Systemic antimicrobial therapy (minocycline) as an adjunct to non-surgical approach to recurrent chronic generalized gingival hyperplasia.

Systemic antibiotic treatment has emerged as a powerful adjunct to conventional mechanical debridement for therapeutic management of the periodontal diseases. The conceptual basis for treating periodontal diseases as infections is particularly attractive in part because of substantial data indicating that these diseases may be associated with specific putative pathogens. Further, discrete groups of patients respond well to systemic antibiotics and exhibit improvement of clinical parameters, including attachment level and inflammation. This bacterial-host interaction, which is ever-so-present in periodontitis, directs us toward utilizing antimicrobial agents along with the routine mechanical debridement. This case report presents a case of a female patient with recurrence of the chronic generalized periodontitis with gingival enlargement, which is treated thrice by referral dentist. A through clinical examination was carried out pre-operatively and treatment was planned with systemic minocycline in conjunction with the conventional non-surgical approach. There was a significant reduction of pocket depth, gain in attachment with dramatic improvement clinically.

INTRODUCTION

Periodontal disease is a multifactorial disease, characterized by periodontal pocket formation, loss of clinical attachment and alveolar bone resorption. Various risk factors have been described for the onset and progression of periodontal disease. However, dynamic interactions between the bacterial factors and host response with genetic and environmental factors are considered as the primary cause for tissue destruction in periodontitis.[1] Periodontitis is an infectious disease in the gingival crevice caused by periodontopathic bacteria, including Porphyromonas gingivalis, Prevotella intermedia, Actinobacillus actinomycetemcomitans and Tennerella forsythensis and antibacterial agents are directly administered to the site of infection as chemotherapy to treat it. Due to their efficacy against periodontopathic bacteria, drugs such as minocycline (MINO), doxycycline (DOX) and tetracycline are widely used as topical therapy.[2]

In consideration to this bacterial-host response, treatment approach to periodontitis should be conventional mechanical debridement and the use of pharmacotherapeutic agents.

Antibiotics can often be prescribed to patients who are non-responsive to conventional mechanical therapy, for patients with acute periodontal infections associated with systemic manifestations, as a prophylactic agent in medically compromised patients and as an adjunct to mechanical therapy.[3] Tetracycline's are broad-spectrum antibiotics, which inhibit ribosomal protein synthesis and may also serve as a bacteria-reducing and host-modulating agent.[4]

MINO is a semi-synthetic derivative of tetracycline. This drug is mainly used for the treatment of acne, chronic respiratory diseases and rheumatoid arthritis. MINO has many advantages over other tetracycline's, e.g. both anti-inflammatory as well as antibiotic properties, better absorption, increased antimicrobial activity and negligible or no phototoxicity.[5] Being lipid soluble, MINO can easily penetrate into various body fluids, such as saliva and gingival crevicular fluid and can act locally at the site of infection. Clinical trials of the treatment of periodontal diseases have revealed that most forms of disease are treated predictably by conventional periodontal therapy and that the established periodontal health can be maintained for a long period of time with proper maintenance care programs.[6]

CASE REPORT

A 28-year-old female patient reported with the complaints of generalized swollen gums since last 1 year, preventing proper speech and mastication. Detailed case history disclosed that in last 4 years she has been operated for the same problem four times by the dentist once full mouth open flap debridement and three times gingivectomy was performed, but again causing the recurrence of gingival enlargement within 4-5 months. Patient was generally healthy, but displayed a long-term history of advanced unsuccessfully treated periodontal disease.

Examination

Extra oral examination revealed that patient has incompetent averted lips and convex profile. No significant family history. No harmful habits.

An intraoral examination revealed generalized diffused, nodular enlargement of gingiva, more on the right side. Gingiva was fiery red in color with soft and spongy consistency and bleeding on slightest of provocation. The teeth were covered with enlarged gingiva until the middle one-third [Figure 1a–c].

Figure 1

(a) Recurrent gingival hyperplasia anterior view. (b) Recurrent gingival hyperplasia right posterior view. (c) Recurrent gingival hyperplasia left posterior view

Generalized re-infected periodontal pocket of 7 mm or more. Gingival inflammation was recorded using papillary bleeding index score system (PBS) after gentle probing along the gingival margin up to 3 mm subgingivally. Finally probing pocket depth (PD) and loss of attachment was assessed to the nearest mm using graduated periodontal probe with a point diameter of 0.4 mm.

Investigations

Panoramic radiograph revealed generalized horizontal bone loss [Figure 2] and teeth no. 11, 21, 45 and 46 were root canal treated with crowns on them. Pre-operative incisional biopsy of the gingival hyperplastic tissue was taken from upper right canine palatal papillary gingiva from esthetic consideration. The tissue on the microscopic examination [Figure 3] revealed the parakeratotic stratified squamous epithelium with elongated, hyperplastic retepegs with acanthosis. The loosely arranged fibro collagenous connective tissue component shows the marked response of chronic inflammatory cells chiefly lymphocytes, plasma cells, polymorphs and some mast cells and also increased proliferation of capillaries due to the inflammatory response. Hematological investigations showed all the blood elements within the normal limits.

Figure 2

Panoramic radiograph showing generalized horizontal bone loss

Figure 3

Histological preoperative incisional biopsy (H and E, ×40)

Diagnosis and treatment

At routine reexamination by the specialist recurrent periodontal disease was diagnosed. Despite increased understanding of the etiology and pathogenesis of periodontal infections, the diagnosis and classification of these diseases is still based almost entirely on traditional clinical assessments. And this patient was diagnosed as recurrent periodontitis with gingival hyperplasia. An intense treatment plan was therefore designed for the patient, comprising of systemic antimicrobial therapy and mechanical plaque control (non-surgical periodontal therapy).

Thus, non-surgical periodontal therapy in the form of scaling and root planning was chosen as the mode of therapy along with systemic administration of MINO and written informed consent was taken from the patient. MINO modified released 100 mg (Minoz OD, Ranbaxy) once daily was advised to start with for 1 week. After 1 week the prognosis was better and there was a gradual reduction in gingival hypertrophy and PD, so MINO was continued as an adjunct for another 1 week [Figure 4a–c].

Figure 4

(a) Reduction of gingival hyperplasia anterior view at 1st week. (b) Reduction of gingival hyperplasia right posterior view at 1st week. (c) Reduction of gingival hyperplasia left posterior view at 1st week

On recall visits at the end of 2 weeks, patient showed good improvement with reduction of gingival enlargement. On periodontal examination, gingival shows coral pink color, firm and resilient consistency and no bleeding on probing indicating of healthy gingival [Figure 5a–c] periodontal pocket measuring 3 mm or less. PBS (Gusberti et al. 1983) results inference as normal indicating a reduction in gingival inflammation. Gain in the attachment level was seen post operatively. Furthermore, patient could maintain oral hygiene procedure routinely without any discomfort, pain, or bleeding. Patient was advised to stop the medication after 2 weeks and was kept on regular follow-up for next 1 year with every month check-up.

Figure 5

(a) Post-treatment healthy overall gingiva anterior view at 2nd week. (b) Post-treatment healthy overall gingiva right posterior view at 2nd week. (c) Post-treatment healthy overall gingiva left posterior view at 2nd week

DISCUSSION

Treatment of recurrent periodontal disease was planned with non-surgical periodontal therapy along with systemic antimicrobial therapy and compared pre-operative and post-operative periodontal status. There was a gradual reduction of probing depth and gain in clinical attachment. This likely represents a decreased disease activity compared with a general supportive periodontal therapy (SPT) population.[7] Several research reports indicate that full mouth treatment with antimicrobial results in a more positive clinical response overall which may be due to the decrease in the bacterial load.[8] This case report is a strong evidence of the benefits of non-surgical periodontal therapy with systemic MINO in the same patient.

Research indicates that tetracycline may be used in conjunction with scaling and root planning in SPT patient or as a monotherapy in refractory periodontitis patients[9] with considerable success. McCulloch et al.[9] conducted a placebo controlled randomized controlled trial of systemic DOX in subject included on the basis of their treatment history and clinical evidence of gingival attachment loss or recurrent abscess following scaling and root planning (SRP) therapy in the preblinding, pre-assignment period. The outcome was positive as the DOX group experienced a 43% reduction in risk of recurrence in a 7 month period relative to the placement to the placebo group. Thus, this study strongly supported this case as there was gradual reduction of probing depth and gain in attachment with good improvement in clinical gingival health. Clinical improvement corresponded to biological outcomes of reduction in total bacterial load and collagenase activity.[10] This prop up the case, as there was gradual reduction in bleeding on probing and gingival inflammation, like reduction in papillary bleeding index score.

Haffajee et al.[11] have conducted studies monitoring clinical and microbiological variables in patients displaying various rates of progressive gingival attachment loss before and after treatment by surgical combined with systemic administration of tetracycline-hydrochloride. As the MINO is a broad spectrum antimicrobial agent, which acts systemically on gingiva by the host microbial action in recurrent periodontal therapy.

The conventional periodontal therapy is the removal of bacterial biofilm and supra and subgingival calculus, as much as possible. However, because of the lack of visibility to the subgingival areas, complete plaque and calculus removal is difficult to achieve. Waerhaug described that non-surgical scaling and root planning is not capable of removing subgingival deposits in sites with probing depths exceeding 5 mm.[12] Therefore, the use of antimicrobial agents in conjunction with periodontal therapy was proposed.

In the present case, there were significant improvements in all clinical parameters on follow-up visits. This is the expected outcome in association with non-surgical periodontal therapy. These results were also consistent with previous studies where MINO was administered systemically. Basegmez et al.[13] also found reduction in gingival inflammation and probing PD in the MINO group and they suggested that additional use of systemic MINO demonstrated improvement on metalloproteinases-8 and prostaglandin E2. They also speculated that MINO has a kind of host-modulating capacity when used systemically for 2 weeks.[13] Studies also evidenced that tetracycline accumulates within phagocytes. This accumulation could potentially improve the intracellular killing of the bacteria. Migration of neutrophils with tetracycline to the infected site could potentially boost the concentration of tetracycline at local sites. Neutrophils tendency to penetrate site of infection in great numbers could result in enhanced tetracycline action.[14]

CONCLUSION

Systemic administration of antimicrobial therapy in conjunction with scaling and root planning is a powerful management for recurrent periodontal disease. Even though, recurrence cannot be predicted, psychological and functional benefits far outweigh the recurrence. Oral hygiene maintenance and the plaque accumulation have a very crucial effect on prognosis of any periodontal therapy. Long-term follow-up will be required to evaluate the predictability of the therapy carried out.