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

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

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

Management of Cyclosporine-Influenced Gingival Enlargement With Azithromycin

INTRODUCTION

Management of drug-influenced gingival enlargement is challenging, and surgery is most often indicated. However, because of a unique mechanism of action, azithromycin helps in the management of gingival enlargement caused by cyclosporine. An incidental observation of the effect of azithromycin in the cyclosporine-influenced gingival enlargement by physicians in 1995 led to series of basic investigations and clinical trials confirming this observation and providing a non-surgical treatment modality.

CASE PRESENTATION

In this report, successful management of cyclosporine-influenced gingival enlargement in a 39-year-old renal transplant patient with the use of azithromycin without any surgical intervention is presented.

CONCLUSION

Use of azithromycin for managing cyclosporine-influenced gingival enlargement is a useful alternative or adjunct to surgical management. It is hoped that this report will raise further awareness of this non-surgical modality in patients taking cyclosporine.

The miR-3940-5p inhibits cell proliferation of gingival mesenchymal stem cells

OBJECTIVES

Drug-induced gingival overgrowth (DIGO) is a well-recognized side effect of nifedipine (NIF). However, the molecular mechanisms of DIGO are still unknown. Here, we explored the possible role of miR-3940-5p in DIGO using NIF-treated gingival mesenchymal stem cells (GMSCs).

MATERIAL AND METHODS

CFSE and cell cycle assays were used to examine cell proliferation. The alkaline phosphatase (ALP) activity assay, Alizarin Red staining, quantitative calcium analysis, and osteogenesis-related gene expression were used to examine osteo/dentinogenic differentiation.

RESULTS

The CFSE assay showed that NIF enhanced cell proliferation, and the over-expression of miR-3940-5p inhibited the proliferation of GMSCs with or without NIF stimulation. Cell cycle assays revealed that the cell cycle was arrested at the G0/G1 phase. Furthermore, it was found that the over-expression of miR-3940-5p upregulated p15^INK4b , p18^INK4c , p19^INK4d , and Cyclin A and downregulated Cyclin E in GMSCs with or without NIF treatment. In addition, the over-expression of miR-3940-5p enhanced ALP activity and mineralization in vitro and increased the expression of the osteo/dentinogenic differentiation markers DSPP and DMP1 and the key transcription factor DLX5 in GMSCs.

CONCLUSIONS

miR-3940-5p inhibited cell proliferation, enhanced the osteo/dentinogenic differentiation of GMSCs, and might play a role in DIGO as a potent agent in the treatment of nifedipine-induced gingival overgrowth.

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 inductive effects of different concentrations of cyclosporine A on MMP-1, MMP-2, MMP-3, TIMP-1, and TIMP-2 in fetal and adult human gingival fibroblasts

Background The etiology of gingival overgrowth due to cyclosporine A (CsA) is still unknown. The aim of this study was to determine the possible role of matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) on extra-cellular matrix (ECM) homeostasis when treated with different levels of CsA and its difference between fetal and adult human gingival fibroblasts (HGFs). Methods Each group of cells (adult and fetal) was cultured in 40 wells that consisted of four different CsA treatment concentrations. Every 10 wells were treated with 0, 50, 100, and 150 ng/mL of CsA which makes a total of 80 wells. Supernatants of every well were used to determine the concentration of MMPs and TIMPs using the Elisa kits from Boster, CA, USA. Results MMP-1 level increased with the treatment of CsA when treated with 50 and 150 ng/mL of CsA (p = 0.02 and p = 0.04) as TIMP-1 decreased (p < 0.0001) in adult group; while in the fetal group, TIMP-1 level increased with treatment of 150 ng/mL (p < 0.0001). MMP-2 level increased in both adult and fetal groups (p < 0.0001). MMP-3 level decreased in adult group (p < 0.0001) but went up in fetal HGFs (p = 0.01) when treated with 150 ng/mL CsA. TIMP-2 level increased in all wells significantly when treated with CsA (p < 0.0001). The study showed that CsA affects secretion of MMPs and TIMPs. MMP-1 increment and TIMP-1 decrement were observed, which indicate more degradation of ECM. This may be due to single donor use in this study. TIMP-2 and MMP-2 were both more active when treated with CsA which may be due to the gelatinase activity of them and that in CsA gingival overgrowth. There was more inflammation rather than fibrosis.

Connective Tissue Metabolism and Gingival Overgrowth

Gingival overgrowth occurs mainly as a result of certain anti-seizure, immunosuppressive, or antihypertensive drug therapies. Excess gingival tissues impede oral function and are disfiguring. Effective oral hygiene is compromised in the presence of gingival overgrowth, and it is now recognized that this may have negative implications for the systemic health of affected patients. Recent studies indicate that cytokine balances are abnormal in drug-induced forms of gingival overgrowth. Data supporting molecular and cellular characteristics that distinguish different forms of gingival overgrowth are summarized, and aspects of gingival fibroblast extracellular matrix metabolism that are unique to gingival tissues and cells are reviewed. Abnormal cytokine balances derived principally from lymphocytes and macrophages, and unique aspects of gingival extracellular matrix metabolism, are elements of a working model presented to facilitate our gaining a better understanding of mechanisms and of the tissue specificity of gingival overgrowth.

Gingival fibromatosis: clinical, molecular and therapeutic issues

Gingival fibromatosis is a rare and heterogeneous group of disorders that develop as slowly progressive, local or diffuse enlargements within marginal and attached gingiva or interdental papilla. In severe cases, the excess tissue may cover the crowns of the teeth, thus causing functional, esthetic, and periodontal problems, such as bone loss and bleeding, due to the presence of pseudopockets and plaque accumulation. It affects both genders equally. Hereditary, drug-induced, and idiopathic gingival overgrowth have been reported. Hereditary gingival fibromatosis can occur as an isolated condition or as part of a genetic syndrome. The pathologic manifestation of gingival fibromatosis comprises excessive accumulation of extracellular matrix proteins, of which collagen type I is the most prominent example. Mutation in the Son-of-Sevenless-1 gene has been suggested as one possible etiological cause of isolated (non-syndromic) hereditary gingival fibromatosis, but mutations in other genes are also likely to be involved, given the heterogeneity of this condition. The most attractive concept of mechanism for drug-induced gingival overgrowth is epithelial-to-mesenchymal transition, a process in which interactions between gingival cells and the extracellular matrix are weakened as epithelial cells transdifferentiate into fibrogenic fibroblast-like cells. The diagnosis is mainly made on the basis of the patient's history and clinical features, and on histopathological evaluation of affected gingiva. Early diagnosis is important, mostly to exclude oral malignancy. Differential diagnosis comprises all pathologies in the mouth with excessive gingival overgrowth. Hereditary gingival fibromatosis may present as an autosomal-dominant or less commonly autosomal-recessive mode of inheritance. If a systemic disease or syndrome is suspected, the patient is directed to a geneticist for additional clinical examination and specialized diagnostic tests. Treatments vary according to the type of overgrowth and the extent of disease progression, thus, scaling of teeth is sufficient in mild cases, while in severe cases surgical intervention is required. Prognosis is precarious and the risk of recurrence exists.

Molecular and clinical aspects of drug-induced gingival overgrowth

Drug-induced gingival overgrowth is a tissue-specific condition and is estimated to affect approximately one million North Americans. Lesions occur principally as side-effects from phenytoin, nifedipine, or ciclosporin therapy in approximately half of the people who take these agents. Due to new indications for these drugs, their use continues to grow. Here, we review the molecular and cellular characteristics of human gingival overgrowth lesions and highlight how they differ considerably as a function of the causative drug. Analyses of molecular signaling pathways in cultured human gingival fibroblasts have provided evidence for their unique aspects compared with fibroblasts from the lung and kidney. These findings provide insights into both the basis for tissue specificity and into possible therapeutic opportunities which are reviewed here. Although ciclosporin-induced gingival overgrowth lesions exhibit principally the presence of inflammation and little fibrosis, nifedipine- and especially phenytoin-induced lesions are highly fibrotic. The increased expression of markers of gingival fibrosis, particularly CCN2 [also known as connective tissue growth factor (CTGF)], markers of epithelial to mesenchymal transition, and more recently periostin and members of the lysyl oxidase family of enzymes have been documented in phenytoin or nifedipine lesions. Some oral fibrotic conditions such as leukoplakia and oral submucous fibrosis, after subsequent additional genetic damage, can develop into oral cancer. Since many pathways are shared, the study of gingival fibrosis and comparisons with characteristics and molecular drivers of oral cancer would likely enhance understandings and functional roles of molecular drivers of these oral pathologies.

Phenytoin-induced gingival overgrowth management with periodontal treatment

Phenytoin-induced gingival overgrowth (PIGO) is a common complication of the continuous use of medications. This paper presents a case of PIGO hindering oral function and compromising oral hygiene and aesthetics, which was treated with a combination of nonsurgical and surgical periodontal therapies. A 39-year-old male patient was referred for dental treatment with several complaints, especially upper and lower gingival overgrowth that hindered speech and swallowing. Generalized deep probing pockets and bone loss were detected. Diagnosis of gingival overgrowth associated with phenytoin and chronic periodontitis was established. The treatment plan consisted of conservative therapy with education on oral health, motivation and meticulous oral hygiene instruction in combination with scaling and root planing. During the revaluation period, a marked reduction in the clinical parameters was noted, particularly probing pocket depth reduction. Surgical therapy for removal of gingival overgrowth was also performed to achieve pocket reduction. Supportive periodontal therapy was proposed and the patient is currently under follow-up for 4 years. Management of PIGO may be obtained by the use of periodontal procedures combined with good oral hygiene and periodontal supportive care.

Effect of adjunctive roxithromycin therapy on interleukin-1β, transforming growth factor-β1 and vascular endothelial growth factor in gingival crevicular fluid of cyclosporine A-treated patients with gingival overgrowth

BACKGROUND AND OBJECTIVE

Systemic macrolide antibiotic administration has been shown to result in the elimination or reduction cyclosporine A-induced gingival overgrowth. Roxithromycin (ROX) is known to have anti-inflammatory, immunomodulatory and tissue reparative effects. This study was to evaluate the effect of adjunctive ROX therapy on cyclosporine A-induced gingival overgrowth and interleukin (IL)-1β, transforming growth factor (TGF)-β1 and vascular endothelial growth factor (VEGF) levels in gingival crevicular fluid of renal transplant patients.

MATERIAL AND METHODS

Thirty-one patients with clinically significant overgrowth and 16 periodontally healthy subjects were included in this randomized, double-blind, placebo-controlled, parallel-arm study. Patients received scaling and root planing (SRP) at baseline and randomized to take either ROX or placebo for 5 d. The clinical parameters, including plaque index, papillary bleeding index, probing depth and gingival overgrowth scores, were recorded. The amounts of IL-1β, TGF-β1 and VEGF in gingival crevicular fluid were detected by ELISA. Periodontal parameters as well as gingival crevicular fluid biomarker levels were evaluated at baseline and at 1 and 4 wk post-therapy.

RESULTS

Following SRP plus ROX and SRP plus placebo therapy, significant improvements in clinical periodontal parameters of both study groups were observed (p < 0.025). In the ROX group, adjunctive ROX therapy resulted in a greater gingival overgrowth scores reduction compared with those in the placebo group at 4 wk (p < 0.017). Initial amounts of IL-1β, TGF-β1 and VEGF for both the ROX and placebo groups were significantly higher than those for healthy subjects (p < 0.017), with no statistical difference between the two study groups. At 1 and 4 wk post-therapy, significant decreases in the amounts of IL-1β, TGF-β1 and VEGF were observed in both study groups when compared with baseline (p < 0.025), but there was no difference in the levels of IL-1β and VEGF between the two study groups. The amount of decrease in TGF-β1 levels for the ROX group was statistically significant compared to that for the placebo group at 4 wk after treatment (p < 0.017).

CONCLUSION

Our study indicated that combination of ROX with non-surgical therapy improves gingival overgrowth status and decreases gingival crevicular fluid TGF-β1 levels in patients with severe gingival overgrowth. The reduction of gingival crevicular fluid TGF-β1 following ROX therapy suggests an anti-inflammatory/immunomodulatory effect of ROX on the treatment of cyclosporine A-induced gingival overgrowth.

Requirement for active glycogen synthase kinase-3β in TGF-β1 upregulation of connective tissue growth factor (CCN2/CTGF) levels in human gingival fibroblasts

Connective tissue growth factor (CCN2/CTGF) mediates transforming growth factor-β (TGF-β)-induced fibrosis. Drug-induced gingival overgrowth is tissue specific. Here the role of the phosphoinositol 3-kinase (PI3K) pathway in mediating TGF-β1-stimulated CCN2/CTGF expression in primary human adult gingival fibroblasts and human adult lung fibroblasts was compared. Data indicate that PI3K inhibitors attenuate upregulation of TGF-β1-induced CCN2/CTGF expression in human gingival fibroblasts independent of reducing JNK MAP kinase activation. Pharmacologic inhibitors and small interfering (si)RNA-mediated knockdown studies indicate that calcium-dependent isoforms and an atypical isoform of protein kinase C (PKC-δ) do not mediate TGF-β1-stimulated CCN2/CTGF expression in gingival fibroblasts. As glycogen synthase kinase-3β (GSK-3β) can undergo phosphorylation by the PI3K/pathway, the effects of GSK-3β inhibitor kenpaullone and siRNA knockdown were investigated. Data in gingival fibroblasts indicate that kenpaullone attenuates TGF-β1-mediated CCN2/CTGF expression. Activation of the Wnt canonical pathways with Wnt3a, which inhibits GSK-3β, similarly inhibits TGF-β1-stimulated CCN2/CTGF expression. In contrast, inhibition of GSK-3β by Wnt3a does not inhibit, but modestly stimulates, CCN2/CTGF levels in primary human adult lung fibroblasts and is β-catenin dependent, consistent with previous studies performed in other cell models. These data identify a novel pathway in gingival fibroblasts in which inhibition of GSK-3β attenuates CCN2/CTGF expression. In adult lung fibroblasts inhibition of GSK-3β modestly stimulates TGF-β1-regulated CCN2/CTGF expression. These studies have potential clinical relevance to the tissue specificity of drug-induced gingival overgrowth.

Periodontal management of a patient with severe aplastic anemia: a case report

This article describes the periodontal management of a patient with severe aplastic anemia. A 51-year-old female patient was hospitalized with aplastic anemia and was referred for the management of her cyclosporine-induced gingival enlargement and bleeding from her gums. She also complained of pain in the palatal area and the mandibular anterior region. The patient was managed successfully with supra- and subgingival instrumentation, local drug delivery (LDD), electrosurgery, repeated oral hygiene instruction, and constant supervision. The treatment resulted in dramatic improvement in the patient's oral health and quality of life. This report highlights the importance of nonsurgical therapy followed by electrosurgery for the management of residual gingival enlargement.

Comparison of Azithromycin and Oral Hygiene Program in the Treatment of Cyclosporine-Induced Gingival Hyperplasia

BACKGROUND

It has been shown that azithromycin improves cyclosporine-induced gingival hyperplasia (GH), but its efficacy was never compared against an efficient oral hygiene program (OHP). The aim of this study was to analyze the effects of azithromycin plus OHP versus OHP alone in patients with cyclosporine-induced GH.

METHODS

After periodontal evaluation, 20 renal transplant recipients received detailed oral hygiene instructions and a complete OHP, and were randomized to control (OHP) or azithromycin groups (OHP plus azithromycin). Patients were re-evaluated after 15 and 30 days. Both groups were similar in time after transplant, age, gender, cyclosporine dose, and cyclosporine through level and serum creatinine. The control group had fewer patients using calcium cannel blockers (10% vs. 70%, p = 0.02).

RESULTS

All patients improved in pain, halitosis, and gum bleeding after OHP. The control group did not improve plaque index (PI) or GH. In contrast, baseline PI decreased from 1.52 +/- 0.28 to 0.50 +/- 0.16 on day 15 (p < 0.01) and to 0.46 +/- 0.14 on day 30 (p < 0.01) in the azithromycin group, and the GH score decreased from 1.9 +/- 0.27 to 0.90 +/- 0.27 on day 15 (p < 0.05) and to 0.70 +/- 0.21 on day 30 (p < 0.01).

CONCLUSION

Azithromycin associated to efficient OHP induced a striking reduction in cyclosporine-induced GH, while efficient OHP alone improved oral symptoms but did not decrease cyclosporine-induced GH.

Non-surgical treatment of gingival overgrowth induced by nifedipine: a case report on an elderly patient

Drug-induced gingival overgrowth (DIGO) is a significant problem for periodontologists and this side effect is frequently associated with three particular drugs: phenytoin, cyclosporin A and nifedipine. A case report of gingival overgrowth induced by nifedipine in an elderly patient treated with non-surgical periodontal therapy is described. A 75-year-old male with generalised gingival overgrowth reported the problem of oral malodour and significant gingival bleeding. The medical history revealed a controlled hypertensive state and Cerebral Vascular Accident (CVA) 3 years prior to consultation. The diagnosis was gingival overgrowth associated with nifedipine, no other risk factors being identified. The patient had been taking nifedipine for 18 months, but after the consultation with the patient's doctor, nifedipine was suspended, as the hypertension was controlled. Treatment consisted of meticulous oral hygiene instruction, scaling, root surface instrumentation and prophylaxis. Six months after the first intervention, clinical parameters revealed a significant improvement with a considerable reduction in gingival overgrowth, demonstrating the effect of non-surgical periodontal therapy in severe cases of gingival overgrowth. Non-surgical treatment of DIGO is a far less invasive technique than surgical approaches and has demonstrated an impressively positive treatment response. It should therefore be considered as a first treatment option for DIGO.

Transforming growth factor-beta1 gene expression and cyclosporine A-induced gingival overgrowth: a pilot study

AIMS

The relationship between gingival overgrowth (GO) induced by cyclosporine A (CsA) and transforming growth factor-beta1 (TGF-beta1) remains unclear. The aims of the present study were to evaluate TGF-beta1 gene expression under different immunosuppressive treatments and its association with TGF-beta1 gene functional polymorphism and GO in renal transplant recipients.

MATERIAL AND METHODS

The study included 98 CsA-treated renal transplant recipients (with and without GO) and 44 tacrolimus-treated transplant patients (without GO). TGF-beta1 mRNA expression was measured using a real-time quantitative polymerase chain reaction assay. The levels were correlated with TGF-beta1 gene polymorphisms at codons 10 and 25, with different immunosuppressive treatment and GO.

RESULTS

The level of TGF-beta1 gene expression was insignificantly lower in the CsA-treated group compared with the tacrolimus group, and significantly lower in the group with GO compared with patients without GO. In tacrolimus- and CsA-treated patients, but not in patients with GO, the level of TGF-beta1 gene expression was associated with functional phenotypes of TGF-beta1. The incidence, degree and extent of GO were higher in recipients with lower TGF-beta1 gene expression.

CONCLUSIONS

Lower level TGF-beta1 gene expression, not functional polymorphism, in patients treated with CsA may be considered to be a risk factor for GO.

Non-surgical periodontal treatment of cyclosporin A-induced gingival overgrowth: immunohistochemical results

AIM

The present study was planned to analyze the effects of a 12-month non-surgical periodontal treatment on histologic and immunohistochemical features of cyclosporin A (CsA)-induced gingival overgrowth (GO).

MATERIALS AND METHODS

Gingival samples were collected from 21 liver transplant subjects exhibiting CsA-induced GO prior to, and 12 months after non-surgical periodontal therapy including oral hygiene instructions, scaling and 2-month recall appointments, and also from 18 healthy control subjects. Gingival biopsy specimens were stained with hematoxylin-eosin and monoclonal antibodies for vimentin, CD3 (T-lymphocytes), CD20 (B-lymphocytes), CD34 (endothelium) and Ki-67 (fibroblasts proliferation rate), using a streptavidin-biotin-peroxidase complex method.

RESULTS

Total inflammatory cells, gingival vessels and fibroblast proliferation rate demonstrated significant reduction after non-surgical periodontal treatment (P < 0.0001) in overgrown gingiva, while B- and T-lymphocytes remained nearly unchanged (P = 0.61 and 0.33, respectively). At the 12-month evaluation no significant differences were found when comparing the gingival biopsies from CsA-treated patients and those from healthy controls (P > 0.05).

CONCLUSIONS

Control of clinical inflammation by means of non-surgical periodontal treatment results both in lowering of inflammatory infiltrate and in changes in connective tissue composition. Thus, plaque-induced inflammation would seem to modulate the drug-gingival tissue interaction.

CLINICAL RELEVANCE

A strict plaque control program play a pivotal role in the management of transplant patients exhibiting cyclosporin A-GO.

Hiperplasia gengival medicamentosa: parte I

INTRODUÇÃO: A hiperplasia gengival pode ser causada por alguns medicamentos, entre os quais a fenitoína. Torna-se importante a prevenção, o diagnóstico precoce e o seguimento de pessoas com epilepsia por profissional da área odontológica. OBJETIVO: O presente artigo tem o propósito de discutir os aspectos etiológicos, clínicos e terapêuticos da hiperplasia gengival medicamentosa. METODOLOGIA: Revisão da literatura. RESULTADOS: A necessidade de aliar o tratamento odontológico ao tratamento medicamentoso é enfatizada como forma de prevenir e/ou minimizar a hiperplasia gengival medicamentosa conseqüente à ação farmacológica de algumas drogas e fatores irritantes localizados nos tecidos dentais e periodontais.

[Histometric analysis of gingival hyperplasia in Wistar rats during nifedipine administration]

BACKGROUND/AIM

The use of calcium channel blockers, especially nifedipine, causes gingival hyperplasia which leads to the destruction of the deeper periodontal tissues. During this process, inflammatory changes and the changes of colagen fibers occur. The aim of this study was to metrically compare the extent of proliferation of connective tissue in the deeper periodontal tissue in experimental animals regarding the dose and duration of nifedipine administration.

METHODS

The study involved 50 Wistar rats to which water solution of nifedipine was given in certain time intervals and doses. Before starting the experiment, i.e. before nifedipine administration, and in the defined time intervals, measuring of the morphology of gingival size was performed including the buccolingual and mesiodistal wideness and vertical altitude of the central interdental papilla. The measurement was performed by the use of a special graduated probe. Histometric analyses of the tissue samples were done on the sagital cross-sections in the direction from the top to the bottom of papilla on five levels. For the statistical analysis of the data, the established values to the extent of the most present changes were used. The mesiodistal and buccolingual diameters for the levels L2 and L3 were quantitively determined and compared. These values were compared to the vertical diameter of gingival growth determined before the onset of patohistologic analyses of the tissue samples.

RESULTS

At the begining of the experiment, the volume of the lower incisive central papilla in the rats was 12 mm(3). The central interdental papilla vertical altitude was 6.6 mm in rats which had received a lower dose of nifedipine, 8 mm in rats which had received a higher dose in the defined time intervals while the value for the control group was 3.8 mm.

CONCLUSION

The obtained results showed that the administration of nifedipine led to the extensive gingival hyperplasia in the experimental animals. Gingival hyperplasia correlates with both the dose of nifedipine and the duration of its administration.

The management of drug-induced gingival overgrowth

OBJECTIVES

This review critically evaluates the different therapies that are available to manage drug-induced overgrowth (DIGO).

MATERIAL AND METHODS

This review is based on literature identified using the online databases MEDLINE and PUB MED. It is not a systematic review, but a conventional review of the relevant literature.

RESULTS

Patients benefit from a non-surgical approach if this can be delivered before commencement of medication although in many instances this may not be practicable. Systemic antibiotic usage has been evaluated in the management of ciclosporin-induced gingival overgrowth. Efficacy appears to be equivocal and long-term use is undesirable. Surgical excision remains the main treatment option especially for patients with severe overgrowth. Few studies have compared different techniques with respect to recurrence rate or post-operative sequelae.

CONCLUSION

DIGO is a common clinical problem that often requires intervention. Non-surgical techniques can limit the occurrence of this unwanted affect, reduce the extent of plaque-induced gingival inflammation and reduce the rate of recurrence. Wherever possible this management strategy should be adopted first. Surgical treatment is often the most reliable option and scalpel gingivectomy remains the treatment of choice. Further investigations are required to develop appropriate management strategies to prevent recurrence of DIGO.

Four-year follow-up of oral health surveillance in renal transplant children

To outline the specific oral surveillance needs of renal transplant children, we report the 4-year follow-up data of 106 children examined routinely on a 6-month basis and upon request from the medical team or the parents in the interval. Data were recorded for hard and soft dental tissues, including enamel defects carious lesions, gingival status, orthodontic treatment needs, and wisdom teeth eruption. Hard-tissue lesions were noted in 34.9% of the children, caries lesions on the permanent teeth were seen in 15.0% of cases, 18.86% of the patients had orthodontic treatment. Spontaneous examination, upon request for medical reasons, was given for 26 children. Twenty-one demands originated from the parents. Over a 4-year period the attendance of a dental specialist resulted in a significant improvement in the oral health of the renal transplant children.

Facial distortion secondary to idiopathic gingival hyperplasia: surgical management and oral reconstruction with endosseous implants

Little information exists regarding the surgical and oral reconstructive options for the patient with idiopathic gingival hyperplasia, especially with regard to endosseous implant placement and recurrence of the disease. The authors report a case of severe gingival enlargement and bone resorption involving the maxillary and mandibular arches in a 21-year-old female causing distortion of facial features. The etiology could not be established but the condition was exacerbated during pregnancy, causing chewing, speaking, and esthetic problems. The hyperplastic tissue and all the teeth were removed surgically, followed by immediate placement of 2 endosseous implants. Restoration of esthetics and function with a maxillary denture and mandibular overdenture were completed 3 months later. No disease recurrence was noted at the 6-month postoperative interval.

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.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Gingival tissue proteoglycan and chondroitin-4-sulphate levels in cyclosporin A-induced gingival overgrowth and the effects of initial periodontal treatment

OBJECTIVES

Cyclosporin A (CsA) is a potent immunosuppressive drug used in organ transplant patients to prevent graft rejection. CsA-induced gingival overgrowth is one of the side effects of this drug and its pathogenesis is still unclear. The present study was planned to comparatively analyse total proteoglycan (PG) and chondroitin-4-sulphate (C4S) levels in CsA-induced overgrown gingival tissue samples obtained before and after initial periodontal treatment and to compare these findings with the situation in healthy gingiva.

MATERIAL AND METHODS

Gingival tissue samples were obtained from nine patients with CsA-induced gingival overgrowth before and 4 weeks after initial periodontal treatment including oral hygiene instruction and scaling and also from 10 healthy control subjects. Total PG and C4S levels were determined by biochemical techniques. PG levels were analysed using modified Bitter and Muir method. C4S assay was carried out using chondroitin sulphate lyase AC and chondroitin-6 sulphate sulphohydrolase enzymes. The results were tested statistically using non-parametric tests.

RESULTS

All clinical measurements in the CsA-induced gingival overgrowth group demonstrated significant reductions 4 weeks after initial periodontal treatment (p<0.05). There was no significant difference between the levels of baseline total PG in CsA-induced gingival overgrowth and healthy control groups (p>0.05). The gingival tissue levels of PG in CsA-induced gingival overgrowth group decreased significantly 4 weeks after treatment (p=0.043). Gingival tissue C4S levels in the overgrowth group were significantly higher than the healthy control group at baseline (p=0.000). C4S levels of the overgrowth group were significantly reduced after treatment (p=0.033), but these levels were still significantly higher than the healthy control group (p=0.000).

CONCLUSION

The observed prominent increase in gingival tissue C4S levels may be interpreted as a sign of an increase in C4S synthesis in CsA-induced gingival overgrowth. Furthermore, remission of clinical inflammation by means of initial periodontal treatment had a positive effect on tissue levels of these extracellular matrix molecules.

Pathologic Tooth Migration

Pathologic tooth migration (PTM) is a common complication of moderate to severe periodontitis and is often the motivation for patients to seek periodontal therapy. In this review of the literature, available information concerning prevalence, etiology, treatment, and prevention of pathologic tooth migration is summarized. Prevalence of PTM among periodontal patients has been reported to range from 30.03% to 55.8%. A survey of the literature regarding chief complaints of periodontal patients support these high prevalence findings. The etiology of PTM appears to be multifactorial. Periodontal bone loss appears to be a major factor in the etiology of PTM. Many aspects of occlusion can contribute to abnormal migration of teeth, and more than one of those factors may be present in an individual patient. Soft tissue forces of the tongue, cheeks, and lips are known to cause tooth movement and in some situations can cause PTM. Also considered important in the etiology of PTM is pressure produced from inflammatory tissues within periodontal pockets. Because extrusion is a common form of PTM, clinical observations support the theory that eruption forces sometimes play a role in the etiology of PTM. Many oral habits have been associated with PTM which are often difficult for the therapist to detect. Most cases of severe PTM require a team approach to achieve success. Periodontal, orthodontic, and prosthodontic treatment are often required. Many patient variables enter into the selection of treatment for PTM. In early stages of PTM, spontaneous correction of migrated teeth sometimes occurs after periodontal therapy. Light intrusive forces are used successfully to treat extrusion and flaring forms of PTM. Based on the literature reviewed, it appears that many cases of PTM could be prevented through the early diagnosis and treatment of periodontal disease, occlusal contributing factors, gingival enlargement, and oral habits.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Hereditary gingival fibromatosis associated with generalized aggressive periodontitis: a case report

BACKGROUND

Hereditary gingival fibromatosis is a rare, genetically inherited overgrowth condition that is clinically characterized by a benign fibrous enlargement of maxillary and mandibular keratinized gingiva. A syndromic association between gingival fibromatosis and a wide variety of other genetically inherited disorders has been described. However, its coexistence with aggressive periodontitis has not been reported.

METHODS

A 24-year-old African-American female, patient (proband X, [Px]) reported with a chief complaint of tooth mobility and gingival enlargement. Clinical examination revealed moderate to severe gingival overgrowth on both mandible and maxilla. Generalized attachment loss and mobility of the teeth were observed. Radiographic evaluation demonstrated severe alveolar bone loss. The patient was diagnosed with gingival fibromatosis and aggressive periodontitis based on the clinical and radiographic findings. Her brother (Bx) and her mother (Mx) were evaluated and diagnosed with gingival fibromatosis suggesting that this is a dominant trait in the family and gingival fibromatosis might be of hereditary origin. In addition, the brother also exhibited localized aggressive periodontitis. Medical history revealed no other systemic or local contributory factors associated with the oral findings in any of the subjects.

RESULTS

Surgical therapy included internal bevel gingivectomy combined with open flap debridement procedures for Px and Bx. Only internal bevel gingivectomy was performed for Mx since there was mild bone resorption and no intrabony defects. At the time of surgery, gingival biopsies were obtained and fixed in 4% paraformaldehyde. Multiple serial sections were stained with hematoxylin and eosin. Microscopic evaluation of the gingival specimens revealed large parallel collagen bundles associated with scarce fibroblasts in the connective tissue. The collagen bundles reached into the subepithelial connective tissue where elongated rete-pegs were also observed. Following the completion of the treatment, no signs of recurrence or bone resorption were observed over 2-year follow-up.

CONCLUSIONS

This is the first report of hereditary gingival fibromatosis associated with aggressive periodontitis. Combined treatment comprising removal of fibrotic gingival tissue and traditional flap surgery for the elimination of intrabony defects represents a unique treatment approach in periodontal therapy. Two-year follow-up revealed that both the gingival overgrowth and the destructive lesions were successfully treated.

Relationship of Subgingival and Salivary Microbiota to Gingival Overgrowth in Heart Transplant Patients Following Cyclosporin A Therapy

BACKGROUND

Severe gingival overgrowth (GO) is induced in patients taking cyclosporin A (CsA) following organ transplantation. Determining which patient will develop GO is still not possible. The purpose of this study was to establish an association between CsA and gingival overgrowth in heart transplant patients taking into account periodontal and microbiological conditions.

METHODS

Thirty patients (10 female, 20 male; range: 13 to 67 years; mean age: 44.89) undergoing CsA treatment were evaluated using the gingival index (GI), plaque index (PI), probing depth (PD), and clinical attachment level (CAL). Subgingival samples collected from the deepest site of each quadrant and saliva samples were submitted to microbial analysis. All patients had at least 12 teeth. Exclusion criteria were the use of antibiotics and/or having undergone periodontal treatment 6 months prior to the study. Patients were divided in two groups: with gingival (GO+) and without gingival overgrowth (GO-).

RESULTS

There were no statistically significant differences between the GO+ and GO- groups when CsA dosage, time since transplant, GI, PI, PD, and CAL were compared. Microbiological examination of the subgingival samples detected the following microorganisms: Actinobacillus actinomycetemcomitans (23%), Porphyromonas gingivalis (36%), Prevotella intermedia (93%), Fusobacterium sp. (66%), Campylobacter rectus (30%), Micromonas micros (66%), enteric rods (0%), and yeasts (30%). A positive association between M. micros and the GO+ group was found (P < 0.001). Yeasts were detected in 30% of the subgingival and saliva samples.

CONCLUSIONS

Clinical parameters were not sufficient to determine which patients would develop GO. However, colonization by M. micros might play a role in the etiology of GO.

Conversion from Cyclosporin A to Tacrolimus as a Non-Surgical Alternative to Reduce Gingival Enlargement: A Preliminary Case Series

BACKGROUND

Gingival enlargement (GE) is a frequent side effect that occurs in organ transplant recipients (OTR) after the administration of cyclosporin A (CsA). The availability of new drugs used to suppress graft rejection in OTR offers an opportunity to manage GE non-surgically. This preliminary case series aimed to analyze the effect of CsA withdrawal and its substitution by another immunosuppressant in OTR with severe GE.

METHODS

Four organ transplant recipients who had received a liver or renal allograft were recruited for this study. All OTR had developed clinically severe CsA-induced GE. GE scores were assessed for each patient at baseline and at weeks 2, 4, 8, 12, 16, and 54 following conversion to tacrolimus. Scaling and root planing were initially performed and repeated monthly during the first 6 months. Careful polishing of the teeth was carried out once every 2 weeks until month 6 and then monthly until month 12. Hygiene instructions and reinforcement to optimize oral hygiene were maintained throughout the study.

RESULTS

The four patients showed a rapid decrease in their gingival symptoms and in the size of the gingivae. This change was clinically evident 8 weeks after conversion to tacrolimus. One year later, all the patients experienced GE regression, although some anatomic irregularities persisted in the interdental papillae of one of the patients. No adverse effects from tacrolimus were observed during the study except in one patient who presented headaches.

CONCLUSION

It seems that CsA withdrawal and its conversion to tacrolimus in organ transplant recipients who develop severe gingival enlargement, together with an extensive plaque control program, provide an effective means to control/eliminate gingival hyperplasia, with minimal risk of graft dysfunction.

Antibiotic treatment of incipient drug-induced gingival overgrowth in adult renal transplant patients

BACKGROUND

Drug-induced gingival overgrowth (GO) remains a challenge in periodontics. Partial and total regressions of this GO have been reported after a short course of antibiotics.

METHODS

We conducted a double-blinded controlled randomised study to determine the effect of metronidazole (MNZ) or azithromycin (AZM) on the regression of incipient cyclosporin A-induced GO in 40 adult renal transplanted patients. The quantitation of the GO was performed with Image Digital Analysis.

RESULTS

None of the patients with GO showed complete remission after 30 days. The pretreatment GO index was 0.895 +/- 0.16 in the metronidazole treatment group (MNZ group, n = 13), 0.932 +/- 0.11 in the azithromycin treatment group (AZM group, n = 14), and 1.073 +/- 0.32 in the controls (placebo group, n = 13). At the end of the study (30 days), the GO index score was lower in 54.4% and 62.3% of the MNZ and AZM groups, respectively, and the mean score differences were statistically significant between the groups (0.897 +/- 0.28, MNZ group vs. 0.909 +/- 0.15, AZM group vs. 1.130 +/- 0.3, placebo group, P < 0.05 ANOVA).

CONCLUSIONS

A 7-day course of MNZ or AZM does not induce remission of CsA-induced GO, although it acts on concomitant bacterial over-infection and gingival inflammation.

Subgingival microbiota of renal transplant recipients

Renal transplant patients undergoing immunosuppressive therapy may experience periodontal side-effects such as gingival overgrowth. This study evaluated the subgingival microbiota of renal transplant recipients with or without periodontal tissue destruction who may have concurrent gingival enlargement. Subgingival paper point samples taken from the deepest probing sites of 38 subjects (one per patient) were examined using direct microscopy and culture techniques. A complex microflora comprising gram-positive and gram-negative cocci, rods and filaments, fusiforms, curved rods and spirochetes was observed using microscopy. Yeasts were occasionally detected. Significantly higher proportions of gram-positive morphotypes, including gram-positive cocci, were observed in samples from periodontally healthy patients. The predominant cultivable microflora from anaerobic culture comprised several species of facultative and obligate anaerobes. Colonization of the subgingival sites by 'foreign' microbes that are normally dermal, intestinal or vaginal flora was detected in up to 50% of the samples. High mean proportions of lost or unidentified species were also occasionally noted. The results showed that the subgingival biofilm of renal transplant recipients with chronic periodontitis comprised mainly gram-negative rods and spirochetes. Besides the usual predominant cultivable subgingival microbiota associated with periodontitis, the high prevalence of unidentified and 'foreign' microbes indicates the possibility of subgingival microbial alteration in renal transplant patients.

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

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

Cyclosporin A-induced gingival overgrowth in renal transplant patients

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Connective tissue growth factor in drug-induced gingival overgrowth

BACKGROUND

Drug-induced gingival overgrowth is a known side effect of certain chemotherapeutic agents used for the treatment of systemic disorders. The pathogenesis and mechanisms responsible for this condition are not fully understood. This study assesses for the presence and localization of connective tissue growth factor (CTGF) in drug-induced gingival overgrowth tissues. CTGF immunostaining was compared with sections stained with transforming growth factor (TGF)-beta1 and CD31 antibodies in order to investigate possible pathogenic mechanisms.

METHODS

Gingival overgrowth samples were obtained from patients undergoing therapy with phenytoin (n = 9), nifedipine (n = 4), cyclosporin A (n = 5), and control tissues from systemically healthy donors (n = 9). Tissue sections were subjected to peroxidase immunohistochemistry and were stained with CTGF and TGF-beta1 polyclonal primary antibodies. Possible relationships between CTGF staining and angiogenesis were also studied using an anti-CD31 antibody as a marker for endothelial cells. Staining was analyzed by computer-assisted quantitative and semiquantitative methodology at 5 defined sites in all samples based on the location of specific landmarks including epithelium and underlying connective tissues.

RESULTS

Cellular and extracellular CTGF content in phenytoin gingival overgrowth tissues was significantly (P<0.05) higher compared to the other gingival overgrowth tissues and the controls. Higher CTGF staining in phenytoin gingival overgrowth tissues was accompanied by an increased abundance of fibroblasts and connective tissue fibers. No strong association of CTGF staining with TGF-beta1 or CD31 staining was found.

CONCLUSIONS

The data from the present study show significantly higher CTGF staining in phenytoin-induced gingival overgrowth tissues compared to controls, cyclosporin A-, or nifedipine-induced gingival overgrowth. Moreover, semiquantitative analyses of histologic samples support the concept that the phenytoin overgrowth tissues are fibrotic. These associations suggest a possible role for CTGF in promoting development of fibrotic lesions in phenytoin-induced gingival overgrowth.

Matrix metalloproteinases (MMP-8 and -9) and neutrophil elastase in gingival crevicular fluid of cyclosporin-treated patients

BACKGROUND

Gingival overgrowth (GO) is one of the most important side effects of cyclosporin A (CsA) medication, but its pathogenesis is not completely understood. The aim of this study was to identify and compare collagenase-2 (MMP-8), gelatinase-B (MMP-9), and neutrophil (PMN)-elastase levels in gingival crevicular fluid (GCF) from 15 renal transplant patients receiving CsA therapy and exhibiting CsA GO, 14 patients with gingivitis, and 10 periodontally healthy subjects.

METHODS

Clinical data were obtained on plaque index, papilla bleeding index, and hyperplastic index from each site studied. GCF samples and clinical data were collected from: 2 sites exhibiting CsA GO (CsA GO+) and 2 sites not exhibiting CsA GO (CsA GO-) in each CsA-treated patient; 2 diseased sites in each patient with gingivitis; and 2 healthy sites in each subject with clinically healthy periodontium. CsA GO+ and CsA GO- sites were divided into 2 subgroups as clinically not inflamed (PBI = 0) and inflamed (PBI > or =1). GCF MMP-8, MMP-9, and PMN-elastase levels were analyzed by immunofluorometric assay.

RESULTS

GCF MMP-8 and -9 levels and clinical degrees of gingival inflammation in CsA GO+ sites were similar to those in diseased sites. However, GCF elastase levels were significantly lower in CsA GO+ sites compared to those in diseased sites. GCF MMP-8, -9 and PMN-elastase levels were not different between CsA GO- sites and healthy sites. Additionally, GCF MMP-8 and -9 levels in inflamed CsA GO+ sites were higher but not statistically significantly than those in diseased sites. In contrast, GCF PMN-elastase levels in inflamed CsA GO+ sites were significantly lower than the levels in diseased sites.

CONCLUSIONS

These results show that CsA therapy does not have a significant effect on GCF MMP-8 and MMP-9 levels, but the gingival inflammation seems to be the main reason for their elevations. However, low GCF PMN-elastase levels can be an important factor in the pathogenesis of CsA-induced gingival overgrowth. CsA therapy does not eliminate the potential use of GCF MMP-8 and -9 as future diagnostic markers of gingival inflammation.

Cyclosporine A-induced gingival hyperplasia pemphigus vulgaris: literature review and report of a case

Gingival hyperplasia appears in 8% to 85% of patients treated with cyclosporine. Most studies show an association between oral hygiene status and the prevalence and severity of this gingival overgrowth. Thus, besides attempting to substitute this drug with another whenever possible, treatment usually involves maintenance of strict oral hygiene coupled with scaling and root planing and removal of iatrogenic factors. Sometimes a second treatment phase involving periodontal surgery is necessary. Cyclosporine-induced gingival overgrowth has been mainly described in post-organ transplant patients. The present case describes, for the first time, a severe form of cyclosporine-induced gingival overgrowth arising in a 15 year-old male with pemphigus vulgaris. Periodontal treatment included oral hygiene and scaling and root planing under local anesthesia. There was a significant reduction in gingival enlargement, as well as a reduction in plaque levels and inflammation. Cessation of drug administration, combined with continuous periodontal treatment, brought further improvement. This successful conservative treatment of cyclosporine-induced gingival overgrowth in a pemphigus vulgaris patient suggests that early diagnosis and comprehensive treatment of these lesions may yield good response and reduce the need for periodontal surgery.