"GINGIVAL-ENLARGEMENT"
- 1. GOOD MORNING
- 4. DEFINITION Increase in size of gingiva or gingival overgrowth. Carranza11th edition.
- 5. GINGIVAL ENLARGEMENT CAN BE CLASSIFIED ACCORDING TO ETIOLOGIC FACTORS AND PATHOLOGIC CHANGES AS FOLLOWS I. Inflammatory enlargement A.Chronic B.Acute II.Drug- induced enlargement. III.Enlargement associated with systemic diseases or conditions A.Conditioned enlargement. 1.Pregnancy 2.Puberty 3.Vitamin C deficiency 4.Plasma cell gingivitis. 5.Nonspecific conditioned enlargement(pyogenic granuloma) B.Systemic diseases causing gingival enlargement 1.Leukemia. 2.Granulomatous diseases(e.g.,Wegener’s granulomatosis,sarcoidosis) IV. Neoplastic enlargement(gingival tumors) A.Benign tumors B.Malignant tumors V. False enlargement.
- 6. ON THE BASIS OF LOCATION AND DISTRIBUTION LOCALIZED GENERALISED MARGINAL
- 8. 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 II-Enlargement involves papilla and marginal gingiva. Grade III-Enlargement covers three quarters or more of the crown.
- 9. CHRONIC INFLAMMATORY ENLARGEMENT CLINICAL FEATURES Site - interdental papilla and marginal gingiva. Shape -Life preserver shaped bulge can increase in size until it covers part of crowns. May be localized or generalized. Progresses slowly and painlessly. Painful ulceration sometimes.
- 11. HISTOPATHOLOGY • Exudative and proliferative features. • Lesions that are clinically deep red or bluish redsoft and friable,bleed easily due to vascular engorgement. • Lesions that are relatively firm,resilient and pink hue have a greater fibrotic component with an abundance of fibroblasts and collagen fibres.
- 12. TREATMENT Scaling and Curettage. Surgical removal Gingivectomy and Flap operation. Enlargment with significant fibrotic component If the size of enlargemrnt interferes to root surface deposits
- 13. ETIOLOGY • Prolonged exposure to dental plaque • poor oral hygiene • irritation by anatomic abnormalities • improper restorative & orthodontic appliances. • Mouth breathing habit .
- 14. ACUTE INFLAMMATORY ENLARGEMENT GINGIVAL ABSCESS ETIOLOGY Bacteria carried deep into the tissues when a foreign substance like toothbrush bristles, piece of apple core etc.is forcefully embedded into gingiva CLINICAL FEATURES: • site - marginal gingiva or interdental papilla • localized, painful, rapidly expanding. • Within 24 to 48 hrs lesion becomes fluctuant & pointed with a surface orifice from which a purulent exudate may be expressed.
- 15. GINGIVAL ABSCESS
- 16. HISTOPATHOLOGY Surfaceepithelium • Varying degree of intra and extracellular oedema. • Leukocytic invasion & ulceration Connective tissue • purulent focus surrounded by PMNs. • edematous tissue • vascular engorgement. PERIODONTAL ABSCESS • involves the supporting periodontal tissues.
- 17. TREATMENT Cause of the abscess should be removed. Drainage can be established . If lesion persists it can be curetted under L.A. or incised. If persistent and severe systemic antibiotic may be prescribed. Any residual pockets subgingival curettage or localized gingivectomy.
- 18. DRUG INDUCED GINGIVAL ENLARGEMENT Anticonvulsants Immunosuppressants Calcium channel blockers • affects the speech, mastication, tooth eruption, and aesthetics problems. General clinical features: • site - interdental papilla, facial and lingual gingival margins
- 19. • Starts as a painless beadlike enlargement of the interdental papilla • mulberry shaped , firm , pale pink, resilient • no tendency to bleed • appears to project from beneath the gingival margin separated by a linear groove . • Plaque control becomes difficult resulting in secondary inflammation. produce • red, bluish discoloration, obliterate lobulated surface demarcations and increase bleeding tendency. • Regress spontaneously within few months after discontinuation of the drug.
- 20. HISTOPATHOLOGY • Epithelium - acanthosis, elongated rete pegs . • Connective Tissue - densely arranged collagen bundles, fibroblasts, neovascularisation • abundance of amorphous ground substance . • CYCLOSPORINE- Highly vascularised & foci of chronic inflammatory cells. • PHENYTOIN - fibroblast to collagen ratio normal, oxytalan fibers are numerous .
- 21. ANTICONVULSANTS • First gingival enlargement reported . • Introduced by Merritt and Putnam in 1938. • Drugs used for the treatment of epilepsy. • Phenytoin, ethotoin, mephenytoin, succinimides etc. • 50% of the patients • younger patients more prone . • appears in saliva • systemic administration accelerates the healing of gingival wounds in non- epileptic humans.
- 22. • MECHANISM(PHENYTOIN ) Fibroblasts from a phenytoin induced gingival overgrowth show increased synthesis of sulfated glycosaminoglycans in vitro Phenytoin may induce a decrease in collagen-degradation as a result of the production of an inactive fibroblastic collagenase.
- 24. IMMUNOSUPPRESSANTS • CYCLOSPORINES used to prevent organ transplant rejection & to treat autoimmune origin diseases. • if dosage > 500mg/day reported to induce gingival enlargement. • 30% patient. • More vascularised . • associated with nephrotoxicity, hypersensitivity, hypertension, hyperthricosis.
- 26. CALCIUM CHANNEL BLOCKERS (nifedipine,diltiazem, felodipine, nitrendipine and verapamil) • used for CVS disorders, hypertension , angina pectoris, coronary artery spasm & cardiac arrhythmia. • Nifedipine induces enlargement in 20% cases • Nifedipine + cyclosporines (for kidney transplant) • larger overgrowth • dose dependent growth
- 29. IDIOPATHIC GINGIVAL ENLARGEMENT • termed as gingivostomatitis, elephantiasis, idiopathicfibromatosis, hereditary gingival hyperplasia & congenital familial fibromatosis. ETIOLOGY : • unknown • hereditary basis (autosomal dominant or recessive) • begins with primary & secondary dentition eruption.
- 30. CLINICAL FEATURES: • Site - attached gingiva, gingival margin, and interdental papilla • pink,firm and leathery with pebbled surface. • Teeth are completely covered. • Severe cases jaw appears distorted due to bulbous enlargement • secondary inflammation
- 31. HISTOPATHOLOGY: • Epithelium -thickened & acanthotic with elongated rete pegs. • Connective Tissue- relatively avascular, densely arranged collagen bundles & numerous fibroblasts
- 32. ENLARGEMENT ASSOCIATED WITH SYSTEMIC DISEASES • Many systemic diseases oral manifestations two different mechanisms 1. Magnification of existing inflammation initiated by dental plaque.. “Conditioned enlargement” 2. Manifestation of the systemic disease independent of the inflammatory status of the gingiva.This group is described as “ Systemic diseases causing gingival enlargement”.
- 33. CONDITIONED ENLARGEMENT • systematic condition of the patient exaggerates the usual gingival response to dental plaque. • bacterial plaque is necessary for its initiation. a). Hormonal conditions (pregnancy & puberty) b). Nutritional (vitamin C deficiency) c). Non- specific conditioned enlargement
- 34. ENLARGEMENT IN PREGNANCY marginal and generalized or single or multiple tumor like masses. ETIOLOGY - increase in progesterone and estrogen till 3rd trimester. increased vascular permeability and gingival edema. 1.MARGINAL ENLARGEMENT results from aggravation of previous inflammation.
- 35. 2.TUMOR LIKE GINGIVAL ENLARGEMENT (pregnancy tumor) • inflammatory response to bacterial plaque CLINICAL FEATURES • lesions are discrete, mushroom like, flattened spherical masses • sessile, pedunculated base • exhibits deep red pin point markings. • Painful ulcerations may occur.
- 36. HISTOPATHOLOGY (angiogranuloma) • central mass of connective tissue. • neovascularisation lined by cuboidal endothelial cells. • varying degree of edema & chronic inflammatory infiltrate • epithelium thickened, prominent retepegs.
- 37. TREATMENT minimize the potential exaggerated inflammatory response related to hormonal alteration. Plaque control,scaling and root planing should be non emergent procedures performed. Long stressful appointment and periodontal surgical procedures should be postponed until postpartum. No medications and radiographs Marginal and interdentalScaling and curettage. Tumor like enlargementSurgical excisionif possible postpone.
- 38. ENLARGEMENT IN PUBERTY CLINICAL FEATURES : • -marginal & interdental (often facial gingiva) • - associated with chronic gingival disease. • -reduces after puberty. • -Capnocytophaga sp.. & P. intermedia
- 39. HISTOPATHOLOGY • chronic inflammation with edema. TREATMENT • Scaling,curretage and oral hygiene instructions. • Surgical removal may be performed in severe cases.
- 40. ENLARGEMENT IN VITAMIN C DEFICIENCY CLINICAL FEATURES : • Marginal gingivitis • hemorrhage on slight provocation and surface necrosis with pseudomembrane formation.
- 41. HISTOPATHOLOGY(VIT-C) • chronic inflammatory cellular infiltrate with superficial acute response • scattered areas of hemorrhage • diffuse edema, collagen degeneration & scarcity of collagen.
- 42. PLASMA CELL GINGIVITIS (atypical gingivitis,plasma cell gingivostomatitis ) • site- marginal and attached gingiva . CLINICAL FEATURES : • red, friable, bleeds easily • site-oral aspect of attached gingiva
- 43. HISTOPATHOLOGY(Plasma Cell Gingivitis) • Epithelium- spongiosis and infiltrated with chronic inflammatory cells. • lower spinous layer and basal layer damaged • plasma cells infiltrate
- 44. NON SPECIFIC CONDITIONED ENLARGEMENT (pyogenic granuloma) • Tumor like gingival enlargement. • conditioned response to minor trauma. CLINICAL FEATURES: • discrete spherical tumor like mass • red friable with ulceration,purulent exudation. • Involute to become fibroepithelial papilloma.
- 45. HISTOPATHOLOGY • chronic inflammation with granulation tissue • vascular spaces & epithelial atrophy TREATMENT removal of lesion and local irritating factors .
- 46. SYSTEMIC DISEASES CAUSING GINGIVAL ENLARGEMENT LEUKEMIA CLINICAL FEATURES : • diffuse or marginal • localized or generalized tumor like mass in interproximal spaces • red, friable, firm and hemorrhagic • painful necrotising • ulcerative inflammation
- 47. HISTOPATHOLOGY • Epithelium - varying degree of leukocytic infiltration & edema • Psuedomembranous meshwork of fibrins, necrotic epithelial cells, PMNS & bacteria. • Connective Tissue - infiltrated with a dense mass of immature & proliferating leukocytes • engorged capillaries.
- 48. TREATMENT In leukemic patients (in general) Refer the patient to physician. Prior to chemotherapy, a complete periodontal treatment plan should be prepared. Treatment plan Monitor hematological lab values daily Administer antibiotics prior to any periodontal therapy Extract non-maintainable or potentially infectious teeth,atleast 10 days prior to initiation of chemotherapy. Thorough periodontal debridement is done and oral hygiene instructions are given
- 49. During acute phases of leukemia,patients should receive only emergency periodontal care. • If there is a persistent gingival bleeding • Cleanse the area with 3 percent hydrogen peroxide. • Carefully explore the area and remove any etiologic local factors • Recleanse with 3 percent H2O2 place the cotton pellet soaked in thrombin against bleeding point. • Cover with a gauze • If oozing persists after removal of gauze,replace cotton and then place a periodontal dressing over the area for 24 hours.
- 50. GRANULOMATOUS DISEASES WEGENER’S GRANULOMATOSIS ETIOLOGY : • cause unknown (immunologically mediated tissue injury) • characterized by acute granulomatous necrotising lesion of respiratory tract involving the orofacial region . CLINICAL FEATURES : • reddish purple bleeds easily. HISTOPATHOLOGY: • chronic inflammatory giant cells & foci of acute inflammation, microabscesses covered by a thin acanthotic epithelium.
- 51. SARCOIDIOSIS ETIOLOGY • unknown. • red, smooth, painless enlargement . HISTOPATHOLOGY • discrete, noncaseating whorls of epitheloid cells & multinucleated • foreign-body-type giant cells
- 52. NEOPLASTIC ENLARGEMENT (GINGIVAL TUMORS) Benign tumors of gingiva Malignant tumors Epulis Squamous cell carcinoma Fibroma Malignant melanoma Papilloma Sarcoma Peripheral giant cell granuloma Fibrosarcoma Cental giant cell granuloma Lymphosarcoma Leukoplakia Reticulum cell carcinoma Gingival Cyst Kaposis sarcoma Other benign masses like nevus Renal cell carcinoma
- 53. FALSE ENLARGEMENT • Not true enlargement but appear as an increase in size of underlying osseous or dental tissues. • A). Underlying osseous lesions • Enlargement of bone - exostosis or tori (paget’s disease, fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma osteoma, osteosarcoma)
- 54. B). Underlying dental tissues • during stages of eruption particularly primary dentition. • labial gingiva- bulbous marginal distortion called developmental enlargement • & persists until junctional epithelium has migrated from enamel to CEJ • Physiologic • complicated by marginal inflammation.
- 56. CONCLUSION • The treatment of gingival enlargement depends on the type of clinical enlargement encountered. • The enlargement can be inflammatory,fibrotic or a combination of both. • Plaque induced inflammation appears to be a general stimulating effect regardless of the mechanism of gingival enlargement. • In recent years,flap surgery have been used more often to treat gingival enlargement than gingivectomy.
- 57. REFERENCES Clinical periodontology and Implant dentistry(5th Edition) Jan Lindhe Vol 1. Carranza’s Clinical Periodontology Eleventh edition. Outline of periodontics,J.D.Manson,B.M.Eley. Essentials Of Periodontology,Sahitya Reddy S. Glickman:Hyperplasia of the gingiva associated with Dilantin therapy. Hallmon WW,Rossman JA:The role of drugs in the pathogenesis of gingival overgrowth. Slavin J,Taylor J :Cyclosporine,nifedipine and gingival hyperplasia . Rushton MA:Hereditary or Idipathic hyperplasia of the gums