enlargements associated with systemic diseases and syndromes

1. Presented By
Dr. M. Shiva Shanker
Ist Year Post Graduate Student ,
Dept of Periodontics, Mamata Dental College.

2. Contents
Introduction
Terminologies
Classification of gingival enlargements
Gingival enlargement associated with systemic diseases and their clinical &
Histopathological features
Diagnosis
Management of gingival enlargement
Recurrence of gingival enlargement
Conclusion

3. Introduction
Accepted current terminology for this condition is gingival
enlargement and gingival overgrowth.
These are strictly clinical descriptive terms and to avoid the
erroneous pathologic connotations of terms used in the past
such as hypertrophic gingivitis or gingival hyperplasia.
Gingival enlargement is the overgrowth of the gingiva
characterized by an expansion and accumulation of the
connective tissue with occasional presence of increased
number of cells. It is caused by several factors, such as,
inflammation, leukemia, drugs and inheritance.

4. Terminologies
 Gingival Enlargement: An overgrowth or
increase in size of the gingiva
 Gingival Hyperplasia: An enlargement of the
gingiva due to an increase in the number of
cells
 Gingival Hypertrophy: An enlargement of the
gingiva due to an increase in the size of cells
(According to the Glossary of Periodontal Terms, 4th Edition,
2001)

5. CLASSIFICATION
I. Inflammatory enlargement
A. Chronic
B. Acute
II. Drug-induced enlargement
III. Enlargements associated with systemic diseases
A. Conditioned enlargement
Pregnancy
Puberty
Vitamin C deficiency
Plasma cell gingivitis
Nonspecific conditioned enlargement (granuloma pyogenicum)
B. Systemic diseases causing gingival enlargement
Leukemia
Granulomatous diseases (Wegener’s granulomatosis, Sarcoidosis etc.)
IV. Neoplastic enlargement (gingival tumors)
A. Benign tumors
B. Malignant tumors
V. False enlargement

6. Based on location and distribution
 Localized
 Generalised
 Marginal
 Papillary
 Diffuse
 Discrete

7. Gingival enlargement associated with systemic
diseases
Many systemic diseases can develop oral manifestations that may
include gingival enlargement
These systemic diseases and/or conditions can affect the
periodontium by two different mechanisms as follows:
1. Magnification of an existing inflammation initiated by dental plaque
2. Manifestation of the systemic disease independently of the inflammatory
status of the gingiva

8. Conditioned Enlargement
 Conditioned enlargement occurs when the systemic condition of the patient
exaggerates or distorts the usual gingival response to dental plaque
 The 3 types of conditioned gingival enlargement are-
1. Hormonal (pregnancy, puberty)
2. Nutritional (associated with vitamin C deficiency)
3. Allergic

9. Enlargement in Pregnancy:
 During pregnancy there is an increase in levels of both
progesterone and estrogen, which induce changes in vascular
permeability, leading to gingival edema and an increased
inflammatory response to dental plaque.

10. Why??????????
 The estrogen receptors such as ER-α and ER-β are
present on the vascular smooth muscles which causes
smooth muscle relaxation and results in vasodilation.
 The estrogen causes increased levels of Vascular
endothelial growth factor which is a potent stimulator of
microvascular permeability.
 Progesterone induces vascular permeability by formation
of gaps in the normally intact endothelial lining.

11. Susceptibility to infections (e.g. periodontal infection) increases during
early gestation due to
 Suppression of T-cell activity
 Decreased neutrophil chemotaxis and phagocytosis,
 Altered lymphocyte response
 Depressed antibody production
 Chronic maternal stress
 Down regulation of IL-6 production, rendering the gingiva less efficient
at resisting the inflammatory challenges produced by the bacteria
 decreased levels of immunoglobulin G (IgG)

12. Marginal enlargement-
 The enlargement is usually generalized and tends to be more
prominent interproximally
 The enlarged gingiva is bright red or magenta, soft, and friable, and
has a smooth, shiny surface
Tumorlike Gingival Enlargement-
 The so-called pregnancy tumor is not a neoplasm.
 It usually occurs after the third month of pregnancy but may occur
earlier

13. A heightened gingival response to plaque during pregnancy
results in pregnancy-associated gingivitis

14. Localized gingival enlargement in a 27-year old pregnant
patient…

15. Microscopic view of gingival enlargement in pregnant
patient showing abundance of blood vessels and
interspersed inflammatory cells…

16. Enlargement in Puberty:
 It is seen sometimes during puberty in both male and female
adolescents and appears in areas of plaque accumulation
 The enlargement is marginal and interdental and is characterized by
prominent bulbous interproximal papillae
 The degree of enlargement and the tendency to develop massive
recurrence in the presence of relatively scant plaque deposits
distinguish pubertal gingival enlargement from uncomplicated
chronic inflammatory enlargement

17.  Tiainen et al. [1992] showed that the severity
of puberty gingivitis was related more closely
to plaque build up than to hormones.

18. Conditioned gingival enlargement in puberty in a 13-year old boy…

19. Inflammation due to increased sex hormones during
puberty

20. Enlargement in Vitamin C Deficiency:
 Acute vit C deficiency itself does not cause gingival inflammation,
but it does cause hemorrhage, collagen degeneration, and edema of
the gingival connective tissue
 The enlargement is marginal; the gingiva is bluish-red, soft and
friable and has a smooth, shiny surface

21. Gingival enlargement in patient with vitamin C deficiency…

22. Plasma Cell Gingivitis:
 Also called Atypical gingivitis and Plasma cell gingivostomatitis
 Plasma cell granuloma- Bhasker 1988
 Plasma cell gingivitis is thought to be allergic in origin, possibly related to
components of chewing gum, dentifrices, or various diet components
 Often shows a mild marginal gingival enlargement, that extends to the attached
gingiva
 The gingiva appears soft, friable, and sometimes granular and bleeds easily

23. Plasma cell gingivitis…
In a case report of PCG, PCG associated with generalized aggressive periodontitis
(GAgP), which was brought on by the use of herbal toothpaste containing “Acacia” extract
from the tree “Acacia Arabica.”
Anjali makkar, JISP, 2013 Jul-Aug; 17(4): 527–530.

24. Nonspecific Conditioned
Enlargement (Pyogenic
Granuloma):
 The lesion varies from a discrete, spherical, tumor like mass
with a pedunculated attachment to a flattened, keloid like
enlargement with a broad base

25. Why????????????
 Oral pyogenic granuloma arises as a result of some minor trauma to
the tissues that provide a pathway for invasion of nonspecific types of
microorganisms.
 The tissues responds to these organisms of low virulence by the
overzealous proliferation of a vascular type of connective tissue.
 Ainamo suggested that trauma can cause release of various
endogenous substances including angiogenic factors from the tumor
cells and it may also cause disturbances in the vascular system of the
affected area.

26. Pyogenic granuloma in a young woman…

27. Systemic Diseases That Cause Gingival Enlargement
 Several systemic diseases may result in gingival enlargement
through different mechanisms
 These are usually uncommon cases
Leukemia
Granulomatous diseases:
Wegener’s Granulomatosis
Sarcoidosis

28. Leukemia
Leukemia, like other cancers, results from mutations in the
DNA.
Certain mutations can trigger leukemia by
activating oncogenes or deactivating tumor suppressor
genes, and thereby disrupting the regulation of cell death,
differentiation or division.
These mutations may occur spontaneously or as a result of
exposure to radiation or carcinogenic substances

29. In leukemia typically the lamina propria is
densely packed with leukemic cells extending
from the basal cell layer of the epithelium into
the gingiva, there by altering the normal
anatomy.
Regional blood vessels are compressed by
infiltration

30. Leukemic gingival enlargement…

31. Granulomatous Diseases
 Wegener's Granulomatosis
Charecterised by a triad of necrotic vasculitis, necrotic glomerulonephritis and
granulomatous inflammation of the upper or lower respiratory tract
Anti-neutrophil cytoplasmic antibodies (ANCA) to the cytoplasmic antigens of
neutrophil granulocytes

32.  Sarcoidosis
 Tuberculousis associated gingival enlargement
Varadhan Karthikeyan in 2006 has reported a rare case of diffuse
gingival enlargement in a patient with primary tuberculosis.

33. Syndromes typically associated
with gingival enlargements:
Apert’s syndrome:
 Apert’s syndrome is a form of acrocephalosyndactyly
 Apert’s syndrome occurs as a result of androgen end organ
hyper-response affecting the epiphyses and sebaceous glands
that results in early epiphyseal fusion leading to short stature,
short and fused digits and acrocephaly.
Premalatha et al; JISPP: 2010, issue 4, vol 28

34.  The oral cavity of Apert patients includes a reduction in the size of the
maxilla, tooth crowding, anterior open-bite of the maxilla, impacted teeth,
delayed eruption, ectopic eruption, supernumerary teeth, and thick gingiva.
The mandible usually is within normal size and shape, and simulates a
pseudoprognathism
clinical and radiographic features and case report: Felipe Paes Varoli et al, Rev
Odonto Cienc 2011

35. Cross–McKusick–Breen syndrome
 also known as "Cross syndrome," "Hypopigmentation and
microphthalmia," and "Oculocerebral-hypopigmentation
syndrome“
 extremely rare disorder characterized by white skin, blond hair
with yellow-gray metallic sheen, small eyes with cloudy
corneas, jerky nystagmus, gingival fibromatosis and severe
mental and physical retardation.
 It was characterized in 1967

36. Melkersson-Rosenthal
Syndrome:
 Melkersson-Rosenthal syndrome (MRS) is a very rare
neurological disorder.
 The origin of MRS is as yet unknown.
 The diagnosis of the disease usually occurs in the patient’s
second or third decade of life.
 The clinical symptoms are remittent swellings of the oral,
pharyngeal and laryngeal mucosa as well as the lips. Due to the
presence of granulomata in all orofacial soft tissues, a plicated
tongue as well as facial nerve paralysis may occur. Intermittent
increase of mucosal swelling, including swelling of the
gingiva, may increase the risk of development of chronic
periodontitis by inhibiting local plaque removal.

37.  Generalised swelling and hypoplastic keratinisation of the
gingiva. Chronic Periodontitis in Conjunction with
Melkersson-Rosenthal Syndrome:
A Case Report and Literature Review: Frank Broseler, Angelika
Neuber: Perio 2006; Vol 3, Issue 1: 43–48.

38. Sturge weber syndrome
 Sturge Weber syndrome (SWS) was first described by Schirmer in
1860 and later more specifically by Sturge in 1879
 Most common features are epilepsy, Port-wine stain and dermal
angiomas, abnormal findings in skull radiographs, mental retardation,
ocular involvement and hemiplegia. the most common feature is a
gingival hemangiomatous lesion usually restricted to ipsilateral
maxilla, mandible, floor of mouth, lips, cheeks, palate and tongue.
A Case Report Neha Khambete et al INTERNATIONAL JOURNAL OF
DENTAL CLINICS Vol 3 JAN-MAR 2011
 Oral changes occur in 40% cases of this syndrome and may include
massive growth of the gingiva and asymmetric jaw growth. Sturge-
Weber syndrome: A case report MUKHOPADHYAY S. J Indian Soc
Pedod Prevent Dent - Supplement 2008.

39. Diagnosis

40. MANAGEMENT OF GINGIVAL ENLARGEMENTS
 Gingivectomy using scalpel
The dotted line represents the
external bevel incision, and the
shaded area corresponds to the tissue
to be excised.
Gingivectomy incision may not
remove the entire hyperplastic tissue
(shaded area) and may leave a wide
wound of exposed connective tissue.

41. Flap technique
A, Initial reverse bevel incision followed by thinning of the enlarged
gingival tissue; dotted lines represent incisions, and the shaded area
represents the tissue portion to be excised.
B, After flap elevation, enlarged portion of the gingival tissue is removed.
C, The flap is placed on top of the alveolar bone and sutured.

42. Ledge and Wedge and Internal Bevel Gingivectomy Techniques
A, Preoperative diagram showing
gingival enlargement.
B, The initial facial and lingual incisions (1)
are made perpendicular to the gingiva to
strike the base of the soft tissue pockets.
C,Secondary incisions (2) are made on the
facial and lingual at a 45-degree external
bevel to remove the remaining soft tissue
ledges.
D, Postoperative result.

44.  Gingivectomy using electrocautery
COAG -20-30 (25)W
Blend-Cut -20-30 W

45. Advantages
 Electrosurgery is thought of
as the sculpture of living
tissue because it works
without pressure, unlike
scalpel.
 Bleeding is controlled by
electrosurgery.
 Adjunct to other therapies
due to its ability to induce
heat in fluid. For eg:
accelerating desensitizing
agents, in gingival
curettage, in root canal
sterilization, accelerating
whitening agents in spot
whitening.
Disadvantages
 Unpleasant odor.
 When the bone touches it
causes necrosis.
 The heat generated causes
loss of periodontal support
when the electrode is used to
close to bone.
 Causes cementum burns
 The smoke is considered a
mild carcinogen.

46. Gingivectomy using laser
 CO2 laser -7-W of power continuous
wave mode.
 Er:YAG laser -3 W of power
continuous wave mode
 Nd:YAG laser- 4 W of power
continuous wave mode
 diode laser- 2 W of power continuous
wave mode

47.  Relative bloodless operative and post-operative field
 Greater accuracy in making incisions
 Sterilization of the operating field
 Minimal swelling and scarring
 Less post-operative pain
 Hemostasis

48. TREATMENT OF LEUKEMIC GINGIVAL
ENLARGEMENT
 Bleeding & clotting times and platelet count of the
patient should be checked and the hematologist
consulted before periodontal treatment
 The enlargement is treated by scaling and root planing
carried out in stages under topical anesthesia.
 The initial treatment consists of gently removing all
loose accumulations with cotton pellets.
 Progressively deeper scalings are carried out at
subsequent visits.
 Antibiotics are administered systemically the evening
before and for 48 hours after each treatment to reduce
the risk of infection

49. TREATMENT OF GINGIVAL ENLARGEMENT IN
PREGNANCY
 Treatment requires elimination of all local irritants responsible for
precipitating the gingival changes in pregnancy
 Marginal and interdental gingival inflammation and enlargement are treated
by scaling and curettage.
 Treatment of tumor-like gingival enlargements consists of surgical excision
and scaling and planing of the tooth surface.
In pregnancy, the emphasis should be on-
 Preventing gingival disease before it occurs
 Treating existing gingival disease before it worsens

50. TREATMENT OF GINGIVAL
ENLARGEMENT IN PUBERTY
 Gingival enlargement in puberty is treated by performing
scaling and curettage, removing all sources
 The use of escharotic drugs has been recommended in
the past for the removal of gingival enlargements of
irritation, and controlling plaque.

51. RECURRENCE OF GINGIVAL ENLARGEMENT
 Recurrence of chronic inflammatory enlargements immediately after
treatment indicates that all irritants have not been removed.
 If the enlargement recurs after healing is complete and normal contour is
attained, inadequate plaque control by the patient is the most common
cause.
 Recurrence during the healing period is manifested as red, beadlike,
granulomatous masses that bleed on slight provocation.
 Treatment consists of removal of the lesions plus the elimination of
irritating local factors.

52. conclusion
 Many systemic diseases may mimic periodontitis or
gingivitis.
 These include many immunologic, infectious, neoplastic
and metabolic disorders.
 In comparision with periodontitis and gingivitis, these
disorders are considerably less common.
 However. Since their diagnosis and management differ, a
high index of suspicion is frequently needed when
confronted a patient presenting with gingival or
periodontal disease.

53. References
 Text book of clinical periodontology- Carranza 10th edition
 Text book of clinical periodontology and implantology- Jan
linde 5th edition
 Text book of periodontology- Rose& Maley
 Text book of oral medicine- Burkitt’
 Perio 2000, 1999 vol 21, 84-105
 Perio 2000, 2003 vol 32, 59-81
 Perio 2000, 2004 vol 34, 217-229

54. •Vinutna Buddiga, Naveen kumar Ramagoni, Snehalatha, Mahantesh. Gingival
enlargement a case series. Annals and Essences of dentistry.2012. vol 4, issue 1
pg 73-76
•NW Savage, CG Daly. Gingival enlargements and localized gingival
overgrowths. Australian dental Journal. 2010, vol 55 pg 55-60
•Bettina Dannewitz. Proliferation of the gingiva: aetiology, risk factors and
treatment modalities for gingival enlargement. Perio 2007; 4 (2): 83-92
•J. S. Gill, S. Sandhu, S. Gill. Primary tuberculosis masquerading as gingival
enlargement. British dental Journal. 2010 208 ;(8);343-345
•Sumanth ShivaSwamy, A. Sanjay Jain, Sonal Tambwekar. A rare case of
generalized Pyogenic granuloma: A case report. Quintessence international. 2011,
42 (6);493-499
•Dwight E. McLeod. Severe postpartum gingival enlargement- A case report. JOP.
2009 vol 80, (8);1365-1369

55.  Eleni Markou. The influence of sex steroid hormones on
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 Vela D Desai. Scurvy Extinct? Think again! International
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 Laser assisted gingivectomy : A novel alternative
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 Varadhan Karthikeya,Avani Raju Pradeep,C.G. Dileep
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