What are the common and uncommon causes of gingival swelling and the recommended initial management?

Swollen Gums: Etiology and Initial Management

Common Causes of Gingival Swelling

The most common cause of swollen gums is plaque-induced gingivitis, which results from bacterial biofilm accumulation on teeth adjacent to the gingiva. 1, 2

Plaque-Induced Inflammatory Conditions

• Gingivitis is the mildest form, affecting up to 90% of the worldwide population, characterized by gingival inflammation without destruction of underlying tooth-supporting structures 2
• Periodontitis represents advanced disease with irreversible destruction of connective tissue, periodontal ligaments, and alveolar bone 3, 2
• Periodontal abscess presents as an acute, localized purulent infection within periodontal tissues, often with rapid onset of pain, swelling, and potential tooth mobility 4
• Necrotizing periodontal diseases manifest with three cardinal features: papilla necrosis, gingival bleeding, and pain, representing the most severe biofilm-associated conditions 4

Medication-Induced Gingival Enlargement

• Calcium channel blockers (antihypertensives) are among the most common causes of drug-induced gingival enlargement in patients with chronic kidney disease and dialysis patients 1
• Cyclosporine A (immunosuppressant) causes gingival enlargement more frequently than tacrolimus in transplant recipients 1

Trauma-Related Causes

• Mechanical trauma from ill-fitting dentures, fractured teeth, or dental prostheses can cause localized gingival swelling 1
• Dental trauma in primary or permanent dentition may result in gingival swelling, increased tooth mobility, or parulis formation 1

Infection-Related Causes (Non-Plaque)

• Dental abscess with pulpal necrosis presents with gingival swelling, increased mobility, and/or parulis, often requiring urgent intervention 1, 5
• Peri-implant mucositis and peri-implantitis can cause swelling around dental implants, particularly in patients with poor oral hygiene 1

Systemic Disease Manifestations

• Immune-mediated conditions including mucocutaneous disorders can present with gingival lesions resembling plaque-induced disease 6, 4
• Hereditary and autoinflammatory conditions may manifest as gingival inflammation that does not respond to conventional plaque control 6
• Hematological disorders can have periodontal manifestations with gingival swelling 2
• X-linked hypophosphatemia (XLH) increases the frequency and severity of periodontitis in adults, with reduced cementum thickness and impaired periodontal ligament attachment 1

Cancer Therapy-Related Causes

• Chemotherapy and radiation-induced mucositis can cause oral mucosal injury and gingival inflammation 1
• EGFR and VEGFR inhibitors are associated with dermatological and mucosal inflammation 1

Initial Management Algorithm

Step 1: Distinguish Plaque-Induced from Non-Plaque-Induced Lesions

Key clinical assessment points:

• Evaluate whether swelling resolves with improved oral hygiene and professional plaque removal 7, 6
• Assess for systemic symptoms: fever, malaise, lymphadenopathy, or signs of spreading infection 5, 8
• Identify medication history, particularly calcium channel blockers, cyclosporine, or recent cancer therapy 1
• Look for trauma sources: ill-fitting prostheses, fractured teeth, or recent dental procedures 1

Step 2: Initial Treatment Based on Etiology

For Plaque-Induced Gingivitis (Most Common)

• Professional mechanical plaque removal through scaling is the cornerstone of treatment 7
• Patient education on proper oral hygiene: brush with soft toothbrush after meals and before sleep using Bass or modified Bass technique with mild fluoride-containing, non-foaming toothpaste 1, 7
• Adjunctive chlorhexidine 0.2% mouthwash twice daily for 60 seconds to reduce plaque and inflammation 7
• Alternative natural mouthwashes with comparable efficacy include 0.25% lemongrass oil, 0.1% turmeric, 100% aloe vera, green tea, or Triphala (10mL twice daily) 7
• Reassess after 2-4 weeks to adjust treatment plan 7

Critical pitfall: Do not start interdental cleaning if the patient is not already using it regularly, as it can break the epithelial barrier and cause gingival bleeding 1, 7

For Suspected Dental Abscess

• Surgical intervention is mandatory and should not be delayed: incision and drainage, root canal therapy for salvageable teeth, or extraction for non-restorable teeth 5, 8
• Antibiotics are adjunctive only and indicated when systemic involvement is present (fever, tachycardia, tachypnea, elevated WBC), spreading infection (cellulitis, diffuse swelling), or patient is immunocompromised 5, 8
• First-line antibiotic when indicated: amoxicillin 500mg three times daily for 5-7 days 5
• For penicillin allergy: clindamycin 300-450mg three times daily 5

Critical pitfall: Antibiotics without surgical drainage are ineffective and contribute to antibiotic resistance 5, 8

For Necrotizing Periodontal Disease

• Superficial debridement with careful mechanical oral hygiene 4
• Chlorhexidine rinsing with daily re-evaluation 4
• Systemic metronidazole as first-line antibiotic in severe cases or nonresponding conditions 4
• Address predisposing factors: HIV infection, malnutrition, stress, tobacco smoking 4

For Medication-Induced Gingival Enlargement

• Consult with prescribing physician (nephrologist for calcium channel blockers, transplant team for cyclosporine) to consider medication substitution 1
• Maintain rigorous periodontal hygiene to prevent or minimize enlargement 1
• Consider switching cyclosporine A to tacrolimus if gingival enlargement develops, as tacrolimus is less frequently associated with this side effect 1

Step 3: When to Avoid Antibiotics

Antibiotics are NOT indicated for:

• Irreversible pulpitis without systemic involvement 5
• Acute apical periodontitis without systemic signs 5
• Localized dental abscess without systemic manifestations when adequate surgical drainage can be achieved 5
• Routine gingivitis treatment 7

Step 4: Red Flags Requiring Urgent Referral

• Airway compromise risk from facial space infection requires hospitalization and IV antibiotics (ampicillin-sulbactam 1.5-3.0g every 6 hours) 5
• Extension into cervicofacial tissues requires aggressive management as potential necrotizing fasciitis 5
• Failure to improve within 48-72 hours necessitates reassessment for inadequate drainage, culture for resistant organisms, and antimicrobial adjustment 5
• Systemic toxicity with fever and altered mental status may require hospitalization 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics as substitute for surgical intervention in dental abscesses—this is ineffective and promotes resistance 5, 8
• Do not wait 30 minutes after toothbrushing before using chlorhexidine mouthwash—toothpaste ingredients may inactivate it 7
• Do not discontinue treatment prematurely before complete resolution of inflammation 7
• Do not ignore medication history—calcium channel blockers and immunosuppressants are common causes of gingival enlargement 1
• Do not assume all gingival swelling is plaque-induced—systemic diseases can mimic periodontal conditions and require different management 6, 4