Phenytoin chemical structure
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Dilantin

Phenytoin sodium (marketed as Dilantin® in the USA and as Epanutin® in the UK, by Parke-Davis, now part of Pfizer) is a commonly used antiepileptic. It was approved by the Food and Drug Administration in 1953 for use in seizures. Phenytoin acts to damp the unwanted, runaway brain activity seen in seizure by reducing electrical conductance among brain cells. more...

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History

Phenytoin (diphenylhydantoin) was first synthesized by a German physician named Heinrich Biltz in 1908. Biltz sold his discovery to Parke-Davis, which did not find an immediate use for it. In 1938, outside scientists including H. Houston Merritt and Tracy Putnam discovered phenytoin's usefulness for controlling seizures, without the sedation effects associated with phenobarbital. There are some indications that phenytoin has other effects, including anxiety control and mood stabilization, although it has never been approved for those purposes by the FDA.

Jack Dreyfus, founder of the Dreyfus Fund, became a major proponent of phenytoin as a means to control nervousness and depression when he received a prescription for Dilantin in 1966. Dreyfus' book about his experience with phenytoin, A Remarkable Medicine Has Been Overlooked, sits on the shelves of many physicians courtesy of the work of his foundation. Despite more than $70 million in personal financing, his push to see phenytoin evaluated for alternative uses has had little lasting effect on the medical community. This was partially due to Parke-Davis's reluctance to invest in a drug nearing the end of its patent life, and partially due to mixed results from various studies.

Dilantin made an appearance in the 1962 novel One Flew Over the Cuckoo's Nest by Ken Kesey, both as an anticonvulsant and as a mechanism to control inmate behavior.

Side-effects

At therapeutic doses, phenytoin produces horizontal gaze nystagmus, which is harmless but occasionally tested for by law enforcement as a marker for drunkenness (which can also produce nystagmus). At toxic doses, patients experience sedation, cerebellar ataxia, and ophthalmoparesis, as well as paradoxical seizures. Idiosyncratic side effects of phenytoin, as with other anticonvulsants, include rash and severe allergic reactions.

There is some evidence that phenytoin is teratogenic, causing what Smith and Jones in their Recognizable Patterns of Human Malformation called the fetal hydantoin syndrome. There is some evidence against this. One blinded trial asked physicians to separate photographs of children into two piles based on whether they showed the so-called characteristic features of this syndrome; it found that physicians were no better at diagnosing the syndrome than would be expected by random chance, calling the very existence of the syndrome into question. Data now being collected by the Epilepsy and Antiepileptic Drug Pregnancy Registry may one day answer this question definitively.

Phenytoin may accumulate in the cerebral cortex over long periods of time, as well as causing atrophy of the cerebellum when administered at chronically high levels. Despite this, the drug has a long history of safe use, making it one of the more popular anti-convulsants prescribed by doctors, and a common "first line of defense" in seizure cases. Phenytoin may also cause gingival hyperplasia.

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Folic acid mouthwash for gingivitis
From Townsend Letter for Doctors and Patients, 6/1/05 by Alan R. Gaby

Thirty dental students and auxiliary personnel (aged 21-32 years) were randomly assigned, in double-blind fashion, to rinse their mouths for 5 minutes twice a day with 5 ml (1 teaspoon) of either a 0.1% folic acid solution or placebo solution. After 60 days of treatment, gingival inflammation, as assessed by the gingival index and bleeding index, was significantly less in the folic acid group than in the placebo group.

[ILLUSTRATION OMITTED]

Comment: Several studies have shown that folic acid supplementation can improve gingivitis. Topical application of folic acid, as in a mouth rinse, has been found to be more effective than oral ingestion of a similar amount of the vitamin. It has been suggested that a localized deficiency of folic acid plays a role in the development of gingivitis, and that this deficiency can be corrected by bathing the gingival tissues in folic acid.

Folic acid has also been used to treat phenytoin (dilantin)-induced gingival hyperplasia. Although this treatment may improve gum health, it should be used with caution, because large doses of folic acid (more than 1 mg/day) have the potential to interfere with the anticonvulsant effect of phenytoin. On the other hand, treatment with phenytoin frequently causes folic acid deficiency, so people taking this drug should receive at least a modest dose of supplemental folic acid.

Vogel RI, et al. The effect of topical application of folic acid on gingival health. J Oral Med 1978;33:20-22.

by Alan R. Gaby, MD

301 Dorwood Drive * Carlisle, Pennsylvania 17013

COPYRIGHT 2005 The Townsend Letter Group
COPYRIGHT 2005 Gale Group

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