Cyclosporin-A-induced gingival overgrowth in heart transplant patients. A cross-sectional study

Drug-induced gingival overgrowth in cardiovascular patients

Drug-induced gingival overgrowth (DIGO) is a pathological growth of gingival tissue, primarily associated with calcium channel blockers and immunosuppressants. Consequently, it is mainly seen in cardiovascular and transplanted patients. Nifedipine remains the main calcium channel blocker related to the development of this unpleasant side-effect. As for immunosuppressants, cyclosporin is the leading causative agent, whereas other drugs from this drug-group, including tacrolimus, have better safety profiles. Accumulated collagen with inflammatory infiltrates is the histological hallmark of this condition. Several factors are involved in the pathogenesis and can increase the risk, such as male gender, younger age, pre-existing periodontal inflammation, and concomitant use of other DIGO-inducing medications. Patients with DIGO may experience severe discomfort, trouble with speech and mastication, pain, and teeth loss, aside from cosmetic implications. Furthermore, these patients also have an increased risk for cardiovascular diseases. The interdisciplinary approach and cooperation with dental care experts are necessary for patient management. Treatment includes discontinuing the drug and switching to one with a better profile, improving oral hygiene, and surgical removal of enlarged tissue. Recognizing the potential of commonly used medications to cause DIGO and its effect on patients' health is necessary for early detection and adequate management of this complication.

Oral health complications after a heart transplant: a review

Background Heart transplants have become a successful treatment for some cardiovascular diseases. To prevent rejection of the transplanted heart, patients have to take immunosuppressive medication.Aims The aims of this study were to identify and review oral health complications after heart transplantation.Methods The electronic database PubMed was searched for relevant articles. The search yielded 332 papers, of which 24 matched the criteria for this review.Results Gingival hyperplasia was observed in 8.3-67% of the patients. Heart transplant patients who received professional periodontal treatment starting six months after transplantation showed significantly better scores on the Gingival Index (GI) and gingival hyperplasia. In comparison to a control group, heart transplant patients did not differ significantly in the DMF(T) index. The incidence of fungal infection in patients receiving a heart transplant varied between 10% and 25%. Heart transplant patients had a 4.3 times higher chance of developing oral cancer.Conclusion Patients who underwent a heart transplant and subsequently used immunosuppressive medicines appear to have a higher risk of gingival hyperplasia, periodontal conditions, the presence of Candida species and oral malignancies, in comparison to healthy individuals. The association between heart transplants and dental caries was unclear. It is recommended that heart transplant patients receive frequent oral examination and professional dental cleaning.

A systematic review of the effectiveness of oral health promotion activities among patients with cardiovascular disease

AIMS

This study aimed to review the effectiveness of oral health promotion activities conducted among patients with cardiovascular disease.

METHODS AND RESULTS

Three electronic databases were searched for effective papers using standardized search methods, and key findings of effective studies were summarized. The initial search yielded 3101 papers but only 8 studies met the criteria for this review: 3 were randomized controlled studies, 3 were pre-/post group interventions, 1 was a randomized split-mouth study, and 1 was a quasi-experimental study. Studies retrieved concerned oral health promotion activities in patients with coronary heart disease, hypertension, heart transplantation, and stroke. Interventions comprised periodontal treatment performed by dental personnel, and oral hygiene interventions provided by nursing home care assistants. Outcomes included improvements in periodontal health, and modifications of systemic inflammatory markers. No studies, however, evaluated the effects of oral health promotion interventions on oral microflora.

CONCLUSION

There are limited studies on the efficacy of oral health promotion activities in patients with cardiovascular disease, particularly stroke patients. Oral health promotion activities appear to produce improvements in periodontal health, and also result in changes to systemic markers of inflammation and endothelial function (at least) in the short term. Whether these effects can ultimately lower the risk of secondary cardiovascular events has not yet been determined.

South American Heart Transplantation Registry of patients receiving everolimus in their immunosuppressive regimens

The increasing number of heart transplant recipients receiving immunosuppression with mammalian target of rapamycin inhibitors prompted the implementation of a South American Transplant Physicians Group to register these patients in a database. Everolimus (EVL) is a signal proliferation inhibition that reduces graft vascular disease when used de novo. Recently, its administration has expanded to subjects with resistant rejection or with side effects due to other immunosuppressive drugs (calcineurin inhibitors and/or steroids), allowing for better regulation of the immunosuppressive regimen. Herein we have shown the data collected from patients receiving EVL in ten South American Heart Transplant Centers. We have concluded that the administration of EVL is a useful adjunctive therapy that allows the reduction or suspension of other immunosuppressive drugs that caused unwanted side effects, without a loss of immunosuppressive efficacy, with manageable side effects, and constituting a valuable therapeutic option.

Effectiveness of periodontal therapy on the severity of cyclosporin A-induced gingival overgrowth

AIM

The purpose of the present study was to evaluate the clinical effects of aetiological periodontal treatment in a group of transplant patients medicated with cyclosporin A (CsA) who exhibited severe gingival overgrowth.

MATERIALS AND METHODS

Twenty-one patients received oral hygiene instructions, supra- and subgingival scaling and periodontal maintenance therapy and were monitored for 12 months. Full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), periodontal probing depth and degree of gingival overgrowth (Seymour index GO) were recorded at baseline, 6 and 12 months after treatment.

RESULTS

Statistical evaluation revealed that all clinical variables significantly decreased compared with baseline. At baseline 18 out of 21 treated patients (85.71%) exhibited clinically significant overgrowth. Initial GO score of 2.38+/-1.92 in the anterior sextants and of 1.29+/-1.59 in the posterior segments were reduced to 0.56+/-0.83 and to 0.45+/-0.84 at 12 months (p<0.001). A difference of 1.82 and 0.84 in the severity of treated GO was accompanied by a 42% and 34% decrease in FMPS and FMBS, respectively.

CONCLUSIONS

Aetiological periodontal treatment and regular maintenance therapy were effective in resolving the inflammation and in eliminating the need for surgical treatment in patients receiving CsA.

Cyclosporin-Induced Gingival Overgrowth: A Clinical–Epidemiological Evaluation of 121 Italian Renal Transplant Recipients

BACKGROUND

Although other immunosuppressive agents have been recently introduced (e.g., tacrolimus), it has been calculated that in the next decade about 1 million people will still be taking cyclosporin (CsA). The association between gingival overgrowth (GO) and the use of CsA is still not clear. In the present study we evaluated the prevalence and the degree of GO in a group of Italian renal transplant patients and the possible relationship between gingival lesions and demographic, oral, systemic, and pharmacological variables.

METHODS

One hundred twenty-one renal transplant recipients receiving immunosuppressive therapy with CsA were evaluated in this study. Patients were classified in two groups. In the first (screening group), we included all those patients referred by the Parma University Renal Transplant Center for a general oral checkup, with no specific indications for GO. The second group (non-screening group) included all those patients who specifically had been referred to the Oral Pathology and Oral Medicine Unit because of GO. We considered the following variables: gender, daily CsA dose, duration of immunosuppressive treatment, CsA plasma concentration, concomitant use of another immunosuppressive agent (azathioprine), use of other GO inducers (calcium channel blockers, anti-epileptic drugs), oral hygiene scores, and other drugs taken at the time of oral examination.

RESULTS

Fisher's exact test and chi square test demonstrated that in the screening group, duration of immunosuppressive treatment and oral hygiene scores were associated both with the prevalence and the high GO scores (P (1) (DIT) <0.0001; P (2) (DIT)=0.0023; P (1) (hyg)=0.0084; P (2) (hyg)=0.0068). In the screening group, concomitant use of CsA and azathioprine is related to a low development degree of GO (P=0.0088). In the non-screening group, we found a significant association between poor oral hygiene and high degree of GO (P=0.0349).

CONCLUSION

In addition to a probable genetic predisposition, duration of immunosuppressive treatment and oral hygiene status are the most important variables related to development and degree of GO during the use of CsA in this study.

Cyclosporin A specifically affects nuclear PLCbeta1 in immunodepressed heart transplant patients with gingival overgrowth

One of the most commonly observed adverse effects of cyclosporin A (CsA) is the development of gingival overgrowth (GO). Fibroblasts are involved in GO, but the question why only a percentage of patients undergoing CsA treatment shows this side-effect remains unanswered. In a previous study, CsA has been demonstrated to induce over-expression of phospholipase C (PLC) beta(1) in fibroblasts of patients with clinical GO, in cells from both enlarged and clinically healthy gingival sites. In this work, we assessed the expression of PLCbeta isoforms to investigate whether the exaggerated fibroblast response to CsA related to increased PLCbeta(1) expression could also be detected in CsA-treated patients without clinical signs of GO. Our results support the hypothesis of a multi-factorial origin of gingival overgrowth, including specific changes within the gingival tissues orchestrating fibroblastic hyper-responsiveness as a consequence of a long-term in vivo exposure to cyclosporin A.

Risk factors for gingival overgrowth in patients medicated with ciclosporin in the absence of calcium channel blockers

OBJECTIVES

This study investigates the effect of a range of potential risk factors on the severity of gingival overgrowth in transplant patients medicated with ciclosporin in the absence of any calcium channel blockers.

MATERIALS AND METHODS

One hundred dentate solid organ transplants medicated with ciclosporin (but not calcium channel blockers or phenytoin) were recruited for the study. Demographic, pharmacological and periodontal data were recorded and gingival overgrowth assessed from stone models.

RESULTS

Univariate analysis identified the duration of transplant, papilla bleeding index, creatinine serum concentration, azathioprine and prednisolone dosage as risk factors for overgrowth severity. Multivariate modelling, excluding the periodontal parameters, gave a predictive model that included dosages of ciclosporin, azathioprine, prednisolone and weight (p<0.0001, adjusted-R2=19%). Adding the periodontal variables strengthened the model (p<0.0001, adjusted-R2=34.5%).

CONCLUSION

The explanatory models in this study contain a number of variables that moderate inflammation (azathioprine and prednisolone) or are markers of it (papilla bleeding index). Dosage of each of the three immunosuppressants was identified as a risk factor for the severity of gingival change. This observation appears to have been masked by the effects of the calcium channel blockers in earlier studies.

Is oral azithromycin effective for the treatment of cyclosporine-induced gingival hyperplasia in cardiac transplant recipients?

Anecdotal evidence suggests that azithromycin is effective for the treatment of cyclosporine-induced gingival hyperplasia in solid-organ transplant recipients. We present the cases of two heart transplant patients who insidiously developed gingival hyperplasia, likely because of immunosuppression with cyclosporine, which was treated with azithromycin. Evidence supporting the efficacy of azithromycin in the treatment of cyclosporine-induced gingival hyperplasia in solid organ transplant recipients was searched for, identified, and then critically assessed. While no data were found specifically evaluating azithromycin in cardiac transplant patients, there were nine pertinent papers identified that evaluated the clinical question of interest in the renal transplant population [Wahlstrom et al. (1995) The New England Journal of Medicine 332, 753; Boran et al. (1996) Transplantation Proceedings 28, 2316; Gomez et al. (1997) Nephrology Dialysis Transplantation 12, 2694; Ljutic (1997) Dialysis & Transplantation 26, 787; Puig et al. (1997) Transplantation Proceedings 29, 2379; Nash et al. (1998) Transplantation 65, 1611; Nowicki et al. (1998) Annals of Transplantation 3, 25; Wirnsberger et al. (1998) Transplantation Proceedings 30, 2117; Citterio et al. (2001) Transplantation Proceedings 33, 2134]. These studies and case reports are summarized. While more evidence is required to support routine use of azithromycin for the treatment of cyclosporine-induced gingival hyperplasia in cardiac transplant recipients, preliminary published evidence from renal transplant patients is certainly favourable.

Superinfecting microorganisms in patients under treatment with cyclosporin-A and its correlation to gingival overgrowth

The aim of this study was to identify the presence of superinfecting microorganisms (Gram-negative enteric rods and Candida sp.) in heart transplant patients and correlate this with gingival overgrowth. Thirty patients (10 females, 20 males--mean age 45 years) were examined. All were under cyclosporin-A (CsA) therapy. Patients who had taken any antibiotics 3 months prior the study or had been submitted to periodontal therapy were not enrolled. Patients were required to have at least 6 teeth. The plaque index (PI), gingival index (GI), pocket depth (PD) and clinical attachment level (CAL) were recorded. Microbiological samples were taken from sulcus/pocket (s/p) and from stimulated saliva (ss) and submitted to analysis. Patients were divided into two groups: the ones with gingival overgrowth (GO) and those without gingival overgrowth (WGO). After statistical analysis (chi-square test, Student's t-test, Fisher test, p < or = 0.05), we concluded that there was no statistical difference between groups in the parameters of gender, CsA dosage, time since transplantation, PI, GI, PD and CAL. Gram-negative rods from either the sulcus/pocket or saliva samples were not found. Candida sp. was detected (s/p-30% and ss-30%). Stimulated saliva samples analysis determined that the presence of Candida sp. was associated with patients without gingival overgrowth.

Cyclosporin A-induced gingival overgrowth in renal transplant patients

BACKGROUND

The incidence of gingival overgrowth (GO) associated with the use of cyclosporin A (CsA) is controversial. In the present study, we determined the incidence of GO in Brazilian renal transplant patients treated with CsA and the possible associations between periodontal and pharmacological variables.

METHODS

The test group consisted of 20 renal transplant patients, and the control group included 20 non-transplant patients. Periodontal conditions were evaluated based on the plaque index (PI), gingival index (GI), probing depth (PD), and the rate of gingival overgrowth, together with pharmacological variables (daily CsA dose and duration of treatment).

RESULTS

A significant difference in PI (P < 0.0001) and PD (P < 0.0001) was observed between groups, while GI (P = 0.15) did not differ significantly. Using the Pearson correlation coefficient, a significant correlation was observed not only between GI (P < 0.001; r = 0.8141) and GO, but also for PD (P < 0.001; r = 0.866) and GO. The other correlations were not statistically significant.

CONCLUSIONS

We conclude that GO induced by CsA may vary according to the individual sensitivity of each patient and may or may not be correlated with other local factors (periodontal variables).

Cyclosporin A upregulates phospholipase C beta1 in fibroblasts from gingival overgrowth

BACKGROUND

In an attempt to evaluate the influence of cyclosporin A (CsA) on fibroblast metabolism, the phospholipase C beta1, (PLC beta1) nuclear expression was evaluated in fibroblasts from heart transplantation patients treated with CsA who exhibited gingival overgrowth (GO) and from controls.

METHODS

PLC beta1 was assessed by immunoblotting and immunocytochemistry means.

RESULTS

Findings did not show any difference in terms of PLC beta1 expression between the 2 groups when fibroblasts were incubated in media without CsA, while the addition of CsA highly stimulated the fibroblasts from CsA-treated patients compared to controls. The abnormal fibroblastic response in CsA-treated patients was detected both in cells from enlarged gingival sites and in cells from clinically healthy gingival sites.

CONCLUSIONS

These results do not explain whether the exaggerated reactivity to in vitro CsA is the consequence of a genetically transmitted susceptibility to CsA that identifies those subjects at risk for developing GO, or whether it is a secondary effect of the long-term in vivo exposure to CsA. However, the present data underline the lack of any close relationship between enhanced fibroblast activity and clinical signs of GO and support the hypothesis that some other factors, together with CsA, are involved in the pathogenesis of CsA-induced GO.

Effectiveness of periodontal therapy in patients with drug-induced gingival overgrowth. Long-term results

BACKGROUND

Drug-induced gingival overgrowth (DGO) is one of the well-recognized side effects of cyclosporin A (CsA) or nifedipine (Ni). After surgical periodontal therapy, the incidence of DGO recurrence is not known. The aim of this study was to evaluate the results of surgical periodontal therapy in patients receiving CsA or Ni and who exhibit severe long-term DGO. In addition, the relationship between various variables and the recurrence of severe DGO after periodontal surgery was investigated.

METHODS

A total of 38 patients, 22 with CsA-induced DGO and 16 with Ni-induced DGO, were included in this study. At baseline, patients received initial periodontal therapy, after which either the upper or lower anterior segment in each patient was surgically treated. Surgical periodontal therapy consisted of the flap technique with a 90 degrees gingivectomy incision. Following surgery, patients were placed on a maintenance therapy recall program and were monitored for 18 months. Patients were seen once a month for the first 3 months and once every 3 months for the following 15 months. Plaque index (PI), papilla bleeding index (PBI) and DGO scores in the treated segments were recorded at each recall appointment. Attendance at recall appointments was also noted for each patient.

RESULTS

Recurrence of severe DGO was observed in 13 of the 38 patients (34%) 18 months following periodontal surgery. Multiple regression analysis indicated that age, gingival inflammation, and attendance at recall appointments were significant determinants of the recurrence of severe DGO.

CONCLUSIONS

This study suggests that regular re-motivation and professional care at frequent recall appointments after periodontal surgery are of great importance in patients receiving CsA or Ni. By maintaining periodontal health, the life quality of these patients may be raised.

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.

Contribution of individual drugs to gingival overgrowth in adult and juvenile renal transplant patients treated with multiple therapy

Drug regimens for transplantation often consist of multiple therapeutic agents and may result in drug-induced gingival overgrowth (DIGO). The aim of this study was to investigate the contribution of individual drugs in renal transplant patients. 147 adults (19-84 years) and 60 juveniles (3-18 years) were scored for DIGO and other clinical variables. Duration of treatment, dosage of drugs per kg body weight and serum cyclosporin levels were recorded. 44% of adults and 27% of children had DIGO. All patients were receiving prednisolone. More adults than children were administered cyclosporin, the reverse was true of azathioprine (p<0.01). Explanatory models were evaluated by stepwise ordinal polynomial logistic regression. Statistically significant explanation (p<0.05) of DIGO was afforded by prednisolone, nifedipine and azathioprine concentrations in adults and by cyclosporin, nifedipine and azathioprine concentrations in juveniles. Prednisolone and azathioprine were inversely related to the degree of DIGO. Plaque and irregularity scores, lip coverage and mouthbreathing status showed significant additional explanation in adults, replacing nifedipine and azathioprine in the final model. Irregularity was additionally explanatory in children, but no other clinical variables. A larger proportion of the variance of DIGO was explained by the available variables in children than in adults (pseudo r2=0.50 versus 0.25). The degree of DIGO in renal transplant patients is influenced by the dosage of a number of individual components of multiple drug therapy independently of the presence of local clinical factors.