The Impact of Systemic Disease-Associated Gingival Enlargement on Pediatric Patients

Other Health Conditions and Gingival Growth

Attention-Deficit Hyperactivity Disorder

In 2005, almost 4.5 million children 3 to 17 years of age (7%) have ADHD.1 Boys (11%) were more than twice as likely as girls (4%) to have ADHD. Stimulants, such as amphetamine (Adderall^®, Shire US Inc,www.shire.com) and methylphenidate (Ritalin SR^®, Novartis Patient Assistance Program,www.pharma.us.novartis.com), are commonly prescribed to treat ADHD, and in 2003 the US Centers for Disease Control and Prevention estimated that more than 50% of children with ADHD were taking medications for the condition.

A study with 20 subjects medicated with amphetamine for behavioral disturbances showed that children taking Adderall had a statistically significant increase in the prevalence of gingival enlargement over a group of 20 healthy control subjects taking no medications. The test subjects were not taking phenytoin, cyclosporine, or calcium channel blockers. Studies have shown an increased risk for heart attack, stroke, arrhythmia, and hypertension related to amphetamine use. Physicians have been advised to monitor the blood pressure of children treated with these drugs and to prescribe hypertensive drugs, if indicated. Therefore, this group of children may be at an additional risk for gingival overgrowth if prescribed antihypertensive (calcium channel blockers) medication.

Cerebral Palsy

Guare et al reported that the prevalence of periodontal disease and gingival enlargement was increased in the primary dentition of children with cerebral palsy (CP). About 500,000 people in the United States have some form of CP. Each year 8,000 infants and nearly 1,500 preschool-age children are diagnosed with CP. The gingival overgrowth detected in the CP subjects of this study may not have been induced by any specific drug. Yet, the findings highlight that periodontal infection in medically compromised children can manifest with a measurable gingival enlargement, which may itself support a reservoir environment for further viral replication and microbial colonization. The role of periodontal infections in the pathogenesis of systemic disease remains scientifically unresolved. However, Dietrich and Gracia’s review of the literature noted observations of associations between periodontal disease and systemic disease, with or without noting specific drugs as contributing variables.

Emotional And Psychological Effects Of Gingival Overgrowth

Finally, it must be noted that the psychological and emotional impact of gingival overgrowth receives no or little attention. As increasing numbers of pediatric patients are affected by systemic disease-associated gingival overgrowth, concern should be shown for how pediatric patients interpret what is happening to them and how affected children manage difficulties associated with facial appearance (Figure 1, Figure 2, Figure 3 andFigure 4).

Facial differences can bring stigma upon children and adolescents, affect their psychosocial development, self-esteem, and quality of life. Because of the centrality of the face, the mouth, and a smile in human interactions, the effect of gingival overgrowth on the smiles of thousands of children cannot be minimized. Regrettably, the media and public culture place a huge value on physical appearance, which can result in a lack of opportunity for and acceptance of those who look different. Reports of perception of physical appearance and social alienation suggest that children with facial differences undergo serious psychological and emotional problems as a result of the feelings of isolation and powerlessness. Because gingival overgrowth is a visible facial feature it can be categorized as a facial difference. Therefore, by extrapolation, the studies cited support that human relationships and interaction are negatively influenced by the appearance of gingival overgrowth. Life can be only the sum of moments, and moments lost to pain and suffering that are psychological or social in nature can mean as much or more than moments lost to physical pain and suffering.

A Framework for Action

Research has led to a variety of approaches to improve periodontal health through prevention, early diagnosis, and treatment. Early diagnosis ensures the greatest chance for successful treatment. By learning how to identify and prevent periodontal conditions such as gingival overgrowth that can occur, oral health professionals can improve the overall health of infants and young children with special healthcare needs.

Currently, periodontal disease prevention programs are not being implemented in the vast majority of medical centers. Periodontal health can be raised for those affected by systemic disease-associated gingival enlargement through interdisciplinary collaboration. Awareness at all levels about the overall good prognosis of the preventive and therapeutic measures available is essential to encourage implementation of effective programs with targeted interventions. Periodontists and dental hygienists are in a unique position to reduce or eliminate the risk of gingival overgrowth in patients undergoing immunosuppression or taking other medications that are associated with gingival overgrowth.