Journal of Indian Society of Periodontology
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   Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 25  |  Issue : 4  |  Page : 350-354  

Self-correction of pathologic tooth migration after nonsurgical periodontal treatment in a metabolic syndrome patient with severe periodontitis and drug-influenced gingival enlargement


1 Sinhon Dental Clinic, Taichung City, Taiwan
2 Department of Stomatology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
3 Department of Stomatology, National Cheng Kung University Hospital, Tainan City, Taiwan

Date of Submission10-Jun-2020
Date of Decision18-Aug-2020
Date of Acceptance30-Aug-2020
Date of Web Publication01-Jul-2021

Correspondence Address:
Kuo Yuan
Department of Stomatology, National Cheng Kung University Hospital, 138 Sheng.Li Road, Tainan City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_417_20

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   Abstract 


Drug-influenced gingival enlargement (DIGE) and reduced bone support caused by periodontitis are two of the etiologic factors for pathologic tooth migration (PTM). Comprehensive management, including surgical, orthodontic, and prosthodontic treatment, is usually required for recovery from severe DIGE and PTM. An 85-year-old Taiwanese male with a history of hypertension and uncontrolled diabetes mellitus (DM) visited our dental department for severe gingival enlargement and spontaneous bleeding. He was diagnosed as having advanced periodontitis and DIGE. Remarkable PTM occurred on the front sextants of his dentition. The patient's DM was gradually controlled, and his calcium channel blocker treatment was substituted with a new regimen for 7 months. One year after nonsurgical periodontal treatment and reinforcing the patient's oral care, both DIGE and PTM were spontaneously resolved without any surgical or orthodontic intervention. We advocate the value of early diagnosis, improving patient's oral hygiene, and meticulous nonsurgical treatment for both DIGE and PTM.

Keywords: Calcium channel blockers, gingival overgrowth, periodontal debridement, periodontal diseases, tooth migration


How to cite this article:
Lee HC, Wu CN, Yuan K. Self-correction of pathologic tooth migration after nonsurgical periodontal treatment in a metabolic syndrome patient with severe periodontitis and drug-influenced gingival enlargement. J Indian Soc Periodontol 2021;25:350-4

How to cite this URL:
Lee HC, Wu CN, Yuan K. Self-correction of pathologic tooth migration after nonsurgical periodontal treatment in a metabolic syndrome patient with severe periodontitis and drug-influenced gingival enlargement. J Indian Soc Periodontol [serial online] 2021 [cited 2021 Aug 4];25:350-4. Available from: https://www.jisponline.com/text.asp?2021/25/4/350/319663




   Introduction Top


Patients may develop gingival enlargement (GE) after taking specific drugs, such as calcium channel blockers.[1],[2] Strong evidence has indicated that poor oral hygiene exacerbates drug-induced GE (DIGE).[3] Furthermore, diabetes mellitus (DM) has been reported to affect GE although the underlying mechanisms remain unclear.[4] Pathologic tooth migration (PTM) is highly prevalent in patients with severe periodontitis.[5],[6],[7] Multiple factors are involved in PTM pathogenesis.[5] Several reports also suggest that DIGE can cause PTM.[8],[9],[10] Regarding treatment protocols for severe DIGE and PTM, one study suggests that surgical correction is warranted for DIGE with a gingival overgrowth index of >30%.[11] Treatment of severe PTM frequently involves orthodontic therapy.[5] This report presents the nonsurgical management of a case of advanced periodontitis complicated with type 2 DM, hypertension, and DIGE. Near-complete resolution of the DIGE and PTM was achieved after medical and dental care without surgical or orthodontic interventions.


   Case Report Top


An 85-year-old Taiwanese male with a history of hypertension was admitted to the emergency department of our hospital, reporting unexplained weight loss and frequent urination persisting for several days. His nonfasting blood glucose level was 777 mg/dL. He had been taking amlodipine and enalapril maleate for 14.5 years to control his hypertension. During his hospitalization, he was diagnosed with type 2 DM and referred to our dental department for severe GE and spontaneous bleeding. The dentist made a diagnosis of DIGE and recommended that alternative treatments be administered to control the patient's hypertension. A physician specialized in metabolic medicine replaced amlodipine and enalapril maleate with valsartan + hydrochlorothiazide (Co-Diovan®, Novartis, London, United Kingdom) for hypertension and prescribed metformin to control the patient's DM. The patient was discharged 12 days later. After 7 months of discharge, the aforementioned physician switched the patient's hypertension regimen again to benazepril + amlodipine (Amtrel®, TTY Biopharm, Taipei, Taiwan). According to his latest blood test results, his HbA1c was as normal as 6.3%.

The patient visited our outpatient dental clinic because of severe swollen and erythematous gum, which had been deteriorating over the previous 3 months. Oral examination revealed that his oral hygiene was poor. Severe GE was noted throughout all quadrants [Figure 1]. His gingival overgrowth index (as established by Seymour et al.)[12] was 90%. All teeth had a probing depth of ≥7 mm at the deepest site. According to the patient's self-observation, teeth #13–23 and #43–44 had significant PTM [Figure 1] and [Figure 2]. The radiographs revealed generalized severe bone loss, particularly in teeth #16 and #26 [Figure 3]. The patient gave oral consent for treatment.
Figure 1: Full-mouth intraoral photographs were taken at the initial examination. The severe gingival enlargement was generalized. Anterior teeth displacement and multiple diastemas were noted

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Figure 1: Full-mouth intraoral photographs were taken at the initial examination. The severe gingival enlargement was generalized. Anterior teeth displacement and multiple diastemas were noted

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Figure 3: Full-mouth radiographs were taken at the initial examination. Generalized severe periodontal bone loss was noted

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After the necessary periodontal parameters were collected, the patient was diagnosed as having DIGE and generalized Stage IV Grade C periodontitis on the basis of the new classification system for periodontal and peri-implant diseases developed in 2017.[13] Full-mouth scaling and root planing were accomplished within 1 week, divided into four appointments. Adjunctive antibiotics (amoxicillin 250 mg q8 h + metronidazole 250 mg q8 h) were prescribed for 8 days. Oral hygiene instructions were provided continuously. The patient's oral hygiene exhibited gradual improvements during the periodontal treatment period. We suggested extraction for teeth #16 and #26, but the patient chose to postpone the procedure. The extraction of the residual root of tooth #18 and the restoration of tooth #46 caries were performed during the root planing appointments.

All the periodontal parameters were re-evaluated 5 weeks after scaling and root planing was completed. The patient's oral hygiene exhibited considerable improvement: gingival swelling, enlargement, and bleeding considerably subsided [Figure 4] and [Figure 5] and gingival overgrowth index decreased to 22%. Moreover, compared with [Figure 2], [Figure 5] illustrates a considerable reduction in the degree of PTM. Probing depths also demonstrated generalized reduction. The patient and his family refused additional surgical or prosthetic treatment. We reinforced the oral hygiene instructions and arranged for maintenance every 3 months. Teeth #16 and #26 were extracted 3 months later because of recurrent abscesses.
Figure 4: Full-mouth intraoral photographs were taken 5 weeks after initial treatment. Full-mouth gingival enlargement has subsided compared with the initial examination. Remaining gingiva inflammation was noted. The degree of diastema and tooth migration exhibited a decrease

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Figure 5: Intraoral photographs for occlusal view 5 weeks after initial treatment. Labial drifting of the upper lateral incisors and interdental spacing between all the anterior teeth was reduced

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One year after initial periodontal treatment, 94.7% of detection sites displayed a probing depths of ≤3 mm. The patient's GE and PTM exhibited a near-complete resolution [Figure 6] and [Figure 7]. His gingival overgrowth index was 4%. Radiography revealed reduction in the furcation defects in teeth #46 and #47 [Figure 8]. The patient is currently in periodontal supportive treatment every 3 months, and no further complications have been reported.
Figure 6: Full-mouth intraoral photographs were taken 1 year after initial treatment. Spontaneous realignment of anterior teeth had occurred and the gingival inflammation had subsided considerably, excluding in the interdental area between teeth #14 and #15

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Figure 7: Intraoral photographs for occlusal view 1 year after initial treatment. Tooth migration was almost completely resolved. Diastema only remained between teeth #33 and #34

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Figure 8: Full-mouth radiographs were taken 1 year after the initial examination. All the interdental spacings between anterior teeth were reduced. The radiolucent area at the furcation of teeth #46 and #47 was reduced. Teeth #17, #15, #14, and #46 exhibited new restoration. Endodontic treatment was performed for tooth #27

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   Discussion Top


This patient was first admitted to our hospital for symptoms related to undiagnosed DM. The relationship between DM and periodontitis is well documented,[14],[15] but the DM-GE association remains unclear.[4],[16] It has been long demonstrated that DM is a risk factor for periodontal diseases, as periodontitis is significantly aggravated in poorly controlled diabetic patients.[15] Although routine use of systemic antibiotics for treatment of chronic periodontitis in systemically healthy patients is not justified, studies have supported that adjunctive antibiotics are beneficial for poorly controlled diabetic patients with periodontitis.[15],[17],[18] We adopted the protocol of Miranda et al.[18] and prescribed metronidazole + amoxicillin as adjuncts to scaling and root planing for our case.

Whether change in medication, such as in this case, is essential for the alleviation of GE remains unclear. The patient's GE has not recurred thus far, despite he is being prescribed with amlodipine again by his physician. Studies have concluded that patients with DIGE can benefit from effective oral hygiene measures and nonsurgical periodontal treatment. Nonsurgical treatment can reduce gingival inflammation degree and recurrence rate. These measures could aid in avoiding or simplifying further surgical correction.[11]

A review article reported critical risk factors for PTM.[5] Our patient exhibited at least two of these potential risk factors: Severe periodontal bone loss and inflammatory tissue pressure from both periodontitis and DIGE. Professional nonsurgical treatment in conjunction with improved oral care is very effective in controlling periodontal inflammation.[19] Studies have revealed that spontaneous correction of mild PTM (≤2 mm) frequently occurs after periodontal (nonsurgical/surgical) therapy alone.[5],[9],[10],[20] Dadlani et al. suggest that moderate PTM cases require a combination of periodontal and minor orthodontic treatment, while teeth with severe PTM usually cannot be saved and are best replaced with prosthodontic therapy.[20] Our patient with severe PTM and DIGE unexpectedly achieved a spontaneous resolution of both conditions after nonsurgical treatment alone. The follow-up radiographs indicated that the gain of periodontal bone support was only evident on the lower right sextant. Because the subsidence of DIGE and periodontitis were generalized in this patient, the resolution of his PTM was possibly due to the elimination of the pressure from inflammatory tissues in the periodontal pockets and overgrown gingiva, rather than because of increased bone support. The term “reactive positioning” has been used to describe tooth movement that occurs without the use of appliances after periodontal treatment.[21] Plausible explanation for this phenomenon includes wound contraction and re-established equilibrium of forces by healthy collagen fibers that reoccupy the tooth periodontium interface after subsidence of inflammation by periodontal therapy.[22] Furthermore, the contractile force of the transseptal fibers in the interproximal region may play an important role in PTM.[5] Interdental papillae are usually the initiation and most severe sites for DIGE.[2],[3] Resolution of DIGE in the interproximal region after periodontal treatment may facilitate repristination of the transseptal fibers and direct the teeth to their original positions.


   Conclusion Top


Dentists should consider the effectiveness of meticulous initial phase periodontal therapy and oral hygiene reinforcement on periodontitis and DIGE and the associated PTM, even in advanced cases. Most patients with GE and PTM could benefit from a nonsurgical approach, which may at the very least curtail the need for more complex and expensive surgical and restorative procedures. Reducing the need for surgical correction for DIGE is essential for patients with severe systemic diseases, such as bleeding disorders, malignancy, cardiovascular diseases, and uncontrolled DM.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Miranda TS, Feres M, Perez-Chaparro PJ, Faveri M, Figueiredo LC, Tamashiro NS, et al. Metronidazole and amoxicillin as adjuncts to scaling and root planing for the treatment of type 2 diabetic subjects with periodontitis: 1-year outcomes of a randomized placebo-controlled clinical tiral. J Clin Periodontol 2014;41:890-9.  Back to cited text no. 18
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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