GINGIVAL

ENLARGEMENT
 CONTENTS

• INTRODUCTION

• CLASSIFICATION
• ETIOLOGY

• CLINICAL FEATURES

• DIFFERENTIAL DIAGNOSIS

• MANAGEMENT

INTRODUCTION
• GINGIVA:-
It is defined as that part of oral mucous
membrane that covers the alveolar bone and
surrounds the necks of all the teeth.
• gingiva can be divided into
1.marginal
2.interdental .
3.attached
Normal characteristics of healthy gingiva
1.colour:-colour is coral pink and may vary as darker in
people with darker complexions.
2.contour/shape:-shape of free gingiva is knife edged
&closely adapted to tooth surface.
3.consistency:-firm in consistency.
4.Surface texture:-free gingiva is smooth in texture.
Attached gingiva exhibits surface stippling.

5.size:-free gingiva is flat& fits snugly around the teeth.

GINGIVAL ENLARGEMENT

DEFINITION:-
 • It is defined as increase in size of gingiva so that soft
tissue overfills the interproximal spaces, balloons out
over the teeth &protrudes into the oral cavity.

CAUSES:-
1.poor oral hygiene.
2.food impaction.
3.mouth breathing.
4.harmonal changes.
5.drug therapy.

CLASSIFICATION
According to the etiologic factors and pathologic
changes.
I) Inflammatory enlargement
a). Chronic
b). Acute
II) Drug induced enlargement
III) Enlargements associated with systemic diseases
 A). Conditioned enlargement
1). Pregnancy
2). Puberty
3). Vitamin C
4). Plasma cell gingivitis
5). Nonspecific conditioned enlargement
B). Systemic diseases causing gingival enlargement
1). Leukemia
2). Granulomatous diseases (Wegener’s
granulomatosis, sarcodiosis)
IV) Neoplastic enlargement
A). Benign tumors
B). Malignant tumors
V) False enlargement
On the basis of location and distribution
A). Localized: Limited to the gingiva adjacent to a
single tooth or group of tooth.
eg. The gingival enlargement localized in the canine
region
B). Generalized involving the gingiva throughout the
mouth.
C). Diffuse; Involving the marginal and attached
gingiva and papillae
D). Papillary: Confined to the interdental papilla
E).Marginal: confined to marginal papilla.
f).Discrete: an isolated tumour like enlargement

Scoring of gingival enlargement

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

INFLAMATORY ENLARGEMENT
Gingival enlargement may result from chronic or
acute changes.
Chronic inflammatory enlargement
Etiology:
.Prolonged exposure to dental plaque
.poor oral hygiene
.irritation by anatomic abnormalities
.improper restorative & orthodontic appliances.
.Mouth breathing habit
Clinical features :
 Site - interdental, marginal, attached
gingiva
 Shape - slight ballooning to life preserver
shaped bulge
 slow progressing and painless
 painful ulceration sometimes

Acute inflammatory enlargement-

Gingival abscess
Etiology:
 Bacteria carried deep into the tissues by
toothbrush bristles, piece of apple coat etc.
Clinical features:
 site - marginal and interdental gingiva
 localized, painful, rapidly expanding.
 Within 24 to 28 hrs lesion becomes
fluctuant & purulent exudate expressed as
surface orifice & rupture spontaneously
DRUG INDUCED GINGIVAL
ENLARGEMENT.
• Anticonvulsants
• Immunosuppressant's
• Calcium channel blockers
• affects the speech, mastication, tooth eruption,
and aesthetics problems

General clinical features:

 site - interdental papilla, facial and lingual
gingival margins
 Starts as a bead massive tissue fold
covering the crown.
 mulberry shaped , firm , pale pink, resilient.
 no tendency to bleed.
 appears to project from beneath the gingival
margin separated by a linear groove.
 Plaque control becomes difficult.

secondary inflammation .
  red, bluish colored lobulated demarcations,
increased bleeding.

1).Anticonvulsants
 First gingival enlargement reported
 Introduced by Merritt and Putnam in 1938.
 Drugs used for the treatment of epilepsy
 Phenytoin, ethotoin, mephenytoin,
succinimides etc.
 50% of the patients
 younger patients more prone
 appears in saliva
 in systemic administration accelerates the
healing of gingival wounds in non- epileptic
humans.
MECHANISM
PHENYTOIN
stimulates fibroblast production of an
proliferation inactive fibroblastic
collagenase
gingival overgrowth
increase in the sulfated decrease in the
glycosaminoglycans in collagen degradation
vitro.

2). Immunosuppressants
 Cyclosporine's used to prevent organ
transplant rejection & to treat autoimmune
origin
 if dosage > 500mg/day reported to induce
gingival enlargement.
 30% patient.
 More vascularised
 associated with nephrotoxicity,
hypersensitivity, hypertension,
hyperthricosis.
3).Calcium channel blockers
 used for CVS disorders, hypertension, angina
pectoris, coronary artery spasm & cardiac
arrhythmia.
 Drugs like nifedipine,diltiazem, felodipine,
nitrendipine and verapamil.
 Nifidipine induces enlargement in 20% cases
 Nifidipine + cyclosporine (for kidney
transplant)
 larger overgrowth
 dose dependent growth
Idiopathic gingival enlargement
 termed as gingivostomatitis, elephantiasis,
idiopathic fibromatosis, hereditary gingival
hyperplasia & congenital familial fibromatosis.
Etiology:-
 unknown
 hereditary basis (autosomal dominant or
recessive)
 begins with primary & secondary dentition
eruption.
Clinical features:
 Site - attached gingiva, gingival margin, and
interdental papilla
 pink, firm and leathery with pebbled
appearance
 Severe cases jaw appears distorted due to
bulbous enlargement
ENLARGEMENT ASSOCIATED WITH
SYSTEMIC DISEASES
 Many systemic diseases can develop oral
manifestations that may affect the
periodontium by two different mechanisms
1). Magnification of existing inflammation
initiated by dental plaque “Conditioned
enlargement”
a). Hormonal conditions(pregnancy & puberty)
b). Nutritional (vitamin C deficiency)
c). Non- specific conditioned enlargement
secondary inflammation

2). Manifestation of systemic disease independent

of the inflammatory status of the gingiva. This
group described as “Systemic diseases causing
gingival enlargement
Conditioned enlargement
 systematic condition of the patient
exaggerates the usual gingival response to
dental plaque
bacterial plaque is necessary for its initiation
3 types
a) Enlargement in pregnancy
b) Enlargement in puberty
c) Enlargement in vitamin C deficiency

A) Enlargement in pregnancy
Marginal and generalized
 Etiology-
 increase in progesterone and
estrogen till 3rd trimester
 increased vascular permeability and
gingival edema.
Marginal enlargement

Clinical features :-
 generalized and interproximal
 bright red, soft friable and bleeds
spontaneously.

B) Enlargement in Puberty
 In both male & female adolescents
 Clinical features :
 -marginal & interdental
 -chronic gingival disease
 -reduces after puberty
 -Capnocytophaga sp.. & P. intermedia

C) enlargement in Vitamin C
deficiency
Clinical features :
 Marginal gingivitis
 hemorrhage on slight provocation and
surface necrosis with pseudomembrane
formation
Plasma cell gingivitis

Referred to as atypical gingivitis and plasma

cell gingivostomatitis
site- marginal and attached gingiva
Clinical features :
-red, friable, bleeds easily
-oral aspect of attached gingiva

Non specific conditioned enlargement

(pyogenic granuloma)

Tumor like gingival enlargement

conditioned response to minor trauma

Clinical features:
 discrete spherical tumor like mass
 pedunculated, keloid like
  red friable with ulceration
 fibro epithelial papilloma

Systemic diseases causing gingival

enlargement :-
Leukemia
Clinical features:
 -diffuse or marginal
 localized or generalized tumor like mass in
interproximal spaces
 red, friable, firm and hemorrhagic
 painful necrotizing
 ulcerative inflammation

Granulomatous diseases :-
Wegener’s granulomatosis
Etiology: cause unknown (immunologically
mediated tissue injury)
 Characterized by acute granulomatous
necrotizing lesion of respiratory tract involving
the orofacial region
Clinical features:
 reddish purple bleeds easily.
 Sarcoidiosis :-
Etiology:-
 unknown
 red, smooth, painless enlargement

NEOPLASTIC ENLARGEMENT (GINGIVAL

TUMORS) :-

A).Benign tumors of gingiva

Epulis all discrete tumors & tumor like masses
of gingiva
considered inflammatory
 growth of gingiva & hard palate

1)Fibroma:- arises from connective tissue or

PDL
 slow growing, firm, nodular, soft,
vascular, pedunculated.

2). Papilloma:
  proliferation of surface epithelium
associated with human papilloma
virus(HPV)
 cauliflower like protuberances
broad, hard.

Human Papilloma Virus(HPV) :-

Histopathology:
 Finger like projections of stratified squamous
epithelium, often hyperkeratotic.
 fibrovascular core.

3)Peripheral giant cell granuloma

Clinical features

 interdentally, gingival margin

 pedunculated, smooth,
multilobulated,ulcerations
 painless, firm , spongy
locally invasive destroys underlying bone

Central giant cell granuloma :-

  within the jaw and produce central
cavitations.

Leukoplakia

 Defined as “a white plaque that cannot be

diagnosed as any other etiology other than
that associated with tobacco chewing”.

Etiology- C. albicans, HPV-16, trauma.

Clinical features - white, flattened, scaly,

thick keratinous plaque.

Gingival cyst :-
 Localized, marginal& attached
mandibular canine & premolar areas
painless& erodes the bone
 Cyst developers from odontogenic
epithelium

2).Malignant tumors

Carcinomas
  3% of all malignant tumors in the body.
 squamous cell carcinoma- common.
clinical features :-
 Exophytic, irregular growth, ulcerative, flat,
erosive lesions.
 symptomless initially then painful
invades the bone .

Malignant melanoma

 site - hard palate& maxillary gingiva

localized pigmentation
 flat or nodular
 rapid growth with early metastasis
 arises from melanocytes from the gingiva

Sarcoma
Fibrosarcoma, lymphosarcoma& reticulum cell
sarcoma of gingiva
Kaposi’s sarcoma.

False enlargement :-
Appear as a result of increase in size of
underlying osseous or dental tissues.

A.UNDERLYING OSSEOUS LESIONS:-

 Enlargement of bone subjacent to the
gingival area occurs, most often in tori
& exostosis & can also occur in pagets
disease, fibrous-
dysplasia,cherubism,osteoma,osteos-
arcoma.

B. Underlying dental tissues

 during stages of eruption particularly

primary dentition.
 labial gingiva may show a bulbous
marginal distortion.
This enlargement is called developmental
enlargement.

Syndromes associated with

gingival enlargement :-
1.Cross syndrome:- gingival enlargement,
hypopigmentation,
microopthalmos,
athetosis,
oligophrenia
2.Rutherford syndrome:- gingival enlargement
,corneal dystrophy.
 3.Robinow syndrome:- gingival enlargement,
foetal face.

4.Sturge-webersyndrome:- gingival angiomas ,

Enchephalofacial angoimatosis.

5.Cowdens syndrome:-generalized
papillomatosis.
6.Murray-Puretic- Dresher syndrome:- gingival
fibromatosis with multiple fibromas.

DIFFERENTIAL DIAGNOSIS:-

1.Fibrotic gingival enlargement –tissue is

firm,hard,fibrous in consistency.do not bled readily.
2.Tumour like gingival enlargement :- lesions ar
discrete mushroom like spherical masses with deep
red pinpoint margins.
3.Inflammatory gingival enlargement :- involved
tissues are glossy,smoth, oedematous and bleed
readily.
4.Idiopathic gingival enlargement :- gingiva is pink
,firm,leatherywith pebbled appearance.
5.enlargement in pregnancy :-gingiva is bright
red,soft friable& bleeds spontaneously.
6.Enlargement in vitamin c deficiency :-gingiva is
bluish red,soft, shiny surface.
7.Non specific condiotioned enlargement:-discrete
spherical ,tumour like masseswith pedunculated
attachment.
8.Leukaemia :- lesions are red,friable,firm&
necrotizing.
9.Wegners granulomatosis :-reddish purple lesion.
10.Sarcoidosis :- lesion is smooth,red ,painless.

MANAGEMENT
1). CHRONIC INFLAMMATORY ENLARGEMENT
Enlargements which are soft ,discolored are treated
by scaling and root planning.
Enlargements which are fibrous are treated by
surgical removal.
Surgical removal involves 2 techniques –
 1.GINGIVECTOMY.
2.FLAP OPERATION.
2).TUMORLIKE INFLAMMATORY
ENLARGEMENT :-
These are treated by gingivectomy as follows,
Local anaesthesia is given to the patient and tooth
surfaces beneath the mass arescaled to remove
calculus and debris.

Lesion is separated from the mucosa at its base with a

number 12 bard parker blade.

The involved tooth surfaces are scaled &the area is

cleansed with warm water.

A periodontal pack is applied and removed after a

week.

3). PERIODONTAL ABSCESSES :-

These are treated by following steps,
1.Drianage through pocket retraction or incision.
2.scaling and root planning.
3.Periodontal surgery.
4.Systemic antibiotics.
5.Tooth removal.
4).GINGIVAL ABSCESSES :-
 Scaling and root planning leads to removal of
microbial deposits.
 In acute situations,flctuant area is incised with a
15 scalpel blade,exudates is expressed by gentle
pressure.
 The area is irrigated with warm water and
covered with moist gauze

5).DRUG ASSOCIATED GINGIVAL

ENLARGEMENT :-
 Primary consideration should be possibility of
discontinuing the drug or changing medication.

ANTICONVULSANT ALTERNATIVE
DRUG
Phenytoin Carbamazepine
Valproic acid

CALCIUM CHANNEL ALTERNATIVE

DRUG BLOCKERS
Nifedipine Diltiazem
 Verapamil

IMMUNOSUPPRESANTS ALTERNATIVE DRUG

Cyclosporine Tacrolimus

 Secondarily plaque control is emphasized.

 Tertiarily persisting gingival enlargements are
treated with gingivectomy and flap surgery
 Recurrence of drug induced enlargement is seen
in surgically treated cases.
 Chlorhexidine gluconate rinses,professional
cleanings can decrease the speed & degree of
recurrence.

LEUKAM IC GINGIVAL ENLARGEMENT :-

 Scaling and root planning under local

anesthesia.
 Initial treatment consists of removing all
loose accumulations with cotton pellets,
performing superficial scaling
 Progressively deeper scaling is carried out at
subsequent levels.
 Antibiotics are administered systemically the
evening before and for 48 hrs after each
treatment to reduce risk of infection.
GINGIVAL ENLARGEMENT IN
PREGNANCY:-

 Elimination of all local irritants.

 Marginal and interdental gingival
enlargement are treated by scaling and
curettage.
 Good preventive dental programme
consisting of nutritional counseling,plaque
control measures.
 Lesions should be removed surgically
during pregnancy only if they interfere
with mastication or it is unaesthetic.
GINGIVAL ENLARGEMENTS IN
PUBERTY :-

 Scaling and curettage.

 Removal of al sources of irritation and
controlling plaque.
 Anti microbial mouth
washes,antibiotic therapy in severe
cases.
REFERENCE BOOKS

*BURKITTS –ORAL MEDICINE

*CARRANZA-TEXTBOOK OF
PERIODONTOLOGY

*SHAFFERS –ORAL PATHOLOGY

*CRISPY AND SCULLY

*INTERNET