World Journal of W J C C Clinical Cases Submit a Manuscript: http://www.wjgnet.com/esps/ World J Clin Cases 2015 September 16; 3(9): 779-788 Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx ISSN 2307-8960 (online) DOI: 10.12998/wjcc.v3.i9.779 © 2015 Baishideng Publishing Group Inc. All rights reserved. MINIREVIEWS Gingival enlargements: Differential diagnosis and review of literature Amit Arvind Agrawal Amit Arvind Agrawal, Department of Periodontics, MGV’s makes a final diagnosis or diagnosis of exclusion. KBH Dental college and hospital, Nashik, Maharashtra 422002, A perfect diagnosis is critically important, since the India management of these lesions and prevention of their recurrence is completely dependent on it. Furthermore, Author contributions: Agrawal AA solely wrote this paper. in some cases where gingival enlargement could be the primary sign of potentially lethal systemic diseases, a Conflict-of-interest statement: None. correct diagnosis of these enlargements could prove Open-Access: This article is an open-access article which was life saving for the patient or at least initiate early selected by an in-house editor and fully peer-reviewed by external treatment and improve the quality of life. The purpose reviewers. It is distributed in accordance with the Creative of this review article is to highlight significant findings Commons Attribution Non Commercial (CC BY-NC 4.0) license, of different types of gingival enlargement which would which permits others to distribute, remix, adapt, build upon this help clinician to differentiate between them. A detailed work non-commercially, and license their derivative works on decision tree is also designed for the practitioners, which different terms, provided the original work is properly cited and will help them arrive at a diagnosis in a systematic the use is non-commercial. See: http://creativecommons.org/ manner. There still could be some lesions which may licenses/by-nc/4.0/ present in an unusual manner and make the diagnosis Correspondence to: Dr. Amit Arvind Agrawal, MDS, MPhil, challenging. By knowing the existence of common Professor, Department of Periodontics, MGV’s KBH Dental and rare presentations of gingival enlargement, one college and hospital, Mumbai-Agra road, Nashik, Maharashtra can keep a broad view when formulating a differential 422002, India. [email protected] diagnosis of localized (isolated, discrete, regional) or Telephone: +91-982-2107562 generalized gingival enlargement. Fax: +91-253-2517354 Key words: Differential diagnosis; Gingival hyperplasia; Received: February 1, 2015 Gingival overgrowth; Gingival diseases; Decision tree Peer-review started: February 2, 2015 First decision: May 13, 2015 © The Author(s) 2015. Published by Baishideng Publishing Revised: June 8, 2015 Group Inc. All rights reserved. Accepted: July 29, 2015 Article in press: August 3, 2015 Published online: September 16, 2015 Core tip: In clinical dentistry, patients frequently report with isolated/regional or generalized gingival enlargements, which could fall under varied presenta- tions. The diagnosis of these lesions is essential for their Abstract successful management and of the patient as a whole. This article revises the existing knowledge of different Gingival enlargement is one of the frequent features types of enlargements and highlights some important of gingival diseases. However due to their varied diagnostic features. A customized decision tree is presentations, the diagnosis of these entities becomes designed, which will help clinicians to keep a broad view challenging for the clinician. They can be categorized when formulating a differential diagnosis of localized based on their etiopathogenesis, location, size, extent, (isolated, discrete, regional) or generalized gingival etc . Based on the existing knowledge and clinical enlargement and arrive at a particular diagnosis is an experience, a differential diagnosis can be formulated. easy and systematic manner. Subsequently, after detailed investigation, clinician WJCC|www.wjgnet.com 779 September 16, 2015|Volume 3|Issue 9| Agrawal AA. Gingival enlargements [3] Agrawal AA. Gingival enlargements: Differential diagnosis and “reactive lesion of the gingiva” , seems to be more review of literature. World J Clin Cases 2015; 3(9): 779-788 appropriate for these category of swellings. Frequent Available from: URL: http://www.wjgnet.com/2307-8960/full/ diagnosis in this category is inflammatory rather than v3/i9/779.htm DOI: http://dx.doi.org/10.12998/wjcc.v3.i9.779 neoplastic and may fall in one of the following group of reactive lesions: fibrous epulis/peripheral fibroma, angiogranuloma/pyogenic granuloma and the peripheral giant cell lesion/granuloma. INTRODUCTION Fibrous epulis/peripheral fibroma Gingival enlargement or gingival overgrowth, a common In adults, this lesion frequently represents as firm, pink, trait of gingival disease, is characterized by an increase un-inflammed mass, and it seems to grow from below in the size of gingiva. Pertinent management depends the free gingival margin/interdental papilla (Figure 1A). on precisely diagnosing the origin of enlargement. Most often the lesion is painless. Pain may be associated However, the skills of a clinician is put to test when due to secondary traumata via brushing, flossing or arriving at a particular diagnosis among the myriad of chewing. Histologically, the fibroma may show additional gingival enlargements that can be classified according focus of calcification (peripheral calcifying fibroma), foci to etiologic factors and pathologic changes, according of cementicles (peripheral cementifying fibroma, Figure to location and distribution and/or according to the 1B) or trabeculae of bone (peripheral ossifying fibroma, degree of enlargement. Based on etiopathogenesis, Figure 1C). enlargements could be inflammatory, drug influenced, those associated with systemic conditions or diseases, Angiogranuloma/pyogenic granuloma neoplastic or false enlargements. According to location, Presents in adults as smooth surfaced mass, often enlargements could be marginal, papillary or diffuse. ulcerated and grows from beneath the gingival margin. Based on distribution they can be localized or generaliz­ These reddish/bluish color mass are highly vascular, ed. Localized enlargements could be further divided into compressible and could bleed readily. Typically they three sub­types, viz., “isolated, discrete” or “regional”. grow rapidly within first few weeks and then slowly. “Isolated” enlargements are those limited to gingiva The mass may penetrate interdentally and present as adjacent to single or two teeth (e.g., gingival/periodontal bilobular (buccal and lingual) mass connected through abscess). “Discrete” lesions are isolated sessile or the col area, but bone erosion in uncommon (Figure pedunculated, tumor­like enlargements (e.g., fibroma/ 2A). Angiogranuloma which appears during pregnancy pyogenic granuloma). “Regional” enlargements refer are termed as pregnancy epulis/tumor or granuloma to involvement of gingiva around three or more teeth gravidarum (Figure 2B). in one or multiple areas of the mouth (e.g., inflam­ Histologically, the stratified squamous epithelium is matory enlargement associated with mouth breathing in thickened, with prominent rete pegs and some degree maxillary and mandibular anterior region). “Generalized” of intracellular and extracellular edema, prominent enlargement refers to involvement of gingiva adjacent intercellular bridges and leukocytic infiltration. to almost all the teeth present (e.g., drug influenced gingival overgrowth). Inglés et al[1] summarized different Peripheral giant cell granuloma methods and presented their clinical index to measure They occur particularly in anterior region in young the degree of gingival enlargements. patients or in posterior mouth during mixed dentition The purpose of this article is to highlight significant phase and in adults. They are very aggressive lesions findings of different types of gingival enlargement which with significant growth potential. The high vascularity would help clinician to differentiate between them. of these lesions can be understood by their purplish­red For the purpose of clinical diagnosis, enlargements color and tendency to bleed. They also tend to penetrate mentioned in this review are grossly are divided into interdentally and erosion of adjacent bone along with isolated lesions (epulis) and regional or generalized separation of adjacent teeth is a common occurrence (Figure 3). gingival enlargements. Among these, diagnostic points are discussed for the more commonly occurring lesions and the very rare and unusual presentation are listed as Gingival cysts per the category to which they belong. Gingival cysts are unusual cysts of odontogenic source. They are frequently found in females in their 50’s or 60’s. A greater number of these are found on ISOLATED REACTIVE LESIONS OF THE the labial attached gingiva of the mandibular anterior GINGIVA teeth. Presence of fluid may give them a bluish hue and they may lead to resorption of the labial bone due Localized enlargement of gingiva, historically termed as to pressure. Radiographically, its radiolucency may [2] edulis , refers to any solitary/discrete, pedunculated sometimes lead to confusion with lateral periodontal or sessile swellings of the gingiva with no histologic cyst. Excisional biopsy is the best management for characterization of a particular lesion. A corrective term these lesions[4]. WJCC|www.wjgnet.com