Gingival Hyperplasia - Causes, Types, and Management

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 Is the Etiology of Gingival Enlargements?

Gingival hyperplasia though multicausative in origin, still mainly stems from three major causes:

1. Inflammatory induced enlargement
2. Drug-induced/medication-induced enlargement
3. Systemic disease-induced enlargement.

The modalities for managing gingival hyperplasia are mainly dependent on the etiology and may be invasive or non-invasive depending on the extent of inflammation or enlargement.

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/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, etc.

• Systemic disease is most often associated with these conditions: granulomatosis, Crohn’s disease, sarcoidosis, acromegaly, type 1 neurofibromatosis, Kaposi's sarcoma, etc.

• 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.