GINGIVAL ENLARGEMENT ASSOCIATED WITH NOCTURNAL FRONTAL LOBE EPILEPSY.
A CASE REPORT
GINGIVAL ENLARGEMENT ASSOCIATED WITH NOCTURNAL
FRONTAL LOBE EPILEPSY. A CASE REPORT
1. MDS, Head of Department of Periodontology, Subharti Dental College and Hospital, Swami Vivekanand Subharti University,
Uttar Pradesh, India
2. PG student, Department of Periodontology, Subharti Dental College and Hospital, Swami Vivekanand Subharti University, Uttar
Pradesh, India
Contact person: Dr. Anamika Sharma - periodontics.subharti1@gmail.com
Abstract
„Epilepsy” refers to a group of neurological disorders
characterized by chronic, recurrent, paroxysmal seizure
activity. Nocturnal frontal lobe epilepsy is a neurological
disorder characterized by brief, recurring seizures produ‑
ced in the frontal lobes of the brain, often while the patient
is sleeping, and also by clusters of brief motor seizures.
Seizure disorders may affect the dental status and oral
health of patients. Epileptic drugs lead to gingival hyper‑
plasia, namely tissue enlargement, caused by an increased
number of cells.
Keywords: nocturnal frontal lobe epilepsy, drug-induced
gingival hyperplasia, internal bevel gingivectomy
INTRODUCTION
Seizures, one of the most commonly encoun‑
tered neurological disorders, may manifest as an
isolated incident with unknown etiology, or as a
symptom requiring a long-term treatment. When
patients experience recurring seizures, the disor‑
der is termed epilepsy. During a seizure, a fun‑
damental brain abnormality results in
synchronous, excessive, abnormal electrical dis‑
charges of the neurons in the central nervous
system. Manifestation of these discharges,
termed as seizure, can take the form of motion
disturbances, altered feelings, or changes in
patient’s level of consciousness.1 Frontal-lobe
epilepsy accounts for a significant ratio of all par‑
tial epilepsies, although the numerous difficul‑
ties in the diagnosis of frontal-lobe epilepsy led
to disparate estimations on its incidence. How‑
ever, evidence from surgical centers has indi‑
cated that frontal-lobe foci represent the second
most common epilepsy type. Despite the relative
frequency of frontal-lobe seizures, there still
remain controversy and debate over many of the
International Journal of Medical Dentistry
Periodontology
Sharma ANAMIKA1, Munjal VIDHI2
features of such a condition.2 Autosomal domi‑
nant nocturnal frontal-lobe epilepsy, a recently
identified idiopathic partial epilepsy, is a syn‑
drome characterized by clusters of frontal lobe
motor seizures occurring during sleep.3 Hyper‑
plasia refers to some tissue enlargement, caused
by an increased number of normal cells, wholly
different from hypertrophy, when the enlarge‑
ment is due to an increase in the size of the cells
as the result of an increased number of local cel‑
lular elements and intracellular fibers.4 Clini‑
cally, the gingival enlargements induced by
different drugs are virtually indistinguishable,
occurring most frequently in the labial anterior
gingiva, in the presence of bacterial accumula‑
tion and gingival inflammation.5
CASE REPORT
A 32 year-old male patient reported to the
Department of Periodontology, Subharti Dental
College and Hospital with the chief complaint of
swollen gums in the upper and lower anterior
teeth region, and also of generalized bleeding
from the gums and difficult chewing. Medical
history revealed that the patient was epileptic
since the age of 2 years and complained of attack
of seizures during sleeping at night. In the past
one and a half year, the patient was on ayurvedic
medicine. Oral examination revealed Grade II
enlargement of gingiva in relation to upper ante‑
rior teeth, and Grade III enlargement of gingiva
in relation to lower anterior teeth, with a fibrotic
aspect and leathery consistency. (Fig.I) General‑
ized bleeding occurred on probing; routine blood
investigations were within normal limits.
291
Sharma Anamika, Munjal Vidhi
Fig.I Pre-operative
TREATMENT
Periodontal therapy including scaling and
root planning (two sittings at one week interval)
alongwith oral hygiene instructions were dis‑
cussed. The treatment of choice was internal
bevel gingivectomy. One week after scaling and
root planning, an excisional biopsy of the lesion
was performed by internal bevel gingivectomy.
Antibiotics and analgesics were prescribed for 5
days. The biopsy specimen was embedded in
10% formalin and sent to the department of oral
pathology. Routine histological examination
with hematoxylin and eosin stains was per‑
formed, evidencing focal gingival hyperplasia,
and parakeratinized hyperplastic stratified squa‑
mous epithelium with pseudoepitheliomatous
hyperplasia. The connective tissue was highly
vascularised with focal accumulations of the
infiltrating inflammatory cells. The predominant
Fig.II One month post-operative
292
cell type in the inflammatory infiltrate was plas‑
matic, with fewer lymphocytes. The patient was
referred to his physician for the change of medi‑
cation. After 1 month, no recurrent enlargement
was seen. (Fig.II)
DISCUSSION
M. R. Robbins6 stated that epileptic patients
have significantly worse dental condition than
the general population. The disease may affect
their dental status and oral health in several
ways, e.g., by a higher number of decayed and
missing teeth. The seizures themselves can cause
injuries to both teeth and dental prostheses. Also,
some anti-epileptic drugs can cause periodontal
disease. Specific considerations for epileptic
patients include the treatment of oral soft tissue
side effects induced by medications and of the
damaged hard and soft tissue of the orofacial
region, secondary to seizure trauma.
As stated by Hefti et al.7, the age of the patient
may be a factor of influence in the incidence and
severity of this enlargement. Most of the authors
have reported that gingival overgrowth is more
common at younger ages, which may be due to
a more intense fibroblastic metabolism or to the
hormonal changes occurring during puberty.
Montebugnoli et al.8 stated that the feasibility
of drug discontinuing and its replacement with
a suitable alternative should be discussed with
the physician. After such replacement, spontane‑
ous regression of the excess tissue may occur
within 12 months, if the patient maintains the
oral hygiene. If the enlargement is of non-inflam‑
matory type, then discontinuation or change of
the drug is the only method of eliminating it.
Surgical management of drug-induced gingi‑
val enlargement includes scalpel gingivectomy,
flap surgery, electrosurgery and laser excision.
Removal of the excess tissue can be done by gin‑
givoplasty, gingivectomy, undisplaced flap sur‑
gery or by an excisional flap procedure. Rostock
et al.9 stated that, where the causative agent can‑
not be discontinued, resective surgical therapy
often becomes the treatment of choice.
volume 3 • issue 4 October / December 2013 • pp. 291-293
 GINGIVAL ENLARGEMENT ASSOCIATED WITH NOCTURNAL FRONTAL LOBE EPILEPSY. A CASE REPORT
CONCLUSIONS
Gingival procedures may be needed to
improve the function, aesthetics and access to
home care. The periodontist is restricted in con‑
trolling gingival inflammation, correcting gingi‑
val contour and treating any pre-existing
periodontal disease. Ideally, all patients follow‑
ing medication with cyclosporine, phenytoin or
a calcium channel blocker should undergo full
periodontal assessment and also a suitable treat‑
ment to any possible disease manifested. Physi‑
cians should be able to identify changes in the
oral cavity related to the health of their patients.
Unfortunately, most medical education curricula
do not include sufficient information, permitting
the physician to appreciate oral biology and oral
pathology. Thus, it is imperative that dental
medicine and general medicine should work
together in cases of drug-induced gingival
enlargement.
References
1. Bryan R.B, Sullivan S.M Management of Dental
Patients with Seizure Disorders Dent Clin N Am
2006;50:607–623.
International Journal of Medical Dentistry
2. Upton D, Thompson P.J Neuropsychological test
performance in frontal-lobe epilepsy: The influence
of aetiology, seizure type, seizure frequency and
duration of disorder Seizure 1997; 6: 443-447
3. Phillips H.A, Scheffer E, Crossland K.M, Bhatia K.P,
Fish D.R, Marsden C.D et al Autosomal Dominant
Nocturnal Frontal-Lobe Epilepsy: Genetic Hetero‑
geneity and Evidence for a Second Locus at 15q24
Am. J. Hum. Genet.1998; 63:1108–1116
4. Raviv H.M, Eckler M, Lalani K, Raviv E, Gornitsky
M Nifedipine-induced gingival hyperplasia Oral
Surg Oral Med Orat Pat 1995;79:715-22
5. Pradhan S, Mishra P, Joshi S Drug induced gingival
enlargement – A review
6. Robbins M.R Dental Management of Special Needs
Patients Who Have Epilepsy Dent Clin N Am
2009;53: 295–309
7. Hefti A.F, Hassell T.M Gingival Overgrowth in
Cyclosporine A Treated Multiple Sclerosis Patients
J Periodontol 1994;65:744-749
8. Montebugnoli, Servidio L, Bernardi D, Federico The
rôle of time in reducing gingival overgrowth in
heart-transplanted patients following cyclosporin
therapy J Clin Periodontol;2000, 27:611-614
9. Rostock M.H, Fryt H.R, Turner J.E Severe Gingival
Overgrowth Associated with Cyclosporine Therapy
J. Periodontol 1986;57:294-299
293