Top causes of gingival enlargement and treatment options

Originally published in 2017. Updated in 2022.

The gummy smile is caused by gingival enlargement and can be induced by three main causes: (1) inflammation, (2) medication, and (3) systemic disease. Treatment can be in the form of natural healing, once the etiology is removed, by instituting proper dental hygiene, and through nonsurgical treatment and/or surgical treatment.

This article will briefly discuss examples of gingival enlargement and its associated causes, as well as present surgical treatment that can assist in correcting certain types of gingival enlargement.

Figure 1: Gum tissue inflammation caused by bacteria, leading to gum disease and the appearance of swollen gums

How does oral bacteria cause gingival enlargement?

One reason people develop gummy smiles is inflammatory-induced gingival enlargement, typically caused by biofilm (bacteria) and the host response. Gum disease (gingivitis and periodontitis) can result in gum tissue swelling, redness, gum overgrowth, and bleeding (figure 1). In addition to bacterial infiltration of the gums due to poor oral hygiene, orthodontic appliances have been associated with gingival enlargement since braces can act as food traps (figure 2).

Figure 2: Gummy smile caused by a combination of poor oral hygiene and orthodontics exacerbating bacterial accumulation

Typical first-line treatment includes instituting good oral hygiene and dental cleanings (nonsurgical mechanical debridement). In some instances, surgical removal of excess gingival tissue may be needed (figure 2a).

Figure 2a: Correction of a gummy smile after removal of excess gum tissue with the Solea dental laser

Further reading: Considerations when using veneers to fabricate a perfect smile

Medications that cause gingival enlargement

Medication-induced (drug-induced) gingival enlargement can be caused by certain classes of drugs people may be taking.¹ The following classes of drugs have been associated with gum overgrowth:

Anticonvulsants (phenytoin, phenobarbital, lamotrigine, vigabatrin, ethosuximide, topiramate, and primidone)
Antihypertensives (calcium channel blockers such as nifedipine, amlodipine, and verapamil)
Immunosuppressants (cyclosporine)
Amphetamines (cocaine, Ritalin, methamphetamine)

Consider this when evaluating the incidence of drug-induced gingival enlargement:

Figure 3: Gingival overgrowth caused by a combination of the patient being on phenytoin and having poor oral hygiene

50% of the cases are typically attributed to phenytoin (figure 3).
30% of the cases are typically attributed to cyclosporine.
10% to 20% of the cases are typically attributed to calcium channel blockers, with nifedipine being the most notable problem (figures 4a and 4b).
10% or fewer of the cases are typically attributed to amphetamines.

Figure 4a: Gingival overgrowth caused by a patient being on nifedipine and having poor oral hygiene

Treatment may not be needed, and spontaneous resolution may occur if the drug causing the problem is discontinued or another drug is substituted. Bacteria

Figure 4b: Gingival overgrowth caused by a patient being on nifedipine and having poor oral hygiene

caused by poor oral hygiene can exacerbate the drug’s effect, therefore nonsurgical mechanical debridement and good home care should be emphasized. If these methods do not result in the resolution of gingival

Figure 4c: The result after gingival overgrowth was treated with the Solea dental laser without the need for sutures and no bleeding (because of the laser’s cauterization ability)

enlargement, surgical treatment may be necessary (figures 4c and 4d).

What are the systemic causes of gingival enlargement?

Systemic causes of gingival enlargement may result in localized gum tissue overgrowth or a generalized response in which all the teeth are affected. Consider these systemic causes:

Hormonal changes associated with pregnancy or puberty
Diseases requiring hormone replacement therapy
Vitamin deficiencies (mostly vitamin C and vitamin Bs)
Benign neoplasms such as giant cell granuloma, papillomas, and fibromas
Other more serious causes of gingival enlargement include leukemias, malignant neoplasms/carcinomas, as well as many forms of granulomatous diseases.

Treatment of gingival enlargement

Figure 4d: The result after gingival overgrowth was treated with the Solea dental laser without the need for sutures and no bleeding (because of the laser’s cauterization ability)

The first line of treatment is most often noninvasive and includes the discontinuation of any offending medication, controlling the systemic disease with medical care, institution of good home oral care, and nonsurgical mechanical debridement (dental cleaning). Azithromycin has been used in some cases of drug-induced gingival overgrowth, as this antibiotic can slow down fibroblast division and lead to a reduction in excess gum tissue.²

If these methods are ineffective, surgical treatment is warranted. Conventional surgical treatment includes the use of surgical blades, knives, and high-speed burs to remove the excess gingival tissue. Dental lasers such as diodes, 10.6 micron CO₂, erbium YAG, erbium chromium YAG, and Nd:YAG lasers have also been implemented to remove excess soft tissue.³

Another laser that has been used to treat gingival enlargement and gummy smiles is a 9.3 micron CO₂ laser (Solea from Convergent Dental; figure 2a). Unlike other lasers, the Solea laser has the capabilities of removing both soft and hard tissue, precise cutting accuracy due to control of both laser beam power and size, and the ability to cauterize inflamed tissue (figures 4c and 4d). Conventional instrumentation—such as blades, knives, and high-speed burs—can often lead to bleeding after surgical removal when the tissue is inflamed. With this type of CO₂ laser, sutures and/or surgical dressing are often not needed.

Conclusion

Treatment of the gummy smile due to gingival enlargement is dependent on the etiologic agent and the category the disease falls under. If the enlargement is induced by medication, suspension of the drug and institution of proper home care will resolve the problem. When caused by a systemic problem, treatment of the disease usually will result in treatment of the gingival enlargement. Hormonal fluctuations caused by pregnancy and puberty are often unavoidable; many times, gingival enlargement can be precluded/alleviated with excellent home care and routine dental maintenance visits. When these noninvasive modalities do not result in a resolution of the gingival enlargement, surgical treatment is often needed to remove excess tissue.

Editor’s note: This article originally appeared in Perio-Implant Advisory, a chairside resource for dentists and hygienists that focuses on periodontal- and implant-related issues. Read more articles and subscribe to the newsletter.

References

Tungare S, Paranjpe AG. Drug-induced gingival overgrowth. [Updated 2021 Sep 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538518/
Kim JY, Park SH, Cho KS, et al. Mechanism of azithromycin treatment on gingival overgrowth. J Dent Res. 2008;87(11):1075-1079. doi:10.1177/154405910808701110
Lione R, Pavoni C, Noviello A, Clementini M, Danesi C, Cozza P. Conventional versus laser gingivectomy in the management of gingival enlargement during orthodontic treatment: a randomized controlled trial. Eur J Orthod. 2020;42(1):78-85. doi:10.1093/ejo/cjz032