Gingival overgrowth: Part 2: management strategies

Chronic Inflammatory Gingival Enlargement: A Case Report

Gingival enlargement can be referred to as an increased size of the gingival tissues. It might have originated because of inflammation, induced by certain drugs, linked to generalized illness, malignant, or pseudo enlargement, based on its etiology and pathogenesis. Enlargements may be widespread, papillary, or marginal, depending on the location. It affects the patient's masticatory, functional, aesthetic, and psychological health. Diagnosing the condition and its underlying cause through a detailed history is the mainstay for management. Diagnosis is based on a careful clinical examination in relation to the consistency, texture, and color of enlarged gingival tissues. Once diagnosed, the intervention relies on treating the causative factor involved in the condition. Early diagnosis and treatment with the elimination of the etiologic factor along with strict oral hygiene instructions and regular follow-up results in the restoration of aesthetics and function. This article presents a case report of a female patient aged 31 years who presented to the Oral Medicine and Radiology Department with chief complaints of swollen gums, bleeding gums while brushing for one month, and pain and loosening of teeth in the upper left back region of the jaw since 15 days. On thorough clinical examination, oral hygiene instructions were given along with antimicrobials and analgesic medications, and extensive scaling and sub-gingival curettage were done. On the follow-up visit after seven days, there was reduced inflammation due to the removal of local irritants like plaque and calculus and reduced gingival enlargement. The takeaway message from this case is that clinicians should be thoroughly acquainted with the normal and pathologic alterations of the gingival tissues and possible etiologic factors for it. Careful examination, prompt diagnosis, and treatment form the mainstay of management.

Fibrocyte: A missing piece in the pathogenesis of fibrous epulis

OBJECTIVES

To explore the role of fibrocytes in the recurrence and calcification of fibrous epulides.

METHODS

Different subtypes of fibrous epulides and normal gingival tissue specimens were first collected for histological and immunofluorescence analyses to see if fibrocytes were present and whether they differentiated into myofibroblasts and osteoblasts upon stimulated by transforming growth factor-β1 (TGF-β1). Electron microscopy and elemental analysis were used to characterize the extracellular microenvironment in different subtypes of fibrous epulides. Human peripheral blood mononuclear cells (PBMCs) were subsequently isolated from in vitro models to mimic the microenvironment in fibrous epulides to identify whether TGF-β1 as well as the calcium and phosphorus ion concentration in the extracellular matrix (ECM) of a fibrous epulis trigger fibrocyte differentiation.

RESULTS

Fibrous epulides contain fibrocytes that accumulate in the local inflammatory environment and have the ability to differentiate into myofibroblasts or osteoblasts. TGF-β1 promotes fibrocytes differentiation into myofibroblasts in a concentration-dependent manner, while TGF-β1 stimulates the fibrocytes to differentiate into osteoblasts when combined with a high calcium and phosphorus environment.

CONCLUSIONS

Our study revealed fibrocytes play an important role in the fibrogenesis and osteogenesis in fibrous epulis, and might serve as a therapeutic target for the inhibition of recurrence of fibrous epulides.

Refining the Mechanism of Drug-Influenced Gingival Enlargement and Its Management

Drug-influenced gingival enlargement (DIGE) or overgrowth manifests as abnormal enlargement of the gingiva due to an adverse effect of certain drug reactions in patients treated with anticonvulsants, immunosuppressants, or calcium channel blockers (CCBs). As the gingival enlargement became significant, it may interfere with the normal oral hygiene measures, aesthetics, as well as masticatory functions of the patients. The exact mechanism of how this undesirable condition develops is yet unknown, and complicated, with non-inflammatory and inflammatory pathways involved. This review illuminates these putative pathways of DIGE and highlights various treatment approaches based on existing research and current observations.

Non-Plaque Induced Diffuse Gingival Overgrowth: An Overview

Non-plaque induced diffuse gingival overgrowth represents a broad class of conditions caused by several etiological factors. The aim of this review is to highlight the most recent updates and classifications of all the existent gingival overgrowths. In addition, we highlighted the diagnostic pathway that should be employed in patients affected by gingival overgrowth. Gingival overgrowth can be related to syndromic diseases including a wide spectrum of genetic and chromosomal alterations. However, thanks to scientific sharing and the availability of genetic panels it is possible to obtain an accurate phenotypic identification of well-known syndromes and also to identify new ones. This narrative review shows that through rigid, strict diagnostic protocols, the work of the clinician is greatly facilitated, despite the wide variety of pathologies considered. In conclusion, the exchange of specialists’ competencies and the multidisciplinary management of these patients, are crucial to reach diagnosis and the correct clinical-therapeutic management.

High expression of aryl hydrocarbon receptor (AhR) plays an important role in the formation of fibrous epulis

OBJECTIVES

Epulis is considered to be a massive reactive lesion rather than a true neoplasia. AhR is thought to be associated with inflammation and development of neoplasms. Here, we aimed to observe the expression of AhR in fibrous epulis and explore its role and possible mechanism in the pathogenesis of epulis.

MATERIALS AND METHODS

Epulis and normal gingival tissues were collected, and AhR expression was detected at the mRNA and protein levels by quantitative polymerase chain reaction (qPCR) and immunohistochemistry, respectively. The expression levels of proinflammatory cytokines and apoptosis-related factor genes in human periodontal ligament cells (hPDLCs) and human gingival fibroblasts (hGFs) transfected with AhR short interfering RNA (siRNA) or negative control siRNA, upon stimulation with lipopolysaccharide of Porphyromonas gingivalis (Pg-LPS), were then examined. Finally, the expression levels of the proinflammatory cytokines and apoptosis-related factor genes in the epulis tissues were observed by qPCR.

RESULTS

AhR expression in fibrous epulis was significantly increased at both the mRNA and protein levels. The expression of proinflammatory cytokines and apoptosis-related factor genes in hPDLCs transfected with AhR siRNA was significantly decreased when stimulated with Pg-LPS. The same trends were observed for hGFs. The opposite trend was detected in the epulis tissues.

CONCLUSION

AhR may be a key factor in fibrous epulis pathogenesis that acts by regulating the expression of BCL2 family genes and inflammatory factor-related genes.