Gingival enlargement

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Gingival enlargement
Other namesGingival overgrowth (GO), hypertrophic gingivitis, gingival hyperplasia, gingival hypertrophy
Gingivitis (crop).jpg
Gingivitis, a common cause of inflammatory gingival enlargement.
Specialty Periodontology
Symptoms increase in gum size
Causesinflammatory conditions, Drug-induced, genetic

Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. [1] Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medications. The treatment is based on the cause. [1] A closely related term is epulis, denoting a localized tumor (i.e. lump) on the gingiva.

Contents

Classification

The terms gingival hyperplasia and gingival hypertrophy have been used to describe this topic in the past. [1] These are not precise descriptions of gingival enlargement because these terms are strictly histologic diagnoses, and such diagnoses require microscopic analysis of a tissue sample. Hyperplasia refers to an increased number of cells, and hypertrophy refers to an increase in the size of individual cells. [2] As these identifications cannot be performed with a clinical examination and evaluation of the tissue, [3] the term gingival enlargement is more properly applied. Gingival enlargement has been classified according to cause into 5 general groups: [1]

Causes

Inflammatory enlargement

Gingival enlargement has a multitude of causes. The most common is chronic inflammatory gingival enlargement, when the gingivae are soft and discolored. This is caused by tissue edema and infective cellular infiltration caused by prolonged exposure to bacterial plaque, and is treated with conventional periodontal treatment, such as scaling and root planing. [1]

Gingivitis and gingival enlargement are often seen in mouth breathers, [4] as a result of irritation brought on by surface dehydration, but the manner in which it is caused has not been demonstrated. [1]

The accumulation and retention of plaque is the chief cause of inflammatory gingival enlargement. Risk factors include poor oral hygiene, [5] as well as physical irritation of the gingiva by improper restorative and orthodontic appliances. [1]

Drug-induced enlargement

This type of gingival enlargement is sometimes termed "drug induced gingival enlargement" or "drug influenced gingival overgrowth", [6] abbreviated to "DIGO". [7] Gingival enlargement may also be associated with the administration of three different classes of drugs, all producing a similar response: [8] Gingival overgrowth is a common side effect of phenytoin, termed "Phenytoin-induced gingival overgrowth" (PIGO). [9]

Of all cases of DIGO, about 50% are attributed to phenytoin, 30% to cyclosporins and the remaining 10-20% to calcium channel blockers.

Drug-induced enlargement has been associated with a patient's genetic predisposition, [11] and its association with inflammation is debated. Some investigators assert that underlying inflammation is necessary for the development of drug-induced enlargement, [12] while others purport that the existing enlargement induced by the drug effect compounds plaque retention, thus furthering the tissue response. [13] Careful attention to oral hygiene may reduce the severity of gingival hyperplasia. [14] In most cases, discontinuing the culprit drug resolves the hyperplasia. [14]

Enlargement associated with systemic factors

Many systemic diseases can develop oral manifestations that may include gingival enlargement, some that are related to conditions and others that are related to disease: [15]

Mechanism

Drug Induced gingival overgrowth:

Management

The first line management of gingival overgrowth is improved oral hygiene, ensuring that the irritative plaque is removed from around the necks of the teeth and gums. Situations in which the chronic inflammatory gingival enlargement include significant fibrotic components that do not respond to and undergo shrinkage when exposed to scaling and root planing are treated with surgical removal of the excess tissue, most often with a procedure known as gingivectomy. [1]

In DIGO, improved oral hygiene and plaque control is still important to help reduce any inflammatory component that may be contributing to the overgrowth. Reversing and preventing gingival enlargement caused by drugs is as easy as ceasing drug therapy or substituting to another drug. However, this is not always an option; in such a situation, alternative drug therapy may be employed, if possible, to avoid this deleterious side effect. In the case of immunosuppression, tacrolimus is an available alternative which results in much less severe gingival overgrowth than cyclosporin, but is similarly as nephrotoxic. [19] The dihydropyridine derivative isradipidine can replace nifedipine for some uses of calcium channel blocking and does not induce gingival overgrowth. [20]

Epidemiology

Gingival enlargement is common. [21]

Other animals

Gingival hyperplasia Gingival hyperplasia.JPG
Gingival hyperplasia

It is commonly seen in Boxer dogs and other brachycephalic breeds, [22] and in the English Springer Spaniel. [23] It usually starts around middle age and progresses. Some areas of the gingiva can become quite large but have only a small attachment to the rest of the gingiva, and it may completely cover the teeth. Infection and inflammation of the gingiva is common with this condition. Under anesthesia, the enlarged areas of gingiva can be cut back with a scalpel blade or CO2 laser, but it often recurs. [24] Gingival enlargement is also a potential sequela of gingivitis. As in humans, it may be seen as a side effect to the use of ciclosporin. [25]

Related Research Articles

<span class="mw-page-title-main">Periodontal disease</span> Medical condition

Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cause of tooth loss for adults worldwide. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Halitosis may also occur.

<span class="mw-page-title-main">Gums</span> Soft tissue surrounding the roots of the teeth

The gums or gingiva consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

An oral medicine or stomatology doctor/dentist has received additional specialized training and experience in the diagnosis and management of oral mucosal abnormalities including oral cancer, salivary gland disorders, temporomandibular disorders and facial pain, taste and smell disorders; and recognition of the oral manifestations of systemic and infectious diseases. It lies at the interface between medicine and dentistry. An oral medicine doctor is trained to diagnose and manage patients with disorders of the orofacial region.

Orofacial granulomatosis (OFG) is a condition characterized by persistent enlargement of the soft tissues of the mouth, lips and the area around the mouth on the face, causing in most cases extreme pain. The mechanism of the enlargement is granulomatous inflammation. The underlying cause of the condition is not completely understood, and there is disagreement as to how it relates to Crohn's disease and sarcoidosis.

<span class="mw-page-title-main">Gingival sulcus</span> Space between tooth and gums

The gingival sulcus is an area of potential space between a tooth and the surrounding gingival tissue and is lined by sulcular epithelium. The depth of the sulcus is bounded by two entities: apically by the gingival fibers of the connective tissue attachment and coronally by the free gingival margin. A healthy sulcular depth is three millimeters or less, which is readily self-cleansable with a properly used toothbrush or the supplemental use of other oral hygiene aids.

<span class="mw-page-title-main">Gingival and periodontal pocket</span>

Gingival and periodontal pockets are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth.

Bleeding on probing (BoP) which is also known as bleeding gums or gingival bleeding is a term used by dentists and dental hygienists when referring to bleeding that is induced by gentle manipulation of the tissue at the depth of the gingival sulcus, or interface between the gingiva and a tooth. BoP is a sign of periodontal inflammation and indicates some sort of destruction and erosion to the lining of the sulcus or the ulceration of sulcular epithelium. The blood comes from lamina propria after the ulceration of the lining. BoP seems to be correlated with Periodontal Inflamed Surface Area (PISA).

Gingivectomy is a dental procedure in which a dentist or oral surgeon cuts away part of the gums in the mouth.

<span class="mw-page-title-main">Gingivitis</span> Inflammation of the gums

Gingivitis is a non-destructive disease that causes inflammation of the gums; ulitis is an alternative term. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms that are attached to tooth surfaces, termed plaque-induced gingivitis. Most forms of gingivitis are plaque-induced.

Gingival disease is a term used to group the diseases that affect the gingiva(gums). The most common gingival disease is gingivitis, the earliest stage of gingival-related diseases. Gingival disease encompasses all the conditions that surround the gums, this includes plaque-induced gingivitis, non-dental biofilm plaque-induced gingivitis, and periodontal diseases.

<span class="mw-page-title-main">Plasma cell gingivitis</span> Medical condition

Plasma cell gingivitis is a rare condition, appearing as generalized erythema (redness) and edema (swelling) of the attached gingiva, occasionally accompanied by cheilitis or glossitis. It is called plasma cell gingivitis where the gingiva (gums) are involved, plasma cell cheilitis, where the lips are involved, and other terms such as plasma cell orifacial mucositis, or plasma cell gingivostomatitis where several sites in the mouth are involved. On the lips, the condition appears as sharply outlined, infiltrated, dark red plaque with a lacquer-like glazing of the surface of the involved oral area.

Epulis is any tumor-like enlargement situated on the gingival or alveolar mucosa. The word literally means "(growth) on the gingiva", and describes only the location of the mass and has no further implications on the nature of the lesion. There are three types: fibromatous, ossifying and acanthomatous. The related term parulis refers to a mass of inflamed granulation tissue at the opening of a draining sinus on the alveolus over the root of an infected tooth. Another closely related term is gingival enlargement, which tends to be used where the enlargement is more generalized over the whole gingiva rather than a localized mass.

Aggressive periodontitis describes a type of periodontal disease and includes two of the seven classifications of periodontitis as defined by the 1999 classification system:

  1. Localized aggressive periodontitis (LAP)
  2. Generalized aggressive periodontitis (GAP)
<span class="mw-page-title-main">Peri-implantitis</span> Inflammatory disease

Peri-implantitis is a destructive inflammatory process affecting the soft and hard tissues surrounding dental implants. The soft tissues become inflamed whereas the alveolar bone, which surrounds the implant for the purposes of retention, is lost over time.

Drug-related gingival hyperplasia is a cutaneous condition characterized by enlargement of the gums noted during the first year of drug treatment. Although the mechanism of drug related gingival hyperplasia is not well understood, some risk factors for the condition include the duration of drug use and poor oral hygiene. In most cases, alternative drugs are given, in order to avoid this side effect.

Peri-implant mucositis is defined as an inflammatory lesion of the peri-implant mucosa in the absence of continuing marginal bone loss.

Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva. It can cover teeth in various degrees, and can lead to aesthetic disfigurement. Fibrous enlargement is most common in areas of maxillary and mandibular tissues of both arches in the mouth. Phenotype and genotype frequency of HGF is 1:175,000 where males and females are equally affected but the cause is not entirely known. It mainly exists as an isolated abnormality but can also be associated with a multi-system syndrome.

Drug-induced gingival enlargement (DIGE), also referred to as drug-induced gingival hyperplasia (DIGH) or drug-induced gingival overgrowth (DIGO), is a side effect of many systemic medications for which the Gingervae are not the target receptor. It is normally resultant of medications including immunoregulators, calcium channel blockers and anticonvulsants. When allowed to progress assisted by routinely poor oral hygiene, DIGE can lead to pain and disfigurement, however there are great variations in its presentation and severity dependent on the case. It is suggested that enlargement is aided by genetic predispositions, tending to occur more frequently in the papillae of the anterior Gingivae in younger age groups.

References

  1. 1 2 3 4 5 6 7 8 Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. (2012). Carranza's clinical periodontology (11th ed.). St. Louis, Mo.: Elsevier/Saunders. pp.  84–96. ISBN   978-1-4377-0416-7.
  2. ↑ Merriam-Webster's Medical Desk Dictionary, 2002, ISBN   1-4018-1188-4, page 367-368.
  3. ↑ Oral Pathology Lecture Series Notes, New Jersey Dental School, 2004–2005, page 24.
  4. ↑ Lite, Theodore; Dominic J. DiMaio; Louis R. Burman (1955). "Gingival pathosis in mouth breathers: A clinical and histopathologic study and a method of treatment". Oral Surgery, Oral Medicine, Oral Pathology. 8 (4): 382–391. doi:10.1016/0030-4220(55)90106-7. ISSN   0030-4220. PMID   14370764.
  5. ↑ Hirschfield, I (1932). "Hypertrophic gingivitis; its clinical aspect". Journal of the American Dental Association (19): 799.
  6. ↑ Lindhe J, Lang NP, Karring T, eds. (2008). Clinical periodontology and implant dentistry (5th ed.). Oxford: Blackwell Munksgaard. pp.  641. ISBN   9781405160995.
  7. ↑ Subramani, T; Rathnavelu, V; Yeap, SK; Alitheen, NB (Feb 2013). "Influence of mast cells in drug-induced gingival overgrowth". Mediators of Inflammation. 2013: 275172. doi: 10.1155/2013/275172 . PMC   3569901 . PMID   23431239.
  8. ↑ Butler RT, Kalkwarf KL (1987). "Drug-induced gingival hyperplasia: phenytoin, cyclosporine, and nifedipine". Journal of the American Dental Association. 114 (1): 56–60. doi:10.14219/jada.archive.1987.0050. PMID   3468168.
  9. ↑ Arya, R; Gulati, S (March 2012). "Phenytoin-induced gingival overgrowth". Acta Neurologica Scandinavica. 125 (3): 149–55. doi: 10.1111/j.1600-0404.2011.01535.x . PMID   21651505. S2CID   6274158.
  10. 1 2 3 Bolognia, Jean L. (2007). Dermatology. St. Louis: Mosby. ISBN   978-1-4160-2999-1.
  11. ↑ Hassell, T.M.; Burtner, A. Paul; McNeal, Donald; Smith, Robert G. (1994). "Hypertrophic Oral problems and genetic aspects of individuals with epilepsy". Periodontology 2000. 6 (1): 68–78. doi:10.1111/j.1600-0757.1994.tb00027.x. PMID   9673171.
  12. ↑ Ciancio, SG (1972). "Gingival hyperplasia and diphenylhydantoin". Journal of Periodontology. 43 (7): 411–4. doi:10.1902/jop.1972.43.7.411. PMID   4504524.
  13. ↑ Carranza'a Clinical Periodontology, 9th Ed. W.B. Saunders 1996 ISBN   0-7216-8331-2, page 282.
  14. 1 2 Brian K. Alldredge; et al., eds. (2013). Applied therapeutics : the clinical use of drugs (10th ed.). Baltimore: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1403. ISBN   978-1609137137.
  15. ↑ Carranza'a Clinical Periodontology, 9th Ed. W.B. Saunders 1996 ISBN   0-7216-8331-2, page 285.
  16. ↑ Leão, JC; Hodgson, T; Scully, C; Porter, S (Nov 15, 2004). "Review article: orofacial granulomatosis". Alimentary Pharmacology & Therapeutics. 20 (10): 1019–27. doi: 10.1111/j.1365-2036.2004.02205.x . PMID   15569103.
  17. ↑ Trackman, P.C.; Kantarci, A. (2017-03-22). "Molecular and Clinical Aspects of Drug-induced Gingival Overgrowth". Journal of Dental Research. 94 (4): 540–546. doi:10.1177/0022034515571265. ISSN   0022-0345. PMC   4485217 . PMID   25680368.
  18. ↑ Subramani, Tamilselvan; Rathnavelu, Vidhya; Alitheen, Noorjahan Banu (2013). "The Possible Potential Therapeutic Targets For Drug Induced Gingival Overgrowth". Mediators of Inflammation. 2013: 1–9. doi: 10.1155/2013/639468 . PMC   3652200 . PMID   23690667.
  19. ↑ Spencer, CM; Goa, KL; Gillis, JC (1997). "Tacrolimus: an update of its pharmacology and drug efficacy in the management of organ transplantation". Drugs. 54 (6): 925–75. doi:10.2165/00003495-199754060-00009. PMID   9421697.
  20. ↑ Westbrook, P (1997). "Regression of nifedipine-induced gingival hyperplasia following switch to a same class calcium channel blocker, isradipine". Journal of Periodontology. 68 (7): 645–50. doi:10.1902/jop.1997.68.7.645. PMID   9249636.
  21. ↑ Livada, R; Shiloah, J (December 2012). "Gummy smile: could it be genetic? Hereditary gingival fibromatosis". The Journal of the Michigan Dental Association. 94 (12): 40–3. PMID   23346694.
  22. ↑ "Gingival Fibroma and Epulides". The Merck Veterinary Manual. 2006. Retrieved 2007-03-08.
  23. ↑ Gorrel, Cecilia (2003). "Periodontal Disease". Proceedings of the 28th World Congress of the World Small Animal Veterinary Association. Retrieved 2007-03-25.
  24. ↑ Bellows, Jan; McMorran, Elizabeth (2017-02-01). "Use CO2 laser on gingival enlargement" . Retrieved 2017-02-02.
  25. ↑ Guaguère E, Steffan J, Olivry T (2004). "Cyclosporin A: a new drug in the field of canine dermatology". Veterinary Dermatology. 15 (2): 61–74. doi:10.1111/j.1365-3164.2004.00376.x. PMID   15030555.
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