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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 122-124

An unusual association of gingival enlargement with generalized aggressive periodontitis combined with hypothyroidism and plasma cell gingivitis


1 Dental Surgeon, Health and Family Welfare Department, Jammu (J&K), (U.P), India
2 Department of Periodontology, TMDCRC, Moradabad, (U.P), India

Date of Web Publication29-Dec-2017

Correspondence Address:
Zoya Chowdhary
Dental Surgeon, Health and Family Welfare Department, Jammu (J&K)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_8_17

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   Abstract 


Gingival enlargements are most commonly encountered problem in day-to-day periodontal practice. They are classified on the basis of etiology, pathology, location, and distribution in the oral cavity. The enlargements may be associated with hormonal, nutritional imbalance or other local factors and systemic diseases. The combination of various conditions may lead to rapid progression leading to severe periodontal destruction. If they are not properly diagnosed and managed in time, may lead to further complications. Correct diagnosis should be made based on clinical and radiological examination along with the blood and histopathological investigations. Presenting an interesting rare case of generalized gingival enlargement associated with hypothyroidism, generalized aggressive periodontitis and plasma cell gingivitis, which was diagnosed and managed successfully in the Department of Periodontology.

Keywords: Generalized aggressive periodontitis, gingival enlargement, hypothyroidism, plasma cell gingivitis


How to cite this article:
Chowdhary Z, Mohan R, Mehrotra S. An unusual association of gingival enlargement with generalized aggressive periodontitis combined with hypothyroidism and plasma cell gingivitis. J Interdiscip Dentistry 2017;7:122-4

How to cite this URL:
Chowdhary Z, Mohan R, Mehrotra S. An unusual association of gingival enlargement with generalized aggressive periodontitis combined with hypothyroidism and plasma cell gingivitis. J Interdiscip Dentistry [serial online] 2017 [cited 2020 Jan 20];7:122-4. Available from: http://www.jidonline.com/text.asp?2017/7/3/122/221895




   Clinical Relevance to Interdisciplinary Dentistry Top


Gingival hyperplasia, also known as the “Gingival enlargement” is commonly encountered by the dentists in the day to day clinical practice. It may be associated with various systemic diseases, generalised aggressive periodontitis and plasma cell gingivitis. Focus should be on correct diagnosis of systemic and periodontal diseases and simultaneous interdisciplinary management of both the conditions, restoring normal functions with improved esthetics.


   Introduction Top


Gingival hyperplasia is a bizarre condition causing esthetic, functional, psychological, and masticatory disturbance of oral cavity; caused due to plaque accumulation, poor oral hygiene, inadequate nutrition, or systemic and hormonal disturbances.[1] Coexistence of gingival enlargement is a rare entity having limited review in the literature. Nitta H et al.[2] in 1993, Casavecchia P et al.[3] in 2004, Chaturvedi R[4] in 2009 and Sandhu et al.[5] in 2009; have reported cases of gingival fibromatosis with aggressive periodontitis in the past. The correct diagnosis and treatment plan form the most essential part of the treatment of gingival enlargement to achieve proper functional and esthetic harmony.

The authors report a case of coexistence of gingival enlargement with hypothyroidism, generalized aggressive periodontitis and plasma cell gingivitis and its successful management.


   Case Report Top


A 22-year-old unmarried female patient reported in the Periodontology Department with a chief complaint of swollen gums around the left upper and lower tooth region due to which facial asymmetry of the involved side was evident along with interference in speech and mastication. The patient gave a history of a similar lesion on the right side of upper and lower arches which was surgically excised along with the extraction of teeth (15, 16, 17, 46, and 47) 7 years ago. The patient also complaint of gradual weight gain since last 2 years.

Intraoral examination revealed, generalized gingival enlargement involving maxillary and mandibular arches of both sides [Figure 1]. The enlargement was firm and fibrous accompanied by secondary inflammation due to the inability of the patient to maintain adequate oral hygiene. On probing there was severe attachment loss, deep pockets with mobility of varying grades of all the teeth.
Figure 1: Preoperative photograph of the patient showing generalized gingival enlargement of both maxillary and mandibular arches

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Radiographic examination (orthopantomography) revealed generalized severe bone loss with one-third of remaining bone [Figure 2]. A provisional diagnosis of gingival enlargement with Generalized Aggressive Periodontitis was made. Routine hematological investigations were carried out which revealed 8.8% hemoglobin and differential leukocyte count of polymorphonuclear leukocytes 68%, lymphocytes 30%, monocytes 0%, eosinophils 2%, and basophils 0%. Acid phosphatase test 4.30 U/L, Thyroid function tests such as T3 0.84 ng/dl, T4 10.4 ng/dl, and thyroid stimulating hormone (TSH) 10.32 μIU/ml were performed, and diagnosing a case of Hypothyroidism.
Figure 2: Photograph shows radiographic findings showing severe bone loss of both maxillary and mandibular arches in a panoramic view

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An incisional biopsy was performed for histopathological investigation. It revealed para-keratinized stratified squamous epithelium, showing hyperplasia. The connective tissue stroma appeared densely collagenized, showing numerous dilated vascular channels along with numerous budding capillaries and an extremely dense chronic inflammatory cell infiltrate that is composed predominantly of plasma cells [Figure 3].
Figure 3: Photograph shows a histopathological finding of the gingival enlargement showing a para-keratinized stratified squamous epithelium with dense connective tissue stroma. It also shows dilated vascular channels with numerous budding capillaries, as well as an extremely dense plasma cells infiltrates

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Based on the above findings, the diagnosis of Gingival enlargement with Generalized Aggressive Periodontitis and Plasma Cell Gingivitis (associated with Hypothyroidism) was established.

Treatment

The patient was referred to a Physician for the management of hypothyroidism following phase I therapy, i.e., scaling and root planing of both the arches. The patient was evaluated after a month, the level of TSH was under control with the medication. A full mouth flap surgery was planned and executed for a period of 1 month for the elimination of pockets.

Postsurgical healing was uneventful. The patient was satisfied with the results [Figure 4] as her functions were restored.
Figure 4: Postoperative photograph of the patient showing satisfactory results

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   Discussion Top


Gingival enlargement of varying degree is the most commonly encountered clinical manifestations in periodontal practice. It may interfere in speech, proper brushing, and mastication causing great esthetic concern. These could be inflammatory, fibrotic, neoplastic, or maybe associated with systematic diseases. Coexistence of gingival enlargements with various conditions simultaneously is rare and only few cases have been reported till date.

Various cases of gingival fibromatosis with aggressive periodontitis have been reported in the literature by Nitta H et al,[2] Casavecchia et al.,[3] Chaturvedi,[4] Sandhu et al.,[5] Padmanabhan and Dwarakanath[6] and Dixit et al.[7] Although the coexistence of plasma cell gingivitis with aggressive periodontitis have been reported in the past,[8],[9] no such association has been reported earlier with hypothyroidism except for a case reported by Chaikin.[10]

The oral manifestations related to hypothyroidism may vary depending on extent and length of the deficiency, and euthyroid restoration and maintenance is a long-term goal.[11]

The present case reports the generalized aggressive periodontitis associated with gingival fibromatosis, plasma cell gingivitis and hypothyroidism. The case was successfully managed by a multi-disciplinary approach. As there is very little literature review on such coexistence and especially the association of hypothyroidism with gingival enlargement, so prospective epidemiological studies, as well as studies at molecular level, should be undertaken to understand the mechanism and association of the disease.


   Conclusion Top


Gingival enlargements of varying degrees are the most commonly encountered clinical manifestations in periodontal practice. The case becomes more challenging when associated with hypothyroidism, generalized aggressive periodontitis and plasma cell gingivitis, which has a synergistic effect on the progression of the lesion. A careful interdisciplinary treatment plan and execution of it is essential in order to restore the health, function and esthetics gaining over-all patient satisfaction and confidence.

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.
Regezi JA, Sciuba JJ. Connective tissue lesions. In: Oral Pathology: Clinical Pathologic Correlations. Philadelphia, PA, USA: W.B. Saunders; 1999. p. 179-83.  Back to cited text no. 1
    
2.
Nitta H, Kameyama Y, Ishikawa I. Unusual gingival enlargement with rapidly progressive periodontitis. Report of a case. J Periodontol 1993;64:1008-12.  Back to cited text no. 2
    
3.
Casavecchia P, Uzel MI, Kantarci A, Hasturk H, Dibart S, Hart TC, et al. Hereditary gingival fibromatosis associated with generalized aggressive periodontitis: A case report. J Periodontol 2004;75:770-8.  Back to cited text no. 3
    
4.
Chaturvedi R. Idiopathic gingival fibromatosis associated with generalized aggressive periodontitis: A case report. J Can Dent Assoc 2009;75:291-5.  Back to cited text no. 4
    
5.
Sandhu SP, Kakar V, Gogia G, Narula SC. Unilateral gingival fibromatosis with localized aggressive periodontitis (involving first molars): An unusual case report. J Indian Soc Periodontol 2009;13:109-13.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Padmanabhan S, Dwarakanath CD. Severe gingival enlargement associated with aggressive periodontitis. J Indian Soc Periodontol 2013;17:115-9.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Dixit A, Dixit S, Kumar P. Unusual gingival enlargement: A rare case report. Case Rep Dent 2014;2014:536312.  Back to cited text no. 7
    
8.
Saify F, Moda P. Idiopathic gingival fibromatosis associated with generalized aggressive periodontitis combined with plasma cell gingivitis: A rare case report. Oral Maxillofac Pathol J 2012;3:354-7.  Back to cited text no. 8
    
9.
Parashis AO, Vardas E, Tosios K. Generalized aggressive periodontitis associated with plasma cell gingivitis lesion: A case report and non-surgical treatment. Clinic Adv Periodontics 2013;84:1-12.  Back to cited text no. 9
    
10.
Chaikin BS. Report of a case of fibromatosis of the gingivae associated with a hypothyroidism. Periodontics 1965;3:306-9.  Back to cited text no. 10
    
11.
Burkhart NW. Hashimoto's disease: Hypothyroidism is autoimmune disease. RDH 2013;33(3). Available from: http://www.rdhmag.com/articles/print/volume33/issue3/columns/hashimoto'sdisease:hypothyroidism is autoimmune disease.html. [Last accessed on 2017 Jan 10].  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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