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Gingival Enlargement
I. Inflammatory enlargement A. Chronic B. Acute
Gingival Enlargement
I. Inflammatory enlargement A. Chronic: prolonged exposure to dental plaque anatomic abnormalities, improper restorative and orthodontic appliances.
Gingival Enlargement
I. Inflammatory enlargement A. Chronic:
Gingival Enlargement
I. Inflammatory enlargement A. Chronic: Usually painless and progresses slowly Histopathologic features: inflammatory cells and fluids with vascular engorgement. fibroblasts, collagen fibers and new capillaries in the connective tissue.
Gingival Enlargement
I. Inflammatory enlargement B. Acute: Gingival Abscess: A localized, painful, rapidly expanding lesion that is usually of sudden onset. It is generally limited to the marginal 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
Treatment
Elimination of foreign object Drainage through sulcus with probe or light scaling Control of discomfort Follow-up after 24-48 hours Recommend warm saline rinses
II. Drug induced gingival enlargement 3 major groups (according to therapeutic action): 1. Anticonvulsants (anti-epilyptics). 2. Immunosuppressants. 3. Calcium channel blockers (antihypertensive drugs).
These medications modify fibroblast function, either directly or indirectly through altering levels of cytokines/MMP activity within the tissue and Calcium ions influx to the cells.
Phenytoin Fibroblasts show increased synthesis of sulfated glycosaminoglycans GAG. Decrease in collagen degradation (inactive fibroblast collagenase)
AAP 1999
Clinical presentation
Gingival overgrowth normally begins at the interdental papillae and is frequently found in the anterior segment of the labial surfaces (Darby 2006). Clinical manifestation usually appears within 1 to 3 months after initiation of treatment with the medications (AAP 2004). For patients on cyclosporin, significant overgrowth was commonly observed between 3 and 6 months (Seymour et al 1987).
Clinical presentation
The fibrotic enlargement normally is confined to the attached gingiva but may extend coronally and interfere with aesthetics, mastication, or speech. Does not necessarily altering the underlying periodontium.
Clinical presentation
Cyclosporin induced gingival overgrowth pebbly or papillary lesions which appear on the surface of larger lobulations (Marshall and Bartold 1999). Nifedipine induced gingival overgrowth generalized lobulated enlargement of the facial and lingual gingiva, with the nodular growths originating interdentally and extending across the tooth surfaces (Lederman et al 1984).
Phenytoin
Cyclosporin ..
Niphedipine..
Verapamil..
Felodipine
Pathogenesis
no definitive explanation . Not all patients taking phenytoin, cyclosporin and/or nifedipine develop gingival overgrowth (Seymour et al 1996). gingival overgrowth is rarely observed on edentulous alveolar crests (Badar et al 1998)
Combination of drugs
Combination of drugs:Synergistic effect (Thomason et al 1993 & 1996, Slavin & Taylor 1987). A significant increase in the incidence of gingival overgrowth has been described in renal transplant patients taking nifedipine as well as cyclosporine compared with those taking cyclosporin alone (48% compared to 30%) (Thomason et al 1993)
Duration of use
Increased duration of phenytoin (Panuska et al 1961) or cyclosporin (Thomason et al 1996) resulted in more gingival overgrowth
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Individual Susceptibility
Influenced by: Age. Gender. Genetics.
Age
Children and adolescents appear more susceptible than adults (Seymour et al 1996, Thomason et al 1996, Darby 2006). However, these studies are limited to both phenytoin and cyclosporin that are more commonly prescribed in this younger age group.
Treatment
Four steps: Drug substitution. Oral Hygiene. Antibiotics. Surgical intervention.
Treatment-Drug substitution
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Treatment-Oral Hygiene
Reduces the inflammatory component. Better surgical field. Consider use of Chlorhexidine mouthrinse or 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 of different modalities in 6months Mavrogiannis
et al (2006)
Treatment-Surgical intervention
Recurrence if patient still on medication. Recurrence rate with cyclosporin and nefidipine is 40% within 18 months after active treatment (AAP 2004).
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False enlargements
Increase in size of the underlying osseous or dental tissues : Bone: Normal: tori, exostoses , Disease: fibrous dysplasia, cherubism, central giant cell granuloma, ameloblastoma, osteoma, and osteosarcoma.
False enlargements
False enlargements
Increase in size of the underlying osseous or dental tissues : Underlying Dental Tissues During the various stages of eruption
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