Investigation on the management of Gingival Enlargement using

Periodontal flap versus Gingivectomy

Sok Chea D.D.S, F.A.D.I, F.I.C.C.D.E, F.C.S.PPost Graduate Diploma in PeriodontologyPeriodontal SpecialistCert. Periodontic (Japan)Cert. Gingival Esthetic Reconstruction, SNUDH (Korea)Cert. Intensive Oral Implantology (H.K)Former President of Cambodian Dental AssociationFounder of Cambodian Society of Periodontology

AbstractTHE PURPOSE OF STUDY was to compare probing dept resolution achieved by gingvectomy andperiodontal flap techniques in the treatment of nifedipine-induced gingival enlargement. Tenpatients who were receiving nifedipine for at least 6 months participated in the study. Fivepatients were randomly to the ginvivectomy group and five patients to the periodontal flapgroup. Only anterior segment of the oral cavity (canine to canine) were surgical treated. Clinicalmeasurements, including probing depths, plaque index, and gingival sulcus index, were taken atbaseline, 6 weeks, 6 months, and 1 year. Result showed that probing depths were similar in sixweeks in both groups after treatment, while significant differences were found for theperiodontal flap group when compared to the gingivectomy group at 6 months (2.58 ± 0.38mmversus 4.9 ± 0.8mm, respectively) and one year (3.3 ± 0.65mm versus 6.40mm ± 1.02mm,respectively). Within its limitations, this study suggests that pocket reduction achieved by theperiodontal flap may be sustained of longer periods of the time than by the gingivectomytechniques in the treatment of nifedipine-include gingival enlargement.

Gingival Enlargement

Gingival Overgrowth = Gingival Hyperplasia or Hypertrophic

And/orInflammation Fibrotic component

Gingival enlargement results from inflammatory changes induced byDeposition of plaque and CalculousSystemic administration of certain drugs

including Phenytoin, Nifedipine, and Cyclosporine A

Inflammatory enlargement Chronic Acute

Drug-induced enlargement Enlargements associated with systemic diseases

Conditioned enlargement Pregnancy Puberty Vitamin C deficiency

Systemic disease causing gingival enlargement Leukemia Granulomatous disease

Neoplastic enlargement Benign tumorsMalignant tumors

False enlargement

Inflammatory enlargement Chronic Acute

Drug-induced enlargement Enlargements associated with systemic diseases

Conditioned enlargement Pregnancy Puberty Vitamin C deficiency

Systemic disease causing gingival enlargement Leukemia Granulomatous disease

Neoplastic enlargement Benign tumorsMalignant tumors

False enlargement

Drug-induced gingival enlargement

Anti-convulsion Immuno-supressant cyclosporineCalcium Channel Blockers ( Nifadepine )

Drug-induced gingival enlargement

Anti-convulsion Immuno-supressant cyclosporineCalcium Channel Blockers ( Nifedipine )

Purpose The purpose of this study was to compare

probing depth resolution archived by gingivectomy and periodontal flap techniques as surgical treatment modalities for gingival enlargement associated with Nifedipine.

Journal of Human Hypertension (2010), 1-9P Isaakidis, M-E Raguenaud, C Say, H De Clerck, C Kim, R Pottier, S KuochU prahors, S Chour, W Van Damme and T Reid

The prevalence of hypertension was 12 % in a rural community and 25 % in a semi-urban community ( Aged 35 to 64 years )

Among these with hypertension 28 % were Diabetes

The most commonly prescribed drugs

Thiazide diuretic Beta-blockers Angiotension-converting enzyme inhibitors Calcium Channel Blockers ( Nifedipine )

The most commonly prescribed drugs

Thiazide diuretic Beta-blockers Angiotension-converting enzyme inhibitors Calcium Channel Blockers ( Nifedipine )

Nifedipine is a dihydropyridine which belong to the class of pharmacological agents known as calcium antagonistCalcium Channel Blockers are drugs developed for the treatment:

Angina pectoris, unstable angina, chronic stable angina, ventricular arrhythmias, hypertension, Coronary artery spasms and Cardiac arrythmia

Calcium Channel blockers commonly used inCambodia

- Norvase (A) USA - Stamlo (A) - Adalate (N) Fr. - Loxen (Na) Fr.- Nifelat (N) - Topdip (A)- Amdocal plus (A) - Adipin (A)- Amlopres (A) - Nipine (A)- Amzel (A) - Amlopin (A)- Amark (A) - Medicolat (N)- Amlocor (A) - Nifedipine denk (N)

Materials and MethodsPatient Eight individual patients ( 6 men, 4 women) Aged 37 to 71 years All of them had a history of hypertension and

cardiovascular disorders Nifedipine 20-40 mg per day ( 6 to 38 ) months Gingival enlargement covering at least one third

of clinical crown and no evident of clinical attachment loss

Only anterior teeth has been selected ( Canine to canine ) in this study

Clinical Parameters Probing depth (PD) Clinical attachment level (CAL) Plaque index Gingival sulcus index

Surgical Treatment Gingivectomy techniqueA scalloped external bevel incision was made at

CEJ level Kirkland knife and Orban knife Following removal of the enlarged gingival

tissue, gingivoplasty was performed using a #8 round diamond bur at high speed in order to restore physiological gingival form.

Scaling and root planing was performed by hand currets and hemostasis achieved by pressure

Periodontal flap techniqueBuccal and lingual Periodontal flap were

performed from mesial line angle of the first bicuspid to the mesial line angle of the contra-lateral bicuspid

An inverse bevel incision was performed with a # 15 blade at the CEJ level

The inner surfaces of the buccal and lingual flaps were thinned with the same blade

The flaps were raised by Periosteal elevator and the collar of tissue was removed by currets and scaling and root planning performed

4-0 Vicryl suture were employed

Gingivectomy

Flap operation

Gingivectomy

Patients in both group were received periodontal dressing following surgical procedure and oral hygiene were instructed.

0.2 chlorexidine solution ( 1 minute rinses every 8 hours for 7 days )

Amoxicillin ( 500 mg every 8 hours for 7 days )Acetaminophen 500mg and Ibuprfen 400 mg( every 8 hours as needed )Post operative examinations consisting probing depth, plaque index and gingival index were performed at 6 weeks and 6 months

Plaque Index (O’leary) and ginnigival Sulcus Index for the Gingivectory ( GV) and Periodontal flap ( Flap)

Plaque IndexGV Flap

Base Line 12.6 ± 4.1 11.5 ± 4.0 6 Weeks 9.2 ± 3.0 8.8 ± 3.1 6 Months 10.1 ± 2.0 9.9 ± 1.4

Results

Gingival Sulcus Index

GV FlapBaseline 0.79 ± 0.18 0.92 ± 0.146 Weeks 0.32 ± 0.05 0.32 ± 0.106 Months 0.44 ± 0.20 0.44 ± 0.15

Probing Depths for Gingivectomy and periodontal Flap Groups

Probing DepthGingivectomy Periodontal flap

Baseline 8.12 ± 0.77 7.82 ± 0.40 6 Weeks 2.00 ± 0.31 1.98 ± 0.24 6 Months 5.00 ± 0.80 2.45 ± 0.38 1 Year 6.40 ± 1.02 3.30 ± 0.65

Probing Depth

8.12

2.00

5.00

6.40

7.82

1.982.45

3.30

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Baseline 6 Weeks 6 Months 1 Year

Gingivectomy

Periodontal Flap

Probing Depths for Gingivectomy and periodontal Flap Groups

Surgical treatment of cyclosporine A and Nifedipine-induced gingival enleargementJ Periodontal, 1998, 69 (7): 791-7Pilloni A, Camargo PM, Carere M, Carranza FA

Probing DepthGingivectomy Periodontal flap

Baseline 7.72 ± 0.77 7.21 ± 0.40 6 Weeks 2.04 ± 0.31 1.78 ± 0.24 6 Months 4.87 ± 0.79 2.48 ± 0.34 1 Year 6.40 ± 0.65 3.22 ± 0.65

Discussion Gingival hyperplasia is an important side affect for

people who takes Calcium antagonists ( Nifedipline ) over than three month

After treatment, good oral hygiene in preventing severe hyperplasia was supported by our finding

Gingival enlargement is more severe in area where local irritants such as plaque, defective restoration

Some hyperplastic tissue can interfere with dental occlusion and mastication

There was no significant different of probing depth in six weeks between gingivectomy and flap operation technique

Conclusion

Long term use of Nifedipine induce Gingival Enlargment

Good oral hygiene and regular maintenance can control severe gingival hyperplasia

Pocket reduction achieved by the periodontal flap may be sustained of longer period of the time than by gingivectomy techniques in the treatment of Nifedipine - induce gingival enlargement

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