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Case Report

Amlodipine-induced gingival
overgrowth
M. G. Triveni, C. Rudrakshi, D. S. Mehta

Departments of Abstract:
Periodontology and Gingival overgrowth represents an over-exuberant response to a variety of local and systemic conditions.
Implantology, Bapuji Certain anticonvulsants, immuno-suppressive drugs and a number of calcium channel blockers have been
Dental College and shown to produce similar gingival overgrowths in certain susceptible patients. Amlodipine is a comparatively
Hospital, Davangere, new calcium channel blocker and has been used with increasing frequency in the management of hypertension
Karnataka, India and angina. Although amlodipine is considered as a safe drug, very rarely it may induce gingival overgrowth
also. A rare case of amlodipine-induced gingival overgrowth has been reported herein in a 50-year-old female
patient. The treatment aspect included Phase-1 therapy, substitution of the drug, the surgical excision and the
maintenance and supportive therapy resulting in excellent clinical outcome.
Key words:
Amlodipine, calcium channel blockers, gingival overgrowth

INTRODUCTION Amlodipine is a new dihydropyridine calcium

channel blocker that is used in the management

G ingival overgrowth is one of the most

important clinical features of gingival
pathology. It has multifactorial etiologies and has
of both hypertension and angina. Ellis et al.,[4] first
reported gingival sequestration of amlodipine
and amlodipine-induced gingival overgrowth.
been frequently associated with inflammatory Since then, very few isolated cases of AIGO have
changes in the gingiva. Other factors related to this appeared in the dental literature although there
condition are hereditary (familial), malignancies are numerous reports of nifedipine (another
and those resulting from adverse effects associated member of calcium channel blockers)-induced
with systemic administration of certain drugs.[1] gingival overgrowth till date.

Drug-induced gingival overgrowth (DIGO) Clinical manifestations of gingival enlargement

remains a significant problem for the dental frequently appear within one to three months,
clinicians and the periodontologists. Patients after initiation of treatment with the associated
medicated with certain drugs may be implicated medications. Gingival overgrowth normally
in this unwanted side effect (DIGO), which may begins at the interdental papillae and is more
interfere with esthetics, mastication or speech. frequently found in the anterior segment of the
Disfiguring gingival overgrowth triggered by these labial surfaces. Gradually, gingival lobulations
medications is not only esthetically displeasing but are formed that may appear inflamed or fibrotic
also often impairing nutrition and access for oral in nature depending on the degree of local
hygiene resulting in an increased susceptibility to factor‑induced inflammation. However, the
oral infection, caries and periodontal diseases.[2] fibrotic enlargement is normally confined to
Address for the attached gingiva, but may extend coronally
correspondence: causing the extensive disfigurement of gingiva.
An increasing number of medications are
Dr. D. S. Mehta,
associated with gingival overgrowth. Currently,
Department of In the present report, a case of amlodipine‑induced
Periodontology and more than 20 prescription medications are
associated with gingival enlargement.[3] Drugs gingival overgrowth has been presented wherein
Implantology, Bapuji
Dental college and associated with gingival overgrowth can the AIGO was treated in the following phases:
Hospital, Davangaree - be broadly divided into three categories: (1) thorough Phase-1 therapy, (2) substitution
577004, Karnataka, India. Anticonvulsants, calcium channel blockers, of the drug, (3) surgical excision of the residual
E-mail: dsmehta99@ and immunosuppressants. Although the gingival overgrowth and (4) maintenance and
rediffmail.com pharmacologic effect of each of these drugs is supportive therapy.
different and directed toward various primary
Submission: 14-10-08
Accepted: 30-12-09 target tissues, all of them seem to act similarly CASE REPORT
on a secondary target tissue, that is, the gingival
DOI: 10.4103/0972- connective tissue causing common clinical and A 50-year-old female patient came to the
124X.60231 histopathological findings. Department of Periodontics, Bapuji Dental

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Triveni, et al.: Amlodipine induced gingival overgrowth

College and Hospital, Davangere with the chief complaint contour giving the patient an esthetically pleasing appearance
of enlarged gums in the upper and lower front tooth region [Figures 5 and 6].
for three months. Patient was not aware of such growth until
three months back when she noticed a small bead-like nodular DISCUSSION
enlargement of the gums that gradually progressed to the
present size covering almost the entire front teeth. Enlargement ‘Gingival overgrowth’ or ‘gingival enlargement’ is the
was not associated with bleeding from the gums and loosening preferred term for many of these medication-related gingival
of teeth. Her past medical history revealed that the patient was conditions previously labeled as gingival hyperplasia or gingival
hypertensive for last four years and was under medication hypertrophy. These earlier terms do not accurately reflect our
(Amlodipine 5 mg, once daily). However, her past dental current understanding of the macroscopically enlarged and
history was noncontributory. histologically altered gingiva. Drugs associated with gingival
overgrowth can be broadly categorized into three major groups
Her personal history reveled that she was a regular betel nut according to their therapeutic actions, namely, anticonvulsants,
chewer. She used to clean her teeth once daily with brush immunosuppressants and calcium channel blockers.[3]
and paste, which she discontinued recently because of the
coverage of teeth with the enlarged gums. Her general physical The widespread use of calcium channel blockers began in
examination revealed that the patient was moderately built 1980s. The dihydropyridones (e.g. nifedipine) tend to be more
and her vital signs were within the normal range. There were commonly associated with the gingival enlargement than
no significant extraoral findings. with other sub groups of calcium channel antagonists such
as amlodipine. Prescription of calcium channel blockers is
On intraoral examination, marginal and interdental gingival relatively common, making it difficult to determine the true
enlargement was well appreciated covering almost coronal incidence of drug-induced gingival enlargement.
one‑third of maxillary and mandibular anterior teeth
[Figures 1 and 2]. Gingiva was pink in colour with erythematous Amlodipine is a third generation dihydropyridine calcium
area and lobulated surface. Margins of the gingiva were rolled antagonist, which has a mode of action pharmacodynamically
out with loss of normal gingival scalloping. On palpation, comparable to nifedipine. [5] However, amlodipine has a
gingiva was firm and resilient in consistency. Hypertrophied unique physiochemical profile, which is characterized by near
areas were painless and did not bleed on touch. Poor oral complete absorption, late-peak plasma concentrations, high
hygiene status of the patient was assessed from the presence bioavailability and slow hepatic biodegradation. The associated
of local irritating factors contributing to the mild inflammatory slow elimination of amlodipine with resulting long duration
component of the gingival enlargement. The probing of of its action means that only a single-daily dose is required.
gingival sulcus revealed presence of pseudo-pockets and This in turn results in better patient compliance and has until
elicited the bleeding. now been associated with similar or reduced severity of side
effects compared with nifedipine.[5,6]
Patient was subjected to complete hemogram and all
the parameters were found to be within normal range. Patients taking nifedipine appear to be at increased risk for
Orthopantomogram revealed complete set of dentition with developing significant overgrowth than those on amlodipine.
generalized bone loss. Histopathological report revealed The difference between nifedipine and amlodipine is of interest,
mixture of dense and loose fibrous component with as both drugs are dihydropyridones and hence structurally
inflammatory cell infiltrate and few areas of calcifications in similar. Also, both are secreted in the gingival crevicular fluid,
the stroma. On the basis of the patient’s history and clinical but differ in their physico-chemical profile. Amlodipine is more
features, a clinical diagnosis of amlodipine induced gingival polar than the other dihydropyridones, with a pKa value of 8.7.
overgrowth (AIGO) was made. In contrast, nifedipine is intensely lipophilic and will readily
dissolve within the cell membrane and pass into the cytoplasm.
The treatment of the patient was started with nonsurgical While the mechanism of drug-induced gingival overgrowth is
approach. Patient was subjected to Phase-1 therapy including considered to be multifactorial, the drug/cellular interaction
the planned sessions of scaling and root planing. Patient’s is pivotal in the pathogenesis of this effect.[7]
physician was consulted regarding drug substitution or
withdrawal of the drug. The physician substituted the drug The clinician should emphasize plaque control as the first
with tab. Normadate 100 mg (Labetolol). Patient was instructed step in the treatment of drug-induced gingival enlargement.
to maintain good oral hygiene with the use of chlorhexidine Although the exact role played by bacterial plaque in
oral rinses. drug‑induced gingival enlargement is unclear, there is evidence
that elimination of local factors and regular maintenance of
A dramatic response was noticed after three months of good oral hygiene decrease the degree and severity of the
drug substitution and maintenance of regular oral hygiene. gingival enlargement and improve the overall gingival health.
There was regression in the size of gingival enlargement Usually, a three-month interval for periodontal maintenance
with minimal of fibrotic component left [Figure 3]. Finally, therapy has been recommended in DIGO.
surgical excision of gingival hyperplastic tissue was planned
employing the techniques of gingivectomy/gingivoplasty to The treatment options for drug-induced gingival enlargement
restore the normal shape and contour of the gingiva [Figure 4]. should be based on the medication being used and the clinical
Postoperatively, there was successful elimination of enlarged presentation of the individual case. First, consideration
gingival tissue and restoration of a physiological gingival should be given to the possibility of discontinuing or

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Triveni, et al.: Amlodipine induced gingival overgrowth

Figure 1: Preoperative view showing extensive gingival overgrowth (facial view) Figure 2: Preoperative view showing gingival overgrowth in lingual side of lower
anteriors (lingual view)

Figure 3: Three months after change of drug Figure 4: Immediate postoperative view after gingivectomy and gingivoplast

Figure 5: Three months postsurgically (facial view) Figure 6: Three months postsurgically (lingual view)

substituting the drug. Either of those scenarios should Consideration may be given to the use of another class of
be examined in consultation with the patient’s physician. antihypertensive medications, which are known to be not-
Simple discontinuation of the offending agent is usually not associated with the gingival enlargement. In the present case,
a practical solution. However, its replacement with another substitute drug, that is, Normadate 100 mg along with Phase-1
medication might be the practical solution. It may take therapy resulted in clinically significant improvement in six
from 1 to 8 weeks for resolution of gingival overgrowth. weeks time.

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Triveni, et al.: Amlodipine induced gingival overgrowth

The need for, and timing of, any surgical intervention needs 2007;122:23-4.
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alternative. In the present report, as the gingival overgrowth Gingival sequestration of amlodipine and amlodipine-induced
gingival overgrowth (letter). Lancet 1993;341:1102-3.
was not associated with the true periodontal pockets and
5. Jorgensen MG. Prevalence of amlodipine-related gingival
the osseous defects, external bevel gingivectomy followed
hyperplasia. J Periodontol 1997;68:676-8.
by gingivoplasty was carried out. The postoperative results
6. Seymour RA, Ellis JS, Thomason JM, Monkman S, Idle JR.
were found to be extremely satisfactory both esthetically and Amlodipine-induced gingival overgrowth. J Clin Periodontol
functionally. 1994;21:281-3.
7. Dongari A, McDonell TH, Langlais RP. Drug induced gingival
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1. Bhatia V, Mittal A, Parida AK, Talwar R, Kaul U. Amlodipine Source of Support: Nil, Conflict of Interest: None declared.
induced gingival hyperplasia: A rare entity. Int J Cardiol

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