Periodontics · patient case with 1 question
Nine years of phenytoin
Patient: Male, 24 years old
Chief Complaint: “My gums have grown over my teeth and I can hardly clean them.”
Background: Epilepsy since childhood, controlled on phenytoin for nine years. No other medications. Lives independently.
Vital Signs: BP 118/72 mmHg · HR 74 bpm
Findings: Gross generalised gingival enlargement covering approximately two-thirds of the clinical crowns. The tissue is firm, pink, stippled and fibrotic in the deeper portions, with red oedematous inflamed margins. Heavy plaque accumulation throughout with generalised bleeding on probing. The enlargement begins at the interdental papillae and does NOT cross the mucogingival junction.
Question 1
What is the appropriate sequence of management?
Show answer and explanation
Correct answer: A. Non-surgical debridement and rigorous plaque control first, then gingivectomy for residual fibrotic tissue, with physician liaison about substituting the drug
- A. CORRECT. The SEQUENCE is what this question tests. Begin with meticulous plaque control and non-surgical debridement, because inflammation substantially amplifies the drug effect and a real proportion of this enlargement is inflammatory OEDEMA that will resolve without any surgery at all. Then resect the residual FIBROTIC component by gingivectomy and gingivoplasty — or by an internal bevel flap where attached gingiva is limited or bone recontouring is required. In parallel, liaise with the physician about substituting the drug where the epilepsy allows, since without both a drug change and sustained hygiene the enlargement recurs.
- B. NEVER stop an anticonvulsant. Abrupt withdrawal of phenytoin risks status epilepticus, and the decision belongs entirely to the prescribing physician. The dentist's role is to raise the question, not to act on it.
- C. Operating first means cutting into inflamed, bleeding tissue, removing tissue that would have resolved without surgery, and — because the plaque and the drug both remain — guaranteeing recurrence.
- D. Surgery without a preceding hygiene phase is the classic failure in this condition. Recurrence after gingivectomy in a mouth with uncontrolled plaque approaches certainty, and the patient has then undergone surgery for nothing.
Note: The three drug classes to know: PHENYTOIN, the CALCIUM CHANNEL BLOCKERS (dihydropyridines especially, notably nifedipine) and CICLOSPORIN. The mechanism involves a susceptible subpopulation of gingival fibroblasts responding with increased collagen and ground substance. Note the diagnostic feature stated in the findings: the enlargement begins at the INTERDENTAL PAPILLAE and is confined to the ATTACHED GINGIVA, characteristically NOT crossing the mucogingival junction — which is what distinguishes it from a neoplastic or infiltrative process.