Gingival enlargement
Encyclopedia
Gingival enlargement, the currently accepted terminology for an increase in the size of the gingiva
, is a common feature of gingival disease
. This is strictly a clinical description of the condition and avoids the erroneous pathologic connotations of terms used in the past such as hypertrophic gingivitis, gingival hyperplasia or '"gingival hypertrophy'". Gingival enlargement can be caused by a number of various stimuli, and "treatment is based on an understanding of the cause and underlying pathologic
changes."
diagnoses
, and such diagnoses require microscopic
analysis of a tissue sample. Hyperplasia
refers to an increased number of cell
s, and hypertrophy
refers to an increase in the size of individual cells. Because these identifications obviously cannot be performed with a clinical examination and evaluation of the tissue, the term gingival enlargement is more properly applied.
inflammatory
gingival enlargement, when the gingiva
presents clinically as soft and discolored. This is caused by tissue edema
and infective
cellular infiltration
caused by prolonged exposure to bacteria
l plaque, and is treated with conventional periodontal treatment, such as scaling and root planing
. Situations in which the chronic inflammatory gingival enlargement include significant fibrotic
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 as gingivectomy
.
Gingivitis
and gingival enlargement are often seen in mouth breathers, as a result of irritation brought on by surface dehydration, but the manner in which it is caused has not been demonstrated.
is the chief cause of inflammatory gingival enlargement. Risk factors include poor oral hygiene
, as well as physical irritation of the gingiva by improper restorative
and orthodontic appliances.
, and its association with inflammation is debated. Some investigators assert that underlying inflammation is necessary for the development of drug-induced enlargement, while others purport that the existing enlargement induced by the drug effect compounds plaque retention, thus furthering the tissue response.
In drug-induced disease, reversing and preventing gingival enlargement is as easy as ceasing drug therapy. However, this is not always an option; in such a situation, alternative drug therapy may be employed, if possible, to avoid this deleterious side effect
. In the case of immunosuppression, tacrolimus is an available alternative which results in much less severe gingival overgrowth than ciclosporin, but is similarly as nephrotoxic
. The dihydropyridine derivative isradipidine can replace nifedipine for some uses of calcium channel blocking and does not induce gingival overgrowth.
It is commonly seen in Boxer dogs
and other brachycephalic
breeds, and in the Springer Spaniel
. 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, but it usually recurs. Gingival enlargement is also a potential sequela of gingivitis
. As in humans, it may be seen as a side effect to the use of ciclosporin
.
Gingiva
The gingiva , or gums, consists of the mucosal tissue that lies over the mandible and maxilla inside the mouth.-General description:...
, is a common feature of gingival disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
. This is strictly a clinical description of the condition and avoids the erroneous pathologic connotations of terms used in the past such as hypertrophic gingivitis, gingival hyperplasia or '"gingival hypertrophy'". Gingival enlargement can be caused by a number of various stimuli, and "treatment is based on an understanding of the cause and underlying pathologic
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
changes."
Imprecise use of terminology
The terms hyperplasia and hypertrophy are not precise descriptions of gingival enlargement because these terms are strictly histologicHistology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
diagnoses
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
, and such diagnoses require microscopic
Microscope
A microscope is an instrument used to see objects that are too small for the naked eye. The science of investigating small objects using such an instrument is called microscopy...
analysis of a tissue sample. Hyperplasia
Hyperplasia
Hyperplasia means increase in number of cells/proliferation of cells. It may result in the gross enlargement of an organ and the term is sometimes mixed with benign neoplasia/ benign tumor....
refers to an increased number of cell
Cell (biology)
The cell is the basic structural and functional unit of all known living organisms. It is the smallest unit of life that is classified as a living thing, and is often called the building block of life. The Alberts text discusses how the "cellular building blocks" move to shape developing embryos....
s, and hypertrophy
Hypertrophy
Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It should be distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number...
refers to an increase in the size of individual cells. Because these identifications obviously cannot be performed with a clinical examination and evaluation of the tissue, the term gingival enlargement is more properly applied.
Inflammatory enlargement
As previously mentioned, gingival enlargement may be caused by a multitude of causes. The most common is chronicChronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
inflammatory
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
gingival enlargement, when the gingiva
Gingiva
The gingiva , or gums, consists of the mucosal tissue that lies over the mandible and maxilla inside the mouth.-General description:...
presents clinically as soft and discolored. This is caused by tissue edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
and infective
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
cellular infiltration
Cellular infiltration
Cellular infiltration is migration of cells from their sources of origin, or direct extension of cells as a result of unusual growth and multiplication, thereby resulting in fairly well-defined foci, irregular accumulations, or diffusely distributed individual cells in the connective tissue and...
caused by prolonged exposure to bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
l plaque, and is treated with conventional periodontal treatment, such as scaling and root planing
Scaling and root planing
The objective of scaling and root planing, otherwise known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is to remove or eliminate the etiologic agents which cause inflammation: dental plaque, its products and calculus, thus helping to establish a...
. Situations in which the chronic inflammatory gingival enlargement include significant fibrotic
Fibrosis
Fibrosis is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process. This is as opposed to formation of fibrous tissue as a normal constituent of an organ or tissue...
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 as gingivectomy
Gingivectomy
A gingivectomy is a periodontal surgical procedure which includes the removal of gingival tissue in order to achieve a more aesthetic appearance and/or functional contour. The procedure is particularly useful if the gingival tissues have become enlarged, e.g. due to certain medications...
.
Gingivitis
Gingivitis
Gingivitis is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease...
and gingival enlargement are often seen in mouth breathers, as a result of irritation brought on by surface dehydration, but the manner in which it is caused has not been demonstrated.
Drug-induced enlargement
Gingival enlargement may also be associated with the administration of three different classes of drugs, all producing a similar response:- anticonvulsantAnticonvulsantThe anticonvulsants are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers, and in the treatment of neuropathic pain. The goal of an...
s (such as phenytoinPhenytoinPhenytoin sodium is a commonly used antiepileptic. Phenytoin acts to suppress the abnormal brain activity seen in seizure by reducing electrical conductance among brain cells by stabilizing the inactive state of voltage-gated sodium channels...
, phenobarbitalPhenobarbitalPhenobarbital or phenobarbitone is a barbiturate, first marketed as Luminal by Friedr. Bayer et comp. It is the most widely used anticonvulsant worldwide, and the oldest still commonly used. It also has sedative and hypnotic properties but, as with other barbiturates, has been superseded by the...
, lamotrigineLamotrigineLamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
, valproate, vigabatrinVigabatrinVigabatrin is an antiepileptic drug that inhibits the catabolism of gamma-aminobutyric acid by irreversibly inhibiting GABA transaminase. It is an analog of GABA, but it is not a receptor agonist...
, ethosuximideEthosuximideEthosuximide is a succinimide anticonvulsant, used mainly in absence seizures.-Approved:It is approved for absence seizures. Ethosuximide is considered the first choice drug for treating absence seizures in part because it lacks the idiosyncratic hepatotoxicity of the alternative anti-absence...
, topiramateTopiramateTopiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
and primidonePrimidonePrimidone is an anticonvulsant of the pyrimidinedione class, the active metabolites of which, phenobarbital and phenylethylmalonamide , are also anticonvulsants...
) - calcium channel blockerCalcium channel blockerA calcium channel blocker is a chemical that disrupts the movement of calcium through calcium channels.CCB drugs devised to target neurons are used as antiepileptics. However, the most widespread clinical usage of calcium channel blockers is to decrease blood pressure in patients with...
s, such as nifedipineNifedipineNifedipine is a dihydropyridine calcium channel blocker...
, amlodipineAmlodipineAmlodipine is a long-acting calcium channel blocker used as an anti-hypertensive and in the treatment of angina...
, and verapamilVerapamilVerapamil is an L-type calcium channel blocker of the phenylalkylamine class. It has been used in the treatment of hypertension, angina pectoris, cardiac arrhythmia, and most recently, cluster headaches. It is also an effective preventive medication for migraine...
. The dihydropyridine derivative isradipidine can replace nifedipine and does not induce gingival overgrowth. - ciclosporinCiclosporinCiclosporin , cyclosporine , cyclosporin , or cyclosporin A is an immunosuppressant drug widely used in post-allogeneic organ transplant to reduce the activity of the immune system, and therefore the risk of organ rejection...
, an immunosuppresant.
Enlargement associated with systemic factors
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:- Conditioned enlargement
- pregnancyPregnancyPregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
- pubertyPubertyPuberty is the process of physical changes by which a child's body matures into an adult body capable of reproduction, as initiated by hormonal signals from the brain to the gonads; the ovaries in a girl, the testes in a boy...
- vitamin CVitamin CVitamin C or L-ascorbic acid or L-ascorbate is an essential nutrient for humans and certain other animal species. In living organisms ascorbate acts as an antioxidant by protecting the body against oxidative stress...
deficiency - nonspecific, such as a pyogenic granulomaPyogenic granulomaPyogenic granuloma is a primarily oral disease which appears as an overgrowth of tissue due to irritation, physical trauma or hormonal factors...
- pregnancy
- Systemic disease causing enlargement
- leukemiaLeukemiaLeukemia or leukaemia is a type of cancer of the blood or bone marrow characterized by an abnormal increase of immature white blood cells called "blasts". Leukemia is a broad term covering a spectrum of diseases...
- granulolomatous diseases, such as Wegener's granulomatosisWegener's granulomatosisWegener's granulomatosis , more recently granulomatosis with polyangiitis , is an incurable form of vasculitis that affects the nose, lungs, kidneys and other organs. Due to its end-organ damage, it is life-threatening and requires long-term immunosuppression...
and sarcoidosisSarcoidosisSarcoidosis , also called sarcoid, Besnier-Boeck disease or Besnier-Boeck-Schaumann disease, is a disease in which abnormal collections of chronic inflammatory cells form as nodules in multiple organs. The cause of sarcoidosis is unknown... - neoplasm
- benignBenignA benign tumor is a tumor that lacks the ability to metastasize. Common examples of benign tumors include moles and uterine fibroids.The term "benign" implies a mild and nonprogressive disease. Indeed, many kinds of benign tumors are harmless to human health...
neoplasms, such as fibromaFibromaFibromas are benign tumors that are composed of fibrous or connective tissue. They can grow in all organs, arising from mesenchyme tissue. The term "fibroblastic" or "fibromatous" is used to describe tumors of the fibrous connective tissue...
s, papillomaPapillomaPapilloma refers to a benign epithelial tumor growing exophytically in finger-like fronds. In this context papilla refers to the projection created by the tumor, not a tumor on an already existing papilla . When used without context, it frequently refers to infections caused by human...
s and giant cell granulomas - malignantMalignantMalignancy is the tendency of a medical condition, especially tumors, to become progressively worse and to potentially result in death. Malignancy in cancers is characterized by anaplasia, invasiveness, and metastasis...
neoplasms, such as a carcinomaCarcinomaCarcinoma is the medical term for the most common type of cancer occurring in humans. Put simply, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that generally arises from cells originating in the endodermal or ectodermal germ layer during...
or malignant melanoma
- benign
- false gingival enlargements, such as when there is an underlying bony or dental tissue lesionLesionA lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
- leukemia
Inflammatory enlargement
The accumulation and retention of plaqueDental plaque
Dental plaque is a biofilm, usually a pale yellow, that develops naturally on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to a smooth surface...
is the chief cause of inflammatory gingival enlargement. Risk factors include poor oral hygiene
Oral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
, as well as physical irritation of the gingiva by improper restorative
Dental restoration
A dental restoration or dental filling is a dental restorative material used to restore the function, integrity and morphology of missing tooth structure. The structural loss typically results from caries or external trauma. It is also lost intentionally during tooth preparation to improve the...
and orthodontic appliances.
Drug-induced enlargement
Drug-induced enlargement has been associated with a patient's genetic predispositionGenetic predisposition
A genetic predisposition is a genetic affectation which influences the phenotype of an individual organism within a species or population but by definition that phenotype can also be modified by the environmental conditions. In the rest of the population, conditions cannot have that effect...
, and its association with inflammation is debated. Some investigators assert that underlying inflammation is necessary for the development of drug-induced enlargement, while others purport that the existing enlargement induced by the drug effect compounds plaque retention, thus furthering the tissue response.
In drug-induced disease, reversing and preventing gingival enlargement is as easy as ceasing drug therapy. However, this is not always an option; in such a situation, alternative drug therapy may be employed, if possible, to avoid this deleterious side effect
Adverse effect
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
. In the case of immunosuppression, tacrolimus is an available alternative which results in much less severe gingival overgrowth than ciclosporin, but is similarly as nephrotoxic
Nephrotoxicity
Nephrotoxicity is a poisonous effect of some substances, both toxic chemicals and medication, on the kidneys. There are various forms of toxicity. Nephrotoxicity should not be confused with the fact that some medications have a predominantly renal excretion and need their dose adjusted for the...
. The dihydropyridine derivative isradipidine can replace nifedipine for some uses of calcium channel blocking and does not induce gingival overgrowth.
In non-humans
Boxer (dog)
Developed in Germany, the Boxer is a breed of stocky, medium-sized, short-haired dog. The coat is smooth and fawn or brindled, with or without white markings. Boxers are brachycephalic , and have a square muzzle, mandibular prognathism , very strong jaws and a powerful bite ideal for hanging on to...
and other brachycephalic
Cephalic index
Cephalic index is the ratio of the maximum width of the head multiplied by 100 divided by its maximum length ....
breeds, and in the Springer Spaniel
Springer Spaniel
Springer Spaniel refers to two different breeds of dogs, both of which are commonly called simply Springer Spaniel:*English Springer Spaniel*Welsh Springer Spaniel...
. 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, but it usually recurs. Gingival enlargement is also a potential sequela of gingivitis
Gingivitis
Gingivitis is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease...
. As in humans, it may be seen as a side effect to the use of ciclosporin
Ciclosporin
Ciclosporin , cyclosporine , cyclosporin , or cyclosporin A is an immunosuppressant drug widely used in post-allogeneic organ transplant to reduce the activity of the immune system, and therefore the risk of organ rejection...
.