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Drug Induced Gingival Hyperplasia

Gingival hyperplasia

Gingival hyperplasia, or hyperplastic gingiva, is common in patients taking phenytoin, cyclosporine, or calcium channel blockers. Speech, chewing, tooth eruption, and aesthetics can all be altered. Controlling the inflammatory component through a proper oral hygiene program can benefit patients by limiting the severity of gingival overgrowth. 

Identifying the condition and referring to a general dentist or periodontist are appropriate management steps for patients who have developed or are expected to develop gingival overgrowth

Important aspects are the physician's awareness of the potential for overgrowth and the dentist's role in trying to prevent or minimize this problem. In this article, we discuss medications and describe recommendations for gingival hyperplasia.

Medically induced gingival hyperplasia

Medically induced gingival hyperplasia or gingival overgrowth is a phenomenon that occurs in response to various types of therapeutic agents. The disorder has been recognized since 19391, shortly after the introduction of phenytoin 2 to control seizures. 

Although anticonvulsants, calcium channel blockers, and immunosuppressants cyclosporine are pharmacologically distinct, they share a common ability to induce gingival overgrowth. 

The occurrence of this phenomenon, especially in advanced cases, interferes with speech, chewing, and tooth eruption, and is aesthetically undesirable. 3,4 Non-drug factors such as congenital or hormone-induced or chronic poor oral hygiene may be associated with gingival overgrowth; 5 however, one is medically induced more severe growth. 

This article provides an overview of medications related to gingival overgrowth, treatment, and prevention.

Anticonvulsant Drugs

Although the association between phenytoin and gingival overgrowth is well known, other anticonvulsant drugs such as barbiturates, valproic acid, succinimide, and carbamazepine have been reported to induce gingival overgrowth. 6,7,8 The incidence of gingival overgrowth associated with these drugs is lower compared to phenytoin-induced gingival growth. 

About half of the roughly 2 million patients taking phenytoin develop some degree of gingival hyperplasia. 9 Phenytoin-induced gingival hyperplasia usually begins at the anterior interdental papilla, usually within 1 month of starting treatment. 

The degree of overgrowth may be related to the dose, duration and plasma levels of the drug,7 but some studies do not support this concept. 1011 Numerous studies have found a direct correlation between the degree of plaque and calculus accumulation and the severity of gingival overgrowth.


The link between cyclosporine and gingival overgrowth became apparent soon after the drug was introduced as an immunosuppressant in humans in 1978. 13 Reports indicate a variable incidence, ranging from 13% to 85%. 1415 Patients taking cyclosporine are also taking other systemic medications, such as calcium channel blockers, which can cause overgrowth of the gums. 

Cyclosporine-induced overgrowth has been reported to be less common in bone marrow transplant recipients than in solid organ transplant recipients.

Clinically, cyclosporine-induced gingival overgrowth is similar to phenytoin-induced gingival overgrowth. The anterior lip interproximal gingiva is first affected. Subsequently, the marginal gingiva is involved, which increases in size to cover part of the clinical crown


The calcium channel blocker that is most commonly associated with gingival overgrowth is nifedipine, with a reported incidence of approximately 38%. 

Other agents that have been found to have an association with gingival overgrowth include diltiazem, incidence of 20%; verapamil, incidence of 4 to 19%; and amlodipine, incidence of 3%. Case reports have indicated that gingival overgrowth can also occur with the use of felodipine and nitrendipine