Chemical injuries affecting oral cavity Biliary Atresia Green discoloration Drug Induced Hyperplasia Phenytoin Nifedipine Cyclosporine

1. Oral Pathology Presentation
Sana Rasheed

2. Learning Outcomes
 Chemical Injuries affecting Teeth: Biliary Atresia
• Introduction and definition
• Effects on teeth.
 Chemical Injuries affecting Gingiva (Drug induced Gingival
hyperplasia):
• Medicines: Phenytoin, Cyclosporine and Nifedipine.
• Their Uses
• Mechanism of Action on gingiva
• Clinical Features of Gingival enlargement
• Complications and Treatment

3. Biliary Atresia
Bile, is a dark-green-to-yellowish-brown
fluid produced by the liver.
Atresia, literally means absence or
abnormal narrowing of a lumen in the
body.
Biliary atresia is a congenital condition in infants
in which the bile ducts outside and inside the
liver are narrowed, scarred and blocked.
This congenital blockage may be fatal and infants
may die within months of birth.

4. Bile can't flow into the intestine, so it builds up in the liver and pushes its way through the epithelial cells
and leak out into the blood.
Bilirubin levels are elevated in the blood. This causes Neonatal Jaundice.

5. Jaundiced patients will exhibit
discolored teeth, particularly in the
primary dentition.
The teeth will have a dark greenish
color with the roots more intensely
stained than the crowns.
The degree and distribution of tooth
discoloration depends on the ability
to manage the medical condition
during tooth development in both
the deciduous and permanent
dentition.

6. Differential Diagnosis
The differential diagnosis of green teeth includes
Extrinsic discolorations caused
• by chromogenic bacteria or medicaments
Intrinsic discoloration caused by
• dentinogenesis imperfecta
• ameologenesis imperfecta
• tetracycline
• congenital erythropoietic porphyria

7. Summary
1. Biliary atresia is a congenital condition. It can be fatal.
2. Bile starts to build up in the liver after bile ducts are blocked or are congenitally
absent.
3. Conjugated bilirubin pushes its way into blood and infant develops jaundice.
4. Jaundiced infants develop discolored teeth.
5. Discoloration is more severe if the medical condition is not managed during
tooth development.

8. Chemical
Injuries
affecting
the Gingiva

9. Chemical effects on gingiva may be in two forms:
(1) Pigmentations that result from the ingestion of medications containing heavy metals such as bismuth,
silver, mercury, gold, copper, and zinc or
(2) Hyperplasia of the collagenous component.
The medications that most commonly affect the
gingiva are those that have the overproduction of
collagen as a side effect.
These medications are
Complication:
Advanced periodontitis with eventual premature loss of the
dentition.

10. Phenytoin
• It is sold in the market by the
trade name Dilantin.
• It is an anticonvulsant used to
treat seizures in patients of
epilepsy, brain tumors and other
CNS conditions.

11. Mechanism of Gingival enlargement by phenytoin
The mechanism is not completely known. But some suggested mechanisms may be direct effect of
phenytoin on fibroblasts or indirectly through causing alteration of mast cell degranulation.

12. • The incidence of gingival hyperplasia is in the range of 40% to 50%.
• Gingival enlargement appears 2 to 3 months after administration of
phenytoin and reaches its maximal severity in 12 to 18 months.
• Dose does not affect the severity.
• Risk factors may be Poor oral hygiene and some Hereditary factors.

13. Clinical Presentation
• Location : Anterior mouth > Posterior parts.
The generalized growths can enlarge to cover
part or all of the crowns of the teeth.
• Appearance: Bulbous or lobular growth of
interdental papillae which occurs buccally as
well as lingually. Marginal gingiva also
included.
• Painless, bead like appearance generally.
• When not inflamed, the enlarged gingiva
appears pink in color with a normally stippled
surface.
• Consistency and Bleeding: The
enlargement is firm with little resiliency and
does not bleed when probed.
COMPLICATIONS
• Esthetic disfigurement
• Malpositioning of teeth
• Interfere with mastication
• Problem in speech
• Inability to maintain proper oral hygiene

14. Gingival
enlargement by
Phenytoin
Pink in color
Normal
stippled
surface
Firm
No bleeding
on probing
Inflamed Gingiva
Dark red
Edematous
Friable
Bleeding on
probing
Treatment consists of
surgical removal of
excessive tissue as
necessary to allow function
and maintenance
of oral hygiene

15. Summary
1. Chemical effects on the gingiva may be pigmentation or hyperplasia.
2. The medicines cause hyperplasia by overproducing collagen. These can be Phenytoin,
Cyclosporine, and Nifedipine.
3. Phenytoin is an anticonvulsant used to treat seizures.
4. It acts on gingival fibroblasts either directly or indirectly through altering mast cell
degranulation.
5. The growth is generalized and anterior mouth is most affected.
6. There is painless, uninflamed, bead like appearance of bulbous and lobular growth in
interdental papillae and marginal gingiva which does not bleed on probing.
7. It can cause several complications and the treatment can be surgical removal and
improvement in oral hygiene.

16. Cyclosporine
Cyclosporine has a selective
immunosuppressive effect on the T
lymphocyte helper cells but without bone
marrow suppression.
• Uses :
1. In organ transplant patients to reduce
the chance of rejection.
2. In the treatment of some
autoimmune diseases.
• Toxic effects:
Nephrotoxic and hepatotoxic effects.

17. Side effects in oral cavity:
1. Generalized gingival hyperplasia
2. Perioral hyperesthesia
Incidence:
• 50% of all patients
• 100% in patients younger than 20
years of age.
Onset of gingival enlargement:
• Within 1- 3 months after start of
therapy
• Maximized at 1 year.

18. Mechanism is not well understood. And not all patients are affected.
Mechanism of
cyclosporine-induced
gingival hyperplasia
Selective stimulation of
fibroblasts is suspected
An increase in the non-
collagenous extracellular
matrix
Consistent with the clinical
observation that with cessation
of the medication, gingival
enlargement often subsides
substantially

19. Clinical appearance
• Both marginal gingiva and interdental
papillae appear enlarged and firm
• a surface that may be smooth, stippled, or
lobulated
• with little or no inflammation
 It is more pronounced in the anterior aspect
of the mouth.
 It can enlarge to cover the crowns of the
teeth.
 The extent of inflammation depends on the
degree of local irritants.
 The incidence of progressive periodontitis
maybe enhanced because of the
compromised defense system within the
gingiva.
COMPLICATIONS
• Esthetic disfigurement
• Malpositioning of teeth
• Interfere with mastication
• Problem in speech
• Inability to maintain proper oral hygiene
• Periodontitis
TREATMENT
• The ideal treatment for cyclosporine-induced
gingival hyperplasia is withdrawal of the
medication.
• Meticulous oral hygiene
• Surgical excision

20. Summary
• Cyclosporine is an immunosuppressant used in organ transplant patients and for autoimmune
diseases.
• In the oral cavity is caused generalized gingival hyperplasia and perioral hyperesthesia.
• Mechanism of action is by selectively stimulating fibroblasts or inceasing non-collagenous
extracellular matrix.
• Clinical appearance of gingiva is generalized lobulated enlargement with a smooth non inflamed
surface. Anterior mouth is most affected.
• There are several complications including increased risk of periodontitis.
• Treatment is by withdrawal of drug, surgical management and improving oral hygiene.

21. Nifedipine
Nifedipine is a calcium channel–
blocking agent used as a vasodilator.
For the treatment of cardiovascular
disorders such as
• angina pectoris
• hypertension
1. It inhibits calcium ion influx in the
smooth muscle of cardiac tissue so
reduces their contraction
2. Enables the relaxation of blood
vessels so it reduces vascular
hypertension and the tendency for
spasms in coronary arteries.

22. MOA of Gingival Enlargement by Nifedipine:
Altered calcium influx into fibroblasts interfering with the production of
collagenase.
Thus collagen is not degraded and accumulates.
Incidence:
25% and 50% of patients taking the medication will develop gingival
enlargement.
Onset:
The enlargement begins 1 to 3 months after treatment starts and
does not appear to be correlated with the dose
Clinical Appearance:
The gingival hyperplasia of nifedipine is clinically similar to that of phenytoin and cyclosporine.
It is nodular and firm, originating in the interdental papillae of the anterior teeth.
The enlargements are more severe when local irritants such as plaque, calculus, and defective fillings and crowns are
present.

23. Treatment
• The best treatment for calcium channel blocker– induced gingival hyperplasia is the substitution
of another vasodilator.
• If this is not possible, gingivectomy and meticulous oral hygiene can be used to control the
severity of the condition.

24. Differential Diagnosis of Drug induced Gingival enlargement
Hereditary gingival fibromatosis
Diagnosis can be made by a positive family
history of gingival enlargement.
Confirmed on histopathology : The stroma
shows irregular fibrosis and infiltration by
chronic inflammatory cells with no evidence of
malignant change.
Mouth-breathing gingivitisInflammatory gingival enlargement
They are frequently friable
and soft with a smooth shiny
surface and they usually
bleed easily.
Diagnostic feature is presence of
significant enlargement in maxillary and
mandibular anterior regions and no
involvement of posteriors

25. Differential Diagnosis of Drug induced Gingival enlargement
Conditioned gingival enlargement
Generalized gingival hyperplasia, during pregnancy
and puberty. The enlarged gingiva usually is soft and
friable, bright red or magenta, with a smooth, shiny
surface. Bleeding may occur extemporaneously or on
mild stimulation
Gingival enlargement associated
with Leukemia
Other associated features could be oral ulceration,
spontaneous gingival bleeding, petechiae, mucosal
pallor, herpetic infections and candidiasis. Confirm
diagnosis can be made by a simple full blood count.
Wegener’s Granulomatosis
Reddish-purple exophytic gingival swelling
with petechial haemorrhages.
Granulomatous inflammation on biopsy.
Ulcerative lesions of oral mucosa or nasal
bleeding or inflammation.

26. Phenytoin Cyclosporine Nifedipine
Drug class and uses Anticonvulsant used to treat seizures. Immunosuppressant used in organ transplant
patients and for autoimmune diseases.
Calcium channel blocker used for blood
pressure management and in CVS disorders.
Mechanism of Action on Gingiva It acts on gingival fibroblasts either directly or
indirectly through altering mast cell
degranulation.
Mechanism of action is by selectively
stimulating fibroblasts or inceasing non-
collagenous extracellular matrix.
Altered calcium influx into fibroblasts
interfering with the production of
collagenase. So collagen accumulates.
Incidence 40 – 50% 50% - All patients
100% - 20 years or younger
25 – 50%
Onset 2 – 3 months after administration and
maximal severity in 12 – 18 months.
Within 1 – 3 months.
Maximum in 1 year.
1 – 3 months
Clinical Appearance 1. The growth is generalized and
anterior mouth is most affected.
2. There is painless, uninflamed, bead
like appearance of bulbous and
lobular growth in interdental papillae
and marginal gingiva which does not
bleed on probing
1. Both marginal gingiva and interdental
papillae appear enlarged and firm.
2. A surface that may be smooth, stippled, or
lobulated with little or no inflammation.
3. No bleeding on probing.
Same as phenytoin and cyclosporine.
It is nodular and firm, originating in the
interdental papillae of the anterior teeth.
Complications Esthetic disfigurement
Malpositioning of teeth
Interfere with mastication
Problem in speech
Inability to maintain proper oral hygiene
Periodontitis
Esthetic disfigurement
Malpositioning of teeth
Interfere with mastication
Problem in speech
Inability to maintain proper oral hygiene
Periodontitis
Esthetic disfigurement
Malpositioning of teeth
Interfere with mastication
Problem in speech
Inability to maintain proper oral hygiene
Periodontitis
Treatment Surgical removal
Maintenance of oral hygiene.
Withdrawal of drug
Meticulous oral hygiene
Surgical removal
Substitution of drug
Gingivectomy
Meticulous oral hygiene

27. References
• Contemporary Oral and Maxillofacial Pathology
• Osmosis.org