Clinical case
A 48-year-old man attends complaining that his gums have “grown over” his teeth over several months, making cleaning difficult and affecting appearance. He takes amlodipine for hypertension. Examination shows firm enlargement beginning at the interdental papillae in the anterior dentition, extending to involve the marginal gingiva. The tissue is lobulated and mostly pink, although some areas bleed where plaque has accumulated. There is no enlargement in edentulous areas.
Pathophysiology
The mechanism is not fully understood, but drug-induced gingival enlargement appears to result from a disturbance in connective tissue turnover, particularly an imbalance between collagen synthesis and collagen degradation.
Altered gingival fibroblast activity, reduced collagenase function, and modification of the inflammatory response to plaque biofilm are all implicated. Plaque is not always the primary cause, but local inflammation commonly worsens the severity and bleeding tendency of the enlargement.
Epidemiology and Risk Factors
The condition is most strongly associated with the three major drug groups:
Calcium channel blockers
Phenytoin
Ciclosporin
Severity varies between individuals and between drugs. Phenytoin-associated enlargement has historically been reported frequently, especially in younger patients, while nifedipine is among the calcium channel blockers most often implicated. Concurrent plaque-induced inflammation substantially increases clinical severity. Combined therapy, particularly ciclosporin with a calcium channel blocker, may increase the risk of pronounced enlargement.
Non-modifiable | Modifiable |
|---|---|
Younger age in phenytoin associated cases | Poor plaque control |
Underlying medical conditions such as epilepsy, hypertension or post-transplant immunosuppression | Local plaque retentive factors |
Clinical Features
|
|
|---|---|
| Painless gingival enlargement |
| Tissues can become redder, softer and bleed more easily |
Halitosis | Lesions most common around anterior teeth |
Drug class | Main indications | Key mechanism/action | Characteristic gingival enlargement points | Important notes |
|---|---|---|---|---|
Calcium channel blockers | Hypertension, angina, arrhythmias | Block L-type calcium channels | Enlargement typically starts as bead-like papillary swellingand may extend to the marginal gingiva; tissue is often firm, pink, and lobulated unless secondarily inflamed |
|
Phenytoin | Epilepsy | Anticonvulsant; associated with reduced collagen breakdown | Often causes a fibrotic gingival overgrowthbeginning at the interdental papillae; may become more generalised over time |
|
Ciclosporin | Immunosuppression, especially post-transplant | Selectively inhibits T-helper cell function | Gingival enlargement may be more vascular and sometimes less fibrotic than with the other drug classes |
|