Individualized digitally designed surgical template for guided soft tissue surgery in cases with severe gingival enlargement: A clinical application in hereditary gingival fibromatosis.

AIM: The purpose of this study was to present the use of computer-assisted periodontal surgery utilizing a novel surgical guide for cases with severe gingival enlargement through a clinical application in a patient with hereditary gingival fibromatosis. MATERIALS AND METHODS: The treatment plan included nonsurgical periodontal therapy, surgical periodontal treatment, and regular periodontal maintenance before the initiation of orthodontic treatment. Due to the increased soft tissue thickness, a surgical guide with a novel design was fabricated to facilitate the periodontal surgery since most of the patient's teeth were malpositioned and underexposed due to fibromatosis. For this purpose, the patient's intraoral scan was merged with a CBCT image in order to plan surgical excisions based on the anatomy of the teeth and the bone contour. RESULTS: The customized surgical guide facilitated the gingivectomy by controlling not only the shape of the initial incisions but also their orientation toward the level of the cementoenamel junction, improving the efficiency of the clinical time compared with freehand surgery and assisting in the verification of the final soft tissue shape, based on the treatment plan. CONCLUSION: Digital technology through the superimposition of multiple data sets can assist in the diagnosis and multidisciplinary management of cases with gingival fibromatosis. The proposed design of the surgical guide can facilitate soft tissue surgery based on the digital treatment plan, leading to more predictable management of the soft tissue, especially in patients with severe gingival enlargement, as in cases with hereditary gingival fibromatosis or drug-induced gingival overgrowth.

Uso de membrana de celulosa oxidada post-gingivectomía en hiperplasia gingival inducida por fenitoína / Use of oxidized cellulose regenerated post-gingivectomy on ginigival hyperplasia induced by phenytoin

Introducción: La hiperplasia gingival es una condición benigna caracterizada por el aumento de volumen de la encía. Algunos fármacos, factores genéticos, aparatología y placa dentobacteriana son factores que pueden inducir esta condición. Objetivo: Devolver la anatomía a la encía brindando una mejor estética y permitiendo una óptima higiene oral. Material y métodos: Paciente masculino de 20 años de edad con antecedentes de fenitoína presenta aumento de volumen en la encía. Resultados: Se obtuvieron resultados estéticos y funcionales satisfactorios con el tratamiento quirúrgico y el uso de membrana de celulosa oxidada. Conclusión: En el manejo de la hiperplasia gingival es importante el enfoque no quirúrgico como control de placa dentobacteriana y medidas de higiene del mismo paciente (AU)

Introduction: Gingival hyperplasia is a benign condition characterized for the grown on the gingival volume. Some drugs, genetic, orthodontic and dental plaque are some factors that can induce this condition. Objective: To return the gingival anatomy, providing a better aesthetic allowing also good oral hygiene. Material and methods: A male 20 years of age with medical history of phenytoin display grown on the gingival volume. Results: Aesthetic and functional results were achieved with the surgical treatment and the oxidized cellulose membrane. Conclusion: In the gingival hyperplasia management is important de non-surgical approach, as dental plaque control and oral hygiene of the patient (AU)

Orofacial granulomatosis associated with gingival enlargement: a case report.

Orofacial granulomatosis (OFG) is an uncommon condition with varying clinical presentation. Gingival enlargement in children could be due to a varied etiology. The present case report is of an adolescent female with initial presentation of generalized gingival enlargement, lip swelling and perioral discoloration without any known etiopathological factors or systemic involvement. Conservative excision of the enlargement was performed and histopathological examination revealed a non caseating granulomatous lesion. Diagnosis of orofacial granulomatosis in context to sarcoidosis was arrived after excluding other granulomatous diseases. Follow up after 18 months showed no recurrence and regression of lip swelling and perioral discoloration. Gingival enlargement can be considered as one of the presenting features of sarcoidosis.

Lamotrigine-Induced Gingival Enlargement: An Older Problem Due to a Newer Drug - A Rare Case Report.

INTRODUCTION: Gingival enlargement (GE) due to anti-epileptic drugs (AEDs) shows a high prevalence rate. However, lamotrigine, a newer AED, has not shown to induce GE. The present case report describes a rare case of GE in a patient with epilepsy under lamotrigine therapy for the past 3 years. CASE PRESENTATION: In this report, successful management of lamotrigine-influenced GE in a 24-year-old patient with epilepsy by gingivectomy followed by stringent oral hygiene protocol is presented. CONCLUSION: The present case report suggests that, even this newer AED can cause GE and the oral hygiene status of the patients could be an important triggering factor.

Test Yourself-Question: Multiple facial skin lesions associated with gingival hypertrophy in a pair of siblings.

Two brothers, completely asymptomatic until their first year of life, started to complain from gingival hypertrophy, progressive development of painful soft tissue masses on the fingers and toes, on the face and on the scalp. There were no neurological symptoms or mental delay for both brothers.

[Evaluation of the effects of plaque and inflammation control on treatment of gingival enlargement].

Gingival enlargement or hypertrophy is one of the common clinical symptoms in patients with periodontitis. Plaque stimulation, hormones and drug use could be the promoting factors for the occurrence of gingival enlargements. This paper reviews the literature on the pathogenesis, treatment methods and the effect of plaque and inflammation control in the treatment of various types of gingival hypertrophy. The therapeutic effect of controlling plaque and inflammation on various types of gingival hypertrophy is also discussed and the treatment scheme of gingival hypertrophy is proposed, which may provide reference for clinical work.

Cowden syndrome: new clinical features in a large family; joint hyperextensibility, dental abnormalities and gingival enlargement.

A 4-year-old boy presented with his mother to genetics in the 1980s, with a family history (FH) of macrocephaly and intellectual disability (ID). He remained undiagnosed until his mother developed multiple cancers and was diagnosed with Cowden syndrome (CS) in 2017, a rare, multisystem cancer predisposition syndrome. CS was then confirmed in multiple family members. Clinical examination revealed potentially novel features; gingival enlargement, dental abnormalities and joint hyperextensibility. These features could contribute to revised PTEN hamartoma tumour syndrome, National Comprehensive Cancer Network, minor diagnostic criteria. The paediatric CS phenotype is still emerging and features expressed in this family during childhood could potentially aid paediatric diagnosis. This case reminds clinicians to seek genetic input for PTEN testing when macrocephaly is identified alongside, a personal or FH of ID, early-onset tumours (especially breast, bowel or thyroid) or multiple tumours. Thus detailed FH is pivotal to earlier CS diagnosis and improved patient outcomes.

Alteración del colágeno en la Hipertrofia Gingival en pacientes con ortodoncia: caracterización histológica e inmunohistoquímica / Collagen alteration in gingival hypertrophy in orthodontic patients: histological and immunohistochemical characterization

Resumen Introducción: La hipertrofia gingival (HG) es el aumento del volumen de la encía asociado a ciertas enfermedades sistémicas, hereditarias (idiopático), ingesta de algunos medicamentos o a factores locales como el tratamiento ortodóntico, capaz de provocar cambios histológicos en el tejido conectivo gingival. Objetivo: Describir las características histológicas e identificar el colágeno tipo I y tipo III en tejidos gingivales de sujetos con hipertrofia gingival portadores de ortodoncia. Materiales y método: Se diseñó un estudio de casos y controles que incluyó el análisis de biopsias de tejido gingival de 12 pacientes sometidos a cirugías periodontales. La muestra se dividió en dos grupos: individuos sanos (control; n= 6) y pacientes con HG portadores de ortodoncia (pacientes; n= 6). Las muestras fueron procesadas e incluidas en parafina. Las tinciones Masson-Goldner y rojo sirius/verde rápido fueron empleadas. El colágeno tipo I y tipo III fueron identificados mediante inmunohistoquímica con anticuerpos monoclonales. Resultado: En los pacientes con HG portadores de ortodoncia se observó un epitelio hiperplásico y tejido conectivo denso con abundantes fibras de colágeno distribuidos aleatoriamente. La inmunodetención de colágeno tipo I indicó la presencia de abundantes fibras desorganizadas y el colágeno tipo III fue inmunolocalizado subyacente a la membrana basal, vasos sanguíneos y toda la extensión del tejido conectivo de los pacientes con HG con tratamiento ortodóntico. Conclusión: La acumulación de fibras de colágeno, particularmente del colágeno tipo I y tipo III, son hallazgos histológicos que caracterizan la HG en pacientes portadores de ortodoncia. Futuros estudios son necesarios para dilucidar el fenotipo de los fibroblastos gingivales y la probable pérdida homeostática entre la producción y degradación de colágeno en esta patología.

Abstract Introduction: Gingival hypertrophy (GH) is the increase in the volume of the gingiva associated with certain systemic, hereditary (idiopathic) diseases, the intake of some medications or local factors such as orthodontic treatment, capable of causing histological changes in the gingival connective tissue. Objective: To describe the histological characteristics and identify type I and type III collagen in gingival tissues of subjects with gingival hypertrophy wearing orthodontics. Method: A case-control study was designed that included the analysis of gingival tissue biopsies from 12 patients submitted to periodontal surgeries. The sample was divided into two groups: healthy individuals (Control; n= 6) and patients with GH wearing orthodontics (Patients; n= 6). The samples were processed and embedded in paraffin. Masson-goldner and sirius red/fast green stains were used. Type I and type III collagen were identified by immunohistochemistry with monoclonal antibodies. Result: A hyperplastic epithelium and dense connective tissue with abundant randomly distributed collagen fibers were observed in patients with orthodontic GH. Immunodetention of type I collagen indicated the presence of abundant disorganized fibers and type III collagen was inmunolocalized underlying the basement membrane, blood vessels and the entire extension of the connective tissue of patients with GH orthodontic. Conclusion: The accumulation of collagen fibers, particularly type I and type III collagen, are histological findings that characterize GH in orthodontic wearers. Future studies are necessary to elucidate the phenotype of gingival fibroblasts and the probable homeostatic loss between collagen production and degradation in this pathology.

Effectiveness and safety of tacrolimus with or without eltrombopag, as a part of immunosuppressive treatment of aplastic anemia in adults: a retrospective case series.

First-line treatment of aplastic anemia(AA) and for AA patients ineligible for hematopoietic stem cell transplantation (HSCT) has consisted of antithymocyte globulin (ATG), the calcineurin inhibitor cyclosporine A (CsA), and more recently eltrombopag. However, at our institution, we have successfully substituted another calcineurin inhibitor, tacrolimus, as a part of immunosuppressive threatment (IST) for AA due to more favorable toxicity profile. Since there is limited data on the use of tacrolimus in aplastic anemia, we conducted a retrospective review of twenty patients treated with tacrolimus-based immunosuppressive therapy (IST) as a first- or second-line treatment. The overall response rate was comparable to that of patients treated with CsA (18 patients). However, there were no cutaneous side effects observed in patients receiving tacrolimus, a relatively common finding with CsA use. Our data suggest that tacrolimus-based IST is a potential option in AA and might have a more favorable toxicity profile compared to CsA.

Expression of type III collagen in hypertrophic gingival tissue of patients with orthodontic treatment: a pilot study / Expresión del colágeno tipo III en tejido con hipertrofia gingival de pacientes con tratamiento ortodóntico: un estudio piloto

ABSTRACT Introduction: gingival hypertrophy (GH) is the uncontrolled increase in gingival volume induced by different etiological factors, including orthodontic treatment. This pathology is characterized by changes in epithelial and connective tissue, including modifications in the extracellular matrix. The present study determined the presence and distribution of type III collagen in tissues of patients with GH wearing fixed orthodontic appliances. Methods: 12 samples of gingival tissue were obtained from patients undergoing periodontal surgery. They were divided into two groups, the first with healthy patients (control; n = 6) and the second with patients diagnosed with GH and orthodontic treatment (patients; n = 6). Each obtained sample was subjected to the hematoxylin-eosin stain, Masson-Goldner staining, and type III collagen immunohistochemistry. Results: the hematoxylin-eosin and Masson-Goldner histological stains showed hypertrophia of epithelial tissue and connective tissue with a marked collagen fiber increase in the gingival tissue of orthodontic wearers with GH compared to individuals in the control group. The gingival tissue of patients with GH caused by orthodontic treatment showed a distribution and location of type III collagen near the basal lamina, around the blood vessels, but unlike the control group, its location was noticeable throughout the connective tissue. Conclusion: the gingival tissues of orthodontic wearers with GH experience an increase in the number and density of collagen fibers. Type III collagen seems to lose its usual location in the gingival tissues of orthodontic wearers with GH.

RESUMEN Introducción: la hipertrofia gingival (HG) es el aumento descontrolado del volumen de la encía debido a diversos factores etiológicos, entre ellos el tratamiento ortodóntico. Esta patología se caracteriza por cambios del tejido epitelial y conectivo, incluyendo modificaciones en la matriz extracelular. El presente estudio determinó la presencia y distribución de colágeno tipo III en tejidos de pacientes con HG portadores de ortodoncia fija. Métodos: se obtuvieron 12 muestras de tejido gingival de pacientes sometidos a cirugías periodontales. Se dividieron en dos grupos, el primero, integrado por pacientes sanos (control; n=6), y el segundo por pacientes diagnosticados con HG con ortodoncia (pacientes; n=6). Cada muestra obtenida fue sometida a la coloración hematoxilina-eosina, Masson-Goldner e inmunohistoquímica del colágeno tipo III. Resultados: las tinciones histológicas hematoxilina-eosina y Masson-Goldner permitieron constatar hiperplasia del tejido epitelial y un tejido conectivo denso con notable aumento de las fibras de colágeno en el tejido gingival de los pacientes con HG portadores de ortodoncia en comparación con los individuos del grupo control. El tejido gingival de pacientes con HG por ortodoncia evidenció una distribución y localización del colágeno tipo III cerca de la lámina basal, alrededor de los vasos sanguíneos, pero a diferencia del grupo control, su localización fue notoria en toda la extensión del tejido conectivo. Conclusión: los tejidos gingivales de pacientes con HG portadores de ortodoncia experimentan aumento en número y densidad de las fibras de colágeno. El colágeno tipo III parece perder su localización habitual en los tejidos gingivales de pacientes con HG portadores de ortodoncia.

Tratamiento no quirúrgico del agrandamiento gingival asociado a la pubertad: reporte de caso clínico / Non-surgical treatment of gingival enlargement associated with puberty: a clinical case report

RESUMEN Introducción: los agrandamientos gingivales suelen tratarse a través de terapias quirúrgicas de gingivectomías; su tratamiento no quirúrgico mecánico también es una opción sobre todo en los casos de gingivitis asociada a la pubertad como consecuencia de los cambios hormonales. Objetivo: describir el tratamiento no quirúrgico de una paciente de 12 años con agrandamiento gingival asociado a la pubertad y lesiones gingivales inducidas por biofilm dental. Presentación del caso: el caso presentó un agrandamiento gingival leve localizado que remitió al cabo de un mes a la primera fase de tratamiento, después de tres sesiones de fisioterapias con la remoción de biofilm calcificado se obtuvo una reducción del porcentaje del índice de higiene oral sin requerir intervención quirúrgica. A los cuatro años de seguimiento se observó reducción completa del agrandamiento gingival y bolsas periodontales. Conclusiones: la terapia periodontal mecánica es una alternativa eficaz en la reducción de la inflamación gingival inducida por hormonas durante la pubertad sin la necesidad de requerir intervenciones quirúrgicas para el tratamiento del agrandamiento gingival. Otras alternativas como las gingivectomías son aplicables; sin embargo requieren procedimientos más complejos, costosos y aumento de la morbilidad del paciente; en ese sentido el tratamiento mecánico no quirúrgico se muestra como una opción viable(AU)

ABSTRACT Introduction: Gingival enlargement is usually treated with gingivectomy as an alternative to surgery; however, non-surgical mechanical treatment is another option especially in cases of gingivitis associated with puberty as a result of hormonal changes. Objective: To describe the non-surgical treatment of a 12-year-old patient with gingival enlargement associated with puberty and gingival lesions induced by dental biofilm. Case presentation: The patient presented a localized mild gingival enlargement that relapsed to the first phase of treatment after one month. Three months after physiotherapy sessions with removal of calcified biofilm, a reduction in the percentage of oral hygiene index to "good" was obtained; therefore, surgical treatment was not required. Four years later, there was a complete reduction in gingival enlargement and periodontal pockets. Conclusions: Mechanical periodontal therapy is an effective alternative to reduce gingival inflammation induced by hormones during puberty not requiring surgical intervention to treat gingival enlargement. Other alternatives such as gingivectomies are performed; however, they require more complex, expensive procedures and they can also increase patient morbidity. In that sense, the uniqueness of the non-surgical mechanical treatment is chosen as a feasible option(AU)

Hiperplasia gengival durante uso de ciclosporina / Gingival hyperplasia during cyclosporine use

Paciente do sexo masculino, com 24 anos, portador de dermatite atópica desde o primeiro ano de vida. Começou a evoluir com forma grave da dermatite atópica aos 17 anos, e devido à refratariedade clínica ao tratamento convencional tópico, foi encaminhado para serviço de referência. Após otimizar os cuidados com uso de emolientes, corticoides tópicos e cursos de antibioticoterapia, manteve persistência de eczema generalizado, com SCORAD oscilando entre 40 e 50 no período de 4 meses. Dessa forma, optou-se por terapia sistêmica, sendo iniciado o uso de ciclosporina oral na dose de 200 mg. A resposta terapêutica com a ciclosporina foi percebida após 4 semanas, sendo refletida na redução do escore de gravidade (SCORAD=10). Durante o seguimento, além da melhora clínica, eram monitorados potenciais eventos adversos. O paciente fez uso da ciclosporina durante 5 anos sem apresentar eventos adversos, com necessidade de aumento de dose para 300 mg/dia dois anos após início da medicação. Porém, neste quinto ano de uso da ciclosporina, o paciente apresentou hipertrofia gengival importante. Assim, optou-se por reduzir a dose de ciclosporina de 300 para 200 mg/dia. Nenhum outro sinal ou sintoma foi observado, e os exames laboratoriais também não mostraram qualquer toxicidade. O paciente se mostrou resistente à redução da medicação, pois o temor de piora das lesões de pele o aflige muito. Orientamos sobre a necessidade de melhorar a higiene bucal de forma disciplinada, e agendamos reavaliação clínica mensal. Além disso, foi encaminhado para avaliação odontológica.

A 24-year-old man had atopic dermatitis since the first year of life. He first developed a severe form of atopic dermatitis at the age of 17, and because of clinical refractoriness to conventional topical treatment, he was referred to an excellence center. After care was optimized with emollients, topical corticosteroids and courses of antibiotic therapy, generalized eczema persisted, with Scoring Atopic Dermatitis (SCORAD) score oscillating between 40 and 50 in a period of 4 months. Thus, systemic therapy was chosen, with use of oral cyclosporine at a dose of 200 mg. Therapeutic response with cyclosporine was observed after 4 weeks, with a reduction in the severity score (SCORAD = 10). During followup, in addition to clinical improvement, potential adverse events were monitored. The patient used cyclosporine for 5 years with no adverse events, requiring a dose increase to 300 mg 2 years after initiating the medication. However, in the 5th year of cyclosporine use, the patient had significant gingival hyperplasia. Thus, we decided to reduce the dose of cyclosporine from 300 to 200 mg. No other signs or symptoms were observed and laboratory tests also showed no toxicity. The patient was resistant to reducing the medication, as he feared the skin lesions would aggravate. We advised him on the need to improve oral hygiene in a disciplined manner and scheduled a monthly clinical reevaluation. In addition, he was referred to dental evaluation.

Oral Manifestations of Autoimmune Neutropenia: A Case Report.

Autoimmune neutropenia is a self-limiting condition characterized by the presence of granulocyte-specific autoantibodies. This case report describes a 2-year-old female who presented to the Department of Pediatric Dentistry with a history of oral ulceration, complicated by high temperature, gingival hypertrophy and gingival hemorrhage. These symptoms had precipitated an admission to a district general hospital and diagnosis of viral tonsillitis. The severity of the presentation to the Pediatric Dental Department prompted a review of recent discharge blood investigations, which revealed a neutrophil count of 0.07×109/L(1.0-8.5 ×109/L) indicating severe neutropenia. Urgent referral to Pediatric Hematology resulted in same-day admission and a diagnosis of autoimmune neutropenia was established. The patient was managed with chlorhexidine mouthwash, prophylactic antimicrobial and antifungal medication and granulocyte colony stimulating factor (G-CSF). Neutropenia may present with features exclusive to the oral cavity. Recognition of atypical presentations such as oral ulceration with associated systemic illness may assist in early diagnosis.

Medical Complications Of Renal Transplant - 2 Years' Experience At Armed Forces Institute Of Urology.

BACKGROUND: Renal transplant is the renal replacement therapy of choice for all patients of chronic kidney disease. The aim of this study was to analyse the trends of medical complications in renal transplant recipients at our centre. METHODS: it is a prospective cross sectional descriptive study. All the patients undergoing renal transplant at Armed Forces Institute of Urology from September 2013 to September 2015 were included in the study. The patients were followed prospectively till March 2016 and a complete data about their complications and lab investigations was maintained.. RESULTS: This study included a total of 63 patients with a mean duration of follow-up of 14.05 months (SD±4.45). Infective complications as a group are the commonest complication occurring in over 50% of cases followed by haematological complications (17.5%), new onset diabetes after transplant (15.9%) and transplant dysfunction (14.3%) Cardiovascular complications were seen in only 4.8% cases but with high mortality. Gingival hypertrophy was seen in 4.8% cases. CONCLUSIONS: Medical complications are common after renal transplant especially in the early post-operative period. The only way forward is early recognition and aggressive treatment, as delays can cost losses in the form of kidney function, life and higher health care cost.