A nine year old female patient reported to the Department of Oral Medicine and Periodontics with the chief complaint of bleeding from the gums while brushing and gives history of enlarged gums for the past six months. History revealed that the enlargement of gingiva which was initially localized to the anterior two teeth in the upper and lower jaw gradually over a period of six months spread to other teeth. There was no pain associated with the enlargement and the only symptom was bleeding from the gums which occurred during brushing. On consultation with general dentist who did a thorough oral prophylaxis and put the patient on short course of systemic antihistaminics (diphenhydramine maleate). The clinical condition did not regress and the patient was referred to our hospital for further evaluation and management.
Clear history was recorded for any gastrointestinal disturbance, loss of weight, loss of appetite, cough, fever and any other systemic signs or symptoms. There was no history of any medication and allergic reactions to any food substances or drugs.
Intra oral examination revealed enlarged gingiva of the maxillary and mandibular anterior region, which is diffuse and curtain like enlargement as shown in . There was slight bleeding on probing and minimal plaque and calculus were present. The enlargement involved the marginal gingival, interdental papilla and attached gingival extending till the mucogingival junction. Secondary changes like pus, ulcerations were not seen over the lesion. On palpation the enlarged gingiva was uniformly soft in consistency and non tender. The teeth in the region of the gingival enlargement were normal except for the fractured 21 which occurred two years before due to trauma. The fractured tooth was asymptomatic. The intra oral periapical radiographs of upper and lower anterior teeth didn’t show any abnormality. Based on the history and clinical features, clinical differential diagnosis of tuberculous gingivitis, plasma cell gingivitis, histoplasmosis, allergic gingival enlargement, gingival enlargement due to any hormonal changes or an idiopathic granulomatous enlargement.
Hematological investigation was performed for RBC. Count, WBC count, Differential Count, platelet count, ESR, Hb%, serum ACE, PCV, MCV, MCH and MCHC. All the levels were within the normal range and the ACE level was 40 U/L which is also within the normal range.
The mantoux test was also negative and the chest radiograph didn’t reveal any abnormal pathology. Polymerase Chain Reaction (PCR) was done to rule out Tuberculosis infection. PCR for detection of Mycobacterium tuberculosis genome by nested PCR which detects MPB64 and IS 6110 were negative, thus ruling out tuberculosis involvement.
An incisional biopsy of the enlarged gingiva was performed in relation to 13, 14 region and 32, 33 region and the tissue was sent for histological examination. The histological report showed the presence of parakeratinised stratified squamous epithelium of variable thickness and multinucleated giant cells with peripherally arranged nucleus suggestive of Langhans giant cell surrounded by modified macrophages suggestive of epitheleoid cells as shown in . There was also a rim of inflammatory cells primarily lymphocytes. The connective tissue showed areas of moderate vascularity and areas of hemorrhage as shown in . Multiple granulomas containing lot of giant cells suggestive of a granulomatous lesion.
Histopathological photograph showing granulomas (H and E stain, 20×)
Histopathologicval photograph showing multiple granulomas (H and E stain, 20×)
Thus correlating the history, clinical findings, laboratory investigations and histopathological examination, a final diagnosis of idiopathic orofacial granulomatosis was made.
Since in our case there was only the gingival enlargement without any systemic involvement, we planned for surgical excision. Gingivectomy of both upper and lower arches was carried out under local anesthesia. The case was followed for one year without any recurrence as shown in .
Follow up photograph of patient after one year