GINGIVAL ENLARGEMENTGingival enlargement refers to excessive growth of the gums, and may also be known as gingival hyperplasia or hypertrophy.
CLASSIFICATION1. Inflammatory enlargementa. Chronicb. Acute2. Drug induced enlargement3. Enlargement associated with systemic diseases or conditionsa. Pregnancyb. Pubertyc. Vitamin c deficiencyd. Plasma cell gingivitise. Non specific conditioned enlargement (pyogenic
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 Demograph Drug Saliva conc. ic variablesSerum conc. HLA Antigen Genetic Chronic predisposit irritation ion Genetic markers Oral Hormones hygiene Molecular Pharmaco &cellular kinetic changes variables
DiagnosisThe diagnosis of drug-induced gingival overgrowth is mainly based on :Clinical appearanceMedical historyHistopathological features
• Discomfort• Interfere with speech or chewing• Halitosis (bad odour to the breath)• Look unsightly
Clinical presentation • Painless beadlike enlargement of IDP • Extend to marginal gingiva• Massive tissue fold covering tooth crown
Continue…• 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 themanagement of epilepsy, 50 to 100% of treated patients can occur Male patients are at high risk
Continue…• Phenytoin analogues(1-allyl-5- phenylhydantoinate & 5-methyl-5- phenylhydantoinate)• Accumulation of gingival fibroblasts• Decreased collagen degradation• Accumulation of connective tissue
Continue… • Enlargement is Independent of local inflammation • Also Precipitate megaloblastic anemia & folic acid deficiency
, an immunosuppressantdrug 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.
• 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
• 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: • 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 theonset and development of gingivalenlargement.