Scott Froum, DDS, editorial director of Perio-Implant Advisory, describes the various causes and dental treatment options for gingival enlargement, a condition mistakenly used synonymously with gingival hypertrophy and gingival hyperplasia. He also presents a new form of surgical treatment that can assist in correcting certain types of gingival enlargement.
Gingival enlargement, also mistakenly used synonymously with gingival hypertrophy and gingival hyperplasia, describes a condition that occurs when the size of the gingiva increases. Gingival hyperplasia typically refers to the increase in the number of cells, whereas gingival hypertrophy deals with the increase in cell size. These microscopic distinctions are both indicative of a disease process.
Gingival enlargement can be induced by three main causes stemming from (1) inflammation, (2) medication, and (3) systemic disease. Treatment can be in the form of allowing for spontaneous resolution once the etiology is removed, instituting proper dental hygiene, nonsurgical treatment, and/or surgical treatment.
This article will briefly discuss examples of gingival enlargement and its associated causes, as well as present a new form of surgical treatment that can assist in correcting certain types of gingival enlargement.
Inflammatory-induced gingival enlargement
Inflammatory-induced gingival enlargement is typically caused by biofilm (bacteria) and the host response, resulting in familiar forms of periodontal disease such as gingivitis and periodontitis. Swelling, erythema, and bleeding are signs of these diseases (figure 1). In addition to poor oral hygiene, orthodontic appliances have been associated with this type of gingival enlargement (figure 2). Typical treatment includes instituting good oral hygiene and nonsurgical mechanical debridement. In some instances, surgical removal of excess gingival tissue may be needed (figure 2a).
|Figure 2||Figure 2a
Medication-induced (drug-induced) gingival enlargement
- Anticonvulsants (phenytoin, phenobarbital, lamotrigine, vigabatrin, ethosuximide, topiramate, and primidone)
- Antihypertensives (calcium channel blockers such as nifedipine, amlodipine, and verapamil)
- Immunosuppressant (cyclosporine)
Most literature states that when considering the overall incidence of drug-induced gingival enlargement, 50% is attributed to phenytoin (figure 3), 30% to cyclosporine, and the remaining 10% to 20% to calcium channel blockers, whereas nifedipine seems to be the major cause (figures 4a and 4b). Treatment may not be needed and spontaneous resolution may occur if the drug is discontinued or another drug is substituted. It is believed that plaque bacteria caused by poor oral hygiene can exacerbate the drug’s effect, and therefore nonsurgical mechanical debridement and good home care should be included. If these methods do not result in the resolution of gingival enlargement, surgical treatment may be necessary (figures 4c and 4d).
|Figure 4a||Figure 4b|
Systemic causes of gingival enlargement
Systemic causes of gingival enlargement may induce a localized or generalized response. Hormonal changes associated with pregnancy or puberty and vitamin deficiencies (mostly vitamin C) are some of the more common causes in this category. Benign neoplasms—such as giant cell granuloma, papillomas, and fibromas—can cause enlargement of the gingiva. Other more serious causes of gingival enlargement include leukemias, malignant neoplasms/carcinomas, as well as many forms of granulomatous diseases.
The first line of treatment is most often noninvasive and includes the discontinuation of any offending medication, treatment of the systemic disease, institution of good home care, and nonsurgical mechanical debridement. If these methods are ineffective, surgical treatment is warranted. Conventional surgical treatment includes the use of surgical blades, knives, and high-speed burs to remove the excess gingival tissue. Dental lasers such as diodes, CO2, and erbium YAG have also been implemented to remove excess soft tissue.
A new laser that can be used to treat gingival enlargement (figures 2 and 2a) is a 9.3 micron CO2 laser (Solea) from Convergent Dental, with the capabilities of both soft- and hard-tissue removal. Because this laser has both pinpoint cutting accuracy as well as cauterizing ability, it is very useful when encountering inflamed tissue. Conventional instrumentation—such as blades, knives, and high-speed burs—can often lead to bleeding after surgical removal when the tissue is inflamed. With this type of CO2 laser, sutures and/or surgical dressing is often not needed (figures 4a through 4d).
Treatment for gingival enlargement is dependent on the etiologic agent and the category the disease falls under. If the enlargement is induced by medication, suspension of the drug and institution of proper home care will usually result in resolution. Similarly, when caused by a systemic problem, treatment of the disease usually will result in treatment of the enlargement. Hormonal fluctuations caused by pregnancy and puberty are often unavoidable, and gingival enlargement can often be precluded/alleviated with excellent home care and routine maintenance visits. When these noninvasive modalities do not result in resolution of gingival enlargement, surgical treatment is often needed to remove excess tissue.
Scott Froum, DDS, a graduate of the State University of New York Stony Brook School of Dental Medicine, is a periodontist in private practice in New York City. He is the editorial director of Perio-Implant Advisory e-newsletter, as well as a contributing author for DentistryIQ and Dental Economics. Dr. Froum, a diplomate of the American Board of Periodontology, is a clinical associate professor at both SUNY Stony Brook and the NYU Dental School in the Department of Periodontology and Implantology. He serves on the board of editorial consultants for the Academy of Osseointegration's Academy News. Contact him by email at firstname.lastname@example.org or through his website at drscottfroum.com.