What is Gingival Enlargement: Causes, Symptoms, Treatment, Classification, Epidemiology

Gingiva is the medical term for gums. It is the portion of the oral mucosa that covers the alveolar bone and surrounds the teeth. It extends over the maxillary and mandibular bone, and plays a vital role in providing support and protection to our teeth. A healthy gingiva generally appears coral pink in colour with melanin pigmentation in some individuals. The health of the gingiva can help in diagnosis of various periodontal diseases and oral conditions. It also helps in early detection and prediction of various underlying systemic disorders.

The gingiva can be classified into 3 parts broadly:

• Free gingiva/marginal gingiva
• Attached gingiva
• Interdental gingiva/interdental papilla

Marginal gingiva is the free end of the gingiva that surrounds the tooth in a collar like fashion. Attached gingiva is the immovable portion of the gingiva, which extends from the attached end of the marginal gingiva up to the alveolar mucosa. The interdental gingiva (also known as interdental papilla), is the v-shaped portion that occupies the interdental area; i.e. the area between two adjacent teeth. The depressed portion of the interdental gingiva (called Col), found between below the proximal contact area of 2 adjacent area is highly prone to infection.

Gingival enlargement is a multifactorial condition characterised by abnormal increase in size of the gingiva. It is the most common feature of any gingival disease. Besides being unpleasant and non- aesthetic in appearance, gingival overgrowth may cause discomfort and difficulty with speech and mastication. In certain cases, gingival enlargement may also lead to bleeding and foul odour from the oral cavity.

Gingival enlargement can be broadly classified as:

• Localized: Confined to a single tooth.
• Generalized: Involves the entire gingiva.
• Marginal: Confined only to marginal gingiva.
• Papillary: Confined to interdental papilla.
• Diffuse: Involving the marginal, attached gingiva and/or interdental gingiva.
• Discrete: Isolated enlargement.

Based on Etiology and Pathogenesis, Gingival Enlargement Can be Classified as Follows:

• Inflammatory enlargement
  • Chronic
  • Acute
• Drug induced enlargement
  • E.g.: Phenytoin, Cyclosporine, Calcium channel blockers such as Nifedipine, Amlodipine and Verapamil.
• Enlargements associated with systemic diseases
  • Conditioned enlargement
    • Hormonal (Pregnancy, puberty)
    • Vitamin C deficiency
    • Plasma cell gingivitis (Allergy to chewing gum, tooth paste, eatables etc.)
    • Non-specific conditioned enlargement
  • Systemic disease causing gingival enlargement
    • Leukaemia
    • Granulomatous diseases (Wegener’s granulomatosis, sarcoidosis etc.)
    • Syndromes
• Neoplastic/cancerous enlargement
  • Benign tumours
  • Malignant tumours
• False enlargement

Periodontal diseases, largely characterised by gingival enlargement, ever since the days of Hippocrates have affected the human dentition. Host, agent and environment are the 3 main factors that cause the enlargement. Host being the oral cavity; agent being causative organisms; and environment being the favourable condition for development of the disease. The causative factors can be divided into 2 basic classifications like, Local and Systemic.

• Local Factors for Gingival Enlargement: They are within the immediate vicinity of the periodontium e.g. plaque, calculus, malocclusion etc.
• Systemic Factors for Gingival Enlargement: They relate to the general health and metabolism of the patient.

Studies have shown that gingivitis alone is more common in male children than in female. Puberty and pregnancy are known to cause gingival overgrowth in view of endocrinal changes within the body. Dilantin sodium used in the treatment of epilepsy has been found to cause fibrotic enlargement of the gingiva.

Certain genetic anomalies and acquired inborn errors of metabolism may have an unusually high susceptibility to gingival enlargement. Also, it may be more common in emotionally disturbed individuals.

Gingival enlargement may be caused by dental issues such as plaque accumulation, poor oral hygiene, improper brushing technique, anatomic deformities, and irritation from inappropriate restorations, ill-fitting prosthesis and improper orthodontic appliances. A large number of systemic diseases can also present itself with gingival enlargement as a vital symptom. In addition to dental issues and systemic disorders, gingival enlargement can also be caused by result of hormonal changes in the body. It can also present itself as a response to certain drug.

Gingival enlargement may be self-diagnosed when warnings signs such as:

• Swollen gums
• Tender gums
• Bleeding gums when eating and brushing are noticed.

Clinically it is characterised by local changes in appearance, swelling or oedema, change in colour of the gums and increased tendency to bleed upon periodontal probing. In systemic conditions such as leukemia, symptoms may be associated with spontaneous gingival bleeding, petechiae, mucosal pallor, herpetic lesions and candidiasis. A complete blood work can be useful in diagnosis of underlying systemic disease. If an exact diagnosis could not be made based on the patient history and clinical examination, a biopsy is done on a tissue specimen and haematological examination are done. Appropriate guidance and education can help in prevention and detection at an early stage.

Treatment of gingival enlargement is based on correct understanding of the underlying pathological changes and root cause agent. The treatment options are:

• Primary Stage Treatment for Gingival Enlargement: In the primary stage, treatment involves elimination of the causative agent and local irritants responsible for the condition. The enlargement is treated primarily by removal of the plaque accumulation done by:
  • Scaling
  • Curettage, and
  • Root planning carried out in subsequent visits with or without local anaesthesia.
• Drug Induced Gingival Enlargement Treatment: For drug induced gingival enlargement, altering the causative medication after consulting a physician can be beneficial.
• Treatment for Systemic Diseases Causing Gingival Enlargement: In the case of enlargement caused by systemic diseases, treatment of the underlying disease may lead to partial or complete resolution of the condition.
• Gingival Enlargement Treatment for Advance Stage: In advanced stages, gingivectomy may be considered as an option. It is a process where the enlarged portion of the gingiva is incised either surgically or by using electrocautery or laser.

Antibiotics are often prescribed to reduce the risk of infection. Regular follow up with a periodontist is advised for maintenance and limiting reoccurrence.

Plaque build-up being one of the key causes for gingival enlargement, adequate maintenance of oral hygiene is a must. This includes brushing in the right technique at least twice a day with regular use of floss and mouthwash. Periodic visit to the dentists, preferably a periodontist, is highly recommended for regular evaluation and preventive measures. One may also consider scaling once every 6 months for maintaining healthy gums.