*4.5.4 Drainage through an external incision*

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

#### *4.5.5 Chronic abscess*

*Gingival Disease - A Professional Approach for Treatment and Prevention*

should be instituted before any surgical therapy.

*4.5.1 Chronic inflammatory enlargement*

**4.5 Treatment protocol**

sutures are given [6].

*4.5.2 Periodontal and gingival abscesses*

*4.5.3 Drainage through the periodontal pocket*

based on the clinical and pathological signs and symptoms. The phase I therapy

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.

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

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

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].

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].

deposits [26]. This leads to shrinkage of tissue, slight if not complete.

**98**

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].

## *4.5.6 Gingival abscess*

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

## **4.6 Drug-induced gingival enlargement**

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 combination of drugs and biofilm [6].

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,

but alternate substitute of the drug may be an option. If any drug substitution is attempted, a time period of 6- to 12-month should be stalled between discontinuation of the offending drug and substitution with an alternative drug [2].

Along with this, oral hygiene instructions, scaling, and root planing should always be instituted. Reevaluation of the gingival enlargement after the alteration of drug therapy and planning of surgical treatment should be done. Alternative medications to the anticonvulsant phenytoin include carbamazepine and valproic acid, both of which have been reported to induce gingival enlargement to a lesser degree. A murine study suggested that lovastatin may attenuate the onset of gingival enlargement induced by phenytoin [28]. Further research is necessary to confirm the therapeutic value of lovastatin. For patients who are taking nifedipine, which has a reported prevalence of gingival enlargement of up to 86%, other calcium channel blockers such as diltiazem or verapamil may be viable alternatives. The reported prevalence of inducing gingival enlargement is 20% for diltiazem and 4% for verapamil [29]. In addition, consideration should be given to the use of another class of antihypertensive medications rather than calcium channel blockers. None of these drugs are known to induce gingival enlargement. Drug substitutions for cyclosporine are more limited.

Tacrolimus is another immunosuppressant that is used in organ transplant recipients [30]. The incidence of gingival enlargement in patients receiving tacrolimus therapy is approximately 65% lower than that in individuals who are receiving cyclosporine [30]. Clinical trials have also shown that the substitution of cyclosporine with tacrolimus results in a significant decrease in the severity of gingival enlargement as compared with patients who are kept on cyclosporine therapy [31]. The use of azithromycin to decrease cyclosporine-induced gingival enlargement resulted in significantly greater changes than those observed with an improvement in oral hygiene. The topical administration of azithromycin in the form of a toothpaste also decreased the severity of cyclosporine-induced gingival enlargement [32, 33].

Secondly, biofilm control is a mandatory step and hence should be prioritize by the clinician in the treatment of drug-induced gingival enlargement. Although the exact role played by bacterial biofilm is not fully understood, evidence suggests that good oral hygiene, chemotherapeutic agents, and the frequent professional removal of biofilm decrease the degree of gingival enlargement and improve overall gingival health [27, 34]. Due to the presence enlarged gingival tissue, it is associated with pseudo-pocket formation and abundant biofilm accumulation, which may lead to the development of periodontitis. Hence, meticulous biofilm control helps to maintain attachment levels. In addition, adequate biofilm control may help to prevent the recurrence of gingival enlargement in surgically treated cases. Still in many patients, gingival enlargement persists after careful consideration of the previous two approaches. With these patients, surgical removal of the enlarged gingiva must be considered [6].

The recurrence of drug-induced gingival enlargement is a reality in surgically treated cases. The major cause of the recurrence of gingival enlargement is the difficulty with postsurgical oral hygiene. Meticulous home care, with a soft, postsurgical brush and chlorhexidine gluconate rinses, is indicated. Frequent professional cleanings can also help reduce the degree of recurrence [35].

#### **4.7 Leukemic gingival enlargement**

Leukemic enlargement occurs with acute or subacute leukemia, and it is uncommon among patients in the chronic leukemic state. The patient's blood profile including bleeding and clotting times and platelet count should be checked before treatment, and the hematologist should be consulted before periodontal treatment

**101**

*Treatment of Gingival Enlargement*

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

each treatment to reduce the risk of infection [6].

**4.8 Gingival enlargement during pregnancy**

**4.9 Gingival enlargement during puberty**

**4.10 Idiopathic enlargement**

otherwise. Maintenance therapy is recommended [6].

ing on presence or absence of loss of attachment.

is instituted. Gingival bleeding, sometimes spontaneous, is often associated with leukemic gingival enlargement. After subsiding of acute symptoms, attention is directed to correction of the gingival enlargement. Removal of local irritating factors helps in controlling the inflammatory component of the enlargement. Scaling and root planning is done to achieve it. The initial treatment steps consist of gently removing all loose debris with cotton pellets, performing superficial scaling, and instructing the patient in oral hygiene for biofilm control. This hygiene should include the daily use of chlorhexidine mouthrinses. Oral hygiene procedures are of supreme important for these patients. Definitive scaling and root planing are carried out at subsequent visits using local anesthesia (if required). Treatment sessions are confined to a small area of the mouth if hemostasis poses a challenge. Antibiotics are administered systemically the evening before and for a week after

The elimination of all local irritants that may be responsible for precipitating the gingival changes that occur during pregnancy should be done. This elimination is a preventive procedure to avoid any unfavorable situation as well as the treatment of gingival enlargement after it occurs. Marginal and interdental gingival inflammation and enlargement are treated by scaling and root planing. Treatment of tumor-like gingival enlargements consists of surgical excision, as well as the scaling and root planing of the tooth surfaces adjacent to the lesion. The enlargement may recur unless all irritants are removed. Food impaction is frequently an inciting factor. Gingival lesions during pregnancy should be treated as soon as they are detected, although not necessarily by surgical means. Scaling and root planing procedures and adequate oral hygiene measures may reduce the extent of the enlargement. Gingival enlargements do shrink after pregnancy, but they usually do not disappear. After pregnancy, the entire periodontal status of the patient should be reevaluated, and comprehensive treatment should be undertaken. Lesions should be removed surgically during pregnancy if they interfere with mastication or produce an esthetic disfigurement that bothers the patient. During pregnancy, the emphasis should be on (1) preventing gingival disease before it occurs and (2) treating existing gingival disease before it worsens [14].

Gingival enlargement during puberty should be treated by phase I therapy, removal of all local irritant factors, controlling and removing the biofilm. Surgical removal is considered in severe cases and after instituting scaling and root planing. Oral hygiene measures are reinforced as high chances of recurrence is anticipated

It usually requires surgical correction. Phase I therapy is undertaken to remove any source of irritants. Inflammatory component if present should be controlled. Functional and esthetic correction using a surgical therapy is undertaken depend-

According to several authors, the best time is when all of the permanent dentition has erupted, because the risk of recurrence is higher before it [36]. Emerson demonstrated that the degree of enlargement did not appear to be related to the oral hygiene or to the amount of calculus present and that a correct physiologic contour of the marginal gingiva is more important to prevent recurrence [37] (**Table 1**).

#### *Treatment of Gingival Enlargement DOI: http://dx.doi.org/10.5772/intechopen.82664*

*Gingival Disease - A Professional Approach for Treatment and Prevention*

for cyclosporine are more limited.

but alternate substitute of the drug may be an option. If any drug substitution is attempted, a time period of 6- to 12-month should be stalled between discontinua-

Along with this, oral hygiene instructions, scaling, and root planing should always be instituted. Reevaluation of the gingival enlargement after the alteration of drug therapy and planning of surgical treatment should be done. Alternative medications to the anticonvulsant phenytoin include carbamazepine and valproic acid, both of which have been reported to induce gingival enlargement to a lesser degree. A murine study suggested that lovastatin may attenuate the onset of gingival enlargement induced by phenytoin [28]. Further research is necessary to confirm the therapeutic value of lovastatin. For patients who are taking nifedipine, which has a reported prevalence of gingival enlargement of up to 86%, other calcium channel blockers such as diltiazem or verapamil may be viable alternatives. The reported prevalence of inducing gingival enlargement is 20% for diltiazem and 4% for verapamil [29]. In addition, consideration should be given to the use of another class of antihypertensive medications rather than calcium channel blockers. None of these drugs are known to induce gingival enlargement. Drug substitutions

Tacrolimus is another immunosuppressant that is used in organ transplant recipients [30]. The incidence of gingival enlargement in patients receiving tacrolimus therapy is approximately 65% lower than that in individuals who are receiving cyclosporine [30]. Clinical trials have also shown that the substitution of cyclosporine with tacrolimus results in a significant decrease in the severity of gingival enlargement as compared with patients who are kept on cyclosporine therapy [31]. The use of azithromycin to decrease cyclosporine-induced gingival enlargement resulted in significantly greater changes than those observed with an improvement in oral hygiene. The topical administration of azithromycin in the form of a toothpaste also decreased the severity of cyclosporine-induced gingival enlargement [32, 33].

Secondly, biofilm control is a mandatory step and hence should be prioritize by the clinician in the treatment of drug-induced gingival enlargement. Although the exact role played by bacterial biofilm is not fully understood, evidence suggests that good oral hygiene, chemotherapeutic agents, and the frequent professional removal of biofilm decrease the degree of gingival enlargement and improve overall gingival health [27, 34]. Due to the presence enlarged gingival tissue, it is associated with pseudo-pocket formation and abundant biofilm accumulation, which may lead to the development of periodontitis. Hence, meticulous biofilm control helps to maintain attachment levels. In addition, adequate biofilm control may help to prevent the recurrence of gingival enlargement in surgically treated cases. Still in many patients, gingival enlargement persists after careful consideration of the previous two approaches. With these patients, surgical removal of the enlarged gingiva must

The recurrence of drug-induced gingival enlargement is a reality in surgically treated cases. The major cause of the recurrence of gingival enlargement is the difficulty with postsurgical oral hygiene. Meticulous home care, with a soft, postsurgical brush and chlorhexidine gluconate rinses, is indicated. Frequent professional

Leukemic enlargement occurs with acute or subacute leukemia, and it is uncom-

mon among patients in the chronic leukemic state. The patient's blood profile including bleeding and clotting times and platelet count should be checked before treatment, and the hematologist should be consulted before periodontal treatment

cleanings can also help reduce the degree of recurrence [35].

**4.7 Leukemic gingival enlargement**

tion of the offending drug and substitution with an alternative drug [2].

**100**

be considered [6].

is instituted. Gingival bleeding, sometimes spontaneous, is often associated with leukemic gingival enlargement. After subsiding of acute symptoms, attention is directed to correction of the gingival enlargement. Removal of local irritating factors helps in controlling the inflammatory component of the enlargement. Scaling and root planning is done to achieve it. The initial treatment steps consist of gently removing all loose debris with cotton pellets, performing superficial scaling, and instructing the patient in oral hygiene for biofilm control. This hygiene should include the daily use of chlorhexidine mouthrinses. Oral hygiene procedures are of supreme important for these patients. Definitive scaling and root planing are carried out at subsequent visits using local anesthesia (if required). Treatment sessions are confined to a small area of the mouth if hemostasis poses a challenge. Antibiotics are administered systemically the evening before and for a week after each treatment to reduce the risk of infection [6].
