Gingival enlargement10615

6/1/2015 Dr Saif Khan

Increase in size of gingiva

Common feature of gingival disease

Also called Gingival Overgrowth

“Hypertrophic gingivitis” and “Gingival

hyperplasia” are misnomer and should be

avoided


I. Inflammatory Enlargement

A. Chronic

B. Acute

II. Drug- induced Enlargement

III. Enlargement associated with Systemic

disease or conditions

A. Conditioned Enlargement

1. Pregnancy

2.Puberty

3. Vitamin C Deficiency


4. Plasma cell ginivitis

5. Nonspecific Conditioned

Enlargement(Pyogenic granuloma)

B.Systemic diseases causing gingival

enlargement

1. Leukemia

2. Granulamatous diseases (eg. Wegener’s

granulomatosis, sarcoidosis)

IV. Neoplastic enlargement

A. Benign

B. Malignant


Localised: limited to the gingiva adjacent to single or group of teeth

Generalised: Involving gingiva throughout the mouth

Marginal: Confined to marginal gingiva

Pappilary: Confined to interdental pappila

Diffuse: Involving the marginal and attached gingivae and pappilae.

Discrete: An isolated sessile or pedunclated, tumorlike enlargement


Grade 0: No signs of gingival enlargement.

Grade I : Enlargement confined to

interdental pappila.

Grade II: Enlargement involves pappila and

marginal gingiva

Grade III: Enlargement covers three quarter

or more of the crown


Result from chronic or acute inflammatory

changes.

Chronic enlargement are more common

As secondary complication to any other type

of enlargement creating

‘combined enlargenent”


C/F:

Slight balooning of interdental pappila or

marginal gingiva

In early stages; life preserver bulge around

involved tooth

This bulge can increase in size and cover whole

of the crown

Localised/generalised or sessile/pedunclated


Progresses slowly and painlessly unless

complicated by acute infection or trauma

May undergo spontaneous reduction in size

followed by exacerbation or continued

enlargement.

Painful ulceration can occur between the

overgrowth and adjacent gingiva


Chronic inflammatory GE show exudative and

proliferative features of chronic inflammation

Clinically Deep Red or Bluish Red are soft and

Friable

Smooth and shiny surface and are

hemorrhagic

Predominance of inflammatory cells and fluid

with vascular engorgement


Also associated degenerative changes

are seen

Lesions that are firm and resilient have

greater fibrotic component with

abundant fibroblasts and collagen

fibres.


Prolonged exposure to dental plaque

Factors favouring dental plaque accumulation ;

poor oral hygiene, anatomic abnormalities,

improper restorative or orthodontic appliances

Gingivitis and gingival enlargement are seen in

mouth breathers

The maxillary anterior region is common site of

involvement.

Surface dehydration has been produced as a

possible cause.


Gingival abscess:

Etiology: when a foreign body such as toothbrush

bristle, piece of apple, lobster shell fragment

forcefully implants bacteria into the gingiva

Clinical features

localised, painful rapidly expanding lesion of sudden

onset

Limited to marginal gingiva or interdental pappila

Initially appears as red swelling and smooth, shiny

surface

Within 24-48 hrs lesion becomes fluctuant and

pointed with surface orifice from which purulent

exudate can be expressed


Histopathology of Gingival A bscess;

Purulent focus of connective tissue surrounded by a

diffuse infiltration of PMNs, edematous tissue and

vascular enlargement

Surface epithelium has varying degree of

intravascular and extravascular edema, leukocyte

invasion and sometimes ulceration


Side effects of some anticonvulsants,

Immunosuppressant and antihypertensives

Clinical and microscopic features of the

enlargements caused by different drug are

similar.

Painless beadlike enlargement of the

interdental pappila is seen which extends to

facial and lingual aspect

The marginal and pappillary segment unite

ultimately leading to massive fold tissue

covering a considerable portion of crown and

interfering with occlusion


Lesions are mulberry shaped, firm, pale pink and

resilient with a minutely lobulated surface and

seldom bleed when uncomplicated by inflammation

Enlargement characteristically projects from

beneath gingival margin from which it is separated

by linear groove

This enlargement can become secondary inflammed

due plaque accumulation

Secondary inflammation not only leads to increase

in size of the enlargement but also produces red or

bluish discoloration, obliterate the the lobulated

surface demarcations and increase bleeding

tendency


The enlargement is usually generalised

throughout the mouth but is more severe in

maxillary and mandibular anterior regions

Gingival enlargement is seen in the area where

teeth are present and disappears in the area

where teeth are extracted

Drug-induced gingival enlargement can occur in

mouths with little or no plaque and may be

absent in mouths with abundant deposits

Suggesting a genetic predisposition to its

occurence



Pronounced hyperplasia of the connective tisuue and

epithelium is seen

Acanthosis of the epithelium along with elongated rete

pegs extending deeply into connective tissue

Densely arranged collagen bundles

Increase in number of fibroblasts and blood vessel

Increased Amorphous ground substance

Structural changes in outer epithelium is seen in outer

epithelial surface in cyclosporine- induced ginigval

enlargements

Cyclosporine induced gingival enlargements have a

more highly vascularised connective tissue with foci of

chronic inflammation, particularly plasma cells

First drug induced gingival enlargement

was reported in Phenytoin(Dilantin)

Other drugs also known to produce GE are

Ethotoin, mephenytoin,Succinimides,

methsuximides and valproic acid

Gingival enlargement occurs in about 50%

of patients receiving the drug although

incidences range from 3% to 84.5%

It occurs more often younger patients

Its occurrence and severity are not related

to dosage after threshold level have been

exceeded


Tissue-culture experiments have shown that

phenytoin stimulates proliferation of

fibroblast like cells

Analogs of phenytoin (1-allyl-5-

phenylhydantoinate and 5-methyl-5-

phenylhydantoinate) have similar effects on

fibroblasts like cells

Fibroblasts from phenytoin induced gingival

overgrowth show increased synthesis of

sulfated glycosaminoglycans in vitro

Phenytoin may induce decreased collagen

degradation as result of production of

inactive fibroblastic collagenase


Cyclosporine is a potent immunosuppressive

agent used to prevent organ transport

rejection and to treat autoimmune disease

It selectively and reversibly inhibits helper T-

cells which play role in humoral and cellular

immunity

Cyclosporine A is administered IV or PO

Dosage more than 500mg/day have shown to

induce gingival overgrowth

GE is more vascularised than that of

phenytoin


Occurrence varies 25%-75%

Affects children more frequently

Magnitude is more related to to plasma concentration

than to periodontal status

Microscopic finding show many plasma cells and

abundant amorphous extracellular substance

suggesting hypersensitivity reaction to cyclosporine

Other sideeffects of cyclosporine are nephrotoxicity,

hypertension and hypertrichosis

Another immunosuppressive drug Tacrolimus also

causes gingival overgrowth


Treatment of HTN,Angina pectoris,

coronary artery spasm, cardiac arythmias

Induce direct vasodilation of coronary

arteries and arterioles, improving oxygen

supply to the heart muscles and also reduces

hypertension by dilating peripheral

vasculature

They are classified

Dihydropyridine derivatives(amlodipine,

nifedipine)

Benzothiazine derivative derivatives (diltiazem)

Phenlylalkylamine (verapamil)


Nifedipine induces gingival enlargement in

20% of patients

Diltiazem, Felodipine, nitrendipine, and

verapamil also induces gingival enlargement

Nifedipine is used with cyclosporin in organ

transplant patients and combined use

produces larger gingival overgrowths


Also called Gingivamatosis, Idiopathic

fibromatosis, Hereditary gingival

Hyperplasia and Congenital familial

fibromatosis

Enlargement affects attached as well as

marginal gingiva and interdental pappilae

Facial and lingual surface of mandible and

maxilla are affected but enlargement can be

limited to either jaw

GE presents as pink, firm and leathery in

consistency and has characteristic minutely

pebbled surface

In severe cases the teeth are almost covered

and enlargement projects into oral vestibule 6/1/2015 Dr Saif Khan

Histopathology:

There is bulbous increase in the amount of

connective tissue which is relatively

avascular and consists of densely arranged

collagen bundles and numerous fibroblasts.

The surface epithelium is thickened and

acanthotic.

Etiology: unknown (idiopathic)

mode of inheritance AR and AD

The enlargement begins with eruption of primary

or secondary dentition and may regress after

extraction suggesting teeth or plaque attached

to it as intiating factor


Syndrome characterized by gingival hyperplasia, increased growth of hair, epilepsy and mental retardation

Autosomal dominant


Magnification of an existing inflammation

initiated by dental plaque included in

“Conditioned enlargement”

Manifestation of the systemic disease

independently of the inflammatory status

of the gingiva


Occurs when systemic condition exaggerates

or distorts the usual gingival response to

dental plaque

Bacterial plaque is necessary for the

initiation of this type of enlargement but it is

not the sole determinant of the nature of the

clinical features

The three types of enlargements are

1. Hormonal (pregnancy, puberty)

2. Nutritional (vitamin C def )

3. Allergic (nonspecific GE)


In pregnancy there is increase in the level

of progesterone and estrogen and by the

end of third trimester reach 10 and 30

times the levels during menstrual cycle

respectively

These hormone changes induce changes is

vascular permeablity,leading to gingival

edema and increase inflammatory

response to dental plaque

There is change in subgingival microbiota

leading to increase in Prevotell intermedia


Results from aggravation of previous

inflammation

Enlargement is usually generalised and

tends to be more prominent interproximally

than on facial or lingual surface

Enlarged gingiva is bright red or magenta

in color, soft and friable and has smooth and

shiny surface.

Bleeding occurs on slightest provocation


Also called Pregnancy tumor

Smooth glistening surface having

numerous deep red pinpoint markings

Inflammatory response to dental plaque

modified by patient’s condition

Occurs after 3rd month of pregnancy or

earlier and incidence is 1.8% to 5%


Lesion appears as discrete, mushroom like

flattened spherical mass that protrudes

from gingival margin or interproximal space

and attached by sessile or pedunclated

base.

It tends to expand laterally and pressure

from the tongue and cheek gives its

flattened appearance

lesion is superficial usually and does not

invade underlying bone


The mass is usually semifirm but has various

degree of softness and friability

Usually painless unless its shape and size

foster accumulation of debris under its

margin or interfere with occlusion

Histopathology:

Gingival enlargement in pregnancy is

Angiogranuloma


Involve Marginal and interdental gingivae

and characterized by prominent bulbous

interproximal papilla

Often facial gingiva are enlarged and

lingual are spared

Tendency to develop massive recurrence in

the presence of relatively scant plaque

deposits distinguishes pubertal gingival

enlargement from uncomplicated chronic

gingival enlargement


Acute vitamin C deficiency itself does not

cause gingival inflammation but causes

hemorrhage,collagen destruction and

edema of connective tissue

Gingival Enlargement in scurvy is marginal,

gingiva is bluish red, soft, and friable and has

smooth shiny surface

Hemorrhage can occur spontaneously or on

slightest provocation


Surface necrosis with pseudomembrane

are common feature

Histopathologically the gingiva has a

chronic inflammatory cellular infiltration

with superficial acute response

There are scattered areas of hemorrhage and

engorged capillaries

Marked diffuse edema, collagen

degeneration and scarcity of collagen

fibrils or fibroblasts are striking findings


Also called atypical gingivitis or plasma cell

gingivitis

Consists of mild marginal gingival

enlargement that extends to the attached

gingiva

Gingiva appears red, friable, sometimes

granular and bleeds easily

There is no loss of attachment

The lesion is located in the oral aspect of

the attached gingiva and therefore differs

from plaque induced gingivitis


Histopathology:

Epithelium shows spongiosis and

inflammatory cells inflitration

Ultrastucturally there is damage in the lower

spinous and basal cell layers

Connective tissue contains dense infiltrate

of plasma cells which extends to oral

epithelium inducing dissecting type injury

Plasma cell gingivitis is thought to be of

allergic origin caused due to some

ingredients of chewing gum, dentrifices and

diet


Pyogenic granuloma is tumour like

enlargement which is an exagerrated

conditioned response to minor trauma

Lesion varies from discrete spherical, tumour

like mass with a pedunclated attachment to a

flattened keloid like enlargement with abroad

base

Bright red or purple in color, friable or firm

depending on its duration

In majority of cases it presents with surface

ulceration and purulent exudation


The lesions either involutes spontaneously

or becomes fibroepithelial papilloma and

persists for years

Histopathology:

Consists of mass of granulation tissue with

chronic inflammatory infiltration

Endothelial proliferation and formation of

numerous vascular spaces

Surface epithelium is atrophic in some

areas and hyperplastic in other

Surface ulceration and exudation are common

feature


Recurrence rate

;15%.

Similar in clinical

appearance to the

conditioned

enlargement seen

in pregnancy


1.leukemia:

AML

CML

2.Granulamatous diseases:

Wegener granulomatosis

sarcoidodis


1. Benign tumours

Fibroma

papilloma

peripheral giant cell granuloma

central giant cell granuloma

leukoplakia

Gingival cyst

2. Malignant tumours

Carcinoma

Malignant melanoma


False enlargements are not true enlargements

of gingival tissue but may appear as such as

a result of increase in size of underlying

osseous or dental tissue

Underlying osseous tissue

Eg. Tori and exostoses

Underlying dental tissue

eg: various stages of eruption due to bulge of

crown.


Gingival enlargement10615

Health & Medicine

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