A 57-year-old female, presented with the chief complaint of bleeding gums from the anterior part of the mouth and protrusion of an upper right anterior tooth. She was a known diabetic with hypertension, and had no history of previous periodontal treatment. She was on oral hypoglycemic (Metformin) and antihypertensive (Nifedipine). She was from a low socio economic background, with no betel chewing or other parafunctional habits.

Her lips were slightly incompetent and maxillary right central incisor was protruding with one third of the tooth visible from the incisal edge extra-orally. Gingiva was oedematous, dark pink in colour with significant overgrowth in upper anterior palatal and lower anterior labial segments (Figure 1, Figure 2) All teeth were present with a retained root of maxillary left 3^rd molar . Deep caries with pulp exposure were detected in maxillary right 1^st molar and mandibular right 1^st molar, while maxillary right 2^nd molar had dentinal caries (Figure 3). Migration of maxillary right central incisor labially, lateral incisor distally were noted with anterior spacing of maxillary right central incisor, left central incisor ,left lateral incisor and left canine.

   A Dental Panoramic Tomogram (DPT) and intra oral periapical radiographs (IOPA) revealed varying degrees of horizontal bone loss of upper and lower anterior teeth (Figure 4). Multiple radioopacities were visible at the apices of roots in the DPT which were suggestive of florid cement-osseous dysplasia or idiopathic osteosclerois.

   According to the findings, the diagnosis was made as “chronic localized mild to moderate periodontitis with nifidipine-induced gingival overgrowth in a 57-year-old female with metabolic syndrome”.

A care plan was proposed to address the identified problems. The patient was first educated about existing diseases. The bidirectional relationship between periodontitis and diabetes mellitus as well as antihypertensive medication, nifedipine and gingival overgrowth was explained. Phase 1 with non surgical periodontal therapy (NSPT) included oral hygiene and plaque control instructions, scaling and root surface debridement (RSD) with hand and ultrasonic instruments. Endodontic treatment of maxillary right 1^st molar and mandibular right 1^st molar was carried out (Figure 5) while dentinal caries of maxillary right 2^nd molar was restored with composite resin.

Following successful completion of phase 1 therapy (Figure 6, Figure 7), patient’s medical status was reviewed at the 8 th week. Considering her satisfactory outcome of NSPT together with good glycemic (FBS 108mg/dl) and blood pressure (130mmHg/85mmHg) control, it was decided to proceed with phase 2 (surgical) therapy. The review period between phase 1 and 2 therapy was 10 weeks.

Gingivectomy was performed on palatal surfaces extending from maxillary right canine to left canine, labial and interdentally surfaces of mandibular right lateral incisor and canine, maxillary right 1^st and 2^nd molar (Figure 8). Excisional New Attachment Procedure (ENAP) 6, 7 was carried out in relation to the labial aspect of maxillary right canine to left canine (Figure 9). Surgical site was covered with a periodontal dressing (Coe-Pack) to promote healing and to reduce post-operative discomfort (Figure 10). Antibiotics and analgesics were prescribed to prevent post-operative infection and pain. Patient was recalled after 7 days from surgical treatment and healing was uneventful. Periodontal re-evaluation was carried out 3 months following the surgical phase. It revealed marked probing depth reductions (Annexure 1,2). Although her medical status was under control, medical advice was obtained from her physician since she was under nifedipine treatment for hypertension. Physician’s recommendation was to alter nifedipine into captopril as a precautionary measure to overcome any recurrence of gingival overgrowth.

Since the patient had satisfactory plaque control with significant improvement in periodontal status, phase 3 (restorative phase) was performed 3 months following the surgical phase. Metal onlay was constructed on endodontically treated maxillary right 1^st molar as it was not in the aesthetic zone.

Although the available treatment options were explained to the patient for improvement of aesthetics of extruded and spaced maxillary right central incisor, she did not consent for lengthy, expensive orthodontic interventions. Therefore, composite resin restoration and recontouring of maxillary right central incisor with selective grinding of enamel at the incisal edge was carried out. Spaces between teeth (maxillary anteriors) were restored with composite resins (Figure 11). Patient was pleased with the final outcome of the treatment. Periodontal maintenance care was arranged with recall intervals varying from 6-12 weeks.

Gingival enlargement is undue overgrowth of gingival tissue, histologically known as gingival hyperplasia (increase in cell number) or hypertrophy (increase in cell size) 3. It can be either plaque-induced or non-plaque induced, although the commonest being plaque-induced inflammatory process modified by systemic factors including some medications. This patient was on antihypertensive, nifedipine which is known to contribute towards gingival overgrowth.

   Drug induced gingival overgrowth (DIGO) may be a result of anticonvulsants, calcium channel blockers (CCB) and immunosuppressive medications. Cation influx of folic acid active transport within gingival fibroblast is reduced by all these drug categories which lead to change in matrix metalloproteinase metabolism and failure to activate collagenase. Degradation of accumulated connective tissue component is reduced in DIGO due to lack of available activated collagenases 8.These drugs induce glycosaminoglycans and collagen proliferation of gingival fibroblast, leading for accumulation of collagen in the cells 9.

Chronic periodontitis is a common disease of the oral cavity, and identification of causative factors including systemic risk factors was important in the management of this patient. Patient was regularly reviewed at the medical clinic by the physician. She was a known patient with uncontrolled diabetes and hypertention. Her waist circumference was > 35 inches (890mm) and considered as obese. Therefore, according to accepted diagnostic criteria of metabolic syndrome(MS), she had three features to be diagnosed as of MS 10, 11.

Diabetes mellitus is a strong systemic risk factor for PDD, where susceptibility for periodontitis can be increased by three folds 12. On the other hand, PDD is considered as the sixth complication of diabetes mellitus 1 .

   The primary aim of periodontal therapy is to preserve the dentition and prevent further loss of periodontal attachment. NSPT is of utmost importance in the initial periodontal management of a patient where elimination of aetiological and risk factors together with reduction of drug dose or switching to non-CCB antihypertensive and surgical excision if required provides satisfactory results 13, 14. In this patient, a successful outcome was achieved after completing both nonsurgical and surgical approaches of treatment together with changing antihypertensive medication to captopril.

Management of chronic periodontitis can be challenging when it coexists with numerous risk factors, both systemic and local. However, careful diagnosis and treatment planning are crucial aspects for a successful outcome. This case report highlights how a dental practitioner should carefully identify the medical risk factors in a patient and seek appropriate advice of the physician. Similarly the case highlights the systematic approach for both non-surgical and surgical methods of treatment adequately phased out with long term maintenance care.