ABSTRACT
Gingival enlargements are a common clinical finding and most represent a reactive hyperplasia as a direct result of plaque
related inflammatory gingival disease. These generally respond to conservative tissue management and attention to plaque
control. However, a small group are distinct from these and whilst they also represent a reactive tissue response, this occurs
at the level of the superficial fibres of the periodontal ligament. These epulides grow from under the free gingival margin and
not as a result of a primary inflammatory gingival enlargement. This distinct aetiopathogenesis separates this group of
lesions both in terms of their specific clinical presentation and behaviour and their propensity for recurrence if managed
inadequately.
Keywords: Gingival enlargement, epulis.
Abbreviations and acronyms: AG = angiogranuloma; GCL = giant cell lesion; GVHD = graft-versus-host disease; PF = peripheral fibroma;
PGCG = peripheral giant cell granuloma.
INTRODUCTION
Gingival enlargement is a common finding in clinical
practice and the appropriate treatment depends on
correctly diagnosing the cause of the enlargement. The
most common form of enlargement is due to plaqueinduced inflammation of the adjacent gingival tissues
(inflammatory hyperplasia) and this tends to be associated most commonly with the interdental papillae and
may be localized or generalized. Such gingival enlargement can be exaggerated by hormonal effects, as found
in puberty and pregnancy, and may also be complicated
by certain systemic medications.1 Plaque-induced
inflammatory hyperplasia should resolve with debridement of plaque and calculus and improved oral hygiene,
especially when the gingival tissue is oedematous.
Where the gingival tissue is fibrotic, resolution of
enlargement may not occur, resulting in the persistence
of periodontal pocketing such that effective oral
hygiene is impeded. This scenario requires a more
detailed assessment and a longer term management
plan designed to map the level of gingival and possibly
periodontal involvement. Surgical management to
remove enlarged tissue and provide improved access
for the patients oral hygiene may be required.
In addition to plaque-induced gingival enlargement,
there are a number of other types ranging from the
2010 Australian Dental Association
site along the free gingival margin and characteristically grow out from the gingival sulcus with a cervical
displacement of the gingival margin. In many lesions,
the original free gingival margin can be seen running
across the lesion and this defines the site of origin, the
dominant direction of growth (supra or subgingival)
and the likely disruption to the attached gingiva and
mucogingival junction during any subsequent surgical
procedure (Fig 1). The defining features of this group
are shown in Table 2. The members of the group
identified for discussion are the fibrous epulis peripheral fibroma (PF), angiogranuloma pyogenic granuloma (AG) and the peripheral giant cell lesion granuloma (PGCG). A number of large case studies5,6 have
been published and these are consistent in the general
demographic features with PF being the most frequently encountered, followed by AG, PF with calcification and PGCG. There is some variation in
male female distribution but most favour a M:F ratio
ranging from 1:1.31 for PF to 1:1.99 for AG and 1:1.5
Fig 1. Epulis growing from beneath the free gingival margin and
showing the derivation from the deeper tissues of the periodontium.
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for PGCG.6 The site and size also vary but with a
dominant presentation in the maxilla and size within
the 0.5 to 1.5 cm range.
Fibrous epulis peripheral fibroma
This lesion represents the archetype and most common
of the epulides with a female bias and predominantly
adult distribution. It is also the endpoint for some
epulides that may progressively mature and undergo
fibrosis, e.g., some angiogranulomas.
The PF is essentially a reactive fibrous hyperplasia.
The lesion typically presents in adults as a firm, pink
and uninflamed mass growing from under the free
gingival margin or interdental papilla (Fig 2). The
(a)
(b)
concerns, can be left until after delivery. Most pregnancy epulides will resolve fully approximately six
weeks post-partum or will reduce considerably in size
and be much less haemorrhagic, thus permitting easier
surgical excision. Failure to remove a residual mass
following pregnancy can lead to larger lesions at
subsequent pregnancies causing significant functional
and cosmetic problems (Figs 5a and 5b).
The angiogranuloma can also occur in intraoral or
perioral sites unconnected with the gingiva, commonly
(a)
(b)
(a)
Fig 6. Typical highly vascular deeply coloured giant cell lesion with
lateral extension and displacement of the gingival margin.
Fig 7. Giant cell lesion with a multilobular contour and showing the
propensity for local extension often seen with this lesion.
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(b)
Fig 8. (a) Giant cell lesion in a young patient with active displacement
of the coincident incisors and interdental spread. (b) Radiograph
showing interdental bone destruction caused by the PGCG.
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