue
with exposure of teeth is necessary.However
recurences are common.
- Extraction of teeth.

24. COMBINED ENLARGEMENT
• It results when gingival hyperplasia is
complicated by secondary inflammatory
changes.
• these changes occurs when gingival
hyperplasia produces conditions
favourable for the accumulation of plaque
& interferes with effective oral hygiene
meausures
• Treatment:-Gingivectomy/gingivoplasty is
indicated

25. PREGNANCY INDUCED GINGIVAL
ENLARGEMENT
• It maybe marginal or generalised & may occur
as a single or multiple tumour like masses.
• C/f:
Marginal enlargement
-It tends to be more prominent interproximally
-Colour:Bright red / magenta
-Consisteny: Soft & friable
-Smooth & shiny surface
-Bleeding occurs spontaneusly or on slight
provocation

26. • Pregnancy tumour
- It is an inflammatory reaction to local
irritants
- Appears after 3rd month of pregnancy
Apperance:
- Appear as discrete mushroom like
flattened spherical masses that
protrude from the gingival margin or
the interdental papilla & is attached by
a sessile or pedunculated base
- It tends to expand laterally & pressure
from the tongue & cheek increases its
flattened appearance.

27. Color
Dusky red or magenta with smooth
glistening surface thet frequently exhibit
numerous deep red, pinpoint markings.
Consistency
Semifirm but may have varying degree of
softness and friability
Symptoms
Usually painless unless complicated by
either acumulation of debris under its
margin or interference with occlusion.

28. • Management
- Maintenance of oral hygiene for
prevention
- Non-surgival theraphy including
subgingival scalling & root planning which
can be performed during 2nd trimester.
- Surgical treatment if there is residual
enlargement after labour is excised as it
interferes with proper mechanical plaque
control &mastication.

29. PUBERTY INDUCED GINGIVAL
ENLARGEMENT
• Usually associated with inflammatory type
• C/f:
Sex : = predilection
Age: pubertal age groups
Site: it involves mainly the marginal & interdental gingiva
Appearance : characterised by prominent bulbous
interproximal papilla
• Diagnosis:
Clinical Diagnosis:Bulbous enlargement at the onset of puberty
Lab Diagnosis:Microscopic picture is that of chronic
inflammatory cells with prominent oedema & associated
degenerative changes
• Management:
Removal of local irritant:after puberty the enlargement
undergoes spontaneous reduction, but does not disappear
until local irritants are removed

31. VITAMIN C DEFICIENCY
• Acute Vit C deficiency itself does not
cause gingival inflammation but it
causes hemorrhage,collagen
degeneration & edema of gingival
connective tissue.These changes
modify the response of the gingiva to
plaque.
• C/f:
-Site:Marginal gingiva
-Color:Bluish red
-Consistency:Soft & friable
-Smooth, Shiny surface
-Bleeding spontaneously or on slight
provocation
-Surface necrosis & pseudomembrane
formation are common feature

32. PLASMA CELL GINGIVITIS
• Syn : Atypical Gingivostomatitis,Atypical Gingivitis
• Etiology :-allergic in origin &caused by some ingredients
in chewing gums, dentifices or various diet component
• C/f:
Sex : F>
Age:Young adults
Site:Oral aspect of the attached gingiva, therefore differs
from plaque induced gingivitis
Symptoms:C/o sore & burning mouth,Angular cheilitis,
scaling of lips
Appearance : Entire free & attached gingiva is oedematous,
friable,granular, bright red & bleeds on
slightest provocation.
Diagnosis: Clinical:bright red color inflammation with h/o
allergen
Lab:ct infiltrated by plasma cells
Management : cessation of exposure

34. NONSPECIFIC CONDITIONED ENLARGEMENT
(GRANULOMA PYOGENICUM)
• It is a tumour like gingival enlargement that is considered
to be an exagerrated conditioned response to minor
trauma.Exact nature is uknown.
• C/f:
Appearance: Varies from a discrete, spherical tumour with
a pedunculated attachment to a flattened, keloid like
arrangement with a broad base.
Color : bright red/purple
Consistency: Friable/firm depending on duration
It presents with surface ulceration & purulent exudation
• D/d: Pregnancy tumour
• The lesion tend to involute spontaneously to become a
fibroepthelial papilloma or persist relatively unchanged
for years
• Treatment: Consist of removal of the lesion along with
the elimination of local irritating factors.

36. LEUKEMIA
• Location & extent
:Diffuse/marginal ,
localized/generalised
• Appearance
Oversized extension of marginal
gingiva
or a discrete tumour like
interproximal mass
Color:Bluish red with a shiny
surface
Consistency:Mod firm but there is
tendency towards friability
Bleeding : Spontaneously/on slight
provocation
ANUG is sometimes seen.

37. NEOPLASTIC ENLARGEMENT
• Benign tumours of the Gingiva
Fibroma
papilloma
PGCG
CGCG
Leukoplakia
Gingival cyst
• Malignant Tumors of the gingiva
– Carcinoma
– Malignant Melanomas
– Sarcoma most commonly Kaposi's sarcoma
– Metastasis

38. FIBROMA
• Etiology : Reaction to trauma or
chronic irritation
• Arises from the gingival ct / from the
pdl
• C/f
Location & distribution :
Localized, diffuse & discrete
Shape: spherical
Progression : slow
Consistency : Firm & nodular but
maybe soft & vascular
Usually pedunculated
• Treatment:Conservative surgical

39. PAPILLOMA
• Etiology : Mostly due to HPV, come unknown
• C/f
Location & distribution : localized, diffuse &
discrete
Appearance: -solitary wartlike or cauliflower
projection
-maybe small & discrete or broad,
hard elevations with minutely
irregular surfaces
• Treatment:Surgical excission

40. PGCG
• Etiology : Local injury
• C/f :
Location & distribution:
Interdental or from gingival margin,
frequently on labial surface
Appearance:
Smooth regularly outlined masses to
irregularly shaped multilobulated
protuberance with surface
indentation.
Sessile/Pedunculated
Painless
Consistency: Firm & spongy
Color:Pink to deep red or purplish
blue
Ulcerations are sometimes seen.
• Treatment:Surgical excission

41. CGCG
Etiology: H/o of injury
C/f:
Site:man>max, ant>posterior
does not uncommonly cross the midline
Appearance: Arises within the jaw &
produces expansion, no pain but slight
discomfort, slight to moderate bulging due
to the expansion of bone.
• Treatment:Surgical excission/curettage

42. SQUAMOUS CELL CARCINOMA
• Etiology: Chronic irritation, tobacco,
alcohol,syphilis,nutritional deficiency.
• C/f:
Location & distribution:man dingiva>max gingiva,
attached gingiva>free gingiva
Presentation:
- Exophytic or ulcerative lesion which appears as
flat/erosive lesion
Locally invasive to underlying bone or adjacent mucosa
Metastasis is common

44. MALIGNANT MELANOMA
• Etiology: Neoplasm of epidermal
melanocytes, sunlight exposure is a
possible etiological agent
• C/f:
Location & distribution:palate, maxillary
gingiva & alveolar ridge.
Presentation:deeply pigmented area at
times ulcerated & hemorrhagic which
increases in size.

46. FALSE ENLARGEMENT
• Not true enlargement of gingival tissues but may appear as a result
of incrcrease in size due to enlargement of underlying bone or
dental structure.
• Underlying osseous lesion:
Tori & exostosis
Paget's disease
Cherubism
Osteoma
Osteosarcoma
C/f: gingiva is normal except massice increase insize at certin area.
• Underlying dental tissue
Development enlargement-during various stages of eruption of primary
dentition(physiologic enlargement)
C/f:bulbous, maginal distortion caused by the siperimposition of the
bulk of gingiva on the normal prominence of the enamel in the
gingiva half of the crown.