# Non-Plaque Induced Diffuse Gingival Overgrowth: An Overview
## 8 Diagnostic Pathway in Gingival Overgrowth
### Clinical Examination  
The clinical examination plays a fundamental role in the management of patients with diffuse gingival volume increase not induced by plaque. Together with the medical history and laboratory tests, it helps to assess whether the condition is hereditary or acquired and the presence of other diseases [34; 38]. Extra-oral and intraoral clinical examination must be performed. The extraoral clinical examination distinguishes and identifies syndromic HGFs. As described above, these syndromes present a series of common characteristics and other elements typical of each syndrome. Therefore, the clinician needs a complete and comprehensive overview of the patient, assessing not only what he sees in the oral cavity, but the patient as a whole. For this reason, the clinician should have competences of general medical practice that could address the patient through a multidisciplinary approach with the support of other professionals from different specialties interested in the syndromes treated [5; 38]. The intraoral clinical examination assesses the extent of the gingival enlargement [38]. According to the classification made by [PERSON] et al., a gingival overgrowth is diffuse when it involves the gingival margin and the rest of the gingival mucosa up to the mucogingual fold and for a variable distance along the lingual/palatal surface [1]. NPIGOs all have very similar clinical aspects. Exceptions are some neoplastic forms showing gingival bleeding, erythema, and a bright red color of the gum (especially marginal). In other cases, the gingiva will have a pink aspect, hard consistency, with a non-hemorrhagic diathesis except for superinfections or overlapping gingivitis [9]. The clinical examination, together with family history and histological exams, is extremely important for the diagnosis of isolated HGF for which, according to various studies, there is no indication to carry out genetic tests to confirm the diagnosis [2; 4; 5; 31; 34; 38]. For the intraoral clinical assessment of the size of the gingival enlargement two complementary indices can be used: the vertical index GOi and the horizontal index of Miranda and Brunet (MBi) [91]. The GOi measures the height of the gingival tissues in the apico-coronal direction from the CEJ to the free gingival margin [80]. This index allows evaluation, with the use of a periodontal probe, the height of the gum in the gingival overgrowth and the degree of partial or total coverage of a dental element using six criteria [80]:  
* 0 mm = normal gingiva
* 1 mm = slight increase
* \(<\)2 mm = the gingiva covers the cervical third or less of the anatomical crown
* 2 mm = moderate increase of 2-4 mm with gingiva extended in the middle third of the clinical crown
* 3 mm = severe
* \(>\)4 mm = the gingiva covered more than 2/3 of the clinical crown  
The MBi, also known as the nodullary-papilla index, measures the horizontal enlargement of the papilla from the tooth enamel surface or from the interdental point of contact of the teeth to the outermost portion of the papilla surface in the buccal direction [80]. Also, in this case, the periodontal probe is used for the measurements and two ratings are considered, one for the buccal papilla and one for the lingual-palatal papilla according to the following criteria [80]:  
* 0 mm
* \(<\)1 mm
* 1 mm
* 2 mm
* \(>\)2 mm  
According to [PERSON] et al. a simple grading system can be used to describe the extent of the gingival enlargements [11]:  
* 0 = No sign of gingival enlargement
* 1 = gingival enlargement confined to the interdental papilla
* 2 = gingival enlargement involving the papilla and the marginal gingiva
* 3 = gingival enlargement surrounding \(\frac{3}{4}\) or more of the crown of a tooth  
Grading and the extent of inflammation can provide important data on etiology [11]. A hard, fibrous, pink, homogeneous consistency gingival overgrowth indicates no inflammation [11].