Periodontics · patient case question
What is the appropriate FIRST step in managing this enlargement?
Patient case: Generalized gingival enlargement in a patient on multiple medications
Patient: Male, 45 years old
Chief Complaint: “My gums are growing over my teeth.”
Background: Epilepsy controlled on phenytoin for nine years. Hypertension on amlodipine. Renal transplant six years ago, on ciclosporin. Irregular brushing, no interdental cleaning.
Vital Signs: BP 136/86 mmHg · HR 76 bpm · T 98.2°F
Findings: Firm, pale, stippled gingival enlargement beginning at the interdental papillae and extending to cover up to a third of several clinical crowns, most marked anteriorly and on the labial surfaces. Heavy plaque and calculus. No ulceration, no fever, no lymphadenopathy.
Show answer and explanation
Correct answer: B. Rigorous plaque control with scaling and root planing, alongside liaison with his physicians about substituting the causative drugs
- A. Gingivectomy performed while plaque control remains poor and the drugs continue unchanged has a high recurrence rate. Surgery may still be needed, but it is the SECOND step, not the first.
- B. CORRECT. PLAQUE IS THE MODIFYING FACTOR. The drug creates susceptibility, but the degree of enlargement tracks the inflammatory burden — which is why meticulous scaling, root planing and oral hygiene instruction produce genuine reduction on their own. In parallel, consult the prescribing physicians: valproate or levetiracetam can replace phenytoin, a non-dihydropyridine antihypertensive can replace amlodipine, and tacrolimus causes far less enlargement than ciclosporin. Re-evaluate after resolution of inflammation and only then decide whether residual fibrous tissue needs excision.
- C. Apically positioned flap surgery with osseous recontouring addresses pocket elimination in periodontitis with bony defects. This patient has pseudopockets from enlarged tissue, not intrabony defects.
- D. Metronidazole treats anaerobic infection. Some studies report modest reduction in ciclosporin-associated enlargement, but it is adjunctive at best and is not the first step.
Note: Sequence: plaque control and drug substitution first; re-evaluate at six to eight weeks; then excise residual fibrous tissue by gingivectomy for accessible enlargement, or by an internal-bevel flap where attached gingiva is limited or bone must be exposed. Without ongoing plaque control after surgery, it recurs.