Gingival Enlargement: Causes, Classification, and Management

Gingival Enlargement

Increase in size of gingiva is known as gingival enlargement. It is a result of interaction between host and variety of other factors.

Classification of Gingival Enlargement

According to etiologic factors and pathologic changes, gingival enlargements are:

• inflammatory enlargement
  • Chronic
  • Acute.
• Drug-induced enlargement
• Enlargement associated with systemic disease
  • Conditional enlargement:
    • Pregnancy
    • Puberty
    • Vitamin C deficiency
    • Plasma cell gingivitis
    • Non-specific conditional enlargement.
  • Systemic diseases causing gingival enlargement
    • Leukemia
    • Granulomatous disease.
• Neoplastic enlargement
  • Benign tumors
  • Malignant tumors
• False enlargement

According to Location and Distribution Gingival Enlargement is Classified as:

• Localized: Gingival enlargement limited to one or more teeth.
• Generalized: Entire mouth, gingiva is enlarged.
• Marginal: limited to marginal gingiva.
• Papillary: Confined to interdental papilla.
• Diffuse: Involves all parts of gingiva that is marginal, attached and interdental.
• Discrete: Isolated sessile or pedunculated tumor like enlargement.

According to Degree of Gingival Enlargement

• Grade 0: No sign of gingival enlargement.
• Grade 1: Enlargement confirmed to interdental papilla
• Grade 2: Enlargement involves papilla and marginal gingiva.
• Grade 3: Enlargement covers three quarters or more of the crown.

Drug-induced Enlargement

• Drug-induced enlargement is associated with three types of drugs, i.e. anticonvulsant, calcium-channel blocker and immunosuppressant.
• These drugs inhibit intracellular calcium ion influx, so the action of these drugs on sodium and calcium influx may be the reason for these dissimilar drugs to have a common side effect upon a secondary target tissue-like gingiva in susceptible individuals.
• In anticonvulsants phenytoin is the most common drug which leads to gingival enlargement. Other drugs which causes gingival enlargement are ethosuximide and sodium valproate.
• In immunosuppressants, cyclosporine is the most common drug which leads to gingival enlargement. When the drug should be given more than 500 mg/day, it causes gingival enlargement. Other drug is tacrolimus.
• In calcium-channel blockers, nifedipine is the most common drug which leads to gingival enlargement. Diltiazem and verapamil also causes gingival enlargement.
• Other drugs which lead to gingival enlargement are contraceptives. Besides these erythromycin can also cause gingival overgrowth.

Gingival Enlargement Clinical Features

• The enlargement starts as a painless, bead-like enlargement of facial and lingual gingival margins and interdental papillae.
• As condition progresses, the marginal and papillary enlargement unite and develop into a massive tissue fold covering considerable portion of crown and may interfere with occlusion.
• When uncomplicated by inflammation, the lesion is mulberry shape, firm, pale pink and resilient with a minutely lobulated surface with no tendency to bleed.
• Hyperplasia is generalized throughout the mouth but is more severe in maxillary and mandibular anterior region.
• Presence of enlargement will result in secondary inflammatory process that complicates gingival hyperplasia caused by drug.
• Secondary inflammatory changes produce red or bluish red discoloration and results in increased tendency towards bleeding.

Gingival Enlargement Treatment

Gingival Enlargement Histopathology

Several changes are seen in epithelium and connective tissue, i.e.

• The epithelium shows verifying degree of acanthoses, with elongated thin rete pegs that divide at their ends.
• This gives rise to increase incidence of epithelial pearls.
• The degree of determination will determine the presence and extent of PMN neutrophils in gingival epithelium.
• The main change in lamina propria is proliferation of fibroblasts and increase in collagen production.

Etiopathogenesis of Gingival Enlargement

All the three drugs have different biologic behavior but achieve their functions through similar molecular mechanism, i.e. manipulation of calcium gradient. So, various theories are given regarding drug-induced gingival overgrowth:

• Role of fibroblast: It was proposed that hetrogenous population of gingival fibroblasts known as responder fibroblast are chosen or affected by these drugs which create conditions which are favorable for their growth.
• Decrease in the synthesis of matrix metalloproteinases leads to diminished tissue resorption which indirectly leads to tissue overgrowth.
• Role of growth factors: Rise in the levels of platelet-derived growth factor, transforming growth factor, epidermal growth factor and connective tissue growth factor in response to these drugs help in increasing the bulk tissue.
• Genetic predisposition is also a suspected factor.

Gingival Enlargement Causes

Gingival Enlargement Differential Diagnosis

• Anticonvulsants: Dilantin-induced gingival hyperplasia of alveolar mucosa appear in young dentate patients. Onset of the condition is such that there is gradual enlargement of one or more interdental papillae. Clinically, the involved mucosa is firm with normal color and is prominent. Gingiva is coarse and shows stippling.
• Immunosuppressant: Cyclosporine-induced gingival enlargement is more vascularized and inflamed as compared to dilantin or nifedipine-induced gingival hyperplasia.
• Calcium channel blockers: Gingival overgrowth is seen in older patients.

Gingival Enlargement Management

Three different types of drug are associated with gingival enlargement that is anticonvulsants, calcium-channel blockers and immunosuppressant.

Gingival Enlargement First Step

• Oral hygiene reinforcement, chlorhexidine gluconate rinses, scaling and root planning.
• Possible drug substitution: When it is attempted it is necessary to allow at least a period of 6 to 12 months between discontinuation of offending drug and possible resolution of gingival enlargement.
• Professional recalls.
• Azithromycin decreases the severity of cyclosporine induced gingival enlargement.
• Folic acid supplementation significantly decreases the incidence of gingival overgrowth.
• Periodic recall visits.

Gingival Enlargement Classification

Gingival Enlargement Second Step

• If enlargement persists after following the above steps: Surgical therapy is indicated. There are two surgical options available based on feature it presents.
• Small areas of enlargement with no attachment loss or bone loss and has good keratinized tissue, gingivectomy is treatment of choice.
• Large areas of enlargement with presence of osseous defects and limited keratinized, gingival, periodontal flop surgery are indicated.