Sarah Ahmad Alfaqeeh1 , Sukumaran Anil2
1. Post-graduate student, Demonstrator, Division of Orthodontics, Department of Preventive Dental Sciences, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia.
2. Professor, Division of Periodontics, Department of Preventive Dental Sciences, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia.
Corresponding author: “Dr. Sarah A. A1-Facieeh” firstname.lastname@example.org
J Pak DentAssoc.2009; 18(1): 025 – 029.
Adult patients have many preexisting conditions that are not seen in the adolescent population including tooth loss, severe skeletal dysplasias, periodontal disease and various forms of temporomandibular dysfunction (TMD). Frequently, the preexisting conditions that are present in the adult patient interfere with the achievement of orthodontisc’s general idealized goals. Problem-oriented synthesis of the dental needs of each case helps determine specific treatment objectives that one must establish before determining the treatment plan. A 51 years old patient approached the dental clinic to improve her smile esthetics. She was a skeletal class III high angled case with an increased lower facial height and a dentally class I with supraerupted upper right central incisor, mild spacing between right upper central and lateral incisors and moderate lower anterior crowding. Bolton discrepancy showed 4 mm of overall tooth material excess in the lower arch. Gingival overgrowth associated with nifedipine intake was also recorded. As a more realistic treatment plan with an interdisciplinary approach was considered to be appropriate in terms of treatment efficacy and duration, a team comprising of a periodontist, an orthodontist and a restorative dentist was formed to manage the case. The importance of multidisciplinary approach in managing the case was explained. After gingivectomy, the patient was kept in a maintenance program, including oral hygiene instructions and professional tooth cleaning during the complete orthodontic treatment. Follow-up of the case for a year did not reveal any recurrence of the drug induced gingival enlargement. This case not only emphasizes the role of meticulous oral hygiene maintenance in preventing the recurrence of gingival enragement but also the ease with which adult cases could be managed efficiently with minimal endeavors by a team approach.
Drug induced gingival enlargement, multidisciplinary approach, nifedipine, orthodontic treatment.
Orthodontics is one of the most dramatic means available to modify local factors and site specificity of the disease process. To manage the periodontal issues in adult treatment effectively; the orthodontist must make an accurate assessment of the patient’s potential for bone or gingival recession during orthodontic tooth movement. Therefore appropriate management of several factors is needed to prevent negative periodontal sequelae during orthodontic treatment. Drug induced gingival overgrowth is frequently observed as a side effect with the use of several medications in susceptible patients.’ Nifedipine is a calcium channel-blocking agent of the dihydropyridine group widely used as a vasodilating agent for the treatment of hypertension and ischemic heart disease.2 Although gingival enlargement may affect all parts of the mouth; it has been reported as more pronounced on the labial aspects of the upper and lower anterior teeth.’ Gingival overgrowth, which normally begins in the region of the interdental papilla, may favor the appearance of clinical symptoms and signs that include pain, bleeding and friability of the tissue, abnormal movement of the teeth, changes of appearance, phonetics and occlusion as well as the appearance of dental caries and other periodontal disorders.4
The prevalence of gingival enlargement has been reported to be between 20 to 40 percent in patients receiving nifedipine.5 It has been suggested that the extent of enlargement may be related to duration of drug therapy, level of oral hygiene, severity of gingival inflammation and genetic susceptibility but the individual impact of these factors has not been determined.’
Gingival inflammation can be reduced or eliminated through initial periodontal therapy consisting of oral hygiene instruction, scaling and root planing and, when indicated, surgical therapy.’ The success of active periodontal therapy depends on maintenance therapy in recall appointments.’ It has been suggested that gingival inflammation might play a role in the pathogenesis of drug induced gingival overgrowth.’ Therefore, maintenance therapy can prevent not only gingival re-inflammation but also recurrence of gingival enlargement in patients receiving nifedipine. It has been reported that optimal plaque control and regular attendance to maintenance appointments after active periodontal therapy were successful in controlling the degree or recurrence of gingival enlargement.’ Other researchers have stated that development of drug induced gingival overgrowth could be minimized, but not prevented, by plaque control and frequent recall appointments.”‘
Ilgenli et al recommended meticulous plaque control and surgical removal of the hyperplastic tissue by means of gingivectomy whenever necessary to treat drug induced gingival enlargement.’ Unfortunately, the condition is progressive in nature which might necessitate repeated surgical removal of the tissue unless the medication is discontinued.’2 Although withdrawing the offending medication generally reverses hyperplasia; this course of action may be less effective following prolonged exposure.13
A case of nifedipine induced gingival enlargement is presented here. A multidisciplinary approach in managing the case is presented. The importance of periodic recall and meticulous oral hygiene measures showed no recurrence of the gingival enlargement
A 51 years old female patient presented to the orthodontic clinic complaining of unsightly arrangement of her front teeth. On eliciting her medical history it was found that she is a hypertensive on administering nifedipine 20 mg/day (Adalat® Bayer Healthcare Baytown USA) for the past two years. On clinical examination, gingival enlargement in the upper and lower anterior region, spacing between upper right central and lateral incisors and crowding in the lower anterior region were evident. The upper right central incisor was also extruded (Figure 1). She had a fair oral hygiene status, fibrotic gingiva, moderate caries activity, several restorations, two crowns and all of her permanent teeth were present.
Radiographic examination revealed satisfactory root canal treatment beneath the crowned teeth and generalized moderate horizontal bone loss (Figure 2). Cephalometric analysis showed skeletal class III pattern, protruded chin, high angled case, increased lower facial height and retroclined upper and retroclined and retruded lower incisors (Figure 3). Dental model analysis showed class I right and left molar and canine relationships, coincident upper and lower dental midlines, supraerupted upper right central incisor, 2.75 mm overjet, 3 mm (40%) overbite and 1.75 mm upper and 3.25 mm lower crowding. Bolton discrepancy was present in the form of an overall 4 mm tooth material excess in the lower teeth of which 2.4 mm were anteriorly located
The patient’s chief concern was to improve her dental esthetics. Hence the treatment priorities were set accordingly and decided upon a multidisciplinary approach for management of the case. The treatment plan consisted of gingivectomy followed by fixed orthodontic therapy. The treatment objectives aimed at prevention of further lower anterior crowding, improving her smile esthetics while psychologically addressing her chief complaint. A non-surgical non-extraction treatment plan included fixed orthodontic appliances (0.022×0.028″ slot bracket) to level the upper arch by intruding the right central incisor and to relieve the crowding in the lower arch gaining the space required by interproximal stripping where needed. Due to the Bolton discrepancy spacing in the upper arch is anticipated and a conservative restorative management for the case was planned for Accordingly, gingivectomy was performed in both the upper and lower anterior segments. After an adequate healing period, the orthodontic treatment was instituted. The patient was periodically followed up in both the orthodontic and periodontic clinics every month throughout her full orthodontic treatment duration which lasted for 12 months. Care was taken to maintain the overbite, to minimize plaque accumulation and to maintain a healthy periodontium.
First molars bonding was preferred over banding and low forces were tried to avoid any untoward effect of orthodontic treatment on the periodontium. During the leveling and alignment stage forces were kept at a very low level using 0.014″ Niti archwire. Tooth movement was initiated on 0.016″ stainless steel wire which was maintained through the finishing phase also. At the finishing stage; spaces revealed distal to the upper lateral incisors as anticipated due to the Bolton discrepancy detected earlier while studying the case. The restorative dentist bonded shade matched-tooth color composite to the distal surfaces of the upper lateral incisors and the mesial surfaces of the upper canines to constitute tight contacts between these teeth before debonding the case along with bonding the upper left central incisor’s mesioincisal angle (Figure 4). Bonded upper (lateral incisor to lateral incisor) and lower (canine to canine) lingual retainers and upper removable modified Hawley’s retainer were the retention protocol followed
Changed lifestyles and patient awareness have increased the demand for adult orthodontic treatment and multidisciplinary dental therapy has allowed better management of the more complicated and unique requirements of the adult patient population thereby greatly improving quality of care and treatment prognosis. Dental care for adults should provide a permanent dentition with a healthy periodontium, optimal chewing function and pleasant esthetics. Problem-oriented synthesis of the dental needs of each case helps in determining specific treatment objectives that one must establish before determining the orthodontic treatment
plan. Beginning treatment without knowing the specific goals for the individual patient or with unrealistic goals can lead to treatment failure. It is essential to identify patients who have periodontal disease or are at a risk of developing it and to know what treatment approaches should be avoided to prevent negative sequelae. Teamwork is also important in monitoring the periodontal health of patients throughout the course of orthodontic therapy.14
Gingival hyperplasia with its potential cosmetic implications and also the new niches for the growth of microorganisms its providing is a serious concern for both the patient and the clinician. Calcium channel blockers are considered potential etiologic agents of drug induced gingival hyperplasia.’ Although the incidence of drug induced gingival hyperplasia is not infrequent;”‘” very few reports have been published in the literature on the impact of orthodontic treatment in such patients!’
In the present case, the patient’s periodontal condition was carefully examined on every visit. The oral hygiene instructions were always stressed and the role of the patient throughout the treatment phase was fully addressed from the beginning. The periodontal state was maintained throughout the orthodontic treatment duration as revealed by the patient’s before and after panoramic radiographs (Figure 2 & 5). Slight mobility of the lower incisors was noted during the movement stage but not to the degree that warranted the discontinuation of the applied forces and found to be as normal as that found in many other cases.
Gingivectomy was performed prior to the orthodontic treatment in this case. It has been suggested that the patient may benefit from removal of excessive gingival tissue from the crowns of the teeth which may add to the stability of the orthodontic correction.’ Gingival enlargement did not recur after gingivectomy when thorough plaque control was carried out which support the additional role of inflammation and plaque in drug induced gingival enlargement (Figure 6).19‘20
The authors would like to express their thanks to Dr. Abdullah M. Aldrees for his expert opinion and advice in the treatment planning. The assistance of Dr. Mashael Bin Hasan is gratefully acknowledged
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