Case Study: Managing Severe Periodontal Disease & Drug-Induced Gingival Hyperplasia

Patient Overview: Managing Severe Periodontal Disease & Drug-Induced Gingival Hyperplasia

A 61-year-old male was referred for advanced periodontal disease that had not responded to conventional hygienist treatment. He admitted to neglecting his oral health for years but was now motivated to retain his teeth.

His primary complaint was profuse gum bleeding and swelling.

Medical History

• Medications: Candesartan, Allopurinol, Amlodipine (10mg), Bendroflumethiazide
• Non-smoker

Key Concern: Long-term use of Amlodipine, a calcium channel blocker, which is associated with drug-induced gingival hyperplasia (gum overgrowth).

Clinical Examination

🔹 Oral Hygiene: Poor – The patient was not using interdental brushes
🔹 Subgingival Calculus: Heavy deposits on most teeth
🔹 Pocketing: Generalized 5-7mm pockets, with a bleeding score of 40%
🔹 Bone Loss:

• Generalised 33% bone loss
• 50% bone loss in the lower incisors and upper right region

Diagnosis

📌 Generalised Periodontitis Stage III, Grade B
📌Possible Drug-Induced Gingival Hyperplasia (Amlodipine-Related)

Treatment Plan

✅ Non-Surgical Periodontal Debridement
✅ Comprehensive Oral Hygiene Instruction – Focus on interdental cleaning
✅ Medical Consultation – Discussion with the patient about Amlodipine’s role in gum overgrowth
✅ GP Referral – Patient spoke to his doctor, who initially reduced and later discontinued Amlodipine

Outcome (2 Months Later)

✔️ Significant improvement in gingival overgrowth
✔️ Improved oral hygiene habits
✔️ Bleeding score reduced from 40% to 14% (target <10%)
✔️ Pocketing reduced considerably
✔️ Now suitable for ongoing maintenance with hygienist care

This case highlights the importance of reviewing medication history when diagnosing periodontal disease and considering the potential role of calcium channel blockers in gingival hyperplasia.

Understanding Drug-Induced Gingival Hyperplasia

What Is Gingival Hyperplasia?

Gingival hyperplasia (or gingival overgrowth) is an increase in gum tissue volume that can be caused by certain medications, leading to swollen, lobulated, or granular gum tissue.

Common Medications That Cause Gingival Overgrowth

Calcium Channel Blockers (CCBs) – Amlodipine, Felodipine, Nifedipine
Anti-Epileptic Drugs – Phenytoin (less common today)
Immunosuppressants – Cyclosporin (rarely seen in general practice)

How It Develops

• Changes usually appear 1-3 months after starting the medication.
• The interdental papillae become swollen and may enlarge further, affecting both marginal and attached gingiva.

Prevalence & Risk Factors

• Phenytoin: ~50% of users
• Cyclosporin: ~30% of users
• Calcium Channel Blockers (Amlodipine): 5-85% (dose-dependent)

Key Factors That Worsen Severity:
🔹 Higher drug dosage (>10mg of Amlodipine increases risk)
🔹 Poor oral hygiene and existing periodontal inflammation

Management Strategies for Dentists

🔹 Review Medication History – Identify patients on CCBs like Amlodipine.
🔹 Educate & Prevent – Patients should be informed before starting these medications about the risk of gum overgrowth and the need for excellent oral hygiene.
🔹 Consult with GP – If hyperplasia is suspected, discuss the possibility of reducing or switching medications.
🔹 Periodontal Treatment First? – If medication change is possible, delay periodontal treatment until after withdrawal for optimal healing.

📌 Key Takeaway: If patients are on Amlodipine, check for gum overgrowth and consider a medical referral. Improving oral hygiene can help, but in many cases, medication adjustment leads to the best long-term outcome.

Final Thoughts

This case demonstrates how a holistic approach, combining periodontal therapy, oral hygiene reinforcement, and medical collaboration, can lead to outstanding patient outcomes.

Do you have patients on Amlodipine with signs of gingival overgrowth? Reviewing their medication could make a significant difference in their treatment success

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