Prevention and non-surgical periodontal therapy of calcium channel blockers induced severe gingival overgrowth. / A kalciumcsatorna-blokkoló gyógyszerek által indukált súlyos gingivahyperplasia konzervatív kezelése és megelozésének lehetoségei.

Összefoglaló. Bevezetés és célkituzés: A gingivahyperplasia a kalciumcsatorna-blokkoló gyógyszerek gyakori mellékhatása. Eredményeink közlésének célja, hogy bemutassuk, sebészi terápia nélkül, megfelelo egyéni szájhigiénia kialakításával és nem sebészi parodontalis terápiával milyen eredményt tudunk elérni az ínymegnagyobbodás kezelése során. Módszer: A Szegedi Tudományegyetem Fogorvostudományi Karának Parodontológiai Tanszékén 2015 és 2019 között 10 - 7 no és 3 férfi, átlagéletkoruk 56 év (50-69 év) volt -, kalciumcsatorna-blokkoló gyógyszer szedése során kialakuló, Grade III. ínyhyperplasiában szenvedo páciens kezelését végeztük konzervatív parodontalis módszerekkel, a gyógyszercsere mellozésével. A legfontosabb parodontalis értékeket rögzítettük, a tasakmélység, a vérzési index, a plakkindex és a fogmozgathatóság értékeit összegeztük vizsgálatunkban. A parodontium destrukciója mértékének megállapításához ortopantomogram és periapicalis röntgenfelvételeket értékeltünk. Eredmények: Minden parodontológiai paraméterben jelentos javulást tapasztaltunk. A nem sebészi parodontalis terápia eredményeként megszunt az elváltozás mind a 10 betegnél, és a szigorú fenntartó terápiának is köszönhetoen nem is újult ki. Következtetés: A nem sebészi terápia alkalmasnak bizonyult a súlyos gingivahyperplasia definitív kezelésére, ha az gingivitis vagy enyhe és középsúlyos parodontitis talaján alakult ki. Arra is következtethetünk az eredményeinkbol, hogy a gyógyszeres terápia megkezdése elott vagy azzal párhuzamosan parodontológiai terápiában részesülo páciensek nagy részénél a gingivahyperplasia - s ezzel a hosszú ideig tartó, drága kezelés - megelozheto lenne. Orv Hetil. 2022; 163(13): 506-512. INTRODUCTION AND OBJECTIVE: Gingival overgrowth is an adverse drug reaction in patients on long-term calcium channel blocker therapy. The aim of this study was to assess the efficacy of non-surgical pocket therapy in patients suffering from Grade III drug-related gingival overgrowth. METHOD: 10 (7 female and 3 male) patients (age between 50-69 years) diagnosed with severe, Grade III gingival overgrowth were treated in our department. Non-surgical periodontal therapy consists of improving of individual oral hygiene, scaling, polishing and subgingival mechanical debridement instrumentation. The main periodontal parameters (probing pocket depth, bleeding index, plaque index and mobility) were scored in this study. Bone loss was evaluated by orthopantomograms and periapical radiographs. Calcium channel blockers have not been replaced by any other medications during the whole course of periodontal treatment. RESULTS: Compared with baseline parameters, all scores improved after therapy. All patients showed decrease in the average probing pocket depth, deepest probing pocket depth, bleeding scores, plaque scores and tooth mobility. None of the patients needed further surgical treatment. In our followed-up patients, recurrence of gingival overgrowth has not been observed during the two-year meticulous supportive periodontal care in the patient group. CONCLUSION: Non-surgical periodontal treatment can be a potential definitive therapy in Grade III gingival overgrowth associated with gingivitis or moderate periodontitis. Periodontal screening and treatment before or simultaneously with the administration of calcium channel blockers can prevent the gingival enlargement in the majority of patient. These results outline the importance of the successful cause related periodontal therapy, started before or simultaneously with the administration of anithypertensive medications and in this way a series of further expensive therapies could be anticipated. Orv Hetil. 2022; 163(13): 506-512.

[A woman with gingival enlargement]. / Een vrouw met gezwollen tandvlees.

A 65-year-old female complained of diffuse and rapidly progressive gingival enlargement. Gingival overgrowth can be caused by medication, infections or systemic diseases. In case of generalized, quickly progressive gingival enlargement, acute myeloid leukemia should be considered. Blood results showed an acute myelomonocytic leukemia. Treating the leukemia resolved the symptoms.

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.

Oral Manifestations of Commonly Prescribed Drugs.

Drugs are being prescribed with more frequency and in higher quantities. A serious adverse drug event from prescribed medications constitutes 2.4% to 16.2% of all hospital admissions. Many of the adverse drug events present intraorally or periorally in isolation or as a clinical symptom of a systemic effect. Clinical recognition and treatment of adverse drug events are important to increase patient adherence, manage drug therapy, or detect early signs of potentially serious outcomes. Oral manifestations of commonly prescribed medications include gingival enlargement, oral hyperpigmentation, oral hypersensitivity reaction, medication-related osteonecrosis, xerostomia, and other oral or perioral conditions. To prevent dose-dependent adverse drug reactions, physicians should prescribe medications judiciously using the lowest effective dose with minimal duration. Alternatively, for oral hypersensitivity reactions that are not dose dependent, quick recognition of clinical symptoms associated with time-dependent drug onset can allow for immediate discontinuation of the medication without discontinuation of other medications. Physicians can manage oral adverse drug events in the office through oral hygiene instructions for gingival enlargement, medication discontinuation for oral pigmentation, and prescription of higher fluoride toothpastes for xerostomia.

[Relationship of orthodontic treatment and periodontal soft tissue health].

With the increasing number of the orthodontic patients, the relationship between periodontal and orthodontic becomes increasingly close. Orthodontic treatment can improve periodontal status, but the adverse clinical problems of periodontal tissue during orthodontic treatment are relatively common. In this paper, we discuss the problems of soft tissue, including causes, prevention, and treatment of gingivitis, gingival enlargement, gingival recession, and gingival invagination in orthodontic treatment.

La toxina botulínica como adyuvante en el tratamiento de la sonrisa gingival / Botulinum toxin as an adjuvant in the treatment of gummy smile

RESUMEN: La búsqueda de la excelencia estética es un objetivo importante de la odontología. La sonrisa gingival es una de las principales quejas estéticas, ya que perjudica la autoestima y las relaciones sociales del paciente. Nuevas técnicas como la aplicación de la toxina botulínica (TB) pueden tornarse una opción terapéutica más conservadora, y ayudar a disminuir las proporciones de las intervenciones quirúrgicas resectivas. El propósito de este trabajo es describir la aplicación de la TB como adyuvante de la cirugía gingival resectiva, a través del reporte de un caso clínico de discrepancia dentogingival y sonrisa gingival. Con la cirugía resectiva el equilibrio dentogingival fue mejorado, y la aplicación de TB tipo A causó la dehiscencia uniforme del labio superior, devolviendo la armonía facial. La TB es un complemento útil y conservador en la mejora estética de la sonrisa, y puede aumentar los resultados de la cirugía gingival resectiva.

ABSTRACT: The search for aesthetic excellence is an important goal in dentistry. The gummy smile is one of the main aesthetic complaints as it can affect self-esteem, and prejudice the patients' social relationships. New techniques, such as the application of botulinum toxin (BT) may become a more conservative treatment option and help to reduce the proportions of resective surgery. The purpose of this paper is to describe the application of BT, used as an adjuvant to gingival resection surgery, using a case report of a dento-gingival discrepancy and gummy smile. The resection surgery improved the dento-gingival equilibrium and the application of BT led to a uniform dehiscence of the upper lip, and facial harmony. BT is a useful and conservative adjuvant in the aesthetic enhancement of the smile, and can improve the outcomes of gingival resection surgery.

A novel gingival overgrowth mouse model induced by the combination of CsA and ligature-induced inflammation.

Drug-induced gingival overgrowth (DIGO) is a side effect of the enlargement of gingival tissue by phenytoin, nifedipine, and cyclosporine A (CsA). Gingival inflammation has been identified as a key factor that initiates DIGO. However, a sufficient animal model for clarifying the role of inflammation in DIGO has not yet been generated. We herein describe a novel CsA-induced gingival overgrowth mouse model to evaluate the role of inflammation. A ligature was placed around the second molar in maxillae for 7days to induce gingival inflammation, and CsA (50mg/kg/day) was administered to mice during each experimental period. The severity of gingival overgrowth and mRNA expression of inflammatory cytokines in gingiva were assessed by the gingival overgrowth degree, histological analyses, and RT-PCR. The administration of CsA for 28days in combination with ligation significantly increased the gingival overgrowth degree and expanded the connective tissue area. Increases in the gingival overgrowth degree continued in a time-dependent manner until 21days. Furthermore, the cessation of CsA reduced gingival overgrowth. Thin ligatures (7-0 size) induced weaker tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, and IL-6 mRNA expression and less gingival overgrowth than thick ligatures (5-0 ligature). Moreover, the administration of an antibiotic cocktail, which suppressed the expression of these inflammatory cytokines in gingiva, attenuated gingival overgrowth induced by ligatures and CsA. These results suggest that inflammation in gingival tissue plays a role in initiating CsA-induced gingival overgrowth. This gingival overgrowth mouse model has potential for elucidating the etiology of DIGO from the view point of gingival inflammation.

Gingival overgrowth: Part 2: management strategies.

The effective and predictable management of gingival overgrowth requires correct diagnosis and consideration of aetiological factors, as discussed in Part 1 (BDJ 2017; 222: 85-91). Initial management should involve cause-related therapy, which may resolve or reduce the lesion. If functional, aesthetic and maintenance complications persist following this phase; further treatment may be required in the form of surgery. This paper discusses management strategies, including management of aetiological factors and surgical techniques.

Ca-channel blocker-induced gingival overgrowth that improved with non-surgical therapy during visiting care: a case report.

OBJECTIVES: To present a case of gingival overgrowth during visiting care. BACKGROUND: Ca-channel blocker-induced gingival overgrowth is a well-known adverse event. However, only limited information on the treatment of calcium-channel blocker-induced gingival overgrowth during visiting care has been reported. CLINICAL REPORT: The patient was an 88-year-old female living in a nursing home since dementia. She had been taking a calcium-channel blocker and observed gingival overgrowth. Initial therapy was performed and changed the antihypertensive medication from a calcium-channel blocker to an angiotensin converting enzyme inhibitor. After initial therapy, the gingival overgrowth improved significantly. In addition, the defecation rate was improved. CONCLUSION: This case indicated that periodontal therapy is useful even for dementia patients during visiting dental care.

Successful nonsurgical management of post-orthodontic gingival enlargement with intensive cause-related periodontal therapy.

Successful nonsurgical management of severe postorthodontic gingival enlargement and erythema in a 24-year-old male is presented. The patient received an intensive cause-related periodontal therapy, consisting of oral hygiene instruction, scaling and root planing, and weekly recall visits. At week five, complete resolution of the lesions was achieved. By targeting the primary etiologic factor, i.e., plaque, periodontal health was restored without needing surgical intervention. Reducing the bacterial load will give the biologic natural healing capacity of the body the opportunity to stabilize the periodontal condition and, thus, should be considered as the first line of intervention before a surgical approach is taken.

Periodontal management of a patient with severe psoriasis: A case report.

UNLABELLED: Psoriasis is a common, disfiguring and stigmatizing skin disease associated with impaired quality of life. In patients with severe psoriasis unresponsive to other treatments, cyclosporine can induce a rapid remission. Although drug-induced gingival overgrowth (GO) is a frequent side effect, in the guidelines for the use of cyclosporine for psoriasis regular dental examinations were not mentioned as an essential part of monitoring of these patients. CASE REPORT: A 59-year-old man with GO involving almost all the interdental papillae (Seymour's grading score 1-5) reported difficulties in mastication and gingival swelling. The medical history revealed severe recalcitrant psoriasis treated by oral cyclosporine. The periodontal treatment consisted of strict oral hygiene instructions, scaling, root surface instrumentation, and a 2-month interval periodontal supportive treatment. At 12 months an almost complete regression of GO was observed. A careful nonsurgical periodontal treatment combined with meticulous self-performed oral hygiene may avoid the need for surgical intervention, even in advanced cases.

Non-drug induced gingival enlargement.

Gingival enlargement refers to an increase in the size of the gingival tissue. The etiology varies, and often is multifactorial; however, local and systemic conditions, disease, and idiopathic factors may contribute to gingival enlargement. Tissue consistency can vary from soft and spongy to dense, typically appearing darker in shade compared to the drug-induced gingival enlargement. Treatment modalities usually involve surgical removal of excess tissue, non-surgical debridement, use of chemotherapeutic agents, and/or elimination or mitigation of contributing factors and conditions.

Effect of periodontal therapy on the course of cyclosporin-induced gingival overgrowth: role of ABCB1 and PAI-1 gene polymorphisms.

OBJECTIVES: Etiological periodontal therapy is effective in reducing cyclosporin A-induced gingival overgrowth, but a high variability among subjects has been observed. This study aimed to evaluate the role of polymorphisms in PAI-1 and A BCB1 genes on the course of this side effect following periodontal therapy. METHOD AND MATERIALS: Forty-five transplant patients were subjected to nonsurgical periodontal therapy and evaluated for hypertrophy index, probing depths, bleeding, and plaque scores at baseline, and after 3 and 6 months. A BCB1 (C3435T and G2677T) and PAI-1 (4G/5G) polymorphisms were studied with polymerase chain reaction-restriction fragment length polymorphism and allele-specific polymerase chain reaction respectively. RESULTS: All the monitored periodontal indexes decreased significantly during the six months. Modeling of hypertrophy index by linearmixed- effect models (allowing non-normal distribution of the outcome variable hypertrophy index) resulted in the selection as the most significant model, of the one comprising the independent variables: time, C 3435T genotype, and their interaction term. This model indicated that C 3435T-mutated patients had significantly higher baseline hypertrophy index values (90% Markov chain Monte C arlo empirical confidence intervals: 5.08, 30.00). The decrease in hypertrophy index values over time showed a trend toward being faster in mutated than nonmutated patients (interaction time: C 3435T nonmutated, 90% Markov chain Monte C arlo empirical confidence interval: -11.08, -0.40). When hypertrophy index values were normalized, the significance and trend were lost. No effect of the A BCB1 G2677T and PAI-1 4G/5G polymorphisms was observed. CONCLUSION: These preliminary results suggest that C 3435T polymorphism is a genetic factor that could influence the course of cyclosporin A-induced gingival overgrowth in transplant patients subjected to periodontal therapy.

Treatment modalities for drug-induced gingival enlargement.

PURPOSE: This paper identifies 3 specific classifications of commonly prescribed medications that are known to cause gingival enlargement and describes surgical and non-surgical treatment therapies. Primary risks associated with drug-induced gingival enlargement, including increased dental decay and periodontal disease are also discussed. The precise bacterial etiology in gingival enlargement remains unclear, although sufficient evidence exists to support the role of good oral hygiene in decreasing the incidence and severity of gingival enlargement and improving overall gingival health. Etiology, treatment planning and coordination of care between physician, dentist or dental hygienist when indicated are important factors determining whether a surgical or non-surgical course of treatment should be considered.

Drug-induced gingival overgrowth: a case report.

A variety of systemic drugs can lead to adverse effects in the oral environment. This article reports the case of a 61-year-old man who had a severe drug-induced gingival overgrowth (DIGO) caused by nifedipine. DIGO is relevant due to severe gingival enlargement, which causes disfigurement and blocks physiological and social functions such as mastication and speaking. Management of DIGO is always a challenge due to the patient's systemic condition. This article shows, step-by-step, how the treatment was executed and how the DIGO was reversed.

Clinical case report of long-term follow-up in type-2 diabetes patient with severe chronic periodontitis and nifedipine-induced gingival overgrowth.

In this case report, we describe the clinical course over a 14-year follow-up in a 47-year-old diabetes patient with severe chronic periodontitis and nifedipine-induced gingival overgrowth. The patient had a history of hypertension for over 5 years and uncontrolled type 2 diabetes. Overgrown gingiva was observed in most of the teeth and was marked in the upper and lower anterior teeth. A probing pocket depth of ≥ 4 mm and bleeding on probing (BOP) were observed in 94 and 90% of sites examined, respectively. At baseline, his hemoglobin A1c (HbA1c) was 8.5%. The patient received periodontal and diabetic treatment simultaneously. Medication was changed from nifedipine chloride to an angiotensin-converting enzyme inhibitor. After initial therapy and subsequent periodontal surgery, gingival overgrowth disappeared and probing depth and BOP showed a significant improvement. No recurrence was observed during supportive periodontal therapy (SPT). The HbA1c level improved from 8.5 to 6.3% after periodontal treatment, subsequently remaining at a good level during SPT over 10 years. This study demonstrated that periodontal treatment, withdrawal of medication and control of diabetes can result in remarkable improvements in type 2 diabetes patients with chronic periodontitis and nifedipine-induced gingival overgrowth. These results suggest that comprehensive periodontal treatment in combination with treatment for diabetes mellitus can exert a positive influence on blood glucose levels and periodontal condition in diabetic patients.

Functional aesthetic treatment of patient with phenytoin-induced gingival overgrowth.

Gingival overgrowth (GO) may be related to the frequent use of certain medications, such as cyclosporin, phenytoin (PHT), and nifedipine, and is therefore denominated drug-induced GO. This article reports a case of a patient who with chronic periodontitis made use of PHT and presented generalized GO. A 30-year-old man with GO was referred to the clinic of the Universidade Estadual Paulista, Brazil. The complaint was poor aesthetics because of the GO. The patient had a medical history of a controlled epileptic state, and PHT was administered as an anticonvulsant medication. The clinical examination showed generalized edematous gingival tissues and presence of bacterial plaque and calculus on the surfaces of the teeth. The diagnosis was GO associated with PHT because no other risk factors were identified. Treatment consisted of meticulous oral hygiene instruction, scaling, root surface instrumentation, prophylaxis, and daily chlorhexidine mouth rinses. After this stage, periodontal surgery was performed, and histopathologic evaluation was made. The patient has been under control for 3 years after the periodontal surgery, and up to the present time, there has been no recurrence. It can be concluded that PHT associated with the presence of irritants favored gingival growth and that the association of nonsurgical and surgical periodontal therapies was effective in the treatment of GO. Besides, motivating the patient to maintain oral hygiene is a prerequisite for the maintenance of periodontal health.

Clinical, microbiologic, and immunologic factors of orthodontic treatment-induced gingival enlargement.

INTRODUCTION: The aim of this study was to investigate the microbiologic and immunologic factors related to orthodontic treatment-induced gingival enlargement (GE). METHODS: Our study included 12 patients with GE undergoing fixed orthodontic treatment and 12 periodontally healthy controls. At baseline, periodontal variables, subgingival plaque samples, and gingival crevicular fluid (GCF) samples were taken from 2 preselected sites in both the GE and the control groups. The levels of Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Treponema denticola and Tannerella forsythia were determined by real-time polymerase chain reaction. GCF interleukin (IL)-1ß and transforming growth factor-beta 1 (TGF-ß1) were detected by enzyme-linked immunosorbent assay (Invitrogen, Camarillo, Calif). Periodontal therapy was given to the GE group, and all parameters were reassessed after 4 weeks. RESULTS: At baseline, the GE group showed higher prevalences of the 5 periodontal pathogens than did the control group (P <0.05). IL-1ß and TGF-ß1 levels at the GE sites were also significantly higher than those at the control sites (P <0.05). Four weeks after periodontal therapy, the GE group showed significant improvements in the clinical parameters associated with significant reductions of P gingivalis, A actinomycetemcomitans, and T denticola. The levels of IL-1ß decreased significantly compared with the baseline (P <0.05), whereas there was no significant change in TGF-ß1 levels (P >0.05). CONCLUSIONS: Periodontal pathogens might have a relationship with the initiation and development of orthodontic treatment-induced GE. Inflammatory cytokines (IL-1ß and TGF-ß1) can also be considered as contributing factors.