1. DRUG INDUCED GINGIVAL ENLARGEMENT

2. CONTENTS INTRODUCTION CLASSIFICATION DRUG INDUCED GINGIVAL ENLARGEMENT
ETIOPATHOGENESIS
DIAGNOSIS
SYMPTOMS
CLINICAL PRESENTATION
TREATMENT
RISK FACTORS
PROGNOSIS
PREVENTION

3. INTRODUCTION Terminology Gingival enlargement Hypertrophic gingivitis
Gingival hyperplasia.

4. GINGIVAL ENLARGEMENT
Gingival enlargement refers to excessive growth of the gums, and may also be known as gingival hyperplasia or hypertrophy.

5. CLASSIFICATION According to etiologic factors and pathologic changes
1. Inflammatory enlargement
Chronic
Acute
2. Drug induced enlargement
3. Enlargement associated with systemic diseases or conditions
Pregnancy
Puberty
Vitamin c deficiency
Plasma cell gingivitis
Non specific conditioned enlargement (pyogenic granuloma)

6. 4. specific diseases causing gingival enlargement
Leukemia
Granulomatous diseases
5. neoplastic enlargement
Benign tumors
Malignant tumors
6. false enlargment

7. Drug-induced enlargement
Drug-induced gingival overgrowth occurs as a side effect of some systemic medications.
"anticonvulsants "(such as phenytoin, phenobarbital, lamotrigine, valproate, vigabatrin, ethosuximide, topiramate and primidone)
"calcium channel blockers" , such as nifedipine and verapamil.the dihydropyridine derivative isradipidine can replace nifedipine and does not induce gingival overgrowth.
"Immunosuppressant", cyclosporine

8. Etiopathogenesis Age Demographic variables Genetic predisposition
Oral hygiene
Pharmaco kinetic variables
Molecular &cellular changes
Hormones
Chronic irritation
Drug
Dose
Duration
Saliva conc.
Serum conc.
HLA Antigen
Etiopathogenesis
Genetic markers

9. Diagnosis
The diagnosis of drug-induced gingival overgrowth is mainly based on :
Clinical appearance
Medical history
Histopathological features

10. What are the symptoms? Discomfort Interfere with speech or chewing
Halitosis (bad odour to the breath)
Look unsightly

11. CLINICAL CHARACTERISTICS:
Gingival enlargement
Normal gingiva

12. Clinical presentation
Painless beadlike enlargement of IDP
Extend to marginal gingiva
Massive tissue fold covering tooth crown

13. Predilection for anterior gingiva
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

14. Phenytoin, a drug used for the management of epilepsy,
50 to 100% of treated patients can occur
Male patients are at high risk

15. Anti convulsants
Continue…
Phenytoin analogues(1-allyl-5-phenylhydantoinate & 5-methyl-5-phenylhydantoinate)
Accumulation of gingival fibroblasts
Decreased collagen degradation
Accumulation of connective tissue

16. Enlargement is Independent of local inflammation
Continue…
Enlargement is Independent of local inflammation
Also Precipitate megaloblastic anemia & folic acid deficiency

17. Cyclosporin, 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.

18. Immuno suppressants 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

19. Cyclosporine+Hydroxycyclosporine Stimulate fibroblast proliferation
Excessive extracellular accumulation
Gingival enlargement

20. calcium-channel blockers -a group of anti-hypertensive drugs
10 to 30% treated patients can occur
nifedipine, verapamil, diltiazem, oxodipine, amlodipine),

21. Calcium channel blocker
Increases gingival fibroblast
Increase in production of connective tissue matrix
Used in the treatment of cvs conditions,
In kidney transplantation patient along with cyclosporine

22. Other drugs, such as antibiotics (erythromycin) and hormones, have been also associated with this
side effect.

23. Histopathology
Pronounced hyperplasia of connective tissue & epithelium
Acanthosis of epithelium
Elongated rete pegs
Increased fibroblast, collagen, new blood vessels
Abundant amorphous ground substance.

24. TREATMENT

25. Plaque control
Medical management
Surgical management

26. Plaque control

27. Tooth brushing Flossing Chlorhexidine Mouth washes:
Mild gingival enlargement will often diminish
with removal of plaque and calculus deposits.
Mouth washes:
Chlorhexidine
Tooth brushing
Flossing

28. Medical management
Altering the medication
Reducing the dose

29. Drug substitution
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

30. Antibiotic regimen
Patient taking cyclosporin, the azithromycin decrease the severity of gingival overgrowth
Organ transplant patients,dosages of both prednisolone and azathioprine

31. Surgical treatment 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.

32. 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

33. Why bleeding and time loss ???

34. Lasers….
CO2 or argon-laser surgery has been proposed as surgical treatment of gingival overgrowth because of decreased surgical time and rapid post-operative haemostasis.

35. Good oral hygiene for preventing or retarding the recurrence of the gingival overgrowth is important after surgery.

36. 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

37. Prognosis
Recurrences are frequent, particularly in patients with less than optimal plaque control and when the drug regimens cannot be modified or reduced.

38. Prevention
"Good oral hygiene" may help to prevent the onset and development of gingival enlargement.

39. References… Clinical periodontology – Carranza
Periodontology and implant dentistry – Lindhe (vol 1)

40. THANK YOU