DENT 267: LO1 LS4- Gingival Diseases Modified by Meds and Hereditary Factors

gingival diseases modified by meds: what can certain prescription drugs cause?

-gingival enlargement

-xerostomia

-candidiasis

-Lichenoid reactions

-oral contraceptive associated gingivitis

gingival diseases modified by meds: what is the AAP classification?

-drug induced gingival enlargements

-hereditary gingival enlargements (fibromatosis)

what are some factors that cause gingival enlargements?

-bacterial biofilm (inflammatory enlargements)

-mouth breathing

-bacterial biofilm & the hormonal changes

-systemic blood dyscrasias (leukemia)

-meds

-hereditary disorders (CF, sickle cell, Huntington's)

-idiopathic enlargement

-neoplasia (abnormal/uncontrolled cell growth)

-false enlargements (tori)

gingival enlargements

-drug induced: enlargement due to med

-AAP: biofilm is a co-factor

-familial tissue overgrowth: related to genetic factors

-aggravated by biofilm

-more biofilm, more severe enlargement

-excessive production of collagen

-decreased action of collagenase

-fibroblasts become sens to meds

what are preferred terms for gingival enlargements

-gingival overgrowth or enlargement rather than hypertrophy or hyperplasia

drug induced gingival enlargements: 3 types of meds

-anti-convulsant

-immunosuppressant

-calcium blocking drugs

drug induced gingival enlargement med: anti-convulsant

-dilantin (phenytoin)

-less common w/ valproate, phenobarbitone

drug induced gingival enlargement med: immunosuppressant

-cyclosporine

drug induced gingival enlargement med: calcium blocking drugs

-used for heart condition

when can enlargements show up after initiation of drug therapy

-within 1-3 months

where can medication gingival enlargements show up in the tissue

-anterior or labial tissues

what can effect the severity of dilantin related gingival enlargements

-dose, plasma level and biofilm control

what are clinical characters of dilantin induced gingival enlargements

-gingival pockets

-occlusion

-firm, fibrotic and pink

-can appear red or blush red

-little tendency to bleed if no inflammation and biofilm or increase tendency to bleed w/ inflammation

-generalized enlargement but may be more pronounced in the ants

where does gingival overgrowth begin?

-in the IP area

-enlarged papillae fuse mesially and distally and partially cover the anatomical crown

radiographic signs and histopathology of gingival enlargement

-underlying perio, may be bone loss

-previously referred to as hyperplasia

-increase in number of collagen fibres, fibroblasts, inflammatory and epithelial cells

-more dense tissues

gingival enlargement due to meds: etiology

-increase in volume due more to a CT response rather than epithelial cell involvement

-collagen and intercellular ground substance

-abnormal susceptibility to the drug

-elevated levels of certain cytokines (IL-6) may play a role in enhancing proliferation

-inflamed tissue is more susceptible to hyperplastic response

gingival enlargement associated w/ Dilantin- etiology

-reaction of gingival CT cells to Dilantin

-enlarged tissue interferes w/ OH

-genetic predisposition may play a role as well

drug induced enlargement: prognosis

-drug influenced enlargement persists as long as client is taking the med, especially if biofilm control is poor

-enlargement usually subsides if drug is discontinued

-good dietary habits support health & repair

care plan for Dilantin-induced gingival enlargements

-depends on etiology

-if no local factors or inflammation: cons physician re: possible use of another anticonvulsant

-if Dilantin is discontinued, then enlargement usually subsides in 1-2 months

-if dilantin cannot be discontinued, then gingivectomy may be indicated

-client education, debridement, biofilm control, referrals, eval, frequent & regular perio maintenance (3 months)

what else may help w/ Dilantin induced gingival enlargements

-0.12% chlorhexidine rinses or other antimicrobial rinses (Listerine) may be suggested

cyclosporine related gingival enlargements

-more common on labial and anterior

-renal/cardiac fibrosis

-usually begins in interdental gingiva

-reversible if Cyclosporine is discontinued

-more severe when local irritating factors are present

-25-30% of patients on cyclosporine, in children as high as 70%

management of cyclosporine related gingivitis enlargements

-must cons w/ physician: leukopenia (low WBC) prior to invasive tx (may need antibiotic premed) and regarding a substitute med (Tacrolimus) or decreasing the dose

-frequent maintenance

-meticulous biofilm control

-may be reversible

enlargements related to calcium channel blockers

-nifedipine (Adalat, Procardia) and diltiazem (Cardizem)

-hyperplastic changes like those seen with Dilantin induced enlargements

-prevalence rate reported is 6-15%

Nifedipine-associated gingival enlargement

-care is directed at drug substitutes, effective control of inflammatory factors (biofilm/calc), possible perio surgery, frequent continuing care

gingival lesions of genetic origin

-small % of diseases are non-dental biofilm induced

-biofilm can increase severity

-hereditary gingival fibromatosis

-AAP: non-biofilm induced but because of the enlargement, almost always biofilm present

-rare

hereditary gingival enlargements

-isolated gingival fibromatosis

-may be a component of several inherited syndromes

-localized or generalized

-AKA familial, idiopathic

-when localized, the max tuberosities and the labial gingiva around the mand molars are more frequently involved

hereditary gingival enlargements: isolated gingival fibromatosis

-autosomal-dominant trait, no other associated abnormalities

hereditary gingival enlargements: component of several inherited syndromes

-enlargement occurs early in life and within a few years, teeth are completely covered (may affect primary and permanent dentitions)

-also reported w/ deficiency in growth hormone

histological features: hereditary gingival enlargements

-non-specific (amount of collagen fibers increases and surface epithelium may thicken)

-diagnosis of hereditary gingival enlargements (look at history and clinical features)

-rule out meds, systemic conditions (hormonal, blood dyscrasias)

-family history of gingival enlargements

what can hereditary gingival enlargements look liek

-gingival pocket formation, B and L

-may be limited to just 1 arch

-pink, firm, fibrotic and no tendency to bleed

-may interfere w/ occlusion

-local irritants can superimpose inflammation

care plan for hereditary gingival enlargements

-refer to periodontist for surgery

-gingivectomy of excessive enlarged tissue & elimination of local factors

-biofilm control, client education

-frequent perio maintenance therapy

-enlargement will recur over the long term

-prevents enlargement by local factors & not familial component

neoplastic gingival enlargements

-benign (nevus, hemangioma, papilloma)

-malignant (squamous cell carcinoma, malignant melanoma)

what are false enlargements

-not true enlargements of the gingival tissues

-enlargement of bone sub-adjacent to the gingival area occurs most often w/ tori and exostosis

-can occur w/ Paget's Disease, fibrous dysplasia, cherubism

during tooth eruption, what may occur?

-false enlargement: labial gingival may show bulbous distortion caused by the superimposition of the bulk of the gingiva on the normal prominence of the enamel

-is normal