Gingival Overgrowth GN PDF

Gingival Overgrowth Julie Watson  GDC learning Outcomes 1.1 1.1.1 1.9.1 1.1.2 1.10.2. 1.1.3 1.10.3 1.1.4 1.10.4 1.1.11 1.10.5 1.2.2 3.1 1.2.3 3.2 1.2.4 5.2 1...

Gingival Overgrowth Julie Watson  GDC learning Outcomes 1.1 1.1.1 1.9.1 1.1.2 1.10.2. 1.1.3 1.10.3 1.1.4 1.10.4 1.1.11 1.10.5 1.2.2 3.1 1.2.3 3.2 1.2.4 5.2 1.5.3 6.1 1.7.1 6.2 1.7.3 6.3 2 Forma9ve Assessment. Please complete the following 2 pieces of work. Compile a mind map @tled; “The management of the pa@ent presen@ng with drug induced gingival overgrowth” Complete the Gingival Overgrowth Workbook *Work to be returned to Mrs Watson 3 Aim The aim for todays lecture on Gingival Overgrowth is to bring awareness of this condi@on to you. To cover the causes, implica@ons to us as clinicians. How we can assist our pa@ents with this condi@on. 4 Learning outcomes List the ClassiTca@on of Gingival Overgrowth and state the areas in the Iden@fy the clinical features mouth where this may associated with gingival present overgrowth Evaluate the impact of Categorize the poten@al gingival overgrowth to the causa@ve factors of gingival health of the oral cavity overgrowth and well-being of the Select appropriate pa@ent assessment measures of Recommend the poten@al pa@ents presen@ng with management of pa@ents gingival overgrowth with this condi@on.  The overgrowth is chronic and Gingival Overgrowth slowly increases in size. Gingival enlargement or Is pain free. overgrowth is the prolifera@on and intensiTca@on of the gingiva. If removed surgically, it tends to reoccur. It is a common place clinical problem, usually associated with speciTc condi@ons. Spontaneous disappearance Typically, it occurs in areas happens within a few months where teeth are present, not in aZer discon@nua@on of the edentulous spaces, and the drug. overgrowth disappears in areas should a tooth require extrac@on. 6  ALWAYS USE GINGIVAL OVERGROWTH AS A TERM, NOT HYPERPLASIA Overgrowth/Enlargement V Hyperplasia What is the diCerence? The terms hyperplasia and hypertrophy have been used in the past to describe this condi@on. However, these are not precise descrip@ons of gingival enlargement because these terms require an histological analysis of a @ssue sample. Biopsy Hyperplasia Images, Stock Photos & Vectors | Shu ^erstock 7 Enlargement may be cause by 1 or more of these pathological processes 3.Cellular Hyperplasia 2. Fibrosis – – an increase an in the number of individual accumulation of 02 cells. collagenous connective tissue Enlargement 01 03 4.Oedema – A 1. Cellular collection of an Hypertrophy – abnormally large an increase in amount of 8uid in 04 the size of the the intercellular individual cell. spaces.  INFLAMMATORY Chronic — could be due to OH, restorations, ortho — continual irritation Lots of reasons why gingival overgrowth might happen ENLARGEMENTS Acute — gingival abscess Important to take medical history – CHRONIC & ACUTE FALSE ENLARGEMENT- NOT TRUE ENLARGEMENT BUT APPEAR AS AN INCREASE IN SIZE DRUG INDUCED DUE TO ENLARGEMENT UNDERLYING OSSEOUS OR CLASSIFICATION DENTAL TISSUES. – TORI/GRNAULOMA OF GINGIVAL OVERGROWTH Generalised or localised ENLARGEMENTS Often associated with systemic disease NEOPLASTIC ASSOCIATED Hormonal/pregnancy/nutritional (Vit C), autoimmune disease ENLARGEMENT – WITH SYSTEMIC Malignant — carcinoma etc. GINGIVAL DISEASES AND Benign — granulomas, cysts etc. TUMOURS CONDITIONS 9 Gingival Enlargement can be further classiVed by; Loca9on or Distribu9on 10  Could be pregnancy related, could be acute or chronic Fibrous or floppy Might be able to probe under or not Need to be able to help patient, aid with oral hygiene education to patient — single tufted brush Localised Limited to the gingiva adjacent to a single tooth or group of teeth. 11 Intechopen.com  Drug induced — but can never assume without speaking with patient and taking medical history More bolbus Interdental papillae very inflamed and along gingival margin Always describe what you can see Specific oral hygiene instruction required to patient — brush and single tufted to start to get underneath gingival overgrowth Generalized Involving the gingiva throughout the mouth. 12 gskhealthpartner.com  Could be long term plaque not being removed, underlying medical conditions Can never identify cause without asking patient and taking medical history Oral hygiene instruction — precise and accurate toothbrushing on gingival margin Should see response with just oral hygiene instruction Marginal ConTned to the gingival margins. 13 Image from Google March 21  Growth of interdental papilla Could be chronic — not painful Might be fibrous Might be drug induced or underlying medical condition Need to decrease plaque as it makes initial issue worse Good oral hygiene instruction required Papillary ConTned to the interdental papilla. 14 Image from Google March 21 Discrete An isolated enlargement, such as an abscess. Might be perio endo lesion and require local anaesthetic and sub gingival PMPR 15 En.wikipedia.org  Whole gingiva looks stretched and solid Most likely medical condition Oral hygiene wont change this but good oral hygiene in important to manage condition and not make worse by plaque stagnation. DiCuse Involving the gingival margins, a^ached gingivae and interdental papillae. 16 Image from Google March 21  There is a scoring guide for gingival enlargement. This is something which could be incorporated into the body of contemporaneous note keeping. It would allow a record of progression or reduc9on of this condi@on. 17  Gingival enlargement scoring guide No signs of gingival enlargement. 0 Enlargement conVned to the 1 interdental papillae. Enlargement involves papilla and 2 gingival margins. 3 Covers more than ¾ of the tooth Gingival overgrowth scoring guide 19 [email protected]  INFLAMMATORY ENLARGEMENTS – CHRONIC & ACUTE FALSE ENLARGEMENT- NOT TRUE ENLARGEMENT BUT APPEAR AS AN INCREASE IN DRUG INDUCED SIZE DUE TO ENLARGEMENT UNDERLYING OSSEOUS OR DENTAL TISSUES. CLASSIFICATION – TORI/GRNAULOM OF GINGIVAL A OVERGROWTH ENLARGEMENTS NEOPLASTIC ASSOCIATED ENLARGEMENT – WITH SYSTEMIC GINGIVAL DISEASES AND TUMOURS CONDITIONS 20 What we are going to concentrate on today is Drug Induced Gingival Overgrowth D I G O 21  DRUG INDUCED GINGIVAL OVERGROWTH DIGO Manifests as abnormal growth of the gingiva due to an adverse drug reac@on, it occurs as a side eaect following the administra@on of systemic drug use. It is exacerbated by pa@ents with a gene9c predisposi9on, the presence of plaque or gingival in[amma9on. 22 Image from Google March 21  Drug Groups Associated with DIGO The groups of drugs that mainly cause DIGO are: An@ Convulsants Immunosuppressants Calcium Channel Blockers High blood pressure 23 Image from Google March 21  Down’s syndrome - side effect can be epilepsy ANTI CONVULSANTS These are a group of drugs used for the treatment of epilep@c pa@ents. In the main The Trst an@-epilep@c drug was introduced in 1938. Within a year of its introduc@on for clinical use DIGO was reported. It is suspected that up to 50% of pa@ents who are taking An@ Convulsant medica@on will present with DIGO. Younger pa@ents appear more suscep@ble. DIGO becomes clinically no@ceable within 2 to 3 months aZer ini@al administra@on, and reaches its maximum severity at 12 to 18 months. 24 Image from Google March 21  ANTI CONVULSANTS DRUGS Not full list — always changing MEDICAL CONDITIONS Phenytoin Ethatoin Downs Syndrome Sodium Valproate Parkinson’s Disease Phenobarbitone Epilepsy Vigabatrin Essen@al Tremor Primidone Mephenytoin Ethosuximide Methosuxinimide * Not an exhaus@ve list 25  Speak with patient Might be able to put on alternative medication, ask patient to go back to GP to ask if possible Within dental therapist remit Severe — grade 3 An9 Convulsant DIGO Phenytoin drug induced Gingival overgrowth 26 Casereports.bmj.com  No signs of gingival enlargement. 0 Enlargement conVned to the 1 interdental papillae. Enlargement involves papilla and 2 gingival margins. 3 Covers more than ¾ of the tooth  Speak with patient Might be able to put on alternative medication, ask patient to go back to GP to ask if possible Within dental therapist remit IMMUNOSUPPRESSANTS These are a group of drugs which are widely used for the preven@on of transplant rejec@on as well as for management of a number of auto immune condi@ons. The gingiva appears more vascularised than with an@ Convulsants. Ciclosporin, Tacrolimus and Sirolimus are some of the immunosuppressant’s that cause DIGO. The most common being Ciclosporin. One study found the incidence of gingival overgrowth to be nearly 53% in pa@ents with renal transplants on Ciclosporin. 28 Dir.indiamart.com Tacrolimus another immunosuppressant some@mes used in place of Ciclosporin causes less hepatoxicity and renal toxicity and although DIGO is s@ll evident, appears less severe. Ciclosporin induced gingival overgrowth appears to be more prominent on the labial surface. It is hyperemic, soZ and has a higher bleeding tendency and gingival overgrowth is considerably higher should a pa@ent be taking a combina@on of Ciclosporin and Amlodipine/Nifedipine. astellas.com 29  IMMUNOSUPPRESSANTS DRUGS MEDICAL CONDITIONS The 3 that are most common to cause DIGO Ciclosporin organ transplant Tacrolimus inkammatory bowel disease Sirolimus crohns disease ulcera@ve coli@s rheumatoid arthri@s ankylosing spondyli@s * Not an exhaus@ve list 30 Immunosuppressant DIGO Grade 3 Ciclosporin drug induced Gingival overgrowth 31 Clinmedjournals.org CALCIUM CHANNEL BLOCKERS This group of drugs is widely used and is common place. They are used in the management and treatment of; Hypertension, Angina Pectoris, Peripheral Vascular Disease, Cardiac Arrhythmia and Coronary Artery Spasm to name a few. Calcium channel blocker induced gingival overgrowth appears to be more prominent in the papillary region resul@ng in a nodular/lobular morphology extending to the a^ached and marginal gingiva. These will be encountered regularly when taking a medical history. 32 Ukmeds.co.uk  Speak with patient Might be able to put on alternative medication, ask patient to go back to GP to ask if possible Within dental therapist remit CALCIUM CHANNEL BLOCKERS DRUGS MEDICAL CONDITIONS Amlodipine hypertension Felodipine gastro oesophageal rekux disease Nicardipine Hydrochloride arrhythmias Nifedipine angina Verapamil Hydrochloride peripheral vascular disease Dil@azem Hydrochloride coronary artery spasm Cardizem Dilacort 33  Can happen very fast When patients come off medication or change the gingival may not return to normal knife stippled edge — may require surgery (gingivectomy) Calcium Channel Blocker DIGO Amlodipine drug induced Gingival overgrowth 34 Jcrsmed.org Aesthetic concerns Functional difficulties (eating) Painful to eat/brush No pleasure in eating Complica9ons Due To DIGO Effects speaking due to taking up room in mouth Increased caries risk Increased periodontal disease risk Teeth movement due to pressure of gingival overgrowth Mouth breathing due to gingival overgrowth causing patient not able to close mouth fully. This then leads to xerostomia No natural cleansing due to overgrowth and xerostomia Halitosis Low self esteem Poor oral hygiene Thinking hats Underlying condition that takes priority Push back from GPs when trying to change medications on! 35 ProoZhatblog.com  Most exacerbating factor is plaque that we need to remove and educate patient how to remove at home Exacerba9ng factors 36 Image from Google March 21 THANK YOU! 37 Further Reading h^ps://www.ncbi.nlm.nih.gov/books/NBK538518/#:~: text=Drug%2Dinduced%20gingival%20overgrowth%20(DIGO,not%20t he%20intended%20target%20organ. h^ps://pubmed.ncbi.nlm.nih.gov/8724703/ h^ps:// www.researchgate.net/publica@on/295402193_Drug_induced_gingiv al_enlargement h^ps ://www.slideshare.net/dimpunani/drug-induced-gingival-enlargemen t h^ps:// 38 eaom.eu/wp-content/uploads/2020/03/DRUG_INDUCED_GINGIVAL_  h^ps://www.nature.com/articles/sj.bdj.2017.71/tables/1