1. GINGIVAL ENLARGEMENT

2. Increase in size of the gingiva is a common feature of gingival disease .
Accepted current terminology for this condition is gingival enlargement and gingival overgrowth.

3. CLASSIFICATION I. Inflammatory enlargement A. Chronic B. Acute
II. Drug-induced enlargement
III. Enlargements associated with systemic diseases
A. Conditioned enlargement
1. Pregnancy
2. Puberty
3. Vitamin C deficiency
4. Plasma cell gingivitis
5. Nonspecific conditioned enlargement
(granuloma pyogenicum)

4. CLASSIFICATION B. Systemic diseases causing gingival enlargement
1. Leukemia
2. Granulomatous diseases (Wegener's
granulomatosis, sarcoidosis, and so on)
IV. Neoplastic enlargement (gingival tumors)
A. Benign tumors
B. Malignant tumors
V. False enlargement

5. Using the criteria of location and distribution, gingival enlargement is designated as follows:
Localized: Limited to the gingiva adjacent to a single
tooth or group of teeth
Generalized: Involving the gingiva throughout the mouth
Marginal: Confined to the marginal gingiva
Papillary: Confined to the interdental papilla
Diffuse: Involving the marginal and attached gingiva
and papillae
Discrete: An isolated sessile or pedunculated tumorlike
enlargement

6. The degree of gingival enlargement can be scored as follows:
Grade 0: No signs of gingival enlargement
Grade I: Enlargement confined to
interdental papilla
Grade II: Enlargement involves papilla and
marginal gingiva
Grade III: Enlargement covers three quarters or
more of the crown

7. INFLAMMATORY ENLARGEMENT
Chronic Inflammatory Enlargement
CLINICAL FEATURES
slight ballooning of the interdental papilla and/or the marginal gingiva
life preserver-shaped bulge around the involved teeth
localized or generalized

8. discrete sessile or pedunculated mass resembling a tumor
interproximal or on the marginal or attached gingiva
slow growing and usually painless
painful ulceration sometimes occurs

9. HISTOPATHOLOGY
preponderance of inflammatory cells and fluid with vascular engorgement, new capillary formation, and associated degenerative changes.
greater fibrotic component with an abundance of fibroblasts and collagen fibers.

10. ETIOLOGY
Prolonged exposure to dental plaque.
Factors that favor plaque accumulation and retention include poor oral hygiene as well as irritation by anatomic abnormalities and improper restorative and orthodontic appliances.

11. INFLAMMATORY GINGIVAL ENLARGEMNT
INFLAMMATORY GINGIVAL ENLARGEMENT

12. Chronic inflammatory gingival enlargement

13. Gingival Changes Associated with Mouth Breathing
Gingivitis and gingival enlargement
gingiva appears red and edematous with a diffuse surface shininess of the exposed area
maxillary anterior region is the common site
altered gingiva is clearly demarcated from the adjacent unexposed normal gingiva
harmful effect is generally attributed to irritation from surface dehydration.

14. Mouth Breathing

15. ACUTE INFLAMMATORY ENLARGEMENT
GINGIVAL ABSCESS
localized, painful, rapidly expanding lesion that is usually of sudden onset
limited to the marginal gingiva or interdental papilla
early stages it appears as a red swelling with a smooth, shiny surface

16. GINGIVAL ABSCESS

17. Within 24 to 48 hours, the lesion usually becomes fluctuant and pointed with a surface orifice from which a purulent exudate may be expressed
adjacent teeth are often sensitive to percussion
if permitted to progress, the lesion generally ruptures spontaneously.

18. ETIOLOGY
results from bacteria carried deep into the tissues when a foreign substance such as a toothbrush bristle, a piece of apple core, or a lobster shell fragment is forcefully embedded into the gingiva.
confined to the gingiva
should not be confused with periodontal or lateral abscesses.

19. PERIODONTAL (LATERAL) ABSCESS
Periodontal abscesses generally produce enlargement of the gingiva, but they also involve the supporting periodontal tissues.

21. DRUG-INDUCED GINGIVAL ENLARGEMENT
Gingival enlargement is a well-known consequence of the administration of some anticonvulsants, immunosuppressants, and calcium channel blockers and may create speech, mastication, tooth eruption, and aesthetic problems.

22. GENERAL INFORMATION CLINICAL FEATURES
growth starts as a painless, beadlike enlargement of the interdental papilla and extends to the facial and lingual gingival margins
As the condition progresses, the marginal and papillary enlargements unite
they may develop into a massive tissue fold covering a considerable portion of the crowns, and they may interfere with occlusion

23. When uncomplicated by inflammation, the lesion is mulberry shaped, firm, pale pink, and resilient, with a minutely lobulated surface and no tendency to bleed
enlargement characteristically appears to project from beneath the gingival margin, from which it is separated by a linear groove.
generalized throughout the mouth but is more severe in the maxillary and mandibular anterior regions

24. Occurs in areas in which teeth are present, not in edentulous spaces, and the enlargement disappears in areas from which teeth are extracted
Hyperplasia of the mucosa in edentulous mouths has been reported but is rare

25. Drug-induced enlargement may occur in mouths with little or no plaque and may be absent in mouths with abundant deposits
However, the presence of the enlargement makes plaque control difficult, often resulting in a secondary inflammatory process that complicates the gingival overgrowth caused by the drug
The resultant enlargement can be a combined enlargement

26. HISTOPATHOLOGY
pronounced hyperplasia of the connective tissue and epithelium
acanthosis of the epithelium
elongated rete pegs
connective tissue exhibits densely arranged collagen bundles with an increase in the number of fibroblasts and new blood vessels.

27. Recurring enlargements appear as granulation tissue composed of numerous young capillaries and fibroblasts and irregularly arranged collagen fibrils with occasional lymphocytes

28. ANTICONVULSANTS
first drug-induced gingival enlargements reported were those produced by phenytoin (Dilantin)
Other hydantoins known to induce gingival enlargement are ethotoin (Paganone), and mephenytoin (Mesantoin)
Other anticonvulsants are the succinimides (ethosuximide [Zerontinj, methsuxinimide [Celontinj), and valproic acid (Depakene)

29. Tissue culture experiments indicate that phenytoin stimulates proliferation of fibroblast-like cells
Phenytoin may induce a decrease in collagen degradation as a result of the production of an inactive fibroblastic collagenase

30. Phenytoin gingival enlargement, facial view.

31. Phenytoin gingival enlargement, occlusal view

32. IMMUNOSUPPRESSANTS
Cyclosporine is a potent immunosuppressive agent used to prevent organ transplant rejection and to treat several diseases of autoimmune origin
Cyclosporine-induced gingival enlargement is more vascularized than the phenytoin enlargement, occurs in approximately 30% of patients receiving the drug, is more frequent in children, and its magnitude appears to be related more to the plasma concentration than to the patient's periodontal status

33. microscopic finding of many plasma cells plus the presence of an abundant amorphous extracellular substance has suggested that the enlargement is a hypersensitivity response to the cyclosporine

34. Cyclosporine gingival enlargement

35. CALCIUM CHANNEL BLOCKERS
Calcium channel blockers are drugs developed for the treatment of cardiovascular conditions
Some of these drugs can induce gingival enlargement.
Nifedipine, Diltiazem, felodipine,
nitrendipine, and verapamil

36. IDIOPATHIC GINGIVAL ENLARGEMENT
Idiopathic gingival fibromatosis is a rare condition of undetermined cause.
It has been designated by such terms as gingivomatosis, elephantiasis, idiopathic fibromatosis, hereditary gingival hyperplasia, and congenital familial fibromatosis.

37. CLINICAL FEATURES
affects the attached gingiva, gingival margin and inter- dental papillae
facial and lingual surfaces of the mandible and maxilla are generally affected
pink, firm, and almost leathery in consistency and has a characteristic minutely pebbled surface
severe cases the teeth are almost completely covered
Secondary inflammatory changes are common

38. Gingival fibromatosis.

39. HISTOPATHOLOGY
Bulbous increase in the amount of
connective tissue
relatively avascular
consists of densely arranged collagen bundles and numerous fibroblasts
Thickened surface epithelium- acanthotic with elongated rete pegs

40. ETIOLOGY
cause is unknown
Some cases have a hereditary basis
autosomal recessive in some cases and autosomal dominant in others
begins with the eruption of the primary or secondary dentition and may regress after extraction

41. ENLARGEMENTS ASSOCIATED WITH SYSTEMIC DISEASES
Many systemic diseases can develop oral manifestations.
These conditions affect the periodontium by 2 different mechanisms:-
Magnification of an existing inflammation initiated by dental plaque
Manifestation of the systemic disease independently of the inflammatory status of the gingiva

42. CONDITIONED ENLARGEMENT
Occurs when the systemic condition of the patient exaggerates or distorts the usual gingival response to dental plaque
Bacterial plaque is necessary for the initiation of this type of enlargement
Three types of conditioned gingival enlargement are hormonal (pregnancy, puberty), nutritional (associated with vitamin C deficiency), and allergic
Nonspecific conditioned enlargement is also seen.

43. Enlargement in Pregnancy
may be marginal and generalized
may occur as single or multiple tumor-like masses
There is an increase in levels of both progesterone and estrogen
Hormonal changes induce changes in vascular permeability leading to gingival edema and an increased inflammatory response to dental plaque

44. MARGINAL ENLARGEMENT
Marginal gingival enlargement during pregnancy results from the aggravation of previous inflammation
does not occur without the presence of bacterial plaque.
Clinical Features
varies considerably
generalized and tends to be more prominent interproximally
bright red or magenta, soft, and friable
spontaneous bleeding

45. TUMORLIKE GINGIVAL ENLARGEMENT
so- called pregnancy tumor is not a neoplasm
is an inflammatory response to bacterial plaque
modified by the patient's condition
usually appears after the third month of pregnancy

46. Clinical Features
appears as a discrete, mushroomlike, flattened spherical mass
protrudes from the gingival margin or more commonly from the interproximal space
Sessile or pedunculated
dusky red or magenta
surface exhibits numerous deep red, pinpoint markings
painless unless painful ulceration occurs

47. Pregnancy gingival enlargement

48. HISTOPATHOLOGY
Gingival enlargement in pregnancy is called angiogranuloma
central mass of connective tissue
numerous diffusely arranged, newly formed, and engorged capillaries lined by cuboid endothelial cells
moderately fibrous stroma with varying degrees of edema and chronic inflammatory infiltrate

49. Enlargement in Puberty
occurs in both male and female adolescents
appears in areas of plaque accumulation

50. CLINICAL FEATURES
It is marginal and interdental and is characterized by prominent bulbous inter- proximal papillae
Often only the facial gingivae are enlarged
features generally associated with chronic inflammatory gingival disease
scant plaque deposits that distinguish pubertal gingival enlargement
HISTOPATHOLOGY
The microscopic picture is that of chronic inflammation with prominent edema and associated degenerative changes.

51. Enlargement in Vitamin C Deficiency
generally included in classic descriptions of scurvy
is essentially a conditioned response to bacterial plaque
Acute vitamin C deficiency does not of itself cause gingival inflammation, but it does cause hemorrhage, collagen degeneration, and edema of the gingival connective tissue

52. combined effect of acute vitamin C deficiency and inflammation produces the massive gingival enlargement in scurvy
CLINICAL FEATURES
Marginal
the gingiva is bluish red, soft, and friable and has a smooth, shiny surface
Hemorrhage, occurring either spontaneously or on slight provocation
surface necrosis with pseudo membrane formation

53. HISTOPATHOLOGY
chronic inflammatory cellular infiltration with a superficial acute response
scattered areas of hemorrhage, with engorged capillaries
Marked diffuse edema
collagen degeneration
scarcity of collagen fibrils or fibroblasts

54. Plasma Cell Gingivitis
referred to as atypical gingivitis and plasma cell gingivostomatitis
often consists of a mild marginal gingival enlargement
extends to the attached gingiva.
localized lesion, referred to as plasma cell granuloma

55. CLINICAL FEATURES
gingiva appears red, friable, and sometimes granular and bleeds easily
usually it does not induce a loss of attachment.
is located in the oral aspect of the attached gingiva and therefore differs from plaque-induced gingivitis.

56. HISTOPATHOLOGY
oral epithelium shows spongiosis and infiltration with inflammatory cells
ultrastructurally there are signs of damage in the lower spinous layers and the basal layers

59. Nonspecific Conditioned Enlargement (Pyogenic Granuloma).
tumorlike gingival enlargement that is considered an exaggerated conditioned response to minor trauma
discrete spherical, tumorlike mass with a pedunculated attachment to a flattened, keloidlike enlargement with a broad base.
It is bright red or purple and either friable or firm

60. HISTOPATHOLOGY
appears as a mass of granulation tissue with chronic inflammatory cellular infiltration.
Endothelial proliferation
formation of numerous vascular spaces
surface epithelium is atrophic in some areas and hyperplastic in others

61. Systemic Diseases Causing Gingival Enlargement
LEUKEMIA
CLINICAL FEATURES
enlargement may be diffuse or marginal
localized or generalized
may appear as a diffuse enlargement of the gingival mucosa
oversized extension of the marginal gingiva, or a discrete tumorlike inter. proximal mass

62. Gingiva bluish red and has a shiny surface.
consistency is moderately firm
a tendency toward friability and hemorrhage

63. HISTOPATHOLOGY
various degrees of chronic inflanimation with mature leukocytes
areas of connective tissue infiltrated with a dense mass of immature and proliferating leukocytes

65. Granulomatous Diseases
WEGENER'S GRANULOMATOSIS
is a rare disease characterized by acute granulomatous necrotizing lesions of the respiratory tract, including nasal and oral defects
initial manifestations may involve the orofacial region and include oral mucosal ulceration, gingival enlargement, abnormal tooth mobility, exfoliation of teeth, and delayed healing response

66. CLINICAL FEATURES
reddish purple and bleeds easily on stimulation
CAUSE UNKNOWN
considered an immunologically mediated tissue injury
use of immunosuppressive drugs has produced prolonged remissions in more than 90% of cases

67. SARCOIDOSIS granulomatous disease of unknown etiology
individuals in their twenties or thirties
affects predominantly blacks
can involve almost any organ, including the gingiva, where a red, smooth, painless enlargement may appear

68. HISTOPATHOLOGY
consist of discrete, noncaseating whorls of epitheliold cells and multinucleated foreign-body-type giant cells with peripheral mononuclear cells

69. NEOPLASTIC ENLARGEMENT
Benign Tumors of the Gingiva
EPULIS
is a generic term used clinically to designate all discrete tumors and tumorlike masses of the gingiva.
Most lesions referred to as epulis are inflammatory rather than neoplastic.

70. Fibroma
arise from the gingival connective tissue or from the periodontal ligament
They are slow-growing, spherical tumors that tend to be firm and nodular but may be soft and vascular.
Fibromas are usually pedunculated

71. HISTOPATHOLGY
Well formed collagen bundles with scattering of fibrocytes

72. Papilloma
benign proliferations of surface epithelium associated with the human papillomavirus
solitary, wartlike or 'cauliflower“ like protuberances and may be small and discrete or broad, hard elevations with minutely irregular surfaces.

73. HISTOPATHOLOGY
consists of fingerlike projections of stratified squamous epithelium, often hyperkeratotic, with a central core of fibrovascular connective tissue.

74. Peripheral Giant Cell Granuloma
arise interdentally or from the gingival margin
occur most frequently on the labial surface, and may he sessile or pedunculated
Varies fromsmooth, regularly outlined masses to irregularly shaped, multilobulated protuberances with surface indentations
painless

75. may be firm or spongy, and the color varies from pink to deep red or purplish blue
HISTOPATHOLOGY
Has numerous foci of multinuclear giant cells and hemosiderin particles in a connective tissue stroma
overlying epithelium is usually hyperplastic, with ulceration at the base

76. Central Giant Cell Granuloma
These lesions arise within the jaws and produce central cavitation.
They occasionally create a deformity of the jaw that makes the gingiva appear enlarged.

77. Central giant cell granuloma

78. Malignant Tumors of the Gingiva
CARCINOMA
Oral cancer accounts for less than 3% of all malignant tumors in the body but is the sixth most common cancer in males and the twelfth in females." The gingiva is not a frequent site of oral malignancy (6% of oral cancer).

79. Squamous cell carcinoma is the most common malignant tumor of the gingiva. It may be exophytic, presenting as an irregular outgrowth, or ulcerative, which appear as flat, erosive lesions

81. Malignant Melanoma
rare oral tumor that tends to occur in the hard palate and maxillary gingiva of older persons
darkly pigmented and is often preceded by the occurrence of localized pigmentation
flat or nodular and is characterized by rapid growth and early metastasis

82. SARCOMA.
Fibrosarcoma, lymphosarcoma, and reticulum cell sarcoma of the gingiva are rare
Kaposi's sarcoma often occurs in the oral cavity of patients with acquired immunodefidency syndrome particularly in the palate and the gingiva

83. METASTASIS
not common
Such metastasis has been reported with various tumors, including adenocarcinoma of the colon, lung carcinoma, primary hepatocellular carcinoma
Ulcerations that do not respond to therapy in the usual manner, as well as all gingival tumors and tumorlike lesions must be biopsied and submitted for microscopic diagnosis

84. FALSE ENLARGEMENT
not true enlargements of the gingival tissues but may appear as such as a result of in- creases in size of the underlying osseous or dental tissues
massive increase in size of the area.

85. UNDERLYING OSSEOUS LESIONS
occurs most commonly in tori and exostoses, but it can also occur in Paget's disease, fibrous dysplasia, cherub- ism, central giant cell granuloma, ameloblastoma, os- teoma, and osteosarcoma
gingival tissue can appear normal or may have unrelated inflammatory changes.

86. UNDERLYING DENTAL TISSUES
During the various stages of eruption, particularly of the primary dentition, the labial gingiva may show a bulbous marginal distortion caused by superimposition of the bulk of the gingiva on the normal prominence of the enamel in the gingival half of the crown –DEVELOPMENTAL ENLARGEMENT
physiologic and ordinarily present no problems