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Gingival Hyperplasia - Causes, Types, and Management

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Gingival Hyperplasia - Causes, Types, and Management

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Gingival hyperplasia is the abnormal growth of the gum tissue in the mouth due to various reasons. Find out what to do incase this occurs and cure for it.

Medically reviewed by

Dr. Chithranjali Ravichandran

Published At June 2, 2021
Reviewed AtDecember 27, 2023

Introduction

Gingival hyperplasia, also known as gingival overgrowth or hypertrophic gingivitis, is a common oral condition characterized by an abnormal and excessive growth of the gum tissue surrounding the teeth. This condition can affect individuals of all ages and is often associated with certain medications, hormonal changes, or underlying health issues. Gingival hyperplasia can lead to aesthetic concerns, discomfort, and potential complications if left untreated. Understanding the causes, symptoms, and available treatment options for gingival hyperplasia is crucial in managing and maintaining optimal oral health.

What Is Gingival Hyperplasia or Hypertrophy?

It is a localized or generalized irregular enlargement of the marginal or attached gingiva due to chronic inflammation of the gum tissues locally or systemic induced inflammatory changes by drugs, nutritional deficiencies, hormonal changes or abnormalities, or autoimmune changes and infections.

Gingival inflammation may be limited only to a particular quadrant or specific area in between or surrounding the teeth in the oral cavity or maybe generalized in all quadrants. Hyperplasia is an increase in the number of cells, while hypertrophy is an increase in the size of individual cells. Though these two terminologies are considered different because of microscopic distinctions, the disease process is the result of gingival inflammation, referred to as gingival enlargement.

What Are The Causes of Gum Enlargement?

Gingival hyperplasia, also known as gum enlargement, can be attributed to various underlying factors, with three major causes standing out as primary contributors:

  • Inflammatory Induced Enlargement: Inflammation of the gum tissue is a common cause of gingival hyperplasia. Poor oral hygiene, which leads to the buildup of dental plaque and tartar, can trigger gum inflammation. The body's immune response to the bacterial irritants in the plaque can result in swollen and enlarged gums. Conditions such as gingivitis and periodontitis, which are characterized by gum inflammation, can lead to significant gum enlargement if left untreated.
  • Drug-Induced or Medication-Induced Enlargement: Certain medications have been linked to the development of gingival hyperplasia as a side effect. These drugs, often prescribed to manage various medical conditions, can interfere with the normal growth and turnover of gum tissue. Medications such as anticonvulsants (for example, Phenytoin), immunosuppressants (for example, Cyclosporine), and calcium channel blockers (for example- Nifedipine) have been associated with gum enlargement in some individuals.
  • Systemic Disease-Induced Enlargement: Underlying systemic diseases can also play a role in causing gingival hyperplasia. Conditions such as leukemia, Crohn's disease, and granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis) have been linked to gum enlargement. In these cases, the underlying disease process can lead to abnormal growth of gum tissue.

What Are the Types of Gingival Enlargements?

1. Inflammatory Gingival Enlargement:

This type of enlargement is more often associated with a local specific cause that results in a reddish, soft, shiny texture, and bleeding appearance of the gingiva or gums.

The specific causes would be due to:

  • Poor dental hygiene and maintenance - promoting the growth of bacterial biofilm or plaque on the tooth surface (enamel), leading to gingivitis and periodontitis or bone loss surrounding the tooth.
  • Smoking - a well-established risk factor for gingival and periodontal disease as it alters the microflora and physiology of the oral immune response. Nicotine in any form of tobacco is not only toxic but also irritant and can be a potent carcinogen.
  • Mouth breathing.
  • Overcrowded teeth.
  • Orthodontic appliances may also cause inflammatory enlargement occasionally.

2. Drug-Induced Gingival Enlargement:

Medication-induced gingival enlargement is featured by fibrous overgrowth on the gingiva or the superimposed boggy appearance of the gums. It occurs commonly in these patients on the following medications :

  • Anticonvulsants - Phenytoin, Lamotrigine, Phenobarbital,Topiramate, Primidone, Ethosuximide,Vigabatrin etc.
  • Antihypertensives - calcium channel blockers such as Nifedipine, Verapamil, and Amlodipine.
  • Immunosuppressive drugs like Cyclosporine.

According to research and medical literature, anticonvulsant therapy-related gingival enlargement constitutes the major number of cases or peak incidence of around 50 %, especially with Phenytoin, also referred to as Dilantin Hyperplasia. Calcium channel blockers and Cyclosporine or immunosuppressant constitute 30 % and 10-20 % of cases with gingival enlargement. There is evidence regarding the mechanism of action of these drugs as they can impair the secretion of collagenase by the gingival fibroblast cells resulting in an excessive accumulation of gingival collagen.

3. Systemic-Linked Gingival Enlargement:

The systemic or bodily conditions that are linked to gingival hyperplasia and hypertrophy are diverse. The inflammatory response seen on the gingiva would be localized or generalized because of the following conditions:

  • Hormonal states of variation as in pregnancy and puberty.
  • Nutritional deficiencies, especially with the incidence of a vitamin C deficiency or scurvy.
  • Blood disorders or diseased conditions like acute leukemia, lymphoma, or aplastic anemia.
  • Genetic disorders – hereditary fibromatosis, Cowden’s syndrome, Sturge weber angiomatosis, Pfeiffer syndrome, tuberous sclerosis, i-cell disease, Fabry disease, fucosidosis, aspartylglucosaminuria, and so on.
  • Systemic disease is most often associated with these conditions: granulomatosis, Crohn’s disease, sarcoidosis, acromegaly, type 1 neurofibromatosis, Kaposi's sarcoma, and others.
  • Benign neoplasms like granulomas, papilloma’s or fibromas can also cause gingival hypertrophy or hyperplasia.

How Is Gingival Hyperplasia Managed?

The aim of treatment for gingival enlargement is to alleviate the patient’s discomfort while eating and chewing, treating the inflammation, and reduce the gingival swelling and give a better cosmetic appearance. The modalities of treatment are medical and surgical.

In the medical line of management, surgery is reserved for recurrences or cases that persist despite good medical treatment. Discontinuing the medication in case of drug-induced gingival enlargement and substituting it with an alternative to Phenytoin (on the advice of the neurologist) like Carbamazepine and Valproic acid, which has shown a lower impact on gingival enlargement would be effective. Similarly, the use of Azithromycin in combination with Cyclosporine or substitution with Tacrolimus has shown decreased severity in drug-induced gingival enlargement. Diltiazem and Verapamil exhibit a lower prevalence of gingival enlargement side effects compared to Nifedipine which is a commonly used calcium channel blocker drug for hypertension.

Before the surgery options can be considered, management by the dental surgeon includes plaque control, proper oral hygiene, and professional plaque removal by periodic deep scaling. Control of inflammation, including NSAIDS (Non-steroidal anti-inflammatory agents), antibiotic prophylaxis to control infection, and, if needed, topical antifungals medications like Nystatin may also be added as an adjunct to non-surgical therapy by the dentist in managing gingival hyperplasia. Folate supplementation has also proved beneficial by dental surgeons in controlling hyperplasia and hypertrophy.

How Is Gingival Hyperplasia Surgically Treated?

Conventional surgical treatment includes the use of surgical blades, knives, 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 after surgical intervention. The surgical methods mainly include gingivectomy (the oldest surgical approach in periodontal therapy and involves the removal of a pocket wall, providing visibility and accessibility for complete calculus removal and thorough smoothening of the tooth root) and periodontal flap surgery.

Electrocautery may be used in difficult cases, in children, or where the gingiva is fragile and likely to bleed. The CO2 laser has a wavelength of 10600 nm that is readily absorbed by water and therefore is effective in the surgery of soft tissue with high water content like the gingiva. Blood vessels up to a diameter of 0.5 mm can be seen effectively and provide a dry field for better visibility of the surgical field. A laser is preferred over the scalpel as it has strong bactericidal and hemostatic effects.

Conclusion

To conclude, gingival enlargement is associated with a diverse range of local, medical, or drug-induced conditions. The diagnosis and investigations include a differential diagnosis for false enlargement for gingival hyperplasia or hypertrophy is made only by the dental surgeon who may either treat the cause by surgical or non-surgical debridement, prophylaxis, and management of the medications. It is absolutely essential to visit the dentist on time to improve the physiological and aesthetic outcomes of the affected gingival tissue.

Frequently Asked Questions

1.

Which Drugs Induce Gingival Hyperplasia?

Drug-induced gingival enlargement is caused by Calcium channel blockers, anticonvulsants, and immunosuppressants. Calcium channel blockers include Nifedipine, Nitrendipine, Felodipine, Nicardipine, Manidipin, Amlodipine, Nimodipine, Nisoldipine, Verapamil, and Diltiazem. Anticonvulsant drugs comprise Phenytoin, Sodium valproate, Phenobarbitone, Vigabatrin, Primidone, Mephenytoin, Ethotoin, and Ethosuximide. Tacrolimus, Sirolimus, and Cyclosporin are the immunosuppressants that are responsible for gum hyperplasia.

2.

What Are the Types of Gingival Hyperplasia?

- Drug-induced enlargement.
- Acute and chronic inflammatory enlargement.
- Hormonal and conditioned enlargement.
- Enlargement due to systemic diseases.
- Neoplastic gingival enlargement.
- Idiopathic gingival enlargement.

3.

How Can We Treat Gingival Enlargement?

Eliminating the causative agent along with well-maintained oral hygiene can help in reducing the aggression of the disease. In moderate gingival hyperplasia, scaling (debridement of plaque and calculus) and root planing (smoothing the surfaces) can provide adequate relief and reverse the condition. On the other hand, in severe gingival enlargement, surgical removal of the excessive gum tissues is needed, which can be done by laser excision, electrosurgery, periodontal flap surgery, or gingivectomy.

4.

How Does Gingival Hyperplasia Appear Clinically?

Gingival enlargement presents as reddish, tender, swollen, and bleeding gums, along with pain, malodor, and plaque deposition. In extreme cases, the gingiva may fully embrace the tooth, making it even more difficult to maintain oral hygiene and cause disturbance to teeth alignment.

5.

What Causes Gingival Enlargement in a Single Tooth?

Localized gingival enlargement can result from plaque deposition or can be a reactive lesion, as in the case of a fibrous nodule, pyogenic granuloma, and peripheral giant cell granuloma. It can also be due to malignant, idiopathic (unknown), or developmental causes.

6.

How Long Does It Take to Cure Gingival Hyperplasia?

After removing the cause of gingival enlargement or starting the treatment and surgery, it will take about one to eight weeks to cure your gingival hyperplasia.

7.

What Is the Reason for Gingival Hyperplasia in Kids?

Gingival hypertrophy due to consumption of drugs like Cyclosporin, Phenytoin, and Nifedipine, hereditary gingival fibromatosis, and von Recklinghausen disease are the most common causes for gum enlargement in children.

8.

Is Gingival Hyperplasia a Communicable Condition?

Gingival enlargement is not a contagious condition as it can neither be acquired nor transmitted from one person to another person. However, the bacteria causing gingival diseases can be transmitted through saliva.

9.

Can Gingival Hyperplasia Turn Malignant?

A small number of gingival enlargements can turn cancerous. It accounts for about 8 percent of oral tumors. Benign tumors of the gingiva are fibroma, papilloma, peripheral giant cell granuloma, etc. Malignant tumors include squamous cell carcinoma, malignant melanoma, and sarcoma.

10.

How Can We Identify False Enlargements of the Gingiva?

False or pseudo enlargements of the gingiva occur due to the development of the underlying dental or osseous tissues. They can be differentiated from gingival enlargement by the fact that they show an increase in the size of the area but do not present any abnormal clinical features, including inflammation. These false enlargements are seen in tori, Paget’s disease, osteoma, osteosarcoma, fibrous dysplasia, etc.
Dr. Achanta Krishna Swaroop
Dr. Achanta Krishna Swaroop

Dentistry

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