Prevalence of gingival overgrowth induced by antihypertensive drugs: A hospital-based study

Targeting SRD5A1 and MMP-2/NLRP3/TGF-β1 axis alleviates the amlodipine-induced gingival hyperplasia in rats: Emerging role of saw palmetto and folic acid

Saw palmetto (SAW), the herbal drug used to treat prostatic hyperplasia, exerts its antiproliferative effects by blocking steroid 5 alpha-reductase (SRD5A1) activity, that has also been involved in gingival hyperplasia (GH) pathogenesis. Concurrently, folic acid (FA) could reduce GH prevalence via its antioxidant and anti-inflammatory effects. Thus, this study tended to assess the potential therapeutic efficacy of SAW, alone and along with FA, against amlodipine-induced gingival inflammation and overgrowth in rats. Rats were grouped into (CONT, AIGH, SAW, SAW-treated, FA-treated, and SAW + FA-treated). SAW and FA were administered once daily for 4 weeks. Gingival SRD5A1, CTGF, GSK-3β, and NLRP3 expressions, as well as T, DHT, MDA, TAC, ET-1, and MMP2 levels were determined. In addition, histopathological and immunohistochemical analyses of TNF-α, IL-6, TGF-β1, and α-SMA were documented. Results declared that SAW and FA administration markedly ameliorated amlodipine-associated GH and may be presenting a novel therapeutic avenue in the future.

Nifedipine-Influenced Enlargement of the Masticatory Mucosa in an Elderly Edentulous Patient: A Rare Case Report with a Two-Year Follow-Up

Drug-influenced gingival enlargement is a common side effect associated with certain medications, particularly calcium channel blockers like nifedipine, which has been extensively documented. However, the occurrence of nifedipine-influenced masticatory mucosa overgrowth in edentulous patients is rare. Here, we present a case of nifedipine-influenced mucosal enlargement persisting in a 67-year-old edentulous patient 3 months after the extraction of all his teeth. The patient underwent flap surgery and alveoloplasty to excise the overgrown tissue, followed by complete denture restoration. The antihypertensive medication was replaced with valsartan. A 2-year follow-up revealed no recurrence of overgrowth, indicating the effectiveness of this management strategy for such clinical situation.

Calcium Channel Blockers- Induced Iatrogenic Gingival Hyperplasia: Case Series

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

Gingival Enlargement Caused by Calcium Channel Blockers

Calcium channel blockers, a group of drugs widely used in the treatment of cardiovascular patients, although effective, often cause gingival enlargement, a side effect that is rarely recognized in clinical practice and is not given sufficient importance. Gingival enlargement caused by calcium channel blockers can be localized or generalized, mild or severe. It can negatively affect patients’ appearance, mastication, and speech, thus considerably reducing the quality of life of patients. Risk factors and pathogenesis of this side effect have been the subject of many studies but are still unknown, making this condition a major therapeutic challenge, especially if the cessation of the offending drug is not possible. This study aimed to review the etiology, potential risk factors, pathogenesis, clinical features, and therapy possibilities for gingival enlargement caused by calcium channel blockers.

Calcium Channel Blockers Induced Gingival Overgrowth: A Comprehensive Review from a Dental Perspective

BACKGROUND

Gingival overgrowth (GO) as a manifestation of calcium channel blockers (CCBs) was first introduced in the literature by Ramon et al. in 1984. Since then, the use of CCBs as a treatment modality for hypertension has been recorded extensively in the literature for its association with GO.

AIM

The aim of our study is to evaluate histopathology, treatment, and follow-up for the cases detailed in various studies and also to highlight the protocol mentioned to identify these presentations.

MATERIALS AND METHODS

A broad search was conducted from the period 1980 to 2021 using electronic databases PubMed Central, Scopus, Cochrane, and SciELO databases. About 293 articles were initially chosen. The articles further excluded did not fit the criteria for the study and eventually 50 articles which met the inclusion criteria were chosen as part of this literature review.

RESULTS

A comparative analysis was carried out regarding histopathology, treatment modalities, drug dosage, and duration to evaluate the differences in cases between 1980 and 2021. From the available studies, it was found that the histopathological and clinical findings were varied. Treatment strategies employed were different, though follow-ups in most cases were uniform.

CONCLUSION

CCBs and their relationship with GO have been widely reported in the literature. Dentists should approach this condition by taking appropriate medical and dental history and follow evidence-based treatment guidelines to provide more relevant and judicious management of this condition. Inter-disciplinary treatment approaches would provide better outcomes.

Treatment of calcium channel blocker-induced gingival overgrowth without modifying medication

Gingival overgrowth is a common side effect of calcium channel blockers used in the treatment of cardiovascular diseases. While controversial, management includes discontinuing the calcium channel blocker. We report the case of a 66-year-old Japanese man with hypertension and type 2 diabetes mellitus who was diagnosed with severe periodontitis covering almost all the teeth. The patient had been on nifedipine (40 mg/day) and amlodipine (10 mg/day) medication for 5 years. With his physician's consent, nifedipine was discontinued during his treatment for periodontitis, which consisted of oral hygiene instructions and scaling and root planing on all areas. Gingivectomy was performed on the areas of hard fibrous swelling. Nifedipine was resumed during periodontal treatment when the patient's hypertension worsened. His periodontal scores improved when he resumed treatment. We report that significant improvement in gingival overgrowth can occur with basic periodontal treatment, surgery and sustained intensive follow-up without adjusting calcium channel blockers.

miR-4651 inhibits cell proliferation of gingival mesenchymal stem cells by inhibiting HMGA2 under nifedipine treatment

Drug-induced gingival overgrowth (DIGO) is recognized as a side effect of nifedipine (NIF); however, the underlying molecular mechanisms remain unknown. In this study, we found that overexpressed miR-4651 inhibits cell proliferation and induces G0/G1-phase arrest in gingival mesenchymal stem cells (GMSCs) with or without NIF treatment. Furthermore, sequential window acquisition of all theoretical mass spectra (SWATH-MS) analysis, bioinformatics analysis, and dual-luciferase report assay results confirmed that high-mobility group AT-hook 2 (HMGA2) is the downstream target gene of miR-4651. Overexpression of HMGA2 enhanced GMSC proliferation and accelerated the cell cycle with or without NIF treatment. The present study demonstrates that miR-4651 inhibits the proliferation of GMSCs and arrests the cell cycle at the G0/G1 phase by upregulating cyclin D and CDK2 while downregulating cyclin E through inhibition of HMGA2 under NIF stimulation. These findings reveal a novel mechanism regulating DIGO progression and suggest the potential of miR-4651 and HMGA2 as therapeutic targets.

The Management of Drug-Influenced Gingival Enlargement

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

Case report on low dose of Cilnidipine: A fourth-generation calcium channel blocker-induced gingival overgrowth

Drug-induced gingival overgrowth is a frequently observed adverse effect of antihypertensive drug calcium channel blockers (CCBs). Gingival enlargements are more common with the dihydropyridine class of CCBs. The fourth-generation dihydropyridine CCB Cilnidipine was introduced in 1995 and is used as an antihypertensive agent for patients in the Indian subcontinent. This is the first report in literature to document an isolated case of generalized gingival overgrowth induced by the long-term use of low dose of cilnidipine in an elderly female patient who is under antihypertensive therapy. Gingival overgrowth is an adverse drug reaction of new-generation CCB Cilnidipine when administered even as low-dose antihypertensive therapy agent. Physicians and dentists should identify such late changes in susceptible individuals.

Periodontal complications of prescription and recreational drugs

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

Is dental plaque the only etiological factor in Amlodipine induced gingival overgrowth? A systematic review of evidence

BACKGROUND

Amlodipine, a dihydropyridine calcium channel blocker (CCB) is commonly prescribed for cardiovascular conditions. Its administration may produce an uncommon adverse oral manifestation, the gingival overgrowth (GO). Lately, there has been an increase in the rate of GO in patients on amlodipine therapy. The current systematic review was undertaken to evaluate the evidence on plausible risk factors involved in amlodipine induced gingival overgrowth (AIGO).

MATERIAL AND METHODS

Literature search was conducted in the databases like Pubmed (Medline), Scopus and Google Scholar to include the original research articles related to etio-pathogenesis of AIGO.

RESULTS

About 270 documents were identified through primary search, of which 13 original research articles were included. Most common risk factor for AIGO was administration of amlodipine in subjects with poor plaque control. However, high dosage of drug, duration of therapy and inherent genetic susceptibility were recognized as other plausible risk factors.

CONCLUSIONS

It was concluded that AIGO is no longer a rare phenomenon. It is therefore imperative for the physician to identify and inform patients, about the risk factors associated with the overgrowth at the initiation of therapy. This would prevent the development of GO's and improve the patient's quality of life. Key words:Amlodipine, calcium channel blockers, gingival overgrowth, hypertension.