Cyclosporine and gingival overgrowth

Er:YAG Laser and Cyclosporin A Effect on Cell Cycle Regulation of Human Gingival Fibroblast Cells

Introduction: Periodontitis is a set of inflammatory disorders characterized by periodontal attachment loss and alveolar bone resorption. Because of deficiency in periodontitis mechanical therapy, this study was aimed to explore the molecular influence of the erbiumdoped: yttrium aluminum garnet (Er:YAG) laser and cyclosporin A (CsA) on human gingival fibroblasts (HGFs) for improvement in periodontal diseases therapy. Methods: We focused on articles that studied the proteome profiles of HGFs after treatment with laser irradiation and application of CsA. The topological features of differentially expressed proteins were analyzed using Cytoscape Version 3.4.0 followed by module selection from the protein-protein interaction (PPI) network using Cluster ONE plugin. In addition, we performed gene ontology (GO) enrichment analysis for the densely connected region and key proteins in both PPI networks. Results: Analysis of PPI network of Er:YAG laser irradiation on HGFs lead to introducing YWHAZ, VCP, HNRNPU, YWHAE, UBA52, CLTC, FUS and IGHG1 as key proteins while similar analysis revealed that ACAT1, CTSD, ALDOA, ANXA2, PRDX1, LGALS3, ARHGDI and EEF1A1 are the crucial proteins related to the effect of drug. GO enrichment analysis of hubbottleneck proteins of the 2 networks showed the different significant biological processes and cellular components. The functional enrichments of module of Er:YAG laser network are included as fatty acid transmembrane transport, cytokinesis, regulation of RNA splicing and asymmetric protein localization. There are not any significant clusters in network of HGF treated by CsA. Conclusion: The results indicate that there are 2 separate biomarker panels for the 2 treatment methods.

The Relationship between Proliferating Cell Nuclear Antigen Expression and Histomorphometrical Alterations in Cyclosporin A-Induced Gingival Overgrowth in Rats

The aim of this study was to investigate the relationship between Proliferating Cell Nuclear Antigen (PCNA) expression and histomorphometrical alterations in cyclosporin A (CsA)-induced gingival overgrowth with or without microbial dental plaque accumulation. Forty male Wistar rats were equally divided into 4 groups; Group I (control); Group II (CsA); Group III (ligature); Group IV (ligature and CsA). After 8 weeks of experimental period, rats were subsequently decapitated and mandibular molars were dissected. Gingival overgrowth was determined by measuring depth of the gingival sulcus, then the mandible were decalcified and serial sections were obtained for histomorphometric and immunohistochemical analysis. Histomorphometric analysis included the measurement of epithelial thickness; immunohistochemical analysis included the assessment of PCNA expression in the oral and sulcular epithelium of buccal and lingual gingiva. Epithelial thickness and PCNA expression were significantly increased in buccal oral epithelium of Group II ( p < 0.05) and in all regions in Group IV ( p < 0.05) compared to control group. Also gingival overgrowth was more prominent in Group IV in comparison to Group II. These results indicate that CsA-induced gingival alterations are closely accociated with increased epithelial proliferative activity, and dental plaque accumulation seems not to be an essential but to be an aggrevating factor for the progression of the lesion.

Immunoexpression of interleukin-6 in drug-induced gingival overgrowth patients

BACKGROUND

To analyze the role of proinflammatory cytokines in drug-induced gingival enlargement in Indian population.

AIM

To evaluate for the presence of interleukin-6 (IL-6) in drug-induced gingival enlargement and to compare it with healthy control in the absence of enlargement.

MATERIALS AND METHODS

Thirty-five patients selected for the study and divided into control group (10) and study group (25) consisting of phenytoin (10); cyclosporin (10) and nifedipine (5) induced gingival enlargement. Gingival overgrowth index of Seymour was used to assess overgrowth and allot groups. Under LA, incisional biopsy done, tissue sample fixed in 10% formalin and immunohistochemically evaluated for the presence of IL-6 using LAB-SA method, Labeled- Streptavidin-Biotin Method (LAB-SA kit from Zymed- 2(nd) generation LAB-SA detection system, Zymed Laboratories, CA). The results of immunohistochemistry were statistically analyzed using Kruskaal-Wallis and Mann-Whitney test.

RESULTS

The data obtained from immunohistochemistry assessment shows that drug-induced gingival overgrowth (DIGO) samples express more IL-6 than control group and cyclosporin expresses more IL-6 followed by phenytoin and nifedipine.

CONCLUSION

Increased IL-6 expression was noticed in all three DIGO groups in comparison with control group. Among the study group, cyclosporin expressed maximum IL-6 expression followed by phenytoin and nifedipine.

Impact of three different mouthwashes on the incidence of gingival overgrowth induced by cyclosporine-A: a randomized controlled experimental animal study

OBJECTIVE

This study aimed to evaluate the effects of three different mouthwashes on the incidence of cyclosporine-A-induced gingival overgrowth.

STUDY DESIGN

One hundred albino rats were divided into five equal groups. Group I rats received no treatment. Group II rats were administered cyclosporine-A. Group III, IV, and V rats were handled as group II and concomitantly treated with chlorhexidine gluconate, cetylpyridinium chloride, and essential oil mouthwashes, respectively. Ten rats from each group were euthanized after the first week of treatment, and the remaining rats were euthanized after the second week of treatment. The obtained specimens were stained with hematoxylin and eosin, Masson's trichrome, and tumor growth factor beta (TGF-β), matrix metalloproteinase 1 (MMP-1), and interleukin 6 (IL-6) immunohistochemical stains.

RESULTS

The histologic findings at the end of the first and second weeks revealed marked increases in gingival overgrowth for groups II and IV in comparison with groups III and V. Increased epithelial thickness and collagen accumulation were prominent in groups II and IV compared with the other groups. Groups II and IV revealed the highest immunoreactivities for TGF-β and for IL-6. Groups I, III, and V revealed the highest level of MMP-1 expression.

CONCLUSIONS

Essential oils and chlorhexidine gluconate mouthwashes significantly reduced the incidence of gingival overgrowth compared with cetylpyridinium chloride.

Proteomic analysis in cyclosporin A-induced overgrowth of human gingival fibroblasts

Cyclosporin A (CsA) has been used as an immunosuppressive drug to prevent organ transplant rejection and to treat autoimmune diseases. CsA has a proliferative effect on human gingival fibroblasts (HGF) in vitro. However, the molecular mechanisms underlying CsA-induced proliferation in HGF remain to be elucidated. This study was aimed to investigate the CsA responsive proteins in HGF using systematic proteomic approach. Cell viability was determined by MTT assay and reactive oxygen species (ROS) was measured by fluorescent spectrometer. Proteins profiled by two-dimensional gel electrophoresis (2-DE) were identified by matrix-assisted laser desorption ionization time-of flight (MALDI-TOF) and electrospray ionization quadrupole time-of-flight mass spectrometry (EIQ-TOF MS). To confirm the expression changes of proteins by proteomics analysis, Western blot was performed using specific antibody. CsA increased the cell viability of HGF in a dose- and time-dependent manner. Significantly, seventeen proteins were overexpressed in the CsA-treated HGF, whereas three proteins were found to be expressed less than the untreated cells. The identified proteins were mainly related with cell proliferation, metabolism, and oxidation. The overexpression of peroxiredoxin 1 (Prx 1) confirmed by Western blotting and reduction of cytosolic reactive oxygen species (ROS) levels in the CsA-treated HGF demonstrated that Prx 1 may play a crucial role in the HGF proliferation induced by CsA. Upregulation of Galectin 3 in CsA-treated HGF indicated that it is related to CsA-induced proliferation. These proteomic analysis data will provide an efficient approach in understanding the mechanisms of HGF proliferation by CsA.

Expression of transforming growth factor-beta receptor II mRNA in cyclosporine-induced gingival overgrowth

Gingival overgrowth (GO), characterized by increased cellular and extracellular matrix components in gingival tissue, is a frequent side effect of cyclosporine (CsA). In previous studies, elevated levels of transforming growth factor-beta (TGF-beta) have been detected in GO tissue, which led to the conclusion that TGF-beta plays a major part in the pathogenesis. TGF-beta activity is mediated by three receptors; TGF-beta receptor II (TGF-beta RII), the most important, has been immunohistochemically detected in GO and normal gingival tissue. The aim of this study was to clarify whether TGF-beta RII is overexpressed in CsA-induced GO. The expression of TGF-beta RII mRNA in GO tissue of patients on CsA (n = 10, 5 women, aged 42.5 +/- 14.9 years) with renal transplantation (transplant duration 3.6 +/- 0.96 years) was compared with that in healthy gingiva of control subjects (n = 10, 5 women, aged 42.5 +/- 7.6 years). Semiquantitative reverse transcribed-polymerase chain reactions (RT-PCR) were applied with glyceraldehyde-3-phosphate dehydrogenase (GAPDH) as an internal standard. TGF-beta RII mRNA was readily detected in the GO tissue of patients on CsA. The level of TGF-beta RII mRNA relative to GAPDH in GO cases was not significantly higher than the relative TGF-beta mRNA level in normal gingiva (0.60 +/- 0.16 vs 0.52 +/- 0.19; P = .575). The precise mechanism of CsA-induced GO remains uncertain. According to our results, TGF-beta RII was not upregulated in CsA-induced GO, and may have no important role in this disorder. However, the involvement of TGF-beta in the molecular pathology of GO may be mediated via TGF-beta RI or RIII.

High-turnover osteoporosis is induced by cyclosporin A in rats

Cyclosporin A (CsA) is used widely as an immunosuppressive agent, but it induces osteoporosis as a prominent side effect. To elucidate the mechanisms involved in CsA-induced osteoporosis, the effects of CsA on bone metabolism were investigated in a rat experimental model. Fifteen-day-old rats were fed a powdered diet containing or lacking CsA for 8-30 days. Analysis was performed by micro-computed tomography (muCT) and light microscopy to examine histomorphometric changes in rat tibiae on days 8, 16, and 30. Plasma parathyroid hormone (PTH) and osteocalcin (OCN) levels were determined by enzyme-linked immunosorbent assay (ELISA) on days 8, 16, and 30. The expression of OCN, osteopontin (OPN), and cathepsin K mRNAs in tibial bone marrow was examined by Northern blot analysis on days 8 and 16. Although no significant differences were observed in tibial length during the experimental periods, or in histomorphometric parameters on day 8, an apparent decrease in bone volume was observed in the CsA-treated group after day 16. Histologic analysis showed that the number of osteoblasts and osteoclasts on the surface of trabecular bone in the CsA-treated group had increased significantly on day 16. Plasma PTH and OCN levels in CsA-treated rats were significantly higher than those in control animals on day 8. Northern blot analysis revealed that the CsA-treated group showed an increase in the expression of OCN, OPN, and cathepsin K mRNAs on day 8 compared with the controls. These findings suggest that bone resorption in CsA-treated rats is induced by high-turnover osteoporosis and that bone remodeling activity may be activated by PTH.

Increased Expression of Vascular Endothelial Growth Factor in Cyclosporin A-Induced Gingival Overgrowth in Rats

BACKGROUND

Gingival overgrowth is a side effect associated with cyclosporin A (CsA) therapy. The lesion is characterized by increased epithelial thickness, enlargement of connective tissue, and increased vascularization. The aim of this experimental study was to examine the role of vascular endothelial growth factor (VEGF) in the pathogenesis of CsA-induced gingival overgrowth.

METHODS

Twenty male Wistar rats were divided into two groups of 10 animals each. For the development of gingival overgrowth, one group received CsA therapy subcutaneously in a daily dose of 10 mg/kg for 60 days, and the other group was used as a control. At the end of the experimental period, rats were subsequently decapitated, and the mandibles with the surrounding gingiva and soft tissue were removed. Half of each sample was used for histomorphometric analysis, and the other half was used for biochemical analysis. Histomorphometric analysis included the measurements of the number and diameter of blood vessel profiles under a microscope, and biochemical analysis included the assessment of VEGF concentration by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The histomorphometric findings showed that the number of blood vessel profiles increased in the CsA group compared to the control group (P <0.001), although the increase in the diameter of blood vessel profiles was not significant (P >0.05). The biochemical findings showed that in vivo VEGF expression was higher in the CsA group compared to the control group (P <0.001).

CONCLUSION

The results of this study suggest that increased VEGF expression may be associated with the pathogenesis of CsA-induced gingival overgrowth.

Growth factors and proliferation of cultured rat gingival cells in response to cyclosporin A

OBJECTIVE

The prominent side-effect of cyclosporin A, an immunosuppressive drug, in oral tissues is gingival outgrowth, although the exact mechanism underlying this side-effect is unclear. The main purposes of the present study were to determine whether cyclosporin A induced the gingival outgrowth by promoting proliferation of gingival cells and whether growth factors such as transforming growth factor-betas (TGF-betas), fibroblast growth factor-2 (FGF-2), platelet-derived growth factors (PDGFs), and insulin-like growth factors (IGFs) are involved in the possible changes in the proliferation of gingival cells induced by cyclosporin A.

METHODS

Cells isolated from rat gingival tissues were cultured with cyclosporin A or IGF-I for 3 days. The effects of cyclosporin A or IGF-I on the proliferation of cultured rat gingival cells were analyzed with a CellTiter 96 proliferation assay kit. The mRNA expression levels for TGF-betas, FGF-2, PDGFs, IGFs, insulin-like growth factor receptors (IGFRs), and insulin-like growth factor binding proteins (IGFBPs) in the rat gingival cells treated with cyclosporin A were measured using competitive reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Cyclosporin A induced 23-25% (p < 0.001) increases in the proliferation of rat gingival cells and approximately 130% (p < 0.05) and 60% (p < 0.05) elevations in the mRNA expression levels for TGF-beta1 and FGF-2, respectively. On the other hand, exogenous IGF-I induced 8-11% (p < 0.05) increases in the proliferation, but cyclosporin A induced 30-80% (p < 0.05-0.01) reductions in the mRNA expression levels for endogenous IGF-I, IGFR1, IGFBP2, IGFBP3, IGFBP5, and IGFBP6.

CONCLUSIONS

Cyclosporin A stimulates the proliferation of rat gingival cells. TGF-beta1 and FGF-2 could be involved, but IGFs, IGFRs and IGFBPs could not be directly involved in this cyclosporin A induced-stimulation of the gingival cell proliferation.

Effects of azithromycin on cyclosporine-induced gingival hyperplasia in renal transplant patients

BACKGROUND

Gingival hyperplasia is a well-known complication of cyclosporine therapy, affecting 21% to 35% of renal transplant patients. Metronidazole, clarithromycin, and azithromycin, all azalid antimicrobial agents derived from the macrolide antibiotic erythromycin, have been used for treatment. Marked improvements in gingival hyperplasia have been recorded in particular with azithromycin. The aim of the present study was to investigate histopathological features of cyclosporine-induced gingival hyperplasia and to evaluate the quantitative efficacy of short-term azithromycin therapy.

METHODS

Eighteen renal transplant patients with cyclosporine-induced gingival hyperplasia were included in the study. All patients received azithromycin with a dose of 500 mg/d for 3 consecutive days. Changes in gingival hyperplasia were evaluated by measuring the gingival sulcus depth to the cementum-enamel junction of every tooth in each of the four quadrants on days 0, 7, 30, 90, 180. Gum biopsies were obtained on days 0 and 30; the degree of inflammation was classified as "mild," "intermediate," and "severe".

RESULTS

Gingival hyperplasia was reduced in all treated patients throughout the study. The degree of improvement was more significant between 0 to 7 and 7 to 30 days than at other times (respectively, P < .0001 and P < .002). Histopathologically, eight patients had severe and one patient moderate chronic inflammation at the beginning of therapy. Three other biopsies were reported as papilloma, mucosal hyperplasia, and normal gingival tissue biopsy.

CONCLUSIONS

Azithromycin appears to be useful to treat cyclosporine-induced gingival hyperplasia in renal transplant patients. Treatment is inexpensive and free from known adverse effects.

Evaluation of matrix metalloproteinase-1 and tissue inhibitor of metalloproteinase-1 levels in gingival fibroblasts of cyclosporin A-treated patients

BACKGROUND

Cyclosporin A (CsA) is a potent immunosuppressant used to prevent organ transplant rejection and to treat various autoimmune diseases. CsA-induced gingival overgrowth (CsA GO) is the most widely seen side effect of this drug; its pathogenesis is not completely understood. The aim of this study was to identify and compare matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinase-1 (TIMP-1) levels in gingival fibroblast cultures of tissues derived from renal transplant patients receiving CsA and exhibiting gingival overgrowth and from periodontally healthy control subjects.

METHODS

Gingival overgrowth samples were obtained from patients undergoing therapy with CsA, and control tissues were obtained from systemically healthy donors. Gingival fibroblasts were grown using explant cultures. Three different study groups were identified: 1) CsA GO fibroblast culture; 2) CsA-treated healthy gingival fibroblast culture (H+CsA); and 3) healthy gingival fibroblast culture (H). The levels of MMP-1 and TIMP-1 in these groups of gingival fibroblasts were analyzed by enzyme-linked immunoabsorbent assay (ELISA).

RESULTS

The levels of TIMP-1 were significantly lower in CsA GO than H (P < 0.05). There was no statistically significant difference in the levels of MMP-1 between H and CsA GO (P = 0.505). The ratio of MMP-1 to TIMP-1 was significantly higher in CsA GO than H (P < 0.05).

CONCLUSIONS

The results of this study indicate that CsA therapy does not have a significant effect on MMP-1 levels. However, low TIMP-1 levels can be an important factor in the pathogenesis of CsA GO, since the balance between MMP-1 and TIMP-1 levels was changed by CsA.

Digestive System 1

This chapter deals with the digestive system. The major and minor salivary glands and their secretions also represent and integral part of the protective mechanism of the oral cavity, and derangement of saliva production may lead to loss of integrity of the oral mucosa. Drug-induced abnormalities of taste sensation are also well-described phenomena occurring in man although human studies are necessary for the detection of these effects. Inflammation of the oral cavity may involve the buccal mucosa, the gingiva (gingivitis), the tongue (glossitis), and the peridontal tissues (peridontitis). Therapeutic agents can induce inflammatory lesions in the tongue. Moreover, a protective layer of mucus, a visco-elastic material containing high molecular weight glycoproteins produced by the major and minor salivary glands, covers the stratified squamous mucosa of the oral cavity. Salivary secretions also possess digestive enzyme activity although in herbivores and carnivores, it is usually low in contrast to high digestive enzyme activity in omnivorous species.

Clinical effects of periodontal therapy on the severity of cyclosporin A-induced gingival hyperplasia

BACKGROUND

Gingival hyperplasia (GH) is a major side effect associated with cyclosporin A (CsA) therapy. The condition is further augmented due to the gingival inflammation. In this study, the effects of initial periodontal therapy and gingival curettage are analyzed in a group of patients with clinically significant (>30%) CsA-induced gingival hyperplasia.

METHODS

The test group of 15 patients received oral hygiene instructions, supra- and subgingival scaling, polishing, and gingival curettage only oral hygiene instructions were given to 16 control subjects. Plaque index (PI), gingival index (GI), calculus index (CI), periodontal probing depth (PD), and gingival hyperplasia were recorded at baseline and repeated 8 weeks after treatment. Current doses of immunosuppressive agents, serum concentrations of CsA, and duration of CsA therapy were recorded as the pharmacological parameters.

RESULTS

Statistical evaluation revealed that all clinical variables showed statistical decreases compared to baseline in the treated patients, while none of the parameters changed significantly in the control group. Initial GH scores of 53.63% in controls and 53.40% in the treated patients were 52.83% and 32.13% following treatment, respectively. A difference of 21.27% in the severity of treated GH was accompanied by a 0.56 decrease in GI scores in the test group.

CONCLUSIONS

Compared to the initial observations, the results suggested that nearly 60% of the condition could be of fibrotic origin. Initial periodontal therapy and curettage resulted in the resolution of the inflammation in CsA-induced GH. Further investigation of the treated patients has shown that 7 out of 15 patients (47%) in the test group responded well and their GH scores decreased below 30% at the end of the study. The treatment in this study was effective in eliminating the necessity of more extensive surgical modes of treatment, such as gingivectomy, in 47% of cases.

Phagocytosis of new cementum-like islets formed inside the gingival connective tissue in cyclosporin-A treated rats

Three control and 3 experimental rats were administered vehicle or cyclosporin-A solutions. Animals were anaesthetized, tissues fixed and jaws processed for Epon inclusion. Histological examination of serially cut areas revealed the presence inside the gingival connective tissue of new cementum-like islets (NCLIs) associated to or engulfed by voluminous multinucleated cells (MCs). These complexes were located adjacent to blood vessels, at 250-350 microns from the root surface. Histomorphometric study indicated that the volume of the NCLIs varied from 3900 to 72,900 microns 3 and that of the MCs from 822 to 56,190 microns 3. The latter bore up to 14 nuclear profiles. Comparative evaluation of the NCLI-MC associations to other complexes "multinucleated cell(s)-resorbed material" seems to indicate that the phagocytosis of the NCLIs is dictated by their ectopic location, rather than their nature (new cementum-like structures). Therefore the MCs should be considered as foreign body giant multinucleated cells rather than cementoclasts.

Cyclosporin A-induced gingival overgrowth in the rat: a histological, ultrastructural and histomorphometric evaluation

This investigation was undertaken to further study cyclosporin A (CsA)-induced gingival overgrowth. Thirty mg/kg/d of vehicle or CsA solutions were given orally to 6-wk-old male Sprague-Dawley rats. After 4, 9, 14 and 19 wk 2 control and 2 experimental rats were anaesthetized, tissues fixed by intracardiac perfusion of fixative solution and jaws processed for Epon inclusion. Histological and ultrastructural studies conducted in a gingival portion (free gingiva) revealed the presence of hyalinization areas and of multinucleated cells (MCs) containing collagen fibrils (connective tissue), of amorphous areas and disorders of keratinization (epithelia). Histomorphometric evaluation indicated that in the CsA rats the mean cross-sectional area of the free gingiva was 2.52-fold increased compared to the controls. The connective tissue comprised 41.43% of this area (instead of 31.49% in controls). Additional histomorphometric evaluation was performed in 3 groups of free gingival portions: control (C group), CsA-non-respondent (CsA-nR) and CsA-respondent (CsA-R). The cross-sectional gingival areas studied were slightly lower than the mean area of all the control sites previously defined (groups C and CsA-nR) or showed the higher degrees of enlargement (CsA-R). In the CsA-R group the mean cross-sectioned area of the vessel profiles was increased and the number of fibroblast profiles decreased. In the CsA-nR group the number of vessel profiles and that of MCs profiles were increased. In the epithelia of the CsA-R group were increased (a) keratinized epithelia: thickness; thickness of the inner and of the outer compartments; surface area of spinous cell profiles; (b) oral gingival epithelium: number of cell layers (inner compartment); (c) oral sulcular epithelium: surface area of granular cell profiles; (d) junctional epithelium: thickness; number of cell layers. These results indicate that (a) the CsA induced modifications are not limited to enlarged gingiva (b) the overgrowth of the GCT is the result of a vasodilatation and of an increase in the volume of the extracellular matrix and (c) the increase of the epithelial thickness is mainly the result of a cell hypertrophy in the keratinized epithelia and of a cell hyperplasia in the junctional epithelium.

Lack of influence of cyclosporin A on levels of gingival procollagen types I and III mRNAs in rats of different ages

Previous studies showed that gingival overgrowth following cyclosporin A (CsA) administration is not associated with an increase in interstitial collagen. It also was shown that CsA causes a significant decrease in collagen content within the gingival stroma. In order to determine whether this decrease is caused by down-regulation of collagen mRNA, the procollagen mRNA level in gingiva of young and old rats was measured correlated with the ratio of interstitial collagen to DNA in these regions. Hybridization of 32P-labelled cDNA probes for procollagen types I and III with total RNA extracted from the molar gingiva showed that administration of Csa did not change the steady-state levels of mRNAs for both procollagens in the gingiva of either young or old rats. The ratio of gingival interstitial collagen to DNA was significantly reduced in the CsA-treated animals (4.2 +/- 0.85) relative to the controls (7.8 +/- 1.6). It is concluded that the reduction in interstitial collagen following CsA treatment is not age-related, and is most probably caused by increased degradation rather by decreased biosynthesis.

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

The incidence of gingival overgrowth secondary to the administration of cyclosporine A (CsA) is widely reported in renal transplant recipients, while there is no information about periodontal conditions in heart transplant patients. In the present cross-sectional investigation the relationship between clinical periodontal conditions and pharmacological profiles of CsA was determined in 39 patients (31 male and 8 female, aged 18-63 years, mean 45.6 +/- 15.2 years) who possessed their 6 upper and 6 lower anterior teeth. All patients had been on a CsA-based immunosoppression regimen for at least 6 months (6-101, mean 39.3 +/- 30.1). 2 periodontal parameters (recorded on the 12 anterior teeth only) relating to gingival overgrowth were considered: hyperplastic index and % of sites with probing depth > 3 mm. These parameters were always recorded by the same observer at first appointment and 2 months after an oral hygiene programme. Both non parametric statistical analysis (Kruskal-Wallis one-way analysis by rank, Wicoxon signed rank-test and Mann Whitney U-test) and parametric analysis (stepwise multiple regression analysis, one-sample and two-sample t-test) were used to investigate the relationship between the periodontal parameters (dependent variables) and a series of independent variables: age, sex, plaque index (PI), gingival index (GI), CsA dose, CsA blood level, duration of therapy (months since allograft). Results failed to demonstrate any significant correlation between gingival overgrowth and age, sex, CsA dose or CsA blood level, PI. A positive significant correlation was found between periodontal conditions and GI and a significant inverse correlation between periodontal conditions and duration of therapy, suggesting that the relation between CsA therapy and gingival overgrowth in heart-transplant patients could be time-related and the negative influence of the drug on the periodontal status could spontaneously decrease over time.

Human papillomavirus in a patient with severe gingival overgrowth associated with cyclosporine therapy. A case report

Cyclosporin a is an endecapeptide that has been used clinically since 1978 as an immunosuppressant agent. Although cyclosporine appears to be uniformly beneficial in the treatment of a wide variety of disorders, its use may result in a number of side effects. One of the most important adverse effects is gingival overgrowth. This report relates a case of severe gingival overgrowth in a 31-year-old female who had received cyclosporine therapy in conjunction with a kidney transplant. Because of the severe gingival overgrowth, we analyzed a biopsy, which was positive for human papillomavirus. The case was treated and followed for 18 months.

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 periodontal problems and management of the renal transplant patient

This review considers the periodontal problems of renal transplant patients with particular reference to their drug therapy and the pretransplant uremia. It would appear that either disease- or drug-induced immunosuppression affords the renal transplant patient a degree of "protection" against periodontal breakdown. However, of more significance to the periodontologist is the problem of drug-induced gingival overgrowth with reference to both cyclosporin and nifedipine. Approximately 30% of dentate renal transplant patients medicated with cyclosporin alone experience significant gingival overgrowth which requires surgical excision. This figure increases to 40% when patients are medicated with both drugs. The pathogenesis of this unwanted effect is uncertain and the relationship between the expression of gingival overgrowth and various periodontal or pharmacokinetic variables remains a contentious issue. Clinical measures to prevent the occurrence of either cyclosporin- or nifedipine-induced gingival overgrowth are unsatisfactory.

Clinical and histological evaluation of ligature-induced periodontal breakdown in domestic ferrets immunosuppressed by Cyclosporin-A

The aim of this study was to evaluate, clinically and histologically, the effect of Cyclosporin-A (CyA) on the progression of the periodontal breakdown in the domestic ferret, using the ligature induced periodontitis model. At the start of the experiment (day 0), silk ligatures were placed at the gingival margin level of experimental teeth. The contralateral teeth served as non-ligated control teeth. Clinical measurements included gingival index, probing pocket depth (PPD), probing attachment level (PAL) and gingival overgrowth (GO) and they were performed on days 0, 14 and 28. Cyclosporin-A, 10 mg/kg/d, was given subcutaneously from day 0 to 21, while in the last week there was a reduction of this dose to 5 mg/kg/d. Blood samples were taken on days 0, 14 and 28. On day 28 the animals were sacrificed. Histological sections were prepared for light microscopy. The histometric measurements performed were: (1) the distance between cemento-enamel junction and the alveolar bone crest and (2) loss of connective tissue attachment. The number of sections with root resorption areas was observed. Cell counts were taken in 4 different areas. The results showed, on days 14 and 28, a significant increase of the mean values of PPD and PAL at experimental teeth as compared to the control teeth. GO was present on experimental teeth on days 14 and 28. On day 28, the control teeth presented a very small increase in GO, mainly at the buccal sites of P4 and M1. The histometric results showed a significant loss of attachment and bone resorption in the experimental teeth. Root resorption was found in experimental teeth only. The predominant inflammatory cell in the 4 experimental areas was polymorphonuclears.(ABSTRACT TRUNCATED AT 250 WORDS)

Levels of cyclosporin-A (CsA) in saliva in children after oral administration of the drug in mixture or in capsule form

The cyclosporin-A (CsA) level in human unstimulated whole saliva was studied in 5 children, aged 9-16 yr, receiving the immunosuppressive drug CsA following renal allograft transplantation. The time-concentration relationship of CsA in saliva was determined in the children who were taking the drug orally in mixture form (n = 3) as well as in capsule form (n = 3). For the mixture, the median maximal level of CsA in whole saliva was 2867 ng/ml compared to 5.4 ng/ml for the capsule. The oral mucosal exposure of CsA during the dosage interval was approximately 130 times higher when the drug was administered in mixture form than in capsule form. The study demonstrates that gingival tissue is exposed to a considerable concentration of CsA throughout the dosage interval in patients taking CsA in mixture form. Therefore the vehicle in which the drug is administered should be considered in the pathogenesis of CsA-induced gingival overgrowth.

Biochemical and immunohistochemical studies on overgrown gingival tissues associated with mannosidosis

The gingival tissues of a male patient suffering from mannosidosis and presenting with gingival overgrowth have been studied. Routine histological assessment highlighted the presence of highly enlarged and vacuolated lymphocytes. The morphology of the connective tissues, fibroblasts and epithelium appeared normal. Immunohistochemical staining of the tissues for chondroitin sulfate proteoglycan demonstrated a normal distribution of this component throughout the connective tissues and intense staining associated with the vacuolated lymphocytes. In vitro studies indicated that fibroblasts isolated from the overgrown tissue did not differ from age and sex matched control fibroblasts with respect to proliferation, protein and proteoglycan synthesis. Taken together, these findings imply that the gingvial overgrowth noted in this patient was not due to a defect in the resident fibroblasts but rather reflected a secondary response to the tissues to impaired host defence mechanisms.

Influence of cyclosporine A on growth and extracellular matrix synthesis of human fibroblasts

Cyclosporine A (CyA) is a powerful nonsteroidal immunosuppressive agent used to prevent graft rejection of organ and bone marrow transplants. A major side effect observed can be attributed to the fibroblast and its functions: proliferation of fibroblasts and formation of fibrotic tissue in the gingiva (fibrous hyperplasia) and in the kidney are induced. The mechanism of both is still obscure. In order to elucidate whether these side effects are due to the drug acting on human fibroblasts itself or whether they are indirect ones mediated by factors released by lymphocytes, cultures of human gingiva fibroblasts were exposed to CyA under defined in vitro conditions. Incubation with CyA for 72 hours resulted in a dose-dependent stimulation of DNA synthesis, whereas glycosaminoglycan (GAG) synthesis was slightly suppressed. Long-term incubation (6 weeks) with 1 micrograms/ml CyA resulted again in stimulation of growth parameters: compared to the drug-free control, cell number increased to 168%, incorporation of 3H-thymidine into DNA to 143%, and overall protein content to 159%. Collagen and GAG synthesis were elevated to approximately 120%. When corrected for cell number or cell protein content, this represents a decline in matrix synthesis, comparable to short-term incubations. These results indicate that a direct effect of CyA on proliferation of human gingival fibroblasts is responsible for some of the observed hyperplasia.

The effect of cyclosporin and lipopolysaccharide on fibroblasts: implications for cyclosporin-induced gingival overgrowth

Drug-induced gingival overgrowth is an adverse side effect associated principally with 3 different types of drugs; specifically the antiepileptic phenytoin, the calcium channel antagonist nifedipine, and the immunosuppressant cyclosporin. The present study has analyzed the effect of cyclosporin and lipopolysaccharide on fibroblasts from 3 different sources: 1) normal healthy human gingiva (NHGF); 2) overgrown gingiva from 2 patients taking cyclosporin (CHGF); and 3) human fetal lung (WI-38). Fibroblasts isolated from cyclosporin-associated gingival overgrowth were significantly less responsive to cyclosporin in terms of DNA, total protein, and proteoglycan synthesis. This finding supports the in vivo response where few fibroblasts are seen but marked overgrowth of fibrous tissue occurs. Lipopolysaccharide derived from Fusobacterium nucleatum and Escherichia coli was capable of inhibiting DNA synthesis significantly in all 3 fibroblast types. Total protein synthesis by CHGF cells was inhibited differentially by Fusobacterium nucleatum LPS and addition of cyclosporin to this system resulted in reversal of the inhibition. A synergistic effect was noted when the proteoglycan output of NHGF cells was assessed in response to co-incubation with cyclosporin and Escherichia coli LPS. The study shows that bacterial LPS may be an important co-factor in the pathogenesis of cyclosporin-induced gingival overgrowth.

Cyclosporin-A increases type I procollagen production and mRNA level in human gingival fibroblasts in vitro

In order to study the pathogenesis of gingival overgrowth induced by the immunosuppressive drug cyclosporine-A (CyA), we investigated its effect on 3H thymidine incorporation and on collagen production and mRNA levels in fibroblast cultures obtained from normal human gingiva. At concentrations of 100, 500 and 1000 ng/ml, CyA did not modify thymidine incorporation after 24 and 72 h of incubation. However, after 24 h it significantly increased the level of 3H proline-containing proteins in the medium. In addition, CyA increased alpha-procollagen chains by up to three times. This CyA-induced change was related to a rise in the level of type I procollagen. The CyA effect on fibroblasts was markedly reduced by cycloheximide, an inhibitor of protein synthesis, and it correlated well with an increase of type I procollagen mRNA. Overall, our data indicate a direct stimulatory action of CyA on collagen synthesis, but not on DNA synthesis, in human gingival fibroblasts.

Resolution of cyclosporin A (CsA)-induced gingival enlargement following reduction in CsA dosage

Gingival enlargement due to the immunosuppressive drug, cyclosporin A (CsA), will resolve following discontinuation of drug therapy or extraction of adjacent teeth. This report presents a clinical observation on a patient in whom CsA-induced gingival enlargement failed to resolve with improved plaque control and scaling, but resolved quickly following reduction in the daily dosage of CsA. Despite less than optimal plaque control, the CsA-induced gingival enlargement did not recur on the reduced drug dosage over a 2-year observation period. This finding raises the possibility that reduction of CsA dosage below a certain critical level may lead to resolution of CsA-induced gingival enlargement.

Cyclosporin and the gingival tissues

Cyclosporin is a selective immunosuppressant that has a variety of applications in medical practice. Like phenytoin and the calcium channel blockers, the drug is associated with gingival overgrowth. This review considers the pharmacokinetics, pharmacodynamics, uses and unwanted effects of cyclosporin, in particular the action of the drug on the gingival tissues. Clinical and cell culture studies suggest that the mechanism of gingival overgrowth is a result of an interaction between the drug and its metabolites with susceptible gingival fibroblasts. Plaque-induced gingival inflammation appears to enhance this interaction.

Fibroblast heterogeneity in collagenolytic response to cyclosporine

To investigate the mechanism of cyclosporine (CS)-induced fibrotic gingival enlargement, the effect of CS on the collagenolytic activities of 14 different human gingival fibroblast strains derived from healthy individuals with non-inflammed gingiva was examined in vitro. There was marked heterogeneity among individuals in basal levels of collagenase activity, and there was also variation among the subpopulations derived from one strain. Fibroblasts from different individuals also varied markedly in their collagenolytic response to CS (0.1 to 0.75 micrograms/ml). In most strains, CS decreased collagenase activity, but in some, the drug caused no change or significantly increased activities. In most of the subpopulations CS significantly decreased collagenolytic activity. Two of the fibroblasts strains and the subpopulations described above were examined for the production of immunoreactive collagenase and tissue inhibitor of metalloproteinase (TIMP). The two strains made similar amounts of collagenase, but differed markedly in TIMP levels; CS affected their collagenase production differently but had similar effects on TIMP. Among the subpopulations there was variation in the production of collagenase, although none made detectable levels of TIMP; they also varied in the production of both proteins in response to CS. In two of the subpopulations and in both strains at some concentrations, the effect of CS on the relative levels of collagenase and TIMP could account for the decreased collagenase activity; i.e., the level of collagenase was unchanged or decreased, and TIMP production was unchanged or increased. This study demonstrates the variation among individuals as well as intrastrain heterogeneity of human gingival fibroblasts with regard to collagenase activity and the production of collagenase and TIMP. The heterogeneity of the collagenolytic response of different gingival fibroblast strains and their subpopulations to CS treatment may partly explain the susceptibility of only some individuals to CS-induced gingival enlargement.

The effect of a plaque control programme on the incidence and severity of cyclosporin-induced gingival changes

The efficacy of plaque control as a means of preventing cyclosporin-induced gingival overgrowth was assessed in 27 adult renal transplant patients. After baseline examination, patients were randomly allocated to receive intensive oral hygiene instructions, scaling and root planing (OH group) or no treatment (no treatment group). Gingival condition was assessed 6 months after baseline and changes in gingival form were related to various periodontal and pharmacokinetic measures. In both treatment groups, there was a significant increase (P less than 0.05) in gingival hyperplasia scores at 6 months. In the OH group, plaque scores were significantly lower (P less than 0.05) at 6 months, whereas in the no treatment group, a significant increase in plaque scores, gingival inflammation and probing depths was observed at 6 months. Dosages of cyclosporin, whole blood concentrations of cyclosporin, baseline gingival index, hyperplasia scores, and 6-month plaque index were not important determinants for the increase in gingival over-growth in both treatment groups. It is concluded that attention to plaque control and the removal of local irritants is of some benefit for the gingival health of cyclosporin-treated adult renal transplant patients, but these measures alone did not prevent gingival overgrowth. Pharmacokinetic variables of cyclosporin and various periodontal measures were not good predictors of cyclosporin-induced gingival changes.

Interleukin-1 beta- and tumor necrosis factor-alpha-independent monocyte stimulation of fibroblast collagenase activity

To investigate the mechanism of cyclosporine (Cs)-induced fibrous gingival enlargement, the indirect effects of Cs on fibroblast collagenolysis via the drug's effect on the synthesis of the fibroblast regulatory monokines interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF alpha) have been studied. Peripheral blood monocytes stimulated with lipopolysaccharide (LPS) for 48 h produced conditioned media (MCM-LPS) that contained 665 pg/ml IL-1 beta and 16 pg/ml TNF alpha and significantly (P less than 0.001) enhanced the collagenase activity of a fibroblast strain (GN 23) derived from a healthy individual with clinically normal gingiva. The concurrent addition of Cs (50, 100, or 150 ng/ml) with LPS to the monocytes (MCM-LPS-Cs) significantly diminished their ability to enhance GN 23 collagenase activity in a dose-dependent manner, with MCM-LPS-Cs (150 ng/ml) causing the greatest effect. Cs also significantly inhibited IL-1 beta and TNF alpha production. Although the greatest inhibition of both cytokines was at 50 ng/ml Cs, the corresponding MCM-LPS-Cs caused the least diminution (16%) of the collagenase stimulation caused by MCM-LPS (no Cs). This suggested that factor(s) other than or in addition to IL-1 beta and TNF alpha might be responsible for the stimulation of GN 23 collagenase activity. MCM-LPS depleted of IL-1 beta by affinity chromatography retained its stimulatory effect on GN 23 collagenolysis, and human recombinant IL-1 beta and TNF alpha, when tested alone or together at levels found in the stimulatory MCM-LPS and MCM-LPS-Cs, did not stimulate GN 23 collagenase activity as did the crude conditioned media. This evidence suggested that the conditioned media contained the complex mixture of cytokines necessary to stimulate collagenase activity of this fibroblast strain and that IL-1 beta and TNF alpha were not necessarily involved. Cs may alter the synthesis of other collagenase-stimulating cytokines, accounting for the diminished ability of Cs-treated monocytes to enhance collagenase activity of susceptible fibroblast strains. Decreased collagenase activity, therefore, resulting from Cs suppression of monokine production, may be an important factor in the development of fibrous gingival enlargement seen in some susceptible patients treated with Cs.

Immunohistochemical analysis of effects of cyclosporin A on gingival epithelium

Cyclosporin A (CSA)-induced gingival overgrowth was immunohistochemically compared with that phenytoin-induced and nonspecific inflammatory gingiva, and CSA concentration was determined for dental plaque. Leu-6+ epithelial dendric cells (EDC) were found to significantly decrease in number in CSA-induced gingival overgrowth, while the ratio of HLA-DR+ EDC to Leu-6+ EDC did not change significantly. The expression of class II major histocompatibility complex antigens, such as HLA-DR, -DP and -DQ on keratinocytes did not change by CSA-treatment. Leu-4+ mononuclear cells in CSA-induced gingival overgrowth were located primarily in the connective tissue far outside the epithelium. CSA concentration was much higher in dental plaque than in blood and other tissues. Immune response thus appears to be suppressed in the epithelial layer of CSA-induced gingival overgrowth through decrease in Leu-6+ HLA-DR+ EDC and T cell infiltration, both due to CSA in dental plaque. DNA polymerase alpha was detected in much fewer basal keratinocytes of CSA- and phenytoin-induced gingival overgrowth. Epithelial hyperplasia may thus be not due to increased keratinocyte proliferation, but rather to enhanced keratinocyte life span.

Regulation of human gingival fibroblast growth and synthetic activity by cyclosporine-A in vitro

Gingival overgrowth is an adverse side-effect seen in a proportion of patients taking cyclosporin-A which indicates that cyclosporine-A may modulate the activities of cells other than T lymphocytes. Therefore, the effect of cyclosporine on human gingival fibroblasts has been studied in vitro. Cyclosporine-A was found to stimulate DNA synthesis and the proliferative activity of these cells with maximal stimulation noted at a concentration of 10(-9) g/ml. Although this stimulation was most noticeable in the presence of 10% fetal calf serum, proliferation still occurred in serum-free medium. In the presence of lipopolysaccharide, at a concentration which normally inhibits gingival fibroblast proliferation, cyclosporine retained its capacity to stimulate proliferative activity. Fibroblasts isolated from overgrown gingival tissue responded to a greater extent than those isolated from a healthy site from the same individual. This stimulatory effect was not restricted to gingival fibroblasts, since human foreskin fibroblasts responded in a similar fashion. Cyclosporine-A did not significantly alter protein or proteoglycan production by these cells. These responses are considered to reflect the in vivo response of gingival overgrowth in patients taking cyclosporine-A. The reversal of lipopolysaccharide inhibition of gingival fibroblast proliferation by cyclosporine-A may explain, in part, why gingival overgrowth is most prominent in areas of heavy dental plaque accumulation.

Effect of cyclosporine-A on connective tissue deposition in experimental inflammatory lesions

The effect of cyclosporine-A, a potent immunosuppressant, on the development of experimental inflammatory lesions in rats was studied both histologically and biochemically. Continuous treatment with cyclosporine was begun after the implantation of sponges impregnated with heat-killed Mycobacterium tuberculosis and continued for up to 63 days. Cyclosporine-A significantly reduced the numbers of neutrophil polymorphonuclear leukocytes and lymphocytes present during both the acute and chronic phases. In addition, greater amounts of mature fibrous tissue were present in the sponges removed from animals which had been treated with cyclosporine-A. Biochemical analyses of the collagen and glycosaminoglycan content of the sponges at varying times confirmed that cyclosporine-A can influence the deposition of connective tissue macromolecules. These data provide additional evidence that cyclosporine-A affects not only the inflammatory response but also influences subsequent connective tissue metabolism.

Cyclosporin A inhibits directly in vivo keratinocyte proliferation of living human skin

A direct in vivo antiproliferative effect of cyclosporin A (CsA) on human epidermal keratinocytes (EK) grafted onto nude mice was evaluated. Using pulse-labeling of 5-bromo-2'-deoxyuridine (BrdU), a thymidine analogue incorporated into the nuclei of DNA-synthesizing (S-phase) cells, the antiproliferative effect of CsA was revealed as a decrease in the number of BrdU-positive human EK grafted onto nude mice receiving a daily subcutaneous injection of 50 mg/kg of CsA. The blood level of CsA in the treated mice, evaluated by a radioimmunologic assay, was 679 +/- 501 ng/ml (n = 3). Using an antibody to leukocyte common antigen, it was shown that no human lymphocytes were present in the grafted skin. Therefore, this antiproliferative effect of CsA on human EK seems to be due to a direct effect on EK rather than to lymphocyte regulation.

Cyclosporine-induced gingival overgrowth in beagle dogs

Development of gingival overgrowth during daily long-term cyclosporine A treatment was studied in 2-yr-old beagles. Gingival enlargement developed in five of 12 dogs (42%), primarily in the mandibular anterior area. The earliest gingival changes occurred by 3 wk as an increase in the size of the interdental papillae. The lesions progressively became more severe, in some cases obscuring portions of teeth by wk 6. The redundant tissue exhibited an increase in connective tissue components and an inflammatory infiltrate primarily of plasma cells. Severity of the overgrowth varied in responding animals; both incidence and severity were related to the CSA concentration in blood. The mean CSA blood levels of responders were significantly greater than nonresponders at wk 3, 6 and 10. Since beagles develop gingival overgrowth similar to humans, they provide an excellent model to investigate the roles of local and systemic factors in the induction of gingival overgrowth.