020.gingival enlargement

1. Dr Jaffar Raza Syed Page 1
Gingival Enlargement
What are the possible causes?
• Poor dental hygiene
• Smoking, mouth breathing and overcrowded teeth
• Systemic diseases
• Hormonal states: pregnancy, puberty
• Nutritional deficiency: scurvy (vitamin C deficiency)
• Medications
• Genetic conditions, often present at birth (all rare conditions)
• Blood conditions such as acute leukaemia

2. Dr Jaffar Raza Syed Page 2
Classification
According to
etiological and
pathological changes
According to
location and
distribution

3. Dr Jaffar Raza Syed Page 3
Inflammatory
enlargement
•Acute
•Chronic
Drug-induced
enlargement
or Non
inflammatory
gingival
enlargement
Enlargement
associated
with systemic
diseases
•Conditioned
enlargement
•Systemic
diseases causing
gingival
enlargements
Neoplastic
Enlargement
False
Enlargement
CLASSIFICATION
A. According to etiologic factors and pathologic changes
I. Inflammatory enlargement
a. Chronic
b. Acute
II. Drug-induced enlargement

4. Dr Jaffar Raza Syed Page 4
Inflammatory
enlargement
• Acute
• Chronic
Drug-induced
enlargement or
Non inflammatory
gingival
enlargement
Enlargement
associated with
systemic diseases
• Conditioned
enlargement
• Systemic diseases
causing gingival
enlargements
Neoplastic
Enlargement
False Enlargement
III. Enlargements associated with systemic diseases
a. Conditioned enlargement
(i) Pregnancy
(ii) Puberty
(iii) Vitamin C deficiency
(iv) Plasma cell gingivitis
(v) Nonspecific conditioned enlargement (Granuloma pyogenicum)
b. Systemic diseases causing gingival enlargements
(i) Leukemia
(ii) Granulomatous diseases

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Inflammatory
enlargement
•Acute
•Chronic
Drug-induced
enlargement or
Non
inflammatory
gingival
enlargement
Enlargement
associated with
systemic
diseases
•Conditioned
enlargement
•Systemic diseases
causing gingival
enlargements
Neoplastic
Enlargement
False
Enlargement
IV. Neoplastic enlargement (Gingival tumors)
a. Benign tumors
b. Malignant tumors
V. False enlargement

6. Dr Jaffar Raza Syed Page 6
B. According to location and distribution
Localized : Gingival enlargement limited to one or more (group of) teeth.
Generalized : Entire mouth, the gingiva is enlarged
Marginal : Limited to the marginal gingiva
Papillary : Confined to the interdental papilla
Diffuse : Involves all the parts of the gingiva, i.e. marginal, attached and
Interdental gingiva
Discrete : Isolated sessile or pedunculated tumor-like enlargement

7. Dr Jaffar Raza Syed Page 7
According to the Degree of Gingival Enlargement
Grade 0 : No sign of gingival enlargement
Grade I : Enlargement confined to the interdental papilla
Grade II : Enlargement involves papilla and marginal gingiva
Grade III : Enlargement covers three quarters or more of the crown

8. Dr Jaffar Raza Syed Page 8
Acute
inflammatory
enlargement
Gingival
abscess
Periodontal
abscess
Periapical
abscess
Pericoronal
abscess

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INFLAMMATORY ENLARGEMENT
two types: a. Acute b. Chronic
Acute Inflammatory Enlargement
Signs and Symptoms
a. Rapidly expanding lesion, usually limited to marginal gingiva or interdental papilla.
b. red, painful swelling with teeth sensitive tom purcussion
c. The lesion becomes fluctuant and pointed with a surface orifice from which
purulent exudate may be expressed.
Treatment
--Vigourous OHM
--Removal of abscess by I&D
--Warm salt water mouthwashes used every 2 hours
--Any residual pocketing can be removed by subgingival curettage or localized gingivectomy

10. Dr Jaffar Raza Syed Page 10

11. Dr Jaffar Raza Syed
Chronic Inflammatory Enlargement
Types are:
• Localized
• Generalized
• Discrete/Tumor-like.
Localized/Generalized
• It originates as a slight ballooning
• In the early stages, it produces a lifesaver
this bulge increases until it covers part of the crown
• It progresses slowly and painlessly unless it is
• discrete sessile or pedunculated
the interproximal/marginal/attached gingiv
Chronic Inflammatory Enlargement
ballooning of the interdental papilla or margin
lifesaver-like bulge around the involved tooth and
it covers part of the crown.
and painlessly unless it is complicated by acute infection or trauma
mass resembling a tumor. It may occur in
interproximal/marginal/attached gingiva
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papilla or marginal gingiva.
around the involved tooth and
complicated by acute infection or trauma.
mass resembling a tumor. It may occur in

12. Dr Jaffar Raza Syed
Etiology
--prolonged local irritation
--poor oral hygiene,
--abnormal relationships of adjacent teeth and
opposing teeth,
--lack of tooth function,
--cervical cavities,
--overhanging margins of dental restorations,
--food impaction,
--irritation from clasps or saddle are
--nasal obstructions,
--habits such as mouth breathing and tongue thrusting
relationships of adjacent teeth and
dental restorations,
or saddle areas of removable prosthesis,
habits such as mouth breathing and tongue thrusting.
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13. Dr Jaffar Raza Syed Page 13
Treatment
a. Scaling and curettage:
b. Surgical removal:
indicated for two reasons:
i. if it is fibrotic component
ii. If the size of the enlargement interferes with the access to the root surface deposits.
Surgical techniques include:
a. Gingivectomy technique.
b. Flap operation.

14. Dr Jaffar Raza Syed
convulsants
Phenytoin
Noninflammatory Gingival Enlargement (Fibrotic Gingival Enlargement)
produced by factors other than local irritation
Mostly are drug induced as
phenytoin,
cyclosporine,
nifedipine,
diltiazem,
verapamil and
sodium valproate Drug-induced
enlargement or
Non
inflammatory
gingival
enlargement
Anti-
convulsants
Phenytoin
Calcium
channel
blockers
Nifedipine
immunosup
pressant's
Cyclospori
ne
Noninflammatory Gingival Enlargement (Fibrotic Gingival Enlargement)
produced by factors other than local irritation.
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immunosup
pressant's
Cyclospori
ne
Idiopathic
Gingival
Fibromatosi
s
Noninflammatory Gingival Enlargement (Fibrotic Gingival Enlargement)

15. Dr Jaffar Raza Syed
Phenytoin-induced Gingival Hyperplasi
--overgrowth usually becomes apparent
--starts as a painless, bead-like enlargement
and interdental papillae.
--As the condition progresses, the marginal and papillary
into a massive tissue fold covering a considerable portion of the crown and may
interfere with the occlusion
--hyperplasia is usually generalized
--secondary inflammatory process
induced Gingival Hyperplasia
usually becomes apparent in the first three months after phenytoin dosage
ike enlargement of facial and lingual gingival margins
As the condition progresses, the marginal and papillary enlargement unite and develop
covering a considerable portion of the crown and may
d but severe in max and mand anterior regions
secondary inflammatory process will complicates gingival hyperplasia caused by the dru
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in the first three months after phenytoin dosage
of facial and lingual gingival margins
enlargement unite and develop
covering a considerable portion of the crown and may
but severe in max and mand anterior regions
gingival hyperplasia caused by the drug

16. Dr Jaffar Raza Syed
Treatment
--Oral hygiene reinforcement
--Possible drug substitution
--Professional recalls
--surgical therapy
a.Small areas of enlargement with no attachment loss
b.Large areas of enlargement with presence of osseous
Small areas of enlargement with no attachment loss
(Gingivectomy)
Large areas of enlargement with presence of osseous defect
(periodontal flap)
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defects

17. Dr Jaffar Raza Syed
Enlargements associated with systemic diseases
Conditional
enlargement
Systemic
diseases
causing gingival
enlargments
Enlargements associated with systemic diseases
• Pregnancy
• Puberty
• Vitamin C deficiency
• Plasma cell gingivitis
• Non-specific conditioned enlargment
(Granuloma pyogenicum)
• Leukemia
• Granulomatous diseases
causing gingival
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enlargment

18. Dr Jaffar Raza Syed
Enlargement in Pregnancy
--Aggravation of previous inflammatio
--Pregnancy does not cause the condition. The altered
pregnancy accentuates the response
--bright-red or magenta, soft and friable and has a smooth, shiny surface
--Bleeding occurs spontaneously or on slight provocatio
--Tumor-like Gingival Enlargement or
ggravation of previous inflammation
Pregnancy does not cause the condition. The altered tissue metabolism in
pregnancy accentuates the response to local irritation usually generalize
friable and has a smooth, shiny surface
or on slight provocation
like Gingival Enlargement or Pregnancy Tumor
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tissue metabolism in
usually generalized
friable and has a smooth, shiny surface.

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Treatment
--Aim is to minimize the potential exaggerated inflammatory response related to
hormonal alteration
--Meticulous plaque control
--The second trimester is the safest time in which treatment may be performed.
However, long stressful appointment and periodontal surgical procedures should
be postponed until postpartum
--Fully reclining position should be avoided
--Medication and radiographs should not be prescribed.
--In case of marginal and interdental enlargement, scalingnand curettage can be performed.
--In case of a tumor-like enlargement, surgical excision is required

20. Dr Jaffar Raza Syed
Enlargement in Puberty
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21. Dr Jaffar Raza Syed
Nonspecific Conditioned Enlargement
tumor-like gingival enlargement that is considered
to be an exaggerated conditioned response
to minor trauma.
lesion varies from a discrete, spherical
tumor-like mass with a pedunculated attachment
to a flattened, keloid-like enlargement with a broad bas
Treatment includes
removal of the lesion along with the elimination
local irritating factors.
Nonspecific Conditioned Enlargement (Granuloma Pyogenicum)
like gingival enlargement that is considered
be an exaggerated conditioned response
lesion varies from a discrete, spherical
mass with a pedunculated attachment
like enlargement with a broad base
removal of the lesion along with the elimination of
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22. Dr Jaffar Raza Syed
Systemic Disease Causing Gingival
Leukemia
The enlargement may be
Diffuse
marginal,
localized or generalized.
It may appear as an oversized extension
of the marginal gingiva or a discrete tumor
interproximal mass.
Appearance  bluish-red with a shiny surface.
The consistency is moderately firm
hemorrhage occurring either spontaneously or on sli
True leukemic enlargement occurs commonly in acute
subacute leukemia. It seldom occurs in chronic leukemia
Systemic Disease Causing Gingival Enlargement
It may appear as an oversized extension
marginal gingiva or a discrete tumor-like
red with a shiny surface.
consistency is moderately firm.
either spontaneously or on slight provocation.
True leukemic enlargement occurs commonly in acute leukemia but may also be seen in
seldom occurs in chronic leukemia
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leukemia but may also be seen in

23. Dr Jaffar Raza Syed Page 23
Treatment
 remove the local deposits
 control inflammatory component of the enlargement
 scaling and curettage
 OHM and OHI
 Antibiotics
 Refer the patient to the physician for medical evaluation and treatment
 Prior to chemotherapy, a complete periodontal treatment plan should be prepared
 Monitor hematological lab values daily
 During acute phases of leukemia, patients should receive only emergency periodontal
care

24. Dr Jaffar Raza Syed Page 24
Neoplastic enlargements
Benign
tumors
Malignant
tumors

25. Dr Jaffar Raza Syed Page 25
Benign Tumors of the Gingiva
• Fibroma
• Papilloma
• Peripheral giant cell granuloma
• Central giant cell granuloma
• Leukoplakia
• Gingival cyst
Malignant Tumors of the Gingiva
• Malignant melanoma
• Sarcoma most commonly Kaposi's sarcoma
• Metastasis

26. Dr Jaffar Raza Syed
Scoring of gingival enlargement
Grade 0
• No sign of gingival enlargement
Grade 1
• Enlargement confined to the
Grade 2
• Enlargement involves papilla and marginal
Grade 3
• Enlargement covers three quarters or more of the crown
Scoring of gingival enlargement
No sign of gingival enlargement
Enlargement confined to the interdental papilla
Enlargement involves papilla and marginal gingiva
Enlargement covers three quarters or more of the crown
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papilla
gingiva
Enlargement covers three quarters or more of the crown

27. Dr Jaffar Raza Syed Page 27
False Enlargement
not true enlargements of gingival tissues
appear as a result of increase in size of the underlying
osseous or dental tissues.