Management of periodontal disease in patients using calcium channel blockers - gingival overgrowth, prescribed medications, treatment responses and added treatment costs

Medications Affecting Treatment Outcomes in Dentistry: Part 2

Today, it is common for medically complex patients who are receiving multiple medications, to seek routine and emergent dental care. It is essential for the practitioner to recognize and comprehend the impact of such medications on the patient's ability to tolerate the planned dental treatment and on dental treatment outcomes. An active appraisal of current literature is essential to stay abreast of emerging findings and understand their treatment implications. This article outlines the process of such active critical appraisal, illustrating key paradigms of the models that describe the impact of medications on treatment outcomes.

Non-surgical Treatment of Severe Drug-Influenced Gingival Enlargement: A Report of Two Cases

Drug-influenced gingival enlargement (DIGE) is a well-known adverse drug reaction associated with multiple medications. Although a benign condition, DIGE can have a significant impact on patients' aesthetic comfort and function. A surgical resection approach is usually proposed to treat severe and generalized DIGE. In this report, we describe the cases of a 47-year-old male and a 58-year-old male, both presenting with severe and generalized DIGE associated with amlodipine, a calcium channel blocker used for hypertension treatment. A non-surgical, cause-related approach, including drug substitution and repeated sessions of mechanical instrumentation, led to the complete resolution of severe DIGE, with no recurrence observed after 18 months in Case 1 and 12 months in Case 2. Throughout the observation period, the bleeding on probing score decreased from 100% at baseline to 10% or less, and the number of periodontal sites with probing pocket depth ≥ 5 mm decreased by more than 90% compared to the initial assessment. Both patients reported a high level of satisfaction with the treatment outcomes. These successful results should encourage clinicians to give greater consideration to non-surgical management of DIGE as a less invasive option before proceeding to surgical treatments.

Non-surgical treatment of idiopathic gingival enlargement: A case report

BACKGROUND

Idiopathic gingival enlargement is associated with plaque, but other contributing factors are unclear. The prognosis of idiopathic gingival enlargement is closely related to the patient's oral hygiene habits and regular follow-up.

CASE PRESENTATION

This article reports a case of a 32-year-old male patient with idiopathic gingival enlargement. The patient presented to the department of stomatology with a 2-month history of gingival swelling and pain on the right upper posterior teeth. During the treatment, oral hygiene instruction, supragingival cleaning, subgingival scaling, and root planning were carried out, and part of the hyperplastic gingiva was taken and sent for pathology. Pathological examination showed gingival enlargement with chronic suppurative inflammation. At 4-month follow-up, the patient's periodontal condition remained basically stable, and the gingival enlargement did not recur.

CONCLUSION

The treatment of this case resulted in significant reduction of gingival swelling and patient's pain reduction through non-surgical treatment and good plaque control, indicating that patients with idiopathic gingival enlargement can also achieve ideal results through non-surgical treatment. Through oral hygiene instruction, the patient mastered the method of self-plaque control, which is conducive to the long-term stabilization of the periodontal situation.

A 30-year retrospective cohort outcome study of periodontal treatment of stages III and IV patients in a private practice

AIM

Tooth loss studies show that periodontal treatment is effective. However, it is not known whether these results can be projected into a lifetime of treatment. The aim of the study was to study all patients with stages III/IV of periodontitis over 30 years in a private practice.

MATERIALS AND METHODS

All patients referred between 1986 and 1990 were monitored for 30 years for tooth loss and prognostic factors. All dropouts were accounted for.

RESULTS

In all, 386 patients were followed, of whom 283 patients dropped out, leaving 103 patients (67 females and 36 males, average age 40.1 years) monitored over 30 years. Tooth loss was stable until 16 years, when the population was divided into groups of low (n = 65), moderate (n = 18) and high (n = 20) tooth loss, losing 1.05 (SD 1.27), 4.83 (SD 0.96) and 11.90 (SD 4.25) teeth, respectively. The strongest prognostic factors were first-degree relatives with periodontitis, periodontal treatment before the age of 35 years, diabetes and patients with teeth with initial hopeless prognosis.

CONCLUSION

The majority of patients with stages III and IV periodontitis could be successfully treated with conventional periodontal treatment over a period of 30 years. The findings suggest that retrospective studies with shorter observation times cannot automatically be projected onto the outcome of a lifetime of periodontal treatment.

Calcium Channel Blockers- Induced Iatrogenic Gingival Hyperplasia: Case Series

Hypertension rightfully termed as "Silent killer" is associated with increase in morbidity and mortality when left untreated. Calcium channel blockers are the most commonly prescribed first-line anti-hypertensive drugs in India. Calcium channel blockers are known to cause gingival hyperplasia but with lower incidence rates compared to the other two groups causing iatrogenic gingival overgrowth, immunosuppressants, and anticonvulsants. Nifedipine administration, among the calcium channel blockers, has been frequently associated with iatrogenic gingival hyperplasia. Incidence of amlodipine-induced gingival hyperplasia which has similar pharmacodynamic action like nifedipine, had been reported rarely. Here, we present a case series of drug induced gingival overgrowth caused by calcium channel blockers used for the management of hypertension. All the patient's condition improved after withdrawal of the offending drug, oral prophylaxis and intervention, and alternate drug from other first-line drugs were started for managing hypertension.

Periodontitis in obese adults with and without metabolic syndrome: a cross-sectional study

BACKGROUND

Epidemiological studies support an association between obesity, metabolic syndrome (MetS), and periodontitis. Still, understanding of the effects of low-grade inflammation in obese subjects on periodontitis and influence of MetS remains incomplete. The aims of this cross-sectional study were to explore the association between obesity related variables and periodontitis, and assess if MetS is a risk indicator for periodontitis in a sample of obese adults.

METHODS

The study sample comprised 52 adults with a body mass index (BMI) of ≥ 30 kg/m2 referred for obesity therapy at the Obesity Centre at Haukeland University Hospital (HUH), Bergen, Norway. The subjects had prior to enrolment completed a 5-month lifestyle intervention course as part of a 2-year managing program. According to the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) classification of MetS, 38 subjects were recruited to the MetS group and 14 subjects to the non-MetS group. Medical data including peripheral blood samples were obtained from records at HUH at the time of enrolment. Probing depth, clinical attachment level, tooth mobility, furcation involvement, bleeding on probing (BoP) were recorded and intraoral bitewings evaluated at a full-mouth periodontal examination. Associations between risk variables for obesity/MetS and periodontitis were explored using linear and logistic regression models.

RESULTS

In the present sample 79% of the subjects were diagnosed with periodontitis. The prevalence of stage III/IV periodontitis was 42.9% in the non-MetS group vs. 36.8% in the MetS group (p = 0.200). In the non-MetS group 29.8% of the sites displayed BoP vs. 23.5% in the MetS group (p = 0.048). For stage III/IV periodontitis, the effect of age appeared to be significant for obesity related variables and MetS (p = 0.006, p = 0.002, respectively). None of the other analyses showed significant association with the outcome variables.

CONCLUSION

In the present sample of obese subjects, periodontitis occurred independently of MetS. Reaching a certain BMI level, suggested association between MetS and periodontitis might be non-significant due to the dominating impact of obesity related variables undermining the effect of other systemic factors.

TRIAL REGISTRATION

The principal clinical trial, entitled "Obesity and Oral Diseases", was prospectively registered in ClinicalTrials.gov with registration NCT04602572 (20.10.2020).

Crown Preparation in a Patient with Hypertension and Type 2 Diabetes Mellitus

Management of the diabetic dental patient should focus on the delivery of comprehensive dental care with an emphasis on maintaining periodontal health. Gingivitis, periodontitis, and associated bone loss independent of plaque accumulation are associated with poorly controlled diabetes. Periodontal status should be monitored carefully in patients with diabetes and underlying disease managed aggressively. Likewise, the dental team plays an important role in the identification of hypertension and managing dental-related side effects of anti-hypertensives.

The PTEN hamartoma tumor syndrome: how oral clinicians may save lives

INTRODUCTION

Patients with the PTEN hamartoma tumor syndrome (PHTS) have an 81%-90% cumulative lifetime risk of developing cancer. Around 90% of these patients have recognizable oral features. Receiving a diagnosis may save these patients' lives. This is the first presentation of a family with the PHTS diagnosis with focus on the oral and periodontal findings and treatments.

CASE PRESENTATION

All three children (one son and two daughters) inherited the same heterozygous variant in the PTEN gene from their father. Gingival overgrowth was observed in all patients in addition to macrocephaly. Other findings included fissured tongue, high arched palate, papules, and trichilemmomas. The father had experienced severe tooth loss. Surgery was performed to treat the gingival overgrowth and periodontal pockets; however, the treatment was characterized by multiple recurrences of the overgrowth.

CONCLUSIONS

Oral changes, macrocephaly, tumors, and/or a family history of benign or malignant lesions are important features that oral clinicians should be aware of for a possible PHTS diagnosis. Patients suspected of having PHTS should be referred to a medical practitioner, specifically a geneticist, for further diagnostic investigations. The periodontal problems seemed to be difficult to control for these patients. They will likely need an active and frequent maintenance therapy to control the persistent inflammation and gingival overgrowth. In addition, they need a thorough monitoring for benign or malignant changes in the orofacial regions. Why are these cases new information? Oral features are found in 90% of the cases with the PHTS diagnosis. The periodontal findings showed a persistent recurrence of gingival overgrowth with a strong probability of serious periodontal diseases. What are the keys to successful management of these cases? A suspicion of a PHTS diagnosis with a referral to a medical practitioner, specifically a geneticist, for complete workup may help save these patients' lives. Close monitoring during maintenance therapy with re-treatment as needed to prevent further periodontal complications. Continued monitoring and treatment throughout the patient's lifetime for development of recurrent or new, benign or malignant lesions at relevant sites. What are the primary limitations to success in these cases? A failure to identify the PHTS syndrome with the accompanying oral and periodontal complications. Complications may lead to a delay in appropriate treatment. Inability to control the persistent gingival overgrowth and a deteriorating periodontal condition. A failure to discover benign and malignant lesions in the orofacial region.

Bibliometric analysis of research trends and characteristics of drug-induced gingival overgrowth

Objectives

Drug-induced gingival overgrowth (DIGO) is a frequent adverse medication reaction that is generally caused by cyclosporine, phenytoin, and nifedipine, which belong to the category of immunosuppressants, anticonvulsants, and calcium channel blockers, respectively. This bibliometric analysis aims to depict the main citation characteristics and analyze the research trends in DIGO investigations.

Methods

An exhaustive search was performed in the Scopus database to create the bibliometric list of DIGO in the syntax. Furthermore, the information related to the number of citations, drugs related to DIGO, study topic and design, authorship, publication year, journal, contributing institution, country of origin, and the department was extracted.

Results

In total, 399 papers on DIGO were retrieved in this study. The total number of citations and that after the removal of self-citations were 7,814 and 7,314, respectively. The mean number of citations was 19.6 in a range of 0-608. The main paper types were articles (76.94%) and reviews (19.55%). A remarkable increasing trend in the number of citations has been observed since 1994. Cyclosporine (44.89%) is the most commonly used drug that shares a close relationship with DIGO, followed by phenytoin (18.22%), nifedipine (17.93%), and amlodipine (6.81%). The review (27.82%) type constituted the most widely used design in the DIGO studies. According to the top 20 keywords, the risk factors and pathogenesis of DIGO have been prominent topics of research works for several years.

Conclusions

This bibliometric analysis will facilitate the understanding of researchers and clinicians, especially those at the beginning of their careers in periodontology on DIGO, by identifying landmark research and providing an overview of this field.

Periodontal and systemic health of morbidly obese patients eligible for bariatric surgery: a cross-sectional study

Background

In obese patients, periodontitis might be associated with deprived systemic health. Edmonton obesity staging system (EOSS) is a new tool for classification of obesity that considers the metabolic, physical, and psychological health. The cross-sectional study aimed to evaluate the periodontal status of morbidly obese patients eligible for bariatric surgery and the association between periodontitis, obesity-related comorbidities, and EOSS.

Methods

Morbidly obese patients eligible for bariatric surgery underwent detailed periodontal examination and were divided into the periodontitis group (PG) and the non-periodontitis group (NPG). The medical and demographic data were obtained from medical files, while behavioural data were obtained by the interview. Descriptive statistics and simple statistical tests were used to summarise the characteristics of the sample and the differences between PG and NPG. The logistic regression models were used to calculate the association (odds ratio (OR)) between periodontitis and obesity-related diseases and EOSS.

Results

The study included 79 patients, with an average BMI of 44.6 kg/m² (SD = 7.2). The prevalence of periodontitis was 65% (CI 95% 53%-75%). PG patients (n = 51) were older, more often smokers and were more often hypertensive than NPG patients (n = 28) (p < 0.05). Hypertension was positively associated with periodontitis with adjusted OR 3.98 (95% CI 1.23–12.8; p = 0.021)) and age with adjusted OR 1.06, (95% CI 1.01–1.13; p = 0.038)), while other tested conditions (diabetes, dyslipidaemia, and smoking habits) did not show significant association with periodontitis. Periodontitis did not correlate with EOSS or other obesity-related comorbidities (p > 0.05).

Conclusion

The morbidly obese patients eligible for bariatric surgery show a high prevalence of periodontitis and, therefore, are advised to be examined by a dentist before undergoing surgery. They have higher odds of hypertension but not of other obesity-related diseases or higher stages of EOSS. The medical personnel should raise awareness among obese patients on the potential association of poor periodontal health with hypertension.

Trial registration

NCT04653714.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02207-0.

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.

Management of medication-induced gingival hyperplasia: a systematic review

OBJECTIVE

Medication-induced gingival hyperplasia (MIGH) has been linked to several medications, with a reported prevalence ranging between 0.5% and 85%. The aim of this study was to systematically review the management approaches for MIGH and estimate recurrence rate and time to relapse.

STUDY DESIGN

An electronic literature search was conducted using PICO questions (P = patients with medication-induced gingival hyperplasia; I = surgical and/or nonsurgical treatment options; C = no control is required; and O = partial or complete resolution and recurrence) and medical subject heading terms in the PubMed and Web of Science databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol up to December 2019. All English-language articles on MIGH surgical and nonsurgical management options were included. Eligible articles were systematically reviewed and assessed for bias using preset criteria and multiple levels of elimination. Data were extracted from eligible studies and analyzed.

RESULTS

Twenty-two eligible articles were included in this study. Management approaches included discontinuation or change of the offending medication if medically feasible in addition to surgical and nonsurgical interventions. Nonsurgical approach included scaling and root planing, oral hygiene instructions, and antimicrobial mouthrinses. Persistent or relapsed cases had complete resolution with excision of hyperplastic gingiva. Laser-assisted surgeries combined with intensive plaque control measures demonstrated less risk of recurrence.

CONCLUSIONS

Several treatment options for MIGH have been reported with variable outcomes. Duration and size of hyperplastic gingival tissue may have an effect on overall recurrence rate.

Influence of different anti-hypertensive drugs on gingival overgrowth: A cross-sectional study in a Turkish population

OBJECTIVE

The purpose of this study was to evaluate the occurrence rate of drug-induced gingival overgrowth (DIGO) in patients treated with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) such as amlodipine, lercanidipine, and benidipine, as well as to assess the relationship of those mentioned above with medication variables and oral hygiene.

METHODS

Sociodemographic details, DIGO, and clinical periodontal parameters were obtained from one hundred and thirty-one patients receiving ACE inhibitors, ARBs, and CCBs for a period of at least 2 years.

RESULTS

The occurrence rate of DIGO was 19.6% in patients using CCB, 12.5% in the ARB group, and 7.5% in the ACE inhibitor group. In a subgroup analysis of CCBs, DIGO was found to be 31.8% in the amlodipine group, 13.3% in the lercanidipine group, and 7.1% in the benidipine group. While there was a significant relationship between amlodipine drug dosage and DIGO, no association was found between the duration of therapy and DIGO in all CCB subgroups.

CONCLUSION

There was no difference between the groups in terms of DIGO. Duration of therapy and drug dosage did not affect the severity of DIGO in both ACE inhibitors and ARB groups.

The Management of Drug-Influenced Gingival Enlargement

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

Familial tendency as a determinant of tooth loss during long-term periodontal therapy

AIM

Little evidence exists on how familial tendencies affect the long-term success of periodontal therapy. The aim of this study was to compare outcomes for two generations and their control patients treated in the same private practice.

MATERIALS/METHODS

Parents and their children were observed for tooth loss between 1986 and 2017. Matching control groups were identified from the same practice, one for the parent and one for the children group. The control patients had no close family members with a history of periodontal diseases. Both the generations and control groups completed a similar course of periodontal therapy. The matching strategy aimed at making the groups as similar as possible with respect to well-known risk and prognostic factors. The data were analysed by multiple regression where the outcome was the number of teeth lost due to periodontal disease.

RESULTS

A total of 435 patients were identified (148 parents, 154 children and 133 controls). 72 parents and 61 children (133) had more than 5 years follow-up (average 15.5 and 12.9 years, respectively). Balancing tests showed that the matching was successful. 65% of tooth loss was attributable to close family history. The regression showed that the parent generation lost 1.02 more teeth than the controls, while the children lost 0.61 more teeth.

CONCLUSION

Having close family members with a history of periodontal diseases is a strong prognostic factor affecting the long-term outcome of periodontal therapy.

Periodontal complications of prescription and recreational drugs

Drug use for both therapeutic and recreational purposes is very widespread in most societies. The range of drugs used, the variations in response to these drugs and other health and behavioral confounders mean that drug use may be an important contributor to individualized periodontal diagnoses. In this narrative review, we review the main reported effects of drugs on the periodontal tissues and periodontal disease processes. Although some of the more common adverse drug reactions on periodontal tissues are well described, in many other cases the evidence for these drug effects is quite limited and based on small case series or isolated reports. Prescription drugs are responsible for a range of effects, including drug-induced gingival overgrowth and increased gingival bleeding, and influence periodontal inflammation and periodontal breakdown. The effects of recreational drugs on the periodontal tissues is less well researched, perhaps for the obvious reason that assembling large cohorts of recreational drug users presents particular challenges. Use of nearly all of these substances is associated with poorer periodontal and dental health, although there is almost certainly a large degree of behavioral confounding in these findings. Overall, further studies of adverse drug reactions on the periodontal tissues are required as this continues to be an important and increasing factor in periodontal health determination.

The oral health status, behaviours and knowledge of patients with cardiovascular disease in Sydney Australia: a cross-sectional survey

BACKGROUND

Periodontal disease is a risk factor for atherosclerotic cardiovascular disease and it is recommended internationally that patients with cardiovascular disease should engage in preventative oral health practices and attend regular dental care visits. This study aimed to explore the oral health status, behaviours and knowledge of patients with cardiovascular disease.

METHODS

A cross-sectional questionnaire containing 31 items was administered to patients with cardiovascular disease from cardiac rehabilitation and outpatient clinics in Sydney Australia in 2016-2017.

RESULTS

Of the 318 patients surveyed, 81.1% reported having at least one oral health problem. Over a third (41.2%) of participants had not seen a dentist in the preceding 12 months and 10.7% had received any oral healthcare information in the cardiac setting. Those with valvular conditions were more likely to have received information compared to those with other cardiovascular conditions (40.6% versus 7.4%, p < 0.001). Only half of the participants had adequate oral health knowledge.

CONCLUSIONS

Despite a high incidence of reported oral health problems, many patients lacked knowledge about oral health, were not receiving oral health information from cardiac care providers and had difficulty accessing dental services. Further research is needed to develop oral health strategies in this area.

Periodontal disease and FAM20A mutations

Enamel-renal-gingival syndrome (ERGS; OMIM #204690), a rare autosomal recessive disorder caused by mutations in FAM20A, is characterized by nephrocalcinosis, nephrolithiasis, amelogenesis imperfecta, hypoplastic type, gingival fibromatosis and other dental abnormalities, including hypodontia and unerupted teeth with large dental follicles. We report three patients and their families with findings suggestive of ERGS. Mutation analysis of FAM20A was performed in all patients and their family members. Patients with homozygous frameshift and compound heterozygous mutations in FAM20A had typical clinical findings along with periodontitis. The other had a novel homozygous missense mutation in exon 10, mild gingival fibromatosis and renal calcifications. The periodontitis in our patients may be a syndrome component, and similar findings in previous reports suggest more than coincidence. Fam20a is an allosteric activator that increases Fam20c kinase activity. It is hypothesized that lack of FAM20A activation of FAM20C in our patients with FAM20A mutations might have caused amelogenesis imperfecta, abnormal bone remodeling and periodontitis. Nephrocalcinosis appears not to be a consistent finding of the syndrome and the missense mutation may correlate with mild gingival fibromatosis. Here we report three patients with homozygous or compound heterozygous mutations in FAM20A and findings that extend the phenotypic spectrum of this disorder, showing that protein truncation is associated with greater clinical severity.

Using prognostic factors from case series and cohort studies to identify individuals with poor long-term outcomes during periodontal maintenance

BACKGROUND

The accuracy of applying prognostic factors to individual patients is uncertain.

AIM/METHOD

The aim was to apply prognostic factors from several outcome studies (case series and cohort) to identify: (1) patients who lost a tooth/teeth during periodontal maintenance; (2) patients who were non-responding to treatment; (3) patients needing re-treatment during periodontal maintenance. In addition, tooth loss was related to initial prognosis and it was determined which of the prognostic factors were also risk factors. Chi squared analysis was carried out for the outcomes of patients with-, and without prognostic factors. Significance level was set at p ≤ 0.05. Sensitivity and specificity was calculated for patients with and without prognostic factors.

RESULTS

The prognostic factors only identified a small proportion of patients who lost teeth (34-38%). Combining the prognostic factors resulted in a lower accuracy. A higher proportion of patients with no prognostic factors lost teeth (53.8-96.2%). The chance of identifying a non-responding patient based on family history was 5.9%, for stress 32.4%, and for heavy smoking 8.7%. Significantly more patients (29/40 , χ² = 16.2 p < 0.05) with initial uncertain/poor prognosis and significantly fewer patients (11/40, χ² = 16.2, p < 0.05) with erratic/no compliance needing re-treatment were identified. 21 of 40 patients (52.5%) (p = 0.655) with family history needing retreatment were identified. Combining the prognostic factors identified 5-22% out of a total of 40% of patients needing re-treatment. six out of nine (67%) teeth with an initial hopeless prognosis were lost, 10/109 (9%) teeth with a poor prognosis were lost, 11/346 (3%) teeth with a moderate prognosis were lost and 9/1972 (0.46%) of teeth with a good prognosis were lost. None of the prognostic factors was found also to be a risk factor for developing periodontal diseases.

CONCLUSION

Applying prognostic factors to identify individual patients with poor long-term outcomes is associated with low accuracy.

Gingival Enlargement Induced by Felodipine Resolves with a Conventional Periodontal Treatment and Drug Modification

We present a case of a 47-year-old male who suffered from GE around his lower anterior teeth as soon as he started treatment with Felodipine 400 mg. We show that oral hygiene measures, antibiotics, and conventional periodontal treatment (scaling and root planing SRP) were all not sufficient to resolve the drug induced GE, which will persist and/or recur provided that systemic effect of the offending medication is still present. The condition immediately resolved after switching to a different medication. The mechanism of GE is complex and not fully understood yet. It is mainly due to overexpression of a number of growth factors due to high concentrations of calcium ions (Ca²⁺). This affects fibroblasts proliferation and DNA synthesis and leads to a heavy chronic inflammatory cell infiltrate. Our case was managed according to the suggested protocols in previous case studies. The unique features in our case were the immediate onset of the adverse effect after starting the medication and the absence of any underlying medical condition apart from high blood pressure. Improving the oral hygiene together with SRP and cessation of the medication resolves drug induced GE.