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Introduction: Gingival enlargement (GE) due to anti-epileptic drugs (AEDs) shows a high prevalence rate. However, lamotrigine, a newer AED, has not shown to induce GE. The present case report describes a rare case of GE in a patient with epilepsy under lamotrigine therapy for the past 3 years., Case Presentation: In this report, successful management of lamotrigine-influenced GE in a 24-year-old patient with epilepsy by gingivectomy followed by stringent oral hygiene protocol is presented., Conclusion: The present case report suggests that, even this newer AED can cause GE and the oral hygiene status of the patients could be an important triggering factor., (© 2020 American Academy of Periodontology.)

First-line treatment of aplastic anemia(AA) and for AA patients ineligible for hematopoietic stem cell transplantation (HSCT) has consisted of antithymocyte globulin (ATG), the calcineurin inhibitor cyclosporine A (CsA), and more recently eltrombopag. However, at our institution, we have successfully substituted another calcineurin inhibitor, tacrolimus, as a part of immunosuppressive threatment (IST) for AA due to more favorable toxicity profile. Since there is limited data on the use of tacrolimus in aplastic anemia, we conducted a retrospective review of twenty patients treated with tacrolimus-based immunosuppressive therapy (IST) as a first- or second-line treatment. The overall response rate was comparable to that of patients treated with CsA (18 patients). However, there were no cutaneous side effects observed in patients receiving tacrolimus, a relatively common finding with CsA use. Our data suggest that tacrolimus-based IST is a potential option in AA and might have a more favorable toxicity profile compared to CsA.

Gum hypertrophy is a well-known and important adverse effect of phenytoin therapy in a neurosurgical patient. We present an interesting case of a 21-year-old man who, following head injury after a road traffic accident, developed status epilepticus diagnosed with gum hypertrophy in the jaws, with ongoing antiepileptics. He was managed conservatively as per hospital protocol., (2015 BMJ Publishing Group Ltd.)

Gingival hypertrophy (GH) is a well-known physical manifestation due to inflammatory conditions, pregnancy, vitamin C deficiency, systemic diseases like leukemia, Wegners granulomatosis, and various drugs like anticonvulsants, immunosuppresant, and calcium channel blockers (CCBs).We present here a case of a 45-year-old woman, who has been taking Amlodipine 10mg once a day together with Atenelol 50mg per day for one and half years, and has subsequently developed gum hypertrophy. This manifestation was reversed after stopping of Amlodipine. Though this case presentation is described in literature, we hereby present it in a pictorial form, to sensitize the treating physician toward it., (Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Aim: In the present immunohistochemical study, the expression of vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67 in the gingival tissues of renal transplant patients treated with cyclosporin A was assessed. Gingival overgrowth (GO) frequently occurs in transplant patients receiving immunosuppressive drugs such as cyclosporine and this gingival inflammation might play an important role in the pathogenesis of drug-induced GO., Methods: Twenty-eight human gingival biopsies were taken from healthy patients with chronic periodontitis (N.=14 control group), and from renal transplant recipients treated with cyclosporin A (N.=14 test group). The retrieved specimens were immunohistochemically processed and stained for vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67., Results: The levels of vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67 were found to be significantly different among groups (P>0.001), with patients treated with cyclosporin A showing higher levels of all the analyzed markers compared to control group., Conclusion: In summary, the data from this pilot study suggests that the investigated factors have a role in the inflammation processes associated to immunosuppressive therapy. However, further studies with a larger sample population need to be conducted for an exhaustive knowledge of the mechanisms leading to GO.

Aim: The aim of the present study was to highlight the relationship between the level of oral hygiene and the context in which the patient receives dental treatment, demonstrating that home service is essential and effective to decrease the incidence of periodontal diseases., Methods: The study was initially conducted on a heterogeneous sample of patients including 48 individuals with psycho-motor deficits. The study included 28 males (58.3%) and 20 females (41.7%) aged between 18 and 50 years, coming from two different sites ("Fa.Di.Vi… e oltre" and "Dentistry Unit, Istituto G. Gaslini" in Genoa). The patients were evaluated during the period 2008-2009. After this first pilot study, a clinical trial was conducted within the educational center "Il Granello", with the participation of 20 patients with disabilities., Results: This study demonstrates that home assistance is essential and effective to decrease the incidence of those periodontal diseases induced by bacterial dental plaque accumulation, and associated with aggravating factors like the repeated use of drugs, such as benzodiazepines, phenylhydantoin, and cyclosporin A, that cause gingival hypertrophia., Conclusion: This study was proposed to demonstrate that the availability of a dental service within institutions could improve not only the dental-periodontal conditions of the participants, but also decrease the admission of these subjects to hospitals, contributing to the reduction of public expenditure by the Health Care System.

Introduction: Gingival enlargement is a common form of periodontal tissue reaction to several irritating factors. The most common form is the drug related gingival hyperplasia--nevertheless the heredity gingival fibromatosis and hematological cases can also occur and might impose a challenge to periodontists. After a short literature summary three Case reports are presented. The first case is a drug related gingival overgrowth in a young kidney transplant women who took Cyclosporin-A. The excessive mass of fibrotic tissue was removed by a series of internal beveled incision and the oral and buccal gingival flaps were united with sutures. The healing was uneventful and during the follow up patient's compliance and oral hygiene was superb. The second case is a very severe antihypertensive drug related gingival overgrowth in a 62 years old man interfering with the closure of his lip and corrected with a combination of conventional gingivectomy and internal reverse beveled incision both and Ca-channel blockers. The third case is a 42 years old woman with chronic idiopathic hemolytic anemia who presented a sudden onset acute excessive generalized gingival enlargement accompanied with severe pain and fever. At admission she was suspect for leukemia. After obtaining biopsy samples and having negative histology the soft tissue mass was removed under general anesthesia with conventional gingivectomy technique, but after a couple of days the severe pain and gingival swelling recurred. With administering systemic corticosteroid therapy (32 mg Medrol), the gingiva healed in five days and the one year follow-up showed a stable hematological and periodontal status. Today the more conservative internal beveled incision is preferred over the conventional gingivectomy in the most cases because it provides a more predictable healing and better esthetics. The recurrence of the drug related gingival hyperplasia can be anticipated by meticulous postoperative individual oral hygiene and regular supportive therapy., Conclusion: The combined conservative and surgical therapy leads to predictable postoperative result even in very severe systematically motivated gingival enlargements, nevertheless the successful patients management needs good cooperation with medical doctors and with the patients themselves.

Background and Objective: The objective of this study was to analyze the concordance of the vertical gingival overgrowth index (GOi) and the horizontal Miranda & Brunet index (MBi) and to compare their reliability and reproducibility for an early diagnosis of gingival enlargement. A wide range of methods has been employed to determine the severity of drug-induced gingival enlargement (DIGE) that has resulted in uncertainty with regard to the prevalence of this side effect. In recent studies, different indices have been used to grade DIGE. The large variability observed between studies and the differences between vertical and horizontal gingival-enlargement measurements could be the result of the use of nonreliable indices during the measurement process. Some indices involve invasive procedures that require many measurements, or even a data-processing system, while others are less convenient and technically expensive and complex. In previous studies we used two complementary indices - the vertical GOi and the horizontal MBi. The results of these studies found some differences between both indices, with the MBi rendering higher estimates of DIGE prevalence that was attributed to its greater sensitivity for the detection of minimal changes in gingival thickness. To our knowledge, there are no studies comparing different measurement indices for gingival enlargement that are supported by statistical concordance analysis., Material and Methods:   Twelve plaster casts from patients who had worn orthodontic brackets, and who had different degrees of chronic inflammatory gingival enlargement, were analyzed. Three previously trained examiners registered twice the degree of buccal overgrowth, using the GOi and MBi, in all cast models with a minimum interval of 7 d between the first and the second evaluation. In total, from each cast, measurements from 16 gingival sites were taken using the GOi, and from nine gingival units (mesial and distal sites measurements) using the MBi. Concordance analysis of the registered measurements (intra-examiner and among examiners) for each index and between indices was assessed using the nonweighted Kappa index with a confidence interval of 95%., Results: We obtained 648 values for the GOi and the MBi. The overall score 0 (indicating absence of enlargement) was 32.7% and 19.8% for GOi and MBi, respectively, score 1 (light/moderate) was 39.7% and 48.1%, and score 2 (severe) was 27.6% and 32.1%. Concordance analysis for each index showed intra-examiner Kappa values of 0.820 for the GOi and 0.830 for the MBi. Interexaminer Kappa values were 0.720 for the GOi and 0.770 for the MBi. Concordance between indices showed Kappa values for the same examiner of 0.600, whereas concordance among different examiners was 0.550. Discrepancies between indices indicated a systematic skew, with 79-82.1% of discrepancy associated with a higher value for the MBi compared with the GOi., Conclusion: Both gingival enlargement indices analyzed are reliable, complementary and applicable for measuring gingival overgrowth. However, the MBi shows, with fewer measurements, a greater sensitivity than the GOi for the detection of the early stages of gingival enlargement, being adequate for the screening of large populations at risk., (© 2012 John Wiley & Sons A/S.)

Objective: To compare the current (t1) periodontal status of post-liver transplantation patients to their status 10 years earlier (t0)., Method and Materials: Seventeen patients 45 to 71 years of age who were evaluated approximately 10 years previously were enrolled in the study. All subjects had undergone a liver transplantation 1 to 10 years prior to the initial examination (t0). Clinical and radiographic parameters were recorded for the Ramfjord Index teeth and compared between t0 and t1, including Plaque Index (PI), Gingival Index (GI), probing depth (PD), clinical attachment level (CAL), and gingival overgrowth (GO). Bone loss was measured on digitized images of panoramic radiographs., Results: Mean PI, GI, CAL, and GO were slightly lower at t1 than at t0; however, these differences were not statistically significant (P > .05, Student t test for paired observations). The mean PD was reduced at t1 (2.43 ± 0.18 mm) compared with t0 (3.35 ± 0.22 mm), which was statistically significant (P = .001, Student t test for paired observations). To the contrary, the mean radiographic bone loss at t1 was higher than at t0 (5.61 vs 4.48 mm, respectively), which was also statistically significant (P = .017). Tooth loss was observed in some of these patients, ranging from 0 to 4 during the 10 years of follow-up, which amounted to an annual rate of 0.24 teeth per patient., Conclusion: Post-liver transplantation patients maintained stable clinical periodontal parameters during a 10-year period; however, some radiographic bone loss occurred during this time.

Objectives: Cyclosporine A (CsA) is used as an immunosuppressive agent and its prominent side effect is the induction of gingival overgrowth. Type I plasminogen activator inhibitor (PAI-1) has shown to play an important role in CsA-induced gingival overgrowth. However, little is known about whether factors can modulate CsA-induced PAI-1 expression., Methods: Cytotoxicity, reverse transcriptase-polymerase chain reaction, and enzyme-linked immunosorbent assay were used to investigate the effects of Human gingival fibroblasts (HGFs) exposed to CsA. In addition, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, interlukin-1alpha, tumor necrosis factor-alpha, mitogen-activated protein kinase kinase (MEK) inhibitor U0126, signal-regulated protein kinase (ERK) inhibitor PD98059 and cell-permeable glutathione precursor N-acetyl-L-cysteine (NAC) were added to test how they modulated the effects of CsA-induced PAI-1 expression., Results: The concentration of CsA higher than 500 ng ml(-1) demonstrated cytotoxicity to HGFs (P < 0.05). Periodontal pathogens as well as proinflammatory cytokines were found to increase the CsA-induced PAI-1 mRNA and protein expression (P < 0.05). Pharmacological agents NAC, U0126, and PD98059 were found to decrease the CsA-induced PAI-1 mRNA and protein expression (P < 0.05)., Conclusions: Cyclosporine A (CsA) may predispose to gingival overgrowth under inflammatory environments. The regulation of PAI-1 expression induced by CsA might be critically related with the intracellular glutathione and the ERK-MAPK pathway.

An immunoperoxidase technique was used to compare the number of CD1a+ and factor XIIIa+ dendritic cells (DCs), and CD68+ Macrophages (M) in 30 gingival samples from subjects with clinically healthy periodontitium (HP) and 10 samples from subjects with drug-induced gingival enlargement (DIGE). Fewer CD1a+ and factor XIIIa+ DCs were found in areas with inflammatory infiltration (II) of the lamina propria (LP) in the group with immunosuppressed DIGE (IDIGE) compared to the group with HP. In the sulcular and junctional/pocket epithelia, the number of CD1a+ DCs was decreased in the group with IDIGE (p<0.05). There was a tendency toward a reduced number of CD1a+ DCs and CD68+ M in areas without inflammatory infiltrate of the LP in the group with IDIGE. The alterations in the number of antigen-presenting cells (APCs) may be the reason for the decreased periodontal inflammation and breakdown clinically observed in subjects who are immunosuppressed.

Aim: To assess gingival overgrowth prevalence and severity in a group of kidney transplant (KT) patients, and analyze the effect of immunosuppressor drugs Cyclosporin A (CsA), Tacrolimus (Tac), Sirolimus (Siro), Azathioprine (Aza) and Mofetil Mycophenolate on this complication., Methods: Gingival overgrowth presence and severity was classified, and the impact of immunosuppressor drugs, age, oral hygiene, verapamil and nifedipine on this condition was analyzed by multiple logistic regression., Results: 172 KT pts. were examined; 137 used CsA, 25 Tac, 6 Sirolimus, 107 Aza and 56 MMF. Gingival overgrowth prevalence was 59.1% on CsA, 12.0% on Tac, and 16.7% on Sirolimus. CsA odds ratio (OR) 15.2, age <45 OR 5.6, and poor oral hygiene OR 3.2, increased, and Aza OR 0.05 and MMF OR 0.03, decreased GO prevalence., Conclusions: Aza and MMF effect was a significant protection against GO prevalence in this group of KT patients.

Gingival hypertrophy is a well-known and extensively documented undesirable side effect of cyclosporine in posttransplant patients. However, severe lip enlargement associated with cyclosporine is less recognized and has seldom been reported in the literature. Lip enlargement may lead to social, physical, and psychological stress, especially in the older childhood and adolescent age groups. We present a case of marked lip hypertrophy and concomitant gingival hypertrophy secondary to cyclosporine (Neoral) treatment in a pediatric bilateral lung transplant recipient. We also discuss the various side effects and treatment considerations available including more recent substitution therapy. Cyclosporine has most effectively and conclusively enabled transplantation of solid organs by reducing transplant-associated morbidity. We believe clinicians should be knowledgeable and aware of lip hypertrophy associated with cyclosporine use. This rare and less understood adverse effect should be recognized during the clinical evaluation of the posttransplant patient.

Patients who undergo a renal transplant also require a pharmacological immunosuppressor therapy with cyclosporine (CsA) as well as anti-hypertensive calcium channel-blockers (CCBs); the former suppresses interferon and interleukin-2 production thus interfering with T cell cell-mediated activity, while the latter are used in order to counteract the nephrotoxicity of CsA which causes the local release, of thromboxane A2 with vascular vasoconstriction in the kidney. The use of both these drugs, particularly if used in association, leads to the onset of a clinical picture of variable entity, characterized mainly by a hypertrophy originating usually at the level of interdental papillae, and more pronounced in the anterior maxillary areas and the vestibular surfaces of the teeth, in a more or less symptomatic manner. The therapy is above all preventive, with an appropriate oral hygiene program, both professionally as well as at home, and with the use of substitutive drugs that do not present such side effects.

A 9-year-old boy diagnosed with gingival hypertrophy and with a history of West syndrome and associated low platelet levels underwent gingival reduction surgery. Because difficult intubation was foreseen, the fiberoptic tube was inserted through the nose with the patient breathing spontaneously under remifentanil for sedation and analgesia. The procedure was carried out under balanced general anesthesia and with standard monitoring. At the end of gingivectomy, a tracheostomy was performed and the patient was transferred to the pediatric intensive care unit for postoperative observation.

Nephrotoxicity is a well-known adverse effect of cyclosporine A (CyA) treatment in children with steroid-dependent (SD) and steroid-resistant (SR) nephrotic syndrome (NS). We analyzed nine children (age: 3.3-15.7 years, two girls) with SD or SR NS who experienced a significant decrease in their GFR under CyA treatment as measured by inulin clearance (C(IN)). Mycophenolate mofetil (MMF) was introduced progressively until doses of 1 g/1.73 m(2) twice daily were reached. CyA treatment was stopped after introduction of MMF and oral steroids were reduced if possible. After a median follow up of 261 days, no adverse effects of MMF such as diarrhea or hematological anomalies occurred in our patients. After switching from CyA to MMF, those children with SD NS remained in remission without proteinuria and those with SR NS did not show any significant changes in their residual proteinuria. The serum protein level did not change significantly in any of the children analyzed. GFR increased from a mean of 76.9+/-4.8 to 119.9+/-5.9 mL/1.73 m(2) per min (P<0.001). Oral steroid treatment could be reduced from a median [range] prednisone dose of 0.85 [0.26-2.94] mg/kg/d pre-MMF to 0.29 [0-1.1] mg/kg per day (P=0.026), and blood pressure decreased moderately after CyA withdrawal, but the difference did not reach statistical significance. We conclude that a switch from CyA to MMF seems to be safe for children with SDNS and SRNS in terms of side effects as well as disease control, at least in the short term. Interruption of CyA treatment lead to rapid amelioration of kidney function in these children, often associated with steroid sparing, which may lead to additional benefit for growth velocity, blood pressure and physical appearance.

Objective: The inter-individual variability of cyclosporine (CsA) pharmacokinetics is well known. However, there is obviously also an inter-individual pharmacodynamic variability, which might be explored by the measurement of biomarkers of CsA effects., Methods: In 11 renal transplant patients, blood CsA concentrations, calcineurin inhibition in peripheral blood mononuclear cells and endothelin plasma concentrations were measured over a 4-h period after CsA intake., Results: Mean plasma endothelin concentrations were higher than those of healthy subjects (3.66+/-0.46 pg ml(-1) versus 3.15+/-0.40 pg ml(-1), P<0.01) but were not related to CsA dose or blood concentrations. There was a linear relationship between calcineurin inhibition at t (0) and mean endothelin concentrations (r (2)=0.51, P<0.05). Patients with gingival hypertrophy had higher mean endothelin concentrations than patients without this complication (4.0 pg ml(-1) versus 3.4 pg ml(-1), P<0.01), although CsA doses and concentrations were not different between these two groups., Conclusion: We observed a correlation between calcineurin inhibition and endothelin concentrations. Endothelin plasma concentrations is a biomarker of CsA effect, which may provide more information than CsA blood concentrations.

Background: Over-the-counter and prescription drugs are used frequently, in large quantities and by many adults, particularly by those older than 65 years of age. A number of medications (prescription, over-the-counter, vitamins and minerals, herbal preparations) can affect oral health. With the population's aging, and as more drugs become available, dentists can expect to encounter medication-related oral side effects among their patients., Types of Studies Reviewed: The author reviewed studies that ranged from case reports to randomly controlled, double-blinded studies. However, in view of the subject matter, the majority of findings are based on case reports., Conclusions: Since many patients regularly take medications, both prescribed and nonprescribed, dentists always must take a thorough medical history so that they can be aware of medication-related problems and the impact of medications on diagnosis and treatment planning., Clinical Implications: Dentists must be aware of the potential oral tissue complications that medications can create and develop appropriate treatment plans for their patients that consider the oral health impact of the medications they take.

Purpose: The purpose of this study was to determine the relationship between amphetamine ingestion and gingival enlargement., Methods: A total of 40 subjects were included in this study. Group 1 consisted of 20 subjects taking amphetamines and attending the dental clinic at Children's Hospital of Buffalo and The University at Buffalo School of Dental Medicine. These subjects were not taking phenytoin, cyclosporine, or calcium channel blockers. Patients with cardiovascular or hormonal disorders were excluded from the study. The information obtained from patients' parents or legal guardians were: (1) the time when the patient started taking the medication; (2) how often the patient took the medication per day; and (3) the medication's dosage. Gingival and plaque indices were also measured to assess gingival health. The Silness and Löe plaque index and modified gingival index were used. A second group of 20 healthy subjects not taking any medications was used as a control group. Gingival enlargement was evaluated clinically by one examiner and evaluated from intraoral photographs by another examiner., Results: The results of this study demonstrated a relationship between amphetamine usage and gingival enlargement. There was a statistically significant increased prevalence (P<.05) of gingival enlargement in the group of patients taking amphetamines., Conclusions: This study shows that patients taking amphetamines have an increased risk of gingival enlargement. A stringent effort to minimize gingival inflammation should be instituted, and patients should be monitored closely with more follow-up appointments than nonmedicated patients.

Background: Focal segmental glomerular sclerosis (FSGS) has a high propensity for recurrence after renal transplantation, with a 50% risk for graft failure from recurrent disease., Methods: We report on the efficacy of high-dose oral cyclosporin A (CsA) in the treatment of recurrent FSGS in children. Between August 1991 and January 2003, a total of 24 patients with FSGS underwent transplantation at 1 institution. Sixteen patients (67%) had recurrent disease. In these 16 patients, CsA dose was increased gradually until remission was achieved or there was evidence of renal toxicity. Seven patients also underwent plasma exchange., Results: Thirteen patients (81%) achieved remission. Remission was complete in 11 patients and partial in 2 patients. The CsA dose necessary for inducing remission ranged from 6 to 25 mg/kg/d. Four of these patients also underwent plasma exchange. After remission, CsA dose was reduced gradually toward the standard posttransplantation regimen. Eleven of 13 responders have a functioning graft after a follow-up ranging from 10 months to 12 years. One graft was lost because of recurrent FSGS, and another graft because of recurrence and cellular rejection; noncompliance was a factor in both losses. The 3 patients with disease that did not respond to high-dose CsA therapy lost their grafts because of recurrent FSGS. A common factor in these 3 patients was the inability to increase the CsA dose because of early evidence of nephrotoxicity, evidenced by an increase in serum creatinine level., Conclusion: High-dose oral CsA therapy is effective in producing long-lasting remission of recurrent nephrotic syndrome in children with FSGS.

Cyclosporin A (CsA) induced gingival overgrowth is one of the major side-effects conditioning the quality of life of the patient under immunosuppressive therapy. This adverse effect has been first reported in 1983 and affects almost 30% of treated patients. Several papers have been published concerning the cellular/molecular mechanisms by which CsA may induce, at the same time, an immunosuppressive and proliferative action. In this review various factors concerning the patient and his milieu that account for the different prevalence of the severity of gingival overgrowth in clinical studies are analyzed and briefly discussed. In particular, age, sex, pharmacokinetic properties, pharmaceutical preparation, genetic predisposition, association with other drugs and the parodontal conditions before transplantation are considered. In addition, a unique approach to the patients with gingival overgrowth as well as effective methods of prevention and therapy are suggested.

Previous studies suggested that the onset of phenytoin-induced gingival overgrowth depended on serum phenytoin concentration. Cytochrome P450 2C (CYP2C) plays an important role in phenytoin metabolism. Recently, single nucleotide polymorphisms in the coding region of CYP 2C influencing phenytoin metabolism were identified. The purpose of the present study was to see if CYP 2C polymorphisms might relate to the onset and severity of phenytoin-induced gingival overgrowth. Twenty-eight epileptic patients taking phenytoin aged 15 to 75 (mean age: 42.2 years old, 20 males and 8 females) and 56 unrelated healthy subjects aged 30 to 48 (mean age: 36.8 years old, 48 males and 8 females) were examined for CYP 2C polymorphisms. All epileptic subjects were examined for the degree of gingival overgrowth, daily phenytoin dose and serum phenytoin concentration. The results indicated about 7% of the subjects including epileptic and healthy subjects examined were positive for CYP 2C9*3. However, the degree of gingival overgrowth did not directly correlate with CYP 2C polymorphisms. Nevertheless, the subjects with severer gingival overgrowth exhibited significantly higher serum phenytoin concentration, indicating that phenytoin metabolism is an important determinant for the severity of the disease. Additionally, CYP 2C9*3 carriers exhibited significantly higher serum drug concentration to drug dose. Therefore, we concluded although the gene analysis is not directly related to diagnose the disease itself, it can be utilized in estimating serum phenytoin concentration from drug dose, which in turn serves to predict the future development and clinical course of the disease.

Purpose: The aim of this study was to evaluate periodontal disease prevalence in the primary dentition of children with cerebral palsy (CP)., Methods: The experimental group consisted of 100 children with CP and the control group, 100 healthy children. The indices used in the oral examination were: debris index, calculus index, gingival index, Simplified Oral Hygiene Index (OHI-S), and gingival hyperplasia index., Results: It was observed that the mean values for the debris index, OHI-S, and gingival index were higher in the children with CP than in the control group. In the CP group, the percentage of children who had their teeth brushed by their parents or another person was greater than in the control group., Conclusions: From this study, it was concluded that children with CP had greater prevalence of periodontal disease in the primary dentition than children in the control group.

Seizure disorders and epilepsy represent neurologic conditions that commonly are seen among patients requiring dental treatment. When dentists possess a working knowledge of seizures, in addition to an understanding of updated therapies for seizure management and oral complications associated with pharmacological therapy, they are able to treat patients with these disorders more effectively. Neurologic consultations and selecting an appropriate venue for treatment may need to be addressed prior to treatment, depending on the level of seizure control. Laboratory tests designed to evaluate medication levels, leukocyte counts, and clotting ability also may be required. Frequent recall visits may be necessary for seizure disorder patients who display adverse oral complications from medication, such as gingival hypertrophy, xerostomia, and oral yeast infections.

Several studies, during the last 20 years, tried to explain the pathogenetic mechanisms of the cyclosporine (CS) induced gingival overgrowth (and in general, of the drugs induced gingival overgrowth), but they are still poorly understood. The relationship between the drug and the different pharmacokinetic variables (dosage, duration of therapy, plasmatic and salivary Cs concentration) is still on discussion. It is accepted that a threshold concentration is necessary, in the gingival tissues, to begin or to enhance the morphostructural changes of the gums, but the total Cs weight, from the beginning of the therapy to the time of clinical examinations, has to be evaluated. The pharmacokinetic variables are associated with many other factors (first of all the oral hygiene score) that are probably connected with the developing of the gingival lesions. Gingival inflammation could be very important in the pathogenesis of gingival overgrowth. It has been shown by several cross-sectional studies a strong association between plaque and gingival lesions, but it is not yet clear if plaque accumulation is a causal factor or a consequence of the morphological gums changes. It would seem that the morphological alterations, in drug-induced gingival overgrowth, could be started by the plaque induced inflammation, and this would lead to an hyperemic and edematous gingival tissue. Oral hygiene (professional and at home) is more difficult and represents an irritation factor that makes the pathological cycle to go on. Other factors, probably connected with the cyclosporine induced gingival overgrowth, are represented by age, gender, genetic predisposition, alterations of gingival connective homeostasis and metabolism, inflammatory alterations, interactions with the growth factors and protective or synergic effects of other drugs.

Aim: The purpose of this article was to present a case in which nickel sensitivity of the oral mucosa was demonstrated during the use of a transpalatal arch appliance (TPA)., Case Report: An 11-year 8-month old post-menarchal female presented for orthodontic treatment with Class III buccal segments and bilateral open bite. The treatment plan consisted of placing a rapid palatal expansion appliance (RPE) and a TPA with soldered lateral tongue cribs, in order to eliminate her tongue thrusting habit. 8 months into treatment, the gingiva of the right posterior segment began to hypertrophy, particularly around the bands of the right first molar and premolar. A patch test of 5% nickel sulfate indicated a positive reaction to nickel. The treatment was finished without the use of nickel titanium wires and the mucosa reaction resolved. The patient had had her ear pierced at age 2 days old, which was 11 years before orthodontic treatment was initiated. The literature shows that this exposure may have been the sensitizing event., Conclusions: While the nickel sensitive patient may not present an extreme medical risk, the orthodontist must be aware of the problem and the likelihood of treating patients with this condition. It appears that the reaction may vary from patient to patient. The practitioner should possess a basic understanding of the occurrence rate, sex predilection, and signs and symptoms of allergy to nickel, and should be familiar with the best possible alternative modes of treatment, to provide the safest, most effective care possible in these cases. Practitioners should be aware that symptoms of nickel allergy may closely mimic those of typical gingival changes during orthodontic treatment of circumpubertal children.

Gingival overgrowth occurs with phenytoin, cyclosporin, and calcium antagonists. It can be disfiguring and painful. The prevalence of gingival overgrowth with the use of calcium antagonists may be as high as 38%. The prevalence with nifedipine may be greater than with other calcium blockers. Overgrowth occurs 3.3-times more commonly in men than in women. Plaque control is necessary. Some patients may require gingival surgery., (Copyright 2002 Le Jacq Communications, Inc.)

Gingival enlargement (GE) may be induced by cyclosporin A, phenytoin or calcium channel blockers, used either singly or in combination. The lesion can cause significant disfigurement and functional difficulty as it interferes with eating and speech, impedes effective plaque control, and disturbs occlusal relationships. Orthodontic problems may originate independently of the soft tissue lesion or they may develop secondary to the GE. Management of drug-induced GE with orthodontic complications requires co-operative teamwork. This will be discussed in the management of cases with medical, orthodontic and periodontal interventions.

Eighty-two patients were observed at the Dental Department at Parma University. Seventy-six of them had renal transplant and 6 liver transplant. They were in immunosuppressive therapy with cyclosporina, 42 of them were also in calcium antagonist therapy. Gingival hypertrophy was observed in 52 subjects (63.4%) 25 (30%) patients underwent surgical operation, 6 of them (24%) showed a relapse about 3 months after the first operation. Clinical data were measured in accordance with 5 indicators: the level of oral hygiene, cyclosporinemia, contemporaneous use of calcium antagonist, the duration of therapy and the DMF index. By the results obtained, it's possible to suppose that the gravity of the disease is related to the contemporaneous use of calcioantagonist, but it wasn't highly significant (p < 0.05). The degree of oral hygiene was decidedly in relation to the most severe forms of gingival hyperplasia (grade 2-3), (p < 0.001). No relation was found for the duration of therapy, distribution of the DMF index and the level of drugs in the blood.

A case report is described of significant aspirin-induced haemorrhage following a gingivectory procedure in an organ transplant patient. Aspirin-induced platelet impairment secondary to low-dose aspirin was implicated as the cause of the haemorrhage. Haemostasis was eventually achieved after platelet transfusion. The case illustrates the problems that can arise when carrying out gingival surgery on patients medicated with low-dose aspirin.

Cyclosporine is now the elective drug for immunosuppressive treatment in organ transplant patients. Compared to traditional immunosuppressants this molecule offers the therapeutic advantage that it does not act indiscriminately on all components of the immune system. In addition to the primary pharmacological action, cyclosporine also presents a number of undesirable effects, among which it is worth mentioning short and long-term nephrotoxicity and the development of neoplasia, in particular lymphomas. Other undesired effects of the drug are the possibility of overinfection, thrombosis, hypertension, hypertrichosis, hepatotoxicity and the development of the hypertrophic and hyperplastic gingival pathology.

A case of severe gingival overgrowth associated with combined drug therapy of cyclosporin A and nifedipine is reported. The frequently increased vascularity of the gingival tissues in such cases often causes problems with bleeding both during and after surgery. Acrylic suckdown splints have been used postoperatively to assist haemostasis; however, these can interfere with function and cause discomfort. This report describes a combined treatment approach using conventional gingivectomy and carbon dioxide laser for the removal of the hypertrophic soft tissue. The benefits of such combined treatment include reduced bleeding during surgery with consequent reduced operating time and rapid post-operative haemostasis, thus eliminating the need for a splint.

In an open clinical trial we assessed the tolerance and safety of the 1:1 conversion of traditional cyclosporine A (CyA) to a new cyclosporine formulation based on a microemulsion technology (CyN) in 18 patients with stable renal allografts. 56% patients were female. Median patient age was 40.9 +/- 3.2 years (range 18 to 65). Renal transplantation was performed in 24.1 +/- 4.6 months (range 6 to 67 months), prior to the beginning of the study, and 67% of the transplants were from cadaveric donor. The most frequent underlying renal disease was glomerulonephritis (44.4%). None of the patients entering the study were withdrawn prematurely. After 2 weeks of observation for graft function stability, the study was divided in two phases: I: during 4 weeks the patients received CyA traditional at fixed doses (Mean dose administered 3.056 +/- 0.25 mg/Kg/d) and II: during the consecutive 6 weeks with conversion to CyN, with doses adjustment as required (Mean dose 2.887 +/- 0.21 mg/Kg/d). Clinical events, adverse reactions and laboratory parameters were evaluated. Levels of 100-200 ng/ml measured by monoclonal specific fluorescence polarization immunoassay were considered appropriate. There were no significant changes in physical examination and laboratory parameters between phases. The incidence of adverse reactions reported in phase I was only gingival hypertrophy (5%) which persisted in phase II, qualified as probably related to the cyclosporine, and in phase II tremor in 17%, qualified as definitively related. Both drugs were well tolerated and there was no report of acute rejection during the study. We conclude that the tolerance and safety of the 1:1 conversion of CyA to CyN were confirmed by our results, and considering the improved pharmacokinetic properties of the second, the microemulsion presentation will be used preferentially as immunosuppressive drug in the treatment of stable kidney transplant patients.

Cyclosporine, substituted Dihydropyridines and Phenytoin are three drugs that are often correlated with gingival overgrowth. Differences in incidence and histology are reviewed. Due to the large range of illnesses for which these drugs are prescribed, we can only anticipate a high increase in the number of patients who seek treatment for their enlarged gums. Contemporary treatment modalities are changing towards increased usage of these pharmaceutics which will lead to a high frequency of patients which have drug induced alterations of their gingival structures. The dental practitioners will also need to be consulted prior to drug treatment so that preventive measures can be taken. Treatment of gingival overgrowth is discussed.

This review considers the periodontal problems of renal transplant patients with particular reference to their drug therapy and the pretransplant uremia. It would appear that either disease- or drug-induced immunosuppression affords the renal transplant patient a degree of "protection" against periodontal breakdown. However, of more significance to the periodontologist is the problem of drug-induced gingival overgrowth with reference to both cyclosporin and nifedipine. Approximately 30% of dentate renal transplant patients medicated with cyclosporin alone experience significant gingival overgrowth which requires surgical excision. This figure increases to 40% when patients are medicated with both drugs. The pathogenesis of this unwanted effect is uncertain and the relationship between the expression of gingival overgrowth and various periodontal or pharmacokinetic variables remains a contentious issue. Clinical measures to prevent the occurrence of either cyclosporin- or nifedipine-induced gingival overgrowth are unsatisfactory.

Fibroblasts from nifedipine-induced fibrotic gingiva (NFG) have been characterized with respect to several cellular functions which could contribute to the characteristic clinical overgrowth of the gingiva: collagen synthesis and breakdown, glycosaminoglycan production, fibronectin synthesis, and proliferation. Histologic examination of NFG tissue revealed a hyperplastic epithelium with elongated, branched rete pegs. The connective tissue consisted of densely-packed collagen fibers and numerous enlarged fibroblasts, as well as regions of thinner, disorganized collagen fibers in the vicinity of scattered inflammatory and mast cells. Results of in vitro experiments showed that the fibroblast strains from the fibrotic gingiva (NFG) produced significantly greater amounts of collagen and lower levels of collagenase activity when compared to age- and sex-matched normal human gingival fibroblast strains. The NFG fibroblasts did not produce significantly greater amounts of fibronectin, and their level of glycosaminoglycan production was less than that of the normal fibroblasts. The NFG fibroblasts did not proliferate significantly more rapidly than the normal fibroblast strains. These findings therefore show that there are defects in the regulation of collagen production by NFG fibroblasts in vitro, and suggest that these alterations in collagen metabolism contribute to the over-deposition of collagen in this tissue, rather than hyperproliferation of the fibroblasts or through the production of increased amounts of fibronectin and glycosaminoglycans.