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Treatment of Drug-Induced Gingival Hyperplasia Around Full
Maxillary and Mandibular Screw-Retained Fixed Prostheses

Over Titanium Dental Implants: A Clinical Case Report

(Corrected article)
By Raid Sadda DDS, MS, MFDRCSI and Aram R. Sadda, DDS, MS

Abstract: Case Report:
Drug-induced gingival hyperplasia is a known side effect caused A 55-year-old woman was treated with maxillary and mandibular
by several medications and is a physiologic response to a vari- fixed titanium implant supported prostheses. Seven endosseous
ety of local and systemic conditions. Gingival overgrowth around titanium external hex implants were placed to support a screw
natural teeth has been previously reported in the literature with retained mandibular prosthesis. Four weeks later, eight implants
patients taking calcium channel blockers (CCBs), anticonvul- of the same brand
sants and immunosuppressants, but has not been documented with were placed to sup-

angiotensin II receptor blockers (ARBs) as a significant cause. port a screw retained
CCBs, as a group, have been implicated as an etiologic factor for maxillary prosthesis
drug-induced gingival enlargement. This enlargement can be lo- (Fig.1 and 2) The
calized or generalized and can range from mild to extremely se- patient was satisfied
vere, affecting patient’s esthetics and function. However, there has with the appearance
not been any documented case of gingival hyperplasia secondary and function of the
to angiotensin II receptor blockers. This case report describes the restorations and was
development and treatment of gingival hyperplasia around dental placed on periodic
implants in a patient taking a combination of hydrochlorothiazide six month recall vis- Figure 1. Eight external hex titanium implants
and angiotensin II receptor blocker one year after the insertion of its. paced in the maxillary arch.
fixed maxillary and mandibular prostheses.
Approx-
Key words: Peri-implant gingival hyperplasia, angiotensin II re- imately
ceptor blocker, calcium channel blocker ten years
Literature Review: follow-
Gingival hyperplasia is one of the side effects associated with ing the
the administration of several medications such as anticonvulsants com -
(phenytoin), CCBs (nifedipine), and immunosuppressants (cyclo- pletion
sporine). The mechanism by which any of the above mentioned of her
medications induce the formation of hyperplastic gingiva is not implant
well understood and may be distinct for each drug; however, the prosthe-
clinical features of gingival enlargement that are observed with sis, the Figure 2. Panoramic X-ray revealed endosseous titanium
these medications are similar. It is well documented that the peri- patient external hex implants of the maxilla and mandible.
odontium around natural teeth and dental implants are similar and, was diagnosed with hypertension and was prescribed amlodipine
therefore, will react to both local and systemic factors in a similar by her physician. Despite dose adjustments, the patient did not
way. Interestingly, not all patients taking these medications, to- have proper blood pressure control, so her cardiologist began treat-
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gether or separately, develop gingival enlargement, and the reason ing her hypertension with OM-HCTZ. The patient returned for im-
is not well understood. plant and prosthesis re-evaluation one year after having taken OM-
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HCTZ. On clinical exam, the patient was found to have gingival
Not all hypertensive medications are known to cause gingival enlargement, which was generalized and presented as firm nodular
hyperplasia. Among CCBs, nifedipine is the most frequently enlargement of the interdental papilla and gingival margins. It was
implicated culprit in drug-induced gingival hyperplasia . As for greater in the anterior area and more pronounced on the buccal
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amlodipine, the prevalence is significantly lower than that of than lingual surfaces. A full mouth radiographic series revealed no
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nifedipine. Drug-induced gingival enlargement could be detected active bone resorption around the dental implants (Fig. 3). To rule
Fig 3. Ten years aNer inserJon of prosthesis
clinically as early as one to three months following the initial dose out pathology, an incisional biopsy of the hyperplastic peri-im-
of a calcium channel blocker.
Among hypertensive medications, ARBs have not
been documented as a cause for gingival hyperpla-
sia in regards to peri-implant tissues. Thiazide di-
uretics also do not typically play a role in the devel-
opment of peri-implant hyperplastic gingiva. One
agent, olmesartan medoxomil-hydrochlorothiazide
(OM-HCTZ), is a combination of an angiotensin II
receptor antagonist and a thiazide diuretic. Com-
mon side effects of OM-HCTZ include dizziness,
diarrhea, stomach pain, joint pain and dry cough.
Gingival hyperplasia associated with natural den-
tition occurs in 0.0497 percent of patients taking
OM-HCTZ, but has not been reported as a side ef-
fect around dental implants secondary to its use.
www.nysagd.org l Fall 2021 l GP 6 Figure 3. Ten years after insertion of prosthesis.

Fig.5 - Enlargement of the interdental papilla and the margins around the maxillary and
mandibular anterior and posterior screw retained prosthesis