Periodontology Gingival Enlargement Question And Answers

Gingival Enlargement

Gingival enlargement may be a result of increased cellular activity, increased deposition of extracellular substance (matrix) or both.

Question 1: Classify gingival enlargement.
Answer:

Classification Of Gingival Enlargement

Inflammatory enlargement

• • Chronic
  • Acute
• Fibrotic enlargement (gingival hyperplasia)
• Drug induced gingival overgrowth
• Idiopathic gingival enlargement
• Combined inflammatory (inflmmatory + firotic)

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• Enlargements associated with systemic diseases/conditions
  • Conditional enlargement.
  • Systemic diseases causing gingival enlargement.
• Neoplastic enlargement (gingival tumors)Benign tumors.
• Malignant tumors.
• False enlargement

Question 2: Discuss inflammatory gingival enlargement.
Answer:

Inflammatory Gingival Enlargement

Inflammatory enlargements may be acute or chronic.  Acute enlargements may be periodontal or gingival abscesses. These have been described in later chapters.

• Chronic inflammatory enlargement occurs in response to plaque as a result of
• inflammatory edema.
• It may be seen more often on the facial side when compared to the palatal or lingual side.
• The consistency may become firm due formation of fibrotic tissue in long-standing lesions.
• Chronic inflammatory gingival enlargement is primarily managed by scaling and root planning.
• In case of the presence of a fibrotic component, the excessive tissue may be removed by gingivectomy or internal bevel flap surgery.

Question 3: Write briefly about conditioned enlargement.
Answer:
 
These enlargements are not seen in the absence of plaque. A common feature of all these lesions is that regardless of the underlying condition, there is an exaggerated response to plaque that results in the enlargement.

Associated with the endocrine system—female sex hormones (estrogen and progesterone):
 
Gingiva has been shown to react to increased levels of these hormones by aggravating pre-existing gingivitis.

Puberty associated gingivitis: In puberty, the increased hormonal especially, estrogen exaggerates the gingival response to the local irritants in female adolescents.

• It is seen usually in the marginal and interdental areas of the facial gingival, seen as bluish red, edematous enlargements that bleed on the slightest provocation.
• After puberty, the enlargement spontaneously diminishes, but is completely eliminated only after removal of local irritants.

Contraceptives: Oral contraceptives aggravate the gingival inflammation due to local irritants and when taken for more than one and half years, it increases periodontal destruction.

Pregnancy Associated Gingivitis and Pyogenic Granuloma

Pregnancy results in increased circulating levels of estrogen and progesterone that accentuate the gingival response to local irritants and accentuates the inflammatory response. It may be more pronounced during the second and third trimester.

• The marginal and the interdental papilla are affected, resulting in smooth, shiny, and edematous gingival that resembles a raspberry and bleeds spontaneously even.
• In some cases, the inflamed gingiva forms discrete ‘tumour-like’ masses referred to as pregnancy tumors or angiogranuloma (Figure 15.2). These are bright red/magenta colored, with a mulberry like surface, seen most often in the interdental gingiva.
• P. intermedia is associated strongly with this lesion and it has been stipulated that this organism can substitute sex hormones for vitamin K that is required for their growth.
• The vascularity of the tissues is greatly enhanced and a number of tortuous capillaries are seen in the engorged connective tissues.

Management

Generally, the lesion regresses about two months post-partum but surgery may be needed at times to correct gingival architecture.

Question 4: Describe the gingival enlargement associated with systemic disease.
Answer:

Leukemia Associated Gingivitis

Gingival enlargement is seen most often in acute monocytic leukemia (20–30). Gingival enlargement occurs due to massive leukemic cell infiltration into the gingival connective tissue.
Clinically, the gingiva initially appears bluish red and cyanotic and may present as enlargements in the presence of plaque.

• These lesions may be sometimes associated with ulcerative lesions, or necrotic ANUG like lesions.
• The characteristic feature of these enlargements is the extreme sensitivity to provocation that results in excessive bleeding.
• Gingival lesions in leukemia have been termed chloroma in older textbooks. Histologically, the gingival connective tissue appears suffused with immature leukocytes.

Management

Caution must be exercised while treating these lesions and must be undertaken only under a hematologist advice. Conservative management may be undertaken if the blood profile is unremarkable.

Question 5: Describe the etiopathogenesis of drug induced gingival enlargement.
Answer:
These enlargements occur as a result of certain drugs on the gingival tissue. The most common drugs that produce gingival enlargement include anticonvulsants like phenytoin sodium, calcium channel blockers like nifedipine, and immune suppressants like cyclosporin.

• The enlargement begins as bead shaped masses in the marginal gingival and inter-dental papilla which typically is pink, firm, and appears uninflamed in early stages.
• They may increase in size gradually to form larger lobulated, firm, fibrous masses that may even interfere with occlusion (Figure 15.3).
•  However, these enlargements provide areas for plaque accumulation that can result in secondary inflammation, whereupon signs of gingivitis may be superadded.

Pathogenesis

There is a marked increase in the proliferation of fibroblasts, increased production of collagen and non collagenous proteins into the extracellular matrix. In addition, the activity of collagenase is suppressed thus resulting in decreased turnover and enlargement.
 
Vitamin C-Ascorbic Acid Defiiency Gingivitis

• Gingival enlargement is characterized by soft friable masses with a smooth, shiny surface. ulcerations, hemorrhage and necrosis and pseudomembrane formation have also been reported.
• Treatment consists of local mechanical and chemical plaque control measures along with dietary supplementation of vitamin C.

Pathogenesis

Low levels of vitamin C impair the ability of connective tissue to regenerate and repair as it is required for collagen production.

• Formation of hydroxyproline and hydroxylysine in the collagen molecule are impaired in the presence of vitamin C deficiency. Consequently, vascular response is affected as is the response to wound healing.

Conclusion

Most of the systemic conditions that have been outlined above influence gingiva by a variety of mechanisms.

• The one underlying common mechanism is that they accentuate the effect of plaque on gingival inflammation.
• By themselves, these conditions rarely cause disease, however, in the presence of plaque, they can lead to an exaggerated inflammatory response.

Question 6: Discuss hereditary gingival fibromatosis and its management.
Answer:

Gingival enlargement is the overgrowth of the gingival, involving the attached gingiva, characterized by gross pink, lobulated enlargement that results in spacing, malpositioned teeth, prolonged retention of primary dentition, delayed eruption cross and open bite, prominent lips, and open lip posture (Figure 15.4).

• It is an autosomal dominant disease. It may be associated with other syndromes, such as Jones syndrome, Zimmerman Laband syndrome, etc. which may be transmitted as a recessive trait.
• The biologic mechanisms underlying HGF may be due to the autocrine activation by TGF-b1 that results in abnormally high collagen production.
• Histological features are increased amount of collagen fiber bundles and oxytalan but very few elastic fibers with few fibroblasts and myofibroblasts.
• These collagen fibrils may have structural abnormalities. Mild chronic inflammatory infiltrates may be observed in the subepithelial connective tissue. The epithelium may show areas of atrophy between the long papilla.
• Treatment depends on the severity of the enlargement and may show varying degree of success. When the enlargement is minimal, thorough scaling of the teeth and home care may be all that is required. But, if the overgrowth is severe, surgical removal is indicated.
• The techniques used for the excision of the enlargement include external or internal bevel gingivectomy in association with gingivoplasty, an apically positioned flap, electrocautery, and carbon dioxide laser.
• This is followed by 0.125 chlorhexidine oral rinse twice daily for two weeks. Recurrence is unpredictable and occurs faster in areas with dental plaque.

Question 7: Describe the conditions resulting in localized gingival enlargement.
Answer:

Localized Gingival Enlargement

Pyogenic Granuloma

It occurs most frequently on the gingiva but may be present in other parts of the oral cavity. It is reddish or bluish, may be sessile or pedunculated.

• The overlying epithelium may be ulcerated and can bleed or express pus like material-hence its name.
• Histopathologically the lesion is characterized by vascular proliferation with numerous vascular spaces filled with erythrocytes and solid sheets of endothelial cells.
• The surface epithelium is ulcerated with areas of acute inflammation beneath.
• Treatment is surgical excision but the lesion has the potential to recur. Sources of irritation must also be removed.

Peripheral Giant Cell Granuloma

It occurs exclusively on the gingiva or edentulous alveolar ridge. The lesions are pedunculated or sessile, red in color, and may be ulcerated. It can cause erosion of the underlying bone which can be detected on the radiograph.

• Local irritation/trauma may be the cause for its occurrence. Histopathologically it is characterized by focal collection of multinucleated osteoclast-like giant cells with a richly cellular and vascular stroma separated by collagenous septa.
• Local excision or enucleation is the most common type of treatment. It has a tendency to recur.

Neoplasm

Most gingival neoplasms affect the mandible and are located posterior to the premolars. It may begin as a nodule and later ulcerate.

• It infiltrates rapidly along the periodontal ligament and caused destruction of the supporting bone. Pain and loosening of the teeth may also be associated with this lesion.
• Identification is done by histopathology of the excised lesion. Metastasis from the lung or breast may be the primary source of the cancer. Treatments include surgery, irradiation or combination of both.