Archives of Dental Research 2023;13(2):122–125
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Archives of Dental Research
Journal homepage: https://www.adr.org.in/
Case Report
A case report of plaque-induced gingival enlargement - unlike the ordinary
Raaja Sreepathy CS 1 *, D Lekha Alanija 1 , C. Vikram 1 ,
Arunmozhi Ulaganathan 1 , Shanmugapriya Ramamurthy 1 ,
Rathinasamy Kadhiresan 1
1 Dept. of Periodontics and Implantology, Sri Venkateswara Dental College and Hospital, Chennai, Tamil Nadu, India
ARTICLE INFO ABSTRACT
Article history: Gingival enlargements are one of the most common conditions affecting the periodontium. These
Received 01-10-2023 enlargements occur due to a variety of factors, like plaque accumulation, hormonal changes, or systemic
Accepted 30-11-2023 drug influence. Improper oral hygiene and microbial dysbiosis predispose an individual to plaque-
Available online 18-12-2023 induced gingival enlargement. The treatment strategy involves thorough oral prophylaxis and stringent
oral hygiene maintenance. Described here is a case report of plaque-induced gingival enlargement, which
has been managed with complete non-surgical and localized surgical periodontal therapy. The therapeutic
Keywords:
intervention significantly reduced clinical parameters like bleeding on probing and periodontal pocket
Gingival Overgrowth depth.
Gingival Hyperplasia
Gingival This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons
Hypertrophy Attribution-NonCommercial 4.0 International, which allows others to remix, and build upon the work non-
commercially, as long as appropriate credit is given and the new creations are licensed under the identical
terms.
For reprints contact: reprint@ipinnovative.com
1. Introduction This can cause further inflammation and plaque build-up,
continuing the vicious cycle. Gingival overgrowth has a
The continual exposure of the oral mucosa to internal and
complex origin, and it is caused by a variety of plaque or
external stimuli results in a wide range of disorders, from
linked to hormone imbalances. Intake of systemic drugs
developmental to reactive to malignant. A majority of oral
for various systemic conditions like hypertension, etc has
mucosal lesions that affect people are reactive in origin.
been proven to have an effect on the gingiva. Drugs like
As a result of a reaction to a low-grade injury, irritation,
amlodipine, phenytoin, etc are commonly reported to cause
calculus, or prosthetic appliances or restorations that were
gingival enlargement. The influence of hormonal changes
incorrectly shaped and created, these lesions are known as
will also implicate changes in the gingiva mainly during
reactive lesions. Chronic irritation increases the growth of
puberty and pregnancy. 3 Functional issues including trouble
granulation tissue in the early stages. Inflammatory gingival
chewing, impaired speech, and aesthetics are brought on by
enlargement can be classified as acute or chronic, with
these enlargements. 4
chronic alterations occurring more frequently. 1 Prolonged
exposure to plaque leads to chronic inflammatory gingival In 1987, Mc Gaw et al., graded gingival overgrowth 5
enlargement (CIGE). Inflammatory gingival enlargements
caused by plaque may not resolve if the gingival tissue is
1. Grade 0: No overgrowth, feather-edged gingival
fibrotic, leading to the persistence of the periodontal pocket
margin,
and making it challenging to maintain proper oral hygiene. 2
2. Grade 1: Blunting of ginigval margin,
* Corresponding author. 3. Grade 2: Moderate gingival overgrowth (one-third of
E-mail address: csraaja@gmail.com (Raaja Sreepathy CS). crown length),
https://doi.org/10.18231/j.adr.2023.024
2277-3401/© 2023 Author(s), Published by Innovative Publication. 122
Raaja Sreepathy CS et al. / Archives of Dental Research 2023;13(2):122–125 123
4. Grade 3: Marked gingival overgrowth (more than one-
third of the crown).
This overgrowth was later enhanced by Bokenkamp et al.,
in 1994 graded gingival over growth: 6
1. Grade 0: No sign of enlargement,
2. Grade 1: Enlargement confined to interdental papilla,
3. Grade 2: Enlargement involving interdental papilla
and marginal gingiva,
4. Grade 3: Enlargement covering three-quarters of the
crown of the tooth or more.
The treatment of choice for gingival enlargement is
Figure 1: (A): Preoperative facial view (B): Preoperative left
gingivectomy and the first mention of gingivectomy dates
lateral view (C): Preoperative right lateral view
to 1742, when Fauchard describes the method for removing
too much tissue. Later, Robicsek reported a similar process
where the granulation tissues were eliminated and the
tissues were excised. 7
The underlying causes of gingival enlargement and the
subsequent changes they cause in the tissues are the basis
for the treatment strategies used to treat it. The main modes
of treatment include compiling a thorough medical history,
noninvasive periodontal therapy, and surgical excision to
maintain aesthetic and functional requirements.
This case report depicts a case of chronic inflammatory
gingival enlargement and its management strategy. These
enlargements often correspond to an ongoing bacterial Figure 2: Post non-surgical periodontal therapy
plaque buildup. Regular professional oral prophylaxis and
good patient compliance are mandatory in the management
of such cases.
2. Case Report
A 20-year-old female patient reported to the Department of
Periodontics and Implantology, at Sri Venkateshwara Dental
College and Hospital, Chennai, with a chief complaint of
swollen gums in both upper and lower front teeth region for
the past 6 months. The patient also reported bad breath and
bleeding gums while brushing. On intra-oral examination Figure 3: External bevelgingivectomy
painless, Grade II type of Gingival enlargement was
found (Bokenkamp, 1994). Gingival examination reveals
papilla was seen in the mandibular anterior. There was no
erythematous marginal and papillary gingiva with soft and
systemic, family, or drug history reported.
edematous consistency in the maxillary and mandibular
On the basis of medical history and intra-oral
arches, with the labial and buccal aspects being more
examination, a provisional diagnosis of Chronic
noticeable than the palatal and lingual regions. The gingiva
inflammatory gingival enlargement was made.
appeared friable and soft with a smooth and shiny surface,
Orthopantomogram results showed no bone deficiencies
loss of stippling, and obliterated contour. There was the
and complete hemogram readings were within the normal
presence of false pockets (pseudo pockets). Some regions
range.
showed signs of ongoing acute inflammation.
Periodontal examination revealed the presence of sub-
2.1. Treatment done
gingival plaque, calculus, and bleeding on probing. The
enlargement was diffuse, soggy in appearance with a Non-surgical periodontal therapy was initiated. Complete
probing depth of around 5mm and generalized gingival Ultrasonic Scaling was done on both arches. After 2
bleeding on probing Slight ballooning of the interdental weeks, there was some amount of resolution of Gingival
124 Raaja Sreepathy CS et al. / Archives of Dental Research 2023;13(2):122–125
(b) Acute
• Drug-induced enlargement
• Enlargement associated with systemic disease
A. Conditioned enlargement
1. Pregnancy
2. Puberty
3. Vitamin C deficiency
4. Plasma cell gingivitis
5. Nonspecific
B. Systemic diseases causing gingival enlargement
Figure 4: (A): Post-operative healing after 12 Weeks (B): Left 1. Leukemia
lateral post-operative after 12Weeks (C): Right lateral post- 2. Granulomatous diseases
operative after 12 Weeks
• Neoplastic enlargement:
Enlargement with no bleeding on probing. So, root 1. Benign tumors
surface debridement was planned. Under local anesthesia 2. Malignant tumors
(2% lignocaine hydrochloride with 1:80,000 epinephrine), • False enlargement
curettage was performed in the anterior maxillary and The most common form of enlargement is inflammatory
mandibular arch with the help of Gracey curettes # 1, 2, which is due to plaque-induced inflammation of the gingival
3, 4,5,6. The patient was advised to perform proper oral tissues. It can be localized or generalized, exaggerated
hygiene maintenance and trained in the proper brushing by hormonal effects, as seen in puberty or pregnancy, or
technique (Modified Bass Technique). complicated by certain systemic medications. Both adults
Chlorhexidine 1.2% mouthwash was prescribed and and teenagers are frequently affected by this condition. Most
warm saline rinses were advised along with it. The patient cases have been reported in the fourth to sixth decade of life,
was recalled in 14 days. On the basis of the existing determining a direct relationship between the frequency of
enlargement, a gingivectomy with a scalpel was planned. the injury with the increased time of use of the prosthesis;
Prior to the surgery, written informed consent was obtained. a minority (<5%) of the cases occurs in children, especially
Under local anesthesia, an external bevel gingivectomy was in those who are in mixed dentition.
carried out. Tin foil was placed as a barrier and the area was Local factors that cause inflammation to increase are
covered with a periodontal pack. self-reinforcing since it is frequently difficult to thoroughly
Immediately following surgery, ice packs were clean the "pseudo pockets" created by swollen tissue.
recommended intermittently for three hours and the Halitosis may occur due to the collecting bacteria breaking
patient was advised to use 0.12% chlorhexidine gluconate down food debris. While local etiologic causes are nearly
mouth rinse for four weeks. Systemic antibiotics and always present in cases of inflammatory-type gingival
analgesics were prescribed (Amoxicillin-500 mg, three enlargement, a number of significant systemic variables may
times daily for five days). Healing was uneventful with also contribute to the issue and jeopardize the effectiveness
very minimal post-operative pain. Recall check-up showed of treatment intended to eliminate focal irritants. 9
uneventful healing and the patient was followed for the next
6 months at a regular interval of 1 month. The patient was
4. Conclusion
recalled after 1 month for review.
The definitive diagnosis of the causative factors,
3. Discussion improvement of oral hygiene, aesthetics, and function
by removal of local factors, and surgical removal of the
A typical sign of gingival disease is gingival enlargement, overgrowth are all essential for the successful treatment of
which can be brought on by gingival inflammation, fibrous gingival enlargement. This case report demonstrates the
overgrowth, or a combination of the two. value of a thorough case history and clinical examination
Gingival enlargement can be classified according to in the management of enlargements. Plaque and calculus,
etiologic factors and pathologic changes. 8 which are local factors, are known to contribute to gingival
• Inflammatory enlargement hypertrophy. As a result, oral prophylaxis and routine
check-ups are crucial components of supportive periodontal
1. (a) Chronic treatment that cannot be overlooked. 10
Raaja Sreepathy CS et al. / Archives of Dental Research 2023;13(2):122–125 125
5. Source of Funding 9. Hassell TM, Jacoway JR. Clinical and scientific approaches to gingival
enlargement. Quintessence Int Dent Dig. 1980;11(10):53–60.
None. 10. Anuroopa DP, Savita S. Importance of Supportive Periodontal
Therapy in the Treatment of Inflammatory Gingival Overgrowth: A
12 Month Follow- Up. Scholars J Dent Sci . 2015;2(2A):140–3.
6. Conflict of Interest
None.
Author biography
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Res 2023;13(2):122-125.
