A male patient aged 11 years reported with the complaint of swelling of the gums since 6 months. A detailed history was taken and revealed no positive features.
On clinical examination, the patient had gingival enlargement in the upper arch. This enlargement involved attached gingiva and covered almost one-third to one-half of the crown length. Periodontal probing showed presence of false pocket with no signs of clinical attachment loss. As the patient was in mixed dentition stage, few primary teeth were mobile. There was presence of grade II local factors.
Looking at the history and clinical picture, the enlargement was considered to be due to the local factors and the mixed dentition stage that made the maintenance difficult by the patient.
He was treated with scaling followed by gingivectomy operation. The patient was perfectly fine. Regular follow-ups could not be carried out due to patient's poor compliance.
After 4 years of treatment, the patient came with milder form of gingival enlargement. This time, the enlargement was accompanied by swelling of upper lip.
On elaborating the history, the swelling of gingiva began before 2 months with no change in the oral hygiene or food habits. His medical history was unremarkable and he had no history of any intestinal disease, TB, or any signs of chronic fatigue.
The gingival examination revealed rubbery consistency involving the attached gingiva, with the presence of false pockets, slight bleeding on probing, and very less local deposits . This enlargement was resembling the previous enlargement in all aspects except the severity which was less this time. On palpation, the upper lip felt nontender and soft in consistency. There were no appreciable changes on the dorsal surface of the tongue. The rest of the intraoral examination was unremarkable.
(a) Preoperative; (b) Postoperative – after 3 months; (c) Postoperative – 2 years
Upper lip enlargement with the given background and good oral hygiene led us to think about the granulomatous disease. The clinical differential diagnosis included OFG, angioedema (idiopathic or hereditary), sarcoidosis, Crohn's disease, and an allergic reaction.
Melkersson-Rosenthal syndrome (MRS) was ruled out because of the absence of facial paralysis and clinically normal tongue.
To rule out Crohn's disease, chest radiography and a series of blood tests were requested. They turned out to be normal. An in-depth gastrointestinal investigation did not appear justified in this case, since there were no signs of anemia or symptoms suggestive of Crohn's disease.
A biopsy sample of the upper lip was obtained for histopathologic evaluation. The histopathologic analysis showed nodular tuberculoid granulomatous inflammation in patchy pattern throughout the submucosa. The granuloma consisted of lymphocytes, histiocytes, epitheloid cells, and occasional plasma cells with scattering of neutrophils. Overlying epidermis showed mild spongiosis and slight hyperplasia, giving the histological impression of granulomatous cheilitis . The results of the other investigations were negative. Therefore, a final diagnosis of idiopathic OFG was made.
(a) Histopathologic picture showing granulomatous lesion in connective tissue; (b) Histopathologic slide showing granulomatous infiltrates
Once the diagnosis was made, we started with the local treatment. To our surprise, as it occurs in very rare cases, the lip swelling reduced in size without any intervention during this investigation period. So, we decided to wait for further reduction and treat the gingival enlargement by gingivectomy meanwhile. The patient was explained regarding the recurrence and was kept on regular follow-up regimen. After 2 months of treatment, the lip swelling subsided completely. He is responding well with the recent recall showing no signs of recurrence even after 2 years.