A rare case of idiopathic multiple hyperplasia of inflammatory granulation in the oral cavity

Cases of idiopathic gingival enlargement are so infrequent that the etiology and treatment are subjects of discussion. The case of a 49-year-old woman who presented with a rapidly diffuse enlargement of gingiva, clusters of patches on the buccal mucosa, and a furry-coated tongue within 2 months is reported. Results of various laboratory investigations and additional tests, such as the antineutrophil cytoplasmic antibodies (ANCA) and autoantibody to nuclear antigen (ANA) tests, were all negative. Histopathologic examination showed hyperplasia of inflammatory granulation tissues. Oral steroid therapy was effective. Although cases of multiple hyperplasia of inflammatory granulation in the oral cavity are very rare, clinicians should be aware of such cases and understand the efforts to further delineate the etiology, the management, and the prevention of the recurrence of this condition.

Amlodipine-induced gingival hyperplasia in chronic renal failure: a case report

Amlodipine is a dihydropyridine calcium channel blocker that is used in the management of both hypertension and angina. Amlodipine induced side effects are headache, dizziness, edema, flushing, palpitations, and rarely gingival hyperplasia. The exact reason of amlodipine-induced gingival hyperplasia is not known. We presented a case with chronic renal failure (CRF) that developed gingival hyperplasia due to amlodipine use, which improved after ceasing the drug.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review

BACKGROUND

Hyperplastic granular gingivitis or "strawberry gingivitis" is a rare manifestation of Wegener's granulomatosis (WG), but it is nearly pathognomonic for this multisystem autoimmune vasculitis. The dentist may be the first health care professional to see patients with symptoms and findings of this condition. Early diagnosis and treatment is the most important factor in the management of this potentially fatal disease.

METHODS

The authors present three case reports that demonstrate the disease spectrum and conducted a literature review focused on current understanding of this disease.

RESULTS

The first patient had only the classic gingival manifestations of the disease. The second patient had simultaneous typical gingival lesions, as well as dermatologic findings. The third patient had an atypical oral presentation of aphthous ulcers and erythematous gingiva, as well as respiratory and genital involvement. Reaching a definitive diagnosis sometimes is challenging owing to the subtle onset of the disease and variable clinical and laboratory findings.

CONCLUSION AND CLINICAL IMPLICATIONS

Clinicians should be familiar with the broad variety of oral and systemic components of WG, as well as strategies to facilitate prompt disease recognition and to provide continued oral health care to these medically complex patients.

Drug-associated gingival enlargement: case report and review of aetiology, management and evidence-based outcomes of treatment

"Gingival enlargement" is the term now used to describe medication-related gingival overgrowth or gingival hyperplasia (AAP, 2004), a condition commonly induced by three main classes of drugs: anticonvulsants, antihypertensive calcium antagonists and the immunosuppressant cyclosporin. It is important that the health practitioner is aware of the potential aetiologic agents and characteristic features in order to be able to accurately diagnose and successfully manage patients who present with a condition such as outlined in the following case presentation.

Effects of azithromycin on cyclosporine-induced gingival hyperplasia in renal transplant patients

BACKGROUND

Gingival hyperplasia is a well-known complication of cyclosporine therapy, affecting 21% to 35% of renal transplant patients. Metronidazole, clarithromycin, and azithromycin, all azalid antimicrobial agents derived from the macrolide antibiotic erythromycin, have been used for treatment. Marked improvements in gingival hyperplasia have been recorded in particular with azithromycin. The aim of the present study was to investigate histopathological features of cyclosporine-induced gingival hyperplasia and to evaluate the quantitative efficacy of short-term azithromycin therapy.

METHODS

Eighteen renal transplant patients with cyclosporine-induced gingival hyperplasia were included in the study. All patients received azithromycin with a dose of 500 mg/d for 3 consecutive days. Changes in gingival hyperplasia were evaluated by measuring the gingival sulcus depth to the cementum-enamel junction of every tooth in each of the four quadrants on days 0, 7, 30, 90, 180. Gum biopsies were obtained on days 0 and 30; the degree of inflammation was classified as "mild," "intermediate," and "severe".

RESULTS

Gingival hyperplasia was reduced in all treated patients throughout the study. The degree of improvement was more significant between 0 to 7 and 7 to 30 days than at other times (respectively, P < .0001 and P < .002). Histopathologically, eight patients had severe and one patient moderate chronic inflammation at the beginning of therapy. Three other biopsies were reported as papilloma, mucosal hyperplasia, and normal gingival tissue biopsy.

CONCLUSIONS

Azithromycin appears to be useful to treat cyclosporine-induced gingival hyperplasia in renal transplant patients. Treatment is inexpensive and free from known adverse effects.

Gingival overgrowth in kidney transplant recipients treated with cyclosporine and its relationship with chronic graft nephropathy

Our previous study of a group of renal transplant recipients treated with CsA showed a significantly faster development of chronic graft failure among patients with gingival hyperplasia (GH) compared to unaffected patients. The aim of the present research was to establish the impact of CsA dose and blood levels on the incidence of chronic graft nephropathy and gingival overgrowth as well as to assess risk factors for chronic graft nephropathy. The study included 64 renal graft recipients (32 patients with GH and 32 without GH) transplanted between 1989 and 1994. There were no significant differences between the pretransplant demographic and clinical data of the patients with and without GH. Patients with GH received a significantly higher total yearly dosages of CsA compared those without GH (P <.03). Serum creatinine in the first year posttransplant in patients with GH was 1.9 mg/dL versus 1.6 mg/dL in those without GH. During 9 to 14 years follow-up, end-stage renal failure due to chronic nephropathy occurred in 18 patients (56%) with GH and eight patients (25%) without GH. Ten-year renal graft survival was 35% in GH patients and 69% in patients without GH. Ten-year patient survival was 69% in the GH group and 91% in the group without GH. CsA dosage was a risk factor for GH and for graft loss, which implies a role of CsA toxic effects on the pathological mechanisms of GH and of chronic allograft nephropathy.

Strawberry gingiva: a distinctive sign in Wegener's granulomatosis

A 37-year-old man presented with gingival hyperplasia accompanied by an ulcer on the eyelid, nasal obstruction, ear discharge, and discharging nodules on the cheek and back. An evaluation for infectious diseases and leukemia was negative. During his hospital stay, he had fever and migratory joint pains develop, suggesting a diagnosis of Wegener's granulomatosis, which was confirmed by a strongly positive cytoplasmic antineutrophil cytoplasmic antibody test. He responded promptly to treatment with oral prednisolone and cyclophosphamide. In retrospect, the diagnosis could have been suspected earlier because of the distinctive red, friable, and granular appearance of the gingiva.

Is oral azithromycin effective for the treatment of cyclosporine-induced gingival hyperplasia in cardiac transplant recipients?

Anecdotal evidence suggests that azithromycin is effective for the treatment of cyclosporine-induced gingival hyperplasia in solid-organ transplant recipients. We present the cases of two heart transplant patients who insidiously developed gingival hyperplasia, likely because of immunosuppression with cyclosporine, which was treated with azithromycin. Evidence supporting the efficacy of azithromycin in the treatment of cyclosporine-induced gingival hyperplasia in solid organ transplant recipients was searched for, identified, and then critically assessed. While no data were found specifically evaluating azithromycin in cardiac transplant patients, there were nine pertinent papers identified that evaluated the clinical question of interest in the renal transplant population [Wahlstrom et al. (1995) The New England Journal of Medicine 332, 753; Boran et al. (1996) Transplantation Proceedings 28, 2316; Gomez et al. (1997) Nephrology Dialysis Transplantation 12, 2694; Ljutic (1997) Dialysis & Transplantation 26, 787; Puig et al. (1997) Transplantation Proceedings 29, 2379; Nash et al. (1998) Transplantation 65, 1611; Nowicki et al. (1998) Annals of Transplantation 3, 25; Wirnsberger et al. (1998) Transplantation Proceedings 30, 2117; Citterio et al. (2001) Transplantation Proceedings 33, 2134]. These studies and case reports are summarized. While more evidence is required to support routine use of azithromycin for the treatment of cyclosporine-induced gingival hyperplasia in cardiac transplant recipients, preliminary published evidence from renal transplant patients is certainly favourable.

The effect of conversion from cyclosporine to tacrolimus on gingival hyperplasia, hirsutism and cholesterol

The use of cyclosporine for immunosuppression in renal transplantation allograft recipients is associated with hypertrichosis, gingival hyperplasia, and hypercholesterolemia. Conversion of patients to tacrolimus may lead to an improvement in these effects with minimal risk of rejection or allograft dysfunction.

METHODS

Sixteen renal transplant recipients were prospectively converted from CsA to tacrolimus and followed for 1 year. Gingival hyperplasia index, total cholesterol, and blood pressure were recorded at the outset, 4-, 8-, and 12-month intervals. Glomerular filtration rate was checked before conversion and 1 year later. Photographs documenting hypertrichosis were taken before conversion and 1 year later. Adverse effects from tacrolimus were recorded at 4, 8, and 12 months.

RESULTS

Twelve patients with hypertrichosis noted rapid improvement. Mean gingival hyperplasia index decreased from 24 to 6; mean total cholesterol decreased from 237 to 195. Glomerular filtration rate was essentially unchanged (56 to 54). One episode of rejection occurred, three patients developed diarrhea, three noted headaches, and one had a tremor.

CONCLUSION

If carefully monitored, patients suffering adverse effects secondary to cyclosporine may be converted to tacrolimus with minimal risk of allograft dysfunction or rejection.

Partial regression of advanced cyclosporin-induced gingival hyperplasia after treatment with azithromycin. A case report

Gingival hyperplasia is a well recognised complication of cyclosporin A therapy. Although its pathogenesis is still debated in several recent reports a second generation macrolide antibiotic-azithromycin induced partial or even complete regression of hyperplasia. We present a patient after kidney transplantation treated with cyclosporin who developed very advanced gigival overgrowth (stage 3+). The patient received a 3-day treatment with azithromycin which was repeated after 3 months. The first course of the drug caused a partial regression of gingival hyperplasia during following months but the repeated treatment did not provide a further regression of the changes.

Efficacy of azithromycin in the treatment of cyclosporine-induced gingival hyperplasia in renal transplant recipients

BACKGROUND

Gingival hyperplasia (GH) is a common side effect of cyclosporine . Azithromycin (Zithromax; AZI) is a macrolide antibiotic reported in case studies to reduce cyclosporine-induced gingival hyperplasia (CIGH) in renal transplant recipients (RTR).

METHODS

The efficacy of AZI to treat CIGH in RTR was examined in a double-blind, randomized crossover trial. Patients (n=17) with CIGH were randomized to receive AZI and a matching placebo in alternate order for 5 days, separated by a 2-week washout period. Follow-up visits were conducted at week 6 and week 12. Changes in GH were evaluated by measuring the clinical gingival sulcus depths, tooth length, and the length of the interdental papillae to the cementum-enamel junction of two teeth in each of the four quadrants.

RESULTS

Significant improvements were observed in all three types of periodontal measurements, representing reductions of gingival tissue above the medial aspect of the tooth, of the gingival sulcus depth, and of the length of the interdental papillae. Patients reported an improvement in gum bleeding. AZI was well tolerated, and 67% of the patients reported that the treatment was at least somewhat useful.

CONCLUSIONS

AZI should be considered for RTR with CIGH.

Treatment of cyclosporin-induced gingival hyperplasia with azithromycin

BACKGROUND

Gingival hyperplasia is a known complication of cyclosporin therapy. Although plaque control has been shown to be of benefit, gingival surgery is occasionally necessary. The aim of this study was to review the effect of a short-course therapy with azithromycin in renal transplant patients with cyclosporin-induced gingival hyperplasia.

METHODS

Thirty-eight patients received 500 mg/day of azithromycin for 3 consecutive days. The degree of gingival hyperplasia was classified as: 0, no gingival overgrowth; 1, mild overgrowth; 2, moderate overgrowth, and 3, severe overgrowth. Gingival bleeding and evolution of gingival hyperplasia were determined at 0 (pretreatment), 7, 30, 90 and 180 days. Cyclosporin, serum creatinine and ALT levels were simultaneously determined on the same days.

RESULTS

Seven patients were excluded, leaving a total of 31 included in the trial. Eleven had a score of 3, 17 a score of 2, and 3 a score of 1. The degree of gingival hyperplasia was unrelated to the dose and levels of cyclosporin. Gingival hyperplasia improved in all patients (P < 0.001, Friedman test). The degree of improvement was better when the degree of hyperplasia was lower. In 27 patients gingival hyperplasia remained absent 6 months later, 3 patients required a second course of treatment, and another required gingival surgery. Gingival bleeding, present in 28 patients when diagnosed, disappeared in all cases in 2.2 +/- 1.2 (1-7) days. No adverse effects were observed. Cyclosporin, serum creatinine, and ALT levels were not affected by treatment.

CONCLUSIONS

Azithromycin improves cyclosporin-associated gingival hyperplasia, especially when administered early in the process.

Oral metronidazole does not improve cyclosporine A-induced gingival hyperplasia

Recently, resolution of cyclosporine A (CSA)-induced gingival hyperplasia was reported with antibiotic treatment. We therefore assessed the oral status of 45 children on CSA after renal transplantation and evaluated the effects of metronidazole treatment in children with high-grade gingival hyperplasia. Gingival hyperplasia was absent in 19 (42%), mild in 5 (11%), moderate in 13 (29%), and severe in 8 (18%) children. There was no significantly different incidence in high-grade gingival hyperplasia (moderate and severe) between children with (16 of 30) or without (5 of 15) concomitant treatment with calcium channel blockers. The mean trough level of CSA was not different between children with varying severities of gingival hyperplasia. We treated 13 children with high-grade CSA-induced gingival hyperplasia (9 boys, 4 girls, mean age 14.2 +/- 3.4 years) with 750 mg metronidazole in three divided doses (10-25 mg/kg) for a total of 7 days. All 13 children were concomitantly treated with calcium channel blockers for hypertension; their mean monoclonal CSA trough level was 246 +/- 34 ng/ml. Oral examination and photographic documentation were performed by the same examiner on all patients before and 1 and 3 months after metronidazole treatment. We found no changes in gingival hyperplasia; gingival inflammation improved in 5 children (P = ns). We conclude that synergistic effects of calcium channel blockers and high concentrations of CSA in our population may outweigh beneficial effects of metronidazole treatment of CSA-induced gingival hyperplasia after renal transplantation.

'Strawberry gums'--a case of Wegener's granulomatosis

We report a case of Wegener's granulomatosis (WG), localised to the upper aerodigestive tract, which presented as an unusual form of hyperplastic gingivitis in a 36-year-old female. The clinical, serological and histopathological findings are described. The resemblance of the affected gums to over-ripe strawberries is emphasised, in order to draw attention to this characteristic oral manifestation of a rare and potentially life-threatening condition. The response to co-trimoxazole as sole therapy is noted.

The administration of folic acid to institutionalized epileptic adults with phenytoin-induced gingival hyperplasia. A double-blind, randomized, placebo-controlled, parallel study

Twenty severely retarded institutionalized epileptic adults with phenytoin-induced gingival hyperplasia were divided into two groups and received a daily 3 mg capsule of either folic acid or lactose for 16 weeks in a randomized, double-blind, parallel study. Serum folate and phenytoin levels were recorded at baseline and on completion of the study. Twelve areas of the gingiva on each patient were graded at 4-week intervals for 16 weeks with respect to the three indexes: hyperplasia, gingival health, and plaque index. There were no significant differences between treatment groups for any of the three indexes over time. The poststudy serum folate levels were three times baseline levels for the active drug group (p less than 0.001) but unchanged in the placebo group. Phenytoin blood levels that began within the therapeutic window (10 to 20 micrograms/ml) tended to remain within the therapeutic window for both groups, with no reported seizure activity. A single daily oral 3 mg capsule of folic acid did not show efficacy as the sole therapeutic agent in the reduction of phenytoin-induced gingival hyperplasia.

Folate treatment of diphenylhydantoin-induced gingival hyperplasia

It has recently been reported that folic acid supplementation reduced DPH-induced gingival hyperplasia in cat and in a pilot study also in man. The present study was performed to further evaluate this therapy in man. Twenty-three children with DPH-treatment for more than 1 yr, and eight children with short-time DPH-treatment were randomly assigned to groups with and without daily supplementation of folic acid (5 mg Folacin) for 1 yr. Although the DPH-levels were in many cases below the lower reference value, the seizure control of the children was good before and during the year of study. The plasma and red cell folate levels were within or above the given reference values in all but one child. There were no significant changes in the size of the gingival hyperplasias after 1 yr of folate supplementation. Nine severely mentally retarded DPH-treated adults were also given supplementation with folic acid. Their serum DPH-levels were above the higher reference values both at the start and during the study. Their plasma and red cell folic acid levels were below the reference value at the start of the study, but as a consequence of the Folacin supplementation these values rose. The size of the gingival hyperplasias was significantly reduced. Seizure control was unchanged. Folate levels should be checked and supplementation with folic acid considered in patients on long-term anticonvulsive multipharmacy therapy.

Effect of folate on phenytoin hyperplasia

There have been some reports that folic acid inhibits phenytoin-induced gingival hyperplasia. The purpose of this double-blind study was to quantify clinically the effects of both systemic and topical administration of folic acid on phenytoin-induced gingival overgrowth in man. For a period of 6 months, one group of phenytoin patients received 2 daily topical applications of a folate solution. An additional group received 2 daily doses of systemic folate while a control group received placebo medication. Results indicate that throughout the 180-day period of the study, the topical folate significantly inhibited gingival hyperplasia to a greater extent than either systemic folate or placebo groups.

Effect of topical application of phenylephrine hydrochloride on hyperplastic gingivitis

A double blind study was conducted to evaluate the effectiveness of Phenodent Type A (brand of phenylephrine hydrochloride) on decongesting hyperplastic gingivitis. Three solutions were used: a 0.5% a placebo, and a 0.25% concentration of phenylephrine hydrochloride. The periodontal disease index was used to score variables which might have an effect on gingival response to local irritants. Impressions were taken and casts were made on 45 subjects at 0, 1, 3, and 6-week intervals. An instrument with accuracy of 0.001 inch was constructed to measure the changes in the interdental papillae of the stone casts. No significant reduction of gingival volume was established for any of the three solutions.

The effect of urea peroxide on dilantin hyperplasia

1. A significant inverse relationship was found between the severity of the hyperplasia and the duration of SDH. 2. The severity of hyperplasia and in flammation was found to vary significantly and inversely with oral hygiene scores. 3. Tooth brushing twice a day and the application of Oxygel showed no significant clinical changes on the inflammation and hyperplasia in the test group, whereas the control group using a placebo showed a moderate reduction in gingival inflammation.