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plant tissues was sent for histopathologic evaluation. The biopsy The literature contains several reports which indicate that pre-ex-
report revealed epithelial cells and fibrous hyperplasia, consistent isting plaque resulting in gingival inflammation is a predisposing
with gingival hyperplasia. factor for gingival enlargement, and that maintaining excellent
oral hygiene may be effective in preventing these hyperplastic
The patient was referred back to her cardiologist for a re-evalua- changes. Most studies show an association between oral hygiene
6,7
tion with regards to the usage of OM-HCTZ and recommendations status and severity of drug induced gingival hyperplasia . The in-
8
for discontinuation or changing to a different medication due to the teraction between the drug and gingival tissues could be enhanced
development of gingival hyperplasia and possible risk of peri-im- by gingival inflammation caused by poor oral hygiene. It has also
plantitis. The cardiologist recommended that the patient continue been documented that, upon discontinuation of these drugs, gin-
Fig 3. Ten years aNer inserJon of prosthesis
OM-HCTZ since she was unable to tolerate or control her blood gival enlargement may be reduced within one week. If the hyper-
pressure with other hypertensives. plastic gingival tissue does not respond to plaque control or scaling
and root planning, it needs to be excised.
Fortunately, this did not interfere with patient home care and there-
fore surgical correction for the hyperplastic tissue was not per- Discontinuation of the related medication has been shown to re-
formed. Additionally, the patient has a low smile line and there duce gingival overgrowth; however, the growth will recur when
was no complaint regarding her esthetics. The subsequent manage- the medication is readministered . In cases where alternative
4
ment consisted of placing the patient on a program of meticulous medications can be used, substitution of the related drug has been
plaque control along with frequent professional cleanings every shown to result in regression of the overgrowth. In this case report
three months. At her three months re-evaluation, there was no it was found that the amlodipine was not well tolerated and when
erythema and the degree of periodontal inflammation around the she began taking OM-HCTZ, she developed gingival hyperplasia.
implants were generally diminished. However, hyperplasia was Maintaining adequate blood pressure control cannot be compro-
still present to some degree (Fig.4). The recommendations includ- mised and thus measures at plaque control is of utmost importance
ed regular oral hygiene in controlling the rate and degree of gingival overgrowth. The
reinforcement, scaling patient was required to return for 3 month recalls for deep scal-
and root planing four ing and root planing, which worked well to reduce gingival over-
times yearly, and chlor- growth to an acceptable level, thereby making surgical treatment
hexidine rinses 0.12% unnecessary.
to be used twice daily.
Summary:
Discussion: The use of OM-HCTZ has been rarely initiated or known to ex-
There is a clear connec- acerbate gingival enlargement around both natural dentition and
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Figure 4. One year after treatment with tion between oral med- dental implants in certain susceptible individuals. This case re-
proper oral hygiene maintenance and ications such as cyclo- port demonstrated that the administration of OM-HCTZ can cause
chlorhexidine gluconate oral rinse. sporine, phenytoin, and gingival hyperplasia around dental implants. The subsequent
CCBs with regards to management of medication induced gingival hyperplasia consists
Fig. 6
gingival hyperplasia. Among CCBs, nifedipine has been shown of placing the patient on a program of meticulous plaque control

to be a more common culprit that causes hyperplastic gingiva. Al- along with frequent quarterly professional cleanings. 10
though rare, one should not discount ARBs as a contributing medi-
cation to this outcome. Several factors may influence the relation- For patients with mild gingival hyperplasia, conservative oral
ship between the medications and gingival hyperplasia including hygiene measures could reduce the overgrowth of the gingival to
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Fig.5 - Enlargement of the interdental papilla and the margins around the maxillary and
genetics, age, alteration in gingival connective tissue homeostasis, acceptable levels. Adjunctive antimicrobial chlorhexidine gluco-
mandibular anterior and posterior screw retained prosthesis
inflammatory changes, and direct action of medications on growth nate rinses have been recommended in managing gingival hyper-
factors. plasia to help eliminate the indication for surgical intervention. In
moderate gingival hyperplasia, conservative treatment and routine
Gingival hyperplasia may appear as a firm, nodular enlargement of scaling and root planing would shorten the subsequent surgical in-

the interdental papillae, and its prevalence in the mouth is varied. tervention and reduce the risk of postoperative infection. 11
It affects the anterior more than the posterior and are more pro-
nounced on the facial than the lingual gingival surfaces of teeth or Surgical removal by gingivectomy and gingivoplasty is neces-
implants (Fig. 5,6,7). sary in severe cases to eliminate periodontal defects and restore
Fig. 6 Fig. 7

Figures 5-7. Enlargement of the interdental papilla and the margins around the maxillary and mandibular anterior and posterior
Fig. 6
screw retained prosthesis InformaJon about the authors:

Fig. 7
Raid Sadda, DDS, MS, MFDRCSI
www.nysagd.org l Fall 2021 l GP 7

InformaJon about the authors:
Fig. 7 Raid Sadda, DDS, MS, MFDRCSI

InformaJon about the authors:
Raid Sadda, DDS, MS, MFDRCSI