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Gingival Hyperplasia

Authors:

Karen Hayes

Terri Hallenbeck

FCCJ Dental Hygiene Students

     Gingival hyperplasia is a condition in which the gingiva is enlarged. This condition has fairly consistent manifestations, but it can result from several different sources, such as medications, hormonal changes, and diseases.(Requa-Clark, 2000).  Since it has been found that all of these can cause tissue overgrowth in the oral cavity, and the condition’s origins are better understood, it is now referred to as gingival enlargement.  Though treatment is limited and usually requires surgery for resolution, it has been found that all forms of gingival enlargement are associated with plaque but are complicated by other factors.  Therefore meticulous plaque control and rigorous oral hygiene can diminish the effects of gingival hyperplasia.  Dental hygienists have the opportunity to play a significant role in the treatment of these patients.  They can not only help the patient understand their condition and its causes, but also provide information on proper home care and treatment options.  
     Gingival hyperplasia appears clinically as pink or red, bulbous overgrowth.  It occurs in free and attached gingiva, most often involving interdental papillae of maxillary anterior facial gums.(Lozada-Nur, 2001).  More severe cases will be generalized and can even affect the entire dentition.  The contour of the gingiva may be bulky, outlining the cervical areas of the teeth or may grow enough to partially or entirely cover the crowns of the teeth.  The consistency of hyperplastic tissue can range from soft and spongy to firm and fibrotic. 

     Gingival enlargement can affect men, women, and children.  The most common cause of this condition presents as a side effect resulting from ingestion of certain medications.  Nifedipine which is a calcium channel blocker used for treating angina, hypertension, and ventricular arrythmias is one medication that causes gingival enlargement.  Cyclosporine, an immunosuppressant, that is given to all kidney transplant patients, and given to many patients with other organ transplants to prevent rejection has also caused overgrowth of tissue in the oral cavity.  The medication most known for causing this condition is phenytoin or dilantin, which is usually used to control seizures, but also has other uses such as relieving headaches, cardiac conditions, and controlling behavior problems.  Twenty five to fifty percent of patients using phenytoin experience gingival enlargement.  This has also been termed dilantin hyperplasia.(Wilkins, 1999). Although it affects children and adults, there is a greater incidence of hyperplasia in younger patients.(Lozada-Nur, 2001)  The overgrowth is usually painless and begins in interdental areas with inflammation.  Tissue then increases in size and may become fibrotic.  In severe cases gingiva covers enamel and pushes the teeth apart, which can then interfere with mastication.  This condition can occur as soon as a few weeks after initial administration of the drug, or can take years for it to appear.  There has been no correlation in dosage or duration of treatment in causing enlargement.  Though there is no known reason for these drugs to cause this condition, microscopically phenytoin is evident in saliva, blood, and plaque.  During use of this medication, there is an increase in collagen, the number of fibroblasts, and inflammatory cells near the base of the pocket.(Wilkins, 1999). 

     Hormonal changes such as puberty and pregnancy have also been linked to this condition.  During puberty, enlargement of the oral tissues begins with inadequate poor oral hygiene.  Plaque control is not generally a priority with this group and it is thought that the hyperplasia is an exaggerated response to this bacterial plaque as well as a reaction to hormonal changes.  In pregnancy, gingival hyperplasia can manifest as general edema of the dentition or may also present as a pyogenic granuloma, also known as an epulis gravidarum.  A pyogenic granuloma usually consists of an isolated, round, red lesion located in interdental areas.  This lesion bleeds easily and is most often painless unless it grows large enough to interfere with occlusion, and then it may be painful and complicate eating.  These lesions are not typically removed until after the patient gives birth.  When they have been removed by excision during pregnancy, they have usually recurred.  Although hormones can play a large part in this tissue growth, once again plaque retention and poor oral hygiene contribute to the severity of the condition.(Wilkins, 1999).

      Diseases, such as blood dyscrasias also account for cases of gingival hyperplasia.  Blood disorders affect functions of red and white blood cells.  Acute myeloblastic leukemia is most often associated with gingival enlargement.  Leukemic cells accumulate in the tissues and swelling is caused by inflammation due to plaque.  Leukemia is often   differentially diagnosed in the dental office first because of the bleeding, edematous gingiva that can not be explained otherwise.(Ibsen, 2000). 

      The most severe cases of gingival overgrowth are evident in a very rare disorder known as hereditary gingival fibromatosis.  It is transmitted genetically as an autosomal dominant trait.  In this case the gingiva proliferates at an early age and completely covers the teeth within a few years.(Perry, 2001). 

     Other factors that can contribute to hyperplasia and occur in combination with the medications and diseases include mouth breathing, overhanging restorations, and plaque.(Wilkins, 1999). 

     There are only a few options for treatment of this condition and they do vary with the causes.  Treatment for drug induced gingival enlargement should begin before the drug is initially administered.  Patients should be made aware that poor oral hygiene will contribute tremendously to the severity of their condition.(Little, 1993).  Adolescents, pregnant women, and patients with blood disorders such as leukemia also need to know that they must have meticulous plaque control to lessen the chances of contracting this condition.  In some of these situations gingival hyperplasia can be prevented with rigorous home care and frequent appointments for scaling and professional plaque removal.  In other instances medications can be changed or stopped to alleviate the overgrowth of tissue, but once the tissue has reached a fibrotic stage, the only option left is surgery.(Langlais, 1998).  Occasionally gingivoplasty is used to reshape the tissues, but typically a gingivectomy is performed.  Once this tissue is excised it will not usually grow back unless the causative agent is still present.

     The role of the hygienist is very important for these patients.  The hygienist can educate the patient about the oral manifestations of their condition, whether they are caused by drugs or other factors.  Treatment should be administered immediately after diagnosis to obtain best results.  Oral hygiene instructions are most important for these patients because gingival enlargement causes retention of bacterial plaque.(Wilkins, 1999). The hygienists must show patients how to brush and floss effectively and must suggest other therapy, such as antimicrobial rinses.  Patients should have frequent professional oral care and excellent home care. Compliance should be evaluated at each recall appointment.  When the patient suffers from this condition despite effective home care, the hygienist along with the dentist can suggest other treatment, such as surgery.

     Although there are many causes of gingival enlargement, and surgery is often necessary to correct the problem, hygienists have an essential role in teaching the patient how to prevent or control their condition.  Bacterial plaque is the primary factor in almost every cause, so if hygienists can convince patients to comply with meticulous plaque control, they can diminish the effects of their medications, hormonal changes, and diseases on oral tissues.                               

REFERENCES

 Ibsen, Olga A. C. ; W. B. Saunders Company. (2000). Oral Pathology for the Dental Hygienist 

Langlais,Robert P., Craig S. Miller; Lippincott Williams & Wilkins.(1998).  Color Atlas of Common Oral Diseases.

 Perry, Dorothy A., Phyllis Beemsterboer, Edward J. Taggart, Jr.; W. B. Saunders Company. (2001).  Periodontology for the Dental Hygienist. 

Requa-Clark, Barbara; Mosby. (2000). Applied Pharmacology for the Dental Hygienist.

 Wilkins, Esther M.; Lippincott Williams & Wilkins. (1999).  Clinical Practice of the Dental Hygienist.  
 

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