reaction [13] (Figure 1.3.2). These features are characteristic but not specific to oral LP. Other interface processes including lupus erythematosus and chronic ulcerative stomatitis have similar histopathologic presentations.
I. Reticular LP often causes no symptoms and need not be treated. The first line of treatment for symptomatic erosive LP is topical corticosteroids. Fluocinonide gel applied to the most symptomatic areas or dexamethasone elixir used as a mouth rinse up to four times per day is often sufficient to induce healing within one to two weeks. Patients should be informed that the lesions will likely return and the corticosteroids should be reapplied. Patients should be monitored for their response and for the possibility of candidiasis induced by use of the steroids. Another important part of the therapeutic regimen in patients with DG is meticulous plaque control, which results in significant improvement in many patients [14].
Figure 1.3.2 Characteristic histopathology of lichen planus demonstrates parakeratinized and/or orthokeratinized stratified squamous epithelium with sawtooth‐shaped rete ridges, squamatization of basal cells, and a bandlike infiltrate of lymphocytes in the superficial connective tissue.
J. LP is a chronic condition with lesions that wax and wane over time. The erosive form should be monitored and treated as necessary to improve patient comfort. There has long been controversy over the malignant potential of LP. Recent studies suggest malignant transformation appears to be more common in older females, often with erythematous LP, and the rate has been reported to range from 0.9 to 1.1% [15,16].
Case 1.4 Gingival Enlargement
CASE STORY
A 35‐year‐old Caucasian female presented with a chief complaint of “My gums are swollen and bleed.” The patient noticed swelling of the gingiva two months after she started taking phenytoin (Dilantin) for epilepsy, which was first diagnosed 13 years ago. The patient did not brush or floss her teeth consistently.
LEARNING GOALS AND OBJECTIVES
To be able to diagnose gingival enlargement
To identify the etiology and to address it in the treatment plan
To understand the difference between true pockets and pseudo‐pockets
Medical History
The patient was diagnosed with epilepsy 13 years ago. Since that time she has been taking Dilantin 500 mg daily, and currently in addition 2000 mg Depakote daily (1000 mg b.i.d.) and 10 mg Zyprexa at bedtime. There were no other significant medical problems and the patient had no known allergies.
Social History
The patient did not smoke or drink alcohol.
Extraoral and Intraoral Examinations
There were no significant findings on extraoral examination. The patient had no masses or swelling and the temporomandibular joint was within normal limits.
With the exception of the gingiva, the soft tissues of the mouth including the tongue appeared normal.
Examination of the gingiva revealed generalized marginal erythema, edema, rolled margins, enlarged papillae, and bleeding on probing (Figures 1.4.1 and 1.4.2). Probing depths ranged from 2 to 5 mm (pseudo‐pockets due to gingival enlargement; Figure 1.4.3).
The hard tissue examination found multiple restorations.
Occlusion
Angle class II, division 2 occlusion with tooth #12 in crossbite due to arch incongruence.
Radiographic Examination
A full‐mouth set of radiographs revealed normal levels of alveolar bone throughout the mouth including the maxillary and mandibular anterior where clinical gingival enlargement was present (Figure 1.4.4).
Figure 1.4.1 Initial presentation of a patient with phenytoin‐induced gingival enlargement: smile frontal, right, and left views.
Figure 1.4.2 Initial presentation of a patient with phenytoin‐induced gingival enlargement: buccal view in occlusion, maxilla and mandible occlusal views. Note that gingival enlargement is localized to anterior and facial segments on both maxilla and mandible.
Diagnosis
After reviewing the history and the clinical and radiographic examinations, the patient was diagnosed with phenytoin‐associated drug‐influenced gingival enlargement and a differential diagnosis was generated (A).
Treatment Plan
The treatment plan for the phenytoin‐associated gingival enlargement includes interdisciplinary consultation (to include the primary care physician regarding alternative medication for treatment of epilepsy), oral hygiene instructions, initial phase therapy consisting of supragingival and subgingival scaling with polishing, reevaluation at six weeks, and surgical phase (gingivectomy) if gingival enlargement persists. Routine maintenance therapy should be performed every three months following resolution of the gingival enlargement (G).
Treatment
The patient received full‐mouth scaling and polishing. The patient was referred to a restorative dentist for detailed hard tissue examination and treatment of active decay. At six‐week reevaluation, the patient demonstrated excellent oral hygiene, but the clinical signs and symptoms had improved only slightly. Therefore, gingivectomy and gingivoplasty were performed to restore gingival contours (G; see also Chapter 3, Case 1). The patient is currently on three‐month recall.
Figure 1.4.3 Probing pocket depth measurements.