International Dental & Medical Journal of Advanced Research (2017), 3, 1–4

PERSPECTIVE

Association of drug-induced gingival enlargement

(calcium channel blockers) and local factors: Who is the
culprit?
Ajay Chouksey1, Nitin Awasthi2, Jayesh Rai3, Abhishek Chaudhary4
Department of Periodontology, Mansarovar Dental College and RC, Bhopal, Madhya Pradesh, India, 2Department of Oral Pathology and Microbiology,
1

Mansarovar Dental College and RC, Bhopal, Madhya Pradesh, India, 3Department of Oral and Maxillofacial Surgery, Mansarovar Dental College and RC, Bhopal,
Madhya Pradesh, India, 4Department of Orthodontics, RKDF Dental College, Bhopal, Madhya Pradesh, India

Keywords
Calcium channel blockers, gingival enlargement,
home care, local factors, professional cleaning
Correspondence
Ajay Chouksey, Department of
Periodontology, Mansarovar Dental College
and RC, Gramm-Hanotiya Alam, Bhopal,
Madhya Pradesh, India.
Phone: +91-9479653998.
Email: success.in.bds@gmail.com
Received 04 March 2017
Accepted 10 April 2017
doi: 10.15713/ins.idmjar.68
Abstract
Background: Several drugs are used for the management of hypertension. Among
these drugs, calcium channel blockers (CCBs) are the most potent and generally used
drug. Gingival enlargement is a recognized outcome of the administration of CCBs.
Other drugs which cause gingival enlargement are antiepileptic drugs (phenytoin)
and immunosuppressants (cyclosporine). The role of bacterial plaque in the overall
pathogenesis of drug-induced gingival enlargement is not clear as some studies
indicate that plaque is a prerequisite for gingival enlargement, whereas others suggest
that the presence of plaque is a result of its accumulation caused by the enlarged
gingiva.
Aim: The aim of this study is to find the association of local factors with CCBs-induced
gingival enlargement.
Conclusion: The observations made in this report support that the presence of local
factors augments the degree of the gingival enlargement present.
Significance: As the prevalence of CCB use is relatively high in the population, especially
among patients with cardiovascular disease, it is important that medical professionals are
aware of the association between drug-induced gingival enlargement and local factors so
that they can emphasize thorough home care and professional cleaning in the treatment
of drug-induced gingival enlargement.

Introduction inflammatory changes are pivotal. The nature of the relationship

Gingival overgrowth/enlargement is characterized by an
increased gingival volume, including an increased number of cells
and by an accumulation of extracellular matrix within the gingival
connective tissue, particularly the collagenous components.[1]
Gingival enlargement may generate esthetics, mastication, and
speech problem and it may also cause impaired nutrition, reduced
oral hygiene maintenance, and increased risk of caries and
periodontal diseases.[2] The enlargement is usually generalized
throughout the mouth, but it is more severe in the maxillary and
mandibular anterior region. It occurs in areas in which teeth are
present, not in edentulous spaces.[3] The prevalence of gingival
enlargement has been estimated to vary between 30% and 50%
in nifedipine-treated patients.[4] Among the several pathogenesis
of drug-influenced gingival enlargement, the plaque-induced
between plaque and the expression of gingival enlargement is
unclear.[5-8]
The role of bacterial plaque in the overall pathogenesis of
drug-induced gingival enlargement is not clear as some studies
indicate that plaque is a prerequisite for gingival enlargement,[9]
whereas other suggest that the presence of plaque is a
consequence of its accumulation caused by the enlarged gingiva.
Therefore, the purpose of this study is to find the association of
local factors with calcium channel blockers (CCBs)-induced
gingival enlargement.
Scenario 1
A 55-year-old female reported to the department of periodontics
with the chief complaint of gingival enlargement; her medical

International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 20171

Role of plaque in the pathogenesis of drug-induced gingival enlargement
history revealed that she was hypertensive and was taking CCBs
from the past 7 years. Clinical examination revealed gingival
enlargement more severe in the areas, where local factors were
higher (upper, lower right region, and anterior region). Gingival
enlargement was not seen in the left region. Enlargement and
local factor were more severe in mandibular anterior lingual
region [Figure 1].
Bokenkamp A gingival enlargement scoring is depicted as
follows: [10]
III III III III IIII IIII II II II II I 0 0 0 00 0
I II I I I I I I II II III III III II M M
M: Missing
Scenario 2
A 52-year-old male reported to the department of periodontics
with the chief complaint of gingival enlargement; his medical
history revealed that he was hypertensive and was taking CCBs
from the past 5 years. Clinical examination revealed that gingival
enlargement and local inflammatory factors were more severe in
maxillary and mandibular anterior region [Figure 2].
Bokenkamp A gingival enlargement index is depicted as
follows: [10]
Figure 1: Clinical examination of the patient revealing gingival enlargement, especially more severe (red arrow) in the areas, where local
factors were more (yellow arrow) upper, lower right region and anterior region. Gingival enlargement is not seen in the left region
Figure  2: Clinical examination revealing severe gingival enlargement in maxillary and mandibular anterior region. Local inflammatory
factors were also seen in anterior region
2
Chouksey, et al.
MII M M II MII IIIII III III III II II M M II M0 M
I II I I I I I I III III III III I M I I
M: Missing
Scenario 3
A 47-year-old female, hypertensive, reported to the department
of periodontics with a chief complaint of gingival inflammation.
She gave a medical history of taking CCBs from the past 7 to
8 years. Her clinical examination revealed gingival enlargement
in maxillary and mandibular right posterior region and also
in mandibular anterior region. It was also noted that more
subgingival deposits were seen in the same area [Figure 3].
Bokenkamp A gingival enlargement index is depicted as
follows: [10]
MII II II II IIII IIII II II II II II II II M M0 M
M III II II II II II II II II II III II II II M
M: Missing
Scenario 4
A 58-year-old female was hypertensive and was taking CCBs
from the past 10 years. Clinical examination revealed generalized
International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 2017
Chouksey, et al.
Figure 3: Clinical examination revealing gingival enlargement in areas where local factors were also present
gingival enlargement and local factors. It was observed that
severity of enlargement was more where local inflammatory
factors were present [Figure 4].
Bokenkamp A gingival enlargement index is depicted as
follows: [10]
MII III III II IIII IIII II II II II II II II III III0 M
M III II II II III III III III III III III II II II M
M: Missing
Discussion
Drugs associated with gingival enlargement can be mostly
divided into three categories: Anticonvulsants, CCBs, and
immunosuppressants. CCBs, especially dihydropyridines
group, produce gingival hyperplasia. Approximately 10% of
patients taking nifedipine develop clinically significant gingival
hyperplasia. It has the potential of cosmetic implications and
provides new niches for the growth of microorganisms and
is of serious concern for both the patient and the clinician.
Cardiovascular diseases are the common finding among people
owing to today’s life style. CCBs are one of the most commonly
used drugs for the management of cardiovascular disorders.
Gingival overgrowth is now an accepted unwanted effect
associated with many of the CCBs. Of this large group of drugs,
the dihydropyridines (i.e. nifedipine, nitrendipine, felodipine)
are the agents most frequently implicated. Any plaque-induced
inflammatory changes within tissues will worsen the appearance
of drug-induced gingival overgrowth. This finding suggests
causality, with a patient’s oral hygiene being a significant risk
factor for both the growth and the expression of drug-induced
gingival overgrowth,[11-14] although reports to the opposing have
also been reported.[15] Most of the evidences supporting the
association between bacterial plaque and drug-induced gingival
overgrowth have been derived from cross-sectional studies,
and in such studies, it is difficult to conclude whether plaque
is a causative factor to or an outcome of the gingival changes.
Although there may be some dispute as to the role of plaque
and gingival inflammation in drug-induced gingival overgrowth,
there is no doubt that improving a patient’s oral hygiene and
International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 20173
Role of plaque in the pathogenesis of drug-induced gingival enlargement
Figure  4: Clinical examination revealing generalized gingival
enlargement and local factors. We have observed that severity of
enlargement was more where local inflammatory factors were
present
reducing the inflammatory component in the gingival tissue by
nonsurgical means do have an impact on this unwanted effect.
Despite such measures, there still remains a group of patients
who develop overgrowth irrespective of their oral hygiene or
periodontal condition.[16] In such patients, other risk factors may
be more significant. In the present report, we have observed that
gingival overgrowth occurs and it is more severe in patients with
CCBs therapy, in the area where local inflammatory factors were
present. According to Chiu et al., hyperplastic change of gingiva
starts only in areas displaying signs of inflammation, but not in
healthy areas.[17] Some investigators believe that inflammation
is a requirement for the development of the enlargement,
which, therefore, could be prevented by plaque removal and
fastidious oral hygiene.[18] Control of gingival inflammation and
maintenance of effective oral hygiene are key factors in preventing
and managing gingival overgrowth associated with this class of
medications.[19] A marked reduction of the enlargement occurs
following scaling and root planing.[20] Adequate plaque control
is a prime factor in the prevention and control of drug-induced
gingival enlargement.[21] Within limitation, this case report
suggests that the presence of local factors augments the degree
Role of plaque in the pathogenesis of drug-induced gingival enlargement
of the gingival enlargement present. It is necessary that medical
professionals are aware of the association between drug-induced
gingival enlargement and local factors so that they can emphasize
thorough home care and professional cleaning in the treatment
of drug-induced gingival enlargement.
Conclusion
In this perspective, we have observed the positive correlation
between local factors and gingival enlargement; this case reports
support that the presence of local factors augments the degree
of the gingival enlargement present. Thus, we emphasize the
importance of thorough home care and professional cleaning in
the treatment of drug-induced gingival enlargement.
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How to cite this article: Chouksey A, Awasthi N, Rai J,
Chaudhary A. Association of drug-induced gingival enlargement
(calcium channel blockers) and local factors: Who is the culprit?
Int Dent Med J Adv Res 2017;3:1-5.
International Dental & Medical Journal of Advanced Research ●  Vol. 3  ● 2017