Plasma cell gingivitis - A rare case related to Colocasia (arbi) leaves

Abstract

Plasma cell gingivitis is an uncommon inflammatory condition of uncertain etiology often flavoured chewing gum, spices, foods, candies, or dentifrices. The diagnosis of plasma cell gingivitis is based on comprehensive history taking, clinical examination, and appropriate diagnostic tests. Here we are presenting a rare case of plasma cell gingivitis caused by consumption of colocasia (arbi) leaves. Colocasia is a kind of vegetable, very commonly consumed in the regions of North India.

Introduction

Plasma cell gingivitis (PCG) is a rare benign condition of the gingiva characterized by dense infiltrate of normal plasma cells separated into aggregates of collagen strands.[1] Plasma cell gingivitis is an uncommon inflammatory condition of uncertain etiology[2] often flavoured chewing gum, spices, foods, candies, or dentifrices.[3] Plasma cell gingivitis was first reported in early 1970s as plasmocytosis of the gingiva, idiopathic gingivostomatitis, plasma cell gingivostomatitis, atypical gingivostomatitis, and allergic gingivostomatitis. Clinically, these cases are limited to the oral cavity with symptoms of angular cheilitis, erythematous gingivitis and glossitis although one case was reported with laryngeal manifestation.[4]

The diagnosis requires haematological screening in addition to clinical and histopathological examination. Pathologic changes are clinically similar to those of leukaemia, HIV infection, discoid lupus erythematosis, atrophic lichen planus, desquamative gingivitis, cicatricial pemphigoid which must be differentiated through hematologic and serologic testing.[5,6]

Once the diagnosis of plasma cell gingivitis is made, it is still imperative to identify the antigen source of the inflammation.

A case of plasma cell gingivitis is presented here, in which the identification of the etiological agent was elusive.

Case Report

A female patient of age 48 years reported to Department of Periodontology and Oral Implantology of D.A.V (c) Dental College and Hospital, Yamunanagar (India) with chief complaint of swelling of gums in front region from last 6 months. Clinically, the patient presented with severe inflammation of the gingival tissues from the free gingival margin to the mucogingival junction in maxillary anteriors and premolars. Heavy plaque accumulations were present all around the teeth. The gingiva bled with the slightest provocation. There was negative Nikolsky sign and no evidence of any cutaneous lesions. There was no evidence of ulceration or, of a vesicular eruption. The patient exhibited moderate loss of periodontal attachment in maxillary anteriors [Figure 1].

Figure 1.

Pre-operative picture with gingival inflammation

The only positive finding was that patient had consumed colocacia leaves in her meals. After the consumption of these leaves, she had started developing all signs and symptoms.

Blood investigation was done to rule out leukaemia or any other blood dyscrasias. The complete blood count investigations were normal and patient presented no relevant medical history.

A provisional diagnosis of localised chronic periodontitis in maxillary anteriors with generalized diffuse gingivitis was made. Initial therapy included oral hygiene instructions, scaling and root planing. Patient was strictly advised for not consuming the leaves.

The removal of local factors did not resolve the condition even after 4 weeks. A decision was made to excise enlarged gingival tissue under local anaesthesia and excised tissue was given for biopsy with the written consent of the patient. Patient reported after 2 weeks and the healing was uneventful [Figure 2].

Figure 2.

Post-operative picture after 2 weeks of treatment

Histopathological Examination

H/E stained section revealed stratified squamous epithelium. The epithelium showed severe thinning over connective tissue pegs. The underlying connective tissue was highly infiltrated with plasma cells which were present within strands of collagen [Figure 3 (×10), Figure 4 (×40)].

Figure 3.

Histopathological picture of the excised tissue (×10)

Figure 4.

Histopathological picture of the picture showing plasma cells (×40)

Based on clinical features, histopathological features and history, a diagnosis of plasma cell gingivitis was made.

Discussion

Plasma cell gingivitis is an uncommon condition. The etiology of plasma cell gingivitis is not clear but due to obvious presence of plasma cells, it appears as immunological reaction to allergens such as tooth paste, chewing gums, mint and certain food.

The patient mentioned in this case report about development of symptoms after consuming colocacia leaves in her diet. Therefore, there is always a need to explore patient's habit before diagnosis and treatment planing.

In this case, patient reported with diffuse reddening of maxillary gingiva (anteriors and premolars) with oedematous swelling, which did not improve after conventional periodontal therapy. The differential diagnosis with cutaneous disorders (Desquamative lesions) was eliminated because of negative Nikolsky sign. Haematologic examination excluded leukaemia and lupus erythematosis.

The diagnosis of plasma cell gingivitis was made on the basis of histopathological examination of the excised gingival tissue. The presence of a large number of plasma cells in the established lesion of chronic inflammatory periodontal disease can occasionally lead to difficulty in distinguishing this condition from more exotic plasma cell lesion affecting the gingiva. These include rare case of extra medullary plasmacytoma, plasmacytosis of gingiva, plasma cell gingivitis and plasma cell granuloma.[7,8,9] Failure of response to conventional periodontal treatment alone and remission of condition after elimination of exposure to etiologic agent colocasia leaves confirmed the diagnosis of plasma cell gingivitis.

Conclusion

The diagnosis of plasma cell gingivitis is based on comprehensive history taking, clinical examination, and appropriate diagnostic tests. Histopathological examination is the key for differentiating plasma cell gingivitis from other mimicking lesions.