PRACTICE Gingival overgrowth: Part 1: aetiology and clinical diagnosis J. Beaumont,*1 J. Chesterman,1 M. Kellett1 and K. Durey1 InIn brief brief Provides overview of possible aetiology of gingival Discusses history and key clinical features which aid in Discussion of systemic disease which may contribute to overgrowth. diagnosis. gingival overgrowth Most commonly, gingival overgrowth is a plaque-induced inflammatory process, which can be modified by systemic disease or medications. However, rare genetic conditions can result in gingival overgrowth with non-plaque-induced aetiology. It is also important to appreciate the potential differential diagnoses of other presentations of enlarged gingival tissues; some may be secondary to localised trauma or non-plaque-induced inflammation and, albeit rarely, others may be manifestations of more sinister diseases or lesions. A definitive diagnosis will then enable an appropriate management strategy. This paper aims to discuss clinical features and diagnoses for conditions presenting with gingival overgrowth and other enlargements of gingival tissues. Background Aetiology Gingival overgrowth describes a generalised Gingival diseases including gingival overgrowth or localised enlargement of the gingival can be categorised as ‘plaque-induced’ and non- tissues. This term has replaced gingival hyper- plaque-induced;2,3 however, often a more specific plasia (increase in cell number) and gingival primary aetiology can be identified (Table 1). hypertrophy (increase in cell size) as these are There are several conditions which are not histological diagnoses and do not accurately reliant on plaque induction, being genetic, describe the varied pathological processes systemic or infective in nature.4 In these con- seen within the tissues. It is now understood ditions, associated plaque accumulation may 1 that true enlargement involves changes in the exacerbate the clinical presentation. Fig. 1 Chronic plaque induced gingivitis. cell size, cell multiplication, gingival vascula- Within this paper, aetiology has been Note the plaque deposits, reddened gingival ture and the extracellular matrix to varying broadly classified into local and systemic. margins with spontaneous bleeding degrees.1,2 A number of conditions present as swelling Local factors of the gingivae, rather than overgrowth per se, and these have been included in this article Inflammatory gingival overgrowth for completeness. Chronic inflammatory changes are common in cases of gingival overgrowth.5 This may be a result of prolonged exposure to dental plaque,6 localised trauma or a combination of factors as outlined in Table 1. Clinical examination frequently reveals poor 1Leeds Dental Institute, Restorative Dentistry, The Worsley Building, Clarendon Way, Leeds, LS2 9LU oral hygiene (Fig. 1). This may be secondary *Correspondence to: J Beaumont to tooth displacement, anatomical anomalies Email: [email protected] or dental work including prostheses (Fig. 2), Refereed Paper. Accepted 31 October 2016 poorly contoured restorations and orthodontic Fig. 2 Chronic periodontal disease with plaque retentive removable acrylic dentures DOI: 10.1038/j.bdj.2017.71 appliances, which favour the accumulation and ©British Dental Journal 2017; 222: 85-91 and localised gingival enlargement 11 and 12 retention of plaque.2,7 BRITISH DENTAL JOURNAL | VOLUME 222 NO. 2 | JANUARY 27 2017 85 ©2017 British Dental Associati on. All ri ghts reserved. PRACTICE Gingival enlargement due to chronic Table 1 Classification of gingival enlargement local factors inflammation has also been seen in mouth local factors breathers and patients with incompetent lips Inflammatory (Figs 3a and b).8,9 Typically this appears as a 9 Abscesses Gingival/periodontal/periapical red, oedematous lesion with a shiny surface. Acute It is not fully understood why this occurs, it is Pericoronitis theorised that it is due to chronic inflammation Chronic inflammatory gingival Plaque induced from long term surface dehydration.10 An asso- overgrowth Appliance induced ciation has also been made between obstructive Fibrous epulis sleep apnoea and increased periodontal disease, Chronic Pyogenic granuloma however, the causal affect is debatable.11 Localised gingival overgrowth may present Plasma cell gingivitis as a fibrous epulis. It is considered that inflam- Denture induced fibrous hyperplasia Iatrogenic Implant/orthodontic appliance induced mation from local trauma can be exacerbated by poor plaque control and cause these lesions. False enlargement Clinically, this appears as a firm, rubbery, pale Altered passive eruption Dental pink swelling which may be sessile or pedun- Odontogenic tumours/cysts culated, often between two teeth. This is differ- Tori entiated from the vascular pyogenic granuloma Padget’s disease which presents as a diffuse swelling which is Underlying hard tissues soft, shiny red-purple and bleeds readily (Fig. 4). Fibrous dysplasia There is likely to be plaque, calculus or food Other tumours/cysts debris associated with these types of lesions. Neoplastic lesions Abscesses Papilloma Localised enlargement of the gingivae may also Benign Peripheral giant cell granuloma be attributed to abscesses related to dental or Central giant cell granuloma gingival tissues. Bacterial infection of an endo- Squamous cell carcinoma dontic or periodontal origin may present as a buccal or palatal swelling, which may be at Melanoma Malignant the gingival margin or closer to the sulcus if Minor salivary gland tumours associated with periapical tissues. Metastases These may have varying presentations but are often raised, fluctuant and erythematous as Systemic factors well as being tender to palpation. Pericoronitis Pregnancy around a partially erupted tooth may have a Puberty similar appearance. Hormonal Menstruation Denture-induced fibrous Oral contraceptive pill inflammatory hyperplasia (FIH) Calcium channel blockers Denture-induced FIH occurs around the 12 Drug-influenced gingival overgrowth Anticonvulsants/phenytoin borders of an ill-fitting denture. Initially, a small ulcer may occur, which after chronic Ciclosporin irritation from the flange can lead to inflam- Leukaemia matory hyperplasia.12 It is often a raised, sessile Lymphoma mass in the form of folds with a smooth surface Malnutrition Ascorbic acid deficiency and normal mucosa colouring. The lesions are benign and often asympto- Wegener’s granulomatosis matic; however, areas of chronic irritation and Sarcoidosis trauma may be predisposed to the develop- Granulomatous disorders 13 Orofacial granulomatosis ment of neoplastic changes. Chron’s disease False gingival enlargement Malignant metastases There may be an increase in the size of the Hereditary gingival fibromatosis Hereditary gingival tissues due to the underlying hard tissues. Neurofibromatosis Conditions that may cause this include benign Other Sturge-Weber syndrome bony tori or more sinister disease processes such 86 BRITISH DENTAL JOURNAL | VOLUME 222 NO. 2 | JANUARY 27 2017 ©2017 British Dental Associati on. All ri ghts reserved. PRACTICE Fig. 3 a) Chronic plaque-induced gingival overgrowth with mouth breathing and lip Fig. 4 Pregnancy epulis (pyogenic incompetence; b) Associated lip incompetence and mouth breathing attributing to granuloma). Note that typically these are dehydration of the mucosa more vascular in appearance while this resembles a more characteristic appearance of a fibrous epulis gingival microflora and increased presence of serum antibodies.16 Oral contraceptive pill Oral contraceptives are one of the most commonly prescribed medications.17 Some clinical case reports have suggested gingival Fig. 5 Altered passive eruption on the Fig. 6 Pregnancy-related generalised enlargement linked to the use of oral contracep- palatal aspect of the maxillary incisors gingival overgrowth tives.18 Preshaw et al. found no effect of modern low dose oral contraceptives on gingival tissues.19 as Paget’s disease, fibrous dysplasia or cysts and susceptible to intra-cellular pathogens such as Drug-influenced gingival overgrowth tumours of odontogenic or other origins.10 The P. gingivalis, P. intermedia and A. actinomyce- (DIGO) overlying tissues may appear normal or have temcomitans, which avoid the host defences Gingival overgrowth is a side effect of a number coincidental inflammatory changes.10 and are locally invasive.15 Sex hormones have of medications,20,21 where the lesions are clini- Developmental gingival overgrowth involves an effect on the peripheral neutrophils, which cally and histologically indistinguishable from the gingival tissues around erupting teeth.10 reduce the effectiveness of phagocytosis and one another.21 If these medications are pre- Bulky gingival tissues may occur overlying the bactericidal mechanisms.15 They also have an scribed in combination there will often be a syn- unerupted/partially erupted dentition.10 This is effect on pro-inflammatory mediators such as ergistic effect, worsening the clinical picture.22 usually self-limiting and will resolve once the prostaglandin E2, via endotoxin-stimulated Drug-induced gingival overgrowth tends junctional epithelium migrates to the cemento- monocytes.15 Finally, the sex hormones cause to occur in the anterior gingivae,20 with onset enamel junction.10 If this does not happen, it increased permeability of the blood vessels and typically within three months of starting the is termed altered passive eruption and surgical reduce the keratinisation of the gingiva, which medication.23 It is not associated