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.
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
A 55-year old Chinese woman was referred to the
Department of Periodontology, Faculty of
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Dentistry, University of Malaya complaining of
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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
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
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hyperplasia. Lancet, 2: 86.
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Jorgensen MG (1997). Prevalence of Amlodipine-
periodontal status, to assess and reinforce oral
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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.
the photographs during prosthesis construction.
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