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12 years old female come with unusual gingival enlargement and on examination it was obvious that there is a "double gingiva" pseudo gingiva which is easily detached and beneath the true attached one.... She had a history of lip trauma causing injury in the lip inside , suturing the wound caused narrowing of the labial sulcus as the wound edges were approximated to reach the attached gingiva and the alveolar mucosa were disappeared ....

She had a previous tonsillectomy since 7 years while the tonsils were inflamed and as a complication, Rheumatic factor appeared leading to rheumatic arthritis....

She had also a mouth breathing habit.

Investigations was done including CBC , Rheumatic factor (RF) ..... Investigations were within normal and rheumatic factor was negative after treatment and her physician gave me the permission to perform her surgery.

Treatment plan :

1. Correction of the double gingiva to reveal the true attached gingiva and remove the pseudo one which is highly vascular and easily inflamed that resulted from the false wound suturing, this will be done by Gingivectomy.
2. Sulcus deepening to correct the shallow sulcus which resulted from the false suturing of the wound.
3. Habit breaking appliance "oral screen" to treat the mouth breathing to prevent enlargement of the gingiva.
4. orthodontic treatment.

N.B: Treatment is in progress and further Ging

What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease?

Why is this question important?

Gum disease is a common condition in which the gums become swollen, sore or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth, and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance.

Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth, and stop these from affecting the gums.

Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment).

We conducted a review of the evidence from research studies to find out about the benefits and risks of using antibiotics alongside professional dental cleaning to treat gum disease. We also wanted to know if some antibiotics work better than others in this situation.

How did we identify and evaluate the evidence?

First, we searched for randomized controlled studies (clinical studies where people are randomly put into one of two or more treatment groups), because these studies provide the most robust evidence about the effects of a treatment. We then compared the results, and summarized the evidence from all the studies. Finally, we rated our confidence in the evidence, based on factors such as study methods and sizes, and the consistency of findings across studies.

What did we find?

We found 45 studies that involved a total of 2664 people over the age of 18 who had gum disease. The studies compared professional cleaning plus antibiotics against professional cleaning alone, or compared different antibiotics used alongside professional cleaning against one another.

We cannot tell whether antibiotics reduce gum disease in the long term (one year or more after treatment), or whether some antibiotics are better than others. This is because we have very little confidence in the evidence we found. We cannot tell whether antibiotics are associated with unwanted effects, because we have too little confidence in the evidence. The most commonly reported unwanted effects were temporary, mild gastrointestinal disturbances, such as nausea, vomiting, diarrhoea, or a metallic taste in the mouth. No serious unwanted effects were reported. No studies reported on antimicrobial resistance or changes in people’s quality of life.

What does this mean?

We do not know whether:

• using antibiotics alongside professional cleaning is beneficial for treating gum disease in the long term (more than one year after treatment);
• using antibiotics alongside professional cleaning is associated with unwanted effects; or
• some antibiotics are better than others for treating gum disease alongside professional cleaning. Our confidence in the available evidence is very low. The results of our review are likely to change if more evidence becomes available. Future studies should clearly define what qualifies as a minimally important improvement in gum disease.

How‐up‐to date is this review?

The evidence in this Cochrane Review is current to March 2020.

Summary of Case Presentations

Case 1

Px of south east asian race was on lamotrigine for bipolar disorder treatment. After 3 weeks the patient noted sore throat, inflamed gums which made him unable to brush his teeth and a slightly inflammed tongue. Afterwards, the patient noted puffiness of eyes which lead to blurred vision and described lights having "halos" around them. A few days later the px noticed erosion of his oral mucosa which spread slowly to his lips which lead to bleeding. Lab tests were all normal: cbc, electrolytes, ast, alt, bun, crea and crp. No rashes were noted. A distant aunt of the px had sjs. Any thoughts?

Case 2

Here with one of those rare, unforgettable presentations... At term newborn, who was consulted by Neurology antenatally for query Agenesis of Corpus Callosum. At that time, given pregnancy and mom's heath were unremarkable, it was thought it was more technical and a post natal MRI would be warranted. Baby was born, and there were noticed 2 lumps: 1 pedunculated mass arising from the columella (the soft part of the nasal septum) partially obstructing the left nostril, and another similar mass, arising from midline gingivolabial sulcus (see pics). Brain MRI showed a significant pericallosal lipoma sized: 3.3 x 0.8 x 1.6 cm (note the chemical shift artifact on T2 sequence, hypointensity on SWI is related to fat content, not blood). there seems to be left fronto-parietal cortical dysplasia (EEG pending). The corpus callosum shows dysgenesis specifically at the rostrum, genu and anterior body. Due to this abnormal CC, lateral ventricles are also abnormaly shaped and run in parallel. There were some concerns if the lesion from the nostril would be related to an encephalocele, which was ruled out on this MRI. As many of you, I never heard about "Pai Syndrome". It seems to be a rare, idiopathic developmental condition that has typical craniofacial abnormalities, including: median cleft lip, cutaneous polyps of the nasal mucosa and face, and midline lipomas of the central nervous system. Since no etiology is known, we don't have risk factors identified either. No preference in sex, and about 60 cases only have been described in the literature (It's thought to be underdiagnosed). From a therapeutic perspective, in general this syndrome has good prognosis, the facial defects will be surgically corrected/excised. Regarding the pericallosal lipoma, usually this goes asymptomatic, but rarely can cause seizures, In our case, we will do a baseline EEG and depending of those results we might need to medicate, or not. No other developmental abnormalities are expected. Given there are a few cases reported with a de novo translocation, we will involve genetics. take home point: if you ever see a newborn with midline lumps on face, order an MRI! Pai syndrome is underestimated! Reference for the attached picture of CC: Kathleen Baynes, in Encyclopedia of the Human Brain, 2002.