Gingival Enlargement and it's types

WHAT IS GINGIVAL ENLARGEMENT?


ClASSIFICATION


A] Based on etiologic factors and pathologic changes

I. Inflammatory Enlargement

  • Acute
  • Chronic

II. Drug-induced enlargement

III. Enlargements associated with systemic diseases or conditions

i) Conditioned enlargement

  • Pregnancy
  • Puberty
  • Plasma cell gingivitis
  • Vitamin C deficiency

ii) Systemic disease causing enlargement

  • Leukemia
  • Granulomatous diseases (Wegener'sg ranulornatosis, sarcoidosis)



IV.) Neoplastic Enlargement

  • Benign
  • Malignant



V.) False enlargement



For drug induced enlargements, those drugs must replaced by their alternatives by the dentist and can be bought online from home health care products.



B] Based on location and distribution

I.Localized

II Generalized

III. Marginal

IV. Papillary

V. Diffuse

VI. Discrete


GRADING OF GINGIVAL ENLARGEMENT

Bokenkamp & Bohnhorst 1994

Grade 0 -4 :No signs of gingival enlargement

Grade 1-4 :Enlargement confined to IDP

Grade 2 -4 :Enlargement involves IDP &marginal gingiva

Grade 3-4 :Enlargement covers three quarters / more of crown or less.



Gingival overgrowth index- Mc Gaw et at 1987



Grade 0-4 :No overgrowth, feather edge gingival margin

Grade 1-4 :Blunting of gingival margin

Grade 2-4 :Moderate gingival overgrowth (one third crown length)

Grade 3-4 :Marked gingival overgrowth (more than one thirds of crown)


Clinical index for drug induced gingival overgrowth 

1. Severe overgrowth profound thickening of gingiva

2. Large portion of the clinical crown is covered

3. Papillae - retractable

4. Probing depth > 3mm

5.buccolingual dimension 3mm



INFLAMMATORY ENLARGEMENT

a. Chronic inflammatory enlargement

Etiology

  • Poor oral hygiene
  • Malocclusion
  • Plaque accumulation & retention
  • Anatomical abnormalities
  • Orthodontic appliances
  • restorations



Clinical Features

  • Slight ballooning of IDP & marginal gingiva
  • Life preserver shaped bulge
  • Smooth , edematous , bleed easily
  • Progress- slowly and painlessly
  • Pseudopockets
  • Discrete sessile or pedunculated tumor like mass
  • Interproximal / marginal or attached gingiva
  • Slow growing and painless



B. ACUTE INFLAMMATORY ENLARGEMENT


1. GINGIVAL ABSCESS


Etiology

Foreign substances


Clinical features

  • Marginal gingiva or IDP
  • Red swelling
  • Smooth shiny surface
  • Fluctuant and pointed with
  • a surface orifice
  • Expresses purulent exudate


2. PERIODONTAL ABSCESS (Lateral abscess /parietal abscess)


Depending on location :

- Gingival

- Periodontal (Acute / Chronic)

-Pericoronal


Etiology

[PERIODONTITIS RELATED]

  • Extension of infection from PD pocket
  • Lateral extension of inflammation
  • Pocket with a tortuous course
  • Incomplete removal of calculus



[NON PERIODONTITIS RELATED]

  • Impaction of foreign bodies
  • Endodontic perforation
  • Lateral cyst infection


Signs and symptoms


Acute abscess

  • Mild to severe discomfort
  • Localized red, ovoid
  • Mobility
  • Tooth elevation in the socket
  • Tenderness to percussion or biting
  • Suppuration
  • Localized inflammatory lesion
  • Usually without systemic
  • involvement
  • Elevated temperature

Chronic abscess

  • No pain or dull pain
  • Periodontal pocket
  • Slight tooth elevation
  • Fistulous tract often associated with deep pocket
  • Intermittent exudation
  • Regional Lymphadnopathy


Enlargement in pregnancy

1. Marginal and generalised enlargement


2. Single or multiple tumor like masses

Hormonal changes

Progesterone and estrogen

Vascular permeability — edema , t inflammatory response



Marginal enlargement
Generalised , more prominent interdentally

Bright red or magenta colour

Friable , smooth & shiny surface

Bleeding spontaneously on slight provocation

"Pregnancy rhinitis"



Tumor like gingival enlargement "Pregnancy tumor"
Discrete mushroom like ,flattened

spherical mass

Dusky red or magenta , smooth

glistening surface

Does not invade underlying bone

Semifirm — soft ., friable

sessile or pedunculated

Painless unless its size and shape foster

accumulation of debris

Treatment

• Removal of plaque and calculus

• Tumor like gingival enlargement is excised surgically. 




Enlargement in puberty
• Male and female adoloscents

• Areas of plaque accumulation

• Facial surface

• Marginal and interdental


Enlargement in vitamin C deficiency
• Classic description of scurvy

• Acute deficiency — hemorrhage , collagen degeneration , edema

• modify response to plaque


Clinical features

- Bluish red , soft in texture, smooth & shiny surface

Haemorrhage — spontaneous / slight provocation

Surface necrosis with pseudomembrane formation


Plasma cell gingivitis
• Atypical gingivitis / plasma cell gingivostomatitis

• plasmacyte granuloma localised form • Allergic in origin

Clinical features

• Discrete tumor mass ,spherical in shape having pedunculated smooth surface

• it is either bright red or purple, can be friable or firm 

• Painless

• Hemorrhage is characterisation. 


Systemic Disease That Cause Gingival Enlargement

1. Leukemia

-malignant neoplasia of WBC precursors

- diffuse replacement of bone marrow proliferating leukemic cell

-abnormal number and forms of immature WBCs widespread infiltrates.


Clinical features
Diffuse / marginal

Localised / generalised

Overextension of gingiva

Discrete tumor like interproximal mass

Bluish red , shiny surface Firm

Hemorrhage

Leukemic infiltration

Leukemic cell infiltration of gingiva

Gingival thickness

Gingival pockets

Plaque accumulation

Secondary inflammatory lesion



2. Granulomatous disease a.Wegeners granulomatosis

- Acute granulomatous necrotising lesions of respiratory tract , nasal and oral defects

- Acute necrotising vasculitis

Clinical features

-oral mucosal ulcerations

-delayed healing

-Papillary enlargement reddish purple

-bleeds easily

-Strawberry gingiva


Etiology

- Unknown

- Immunologically mediated tissue injuries


NEOPLASTIC ENLARGEMENT


1. Benign tumors of gingiva Epulis

a. Fibroma

i) Giant cell fibroma

ii) Peripheral ossifying fibroma

b. Papilloma

- Proliferations of surface epithelium associated with HPV - HPV & 11

c. Peripheral Giant Cell Granuloma 
d.Central Giant Cell Granuloma

- Arise within the jaw central cavitation

e. Leukoplakia

• WHO: White patch or plaque that does

not abrade & can't be diagnosed as the other disease

• Associated use of tobacco

Other probable factors: Candida, HPV-16, HPV-18 Trauma


2. Malignant tumors of gingiva


Squamous cell carcinoma:

• 90% of all Oral cancer

• 6th —most common cancer in males

• 12th - females

• Most common malignant tumor of gingiva


Malignant melanoma:

• Rare tumor hard palate, maxillary gingiva -older persons

• Darkly pigmented, rapid growth, early metastasis


Drugs associated with gingival overgrowth

Anticonvulsants

Phenytoin

Sodium valproate

Phenobarbitone

Vigabatrin

Immunosuppressants

Cyclosporin

Calcium channel blocker

 Nifedipine

Felopdipine

Amlodipine

Phenylalkylamine 

Benzothiazepine 

Diltiazem


Idiopathic gingival enlargement

•Gingivomatosis , Elephantiasis, Idiopathic fibromatosis

• rare oral disease

• autosomal dominant

• hypertrichosis, mental retardation and epilepsy

• Nodular form

• Symmetric form- most common type 

• During eruption of permanent teeth

• most common effects • diastemas,

• Malpositioning of teeth

• the alveolar bone is not affected (Bittencourt et al. 2000).

False enlargement

Commonly seen in 4 Paget's disease, Fibrous dysplasia, Cherubism, Central giant cell granuloma, Ameloblastoma, Osteoma and Osteosarcoma. 

Dental hygiene is very important as it is the way that gives entry to microbials into our body. For systemic causes that leads to dental problems, cause must be treated first by medications. Medicines can be bought online from online pharmacy store in India. 

Conclusion

Gingival enlargement are multifactorial and sophisticated in nature , which can be in respone to varied interaction between host and environment. GO considerably reduce the standard of life and should end in serios emotional and social problems thanks to esthetics and functionality hence the prevention and treatment supported the understanding the cause and underlying pathologic changes ,






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