CS4-12)Gingival Enlargement_PROF.DR.TOLGA TÖZÜM.pdf

Prof. Dr. TOLGA TOZUM YAKINDOĞU ÜNİVERSİTESİ DİŞHEKİMLİĞİ FAKÜLTESİ Learning outcomes: 1- Will be able to classify gingival enlargements 2- Will be able List the causes of gingival enlargement 3- Will be able to clinically distinguish gingival enlargements according to their causes. 4-Will be able...

Prof. Dr. TOLGA TOZUM YAKINDOĞU ÜNİVERSİTESİ DİŞHEKİMLİĞİ FAKÜLTESİ Learning outcomes: 1- Will be able to classify gingival enlargements 2- Will be able List the causes of gingival enlargement 3- Will be able to clinically distinguish gingival enlargements according to their causes. 4-Will be able to determine the situations in which a physician should be consulted in the phase 1 treatment of gingival enlargement. Gingival Enlargement An increase in size of the gingiva is a common feature of gingival disease. The accepted current terms for this condition are gingival enlargement and gingival overgrowth. These are strictly clinical descriptive terms, and they avoid the erroneous pathologic connotations of terms used in the past, such as hypertrophic gingivitis and gingival hyperplasia. I. Inflammatory enlargement A. Chronic B. Acute II. Drug-induced enlargement A. General information B. Anticonvulsants C. Immunosuppressants D. Calcium channel blockers III. Enlargements associated with systemic diseases or conditions A. Conditioned enlargement 1. Pregnancy 2. Puberty 3. Vitamin C deficiency 4. Plasma cell gingivitis 5. Nonspecific conditioned enlargement (pyogenic granuloma) B. Systemic diseases that cause gingival enlargement 1. Leukemia 2. Granulomatous diseases (e.g., Wegener’s granulomatosis,sarcoidosis) IV. Neoplastic enlargement (gingival tumors) A. Benign tumors B. Malignant tumors V. False enlargement With the use of the criteria of location and distribution, gingival enlargement is designated as follows: • Localized: Limited to the gingiva adjacent to a single tooth or group of teeth • Generalized: Involving the gingiva throughout the mouth • Marginal: Confined to the marginal gingiva • Papillary: Confined to the interdental papilla • Diffuse: Involving the marginal and attached gingivae and papillae • Discrete: An isolated sessile or a pedunculated, tumorlike enlargement The degree of gingival enlargement can be scored as follows: • Grade 0: No signs of gingival enlargement • Grade I: Enlargement confined to interdental papilla • Grade II: Enlargement involves papilla and marginal gingiva • Grade III: Enlargement covers three quarters or more of the crown Inflammatory Enlargement Gingival enlargement may result from chronic or acute inflammatory changes, although chronic changes are much more common. In addition, inflammatory enlargements are usually a secondary complication of any of the other types of enlargement, thereby creating a combined gingival enlargement. In these cases, it is important to understand the double etiology and to treat both causes adequately. Chronic Inflammatory Enlargement Clinical Features. Chronic inflammatory gingival enlargement originates as a slight ballooning of the interdental papilla and marginal gingiva. In the early stages, it produces a life-preserver shaped bulge around the involved teeth. This bulge can increase in size until it covers part of the crowns. The enlargement may be localized or generalized; it progresses slowly and painlessly, unless it is complicated by acute infection or trauma Etiology. Chronic inflammatory gingival enlargement is caused by prolonged exposure to dental plaque. Factors that favor plaque accumulation and retention include poor oral hygiene, irritation by anatomic abnormalities, and improper restorative and orthodontic appliances. Gingival Changes Associated with Mouth Breathing. Gingivitis and gingival enlargement are often seen in patients who are mouth breathers. The gingiva appears red and edematous,with a diffuse surface shininess of the exposed area. The maxillary anterior region is the common site of such involvement. In many cases, the altered gingiva is clearly demarcated from the adjacent unexposed normal gingiva. Acute Inflammatory Enlargement Gingival Abscess. A gingival abscess is a localized, painful, rapidly expanding lesion that usually has a sudden onset . It is generally limited to the marginal gingiva or the interdental papilla. In its early stages, it appears as a red swelling with a smooth, shiny surface. Within 24 to 48 hours, the lesion usually becomes fluctuant and pointed, with a surface orifice from which a purulent exudate may be expressed. The adjacent teeth are often sensitive to percussion. If permitted to progress, the lesion generally ruptures spontaneously. Etiology. Acute inflammatory gingival enlargement results from bacteria carried deep into the tissues when a foreign substance (e.g., toothbrush bristle, piece of apple core, lobster shell fragment) is forcefully embedded into the gingiva. The lesion is confined to the gingiva and should not be confused with periodontal or lateral abscesses. Periodontal (Lateral) Abscess. Periodontal abscesses involve the supporting periodontal tissues and generally produce enlargement of the gingiva. For a detailed description of periodontal abscesses, Drug-Induced Gingival Enlargement Gingival enlargement is a well-known consequence of the administration of some anticonvulsants, immunosuppressants, and calcium channel blockers. The condition may create speech, mastication, tooth eruption, and aesthetic problems. Clinical and microscopic features of the enlargements caused by the different drugs are similar. These are presented first, followed by a description of the particular features of each drug. General Information Clinical Features. The growth starts as a painless, beadlike enlargement of the interdental papilla that then extends to the facial and lingual gingival margins. As the condition progresses, the marginal and papillary enlargements unite, and they may develop into a massive tissue fold that covers a considerable portion of the crowns; this may interfere with occlusion The enlargement is usually generalized throughout the mouth, but it is more severe in the maxillary and mandibular anterior regions. It occurs in areas in which teeth are present (not in eden-tulous spaces), and the enlargement disappears in areas from which teeth have been extracted. Hyperplasia of the mucosa in edentulous mouths has been reported but is rare. Drug-induced enlargement may occur in mouths with little or no plaque, and it may be absent in mouths with abundant deposits. However, some investigators believe that inflammation is a prerequisite for development of the enlargement, which therefore could be prevented by plaque removal and fastidious oral hygiene. Anticonvulsants The first drug-induced gingival enlargements reported were those produced by phenytoin (Dilantin). Dilantin is a hydantoin that was introduced by Merritt and Putnam in 1938 for the treatment of all forms of epilepsy, except petit mal seizures. Shortly thereafter, its relationship with gingival enlargement was reported.Other hydantoins that are known to induce gingival enlargement are ethotoin (Peganone) and mephenytoin (Mesantoin). Other anticonvulsants that have the same side effect are the succinimides (ethosuximide [Zarontin], methsuximide [Celontin]) and valproic acid (Depakene). Gingival enlargement occurs in about 50% of patients receiving the drug,109 although different authors have reported incidences from 3% to.5%.2,35,79 It occurs more often in younger patients.5 Its occurrence and severity are not necessarily related to the dosage after a threshold level has been exceeded. Immunosuppressants Cyclosporine is a potent immunosuppressive agent that is used to prevent organ transplant rejection and to treat several diseases of autoimmune origin.20 Its exact mechanism of action is not well known, but it appears to selectively and reversibly inhibit helper T cells, which play a role in cellular and humoral immune responses. Cyclosporine A (Sandimmune, Neoral) is administered intravenously or by mouth, and dosages of more than 500 mg/day have been reported to induce gingival overgrowth.Cyclosporine-induced gingival enlargement is more vascularized than phenytoin enlargement. Its occurrence varies, according to different studies, from 25% to 70%. It affects children more frequently, and its magnitude appears to be related more to the plasma concentration than to the patient’s periodontal status.95 Gingival enlargement is greater in patients who are medicated with both cyclosporine and calcium channel blockers. Calcium Channel Blockers Calcium channel blockers are drugs that were developed for the treatment of cardiovascular conditions such as hypertension, angina pectoris, coronary artery spasms, and cardiac arrhythmias. They inhibit calcium ion influx across the cell membrane of heart and smooth muscle cells, thereby blocking the intracellular mobilization of calcium. This induces the direct dilation of the coronary arteries and arterioles and improves oxygen supply to the heart muscle; it also reduces hypertension by dilating the peripheral vasculature. These drugs are the dihydropyridine derivatives (amlodipine [Lotrel, Norvasc], felodipine [Plendil], nicardipine [Cardene], nifedipine [Adalat, Procardia]); the benzothiazine derivatives (diltiazem [Cardizem, Dilacor XR, Tiazac]); and the phenylalkylamine derivatives (verapamil [Calan, Isoptin, Verelan, Covera HS]).Some of these drugs can induce gingival enlargement. Nifedipine, which is one of the most often used, induces gingival enlargement in 20% of patients.Diltiazem, felodipine, nitrendipine, and verapamil also induce gingival enlargement. The dihydropyridine derivative isradipine can replace nifedipine in some cases; it does not induce gingival overgrowth.Nifedipine is also used with cyclosporine in kidney transplant recipients, and the combined use of both drugs induces larger overgrowths. Nifedipine gingival enlargement has been induced experimentally in rats, where it appears to be dose dependent; in humans, however, this dose dependency is not clear. One report indicates that nifedipine increases the risk of periodontal destruction in patients with type 2 diabetes mellitus. Idiopathic Gingival Enlargement Idiopathic gingival enlargement is a rare condition of undetermined cause. It has been designated by such terms as gingivostomatosis, elephantiasis, idiopathic fibromatosis, hereditary gingival hyperplasia, and congenital familial fibromatosis. General Information Clinical Features. The enlargement affects the attached gingiva as well as the gingival margin and the interdental papillae. This is in contrast withphenytoin-induced overgrowth, which is often limited to the gingival margin and the interdental papillae.The facial and lingual surfaces of the mandible and maxilla are generally affected, but the involvement may be limited to either jaw. Etiology. The cause is unknown, and thus the condition is designated as “idiopathic.” Some cases have a hereditary basis,but the genetic mechanisms involved are not well understood. A study of several families found the mode of inheritance to be autosomal recessive in some cases and autosomal dominant in others. Enlargements Associated with Systemic Diseases Many systemic diseases can develop oral manifestations that may include gingival enlargement. These diseases and conditions can affect the periodontium via two different mechanisms: 1. The magnification of an existing inflammation initiated by dental plaque. This group of diseases, which are discussed in the Conditioned Enlargements section, includes some hormonal conditions (e.g., pregnancy, puberty), some nutritional diseases (e.g., vitamin C deficiency), and some cases in which the systemic influence is not identified (i.e., nonspecific conditioned enlargement). 2. The manifestation of the systemic disease independently of the inflammatory status of the gingiva. These mechanisms are described in the Systemic Diseases that Cause Gingival Enlargement section and the Neoplastic Enlargement (Gingival Tumors) section. Conditioned Enlargements Conditioned enlargements occur when the systemic condition of the patient exaggerates or distorts the usual gingival response to dental plaque. The specific manner in which the clinical picture of conditioned gingival enlargement differs from that of chronic gingivitis depends on the nature of the modifying systemic influence. Bacterial plaque is necessary for the initiation of this type of enlargement. However, plaque is not the sole determinant of the nature of the clinical features. The three types of conditioned gingival enlargement are hormonal (pregnancy, puberty), nutritional (associated with vitamin C deficiency), and allergic. Nonspecific conditioned enlargement is also seen. Enlargement in Pregnancy. Pregnancy gingival enlargement may be marginal and generalized, or it may occur as a single mass or multiple tumorlike masses . During pregnancy, there is an increase in levels of both progesterone and estrogen, which by the end of the third trimester reach levels 10 and 30 times the levels present during the menstrual cycle, respectively. These hormonal changes induce changes in vascular permeability, which leads to gingival edema and an increased inflammatory response to dental plaque. The subgingival microbiota may also undergo changes, including an increase in Prevotella intermedia. Marginal Enlargement. Marginal gingival enlargement during pregnancy results from the aggravation of previous inflammation, and its incidence has been reported as 10%18 and 70%.The clinical picture varies considerably. The enlargement is usually generalized, and it tends to be more prominent interproximally than on the facial and lingual surfaces. The enlarged gingiva is bright red or magenta, soft, and friable, and it has a smooth, shiny surface. Bleeding occurs spontaneously or on slight provocation. Tumorlike Gingival Enlargement. The so-called pregnancy tumor is not a neoplasm; it is an inflammatory response to bacterial plaque, and it is modified by the patient’s condition. It usually appears after the third month of pregnancy, but it may occur earlier. The reported incidence is 1.8% to 5%.66 Enlargement in Puberty. Enlargement of the gingiva is sometimes seen during puberty. It occurs in both male and female adolescents, and it appears in areas of plaque accumulation.The size of the gingival enlargement greatly exceeds that usually seen in association with comparable local factors. It is marginal and interdental, and it is characterized by prominent bulbous interproximal papillae. Often, only the facial gingivae are enlarged, and the lingual surfaces are relatively unaltered; the mechanical action of the tongue and the excursion of food prevent a heavy accumulation of local irritants on the lingual surface. Gingival enlargement during puberty has all of the clinical features that are generally associated with chronic inflammatory gingival disease. It is the degree of enlargement and its tendency to recur in the presence of relatively scant plaque deposits that distinguish pubertal gingival enlargement from uncomplicated chronic inflammatory gingival enlargement. After puberty, the enlargement undergoes spontaneous reduction, but does not disappear completely until the plaque and calculus are removed. Enlargement in Vitamin C Deficiency. The enlargement of the gingiva is generally included in classic descriptions of scurvy. Acute vitamin C deficiency itself does not cause gingival inflammation, but it does cause hemorrhage, collagen degeneration, and edema of the gingival connective tissue. These changes modify the response of the gingiva to plaque to the extent that the normal defensive delimiting reaction is inhibited and the extent of the inflammation is exaggerated, thereby resulting in the massive gingival enlargement seen in patients with scurvy Plasma Cell Gingivitis. Plasma cell gingivitis consists of a mild marginal gingival enlargement that extends to the attached gingiva. The gingiva appears red, friable, and sometimes granular, and it bleeds easily; usually it does not induce a loss of attachment . This lesion is located in the oral aspect of the attached gingiva and therefore differs from plaque-induced gingivitis. Nonspecific Conditioned Enlargement (Pyogenic Granuloma). Pyogenic granuloma is a tumorlike gingival enlargement that is considered an exaggerated conditioned response to minor trauma. The exact nature of the systemic conditioning factor has not been identified. Pyogenic granuloma is similar in clinical and microscopic appearance to the conditioned gingival enlargement seen during pregnancy. The differential diagnosis is based on the patient’s history. Treatment consists of the removal of the lesions plus the elimination of irritating local factors. The recurrence rate is about 15%. Systemic Diseases that Cause Gingival Enlargement Several systemic diseases may result in gingival enlargement by different mechanisms. These are uncommon cases, and they are only briefly discussed. Leukemia. Leukemic gingival enlargement may be diffuse or marginal and localized or generalized . It may appear as a diffuse enlargement of the gingival mucosa, an oversized extension of the marginal gingiva, or a discrete tumorlike interproximal mass. Clinical Features. In patients with leukemic enlargement, the gingiva is generally bluish red, and it has a shiny surface. The consistency is moderately firm, but there is a tendency toward friability and hemorrhage that occur either spontaneously or with slight irritation. Acute painful necrotizing ulcerative inflammatory involvement may occur in the crevice formed at the junction of the enlarged gingiva and the contiguous tooth surfaces. Granulomatous Diseases. Wegener’s Granulomatosis. Wegener’s granulomatosis is a rare disease that is characterized by acute granulomatous necrotizing lesions of the respiratory tract, including nasal and oral defects. Renal lesions develop, and acute necrotizing vasculitis affects the blood vessels. The initial manifestations of Wegener’s granulomatosis may involve the orofacial region and include oral mucosal ulceration, gingival enlargement, abnormal tooth mobility, exfoliation of teeth, and delayed healing response. Sarcoidosis. Sarcoidosis is a granulomatous disease of unknown etiology. It starts in individuals during their twenties or thirties, it predominantly affects blacks, and it can involve almost any organ, including the gingiva, in which a red, smooth, painless enlargement may appear. Neoplastic Enlargement (Gingival Tumors) This section provides only a brief description of some of the more common neoplastic and pseudoneoplastic lesions of the gingiva. The reader is referred to oral pathology texts for more comprehensive coverage. Benign Tumors of the Gingiva Epulis is a generic term that is used clinically to designate all discrete tumors and tumorlike masses of the gingiva. It serves to locate the tumor but not to describe it. Most lesions referred to by this term are inflammatory rather than neoplastic. Fibroma. Fibromas of the gingiva arise from the gingival connective tissue or from the periodontal ligament. They are slowgrowing spherical tumors that tend to be firm and nodular but that may be soft and vascular. Fibromas are usually pedunculated. Hard fibromas of the gingiva are rare; most of the lesions that are diagnosed clinically as “fibromas” are inflammatory enlargements. Papilloma. Papillomas are benign proliferations of surface epithelium that are, in many (but not all) cases, associated with the human papillomavirus (HPV). Gingival papillomas appear as solitary wartlike or cauliflower-like protuberances. They may be small and discrete, or they may be broad, hard elevations with minutely irregular surfaces. Peripheral Giant Cell Granuloma. Giant cell lesions of the gingiva arise interdentally or from the gingival margin; they occur most frequently on the labial surface, and they may be sessile or pedunculated. They vary in appearance from smooth, regularly outlined masses to irregularly shaped, multilobulated protuberances with surface indentations. Central Giant Cell Granuloma. Giant cell lesions arise within the jaws and produce central cavitation. They occasionally create a deformity of the jaw that makes the gingiva appear enlarged. Mixed tumors, salivary gland types of tumors, and plasmacytomas of the gingiva have also been described but are not often seen. Leukoplakia. Leukoplakia is a strictly clinical term defined by the World Health Organization as a white patch or plaque that does not rub off and that cannot be diagnosed as any other disease. The cause of leukoplakia remains obscure, although it is associated with the use of tobacco (smoke or smokeless). Other probable factors are Candida albicans, HPV-16 and HPV-18, and trauma. Leukoplakia of the gingiva varies in appearance from a grayish white, flattened, scaly lesion to a thick, irregularly shaped keratinous plaque. Gingival Cyst. Gingival cysts of microscopic proportions are common, but they seldom reach a clinically significant size.When they do, they appear as localized enlargements that may involve the marginal and attached gingiva. Other Benign Masses. Other benign tumors have also been described as rare or infrequent findings in the gingiva. They include nevus,10 myoblastoma,36 hemangioma,108 neurilemoma,31 neurofibroma,81 mucus-secreting cysts (mucoceles),113 and ameloblastoma.105 Malignant Tumors of the Gingiva Carcinoma. Oral cancer accounts for less than 3% of all malignant tumors in the body, but it is the sixth most common cancer in males and the twelfth most common in females. The gingiva is not a frequent site of oral malignancy, accounting for only 6% of oral cancers.Squamous cell carcinoma is the most common malignant tumor of the gingiva. It may be exophytic, presenting as an irregular outgrowth, or ulcerative, appearing as flat, erosive lesions. It is often symptom free, going unnoticed until complicated by inflammatory changes that may mask the neoplasm but cause pain; some times it becomes evident after tooth extraction. These masses are locally invasive, and they involve the underlying bone and periodontal ligament of adjoining teeth and the adjacent mucosa . Metastasis is usually confined to the region above the clavicle; however, more extensive involvement may include the lung, liver, or bone. Malignant Melanoma. Malignant melanoma is a rare oral tumor that tends to occur in the hard palate and maxillary gingiva of older persons. It is usually darkly pigmented, and it is often preceded by localized pigmentation. It may be flat or nodular, and it is characterized by rapid growth and early metastasis. It arises from melanoblasts in the gingiva, cheek, or palate. Infiltration into the underlying bone and metastasis to cervical and axillary lymph nodes are common. False Enlargement False enlargements are not true enlargements of the gingival tissues, but they may appear as such as a result of increases in the size of the underlying osseous or dental tissues. The gingiva usually presents with no abnormal clinical features except the massive increase in the size of the area. Underlying Osseous Lesions Enlargement of the bone subjacent to the gingival area occurs most often with tori and exostoses, but it can also occur with Paget’s disease, fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma, osteoma, and osteosarcoma. Underlying Dental Tissues During the various stages of eruption, particularly of the primary dentition, the labial gingiva may show a bulbous marginal distortion caused by the superimposition of the bulk of the gingiva on the normal prominence of the enamel in the gingival half of the crown. This enlargement has been called developmental enlargement, and often persists until the junctional epithelium has migrated from the enamel to the cementoenamel junction.