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J Gandhara Med Dent Sci
April - June 2025
:
:
ORIGINAL ARTICLE
PREVALENCE AND CONTRIBUTING FACTORS OF GINGIVAL HYPERPLASIA IN
ORTHODONTIC PATIENTS
Zeeshan Danish
1
,
Abira Hamid
2
,
Mahira Iqbal
3
,
Taif Ahmad
4
,
Hina Tariq
5
,
Hafiza Tayyaba
Muqarrab
6
ABSTRACT
OBJECTIVES
This study evaluates the prevalence and factors contributing to gingival
hyperplasia in orthodontic patients in Peshawar.
METHODOLOGY
A cross
-
sectional study was conducted at the teaching dental hospital
of
Peshawar from January to September 2025, involving 300 orthodontic
patients aged 15
-
40 years. Clinical examinations assessed gingival
enlargement using the Gingival Overgrowth Index (GOI). Statistical analyses
examined associations between gingival hype
rplasia and factors such as age,
gender, oral hygiene practices, and duration of orthodontic treatment.
RESULTS
Gingival hyperplasia was noted in 45% of the participants involved in the
study. A more detailed analysis revealed that this condition was
particularly
prevalent among individuals with poor oral hygiene practices, affecting 63%
of this group. Additionally, those undergoing treatment for longer than 12
months showed a significant prevalence rate of 54%. When examining the
data by gender, it wa
s found that females exhibited a slightly higher incidence
of gingival hyperplasia at 48%, compared to 41% in males. This suggests that
oral hygiene and treatment duration may play critical roles in developing
gingival hyperplasia, which warrants further i
nvestigation to understand the
underlying mechanisms and potential preventive measures.
CONCLUSION
Gingival hyperplasia is prevalent in nearly half of orthodontic patients,
emphasising the importance of rigorous oral hygiene practices and regular
professio
nal monitoring during treatment.
KEYWORDS:
Orthodontic, Gingival Hyperplasia, Oral hygiene, Prevalence
How to cite this article
Danish Z, Hamid A, Iqbal M, Ahmad
T, Tariq H, Muqarrab HT.
Prevalence
and Contributing Factors of Gingival
Hyperplasia in Orthodontic Patients
.
J
Gandhara Med
Dent Sci. 2025;12(2):73-
77.http://doi.org/10.37762/jgmds.654
Date of
Submission:
30
-
11
-
2024
Date Revised:
26
-
01
-
2025
Date
Acceptance:
20
-
03
-
2025
2
Lecturer, Department of Periodontology,
Peshawar Dental College
3
Assistant Professor, Department of
Periodontology, Peshawar Dental College
4
Taif Ahmad, Senior Registrar,
,
Department of Periodontology,
Peshawar Dental College
5
Lecturer, Department of Periodontology,
Peshawar Dental College
6
Lecturer, Department of Periodontology,
Peshawar Dental College
Correspondence
1
Assistant Professor, Department of
Periodontology, Peshawar Dental
College
+92-332-9509849
taifahmad5@gmail.com
INTRODUCTION
Orthodontic treatment
is crucial in correcting
malocclusions, enhancing function, and improving
facial aesthetics. However, these treatments can also
lead to adverse effects on oral health, with gingival
hyperplasia being one of the most common
complications. Gingival hyperpla
sia, often called
gingival enlargement, is characterised by an overgrowth
of the gingival tissues due to chronic inflammation or
hyperplastic responses initiated by local irritants, such
as plaque accumulation and fixed orthodontic
appliances.
1
If left unmanaged, this condition can result
in significant discomfort, bleeding, aesthetic concerns,
and an elevated risk of periodontal diseases.
2
Gingival
hyperplasia in orthodontic patients is predominantly
linked to suboptimal oral hygiene practices,
accumulating plaque around orthodontic brackets and
wires, creating a fertile ground for oral health issues.
3
The mechanical irritation provoked by these appliances
and the patient's struggle to maintain effective oral
hygiene triggers a pronounced inflam
matory response
in the gingival tissues.
4
Research indicates that gingival
hyperplasia typically manifests within the first year of
orthodontic treatment, with its severity fluctuating
based on factors such as the quality of oral hygiene, the
length of tre
atment period, and individual patient
vulnerabilities.
5
A recent study has underscored the
heightened risk faced by orthodontic patients with poor
plaque control, who are more susceptible to developing
various periodontal complications, including the
distr
essing condition of gingival hyperplasia.
6
Several
additional factors also play a significant role in the
prevalence of gingival hyperplasia. Socioeconomic
status often dictates access to essential dental care and
preventive services, shaping oral hygiene
behaviours
and overall periodontal health.
7
Individuals from lower
-
income backgrounds generally show higher prevalence
rates of gingival hyperplasia due to restricted access to
professional dental care and oral hygiene education.
Furthermore, educational a
ttainment is vital in molding
health behaviors concerning oral hygiene. Those with a
higher level of education are typically more diligent in
following recommended oral hygiene practices and are
more likely to attend regular dental appointments.
8
Recently,
caffeine consumption has emerged as a
74
J Gandhara Med Dent Sci
April - June 2025
potential factor influencing gingival health. Various
studies have proposed that excessive caffeine intake can
affect periodontal tissues by inducing vasoconstriction
and diminishing blood flow, potentially intensifyi
ng
gingival inflammation.
4,9
While the existing evidence is
still limited, this intriguing link calls for further
investigation, especially in demographics characterised
by high caffeine consumption. The background of a
patient’s dental history, including
previous periodontal
treatments and oral hygiene habits prior to orthodontic
intervention, is also a significant determinant. Those
with a history of gingivitis or insufficient plaque control
find themselves at an elevated risk for developing
gingivitis du
ring their orthodontic treatment journey.
10
Moreover, the duration of orthodontic therapy has
shown a strong correlation with the incidence of
gingival hyperplasia. Extended treatment periods result
in increased cumulative exposure of gingival tissues to
i
rritants such as plaque, food residues, and mechanical
forces exerted by orthodontic appliances, thereby
heightening the risk of developing inflammation.
11
Gender differences have been documented as well, with
some studies revealing a slightly higher preva
lence of
gingival hyperplasia among females, potentially linked
to hormonal fluctuations during puberty, pregnancy, or
menstruation.
12
While numerous international studies
have reported varying prevalence rates of gingival
hyperplasia among orthodontic pat
ients, notable
regional disparities exist. For instance, research from
high
-
income countries reports lower prevalence rates
attributed to superior access to dental care and health
education. Comparatively, studies conducted in low
-
and middle
-
income nation
s highlight significantly
higher rates, likely reflecting limited resources and
lower levels of oral health awareness.
13,14
One study
reported a striking 46% prevalence rate of gingival
hyperplasia among orthodontic patients, climbing even
higher among tho
se exhibiting poor oral hygiene
practices.
15
Another research effort noted a prevalence
rate of 52%, further emphasising the critical importance
of consistent oral hygiene and regular dental check
-
ups
in preserving periodontal health.
16
Despite these
valua
ble insights, there remains a significant lack of
comprehensive data on gingival hyperplasia in
orthodontic patients across diverse populations. This
study aims to bridge this knowledge gap by assessing
the prevalence of gingival hyperplasia and exploring
its
associations with oral hygiene practices, treatment
duration, socioeconomic factors, educational levels,
caffeine consumption, and dental history. This research
aims to inform targeted prevention and management
strategies to enhance periodontal outcome
s in
orthodontic care by identifying modifiable risk factors.
METHODOLOGY
This cross
-
sectional study was conducted at a dental
teaching hospital in Peshawar over eight months from
January to August 2024. It received ethical approval
from the Institutiona
l Review Board (Ref: IRB
-
2023/045). The sample consisted of 300 patients,
determined based on an estimated prevalence rate of
40%, a margin of error of 5%, and a confidence interval
of 95%. Participants included individuals aged 15 to 40
undergoing fixed o
rthodontic treatment for at least six
months. The study included patients meeting several
criteria: they must be currently receiving active
orthodontic treatment, should not have any systemic
conditions that could impact periodontal health, and
must not be
using medications known to cause gingival
overgrowth, such as phenytoin or cyclosporine.
Exclusions were made for patients with preexisting
periodontal diseases or systemic disorders. Calibrated
dentists performed clinical examinations and utilised
the Gi
ngival Overgrowth Index (GOI) to determine the
severity of gingival hyperplasia. The GOI categorises
gingival enlargement into four grades:
-
Grade 0: No overgrowth
-
Grade 1: Mild overgrowth
-
Grade 2: Moderate overgrowth covering up to two
-
thirds of the
crown
-
Grade 3: Severe overgrowth covering more than two
-
thirds of the crown
Oral hygiene was assessed using the Plaque Index (PI),
and data regarding treatment duration and demographic
characteristics were also collected. Statistical analyses
were perfor
med using SPSS v26, employing descriptive
statistics to summarise prevalence rates and
demographics. Furthermore, Chi
-
square tests and
logistic regression were utilised to explore the
associations between gingival hyperplasia and various
potential risk fac
tors, with a significance threshold set
at p < 0.05.
RESULTS
The study included 300 participants, with 160 females
(53%) and 140 males (47%). The mean age was 23.4 ±
5.8 years. Most participants (62%) had been undergoing
treatment for 6
-
18 months, with a
n average Plaque
Index of 1.9 ± 0.7. Gingival hyperplasia was identified
in 135 patients (45%). Of these, 60% exhibited mild
overgrowth, 30% moderate, and 10% severe.
Table 1: Prevalence of Gingival Hyperplasia by Severity
Severity
Patients (n)
%age
Mild
81
27
Moderate
41
14
Prevalence and Contributing Factors of Gingival
75
J Gandhara Med Dent Sci
April - June 2025
Oral hygiene status significantly influenced gingival
hyperplasia prevalence, with patients with poor oral
hygiene demonstrating higher rates (63%, p <
0.001).
Longer treatment durations also correlated with
increased prevalence, with 54% of patients treated for
>12 months affected. Gender differences were
observed, with females showing a slightly higher
prevalence (48%) compared to males (41%), though
t
his was not statistically significant (p=0.08p =
0.08p=0.08).
Table 2: Factors Associated with Gingival Hyperplasia
Factor
Patients with Gingival
Hyperplasia (n = 135)
P
-
Value
Oral Hygiene Status
Good
34 (28)
<0.001
Poor
101 (63)
Treatment Duration
≤12 months
51 (37)
<0.01
>12 months
84 (54)
Socioeconomic Status
Low
78 (58)
<0.01
Medium/High
57 (35)
Education Level
Secondary or below
77 (57)
<0.05
College or above
58 (38)
Gender
Female
76 (48)
0.08
Male
59 (41)
Caffeine Consumption
High (>3 cups/day)
72 (53)
<0.05
Low/None (≤3
cups/day)
63 (38)
DISCUSSION
This study highlights a 45% prevalence of gingival
hyperplasia among orthodontic patients, with
significant associations between oral hygiene,
socioeconomic status, treatment
duration, and education
level. These findings align with prior research but
provide new insights into socioeconomic disparities and
caffeine consumption. Our findings are consistent with
previous studies reporting prevalence rates ranging
from 40% to 60%.
A study reported 46% prevalence
among Brazilian orthodontic patients, emphasising the
role of plaque retention in gingival hyperplasia.
15
Similarly, a 40% prevalence was observed in European
orthodontic populations, reinforcing the importance of
maintaining oral hygiene during treatment.
13
However,
lower prevalence rates (~25%) have been reported in
Scandinavian countries due to robust dent
al care
systems and widespread oral health education.
17
Poor
oral hygiene was the strongest predictor of gingival
hyperplasia, observed in 63% of affected participants.
This aligns with another study that reported that plaque
accumulation around orthodont
ic appliances is a
persistent irritant, triggering inflammatory responses.
3
The findings of this study are consistent with previous
research that highlights the significant impact of
mechanical irritation caused by orthodontic appliances
and the accumulati
on of plaque in the development of
gingival overgrowth.
18
A notable observation was that
63% of patients exhibiting poor oral hygiene ultimately
developed gingival hyperplasia, a statistically
significant statistic (p < 0.001).
19
This reinforces the
conclu
sions that identified inadequate plaque control as
the most critical factor influencing the risk of gingival
enlargement among orthodontic patients.
20
Such
correlations underscore the need for effective oral
hygiene practices to mitigate potential complica
tions
during orthodontic treatment. A notable trend in the
dataset shows that longer treatment durations (>12
months) correlate with a higher prevalence of issues
(54%, p < 0.01). Extended use of orthodontic
appliances increases plaque retention and inflam
mation,
highlighting the need for timely treatment completion
and regular periodontal monitoring. This aligns with
previous studies indicating that prolonged orthodontic
appliance use worsens gingival inflammation and
hyperplasia due to chronic irritation
and poor oral
hygiene maintenance.
21
Similarly, a study found that
patients wearing fixed orthodontic appliances for over a
year had significantly higher odds of developing
gingival overgrowth than those undergoing shorter
treatment durations.
22
Socioecono
mic factors
significantly impacted oral health, with low
socioeconomic status (SES) patients showing a higher
prevalence (58%, p < 0.01) of periodontal conditions
like gingival hyperplasia due to limited access to dental
care.
23
Additionally, patients with
secondary education
or lower had higher rates (57%, p < 0.05) compared to
those with college education or above (38%). This
aligns with another study, which noted that education
level affects oral health awareness and hygiene
practices.
24
Gender differenc
es in gingival hyperplasia
prevalence show that females (48%) experience slightly
higher rates than males (41%), but the difference is not
statistically significant (p = 0.08). A study reported that
hormonal fluctuations in females may increase
susceptibil
ity to gingival overgrowth.
25
However, there
are no significant gender differences, indicating that
factors like oral hygiene and genetics may also play a
role.
26
Caffeine consumption was identified as a
significant factor, with those drinking over three c
ups
of coffee daily showing a higher prevalence of gingival
hyperplasia (53%, p < 0.05) compared to those with
lower intake (38%). Excessive caffeine may lead to
periodontal inflammation by altering oral microbiota,
although another study found no signific
ant link
between caffeine and gingival hyperplasia.
27,28
Further
research with larger samples and longitudinal studies is
needed to clarify these associations and develop
preventive strategies for at
-
risk patients.
Prevalence and Contributing Factors of Gingival
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J Gandhara Med Dent Sci
April - June 2025
LIMITATIONS
This study’s large sample s
ize and inclusion of diverse
risk factors strengthen its findings. However, the cross
-
sectional design precludes causal inferences, and self
-
reported data on socioeconomic status and caffeine
consumption may introduce bias.
CONCLUSIONS
Gingival
hyperplasia is a prevalent condition observed
in approximately 50% of patients undergoing
orthodontic treatment. Key contributory factors include
inadequate oral hygiene and extended treatment
durations. These insights underscore the critical need
for stri
ngent oral hygiene protocols, comprehensive
patient education, and consistent professional
monitoring throughout orthodontic therapy.
Additionally, incorporating periodontal health
evaluations into standard orthodontic procedures may
substantially reduce t
he incidence of this common
complication.
CONFLICT OF INTEREST:
None
FUNDING SOURCES:
None
REFERENCES
1.
Zemouri C, Jakubovics NS, Crielaard W, Zaura E, Dodds M,
Schelkle B, et al. Resistance and resilience to experimental
gingivitis: a systematic
scoping review. BMC Oral Health.
2019;19(1):212
-
. doi: 10.1186/s12903
-
019
-
0889
-
z. PubMed
PMID: 31511002.
2.
Ebersole JL, Dawson D, Emecen‐Huja P, Nagarajan R, Howard
K, Grady ME, et al. The periodontal war: microbes and
immunity. Periodontology 2000. 2017
;75(1):52
-
115. doi:
10.1111/prd.12222.
3.
Eddy Heriyanto H, Wa Ode Nur A. The effect of using fixed
orthodontic appliances on periodontal health: Literature review.
Makassar Dental Journal. 2022;11(3):344
-
7. doi:
10.35856/mdj.v11i3.655.
4.
Al
-
Abdaly
MMAA, Asiri AMA, Al
-
Abdaly GMM, Ghabri MA,
Alqaysi MAH, Aljathnan AMS, et al. Evaluation of the
Influence of Fixed Orthodontic Treatment Duration on the
Severity of Inflammatory Gingival Enlargement (Fixed
Orthodontic Induced Gingival Enlargements) and Som
e
Properties of Saliva. International Journal of Clinical Medicine.
2022;13(03):132
-
46. doi: 10.4236/ijcm.2022.133011.
5.
Kim T
-
I. Future endeavors needed to close the socioeconomic
gap in periodontal health. J Periodontal Implant Sci.
2017;47(5):263
-
. Ep
ub 2017/10/30. doi:
10.5051/jpis.2017.47.5.263. PubMed PMID: 29093984.
6.
Marincak Vrankova Z, Rousi M, Cvanova M, Gachova D,
Ruzicka F, Hola V, et al. Effect of fixed orthodontic appliances
on gingival status and oral microbiota: a pilot study. BMC Oral
Health. 2022;22(1):455
-
. doi: 10.1186/s12903
-
022
-
02511
-
9.
PubMed PMID: 36303145.
7.
Shah A, Shah P, Goje SK, Shah R, Modi B. Gingival Recession
in Orthodontics: A Review. Advanced Journal of Graduate
Research. 2017;1(1):14
-
23. doi: 10.21467/ajgr.1.1.14
-
23
.
8.
Agrawal D, Jaiswal P. Gingival enlargement during orthodontic
therapy and its management. Journal of Datta Meghe Institute of
Medical Sciences University. 2020;15(1):136. doi:
10.4103/jdmimsu.jdmimsu_218_19.
9.
Alimi Y, Merle C, Sosin M, Mahan M, Bh
anot P. Mesh and
plane selection: a summary of options and outcomes. Plastic and
Aesthetic Research. 2020;2020. doi: 10.20517/2347
-
9264.2019.39.
10.
Möhlhenrich SC, Kötter F, Peters F, Kniha K, Chhatwani S,
Danesh G, et al. Effects of different surgical te
chniques and
displacement distances on the soft tissue profile via orthodontic
-
orthognathic treatment of class II and class III malocclusions.
Head Face Med. 2021;17(1):13
-
. doi: 10.1186/s13005
-
021
-
00264
-
4. PubMed PMID: 33853633.
11.
Carmen K, Hong AKB. Th
e Prevalence of Systemic Diseases
and Its Association with Periodontal Disease among Patients
Referred to a Government Periodontal Specialist Clinic in
Melaka, Malaysia. Malaysian Dental Journal. 2024;47(1):20
-
6.
doi: 10.4103/mdj.mdj_1_24.
12.
Belibasakis
GN, Belstrøm D, Eick S, Gursoy UK, Johansson A,
Könönen E. Periodontal microbiology and microbial etiology of
periodontal diseases: Historical concepts and contemporary
perspectives. Periodontology 2000. 2023. doi:
10.1111/prd.12473.
13.
Prevalence of Ging
ival Enlargement in Patients Undergoing
Fixed Orthodontic Treatment in Chennai Population
-
A
Retrospective Study. International Journal of Pharmaceutical
Research. 2020;12(sp2). doi: 10.31838/ijpr/2020.sp2.266.
14.
Tiro A. Orthodontic treatment
-
related ris
ks and complications:
part II periodontal complications. South European Journal of
Orthodontics and Dentofacial Research. 2018;5(1). doi:
10.5937/sejodr5
-
17437.
15.
Kim Y
-
R, Nam S
-
H. Comparison of Periodontal Status
According to the Additives of Coffee: Ev
idence from Korean
National Health and Nutrition Examination Survey (2013
-
2015). Int J Environ Res Public Health. 2019;16(21):4219. doi:
10.3390/ijerph16214219. PubMed PMID: 31683501.
16.
Pinto AS, Alves LS, Zenkner JEdA, Zanatta FB, Maltz M.
Gingival enla
rgement in orthodontic patients: Effect of
treatment duration. American Journal of Orthodontics and
Dentofacial Orthopedics. 2017;152(4):477
-
82. doi:
10.1016/j.ajodo.2016.10.042.
17.
Li A, Vermaire JH, Chen Y, van der Sluis LWM, Thomas RZ,
Tjakkes G
-
HE, et
al. Trends in socioeconomic inequality of
periodontal health status among Dutch adults: a repeated cross
-
sectional analysis over two decades. BMC Oral Health.
2021;21(1):346
-
. doi: 10.1186/s12903
-
021
-
01713
-
x. PubMed
PMID: 34266415.
18.
Rădeanu AC, Liliac
IM, Munteanu MC, Surpăţeanu M, Pătru
CL, Andrei EC. Gingival overgrowth in fixed orthodontic
therapy. Romanian journal of morphology and embryology=
Revue roumaine de morphologie et embryologie.
2024;65(4):759
-
64.
19.
VINCENT
-
BUGNAS S, BORSA L, GRUSS A, Lu
pi L.
Prioritization of risk factors of gingival hyperplasia during
orthodontic treatment: the role of biofilm. BMC Oral Health.
2020;2:1
-
15.
20.
Almansob Y, Alhammadi M, Luo X, Alhajj M, Zhou L,
Almansoub H, et al. Comprehensive evaluation of factors that
induce gingival enlargement during orthodontic treatment: A
cross
-
sectional comparative study. Nigerian Journal of Clinical
Practice. 2021;24(11):1649
-
55.
21.
Cerroni S, Pasquantonio G, Condò R, Cerroni L. Orthodontic
fixed appliance and periodontal statu
s: an updated systematic
review. The open dentistry journal. 2018;12:614.
22.
Ilma R, Manola K, Saimir H. Gingival hypertrophy seen in
perspective of typology and treatment trends, at patients treated
with fixed orthodontic appliances. Yemen Journal of Med
icine.
2024;3(2):148
-
55.
Prevalence and Contributing Factors of Gingival
77
J Gandhara Med Dent Sci
April - June 2025
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23.
Alsadany AM, Wagih R. IMPACT OF SOCIOECONONOMIC
STATUS AND ORAL HYGIENE PRACTICE ON
PERIODONTAL HEALTH OF EGYPTIAN ADULTS A
HOSPITAL BASED CROSS
-
SECTIONAL STUDY. Egyptian
Dental Journal. 2025;71(1):389
-
98.
24.
Chen L, Hong J, X
iong D, Zhang L, Li Y, Huang S, et al. Are
parents’ education levels associated with either their oral health
knowledge or their children’s oral health behaviors? A survey of
8446 families in Wuhan. BMC Oral Health. 2020;20:1
-
12.
25.
Sathish AK, Varghese J
, Fernandes AJ. The impact of sex
hormones on the periodontium during a woman’s lifetime: a
concise
-
review update. Current Oral Health Reports.
2022;9(4):146
-
56.
26.
Strzelec K, Dziedzic A, Łazarz
-
Bartyzel K, Grabiec AM,
Gutmajster E, Kaczmarzyk T, et al.
Clinics and genetic
background of hereditary gingival fibromatosis. Orphanet
journal of rare diseases. 2021;16:1
-
9.
27.
Thariny E, Malaiapp S. Comparison of gingival overgrowth
status between drug induced and inflammatory gingival
overgrowth. 2021.
28.
Als
hahrani KM, Alshehri WA, Alawami JH, Mohammad H,
Alabbad MTA, Hawsawi MM. Causes, Management and
Prevention of Orthodontic Discomfort. 2024.
CONTRIBUTORS
1.
Zeeshan Danish
-
Concept & Design; Critical Revision; Final
Approval
2.
Abira Hamid
-
Data
Acquisition; Data Analysis/Interpretation;
Drafting Manuscript; Critical Revision
3.
Mahira Iqbal
-
Concept & Design; Data
Analysis/Interpretation; Drafting Manuscript;
4
.
Taif Ahmad
-
Data Acquisition; Drafting Manuscript; Critical
Revision
5.
Hina Tariq
-
Concept & Design; Critical Revision; Supervision
6
.
Hafiza Tayyaba Muqarrab
-
Data Acquisition; Data
Analysis/Interpretation; Critical Revision
Prevalence and Contributing Factors of Gingival