Hyperplasia

= Case #1 - Hyperplasia =

** Overview of gingival hyperplasia **
Also known as gingival enlargement or gingival overgrowth. Hyperplasia is an increased number of cells causing gingival overgrowth or enlargment. The many types of gingival enlargement can be classified according to etiologic factors and pathologic changes as follows:

A. Inflammatory enlargement a. Chronic b. Acute

B. Drug-induced enlargement

C. Enlargements associated with systemic diseases or conditions a. Conditioned enlargement b. Systemic diseases causing gingival enlargement
 * 1. Pregnancy
 * 2. Puberty
 * 3. Vitamin C deficiency
 * 4. Plasma cell gingivitis
 * 5. Nonspecific conditioned enlargement (pyogenic granuloma)
 * 1. Leukemia
 * 2. Granulomatous diseases (e.g., Wegener’s granulomatosis, sarcoidosis)

D. Neoplasic enlargement (gingival tumors) a. Benign tumors b. Malignant tumors

E. False enlargement Using the criteria of location and distribution, gingival enlargement is designated as follows: · // Localized: // limited to the gingiva adjacent to a single tooth or group of teeth · // Generalized: // involving the gingiva throughout the mouth · // Marginal: // confined to the marginal gingiva · // Papillary: // confined to the interdental papilla · // Diffuse: // involving the marginal and attached gingivae or papillae · // Discrete: // //An isolated sessile or pedunculated, tumorlike enlargement// The degree of gingival enlargement can be scored as follows: ** Medical History ** __Dilantin (phenytoin)__ used in the treatment of tonic-clonic (grand mal) complex partial seizures and to prevent seizures after head trauma. //Dental implications:// no information available to require special precautions. //Dental contraindications//: ginvival hyperplasia is a common problem observed during the first 6 months of therapy appearing as gingivitis or gum inflammation. Patient should have a professional cleaning and plaque control education 10 days after anti-convulsant therapy to minimize severity and growth rate of gingival tissue. Effects on oral contraceptives are decreased and patient should use another form of birth control.
 * // Grade 0: // No signs of gingival enlargement
 * // Grade I: // Enlargement confined to interdental papilla
 * // Grade II: // Enlargement involves papilla and marginal gingiva
 * // Grade III: // Enlargement covers three quarters or more of the crown
 * History of seizures
 * Medications: Dilantin (phenytoin)
 * ASA II
 * Last preventive appointment: three months ago

Free: generalized erythemic, bulbous, firm and resilient, and shiny with localized blunting between 8 & 9 due to diastema and localized clefting on 25 &23. Attached: generalized erythemic, firmly bound down to underlying bone, shiny, and glossy.
 * Gingival Description**

E & I findings: Bilateral linea alba, bilateral Fordyce granules, bilateral mandibular tori. 2 mm X 2 mm cheek bite on left buccal mucosa – asymptomatic. Maximum Opening: 52mm Skeletal class: Mesognathic Angles Class: Class I bilateral molar relation MBI: 12% Probing Depth: Generalized 5-6mm and localized 7mm BOP: 36% Mobility: + on 7-10 and 23-26 Fremitus: + on 8 and 9 Furcations: none Mucogingival Defects: none ADA and AAP: generalized ADA I due to having pseudopockets but no bone loss. AAP: generalized moderate gingivitis due to plaque and calculus and modified by medication – Dilantin Calculus Code: light/medium PI: 52%
 * Assessment Findings**

Bass tooth brushing technique 3X/ day. C-shape flossing technique 1X/day. May want to recommend a electric toothbrush if the patient’s OHI is inadequate. Educate this patient on his/her gingival hyperplasia and the reason for it as well as the importance of oral hygiene instructions.
 * OHI**

Appointment 1: Assessments, x-ray check, DDS exam, 2nd check-in, OHI, PI. Refer patient to physician for possible drug substitution. Appointment 2: Right ½ mouth scale with Anesthesia. Appointment 3: Left ½ mouth scale with Anesthesia. Fluoride treatment: NaF. Nutritional counseling may be a benefit to this patient to make sure he/she has adequate nutrition. If drug substitution is attempted, it is important to allow for a 6-12 month period to elapse between discontinuation of the drug. Possible resolution of gingival enlargement before a decision to implement surgical treatment. 3 month re-care for 12 months 12 month re-care appointment do reevaluation: If gingiva regresses, maintain good oral hygiene and maintain re-cares. If gingival enlargement persists, periodontal surgery may be indicated. If areas of enlargement include more than 6 teeth, presence of osseous defects, and if limited keratinized tissue, periodontal flap may be considered. If enlargement includes less than 6 teeth, no attachment loss or horizontal bone loss, and abundance of keratinized tissue, gingivectomy may be considered. After periodontal surgery, maintenance of oral hygiene is required, chlorhexidine gluconate rinses with re-care appointments are required. Periodic surgical re-treatment may be considered.
 * Treatment Plan**
 * Additional treatment**

Prognosis is fair due to the presence of systemic disease, the use of Dilantin, acceptable patient cooperation, and adequate maintenance possible.

Questions
1. How long after a patient begins taking Dilantin does the hyperplasia usually begin? a. 1-2 weeks b. 2 weeks – 3 months c. 1-3 months d. 3-6 months

2. How long after a patient discontinues Dilantin does it take for gradual regression of the overgrowth? a. 3 months b. 6 months c. 1 year d. 2 years

3. If a drug substitution is attempted, how much time is required before results are noticed? a. 2-4 weeks b. 1-3 months c. 3-6 months d. 6-12 months

4. According to Fermin Carranza, what percentage of patients taking hydantoins, such as Dilantin, develop gingival enlargements? a. 3% b. 25% c. 50% d. 85%

5. Which of the following medications could be prescribed as a substitution for Dilantin to reduce gingival enlargement? a. phenytoin and valproic acid b. nifedipine and valproic acid c. carbamazepine and valproic acid d. cyclosporine and valproic acid

6. Should a patient with drug-induced gingival enlargement receive surgical treatment to reduce enlargement, what is the average length of time the results are maintained? a. 1-2 months b. 3-12 months c. 12-24 months d. forever

7. Biofilm is the most important determinant of the severity of drug-induced gingival enlargement. Adequate biofilm control, especially if started prior to administration of drug, helps control the extent of gingival overgrowth. a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

8. Information to obtain from the patient during the medical history review includes all of the following EXCEPT: a. Frequency of seizures b. Medications, surgery, or diet c. Description of aura is not necessary d. Physician's name and phone number

9. It is important to teach the patient the relationship of systemic health to oral health. Encourage the patient to seek immediate care if any oral change or injury is suspected. a. Both statements are TRUE. b. Both statements are FALSE. c. The first statement is TRUE; the second statement is FALSE. d. The first statement is FALSE; the second statement is TRUE.

10. Refer to the picture below. The degree of gingival enlargement for this patient is: a. Class 0 b. Class I c. Class II d. Class III