Professional Documents
Culture Documents
Gingival bleeding
and enlargement
SUMMARY
Kayleigh is 15 years old. She is concerned that her
upper gums look abnormal and they bleed when-
ever she brushes them ( Fig. 39.1 ).
History
Kayleigh has noticed bleeding when she has been brushing
for the last year. She is frightened of brushing because of
the bleeding and feels that the bleeding is getting worse. She
is also very socially conscious of her gums because they look
very red and are bigger than normal.
Medical history
Kayleigh has insulin-dependent diabetes. She takes her
insulin by subcutaneous injection at 07.30 and 17.30 hours.
She has a regulated gram intake of carbohydrate at 07.30,
11.00, 13.00, 15.00, 17.30 and 21.00 hours. Apart from this
she is an active girl who plays basketball and hockey at
school and has learnt to increase her carbohydrate intake
appropriately to cover her sporting activities. Her mum
reports that Kayleigh has had the occasional rebellion
against her condition and at these times diabetic control has
been poor, but generally her control is now good with a
stable regimen. She is seen every 2 months by her doctor,
and she monitors her blood glucose and urinary glucose at
home herself.
Dental history
Kayleigh and her family are regular dental attenders and
have just moved to the area with her father s job. This is the
rst time you have seen her.
Examination
Extraoral examination is normal with no signs of infection.
Intraorally there is widespread marginal gingivitis, which
is particularly bad in the upper right quadrant anteriorly
( Fig. 39.1 ). Clinical and radiographic examination of the
teeth reveal a low caries rate with only the need to
replace a cracked and decient restoration in a lower rst
permanent molar that has recurrent caries.
What factors are contributing to the chronic marginal
gingivitis?
Poor oral hygiene.
Hormonal changes of puberty.
Poorly controlled diabetes mellitus.
Fig. 39.1 Chronic gingivitis.
Key point
Gingival bleeding can be as a result of:
Local causes.
Systemic causes.
The commonest local and systemic causes of gingival
bleeding in childhood/adolescence are shown in Box 39.1 .
Box 39.1 Commonest causes of gingival bleeding in childhood and
adolescence
Local causes
Eruption gingivitis.
Acute/chronic gingivitis.
Chronic periodontitis.
Foreign body entrapment.
Acute necrotizing ulcerative gingivitis.
Haemangioma.
Reactive hyperplasias such as pyogenic granuloma.
Factitial injury.
Systemic causes
Hormonal changes such as pregnancy or puberty.
Diabetes mellitus poor control.
Anaemia.
Leukaemia.
Any platelet disorder.
Clotting defects.
Drugs (e.g. anticoagulants).
Scurvy.
HIV-associated periodontal disease.
Local causes
Eruption gingivitis.
Acute/chronic gingivitis.
Chronic periodontitis.
Foreign body entrapment.
Acute necrotizing ulcerative gingivitis.
Haemangioma.
Reactive hyperplasias such as pyogenic granuloma.
Factitial injury.
Systemic causes
Hormonal changes such as pregnancy or puberty.
Diabetes mellitus poor control.
Anaemia.
Leukaemia.
Any platelet disorder.
Clotting defects.
Drugs (e.g. anticoagulants).
Scurvy.
HIV-associated periodontal disease.
39 G I N G I VA L B L E E D I N G A N D E N L A R G E ME N T
157
158
stuck to the teeth. Use sugar-free gum if it is not possible to
brush the teeth during the day.
What other oral manifestations can occur in diabetes?
Dry mouth.
Swelling of salivary glands (sialosis).
Glossitis.
Burning of tongue.
Oral candidosis if control is poor.
These manifestations are more commonly seen in adults.
Recommended reading
Firatli E, Yilmaz O, Onan U 1996 The relationship between
clinical attachment loss and the duration of insulin
dependent diabetes mellitus (IDDM) in children and
adolescents. J Clin Periodontol 23:362366.
Karjalainen KM, Knuuttila MLE, Kaar M-L 1997
Relationship between caries and level of metabolic
balance in children and adolescents with insulin-
dependent diabetes mellitus. Caries Res 31:1318.
Position paper 1996 Diabetes and periodontal diseases. J
Periodontol 67:166176.
For revision, see Mind Map 39, page 201.
Key point
In diabetes:
Poor oral hygiene will accelerate attachment loss.
Infection can interfere with diabetic control.
Why is the timing of the appointment to restore Kayleighs
frst permanent molar important?
To not interfere with Kayleighs carbohydrate intake and
precipitate hypoglycaemia, it is probably best to give her an
appointment either rst thing in the morning, or directly
after lunch. For any prolonged surgical procedure in a dia-
betic person, or any treatment that requires general anaes-
thesia (GA), a referral to hospital is required. GA will
require admission pre-operatively to stabilize insulin and
glucose requirements via a drip so that hypoglycaemic
coma does not occur with pre-operative GA starvation.
What dietary advice should you give to diabetic patients?
Do not change your required carbohydrate intakes as these
are critical to diabetic control.
Tailor the dental advice to the specic needs of the
patient, i.e. take your toothbrush to school if possible. Try
to clean your teeth after snacks and at lunchtime. Try to take
snacks that provide the necessary sugar but dont remain
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201
MI N D MA P 3 9
eruption gingivitis
acute / chronic gingivitis
chronic periodontitis
foreign body entrapment
ANUG
haemangioma
reactive hyperplasia
factitial
hormonal
diabetes mellitus
anaemia
leukaemia
platelet disorder
clotting defects
anticoagulants
scurvy
HIV
Bleeding
congenital
hereditary gingival fibromatosis
mucopolysaccharidosis
infantile systemic hyalinosis
puberty / pregnancy gingivitis
plasma cell gingivitis
infections HSV
haematological
vitamin C deficiency (scurvy)
aplastic anaemia
leukaemia
acute myeloid
preleukaemic
drugs
deposits
mucocutaneous amyloidosis
chronic granulomatous disorders
sarcoidosis, Crohn disease, orofacial
granulomatosis
phenytoin, ciclosporin, calcium channel
blockers, vigabatrim
acquired
Enlargement
local
systemic
Gingival Bleeding and Enlargement