Primarily Gingival Alterations (Type I B)

In the following pages, the disorders shown below with a black dot are described and depicted.

Hormonal Complications

• Pregnancy gingivitis (p. 92)

• ˆ Gingivitis due to the “pill”

• Puberty gingivitis (p. 92)

• ˆ Gingivitis menstrualis and intermenstrualis

• ˆ Gingivitis climacterica

Medicament-Elicited Hyperplasia

• Phenytoin gingival overgrowth (p. 121)

• Dihydropyridine-induced gingival overgrowth (p. 122)

• Cyclosporine-induced gingival overgrowth (p. 123)

• Medicament combinations (cyclosporine/nifidepine, p. 124)

Gingival Overgrowth, Tumors

• Epulis (p. 125)

• Idiopathic and hereditary fibrosis (p. 126)

• Neoplasms

  • benign tumors (p. 126)

  • malignant tumors (p. 127)

Autoimmune Diseases, Desquamative and Bullous Gingival Alterations, Anomalies of Keratinization, Dermatologic Diseases

• Gingivosis (p. 128)

• Pemphigoid (p. 128)

• Pemphigus vulgaris (p. 128)

• ˆ Epidermolysis bullosa

• ˆ Exudative erythema multiforme

• Lichen (p. 129)

• Leukoplakia–precancerous lesions (p. 130)

• Oral granulomatosis (p. 130)

• ˆ Dermatomyositis, scleroderma, psoriasis etc.

Specific Infections

• Herpes (p. 131)

• Aphthae ? (p. 131)

• ˆ Toxoplasmosis

• ˆ Actinomycosis, candidiasis

• ˆ Gonorrhea, syphilis etc.

Allergies

• To medicaments

• To metals, mercury

Toxic Reactions

These may occur locally in the oral cavity through release of metal ions possessing high toxic potential, from dental materials (nickel, cadmium, bismuth, beryllium, vanadium etc; Wirz et al. 1997 a, b):

• Dental materials of varying composition

• Lead and other metals

Injuries, Chemical Injuries

Gingival and Periodontal Alterations (Type IV A/B)

Metabolic Disturbances

• Diabetes (p. 132)

• Acatalasemia (Takahara’s Disease)

• Eosinophilic granuloma

• Pre-leukemic syndrome

Nutritional Deficiency

Nutritional deficiency as a cause or co-factor in gingivitis or periodontitis is practically no longer observed in the western/northern hemispheres. In extreme conditions (e.g., in the Third World) one may observe:

• Ascorbic acid deficiency (scurvy)

• Kwashiorkor (protein deficiency) etc.

Genetically-Elicited Systemic Syndromes

It is not uncommon that rare, partially inherited systemic syndromes are characterized by severe periodontitis:

• Down syndrome (p. 134)

• Papillon-Lefèvre syndrome (p. 136)

• Chediak-Higashi Syndrome

• Hypophosphatasia (Rathbun Syndrome)

• Pelger-Huet nucleus anomaly

• Ehlers-Danlos syndrome etc.

Blood Cell Diseases

Every blood cell disorder reduces the immune response and, therewith, local defense reactions.

• Leukemia

• Panmyelopathy—Fanconi anemia

• Cyclic neutropenia

• Agranulocytosis

• Erythroblastic anemia etc.

Immune Deficiencies

Any weakening of the immune system may elicit or enhance periodontitis. Perhaps most important today is infection by the human immunodeficiency virus HIV.

• HIV infection, AIDS (p. 139)

Phenytoin-induced Gingival Overgrowth

Phenytoin (hydantoin) prevents or reduces the incidence or severity of seizures associated with most types of epilepsy (grand mal), with the exception of petit mal. Phenytoin is also often prescribed following neurosurgical operations or cranial trauma. The anticonvulsive effect is probably due to the inhibition of the spread of nerve potentials in the brain cortex (Hassell 1981).

Systemic side effects of phenytoin are relatively minor. Some bone pathology may be observed after long-term therapy. The patient’s mental capacity and reaction time may be negatively influenced (thus, no driver’s license!).

The most important oral side effect is an often pronounced and secondarily inflamed gingival overgrowth.

Therapy: Motivation, repeated oral hygiene instructions, professional plaque and calculus removal. Once inflammation subsides, fibrous tissue can be excised. Lesions frequently recur.

In collaboration with the patient’s physician, in some cases it may be possible to change to a different medication, e.g., valproic acid, benzodiazepine, barbituric acid derivatives, etc.

Dihydropyridine-induced Gingival Overgrowth

The substituted dihydropyridines (nifedipine, nitrendipine etc.) are calcium antagonists that reduce the influx of calcium ions into heart muscle and thereby reduce the strength of contraction as well as the vascular resistance. This reduces oxygen consumption by the heart while simultaneously increasing cardiac circulation. Thus, dihydropyridines exert both anti-anginal and anti-hypertensive effects. Some general side effects as well as interactions with other drugs are observed. In contrast to phenytoin, dihydropyridines are taken by primarily by older cardiac patients, who often have a pre-existing periodontitis.

The most important oral side effect is an often pronounced, secondarily inflamed gingival overgrowth. The pathogenesis of the overgrowth is suspected to be similar to that observed in phenytoin-treated individuals (connective tissue accumulation), but an increase in acid mucopolysaccharides (ground substance) also appears to occur (Lucas et al. 1985, Barak et al. 1987).

Therapy: Following patient motivation, repeated oral hygiene instruction and initial periodontal therapy, severe lesions may be eliminated surgically (gingivoplasty).

Cyclosporine-induced Gingival Overgrowth

The immunosuppressive effect of cyclosporine-A (“Sandimmune,” Novartis Co.) derives from the suppression of antibody formation against T cell-dependent antigens, the suppression of cell-mediated immunity, and interference with the production of cytokines (IL-2 etc).

Systemic side effects occur frequently: increased blood pressure, increase in body hair (hirsutism), formation of lymphoma, as well as nephro– and hepatotoxicity.

The oral manifestation of cyclosporine is the side effect of gingival overgrowth, which is usually secondarily inflamed. The incidence and severity of the gingival lesions are strictly dose-dependent and correlated to blood levels of the drug. New medicines (e.g., Prograf, Cellcept etc.) are reported to have fewer side effects.

Therapy: Good oral hygiene coupled with initial periodontal therapy can reduce both the inflammation and the overgrowth. If instituted early, such measures may actually prevent development. In severe cases, surgical gingivoplasty may be indicated. Organ transplant patients should receive comprehensive dental care before organ transplant (Rateitschak-Plüss et al. 1983a, b).

Gingival Hyperplasia Following Combined Drug Therapies

Dihydropyridine and Cyclosporine

When systemic medications are prescribed, every effort should be made to reduce adverse side effects by setting the dose as low as possible. In certain cases, the use of a combination of medications can also serve to reduce the dosage. For example, today, following organ transplantation (kidney, heart etc.), cyclosporine is often combined with azathioprine and prednisone.

On the other hand, the necessary combination of two medications that may both possess the same side effect (e.g., gingival overgrowth) may massively increase the adverse effect.

Therapy: In the case presented here, a 30-year-old male (kidney transplant), cyclosporine was prescribed. This medicament can increase blood pressure, so she was also treated with the calcium-antagonist nifedipine (p. 122). Very severe gingival overgrowth was the consequence of this co-medication. In such cases, alternative antihypertensive medications should be employed.

Benign Tumors—Epulis

Gingival epulis represents a family of benign tumors. The classification includes:

• Granulomatous epulis, pyogenic granuloma

• Giant cell epulis

• Fibrous epulis

Giant cell epulis and granulomatous epulis may develop relatively quickly; fibrous epulis grows slowly. The etiology of such tumors is not completely understood, but marginal irritation is one likely cause. Some pathologists contend that giant cell epulis is the only true epulis. It is a fact that no histologic differences exist between fibrous epulis and fibromas in other areas of the oral cavity.

Therapy: Pyogenic granuloma and fibrous epulis can be removed by simple excision.

The giant cell epulis has a tendency to recur; following excision of such tumors, a gingival flap should be reflected, the tooth (and root) surfaces thoroughly cleaned and planed, and the bone filed.