11 year old girl with complex epilepsy (including grand mal seizures) was initially treated with ph

Fråga: 11 year old girl with complex epilepsy (including grand mal seizures) was initially treated with phenytoin which had to be stopped due to severe hirsutism and acne. Now, for 2-3 years, she has been treated with Mylepsin (primidone) and Mogadon (nitrazepam). In the Summer of 1985 she developed gingival hyperplasia. Can it be due to Mylepsin or Mogadon?

Sammanfattning: In summary, gingival hyperplasia is a common side effect of phenytoin therapy. The association of other anticonvulsants such as primidone and valproic acid and this side effect has not been established.

There are no reports of association of carbamazepine and phenobarbital and gingival hyperplasia.

In a patient with possibly drug induced hyperplasia the current drug therapy should be evaluated and possibly changed. Also, oral surgical intervention could be considered.

We recommend that this case be reported to the Socialstyrelsen´s läkemedelsbiverkningskommitte (Swedish National Board of Health and Welfare - Adverse Drug Reaction Committee).

Svar: Through Medline-search of literature between 1977 and 1985 only one case of gingival hyperplasia in a patient on primidone was found. However, the patient also had tuberous sclerosis and his condition was thought to be more likely the cause of the gingival hyperplasia than the drug.

Smith in his review of the association of anticonvulsants and gingival hyperplasia noted that about one third of the patiens on phenytoin are affected. Prior to puberty the incidence drops to 10 per cent (1).

The causal relationship between valproic acid and gingival hyperplasia has not been established. Seymor in his study of 30 patients on valproic acid or phenytoin observed that there were no significant differences in periodontal effects between the valproic acid and the placebo groups (2). There is, however one case of gingival hyperplasia associated with sodium valproate reported by Syrjänen (3).

There are no reports of gingival hyperplasia caused by phenobarbital, carbamazepine or nitrazepam.

A treatment strategy (both drug and non-drug) in a patient with severe gingival hyperplasia is described by Reynolds (4). It may be of assistance in the case in question. A copy is attached.