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JMSCR Vol||07||Issue||03||Page 436-441||March 2019 JMSCR Vol||07||Issue||03||Page 436-441||March 2019 www.jmscr.igmpublication.org Index Copernicus Value: 79.54 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v7i3.79 Amlodipine Induced Gingival Overgrowth and its Nonsurgical Management– A Case Report Authors Dr Suchetha Aghanashini, M.D.S1, Dr Suma Prashanth2, Dr Apoorva. S.M, M.D.S3 Dr Darshan. B.M, M.D.S4, Dr Sapna.N, M.D.S5, Dr Divya Bhat, M.D.S6 1Professor and Head of the Department, Department of Periodontics 2Post Graduate Student, Department of Periodontics 3,4,5Reader, Department of Periodontics 6Lecturer, Department of Periodontics D.A.P.M. R V Dental College Bangalore, India Abstract Gingival enlargement or overgrowth is a well-known adverse effect associated with three major groups of drugs i.e., anticonvulsants, calcium channel blockers, and immunosuppressants. Among calcium channel blockers, nifedipine is the commonest cause for drug induced gingival overgrowth with the incidence of 10% whereas case report of gingival enlargement due to amlodipine are very less compared to nifedipine. Hence, we hereby report a case of amlodipine induced gingival overgrowth which intends to highlight the efficacy of conservative management with scaling, root planing and drug substitution. Keywords: gingival overgrowth, amlodipine, scaling and root planing, drug substitution. Introduction which are “isolated” are those confined to gingiva Gingival enlargement or gingival overgrowth is adjacent to single or two teeth (e.g., characterized by an increase in the size of gingiva. gingival/periodontal abscess). Lesions which are Gingival enlargements can be classified depending “discrete” include isolated sessile or pedunculated, on the etiologic factors and pathologic changes, tumor-like enlargements (e.g., fibroma/pyogenic according to location and distribution and/or granuloma). Enlargements which are “regional” according to the degree of enlargement. are those with the involvement of gingiva around According to etiopathogenesis, enlargements could three or more teeth in one or multiple areas of the be inflammatory, drug influenced, those associated mouth (e.g., inflammatory enlargement associated with systemic conditions or diseases, neoplastic or with mouth breathing in maxillary and mandibular false enlargements. Based on location, anterior region). Enlargement which are enlargements could be marginal, papillary or “generalized” means involvement of gingiva diffuse. According to distribution they can be adjacent to almost all the teeth present (e.g., drug localized or generalized. Localized enlargements influenced gingival overgrowth).1 could be further divided into three sub-types, Drug-induced gingival enlargement presents as “isolated, discrete” or “regional”. Enlargements abnormal growth of the gingiva due to an adverse Dr Suchetha Aghanashini et al JMSCR Volume 07 Issue 03 March 2019 Page 436 JMSCR Vol||07||Issue||03||Page 436-441||March 2019 drug reaction in patients treated with receivers become affected with hyperplasia and anticonvulsants, immunosuppressants, and calcium others do not, probably this can be mainly because channel blockers. of the biological differences among human beings, As gingival enlargement develops, it affects the such as the existence of different subgroups of routine oral hygiene practice and may interfere gingival fibroblasts. with masticatory functions. It gradually becomes a Amlodipine Induced Enlargement source of pain because of the inflammation and the A newer agent of dihydropyridine is amlodipine condition often leads to disfigurement. There which is used for the treatment of hypertension and appears to be variability in the extent and severity angina, was first reported for causing gingival of the gingival changes. 2 overgrowth as a side effect by Seymour et al in Drugs Causing Gingival Enlargement 1994. The other members of dihydropyridine Drugs causing gingival enlargement include include nifedipine, nicardipine, isoradipine, calcium channel blockers like Amlodipine, nitrendipine, and felodipine. These drugs cause Diltiazem, Felodipine, Isradipine, Nicardipine, coronary and peripheral arterial vasodilatation at a Nifedipine, Nisoldipine, Verapamil3, Manidipine4, dose of 2.5 or 5 grams (alone or in combination immunosuppressants like tacrolimus and with atenolol), with the following adverse effects cyclosporine5, anticonvulsants like phenobar- of headaches, facial flushing, dizziness, edema, bitone, primidone, and valproic acid, gingival hyperplasia, and the drug is detectable in miscellaneous like erythromycin and sertraline, gingival crevicular fluid.8 etc.6 The mechanism through which calcium channel Clinical Manifestations of Gingival blockers causes gingival enlargement is by Enlargement inhibiting the intracellular Ca2+ uptake thereby Frequently appear within one to three months, after stimulating gingival fibroblasts. Human gingival the initiation of treatment with the associated fibroblasts produce collagenous protein when the medications. Gingival overgrowth begins at the cells are exposed simultaneously to calcium interdental papillae and is more frequently found in channel blockers and elevated levels of interleukin- the anterior segment of the labial surfaces. 1β (a proinflammatory cytokine) in inflamed Gradually, gingival lobulations are formed that gingival tissues. Fibroblasts are targeted by may appear inflamed or fibrotic depending on the interleukin-6 which trigger the proliferation of degree of local factor-induced inflammation. fibroblasts and exert the positive regulation on However, the fibrotic enlargement is confined to collagen and glycosaminoglycans synthesis. Hence the attached gingiva but may extend coronally this cytokine has been proposed to play a causing the extensive disfigurement of gingiva.7 pathogenic role in fibrotic gingival enlargement.9 Several factors namely; age, genetic The prevalence of amlodipine-induced gingival predisposition, presence of pre-existing plaque, hypertrophy has been shown to be between 1.7% and gingival inflammation influence the and 3.3%.8 Amlodipine-induced gingival relationship between the drugs and gingival tissue. enlargement is comparatively less prevalent than There is a variable gingival response in patients other calcium channel blocker.10 The highest taking drugs and can be categorized into prevalence of gingival enlargement was in the “responders” and “non-responders”. Furthermore, fourth decade of life, with the incidence of within the group of patients those who develop this overgrowth being higher in males compared to unwanted effect, there appears to be variability in females.11 the extent and severity of the gingival changes.2 The management for amlodipine induced gingival Despite the similar conditions concerning plaque enlargement can be started with the nonsurgical and amlodipine dosage, only some of the drug approach of scaling and root planing. Patient's Dr Suchetha Aghanashini et al JMSCR Volume 07 Issue 03 March 2019 Page 437 JMSCR Vol||07||Issue||03||Page 436-441||March 2019 physician has to be consulted regarding drug A 62-year-old female patient reported to substitution or withdrawal of the drug. After 3to 6 Department of Periodontics, DAPMRV Dental months of drug substitution, surgical excision of College Bengaluru, with the chief complaint of retained gingival overgrowth will be planned using gingival enlargement and wanted to replace her the techniques of gingivectomy or gingivoplasty to missing front teeth. On taking a detailed case restore the normal shape and contour of the history, the patient reported that she got her front gingiva. Patient will be instructed to maintain good teeth extracted 3 months back due to severe oral hygiene. mobility. Medical and drug history of the patient Amlodipine can be substituted with verapamil, revealed that patient was known hypertensive and diltiazem, angiotensin receptor blockers like was on medication for last 10 years (Amlodipine losartan etc. There was no recurrence of gingival 5mg once daily). overgrowth observed after amlodipine being On intraoral examination, Gingiva was pink in substituted for any of the drug mentioned earlier color with reddish discoloration wrt 12, 13, 22-28, which was reported by AK Srivastava et al.10 33-37, 43-47. Marginal gingiva was rolled out with This report presents a case of amlodipine-induced loss of normal gingival scalloping. On palpation, gingival overgrowth where it was treated in the gingiva was soft and oedematous in consistency. following phases: (1) thorough Phase-1 therapy, Diffuse gingival enlargement was appreciated, and (2) substitution of the drug, (3) surgical excision of the surface was lobulated almost covering coronal tissue for biopsy and (4) maintenance and third of 24,44,45,46. The probing elicited supportive therapy. generalized bleeding. Based on the patient's history and clinical features, a clinical diagnosis of Case Report amlodipine-induced gingival overgrowth (AIGO) was made. Preoperative view showing gingival overgrowth (frontal and lateral view) Treatment examination of the overall gingival tissue showed Treatment for drug-induced gingival overgrowth reduction of the inflammatory component, comprises of non-surgical and/or surgical bleeding on probing, the erythema, edema and therapies. Non-surgical treatment, Phase I therapy surface shininess. Incisional biopsy was done for was done which included the scaling and root histopathological confirmation, tissue was excised planing for removing the local factors and
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