Surgical removal of an oral pyogenic granuloma and subsequent root coverage with a pedicle graft

Pyogenic granuloma (PG) is a lesion characterized by non-neoplastic proliferation of endothelial cells, occurring in gingival tissue and representing an excessive reaction of the connective tissue to stimuli or injuries. The purpose of this report was to describe the treatment of an oral pyogenic granuloma, with emphasis on clinical, histopathological, and radiographic aspects. The surgical therapy comprised lesion excision followed by pedicle graft to cover the exposed root surface. The patient's pyogenic granuloma has been under control for a year, and recurrence has not been observed. The permanent teeth erupted correctly and the gingival tissue of both the receptor and donor sites shows a satisfactory clinical appearance.

P2X4 is up-regulated in gingival fibroblasts after periodontal surgery

Several studies have shown that surgical detachment of marginal gingiva close to the cervical cementum of molar teeth in a rat mandible is a distinct stimulus for alveolar bone resorption. Recently, we found that P2X4, an ATP-receptor, is significantly up-regulated in marginal gingival cells soon after surgery. We hypothesized that local release of ATP signaling through P2X4 elicits activation of osteoclasts on the alveolar bone surface. In this study, we identified intense immunoreactivity of gingival fibroblasts to P2X4-specific antibodies and a 6.4-fold increase in expression by real-time RT-PCR. Moreover, a single local application, at the time of surgery, of Apyrase (which degrades ATP) or Coomassie Brilliant Blue (an antagonist of purinoreceptors) significantly reduced alveolar bone loss. We propose that ATP flowing from cells after surgery can directly activate P2X4 receptors in the sensor cells of marginal gingiva through Ca(2+) signaling, or by direct activation of osteoclasts on the bone surface.

Extensive bleeding during surgical treatment for gingival overgrowth in a patient on haemodialysis--a case report and review of the literature

Before performing renal transplantation, a most important concern is to control any infection, including oral infections before transplantation. The bleeding diathesis of patients with uraemia is a significant clinical concern, especially when surgery is required. A 44-year-old female patient on haemodialysis was referred for evaluation of gingival overgrowth. The patient was planning a renal transplantation two months later. As the lesions were not considered successfully treatable before transplantation, a gingivectomy and teeth extraction was performed. In pre-operative examinations, an abnormal bleeding time was not detected and other coagulation tests were normal. Under general anaesthesia, 19 teeth were extracted and overgrown gingiva was removed. During the operation, extensive blood loss of 1650ml occurred and four units of concentrated red blood cells were transfused. This study suggests that patients with renal failure undergoing dental surgery require careful pre-surgical evaluation including assessment of their coagulation ability.

Post-Surgical Infections: Prevalence Associated With Various Periodontal Surgical Procedures

BACKGROUND

Of the various adverse outcomes that may be encountered following periodontal surgery, the risk of infection stands at the forefront of concern to the surgeon, since infection can lead to morbidity and poor healing outcomes. This paper describes a large-scale retrospective study of multiple surgical modalities in a diverse periodontal practice undertaken to explore the prevalence of clinical infections post-surgically and the relationship between diverse treatment variables and infection rates.

METHODS

A retrospective review of all available periodontal surgical records of patients treated in the Department of Periodontics at Wilford Hall Medical Center, San Antonio, Texas, was conducted. The sample comprised 395 patients and included 1,053 fully documented surgical procedures. Surgical techniques reviewed included osseous resective surgery, flap curettage, distal wedge procedures, gingivectomy, root resection, guided tissue regeneration, dental implant surgery, epithelialized free soft tissue autografts, subepithelial connective tissue autografts, coronally positioned flaps, sinus augmentations, and ridge preservation or augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various treatment variables was examined including the use of bone grafts, membranes, soft tissue grafts, post-surgical chlorhexidine rinses, systemic antibiotics, and dressings. Results were analyzed using Fisher's exact test and Pearson's chi-square test.

RESULTS

Of the 1,053 surgical procedures evaluated in this study, there were a total of 22 infections for an overall prevalence of 2.09%. Patients who received antibiotics as part of the surgical protocol (pre- and/ or post-surgically) developed eight infections in 281 procedures (2.85%) compared to 14 infections in 772 procedures (1.81%) where antibiotics were not used. Procedures in which chlorhexidine was used during post-surgical care had a lower infection rate (17 infections in 900 procedures, 1.89%) compared to procedures after which chlorhexidine was not used as part of post-surgical care (five infections in 153 procedures, 3.27%). The use of a post-surgical dressing demonstrated a slightly higher rate of infection (eight infections in 300 procedures, 2.67%) than non-use of a dressing (14 infections in 753 procedures, 1.86%). Despite these trends, no statistically significant relationship was found between post-surgical infection and any of the treatment variables examined, including the use of perioperative antibiotics.

CONCLUSIONS

The results of this study confirm previous research demonstrating a low rate of postoperative infection following periodontal surgical procedures. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections. Further large-scale, controlled clinical studies are warranted to determine the role of perioperative antibiotics in the prevention of periodontal post-surgical infections.

Gingival prostheses--a review

Gingival replacement is often a component of comprehensive prosthodontics. Gingival prostheses may be fixed or removable and may be made from acrylics, composite resins, silicones or porcelain-based materials. Undercuts or dental attachments are used to secure removable prostheses, which are esthetically pleasing and easy to maintain. This paper describes several clinical situations in which gingival prostheses were used effectively.

Dracula's teeth syndrome

OBJECTIVE

To describe a patient with facial pain, ipsilateral facial dystonia, and phantom supernumerary teeth, beginning after resection of hypertrophic gums. She had familial sensorineural deafness.

BACKGROUND

Atypical cranial dystonia subsequent to dental procedures is associated with facial pain, dysesthesias, or phantom phenomena, but not with phantom supernumerary teeth. Patients with migraine are susceptible to experience cephalic phantom phenomena after dental procedures. Wynne syndrome is a hereditary autosomal dominant disorder characterized by congenital sensorineural deafness and supernumerary teeth.

METHODS

Clinical examination, computerized tomography of paranasal sinuses and facial bones, magnetic resonance imaging of the brain, cranial electrophysiological testing, and electroencephalogram.

RESULTS

A 52-year-old woman with history of migraine without aura for 40 years exhibited focal right facial involuntary tonic contracture accompanying chronic severe pain over the same area after gum resection. She reported a daily sensation of having two extra upper canine teeth pressing on her tongue, simulating vampire's ("Dracula's") teeth. She had high-frequency bilateral sensorineural deafness. Her computerized tomography studies, brain magnetic resonance imaging, and cranial electrophysiological testing were normal.

CONCLUSION

This patient with chronic migraine had atypical cranial dystonia beginning after a dental procedure. Her dystonia was complicated by the unusual phenomenon of phantom supernumerary teeth. This condition may be misdiagnosed as atypical or psychogenic facial pain when facial dystonia is localized or subtle and is, therefore, confused with an idiosyncratic gesture or habitual spasm. Her signs and symptoms are reminiscent of Wynne syndrome.

Increase in volume of lignocaine/adrenaline-containing local anaesthetic solution causes increase in acute postoperative pain after gingivectomy

A randomized, single-blind, within-patient, crossover study was done in 44 patients (27 women and 17 men mean age 47 years, range 29-63) who had bilateral 'identical' gingivectomies. On one occasion a standard volume of local anaesthetic containing lignocaine 2% and adrenaline (1/80 000) was infiltrated into the mucosal tissue before operation. On the other occasion double the standard volume was infiltrated. The intensity of pain postoperatively was recorded by the patients on 100 mm visual analogue scale every hour for an 11-hour observation period. The intensity of pain when double volume had been given was significantly higher than that after the standard volume from 2 to 8 hours postoperatively (P < 0.04), the median (range) being 52.0 mm (0.0-434.0) compared with 30.5 mm (0.0-359.0) after the standard volume (P < 0.005). Doubling the volume of local anaesthetic containing adrenaline that was infiltrated increased the intensity of acute pain after gingivectomy.

Comparison of 1% and 2% lidocaine hydrochloride used as single local anesthetic: effect on postoperative pain course after oral soft tissue surgery

It is known that some local anesthetics may cause pain when the initial local anesthetic effect disappears. The aim of this trial was to compare the postoperative pain intensities after infiltration of plain lidocaine 1% and 2% used in gingivectomies. The trial was done as a controlled, randomized, double-blind, parallel group study involving 117 patients with mean age 48 years (range 29-71 years) allocated to two treatment groups. There was no statistically significant difference between the mean postoperative pain courses of lidocaine 1% and 2% after gingivectomies during an 11-h observation period. A numerical difference was seen from 7 to 11 h in favor of lidocaine 1%. There were more patients experiencing no pain, but more patients reporting higher pain scores in the lidocaine 2% group than in the lidocaine 1% group. These differences were not statistically significant. It can be concluded that there is apparently no difference between lidocaine 1% and 2% with respect to postoperative pain experience when using gingivectomy as a pain model.

[Conditions of the successful outcome of mucogingival surgery during orthodontic treatment]

For the last twenty years the mucogingival surgical technics, particularly displaced flaps, have brought gingival tissue when it is missing improving the periodontic outcome of orthodontic treatment. The displaced flaps are indicated where is a deficient attached gingiva or for uncovering retained cuspids. This state of the art is done both for the surgical and orthodontic care that are necessary as well as for the possible problems and complications after surgery.

Aspirin-induced post-gingivectomy haemorrhage: a timely reminder

A case report is described of significant aspirin-induced haemorrhage following a gingivectory procedure in an organ transplant patient. Aspirin-induced platelet impairment secondary to low-dose aspirin was implicated as the cause of the haemorrhage. Haemostasis was eventually achieved after platelet transfusion. The case illustrates the problems that can arise when carrying out gingival surgery on patients medicated with low-dose aspirin.

Phenobarbital-induced gingival overgrowth? Report of two cases and complications in management

Gingival overgrowth is a known side effect of several seizure, immunosuppressant and calcium channel-blocker medications. Gingival overgrowth is not a reported side-effect of phenobarbital. This case report describes two patients with marked gingival overgrowth who had been medicated with phenobarbital exclusively since the initiation of seizure disorders. The clinical findings, surgical management, bleeding complications, and recommendations in management are discussed.

Doxycycline prevents root resorption and alveolar bone loss in rats after periodontal surgery

The effect of systemic doxycycline administration on frequency of root resorption cavities and extent of bone loss following periodontal surgery was studied in albino rats. Thirty Wistar rats with healthy gingiva were divided into four groups. Six untreated animals (Group 1) served as controls. Gingivectomy (Group 2, six rats), mucoperiosteal flap operation (Group 3, eight rats), and mucoperiosteal flap operation with doxycycline added to the drinking water (Group 4, 10 rats) were performed on the palatal aspect of maxillary left molars. After a healing period of 3 wk, the rats were killed by an overdose of sodium pentothal, and specimens of first molars were prepared for light microscopy. Root resorption was absent in normal and gingivectomized animals (Groups 1 and 2). Resorption cavities occurred in all flap-operated animals (Group 3) and in one of 10 doxycycline-treated animals (Group 4). The distance from cementoenamel junction to alveolar bone crest remained unchanged in gingivectomized (Group 2) and doxycycline-treated animals (Group 4), as compared with control specimens. In flap-operated animals (Group 3), the crestal bone level was located more apically than in doxycycline-treated rats (Group 4). This study has shown that root resorption and bone loss were associated with flap operations involving exposure of periodontal ligament and bone. Systemic doxycycline prevented both root resorption and bone loss.

Postoperative pain experience after gingivectomies using different combinations of local anaesthetic agents and periodontal dressings

The present study examines postoperative pain experience following 243 gingivectomies in Norwegian patients using possible combinations of 3 local anaesthetics (lidocaine-adrenalin, prilocaine-felypressin or mepivacaine) and 3 periodontal dressings (Coe-pak, Wondrpak or Nobetec). When Coe-pak was used, the mean pain score was higher (P less than 0.05) in the group treated with lidocaine-adrenalin 4 to 6 h after gingivectomy than the groups treated with prilocaine-felypressin or mepivacaine. There was no significant difference between the groups treated with prilocaine-felypressin or mepivacaine. When Wondrpak or Nobetec were used, there was no significant difference between any of the local anaesthetics used. The present finding shows that the local anaesthetic combination of lidocaine-adrenalin (1:80,000) gives rise to a higher mean postoperative pain experience after gingivectomy than prilocaine-felypressin or mepivacaine. However, the relative difference in pain experience seen after gingivectomy when using the present local anaesthetic agents is masked when using an eugenol-containing periodontal dressing. Thus, the higher pain experience reported after lidocaine-adrenalin may only be clinically important when using periodontal dressings without local anaesthetic components such as eugenol.

Effect of non-eugenol- and eugenol-containing periodontal dressings on the incidence and severity of pain after periodontal soft tissue surgery

This study examines the incidence and severity of postoperative pain after gingivectomy using one non-eugenol-containing periodontal dressing, Coe-pak (n = 76) and 2 eugenol-containing periodontal dressings, Wondrpak (n = 64) and Nobetec (n = 86). All patients were subjected to gingivectomy using 1 type of local anaesthesia (lidocaine + adrenalin) only and covering the surgical areas with either of the 3 different dressings in a randomized study. Postoperative pain was assessed on 100 mm visual analogue scales over 5 days starting immediately after surgery. No pain was reported by 22.0% of the patients after Coe-pak, 23.4% after Wondrpak and 30.2% after Nobetec. 13.2% of the patients took analgesics after Coe-pak treatment, 3.1% after Wondrpak and 1.2% after Nobetec. Mean pain score after Coe-pak was higher (P less than 0.05) than after Nobetec 2 h after operation until the morning on the 3rd postoperative day. Mean pain score after Coe-pak was higher (P less than 0.05) than after Wondrpak 3 h to 9 h after operation. No statistically significant difference was found between Wondrpak and Nobetec regarding mean pain score.

The effect of chlorhexidine supplementation in a periodontal dressing

Most commercial periodontal dressings claiming antibacterial activity lose this activity shortly after application. Chlorhexidine (CH) is an antibacterial agent with long-term activity in the oral cavity owing to its substantiveness and slow-release properties. In a double-blind split-mouth-designed clinical trial the effect of incorporating CH acetate in periodontal dressing was tested on wound healing after gingivectomy. Eleven patients, each needing at least two gingivectomies, constituted the test panel. Wound healing, as assessed by bleeding tendency after removal of dressing 7 days postoperatively was significantly delayed when control dressings were applied as compared with test dressings. Variables with regard to patient comfort also yielded results in favor of the test pack. Incorporation of antibacterial agents with high retention and slow release properties in the mouth in surgical dressings seems advantageous.

Root surface caries subsequent to gingivectomy in rats inoculated with Streptococcus sobrinus (mutans) and Actinomyces viscosus

We studied the effect of oral infection with cariogenic micro-organisms on alveolar bone loss and root surface caries subsequent to gingivectomy in rats. Thirty-six rats were fed diet MIT 200 (67% sucrose); one-half, the controls, had antibiotics added to the diet. At ages 18, 19, and 21 days, the experimental group was orally infected with streptomycin-resistant Streptococcus sobrinus (mutans) 6715 and Actinomyces viscosus M-100. At age 30 days, all animals were subjected to a gingivectomy on maxillary and mandibular left quadrants. The experimental group was re-inoculated at age 36 days. Animals were killed seven weeks after surgery. Jaws were stained, and planimetric measurements of exposed root surface area and caries on lingual/palatal surfaces of 1st and 2nd molars were made from video images with a computer/digitizer. Compared with the non-operated contralateral quadrants, gingivectomy significantly increased exposed root surface area in the maxilla and in the mandible in both the control and experimental groups. Oral inoculation significantly increased exposed root surface in mandibular (but not maxillary) quadrants which had received a gingivectomy, but had no effect on non-gingivectomized quadrants. There was no caries in the control group, whereas ten rats in the experimental group had root surface caries lesions, all in quadrants which had received a gingivectomy. This rat model should prove useful in further studies of root surface caries.

Subcutaneous emphysema

This case describes the development of subcutaneous emphysema following restorative dentistry performed under general anesthesia. Initial treatment consisted of intravenous epinephrine and dexamethasone due to difficulty in breathing and laryngeal stridor. Dexamethasone and other adjunctive drugs were administered over the 4 days following surgery while the symptoms subsided. The author emphasizes the importance of early recognition and prompt management in managing this unusual complication.

Peridontal status following surgical-orthodontic alignment of impacted teeth

Treatment of impacted teeth is often a combination between oral surgery and orthodontics. This study evaluates the gingival condition of impacted teeth after surgical-orthodontic treatment, where two different surgical methods were used. In one group (n = 11) the teeth were radically exposed and orthodontically moved to their final position. In the other group (n = 11) the teeth were partially exposed by raising a mucoperiosteal flap. Orthodontic traction was then applied; whereafter the flap was sutured back into place. The results showed that one of the teeth in the partial exposure group and seven in the radical exposure group showed loss of attachment. This study indicates that a combination of mucoperiosteal flap technique and applied orthodontic traction is prefered to minimize the loss of attachment in cases of displaced impacted teeth.

Giant-cell hyalin angiopathy

Seven examples of an unusual hyalin degenerative change in the walls of blood vessels are discussed. We believe this is a localized phenomenon, not connected to systemic vascular disease. Inflammation is usually present, and in each case a dental procedure had previously been performed. Dental extraction was the most common procedure. Giant cells of the foreign-body type are present, but particulate foreign material was seen in only one case.

The destructive potential of electrosurgery on the periodontium

Three cases have been presented illustrating the complications which may arise from the use of electrosurgery. These cases provide clinical evidence of the potential for severe periodontal destruction, a potential that must be weighed carefully by any practitioner who uses an electrosurgical instrument. It is suggested that new scientific studies be initiated to establish basic principles that will eliminate the hazards that now exist in the routine use of electrosurgery.

Effects of electrosurgery on the gingival attachment in rhesus monkeys

A biometric and histometric study of electrosurgical gingival "troughing" with a fully rectified current was accomplished in four Rhesus monkeys. The operation resulted in a statistically significant recession of the free gingival margin and loss of connective tissue attachment associated with apical migration of the junctional epithelium. Burn marks from contacts with the electrodes were observed on the cemental surfaces and in the dentin under the enamel close to the cemento-enamel junction. The cemental burn marks usually were covered by epithelium, which may explain the apical migration of the junctional epithelium observed in the experiemtal teeth. A slight loss of crestal alveolar bone occurred in the experimental areas and a bone sequestrum formed in one instance. Secondary dentin was found in response to electrosurgical contact of the cemental surface.

Bacteremia in pediatric patients following dental manipulations

A recent study has claimed that children who do not have gingivitis do not have bacteremia following dental manipulations and that these children do not require antibiotic prophylaxis. Postoperative blood cultures from 53 children and adolescents with and without gingivitis drawn within ten minutes of elevation of the gums, extraction of teeth, and extensive gingivectomies were sterile in all cases. The collection and laboratory methods and media were carefully evaluated and found satisfactory. However, the time interval between the dental procedure and the collection of the blood is believed to have been too short for reliable results and that the abandonment of the antibiotic prophylaxis in children is unwarranted.