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   Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 24  |  Issue : 3  |  Page : 284-288  

Periodontal management of severe periodontitis and generalized gingival enlargement in a patient with chronic renal failure


Department of Periodontics, Dr. Ziauddin Ahmad Dental College, Faculty of Medicine, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission26-Mar-2019
Date of Decision04-Jun-2019
Date of Acceptance13-Jun-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Jaiti Uppal
Department of Periodontics, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_194_19

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   Abstract 


Gingival enlargement is a common periodontal pathology seen in medically compromised patients. Although it is not the disease itself, certain medications used to treat these chronic diseases are known to precipitate the gingival enlargement. Periodontitis (PD) and gingival enlargement have been reported increasingly in patients with chronic renal failure. Severe enlargement is detrimental to esthetics and function while having a negative impact on the overall oral health-related quality of life. Treatment of such cases requires comprehensive periodontal management by a specialist, keeping in mind the medically compromised state of the patient. This report presents a case of severe PD with generalized gingival enlargement in a 45-year-old male who was a known case of Stage 4 chronic kidney disease, obstructive uropathy, and hypertension. Gingival enlargement was managed by gingivectomy and gingivoplasty. Six months' follow-up showed no sign of recurrence.

Keywords: Chronic kidney disease, gingival enlargement, hypertension, nifedipine, obstructive uropathy


How to cite this article:
Uppal J, Trivedi H, Gupta ND, Bey A. Periodontal management of severe periodontitis and generalized gingival enlargement in a patient with chronic renal failure. J Indian Soc Periodontol 2020;24:284-8

How to cite this URL:
Uppal J, Trivedi H, Gupta ND, Bey A. Periodontal management of severe periodontitis and generalized gingival enlargement in a patient with chronic renal failure. J Indian Soc Periodontol [serial online] 2020 [cited 2020 Jun 2];24:284-8. Available from: http://www.jisponline.com/text.asp?2020/24/3/284/276960




   Introduction Top


Gingival enlargement is the pathologic enlargement of the gingiva having multiple etiologies among which drug-induced enlargement is a common reason. Drugs such as immunosuppressants, antihypertensives, and antiepileptics are chief groups causing the hypertrophy. Nifedipine is one of the common drugs used to treat hypertension, and gingival enlargement occurs in around 45% of cases. Chronic kidney disease (CKD) is a major cause of secondary hypertension, can be caused by diabetes mellitus, chronic glomerulonephritis, obstructive uropathy, autoimmune disease, and obesity.[1],[2],[3],[4],[5],[6] Uremia develops and adversely affects every system of the body, including the oral cavity and the periodontium. Poor plaque control, xerostomia, gingival enlargement promote unchecked progression of periodontitis (PD), and low renal function is associated with disrupted regulation of Vitamin D and calcium levels, which contribute to advanced bone loss.[7],[8] Systemic abnormalities, such as anemia, platelet disorder, and hypertension, can be observed in individuals with chronic renal disease. This report presents a case of severe PD with generalized gingival enlargement in a 45-year-old male who was a known case of Stage 4 chronic renal disease, obstructive uropathy, and secondary hypertension and was managed by gingivectomy and gingivoplasty for the enlargement.


   Case Report Top


A 45-year-old male reported to the department of periodontics and community dentistry, with the chief complaints of swollen gums since 3 months and pain on mastication since 1 month. According to the patient, the swelling began in the upper back jaw region and gradually swelling became diffuse involving all the gums [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d with bleeding on brushing and pain in all teeth on mastication.
Figure 1: (a and d) Generalized gingival enlargement, note mulberry-shaped nodular papillae with pale pink color and firm-fibrotic consistency

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The patient gave a significant medical history and informed consent was taken from him. He was diagnosed with obstructive uropathy and Stage 4 CKD 5 years ago. As reported by the patient, initially, he suffered from renal stone that was removed surgically. Subsequently, he developed recurrent renal stone of 5 mm diameter in the left kidney and urinary bladder. Following this, he suffered from renal fibrosis and hypotrophy and developed secondary hypertension for which he was taking antihypertensive medication (nifedipine) since 4 years.

Intraoral examination

The oral hygiene status was poor with abundant plaque and subgingival calculus. Intraoral examination revealed generalized Grade III gingival enlargement involving the interdental papillae and the marginal and attached gingiva, reddish pink in color, rounded, and bulbous contour, smooth surface texture covering most of the clinical crowns of teeth. On palpation, it had a firm-fibrotic consistency without exudation on pressure. There were deep pockets of 8–10 mm in several teeth and Grade I mobility in most of the teeth.

Investigations

Panoramic radiograph revealed generalized bone loss that was severe around molars [Figure 2]. Blood tests included complete hemogram and bleeding time, clotting time, and renal function tests.
Figure 2: Orthopantomograph showing severe generalized chronic periodontitis

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The values of blood urea, serum creatinine were raised, and serum electrolytes were under normal range except mild derangement in serum calcium phosphate ratio (hypocalcemia and hyperphosphatemia).

Diagnosis

A diagnosis of chronic PD with drug-induced gingival enlargement was made, and the patient was referred back to his nephrologist to substitute the antihypertensive drug nifedipine that is a known cause for gingival enlargement. The drug was substituted with telmisartan.

Treatment plan

Complete periodontal management was planned for the patient that included Phase 1 therapy, maintenance therapy, surgical therapy followed by supportive periodontal therapy.

Phase I therapy

Patient education and motivation about maintaining proper oral hygiene, demonstration of professional tooth brushing was done. Multiple scaling and root planing sessions were undertaken along with subgingival irrigation of 0.2% chlorhexidine for the inflammatory component to subside. Antimicrobial dose of doxycycline was prescribed as an adjunct to nonsurgical periodontal therapy to treat chronic PD followed by host modulation with subantimicrobial dose of doxycycline (20 mg × BD) for 3 months. As the enlargement did not subside after drug substitution and Phase 1 therapy [Figure 3], surgical phase was planned further.
Figure 3: (a and b) Six weeks' post-Phase 1 therapy completion. The inflammatory component has subsided leaving behind the fibrotic component of the drug-induced gingival enlargement and pockets of 5 mm

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Surgical phase

Surgical phase followed the maintenance phase in which external bevel gingivectomy was done under local anesthesia (lignocaine without adrenaline) using scalpel, periodontal knives, and curettes. Surgery was executed sextant wise in multiple visits to resect the enlarged gingiva followed by gingivoplasty to achieve a physiological gingival contour [Figure 4]a, [Figure 4]b, [Figure 4]c. Electrocautery was used to achieve hemostasis. Periodontal dressing was placed [Figure 4]d, postoperative instructions were given, and analgesic antibiotic medications were prescribed (tablet paracetamol 500 mg BD, capsule amoxicillin 500 mg TDS × 5 days). 0.2% chlorhexidine mouth rinses twice daily were advised to obtain chemical plaque control.
Figure 4: (a and b) External bevel gingivectomy followed by gingivoplasty using scalpel and Gracey curettes; (c) Haemostasis achieved with electrocautery; (d) Coe-pack placed on the surgical site

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Follow-up

The patient was kept on regular weekly recall. Healing was uneventful, and the patient was able to maintain meticulous plaque control after 6 weeks using toothbrush and dentifrice, interdental brushes, 0.12% chlorhexidine mouthwash, and warm saline rinses [Figure 5].
Figure 5: (a-e) Six weeks' postsurgery. Note physiological gingival contour achieved that is maintainable by the patient

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Six months' follow-up

Six-month follow-up of the patient revealed no sign of recurrence of the enlargement [Figure 6]. Physiological gingival contour was preserved that was maintainable by the patient's daily oral hygiene practices. There was an improvement in the renal function tests, the levels of urea and creatinine had dropped from 96 to 60 mg/dl and 8.2–3.4 mg/dl and serum electrolytes were under normal range.
Figure 6: (a-c) Six months' postsurgery follow-up showing no sign of recurrence

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   Discussion Top


CKD or chronic renal failure (CRF) is the progressive loss of renal function over a period of months or years and is defined by the National Kidney Foundation of the USA as – “Kidney damage or glomerular filtration rate <60 mL/min/1.73 m2 for more than three months.” It is classified into five stages on the basis of glomerular filtration rate and Stage 5 being the end-stage renal disease. According to the literature, patients with CKD and uremia have poor oral health and increased incidence of xerostomia, uremic stomatitis, periodontal disease, and maxillary and mandibular radiographic alterations than healthy controls.[9] Periodontal diseases that are highly prevalent among patients with CRF are gingivitis, PD, gingival enlargement that may be drug induced.[9],[10],[11] According to a recent systematic review and meta-analysis in 2018, evaluating the association between PD and CKD and the potential influence of periodontal treatment in patients with CKD, an association existed between CKD and PD and strength of this association was increased when severe PD was considered (odds ratio [OR] = 2.39 [1.70–3.36]). The association could be observed even after adjustment for major CKD risk factors or the use of precise diagnosis criteria (OR = 2.26 for severe PD [1.69–3.01]).[12] Earlier studies have reported an increased prevalence and severity of periodontal disease in patients with CKD.[13],[14] CKD patients have higher levels of systemic inflammatory markers (C-reactive protein and interleukin-6), pro-hepcidin, along with increased severity of alveolar bone loss, pocked probing depth, and clinical attachment loss that get decreased after periodontal treatment.[15],[16]

The association between CKD and PD has been poorly understood in terms of etiopathogenesis and response to periodontal treatment, some of the possible causes may include hyposalivation and xerostomia, immunocompromised status and poor wound healing, anemia, diabetes mellitus, malnutrition, and a state of general disability that may impair oral hygiene.[3],[17] Renal osteodystrophy in CKD patients may lead to severe bone loss due to increased serum/salivary osteocalcin levels.[18] Some studies also suggest that PD may contribute to systemic inflammatory burden in CKD patients on hemodialysis maintenance therapy.[19]

The patient in this report had Stage 4 CKD due to obstructive uropathy and hypertension and suffered from generalized severe PD with Grade III drug-induced gingival enlargement that did not resolve with drug substitution and nonsurgical periodontal therapy for 3 months. An earlier case report regarding severity of PD and inflammatory gingival enlargement in CKD patient showed a lack of response to nonsurgical periodontal treatment.[20] It was decided to manage the case surgically after obtaining patient consent and in coordination with patient's nephrologist. Healing was uneventful and the periodontal status was significantly improved without any sign of recurrence within 6 months of surgery. Improvement in renal function tests after successful periodontal therapy indicates a positive effect of treatment on the systemic health of the patient. Further studies and interventional trials are required to understand the bidirectional nature of PD and CKD. The patient is still on follow-up since 1 year and is periodontally stable with supportive therapy.

Nonsurgical management is usually advocated for chronic renal disease as the use of antibiotics and other anti-inflammatory drugs are a major concern in such patients. In this case report, the treatment plan started with Phase I therapy, and the inflammatory component subsided after 6 weeks of completion of nonsurgical periodontal therapy. Fibrotic nature of nifedipine-induced gingival enlargement was persistent and hindering oral hygiene maintenance. Hence, surgical therapy was planned. Regarding the use of drugs, clearance was obtained from the nephrology department for the use of drugs such as doxycycline, amoxicillin, and paracetamol. All these are effective line of drugs in periodontal therapy and can be safely administered without dose adjustment in renally compromised patients.

The precautions that were taken during surgery were stress reduction protocol, short, morning appointments, taking care of patient comfort, sextant-wise approach to limit the area of surgical wound created that would reduce patient discomfort and be conducive to healing, use of plain lignocaine without vasoconstrictor and hemostasis achieved by electrocautery, minimal use of drugs that are safe in renally compromised patients to prevent any drug interaction and adverse effect on kidneys, host modulation therapy using subantimicrobial dose of doxycycline (20 mg × BD) for 3 months to address severe bone loss associated with PD, and regular patient follow-up and motivation for self-performed oral hygiene measures.


   Conclusion Top


The current literature describing the association of PD with CRF is scarce, and no specific protocol exits for the periodontal management of CRF patients. This case report shows that when drug substitution and nonsurgical treatment does not suffice, one may opt for conservative surgical treatment to manage gingival hyperplasia and PD along with host modulation therapy in such patients. As the burden of chronic diseases is increasing globally, the number of medically compromised patients with periodontal treatment needs continue to grow, and it is on the part of the dentist to keep updated with the field of periodontal medicine for adequate management of renally compromised patients. Oral health definitely has an impact on the quality of life of such patients. Further studies are required to evaluate the effect of periodontal treatment on the systemic health of CRF patient.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Kshirsagar AV, Moss KL, Elter JR, Beck JD, Offenbacher S, Falk RJ. Periodontal disease is associated with renal insufficiency in the atherosclerosis risk in communities (ARIC) study. Am J Kidney Dis 2005;45:650-7.  Back to cited text no. 10
    
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Thorman R, Neovius M, Hylander B. Clinical findings in oral health during progression of chronic kidney disease to end-stage renal disease in a Swedish population. Scand J Urol Nephrol 2009;43:154-9.  Back to cited text no. 11
    
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Davidovich E, Schwarz Z, Davidovitch M, Eidelman E, Bimstein E. Oral findings and periodontal status in children, adolescents and young adults suffering from renal failure. J Clin Periodontol 2005;32:1076-82.  Back to cited text no. 13
    
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Messier MD, Emde K, Stern L, Radhakrishnan J, Vernocchi L, Cheng B, et al. Radiographic periodontal bone loss in chronic kidney disease. J Periodontol 2012;83:602-11.  Back to cited text no. 15
    
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Bastos Jdo A, Vilela EM, Henrique MN, Daibert Pde C, Fernandes LF, Paula DA, et al. Assessment of knowledge toward periodontal disease among a sample of nephrologists and nurses who work with chronic kidney disease not yet on dialysis. J Bras Nefrol 2011;33:431-5.  Back to cited text no. 16
    
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Klassen JT, Krasko BM. The dental health status of dialysis patients. J Can Dent Assoc 2002;68:34-8.  Back to cited text no. 17
    
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Yoshihara A, Hayashi Y, Miyazaki H. Relationships among bone turnover, renal function and periodontal disease in elderly Japanese. J Periodontal Res 2011;46:491-6.  Back to cited text no. 18
    
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Rahmati MA, Craig RG, Homel P, Kaysen GA, Levin NW. Serum markers of periodontal disease status and inflammation in hemodialysis patients. Am J Kidney Dis 2002;40:983-9.  Back to cited text no. 19
    
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