Gingival Enlargement

Gingival Enlargement(gingival overgrowth) : increase the size of gingival to cover part of the crown.

Classification of gingival enlargement (according to the etiology & pathologic changes):

I. inflammatory enlargement: a) chronic. b) acute.II . fibrotic enlargement.

a) drug-induced.b) Idiopathic.

III . combined enlargement (fibrotic + inflammatory)IV . enlargement associated with systemic diseases/conditioned

1) conditioned enlagement: pregnancy. Puberty. Vit. C deficiency. Plasma cell gingivitis. Nonspecific conditioned enlarement.

2) systemic diseases causing gingival enlargement:1. leukemia.2. granulamatous diseases ( wegener’s

granulamatosis,sarcoidosis,..)V . Neoplastic enlargement ( gingival tumor):

1. benign tumors.2. malignant tumors.

VI. False enlargement.

Location & distribution: -Localized = single tooth or group of teeth.-Generalized = involving gingiva through out the mouth.Papillary = confined to the interdental papilla.Marginal = confined to the marginal gingival.

I

Diffuse = involving the marginal & attached gingivae & papillae.Discrete = isolated sessile or pedunculated (tumor like) enlargement.

The degree of gingival enlargement can be scored as follows: Grade 0: no signs of gingival enlargement. Grade 1: enlargement confined to interdental papilla. Grade 2: enlargement involved papilla & marginal gingiva. Grade 3: enlargement covers ¾ or more of the crown.

Chronic inflammatory enlargement:

Forms of chronic inflammatory enlargement;1) May be localized or generalized.

- Originate as a slight ballooning of the IDP & /or gingival margin.- in early stages a life saver-like, bulge around

the involved teeth. - IDP & gingival margin increase in size until it

covers part of crown.- Progress slowly & painlessly unless complicated

by infection or trauma.

2) discrete (tumor like )may be:- sessile or pedunculated mass.- Interproximal or on marginal or attached gingival.- Grow slowly, painless, painful ulceration in the fold

between the mass & gingival.- May undergo spontaneous reduction , may

followed by exacerbation & continued enlargement.

3) Gingival changes associated with mouth breathing: - gingivitis – gingival enlargement. - gingiva red & edematous with diffuse shiness.

-maxillary anterior region is the common site, the altered gingiva is clearly demarcated from adjacent normal gingival.-The exact manner in which breathing affect gingiva in not known.-It’s harmful effect is generally attributed to irritation from surface dehydration.

Etiology of chronic inflammatory enlargement:

II

-prolonged local irritation, poor oral hygiene.-Factors that favorplaque acculolation and retention:abnormal relationship between teeth, over hanging margin, food impaction, irritation from clasps, orthodontic therapy, habits, eg: mouth breathing, pressing the tongue against the gingiva.

Acute inflammatory enlargement: Gingival abscess:-localized, painful, rapidly expanding lesion.- sudden onset, limited to marginal or IDP.- in early stages red swelling, smooth shiny surface become fluctuant & pointed, purulent exudates rupture spontaneously.

Etiology of gingival abscess:- When the bacteria carried deep into the tissue.- When foreign substances (tooth brush bristle…)

forcefully embedded into the gingiva ONLY confined to the gingiva.

Periodontal abscess: produce enlargement but involve the supporting periodontal tissue.

Fibrotic enlargement: - produced by factors other than local irritation.- most cases occurs in association with therapy with drugs such as: ( phenytoin, cyclosporine, nefidipine) Drug induced gingival hyperplasia: Anti convalescent e.g.: Phenytoin-not related to duration or dosage or local irritation.- rarely occur in edentulous spaces.- surgically removed recurs.- spontaneous disappear after drug discontinued.

Clinical features of drug induced enlargement:

Clinical & microscopic features of enlargement caused by the different drugs are similar. starts as painless bead-like enlargement (lingual, facial gingival margin & IDP) unite develop into massive tissue covering part of crown.* uncomplicated mulberry shaped, firm, pale pink in color.

III

Resilient with minutely lobulated surface, no tendency toward bleeding.

- Complicated by local factors add size to lesion red or bluish red & obliterated the lobulation increase the tendency to bleeding.

drug induced (phenytoin)

Histopathology of drug induced enlargement:- acanthosis of epithelium.- Enlarged rete pegs.- Densely arranged collagen bundle with increase

fibroblast + b.v.- The mature form has a fibroblast to collagen

ratio equal to normal gingiva. immunosuppresor agent e.g. : CyclosporineExact mechanism of action is not known, occur in 30% of patient, cyclosporine IV or by mouth.Dosage: > 500 mg/day induce gingival overgrowth.Clinically: similar to Phenytoin, but it’s more vascularized than Phenytoin.- in some cases may be more inflammatory character.- histopathology: similar to phenytoin.

Cyclosporine induced

Calcium channel blockers enlargement e.g. : Nefidipine - is a Ca chanel blocker dilation for coronary artriesreduced hypertension + improve O2 supply to the heart muscles by dilating the peripheral vasculature.- overgrowth occurs in 20% in cases.- clinical & HP similar to phenytoin.

IV

- nefidipine is also used with Cyclosporine in kidney transplant, recipients. And the combined use of both drugs induces larger overgrowth.

Idiopathic gingival fibromatosis: It has been designated by such terms as:( gingivomatosis, elephantiasis, diffuse fibroma, familial elephantiasis, idiopathic fibromatosis)-rare condition. Etiology: unknown, may be hereditary base.Enlargement may be gingivaly with eruption of 1ry or 2ndry dentition, may regress after extraction.local irritation is complicating factor.

Clinical features:

- affect the attached gingiva + gingival margin + IDP.

- Buccal & lingual surfaces of max. & mand.are generally affected

- But enlargement may limited to either jaw.- Enlarged gingiva is pink. Firm, leathery in

consistency.- Severe teeth completely covered.- Inflammatory change are common in ging. Margin.

Combined enlargement: - ging. Enlargement is complicated by 2ry inflammation.- consists of two components 1ry hyperplasia of C.T & epithelium (unrelated to inflammation) 2dry complicating inflammation component.- the removal of local factors eliminate 2dry component only but non inflammatory remains.- removal of cause elimination of 1ry components.

V

VI