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Plasma Cell Gingivitis Associated with Dry Flower Buds

Plasma Cell Gingivitis Associated with Dry Flower Buds

pISSN, eISSN 0125-5614 Case Report M Dent J 2017; 37 (2) : 155-162 Plasma cell associated with dry flower buds of clove: a case report Naruemon Panpradit1 ,Puangwan Lapthanasupkul2 1 Department of Oral Medicine and Periodontology, Faculty of Dentistry, Mahidol University 2 Department of Oral and Maxillofacial Pathology, Faculty of Dentistry, Mahidol University (PCG) is an uncommon condition of the gingiva characterized by erythematous, edematous and easily-bleeding gingiva. Its etiology is unknown, but hypersensitivity reaction has been proposed. Here we reported a 35-year-old female who used dry flower buds of clove as herbal oral lozenge and later noticed redness of the and gingiva. Oral examination revealed fiery red gingiva with easily bleeding. Upper and lower labial mucosa showed moderate with slightly erosive surface and burning sensation. Histopathological examination revealed a hyperplastic epithelium with spongiosis and exocytosis. The lamina propria showed intense infiltration of mature plasma cells with a few lymphocytes and numerous dilated capillaries. These characteristics were compatible with the diagnosis as PCG. Additionally, we proceeded direct immunofluorescent (DIF) study of the lesion. Besides oral hygiene care and suggestion to refrain from causative agents as well as herbal related products, the use of systemic and topical corticosteroids brought successful treatment outcomes with no need for surgical procedures. There was no sign of recurrence during the period of 2-year follow-up. Key words: clove, corticosteroid, direct immunofluorescent (DIF) study, plasma cell gingivitis How to cite: Panpradit N, Lapthanasupkul P. Plasma cell gingivitis associated with dry flower buds of clove: a case report. M Dent J 2017; 37:155-162

Introduction some cases presented with burning sensation and pain [1,2,4,7-10]. Plasma cell gingivitis (PCG) is a rare The other names of PCG such as idiopathic inflammatory gingival condition with unknown gingivostomatitis, atypical gingivostomatitis, etiology. Clinical features mainly present as diffuse plasmacytosis of gingiva and allergic gingival erythema with edematous swelling, as gingivostomatitis are also mentioned in the well as smooth, shiny and velvety texture involving literatures [11-12]. Although the precise free gingiva and attached gingiva. The lesion etiopathogenesis is still unclear, the hypersensitivity shows a sharp demarcation and frequently reaction to some allergens such as components of extends to mucogingival border [1,2]. Sometimes chewing [11,13] and dentifrices [14-17] or desquamation, erosion and ulceration have also specific leaves [3,4,18] were reported. been reported [3,4]. Due to the , this The differential diagnosis includes the lesion is easily bleeding. PCG is seldom found as lesions that possess similar clinical characteristics, an exophytic mass mimicking including , [5,6]. Most of the cases are asymptomatic, but vulgaris, HIV gingivitis, and .

Corresponding author: Naruemon Panpradit, Department of Oral Medicine and Periodontology, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Rachathewee District, Bangkok 10400, Thailand Email: [email protected] Received : 31 January 2017 Accepted : 2 May 2017 Naruemon Panpradit, et al

Histopathological features of PCG consist of stopped using that herb. However, the reactions a dense infiltration of plasma cells in the further progressed and her gums had more subepithelial layer, resulting in a disruption to the swelling, more redness and severe burning basement membrane, and dilated capillaries [19]. sensation especially when contacting with hot, Hematological examination is one of the important spicy or sour foods, as well as the feeling of supplementary investigations to rule out other tension on the lips. Around 2 weeks before serious plasma cell lesions, including multiple presenting to Oral Medicine Clinic, she was myeloma or solitary plasmacytoma, since the prescribed with anti-inflammatory and anti-allergic histopathological changes of PCG mimic those drugs for 10 days with minimal reduction of the lesions [1]. . At the same time, the patient also received No standard protocol for the management of full mouth scaling. Besides the history of prolong PCG is available. In general, the management contact to dry flower buds of clove, she regularly starts with avoidance of known relevant allergens, along used herbal toothpaste containing clove. with plaque and oral hygiene control [3,4,13-15,20]. For medical history, patient had the last Some of cases ended up with surgical treatment medical check-up around 2 years ago and denied as gingivectomy and gingivoplasty [1,9,10,17,18,21,22]. any medical problems, except occasionally While the benefits of using topical and systemic experiencing mild burning stomach pain. She also corticosteroid are still controversy [12,21,23] , denied drug allergy, but had a history of allergic a few of other medications such as topical antibiotics reactions as itching and when wearing the [8] and anti-allergic drugs [24] are prescribed with Silver-contained accessories. Extra-oral successful results. examination was unremarkable except the lower This report presents a case of PCG that appeared as a slightly swelling. Intra-oral concomitantly occurring with mucositis of the examination revealed generalized edematous labial mucosa in a female who is firstly described swelling of upper and lower gingiva with fiery red to have a relevant cause of using dry flower buds color and glistening surface. The margin of lesion of clove. In addition, the description of direct at labial and buccal aspect of gingiva extended immunofluorescent (DIF) finding is also reported. up to mucogingival junction (figure 2A) and the inflamed gingiva showed easily bleeding up on gently provocation. Both upper and lower labial Case report mucosa showed moderate erythema with slightly erosive surface (figure 2B and 2C). Panoramic A 35-year-old female presented to Oral radiograph revealed no bony destruction, except Medicine Clinic, Dental Hospital, Faculty of lower right lateral incisor (tooth 42) had a periapical Dentistry, Mahidol University with the chief radiolucency (figure 3). Tooth 42 showed complaints of swollen gums and burning sensation. discoloration, negative to percussion and no The problems started since 2-3 months back, after response to electric pulp tester, confirming the she reported about using dry flower buds of clove diagnosis of with asymptomatic (figure 1) as herbal oral lozenge with the believe apical periodontitis, and was referred to an that it might help to improve the oral malodor. She endodontist for the root canal treatment. had put a bud onto the around At first visit, after history taking and oral 3 times per day, everyday for a month. During that examination, the incisional was done on time, the patient noticed redness of lips and had the labial gingiva around lower left lateral incisor spicy feeling on oral mucosa. As a result, she then and canine (tooth 32 and 33). Biopsy specimens

156 M Dent J 2017 August; 37 (2): 155-162 Plasma cell gingivitis associated with dry flower buds of clove: a case report were sent for histopathological and DIF investigations. In addition, blood investigation, urinalysis, chest x-ray and stool examination were also performed with insignificant results. The histopathological examination revealed a hyperplastic epithelium with thin elongated rete ridges and suprapapillary thinning. Spongiosis and exocytosis were noticed in the epithelium. The lamina propria showed an extremely intense infiltration of chronic inflammatory cells consisting Figure 1. Dry flower buds of clove. predominantly of mature plasma cells. Numerous dilated capillaries and a few lymphocytes were erythematous candidiasis. The result revealed no also seen (figure 4A and 4B). Taken together, growth of organisms. these characteristics were compatible with the The treatment began with systemic diagnosis of PCG. DIF results showed negative (-) corticosteroid as prednisolone 25 mg/day to immunoglobulin G (IgG), positive (+) to IgM, IgA (approximately 0.5 mg/kg). The prescription of and complement 3 (C3) at colloid bodies, + to omeprazole 20 mg/day was also added to prevent Fibrinogen (F) at dermal-epidermal junction. Due the side effects of corticosteroid since the patient to burning sensation and redness of the lesion, reported experience of mild bruning pain stomach candida culture swabbed from generalized if she unble to have a meal on time. A strong lesional mucosa was examined to rule out advice to refrain from any herbal contained

Figure 2. (A) Fiery red and edematous swelling gingiva extended to mucogingival junction. (B and C) Moderate erythema with slightly erosive surface on upper and lower labial mucosa. products such as toothpaste or foods and food ingredients was informed. After 6 days, the lesion had dramatically regressed by reducing in redness and swelling of gingiva and labial mucosa. Thereafter, the step for tapering dose of prednisolone was started. Additionally, topical corticosteroid as fluocinolone acetonide 0.1% in oral paste was prescribed to apply at the lesion 3 times/day. Then adjusted dose was performed Figure 3. Panoramic radiograph revealed no bony when the lesion was ameliorated. During the destruction, except tooth 42 showing follow-up visits along 2 months, the lesion was periapical radiolucency.

http://www.dt.mahidol.ac.th/division/th_Academic_Journal_Unit 157 Naruemon Panpradit, et al continuously improved. The stimulation of oral PCG is a peculiar oral lesion that is mainly hygiene care and periodic periodontal treatment believed to relate with the allergic reactions, were also constantly proceeded. However, signs though the exact cause and mechanism of of occasionally exacerbations including mild is still unknown [19]. The possible allergens were erythema and slightly swelling gingiva with slight herbal containing products. The herbs mentioned burning sensation when the patient tried some in the literatures were black pepper, black salt, foods containing herbs and spices were noticed. alum, ajwain [1], cinnamon [7,15], mint [7,17], Tvherefore, the management with topical clove [17], and acasia [22]. Some cases of PCG corticosteroid was used to control the lesion. The were associated with a direct contact or chewing clinical feature as completely free from the lesion the specific leaves such as khat [3,4] and colocacia was detected around 8 months after the initial (arbi) [18]. To the best of our knowledge, this is the treatment (figure 5A, 5B, 5C), since the patient first report that dry flower buds of clove is strictly avoided any kinds of foods or products a causative allergen. Clove, an important medical containing herbs. The periodically recall was plant, has a scientific name as Syzygium scheduled and the oral mucosa was showed the aromaticum or Eugenia cariophylata. The dry remission of PCG even at the 2 year-visit of follow-up. flower buds are extracted for essential oil or clove oil in which is the main compound. Since clove oil has various benefits such as antioxidant, Discussion antimicrobial, antinociceptive, and antiviral

Figure 4A. The mucosa shows a hyperplastic epithelium Figure 4B. A high-power view reveals numerous plasma with a heavy plasma cell infiltrate in the cells and dilated capillaries in the lamina lamina propria (hematoxylin-eosin, original propria (hematoxylin-eosin, original magnification x100). magnification x400).

Figure 5. (A, B, C) Gingiva and labial mucosa appeared normal after 8 months of treatment.

158 M Dent J 2017 August; 37 (2): 155-162 Plasma cell gingivitis associated with dry flower buds of clove: a case report activity, it is widely used in dental products [26,27]. application of chlorpheniramine maleate 25 mg In this case, the herbal toothpaste containing tablet crusting into powder form over the lesion 3 clove was also involved as a causative agent of times/day also led to complete resolution [24].. PCG which similar to the previous report using However, some studies presented that surgical herbal toothpaste containing mint and clove [17]. removal of hyperplastic gingival tissue with or Interestingly, even the meticulous history takings without laser technic was necessary after were done, many reports could not identify any noninvasive treatment was unsuccessful relevant or causative agents [2,8,9,12,21-24]. [1,9,10,17,18,21,22]. The diagnosis of PCG depended on In this case, the initial dose of prednisolone a history of contacting to allergenic causes and 25 mg/day (approximately 0.5 mg/kg) could bring heavy plasma cell infiltration in submucosal layer. dramatically regression within 6 days. After To rule out other immune mediated disorders that tapering systemic corticosteroid, PCG could be possess similar clinical characters such as controlled by application of fluocinolone acetonide pemphigus or pemphigoid DIF investigation was 0.1% in oral paste. However, the former studies performed. Our DIF results revealed as - IgG, + were disagreed with the affects of topical and IgM, IgA and C3 at colloid bodies, + F at dermal- systemic corticosteroids. One study reported epidermal junction. Only one study reported DIF successful treatment of 6 cases from 12 cases by information of PCG as nonspecific reaction on using systemic prednisone with the doses not IgG, IgM, IgA and C3 [23]. Another study showed exceeding 40 mg/day [12]. Another study reported an immunohistochemical examination revealing of the decrease of symptoms and inflammation, but IgG + plasma cells were 90% while of IgA and was unable to reach complete healing by topical IgM + cells were less than 5% [8]. These results 0.05% clobetasol proprionate or 0.05% seem to be different from our study. However, until fluocinonide [23]. Although, our case showed now there is no standard criteria for the diagnosis of complete healing and no recurrence within 2 year- PCG from DIF or immunohistochemical data. period of follow-up, the time to reach completely Further studies are required to gain more normal oral mucosa was long as 8 months. During information and knowledge. that time , there were signs of recurrences when The important management of PCG is to patient re-used herbal toothpaste containing absolutely avoid identified allergens or relevant clove, or contacting with spices and herb- products. Many studies showed the dramatically containing foods. Consequently, the advice for improvement merely refraining from the causative strictly refraining from causative agents and agents and intensive oral hygiene care relevant allergens is quite important and should be [3,4,13-15,20]. Combined treatment using repeatedly done. chlorhexidine gluconate mouthrinse was also Until present, only a few information reported [1,2,17,27]. The effective medication for regarding the pathogenesis of PCG is available. PCG was scarce. One reported case used topical There is no definite protocol or regimen for 2% fusidic acid in a tetracaine-containing adhesive treatment PCG. Therefore, our report of PCG in a ointment applying 4 times/day [8], while another 35-year-old female added more information of reported case used topical Fucibet that contained allergenic cause, clinical features, DIF findings, betamethasone and fusidic acid for applying at and the alternative way for successful treatment least 3 times/day [27]. The treatment with modified without surgical procedure.

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Acknowledgment: 11. Kerr DA, McClatchey KD, Regezi JA. Idiopathic gingivostomatitis. , , gingivitis syndrome; atypical gingivostomatitis, plasma-cell Associate Professor Dr. Supanee gingivitis, plasmacytosis of gingiva. Oral Surg Oral Rassameemasmaung for suggestions for revision. Med Oral Pathol 1971; 32: 402-23. 12. Silverman S Jr, Lozada F. An epilogue to plasma-cell Assistant Professor Dr. Jira gingivostomatitis (allergic gingivostamtitis). Oral Surg Kitisubkanchana for providing radiographic Oral Med Oral Pathol 1977; 43: 211-7. illustration. 13. Kerr DA, McClatchey KD, Regezi JA. Allergic gingivostomatitis (due to gum chewing). J Periodontol Funding: None 1971; 42: 709-12. Competing interests: None declared 14. Lamey PJ, Lewis MA, Rees TD, Fowler C, Binnie WH, Ethical approval: Not require Forsyth A. Sensitivity reaction to the cinnamonaldehyde component of toothpaste. Br Dent J 1990; 168: 115-8. 15. Anil S. Plasma cell gingivitis among herbal toothpaste References users: a report of three cases. J Contemp Dent Pract 2007; 8: 60-6. 16. Lamdari N, Pradhan S. Plasma cell gingivitis: a case 1. Mishra MB, Sharma S, Sharma A. Plasma cell report. J Nepal Med Assoc 2012; 52: 85-7. gingivitis: an occasional case report. N Y State Dent 17. Mukherjee M, Katarkar A, Bandyopadhyay P, J 2015; 81: 57-60. Chaudhuri K. A curious case of plasma cell gingivitis. 2. Agarwal S, Chaubey KK, Arora VK, Nirwal A, Thakur J Case Rep 2015; 5: 494-8. R, Madan E. Plasma cell gingivitis- a misnomer or 18. Bali D, Gill S, Bali A. Plasma cell gingivitis - A rare reality. J Adv Res Bio Sci 2013; 6: 58-62. case related to Colocasia (arbi) leaves. Contemp Clin 3. Marker P, Krogdahl A. Plasma cell gingivitis Dent 2012; 3, Suppl S2: 182-4. apparently related to the use of khat: report of a case. 19. Regezi JA, Sciubba JJ, Jordan RCK. Oral Pathology: Br Dent J 2002; 192: 311-3. clinical pathologic correlations. 6th ed. St. Louis: 4. Rawal SY, Rawal YB, Anderson KM, Bland PS, Stein Elsevier; 2012: 130-1. SH. Plasma cell gingivitis associated with khat 20. Arduino PG, D'Aiuto F, Cavallito C, Carcieri P, chewing. Perio 2008; 5: 21-8. Carbone M, Conrotto D, et al. Professional oral 5. Kumar V, Tripathi AK, Saimbi CS, Sinha J. Plasma cell hygiene as a therapeutic option for pediatric patients gingivitis with severe alveolar bone loss. BMJ Case with plasma cell gingivitis: preliminary results of a Rep 2015; doi: 10.1136/bcr-2014-207013. Online 14 prospective case series. J Periodontol 2011; 82: January 2016. 1670-5. 6. Shruthi S, Kumar S, Hegde U, Kumar V. Unusual 21. Janam P, Nayar BR, Mohan R, Suchitra A. Plasma cell clinical presentation of a case of localized plasma gingivitis associated with cheilitis: a diagnostic cell gingivitis. J Clin Diag Res 2011; 5: 1125-7. dilemma. J Indian Soc Periodontol 2012; 16: 115-9. 7. Parashis AO, Vardas E, Tosios K. Generalized 22. Makkar A, Tewari S, Kishor K, Kataria S. An unusual associated with a plasma clinical presentation of plasma cell gingivitis related cell gingivitis lesion: a case report and non-surgical to "Acacia" containing herbal toothpaste. J Indian Soc treatment. Clin Adv Periodontics 2015; 5: 91-8. Periodontol 2013; 17: 527-30. 8. Mahler V, Hornstein OP, Kiesewetter F. Plasma cell 23. Sollecito TP, Greenberg MS. Plasma cell gingivitis. gingivitis: treatment with 2% fusidic acid. J Am Acad Report of two cases. Oral Surg Oral Med Oral Pathol Dermatol 1996; 34: 145-6. 1992; 73: 690-3. 9. Dhir S, Mehendiratta M, Malhotra R, Gupta G. The 24. Ranganathan AT, Chandran CR, Prabhakar P, plasma cell : the diagnostic and Lakshmiganthan M, Parthasaradhi T. Plasma cell esthetic concerns. Indian J Oral Sci 2012; 3: 117-20. gingivitis: treatment with chlorpheniramine maleate. 10. Joshi C, Shukla P. Plasma cell gingivitis. J Indian Soc Int J Periodontics Restorative Dent 2015; 35: 411-3. Periodontol 2015; 19: 221-3.

160 M Dent J 2017 August; 37 (2): 155-162 Plasma cell gingivitis associated with dry flower buds of clove: a case report

25. Cortés-Rojas DF, de Souza CR, Oliveira WP. Clove oil, Eugenia caryophyllata (Syzigium aromaticum L. (Syzygium aromaticum): a precious spice. Asian Pac Myrtaceae): a short review. Phytother Res 2007; 21: J Trop Biomed 2014; 4: 90-6. 501-6. 26. Chaieb K, Hajlaoui H, Zmantar T, Kahla-Nakbi AB, 27. Vaidya P, Gupta U. Plasma cell gingivitis – a case Rouabhia M, Mahdouani K, et al. The chemical report. Indian J Dent Sci 2010; 2: 23-5. composition and biological activity of clove essential

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