Risk factors for drug-induced gingival overgrowth

Do antihypertensive medications have an effect on dental implants? A systematic review

PURPOSE

The purpose of this systematic review was to compare the clinical outcomes of dental implants in users of antihypertensive medication with those of nonusers.

METHODS

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and was registered in the International Prospective Register of Systematic Reviews under the number CRD42022319336. The electronic databases Medline (PubMed) and Central Cochrane were searched for relevant scientific literature published in English through May 2022. The focused question was, "Do patients taking antihypertensive medications have a similar impact on the clinical outcome and survival of dental implants compared with nonusers?".

RESULTS

A total of 49 articles were found, of which 3 articles were finally selected for a qualitative synthesis. The three studies included 959 patients. In all three studies, the commonly used medication was renin-angiotensin system (RAS) inhibitors. Two studies mentioned implant survival rate, which was 99.4% in antihypertensive medication users and 96.1% in the nonusers. One study found a higher implant stability quotient (ISQ) in patients taking antihypertensive medication (75.7 ± 5.9) compared with patients not taking antihypertensive medication (73.7 ± 8.1).

CONCLUSIONS

The limited available evidence showed that patient taking antihypertensive medications had comparable success rate and implant stability to patients not taking medications. The studies included patients taking different antihypertensive medications, so a drug-specific conclusion regarding the clinical outcome of dental implants is not possible. Further studies are needed, including patients taking certain antihypertensive medications, to determine their effects on dental implants.

Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases

Non-biologic immunosuppressive drugs, such as azathioprine, dapsone or methotrexate are fundamental treatment options for a wide range of autoimmune and chronic inflammatory skin diseases. Some of these drugs were initially used for malignancies (e.g., azathioprine or methotrexate) or infectious diseases (e.g., hydroxychloroquine or dapsone) but are nowadays mostly used for their immunosuppressive/immunomodulating action. Although dermatologists have years of clinical experience with these drugs, some of the mechanisms of action are not fully understood and are the subject of research. Although these drugs are commonly used, lack of experience or knowledge regarding their safety profiles and management leads to skepticism among physicians. Here, we summarize the mechanism of action and detailed management of adverse effects of the most commonly used immunosuppressive drugs for skin diseases. Furthermore, we discuss the management of these drugs during pregnancy and breastfeeding, as well as their interaction and handling during vaccination.

Nicht-Biologika-Immunsuppressiva bei entzündlichen und autoimmunen Hautkrankheiten: Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases

Nicht‐Biologika‐Immunsuppressiva wie Azathioprin, Dapson oder Methotrexat sind grundlegende Behandlungsmöglichkeiten für ein breites Spektrum von Autoimmunerkrankungen und chronisch‐entzündlichen Hauterkrankungen. Einige dieser Medikamente wurden ursprünglich bei malignen Erkrankungen (zum Beispiel Azathioprin oder Methotrexat) oder Infektionskrankheiten (zum Beispiel Hydroxychloroquin oder Dapson) eingesetzt, werden aber heute hauptsächlich wegen ihrer immunsuppressiven/immunmodulierenden Wirkung verwendet. Obwohl Dermatologen über jahrelange klinische Erfahrung mit diesen Arzneimitteln verfügen, sind einige der Wirkmechanismen noch nicht vollständig geklärt und noch Gegenstand der Forschung. Obwohl diese Medikamente häufig eingesetzt werden, führen mangelnde Erfahrung oder fehlendes Wissen über ihre Sicherheitsprofile und ihr Management zu einer skeptischen Haltung bei den Ärzten. Hier fassen wir den Wirkmechanismus und das detaillierte Management der Nebenwirkungen der am häufigsten verwendeten immunsuppressiven Medikamente für Hautkrankheiten zusammen. Darüber hinaus diskutieren wir den Umgang mit diesen Medikamenten während der Schwangerschaft und Stillzeit sowie ihre Wechselwirkung und Handhabung im Zusammenhang mit Impfungen.

Gingival overgrowth approached using recent mechanical and laser technologies: A case report

Gingival enlargement is a side effect of different drug classes, with calcium channel blockers being among the most often cited examples. Most often accompanied by a disruption in the oral biofilm, this form of gingival overgrowth, with histological signs of hyperplasia and hypertrophy, becomes a chronic inflammatory condition with the oral biofilm a primary cause. This periodontal disease is now classified as 'dental biofilm-induced gingivitis', and its preferred name is drug-influenced gingival expansion. The present study presented the case of a patient with gingival enlargement while being treated with nifedipine for cardiac disease. This patient had factors that contributed to the retention of bacteria, ranging from poor oral hygiene practices to poorly adapted prosthodontics. After reducing these factors, a multimodal treatment was conducted, including bacterial mechanical decontamination through guided biofilm therapy protocol, laser bacterial decontamination, and surgical laser gingivectomy. The patient was referred to their cardiologist for substituting the calcium channel blocker medication. Clinical evaluations followed each treatment step. At 12 months, the patient presented positive, stable results, with an improvement in gingival status (no gingival overgrowth in the area where all risk factors were eliminated and minimal overgrowth in the area where old poorly marginally adapted prosthodontics were kept in place and no/minimal signs of gingival inflammation).

Management of Chronic Inflammatory Gingival Enlargement: A Short Review and Case Report

Inflammatory gingival enlargement, sometimes referred to as gingival hyperplasia or gingival hypertrophy, is an abnormal proliferation of gingival tissues caused by underlying inflammation. It might also be related to long-term periodontitis. Herein, we discuss the case of a young, otherwise healthy male patient wherein the anterior regions of both the upper and lower arches were affected by long-standing gingival growth. The overgrowth was removed, and an excellent aesthetic outcome was achieved, using a surgical procedure termed gingivectomy. After a 15-day follow-up period, the healing process was satisfactory and no negative effects were found.

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.

Biological Roles of Fibroblasts in Periodontal Diseases

Periodontal diseases include periodontitis and gingival overgrowth. Periodontitis is a bacterial infectious disease, and its pathological cascade is regulated by many inflammatory cytokines secreted by immune or tissue cells, such as interleukin-6. In contrast, gingival overgrowth develops as a side effect of specific drugs, such as immunosuppressants, anticonvulsants, and calcium channel blockers. Human gingival fibroblasts (HGFs) are the most abundant cells in gingival connective tissue, and human periodontal ligament fibroblasts (HPLFs) are located between the teeth and alveolar bone. HGFs and HPLFs are both crucial for the remodeling and homeostasis of periodontal tissue, and their roles in the pathogenesis of periodontal diseases have been examined for 25 years. Various responses by HGFs or HPLFs contribute to the progression of periodontal diseases. This review summarizes the biological effects of HGFs and HPLFs on the pathogenesis of periodontal diseases.

Bibliometric analysis of research trends and characteristics of drug-induced gingival overgrowth

Objectives

Drug-induced gingival overgrowth (DIGO) is a frequent adverse medication reaction that is generally caused by cyclosporine, phenytoin, and nifedipine, which belong to the category of immunosuppressants, anticonvulsants, and calcium channel blockers, respectively. This bibliometric analysis aims to depict the main citation characteristics and analyze the research trends in DIGO investigations.

Methods

An exhaustive search was performed in the Scopus database to create the bibliometric list of DIGO in the syntax. Furthermore, the information related to the number of citations, drugs related to DIGO, study topic and design, authorship, publication year, journal, contributing institution, country of origin, and the department was extracted.

Results

In total, 399 papers on DIGO were retrieved in this study. The total number of citations and that after the removal of self-citations were 7,814 and 7,314, respectively. The mean number of citations was 19.6 in a range of 0-608. The main paper types were articles (76.94%) and reviews (19.55%). A remarkable increasing trend in the number of citations has been observed since 1994. Cyclosporine (44.89%) is the most commonly used drug that shares a close relationship with DIGO, followed by phenytoin (18.22%), nifedipine (17.93%), and amlodipine (6.81%). The review (27.82%) type constituted the most widely used design in the DIGO studies. According to the top 20 keywords, the risk factors and pathogenesis of DIGO have been prominent topics of research works for several years.

Conclusions

This bibliometric analysis will facilitate the understanding of researchers and clinicians, especially those at the beginning of their careers in periodontology on DIGO, by identifying landmark research and providing an overview of this field.

Drug-Induced Gum Overgrowth With Low-Dose Amlodipine: A Case Report

Drug-induced gingival overgrowth is an adverse effect of certain drugs, including amlodipine, in genetically susceptible individuals. Although the exact mechanism of gingival hypertrophy remains unclear, a unifying multifactorial hypothesis has been constructed. Gingival hypertrophy causes difficulty in speech and mastication, poor oral hygiene, and poor aesthetic appearance. Here, we present the case of a 49-year-old woman who developed gum hypertrophy following amlodipine use for two years. Maintenance of oral hygiene and substitution of offending agent is commonly the first step in management.

Gingival enlargement improvement following medication change from amlodipine to benidipine and periodontal therapy

The use of calcium channel blockers (CCBs) is associated with gingival enlargement, which adversely affects oral function, hygiene and aesthetics. Although CCB-induced gingival enlargement is a known adverse effect, it is rarely or never caused by some CCBs. In this paper, we report the case of a late 80's female patient with hypertension who experienced amlodipine-induced gingival enlargement. The patient's antihypertensive medication was changed from amlodipine to another CCB of the same class, benidipine, which has not been reported to cause gingival enlargement. The patient also received periodontal therapy. A significant improvement in gingival enlargement was noted, and blood pressure control was maintained. This case indicates that it might be beneficial for patients with hypertension presenting CCB-induced gingival enlargement to switch from the CCB that caused gingival enlargement to another CCB with little to no risk.

Proteomic Analysis in Nifedipine Induced Gingival Overgrowth: A Pilot Study

Objective: The aims of the present study were to investigate the proteomic profile of nifedipine induced overgrown gingiva and compare with non-overgrown gingival tissues obtained from the same patients. Methods: Seven subjects under nifedipine medication for at least 6 months and diagnosed as nifedipine induced gingival overgrowth (NIGO) participated in the study. Periodontal clinical parameters were recorded. Gingival tissue samples were harvested from overgrown (GO+ Group, n=7) and non-overgrown regions (GO- Group, n=7) of the same patients. Proteomics was performed using Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) technique. The identified proteins were further classified according to their molecular functions, biological processes and cellular component distribution for functional gene ontology analysis using a web-based bioinformatics tool. Mann Whitney-U and ANOVA tests were performed to compare clinical parameters and identified proteins with proteomics, respectively. Results: Bleeding on probing and gingival overgrowth index of the GO+ group were statistically significantly higher than the GO- group (p

Hepatocyte growth factor exhibits anti-fibrotic effects in an in vitro model of nifedipine-induced gingival overgrowth

PURPOSE

The aim of this study was to establish an in vitro model of nifedipine-induced gingival overgrowth and characterize the anti-fibrotic effect of hepatocyte growth factor (HGF) using this model.

METHODS

Human gingival fibroblasts were cultured-treated with 0.1, 1, or 10 µg/mL nifedipine or 10 ng/mL IL-1β + 0.1, 1, or 10 µg/mL nifedipine (0.1N, 1N, 10N, IL + 0.1N, IL + 1N, IL + 10N). Cell proliferation and levels of type I collagen, TGF-β1, CCN2/CTGF, and α-SMA were measured 48 h after the simultaneous addition of 10 and 50 ng/mL HGF (10 and 50HGF) along with IL-1β and nifedipine. Type I collagen was measured after administration of anti-HGF neutralizing antibody.

RESULTS

Significant increases in type I collagen, TGF-β1, and CCN2/CTGF were observed after treatment in the 1N and IL + 0.1N groups. Levels of type I collagen and CCN2/CTGF differed significantly between the IL + 0.1N group and the IL + 0.1N + 50HGF group. Production of type I collagen increased significantly following addition of anti-HGF antibody.

CONCLUSION

This study demonstrated the establishment of an in vitro model of nifedipine-induced gingival overgrowth by showing increased collagen levels. Experiments using this model suggested that HGF exerts anti-fibrotic effects.

Necrotizing Ulcerative Gingivitis, a Rare Manifestation as a Sequel of Drug-Induced Gingival Overgrowth: A Case Report

Purpose

The purpose of this case report is to present a rare case of amlodipine-induced gingival overgrowth with a secondary formation of necrotizing ulcerative gingivitis involving the upper and lower arches of a 68-year-old female patient with a chief complaint of “swollen gums and pain on mastication which has been recurring for the past 5 years.”

Materials and Methods

The treatment plan of this case was divided according to quadrants of the mouth. Each week, one quadrant was surgically excised, and the remaining quadrants were observed for any changes. The gingival overgrowths were excised using a 15 blade, and debris/plaque was removed with Gracey curettes.

Results

Although full-mouth exodontia was performed, the patient unfortunately suffered with recurrences in GO. These results are suggestive of idiopathic causes of GO.

Conclusion

Careful examination, physician referrals, and biopsy to rule out any specific anomalies and to assist in proper diagnosis are followed by sequential management of the case results in productive outcomes.

The role of nuclear receptor 4A1 (NR4A1) in drug-induced gingival overgrowth

Drug-induced gingival overgrowth (DIGO) is a side effect of cyclosporine A (CsA), nifedipine (NIF), and phenytoin (PHT). Nuclear receptor 4A1 (NR4A1) plays a role in fibrosis in multiple organs. However, the relationship between NR4A1 and DIGO remains unclear. We herein investigated the involvement of NR4A1 in DIGO. In the DIGO mouse model, CsA inhibited the up-regulation of Nr4a1 expression induced by periodontal disease (PD) in gingival tissue, but not that of Col1a1 and Pai1. We detected gingival overgrowth (GO) in Nr4a1 knock out (KO) mice with PD. A NR4A1 agonist inhibited the development of GO in DIGO model mice. TGF-β increased Col1a1 and Pai1 expression levels in KO mouse gingival fibroblasts (mGF) than in wild-type mice, while the overexpression of NR4A1 in KO mGF suppressed the levels. NR4A1 expression levels in gingival tissue were significantly lower in DIGO patients than in PD patients. We also investigated the relationship between nuclear factor of activated T cells (NFAT) and NR4A1. NFATc3 siRNA suppressed the TGF-β-induced up-regulation of NR4A1 mRNA expression in human gingival fibroblasts (hGF). CsA suppressed the TGF-β-induced translocation of NFATc3 into the nuclei of hGF. Furthermore, NIF and PHT also decreased NR4A1 mRNA expression levels and suppressed the translocation of NFATc3 in hGF. We confirmed that CsA, NIF, and PHT reduced cytosolic calcium levels increased by TGF-β, while CaCl₂ enhanced the TGF-β-up-regulated NR4A1 expression. We propose that the suppression of the calcium-NFATc3-NR4A1 cascade by these three drugs plays a role in the development of DIGO.

Self-correction of pathologic tooth migration after nonsurgical periodontal treatment in a metabolic syndrome patient with severe periodontitis and drug-influenced gingival enlargement

Drug-influenced gingival enlargement (DIGE) and reduced bone support caused by periodontitis are two of the etiologic factors for pathologic tooth migration (PTM). Comprehensive management, including surgical, orthodontic, and prosthodontic treatment, is usually required for recovery from severe DIGE and PTM. An 85-year-old Taiwanese male with a history of hypertension and uncontrolled diabetes mellitus (DM) visited our dental department for severe gingival enlargement and spontaneous bleeding. He was diagnosed as having advanced periodontitis and DIGE. Remarkable PTM occurred on the front sextants of his dentition. The patient's DM was gradually controlled, and his calcium channel blocker treatment was substituted with a new regimen for 7 months. One year after nonsurgical periodontal treatment and reinforcing the patient's oral care, both DIGE and PTM were spontaneously resolved without any surgical or orthodontic intervention. We advocate the value of early diagnosis, improving patient's oral hygiene, and meticulous nonsurgical treatment for both DIGE and PTM.

High expression of aryl hydrocarbon receptor (AhR) plays an important role in the formation of fibrous epulis

OBJECTIVES

Epulis is considered to be a massive reactive lesion rather than a true neoplasia. AhR is thought to be associated with inflammation and development of neoplasms. Here, we aimed to observe the expression of AhR in fibrous epulis and explore its role and possible mechanism in the pathogenesis of epulis.

MATERIALS AND METHODS

Epulis and normal gingival tissues were collected, and AhR expression was detected at the mRNA and protein levels by quantitative polymerase chain reaction (qPCR) and immunohistochemistry, respectively. The expression levels of proinflammatory cytokines and apoptosis-related factor genes in human periodontal ligament cells (hPDLCs) and human gingival fibroblasts (hGFs) transfected with AhR short interfering RNA (siRNA) or negative control siRNA, upon stimulation with lipopolysaccharide of Porphyromonas gingivalis (Pg-LPS), were then examined. Finally, the expression levels of the proinflammatory cytokines and apoptosis-related factor genes in the epulis tissues were observed by qPCR.

RESULTS

AhR expression in fibrous epulis was significantly increased at both the mRNA and protein levels. The expression of proinflammatory cytokines and apoptosis-related factor genes in hPDLCs transfected with AhR siRNA was significantly decreased when stimulated with Pg-LPS. The same trends were observed for hGFs. The opposite trend was detected in the epulis tissues.

CONCLUSION

AhR may be a key factor in fibrous epulis pathogenesis that acts by regulating the expression of BCL2 family genes and inflammatory factor-related genes.

PCR array analysis identified hyperproliferation but not autophagy or apoptosis in fibrous epulis

BACKGROUND

The pathogenesis of fibrous epulis is still quite unclear. Our recent genome-wide RNA sequencing analysis revealed that in fibrous epulis, RAS-PI3K-AKT-NF-κB pathway regulates the expression of Bcl-2 family and IAP family genes, leading to increased proliferation and the inhibition of apoptosis. The PI3K/AKT signaling pathway can promote autophagy in human gingival fibroblasts; therefore, the purpose of the present study was to identify whether autophagy is involved in the pathogenesis of fibrous epulis.

METHODS

Differentially expressed genes (DEGs) between fibrous epulis lesions and normal gingival tissues were identified using the PCR array. The expression levels of eighteen autophagy-related (ATG) family genes, twelve B-cell lymphoma 2 (Bcl-2) family genes, and eleven cysteine-dependent aspartate-directed protease (caspase) family genes were validated using quantitative real-time PCR (qRT-PCR). Autophagy induction was determined by measuring microtubule-associated protein light chain 3 (LC3) conversion (LC3-I to LC3-II) by immunoblot analysis.

RESULTS

The PCR array identified six upregulated genes, whereas no genes were expressed at significantly lower levels. The upregulated genes were BCL2, BCL2L1, CXCR4, HSP90AA1, HSPA8, and IGF1, which all belong to the "regulation of autophagy" group but not the "autophagy machinery components" group. qRT-PCR verified that the expression levels of BCL2, BCL2L1 (also known as BCL-XL), and BCL2L2 (also known as BCL-W) were significantly increased in fibrous epulis. No LC3-I to LC3-II conversion was observed.

CONCLUSIONS

The present study reveals that in fibrous epulis, Bcl-2 and Bcl-xL coordinately mediate gingival cell escape from apoptosis, leading to uncontrolled proliferation. Moreover, ATG family genes are not activated, and autophagy is not involved in this process.

Drug-induced gingival overgrowth in cardiovascular patients

Drug-induced gingival overgrowth (DIGO) is a pathological growth of gingival tissue, primarily associated with calcium channel blockers and immunosuppressants. Consequently, it is mainly seen in cardiovascular and transplanted patients. Nifedipine remains the main calcium channel blocker related to the development of this unpleasant side-effect. As for immunosuppressants, cyclosporin is the leading causative agent, whereas other drugs from this drug-group, including tacrolimus, have better safety profiles. Accumulated collagen with inflammatory infiltrates is the histological hallmark of this condition. Several factors are involved in the pathogenesis and can increase the risk, such as male gender, younger age, pre-existing periodontal inflammation, and concomitant use of other DIGO-inducing medications. Patients with DIGO may experience severe discomfort, trouble with speech and mastication, pain, and teeth loss, aside from cosmetic implications. Furthermore, these patients also have an increased risk for cardiovascular diseases. The interdisciplinary approach and cooperation with dental care experts are necessary for patient management. Treatment includes discontinuing the drug and switching to one with a better profile, improving oral hygiene, and surgical removal of enlarged tissue. Recognizing the potential of commonly used medications to cause DIGO and its effect on patients' health is necessary for early detection and adequate management of this complication.

Aromatase inhibitor anastrozole modifies cellular functions in gingival fibroblasts and endothelial cells: possible periodontal complications of aromatase inhibitor treatment

BACKGROUND

Recent studies have shown that treatment with aromatase inhibitors contributes to an increased prevalence of periodontitis.

OBJECTIVE

In this study, we assessed effects of the aromatase inhibitor anastrozole on cellular function of human gingival fibroblasts (HGFs) and endothelial cells.

METHODS

Expression levels of collagen, extracellular matrix (ECM) proteins, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs) were examined in HGFs exposed to anastrozole. Furthermore, inflammatory responses in HGFs cultured with anastrozole were evaluated in the presence of Porphyromonas gingivalis lipopolysaccharide. We also evaluated the vascular permeability and vascular endothelial (VE)-cadherin expression of endothelial cells exposed to anastrozole.

RESULTS

Anastrozole enhanced expression levels of collagen, ECM proteins, TIMPs, and inflammatory cytokines in HGFs, as well as vascular permeability of endothelial cells. In addition, anastrozole reduced expression levels of MMPs in HGFs and VE-cadherin in endothelial cells.

CONCLUSION

These results suggest that anastrozole modulates various cellular functions in HGFs and endothelial cells.

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.

Local and Systemic Effects of Cyclosporine A on the Severity of Gingival Overgrowth in Post-Transplant Renal Patients

Background:

Cyclosporine A (CsA) is a potent immunosuppressant widely used to prevent renal post transplantation rejection. Gingival overgrowth (GO) is among various side effects of the long-term administration of CsA. Up to 90% of the patients under CsA therapy has been reported to develop CsA-induced GO.

Objectives:

The aim of the present prospective pilot study is to determine the local and systemic effects of Cyclosporine A (CsA) on the severity of gingival overgrowth and its relationship with periodontal parameters in post-transplant renal patients

Methods:

Twenty post-transplant renal patients, 12 females and 8 males, presenting gingival overgrowth were selected from Rizk Hospital’s clinic in Beirut. Patient’s CsA plaque levels were evaluated when CsA is administered by syrup and capsules mode. Periodontal parameters including gingival overgrowth, papillary bleeding, plaque and gingival indices were assessed for all patients.

Results:

Plaque concentration CsA levels, when administered in syrup mode, affected significantly the severity of gingival overgrowth as opposed to the administration by capsule mode. Significant correlations between severity of gingival overgrowth on one hand and plaque index, gingival index, and papillary bleeding index on the other hand were only observed in the Capsule group but not in the syrup group. A significant relationship was established between the severity of gingival overgrowth and all periodontal parameters (gingival, papillary and plaque).

Conclusion:

The present study underlines CsA dental plaque local effect, as a co-factor, in the development of gingival overgrowth. Cyclosporine plaque accumulation acts as a reservoir in the gingival inflammation and the periodontal indices seem to be the most accurate parameters associated with gingival overgrowth severity. Plaque CsA concentrations could be considered as a risk factor for inflammation and gingival overgrowth depending on CsA delivery mode in renal transplant patients.

Massive gingival bleed: a rare manifestation of cyclosporine toxicity

A 12-year-old patient of thalassaemia major developed autoimmune cytopaenia after undergoing haematopoietic stem cell transplantation. She was started on cyclosporine (CsA) in view of poor response to steroids. She developed CsA toxicity manifesting as gum hyperplasia with multiple episodes of gum bleed. During endotracheal intubation for an elective splenectomy, she developed significant bleeding from gums requiring massive transfusion. Postoperatively the gum bleed persisted even after embolisation of facial artery and multiple transfusions. The catastrophic sequelae include transfusion-related lung injury, acute circulatory failure with subsequent cardiac arrest and death. Gum hyperplasia is a commonly reported toxic effect of CsA. Lethal presentations of this toxicity with such severity are limited in the medical literature. Evaluation of the patient's medical and laboratory records, along with a review of literature, was very helpful in understanding more about the toxicity of CsA.

miRNA-26-5p inhibits cyclosporine A-induced overgrowth of gingival fibroblasts by regulating PTEN/PI3K/AKT pathway

We evaluated the effect of cyclosporine A (CsA) administration on the level of miR-26-5p in rat gingival tissues and human gingival fibroblasts (HGFs) by qRT-PCR assay. Further, we conducted Western blotting and immunohistochemical analysis to assess the expressions of PTEN, PI3K, and p-AKT, and evaluated cell proliferation of HGFs by MTT assay. CsA treatment significantly downregulated the expressions of miR-26-5p and PTEN and upregulated the expressions of PI3K and p-AKT in both rat gingival tissues and HGFs. Overexpression of miR-26-5p inhibited CsA-induced overgrowth of HGFs, whereas knockdown of miR-26-5p promoted the overgrowth. PTEN knockdown not only promoted CsA-induced overgrowth of human HGFs but also reversed the repressive effects of miR-26-5p on CsA-induced overgrowth of HGFs. Our results revealed that miRNA-26-5p could repress CsA-induced overgrowth of human HGFs by regulating PTEN/PI3K/AKT pathway.

Influence of antihypertensive medications on the clinical parameters of anodized dental implants: a retrospective cohort study

Background

Hypertension is a chronic medical condition in which blood pressure in the arteries is elevated. Given the large proportion of dental implant patients using antihypertensive medications, it is crucial to evaluate the effects of these drugs on the clinical parameters of osseointegrated implants. The aim of the present retrospective cohort study was to evaluate the influence of antihypertensive medications on clinical peri-implant tissue parameters.

Methods

Thirty-five patients received a total of 77 anodized dental implants. Based on the history of the use of antihypertensive medications, the patients were divided into two groups: the group taking antihypertensive medications (AH group) and the group of healthy patients (H group). Implants were followed up clinically and radiologically, with a focus on the peri-implant soft tissue parameters probing pocket depth, bleeding on probing, modified plaque index, and marginal peri-implant bone level stability.

Results

None of the implants were lost, and no technical failures occurred. The mean follow-up duration was 7 years and 1 month. A significant difference was observed in the probing pocket depth 3.8 ± 1.3 mm in the AH group and 3.0 ± 0.7 mm in the H group. In the AH and H groups, 26.5% (9/34) and 4.7% (2/43) of the patients were diagnosed with peri-implantitis at the implant level, respectively.

Conclusions

Our findings suggest some correlations between antihypertensive medication use and clinical parameters in anodized peri-implant tissue.

Transcriptional Analysis Reveals Key Genes in the Pathogenesis of Nifedipine-Induced Gingival Overgrowth

Background

Nifedipine-induced gingival overgrowth (NGO) is a multifactorial pathogenesis with increased extracellular matrix including collagen and glycans, inflammatory cytokines, and phenotype changes of fibroblasts. However, the molecular etiology of NGO is not well understood. The objective of this study is to investigate the key genes in the pathogenesis of NGO.

Methods

In this study, we examined the proliferation and migration abilities of fibroblasts derived from patients with chronic periodontitis, nifedipine nonresponder gingival overgrowth, gingival overgrowth caused by nifedipine, and healthy normal gingiva. We conducted RNA-Seq on these four groups of fibroblasts and analysed the differentially expressed genes (DEGs).

Results

Fibroblasts derived from NGO patients had higher proliferation and migration abilities than those of the other groups. Protein-protein interaction network analysis indicated that TGFB2, ITGA8, ITGA11, FGF5, PLA2G4D, PLA2G2F, PTGS1, CSF1, LPAR1, CCL3, and NKX3-1 are involved in the development of NGO. These factors are related to the arachidonic acid metabolism and PI3K/AKT signaling pathways.

Conclusion

Transcriptional gene expression analysis identified a number of DEGs that might be functionally related to gingival overgrowth induced by nifedipine. Our study provides important information on the molecular mechanism underlying nifedipine-induced gingival overgrowth.

Gabapentin affects the expression of inflammatory mediators on healthy gingival cells

Gabapentin is one of the most used drugs to treat postoperative pain with antihyperalgesic properties and has a unique mechanism of action, which differentiates it from other commonly used drugs. Various studies have shown that the perioperative use of gabapentin reduces postoperative pain. In our study, fragments of gingival tissue of healthy volunteers were collected during operation. Gene expression of 29 genes was investigated in gingival fibroblasts cell culture treated with gabapentin, compared with untreated cells. Of the different chemokines and interleukins studied, only 10 were statistically significant (CCL1, CCR1, CCR4, CCR5, CCR6, ILI1A, ILI1B, IL5, IL6R, TNFSF10). The overexpression of these cytokines, obtained in many studies, leads us to think that gabapentin can interact and cause post-inflammatory gingival hyperplasia, but, probably, in our study the gabapentin has not the same effect, because we used gingival fibroblasts of healthy people.

Elevated Interleukin-17A expression in amlodipine-induced gingival overgrowth

BACKGROUND AND OBJECTIVES

Amlodipine, a calcium channel blocker derivative, is frequently used by patients with high blood pressure. Studies reported that it can induce gingival overgrowth. However, the underlying mechanism is not fully described yet. Interleukin-17A (IL-17A) is known as a proinflammatory cytokine, but current studies indicate that it has a role in fibrotic disorders and epithelial-mesenchymal transition (EMT). The aim of this study was to figure out the possible role of IL-17A in amlodipine-induced gingival overgrowth.

MATERIALS AND METHODS

Twenty-nine (29) individuals participated in the study, and they were assigned into 3 groups based on medical status and clinical periodontal examination; 9 patients with amlodipine-induced gingival overgrowth, 11 patients with inflammatory gingival overgrowth, and 9 healthy individuals as a control group. Clinical periodontal parameters including plaque index (PI), gingival index (GI), and gingival overgrowth index (GOI) were recorded. Blood and gingival crevicular fluid (GCF) samples were obtained. Gingival tissues were taken by appropriate periodontal surgery following initial periodontal therapy. To detect IL-17A on tissue samples, immunohistochemistry (IHC) was performed. Quantitative analysis was done, and the expression level of IL-17A was given as the percent positively stained cells. Enzyme-linked immunosorbent assay (ELISA) kits were used to analyze IL-17A in serum and GCF samples.

RESULTS

All recorded clinical parameters were significantly higher in gingival overgrowth groups compared with control. Evaluation of inflammation on tissue sections did not show any significant change within the groups. Immunohistochemistry findings showed that IL-17A expression was increased in amlodipine samples (81.90%) compared with control samples (42.35%) (P < .001). There was an increase in the inflammatory group (66.08%) which is significantly less than the amlodipine group (P < .05). IL-17A levels in serum and GCF samples were not different within the study groups.

CONCLUSION

In this study, elevated IL-17A expression regardless of inflammation shows that amlodipine might cause an increase of IL-17A in gingival tissues. This increase might induce fibrotic changes and EMT in gingival overgrowth tissues. The association of IL-17A with fibrosis and EMT in gingival tissues requires further investigation.

Nizam MN, Alshammari A. An Update on the Mechanisms of Phenytoin Induced Gingival Overgrowth

Background:

Phenytoin induced gingival overgrowth, a side effect with multifactorial aetiology, is characterized by an increase in the volume of extracellular tissues, particularly collagenous components, with varying degrees of inflammation.

Objective:

The aim of this paper is to review the available literature regarding the pathophysiological mechanisms of phenytoin induced gingival overgrowth.

Methods:

A thorough literature search of the PubMed/ Embase/ Web of science/ Cochrane central database was conducted to identify the mechanisms involved in the process of phenytoin-induced gingival overgrowth using the following keywords: Phenytoin; Anticonvulsant; Gingival Overgrowth; Gingival Enlargement, Gingival Hyperplasia; Drug Induced Gingival Enlargement; Drug Induced Gingival Overgrowth

Results:

According to the available evidence, several mechanisms have been proposed addressing the pathophysiological mechanism of phenytoin induced gingival overgrowth both at a cellular and molecular level. Evidence suggests that the inflammatory changes in the gingival tissues orchestrate the interaction between phenytoin and fibroblasts particularly resulting in an increase in the extracellular matrix content.

Conclusion:

However, the mechanism of production of inflammatory mediators is not fully understood. This, together with the high prevalence of Phenytoin induced gingival overgrowth, warrants further research in this area in order to develop treatment and preventive strategies for the management of this condition.

Factors affecting decision making at reassessment of periodontitis. Part 2: interpretation of clinical findings - systemic factors

This paper is the second in a four-part series outlining treatment planning at periodontal reassessment. The first article focussed on the information that should be gathered at the reassessment appointment. Treatment can involve a range of non-surgical and surgical approaches. A variety of general, practical and local site factors can affect the choice of one option over another in choosing the most predictable treatment option. Residual periodontal probing depths can be associated with both systemic and local factors. This article (part 2) outlines systemic factors that need to be assessed when faced with residual periodontal probing depths.

Dental plaque-induced gingival conditions

OBJECTIVE

This review proposes revisions to the current classification system for gingival diseases and provides a rationale for how it differs from the 1999 classification system.

IMPORTANCE

Gingival inflammation in response to bacterial plaque accumulation (microbial biofilms) is considered the key risk factor for the onset of periodontitis. Thus, control of gingival inflammation is essential for the primary prevention of periodontitis.

FINDINGS

The clinical characteristics common to dental plaque-induced inflammatory gingival conditions include: a) clinical signs and symptoms of inflammation that are confined to the gingiva: b) reversibility of the inflammation by removing or disrupting the biofilm; c) the presence of a high bacterial plaque burden to initiate the inflammation; d) systemic modifying factors (e.g., hormones, systemic disorders, drugs) which can alter the severity of the plaque-induced inflammation and; e) stable (i.e., non-changing) attachment levels on a periodontium which may or may not have experienced a loss of attachment or alveolar bone. The simplified taxonomy of gingival conditions includes: 1) introduction of the term "incipient gingivitis;" 2) a description of the extent and severity of gingival inflammation; 3) a description of the extent and severity of gingival enlargement and; 4) a reduction of categories in the dental plaque-induced gingival disease taxonomy.

CONCLUSIONS

Dental plaque-induced gingival inflammation is modified by various systemic and oral factors. The appropriate intervention is crucial for the prevention of periodontitis.

The RAS-PI3K-AKT-NF-κB pathway transcriptionally regulates the expression of BCL2 family and IAP family genes and inhibits apoptosis in fibrous epulis

Background

Epulis has a tumor‐like appearance but is considered to be a massive reactive lesion rather than a true neoplasia. Limited information about the pathogenesis of epulis is available. The purpose of our study was to identify potential signaling pathways in fibrous epulis through transcriptome profiling.

Methods

Differentially expressed genes (DEGs) between fibrous epulis lesions and normal gingival tissues were detected using RNA sequencing (RNAseq). The expression levels of eighteen genes were validated using quantitative real‐time PCR (qRT‐PCR).

Results

RNAseq identified 533 upregulated genes and 732 downregulated genes. The top 10 upregulated genes were IL11, OSM, MMP3, KRT75, MMP1, IL6, IL1B, IL24, SP7, and ADGRG3. The top 10 downregulated genes were BCHE, TYR, DCT, KRT222, RP11‐507K12.1, COL6A5, PMP2, GFRA1, SCN7A, and CDH19. KEGG pathway analysis further indicated that the DEGs were enriched in “Pathways in cancer” and the “Ras signaling pathway”. quantitative real‐time PCR verified that the expression levels of SOS1, HRAS, PIK3CA, AKT3, IKBKA, IKBKB, NFKB1, BCL2, BCL2L1, XIAP, BIRC2, and BIRC3 were increased significantly.

Conclusions

The current transcriptomic profiling study reveals that in fibrous epulis, RAS‐PI3K‐AKT‐NF‐κB pathway transcriptionally regulates the expression of BCL2 family and IAP family genes, leading to increased proliferation and apoptosis inhibition.

Periodontal Microbiological Status Influences the Occurrence of Cyclosporine-A and Tacrolimus-Induced Gingival Overgrowth

Immune suppressed renal transplant patients are more prone to developing oral tissue alterations due to medications associated with a pleiotropic set of side effects involving the oral cavity. Drug-induced gingival overgrowth (DIGO) is the most commonly encountered side effect resulting from administration of calcineurin inhibitors such as cyclosporine-A (CsA), the standard first-line treatment for graft rejection prevention in transplant patients. Pathogenesis of gingival overgrowth (GO) is determined by the interrelation between medications and a pre-existing inflammatory periodontal condition, the main modifiable risk factor. Severity of gingival hyperplasia clinical manifestation is also related to calcium channel blocker association, frequently provided in addition to pharmacological therapy of transplant recipients. Specifically, nifedipine-induced enlargements have a higher prevalence rate compared to amlodipine-induced enlargements; 47.8% and 3.3% respectively. Available epidemiological data show a gender difference in prevalence, whereby males are generally more frequently affected than females. The impact of GO on the well-being of an individual is significant, often leading to complications related to masticatory function and phonation, a side effect that may necessitate switching to the tacrolimus drug that, under a similar regimen, is associated with a low incidence of gingival lesion. Early detection and management of GO is imperative to allow patients to continue life-prolonging therapy with minimal morbidity. The purpose of this study was threefold: firstly, to determine the prevalence and incidence of GO under the administration of CsA and Tacrolimus; secondly, to assess the correlation between periodontal status before and after periodontal therapy and medications on progression or recurrence of DIGO; and finally, to analyse the effect of immunosuppressant in association to the channel blocker agents on the onset and progression of gingival enlargement. We compared seventy-two renal transplant patients, including 33 patients who were receiving CsA, of which 25% were also receiving nifedipine and 9.72% also receiving amlodipine, and 39 patients who were receiving tacrolimus, of which 37.5% were also receiving nifedipine and 5.55% also receiving amlodipine, aged between 35 and 60 years. Medical and pharmacological data were recorded for all patients. Clinical periodontal examination, in order to establish the inflammatory status and degree of gingival enlargement, was performed at baseline (T0), 3 months (T1), 6 months (T2), and 9 months (T3). All patients were subjected to periodontal treatment. Statistically significant correlation between the reduction of the mean value of periodontal indices and degree of gingival hyperplasia at the three times was revealed. The prevalence of GO in patients taking cyclosporine was higher (33.3%) in comparison with those taking tacrolimus (14.7%). In accordance with previous studies, this trial highlighted the clinical significance of the pathological substrate on stimulating drug-induced gingival lesion, confirming the key role of periodontal inflammation in pathogenesis of gingival enlargement, but did not confirm the additional effect of calcium-channel blocker drugs in inducing gingival enlargement.

Periodontal Management of Cyclosporin A-Induced Gingival Overgrowth: A Nonsurgical Approach

Gingival overgrowth is a major and frequent unwanted effect accompanying the chronic usage of antihypertensive, anticonvulsant, and immunosuppressant drugs. The expression and the severity of this tissue-specific condition are influenced by a variety of factors, mainly drug and periodontal variables. Such increased volume of gingiva may compromise normal oral functions, aesthetics in addition to the patients' ability to practice optimal oral hygiene. The management of gingival overgrowth includes nonsurgical approach, surgical approach, or both of them for severe cases of gingival overgrowth as well as drug withdrawal. This case report illustrates a successful nonsurgical management of a 21-year-old patient with cyclosporin A-induced gingival overgrowth who experienced a total regression of the gingival enlargement without any surgical procedure or drug substitution. And it highlights therefore the key role of supportive periodontal therapy in maintaining good and stable outcomes over 2 years of follow-up.

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

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

Nifedipine induced gingival enlargement in an edentulous patient: a case report with one year follow up

Background

Gingival enlargement due to calcium channel blockers is a common complaint reported by patients. It can be localized or generalized and can range from mild to severe, affecting patients appearance and function. Nifedipine induced gingival enlargement is noticed only in 10 % of patients and very few cases of Nifedipine induced gingival enlargement in an edentulous patient have been documented in the literature.

Case presentation

Here in, we report a case of gingival enlargement in a 70 year old hypertensive edentulous patient who was on low dose Nifedipine therapy. Patient wanted complete dentures. We planned to excise the overgrowth and followed up for 1 year.

Conclusion

Nifedipine induced gingival enlargement noticed only in 10 % of patients. Hence, there is a need for physicians and dentist to make a coordinated treatment plan and practice care while prescribing these drugs which are associated with gingival overgrowth.

Cyclosporine A - Induced gingival overgrowth and proliferating cell nuclear antigen expression in experimental periodontitis

The most important microscopic characteristic of Cyclosporine A-induced gingival overgrowth is fibroepithelial hyperplasia.

OBJECTIVE

The objective was to investigate the influence of previous exposure to Cyclosporine A over gingival epithelium in experimental periodontitis in rats.

METHODS

Twenty Wistar rats with 12 weeks-old were divided into four groups with 5 animals each: Control Group (CG); Cyclosporine Group (CsAG); Ligature group (LG) and Cyclosporine and Ligature Group (CsALG). Daily doses of CsA (10 mg/kg) were applied to CsAG and CsALG during 60 days since the beginning of the experiment and, a ligature was placed in LG and CsALG 30 days after the beginning of the experiment. After 60 days, animals were euthanized and gingival tissue was processed to histomorphometric analysis of epithelial thickness (mm²), immunohistochemical expression of PCNA (%) and inflammatory response. Data were analyzed by Kruskal-Wallis and Mann Whitney at 0.05 significance level.

RESULTS

Considering epithelial thickness, CG was thinner than all groups, CsALG was the largest and CsAG and LG were similar between each other. Regarding the PCNA expression CG (16.46 ± 9.26) was similar to CsAG (34.47 ± 19.75) and, LG (59.02 ± 10.33) was similar to CsALG (40.59 ± 18.25). Significant difference (p < 0.05) occurred only in inflammation presence comparing CG/LG and CsAG/CsALG. A weak positive correlation between the number of PCNA+ and inflammatory cells (p = 0.001; r = 0.611) was observed.

CONCLUSION

Based on these results it was concluded that the enlargement of gingival epithelium observed in experimental periodontitis can be increased by previous exposition to CsA and inflammatory conditions enhanced proliferative activity of the keratinocytes.

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.

Drug-induced atypical hyperplasia enveloping salivary gland malignancy

Gingival enlargement is a very common side effect associated with the administration of several drugs, mainly anticonvulsants, calcium channel blockers (CCBs), and immunosuppressants. Amlodipine (a CCB) is a safe antihypertensive drug with a longer duration of action. Gingival enlargement induced by amlodipine is less prevalent among CCBs. Since the pathogenesis is not well understood, it is still a challenge for clinicians to diagnose and manage cases effectively. This case presents an atypical unilateral palatal gingival enlargement in a 61-year-old hypertensive female taking amlodipine. Difficulty for a pathologist in diagnosing in spite of repeated sample submission from the lesion and repeated failure for the operator to reach the underlying pathology due to amlodipine-induced hyperplasia have also been discussed in this case report.

Drug-induced gingival hyperplasia: a retrospective study using spontaneous reporting system databases

Background

Drug-induced gingival hyperplasia (DIGH) causes problems with chewing, aesthetics, and pronunciation, and leads to the deterioration of the patient’s quality of life (QOL). Thus, the aim of this study was to evaluate the incidence of DIGH using spontaneous reporting system (SRS) databases.

Methods

We analyzed reports of DIGH from SRS databases and calculated the reporting odds ratios (RORs) of suspected drugs (immunosuppressants, calcium channel blockers, and anticonvulsants). The SRS databases used were the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and the Japanese Adverse Drug Event Report (JADER) database. With the data, we evaluated the time-to-onset profile and the hazard type using the Weibull shape parameter (WSP). Furthermore, we used the association rule mining technique to discover undetected relationships such as possible risk factors.

Results

The FAERS contained 5,821,716 reports. The RORs (95% confidence interval: CI) for cyclosporine, everolimus, sirolimus, mycophenolate mofetil, amlodipine, nifedipine, carbamazepine, clobazam, levetiracetam, phenobarbital, phenytoin, primidone, topiramate, and valproic acid, were 39.4 (95% CI: 30.3–51.2), 4.2 (1.7–10.0), 6.6 (2.5–17.7), 13.1 (7.2–23.2), 94.8 (80.0–112.9), 57.9 (35.7–94.0), 15.1 (10.3–22.3), 65.4 (33.8–126.7), 6.5 (3.6–11.8), 19.7 (8.8–44.0), 65.4 (52.4–82.9), 56.5 (21.1–151.7), 2.9 (1.1–7.7), and 17.5 (12.6–24.4), respectively. The JADER database contained 430,587 reports. The median time-to-onset of gingival hyperplasia values for immunosuppressants, calcium channel blockers, and anticonvulsants use were 71, 262, and 37 days, respectively. Furthermore, the 95% CI of the WSP β for anticonvulsants was over and excluded 1, which meant that they were wear-out failure type.

Conclusions

Our results suggest that DIGH monitoring of patients administered immunosuppressants, calcium channel blockers, or anticonvulsants is important. We demonstrated the potential risk of DIGH following the long-term use of calcium channel blocker over approximately 260 days. Based on the results of the association rule mining approach, patients with intellectual disability who are administered phenytoin should be monitored carefully. We recommend that patients who experience symptoms related to DIGH should be closely monitored.

Part 3: Impact of systemic conditions and medications on oral health

The people who are treated in the community setting will often have multiple comorbidities. Systemic medical conditions can have a negative impact on oral health. In addition, the medications used to treat systemic conditions may also themselves cause oral symptoms. As a large proportion of patients treated by the community nursing team will be elderly, this paper will focus on common geriatric conditions that can display oral or dental symptoms. The effects of medications will be discussed and linked to oral complaints patients may express. The primary aims are to give a broad overview of the oral effects of ageing, of illness and of polypharmacy and advise on how these can be best managed by the nursing team.

Effect of Calcium Channel Blockers on Gingival Tissues in Hypertensive Patients in Lagos, Nigeria: A Pilot Study

Background:

Long-term treatment of common chronic cardiac conditions such as hypertension with calcium channel blockers (CCBs) has long been associated with gingival hyperplasia. This oral side effect may affect esthetics and function, yet often overlooked and therefore underreported among Nigerians.

Aim:

This study aimed to determine the association of CCBs with gingival overgrowth (GO) in hypertensive patients.

Methods:

This was a hospital-based, case–control study conducted among 116 hypertensive patients (58 CCB and 58 non-CCB age-matched controls) attending the medical outpatient clinic of a tertiary health institution in Lagos, Nigeria. Data collection tools included interviewer-administered questionnaires and periodontal examination. Sociodemographic details, medical history, and periodontal indices (gingival index, plaque index, class of GO according to drug-induced GO [DIGO] Clinical Index) were recorded.

Results:

The mean age was 59.4 ± 12.6 years, females representing 50.9%. In the CCB group, 39 (67.2%) participants were on amlodipine and 19 (32.8%) were on nifedipine. The mean duration of CCB use was 55.6 ± 53 months. DIGO was higher in CCB (36.2%) than that in non-CCB participants (17.2%) (χ² = 4.4, P = 0.036). The risk of GO was higher in CCB users (odds ratio [OR] 2.7, [95% confidence interval (CI)]: 1.1–6.5). Amlodipine users had higher DIGO (37.5%) than that of nifedipine users (21.1%) (OR 2.3, [95% CI]: 1.0–5.3). The predominant class of DIGO among the CCB users was Class 2 DIGO Clinical Index (90.5%).

Conclusion:

The study reveals that the risk of GO is nearly three times in CCB than that of non-CCB users and twice higher in amlodipine than nifedipine users in Nigeria.

Connective Tissue Metabolism and Gingival Overgrowth

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