Clinical and Microbiological Evaluations of Gingival Fibromatosis in Children
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PEDIATRIC DENTAL JOURNAL 14(1): 141–146, 2004 141 Case Report Clinical and microbiological evaluations of gingival fibromatosis in children: Report of two cases Kazuhiko Nakano, Naoko Nishiyama, Kiyoko Tamura, Hidekazu Sasaki and Takashi Ooshima Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry 1-8 Yamada-oka, Suita, Osaka 565-0871, JAPAN Abstract Gingival fibromatosis is a rare clinical finding of non-inflammatory Key words gingival overgrowth. Here we present 2 cases of children with gingival Children, fibromatosis and provide a longitudinal analysis of the correlation between Gingival fibromatosis, the presence of periodontal bacteria and clinical condition. The first case, a Periodontal bacteria, boy treated from age 2 to 6, showed periodontitis in the lower anterior region, Polymerase chain reaction which recovered to a good periodontal condition by a professional therapeutic approach. The second case is a girl, treated for 2 years from age 10, who presented with extremely enlarged gingiva and severe gingivitis, and a gingivectomy was carried out to eliminate the dental plaque accumulation. In both cases, periodontal bacteria were assessed periodically using PCR (Polymerase Chain Reaction) method, and the results compared with the clinical conditions. In both cases, increased numbers of periodontal bacteria were detected during the bad gingival condition period. In addition, Prevotella nigrescens and Prevotella intermedia were especially detected. Clinical condition seems to be influenced by the number of the periodontal bacteria present, which indicates that an effective monitoring of such bacteria would be beneficial for not only evaluating the current periodontal condition, but also for making an appropriate prognosis of a lesion. Introduction of the maxillary tuberosities. Gingival fibromatosis causes esthetic and functional problems such as Gingival fibromatosis is an uncommon gingival malposition of teeth, prolonged retention of primary overgrowth associated with increased levels of teeth, and delayed eruption of permanent successors. mature collagen1). The enlarged gingivae associated In addition, hyperplastic lesions produce conditions with this condition are usually normal in color, firm favorable for the accumulation of dental plaque, in consistency, painless, and occasionally nodular causing the secondary inflammatory changes of with little inflammation. Some patients have a gingivitis, though alveolar bone is not usually hereditary predisposition, whereas others have no affected4). apparent genetic link2). Gingival enlargement usually In our previous study5), we reported the detection begins with the eruption of primary or permanent of 10 putative periodontopathic bacteria found in dentition. However, some cases have been reported subgingival plaque from 144 healthy children (2–13 to be present at birth while others have not been years old, 12 subjects for each year of age) using a identified until adult life3). Gingival enlargement polymerase chain reaction (PCR) method. Capno- may be generalized or localized to a specific site, cytophaga ochracea, Capnocytophaga sputigena, though it is frequently found at the palatal surface Campylobacter rectus, and Actinobacillus actino- mycetemcomitans were found in approximately 50% Received on June 20, 2003 of those plaque samples from all ages. Prevotella Accepted on November 14, 2003 nigrescens was also frequently detected as aging, 141 142 Nakano, K., Nishiyama, N., Tamura, K. et al. a) a) b) b) c) Fig. 1 Oral photographs of case 1 Fig. 2 Periapical radiographs of case 1 a) 2 years 1 month b) 4 years 11 months c) 6 years 8 months a) 3 years 1 month b) 4 years 11 months whereas Bacteroides forsythus and Prevotella inter- cleaning was performed with a shorter interval media were detected less frequently, and Porphyro- between sessions. An excisional biopsy was performed monas gingivalis and Treponema denticola were not under infiltration anesthesia at the age of 4 years 1 found. The purpose of the present study is to describe month, which was submitted to routine histopatho- two cases of gingival fibromatosis identified in a logical examination. The histopathological features 2-year-old boy and a 10-year-old girl, as well as demonstrated the existence of a large number of report on the longitudinal examination of clinical irregular collagen fibers under the extended rete peg, conditions and periodontopathic bacteria using a which was diagnosed as a gingival fibromatosis. At PCR method. 4 years 9 months, dental plaque was found moderately accumulated in the region of the lower anterior teeth, Case Reports and tooth brushing instruction was given again. Two months later, at 4 years 11 months, his oral hygiene Case 1 was improved and the swelling had changed into A 2-year-1-month-old boy, who had a cleft lip and a non-inflammatory hyperplastic lesion (Fig. 1b), palate, was referred to the Pedodontic Clinic of Osaka however, alveolar bone losses were still found around University Dental Hospital for oral prophylaxis. the primary lower lateral incisors and canines (Fig. There was no dental caries detected, but non- 2b). The degree of swelling reduced as the patient inflammatory gingival overgrowth was found at grew older. At 5 years 11 months, oral hygiene was the labial site of the lower anterior region (Fig. 1a). judged to be fair, and the gingiva still showed non- Professional tooth cleaning was performed and inflammatory swelling. When the patient was 6 proper tooth brushing instruction was given. At 2 years 7 months old, the lower primary incisors had years 4 months of age, the swelling had increased, exfoliated and soon thereafter permanent successor while slight gingival inflammation and mobility of teeth emerged into the oral cavity (Fig. 1c). the teeth in the region were identified. At 3 years 10 months, the gingival condition had worsened and Case 2 periapical radiographs showed alveolar bone loss A 10-year-2-month-old girl was referred to our clinic around the primary lower lateral incisors and canines with the chief complaint of swollen gingivae in the (Fig. 2a). As a result, routine professional tooth incisor regions that caused an esthetic problem. A GINGIVAL FIBROMATOSIS IN CHILDREN 143 a) plaque index6), and gingival index7). Pocket depth was measured to the nearest millimeter at 6 points around the circumference of each tooth (mesio-, mid-, and disto-buccal; and disto-, mid-, and mesio- lingual) from the gingival margin to the deepest probeable point, using a round ended probe tip 0.4 mm in diameter. Bleeding on probing was scored immediate bleeding on probing, or (ם) ;as follows no bleeding. Tooth mobility was scored as (מ) b) follows; (2) moderate mobility (1–2 mm) in a bucco- lingual direction and (1) slight mobility (0.2–1 mm) in a bucco-lingual direction, or (0) physiological mobility within 0.2 mm. Pus discharge was scored as no (מ) spontaneous pus discharge, or (ם) ;follows pus discharge. Microbiological examinations Microbiological examinations were performed Fig. 3 Oral photographs of case 2 multiple times in both cases using a PCR assay. a) First visit at 10 years 2 months Subgingival plaque was collected from the lower b) Three months after gingivectomy at 11 years 2 months left primary canine in case 1 and the upper right permanent central incisor in case 2 with sterile Gracy curettes, and the samples were suspended clinical examination revealed severe generalized in 1 ml of sterile saline, after gently removing gingival overgrowth involving both the upper and supragingival plaque. Plaque samples in 1 ml of lower arches, which covered almost half of the saline were centrifuged at 15,000 rpm for 5 minutes tooth crown (Fig. 3a). She had no other medical to pellet the bacterial cells. Bacterial genomic DNA disorders and none of the members of her family had was then isolated from the pellet using a DNA gingivae problems. Dental plaque was found heavily isolation kit (Puregene, Gentra Systems, Minneapolis, accumulated in the region of the posterior teeth, MN, USA). which led us to initiate professional oral cleaning Expectorated whole saliva was collected from and tooth brushing instruction. At 10 years 5 months the patients and kept in sterile plastic tubes. The of age, her oral hygiene was still poor and at 10 years samples were mixed with Chelex 100 (Bio-Rad 8 months conventional gingivectomy was scheduled, Laboratories, Hercules, CA, USA) and incubated at as the gingiva had become inflamed. The procedure 56°C for 30 minutes, followed by boiling at 100°C was carried out under infiltration anesthesia at the for 10 minutes, as described by Mättö et al.8) Saliva age of 10 years 11 months and the histopathological samples were then centrifuged at 15,000 rpm for 20 diagnosis was gingival fibromatosis. When she was minutes and the supernatants were used as template 11 years 2 months old, the fibrous swelling had for PCR. completely disappeared and the periodontal condition Gram-negative anaerobic bacterial species, of the affected regions was shown to be almost P. gingivalis, T. denticola, C. ochracea, C. sputigena, normal (Fig. 3b). However, at 11 years 6 months of P. intermedia, P. nigrescens, C. rectus, A. actinomy- age, her oral hygiene was found to be poor with cetemcomitans, B. forsythus, and Eikenella corrodens the dental plaque accumulated in the region of the were selected, based on a list of putative peri- posterior teeth. Throughout the observation period, odontopathogens. The species-specific PCR primers alveolar bone loss was not