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Treatment of Drug-Induced Gingival Enlargement with Er:YAG Laser

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Treatment of Drug-Induced Gingival Enlargement with Er:YAG Laser I industry report Treatment of drug-induced gingival enlargement with Er:YAG laser Authors _Dr Blagovesta Yaneva, Professor Georgi Tomov, Bulgaria _Introduction Fig. 1 _Treatment scheme. use of drug can cause gingival enlargement According to the Classification System for Peri - odontal Diseases and Conditions (1999) 1, drug-in - duced gingival enlargement belongs to the group of presence of gingival lack of gingival gingival diseases modified by medications which enlargement enlargement are part of dental plaque-induced gingival diseases. Gingival overgrowth is associated with systemic use of anticonvulsant drugs used for treatment of – enforced oral hygiene – oral hygiene epilepsy, immunosuppressive drugs used to avoid – CHX* rinses – control examinations host rejection of grafted tissues and calcium chan - – scaling and root planing – control examinations nel blockers used as antihypertensive drugs. It was first reported by Kimball in 1939 connected to sys - temic use of phenitoin. 2 Since then, gingival en - reexamination regression largement has been reported in association of ad - ministration of several drugs including cyclosporin 3 and different antihypertensive drugs as calcium 4,5 persistence – oral hygiene channel blockers , angiotensine converting en - 6 – control examinations zyme (ACE) inhibitors and ß -blockers. Clinically, gingival enlargement is presented as periodontal surgery painless, firm, nodular expansion of interdental papilla. It is a generalised condition, but is more se - vere in the maxillary and mandibular anterior seg - ments. Gingival enlargement occurs in proximity to – large areas > 6 teeth – large areas > 6 teeth the teeth and not in toothless jaw sections. Drug-in - – intrabony pockets – suprabony pockets – insufficient attached gin - – presence of attached duced gingival overgrowth can occur in sites with giva gingiva minimal or no plaque, but it interferes with oral hy - giene and may often lead to chronic inflammation, which complicates the enlargement. In cases with secondary gingival inflammation, the gingiva is flap surgery gingivectomy bluish-red in colour, with a lobulated surface and a tendency for bleeding. 7 maintenance program maintenance program Histopathologically this condition is presented by hyperplasia of connective tissue and epithelium. There is acanthosis of the epithelium and deep ep - laser 34 I 3_2013 industry report I Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 ithelial ridges are penetrating into the subepithelial ing points are marked first with probes and then the Fig. 2 _Initial clinical situation. connective tissue. 8 The connective tissue presents incision is performed apically from these points in Fig. 3 _After professional oral hy - many blood vessels and inflammatory cells. But the coronal direction. The aim of the procedure is to giene. target cells in this disease are the fibroblasts and move out the gingival tissue above the bone crest Fig. 4 _Before gingivectomy. there is proliferation of fibroblasts and increased without touching it and without operating on the Fig. 5 _Immediately after laser gin - formation of collagen fibres. bone. The standard gingivectomy procedure is per - givectomy. formed with scalpels and periodontal knives. Fig. 6 _One day after laser gingivec - _Treatment modalities for tomy. gingival enlargement Later, other techniques were reported like tissue Fig. 7 _One week after laser gin - removal by using caustic chemicals 13 , gingivectomy givectomy. The possibility of drug substitution must be dis - by electrosurgery 14 , gingivectomy by cryosurgery 15 cussed with the physician of the patient. Subse - and gingivectomy by lasers. 16 Different types of quently, a treatment scheme as can be seen in Fig - laser systems can be used in gingivectomy proce - ure 1 should be considered (adapted from Car - dures, like CO 2, diode, Nd:YAG, and Er:YAG. All of ranza’s Clinical Periodontology). them interact in different ways with biological tis - sues depending on their wavelength. 17 _Surgical treatment The Er:YAG laser has the best absorption in water Surgical intervention is the most frequent man - molecules and thus is particularly well suited for the agement strategy for gingival enlargement caused treatment of soft tissue such as the gingiva. 18 In Fig. 8 _Six months after laser gin - by drugs. 10 Gingivectomy was firstly introduced by contrast to other laser systems, the Er:YAG does not givectomy. Robicsek in 1884 11 , but the procedure that is em - have haemostatic properties, but the healing Fig. 9 _Two months later. ployed today was first described by Goldman in process after Er:YAG laser surgery is faster, without Fig. 10 _Six months after laser gin - 1951. 12 Following the rules of the procedure, bleed - thermal damage, necrosis etc. 19 givectomy. Fig. 8 Fig. 9 Fig. 10 laser 3_2013 I 35 I industry report Fig. 11 Fig. 12 Fig. 13 Fig. 11 _Before gingivectomy. The present report deals with Er:YAG laser surgical _Management of the patients Fig. 12 _One week after laser gin - treatment of two patients with drug-induced gingival givectomy. hyperplasia. We assess the treatment results and fol - Before treatment, a written consent was ob - Fig. 13 _Two months later. low-ups, and investigate the technique to: (a) maxi - tained from the patients and their physicians re - mize the precision of the gingival surgery; (b) control ported no contraindications for dental procedures. postoperative pain after the excision of the hyper - Then, the patients were instructed for intensive oral trophic gingival tissue; (c) reduce the frequency of re - hygiene including tooth brushing two times a day, lapse in the treated area; and (d) ensure a rapid and rinsing with 0.2 % CHX solution and diluted 3 % compliant postoperative course H2O2. They were also instructed to use additional oral hygiene tools like interdental brushes and floss - _Clinical cases ing once daily. The initial treatment phase also in - cluded ultrasonic cleaning with Piezon Master 400 Two patients aged 67 and 73 with complaints of (EMS, Switzerland). Scaling and root planning with gingival enlargement were referred to the department Gracey curettes (Hu Friedy, USA) was performed in of Periodontology, Medical University, Plovdiv. Besides one week. gingival hyperplasia, they reported also bleeding gums, halitosis and inability for good oral hygiene. The pa - Persistent gingival enlargement was evident af - tients’ medical history revealed systemic use of ACE in - ter one month and laser gingivectomy was per - hibitors (Prestarium 2.5 mg and Co-Enalapril 20 formed in two to four sessions (depending on the mg/12.5 mg) for antihypertensive treatment. treated area) with one week interval between ses - sions. The intraoral examination revealed generalised, grade II gingival enlargement 20 in the anterior seg - _Laser gingivectomy ment of the mandible (case I and case II) and the max - illa (case II). There was a high score of debris and cal - Gingivectomy was performed by Er:YAG laser culus index according to Greene-Vermillion index. 21 (LiteTouch™, by Syneron Dental Lasers, Israel) at the The gingiva showed signs of inflammation as redness, following settings: 200 mJ, 18 Hz, 3-4 water spray bleeding on probing and suppuration. Halitosis was level. External bevel gingivectomy with tip (0.4 x 17 also detected. The measurement of pocket probing mm) was performed. Only 10 % Lidocaine spray was Fig. 14 _Six months after laser depth revealed deep pockets of about 7-8 mm (Figs. used for local anaesthesia. An excisional biopsy was gingivectomy. 2-14). taken during gingivectomy, which was fixed in 10 % formalin solution and referred for pathological ex - amination (Fig. 15). The level of pain and discomfort during the treatment and healing period was as - sessed by visual analog scale (VAS). _Results The Er:YAG laser ablated the soft tissue easily and effectively and the procedure was performed with lo - cal anaesthesia only. Although the Er:YAG laser does not possess good haemostatic action, there was no excessive bleeding during and after the gingivec - tomy. Healing and the patients’ subjective assess - ment were estimated one day, one week and one Fig. 14 month after the procedures. The healing process pro - laser 36 I 3_2013 industry report I ceeded without complications and side effects. Pa - Fig. 15 _Histopathological view of the tients reported score 0 in the VAS examination, which excised specimen shows stratified meant absence of pain and discomfort during and af - squamous epithelium with proliferat - ter the laser gingivectomy procedure. Pathological ing rete ridges; connective tissue examination confirmed the diagnosis gingival hyper - showing abundant plump and prolif - plasia. The tissue samples showed no thermal dam - erating fibroblasts that are spindle age in the incision area. Wound healing was fast and shaped forming a network. Few en - complete within one to two weeks. There were no side dothelial lined blood vessels are also effects or complications. Patients were monitored for observed (H&E, 60x). recurrence during a one-year period. _Discussion As a first line of treatment for the reduction of different procedures such as gingivectomy, frenec - gingival overgrowth and anticipating recurrence tomy, operculectomy, incisions, etc. 22 after surgery, drug withdrawal or substitution was considered. Surgical reduction of the overgrown In the presented cases, the gingival overgrowth tissues is frequently necessary to accomplish an was treated satisfactorily via initial periodontal aesthetic
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