Severe gingival enlargement associated with aggressive periodontitis
In the end of November 2005, an 18-year-old unmarried girl presented herself to the Department of Periodontology, The Oxford Dental College and Hospital, complaining of swollen gums in her upper and lower jaws. One month back, the patient had undergone an extraction adjacent to a localized swelling in the lower posterior teeth owing to hypermobility and pain. Post-extraction, the swelling gradually spread to envelop the entire dentition. She gave no previous history of any swelling and family history did not reveal anything of significance. The patient had received no other treatment except that she complained of frequent evening rise in temperature.\nOn physical examination, the patient was moderately built, but poorly nourished and anemic. She also had lack of extraoral melanin pigmentation. Three years back, she gave a history of having a wheatish complexion following which she developed hypopigmented patches on her forehead and arms. These hypopigmented areas soon spread to envelop the entire body. There was bilateral submandibular lymph node enlargement, which was tender and mobile. Her cheeks appeared to be swollen and she was unable to close her mouth due to severe enlargement.\nIntraorally, the gingiva seemed to be grossly enlarged - Grade IV gingival enlargement.[] The enlargement was firm and fibrotic accompanied by an inflammatory component probably due to her inability to maintain adequate personal oral hygiene. It was a generalized type of enlargement extending from the buccal to the lingual/palatal mucosa communicating interdentally exposing only the incisal edges of most teeth. The diffuse type of enlargement involved the marginal, interdental, and attached gingiva and was severe enough to displace the teeth out of occlusion. All the areas showed a combined probing depth with generalized mobility [Figure –]. Radiographically, orthopantamogram and full-mouth intra-oral peri-apical radiographs revealed the presence of remaining bone in the range of 30-35% [Figure and ].\nLaboratory tests, including blood biochemistry, were carried out, but failed to show any abnormality [Tables and ].\nIncisional biopsy was performed which showed stratified squamous epithelium and acanthosis at a few places. The subepithelial tissue was edematous and consisted of thin and delicate collagen fibers. The connective tissue was highly vascular with a number of capillaries infiltrated with lymphocytes and plasma cells and a few neutrophils and eosinophils suggestive of chronic non-specific inflammatory gingival hyperplasia.\nDue to the severity of the enlargement, initial therapy and subsequent oral hygiene maintenance were not possible. Full mouth gingivectomy was performed by electro-section and electro-coagulation method under local anesthesia. The surgery was performed sextant wise in six sittings. Supra- and subgingival scaling were performed under antibiotic coverage (Ciplox – TZ bd for 10 days) following 1 week after the last surgical procedure. Initially gross debulking cuts were given with an intention of undertaking a second step pocket reduction therapy with possible regenerative periodontal surgery [Figure and ].\nDue to personal reasons the patient did not return for the second procedure. Six-month post-operative when the patient visited the department, it was found that there was no recurrence and the patient was able to maintain oral hygiene adequately. Intraoral examination revealed a marked reduction in probing pocket depth with reduction in mobility of most teeth except the upper right first molar (# 16) tooth which presented itself with a soft and edematous swelling and exudation [Figure –].\nRadiographically, there was marked improvement in the crestal bone pattern except in 16 which showed extensive periapical pathology and was subsequently indicated for extraction.\nAn important observation made was that the patient developed patches of hyperpigmentation extraorally within a span of 6 months post-operatively.