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Clinical Cases in Periodontics


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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.

Photo depicts 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 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

      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.

      The patient did not smoke or drink alcohol.

       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.

      Angle class II, division 2 occlusion with tooth #12 in crossbite due to arch incongruence.

Photos depict initial presentation of a patient with phenytoin-induced gingival enlargement: smile frontal, right, and left views.

      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).

      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).

      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.

Schematic illustration of probing pocket depth measurements.