Home About us Editorial board Ahead of print Current issue Archives Submit article Instructions Subscribe Search Contacts Login 
  • Users Online: 1702
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 31  |  Issue : 4  |  Page : 397-400

Diagnosis lies in the eyes of beholder: Linear gingival erythema in a non-HIV pediatric patient


Faculty of Dentistry, AIMST University, Bedong, Kedah, Malaysia

Date of Submission26-Jun-2019
Date of Acceptance20-Dec-2019
Date of Web Publication03-Mar-2020

Correspondence Address:
Dr. Khushboo Gupta
Faculty of Dentistry, AIMST University, Semeling, Bedong, Kedah - 08100
Malaysia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_125_19

Rights and Permissions
   Abstract 


Linear gingival erythema (LGE), formally referred to as HIV gingivitis, is the most common form of HIV associated periodontal disease in the HIV infected population. There is now evidence that this disease also occurs in HIV negative immunocompromised individuals and is not specific to HIV infection. A 13 years old boy presented with gingival inflammation in upper and lower anterior teeth mimicking LGE, but blood investigations showed HIV negative status. The microbial sample from the affected area confirmed candida infection and antifungal therapy with scaling helped to resolve the lesion. This case report emphasis that the clinician should obtain an in depth medical history to investigate such a condition. If there are signs and symptoms suggesting a systemic disease such as HIV, appropriate diagnostic testing such as blood testing or cytology must be considered. Patients with LGE should undergo laboratory testing to ensure that any underlying disorder is diagnosed and treated at the earliest possible time.

Keywords: Candida infection, HIV-gingivitis, linear gingival erythema


How to cite this article:
Gupta K, Singh S, Kannan S. Diagnosis lies in the eyes of beholder: Linear gingival erythema in a non-HIV pediatric patient. J Indian Acad Oral Med Radiol 2019;31:397-400

How to cite this URL:
Gupta K, Singh S, Kannan S. Diagnosis lies in the eyes of beholder: Linear gingival erythema in a non-HIV pediatric patient. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2020 Apr 4];31:397-400. Available from: http://www.jiaomr.in/text.asp?2019/31/4/397/279846




   Introduction Top


Case report: A challenge

A 13-year-old boy came to the outpatient clinic at AIMST University, Malaysia with the chief complaint of bleeding from gums while brushing. The full case history was taken which did not reveal any medical problems. Intraoral examination revealed moderate plaque and calculus extending till the gingival third of teeth in both upper and lower dentition. Bleeding on gentle probing was seen, and was more profuse in the anterior region of both the jaws compared to posterior teeth. Further gingival examination showed an erythematous linear band that extended approximately 2–3 mm from the free gingiva extending till attached gingiva from anterior teeth to premolar region in both upper and lower dentition [Figure 1]. On extraoral examination, it was noticed that the patient had class 2 malocclusion with proclined anterior and incompetent lips. The lesion did not cause clinical problems or interfere with nutrition. The treatment plan was made which included a plaque and supragingival calculus removal on the first visit. The patient was given oral hygiene instructions and proper brushing technique was also advised. The patient was also advised to use chlorhexidine mouthwash for 2 weeks to decrease the bacterial load. The next visit after 2 weeks involved scaling and removal of any subgingival calculus. The condition did not show any improvement in that span of time.
Figure 1: Intraoral photograph showing linear red erythematous gingival in upper and lower anterior teeth

Click here to view


To diagnose the causative reason, full blood analysis including the HIV status of the patient was done. The report of the patient was normal with all the complete blood count within normal range and the HIV status was negative. The patient's hemoglobin percentage was also normal stating that the patient was neither anemic nor immunocompromised. To discover the etiology, a microbial sample from the gingival area was taken. This sample was used for culture in Sabouraud Dextrose Agar (SDA) which showed Candida colonies after 3 days of incubation. To confirm the Candida albicans as the causative factor, the germ tube test was done which came positive. Now, the treatment plan included antifungal therapy.

The patient was prescribed topical antifungal drug nystatin cream 100,000 unit four times a day for 2 weeks. The patient showed remarkable improvement with no red band seen in the lower gingiva within 1 week [Figure 2].
Figure 2: Intraoral photograph post-treatment with a resolved lower lesion

Click here to view


Can you make the diagnosis: “A differential diagnosis included”

  1. HIV-associated linear gingival erythema (LGE)
  2. Chronic marginal gingivitis
  3. Candida-induced LGE
  4. Herpetic gingivostomatitis



   The Diagnosis and Discussion Top


C. Candida-induced linear gingival erythema (LGE)

LGE, formally referred to as HIV-gingivitis, is the most common form of HIV-associated periodontal disease in the HIV-infected population.[1] There is now evidence that this disease also occurs in HIV negative immunocompromised individuals and is not specific to HIV infection.[2] However, the prevalence of this lesion was significantly higher for HIV-infected children.[3]

In the above-reported case, the fact that this patient presented typical LGE lesions, which was resistant to conventional plaque-removal therapies, has led to a microbiological investigation. This investigation provided strong evidence that LGE in non-HIV-infected children may be considered of fungal etiology since Candida species were isolated from LGE lesion. In the current case, as the patient was non-immunocompromised but the mouth breathing due to incompetent lips and pubertal age could be the cofactor to aggravate the chronic gingivitis and causing normal commensal Candida to parasitic existence.

C. albicans was the most frequent species isolated, encountered in five of six patients, which confirms that such yeast is the main etiologic agent of mucosal candidiasis.[4] These findings corroborate the study of Velegraki et al. (1999) in which HIV-pediatric patients presented LGE with positive cultures for Candida.[5] They are also in agreement with the consulted literature which classifies LGE as a lesion of fungal etiology.[6] Previously reported case of a patient presented a mixed culture of C. albicans and Candida tropicalis, confirming the association of other species rather than C. albicans isolates with oral candidiasis. Another patient exhibited positive growth for Candida dubliniensis indicating that this species is also present in the oral pediatric HIV seropositive population.[7] The microflora of LGE may closely mimic that of periodontitis rather than gingivitis. However, candida infection has been implicated as a major etiologic factor, and human herpesviruses have been proposed as possible triggers or cofactors.[8]

LGE is characterized by intense gingival inflammation which does not respond to treatment with scaling and root planing or hygiene control. Although LGE may sometimes be unresponsive to corrective therapy, such lesions may undergo spontaneous remission. LGE-like lesions can sometimes be adequately managed by following the therapeutic principles associated with marginal gingivitis. However, as mentioned previously, it has been suggested that gingivitis lesions that respond to conventional therapy do not represent LGE. The affected sites should be scaled and polished. Subgingival irrigation with chlorhexidine or 10% povidone-iodine may be beneficial.

Treatment

The patient should be carefully instructed regarding the performance of meticulous oral hygiene procedures. The condition should be reevaluated 2–3 weeks after initial therapy. If the patient is compliant with home care procedures and the lesions persist, the possibility of a candida infection should be considered. The first treatment should be topical antifungal therapy, that is, oral nystatin suspension 2–5 mL, 4–6 times/day or clotrimazole troches 10-mg tablet, 3–5 times/day but it is doubtful that topical antifungal rinses will reach the base of the gingival crevices. Consequently, the treatment of choice may be the empiric administration of a systemic antifungal agent for 7 days such as fluconazole 3–5 mg/kg once daily or itraconazole 100 mg/day orally for children > 3 years of age or ketoconazole 5–10 mg/kg/day. It is important to remember that LGE is often refractory to the treatment. If so, the patient should be carefully monitored for developing signs of more severe periodontal conditions (e.g. necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, necrotizing ulcerative stomatitis). The patient should be placed on a 2- to 3-month recall maintenance interval and retreated as necessary.[9]


   Differential Diagnosis Top


HIV associated LGE

LGE, formally referred to as HIV-gingivitis, is the most common form of HIV-associated periodontal disease in the HIV-infected population. It is characterized by a fiery red, linear band approximately 2–3 mm wide on the marginal gingival accompanied by petechiae-like or diffused red lesions on the attached gingival. Unlike conventional gingivitis, LGE is not significantly associated with plaque. It is considered resistant to conventional plaque-removal therapies, being considered, nowadays, a lesion of fungal etiology.[10] The prevalence of this lesion varies widely in different studies, ranging from 0 to 48% probably because in many of them, LGE was misdiagnosed as gingivitis.[11],[12] According to recent studies, the prevalence of LGE ranges from 2 to 25%.[13]

LGE, most commonly associated with the upper and lower anterior dentition, has been observed in pediatric patients. Based on clinical experience, it has been determined that approximately 10% of children have this condition. These lesions usually do not cause clinical problems or interfere with nutrition.[14]

A literature search showed that very few cases have been reported of LGE without HIV. In the present case, the patient had gingivitis which later due to poor oral hygiene and superimposed candida infection, turned into LGE. The present case gives an insight into this condition that in such LGE cases it is not always HIV the causative agent.

Herpetic gingivostomatitis

It affects both the gingivae and other parts of the oral mucous membrane. The above patient did not complain of any ulceration in other parts of the oral cavity. Infection usually follows bouts of childhood fever. The onset of generalized gingivitis is preceded by a prodromal period with symptoms such as irritability, malaise, vomiting, and fever and the appearance of small vesicles that rupture to reveal small yellowish painful ulcers with erythematous margins.[15] The above patient did not have any history of fever or vesicles. The condition is associated with drooling of saliva, inability to chew and swallow and the child may become increasingly uncooperative during tooth brushing. The condition is self-limiting, the management is to encourage bed rest, plenty of fluid intakes, and maintenance of good oral hygiene through gentle debridement. Analgesics are prescribed to relieve the pain and antibiotics are useful in preventing superimposed bacterial infection.

Chronic marginal gingivitis

Gingivitis or inflammation of the gingiva is the commonest oral disease in children and adolescents. It is characterized by the presence of gingival inflammation without detectable bone loss or clinical attachment loss. In poor oral hygiene, food debris, plaque, and microorganisms also accumulate and the process of inflammation starts. This leads to gingivitis, which, if not taken care of can progress to the gradual destruction of supporting soft and hard tissues of the teeth. In such patients, local deposits such as plaque and calculus are the key to diagnosis and treatment with scaling and root planing or hygiene control it can be treated. In the above patient, the simple routine procedure did not correct the lesion, which leads us to identify the underlying cause.[14]

Class II malocclusion presenting with proclined incisors is usually associated with incompetent lips, causing the bacterial accumulation in the anterior dental area, the immunological role of saliva is reduced, and in long-term increases the frequency of periodontal lesions.[16] In the oral cavity, tissues are protected from desiccation by salivary mucins that bind with water and form a coating over the oral mucosa, thereby, maintaining the tissue's hydration.[17] In individuals with mouth breathing, alterations in the ecology of dentogingival area and hydration status of investing tissues of the periodontium may alter the healing response of periodontium after periodontal therapy. It has been reported that this plays a role in the gingival area.[18] In our patient, mouth breathing and decreased upper lip coverage could be the contributing factors for decreased response to scaling, so the patient was advised to undergo orthodontic treatment to prevent the recurrence of the condition.


   Conclusion Top


LGE is not always associated with HIV infection. The differential diagnosis for a patient with LGE should include candida infection, chronic gingivitis, and herpetic gingivitis. The clinician should obtain an in-depth medical history to investigate such a condition. If there are signs and symptoms suggesting a systemic disease such as HIV, appropriate diagnostic testing such as blood testing or cytology must be considered. Patients with LGE should undergo laboratory testing to ensure that any underlying disorders are diagnosed and treated at the earliest possible time.

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.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ramos-Gomez FJ, Petru A, Hilton JF, Canchola AJ, Wara D, Greenspan JS. Oral manifestations and dental status in paediatric HIV infection. Int J Paediatr Dent 2000;10:3-11.  Back to cited text no. 1
    
2.
Barasch A, Safford MM, Catalanotto FA, Fine DH, Katz RV. Oral soft tissue manifestations in HIV-positive vs. HIV negative children from an inner city population: A two-year observational study. Pediatr Dent 2000;22:215-20.  Back to cited text no. 2
    
3.
Grbic JT, Mitchell-Lewis DA, Fine JB. The relationship of candidiasis to linear gingival erythema in HIV-infected homosexuals and parenteral drug users. J Periodontol 1995;66:30-7.  Back to cited text no. 3
    
4.
Baumgartner C, Freydiere AM, Gille Y. Direct Identification and recognition of yeast species from clinical material by using albicans ID and CHROM agar Candida plates. J Clin Microbiol 1996;34:454-6.  Back to cited text no. 4
    
5.
Velegraki A, Nicolatou O, Theodoridou M, Mostrou G, Legakis N. Paediatric AIDS-related linear gingival erythema: A form of erythematous candidiasis? J Oral Pathol Med 1999;28:178-82.  Back to cited text no. 5
    
6.
Holmstrup P, Westergaard J. HIV infection and periodontal diseases. Periodontology 2000;18:37-46.  Back to cited text no. 6
    
7.
Brown DM, Jabra-Rizk MA, Falkler WA, Baqui AA, Meiller TF. Identification of Candida dubliniensis in a study of HIV-seropositive pediatric dental patients. Pediatr Dent 2000;22:234-8.  Back to cited text no. 7
    
8.
Newman MG, Takei H, Klokkevold PR, Carranza FA. Newman and Carranza's Clinical Periodontology, 13th Edition; Elsevier. Chapter Pathology and management of periodontal problems in patients with Human immunodeficiency virus infection; p. 370.  Back to cited text no. 8
    
9.
Scully C, Kabir M, Samaranayake LP. Candida and oral candidosis: A review. Crit Rev Oral Biol Med 1994;5:125-57.  Back to cited text no. 9
    
10.
Lamster IB, Grbic JT, Mitchell-Lewis DA, Begg MD, Mitchell A. New concepts regarding the pathogenesis of periodontal diseases in HIV infection. Ann Periodontal 1998;3:62-75.  Back to cited text no. 10
    
11.
Portela, Maristela Barbosa. Candida spp. In linear gingival erythema lesions in HIV- infeceted children: reports of six cases.”. Revista fluminense de odontologia 2013;1:51-55.  Back to cited text no. 11
    
12.
Umadevi M, Adeyemi O, Patel M, Reichart PA, Robinson PG. (B2) Periodontal diseases and other bacterial infections. Adv Dent Res 2006;19:139-45.  Back to cited text no. 12
    
13.
Leggott P. Oral manifestations of HIV infection in children. Oral Surg Oral Med Oral Pathol 1992;73:187-92.  Back to cited text no. 13
    
14.
Oh TJ, Eber R, Wang HL. Periodontal disease in the child and adolescent. J Clin Periodontol 2002;29:400-10.  Back to cited text no. 14
    
15.
Kolokotronis A, Doumas S. Herpes simplex virus infection, with particular reference to the progression and complications of primary herpetic gingivostomatitis. Clin Microbiol Infect 2006;12:202-11.  Back to cited text no. 15
    
16.
Geiger AM, Wasserman BH. Relationship of occlusion and periodontal disease: Part IX. Incisor inclination and periodontal status. Angle Orthod 1976;46:99-110.  Back to cited text no. 16
    
17.
Mandel ID. The functions of saliva. J Dent Res 1987;66:623-7.  Back to cited text no. 17
    
18.
Wagaiyu EG, Ashley FP. Mouthbreathing, lip seal and upper lip coverage and their relationship with gingival inflammation in 11–14 year old schoolchildren. J Clin Periodontol 1991;18:698-702.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

   Abstract Introduction The Diagnosis an... Differential Dia... Conclusion Article Figures
  In this article
 References

 Article Access Statistics
    Viewed73    
    Printed1    
    Emailed0    
    PDF Downloaded37    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]