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147]

Case Report

Management of amlodipine-induced
gingival enlargement: Series of three
cases
Amit Kumar Srivastava, Debabrata Kundu, Prasanta Bandyopadhyay,
Asit Kumar Pal

Abstract:
Department of Gingival enlargement is one of the side effects associated with certain drugs. Amlodipine, a calcium channel
Periodontics, blocker, used as antihypertensive drug has been found associated with gingival hyperplasia. This case series
Dr. R. Ahmed presents diagnosis and management of amlodipine-induced gingival hyperplasia. Amlodipine-induced gingival
enlargement was diagnosed and managed by thorough scaling and root planning. Drug substitution and surgical
Dental College &
intervention was performed in first two cases. The pathogenesis of gingival enlargement is uncertain and the
Hospital, Kolkata, treatment is still largely limited to the maintenance of an improved level of oral hygiene and surgical removal of
West Bengal, India the overgrown tissue. Several factors may influence the relationship between the drugs and gingival tissues as
discussed by Seymour et al. Meticulous oral hygiene maintenance, switchover to alternative drug, professional
scaling and root planning and surgical excision of enlarged gingival tissue may help overcome the effect of
these drugs.
Key words:
Calcium channel blocker, drug-induced gingival overgrowth, gingivectomy

INTRODUCTION Department of Periodontia of Dr. R. Ahmed

Dental College and Hospital, Kolkata with
Access this article online
Website:
www.jisponline.com G ingival enlargement is one of the side
effects associated with the administration
of several drugs. [1] Currently, more than 20
complaints of gingival enlargement with foul
odor, bleeding and fetid discharge from gums
since 1 year. General examination revealed
DOI:
drugs are associated with gingival enlargement. normal built. Patient was hypertensive with
10.4103/0972-124X.76931
Drugs having side effect of gingival enlargement history of taking amlodipine 5 mg once
Quick Response Code: daily+losartan 50 mg once daily since last 7 years.
can be broadly divided into three categories:
anticonvulsants, calcium channel blockers
and immunosuppressants. Many of the calcium Intraoral examination revealed poor oral
channel blockers used as antihypertentive hygiene, generalized nodular enlargement of
gingiva mainly on the facial aspect of teeth.
drugs have been implicated in causing gingival
Gingiva was inflammed and soft to firm in
enlargement. Amlodipine is dihydropyridine
consistency [Figure 1a].
derivative used as antihypertensive drug
having longer action and comparatively lesser side
Investigation
effect than Nifedipine (calcium channel blocker).
Routine blood and orthopantomographical
Amlodipine-induced gingival enlargement is
examination were within normal limit.
comparatively less prevalent among calcium
channel blockers. Since pathogenesis of gingival
Treatment
enlargement is not well-understood, it is still a
Amlodipine was omitted as per advice of
challenge for the periodontists to diagnose and physician, switching over to monotherapy
manage the case effectively. of losartan 50 mg once in a day. Patient was
Address for
correspondence: educated and motivated for maintenance of
Dr. Amit Kumar Srivastava,
Prevalence proper oral hygiene. Professional scaling and
Department of Amlodipine-induced gingival enlargement is root planning was performed. After 3 months of
Periodontics, Dr. R. Ahmed comparatively less prevalent than other calcium phase-1 therapy, remaining excess gingival tissue
Dental College & Hospital, channel blocker. Jorgensen, 1997 had reported was planned to correct by surgical intervention.
114, A.J.C. Bose Road, the prevalence of amlodipine-induced gingival [Figure 1b] Gingivectomy was instituted for
Kolkata - 700 014, enlargement as 3.3%.[2] maxillary gingival tissue flap procedure and for
West Bengal, India.
mandibular gingival tissue [Figure 1c and d].
E-mail: amit.radc@gmail.
com CASE REPORT
Histopathological examination
Submission: 15-07-2010 Case 1 Excised tissue was sent for histopathological
Accepted: 04-10-2010 A 47-year-old female was referred to the examination. Section stained with H and E
Journal of Indian Society of Periodontology - Vol 14, Issue 4, Oct-Dec 2010 279
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Srivastava, et al.: Management of amlodipine-induced gingival enlargement

a a

b b

c c

Figure 2: Case 2 (a) intraoral picture at first visit (b) ten weeks after phase-1
therapy (c) nine-month postoperative view

Figure 3: Case 3 (a) intraoral picture at first visit (b) two months after phase-1
therapy

revealed the presence of hyperplastic squamous epithelium

without any dysplastic features. There was mild chronic
f inflammatory cells infiltrate in the connective tissue [Figure 1e].
Figure 1: Case 1 (a) intraoral picture at first visit (b) three months after phase-1
therapy (c) after correction of maxillary gingival overgrowth by flap procedure (d)
Followup visit
after correction of mandibular gingival overgrowth by external bevel gingivectomy On seventh day of follow-up visit periodontal pack was
(e) photomicrogragh showing hyperplastic squamous epithelium with few chronic removed. Healing procedure was uneventful. Clinical outcome
inflammatory cells in connective tissue (f) twelve-month postoperative view on 12 months of follow-up visit is shown in [Figure 1f].

280 Journal of Indian Society of Periodontology - Vol 14, Issue 4, Oct-Dec 2010
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Srivastava, et al.: Management of amlodipine-induced gingival enlargement
Case-2
A female patient of 50 years reported with complaints of gum
swelling and generalized sensitivity of teeth since 2 months.
Patient was under treatment of essential hypertension for 5
months and was taking amlodipine 5 mg (OD) +telmisartan 40
mg (OD) since 5 months. Intraoral examination revealed very
poor oral hygiene; generalized gingival enlargement covering
one-third to half of the tooth surface. Gingival enlargement
involved marginal, papillary gingiva as well as attached
gingiva also. Gingiva was highly inflamed with multiple
areas of spontaneous bleeding with generalized abrasion and
staining of teeth [Figure 2a].
Investigation
OPG revealed generalized horizontal bone loss. Report of
hemogram and other blood test were within normal range.
Treatment
Amlodipine was substituted to telmisartan 40 mg (OD) and
verapamil 40 mg (BD). Phase-1 therapy was performed.
After 10 weeks of follow-up inflammation was markedly
reduced with some reduction in gingival enlargement
[Figure 2b]. Remaining excess gingival was corrected by
surgical periodontal treatment. Healing was uneventful.
Histopathology
Microscopic picture revealed presence of hyperplastic-
straitified squamous epithelium without dysplasia. The
underlying connective tissue contained scanty inflammatory
cells.
Followup visit
Patient was recalled after every 3 months. The 9-month follow-
up visit is shown in [Figure 2c].
Case-3
A 60-year-old female patient presented with generalized
gingival enlargement with localized pink fibrous, pedunculated,
23 cm soft tissue mass in relation to maxillary left canine-
premolar region. Poor oral hygiene with spacing in maxillary
and mandibular anterior teeth was also observed [Figure 3a].
Patient was taking amlodipine 5 mg (OD) since last 10 years.
ECG and blood investigation report was within normal limit.
Treatment
Oral hygiene maintenance instructions were given to patient.
Thorough scaling and root planning were performed and
amlodipine was substituted with losartan 50 mg (OD).
After 2 months there was significant reduction in gingival
enlargement. Patient is under regular follow-up [Figure 3b].
DISCUSSION
Gingival hyperplasia, with its potential cosmetic implication
and tendency to provide niche for further growth of
microorganism, possess a serious concern to patients and
clinicians. Calcium channel blockers are considered as potential
etiological agent for inducing gingival enlargement. Lafzi et al.
(2006) had reported rapidly developing gingival hyperplasia
Journal of Indian Society of Periodontology - Vol 14, Issue 4, Oct-Dec 2010 281
in patient receiving 10 mg/day of amlodipine within 2 month
of onset.[3] The prevalence of amlodipine-induced gingival
overgrowth was reported to be 3.3% (Jogersen, 1997). The
underlying mechanism of gingival enlargement still remains
to be fully understood. However, two main inflammatory and
non-inflammatory pathways have already been suggested.
The proposed non-inf lammatory mechanisms include
defective collagenase activity due to decreased uptake of
folic acid,[4] blockage of aldosterone synthesis in adrenal
cortex and consequent feedback increase in ACTH level[5] and
upregulation of keratinocyte growth factor.[6] Alternatively,
inflammation may develop as a result of direct toxic effects of
concentrated drug in crevicular gingival fluid and/or bacterial
plaques.[7] This inflammation could lead to the upregulation of
several cytokine factors such as TGF-1.[8] Marked reduction
in inflammation and gingival overgrowth was observed in all
three cases after phase-1 therapy and substitution of amlodipine
to other drug. Meticulous oral hygiene maintenance by patient
may also be responsible for reduction in gingival overgrowth.
In the first two cases, surgery was performed after a follow-up
period of nearly 3 months. In the third case, only a 2-month
follow-up report is presented. Marvogiannis et al., 2006
suggested that there may be recurrence of gingival hyperplasia
if medication is continued and also persistence of other risk
factors.[9] But no recurrence was noted in our case series.
CONCLUSION
Stringent maintenance of oral hygiene, switchover to
alternative drugs and surgical therapy if required, remains the
main stay of available treatment modalities. Better results were
obtained where drug substitution along with oral prophylaxis
were followed.
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Source of Support: Nil, Conflict of Interest: None declared.