Drug Induced Gingival Enlargement : Signs, Symptoms, Causes, Treatment, Prognosis, Epidemiology

Gingival Enlargement is a medical condition in which the gums become enlarged and this can occur due to multiple reasons, one amongst which is drug administration. There are certain drugs that cause gingival enlargement due to which the gums almost completely cover the crowns of the teeth which further leads to problems such as gum disease, tooth eruption and tooth alignment issues.

Gingival enlargement is a condition in which the cells present within the gum tissues tend to grow abnormally and increase in number as well as in size, which in turn covers up the teeth either partially or completely. When the cells increase in number then such kind of enlargement is called gingival hyperplasia and when the cells in the gum do not increase in number but increase in size then the medical condition is called gingival hypertrophy. This further result in pain and tenderness within the gums thus gives way to other medical problems.

Gingival enlargement can be broadly classified into four categories based on the causative factor behind the condition. These are inflammatory, Drug induced, hereditary and systemic. Inflammatory gingival enlargement occurs as a result of inflammatory response due to plaque accumulation. In contrast to the inflammatory gingival enlargement, the drug induced gingival enlargement occurs when the patient consumes specific drugs. Hereditary gingival enlargement is rare occurrence, slow in growth and usually develops during childhood whereas the gingival enlargement due to systemic causes usually is caused due to leukaemia, hormonal imbalance and pregnancy.

The drug induced gingival enlargement occurs when drugs like Phenytoin, Cyclosporine and Nifedipine interfere with the proper functioning of the fibroblasts, epithelial keratinocytes and collagen cells, thereby leading to cellular overgrowth of the gingiva. The mechanism behind drug induced gingival enlargement is still not completely understood but influence of the above medications have definitely been observed on the age dependent hormones like testosterone which directly affects the growth properties of the gingival cells.

The common symptoms that appear as a consequence of drug induced gingival enlargement are:

• Gums become firm
• Colour of the gums becomes pale and becomes less pink
• Gums become shiny
• Firmness of gums leads to lower tendency of gum bleeding
• Crowns of the teeth get covered partly or completely
• Discomfort in chewing
• Difficulty in speaking
• Bad odour from mouth

The occurrence rate of drug induced gingival enlargement is rare. However, the cases that do occur account for almost fifty percent cases due to consumption of Phenytoin medication, thirty percent cases occur due to prevalence of Cyclosporine transplant and the remaining twenty percent cases occur in patients that are treated with Calcium Antagonists.

The outlook for the drug induced gingival enlargement is good. The condition though is recurrent but with thorough and meticulous maintenance of the mouth and teeth health through modification of the drug regime, self-care and dentist care, drug induced gingival enlargement can be successfully treated.

The drug induced gingival enlargement is caused primarily by three classes of drugs. These are:

• Anticonvulsants Responsible for Causing Drug Induced Gingival Enlargement: Drugs like Phenobarbital, Cyclosporine, Phenytoin, Nifedipine, Valproate, Tacrolimus, Verapamil, and Amlodipine are the anticonvulsants that are known to cause gingival overgrowth by hampering the fibroblast functions and increasing the growth of gum tissues.
• Immunosuppressive Drugs Causing Drug Induced Gingival Enlargement: Immunosuppressive agents like Valproic acid, Mycophenolate mofetil, Estradiol and Clarithromycin contribute greatly to gingival enlargement.
• Calcium Channel Blockers as a Reason for Drug Induced Gingival Enlargement: The combination of calcium channel blockers and Cyclosporine accentuates the gingival overgrowth. The commonly administered calcium channel blockers are Benzothiazepines and Dihydropyridines.

There are certain risk factors that play a key role in gingival enlargement. These factors are:

• Gender as a Risk Factor for Drug Induced Gingival Enlargement: Research shows the prevalence of the condition more in males compared to females owing to the androgen metabolism. The androgens levels are elevated through the drugs which further affect the fibroblast functions, thereby leading to gingival overgrowth.
• Medication Dosage as a Potential Factor for Drug induced Gingival Enlargement: Though definite research does not exist but certain drugs when consumed in higher dosage have shown increased gingival growths.
• Dental Plaques as a Risk Factor for Drug Induced Gingival Enlargement: The presence of dental plaque allows the accumulation of drugs like cyclosporine and phenytoin which further leads to gingival overgrowth.
• Age as a Potential Risk Factor Leading to Drug Induced Gingival Enlargement: Though age itself does not act as a risk factor but the medications prescribed are usually prescribed to middle aged and older patients. Thus, it becomes an indirect risk factor.

The treatment of drug induced gingival enlargement involves surgical as well as non-surgical measure.

• Non-Surgical Treatment to Cure Drug Induced Gingival Enlargement: The approach for non-surgical treatment follows below rules with respect to drug therapy to decrease the severity of the condition.
  • Interruption or stopping of drugs that has caused the condition.
  • Dosage modification
  • Replacement of drugs.

For instance, when Cyclosporine is prescribed along with Azithromycin then severity of gingival overgrowth reduces subsequently. Also, in cases of organ transplant Prednisolone and Azathioprine are given together to the patient to check gingival overgrowth.

Apart from above measure, practicing meticulous oral hygiene with regular removal of plaque is strongly advisable to check gingival overgrowth.

• Surgical Treatment to Treat Drug Induced Gingival Enlargement: Surgical treatments are opted when, even after drug interruption therapy, severity of the gingival growth is not reduced. The surgical treatment aims at achieving below objectives:
  • Abscission of excess tissue
  • Removal of pockets
  • Restoration of the appearance and proper functioning of the tissue.

The surgical treatment can be individual or a combination of surgeries. The surgical treatments available for gingival enlargement are:

• Gingivectomy: This type of surgery involves minimal removal of overly grown gingiva and it is done when the gingival overgrowth is over a small area covering around six teeth or less.
• Periodontal Flap: The periodontal flap surgery is similar to gingivectomy but the area involving the overgrowth is greater than six teeth. Also, there is evident gingival loss with minor bone defects.
• CO₂/Argon Laser Surgery: This surgery does the same as the above; however, it has the advantage of less time consumption, fast recovery as well as post-operative haemostasis.

The only key to prevention of gingival enlargement lies in practicing good oral hygiene through frequent oral rinses using chlorhexidine, dental flossing and regular plaque removal.

Drug induced gingival enlargement commonly follows up after the treatment from anticonvulsants, immunosuppressant and calcium channel blockers. The condition can be readily checked by following a drug interruption, modification or replacement therapy along with maintaining proper oral hygiene and care. In some cases when even above measures fail then surgery is opted to get rid of excessive tissue along with restoration of appearance and functioning.

References:

Also Read:

• What is Gingival Enlargement: Causes, Symptoms, Treatment, Classification, Epidemiology