Investigation of the effect of FK506 (tacrolimus) and cyclosporin on gingival overgrowth following paediatric liver transplantation

Long-term Follow-up of a Randomized Trial of Tacrolimus or Cyclosporine A Microemulsion in Children Post Liver Transplantation

The aim of this study was to determine the long-term efficacy and safety of tacrolimus (Tac) and cyclosporine immunosuppression in pediatric liver transplantation (LTx).

Clinical periodontal and dental findings in liver transplant patients: a systematic review and meta-analysis

Objectives This systematic review aimed to investigate the oral health of post-liver transplant recipients (postLTx), in terms of dental and periodontal clinical results.Data sources Pubmed/MEDLINE and Cochrane Library databases were searched electronically.Data selection Prospective, cross-sectional and case-control studies comparing periodontal and dental health of postLTx patients with healthy and/or pre-liver transplant patients.Data extraction This was performed independently by two authors. Quality assessment was done by using tools from the National Heart, Lung, and Blood Institute.Data synthesis Nine studies were eligible for inclusion in the systematic review. A meta-analysis was performed on gingival inflammation, expressed by scores, on four studies including healthy controls. The gingival index scores were significantly higher in postLTx patients compared with healthy controls (p <0.001). The weighted mean difference was 0.91 (95% confidence interval, 0.44 to 1.38, heterogeneity I² = 99.5%). Increased tendency of gingival enlargement was noticed in postLTx patients, especially after immunosuppression with Cyclosporine A. Controversial results were reported for the prevalence of caries in postLTx recipients, but there seems to be an increase.Conclusion The results suggest that patients with liver transplants, due to systemic condition and immunosuppressive therapy, exhibit a higher degree of gingival inflammation compared with unexposed patients.Prospero registration number: CRD42019121893.

Oral Health Status of Kuwaiti Children with a History of Chronic Liver Disease

OBJECTIVE

To investigate the oral health status and dental manifestations of children with a history of chronic liver disease (CLD) compared to healthy children.

SUBJECTS AND METHODS

Twenty children (15 boys and 5 girls) with a history of CLD were compared to 20 healthy controls matched for age and gender. The clinical examination was carried out by the same dentist. Caries prevalence, using the decayed, missing, and filled primary and permanent teeth indices (dmft/DMFT), was recorded. Developmental enamel defects, plaque scores, and gingival overgrowth were also investigated.

RESULTS

No statistically significant differences were found in mean dmft scores for children with a history of CLD (4.9 ± 5.4) and for healthy individuals (3.9 ± 4.5). However, the mean DMFT score was significantly higher (p =0.025) in children with CLD (4.2 ± 4.6) compared to controls (1.7 ± 1.6). The mean decayed teeth parameter (DT) was also significantly higher in children with CLD (p =0.004). All patients with CLD exhibited enamel defects compared to only 33% in the control group (p< 0.05). A higher mean plaque index was observed in children with a history of CLD (p< 0.001). Also, a positive correlation for gingival overgrowth was noted in patients with a history of CLD (p< 0.05). Green staining was evident only in the permanent dentition of 1 child with CLD.

CONCLUSION

Children with a history of CLD exhibited a high caries prevalence, high plaque scores, and more enamel defects compared to healthy subjects. Gingival overgrowth is less prevalent among pediatric liver transplant patients on tacrolimus therapy.

Gingival overgrowth in renal transplant subjects: a 44-month follow-up study

BACKGROUND

To assess changes in gingival status of renal transplant subjects under immunosuppressive regimens based on cyclosporine (CsA), tacrolimus (Tcr), and sirolimus (Sir).

METHODS

From a sample of 135 subjects (baseline examination [BE]), 89 without periodontal treatment, who maintained the immunosuppressive regimen based on the same main agent (CsA=23, Tcr=31, and Sir=35), were reexamined after 44 months (follow-up examination [FE]). Demographic, pharmacologic, and periodontal variables were collected and gingival overgrowth (GO) was assessed by visual examination.

RESULTS

In Tcr and CsA groups, although not significant, occurrence of GO decreased (CsA [BE=56.5% and FE=34.8%; P=0.063] and Tcr [BE=19.4% and FE=12.9%; P=0.500]). In addition, the severity of GO decreased significantly in CsA group (mean score BE=10.29 ± 7.70 and mean score FE=0.78 ± 1.38; P=0.003). In Sir group, GO decreased from 17.1% (BE) to 0.0% (FE) (P=not applicable). In total sample, GO was associated with papillary bleeding index (P=0.001) and concomitant use of calcium channel blockers (P=0.029); in CsA and Tcr groups, GO was associated with papillary bleeding index (P=0.029 and 0.033, respectively).

CONCLUSIONS

There was no incidence of GO, and a decrease in the occurrence and severity of GO was significant in total sample. This decrease can be attributed to changes in pharmacologic and periodontal variables over this period of time.

Effects of tacrolimus and nifedipine, alone or in combination, on gingival tissues

BACKGROUND

The aim of this study is to compare gingival changes induced by short- and long-term tacrolimus and nifedipine administration, alone or in combination, and evaluate the expression levels of tumor suppressor phosphatase and tensin homolog (PTEN) in drug-induced gingival overgrowth.

METHODS

Eighty rats were equally divided into eight groups: 1) tacrolimus for 8 weeks; 2) nifedipine for 8 weeks; 3) tacrolimus and nifedipine for 8 weeks; 4) 8-week control; 5) tacrolimus for 24 weeks; 6) nifedipine for 24 weeks; 7) tacrolimus and nifedipine for 24 weeks; and 8) 24-week control. Histomorphometric analyses included measurements of epithelial thickness, connective tissue thickness, and height. Stereologic analyses included measurements of volumetric densities of fibroblasts (Vf), collagen fibers (Vcf), and blood vessels (Vbv). In addition, PTEN expression was analyzed using immunohistochemistry.

RESULTS

Epithelial thickness and connective tissue thickness were significantly increased in groups 5, 6, and 7 compared to group 8 (P <0.05), whereas connective tissue height was significantly increased in groups 5 and 7 (P <0.001). Vf and Vcf were significantly increased in group 7 compared to group 8 (P <0.001). PTEN immunoreactivity was significantly decreased in all experimental groups compared to the control groups (P <0.05).

CONCLUSIONS

Results suggest that duration of drug administration is a more important risk factor than drug combination. The results include a potentially new insight about PTEN's role in the etiology of drug-induced gingival overgrowth.

Gingival overgrowth in subjects under immunosuppressive regimens based on cyclosporine, tacrolimus, or sirolimus

AIM

To assess the prevalence and variables associated with gingival overgrowth (GO) in renal transplant recipients medicated with cyclosporine (CsA), tacrolimus (Tcr), or sirolimus (Sir).

MATERIALS AND METHODS

One hundred and thirty-five eligible subjects were divided in CsA, Tcr, and Sir groups comprising 45 subjects each. GO was visually assessed and subjects were assigned as GO+ or GO- in a post hoc definition. Saliva samples were collected and the presence of periodontal pathogens was assessed through polymerase chain reaction. Variables of interest were compared between GO+ and GO- subjects through univariate and multivariate analysis.

RESULTS

Prevalence of GO was of 60.0% for CsA, 28.9% for Tcr, and 15.6% for Sir groups. Within the CsA group, GO was associated with papillary bleeding index (p=0.001); within the Tcr group, GO was associated with CsA previous use (p=0.013), and calcium channel blockers (CCB) use (p=0.003); within the Sir group, GO was associated with papillary bleeding index (p=0.018), and CCB use (p=0.020). A higher frequency of Tannerella forsythia was observed among GO+ subjects medicated with Tcr.

CONCLUSION

Pharmacological and periodontal variables were associated with GO in different immunosuppressive regimens. Integration between the medical and the dental team may be an important approach in the post-transplant maintenance routine.

Gingival status of Brazilian renal transplant recipients under sirolimus-based regimens

BACKGROUND

Although the prevalence of gingival overgrowth (GO) in calcineurin-inhibitor (CNI) immunosuppressive regimens has been well documented, to the best of our knowledge data from sirolimus (SIR) regimens have not been described. We sought to investigate the gingival status of renal transplant recipients under SIR-based regimens with regard to the prevalence and potential risk variables associated with GO.

METHODS

A cross-sectional study was conducted at a public hospital in Belo Horizonte, MG, Brazil. Of 886 transplant recipients, an eligible sample of 144 subjects was selected. Medical, pharmacologic, and periodontal variables were recorded for each subject. GO was assessed through visual inspection and was evaluated in relation to variables of interest by univariate and multivariate analyses.

RESULTS

Although not clinically significant, 20.8% of the samples had GO, with a mean GO score of 5.0% +/- 3.98% (range, 0% to 19%) and mean GO score per papilla of 0.378 +/- 0.361 (range, 0.1 to 1.9); the percentage of papilla affected by GO was 14.35% +/- 9.86% (range, 5% to 45%). The multivariate final model, excluding periodontal variables, showed that the concomitant use of calcium channel blockers (P = 0.033) and the interaction between time since transplant and previous CNI use (P <0.001) were associated with GO. Adding periodontal variables to the model improved its accuracy and retained papillary bleeding index as being strongly associated with GO (P <0.001).

CONCLUSIONS

GO was observed in a considerable number of subjects under SIR-based immunosuppressive regimens, although the relationship was not clinically significant. Findings point to the importance of cooperation between medical and dental health care personnel in the maintenance of renal transplant recipients under SIR-based immunosuppressive regimens.

Gingival overgrowth in renal transplant recipients: a study concerning prevalence, severity, periodontal, and predisposing factors

Gingival overgrowth (GO) is the main oral manifestation in transplant recipients who use calcineurin inhibitors. In the present study, factors for GO development were investigated in Brazilian renal transplant recipients who were prescribed cyclosporine (CsA) or tacrolimus (TAC). Demographic, pharmacological, clinical, and periodontal data were obtained from 83 patients, as well as HLA expression in 51 of them. The prevalence of GO was high (47%), but its severity was low according to periodontal indices. The prevalence of GO was greater among patients who used CsA (n = 49) than those receiving used TAC (n = 34) namely, 61% versus 26.5% (P = .003). Comparisons between patients with versus without GO were performed independent of the administered immunossupressant. The group with GO showed a greater degree of gingival inflammation index. HLA-A68 had greater expression among patients without GO (P = .04). The risk factors for GO occurrence were evaluated using a multivariate analysis that identified gingival inflammation and HLA-A24 expression as risk factors. Increased age and use of TAC were identified as protective factors. GO showed a high prevalence, yet a light intensity. Patients who were younger, men, or received CsA showed a greater occurrence of GO. The risk factors identified for GO development were the presence of gingival inflammation and HLA-A24 expression.

Renal disease and the mouth

Oral manifestations of renal disease are common. They may present as unique signs of multi-system disease affecting the kidneys (such as vasculitis), or as common oral pathologies found at an increased prevalence in patients with end-stage renal disease. Despite more oral and dental disease in patients on renal replacement therapy, attendance at dental clinics is infrequent, and physician awareness of the problem is low. In our short review, aimed at renal, transplant, and general physicians, we discuss the link between clinical changes in the mouth and multi-systemic disease involving the kidney. We suggest a standardized approach to oral examination to increase diagnostic yield and discuss common oral complications in patients on dialysis or successfully transplanted. Finally, we suggest potential treatments for oral disease that nephrologists might safely institute.

Prevalence, Severity, and Risk Variables Associated With Gingival Overgrowth in Renal Transplant Subjects Treated Under Tacrolimus or Cyclosporin Regimens

BACKGROUND

Some reports suggest that the prevalence and severity of gingival overgrowth (GO) is lower in patients taking tacrolimus (Tcr) than in those taking cyclosporin A (CsA). The present study was conducted to determine the prevalence and severity of GO in a group of renal transplant recipients treated with Tcr in comparison to those treated with CsA and to evaluate the risk variables associated with the development of GO in these two drug regimens.

METHODS

A cross-sectional study was conducted in a public hospital in Belo Horizonte City, Brazil. Demographic, pharmacological, and periodontal data were recorded for each subject. Variables from 134 subjects taking Tcr were compared to 451 subjects taking CsA using independent sample t, chi(2) statistic, or Mann-Whitney tests. The effects of potential risk factors on GO severity were determined using forward and backward stepwise regression analysis.

RESULTS

Subjects taking CsA showed a higher mean GO score (29.03% +/- 22.9%) compared to subjects taking Tcr (16.9% +/- 3.4%) (P = 0.0038). In the Tcr group, 17.9% of the subjects had clinically significant GO compared to 38.1% in the CsA group (P = 0.045). In the multivariate final model, papillary bleeding index, azathioprine dosage, and concomitant use of calcium channel blockers (CCB) were significant variables associated with severity of GO in Tcr and CsA groups. In addition, previous CsA use also remained significant for GO in subjects under a Tcr regimen.

CONCLUSIONS

The prevalence and severity of GO is lower in transplant subjects taking Tcr compared to CsA. GO severity in both groups was strongly associated with the papillary bleeding index, highlighting the role of inflammation in this condition. Concomitant CCB use, azathioprine dosage, and previous CsA use in the Tcr group reinforces the possible synergistic effects of these pharmacological variables on GO severity.

Oral health in renal transplant recipients administered cyclosporin A or tacrolimus

OBJECTIVE

The aim of this study was to determine the oral status of renal transplant recipients receiving cyclosporin A (CsA) or tacrolimus (FK-506) as immunosuppressant.

SUBJECTS AND METHODS

A total of 88 renal transplant recipients receiving CsA (63 men and 25 women, mean age 51.4 years) and 67 receiving FK-506 (57 men and 10 women, mean age 33.5 years) were included in the study. Donor type, histocompatibility, cold ischemia time and prior delayed graft function were similar between the two groups. Demographics and pharmacological data were recorded for all subjects.

RESULTS

The results demonstrated that CsA caused a greater number of oral diseases. A greater number of gingival overgrowth was present in patients treated with CsA. However, the combined use with calcium channel blockers increased the gingival overgrowth number. The occurrence of candida in saliva was observed in 80 renal recipients treated with CsA and 20 treated with FK-506. The presence of squamous oral carcinoma (n = 3) and herpes simplex (n = 10) was observed in patients treated with CsA. These alterations were not observed in renal recipients treated with FK-506.

CONCLUSIONS

Renal recipients constitute a high-risk group for oral diseases, as they are immunocompromised. However, the FK-506 regime appears to ameliorate this effect, compared with CsA. Adequate pre- and post-transplant oral health care is recommended for these subjects, irrespective of the time interval for which the drug is administered.

Posttransplantation Quality of Life: More Than Graft Function

Whereas newer immunosuppressive therapies have increased patient and graft survival, long-term treatment with these drugs has been linked to medical and physical complications that may impact on posttransplantation quality of life. Immunosuppression-related physical side effects that can alter appearance--including hirsutism, gingival hyperplasia, weight gain, cushingoid facies, hand tremors, alopecia, and skin disorders--are among the most bothersome to patients and may have serious psychosocial implications. In addition, physical side effects may influence patient adherence to their prescribed treatment regimens and result in more serious complications, such as acute rejection, graft loss, rehospitalization, and even mortality. Therefore, strategies for minimizing side effects of immunosuppressive therapy and improving medication adherence are integral to better long-term transplant recipient management.

A Morphologic Comparison of Gingival Changes Influenced by Cyclosporin and Tacrolimus in Rats: An Experimental Study

BACKGROUND

The aim of this study was to compare the morphologic changes in the gingiva brought about by the administration of cyclosporin and tacrolimus in rats.

METHODS

The study was conducted on 30 six-week-old male Sprague-Dawley rats, divided into three groups of 10 rats each, for a period of 4 weeks. Group I rats received cyclosporin (30 mg/kg body weight), and group II rats received tacrolimus (1.5 mg/kg body weight), by means of a gavage. Group III served as control and received olive oil alone. Impressions of the mandibular incisal region were made weekly, and stone casts were prepared for measuring morphologic changes of the gingiva.

RESULTS

An increase in the measured gingival dimensions was observed in the test groups as early as week 2 after the commencement of drug administration. Intergroup comparison revealed that the increase in the measured dimensions was greater in group I than group II at the end of 4 weeks.

CONCLUSIONS

Cyclosporin and tacrolimus were capable of causing gingival enlargement in Sprague-Dawley rats. However, the magnitude of tacrolimus-influenced gingival enlargement seemed to be comparatively less than cyclosporin.

Cyclosporin-induced gingival overgrowth in children

Cyclosporin is a potent immunosuppressant drug commonly used to prevent organ transplant rejection. In recent years, there has been a widening of its therapeutic use and an increase in the number of patients undergoing transplantation. Gingival overgrowth is one of several oral side-effects of cyclosporin, with a quoted prevalence of between 8% and 100%. There is continued debate over the factors which modify the degree of overgrowth, including individual sensitivity, age, dose of drug, duration of drug therapy and the presence of dental plaque. The exact mechanism of gingival overgrowth is still being debated, but appears to be caused by a combination of the proliferation of fibroblasts within the gingival tissue, an increase in the deposition of collagen and extracellular matrix, and a decrease in phagocytosis with a net gain in gingival tissue mass. A number of treatment options are utilized in the treatment of gingival overgrowth, including CO2 laser surgery, improved oral hygiene, the use of antibiotics such as metronidazole and azithromycin, and surgical intervention. In the clinical application of cyclosporin, there is little correlation between cyclosporin dose, serum trough levels and total exposure to the drug, making it difficult to achieve the desired therapeutic response. These problems were previously further complicated by the variability of absorption of the drug via the gastrointestinal tract. The original cyclosporin formulation, Sandimmune, was replaced by a new formulation, Neoral, which has a more reliable absorption, and gives a closer correlation between trough concentration levels and individual bioavailability. There is a conflict of opinion over whether or not the side-effect profile of Neoral varies from its precursor Sandimmune. It has yet to be seen whether the increased bioavailability of Neoral will result in an increased severity and prevalence of gingival overgrowth. An alternative immunosuppressant drug, tacrolimus, which is a macrolide antibiotic with a different side-effect profile, has emerged as a substitute for cyclosporin in organ transplantation. However, there have been conflicting reports of its side-effects and its capacity to cause gingival overgrowth.

Differential effect of Cyclosporin A and FK506 on SPARC mRNA expression by human gingival fibroblasts

BACKGROUND

Secreted protein acidic and rich in cysteine (SPARC) is a glycoprotein that mediates cell-matrix interactions. In adults, its expression is mostly limited to tissue undergoing remodeling. During the development of Cyclosporin A (CsA)-induced gingival overgrowth (GO) a remodeling of the connective compartment occurs. By contrast, clinical trials showed that FK506 is not related to GO. SPARC expression and its involvement in GO is unknown. Our aim was, therefore, to analyze the effect of CsA and FK506 on SPARC gene expression.

METHODS

Cultured human gingival fibroblasts were incubated with CsA, FK506 or with their vehicle (VH) for 24, 48 and 72 h. SPARC gene expression was determined by RT-PCR.

RESULTS

SPARC mRNA levels tended to increase 72 h after CsA treatment, whilst they are undetectable in FK506-treated fibroblasts, compared to VH.

CONCLUSION

This gene expression profile is consistent with the involvement of SPARC in the mechanisms leading to the development of CsA-induced GO. By contrast, the undetectable SPARC mRNA levels in FK506-treated fibroblasts suggest that FK506 may be associated with a role of ECM stabilization, that does not induce GO.

Can diabetes be cured by therapeutic cloning?

With the increasing incidence of diabetes mellitus (DM), it is imperative to develop novel treatments. Stem cells offer the potential for use as renewable sources of glucose-responsive, insulin-secreting cells. However, developing a consistent protocol to enrich beta-cells is not a trivial issue. The question whether embryonic, fetal, or adult stem cells offer particular advantages as the starting material remains to be resolved experimentally. While somatic cell nuclear transfer avoids many of the problems associated with heterologous transplantation, the problem of autoimmune destruction of the beta-cells in type 1 DM might still remain. This review summarizes the innovative treatment strategies for DM and considers the possible advantages and problems.

Oral and dental aspects of chronic renal failure

The present article reviews, in detail, the current knowledge of the oral and dental aspects of chronic renal failure (CRF). Worldwide, increasing numbers of persons have CRF; thus, oral health care staffs are increasingly likely to provide care for patients with such disease. Chronic renal failure can give rise to a wide spectrum of oral manifestations, affecting the hard or soft tissues of the mouth. The majority of affected individuals have disease that does not complicate oral health care; nevertheless, the dental management of such individuals does require that the clinician understand the multiple systems that can be affected. The clinician should also consider the adverse side-effects of drug therapy and appropriate prescribing, in view of compromised renal clearance.

Immunosuppression and gingival overgrowth: gene and protein expression profiles of collagen turnover in FK506-treated human gingival fibroblasts

AIM

FK506 is an immunosuppressive agent that, unlike cyclosporin A (CsA), does not induce gingival overgrowth (GO). CsA-induced GO is caused by quantitative modifications of the extracellular matrix components, particularly collagen (COL). Up to now, clinical trials have only investigated FK506 in relation with GO, so we aimed at analysing the effect of FK506 on COL turnover using a molecular approach, to evaluate the expression of genes and proteins related to this process.

MATERIALS AND METHODS

Human gingival fibroblasts were incubated with FK506 or its vehicle (VH) for 24, 48 and 72 h. COL type I (COL-I), matrix metalloproteinases (MMP)-1 and 2, tissue inhibitor of MMP (TIMP)-1 and transforming growth factor (TGF)-beta1 mRNA were assayed by Reverse transcriptase polymerase chain reaction; COL-I protein levels were determined by dot blot, MMP-1 and MMP-2 activity by zymography.

RESULTS

Fibroblast proliferation decreased 48 and 72 h after treatment. COL-I gene and protein expression, TGF-beta1 and TIMP-1 mRNA levels were not significantly affected, whereas MMP-1 gene and protein expression and MMP-2 mRNA levels rose significantly in treated fibroblasts compared with VH.

CONCLUSIONS

These findings suggest that increased MMP-1 gene and protein expression may be important for regulating COL-I homeostasis in the gingival connective compartment of FK506-immunosuppressed subjects.

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.