Download gingival enlargement

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INTRODUCTION
CLASSIFICATION
DRUG INDUCED GINGIVAL ENLARGEMENT
ETIOPATHOGENESIS
DIAGNOSIS
SYMPTOMS
CLINICAL PRESENTATION
TREATMENT
RISK FACTORS
PROGNOSIS
PREVENTION
INTRODUCTION
Terminology
Gingival enlargement
Hypertrophic gingivitis
Gingival hyperplasia.
GINGIVAL ENLARGEMENT
Gingival enlargement refers to excessive growth of
the gums, and may also be known as gingival
hyperplasia or hypertrophy.
CLASSIFICATION
1. Inflammatory enlargement
a. Chronic
b. Acute
2. Drug induced enlargement
3. Enlargement associated with systemic diseases or conditions
a. Pregnancy
b. Puberty
c. Vitamin c deficiency
d. Plasma cell gingivitis
e. Non specific conditioned enlargement (pyogenic
granuloma)
4. specific diseases causing gingival enlargement
a. Leukemia
b. Granulomatous diseases
5. neoplastic enlargement
a. Benign tumors
b. Malignant tumors
6. false enlargment
Drug-induced enlargement
• Drug-induced gingival overgrowth occurs as a
side effect of some systemic medications.
(such as phenytoin,
phenobarbital, lamotrigine, valproate, vigabatrin,
ethosuximide, topiramate and primidone)
, such as
nifedipine and verapamil.the dihydropyridine
derivative isradipidine can replace nifedipine and
does not induce gingival overgrowth.
, cyclosporine
Age
Dose
Duration
Saliva conc.
Serum conc.
Demograph
ic variables
Drug
HLA Antigen
Genetic
predisposit
ion
Chronic
irritation
Genetic markers
Oral
hygiene
Hormones
Molecular
&cellular
changes
Pharmaco
kinetic
variables
Diagnosis
The diagnosis of drug-induced gingival
overgrowth is mainly based on :
Clinical appearance
Medical history
Histopathological features
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Discomfort
Interfere with speech or chewing
Halitosis (bad odour to the breath)
Look unsightly
CLINICAL CHARACTERISTICS:
Normal gingiva
Gingival enlargement
Clinical presentation
• Painless beadlike enlargement of IDP
• Extend to marginal gingiva
• Massive tissue fold covering tooth crown
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• Mulberry shaped, firm, pale pink, resilient,
lobulated surface, no tendancy to bleed.
• When complicated by inflammation,:
red/bluish red color,obliterate the surface
demarcation, tendency to bleed
• Onset within 3 months
• Predilection for anterior gingiva
, a drug used for the
management of epilepsy,
50 to 100% of treated patients can occur
Male patients are at high risk
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• Phenytoin analogues(1-allyl-5phenylhydantoinate & 5-methyl-5phenylhydantoinate)
• Accumulation of gingival fibroblasts
• Decreased collagen degradation
• Accumulation of connective tissue
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• Enlargement is Independent of local
inflammation
• Also Precipitate megaloblastic anemia & folic
acid deficiency
, an immunosuppressant
drug used to reduce organ transplant
rejection
15 to 85% of treated patients can occur
Male patients are at high risk
cyclosporin solution experience earlier onset of
gingival changes than using capsules.
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Prevent organ transplant rejection
Reversibly inhibit helper T cell
Dosage >500 mg/day induce g.enlargement
More vascularized connective tissue
Enlargement is a hypersensitivity reaction
• Cyclosporine+Hydroxycyclosporine
• Stimulate fibroblast proliferation
• Excessive extracellular accumulation
• Gingival enlargement
-a group of
anti-hypertensive drugs
10 to 30% treated patients can occur
nifedipine, verapamil, diltiazem, oxodipine, amlodipine),
• Increases gingival fibroblast
• Increase in production of connective tissue
matrix
• Used in the treatment of cvs conditions,
• In kidney transplantation patient along with
cyclosporine
Other drugs, such as antibiotics
and
have
been also associated with this
side effect.
Histopathology
• Pronounced hyperplasia of connective tissue
& epithelium
• Acanthosis of epithelium
• Elongated rete pegs
• Increased fibroblast, collagen, new blood
vessels
• Abundant amorphous ground substance.
Mild gingival enlargement will often diminish
with removal of plaque and calculus deposits.
Mouth washes:
Chlorhexidine
Tooth brushing
Flossing
• Altering the medication
• Reducing the dose
• It may take from 1 to 8 weeks for resolution of
gingival lesions.
• CCB: amlodipine and felodipine, isradipin
• Cyclosporine: tacrolimus
• Phenytoin: valproic acid, carbamazepine, or
phenobarbitone, vigabatrin
• Patient taking cyclosporin, the azithromycin
decrease the severity of gingival overgrowth
• Organ transplant patients,dosages of both
prednisolone and azathioprine
• Gingivectomy is the treatment preferred when
the
• Gingival overgrowth involves small areas (up
to six teeth), there is no evidence of
attachment loss and
• There is at least 3 mm of keratinized tissue.
• The periodontal flap is preferred when the
• gingival overgrowth involves larger areas
(more than six teeth) and there is evidence of
attachment loss combined with osseous
defects
• CO2 or argon-laser surgery has been
proposed as surgical treatment of gingival
overgrowth because of decreased surgical
time and rapid post-operative haemostasis.
• Good oral hygiene for preventing or retarding
the recurrence of the gingival overgrowth is
important after surgery.
RISK FACTORS
• Potential risk factors for drug-induced gingival
overgrowth include the following:
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Poor oral hygiene
Periodontal disease
Periodontal pocket depth
Gingival inflammation
Degree of dental plaque
Duration and dose of cyclosporine
Prognosis
• Recurrences are frequent, particularly in
patients with less than optimal plaque control
and when the drug regimens cannot be
modified or reduced.
Prevention
may help to prevent the
onset and development of gingival
enlargement.
• Clinical periodontology – Carranza
• Periodontology and implant dentistry – Lindhe
(vol 1)