Cyclosporin A-induced gingival overgrowth in renal transplant patients

Comparative evaluation of periprostatic nerve block and diclofenac patch in transrectal ultrasound-guided prostatic needle biopsy

Background

The aim of the present study was to compare two analgesic techniques for transrectal ultrasound (TRUS)-guided biopsy: diclofenac patch versus periprostatic nerve block with 1% lidocaine.

Objectives

To study the efficacy of and compare diclofenac patch and periprostatic nerve block as analgesia in TRUS-guided prostate needle biopsy.

Patients and Methods

In total, 60 patients were prospectively randomized into three groups: those in whom a diclofenac patch was used (n = 20), those in whom periprostatic nerve block was used (n = 20), and a control group (n = 20). Prostate biopsy was performed after administration of analgesia according to group.

Results

The three groups were similar in terms of age, prostate volume, and PSA (prostate-specific antigen) levels. Pain scores were significantly lower in the nerve block group (P = 0.000) at the time of biopsy until 2 h postprocedure, but not at 4 h postprocedure (P = 0.068). No significant difference in pain score was observed in the diclofenac patch group at the time of biopsy (P = 0.106) as compared to the control group, but the diclofenac patch provided adequate pain relief 1 h (P = 0.000), 2 h (0.000), and 4 h (0.002) postprocedure. No significant difference was observed in pain score between the nerve block (P = 0.520) and control groups (0.057) at probe insertion. The pain score at 4 h was significantly lower in the patch group compared to the nerve block and control groups.

Conclusions

Periprostatic nerve block provides superior analgesia for TRUS-guided biopsy. Diclofenac patch is useful as an adjunct.

The impact of amlodipine on gingival enlargement after kidney transplantation

Abstract

Background: Although cyclosporine (CsA) and calcium channel blockers (CCBs) parallel to each other may provoke gingival enlargement (GE), there are few considerations about combined effects of CsA and CCBs on gingival tissues.

Objectives: This study aimed to determine prevalence of GE among renal transplant recipients and to compare its occurrence in patients who received only CsA and those who were on CsA and amlodipine.

Patients and Methods: We conducted a prospective randomized case-control trial including 213 renal transplant recipients between February 2010 and August 2010. They were randomly divided into two groups including control group (on continuous treatment with CsA alone; n = 112) and trial group (treated with combined CsA and amlodipine; n = 101). Buccal, lingual, and inter-proximal membranes at last 12 anterior teeth were assessed for GE and packet depth (PD) using Gingival Index of McGaw and others, and Packet Index of Turesky–Gilmore–Glickman, respectively.

Results: Marked GE was observed in 26 patients (25.7%) in trial group and only in 4 individuals (3.6%) in control group (P = 0.000). In logistic regression analysis, obese (OR = 3, P = 0.04), older (OR = 2.8, P = 0.03), and female (OR = 1.3, P = 0.03) recipients as well as who received high dose amlodipine (OR = 4.4, P = 0.000) were at risk for marked GE.

Conclusions: There is a strong correlation between GE, in particular marked GE, and combination therapy with CsA and amlodipine in transplant patients compared to those treated by CsA alone. We suggest CsA dose reduction may restrain this adverse effect.

Cyclosporine-induced gingival overgrowth correlates with NFAT-regulated gene expression: a pilot study

OBJECTIVE

To determine whether incidence and severity of cyclosporine A (CsA)-induced gingival overgrowth (GO) is related to expression nuclear factor of activated T cells-regulated genes (NFAT-regulated genes).

MATERIAL AND METHODS

Expression of NFAT-regulated genes was determined in 36 transplant patients medicated with CsA by real-time PCR before and 2 h after drug intake and residual NFAT activity was estimated as ratio of both measurements. Demographic, periodontal and pharmacologic parameters were recorded and GO assessed from models. Subjects were divided into two groups according to the degree of GO (responders: GO score≥10%). Groups were compared using parametric and non-parametric tests. The association of various CsA-specific and periodontal parameters on incidence and extent of GO were determined using regression analysis.

RESULTS

Responders had a more than twofold lower residual NFAT activity than non-responders (7.9% and 18.1%, respectively; p<0.001). Multiple regression analysis revealed gingival inflammation, salivary CsA concentration, and residual NFAT activity to be significant factors influencing the expression of GO. Seventy-seven percent of the variability of GO could be explained by these parameters.

CONCLUSIONS

This study showed that pharmacodynamic parameters such as residual NFAT activity may be promising prognostic indicators to identify patients with increased risk for GO.

TGF-β1 gene polymorphism in renal transplant patients with and without gingival overgrowth

BACKGROUND

The incidence of gingival overgrowth among renal transplant patients treated with cyclosporine A ranges from 13% to 84.6%, and the overgrowth is not only esthetic but also a medical problem. We studied the determination of association between TGF-β1 (TGFB1) gene polymorphism and gingival overgrowth in kidney transplant patients medicated with cyclosporin A.

METHODS

Eighty-four kidney transplant patients with gingival overgrowth and 140 control transplant patients without overgrowth were enrolled into the case control study. TGFB1 polymorphism was determined using the PCR-RFLP assay for +869T > C in codon 10 and +915G > C in codon 25 as well as TaqMan real-time PCR assays for promoter -800G>A and -509C > T SNPs.

RESULTS

In kidney transplant patients suffering from gingival overgrowth, mean score of gingival overgrowth was 1.38 ± 0.60, whereas in control subjects it was 0.0. The patients with gingival overgrowth were characterized by similar distribution of TGFB1 genotypes and allele in comparison to subjects without gingival overgrowth. Among 16 potentially possible haplotypes of TGFB1 gene, only four were observed in the studied sample of kidney transplant patients: G_C_T_G, G_T_C_G, G_C_C_C, and A_C_T_G, with similar frequency in patients with and without gingival overgrowth.

CONCLUSION

No association between the TGFB1 gene polymorphism and gingival overgrowth was revealed in kidney transplant patients administered cyclosporine A.

Effect of cyclosporin A on proliferation and differentiation of human periodontal ligament cells

OBJECTIVE

Cyclosporin A (CsA) is widely used to prevent rejection after organ transplantation. However, it also causes several side-effects, including gingival overgrowth and bone resorption. Cellular mechanisms underlying the effect of CsA on periodontal tissue remain unclear. In this study, we investigated the effect of CsA on the proliferation and expression of characteristic markers in periodontal ligament cells (PDLs).

MATERIAL AND METHODS

The proliferation and viability of PDLs were measured by direct cell counting and 3,4,5-dimethylthiazol-2-yl-2,5-diphenyl tetrazolium bromide assay, respectively. mRNA expression levels of the specific proteins alkaline phosphatase (ALP), osteocalcin (OC) and collagen type 1 (Coll-1) were quantified using real-time polymerase chain reaction. Finally, ALP activity of PDLs was investigated using a specific colorimetric assay.

RESULTS

We found that proliferation of PDLs was stimulated by 0.01–0.1 μg/ml CsA and unaffected by 1 μg/ml CsA. The viability of PDLs was increased by 0.1 μg/ml CsA and not affected by 0.01 μg/ml and 1 μg/ml CsA. Furthermore, the mRNA expression levels of ALP, OC and Coll-1 in PDLs were significantly increased upon stimulation with 0.1 μg/ml CsA for 24 h or by stimulation with 0.01 μg/ml CsA for 48 h. In contrast, significantly lower expression levels of all three proteins in PDLs were observed upon stimulation with 1 μg/ml CsA for 48 h. The ALP activity of PDLs exhibited a similar pattern of changes upon CsA stimulation.

CONCLUSION

Our data demonstrated that CsA may influence both the proliferation and differentiation of human PDLs, which may play an important role in the homeostasis of periodontal tissue.

Gingival overgrowth in cyclosporine, tacrolimus, or sirolimus-based immunosuppressive regimens and the single nucleotide IL-6 (-174 G/C) gene polymorphism

OBJECTIVE

Interleukin-6 (IL-6) may be involved in drug-induced gingival overgrowth (GO). The present study was conducted to assess the association between IL-6 (-174 G/C) gene polymorphism and GO in renal transplant recipients under cyclosporine (CsA), tacrolimus (Tcr), or sirolimus (Sir)-based regimens.

METHODS

Within an eligible population, 45 unrelated subjects were selected for each CsA, Tcr, and Sir group, totaling a sample of 135 subjects. GO was visually assessed and subjects were assigned as controls (non-responders) or cases (responders) in a post hoc definition. IL-6 gene polymorphism was assessed using the polymerase chain reaction amplification and digestion. The distribution of genotypes and allele frequencies in responders and non-responders were compared using the Chi-squared test.

RESULTS

The number of responders was 27 (60.0%), 13 (28.9%), and 7 (15.6%) in the CsA, Tcr, and Sir groups, respectively. No differences could be observed at frequencies of -174GG, -174CG, and -174CC genotypes when comparing responders to non-responders in the CsA, Tcr, and Sir groups. Similar to genotypes, allele frequencies showed no differences between responders and non-responders in all groups.

CONCLUSIONS

No association between IL-6 (-174 G/C) gene polymorphism and gingival overgrowth was observed in renal transplant recipients under CsA, Tcr, or Sir-based immunosuppressive maintenance regimens.

Gingival status of Brazilian renal transplant recipients under sirolimus-based regimens

BACKGROUND

Although the prevalence of gingival overgrowth (GO) in calcineurin-inhibitor (CNI) immunosuppressive regimens has been well documented, to the best of our knowledge data from sirolimus (SIR) regimens have not been described. We sought to investigate the gingival status of renal transplant recipients under SIR-based regimens with regard to the prevalence and potential risk variables associated with GO.

METHODS

A cross-sectional study was conducted at a public hospital in Belo Horizonte, MG, Brazil. Of 886 transplant recipients, an eligible sample of 144 subjects was selected. Medical, pharmacologic, and periodontal variables were recorded for each subject. GO was assessed through visual inspection and was evaluated in relation to variables of interest by univariate and multivariate analyses.

RESULTS

Although not clinically significant, 20.8% of the samples had GO, with a mean GO score of 5.0% +/- 3.98% (range, 0% to 19%) and mean GO score per papilla of 0.378 +/- 0.361 (range, 0.1 to 1.9); the percentage of papilla affected by GO was 14.35% +/- 9.86% (range, 5% to 45%). The multivariate final model, excluding periodontal variables, showed that the concomitant use of calcium channel blockers (P = 0.033) and the interaction between time since transplant and previous CNI use (P <0.001) were associated with GO. Adding periodontal variables to the model improved its accuracy and retained papillary bleeding index as being strongly associated with GO (P <0.001).

CONCLUSIONS

GO was observed in a considerable number of subjects under SIR-based immunosuppressive regimens, although the relationship was not clinically significant. Findings point to the importance of cooperation between medical and dental health care personnel in the maintenance of renal transplant recipients under SIR-based immunosuppressive regimens.

Expression of p21 and p53 in rat gingival and human oral epithelial cells after cyclosporine A treatment

BACKGROUND AND OBJECTIVE

Expression of p21 and p53 were examined, at gene and protein levels, in edentulous gingival epithelial cells from rats and from a human oral epidermoid carcinoma cell line, OECM1, after cyclosporine A therapy.

MATERIAL AND METHODS

In vivo: 20 partially edentulous SD rats were assigned into cyclosporine A feeding and control groups. After the rats were killed, p21 and p53 in gingiva were evaluated by reverse transcription-polymerase chain reaction and immunohistochemistry. In vitro: after cyclosporine A treatment, p21 and p53 of OECM1 cells were evaluated by western blot and the luciferase assay. The distribution of OECM1 cells in each phase of the cell cycle was evaluated by flow cytometry.

RESULTS

The mRNA expression of p21 was significantly higher in the cyclosporine A group than in the control group. A greater number of positive anti-p21-stained cells were observed in the gingival epithelium of the cyclosporine A group than in the control group. Significantly higher levels of p21 protein and activity were observed in OECM1 cells after cyclosporine A treatment than in cells without treatment. A relative increase of cells in G0/G1 phases, and a decrease of cells in G2/M phases, were observed in OECM1 cells after cyclosporine A treatment.

CONCLUSION

In the present study, higher p21 mRNA and protein expressions were observed after cyclosporine A treatment. Thus, an up-regulation of p21 expression, via a p53-independent pathway, by cyclosporine A in gingival and oral epithelial cells was suggested.

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.

Case report: Denys- Drash syndrome

BACKGROUND

Denys-Drash Syndrome (DDS) is an uncommon disorder that appears sporadically and in rare cases may be inherited as an autosomal dominant trait It manifests either at birth or within the first year of life and typically consists of the triad of congenital nephropathy, Wilms tumour and intersex disorder.

CASE REPORT

A 10 year-old Caucasian girl was referred to the Dental Department, at Glasgow Royal Hospital for Sick Children by her Paediatric Nephrologist Consultant. The patient was being teased by her peers over her markedly discoloured teeth. The dental history revealed that the patient was a regular dental attendee from an early age. She was dentally anxious having only experienced dental treatment under general anaesthesia (GA) when she was 4 years old. Apparently her primary dentition also showed a generalised discolouration.

TREATMENT

This consisted of multiple visits for diet analysis and tooth brushing instruction with the use of disclosing tablets. Plaque control significantly improved when using a battery operated toothbrush because of its larger handle which the patient found easier to use and a 0.05% sodium fluoride mouthwash was given for daily use. Dyract(AP) veneers directly bonded onto maxillary permanent incisors and mandibular permanent anterior teeth was carried out. This was an interim measure to improve the patient's appearance while assessing the patient co-operation. The compomer facings were replaced with BelleGlass NG veneers which were cemented onto the maxillary incisors and mandibular anterior teeth using Adhesive By Choice (ABC) system under rubber dam on two separate visits.

FOLLOW-UP

At her last visit, 27 months after treatment, the patient was still satisfied with the restorative treatment. However, further teeth had erupted including all the premolars. BelleGlass NG crowns were indicated. It was also decided to replace the preformed chrome cobalt crowns with full coverage BelleGlass NG crowns.

[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.

Demographic, Pharmacologic, and Periodontal Variables for Gingival Overgrowth in Subjects Medicated With Cyclosporin in the Absence of Calcium Channel Blockers

BACKGROUND

The role of cyclosporin in the absence of calcium channel blockers and the associated risk variables of development and severity of gingival overgrowth have not yet been properly established. The present study was conducted to determine the effect of potential risk variables for gingival overgrowth severity in Brazilian renal transplant subjects medicated with cyclosporin in the absence of any calcium channel blockers.

METHODS

A cross-sectional study was conducted in a public hospital in Belo Horizonte, Brazil. Demographic, pharmacologic, and periodontal data, recorded from 194 subjects taking cyclosporin in the absence of calcium channel blockers, were analyzed using independent sample t, chi2 statistic, or Mann-Whitney U tests. The effects of potential risk variables of gingival overgrowth severity were determined using backward stepwise regression analysis.

RESULTS

The prevalence of clinically significant gingival overgrowth was 34.5% (N = 67). These subjects presented a significantly higher papillary bleeding index and a higher plaque index compared to those without clinically significant gingival overgrowth. When all demographic, pharmacologic, and periodontal data were evaluated in relation to gingival overgrowth severity, time since transplant, papillary bleeding index, serum cyclosporin concentration, and prednisolone and azathioprine dosages were significant in the univariate modeling (P <0.05) and remained significant when evaluated in the multivariate modeling (P <0.0001; adjusted R2 = 39.4%).

CONCLUSIONS

In the absence of calcium channel blockers, this study showed that pharmacologic variables, such as cyclosporin serum concentration, prednisolone and azathioprine dosages, and time since transplant, are strongly related to gingival overgrowth. In addition, the periodontal variable papillary bleeding index highlighted the primary role of inflammation on the pathogenesis and severity of gingival overgrowth.

Relationship between IL-1A polymorphisms and gingival overgrowth in renal transplant recipients receiving Cyclosporin A

AIM

Levels of interleukin-1alpha (IL-1alpha) are elevated in periodontal inflammation. IL-1A gene polymorphisms are associated with inflammatory diseases. This study aimed to investigate IL-1A gene polymorphism in Cyclosporin A (CsA)-treated renal transplant patients and investigate the association between this polymorphism and gingival crevicular fluid (GCF) levels of several cytokines.

MATERIALS AND METHODS

Fifty-one renal transplant patients on CsA treatment (25 with and 26 without gingival overgrowth) and 29 healthy controls were recruited for the study. Demographic, pharmacological and periodontal parameters were recorded and gingival overgrowth was assessed.

RESULTS

Multiple regression analysis showed that genotype was significantly associated with gingival overgrowth (p=0.02). Carriage of the IL-1A (-889) T allele was strongly protective [95% confidence interval (CI): 0.046-0.77], although not significantly associated with IL-1alpha protein levels in GCF. IL-1alpha, IL-1beta and IL-8, but not IL-6, were detected in GCF of CsA-treated patients, but none of them was significantly associated with gingival overgrowth.

CONCLUSIONS

This study is the first to associate a gene polymorphism as a risk factor for CsA-induced gingival overgrowth in renal transplant patients, demonstrating that IL-1A polymorphism might alter individual susceptibility to CsA. However, there was no association between GCF cytokine levels and the presence of gingival overgrowth or patient IL-1A genotype.

Matrix Metalloproteinase-1 Gene Polymorphism in Renal Transplant Patients With and Without Gingival Enlargement

BACKGROUND

Gingival enlargement frequently occurs in transplant patients receiving immunosuppressive drugs. It was hypothesized that gingival enlargement associated with cyclosporin use results in a disturbance of the homeostatic balance, which is characterized by an increase in the number of fibroblasts and volume of the extracellular matrix. Matrix metalloproteinase (MMP) serves as an initiator of extracellular matrix destruction. The aim of this study was to determine whether there is an association between genotypes of the MMP-1 gene and gingival enlargement in kidney transplant patients.

METHODS

Sixty-one unrelated kidney transplant patients with gingival enlargement and 121 control transplant patients without enlargement were enrolled in the study. Six months after transplantation, all patients were given medication, which included cyclosporin A, and gingival enlargement was assessed. MMP-1 polymorphism was determined using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay.

RESULTS

In kidney transplant patients with gingival enlargement, the mean score of gingival enlargement was 1.42+/-0.63, whereas in control subjects, it was 0.0. There were no significant differences in the frequency of -1607 1G>2G alleles and genotypes between patients with and without gingival enlargement. In all subjects (N=182) and in patients without gingival enlargement, the genotype distribution met Hardy-Weinberg equilibrium criteria, whereas in patients with gingival enlargement, it was markedly different (P<0.06). There was a trend for carriers of at least the 1G allele to have an increased risk of gingival enlargement, but the trend was not statistically significant (odds ratio, 2.32; P<0.073).

CONCLUSION

No association between the MMP-1 gene polymorphism and gingival enlargement was revealed in kidney transplant patients who were administered cyclosporin A as a principal immunosuppressive agent.

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.

The Relationship of Transforming Growth Factor-β1 Gene Polymorphism, Its Plasma Level, and Gingival Overgrowth in Renal Transplant Recipients Receiving Different Immunosuppressive Regimens

BACKGROUND

Cyclosporin A (CsA) induces gingival overgrowth (GO) in patients who seem to be prone to this disorder. It is still impossible to determine which patients will develop GO. Patients treated with the new immunosuppressive drug tacrolimus seem not to have GO. The aims of this study were to investigate transforming growth factor-beta1 (TGF-beta1) gene polymorphisms in renal transplant recipients treated with CsA or tacrolimus and to establish an association between these polymorphisms and TGF-beta1 plasma concentration and the incidence of GO.

METHODS

The examined group consisted of 134 renal transplant recipients. Ninety-two underwent CsA treatment (50 with and 42 without GO), and 42 underwent tacrolimus treatment. Age, gender, time after transplantation, calcineurin inhibitor total dosage, number of teeth, and sulcus bleeding index were analyzed. TGF-beta1 plasma levels were estimated in 60 CsA- and 30 tacrolimus-treated patients. Two biallelic polymorphisms of the TGF-beta1 gene were studied at codon 10 (at position +869) and at codon 25 (at position +915) in patients from the examined group and in 108 healthy volunteers (the control group).

RESULTS

The distribution of the high, intermediate, and low TGF-beta1 producer phenotypes was comparable in all the studied groups and in the healthy controls. The high producer phenotype was more frequent in patients with GO. TGF-beta1 levels in the CsA group showed correlation with the phenotypes. The lowest incidence of GO was observed in the 10C/C genotype, whereas the highest was observed in the 10T/C genotype.

CONCLUSION

High and intermediate TGF-beta1 producer phenotypes and heterozygous genotype 10T/C might be considered risk factors for GO in patients treated with CsA.

Interleukin-6 gene polymorphism in renal transplant patients with and without gingival overgrowth

OBJECTIVE

To determine whether there is an association between genotypes of interleukin-6 (IL-6) and gingival overgrowth in kidney transplant patients.

METHODS

Sixty-three unrelated kidney transplant patients suffering from gingival overgrowth as well 125 control transplant patients without overgrowth were enrolled into the study. Gingival overgrowth was assessed by two independent periodontal specialists at 6 months after transplantation. During the post-transplant period, all patients were given medication, which included cyclosporin A, diltiazem or verapamil, prednisone, and azathioprine. IL-6 polymorphism was determined using the polymerase chain reaction-restriction fragment length polymorphism assay.

RESULTS

In kidney transplant patients suffering from gingival overgrowth mean score of gingival overgrowth was 1.41+/-0.64, whereas in control subjects it was 0.0. Patients with gingival overgrowth induced by immunosuppressive medication were characterized by genotypes similar to the controls distribution of IL-6. There were no significant differences of analyzed genotypes' distribution, i.e. -174G/G, -174G/C and -174C/C between patients with gingival overgrowth 33.3%, 39.7%, 27.0% and without gingival overgrowth 30.4%, 49.6% and 20.0%, respectively. The risk of gingival overgrowth was the highest among patients carrying -174C/C genotype (OR 1.48), but did not differ markedly from the other genotypes, i.e. -174G/G (OR 1.15) and -74G/C (OR 0.67). Similar to genotypes, the distribution of alleles was similar in patients with gingival overgrowth and healthy gingiva. The -174G allele was found in 53.2% and 46.8% of subjects whereas -174C allele was revealed in 46.8% and 44.8% of patients with and without gingival overgrowth, respectively. The evaluated risk of gingival overgrowth in patients with -174G allele was 1.09 versus those with healthy gingiva. The medication regimen administered in both groups of the study was comparable.

CONCLUSION

No association between the IL-6 gene polymorphism and gingival overgrowth was revealed in kidney transplant patients administered cyclosporin A as a principal immunosuppressive agent.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of Cyclosporin A on the Mineral Apposition Rate of Cementum and Dentin in Growing Rats

BACKGROUND

Since there is no direct information to verify whether cyclosporin A (CsA) can affect the mineralization of dental hard tissue, the formation of dentin and cementum in growing rats was recorded by labeling the mineral phase of these tissues with fluorochrome marker in this study.

METHODS

After the extraction of the right maxillary molars, 30 male 3-week-old Sprague-Dawley rats were assigned to two groups. Following a 2-week healing period, the experimental rats received 30 mg/kg CsA daily for 7 weeks, while the control rats received only mineral oil. The fluorescent markers, calcein and alizarin red, were given on alternate weeks for 7 weeks. At the end of study, the mandibles were obtained and undemineralized sections were processed. Serial sections, 8 microm thick, were cut for the entire distal roots of the first molars. Five central sections were selected to determine the mineral apposition of cellular cementum and dentin at the apex and middle of root, respectively.

RESULTS

The apposition rates of apical cellular cementum were significantly influenced by CsA therapy, occlusal function, and observation duration. However, the dentin apposition rates were significantly influenced by the observation intervals only.

CONCLUSIONS

In this study, CsA therapy and occlusal function significantly influenced the apposition rates of apical cementum, but not the rates of mid-root dentin. Our hypothesis that CsA can induce oral hard tissue alterations, as well as gingival overgrowth, is demonstrated.

Plasma TGF-beta1 as a risk factor for gingival overgrowth

BACKGROUND AND AIMS

Induction of the pro-fibrotic growth factor TGF-beta1 has been suggested as a possible mechanism through which immunosuppressant drugs may induce gingival overgrowth. This study aims to investigate plasma levels of TGF-beta1 and relate them to the development and severity of gingival overgrowth in immunosuppressed transplant patients.

MATERIALS AND METHODS

One hundred and thirty-two ciclosporin-treated and 13 tacrolimus-treated transplant patients and 24 drug-free control subjects underwent a full periodontal examination including a determination of the presence and severity of gingival overgrowth.

RESULTS

Plasma TGF-beta1 concentrations were determined by ELISA, and were found to be significantly elevated in samples from the transplant patients (mean=29.1 ng/ml) as compared with controls (mean=6.1 ng/ml, p<0.0001). There was no significant difference between the levels of plasma TGF-beta1 in the ciclosporin- and tacrolimus-treated patient groups.

CONCLUSIONS

Furthermore, concomitant treatment with calcium channel blockers did not influence the levels of plasma TGF-beta1 in the patients group. The relationship between gingival overgrowth, independent periodontal variables and TGF-beta1 plasma concentrations was examined using univariate and multivariate regression analyses; low TGF-beta1 plasma concentrations were found to be a risk factor for gingival overgrowth in immunosuppressed patients concomitantly receiving a calcium channel blocker.

P-glycoprotein drug transporter MDR1 gene polymorphism in renal transplant patients with and without gingival overgrowth

OBJECTIVE

To determine whether there is association between genotypes of drug transporter multidrug resistant (MDR)1 gene coding drug transporter P-glycoprotein and gingival overgrowth in kidney transplant patients.

METHODS

Fifty-four unrelated kidney transplant patients suffering from gingival overgrowth as well 120 control transplant patients without overgrowth were enrolled into the study. Gingival overgrowth was assessed by two independent periodontal specialists at 6 months after transplantation. During the post-transplant period all patients were given medication, which included cyclosporine A, diltiazem or verapamil, prednisone, azathioprine. MDR1 C3435T polymorphism was determined using the polymerase chain reaction-restriction fragment length polymorphism assay.

RESULTS

In kidney transplant patients suffering from gingival overgrowth mean score of gingival overgrowth was 1.43 +/- 0.63, whereas in control subjects was 0.0. Patients with gingival overgrowth induced by immunosuppressive medication were characterized by similar distribution of MDR1 genotypes. There were no significant differences of 3435CC, 20.4% and 22.5%, 3435CT, 61.1% and 54.2% and 3435TT, 18.5% and 23.3% genotypes (frequencies) between patients with and without gingival overgrowth. The risk of gingival overgrowth was the highest among patients carrying 3435CT genotype (OD 1.33), but did not differ markedly from the other genotypes, i.e. 3435CC (OD 0.88) and 3435TT (OD 0.75). Likewise to genotypes, distribution of alleles was similar in patients with gingival overgrowth and healthy gingiva. The wild-type allele 3435C was found in 50.9% and 49.6% of subjects whereas the mutated allele 3435T was revealed in 49.1% and 50.4% of patients with and without gingival overgrowth, respectively. The evaluated risk of gingival overgrowth in patients with 3435C allele was 1.06 versus 0.95 in those with healthy gingiva. The medication regimen administered in both groups of the study was comparable. Immunohistochemical studies revealed expression of P-glycoprotein in ducts of the salivary gland.

CONCLUSION

No association between the MDR1 gene polymorphism and gingival overgrowth was revealed in kidney transplant patients administered cyclosporine A as a principal immunosuppressive agent. Further studies are needed to elucidate the role of P-glycoprotein in drug transport in salivary glands.