Oral mucosa is commonplace, which is predisposed to external as well as internal stimuli; therefore, it is not uncommon to find spectrum of diseases from developmental, inflammatory, and reactive to neoplastic lesions presenting themselves in the oral cavity.1 Most frequently encountered oral mucosal lesions in human beings are reactive in nature.2 These lesions are called reactive since they are due to some kind of reaction to low-grade injury, irritation, calculus, improperly contoured, and designed prosthetic appliances or restorations.3 In early stage, chronic irritant stimulates the formation of granulation tissue; later the tissue begins to undergo a process of fibrosis. The presence of irritative factors in the mucosa triggers a chronic inflammatory process, leading to the formation of hyperplastic asymptomatic fibrous tissue.4
Gingival enlargement is a common finding in clinical practice, and appropriate treatment depends on correctly diagnosing the cause of the enlargement. The most common form of enlargement is due to plaque-induced inflammation of the adjacent gingival tissues (inflammatory hyperplasia), and this tends to be associated most commonly with the interdental papillae and may be localized or generalized. Such type of gingival enlargement can be exaggerated by hormonal effects, as influenced in puberty and pregnancy, and may be complicated by certain systemic medications.5 Plaque-induced inflammatory hyperplasia should resolve with debridement of plaque and calculus and improved oral hygiene, especially when the gingival tissue is edematous. Where the gingival tissue is fibrotic, resolution of enlargement may not occur, resulting in the persistence of periodontal pockets such that the effective oral hygiene is impeded. This scenario requires a more detailed assessment and a long-term management plan designed to map the level of gingival and possibly periodontal involvement. Surgical management to remove enlarged tissue and provide improved access for the patient's oral hygiene may be required.6
This condition is commonly present in adolescents and adults. Most cases have been reported in the fourth to sixth decade of life, determining a direct relationship between the frequencies of the injury with the increased time of use of the prosthesis; a minority (<5%) of the cases occurs in children, especially in those who are in mixed dentition. It is mainly associated with maladaptive oral prosthesis in adults and biofilm, dental malposition, and fixed/removable appliances in children and adolescents.7
A 34-year-old male patient reported to the Department of Periodontology, Mahatma Gandhi Dental College & Hospital, Jaipur, Rajasthan, India, with a chief complaint of swelling and bleeding gums in upper and lower anterior tooth region since 2 years (Fig. 1). Patient had complained of difficulty in chewing, bleeding from gums, and was also concerned about esthetics. With insignificant past medical and family history, no history of medications, antiepileptic, antihypertensive, or immunosuppressive medications was reported.
An intraoral examination revealed the presence of grade III enlargement in relation to the maxillary and mandibular anterior teeth region, with generalized gingival bleeding on probing, and probing depth of more than 5 mm was present in the anterior region. On examination, poor oral hygiene and a faulty prosthesis in upper central incisor region were found to be the significant factors for inflammation.
Oral prophylaxis was carried out after removal of faulty prosthesis. Patient was motivated for maintenance of oral hygiene.
Periodontal therapy including phase I therapy followed by external bevel gingivectomy by using conventional (scalpel) and electrocautery techniques, both for esthetic benefit and improved healing, were performed. Pockets were measured with pocket marker and bleeding points were produced on the outer surface of the gingiva. Residual plaque and calculus was removed and thorough root planing was done (Fig. 2). Periodontal dressing was placed (Fig. 3) and the excised tissue was histopathologically examined (Fig. 4).
Hematoxylin and eosin staining showed parakeratinized hyperplastic stratified squamous epithelium with underlying fibrocellular connective tissue showing diffusely spread increased chronic inflammatory infiltrate mainly composed of plasma cells and lymphocytes with numerous blood vessels. These features suggested inflammatory fibroepithelial hyperplasia. The patient was given antibiotic and antiinflammatory drugs thrice a day for 5 days, and chlorhexidine mouthwash 0.2% twice daily for 3 weeks. Postoperative oral hygiene instructions were given and the patient was recalled after 10 days for reevaluation and reinforcement of oral hygiene (Fig. 5). Patient was recalled at frequent intervals for the next 2 months, which showed uneventful healing (Fig. 6).
Gingival enlargement is a common feature of gingival disease and may be caused by fibrous overgrowth or gingival inflammation or a combination of the two.8 Gingival enlargement can be classified according to etiologic factors and pathologic changes9:
Enlargement associated with systemic disease
According to location as marginal, papillary, or diffuse enlargements and localized or generalized enlargements based on distribution.10 Localized enlargement is further divided as “isolated, discrete” or “regional.” “Isolated” enlargements are limited to gingiva adjacent to single or two teeth (e.g., gingival/periodontal abscess). “Discrete” lesions are isolated sessile or pedunculated, tumor-like enlargements (e.g., fibroma/pyogenic granuloma). “Regional” enlargements refer to involvement of gingiva around three or more teeth in one or multiple areas of the mouth (e.g., inflammatory enlargement associated with mouth breathing in maxillary and mandibular anterior region). “Generalized” enlargement refers to involvement of gingiva adjacent to almost all the teeth present (e.g., drug-influenced gingival overgrowth).10
The most common form of enlargement is due to plaque-induced inflammation of the adjacent gingival tissues (inflammatory hyperplasia), and this tends to be associated most commonly with the interdental papillae and may be localized or generalized. Gingival enlargement can be exaggerated by hormonal effects, such as found in puberty and pregnancy, and can be complicated by some systemic medications.5
Plaque-induced inflammatory hyperplasia should resolve with debridement of plaque and calculus and improved oral hygiene, especially when the gingival tissue is edematous. Where the gingival tissue is fibrotic, resolution of enlargement may not occur, resulting in the persistence of periodontal pockets such that effective oral hygiene is impeded. This scenario requires a more detailed assessment and a long-term management plan designed to map the level of gingival and possibly periodontal involvement. Surgical management to remove enlarged tissue and provide improved access for the patient's oral hygiene may be required.6 Surgical removal of the excess tissue is done most often with a procedure known as gingivectomy.11
In the present case, inflammatory enlargement was present in relation to both maxillary and mandibular anterior teeth region causing problem in phonetics and esthetic concern for the patient. After nonsurgical therapy, there was reduction of the inflammation in relation to the lower and upper anterior sextant. Fibrotic component was present in both upper and lower anterior sextant, which was then corrected by gingivectomy. Patient showed uneventful healing, and significant improvement in esthetics was observed.
Gingival enlargement is a common finding in clinical practice and requires appropriate treatment. It affects patient's oral hygiene practice, esthetics, hampers speech, mastication, and naturally self-confidence. The local factors, i.e., plaque and calculus, are mostly responsible for gingival enlargement. Maintaining oral hygiene, regular dental check-up, and oral prophylaxis (when required) are of utmost importance. In the present case, size of the hyperplastic tissue and bleeding gums was the main concern for the patient; therefore, thorough prophylaxis with tissue excision was performed. This case report highlights the importance of patient motivation and compliance in treatment planning.