Certain blood pressure, epilepsy and immunosuppressant medicines cause the gums to enlarge. The drug starts it but plaque drives it; how it is brought under control.
Gum growing up over the teeth troubles patients both in appearance and in cleaning. The cause often lies not in the mouth but in a medicine the patient takes regularly — though the key point is that the drug does not produce this picture on its own.
Which medicines are responsible
Three groups of medicine are classically associated with this picture. What they share is that cells in the gum's connective tissue produce more than normal.
- Calcium channel blockers, widely used for blood pressure
- Phenytoin, an antiepileptic used in seizure control
- Ciclosporin, an immunosuppressant used after transplantation
It does not occur in everyone taking these drugs; individual susceptibility decides. It usually appears within the first three months of starting and is more marked at the front of the mouth.
The drug alone is not enough
The most important feature of this picture is that the drug prepares the ground, while what actually triggers the growth is plaque at the gum margin. In patients with very good oral hygiene the same drug produces either no enlargement or only a mild one.
This gives patients grounds for optimism, because stopping the drug is often not possible while plaque control is entirely within their hands. It sits at the centre of treatment.
How it progresses
Growth begins in the triangular section of gum between the teeth. That section thickens and climbs over the tooth. As it advances it merges with neighbouring sections and the visible length of the tooth shortens.
The enlarged tissue closes off the tooth surface beneath it from the brush. Plaque increases in the area that cannot be cleaned, and as plaque increases the growth accelerates. The cycle establishes itself and becomes self-sustaining.
What troubles the patient
The complaints are not limited to appearance. Bleeding on brushing, discomfort while eating, difficulty with speech and chewing, and bad breath are all commonly reported. In advanced cases even the bite can be disturbed.
In children and adolescents concern about appearance carries extra weight; in young people taking antiepileptic medication in particular, this picture can lead to social withdrawal.
The first step: plaque control
Treatment always begins with professional cleaning. Once deposit at the gum margin and within the pocket is removed, part of the enlargement regresses on its own. This is a gain achievable without surgery.
Home care in these patients must exceed the standard: interdental brushes, an antiseptic rinse where indicated, and professional cleaning every three months. Without that programme, any surgery performed relapses quickly.
Can the medicine be changed?
This decision does not belong to the dentist. The patient's own doctor is contacted and asked whether an alternative molecule with the same effect would be suitable. In some patients this is possible and the picture regresses markedly.
Patients must never stop their medication on their own initiative. Interruption in blood pressure, epilepsy and post-transplant treatment carries serious consequences; a gum problem does not warrant that risk.
When surgery is needed
Where growth continues despite cleaning and improved hygiene, the excess tissue is removed surgically. The procedure is done under local anaesthetic and the gum is reshaped to its natural contour.
As long as the medicine continues, however, recurrence remains possible. Surgery is therefore planned as part of a strict maintenance programme rather than on its own. In patients who keep to that programme the recurrence rate falls markedly.
Other causes of gum enlargement
Not every enlargement is drug-related. Hormonal phases — pregnancy and adolescence in particular — make the gum over-responsive to plaque and produce similar thickening. This picture regresses after birth or once hygiene improves.
In mouth breathers the gum at the front dries continually and can thicken. Rarely, blood disorders and genetic syndromes produce the same appearance; where enlargement occurs in a patient on no medication, the assessment is therefore widened.
What can be done before starting the drug
Where it is known that one of these medicines is to be started, a dental check beforehand is very valuable. Existing tartar is removed, inflammation resolved and a targeted cleaning programme taught.
This preparation can prevent enlargement beginning at all, or keep it very mild. Arranging a review within the first three months of starting treatment also gives the chance to intervene early.
