“GINGIVAL TUMORS AND FALSE

GINGIVAL ENLARGEMENT”

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 CONTENT
Introduction
Classified according to etiologic factors and
pathologic changes as follows:
I. Inflammatory enlargement
A. Chronic
B. Acute
II. Drug-induced enlargement

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 Cont.
III. Enlargements associated with systemic diseases or conditions
A. Conditioned enlargement
1. Pregnancy
2. Puberty
3. Vitamin C deficiency
4. Plasma cell gingivitis
5. Nonspecific conditioned enlargement (pyogenic
granuloma)
B. Systemic diseases causing gingival enlargement
1. Leukemia
2. Granulomatous diseases (e.g., Wegener’s granulomatosis,
sarcoidosis)
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 Cont.
IV. Neoplastic enlargement (gingival tumors)
A. Benign tumors
B. Malignant tumors
V. False enlargement

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 Using the criteria of location and
distribution
Localized
Generalized
 Marginal
 Papillary
 Diffuse
 Discrete

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 The degree of gingival enlargement can be
scored as follows
• Grade 0
• Grade I
• Grade II
• Grade III

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 Introduction
Increase in size of the gingiva is a common feature
of gingival disease.
Accepted current terminology for this condition is
gingival enlargement or gingival overgrowth.
These are strictly clinical descriptive terms and
avoid the erroneous pathologic connotations of
terms used in the past, such as “hypertrophic
gingivitis” or “gingival hyperplasia.

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According to location and distribution, gingival
enlargement can be classified as follows:

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According to the Degree of Gingival
Enlargement

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 INFLAMMATORY ENLARGEMENT
 Result from chronic or acute inflammatory changes
Chronic Inflammatory Enlargement
Clinical features
 Originates as a slight ballooning of the interdental papilla
and marginal gingiva
 progresses slowly and painlessly
 Localized or generalized
Etiology
 prolonged exposure to dental plaque
 Often seen in mouth breather
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 Gingival Changes Associated with Mouth
Breathing
Gingivitis and gingival enlargement
 The gingiva appears red and edematous, with a
diffuse surface shininess of the exposed area.
The maxillary anterior region is the common site
of such involvement.
 Altered gingiva is clearly demarcated from the
adjacent unexposed normal gingiva.

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Cont.

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 Cont.
Acute Inflammatory Enlargement
Gingival Abscess:
is a localized, painful, rapidly expanding lesion that usually has
a sudden onset.
It is generally limited to the marginal gingiva or interdental
papilla.
 In its early stages, it appears as a red swelling with a smooth,
shiny surface.
The adjacent teeth are often sensitive to percussion.
If permitted to progress, the lesion generally ruptures
spontaneously. 13
Cont.

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 DRUG-INDUCED GINGIVAL ENLARGEMENT
 Anticonvulsants
Immunosuppressants
 Calcium channel blockers
Clinical Features:
 The growth starts as a painless, beadlike enlargement of
the interdental papilla
 The enlargement is usually generalized throughout the
mouth but is more severe in the maxillary and
mandibular anterior regions. It occurs in areas in which
teeth are present, not in edentulous spaces, and the
enlargement disappears in areas from which teeth are
extracted. 15
Different drugs known to predispose to gingival
enlargement

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 Anticonvulsants
The first drug-induced gingival enlargements
reported were those produced by phenytoin. Other
hydantoins known to induce gingival enlargement
are ethotoin, mephenytoin, succinimides
(ethosuximide, methsuximide), and valproic acid).
50% of patients receiving the drug.
not necessarily related to the dosage.

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 Cont.
•Tissue culture experiments indicate that phenytoin
stimulates proliferation of fibroblast-like cells and
epithelium.
•Experimental attempts to induce gingival
enlargement with phenytoin administration in
laboratory animals have been successful only in the
cat, the ferret, and the Macaca speciosa monkey. In
experimental animals, phenytoin causes gingival
enlargement that is independent of local
inflammation. 18
Phenytoin-induced gingival overgrowth

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 Immunosuppressants
•Cyclosporine is a potent immunosuppressive
agent used to prevent organ transplant rejection
and to treat several diseases of autoimmune origin.
•Its exact mechanism of action is not well known,
but it appears to selectively and reversibly inhibit
helper T cells which play a role in cellular and
humoral immune responses

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 Cont.

•more vascularized than phenytoin enlargement

•its occurrence varies according to different
studies from 25% to 70%, it affects children
more frequently, and its magnitude appears to be
related more to the plasma concentration than to
the patient’s periodontal status

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Clinical presentation of cyclosporine-A-
induced gingival overgrowth

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 Calcium Channel Blockers
•Calcium channel blockers are drugs developed for
the treatment of cardiovascular conditions such as
hypertension, angina pectoris, coronary artery
spasms, and cardiac arrhythmias.
•Nifedipine, one of the most often used induces
gingival enlargement in 20% of patients. Diltiazem,
felodipine, nitrendipine, and verapamil also induce
gingival enlargement
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Nifedipine induced-gingival enlargement

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 IDIOPATHIC GINGIVAL ENLARGEMENT

Idiopathic gingival enlargement is a rare condition

of undetermined cause.
It has been designated by such terms as
gingivomatosis, elephantiasis, idiopathic
fibromatosis, hereditary gingival hyperplasia, and
congenital familial fibromatosis.

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 Cont.
Etiology
 The cause is unknown
 Some cases have a hereditary basis
 A study of several families found the mode of
inheritance to be autosomal recessive in some cases
and autosomal dominant in others
begins with the eruption of the primary or
secondary dentition and may regress after
extraction. 26
 Cont.
Clinical Features
• The enlargement affects the attached gingiva, as
well as the gingival margin and interdental papillae,
in contrast to phenytoin-induced overgrowth, which
is often limited to the gingival margin and
interdental papillae.

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IDIOPATHIC GINGIVAL ENLARGEMENT

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NEOPLASTIC ENLARGEMENT (GINGIVAL TUMORS)

a. Benign tumors
b. Malignant tumors

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 Cont.
•Benign Tumors of the Gingiva
•Fibroma: Fibromas of the gingiva arise from the gingival
connective tissue or from the periodontal ligament.
•They are slowgrowing, spherical tumors that tend to be
firm and nodular but may be soft and vascular.
•The so-called giant cell fibroma contains multinucleated
fibroblasts. In another variant, mineralized tissue (bone,
cementum-like material, and dystrophic calcifications)
may be found; this type of fibroma is called peripheral
ossifying fibroma.
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Cont.

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 Cont.
•Papilloma: Papillomas are benign proliferations
of surface epithelium that are in many but not all
cases associated with the human papillomavirus
(HPV).
• Gingival papillomas appear as solitary wartlike or
cauliflower-like protuberances.
•They may be small and discrete or broad, hard
elevations with minutely irregular surfaces.
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Papilloma of the gingiva

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 Cont.
Peripheral Giant Cell Granuloma: Giant cell
lesions of the gingiva arise interdentally or from the
gingival margin, occur most frequently on the labial
surface.
 They vary in appearance from smooth, regularly
outlined masses to irregularly shaped.
 Ulceration of the margin is occasionally seen. The
lesions are painless, vary in size, and may cover
several teeth.

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 Cont.

•There are no pathognomonic clinical features

whereby these lesions can be differentiated from
other forms of gingival enlargement.
•Microscopic examination is required for
definitive diagnosis.
•The prefix “peripheral” is needed to differentiate
them from comparable lesions that originate within
the jawbone (central giant cell granulomas)
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Cont.

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 Cont.
•Central Giant Cell Granuloma: Giant cell
lesions arise within the jaws and produce central
cavitation.
•They occasionally create a deformity of the jaw
that makes the gingiva appear enlarged.

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Central Giant Cell Granuloma

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 Cont.
•Leukoplakia: Leukoplakia is a strictly clinical term defined by
the World Health Organization as a white patch or plaque that
does not rub off and cannot be diagnosed as any other disease.
• The cause of leukoplakia remains obscure, although it is
associated with the use of tobacco (smoke or smokeless). Other
probable factors are Candida albicans, HPV-16 and HPV-18,
and trauma.
•Leukoplakia of the gingiva varies in appearance from a grayish
white, flattened, irregularly shaped.
•Most leukoplakias (80%) are benign; the remaining 20% are
malignant or premalignant.
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Cont.

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 Cont.

•Other Benign Masses: Other benign tumors

have also been described as rare or infrequent
findings in the gingiva. They include nevus,
myoblastoma, hemangioma, neurilemoma,
neurofibroma, mucus-secreting cysts
(mucoceles), and ameloblastoma.

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 Malignant Tumors of the Gingiva

 Oral cancer accounts for less than 3% of all

malignant tumors in the body but is the sixth
most common cancer in males and the twelfth in
females. The gingiva is not a frequent site of oral
malignancy.
 presenting as an irregular outgrowth, or
ulcerative, appearing as flat, erosive lesions.

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 Cont.
•Squamous cell carcinoma: is the most common
malignant tumor of the gingiva. It may be
presenting as an irregular outgrowth, or ulcerative.
It is often symptom free, going unnoticed until
complicated by inflammatory changes that may
mask the neoplasm but cause pain; sometimes it
becomes evident after tooth extraction.
• Metastasis is usually confined to the region above
the clavicle; however, more extensive involvement
may include the lung, liver, or bone. 43
Squamous cell carcinoma of the gingiva.

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 Cont.

Malignant Melanoma: Malignant melanoma is

a rare oral tumor that tends to occur in the hard
palate and maxillary gingiva of older persons.
 It is usually darkly pigmented. It may be flat or
nodular and is characterized by rapid growth
and early metastasis. It arises from
melanoblasts in the gingiva, cheek, or palate.

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Cont.

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 Cont.

•Sarcoma: Fibrosarcoma, lymphosarcoma, and

reticulum cell sarcoma of the gingiva are rare.
•Kaposi’s sarcoma often occurs in the oral cavity
of patients with acquired immunodeficiency
syndrome (AIDS), particularly in the palate and
the gingiva.

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 Cont.

•Symptoms of gingiva tumor( gum cancer)

•Gum tumor ( cancers) may start out looking like a
bump or a sore that does not heal. The sore may be
red or white, and it may look like a thickening of
the gum. It might also bleed.
•Teeth near the sore may become loose, or you may
find that your dentures do not fit well.

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 Cont.
• Other symptoms of Gingiva tumor
( cancer )can include:
• A lump that does not go away
• A non-healing sore — which may be white, pale, red, dark, or
otherwise discolored — that does not heal within 14 days
• Bleeding gums
• Cracking of the gum
• Difficulty eating
• Loosening of the teeth or ill-fitting dentures
• Pain
• Swollen lymph nodes in the neck
• A thickened area of the gums
• Unexplained weight loss 49
 Cont.
•Risk factors for Gingiva tumor
include:
• Being over 40 years old
• Consuming a lot of alcohol
• Following a diet low in fruits and vegetables
• Being male
• Having poor oral hygiene
•Smoking or using other tobacco products

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 Cont.
•Common treatments for
Gingiva tumor
•Some common treatments for gum cancer include:
• Chemotherapy to attack cancer cells
• Radiation therapy to attack cancer cells
• Surgery to remove the cancer and evaluate how
far it has spread
• Targeted therapy to directly destroy or prevent
the growth of cancer cells
• Immunotherapy to teach your immune system to
target cancer cells
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 FALSE ENLARGEMENT

are not true enlargements of the gingival

tissues but may appear as such as a result of
increases in size of the underlying osseous or
dental tissues.
The gingiva usually presents with no abnormal
clinical features except the massive increase in
size of the area.

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 Cont.

•Underlying Osseous Lesions

Enlargement of the bone subjacent to the gingival
area occurs most often in tori and exostoses, but it
can also occur in Paget’s disease, fibrous dysplasia,
cherubism, central giant cell granuloma,
ameloblastoma, osteoma, and osteosarcoma.

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 Cont.
•Underlying Dental Tissues
This enlargement has been termed developmental
enlargement and often persists until the junctional
epithelium has migrated from the enamel to the
cementoenamel junction.

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 FALSE ENLARGEMENT

A: The overlying gingiva presents with no abnormal

clinical features except the massive increase in size
of the area; B: Formed completely by underlying
bone. 55
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