Foreign body gingivitis: clinical and microscopic features of 61 cases

Increased frequency of oral plasma cell mucositis/plasma cell gingivitis after the COVID-19 pandemic: a 23-year retrospective analysis and review of diagnostic challenges relating to this condition

OBJECTIVE

Oral plasma cell mucositis (PCM) or localized plasma cell gingivitis (PCG) is an idiopathic inflammatory condition often associated with hypersensitivity reactions. This study aimed to evaluate the frequency and features of PCM/PCG in a large biopsy service over a time period of more than 20 years.

STUDY DESIGN

The biopsy archives at University of Florida College of Dentistry were searched from 2000 through the first quarter of 2023 for cases of oral PCM or PCG. Case data were aggregated and analyzed.

RESULTS

A total of 107 cases were included. Between 2000 and 2019, PCM/PCG was diagnosed in 0.03% of all biopsy cases. Starting in 2020 through 2023, the percentage of biopsies diagnosed as PCM/PCG increased threefold to 0.10% of all biopsy cases, and the mean patient age increased by 3 years. There were no statistically significant differences between cases diagnosed from 2000 to 2019 and those from 2020 to 2023 regarding age, sex, location, or histology.

CONCLUSIONS

A significant increase in PCM/PCG was identified in this study at one institution coinciding with the start of the COVID-19 pandemic. Further investigation is recommended to determine if this is a widespread phenomenon and identify possible etiologic mechanisms.

Plasma Cell Gingivitis and Its Mimics

Plasma cell gingivitis (PCG) is an inflammatory condition that affects the gingival mucosa of the oral cavity. It is characterized by polyclonal dense plasma cell infiltrate in the connective tissue. Lesions do not respond to prophylactic treatment. Etiology is most likely hypersensitivity to certain antigens (eg, toothpastes, oral rinses, chewing gums, spices). Differential diagnosis of PCG includes reactive, granulomatous, and neoplastic lesions. The diagnostic workup is based on patient's history and the clinicopathologic correlation to rule out mimics of PCG. Dermatologic patch test may be indicated in chronic conditions to identify the allergen.

Gingival lichen planus: A clinical and pathological study

BACKGROUND

Oral lichen planus (OLP) is a common immune-mediated chronic inflammatory disease affecting the oral mucosa. It is most likely to occur in adults, particularly in women. The most commonly affected areas are the buccal mucosa, tongue and gingiva, either alone or in combination. The aim of this study was to analyse the clinicopathological characteristics of gingival lichen planus in a series of patients diagnosed between 2000 and 2019.

MATERIALS AND METHOD

Files of 190 patients with histopathologically confirmed gingival lichen planus were retrieved from the archives of the Laboratory of Oral and Maxillofacial Pathology of the Geneva University Hospitals. We analysed the demographic characteristics of the patients, the location, clinical presentation and histopathological characteristics of the lesions, and the presence of symptoms.

RESULTS

The majority of the patients were women (74.2%). The age ranged between 12 and 88 years of age, with a mean of 58.6 years. 79 cases (41.6%) of gingival lichen planus were confined to the gingiva. In the remaining cases, the gingival lesions were associated with other localisations, mostly the buccal mucosa and the tongue, as well as other intraoral and extra-oral sites. 38.7% of the patients presented mixed form of OLP, 27.8% keratotic form and 22.4% erythematous/erosive form. The mixed and the erythematous/erosive forms were the most symptomatic lesions. The majority of gingival lichen planus were active atrophic. A total of seven malignant transformation were found (3.7% of the cases).

CONCLUSION

Gingival lichen planus is a chronic disease that can have many different clinical and histological presentations. Long-term regular follow-up of gingival lichen planus is recommended to detect signs of malignant transformation.

Oral cyst-like nodule caused by a long standing unusual embedded foreign object: Report of a case

Traumatic implantation of foreign material in the oral mucosa is unusual and may occur. In this article, we report the presence of an unusual foreign object associated with a cyst-like inflammatory response in a 50-year-old male. The patient presented with a painless recurrent soft tissue swelling in the anterior vestibule of maxilla of at least 2-year duration. The lesion was surgically excised and a retained shrapnel-like object within a cyst-like and thick-walled structure was obtained. Histopathologically, the cyst-like structure exhibited a lymphohistiocytic infiltrate in the wall and a luminal synovial metaplasia-like change, predominantly composed of histiocytes. Immunohistochemical stain of CD163 highlighted the histiocytes. The patient stated a history of traumatic implantation of shrapnel fragments in the area that occurred 30 years ago due to an explosion in the Iran-Iraq war.

Investigation of foreign materials in gingival lesions: a clinicopathologic, energy-dispersive microanalysis of the lesions and in vitro confirmation of pro-inflammatory effects of the foreign materials

OBJECTIVES

This study aimed to evaluate the clinical and histopathologic features of gingival lesions containing foreign material (GLFMs). In parallel, the composition of the foreign material and its effects in primary human gingival fibroblasts (HGFs) were investigated.

STUDY DESIGN

Eighty-six GLFMs were retrieved from an oral pathology biopsy service. Clinical and microscopic data were analyzed, and the composition of the particles was identified by using energy-dispersive X-ray spectroscopy (EDX). Furthermore, HGFs were stimulated with silica (SiO₂) microparticles to investigate the production of collagen type 1 (COL-1), matrix metalloproteinase 2 (MMP2), and inflammatory cytokines.

RESULTS

GLFMs were most commonly found in women (60.5%) and most frequently described as white plaques. Histopathologic examination identified verrucous hyperplasia in 59% and epithelial dysplasia in 28% of the cases. EDX microanalysis revealed that Si (94%) was the most frequently detected foreign element. SiO₂ microparticles induced higher COL-1 expression; higher levels of proinflammatory cytokines, such as interleukin-6 (IL-6), IL-8, and transforming growth factor-β, and increased MMP-2 activity in HGFs.

CONCLUSIONS

There was a strong association between the presence of foreign material in the gingiva and white verrucous clinical lesions. In addition, the most common element in the foreign material was Si, and our in vitro findings demonstrate the importance of silica-mediated effects on gingival fibroblasts.

Lichenoid reaction with granulomatous stomatitis: A retrospective histologic study of 47 patients

OBJECTIVES

Lichenoid granulomatous reaction can be subcategorized into lichenoid granulomatous dermatitis or lichenoid granulomatous stomatitis. It is described in the literature as demonstrating a band-like lichenoid infiltration with clusters of histiocytic or granuloma formation. In this study, we presented a large case series of lichenoid granulomatous stomatitis including demographics, histological features, and subcategories and compared findings with current literature.

METHODS AND MATERIALS

We retrieved all cases diagnosed with lichenoid reaction with granulomatous inflammation between January 1, 2000, and August 1, 2016, from the University of Florida Oral Pathology Biopsy Service Archives.

RESULTS

A total of 47 patients with tissue from 50 biopsy sites were included. The majority of the cases were noted in females (64%) with a mean age of 59 years (range 30-88). Most patients were Caucasian, and the most common sites in descending order were: gingiva, buccal mucosa, vestibule, tongue, lip, palate, and occasional multifocal involvement. Clinical impressions by the treating clinicians included leukoplakia, dysplasia, carcinoma in situ, squamous cell carcinoma, lichen planus, vesiculobullous disease, trauma, and allergy. The histologic features of these cases ranged from lichenoid mucositis with numerous aggregates of histiocytes to well-formed granulomas, in accordance with previous classifications of similar dermatologic lesions. All cases revealed positive CD 68 in the histiocytic infiltrates and were negative for microorganisms utilizing acid-fast bacilli, Grocott methenamine-silver, and periodic acid-Schiff stains.

CONCLUSION

Lichenoid granulomatous disease may be more common than previously reported; however, its etiology remains unknown and patients should be kept under long-term clinical follow-up.

An unusual microscopic pattern of foreign body reaction as a complication of dry socket management

Foreign body reactions in the oral cavity are relatively common, frequently resulting from iatrogenic causes. Depending on the nature of the foreign material, various microscopic patterns may be observed, causing diagnostic difficulties. Recognition of the ensuing unusual microscopic pattern, especially for cases in which the possibility of a foreign body reaction is not entertained in the clinical differential diagnosis, necessitates sufficient degree of suspicion, familiarization with the spectrum of microscopic appearances, and careful clinicopathologic correlation. Medicated dressings of various compositions are commonly placed for prevention or management of dry socket (or alveolar osteitis, a common postoperative complication of tooth extraction) and may be a cause of foreign body reaction. Here, we report a foreign body reaction to a medical dressing material in a postextraction socket, with an unusual microscopic pattern bearing resemblance to parasitic infestation.

An unusual green macular lesion of the gingiva: a foreign-body granulomatous reaction

The current clinical case highlights the diagnostic process in characterizing an unusual green macular lesion of the maxillary gingiva. A review of the history revealed that the patient had suffered trauma to the oral tissues during a soccer match 2 years prior. An incisional biopsy was performed and microscopic analysis demonstrated the presence of a granulomatous reaction to a needle-shaped, birefringent foreign material. Comparative analysis of a specimen collected from the soccer field confirmed that the foreign material was artificial grass. Foreign material was also found inside the gingival epithelial cells.

Chronic swelling from entrapment of acrylic resin in a surgical extraction site

When acrylic resin is inadvertently embedded in oral tissue, it can result in a pronounced chronic inflammatory response. This report describes a case in which temporary crown and bridge resin was forced into a surgical extraction site after the two adjacent teeth were prepared for a bridge immediately following extraction of a maxillary premolar. The patient experienced swelling at the extraction site over a ten month period despite treatment with antibiotics and anti-inflammatory drugs. After detection and removal of the foreign body, the symptoms resolved. The episode contributed to periodontal bone loss around an adjacent tooth. While morbidity of this nature is rare, this case reinforces the need to investigate persistent signs of inflammation and account for dental materials that are lost during the course of treatment.

Orthodontic elastic separator-induced periodontal abscess: a case report

Aim. Orthodontic elastic bands were proposed as being the source of gingival abscesses that can rapidly lead to bone loss and teeth exfoliation. We report an adolescent, otherwise, healthy patient whose periodontal status was sound. Shortly after undergoing preparations for orthodontic treatment consisting of orthodontic separators, he presented with a periodontal abscess for which there was no apparent etiology. A non-orthoradial X-ray was inconclusive, but an appropriate one revealed a subgingival orthodontic separator as the cause of the abscess. Removal of the separator and thorough scaling led to complete resolution of the abscess, but there was already residual mild damage to the alveolar bone. Summary. Failure to use appropriate imaging to reveal the cause of gingival abscesses can result in the delay of implementing treatment and halting irreversible alveolar bone loss. An inflammatory process restricted to the gingiva and refractive to conventional therapy should raise the possibility of a foreign body etiology.

Gingival Involvement of Oral Lichen Planus

BACKGROUND

Oral lichen planus (OLP) is one of the most common oral mucosa disorders. OLP gingival involvement is very frequently observed and is characterized by a wide range of clinical appearance, symptomatology, and locations. The purpose of this study was to analyze the prevalence and clinical aspects of gingival lesions in a series of 213 patients affected by OLP.

METHODS

We analyzed the prevalence and clinical aspects (location, morphology, and symptomatology) of the gingival lesions in a total of 213 clinically and histopathologically assessed patients affected by OLP.

RESULTS

Gingival lesions were diagnosed in 38.4% of cases. White lesions were the most frequently observed in the gingiva (42.7%), followed by mixed lesions (31.7%), and red lesions (25.6%). For the three clinical forms, the most frequent gingival location was the simultaneous involvement of the attached and marginal gingiva. None of the white lesions presented symptomatology, whereas most red lesions or mixed forms presented symptoms that varied from discomfort to severe oral pain or a burning sensation.

CONCLUSIONS

Considering the high frequency of gingival involvement in OLP, the diversity of clinical manifestations, and its potential relationship with general and oral health in patients, periodontists should be familiar with the most common clinical aspects of OLP in the gingiva.

Foreign body gingival lesions: distribution, morphology, identification by X-ray energy dispersive analysis and possible origin of foreign material

BACKGROUND

Foreign material may cause and aggravate gingival lesions. This is rarely considered clinically. The lesions are resistant to frequently protracted conventional therapy. The foreign material is often inconspicuous and easily overlooked by the pathologist.

METHODS

85 cases of gingival lesions containing foreign material were investigated by conventional and polarization light microscopy, focusing on the morphology and optical characteristics of the foreign substance. Supplemented with the results of X-ray energy dispersive analysis the foreign material was compared with commonly used dental materials.

RESULTS

The foreign material was most frequently compatible with amalgam. Inconspicuous crystals, often revealed only by polarization microscopy, were most commonly compatible with abrasives, particularly corundum and silicates, and mostly occurred together with amalgam dust.

CONCLUSIONS

Iatrogenic introduction of dental materials during dental procedures explains most foreign body gingival lesions which could be reduced or avoided by prophylactic measures. Pathologists should meticulously scrutinize gingival biopsies routinely applying polarization microscopy.

Lichenoid and granulomatous stomatitis: an entity or a non-specific inflammatory process?

BACKGROUND

The presence of lichenoid or granulomatous inflammation in an oral mucosal biopsy usually suggests a distinct range of diagnostic possibilities. However, the presence of both patterns of inflammation in the same biopsy is uncommon.

METHODS

A clinico-pathological study of six patients.

RESULTS

All the patients in this study presented with similar mucosal lesions of the upper lip. Microscopically the lesions were characterized by the presence of lichenoid inflammation with concomitant granulomatous inflammation. The lesions were persistent and refractory to treatment with steroid medications, but remained localized and did not appear to herald the onset of systemic inflammatory or neoplastic disease.

CONCLUSION

We propose the designation 'lichenoid and granulomatous stomatitis' for the cases described in this study. The clinico-pathological features of a subset of these cases suggest an unusual drug eruption.

Number V Oral lichen planus: clinical features and management

Oral lichen planus (OLP) is a relatively common chronic inflammatory disorder affecting stratified squamous epithelia. Whereas in the majority of instances, cutaneous lesions of lichen planus (LP) are self-limiting and cause itching, oral lesions in OLP are chronic, rarely undergo spontaneous remission, are potentially premalignant and are often a source of morbidity. Current data suggest that OLP is a T cell-mediated autoimmune disease in which auto-cytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells. The characteristic clinical aspects of OLP may be sufficient to make a correct diagnosis if there are classic skin lesions present. An oral biopsy with histopathologic study is recommended to confirm the clinical diagnosis and mainly to exclude dysplasia and malignancy. The most commonly employed and useful agents for the treatment of lichen planus (LP) are topical corticosteroids but other newer agents are available.

Non-plaque-induced gingival lesions

The origin of gingival inflammation is occasionally different from that of routine plaque-associated gingivitis, and such non-plaque-associated types of gingivitis often present characteristic clinical features. Examples of such forms of gingivitis are specific bacterial, viral, and fungal infections. Specific bacterial infections of gingiva may be due to Neisseria gonorrhea, Treponema pallidum, streptococci, and other organisms. The most important viral infections of gingiva are herpes simplex virus type 1 and 2 and varicella-zoster virus. Fungal infections may be caused by several fungi, the most important of these being Candida species including C. albicans, C. glabrata, C. krusei, C. tropicalis, C. parapsilosis, and C. guillermondii. Gingival histoplasmosis is a granulomatous disease caused by the fungus Histoplasma capsulatum and, as for the other specific infections of gingiva, a confirmed diagnosis may require histopathologic examination and/or culture. Atypical gingivitis may also occur as gingival manifestations of dermatological diseases, the most relevant of these being lichen planus, pemphigoid, pemphigus vulgaris, erythema multiforme, and lupus erythematosus. Non-plaque induced gingival inflammation can be caused by allergic reactions to dental restorative materials, toothpastes, mouthwashes, and foods. In addition, gingival inflammation may result from toxic reactions, foreign body reactions, or mechanical and thermal trauma.

Foreign body gingivitis: identification of the foreign material by energy-dispersive x-ray microanalysis

Foreign bodies identified in 61 cases of foreign body gingivitis were analyzed by energy-dispersive x-ray microanalysis. This was compared with the energy-dispersive x-ray microanalysis of 62 dental materials. Comparative analysis indicated most foreign bodies were of dental material origin, usually abrasives. It is suggested that they are factitially and iatrogenically introduced during a variety of self-administered and professionally performed dental hygiene and restorative procedures. Individual elements, and elements by class, were correlated with previously described clinical and microscopic features of the cases. There was no association between any microscopic or clinical attribute of FBG and the presence of allergenic or cytotoxic elements. It is postulated that the physical presence of foreign bodies may be sufficient for the development of foreign body gingivitis. Dentists should be aware of the potential for chronic tissue damage that can result from the unguarded use of abrasive material next to the gingiva.