Treatment of Gingival Enlargement Chronic Inflammatory Enlargement Characterized by: soft gingival tissues, altered gingival color, usually caused by edema and cellular infiltration. Therapy: SRP to remove deposits when there is a significant fibrotic component that does not undergo shrinkage after SRP, or if the extent of GO is so severe that access to the deposits on the tooth surface is impossible, surgical removal is the treatment of choice.

1. TREATMENT OF
GINGIVAL
ENLARGEMENT
Chapter 61

2.  The treatment of gingival enlargement is
based on an understanding of the cause.
 PROBLEMS:
• Biofilm control
• Impaired function (mastication, eruption,
speech)
• Aesthetics.

3. Chronic Inflammatory Enlargement
 Characterized by: soft gingival tissues, altered
gingival color, usually caused by edema and
cellular infiltration.
 Therapy: SRP to remove deposits
when there is a significant fibrotic component that
does not undergo shrinkage after SRP, or if the
extent of GO is so severe that access to the
deposits on the tooth surface is impossible, surgical
removal is the treatment of choice.

4. SURGERY
 Techniques: gingivectomy and the flap operation
 Before surgical therapy, biofilm control and SRP
should always be completed and sufficient time
should be allowed to heal before re-evaluating the
periodontal status.
 Selection of the appropriate surgical technique
depends on the extent of the enlargement and the
status of the gingival tissues.

5.  When the enlarged gingiva remains soft and friable even after
SRP, the gingivectomy technique may be preferable because
management of the periodontal flap may be technically
difficult on the friable tissues.
 If the tissue is firm and fibrotic, preference is given to the
flap operation, which is always the favorable choice because
healing is by primary intention and the keratinized tissue is
better preserved.
 Conservation of the keratinized, attached gingiva must be
considered along with removal of the excessive tissue.
 Tumor-like, localized, and severe inflammatory enlargements
can be treated by gingivectomy

6. INFLAMMATORY GINGIVAL ENLARGEMNT

7. Periodontal and Gingival Abscesses
The enlargement due to abscesses is usually
localized and the content of the enlarged
area is purulent material, which must be
drained and the area curetted.

8. Drug-Induced Gingival Enlargement
 The overgrown tissues have two components:
fibrotic, which is the result of the action of the drug
on gingival collagen turnover, and inflammatory,
which is induced by bacterial biofilm.
 Although the fibrotic and inflammatory components
are the result of distinct pathologic processes, they
almost always are observed as gingival enlargement
induced by the combination of drugs and biofilm.

9. Treatment Options
 It should be based on the medication used and the clinical
features of the case.
 First consideration: the possibility of discontinuing or
changing the medication in consultation with the patient’s
physician.
 If any drug substitution is attempted, it is important to allow
a 6 to 12 month period always in combination with SRP and
oral hygiene instructions.
 Re-evaluation after the alteration of drug therapy is necessary
before any surgical treatment is planned.

10.  Alternative medications to phenytoin: carbamazepine and
valproic acid, both of which have been reported to induce
gingival enlargement to a lesser degree.
 A study suggested that lovastatin may attenuate the onset of
gingival enlargement induced by phenytoin.
 For nifedipine (prevalence of GO: up to 86%): other calcium
channel blockers like diltiazem (prevalence of GO: 20%) or
verapamil (prevalence of GO: 4%) may be viable alternatives.
 In addition, consideration should be given to the use of
another class of antihypertensive medications rather than
calcium channel blockers. None of these drugs are known to
induce gingival enlargement.

11.  Drug substitutions for cyclosporine: The incidence of GO in
patients receiving tacrolimus is approximately 65% lower than
cyclosporine. There is also a significant decrease in the
severity of gingival enlargement.
 Patients who take cyclosporine in combination with a calcium
channel blocker tend to have an overall lower prevalence of
and less severe GO if the antihypertensive drug is amlodipine
as compared with nifedipine.

12.  The administration of azithromycin has decreased the severity
of cyclosporine-induced GO. A 3-day course of systemic
azithromycin significantly decreased GO, and the effect was
observed as early as 7 to 30 days after the initiation of
antibiotic therapy. Also, it resulted in significantly greater
changes than improvement in oral hygiene.
 The topical administration of azithromycin in the form of a
toothpaste also decreased the severity of cyclosporine-
induced GO.
 The decrease in GO with the administration of antibiotics
indicates the association of plaque biofilm (bacteria) as one
cause, along with medications such as cyclosporine.

13.  Second: the clinician should emphasize biofilm control as the
first step in the treatment of drug-induced GO.
 Good oral hygiene, chemotherapeutic agents and frequent
professional removal of biofilm, decrease the degree of GO
and improve overall gingival health.
 The presence of DIGO associated with pseudo-pocket
formation, frequently with abundant biofilm accumulation,
may lead to the development of periodontitis. Therefore,
meticulous biofilm control helps to maintain attachment
levels.
 In addition, adequate biofilm control may help to prevent the
recurrence of gingival enlargement in surgically treated cases.

14. Third:
 in many patients, gingival enlargement persists after careful
consideration of the previous two approaches. With these
patients, surgical removal of the enlarged gingiva must be
considered (gingivectomy or flap operation)

15. INFLAMMATORY GINGIVAL ENLARGEMNT

16. Gingivectomy
 Advantages: ease and simplicity of the procedure.
 Disadvantages (in contrast with flap operation): more
postoperative discomfort and an increased chance of
postoperative bleeding. It also sacrifices keratinized tissue
and does not allow for osseous recontouring. Healing is by
secondary intention.
 Clinician’s decision between the two techniques is based on:
• extent of the area,
• severity of the enlargement,
• the presence of periodontitis and osseous defects, and
• The location of the base of the pockets in relation to M.G.J

17.  In general, small areas (up to six teeth) of GO with no
evidence of clinical attachment loss and therefore no
anticipated need for osseous surgery can be effectively
treated with gingivectomy.
 An important consideration is the amount of keratinized
tissue present. The removal of excessive amount of
keratinized gingiva will create a mucogingival problem.
 Gingivectomy or gingivoplasty can also be performed with
electrosurgery or laser. Some evidence indicates that
recurrence of DIGO is reduced in patients treated via laser
as compared with conventional gingivectomy or Flap surgery.

20. Flap Operation
 For larger areas of gingival enlargement (more than six teeth)
and where attachment loss and osseous defects are present,
flap surgery is recommended.
 Sutures and periodontal dressing are removed after 1 to 2
weeks, depending on the extent of the surgery. The patient is
instructed to begin biofilm control practices. Usually it is
convenient for the patient to use chlorhexidine oral rinses
once or twice daily for 2 to 4 weeks.
 The use of flap surgery to reduce GO is favored over
gingivectomy. By using flap surgery, recurrence of gingival
tissue is minimized both in amount of tissue and in time to
recurrence.

23. Recurrence after surgery
 Major cause: difficulty with postsurgical oral hygiene.
 Meticulous home care with a soft, postsurgical brush and
chlorhexidine gluconate rinses is indicated. Frequent
professional cleanings can also help reduce the degree of
recurrence. A hard, custom-fitted occlusal guard worn at night
may also be helpful to control recurrence.
 Recurrence may occur as early as 3 to 6 months after surgical
treatment. In general, surgical results with minimal recurrence
are possible for at least 12 months.

24. Leukemic Gingival Enlargement
 Occurs with acute or subacute leukemia and is uncommon in
the chronic state. Gingival bleeding, sometimes spontaneous,
is often associated with leukemic GO.
 Bleeding and clotting times and platelet count should be
checked before treatment, and the hematologist should be
consulted before periodontal treatment. After acute symptoms
subside, attention is directed to correction of GO.
 The rationale is to remove the local irritating factors by SRP to
control the inflammatory component of the enlargement.

25.  Initial treatment steps: gently removing all loose
debris with cotton pellets, superficial scaling and
instructing oral hygiene.
 Definitive SRP are carried out at subsequent visits
using local anesthesia. Treatment sessions are
confined to a small area of the mouth if hemostasis
poses a challenge.
 Antibiotics are administered systemically the evening
before and for a week after each treatment to
reduce the risk of infection.

26. Gingival Enlargement During Pregnancy
 Treatment: the elimination of all local irritants that may be
responsible for gingival changes. SRP early in pregnancy is a
preventive measure against gingival disease, and prevention
is preferable to treatment of GO after it occurs.
 Treatment of tumor-like GO consists of surgical excision, as
well as SRP of the tooth surfaces adjacent to the lesion. The
enlargement may recur unless all irritants are removed.
 Food impaction is frequently an inciting factor.
 Lesions should be treated as soon as detected, but not
necessarily by surgical means. SRP and adequate oral hygiene
measures may reduce the extent of the enlargement.

27.  Gingival enlargements do shrink after pregnancy, but they
usually do not disappear. After pregnancy, the entire
periodontal status should be re-evaluated and comprehensive
treatment should be undertaken.
 Lesions should be removed surgically during pregnancy if they
interfere with mastication or produce an aesthetic problem
that bothers the patient.
 During pregnancy, the emphasis should be on (1) preventing
gingival disease before it occurs and (2) treating existing
gingival disease before it worsens. Every pregnant patient
should be scheduled for periodic maintenance visits.

28. Gingival Enlargement During Puberty
 Treatment: SRP, removing all sources of irritation,
and controlling biofilm.
 Surgical removal may be required in severe cases.
The most important problem is recurrence, for which
close maintenance therapy is recommended.