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Full Mouth Disinfection As A Non Surgical Treatment Approach For

Drug Induced Gingival Overgrowth: A Series Of 11 Cases.

Bettina D et al.IJPRD 2010;30:63-71.

Shilpa Shivanand

II MDS

Introduction• Drugs associated with GO can be broadly divided into three

categories: anticonvulsants, calcium channel blockers, and immunosuppressants.

Dongari-Bagtzoglou A 2004, Seymour RA 2006• The nature of the relationship between plaque and the

expression of GO is unclear, and controversy exists as to whether plaque accumulation is the cause or consequence of the gingival changes.

• Severe GO is often disfiguring and can interfere with both speech and mastication.

• Moreover, the massive plaque accumulation in the gingival pockets may be a consistent source for transient bacteremia, which increases the risk of systemic infections in immunocompromised patients, leading to profound complications.

Guggenheimer J, Mayher D, Eghtesad B 2005

• Although surgery remains the main option for treatment of DIGO, alternative strategies have been investigated to either prevent this unwanted effect or reduce the incidence of its recurrence.

• A variety of conservative approaches have been proposed, including NSPT, antiseptic mouthwashes, systemic use of antibiotics, and change of medication.

Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA 2006

• The primary aim of nonsurgical therapy is to reduce the inflammatory component in the gingival tissue by suppressing or minimizing the amount of periodontal pathogens.

Somacarrera ML, Lucas M, Scully C, Barrios C 1977• To achieve this, an anti-infective regime combining

nonsurgical mechanical therapy and a chemotherapeutic approach called “one-stage full-mouth disinfection” was introduced by Quirynen and coworkers.

Quirynen M, Bollen CML, Vandekerckhove BNA, Dekeyser C, Papaioannou W, Eyssen H 1995

Aim• The aim of this retrospective case series was to evaluate

whether a nonsurgical approach according to the fullmouth disinfection (FMD) concept is effective in preventing further surgical excision of drug-induced GO.

Case reports - patients• 11 patients (4 men, 7 women) between the ages of 23 and

74 years (mean, 53 ± 17 years) with DIGO were consecutively scheduled for this study.

• GO resulted from therapy with calcium channel blockers (n = 4), cyclosporine (CsA; n = 1), or a combination of CsA and calcium channel blockers (n = 6).

• All patients were nonsmokers.

Clinical examinations• Before therapy (baseline), at reevaluation, and at the last

recall visit, the following clinical parameters were assessed: number of teeth, PPD, BOP, plaque control record (PCR- O’Leary), and gingival bleeding index (GBI-Ainamo & Bay).

• Because of the overgrowth, it was impossible to measure the clinical attachment level reliably at most sites at baseline.

• Therefore, it was not considered for further analysis.

• Since plaster models were not available for all patients, photographs of the clinical situation were taken routinely in a standardized manner and magnified for monitoring the treatment phase.

• Moreover, the scoring system was expanded to allow recording of all visible interdental sites, not only the anterior sextant.

• A GO score was assigned to each interdental unit (gingival unit) and was the sum of two components.

GO score• The first component measured the degree of gingival thickening

by means of a 3-point scale (0 = normal width, 1 = thickening up to a tangent drawn between the labial surfaces of the two neighboring teeth, 2 = thickening over the tangent).

• The second component measured the extent of encroachment of the gingival tissues on the labial aspect of the adjacent tooth crown and ranged from 0 (no clinical evidence of overgrowth) to 3 (overgrowth covering three-fourths of the tooth crown). Since encroachment at the lingual aspect could not be examined properly on the photographs, scoring was limited to the labial aspect. Seymour et al 1985

• The maximum score possible using this method was 5. • The degree of GO was expressed as a mean score and as a

percentage in relation to the total number of gingival units per patient.

• Radiographic bone loss at the beginning of periodontal therapy was measured at every tooth possible to assess the percentage of bone loss.

Therapy • Periodontal therapy consisted of an active phase including

oral hygiene instructions, professional cleaning of all teeth, subgingival scaling and root planing, and if necessary, further surgical intervention.

• In patients taking CsA, periodontal therapy was performed under antibiotic prophylaxis because of the patient’s increased susceptibility to infections.

• Subgingival debridement was performed according to the FMD concept, which consisted of scaling and root planing of all pockets (≥ 4 mm) in two visits within 24 hours, using sonic scalers and hand instrumentation under local anesthesia.

• Furthermore, the tongue was brushed with 1% chlorhexidine gel for 1 minute, the mouth was rinsed with a 0.12% chlorhexidine solution for 2 minutes, and all pockets were irrigated subgingivally with the 1% chlorhexidine gel.

• For the following 2 weeks, patients brushed their teeth with 1% chlorhexidine gel and rinsed with 0.12% chlorhexidine solution twice daily.

• After those 2 weeks, all teeth were polished and patients obtained further oral hygiene instructions and motivation.

Follow up• The FMD clinical situation was reevaluated 2 to 4 months

later, and if necessary, further surgical therapy was planned.• Indication for surgical gingivectomy was given in cases of

persistently increasing PPD or GO that interfered with effective oral hygiene or impaired the patient’s esthetics.

• After active periodontal therapy, all patients were included in a regular supportive periodontal treatment program at intervals of 3 to 6 months.

• All patients completed the reevaluation, but one patient was lost to follow-up.

• The remaining 10 patients were followed for a mean of 28 months (range, 11 to 71 months).

Statistical analysis• Statistical analysis was performed using a commercially

available software program.• Linear regression models were used to compare the

differences between mean PPD, PPD categories, and GO score values obtained at baseline, reevaluation, and the last recall visit.

• Differences in GBI and PCR between baseline, reevaluation, and the last recall were analyzed with the one-sample t test.

• Statistical significance was set at P < 0.05.

Results • At baseline, 11 patients had a total of 282 teeth, with a mean of

25.6 teeth per patient.• During active periodontal therapy, 6 teeth were extracted.• After reevaluation, an external gingivectomy was performed in 1

patient, which was limited to the area of the buccal aspect of the maxillary anterior teeth.

• Another 2 patients received internal gingivectomies carried out locally at the posterior teeth.

• Altogether, further surgical interventions were indicated for 17 teeth after FMD according the previously mentioned criteria.

The severity of GO, for the anterior and posterior segment in the maxilla and mandible is presented in Fig:

The changes in PPD throughout therapy regarding the different PPD categories are presented in Fig:

Regarding gingival inflammation, periodontal therapy resulted in a statistically significant reduction in the GBI (from 62.6% to 11.0%),

which further improved until the last recall visit (8.6%). The individual PCR improved as well from baseline (57.6%) to the

reevaluation (41.5%) to the last recall visit (37.4%)

Discussion • Different treatment strategies have been discussed for DIGO,

including nonsurgical approaches, application of antiseptic mouthwashes, systemic antibiotics, change of medication, and surgical intervention.

Pilatti GL 1994, Wong W 1998• The authors of two current reviews addressing treatment

options for GO, the authors concluded that surgery remains the main option, and that scalpel gingivectomy is still the treatment of choice.

Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM 2006

• As an alternative, laser gingivectomy offers some advantages, including reduced hemorrhage during excision and minimal postoperative discomfort.

Bornstein MM, Suter VG, Stauffer E, Buser D 2003• Moreover, laser excision results in a reduced rate of

recurrence compared to scalpel gingivectomy.• However, there is evidence that nonsurgical periodontal

therapy may resolve or at least reduce the severity of overgrowth and the need for surgical intervention.

Aimetti M, Romano F 2005, Hancock RH, Swan RH 1992

• Adjunctive chemical plaque removal has been used in the management of GO.

• Animal studies have shown that regular application of chlorhexidine solution in rats medicated with CsA resulted in significantly less overgrowth than in control animals.

Pilatti GL, Sampaio JE 1997• In humans, chlorhexidine has only been evaluated in the

therapy of phenytoin-induced GO, and it was found that regular use of this mouthrinse helps to reduce the recurrence rate after surgery.

O’Neil TC, Figures KH 1982

• Applying the FMD regime in patients with DIGO resulted in a statistically significant reduction of the GO and concomitantly the PPDs.

• The results after nonsurgical therapy of DIGO described in the literature are conflicting.

• Some authors concluded that a nonsurgical approach including supra- and subgingival tooth cleaning was adequate in treating DIGO.

Aimetti M, Romano F, Debernardi C 2005

• In contrast, other investigators demonstrated that oral hygiene programs or nonsurgical periodontal therapy, while of some benefit to the patient, failed to completely prevent or resolve GO.

Seymour RA, Smith DG 1991, Kantarci A et al 1991

• The patients in this study were followed for a mean of 28 months.

• The most beneficial effects occurred within 4 to 6 months post treatment and were followed by a period of stability.

• The individual plaque control improved throughout therapy but was still not optimal in most patients at the reevaluation and the last recall visit.

• However, no recurrence of GO could be observed; this may be attributable to regular professional tooth cleaning and maintenance scaling.

Conclusion • Within its limitations, the present case series suggests that

FMD is a beneficial treatment concept for drug-induced GO, combining the administration of chlorhexidine and nonsurgical scaling and root planing and thereby reducing the need for further surgical intervention.

• However, further controlled clinical trials need to be carried out to evaluate the effects of FMD in a homogenous study population.

Critical evaluation• Radiographs were taken – no records presented.• Not compared reduction in between two groups – as to

which DIGO is responding better – cyclosporin or Ca channel blocker or combination group

• No casts were present and scores were based on photographs – so enlargement grading could have been biased because palatal/lingual enlargement was not considered.

CROSS REFERENCE

I. The management of drug-induced gingival overgrowth. Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA , JCP 2006.

OBJECTIVES: This review critically evaluates the different therapies that are available to manage drug-induced overgrowth (DIGO).MATERIAL AND METHODS: This review is based on literature identified using the online databases MEDLINE and PUB MED. It is not a systematic review, but a conventional review of the relevant literature.

CONCLUSION: DIGO is a common clinical problem that often requires intervention. Non-surgical techniques can limit the occurrence of this unwanted affect, reduce the extent of plaque-induced gingival inflammation and reduce the rate of recurrence. Wherever possible this management strategy should be adopted first. Surgical treatment is often the most reliable option and scalpel gingivectomy remains the treatment of choice. Further investigations are required to develop appropriate management strategies to prevent recurrence of DIGO.

II. The efficacy of three different surgical techniques in the management of drug-induced gingival overgrowth.

Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM, JCP 2006.OBJECTIVES: The aim of the present study was to evaluate the efficacy of three different surgical techniques in both the management and effect upon rate of overgrowth recurrence of drug-induced gingival overgrowth (DIGO).MATERIALS AND METHODS: Two cohorts of patients who required surgical correction of their DIGO participated in the study. After baseline periodontal measures the patients underwent surgery. A split-mouth, crossover design was used to compare conventional gingivectomy with flap surgery (n=27), and conventional gingivectomy with laser excision (n=23). The main outcome variable was the rate of recurrence of DIGO following surgery.

RESULTS: At 6 months, there was significantly less recurrence (p=0.05) in patients treated with laser excision, compared with those treated by conventional gingivectomy. The differences in rate of recurrence of DIGO were also reflected in changes in several periodontal parameters. Flap surgery offered no advantage over conventional gingivectomy with respect to the rate of recurrence.CONCLUSIONS: DIGO can be managed by a variety of techniques. Laser excision results in a reduced rate of recurrence.