Microsoft word - 6164_haslina_amlodipine.doc

Archives of Orofacial Sciences (2007) 2, 61-64
CASE REPORT
Amlodipine-induced gingival overgrowth: a case
report
Taib Ha, Ali TBTb, Kamin Sb a School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. b Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia. (Received 19 March 2007, revised manuscript accepted 30 October 2007) KEYWORDS
Abstract Gingival overgrowth is frequently observed in patients taking
certain drugs such as calcium channel blockers, anticonvulsants and immunosuppressant. This can have a significant effect on the quality of life as well as increasing the oral bacterial load by generating plaque retention sites. Amlodipine, a third generation calcium channel blockers has been shown to promote gingival overgrowth although in very limited cases reported. The management of gingival overgrowth seems to be directed at controlling gingival inflammation through a good oral hygiene regimen. However in severe cases, surgical excision is the most preferred method of treatment, followed by rigorous oral hygiene procedures. This case report describes the management of gingival overgrowth in a hypertensive patient taking amlodipine. Combination of surgical gingivectomy and CO2 laser treatment was used to remove the gingival overgrowth. CO2 laser surgery produced good hemostasis and less pain during the procedure and post operatively. This case report has also shown that periodontal treatment alone without a change in associated drug can yield satisfactory clinical response.
Introduction
effect compared to the first generation such as nifedipine (Ellis et al., 1993). The prevalence of Drug induced gingival overgrowth (GO) is GO in patients taking amlodipine was reported to frequently observed as a side effect with the use be 3.3% (Jorgensen, 1997) which is lower than of several medications in the susceptible patients. the rate in patients taking nifedipine, 47.8% (Nery Medication mainly implicated are the et al., 1995). anticonvulsant such as phenytoin for treatment to control seizure disorders in epileptic patient, presented as enlarged interdental papillae and resulting in a lobulated or nodular morphology nifedipine for treatment of hypertension or angina (Hallmon and Rossmann, 1999). The effects pectoris, immunosuppressant such as normally limited to the attached and marginal cyclosporine A for treatment to prevent rejection gingivae and more frequently observed anteriorly. in patient received organ transplant (Seymour et Histologically, in nifedipine-induced gingival overgrowth it was described as thickening of the taking nifedipine induced GO. During the past few hyperkeratosis, fibroblastic proliferation and years amlodipine has been used with increasing frequency and also has been reported to promote Rossmann, 1999). In this case report, we treated GO (Seymour et al., 1994). Recently, Lafzi et al. severe GO in patient taking amlodipine for (2006) had reported rapidly developed gingival treatment of hypertension. The management hyperplasia in patient received 10 mg per day of amlodipine within two months of onset. combination of surgical gingivectomy and CO2 Amlodipine, a dihydropyridine derivative is a third generation of calcium channel blockers which shown to have longer action and weaker side Case Report
A 55-year old Chinese woman was referred to the Department of Periodontology, Faculty of Tel.: +609-766 3764 Fax: +609-764 2026. Dentistry, University of Malaya complaining of E-mail address: haslina@kck.usm.my swellings on her gingiva for several months in duration. She felt very uncomfortable as the Review after one week revealed some reduction swelling interfered while chewing and sometimes of the GO particularly at the upper arch. All there was bleeding spontaneously. She had multiple roots were then extracted under local anaesthesia. At the following visit, surgical and medications ie. Amlodipine 5mg daily, Metoprolol laser gingivectomy was performed for the lower 100mg daily, Lovastatin as an adjunct to unwanted gingiva. The overgrown tissue was cholesterol control and Aspirin 75 mg daily. resected by using scalpel blade size 15. Surgical site was then treated with a superpulsed wave Intraorally, there was massive GO on the labial/ mode CO2 laser (Luxar Navopulse, Boston, USA) palatal of the upper and lower teeth with less set at 5 watts (Figure 3). The charred layer pronounced at the lower right quadrant. The produced by lasering acts as protective barrier interdental papillae were inflamed and lobulated in and was not removed after this procedure. Four appearance mainly at the lower anterior teeth weeks later the same procedure was done for the (Figure 1). Her oral hygiene was very poor with upper GO. All procedures were carried out under abundant plaque and calculus. Bleeding on local anaesthesia. Few pieces of enlarged tissue probing was detected on all affected areas. There from the labial part of the teeth 31, 32 and the were multiple retained roots embedded in the overgrown tissues of the upper arch (Figure 2). histopathological examination (HPE). Patient was Periodontal pockets were 3 to 9 mm characterized prescribed tablet paracetamol 1g for three days more of pseudopockets. Her upper left central and mouthwash Chlorhexidine Gluconate 0.12% incisors and canine were deeply carious. Tooth 38 for two weeks after each surgical procedure. The was mobile grade I with Class III furcation involvement and a few teeth were missing. The overgrowth composed of collagenous connective clinical diagnosis was drug-induced gingival tissues with a diffuse chronic inflammatory cell hyperparakeratotic and acanthotic stratified Figure 3 Surgical gingivectomy and CO2 laser
treatment on the lower buccal gingiva. Note that Figure 1 Intraoral picture showing the gingival
charred layer and less bleeding after the monthly. Upon examination at 3 month review, the periodontal pockets were generally reduced to 3 mm. Very mild gingivitis was observed at the labial surface of lower incisors. Regular oral hygiene reinforcement and scaling was done for her. Two years after completion of the surgery, disappearance of GO and satisfactory periodontal condition were confirmed (Figure 4). Patient was then referred to Prosthodontist for the construction of prosthesis. Removable partial overdenture was planned with the teeth 13 and 22 served as the abutments. Teeth 21 and 38 were extracted due to poor prognosis. Elective endodontic was done for teeth 13 and 22. Both teeth were then decoronated at supragingival Figure 2 Gingival appearance at the palatal
level and the canal opening was sealed with amalgam filling. Overdenture was then issued with some occlusal adjustment done. At 6 month follow up the patient was still on amlodipine teeth was done and patient was given oral however the periodontal conditions appeared hygiene instruction and motivation at the first visit. regimen to control the gingival inflammation (Nery et al., 1995). The interaction between the drug and the gingival tissues could be enhanced by gingival inflammation caused by poor oral hygiene (Seymour, 1991). It has been shown that there was significant reduction of nifedipine-induced GO by thorough scaling and root planing and scrupulous plaque control (Hallmon and Rossmann, 1999). Surgical reduction of the overgrown tissues is frequently necessary to accomplish an aesthetic and functional outcome (Hal mon and Rossman, 1999). The treatment may consist of surgical Figure 4 Gingival overgrowth had disappeared
gingivectomy and/ or laser gingivectomy. Laser is modalities in periodontal treatment. The CO2 laser has a wavelength of 10,600nm, is readily absorbed by water and therefore very effective for the surgery of soft tissues, which have a high water content. Blood vessels in the surrounding tissues up to 0.5 mm are sealed (Aoki et al., 2004). Thus the advantageous of laser over the scalpel are the strong hemostatic and bactericidal effect and provide a relatively dry field for improved visibility (AAP, 2002). Discontinuation of the related drug has been shown to reduce the GO, however the growth will Figure 5 Intraoral view at sixth month review
(Lederman et al., 1984). In cases where alternate Discussion
medication can be used, substitution in the related drug has been shown to result in regression of the overgrowth. Isradipine, a companion The pathogenesis of GO is uncertain and the dihydropyridine calcium channel blocker has treatment is still largely limited to the maintenance of an improved level of oral hygiene and surgical previously induced by nifedipine (Hallmon and removal of the overgrown tissue. Several factors Rossman, 1999; Khera et al., 2005). may influence the relationship between the drugs Another treatment modality that has been and gingival tissues as discussed by Seymour et suggested was the use of topical application of al. (1996). Those factors were including age, folate solution on the GO. Drew et al. (1987) have genetic predisposition, pharmacokinetic variables, demonstrated significant decreased of the GO alteration in gingival connective tissue when acid folic was topically applied on the homeostasis, histopathology, ultrastructural phenytoin-induced gingival hyperplasia. Inoue and factors, inflammatory changes and drug action on Harrison (1981) also found that folic acid supplementation decreases the severity of the Most studies show an association between GO. Phenytoin interferes with folic acid the oral hygiene status and the severity of drug- metabolism and lead to acid folic deficiency which induced GO. This suggests that plaque-induced gingival inflammation may be important risk factor inflammation. However there was no study in the development and expression of the gingival reported the use of folic acid in the amlodipine- changes (Barclay et al., 1992). In this present case the local environmental factors such as poor In this present case, gingival overgrowth was plaque control and multiple retained roots at the satisfactorily treated via initial periodontal therapy initial presentation may act as risk factors that had including oral hygiene instruction and motivation, contributed to worsen the existing gingival followed with surgical gingivectomy and CO enlargement and therefore complicate the oral treatment. This case report also demonstrated hygiene procedures (Ikawa et al., 2002). There that without a change in associated drug, was some reduction of the overgrowth observed periodontal treatment alone can yield satisfactory particularly at the upper arch after the initial clinical response (Ikawa et al., 2002). As the therapy was advocated including extraction of the periodontal condition was under controlled, retained roots. Age is also an important risk factor prosthesis was constructed in order to fulfill the for GO with particular reference to phenytoin and function and aesthetic of the patient. The cyslosporin (Seymour, 2006) however is not prosthesis was designed to minimize the plaque applicable for CCB since the used of the drug is retention sites. However there is possibility for the usually confined to the middle-aged and older GO to recur as long as the associated medication adult (Seymour et al., 2000). The management of is continued and persistence with other risk GO seems to be focusing at good oral hygiene factors (Mavrogiannis et al., 2006). Therefore patient must be informed of this Ikawa K, Ikawa M, Shimauchi H, Iwakura M and tendency and the importance of maintenance of Sakamoto S (2002). Treatment of gingival the effective oral hygiene as key factors in overgrowth induced by manidipine administration: a preventing and managing gingival overgrowth case report. J Periodontol, 72: 115-122.
associated with this drugs. Supportive followed up Inoue F and Harrison J (1981). Folic acid and phenytoin hyperplasia. Lancet, 2: 86.
is necessary in an effort to monitor her gingival/ Jorgensen MG (1997). Prevalence of Amlodipine- periodontal status, to assess and reinforce oral Related Gingival Hyperplasia. J Periodontol, 68: 676-
hygiene and to periodically provide professional care (Hallmon and Rossmann 1999) thus prevent Khera P, Zirwas MJ and English JC (2005). Diffuse gingival enlargement. J Am Acad Dermatol, 52: 491-
Acknowledgement
Lafzi A, Farahani RM and Shoja MA (2006). Amlodipine- induced gingival hyperplasia. Med Oral Patol Oral Cir The authors wish to thank Dr. Pauziah Ahmad for Bucal, 11(6): E480-E482.
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