What is Drug-Induced Gingival Overgrowth?
Drug-induced gingival overgrowth, also called drug-induced gingival enlargement, is a side effect from specific drugs that unintentionally impacts the gum tissue. This condition is most commonly triggered by anticonvulsant, immunosuppressant, and calcium channel blocker drugs. This overgrowth makes proper dental hygiene challenging and can lead to cosmetic concerns, as well as painful chewing and eating experiences.
The first step in treatment typically does not involve surgery. Instead, it includes maintaining good oral hygiene and possibly discontinuation or replacement of the trigger drug. Azithromycin, a medication, has recently gained popularity due to its effectiveness in improving this gum overgrowth in patients taking a drug known as cyclosporin A. This makes it possible to treat the condition without having to change the offending drug. If the medical treatment isn’t successful, then surgical treatment may be considered. However, it’s worth noting that the condition often comes back, and the effects of treatment usually last around a year.
What Causes Drug-Induced Gingival Overgrowth?
One of the main reasons for gum enlargement is due to certain medications. This condition, known as DIGO, can develop as a side effect in patients who take drugs for seizure control, immune system suppression, or blood pressure regulation. Whether a person will experience this side effect can be influenced by their genetic makeup and the presence of plaque or inflammation in the gums.
Among the medications that can cause gum enlargement, certain anticonvulsants, used mainly to control different types of seizures, are particularly notable. For instance, phenytoin is an anti-seizure medication that is strongly linked to gum enlargement. It is metabolized in the body into a substance that triggers overgrowth of gum tissue. Sometimes, patients are given several anti-seizure medications at the same time, which can interact and worsen gum enlargement.
Immunosuppressants, another type of medication, can cause the gums to enlarge. These drugs are often given to organ transplant recipients to prevent their bodies from rejecting the new organ, and to people with certain autoimmune diseases, like rheumatoid arthritis. Some examples of these drugs are cyclosporin, sirolimus, and tacrolimus. Cyclosporin, widely used following organ transplants, has been associated with gum enlargement in approximately 53% of patients who take it after a kidney transplant. Tacrolimus is less harmful than cyclosporin, causing less severe gum enlargement and less damage to the liver and kidneys. Sirolimus is another immunosuppressant that can cause gum enlargement.
Lastly, calcium channel blockers, used to manage high blood pressure, chest pain caused by heart disease and peripheral vascular disease, can also lead to gum enlargement. This group of drugs includes nifedipine, nitrendipine, felodipine, amlodipine, nisoldipine, verapamil, and diltiazem. Notably, amlodipine was reported to cause gum enlargement in patients after just two months of treatment with a daily dose as reported in a study. In kidney transplant patients taking immunosuppressants like cyclosporin, gums were more likely to enlarge if they were also taking nifedipine or diltiazem with cyclosporin causing more significant gum enlargement. Indeed, the combination of drugs can compound their effects, leading to an exaggerated enlargement of gum tissue.
Risk Factors and Frequency for Drug-Induced Gingival Overgrowth
Drug-induced gingival overgrowth, or DIGO, primarily affects males who are children and teenagers, especially in the forefront of their gums. The person’s individual genetic makeup plays a role in the development of this condition. The degree of gum overgrowth depends on the specific drug causing the problem. The three most common drugs that lead to DIGO are Phenytoin, Cyclosporin, and Nifedipine, with Phenytoin being the most prevalent. It’s estimated that:
- Half of adults using Phenytoin face gum enlargement,
- About 30% of those using Cyclosporin, and
- Roughly 20% of Nifedipine users experience the same issue.
Signs and Symptoms of Drug-Induced Gingival Overgrowth
Drug-induced gingival overgrowth (DIGO) is a condition often seen in patients with a medical history of high blood pressure, chest pain, epilepsy, or those who have recently received an organ transplant. Issues surfacing 1 to 3 months after beginning treatment with certain drugs typically include enlarged gums, pain when chewing, and a change in appearance of the gums. Enlarged gums due to the medication can make keeping one’s mouth clean difficult, leading to more dental plaque and additional inflammation.
It was once believed that all drug-induced gum overgrowth was fibrotic (tough or scar-like), but that’s not the case. Phenytoin-related overgrowth is the most fibrotic. Overgrowth from cyclosporin is more inflammatory and has a small fibrotic element, while nifedipine-related overgrowth is a mix of both.
The gum enlargement related to the disease might disappear if the affected teeth are removed.
- Firm, painless, nodular enlargement of the gums, specifically around the teeth, may occur.
- In severe cases, a large flap of extra gum tissue may cover the teeth.
- When no secondary inflammation is present, the gums appear firm, pale pink with small bulges, swelling from under the gum line. There’s a crease of tissue that doesn’t bleed when touched.
- If inflammation exists, the gums may appear smooth and turn red or bluish-red.
- Overall gum enlargement is common but usually more noticeable in the front areas of the mouth.
- Typically, gum overgrowth does not occur in area without teeth.
Testing for Drug-Induced Gingival Overgrowth
If a patient is suspected to have drug-induced gum overgrowth, a doctor will decide based on a physical exam and their medical history. A detailed check-up of the gums is required to look for any gum disease.
Before the treatment starts, specific x-rays of the entire mouth are needed to rule out any gum illness. If patients are experiencing significant gum bleeding along with gum enlargement, a complete blood count test is needed. This is to check for anemia and leukemia, even if the gum enlargement is caused by medication.
In the case where the disease seems unusual, a tissue sample from the gums must be taken. Additionally, any overgrowth that persists has to be examined thoroughly under a microscope in order to look for any signs of cancer.
To ensure there are no infections like candidiasis, a culture test might be necessary. This involves sampling a small amount of the microbes in the mouth for further testing.
Treatment Options for Drug-Induced Gingival Overgrowth
The goal of treating Drug Induced Gingival Overgrowth (DIGO), a dental condition, is to ease the patient’s discomfort, reduce inflammation and swelling, and enhance the appearance of the gums. Treatment typically involves medication as the first line of defense, and surgery for cases that continue to persist or reoccur despite proper drug treatments.
It is often considered to either stop or change the potentially harmful medication. Phenytoin, for instance, can be replaced with carbamazepine or valproic acid, which both have a lesser chance of causing gum enlargement. Heart medications such as Diltiazem and Verapamil, are less likely to result in gum enlargement compared to Nifedipine. Swapping Cyclosporin, another medication, can be more complex due to the limited alternatives available. However, azithromycin, when used alongside Cyclosporin, has shown to decrease the severity of DIGO.
Improving oral hygiene is the first step towards managing DIGO. This can include learning the right ways to clean one’s teeth, regular professional cleaning sessions to remove plaque, and periodic scaling treatments. As inflammation occurs, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), antibiotics, and antifungal medications like nystatin can also be used. It can also be helpful to take Folate supplements.
In cases where the influencing drug has been stopped, a window of 6 to 12 months should typically be given before considering surgical interventions. These procedures can range from gum surgery (gingivectomy) to periodontal flap surgery (a more invasive procedure to treat gum disease). Techniques such as electrocautery can be employed for difficult cases, children, or when gums are fragile and prone to bleeding. The CO2 laser is frequently used in these surgeries because it can handle soft tissues containing a high amount of water and effectively seal small blood vessels, thereby providing better clarity for the surgeon. Moreover, lasers are preferred over scalpels due to their germ-killing and blood-stopping capabilities.
Recent research has suggested that azithromycin can aid in reversing gum overgrowth caused by cyclosporine A, particularly in kidney transplant patients. Interestingly, azithromycin does not interfere with the blood levels of cyclosporin A nor the kidney functions, thus eliminating the need to change this medication due to DIGO. The effect of azithromycin has been studied on cyclosporine A-induced build-up of collagen and cell growth. The conclusion was that azithromycin is capable of slowing down the proliferation of human gum cells and the accumulation of collagen – both induced by cyclosporin A. It activates specific enzymes in renal transplant and normal fibroblast cells, leading to a decrease in type 1 collagen and an increase in these enzymes’ levels.
What else can Drug-Induced Gingival Overgrowth be?
When a patient experiences an abnormal growth of the gums (gingival overgrowth), it could be due to various reasons. Here are a few possibilities:
- Bony tissue enlargement: Sometimes, it might look like a person has larger gums. However, the gums are normal, and the gum tissue appears larger because of an underlying bony tissue enlargement.
- Inflammation: If a person’s gums are constantly inflamed, they may become red or dark purple, smooth, and bleed easily when touched.
- Genetic factors: Certain family or genetic conditions can cause overgrown gums. These include conditions like familial fibromatosis, idiopathic fibromatosis, gingivomatosis, and hereditary gingival hyperplasia. In such cases, the gums appear pink, are not painful, and feel firm and tough.
- Hormonal changes: Gums can also enlarge during certain life stages, like puberty and pregnancy.
- Vitamin C deficiency: Lack of sufficient Vitamin C (a condition known as scurvy) can cause the gums to become extremely tender and bleed.
- Systemic diseases: Certain conditions like leukemia, tuberculosis, sarcoidosis can exhibit gum overgrowth. Doctors can confirm these diagnoses through blood tests.
Doctors may require a thorough patient history, a physical examination, and certain investigations, including a biopsy, to diagnose these conditions accurately.
Also, some conditions might look similar to gingival enlargement, such as:
- Fibrous epulis or peripheral fibroma
- Angiogranuloma or Pyogenic granuloma
- Gingival cysts
- Tumors: These can be both harmless (benign) or harmful (malignant). Harmless ones include fibroma, peripheral and central giant cell granuloma, papilloma, leukoplakia, nevus, myoblastoma, hemangioma, neurilemoma, neurofibroma, and ameloblastoma. Harmful ones include squamous cell carcinoma (a type of skin cancer) and Kaposi sarcoma, and others.
What to expect with Drug-Induced Gingival Overgrowth
If a medication that’s causing gum overgrowth can be replaced with another one that’s less likely to cause this problem, the gum tissue might return to normal if plaque is properly managed. However, even after switching the drug and maintaining good plaque control, gums might still continue to grow. In such situations, surgery may be needed to restore normal gum shapes.
Though effective, these treatments don’t always stop the problem from recurring. In some cases where surgery has been done to treat the gum overgrowth, the problem can reoccur as soon as 3 to 6 months after the surgery. But generally, the results of these treatments last for at least 12 months.
Possible Complications When Diagnosed with Drug-Induced Gingival Overgrowth
Drug-induced gum overgrowth can lead to a number of complications, such as:
- Functional difficulties
- Esthetic concerns
- Increased chances of cavities
- Delayed appearance of teeth
- Abnormal shifting of teeth
- Prolonged retention of baby teeth
- Gaps and spacing issues
- Consequences of poor plaque control, which include gum disease
Preventing Drug-Induced Gingival Overgrowth
Some research suggests that the buildup of bacteria, known as plaque, on teeth may be necessary for certain gum diseases to develop. However, other researchers think that the plaque may result from the challenges of maintaining good oral hygiene due to gum swelling, which further worsens the swelling. Regardless of these differing views, one fact remains clear: bacterial plaque contributes significantly to the development of certain gum diseases. Therefore, it’s crucial for patients to learn proper brushing and flossing techniques.
Patients can also use a rinse, such as one containing chlorhexidine gluconate, to help manage the levels of plaque. It’s also very important for patients to regularly visit their dentist for professional teeth cleaning. By following these measures, patients can either prevent these gum diseases or slow down their progression and severity.
