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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 94-97

Plasma cell gingivitis: A rare and perplexing entity


Department of Oral Medicine and Radiology, Farooqia Dental College and Hospital, Mysuru, Karnataka, India

Date of Web Publication8-Sep-2016

Correspondence Address:
Susmitha Hosagadde Rathnakara
Department of Oral Medicine and Radiology, Farooqia Dental College and Hospital, Mysuru - 570 021, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.189997

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   Abstract 

Plasma cell gingivitis, an infrequent benign entity, is an inflammatory or reactive condition of the gingiva to certain allergens or to an unknown factor. It is clinically characterized by erythematous, edematous, granular/cobblestone appearance of gingival surfaces with clear demarcation from the mucogingival junction. It easily bleeds on manipulation and may be associated with a burning sensation to spicy food consumption. Histologically, the lesion shows dense plasma cell infiltrate of the connective tissue. Here, we report a case of a 12-year-old girl, who presented with this rare condition, and its management with topical and systemic corticosteroids

Keywords: Allergic, inflammatory gingivostomatitis, Plasma cell gingivitis


How to cite this article:
Shivalingu MM, Rathnakara SH, Khanum N, Basappa S. Plasma cell gingivitis: A rare and perplexing entity. J Indian Acad Oral Med Radiol 2016;28:94-7

How to cite this URL:
Shivalingu MM, Rathnakara SH, Khanum N, Basappa S. Plasma cell gingivitis: A rare and perplexing entity. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2020 Oct 22];28:94-7. Available from: https://www.jiaomr.in/text.asp?2016/28/1/94/189997


   Introduction Top


Plasma cell gingivitis is an uncommon benign inflammatory condition of unclear etiology. It was first reported in the early 1970s as plasmacytosis of the gingiva. Various appellations used in the literature are idiopathic gingivostomatitis, plasma cell gingivostomatitis, atypical gingivostomatitis and allergic gingivostomatitis.[1] Predisposing factors found to be responsible for this condition reported in literature are toothpastes, food (chillies, cinnamon), mint, candies, chewing of khat leaves, colocasia leaves, and unknown origin.[2] There is no particular sex predilection or age distribution. The incidence appears to be mainly habit oriented. The diagnosis needs clinical and histopathological examination with hematological screening to rule out other clinically similar pathologic changes.[1]


   Case Report Top


A 12-year-old female patient visited our department with the complaint of swollen gums with burning sensation since 2 months. She revealed a history of bleeding on slight provocation and burning sensation on consumption of spicy food. Her medical, dental, family history and personal history were non contributory. There was no history of any allergy or parafunctional habits such as mouth breathing. No abnormalities were detected in her general physical and extraoral examination. On intraoral examination of maxillary and mandibular arch, the labial and palatal/lingual marginal gingiva and interdental papilla were edematous and erythematous. The labial/buccal attached gingiva was red in color, with loss of stippling and granular surface, extending up to the mucogingival junction, and predominantly involving the maxillary and mandibular anterior teeth. Areas of whitening and epithelial sloughing were also noted. The gingiva was free of ulceration and vesicles [Figure 1] and [Figure 2]. The position of the gingival margin was approximately 2–3 mm coronal to the cementoenamel junction, with altered contour and rolled out margins. On palpation, the gingiva was friable along with bleeding on minor provocation. Probing pocket depth was measured to be 2–3 mm. Nikolsky's sign was negative.
Figure 1: Pre-treatment image of maxillary gingiva

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Figure 2: Pre-treatment image of mandibular gingiva

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A provisional diagnosis of desquamative gingivitis secondary to lichen planus was given. In addition, a differential diagnosisof atypical gingivitis and leukemia-associated gingivitis were considered. Her complete hemogram values were within normal limits and peripheral smear impression of normocytic and normochromic was obtained. Screening orthopantomogram revealed no bony changes. Histopathologic examination of incisional biopsy specimen showed stratified squamous epithelium with predominant plasma cell infiltrate of the connective tissue component [Figure 3] and [Figure 4]. Based on these, a final diagnosis of plasma cell gingivitis was confirmed. Management of the patient was started by counselling the patient about the nature of the lesion. She was advised for oral prophylaxis and to maintain strict oral hygiene measure. Initially, she was prescribed antihistamine, tab levocetrizine 5 mg (once daily for 5 days), an immunomodulator, tab levamisole 50 mg (twice daily for 3 days), along with topical triamcinolone acetonide 0.1% in orabase application using soft splint and tab betamethasone 0.5 mg to be dissolved in water and used as mouth wash thrice daily for 15 days. As the patient did not respond, in phase 2 therapy, she was prescribed tab prednisolone 5 mg (20 mg/day in divided doses) for 7 days along with topical steroid application. Following which improvement was noted in the contour and texture of the gingiva with reduced edema. Then, the dose was gradually tapered from 15 mg/day in divided doses to 5 mg/day at weekly intervals. Patient presented with resolution of the lesion after 4 weeks of treatment [Figure 5] and [Figure 6]. She was advised to continue with topical steroid application for another week, which was also gradually tapered. Patient was regularly followed-up for about 6 months with no sign of recurrence.
Figure 3: Tissue sections stained with hematoxylin and eosin viewed at 40× magnification showing stroma with inflammatory infiltrate of abundant plasma cell component

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Figure 4: Tissue sections stained with hematoxylin and eosin viewed at 100× magnification showing stroma with inflammatory infiltrate of abundant plasma cell component

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Figure 5: Post-treatment image of maxillary gingiva

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Figure 6: Post-treatment image of mandibular gingiva

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   Discussion Top


Plasma cell gingivitis is considered to be a rare condition of gingiva and represents a hypersensitive reaction with predominant plasma cell infiltration of the connective tissue component of the epithelium with unclear etiology.[2] However, it has been hypothesized that the immunologic reaction to some allergic antigen might be the possible causative agent. Mint in the toothpaste, chewing gum, cinnamonaldehyde, strong spices, chilies, chewing of khat, and certain constituents of herbal toothpastes have been documented as the reported allergens in the literature.[2],[3],[4] Based on etiology, plasma cell gingivitis is categorized as three types: (1) lesions of unknown cause, (2) lesions owing to some allergen, and (3) lesions due to neoplastic origin.[2] This entity is thought to be a B-cell mediated disorder with T-cells augmenting the response.[5] In the present case, because the patient did not give any history of allergy or any recent change in her diet and oral habits, no cause could be elucidated.

This benign condition was first described in the year 1952 when Zoon referred to the term “plasma-cell infiltrate” condition involving the glans penis.[6] These conditions have also been reported on the lips, tongue, vulva, conjunctiva, nasal aperture, larynx, and epiglottis.[7] Kerr and his associates in the year 1971 reported a case of plasmacytosis of gingiva and revealed the most causative agent responsible for the allergic response to be chewing gum. He observed that if the patients discontinued the use of the chewing gum, the tissues returned to normal.[2],[3]

The most common clinical presentation of plasma cell gingivitis is an inflammatory, either generalized or localized erythematous, edematous, macular lesions with cobblestone/nodular or velvety appearance with a sharp demarcation at the mucogingival junction. Areas of whitening, epithelial sloughing, and erosions also have been observed.[6],[8] Whitening can be due to acanthosis and increase in the cellular spaces between keratinocytes with alternate area of atrophy.[7] Clinically, the whitish network with areas of atrophy led to the diagnosis of lichen planus in our case. The most consistent symptoms include oral pain, pruritis, burning sensation, and bleeding on manipulation. Clinical differential diagnosis may include any of the desquamative gingivitis, such as erythematous/erosive lichen planus, autoimmune vesiculobullous diseases, such as mucous membrane pemphigoid and pemphigus vulgaris, pubertal or pregnancy-induced gingivitis, and leukemia associated gingivitis. Laboratory investigations usually are within normal limits and sometimes an elevated erythrocyte sedimentation rate can be seen. Patch test to identify an allergen may be helpful. A biopsy would be of great help in differentiating other gingival conditions.[5] The most significant histological finding is dense sheets of plasma cells in the lamina propria; many dilated capillaries lie close to the surface, accounting for the marked erythema. The prognosis of this benign condition is considered to be good because of no malignant transformation potential.

Management is symptomatic and is directed toward the elimination of any allergic or predisposing factors, if any. Topical steroids may help reduce inflammation and speed healing. Intralesional triamcinolone injections and prednisone also have been tried. 2% fusidic acid has also been tried with some improvement in treatment of plasma cell balanitis. Gingivectomy may be needed to recontour lesions that are long standing and more fibrotic. Cryosurgery, electrocoagulation, and CO2 lasers have also been tried with certain therapeutic values.[5],[6],[7],[8],[9] In the present case, the patient did not show any improvement with oral prophylaxis and to topical steroid application, which may be attributed to noncompliance due to bitter taste of the topical steroid, however, responded positively to systemic steroid therapy with tapering dose.


   Conclusion Top


It is important that plasma cell gingivitis should be recognized as one of the entity in differential diagnosis of gingival conditions because diagnosis is dependent on correlation between clinical and histological examination. The present case is reported with the intention of bringing greater awareness of the condition of plasma cell gingivitis and its management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Bali D, Gill S, Bali A. Plasma cell gingivitis – A rare case related to Colocasia (arbi) leaves. Contemp Clin Dent 2012;3:S182-4.  Back to cited text no. 1
    
2.
Sangeeta D, Monica M, Ranjan M, Gunjan G. The plasma cell gingival enlargement: The diagnostic and esthetic concerns. Indian J Oral Sci 2012;3:117-20.  Back to cited text no. 2
    
3.
Anil S. Plasma cell gingivitis among herbal toothpaste users: A report of three cases. J Contemp Dent Pract 2007;8:60-6.  Back to cited text no. 3
    
4.
Rawal SY, Rawal YB, Anderson KM, Bland PS, Stein SH. Plasma cell gingivitis associated with khat chewing. Perio 2008;5:21-8.  Back to cited text no. 4
    
5.
Michael G. Burket's Oral Medicine. 12th ed. USA: Shelton (CT): People's Medical Publishing House; 2015.  Back to cited text no. 5
    
6.
Mohammed SA, Khaled AA, Nezar NA. Oral plasma-cell mucositis exacerbated by qat chewing – A case series. Saudi J Dent Res 2015;6:60-6.  Back to cited text no. 6
    
7.
Román CC, Yuste CM, González MA, González AP, López G. Plasma cell gingivitis. Cutis 2002;69:41-5.  Back to cited text no. 7
    
8.
Solomon LW1, Wein RO, Rosenwald I, Laver N. Plasma cell mucositis of the oral cavity: Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:853-60.  Back to cited text no. 8
    
9.
Gupta SR, Gupta R, Saran RK, Krishnan S. Plasma cell mucositis with gingival enlargement and severe periodontitis. J Indian Soc Periodontol 2014;18:379-84.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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