Pearls of Wisdom: Gingival Hyperplasia
James, a 62-year-old male veteran, comes in for a routine hypertension checkup, and you notice that he has substantial gingival hyperplasia. His past medical history includes hypertension, diabetes, and hypothyroidism.
When asked, James says his gums have been swollen for roughly 2 years.
He has neither a history of seizures nor any indication for dilantin. He has brought in all of his medications, which match his medical records.
James said he never brought up the swollen gums as he considered it a part of getting old.
Which of the patient’s medications is associated with gingival hyperplasia?
A. Metformin
B. Glipizide
C. Diltiazem
D. Chlorthalidone
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
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Answer: Diltiazem
Gingival hyperplasia is problematic for both cosmetic and hygienic reasons. Although no specific treatment is available to reverse gingival hyperplasia, it is recommended that patients intensify oral hygiene measures (eg, flossing and brushing) to minimize disease progression and maintain optimum oral health.
Figure. Erythematous hyperplasia of the maxillary and mandibular gingivae and the alveolar mucosa.1 (Photo credit to William Lawson, MD, DDS)
Note: Dilantin is the most common inducer of gingival hyperplasia. In cases when it is the treatment of choice for seizures, patients may simply have to deal with the condition.
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The Research
A study2 at a Veterans Affairs medical center identified calcium channel blocker antihypertensives as another, much less well-recognized, cause.
Using a case-control methodology, researchers found that the relative risk of gingival hyperplasia was 5 to 10 times greater in patients treated with nifedipine, verapamil, or diltiazem than patients not receiving calcium channel blockers.
Cyclosporin is another etiologic agent—but a much smaller number of persons are exposed to cyclosporin than dilantin.
What’s Causing that Gingival Hyperplasia?2
Although calcium channel blockers are excellent treatment for a variety of disorders (eg, hypertension and rate-slowing in atrial fibrillation), they are usually not the only option. The diversity of available agents for hypertension treatment should allow most persons who suffer gingival hyperplasia on calcium channel blockers to select another form of treatment.
What’s the “Take Home”?
Although pregnancy and dilantin are the 2 most common causes of gingival hyperplasia, calcium channel blockers—especially nifedipine—may also cause it.
Unless there is a specific reason why a calcium channel blocker is required, induction of gingival hyperplasia should suggest switching the patient to another medication.
1. Lawson W. Erythematous oral lesions: when to treat, when to leave alone. Consultant. 2012;52(6):455.
2. Steele RM, Schuna AA, Schreiber RT. Calcium antagonist-induced gingival hyperplasia. Ann Intern Med. 1994;120:663-664.