GINGIVAL ENLARGEMENT

ASSOCIATED WITH SYSTEMIC DISEASES

Presented ByDr. M. Shiva Shanker

Ist Year Post Graduate Student ,Dept of Periodontics, Mamata Dental

College.

ContentsIntroduction

Terminologies

Classification of gingival enlargements

Gingival enlargement associated with systemic diseases and their clinical &

Histopathological features

Diagnosis

Management of gingival enlargement

Recurrence of gingival enlargement

Conclusion

Introduction

Accepted current terminology for this condition is gingival

enlargement and gingival overgrowth.

These are strictly clinical descriptive terms and to avoid the

erroneous pathologic connotations of terms used in the past

such as hypertrophic gingivitis or gingival hyperplasia.

Gingival enlargement is the overgrowth of the gingiva

characterized by an expansion and accumulation of the

connective tissue with occasional presence of increased

number of cells. It is caused by several factors, such as,

inflammation, leukemia, drugs and inheritance.

Terminologies Gingival Enlargement: An overgrowth or

increase in size of the gingiva

Gingival Hyperplasia: An enlargement of the gingiva due to an increase in the number of cells

Gingival Hypertrophy: An enlargement of the gingiva due to an increase in the size of cells

(According to the Glossary of Periodontal Terms, 4th Edition, 2001)

CLASSIFICATION

I. Inflammatory enlargement

A. Chronic

B. Acute

II. Drug-induced enlargement

III. Enlargements associated with systemic diseases

A. Conditioned enlargement

Pregnancy

Puberty

Vitamin C deficiency

Plasma cell gingivitis

Nonspecific conditioned enlargement (granuloma pyogenicum)

B. Systemic diseases causing gingival enlargement

Leukemia

Granulomatous diseases (Wegener’s granulomatosis, Sarcoidosis etc.)

IV. Neoplastic enlargement (gingival tumors)

A. Benign tumors

B. Malignant tumors

V. False enlargement

Based on location and distribution

Localized

Generalised

Marginal

Papillary

Diffuse

Discrete

Gingival enlargement associated with systemic diseases

Many systemic diseases can develop oral manifestations that may include gingival enlargement

These systemic diseases and/or conditions can affect the periodontium by two different mechanisms as follows:

1. Magnification of an existing inflammation initiated by dental plaque

2. Manifestation of the systemic disease independently of the inflammatory status of the gingiva

Conditioned Enlargement

Conditioned enlargement occurs when the systemic condition of the patient exaggerates or distorts the usual gingival response to dental plaque

The 3 types of conditioned gingival enlargement are-

1. Hormonal (pregnancy, puberty)

2. Nutritional (associated with vitamin C deficiency)

3. Allergic

Enlargement in Pregnancy:

During pregnancy there is an increase in levels of both

progesterone and estrogen, which induce changes in vascular

permeability, leading to gingival edema and an increased

inflammatory response to dental plaque.

Why??????????

The estrogen receptors such as ER-α and ER-β are present

on the vascular smooth muscles which causes smooth

muscle relaxation and results in vasodilation.

The estrogen causes increased levels of Vascular

endothelial growth factor which is a potent stimulator of

microvascular permeability.

Progesterone induces vascular permeability by formation of

gaps in the normally intact endothelial lining.

Susceptibility to infections (e.g. periodontal infection) increases during early gestation due to

Suppression of T-cell activity

Decreased neutrophil chemotaxis and phagocytosis,

Altered lymphocyte response

Depressed antibody production

Chronic maternal stress

Down regulation of IL-6 production, rendering the gingiva less efficient at resisting the inflammatory challenges produced by the bacteria

decreased levels of immunoglobulin G (IgG)

Marginal enlargement-

The enlargement is usually generalized and tends to be more prominent interproximally

The enlarged gingiva is bright red or magenta, soft, and friable, and has a smooth, shiny surface

Tumorlike Gingival Enlargement-

The so-called pregnancy tumor is not a neoplasm.

It usually occurs after the third month of pregnancy but may occur earlier

A heightened gingival response to plaque during pregnancy results in pregnancy-associated gingivitis

Localized gingival enlargement in a 27-year old pregnant patient…

Microscopic view of gingival enlargement in pregnant patient showing abundance of blood vessels and interspersed inflammatory cells…

Enlargement in Puberty:

It is seen sometimes during puberty in both male and female adolescents and appears in areas of plaque accumulation

The enlargement is marginal and interdental and is characterized by prominent bulbous interproximal papillae

The degree of enlargement and the tendency to develop massive recurrence in the presence of relatively scant plaque deposits distinguish pubertal gingival enlargement from uncomplicated chronic inflammatory enlargement

Tiainen et al. [1992] showed that the severity of puberty gingivitis was related more closely to plaque build up than to hormones.

Conditioned gingival enlargement in puberty in a 13-year old boy…

Inflammation due to increased sex hormones during puberty

Enlargement in Vitamin C Deficiency:

Acute vit C deficiency itself does not cause gingival inflammation, but it does cause hemorrhage, collagen degeneration, and edema of the gingival connective tissue

The enlargement is marginal; the gingiva is bluish-red, soft and friable and has a smooth, shiny surface

Gingival enlargement in patient with vitamin C deficiency…

Plasma Cell Gingivitis:

Also called Atypical gingivitis and Plasma cell gingivostomatitis

Plasma cell granuloma- Bhasker 1988

Plasma cell gingivitis is thought to be allergic in origin, possibly related to components of chewing gum, dentifrices, or various diet components

Often shows a mild marginal gingival enlargement, that extends to the attached gingiva

The gingiva appears soft, friable, and sometimes granular and bleeds easily

Plasma cell gingivitis…

In a case report of PCG, PCG associated with generalized aggressive periodontitis

(GAgP), which was brought on by the use of herbal toothpaste containing “Acacia” extract

from the tree “Acacia Arabica.”

Anjali makkar, JISP, 2013 Jul-Aug; 17(4): 527–530.

Nonspecific Conditioned Enlargement (Pyogenic Granuloma):

The lesion varies from a discrete, spherical, tumor like mass

with a pedunculated attachment to a flattened, keloid like

enlargement with a broad base

Why????????????

Oral pyogenic granuloma arises as a result of some minor trauma to the tissues that provide a pathway for invasion of nonspecific types of microorganisms.

The tissues responds to these organisms of low virulence by the overzealous proliferation of a vascular type of connective tissue.

Ainamo suggested that trauma can cause release of various endogenous substances including angiogenic factors from the tumor cells and it may also cause disturbances in the vascular system of the affected area.

Pyogenic granuloma in a young woman…

Systemic Diseases That Cause Gingival Enlargement

Several systemic diseases may result in gingival enlargement through different mechanisms

These are usually uncommon cases

Leukemia

Granulomatous diseases:

Wegener’s Granulomatosis

Sarcoidosis

Leukemia

Leukemia, like other cancers, results from mutations in the

DNA.

Certain mutations can trigger leukemia by

activating oncogenes or deactivating tumor suppressor

genes, and thereby disrupting the regulation of cell death,

differentiation or division.

These mutations may occur spontaneously or as a result of

exposure to radiation or carcinogenic substances

In leukemia typically the lamina propria is

densely packed with leukemic cells extending

from the basal cell layer of the epithelium into

the gingiva, there by altering the normal

anatomy.

Regional blood vessels are compressed by

infiltration

Leukemic gingival enlargement…

Granulomatous Diseases

Wegener's Granulomatosis

Charecterised by a triad of necrotic vasculitis, necrotic glomerulonephritis and

granulomatous inflammation of the upper or lower respiratory tract

Anti-neutrophil cytoplasmic antibodies (ANCA) to the cytoplasmic antigens of

neutrophil granulocytes

Sarcoidosis

Tuberculousis associated gingival enlargement

Varadhan Karthikeyan in 2006 has reported a rare case of diffuse

gingival enlargement in a patient with primary tuberculosis.

Syndromes typically associated with gingival enlargements:

Apert’s syndrome:

Apert’s syndrome is a form of acrocephalosyndactyly

Apert’s syndrome occurs as a result of androgen end organ hyper-response affecting the epiphyses and sebaceous glands that results in early epiphyseal fusion leading to short stature, short and fused digits and acrocephaly.

Premalatha et al; JISPP: 2010, issue 4, vol 28

The oral cavity of Apert patients includes a reduction in the size of the maxilla, tooth crowding, anterior open-bite of the maxilla, impacted teeth, delayed eruption, ectopic eruption, supernumerary teeth, and thick gingiva. The mandible usually is within normal size and shape, and simulates a pseudoprognathism

clinical and radiographic features and case report: Felipe Paes Varoli et al, Rev Odonto Cienc 2011

Cross–McKusick–Breen syndrome

also known as "Cross syndrome," "Hypopigmentation and microphthalmia," and "Oculocerebral-hypopigmentation syndrome“

extremely rare disorder characterized by white skin, blond hair with yellow-gray metallic sheen, small eyes with cloudy corneas, jerky nystagmus, gingival fibromatosis and severe mental and physical retardation.

It was characterized in 1967

Melkersson-Rosenthal Syndrome:

Melkersson-Rosenthal syndrome (MRS) is a very rare neurological disorder.

The origin of MRS is as yet unknown.

The diagnosis of the disease usually occurs in the patient’s second or third decade of life.

The clinical symptoms are remittent swellings of the oral, pharyngeal and laryngeal mucosa as well as the lips. Due to the presence of granulomata in all orofacial soft tissues, a plicated tongue as well as facial nerve paralysis may occur. Intermittent increase of mucosal swelling, including swelling of the gingiva, may increase the risk of development of chronic periodontitis by inhibiting local plaque removal.

Generalised swelling and hypoplastic keratinisation of the gingiva. Chronic Periodontitis in Conjunction with Melkersson-Rosenthal Syndrome:

A Case Report and Literature Review: Frank Broseler, Angelika Neuber: Perio 2006; Vol 3, Issue 1: 43–48.

Sturge weber syndrome Sturge Weber syndrome (SWS) was first described by Schirmer in

1860 and later more specifically by Sturge in 1879

Most common features are epilepsy, Port-wine stain and dermal angiomas, abnormal findings in skull radiographs, mental retardation, ocular involvement and hemiplegia. the most common feature is a gingival hemangiomatous lesion usually restricted to ipsilateral maxilla, mandible, floor of mouth, lips, cheeks, palate and tongue.

A Case Report Neha Khambete et al INTERNATIONAL JOURNAL OF DENTAL CLINICS Vol 3 JAN-MAR 2011

Oral changes occur in 40% cases of this syndrome and may include massive growth of the gingiva and asymmetric jaw growth. Sturge-Weber syndrome: A case report MUKHOPADHYAY S. J Indian Soc Pedod Prevent Dent - Supplement 2008.

Diagnosis

MANAGEMENT OF GINGIVAL ENLARGEMENTS

Gingivectomy using scalpel The dotted line represents the external bevel incision, and the shaded area corresponds to the tissue to be excised.Gingivectomy incision may not remove the entire hyperplastic tissue (shaded area) and may leave a wide wound of exposed connective tissue.

Flap technique

A, Initial reverse bevel incision followed by thinning of the enlarged gingival tissue; dotted lines represent incisions, and the shaded area represents the tissue portion to be excised.B, After flap elevation, enlarged portion of the gingival tissue is removed.C, The flap is placed on top of the alveolar bone and sutured.

Ledge and Wedge and Internal Bevel Gingivectomy Techniques

A, Preoperative diagram showing

gingival enlargement.

B, The initial facial and lingual incisions (1) are made perpendicular to the gingiva to strike the base of the soft tissue pockets.

C,Secondary incisions (2) are made on the facial and lingual at a 45-degree external bevel to remove the remaining soft tissue ledges.

D, Postoperative result.

Gingivectomy using electrocautery

COAG -20-30 (25)W

Blend-Cut -20-30

W

Advantages Electrosurgery is

thought of as the sculpture of living tissue because it works without pressure, unlike scalpel. 

Bleeding is controlled by electrosurgery.

Adjunct to other therapies due to its ability to induce heat in fluid. For eg: accelerating desensitizing agents, in gingival curettage, in root canal sterilization, accelerating whitening agents in spot whitening.

Disadvantages Unpleasant odor.

When the bone touches it causes necrosis. 

The heat generated causes loss of periodontal support when the electrode is used to close to bone.

Causes cementum burns  

The smoke is considered a mild carcinogen.

Gingivectomy using laser CO2 laser -7-W of power continuous

wave mode.

Er:YAG laser -3 W of power continuous wave mode

Nd:YAG laser- 4 W of power continuous wave mode

diode laser- 2 W of power continuous wave mode

Relative bloodless operative and post-operative field Greater accuracy in making incisions Sterilization of the operating field Minimal swelling and scarring Less post-operative pain Hemostasis

TREATMENT OF LEUKEMIC GINGIVAL ENLARGEMENT

Bleeding & clotting times and platelet count of the patient should be checked and the hematologist consulted before periodontal treatment

The enlargement is treated by scaling and root planing carried out in stages under topical anesthesia.

The initial treatment consists of gently removing all loose accumulations with cotton pellets.

Progressively deeper scalings are carried out at subsequent visits.

Antibiotics are administered systemically the evening before and for 48 hours after each treatment to reduce the risk of infection

TREATMENT OF GINGIVAL ENLARGEMENT IN PREGNANCY

Treatment requires elimination of all local irritants re sponsible for precipitating the gingival changes in pregnancy

Marginal and interdental gingival inflammation and enlargement are treated by scaling and curettage.

Treatment of tumor-like gingival enlargements consists of surgical excision and scaling and planing of the tooth surface.

In pregnancy, the emphasis should be on-

Preventing gingival disease before it occurs

Treating existing gingival disease before it worsens

TREATMENT OF GINGIVAL ENLARGEMENT IN PUBERTY

Gingival enlargement in puberty is treated by performing scaling and curettage, removing all sources

The use of escharotic drugs has been recommended in the past for the removal of gingival enlargements of irritation, and controlling plaque.

RECURRENCE OF GINGIVAL ENLARGEMENT

Recurrence of chronic inflammatory enlargements immediately after treatment indicates that all irritants have not been removed.

If the enlargement recurs after healing is complete and normal contour is attained, inadequate plaque control by the patient is the most common cause.

Recurrence during the healing period is manifested as red, beadlike, granulomatous masses that bleed on slight provocation.

Treatment consists of removal of the lesions plus the elimination of irritating local factors.

conclusion

Many systemic diseases may mimic periodontitis or gingivitis.

These include many immunologic, infectious, neoplastic and metabolic disorders.

In comparision with periodontitis and gingivitis, these disorders are considerably less common.

However. Since their diagnosis and management differ, a high index of suspicion is frequently needed when confronted a patient presenting with gingival or periodontal disease.

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