Gingival swelling/gingival Enlargement

Cause of gingival swelling /Classification of gingival enlargement

1.       Inflammatory enlargement

·         Chronic

·         Acute

2.       Drug induced enlargement

3.       Enlargement associated with systemic disease

·         Conditioned enlargement

Ø  Pregnancy

Ø  Puberty

Ø  Vitamin c deficiency

Ø  Plasma cell gingivitis

Ø  Non-specific conditioned enlargement

·         Systemic disease causing gingival enlargement

Ø  Leukaemia

Ø  Granulomatosis diseases

4.       Neoplastic Enlargement

·         Benign tumors

·         Malignant tumors

5.       False enlargement

Acute inflammatory enlargement

		Gingival abscess	Periodontal abscess		Periapical abscess	Pericoranal abscess
Location		Localised swelling affecting the marginal & interdental gingiva	Usually effects deeper periodontal structures including deep pockets,furcations & vertical osseous defects & located beyond the mucogingival junction		Usually seen near the root apex	Seen in Incompletely erupted teeth
Etiology		Impaction of foreign objects in previously healthy sites.	Periodontal pocket related to destruction by periodontitis.		Due to dental caries involving the pulp	Plaque induced inflammation of the pericoronal flap
Associated clinical findings		Gingiva appear to be red,swollen & extremely painful & sometimes impacted foreign object may still be embedded in to the gingiva	Associated with periodontal pocket,tooth elevation, mobility, tender on lateral percussion		Tooth is tender on percussion	Gingiva apeears red, erythematous,swollen & extremely painful, food impaction
Radiographic features		No bone loss is evident	Bone loss is seen. Radiolucency along the lateral border of the root		No bone loss.periapical radiolucency	Impacted tooth
Treatment	Incision & drainage followed by saline mouthwash every 2 hrs.		Drainage through pocket, scaling & curratage, systemic antibiotics	RCT, extraction		Incision & drainage.

Gingival swelling/gingival enlargement(gingival abscess)

Chronic inflammatory gingival enlargement

Chronic gingival enlargement/Gingival swelling

Etiology

• Prolonged exposure of dental plaque due to poor oral hygiene.
• Food impaction
• Habit such as mouth breathing

Treatment

• Scaling & curettage
• Surgical removal-gingivectomy, flap operation

Gingival enlargement due to drugs/Gingival swelling

Many drugs may cause gingival enlargement or gingival swelling.

Drug-induced gingival enlargement/gingival swelling

Anticonvulsant drug like dilantin sodium, phenytoin.,Cyclosporine(Immunosupressive agent used to prevent organ transplantation rejections & to treat several diseses of autoimmune origin.)Nifidipine(calcium channel blocker used in hypertention)

Clinical features

• The gingival enlargement usually becomes apparent in the first three months after anticonvulsant drugs and is most rapid in the first year.
• The gingival enlargement is generalised throughout the mouth, but it is most severe in maxillary & mandibular anterior region.It starts as a painless,bead like enlargement  of gingival margins & interdental papillae.
• As the condition progresses, the marginal & papillary enlargement unite & develop into a missive tissue fold covering a considerable portion of the crown & may interfere with the occlusion.
• The surface of gingival shows an increase in stippling & finally acauliflower, warty or pebbled surface.
• As the gingival enlargement increases, the gingival tissue becomes lobulated & clefts are seen between each enlarged gingival.
• It does not occur in edentulous spaces.
• It may be present in mouths with little or no plaque and assent in mouths with abundant deposits.
• The presence of the gingival enlargement makes plaque control difficult, resulting in secondary inflammatory process that complicates the gingival swelling.

Treatment of gingival enlargement

First step:-

1. Oral hygiene reinforcement, chlorhexidine gluconate rinses, scaling & root planning.
2. Possible drug substitution-When it is attempted it is necessary to allow at least a period of 6-12 months between the discontinuation of the offending drug & the possible resolution of gingival enlargement.

Second step:-

• If the enlargement persists even after above treatment, surgical therapy is indicated.-for small areas of gingival enlargement-gingivectomy, with larger areas flap surgery may be indicated.

Gingival enlargements associated with systemic diseases
Conditioned enlargement

	Etiology	Clinical feature	Treatment
Pregnancy(marginal gingival enlargement)	Altered tissue metabolism (increased in estrogen & progesterone.) Pregnancy accentuates the response to local irritation	Gingival enlargement is more prominent interproximally Colour-Gingiva is bright red in colour, soft & friable & has a smooth shiny surface Bleeding occurs spontaneously or on slight provocation.	Meticulous plaque control, scaling & root planning. Second trimester is safe for treatment.
Pregnancy tumour	It usually occur in first trimester but can occur early also	Discrete, mushroom like spherical mass, that protrudes from the gingival margins or more frequently from the interproximal space & are attached by sessile or pedunculated base. It is usually painless, unless its size and shape foster the accumulation of debris under its margin or interfere with occlusion, in which cases painful ulcerations may occur.	Surgical excision is required which is possible should be postponed until postpartum. During pregnancy the lesion should be removed surgically only when it interferes with mastication & causes severe disfigurement & if the patient willingly wants to get it removed.
Gingival enlargement in puberty	Altered endocrine disturbance with local factor. More common in 11-17 years of age.	Occurs in both the sex. Many involve marginal gingiva & interdental gingiva. It is characterized by prominent bulbous interproximal papillae. Sometimes only facial gingiva is enlarged as the mechanical action of the tongue prevents heavy accumulation of local irritants on the lingual surface. After puberty, the enlargement undergoes spontaneous reduction, but does not disappear until local irritants are removed.	Scaling, curettage and oral hygiene instructions. Surgical removal may be performed in severe cases.
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. Located on oral aspect of attached gingiva.	Cessation of exposure to allergens resolve the lesion.
Vitamin C deficiency	Deficiency of vitamin C	Marginal gingiva is involved. Gingiva is bluish red, soft, friable has smooth, shiny surface. Tissue is spongy,hyperemic & bleeds spontaneously	Supplements of vitamin C
Granuloma pyogenicum	Trauma	Localised, discrete spherical tumor like mass with pedenculated attachment to a flattened keloid like enlargement having broad base. Bright red or purple & can be friable or firm. Surface exudation & purulent exudation.	Removal of lesion along with the elimination of local irritating factors.

gingival enlargement

gingival enlargement

Gingival enlargement

Systemic disease causing gingival enlargement

Leukemia

• The gingival enlargement may be diffuse or marginal, localised or generalised.It may appear as an oversized extension of the marginal gingiva or a discrete tumor like interproximal mass.
• The gingiva appears as a bluish-red with a shiny surface.
• The consistency is moderately firm but there is a tendency towards friability & hemorrhage occuring either spontaneously or on slight provocation.
• True leukemic enlargement occurs commonly in acute leukemia but may also be seen in sub-acute leukemia.It seldom occurs in chronic leukemia.
• Treatment-After the acute symptoms subside,attention is directed to correct the gingival enlargement.The local deposits are removed to control inflammatory components of the enlargedment.
• Enlargement is treated by scaling & curettage which is carried out in stages under topical anesthesia.
• Antibiotics are administered systemically the evening before & for 24 hours after each treatment to reduce the risk of infection.

Granulomatous disease

	Wegener’s Granulamatosis (multisystem granuloma)	Sarcoidosis
Etiology	Immunologically-mediated tissue injury	Unknown, but may be impaired cell-mediated immunity
Location & Distribution	Papillary enlargement	Non-specific
Clinical features	Shows oral mucosal ulceration, reddish purple gingival enlargement, bleeds on stimulation, abnormal tooth mobility, exfoliation of teeth & delayed healing response.	Red, smooth enlargement

Neoplastic gingival enlargement

Benign tumors of the gingiva

	Etiology	Location & distribution	Clinical features
Fibroma	Reaction to trauma or chromic irritation	Localised,diffuse & discrete	Slowly growing spherical mass that tends to be firm & nodular, but may be soft & vascular. Usually pedunculated
papilloma	Mostly due to papilloma virus some unknown	Localised,diffuse & discrete	Hard,wart like protuberance from gingival surface.
Peripheral giant cell granuloma	Local injury	Interdental or form gingival margin.frequently on labial surface.	Smooth regularly outlined mass to irregular in shape, multilobulated.painless.Firm or spongy & color varies from pink to deep red or purpalish.Ulcerations are seen
Central giant cell granuloma	History of injury	Mandible is most commonly involved. More common in anterior segment & does not uncommonly cross midline.	Arises with in the jaw and produces cavitaton.No pain.Slight to moderate bulging of jaw due to expansion of cortical plate.
Leukoplakia	Tobacco, chronic irritation,alcohol,syphilis,vitamin deficiency,hormones,candidiasis	Buccal mucosa,commissures,alveolar mucosa,tongue,lpis,hard & soft palate,floor of mouth & gingiva	Varies from grayish-white, flattened scaly lesion to athick irregularly shaped keratinous plaque.
Gingival cyst	Remnants of dental lamina, enamel organ, epithelial islands of periodontal membrane, traumatic implantation of epithelium.	Mandibular bicuspids,cuspid Incisor area	Painless & cause erosin of bone with expansion

Malignant tumors of gingiva

• Carcinoma
• Malignant melanoma

False enlargement of gingiva/Gingival swelling

These are not true enlargements of gingival tissues but may appear as a resulat of increase in size of the underlying osseous or dental tissues.