Hindawi

Case Reports in Dentistry

Volume 2021, Article ID 4120148, 7 pages
https://doi.org/10.1155/2021/4120148

Case Report
Necrotizing Ulcerative Gingivitis, a Rare Manifestation as a
Sequel of Drug-Induced Gingival Overgrowth: A Case Report

Marah Damdoum ,1 Sudhir Rama Varma ,1,2 Mohamed A. Jaber ,1,2

and Manjusha Nambiar 3
1
Department of Clinical Sciences, College of Dentistry, Ajman University, Ajman, UAE
2
Centre of Medical and Biomedical Allied Health Sciences Research, Ajman University, Ajman, UAE
3
Department of Periodontics, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Banguluru, Karnataka State 560032, India

Correspondence should be addressed to Marah Damdoum; marahdamdoum@gmail.com

and Sudhir Rama Varma; s.varma@ajman.ac.ae

Received 26 June 2021; Revised 7 August 2021; Accepted 2 September 2021; Published 22 September 2021

Academic Editor: Ronald S. Brown

Copyright © 2021 Marah Damdoum et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. The purpose of this case report is to present a rare case of amlodipine-induced gingival overgrowth with a secondary
formation of necrotizing ulcerative gingivitis involving the upper and lower arches of a 68-year-old female patient with a chief
complaint of “swollen gums and pain on mastication which has been recurring for the past 5 years.” Materials and Methods.
The treatment plan of this case was divided according to quadrants of the mouth. Each week, one quadrant was surgically
excised, and the remaining quadrants were observed for any changes. The gingival overgrowths were excised using a 15 blade,
and debris/plaque was removed with Gracey curettes. Results. Although full-mouth exodontia was performed, the patient
unfortunately suffered with recurrences in GO. These results are suggestive of idiopathic causes of GO. Conclusion. Careful
examination, physician referrals, and biopsy to rule out any specific anomalies and to assist in proper diagnosis are followed by
sequential management of the case results in productive outcomes.

1. Introduction related to DIGO [7–11]. Drug-induced gingival overgrowth

is typically detected after 3 months of drug consumption
Drug-induced gingival overgrowth (DIGO) manifests as a [12]. Clinical features of DIGO could be localized or gen-
result of drug interactions mainly produced by anticonvul- eralized and may range from mild to severe enlargements
sants [1], immunosuppressants [2], and calcium channel of the marginal and papillary gingiva [13]. The anterior
blockers [3]. Several factors including age, sex, genetic predis- region of the mouth is more affected than the posterior
position, systemic diseases, hormonal imbalances, congenital region and is more pronounced on the facial surfaces than the
disorders, poor oral hygiene, and local plaque/debris may palatal/lingual surfaces [14]. DIGO cannot be prevented in
influence the relationship of these drugs to gingival over- susceptible patients but it can be tolerated by regular periodon-
growth [4]. Gingival overgrowths can affect speech, mastica- tal therapy and plaque control [15]. The current case report
tion, and esthetics, and there are various methods of presents a rare case of necrotizing ulcerative gingivitis as a
treatment for excising the excess tissue [5]. These overgrowths secondary reaction to amlodipine-induced gingival overgrowth.
can be classified according to their size and location and
graded between grade 0 and grade III [6] (Table 1). The phar- 2. Pathophysiology
macological action of each drug is different; however, they all
act similarly to secondary tissue receptors by creating enlarge- The mechanism of gingival overgrowth and its contributory
ments in the gingival tissue. The exact mechanism of these mechanism with relation to fibroblastic proliferation are var-
gingival overgrowths in association to drugs is not fully ied. A theory of genetic predisposition was earlier postulated
understood, and there are many hypotheses and theories by Seymour et al. in 1996 [3]. The inflammatory changes
2 Case Reports in Dentistry

Table 1: Bokenkamp and Bohnhorst, 1994 classification.

Grade Clinical findings

Grade 0 No signs of gingival overgrowth
Grade I Gingival hyperplasia confined to interdental papilla
Grade II Hyperplasia of interdental papilla and marginal gingiva
Grade III Gingival hyperplasia covering at least three quarters of tooth crowns

and responses of gingival fibroblasts coupled with connec- Bokenkamp’s 1994 classification for gingival overgrowth
tive tissue matrix proliferation exemplify the fibroblastic [6] (Table 1). Additionally, a yellowish-white pseudomem-
characterization with relation to the various drugs responsi- branous slough was found covering the interdental papilla
ble for this change [16]. Another theory postulated that in the mandibular left area (Figure 2). Radiographically,
bacterial plaque was responsible for gingival inflammation. bone loss can be observed around the teeth and implants;
The drugs responsible for gingival overgrowth causes an however, clinically, the implants are not mobile as sub-
increased production of glycosaminoglycans. The drugs merged (Figure 3). Abrasion of the teeth can be observed
further reduce folate uptake in the cellular matrix. Reduced indicating parafunctional habits, as the patient had given a
folate uptake results in decreased synthesis of matrix metal- history of clenching which was consciously done and also
loproteinases which is responsible for conversion of collage- from her family member, that patient was a bruxer and
nase precursor into mature collagenase, resulting in a matrix exhibited grinding at night. This also confirmed our diagno-
and connective tissue build up. The bacterial plaque when sis as stage 4, grade C periodontitis, currently unstable.
present causes the inflammatory component, thus complet-
ing the cycle [17]. 3.1. Sequence of Treatment. The treatment plan of this case
was divided according to quadrants of the mouth. Each
3. Case Report week, one quadrant was surgically treated with the over-
grown gingival tissue being excised, and the mobile teeth
This case presents a 68-year-old female patient with a chief were extracted. The decision to extract her teeth was from
complaint of swollen gums and pain on mastication which a multidisciplinary point of view involving a periodontist
has been recurring for the past 5 years. According to the and prosthodontist, as salvaging the remaining teeth was
patient, she started taking amlodipine 5 mg/day 7 years ago challenging and time consuming with hopeless prognosis.
and started experiencing enlargements of the gingiva 5 years Since the overgrowths affected mastication, speech, and
ago. She stopped taking amlodipine for 6 months and claims esthetics, a surgical approach (i.e., gingivectomy) was uti-
the enlargements improved. However, her physician recom- lized with local anesthesia being administered. The gingival
mended that she continue taking amlodipine 10 mg/day due overgrowths were excised using a 15 blade; plaque and cal-
to her uncontrolled hypertension. Medical history was culus were removed with Gracey curettes (Dentsply, USA).
taken in which the patient reported having diabetes mellitus After every gingivectomy, azithromycin-xithrone (Amoun
type II and hypercholesterolemia for the past 8 years. She Egypt) 500 mg, diclofenac-rofenac (Bin Sina, UAE) 50 g
takes a series of drugs for her medical conditions sachet, along with chlorhexidine mouthwash (Curasept,
(Table 2). She has been hypertensive for the past 7 years UK), were prescribed. Surgical excision began in quadrant
and has been taking amlodipine since then. She stopped 4, which was the least affected quadrant. An external bevel
amlodipine 2 years ago for 6 months due to gingival over- incision gingivectomy was performed along with scaling
growths; however, amlodipine had to be continued due to and root surface debridement. The gingiva was sutured with
her uncontrolled hypertension. silk (Black Braided, size 4-0, 19 cm, Teleflex, USA). At one-
On taking dental history, it was found that she under- week surgical postop, the following was noted: the gingiva
went multiple gingivectomies in the past with recurrence in the mandibular right quadrant was healing within normal
every few months. During previous episodes, the patient limits. The gingiva in the mandibular left quadrant was
had described the condition as similar to the one presented edematous, fibrous, hemorrhagic, and painful swellings
currently with excruciating pain and pus discharge. Further- which had purulent exudate (Figure 2). An external bevel
more, the patient described the treatment advised as “gum incision gingivectomy was done along with extraction of
shaping by the doctor”. From patient’s explanations, it was #33, #34, #35, and 45 due to extensive grade III mobility
assumed that the clinical picture matched the current situa- (Figures 4 and 5). The mobile teeth were diagnosed as stage
tion, and a history of NUG could have been prevalent at that 4 grade C periodontitis, currently unstable (AAP Classifica-
time period. tion, 2017). Apical curettage was performed, and copious
The patient presented with a dental history that includes irrigation with saline was done. Simple interrupted sutures
thick deposits of calculus and plaque on all remaining teeth were placed with silk. Placement of a periodontal pack along
with fibrous, nodular, hard gingival overgrowths extending with oral hygiene reinforcement instructions was given.
to most of the clinical crown in the anterior and posterior During the follow-up visit the following week, healing was
parts of the maxillary and mandibular arches (Figure 1). uneventful for the most part with slight regression of gingi-
The overgrowths can be classified as grade III according to val overgrowth. Poor oral hygiene can be observed along the
Case Reports in Dentistry 3

Table 2: Drugs taken by the patient.

Name of the drug Dosage Duration Pharmacological action Medical condition

Gliclazide 60 mg 8 years Sulfonylureas Diabetes mellitus type II
Bisoprolol hemifumarate 2.5 mg 1 year Nonselective beta blocker Heart murmurs
Perindopril arginine 5 mg 1 year ACE inhibitor Hypertension
Amlodipine besylate 10 mg 7 years Calcium channel blocker Hypertension
Rosuvastatin 10 mg 8 years HMG-CoA reductase inhibitor Hypercholesterolemia

Figure 3: Panoramic radiograph presenting bone loss around teeth

Figure 1: Fibrous, nodular, hard gingival overgrowths extending to and lower 4-unit implant-retained bridge.
most of the clinical crown in the anterior and posterior parts of the
mandibular arch.
was referred to a cardiologist for a follow-up and possible
substitution of amlodipine. Perindopril indapamide (a
thiazide-like diuretic) was recommended by the cardiologist
as an alternative. The remaining drugs consumed by the
patient continued normally. During the first recall visit after
complete exodontia and drug substitution, the patient
presented with recurrence in the upper and lower arches.
Since gingival overgrowth did not subside after complete
exodontia and drug substitution, it can be assumed that
the submerged implants in the lower anterior region and
upper right posterior region could be the cause for this
recurrence. Treatment modalities were further contemplated
with regard to removal of the submerged implants; however,
after clinical and radiographic assessment, it was further
decided to retain the implants and to put the patient on
follow-up to see if there was a possibility of recurrence.
The patient was put on a strict oral hygiene plan and main-
tenance recall phase every 2 months.
Figure 2: Yellowish-white pseudomembranous slough was found
covering the interdental papilla in the mandibular left area.
4. Results
sutures which were surrounded by plaque and debris
(Figure 6). For the maxillary arch, an external bevel incision This case report presents a rare case of nonhealing AIGO
gingivectomy was done, and extraction of #11, #21, and #12 with a secondary NUG reaction. Two biopsies were taken
was done due to grade III mobility (Figures 7–9). to confirm the diagnosis in which both biopsies revealed
During the follow-up visits, the maxillary arch presented chronic inflammatory processes. For AIGO-associated
with signs of inflammation, pus, and exudates around the conditions, there are a range of treatment modalities that cli-
teeth and sutures (Figure 10). There also seemed to be recur- nicians can explore. The proposed modes of treatment in the
rence of gingival overgrowth around the implant-retained 4 literature include nonsurgical and surgical drug modification
unit bridge in the anterior mandible (Figure 11). The bridge and periodontal therapies. For the current case, all of these
was removed, and implants remained submerged in the modalities were performed, and biopsies were done to
alveolar bone. After bridge removal, azithromycin was pre- confirm NUG as a manifestation of DIGO. Although full-
scribed as reported in earlier literature about its efficiency mouth exodontia was performed, the patient unfortunately
in treating DIGO [18]. During a 2-week follow-up, recur- suffered with recurrences in GO. These results are suggestive
rence of GO was identified in all quadrants. The patient of idiopathic causes of GO.
4 Case Reports in Dentistry

Figure 7: External bevel gingivectomy of the upper right quadrant.

Figure 4: External bevel incision gingivectomy of the lower left
quadrant and exodontia of #33, #34, and #35.

Figure 8: Gingiva removed from the upper left quadrant and

extracted teeth (#11 and #21).

Figure 5: Gingiva removed from the lower left quadrant and

extracted teeth (#33, #34, and #35).

Figure 9: External bevel gingivectomy of the upper left quadrant.

val hyperplasia [4]. Seymour et al. reported in 2000 that

most of the evidence to support a relationship between bac-
Figure 6: 1 week after surgical excision of the lower left quadrant. terial plaque and gingival overgrowth has been derived from
crosssectional studies, and it is not clear whether plaque is a
contributory factor or a consequence of the gingival changes
5. Discussion [4]. A 2015 case report by Mathur et al. took a nonsurgical
approach to their DIGO case. They reported that “there
5.1. Oral Hygiene. Some studies say oral hygiene and local appears to be three significant factors which are important
factors like plaque and calculus can affect the severity of for the expression of these gingival changes, notably drug
gingival overgrowth; however, it is not a requirement for variables, plaque-induced inflammatory changes in gingival
DIGO [4, 19]. A crosssectional study done in 1973 tested tissue, and genetic factors which determine the heterogene-
the association between dilantin-induced gingival over- ity of the fibroblasts” [19]. The gingival overgrowths
growth and oral hygiene. The study did not show that oral subsided after periodontal therapy, and no surgical interven-
hygiene was statistically significant in the formation of gingi- tion was needed. In a 2020 case report by Uppal et al., they
Case Reports in Dentistry 5

Our biopsy showed areas of ulcerations, predominance

of plasma cells (indicating a chronic lesion), along with some
PMNs. The signs and symptoms along with the histopatho-
logical review were suggestive of NUG as a secondary reac-
tion to AIGO. A second biopsy was taken of healthy
gingival tissue, to confirm our diagnosis of AIGO. The
biopsy was received in a labelled container with patient iden-
tification and fixed in formalin, where multiple pieces are
gray brown in color, irregular soft tissue, and measured in
aggregate 1:5 × 1 × 0:2 cm. All submitted in one cassette.
The gingival biopsy revealed squamous epithelium hyperpla-
sia with underlying chronic inflammation (Figures 12 and
13), consistent with a reactive process, and negative for
Figure 10: Recall after 2 weeks of surgical intervention of maxillary hyperkeratosis and atypia. These reports are consistent with
arch. Pus and exudates were observed around teeth and sutures. a secondary inflammatory reaction (NUG) as a manifesta-
Full exodontia was done for the remaining teeth in the upper arch. tion of amlodipine-induced gingival overgrowth [21]. The
current case is similar to a case report where DM type 2,
hypercholesterolemia, and amlodipine for hypertension
were of similar findings. The difference being the time frame
for the presentation, in the current case, was nine months
ago, while in the earlier reported literature, it had presented
after three years of intake of the medication (amlodipine)
[22]. Meanwhile, our patient has had GO for the past 5 years
and experienced the changes in her gingiva almost instantly
after switching back to amlodipine the second time. Interest-
ingly, in the current case, a possible role of statins in the
progression of GO could be attributed as seen from a previ-
Figure 11: 1 month recall after surgical intervention of the ous study where statins and calcium channel blockers when
mandibular arch. Recurrence was presented, and full-mouth
prescribed together resulted in adverse effects, a predomi-
exodontia was done for the lower arch.
nant feature being GO [23].
report a case of DIGO that was treated nonsurgically 5.3. Secondary Reactions. In our case, we reported necrotiz-
through a periodontal approach first and report that “as ing ulcerative gingivitis (NUG) as a secondary reaction to
the enlargement did not subside after drug substitution amlodipine-induced gingival overgrowth. In an earlier study
and phase 1 therapy, surgical phase was planned further” by Vishnusdas et al., they reported a case involving
[20]. There is definitely an unclear definition as to whether amlodipine-induced gingival plasma cell granuloma, and
oral hygiene plays a role in DIGO, but regardless, patient the etiology is multifactorial, with a possible role of drug/cel-
education on oral hygiene and maintenance is crucial in lular interaction playing a contributory role in the pathogen-
every treatment plan. esis of this entity [24]. Another case report done in 2019 by
Gulati et. al found an unusual plasma cell granuloma forma-
5.2. Histopathology. For this case, a biopsy was sent with a tion secondary to GO. This case report states that biopsies
gross description of the tissue sample; it consisted of two for unusual lesions should be comprehensively examined
pieces of gray white to brown tissue measuring 2:0 × 0:8 × regardless of clinical appearance or treatment success rate
0:5 cm and 1:5 × 1:4 × 0:8 cm. in order to rule out neoplasms and plan for treatment
Microscopically, the histopathological sections show accordingly [21]. For this case, a biopsy was sent with a gross
mucosa covered soft tissue with an area of ulceration along description of the tissue sample, it consisted of two pieces of
with granulation tissue. Subepithelial soft tissue is hyalinized gray white to brown tissue measuring 2:0 × 0:8 × 0:5 cm and
and shows a dense infiltrate composed predominantly of 1:5 × 1:4 × 0:8 cm. Microscopically, the histopathological
plasma cells merged with a few lymphocytes, eosinophils, sections show mucosa covered soft tissue with an area of
and neutrophils. These features are consistent with acute on ulceration along with granulation tissue. Subepithelial soft
chronic inflammatory processes. The predominance of tissue is hyalinized and shows a dense infiltrate composed
inflammatory cells indicates that the gingival overgrowth predominantly of plasma cells merged with a few lympho-
was not only caused by a drug induction but rather by pres- cytes, eosinophils, and neutrophils. These features are con-
ence of a secondary condition as well. This secondary condi- sistent with acute on chronic inflammatory processes. The
tion can be identified as necrotizing ulcerative gingivitis. In predominance of inflammatory cells indicates that the gingi-
the literature, the histopathology of NUG has been identified val overgrowth was not only caused by a drug induction, but
as ulcerations with dense infiltrations of PMNs and plasma rather by presence of a secondary condition as well. This
cells which is interpreted as an area of established chronic gin- secondary condition can be identified as necrotizing ulcera-
givitis on which the acute lesion became superimposed [2]. tive gingivitis. In the literature, the histopathology of NUG
6 Case Reports in Dentistry

almost instantly after switching back to amlodipine the sec-

ond time. Interestingly, in the current case, a possible role of
statins in the progression of GO could be attributed as seen
from a previous study where statins and calcium channel
blockers when prescribed together resulted in adverse effects,
a predominant feature being GO [23].

6. Conclusion
DIGO related to calcium channel blockers, immunosuppres-
sants, and anticonvulsants in the past reported clinical pre-
Figure 12: Histopathological slide of gingival biopsy revealed sentations concluded by clinicians as rare entities. The case
squamous epithelium hyperplasia with underlying chronic presented in our study shows the possible effects of
inflammation. amlodipine-induced GO and the challenges dentists can face
in the management of this condition. Careful examination,
physician referrals, and biopsy to rule out any specific anom-
alies and to assist in proper diagnosis are followed by sequen-
tial management of the case results in productive outcomes.

Abbreviations
DIGO: Drug-induced gingival overgrowth
AIGO: Amlodipine-induced gingival overgrowth
GO: Gingival overgrowth
NUG: Necrotizing ulcerative gingivitis
PMN: Polymorphonuclear cells.

Figure 13: Histopathological slide of gingival biopsy revealed Conflicts of Interest

squamous epithelium hyperplasia with underlying chronic
inflammation. The authors declare no conflict of interest.

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