3. INTRODUCTION
■ What is gingival enlargement ?
Increase in size of gingiva or gingival growth.
-Carranza 11th edition
Gingival (gum) enlargement, also known as gingival hyperplasia or
hypertrophy , is an abnormal overgrowth of gingival tissues.
There are several causes of gingival enlargement, and they are –
1. Inflammatory gingival enlargement
2. Medication induced gingival enlargement
3. Hereditary gingival fibromatosis
4. Systemic causes of gingival enlargement
4. Drug-induced gingival enlargement or overgrowth occurs in whole or in
part from systemic drug use. It occurs as a side effect following the
administration of drugs used mainly for non-dental treatment and thus ,
the overgrowth cannot be explained as a variation of the intended
pharmacological action of drug.
Generally, gingival enlargement is caused by Anti-epileptics, calcium
channel blockers, immunosuppressant and miscellaneous are
Erythromycin and sertraline.
6. ANTI CONVULSANTS
Phenytoin
■ Introduced by merritt and Putnam in 1938
■ Used to control seizures in patients with epilepsy
■ Most commonly used because of low cost , easy availability and
effective.
■ Hyperplastic changes were first reported in 1939 by Kimball.
7. Mechanism of action
Selectively depress
the motor cortex of
CNS
Blocks voltage
dependent Na
channels
Limit the
progression of
neuronal excitation
Blocks high frequency
firing seen in seizures
8. PATHOGENESIS
■ Shafer (1984) reported that the optimal rate of cell growth at phenytoin
concentration 5µg/ml
■ Hassell and page (1992) demonstrated GO in response to ‘5-
parahydroxyphenyl-5-phenylhydantoin’
CLINICAL FEATURES
■ Soreness and tenderness
■ Initial involvement of interdental papilla
■ Granulated lobules or pebbly surface
9.
10. HISTOLOGICAL FEATURES
■ Acanthosis of squamous epithelium
■ Numerous young capillaries and fibroblasts and irregularly arranged
collagen fibrils with occasional lymphocytes
11. IMMUNOSUPPRESANTS
■ Cyclosporine ,a metabolite of fungal species Beauveria Nivea
■ The first human clinical trials of CsA in human kidney transplantation in
1978
■ Cyclosporine induced gingival overgrowth was first reported by
Rateischak – pluss et al
Drugs that lower the body’s ability to reject a
transplanted organ.
12. Mechanism of action
■ Specifically, Cyclosporine A inhibits interleukin-2 (IL-2) synthesis ,
hence inhibits the ability of cytotoxicT lymphocytes to respond to IL-2
at oral dosages of 10-20 mg/kg.
■ Inhibits the activation of macrophages and preventing the production
of IL-1 receptors on the surface ofT-helper cells.
13. PATHOGENESIS
■ Wyosocki et al 1983 ,fibroblasts sensitive to cyclosporine
■ Schincaglia et al 1992 – the anti-collagenase activity by decreasing
MMPase
■ Enhanced macrophage platelet derived growth factor β
promotes
fibroblasts proliferations and production of extracellular matrix
constituents.
14. CLINICAL FEATURES
■ Children and females are frequently affected
■ Enlarged gingival tissues is soft ,red or bluish red , extremely fragile and
bleed easily on probing.
■ Overgrowth is restricted to width of attached gingiva.
15. HISTOLOGICAL FEATURES
■ Acanthosis and parakeratinization of the epithelium with
pseudoepitheliomatous proliferations.
■ Inflammatory cells are seen
■ Mariani et al found that the basal and spinous layers of epithelium
show distinct dilatation of the intercellular spaces , characteristic of
disease related overgrowth.
16. CALCIUM CHANNEL BLOCKERS
■ First reported case of GH induced by nifedipine was reported by
Ramon at al
■ Interdental papilla become enlarged
■ In many areas it shows ulcerations and BOP
■ False periodontal pockets without bone loss
Medications that relax blood vessels and increase the
supply of blood and oxygen to the heart while also
reducing the heart’s workload.
17. Mechanism of action
NIFEDIPINE
Stimulates synthesis of DHT
from testosterone in gingival
fibroblast
Production of large amount of
collagen
Inactive form of collagenase
Gingival overgrowth
+
5– reductase activity
18. PATHOGENESIS
■ Fuji et al in 1991 tested the effect of Ca channel blockers on cell
proliferations, DNA synthesis and collagen synthesis
■ Luca et al and jones et al in 1994 suggested that GO results from over
production of extracellular ground substance characterized by increased
presence of GAG and collagen
■ Nifedipine induces gingival hyperplasia in rats through inhibition of
apoptosis , which prolongs cell life………..( shimizu et al , 2001 )
20. HISTOLOGICAL FEATURES
■ Epithelium exhibits para keratosis , proliferations and elongation of
rete pegs that extends into lamina propria
■ Increase in epithelial width , infiltrates of lymphocytes and plasma
■ Fibroblasts contain strongly mucopolysaccharides and secretory
granules.
21. MANAGEMENT
■ Key strategies in gingival enlargement
PLAQUE
CONTROL
MEDICAL
MANAGEMENT
MULTIDISCIPLINARY
DENTAL CARE
PERIODONTAL SURGICAL
PROCEDURES
22. PLAQUE CONTROL
■ Mild gingival enlargement may only require local management as
improvement in oral hygiene , together with professional cleaning of
the teeth , can lead to resolution of inflammation and reduction in
gingival enlargement.
■ Gingival enlargement may require changes to the medication regimen ,
periodontal surgery to remove excess tissue , or a combination of two.
23. DRUG SUBSTITUTION
■ CCB’s : Nifedipine with Isradipine ( 20 mg BD )
ACE inhibitors like captopril ( 12.5 to 50mg BD )
Enalapril ( 2.5 to 20 mg OD ) to control hypertension
■ Phenytoin with phenobarbital ( 60 mgTDS )
primidone ( 100 mgTDS )
carbamazepine ( 200-400mgTDS )
valproic acid ( 200-500mgTDS )
■ CyclosporinA with Tacrolimus ( 0.15 – 0.20/kg/d)
Rapamycin
24. SURGICALTREATMENT OF GINGIVAL
ENLARGEMENT
■ Gingivectomy
Excision of gingiva , simple and quick technique
■ Gingivectomy by Electro surgery
ADVANTAGE - Permits an adequate contouring of the tissue , controls haemorrhage
DISADVANTAGES - Unpleasant odour , irreparable damage to bone , use limited to
superficial procedures , heat generated can cause tissue damage & loss of periodontal
support.
■ Laser gingivectomy
CO2 lasers used for excision of gingiva
ADVANTAGE - Excellent soft tissue ablation , Haemostatic characteristic
DISADVANTAGE – Healing is delayed , requires precautionary measures , application to
root surface or alveolar bone causes carbonization & major thermal damage
