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Gingival Overgrowth: an Enigma to Periodontists

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Gingival Overgrowth: an Enigma to Periodontists Galore International Journal of Health Sciences and Research Vol.2; Issue: 1; March 2017 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321 Gingival Overgrowth: An Enigma to Periodontists Dr. Rosiline James Post Graduate Student, Rural Dental College, Pravara Institute of Medical Sciences, Loni, India ________________________________________________________________________________________________________________ ABSTRACT sex predilection, and effect of local inflammation also affected the severity of Gingival overgrowth which is an abnormal the overgrowth. growth of the periodontal tissue is mainly The capacity of the host to deal associated with dental plaque-related metabolically with chronically administered inflammation and drug therapy. Its true drugs, the responsiveness of gingival tissue incidence in the general population is unknown. Gingival enlargement produces aesthetic to the drugs, and the pre existing gingival changes, pain, gingival bleeding and periodontal condition may differ among different disorders. The three classes of drugs namely, individuals. Moreover, calcium channel anti epileptic, immune-suppressive, produce blockers are mainly prescribed for post- important changes in fibroblast function, which middle-aged patients to control induce an increase in the extracellular matrix of hypertension, cardiac insufficiencies or the gingival connective tissue. In the majority of myocardial events, whereas phenytoin and those patients for whom dosage reduction, or cyclosporine A (CsA) are prescribed for a drug discontinuation or substitution is not wide range of patients due to their wide possible, and for whom prophylactic measures spectrum of efficacy. These make it difficult have failed, surgical excision of gingival tissue to evaluate the etiology of drug induced remains the only treatment of choice. Brunet et al. [1] gingival overgrowth caused by phenytoin, CsA, and calcium channel blockers and to [2] Key words: Gingival enlargement, gingival compare the factors involved. hyperplasia, gingival overgrowth, amlodipine, The influence of plaque on the phenytoin, drug induced gingival enlargement. induction of gingival enlargements by drugs in humans has not been fully elucidated; INTRODUCTION however, it does appear that the severity of An adverse effect caused due to an the lesion is influenced by the oral hygiene intake of three types of drugs namely of the patient. [3] phenytoin, an antiepileptic; cyclosporine A, Characteristics of drug influenced an immunosuppressant; and calcium gingival enlargement channel blockers, such as dihydropyridines • Variation in inter and intra patient (i.e., nifedipine, nitrendipine, and pattern. felodipine), diltiazem and Verapamil. The • Predilection for anterior gingival. first report of phenytoin induced gingival • Higher prevalence in children. overgrowth was reported by Kimball in • Onset within 3 months. 1939, many clinical and investigative • Change in gingival contour leading to studies have been carried out to determine modification of gingival size. the etiopathogenesis of this disorder. Even • Enlargement first observed at the though these studies gave various interdental papilla. pathogenetic data, it is still unknown why • Change in gingival color. drugs with such different pharmacological • Increased gingival exudates. actions induce similar gingival changes. • Bleeding upon provocation. Also the blood drug levels and/or duration of drug intake and the severity of growth, Galore International Journal of Health Sciences and Research (www.gijhsr.com) 26 Vol.2; Issue: 1; March 2017 Rosiline James. Gingival Overgrowth: An Enigma to Periodontists! • Found in gingiva with or without bone 1. Gingival Enlargement of loss but is not associated with Pregnancy attachment loss. 2. Gingival Enlargement of Puberty • Pronounced inflammatory response of B. Leukemic Gingival Enlargement gingiva in relation to the plaque present. C. Gingival Enlargement Associated • Reductions in dental plaque can limit the with Vitamin C Deficiency severity of the lesion. Neoplasms • Must be using phenytoin, cyclosporine Developmental gingival enlargement [5] A or certain calcium channel blockers; the plasma concentrations to induce the Classification based on scoring the extent lesion have not been clearly defined in of the overgrowth: [4] humans. • Grade 0: No signs of gingival The current term is gingival overgrowth. enlargement. It had been named gingival hyperplasia/ • Grade I: Enlargement confined to hypertrophy and gingival enlargement. The interdental papilla. term hyperplasia is only relevant with the • Grade II: Enlargement involves papilla incre3ased number of cells and hypertrophy and marginal gingiva. coincides with increased size. • Grade III: Enlargement covers three Classification based on the location and quarters or more of the crown. distribution "Localized" - Limited to the gingiva in Etiopathogenesis of Gingival relation to a single tooth or group of Enlargement teeth. It was observed that drug induced "Generalized"- involving the gingival gingival enlargement occurred in mostly throughout the mouth. all the individuals who were on the "Marginal" - Involvement limited to the above mentioned three classes of drugs. gingival margin. The overgrowth regressed significantly "Diffuse" - involving the gingival after cessation of the drug. This margin and the remainder of the gingival concluded that the overgrowth depends mucosa up to the mucobuccal fold and upon the blood drug concentration. for a varying distance along the lingual surface. The order of induced gingival Classification based on the underlying overgrowth was phenytoin < nifedipine histopathological changes and etiology < Cephalosporins. Inflammatory Phenytoin decreases the collagen A. Chronic Inflammatory Gingival degradation as a result of the production Enlargement of an inactive fibroblastic collagenase. 1. Generalized or localized [6] 2. Discrete (Tumor-like) Males are more susceptible than the B. Acute Inflammatory Gingival female counterparts. This is mainly due Enlargement to the female hormone progesterone. (Gingival abscess) Progesterone decreases Non Inflammatory hyperplastic gingival glycosaminoglycan synthesis by human enlargement gingival fibroblasts in vitro. A. Marginal Younger age predilection was observed B. Diffuse for nifedipine and phenytoin drug intake but not for cephalosporin intake. Combined enlargement Dental plaque as observed in many Conditioned gingival enlargement studies is the primary causative agent A. Hormonal and factor for any periodontal disease. Galore International Journal of Health Sciences and Research (www.gijhsr.com) 27 Vol.2; Issue: 1; March 2017 Rosiline James. Gingival Overgrowth: An Enigma to Periodontists! However in drug induced gingival Painful ulcerations sometimes occur in overgrowth, it is an aggravating factor the fold between the mass and the rather than a causative factor. This is adjacent gingiva. because it is difficult to assess the state of oral hygiene prior to drug Clinical features of drug induced gingival administration and that overgrowth often overgrowth: produces secondary gingival The enlargement is generalized but is inflammation. Also if the individual is severe in the maxillary and mandibular on a thorough oral hygiene protocol anteriors. while taking phenytoin, the overgrowth The exhibited growth starts as a can be minimal but not totally absent. painless, beadlike enlargement of the The overgrowth is severe in individuals interdental papilla extending to the with poor plaque control facial and lingual gingival margins. Epidermal growth factor (EGF) was After time a union of the marginal and involved in phenytoin induced gingival papillary enlargements occur and may overgrowth. It was found that phenytoin develop into a massive tissue fold increased the level of EGF receptors in covering a considerable portion of the human gingival fibroblasts, resulting in tooth crowns. increased cellular responsiveness to This might interfere with occlusion. EGF thereby can stimulating cellular When uncomplicated by inflammation, DNA synthesis. the lesion is mulberry shaped, firm, and Phenytoin can stimulate testosterone pale pink, and resilient, with a minutely metabolism, increasing the level of 5a lobulated surface and does not bleed on dihydrotestosterone which is a provocation. stimulator of fibroblast growth in the [2] The enlargement projects from beneath overgrown tissue. the gingival margin, from which it is separated by a linear groove. Clinical features of chronic inflammatory Plaque control is difficult leading to a enlargement secondary inflammation complicating It produces a life preserver– shaped this which results to combination of the bulge around the involved teeth which increase in size caused by the drug and can increase in size until it covers part of the complicating inflammation caused the crowns. by bacteria. The enlargement may be localized or This produces a red or bluish red generalized progressing slowly and discoloration, obliterates the lobulated painlessly, unless it is complicated by surface demarcations and increased acute infection or trauma. bleeding tendency. It presents like a slight ballooning of the It is present in the areas where teeth are interdental papilla and the marginal present but also may exhibit in regions gingival. where there is absence of teeth. [7,8] It can also occur as a discrete sessile or pedunculated mass resembling a tumor Clinical features of Idiopathic gingival
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