Gingival Enlargement

Malik Hudieb, BDS, PhD

Department of Preventive Dentistry Faculty of Dentistry Jordan University of Science and Technology

Gingival Enlargement (etiology)

I. Inflammatory enlargement II. Drug induced gingival enlargement III. Enlargements associated with systemic disease IV. Neoplastic enlargement (gingival tumors) V. False enlargement

Gingival Enlargement (location)

1. Localized: single tooth or a group of teeth. 2. Generalized: gingiva throughout the mouth. 3. Marginal: Confined to the marginal gingiva. 4. Papillary: Confined to the interdental papilla. 5. Diffuse: the marginal, attached and papillae. 6.Discrete: isolated sessile or pedunculated tumor like enlargement.

SCORING OF GINGIVAL ENLARGEMENT

Grade 0 : No signs of gingival enlargement Grade I : confined to interdental papilla Grade II : involves papilla and marginal gingiva Grade III : covers three quarters or more of the crown.

Gingival Enlargement
I. Inflammatory enlargement A. Chronic B. Acute

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Gingival Enlargement
I. Inflammatory enlargement A. Chronic: prolonged exposure to dental plaque anatomic abnormalities, improper restorative and orthodontic appliances.

Gingival Enlargement
I. Inflammatory enlargement A. Chronic:

Gingival Enlargement
I. Inflammatory enlargement A. Chronic: Usually painless and progresses slowly Histopathologic features: inflammatory cells and fluids with vascular engorgement. fibroblasts, collagen fibers and new capillaries in the connective tissue.

Gingival Enlargement
I. Inflammatory enlargement B. Acute: Gingival Abscess: A localized, painful, rapidly expanding lesion that is usually of sudden onset. It is generally limited to the marginal gingiva or interdental papilla.

Gingival Abscess Periodontally healthy mouth Foreign object is forced into a healthy sulcus. Limited to gingival margin Localized Painful swelling Purulent exudate may be present

Gingival Abscess Involves the marginal gingiva or interdental papilla

Gingival Abscess Involves the marginal gingiva or interdental papilla

Gingival Abscess
Treatment
Elimination of foreign object Drainage through sulcus with probe or light scaling Control of discomfort Follow-up after 24-48 hours Recommend warm saline rinses

Gingival Enlargement (etiology)

I. Inflammatory enlargement

II. Drug induced gingival enlargement

Importance of Medical History.. Ask twice .. Medications..

II. Drug induced gingival enlargement

III. Enlargements associated with systemic disease IV. Neoplastic enlargement (gingival tumors) V. False enlargement

II. Drug induced gingival enlargement

Mostly related to enlarged interdental papillae which coalesce. Hereditary enlargement involves the entire gingiva. May compromise esthetics, function and impair adequate oral hygiene.

II. Drug induced gingival enlargement

Clinical Features: Initially the growth is painless, starts at the interdental papilla and extends to the facial and lingual gingival margins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

II. Drug induced gingival enlargement

Clinical Features: The marginal and papillary enlargements unite and cover a considerable portion of the crowns, which interfere with occlusion.

II. Drug induced gingival enlargement Anterior regions Interdental papilla

II. Drug induced gingival enlargement 3 major groups (according to therapeutic action): 1. Anticonvulsants (anti-epilyptics). 2. Immunosuppressants. 3. Calcium channel blockers (antihypertensive drugs).

II. Drug induced gingival enlargement

Anticonvulsant drugs: Phenytoin, Phenobarbital, Carbamazepine, Sodium Valproate, Primidone and Felbamate. Antihypertensive drugs: Nifedipine, Amlodipine, Nimodipine, Nicardine, Nitrendipine, Diltiazem, Felodipine and Bepridil.

II. Drug induced gingival enlargement

II. Drug induced gingival enlargement

These medications modify fibroblast function, either directly or indirectly through altering levels of cytokines/MMP activity within the tissue and Calcium ions influx to the cells.

Phenytoin Fibroblasts show increased synthesis of sulfated glycosaminoglycans GAG. Decrease in collagen degradation (inactive fibroblast collagenase)

Role of Dental Plaque

Emphasized in Armitage classification (1999):
Gingival disease A: Dental plaque-induced gingival disease 3. Gingival disease modified by medications a) drug-induced gingival diseases 1) drug-influenced gingival enlargements 2) drug-influenced gingivitis a. oral contraceptive-associated gingivitis b. other

AAP 1999

Role of Dental Plaque

Relationship between plaque and drug induced gingival overgrowth raises the chicken or egg first question. enlarged tissue itself does not bleed, it aids plaque accumulation by preventing adequate oral hygiene, thus leading to gingival inflammation (Glickman & Lewitus 1941, Seymour et al 1996, Darby 2006).

Role of Dental Plaque

with poor oral hygiene had greater severity of gingival overgrowth than those with good oral hygiene (Panuska et al.1961) . Thomason et al (1993) and Ciancio et al (1972) also found an association between the two. Barclay et al (1992) found gingival changes in nifedipine patients were not related to drug dosage or plaque scores.

Clinical presentation
Gingival overgrowth normally begins at the interdental papillae and is frequently found in the anterior segment of the labial surfaces (Darby 2006). Clinical manifestation usually appears within 1 to 3 months after initiation of treatment with the medications (AAP 2004). For patients on cyclosporin, significant overgrowth was commonly observed between 3 and 6 months (Seymour et al 1987).

Clinical presentation
The fibrotic enlargement normally is confined to the attached gingiva but may extend coronally and interfere with aesthetics, mastication, or speech. Does not necessarily altering the underlying periodontium.

Clinical presentation
Cyclosporin induced gingival overgrowth pebbly or papillary lesions which appear on the surface of larger lobulations (Marshall and Bartold 1999). Nifedipine induced gingival overgrowth generalized lobulated enlargement of the facial and lingual gingiva, with the nodular growths originating interdentally and extending across the tooth surfaces (Lederman et al 1984).

Phenytoin

Cyclosporin ..

Niphedipine..

Verapamil..

Felodipine

Pathogenesis
no definitive explanation . Not all patients taking phenytoin, cyclosporin and/or nifedipine develop gingival overgrowth (Seymour et al 1996). gingival overgrowth is rarely observed on edentulous alveolar crests (Badar et al 1998)

Effect of drug dosage

Conflicting studies on the effect of increasing dosage on the degree of overgrowth.

Combination of drugs
Combination of drugs:Synergistic effect (Thomason et al 1993 & 1996, Slavin & Taylor 1987). A significant increase in the incidence of gingival overgrowth has been described in renal transplant patients taking nifedipine as well as cyclosporine compared with those taking cyclosporin alone (48% compared to 30%) (Thomason et al 1993)

Duration of use
Increased duration of phenytoin (Panuska et al 1961) or cyclosporin (Thomason et al 1996) resulted in more gingival overgrowth

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Individual Susceptibility
Influenced by: Age. Gender. Genetics.

Age
Children and adolescents appear more susceptible than adults (Seymour et al 1996, Thomason et al 1996, Darby 2006). However, these studies are limited to both phenytoin and cyclosporin that are more commonly prescribed in this younger age group.

Treatment
Four steps: Drug substitution. Oral Hygiene. Antibiotics. Surgical intervention.

Treatment-Drug substitution

NOT MY WORK.. PLEASE

CONSULT PATIENT PHYSICIAN!

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Treatment-Oral Hygiene
Reduces the inflammatory component. Better surgical field. Consider use of Chlorhexidine mouthrinse or gel. Usually does not result in complete resolution.

Treatment- Antibiotics
Conflicting reports. Cant depend on their use. May resolve the inflammatory component.

Treatment-Surgical intervention
External bevel or internal bevel incisions. Laser. CO2 Mostly for esthetic purposes, sometimes to facilitate oral hygiene. No difference between the outcome of different modalities in 6months Mavrogiannis
et al (2006)

Treatment-Surgical intervention
Recurrence if patient still on medication. Recurrence rate with cyclosporin and nefidipine is 40% within 18 months after active treatment (AAP 2004).

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False enlargements
Increase in size of the underlying osseous or dental tissues : Bone: Normal: tori, exostoses , Disease: fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma, osteoma, and osteosarcoma.

False enlargements

False enlargements
Increase in size of the underlying osseous or dental tissues : Underlying Dental Tissues During the various stages of eruption

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