|Year : 2013 | Volume
| Issue : 2 | Page : 126-129
Management of phenytoin induced gingival enlargement associated with cerebral palsy: A challenge to the clinician
Anupama Shriram Rao1, Amit K Walvekar2, Subramaniam M Rao3, Biju Thomas4
1 Department of Periodontics, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, Karnataka, India
2 Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet, Coorg, Karnataka, India
3 Department of Periodontics, PMNM Dental College and Hospital, Bagalkot, Karnataka, India
4 Department of Periodontics, A.B. Shetty Dental College, Deralakatte, Mangalore, Karnataka, India
|Date of Web Publication||26-Jul-2013|
Anupama Shriram Rao
Department of Periodontics, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Phenytoin, which is the drug of choice for treatment of grandmal, psychomotor seizures associated with cerebral palsy, has serious side effect like gingival enlargement. Drug induced gingival enlargement is not only esthetically disfiguring but often impairs speech, mastication, nutrition and plaque control measures. In addition, poor oral hygiene, lack of motor coordination and muscular limitations in mentally disabled individuals results in increased susceptibility to periodontal disease. The present case report unfolds a complex nature of the management of phenytoin induced gingival enlargement, secondarily complicated by inflammation, and in the cerebral palsy patient. A supportive team work of periodontist, neurophysician, and general anesthetist plays a significant role in maintaining the quality of life in mentally disabled patient.
Keywords: Cerebral palsy, drug induced gingival enlargement, gingivectomy, phenytoin
|How to cite this article:|
Rao AS, Walvekar AK, Rao SM, Thomas B. Management of phenytoin induced gingival enlargement associated with cerebral palsy: A challenge to the clinician. Int J Health Allied Sci 2013;2:126-9
|How to cite this URL:|
Rao AS, Walvekar AK, Rao SM, Thomas B. Management of phenytoin induced gingival enlargement associated with cerebral palsy: A challenge to the clinician. Int J Health Allied Sci [serial online] 2013 [cited 2020 Jan 24];2:126-9. Available from: http://www.ijhas.in/text.asp?2013/2/2/126/115690
| Introduction|| |
Drug induced gingival overgrowth is a well-known side-effect in cerebral palsy patients using phenytoin for the control of seizures.  Cerebral palsy results in mental disability where in an individual's intellectual development is significantly lower than average and his ability to adapt to the environment is constantly limited. Owing to un-co-operative nature of such patient, it is an additional challenge for the clinician to manage a case under local anesthesia and maintain the periodontal health thereafter.  This case report describes multidisciplinary approach for the management of cerebral palsy patient who developed gingival enlargement primarily due to phenytoin drug.
| Case Report|| |
A 24-year-old male mentally disabled with the history of epilepsy since 5 years of age and on medication for the same, reported to Department of Periodontics with swollen and bleeding gums. Medical history reveled that patient had cerebral palsy (dyskinetic) since the birth and history of grand mal seizures since 5 years of age. Patient was on eptoin 100 mg 2-0-1 and gardinal 160 mg 1-0-1 since 5 years of age. General examination revealed that patient was mentally disabled (profound degree of mental disability with Stanford-Binet intelligence scale of lesser than 25) and grand mal epileptic since childhood. Patient was conscious with no communicating skills, highly uncooperative, malnourished with abnormal gait. Patient had dysarthria and impaired hearing. Involuntary movements of neck muscles were evident. On intra-oral examination, there was the presence of moderate amount of local factors (plaque and calculus), generalized bleeding on probing, suppuration, Grade-III generalized bead like gingival enlargement (according to Angelopoulos and Goaz index), and Grade-III tooth mobility in relation to 21, 24, 32, and 42 [Figure 1] and [Figure 2]. Routine blood examination revealed that the hemoglobin (Hb) percentage was 7.6 g %, total white blood cell count was 9000/mm 3 . The histopathological report showed hyperplasia of epithelium and connective tissue, long rete pegs extending into connective tissue, dense infiltration of inflammatory cells, and proliferating blood vessels, densely arranged collagen bundles in the connective tissue [Figure 3]. Based on clinical and history-pathological evaluation, diagnosis was given as phenytoin induced gingival enlargement combined with inflammatory enlargement. As the patient was mentally disabled, education and motivation about oral hygiene practices were instructed to patient's care taker. As the patient was highly unco-operative, the treatment was planned in Operation Theatre under general anesthesia. Folic acid and iron supplementation were given to increase Hb percentage in the blood before planned surgery. When the Hb percentage was brought to an appropriate level (13.6 g %), patient was admitted in medical college hospital. After obtaining an informed consent from patient's care taker, patient was prepared for surgery. After administering pre-anesthetic medication, patient was transferred to the operation theater. Under general anesthesia extraction of hopeless teeth (Grade-III mobility) 21, 24, 32, and 42 was carried out. Using a scalpel blade no. 15 (Bard Parker) and electrocautery, full mouth gingivectomy was performed, followed by thorough scaling, and root planning [Figure 4]. Post-operative instructions were given to patient's care taker. Antiobiotic (cefixime 200 mg twice a day for 7 days) and analgesic (diclofenac 50 mg twice a day for 3 days), and 0.2% chlorhexidine mouth rinse was prescribed twice daily for 3 weeks. Patient was discharged after 3 days of uneventful hospital stay. Satisfactory results were seen at the follow-up visit [Figure 5] and [Figure 6]. After careful case follow-up phenytoin was substituted by lamotrigine. As the recurrence of gingival enlargement is very common in mentally disabled patient, due to lack of dexterity, oral hygiene practice reinforcement was stressed to care takers of the patient during regular follow-up visit.
|Figure 1: Clinical presentation showing phenytoin induced gingival enlargement combined with inflammatory enlargement|
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|Figure 3: Histopathological picture showing hyperplastic epithelium, long rete pegs, chronic inflammatory cells in the connective tissue|
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|Figure 4: Intra‑operative photo after gingivectomy under general anesthesia|
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| Discussion|| |
Phenytoin (Dilantin, Pfizer, New York, USA) commonly prescribed for control of seizures in cerebral palsy,  was the first drug reported to produce gingival enlargement with the incidence ranging from 3% to 85%. ,, Clinically, gingival enlargement frequently appears within 1 year of the initiation of treatment with the phenytoin drug.  The facial surfaces of the gingiva in anterior sextants are often most severely involved, and the patient may present with inflamed, fibrotic masses spreading from the interdental papilla to the attached gingiva that may interfere with mastication, speech, and esthetics.  Phenytoin induced gingival overgrowth develops as a result of an increase in the connective tissue extracellular matrix. Theories and investigations on the histopathology and molecular mechanisms with which the overgrowth occurs have been widely published. Occurrence of the overgrowth can be related to such variables as type of drug, dosage levels, interactions with other drugs, pre-existing periodontal disease, presence of dental plaque, current oral hygiene care, and individual variations of response. The condition is recognized as multifactorial and connective tissue metabolism has been extensively studied in attempt to delineate its role.  Cerebral palsy is invariably associated with many deficits such as mental disability, speech, and oro-motor problems.  Clinician should particularly be concerned with drug induced gingival enlargement in cerebral palsy patient as it poses problems such as poor plaque control, improper mastication and therefore deteriorates overall health. Periodontal health in such individuals can be restored through multidisciplinary collaboration. Baptista,  Yalçin et al.,  Walker,  and Günay and Evers  reported cases of gingival enlargement, which were successfully treated under general anesthesia.
In the present case, along with drug induced enlargement, there was inflammatory enlargement attributed to mental disability of the individual, as well as low socio-economic background and illiteracy of the parents who were not aware of importance of oral hygiene practices. Spontaneous healing of gingival overgrowth was observed in just 1 week after surgical intervention as well as adoption of meticulous mechanical plaque control measures was noticed.
Studies have found an inverse relationship between levels of mental retardation and oral hygiene status; lower IQ level and higher oral hygiene index score.  Poor oral hygiene, lack of motor coordination and muscular limitations in mentally disabled individual's results in progression of periodontal diseases. Hence, it is important that the caretakers should well be informed about the importance of maintaining oral hygiene in preventing the periodontal diseases. Recurrence of drug induced gingival enlargement is a reality in surgically treated cases. The extent of recurrence is correlated with control of gingival inflammation, compliance of the patient, periodic supportive periodontal therapy, and stability of underlying systemic condition. In conclusion, early identification of susceptible patient, maintaining them under constant supervision, and drug substitution are the key factors to prevent such incidents of gingival enlargement in mentally challenged individuals. A team approach involving a consultation with a periodontist and the patient's physician is a critical step in successful management of drug induced enlargement in cerebral palsy patients.
| Acknowledgment|| |
We acknowledge Department of Anesthesia and Department of Neurology from KSHEMA Hospital, Deralakatte for constant communication and guidance regarding this particular case.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]