available at www.jstage.jst.go.jp/browse/islsm
CASE REPORT
CO2 LASER TREATMENT OF DRUG-INDUCED GINGIVAL OVERGROWTH - CASE REPORT Carlo Fornaini 1,2 and Jean Paul Rocca 1,2
1: Faculty of Dentistry, University of Nice-Sophia Antipolis, Nice, France 2: Laser Surgery Unit, University Hospital “St. Roch”, Nice, France
INTRODUCTION Possibility, by several drugs, to produce, as collateral effect, gingival overgrowth, is largely described in literature 1,2) since 1939, when Kimball, reported for the first time the case of a hyperplasic modification in the gum of an epileptic patient treated with Dilantin. Actually, the agents causing gingival hyperplasia belong to three categories: anticonvulsivants (Phenytoin), immunosuppressant (Cyclosporine A) and calcium channel blockers for cardiovascular disease. 3) The last belongs to the so called “calcium channel blockers” and its main action is to stop the passage of Ca++ ions through the membranes of the muscular cells of vessels and heart without modifying the haematic level of the calcium; in this way the contractile processes of the main arteries and coronaries are inhibited. 4-6) Gingival overgrowth normally appears within 13 months after the start of therapy, beginning from the interdental papilla; 7) clinical manifestation usually is similar with different type of drugs, even if some authors reported a more lobulated and hyperaemic gingival for patients treated with Cyclosporin A. 8) Histopathologic characteristics of gingival lesions are very similar independently from the drug assumed, and they consist in an excessive accumulation of extracellular matrix proteins (e.g. collagen) or amorphous ground substance, with a connective tisAddressee for Correspondence: Carlo Fornaini MD, DMD, MSc Faculty of Dentistry University of Nice-Sophia Antipolis Nice, France E-mail: [email protected] ©2012 JMLL, Tokyo, Japan
sue response more implicated than epithelial cell layer involvement; 9) it is also always present a lympho-plasmocitary infiltrate, typical of chronic inflammation even when an acute flogosis, due to the bacterial plaque in the sulcular areas, is associated. 10,11) In these conditions, when the anamnestic investigation leads to the hypothesis of a relation between the agent assumed and the conditions of gums, it is mandatory to contact the specialist who prescribed the agent in order to substitute this drug with another, if possible. The surgical therapy is not easy, due to the particular general clinical situation of these patients: 12) even if, in most important cases conventional intervention by scalpel must be done during hospitalization in order to have a control of bleeding because, in this kind of patient, risk is very high, 13,14) several authors proposed also the use of laser surgery in alternative to conventional intervention: less bleeding and pain, easier post-operative period, much less wound contraction and scarring are the advantages of this technique vs. scalpel. 15) Use of several different wavelengths to treat gingival overgrowth, such Argon, Nd:YAG, Diode, Er,Cr:YSGG, Er:YAG and CO2 has been reported in several works, 16-18) but in the case below described we decided to use Carbon Dioxide Laser, considering the importance of the lesion, the age of the patient and his general health conditions. 19) CO2 is a gas active medium laser which emits a beam of 10600 nm, in region of far infrared spectrum, with a great affinity for water and, even if it Manuscript received: Novembre 19th, 2011 Accepted for publication: January 17th, 2012 J-STAGE advance published: January 22nd, 2012
Laser Therapy 21.1: 39-42
39
CASE REPORT generally has a delivery system by articulated arm, it can also be distributed by hollow fibbers; the great advantage of this laser is that it can emit in CW (Continuous Wave), in Pulsed Mode and also in Superpulsed Mode and this last way allows to control thermal elevation in target tissue. In this case we decided to utilise it in two modalities, superpulsed to make ablation and CW to produce coagulation in the tissue.
CLINICAL CASE Patient DL, 75 years old male, came to the hospital for a great inflammation of gum and, at clinical observation, it was appreciated a situation of gingival overgrowth with oedema and bleeding of the gum, associated to poor oral hygiene conditions. The patient told he had a great discomfort related to eating. Clinical history of the patient revealed he was in treatment by several years with Nifepidine to control his chronic hypertension and his medical doctor was soon contacted in order to take in consideration to change the drug; according with patient, a laserassisted surgical intervention was chosen to reduce the hypertrophy of the gum. Considering the age of the patient, his general conditions and the state of great inflammation and bleeding of the gums, we decided to use CO2 laser, in order to have a great coagulation of the wound; before intervention patient was treated by dental
Fig. 1: Patient before oral care 40
available at www.jstage.jst.go.jp/browse/islsm
hygienist and instructed to maintain an adequate oral hygiene. The intervention was made in three sessions, with an interval of one week between every session and the laser appliance used was Miran 25 Mediclase (Israel). Before every session anaesthesia of the area of intervention was obtained by injection of a phial of carbocaine; then, a first passage to make ablation of the hypertrophic tissue was applied in Superpulsed Mode (10 W, 250 Hz, 300 µsec pulse duration), followed by a second passage performed in CW (4 W) to make coagulation in order to reduce bleeding and avoid use of suture. A sample of the excised gum was sent to pathologist in order to make histological examination: diagnosis of gingival hypertrophia was confirmed also from a histological point of view. After intervention no drugs were prescribed to patient and evaluation of pain, made by a form filled by the patient, showed the absence of any significant postoperative problem; the complete healing process was observed after three weeks and the observations made monthly did not show any relapse, even if the very poor hygienic conditions of the patient. We may conclude that the use of CO2 superpulsed laser is a great opportunity to treat important pathological situations of gum, even in patients with general health problems with success and comfort of patients.
Fig. 2: After first surgical session Fornaini C. and Rocca J.P.
available at www.jstage.jst.go.jp/browse/islsm
CASE REPORT
Fig. 3: Samples to pathological examination
Fig. 4: Patient before the second surgical session
Fig. 5: Patient after second surgical session
Fig. 6: Patient after third surgical session
Fig. 7: Patient one month after last intervention
Fig. 8: Patient one year after intervention
LASER TREATMENT OF GINGIVAL OVERGROWTH
41
CASE REPORT
available at www.jstage.jst.go.jp/browse/islsm
References 1: Kataoka M, Kido J, Shinohara Y, Nagata T.: Druginduced gingival overgrowth--a review. Biol Pharm Bull. 2005 Oct;28(10):1817-21. 2: Tajani AH, Nesbitt SD.: Gingival hyperplasia in a patient with hypertension. J Clin Hypertens (Greenwich). 2008 Nov;10(11):863-5. 3: Thompson AL, Herman WW, Konzelman J, Collins MA.: Treating patients with drug-induced gingival overgrowth. J Dent Hyg. 2004 Fall;78(4):12. Epub 2004 Oct 1. 4: Fourtounas C, Vlachojannis JG. : Gingival hyperplasia and calcium channel blockers. J Clin Hypertens (Greenwich). 2009 Feb;11(2):111. 5: Meisel P, Schwahn C, John U, Kroemer HK, Kocher T.: Calcium antagonists and deep gingival pockets in the population-based SHIP study. Br J Clin Pharmacol. 2005 Nov;60(5):552-9 6: Palattella A, Marano G, Bollero P, Tomarelli F.: Gingival overgrowth with calcium-channel blockers. Treatment options. Minerva Stomatol. 2005 Jun;54(6):339-49. 7: Bullon P, Gallardo I, Goteri G, Rubini C, Battino M, Ribas J, Newman HN.: Nifedipine and cyclosporin affect fibroblast calcium and gingiva. J Dent Res. 2007 Apr;86(4):357-62. 8: Gonçalves SC, Díaz-Serrano KV, de Queiroz AM, Palioto DB, Faria G.: Gingival overgrowth in a renal transplant recipient using cyclosporine A. J Dent Child (Chic). 2008 Sep-Dec;75(3):313-7. 9: Lafzi A, Farahani RM, Shoja MA. : Phenobarbitalinduced gingival hyperplasia. J Contemp Dent Pract. 2007 Sep 1;8(6):50-6. 10: Wynn RL. : Calcium channel blockers and gingival hyperplasia--an update. Gen Dent. 2009 MarApr;57(2):105-7. 11: Lucchesi JA, Cortelli SC, Rodrigues JA, Duarte PM.: Severe phenytoin-induced gingival enlargement
42
associated with periodontitis. Gen Dent. 2008 MarApr;56(2):199 12: de Carvalho Farias B, Cabral PA, Gusmão ES, Jamelli SR, Cimões R.: Non-surgical treatment of gingival overgrowth induced by nifedipine: a case report on an elderly patient. Gerodontology. 2009 Jun 22 13: Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM. The efficacy of three different surgical techniques in the management of drug-induced gingival overgrowth. J Clin Periodontol. 2006 Sep;33(9):677-82. Epub 2006 Jul 20. 14: Vorkas CK, Gopinathan MK, Singh A, Devinsky O, Lin LM, Rosenberg PA.: Epilepsy and dental procedures. A review. N Y State Dent J. 2008 Mar;74(2):39-43. 15: Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA.: The management of drug-induced gingival overgrowth. J Clin Periodontol. 2006 Jun;33(6):4349. 16: Fornaini C, Rocca JP, Bertrand MF, Merigo E, Nammour S, Vescovi P.: Nd:YAG and diode laser in the surgical management of soft tissues related to orthodontic treatment. Photomed Laser Surg. 2007 Oct;25(5):381-92. 17: Haytac CM, Ustun Y, Essen E, Ozcelik O.: Combined treatment approach of gingivectomy and CO2 laser for cyclosporine-induced gingival overgrowth. Quintessence Int. 2007 Jan;38(1):e549. 18: Tracey R.: Soft-tissue surgery: use of the Er,Cr:YSGG laser. Dent Today. 2008 Feb;27(2):1569. 19: Gama SK, De Araújo TM, Pozza DH, Pinheiro AL.: Use of the CO2 laser on orthodontic patients suffering from gingival hyperplasia. Photomed Laser Surg. 2007 Jun;25(3):214-9.
Fornaini C. and Rocca J.P.
CASE REPORT
CO2 LASER TREATMENT OF DRUG-INDUCED GINGIVAL OVERGROWTH - CASE REPORT Carlo Fornaini 1,2 and Jean Paul Rocca 1,2
1: Faculty of Dentistry, University of Nice-Sophia Antipolis, Nice, France 2: Laser Surgery Unit, University Hospital “St. Roch”, Nice, France
INTRODUCTION Possibility, by several drugs, to produce, as collateral effect, gingival overgrowth, is largely described in literature 1,2) since 1939, when Kimball, reported for the first time the case of a hyperplasic modification in the gum of an epileptic patient treated with Dilantin. Actually, the agents causing gingival hyperplasia belong to three categories: anticonvulsivants (Phenytoin), immunosuppressant (Cyclosporine A) and calcium channel blockers for cardiovascular disease. 3) The last belongs to the so called “calcium channel blockers” and its main action is to stop the passage of Ca++ ions through the membranes of the muscular cells of vessels and heart without modifying the haematic level of the calcium; in this way the contractile processes of the main arteries and coronaries are inhibited. 4-6) Gingival overgrowth normally appears within 13 months after the start of therapy, beginning from the interdental papilla; 7) clinical manifestation usually is similar with different type of drugs, even if some authors reported a more lobulated and hyperaemic gingival for patients treated with Cyclosporin A. 8) Histopathologic characteristics of gingival lesions are very similar independently from the drug assumed, and they consist in an excessive accumulation of extracellular matrix proteins (e.g. collagen) or amorphous ground substance, with a connective tisAddressee for Correspondence: Carlo Fornaini MD, DMD, MSc Faculty of Dentistry University of Nice-Sophia Antipolis Nice, France E-mail: [email protected] ©2012 JMLL, Tokyo, Japan
sue response more implicated than epithelial cell layer involvement; 9) it is also always present a lympho-plasmocitary infiltrate, typical of chronic inflammation even when an acute flogosis, due to the bacterial plaque in the sulcular areas, is associated. 10,11) In these conditions, when the anamnestic investigation leads to the hypothesis of a relation between the agent assumed and the conditions of gums, it is mandatory to contact the specialist who prescribed the agent in order to substitute this drug with another, if possible. The surgical therapy is not easy, due to the particular general clinical situation of these patients: 12) even if, in most important cases conventional intervention by scalpel must be done during hospitalization in order to have a control of bleeding because, in this kind of patient, risk is very high, 13,14) several authors proposed also the use of laser surgery in alternative to conventional intervention: less bleeding and pain, easier post-operative period, much less wound contraction and scarring are the advantages of this technique vs. scalpel. 15) Use of several different wavelengths to treat gingival overgrowth, such Argon, Nd:YAG, Diode, Er,Cr:YSGG, Er:YAG and CO2 has been reported in several works, 16-18) but in the case below described we decided to use Carbon Dioxide Laser, considering the importance of the lesion, the age of the patient and his general health conditions. 19) CO2 is a gas active medium laser which emits a beam of 10600 nm, in region of far infrared spectrum, with a great affinity for water and, even if it Manuscript received: Novembre 19th, 2011 Accepted for publication: January 17th, 2012 J-STAGE advance published: January 22nd, 2012
Laser Therapy 21.1: 39-42
39
CASE REPORT generally has a delivery system by articulated arm, it can also be distributed by hollow fibbers; the great advantage of this laser is that it can emit in CW (Continuous Wave), in Pulsed Mode and also in Superpulsed Mode and this last way allows to control thermal elevation in target tissue. In this case we decided to utilise it in two modalities, superpulsed to make ablation and CW to produce coagulation in the tissue.
CLINICAL CASE Patient DL, 75 years old male, came to the hospital for a great inflammation of gum and, at clinical observation, it was appreciated a situation of gingival overgrowth with oedema and bleeding of the gum, associated to poor oral hygiene conditions. The patient told he had a great discomfort related to eating. Clinical history of the patient revealed he was in treatment by several years with Nifepidine to control his chronic hypertension and his medical doctor was soon contacted in order to take in consideration to change the drug; according with patient, a laserassisted surgical intervention was chosen to reduce the hypertrophy of the gum. Considering the age of the patient, his general conditions and the state of great inflammation and bleeding of the gums, we decided to use CO2 laser, in order to have a great coagulation of the wound; before intervention patient was treated by dental
Fig. 1: Patient before oral care 40
available at www.jstage.jst.go.jp/browse/islsm
hygienist and instructed to maintain an adequate oral hygiene. The intervention was made in three sessions, with an interval of one week between every session and the laser appliance used was Miran 25 Mediclase (Israel). Before every session anaesthesia of the area of intervention was obtained by injection of a phial of carbocaine; then, a first passage to make ablation of the hypertrophic tissue was applied in Superpulsed Mode (10 W, 250 Hz, 300 µsec pulse duration), followed by a second passage performed in CW (4 W) to make coagulation in order to reduce bleeding and avoid use of suture. A sample of the excised gum was sent to pathologist in order to make histological examination: diagnosis of gingival hypertrophia was confirmed also from a histological point of view. After intervention no drugs were prescribed to patient and evaluation of pain, made by a form filled by the patient, showed the absence of any significant postoperative problem; the complete healing process was observed after three weeks and the observations made monthly did not show any relapse, even if the very poor hygienic conditions of the patient. We may conclude that the use of CO2 superpulsed laser is a great opportunity to treat important pathological situations of gum, even in patients with general health problems with success and comfort of patients.
Fig. 2: After first surgical session Fornaini C. and Rocca J.P.
available at www.jstage.jst.go.jp/browse/islsm
CASE REPORT
Fig. 3: Samples to pathological examination
Fig. 4: Patient before the second surgical session
Fig. 5: Patient after second surgical session
Fig. 6: Patient after third surgical session
Fig. 7: Patient one month after last intervention
Fig. 8: Patient one year after intervention
LASER TREATMENT OF GINGIVAL OVERGROWTH
41
CASE REPORT
available at www.jstage.jst.go.jp/browse/islsm
References 1: Kataoka M, Kido J, Shinohara Y, Nagata T.: Druginduced gingival overgrowth--a review. Biol Pharm Bull. 2005 Oct;28(10):1817-21. 2: Tajani AH, Nesbitt SD.: Gingival hyperplasia in a patient with hypertension. J Clin Hypertens (Greenwich). 2008 Nov;10(11):863-5. 3: Thompson AL, Herman WW, Konzelman J, Collins MA.: Treating patients with drug-induced gingival overgrowth. J Dent Hyg. 2004 Fall;78(4):12. Epub 2004 Oct 1. 4: Fourtounas C, Vlachojannis JG. : Gingival hyperplasia and calcium channel blockers. J Clin Hypertens (Greenwich). 2009 Feb;11(2):111. 5: Meisel P, Schwahn C, John U, Kroemer HK, Kocher T.: Calcium antagonists and deep gingival pockets in the population-based SHIP study. Br J Clin Pharmacol. 2005 Nov;60(5):552-9 6: Palattella A, Marano G, Bollero P, Tomarelli F.: Gingival overgrowth with calcium-channel blockers. Treatment options. Minerva Stomatol. 2005 Jun;54(6):339-49. 7: Bullon P, Gallardo I, Goteri G, Rubini C, Battino M, Ribas J, Newman HN.: Nifedipine and cyclosporin affect fibroblast calcium and gingiva. J Dent Res. 2007 Apr;86(4):357-62. 8: Gonçalves SC, Díaz-Serrano KV, de Queiroz AM, Palioto DB, Faria G.: Gingival overgrowth in a renal transplant recipient using cyclosporine A. J Dent Child (Chic). 2008 Sep-Dec;75(3):313-7. 9: Lafzi A, Farahani RM, Shoja MA. : Phenobarbitalinduced gingival hyperplasia. J Contemp Dent Pract. 2007 Sep 1;8(6):50-6. 10: Wynn RL. : Calcium channel blockers and gingival hyperplasia--an update. Gen Dent. 2009 MarApr;57(2):105-7. 11: Lucchesi JA, Cortelli SC, Rodrigues JA, Duarte PM.: Severe phenytoin-induced gingival enlargement
42
associated with periodontitis. Gen Dent. 2008 MarApr;56(2):199 12: de Carvalho Farias B, Cabral PA, Gusmão ES, Jamelli SR, Cimões R.: Non-surgical treatment of gingival overgrowth induced by nifedipine: a case report on an elderly patient. Gerodontology. 2009 Jun 22 13: Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM. The efficacy of three different surgical techniques in the management of drug-induced gingival overgrowth. J Clin Periodontol. 2006 Sep;33(9):677-82. Epub 2006 Jul 20. 14: Vorkas CK, Gopinathan MK, Singh A, Devinsky O, Lin LM, Rosenberg PA.: Epilepsy and dental procedures. A review. N Y State Dent J. 2008 Mar;74(2):39-43. 15: Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA.: The management of drug-induced gingival overgrowth. J Clin Periodontol. 2006 Jun;33(6):4349. 16: Fornaini C, Rocca JP, Bertrand MF, Merigo E, Nammour S, Vescovi P.: Nd:YAG and diode laser in the surgical management of soft tissues related to orthodontic treatment. Photomed Laser Surg. 2007 Oct;25(5):381-92. 17: Haytac CM, Ustun Y, Essen E, Ozcelik O.: Combined treatment approach of gingivectomy and CO2 laser for cyclosporine-induced gingival overgrowth. Quintessence Int. 2007 Jan;38(1):e549. 18: Tracey R.: Soft-tissue surgery: use of the Er,Cr:YSGG laser. Dent Today. 2008 Feb;27(2):1569. 19: Gama SK, De Araújo TM, Pozza DH, Pinheiro AL.: Use of the CO2 laser on orthodontic patients suffering from gingival hyperplasia. Photomed Laser Surg. 2007 Jun;25(3):214-9.
Fornaini C. and Rocca J.P.
