CODSJOD KL Vandana et al. 10.5005/jp-journals-10063-0030 CASE REPORT Idiopathic Gingival Enlargement with Aggressive Periodontitis Treated with Surgical Gingivectomy and 0.2% Hyaluronic Acid Gel (Gengigel®) 1Kharidhi L Vandana, 2Priyanka Dalvi, 3Neha Mahajan ABSTRACT INTRODUCTION Background: Idiopathic gingival fibromatosis is known to be In inflammatory periodontal diseases, gingival enlarge- a benign slow growing proliferation of the gingival tissue. It is ment will be a common finding. Based on the etiologic genetically heterogeneous, associated with syndromes and rarely presents as an isolated disorder. Aggressive periodontitis factors and histopathologic findings, there are several (AP) is a disorder that results in severe rapid destruction of the kinds of gingival enlargement. Gingival enlargement tooth-supporting apparatus and is also a genetically transmitted induced by drugs such as phenytoin, cyclosporine, and disorder of the periodontium. In the case of gingival enlarge- calcium channel blockers associated with systemic dis- ment there will be an excessive display of gingiva affecting the esthetic and functional problems. Gingival enlargement in orders produced by hormonal factors, leukemia, vitamin association with generalized AP is very rare. C deficiency, and idiopathic gingival fibromatosis have Case description: A 23-year-old female was reported with a been reported.1 recurrence of gingival enlargement along with generalized tooth Aggressive periodontitis (AP) is a rare condition of mobility. On detailed history, clinical and laboratory findings, periodontitis which can be localized (LAP) or generali- it was diagnosed as recurrent idiopathic gingival enlargement with generalized aggressive periodontitis. This patient has been zed (GAP) based on the clinical and laboratory findings. followed up for nearly 9 years ever since she first reported to A case may be diagnosed as AP if it presents with the us in the year 2004 with a similar finding. Treatment included major common features2 like non-contributory medical extraction of teeth with a hopeless prognosis, through phase I history, rapid attachment loss, bone destruction, and therapy, local drug delivery of gengigel® 0.2% hyaluronic acid, gingivectomy using electrocautery, follow up visits and pros- familial aggregation, according to the 1999 International thetic rehabilitation using a treatment partial denture. classification workshop. Secondary features that are gen- Conclusion: In generalized AP, rapid destruction of periodontal erally present but may not be seen with AP include; the tissues can be prevented by early diagnosis. Also, diagnosis amount of microbial deposits inconsistent with the sever- of GAP can be complicated by associated conditions like gin- ity of periodontal destruction; the elevated proportion of gival enlargement. Therefore the diagnosis should be based on complete history radiographical microbiological and clinical Aggregatibacteractinomycetemcomitans (Aa); phagocyte findings. The use of local application of agents such as Gen- abnormalities, hyper-responsive macrophages, producing ® gigel is recommended to improve the periodontal condition. increased PGE2 and IL and in some cases, self-arresting Keywords: Aggressive periodontitis, Gingival enlargement, disease progression. Gingivectomy, Gengigel®, Local drug delivery. The GAP represents the most heterogeneous group How to cite this article: Vandana KL, Dalvi P, Mahajan N. and includes the most severe forms of periodontitis pre- Idiopathic Gingival Enlargement with Aggressive Periodontitis Treated with Surgical Gingivectomy and 0.2% Hyaluronic Acid viously diagnosed as generalized juvenile periodontitis, Gel (Gengigel®). CODS J Dent 2017;9(1):36-40. GAP may be diagnosed based on findings:3 persons Source of support: Nil under 30 years (however maybe older), generalized Conflict of interest: None interproximal loss of attachment affecting at least three permanent teeth other than first molars and incisors, pronounced episodic nature of periodontal destruction and poor serum antibody response to infecting agents. 1Senior Professor, Former Associate Dean, 2Postgraduate Student, 3Senior Lecturer Some patients of GAP may present with systemic mani- 1,2Department of Periodontics, College of Dental Sciences, festations such as weight loss, depression and general Davangere, Karnataka, India malaise.2 3Department of Periodontics, Himachal Dental College, Himal- chal Pradesh, India The GAP usually presents as severe acute gingival Corresponding Author: Kharidhi L Vandana, Senior inflammation associated with bleeding on probing; pink Professor, Former Associate Dean, Department of Periodontics, gingival tissues, free of inflammation and occasionally College of Dental Sciences, Davangere, Karnataka, with some degree of stippling seen.4 Gingival enlarge- India e-mail: [email protected] ment is an infrequent finding in a case of GAP. 36 CODSJOD Idiopathic Gingival Enlargement with Aggressive Periodontitis Treated with Surgical Gingivectomy and 0.2% Hyaluronic Acid Gel It is not always possible to identify the precise cause of cularly in molars and incisors for three weeks. Gengigel®, gingival enlargement. The following report will present i.e. 0.2% hyaluron gel has an anti-inflammatory and anti- a case of GAP with gingival enlargement and discuss its oedematous effect and promotes wound healing Studies periodontal management by surgical and local delivery have asserted that application of gengigel® or hyaluron of 0.2% hyaluronic acid gel (Gengigel®). gel (0.2%) in adjunct to scaling root planning may have beneficial effect on periodontal health in patients with CASE REPORT chronic periodontitis. The anti-inflammatory effect of HA The patient was an Indian girl, 23 years of age, who occurs by its action of de-activating bacterial hyaluroni- consulted for the treatment of recurrent gingival enlarge- dases, normalizing the macro-aggregation of connective ment, increased spacing and mobility in her teeth. She tissue proteoglycans, and bonding with free water, thus was systematically healthy, and there was no history of causing an anti-edema effect. Also HA is a natural and any drug intake. She had no habit of drinking or smoking, essential extracellular matrix substance that promotes and her family history did not reveal any significant healing by stimulating angiogenesis, has bacteriostatic information related to her present condition. Episode and antiseptic properties, maintains the structural integ- of gingival enlargement had occurred in the year 2004, rity of the tissues, regulates hydration of tissues and cell when she was 14 years old she reported with swollen physiology, protects the tissues by formation of a barrier, gums of the left side of both upper and lower jaws since stimulates pro-inflammatory cytokines production, regu- three years which was gradual on onset, inability to chew lates the phagocytic migration, prevents colonization of food from that side, bleeding gums while brushing teeth bacteria, stimulates granulation tissue formation and and bad breath since 2 to 3 months. Inspectory findings healing, interacts with growth factors for the develop- were confirmed on palpation. The details of findings are ment of mineralized and non-mineralized tissues, and is listed in Table 1. locally absorbed when applied to tissues.5 The gingival She underwent thorough phase I therapy, extraction condition of the patient improved following professional of hopeless teeth, internal bevel gingivectomy, and use care and maintenance therapy. The patient was referred to of electrocautery permitted adequate contouring of the Department of Prosthodontics for occlusal rehabilitation. tissues with periodic revaluation, and the case was fol- A treatment partial denture replaced the extracted teeth. lowed up for 2 years with regular supportive periodontal DISCUSSION therapy and instructions to report if any recurrence of This paper reports superimposition of recurrent idiopathic any gum enlargement. gingival enlargement in a patient with generalized AP. The The condition resolved after professional care and patient reported with swollen and bleeding gums 9 years maintenance by the patient. The gingival enlargement ago. In the present case, the patient was systematically reappeared after the treatment for which the patient tried healthy and under no medication which could contribute to avail treatment from non-institutional doctors but in to gingival overgrowth. She also did not give a history of vain. The patient failed to report for regular follow-ups pregnancy. General physical examination of the patient later until she reported again in the year 2013 with a revealed no syndromic association which could con- similar chief complaint of swollen gums and inability tribute to gingival overgrowth. The clinical, histopatho- to chew food. logical features and systemic examination exclude the The details of the clinical findings and the treatment diagnosis of an enlargement of neoplastic origin. Gingival at different periods are listed out in the Table 1. enlargement is also associated with scurvy;1 however, our patient did not present with other signs of scurvy Treatment Planning (Table 1) such as petechiae, ecchymosis or spontaneous bruising Periodontal treatment planning included internal bevel of the extremities. All the hematological investigations gingivectomy for the gingival enlargement and was were within normal limits. Histopathological examina- explained to the patient. The patient was given proper