Amlodipine-induced gingival overgrowth

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

Oral Implications of Polypharmacy in Older Adults

Over the next several decades, rates of aged populations will increase rapidly. These populations are susceptible to multimorbidities and polypharmacy (concurrently, prescribed 5 or more medications). Many medications have side effects that manifest orally. Therefore, it essential to possess current pharmacologic knowledge to diagnose and treat oral implications of commonly prescribed medications. This article details common medication-induced oral lesions and patient assessment of risk factors for polypharmacy and provides a template to integrate medication reconciliation into dental clinical practice.

Drug-Induced Gingival Hyperplasia in a Hypertensive Patient: A Case Report

Hypertension is one of the most notorious non-communicable diseases the medical fraternity is dealing with in this decade. A wide array of medications have been included in the treatment regimen, one of which is calcium channel blockers. Amlodipine is commonly administered from this class. The reports of adverse drug reactions to the intake of amlodipine are very scarce to date. Association of gingival hyperplasia with the administration of this drug is rare and is what we have reported in this case. The theory that is being put forward for this adverse reaction is that the gingival fibroblasts are induced via the proliferative signaling pathways in association with the formation of bacterial plaques. Several classes of drugs other than calcium channel blockers are known to cause this reaction. Anti-epileptics along with anti-psychotic drugs are comparatively more prevalent. Thorough scaling and root planing are used to identify and treat amlodipine-induced gingival hypertrophy. The cause of gingival expansion is unknown, and there is currently no cure other than surgically removing the enlarged tissue and maintaining better dental hygiene. Immediate stoppage of the causative drug is advised in these cases along with the surgical remodeling of the affected gingiva.

Treatment of Gingival Growth Due to Amlodipine Use With a 445-nm Diode Laser: A Case Report

Amlodipine is a widely used calcium channel blocker associated with gingival enlargement. The effects of amlodipine on gingival enlargement vary depending on the duration of drug use and the dose of the active substance. This report presents a 56-year-old male hypertensive patient who had been using amlodipine (5 mg/day orally, single dose) for the last two years. He presented with diffuse gingival enlargement, complaining of gingival swelling and bleeding. This case report demonstrates the treatment of gingival enlargement with a novel 445-nanometer (nm) blue light diode laser after drug change and oral hygiene, which resulted in permanent and satisfactory clinical results.

Necrotizing Ulcerative Gingivitis, a Rare Manifestation as a Sequel of Drug-Induced Gingival Overgrowth: A Case Report

Purpose

The purpose of this case report is to present a rare case of amlodipine-induced gingival overgrowth with a secondary formation of necrotizing ulcerative gingivitis involving the upper and lower arches of a 68-year-old female patient with a chief complaint of “swollen gums and pain on mastication which has been recurring for the past 5 years.”

Materials and Methods

The treatment plan of this case was divided according to quadrants of the mouth. Each week, one quadrant was surgically excised, and the remaining quadrants were observed for any changes. The gingival overgrowths were excised using a 15 blade, and debris/plaque was removed with Gracey curettes.

Results

Although full-mouth exodontia was performed, the patient unfortunately suffered with recurrences in GO. These results are suggestive of idiopathic causes of GO.

Conclusion

Careful examination, physician referrals, and biopsy to rule out any specific anomalies and to assist in proper diagnosis are followed by sequential management of the case results in productive outcomes.

Oral Implications of Polypharmacy in Older Adults

Over the next several decades, rates of aged populations will increase rapidly. These populations are susceptible to multimorbidities and polypharmacy (concurrently, prescribed 5 or more medications). Many medications have side effects that manifest orally. Therefore, it essential to possess current pharmacologic knowledge to diagnose and treat oral implications of commonly prescribed medications. This article details common medication-induced oral lesions and patient assessment of risk factors for polypharmacy and provides a template to integrate medication reconciliation into dental clinical practice.

Transcriptional Analysis Reveals Key Genes in the Pathogenesis of Nifedipine-Induced Gingival Overgrowth

BACKGROUND

Nifedipine-induced gingival overgrowth (NGO) is a multifactorial pathogenesis with increased extracellular matrix including collagen and glycans, inflammatory cytokines, and phenotype changes of fibroblasts. However, the molecular etiology of NGO is not well understood. The objective of this study is to investigate the key genes in the pathogenesis of NGO.

METHODS

In this study, we examined the proliferation and migration abilities of fibroblasts derived from patients with chronic periodontitis, nifedipine nonresponder gingival overgrowth, gingival overgrowth caused by nifedipine, and healthy normal gingiva. We conducted RNA-Seq on these four groups of fibroblasts and analysed the differentially expressed genes (DEGs).

RESULTS

Fibroblasts derived from NGO patients had higher proliferation and migration abilities than those of the other groups. Protein-protein interaction network analysis indicated that TGFB2, ITGA8, ITGA11, FGF5, PLA2G4D, PLA2G2F, PTGS1, CSF1, LPAR1, CCL3, and NKX3-1 are involved in the development of NGO. These factors are related to the arachidonic acid metabolism and PI3K/AKT signaling pathways.

CONCLUSION

Transcriptional gene expression analysis identified a number of DEGs that might be functionally related to gingival overgrowth induced by nifedipine. Our study provides important information on the molecular mechanism underlying nifedipine-induced gingival overgrowth.

Drug-induced gingival hyperplasia: An in vitro study using amlodipine and human gingival fibroblasts

Gingival overgrowth is a serious side effect that accompanies the use of amlodipine. Several conflicting theories have been proposed to explain the fibroblast’s function in gingival overgrowth. To determine whether amlodipine alters the inflammatory responses, we investigated its effects on gingival fibroblast gene expression as compared with untreated cells. Fragments of gingival tissue of healthy volunteers (11 years old boy, 68 years old woman, and 20 years old men) were collected during operation. Gene expression of 29 genes was investigated in gingival fibroblast cell culture treated with amlodipine, compared with untreated cells. Among the studied genes, only 15 (CCL1, CCL2D, CCL5, CCL8, CXCL5, CXCL10, CCR1, CCR10, IL1A, IL1B, IL5, IL7, IL8, SPP1, and TNFSF10) were significantly deregulated. In particular, the most evident overexpressed genes in treated cells were CCR10 and IL1A. These results seem to indicate a possible role of amlodipine in the inflammatory response of treated human gingival fibroblasts.

Elevated Interleukin-17A expression in amlodipine-induced gingival overgrowth

BACKGROUND AND OBJECTIVES

Amlodipine, a calcium channel blocker derivative, is frequently used by patients with high blood pressure. Studies reported that it can induce gingival overgrowth. However, the underlying mechanism is not fully described yet. Interleukin-17A (IL-17A) is known as a proinflammatory cytokine, but current studies indicate that it has a role in fibrotic disorders and epithelial-mesenchymal transition (EMT). The aim of this study was to figure out the possible role of IL-17A in amlodipine-induced gingival overgrowth.

MATERIALS AND METHODS

Twenty-nine (29) individuals participated in the study, and they were assigned into 3 groups based on medical status and clinical periodontal examination; 9 patients with amlodipine-induced gingival overgrowth, 11 patients with inflammatory gingival overgrowth, and 9 healthy individuals as a control group. Clinical periodontal parameters including plaque index (PI), gingival index (GI), and gingival overgrowth index (GOI) were recorded. Blood and gingival crevicular fluid (GCF) samples were obtained. Gingival tissues were taken by appropriate periodontal surgery following initial periodontal therapy. To detect IL-17A on tissue samples, immunohistochemistry (IHC) was performed. Quantitative analysis was done, and the expression level of IL-17A was given as the percent positively stained cells. Enzyme-linked immunosorbent assay (ELISA) kits were used to analyze IL-17A in serum and GCF samples.

RESULTS

All recorded clinical parameters were significantly higher in gingival overgrowth groups compared with control. Evaluation of inflammation on tissue sections did not show any significant change within the groups. Immunohistochemistry findings showed that IL-17A expression was increased in amlodipine samples (81.90%) compared with control samples (42.35%) (P < .001). There was an increase in the inflammatory group (66.08%) which is significantly less than the amlodipine group (P < .05). IL-17A levels in serum and GCF samples were not different within the study groups.

CONCLUSION

In this study, elevated IL-17A expression regardless of inflammation shows that amlodipine might cause an increase of IL-17A in gingival tissues. This increase might induce fibrotic changes and EMT in gingival overgrowth tissues. The association of IL-17A with fibrosis and EMT in gingival tissues requires further investigation.

Molecular Aspects of Drug-Induced Gingival Overgrowth: An In Vitro Study on Amlodipine and Gingival Fibroblasts

Gingival overgrowth is a serious side effect that accompanies the use of amlodipine. Several conflicting theories have been proposed to explain the fibroblast’s function in gingival overgrowth. To determine whether amlodipine alters the fibrotic response, we investigated its effects on treated gingival fibroblast gene expression as compared with untreated cells. Materials and Methods: Fibroblasts from ATCC^® Cell Lines were incubated with amlodipine. The gene expression levels of 12 genes belonging to the “Extracellular Matrix and Adhesion Molecules” pathway was investigated in treated fibroblasts cell culture, as compared with untreated cells, by real time PCR. Results: Most of the significant genes were up-regulated. (CTNND2, COL4A1, ITGA2, ITGA7, MMP10, MMP11, MMP12, MMP26) except for COL7A1, LAMB1, MMP8, and MMP16, which were down-regulated. Conclusion: These results seem to demonstrate that amlodipine has an effect on the extracellular matrix of gingival fibroblast. In the future, it would be interesting to understand the possible effect of the drug on fibroblasts of patients with amlodipine-induced gingival hyperplasia.

Oral Adverse Drug Reactions to Cardiovascular Drugs

A great many cardiovascular drugs (CVDs) have the potential to induce adverse reactions in the mouth. The prevalence of such reactions is not known, however, since many are asymptomatic and therefore are believed to go unreported. As more drugs are marketed and the population includes an increasing number of elderly, the number of drug prescriptions is also expected to increase. Accordingly, it can be predicted that the occurrence of adverse drug reactions (ADRs), including the oral ones (ODRs), will continue to increase. ODRs affect the oral mucous membrane, saliva production, and taste. The pathogenesis of these reactions, especially the mucosal ones, is largely unknown and appears to involve complex interactions among the drug in question, other medications, the patient’s underlying disease, genetics, and life-style factors. Along this line, there is a growing interest in the association between pharmacogenetic polymorphism and ADRs. Research focusing on polymorphism of the cytochrome P450 system (CYPs) has become increasingly important and has highlighted the intra- and inter-individual responses to drug exposure. This system has recently been suggested to be an underlying candidate regarding the pathogenesis of ADRs in the oral mucous membrane. This review focuses on those CVDs reported to induce ODRs. In addition, it will provide data on specific drugs or drug classes, and outline and discuss recent research on possible mechanisms linking ADRs to drug metabolism patterns. Abbreviations used will be as follows: ACEI, ACE inhibitor; ADR, adverse drug reaction; ANA, antinuclear antigen; ARB, angiotensin II receptor blocker; BAB, beta-adrenergic blocker; CCB, calcium-channel blocker; CDR, cutaneous drug reaction; CVD, cardiovascular drug; CYP, cytochrome P450 enzyme; EM, erythema multiforme; FDE, fixed drug eruption; I, inhibitor of CYP isoform activity; HMG-CoA, hydroxymethyl-glutaryl coenzyme A; NAT, N-acetyltransferase; ODR, oral drug reaction; RDM, reactive drug metabolite; S, substrate for CYP isoform; SJS, Stevens-Johnson syndrome; SLE, systemic lupus erythematosus; and TEN, toxic epidermal necrolysis.

Drug-induced gingival overgrowth: A critical insight into case reports from over two decades

Drug-induced gingival overgrowth (DIGO) is a well-recognized adverse effect of certain systemic medications. Calcium channel blockers, anticonvulsants, and immunosuppressants are frequently implicated drugs in the etiology of DIGO. Drug variables, plaque-induced inflammation, and genetic factors are the three important factors in the expression of gingival changes after systemic medication use. Careful clinical examination and thorough history taking form the basis for diagnosis of DIGO. Histopathological examination is often neglected; however, it is an important aid that helps in differential diagnosis. Cessation or change of drug and meticulous plaque control often leads to regression of the lesion, which however might need surgical correction for optimal maintenance of gingival health. The purpose of the present article is to review case reports and case series published in the last two decades and to assimilate and compile the information for clinical applications such as diagnosis and therapeutic management of DIGO.

Prevalence of gingival overgrowth induced by antihypertensive drugs: A hospital-based study

BACKGROUND

Gingival overgrowth (GO) is a known side-effect of calcium channel blockers. Although there have been several case reports, few studies have examined the prevalence of nifedipine, diltiazem, and amlodipine. This study was conducted to determine the prevalence and risk factors for GO in patients treated with calcium channel blockers.

MATERIALS AND METHODS

A cross-sectional study was conducted in out patient Department of Medicine, Government Medical College, Calicut. 133 patients taking antihypertensives were examined for the presence of GO using two different indices: Vertical GO in 6 points around each tooth and horizontal Miranda-Brunet index in the interdental area. Gingival index (GI), plaque index, and probing depth were also evaluated.

RESULTS

The frequency of GO was significantly higher in nifedipine-treated cases than other drug groups. Frequency of GO was 75% for nifedipine, 31.4% for amlodipine and 25% for amlodipine + metoprolol. Higher gingival, plaque and calculus were observed in patients taking calcium channel blockers. Among the possible risk factors, only the GI showed a significant correlation with GO.

CONCLUSIONS

Patients taking antihypertensives had poor oral hygiene. Patients taking nifedipine showed a higher frequency of GO. Gingival inflammation acts as a predisposing factor.

Amlodipine-induced Gingival Hyperplasia - A Case Report and Review

Anticonvulsants, antihypertensive calcium channel blockers and immunosuppressants are the three main classes of drugs known to cause drug-induced gingival hypertrophy or hyperplasia. Among the calcium channel blockers, nifedipine administration has most frequently been associated with medication-related gingival hyperplasia. The incidence with amlodipine, which has a mode of action pharmacodynamically comparable to nifedipine, has rarely been reported. Here, we present a rare case of amlodipine-induced gingival hyperplasia in a hypertensive patient.

Severe gingival enlargement with coexisting erosive lichen planus in severe chronic periodontitis patient

Plaque induced gingival enlargement is most commonly seen and when encountered simultaneously with erosive lichen planus poses a challenge to the treating dentist. Prognosis of one condition may influence the prognosis of another condition. The presented case highlights the significance of proper diagnosis and the management of simultaneously occurring gingival lesions. A 49-year-old hypertensive female presented with painful enlarged bleeding and suppurating gums with burning sensation on eating food along with long-term usage of antihypertensive drug amlodipine known for its gingival enlargement effect. All these multiple factors led to diagnostic dilemma. Effective management of the gingival enlargement was done by using electrocautery to rehabilitate the functions and esthetics of the patient. Gingival condition was also complicated by the presence of coexisting lichen planus which was predominantly erosive for which topical corticosteroid, antifungal, and antimicrobial agents were prescribed. Eight-month follow-up did not show recurrence of gingival enlargement. Electrocautery is an effective tool for the gingivectomy in severe inflammatory type of gingival enlargement because of rapid postoperative hemostasis. For the management of erosive lichen planus, long-term use of topical corticosteroids is an effective approach. Maintenance of oral hygiene and regular follow-ups are essential for these conditions.

Combined treatment for a combined enlargement

Calcium channel blockers are widely used in medical practice for the management of hypertension and in the prophylaxis of angina. Gingival overgrowth is now a recognized unwanted effect associated with many of calcium channel blockers. This can have a significant effect on the quality of life as well as increasing the oral bacterial load by generating plaque retention sites. Amlodipine, a third generation calcium channel blockers has been shown to promote gingival overgrowth, although reported in very limited cases. The management of gingival overgrowth seems to be directed at controlling gingival inflammation through a good oral hygiene regimen. However, in severe cases, surgical excision is the most preferred method of treatment, followed by rigorous oral hygiene procedures. This case report describes the management of gingival overgrowth in a hypertensive patient taking amlodipine.

Incidence of amlodipine-induced gingival overgrowth in the rural population of Loni

Aims:

Since the incidence of gingival overgrowth induced by amlodipine remains poorly defined, this study was carried out with an aim to determine the incidence.

Materials and Methods:

Dental patients who received amlodipine (N = 115), for more than 3 months were studied to determine the drug-induced gingival overgrowth. Clinical diagnosis of drug-induced overgrowth was verified by disappearance or decreased severity of gingival overgrowth after withdrawal of the causative drug.

Results:

The prevalence rate of amlodipine-induced gingival hyperplasia among experimental patients was 3.4%, while it was not observed among the control subjects. Oral examination revealed gingival overgrowth as a lobular or nodular enlargement on interdental papilla located in the anterior interproximal regions.

Conclusions:

In this study, there was a significant relationship between gingival inflammation resulting from dental plaque and drug dosage, and hyperplasia.

Drug-induced gingival overgrowth: The nemesis of gingiva unravelled

Drug-induced gingival overgrowth or enlargement manifests as abnormal growth of the gingiva due to an adverse drug reaction (ADR) in patients treated with anticonvulsants, immunosuppressants, and calcium channel blockers. As gingival enlargement develops, it affects the normal oral hygiene practice and may interfere with masticatory functions. It gradually becomes a source of pain and the condition often leads to disfiguration. Within the group of patients that develop this unwanted effect, there appears to be variability in the extent and severity of the gingival changes. It would seem pertinent to identify and explore possible risk factors and relating them with the treatment plan. This article throws light on respective drugs and their association with gingival overgrowth and approaches to treatment based on current knowledge and investigative observations.

Gingival Hypertrophy Associated with Amlodipine Use in an HIV-Infected Woman

Objective:

To report the case of a 46-year-old woman with HIV infection who developed gingival hypertrophy while taking amlodipine for hypertension and review the literature discussing gingival hypertrophy associated with amlodipine and other calcium channel blockers.

Case Summary:

A 46-year-old HIV-infected female was taking amlodipine 5 mg daily to manage hypertension. After 4 1/2 years of exposure to amlodipine, the patient presented with new-onset gingival hypertrophy. Concurrent medications included atazanavir, ritonavir, tenofovir/emtricitabine, a multivitamin, and ibuprofen and tramadol as needed. Amlodipine was discontinued and lisinopril was initiated to manage hypertension. Resolution of gingival hypertrophy was noted at 3- and 12-month follow-up visits.

Discussion:

Drug-induced gingival hypertrophy has been associated with anticonvulsants, immunosuppressants, and calcium channel blockers. Cases of gingival hypertrophy are uncommon, especially after such extended exposure. The Naranjo probability scale classified the reaction as probable. Discontinuation of amlodipine led to resolution of gingival hypertrophy.

Conclusions:

Patients with new-onset gingival hypertrophy should have a complete medication review to identify potential causative agents. Development of gingival hypertrophy may present acutely or with extended exposure. Resolution of gingival hypertrophy generally occurs with discontinuation of the inciting agent.

Prevalence of gingival overgrowth among elderly patients under amlodipine therapy at a large Indian teaching hospital

OBJECTIVES

To determine the prevalence of amlodipine-induced gingival overgrowth (GO) among elderly subjects attending an Indian teaching hospital and find any association with demographic factors, drug variables, oral hygiene status and gingival inflammation.

METHODS

A cross-sectional pilot study included 157 dentate patients aged 60 years or more, taking Amlodipine for at least 3 months. Data were collected from past medical records and oral examination. Clinical assessment of GO was correlated with patient's age, gender, drug dosage (2.5, 5 or 10 mg/day), duration of drug therapy (3-4, 4-6, 6-12, 12-24 and >24 months) and also with subjects' plaque index and gingival index scores.

RESULTS

Eight patients (5.09%) had GO. No statistically significant relation was observed between age (p = 0.79), gender (p = 0.56), drug dosage (p = 0.25) and duration of drug intake (p = 0.62) and prevalence of GO. GO prevalence related highly significantly (p < 0.001) with plaque and gingival index scores.

CONCLUSIONS

Prevalence of amlodipine-associated GO in the sample of elderly Indian patients was noted higher than that previously reported. Plaque and gingival inflammation were highly correlated with this condition, while demographic characteristics and drug dosage did not relate significantly.

Amlodipine-induced gingival overgrowth

Gingival overgrowth represents an over-exuberant response to a variety of local and systemic conditions. Certain anticonvulsants, immuno-suppressive drugs and a number of calcium channel blockers have been shown to produce similar gingival overgrowths in certain susceptible patients. Amlodipine is a comparatively new calcium channel blocker and has been used with increasing frequency in the management of hypertension and angina. Although amlodipine is considered as a safe drug, very rarely it may induce gingival overgrowth also. A rare case of amlodipine-induced gingival overgrowth has been reported herein in a 50-year-old female patient. The treatment aspect included Phase-1 therapy, substitution of the drug, the surgical excision and the maintenance and supportive therapy resulting in excellent clinical outcome.

Association between calcium channel blockers and gingival hyperplasia

AIM

To study the effect of the dose and type of calcium channel blockers (CCBs) on the risk of gingival hyperplasia and to quantify this association.

METHODS

The study was conducted within the Integrated Primary Care Information Project in The Netherlands. A nested case-control study was designed within a cohort of all patients who were new users of either CCBs or drugs interacting with the renin-angiotensin system (RAS). Cases were all individuals with a validated diagnosis of gingival hyperplasia. Controls were matched on age, gender and index date.

RESULTS

Within the study population, 103 cases of gingival hyperplasia were identified and matched to 7677 controls. The risk of gingival hyperplasia was higher in current users of CCBs [adjusted odds ratio (OR(adj)) 2.2, 95% confidence intervals (95% CI): 1.4-3.4], especially in dihydropyridines (OR(adj) 2.1, 95% CI: 1.3-3.5) and benzothiazepine derivatives (OR(adj) 2.9, 95% CI: 1.3-6.5) than in RAS drug users. The risk increased in patients using more than the recommended daily dose (OR(adj) 3.0, 95% CI: 1.6-5.5) and when the duration of current use was <1 month (OR(adj) 5.2, 95% CI: 2.1-12.6).

CONCLUSION

This study shows that the risk of gingival hyperplasia is twofold higher in current users of CCBs than in users of RAS drugs. The association was dose dependent and the highest for dihydropyridines or benzothiazepine derivates.

Amlodipine Induced Gingival Hyperplasia

Calcium channel blockers are one of the most commonly used drugs for the management of cardiovascular disorders and are known for causing gingival over growth as adverse effects. Now a days, a new drug in this family Amlodipine, is being widely used, because of its duration of action. But it is of concern to the dental practitioner that this drug too has a similar effect on gingival tissues. This paper aims at drawing the attention of dentists towards the adverse effects of amlodipine along with providing a brief review of the pharmacologic profile of this drug, its effects on the gingiva and the management of hyperplasia.

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.

Gingival overgrowth in children: epidemiology, pathogenesis, and complications. A literature review

Gingival overgrowth is the enlargement of the attached gingiva due to an increased number of cells. The most prevalent types of gingival overgrowth in children are drug-induced gingival overgrowth, hereditary gingival fibromatosis (HGF), and neurofibromatosis I (von Recklinghausen disease). Gingival overgrowth induced by drugs such as phenytoin, nifedipine, and cyclosporin develops due to an increase in the connective tissue extracellular matrix. According to epidemiologic studies, it is more prevalent in male children and adolescents. There is an additive effect of those drugs on the degree of gingival overgrowth. Genetic heterogeneity seems to play an important role in the development of the disease. Functional difficulties, disfigurement, increased caries, and delayed eruption of permanent teeth are the main complications of drug-induced gingival overgrowth. HGF is the most common syndromic gingival enlargement in children. This autosomal dominant disease usually appears at the time of eruption of permanent dentition. Histologically, it is characterized by highly collagenized connective tissue. The most important complications are drifting of teeth, prolonged retention of primary dentition, diastemata, and poor plaque control. Neurofibromatosis I is an autosomal dominant disease more common in mentally handicapped individuals. Gingival overgrowth is caused by the formation of plexiform neurofibromas in the connective tissue of the gingiva. Plexiform neurofibromas are pathognomonic of the disease and consist of hypertrophic nerves arranged as lobules in the connective tissue. Complications of the disease are multiple and severe due to neurofibromas and their occasional malignant transformation.

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.

Cardiovascular diseases and periodontology

BACKGROUND

Cardiovascular diseases represent a widespread heterogeneous group of conditions that have significant morbidity and mortality. The various diseases and their treatments can have an impact upon the periodontium and the delivery of periodontal care.

AIM

In this paper we consider three main topics and explore their relationship to the periodontist and the provision of periodontal treatment.

METHOD

The areas reviewed include the effect of cardiovascular drugs on the periodontium and management of patients with periodontal diseases; the risk of infective endocarditis arising from periodontal procedures; the inter-relationship between periodontal disease and coronary artery disease.

RESULTS AND CONCLUSIONS

Calcium-channel blockers and beta-adrenoceptor blockers cause gingival overgrowth and tooth demineralisation, respectively. Evidence suggests that stopping anticoagulant therapy prior to periodontal procedures is putting patients at a greater risk of thromboembolic disorders compared to the risk of prolonged bleeding. The relationship between dentistry and infective endocarditis remains a controversial issue. It would appear that spontaneous bacteraemia arising from a patient's oral hygiene practices is more likely to be the cause of endocarditis than one-off periodontal procedures. The efficacy of antibiotic prophylaxis is uncertain (and unlikely to be proven), and the risk of death from penicillin appears to be greater than the risk of death arising from infective endocarditis. Finally, the association between periodontal disease and coronary artery disease has been explored and there seem to be many issues with respect to data handling interpretation. Many putative mechanisms have been suggested; however, these only further highlight the need for intervention studies.

Adverse dermatologic effects of cardiovascular drug therapy: part II

Cardiovascular disease is common, affecting an increasing number of persons as the population ages. To combat this growing health problem, physicians use a multitude of medications in the treatment of their patients. Although pharmacologic therapy greatly enhances quality of life for a majority of patients, there is always the potential for an unfavorable reaction. For example, cardiovascular drugs can induce a vast array of adverse dermatologic responses. This article reviews the various cutaneous reaction patterns that can occur as a result of treatment with class III, IV, and other antiarrhythmic agents, ACE inhibitors, Angiotensin II receptor blockers, and diuretics.

Calcium channel blocker induced gingival overgrowth

Gingival overgrowth occurs with phenytoin, cyclosporin, and calcium antagonists. It can be disfiguring and painful. The prevalence of gingival overgrowth with the use of calcium antagonists may be as high as 38%. The prevalence with nifedipine may be greater than with other calcium blockers. Overgrowth occurs 3.3-times more commonly in men than in women. Plaque control is necessary. Some patients may require gingival surgery.

Periodontal diseases in the child and adolescent

BACKGROUND

Periodontal diseases are among the most frequent diseases affecting children and adolescents. These include gingivitis, localized or generalized aggressive periodontitis (a.k.a., early onset periodontitis which includes generalized or localized prepubertal periodontitis and juvenile periodontitis) and periodontal diseases associated with systemic disorders. The best approach to managing periodontal diseases is prevention, followed by early detection and treatment.

METHODS

This paper reviews the current literature concerning the most common periodontal diseases affecting children: chronic gingivitis (or dental plaque-induced gingival diseases) and early onset periodontitis (or aggressive periodontitis), including prepubertal and juvenile periodontitis. In addition, systemic diseases that affect the periodontium and oral lesions commonly found in young children are addressed. The prevalence, diagnostic characteristics, microbiology, host-related factors, and therapeutic management of each of these disease entities are thoroughly discussed.

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.

Amlodipine-induced gingival overgrowth: periodontal responses to stopping and restarting the drug

A case history of a woman with gingival overgrowth (GO) induced by amlodipine is presented. A 49-year-old Japanese woman, who was taking amlodipine, had gingival overgrowth and swelling on examination. No specific periodontal treatment was provided to the patient for the GO; however, the amlodipine was replaced with an ACE inhibitor after consultation with her medical practitioner. Within two months, the suspension of amlodipine resulted in a significant improvement in her periodontal condition. Failure to control the hypertension caused the physician to re-prescribe amlodipine. After three months, the gingival overgrowth returned; however, its severity was less when compared with the original periodontal condition, due to reduction in drug dose and periodontal therapy. This experience suggests that temporary suspension of a drug which can induce GO can improve the periodontal condition without the aid of surgical treatment.

A clinical review of drug-induced gingival overgrowths

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

Use of calcium-channel blockers in pediatric renal transplant recipients

Hypertension (HTN) is a significant problem in pediatric renal transplant (TP) recipients, predisposing the individuals to the development of cardiovascular disease and graft dysfunction. Calcium channel blockers (CCB) are considered excellent agents to treat post-TP HTN. We compared the efficacy and adverse effects of the two most commonly prescribed CCBs in our pediatric renal TP population: nifedipine (Procardia, or P) and amlodipine (Norvasc, or N). All patients (n = 24) had been started on a CCB for systolic (SBP) and/or diastolic BP (DBP) > 95%. There were no other changes in adjunctive antihypertensive medications or doses during the cross-over period. Post-TP, pretreatment (pretx) SBP was 137.6 +/- 10.9 mmHg. The post-treatment SBP were (in mmHg): 128.5 +/- 11.9 (all patients, n = 24) (p = 0.009 vs. pretx); 126.4 +/- 10.0 (P alone, n = 15) (p = 0.007 vs. pretx); 132.8 +/- 14.4 (P + other antihypertensive(s), n = 9) (p = 0.331, NS vs. pretx). The post-TP, pretreatment DBP was 88.2 +/- 11.1 mmHg. The post-treatment DBP were (in mmHg): 78.5 +/- 6.9 (all patients, n = 24) (p = 0.03 vs. pretx); 77.2 +/- 7.4 (P alone, n = 15) (p = 0.008 vs. pretx); 80.7 +/- 6.1 (P + other antihypertensive(s), n = 9) (p = 0.063, NS vs. pretx). P and N were equally effective in reducing SBP (p = 0.843, NS) and DBP (p = 0.612, NS). Cyclosporin A (CyA) dose (p = 0.81) and trough levels (p = 0.19) were similar in P- and N-treated patients. Calculated GFR was virtually identical in P- and N-treated patients (p = 0.89). Patients (or parents of) reported a higher incidence of various side-effects while receiving P, including headache, flushing, dizziness and leg cramps. Furthermore, 22/24 (91.7%) reported some degree of gingival hyperplasia during treatment with P, and all these patients reported a stabilization or reduction of hypertrophy after the switch from P to N. We conclude that CCBs (N) are efficacious drugs for the purpose of BP control and renal protection in pediatric renal TP recipients.

Medication induced gingival overgrowth

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

The hypertensive dental patient

The dental team plays an integral role in safeguarding the general health of patients. Dental health care workers should be able to recognize risk factors associated with hypertension and counsel patients in an effort to reduce those that are present. In addition, dental professionals should recognize how these risk factors and associated hypertension affect the provision of dental care. This article reviews recent findings and therapies for hypertension, evaluates historically accepted but unsupported anecdotal information on the dental management of hypertensive patients and proposes guidelines for the dental management of these patients.

Prevalence of amlodipine-related gingival hyperplasia

Calcium channel blockers are known to contribute to gingival hyperplasia. The vast majority of reports discuss patients taking the drug nifedipine. During the past few years a newer calcium channel blocker, amlodipine, has been used with increasing frequency. To date, six cases have been published indicating that amlodipine may also promote gingival hyperplasia; however, no data have been reported regarding the prevalence of this phenomenon. The purpose of this study was to examine a large group of patients taking amlodipine and determine the prevalence of gingival hyperplasia. One hundred fifty dentate patients who had been taking amlodipine, 5 mg per day for at least 6 months, volunteered to undergo a screening examination for gingival hyperplasia. Mild hyperplasia (< 1/3 clinical crown) was found in five patients-a prevalence of 3.3%. This is significantly less (P < .001) than rates reported for patients taking nifedipine, and not significantly different from rates previously reported in control groups of cardiac patients not taking calcium channel blockers. The results from this group of patients indicated that amlodipine, 5 mg per day, did not induce gingival hyperplasia.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

The distribution of gingival overgrowth in organ transplant patients

The distribution of gingival overgrowth was investigated in a cohort of organ transplant patients, who were medicated with cyclosporin or the combination of cyclosporin and a calcium channel blocking drug. Gingival overgrowth scores were significantly higher at buccal sites than lingual-palatally (p < 0.0001). There was no significant difference between upper and lower overgrowth scores (p = 0.88). The most severe overgrowth was seen in the canine region. Overgrowth between the central incisors was significantly less than in the canine region (p > or = 0.044) and was similar to that in the molar and premolar region. Although raised overgrowth scores were associated with increased levels of plaque and gingival inflammation, the distribution could not be explained by this observation.

The pathogenesis of drug-induced gingival overgrowth

Gingival overgrowth is a well-documented unwanted effect, associated with phenytoin, cyclosporin, and the calcium channel blockers. The pathogenesis of drug-induced gingival overgrowth is uncertain, and there appears to be no unifying hypothesis that links together the 3 commonly implicated drugs. In this review, we consider a multifactorial model which expands on the interaction between drug and/or metabolite, with the gingival fibroblasts. Factors which impact upon this model include age, genetic predisposition, pharmacokinetic variables, plaque-induced inflammatory and immunological changes and activation of growth factors. Of these, genetic factors which give rise to fibroblast heterogeneity, gingival inflammation, and pharmacokinetic variables appear to be significant in the expression of gingival overgrowth. A more thorough understanding of the pathogenesis of this unwanted effect will hopefully elucidate appropriate mechanisms for its control.