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

Cosmetic adverse effects of antiseizure medications; A systematic review

BACKGROUND

We systematically reviewed the existing literature on the cosmetic adverse effects of antiseizure medications (ASMs) in order to depict a clear picture of these unwanted side effects of ASMs with a particular attention to hair loss, hirsutism, acne, and gingival hyperplasia.

METHODS

This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE, and Google Scholar from the inception to 25 March, 2021 were systematically searched. These key words (title/abstract) were used: "hair loss" OR "hirsutism" OR "acne" OR "gingival hyperplasia" AND "seizure" OR "epilepsy" OR "anriseizure" OR "antiepileptic". The exclusion criteria included: non-original studies, articles not in English, and animal studies.

RESULTS

The primary search yielded 3938 studies; 127 studies were related to the topic and were included in the current systematic review. The most robust evidence on cosmetic adverse effects of ASMs were related to phenytoin (causing gingival hyperplasia, hirsutism, and acne) and valproate (causing hair loss and hirsutism); however, many other ASMs were also implicated in causing these cosmetic adverse effects.

CONCLUSION

Antiseizure medications may be associated with various cosmetic adverse effects. Phenytoin and valproate are the most notorious ASMs in this regard; but, other ASMs have also been implicated in causing hair loss, hirsutism, acne, and gingival hyperplasia. Physicians should pay more attention to these significant adverse effects that may affect a patient's facial attractiveness, quality of life, and emotional state.

Biology of Drug-Induced Gingival Hyperplasia: In Vitro Study of the Effect of Nifedipine on Human Fibroblasts

Background: It has been proven that the antihypertensive agent nifedipine can cause gingival overgrowth as a side effect. The aim of this study was to analyze the effects of pharmacological treatment with nifedipine on human gingival fibroblasts activity, investigating the possible pathogenetic mechanisms that lead to the onset of gingival enlargement. Methods: The expression profile of 57 genes belonging to the “Extracellular Matrix and Adhesion Molecules” pathway, fibroblasts’ viability at different drug concentrations, and E-cadherin levels in treated fibroblasts were assessed using real-time Polymerase Chain Reaction, PrestoBlue™ cell viability test, and an enzyme-linked immunoassay (ELISA), respectively. Results: Metalloproteinase 24 and 8 (MMP24, MMP8) showed significant upregulation in treated cells with respect to the control group, and cell adhesion gene CDH1 (E-cadherin) levels were recorded as increased in treated fibroblasts using both real-time PCR and ELISA. Downregulation was observed for transmembrane receptors ITGA6 and ITGB4, the basement membrane constituent LAMA1 and LAMB1, and the extracellular matrix protease MMP11, MMP16, and MMP26. Conclusions: The obtained data suggested that the pathogenesis of nifedipine-induced gingival overgrowth is characterized by an excessive accumulation of collagen due to the inhibition of collagen intracellular and extracellular degradation pathways.

Drug-Induced Gingival Overgrowth: A Pilot Study on the Effect of Diphenylhydantoin and Gabapentin on Human Gingival Fibroblasts

INTRODUCTION

The administration of several classes of drugs can lead to the onset of gingival overgrowth: anticonvulsants, immunosuppressants, and calcium channel blockers. Among the anticonvulsants, the main drug associated with gingival overgrowth is diphenylhydantoin.

MATERIALS AND METHODS

In this study, we compared the effects of diphenylhydantoin and gabapentin on 57 genes belonging to the "Extracellular Matrix and Adhesion Molecule" pathway, present in human fibroblasts of healthy volunteers.

RESULTS

Both molecules induce the same gene expression profile in fibroblasts as well as a significant upregulation of genes involved in extracellular matrix deposition like COL4A1, ITGA7, and LAMB3. The two treatments also induced a significant downregulation of genes involved in the expression of extracellular matrix metalloproteases like MMP11, MMP15, MMP16, MMP24, and transmembrane receptor ITGB4.

CONCLUSIONS

Data recorded in our study confirmed the hypothesis of a direct action of these drugs at the periodontium level, inducing an increase in matrix production, a reduction in its degradation, and consequently resulting in gingival hyperplasia.

Phenytoin and gingival mucosa: A molecular investigation

Several distinct classes of drugs, such as anticonvulsants, immunosuppressants, and calcium channel blockers, caused gingival overgrowth. One of the main drugs associated with the gingival overgrowth is the anti-epileptic such as phenytoin, which affects gingival tissues by altering extracellular matrix metabolism. In our study, we evaluate the effect of phenytoin, a drug whose active substance is phenytoin, on gingival fibroblasts of healthy volunteers. Gene expression of 29 genes was investigated in gingival fibroblasts’ cell culture treated with phenytoin compared with untreated cells. Among the studied genes, only 13 genes (CXCL5, CXCL10, CCR1, CCR3, CCR5, CCR6, IL-1A, IL-1B, IL-5, IL-7, IL-6R, BMP-2, and TNFSF-10) were statistically significant. All but one gene resulted downregulated after 24 h of treatment with phenytoin. BPM2 was the only, although weakly, up-expressed gene. Probably, we have not highlighted overexpression of the other inflammatory molecules because the study was performed on healthy people. Many studies show that phenytoin induces the overexpression of these cytokines but, probably, in our study, the drug does not have the same effect because we used gingival fibroblasts of healthy people.

The Management of Drug-Influenced Gingival Enlargement

<br/> Drug-influenced gingival enlargement (DIGE) is a reaction to specific medications, namely phenytoin, ciclosporin and calcium channel blockers. DIGE is encountered increasingly in clinical practice due to the widespread use of calcium channel blocker drugs particularly. Approaches to its management are discussed in this review.<br/> Methods: Narrative review of the literature and discussion of clinical implications.<br/> Findings: Management of DIGE involves nonsurgical treatment and may require surgical reduction of the overgrown gingival tissues. Management is complicated by the difficulties in achieving adequate plaque control, given the unfavourable contour of the enlarged gingival tissues, and the high frequency of recurrence of DIGE after surgical management. Replacing the drug involved can be very beneficial in selected cases, but the management of the underlying medical condition limits its application. The decision to replace a drug is not the responsibility of the dental practitioner, but the patient's physician may make it after consultation.<br/> Conclusions: Management of DIGE can be challenging and may require close co-operation between the dental practitioner and a hygienist, a periodontist and the patient's physician. Long term supportive maintenance programmes need to be in place for optimal outcomes.

Role of Epithelial Mesenchymal Transition in Phenytoin Influenced Gingival Overgrowth in Children and Young Adults. A Preliminary Clinical and Immunohistochemical Study

Objectives: To prove the role of epithelial mesenchymal transition (EMT) in the pathogenesis of phenytoin influenced gingival overgrowth (PIGO) in children and young adults. Study design: Thirty male individuals who are to start with oral phenytoin therapy were recruited for the study. All the 30 individuals underwent full mouth scaling and root planning and were then followed up for a period of one year at intervals of 3 months each. Based on the clinical gingival status they were divided into group1 (responders) individuals who showed gingival overgrowth (GO) and group 2 (non responders) individuals who do not show any GO. Gingival tissue samples were obtained from both the groups at the end of 1 year and subjected to immuno histochemical analysis for E-cadherin expression and histo-pathological for alteration in the basement membrane and confirmation of the fibrosis. Results: Decrease in expression of E cadherin, loss of basement membrane integrity and fibrosis were noted on responder group when compared to non responder group at p<0.001. Fibrosis was seen in the epithelial connective tissue junction. Conclusion: Decrease in cell adhesion, degradation of basement membrane and presence of fibrosis could suggest the role of EMT in the pathogenesis of PIGO.

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.

Phenytoin-induced gingival enlargement: a dental awakening for patients with epilepsy

Drug-induced gingival enlargement is the term now used to describe medication-related gingival hypertrophy or hyperplasia, a condition commonly induced by three main classes of drugs: anticonvulsants, antihypertensive calcium channel blockers and the immunosuppressant cyclosporine. The pathogenesis of drug-induced gingival enlargement is uncertain and there appears to be no unifying hypothesis that links together the three commonly implicated drugs. Phenytoin-induced gingival overgrowth is a well known and frequently reported gingival lesion, which was first detected in 1939. This case report consists of phenytoin usage, duration and poor oral hygiene.

Phenytoin-induced gingival overgrowth

Gingival overgrowth is a common adverse effect of therapy with Phenytoin, having important medical and cosmetic implications. Poor periodontal hygiene is an important risk factor for severity of Phenytoin-induced gingival overgrowth (PIGO), which is a time-dependent process. There is complex interplay of altered fibroblast biology, connective tissue turnover, inflammatory processes, and growth factors on a background of genetic susceptibility to produce increase in various components of interstitial matrix in PIGO tissue. Treatment options have included change of PHT to another anti-seizure drug, measures to improve periodontal hygiene and gingivectomy. There is conclusive evidence that folic acid supplementation significantly decreases the incidence of PIGO.

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.

Prevalence of self-reported epilepsy, health care access, and health behaviors among adults in South Carolina

Behavioral Risk Factor Surveillance System data from South Carolina for 2003-2005 were used to determine epilepsy prevalence and prevalence variation by demographic subgroups, and to compare health insurance coverage, health care visits, and health-related behaviors among persons with epilepsy and the general population. Two percent of respondents reported they had ever been told by a doctor that they had epilepsy, and 1% reported active epilepsy. Almost half of those with active epilepsy reported a seizure in the prior 3 months. More than one-third of respondents with active epilepsy reported that there was a time in the past 12 months when they needed to see a doctor but could not because of cost. Persons with epilepsy were more likely to smoke and have less physical activity. Persons with epilepsy need better access to health care, as well as interventions focused on smoking cessation and increased physical activity.

Plasma and gingival crevicular fluid phenytoin concentrations as risk factors for gingival overgrowth

BACKGROUND

Gingival enlargement is one of the side effects associated with the administration of phenytoin. The mechanism by which phenytoin induces gingival enlargement is not well understood. This study was conducted to investigate the relationship between plasma and gingival crevicular fluid (GCF) phenytoin concentrations and the degree of gingival overgrowth in patients with similar gingival and plaque indices and also to determine the risk factors for gingival enlargement.

METHODS

Eighteen patients taking phenytoin in regular doses > or =6 months prior to the investigation participated in the study. Gingival enlargement was evaluated with two indices to score vertical and horizontal overgrowth. The gingival index (GI), plaque index (PI), gingival bleeding time index (GBTI), probing depth (PD), and clinical attachment level (CAL) were also evaluated. GCF and plasma phenytoin concentrations were determined by using high-performance liquid chromatography (HPLC).

RESULTS

There was no significant difference between responders and non-responders for PD, CAL, PI, GI, and GBTI. Phenytoin was detected in all of the GCF and plasma samples using the HPLC analysis method. The mean concentration of phenytoin in GCF was significantly greater than the concentration of phenytoin in plasma. No significant difference was observed for the concentration of GCF phenytoin between responders and non-responders. However, the concentration of plasma phenytoin was significantly higher in responders than non-responders.

CONCLUSION

This study showed that plasma phenytoin level appeared to be a risk factor for phenytoin-induced gingival overgrowth.

Long-term safety and tolerability of oxcarbazepine in children: a review of clinical experience

Relatively few well-designed studies have demonstrated the long-term safety and tolerability of newer antiepileptic drugs (AEDs) in a large group of children. Extensive clinical data from the worldwide Clinical Development Program (CDP) and a compassionate use program on the safety and tolerability of oxcarbazepine in children are presented. Oxcarbazepine is a newer AED that is indicated for use as monotherapy and adjunctive therapy in children (United States 4 years of age, Europe 6 years of age) with partial epilepsy. The most common adverse events (10%) in the CDP were headache (32.5%), somnolence (31.5%), vomiting (27.6%), and dizziness (23.1%), whereas in the compassionate use program (clinical practice situation), the most common adverse events (1%) reported were rash (2.7%), fatigue (1.6%), nausea (1.2%), and somnolence (1.2%). These data indicate that oxcarbazepine has a good long-term safety and tolerability profile, whether given as monotherapy or adjunctive therapy, in children with partial seizures.

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.

Preservation of the negative image of tooth enamel with dental impression material enhances morphometric measurements of gingival overgrowth

Gingival overgrowth is a common health problem caused by genetic and environmental risk factors. Animal models for quantitative histological studies are needed to uncover genetic predisposition and dose-response data that might put individuals at increased risk for gingival disease. Gingival height, thickness, inflammation, and the degree of encroachment of gingiva over the tooth, are clinical measures of overgrowth; most of these parameters can be measured histologically, but in order to quantify gingival coverage of the tooth, the image of the crown must be present. Tooth and bone typically require decalcification for histology; thus, the tooth crown, a critical landmark, is lost. We describe a method for imaging the crown histologically, using impression materials applied to dissected mouse mandibles. Four dental alginates, three polyvinyl siloxanes, and one polyether and gelatin were used. The impression-material/mandibular tissue blocks were processed routinely. Polyvinyl siloxanes were incompatible with embedding resin; alginates, polyether and gelatin could be fixed, decalcified, embedded, and sectioned. Alginates and gelatin could be stained. Success in imaging the tooth crown varied with the preparation, but the alginates, polyether, and gelatin permitted a useful degree of measurement of exposed crown and enamel thickness, along with other morphometric parameters such as thickness of the dentin, lateral mandibular ramus, rete pegs, height of the gingiva, and volume density of vessels and inflammatory cells in the lamina propria. In conclusion, this new application for impression materials allows gingival coverage of tooth crown, as well as numerous other parameters to be measured for comparison with clinical data.