L24_Treatment for Gingival Enlargementedit

8/12/2019 L24_Treatment for Gingival Enlargementedit

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Treatment of Gingival Enlargement

Rikko Hudyono


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Treatment Choices

is based on an understanding of the cause and

underlying pathologic changes.

Gingival enlargements are of special concern to the

patient and dentist because they pose problems in

plaque control, function (including mastication,

tooth eruption, and speech), and esthetics.


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Chronic Inflammatory Enlargements

Edematous

Fibrous


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Chronic inflammatory enlargements are soft and

discolored and are caused principally by edema and

cellular infiltration.

These gingival enlargements are treated by scaling

and root planing.

The size will be shrink after complete removal ofthe deposits.


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How surgical approaches are needed?

Fibrotic component that does not undergo

shrinkage after scaling and root planing

Obscure deposits on the tooth surfaces andinterfere with access to them


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Selection of the appropriate technique depends on the size of

the enlargement and character of the tissue.

When the enlarged gingiva remains soft and friable even

after scaling and root planing, a gingivectomyis used to

remove it because a flap requires a firmer tissue to perform

the incisions and other steps in the technique.

However, if the gingivectomy incision removes all of the

attached, keratinized gingiva, which will create a

mucogingival problem, then theflap techniqueis

indicated.


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Drug-Associated Gingival Enlargement

Anticonvulsants

Calcium channel blockers

Immunosuppressant


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Drug-Associated Gingival Enlargement

Usually be in combination

Fibrotic components induced by the drugs

Inflammatory components caused by the bacterialplaque


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Treatment Options

First,consideration should be given to the possibility ofdiscontinuing the drug or changing the medication


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Phenytoin to be Carbamazepine or Valproate

Nifedipine to be Diltiazem or verapamil. And

consider to use another class of antihypertensive

medication

Cyclosporine to be Tacrolimus


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Treatment Options

Second,the clinician should emphasize plaque control asthe first step in the treatment of drug-induced gingival

enlargement.


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Treatment Options

Third,in some patients, gingival enlargement persistseven after careful consideration of the previous approaches.

These patients may require surgery, either gingivectomy or

the periodontal flap.


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Gingivectomy

Advantage

simple and quick

Disadvantages

postoperative discomfort

increased chance of postoperative bleeding

Sacrifice keratinized tissue

Doesnt allow osseous reconstruction


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Gingivectomy

Consider

the extent of the area to be operated

the presence of periodontitis and osseous defects

the location of the base of the pockets in relation tothe mucogingival junction.


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Gingivectomy

External bevel cut


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Gingivectomy


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Treatment protocol

Patient taking drug

known to cause

gingival enlargement

Phase I Therapy

Maintenance

Gingival

enlargement

Re-evaluation

Phase II Therapy

Periodontal flapGingivectomy


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Periodontal Flap

Indications:

Larger areas of gingival enlargement (more than six

teeth)

Areas where attachment loss and osseous defects

are present


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After anesthetizing the area, sounding of the underlying alveolar bone is

performed with a periodontal probe to determine the presence and extent of

osseous defects.

With a #15 Bard-Parker blade, the initial scalloped internal bevel incision is made

at least 3 mm coronal to the mucogingival junction, including the creation of newinterdental papillae.

The same blade is used to thin the gingival tissues in a buccolingual direction to

the mucogingival junction. At this point the blade establishes contact with the

alveolar bone, and a full-thickness or a split-thickness flap is elevated.

Using an Orban knife, the base of each papilla connecting the facial and the

lingual incisions is incised. The excised marginal and interdental tissues are removed with curettes.

Tissue tabs are removed, the roots are thoroughly scaled and planed, and the

bone is recontoured as needed.

The flap is replaced and if necessary, trimmed to reach the bone-tooth junction.

The flap is then sutured with an interrupted or a continuous mattress technique.

The surgical area is covered with a periodontal dressing.


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Leukemic Gingival Enlargement

Leukemic enlargement occurs in acute or subacuteleukemia.

The medical care of leukemic patients is oftencomplicated by gingival enlargement andsuperimposed painful acute necrotizing ulcerativegingivitis.

The patient's bleeding and clotting times andplatelet count should be checked, and thehematologist should be consulted beforeperiodontal treatment is instituted


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Treatments

Scaling and root planing with topical and local

anesthesia.

Chlorhexidine mouthwashes. Oral hygiene procedures are extremely important

Progressively deeper scaling is carried out at

subsequent visits.

Antibiotics are administered systemically the

evening before and for 48 hours after each

treatment to reduce the risk of infection.


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Gingival Enlargement in Pregnancy

Treatment requires elimination of all local irritants

responsible for precipitating the gingival changes in

pregnancy.

Elimination of local irritants early in pregnancy is a

preventive measure against gingival disease.


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Treatment of tumorlike gingival enlargements

consists of surgical excision and scaling and planing

of the tooth surface.

The enlargement will recur unless all of the irritants

are removed. Food impaction is frequently an

inciting factor.


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Gingival Enlargement in Puberty

Gingival enlargement in puberty is treated by

performing scaling and curettage, removing all

sources of irritation, and controlling plaque.

Surgical removal may be required in severe cases.

The problem in these patients is recurrence that

results from poor oral hygiene.


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Recurrence

Recurrence after treatment is the most common

problem in the management of gingival

enlargement.

Residual local irritation and systemic or hereditary

conditions causing noninflammatory gingival

hyperplasia are the responsible factors.


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Recurrence

Food impaction

Overhanging margins of restorations

Inadequate plaque control by the patient


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Recurrence

Familial, hereditary, or idiopathic gingival

enlargement recurs after surgical removal even

after all local irritants have been removed. The

enlargement can be maintained at minimal size by

preventing secondary inflammatory involvement.

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