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  2. 2. INTRODUCTIONTerminology Gingival enlargement Hypertrophic gingivitis Gingival hyperplasia.
  3. 3. GINGIVAL ENLARGEMENTGingival enlargement refers to excessive growth of the gums, and may also be known as gingival hyperplasia or hypertrophy.
  4. 4. 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
  5. 5. 4. specific diseases causing gingival enlargementa. Leukemiab. Granulomatous diseases5. neoplastic enlargementa. Benign tumorsb. Malignant tumors6. false enlargment
  6. 6. 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
  7. 7. 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
  8. 8. DiagnosisThe diagnosis of drug-induced gingival overgrowth is mainly based on :Clinical appearanceMedical historyHistopathological features
  9. 9. • Discomfort• Interfere with speech or chewing• Halitosis (bad odour to the breath)• Look unsightly
  10. 10. CLINICAL CHARACTERISTICS:Normal gingiva Gingival enlargement
  11. 11. Clinical presentation • Painless beadlike enlargement of IDP • Extend to marginal gingiva• Massive tissue fold covering tooth crown
  12. 12. 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
  13. 13. , a drug used for themanagement of epilepsy, 50 to 100% of treated patients can occur Male patients are at high risk
  14. 14. Continue…• Phenytoin analogues(1-allyl-5- phenylhydantoinate & 5-methyl-5- phenylhydantoinate)• Accumulation of gingival fibroblasts• Decreased collagen degradation• Accumulation of connective tissue
  15. 15. Continue… • Enlargement is Independent of local inflammation • Also Precipitate megaloblastic anemia & folic acid deficiency
  16. 16. , 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.
  17. 17. • 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
  18. 18. • Cyclosporine+Hydroxycyclosporine • Stimulate fibroblast proliferation• Excessive extracellular accumulation • Gingival enlargement
  19. 19. -a group of anti-hypertensive drugs10 to 30% treated patients can occurnifedipine, verapamil, diltiazem, oxodipine, amlodipine),
  20. 20. • Increases gingival fibroblast• Increase in production of connective tissue matrix• Used in the treatment of cvs conditions,• In kidney transplantation patient along with cyclosporine
  21. 21. Other drugs, such as antibiotics and have been alsoassociated with thisside effect.
  22. 22. Histopathology• Pronounced hyperplasia of connective tissue & epithelium• Acanthosis of epithelium• Elongated rete pegs• Increased fibroblast, collagen, new blood vessels• Abundant amorphous ground substance.
  23. 23. Mild gingival enlargement will often diminish with removal of plaque and calculus deposits.Mouth washes:ChlorhexidineTooth brushingFlossing
  24. 24. • Altering the medication• Reducing the dose
  25. 25. • 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
  26. 26. • Patient taking cyclosporin, the azithromycin decrease the severity of gingival overgrowth• Organ transplant patients,dosages of both prednisolone and azathioprine
  27. 27. • 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.
  28. 28. • 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
  29. 29. • CO2 or argon-laser surgery has been proposed as surgical treatment of gingival overgrowth because of decreased surgical time and rapid post-operative haemostasis.
  30. 30. • Good oral hygiene for preventing or retarding the recurrence of the gingival overgrowth is important after surgery.
  31. 31. 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
  32. 32. Prognosis• Recurrences are frequent, particularly in patients with less than optimal plaque control and when the drug regimens cannot be modified or reduced.
  33. 33. Prevention may help to prevent theonset and development of gingivalenlargement.
  34. 34. • Clinical periodontology – Carranza• Periodontology and implant dentistry – Lindhe (vol 1)