Gingival enlargements: A review

Alteration in size of gingiva is one of the clinical features of periodontal disease. Increase in size of gingiva, which is termed as gingival enlargement or gingival over growth is a common clinical sign of gingival disease and a matter of great clinical concern. Increase in size alters the physiologic contour of gingiva, creates areas of plaque accumulation, intereferes with regular oral hygiene procedures and creates aesthetic problems. In severe cases, it interefere with mastication and phonation. Enlargement may involve one or more components of gingiva. Depending on the involvement of components of gingiva and distribution, gingival enlargement can be Localized, genaralized, marginal, papillary, diffuse and discrete. Depending on etiology and pathogenesis, it can be classifi ed as infl ammatory enlargement, fi brotic enlargement, combined enlargement, enlargement associated with systemic conditions, neoplastic enlargement and false enlargements. Case Report Gingival enlargements: A review Anuja Namala1, Dyamavva Halerolli1, Preethi A Poonja2, Prasanna Kumar Rao3* and Raghavendra Kini4 1Intern Student, Oral Medicine & Radiology, AJ Institute of Dental Sciences, Kuntikana, Mangalore 575004, Karnataka, India 2Assistant Professor, Oral Medicine & Radiology, AJ Institute of Dental Sciences, Kuntikana, Mangalore 575004, Karnataka, India 3Professor, Oral Medicine & Radiology, AJ Institute of Dental Sciences, Kuntikana, Mangalore 575004, Karnataka, India 4Professor and Head, Oral Medicine & Radiology, AJ Institute of Dental Sciences, Kuntikana, Mangalore 575004, Karnataka, India Received: 10 February, 2021 Accepted: 20 March, 2021 Published: 22 March, 2021 *Corresponding author: Dr. Prasanna Kumar Rao, Professor, Oral Medicine & Radiology, AJ Institute of Dental Sciences, Kuntikana, Mangalore 575004, Karnataka, India, Tel: +91 9900151108; E-mail:


Introducion
Infl ammatory gingival enlargement is most common type of over growth, which manifest because of increase in volume of gingival tissue in response to local microbial irritation.
Infl amatory enlargement may be acute or chronic. Fibrotic gingival enlargement or non-infl ammatory fi brous gingival over growth is belived to be the result of genetic predispostion or adverse effect of drug . Large number of drugs and genetic disorders are associated with occurance of gingival over growth in susceptible individuals. They may be [1], • Drug induced gingival enlargement • Idiopathic gingival enlargement

Drug induced gingival enlargement
The drugs that are reported to be associated with gingival over growth are anti-convulsants, immune suppresents and calcium channel blockers (Table 1). Despite their pharmacological diversity all these drugs have similar mechanism of action at cellular level. They are known to inhibit intracellular calcium ion induced infl ux. Therefore the clinical features of gingival over growth (Figure 1), by these agents and even the histologic appearance are reported to have common characteristics such as increase in extra cellular ground substance, number of fi broblast and acanthosis of epithelium.
understood; however, blood and cellular immunity response seems to be infl uenced by selective and reversible inhibition of T helper cells. There is disagreement between severity of gingival enelrgement in blood and saliva. Some studies have reported that development of gingival enlargement requires a threshold of drug concentration In blood plasma, while its severity is not associated with the dose. The dosage 500mg is considred as threshold [3].

Calcium channel blockers
Calium channel blockers induces direct dilation of coronary arteries and arterioles, improving the oxygen supply to the heart muscles. It is used in the treatment of acute and chronic coronary insuffi ciency. Gingival over growth occurs in 20% of cases. The stratifi ed squamous epithelium covering the gingival is thick and has a keratinized layer . The rete pegs are extremely long sometimes called "test pegs" with considerable confl uence seen [4].
Calcium channel blockers affect the Ca metabolism by reducing the intra cellular Ca fl ow and limiting the production of active collagenase. Gingival enlargement occurs by taking 30-100mg Nefedipine per day [4].

Idiopathic gingival enlargement
It is also termed as gingivostomatitis, elephantiasis, fi rm and leathery with pebbled surface. Teeth are completely covered. In severe cases jaw appears distorted due bulbous enlargement [5].

Pregnancy induced gingival enlergement
The prevalence of pregnancy gingivitis changes from 35-100%. The gingiva shows increased level of infl ammation often characterized by edema, colour and contour change and propensity to bleed on gentle stimulation ( Figure 2). The marginal gingival tends to be more prominent than facial and lingual surfaces. And infl ammatory reaction to the local irritants that occurs after 3 rd month of pregnancy is called pregnancy tumour. This lesion appears as discrete, mushroom, fl attened spherical masses, that protrude from gingival margin, more frequently interproximal space and are attached by sessile or pedanculated base [6].

Puberty induced gingival enlargement
It is infl ammatory type of gingival enlargement which occurs in both male and females in pubertal age groups. it involves mainly marginal and interdental gingiva ( Figure   3). It is characterised by prominent bulbous interproximal papilla. After puberty the enlargement undergoes spontaneous reduction but does not disappear until local irritants are removed [7]. Some studies have found that pre threshold serum phenytoin was directly aenlargement, while no association was found post threshold phenytoin and gingival enlergment. Girgis et al found a direct relationship between gingival enlargement in 50% of patients, while no relationship and even an inverse relationship was found in rest 50% [2].
Studies have demonstrated that oral hygiene procedures may limit the severity of the lesion but are unable alone to lead to the reversal of the condition [2].

Immunosuppresants
Cyclosporine is apotent immunosuppressive agent used to prevent organ transplant rejection and to treat several disease of autoimmune origin.Clinically it is similar to that induced by dilantin. Mechanism of action of cyclosporine is not fully

Conclusion
Gingival enlargement has varied presentations, hence diagnosis of these entities become challenging for the clinician.
Detailed investigation is necessary. So prompt diagnosis and removal of the etiologic factors is the main treatment objectives.