Prevalence, Severity, and Risk Variables Associated With Gingival Overgrowth in Renal Transplant Subjects Treated Under Tacrolimus or Cyclosporin Regimens

Cyclosporine A-induced gingival overgrowth in renal transplant patients accompanied by epithelial-to-mesenchymal transition

OBJECTIVE

To investigate the association between the prevalence of cyclosporin A-induced gingival overgrowth and the expression of the epithelial-to-mesenchymal transition factors in the gingival tissues of renal transplant patients.

BACKGROUND

Gingival overgrowth (GO) is a frequent complication in organ transplant patients treated with the immunosuppressant cyclosporin A (CsA). The epithelial-to-mesenchymal transition (EMT) is considered a factor contributing to CsA-induced GO. However, current knowledge on this topic is sparse.

METHODS

Sixty-three renal transplant patients were divided into two groups according to the occurrence of GO: those with gingival overgrowth (GO+ group) and those without gingival overgrowth (GO- group). Data on age, sex, and use of immunosuppressant and calcium channel blocker medications, serum creatinine values, peak concentrations of blood CsA, and gingival hyperplasia scores were recorded to identify clinically pathogenic factors. Gingival tissues from five patients with CsA-induced GO and five healthy subjects were selected for histomorphological observation with hematoxylin-eosin staining, Masson staining, and immunohistochemical staining. The mRNA expression of EMT factors was detected with reverse transcription-quantitative PCR.

RESULTS

The use of CsA significantly increased the prevalence of GO in renal transplant patients. The expression of α-SMA, SMAD4, and TGM2 was upregulated and that of E-cadherin was downregulated in the gingival tissues of patients with CsA-induced GO compared with those of the corresponding controls.

CONCLUSION

Treatment with CsA is closely related to the occurrence of GO in renal transplant patients and EMT plays an important role in CsA-induced gingival tissue hyperplasia.

Er,Cr:YSGG Laser Therapy for Drug-Induced Gingival Overgrowth: A Report of Two Case Series

Background

Drug-induced gingival overgrowth is common but neglected in patients with systemic disease medications until it seriously affects the quality of life.

Methods

Initial periodontal treatment, combined with water laser surgery, was performed sequentially in two cases.

Results

The therapeutic effect was good, and there was no recurrence along with good oral hygiene.

Conclusion

Water laser equipment surgery, as well as initial periodontal treatment, required that surgeons are trained specifically. A tool was devised for various oral diseases, and it was safer, more efficient and more comfortable than others.

Managing the oral side-effects of medications used to treat multiple sclerosis

BACKGROUND

Many medications used to manage multiple sclerosis (MS) affect oral health. This review aimed to identify the oral side-effects of the current drugs recommended in Australia to treat MS and make dental practitioners aware of the range of symptoms.

METHODS

The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for medications used to treat MS. For each medication, the generic name, class, route of administration, dosage and drug company reported side-effects were extracted from the online Monthly Index of Medical Specialties (MIMs) database. Meyler's Side-effect of Drugs Encyclopaedia was used to identify any additional oral adverse reactions to medications used to treat MS.

RESULTS

Fourteen drugs were identified for the treatment of MS progression and 13 drugs for the treatment of MS symptoms. For these medications, 18 oral side-effects were documented: xerostomia was the most common, followed by dysgeusia, dysphagia, mouth ulceration and sinusitis. Anticholinergic drugs caused xerostomia while immunosuppressants resulted in more infection-related side-effects.

CONCLUSIONS

Dental practitioners should be aware of the range of symptoms likely to be reported by this population. Clinicians are encouraged to continue providing dental care for their patients who develop MS and refer complex cases to specialists.

Amlodipine-Induced Gingival Overgrowth With Unusual Presentation as a Gingival Mass and Rapid Regression After Dose Reduction

INTRODUCTION

Gingival overgrowth, a known side effect of calcium channel blockers, particularly nifedipine, usually presents as a diffuse overgrowth. An unusual presentation of amlodipine-induced gingival overgrowth is presented here, with a large, erythematous gingival mass as the most prominent feature, and rapid, almost complete resolution of the mass after reduction of amlodipine dosage.

CASE PRESENTATION

A boy, aged 7 years, presented with a gingival mass first noticed a week previously, with no associated discomfort or bleeding. His medical history was significant for Wiskott-Aldrich syndrome, bone marrow transplant 5 years previously, and subsequent development of severe chronic graft-versus-host-disease. His medication included: 1) amlodipine; 2) enalapril; 3) tacrolimus; 4) sulfamethoxazole/trimethoprim; 5) voriconazole; 6) hydrocortisone cream; and 7) intravenous immunoglobulin infusions. Allergies included: 1) vancomycin; 2) metoclopramide; 3) clonidine; and 4) latex. Examination revealed mild generalized gingival overgrowth and the presence of a large, erythematous, sessile, soft, non-tender mass on the mandibular right gingiva between the primary lateral incisor and canine, resembling a pyogenic granuloma. No suppuration, bleeding on probing, or radiographic abnormalities were noted. A recommendation was made to the physician of the patient to replace amlodipine with a different class of antihypertensive. In response, amlodipine dosage was decreased by 50% to 2.5 mg daily. At a 2-week follow-up visit, considerable reduction in size of the gingival mass had occurred, and shortly after complete resolution was reported by his parents. No other intervention, such as scaling or excision, had been performed.

CONCLUSION

Discontinuation or reduction of the amlodipine dose to <5 mg daily prior to any surgical intervention should be considered in patients taking amlodipine presenting with a gingival mass.

Gingival Crevicular Fluid and Plasma Levels of Transglutaminase-2 and Oxidative Stress Markers in Cyclosporin A-Induced Gingival Overgrowth

BACKGROUND

Transglutaminase (TGM)-2 has been shown to contribute to fibrosis by extracellular matrix accumulation in some organs and is activated by intracellular reactive oxygen species. The aim of this study is to investigate levels of gingival crevicular fluid (GCF) and plasma TGM-2 and oxidative stress markers (OSMs) in cyclosporin A (CsA)-induced gingival overgrowth (GO).

METHODS

The study enrolled 20 healthy (H) individuals; 20 patients with gingivitis (G); 20 CsA-medicated patients with GO (CsA GO+); and 20 CsA-medicated patients without GO (CsA GO-). GCF and plasma levels of TGM-2 were analyzed by enzyme-linked immunosorbent assay. Spectrofluorometry was used to analyze thiobarbituric acid reactive substance (TBARS); ferric-reducing antioxidant power (FRAP); total oxidant status (TOS); and total antioxidant capacity (TAC).

RESULTS

GCF TGM-2 level was elevated in CsA GO+ compared with G (P = 0.048) and H (P = 0.001) groups. GCF TBARS level was elevated in CsA GO+ compared with other groups (CsA GO- group: P = 0.003; G group: P <0.001; and H group: P <0.001) and was higher in CsA GO- than in H (P = 0.048). GCF FRAP level was lower in CsA GO- than in H (P = 0.04). Both CsA GO+ and CsA GO- groups had lower GCF TOS levels than H (P <0.001 and P = 0.002) and G (P = 0.003 and P = 0.04). GCF TAC was higher in CsA GO+ than in H (P = 0.02). Plasma TGM-2 level was elevated in CsA GO+ compared with G (P = 0.048) and H (P = 0.002). Plasma FRAP level was higher in H and CsA GO- than in CsA GO+ (P = 0.008 and P = 0.02).

CONCLUSIONS

CsA use significantly alters GCF and plasma levels of TGM-2 and OSMs. TGM-2 may contribute to CsA-induced GO in CsA-treated patients by changing GCF and plasma levels of OSMs. Further studies are needed to prove causality and its direction.

The Oral Cavity State in Renal Transplant Recipients

AIM

Patients with a solid organ transplant can have many different complications in the mouth, as a result of immunosuppression and side effects of drugs. The aim of this study was to examine the frequency and type of oral lesions in renal transplant patients, dental status, oral hygiene, oral lesions related to drugs which patients take and the time of transplantation as well as the frequency of patient's visits to the dentist in the post-transplant period.

MATERIAL AND METHODS

The study was performed in a period of two years and included 100 subjects with a renal transplant during their regular control visits to the Department of Nephrology and Dialysis, Clinical Hospital Centre Zagreb and the Department of Oral Medicine, School of Dental Medicine, University of Zagreb and 100 randomly selected control subjects at the Department of Endodontics and Restorative Dentistry, School of Dental Medicine, University of Zagreb.

RESULTS

Results showed a significantly higher incidence of oral lesions in patients with renal transplant (31%) compared to control subjects. The most frequent were erythematous (inflammatory changes), keratotic lesions and gingival hyperplasia. The average DMFT index was significantly lower in patients with renal transplant than in the control group. One third of patients had a subjective feeling of dry mouth. Oral hygiene was poor overall, and only a small number of subjects used the additional sustainers for oral hygiene. Most patients did not visit the dentist after the transplantation.

CONCLUSION

Renal transplant patients need a comprehensive and regular dental care during the pre- and post-transplant period and a doctor of dental medicine should be part of a multidisciplinary team of medical specialists.

Interleukin-6 Family of Cytokines in Crevicular Fluid of Renal Transplant Recipients With and Without Cyclosporine A-Induced Gingival Overgrowth

BACKGROUND

Interleukin (IL)-6 family of cytokines, including IL-6, oncostatin M (OSM), leukemia inhibitory factor (LIF), and IL-11, have fibrogenic features. The current study determines gingival crevicular fluid (GCF) levels of fibrosis-related IL-6-type cytokines in cyclosporine A (CsA)-induced gingival overgrowth (GO).

METHODS

Eighty non-smokers were included (40 CsA-medicated renal transplant patients with GO [GO+; n = 20] or without GO [GO-; n = 20], 20 individuals with gingivitis, and 20 healthy participants). Probing depth and plaque, papilla bleeding, and hyperplastic index scores were recorded. GCF samples were obtained from the mesio-buccal aspects of two teeth. GCF IL-6, IL-1β, OSM, LIF, and IL-11 levels were analyzed by enzyme-linked immunosorbent assay.

RESULTS

The GO+ and GO- groups had higher IL-6 total amounts than the healthy group (P <0.008). IL-1β total amounts in the GO+ group were significantly higher than in both the healthy and GO- groups (P <0.008). OSM total amount was elevated in the GO+ and GO- groups compared with both the gingivitis and healthy groups (P <0.008). All groups had similar LIF and IL-11 total amounts (P >0.008). Moderate positive correlations were detected among IL-6, IL-1β, OSM, and IL-11 total amount in GCF and clinical parameters (P <0.05).

CONCLUSIONS

IL-6 and OSM increases in GCF as a result of CsA usage or an immunosuppressed state irrespective of the severity of inflammation and the presence of GO. The IL-6 family of cytokines might not be directly involved in biologic mechanisms associated with CsA-induced GO. Lack of an association between assessed IL-6 cytokines and CsA-induced GO might indicate distinct effects of these cytokines on fibrotic changes of different tissues.

Gingival overgrowth in renal transplant subjects: a 44-month follow-up study

BACKGROUND

To assess changes in gingival status of renal transplant subjects under immunosuppressive regimens based on cyclosporine (CsA), tacrolimus (Tcr), and sirolimus (Sir).

METHODS

From a sample of 135 subjects (baseline examination [BE]), 89 without periodontal treatment, who maintained the immunosuppressive regimen based on the same main agent (CsA=23, Tcr=31, and Sir=35), were reexamined after 44 months (follow-up examination [FE]). Demographic, pharmacologic, and periodontal variables were collected and gingival overgrowth (GO) was assessed by visual examination.

RESULTS

In Tcr and CsA groups, although not significant, occurrence of GO decreased (CsA [BE=56.5% and FE=34.8%; P=0.063] and Tcr [BE=19.4% and FE=12.9%; P=0.500]). In addition, the severity of GO decreased significantly in CsA group (mean score BE=10.29 ± 7.70 and mean score FE=0.78 ± 1.38; P=0.003). In Sir group, GO decreased from 17.1% (BE) to 0.0% (FE) (P=not applicable). In total sample, GO was associated with papillary bleeding index (P=0.001) and concomitant use of calcium channel blockers (P=0.029); in CsA and Tcr groups, GO was associated with papillary bleeding index (P=0.029 and 0.033, respectively).

CONCLUSIONS

There was no incidence of GO, and a decrease in the occurrence and severity of GO was significant in total sample. This decrease can be attributed to changes in pharmacologic and periodontal variables over this period of time.

Alpha 2 integrin gene (ITGA2) polymorphism in renal transplant recipients with and without drug induced gingival overgrowth

BACKGROUND

Variances in fibroblasts' α2β1 integrin intensity may lead to altered adhesion to type I collagen and consequently to suppression of phagocytosis which may be one of the mechanisms for drug induced gingival overgrowth. The present study aimed to evaluate the genotype and allele frequencies of α2 integrin +807 gene in renal transplant patients with and without gingival overgrowth.

MATERIAL AND METHODS

Seventy renal transplant patients with cyclosporine A (CsA)-induced gingival overgrowth (CsA GO+) were enrolled. Renal transplant patients without GO medicated with CsA (CsA GO-; n=79) and tacrolimus (Tac; n=52) served as controls. DNA was obtained from peripheral blood and ITGA2 +807C/T polymorphism was genotyped by polymerase chain reaction and restriction fragment length polymorphism method. Clinical parameters including probing depth and plaque, papilla bleeding and hyperplasia indexes were recorded. Chi-square, Kruskal-Wallis and Mann-Whitney tests were used in statistical analysis.

RESULTS

Clinical parameters of CsA GO+ group were significantly higher than those of the CsA GO- and Tac groups (p<0.05). ITGA2 807C/T genotype and allele frequencies of study groups were similar (p>0.05).

CONCLUSION

Within the limits of the present study it can be concluded that ITGA2 +807 gene polymorphism is not associated with susceptibility to CsA-induced GO.

The role of androgen receptor gene in cyclosporine induced gingival overgrowth

BACKGROUND AND OBJECTIVE

Gingival overgrowth is a prominent side effect of cyclosporine (CsA) therapy in renal transplant patients. Although the exact mechanism by which this drug induces gingival overgrowth is uncertain, marked variations in individual susceptibility to this drug suggest a genetic predisposition. Studies have shown that genetic variation (polymorphism) in the trinucleotide cytosine-adenine- guanine (CAG) sequence in exon 1 of the androgen receptor (AR) gene is related to altered activity of the AR as a transcription factor. However, the relationship between the length of the CAG repeat and gingival overgrowth has not yet been studied. The present study was carried out to determine whether there is an association between CsA-induced gingival overgrowth and the length of the CAG repeats in the AR gene.

MATERIAL AND METHODS

Genomic DNA samples were prepared from the blood of 50 renal transplant patients with CsA-induced gingival overgrowth and from the blood of 100 renal transplant patients on CsA with no gingival overgrowth.

RESULTS

The difference in allele distribution among the subjects with gingival overgrowth and control samples was statistically significant (p = 0.001).

CONCLUSION

The findings suggest a link between CsA7induced gingival overgrowth and a smaller size of CAG repeat in the AR gene.

Interleukin-10 gene promoter polymorphisms are associated with cyclosporin A-induced gingival overgrowth in renal transplant patients

OBJECTIVE

Interleukin-10 (IL-10) is an anti-inflammatory cytokine whose genetic polymorphisms are associated with the production of IL-10 and the susceptibility to periodontal diseases. The aim of this study was to investigate the possible association of IL-10 single nucleotide polymorphisms (SNPs) and cyclosporin A (CsA)-induced gingival overgrowth (GO) in renal transplant patients in a Chinese population, taking into account subgingival microbiota as additional variables.

MATERIAL AND METHODS

A total of 202 patients were dichotomized into two groups: 122 with GO and 80 without GO. The IL-10-1082 SNP, -819 SNP and -592 SNP were measured using an allele-specific PCR method. The levels of subgingival bacteria were measured by real-time PCR. Genotype and allele frequencies were analyzed using the Chi-square test and logistic regression analysis.

RESULTS

The frequency of IL-10-819TT (-592AA) genotype was statistically higher in patients with GO than that in patients without GO (P<0.05). Multiple logistic regression analysis demonstrated that the prevalence of GO is not dependent on age, gender, and pharmacological variables, being significantly associated with the carriers of ATA haplotype (OR=2.425, 95%CI=1.214-4.845, P=0.012). Moreover, ATA positive carriers in the GO group presented significantly higher levels of Porphyromonas gingivalis and Treponema denticola than those negative carriers.

CONCLUSIONS

Our results show that IL-10-819TT (-592AA) genotype and ATA halpotype are associated with susceptibility to CsA-induced GO. Meanwhile, ATA haplotype is associated with a higher detection of P. gingivalis and T. denticola in GO patients, and may increase the risk of developing GO.

Effects of tacrolimus and nifedipine, alone or in combination, on gingival tissues

BACKGROUND

The aim of this study is to compare gingival changes induced by short- and long-term tacrolimus and nifedipine administration, alone or in combination, and evaluate the expression levels of tumor suppressor phosphatase and tensin homolog (PTEN) in drug-induced gingival overgrowth.

METHODS

Eighty rats were equally divided into eight groups: 1) tacrolimus for 8 weeks; 2) nifedipine for 8 weeks; 3) tacrolimus and nifedipine for 8 weeks; 4) 8-week control; 5) tacrolimus for 24 weeks; 6) nifedipine for 24 weeks; 7) tacrolimus and nifedipine for 24 weeks; and 8) 24-week control. Histomorphometric analyses included measurements of epithelial thickness, connective tissue thickness, and height. Stereologic analyses included measurements of volumetric densities of fibroblasts (Vf), collagen fibers (Vcf), and blood vessels (Vbv). In addition, PTEN expression was analyzed using immunohistochemistry.

RESULTS

Epithelial thickness and connective tissue thickness were significantly increased in groups 5, 6, and 7 compared to group 8 (P <0.05), whereas connective tissue height was significantly increased in groups 5 and 7 (P <0.001). Vf and Vcf were significantly increased in group 7 compared to group 8 (P <0.001). PTEN immunoreactivity was significantly decreased in all experimental groups compared to the control groups (P <0.05).

CONCLUSIONS

Results suggest that duration of drug administration is a more important risk factor than drug combination. The results include a potentially new insight about PTEN's role in the etiology of drug-induced gingival overgrowth.

Matrix metalloproteinases, tissue inhibitors of matrix metalloproteinases, and inflammation in cyclosporine A-induced gingival enlargement: a pilot in vitro study using a three-dimensional model of the human oral mucosa

BACKGROUND

It has been suggested that cyclosporine A (CsA) induces gingival enlargement by promoting an increase in the gingival extracellular matrix (ECM). Nonetheless, the variable occurrence of CsA-induced gingival enlargement in patients receiving this medication indicates a multifactorial pathogenesis. Clinical observations suggest that local inflammation is associated with the development and severity of CsA-induced gingival enlargement. Therefore, the purpose of this study is to investigate the effects of CsA and inflammation on the production of ECM homeostatic mediators.

METHODS

The effects of CsA and inflammation (as assessed using interleukin [IL]-1β) on the secretion of mediators involved in ECM homeostasis were determined using fibroblast monolayers and three-dimensional (3D) models of the human oral mucosa. Fibroblast monolayers and 3D cultures were treated with CsA alone or in combination with IL-1β for up to 72 hours, and the secretion of matrix metalloproteinases (MMPs) 1, 2, 3, 8, 9, 10, and 13 and tissue inhibitors of MMPs (TIMPs) 1, 2, and 4 into the culture medium was assessed using enzyme-linked immunoassay-based antibody arrays.

RESULTS

Fibroblast monolayers responded to CsA with no changes in the secretion of ECM mediators. Conversely, 3D cultures responded to CsA treatment with a reduction in MMP-10 secretion. IL-1β alone triggered higher secretory levels of MMPs in both fibroblast monolayers (MMP-3 and MMP-10) and 3D cultures (MMP-9 and MMP-10). Importantly, fibroblast monolayers and 3D cultures treated with a combination of IL-1β and CsA showed a decrease in the MMP-1/TIMP-1 ratio.

CONCLUSIONS

These data support the hypothesis that inflammation may alter the pathogenesis of CsA-induced gingival enlargement by promoting a synergistic decrease in the MMP-1/TIMP-1 ratio.

Low prevalence of gingival overgrowth associated to new imunossupressive protocols with cyclosporin

Gingival overgrowth (GO) is a frequent finding in patients treated with cyclosporine (CsA). This study investigated the prevalence and severity of GO in patients who received kidney transplant and CsA therapy, as well as associations with pharmacological and clinical factors. This cross-sectional study included 63 kidney transplant recipients who were treated with CsA in a university hospital. Demographic, pharmacological, and periodontal data were collected. The primary variable was GO. Independent sample t- and chi-square tests were used to compare means in groups with versus without GO. The response rate was 86.3%. Overall, 40% of patients had some degree of GO. Eleven individuals presented GO scores > 10%, and 5 individuals reached 30%. The mean GO percentage was low (6.79 ± 15.83). Patients that were concurrently under nifedipine treatment showed a non-significant trend toward a greater prevalence of GO. Mean CsA dosage and serum levels were 3.20 ± 0.94 mg/kg/d and 156.12 ± 162.75 ng/mL, respectively. There were no statistically significant differences between patients with versus without GO nor between the groups receiving nifedipine, no drug, or verapamil. The GO prevalence and severity rates were lower than those reported in previous studies and seemed to be independent of drug interactions.

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.

Gingival overgrowth in subjects under immunosuppressive regimens based on cyclosporine, tacrolimus, or sirolimus

AIM

To assess the prevalence and variables associated with gingival overgrowth (GO) in renal transplant recipients medicated with cyclosporine (CsA), tacrolimus (Tcr), or sirolimus (Sir).

MATERIALS AND METHODS

One hundred and thirty-five eligible subjects were divided in CsA, Tcr, and Sir groups comprising 45 subjects each. GO was visually assessed and subjects were assigned as GO+ or GO- in a post hoc definition. Saliva samples were collected and the presence of periodontal pathogens was assessed through polymerase chain reaction. Variables of interest were compared between GO+ and GO- subjects through univariate and multivariate analysis.

RESULTS

Prevalence of GO was of 60.0% for CsA, 28.9% for Tcr, and 15.6% for Sir groups. Within the CsA group, GO was associated with papillary bleeding index (p=0.001); within the Tcr group, GO was associated with CsA previous use (p=0.013), and calcium channel blockers (CCB) use (p=0.003); within the Sir group, GO was associated with papillary bleeding index (p=0.018), and CCB use (p=0.020). A higher frequency of Tannerella forsythia was observed among GO+ subjects medicated with Tcr.

CONCLUSION

Pharmacological and periodontal variables were associated with GO in different immunosuppressive regimens. Integration between the medical and the dental team may be an important approach in the post-transplant maintenance routine.

Gingival overgrowth among patients medicated with cyclosporin A and tacrolimus undergoing renal transplantation: a prospective study

BACKGROUND

The aim of this study is to make a longitudinal evaluation of the incidence and severity of gingival overgrowth (GO) induced by immunosuppressive agents, such as tacrolimus (Tcr) and cyclosporin A (CsA), in the absence of calcium channel blockers in patients undergoing renal transplantation (RT).

METHODS

This longitudinal study is conducted in 49 patients with RT who were divided into a CsA group (n = 25) and Tcr group (n = 24). The individuals were assessed at four time intervals: before transplant and 30, 90, and 180 days after RTs. Demographic data and periodontal clinical parameters (plaque index, cemento-enamel junction to the gingival margin, probing depth, clinical attachment level, bleeding on probing [BOP], and GO) were collected at all time intervals.

RESULTS

The mean GO index was significantly lower in the Tcr group compared to the CsA group after 30 (P = 0.03), 90 (P = 0.004), and 180 (P = 0.01) days of immunosuppressive therapy. One hundred eighty days after RTs, a clinically significant GO was observed in 20.0% of individuals in the CsA group and 8.3% of individuals in the Tcr group. However, this difference was not statistically significant (P = 0.41). There was a reduction in periodontal clinical parameters regarding the time of immunosuppressive therapy for PI and BOP (P <0.001) in both groups.

CONCLUSION

Although there was no statistical difference in the incidences of clinically significant GO after 180 days of immunosuppressive therapy, it was observed that GO occurred later in the Tcr group, and the severity of GO in this group was lower than in patients who used CsA.

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.

Oral disease burden and utilization of dental care patterns among pediatric solid organ transplant recipients

OBJECTIVES

We conducted a study among pediatric renal (RTRs) and liver transplant recipients (LTRs) to determine: a) the overall burden of oral disease; and b) the frequency with which this population utilizes dental care services in relation to sociodemographic factors and oral disease burden.

METHODS

In this cross-sectional survey, study procedures included the completion of a standardized questionnaire (by parents/guardians), oral mucosal examination, assessment of caries, gingival enlargement, and plaque index.

RESULTS

The 142 children (82 RTRs and 60 LTRs) enrolled from April 2002 to November 2005 were predominantly Latino (41 percent) and Caucasian (34 percent). Forty-three percent had at least one carious surface (in either a deciduous or permanent tooth), 19 percent had five or more carious surfaces, and 25 percent had gingival enlargement. We found only one case of oral candidiasis. Even though 72 percent of parents/guardians reported their child had a regular source of dental care, only 49 percent had a dental cleaning and 44 percent had dental radiographs in the past year, reflecting a low prevalence of preventive dental care. Among children with no regular source of dental care, there were statistically significantly higher proportions of Latinos, younger children, and families with an annual household income <$35,000.

CONCLUSION

While the prevalence of oral mucosal disease and gingival enlargement was low, the prevalence of children with caries was high, and there was low use of preventive dental care. Strategies to improve this population's utilization of preventive dental care are needed.

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.

Gingival enlargement among renal transplant recipients in the era of new-generation immunosuppressants

BACKGROUND

Tacrolimus is a new-generation immunosuppressant as successful as cyclosporin in suppressing organ transplant rejection. Although cyclosporin is known to cause gingival enlargement (GE), tacrolimus has not been associated with this condition. We sought to explore the prevalence of GE among renal transplant recipients (RTRs) in relation to cyclosporin and tacrolimus while controlling for the effect of calcium channel blockers (CCBs) and supragingival plaque.

METHODS

RTRs were recruited from our institution's Kidney Transplant Unit. Participants completed a standardized questionnaire and received a complete oral examination, including a soft tissue examination and a periodontal examination measuring probing depth, recession, bleeding on probing, plaque index (PI), and GE.

RESULTS

Among 115 RTRs, 39 (34%) presented with GE, with the highest prevalence among those taking cyclosporin and CCBs (76%) and the lowest among tacrolimus users not on a CCB (15%). Tacrolimus was not found to be associated with GE. Cyclosporin was found to be associated with GE in a univariate analysis stratified by the use of CCBs, but multivariate analysis revealed that the only significant risk factors for GE were the use of CCBs and the widespread presence of abundant supragingival plaque (PI > or =2 on >40% of tooth surfaces).

CONCLUSIONS

This study confirmed that tacrolimus is not associated with GE. Cyclosporin taken at the currently recommended low dosage and not in combination with a CCB may not be associated with a significant risk for GE in individuals with good oral hygiene. CCBs should be avoided among patients taking cyclosporin and those with poor oral hygiene.

Gingival crevicular fluid transforming growth factor-beta1 in cyclosporine and tacrolimus treated renal transplant patients without gingival overgrowth

BACKGROUND

Gingival crevicular fluid (GCF) levels of transforming growth factor-beta(1) (TGF-beta(1)) have been previously investigated in relation to the pathogenesis of cyclosporine-A (CsA)-induced gingival overgrowth (GO) but no clinical data are available regarding the GCF levels of TGF-beta(1) in patients treated with tacrolimus (Tac). However, as gingival inflammation is pronounced at sites of GO and this consequently may lead to an elevation in TGF-beta(1) levels the present study aimed to evaluate gingival crevicular fluid (GCF) TGF-beta(1) levels in renal transplant patients using CsA or Tac without GO.

METHODS

GCF TGF-beta(1) levels were investigated in 30 renal transplant patients without GO medicated with either CsA (n=15) or Tac (n=15). Sixteen gingivitis patients and 15 periodontally healthy subjects were selected as controls. Periodontal status was evaluated by measuring probing depth, plaque index and papilla bleeding index. The TGF-beta(1) levels were analysed by enzyme-linked immunosorbent assay.

RESULTS

Both CsA and Tac groups had significantly elevated GCF TGF-beta(1) total amount compared to gingivitis and healthy groups (p<0.008). GCF TGF-beta(1) total amount of CsA and Tac groups was similar (p>0.008). Gingivitis and healthy groups had also similar GCF TGF-beta(1) total amount (p>0.008).

CONCLUSIONS

Within the limits of the present data it is unlikely that TGF-beta(1) is an exclusive mediator of CsA- or Tac-induced GO. However, pathogenesis of GO is multifactorial and contribution of TGF-beta(1) to the interrelations between cytokines and growth factors with fibrogenic potential cannot be disregarded.

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.