WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

Thomas et al. World Journal of Pharmacy and Pharmaceutical Sciences

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Volume 5, Issue 8, 1025-1028 Case Report ISSN 2278 4357

CASE REPORT ON PHENYTOIN INDUCED GUM HYPERTROPHY IN

AN ELDER PATIENT

Jasmin Elizabeth Thomas*1, Elizabeth Phoeba Paul1, Geethu C.1, Josna James1,
Menaka K.2 and Sivakumar T.3

1
Pharm D Interns, Department of Pharmacy Practice, Nandha College of Pharmacy, Erode,
Tamil Nadu.
2
Lecturer, Department of Pharmacy Practice, Nandha College of Pharmacy, Erode, Tamil
Nadu.
3
Principal, Nandha College of Pharmacy, Erode, Tamil Nadu.

ABSTRACT
Article Received on
30 May 2016, Gum Hypertrophy is the most common dental adverse drug reaction
Revised on 19 June 2016,
receiving Phenytoin as antiepileptic therapy. Adverse drug reaction
Accepted on 09 July 2016
DOI: 10.20959/wjpps20168-7346 due to Phenytoin ranges from adverse effects at therapeutic dose to
toxic dose. Patients regular oral hygiene would help much in
preventing such adverse drug reactions. Dentists must be updated and
*Corresponding Author
conscious of drug induced gum hypertrophy and its clinical features in
Jasmin Elizabeth
Thomas
order to diagnose and effectively treat it as oral hygiene is an important
Pharm D Interns, risk factor for Gum Hypertrophy. We decided to highlight this case of
Department of Pharmacy a patient who was on antiepileptic drug - phenytoin, as an eye opener.
Practice, Nandha College
of Pharmacy, Erode, KEYWORDS: Gum hypertrophy, phenytoin, Oral hygiene.
Tamil Nadu.
INTRODUCTION
Antiepileptic drugs are the commonly prescribed centrally active agents which is used alone
or in combination with other anticonvulsant drugs in the management of epilepsy. They are

. widely used to treat conditions other than epilepsy like migraine, neuropathic pain, anxiety
and bipolar disorders. The advantages of Phenytoin, most commonly prescribed drug, include
its effectiveness, low cost, availability, and frequency of administration. Sedation, ataxia,
skin rash, agranulocytosis and Gum hypertrophy and Steven-Johnson syndrome are some of
the side effects of Phenytoin.

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Thomas et al. World Journal of Pharmacy and Pharmaceutical Sciences

Around 20-50% of patients undergoing treatment with Phenytoin has Gum Hypertrophy
which is the most frequent dental adverse effect.[1] It adversely affects speech, mastication
and tooth eruption. Evidently the etiopathogenesis and the mechanisms of Gum Hypertrophy
is not understood completely, it has been demonstrated that a primary action of these
compounds is the blockade of voltage-dependent sodium channels.[2] These enlargements can
occur as a result of the administration of certain anticonvulsants, immunosuppressants, and
calcium channel blockers too.[3]

Earlier studies have suggested an association of Gum Hypertrophy and multiple antiepileptic
therapies, poor oral hygiene including plaque and calculus accumulation.[1] It is triggered by
medications which often impairs nutrition, and provides access for oral infection, caries, and
periodontal diseases.[2] Clinical manifestations of Gum Hypertrophy frequently appear within
1 to 3 months after initiation of the particular treatment. Phenytoin-induced Gum
Hypertrophy occurs most often in younger patients. Children & adults younger than 30 yrs of
age are more susceptible.[4,5] All patients on phenytoin do not develop gum hypertrophy yet
certain risk factors are associated. The adverse effects of Phenytoin depend on the duration of
exposure to the drug and depends on the dosage.[2]

CASE REPORT
A 50 year old male was admitted with complaints of Gum Hypertrophy in a neuropsychiatric
government hospital. He was diagnosed as a seizure patient with psychosis (auditory
hallucination and mood changes). He was currently on Risperidone 2 mg (0-0-2),
Trihexyphenidyl 2 mg (1-0-0), Eptoin 100 mg (1-1-1) and Clonazepam 2mg (-0-1).
Medication for seizures was started with Eptoin 50 mg (1-0-1) 2 years back and meanwhile
dose was increased with frequency as seizures was not controlled. Patient started developing
Gum Hypertrophy which was confirmed on oral examination which revealed an enlargement
of the interdental papilla extending to lingual gingival margin resulting in the clinical
presence of pseudoclefts. There was a coronal progression of the gingival overgrowth
partially hidden behind the crowns of some teeth. The enlarged gingival was soft, painful and
swollen too and from the psychiatric point of view, it was suggested to taper the dose of
Phenytoin and stop it, then switch on to Sodium Valproate 500 mg HS for 3 days followed by
(500mg-0-500mg) for 3 days and then continue with (500mg-0-700mg) after tapering the
dose of Phenytoin for 30 days subsequently as 100mg for the first 10 days (1-1-1) followed
by 100mg (1-0-1) for the next 10 days and 100mg (1-0-0) for the last 10 days.

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Thomas et al. World Journal of Pharmacy and Pharmaceutical Sciences

DISCUSSION
Phenytoin-induced gingival enlargement is said to occur mostly in younger patients. The
existing pathogenesis of Gum Hypertrophy induced by phenytoin is not known, but some
evidence links it specifically to genetically predetermined subpopulations of fibroblasts,
inactivation of collagenase, and plaque-induced inflammation.[6,7,8] Physicians must be aware
of the incidence, prevalence and risk of gingival overgrowth induced by phenytoin and other
anti-epileptic drugs. Patients should be informed about this dental side effect for the early
diagnosis of this condition.

In this present case, the appearance of enlargement of the interdental papilla could be
minimized if an early diagnosis was made. Several studies have established the benefits of an
awareness programme relating oral hygiene, a dental prophylaxis and reinforcement of oral
hygiene at frequent intervals, for patients taking phenytoin for control of seizures.[9]

Although the preventive programmmes are not able to eradicate gingival enlargement
completely, this overgrowth can be minimal. We, as clinical pharmacists must attempt to
tailor the expected side effect profile of the anti-epileptic drug. Reducing the dose of the drug
or substituting another are the rational options for controlling gingival enlargement induced
by anti-epileptic drugs.[9] Here, in this case, the psychiatrist suggested Sodium Valproate
instead of Phenytoin which the neurologist prescribed as the patient had some signs of
psychosis earlier and now developed Gum Hypertrophy.

CONCLUSION
The importance of oral hygiene in preventing phenytoin induced gum hypertrophy should not
be underrated and the its role must be reinforced at regular intervals to the patients as they
come for routine visits to the physician. Informing patients about the risk of developing Gum
Hypertrophy is very much important. This report, aimed to highlight the ultimate model for
prevention and management of phenytoin-induced Gum Hypertrophy should be discussed
within the context of consultative planning between dentists, neurologists and psychiatrists.

REFERENCES
1. Masood Hasan Khan, Parikshit Sharma, Asif Nafis Khan, Naveen Kumar. Phenytoin-
Induced Gingival Enlargement: Multidisciplinary Clinical Management: A Case Report
Annals of dental speciality 2013; Volume 01: Issue 01.

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Thomas et al. World Journal of Pharmacy and Pharmaceutical Sciences

2. Devesh D Gosavi, Akanksha S, Sanjay N. A Case of Phenytoin induced gum

enlargement. Asian Journal of Pharmaceutical and Clinical Research .2012 Vol 5, Issue 1,
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degradation of matrix collagen in human gingival fibroblasts by the antiepileptic drug
phenytoin. J Periodontol 2005; 76: 941-950.
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influencing phenytoin-induced gingival enlargement. J Clin Periodontol 2000; 27: 506-
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8. Hassell TM, Gilbert GH. Phenytoin sensitivity of fibroblasts as the basis for susceptibility
to gingival enlargement. Am J Pathol 1983; 112: 218-223.
9. Juliana Antico Lucchesi, Sheila Cavalca Cortelli, DDS, MS, PhD, Jose Augusto
Rodrigues, DDS, MS, PhD, Poliana Mendes Duarte, DDS, MS, PhD. Severe phenytoin-
induced gingival enlargement associated with periodontitis. Featured in General
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