den

1. Gingival
Enlargement
Supervisor
Prof . Dr Nevine Kher Eldin
By
Samar Fawki
Ragheed Mohamed
Abubakr Ahmed
Kinan Yasser
Ahmed ibrahim

2. Outline
• TERMINOLOGY
• DIAGNOSIS
• CLASSIFICATIONS

3. Terminology
• Gingival enlargement is an increase in the
size of the gingiva, and It is a common
feature of gingival disease.
• Gingival enlargement can be caused by
several factors, including inflammatory
conditions, systemic diseases and the side
effects of certain medications.

4. • The terms gingival hyperplasia and
gingival hypertrophy have been used to describe this
topic in the past.
• These are not precise descriptions of gingival
enlargement because these terms are
strictly histologic diagnoses, and such diagnoses
require microscopic analysis of a tissue sample.
• Hyperplasia refers to an increased number of cells.
• Hypertrophy refers to an increase in the size of
individual cells.
• As these identifications cannot be performed with a
clinical examination and evaluation of the tissue, the
term Gingival enlargement is more properly applied.
Terminology

5. Classification B. Etiology
A. Location and distribution

6. Location and
Distribution
Localized Generalized Marginal Papillary Diffuse Discrete:

7. A-Criteria of location and distribution
• Localized: Limited to the gingiva
adjacent to a single tooth or group
of teeth.
• Generalized: Involving the
gingiva throughout the mouth .

8. A-Criteria of location and distribution
• Marginal: Confined to marginal
gingiva.
• Papillary: Confined to interdental
papilla.

9. A-Criteria of location and distribution
• Diffuse: Marginal gingiva, attached
gingiva and interdental papillae
• Discrete: Isolated tumor-like enlargement
• (sessile or pedunculated)

10. Diagnosis
Gingival enlargement can be Scored as
following :
• Grade 0……………… No sign of gingival
enlargement
• Grade I ……………… Enlargement confined to
IDP
• Grade II ……………… Enlargement confined to
IDP and marginal gingiva
• Grade III ……………… enlargement covers three
quarters or more of the crown

11. A.Etiological Factors and Pathological Changes
Inflammatory
enlargement
1-Acute
2-Chronic
Drug induced
enlargement
Enlargement
associated with
systemic diseases
1-Leukemia
2-Granulmatous
diseases
Enlargement
associated with
Systemic Conditions
1-Pregnancy
2.Puberty
3-Nutritional
(associated with vit C
deficiency)
4-.Plasma cell
gingivitis
5.Pyogenic
granuloma
Neoplastic
enlargement
(gingival tumors )
False enlargement
Idiopathic
enlargement

12. Inflammatory enlargement
….Acute …
Gingival Abscess:
Etiology:
Acute inflammatory response to foreign
substance forced into the gingiva .
Localized, painful and rapidly expending
lesion.
It is limited to the marginal gingiva or the
interdental papilla .

13. Clinical Features:
• Site: Marginal gingiva or Interdental
papilla.
• Localized, painful, rapidly expanding.
• Within 24 to 48 hours, lesion becomes
fluctuant & pointed with a surface
orifice from which a purulent exudate
may be expressed.
Gingival Abscess

14. Gingival Abscess:
Histopathology:
• Surface Epithelium: Varying degree of
intra and extracellular oedema.
• Leukocytic invasion & ulceration.
• Connective tissue :Purulent focus
surrounded by PMNs.
• Edematous tissue.
• Vascular engorgement.
• Periodontal Abscess: Involves the
supporting periodontal tissues.

15. Inflammatory enlargement
….Chronic …..
Prolonged exposure to dental plaque.
Factors that favor plaque accumulation:
Poor oral hygiene.
Irritation by anatomic
abnormalities.
Improper restorative & orthodontic
appliances.
Mouth breathing habit.
Etiology:

16. Inflammatory enlargement
….Chronic …..
Clinical Features:
Site: Interdental papilla and
marginal gingiva.
Shape: Life preserver shaped
bulge, can increase in size until it
covers part of crowns.
May be localized or generalized.
Progresses slowly and painlessly.
Painful ulceration sometimes.

17. Inflammatory enlargement
….Chronic …..
Histopathology:
• Exudative and proliferative features.
• Lesions that are clinically deep red or bluish
red soft and friable, bleed easily due to
vascular engorgement.
• Lesions that are relatively firm, resilient and
pink hue have a greater fibrotic component
with an abundance of fibroblasts and
collagen fibers.

18. Histopathology
• The histopathological examination revealed a
hyperplastic parakeratinized epithelium overlying
inflamed connective tissue.
• The underlying stromal tissue showed numerous
proliferating young fibroblasts admixed with focal
aggregates of chronic inflammatory cells.
• Few fibroblasts appeared stellate, with numerous
nuclei distributed in a collagenized stroma. At
places the stromal tissue exhibited myxoid
degeneration.

19. B.Etiological Factors and Pathological Changes
Inflammatory
enlargement
1-Acute
2-Chronic
Drug induced
enlargement
Enlargement
associated with
systemic diseases
1-Leukemia
2-Granulmatous
diseases
Enlargement
associated with
Systemic Conditions
1-Pregnancy
2.Puberty
3-Nutritional
(associated with vit C
deficiency)
4-.Plasma cell
gingivitis
5.Pyogenic
granuloma
Neoplastic
enlargement
(gingival tumors )
False enlargement
Idiopathic
enlargement

20. Drug induced Gingival
Enlargement
• Most common forms of DIGO are caused using anticonvulsants, calcium
channel blockers, and immunosuppressants prescribed to patients for
serious health concerns.
• Genetic factors, drug dosage, duration, and local factors can affect the
development and severity of DIGO.
• DIGO frequently results in impaired oral hygiene, biofilm accumulation,
and gingival inflammation.
• Increased prevalence of gingival infection and inflammation among
patients with DIGO poses risk for their general health.

21.  Starts as a painless nodular enlargement of the
interdental papilla
 Mulberry shaped
 Firm and resilient
 Pale pink
 No tendency to bleed
 Dental biofilm and bacterial infection leading to
tissue inflammation , edema , bleeding.
 Severe forms may result in complete coverage of
crowns of teeth .
Drug induced enlargement :

22.  Anticonvulsants
 Immunosuppressant
 Calcium channel blockers
Drug induced enlargement

23. Anticonvulsants
• Phenytoin ( Dilantin ) is the first drug of choice
for treatment of epilepsy .
• Effect on 50% of the patients.
• Others like Phenobarbital and Valproic acid
associated with GO less than Phenytoin .
• GO lesions frequently occur on the anterior
buccal maxilla and mandible, and the entire
dentition can be covered in severe cases.
• Phenytoin-induced GO is characterized by
enlargement of interdental papillae and
increasing aesthetic and functional problems
eased thickening of the marginal tissues , such
as mispositioning of teeth, difficulty in speech,
and impaired oral hygiene.

24. Pathogenesis:
Phenytoin
Decrease in the Ca2+
cell influx leading to a
reduction in the uptake
of folic acid, thus
limiting the
production of active
collagenase . Induces the release
of Growth factors
such as CTGF,
PDGFB, FGF-2 and
TGF-β are found in
higher levels in
fibrotic tissues and
play a role in PGO
by Macrophages
Phenytoin
stimulates
fibroblasts to
produce large
amounts of IL-6,
IL-1, and IL-8
Glycosaminoglycan
metabolism is
impaired in patient
PGO .
Gingival
fibroblast from
PGO
characterized by
elevated levels of
collagen
synthesis .

25. Immunosuppressant
• Cyclosporines used to prevent
organ transplant rejection &
to treat autoimmune diseases.
• Prevalence of cyclosporin A
induce GO reported about
30% but could be much higher
especially for pediatric
patients

26. Pathogenesis:
Cyclosporine
Directly impairs collagen
synthesis by gingival
fibroblast + Rise in the level
of type I collagen .
Decrease expression of
matrix metalloproteinas-1
(MMP-1) and (MMP-3)

27. Calcium channel
blockers
• Used for CVS disorders,
Hypertension, Angina pectoris,
Coronary artery spasm & cardiac
arrhythmia.
• Nifedipine induces enlargement in
20% of cases.

28. Pathogenesis:
Nifedipine
Ca channel blockers decrease
ca level in gingival fibroblast
and T cells
Gingival fibroblast have
defective collagen
production due to decreased
levels of collagenase activity

29. Drug induced Gingival
Enlargement
Benzothiazepine derivatives (e.g., diltiazem), phenylalkylamine derivatives (e.g.,
verapamil), and dyhydropyridines (e.g., amlopidine, felodipine, isradipine, nicardipine,
nifedipine, nitrendipine, oxodipine, nimodipine, nisoldipine) are different types of
Calcium channel blockers that have been associated with some degree of gingival
enlargement.
The histologic characteristics of GO induced by calcium channel blockers are like
phenytoin induced lesions, including epithelial thickness, rete peg formation, and
excessive matrix accumulation

30. A.Etiological Factors and Pathological Changes
Inflammatory
enlargement
1-Acute
2-Chronic
Drug induced
enlargement
Enlargement
associated with
systemic diseases
1-Leukemia
2-Granulmatous
diseases
Enlargement
associated with
Systemic Conditions
1-Pregnancy
2.Puberty
3-Nutritional
(associated with vit C
deficiency)
4-.Plasma cell
gingivitis
5.Pyogenic
granuloma
Neoplastic
enlargement
(gingival tumors )
False enlargement
Idiopathic
enlargement

31. 1. The magnification of an
existing inflammation initiated
by dental plaque.
Conditioned
Enlargements
2. The manifestation of the systemic
disease independently of the
inflammatory status of the gingiva.
Systemic Diseases
that Cause Gingival
Enlargement
Neoplastic
Enlargement
(Gingival Tumors).
Many systemic diseases can develop oral manifestations that may include gingival
enlargement. These diseases and conditions can affect the periodontium via two
different mechanisms:
Enlargement associated with
systemic diseases or conditions

32. Conditioned
enlargement
• Conditioned enlargements occurs when the
systemic condition of the patient exaggerates
or distorts the usual gingival response to
dental plaque.
• The specific way the clinical picture of
conditioned gingival enlargement differs
from that of chronic gingivitis depends on the
nature of the modifying systemic influence.
• Bacterial plaque is necessary for the initiation
of this type of enlargement.

33. Conditioned
Gingival
Enlargement
I.Hormonal
(Pregnancy,
Puberty)
I.Nutritional
(associated
with Vitamin C
Deficiency)
I.Allergic
(Plasma Cell
Gingivitis)
Nonspecific
conditioned
enlargement
(Pyogenic
Granuloma)

34. Conditioned
Enlargements:
I)Enlargement
in Pregnancy
• Pregnancy gingival enlargement may be:
Marginal and generalized
OR
Single mass or Multiple tumorlike masses
• During pregnancy:
1. There is an increase in levels of both progesterone and
estrogen  changes in vascular permeability  gingival
edema and increased inflammatory response to dental
plaque.
2. The subgingival microbiota may also undergo changes,
including an increase in Prevotella intermedia.

35. Marginal
Enlargement:
• The clinical picture varies
considerably.
• Site: More prominent inter-
proximally than on the facial and
lingual surfaces.
• Color : Bright red or magenta
• Surface Texture : soft ,friable, and
it has a smooth shiny surface.
• Bleeding occurs spontaneously or on
slight provocation.

36. Tumor like Gingival
Enlargement:
• The so-called pregnancy tumor is not a neoplasm; it
is an inflammatory response to bacterial plaque, and
it is modified by the patient’s condition.
• Appears after the third month of pregnancy, but it
may occur earlier.
• The lesion appears as : a discrete, mushroom-like,
flattened spherical mass
• Site: protrudes from the gingival margin or more
often from the interproximal space.
• Base: sessile or pedunculated .
• Color: Dusky red or magenta .
• Surface Texture: smooth shiny surface that often
exhibits numerous deep-red pinpoint markings.

37. Conditioned
Enlargements:
II) Enlargement
in Puberty
• Gender: Both male and female
• Age: Adolescents
• The size of the gingival enlargement greatly
exceeds that usually seen in association with
comparable local factors.
• Site: It is marginal and interdental, and it is
characterized by prominent bulbous
interproximal papillae, and often only the facial
gingivae are enlarged.

38. II) Enlargement in Puberty
• A longitudinal study of the subgingival
microbiota of children between the
ages of 11 and 14 years and their
association with clinical parameters
implicated Capnocytophaga species in
the initiation of pubertal gingivitis.
• Other studies have reported that
hormonal changes coincide with an
increase in the proportion of Prevotella
intermedia and Prevotella nigrescens.

39. Conditioned
Enlargements:
III)Enlargement
in Vitamin C
Deficiency
• The enlargement of the gingiva is
generally included in classic descriptions
of scurvy.
• Acute vitamin C deficiency itself does
not cause gingival inflammation, but it
causes : hemorrhage, collagen
degeneration, and edema of the gingival
connective tissue.
• These changes modify the response of the
gingiva to plaque to the extent that the
normal defensive delimiting reaction is
inhibited, and the extent of the
inflammation is exaggerated.

40. III) Enlargement in Vitamin C Deficiency
• Site: Gingival Margin
• Color: bluish red .
• Surface Texture: soft, friable, and
smooth shiny surface.
• Bleeding occurs either spontaneously or
on slight provocation AND surface
necrosis with pseudo membrane
formation are common features.

41. Conditioned
Enlargements:
IV) Plasma
Cell Gingivitis
• Etiology: Allergic in origin and possibly
related to components of chewing gum,
dentifrices, or various diet components.
• Plasma cell gingivitis consists of a mild
marginal gingival enlargement that
extends to the attached gingiva. (Thus
differs from plaque-induced gingivitis.)
• Gingiva: Red ,friable, and sometimes
granular, and it bleeds easily (usually it
does not induce a loss of attachment).
• An associated cheilitis and glossitis have
been reported.

42. Conditioned Enlargements:
IV) Plasma Cell Gingivitis
• Etiology: Allergic in origin and possibly related to
components of chewing gum, dentifrices, or various
diet components.
• Plasma cell gingivitis consists of a mild marginal
gingival enlargement that extends to the attached
gingiva. (Thus differs from plaque-induced
gingivitis.)
• Gingiva: Red ,friable, and sometimes granular, and it
bleeds easily (usually it does not induce a loss of
attachment).
• An associated cheilitis and glossitis have been
reported.

43. Conditioned
Enlargements:
V) Nonspecific
Conditioned
Enlargement
(Pyogenic
Granuloma):
• Pyogenic granuloma is a tumor like
gingival enlargement that is considered
an exaggerated conditioned response to
minor trauma . The exact nature of the
systemic conditioning factor has not been
identified.
• Pyogenic granuloma is similar in clinical
and microscopic appearance to the
conditioned gingival enlargement seen
during pregnancy.
• The differential diagnosis is based on the
patient’s history.
• Treatment consists of the removal of the
lesions plus the elimination of irritating
local factors.
• The recurrence rate is about 15%.

44. V) Nonspecific Conditioned Enlargement
(Pyogenic Granuloma):

45. Systemic Diseases that Cause
Gingival Enlargement
Leukemia
Granulomatous
Diseases
Wegener’s
Granulomatosis
Sarcoidosis

46. Systemic Diseases that Cause Gingival Enlargement
I) Leukemia:
Clinical Features:
• Color: bluish red.
• Consistency :moderately firm.
• Surface Texture: shiny surface.
• Site: diffuse or marginal or discrete tumor like
interproximal mass.
• Tendency toward friability and hemorrhage that
occur either spontaneously or with slight
irritation.

47. Systemic Diseases that Cause Gingival Enlargement
II) Granulomatous Diseases:
A) Wegener’s Granulomatosis:
• Granulomatosis with polyangiitis (GPA),
formerly known as Wegener granulomatosis, is a
rare multisystem autoimmune disease of unknown
etiology.
• Characterized by acute granulomatous necrotizing
lesions of the respiratory tract (including nasal
and oral defects) and renal lesions might develop.
• The initial manifestations involves the orofacial
region and include oral mucosal ulceration,
gingival enlargement, abnormal tooth mobility,
exfoliation of teeth, and delayed healing response.

48. SYSTEMIC DISEASES THAT CAUSE GINGIVAL ENLARGEMENT
II) GRANULOMATOUS DISEASES:
• B) Sarcoidosis:
• Sarcoidosis is a granulomatous disease
of unknown etiology.
• Age: 20-30
• Race: > Blacks
• Site : It can involve almost any organ,
including the gingiva, in which a red,
smooth, painless enlargement may
appear.

49. A.Etiological Factors and Pathological Changes
Inflammatory
enlargement
1-Acute
2-Chronic
Drug induced
enlargement
Enlargement
associated with
systemic diseases
1-Leukemia
2-Granulmatous
diseases
Enlargement
associated with
Systemic Conditions
1-Pregnancy
2.Puberty
3-Nutritional
(associated with vit C
deficiency)
4-.Plasma cell
gingivitis
5.Pyogenic
granuloma
Neoplastic
enlargement
(gingival tumors )
False enlargement
Idiopathic
enlargement

50. Neoplastic enlargement
(gingival tumors )

51. Neoplastic enlargement (gingival tumors )
• Fibroma
• Papilloma
• Peripheral giant cell granuloma
• Central giant cell granuloma
• Leukoplakia
• Gingival cyst
Benign
• Carcinoma : (6% of oral cancer)
• Squamous cell carcinoma (5%)
• Malignant melanoma
• Sarcoma :
•Fibrosarcoma
•Lymphosarcoma
•Reticulum cell sarcoma
•Kaposi sarcoma
•Renal cell carcinoma
• Metastasis
•From lung carcinoma ,melanoma ,adenocarcinoma of colon
Malignant

52. I)Benign tumors
of gingiva

53. A- Fibroma (soft – hard)
• Origin: arise from the gingival
connective tissue or from the periodontal
ligament .
• Shape: slow-growing spherical tumors
• Consistency and surface texture : firm
and nodular but may be soft and vascular
• Sessile or pedunculated.
• Variants:
 Giant cell fibroma (contain
multinucleated fibroblast)
 Peripheral ossifying fibroma (contain
mineralized tissue such as bone –
cementum like tissue)

54. B- Papilloma
Def: Benign proliferations of
surface epithelium that are in many
(but not all) cases, associated with
the human papillomavirus (HPV)
Size: small and discrete
Shape: solitary wartlike or
cauliflower-like protuberances
Consistency :
Surface texture: hard elevations
with irregular surface

56. E- Gingival cyst
• Small, non inflammatory,
developmental cyst of gingiva arising
from the rests of dental lamina.
• Site : in mandibular canine and
premolar area (often on lingual
surface)
• Symptoms : painless but may expand
and cause erosion to alveolar bone .
• DD : lateral periodontal cyst .

57. II)Malignant
tumors of gingiva

58. II)Malignant tumors of
gingiva
• Clinical picture of malignancy include:
1. Any lymphadenopathy
2. unexplained tooth mobility
3. Paresthesia or other sensory
disturbances
4. irregular bone loss
5. ulceration that don’t respond to
therapy in usual manner
6. unusual pigmentation

59. Carcinoma
A- Squamous cell carcinoma in gingiva
Exophytic
Irregular in shape
Irregular surface
Indurated base
Foul odor

60. B- Malignant Melanoma
(rare)
• Malignant melanoma is rare tumor arising
from the uncontrolled growth of
melanocytes found in basal layer of the oral
mucous membrane .
• Site : hard palate and maxillary gingiva
(arise from melanoblast in gingiva or palate )
• Shape : flat or nodular (proceeded by
localized pigmentation)
• Rate of growth : rapid
• Metastasis : early

61. False Enlargement
(not true enlargements of the gingival tissues)
Etiology
Underlying osseous
lesions
Bony exostosis :
tori
Bony Lesions
Peget’s disease
Fibrous dysplasia
Cherubism
Central giant cell granuloma
Osteoma
osteosarcoma
Underlying dental
tissues
Developmental
enlargement

62. Underlying osseous lesions
A - Bony exostosis
Mandibular tori

63. B- Bony lesions
Peget’s disease

64. B- Bony lesions
Cherubism

65. Fibrous dysplasia

66. B- Bony lesions
osteosarcoma

67. B- Bony lesions
Osteoma

68. Underlying dental tissues
Developmental enlargement
• Etiology :
• During eruption( primary dentition); the
labial gingiva may show a bulbous
marginal distortion caused by the
superimposition of the bulk of the
gingiva on the normal prominence of
the enamel in the gingival half of the
crown, and often persists until the
junctional epithelium has migrated from
the enamel to the cementoenamel
junction.

69. Idiopathic gingival enlargement
• Termed as
• gingivostomatosis,Elephantiasis
idiopathic fibromatosis
• hereditary gingival hyper-plasia
• congenital familial fibromatosis.

70. Etiology
• Unknown
• Hereditary (autosomal dominant or recessive) (a specific genetic mutation
with the ‘son of sevenless1’ (SOS1) gene)
• Impairment of physical development
• Begins with eruption of the primary or secondary dentition and it may regress
after eruption (teeth may be initiating factors )

71. Clinical features :
• Site : attached gingiva , gingival margin ,
interdental papillae (facial and lingual
surfaces of mandible and maxilla ) and
projects into the oral vestibule. The jaws
appear distorted as a result of the bulbous
enlargement of the gingiva.
• Color : pink
• Consistency : firm and leathery
• Surface texture :minutely pebbled surface
• Teeth : almost covered (Secondary
inflammatory changes are common at the
gingival margin)

72. Types of Idiopathic gingival enlargements
Nodular Symmetric uniform
enlargement
Combination