| Gingival enlargement | |
|---|---|
| Other names | Gingival overgrowth (GO), hypertrophic gingivitis, gingival hyperplasia, gingival hypertrophy |
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| Gingivitis, a common cause of inflammatory gingival enlargement. | |
| Specialty | Periodontology |
| Symptoms | increase in gum size |
| Causes | inflammatory conditions, Drug-induced, genetic |
Gingival enlargement is an increase in the size of thegingiva (gums). It is a common feature of gingivaldisease.[1] Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medications. The treatment is based on the cause.[1] A closely related term isepulis, denoting a localizedtumor (i.e., lump) on the gingiva.
The terms gingivalhyperplasia and gingivalhypertrophy have been used to describe this topic in the past.[1] These are not precise descriptions of gingival enlargement because these terms are strictlyhistologicdiagnoses, and such diagnoses requiremicroscopic analysis of a tissue sample. Hyperplasia refers to an increased number ofcells, and hypertrophy refers to an increase in the size of individual cells.[2] As these identifications cannot be performed with a clinical examination and evaluation of the tissue,[3] the termgingival enlargement is more properly applied. Gingival enlargement has been classified according to cause into five general groups:[1]
Gingival enlargement has a multitude of causes. The most common ischronicinflammatory gingival enlargement, when thegingivae are soft and discolored. This is caused by tissueedema andinfectivecellular infiltration caused by prolonged exposure tobacterial plaque, and is treated with conventionalperiodontal treatment, such asscaling and root planing.[1]
Gingivitis and gingival enlargement are often seen inmouth breathers,[4] as a result of irritation brought on by surface dehydration, but the manner in which it is caused has not been demonstrated.[1]
The accumulation and retention ofplaque is the chief cause of inflammatory gingival enlargement. Risk factors include poororal hygiene,[5] as well as physical irritation of the gingiva by improperrestorative andorthodontic appliances.[1]
This type of gingival enlargement is sometimes termed "drug induced gingival enlargement" or "drug influenced gingival overgrowth",[6] abbreviated to "DIGO".[7] Gingival enlargement may also be associated with the administration of three different classes of drugs, all producing a similar response:[8] Gingival overgrowth is a common side effect of phenytoin, termed "Phenytoin-induced gingival overgrowth" (PIGO).[9]
Of all cases of DIGO, about 50% are attributed to phenytoin, 30% to cyclosporins and the remaining 10-20% to calcium channel blockers.
Drug-induced enlargement has been associated with a patient'sgenetic predisposition,[11] and its association with inflammation is debated. Some investigators assert that underlying inflammation is necessary for the development of drug-induced enlargement,[12] while others purport that the existing enlargement induced by the drug effect compounds plaque retention, thus furthering the tissue response.[13] Careful attention to oral hygiene may reduce the severity of gingival hyperplasia.[14] In most cases, discontinuing the culprit drug resolves the hyperplasia.[14]
Many systemic diseases can develop oral manifestations that may include gingival enlargement, some that are related to conditions and others that are related to disease:[15]
Drug Induced gingival overgrowth:
The first line management of gingival overgrowth is improvedoral hygiene, ensuring that the irritative plaque is removed from around the necks of the teeth and gums. Situations in which the chronic inflammatory gingival enlargement include significantfibrotic components that do not respond to and undergo shrinkage when exposed to scaling and root planing are treated with surgical removal of the excess tissue, most often with a procedure known asgingivectomy.[1]
In DIGO, improved oral hygiene and plaque control is still important to help reduce any inflammatory component that may be contributing to the overgrowth. Reversing and preventing gingival enlargement caused by drugs is as easy as ceasing drug therapy or substituting to another drug. However, this is not always an option; in such a situation, alternative drug therapy may be employed, if possible, to avoid this deleteriousside effect. In the case of immunosuppression,tacrolimus is an available alternative which results in much less severe gingival overgrowth than cyclosporin, but is similarly asnephrotoxic.[19] The dihydropyridine derivative isradipidine can replace nifedipine for some uses of calcium channel blocking and does not induce gingival overgrowth.[20]
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Gingival enlargement is common.[21]
It is commonly seen inBoxer dogs and otherbrachycephalic breeds,[22] and in theEnglish Springer Spaniel.[23] It usually starts around middle age and progresses. Some areas of the gingiva can become quite large but have only a small attachment to the rest of the gingiva, and it may completely cover the teeth. Infection and inflammation of the gingiva is common with this condition. Under anesthesia, the enlarged areas of gingiva can be cut back with a scalpel blade orCO2 laser, but it often recurs.[24] Gingival enlargement is also a potential sequela ofgingivitis. As in humans, it may be seen as a side effect to the use ofciclosporin.[25]