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Table of Contents
CASE REPORT
Year : 2023  |  Volume : 13  |  Issue : 1  |  Page : 48-50

Comprehensive management of generalized aggressive periodontitis patient with fibrous hyperplasia


1 Department of Periodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu, India
2 Department of Periodontics, Century International Institute of Dental Science, Kasargod, Kerala, India

Date of Submission07-Feb-2022
Date of Acceptance17-Feb-2023
Date of Web Publication28-Apr-2023

Correspondence Address:
Dr. Maria Subash Aaron Muthuraj
Department of Periodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore - 641 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_4_22

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   Abstract 


Gingival enlargement is a condition with an increase in the size of the gingiva and can be caused by inflammation, systemic disease, and medications. Genetic factors and allergic components in dentifrices, chewing gums, etc., also lead to gingival enlargement. Aggressive periodontitis is a periodontal disease with rapid destruction of the periodontium. The pace and severity of destruction make the disease difficult to manage. If it is complicated with fibrous hyperplasia and loss of dentition, it needs additional treatment. Here, in our case report, we are going to discuss the periodontal management and prosthetic rehabilitation of patient having generalized aggressive periodontitis with gingival hyperplasia.

Keywords: Fibrous hyperplasia, fixed partial denture, generalized aggressive periodontitis, gingival hyperplasia


How to cite this article:
Muthuraj MS, Maradi AP, Chithresan K. Comprehensive management of generalized aggressive periodontitis patient with fibrous hyperplasia. J Interdiscip Dentistry 2023;13:48-50

How to cite this URL:
Muthuraj MS, Maradi AP, Chithresan K. Comprehensive management of generalized aggressive periodontitis patient with fibrous hyperplasia. J Interdiscip Dentistry [serial online] 2023 [cited 2023 May 29];13:48-50. Available from: https://www.jidonline.com/text.asp?2023/13/1/48/375287




   Clinical Relevance to Interdisciplinary Dentistry Top


  1. Aggressive periodontitis with gingival enlargement is a rare entity and much more complicated.
  2. In our case periodontist, oral pathologist and prosthodontist teamed up together to get a desirable and stable result.
  3. Fixed denture replacement can be done in patients with aggressive periodontitis if patient's compliance and remaining bone support are good.



   Introduction Top


Aggressive periodontitis is a severe and rapidly destructive form of periodontal disease. It commonly affects patients under 30 years of age with no medical complications.[1] It is a multifactorial disease that develops due to an increased inflammatory response to bacterial plaque harboring specific pathogens. Therefore, factors other than microbial plaque also play a major role in the initiation and progression of the disease.[2] A few cases of aggressive periodontitis associated with gingival enlargement have been reported in past.[3],[4],[5],[6] The uniqueness of this case report lies on the observation that none of the earlier case reports managed to prosthetically rehabilitate the dentition, which was a major goal in this case. Hence, our case report highlights a case of generalized aggressive periodontitis (GAP) with generalized gingival fibrous hyperplasia and reports its interdisciplinarity management.


   Case Report Top


A 25-year-old female reported to the Periodontics Department of Sri Ramakrishna Dental College and Hospital, Coimbatore, with multiple periodontal abscesses in the upper and lower anterior region along with generalized gingival enlargement. A set of 14 full-mouth intraoral periapical radiographs had been taken. As the patient had multiple periodontal abscesses in relation to upper and lower incisors along with poor periodontal support, all the upper and lower incisors had been extracted in oral surgery followed by referral to the Department of Periodontics for management of gingival enlargement and periodontitis [Figure 1]. The patient had been asked about the family history for periodontitis and she revealed that her mother had lost all her tooth within the age of 40 years. Intraoral examination revealed severe attachment loss with a minimum quantity of deposit. Full mouth intraoral periapical radiograph revealed an arc-shaped bone loss in relation to the first molars of all quadrants and severe bone loss in relation to 34, 35 and moderate to advanced bone loss in relation to other teeth. Diagnosis of GAP was made as the patient had a positive family history with severe periodontal destruction at an early age and less quantity of deposits. She had no relevant past medical history also. Laboratory tests also were normal. The prognosis of the remaining teeth had been established. Thirty-four and 35 had a hopeless prognosis and were extracted as both the teeth had severe attachment loss with pocket depth >13 mm. Pocket depth. Pocket depth of 11 mm was present in relation to 13, 16, 36, and 46, and pocket depth of 9 mm was present in relation to 14, 44, 45, 24, and 25. We had made a treatment plan of scaling and root planing (SRP) along with gingival curettage, followed by open flap debridement (OFD) plus internal bevel gingivectomy (IBG). Full mouth SRP along with curettage was done under local anesthesia with oral doxycycline as an adjuvant (200 mg on the 1st day, followed by 100 mg OD for the next 20 days). The patient was recalled 1 month after SRP. IBG was preferred as the patient had periodontal destruction along with generalized gingival hyperplasia. Informed consent was obtained before the procedure. Under local anesthesia, OFD plus IBG was performed in all quadrants in four visits (one quadrant per visit) [Figure 2]a. Continuous sling sutures had been placed [Figure 2]b, and periodontal pack was placed [Figure 2]c. The excised tissue was sent to the histopathologic examination which revealed connective tissue with dense collagen bundles, fibroblasts, blood vessels, and patchy distribution of chronic inflammatory cells. The surface epithelium was a stratified squamous type with hyperplasia and atrophy and some areas of ulceration [Figure 3]. The oral pathologist had interpreted the histopathological section of gingival enlargement as fibrous hyperplasia. Healing was uneventful, and the patient reported after 3 months for review. There was no relapse in gingival enlargement and the periodontal parameters also improved. Pocket depth was reduced to 5 mm in relation to 16, 26, 36, 46, 24, and 25 and to 3 mm in relation to 13, 14, 44, and 45. The patient's oral hygiene maintenance was also good [Figure 4]a. Therefore, the patient had been given a nod for prosthetic replacement of the missing tooth. The fixed prosthesis was planned in relation to all anterior teeth and implant-supported replacement for premolars. The fixed prosthetic denture was given in relation to upper and lower incisors with all canines as the abutment [Figure 4]b. The patient is willing to perform implant-supported denture in relation to left premolars after some time due to financial constraints. The patient is still under follow-up.
Figure 1: Preoperative image after extraction of all incisors

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Figure 2: (a) Internal bevel gingivectomy. (b) Placement of sutures. (c) Placement of periodontal pack

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Figure 3: Histopathology of excised tissue showing revealing hyperplastic stratified squamous epithelium with connective tissue rich in dense collagen bundles and fibroblasts

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Figure 4: (a) Review after 3 months. (b) 9 months after fixed partial denture restoration

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   Discussion Top


Aggressive periodontitis is differentiated from chronic periodontitis by an early age of onset, the rapidly progressive nature, the nature and composition of subgingival microbiota, and changes in the host's immune response and familial aggregation.[1] The major problem associated with GAP is early tooth loss in young adults (<35 years). In our case, the patient had advanced bone loss in relation to 34 and 35, along with multiple periodontal abscesses in relation to upper and lower incisors. The prognoses of upper and lower incisors were established as hopeless and left lower premolars were established as questionable. Therefore, the decision for extraction of the above tooth was made. Incisors were extracted during the first visit, and the premolars were extracted at the second visit. The patient underwent nonsurgical periodontal therapy under antibiotics. As the patient had periodontal destruction along with gingival enlargement IBG along with OFD was done. This is similar to the case reported by Chaturvedi.[3] No regenerative therapy was performed as there were no contained defects. Excised tissue was sent to an oral pathologist and he interpreted it as fibrous hyperplasia. As the patient was followed up for 12 months with no recurrence, the decision to go for a fixed denture replacement was made. In the past, very few case reports had shown complete management of GAP patients with gingival enlargement.[3],[4],[5],[6] The fact that this was rarely reported made us to document and presents this particular case.


   Conclusion Top


While managing GAP patients with gingival enlargement, a complete case history with laboratory and histopathological investigation is mandatory. This only will give a clear picture of the nature of gingival enlargement. A comprehensive treatment plan with good maintenance is necessary to prevent further tooth loss and replacement of the lost tooth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.  Back to cited text no. 1
    
2.
Kulkarni C, Kinane DF. Host response in aggressive periodontitis. Periodontol 2000 2014;65:79-91.  Back to cited text no. 2
    
3.
Chaturvedi R. Idiopathic gingival fibromatosis associated with generalized aggressive periodontitis: A case report. J Can Dent Assoc 2009;75:291-5.  Back to cited text no. 3
    
4.
Arabsolghar M, Kaheh A. Idiopathic gingival fibromatosis with unilateral aggressive periodontitis: A case report. J Oral Health Oral Epidemiol 2014;3:42-6.  Back to cited text no. 4
    
5.
Saify F, Moda P. Idiopathic gingival fibromatosis associated with generalized aggressive periodontitis combined with plasma cell gingivitis: A rare case report. Oral Maxillofac Pathol J 2012;3:253-7.  Back to cited text no. 5
    
6.
Ramachandra SS, Hegde M, Prasad UC. Gingival enlargement and mesiodens associated with generalized aggressive periodontitis: A case report. Dent Update 2012;39:364-6, 369.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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