article wmc003829

Article ID: WMC003829 ISSN 2046-1690

Drug Induced Gingival OvergrowthCorresponding Author:Dr. Balasubramanian Thiagarajan,Professor, Department of Otolaryngology, Stanley Medical College, Chennai Tamilnadu, Sreemagal, 20 I Street,Officers Colony, Rajaram Metha Nagar, 600029 - India

Submitting Author:Dr. Balasubramanian Thiagarajan,Professor, Department of Otolaryngology, Stanley Medical College, Chennai Tamilnadu, Sreemagal, 20 I Street,Officers Colony, Rajaram Metha Nagar, 600029 - India

Article ID: WMC003829

Article Type: Review articles

Submitted on:15-Nov-2012, 10:49:58 AM GMT Published on: 16-Nov-2012, 01:41:04 PM GMT

Article URL: http://www.webmedcentral.com/article_view/3829

Subject Categories:OTORHINOLARYNGOLOGY

Keywords:Gingival overgrowth, Drug induced, Gingival hyperplasia

How to cite the article:Thiagarajan B, Ramamoorthy G. Drug Induced Gingival Overgrowth . WebmedCentralOTORHINOLARYNGOLOGY 2012;3(11):WMC003829

Copyright: This is an open-access article distributed under the terms of the Creative Commons AttributionLicense(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal author and source are credited.

Source(s) of Funding:

None

Competing Interests:

None

WebmedCentral > Review articles Page 1 of 5

http://www.webmedcentral.com/article_view/3829http://creativecommons.org/licenses/by/3.0/http://creativecommons.org/licenses/by/3.0/

WMC003829 Downloaded from http://www.webmedcentral.com on 16-Nov-2012, 01:41:05 PM

Drug Induced Gingival OvergrowthAuthor(s): Thiagarajan B, Ramamoorthy G

Abstract

Gingival hyperplasia / hypertrophy is a rather commoncondition. This article reviews literature pertaining onlyto gingival overgrowth following drug ingestion. A widerange of causes have been attributed to gingivalovergrowth. Drug induced overgrowth commonlyoccurs following medications prescribed for non dentalcauses. Pathogenesis of gingival overgrowth followingingestion of certain drugs is still unsure. Certain highrisk co existant factors like presence of gingivitis hasbeen implicated. Management of this condition shouldtake into consideration the condition for which theoffending drug has been prescribed. Physiciansshould be aware of drugs that could cause gingivalovergrowth in order to identify and manage thisproblem.

Introduction

A large number of drugs have been implicated ascause for gingival hypertrophy / hyperplasia. Use ofthe term hypertrophy / hyperplasia is rathercontroversial. These terms do not accurately reflectthe current understanding of the currenthistopathological scenario. Gingival enlargement inthese patients is not due to increase in the number ofperiodontal cells but due to an increase in theextracellular volume 1. This increase in theextracellular volume is caused by hyperplasiainvolving fibroblasts.

Gingival overgrowth was first described in dentalliterature of 1960?s2 when case reports startedappearing about children who developed enlargedgingiva due to treatment of epilepsy using phenytoin.This condition was also described in children born ofepileptic mothers who were being treated with sodiumvalproate. These children were branded to be sufferingfrom fetal valproate syndrome 3. Fetal valproatesyndrome was first described by Di Liberti in 1984 4.These children also had neurodevelopmentalproblems. Associated congenital defects in thissyndrome include Neural tube defects, congenitalheart defects, orofacial clefts, and limb defects.

Drugs involved in causing gingival enlargement:

Three types of drug categories 6have been implicatedas causative factors of gingival enlargement. They

include:

1. Anti epileptic drugs Phenytoin, Phenobarbitone,Valproic acid, Pr imidone, Vigabatr in andcarbamazepine.

2. Calcium channel blockers Nifidepine, Verapamil,Diltiazem and Amlodepin

3. Immunosuppresive drugs Cyclosporine

Studies reveal that drug induced gingival overgrowthusually occurs within first three months of starting drugtherapy with the offending drug. This usually begins asan enlargement involving Interdental papillae.

Prevalance:

Review of literature shows a wide variation inprevalance rates 7. A high figure of 50% has beenquoted for the drug phenytoin, where as forcyclosporin it is 30% and for calcium channel blockers10%. Recent studies have demonstrated thesynergistic effect of cyclosporin with calcium channelblockers in causing gingival overgrowth 8. Indianstatistics are rather sketchy in this aspect. One studyreports that 57% of epileptic children in the age group8-13 on phenytoin developed gingival overgrowthwithin the first 3 months of starting the treatment9.

Etiology

Etiology although enough pointers are there to pointfingers at an offending drug, is still considered to bemultifactorial. The relationship between the drugdosage, duration of therapy and sex prediliction is stillnot clear. There is still a raging debate going on as towhether drug induced gingival hyperplasia could becaused by hyperplasia of gum epithelium or ofsubcutaneous connective tissue or both.

Certain predisposing risk factors have been indentifiedand documented. They include:

Poor oral hygiene: Presence of dental plaque canprovide a reservoir for accumulation of drugs likephenytoin / cyclosporin8.

In patients who have undergone orthodonticprocedures the presence of nickel could predispose toformation of gingival over growth

Susceptibility of some subpopulation of fibroblasts andkeratinocytes to phenytoin, cyclosporin and otherdrugs which could cause gingival overgrowth

Number of langhans cells10present in the oral


http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref1http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref2http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref3http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref4http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref6http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref7http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref8http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref9http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref8http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref10


epithelium is another risk factor. More the numberworse the risk. These drugs have a tendency toaccumulate inside these cells causing prolonged effecton the gums.

Cytochrome P-450 gene polymorphism 11can causeindividual variations in drug metabolism predisposingto gingival overgrowth

In patients using calcium channel blockers gingivalovergrowth could be caused by:

Defective collagenase activity

Blockage of aldosterone synthesis from adrenal cortexfollowed by feedback increase in the secretion ofACTH

Upregulation of keratinocytes growth factor

Upregulation of transforming growth factor alpha12

Pathology

The tissue overgrowth is classically of dense collagentissue and other connective tissue elements. Scatteredinflammatory cells can also be seen. Classicallygingival tissue adjacent to anterior teeth is morecommonly affected than the posterior ones. Presenceof bacterial plaque in the teeth is essential for gingivalovergrowth to occur. Histology of overgrowth revealedhyperplasia of connctive tissue, epithelial acanthosisand elongated rete ridges.

Management

Stopping / substituting the offending medicine.Gingival overgrowth reverts back to normal within 3months.Maintenance of strict oral hygieneRegular mouth wash using cholorhexidineOral metronidazole for 21 daysSurgical removal of the gingival overgrowth(gingivectomy)

References

1. Desai P, Silver JG. Drug induced gingivalenlargement. J Can Dent Assoc 1998; 64: 263-8.2. Kimbal OP. The treatment of epilepsy with sodiumdiphenyl hydantoinate. J Am Med Assoc 1939; 112:1244-5.3. Rodriguaz-Vazquez M, Carrascosa-Romero MC,Parddal-Fernandoz M, et al. Congenital gingivalhyperplasia in a neonate with foetal valproatesyndrome Neuropediatrics 2007; 38: 251-2.

4. DiLiberti JH, Farndon PA, Dennis NR, Curry CJ.The fetal valproate syndrome. Am J Med Genet1984;19:473-4815. Perlik F, Kolinova M, Zvarova J, et al. Phenytoin asa risk factor in gingival hyperplasia. Therap DrugMonitor 1995; 17: 445-8.6. Perlik F, Kolinova M, Zvarova J, et al. Phenytoin asa risk factor in gingival hyperplasia. Therap DrugMonitor 1995; 17: 445-8.7. Ellis JS, Seymour RA, Steele JG, et al. Prevalenceof gingival overgrowth induced by calcium channelblockers: a community based study. J Periodontol.1999; 70: 63-7.8. Spratt H, Boomer S, Irwin CR, et al. Cyclosporinassociated gingival overgrowth in renal transplantrecipients. Oral Dis 1999; 5 : 27- 31.9. Mejia LM, Lozada-Nur F. Drug induced gingivalhyperplasia. E medicins . Medscope. com 2009; article/ 107626410. Kinane DF, Drummond JR, Chisholm DM.Langerhans cells in human chronic gingivitis andphenytoin induced gingival hyperplasia. Arch Oral Biol1990; 35: 561-4.11. Seymour RA, Ellis JS, Thomason JM. Risk factorsfor drug induced gingival overgrowth . J ClinPeriodontol. 2000; 27 : 217-23.12. Lafzi A, Farahani RMZ, Shoja MM. Amlodipineinduced gingival hyperplasia. Oral Med Pathol Oral CirBuccal 2006; 11: E480-2.


http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref11http://entscholar.wordpress.com/article/drug-induced-gingival-overgrowth/#ref12


Illustrations

Illustration 1

Image showing gingival hyperplasia



DisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview, contents posted on this web portal do not undergo any prepublication peer or editorial review. It iscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions beforesubmitting any information that requires obtaining a consent or approval from a third party. Authors should alsoensure not to submit any information which they do not have the copyright of or of which they have transferredthe copyrights to a third party.

Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater tothe needs of an individual patient. The web portal or any content(s) therein is neither designed to support, norreplace, the relationship that exists between a patient/site visitor and his/her physician. Your use of theWebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harmthat you may suffer or inflict on a third person by following the contents of this website.


IntroductionArticleIllustrationsIllustration 1

article wmc003829

Documents