Cyclosporin-induced gingival overgrowth:

Correlation with dental plaque scores,

gingivitis scores, and cyclosporin levels in
serum and saliva
Tim McGaw. D.D.S.,M.Sc.,* Stephen Lam, B.Sc..** Jim Coates. PhD.,***
Edmonton, Alberta, Canada

UNIVERSITY OF ALBERTA

Gingival overgrowth, dental plaque, and gingivitis were assessed by means of standardized
semiquantitative indices in thirty renal transplant patients undergoing immunosuppression with
cyclosporin-A (Cy-A). Radioimmunoassay techniques were used to determine Cy-A in serum samples and
in parotid, submandibular, and whole saliva samples from each patient. A significant positive correlation
was found between gingival overgrowth scores and both dental plaque and gingivitis scores. A significant
positive correlation was found between whole-saliva Cy-A and both plaque and gingival overgrowth scores.
No such correlation was found when parotid Cy-A or submandibular Cy-A was considered. This was
attributed to differences in saliva-collection methods, and a possible role of dental plaque as a local
reservoir of Cy-A is proposed.
(ORAL Suac. ORAL MED. ORAL.PAIXL 1987;64:293-7)

I n spite of the impressive record of cyclosporin as

an immunosuppressant in organ transplantation pro-
grams,**2 the use of this drug has been associated
with a variety of adverse effects including, nephro-
toxicity, hepatotoxicity, increased risk of lymphoma,
electrolyte disturbances, paresthesia, tremor, hirsut-
ism, and gingival overgrowth.2-S The gingival over-
growth occurring in up to 33% of the patients who
receive cyclosporin impairs dental hygiene and may
lead to the development of foci of oral sepsis that are
potentially serious in an immunocompromised per-
son.
Obvious clinical analogies can be drawn between
the gingival response to cyclosporin and the gingival
overgrowth observed in 30% to 50% of epileptic
patients receiving phenytoin (Dilantin). A striking
feature of the gingival overgrowth that can occur in
*Chairman, Division of Oral Pathology, Faculty of Dentistry.
**Undergraduate dental student.
***Director, Division of Radioisotopes, University of Alberta
Hospitals.
patients receiving either of these drugs is the varia-
tion in individual patient response. This is not easily
explained on the basis of dosing considerations alone,
as no correlation has been shown between serum
levels of the drug and the presence or severity of the
gingival response.
In the case of both drugs, the most marked
overgrowth appears to occur in association with
accumulations of dental bacterial plaque and estab-
lished gingivitis.2-4,6*7 Babcock and Nelson* also dem-
onstrated, in institutionalized epileptic patients, a
direct relationship between the degree of gingival
overgrowth and the salivary concentration of pheny-
toin.
In the present study, an attempt was made to
determine whether statistically significant correla-
tions could be demonstrated between the incidence
and severity of cyclosporin-induced gingival over-
growth and corresponding scores of dental bacterial
plaque accumulation, gingivitis, or cyclosporin levels
in serum or saliva samples.
In addition, the feasibility of employing a salivary
assay as an alternate noninvasive means of therapeu-
tic monitoring of cyclosporin was investigated.

293
294 McGaw, Lam, and Coates
Fig. 1. Severity of cyclosporin-induced gingival over-
growth demonstrated a positive correlation with dental
plaque scores.
MATERIALS AND METHODS
The thirty patients in this study were being fol-
lowed in the renal clinic of the University of Alberta
Hospitals following renal allograft transplantation.
All patients were undergoing immunosuppressive
therapy with cyclosporin. The cyclosporin was taken
orally as a solution in olive oil (100 mg/ml). The
total divided daily dose ranged from 300 mg to 900
mg (mean, 400 mg).
Each patient underwent a routine dental assess-
ment to identify foci of oral sepsis. As part of the
dental screening, a periodontal assessment was per-
formed and scores were recorded for the level of
dental bacterial plaque and gingivitis; established
semiquantitative indices, were used.9 Gingival over-
growth was assessed by means of a modification of
the semiquantitative index developed by Aas’ (Ta-
ble I).
Patients were divided into two groups-responders
and nonresponders. Those patients with a gingival
overgrowth score of grade 1 or less were regarded as
nonresponders.
At the time of the dental screening, saliva and
serum samples were obtained from each subject
before the morning dose of cyclosporin. Stimulated
whole-saliva samples were collected by expectoration
after the chewing of Parafilm (American Can Com-
pany, Greenwich+ Connecticut). Parotid saliva and
submandibular saliva samples were collected directly
from the duct orifices by means of double-lumen
miniature suction cups (N.K. Harvey, Glasgow,
Scotland).
Serum levels of cyclosporin were determined by
Oral Surg.
September 1987
Table I. Gingival overgrowth index
Grade Criteria
No overgrowth, feather-edged
gingival margin
Blunting of gingival margin
Moderate gingival overgrowth
(<% of crown length)
Marked gingival overgrowth
(>% of crown length)
means of a radioimmunoassay kit (Sandoz Canada
Ltd. Dorval, Quebec), used according to the manu-
facturer’s instructions. Salivary levels of cyclosporin
were determined by means of a modified cyclosporin
radioimmunoassay, with iodocyciosporin (‘251-cyclo-
sporin) substituted for ‘H-cyclosporin as the radiola-
beled tracer. Development and standardization of
this modified radioimmunoassay method, as well as
the rationale for its use in the salivary assay, are
described elsewhere.‘O All radioimmunoassay proce-
dures, for both serum and saliva samples, were
performed in duplicate.
From each patient’s medical records, the number
of months of cyclosporin therapy and the mean
serum level of cyclosporin during that time interval
were recorded. A cumulative “cyclosporin exposure
factor” was calculated by multiplying these two
values.
Comparisons were made by t tests between the
responder and nonresponder groups with respect to
age and sex, duration of cyclosporin therapy, cyclo-
sporin exposure factor, plaque scores, gingivitis
scores, gingival overgrowth scores, and cyclosporin
levels in samples of whole saliva, parotid saliva,
submandibular saliva, and serum.
Relationships between variables were determined
by calculation of Pearson correlation coefficients.
The level of significance was set at p < 0.05.
RESULTS
The patient sample was composed of 15 men and
15 women ranging in age from 18 to 62 years (mean,
38 years). All patients had been maintained on
immunosuppressive therapy with cyclosporin for at
least 5 months.
Eight of the thirty patients (26.7%) were classed
as responders with evidence of gingival overgrowth.
This gingival response ranged from modest enlarge-
ment of one or more interdental papillae to large
lobulatiotls extending to cover much of the anatomic
crown of the involved teeth. The most pronounced
overgrowth was noted in areas of dental plaque
Volume 64 Cyclosporin-induced gingival overgrowth 295
Number 3

Table II. Distribution of patient characteristics by Table III. Distribution of dental plaque, gingival
groups inflammation, and gingival overgrowth scores by
groups
Non-
Responders responders Responders Nonresponders
(n = S} (n = 22)
Dental plaque* 2.34 (k0.31) 1.36 (kO.51)
Age (years) 40.3 Gingival inflammation* 1.94 ( kO.32) 0.91 (kO.50)
(k5.1) Gingival overgrowth* 2.01 (20.42) 0.32 (f0.29)
Sex
Male 5 10 ‘Significant difference between groups at p < 0.05
Female 3 12
Duration of cyclosporin 22.6 18.3
therapy (months) (k6.1) (k4.3)
Cyclosporin exposure factor Table IV. Distribution of cyclosporin levels in serum
0.711 0.786
[(ng X months)/ml] (k0.224) (kO.201) and in parotid, submandibular, and whole saliva by
groups
Responders Nonresponders
hW) (n&4

accumulation with associated gingival inflammation
(Fig. 1).
No significant differences between the responder
and nonresponder groups were found for age, sex,
duration of cyclosporin therapy, or cyclosporin expo-
sure factor (Table II).
Plaque and gingivitis scores in the responder group
were significantly higher than in the nonresponder
group (Table III). Within the responder group,
significant positive correlations were found between
gingival overgrowth scores and dental plaque scores
(r = 0.73) and between gingival overgrowth scores
and gingivitis scores (r = 0.75). Nevertheless, several
patients in the nonresponder group had high dental
plaque and gingivitis scores in the absence of a
gingival overgrowth response.
Cyclosporin levels in whole saliva were significant-
ly higher in the responder group (Table IV). In these
patients, the cyclosporin level in whole saliva
exceeded the corresponding serum level of cyclospo-
rin by as much as a factor of 12. Cyclosporin levels in
whole saliva demonstrated a significant positive cor-
relation with dental plaque scores (r = 0.79) and
gingival overgrowth scores (r = 0.63). No significant
correlation was found between cyclosporin levels in
whole saliva and the corresponding cyclosporin levels
in serum, parotid saliva, or submandibular saliva.
Cyclosporin levels in serum, parotid saliva, and
submandibular saliva were not significantly different
between the responder and nonresponder groups
(Table IV). Significant positive correlations were
found between cyclosporin levels in serum and the
corresponding cyclosporin levels in parotid saliva
(r = 0.60) and in submandibular saliva (r = 0.69).
When parotid and submandibular salivary levels of
cyclosporin were expressed as a percentage of the
corresponding serum cyclosporin level, the values
Serum 0.035 (T .016) 0.049 ( f ,022)
Parotid saliva 0.006 (+- .006) 0.008 ( f ,006)
Submandibular saliva 0.005 (+ .002) 0.008 (* .004)
Whole saliva* 0.209 (k ,067) 0.133 (-1.061)
*Significant differencebetween groups at p < 0.05.
ranged from 3.3% to 31% to 6.6% to 35%, respective-
ly*
DISCUSSION
The cyclosporin levels measured in whole saliva in
these thirty renal transplant patients consistently
exceeded corresponding serum levels, in some cases
by as much as a factor of 12. This finding is
extremely incongruous if cyclosporin, like many
drugs, enters the saliva through passive diffusion of
unbound drug from serum.”
The higher levels of cyclosporin measured in whole
saliva suggested the possibility of active transport
and concentration. A number of substances are
actively transported from serum to saliva. Salivary
levels of lithium, for example, are typically 2.2 to 3.3
times as high as the concentration in plasma.‘*
However, the apparent active transport and con-
centration of cyclosporin in whole-saliva samples was
not observed in parotid or submandibular saliva
samples, in which the cyclosporin levels were consis-
tently lower than the corresponding serum cyclospo-
rin level.
The extreme disparities between cyclosporin levels
in whole saliva versus corresponding parotid or
submandibular saliva samples may have been attrib-
utable to differences in sampling techniques. While
parotid and submandibular saliva samples were col-
lected directly from the respective duct orifice, whole
saliva was expectorated following the chewing of
 296 McGaw, Lam, and Coates
Parafilm. If dental plaque subserves a role as a local
reservoir of cyclosporin from previous oral doses, it is
possible that the chewing of Parafilm may have
released cyclosporin from this reservoir into the
whole saliva. In this regard, it is significant to note
that, in both the responder and nonresponder groups,
the whole-saliva cyclosporin concentration was found
to correlate significantly with dental plaque scores.
Preliminary assays on other patients subsequent to
completion of this study have shown that when
pooled whole saliva is collected without the use of
Parafilm chewing, the cyclosporin levels are in the
same range as directly sampled parotid or subman-
dibular saliva. An extraction and assay method to
permit the determination of cyclosporin levels in
dental bacterial plaque is currently being developed
in our laboratory.
An analogous role for dental plaque as a reservoir
for phenytoin in the pathogenesis of phenytoin-
induced gingival overgrowth was proposed by Stein-
berg.13 Phenytoin has been detected in saliva, dental
plaque, and gingival samples of patients exhibiting
phenytoin-induced gingival overgrowth.13*14 Severity
of gingival overgrowth was shown to correlate with
gingival phenytoin levels. l4 Steinberg, using an ani-
mal model, demonstrated the penetration of pheny-
toin from the gingival crevice into the gingival
tissues. I3
The precise role of dental plaque in cyclosporin-
induced gingival overgrowth remains uncertain.
Admittedly, the dental plaque scores were signifi-
cantly higher in the responder group, and a high
degree of correlation was found between gingival
overgrowth scores and dental plaque scores. Howev-
er, it is possible that the redundant gingival tissue
may impair dental hygiene and only secondarily lead
to an increased accumulation of dental plaque.
Delineation of a true causal role will await appropri-
ately controlled longitudinal clinical studies.
It would appear that dental plaque, even if found
to be a necessary predisposing factor, is not sufficient
to account for development of the gingival response
in patients receiving cyclosporin. In the present
study, several patients in the nonresponder group,
while exhibiting high dental plaque and gingivitis
scores and above-average serum levels of cyclosporin,
salivary levels of cyclosporin and cyclosporin expo-
sure factor values, displayed no evidence of gingival
overgrowth.
There clearly remains an unexplained heterogene-
ity in clinical response that may be understood only
through laboratory studies of individual variation in
cyclosporin metabolism or variation in the response
Oral Surg.
September 1987
of gingival fibroblast subpopulations to cyclosporin
and/or its metabolites.
The second objective in this study was to investi-
gate the feasibility of employing radioimmunoassay
of cyclosporin levels in saliva samples as an alternate,
noninvasive means of therapeutic monitoring. Blood
is the usual sample employed in therapeutic drug
monitoring, but it has been suggested that saliva may
offer potential advantages. Routine radioimmunoas-
say determination of serum drug levels does not
distinguish between bound (inactive) and unbound
(active) drug. In contrast, since drugs usually enter
saliva by passive diffusion, the salivary concentration
of many drugs corresponds to the free or unbound
plasma drug concentration.” This may be a more
meaningful value for considerations of pharmacolog-
ic activity or toxicity than a value that reflects both
bound (inactive) and unbound (active) drug. In the
case of phenytoin, the serum and salivary concentra-
tions show a very high correlations, with a consistent
serum:saliva ratio of approximately 10: I .I4 This is an
expected result, given that approximately 10% of
circulating phenytoin is unbound.
In the present study, cyclosporin levels in parotid
and submandibular saliva levels ranged from 3.3% to
35% of the corresponding cyclosporin level in serum.
A significant correlation was found between serum
cyclosporin levels and the corresponding levels of
cyclosporin on both parotid and submandibular sali-
va. However, the degree of correlation is rather low
and raises questions about the potential value of this
approach to therapeutic monitoring of cyclosporin.
Nevertheless, concerns have been expressed about
the reliability of radioimmunoassay of the serum
level of cyclosporin and its lack of correlation with
dosing levels, toxicity, and rejection reactions.15
Therefore, it may be inappropriate to dismiss the
salivary radioimmunoassay method simply on the
basis of its low correlation with corresponding serum
levels of cyclosporin. Further studies to test the
correlation of salivary cyclosporin levels with dosing,
toxicity, and rejection parameters are indicated.
The authors thank Dr. Raymond Ulan and other mem-
bers of the medical staff of the Division of Nephrology for
their assistancewith this study. The statistical analysis was
performed by Dr. Michael Grace and Ms. Jane Percy.
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Reprint requests to:
Dr. Wm. T. McGaw
Division of Oral Pathology
Faculty of Dentistry
University of Alberta
Edmonton, Alberta, T6G 2N8, Canada