gingival enlargement 12.pptx department of periodontics

Gingival enlargement
Department of periodontics

1. GINGIVAL ENLARGEMENT

2. Gingival hyperplasia  is overgrowth of the gingiva (gum tissue) characterized by firm, nonpainful swellings associated with the  gingiva. DEFINITION

3. Synonyms: Gingival hyperplasia Gingival proliferation Gingival enlargement Gingival overgrowth. HYPERPLASIA : Refers to an increase in the size of a tissue or an organ by an increase in the number of its component cells . HYPERTROPHY: Refers to an increase in the size of a tissue or an organ by an increase in the size of its component cells

4. CLASSIFICATION

5. The degree of gingival enlargement can be scored as follows : Grade 0 : No signs of gingival enlargement. Grade I : Enlargement confined to interdental papilla. Grade I I : Enlargement involves papilla & marginal gingiva. Grade III : Enlargement covers more than 3\4 th of the crown .

6. Location & distribution : Localized - Limited to the gingiva adjacent to a signal tooth or group of teeth. Generalized - Involving the gingiva throughout the mouth. Margina l - Confined to the marginal gingiva. Papillary - Confined to the interdental papilla. Diffuse - Involving the marginal, attached gingiva and papillae. Discrete - An isolated sessile or pedenculated , tumor like enlargement.

7. Inflammatory Enlargement

8. Inflammatory enlargement Inflammatory enlargements are usually a secondary complications of other enlargements  Combined enlargement ACUTE CHRONIC

9. Chronic inflammatory enlargements Etiology Prolonged exposure to dental plaque……… Poor oral hygiene Malocclusion Hypofunction Cervical cavities Overhanging margins Irritation from clasps & dentures Orthodontics .. Mouth breathing

10. Clinical features: Originates as a slight ballooning of the interdental papilla and/or the marginal gingiva… Early stages – life preserver-shaped bulge… Progresses slowly.. painless.. acute infection or trauma… Discrete Sessile or Pedunculated mass resembling a tumor… May undergo spontaneous reduction in size, followed by exacerbation & continued enlargement , ulceration

11. Histopathology  Exudative and proliferative features of chronic inflammation Clinically deep red or bluish red are soft and friable with a smooth, shiny surface, Bleed easily… Inflammatory cells & fluid with vascular engorgement , capillary formation , and associated degenerative changes Lesions that are relatively firm, resilient , pink……fibroblasts & collagen fibers

12. Acute inflammatory enlargement Gingival abscess Periodontal abscess It is a localized painful , rapidly expanding lesion that is usually of sudden onset Localized purulent inflammation in the periodontal tissue.

13. Clinical features: Limited to the marginal gingiva or interdental papilla In early stage it appears as a red swelling with a smooth , shiny surface . Within 24 hrs the lesion usually becomes fluctuant and pointed with a surface orifice from which a purulent exudate may be expressed. The adjacent teeth are often sensitive to percussion Gingival abscess

14. Etiology Foreign substance Toothbrush bristle, A piece of apple core, A lobster shell fragment H/P: Purulent focus surrounded by inflammatory cells. Treatment: - Drainage - Warm saline gargles - If residual size too great… remove surgically….

15. Periodontal abscess Main cause of pt to seek treatment …. Acute / Chronic

16. Signs and symptoms Acute abscess - Mild to severe discomfort - Localized red, ovoid swelling - Periodontal pocket - Mobility - Tooth elevation in the socket - Tenderness to percussion or biting - Exudation - Elevated temperature - Regional lymphadenopathy

17. Chronic abscess - No pain or dull pain - Localized inflammatory lesion - Slight tooth elevation - Intermittent exudation - Fistulous tract often associated with deep pocket - Usually without systemic involvement

18. Etiology :- Due to administration of anticonvulsant, Immunosuppressant & Ca channel blockers. 1) Anticonvulsants – Phenytoin, Ethotoin , Mesantoin , Ethosuximide, Methsuxinimide & Valporic Acid . Exact mechanism of gingival enlargement caused by anticonvulsant is unknown . But according to some investigators DRUG INDUCED GINGIVAL ENLARG E MENT

19. 2) Immunosuppressants – Cyclosporine, Tacrolimus Cyclosporin A dosage more than 500 mg\day Gingival Enlargement. Exact mechanism is not known . Cyclosporine induced gingival enlargement is more vascularized. Hence appear reddish. 3) Ca Channel Blockers– Nifedipine . Nifedipine is the one which most often cause gingival enlargement. Nifedipine + Cyclosporine induce larger overgrowth. (combination used in kidney transplant)

20. Gingival Enlargement induced by Cyclosporin A Gingival Enlargement induced by Phenytoin

21. Drugs commonly associated with gingival overgrowth: Category Drugs Anticonvulsants Phenytoin Sodium valproate Phenobarbitone Vigabatrin Immunosuppressant Cyclosporine Calcium channel blockers 1. Dihydropyridines Nifedipine Felodipine 2. Phenylalkylamine Amlodipine Verapamil 3. Benzodiazepine Diltiazem

22. General features of DIGO Starts… painless, beadlike enlargement of the interdental papilla the marginal and papillary enlargements unite and results in massive tissue fold covering most part of the crowns. When uncomplicated by inflammation, the lesion is mulberry shaped , firm, pale pink, and resilient, with a minutely lobulated surface and no tendency to bleed

23. Usually generalized.. severe in anterior regions Genetic predisposition is a suspected… whether a person treated with phenytoin will develop ( Hassell T.M. et al) Enlargement is chronic and slowly increases in size Surgically removed… recurs Spontaneous disappearance occurs… few months after discontinuation of the drug..

24. Histopathology Pronounced hyperplasia of the CT and epi Acanthosis of the epithelium & elongated rete pegs Densely arranged collagen bundles fibroblasts & new blood vessels… Abundance of amorphous ground substance (Mariani et al) The enlargement begins as a hyperplasia of the connective tissue core of the marginal gingiva and increases by its proliferation and expansion beyond the crest of the gingival margin…

25. Painless beadlike enlargement of the interdental papilla Extends to the facial and lingual gingival margins. The lesions are mulberry shaped, firm, pale pink, and resilient, with a minutely lobulated surface and no tendency to bleed. Massive tissue fold covering a considerable portion of the crowns, and they may interfere with occlusion. The marginal and papillary enlargements unite Clinical Features

26. Don't occur on edentulous spaces . No inflammation– i ) lesion is mulberry shaped, firm, pale pink & resilient . ii) no tendency to bleed. Inflammation – i ) red or bluish discoloration of the lesion. ii) increased bleeding tendency. Has the chance of re- occurance after surgery.

27. Histopathology Pronounced hyperplasia of the Connective Tissue and Epithelium Acanthosis of the epithelium, and elongated rete pegs extend deep into the connective tissue Densely arranged collagen bundles with an increase in the number of fibroblasts and new blood vessels. Oxytalan fibers are numerous beneath the epithelium and in areas of inflammation.

28. Kidney transplant-associated gingival enlargement in a 16-year-old girl (Palatal view)

29. DECISION TREE FOR TREATMENT OF DIGO

30. Also designated by such terms as: gingivomatosis , elephantiasis, diffused Fibroma, familial elephantiasis, idiopathic fibromatosis . Etiology :- Exactly not known. Has some hereditary basis but the mechanism is not well understood. Usually begins with the eruption of dentition & regress after extraction . Presence of bacterial plaque is an complicating factor. Clinical Features :- Affects the attached gingiva, gingival margin & interdental papillae . Generally affects the facial & lingual surfaces of maxillary & mandibular teeth. Enlarged gingiva is pink, firm & leathery . Has got pebbled surface.  IDIOPATHIC GINGIVAL ENLARGMENT

31. Idiopathic gingival enlargement

32. These diseases and conditions can affect the periodontium by two different mechanism, as follows: Magnification of an existing inflammation initiated by  dental plaque .   Manifestation of the systemic disease  independently of the inflammatory status of the gingiva. ENLARGEMENT ASSOCIATED WITH SYSTEMIC DISEASES CONDITIONED ENLARGMENT Occur when the systemic condition of the patient distorts the usual gingival response to the dental plaque. Bacterial plaque is necessary for the initiation of this type of enlargement. 3 types– i ) H ormonal (pregnancy, puberty) ii) Nutritional (vitamin C deficiency) iii) Allergy

33. Enlargement in Pregnancy Marginal or generalized Single or multiple tumor like masses Subgingival microbiota may undergo changes, including an ↑se in P.intermedia ( Kornmann K.S. 1980) ↑ed levels of estrogen and progestrone changes in vascular permeability Gingival edema & ↑ed inflammatory response to dental plaque

34. Types of enlargement in pregnancy 2 types – i ) Marginal Enlargement * Result from previous inflammation . * More prominent on interproximal surfaces. * Enlarged gingiva is bright red or magenta in color. * Enlarged gingiva has smooth & shiny surface. * Spontaneous bleeding. ii) Tumorlike Gingival Enlargement * Lesion appear as discrete mushroom like flattened mass. * Has got protruded margins often from interproximal surfaces. * Generally appear dusky red or magenta. * Has smooth & glistening surface .

35. During pregnancy increased level of progesterone & estrogen (in 3 rd trimester it increases to 10 & 30 times more respectively) Vascular permeability Gingival edema Increased inflammatory response to dental plaque Gingival Enlargement

36. Localized gingival enlargement in pregnant patient

37. Puberty gingivitis Occurs in both male and female adolescents Appears in areas of plaque accumulation . As with pregnancy associated gingivitis, puberty associated gingivitis appears to be an exaggerated response of the gingival tissues to plaque mediated by high levels of hormones, perhaps most importantly estrogens and testosterone. (Mariotti 1994)

38. Enlargement in puberty :- Characterized by prominent bulbous interproximal papilla . Study reveals Capnocytophaga sp in the initiation of pubertal gingivitis . According to some investigators hormonal changes coincide with an increase in population of Prevotella intermedia & Prevotella nigrescens . Gingival Enlargement in puberty

39. Scorbutic gingivitis Is essentially a conditioned response to bacterial plaque Acute vitamin C deficiency does not by itself cause gingival inflammation, but it does cause Hemorrhage Collagen degeneration , and Edema of the gingival connective tissue

40. CLINICAL FEATURES The marginal gingiva is bluish red , soft and friable and has a smooth shiny surface . Hemorrhage occurs either spontaneously or on slight provocation. Surface necrosis with psuedomembrane formation.

41. Vitamin C deficiency :- (Scurvy) Vitamin C deficiency Edema of connective tissue Hemorrhage Collagen Degeneration Modify the response of gingiva to the plaque Massive Gingival Enlargement Enlarged gingiva is bluish red, soft, friable & has smooth, shiny surface . Surface necrosis is the common feature. Mainly plaque associated.

42. Gingival Enlargement associated with Scurvy

43. Plasma Cell Gingivitis Plasma Cell Gingivitis is a rare benign inflammatory condition of unknown etiology , clinically characterized by sharply demarcated erythematous and edematous gingiva extending to mucogingival junction . Also called as Atypical Gingivitis and Plasma Cell Gingivostomatitis . Enlarged gingiva appears red, friable and sometimes granular. Bleeds easily. Gingival Enlargement due to Plasma Cell Gingivitis

44. Etiology of plasma cell gingivitis It is allergic in origin & is caused by some ingredients in chewing gums, dentifrices or various diet components More common in women & young adults. Red, friable sometimes granular & bleeds easily . Treatment Cessation of exposure to allergens resolve the lesion.

45. NONSPECIFIC CONDITIONED GINGIVAL ENLARGEMENT (PYOGENIC GRANULOMA ) Lesion varies from a discrete spherical, tumor like mass with a pedunculated attachment to a flattened, keloid like enlargement with a broad base Bright red or purple and either friable or firm Lesion tends to involute spontaneously to become a fibroepithelial papilloma or persists relatively unchanged for years Treatment: Removal of lesion along with the elimination of local irritating factors

46. SYSTEMIC DISEASES CAUSING GINGIVAL ENLARGEMENT LEUKEMIA: Diffuse or marginal Localised or generalized Appear as: Bluish red gingiva with shiny surface. Discrete tumor like masses Consistency is moderately firm , but there is tendency towards friability & hemmorrhage , occuring spontaneously or on slight irritation Acute painful True leukemic enlargement often occurs in acute leukemia

47. Granulomatous disease :- Wegener’s granulomatosis : It is a rare disease characterized by acute granulomatous necrotizing lesions of the respiratory tract, including nasal and oral defects. Granulomatous papillary enlargement is reddish purple . Bleeds easily . Sarcoidosis : It is a granulomatous disease of unknown etiology . Predominantly affects blacks . Painless gingival enlargement. Gingiva appears red and smooth .

48. NEOPLASTIC ENLARGEMENT Benign Tumors of the Gingiva Is a generic term used clinically to designate all discrete tumors and tumor like masses of the gingiva. Most lesions referred to as epulis are inflammatory rather than neoplastic EPULIS

49. Fibroma Arises from the gingival connective tissue or from the periodontal ligament They are slow-growing , spherical tumors that tend to be firm and nodular but may be soft and vascular. Fibromas are usually pedunculated They can grow in all organs, arising from mesenchymal tissue . HISTOPATHOLGY Well formed collagen bundles with scattering of fibrocytes

50. Papilloma Benign proliferations of surface epithelium associated with the human papilloma virus( HPV-6 andHPV-11) Solitary , wart like or 'cauliflower ’ like protuberances are seen which may be small and discrete or broad , hard elevations with minutely irregular surfaces . HISTOPATHOLOGY Consists of fingerlike projections of stratified squamous epithelium, often hyper keratotic , with a central core of fibro-vascular connective tissue.

51. Giant Cell Granuloma : Giant cell lesions of gingiva arise interdentally or from the gingival margin . Most frequently on the labial surface . Smooth, regular outlined masses or irregularly shaped, multilobulated protuberances with surface indentations. Sessile or pedunculated . Lesions are painless . Vary in size and color varies from pink to deep red or purplish blue . Ulceration of margins seen occasionally .

52. Gingival Cyst : These cysts seldom reach a clinically significant size . If do, they appear as localized enlargements involving the marginal and attached gingiva. Occur mostly on the lingual surface of the mandibular canine and premolar areas.   May cause erosion of the surface of alveolar bone . In Adult In Newborn

53. Leukoplakia: Leukoplakia refers to the white erythematous patches in the oral cavity which cannot be characterized as any other definable lesion. It is a precancerous lesion . Associated with the use of tobacco & smoking . Candida albicans , HPV-16, HPV-18 & trauma are other probable factors. Gingiva varies in appearance from grayish white, scaly lesion to a thick, irregular shaped keratinous plaque

54. Malignant tumors of gingiva:- Squamous Cell Carcinoma: Squamous cell carcinoma is one of the most common cancers and usually arises from   ectodermal or endodermal  cells lining body cavities. May be exophytic or ulcerative . Gingival tissues appear dark. Sarcoma: Kaposi’s sarcoma most commonly occurs in the oral cavity of the AIDS patients particularly on the palate & the gingiva . Fibrosarcoma, Lymphosarcoma of the gingiva are rare.

55. Squamous cell carcinoma & Kaposi's sarcoma of gingiva

56. Not true enlargements of gingival tissues. Appear as such as a result of increase in size of underlying osseous and dental tissues. Gingiva present with no abnormal clinical features except the massive increase in size. Occurs most commonly in tori and exostoses , but it can also occur in Paget's disease, fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma, osteoma, and osteosarcoma Gingival tissue can appear normal or may have unrelated inflammatory changes FALSE ENLARG E MENT

57. Underlying Osseous Lesions

58. Underlying Dental tissues UNDERLYING DENTAL TISSUES During the various stages of eruption , particularly of the primary dentition 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 ; this is a developmental enlargement . Physiologic and ordinarily presents no problems .

59. Treatment depends on the underlying causes. Removal of bacterial plaque by i ) thorough tooth brushing & flossing. ii) antiseptic mouthwashes such as chlorhexidine. iii) ultrasonic treatment. iv) antibiotics e.g.- erythromycin . Drugs known to cause gingival enlargement should be discontinued. Surgical removal of overgrown gingival tissue is done in severe cases & may be repeated if necessary. Treatment of Gingival Enlargement

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