**4.4 Treatment**

The treatment of gingival enlargement is based on the understanding of the cause and underlying pathology. The treatment differs for each type of enlargement

**Figure 10.** *Fibroma.*

based on the clinical and pathological signs and symptoms. The phase I therapy should be instituted before any surgical therapy.

#### **4.5 Treatment protocol**

The treatment protocol varies with each type of enlargement. Combinations of surgical and nonsurgical therapy are prevalent; used according to the need of the patient. The functional and esthetic demands should also be kept in mind.

#### *4.5.1 Chronic inflammatory enlargement*

These are presented as soft and edematous gingival tissues. The color changes are prominent with visibly reddish hue of the tissue. Bleeding is spontaneous. The therapy consists of thorough scaling and root planing and complete debridement of deposits [26]. This leads to shrinkage of tissue, slight if not complete.

Chronic gingival enlargement may also show fibrotic components; hence complete shrinkage of the tissue does not happen in such cases. Once the Phase I therapy has been instituted and gingival tissue does not return back to normal stage, surgical therapy should be considered. The surgical therapy consists of either gingivectomy procedures or/and flap operation. If the tissues are soft and edematous gingivectomy procedures are preferred. If the tissues are firm and fibrotic preferred treatment options is flap operation. The conservation of the keratinized, attached gingiva must be considered along with removal of the excessive gingival tissue [26].

During surgical procedure, the tissue is separated from the mucosa at its base by using a surgical blade. If the lesion extends interproximally, the interdental gingiva is included in the incision to ensure the exposure of deposits and form scalloped contour of gingiva. After complete removal of enlarged tissue and adequate accessibility, the root surfaces are scaled and planed, and the area is irrigated. A periodontal dressing is applied which is removed after a week. Depending on the extent of the surgery, the postoperative appointment may have to be scheduled in 2 weeks to allow for further healing. The healing is through secondary intention in gingivectomy. In case of flap operation healing is through primary intention. After removal of excess tissue and elevation of mucoperiosteal flap, roots surface are debrided and sutures are given [6].

#### *4.5.2 Periodontal and gingival abscesses*

Periodontal and gingival abscesses results in acute enlargement of gingival which is usually localized around the area of the lesion, and the content of the enlarged area is purulent material, which must be drained and the area curetted. Drainage should be either from periodontal pocket or external incision [6].

#### *4.5.3 Drainage through the periodontal pocket*

The peripheral area around the abscess is adequately anesthetized. The pocket wall is gently retracted using a periodontal probe or curette in an attempt to initiate drainage through the pocket entrance. Gentle digital pressure and irrigation may be used to express the exudate and drain the pocket. Curette is inserted into the pocket entrance to establish drainage. Thorough scaling and root planing is done. If the lesion is large and drainage cannot be established, root debridement by scaling and root planing or surgical access should be delayed until the major clinical signs have abated. Prophylactic antibiotics should be given. Antibiotic therapy alone without subsequent drainage and subgingival scaling is contraindicated and avoided [26].

**99**

*Treatment of Gingival Enlargement*

*4.5.5 Chronic abscess*

*4.5.6 Gingival abscess*

*DOI: http://dx.doi.org/10.5772/intechopen.82664*

*4.5.4 Drainage through an external incision*

are advised for post-treatment plaque control measures [6].

or poorly accessible, surgical access may be required [26].

**4.6 Drug-induced gingival enlargement**

tion of drugs and biofilm [6].

The lesion is isolated and anesthetized. A vertical incision through the most fluctuant center of the abscess is made with a no. 15 surgical blade. The tissue adjacent to incision can be separated using a curette or periosteal elevator. The fluctuant matter is expressed, and the wound edges are approximated using mild digital pressure with a help of moist gauze pad. In abscesses manifesting with severe swelling and inflammation, aggressive mechanical instrumentation should be delayed in favor of antibiotic therapy to avoid damage to surrounding healthy periodontal tissues. Patient is dismissed after bleeding and suppuration are controlled. Patients

The chronic abscess is treated with scaling and root planing and, if indicated, surgical therapy. Surgical treatment is considered when deep vertical pocket or furcation defects are observed that cannot be treated with mere nonsurgical instrumentation. Access to subgingival calculus is mandatory in areas of deep pockets [6].

Treatment of the gingival abscess is done to reverse the acute phase and immediate removal of the cause. As it is often seen that the lesion gets fluctuant, exudate is expressed and becomes symptomless and the cycle is repeated, the offending agent is to be removed. Topical or local anesthesia by infiltration is administered. When possible, scaling and root planing are completed to establish drainage and remove microbial deposits. In more acute situations, the fluctuant area is incised with a no. 15 scalpel blade, and exudate may be expressed by gentle digital pressure. Any foreign material (offending agent e.g., dental floss, impression material) is removed. The area is irrigated with normal saline and covered with moist gauze under light pressure. Once bleeding is controlled, the patient is dismissed with post treatment instructions. The area is to be reassessed after 24 hours and if resolution is sufficient, scaling not previously completed is done. If the residual lesion is large

The examination of drug-induced gingival enlargement patient shows two components of the overgrown tissues which are either fibrotic, due to action of the drug on the physiologic gingival collagen turnover; or inflammatory, because of the presence of bacterial biofilm. Though the fibrotic and inflammatory changes present in the enlarged gingiva are the consequences of distinct pathologic processes, they almost always are observed as gingival enlargement induced by the combina-

The role of bacterial biofilm in the overall pathogenesis of drug-induced gingival enlargement is not clear. Some studies indicate that biofilm is a prerequisite for gingival enlargement, whereas others suggest that the presence of biofilm is a consequence of biofilm accumulation caused by the enlarged gingiva [27].

The treatment of drug-induced gingival enlargement should be undertaken in consideration the medication used by the patient and the clinical features of the case. First, discontinuation of the drug or alternate medication should be considered. Consultation with the patient's physician is warranted for any such possibilities. It is not practically possible to completely discontinue the offending drug,
