Non-surgical Management of Drug Influenced Gingival Enlargement in Patient with Practice of Turmeric Powder Gum Massage: A Case Report

Introduction

Drug-influenced gingival enlargement (DIGE) has been defined as “an overgrowth or increase in size of the gingiva resulting in whole or in part from systemic drug use”. Calcium channel blockers, immunosuppressants, and antiepileptic medications are the ones that cause gingival enlargement most frequently¹. It may commonly be associated with discomfort and bleeding gums, which in more severe cases, it may impair with speech, mastication, and appearance.

Turmeric is a yellow, water-soluble pigment obtained from perennials of the Zingiberaceae family and is a rhizome of the Curcuma longa plant, a member of the ginger family. The primary active ingredient of turmeric is curcumin, which has a variety of therapeutic properties, including immunological modulation, anticancer, antibacterial, anti-inflammatory, and antioxidation. In studies on the management of periodontitis, curcumin has been utilized as a solution, chip, gel, and capsule². This case report describes a DIGE patient who, on his own initiative, developed a routine of massaging his gums with turmeric powder to improve his gum conditions while undergoing non-surgical periodontal therapy.

Case report

A 79-year-old Indian gentleman patient came to Unit Pakar Periodontik, Klinik Pergigian Labis, Johor with complaints of swollen and bleeding gums for 6 months which made him very uncomfortable to chew. Medically, patient was on oral medications of metformin 250 mg, amlodipine 10 mg and simvastatin 10 mg for diabetes and hypertension. He has been on amlodipine (calcium channel blocker) 10 mg twice daily since last 10 years.

Intra-oral examinations revealed poor oral hygiene status. Generalized gingival inflammation and enlargement was observed with periodontal pockets depth (PPD) ranging 5-8 mm with bleeding on probing and grade III mobility of tooth 32 (Figure 1). Discharging pus was noted from the periodontal pockets at the posterior teeth region. Panoramic radiograph showed generalized alveolar bone loss with severe alveolar bone loss more than half of the root length at molar teeth areas.

Patient was diagnosed with Generalized Periodontitis Stage III; Grade C and drug-influenced gingival enlargement.

Treatment done: –

1. Oral health education and motivation was performed at the initial visit. Patient was briefed regarding the importance of plaque control and the impact of his anti-hypertensive medication towards his gingival conditions. Full mouth scaling and polishing was performed to remove supragingival calculus prior to root surface debridement (RSD). 
2. Patient’s oral hygiene was reviewed after 2 weeks with remarkable improvement of oral hygiene status. Root surface debridement under local anesthesia at sites with PPD ≥5 mm was carried out by quadrants in 2 visits within 1 week. Extraction of poor prognosis tooth 32 was done on the second visit to facilitate plaque control and comfort during brushing.
3. Plaque score and gingival health status was reviewed again at second- and 6-weeks completion of RSD (Figure 2). Full mouth scaling and polishing was performed, and oral hygiene was re-enforced.
4. Full mouth reassessment was carried out following 3 months after the initial RSD. Patient gingival status showed significant improvement of periodontal health. The gingiva appeared pink and firm with remarkable improvement of gingival enlargement (Figure 3). Very minimal bleeding sites on probing were observed with no deep periodontal pocket depth >5mm.  
5. During the period of active treatment, we were informed by the patient that he massaged turmeric powder over his gums every morning after brushing. He thought that the potent antioxidant qualities of turmeric powder could aid in the recovery of his gums.

Patient was happy with the treatment outcomes and achieved his aim to be able to chew meals comfortably. He has been placed under supportive periodontal therapy 3 monthly after his successful non-surgical periodontal treatment.

Discussion

Drug-influenced gingival enlargement was prevalent in 77.3% in patients taking antihypertensive medication more than 5 years³. Clinically, the enlargement is usually seen 1 to 3 months following the initiation of the drug administered. The present case is noteworthy as the patient was taking amlodipine 10 mg twice daily for 10 years ago, but the gingival enlargement was present in 2021. Thus, the possibility of amlodipine induced gingival enlargement should be measured for a late presentation as well.

Non-inflammatory and inflammatory pathways were distinguished as the fundamental mechanisms of DIGE. The non-inflammatory pathways include (1) sodium/calcium ion flux’s inhibitory effects on the mechanisms of cation channels, and (2) defective collagenase activity due to decreased uptake of folic acid. Meanwhile, the inflammatory pathways include (1) modification of inflammatory cytokine production and chemotactic factor interactions and (2) immunological changes and inflammatory process⁵. 

Numerous studies have reported a higher prevalence of DIGE in patients with increased plaque and gingival inflammation, indicating that plaque is a substantial risk factor for enhancing DIGE expression, regardless of the initiating drug⁶. Drug-influenced gingival enlargement is managed by plaque and inflammation control, surgical correction of the enlarged gingival tissues, and in some cases substitution of the drug with a suitable alternative. The decision to replace anti-hypertensive drugs is not on the hand of the dental practitioner, patient’s medical physician must assess and decide. However, dental practitioners can suggest to them.

In the present case, the main aim of non-surgical treatment is to reduce the inflammatory component in the gingival tissues. Considering the challenges of establishing effective plaque control in the presence of gingival enlargement, patient’s motivation and multiple dental visits are needed. Effective brushing including interdental cleaning should be the primary focus of oral hygiene education as progress is made. Short-term use of chlorhexidine mouthwash as an adjunct to mechanical cleaning was beneficial in this case as supported in a study⁶.

Turmeric is often used as a condiment and plays a significant role in the cuisine of Iran, Malaysia, India, China, Polynesia, and Thailand⁷. Periodontal therapy may benefit greatly from the properties of curcumin in turmeric. It has anti-inflammatory properties by inhibiting nuclear factor-kappa B and downregulating the proinflammatory enzyme Cyclooxygenase-2. Antimicrobial properties of curcumin are likely due to its ability to inhibit bacterial lipopolysaccharide‒induced cytokine expression and bacterial quorum sensing systems⁸. Future research has been suggested to focus on the use of adjuvants, the combination with other treatments, the development of curcumin drug delivery routes, curcumin-based nano formulations, curcumin structure modifications, metabolism inhibitors-based administration, and curcumin prodrugs².

Conclusion

The presence of DIGE in a hypertensive patient consuming calcium channel blockers can be in late presentation. Non-surgical periodontal therapy inclusive of oral health education and meticulous plaque control must be carried out with close co-operation between operator and patient in managing DIGE associated with periodontitis. Turmeric with its active ingredient curcumin, could be a promising therapeutic strategy for periodontal disease due to its antimicrobial and anti-inflammatory effects in the future. Additional studies are warranted for further research and development of curcumin advantageous in dentistry.

Clinical photos before and after treatment

Figure 1. Baseline

Figure 2. Review post-operative 6 weeks

Figure 3. Reassessment post-operative 3 months

References

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8. Bhatia, M., Urolagin, S. S., Pentyala, K. B., Urolagin, S. B., Menaka, K. B., & Bhoi, S. (2014). Novel therapeutic approach for the treatment of periodontitis by curcumin. Journal of clinical and diagnostic research: JCDR, 8(12), ZC65.

By Dr. Nuzul Izwan bin Omar, Dr. Ong Zhi Ling