gingival enlargement is a common observation in clinical practice that may occur as a result of a response to varied stimuli and/or interactions with the host and the environment .
these lesions could be either localized to certain aspect of the oral cavity or generalized affecting larger areas .
the possible reasons for this condition may be related to plaque , hormonal imbalances , or systemic - induced manifestation .
these excessive gingival distensions may adversely affect speech , mastication , tooth eruption , esthetics along with major hindrance to the maintenance of routine oral hygiene .
such cases should be treated in a methodical manner , involving a detailed medical history followed by conventional nonsurgical therapy .
however , in order to maintain successful therapeutic outcome , it is crucial to create patient awareness and motivation , along with a timely recall visits .
this case series describes three different conditions of localized gingival overgrowths and its management with prime emphasis on the importance of patient compliance .
neoplasms are characterized by progressive autonomous growth that can be either a benign or a malignant course , whereas nonneoplastic lesions are usually inflammatory or represent a reaction to some kind of irritation or low - grade injury .
most of these lesions have similar clinical findings such as sessile or pedunculated nodule located at the interdental papilla with color variations from pale pink to erythematous .
pyogenic granuloma ( pg ) may occur in all ages and is predominant in the second decade of life in females .
it is a common nonneoplastic , exophytic vascular growth often associated with the history of trauma or chronic irritation .
the present case reports a 23-year - old male patient who reported to the department of periodontology with the chief complaint of growth in the lower right front region of mouth since 1 year .
on detailed conversation with the patient , he revealed an occasional habit of smoking since 2 years with no contributory medical history .
clinical exploration revealed a pedunculated growth at the gingival margin with respect to lower right lateral incisor and canine , measuring 12 mm  15 mm with an interproximal lingual extension [ figure 1a and b ] .
the color of the lesion was pale pink with the consistency being firm toward the coronal two - third whereas the lower one - third was erythematous and soft . in general ,
early stage pgs are highly vascular in appearance because they are composed predominantly of hyperplastic granulation tissue in which capillaries are prominent , whereas mature lesions tend to become firm due to the presence of more collagen network .
there was a moderate amount of calculus present along coronal and subgingival areas of the oral cavity .
an intraoral periapical radiograph revealed mild crestal bone loss with respect to 42 and 43 .
hence , based on the location and clinical findings , a provisional diagnosis of pg was assigned .
a treatment strategy was planned which included oral prophylaxis followed by review after 2 weeks for resolution of existing inflammation .
oral hygiene instructions were given and the use of chlorhexidine mouthwash ( 0.2% clohex , dr .
hyderabad , telangana , india ) twice a day for 1 week was advised . at the follow - up interval ,
. a differential diagnosis of pg , peripheral fibroma , and hyperplastic gingival overgrowth was suggested .
hence , an excisional biopsy was performed with attention to surrounding tissues so as to prevent recurrence .
the surgical site was covered with periodontal dressing and patient was prescribed anti - inflammatory for 3 days .
case 1 ( a ) preoperative clinical picture depicting gingival overgrowth wrt 42 and 43 , ( b ) lingual extension of overgrowth , ( c ) histopathological picture in confirmation with pyogenic granuloma , and ( d ) follow - up at 2 weeks postexcision the sections were stained using h and e stains and a detailed histopathological picture was obtained under 10 magnification .
the stained section showed parakeratinized stratified squamous epithelium , containing hyperplastic and edematous connective tissue dispersed at various sites within the lesion .
the underlying connective tissue stroma was delicate to dense and composed of fibroblasts , fibrocytes with collagen fibers admixed with abundant blood vessels engorged with red blood cells , which is considered a hallmark of pg .
there was moderate , focal aggregation of chronic inflammatory cells chiefly comprising lymphocytes and plasma cells in few areas [ figure 1c ] .
the patient was recalled after a week and healing was found to be satisfactory [ figure 1d ] . correlating the clinical findings with the histological features , a diagnosis of pg
the patient is still on follow - up since 6 months with no evidence of recurrence .
however , literature has reported about 16% of pg recur after excision in spite of being reactive hyperplasias .
peripheral ossifying fibroma ( pof ) is usually an isolated nonneoplastic growth on gingiva that is categorized as a hyperplastic inflammatory lesion . a common gingival growth , it is typically seen on the interdental papilla and is believed to comprise about
females are more commonly affected , and anterior maxilla is the most prevalent location of involvement .
the etiology of pof is uncertain and have been attributed to trauma or local irritants such as plaque , calculus , microorganisms , masticatory forces , ill - fitting dentures , and poor - quality restorations .
following the elimination of causative factors , excision of the lesion is the choice of treatment .
the present case was observed in a 28-year - old male who arrived at the department of periodontology with a complaint of swelling of gums in the upper left back teeth which he noticed 1 month back .
intraoral examination revealed a sessile firm lesion interproximally between 26 and 27 [ figure 2a and b ] .
a tentative diagnosis of fibroma was made and patient was informed about the treatment plan .
the patient was advised on the importance of oral care , which included brushing technique and prescription of chlorhexidine mouthwash ( 0.2% clohex , dr .
india ) was advised twice daily so as to prevent further disease progression and was recalled after a week .
the results presented a lesion comprised of highly cellular connective tissue stroma comprising of delicate collagen and plump fibroblasts . at some areas
, stroma appeared to be dense with ossifying areas assembled as bony trabeculae [ figure 2c ] .
thus , based on clinical and histopathological findings , the final diagnosis was determined as pof .
case 2 ( a ) preoperative clinical picture depicting gingival overgrowth wrt 26 and 27 , ( b ) palatal extension of overgrowth , ( c ) histopathological picture in confirmation with peripheral ossifying fibroma , and ( d ) follow - up at 2 years as reported in literature , the average time interval for recurrence is within a 12 months period .
however , in this present case , no recurrence was seen even at 2 years follow - up [ figure 2d ] .
gingival enlargement is a known adverse effect of calcium channel blockers , especially the dihydropyridine group .
it is a serious concern for both the patient and the clinician due to its unesthetic appearance and formation of new niches for periodontopathogenic bacteria . among the calcium channel blockers ,
gingival enlargement has most frequently been described as an adverse effect following administration of nifedipine ; however , the incidence with amlodipine is rare . in the present case , a 40-year - old female patient reported with the chief complaint of swelling in the lower front region of gums , which had been progressively increasing in size over the previous 6 months .
the disfiguring gingival overgrowth was not only esthetically displeasing but also impaired access for oral hygiene .
the patient 's medical history revealed that she is hypertensive since 8 years and was receiving a single dose of amlodipine 5 mg / day orally since the past 6 years .
intraoral examination revealed severe gingival enlargement with relation to lower labial anterior gingiva involving marginal and papillary gingival [ figure 3a ] .
the enlargement was pink in color , nodular , and slightly edematous with no surface ulcerations .
a prominent nodular growth with a sessile base was also seen with respect to the lower right lateral incisor - canine area on buccal aspect measuring 10 mm  15 mm , soft on palpation , and bleeding on provocation present [ figure 3b ] .
case 3 ( a ) preoperative clinical picture depicting gingival overgrowth wrt lower anteriors , ( b ) isolated overgrowth wrt 42 and 43 , ( c ) 4 months post nonsurgical therapy , ( d ) residual isolated overgrowth wrt 42 and 43 , and ( e ) histopathological picture in confirmation with drug - induced gingival enlargement associated with pyogenic granuloma the oral hygiene status of the patient was poor .
patient was advised on cessation of habit and maintenance of oral hygiene with regular follow - up visits .
she was referred to a physician for drug substitution who replaced amlodipine with atenolol , a beta - blocker .
a full mouth oral prophylaxis was carried out and the patient was placed on a regular recall for 3 months for reinforcement of oral hygiene practice and habit counseling .
the patient had revealed satisfactory results and the gingival tissues had shown marked regression [ figure 3c ] .
the sessile growth revealed a reduction in size to approximately 7 mm  9 mm [ figure 3d ] .
differential diagnosis for the nodular overgrowth included chronic inflammatory gingival enlargement , combined gingival enlargement , peripheral fibroma , peripheral giant cell granuloma , pg , and peripheral fibroma .
hence , an excision was necessary to be performed for maintenance of oral hygiene and to arrive at a definite diagnosis .
the nodular lesion along with surrounding tissues was excised for a complete histologic analysis [ figure 3e ] .
the lesion presented interesting results with one - half of the histological picture showing parakeratotic stratified squamous epithelium with acanthosis and intra- and inter - cellular edema of superficial spinous cells in some areas [ figure 3e ( i ) ] , elongated rete pegs extending deep into connective tissue [ figure 3e ( ii ) ] that exhibited densely arranged collagen fibers and new blood vessels [ figure 3e ( iii ) ] suggestive of drug - induced gingival enlargement .
the other half of the histological picture revealed ulcerations in the epithelium at places that were covered by fibrinous exudate [ figure 3e ( iv ) ] .
connective tissue stroma was edematous , composed of delicate to dense collagen fibers , proliferating blood vessels , and markedly infiltrated by acute and chronic inflammatory cells [ figure 3e ( v ) ] that are seen in pg .
thus , the biopsy picture revealed a combination of drug - induced gingival overgrowth associated with pg .
previously , a case of amlodipine - induced gingival enlargement associated with fibroepithelial hyperplasia has been reported ; however , there has not been any report of amlodipine - induced gingival enlargement associated with pg , to the author 's knowledge .
pyogenic granuloma ( pg ) may occur in all ages and is predominant in the second decade of life in females .
it is a common nonneoplastic , exophytic vascular growth often associated with the history of trauma or chronic irritation .
the present case reports a 23-year - old male patient who reported to the department of periodontology with the chief complaint of growth in the lower right front region of mouth since 1 year .
on detailed conversation with the patient , he revealed an occasional habit of smoking since 2 years with no contributory medical history .
clinical exploration revealed a pedunculated growth at the gingival margin with respect to lower right lateral incisor and canine , measuring 12 mm  15 mm with an interproximal lingual extension [ figure 1a and b ] .
the color of the lesion was pale pink with the consistency being firm toward the coronal two - third whereas the lower one - third was erythematous and soft .
in general , early stage pgs are highly vascular in appearance because they are composed predominantly of hyperplastic granulation tissue in which capillaries are prominent , whereas mature lesions tend to become firm due to the presence of more collagen network .
there was a moderate amount of calculus present along coronal and subgingival areas of the oral cavity .
an intraoral periapical radiograph revealed mild crestal bone loss with respect to 42 and 43 .
hence , based on the location and clinical findings , a provisional diagnosis of pg was assigned .
a treatment strategy was planned which included oral prophylaxis followed by review after 2 weeks for resolution of existing inflammation .
oral hygiene instructions were given and the use of chlorhexidine mouthwash ( 0.2% clohex , dr .
hyderabad , telangana , india ) twice a day for 1 week was advised . at the follow - up interval ,
. a differential diagnosis of pg , peripheral fibroma , and hyperplastic gingival overgrowth was suggested .
hence , an excisional biopsy was performed with attention to surrounding tissues so as to prevent recurrence .
the surgical site was covered with periodontal dressing and patient was prescribed anti - inflammatory for 3 days .
case 1 ( a ) preoperative clinical picture depicting gingival overgrowth wrt 42 and 43 , ( b ) lingual extension of overgrowth , ( c ) histopathological picture in confirmation with pyogenic granuloma , and ( d ) follow - up at 2 weeks postexcision the sections were stained using h and e stains and a detailed histopathological picture was obtained under 10 magnification .
the stained section showed parakeratinized stratified squamous epithelium , containing hyperplastic and edematous connective tissue dispersed at various sites within the lesion .
the underlying connective tissue stroma was delicate to dense and composed of fibroblasts , fibrocytes with collagen fibers admixed with abundant blood vessels engorged with red blood cells , which is considered a hallmark of pg .
there was moderate , focal aggregation of chronic inflammatory cells chiefly comprising lymphocytes and plasma cells in few areas [ figure 1c ] .
the patient was recalled after a week and healing was found to be satisfactory [ figure 1d ] . correlating the clinical findings with the histological features , a diagnosis of pg
the patient is still on follow - up since 6 months with no evidence of recurrence .
however , literature has reported about 16% of pg recur after excision in spite of being reactive hyperplasias .
peripheral ossifying fibroma ( pof ) is usually an isolated nonneoplastic growth on gingiva that is categorized as a hyperplastic inflammatory lesion . a common gingival growth , it is typically seen on the interdental papilla and is believed to comprise about
females are more commonly affected , and anterior maxilla is the most prevalent location of involvement .
the etiology of pof is uncertain and have been attributed to trauma or local irritants such as plaque , calculus , microorganisms , masticatory forces , ill - fitting dentures , and poor - quality restorations . following
the elimination of causative factors , excision of the lesion is the choice of treatment .
the present case was observed in a 28-year - old male who arrived at the department of periodontology with a complaint of swelling of gums in the upper left back teeth which he noticed 1 month back .
intraoral examination revealed a sessile firm lesion interproximally between 26 and 27 [ figure 2a and b ] .
a tentative diagnosis of fibroma was made and patient was informed about the treatment plan .
the patient was advised on the importance of oral care , which included brushing technique and prescription of chlorhexidine mouthwash ( 0.2% clohex , dr .
india ) was advised twice daily so as to prevent further disease progression and was recalled after a week .
the results presented a lesion comprised of highly cellular connective tissue stroma comprising of delicate collagen and plump fibroblasts . at some areas
, stroma appeared to be dense with ossifying areas assembled as bony trabeculae [ figure 2c ] .
thus , based on clinical and histopathological findings , the final diagnosis was determined as pof .
case 2 ( a ) preoperative clinical picture depicting gingival overgrowth wrt 26 and 27 , ( b ) palatal extension of overgrowth , ( c ) histopathological picture in confirmation with peripheral ossifying fibroma , and ( d ) follow - up at 2 years as reported in literature , the average time interval for recurrence is within a 12 months period .
however , in this present case , no recurrence was seen even at 2 years follow - up [ figure 2d ] .
gingival enlargement is a known adverse effect of calcium channel blockers , especially the dihydropyridine group .
it is a serious concern for both the patient and the clinician due to its unesthetic appearance and formation of new niches for periodontopathogenic bacteria . among the calcium channel blockers ,
gingival enlargement has most frequently been described as an adverse effect following administration of nifedipine ; however , the incidence with amlodipine is rare . in the present case , a 40-year - old female patient reported with the chief complaint of swelling in the lower front region of gums , which had been progressively increasing in size over the previous 6 months .
the disfiguring gingival overgrowth was not only esthetically displeasing but also impaired access for oral hygiene .
the patient 's medical history revealed that she is hypertensive since 8 years and was receiving a single dose of amlodipine 5 mg / day orally since the past 6 years .
intraoral examination revealed severe gingival enlargement with relation to lower labial anterior gingiva involving marginal and papillary gingival [ figure 3a ] .
the enlargement was pink in color , nodular , and slightly edematous with no surface ulcerations .
a prominent nodular growth with a sessile base was also seen with respect to the lower right lateral incisor - canine area on buccal aspect measuring 10 mm  15 mm , soft on palpation , and bleeding on provocation present [ figure 3b ] .
case 3 ( a ) preoperative clinical picture depicting gingival overgrowth wrt lower anteriors , ( b ) isolated overgrowth wrt 42 and 43 , ( c ) 4 months post nonsurgical therapy , ( d ) residual isolated overgrowth wrt 42 and 43 , and ( e ) histopathological picture in confirmation with drug - induced gingival enlargement associated with pyogenic granuloma the oral hygiene status of the patient was poor . a provisional diagnosis of combined gingival enlargement
patient was advised on cessation of habit and maintenance of oral hygiene with regular follow - up visits .
she was referred to a physician for drug substitution who replaced amlodipine with atenolol , a beta - blocker .
a full mouth oral prophylaxis was carried out and the patient was placed on a regular recall for 3 months for reinforcement of oral hygiene practice and habit counseling .
the patient had revealed satisfactory results and the gingival tissues had shown marked regression [ figure 3c ] .
the sessile growth revealed a reduction in size to approximately 7 mm  9 mm [ figure 3d ] .
differential diagnosis for the nodular overgrowth included chronic inflammatory gingival enlargement , combined gingival enlargement , peripheral fibroma , peripheral giant cell granuloma , pg , and peripheral fibroma .
hence , an excision was necessary to be performed for maintenance of oral hygiene and to arrive at a definite diagnosis .
the nodular lesion along with surrounding tissues was excised for a complete histologic analysis [ figure 3e ] .
the lesion presented interesting results with one - half of the histological picture showing parakeratotic stratified squamous epithelium with acanthosis and intra- and inter - cellular edema of superficial spinous cells in some areas [ figure 3e ( i ) ] , elongated rete pegs extending deep into connective tissue [ figure 3e ( ii ) ] that exhibited densely arranged collagen fibers and new blood vessels [ figure 3e ( iii ) ] suggestive of drug - induced gingival enlargement .
the other half of the histological picture revealed ulcerations in the epithelium at places that were covered by fibrinous exudate [ figure 3e ( iv ) ] .
connective tissue stroma was edematous , composed of delicate to dense collagen fibers , proliferating blood vessels , and markedly infiltrated by acute and chronic inflammatory cells [ figure 3e ( v ) ] that are seen in pg .
thus , the biopsy picture revealed a combination of drug - induced gingival overgrowth associated with pg .
previously , a case of amlodipine - induced gingival enlargement associated with fibroepithelial hyperplasia has been reported ; however , there has not been any report of amlodipine - induced gingival enlargement associated with pg , to the author 's knowledge .
it is possible to misdiagnose reactive lesions arising from the gingiva . a detailed case history to determine the etiology and histopathological examination is essential for an accurate diagnosis and for proper management .
clinical differential diagnosis for localized gingival overgrowths includes fibroma , peripheral giant cell granuloma , pg , peripheral odontogenic fibroma , and peripheral ossifying fibroma . a relatively healthy oral environment provided by the dentist and maintained by
the patient will reduce local microflora that will help in eliminating the major focus of infection . a critical factor that assists successful therapeutic outcome
the patient should be placed on a regular dental visit , in which a complete description of the existing dental condition should be informed . creating awareness and educating patients regarding the influence of poor oral hygiene and habits to these gingival lesions are essential to avoid further recurrence .
 clinicians are often intrigued by the varied manifestations of the gingival tissue . 
 gingival overgrowth is a common clinical finding and most of them represent a reactive hyperplasia as a direct result of plaque - related inflammatory gingival disease . 
 these types of growth generally respond to good plaque control , removal of the causative irritants , and conservative tissue management . 
 this case series highlights three different cases of localized gingival overgrowth and its management with emphasis on the importance of patient awareness and motivation . 
Introduction
Case Reports
Case 1: Pyogenic granuloma
Case 2: Peripheral ossifying fibroma
Case 3: Pyogenic granuloma in combination with drug-induced gingival enlargement
Conclusion
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Conflicts of interest