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.P Post Graduate Diploma in Periodontology Periodontal Specialist Cert. Periodontic (Japan) Cert. Gingival Esthetic Reconstruction, SNUDH (Korea) Cert. Intensive Oral Implantology (H.K) Former President of Cambodian Dental Association Founder of Cambodian Society of Periodontology

Abstract
THE PURPOSE OF STUDY was to compare probing dept resolution achieved by gingvectomy and periodontal flap techniques in the treatment of nifedipine-induced gingival enlargement. Ten patients who were receiving nifedipine for at least 6 months participated in the study. Five patients were randomly to the ginvivectomy group and five patients to the periodontal flap group. Only anterior segment of the oral cavity (canine to canine) were surgical treated. Clinical measurements, including probing depths, plaque index, and gingival sulcus index, were taken at baseline, 6 weeks, 6 months, and 1 year. Result showed that probing depths were similar in six weeks in both groups after treatment, while significant differences were found for the periodontal flap group when compared to the gingivectomy group at 6 months (2.58 0.38mm versus 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 the periodontal flap may be sustained of longer periods of the time than by the gingivectomy techniques in the treatment of nifedipine-include gingival enlargement.

Gingival Enlargement
Gingival Overgrowth = Gingival Hyperplasia or Hypertrophic And/or
Inflammation Fibrotic component

Gingival enlargement results from inflammatory changes induced by

Deposition

of plaque and Calculous Systemic 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 Leukemia Granulomatous disease

gingival enlargement

Neoplastic enlargement
Benign tumors Malignant 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 Leukemia Granulomatous disease

gingival enlargement

Neoplastic enlargement
Benign tumors Malignant tumors

False enlargement

Drug-induced gingival enlargement

Anti-convulsion Immuno-supressant

cyclosporine Calcium Channel Blockers ( Nifadepine )

Drug-induced gingival enlargement

Anti-convulsion Immuno-supressant

cyclosporine Calcium 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), 1-9

P Isaakidis, M-E Raguenaud, C Say, H De Clerck, C Kim, R Pottier, S Kuoch U 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 antagonist
Calcium 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 in Cambodia

-

Norvase (A) USA Adalate (N) Fr. Nifelat (N) Amdocal plus (A) Amlopres (A) Amzel (A) Amark (A) Amlocor (A)

- Stamlo (A) - Loxen (Na) Fr. - Topdip (A) - Adipin (A) - Nipine (A) - Amlopin (A) - Medicolat (N) - Nifedipine denk (N)

Materials and Methods

Patient 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 technique

A

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 technique

Buccal

and lingual Periodontal flap were performed from mesial line angle of the first bicuspid to the mesial line angle of the contralateral 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

Results
Plaque Index
GV Flap

Base Line 6 Weeks 6 Months

12.6 4.1 9.2 3.0 10.1 2.0

11.5 4.0 8.8 3.1 9.9 1.4

Plaque Index (Oleary) and ginnigival Sulcus Index for the Gingivectory ( GV) and Periodontal flap ( Flap)

Gingival Sulcus Index GV 0.79 0.18 0.32 0.05 0.44 0.20 Flap 0.92 0.14 0.32 0.10 0.44 0.15

Baseline 6 Weeks 6 Months

Probing Depths for Gingivectomy and periodontal Flap Groups

Probing Depth
Gingivectomy Periodontal flap

Baseline 6 Weeks 6 Months 1 Year

8.12 0.77 2.00 0.31 5.00 0.80 6.40 1.02

7.82 0.40 1.98 0.24 2.45 0.38 3.30 0.65

Probing Depth 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Baseline 6 Weeks 6 Months 1 Year 2.001.98 2.45 3.30 5.00 Gingivectomy Periodontal Flap

8.12 7.82 6.40

Probing Depths for Gingivectomy and periodontal Flap Groups Surgical treatment of cyclosporine A and Nifedipine-induced gingival enleargement J Periodontal, 1998, 69 (7): 791-7 Pilloni A, Camargo PM, Carere M, Carranza FA

Probing Depth
Gingivectomy Periodontal flap

Baseline 6 Weeks 6 Months 1 Year

7.72 0.77 2.04 0.31 4.87 0.79 6.40 0.65

7.21 0.40 1.78 0.24 2.48 0.34 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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