Idiopathic Gingival Hyperplasia: A Case ReportMerve Sirin, Meral UnurDepartment of Maxillofacial Surgery, Istanbul University, Turkey

AbstractGingival hyperplasia may be described as an increase in the size of the gingiva. Idiopathic gingival hyperplasia may be observed asfibrotic hyperplasia of gingival tissue, which leads to esthetic and functional problems. Factors that lead to gingival hyperplasiainclude inflammatory causes, hormone-related causes, leukemia, vitamin C deficiency, non-specific causes, neoplasia and drugs.The drugs that may be responsible include anti-convulsive drugs, immune-suppressive drugs, anti-epileptic drugs and calciumchannel blockers. Gingival hyperplasia with unknown causes, not included in any groups, may also be seen.

Key Words: Gingival hyperplasia, Fibrotic hyperplasia, Vitamin C deficiency

IntroductionGingival enlargement or gingival overgrowth, a common traitof gingival disease, is characterized by an increase in the sizeof gingiva [1,2]. Hyperplasia and hypertrophy are two termsused in pathology to explain gingival growth abnormalities inliving tissues. To make the difference between hyperplasiaand hypertrophy is important, as these terms are often used forthis condition. When we say hyperplasia that means that thecells in the gums have increased in numbers. As for thehypertrophy, it means that the cells in the gums havemaintained their number constant but their size has increased.This is why there are specialists who prefer not to use eitherof these two terms but rather choose gingival enlargement asthe final diagnosis [3-7].

Idiopathic gingival hyperplasia may be observed as fibrotichyperplasia of gingival tissue, which leads to esthetic andfunctional problems. Gingival hyperplasia can be categorizedbased on their etiopathogenesis, location, size, extent. Factorsthat lead to gingival hyperplasia include inflammatory causes,hormone-related causes, leukemia, vitamin C deficiency, non-specific causes, neoplasia and drugs [8,9]. The drugs that maybe responsible include anti-convulsive drugs, immune-suppressive drugs, anti-epileptic drugs and calcium channelblockers, not all patients who use this drugs develop gingivalovergrowth, identifying patients at risk is important in order totake all the necessary measures to minimize the onset andseverity of this condition. The etiology of drug-inducedgingival overgrowth is not understood but is clearlymultifactorial [5].

The treatment protocol of gingival enlargement ischangeable and it is related about the reason. You can use justsurgery, replace the missing one, change the types of drugs orjust improvement the oral hygene [1,2]. Gingival hyperplasiawith unknown causes, not included in any groups, may also beseen.

Case ReportA 28-year-old female patient was admitted to the Oral–Maxillofacial Diseases and Surgery Clinic of DentistryFaculty, Istanbul University on 15th of February, 2016. Shewas admitted to the Internal Medicine Outpatient Clinic withthe complaints of gingival swelling and bleeding persisting forapproximately 2 weeks and she was referred to our clinic as

her routine blood tests and clinical examination findings werenormal. Widespread hemorrhagic hyperplasia involving thefree gingiva and almost all teeth both in the vestibular andlingual sides were observed on the intra-oral examination. Thesize of hyperplasia covered almost all of the vestibularsurfaces of the teeth in the anterior, elevated up to the occlusallayer in the posterior side, particularly in the wisdom tooth.No abnormal findings were encountered on the radiologicalinvestigations. Gingival hyperplasia in the vestibular region ofthe right upper jaw was excised using diode laser one weeklater as her complete blood count was within the normalranges. Prophylactic antibiotic (amoxicillin clavulanate) wasprescribed and the treatment was supported withchlorhexidine gluconate. The pathological specimen wasexamined in the Pathology Department of Istanbul Universitywith the pre-diagnosis of leukemia and reported as plasmacells on a background of ulcer and intense inflammatoryinfiltration rich with eosinophils, and hyperplasia in theneighboring mucosa (neoplastic cells were not seen). Allinflammatory tissues were excised in 3 sessions (with laserand lancet surgery). However, the patient underwent bonemarrow aspiration biopsy in order to exclude leukemia whenshe underwent the consultation of the HematologyDepartment and the result was found to be negative. Sheexperienced concurrent influenza infection during herexcisions and she was examined in the PulmonologyDepartment, and the computed tomography of the thoraxperformed with intravenous contrast medium injection wassuggestive of lymphoma, metastasis, sarcoidosis, pleuraltumor, and the biopsy was reported to be consistent withhypersensitivity pneumonia, although the findings supportedbenign inflammatory processes [10]. The report includedstatements such as “The patient should be evaluated togetherwith clinical findings for hypersensitivity pneumonia,connective tissue disorders and drug toxicity under the light ofhistopathological findings”. However, no diagnosis could bemade according to the result of the clinical examinations. Thepatient was referred to the Rheumatology Clinic due to thepresence of nodular lesions in the lung, and Wagenergranulomatosis was suggested. However, it was excluded asp-ANCA was found to be negative. Minor salivary glandbiopsy was obtained due to the pre-diagnosis of sarcoidosisand granuloma was not encountered. The Vitamin C level was

Corresponding author: Merve Sirin, Department of Maxillofacial Surgery, Istanbul University, Turkey, Tel: 0212 440 00 00; E-mail: mervesirin_1987@hotmail.com

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analyzed as vitamin C deficiency may be a cause of gingivalhyperplasia; however, it was found to be normal.

Figure 1. Patient initial photo.

Figure 2. Patient initial left side photo.

Figure 3. After first operation of right side, 3 days later.

Her fillings were removed due to the possibility of allergicreaction as the hyperplasia was reported to develop afterfillings, and thereafter, the patch test was performed in theAllergy Outpatient Clinic of Department of Internal Medicineand the result was determined to be negative. Her intra-oralfindings were completely resolved and no recurrence wasobserved (Figures 1-6).

Figure 4. Patient final photo (7 months later).

Figure 5. Patient final left side photo (7 months later).

Figure 6. Patient final right side photo (7 months later).

DiscussionGingival hyperplasia may lead to esthetic and functionallosses [1]. The pathogenesis may include systemic drug use,

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vitamin deficiency, neoplastic/non-neoplastic hematologicaldisorders.

Omori et al. reported vitamin C deficiency and periodontaldisease in their case report. While vitamin C deficiency maylead to irregular gingival hyperplasia and hemorrhagic fieldsas in our case, it is not encountered frequently in moderncommunities today. The Vitamin C level was normal in ourpatient [7].

Widespread gingival hyperplasia and hemorrhage were seentogether in a patient with acute myelodysplastic leukemia,which was reported by Güzeldemir et al. Although thesefindings were seen together in our patient too, leukemia wasexcluded through blood tests and biopsies [4].

Baltacıoğlu et al. reported gingival hyperplasia in 3 patientswho used cyclosporine and its treatment. However, our patientdid not have the history of drug use causing gingivalhyperplasia like immunosuppressive agents, anticonvulsantsand calcium channel blockers [2].

Gingival hyperplasia was reported to completely cover thevestibular sides of the teeth in the anterior, deep sacs wereobserved in a patient with gingival fibromatosis reported byGüngör et al. however, hemorrhage was not reported. Ourpatient had generalized hemorrhage, although similar gingivalhyperplasia was observed and the biopsy result was notconsistent with fibromatosis [3].

Nuyen et al. reported gingival metastasis in a patient withadeno-carcinoma of the lung in their case report in 2016.Although no metastasis –related gingival pain was felt, ulcerfields and hyperplasia were observed. However, our patientdid not have a medical history or family history of malignancy[6].

Painless gingival hyperplasia lasting for one month in theposterosuperior region of the gingiva was reported in a 42-year-old male patient by Tripathi et al. The patient wasdiagnosed with sarcoidosis and he was treated [11]. Minorsalivary gland biopsy was performed with the pre-diagnosis ofsarcoidosis in our patient too. However, the diagnosis ofsarcoidosis was excluded as granuloma was not encountered.

ConclusionGingival hyperplasia is among the most common gingivaldiseases. It is categorized according to its localization and

size. Management and recurrence depend on its being able tobe diagnosed correctly. Our patient was treated successfully,although a definite diagnosis could not be made and norecurrence was observed in the 7-month follow up. However,we could not make a definitive diagnosis unfortunately. Allpossible diagnoses were excluded through statements of thepatient, tests and biopsies. However, we faced to a case whichwe had overlooked or not encountered before.

We will be glad if our valuable colleagues who have anopinion about the diagnosis provide feedback.

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8. Padmanabhan S, Dwarakanath CD. Severe gingivalenlargement associated with aggresive periodontitis. Journal ofIndian Society of Periodontology. 2013; 17: 115-119.

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