The effects of phenytoin and sodium valproate on the periodontal health of adult epileptic patients

Drug-induced gingival enlargement - Part II. Antiepileptic drugs: not only phenytoin is involved

INTRODUCTION: Gingival enlargement is the term now used to describe medication-related gingival overgrowth or gingival hyperplasia, a common reactionary phenomenon that occurs with the use of several types of therapeutic agents, including antiepileptic drugs. This disorder has been recognized since 1939, shortly after the introduction of phenytoin. METHODS: Review of literature concerning etiology, pathogenesis and management of antiepileptic drug induced gingival enlargement. CONCLUSIONS: It is important that neurologists become aware of the potential etiologic agents of antiepileptic drug induced gingival enlargement and its characteristic features in order to be able to prevent, diagnose and successfully manage it.

Demographic, Pharmacologic, and Periodontal Variables for Gingival Overgrowth in Subjects Medicated With Cyclosporin in the Absence of Calcium Channel Blockers

BACKGROUND

The role of cyclosporin in the absence of calcium channel blockers and the associated risk variables of development and severity of gingival overgrowth have not yet been properly established. The present study was conducted to determine the effect of potential risk variables for gingival overgrowth severity in Brazilian renal transplant subjects medicated with cyclosporin in the absence of any calcium channel blockers.

METHODS

A cross-sectional study was conducted in a public hospital in Belo Horizonte, Brazil. Demographic, pharmacologic, and periodontal data, recorded from 194 subjects taking cyclosporin in the absence of calcium channel blockers, were analyzed using independent sample t, chi2 statistic, or Mann-Whitney U tests. The effects of potential risk variables of gingival overgrowth severity were determined using backward stepwise regression analysis.

RESULTS

The prevalence of clinically significant gingival overgrowth was 34.5% (N = 67). These subjects presented a significantly higher papillary bleeding index and a higher plaque index compared to those without clinically significant gingival overgrowth. When all demographic, pharmacologic, and periodontal data were evaluated in relation to gingival overgrowth severity, time since transplant, papillary bleeding index, serum cyclosporin concentration, and prednisolone and azathioprine dosages were significant in the univariate modeling (P <0.05) and remained significant when evaluated in the multivariate modeling (P <0.0001; adjusted R2 = 39.4%).

CONCLUSIONS

In the absence of calcium channel blockers, this study showed that pharmacologic variables, such as cyclosporin serum concentration, prednisolone and azathioprine dosages, and time since transplant, are strongly related to gingival overgrowth. In addition, the periodontal variable papillary bleeding index highlighted the primary role of inflammation on the pathogenesis and severity of gingival overgrowth.

The management of drug-induced gingival overgrowth

OBJECTIVES

This review critically evaluates the different therapies that are available to manage drug-induced overgrowth (DIGO).

MATERIAL AND METHODS

This review is based on literature identified using the online databases MEDLINE and PUB MED. It is not a systematic review, but a conventional review of the relevant literature.

RESULTS

Patients benefit from a non-surgical approach if this can be delivered before commencement of medication although in many instances this may not be practicable. Systemic antibiotic usage has been evaluated in the management of ciclosporin-induced gingival overgrowth. Efficacy appears to be equivocal and long-term use is undesirable. Surgical excision remains the main treatment option especially for patients with severe overgrowth. Few studies have compared different techniques with respect to recurrence rate or post-operative sequelae.

CONCLUSION

DIGO is a common clinical problem that often requires intervention. Non-surgical techniques can limit the occurrence of this unwanted affect, reduce the extent of plaque-induced gingival inflammation and reduce the rate of recurrence. Wherever possible this management strategy should be adopted first. Surgical treatment is often the most reliable option and scalpel gingivectomy remains the treatment of choice. Further investigations are required to develop appropriate management strategies to prevent recurrence of DIGO.

The Effects of Anabolic Androgenic Steroid Abuse on Gingival Tissues

BACKGROUND

Anabolic androgenic steroid (AAS) is the familiar name for synthetic derivatives of the male sex hormone, testosterone. A large number of young adults abuse AAS to enhance performance and physical appearance. The aim of this study was to evaluate the effects of AAS abuse on the gingival tissues in a group of bodybuilders and weight lifters.

METHODS

The test group was composed of 24 athletes aged between 17 and 29 years who had been using AAS for >1 year. All subjects were clinically examined for plaque levels (plaque index), gingival inflammation (gingival index), and gingival enlargement. The results were compared to a control group of 20 bodybuilders who had never used AAS drugs and who matched for age, educational level, and oral habits according to the data obtained from the test group.

RESULTS

Although there were no statistical differences between the plaque index (P>0.05) and gingival index (P>0.05) scores of the study group and the control group, the AAS abusers had statistically higher scores of gingival thickness, extent of gingival encroachment, and total gingival enlargement scores (P<0.001 each) compared to non-users.

CONCLUSIONS

The results of this study have revealed that the prolonged use of AAS is closely associated with significant levels of gingival enlargement. Because recreational abuse and abuse in non-competitive sports seem to increase despite legislation, dentists and periodontists should be familiar with the adverse effects of these synthetic derivatives of testosterone on the gingival tissues.

Analysis of changes in gingival contour from three-dimensional co-ordinate data in subjects with drug-induced gingival overgrowth

OBJECTIVES

This aim of this study was to develop and assess a technique that could be used to assess accurately the gingival volume changes seen in drug-induced gingival overgrowth by the analysis of data obtained from an entire gingival surface by means of three-dimensional imaging.

MATERIAL AND METHODS

Stone dental models of patients before and after gingivectomy procedures were digitized with a laser scanner and then regenerated as computer models constructed from the acquired three-dimensional co-ordinate data. A comparison of superposed "before" and "after" surfaces was undertaken to assess and accurately quantify changes in gingival contour.

RESULTS

The mean vertical tissue reduction varied from 1.58 to 2.56 mm in the four study subjects and individual differences are shown. The maximum thickness of removed buccal gingival overgrowth was found to range between 1.20 and 3.40 mm. The volume of tissue removed from each inter-dental papilla ranged from 4.2 to 46.1 mm3 and the mean volume of the papilla removed from each subject+/-SD values was 24.8+/-13.1 mm3.

CONCLUSION

This method will measure changes in gingival tissues to within 60 microm in one plane, making it ideal for the assessment of longitudinal changes in gingival contour as seen in the development of gingival overgrowth, its recurrence after surgery or the changes in volume brought about by surgery.

Effectiveness of periodontal therapy on the severity of cyclosporin A-induced gingival overgrowth

AIM

The purpose of the present study was to evaluate the clinical effects of aetiological periodontal treatment in a group of transplant patients medicated with cyclosporin A (CsA) who exhibited severe gingival overgrowth.

MATERIALS AND METHODS

Twenty-one patients received oral hygiene instructions, supra- and subgingival scaling and periodontal maintenance therapy and were monitored for 12 months. Full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), periodontal probing depth and degree of gingival overgrowth (Seymour index GO) were recorded at baseline, 6 and 12 months after treatment.

RESULTS

Statistical evaluation revealed that all clinical variables significantly decreased compared with baseline. At baseline 18 out of 21 treated patients (85.71%) exhibited clinically significant overgrowth. Initial GO score of 2.38+/-1.92 in the anterior sextants and of 1.29+/-1.59 in the posterior segments were reduced to 0.56+/-0.83 and to 0.45+/-0.84 at 12 months (p<0.001). A difference of 1.82 and 0.84 in the severity of treated GO was accompanied by a 42% and 34% decrease in FMPS and FMBS, respectively.

CONCLUSIONS

Aetiological periodontal treatment and regular maintenance therapy were effective in resolving the inflammation and in eliminating the need for surgical treatment in patients receiving CsA.

Tetracycline Fibers as an Adjunct in the Treatment of Nifedipine-Induced Gingival Enlargement

BACKGROUND

The hypothesis that nifedipine-induced gingival enlargement in periodontitis patients can be treated with the adjunctive use of tetracycline (TCN) fibers was tested in this study.

METHODS

Ten patients (mean age 66 +/- 4 years) with chronic periodontitis combined with nifedipine-induced gingival enlargement participated. Full mouth recordings of clinical parameters (probing depth, clinical attachment level, bleeding on probing, presence or absence of plaque) were assessed at baseline and gingival enlargement was estimated from casts. Participants were instructed in proper oral hygiene and received supragingival scaling before being reassessed 1 month later. They subsequently received full-mouth scaling and root planing followed by the immediate placement of TCN fibers in all pockets >5 mm. Clinical parameters were reassessed at 3, 6, and 12 months after completion of treatment.

RESULTS

TCN fiber placement was well tolerated by patients. All clinical parameters recorded displayed significant improvements after treatment, and they were preserved for the 12-month experimental period. A significant reduction of the percentage of pockets >5 mm was noticed after treatment. The reduction of enlargement was still observed at 12 months despite patients not achieving optimal oral hygiene.

CONCLUSION

Placement of tetracycline fibers as an adjunct to mechanical treatment is an option for the non-invasive therapy of nifedipine-induced gingival enlargement in periodontitis patients whose general medical condition and concomitant ailments do not favor a surgical approach.

Immunohistochemical study of cyclosporin-induced gingival overgrowth in renal transplant recipients

BACKGROUND

Cyclosporin A (CsA) is an immunosuppressant widely used to treat transplant patients and various systemic diseases with immunological components. Gingival overgrowth (GO) is a common side effect of CsA administration; however, the pathogenesis of drug-induced GO is poorly understood. The aim of this study was to evaluate the expression of Ki-67, activation molecules (CD71, CD98), leukocytes activation antigens (CD45, CD45RA, CD50, CD11a, CD162, CD227, CD231), neurothelin (CD147), and novel endothelial cell antigens (B-F45, SCF87, B-D46, B-C44, VJ1/6) in gingival tissue in renal transplant recipients treated with CsA.

METHODS

Tissues from 15 renal transplant patients with significant GO and 10 systemically healthy control subjects with gingivitis were studied. Frozen-section biopsies were stained with monoclonal antibodies specific for the above-mentioned antigens using an indirect immunoperoxidase technique.

RESULTS

Comparison of the CsA-treated and control groups revealed no significant differences with respect to expression of Ki-67; CD50; activation molecules; neurothelin; or novel endothelial cell antigens B-D46, B-C44, and VJ1/6. However, expression patterns of CD45, CD45RA, CD11a, CD162, CD227, CD231, B-F45, and SCF87 were significantly different in CsA and control groups.

CONCLUSION

Leukocyte activation antigens play an important role in CsA-induced gingival overgrowth.

Risk factors for gingival overgrowth in patients medicated with ciclosporin in the absence of calcium channel blockers

OBJECTIVES

This study investigates the effect of a range of potential risk factors on the severity of gingival overgrowth in transplant patients medicated with ciclosporin in the absence of any calcium channel blockers.

MATERIALS AND METHODS

One hundred dentate solid organ transplants medicated with ciclosporin (but not calcium channel blockers or phenytoin) were recruited for the study. Demographic, pharmacological and periodontal data were recorded and gingival overgrowth assessed from stone models.

RESULTS

Univariate analysis identified the duration of transplant, papilla bleeding index, creatinine serum concentration, azathioprine and prednisolone dosage as risk factors for overgrowth severity. Multivariate modelling, excluding the periodontal parameters, gave a predictive model that included dosages of ciclosporin, azathioprine, prednisolone and weight (p<0.0001, adjusted-R2=19%). Adding the periodontal variables strengthened the model (p<0.0001, adjusted-R2=34.5%).

CONCLUSION

The explanatory models in this study contain a number of variables that moderate inflammation (azathioprine and prednisolone) or are markers of it (papilla bleeding index). Dosage of each of the three immunosuppressants was identified as a risk factor for the severity of gingival change. This observation appears to have been masked by the effects of the calcium channel blockers in earlier studies.

Prevalence and risk of gingival overgrowth in patients treated with diltiazem or verapamil

OBJECTIVES

This study was conducted to determine the prevalence and risk factors for gingival enlargement in patients treated with diltiazem or verapamil.

MATERIAL AND METHODS

A cross-sectional study was conducted and data from 46 patients actually taking diltiazem or verapamil were compared with 49 cardiovascular controls that never received any of these drugs. All patients were examined for the presence of gingival enlargement using two different indices, the vertical gingival overgrowth (GO) index, and horizontal Miranda & Brunet (MB) index in the inter-dental area. Gingival index, plaque index, and probing depth were also evaluated.

RESULTS

The total study population was 95:32 diltiazem-treated, 14 verapamil-treated and 49 cardiovascular control subjects. Gingival enlargement occurred in 31% (GO index) and 50% (MB index) of the patients taking diltiazem. Gingival enlargement in the verapamil-treated group was 21% for the GO index and 36% for the MB index. The prevalence of gingival enlargement was higher in the diltiazem- and verapamil-treated patients than in controls for both indices. The difference between the diltiazem-treated group and control was statistically significant (p=0.022 for GO and p=0.001 for MB), while the difference between the verapamil-treated group and controls was not significant. The risk of gingival enlargement (OR--Odds Ratio) associated with diltiazem therapy was 4.0 (1.2-13.1) for the GO index and of 6.0 (2.1-17.3) for the MB index. When the OR were adjusted for gingival index (GI) values, the risk of gingival enlargement was 3.5 (1.0-12.4) for the GO index and 6.2 (1.9-20.0) for the MB index. In the verapamil-treated group the OR values were not significant. The level of concordance between GO and MB indices in all three groups showed a kappa-value of 0.72 (p<0.001).

CONCLUSION

Patients taking diltiazem are at high risk for gingival enlargement and gingivitis has a stronger effect than the drug treatment on gingival enlargement risk.

Gingival enlargement in children treated with antiepileptics

This study was conducted to determine the occurrence, severity, and risk factors of gingival enlargement in children treated with valproate and other nonvalproate antiepileptic drugs. A cross-sectional study was carried out in which data obtained from 68 epileptic children under treatment were compared with those from 50 controls. A structured questionnaire was used to collect data on patients' demographics, dental and oral hygiene practices, and medication history. Gingival enlargement, gingival index, plaque index, and probing depth were measured to assess periodontal health. The chi-square and Fisher exact tests were used in statistical analysis. In case of significance, a detailed chi-square analysis was carried out to determine the origin of the difference. Patients in both the valproate and nonvalproate groups showed significantly higher gingival enlargement, gingival index, plaque scores, and pocketing (P < .001 and P < .01, respectively) than the control group. In the valproate group, the duration of the treatment had a significant effect on gingival enlargement (P < .001) but not on gingival index, plaque index, and probing depth values (P > .05). Toothbrushing was most frequent in the control group (P = .000) and more frequent in the valproate group than the nonvalproate group (P = .024). Our study showed significant differences regarding gingival enlargement in children treated with valproate. These findings illustrate that epileptic children on valproate are at risk of periodontal problems.

Plasma TGF-beta1 as a risk factor for gingival overgrowth

BACKGROUND AND AIMS

Induction of the pro-fibrotic growth factor TGF-beta1 has been suggested as a possible mechanism through which immunosuppressant drugs may induce gingival overgrowth. This study aims to investigate plasma levels of TGF-beta1 and relate them to the development and severity of gingival overgrowth in immunosuppressed transplant patients.

MATERIALS AND METHODS

One hundred and thirty-two ciclosporin-treated and 13 tacrolimus-treated transplant patients and 24 drug-free control subjects underwent a full periodontal examination including a determination of the presence and severity of gingival overgrowth.

RESULTS

Plasma TGF-beta1 concentrations were determined by ELISA, and were found to be significantly elevated in samples from the transplant patients (mean=29.1 ng/ml) as compared with controls (mean=6.1 ng/ml, p<0.0001). There was no significant difference between the levels of plasma TGF-beta1 in the ciclosporin- and tacrolimus-treated patient groups.

CONCLUSIONS

Furthermore, concomitant treatment with calcium channel blockers did not influence the levels of plasma TGF-beta1 in the patients group. The relationship between gingival overgrowth, independent periodontal variables and TGF-beta1 plasma concentrations was examined using univariate and multivariate regression analyses; low TGF-beta1 plasma concentrations were found to be a risk factor for gingival overgrowth in immunosuppressed patients concomitantly receiving a calcium channel blocker.

Expression of growth factors in the gingival crevice fluid of patients with phenytoin-induced gingival enlargement

The mechanism underlying phenytoin (PHT)-induced gingival enlargement (GE) is not yet known. The aim of the present study was to investigate transforming growth factor-beta1 (TGF-beta1), platelet-derived growth factor-BB (PDGF-BB) and basic fibroblast growth factor (bFGF) profiles in the gingival crevice fluid (GCF) of patients with PHT-induced GE and to compare the results with healthy controls. Five PHT-treated patients and five healthy subjects with normal periodontal tissue were included in this study. GCF samples were collected from (i) enlarged gingival sites in patients receiving PHT (GE+); (ii) non-enlarged gingival sites in the same patients (GE-); (iii) normal gingival sites of healthy subjects (control). The levels of TGF-beta1, PDGF-BB and bFGF in the GCF samples were analysed by ELISA. The results showed that the total amounts of TGF-beta1 and PDGF-BB in the GE+ group were higher than in the GE- group and significantly higher than in the control group (P < 0.05). However, no significant differences were found between the groups when the concentrations of these growth factors were compared. bFGF levels were not compared as this growth factor could be detected in only 33, 41 and 44% of the GE+, GE- and control GCF samples, respectively. These results show that TGF-beta1 and PDGF-BB are readily detectable in GCF obtained from enlarged and non-enlarged sites of PHT recipients and suggest that since the amounts were markedly higher at the GE+ than the GE- sites, the systemic administration of PHT has a pronounced localised effect on the levels of these growth factors. Moreover, our findings provide evidence that both TGF-beta1 and PDGF-BB are closely associated with the clinical manifestation of PHT-induced GE.

Relationship of Subgingival and Salivary Microbiota to Gingival Overgrowth in Heart Transplant Patients Following Cyclosporin A Therapy

BACKGROUND

Severe gingival overgrowth (GO) is induced in patients taking cyclosporin A (CsA) following organ transplantation. Determining which patient will develop GO is still not possible. The purpose of this study was to establish an association between CsA and gingival overgrowth in heart transplant patients taking into account periodontal and microbiological conditions.

METHODS

Thirty patients (10 female, 20 male; range: 13 to 67 years; mean age: 44.89) undergoing CsA treatment were evaluated using the gingival index (GI), plaque index (PI), probing depth (PD), and clinical attachment level (CAL). Subgingival samples collected from the deepest site of each quadrant and saliva samples were submitted to microbial analysis. All patients had at least 12 teeth. Exclusion criteria were the use of antibiotics and/or having undergone periodontal treatment 6 months prior to the study. Patients were divided in two groups: with gingival (GO+) and without gingival overgrowth (GO-).

RESULTS

There were no statistically significant differences between the GO+ and GO- groups when CsA dosage, time since transplant, GI, PI, PD, and CAL were compared. Microbiological examination of the subgingival samples detected the following microorganisms: Actinobacillus actinomycetemcomitans (23%), Porphyromonas gingivalis (36%), Prevotella intermedia (93%), Fusobacterium sp. (66%), Campylobacter rectus (30%), Micromonas micros (66%), enteric rods (0%), and yeasts (30%). A positive association between M. micros and the GO+ group was found (P < 0.001). Yeasts were detected in 30% of the subgingival and saliva samples.

CONCLUSIONS

Clinical parameters were not sufficient to determine which patients would develop GO. However, colonization by M. micros might play a role in the etiology of GO.

Salivary proteins and cytokines in drug-induced gingival overgrowth

Little is known about the involvement of saliva in gingival overgrowth (GO). It was hypothesized that, in this situation, the composition of saliva is altered. Thus, proteins, albumin, cytokines, and growth factors in whole and glandular saliva were investigated. Differences between glandular and gingival contributions to the composition of saliva were explored in patients medicated with cyclosporin who exhibited GO (responders), those without GO (non-responders), and non-medicated subjects (controls). In whole saliva, interleukin-1alpha (IL-1alpha), IL-6, IL-8, epidermal growth factor (EGF), nerve growth factor (NGF), and albumin were detected, but in glandular saliva only EGF and NGF were identified. Albumin and IL-6 differed significantly between responders and controls, although the overall profile of salivary proteins remained unchanged. Thus, inflammatory cytokines and albumin are confined to whole saliva and are associated with GO, whereas its content of EGF and NGF appears unaffected by cyclosporin.

Prevalence of gingival overgrowth in transplant patients immunosuppressed with tacrolimus

AIMS

The study aims to determine the prevalence and severity of gingival overgrowth in a group of adult organ transplant recipients immunosuppressed with tacrolimus in comparison with ciclosporin, and to examine various risk factors for the development of gingival overgrowth.

METHODS

Forty patients taking tacrolimus were compared with 197 ciclosporin patients. Demographic, pharmacological and periodontal data were recorded for all patients. Comparison between the groups was made using independent sample t-tests, chi2 statistic or Mann-Whitney test. The effects of risk variables on overgrowth severity were examined using forward and backward stepwise regression analysis.

RESULTS

Those taking tacrolimus had a significantly lower mean gingival overgrowth score (14.1%) compared with ciclosporin (22.4%). Fifteen percent of the tacrolimus group had clinically significant gingival overgrowth compared with 30% in the ciclosporin group (p=0.053).

CONCLUSIONS

The prevalence and severity of gingival overgrowth is less in adult transplant patients taking tacrolimus compared with ciclosporin. Concomitant use of calcium channel blockers and previous medication with ciclosporin are significant risk factors for the presence and severity of gingival overgrowth. Patients who have alteration of their immunosuppressant from ciclosporin to tacrolimus may persist in demonstrating gingival overgrowth attributable to their ongoing therapy with calcium channel blockers.

Conversion from Cyclosporin A to Tacrolimus as a Non-Surgical Alternative to Reduce Gingival Enlargement: A Preliminary Case Series

BACKGROUND

Gingival enlargement (GE) is a frequent side effect that occurs in organ transplant recipients (OTR) after the administration of cyclosporin A (CsA). The availability of new drugs used to suppress graft rejection in OTR offers an opportunity to manage GE non-surgically. This preliminary case series aimed to analyze the effect of CsA withdrawal and its substitution by another immunosuppressant in OTR with severe GE.

METHODS

Four organ transplant recipients who had received a liver or renal allograft were recruited for this study. All OTR had developed clinically severe CsA-induced GE. GE scores were assessed for each patient at baseline and at weeks 2, 4, 8, 12, 16, and 54 following conversion to tacrolimus. Scaling and root planing were initially performed and repeated monthly during the first 6 months. Careful polishing of the teeth was carried out once every 2 weeks until month 6 and then monthly until month 12. Hygiene instructions and reinforcement to optimize oral hygiene were maintained throughout the study.

RESULTS

The four patients showed a rapid decrease in their gingival symptoms and in the size of the gingivae. This change was clinically evident 8 weeks after conversion to tacrolimus. One year later, all the patients experienced GE regression, although some anatomic irregularities persisted in the interdental papillae of one of the patients. No adverse effects from tacrolimus were observed during the study except in one patient who presented headaches.

CONCLUSION

It seems that CsA withdrawal and its conversion to tacrolimus in organ transplant recipients who develop severe gingival enlargement, together with an extensive plaque control program, provide an effective means to control/eliminate gingival hyperplasia, with minimal risk of graft dysfunction.

Cyclosporin A-induced gingival overgrowth in renal transplant patients

BACKGROUND

The incidence of gingival overgrowth (GO) associated with the use of cyclosporin A (CsA) is controversial. In the present study, we determined the incidence of GO in Brazilian renal transplant patients treated with CsA and the possible associations between periodontal and pharmacological variables.

METHODS

The test group consisted of 20 renal transplant patients, and the control group included 20 non-transplant patients. Periodontal conditions were evaluated based on the plaque index (PI), gingival index (GI), probing depth (PD), and the rate of gingival overgrowth, together with pharmacological variables (daily CsA dose and duration of treatment).

RESULTS

A significant difference in PI (P < 0.0001) and PD (P < 0.0001) was observed between groups, while GI (P = 0.15) did not differ significantly. Using the Pearson correlation coefficient, a significant correlation was observed not only between GI (P < 0.001; r = 0.8141) and GO, but also for PD (P < 0.001; r = 0.866) and GO. The other correlations were not statistically significant.

CONCLUSIONS

We conclude that GO induced by CsA may vary according to the individual sensitivity of each patient and may or may not be correlated with other local factors (periodontal variables).

Immunohistochemical analysis of lymphocyte subpopulations in cyclosporin A-induced gingival overgrowth

BACKGROUND

Cyclosporin A (CsA) is an immunosuppressive agent that is known to induce gingival overgrowth (GO). Pharmacological, genetic, immunologic, and inflammatory factors seem to be involved in the complex pathogenesis of drug-induced GO. Lymphocyte subpopulations in human gingival connective tissue have been implicated in the pathogenesis of inflammatory periodontal diseases. One purpose of this study was to quantify CD4, CD8-, CD57-, and epithelial membrane antigen (EMA)-positive cells in the gingiva of renal transplant recipients treated with CsA, and compare them to findings in healthy controls. A second aim was to correlate cell numbers with clinical findings.

METHODS

The study included 19 kidney recipients who were taking CsA and had significant GO (CsAGO+), 13 recipients who were taking CsA but showed no GO (CsAGO-), and 14 systemically healthy individuals with gingivitis (C). Sections from gingival biopsies were incubated with monoclonal antibodies for CD4, CD8, EMA, and CD57, and then analyzed using the avidin-biotin complex method. In each specimen, the mononuclear cell types were quantified and their distribution was evaluated in 3 separate tissue zones: S = subepithelial connective tissue beneath the sulcular epithelium; O = subepithelial connective tissue beneath the oral epithelium; and M = middle connective tissue.

RESULTS

There were no significant differences among the groups with respect to the numbers of CD4+ and CD8+ cells in each of the 3 zones (P >0.05). In zone S, the CsAGO+ group had significantly more EMA-positive cells than either the C or CsAGO- groups (P <0.05). There were significant differences among the groups regarding numbers of CD57+ (natural killer) cells in zone M, with the lowest cell numbers in the CsAGO+ patients (P<0.05).

CONCLUSIONS

The results showed that low numbers of natural killer cells are important in the expression of plaque-induced inflammatory changes in CsA-associated GO. It appears that these cells may influence the drug's ability to induce proliferative activity.

Cytomegalovirus and cyclosporin-induced gingival overgrowth in children with liver grafts

OBJECTIVE

To determine whether cytomegalovirus (CMV) is associated with gingival overgrowth in paediatric liver graft recipients treated with cyclosporin.

STUDY DESIGN

Thirty-four children, 25 of whom were under 5 years of age, who had undergone liver transplantation, were examined. An Index of Severity of Gingival Overgrowth was used to measure the prevalence and severity of the gingival overgrowth. The trough cyclosporin level was recorded and the CMV status of the patient matched to the dental findings. The association between the severity of gingival overgrowth and CMV infection was examined using the contingency coefficient. An anova was used to assess the association between the circulating trough cyclosporin concentration and the severity of gingival overgrowth. Pearson's Product Moment Correlation Coefficient was used to examine the association between the duration of exposure to cyclosporin and the severity of gingival overgrowth.

RESULTS

There was a significant inverse association between the duration of exposure to cyclosporin and the severity of gingival overgrowth. There was no relationship between the trough cyclosporin concentration and the severity of gingival overgrowth. There was no association between CMV and gingival overgrowth.

CONCLUSION

Gingival overgrowth was related to the duration of cyclosporin therapy but was neither more prevalent nor more severe in subjects who were CMV seropositive.

Tacrolimus is not associated with gingival overgrowth in renal transplant patients

BACKGROUND

Cyclosporin A is used extensively to prevent the rejection of allogenic renal transplants. However, it is associated with a variety of undesirable side effects including gingival overgrowth. Tacrolimus (FK506), has been marketed as an effective alternative immunosuppressant to cyclosporin A and recent subjective reports suggest patients taking it complain infrequently of gingival problems. This clinical investigation was undertaken to confirm whether or not tacrolimus adversely affected the gingival health of renal transplant recipients.

METHODS

Renal transplant patients (RTPs) under the care of the Renal Transplantation Service at the Manchester Royal Infirmary, who had received a renal allograft at least 18 months earlier, were recruited for this study. All but one of the RTPs had been taking tacrolimus since transplantation. The other had commenced tacrolimus therapy two months after receiving her allograft. A hospital based control group was recruited from non transplanted individuals attending the Turner Dental School, Manchester. Each patient underwent a detailed dental assessment and had dental impressions taken. The extent of gingival overgrowth was determined from plaster models.

RESULTS

25 renal transplant recipients and 26 control patients were included in the study. None of the individuals in either the tacrolimus or control groups had clinically significant overgrowth. The patients in the tacrolimus group with the highest overgrowth scores were those also taking calcium antagonists as treatment for hypertension.

CONCLUSION

This study demonstrates that tacrolimus has no adverse effects on the gingival tissues and thus has potential as an alternative immunosuppressant for individuals susceptible to developing cyclosporin A-induced gingival overgrowth.

Prevalence and risk of gingival enlargement in patients treated with anticonvulsant drugs

BACKGROUND

Predictors of gingival enlargement in patients treated with anti-epileptics have not been previously assessed. This study was conducted to determine, with the aid of two indices that score vertical and horizontal overgrowth, the prevalence and risk factors for gingival enlargement in patients treated with phenytoin and other anticonvulsant drugs.

MATERIALS AND METHODS

A cross-sectional study was conducted and data from 59 patients taking antiepileptics were compared with 98 controls. Gingival enlargement was evaluated with two indices to score vertical overgrowth [Gingival overgrowth index (GO] and horizontal overgrowth [Miranda-Brunet index (MB)]. Gingival index, plaque index, and probing depth were also evaluated.

RESULTS

The prevalence of gingival enlargement was significantly higher (P < 0.0001) for both indices in the anticonvulsants treated groups than in the control group. Gingival overgrowth was significantly higher for both indices in the phenytoin group than in the non phenytoin group. Among the possible risk factors, only the gingival index showed a significant association with gingival enlargement. For the MB index the risk of gingival enlargement (odds ratio) associated to phenytoin therapy and other anticonvulsants therapy were 52.6 (13.5-205) and 6.6 (1.5-28.2). Gingival index-adjusted odds ratios for the same drugs were 5.7 (1.3-24.7) and 18.1 (2-158), respectively. The concordance between GO and MB indices in the control group and in the phenytoin-group and non phenytoin-group showed a Kappa value of 0.773 and 0.697, respectively.

CONCLUSION

This study reports significant differences in the prevalence and severity of gingival overgrowth in two groups of patients, one treated with phenytoin, and another treated with other anticonvulsants. Gingival inflammation is a significant risk factor for gingival enlargement in these patients.

Periodontal changes in liver cirrhosis and post-transplantation patients. I: clinical findings

BACKGROUND

Cyclosporin A (CsA) is widely used to prevent liver transplantation failure. CsA-induced gingival overgrowth is a common side effect. However, the effect of cirrhotic liver disease, liver transplantation, and immunosuppressive therapy on the periodontium is yet unclear. The aim of the present cross-sectional study was to examine the effect of liver cirrhosis, transplantation, and immunosuppressive therapy on the periodontium.

METHODS

The experimental group (LC) consisted of 13 liver cirrhosis patients. A second experimental group (PT) included 24 patients, post-liver transplantation, receiving immunosuppressive therapy. Seventeen healthy subjects formed a control group. The Ramfjord index teeth were recorded for plaque index (PI), gingival index (GI), probing depth (PD), clinical attachment level (CAL), and gingival overgrowth (GO).

RESULTS

Mean PI and mean GI for the LC, PT, and C groups were not statistically different (P >0.05). Mean PD for the LC (3.32+/-0.24 mm) and PT group (3.41+/-0.13 mm) was significantly higher (P = 0.0001, ANOVA) compared to the C group (2.45+/-0.16 mm). Likewise, CAL for the LC (4.89+/-0.47 mm) and PT group (4.68+/-0.47 mm) was significantly higher (P = 0.001, ANOVA) than the C group (2.78+/-0.23 mm). Patients in the PT group exhibited the greatest mean GO scores (0.88+/-0.09) compared to the LC group (0.37+/-0.07) and the C group (0.09+/-0.02). All 3 groups were significantly different from each other (P = 0.0001) despite great variability within the groups. GO in the CsA-treated patients (1.1+/-0.09) was significantly higher (P = 0.0001) than in those treated with tacrolimus (0.57+/-0.1).

CONCLUSIONS

Liver cirrhosis patients demonstrated greater pocketing and attachment loss compared to healthy matched controls. These same differences were observed in patients post-transplantation. Gingival overgrowth occurred as a result of the immunosuppressive therapy with CsA, while to a lesser degree with tacrolimus. Replacement of CsA by tacrolimus in patients manifesting gingival overgrowth might be recommended whenever possible to overcome this problem.

The influence of transforming growth factor-beta1 gene polymorphisms on the severity of gingival overgrowth associated with concomitant use of cyclosporin A and a calcium channel blocker

BACKGROUND

The purpose of this study was to determine whether the prevalence and severity of gingival overgrowth in renal transplant recipients concomitantly treated with cyclosporin and a calcium channel blocker was associated with functional polymorphisms within the signal sequence of the transforming growth factor-(TGF)beta1 gene.

METHODS

The extent and severity of gingival overgrowth for 164 renal transplant recipients immunosuppressed with cyclosporin A and concomitantly taking a calcium channel blocker since transplant were entered into the study (86 in Manchester, 78 in Belfast). Two biallelic polymorphisms of the TGF-beta1 gene were studied at position +869, codon 10 (leucine to proline substitution), and position +915, codon 25 (arginine to proline substitution).

RESULTS

Subjects who were homozygous for proline at codon 10 had significantly higher overgrowth scores than those who were heterozygous (P= 0.03) or homozygous for leucine (P= 0.01). Subjects who were heterozygous (arginine/proline) at codon 25 had a significantly higher (P= 0.04) gingival overgrowth score than those who were homozygous for arginine. Logistic regression analysis indicated that for codon 25 independent predictors of severe gingival overgrowth were the heterozygous arginine/proline genotype (P= 0.009) and whether the individual was young (P= 0.05).

CONCLUSIONS

Polymorphisms in the TGF-beta1 gene influence the expression of gingival overgrowth in renal transplant recipients concomitantly treated with cyclosporin and a calcium channel blocker. The polymorphism in the TGF-beta1 gene at codon 25 represented an independent genetic determinant of severe gingival overgrowth in the susceptible subjects studied.

Prevalence and risk of gingival enlargement in patients treated with nifedipine

BACKGROUND

Gingival enlargement is a known side effect of nifedipine use. This study was conducted to determine the prevalence and risk factors for gingival enlargement in nifedipine-treated patients.

METHODS

A cross-sectional study was conducted in a primary care center. Data from 65 patients taking nifedipine were compared with 147 controls who had never received the drug. All patients were examined for the presence of gingival enlargement using 2 different indices: vertical gingival overgrowth index (GO) in 6 points around each tooth, and horizontal MB index in the interdental area. Gingival index, plaque index, and probing depth were also evaluated.

RESULTS

The prevalence of gingival enlargement was significantly higher in nifedipine-treated cases than in controls (GO index, 33.8% versus 4.1%; MB index, 50.8% versus 7.5%, respectively). Higher gingival and plaque indices were observed in patients taking nifedipine. Among the possible risk factors, only the gingival index showed a significant association with gingival enlargement. The risk (odds ratio [OR]) of gingival enlargement associated with nifedipine therapy was 10.6 (3.8-29.1) for the GO index and 14.4 (6-34.6) for the MB index. Gingival index-adjusted ORs were 9.6 (3.3-28.1) and 9.7 (3.9-23.3), respectively. In the subset of high nifedipine exposure patients, the odds ratio for gingival enlargement increased to 17.4 (5.3-56.3) for the GO index and 23.6 (7.7-72.3) for the MB index. The concordance between GO and MB indices showed a kappa value of 0.689 in controls and 0.642 in patients treated with nifedipine.

CONCLUSIONS

Patients taking nifedipine are at high risk for gingival enlargement, and gingivitis acts as a predisposing factor.

Photographic scoring of gingival overgrowth

BACKGROUND

A wide range of methods have been employed to determine the severity of gingival overgrowth resulting in uncertainty regarding the prevalence of the side-effect. There is no simple, non-invasive, objective, blind method for assessing gingival overgrowth.

AIM

This article aims to describe a method which is suitable for use in large-scale population studies.

MATERIALS AND METHODS

Photographs were taken of the anterior, buccal gingivae and teeth of 925 patients medicated with calcium channel blockers. In addition, each patient was ascribed a clinical gingival overgrowth score. 100 patients had repeat photographs, and a further 10 patients had alginate impressions taken. The models were scored for severity of gingival overgrowth using a described technique. The slides were scored using a modification of this technique.

RESULTS

When photographic and study model scores were compared, photographic scores were consistently higher, and as a result, a photographic score of 38.6% was considered to represent a significant overgrowth. There was good agreement between clinically determined scores and photographic scores (kappa=0.71).

CONCLUSIONS

The results indicate that this method is suitable for large-scale population studies where it also has the advantage of providing a continuous scale of gingival changes for subsequent statistical analysis.

An investigation of the oral status and reported oral care of children with heart and heart-lung transplants

AIM

To investigate the oral health status and oral microflora of children who have received heart and heart-lung transplants. Parental knowledge and current practice of oral health procedures by the child were also investigated.

SAMPLE AND METHOD

Thirty-five children attending the Cardio-Thoracic Transplant Unit, Great Ormond Street Hospital for Children were included. Measurements were compared with children matched by age and gender attending the trauma clinic at the Department of Paediatric Dentistry, Eastman Dental Hospital. Teeth were examined for the presence or absence of caries or enamel defects. Plaque deposition, gingivitis, gingival bleeding and gingival enlargement were measured and a swab was taken to look at the oral microbial flora. A questionnaire was used to assess parental knowledge of dental health procedures and the current practice of these.

RESULTS

There were no significant differences between transplant and control children in caries experience, plaque or gingivitis. Children with heart or heart-lung transplants had significantly greater numbers of enamel defects and more gingival enlargement than control children, children in the heart transplant group had significantly more gingival bleeding. There was little difference in the dental knowledge and reported behaviour of the transplant group compared to the control group.

CONCLUSION

The dental needs of heart and heart-lung transplant patients treated at the Great Ormond Street Hospital for Children were similar to those of the control group in this study, however further improvement could be made in educating parents and children on the importance of caries prevention and good oral hygiene.

Evidence for the involvement of bone morphogenetic protein-2 in phenytoin-stimulated osteocalcin secretion in human bone cells

Recent work has shown that the actions of phenytoin on bone cell proliferation and differentiation are, in part, mediated through the upregulation of transforming growth factor-beta1 (TGF-beta(1)). The present study was undertaken to examine the effect of phenytoin on bone morphogenetic proteins (BMP)-2 and -4, which are well-recognized osteoinductive proteins of the TGF-beta superfamily, in osteoblastic cells. Treatment with 5-50 microM of phenytoin increased the amount of mRNA for BMP-2 after a 0.5-24 h incubation in normal human mandible-derived bone cells (HOB-M cells), but failed to affect the mRNA for BMP-4. Phenytoin treatment for 48 h significantly increased the secretion of BMP-2 by approx. four-fold, at an optimal concentration of 10 microM. While TGF-beta(1) inhibited osteocalcin secretion from HOB-M cells, both phenytoin and BMP-2 significantly stimulated it. Importantly, the stimulatory effects of phenytoin on osteocalcin release were completely blocked by the neutralizing antihuman BMP-2 monoclonal antibody. These results indicate that the stimulatory action of phenytoin on osteocalcin secretion in normal human bone cells is mediated, at least partly, through the upregulation of BMP-2, rather than that of TGF-beta(1).

The effect of conversion from cyclosporine to tacrolimus on gingival hyperplasia, hirsutism and cholesterol

The use of cyclosporine for immunosuppression in renal transplantation allograft recipients is associated with hypertrichosis, gingival hyperplasia, and hypercholesterolemia. Conversion of patients to tacrolimus may lead to an improvement in these effects with minimal risk of rejection or allograft dysfunction.

METHODS

Sixteen renal transplant recipients were prospectively converted from CsA to tacrolimus and followed for 1 year. Gingival hyperplasia index, total cholesterol, and blood pressure were recorded at the outset, 4-, 8-, and 12-month intervals. Glomerular filtration rate was checked before conversion and 1 year later. Photographs documenting hypertrichosis were taken before conversion and 1 year later. Adverse effects from tacrolimus were recorded at 4, 8, and 12 months.

RESULTS

Twelve patients with hypertrichosis noted rapid improvement. Mean gingival hyperplasia index decreased from 24 to 6; mean total cholesterol decreased from 237 to 195. Glomerular filtration rate was essentially unchanged (56 to 54). One episode of rejection occurred, three patients developed diarrhea, three noted headaches, and one had a tremor.

CONCLUSION

If carefully monitored, patients suffering adverse effects secondary to cyclosporine may be converted to tacrolimus with minimal risk of allograft dysfunction or rejection.

The effect of multiple anticonvulsant therapy on the expression of phenytoin-induced gingival overgrowth

The potential effect of co-medication with phenobarbitone, primidone and carbamazepine on plasma and saliva concentrations of 5-(4-hydroxyphenyl)-5-phenylhydantoin (4-HPPH), the major metabolite of phenytoin in man and on the incidence of phenytoin-induced gingival overgrowth was investigated in a group of 36 adult epileptic patients. There were no significant differences in plasma or saliva concentrations of 4-HPPH or phenytoin in patients prescribed phenytoin alone, compared to those who received phenytoin with either phenobarbitone, primidone, or carbamazepine. In addition, the extent and the incidence of gingival overgrowth were similar in the 2 groups. The results suggest that chronic co-medication with other anti-convulsant drugs which induce phenytoin metabolism, does not affect the plasma or saliva 4-HPPB steady-state levels, nor the degree of gingival overgrowth in adult epileptic patients on therapy with phenytoin.

A clinical review of drug-induced gingival overgrowths

There is an increasing number of medications associated with gingival overgrowth. These medications are used to treat a number of common conditions in the Australian population and as such dentists can expect to manage a number of patients with medication-related gingival overgrowth. This review highlights the clinical features and management of the common overgrowths associated with anticonvulsants, immunosuppressants and the calcium channel blockers.

Stimulatory effects of phenytoin on osteoblastic differentiation of fetal rat calvaria cells in culture

Phenytoin (diphenylhydantoin, DPH), an anticonvulsant drug for epileptic patients, has several adverse effects, including calvarial thickening and coarsening of the facial features, which occur with chronic DPH therapy. While previous studies have demonstrated that DPH has an anabolic action on bone cells in vivo and in vitro, the basis of these effects is not fully understood. In this study, the effect of DPH on osteoblastic differentiation of fetal rat calvaria (RC) cells in culture was investigated by measuring bone nodule (BN) formation, cell growth, alkaline phosphatase (ALPase) activity, collagen synthesis, and expression of osteocalcin (OC) and osteopontin (OP) mRNAs. Continuous treatment of RC cells with DPH for 18 days dose-dependently increased the mineralized BN number by 1.2-1.7-fold at concentrations of 12.5-200 micromol/L DPH. Cell growth was not affected at the same concentrations of DPH. ALPase activity was stimulated by DPH (1.1-1.9-fold) dose-dependently and was maintained at higher levels in DPH-treated cells throughout the experimental period. DPH increased mineralized and unmineralized BN formations both in the presence and the absence of 10(-8) mol/L dexamethasone (Dex). Expression of OC and OP mRNAs was markedly augmented by DPH on days 12-24 and on days 12-18, respectively. While control mRNA levels of OC and OP increased with time, the increases in DPH-treated cells were greater than those of the controls and the stimulatory effects were dose-dependent. Type I collagen was also influenced by DPH; mRNA level was enhanced and the percentage of collagen synthesized was increased significantly, by 200 micromol/L DPH. When DPH was added in three different culture stages, days 1-6 (growth), days 7-12 (matrix development), and days 13-18 (mineralization), BN formation was influenced primarily on days 1-6 and secondarily on days 7-12, but not on days 13-18, suggesting that DPH increased BN formation by enhancing not only the proportion of osteoprogenitor cells in the early stage but also the proportion of functional osteoblasts in the middle stage within mixed-cell populations. Moreover, such increases were detected in conditions of both Dex(+) and Dex(-). These findings demonstrate that DPH stimulates osteoblast-associated markers such as BNs, ALPase, OC, OP, and type I collagen by continuously affecting the stages of growth and matrix development in RC cells, and suggests that the stimulatory effects by DPH may possibly be induced independent of those by Dex.

Clinical effects of periodontal therapy on the severity of cyclosporin A-induced gingival hyperplasia

BACKGROUND

Gingival hyperplasia (GH) is a major side effect associated with cyclosporin A (CsA) therapy. The condition is further augmented due to the gingival inflammation. In this study, the effects of initial periodontal therapy and gingival curettage are analyzed in a group of patients with clinically significant (>30%) CsA-induced gingival hyperplasia.

METHODS

The test group of 15 patients received oral hygiene instructions, supra- and subgingival scaling, polishing, and gingival curettage only oral hygiene instructions were given to 16 control subjects. Plaque index (PI), gingival index (GI), calculus index (CI), periodontal probing depth (PD), and gingival hyperplasia were recorded at baseline and repeated 8 weeks after treatment. Current doses of immunosuppressive agents, serum concentrations of CsA, and duration of CsA therapy were recorded as the pharmacological parameters.

RESULTS

Statistical evaluation revealed that all clinical variables showed statistical decreases compared to baseline in the treated patients, while none of the parameters changed significantly in the control group. Initial GH scores of 53.63% in controls and 53.40% in the treated patients were 52.83% and 32.13% following treatment, respectively. A difference of 21.27% in the severity of treated GH was accompanied by a 0.56 decrease in GI scores in the test group.

CONCLUSIONS

Compared to the initial observations, the results suggested that nearly 60% of the condition could be of fibrotic origin. Initial periodontal therapy and curettage resulted in the resolution of the inflammation in CsA-induced GH. Further investigation of the treated patients has shown that 7 out of 15 patients (47%) in the test group responded well and their GH scores decreased below 30% at the end of the study. The treatment in this study was effective in eliminating the necessity of more extensive surgical modes of treatment, such as gingivectomy, in 47% of cases.

Phenytoin metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) in man, cat and rat in vitro and in vivo, and susceptibility to phenytoin-induced gingival overgrowth

Interspecies differences in phenytoin (PHT) metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) were examined in human, cat and rat hepatic microsomes in vitro. Rat liver microsomes were 25 and 650 times more efficient at the conversion of PHT to HPPH than human and cat liver microsomes, respectively. Sulphaphenazole (83%) and tolbutamide (TOL) (64%) were the most potent inhibitors of HPPH formation in human liver microsomes, while ciprofloxacin (27%), enoxacin (27%) and TOL (26%) produced the greatest inhibition in cat liver microsomes. TOL was tested for its effect on HPPH formation and gingival overgrowth in cats in vivo. Eight cats received PHT sodium (4 mg/kg/d) and another 8 cats received PHT sodium together with TOL (20 mg/kg/d) for 10 wk. Six cats (75%) in the PHT group and 4 cats (50%) in the PHT & TOL group developed significant gingival overgrowth by the end of the study. However, the extent and incidence of the overgrowth were similar in the 2 groups. There were no significant differences in mean AUC 0-10 weeks for plasma PHT (552.90 +/- 29.6 micrograms.d/mL [PHT alone] vs. 582.41 +/- 24.49 micrograms.d/mL [PHT & TOL]) and unconjugated HPPH (1016.4 +/- 295.5 ng.d/mL [PHT alone] vs. 1174.5 +/- 397.2 ng.d/mL [PHT & TOL]) concentrations between the 2 groups of cats. Neither PHT nor HPPH were detectable in the plasma of 8 rats which received PHT (4 mg/kg/d) over a 10-wk period. The rats showed no sign of gingival inflammation (mean gingival index = 0) or gingival overgrowth (mean gingival overgrowth index = 0). Thirty-six adult epileptic patients on chronic PHT therapy were examined; 17 (47%) of the patients demonstrated clinically significant overgrowth. The mean steady-state plasma PHT concentration was comparable to, and the mean plasma unconjugated HPPH concentration 5-fold greater than, that observed in the cats. The results suggest that the rapid metabolism and elimination of PHT and HPPH in the rat may enable it to become more resistant towards developing gingival overgrowth, compared to the cat and man.

Cyclosporin associated gingival overgrowth in renal transplant recipients

OBJECTIVES

To investigate the prevalence and severity of gingival overgrowth in a group of renal transplant recipients treated in one centre in Northern Ireland.

STUDY DESIGN

A consecutive group of patients who had had a renal transplant for at least 6 months and were attending the Renal Unit in Belfast City Hospital took part in the study. These were divided into a group of 84 subjects treated with cyclosporin since their transplant who were compared with a control group of 36 transplant recipients who had never received cyclosporin. Each subject had a periodontal examination and completed a questionnaire. The severity of gingival overgrowth was scored from plaster models.

OUTCOME MEASURES

Clinically significant gingival overgrowth was equated with a score of > or = 30 using the index developed by Seymour et al (1985).

RESULTS

41 (49%) of the cyclosporin group had clinically significant gingival overgrowth compared with none of the controls. A significantly higher proportion of males had overgrowth than females. There were significant correlations between age at transplant, plaque, bleeding, pocketing and the severity of gingival overgrowth. Many patients with clinically significant gingival overgrowth were apparently unconcerned about this condition.

CONCLUSIONS

It is concluded that gingival overgrowth is a significant problem for renal transplant patients treated with cyclosporin, particularly if they are also treated with a calcium channel blocker. None of the factors measured, in isolation, explained the variable expression of gingival overgrowth in those at risk.

Prevalence of gingival overgrowth induced by calcium channel blockers: a community-based study

BACKGROUND

The prevalence of gingival overgrowth induced by chronic medication with calcium channel blockers is uncertain. Although there have been several studies examining this question, the results are conflicting, with previous estimates ranging from 20% to 83%. There have been only 2 studies examining the prevalence of overgrowth induced by diltiazem and amlodipine, with estimates of 74% and 3.3%, respectively.

METHODS

The current study aimed to address the problems associated with these studies by examining a sample of patients taking one of 3 calcium channel blockers, who were drawn from a community-based population in northeastern England. Nine hundred eleven (911) subjects were recruited from general medical practices in the area. Of these, 442 were taking nifedipine, 181 amlodipine, and 186 diltiazem. In addition, 102 control subjects were examined. Drug and demographic data for each subject were recorded. The periodontal condition of all subjects was assessed including plaque index, papillary bleeding index, and a photograph of the anterior gingivae for subsequent analysis of overgrowth severity.

RESULTS

More than six percent (6.3%) of subjects taking nifedipine were seen to have significant overgrowth. This overgrowth was statistically greater than the amount of overgrowth seen in either of the other 2 drug groups or the control population. The prevalence of gingival overgrowth induced by amlodipine or diltiazem was not statistically significant when compared to the control group. The severity of overgrowth within the nifedipine group was found to be related to the amount of gingival inflammation and also to the gender of the subject, with males being 3 times as likely to develop overgrowth than females.

CONCLUSIONS

The prevalence of clinically significant overgrowth related to chronic medication with calcium channel blockers is low, i.e., 6.3% for nifedipine. Males are 3 times as likely as females to develop clinically significant overgrowth. The presence of gingival inflammation is an important cofactor for the expression of this effect.

Analysis of peripheral blood leukocytes in patients with cyclosporine A-induced gingival hyperplasia

BACKGROUND

Gingival overgrowth is one of the major adverse effects of the immunosuppressive drug cyclosporine A (CsA). Although several studies have attempted to determine the immunological mechanisms of gingival hyperplasia (GO) due to CsA therapy, the pathogenesis remains unclear. In this study, the distribution of the peripheral blood leukocytes in a group of renal transplant patients undergoing CsA therapy was analyzed and possible correlations of periodontal and pharmacological variables to lymphocyte subpopulations, natural killer cells, and monocytes investigated.

METHODS

Thirty-six patients were classified into 2 groups of 18 each according to the degree of gingival overgrowth. The periodontal evaluation included plaque index (PI), gingival index (GI), gingival overgrowth (GO), calculus index (CI), and probing depth (PD). The pharmacological variables of current doses of the therapeutic serum levels of CsA were investigated. The peripheral blood leukocytes were studied by 2-color flow cytometric analysis using anti-human CD2, CD3, CD4, CD8, CD11b, CD11c, CD16, CD19, HLA-DR, and CD3+HLA-DR+ monoclonal antibodies.

RESULTS

Statistical evaluation revealed that none of the pharmacological variables varied between the 2 groups. Responders (GO >30%) had significantly higher GI, PD, and GO scores compared to nonresponders (GO < or =30%). Of the immunological parameters studied, only CD2 was higher in the responder group. None of the clinical parameters correlated to the immunological values.

CONCLUSIONS

The results of this study may be useful in explaining the underlying mechanisms of drug-induced gingival overgrowth. Several previously unsuspected cells and accessory activation mechanisms for T lymphocytes could play a role in the pathogenesis.

Nifedipine-induced gingival overgrowth in rats: brief review and experimental study

The first case report of gingival overgrowth induced by nifedipine (NIF), a calcium-beta blocker, was in 1984. However, the association between gingival alterations and the drug therapy of sodium diphenyl hydantoinate was initially described in 1939. The purpose of the experimental study was to examine the effect of NIF on gingival morphology in an animal model. Forty-five male Sprague-Dawley rats were randomly divided into 3 groups. Animals in each group daily received NIF in dimethyl sulfoxide by gastric feeding at a dosage of 0 (control), 30, or 50 mg/kg body weight for 9 weeks. Gingival gross morphology was assessed tri-weekly from stone models obtained from the mandibular incisal region. Animals were sacrificed at the end of study and tissue blocks were processed for histopathologic and histometric evaluation. Histometric analysis was performed at 5 selected tissue levels. Macro- and microscopic significantly increased gingival dimensions were demonstrated in NIF-treated animals compared to control. Although a fibrovascular tissue was observed in the tooth-gingiva interface for both NIF-treated and control animals, it was thicker and appeared earlier in NIF-treated animals. The results of the present study suggest that gingival overgrowth can be induced by NIF in rats and that the gingival overgrowth appears dose dependent.

Medication induced gingival overgrowth

A number of idiopathic, pathological and pharmacological reactions may result in an overgrowth of the gingiva. This review concentrates on those overgrowths associated with various pharmacological agents. The pharmaco-kinetics and side effects of each drug associated with gingival overgrowth are discussed along with the clinical and histological features and treatment. By examining the possible pathogeneses for these overgrowths we propose a unifying hypothesis for the causation based around inhibition of apoptosis and decreased collagenase activity modulated by cytoplasmic calcium.

Subgingival microflora associated with nifedipine-induced gingival overgrowth

The purpose of this study was to examine the composition of subgingival plaque of 140 periodontal lesions in 35 patients with cardiovascular disorders who were administered nifedipine and manifested nifedipine-induced gingival overgrowth (GO). Age was inversely associated with the GO. Plaque index and bleeding index showed a significant association with GO, while nifedipine dosage and duration of nifedipine therapy were not found to be significant predictors of GO. The gingival inflammation as expressed in the logistic regression model by the interaction term color x tone was found to be significantly associated with the GO. Statistically significant differences between the groups of comparable probing depth and different degrees of GO were detected for Propionibacterium acnes, Capnocytophaga gingivalis, Capnocytophaga ochracea, Capnocytophaga sputigena, Bacteroides gracilis, Fusobacterium mortiferum, Fusobacterium nucleatum, Fusobacterium varium and Selenomonas sputigena in deep and enlarged lesions. Significantly more frequently isolated were the bacterial species Eubacterium alactolyticum, Campylobacter concisus, C. gingivalis, C. ochracea, C. sputigena, F. mortiferum, F. nucleatum, and F. varium from the more enlarged lesions (GO >3).

Pre-transplant gingival hyperplasia predicts severe cyclosporin-induced gingival overgrowth in renal transplant patients

The relationship between the pre-transplant periodontal status and the development of post-transplant gingival overgrowth was investigated in a longitudinal study. The periodontal condition of 35 patients was examined on 2 occasions while they were on the transplant waiting list and then at 4-6, 10-12, 16 and 20 weeks post-transplant. At each visit the plaque index, the bleeding index and a pocket index (CPITN) were measured. Dental impressions were taken of the pre- and post-transplant gingival condition and used to make stone models which were used to score the gingival overgrowth index (GOI). The patients divided into 3 distinct groups having severe (n=13), mild (n=16) or no post-transplant gingival overgrowth (n=6). Only 1 of the patients had taken cyclosporin prior to inclusion into the study. All the patients who developed severe overgrowth had evidence of gingival hyperplasia before the transplant. There was no difference in the serum cyclosporin levels between the three groups (chi2<2.28, p>0.319). Furthermore, there was no statistical difference for any of the periodontal indices. This study indicates that the hyperplastic gingival inflammatory response of some individuals appears to be potentiated by cyclosporin resulting in severe post-transplant overgrowth. In other patients the same reaction may allow the fibroblastic activity to occur to an extent where it produces a mild clinically apparent overgrowth.

Osteogenic actions of phenytoin in human bone cells are mediated in part by TGF-beta 1

We have recently demonstrated that phenytoin, a widely used therapeutic agent for seizure disorders, has osteogenic effects in rats and in humans in vivo, and in human bone cells in vitro. The goal of the present study was to determine the mechanism of the osteogenic action of phenytoin in normal human mandible-derived bone cells. Because many osteogenic agents increased bone cell proliferation through mediation by growth factors, we tested the hypothesis that the osteogenic effects of phenytoin involved the release of a growth factor by measuring the mRNA level of several bone cell growth factors and insulin-like growth factor (IGF) binding proteins with Northern blots using specific cDNA probes. Treatment with 5-50 microM phenytoin reproducibly and markedly increased (up to 6-fold, p < 0.001) the mRNA of transforming growth factor (TGF)-beta 1, but not that of other growth factors (i.e., IGF-II, platelet-derived growth factor-A [PDGF-A], PDGF-B, and TGF-beta 2) and IGF binding proteins (i.e., IGFBP-3, -4, and -5). The stimulation was dose dependent, with an optimal dose of 10-50 microM. Maximal increase was seen after 1 h of phenytoin treatment. The release of biologically active TGF-beta activity in conditioned media was measured with the mink lung cell proliferation inhibition assay. Twenty-four hours of phenytoin treatment significantly increased the production of biologically active TGF-beta (2-fold, p < 0.05) with the optimal dose between 5-50 microM. Comparisons between the in vitro osteogenic effects of phenytoin and those of TGF-beta 1 reveal that these two agents at their respective optimal doses had similar maximal stimulatory effects on [3H]thymidine incorporation, alkaline phosphatase (ALP)-specific activity, and type I alpha-2 collagen mRNA expression in human bone cells. The stimulatory effects of phenytoin on [3H]thymidine incorporation and ALP-specific activity were completely blocked by a neutralizing anti-TGF-beta antibody. In conclusion, these findings demonstrate for the first time that at least some of the osteogenic actions of phenytoin in human bone cells could be in part mediated by TGF-beta 1.

The effect of verapamil on the prevalence and severity of cyclosporine-induced gingival overgrowth in renal allograft recipients

Cyclosporine A (CsA) and verapamil are two agents used in renal transplantation, both of which are suspected of inducing gingival overgrowth. This study was conducted to investigate the effect of verapamil on the severity and prevalence of CsA-induced gingival overgrowth. Fifty-one (51) renal transplant recipients (total group) of whom 22 were using only CsA (Group A) and 29 of whom were prescribed CsA + verapamil (Group B) were evaluated for various periodontal and pharmacological parameters. No statistically significant differences were found in age, sex, plaque index, gingival index, calculus index, probing depth, CsA oral dose, CsA whole blood level, duration of CsA therapy, azathioprine dose, and prednisolone dose. Although the prevalence of the gingival overgrowth was more pronounced in CsA + verapamil group compared to CsA group (51.72% vs. 40.91%), the difference was not statistically significant. Similarly, the severity of gingival overgrowth, although more manifest in CsA + verapamil group than CsA patients (34.24% vs. 28.91%), was not significantly different. Gingival overgrowth scores in the main group, CsA, and CsA + verapamil groups were found to be positively correlated to periodontal probing depths (r = 0.60, r = 0.70, r = 0.52, respectively) and the gingival index (r = 0.60, r = 0.70, r = 0.54, respectively). CsA oral dose, whole blood level, and duration of CsA therapy were not found to be correlated with the gingival overgrowth in either group. Likewise, the dose of verapamil and the duration of verapamil therapy were not correlated with the gingival overgrowth in Group B. This study indicates that verapamil, when prescribed as the calcium channel blocker in renal transplant patients, has no augmenting effect on the severity and the prevalence of CsA-induced gingival overgrowth.

Cyclosporin-A-induced gingival overgrowth in heart transplant patients. A cross-sectional study

The incidence of gingival overgrowth secondary to the administration of cyclosporine A (CsA) is widely reported in renal transplant recipients, while there is no information about periodontal conditions in heart transplant patients. In the present cross-sectional investigation the relationship between clinical periodontal conditions and pharmacological profiles of CsA was determined in 39 patients (31 male and 8 female, aged 18-63 years, mean 45.6 +/- 15.2 years) who possessed their 6 upper and 6 lower anterior teeth. All patients had been on a CsA-based immunosoppression regimen for at least 6 months (6-101, mean 39.3 +/- 30.1). 2 periodontal parameters (recorded on the 12 anterior teeth only) relating to gingival overgrowth were considered: hyperplastic index and % of sites with probing depth > 3 mm. These parameters were always recorded by the same observer at first appointment and 2 months after an oral hygiene programme. Both non parametric statistical analysis (Kruskal-Wallis one-way analysis by rank, Wicoxon signed rank-test and Mann Whitney U-test) and parametric analysis (stepwise multiple regression analysis, one-sample and two-sample t-test) were used to investigate the relationship between the periodontal parameters (dependent variables) and a series of independent variables: age, sex, plaque index (PI), gingival index (GI), CsA dose, CsA blood level, duration of therapy (months since allograft). Results failed to demonstrate any significant correlation between gingival overgrowth and age, sex, CsA dose or CsA blood level, PI. A positive significant correlation was found between periodontal conditions and GI and a significant inverse correlation between periodontal conditions and duration of therapy, suggesting that the relation between CsA therapy and gingival overgrowth in heart-transplant patients could be time-related and the negative influence of the drug on the periodontal status could spontaneously decrease over time.

Evaluation of the frequency of HLA determinants in patients with gingival overgrowth induced by cyclosporine-A

This study has been designed to investigate the immunogenetic susceptibility of Cyclosporine-A (CsA) immunosuppressed renal transplant patients to development of gingival overgrowth, and the amplifying effect of calcium channel blockers on the severity of this clinical entity. 52 renal transplant recipients were selected and initially grouped as follows: group (Gp)1: CsA (n = 7); Gp 2: CsA + verapamil (n = 26); Gp 3: CsA + diltiazem (n = 6); Gp 4: CsA + nifedipine (n = 13). These groups were not found to be significantly different in age, sex, plaque index (PlI), gingival index (GI), calculus index, periodontal probing depth, serum CsA level, or duration of CsA therapy (p > 0.05). No significant (p > 0.05) additive effect of the calcium channel blockers on the gingival overgrowth (GO) was assessed. The main group (n = 52) was evaluated for the correlations between the clinical and the pharmacological variables and the GO. GI (rs = 0.60) and the periodontal probing depth (rs = 0.71) were found to be moderately correlated with the GO. The patients were regrouped based on the severity of overgrowth and recognized as responders (n = 26) and nonresponders (n = 26). Age, sex, calculus index, serum CsA level, duration of the CsA therapy, were not statistically different among these groups (p > 0.05). PlI, GI, periodontal probing depth, and GO were significantly higher in the responder group (p > 0.05). Analysis of HLA distribution of the responders and the nonresponders and comparison with the controls (n = 3731) revealed that a statistically significant (p < 0.001)% of the nonresponders were positive for HLA-DR1. These data would indicate that an immunogenetic predisposition should be suspected in the pathogenesis of the entity, and that HLA-DR1 would have a protective rôle against gingival overgrowth induced by CsA.