# Non-Plaque Induced Diffuse Gingival Overgrowth: An Overview
## 8 Diagnostic Pathway in Gingival Overgrowth
### Anamnesis  
First, an accurate anamnesis is fundamental. Patients must be questioned about their family medical history with reference to surgeries and/or pathologies that have affected their close relatives, any gingival enlargement and/or manifestations linkable to one of the previously listed syndromes [11,31]. This is crucial when a syndromic or isolated HGF is suspected [5,11,31].  
\begin{table}
\begin{tabular}{l l l} \hline \hline \multicolumn{3}{c}{**Clinical Characteristics**} \\ \hline Acute Leukemia & - & Gingival bleeding. \\ (acute myeloid leukemia, acute & - & Oligival hyperplasia. \\ lymphoblastic leukemia) & - & Ulcers and petechiae. \\  & - & Mucosal pallor related to anemia [83,87,88]. \\  & - & Oral manifestations of CLL are related to an advanced stage of a diagnosed disease, so that they can not be employed to advantage for making an early diagnosis. \\ Chronic Lymphocytic Leukemia & - & Local swelling, with or without ulceration and pain. \\  & - & May also be associated with recurrent oral bleeding [83,88]. \\  & - & Non-bleeding lesions. \\  & - & Gingival hyperplasia. \\  & - & Increased tooth mobility. \\ Lymphomas & - & Progress rapidly. \\  & - & Oral manifestations may present as the first and only sign of disease. \\  & - & Asymptomatic soft swelling [84,89,90] \\ \hline \hline \end{tabular}
\end{table}
Table 3: Clinical characteristics of leukemias and lymphomas related gingival overgrowth.  
Secondly, it is important to proceed with the patient's physiological anamnesis, investigating somatic growth, his/her lifestyle habits, physiological functions, daily life environment from birth up to the present. This type of information on the patient's somatic growth allows evaluation of their birth conditions, breastfeeding, teething, deambulation, puberty, menstrual cycle [11].  
The questions regarding daily environment must explore the patients working and school conditions, while questions on lifestyle give details whether the patient uses alcohol or smokes or takes drugs [11]. Information regarding patients' physiological functions give a picture of the types of diet, the sleep habits, the frequency of miction and the regularity of the bowel [11]. Equally important for the clinician is to be informed about the patient's medications, and the times of both intake and any possible suspension: in fact, it is DIGOs that appear after about 3 months of consumption [11].  
No less important is the patient's remote pathological anamnesis, that describes both the general and dental clinical history, particularly regarding previous oral surgery and the onset of severe disease [11].  
Finally, the close pathological anamnesis is carried out to obtain information regarding appearance, symptoms, and duration of the lesions [11]. This is another crucial element regarding the differential diagnosis between both drug induced forms, or hormonal, and neoplastic and genetic ones [11]. In particular, the genetic forms are already present at 3 years of age while the neoplastic ones (except for acute lymphoblastic leukemia) or the conditioned (depending on the etiological agent) tend to develop later in life. The rapid manifestation of gingival overgrowth, especially in older age, without apparent causes attributable to patients' habits, such as use of drugs, poor oral hygiene, or other causes, should alert the clinician to carry out more tests, as there will be a strong suspicion of an oral manifestation of a neoplastic pathology [11].