Chronic Inflammatory Gingival Enlargement

Long-standing gingivitis in young patients sometimes results in chronic inflammatory gingival enlargement, which may be localized or generalized. It commonly occurs when plaque is allowed to accumulate around orthodontic appliances as shown in Figure 24-3 or in areas chronically dried by mouth breathing. The interdental papillae and the marginal gingiva become enlarged, and the tissue is usually erythematous and bleeds easily. It may be soft and friable with a smooth, shiny surface (see Figure 24-3, A), or dense and fibrotic with a matted surface (see Figure 24-3, B). Inflammatory gingival enlargement often slowly resolves when adequate plaque control is instituted, unless the tissues are fibrotic; in such cases gingivectomy is often required.

Drug-Induced Gingival Enlargement

Long-term therapy with certain systemic medications can produce an overgrowth of gingival tissue (Figure 24-4).⁴ It can occur after therapy with the anticonvulsant phenytoin (Dilantin), the immunosuppressant cyclosporine, or a calcium channel blocker. Cyclosporine is used to control host rejection of transplanted organs and to manage autoimmune diseases. Calcium channel blockers such as nifedipine and nitrendipine are cardiac drugs that are sometimes prescribed for children to control hypertension. The overgrowth is painless and differs from chronic inflammatory enlargement in that it is fibrous, firm, and pale pink, often with little tendency to bleed. The enlargement occurs first in the interdental region and may appear lobular. It gradually spreads to the gingival margin. The condition can become extreme, sometimes covering the crowns of the teeth and interfering with eruption or occlusion.

Drug-influenced gingival enlargement occurs slowly and may resolve to some degree when medication is discontinued. There appears to be a genetic component to susceptibility to gingival enlargement. The severity of the enlargement is also affected by both the adequacy of oral hygiene and the gingival concentration of the medication. If medication cannot be discontinued or changed, the enlargement can be surgically removed, but it will recur. The tissue can be removed either by gingivectomy or by a flap with an internal bevel. Surgery is indicated when the appearance of the gingiva is unacceptable to the patient, when the enlargement interferes with comfortable functioning, or when the enlargement has produced a periodontal pocket that cannot be maintained in a healthy state. The most severe cases of gingival enlargement usually occur in mentally retarded patients, in part because of poor oral hygiene. Postoperative discomfort after gingivectomy can be considerable and should be carefully weighed against potential benefits for patients who may not be able to give fully informed consent.

Development and Defects of the Attached Gingiva

When teeth erupt they pierce through an existing band of keratinized gingiva, and the width of this band and its relationship to the teeth change very little during subsequent growth and development. Deflections in the path of eruption, such as those due to crowding or overretention of primary teeth, may result in a narrowed band of attached gingiva.⁵ This is particularly common when mandibular incisors erupt labial to the alveolar ridge as shown in Figure 24-5. If the band of attached gingiva is very narrow, even a small subsequent loss of attachment can result in a mucogingival defect (which occurs when the pocket depth exceeds the width of keratinized gingiva), and recession may occur as shown in Figure 24-5 (left central incisor). The gingival architecture often makes labially erupted teeth difficult to clean, particularly once recession has occurred, leaving them even more vulnerable to inflammation and further attachment loss. The loss of attachment and recession that occurs with a labially malpositioned tooth is sometimes called stripping. Other factors that may contribute to recession in children and adolescents are habit-related self-inflicted injury and the use of smokeless tobacco.