Management of Amlodipine Influenced Gingival Overgrowth

Surgical Management of Amlodipine influenced gingival overgrowth in Hypertensive patient.

Abstract:

Drug-influenced gingival overgrowth (DIGO) is a serious concern both for the patient and the clinician. Several local and systemic factors such as plaque, hormonal changes, medication ingestion, heredity can cause or influence gingival overgrowth. Certain anticonvulsants, immuno-suppressive drugs and a number of calcium channel blockers have been proven to create similar gingival overgrowths in certain susceptible patients. Amlodipine is a comparatively new calcium route blocker may induce gingival overgrowth in case there is underlying inflammatory element. A 38-year-old hypertensive feminine patient on amlodipine (10 mg/day, solo dose orally) since eight calendar months, sought dental attention as a result of resultant gingival overgrowth. Clinical assessment, Medical history and histological diagnosis further helped to formulate a diagnosis of DIGO. Six weeks after phase-I therapy and drug substitution, undisplaced flap surgery was performed. The patient's gingiva seemed to be normal at six month follow-up visit, without signs of recurrence.

Key words: Gingival overgrowth, Hypertension, Amlodipine, Undisplaced flap surgery. Medicine affected gingival overgrowth.

Introduction:

There are extensive factors (causal or modifying) involved with gingival overgrowth. Plaque deposition on teeth causes gingival inflammation and may lead to inflammatory enlargement. Gingival overgrowth can be seen in patients with familial hereditary gingival fibromatosis, pregnancy, and leukemia. DIGO is a well-documented side effect of some pharmacologic brokers, including, but not limited by, calcium route blockers (CCBs), phenytoin, and cyclosporine[1, 2 ]. It can be a serious matter for patients because of the concomitant unesthetic appearance and the forming of new niche categories for the periopathogenic bacterias [3]. Despite the relatively high prevalence of nifedipine-influenced gingival overgrowth, [4 ] amlodipine has less frequently been reported as the potential etiologic reason behind gingival overgrowth[5]. Amlodipine is a comparatively new long operating dihydropyridine calcium route blocker that is employed in the management of both hypertension and angina. Unwanted side effects associated with persistent usage of

amlodipine are few and are mainly related to vasodilation. The pharmacological effects of these drugs are specific but the medical and histological features of the enlargement brought on by different drugs are similar. The clinical appearance of DIGO is usually quality, although variants have emerged with regards to the location of lesions, the irritants included and the scope of irritation. As the condition advances, the marginal and papillary gingival overgrowth and may interfere with conversation, mastication and aesthetics. Within the patients with preexisting periodontitis and DIGO the deepening of periodontal storage compartments and associated subgingival microbiota may increase periodontal

attachment and bone loss. The surgical treatment is a definitive therapy for DIGO, in lack of spontaneous regression following medicine substitution and phase-I Remedy. The common medical technique is the easy excision of the unnecessary gingival cells with- external bevel gingivectomy (EBG) or interior (opposite) bevel gingivectomy (IBG). The medical way of undisplaced full thickness flap, in this framework, is more suitable to remove periodontal wallets (Pocket wall structure) in occurrence of adequate attached gingiva and also to enhance the alveolar bone morphology. In today's report, a case of amlodipine-influenced gingival overgrowth (AIGO) has been shown wherein the AIGO was cared for in the next phases: (1) substitution of the medication, (2) thorough Period-1 therapy, (3) medical excision of the rest of the gingival overgrowth and (4) maintenance and supportive remedy. Case Information:

A 38-year-old female patient was described us with complaint of swollen and bleeding gums in the top and lower jaw. Past medical history disclosed hypertension for which the individual received amlodipine (10 mg/day, solitary dose orally) for the last eight months. The individual had observed a gradual and painless enhancement of the gingiva for first 4 weeks and then she found bleeding gums. A generalized fibrous gingival enhancement with edematous marginal gingiva, due to superimposed inflammatory component, was found throughout the maxillary and mandibular gingiva (Fig. 1A, B, C, D). Occurrence of generalized periodontal pockets (‰Ґ7-8mm) and clinical attachment damage (‰Ґ5-6mm) was a dominant feature of gingival overgrowth indicating a vertical enhancement of gingiva. Purulent release and bleeding on probing were found which were relative to the infection.

Treatment:

On need, patient's physician substituted amlodipine with Beta Adrenergic blocker (Atenolol), after which, patient was recalled for through scaling and root planing. Dental hygiene instructions, chlorhexidine mouthwash 0. 2% of 10ml double per day was prescribed. At follow-up after six weeks, residual inflammatory element of the enlargement resolved(Fig-2) but the gingival overgrowth needed definitive surgical treatment. Under adequate local anesthesia (xylocaine 2%), the pocket depth was proclaimed, (Fig-3) an interior bevel incision was taken up to the alveolar crest. (Fig-4) Crevicular and interdental incision along the base of the pocket wall structure premiered and full thickness mucoperiosteal flap was reflected. (Fig-5) The excised mass was stored in formalin for even more histopathologic exploration. Scaling, root planning and curettage were completed. Osseous resective surgery, using carbide burs, along with copious saline irrigation was done to recontour thickened bony plates, ledges and deep interdental craters. (Fig-6) Flaps were trimmed and approximated using interrupted silk sutures. Regime post surgical instructions, a course of antibiotics and analgesics (Cap. Amoxycillin 500mg three times a day for five days and nights and Ibufrofen 400 mg three times each day for three days and nights) and 0. 2% chlorhexidine was prescribed twice a day for fifteen days and nights. Microscopic inspection of the gingival biopsy specimens proven a connective tissue hyperplasia, acanthosis of overlying epithelium and elongated rete ridges as well as inflammatory skin cells. Sutures were removed after a week. Curing was uneventful and the patient's appearance and overall function upgraded substantially at six month follow up. (Fig-7) Oral hygiene instructions received from first visit and reinforced in every subsequent trips.

Discussion:

Amlodipine is a second-generation dihydropyridine CCB that can cause gingival overgrowth. The prevalence of amlodipine-influenced gingival overgrowth has been shown to be between 1. 7% and 3. 3%[6, 7]. Lafziet al. (2006) possessed reported rapidly expanding gingival hyperplasia in patient acquiring 10 mg/day of amlodipine within 2 month of starting point. [8] The incidence of gingival overgrowth with nifedipine remedy has been reported to be as high as 20%, [9] and a study by Prisant (2002) [10] reported that the prevalence with the use of CCBs might be of up to 38%. Gingival overgrowth considered to be 3. three times more common in men than in women [10]. The most frequent form is bacterial plaque-influenced gingival disease, which reveals as gingivitis. Usage of phenytoin, cyclosporine, and CCBs, as well as vitamin supplements C insufficiency, can also predispose to development of gingival overgrowth, as can hormonal shifts during pregnancy. The explanation for these adverse events is not absolutely known, but mechanisms including inflammatory and non inflammatory pathways have been advised [11]. For instance, specific sensitivity to a drug's metabolic pathway might be a trigger [11]. Untreated gingival overgrowth might lead to bleeding, an infection, abscess, ulceration, cosmetic deficiency and/or useful difficulty (eg, nibbling, conversing) [10]. Treatment of drug-influenced gingival overgrowth includes cessation/substitution of the medicine and reducing other risk factors with meticulous mechanical and chemical plaque control. Exchanging the affecting medicine with another agent is also advised when possible[12]. In present case of DIGO patient was under treatment for hypertension since last 8 a few months and was approved tablet Amlodipin 10mg/day by her physician. Thorough SRP and upgrading the Amlodipin with Atenolol was done. Drug substitution and in depth SRP didn't end result into regression of the enhancement.

The medical procedures is a definitive remedy for DIGO, in absence of spontaneous regression pursuing medicine substitution and phase-I Therapy. Classic gingival surgery mostly deals with the treating wallets - i. e. , gingival sulci that are deepened credited to a proliferation or a rise in almost all gingival cells in a coronal course, with or without apical migration of the epithelial connection. Exterior bevel gingivectomy (EBG) and internal bevel gingivectomy (IBG) should be reserved for conditions not giving an answer to non surgical methods or severe instances that affect oral hygiene or operation, or can be carried out for plastic reasons. IBG procedure has the benefit for limiting the top denuded connective tissue wound that results from the exterior gingivectomy, thereby minimizing postoperative pain and bleeding. It really is accepted that gingival surgery (both EBG and IBG) is actually limited to the treatment of pseudopockets. But if true pouches associated with bone defects can be found then undisplaced flap surgery can be the treatment modality for the massive enlargement. The advantages of this technique are removal of pocket wall and osseous contouring simultaneously reducing the gingival overgrowth and pocket in presence of adequate attached gingiva. In cases like this report undispalced flap surgery was performed for eradicating pocket and osseous contouring in occurrence of adequate fastened gingiva. However whatever the treatment option employed, regular maintenance and recall follow up are mandatory to achieve the permanent success.

Conclusion

Gingival overgrowth can be an overlooked but potentially harmful side-effect of treatment with amlodipine and other calcium route blockers and every medical doctor should be aware of this, especially if adverse oral symptoms come up during drug use. The amlodipine affected gingival overgrowth in this case completely resolved when the patient was turned to Beta Adrenergic blocker (Atenolol) accompanied by surgical excision of the overgrowth. Another factor adding to the excellent response to the remedy is the individual compliance in retaining the oral hygiene. Lastly the patients' documented data should be distributed to the physician to gain his self-assurance and value for the oral community. In addition, he will be motivated to send patients with complains of gum swelling at a much prior level or in truth, advice dental appointment for improvement of oral hygiene before prescribing the list of drugs that could affect gingival overgrowth in existence of preexisting gingival swelling.

References

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