11

GINGIVAL ENLARGEMENTGINGIVAL ENLARGEMENT

22

CLASSIFICATION BASED ON ETIOLOGYCLASSIFICATION BASED ON ETIOLOGY

INFLAMMATORY ENLARGEMENTINFLAMMATORY ENLARGEMENTAcuteAcute

ChronicChronic FIBROTIC ENLARGEMENTFIBROTIC ENLARGEMENT

drug induced enlargementdrug induced enlargementIdiopathic enlargementIdiopathic enlargement

33

enlargement associated with enlargement associated with systemic diseasesystemic disease

–Conditioned enlargementConditioned enlargementPubertyPuberty

Vita C deficiencyVita C deficiency

PregnancyPregnancy

Plasma cell gingivitisPlasma cell gingivitis

Nonspecific conditioned enlargement(granuloma Nonspecific conditioned enlargement(granuloma pyogenicum)pyogenicum)

Systemic diseases causing gingival Systemic diseases causing gingival enlargementenlargementLeukemiaLeukemia

Granulomatous Granulomatous disease(sarcoidosis,wegenerdisease(sarcoidosis,wegener’’s s granulomatosis)granulomatosis)

44

Neoplastic enlargement Neoplastic enlargement

Benign tumorsBenign tumors Malignant tumorsMalignant tumors

False enlargementFalse enlargementUnderlying osseous lesionUnderlying osseous lesion

Underlying dental tissuesUnderlying dental tissues

55

Criteria for assessing geCriteria for assessing ge

Grade I-Grade I- Grade II-Grade II- Grade III-Grade III- Grade IV-Grade IV-

66

CLASSIFICATION BASED ON CLASSIFICATION BASED ON LOCATION & DISTRIBUTIONLOCATION & DISTRIBUTION

LOCALISED: limited to the gingiva adjacent LOCALISED: limited to the gingiva adjacent to a single tooth or group of teethto a single tooth or group of teeth

Generalized :involving the gingiva Generalized :involving the gingiva throughout the mouththroughout the mouth

Marginal: confined to the marginal gingivaMarginal: confined to the marginal gingiva Papillary: confined to the interdental Papillary: confined to the interdental papillapapilla

Diffuse involving the marginal & attached Diffuse involving the marginal & attached gingiva & papillagingiva & papilla

Discrete :an isolated sessile or Discrete :an isolated sessile or pedunculated tumor like enlargementpedunculated tumor like enlargement

77

PREDISPOSING FACTORS PREDISPOSING FACTORS

AGE-younger age groups are more AGE-younger age groups are more affectedaffected

SEX-males are more affectedSEX-males are more affected SITE-anterior facial areas SITE-anterior facial areas especially the canine region is especially the canine region is more pronemore prone

INFLAMMATION-predisposes to INFLAMMATION-predisposes to enlargementenlargement

88

Age Age

AGE-younger age groups are more AGE-younger age groups are more affectedaffected

Higher dosage may be Higher dosage may be administeredadministered

As age advances the metabolic As age advances the metabolic process in gingival tissue like process in gingival tissue like glycosaminoglycans synthesis glycosaminoglycans synthesis reducesreduces

99

Sex Sex

SEX-males are more susceptibleSEX-males are more susceptible Progesterone a female sex Progesterone a female sex harmone decreases harmone decreases glycosaminoglycan synthesis by glycosaminoglycan synthesis by human gingival fibroblasts.human gingival fibroblasts.

1010

SITESITE

Anterior regions are more affected Anterior regions are more affected especially the canine region is more especially the canine region is more proneprone

Buccal side is more affected than Buccal side is more affected than lingual.lingual.

Dentulous areas are more prone than Dentulous areas are more prone than edentulous areaedentulous area

Related to plaque control & drying Related to plaque control & drying of mucosa .of mucosa .

Temperature difference.Temperature difference.

1111

INFLAMMATIONINFLAMMATION

INFLAMMATION-predisposes to INFLAMMATION-predisposes to enlargement.enlargement.

Enlargement may predisposes to Enlargement may predisposes to plaque accumulation plaque accumulation

1212

Drug induced gingival enlargementDrug induced gingival enlargement

Calcium channel blockersCalcium channel blockers Immuno suppressantsImmuno suppressants Anti-epilepticAnti-epileptic

1313

Calcium channel blockersCalcium channel blockers

NifedipineNifedipine AmlodipineAmlodipine VerapamilVerapamil DilitiazemDilitiazem OxodipineOxodipine

1414

Drug discovered-1960Drug discovered-1960 Therapeutic usage-1980Therapeutic usage-1980 Class I-affect the Class I-affect the heart(verapemil)heart(verapemil)

Class II-affect mainly blood Class II-affect mainly blood vessels vessels &vasodilation(dihydropyridines)&vasodilation(dihydropyridines)

Class III-minimal or slight Class III-minimal or slight inotropic effects(dilitiazem) inotropic effects(dilitiazem)

1515

M.O.A-alter the CaM.O.A-alter the Ca++++ metabolism ,the influx of Cametabolism ,the influx of Ca++++ across the cell membrane is across the cell membrane is decreased due to reduced decreased due to reduced membrane permeability.membrane permeability.

Contraction of muscle cells Contraction of muscle cells occurs when increased occurs when increased intracellular Caintracellular Ca++++ binds to binds to trophonin & in the presence of trophonin & in the presence of ATP causes the myosin bridge to ATP causes the myosin bridge to contract the actin filaments.contract the actin filaments.

1616

Although dosage & duration of Although dosage & duration of medication were cited as medication were cited as possible explanations no clear possible explanations no clear evidence available.evidence available.

1717

Histologic featuresHistologic features

HyperkeratosisHyperkeratosis AcanthosisAcanthosis Elongation of rete pegs(test Elongation of rete pegs(test tube shape)tube shape)

Fibroblast with prominent RERFibroblast with prominent RER

1818

Pathogenesis Pathogenesis

Apoptosis is characterized by Apoptosis is characterized by nuclear & cytoplasmic nuclear & cytoplasmic condensation,membrane condensation,membrane budding,formation of apoptotic budding,formation of apoptotic bodies, on-random fragmentation bodies, on-random fragmentation of DNA. of DNA.

Calcium plays an important Calcium plays an important signaling pathway in triggering signaling pathway in triggering apoptosisapoptosis

1919

Prolongation of cell life Prolongation of cell life through inhibition of through inhibition of keratinocyte apoptosis.keratinocyte apoptosis.

CaCa++++ is needed for keratinocyte is needed for keratinocyte DNA fragmentation.DNA fragmentation.

Low CaLow Ca++++ expresses Bcl-2 gene expresses Bcl-2 gene which suppresses apoptosiswhich suppresses apoptosis

High CaHigh Ca++ ++ expresses Bax gene expresses Bax gene which induces apoptosiswhich induces apoptosis

2020

Indirect action of nifedipine may Indirect action of nifedipine may occur by stimulating either production occur by stimulating either production of IL-2 by T-cells or metabolites of of IL-2 by T-cells or metabolites of testosterone by gingival fibroblasts testosterone by gingival fibroblasts which in turn stimulates proliferation which in turn stimulates proliferation or increased collagen synthesis.or increased collagen synthesis.

Responsiveness of the cells appear to Responsiveness of the cells appear to be inversely proportional to the IL-1 be inversely proportional to the IL-1 ββ levels. levels.

Medullasin(a neutrophil elastase-like Medullasin(a neutrophil elastase-like proteases) plays a role in development proteases) plays a role in development of inflammation & mechanism is not of inflammation & mechanism is not known.known.

2121

A role of TGFA role of TGFββ,bFGF & heparan ,bFGF & heparan sulphate glycosaminoglycan.sulphate glycosaminoglycan.

The site specificity in the The site specificity in the accumulation of collagenous accumulation of collagenous proteins in the ECM may be due proteins in the ECM may be due to the relatively slow to the relatively slow synthesis of these proteins in synthesis of these proteins in other tissues or because of other tissues or because of altered deposition/resorption altered deposition/resorption in susceptible tissues. in susceptible tissues.

2222

Immuno suppressantsImmuno suppressants

CyclosporineCyclosporine TacrolimusTacrolimus

2323

cyclosporincyclosporin

Liphophilic cyclic endecapeptideLiphophilic cyclic endecapeptide Used in the prevention of organ Used in the prevention of organ transplant rejectiontransplant rejection

Peak plasma conc. reached after 3 Peak plasma conc. reached after 3 hrs.hrs.

Serum half life 17-40hrs.Serum half life 17-40hrs. mostly bound to erythrocytes & mostly bound to erythrocytes & lipoproteins. only 5% free in lipoproteins. only 5% free in plasma.plasma.

Therapeutic conc-135Therapeutic conc-135μμg g

2424

The total amount of drug per The total amount of drug per weight in tissue can be upto weight in tissue can be upto 20-fold greater than in plasma 20-fold greater than in plasma & varies between organs & & varies between organs & individuals.individuals.

2525

Pharmacological actionPharmacological action

Cs suppresses T-helper cell Cs suppresses T-helper cell function leaving T-suppresser function leaving T-suppresser cells un affected.cells un affected.

Cs selectively suppresses the Cs selectively suppresses the cellular immune response by cellular immune response by interfering with IL-2 interfering with IL-2 production.production.

2626

MOAMOA

Drug cyclophilin complex binds & Drug cyclophilin complex binds & inhibits calcineurin a calcium & inhibits calcineurin a calcium & calmodulin dependent serine threonine calmodulin dependent serine threonine phosphatase.phosphatase.

This inactivation prevents This inactivation prevents dephosphorylation of nuclear factor dephosphorylation of nuclear factor of activated T-cells(NF-AT) the of activated T-cells(NF-AT) the nuclear import of NF-AT complex & the nuclear import of NF-AT complex & the formation of a transcriptionally formation of a transcriptionally active NF-AT complex. the net active NF-AT complex. the net consequence is inhibition of IL-2.consequence is inhibition of IL-2.

2727

Pathogenesis Pathogenesis During plaque induced inflammation During plaque induced inflammation the humoral response replaces the the humoral response replaces the cell mediated response.cell mediated response.

Several cytokines that play Several cytokines that play important role in humoral response important role in humoral response are known to influence connective are known to influence connective tissue homeostasis.tissue homeostasis.

IL-1IL-1ββ & IL-6 are cytokines known to & IL-6 are cytokines known to play regulatory function in play regulatory function in periodontal tissue turnover with IL-periodontal tissue turnover with IL-11ββ inducing & IL-6 reducing tissue inducing & IL-6 reducing tissue break down.break down.

2828

IL-6 is a multifactorial IL-6 is a multifactorial cytokine found to induce final cytokine found to induce final maturation of B-cells into maturation of B-cells into immunoglobulin producing plasma immunoglobulin producing plasma cells.cells.

The increase in plasma cell The increase in plasma cell number may promote Cs induced number may promote Cs induced alteration of the cytokine alteration of the cytokine profile within gingival tissue, profile within gingival tissue, resulting in disruption of resulting in disruption of normal connective tissue turn normal connective tissue turn overover

2929

The immunosuppresed pts had The immunosuppresed pts had markedly lower no of NK cells markedly lower no of NK cells which could enhance the ability which could enhance the ability of Cs to induce proliferative of Cs to induce proliferative activity not directly, but by activity not directly, but by disrupting the complex conn disrupting the complex conn tissue-homeostasis mechanism. tissue-homeostasis mechanism.

Cs stimulates TGF-Cs stimulates TGF-ββ1,PDGF which 1,PDGF which promote fibroblast growth & promote fibroblast growth & matrix production.matrix production.

Cs reduces the level of MMP-1 & Cs reduces the level of MMP-1 & MMP-2 & increases the level of MMP-2 & increases the level of TIMP.TIMP.

3030

Cs reduces gingival Cs reduces gingival prostacyclin(PGIprostacyclin(PGI22)synthesis.)synthesis.

PGIPGI2 2 has an antiproliferative has an antiproliferative effect via increasing cAMP thus effect via increasing cAMP thus gingival overgrowth may result.gingival overgrowth may result.

3131

Perlecan a type of Perlecan a type of proteoglycans is increased.proteoglycans is increased.

It has high affinity for growth It has high affinity for growth factors has been attributed to factors has been attributed to this proteoglycans ,which ia this proteoglycans ,which ia able to retain these factors able to retain these factors inside the basement membrane.inside the basement membrane.

Perlecan acts as a major Perlecan acts as a major reservoir of FGF-2.reservoir of FGF-2.

3232

Cs could mimic endogenous signals Cs could mimic endogenous signals for wound repair or for wound repair or remodelling,but at the usual remodelling,but at the usual therapeutic dosage levels& in the therapeutic dosage levels& in the absence of any specific absence of any specific inflammatory process, its effect inflammatory process, its effect is sub threshold.is sub threshold.

However when specific inflammatory However when specific inflammatory processes take place within processes take place within localized & specific areas the localized & specific areas the effects of Cs could act effects of Cs could act synergistically with endogenous synergistically with endogenous signals stimulating excessive signals stimulating excessive repair or growth.repair or growth.

3333

Side effects of CsSide effects of Cs

HypertensionHypertension Dihydropyridines are Ca Dihydropyridines are Ca ++++ channel blockers used to treat channel blockers used to treat hypertensionhypertension

3434

RxRx

Conversion to other drugs in Conversion to other drugs in the same group-tacrolimusthe same group-tacrolimus

Reduction or withdraval of the Reduction or withdraval of the drug under medical suoervision drug under medical suoervision if indicatedif indicated

gingivectomygingivectomy

3535

Anti-epilepticAnti-epileptic

PhenytoinPhenytoin Sodium valproateSodium valproate PhenobarbitalPhenobarbital VigabatrinVigabatrin

3636

Phenytoin Phenytoin

Macrophages differ in respect Macrophages differ in respect to location, morphology & to location, morphology & function & they have been function & they have been recognized to be major mediator recognized to be major mediator of connective tissue of connective tissue turnover,maintenence & repair.turnover,maintenence & repair.

3737

Macrophage 27E10-asociated with Macrophage 27E10-asociated with production of pro inflammatory production of pro inflammatory cytokines-IL-1,IL-6 & TNF-cytokines-IL-1,IL-6 & TNF-αα

A reparative/proliferative Macrophage phenotype A reparative/proliferative Macrophage phenotype RM3/1 associated with production of PDGF- RM3/1 associated with production of PDGF- ββ,TGF- ,TGF- ββ1,bFGF.1,bFGF.

Expression of 25F9 antigen is connected with Expression of 25F9 antigen is connected with maturation of macrophage & relative decrease in maturation of macrophage & relative decrease in 25F9 indicates that maturation of tissue 25F9 indicates that maturation of tissue macrophages have been altered.macrophages have been altered.

3838

decreasesdecreases the level of EGF the level of EGF receptors in gingival receptors in gingival fibroblast resulting in fibroblast resulting in increased cellular increased cellular responsiveness to EGF,which can responsiveness to EGF,which can stimulate cellular DNA stimulate cellular DNA synthesis.synthesis.

Phenytoin can stimulate Phenytoin can stimulate testosterone metabolism & testosterone metabolism & increases the level of 5increases the level of 5αα--dihydrotestosterone a stimulator of fibroblast dihydrotestosterone a stimulator of fibroblast growth.growth.

3939

Phenytoin interferes with folic Phenytoin interferes with folic acid metabolism & hence causes acid metabolism & hence causes folic acid deficiencyfolic acid deficiency

Folic acid is necessary for DNA Folic acid is necessary for DNA synthesis, thus tissues with a synthesis, thus tissues with a high turn over could be high turn over could be adversely affectedadversely affected

PHT can cause immuno suppresion PHT can cause immuno suppresion in long term use like decreased in long term use like decreased salivary IgA which could favor salivary IgA which could favor inflammation.inflammation.

4040

PHT & its metabolite P-HPPA PHT & its metabolite P-HPPA induces the release of factors induces the release of factors from monocytes which activate from monocytes which activate quiescence gingival fibroblast quiescence gingival fibroblast to synthesize DNA.to synthesize DNA.

Decreases ACTH which leads to Decreases ACTH which leads to increased somatotrophic harm increased somatotrophic harm one which increases fibroblast one which increases fibroblast proliferation.proliferation.

4141

PHT leads to production of PHT leads to production of collagenase which is inactive.collagenase which is inactive.

Increased PGEIncreased PGE22 leading to leading to increased hyaluronic acid .increased hyaluronic acid .

4242

RxRx

Conversion to other drugs in Conversion to other drugs in the same groupthe same group

Reduction or withdraval of the Reduction or withdraval of the drug under medical suoervision drug under medical suoervision if indicatedif indicated

gingivectomygingivectomy

4343

Others Others

ErythromycinErythromycin

4444

Acute inflammatory Acute inflammatory enlargementenlargement

Gingival abscessGingival abscess Localised,painful expanding Localised,painful expanding lesion that is usually of lesion that is usually of sudden onset.sudden onset.

Generally limited to marginal Generally limited to marginal gingiva or interdental papilla.gingiva or interdental papilla.

Red, swelling with a smooth Red, swelling with a smooth shiny surface. shiny surface.

4545

Within 24-48hrs the lesion Within 24-48hrs the lesion usually becomes fluctuant & usually becomes fluctuant & pointed with a surface orifice pointed with a surface orifice from which a purulent exudates from which a purulent exudates may be expressed.may be expressed.

The adjacent teeth are often The adjacent teeth are often sensitive to percussion.sensitive to percussion.

4646

Etiology Etiology

Bacteria carried deep into Bacteria carried deep into tissues when a foreign tissues when a foreign substance such as substance such as toothbristle,small traumatic toothbristle,small traumatic injury.injury.

4747

Histopathology Histopathology

Polymorphonuclear leucocytes.Polymorphonuclear leucocytes. Edematous tissueEdematous tissue Vascular engorgementVascular engorgement

4848

RxRx

Incision and Incision and drainage.drainage.

Abscess.swf

4949

Chronic inflammatory enlargementChronic inflammatory enlargement

Slight ballooning of the Slight ballooning of the interdental papilla &/or the interdental papilla &/or the marginal gingiva.marginal gingiva.

Early stages it produces a life Early stages it produces a life preserver –like bulge around the preserver –like bulge around the teeth.teeth.

Progresses slowly & painless.Progresses slowly & painless. Enlargement is generally Enlargement is generally papillary or marginal.papillary or marginal.

5050

Occasionally it may occur as a Occasionally it may occur as a discrete sessile or discrete sessile or pedunculated mass resembling a pedunculated mass resembling a tumor.tumor.

Painful ulceration sometimes Painful ulceration sometimes may occurmay occur

5151

Etiology Etiology Prolonged exposure to dental plaque.Prolonged exposure to dental plaque. Factors that favor plaque accumulationFactors that favor plaque accumulation Poor oral hygienePoor oral hygiene Abnormal relationship of adjacent teethAbnormal relationship of adjacent teeth Overhanging marginOverhanging margin Food impactionFood impaction Orthodontic applianceOrthodontic appliance RPDRPD Nasal obstructionNasal obstruction Improperly contoured restoration & Improperly contoured restoration & ponticspontics

5252

Histopathology Histopathology

Exudative & proliferative Exudative & proliferative features of chronic features of chronic inflammation is seen.inflammation is seen.

Edematous tissueEdematous tissueInflammatory cellsInflammatory cells

Vascular engorgementVascular engorgement Fibrotic tissueFibrotic tissue

Abuntance of fibroblasts & collagen Abuntance of fibroblasts & collagen fibersfibers

5353

Treatment Treatment

Removal of plaqueRemoval of plaque Control of inflammationControl of inflammation Scaling & root planning Scaling & root planning Fibrotic enlargement –Fibrotic enlargement –gingivectomy.gingivectomy.

5454

Enlargement associated with mouth Enlargement associated with mouth breathingbreathing

Gingiva appears red & edematousGingiva appears red & edematous Diffuse surface shininess of Diffuse surface shininess of the exposed areathe exposed area

Common site-maxillary anterior Common site-maxillary anterior region.region.

Attributed to irritation from Attributed to irritation from surface dehydration surface dehydration

5555

Idiopathic gingival enlargementIdiopathic gingival enlargement

GingivostomatosisGingivostomatosis ElephantiasisElephantiasis Diffuse fibromaDiffuse fibroma Familial elephantiasisFamilial elephantiasis Idiopathic fibromatosisIdiopathic fibromatosis Hereditary gingival hyperplasiaHereditary gingival hyperplasia Congenital familial Congenital familial fibromatosis fibromatosis

5656

Clinical features Clinical features

It affects the attached gingiva as It affects the attached gingiva as well as the marginal gingiva & well as the marginal gingiva & interdental gingiva.interdental gingiva.

Pink, firm & almost leathery in Pink, firm & almost leathery in consistency & has a characteristic consistency & has a characteristic minutely pebbled surface.minutely pebbled surface.

In severe cases the teeth are In severe cases the teeth are almost covered & projects into the almost covered & projects into the vestibule.vestibule.

Jaws appears distorted because of Jaws appears distorted because of bulbous enlargement.bulbous enlargement.

5757

Combined enlargement Combined enlargement

Gingival hyperplasia is complicated by Gingival hyperplasia is complicated by secondary inflammatory changes because secondary inflammatory changes because it produces conditions favorable for it produces conditions favorable for accumulation of plaque by accentuating accumulation of plaque by accentuating the depth of gingival sulcus. the depth of gingival sulcus.

It consist of 2 portions.It consist of 2 portions. A primary or basic hyperplasia of the A primary or basic hyperplasia of the connective tissue & epithelium.connective tissue & epithelium.

A secondary complicating inflammatory A secondary complicating inflammatory componentcomponent

5858

Enlargement associated with Enlargement associated with systemic diseasesystemic disease

Conditioned enlargementConditioned enlargement The condition itself does not cause The condition itself does not cause the condition, the altered tissue the condition, the altered tissue metabolism accentuates the response metabolism accentuates the response to local irritants.to local irritants.

Magnification of an existing Magnification of an existing inflammation initiated by dental inflammation initiated by dental plaque.plaque.

PubertyPubertyPregnancy(harmonal)Pregnancy(harmonal)Vita C deficiency (nutritional disturbances)Vita C deficiency (nutritional disturbances)

5959

Enlargement in pregnancyEnlargement in pregnancy

Pregnancy does not cause the condition, Pregnancy does not cause the condition, the altered tissue metabolism in the altered tissue metabolism in pregnancy accentuates the response to pregnancy accentuates the response to local irritants.local irritants.

Gingival enlargement in pregnancy is Gingival enlargement in pregnancy is called ANGIOGRANULOMA.called ANGIOGRANULOMA.

Enlargement may be marginal, mostly Enlargement may be marginal, mostly generalized & more prominent in generalized & more prominent in interdental papilla.interdental papilla.

Sometimes it occur as a discrete, Sometimes it occur as a discrete, mushroom like flattened spherical mass mushroom like flattened spherical mass attached by a sessile pedunculated base.attached by a sessile pedunculated base.

6060

Puberty Puberty

6161

Vita CVita C

6262

Non specific conditioned Non specific conditioned enlargement enlargement

Granuloma pyogenicum – is a Granuloma pyogenicum – is a tumour like enlargement that is tumour like enlargement that is considered an exaggerated considered an exaggerated response to minor trauma.response to minor trauma.

6363

Systemic diseases causing gingival Systemic diseases causing gingival enlargementenlargement

LeukemiaLeukemia

Granulomatous diseaseGranulomatous diseaseSarcoidosisSarcoidosis

wegenerwegener’’s granulomatosiss granulomatosis

6464

Neoplastic enlargementNeoplastic enlargement

Benign tumorsBenign tumors Epulis – is a generic term used Epulis – is a generic term used clinically to designate all clinically to designate all discrete tumors & tumor like discrete tumors & tumor like masses of the gingiva.masses of the gingiva.

Most epulis are inflammatory Most epulis are inflammatory rather than neolastic.rather than neolastic.

6565

Benign tumorsBenign tumors

Fibroma Fibroma Papilloma Papilloma Peripheral giant cell granuloma Peripheral giant cell granuloma Central giant cell carcinomaCentral giant cell carcinoma Gingival cystGingival cyst Leukoplakia Leukoplakia

6666

Malignant tumorsMalignant tumors

Squamous cell carcinomaSquamous cell carcinoma Malignant melanomaMalignant melanoma MetastasisMetastasis

– Adenocarcinoma of colonAdenocarcinoma of colon– Lung carcinomaLung carcinoma– Primary hepatocellular carcinomaPrimary hepatocellular carcinoma– Renal cell carcinomaRenal cell carcinoma– HypernephromaHypernephroma– ChondrosarcomaChondrosarcoma– Testicular tumorTesticular tumor

6767

6868

6969

Apoptosis Apoptosis

7070

RxRx

gingivectomygingivectomy

gingivoplasty.swf

Scaling.swf