An unusual clinical presentation of plasma cell gingivitis related to “Acacia” containing herbal toothpaste
A 17-year-old girl was referred to the Department of Periodontics with the chief complaint of gingival overgrowth and mobility in her teeth for the last 2 years. She reported that the problem has begun in lower anterior and progressed involving both the arches. Patient appeared fit and indicated no current or previous systemic disease during her medical history interview.\nIntraorally, severe diffuse gingival enlargement of both the arcades (more pronounced on the right side) was observed covering almost all the surfaces of teeth and projecting into the vestibule [Figure –]. Gingiva was bright red, friable, fibrous as well as edematous in consistency. The erythema was disproportionate to the amount of plaque and calculus remaining on the dentition panoramic radiograph demonstrated generalized alveolar bone loss []. Probing depth ranged from 10 mm to 12 mm with an attachment loss of 7-9 mm and was more in the right molar region. Grade 2 mobility was present around the mandibular and maxillary first and second molars and grade 1 around the mandibular right premolars.\nLaboratory tests revealed no evidence of any systemic disease such as leukemia, scurvy and hormonal disorders.\nInternal bevel gingivectomy was performed in the maxillary arch and left mandibular region[]. Adjunctive amoxicillin (500 mg, 3 × 1) plus metronidazole (400 mg, 3 × 1) for 7 days was prescribed to treat AgP. Patient could not continue her treatment for personal reasons and when she reported after 1 year, the recurrence of gingival enlargement was noticed [Figure –]. Periodic panoramic radiographic examination revealed progressive alveolar bone loss, which was more pronounced on the right lower molars []. Biopsy showed hyperplastic stratified squamous epithelium along with ulceration of epithelium at places. Sub-epithelial tissue revealed a large number of normal plasma cells, few eosinophils and inflammatory granulation tissue [Figure and ]. A diagnosis consistent with PCG was made. To clarify whether this enlargement was due to a hypersensitivity reaction, the screening for the various antigenic substances was done. The patient was questioned about the habitual use of chewing gum, mouthwash and toothpaste. The only relevant history given by the patient was the use of herbal toothpaste (Babool, Dabur Oral Care Products, India) for the last 3-4 years. The patient was advised to discontinue the use of herbal toothpaste, which dramatically reduced the severity of enlargement within 2 weeks [Figure –]. Moreover, the patient herself switched on to other herbal toothpaste (Meswak, Dabur Oral Care Products, India) after discontinuing Babool toothpaste. Thus, it was highly probable that babul extract from the Babul tree “Acacia Arabia” was responsible for the gingival enlargement in the present case as all other constituents of both the herbal toothpastes are similar.\nBlood test (enzyme-linked immunosorbent assay) for allergy of toothpaste components disclosed very high level of allergen specific antibody and symptoms relation for Acacia (105 kUA/L; normal value < 0.35 kUA/L), which confirmed “Acacia” as causative allergen.\nRight mandibular second molar with hopeless prognosis was extracted. Although pocket depth reduced significantly from 10-14 mm to 6-8 mm, but clinical attachment level was not reduced significantly. Surgical procedures were carried out on right molar region to treat AgP and residual enlargement. Patient was advised to continue with regular toothpaste.\nPatient was recalled at 1, 3, 6 months and after that she was recalled at 6 months interval. No recurrence of gingival enlargement was noticed in both arches and probing depth ranged from 3 mm to 5 mm []. Panoramic radiograph showed no further progression of bone loss [].