Plasma-cell gingivitis

Plasma-cell gingivitis R. M. Palmer, B.D.S., F.D.S.R.C.S.(Eng.),* and J. W. Eveson, B.Sc., B.D.S., Ph.D., F.D.S.R.C.P.S.(Glas.), M.R.C.Path.,** London, England ROYAL DENTAL. HOSPITAL OF LONDON AND GUY’S HOSPITAL Two cases of plasma-cell gingivitis identical to those previously reported as so-called “allergic gingivostomatitis” are presented. Glossitis and cheilitis were absent in the present cases, however. There was no evidence that the lesions were allergic in nature. The distinctive clinical and histologic features of the lesion are described. T he presence of large numbers of plasma cells in the established lesion of chronic inflammatory periodontal disease can occasionally lead to difficulty in distin- guishing this common condition from the more exotic plasma-cell lesions reported to affect the gingiva. These include rare cases of extramedullary plas- macytoma, plasmacytosis of the gingiva,’ plasma-cell gingivitis,2 and plasma-cell granuloma.3 Plasma-cell gingivitis has been described under a variety of names, including atypical gingivo-stoma- titis,4, 5 idiopathic ging ivostomatitis,6 and allergic gin- givostomatitis. 7 The condition was frequently associated with cheilitis and glossitis, and many cases were thought to be an allergic reaction to a component of chewing gum. However, the condition, which appeared to be prevalent between 1966 and 1971, suddenly dis- appeared, and in 1977 Silverman and Lozada wrote an epilogue to plasma-cell gingivitis. It was presumed that an allergen producing a hypersensitivity reaction had been present in the suspected products for a limited period of time. Two cases of “plasma-cell gingivitis,” identical to the condition previously described in association with the symptom complex of allergic gingivostomatitis but without glossitis or cheilitis, are presented. CASE REPORTS CASE 1 A 29-year-old woman was referred for investigation of red, swollen gingivae in the upper anterior region. The medical history showed that the patient was allergic to house dust and suffered from asthma, for which she took salbutamol. Rou- tine hematologic investigations showed no abnormality. *Lecturer in Periodontology, Royal Dental Hospital of London. **Senior Lecturer, Department of Oral Medicine and Pathology, Guy’s Hospital. 0030-4220/81/020187+03$00.30/0 0 1981 The C. V. Mosby Co. Fig. 1. Case 1. Photograph showing erythematpus, faintly mottled involvement of attached gingiva in the upper anterior region. On examination, the patient had a bright red, faintly mot- tled area affecting the labial attached gingiva from the maxil- lary left canine to the right canine (Fig. 1). The lesion resem- bled localized chronic atrophic candidosis, but a smear taken from the area showed no candidal hyphae. The lesion was painless, and there was no cheilitis or glossitis. There was an associated marginal gingivitis, which resolved when the pa- tient’s oral hygiene improved. Despite the severely inflamed appearance of the affected gingiva, there was no significant loss of periodontal attachment. Elsewhere in the mouth there was early pocketing 2 to 4 mm. deep, which was most severe in the molar regions. The patient did not chew gum, and there was no obvious dietary cause. The patient was asked to dis- continue the use of toothpaste, but the lesion did not resolve. A biopsy specimen was taken from the gingiva, and the wound healed uneventfully. Histology There was epithelial hyperplasia, elongation of the rete ridges, and thinning of the suprapapillary epithelium, giving a psoriasiform appearance (Fig. 2). There was severe spon- 187 Oral Sure. February. IWI Fig. 2. Psoriasiform hyperplasia of the epithelium and dense plasma-cell infiltration of the corium. (Hematoxylin and eosin stain. Magnification, x40.) Fig. 3. Higher-power photomicrograph showing neutrophils in the superficial epithelium and characteristic plasma-cell infltration of the corium. (Hematoxylin and eosin stain. Magnification, x 350.) giosis and infiltration of the epithelium by inflammatory cells. The infiltrate in the deeper layers was predominantly lympho- cytic, but in the superficial layers neutrophils were conspicu- ous (Fig. 3). There was a dense, mainly plasma-cell infiltration of the corium. Dilated capillaries with neutrophil margination were present in the papillary corium. Special stains failed to show candidal hyphae. Manfbgwwnt The patient is undergoing treatment for chronic marginal periodontitis. A high standard of plaque control is being maintained in the affected area, but there has been no change in the clinical appearance. Empirical antifungal treatment has been ineffective. CASE 2 The patient, a 52-year-old man, complained of red, shiny gingivae which he had noticed for 5 months. The medical history showed that the patient had previously suffered from psoriasis and had Paget’s disease of bone. Examination showed that the labial gingiva from the maxil- lary right canine region to the left premolar region was bright red and had a spongy texture. The full width of the attached gingiva was affected, and there was sharp demarcation at the mucogingival junction. Patches of attached gingiva within the affected area were normal in appearance. The condition was painless, and there was no cheilitis or glossitis. There was chronic marginal gingivitis as a result of poor oral hygiene but no significant loss of periodontal attachment. Improvement of the oral hygiene led to resolution of the marginal gingivitis. but the underlying condition was unchanged. Dietary analysis did not show any obvious causative agents, and discontinua- tion of the use of toothpaste had no effect. The results of routine hematologic examination and serologic investigations Volume 51 Number 2 for iron, B12, and folate were within normal limits. After a biopsy specimen was taken from the affected area, the wound healed uneventfully. The histologic features were similar to those described in Case 1, but the inflammatory cell infiltration of the epithelium was more severe. Special stains failed to show candidal hyphae. In the deeper corium there was perivascular plasma- cell infiltration but no vasculitis. Management Topical ttiamcinolone in Orabase produced a limited im- provement in the condition. As the affected area was painless and did not progress to loss of periodontal attachment over a period of 2 years, no further treatment was undertaken. DISCUSSION The foregoing cases illustrate a distinctive plasma- cell lesion of the gingiva but without other features associated with atypical or allergic gingivostomatitis. The lesion has characteristic clinical features. The involved mucosa has a bright red, faintly stippled sur- face. It is sharply demarcated from the adjacent tissue and may extend from the gingival margin onto and beyond the mucogingival junction. There are no vesi- cles, bullae, ulcers, or associated white lesions. The lesions do not appear to be related to plaque accumula- tion. The clinical differential diagnosis includes mu- cous membrane pemphigoid, atrophic lichen planus, ’ ‘desquamative gingivitis” related to the climacteric, and candidosis. The histologic differential diagnosis includes can- didosis, geographic stomatitis, intraoral psoriasis, and extramedullary plasmacytoma. The cause of the condition is unknown, but it does not seem to be related to dental plaque. Both of the present patients had generalized chronic marginal gin- givitis due to plaque accumulation. Although the mar- Plasma-cell gingivitis 189 ginal gingivitis resolved when the patients’ plaque control improved, the underlying condition remained unchanged. The characteristic gingivitis, with a dense plasma-cell infiltrate, has previously been described in association with cheilitis and glossitis. It was assumed that this symptom complex was an allergic response to an unidentified antigen. No allergic basis for the lesions was detected in the present cases. The authors thank Mr. R. P. Juniper for permission to report Case 2, Mr. M. B. Edwards for supplying histologic material from Case 2, Professor R. A. Cawson for his con- structive criticism of the manuscript, and Mr. J. Mercer for his invaluable assistance with the photomicrographs. REFERENCES 1. Poswillo, D.: Plasmacytosis of the Gingiva, Br. .I. Oral Surg. 5: 194202, 1968. 2. Vickers, R. A., and Hudson, C. D.: A Clinicopathologic Investi- gation of “Plasma Cell Gingivitis,” I.A.D.R. Abstr. 755, p. 241, 1971. 3. Bhaskar, S. N., Levin, M., and Frisch, J.: Plasma Cell Granu- loma of Periodontal Tissues: Report of 45 Cases, Periodontics 6: 272-276, 1968. 4. Owings, J. R.: An Atypical Gingivostomatitis: A Report of Four Cases, J. Periodontol. 40: 538542, 1969. 5. Perry, H. O., Deffner, N. F., and Sheridan, P. J.: Atypical Gin- givostomatitis, Arch. Dermatol. 107: 872-878, 1973. 6. Kerr, D. A., McClatchey, K. D., and Regezi, J. A.: Idiopathic Gingivostomatitis, ORAL SURG. 32: 402-423, 1971. 7. Kerr, D. A., McClatchey, K. D., and Regezi, J. A.: Allergic Gingivostomatitis (Due to Gum Chewing), J. Periodontol. 42: 709-712, 1971. 8. Silverman, S., and Lozada, F.: An Epilogue to Plasma-Cell Gin- givostomatitis (Allergic Gingivostomatitis), ORAL SURG. 43: 211-217, 1977. Reprint requests to: Dr. J. W. Eveson Department of Oral Medicine and Pathology Guy’s Hospital London SE1 9RT, England