Gingival Enlargement Question And Answers

Gingival Enlargement

Question 1. Describe the etiology of chronic inflammatory gingival enlargement. Write management of drug induced gingival hyperplasia.
Answer.

Etiology of Chronic inflammatory Enlargement

• Prolonged exposure to dental plaque.
• Factors which favors the plaque accumulation i.e. poor oral hygiene.
• Irritation due to anatomic abnormalities.
• Due to improper restorative and orthodontic appliances.
• Gingival changes which are associated with mouth breathing such as gingivitis and gingival enlargement.
• Maxillary anterior region is the common site due to irritation from surface dehydration.

Management of Drug-induced Gingival Hyperplasia

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

Read And Learn More: Periodontics Question And Answers

Gingival Enlargement Treatment  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 Treatment  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.

Question 2. Classify the gingival enlargement. Write in detail about drug-induced enlargement.
Or
Write the classification of gingival enlargement. Discuss in detail about drug-induced gingival enlargement.
Or
Classify gingival enlargements. Describe the clinical features of drug-induced gingival enlargements.
Or
Classify gingival enlargements. Discuss induced gingival enlargements (overgrowths) in detail
Or
Write long answer on classification of gingival overgrowth.
Or
Explain drug induced gingival overgrowth and its management.
Or
Define and classify gingival enlargement. Write in detail clinical and histological features and also the treatment of drug-induced gingival enlargement.
Answer. 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.

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

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.

Question 3. Write notes on dilantin sodium gingival enlargement.
Answer. It is also known as phenytoin-induced gingival enlargement.

Dilantin is an anticonvulsant drug which is widely used in the control of epilepsy and various other convulsive disorders.

Gingival Enlargement Clinical Features

• Overgrowth of gingiva becomes apparent in first three months as dilantin dosage is rapid in first year
• 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.
• Enlargement appears to project beneath the gingival margin from which it is separated by linear groove.
• The hyperplasia is generalized throughout the mouth but is more severe in maxillary and mandibular anterior region.
• The 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 Pathogenesis

It is suggested that there are different subpopulation of fibroblasts in gingival tissue some of which synthesize large amount of high activity fibroblasts and others, which are only capable of low activity fibroblasts. So, Hassell suggested that high activity fibroblasts are sensitive to dilantin which causes increase in collagen production.

Gingival Enlargement Management

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.

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.

Question 4. What is gingival enlargement? Classify it and write in detail about conditioned gingival enlargement.
Or
Classify gingival enlargement and describe in detail about conditioned gingival enlargement.
Answer. Increase in the size of gingiva is known as gingival enlargement. It is a result of interaction between host and the variety of other factors.

Conditioned Gingival Enlargement

• Conditioned gingival enlargement occurs when systemic condition of patient exaggerates or distorts the usual gingival response to dental plaque.
• Bacterial plaque is necessary for the initiation of this type of enlargement.
• The three types of conditioned gingival enlargement are:
  • Hormonal (Pregnancy, puberty).
  • Nutritional (Vitamin C deficiency).
  • Allergic.

Conditioned Gingival Enlargement Types

Hormonal Enlargement in Pregnancy or Pregnancy Tumor

Gingival Enlargement Classification

 

• Marginal enlargement
  • It results from aggravation of previous inflammation and does not occur without clinical evidence of local irritation.
  • Pregnancy does not cause this condition, the altered tissue metabolism in pregnancy accentuates the response to local irritation.
  • Clinical features:
    • Enlargement is generalized and tends to be more prominent interproximally than on facial and lingual surface.
    • Enlarged gingiva is bright red or magenta, soft and friable having smooth, shiny surface.
    • Bleeding occurs spontaneously.
• Tumor-like enlargement or pregnancy tumor
  • It is not a neoplasm but an inflammatory response to local irritation and is modified by patient condition. It appears after first trimester but may be early also.

Enlargement in Pregnancy or Pregnancy Tumor Clinical features:

• The lesion appears as discrete, mushroom-like flattened spherical mass that protrude from interdental papilla or gingival margin and is attached by pedunculated base.
• Pregnancy tumor tends to expand laterally and pressure applied from tongue as well as cheek enhances the flattned appearance of pregnancy tumour.
• The color is dusky red or magenta with smooth glistering surface which exhibits numerous deep red, pinpoint markings.
• Consistency is semifirm, but has varying degrees of softness and friability.
• It is painless.

Enlargement in Pregnancy or Pregnancy Tumor Management:

• The aim of periodontal therapy for pregnant patient is to minimize potential exaggerated inflammatory response related to hormonal alteration.
• Meticulous plaque control, scaling and root planning, polishing should be nonemergent periodontal procedures performed.
• Second trimester is the safest time in which treatment is performed.
• In conditions, like ‘supine hypertensive syndrome’ which occur during third trimester, in this appointment should be short and patient should change her position frequently.
• Fully reclining position should be avoided as far as possible.
• Medication and radiographs are avoided.
• In case of marginal and inter dental enlargement scaling and curettge is done.
• In case of tumor-like enlargement, surgical excision is done which is postponed until postpartum. During pregnancy, if it causes problem in mastication, it is removed on patients desire.

Enlargement in puberty

Enlargement in puberty Clinical features

• Enlargement is seen in marginal and interdental papilla and is characterized by prominent bulbous interproximal papilla.
• Frequently only the facial gingiva is affected, because mechanical action of tongue prevents accumulation of food on lingual surfaces.
• 11 to 7 years show high prevalence of gingiva enlargement.

Enlargement in puberty Management

• Scaling, curettage and oral hygiene instructions.
• Surgical removal in severe cases.

Nutritional, i.e. Vitamin C deficiency Enlargement

Acute vitamin C deficiency does not itself cause gingival inflammation but it causes hemorrhage, collagen degeneration and edema of gingival connective tissue. These changes modify response of gingiva to plaque.

Deficiency Enlargement Clinical features

• Gingival enlargement is marginal, bluish red, soft friable and have smooth, shiny surface.
• Hemorrhage occurring either spontaneously or on provocation.
• The surface necrosis with pseudomembrane formation are common features.

Allergic, i.e. Plasma Cell Gingivitis

It is thought to be allergic in origin, possibly related to the components of chewing gum, dentifrices or various diet components.

Plasma Cell Gingivitis Clinical features

• It consist of mild marginal gingival enlargement that extends to the attached gingiva.
• Gingiva appears red, friable and bleeds easily. An associated cheilitis and glossitis is seen.

Plasma Cell Gingivitis Management

• Scaling, curettge and oral hygiene functions
• Surgical removal in severe cases.

Question 5. Write short note on pregnancy tumor.
Or
Write short note on conditioned gingival enlargement.
Answer. Pregnancy tumor is not a neoplasm but an inflammatory response to local irritation and is modified by patient condition. It appears after first trimester but may be early also.

Pregnancy Tumor Clinical Features

• The lesion appears as discrete, mushroom-like flattened spherical mass that protrude from interdental papilla or gingival margin and is attached by pedunculated base.
• Pregnancy tumor tends to expand laterally and pressure applied from tongue as well as cheek enhances the flattned appearance of pregnancy tumor.
• The color is dusky red or magenta with smooth-glistering surface which exhibits numerous deep red, pinpoint markings.
• Consistency is semifirm, but has varying degrees of softess and friability.
• It is painless.

Pregnancy Tumor Etiopathogenesis

• Due to increased levels of progesterone and estrogen.
• Hormonal changes include changes in vascular permeability which leads to gingival edema and an increased inflammatory response to dental plaque.
• Subgingival microbiota undergoes changes which includes increase in Prevotella intermedia.

Pregnancy Tumor Histopathology

• Both marginal and tumor-like enlargement consists of central mass of connective tissue, periphery of which is outlined by stratified squamous epithelium.
• Connective tissue consists of numerous engorged capillaries and between the capillary network, there is presence of firous stroma with varying degrees of edema and leukocytic infitration.
• Epithelium thickening is present with varying degrees of extra- and intracellular edema. Epithelium also shows prominent rete pegs.

Pregnancy Tumor Management

The aim of periodontal therapy for pregnant patient is to minimize potential exaggerated inflammatory response related to hormonal alteration.

• Meticulous plaque control, scaling and root planning, polishing should be nonemergent periodontal procedures performed.
• Second trimester is the safest time in which treatment is performed.
• In conditions like ‘supine hypertensive syndrome’ which occur during third trimester, in this appointment should be short and patient should change her position frequently.
• Fully reclining position should be avoided as far as possible.
• Medication and radiographs are avoided.
• In case of marginal and inter-dental enlargement scaling and curettge is done.
• In case of tumor-like enlargement, surgical excision is done which is postponed until postpartum. During pregnancy, if it causes problem in mastication, it is removed on patient’s desire.’

Gingival Enlargement Causes

Question 6. Write short note on vitamin C.
Or
Write short note on vitamin C Deficiency.
Answer. Vitamin C is also known as ascorbic acid.

• Deficiency of vitamin C leads to scurvy which is mainly characterized by hemorrhagic diathesis and delayed wound healing.
• Scurvy results in defective formation and maintenance of collagen, impairment and cessation of osteoid formation and impaired osteoblastic function.

vitamin C Deficiency Clinical Manifestations

• Hemorrhagic lesions in muscle of extremities, joints and sometime nail beds too
• Petechial hemorrhages around hair follicles
• Increased susceptibility to infection
• Impaired wound healing.
• Presence of bleeding and swollen gingiva with loose teeth.

Histopathological Features

• Defective formation and maintenance of collagen.
• Retardation or cessation of osteoid formation and impaired osteoblastic function.
• Increased capillary permeability.
• Susceptibility to traumatic hemorrhage.
• Hyporeactivity of contractile elements of the peripheral blood vessels.
• Sluggishness of blood flow.

Etiologic Relationships between Vitamin C and Periodontal Disease

• Low levels of ascorbic acid inflence the metabolism of collagen within the periodontium, thereby affecting the ability of the tissue to regenerate and repair by itself.
• It interferes with bone formation leading to the loss of the alveolar bone.
• Increases the permeability of oral mucosa to tritiated endotoxin and inulin.
• Increased levels of ascorbic acid enhances both the chemotactic and migratory action of leukocytes without influencing phagocytic activity.
• Depletion of vitamin C may interfere with the ecologic equilibrium of bacteria in plaque and increases its pathogenicity.

Periodontal Features of Scurvy

• The oral symptoms are that of chronic gingivitis which can involve the free gingiva, attached gingiva and alveolar mucosa.
• In severe cases, the gingiva becomes brilliant-red, tender and grossly swollen. The spongy tissues are extremely hyperemic and bleed spontaneously.
• In long-standing cases, the tissues attain a dark blue or purple hue.
• Alveolar bone resorption with increased tooth mobility has also been reported.

Gingival Enlargement Causes

Question 7. Write short note on vitamin C gingivitis.
Answer. Vitamin C gingivitis occurs due to the deficiency of vitamin C which is also known as scorbutic gingivitis.

• Deficiency of vitamin C modify response of gingiva to plaque to an extent that the persisting inflammation become exaggerated.
• In this, the interdental and marginal gingiva becomes bright red, swollen, smooth and shiny surface.
• In this, hemorrhage either occurs spontaneously or on slight provocation.
• In fully developed scurvy gingiva become boggy, ulcerated and bleeds easily.