Gingival Enlargements PDF

Yrd. Doç.Dr. Erim TANDOĞDU GINGIVAL ENLARGEMENTS DEFINITION Increase in the volume of the gum or excessive growth of the gum. CLASSIFICATION ACCORDING TO LOCATION: ​ Localized ​ Generalized ​ Marginal CLASSIFICATION ACCORDING TO DISTRIBUTION: ​ Papill...

Yrd. Doç.Dr. Erim TANDOĞDU GINGIVAL ENLARGEMENTS DEFINITION Increase in the volume of the gum or excessive growth of the gum. CLASSIFICATION ACCORDING TO LOCATION: ​ Localized ​ Generalized ​ Marginal CLASSIFICATION ACCORDING TO DISTRIBUTION: ​ Papillary ​ Diffuse ​ Isolated GINGIVAL ENLARGEMENT GRADES ​ Grade 0: No signs of gingival enlargement. ​ Grade I: Enlargement is limited to the interdental papilla. ​ Grade II: Enlargement includes the papilla and marginal gingiva. ​ Grade III: Enlargement covers three-quarters or more of the crown. Gingival Enlargements ​ Normal Gingiva: The image shows normal gingiva, which should be distinguished from the redder vestibular mucosa by its light pink color and strip-like shape. Gingival Enlargements ​ Gingivitis: Local irritations like plaque formation, tartar buildup, poor restorations, and poor oral hygiene can be causes. Infective Gingivitis: When gingivitis primarily starts with an infection (like streptococcus), it is called infective gingivitis. Microscopically, the gingiva shows intense leukocyte infiltration and edema in the connective tissue. Clinically, the gingiva is red, swollen, and painful, and antibiotics are used in its treatment. Focal Hyperplastic Gingivitis: This lesion is mostly related to the patient's hormonal status, seen during puberty and pregnancy. It is caused by elevated levels of estrogen and other hormones. It is an inflammatory and fibrous enlargement occurring in the interdental papilla and Yrd. Doç.Dr. Erim TANDOĞDU bleeds with minor irritation. Focal Hyperplastic Gingivitis: Regardless of the cause, in hyperplastic gingivitis, the gingiva is enlarged, firm, and fibrous, covering the crowns of the teeth. Tooth migration may also be observed. Focal Hyperplastic Gingivitis: The gingiva is enlarged, red or bluish-red, edematous, and easily bleeding. The enlargement creates a false pocket. Lesions usually start from the interdental papilla. Hormonal Gingivitis: Gingivitis seen during puberty is called "pubertal gingivitis," and during pregnancy, it is called "pregnancy gingivitis." Both often occur under poor oral hygiene conditions. Gingival lesions spontaneously regress after these periods. Irritation Fibroma (Focal Fibrous Hyperplasia): Focal fibrous hyperplasia is seen in adults on the gingiva, lips, and buccal mucosa, as well as the edges of the tongue. There is no color change. The lesion can remain the same size for many years. Accurate diagnosis requires histopathological examination as mesenchymal lesions can have a similar clinical appearance. If the lesion is on the gingiva, it is also called peripheral fibroma. Treatment involves local excision. Peripheral Ossifying Fibroma: This is a fibrous proliferation, possibly originating from the periosteum or periodontal ligament, and may contain bone and cementum tissue histologically. These can be firm, pedunculated or non-pedunculated lesions starting from the interdental papilla. They are more common in women and excision is recommended. Pyogenic Granuloma: Tumor-like gingival enlargement that responds to minor trauma. Clinically, it appears as a discrete spherical tumor, ulcerated and red with purulent exudation. Treatment involves surgical excision. Peripheral Giant Cell Granuloma: This lesion is either pedunculated or attached to a wide base and is seen on the gingiva. If it occurs in the bone, it is called central giant cell granuloma. Both have the same histopathological appearance and are treated by surgical excision. Atypical Gingivitis (Plasma Cell Gingivostomatitis): ​ Region: Marginal and attached gingiva. ​ Clinical Features: Red, friable, easily bleeding. Plasma Cell Gingivitis Inflammatory Fibrous Hyperplasia (Epulis Fissuratum): Resulting from irritation by poorly made dentures. Also known as epulis fissuratum or denture irritation. Seen in the upper and lower buccal and labial vestibules. The lesion bleeds easily, typically in elderly patients. Yrd. Doç.Dr. Erim TANDOĞDU Treatment involves changing the old denture and excising the excess tissues. C-Vitamin Deficiency Gingival Enlargement: Characterized by marginal gingivitis, bleeding with slight provocation, pseudomembrane formation in surface necrosis, scattered bleeding areas, widespread edema, and collagen degeneration. Gingivitis in Mouth Breathers: Gingivitis is seen in individuals who breathe through their mouths or have lips that do not close. This gingivitis mostly affects the anterior gingiva in young people. Clinically, the gingiva appears swollen, red, dry, and shiny. Drug-Induced Gingival Enlargements: Three main pharmacological agents are known to cause gingival fibroblast proliferation: phenytoin (dilantin), cyclosporine, and nifedipine. Dental plaque and gingival irritation can exacerbate these enlargements. The image shows gingival hyperplasia caused by cyclosporine. These enlargements start from the interdental papilla and can cover the teeth. Clinically, the enlarged tissue is widespread and firm. The condition is more severe in individuals with poor oral hygiene. Drug-Induced Gingival Enlargements: The enlargement continues around the tooth crowns, forming false pockets. Enlargements caused by dilantin and nifedipine are limited to the gingiva. Cyclosporine can cause fibrosis in other organs, especially the retroperitoneum and kidneys. Drug-Induced Gingival Enlargements: Treatment: Most patients cannot discontinue their medication, so local treatment is recommended. Gingivectomy and gingivoplasty are advised for functional and cosmetic reasons. To reduce recurrence, patients should maintain high levels of oral hygiene. Hereditary Gingival Fibromatosis: This lesion is often associated with hypertrichosis (excessive hair), craniofacial deformities, epilepsy, and mental retardation. Diffuse gingival hyperplasia is seen as a hereditary disorder with an unknown mechanism. The gingiva is enlarged, covering the crowns of the teeth. Dominant traits include hypertrichosis and other anomalies (corneal dystrophy, deafness, nail defects, and craniofacial anomalies). In children, it may be accompanied by epilepsy and mental retardation. Treatment involves gingivectomy, with recurrence developing late. Patients should also be taught oral hygiene. Malignant Fibrous Neoplasms: When fibroblasts become malignant, the lesion becomes aggressive and causes tissue damage, called fibrosarcoma. Fibrosarcoma and malignant fibrous histiocytoma can originate from bone. Fibrosarcoma is often seen in the mandible, while malignant fibrous histiocytoma is seen in the maxilla, frequently invading the sinus. Both lesions are aggressive, with rapid progression and metastasis through blood vessels. The prognosis is not good, and treatment involves radical excision and sometimes jaw resection. Leukemic Hyperplasia: Leukemia is a malignant disease of white blood cells. The disease begins with fever and fatigue, followed by swelling of the spleen and lymph nodes. It is acute in children and young people and often results in death within a few weeks. Petechial bleeding is Yrd. Doç.Dr. Erim TANDOĞDU seen on the palate and other body parts, especially the legs. Oral lesions include gingival enlargement, necrosis, and bleeding around the teeth, leading to spontaneous bleeding and subsequent clotting, causing halitosis. Ecchymosis and necrosis are seen on the oral mucosa. All periodontal treatments should be planned before chemotherapy. Neural Tissue-Related Lesions: The head and neck region contains a high concentration of sensitive nerve fibers that degenerate when injured. Many oral tumors related to nerves can be found throughout the oral cavity, with the tongue being a common site. Neural Tissue-Related Lesions (Traumatic Neuroma): Also called amputation neuroma, the most common site for traumatic neuroma in the oral cavity is where the mental nerve distributes, particularly around the mental foramen. The anamnesis often includes a history of nerve severance. Because they are painful, these lesions need to be excised. Congenital Granular Gingival Tumor: A pedunculated tumor often seen in the anterior maxilla of newborns. Also known as congenital epulis. Treatment involves surgical excision. LIP AND TONGUE CHANGES Lip Changes - Angular Cheilitis: Also called angular stomatitis or Perlesche, this condition involves acute and chronic inflammation of the skin and adjacent labial mucosa at the corners of the mouth. Angular Cheilitis Clinic: Usually bilateral, often seen with denture stomatitis or glossitis. Clinically, it is a painful condition with erythematous fissures at the corners of the mouth, often seen in individuals over 50, especially those with dentures and women. Angular Cheilitis: Angular cheilitis has a multifactorial etiology with many local and systemic predisposing factors. Etiology-Predisposing Factors: ​ Anemia ​ Poor oral hygiene ​ Broad-spectrum antibiotics ​ Decreased vertical dimension ​ B group vitamin deficiencies ​ Diabetes mellitus ​ Xerostomia ​ Sjogren's syndrome Yrd. Doç.Dr. Erim TANDOĞDU ANGULAR CHEILITIS Angular cheilitis is often associated with candidal infection. Treatment: ​ First, check for diabetes and anemia. ​ Preventive measures should be taken (eliminating traumatic factors, ensuring oral hygiene, correctly restoring the vertical dimension, etc.). ​ Topical antifungal cream (miconazole) is used. ​ Acrylic dentures should be kept outside the mouth in a hypochlorite solution (effective against candida - sodium hypochlorite (NaClO) - bleach - for at least a week). Angular Cheilitis Treatment: ​ Metal dentures should be kept in chlorhexidine solution as their colors can change in the hypochlorite solution. ACTINIC CHEILITIS Particularly seen in men exposed to sunlight. In this type of cheilitis, epithelial atypia is observed, and it can transform into cancer. This condition is characterized by hardness and crust formation on the lower lip. Actinic Cheilitis: In the acute phase, erythema, edema, and sensitivity are observed. This is followed by a peeling condition. Chronic actinic cheilitis is characterized by atrophy and keratosis over the entire lower lip. The vermilion border of the lower lip may disappear. CONTACT CHEILITIS This is a condition where the lips become irritated and peel due to contact with certain substances. These substances can be lipsticks, some medications used on the face, toothpaste, and sometimes foods or lip creams. These cause allergic cheilitis. PERIORAL DERMATITIS Usually, irritation is limited to the vermilion borders of the lips. However, it can extend beyond this area and cause eczema-like irritation on the skin around the mouth (perioral). Treatment: ​ In simple contact cheilitis cases, treatment begins with eliminating the substances causing the allergy. Yrd. Doç.Dr. Erim TANDOĞDU ​ Topical steroids provide temporary relief for the patient. 1% hydrocortisone cream is sufficient for this purpose. ​ Actinic cheilitis can be prevented by providing sunscreens. It should be remembered that actinic cheilitis is a precancerous lesion. EXFOLIATIVE CHEILITIS Exfoliative cheilitis is characterized by the formation of fissures, desquamation, and hemorrhagic crust formation affecting the lips. Candida albicans, oral sepsis, stress, and habitual lip-biting are etiological factors. Exfoliative Cheilitis: This lesion typically starts as a single fissure near the middle of the lower lip and is followed by the formation of multiple fissures. The fissures appear yellow-white or ulcerated and can cover the entire lip with hemorrhagic crust formation. The burning sensation is the primary complaint. Exfoliative Cheilitis: It has been reported that this lesion is more commonly seen in young women. There is no significant information about its association with other anomalies from examinations of patients with this lesion. However, some patients report a connection with stress and tension. In such cases, tranquilizers can be administered. Treatment: ​ Local and systemic steroids, ​ Cauterization, ​ Cryosurgery have not yielded good results. ​ The best approach is to eliminate predisposing factors and recommend antifungal ointments. CHANGES IN THE TONGUE INTRODUCTION: The tongue occupies a large portion of the oral cavity. Many systemic diseases manifest symptoms on the tongue. The anterior two-thirds of the tongue is in the oral cavity, while the posterior one-third is in the pharyngeal region. The word 'tongue' derives from Greek and Latin. Anatomy: The tongue is a muscular organ located on the floor of the mouth. The tongue functions in washing, tasting, and speaking. Anatomy: The tongue has a root, body, and tip. The tongue has two surfaces (dorsal and ventral). The dorsal surface has oral and pharyngeal parts. The ventral surface is limited to the oral cavity. Tongue muscles: There are two types of muscles, extrinsic and intrinsic. Tongue Muscles: Extrinsic Muscles: ​ Genioglossus, Yrd. Doç.Dr. Erim TANDOĞDU ​ Hyoglossus, ​ Styloglossus, ​ Palatoglossus. Intrinsic Muscles: ​ Superior longitudinal, ​ Inferior longitudinal, ​ Transverse, ​ Vertical muscles. Arteries of the Tongue: ​ Lingual artery ​ Dorsal lingual artery ​ Deep lingual artery ​ Sublingual artery Veins of the Tongue: ​ Deep lingual vein ​ Sublingual vein ​ Dorsal lingual vein Nerves of the Tongue: ​ Hypoglossal nerve ​ Lingual branch of the mandibular nerve ​ Glossopharyngeal nerve ​ Vagus nerve ​ Taste sensation is carried by the chorda tympani, a branch of the facial nerve. Lymphatic Drainage: ​ Submental nodes ​ Submandibular lymph nodes ​ Jugulodigastric nodes ​ Jugulo-omohyoid nodes Functions of the Tongue: ​ Speech ​ Chewing ​ Digestion ​ Taste Yrd. Doç.Dr. Erim TANDOĞDU ​ Barrier (protection) ​ Helps in jaw development (the muscle pressure of the tongue is an important factor in determining the shape of the mandibular arch) Thermal Regulation: (This feature is more pronounced in dogs, where significant heat loss occurs through the tongue)Secretion: The tongue's secretion from the salivary glands helps keep the oral mucosa moist. Protection of the Organism: The tongue's secretory immunoglobulin system plays a role in the body's defense mechanism. Maintaining Oral Hygiene: Due to its high mobility, the tongue reaches all areas of the oral cavity. It removes food debris from the gums and between the teeth, thus aiding in oral hygiene. Sucking Function: The tongue plays an important role in feeding from both bottles and the breast. TONGUE DISEASES: Geographic Tongue: Synonyms: Lingua geographica, map tongue, glossitis migrans, erythema migrans. It is an inflammatory condition characterized by the desquamation of filiform papillae. The etiology is unknown. Geographic Tongue: Etiological factors include stress, nutritional deficiencies, and heredity. Clinically, red areas (bald spots) are visible due to desquamation of the filiform papillae. This gives a map-like appearance. Acidic foods (like lemon, cola drinks, tomatoes) and spicy foods can cause discomfort. Geographic Tongue: This lesion can appear suddenly, spontaneously regress, or recur. When asymptomatic, it is harmless and does not require treatment. Reassure the patient. Sometimes the spots cause a burning pain. In such cases, topical anesthetics and topical steroids can be administered for symptomatic relief. Fissured Tongue: Synonyms: Scrotal tongue, lingua fissurata It is an inherited and congenital anomaly. Characterized by the formation of one or more fissures on the surface of the tongue. The fissures can deepen with age. Fissured Tongue: It does not require treatment, but the tongue should be well-cleaned after meals. The mucosa at the base of the fissure is very thin, allowing microorganisms to enter the body. Food debris can accumulate in the fissures, leading to halitosis if not cleaned. To prevent infection and halitosis, the tongue should be cleaned with a soft brush after meals. Fissured Tongue: More common in Down's syndrome. Can also be seen with geographic tongue. Sometimes part of Melkersson-Rosenthal syndrome. Melkersson-Rosenthal Syndrome: Fissured tongue Cheilitis granulomatoza Unilateral facial paralysis Yrd. Doç.Dr. Erim TANDOĞDU Hairy Tongue: Synonyms: Lingua villosa, coated tongue. Characterized by the abnormal elongation of filiform papillae, giving the dorsal tongue a hairy appearance. Usually white, known as "lingua villosa alba". Hairy Tongue: Exogenous pigments from food, medications, tea, coffee, and smoking can turn the papillae black, known as "lingua villosa nigra". Generally asymptomatic, but sometimes causes itching discomfort. Treatment: Treatment of hairy tongue is quite difficult. Trichloroacetic acid cauterization and cryosurgery have been tried in the past but have not been widely accepted. Median Rhomboid Glossitis: A lesion seen on the midline of the dorsal tongue, in front of the circumvallate papillae. More common in men. Flat or nodular, red or red-white. Generally asymptomatic. Condyloma Acuminatum: Multiple wart-like raised lesions on the dorsum of the tongue. Can be confused with Median Rhomboid Glossitis. NERVE DISORDERS OF THE TONGUE: A. Tongue Paralysis (Glossoplegia): Tongue paralysis often results from central nervous system lesions like tumors, syphilis, apoplexy (stroke). When the paralyzed tongue is protruded, it turns towards the healthy side. B. Tongue Spasm and Tremor: Results from the spasm of muscles innervated by the facial nerve. Characteristic tremor of the tongue and masticatory muscles is an early sign of general paralysis. Tongue and lip tremors can also be seen in ty C. Anesthesia ​ Anesthesia can occur in the tongue after traumatic injuries, the spread of infections, during local anesthesia applications when the needle hits the lingual nerve, and from nerve injuries during tooth extraction using the split technique. D. Paresthesia ​ Paresthesia may occur in the part of the tongue in front of the circumvallate papillae due to irritation of the lingual nerve. ​ Paresthesia presents as numbness, a burning sensation, tingling, or a needle-prick feeling. Yrd. Doç.Dr. Erim TANDOĞDU ​ A burning sensation can also occur with galvanic currents. ​ Anemia and certain blood diseases can also cause such symptoms. In the presence of these symptoms, all irritation foci in the mouth must be eliminated. Additionally, the patient's diet should be regulated, and oral hygiene should be maintained. E. Tongue Pain (Glossodynia) ​ Glossodynia is characterized by pain and an unpleasant sensation (itching or burning) in the tongue. ​ Numerous factors can cause it, including nutritional deficiencies, anemias, xerostomia, cancer phobia, and metal poisoning from galvanic currents. ​ The condition known as "Burning Mouth Syndrome," which primarily affects the tongue, is quite difficult to treat. ​ Systemic diseases, dry mouth, and prosthetic problems should be addressed. F. Taste Disorders ​ The reduction in taste sensation (hypogeusia) or complete loss of taste (ageusia) can result from central or peripheral lesions. ​ Peripheral lesions may involve diseases affecting the tongue mucosa, nose, and middle ear. ​ In the late stage of syphilis, the sense of taste can also be impaired. Taste disturbances can occur following surgical trauma to the chorda tympani during middle ear operations. Radiation therapy for malignancies in the head and neck region can temporarily cause a loss of taste sensation. Sources: 1.​ Crispian Scully.: Oral and Maxillofacial Medicine, Elsevier, 2004. 2.​ Anne Field and Lesley Longman.: Tyldesley’s Oral Medicine, fifth edition, Oxford University Press, 2003. 3.​ George Laskaris.: Pocket Atlas of Oral Diseases, Thieme, 1997. 4.​ Tyldesley.: A Colour Atlas of Oro-Facial Diseases, second edition, ELBS, 1991.