Enlargment [Compatibility Mode]

8/13/2019 Enlargment [Compatibility Mode]

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GingivalEnlargement

Malik Hudieb, BDS, PhD

Department of Preventive Dentistry

Faculty of Dentistry

Jordan University of Science and Technology

Gingival Enlargement(etiology)

I. Inflammatory enlargement

II. Drug induced gingival enlargement

III. Enlargements associated with systemic disease

IV. Neoplastic enlargement (gingival tumors)V. False enlargement

Gingival Enlargement(location)

1. Localized: single tooth or a group of teeth.

2. Generalized: gingiva throughout the mouth.

3. Marginal: Confined to the marginal gingiva.4. Papillary: Confined to the interdental papilla.

5. Diffuse: the marginal, attached and papillae.

6.Discrete: isolated sessile or pedunculated tumorlike enlargement.


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SCORING OF GINGIVAL ENLARGEMENT

Grade 0 : No signs of gingival enlargement

Grade I : confined to interdental papilla

Grade II : involves papilla and marginal gingiva

Grade III : covers three quarters or more of thecrown.

Gingival EnlargementI. Inflammatory enlargement

A. Chronic

B. Acute

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Gingival Enlargement


A. Chronic:

prolonged exposure

to dental plaque

anatomicabnormalities,improper restorativeand orthodontic

appliances.

Gingival Enlargement


A. Chronic:


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A. Chronic:

Usually painless and progresses slowly

Histopathologic features:

inflammatory cells and fluids with vascularengorgement.

fibroblasts, collagen fibers and new capillaries inthe connective tissue.


B. Acute: Gingival Abscess:

A localized, painful, rapidlyexpanding lesion that isusually of sudden onset.

It is generally limited to themarginal gingiva or

interdental papilla.

Gingival Abscess

Periodontally healthy mouth

Foreign object is forced into a healthy sulcus. Limited to gingival margin

Localized Painful swelling

Purulent exudate may be present

Gingival Abscess

Involves the marginal gingiva or interdentalpapilla


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Gingival Abscess

Involves the marginal gingiva or interdentalpapilla

Gingival Abscess Treatment

Elimination of foreign object

Drainage through sulcus withprobe or light scaling

Control of discomfort

Follow-up after 24-48 hours

Recommend warm salinerinses

Gingival Enlargement(etiology)



III. Enlargements associated with systemic disease

IV. Neoplastic enlargement (gingival tumors)

V. False enlargement


Importance of Medical History..

Ask twice ..

Medications..


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Mostly related to enlarged interdental papillaewhich coalesce. Hereditary enlargementinvolves the entire gingiva.

May compromise esthetics, function and impairadequate oral hygiene.


Clinical Features:

Initially the growth is painless,

starts at the interdental

papilla and extends

to the facial and

lingual gingivalmargins

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Clinical Features:

The marginal andpapillary

enlargements uniteand cover aconsiderable portionof the crowns, whichinterfere withocclusion.


Anterior regions

Interdental papilla



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3 major groups (according to therapeutic action):

1. Anticonvulsants (anti-epilyptics).

2. Immunosuppressants.

3. Calcium channel blockers (anti-hypertensive drugs).


Anticonvulsant drugs:

Phenytoin, Phenobarbital, Carbamazepine,Sodium Valproate, Primidone and Felbamate.

Antihypertensive drugs:

Nifedipine, Amlodipine, Nimodipine, Nicardine,Nitrendipine, Diltiazem, Felodipine and Bepridil.

These medications modifyfibroblast function, either directly

or indirectly through altering levels

of cytokines/MMP activity withinthe tissue and Calcium ions influx

to the cells.


Phenytoin

Fibroblasts show increased synthesis

of sulfated glycosaminoglycans GAG.

Decrease in collagen degradation(inactive fibroblast collagenase)



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Role of Dental Plaque Emphasized in Armitage classification (1999):Gingival disease

A: Dental plaque-induced gingival disease

3. Gingival disease modified by medications

a) drug-induced gingival diseases

1) drug-influenced gingival enlargements

2) drug-influenced gingivitis

a. oral contraceptive-associated gingivitisb. other

AAP

1999

Role of Dental Plaque

Relationship between plaque and drug induced

gingival overgrowth raises the chicken or eggfirst question.

enlarged tissue itself does not bleed, it aidsplaque accumulation by preventing adequateoral hygiene, thus leading to gingivalinflammation (Glickman & Lewitus 1941,Seymour et al1996, Darby 2006).

Role of Dental Plaque

with poor oral hygiene had greater severity of

gingival overgrowth than those with good oralhygiene (Panuska et al.1961) .

Thomason et al(1993) and Ciancio et al(1972)also found an association between the two.

Barclay et al(1992) found gingival changes innifedipine patients were not related to drugdosage or plaque scores.


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Clinical presentation Gingival overgrowth normally begins at the

interdental papillae and is frequently found in theanterior segment of the labial surfaces (Darby2006).

Clinical manifestation usually appears within 1 to3 months after initiation of treatment with themedications (AAP 2004). For patients on

cyclosporin, significant overgrowth wascommonly observed between 3 and 6 months(Seymour et al1987).

Clinical presentation The fibrotic enlargement normally is

confined to the attached gingiva but mayextend coronally and interfere withaesthetics, mastication, or speech.

Does not necessarily altering the

underlying periodontium.

Clinical presentation

Cyclosporin induced gingival overgrowth

pebbly or papillary lesions which appear onthe surface of larger lobulations (Marshall andBartold 1999).

Nifedipine induced gingival overgrowthgeneralized lobulated enlargement of the facialand lingual gingiva, with the nodular growthsoriginating interdentally and extending acrossthe tooth surfaces (Lederman et al1984).

Phenytoin


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Cyclosporin .. Niphedipine..

Verapamil.. Felodipine


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Pathogenesis no definitive explanation .

Not all patients taking phenytoin,cyclosporin and/or nifedipine developgingival overgrowth (Seymour et al1996).

gingival overgrowth is rarely observed on

edentulous alveolar crests (Badar et al1998)

Effect of drug dosage Conflicting studies on the effect of

increasing dosage on the degree ofovergrowth.

Combination of drugs

Combination of drugs:Synergistic effect(Thomason et al1993 & 1996, Slavin &Taylor 1987). A significant increase in theincidence of gingival overgrowth has beendescribed in renal transplant patientstaking nifedipine as well as cyclosporinecompared with those taking cyclosporinalone (48% compared to 30%) (Thomasonet al1993)

Duration of use

Increased duration of phenytoin (Panuska etal1961) or cyclosporin (Thomason et al1996)resulted in more gingival overgrowth


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Individual SusceptibilityInfluenced by:

Age.

Gender.

Genetics.

Age Children and adolescents appear more

susceptible than adults (Seymour et al1996,Thomason et al1996, Darby 2006).

However, these studies are limited to both

phenytoin and cyclosporin that are morecommonly prescribed in this younger agegroup.

Treatment

Four steps:

Drug substitution.

Oral Hygiene.

Antibiotics.

Surgical intervention.

Treatment-Drug substitution

NOT MY WORK.. PLEASE

CONSULTPATIENTPHYSICIAN!


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Treatment-Oral Hygiene Reduces the inflammatory component.

Better surgical field.

Consider use of Chlorhexidine mouthrinseor gel.

Usually does not result in complete

resolution.

Treatment- Antibiotics Conflicting reports.

Cant depend on their use.

May resolve the inflammatory component.

Treatment-Surgical intervention

External bevel or internal bevel incisions.

Laser. CO2 Mostly for esthetic purposes, sometimes to

facilitate oral hygiene.

No difference between the outcome ofdifferent modalities in 6months Mavrogianniset al (2006)

Treatment-Surgical intervention

Recurrence if patient still on medication.Recurrence rate with cyclosporin andnefidipine is 40% within 18 months after

active treatment (AAP 2004).


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False enlargementsIncrease in size of the underlying osseous ordental tissues :

Bone:

Normal: tori, exostoses ,

Disease: fibrous dysplasia, cherubism, centralgiant cell granuloma, ameloblastoma, osteoma,and osteosarcoma.

False enlargements

False enlargements

Increase in size of the underlying osseous ordental tissues :

Underlying Dental Tissues

During the various stages of eruption

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Enlargment [Compatibility Mode]