Gingival Enlargement Management in Bir Hospital – A Case Series

An increase in size of gingiva is a common clinical condition termed as gingival overgrowth. The definite aetiology is unknown. It is classified on the basis of aetiologic factors and pathologic changes. Both localised and generalised overgrowth are encountered commonly and patients are aesthetically, socially, psychologically and functionally disturbed until they revert back to the original contour. Localised gingival enlargement frequently is inflammatory and can also be associated with systemic diseases/condition (hormonal, nutritional, allergic, nonspecific conditioned) or neoplasic and sometimes false enlargement. DIGO is a well documented side effect with the use of anticonvulsant, immunosuppressant, and calcium channel blockers. Total 3% to 84.5% of subjects taking these drugs seem to have significant enlargement. Localised overgrowth are managed by proper diagnosis followed by controlling inflammation and other causative factors before surgical excision. DIGO is managed by drug replacement and surgical excision if required after nonsurgical treatment. Gingivoplasty of gingival margin is necessary to create self-cleansing and aesthetic architecture. palpable. Erosion of teeth with plaque and calculus deposit was found. IOPAR revealed no abnormal finding. Treatment consisted of smoking cessation counselling and four visits of nonsurgical periodontal therapy. Excisional biopsy of the enlargement sent for histopathological assessment revealed chronic inflammatory lesion with no dysplasia. Histopathology report: Stratified squamous epithelium with mild acanthosis and pseudo-epithelomatous hyperplasia, fibrocollagenous tissue, edematous stroma along with diffuse chronic inflammatory cell infiltrate, lymphocyte and congested blood vessels in stroma.


INTRODUCTION
Gingival enlargement or gingival overgrowth, a common trait of gingival disease, is characterised by an increase in the size of gingiva. 1 Based on distribution, gingival enlargement can be localised (also called 'reactive lesion of the gingiva' and historically as 'epulis'), regional or generalised. 1,2 Localised gingival enlargement frequently is inflammatory rather than neoplastic. 1 Commonly, gingival disease manifests as regional or generalised gingival enlargement which might fall into one of the different types: 1 • inflammatory gingival enlargement; • gingival enlargement in mouth breathers; • fibrotic (drug induced gingival enlargement; genetic disorders associated with gingival enlargement); • conditioned gingival enlargement (hormonal; vitamin C deficiency; plasma cell gingivitis) Gingival hypertrophy could rarely be due to without apparent cause as idiopathic. 2 "Gingival enlargement" or "gingival overgrowth" is the preferred term for all medication-related gingival lesions previously termed "gingival hyperplasia" or "gingival hypertrophy." 3 Though more than 20 prescription medications are associated with gingival enlargement, the drugs associated with gingival enlargement can be broadly divided into three categories: anticonvulsants, calcium channel blockers, and immunosuppressants. 3 It can be classified on the basis of etiologic factors and pathologic changes. 4 Localised enlargements could be further divided into three sub-types, viz.,isolated, discrete or regional. "Isolated" enlargements are those limited to gingiva adjacent to single or two teeth (e.g, gingival/periodontal abscess). "Discrete" lesions are isolated sessile or pedunculated, tumour-like enlargements (e.g., fibroma/pyogenic granuloma). "Regional" enlargements refer to involvement of gingiva around three or more teeth in one or multiple areas of the mouth (e.g., inflammatory enlargement associated with mouth breathing in maxillary and mandibular anterior region). "Generalised" enlargement refers to involvement of gingiva adjacent to almost all the teeth present (e.g., drug influenced gingival overgrowth).
Drug induced gingival overgrowth (DIGO) is an adverse effect observed with three types of drugs: phenytoin, an antiepileptic; cyclosporine A, an immunosuppressant; and calcium channel blockers, such as dihydropyridines (nifedipine), diltiazem, and verapamil. 5 The prevalence rate of this disorder has been reported to vary from 10% to 50% for phenytoin; 5 8% to 70% for cyclosporine A; 6 and 0.5% to 83% for nifedipine. 7 The accurate determination of the prevalence rate in each category is difficult due to the differing indices of gingival overgrowth as gingival inflammation is one reason for difficulty in the accurate assessment of DIGO, because inflammation acts as an exacerbating factor of gingival overgrowth.
Pathogenesis of gingival overgrowth: Although the definite pathology of DIGO is not known, these disorders seem to      The surgical treatment of choice is the gingivectomy, which was first advocated for drug-induced gingival overgrowth in 1941. 10 The soft tissue wall of the pocket is excised. Perioperative haemorrhage is the main disadvantage of scalpel excision, and this can be significant in highly vascularised and inflamed overgrown gingival tissues. Electrosurgical techniques have been used in dentistry for the past 70 years.
Although such techniques produce adequate haemostasis, they have the disadvantage of causing a surrounding zone of thermal necrosis, which may impede wound healing.
Reports in the literature have confirmed delayed healing of electrosurgery wounds when compared with scalpel wound healing. 11 Flap surgery may be complicated by excessive gingival enlargement, especially in the inter-proximal space.
It would seem to be more suited for those cases of mild to moderate overgrowth associated with both bone and attachment loss.
The dental lasers may be another useful alternative treatment to conventional gingivectomy techniques. The use of laser surgery to remove excess gingival tissue has been described by a number of authors. 11 Lasers have remarkable cutting ability and they also generate a coagulated tissue layer along the wall of the laser incision which promotes healing.