Decreased expression of alpha2 integrin in fibroblasts isolated from cyclosporin A- induced gingival overgrowth in rats

Drug-Induced Gingival Overgrowth—Molecular Aspects of Drug Actions

Drug-induced gingival overgrowth (DIGO) is one of the side effects produced by therapeutic agents, most commonly phenytoin, nifedipine and cyclosporin A. However, the precise mechanism of DIGO is not entirely understood. A literature search of the MEDLINE/PubMed databases was conducted to identify the mechanisms involved in DIGO. The available information suggests that the pathogenesis of DIGO is multifactorial, but common pathogenic sequelae of events emerge, i.e., sodium and calcium channel antagonism or disturbed intracellular handling of calcium, which finally lead to reductions in intracellular folic acid levels. Disturbed cellular functions, mainly in keratinocytes and fibroblasts, result in increased collagen and glycosaminoglycans accumulation in the extracellular matrix. Dysregulation of collagenase activity, as well as integrins and membrane receptors, are key mechanisms of reduced degradation or excessive synthesis of connective tissue components. This manuscript describes the cellular and molecular factors involved in the epithelial–mesenchymal transition and extracellular matrix remodeling triggered by agents producing DIGO.

Gingival overgrowth induced by anticonvulsant drugs: A cross-sectional study on epileptic patients

OBJECTIVE

Our aim was to estimate the prevalence of gingival overgrowth (hyperplasia) and to determine whether active molecules affect the severity of overgrowth in a group of epileptic patients.

BACKGROUND

The effects of phenytoin on oral health have been explored in different studies, yet little information is available on other antiepileptic drugs.

METHODS

Data were collected from 213 subjects of both sexes, from 5 to 80 years. Patients taking the same antiepileptic therapy for at least 1 year and meeting the inclusion criteria of the study (n = 162) were subjected to measurement of gingival overgrowth according to the modified Harris and Ewalt classification and O'Leary's plaque control record (OLR). Descriptive statistics were calculated. Data were analyzed using Pearson's r correlation coefficient and chi-square test. Significance level was set at 5%.

RESULTS

The active drugs lamotrigine, oxcarbazepine, and phenobarbital were significantly associated with gingival overgrowth in 61%, 71%, and 53% of cases, respectively, and phenytoin, valproic acid, and carbamazepine in 50%, 44%, and 32% of cases, respectively.

CONCLUSION

Different antiepileptic molecules may be related to gingival overgrowth. In addition to phenytoin, also lamotrigine, oxcarbazepine, and phenobarbital were associated with increased prevalence of gingival overgrowth. In the management of epileptic patients, dentists should take into account different drugs as possible causes for gingival overgrowth and warn for possible alternatives.

On the Cellular and Molecular Mechanisms of Drug-Induced Gingival Overgrowth

Introduction:

Gingival overgrowth has been linked to multiple factors such as adverse drug effects, inflammation, neoplastic processes, and hereditary gingival fibromatosis. Drug-induced gingival overgrowth is a well-established adverse event. In early stages, this gingival enlargement is usually located in the area of the interdental papilla. Histologically, there is an increase in the different components of the extracellular matrix.

Objective:

The aim of this manuscript is to describe and analyze the different cellular and molecular agents involved in the pathogenesis of Drug-induced gingival overgrowth.

Method:

A literature search of the MEDLINE/PubMed database was conducted to identify the mechanisms involved in the process of drug-induced gingival overgrowth, with the assistance of a research librarian. We present several causal hypotheses and discuss the advances in the understanding of the mechanisms that trigger this gingival alteration.

Results:

In vitro studies have revealed phenotypic cellular changes in keratinocytes and fibroblasts and an increase of the extracellular matrix with collagen and glycosaminoglycans. Drug-induced gingival overgrowth confirms the key role of collagenase and integrins, membrane receptors present in the fibroblasts, due to their involvement in the catabolism of collagen. The three drug categories implicated: calcineuron inhibitors (immunosuppressant drugs), calcium channel blocking agents and anticonvulsant drugs appear to present a multifactorial pathogenesis with a common molecular action: the blockage of the cell membrane in the Ca2+/Na+ ion flow. The alteration of the uptake of cellular folic acid, which depends on the regulated channels of active cationic transport and on passive diffusion, results in a dysfunctional degradation of the connective tissue. Certain intermediate molecules such as cytokines and prostaglandins play a role in this pathological mechanism. The concomitant inflammatory factor encourages the appearance of fibroblasts, which leads to gingival fibrosis. Susceptibility to gingival overgrowth in some fibroblast subpopulations is due to phenotypic variability and genetic polymorphism, as shown by the increase in the synthesis of molecules related to the response of the gingival tissue to inducing drugs. The authors present a diagram depicting various mechanisms involved in the pathogenesis of drug-induced gingival overgrowth.

Conclusion:

Individual predisposition, tissue inflammation, and molecular changes in response to the inducing drug favor the clinical manifestation of gingival overgrowth.

[Research progression of the relationship between integrin α2β1 and drug-induced gingival overgrowth]

Drug-induced gingival overgrowth (DIGO) is characterized by fibrous gingival hyperplasia and increased gingival volume. DIGO is histologically associated with proliferation of cells and deposition of extracellular matrices, particularly collagen. Integrin α2β1 is related to collagen phagocytosis and involved in the occurrence and progression of DIGO. This paper reviews the progress of research on the relationship between integrin α2β1 and DIGO.

Altered oxidative status and integrin expression in cyclosporine A-treated oral epithelial cells

BACKGROUND AND OBJECTIVE

Cyclosporine A (CsA) is an immunosuppressive agent administered to transplant patients. A well-known reported oral side effect of CsA consumption is gingival overgrowth (GO). Changes in the expression of integrins occurring in the gingiva following CsA treatment have been reported but these reports are mainly concerned with the connective tissue of the gingiva. In this study we targeted the alterations in the oral epithelium using KB cells, an oral epithelial cell line.

METHODS

Cultured oral epithelial cells were treated with increasing concentrations of CsA (0.1, 1 and 10 µg/mL) and the molecular changes involving antioxidant enzymes [glutathione peroxidase (GPx) and glutathione reductase (GR)] and the level of reactive oxygen species (ROS) were measured. Quantitative real-time PCR was used to assess the expression of selected integrins (α2, α5 and β1).

RESULTS

At CsA concentration above 0.1 µg/mL GPx demonstrated an increase in activity while GR activity and the level of reduced glutathione were diminished (p < 0.05). α5 and β1 integrin were downregulated at all treatment concentrations of CsA while α2 integrin presented this effect at concentrations above 1 µg/mL (p < 0.05).

CONCLUSION

The results suggest a possible role for oxidative stress and the altered expression of integrins in the pathology of CsA-induced gingival overgrowth.

Alpha 2 integrin gene (ITGA2) polymorphism in renal transplant recipients with and without drug induced gingival overgrowth

BACKGROUND

Variances in fibroblasts' α2β1 integrin intensity may lead to altered adhesion to type I collagen and consequently to suppression of phagocytosis which may be one of the mechanisms for drug induced gingival overgrowth. The present study aimed to evaluate the genotype and allele frequencies of α2 integrin +807 gene in renal transplant patients with and without gingival overgrowth.

MATERIAL AND METHODS

Seventy renal transplant patients with cyclosporine A (CsA)-induced gingival overgrowth (CsA GO+) were enrolled. Renal transplant patients without GO medicated with CsA (CsA GO-; n=79) and tacrolimus (Tac; n=52) served as controls. DNA was obtained from peripheral blood and ITGA2 +807C/T polymorphism was genotyped by polymerase chain reaction and restriction fragment length polymorphism method. Clinical parameters including probing depth and plaque, papilla bleeding and hyperplasia indexes were recorded. Chi-square, Kruskal-Wallis and Mann-Whitney tests were used in statistical analysis.

RESULTS

Clinical parameters of CsA GO+ group were significantly higher than those of the CsA GO- and Tac groups (p<0.05). ITGA2 807C/T genotype and allele frequencies of study groups were similar (p>0.05).

CONCLUSION

Within the limits of the present study it can be concluded that ITGA2 +807 gene polymorphism is not associated with susceptibility to CsA-induced GO.

In Vitro Analysis of CsA-Induced Hepatotoxicity in HepG2 Cell Line: Oxidative Stress and α2 and β1 Integrin Subunits Expression

BACKGROUND

Cyclosporine A (CsA)-induced hepatotoxicity could be due to a reduction in α2β1 integrin expression that may either be from the direct effect of CsA itself or from reactive oxygen species (ROS) overproduction.

OBJECTIVES

In this study we aimed to identify the cellular mechanisms underlying CsA-induced hepatic injury by investigating the activation patterns of the antioxidant enzymes, using HepG2 as an in vitro model.

MATERIALS AND METHODS

HepG2 cells were cultured with different concentrations of CsA (0, 0.1, 1, 10 μg/ml) for 72 h. Effect of CsA on, 1) cellular integrity, 2) glutathione reductase (GR) and glutathione peroxidase (GPx) activity, 3) cellular levels of glutathione (GSH), 4) intracellular ROS, 5) ALT and AST activities, 6) urea production and 7) α2β1 integrin expression were assayed.

RESULTS

CsA treatment demonstrated a dose dependent increase in intracellular levels of ROS, GPx activity and decrease in GSH levels (P<0.05). GR activity was mildly attenuated in 1 and 10 µg/ml concentrations of CsA. Alanine aminotranferase (ALT) and aspartate aminotransferase (AST) levels increased in CsA treated cells, while urea synthesis was significantly decreased following treatment with higher concentrations of CsA (P<0.05). Significant down-regulation of β1integrin expression was observed in 1 and 10 µg/ml CsA treated cells while α2 integrin mRNA was significantly down-regulated in all CsA treated cells.

CONCLUSIONS

The observed reduction of α2β1 integrin expression following CsA treatment could be proposed as a possible pathway of CsA-induced hepatotoxicity. Further studies are required to elucidate whether this attenuated expression is due to the direct effect of CsA or caused by overproduction of ROS.

Immunoexpression of α2-integrin and Hsp47 in hereditary gingival fibromatosis and gingival fibromatosis-associated dental abnormalities

Objective: The purpose of the present study was to investigate the expression of the α2-integrin subunit and heat shock protein 47 (Hsp47) in two families with isolated gingival fibromatosis (GF) form and one family with GF associated with dental abnormalities and normal gingiva (NG). Study Design: Immunohistochemistry was performed with antibodies against α2-integrin and Hsp47 in specimens from two unrelated families with hereditary gingival fibromatosis (Families 1 and 2) and from one family with a gingival fibromatosis-associated dental abnormality (Family 3); NG samples were used for comparison. The results were analysed statistically. Results: Immunoreactivity for α2-integrin and Hsp47 was observed in the nucleus of epithelial cells of both the basal and suprabasal layer and a more discreet signal was noted in connective tissue in all study samples. Hsp47 showed higher immunoreactivity in Family 2 compared with the other families (p≤0.05). Despite the markup α2-integrin was higher in Family 3 there was no statistically significant difference between the families studied (p≥0.05). Conclusions: Our results confirmed the heterogeneity of GF, such that similar patterns of expression of the condition may show differences in the expression of proteins such as Hsp47. Although no difference in α2-integrin expression was observed between GF and NG groups, future studies are necessary to determine the exact role of this protein in the various forms of GF and whether it contributes to GF pathogenesis.

Key words:Gingival fibromatosis, integrin alpha2, heat shock protein Hsp47.

Phenytoin-induced gingival overgrowth: a review of the molecular, immune, and inflammatory features

Gingival overgrowth (GO) is a side effect associated with some distinct classes of drugs, such as anticonvulsants, immunosuppressant, and calcium channel blockers. GO is characterized by the accumulation of extracellular matrix in gingival connective tissues, particularly collagenous components, with varying degrees of inflammation. One of the main drugs associated with GO is the antiepileptic phenytoin, which affects gingival tissues by altering extracellular matrix metabolism. Nevertheless, the pathogenesis of such drug-induced GO remains fulfilled by some contradictory findings. This paper aims to present the most relevant studies regarding the molecular, immune, and inflammatory aspects of phenytoin-induced gingival overgrowth.

Preliminary evaluation of a nanotechnology-based approach for the more effective diagnosis of colon cancers

AIM

The goal of this research was to develop and preliminarily test a novel technology and instrumentation that could help to significantly increase the diagnostic yield of current colon cancer screening procedures. This technology is based on a combined fluorescence-optical coherence tomography (OCT) imaging, and topical delivery of a cancer-targeting agent.

MATERIALS & METHODS

Gold colloid-adsorbed poly(ε-caprolactone) microparticles were labeled with a near-infrared dye, and functionalized with argentine-glycine-aspartic acid (RGD peptide) to effectively target cancer tissue, and enhance fluorescence-imaging contrast. The RGD peptide recognizes the α(v)β(3)-integrin receptor, which is overexpressed by epithelial cancer cells. OCT was used under fluorescence guidance to visualize tissue morphology and, thus, to serve as a confirmatory tool for cancer presence.

RESULTS

A preliminary testing of this technology on human colon cancer cell lines, a mouse model of colon cancer, as well as human colon tissue specimens, was performed. Strong binding of microparticles to cancer cells and no binding to cells that do not significantly express integrins, such as mouse fibroblasts, was observed. Preferential binding to cancer tissue was also observed. Strong fluorescence signals were obtained from cancer tissue, owing to the efficient binding of the contrast agent. OCT imaging was capable of revealing clear differences between normal and cancer tissue.

CONCLUSION

A dual-modality imaging approach combined with topical delivery of a cancer-targeting contrast agent has been preliminarily tested for colon cancer diagnosis. Preferential binding of the contrast agent to cancer tissue allowed the cancer-suspicious locations to be highlighted and, thus, guided OCT imaging to visualize tissue morphology and determine tissue type. If successful, this multimodal approach might help to increase the sensitivity and the specificity of current colon cancer-screening procedures in the future.

Increased expression of integrin alpha2 and abnormal response to TGF-beta1 in hereditary gingival fibromatosis

OBJECTIVE

To investigate the possible correlation between integrin alpha1, alpha2, and beta1 expression and excessive collagen synthesis in fibroblasts from 3 unrelated Chinese families with hereditary gingival fibromatosis (HGF).

DESIGN

Gingival fibroblasts from three Chinese HGF patients and three healthy subjects were included. The expression of alpha1, alpha2, and beta1 integrin subunits was examined by immunohistochemistry, quantitative PCR, and flow cytometry. We also investigated the effects of transforming growth factor-beta1 (TGF-beta1) on the expression of these integrin subunits.

RESULTS

Our results demonstrate that the expression of alpha2 was significantly higher in HGF fibroblasts compared with control fibroblasts (P < 0.01). No significant differences in the expression of alpha1 and beta1 were detected. Furthermore, TGF-beta1 promoted the expression of alpha1 and alpha2 in fibroblasts from both HGF patients and controls. However, it had a larger effect on the expression of alpha2 in HGF fibroblasts than in control cells. In contrast, alpha1 expression was stimulated more in control fibroblasts.

CONCLUSION

The increased expression of integrin alpha2 and the increased response to TGF-beta1 of HGF fibroblasts may be related to the excessive collagen deposition in HGF patients.

Expression of p21 and p53 in rat gingival and human oral epithelial cells after cyclosporine A treatment

BACKGROUND AND OBJECTIVE

Expression of p21 and p53 were examined, at gene and protein levels, in edentulous gingival epithelial cells from rats and from a human oral epidermoid carcinoma cell line, OECM1, after cyclosporine A therapy.

MATERIAL AND METHODS

In vivo: 20 partially edentulous SD rats were assigned into cyclosporine A feeding and control groups. After the rats were killed, p21 and p53 in gingiva were evaluated by reverse transcription-polymerase chain reaction and immunohistochemistry. In vitro: after cyclosporine A treatment, p21 and p53 of OECM1 cells were evaluated by western blot and the luciferase assay. The distribution of OECM1 cells in each phase of the cell cycle was evaluated by flow cytometry.

RESULTS

The mRNA expression of p21 was significantly higher in the cyclosporine A group than in the control group. A greater number of positive anti-p21-stained cells were observed in the gingival epithelium of the cyclosporine A group than in the control group. Significantly higher levels of p21 protein and activity were observed in OECM1 cells after cyclosporine A treatment than in cells without treatment. A relative increase of cells in G0/G1 phases, and a decrease of cells in G2/M phases, were observed in OECM1 cells after cyclosporine A treatment.

CONCLUSION

In the present study, higher p21 mRNA and protein expressions were observed after cyclosporine A treatment. Thus, an up-regulation of p21 expression, via a p53-independent pathway, by cyclosporine A in gingival and oral epithelial cells was suggested.

Cyclosporin inhibition of collagen remodeling is mediated by gelsolin

Cyclosporin A (CsA) inhibits collagen remodeling by interfering with the collagen-binding step of phagocytosis. In rapidly remodeling connective tissues such as human periodontium this interference manifests as marked tissue overgrowth and loss of function. Previous data have shown that CsA inhibits integrin-induced release of Ca(2+) from internal stores, which is required for the binding step of collagen phagocytosis. Because gelsolin is a Ca(2+)-dependent actin-severing protein that mediates collagen phagocytosis, we determined whether gelsolin is a CsA target. Compared with vehicle controls, CsA treatment of wild-type mice increased collagen accumulation by 60% in periodontal tissues; equivalent increases were seen in vehicle-treated gelsolin-null mice. Collagen degradation by phagocytosis in cultured gelsolin wild-type fibroblasts was blocked by CsA, comparable to levels of vehicle-treated gelsolin-null fibroblasts. In wild-type cells treated with CsA, collagen binding was similar to that of gelsolin-null fibroblasts transfected with a gelsolin-severing mutant and treated with vehicle. CsA blocked collagen-induced Ca(2+) fluxes subjacent to bound collagen beads, gelsolin recruitment, and actin assembly at bead sites. CsA reduced gelsolin-dependent severing of actin in wild-type cells to levels similar to those in gelsolin-null fibroblasts. We conclude that CsA-induced accumulation of collagen in the extracellular matrix involves disruption of the actin-severing properties of gelsolin, thereby inhibiting the binding step of collagen phagocytosis.

Drug-induced gingival overgrowth--a review

Drug-induced gingival overgrowth is a side effect associated with 3 types of drugs: anticonvulsants (phenytoin), immunosuppressive agents (cyclosporine A), and various calcium channel blockers for cardiovascular diseases. Gingival overgrowth is characterized by the accumulation of extracellular matrix in gingival connective tissues, particularly collagenous components with various degrees of inflammation. Although the mechanisms of these disorders have not been elucidated, recent studies suggest that these disorders seem to be induced by the disruption of homeostasis of collagen synthesis and degradation in gingival connective tissue, predominantly through the inhibition of collagen phagocytosis of gingival fibroblasts. The integrins are a large family of heterodimeric transmembrane receptors for extracellular matrix molecules. alpha2beta1 integrin serves as a specific receptor for type I collagen on fibroblasts, and alpha2 integrin has been shown to play a crucial role in collagen phagocytosis. Actin filaments, which are assembled from monomers and oligomers, are involved in collagen internalization after binding to integrins. Furthermore, the implication of intracellular calcium in the regulation of integrin-mediated binding activity and gelsolin activity, known as a calcium-dependent actin-severing protein, is also described. In this review, we focus on collagen metabolism in drug-induced gingival overgrowth, focusing on the regulation of collagen phagocytosis in fibroblasts.

Alpha 2 integrin +807 polymorphism in drug-induced gingival overgrowth

Alpha2 integrin on fibroblasts is reported to play an important role in the induction of drug-induced gingival overgrowth, which is characterized by excessive accumulation of type I collagen in gingival connective tissue. Silent polymorphism 807 T/C within the alpha2 integrin gene is associated with high/low alpha2 integrin expression. The aim of this study was to test the hypothesis that expression of alpha2 integrin 807 T/C polymorphism correlates with drug-induced gingival overgrowth. A case-control study comparing 136 subjects taking calcium channel blockers (72 with vs. 64 without drug-induced gingival overgrowth) demonstrated that the frequency of the +807 C allele was significantly higher in the case group than in the controls (odds ratio, 3.61; 95% confidence interval, 2.14 - 6.10; P < 0.05). The present findings suggest that the alpha2 +807 C allele is one of the genetic risk factors for drug-induced gingival overgrowth.

Cyclosporin But Not Tacrolimus Significantly Increases Salivary Cytokine Contents in Rats

BACKGROUND

Cyclosporin (CsA) and tacrolimus (FK-506) are immunosuppressive drugs that specifically inhibit T-cell activation via calcineurin inhibition. Gingival overgrowth is a common side effect following the administration of CsA. The severity of gingival overgrowth seen in patients taking FK-506 is less than that observed with CsA. Little is known about the involvement of saliva in drug-induced gingival overgrowth. The purpose of this study was to investigate the salivary contents of tumor growth factor beta1 (TGF-beta1), epidermal growth factor (EGF), and interleukin-6 (IL-6) as well as the hystometry of gingival tissue obtained from rats treated with either FK-506 or CsA.

METHODS

For 30 or 60 days rats received daily subcutaneous injection doses of either CsA or FK-506 (10 mg/kg). The concentrations of TGF-beta1, EGF, and IL-6 in saliva were determined by enzyme-linked immunosorbent assay, and after histological processing, the oral epithelium and connective tissue were assessed at the region of the lower first molars.

RESULTS

The levels of TGF-beta1, EGF, and IL-6 in saliva were not significantly altered by any of the treatments after 30 days. After 60 days of treatment with CsA, gingival overgrowth and significant increase in salivary TGF-beta1, EGF, and IL-6 concentrations were observed; no statistically significant changes were induced by FK-506.

CONCLUSION

Within the limits of this experimental study, it can be concluded that CsA, but not FK-506, induced gingival overgrowth associated with an increase of the salivary levels of the cytokines TGF-beta1, EGF, and IL-6.

Impaired degradation of matrix collagen in human gingival fibroblasts by the antiepileptic drug phenytoin

BACKGROUND

Gingival overgrowth (GO) is a serious adverse effect associated with the administration of phenytoin (PHT), with PHT-induced GO characterized by a massive accumulation of extracellular matrix components, especially collagen, in gingival connective tissues. However, the etiology of such collagen accumulation is still largely unknown. We examined the effects of PHT on the collagen degradation process leading to collagen accumulation in human gingival fibroblasts (HGF).

METHODS

HGFs were cultured with various concentrations of PHT and viable cell numbers and collagen amounts were determined. Gene and protein expressions of matrix metalloproteinases (MMP) and tissue inhibitors of MMPs (TIMP) were quantified with reverse transcription-polymerase chain reaction (RT-PCR) analyses and Western blotting, respectively. Cellular endocytosis of collagen was assayed using flow-cytometric analysis. The effects of PHT on extracellular signal-regulated kinase 1/2 (ERK1/2) and inhibitor kappaB-alpha (IkappaB-alpha) were assayed.

RESULTS

The proliferation of HGFs was not affected by PHT, whereas it significantly increased collagen accumulation. Further, the expressions of MMP-1, -2, and -3 were markedly suppressed by PHT, whereas that of TIMP-1 was induced in a dose- and time-dependent manner. PHT also markedly prevented collagen endocytosis by HGFs, which was associated with the suppression of alpha2beta1-integrin expression. In addition, the phosphorylation of ERK1/2 and IkappaB-alpha degradation were suppressed by PHT.

CONCLUSIONS

These results suggest that PHT causes an impaired degradation of collagen by suppression of enzymatic degradation with MMPs/TIMP-1 and alpha2beta1-integrin-mediated endocytosis. Those alterations are likely mediated through the cellular signaling pathways of ERK1/2 and nuclear factor kappaB. These synergistic effects may cause collagen accumulation, leading to GO.

Effect of Cyclosporin A on the Mineral Apposition Rate of Cementum and Dentin in Growing Rats

BACKGROUND

Since there is no direct information to verify whether cyclosporin A (CsA) can affect the mineralization of dental hard tissue, the formation of dentin and cementum in growing rats was recorded by labeling the mineral phase of these tissues with fluorochrome marker in this study.

METHODS

After the extraction of the right maxillary molars, 30 male 3-week-old Sprague-Dawley rats were assigned to two groups. Following a 2-week healing period, the experimental rats received 30 mg/kg CsA daily for 7 weeks, while the control rats received only mineral oil. The fluorescent markers, calcein and alizarin red, were given on alternate weeks for 7 weeks. At the end of study, the mandibles were obtained and undemineralized sections were processed. Serial sections, 8 microm thick, were cut for the entire distal roots of the first molars. Five central sections were selected to determine the mineral apposition of cellular cementum and dentin at the apex and middle of root, respectively.

RESULTS

The apposition rates of apical cellular cementum were significantly influenced by CsA therapy, occlusal function, and observation duration. However, the dentin apposition rates were significantly influenced by the observation intervals only.

CONCLUSIONS

In this study, CsA therapy and occlusal function significantly influenced the apposition rates of apical cementum, but not the rates of mid-root dentin. Our hypothesis that CsA can induce oral hard tissue alterations, as well as gingival overgrowth, is demonstrated.