Drug induced gingival hyperplasia and it’s treatment

Background:

Drug induced gingival overgrowth (DIGO) has been traditionally treated with gingivectomy and infrabony defects with flap surgery.

Certain authors suggest that recurrence of gingival overgrowth occurs faster after gingivectomy compared to open flap debridement.

The literature was studied to answer the following questions:

1- Is OFD a better modality of treatment versus gingivectomy in infrabony defects and drug induced gingival overgrowth.

2- What are the long-term healing results of gingivectomy versus OFD in DIGO.

The following articles were reviewed:

· Proestakis G, et al. : Gingivectomy versus flap surgery: the effect of the treatment of infrabony defects. A clinical and radiographic study. J Clin Periodontol 1992; 19: 497-508.

· Pilloni A, et al. : Surgical treatment of Cyclosporine A- and Nifedipine-Induced Gingival Enlargement: Gingivectomy Versus Periodontal Flap. J Periodontol 1998; 69: 791-797.

· Ilgenli T, et al. : Effectiveness of Periodontal Therapy in Patients With Drug-Induced Gingival Overgrowth. Long-Term Results. J Periodontol 1999; 70: 967-972.

· Ramfjord S. D. and Costich E. : Healing After Simple Gingivectomy. J. Periodontol 1963; 34: 401-415.

Proestakis G, et al. compared short-term results (6 months) of gingivectomy versus MWF surgery in the treatment of infrabony defects. 14 patients with 68 bilateral infrabony defects were selected in a split-mouth study design. PlI, GI, BOP, PPD, PAL were assessed at baseline, 3 and 6 months postoperatively. Conventional and subtraction images were used to assess changes in bone level. The results indicate that infrabony defects can be successfully treated by both treatment modalities.

The following variables were not controlled in the present study: smoking, systemic health, oral hygiene, measurement errors between examiner, and use of controlled forced probing devices.

Pilloni A, et al. compared probing depth resolution achieved by gingivectomy or periodontal flap technique in the treatment of DIGO. This is a short-term study (12 months) using 10 kidney transplant patients. PD, CAL, Plaque score (O’Leary et al.), G sulcus index were measured at baseline, 6 weeks, 6 months, and 1 year. Results indicate that at 6 months and 1 year, flap surgery is more effective in maintaining reduction in PD than gingivectomy.

This study has the following short-comings: Nifedipine and Cyclosporine A DIGO don’t have the same clinical features and should not be used in the same study. The amount of Nifedipine or Cyclosporine was not taken into consideration as well as there serum level. A split-mouth study would have been a better design.

Ilgenli T, et al. evaluated the results of surgical periodontal therapy in patients receiving CsA or Ni and who exhibited severe long-term DGO. 38 patients after surgery were followed for 18 months. PlI, PBI, and DGO scores were recorded at each recall appointments. 34% of the patients had recurrence of severe DGO after 18 months following periodontal surgery. The study shows that SPT is the key for long-term success.

Ramfjord S. P. and Costich E. R. studied 10 postgingivectomy specimens in order to investigate the reaction of the periodontal tissues to simple gingivectomy. Thereis a tendency to loose attachment after the surgical procedure. One of the first article to show downgrowth of epithelium along the root surface.

Conclusions:

· Periodontal flaps result in a slower recurrence of probing depths compared to the gingivectomy technique in DIGO.

· SPT is of great importance in maintaining shallow pocket depth after surgical therapy in DIGO.

Comments:

CsA is being replaced by Prograf (tacromilus: IV, 0.15-0.3mg/kg PO daily) which does not produce gingival overgrowth. CsA can induce Lymphoma.

Azithromax may also significantly reduces gingival overgrowth.