39

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

What do you think may have precipitated the initial

gingivitis?
This is likely to have coincided with one of the periods
where diabetic control was poor. Further questioning
revealed that about a year ago Kayleigh was struggling to
come to terms with her insulin-dependent diabetes. She
refused to take her insulin regularly and ended up by being
admitted to hospital in coma with ketoacidosis. Her blood
sugar at that time was very high and her breath smelt of
pear drops due to ketone bodies. This was a hyperglycae-
mic coma. She was resuscitated with intravenous uids as
she was severely dehydrated, prior to restabilization on an
insulin regimen.
What is the other cause of diabetic coma and what are its
signs?
Hypoglycaemic coma occurs due to inadequate carbo-
hydrate (missed meal), exercise or excess insulin. The onset
is quicker than the hyperglycaemic coma. The signs of
hypoglycaemic coma are very similar to having a drink
too many , and can be summarized into those caused by
adrenaline release and cerebral hypoglycaemia:
Adrenaline release:
Sweaty warm skin.
Rapid bounding pulse.
Dilated (reacting pupils).
Anxiety, tremor.
Tingling around mouth.
Cerebral hypoglycaemia:
Confusion, disorientation.
Headache.
Dysarthria.
Unconsciousness.
Focal neurological signs, e.g. ts.
If an individual having a hypoglycaemic episode is con-
scious they should be given sugar orally 25 g glucose. If
comatosed, they require 20 mg of 20% dextrose IV followed
by 25 g orally on arousal. Alternatively if intravenous access
is difcult, give 1 mg intramuscularly of glucagon. In practi-
cal terms, 10 g glucose approximates to:
2 tsp sugar
3 lumps sugar
3 Dextrosol tablets
60 ml Lucozade
15 ml Ribena (full sugar type)
90 ml cola (not diet variety)
one-third pint of milk.
Treatment
Kayleigh s gingivitis probably started as a result of poor
diabetic control and unfortunately has been compounded
by poor oral hygiene and the hormonal changes of
puberty.
Why is the gingivitis worst in the anterior part of the upper
right quadrant?
She is right-handed and this is often the case when a right-
handed person changes their brushing action from the left
hand side of the mouth to the right hand side. The opposite
would be true for the left-hander.
What other generalized causes of gingival enlargement do
you know?
There are a number of causes, which can be classied into
congenital and acquired ( Box 39.2 ).
Box 39.2 Systemic causes of gingival enlargement
Congenital
Hereditary gingival fbromatosis.
Mucopolysaccharidoses.
Infantile systemic hyalinosis.
Acquired
Puberty/pregnancy gingivitis.
Plasma cell gingivitis.
Infections HSV.
Haematological: acute myeloid leukaemia, preleukaemic leukaemia, aplastic
anaemia, vitamin C defciency (scurvy).
Drugs: phenytoin, ciclosporin, calcium-channel blockers, vigabatrin.
Deposits: mucocutaneous amyloidosis.
Chronic granulomatous disorders: sarcoidosis, Crohn disease, orofacial
granulomatosis.
Congenital
Hereditary gingival fbromatosis.
Mucopolysaccharidoses.
Infantile systemic hyalinosis.
Acquired
Puberty/pregnancy gingivitis.
Plasma cell gingivitis.
Infections HSV.
Haematological: acute myeloid leukaemia, preleukaemic leukaemia, aplastic
anaemia, vitamin C defciency (scurvy).
Drugs: phenytoin, ciclosporin, calcium-channel blockers, vigabatrin.
Deposits: mucocutaneous amyloidosis.
Chronic granulomatous disorders: sarcoidosis, Crohn disease, orofacial
granulomatosis.
Fig. 39.2 Gingival and periodontal disease.
Why is it important to eradicate Kayleigh s gingivitis?
Poor oral hygiene in combination with diabetes can result
in rapid periodontal destruction and attachment loss. An
example of this in another subject with diabetes is shown in
Figure 39.2 . There is some evidence that signicant perio-
dontitis can upset glycaemic control.
Kayleigh needs reassurance that the bleeding will reduce
and stop when her oral hygiene improves. She needs to
appreciate the importance of good oral hygiene and the
problems that will occur if oral hygiene is poor.
Why is it important not to leave caries in a diabetic?
Infection of any origin can result in an increased need for
insulin. Without an insulin increase there will be a rise in
blood sugar resulting in ketosis. Therefore, all infections in
a diabetic, including those in the orofacial region, should be
treated vigorously with antibiotics. Caries should be treated
early to prevent infection.
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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
41
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