Calcium Channel Blockers Cause Gingival Hyperplasia and Gingivitis
Calcium channel blockers, particularly nifedipine and amlodipine, are the hypertensive medications that contribute to gingival hyperplasia (overgrowth) and associated gingivitis. 1, 2
Mechanism and Clinical Presentation
Calcium channel blockers cause gingival overgrowth through altered collagen metabolism and fibroblast proliferation in gum tissue, which predisposes to inflammation, bleeding, and gingivitis. 2
The gingival changes manifest as hypertrophy, hyperplasia, increased bleeding tendency during oral hygiene, and secondary inflammatory changes (gingivitis) due to plaque accumulation in the overgrown tissue. 2
Gingival enlargement is one of the most common oral symptoms in patients taking calcium channel blockers, particularly in those with chronic kidney disease and hypertension. 1
Specific Medications Implicated
Nifedipine (Highest Risk)
Nifedipine causes gingival hyperplasia in approximately 75% of patients, making it the calcium channel blocker with the highest incidence. 3
The frequency of gingival overgrowth with nifedipine is significantly higher than other calcium channel blockers in the same class. 3
Amlodipine (Moderate Risk)
Amlodipine causes gingival hyperplasia in approximately 31.4% of patients, though it is a third-generation calcium channel blocker with theoretically lower risk. 4, 3
Despite being newer, amlodipine still demonstrates clinically significant gingival enlargement even at doses as low as 5 mg daily. 4, 5
Other Calcium Channel Blockers
Diltiazem and verapamil can also cause gingival hyperplasia, though they have the disadvantage of inhibiting ciclosporin metabolism and should be avoided in transplant patients. 1
Isradipine appears to have a lower incidence of gingival hyperplasia and may be a reasonable alternative within the dihydropyridine class. 6
Risk Factors and Predisposing Conditions
Gingival inflammation (measured by gingival index) is the only significant risk factor that correlates with drug-induced gingival overgrowth. 3
Poor oral hygiene, increased plaque accumulation, and pre-existing periodontal disease worsen calcium channel blocker-induced gingival changes. 7, 3
Patients taking antihypertensive medications generally have poor oral hygiene status, which compounds the drug effect. 3
Management Algorithm
Step 1: Optimize Oral Hygiene
Initiate meticulous oral hygiene with professional scaling and root planing as first-line management, as gingival hyperplasia worsens with poor dental care. 2, 7
Proper periodontal maintenance is necessary to prevent progression of gingival enlargement around natural teeth and dental implants. 1
Step 2: Consider Drug Substitution
Consult with the prescribing physician to exchange the calcium channel blocker for another antihypertensive class (ACE inhibitors, ARBs, or beta-blockers) if gingival enlargement persists despite optimal oral hygiene. 1, 2
Within the calcium channel blocker class, switching from nifedipine to isradipine may result in regression of gingival hyperplasia while maintaining blood pressure control. 6
60% of patients switching from nifedipine to isradipine exhibited a decrease in hyperplasia, with mean probing depth reduction of 0.59 mm at 8 weeks. 6
Step 3: Surgical Intervention if Needed
If drug substitution is not feasible and conservative management fails, surgical excision of overgrown gingival tissue may be necessary. 5, 7
The gingival changes are typically reversible upon drug discontinuation, though this must be balanced against blood pressure control needs. 2, 5
Important Clinical Caveats
Calcium channel blockers used to treat ciclosporin-induced hypertension (such as nifedipine, isradipine, felodipine, or amlodipine) can add to the gingival hyperplasia effect of ciclosporin itself, creating a compounded problem in transplant patients. 1
The American Heart Association guidelines note that nondihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in heart failure patients, but amlodipine is considered safe. 1
Despite proper periodontal control, gingival enlargement may still appear, necessitating medication adjustment rather than relying solely on dental interventions. 1