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Periodontal abscess:
involves the supporting periodontal tissues.
DRUG INDUCED GINGIVAL
ENLARGEMENT.
Anticonvulsants
Immunosuppressants
Calcium channel blockers
affects th speech, mastication, tooth
eruption, and aesthetics problems
General clinical features:
site - interdental papilla, facial and
lingual gingival margins
Starts as a bead massive tissue fold
covering the crown
mulberry shaped , firm , pale pink, resilient
no tendency to bleed
appears to project from beneath the gingival
margin separated by a linear groove.
Plaque control becomes difficult
secondary inflammation
Phenytoin gingival
enlargement on the
occlusal surface
Phenytoin enlargement
in the posterior region
Phenytoin gingival
enlargement -
close-up view of
anteriors.
2). Immunosuppressants
Cyclosporines used to prevent
organ transplant rejection & to
treat autoimmune origin
if dosage > 500mg/day reported
to induce gingival enlargement.
30% patient.
More vascularised
associated with nephrotoxicity,
hypersensitivity, hypertension,
hyperthricosis.
Cyclosporine induced
gingival
enlargement
in a 14yr old boy
3).Calcium channel blockers
used for CVS disorders, hypertension,
angina pectoris, coronary artery spasm &
cardiac arrhythmia.
Drugs like nifedipine,diltiazem, felodipine,
nitrendipine and verapamil.
Nifidipine induces enlargement in 20%
cases
Nifidepine + cyclosporines (for kidney
transplant)
larger overgrowth
dose dependent growth
Nifedipine induced gingival enlargement
Idiopathic gingival enlargement
termed as gingivostomatitis, elephantiasis,
idiopathicfibromatosis, hereditary gingival
hyperplasia & congenital familial
fibromatosis.
Etiology:
unknown
hereditary basis (autosomal dominant or
recessive)
begins with primary & secondary dentition
eruption.
Clinical features:
Site - attached
gingiva, gingival
margin, and
interdental papilla
pink,firm and leathery
with pebbled
appearance
Severe cases jaw
appears distorted due
to bulbous enlargement
secondary inflammation
Histopathology:
epithelium -thickened & acanthosis
elongated rete pegs.
Conn. Tissue- highly vascular, densely
arranged collagen bundles & numerous
fibroblasts
ENLARGEMENT ASSOCIATED WITH
SYSTEMIC DISEASES
Many systemic diseases can develop oral
manifestations that mayaffect the
periodontium by two different mechanisms
1). Magnification of existing inflammation
initiated by dental plaque “Conditioned
enlargement”
a). Hormonal conditions(pregnancy &
puberty)
b). Nutritional (vitamin C deficiency)
c). Non- specific conditioned enlargement
2). Manifestation of systemic disease
independent of the inflammatory status of
the gingiva.This group described as
“Systemic diseases causing gingival
enlargement”.
Conditioned enlargement
systematic condition of the patient
exaggerates the usual gingival
response to dental plaque
bacterial plaque is necessary for its
initiation
3 types
a) Enlargement in pregnancy
b) Enlargement in puberty
c) Enlargement in vitamin C deficiency
A) Enlargement in pregnancy
Marginal and generalized
Etiology- increase in progesterone and estrogen
till 3rd trimester
- increased vascular permeability
and gingival edema.
Marginal enlargement
Clinical features
-generalized and interproximal
- bright red, soft friable and bleeds
spontaneously.
–
Tumor like gingival enlargement
Also called pregnancy tumor
inflammatory response to
bacterial plaque
clinical features
-lesions are discrete, mushroom
like, flattened spherical
masses
-sessile, pedunclated
-exibits deep red pin point
margins.
-Painful ulcerations
- histopathology:
- called angiogranuloma.
- central mass of connective tissue
- neovascularisation lined by cuboidal
endothelial cells.
-varying degree of edema & chronic
inflammatory infiltrate
- epithelium thickened, prominent retepegs.
Preventable by removal of plaque & calculus.
B) Enlargement in Puberty
In both male & female
adolescents
Clinical features :
-marginal & interdental
-chronic gingival disease
-reduces after puberty
-Capnocytophaga sp.. & P.
intermedia
Histopathology
-chronic inflammation with
edema
C) enlargement in Vitamin C deficiency
Clinical features :
- Marginal gingivitis
- hemorrhage on slight provocation and suface
necrosis with pseudomembrane formation
Histopathology:
- chronic inflammatory cellular infiltrate with
superficial acute response
- scattered hemorrhage
- diffuse edema, collagen degeneration &
scarcity of collagen
Gingival englargement with ulceration
due to severe deficiency of vit C
Plasma cell gingivitis
Referred to as atypical
gingivitis and plasma
cell gingivostomatitis
site- marginal and
attached gingiva
Clinical features :
-red, friable, bleeds
easily
-oral aspect of
attached gingiva
Histopathology:
-epithelium- spongiosis and infiltrated with
chronic inflammatory cells.
-lower spinous layer and basal layer damaged
-plasma cells infiltrate
Non specific conditioned enlargement
(pyogenic granuloma)
Tumor like gingival enlargement
conditioned response to minor
trauma
Clinical features:
-discrete spherical tumor like
mass
-pedunclated, keloid like
-red friable with ulceration
-fibroepithelial papilloma
Histopathology:
-chronic inflammation with granulation tissue
-vascular spaces & epithelial atrophy
Treatment - removal of lesion and local irritating factors
gingival mass at the mass regress 3 time of pregnancy months after pregnancy
Systemic diseases causing gingival
enlargement
Leukemia
Clinical features:
-diffuse or marginal
-localized or generalized tumor like mass in
interproximal spaces
-red, friable, firm and hemorrhagic
-painful necrotising
-ulcerative inflammation
Leukaemic gingival enlargement
Histopathology:
Epithelium - varying degree of leukocytic
infiltration & edema
Psuedomembranous meshwork of fibrins,
necrotic epithelial cells, PMNS & bacteria.
Conn.. Tissue - infiltrated with a dense
mass of immature & proliferating
leukocytes
engorged capillaries
Granulomatous diseases
Wegener’s granulomatosis
Etiology: cause unknown (immunologically
mediated tissue injury)
Characterized by acute granulomatous
necrotising lesion of respiratory tract
involving the orofacial region
Clinical features:
reddish purple bleeds easily
Histopathology:
chronic inflammatory giant cells & foci of
acute inflammation, microabscesses
Red hemorrhagic mass surrounding
gingiva
Sarcoidiosis
Etiology unknown
red, smooth, painless enlargement
histopathology:
Finger like projections
of stratified squamous
epithelium, often
hyperkeratotic
fibrovascular core
3)Peripheral giant cell granuloma
Clinical features
interdentally, gingival margin
pedunclated, smooth, multilobulated,
ulcerations
painless, firm , spongy
locally invasive destroys underlying bone
Histopathology:
Numerous foci of multinucleated giant cells &
hemosiderin particles
chronic infiltration
Peripheral giant cell
granuloma
Hyperplastic epithelium
ulceration
Carcinomas
3% of all malignant tumors in the body.
squamous cell carcinoma- common
clinical features
Exophytic, irregular growth, ulcerative,
flat, erosive lesions
symptomless initially then painful
invades the bone
Malignant melanoma
site - hard palate& maxillary gingiva
localized pigmentation
flat or nodular
rapid growth with early metastasis
arises from melanocytes from the gingiva
Sarcoma
Fibrosarcoma, lymphosarcoma&
reticulum cell sarcoma of gingiva
Kaposi’s sarcoma.
FALSE ENLARGEMENT
Not true enlargement but appear as an
increase in size of underlying osseous or
dental tissues.
A). Underlying osseous lesions
Enlargement of bone - exostosis or tori
paget’s disease, fibrous dysplasia,
cherubism, central giant cell granuloma,
ameloblastoma osteoma, osteosarcoma.
B). Underlying dental tissues
during stages of eruption particularly
primary dentition
labial gingiva- bulbous marginal distortion
Enlargement called developmental
enlargement
& persists until junctional epithelium has
migrated enamel to CEJ
Physiologic
complicated by marginal inflammation