The number of conditions causing focal or diffuse swelling of the gums is far out of proportion to the size of this organ and the fact that physicians frequently pay little attention to it unless the patient mentions it. The best approach is to apply the mnemonic VINDICATE to the gums, and the list of possible causes will quickly come to mind.
· V—Vascular disorders are not a significant cause of swollen gums.
· I—Inflammatory lesions include gingivitis, whether viral (aphthous stomatitis), fusospirochetal (“trench mouth”), or monilial. Focal abscesses of the gums are common. Alveolar abscesses also cause focal swelling of the gums.
· N—Neoplasms remind one of monocytic leukemia and multiple myeloma, which are associated with diffuse hypertrophy, and local tumors such as a sarcoma, papilloma, odontoma, and squamous cell carcinoma.
· D—Deficiency diseases include scurvy and most vitamin deficiencies.
· I—Intoxication suggests the common diffuse hyperplasia in patients with epilepsy taking diphenylhydantoin and related drugs, including barbiturates.
· C—Congenital or acquired malformations remind one of the gingivitis secondary to malocclusion, poor-fitting crowns or orthodontal appliances, and periodontal cysts, secondary to chronic periapical granuloma.
· A—Autoimmune and allergic diseases include the hypertrophy of thrombocytopenic purpura and the contact gingivitis from dentures, mouthwashes, and toothpastes.
· T—Trauma to the gums may cause local hematomas and fractures.
· E—Endocrine disorders suggest several conditions that may cause gum hypertrophy. Gingival hyperplasia in pregnancy, the giant cell granulomas of hyperparathyroidism, juvenile hypothyroidism, pituitary dysfunction, and diabetes mellitus are the most important.
Approach to the Diagnosis
The approach to the diagnosis is to rule out systemic disease by checking other organs by physical examination and laboratory tests (see other useful testsbelow). After this is complete, refer the patient to a periodontist. When making a referral, it is wise to have the patient return or call back with the results of the examination after seeing the specialist. In this way, one can be ready to do a further diagnostic workup should the periodontal examination be negative.
Other Useful Tests
1. CBC (leukemia)
2. Sedimentation rate (dental abscess)
3. Chemistry panel (hyperparathyroidism)
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TABLE 54. Swollen Tongue |
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4. Blood smear (leukemia)
5. X-ray of the teeth (dental abscess, hyperparathyroidism)
6. Thyroid profile (hypothyroidism, pituitary adenoma)
7. Skull x-ray (screen for pituitary adenoma)
8. Drug history (phenytoin)
9. Platelet count (thrombocytopenic purpura)