GINGIVALENLARGEM

ENT

CONTENTS INTRODUCTION -DEFINITION -CLASSIFICATION -GRADING INFLAMMATORY

GINGIVAL ENLARGEMENT

DRUG-INDUCED IDIOPATHICENLARGEMENTS ASS.

WITH SYSTEMIC DISEASES

NEOPLASTICFALSE ENLARGEMENTTREATMENT

INTRODUCTIONDEFINITION

Increase in size of gingiva is called as gingival enlargement (Gingival overgrowth).

Carranza’s 11 th edition

CLASSIFICATIONAccording to etiologic factors and pathologic changes-1.Inflammatory enlargement a. Chronic b. Acute 2.Drug-induced enlargement 1.Anticonvulsants 2.Immunosuppressants 3. Calcium channel blockers 3.Enlargements associated with systemic diseases or

conditions A)Conditioned enlargement i)Pregnancy ii)Puberty iii)Vitamin C deficiency iv)Plasma cell gingivitis v)Non specific conditioned enlargement(pyogenic

granuloma)

B.)Systemic diseases causing gingival enlargement

i)Leukemia ii)Granulomatous disease(Wegener’s

granulomatosis, sarcoidosis)

4.Neoplastic enlargementa) Benign tumorsb) Malignant tumors

5.False enlargement

According To Location And Distribution

LOCALIZED GENERALIZED

Degree Of Gingival Enlargement

Grade 0- No signs of gingival enlargement

Grade 1 - Enlargement confined to interdental papilla

Grade 2 - Enlargement involves papilla and marginal gingiva

Grade 3 - Enlargement covers three quarters or more of the crown

CHRONIC INFLAMMATORY ENLARGEMENT

ACUTE INFLAMMATORY ENLARGEMENT

(GINGIVAL ABSCESS)

CLINICAL FEATURES-Ballooning of interdental papilla & marginal gingivaLocalized or generalizedProgresses slowly & painlesslySite- Interdental papilla, marginal & attached gingiva

CLINICAL FEATURESLocalized, painful, rapidly expanding lesionsLesion becomes fluctuant & pointed with surface orifice within 24-48 hrsSite- Limited to marginal gingiva or interdental papilla

ETIOLOGY-Prolonged exposure to dental plaquePoor oral hygieneAnatomic abnormalitiesImproper restorative & orthodontic appliance

ETIOLOGYBacteria carried deep into tissues with a foreign substance forcefully embedded into gingiva

TYPES OF GINGIVAL INFLAMMATORY ENLARGEMENT

Drug-induced gingival enlargementGingival enlargement is a well known consequence of administration of drugs such as

Anticonvulsants

Immunosuppressants

Calcium channel blockers

Clinical features1. Painless, beadlike enlargement of the interdental papilla and

extends to facial and lingual gingival margins

2. Maxillary & mandibular anterior regions3. When uncomplicated by inflammation is mulberry shaped,

firm,pale pink, and resilient , with a minutely lobulated surface and no tendancy to bleed

4. Project from beneath the gingival margin

SYSTEMIC USE Treatment of all forms of epilepsy except petit mal

Prevent organ transplant rejection & several autoimmune diseases

Treatment of cardiovascular conditions such as hypertension, angina pectoris & cardiac arrythmias

DRUGS SPECIFIC TO CAUSE GINGIVAL ENLARGEMENT

Phenytoin Cyclosporine Nifedipine

Pathogenesis Phenytoin stimulatesproliferation of fibroblasts like cells and epithelium

Formation of abundant extracellular matrix as a hypersensetivity response

Prevalence Gingival enlargement occurs in 50% of patients receiving phenytoin

Cyclosporine causes gingival enlargement in 25%-70% patients

Nifedipine induces gingival enlargement in 20% of patients

DRUGS ANTICONVULSANTS IMMUNOSPRESSANTS Ca CH.BLOCKER

IDIOPATHIC GINGIVAL ENLARGEMENT

Rare condition of undetermined cause.

CLINICAL FEATURES-Affects the attached gingiva as well as the gingival margin and interdental papilla-Involment is limited to the either jaw

-Enlarged gingiva is pink, firm and almost leathery in consistency

-Characterstic minutely pebbled surface

ENLARGEMENTS ASSOCIATED WITH SYSTEMIC DISEASES

Systemic diseases and conditions can affect the periodontium by two different mechanisms-

1. Magnification of an existing inflammation initiated by dental plaque(conditioned enlargement)

2. Manifestation of the systemic disease independently of the inflammatory status of the gingiva.

CONDITIONED ENLARGEMENT

HORMONAL Vit.C DEFICIENCY ALLERGIC

CLINICAL FEATURES1. Generalized2. Prominent

interproximally3. Bright red or

magenta4. Soft and friable &

has smooth & shiny surface

5. Bleeds spontaneously

CLINICAL FEATURES1. Marginal2. Bluish red3. Soft & friable &

smooth & shiny surface

4. Spontaneous bleeding

5. Surface necrosis with pseudomembrane formation

CLINICAL FEATURES1. Frequent in women

& young adults2. Located on oral

aspect of attached gingiva & therefore differs from plaque induced gingivitis.

Female are affected more than male

Common age of occurrence is 11-40 yrs

Its size ranges from 0.9- 2 cm.

Asymptomatic, may be papular or nodular Polypoid mass.

It may become mature and becomes less vascular and more collagenous gradually

converting into a fibrous epulis.

CLINICAL FEATURES

NON SPECIFIC CONDITIONED ENLARGEMENT

(PYOGENIC GRANULOMA)

Lesions are elevated pedunculated or sessile

masses with smooth lobulated or even warty.

Surface is commonly ulcerated and shows

tendency to hemorrhage upon slightest pressure or trauma.

Variegated red and white pattern.

SYSTEMIC DISEASES CAUSING GINGIVAL ENLARGEMENTGRANULOMATOUS DISEASE

(WEGENER’S GRNULOMATOSIS)

CLINICAL FEATURES1. Leukemic enlargement may be diffuse or

marginal localized or generalized.

2. The gingiva becomes soft, edematous and

swollen.

3. Appearance of gingiva is purplish and glossy.

4. There is also pallor in the surrounding mucosa.

5. Ulceration pain and severe hemorrhage can also

occur.

6. It has a spongy consistency and bleeds

frequently.

CLINICAL FEATURES1. It involve the orofacial region and include oral

mucosal ulceration, gingival enlargement, abnormal tooth mobility, exfoliation of teeth, and delayed healing response.

2. “Strawberry gums” appearance of the mandibular gingiva is commonly seen.

3. Enlargement is reddish purple and bleeds easily on stimulation but the condition is considered an

LEUKEMIA

NEOPLASTIC ENLARGEMENT(GINGIVAL TUMORS)

BENIGN

FibromaPapillomaPeripheral giant cell granulomaCentral giant cell granulomaLeukoplakiaGingival cyst

MALIGNANT

CarcinomaMalignant melanoma

BENIGN TUMORS

FIBROMA

PAPILLOMA

PERIPHERAL GIANTCELL GRANULOMA

GINGIVAL CYST

MALIGNANT TUMORS

CLINICAL FEATURES1. Common in 5th and 6th decade of life.2. Carcinoma of mandibular gingiva is more

common 3. The fixed gingiva is invaded more than the free

gingiva.4. It usually occurs in premolar area.5. Quickly spreads from gingiva to alveolar bone

CLINICAL FEATURES1. Malignant melanoma is a rare oral tumor that

tends to occur in the hard palate and maxillary gingiva of older persons.

2. It is usually darkly pigmented and is often preceded by localized pigmentation.

3. It may be flat or nodular and is characterized by rapid growth and early metastasis.

4. It arises from melanoblasts in the gingiva, cheek, or palate.

CARCINOMA

MALIGNANT MELANOMA

FALSE ENLARGEMENT

UNDERLYING OSSEOUS LESION

1. Enlargement of the bone subjacent to the gingival area occur most often in tori and exostoses.

2. It can also occur in paget’s disease, fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma, osteoma and osteosarcoma.UNDERLYING DENTAL TISSUES

During various stages of eruption particularly of the primary dentition, the labial gingiva may show a bulbous marginal distortion caused by superimposition of the bulk of the gingiva on the normal prominence of the enamel in the gingival half of the crown.

TREATMENT

• Scaling • Root planning• Oral hygiene instructionsPHASE I

THERAPY

• Gingivoplasty• Gingivectomy• Periodontal flap surgeryPHASE II

THERAPY

TREATMENT PLAN

GINGIVECTOMY

• Pockets are explored & marked with pocket marker

• External bevel incision- 45˚ to tooth surface

• Curette granulation tissue• Surgical pack

Conventional

• Pockets marked with a pocket marker

• Enlarged tissue removed using needle electrode.

Electrosurgery

• Diode laser and Nd:YAG LASERS• They have wavelength of 890 nm

and 1064 nm.Laser

Methods of external bevel gingivectomy

• 5% formaldehyde or potassium hydroxide can be usedChemosurgery

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