Treatment of cyclosporine-induced gingival hypertrophy

Drug-Induced Gingival Hyperplasia in Transplant Recipients

Gingival hyperplasia is a common occurrence in transplant recipients who are taking cyclosporine. This condition can be complicated when calcium channel blockers or phenytoin are added to the armamentarium of medications; it can be painful and may interfere with eating, speech, and appearance. Multiple mechanisms exist for gingival overgrowth. Prevention with appropriate oral hygiene appears important in controlling the inflammatory component and decreasing the severity of the overgrowth. Patients must be aware of the potential for the development of gingival hyperplasia and must follow up with regular professional cleanings. If the overgrowth persists, treatment options should be discussed between patients and their physician. Conversion from cyclosporine to tacrolimus, treatment with antibiotic therapy, and surgical excision or laser therapy are all potential therapies to consider.

A well known and important adverse effect of phenytoin in a neurosurgical patient

Gum hypertrophy is a well-known and important adverse effect of phenytoin therapy in a neurosurgical patient. We present an interesting case of a 21-year-old man who, following head injury after a road traffic accident, developed status epilepticus diagnosed with gum hypertrophy in the jaws, with ongoing antiepileptics. He was managed conservatively as per hospital protocol.

Trial of metronidazole vs. azithromycin for treatment of cyclosporine-induced gingival overgrowth

Gingival overgrowth usually characterized by increased cellular growth of gingival fibroblasts appears to be multifactorial. In patients receiving CyA for more than 3 months, the incidence can approach 70% and can be attributed to pharmaceutical immunosuppression. Case reports have reported regression of overgrowth with both metronidazole and azithromycin. The goal of this study was to determine the efficacy of metronidazole and azithromycin in reducing CyA-induced gingival overgrowth. Twenty-five patients were included in this double-blinded randomized study. All patients were receiving CyA as medically indicated and diagnosed with gingival overgrowth by a dentist. Patients were randomized to receive either 5-days of azithromycin or 7-days of metronidazole given at baseline only. The extent of gingival overgrowth was measured at 0, 2, 4, 6, 12, and 24 wk. Fourteen patients at CCF and 11 patients at CCHMC were studied. Repeated measures anova was performed to assess differences within and between groups. Gingival overgrowth at baseline was not statistically different between groups. The mean degree of gingival overgrowth after treatment was different across all time intervals (p = 0.0049) showing azithromycin to be more effective than metronidazole. Therapy with azithromycin offers an effective alternative to the management of CyA-induced gingival overgrowth.

Gastrointestinal side effects of drugs

Drugs can have adverse effects on any part of the gastrointestinal (GI) tract from mouth to colon. It is essential that a detailed and accurate drug history is taken in patients presenting with GI complaints. Many drug-induced effects will regress or heal on cessation of treatment. NSAIDs are usually associated with gastric and duodenal ulcers but are also recognised to cause lichen planus in the mouth, oesophageal inflammation and strictures, and small bowel and colonic ulcers and strictures. A newer class of anti-inflammatory drugs, the cyclooxygenase-2 (COX-2)-selective inhibitors, have been developed and have a more favourable GI safety profile than standard NSAIDs. Acute diarrhoea, relapse of inflammatory bowel disease (IBD), microscopic colitis and acute pancreatitis are also induced by ingestion of standard NSAIDs. The calcium antagonists, phenytoin and cyclosporin, induce gum hyperplasia, particularly in patients with poor oral hygiene. Alendronate, a bisphosphonate, has been associated with development of oesophageal ulcers, and specific recommendations are now given to reduce this complication. Of the many different forms of colitis associated with drug ingestion, the most frequent is pseudomembranous colitis. This is a complication of antibiotics and is caused by the toxin produced by Clostridium difficile. Many drugs have been associated with the development of acute pancreatitis, although a definite cause and effect relationship has been shown for only a few drugs. These include didanosine, furosomide, corticosteroids, azathioprine and sodium valproate.

Prevalence and risk of gingival enlargement in patients treated with nifedipine

BACKGROUND

Gingival enlargement is a known side effect of nifedipine use. This study was conducted to determine the prevalence and risk factors for gingival enlargement in nifedipine-treated patients.

METHODS

A cross-sectional study was conducted in a primary care center. Data from 65 patients taking nifedipine were compared with 147 controls who had never received the drug. All patients were examined for the presence of gingival enlargement using 2 different indices: vertical gingival overgrowth index (GO) in 6 points around each tooth, and horizontal MB index in the interdental area. Gingival index, plaque index, and probing depth were also evaluated.

RESULTS

The prevalence of gingival enlargement was significantly higher in nifedipine-treated cases than in controls (GO index, 33.8% versus 4.1%; MB index, 50.8% versus 7.5%, respectively). Higher gingival and plaque indices were observed in patients taking nifedipine. Among the possible risk factors, only the gingival index showed a significant association with gingival enlargement. The risk (odds ratio [OR]) of gingival enlargement associated with nifedipine therapy was 10.6 (3.8-29.1) for the GO index and 14.4 (6-34.6) for the MB index. Gingival index-adjusted ORs were 9.6 (3.3-28.1) and 9.7 (3.9-23.3), respectively. In the subset of high nifedipine exposure patients, the odds ratio for gingival enlargement increased to 17.4 (5.3-56.3) for the GO index and 23.6 (7.7-72.3) for the MB index. The concordance between GO and MB indices showed a kappa value of 0.689 in controls and 0.642 in patients treated with nifedipine.

CONCLUSIONS

Patients taking nifedipine are at high risk for gingival enlargement, and gingivitis acts as a predisposing factor.