Drug-induced gingival enlargement

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Drug-induced gingival enlargement (DIGE), also referred to as drug-induced gingival hyperplasia (DIGH) or drug-induced gingival overgrowth (DIGO), [1] is a side effect of many systemic medications for which the Gingervae are not the target receptor. It is normally resultant of medications including immunoregulators, calcium channel blockers and anticonvulsants. When allowed to progress assisted by routinely poor oral hygiene, DIGE can lead to pain and disfigurement, however there are great variations in its presentation and severity dependent on the case. It is suggested that enlargement is aided by genetic predispositions, tending to occur more frequently in the papillae of the anterior Gingivae in younger age groups.

Contents

Class of drugs

The main classes of drugs that result in gingival hyperplasia are as follows.

CategoryPharmacologic agent
Anticonvulsants Phenytoin

Sodium valproate

Immunoregulating drugs Ciclosporine

Tacrolimus

Sirolimus

Calcium channel blockers Nifedipine

Verapamil

Diltiazem

Amlodipine

Felodipine

Anticonvulsants

Anticonvulsant agents, such as phenytoin, are associated with common forms of gingival overgrowth. [2] It is caused by the increase of metabolites from the breakdown of anticonvulsants in the body. [3] It should also be noted that concurrent usage of different anticonvulsants in children has resulted in accumulative gingival enlargement. [2]

Immunosuppressive drugs

Immunoregulators are often prescribed to patients who have organ transplantations and/or some autoimmune diseases. Common immunosuppressive drugs linked to gingival hyperplasia are cyclosporin and tacrolimus. [1]

The most frequently used immunosuppressive drug is cyclosporin, which is commonly prescribed after an organ transplant. Nearly 53% of patients taking cyclosporin after renal transplants presented with gingival growth. [1] Inflammation from bacterial overgrowth in the gingiva and cyclosporin's main metabolite, hydroxycyclosporin, stimulate production of collagen, while simultaneously inhibiting collagen breakdown — leading to a net increase in production of gingival tissues. [4] Tacrolimus, on the other hand, is less toxic than cyclosporin, causing less severe gingival overgrowth, hepatic and renal toxicity. [1]

Management

If gingival overgrowth becomes a legitimate concern, initial management would be proper oral hygiene habits as it is the least invasive option to alleviate overgrowth. [5] Otherwise, it may also be advisable to cease medication, although this should only be done with the patients’ medical practitioners’ consent, and complete resorption may still take up to 8 weeks. [5] In cases where medication cannot be paused, patients’ medical practitioners or consultants should be consulted to discuss treatment options. Replacement drugs may be suggested. [6] For example, vigabatrin may substitute phenytoin as anticonvulsant. [6] However, this method may be ineffective for long-standing overgrowth. [6]

Another option is the surgical removal of excess tissue via gingivectomy. [7] This method is widely successful, although recurrence has been reported for certain drugs. [6] Nonetheless, the procedure is associated with risk of hemorrhage in the highly inflamed and vascularized gingiva. [7] As such, CO2 laser or ND:YAG laser has been suggested for accurate, cauterized, and sterilized incisions. [6] [7] Other nonsurgical interventions such as fast mimicking diet regime and nonsurgical periodontal therapy has also been suggested for alleviating gingival overgrowth, thus reducing the need for surgical intervention. [5] However, they could not prevent or fully resolve gingival overgrowth alone. [5]

Related Research Articles

<span class="mw-page-title-main">Phenytoin</span> Anti-seizure medication

Phenytoin (PHT), sold under the brand name Dilantin among others, is an anti-seizure medication. It is useful for the prevention of tonic-clonic seizures and focal seizures, but not absence seizures. The intravenous form, fosphenytoin, is used for status epilepticus that does not improve with benzodiazepines. It may also be used for certain heart arrhythmias or neuropathic pain. It can be taken intravenously or by mouth. The intravenous form generally begins working within 30 minutes and is effective for roughly 24 hours. Blood levels can be measured to determine the proper dose.

<span class="mw-page-title-main">Periodontal disease</span> Medical condition

Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cause of tooth loss for adults worldwide. In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Halitosis may also occur.

<span class="mw-page-title-main">Tacrolimus</span> Immunosuppressive drug

Tacrolimus, sold under the brand name Prograf among others, is an immunosuppressive drug. After allogenic organ transplant, the risk of organ rejection is moderate. To lower the risk of organ rejection, tacrolimus is given. The drug can also be sold as a topical medication in the treatment of T-cell-mediated diseases such as eczema and psoriasis. For example, it is prescribed for severe refractory uveitis after a bone marrow transplant, exacerbations of minimal change disease, Kimura's disease, and vitiligo. It can be used to treat dry eye syndrome in cats and dogs.

Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

The vestibular lamina is responsible for the formation of the vestibule and arises from a group of cells called the primary epithelial band. This band is created at about 37 days of development in utero. The vestibular lamina forms shortly after the dental lamina and is positioned right in front of it. The vestibule is formed by the proliferation of the vestibular lamina into the ectomesenchyme. The vestibular lamina is usually contrasted with the dental lamina, which develops concurrently and is involved with developing teeth. Both the vestibular lamina and the dental lamina arise from a group of epithelial cells, called the primary epithelial band.

Peripheral odontogenic fibroma(PFO) is a fibrous connective tissue mass that is exophytic and covered in surface epithelium that contains odontogenic epithelium. The World Health Organization (WHO) classifies peripheral odontogenic fibroma as a fibroblastic neoplasm with variable amounts of odontogenic epithelium that appears to be dormant. Dentine and/or cementum-like material may be present.

<span class="mw-page-title-main">Gingival and periodontal pocket</span>

Gingival and periodontal pockets are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth.

<span class="mw-page-title-main">Gingival enlargement</span> Increase in size of the gums

Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medications. The treatment is based on the cause. A closely related term is epulis, denoting a localized tumor on the gingiva.

Gingivectomy is a dental procedure in which a dentist or oral surgeon cuts away part of the gums in the mouth.

<span class="mw-page-title-main">Gingivitis</span> Inflammation of the gums

Gingivitis is a non-destructive disease that causes inflammation of the gums; ulitis is an alternative term. The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms that are attached to tooth surfaces, termed plaque-induced gingivitis. Most forms of gingivitis are plaque-induced.

<span class="mw-page-title-main">Plasma cell gingivitis</span> Medical condition

Plasma cell gingivitis is a rare condition, appearing as generalized erythema (redness) and edema (swelling) of the attached gingiva, occasionally accompanied by cheilitis or glossitis. It is called plasma cell gingivitis where the gingiva (gums) are involved, plasma cell cheilitis, where the lips are involved, and other terms such as plasma cell orifacial mucositis, or plasma cell gingivostomatitis where several sites in the mouth are involved. On the lips, the condition appears as sharply outlined, infiltrated, dark red plaque with a lacquer-like glazing of the surface of the involved oral area.

Oral pigmentation is asymptomatic and does not usually cause any alteration to the texture or thickness of the affected area. The colour can be uniform or speckled and can appear solitary or as multiple lesions. Depending on the site, depth, and quantity of pigment, the appearance can vary considerably.

Epulis is any tumor-like enlargement situated on the gingival or alveolar mucosa. The word literally means "(growth) on the gingiva", and describes only the location of the mass and has no further implications on the nature of the lesion. There are three types: fibromatous, ossifying and acanthomatous. The related term parulis refers to a mass of inflamed granulation tissue at the opening of a draining sinus on the alveolus over the root of an infected tooth. Another closely related term is gingival enlargement, which tends to be used where the enlargement is more generalized over the whole gingiva rather than a localized mass.

Drug-related gingival hyperplasia is a cutaneous condition characterized by enlargement of the gums noted during the first year of drug treatment. Although the mechanism of drug related gingival hyperplasia is not well understood, some risk factors for the condition include the duration of drug use and poor oral hygiene. In most cases, alternative drugs are given, in order to avoid this side effect.

In dentistry, numerous types of classification schemes have been developed to describe the teeth and gum tissue in a way that categorizes various defects. All of these classification schemes combine to provide the periodontal diagnosis of the aforementioned tissues in their various states of health and disease.

Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva. It can cover teeth in various degrees, and can lead to aesthetic disfigurement. Fibrous enlargement is most common in areas of maxillary and mandibular tissues of both arches in the mouth. Phenotype and genotype frequency of HGF is 1:175,000 where males and females are equally affected but the cause is not entirely known. It mainly exists as an isolated abnormality but can also be associated with a multi-system syndrome.

<span class="mw-page-title-main">Gingival cyst</span> Medical condition

Gingival cyst, also known as Epstein's pearl, is a type of cysts of the jaws that originates from the dental lamina and is found in the mouth parts. It is a superficial cyst in the alveolar mucosa. It can be seen inside the mouth as small and whitish bulge. Depending on the ages in which they develop, the cysts are classified into gingival cyst of newborn and gingival cyst of adult. Structurally, the cyst is lined by thin epithelium and shows a lumen usually filled with desquamated keratin, occasionally containing inflammatory cells. The nodes are formed as a result of cystic degeneration of epithelial rests of the dental lamina.

Oral manifestations of systematic disease are signs and symptoms of disease occurring elsewhere in the body detected in the oral cavity and oral secretions. High blood sugar can be detected by sampling saliva. Saliva sampling may be a non-invasive way to detect changes in the gut microbiome and changes in systemic disease. Another example is tertiary syphilis, where changes to teeth can occur. Syphilis infection can be associated with longitudinal furrows of the tongue.

Laser gingivectomy is a dental procedure that recontours or scalpels the gingival tissue to improve long term dental health or aesthetics. Compared to conventional scalpel surgery, soft-tissue dental lasers, such as laser diode, Nd:YAG laser, Er:YAG laser, Er,Cr:YSGG laser, and CO2 lasers, can perform this procedure, offering a precise, stable, bloodless, often less painful, and accelerated healing experience. However, the laser diode gained more popularity due to its versatility, less interaction with hard tissue, ease of use, and the less expensive set up.

References

  1. 1 2 3 4 Tungare, Sujata; Paranjpe, Arati G. (2022), "Drug Induced Gingival Overgrowth", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30860753 , retrieved 2022-05-04 CC-BY icon.svg Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License.
  2. 1 2 Bharti, Vipin; Bansal, Chhaya (2013). "Drug-induced gingival overgrowth: The nemesis of gingiva unravelled". Journal of Indian Society of Periodontology. 17 (2): 182–187. doi: 10.4103/0972-124X.113066 . ISSN   0972-124X. PMC   3713748 . PMID   23869123.
  3. ↑ Doufexi, Aikaterini; Mina, Mina; Ioannidou, Effie (January 2005). "Gingival overgrowth in children: epidemiology, pathogenesis, and complications. A literature review". Journal of Periodontology. 76 (1): 3–10. doi:10.1902/jop.2005.76.1.3. ISSN   0022-3492. PMID   15830631.
  4. ↑ Mishra, M. B.; Khan, Z. Y.; Mishra, Shanu (February 2011). "Gingival overgrowth and drug association: a review". Indian Journal of Medical Sciences. 65 (2): 73–82. doi: 10.4103/0019-5359.103971 . ISSN   1998-3654. PMID   23196317.
  5. 1 2 3 4 Pundir, Aena Jain; Pundir, Siddharth; Yeltiwar, R. K.; Farista, Sana; Gopinath, V.; Srinivas, T. S. (2014). "Treatment of drug-induced gingival overgrowth by full-mouth disinfection: A non-surgical approach". Journal of Indian Society of Periodontology. 18 (3): 311–315. doi: 10.4103/0972-124X.134567 . ISSN   0972-124X. PMC   4095622 . PMID   25024543.
  6. 1 2 3 4 5 Marshall, R. I.; Bartold, P. M. (December 1999). "A clinical review of drug-induced gingival overgrowths". Australian Dental Journal. 44 (4): 219–232. doi: 10.1111/j.1834-7819.1999.tb00224.x . ISSN   0045-0421. PMID   10687229.
  7. 1 2 3 Mavrogiannis, M.; Ellis, J. S.; Thomason, J. M.; Seymour, R. A. (June 2006). "The management of drug-induced gingival overgrowth". Journal of Clinical Periodontology. 33 (6): 434–439. doi:10.1111/j.1600-051X.2006.00930.x. ISSN   0303-6979. PMID   16677333.
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