GINGIVAL
ENLARGEMENT

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.
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)
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
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
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
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
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

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.
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.
INFLAMMATORY GINGIVAL
GINGIVALENLARGEMNT
ENLARGEMENT
Chronic inflammatory gingival enlargement
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.

Mouth Breathing
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

GINGIVAL ABSCESS

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.
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.
PERIODONTAL (LATERAL)
ABSCESS

Periodontal abscesses generally produce
enlargement of the gingiva, but they also
involve the supporting periodontal tissues.
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.
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


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

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

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
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.

Recurring enlargements appear as
granulation tissue composed of numerous
young capillaries and fibroblasts and
irregularly arranged collagen fibrils with
occasional lymphocytes
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)

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

Phenytoin gingival enlargement, facial view.
Phenytoin gingival enlargement, occlusal view
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

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
Cyclosporine gingival enlargement
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

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.
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

Gingival fibromatosis.
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

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
ENLARGEMENTS ASSOCIATED
WITH SYSTEMIC DISEASES
Many systemic diseases can develop oral
manifestations.
These conditions affect the periodontium by 2
different mechanisms: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

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.

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

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

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

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

Pregnancy gingival enlargement
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
Enlargement in Puberty
occurs in both male and female
adolescents
 appears in areas of plaque accumulation

CLINICAL FEATURES
 It is marginal and interdental and is
characterized by prominent bulbous interproximal 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.
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

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

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
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
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.
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
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

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
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
Gingiva bluish red and has a shiny
surface.
 consistency is moderately firm
 a tendency toward friability and
hemorrhage

HISTOPATHOLOGY
 various degrees of chronic inflanimation
with mature leukocytes
 areas of connective tissue infiltrated with a
dense mass of immature and proliferating
leukocytes
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
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
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

HISTOPATHOLOGY

consist of discrete, noncaseating whorls of
epitheliold cells and multinucleated
foreign-body-type giant cells with
peripheral mononuclear cells
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.

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
HISTOPATHOLGY
 Well formed collagen bundles with
scattering of fibrocytes
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.
HISTOPATHOLOGY
 consists of fingerlike projections of
stratified squamous epithelium, often
hyperkeratotic, with a central core of
fibrovascular connective tissue.
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

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

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.
Central giant cell granuloma
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).

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
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

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

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

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.

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.

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
