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Kumar R, Singh RK, Verma N, Verma UP. Phenytoin-induced severe gingival overgrowth in a child. BMJ Case Rep 2014; 2014:bcr-2014-204046. [PMID: 25053668 DOI: 10.1136/bcr-2014-204046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gingival enlargement or overgrowth (GO) is a common complication of the anticonvulsant drug phenytoin (PHT). GO is evident in almost half of the patients receiving PHT therapy. PHT-induced gingival overgrowth (PGO) is more common in children than in adults and affects both males and females equally. PGO may vary from mild to severe and does not seem to be dose dependant. It is supposed that PHT and its metabolites cause a direct effect on the periodontal tissues; however, poor oral hygiene may contribute to the severity of gingival inflammation in patients with PGO. Management of PGO includes meticulous oral hygiene practice to reduce inflammation and surgical excision of the overgrown tissue, known as gingivectomy. We present a case of PHT-induced severe GO in a 10-year-old boy and discuss the clinical features, aetiology, pathogenesis and management of PGO.
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Affiliation(s)
- Rakesh Kumar
- Department of Paediatric and Preventive Dentistry, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Rajeev Kumar Singh
- Department of Paediatric and Preventive Dentistry, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Nidhi Verma
- Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Umesh Pratap Verma
- Department of Periodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
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Corrêa JD, Queiroz-Junior CM, Costa JE, Teixeira AL, Silva TA. Phenytoin-induced gingival overgrowth: a review of the molecular, immune, and inflammatory features. ISRN DENTISTRY 2011; 2011:497850. [PMID: 21991476 PMCID: PMC3168966 DOI: 10.5402/2011/497850] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 06/13/2011] [Indexed: 01/05/2023]
Abstract
Gingival overgrowth (GO) is a side effect associated with some distinct classes of drugs, such as anticonvulsants, immunosuppressant, and calcium channel blockers. GO is characterized by the accumulation of extracellular matrix in gingival connective tissues, particularly collagenous components, with varying degrees of inflammation. One of the main drugs associated with GO is the antiepileptic phenytoin, which affects gingival tissues by altering extracellular matrix metabolism. Nevertheless, the pathogenesis of such drug-induced GO remains fulfilled by some contradictory findings. This paper aims to present the most relevant studies regarding the molecular, immune, and inflammatory aspects of phenytoin-induced gingival overgrowth.
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Affiliation(s)
- Jôice Dias Corrêa
- Department of Oral Surgery and Pathology, School of Dentistry, Federal University of Minas Gerais, 31270-901 Belo Horizonte, MG, Brazil
| | - Celso Martins Queiroz-Junior
- Department of Oral Surgery and Pathology, School of Dentistry, Federal University of Minas Gerais, 31270-901 Belo Horizonte, MG, Brazil
| | - José Eustáquio Costa
- Department of Oral Surgery and Pathology, School of Dentistry, Federal University of Minas Gerais, 31270-901 Belo Horizonte, MG, Brazil
| | - Antônio Lúcio Teixeira
- Department of Clinical Medicine, School of Medicine, Federal University of Minas Gerais, 31270-901 Belo Horizonte, MG, Brazil
| | - Tarcilia Aparecida Silva
- Department of Oral Surgery and Pathology, School of Dentistry, Federal University of Minas Gerais, 31270-901 Belo Horizonte, MG, Brazil
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Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the periodontal diseases. Periodontol 2000 2006; 40:107-19. [PMID: 16398688 DOI: 10.1111/j.1600-0757.2005.00136.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Denis F Kinane
- University of Louisville School of Dentistry, Kentucky, USA
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Leung WK, Yau JYY, Jin LJ, Chan AWK, Chu FCS, Tsang CSP, Chan TM. Subgingival microbiota of renal transplant recipients. ORAL MICROBIOLOGY AND IMMUNOLOGY 2003; 18:37-44. [PMID: 12588457 DOI: 10.1034/j.1399-302x.2003.180106.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Renal transplant patients undergoing immunosuppressive therapy may experience periodontal side-effects such as gingival overgrowth. This study evaluated the subgingival microbiota of renal transplant recipients with or without periodontal tissue destruction who may have concurrent gingival enlargement. Subgingival paper point samples taken from the deepest probing sites of 38 subjects (one per patient) were examined using direct microscopy and culture techniques. A complex microflora comprising gram-positive and gram-negative cocci, rods and filaments, fusiforms, curved rods and spirochetes was observed using microscopy. Yeasts were occasionally detected. Significantly higher proportions of gram-positive morphotypes, including gram-positive cocci, were observed in samples from periodontally healthy patients. The predominant cultivable microflora from anaerobic culture comprised several species of facultative and obligate anaerobes. Colonization of the subgingival sites by 'foreign' microbes that are normally dermal, intestinal or vaginal flora was detected in up to 50% of the samples. High mean proportions of lost or unidentified species were also occasionally noted. The results showed that the subgingival biofilm of renal transplant recipients with chronic periodontitis comprised mainly gram-negative rods and spirochetes. Besides the usual predominant cultivable subgingival microbiota associated with periodontitis, the high prevalence of unidentified and 'foreign' microbes indicates the possibility of subgingival microbial alteration in renal transplant patients.
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Affiliation(s)
- W K Leung
- Department of Medicine, Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Evian CI, Karateew ED, Rosenberg ES. Periodontal soft tissue considerations for anterior esthetics. JOURNAL OF ESTHETIC DENTISTRY 1998; 9:68-75. [PMID: 9468855 DOI: 10.1111/j.1708-8240.1997.tb00920.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- C I Evian
- University of Pennsylvania, Philadelphia, USA
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Zhou LX, Pihlstrom B, Hardwick JP, Park SS, Wrighton SA, Holtzman JL. Metabolism of phenytoin by the gingiva of normal humans: the possible role of reactive metabolites of phenytoin in the initiation of gingival hyperplasia. Clin Pharmacol Ther 1996; 60:191-8. [PMID: 8823237 DOI: 10.1016/s0009-9236(96)90135-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Gingival hyperplasia is a well-known complication of therapy with cyclosporine, calcium channel blockers, and phenytoin. It is characterized by the presence of inflammation and a marked fibrotic response. The mechanism of this adverse reaction is unknown. We propose that it may be initiated by the metabolic activation of these drugs to form reactive metabolites. These then cause cellular injury and lead to the gingival hyperplasia. To evaluate this hypothesis we examined phenytoin metabolism and the cytochrome P450 contents of gingival tissues from 10 patients undergoing surgery for various periodontal conditions. We found that microsomes obtained from the gingiva show significant phenytoin hydroxylase activity as determined by the production of 5-(4'-hydroxyphenyl)-5-phenylhydantoin (HPPH) (range, 12.8 pmol HPPH/min.mg microsomal protein to 276.9 pmol HPPH/min.mg microsomal protein; rat control, 133.7 +/- 11.5 pmol HPPH/min.mg microsomal protein). We also found that CYP1A1, CYP1A2, CYP2C9, CYP2E1, and CYP3A4 were present in these microsomes. We detected no CYP2B6 or CYP2D6. We believe that these data support our hypothesis that the proliferative inflammation observed with drugs such as phenytoin, nifedipine, and cyclosporine may be initiated by the formation of reactive metabolites and that the formation of these metabolites may be catalyzed by one or more CYPs found in the gingiva. These metabolites may then cause cellular injury and induce a reactive inflammatory response, followed by fibroblastic proliferation. This proliferation leads to the excess collagen deposition observed with gingival hyperplasia.
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Affiliation(s)
- L X Zhou
- Department of Medicine, School of Medicine, University of Minnesota, Minneapolis, USA
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Dongari A, McDonnell HT, Langlais RP. Drug-induced gingival overgrowth. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1993; 76:543-8. [PMID: 8233439 DOI: 10.1016/0030-4220(93)90027-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Certain anticonvulsants, cyclosporine, and a variety of calcium channel blockers have been shown to produce clinically and histologically similar gingival enlargements in certain susceptible patients. These drugs appear to be similar with respect to their pharmacologic mechanism of action at the cellular level. The primary target tissue is the most essential difference among them. Therefore it is tempting to speculate that these agents may act similarly on a common secondary target tissue, such as gingival connective tissue, and cause a hyperplastic response. This tissue reaction may involve a disturbance of calcium ion influx into specific cell populations with a resulting alteration in collagen metabolism and other host cell response mechanisms. A connection between ion exchange, folate uptake, collagenase activation, and bacterial inflammation may exist. Until a more effective approach can be developed from future research results, treatment should continue to emphasize plaque control, professional debridement, and resective gingival procedures to improve function, esthetics, and access for home care.
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Affiliation(s)
- A Dongari
- Dental School, University of Texas Health Center at San Antonio
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Hassell TM, Hefti AF. Drug-induced gingival overgrowth: old problem, new problem. CRITICAL REVIEWS IN ORAL BIOLOGY AND MEDICINE : AN OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION OF ORAL BIOLOGISTS 1991; 2:103-37. [PMID: 1912141 DOI: 10.1177/10454411910020010201] [Citation(s) in RCA: 208] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- T M Hassell
- Department of Periodontology, College of Dentistry, University of Florida, Gainesville 32610
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Abstract
Increasingly, patients with complicated medical problems are coming to dental offices for treatment. These patients report using a variety of medications to control one or more chronic conditions. Many of these medications produce changes in the mouth because of toxic overdoses, side effects, allergic reactions, or as a consequence of the primary action of the drug. These effects include: xerostomia, gingival hyperplasia, candidiasis, mucositis, stomatopyrosis, gingival bleeding, petechia, salivary gland problems, intrinsic stain, cheilitis, erythema multiforme, lichen planus, ulcerations, taste changes, tardive dyskinesias, and soft tissue pigmentation. This article discusses presentations and causes of oral changes secondary to systemic drug use.
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Smith QT, Hinrichs JE. Phenytoin and 5-(p-hydroxyphenyl)-5-phenylhydantoin do not alter the effects of bacterial and amplified plaque extracts on cultures of fibroblasts from normal and overgrown gingivae. J Dent Res 1987; 66:1393-8. [PMID: 3476609 DOI: 10.1177/00220345870660082201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Local irritation of gingival tissue by plaque is among the factors which affect development of gingival overgrowth in patients undergoing chronic phenytoin (PHT) therapy. Variability in the cytotoxicity of plaque components or of plaque substances plus PHT and/or its metabolites toward gingival fibroblasts may relate to whether gingival overgrowth forms in a particular patient. Fibroblasts from healthy and overgrown gingivae were incubated with (a) PHT and its major human metabolite, 5-(p-hydroxyphenyl)-5-phenylhydantoin (HPPH), (b) microbial and "amplified" plaque extracts, and (c) microbial and "amplified" plaque extracts plus PHT and HPPH. Cell numbers and cell-associated protein were determined for each incubation preparation. A wide range in cytotoxic response to a particular microbial or plaque extract occurred among cell strains. Plaque extracts from different subjects had variable cytotoxicity toward a cell strain. The differences among fibroblast strains in response to an extract and the variability in cytotoxicity of different plaque extracts toward a cell strain were not related to their source from normal or overgrown gingivae. Cell numbers and cell-associated protein were similar for incubation mixtures containing extracts with and without PHT and HPPH. These data do not show differences among cytotoxicity levels of plaque extracts, the response of particular gingival fibroblast strains to plaque components, or interaction between drugs and certain plaque samples which explain development of gingival overgrowth in some subjects receiving chronic PHT therapy.
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Abstract
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.
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