Chronic hyperplastic gingivitis

Inflammation of the gums with prolonged hypertrophy or hyperplasia - excessive enlargement - of the cellular elements of its tissues around the teeth is defined as chronic hyperplastic gingivitis or hypertrophic gingivitis. The ICD-10 code for chronic gingivitis is K05.1.

Epidemiology

Hyperplastic (hypertrophic) form of gingivitis is detected in no more than 5% of dental patients with this disease.

That said, according to the American Dental Association, chronic hyperplastic gingivitis occurs in about 60-75% of pregnant women.

As evidenced by clinical statistics, about 50% of cases of drug-induced hyperplastic gingivitis of chronic course are associated with the use of Phenytoin (or Diphenin) - an anticonvulsant drug prescribed for epilepsy, angina pectoris, arterial hypertension, pain syndromes and others.Up to 30% of cases - with the use of immunosuppressant Cyclosporine, and 10-20% of cases are associated with drugs of the group of calcium channel blockers, in particular, Nifedipine (which is prescribed to patients with angina pectoris and elevated BP). [1]

Causes of the chronic hyperplastic gingivitis.

In gingivitis, the inflammatory process is limited to the epithelial tissue of the mucosa surrounding the maxillary part of the teeth and alveolar processes. The increase in the volume of this tissue in the development of chronic hyperplastic (hypertrophic) gingivitis has several causes.

First of all, it is gingival inflammation, which is most often induced by the accumulation of microbial plaque on the teeth (in the gingival sulcus or along the gingival margin), formed by a number of bacteria of the obligate microflora of the oral cavity (Streptococcus, Fusobacterium, Actinomyces, Veillonella, Treponema, etc.). And chronic inflammatory enlargement of the gingiva is the result of prolonged exposure of the infection on its tissues with disruption of metabolic processes occurring in them.

The causes of this condition may be related to irritation of the gum by a broken tooth, a poorly placed crown, poorly fitted dentures, orthodontic systems (braces) that exacerbate plaque buildup.

Hypertrophy of interdental gingival papillae (papilla gingivalis) is characteristic of gingival inflammation in pregnancy (especially in the third trimester), which is associated with changes in the hormonal background of the female body during gestation: increased levels of progesterone and estrogen in the blood serum. In about 5-10% of cases, the so-called epulis gravidarum - granuloma of pregnancy, which is a benign hyperplastic formation of periodontal tissues - appears on the gingival area adjacent to the focus of inflammation.

Sex hormone levels also increase during puberty, which is why adolescents have hyperplastic juvenile gingivitis involving the marginal gingiva (marginalis gingivae), spreading to the adjacent attached gingiva (coniuncta gingivae) and enlarged interdental papillae (papilla gingivalis). Sex hormone-related gingival tissue conditions are most commonly referred to by experts as generalized gingival hyperplasia during pregnancy and puberty. [2]

Also chronic hypertrophic gingivitis of a non-inflammatory nature can be:

• nasal breathing disorders, including chronic nasal congestion, short upper lip, dental anomalies in the form of protruding front teeth of the upper and lower jaw (bimaxillary protrusion);
• with long-term use of anticonvulsants (Phenytoin, Etosuximide), immunosuppressants (Cyclosporine), calcium channel blockers (Amlodipine, Nifedipine), fibrinolytic agents, oral contraceptives, vitamin A and systemic retinoids - with the appearance of signs of medicated gingivitis within two to three months after the start of the drug;
• in case of vitamin C deficiency in the body;
• In hypersensitivity reactions, including to toothpaste, chewing gum or food products;
• in patients with acute myeloblastic leukemia, lymphoma, systemic vasculitis in the form of Wegener's granulomatosis, Crohn's disease (granulomatous inflammation of the GI tract), autoimmune Hashimoto's thyroiditis, hereditary mucolipidosis type II and amelogenesis imperfecta (congenital disorder of tooth enamel formation).

Risk factors

Risk factors associated with chronic hypertrophic gingivitis include: age; poor oral hygiene (leading to bacterial plaque); orthodontic pathologies (twisted teeth), and jaw anomalies and deformities; nasal breathing disorders; use of certain medications that cause dry mouth; smoking; anemia; diabetes; HIV infection; certain autoimmune and hereditary diseases, leukemia.

Pathogenesis

If the usual inflammation of gingival tissues is caused by a response to bacterial antigens (their enzymes and toxins) - activation of the system of pro-inflammatory cytokines that direct protective cells of local immunity to the focus of infection invasion, then the pathogenesis of chronic hypertrophic (hyperplastic) gingivitis - inflammatory increase in the mass of gingival tissue in the form of a slight swelling of the interdental gingival papillae (and the gingival margin, not associated with the periosteum) or dense-elastic fibrous formation - is explained in different ways, but most often by increased proliferation of fibroblasts synthesizing collagen of the extracellular matrix.

Generalized gingival hyperplasia during pregnancy and puberty has been shown to be associated with the effects of endogenous sex steroids (estrogen, progesterone, and testosterone) on periodontal tissue cell differentiation and on the synthesis and collagen maintenance of gingival squamous epithelial cells, which have specific sex hormone receptors.

The mechanism of drug-induced inflammation of gums with their hypertrophy is explained by the fact that metabolites of these drugs can cause proliferation of fibroblasts. Also, immature collagen glycoproteins may accumulate in the extracellular matrix of gingival tissues due to an imbalance between its synthesis and degradation.

But what leads to gingival hypertrophy in the form of pathologic overgrowth of healthy epithelial cells near the anterior teeth of the upper and lower jaw when nasal breathing is disturbed, remains unclear.

Symptoms of the chronic hyperplastic gingivitis.

The first signs of chronic gingivitis with hypertrophy of gingival tissues are manifested by their redness (often with cyanosis), swelling and hypersensitivity.

Periodontists distinguish between edematous (inflammatory) and fibrous (granulating) types or forms of chronic hyperplastic gingivitis. In the edematous form, there is an inflammatory increase in the mass of gingival tissue in the form of an increase in the interdental gingival papillae (to varying degrees overlapping the dental crowns) and not associated with the periosteum of the gingival margin, and in the fibrous form - in the form of dense-elastic fibrous formation, which is a focus of hyperplasia of periodontal tissue (with less pronounced bleeding of the gums and their soreness or complete absence of these symptoms).

In addition to overgrowth of the interdental papillae and their bleeding (when brushing teeth), other symptoms include pain in the gum (especially when eating), itching sensation, and bad breath.

In cases of drug-induced chronic hyperplastic gingivitis, the pathologic process begins with focal enlargement of the interdental papilla and may involve the gingival margin separated from the periosteum by a furrow at the base of the teeth. When gingivitis is not associated with secondary inflammation, the hyperplasia is elastic (pink in color) of dense consistency without bleeding.

In vitamin C deficiency, the gingiva becomes bluish-red, soft and friable, with a smooth shiny surface. Blood may appear on mild irritation or spontaneously. [3]

Complications and consequences

The formation of false periodontal (gingival) pockets, indicating a violation of the gingival margin adherence to the neck area of the teeth and its swelling, as well as the development of ulcerative-necrotic gingivitis and severe periodontitis with destruction of the spongy substance at the tips of the interdental septa (leading to adentia - loss of teeth) are considered the main complications and negative consequences of chronic hypertrophic gingivitis.

In addition, due to overgrowth of gum tissue, patients often experience appearance-related discomfort and certain problems with eating and articulation. [4]

Diagnostics of the chronic hyperplastic gingivitis.

Correct diagnosis is crucial, as it is the key to treating this pathology and preventing its recurrence. The clinical picture may not be sufficient, so anamnesis is collected and a detailed examination of the oral cavity of the patient is carried out. [5]

General and clinical blood tests are taken, as well as coagulogram.

Instrumental diagnostics is used: they take panoramic images of teeth.

Differential diagnosis

The differential diagnosis includes catarrhal gingivitis; chronic periodontitis; gingival, periodontal, periapical, or pericoronary abscesses; odontogenic periodontal cysts; hereditary gingival fibromatosis (occurring as an isolated disease, chromosomal abnormality, or as part of a series of congenital syndromes), and malignant gingival tumors (squamous cell carcinoma or melanoma).

Treatment of the chronic hyperplastic gingivitis.

Treatment of hypertrophic gingivitis often depends on its underlying cause, with the elimination of which the condition usually improves, that is, the greatest positive effect gives etiotropic or pathogenetic therapy of hyperplastic gingivitis.

Hypertrophy of gum tissues in pregnant women decreases after delivery and its treatment during gestation consists of oral hygiene. Also read - Bleeding gums in pregnancy

Commonly practiced first-line treatment includes ensuring good oral hygiene and sanitation with careful removal of plaque from the teeth and gums.

In hyperplastic juvenile gingivitis it is recommended to improve oral hygiene, mouthwash with decoctions of medicinal plants (with astringent and anti-inflammatory properties) or pharmacy rinses with antiseptic properties and anti-inflammatory action, as well as apparatus physiotherapy procedures. [6]

Read more:

• Gum diseases and their treatment
• Treatment of gum inflammation
• Treatment of bleeding gums
• Ointments and gels for gum inflammation

Some cases of the fibrotic form of hyperplastic gingivitis may require surgical removal of excess gingival tissue by:

• gingivectomy (using a scalpel);
• laser excision;
• electrosurgery (diathermocoagulation).

Prevention

Prevention of chronic hyperplastic gingivitis consists of regular hygienic brushing, avoiding traumatization of the gums and timely treatment of dental diseases.

See also - preventing bleeding gums in pregnancy

Forecast

Experts note that when chronic hyperplastic gingivitis is the result of systemic diseases, the prognosis of its outcome may be less optimistic, because despite the improvement of oral hygiene and adequate treatment, the pathological condition may recur.