Gingival enlargement unveiling sarcoidosis: Report of a rare case
A 36-year-old female patient reported to the Department of Periodontics, in our institute, with the chief complaint of generalized overgrowth of gums. Patient had noticed it from the past 10 years, which has gradually increased to the present state. Medical history was not significant. Patient was asked about endocrine abnormality (to rule out pregnancy gingivitis), intake of drugs like nifedipine, cyclosporine and phenytoin (to rule out drug induced gingival enlargement) and history of any allergy. All of which were negative. To rule out hereditary gingival fibromatosis, she was asked about family history, with particular importance to family dental history, which was negative. Her socioeconomic condition was poor and she was uneducated, belonged to a village. She gave a significant dental history of similar gingival overgrowth 12 years back which was treated by a local dental surgeon, then. Patient could not recollect the details regarding treatment given to her at that time. Two years after the treatment, patient noticed a recurrence of gingival enlargement and has been gradually increasing to the present state, much severe than previous one. Patient had difficulty in eating and pain in gums while brushing teeth, with occasional bleeding. Clinically she had severe generalized gingival enlargement, soft and spongy, reddish pink which bled on touching, particularly in lower anterior region where the enlargement almost covered the clinical crowns []. Her oral hygiene status was fair (Greene and Vermillion Index).[] She had missing teeth – 18, 35, 45, 48 (FDI Federation Dentaire Internationale System). She did not give any history about extraction of these teeth.\nAn orthopantomograph was taken which showed mild alveolar bone loss in upper and lower anterior teeth and missing (congenitally) 18, 35, 45, 48 [].\nTreatment consisted of oral prophylaxis (scaling and polishing procedures) and oral hygiene instructions. She was advised to rinse twice daily with 0.2% chlorhexidine mouthwash, 10 ml, 1:1 dilution for 15 days. After 1 month, on reevaluation, it was observed that the enlargement had not reduced in severity, size, clinical appearance and consistency and was same as 1 month back. Hence, the inflammatory cause of gingival enlargement was also ruled out and she was posted for surgical excision.\nInformed consent was taken prior to the surgical procedure. Lower anterior region was chosen for first surgical session as the enlargement was severest in this region. Surgical excision was performed under local anesthesia using the external bevel gingivectomy technique []. The excised tissue was submitted for histopathological examination which demonstrated non-caseating epithelioid cell granulomas, typical of granulomatous conditions, using hematoxylin and eosin staining []. Multinucleated giant cells were evident throughout the granuloma. Based on the histological findings, a number of special investigations were undertaken, to rule out various granulomatous diseases. Mantoux test and Sputum test was negative for tuberculosis. Complete blood count reports showed eosinophil count -24% (normal range 0-4%). Serum angiotensin converting enzyme (sACE) levels were - 1038.5 nkat/L (normal range lesser than 670 nkat/L). Chest X-ray showed hilar lymphadenopathy. Based on the histopathological examination, elevated sACE levels, increased eosinophil count and chest X-ray findings, diagnosis of sarcoidosis was made. The patient was referred to the physician for further investigations and treatment. Since she did not have symptomatic pulmonary involvement she was not given any medications for sarcoidosis and was kept under regular follow-up by the physician for 5 months. She did not show any symptoms of the disease and was referred back for treatment of gingival enlargement.\nOther areas of gingival enlargement were treated by external bevel gingivectomy. Patient was followed-up by us for 1 month after completion of full mouth gingivectomy and showed good healing with no signs of recurrence of gingival enlargement [] after which the patient went back to her village and has not reported again for follow-up.