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The International Journal of Periodontics & Restorative Dentistry The International Journal of Periodontics & Restorative Dentistry © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 63 Full-Mouth Disinfection as a Nonsurgical Treatment Approach for Drug-Induced Gingival Overgrowth: A Series of 11 Cases Bettina Dannewitz, Priv Doz, Dr Med Dent1 Severe forms of gingival overgrowth Jörg Kristian Krieger, Dr Med Dent2 (GO) develop predominantly through Isabel Simon, Dr Med Dent2 use of systemic medication. Drugs 3 Jens Dreyhaupt, Dr Rer Nat, Dipl-Math associated with GO can be broadly 4 Hans Jörg Staehle, Prof Dr Med, Dr Med Dent divided into three categories: anti- Peter Eickholz, Prof Dr Med Dent5 convulsants, calcium channel blockers, and immunosuppressants.1,2 The The treatment of drug-induced gingival overgrowth is compounded by the high prevalence of drug-induced GO varies recurrence rate resulting from chronic use of the medication and the persistence among medications, and a variety of of other risk factors. In this case series, the treatment outcome of a nonsurgical risk factors have been identified and periodontal therapy, according to the concept of full-mouth disinfection in 11 reviewed recently, including age and patients with drug-induced gingival overgrowth, is described. All clinical parame- sex of the patient, drug variables, con- ters improved significantly after therapy. Only 6% of teeth received further surgical treatment. The clinical situation remained stable during the recall. The present comitant medication, genetic factors, case series suggests that full-mouth disinfection might be a beneficial treatment and the inflammatory status of the peri- 2,3 concept for drug-induced gingival overgrowth, reducing the need for further sur- odontal tissues. The nature of the gical intervention. (Int J Periodontics Restorative Dent 2010;30:63–71.) relationship between plaque and the expression of GO is unclear, and con- troversy exists as to whether plaque 1Associate Professor, Department of Conservative Dentistry, Clinic for Oral, Dental, and Maxillofacial Diseases, University Hospital Heidelberg, Heidelberg, Germany; Postdoctoral accumulation is the cause or conse- Research Fellow, Department of Periodontology, Center for Dental, Oral and Maxillofacial quence of the gingival changes. Medicine, University Hospital Frankfurt, Frankfurt, Germany. Severe GO is often disfiguring and can 2Postdoctoral Research Fellow, Department of Conservative Dentistry, Clinic for Oral, Dental, interfere with both speech and masti- and Maxillofacial Diseases, University Hospital Heidelberg, Heidelberg, Germany. 3Postdoctoral Research Fellow, Institute of Medical Biometry and Informatics, University of cation. Moreover, the massive plaque Heidelberg, Heidelberg, Germany. accumulation in the gingival pockets 4 Professor, Department of Conservative Dentistry, Clinic for Oral, Dental and Maxillofacial may be a consistent source for tran- Diseases, University Hospital Heidelberg, Heidelberg, Germany. 5Professor, Department of Periodontology, Center for Dental, Oral and Maxillofacial sient bacteremia, which increases the Medicine, University Hospital Frankfurt, Frankfurt, Germany. risk of systemic infections in immuno- compromised patients, leading to pro- Correspondence to: Dr Bettina Dannewitz, Department of Conservative Dentistry, Clinic for found complications.4 Oral, Dental, and Maxillofacial Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; fax: +49-6221-56-5074; email: bettina_dannewitz@ The treatment of GO is com- med.uni-heidelberg.de. pounded by the high recurrence rate Volume 30, Number 1, 2010 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 64 resulting from chronic use of the med- 74 years (mean, 53 ± 17 years) with ening over the tangent). The second ication and persistence of other risk drug-induced GO were consecutively component measured the extent of factors. Although surgery remains the scheduled for this study. GO resulted encroachment of the gingival tissues main option for treatment of drug- from therapy with calcium channel on the labial aspect of the adjacent induced GO, alternative strategies blockers (n = 4), cyclosporine (CsA; n tooth crown and ranged from 0 (no have been investigated to either pre- = 1), or a combination of CsA and cal- clinical evidence of overgrowth) to 3 vent this unwanted effect or reduce cium channel blockers (n = 6). All (overgrowth covering three-fourths of the incidence of its recurrence.5 A vari- patients were nonsmokers. the tooth crown). Since encroachment ety of conservative approaches have at the lingual aspect could not be been proposed, including nonsurgical examined properly on the pho- periodontal treatment, antiseptic Clinical examinations tographs, scoring was limited to the mouthwashes, systemic use of antibi- labial aspect. The papillae distal to the otics, and change of medication.5 The Before therapy (baseline), at reevalua- dental arch and sites adjacent to eden- primary aim of nonsurgical therapy is tion, and at the last recall visit, the fol- tulous spaces were not measured. The to reduce the inflammatory compo- lowing clinical parameters were maximum score possible using this nent in the gingival tissue by sup- assessed: number of teeth, probing method was 5. The degree of GO was pressing or minimizing the amount of pocket depth (PPD), bleeding on prob- expressed as a mean score and as a periodontal pathogens.6 To achieve ing (BOP), plaque control record percentage in relation to the total num- this, an anti-infective regime combin- (PCR),8 and gingival bleeding index ber of gingival units per patient. ing nonsurgical mechanical therapy (GBI).9 Because of the overgrowth, it Radiographic bone loss at the begin- and a chemotherapeutic approach was impossible to measure the clinical ning of periodontal therapy was mea- called “one-stage full-mouth disinfec- attachment level reliably at most sites sured at every tooth possible using a tion” was introduced by Quirynen and at baseline. Therefore, it was not con- Schei ruler to assess the percentage of coworkers.7 This strategy attempts to sidered for further analysis. bone loss in 20% increments.11 eradicate, or at least suppress, all peri- The degree of GO was graded odontal pathogens in a short time span numerically using a modification of a (24 hours), not only from the peri- scoring system described by Seymour Therapy odontal pockets but also from all their et al.10 Since plaster models were not intraoral habitats (ie, mucous mem- available for all patients, photographs Periodontal therapy consisted of an branes, tongue, saliva). of the clinical situation were taken rou- active phase including oral hygiene The aim of this retrospective case tinely in a standardized manner and instructions, professional cleaning of series was to evaluate whether a non- magnified for monitoring the treatment all teeth, subgingival scaling and root surgical approach according to the full- phase. Moreover, the scoring system planing, and if necessary, further surgi- mouth disinfection (FMD) concept is was expanded to allow recording of all cal intervention. In patients taking CsA, effective in preventing further surgical visible interdental sites, not only the periodontal therapy was performed excision of drug-induced GO. anterior sextant. A GO score was under antibiotic prophylaxis because assigned to each interdental unit (gin- of the patient’s increased susceptibil- gival unit) and was the sum of two com- ity to infections.4 Subgingival debride- Case reports ponents. The first component mea- ment was performed according to the sured the degree of gingival thickening FMD concept, which consisted of scal- Patients by means of a 3-point scale (0 = nor- ing and root planing of all pockets mal width, 1 = thickening up to a tan- (≥ 4 mm) in two visits within 24 hours, Eleven patients (four men, seven gent drawn between the labial surfaces using sonic scalers and hand instru- women) between the ages of 23 and of the two neighboring teeth, 2 = thick- mentation under local anesthesia.7 The International Journal of Periodontics & Restorative Dentistry © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 65 Furthermore, the tongue was brushed site, discriminating between approxi- of 41.97% showing increased GO with 1% chlorhexidine gel (Chlor- mal and buccal/oral sites at posterior scores. The overall GO score at the hexamed, GlaxoSmithKline) for 1 and anterior teeth in the maxilla and reevaluation and the last recall visit was minute, the mouth was rinsed with a mandible. Data were analyzed descrip- reduced to 5.0% and 0.55%, respec- 0.12% chlorhexidine solution (Paroex, tively. Further, linear mixed-effects tively. Ninety-one gingival units of the John O. Butler) for 2 minutes, and all regression models were used to com- 105 examined in the anterior segment pockets were irrigated subgingivally pare the differences between mean (86.7%) and 90 of the 136 assessed in with the 1% chlorhexidine gel. For the PPD, PPD categories, and GO score the posterior (66.2%) showed
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