250 JIDA, Vol. 4, No.

7, July 2010
INTRODUCTION
H
ormonal fluctuations affect more than a womans
reproductive system. They have a surprisingly
strong influence on the oral cavity. The percent of
children affected with gingivitis has been found to
increase significantly with age, and a relationship
between puberty and gingivitis has been postulated in
several clinical studies (Massler et al, 1950, Muhlemann
& Mazor 1958, Sutcliffe 1972).
Changes in the periodontal conditions taking place
concomitantly with increased hormonal secretions have
been reported during pregnancy (Kornman & Loesche
1980), menstruation (Lindhe et al 1969), stress (Kornman
1982, Wirthlin & Devine 1978) and among women taking
oral contraceptives (Holm-Pedersen & Loe 1967).
Hormonal changes are thought to have a direct effect
upon periodontal tissue metabolism by increasing the
permeability of the vascular system (Hugson 1970).
Prevalence
The exact prevalence of gingival enlargement seen in
puberty is not known.
CASE REPORT
A 12- year old female patient reported to the with a
chief complaint of inability to chew food from right side due
to swelling of gums since 1 year.
Past History
There was no history of any drug intake or any
systemic illness.
Intra oral examination
On examination patient had deep bite. Premolars were
erupting on both sides. A localized diffuse enlargement
was seen extending from mesial aspect of #46 to distal
aspect of #47 covering part of crown of #47 (Figs. 1 & 2).
The swelling was more prominent on lingual side. Local
factors (plaque and calculus) were present. Bleeding
upon probing was also positive.
Investigations
Complete Haemogram (CH) showed all blood counts
within normal limits.
Blood sugar levels were normal.
Intra-oral periapical radiograph (IOPA) (Fig. 3)
showed follicle of #48 and 2/3 root formation of
#47.
Differential diagnosis
1) Idiopathic gingival enlargement
2) Chronic inflammatory gingival enlargement
3) Fibroma
4) Peripheral giant cell granuloma
Provisional diagnosis
On the basis of clinical findings, history of the patient
*Postgraduate student; **Associate Professor and Head;
Department of Periodontics, Government Dental College and
Hospital, Aurangabad - 431 001, Maharashtra.
Combined Gingival Enlargement Influenced by
Puberty A Case Report
Aditya N Daultabadkar*, Mangesh B Phadnaik**
Abstract
Hormonal fluctuations affect more than a womans reproductive system. They have a surprisingly strong
influence on the oral cavity. These changes are not necessarily the result of direct hormonal action on the
tissue but are, perhaps, best explained as the effects of the local factors (e.g., plaque on tissues exacerbated by
hormonal activity).
Gingival tissues and the sub gingival micro flora respond with a variety of changes to the increasing hormone
level at the onset of puberty. Microbial changes have been reported during puberty and can be attributed to
changes in the microenvironment seen in the gingival tissue in response to the sex hormones as well as the
ability of some species of bacteria (e.g. porphyromonas gingivalis) to capitalize on the higher concentration of
hormones present. These elevated levels of hormones cause an exaggerated response to the dental plaque on the
teeth and gums, resulting in gingival enlargement.
This paper presents a case of young female with combined gingival enlargement influenced by puberty and its
management.
Key Words : Hormones, Plaque, Puberty, Gingival enlargement.
JIDA, Vol. 4, No. 7, July 2010 251
and investigations, a provisional diagnosis of Idiopathic
gingival enlargement was made.
Treatment
Phase I therapy was performed with instructions for
meticulous oral hygiene. Internal bevel gingivectomy
(Fig. 4) was performed to excise the enlargement after
1month. After doing the gingivectomy procedure, a thick
ledge (Fig. 5) was observed on lingual aspect of #46 and
#47. A flap was raised to perform osteoplasty (Fig. 6)
procedure and it was sutured. The excised tissue was
sent for histopathological examination.
Histopathologic examination
Microscopic inspection of the gingival biopsy
specimens demonstrated a large number of inflammatory
cells in fibrous connective tissue (Fig. 7).
Final diagnosis
On the basis of clinical findings, history of the patient,
investigations and histopathological examination, a
final diagnosis of Combined Gingival Enlargement
Influenced by Puberty was made.
DISCUSSION
Sex hormones originating from the adrenal glands
supposedly play an important part in the pubertal
maturation processes (Sizonenko 1975). Although it is
generally accepted that skeletal maturity is under
endocrinological control, the details of their mechanisms
of action and their clinical influence are still unknown;
obviously, different hormones preponderate at different
times, expressing a wide spectrum of biological activities
(Tanner et al 1983). Testosterone, dihydrotestosterone
and androstenediol begin to rise in boys at a mean age
of 13 years. At the same time, several parameters of genital
development increase. The corresponding age for girls,
when oestradiol shows signs of a marked increase has
been found to be before 12 years of age, whereas oestrone
apparently starts to rise at a mean age of 12.5 years (Gupta
1975). Appreciable sexual maturation in both sexes may
be associated with increased levels of plasma androgens
in boys and oestrogens in girls.
The gingiva acts as a target tissue for the action of sex
steroid hormones. The interaction of these hormones
with inflammatory mediators explains the inflammation
Fig. 9 : Post operative
photograph (1 month)
Fig. 1 : Pre-operative
photograph (occlusal view)
Fig. 2 : Pre-operative photograph (lingual view) Fig : 3 Intra oral periapical view
Fig. 4 : Internal bevel
gingivectomy procedure
Fig. 5 : Bony ledge on
lingual side
Fig. 6 : Osteoplasty procedure Fig. 7 : Histopathologic examination
Fig. 8 : Post operative photograph
(1 week)
252 JIDA, Vol. 4, No. 7, July 2010
in puberty. Porphromonas gingivalis, Prevotella
intermedia, Capnocytophaga species have been found
in plaque at this age. These organisms use steroids as a
substitute for vitamin K growth factor.
Hormonal changes have been identified to influence
the composition at the subgingival microbiota during
pregnancy (Kornman & Loesche 1980). Therefore, it
cannot be excluded that an increased secretion of steroid
hormones during puberty may have affected the
subgingival ecosystem of these adolescents. Since black-
pigmenting Bacteorides have been identified in plaque of
patients prior to the onset of puberty (Van Oosten et al
1988), it may be anticipated that the hormonal changes
promoted a shift in the composition of the subgingival
plaque towards a more pathogenic microbiota. Steroid
hormones in the gingival fluid may substitute for growth
factors for B. intermedius such as menadione (Gibbons
& Mc Donald 1960) and hence, promote the growth of
this organism in vivo (Kornman & Loesche 1982).
The microbiota of dental plaque may also react
specifically to increased availability of hormones in the
oral fluids. Shifts in the composition as well as in
metabolic expressions and in the pathogenic potential
of the plaque microorganisms may result from altered
hormonal levels.
In our case thick bony ledge on lingual aspect of #46
and #47 might have lead to accumulation of plaque,
while hormonal changes associated with puberty have
modified the response of plaque leading to gingival
enlargement.
CONCLUSION
Soft tissue always follows the hard tissue and the
underlying bone morphology may act as a plaque
retentive factor. Elevated levels of hormones cause
exaggerated response to plaque on teeth and gums
resulting in gingival enlargement.
Tissue is the issue in our case but bone sets the tone
modified by hormones resulting in gingival enlargement
and difficulty in mastication needs the removal of
enlargement.
REFERENCES
1. Mombelli A, Lang NP, Burgin WB, et al. Microbial changes
associated with development of puberty gingivitis. J
Periodontal Res 1990; 25: 331.
2. Nakagwa S, Fuji S, Machida Y, et al. A longitudinal study
from prepuberty to puberty of gingivitis: co- relation between
occurrence of Prevotella intermedia and sex hormones. J
Periodontol 1994; 21 : 658.
3. Amar S, Chung KM. Influence of hormonal variation on
periodontium in women. Periodontal 2000 6 : 79, 1994.
4. Woj cicki CJ, Harper DS, Robinson PJ. Differences in
periodontal-disease associated microorganisms in
prepubertal, pubertal and postpubertal children. J Periodontal
1987; 58 : 219.
5. Jenson J, Liljemark W, Bloomquist. The effect of female sex
hormones on subgingival plaque. Journal of Periodontology
1981; 53 : 599-602.
7. Lapp CA, Thomas ME, Lewis J. Modulation of progesterone
of interleukin-6 production by gingival fibroblasts. Journal of
Periodontology 1995; 6 : 279-84.
8. Korman KS, Losche WJ. Effects of estradiol and progesterone
bacteriodes melaninogenicus. Journal of Dental Research 1970:
342-46.
9. Miyagi M, Morishita M, Iwamoto Y. Effects of sex hormones
on production of prostaglandin E2 by human peripheral
monocytes. Journal of Periodontology 1993; 64 : 1075-78.
10. Mombelli, Mgusberti FA, Van Oosten MAC, Lang NP.
Gingival health and gingivitis development during puberty.
Journal of Clinical Periodontology 1989 : 236-42.
11. Sooriyamoorthy M, Gower DB. Hormonal influences of
gingival tissue: relationship to periodontal disease. Journal
of Clinical Periodontology 1989; 16 : 201-08.
ANSWER TO RADIOLOGICAL QUIZ 27
Answer 1 : a) Bilaterally elongated styloid process
b) Well defined corticated mixed radio-opaque -radiolucency seen with lower left posterior
region of lower jaw extending in 34 to 38 region displacing the mandibualr canal
inferiorly suggestive of FIBRO-OSSEOUS LESION.
c) Resorption of left condyle
Answer 2 : Displacement of 37 distally
Answer 3 : Fibrous dysplasia
Cemento ossifying fibroma
Florid osseous dysplasia