A 6-year-old male presented with his mother for evaluation of painful and bleeding gingiva. The patient's mother reported that the gingival changes began seven months ago and that the onset was not associated with any identifiable inciting events, including mechanical, thermal, and chemical trauma; dietary changes; use of new dental hygiene products; or exposure to cinnamon-containing products or foodstuffs. She also denied a history of fever, malaise, and GI symptoms. The patient had seen his pediatrician two weeks prior and undergone a complete blood count (CBC) and metabolic panel, which revealed no abnormalities. A thorough dental prophylaxis had also been performed one week prior with no significant improvement in the appearance of his gingiva.
The patient's medical history was significant for asthma, for which he was using mometasone furoate inhaler once daily and albuterol sulfate inhaler on an as-needed basis. His mother stated that he took special care rinsing his mouth after use of the steroid inhaler as directed by his pediatrician. His review of systems and family history were otherwise unremarkable for cardiovascular, endocrinologic, GI, genitourinary, musculoskeletal, hematologic, and neurologic disorders.
Intraoral examination revealed a very subtle area of mucosal erythema involving the gingiva buccal to the right primary maxillary molar, canine, and lateral incisor (Figure 1) and a more well-defined area of erythema involving the alveolar mucosa facial to the left primary maxillary central and lateral incisors and canine (Figure 2). Also noted were multiple mucosal-colored swellings and ulcerations of the gingiva facial to the right permanent mandibular central and lateral incisors and primary canine (Figure 3). Mild tenderness was elicited on gentle palpation of the affected sites. The remainder of the oral mucosal examination was within normal limits. No bone loss was evident on radiographic examination.
As requested by the referring periodontist, biopsy of the affected mandibular gingiva was performed. Microscopic examination revealed curved portions of oral mucosa surfaced by spongiotic stratified squamous epithelium with evidence of mild inflammatory cell exocytosis; beneath the epithelium, there was a proliferation of fibrous connective tissue with a patchy infiltrate of lymphocytes and plasma cells (Figure 4(a)). In isolated areas, there were well-formed, noncaseating granulomas composed of epithelioid histiocytes and lymphocytes (Figure 4(b)). Periodic Acid-Schiff (PAS), Grocott-Gomori's methenamine silver (GMS), and Acid-Fast Bacilli (AFB) stains were performed to rule out deep fungal infections and mycobacterial infections such as tuberculosis and leprosy as causes of the granulomas. All stains were negative. Examination of the biopsy under both light and polarized light microscopy did not reveal foreign body material. Hence, a diagnosis of granulomatous inflammation was rendered with a comment pertaining to possible etiologies such as Crohn's disease, orofacial granulomatosis, and sarcoidosis.
The patient was provided with a prescription for a mild topical steroid rinse and instructed to rinse and spit four times daily for 14 days. He was also referred to his pediatrician for additional evaluation to rule out for Crohn's disease and other systemic conditions associated with granulomatous inflammation, including sarcoidosis. The patient returned for follow-up three weeks later and demonstrated a modest reduction in the erythema of the maxillary gingiva and swelling of the mandibular gingiva. The patient's mother also reported less pain and bleeding during brushing. The patient was again advised to pursue diagnostic evaluation for systemic causes of granulomatous inflammation. Following evaluation by his pediatrician, he was referred to a pediatric gastroenterologist for consultation. The patient subsequently underwent endoscopic examination and biopsy which showed acute inflammation of the intestinal mucosa. A diagnosis of early Crohn's disease was made. The patient was placed on mesalamine, an anti-inflammatory aminosalicylate, and azathioprine, an immunosuppressant. At one-year follow-up by phone, the patient's mother reports that he continues to respond well to his medications. She states that his oral lesions have completely resolved and that he is currently free of intraoral and GI symptoms.