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Gingival Enlargement and Pregnancy

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1.0  Introduction

Gingival enlargement also known as gingival hypertrophy or hyperplasia is an abnormal overgrowth of gingival tissues6. Studies have revealed that pregnancy is among the risk factors causing periodontal disease, due to increased levels of progesterone and estrogens. Gingiva has been found to be one of the target organs for female sex hormones. In order to reduce incidences of gingival inflammation, it is recommended that pregnant women should maintain their oral hygiene.

The increase in gingival inflammation begins during the second month of pregnancy and and reach its maximum level during the eighth month of pregnancy. The inflammatory changes may lead to gingival appearing edematous, hyperplastic or erythematous. Usually, the changes are either localized or generalized and may be noted on the interdental papilla and also on the marginal gingival. The condition is accompanied by local irritation.

2.0 Purpose of the Project

In this paper, the relationship between gingival enlargement and pregnancy is presented. The paper will enable us discover the causes of gingival enlargement in pregnant women, the intense of the condition and how it can be prevented. Gingival enlargement has been found to cause various problems such as chewing, breathing, speaking and cosmetic problems, especially during pregnancy. Hormonal imbalances, which occur during pregnancy, have been associated with localized and generalized gingival enlargements. Pregnancy does not cause this condition directly, but rather metabolism during pregnancy accentuates the response to irritants, thus causing gingival inflammation. All these are discussed in depth in the paper.

Having a deeper understanding of the relationship between gingival enlargement and pregnancy is crucial because the condition has become a common clinical entity. Because of its association with various local and systematic factors, complete management of the condition requires differential diagnosis. Most gingival enlargement causative factors lead to unusual hyperplastic tissue response, which are associated with local irritants such as calculus, plague, and bacteria.  

3.0 Background

Gingival enlargement is a common clinical entity, especially with pregnant women. Hormonal imbalances, which occur during pregnancy, have been known to be one of the causative factors of gingival enlargement. The paper addresses the relationship between gingival enlargement and pregnancy. The topic has a wide range of importance to health issues.

Hormonal imbalances, which occur during puberty and pregnancy, have been known to be associated with various types of gingival enlargement. The hormonal changes significantly potentiate the effects of irritants on gingival connective tissues. In all body inflammation good oral hygiene is necessary in order to minimize the negative effects of the associated systematic factors. Gingivectomy or Gingivoplasty may be done in combination with oral hygiene and prophylaxis instructions. Lesions that do not cause a significant esthetic or functional problem should be avoided during pregnancy because they may reoccur. Furthermore, they may resolve to a spontaneous post-partum.

The importance of oral prophylaxis and regular check up cannot be overlooked. Though, gingival hyperplasia is a rare condition, it is important for mechanic and cosmetic reasons.  During pregnancy hyperplasia of gingival may be caused by various factors including poor oral hygiene, poor nutrition or by systematic hormonal stimulation.

The objective of the paper is to explain deeply the causes of gingival enlargement during pregnancy, effects and prevention of the condition. The following research questions will be answered in the course of the paper:

¾ How is gingival enlargement related to pregnancy?

¾ What causes gingival enlargement during pregnancy?

¾ What are the influences of hormonal imbalances during pregnancy on the development of gingival lesions?

¾ How can gingival inflammation be prevented and treated?

4.0 Literature Review

Periodontal inflammation and pregnancy have now been linked for many years.  For instance, in1978, Vermeeran discussed the intense of “toothpains" in pregnancy5. Also in 1818, Pitcarin tried to give a description of gingival hyperplasia in pregnancy6.

Pregnancy related abnormalities are most frequent in gingival tissue. Pregnancy does not cause gingivitis, but rather aggravate pre–existing disease. The most common known changes exhibit themselves in gingival vasculature. Various studies have been done to understand how ovarian hormones may increase the enlargement the gingival tissues and exaggerate the response to local irritants. Gingival inflammation has been found to be aggravated by an imbalance or an increase in sex hormones.

According to a study by Pitcarin sex hormones affects and modifies the actions of cells of immune system2. Furthermore, evidence suggests that the interaction of estrogen and immune system can lead to non immune regulatory effects. Estrogen and progesterone receptors have been demonstrated in the gingival. The sub-gingival micro-flora and the gingival tissues respond to the hormonal imbalance during pregnancy with a variety of changes. Epidemiological studies suggests that the prevalence of pregnancy gingivitis ranges from 35% to 100%

During collection of information regarding the topic I made use of pub-med search. Using Google as the search engine I entered the URL. This is the National Library of medicine address. I clicked on PubMed, which took me to simple search interface pages for PubMed. The key words I searched for include the following; gingival enlargement, gingivectomy and periodontal inflammation including many others.

5.0 Theoretical Framework

A study, which was done by Carranza and Newman1 on February 2008, involving 95 pregnant women aged between 15-45 years old, suggests that untreated periodontal diseases in pregnant mothers poses a significant risk factor, which may cause preterm, less than 37 weeks gestation and low birth weight (less than 2500 grams)1. Currently, there have been opinions that the co-relation of periodontal diseases to preterm low birth weights (PLBW) occurs due to infections.

The evidence further suggests that the condition can be mediated indirectly through the translocation of bacterial products such as endotoxin or by the action of maternally produced inflammatory mediators. The biologically active molecules, which are normally in normal parturition, such as prostaglandin PGE and tumor necrosis factors are raised to high levels by the infection. This may foster premature labor. Recently, there has been a positive relation between gingival crevicular fluid levels of PGE with intra amniotic PGE levels, suggesting that negative periodontal infections may present a challenge sufficient to initiate the onset of premature labor through the stimulation of secondary mediators such as PGE and Interleukin 1 beta.

Pregnancy gingivitis manifests itself in various ways. This includes; erythema, hyperplasia, edema and increased bleeding. These manifestations are similar to those of conventional gingivitis. The condition varies from mild to server inflammation and progresses to serious enlargement causing spontaneous bleeding and pain of gingiva. Occasionally, there might appear a localized gingival enlargement called pregnancy tumor. Serious gingival condition leads to tissue inflammation causing periodontal tooth mobility.

It has been observed that during pregnancy hormonal levels increases to a greater extent. For instance, etcradial levels in the plasma increases up to 30 times that during reproductive cycle. Estrogen and progesterone are produced in the placenta during pregnancy. The estrogen produced may regulate cellular differentiation, proliferation and keratinization, while progesterone changes the rate of production of collagen and also affects the permeability of microvasculature. Receptors for progesterone and estrogen have been revealed in the gingival; providing direct biochemical evidence that gingiva can be a target organ for sex hormones.

In addition, there exists an evidence of sex hormone concentration in the crevicular fluid, which provides a growth medium for periodontal pathogens. Also, there are various changes which occur in maternal immune system leading to a decrease in the ration of peripheral T helper cells to T suppressor cells. The changes in maternal immune response increase the degree of gingival inflammation.

Because of increased sex hormones in gingival tissues, gingival crevicular fluid and in the saliva, the response of tissues (gingival) to local factors (plague) becomes exaggerated7. Gingival inflammation, presence of calculus and plague and consequently, gingival bleeding have been found to be more in pregnant women in comparison to non-pregnant women. It has been estimated that the prevalence of gingivitis in pregnant women ranges from 30% to 100%.

According to another study did by Laine, pregnant women need to have a high standard of hygiene4. Because of the hormonal imbalances during pregnancy, pregnant women are more susceptible to gingival-periodontal diseases. This is consistent with the finding by Pinard, which showed that pregnant women need more oral hygiene instructions and care in order to deal with oral diseases3.

Oral hygiene instructions such as instructions on how to care for oral heath during gestation, and after delivering, are among the parameters to be considered for pregnant women6.  Although a considerable proportion of pregnant women experience gingivitis during pregnancy, gingival tissues return to their original healthy state after wards. This happens when the levels of estrogen and progesterone reach baseline values. 

In a clinical situation, apart from a slight increase in gingivitis, a sub-gingival microbial shift and bleeding, healthy pregnant women are unlikely to experience a significant gingival response that would have serious clinical implication. It is important for women, who are susceptible to gingival conditions, to seek treatment to prevent serious extension of inflammation that may cause bacteremia8.  Preventive measures such as meticulous plague control and dental prophylaxis helps in preventing periodontal conditions from development. Hence, it is necessary to include periodontal examination as one of antenatal check up during pregnancy in order to ensure that both the mother and the child are healthy. 

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