390

Plasma Cell

Gingivitis

of Unusual

Origin.

A Case Francis G.

Report

Serio, * Michael A. Siegel,f and Brenda E. Sladex

Plasma cell gingivitis is a rare benign condition of the gingiva. It is marked by a dense infiltrate of normal plasma cells separated into aggregates by strands of collagen. It is a hypersensitivity reaction to some antigen, often flavorings or spices. The importance of this lesion is that it may cause severe gingival inflammation, discomfort, and bleeding and may mimic more serious conditions. Plaque control and conventional periodontal therapy alone will not cure this disease. The etiologic agent must be identified and the substance eliminated from use. This report outlines a case of plasma cell gingivitis which may have been brought on by the use of red peppers in cooking. J Periodontol 1991; 62:390-393.

Key Words: Gingivitis, plasma cell; hypersensitivity.

Plasma cell gingivitis is so named because of the prominent plasma cell infiltrate in the affected tissues.1 Hypersensitivity appears to be the underlying biologic phenomenon. Over the years, case reports of plasma cell gingivitis have appeared in the dental literature. In the 1940s and 1950s, several cases of mucosal hypersensitivity and Cheilitis secondary to the use of chewing gum were described.2,3 A resurgence of reports of hypersensitivity reactions including plasma cell gingivitis appeared in the late 1960s through early 1980s, these reactions brought on by the use of a particular flavoring agent, usually cinnamon, in gum.412 More recently, sensitivity reactions to the cinnamonaldehyde component of toothpaste has been reported.13 A disease complex consisting of plasma cell gingivitis, Cheilitis, and glossitis has also been described.14 In recent years, there have been very few reported cases of plasma cell gingivitis and the condition is currently thought to be quite rare.1,15 Other types of hypersensitivity reactions are still more commonly seen in the oral cavity.16 The importance of diagnosing plasma cell gingivitis is that the appearance of the gingiva can mimic a variety of more serious conditions. The gingival lesions may be similar to those of discoid lupus, lichen planus, cicatricial pemphigoid, or leukemia. The aggressive gingivitis which can be seen in HIV-positive patients must also be differentiated from plasma cell gingivitis. Once the histologie diagnosis of plasma cell gingivitis is made, it is still imperative to

'Department of Periodontics, Baltimore College of Dental Surgery, University of Maryland, Baltimore, MD. Department of Oral Medicine and Diagnostic Sciences.

Department of Prosthodontics.

identify the antigenic source of the inflammation. A case of plasma cell gingivitis is presented in which the identification of the etiologic agent was elusive. CASE REPORT A 37-year old female immigrant from India presented at the University of Maryland Dental School with a request to, "stop the bleeding gums." The patient had seen a dentist only twice before, the most recent time just prior to being referred to the University of Maryland. The only relevant finding in the medical history was an allergy to penicillin. The patient did not report a history of mouth breathing and did not use chewing gum. Clinically, the patient presented with severe inflammation of the gingival tissues from the free gingival margin to the mucogingival junction in both the maxillary and mandibular arches (Fig. 1). There were heavy plaque accumulations around all of the teeth. The gingiva bled with the slightest provocation. There was a negative Nikolsky sign (blister formation) when the gingiva was rubbed with a mirror handle and no evidence of any cutaneous lesions. The patient exhibited a moderate loss of periodontal attachment throughout the dentition and the attachment loss was most severe in the mandibular incisor region. The patient had no Cheilitis and the tongue was normal in appearance. A blood specimen was obtained in order to rule out leukemia or other blood dyscrasias. The complete blood count and differential were normal. An initial diagnosis of generalized moderate adult Periodontitis with associated generalized severe gingivitis was made.

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Figure 1- Clinical appearance upon initial presentation. There is severe inflammation throughout the body of the gingiva. Much of the inflammation is associated with the heavy accumulations of plaque and calculus. Initial therapy included oral hygiene instruction which recommended the use of a soft bristled brush, an interproximal brush, floss, scaling and root planing, and polishing coronal surfaces. The appearance of the gingiva improved with the removal of the plaque and calculus, but the marginal gingiva was still severely erythematous even after the inflammation resolved in the body of the gingiva. The erythema was dis-

proportionate to the amount of plaque and calculus remaining on the dentition. Two weeks of twice daily rinsing with 0.12% Chlorhexidine gluconate did not improve the clinical appearance of the gingival tissues (Fig. 2). Because removal of the local etiologic factors did not resolve the marginal gingivitis, a decision was made to biopsy the affected tissue. A 10 x 10 x 5 mm piece of gingival tissue was removed from the interdental papilla

J Periodontol

392

June 1991

PLASMA CELL GINGIVITIS

Figure 2. Clinical appearance after inflammatory control has been completed. Note the continuing severe marginal erythema and granulomatous appearance

of the tissue.

between the maxillary left lateral incisor and canine and processed for routine histopathologic examination. Microscopic examination disclosed normal appearing epithelium without acanthosis or ulcération. Foci of plasma cells separated by collagen septae were present in the connective tissue. There was no cellular atypia present (Fig. 3). A diagnosis consistent with plasma cell gingivitis was made. The patient was questioned about the habitual use of chewing gum, mouthwash, and toothpaste. Toothpaste and mouthwash were eliminated from the patient's daily regimen for a period of 2 weeks without any change in the clinical signs. Eventually, the patient reported that she used significant amounts of fresh and dried red peppers and chili peppers in cooking. Cessation of the consumption of red pepper for a period of 1 month resulted in significant improvement in the appearance of the gingiva (Fig. 4). DISCUSSION This case illustrates the need to explore a patient's individual background and habits when several possible etiologic agents have been eliminated and the desired clinical result is not obtained with conventional therapy. The initial presentation of severe gingival inflammation associated with adult Periodontitis necessitated the formulation of an extensive differential diagnosis. Most cutaneous disorders were eliminated from consideration by the lack of skin lesions and a negative Nikolsky sign. The leukémiás were eliminated by obtaining a normal complete blood count and differential. The patient had none of the risk factors associated with HIV infection. However, the patient's failure to respond appropriately to initial periodontal therapy necessitated a biopsy of the involved tissue. After initial therapy failed to resolve all of the gingival inflammation a biopsy was performed. The remaining lesions histologically resembled the lobulated arrangement of Bhaskar's so-called "plasma cell granuloma."5 Septae of

A. Low power photomicrograph of the biopsy specimen which reveals normal epithelium and foci ofplasma cells separated by connective tissue septae (original magnification x.35). B. High power photomicrograph of the biopsy specimen which reveals morphologically normal plasma cells without atypia (original magnification 250).

Figure 3.

connective tissue separating the aggregates of plasma cells aided in distinguishing the lesions from those of plaque induced chronic inflammation. Therefore, the diagnosis of plasma cell gingivitis was supported by the biopsy. The lesions were eventually resolved by identifying the etiologic agent and eliminating it from the patient's diet. A follow-up biopsy was not performed due to the benign nature of the lesions and the marked clinical improvement noted once the etiologic agent was removed from the diet. Recently, a plasma cell gingivitis related to the use of herbal toothpaste17 and 2 tartar-control toothpastes have been reported.13 The case presented here is the first reported involving red peppers and chili used in cooking. Histopathologically, it is important to differentiate among the various plasma cell tumors. Aggregates of plasma cells must be carefully examined. Morphologically normal plasma cells are common constituents of allergic soft tissue reactions. However, sheets of atypical plasma cells may represent multiple

myeloma, Waldenström's macroglobulinemia,

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prehensive history, examination, and appropriate diagnostic tests in order to arrive at a definitive diagnosis and treatment plan for gingival conditions which are refractory to conventional therapy. REFERENCES 1. Regezi JA, Sciubba JJ. Oral Pathology. Clinical-Pathologic Correlations. Philadelphia: WB Saunders; 1989:145. 2. Sugarman MM. Contact allergy due to mint chewing gum. Oral Surg Oral Med Oral Pathol 1950;3:1145-1147. 3. Miller J. Cheilitis from sensitivity to oil of cinnamon present in bubble gum. JAm MedAssoc 1941;116:131-132. 4. Poswillo D. Plasmacytosis of the gingiva. BrJ Oral Surg 1968;5:194202. 5. Bhaskar SN, Levin MP, Frisch J. Plasma cell granuloma of periodontal tissues. Report of 45 cases. Periodontics 1968;6:272-276. 6. Owings JR. An atypical gingivostomatitis: A report of four cases. / Periodontol 1969;40:538-542. 7. Kerr DA, McClatchey KD, Regezi JA. Allergic gingivostomatitis (due to chewing gum). J Periodontol \91\· 2: 09- \2. 8. Silverman S, Lozada F. An epilogue to plasma-cell gingivostomatitis (allergic gingivostomatitis). Oral Surg Oral Med Oral Pathol

1977;43:211-217. RE, Hoover D, Dunlap C, Gier R,

9. Paul

Alms T. An immunologie investigation of atypical gingivostomatitis. / Periodontol 1978;49:301-

Final healing after discontinuing the use of the red peppers for 2 months. The patient has been able to maintain this gingival health for more than 1 year.

Figure 4.

solitary plasmacytoma.

These latter diseases are cause because of their potential morbidity or mortality. The histopathologic appearance of the specimen presented here was benign. The resolution of the gingivitis once the causative agent was identified and removed from the patient's diet confirmed the diagnosis of plasma cell gingivitis. This case underscores the necessity of a comor

for great

concern

305. 10. Palmer RM, Eveson JW. Plasma-cell gingivitis. Oral Surg Oral Med Oral Pathol 1981;51:187-189. 11. Lubow RM, Cooley RL, Hartman KS, McDaniel RK. Plasma-cell gingivitis. Report of a case,. J Periodontol 1984;55:235-241. 12. Allen CM, Blozis, GG. Oral mucosal reactions to cinnamon-flavored chewing gum. J Am Dent Assoc 1988;116:664-667. 13. Lamey P-J, Rees TD, Forsyth A. Sensitivity reaction to the cinnamonaldehyde component of toothpaste. BrDentJ 1990;168:115-118. 14. Kerr DA, McClatchey KD, Regezi JA. Idiopathic gingivostomatitis. Oral Surg Oral Med Oral Pathol 1971;32:402-423. 15. Shafer WG, Hine MK, Levy . Textbook of Oral Pathology. 4th ed. Philadelphia: WB Saunders; 1983:773-774. 16. Archard HO. Biology and pathology of the oral mucosa. In: Fitzpatrick TB, Eisen AZ, Wolff , Freedberg IM, Austen FK, eds. Dermatology in General Medicine. 3rd ed. New York: McGraw-Hill; 1987:1177-1178. 17. Macleod RI, Ellis JE. Plasma cell gingivitis related to the use of herbal toothpaste. Br DentJ 1989;166:375-376. Send reprint requests to Dr. Francis G. Serio, Baltimore College of Dental Surgery, University of Maryland Dental School, 666 West Baltimore Street, Baltimore, MD 21201. Accepted for publication January 9, 1991.