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 |
|
Investigations
Primary investigations:
Full medical history and clinical examination
Full periodontal charting
Gold standard investigation:
Diagnosis is clinical, there is no separate laboratory gold standard
Investigations to consider:
Periodical or bitewing radiographs where periodontal attachment loss is suspected
Photographic monitoring
Communication with the patient's physician to confirm medication history and discuss possible alternatives
Biopsy if enlargement is localised, atypical, rapidly growth, ulcerated or suspicious for neoplasia
Differential diagnosis
Plaque-induced inflammatory gingival enlargement
Hereditary gingival fibromatosis
Idiopathic gingival enlargement
Leukaemia
Gingival neoplasms
Management
Plaque control
Oral hygiene instruction
PMPR
Liaison with the patient's physician to explore substitution or reduction of causative medication
If enlargement persists and causes functional, periodontal or aesthetic concerns surgical treatment may be required and could include:
Gingivectomy
Periodontal flap surgery
Complications
Pseudopocketing
Plaque retention
Secondary gingival inflammation
Prognosis
Prognosis is generally good if plaque control is improved and the causative medication can be changed or withdrawn. However, recurrence is common when the offending drug must be continued, especially in the presence of persistent plaque-induced inflammation. Long-term control therefore depends on maintenance care and risk-factor management as much as on surgery itself.
Guidelines
SDCEP — Drug-influenced gingival enlargement | Prevention and Treatment of Periodontal D
The content discusses drug-influenced gingival enlargement, a condition caused by certain medications such as calcium channel blockers, phenytoin, and ciclosporin, typically prescribed for hypertension, epilepsy, and autoimmune disorders. It highlights that non-surgical treatments may be effective for mild cases, while surgical intervention might be necessary for severe cases. It emphasizes the importance of obtaining a comprehensive medical history, providing personalized oral hygiene advice, and managing other risk factors like smoking and diabetes. Additionally, it advises correcting local plaque-retentive factors and consulting physicians for possible drug substitution if gingival enlargement complicates oral hygiene or aesthetics. In unresolved cases, referral to a specialist may be needed.