Drug-induced Gingival Enlargement Research Articles

Nuclear receptor 4A1 (NR4A1) upregulated by n-butylidenephthalide via the mitogen-activated protein kinase (MAPK) pathway ameliorates drug-induced gingival enlargement.

Drug-induced gingival enlargement (DIGE) is a side effect of ciclosporin, calcium channel blockers, and phenytoin. DIGE is a serious disease that leads to masticatory and esthetic disorders, severe caries, and periodontitis but currently has no standard treatment. We recently reported that nuclear receptor 4A1 (NR4A1) is a potential therapeutic target for DIGE. This study aimed to evaluate the therapeutic effects of n-butylidenephthalide (BP), which increases the expression of NR4A1, on DIGE. In this study, NR4A1 mRNA expression was analyzed in the patients with periodontal disease (PD) and DIGE. We evaluated the effect of BP on NR4A1 expression in gingival fibroblasts and in a DIGE mouse model. RNA sequencing (RNA-seq) was conducted to identify the mechanisms by which BP increases NR4A1 expression. The results showed that NR4A1 mRNA expression in the patients with DIGE was significantly lower than the patients with PD. BP suppressed the upregulation of COL1A1 expression, which was upregulated by TGF-β. BP also ameliorated gingival overgrowth in DIGE mice and reduced Col1a1 and Pai1 expression. BP also decreased Il1β mRNA expression in gingival tissue in DIGE. RNA-seq results showed an increase in the expression of several genes related to mitogen-activated protein kinase including DUSP genes in gingival fibroblasts stimulated by BP. Treatment with ERK and JNK inhibitors suppressed the BP-induced increase in NR4A1 expression. In addition, BP promoted the phosphorylation of ERK in gingival fibroblasts. In conclusion, BP increases NR4A1 expression in gingival fibroblasts through ERK and JNK signaling, demonstrating its potential as a preventive and therapeutic agent against DIGE.

What are the main oral manifestations in heart transplant patients? A scoping review.

The purpose of this scoping review is to evaluate the oral manifestations (OM) of heart transplant (HT) patients undergoing immunosuppressive therapy (IT). A literature search was performed using keywords and MeSH terms related to OM and HT in the Medline/PubMed, Web of Science, Cochrane Library, Scopus, LILACS/BBO databases and in gray literature without language or date restrictions until June 2023. Studies that evaluated HT individuals who used any IT and who reported the occurrence of OM were considered eligible. The results from the search were imported to EndNote Web, and duplicates were removed followed by title/abstract and full-text analysis. A total of 402 nonduplicated studies were found and 13 fulfilled the criteria and were included in the present review: 10 cross-sectional, 2 cohorts, and 1 clinical trial. The most reported OM were periodontal diseases, including drug-induced gingival enlargement (DIGE), gingival bleeding, gingivitis, and periodontitis. Reported in a minority of studies are oral cancer, opportunistic infections (oral hairy leukoplakia and erythematous candidiasis), enamel defects, and burning mouth. Considering the methodological heterogeneity of the studies analyzed, DIGE is the most commonly observed oral manifestation in HT individuals.

Evaluation of The Awareness of Medical Practitioners About Drug-Induced Gingival Enlargement: A Preliminary Study

Objective: Gingival enlargement is a clinical condition characterized by hyperplasia and hypertrophy, which has an etiology of inflammation originating from dental plaque, hormones, genetics, malignant or benign lesions, and drugs. The drugs causing gingival enlargement include anti-convulsants, calcium channel blockers, immunosuppressants, and high-dose oral contraceptives. This study aimed to investigate the awareness of specialist and practitioner medical doctors about the drugs causing gingival enlargement. Material and Methods: A total of 100 respondents participated in this questionnaire study. A self-reported questionnaire was formed to evaluate the awareness of the study participants about drugs causing gingival enlargement. The questionnaire was prepared online using Google forms and was introduced and distributed on the social networks of Facebook and WhatsApp. Results: % 27 of the respondents reported that anti-convulsants caused gingival enlargement, followed by immunosuppressants at the rate of 23%, calcium channel blockers at 19%, and oral contraceptives at 11%. Although there is no consensus in the literature that antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) cause gingival enlargement, 9.2% of the study respondents reported that antibiotics caused gingival enlargement, 4.3% NSAIDs, and 5.4% antidepressants. Conclusion: In studies evaluating the awareness of healthcare personnel about drug adverse effects, it has been shown that personnel have knowledge on this subject, but do not report this at a sufficient level. The results of this study suggest that specialist and practitioner medical doctors had insufficient awareness about drugs causing gingival enlargement.

Amlodipine-Induced Gingival Enlargement – A Case Report

One of the etiological factors for Gingival Enlargement is administration of certain drugs like calcium channel blockers, anticonvulsants, and immunosuppressant. The drug that is been commonly used for the management of portal hypertension is calcium channel blockers. Among the various drugs in calcium channel blockers, the occurrence of drug-induced gingival enlargement is high with the use of nifedipine drug whereas the occurrence of gingival enlargement due to the usage of amlodipine drug is a very rare phenomenon. Amlodipine is a third-generation drug belonging to dihydropyridine calcium channel blocker that has been used for its longer duration of action. Treatment for drug-induced gingival enlargement includes referral of patients to their physician for possible drug substitution or alteration in dosage of drug, periodontal therapy that includes oral prophylaxis followed by gingivectomy or gingivoplasty, and maintenance care. In this study, we report a case of gingival enlargement in a 44-year-old female patient taking amlodipine drug for a period of six months and nonsurgical and surgical management of amlodipine-induced gingival enlargement in the patient.

Systemic Observation-Surgical Periodontic Approach In The Management Of Amlodipine Induced Gingival Enlargement

Background: Drug induced gingival enlargement is frequently observed in patients taking three main group of drugs like calcium channel blockers (CCBs), immunosuppressant’s and anticonvulsants. Amlodipine belongs to the dihydropyridine-a third generation calcium channel blockers agents that may cause the side effect of drug-induced gingival enlargement and oral bacteria intervention due to calculus retention. This case report describes the management of gingival enlargement in a hypertensive patient taking amlodipine. Purpose: This case report was aimed to discuss the treatment and maintenance of systemic observationsurgical periodontic approach to restore gingival enlargement. Case Report: A 47-years old man was referred to the Department of Periodontology, Faculty of Dentistry, Airlangga University complaining of swellings and bleeding on his gingiva in all region. He felt very uncomfortable as the swelling interfered while chewing and sometimes there was bleeding spontaneously and halitosis. He had hypertension since 5 years and was on medications Captopril 12,5 mg daily during 4 years and Amlodipine 5mg daily during last 1 year. A provisional diagnosis and systemic observation-periodontal phases treatment were taken to restore gingival enlargement condition. Case Management: Systemic observation of medication use, periodontal phases treatment such as scaling root planning, periodontal surgery as flap surgery, home oral hygiene maintenance, control recall every month during first 3 months were taken. Conclusion: The successful of combination carefully systemic observation-surgery periodontal approach are promising to maintain Amlodipine induced gingival enlargement.

Dermatoglyphics: The elusive nexus decoding the conundrum of amlodipine-induced gingival enlargement – A cross-sectional, pilot, observational study

Abstract: Background: Dermatoglyphics is a scientific study dealing with the dermal ridge configurations of the palmar and plantar surfaces of the upper and lower limbs. Drug-induced gingival enlargement refers to engorgements in gingiva as a consequence of drug usage. This pilot study was done to see the pattern of fingerprints using dermatoglyphics and amlodipine-induced gingival enlargement in hypertensive patients. Materials and Methods: The subjects for the study were prospectively recruited from the outpatients reporting to the Department of Periodontology, Tamil Nadu Government Dental College during the study period of 3 months following the inclusion criteria. Twenty people presenting with amlodipine induced gingival enlargement were thus recruited for the study and their fingerprint patterns were recorded and analyzed with the assistance of magnifying lens. Results: It was thus observed that there was a preponderance of whorls (55%) while observing fingerprint patterns of the recipients of amlodipine presenting with gingival enlargement. Females outnumbered males in the study. The gender difference was seen in the type of fingerprint. A preponderance of whorls (55%, 11 participants) 30% arch (6 participants) and 15% with loop (3 participants). Similar results were recorded in both genders with whorl recording the highest incidence of 80% and 46.67% in males and females, respectively. No zero loop patterns were recorded in males. Conclusion: The relative preponderance of whorls being observed in this study might be a predictive marker for those amlodipine consumers with a heightened predilection to develop gingival enlargement The subdued expression of loops which are otherwise the most commonly expressed fingerprint pattern among the humans, and the ascendancy of whorls characterizing this category of people is indeed a finding, which by further supportive studies, could help find preventive strategies to combat amlodipine-induced gingival enlargement.

Management of initial and surgical management of amlodipine-induced gingival enlargement with multifactorial etiology: a case report with 6 months follow-up

Drug-induced gingival enlargement can be seen as a side effect of systemically used drugs such as calcium channel blockers, anticonvulsants, and immunosuppressants. One of these drugs is amlodipine, a dihydropyridine derivative calcium channel blocker used in the treatment of high blood pressure and coronary artery disease. Amlodipine-induced gingival overgrowth is rarely seen compared to other calcium channel blockers. The aim of this case is to present the diagnosis of gingival overgrowth due to amlodipine use and the identification of other etiologic factors such as labial frenulum, phase 1 initial, and phase 2 surgical treatment approaches. A 56-year-old female patient presented to our clinic with severe gingival overgrowth, intense bleeding, difficulty feeding, and pain. The anamnesis revealed that she had hypertension and had been taking amlodipine derivative Norvasc 10 mg once a day for 8 years. A look inside the mouth showed that there was a lot of gum tissue growing over the crowns from the labial and palatal sides, mainly in the front of the maxilla. Phase 1 treatment was initiated. As a result of the consultation with the patient's cardiologist, the hypertension medication Norvasc 10 mg was replaced with Candexil 16 mg by the medical physician. The preoperative tension and blanch test was positive, and the labial frenulum was seen to mobilize the free gingival margin of the central teeth. After the same session of gingivoplasty, the labial frenulum was removed by a frenectomy operation. After the operation, antibiotics, analgesics, and mouthwash were prescribed. The patient stated that he did not have any problems after the operation. 6-month follow-up showed uneventful healing. No recurrence of gingival growth was found in the 1st, 3rd, and 6th month follow-ups. In conclusion, this case report shows that non-surgical periodontal treatment alone isn't always enough to treat drug-induced gingival overgrowths. The gingival shape should be changed so that the patient can properly clean their teeth, and drug-induced gingival overgrowths, like the one in this case, may have more than one cause and may need additional surgery like a labial frenectomy.

Drug-Induced Gingival Enlargement- A Practical Insight Into its Etiopathogenesis and Management

Drug-induced gingival enlargements are a familiar finding in a dental setup. They are seen especially in the patient on anti-convulsant, immunosuppressive, and calcium channel blockers therapy. Amlodipine used primarily as a monotherapy or in combination therapy in the management of a trailing disease like hypertension is associated with gingival enlargement constantly. This case report unveils the management of amlodipine-induced gingival enlargement and accentuates the important considerations regarding etiopathogenesis and practical ways of managing the case on a daily basis.

Drug-induced gingival enlargement – Oral implications for prescribing physicians

A male patient presented with a main complaint of persistent growth of the upper and lower gingiva that bled easily and resulted in an inability of maintaining proper oral hygiene. He reports that the growth of the gingiva started approximately three years prior to consultation in our clinic and is asymptomatic. His medical history revealed that he suffers from epilepsy and was being treated with a daily anticonvulsant, namely Phenytoin (100mg). Full-mouth non-surgical periodontal therapy was performed and supplemented with an adjunctive chlorhexidine mouth rinse as a chemical plaque control mechanism. Part of the systemic phaseof management of the patient, involved requesting the medical physician change the current epilepsy medication to Epilim®, which was benefi cial in contributing to the resolution of gingival enlargement. Signifi cant reduction in gingival infl ammation and enlargement were achieved with the non-surgical treatment.Corrective surgery therapy was performed to treat those areas of DIGE that had not resolved.

Calcium channel blocker induced gingival enlargement following implant placement in a fibula free flap reconstruction of the mandible: a case report

BackgroundGingival tissue enlargement is a common side effect of antiepileptic medications (e.g. phenytoin and sodium valproate), immunosuppressing drugs (e.g. cyclosporine) and calcium channel blockers (e.g. nifedipine, verapamil, amlodipine) (Murakami et al. 2018, Clin Periodontol 45:S17–S27, 2018). The clinical and histological appearances of lesions caused by these drugs are indistinguishable from one another (Murakami et al. 2018, Clin Periodontol 45:S17–S27, 2018). Drug-induced gingival enlargement is rarely seen in edentulous patients.Case presentationThis case presents a 72-year-old female with a history of squamous cell carcinoma of the floor of the mouth treated with surgical excision and fibula-free flap reconstruction. Following the uncovering of osseointegrated implants placed in the fibular-free flap, the patient developed gingival enlargement of the floor of the mouth. Cessation of amlodipine and switching to an alternative medication lead to a resolution of the enlarged tissue.ConclusionsThis case illustrates that gingival enlargement can occur around dental implants, most notably in rehabilitation cases in patients who have had head and neck cancer. Clinicians should be aware of the risk of gingival enlargement in hypertensive patients taking calcium channel blockers prior to implant placement.

Follicular dendritic cell-secreted protein gene expression is upregulated and spread in nifedipine-induced gingival overgrowth.

Follicular dendritic cell-secreted protein (FDC-SP) is secreted protein expressed in follicular dendritic cells, periodontal ligament and junctional epithelium (JE). Its expression could be controlled during inflammatory process of gingiva; however, responsible mechanism for gingival overgrowth and involvement of FDC-SP in clinical condition is still unclear. We hypothesized that JE-specific genes are associated with the initiation of drug-induced gingival enlargement (DIGE) called gingival overgrowth, and investigated the changes of JE-specific gene's expression and their localization in overgrown gingiva from the patients. Immunohistochemical analysis revealed that the FDC-SP localization was spread in overgrown gingival tissues. FDC-SP mRNA levels in GE1 and Ca9-22 cells were increased by time-dependent nifedipine treatments, similar to other JE-specific genes, such as Amelotin (Amtn) and Lamininβ3 subunit (Lamβ3), whereas type 4 collagen (Col4) mRNA levels were decreased. Immunocytochemical analysis showed that FDC-SP, AMTN, and Lamβ3 protein levels were increased in GE1 and Ca9-22 cells. Transient transfection analyses were performed using luciferase constructs including various lengths of human FDC-SP gene promoter, nifedipine increased luciferase activities of -345 and -948FDC-SP constructs. These results raise the possibility that the nifedipine-induced FDC-SP may be related to the mechanism responsible for gingival overgrowth does not occur at edentulous jaw ridges.

Drug-induced gingival enlargement in a hypertensive patient with chronic smoking behavior - A case report

Drug-induced gingival enlargement in a hypertensive patient with chronic smoking behavior - A case report

An ounce of protection is worth a pound of cure: Periodontal management of Phenyto-in Induced Gingival Enlargement

Gingival enlargement (GE) is a condition of apprehension for both the patient and the doctor. GE can be due to inflammatory, idiopathic or drug induced. Drug induced gingival enlargement (DIGE) is an undesirable side effect resulting from intake of drugs like calcium channel blocker, immunosuppressant and anticonvulsants. Phenytoin an anticonvulsant drug has been associated with a characteristic oral presentation known as Pheny-toin induced gingival enlargement (PIGE). Clinicians need to be aware of the possible side effects of Phenytoin and the treatment options available in order to minimize chances of gingival enlargement. The present case report shows the management of PIGE in a 25yr old female patient with Periodontal therapy by nonsurgical and surgical treatment approach. Key Words: Gingival enlargement, Drug induced gingival enlargement, Phenytoin induced gingival enlarge-ment

Interdisciplinary approach in the management of medically compromised patient with drug-induced gingival enlargement

Drug-induced gingival overgrowth (DIGO) is one of the most common side effects of three important groups of drugs such as anticonvulsants, calcium channel blockers, and immunosuppressants. Calcium channel blockers are the important group of drugs in the management of cardiovascular diseases; however, they are associated with certain side effects such as DIGO in susceptible individuals. Nifedipine is the frequently involved drug; however, there are few cases of amlodipine-induced gingival enlargement as well. The case reported here is a 55-year-old medically compromised male patient on polypharmacy. Based on the clinical, radiographic investigations and medical history, he was diagnosed as having drug-induced gingival enlargement with chronic generalized periodontitis. The case was managed by nonsurgical periodontal therapy alone in addition to interdisciplinary approach and strict supportive periodontal therapy, which resulted in complete resolution of the gingival enlargement with restoration of normal gingival health.

Drug-induced gingival enlargement: A case report

Gingival overgrowth is associated with multiple factors including congenital diseases, hormonal disturbances, poor oral hygiene condition, inflammation, neoplastic conditions, and adverse drug reactions including anticonvulsants, calcium channel blockers, and immunosuppressants. This can have a detrimental effect on the quality of life and also on high oral bacterial load caused by plaque-retentive areas. Various treatment modalities include both surgical (gingivectomy, periodontal flap, electrosurgery, and laser excision) and nonsurgical approaches (oral hygiene measures, scaling and root planing, discontinuation of the drug, or the replacement of the drug with other alternative).

Nonsurgical periodontal treatment and prosthetic rehabilitation of a renal transplant patient with gingival enlargement: a case report with 2-year follow-up

BackgroundDrug-induced gingival enlargement is a common condition which can be observed in patients taking immunosuppressive medications following organ transplant surgery. The disfiguring excessive tissue often hinders proper oral hygiene practices, therefore accompanied by periodontitis, tooth mobility, and even pathological tooth migration in extreme cases. This case report presents a conservative treatment protocol for a patient with the aforementioned conditions involving neither surgical nor orthodontic intervention. Few related studies have reported such a noninvasive protocol for managing these kinds of conditions.Case presentationA 51-year-old woman presented with bleeding gingiva, mobile teeth and complained of chewing difficulties. She had undergone renal transplant surgery 16 years prior to this dental visit and had been taking immunosuppressive drugs including cyclosporine ever since. After clinical and radiographic examinations, the patient was diagnosed with drug-induced gingival enlargement, pathological tooth migration, severe periodontitis, and missing teeth. Through careful and meticulous nonsurgical debridement, oral hygiene instruction, tooth extraction, and occlusal adjustment, the patient’s periodontium was restored to a healthy state without surgical intervention. Moreover, the patient’s chewing function was restored by means of removable partial dentures. Good adaptation of prostheses and satisfaction with overall treatment outcomes were reported.ConclusionsThrough proper diagnosis, treatment, and with good patient cooperation, complex systemic and dental problems can be managed conservatively without invasive surgeries to attain a stable periodontium and eventually, occlusal function could be restored.

Phenytoin activates Smad3 phosphorylation and periostin expression in drug-induced gingival enlargement.

Drug-induced gingival enlargement (DIGE) is a fibrotic condition associated with systemic administration of the anti-epileptic drug, phenytoin. We have previously demonstrated that periostin, which is transforming growth factor-beta (TGF-β) inducible gene, is upregulated in various fibrotic conditions including gingival enlargement associated with nifedipine. The objective of this study was to assess periostin expression in phenytoin-induced gingival enlargement (PIGE) tissues and to investigate the mechanisms underlying periostin expression. Human PIGE tissues were assessed using Masson's trichrome, with cell infiltration and changes in extracellular matrix composition characterized through labeling with antibodies to periostin, phospho-SMAD 3, TGF-β, as well as the macrophage markers CD68 and RM3/1. Using human gingival fibroblasts (HGFs) in vitro we examined the pathways through which phenytoin acts on fibroblasts. In PIGE tissues, which demonstrate altered collagen organization and increased inflammatory cell infiltration, periostin protein was increased compared with healthy tissues. p-SMAD2/3, the transcription factor associated with canonical TGF-β signaling, is localized to the nuclei in both gingival fibroblasts and oral epithelial cells in PIGE tissues, but not in healthy tissue. In vitro culture of HGFs with 15 and 30 μg/ml of phenytoin increased periostin protein levels, which correlated with p-SMAD3 phosphorylation. Inhibition of canonical TGF-β signaling with SB431542 significantly reduced phenytoin induction of SMAD3 phosphorylation and periostin expression in HGFs. Analysis of PIGE tissues showed a subset of CD68 stained macrophages were TGF-β positive and that RM1/3 regenerative macrophages were present in the tissues. Our results demonstrate that phenytoin up-regulates periostin in HGFs in a TGF-β-dependent manner.

Using Evidence-Based Dentistry in the Clinical Management of Combined Periodontal Conditions

ObjectiveThis report proposes a framework to integrate evidence-based dentistry (EBD) in a systematic approach in the clinical management of a patient diagnosed with drug-induced gingival hyperplasia combined with generalized aggressive periodontitis.This report illustrates the case of a 37-year-old female who presented to the Department of Periodontology at Tufts University School of Dental Medicine with enlarged, tender, bleeding gums, and loose teeth combined with a history of uncontrolled hypertension treated with calcium channel blockers. MethodsIncorporating the EBD process, a new 5-step framework is proposed: ask the clinical question, acquire and appraise the evidence, apply it in the clinical setting, and assess the subjective and objective outcomes. Articles on aggressive periodontitis and/or gingival enlargement were sought using the assistance of an expert librarian. The search was conducted on the PubMed, Embase, and Scopus databases. ResultsInitial literature search identified 34 publications. Articles were reviewed by 2 clinicians, and 31 relevant articles were selected. Twenty-six of the references matched the levels of evidence initially agreed upon. Based on the scientific evidence, patient's chief complaint, and clinical expertise, a decision tree highlighting treatment options was compiled. The outcomes of the clinical management revealed that combined conditions can be successfully treated with nonsurgical therapy before proceeding with surgical therapy. ConclusionWithin the limitations of this study, integrating EBD concepts was a reliable method to treat an atypical case, where 2 severe periodontal conditions were combined: drug-induced gingival enlargement and generalized aggressive periodontitis.

Oral shedding of HSV-1 and EBV and oral manifestations in paediatric chronic kidney disease patients and renal transplant recipients

Objective: Previous research demonstrated that salivary shedding of HSV-1 and EBV occurs often in adult renal transplant recipients, but there is a lack of studies on the presence of them in the saliva of paediatric population. Therefore, the objective of this study is to describe oral characteristics and to compare the shedding profile of HSV-1 and EBV in the saliva of children with renal transplant to that of chronic kidney disease patients and controls.Methods: This is a cross-sectional study involving 100 children, being 25 renal transplant recipients, 25 chronic kidney disease patients and 50 healthy children. Demographic and oral clinical characteristics were assessed. Saliva samples were collected and submitted to screening for EBV and HSV-1 by using nested polymerase chain reaction technique. Fisher’s exact, Pearson’s chi-square and Kruskal–Wallis tests were used for statistical analysis at a significance level of 5%.Results: Oral shedding of HSV-1 (28%) and EBV (60%) were significantly higher in renal transplant recipients compared to the other groups. Single vesicles in the oral mucosa were statistically associated with the presence of HSV-1 (p = .035). In children with chronic kidney disease, there was a higher prevalence of pale oral mucosa (32%) and enamel hypoplasia (40%) compared to paediatric renal transplant recipients and controls. Dental calculus (36%), candidiasis (8%), drug-induced gingival overgrowth (16%), mouth blisters (8%), xerostomia (12%) and salivary gland enlargement (20%) were more common in paediatric renal transplant recipients.Conclusions: Therefore, it can be concluded that salivary shedding of HSV-1 and EBV in paediatric patients was more often found in renal transplant recipients than in the renal failure and control children. Transplanted recipients showed more oral manifestations than renal failure and control children did.

Agrandamiento gingival farmacoinducido: Serie de casos

Introducción: El agrandamiento gingival (AG) es una condición benigna de la cavidad oral que se caracteriza por el crecimiento excesivo en masa y volumen de la gingiva. Esta lesión no es únicamente provocada por factores hereditarios ni de deficiente higiene oral, sino también por ingesta de medicamentos, entre los cuales se encuentran fármacos antihipertensivos, anticonvulsivantes e inmunosupresores. Objetivo: Sensibilizar respecto a la prevención o atención temprana en pacientes con patologías que ameritan el uso de antihipertensivos y anticonvulsivantes, conjuntamente con el odontólogo para tratar o evitar el agrandamiento gingival farmacioinducido (AGFI) Materiales y métodos: Se reporta una serie de casos clínicos de pacientes con agrandamiento gingival por distintos fármacos, entre los que se encuentran fenitoina, amlodipino y nifedipino; se aplicaron medidas de fase higiénica periodontal y gingivectomía para obtener mejores efectos. Resultados: Se obtuvieron resultados satisfactorios con una disminución considerable del AGFI. Conclusiones: Es importante el manejo integral en conjunto con el médico tratante para realizar seguimiento del fármaco que pueda encontrarse generando agrandamiento gingival. Emplear un abordaje inicial con estrategias de higiene periodontal, y en casos severos y como último recurso la intervención quirúrgica periodontal con gingivectomía y gingivoplastia.