Scurvy-scorbutic siderosis of gingiva: A diagnostic challenge - A rare case report
A 32-year-old male, farmer by occupation, presented to Dept of Periodontics ACPM Dental College and Hospital, Dhule district of Maharashtra, India, with severe pain and bleeding gums since 1 month.\nAccording to the patient, bleeding gums were associated with severe enlargement and pain that caused difficulty in speech, inability to eat, chew and carry out his routine oral hygiene practice. He also revealed that he had literally stopped consuming his regular diet and was only on liquids for the past 15 days owing to pain. Severe halitosis was noticed as he conversed about his problem.\nMedical history revealed that he was not on any medication known to induce gingival hyperplasia, but he admitted of having been hospitalized few years back owing to severe joint pain involving knees and elbows which had caused limitation of movements. Presently there were no medical reports available regarding it.\nFrom his diet history, he appeared to be a heavy tea drinker, consumed around 8-10 glasses of tea per day. His main diet included bread and milk.\nGeneral physical examination revealed some skin lesions resembling keratotic patches on the temple of face, abdomen and back of neck. His palms too revealed small red dots resembling petechiae, for which he had not consulted any dermatologist [Figures –].\nClinical examination of the periodontium revealed generalized intense dark red colored, painful gingiva with severe inflammation, involving mainly interdental papilla and the margins extending up to mucogingival junction. The gingiva appeared shiny bulbous with soft and spongy consistency [Figures and ]. There appeared whitish pseudo membranous slough over the cervical and interdental regions, revealing either poor oral hygiene or negligence. There appeared spontaneous bleeding on slightest provocation which persisted for few minutes (3-5 min). With these presenting features, a provisional diagnosis of necrotizing ulcerative gingivitis was thought of until there happened to appear a blackish discoloration at the provocated sites []. This observation stopped us from further detailed periodontal examination. The patient was advised for medical referral with complete blood examination and an orthopantomogram (OPG). The hemogram report, showed all the clinical parameters to be within normal limits except for platelet count which was 80,000/cu mm. After obtaining consent from the physician, a gingival biopsy was planned.\nThe next day, under the cover of antibiotics, anti inflammatory and vitamin C supplements, (Antibiotics - Amoxicillin 500 mg, Metronidazole 400 mg, and anti-inflammatory Ibuprofen-400 mg for five days, along with vitamin C supplements-250 mg q.i.d for 2 weeks) slow and gentle removal of necrotic slough with cotton swabs soaked in 3% hydrogen peroxide solution, was carried out, after application of topical anesthesia []. This was followed by irrigation with solution containing povidone and iodine. The superficial accretions were slowly removed with curettes without hurting the gingiva. An incisional biopsy was taken under local anesthesia. Further, a venous blood sample was drawn and sent to the laboratory to detect the neutrophil function. The patient was discharged with the advice of adequate rest and inclusion of a variety of nutritional supplements in his diet.\nMeanwhile, histopathological examination of the biopsy specimen confirmed it to be a case of scorbutic gingivitis. It showed presence of intra-epidermal vesicles and spongiosis in the squamous epithelium. The superficial areas of squamous epithelium show koilocytic change. The deeper connective tissue revealed marked vascularity and acute or chronic inflammatory exudates. Few of the areas also revealed subepithelial hemorrhages and capillaries revealed fibrin thrombi [Figures and ].\nA confirmed diagnosis of scorbutic siderosis of gingiva was made based on the collected information regarding clinical, histopathological, and medical examination.\nMeanwhile the neutrophil defect assay showed reduced chemotaxis and reduced phagocytosis activity. Phagocytic activity was depicted by reduced mean particle number of ingested Candida (Most probable number (MPN)-3). Neutrophil chemotaxis response towards N-formyl-methionyl-leucyl-phenylalanine was −1.1 mm in the present case. The values for the respiratory burst activity and intracellular killing activity by NBT (Nitroblue Tetrazolium) assay and candid cidal assay were within normal limits [].\nAfter 1 week, the patient returned and there was marked improvement at the site of the gingiva and at this time blood examination revealed the platelet count to be 1,30,000/cu.mm. Now a detailed periodontal examination was carried out, which revealed, grade three mobility with 31 and grade two mobility with 41. OPG revealed mild to moderate generalized bone loss []. The patient was advised for extraction of 31 for which he did not agree and insisted on retaining the teeth, therefore, a partial supragingival scaling was carried out. The patient was recalled after one week for subgingival scaling and root planning. At this time provisional splinting of the lower anterior teeth was carried out. The patient was counseled for proper oral hygiene maintenance and the importance of inclusion of fruits and vegetables in his diet were once again stressed. The clinical picture of the gingiva at the end of 2 weeks [Figures and ].\nThe patient returned after 3 months and there was remarkable improvement at the site of gingiva [Figures and ]. Bleeding on probing was minimal with no discoloration at the provocated site. Meanwhile the skin disorder was diagnosed as hyperkeratosis with ringworm infection (Tinea corporis), by the dermatologist and was advised vitamin C supplements, topical application of a steroid ointment and an antifungal cream. The patient is being followed up regularly for 1 year with no recurrence of the lesion so far.