Journal of Indian Society of Periodontology
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CASE REPORT
Year : 2011  |  Volume : 15  |  Issue : 3  |  Page : 280-283  

A rare case of unusual gingival enlargement post radiotherapy


Department of Periodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India

Date of Submission30-Dec-2010
Date of Acceptance08-May-2011
Date of Web Publication4-Oct-2011

Correspondence Address:
Vishal Singh
Manipal College of Dental Sciences, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.85676

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   Abstract 

Oral changes following radiotherapy are not uncommon. Oral mucositis, alteration in salivary gland function, radiation caries, and gingival changes have all been reported following radiotherapy and chemotherapy. The gingival changes seen after radiotherapy may be unusual and often cause diagnostic dilemma. Metastasis to the gingiva has also to be ruled out in these cases. A 30-year-old female patient presented with enlargement of the gingiva of 6 months' duration and lower lip swelling of 7 months' duration. She was a known case of carcinoma of nasopharynx and had received radiotherapy and chemotherapy. Based on the history, the clinical appearance of the gingiva, and the other oral changes we considered both post-radiotherapy gingival enlargement and secondary metastasis to gingiva as possibilities. An incisional biopsy was performed (internal bevel gingivectomy). The histopathological report did not reveal any metastatic changes. Thus, we diagnosed post-radiotherapy gingival enlargement. For the multiple carious teeth, extraction and root canal treatment was carried out as necessary. The patient was referred to the department of Oral and Maxillofacial Surgery for management of swelling of the lips, which was diagnosed as lymphedema of the lip. Gingival enlargement is rare post radiotherapy. Such nonplaque-associated gingival enlargement in a patient who has undergone radiotherapy should be subjected to biopsy and histopathological examination to distinguish between secondary metastasis and post-radiation changes.

Keywords: Gingival enlargement, metastasis, nasopharynx carcinoama, radiotherapy


How to cite this article:
Singh V, Bhat G S, Bhat K M. A rare case of unusual gingival enlargement post radiotherapy. J Indian Soc Periodontol 2011;15:280-3

How to cite this URL:
Singh V, Bhat G S, Bhat K M. A rare case of unusual gingival enlargement post radiotherapy. J Indian Soc Periodontol [serial online] 2011 [cited 2022 Aug 15];15:280-3. Available from: https://www.jisponline.com/text.asp?2011/15/3/280/85676


   Introduction Top


Radiotherapy plays an important role in the management of head and neck cancer, especially oropharyngeal and nasopharyngeal cancer. Radiotherapy is usually recommended as the primary treatment, as an adjunct to surgery, in combination with the chemotherapy, or as a palliative measure. The radiation dose needed for the treatment of cancer depends upon the location and the type of the malignancy and whether or not radiotherapy is the sole treatment or is to be given in combination with other modalities. [1] Most patients treated with curative intent receive a total dose between 50 and 70 Gy, usually given over a 5-7 week period; treatment being given once a day, five days a week, with 2 Gy per fraction. [1] However, in addition to its antitumor effects, ionizing radiation can cause damage to normal tissue located in the field of radiation. In the oral cavity there are complex areas with several dissimilar structures that respond differently to radiation, e.g., mucosal lining, skin covering, submucosal connective tissue, salivary gland tissue, teeth, and bone/cartilage. Acute changes produced by radiotherapy can be observed in the oral mucosa (oral mucositis), [2] skin (erythema, desquamation), [1] salivary glands (hyposalivation), [3],[4] taste buds (decrease acuity), [5] and teeth (radiation caries). [6] At later stages, changes can occur in all tissues. [7],[8] Gingival and periodontal changes, including loss of attachment at the radiation sites, have been reported. [9],[10] Gingival changes, including gingival enlargement, has been observed after radiotherapy. These changes are not specific and often cause confusion. To the best of our knowledge, very few cases of gingival and periodontal changes have been reported. [11],[12] The present case report describes gingival enlargement occurring as a complication of radiotherapy.


   Case Report Top


In June 2009, a 30-year-old female patient was referred to the Department of Periodontics, Manipal College of Dental Sciences, Manipal, India, by an ENT specialist and oncologist for evaluation of enlargement of the gingiva of 6 months' duration and swelling of the lip of 7 months' duration. The patient was a known case of carcinoma of the nasopharynx and had received radiotherapy in January 2007. She gave history of ulcers (mucositis) in the oral cavity during the radiotherapy. The patient had alteration in taste sensation and had consequently developed selective food habits.

The patient reported that her gums and lips were normal prior to radiotherapy. The gingival swelling had slowly increased in size and turned red in color over the last 6 months. The swelling of the left side of the lower lip had also increased over 7 months though it had been relatively stable the last 1 month.

The patient complained of an unaesthetic appearance, discomfort while closing the lips, bleeding while brushing her teeth, and inability to carry out routine oral hygiene procedures. Her general health was otherwise normal.

Extraoral examination revealed a slight swelling of the lower lip, especially on the left side [Figure 1]. There was no itching, burning sensation, or pain. The patient did not give any history of trauma (e.g., biting her lip) or insect bite.
Figure 1: Lymphadema of the lower lip

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Intraoral examination revealed decreased salivary flow, with thick and ropy saliva. There was diffuse gingival enlargement involving the maxillary anterior labial gingiva, with the sweling extending from the mesial surface of the right maxillary canine to the mesial surface of the left canine [Figure 2]. The gingiva was red in color, with pronounced rounded margins. There was diffuse fibrous enlargement, with prominent papillary regions and presence of stippling. Grade II bleeding was present.
Figure 2: Left buccal view of the gingival enlargement

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Hard tissue examination showed missing 36, 37, and 38; the presence of root stumps of 18, 16, 45, and 46; and grossly decayed 28 and 48. All the remaining teeth (17, 15, 14, 13, 12, 11, 21, 22, 23 24, 25, 26, 27, 35, 34, 33, 32, 31, 41, 42, 43, 44, and 47) showed the presence of caries with periapical changes.

The patient had good oral hygiene. Radiographic evaluation revealed minimal horizontal bone loss in the region of gingival enlargement. The other areas did not reveal any bone loss.

Considering the history of chemoradiotherapy, the clinical features, and the other changes in the oral cavity, our differential diagnosis included post radiotherapy gingival enlargement and metastasis to the gingiva. The treatment plan was explained to the patient and was modified according to her needs. Before beginning the dental treatment, the treatment plan was discussed with the oncologist and the patient's consent was obtained. Oral prophylaxis was done. Antibiotics (amoxicillin, 1 g, was administered before tooth extraction, with 500 mg t.i.d to be taken for three days post extraction) All the root stumps were extracted. Teeth 17, 14, 24, 26, 27, and 47 were decayed and pulpally involved. The patient was given the option of root canal treatment (RCT) with post-endodontic restorations for these teeth; however, she refused RCT despite several motivational appointments and therefore these teeth were also extracted. All the extraction sockets healed without any complication. RCT was done for all the other maxillary and mandibular teeth, and post-endodontic restoration was planned.

The treatment plan for the diffuse gingival enlargement was undisplaced flap (internal bevel gingivectomy). During the surgical procedure we encountered unusual bleeding, which was managed without any complications [Figure 3]. Healing following surgery was uneventful [Figure 4]. Tissue was sent for histopathological evaluation.
Figure 3: Internal bevel gingivectomy

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Figure 4: Healing after 6 months

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Histopathological analysis did not show any metastatic deposits. Gingival tissue from the anterior maxillary region revealed connective tissue stroma that was edematous and densely infiltrated with acute and chronic inflammatory cells. There were numerous dilated blood vessels engorged with red blood cells and a few hemorrhagic areas. At certain areas the stroma appeared to be dense. Overlying the connective tissue was hyperplastic, edematous, parakeratinized stratified squamous epithelium infiltrated with acute and chronic inflammatory cells. The histopathlogical picture was nonspecific and suggestive of inflammatory gingival changes.

Follow-up

The patient was referred to the Department of Oral and Maxillofacial Surgery for management of the swelling of the lips, with a provisional diagnosis of lymphedema of the lips secondary to radiotherapy. It was decided to follow-up the patient without any treatment.


   Discussion Top


There are several case reports describing the multiple oral changes following radiothrapy. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] Among these, oral mucositis appears to be the most common. Oral mucositis occurs in 97% of head and neck cancer patients who receive conventional fractionated radiotherapy (i.e., one dose per day, 5 days a week, for 5-7 weeks) and in 100% of patients receiving altered fractionated radiotherapy (two or more doses per day). The incidence of oral mucositis is higher in patients with primary tumors of the oral cavity, oropharynx, or nasopharynx and in those who receive concomitant chemotherapy. It has also been reported that females have an increased risk of developing oral mucositis. [13] In the present case, carcinoma of the nasopharynx was treated with radiotherapy. The post-radiotherapy oral changes seen in this patient included thick ropy saliva, decreased salivary flow, lymphedema of the lower lip, multiple teeth with radiation caries, partial loss of taste sensation, and gingival enlargement.

Oral mucositis has been postulated to result from the direct toxic effect of radiotherapy or chemotherapy on stem cells in the basal and suprabasal layers of the epithelium. [13] Sonis and colleagues, in 2004, [14] proposed five stages in the pathogenesis of oral mucositis, as follows: Initiation of tissue injury, upregulation of inflammation via generation of messenger signals, signaling and amplification, ulceration and inflammation and, finally, healing. The generation of reactive oxygen species, upregulation of proinflammatory cytokines such as TNF-a, and expression of adhesion molecule and cyclooxygenase-2 during the five stages of pathogenesis are responsible for causing tissue injury, apoptosis of cells within the submucosa, primary injury of the cells within the basal epithelium, and angiogenesis. In addition, fibronectin breakdown leads to macrophage activation and subsequent tissue injury, which is mediated by matrix metalloproteinase and production of additional TNF-a. [14] In addition to the above mechanisms there is also increase in leukocyte adhesion to E-selectin [2] or increase in endothelial intercellular adhesion molecules (ICAM-1), [2] which promotes a radiation-induced inflammatory response in squamous epithelium. There is also decrease in the level of salivary epidermal growth factor, [15] with consequent inhibition of the protective mechanisms of oral mucosa.

Multiple mechanisms are probably responsible for the gingival changes, including the gingival enlargement. The gingiva is a part of the oral mucosa and the mechanism of pathogenesis may be the same as that described for oral mucositis. Another possible mechanism for the gingival enlargement is related to increase in gram-negative bacilli. A shift in the oral microflora and increase in the level of endotoxins released by gram-negative bacilli could play a major role in the development inflammatory changes in the gingiva. [11],[16],[17] Hyposalivation and altered flow and consistency of the saliva also contribute to the alteration in the oral microflora and the normal defense mechanisms, which can initiate the changes in the gingiva. [4],[18],[19] Loss of teeth, [6] partial loss of taste sensation, [5] hyposalivation, [4] and change in the life events [20],[21] bring about changes in the quantity and quality of food intake, with the resulting nutritional deficiencies [22] leading to altered tissue response and consequent gingival enlargement.

In the present case, gingival enlargement and enlargement of the lower lip was observed several months after the patient received radiotherapy. This could be because of the dose-limiting factor of the adjacent tissue. Tissues with a rapid turnover manifest acute reactions (early effect), whereas tissues with slower turnover may not show evidence of damage for months or even years after therapy. [7],[8] Gingival connective tissue and the other components of the periodontium have different turnover rates and respond differently to radiation.

In the present case, several carious teeth with pulpal involvement could have been restored and maintained in the dental arch. However, the stress associated with cancer therapy and the life event changes [20],[21] made the patient unwilling to undergo RCT and opt, instead, for extraction of the teeth. It is important that patients undergoing radiotherapy receive appropriate motivation and education regarding dental care, which is necessary for the proper management of oral changes, especially of carious teeth.


   Conclusion Top


Gingival enlargement may rarely occur after radiotherapy. Several possible combinations of mechanisms may be involved. Unfamiliarity with the lesion makes diagnosis difficult. Further, it is necessary to rule out the metastasis to the gingiva. Any unusual appearance of the gingiva that is not related to plaque should be evaluated early. The lesion should be subjected to histopathological evaluation so that appropriate treatment can be provided at an early stage.

 
   References Top

1.Dobbs J, Barret A, Ash D. Practical radiotherpy planing. 3 rd Ed, London, Arnold: Oxford university press; 1999  Back to cited text no. 1
    
2.Handshel J, Prott FJ, Sunderkotte C, Metze D, Meyer U, Joos U. Irradiation induces increase of adhesion molecules and accumulation of beta2-integrin-expressing cells in humans. Int J Radiat Onco Biol Phys 1999:45:475-81.  Back to cited text no. 2
    
3.Taylor SE, Miller EG. preemptive pharmrcologic intervention in the radiation induced salivary dysfunction. Proc Soc Exp Biol Med 1999:221:14-26.  Back to cited text no. 3
    
4.Nagler RM. The enigmatic mechanisms of irradiationinduced damage to major salivary glands. Oral Dis 2002:8;141-6.  Back to cited text no. 4
    
5.Spielman AI. Chemosensory function and dysfunction. Crit Rev Oral Bio Med 1998:9:267-91.  Back to cited text no. 5
    
6.Anneroth G, Holm LE, Karlsson G. The effect of radiation on teeth: A clinical, histological, and microradiographic study. Int J oral Surgey 1985;14:269-74.  Back to cited text no. 6
    
7.Steel CG. Basic clinical radiobiology. 3 rd Ed, London, Arnold: Oxford university press; 2002. p. 231-40.  Back to cited text no. 7
    
8.Hall EJ. Radiobiology for the radiobiologist. 5 th Ed, Philadelphia: Lippincoat Willams and Wilkins; 2000. p. 453-6.  Back to cited text no. 8
    
9.Yosuf ZW, Bakri MM. Severe progressive periodontal destruction due to radiation tissue injury. J Periodontol 1993:64:1253-8.  Back to cited text no. 9
    
10.Epstein JB, Lunn R, Le N, Stevenson-Moore P. Periodontal attachment loss in patients after head and neck radiation therapy. Oral Surg Oral Med Oral Pathol Endod 1998:86:673-7.  Back to cited text no. 10
    
11.Makitziu A, Zafiropoulous G, Tsalilkis L, Cohen L. Gingival health and salivary function in head and neck irradiated patients: Oral Surg Oral Med Oral Path. 1992:73:427-33.  Back to cited text no. 11
    
12.Rees TD. Position paper. Periodontal consideration in the management of cancer patients: J periodontal 1997:68;791-801.  Back to cited text no. 12
    
13.Mccarthy PJ, Millon RR. History of diagnosis and treatment of cancer in the head and neck: In: Millon RR, Cassi NJ. editors. Management of head and neck cancer: A multidisciplinary approach. 2 nd ed. Philadelphia: Lippincott company; 1994. p. 21`  Back to cited text no. 13
    
14.Sonis ST, Elting LS, Keefe D, Peterson DE, Schubert M, Hauer-Jensen M, et al. Perspective on cancer therapy induced mucosal injury: Pathogenesis, measurement, epidemiology and consequences for patients. Cancer 2004:100:1995-2025.  Back to cited text no. 14
    
15.Dumbrigue HB, Sandow PL, Nguyen KH, Mumphreys-Beher MG. Salivary epidermal growth factor levels decrease in patients receiving radiation therapy to the head and neck. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000:89:710-6.  Back to cited text no. 15
    
16.Spijkervet FK, Vansev HK, van Saene JJ, Panders AK, Vermey A, Mehta DM. Mucositis prevention by selective elimination of oral flora in irradiated head and neck cancer patients. J Oral Pathol Med 1990:19:486-9.  Back to cited text no. 16
    
17.Leung WK, Jinl LJ, Samarnayake LP, Chic GK. Subgingival microbiota of a shallow periodontal pocket in individuals after head and neck irradiation. Oral Microbial Immunol 1998:13:1-10.  Back to cited text no. 17
    
18.Burlarge FR, Coopes RP, Meertens H, Strokeman MA, Vissink A. Parotid and sibmandibular/sublingual flow during high dose radiotherapy. Radiother Oncol 2001:61:271-4.  Back to cited text no. 18
    
19.Vissink A, Burlarge FR, Spijkervet FK, Jansma J, Cooper RP. Prevention and treatment of the consequence of the head and neck radiation therpy: Oral sequalae of the head and neck radiotherapy. Crit Rev Oral Boil Med 2003:14;213-5.  Back to cited text no. 19
    
20.Vissnik A, Schaub RM, Van Rinjn LJ, Gravenmade EJ, Pander AK, Vermey A. The efficacy of mucin containing artificial saliva in alalevating symptoms of xerostomia. Gerodontology 1987:6;95-101.  Back to cited text no. 20
    
21.Ohrn KE, Wahlin YB, Sjoden PO. Oral status during radiotherapy: A descriptive study of patients experience and occurrence of oral complications. Support Care Cancer 2001;9:247-57.  Back to cited text no. 21
    
22.Mekhail TM, Adelstein DJ, Rybicki LA, Larto MA, Saxton JP, Leertu P. Entral nutririon during the treatment of head and neck carcinoma: Is per cutaneous endoscopic gastrotomy tube preferable to a nasogastric tube. Cancer 2001:91:1785-90.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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