Drug-induced gingival hyperplasia: a retrospective study using spontaneous reporting system databases. J Pharm Health Care Sci. 2017;3:19. [PMID: 28729910 PMCID: PMC5518137 DOI: 10.1186/s40780-017-0088-5]

Priapism associated with anti-seizure medications: a pharmacovigilance study and a review of published cases

BACKGROUND

Recently, case reports of priapism associated with the use of some anti-seizure medications began to emerge in the literature. We aimed to investigate if there is a potential safety signal of priapism among individual anti-seizure medications and to search the literature for relevant published cases.

RESEARCH DESIGN AND METHODS

We conducted a disproportionality analysis using OpenVigil 2.1 to query the United States Food and Drug Administration's Adverse Event Reporting System (FAERS) database. Literature search was conducted in PubMed/MEDLINE, Scopus and Web of Science up to 12 July 2023.

RESULTS

We identified positive signal of priapism for valproic acid and its derivatives (n = 23, chi-squared = 59.943, PRR = 4.566), gabapentin (n = 20, chi-squared = 9.790, PRR = 2.060), lamotrigine (n = 16, chi-squared = 8.318, PRR = 2.120), levetiracetam (n = 16, chi-squared = 10.766, PRR = 2.329), topiramate (n = 14, chi-squared = 28.067, PRR = 3.972) and carbamazepine (n = 8, chi-squared = 6.147, PRR = 2.568), as well as published cases of priapism associated with these drugs. We also found published cases of priapism for pregabalin and phenytoin in the literature and FAERS, and at least one reported adverse event of priapism in FAERS for clonazepam, lacosamide, ethosuximide, oxcarbazepine, and vigabatrin in which they were considered primary suspect.

CONCLUSIONS

Our study identified signals for priapism for several anti-seizure medications, but these results need to be confirmed in well-designed pharmacoepidemiological studies.

Cyclosporine-Induced Gingival Hyperplasia in a Patient With Lichen Planopilaris: Misfortunes Never Come Singly!

Cyclosporine A constitutes an immunosuppressive medication administered against various autoimmune and autoinflammatory disorders as well as against graft versus host disease. Its most well-known oral adverse effect is gingival hyperplasia. The aim of this study is to report a persistent case of a patient with lichen planopilaris with alopecia treated with cyclosporine leading to the manifestation of gingival hypertrophy. A female patient aged 38 years old was referred to the Department of Oral Medicine/Pathology, Dental School, Aristotle University of Thessaloniki, Greece complaining about gum bleeding, halitosis, and a persistent gingival enlargement, which appeared two months ago. According to her medical history, lichen planopilaris was diagnosed six months ago and was initially treated for 40 days with methylprednisolone 16 mg twice per day without improvement, and was replaced by cyclosporine A 200 mg per day. The clinical oral examination revealed gingival enlargement at areas #34-43, 22-23, and 25-27 without any lesion of lichen planus. The level of oral hygiene was satisfactory, with a limited amount of tartar and plaque. Bleeding on probing was also noticed, and pseudopockets of 5 mm were observed. The serum levels of cyclosporine were 473,60 μg/L, with a normal range, regarding repercussions in the oral cavity, up to 200 μg/L. A decrease of cyclosporine dosage to 150 mg was performed. After 15 days, the clinical appearance significantly improved, and a biopsy was done. The microscopic findings showed mild ulceration and inflammatory infiltrates, together with the abundant presence of collagen stroma, without any sign of malignancy. According to the literature, the high dosage of cyclosporine, its relevant high serum levels, and the presence of plaque were responsible for the manifestation of gingival hypertrophy.

Drug-Induced Gingival Overgrowth—Molecular Aspects of Drug Actions

Drug-induced gingival overgrowth (DIGO) is one of the side effects produced by therapeutic agents, most commonly phenytoin, nifedipine and cyclosporin A. However, the precise mechanism of DIGO is not entirely understood. A literature search of the MEDLINE/PubMed databases was conducted to identify the mechanisms involved in DIGO. The available information suggests that the pathogenesis of DIGO is multifactorial, but common pathogenic sequelae of events emerge, i.e., sodium and calcium channel antagonism or disturbed intracellular handling of calcium, which finally lead to reductions in intracellular folic acid levels. Disturbed cellular functions, mainly in keratinocytes and fibroblasts, result in increased collagen and glycosaminoglycans accumulation in the extracellular matrix. Dysregulation of collagenase activity, as well as integrins and membrane receptors, are key mechanisms of reduced degradation or excessive synthesis of connective tissue components. This manuscript describes the cellular and molecular factors involved in the epithelial–mesenchymal transition and extracellular matrix remodeling triggered by agents producing DIGO.

Osteonecrosis of the Jaw Caused by Denosumab in Treatment-Naïve and Pre-Treatment with Zoledronic Acid Groups: A Time-to-Onset Study Using the Japanese Adverse Drug Event Report (JADER) Database

BACKGROUND

Medication-related osteonecrosis of the jaw is a serious adverse event associated with bone-modifying agents, such as injectable bisphosphonate (zoledronic acid) and the anti-receptor activator of nuclear factor-κB ligand antibody (denosumab).

OBJECTIVE

This study aims to evaluate and compare the time-to-onset profile for medication-related osteonecrosis of the jaw associated with denosumab between treatment-naïve (naïve group) and pre-treatment with zoledronic acid (post-zoledronic acid group) patients using the Japanese Adverse Drug Event Report database.

METHODS

Medication-related osteonecrosis of the jaw was defined according to the Medical Dictionary for Regulatory Activities. The medication-related osteonecrosis of the jaw onset profiles were evaluated using the Weibull shape parameter and the log-rank test.

RESULTS

The Japanese Adverse Drug Event Report database contains 632,409 reports published between April 2004 and March 2020. In the time-to-onset analysis, after extracting the combinations with complete information for the treatment start date and the medication-related osteonecrosis of the jaw onset date, 272 reports of the naïve group and 86 reports of the post-zoledronic acid group were analyzed. The median onset in the naïve and post-zoledronic acid groups was 487.0 (25-75%: 274.0-690.8) and 305.5 (25-75%: 158.3-508.5) days, respectively. Medication-related osteonecrosis of the jaw occurred earlier in the post-zoledronic acid group than in the naïve group, and the log-rank test demonstrated a significant difference in their time transitions (p < 0.0001).

CONCLUSIONS

The results indicated a risk of medication-related osteonecrosis of the jaw in naïve and post-zoledronic acid groups and a shorter onset time in the latter than in the former. Thus, healthcare professionals should take the early risk of medication-related osteonecrosis of the jaw into account when switching patients from zoledronic acid to denosumab treatment.

Periodontal outcomes of children and adolescents with attention deficit hyperactivity disorder: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to answer the following question: Are children and adolescents with attention deficit hyperactivity disorder (ADHD) more likely to have gingival or periodontal disease-related outcomes than their non-ADHD peers?

METHODS

Searches were conducted in the following databases: Embase, Scopus, Web of Science, and PubMed. Google Scholar and OpenGrey were also verified. Observational studies were included in which children and adolescents with ADHD were compared with their healthy peers in terms of gingival and/or periodontal endpoints. Bias appraisal was performed using the Joann Briggs tool for case-control and cross-sectional studies. Meta-analysis was performed using R language. Results are reported as mean difference (MD) and odds ratio (OR). Statistical analyses were performed in RStudio.

RESULTS

A total of 149 records were identified in the searches. Seven studies were included. The meta-analysis showed that children and adolescents with ADHD had a higher mean gingival bleeding index (percentage) than their non-ADHD peers (MD = 11.25; CI = 0.08-22.41; I² = 73%). There was no difference between groups for plaque index (MD = 4.87; CI = - 2.56 to 12.30; I² = 63%) and gingivitis (OR = 1.42; CI = 0.22-9.21; I² = 76%). Regarding the assessment of risk of bias, the major issue found in the articles was the absence of analyses for the control of confounding factors.

CONCLUSION

Children and adolescents with ADHD had more gingival bleeding than their non-ADHD peers, but no difference regarding plaque or gingivitis was detected between groups.

CLINICAL REGISTRATION

CRD42021258404.

Scurvy presenting primarily as gingival manifestation in a young child: a diagnostic dilemma

Vitamin C deficiency, historically known as scurvy, was associated with sailors in the Victorian times, however, a global review in 2020 suggests it still exists in certain at-risk groups.A case is presented of a young non-verbal child with learning difficulties and on a restricted diet, in which the primary symptom was gingival inflammation. It posed a diagnostic dilemma due to the non-specific symptoms, and a delay in the diagnosis, until vitamin C deficiency was confirmed.Gingival inflammation is one of the common findings in vitamin C deficiency and dental professionals may be the first point of contact. The importance of dietary evaluation, identifying and looking for other signs and liaising with the medical colleagues are discussed.This case highlights the role of the dentist in identifying latent cases of vitamin C deficiency and to consider this as a differential diagnosis especially in certain at-risk groups.

Impact of Immunosuppressive Drugs on Fibroblasts: An In Vitro Study

Background: The aim of this study was to compare the direct impact of different agents for immunosuppressive therapy on mouse fibroblasts as a possible cause of drug-induced gingival overgrowth (DIGO). Methods: 3T3 mouse fibroblasts were cultivated in cell-specific media (2 × 104 cells/mL) and treated for 6, 24, 48 and 72 h with one of three immunosuppressive drugs (IsDs): cyclosporin a (CsA), tacrolimus (TaC) and sirolimus (SiR). Different concentrations (10−750 ng/mL) were used to mimic serum levels under active immunosuppressive therapy conditions. Cell population characteristics (cell number, viability and morphology) were assessed using computer-assisted cell analysis. Expression of pro-collagen type I carboxy-terminal propeptide (PICP) was identified using an ELISA assay. Results: The influence of IsDs on the biological status of 3T3 fibroblasts was time- and dose-dependent. Comparing CsA and TaC, the total cell amount was enhanced using concentrations in the range of 10−150 ng/mL (p > 0.05). In contrast, treatment with SiR resulted in a decrease in the average cell number (p < 0.01). PICP and cell diameter of fibroblasts were not susceptible to IsD treatment (p > 0.05). Conclusions: Our results revealed time-dependent effects of IsDs, with distinct influences on cell number. The cell morphology and the PICP balance of the investigated fibroblast cell line remained unaffected. Hence, the potential role of IsDs is not a unilateral mechanism of action but rather a multifactorial process.

Gabapentinoid-induced peripheral edema and acute heart failure: A translational study combining pharmacovigilance data and in vitro animal experiments

INTRODUCTION

Gabapentinoids are ligands of the α2-δ subunit of voltage-gated calcium channels (Cav) that have been associated with a risk of peripheral edema and acute heart failure in connection with a potentially dual mechanism, vascular and cardiac.

OBJECTIVES & METHODS

All cases of peripheral edema or heart failure involving gabapentin or pregabalin reported to the French Pharmacovigilance Centers between January 1, 1994 and April 30, 2020 were included to describe their onset patterns (e.g., time to onset). Based on these data, we investigated the impact of gabapentinoids on the myogenic tone of rat third-order mesenteric arteries and on the electrophysiological properties of rat ventricular cardiomyocytes.

RESULTS

A total of 58 reports were included (gabapentin n = 5, pregabalin n = 53). The female-to-male ratio was 4:1 and the median age was 77 years (IQR 57-85, range 32-95). The median time to onset were 23 days (IQR 10-54) and 17 days (IQR 3-30) for non-cardiogenic edema and acute heart failure, respectively. Cardiogenic and non-cardiogenic peripheral edema occurred frequently after a dose escalation (27/45, 60%), and the course was rapidly favorable after discontinuation of gabapentinoid (median 7 days, IQR 5-13). On rat mesenteric arteries, gabapentinoids significantly decreased the myogenic tone to the same extent as verapamil and nifedipine. Acute application of gabapentinoids had no significant effect on Ca_v1.2 currents of ventricular cardiomyocytes.

CONCLUSION

Gabapentinoids can cause concentration-dependent peripheral edema of early onset. The primary mechanism of non-cardiogenic peripheral edema is vasodilatory edema secondary to altered myogenic tone, independent of Ca_v1.2 blockade under the experimental conditions tested.

Preventive effect of rebamipide on NSAID-induced lower gastrointestinal tract injury using FAERS and JADER

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for their antipyretic, analgesic, and anti-inflammatory properties. However, various aspects of NSAID-induced lower gastrointestinal tract injury remain unclear, and effective prophylaxis has not been established. Based on its pharmacological effect and clinical trials, rebamipide may prevent lower gastrointestinal tract injury, although this evidence is limited by the small scale of trials. The present study used the FDA Adverse Event Reporting System (FAERS) and the Japanese Adverse Event Reporting Database (JADER) to assess the efficacy of rebamipide in combination with loxoprofen and diclofenac in preventing NSAID-induced lower gastrointestinal tract injury. The calculated reporting odds ratio and 95% confidence interval (CI) for rebamipide in combination with loxoprofen and diclofenac were 1.15 (95% CI 0.88–1.51) and 1.28 (95% CI 0.82–2.01) for FAERS, and 0.50 (95% CI 0.35–0.71) and 0.43 (95% CI 0.27–0.67) for JADER, respectively. No signal was detected when combining drugs. These results suggest a prophylactic effect of rebamipide on NSAID-induced lower gastrointestinal tract injury.

Evaluation of Therapeutic Benefits of a Novel Herbal Ingredient-Based Hyaluronic Acid Gel as Monotherapy for Inflammatory Enlargement of a Patient with Diabetes Mellitus

The reason for the destruction of the attachment apparatus in patients with periodontal disease is the supra- and the subgingival microflora. Hence, the treatment of this inflammatory gingival disease is primarily focused on eliminating the cause. The present case report assessed the therapeutic benefit of adjunctive use of a commercially available topical agent containing 1% hyaluronic acid gel combined with nonsurgical periodontal therapy. A patient aged 64 years with type 2 diabetes mellitus reported to the Department of Periodontology. He complained of gum enlargement and frequent bleeding during brushing. The patient was not under any medication for his diabetes control. On examination, there was a localized papillary gingival enlargement. Therefore, Klirich gel containing hyaluronic acid was applied on the surface of the gingiva during the first visit of the patient. During the follow-up visit, he continued with this adjunctive use of the gel along with the nonsurgical periodontal therapy. In addition, he controlled his blood sugar level with diet and exercise. During the follow-up visit after one year, there was a noticeable clinical change in the overall health of his gingiva.

Prescription patterns and dosages of antiepileptic drugs in prevalent patients with epilepsy in Taiwan: A nationwide retrospective cross-sectional study

OBJECTIVE

To evaluate the prescription patterns and prescribed daily dose (PDD)/defined daily dose (DDD) ratios of antiepileptic drugs (AEDs) in prevalent patients with epilepsy in Taiwan.

MATERIALS AND METHODS

A nationwide retrospective cross-sectional study was conducted for prevalent patients with epilepsy in 2016 using the Taiwanese National Health Insurance Research Database. The prescription records of AEDs of all prevalent patients with epilepsy were retrieved. The mean PDDs and PDD/DDD ratios of AEDs in adult patients were obtained to evaluate dosing adequacy. A chi-square test and two-sample t test were used to analyze the differences in AED prescription patterns and dosages, respectively, among patients with different ages, sexes, comorbidities, and therapeutic approaches.

RESULTS

A total of 118,937 prevalent patients with epilepsy were enrolled. The predominant therapeutic approach was monotherapy, especially in the elder adults, accounting for 82.9% of elder adult patients with epilepsy. The proportion of AED monotherapy was higher in patients with dementia (78.9%) and stroke (80.6%). The top three antiepileptic monotherapies were valproic acid (28.7%), levetiracetam (19.1%), and phenytoin (16.9%); however, oxcarbazepine (22.8%) was substituted for carbamazepine (3.9%) as monotherapy for patients aged 0-17 years. Among adult patients with epilepsy, the PDD/DDD ratio of each AED in monotherapy was less than 1.00. The mean PDD of each AED was higher in polytherapy than in monotherapy (p < 0.01), except for lacosamide. The mean PDDs of all evaluated AEDs in monotherapy were lower in elder adult patients than in younger adult patients, most of which reached statistical significance (p < 0.001).

CONCLUSIONS

In Taiwan, valproic acid was the most prescribed AED for prevalent patients with epilepsy. The mean PDDs of most AEDs were lower than the DDDs developed by the World Health Organization.

Descriptive analysis of reported adverse events associated with anti-obesity medications using FDA Adverse Event Reporting System (FAERS) databases 2013-2020

Background Obesity is a globally growing health problem, and its treatment has been challenging. The use of anti-obesity medications (AOMs) has been associated with severe adverse events (AEs). Several AOMs have been withdrawn from the market owing to documented AEs. Aim To describe, estimate and characterize the frequency of AEs attributable to the use of the AOMs, and investigate previously unreported potential AEs associated with AOMs. Method Using the US FDA Adverse Event Reporting System (FAERS) between January 2013 and June 2020, a retrospective, descriptive analysis was conducted to analyze all major reported AEs and outcomes including death, life-threatening, hospitalization, disability, and required intervention or congenital anomaly. The total numbers of AEs reports, cases, adverse reactions and outcomes were calculated for each medication. Results A total of 18,675 unique AEs reports associated with AOMs used for 15,143 patients. The mean age was 49.8 years [SD 1.83], while most patients were female adults (73.4%). The most frequently reported AEs were nausea and vomiting, followed by dizziness and headache, drug ineffectiveness, cardiovascular diseases, and kidney complications. There were 21,229 unique outcomes, including 1039 deaths (fatality ratio of 4.9% of all analyzed reports), 1613 (7.6%) life-threatening events, 7426 (35%) hospitalizations, and 1249 (5.9%) disability cases. Phentermine/topiramate fatal cases represent 6% of the overall medication's reported AEs. Cardiovascular AEs represented 31%, 23%, and 22% of phentermine, liraglutide, and phentermine/topiramate total AEs, respectively. Conclusion The analysis of FAERS database revealed numerous serious AEs associated with AOMs. These AEs can lead to serious cardiovascular and kidney complications. It is necessary to continue and systematically monitor safety of AOMs' to optimize patient anti-obesity therapy.

Dental implications of some commonly prescribed medicines

Several medicines can have an impact on oral health or have implications for dental treatment. It is important that general dental practitioners review the medicines that their patients are taking and consider their potential impact. In this article we highlight some of the medicines or groups of medicines that can affect dental treatment and oral health.

Systemic medicines taken by adult special care dental patients and implications for the management of their care

Introduction Significant changes have taken place in the profile of prescription medicines being taken by the adult UK population over the last decade. The aims of this article are to review the literature to understand the overall trends and underlying factors, and then to compare this with the medication profile of a cohort of adult special care dental (SCD) patients. Materials and method Five hundred patient records were examined and retrospective data on systemic medicines being taken were obtained and classified according to the index used in the British National Formulary (BNF).Results The results revealed a high level of polypharmacy with 57% of SCD patients taking three or more medicines compared to 24% of the population in England. Antiepileptic drugs were the most frequently taken group of medicines (42%), followed by antidepressants (39.7%) and antipsychotics (37.6%). Conclusions Our results demonstrate the medical complexity of patients in this cohort and enable clinicians to increase their familiarity with the most commonly taken medicines and the tools available to manage the implications for dental care.

Evaluation of antibiotic-induced taste and smell disorders using the FDA adverse event reporting system database

Adverse effects can occur owing to anorexia, which can reduce treatment compliance and worsen the patients overall condition. One such side effect, namely drug-induced taste and smell disorders, reduces patients quality of life. Although antibiotics can cause taste and smell disorders, a few studies have examined antibiotic-induced taste and smell disorders. Therefore, this study comprehensively analyzed the relationship between taste and smell disorders and antibiotic usage. The side effects of antibiotics were investigated using the FDA Adverse Event Reporting System database (FAERS). The reporting odds ratios between the listed drugs and taste and smell disorders P values were comprehensively calculated. Adjusted odds ratios were calculated to account for patient background. Furthermore, to clarify the feature of this adverse effect, shape parameters indicating the expression pattern were calculated. Signals that induced taste and smell disorders were detected for six antibiotics, including drugs for which this event is not described in the package insert in Japan. Multiple logistic regression analysis suggested an association of taste and smell disorders with gender, hypertension, mental disorder, and cancer. The median time to onset of antibiotic-induced taste and smell disorders was 2–5 days. Six antibiotics could be analyzed, and four of these drugs matched those with detected signals. Our study supported previous findings on gender and age. Furthermore, antibiotic-induced taste and smell disorders are likely to develop in the early stage of treatment. For these reasons, it is important to remember the risk of developing of taste and smell disorders when administering antibiotics. In addition, it is recommended that the patient be monitored carefully for at least 1 week before initiating treatment, and the patients course should be followed for at least 2 months.

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.

Gingival overgrowth induced by anticonvulsant drugs: A cross-sectional study on epileptic patients

OBJECTIVE

Our aim was to estimate the prevalence of gingival overgrowth (hyperplasia) and to determine whether active molecules affect the severity of overgrowth in a group of epileptic patients.

BACKGROUND

The effects of phenytoin on oral health have been explored in different studies, yet little information is available on other antiepileptic drugs.

METHODS

Data were collected from 213 subjects of both sexes, from 5 to 80 years. Patients taking the same antiepileptic therapy for at least 1 year and meeting the inclusion criteria of the study (n = 162) were subjected to measurement of gingival overgrowth according to the modified Harris and Ewalt classification and O'Leary's plaque control record (OLR). Descriptive statistics were calculated. Data were analyzed using Pearson's r correlation coefficient and chi-square test. Significance level was set at 5%.

RESULTS

The active drugs lamotrigine, oxcarbazepine, and phenobarbital were significantly associated with gingival overgrowth in 61%, 71%, and 53% of cases, respectively, and phenytoin, valproic acid, and carbamazepine in 50%, 44%, and 32% of cases, respectively.

CONCLUSION

Different antiepileptic molecules may be related to gingival overgrowth. In addition to phenytoin, also lamotrigine, oxcarbazepine, and phenobarbital were associated with increased prevalence of gingival overgrowth. In the management of epileptic patients, dentists should take into account different drugs as possible causes for gingival overgrowth and warn for possible alternatives.

Assessment of Reye's syndrome profile with data from the US Food and Drug Administration Adverse Event Reporting System and the Japanese Adverse Drug Event Report databases using the disproportionality analysis

Objectives:

Reye’s syndrome is a rare and potentially fatal illness that is defined as encephalopathy accompanied by liver failure. The aim of this study was to assess Reye’s syndrome profiles by analyzing data from the spontaneous reporting system database.

Methods:

We analyzed reports of Reye’s syndrome using the US Food and Drug Administration Adverse Event Reporting System and the Japanese Adverse Drug Event Report databases. The reporting odds ratio and proportional reporting rate were used to detect the pharmacovigilance signal.

Results:

The US Food and Drug Administration Adverse Event Reporting System contains 12,201,620 reports from January 2004 to June 2020, of which 186 are on Reye’s syndrome. The Japanese Adverse Drug Event Report contains 646,779 reports from April 2004 to September 2020, of which 30 are on Reye’s syndrome. In the US Food and Drug Administration Adverse Event Reporting System database, the reporting odds ratios (95% confidence interval, number of cases) of aspirin, diclofenac, ibuprofen, acetaminophen, and valproate sodium were 404.6 (302.6–541.0, n = 80), 15.1 (6.7–34.1, n = 6), 26.2 (16.1–42.6, n = 18), 10.7 (5.5–20.9, n = 9), and 47.1 (26.2–84.6, n = 12), respectively. In the Japanese Adverse Drug Event Report database, the reporting odds ratios (95% confidence interval, number of cases) of aspirin, diclofenac, ibuprofen, loxoprofen, acetaminophen, and valproate sodium were 14.1 (5.4–36.8, n = 5), 51.7 (22.2–120.5, n = 7), 135.0 (40.8–446.2, n = 3), 17.6 (6.7–46.0, n = 5), 24.0 (9.2–62.6, n = 5), and 13.8 (3.3–57.9, n = 2), respectively. The reported number of female patients aged 30–39 years was the highest in the Japanese Adverse Drug Event Report.

Conclusion:

Although the frequency of the occurrence of Reye’s syndrome is low, the possible risk of the disease occurring in adult females should be considered.

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.

Drug-Induced Gingival Overgrowth: A Pilot Study on the Effect of Diphenylhydantoin and Gabapentin on Human Gingival Fibroblasts

INTRODUCTION

The administration of several classes of drugs can lead to the onset of gingival overgrowth: anticonvulsants, immunosuppressants, and calcium channel blockers. Among the anticonvulsants, the main drug associated with gingival overgrowth is diphenylhydantoin.

MATERIALS AND METHODS

In this study, we compared the effects of diphenylhydantoin and gabapentin on 57 genes belonging to the "Extracellular Matrix and Adhesion Molecule" pathway, present in human fibroblasts of healthy volunteers.

RESULTS

Both molecules induce the same gene expression profile in fibroblasts as well as a significant upregulation of genes involved in extracellular matrix deposition like COL4A1, ITGA7, and LAMB3. The two treatments also induced a significant downregulation of genes involved in the expression of extracellular matrix metalloproteases like MMP11, MMP15, MMP16, MMP24, and transmembrane receptor ITGB4.

CONCLUSIONS

Data recorded in our study confirmed the hypothesis of a direct action of these drugs at the periodontium level, inducing an increase in matrix production, a reduction in its degradation, and consequently resulting in gingival hyperplasia.

Analysis of immune-related adverse events caused by immune checkpoint inhibitors using the Japanese Adverse Drug Event Report database

PURPOSE

The aim of our study was to characterize the clinical features of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs) in a real-world setting using the Japanese Adverse Drug Event Report (JADER) database.

METHODS

The irAEs were defined using the preferred terms of the Medical Dictionary for Regulatory Activities. irAEs were categorized as follows: adrenal insufficiency, colitis, eye diseases, hematological disorder, hepatitis, hyperthyroidism, hypopituitarism, hypothyroidism, myasthenia gravis, myocarditis, nephritis/renal dysfunction, pneumonitis, rash, and type 1 diabetes mellitus. We used several indices such as reporting odds ratio (ROR) to assess disproportionality in pharmacovigilance data, time-to-onset analysis using Weibull shape parameters, and the association rule mining technique to evaluate possible risk factors between variables in the spontaneous reporting system database.

RESULTS

The JADER database contained 534 688 reports from April 2004 to June 2018. The RORs of pneumonitis including interstitial lung disease for nivolumab, pembrolizumab, and ipilimumab were 7.02 (95% confidence interval: 6.55-7.52), 9.08 (8.28-9.97), and 1.74 (1.27-2.38), respectively. The median onsets (quartiles, 25-75%) of myocarditis caused by nivolumab and pembrolizumab were 28.0 (15.5-60.5) and 18.0 (13.0-44.5) days, respectively. Co-therapy with nivolumab and ipilimumab may be associated with irAEs in several categories as per the association rule mining analysis.

CONCLUSION

Our results demonstrated a potential risk of irAEs associated with ICIs, based on RORs and time-to-onset analysis. Furthermore, our findings indicated that patients receiving nivolumab and ipilimumab as co-therapy should be carefully monitored.

Drug-Induced Gingival Overgrowth: The Effect of Cyclosporin A and Mycophenolate Mophetil on Human Gingival Fibroblasts

Drug-induced gingival overgrowth may occur after a chronic administration of three classes of systemic drugs: Anticonvulsants, immunosuppressants, and calcium channel blockers. This study aimed to investigate how cyclosporin A and mycophenolate mophetil (immunosuppressive drugs) could interfere with human gingival fibroblasts functions, leading to gingival enlargement. Human gingival fibroblasts derived from the tissue of a 60-year-old female were cultured in a DMEME medium. A stock solution with 1 mg/mL of mycophenolate and 1 mg/mL of cyclosporine were prepared and dissolved in a DMEM medium to prepare a serial dilution at the concentrations of 5000, 2000, 1000, 500, and 100 ng/mL, for both treatments. Cell viability was measured using the PrestoBlue™ Reagent Protocol. Quantitative real-time RT-PCR was performed in order to analyze the expression of 57 genes coding for gingival fibroblasts "Extracellular Matrix and Adhesion Molecules". Mycophenolate and cyclosporine had no effect on fibroblast cell viability at 1000 ng/mL. Both the treatments showed similar effects on the expression profiling of treated cells: Downregulation of most extracellular matrix metalloproteases genes (MMP8, MMP11, MMP15, MMP16, MMP24) was assessed, while CDH1, ITGA2, ITGA7, LAMB3, MMP12, and MMP13 were recorded to be upregulated in fibroblasts treated with immunosuppressive drugs. It has been demonstrated that gingival overgrowth can be caused by the chronic administration of cyclosporin A and mycophenolate mophetil. However, given the contrasting data of literature, further investigations are needed, making clear the possible effects of immunosuppressive drugs on fibroblasts.

Reactive bite-related tongue lesions in cognitively impaired epilepsy patients: A report of two cases

AIM

Tongue bites frequently occur during seizures in epilepsy patients. We report two cases of cognitively impaired Lennox-Gastaut syndrome patients with reactive lesions on the tongues.

CASE PRESENTATIONS

Case 1 was a 30-year-old man whose chief complaint was mouth pain. Local finding was a small bean-sized pedunculated mass on the tongue, histopathologically diagnosed as inflammatory fibrous hyperplasia. Case 2 was a 45-year-old man whose chief complaint was bleeding from the mouth. His clinical finding was blood loss anemia. Local finding was a 20-mm-diameter pedunculated mass on the tongue, histopathologically diagnosed as pyogenic granuloma.

CONCLUSION

These mass lesions were believed to be reactive, caused by repetitive minor damage involving reparative fibrous tissue response. Therefore, the two cases may have involved reparative responses to mucosal injury incurred by accidental bites during epileptic seizures. Intellectual disability made medical treatment difficult and had allowed the massive lesions to form. It is necessary for cognitively impaired epilepsy patients to undergo regular dental examinations in order to get used to dental checks and to increase the number of intraoral observations in the context of close cooperation between dentists and epilepsy therapists.

Association between periodontitis and systemic medication intake: A case-control study

BACKGROUND

To investigate the frequency of systemic drugs taken by elderly patients with or without periodontitis and the possible association between medication consumption and the severity of periodontitis.

METHODS

A total of 1221 patients, including 608 with generalized moderate to severe periodontitis (periodontitis group) and 613 age- and gender-matched individuals with healthy periodontium (healthy group) were selected. Systemic conditions, medications and periodontal status were recorded. Medication intake frequency (%) was compared using unconditional logistic regression.

RESULTS

The top three most common medications were angiotensin-converting enzyme (ACE) inhibitors (17.9%), antidepressants (17.8%), and lipid-lowering medications (16.5%). Both ACE inhibitors and antidepressants showed statistically higher intake frequency in the periodontitis group relative to healthy controls (21.5% versus 14.4%; odds ratio [OR] = 1.64), (21.1% versus 14.5%, OR = 1.57) (P < 0.01). Additionally, intake of oral hypoglycemic agents, calcium channel blockers (CCB), insulin, and diuretics were significantly higher in the periodontitis group with OR = 2.49, 2.32, 2.08 and 1.79, respectively (P < 0.05). Several medications demonstrated a disease severity-dependent association comparing generalized severe periodontitis with moderate periodontitis and healthy group: oral hypoglycemic agents (17.4% versus 16.8% versus 8.0%), CCB (14.8% versus 14.4% versus 8.0%) and anticonvulsants (13.4% versus 7.7% versus 6.4%) with OR of 2.43, 1.99, and 2.28 (severe periodontitis versus healthy group), respectively.

CONCLUSION

There was a significantly higher frequency of medication intake related to cardiovascular disease and diabetes in patients with periodontitis. A disease severity-dependence with medication intake frequency was also noted. This study provides indirect evidence for the possible relationship between systemic diseases and periodontitis.

Systemic disease or periodontal disease? Distinguishing causes of gingival inflammation: a guide for dental practitioners. Part 2: cancer related, infective, and other causes of gingival pathology

Periodontitis and gingivitis are highly prevalent inflammatory diseases of the oral cavity, and typically are characterised by the presence of dental plaque. However, other causes of oral inflammation exist, which can resemble plaque-induced gingivitis and periodontitis, and may thus first be seen by a dental practitioner. This paper aims to provide dentists with an understanding of the manifestations of systemic diseases to the periodontium and highlights anamnestic and clinical clues important for distinguishing between plaque-induced and non plaque-induced lesions. In the first part of this series immune-mediated and hereditary conditions as causes of gingival lesions were discussed; this second part highlights cancer-related gingival lesions as well as those caused by specific pathogens, medication or malnutrition. A clear clinical, epidemiological and visual overview of the different conditions is provided. Early diagnosis of non plaque-related causes of gingival lesions can be vital for affected patients. Therefore, dental practitioners should be aware of the various manifestations of systemic diseases to the periodontium.

Evaluation of anti-infective-related Clostridium difficile-associated colitis using the Japanese Adverse Drug Event Report database

Clostridium difficile-associated colitis (CDAC) may cause gastrointestinal illness, ranging in severity from mild diarrhea to fulminant colitis and even mortality. The purpose of this study was to evaluate anti-infective-related CDAC profiles using the Japanese Adverse Drug Event Report (JADER) database. Methods: We selected case reports of adverse events of CDAC as specified in the Medical Dictionary for Regulatory Activities. The association between the number of administered anti-infectives and aging was evaluated using reporting odds ratio (ROR) and adjusted for covariates using multiple-logistic regression. We also evaluated anti-infective-related CDAC-onset profiles using Weibull shape parameter. Results: The JADER database contained 534 688 reports from April 2004 to June 2018. There were 1222 anti-infective related CDAC events. The top five anti-infectives were as follows: third-generation cephalosporins (Anatomical Therapeutic Chemical (ATC) code: J01DD, 313 cases), fluoroquinolones (ATC code: J01MA, 201 cases), macrolides (ATC code: J01FA, 146 cases), carbapenems (ATC code: J01DH, 143 cases), and penicillins with extended spectrum (ATC code: J01CA, 103 cases). The adjusted RORs (95% confidence interval) in individuals using 1, 2, and ≥ 3 anti-infectives were 8.88 (7.05-11.18), 9.77 (6.89-13.86), and 18.39 (11.85-28.54), respectively. Moreover, 47.2% of CDACs occurred within 7 days of anti-infective therapy initiation. The adjusted ROR of interaction terms of ≥ 70 years × 1 drug was 21.81 (14.56-32.68). Conclusion: Our results suggest that the number of administered anti-infectives and patient age are associated with CDAC. These data may be particularly beneficial to prescribers and would contribute to improving the management of CDAC.

Analysis of drug-induced hearing loss by using a spontaneous reporting system database

Many drugs can cause hearing loss, leading to sensorineural deafness. The aim of this study was to evaluate the risk of drug-induced hearing loss (DIHL) by using the Japanese Adverse Drug Event Report (JADER) database and to obtain profiles of DIHL onset in clinical settings. We relied on the Medical Dictionary for Regulatory Activities preferred terms and standardized queries, and calculated the reporting odds ratios (RORs). Furthermore, we applied multivariate logistic regression analysis, association rule mining, and time-to-onset analysis using Weibull proportional hazard models. Of 534688 reports recorded in the JADER database from April 2004 to June 2018, adverse event signals were detected for platinum compounds, sulfonamides (plain) (loop diuretics), interferons, ribavirin, other aminoglycosides, papillomavirus vaccines, drugs used in erectile dysfunction, vancomycin, erythromycin, and pancuronium by determining RORs. The RORs of other aminoglycosides, other quaternary ammonium compounds, drugs used in erectile dysfunction, and sulfonamides (plain) were 29.4 (22.4–38.6), 18.5 (11.2–30.6), 15.4 (10.6–22.5), and 12.6 (10.0–16.0), respectively. High lift score was observed for patients with congenital diaphragmatic hernia treated with pancuronium using association rule mining. The median durations (interquartile range) for DIHL due to platinum compounds, sulfonamides (plain), interferons, antivirals for treatment of hepatitis C virus (HCV) infections, other aminoglycosides, carboxamide derivatives, macrolides, and pneumococcal vaccines were 25.5 (7.5–111.3), 80.5 (4.5–143.0), 64.0 (14.0–132.0), 53.0 (9.0–121.0), 11.0 (3.0–26.8), 1.5 (0.3–11.5), 3.5 (1.3–6.8), and 2.0 (1.0–4.5), respectively. Our results demonstrated potential risks associated with several drugs based on their RORs. We recommend to closely monitor patients treated with aminoglycosides for DIHL for at least two weeks. Moreover, individuals receiving platinum compounds, sulfonamides (plain), interferons, and antivirals for HCV infection therapy should be carefully observed for DIHL for at least several months.

Pharmacovigilance Assessment of Drug-Induced Acute Pancreatitis Using a Spontaneous Reporting Database

Background:

Acute pancreatitis (AP) is associated with risks of morbidity and mortality. The incidence of AP recently increased compared to that traditionally reported in the literature.

Objective:

The purpose of this study was to evaluate the possible association between AP and drugs using the Japanese Adverse Drug Event Report (JADER) database, which is a spontaneous reporting database of adverse drug events.

Methods:

Adverse event reports submitted to the JADER database between 2004 and 2017 were analyzed. Disproportionality analysis was performed by calculating the reporting odds ratio (ROR) with 95% confidence intervals for signal detection.

Results:

A total of 3,443 reports (0.17% of all adverse events) were identified as drug-induced AP, in which 431 different drugs were involved. Acute pancreatitis was frequently reported in men (58.5%) in their 60s (19.1%); 40.6% developed AP within 4 weeks after the treatment. Among the most frequently reported drugs, signals were detected for prednisolone, ribavirin, sitagliptin, mesalazine, tacrolimus, and l-asparaginase, which are well-known causes of AP. Telaprevir, donepezil, and ustekinumab also generated signals. As for drugs with high RORs, l-asparaginase and alogliptin were noteworthy.

Conclusion:

Most of the identified drugs were already known to induce AP, but the likelihood of the reporting of AP varied among the drugs. Our results should raise physicians’ awareness of drugs associated with AP, but further investigation of these medications is warranted.

Amlodipine-induced gingival enlargement: A case report

Gingival enlargements (GEs) can be caused by local, systemic diseases or drugs. Three molecules can be responsible of GEs: ciclosporin, phenytoin and calcium channel blockers (CCBs). We report the case of a 56-year-old male treated by Amlodipine, a CCB, for hypertension for many years and who recently developed a severe GE affecting both mandibular and maxillary arches inducing dental malposition. The histological examination showed non-specific inflammation with a predominance of lymphocytes. Amlodipine was suspected and suspended in agreement with his physician. One month later, the enlargement significantly reduced but GE was so severe and dental malposition so marked that all the teeth but the canines were extracted. No recurrence was noted one year later. This exceptional case should encourage every practitioner to be vigilant with patient treated with CCBs and their potential side effects and consequences.

Periodontal Management of Cyclosporin A-Induced Gingival Overgrowth: A Nonsurgical Approach

Gingival overgrowth is a major and frequent unwanted effect accompanying the chronic usage of antihypertensive, anticonvulsant, and immunosuppressant drugs. The expression and the severity of this tissue-specific condition are influenced by a variety of factors, mainly drug and periodontal variables. Such increased volume of gingiva may compromise normal oral functions, aesthetics in addition to the patients' ability to practice optimal oral hygiene. The management of gingival overgrowth includes nonsurgical approach, surgical approach, or both of them for severe cases of gingival overgrowth as well as drug withdrawal. This case report illustrates a successful nonsurgical management of a 21-year-old patient with cyclosporin A-induced gingival overgrowth who experienced a total regression of the gingival enlargement without any surgical procedure or drug substitution. And it highlights therefore the key role of supportive periodontal therapy in maintaining good and stable outcomes over 2 years of follow-up.

Evaluation of medication-related osteonecrosis of the jaw using the Japanese Adverse Drug Event Report database

Background

Bisphosphonates (BPs) and denosumab are widely used to treat osteoporosis and complications associated with bone metastases. However, medication-related osteonecrosis of the jaw (MRONJ) is a serious problem.

Objective

The objective of this study was to evaluate the frequency, outcome, and characteristics of patients with drug-induced MRONJ.

Methods

Retrospective pharmacovigilance disproportionality analysis was conducted using the Japanese Adverse Drug Event Report (JADER) database from the Pharmaceuticals and Medical Devices Agency. Adverse event reports submitted to JADER between 2004 and 2017 were analyzed, and the reporting odds ratio (ROR) was calculated.

Results

Among the BPs that cause MRONJ, zoledronate was the most common; therefore, we compared the characteristics of cases of MRONJ induced by zoledronate with those induced by denosumab. Among the 3,875 (68.1% women) cases of MRONJ, zoledronate-related MRONJ accounted for 1,283 (56.0% women) and denosumab-related MRONJ accounted for 322 (55.3% women). MRONJ was more frequent after 70 years of age regardless of the use of either zoledronate or denosumab; onset occurred after 1 year from the denosumab treatment, but it is unknown when onset occurred after zoledronate treatment. The outcomes for MRONJ were poor, with 406 reports on zoledronate (31.6%) and 152 reports on denosumab (47.2%) demonstrating nonrecovery. Zoledronate (ROR: 319.3, 95% CI: 296.0–344.4) had the highest ROR among BP agents. Denosumab had a high ROR (ROR: 155.2, 95% CI: 136.5–176.3). Zoledronate and denosumab were used in similar patient backgrounds, and their use resulted in a similar frequency of MRONJ.

Conclusion

The findings of this comprehensive evaluation of MRONJ using the JADER database will be helpful for prescribing medications to elderly patients.

Analysis of fall-related adverse events among older adults using the Japanese Adverse Drug Event Report (JADER) database

Background

Falls are a common but serious problem in older adults, and may lead to fractures and bleeding. As many factors, such as medication, aging, and comorbid diseases may simultaneously affect fall-related adverse events (AEs) in older adults, we evaluated the association between fall-related AEs and the use of medication, aging, and comorbid diseases using the Japanese Adverse Drug Event Report (JADER) database.

Methods

We analyzed reports of fall-related AEs associated with α-blockers, diuretics, calcium channel blockers, central nervous system (CNS)-active drugs (opioids, benzodiazepines, hypnotics and sedatives, non-selective monoamine reuptake inhibitors, and selective serotonin reuptake inhibitors (SSRI)) in the JADER database using the reporting odds ratio (ROR). For the definition of falls, we used the Preferred Terms of The Medical Dictionary for Regulatory Activities (MedDRA). We used the association rule mining technique to discover undetected associations, such as potential risk factors.

Results

The JADER database comprised 430,587 reports between April 2004 and November 2016. The RORs (95% CI) of α-blockers, diuretics, calcium channel blockers, opioids, benzodiazepines, hypnotics and sedatives, non-selective monoamine reuptake inhibitors, and SSRIs were 1.63 (1.27–2.09), 0.74 (0.63–0.86), 1.26 (1.15–1.38), 0.93 (0.80–1.07), 1.83 (1.68–2.01), 1.55 (1.12–2.14), 2.31 (1.82–2.95), and 2.86 (2.49–3.29), respectively. From the lift value in the association rule mining, the number of administered CNS-active drugs and patient age were associated with fall-related AEs. Furthermore, the scores of lift for patients with herpes zoster administered calcium channel blockers or benzodiazepines and patients with dementia administered benzodiazepines were high.

Conclusion

Our results suggest that the number of administered CNS-active drugs and patient age are both associated with fall-related AEs. We recommend that patients with herpes zoster treated with calcium channel blockers and benzodiazepines be closely monitored for fall-related AEs.

Unexpected sequel to silver fluoride followed by stannous fluoride treatment of root stumps supporting an overlay denture in an aged-care patient

An institutionalized high care dementia patient, who is unable to maintain his own oral health, presented with five lower anterior carious root stumps supporting a lower overlay denture. Due to limited cooperation, his root stumps were treated with only silver fluoride followed by stannous fluoride applied topically on a 4-monthly cycle. Almost one and a half years after his initial application, there were unexpected calculus formations on the root stumps accompanied by marked gingival inflammation and gingival hyperplasia. At this point prognosis was considered very poor. Because the patient's cooperation was so poor, no attempt was made to remove the calculus deposits. Following continued topical applications directly to the area, there was evidence of a marked and unexpected improvement in gingival health. Some 4 years and 4 months after the initial application, the root stumps demonstrated a hard glossy surface surrounded by healthy gingival tissue. There had been no change in the patient's oral care, minor changes to medications and there had been no operative or periodontal interventions.

Analysis of adverse events of renal impairment related to platinum-based compounds using the Japanese Adverse Drug Event Report database

Objectives:

Platinum compounds cause several adverse events, such as nephrotoxicity, gastrointestinal toxicity, myelosuppression, ototoxicity, and neurotoxicity. We evaluated the incidence of renal impairment as adverse events are related to the administration of platinum compounds using the Japanese Adverse Drug Event Report database.

Methods:

We analyzed adverse events associated with the use of platinum compounds reported from April 2004 to November 2016. The reporting odds ratio at 95% confidence interval was used to detect the signal for each renal impairment incidence. We evaluated the time-to-onset profile of renal impairment and assessed the hazard type using Weibull shape parameter and used the applied association rule mining technique to discover undetected relationships such as possible risk factor.

Results:

In total, 430,587 reports in the Japanese Adverse Drug Event Report database were analyzed. The reporting odds ratios (95% confidence interval) for renal impairment resulting from the use of cisplatin, oxaliplatin, carboplatin, and nedaplatin were 2.7 (2.5–3.0), 0.6 (0.5–0.7), 0.8 (0.7–1.0), and 1.3 (0.8–2.1), respectively. The lower limit of the reporting odds ratio (95% confidence interval) for cisplatin was >1. The median (lower–upper quartile) onset time of renal impairment following the use of platinum-based compounds was 6.0–8.0 days. The Weibull shape parameter β and 95% confidence interval upper limit of oxaliplatin were <1. In the association rule mining, the score of lift for patients who were treated with cisplatin and co-administered furosemide, loxoprofen, or pemetrexed was high. Similarly, the scores for patients with hypertension or diabetes mellitus were high.

Conclusion:

Our findings suggest a potential risk of renal impairment during cisplatin use in real-world setting. The present findings demonstrate that the incidence of renal impairment following cisplatin use should be closely monitored when patients are hypertensive or diabetic, or when they are co-administered furosemide, loxoprofen, or pemetrexed. In addition, healthcare professionals should closely assess a patient’s background prior to treatment.