Resolution of cyclosporin-induced gingival hypertrophy with metronidazole

Nifedipine-Influenced Enlargement of the Masticatory Mucosa in an Elderly Edentulous Patient: A Rare Case Report with a Two-Year Follow-Up

Drug-influenced gingival enlargement is a common side effect associated with certain medications, particularly calcium channel blockers like nifedipine, which has been extensively documented. However, the occurrence of nifedipine-influenced masticatory mucosa overgrowth in edentulous patients is rare. Here, we present a case of nifedipine-influenced mucosal enlargement persisting in a 67-year-old edentulous patient 3 months after the extraction of all his teeth. The patient underwent flap surgery and alveoloplasty to excise the overgrown tissue, followed by complete denture restoration. The antihypertensive medication was replaced with valsartan. A 2-year follow-up revealed no recurrence of overgrowth, indicating the effectiveness of this management strategy for such clinical situation.

Massive gingival bleed: a rare manifestation of cyclosporine toxicity

A 12-year-old patient of thalassaemia major developed autoimmune cytopaenia after undergoing haematopoietic stem cell transplantation. She was started on cyclosporine (CsA) in view of poor response to steroids. She developed CsA toxicity manifesting as gum hyperplasia with multiple episodes of gum bleed. During endotracheal intubation for an elective splenectomy, she developed significant bleeding from gums requiring massive transfusion. Postoperatively the gum bleed persisted even after embolisation of facial artery and multiple transfusions. The catastrophic sequelae include transfusion-related lung injury, acute circulatory failure with subsequent cardiac arrest and death. Gum hyperplasia is a commonly reported toxic effect of CsA. Lethal presentations of this toxicity with such severity are limited in the medical literature. Evaluation of the patient's medical and laboratory records, along with a review of literature, was very helpful in understanding more about the toxicity of CsA.

Management of medication-induced gingival hyperplasia: a systematic review

OBJECTIVE

Medication-induced gingival hyperplasia (MIGH) has been linked to several medications, with a reported prevalence ranging between 0.5% and 85%. The aim of this study was to systematically review the management approaches for MIGH and estimate recurrence rate and time to relapse.

STUDY DESIGN

An electronic literature search was conducted using PICO questions (P = patients with medication-induced gingival hyperplasia; I = surgical and/or nonsurgical treatment options; C = no control is required; and O = partial or complete resolution and recurrence) and medical subject heading terms in the PubMed and Web of Science databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol up to December 2019. All English-language articles on MIGH surgical and nonsurgical management options were included. Eligible articles were systematically reviewed and assessed for bias using preset criteria and multiple levels of elimination. Data were extracted from eligible studies and analyzed.

RESULTS

Twenty-two eligible articles were included in this study. Management approaches included discontinuation or change of the offending medication if medically feasible in addition to surgical and nonsurgical interventions. Nonsurgical approach included scaling and root planing, oral hygiene instructions, and antimicrobial mouthrinses. Persistent or relapsed cases had complete resolution with excision of hyperplastic gingiva. Laser-assisted surgeries combined with intensive plaque control measures demonstrated less risk of recurrence.

CONCLUSIONS

Several treatment options for MIGH have been reported with variable outcomes. Duration and size of hyperplastic gingival tissue may have an effect on overall recurrence rate.

Drug-Induced Gingival Hyperplasia in Transplant Recipients

Gingival hyperplasia is a common occurrence in transplant recipients who are taking cyclosporine. This condition can be complicated when calcium channel blockers or phenytoin are added to the armamentarium of medications; it can be painful and may interfere with eating, speech, and appearance. Multiple mechanisms exist for gingival overgrowth. Prevention with appropriate oral hygiene appears important in controlling the inflammatory component and decreasing the severity of the overgrowth. Patients must be aware of the potential for the development of gingival hyperplasia and must follow up with regular professional cleanings. If the overgrowth persists, treatment options should be discussed between patients and their physician. Conversion from cyclosporine to tacrolimus, treatment with antibiotic therapy, and surgical excision or laser therapy are all potential therapies to consider.

A well known and important adverse effect of phenytoin in a neurosurgical patient

Gum hypertrophy is a well-known and important adverse effect of phenytoin therapy in a neurosurgical patient. We present an interesting case of a 21-year-old man who, following head injury after a road traffic accident, developed status epilepticus diagnosed with gum hypertrophy in the jaws, with ongoing antiepileptics. He was managed conservatively as per hospital protocol.

Azithromycin in periodontal treatment: more than an antibiotic

Azithromycin is a macrolide antibiotic used extensively in medicine for the treatment of a wide range of infections such as upper respiratory tract infections, middle ear infections, sexually transmitted infections and trachoma. It is also effective against the most common periodontopathogens. The versatility of the macrolides extends beyond their antibiotic properties as a result of their well-documented immune-modulating/anti-inflammatory effects. Macrolides, including azithromycin, are therefore used to treat diseases not associated with bacteria, such as severe asthma, chronic obstructive pulmonary diseases and, more recently, cystic fibrosis. Azithromycin is concentrated in neutrophils, macrophages and particularly fibroblasts; all of these cells are central players in the pathogenesis of most periodontal diseases. This paper reviews the diverse properties of azithromycin and the clinical periodontal studies of its effects in both the treatment of periodontitis and in resolving drug-related gingival overgrowth. Evidence exists to support the use of a single course of azithromycin in the treatment of advanced periodontal diseases. Azithromycin could have a triple role in the treatment and resolution of periodontal diseases: suppressing periodontopathogens, anti-inflammatory activity and healing through persistence at low levels in macrophages and fibroblasts in periodontal tissues, even after a single course of three tablets. If future periodontal research confirms these properties, it could become a valuable host-modulator in periodontal treatment.

Idiopathic gingival hyperplasia: a case report with a 17-year followup

This is a case report of a patient with idiopathic gingival hyperplasia and an undiagnosed genetic disorder that demonstrated static encephalopathy, mental retardation, developmental delay, seizures, hypotonia, and severe gingival hypertrophy. The clinical dental management and attempts to obtain a genetic diagnosis are described.

The use of cyclosporine in dermatology: part II

Cyclosporine is highly effective in the treatment of a multitude of dermatoses. Concern over its side effect profile has limited its use in dermatology. Adverse effects are, for the most part, dose dependent and related to duration of therapy. Using the recommended monitoring protocols results in a significant decrease in the incidence of cyclosporine-related toxicities. This article provides a comprehensive review of the pharmacokinetics of cyclosporine, potential drug interactions, adverse effects, and recommendations for monitoring in patients treated with cyclosporine. The use of cyclosporine in pregnancy and in the pediatric population is also addressed.

LEARNING OBJECTIVES

After completing this learning activity, participants should be familiar with the monitoring guidelines of cyclosporine, its contraindications, its possible drug interactions, its adverse effect profile, and its use in pregnancy and the childhood and adolescent populations.

Comparison of Azithromycin and Oral Hygiene Program in the Treatment of Cyclosporine-Induced Gingival Hyperplasia

BACKGROUND

It has been shown that azithromycin improves cyclosporine-induced gingival hyperplasia (GH), but its efficacy was never compared against an efficient oral hygiene program (OHP). The aim of this study was to analyze the effects of azithromycin plus OHP versus OHP alone in patients with cyclosporine-induced GH.

METHODS

After periodontal evaluation, 20 renal transplant recipients received detailed oral hygiene instructions and a complete OHP, and were randomized to control (OHP) or azithromycin groups (OHP plus azithromycin). Patients were re-evaluated after 15 and 30 days. Both groups were similar in time after transplant, age, gender, cyclosporine dose, and cyclosporine through level and serum creatinine. The control group had fewer patients using calcium cannel blockers (10% vs. 70%, p = 0.02).

RESULTS

All patients improved in pain, halitosis, and gum bleeding after OHP. The control group did not improve plaque index (PI) or GH. In contrast, baseline PI decreased from 1.52 +/- 0.28 to 0.50 +/- 0.16 on day 15 (p < 0.01) and to 0.46 +/- 0.14 on day 30 (p < 0.01) in the azithromycin group, and the GH score decreased from 1.9 +/- 0.27 to 0.90 +/- 0.27 on day 15 (p < 0.05) and to 0.70 +/- 0.21 on day 30 (p < 0.01).

CONCLUSION

Azithromycin associated to efficient OHP induced a striking reduction in cyclosporine-induced GH, while efficient OHP alone improved oral symptoms but did not decrease cyclosporine-induced GH.

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.

Trial of metronidazole vs. azithromycin for treatment of cyclosporine-induced gingival overgrowth

Gingival overgrowth usually characterized by increased cellular growth of gingival fibroblasts appears to be multifactorial. In patients receiving CyA for more than 3 months, the incidence can approach 70% and can be attributed to pharmaceutical immunosuppression. Case reports have reported regression of overgrowth with both metronidazole and azithromycin. The goal of this study was to determine the efficacy of metronidazole and azithromycin in reducing CyA-induced gingival overgrowth. Twenty-five patients were included in this double-blinded randomized study. All patients were receiving CyA as medically indicated and diagnosed with gingival overgrowth by a dentist. Patients were randomized to receive either 5-days of azithromycin or 7-days of metronidazole given at baseline only. The extent of gingival overgrowth was measured at 0, 2, 4, 6, 12, and 24 wk. Fourteen patients at CCF and 11 patients at CCHMC were studied. Repeated measures anova was performed to assess differences within and between groups. Gingival overgrowth at baseline was not statistically different between groups. The mean degree of gingival overgrowth after treatment was different across all time intervals (p = 0.0049) showing azithromycin to be more effective than metronidazole. Therapy with azithromycin offers an effective alternative to the management of CyA-induced gingival overgrowth.

Mechanisms and management of gingival overgrowth in paediatric transplant recipients: a review

Increasing numbers of children are receiving solid organ transplants namely kidney, liver, heart and lung. Patient survival rates following such transplants are essentially good with much of the success attributable to the development of Cyclosporine A (CyA), an immunosuppressive drug, that minimizes organ rejection. However the gingival overgrowth (GO) associated with the use of CyA is not only disfiguring but in paediatric recipients, may interfere with normal oral development and function.

OBJECTIVE

The aim of this review is to summarize current knowledge concerning the aetiology, pathogenesis and management of gingival overgrowth.

METHODS

Literature pertaining to gingival overgrowth is reviewed with particular reference to the paediatric population. Emphasis is placed on summarizing the evidence pertaining to the effectiveness of intervention.

CONCLUSION

CyA undoubtedly causes gingival overgrowth, the effects and levels of which appears to be more severe in younger patients. There is conflicting evidence as to the effectiveness of oral hygiene regimes, antibiotics and surgery in reducing overgrowth. The introduction of an alternative immunosuppressive agent (Tacrolimus) offers potential as it does not appear to cause overgrowth, although research to date is limited by the small sample size of many of the studies. This is an area in which multicentre studies would be of great value.

Antibiotic treatment of incipient drug-induced gingival overgrowth in adult renal transplant patients

BACKGROUND

Drug-induced gingival overgrowth (GO) remains a challenge in periodontics. Partial and total regressions of this GO have been reported after a short course of antibiotics.

METHODS

We conducted a double-blinded controlled randomised study to determine the effect of metronidazole (MNZ) or azithromycin (AZM) on the regression of incipient cyclosporin A-induced GO in 40 adult renal transplanted patients. The quantitation of the GO was performed with Image Digital Analysis.

RESULTS

None of the patients with GO showed complete remission after 30 days. The pretreatment GO index was 0.895 +/- 0.16 in the metronidazole treatment group (MNZ group, n = 13), 0.932 +/- 0.11 in the azithromycin treatment group (AZM group, n = 14), and 1.073 +/- 0.32 in the controls (placebo group, n = 13). At the end of the study (30 days), the GO index score was lower in 54.4% and 62.3% of the MNZ and AZM groups, respectively, and the mean score differences were statistically significant between the groups (0.897 +/- 0.28, MNZ group vs. 0.909 +/- 0.15, AZM group vs. 1.130 +/- 0.3, placebo group, P < 0.05 ANOVA).

CONCLUSIONS

A 7-day course of MNZ or AZM does not induce remission of CsA-induced GO, although it acts on concomitant bacterial over-infection and gingival inflammation.

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.

Metronidazole. A therapeutic review and update

The nitroimidazole antibiotic metronidazole has a limited spectrum of activity that encompasses various protozoans and most Gram-negative and Gram-positive anaerobic bacteria. Metronidazole has activity against protozoans like Entamoeba histolytica, Giardia lamblia and Trichomonas vaginalis, for which the drug was first approved as an effective treatment. Anaerobic bacteria which are typically sensitive are primarily Gram-negative anaerobes belonging to the Bacteroides and Fusobacterium spp. Gram-positive anaerobes such as peptostreptococci and Clostridia spp. are likely to test sensitive to metronidazole, but resistant isolates are probably encountered with greater frequency than with the Gram-negative anaerobes. Gardnerella vaginalis is a pleomorphic Gram-variable bacterial bacillus that is also susceptible to metronidazole. Helicobacter pylori has been strongly associated with gastritis and duodenal ulcers. Classic regimens for eradicating this pathogen have included metronidazole, usually with acid suppression medication plus bismuth and amoxicillin. The activity of metronidazole against anaerobic bowel flora has been used for prophylaxis and treatment of patients with Crohn's disease who might develop an infectious complication. Treatment of Clostridium difficile-induced pseudomembraneous colitis has usually been with oral metronidazole or vancomycin, but the lower cost and similar efficacy of metronidazole, coupled with the increased concern about imprudent use of vancomycin leading to increased resistance in enterococci, have made metronidazole the preferred agent here. Metronidazole has played an important role in anaerobic-related infections. Advantages to using metronidazole are the percentage of sensitive Gram-negative anaerobes, its availability as oral and intravenous dosage forms, its rapid bacterial killing, its good tissue penetration, its considerably lower chance of inducing C. difficile colitis, and expense. Metronidazole has notable effectiveness in treating anaerobic brain abscesses. Metronidazole is a cost-effective agent due to its low acquisition cost, its pharmacokinetics and pharmacodynamics, an acceptable adverse effect profile, and its undiminished antimicrobial activity. While its role as part of a therapeutic regimen for treating mixed aerobic/anaerobic infections has been reduced by newer, more expensive combination therapies, these new combinations have not been shown to have any therapeutic advantage over metronidazole. Although the use of metronidazole on a global scale has been curtailed by newer agents for various infections, metronidazole still has a role for these and other therapeutic uses. Many clinicians still consider metronidazole to be the 'gold standard' antibiotic against which all other antibiotics with anaerobic activity should be compared.

Oral lesions in organ transplant patients

Patients who have undergone organ transplantation can present with a variety of oral lesions that appear to be related either directly to their medication or arise as a consequence of drug-induced immunosuppression. Such lesions include hairy leukoplakia, an increased propensity to both fungal and viral infections and a high incidence of malignant change, especially lip cancer. Cyclosporin remains the immunosuppressant of choice in most transplant patients. Gingival overgrowth is the main unwanted oral effect associated with cyclosporin. Some 30% of dentate transplant experience this problem, which is further compounded by concomitant medication with a calcium channel blocker. This review appraises the various oral problems that can arise in this group of patients and emphasises the importance of regular oral screening and the establishment of links with the various transplant teams.