Treating patients with drug-induced gingival overgrowth.

The purpose of this paper is to review the causes and describe the appearance of drug-induced gingival overgrowth, so that dental hygienists are better prepared to manage such patients. Gingival overgrowth is caused by three categories of drugs: anticonvulsants, immunosuppressants, and calcium channel blockers. Some authors suggest that the prevalence of gingival overgrowth induced by chronic medication with calcium channel blockers is uncertain. The clinical manifestation of gingival overgrowth can range in severity from minor variations to complete coverage of the teeth, creating subsequent functional and aesthetic problems for the patient. A clear understanding of the etiology and pathogenesis of drug-induced gingival overgrowth has not been confirmed, but scientists consider that factors such as age, gender, genetics, concomitant drugs, and periodontal variables might contribute to the expression of drug-induced gingival overgrowth.

When treating patients with gingival overgrowth, dental hygienists need to be prepared to offer maintenance and preventive therapy, emphasizing periodontal maintenance and patient education. The affected gingiva presents a bulbous and irregular appearance and requires special modifications in the delivery of dental hygiene care. Dental hygienists play a vital role in the prevention and control of this condition because of the significant correlation between plaque/gingivitis and gingival overgrowth.

Keywords: Gingival overgrowth, cyclosporine, calcium channel blockers, phenytoin, dental hygiene care, oral hygiene instructions, periodontal maintenance

Introduction

Patients affected by a variety of medical conditions may require modifications in dental care. One such example is when the patient's gingival tissues show signs of drug-induced overgrowth. Because the texture and appearance of the affected gingiva may be irregular and bulbous, patients with gingival overgrowth may require special modifications in the delivery of dental hygiene. Dental hygienists should be properly prepared to provide treatment and to suggest individualized oral hygiene instructions for these patients.

Dental hygienists play an important role during the review and update of the patient's medical history. A thorough review of the patient's medical history, including prescription and over-the-counter medications, provides critical information about conditions that may be observed during the oral examination. For instance, patients reporting a diagnosis of high blood pressure may have been prescribed a calcium channel blocker to control the hypertension. These medications can produce a number of oral side effects such as xerostomia and gingival overgrowth. The prevalence of this occurrence has been reported as high as 38%. (1,2)

The purpose of this paper is to review the causes of drug-induced gingival overgrowth and to describe the appearance of this condition so dental hygienists are prepared to readily identify it. Treatment modifications that may be necessary when treating patients with gingival overgrowth are presented, with major emphasis on prevention through patient education.

Clinical Appearance of Gingival Overgrowth

While performing an examination of the oral mucosa, dental hygienists may observe a granular and pebbly gingiva, as in the patient from Figure 1, who was taking cyclosporine. This unsightly appearance has been referred to as "resembling clusters of grapes," as the outer surfaces appear dotted with numerous smaller papillations. (3,4) Biopsies of affected tissue usually show lobules of fibrous connective tissue covered with stratified squamous epithelium. The appearance of gingival overgrowth can cause significant personal and psychosocial problems for patients who often feel uncomfortable when smiling. An example of the appearance of severe gingival overgrowth on a patient taking a combination of cyclosporine and amlodipine (Norvasc) is illustrated in Figure 2. Butterworth states that the clinical manifestation of gingival overgrowth can range in severity from minor variations to complete coverage of the teeth, and that drifting of the teeth can occur, creating subsequent functional and aesthetic problems for the patient. (5)

[FIGURES 1-2 OMITTED]

Etiology of Drug-Induced Gingival Overgrowth

Gingival overgrowth is caused by three categories of drugs: anticonvulsants, immunosuppressants, and calcium channel blockers. These drugs are sometimes taken for the remainder of a patient's life because of chronic health conditions being treated, such as organ transplantations. A clear understanding of the etiology and pathogenesis of …