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Case Report

Drug-Induced Gingival Enlargement: A Case Report

Suhani Goel, Shivjot Chhina, Sachit A. Arora

Department of Gingival overgrowth is associated with multiple factors including congenital

Abstract
Periodontics, I.T.S. Dental diseases, hormonal disturbances, poor oral hygiene condition, inflammation,
College, Hospital, and neoplastic conditions, and adverse drug reactions including anticonvulsants,
Research Centre, Greater
calcium channel blockers, and immunosuppressants. This can have a detrimental
Noida, Uttar Pradesh,
India effect on the quality of life and also on high oral bacterial load caused by plaque-
retentive areas. Various treatment modalities include both surgical (gingivectomy,
periodontal flap, electrosurgery, and laser excision) and nonsurgical approaches
(oral hygiene measures, scaling and root planing, discontinuation of the drug, or
the replacement of the drug with other alternative).
Keywords: Gingival overgrowth, inflammation, neoplastic

Introduction halitosis. Medical history showed that the patient was

G ingival overgrowth (GO) or gingival enlargement

(previously called gingival hyperplasia or gingival
hypertrophy) is characterized by enlarged gingival tissue
with lobulated appearance that gradually extends along
the labial, lingual, and coronal aspects to cover the
entire anatomic crown of teeth. It may often associate
with pain and bleeding gums, which in advanced cases
may cause interference with speech, mastication, and
aesthetics.[1]
The American Academy of Periodontology[2]
defined drug-influenced gingival enlargement as “an
overgrowth or increase in size of the gingiva resulting
in whole or in part from systemic drug use.” The
medications most commonly resulting in gingival
enlargement are antiepileptics (primarily, phenytoin),
immunosuppressants (primarily, cyclosporine), and
calcium channel blockers (primarily, nifedipine and
verapamil), among which phenytoin is the first and the
most commonly associated with gingival enlargement.
Case Report
A 28-year-old female patient reported to the
Department of Periodontology in I.T.S Dental College
and Hospital, Greater Noida, Uttar Pradesh, India,
with the chief complaint of swollen gums in both upper
and lower front and back teeth region for 1 year. The
patient also reported bleeding while brushing and severe
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epileptic since the age of 15, and from last 8 months,
the patient had been put on Phenytoin (Eptoin, 100 mg
tds). She had reportedly not received any dental
treatment. On oral examination, generalized fibrotic
gingival enlargement was seen in both upper and lower
jaw. Gingiva was inflamed and was pinkish red in color
with irregular margins. The interdental papillae were
scalloped, giving lobulated appearance [Figure 1].
Oral hygiene condition revealed abundant plaque and
calculus, and generalized bleeding on probing was evident.
On the basis of medical history and local examination,
provisional diagnosis of phenytoin-induced gingival
enlargement was made. Complete hemogram values
were within the normal limit and Orthopantomogram
revealed no bony changes. All local irritants were
removed and gingivectomy was advised along with the
physician consultation for alternate drug regimen.
With the consent of the patient and her physician,
complete oral prophylaxis was performed and 0.2%
chlorhexidine mouthwash (10 mL bid for 7  days) was
prescribed to the patient. The patient was instructed
to maintain good oral hygiene, and proper brushing
techniques were explained to her. She was reviewed
Address for correspondence: Dr. Suhani Goel,
Department of Periodontics, I.T.S. Dental College,
Hospital, and Research Centre, Knowledge Park 3,
Greater Noida 201308, Uttar Pradesh, India.
E-mail: drsuhanigoel@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
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For reprints contact: reprints@medknow.com

DOI: 10.4103/jdl.jdl_2_19
How to cite this article: Goel S, Chhina S, Arora SA.  Drug-induced
gingival enlargement: A case report. J Dent Lasers 2019;13:49-51.

© 2019 Journal of Dental Lasers  |  Published by Wolters Kluwer - Medknow 49

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Goel S, et al.: Drug-induced gingival enlargement
Figure 1: Pinkish red gingiva with irregular margins (preoperative)
Figure 2: Soft Tissue Diode Laser Photon Plus
after 1 week, revealing some reduction of the GO,
particularly in the lower arch. At the following visit,
surgical intervention, that is, gingivectomy, was
performed to eliminate excessive gingival tissue. Laser
gingivectomy was performed using soft-tissue diode
laser Zolar Photon Plus 810–980  nm (wavelength
980 nm) having a 400  μm diameter with a disposable
tip with contact mode; power set at 2 W in continuous
pulse was used [Figure 2].
Topical lignocaine spray was used and the fiber tip was
cleaved. To initiate the procedure, bleeding points were
created by the pocket marker and laser application
was performed. After laser application, tissue
remnants were removed using sterile gauze with saline,
and interdental papilla and marginal gingiva were
recontoured to recreate normal contour followed by a
Betadine irrigation and periodontal dressing for 7 days
[Figure 3]. The patient was prescribed with medication
and received postoperative instructions.
Discussion
The relationship between the drugs and gingival tissues
was influenced by various factors including age, genetic
predisposition, alteration in gingival connective tissue
homeostasis, histopathology, ultrastructural factors,
50 Journal of Dental Lasers  ¦  Volume 13  ¦  Issue 2  ¦  July-December 2019
inflammatory changes, and action of drugs on growth
factors.[3]
The first case of phenytoin-induced gingival
enlargement was reported in 1939 by Kimball.[4]
A patient with drug-induced gingival enlargement
is characterized by granular or pebbly surface,
with the enlarged papillae extending facially and/
or lingually, obscuring the adjacent tissue and tooth
surfaces. Enlargement of the gingival tissues results
in malpositioning of the teeth and interference with
normal masticatory function, speech, and oral hygiene.
Various pathogenic mechanisms responsible for
phenytoin-associated GO have been described. Vernillo
and Schwartz[5] reported the effect of phenytoin on
human gingival fibroblasts in tissue culture. Shafer[6]
reported that the optimal rate of cell growth (2  ×
1) occurred at a phenytoin concentration of 5 pg/mL,
compared to non-phenytoin controls.
The gingival fibroblasts can also metabolize phenytoin,
which may determine the susceptibility of the patient
to phenytoin-induced gingival enlargement, thereby
suggesting a positive relationship between the dose of
phenytoin and severity of the overgrowth.[7]
Duration of exposure and the dosage of phenytoin
adversely affect the gingival condition. However, poor
oral hygiene, poor socioeconomic class, and poor
educational status are other related risk factors. Dental
plaque also acts as a reservoir for drug accumulation
and is commonly associated with this condition.[8]
As a treatment protocol, conservative periodontal
measures are undertaken initially, which include
vigorous gingival massage coupled with efficient
toothbrushing. However, when surgical measures are
indicated, discontinuation of the drug is suggested.
Drug-induced GO treated surgically shows recurrence
but this can be decreased by proper home care,
chlorhexidine gluconate rinses, and professional
cleaning. Postsurgical recurrence rate varies from
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Goel S, et al.: Drug-induced gingival enlargement

Figure 3: Normal gingiva with well defined margins and contour (postoperative)

3 to 6  months, but in most cases, the results are well Conflicts of interest
maintained for 12 months.[9] There are no conflicts of interest.

Conclusion
Phenytoin-induced gingival enlargement is caused by
unwanted effects of systemic medication on the periodontal
tissues. For an effective control of this problem, proper
treatment protocol would be necessary, which includes
drug substitution and control of local inflammatory
factors. However, surgical intervention is required when
this sequence of treatment fails to resolve the problem.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that
their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
References
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Mon 2011;57:225-30.
2. American Academy of Periodontology. Glossary of
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3. Seymour  RA, Thomason  JM, Ellis  JS. The pathogenesis
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4. Kimball OP. The treatment of epilepsy with sodium diphenyl
hydantoinate. JAMA 1939;112:1244-5.
5. Vernillo  AT, Schwartz  NB. The effects of phenytoin
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6. Shafer  WG. Effect of dilantin sodium analogues on cell
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8. Rees  T. Drug associated gingival enlargement. J Periodontol
2004;75:1424-31.
9. Babcock JR. The successful use of a new therapy for dilantin
gingival hyperplasia. Periodontics 1965;3:196-9.

Journal of Dental Lasers  ¦  Volume 13  ¦  Issue 2  ¦  July-December 2019 51