3: Drug‐Induced Gingivitis

Case 3
Drug‐Induced Gingivitis

Medical History

A medical history related to calcium channel blocker medication would be a patient with hypertension taking medication such as nifedipine commonly known as Procardia.

A medical history related to anticonvulsant medication would be a patient who suffers from seizures or diagnosed with epilepsy. The most common drug taken for this condition is phenytoin also known as Dilantin.

A medical history related to immunosuppressants would be a patient who has received an organ transplant. A commonly used medication to prevent organ rejection is cyclosporine. Brand names for cyclosporine are Gengraf, Meoral, and Sandimmune (Lexicomp 2016).

Immunosuppressant medications may be prescribed for autoimmune conditions such as rheumatoid arthritis, Crohn’s disease, lupus, and immune thrombocytopenia (Lexicomp 2016). Immunosuppressant medications for these conditions include methotrexate or azathioprine.

Dental History

There are various dental histories depending upon the patient’s history. These may include restorations, missing teeth, and or broken teeth, orthodontia, and lack of care due to the patient’s medical condition. Medications that cause drug‐induced gingivitis may also cause xerostomia. Xerostomia can precipitate dental conditions such as dental caries. A thorough review of the patient’s dental history will be necessary for accurate caries and periodontal risk assessments.

Assessments

Periodontal Assessment

Gingival Statement: Gingival descriptors for drug‐induced gingival enlargement will vary depending upon the oral condition and may include generalized gingival enlargement; localized papillary enlargement; fibrotic, firm, and stippled gingiva. If associated with plaque accumulation the gingival descriptors may include the above gingival enlargement with marginal or papillary redness, edema, and bleeding.

Pocket depths will vary according to the patient’s conditions. Pockets associated with drug‐induced gingival enlargement may be pseudo pockets if there is no clinical attachment loss. An indication of this would be that the junctional epithelium attachment is at the level of the cementoenamel junction, the probe tip is on the enamel and the gingival growth is covering the enamel and tooth crown. A periodontal pocket would indicate the probe tip is on the cementum or dentinal surface and is associated with clinical attachment loss and bone loss.

Radiographic Findings

Bone loss would be dependent upon the individual patient’s condition and can range from none to severe.

Risk Assessments

  • Caries – dependent upon findings, history, modifiable, and non‐modifiable factors
  • Periodontal – dependent upon findings, history, modifiable, and non‐modifiable factors

Problem List

  • Gingival enlargement (see Figure 2.3.1)
  • Probing depths
  • Bleeding
  • Dental findings may include: missing or broken teeth, caries, crowding
Image described by caption.

Figure 2.3.1: Phenytoin‐induced gingival enlargement (Darby and Walsh 2015, p. 882).

Dental Hygiene Diagnosis

Unmet human need Evidenced (caused) by Signs/Symptoms
Freedom from health risks Medications/health condition requiring medical consult Need for prophylactic antibiotics
Uncontrolled hypertension
Biologically sound and functioning dentition Risk factors for dental disease Teeth with signs of disease
Broken teeth
Skin and mucous membrane integrity Risk factors for periodontal disease
Presence of plaque accumulation
Medication
Probing depths
Bleeding
Enlarged gingiva

Planned Interventions

Interventions Goals Evaluation
Medical consult The patient will return to primary health‐care provider for evaluation of condition Continuation of planned care
Consultation on medications – dependent on outcomes
Education Patient will understand the disease condition and relationship to medication Patient will schedule appointment for follow up with medical personnel
Intraoral photos and risk assessments, caries prevention (xylitol, fluoride, amorphous calcium phosphate [ACP] interventions),
Education on prevention for broken teeth
Schedule appointment with dentist for exam and treatment plan
Schedule appointment with hygienist for care planned
Appointment scheduled
OHI toothbrushing instruction Patient will demonstrate the proper brushing method Immediate + next visit by reduction of PCR
6–8 weeks re‐evaluation or 3–4‐month recare visits
Prophylaxis or non‐surgical periodontal therapy Patient will schedule appointment for care planned
Reduction of pocket depths, gingival enlargement
Appointments scheduled
6–8 weeks re‐evaluation or
3–4‐month recare visits

Appointment Schedule

The appointment sequence may vary depending upon the necessity for a medical consult. Inclusion of the medical and dental team for planning the patient’s care may increase overall outcomes of the care provided.

Discussion

Assessments should start with a thorough review of the patient’s medical history. Patients with a complex medical history may be taking multiple medications and as such drug interactions should be noted. Oral side effects and side effects related to dental treatment will assist the practitioner in developing an appropriate dental hygiene diagnosis and care plan based on the patient’s need. It is good practice to review all medications patients are taking. An example of a medication summary form is Table 2.3.1. When looking at the side effect for medications one can see that all the medications listed cause gingival hyperplasia. See Table 2.3.1 to review the medications discussed in the case (Lexicomp 2016).

Table 2.3.1: A medication summary form for reviewing patients medications and summarizing drugs reactions, side effects, and dental considerations to be used in formulating a dental hygiene care plan.

Source: Lexicomp (2016).

Date Medication and Dosage Prescribed for Side Effects/Adverse Reactions Drug Effects of Concern to Dentistry Dental Considerations
02/16/15 Sandimmune (cyclosporine) 1–3 mg day−1 Antirejection organ transplant Hypertension, headaches, susceptible to infection, gingival hyperplasia Mouth sores, swallowing difficulty, gingivitis, gingival hyperplasia, xerostomia, abnormal taste, tongue disorder, and gingival bleeding Caries, bleeding with procedures, no special precautions with local anesthetic/vasoconstrictors, gingival overgrowth
2/16/15 Procadia (nifedipine) 30 or 60 mg day−1 High blood pressure Flushing, dizziness/lightheaded Gingival hyperplasia Orthostatic hypertension – sit up slowly, no special precautions with local anesthetic/vasoconstrictors, gingival overgrowth
2/16/15 Dilantin (phenytoin Epilepsy Cardiac arrhythmias, cerebral dysfunction, dermatitis Gingival hyperplasia No special precautions with local anesthetic/vasoconstrictors, no information available on bleeding that require special precautions

Assessments should include a medical and dental history, social, and cultural factors, activities of daily living, extraoral and intraoral examinations, gingival statement, periodontal assessment, plaque and bleeding indices, risk assessments, and radiographs. Through the interview process the clinician can assess risk for developing caries and periodontal diseases and structure planned interventions related to these risks.

Clinical findings for drug‐induced gingivitis may include: interdental papilla gingival overgrowth predominantly on the facial surfaces, fibrotic lobulations, and dependent upon plaque accumulation, gingivitis. See Figure 2.3.1 for an example of the lobulations associated with phenytoin induced gingival enlargement.

For this particular patient group focusing on a primary unmet human need would be freedom from health risks. Darby and Walsh define this as the need to avoid medical contraindications to dental hygiene care (Darby and Walsh 2015). Protecting the patient’s health is central to our code of ethics. Nonharming or do no harm is an obligation of every health‐care provider. Keeping this as the primary dental hygiene diagnosis will ensure the patient’s safety.

Protection from health risks for the patient taking antirejection medications may include a medical consult prior to any dental hygiene care. Organ transplant patients can be immunocompromised and require antibiotic prophylactic coverage prior to any care. They are most likely on multiple medications with various side effects and considerations prior to dental treatment will eliminate complications or medical emergencies. Consultation with medical providers will assist the dental hygienist with developing interventions related to the patient such as the oral effects of multiple medications and the effects that dental hygiene care may have on the patient that is immunocompromised.

For patients taking medication for hypertension, the dental hygienist will need to establish through the patient interview and taking the patients vital signs if the condition is controlled. Uncontrolled hypertension can lead to emergencies in the dental office. Other protection considerations during the dental hygiene appointment are sitting the patient up slowly and having them sit for a few minutes after care will help prevent orthostatic hypertension. Recommendations such as changing hypertensive medication or structuring more frequent dental hygiene care visits are possibilities when evaluating outcomes.

For patients taking Dilantin, knowing triggers for a seizure and the date of their last seizure to determine if they are controlled or not will help to protect the patient during their dental hygiene appointment and help prevent or prepare for any likely emergencies that may occur.

A thorough review of the patient’s history and any medical consultations can decrease the incidence of these emergencies. Focusing on patient‐centered care and protecting the patient from health risks related to dental hygiene care is essential. Communication with the patient is important. Keeping them informed regarding why and how this affects their health will have a positive impact on the patient and their treatment.

The next dental hygiene diagnosis chosen was biologically sound and functioning dentition. Darby and Walsh describe this as the need to have intact teeth and restorations. Dentition that functions properly aids in chewing and digestion. Preventing the progression of dental disease can result in the prevention of pain and another dental hygiene diagnosis. Broken teeth as a result of a seizure can also be considered in this dental hygiene diagnosis. Another diagnosis for broken teeth would be change in the facial image if they were located in the anterior region and prevented the patient from smiling or feeling confident.

Planned interventions for biologically sound and functioning dentition would involve the patient scheduling with the dentist. The level of destruction or pain involved would determine the sequence for appointment scheduling. At this point the dental hygienist would provide appropriate patient education and interventions for prevention such as fluoride and home‐care procedures. Evaluation includes following up to reinforce the need for dental care.

The last dental hygiene diagnosis of skin and mucous membrane integrity of the head and neck may or may not be evidenced by plaque accumulation. The determination of plaque accumulation as related to gingivitis and gingival enlargement will determine the interventions needed. Gingival enlargement may be ameliorated by removal of local factors, frequent maintenance, and meticulous self‐care but these interventions will not completely eliminate the condition. Establishing realistic goals and evaluation timelines is important.

Interventions will be dependent upon the problem list, signs and symptoms, and causes. Aligning the diagnosis with interventions and outcomes or goals will ensure comprehensive care for the patient and can include: detailed oral hygiene instructions, patient education on the relationship of medication and gingival enlargement, and specific rationale for planned treatment. Interventions may range from a prophylaxis to nonsurgical periodontal therapy. Many of the gingival conditions may not be reduced after dental hygiene care or oral hygiene interventions and incorporating referrals in the care plan should be considered. A referral to a periodontist for evaluation of gingival and periodontal conditions beyond the scope of a dental hygienist may be required. Referrals to the primary care provider and discussions of conditions as they relate to the patient may help improve outcomes.

Beginning with the dental hygiene diagnosis of freedom from health risks will eliminate any risks related to care and reduce the incidence of medical emergencies. Having the ability to proceed safely will allow the health‐care provider to focus on subsequent dental hygiene diagnoses and planned care.

Take‐Home Hints

  • Remember dental professionals are health‐care providers, keep the patient’s other health‐care providers informed of your findings.
  • An intra‐ and interdisciplinary approach is in the best interest of the patient.
  • Interventions can include a variety of procedures, education, and oral hygiene instructions dependent on the problem list, signs and symptoms, and evidence.

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 3: Drug‐Induced Gingivitis
Premium Wordpress Themes by UFO Themes