Foreign body gingivitis: a literature review.

ABSTRACT

Foreign body gingivitis (FBG) is a desquamative gingival condition that is associated with foreign material embedded in gingival tissue. It is an unusual but not rare condition most often occurring in females. It is commonly misdiagnosed clinically as a bacteria-induced periodontal condition or autoimmune disease. FBG generally presents as localized gingival redness, edema, ulceration, marginal-to-diffuse inflammation, and sometimes hyperplasia. Symptoms can include burning or pain. A biopsy is required for a definitive diagnosis of FBG so that appropriate therapy can be administered. Often mistaken for oral lichen planus (OLP), FBG lesions are more localized, involving the gingiva especially in the anterior and possibly affecting interdental papillae. Unlike OLP, FBG lesions do not typically respond to topical steroids. Treatment and prevention are key factors in controlling FBG. Possibly because there are very few articles published on this condition, there is a lack of diagnosis and reporting of FBG by dental clinicians.

Keywords: foreign bodies; gingivitis; lichen planus, oral; periodontal diseases

RESUME

La gingivite causee par un corps etranger est une affection gingivale desquamative qui est associee a un materiau etranger inclus dans le tissu gingival. C'est une affection qui, bien qu'inhabituelle, n'est pas rare et elle survient le plus souvent chez les femmes. Elle est frequemment mal diagnostiquee comme une affection gingivale causee par une bacterie ou une maladie auto-immune. Dans un cas de gingivite causee par un corps etranger, il y a presence de rougeur gingivale, oedeme, ulceration, inflammation marginale a diffuse et, quelques fois, hyperplasie. Les symptomes peuvent inclure une sensation de brulure ou de la douleur. Une biopsie est necessaire pour etablir un diagnostique definitif de gingivite causee par un corps etranger afin que le traitement approprie puisse etre administre. Souvent prises a tort pour un lichen plan buccal, les lesions de la gingivite causee par un corps etranger sont plus localisees, notamment sur la gencive anterieure et, possiblement, sur les papilles interdentaires. Contrairement au lichen plan buccal, les lesions de la gingivite causee par un corps etranger ne repondent pas bien aux steroides topiques. Le traitement et la prevention sont des facteurs-cles dans le controle de la gingivite causee par un corps etranger. Possiblement parce qu'il y a tres peu d'articles publies sur cette affection, il y a un manque au niveau du diagnostic et de la declaration de la gingivite causee par un corps etranger de la part des cliniciens dentaires.

BACKGROUND

DALEY AND WYSOCKI (1990) (1) WERE THE FIRST TO DOCument cases of non-microbial gingivitis that appeared to be associated with inorganic foreign materials, other than amalgam, embedded in gingiva tissues. Eight cases of foreign body gingivitis (FBG) exhibiting clinical characteristics were studied in an attempt to determine the source of foreign material through identification of familiar elements. Stained tissue sections from eight cases of granulomatous gingivitis were examined microscopically and by polarized light microscopy to determine the presence of foreign material. Detailed clinical histories from all cases were obtained and two patients were clinically examined. Serial tissue sections were examined by scanning electron microscopy and energy-dispersive x-ray microanalysis (EDXM). Control samples examined by EDXM included five focal fibrous hyperplasias from five age-matched patients, sections of paraffin before and after deparaffinization, and ten samples of dust from the laboratory in which samples were prepared for EDXM. The report identified eight patients with non-microbial gingivitis in maxillary anterior segments, presenting as red or red and white macules and involving both free and attached gingiva. The inflammation was more severe in interdental papillae areas and mandibular gingiva. The condition persisted for up to two years despite professional therapy and reasonable patient homecare. (1)

FBG cases accounted for 0.3% of total biopsies received between January 1, 1988, and November 30, 1994, at the University of Western Ontario Pathology Department. This percentage represents a minimum estimate of clinical incidence of this disorder, as there is probably a general lack of diagnosis and reporting of FBG by dental clinicians. Because of this, many cases are not biopsied or treated. (1)

Most dental procedures incorporate the use of restorative abrasive agents, including disks, stones, or burrs mounted on slow-speed handpieces, steel or diamond burrs on high-speed handpieces, abrasive strips, polishing compounds, or air abrasives. Dental procedures may result in abrasion or cutting of the gingiva, allowing dental materials to be introduced into gingival connective tissue. Daley and Wysocki (1) reported the onset of multifocal lesions in a 44-year-old female patient shortly after a dental hygiene student had carried out a dental prophylaxis on her. Another patient noticed the onset of lesions after placement of a full dental crown; a third had a lesion occur adjacent to the clasps of a removable partial denture.

An amalgam tattoo is a more common presentation of a dental material introduced into oral soft tissue. (1-4) Most common sites are gingiva, alveolar mucosa, and buccal mucosa whereas FBG is limited to the gingiva. Amalgam tattoos contain pigmented fragments of metal within connective tissue. The response to amalgam appears to be related to its particle size and elemental composition. Unlike FBG, fragments are encapsulated by dense fibrous connective tissue and mild or no inflammation can be detected. The fragments can be detected radiographically as radiopaque.

Other localized exogenous pigmentations can be the result of intentional embellishment or accidental tattoos. This may be due to a cultural practice of East African tribes or seen in inmates from correctional facilities. Materials may include pen ink, coal, metal dust, and pencil graphite. (4) Trauma may also result in various foreign materials becoming lodged under superficial skin layers causing colour changes. These foreign materials are inert in the tissue and do not appear to cause inflammatory responses such as those that elicit FBG.

FBG also needs to be differentiated from a surface or contact tissue response to an allergen. Most sensitivities to dental materials are allergic reactions, presenting as either contact stomatitis venenata (an allergic condition of the oral mucosa resulting from contact with a substance to which the individual is sensitive) or systemic allergies. (1,3) Stomatitis venenata may manifest in the oral cavity as mucosal burning, swelling, ulceration, erosions, or gingivitis-like lesions. This tissue reaction resolves when the surface irritant is removed and no foreign material is present within the tissue.

CLINICAL PRESENTATION AND SYMPTOMS

Clinical features of FBG include localized change in gingival colour (bright red to bluish red), edema, ulceration, and marginal-to-diffuse inflammation (see figure 1). The tissue is erythematous or leukoplakic (red or red/white lesions) and may be hyperplastic or hyperkeratotic. Interdental papillae are usually affected with edematous as well as erosive patches. Burning or pain may accompany the lesion(s). The moderate-to-intense discomfort that the FBG patient may experience is due to inflammatory response and can be identified histologically. If raised lesions are present, they may be traumatized by general oral function or oral hygiene care and become secondarily hyperkeratotic in nature. Lesions may involve mandibular or maxillary gingiva, beginning at the free gingival margin, and may extend to attached gingiva in anterior and/or posterior regions with a prevalence tending toward the anterior regions.

ETIOLOGY

A portal of entry for foreign materials may be created by gingival trauma that may be self-induced (such as toothbrush abrasion) or be the result of a periodontal procedure (such as scaling and root planing) or restorative treatment. Inadvertent or intentional curettage may occur as a result of such professional procedures, leading to damage of the gingival epithelium. (1-3,5)

[FIGURE 1 OMITTED]

Oral mucosal ulcerative conditions, such as herpetic lesions, may expose connective tissues, thus allowing foreign body contamination and subsequent inflammatory response. Gingivitis and periodontal disease may permit foreign matter to enter tissue due to ulcerative or desquamative conditions and poor integrity of the gingival sulcus. (1-3,5) Other oral pathologies that may provide possible routes for material introduction include infection, vesiculobullous disease, oral lichen planus (OLP), benign mucous membrane pemphigoid, and pemphigus because the gingival epithelium that normally acts as a barrier has been compromised in these conditions.

DIAGNOSIS AND HISTOLOGY

FBG is often clinically misdiagnosed prior to biopsy as oral erosive lichen planus, benign mucous membrane pemphigoid, pemphigus, fibroma, peripheral ossifying fibroma, pyogenic granuloma, hyperkeratosis dysplasia, papilloma, verruca vulgaris, leukoplakia, gingivitis, periodontitis, herpetic or aphthous ulcers or candidiasis. (1-2) Because of this, clinical diagnosis alone is not sufficient. It is imperative that a biopsy be performed to achieve a definitive diagnosis before appropriate treatment begins.

FBG should be included in differential diagnosis of a lesion that resembles OLP clinically (see table 1) or other ulcerative-immune mucosal conditions. However, FBG may resemble OLP not only clinically but also microscopically, with a band-like inflammation infiltrate underlying an alternately acanthotic and atrophied keratinized epithelium. (2-3) Focal degeneration of the basal lamina layer may be present in both lesions. (3,6) The fundamental histologic difference between the two is the absence of foreign material in OLP. They differ clinically in that FBG is generally limited to the gingiva and does not typically respond to topical steroids. OLP, on the other hand, may be widespread (inclusive of some or all oral tissues) and may include migrating mucosal involvement. (6-10) Topical steroids have been shown to be most predictable and effective for controlling signs and symptoms of OLP. Since topical steroids are largely ineffective for FBG, this fact may support a clinical diagnosis of FBG. (7)

Gordon and Daley included all cases diagnosed as FBG from January 1988 to November 1994 by the Oral Pathology Diagnostic Services of University of Western Ontario. (2) Age-matched cases of chronic, hyperplastic, and subacute gingivitis diagnosed during that time served as controls. As some cases of FBG are granulomatous, all cases diagnosed as granulomatous gingivitis during that time period were also examined as controls. Cases diagnosed microscopically as amalgam tattoo were not included in the study. All tissues were subjected to routine diagnostic procedures before initial diagnosis. Test and control cases were pooled and examined without reference to original diagnosis. One hematoxylin-eosin stained slide of each case was reviewed by light microscopy and polarized light when necessary. This served as a double check of the original diagnosis and a reliability test of the proposed diagnostic criteria. The criteria for diagnosis in the blinded light microscopic examination included presence of chronic inflammation in the gingival specimen, the presence of foreign bodies in an area of inflammation, and consistent localization of foreign bodies in at least two serial tissue sections. Sixteen cases were randomly selected for staining to rule out deep fungal or mycobaterial infection. To reduce diagnostic bias and to achieve the highest possible level of diagnostic certainty, only cases both originally and blindly diagnosed as FBG were included. The majority of diagnosed cases of FBG in this study were female. (2) Gingival inflammation in women may be exaggerated during pregnancy and while taking oral contraceptives and hormonal replacement therapy. This occurs because these conditions/medications may exacerbate inflammatory response. Hormonal influences, therefore, may play a role in gender discrepancy for diagnosis of this condition in females. (2)

Energy-dispersive x-ray (EDX) is an effective research tool for the microanalysis of tissue biopsies; material in biopsies can be compared to a number of common dental restorative, dental hygiene, and home-care products in an attempt to identify specific foreign elements or compounds. (1-3) Gordon and Daley (3) pooled cases with an age-matched control group of 44 cases of chronic, subacute, and hyperplastic gingivitis and 3 cases of granulomatous gingivitis. These were subjected to blind diagnosis. Only cases that were diagnosed as FBG in original and subsequent diagnosis were used for further study. Controls were not subjected to EDX examination, which required microscopically identifiable particles as subject for the analysis. Each tissue sample was examined on the same scanning electron microscope. The foreign body location was identified grossly with reference to tissue section. The foreign bodies were identified by backscatter detection to enable surface particles that could be contaminates to be distinguished from particles located deep in the tissue. Particles located only superficially or not in the area of inflammation were noted on light microscopy and were rejected for further examination. The particles were then subjected to EDX. All tissue analyses were performed by one examiner. Clinical, microscopic, and EDX data were analyzed and examined for association with a data-based program. Dental materials were examined on one of two electron microscopes. To compare atomic analysis of FBG to those of dental materials, similar materials (that is, prophy pastes, polishing strips, polishing disks) were grouped and their total atomic composition was compared with that of each specimen in an attempt to find a match. (3)

"It is difficult to prove an iatrogenic cause based on elemental constituents alone. However, the combined historical, clinical, histological, and EDXM features provide sufficient information on which to draw conclusions." (1) In 28 of 61 cases, there was a match between elements in foreign material (found by EDX) in the tissue and those in a specific class of dental materials. (3) In 21 of 28 cases, there was a match indicating that the material was abrasive. (3)

TREATMENT AND PREVENTION

A critical assessment of hygiene status, particularly subgingival deposits and root roughness, is necessary for patients with FBG and other desquamative gingival conditions to reduce the contributing factors of inflammation. "When oral hygiene measures are complicated by pain and bleeding, inferior plaque control is inevitable. This must be counteracted by more thorough and frequent professional instrumentation, as well as oral hygiene measures tailored to the client's specific requirements." (5) Extensive scaling, root planing, or curettage should not be followed by a coronal polish in affected active areas. Selective coronal polish can be performed at periodontal maintenance appointments using a low abrasive polishing paste at sites with healthy proximal tissues.

Clients with gingival ulcerations should be advised to avoid abrasive dentifrices including tartar control, (5,8,11-17) whitening, (12,13,17) and other potentially irritating compounds (sodium lauryl sulfate, (5,14,16,18) and triclosan (5,11,14,16) formulas at home. Mouth rinses with high alcohol content should also be avoided to minimize tissue desiccation and chemical irritation. Deplaquing may be performed with a soft toothbrush and water alone if oral lesions or ulcerations are present. (5) A chlorhexidine rinse may be helpful for active sites if soreness precludes other hygiene modalities.

Until recently, recommended definitive management for FBG has just been surgical excision of the affected area (gingivectomy). A free gingival graft procedure has been recommended in a recent publication, "Management of Patients with Foreign Body Gingivitis: A Report of 2 Cases with Histologic Findings." (5) (See figure 2.) Clinical findings and treatment histories of two patients were discussed in the case presentations dealing with affected sites that are fragile and prone to gingival recession. (5) Tissue grafting may be necessary for either symptom relief or esthetic purposes. Regular monitoring of affected sites is important so that timely treatment can be provided. The use of short-term topical steroids may provide temporary relief from discomfort if a lichenoid type of inflammation is present. (5,7,10)

[FIGURE 2 OMITTED]

Care must be taken during professional- or client-administered oral procedures to avoid causing gingival trauma that might create a portal for foreign materials. Care should be exercised when placing and trimming restorative margins or removing existing restorative materials. A rubber dam should be used during restorative procedures when inflammation or ulceration is present in the tissue in the restorative area. The use of air abrasion procedures should be avoided if gingiva is highly inflamed or eroded. (5,18)

SUMMARY

FBG is caused by the impregnation of certain irritating foreign materials into the oral mucosa resulting in a foreign-body immune response. Gingival trauma, self-induced or resulting from a professional dental procedure, may damage the oral epithelium, allowing a portal for foreign materials such as dental resins or polishing compounds. Care must be exercised when working around oral tissues, especially when oral epithelium has been damaged and connective tissue exposed. Because treatment options are limited, prevention is important.

Clinically, FBG (without a biopsy) can be confused with erosive lichen planus, benign mucous membrane pemphigoid, pemphigus, gingivitis, as well as other desquamative gingival disorders. Biopsy and microscopic evaluation to show foreign materials in the tissue is needed to make a definitive diagnosis.

Clients with FBG require specific dental and periodontal management that is aimed at minimizing further tissue trauma and keeping other local irritants, such as plaque and calculus to a minimum. Periodontal surgery may be needed for treatment of atrophic or hyperplastic areas. Specialized individual oral home care is important and regular monitoring of these area(s) is important to prevent further breakdown of the gingival tissues.

REFERENCES

1. Daley TD, Wysocki GP. Foreign body gingivitis: an iatrogenic disease? Oral Surg Oral Med Oral Pathol 1990; 69 (6): 708-12.

2. Gordon Sc, Daley TD. Foreign body gingivitis: clinical and microscopic features of 61 cases. Oral Surg Oral Med Oral Pathol Oral Radio Endod .1997;83(5):562-70.

3. Gordan SC, Daley TD. Foreign body gingivitis: identification of the foreign material by energy-dispersive x-ray microanalysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(5): 571-6.

4. Neville B, Damn DD, Allen CM, Bouquot J. Oral and maxillofacial pathology. 2nd ed. St. Louis (MI):W.B. Saunders; 2002.

5. Gravitis K, Daley TD, Lochhead MA. Management of patients with foreign body gingivitis: report of 2 cases with histologic findings. J Can Dent Assoc. 2005;71(2):105-9.

6. Edwards P, Kelsch R. Oral lichen planus: clinical presentation and management. J Can Dent Assoc. 2002;68(8):494-9.

7. DeRossi S, Ciarricca K. Lichen planus, lichenoid drug reactions, and lichenoid mucositis. Dent Clin North Am. 2005;49(1):77-89

8. Lodi G, Scully L, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radial Endod. 2005;100(2):164-78.

9. Prato GP, de Paoli S, Giannoti B. A case of lichen planus: a clinical and histologic investigation during periodontal surgery. Int J Periodontics Restorative Dent. 1984;4(5):50-63.

10. Zakrzewskra JM, Chan ES, Thornhill MH. A systematic review of placebo-controlled randomized clinical trials of treatments used in oral lichen planus. Br J Dermatol. 2005;153(2):336-41.

11. DeLattre VF. Factors contributing to adverse soft tissue reactions due to the use of tarter control toothpastes: report of a case and literature review. J Periodontol. 1999;70(7):803-7.

12. Desautels P, Labreche H. Abrasion relative des dentifrices--un dentifrice pour chacun [in French]. J Dent Que. 1990;27:579-85.

13. Hefferren JJ, Kingman A, Stookey GK, Lehnhoff R, Muller T. An international collaborative study of laboratory methods for assessing abrasivity to dentin. J Dent Res. 1984;63(9):1176-9.

14. Herlofson BB, Barkvoll P. Oral mucosal desquamation caused by two toothpaste detergents in an experimental model. Eur J Oral Sci. 1996;104(1):21-6.

15. Kowitz G, Jacobson J, Meng Z, Lucatorto F. The effects of tartar-control toothpaste on the oral soft tissues. Oral Surg Oral Med Oral Pathol. 1990;70(4):529-36.

16. Miller WA. Experimental foreign body reactions to toothpaste abrasives. J Periodontol. 1976;47(2):101-3

17. Reports of Councils and Bureaus. Abrasivity of current dentifrices. J Am Dent Assoc. 1970;81(5):1177-8.

18. Skaare A, Eide G, Herlofson B, Barkvoll P. The effect of toothpaste containing triclosan on oral mucosal desquamation. A model study. J Clin Periodontol. 1996;23(12):1100-3.

This article has been peer reviewed.

by Marie A. Lochhead, ASc, RDH,* and Karl Gravitis, BSc, DDS, Cert. Perio ([dagger])

* Graduated 1981 with an Associates Degree in Science with honours. After working in the United States, Marie Lochhead currently practises in Ontario, primarily in the field of periodontics. Ms. Lochhead was previously a clinical instructor at Niagara College, board examiner for CDHO, and is a past president of Niagara Dental Hygienists' Society.

([dagger]) Karl Gravitis has a specialist practice limited to periodontics and implant dentistry in St. Catharines, Ontario. After a dental career in the Canadian Armed Forces, Dr. Gravitis studied periodontics at Dalhousie University before returning to Southern Ontario to practise his specialty.

            Foreign body gingivitis

Etiology    * Potentiated by inorganic foreign materials
            * Gingival trauma and or inflammation may allow access of
              foreign substance
Histology   * Biopsy needed for diagnosis
            * Can resemble OLP microscopically
            * Presence of inorganic foreign materials
Clinical    * Localized change in gingival colour (bright red to bluish
appearance    red)
            * Marginal to diffuse inflammation
            * Desquamative gingival tissue
            * Hyperplastic or hyperkeratotic
            * Erythematous/leukoplakic appearance (red or red/white
              lesions); often mistaken for OLP
            * Lesions are stationary
Symptoms    * Burning or pain may accompany lesion
            * Most lesions are present for a "short period" before a
              client seeks professional consultation due either to pain
              or aesthetic concerns
            * Lesions do not disappear or remit
Age/gender  * Mean age is 48 years
tendency    * Frequently in ages 41 to 50
            * Higher prevalence in females
            * FBG may be exacerbated by hormonal influences
Treatment   * Surgical management--gingivectomy or free gingival graft
              for hyperplastic or atrophic areas
            * Monitoring of changes to limit further periodontal tissue
              damage
            * Not typically responsive to topical steroids
            * Frequent and thorough professional instrumentation to
              control plaque and calculus to reduce contributing
              inflammation; (8) specific home care instructions tailored
              to specific needs (5)

            Oral lichen planus

Etiology    * Autoimmune disease
            * May be affected by oral medications or proximity to dental
              amalgams (6,7)
Histology   * Confirmation of OLP should be made by means of biopsy
            * No inorganic foreign material present
Clinical    * Reticular-oral lesions appear as interlacing white striae
appearance    with an erythematous border; commonly found on buccal
              mucosa, buccal vestibule, tongue and gingival
            * Desquamative
            * Erosive OLP--erythematous ulcerations that tend to migrate
              over time
            * Lesions may migrate
Symptoms    * May be asymptomatic or have burning sensation
            * Mucosal sensitivity to hot or spicy foods and sour fruits
            * Symptoms may spontaneously disappear with periods of
              exacerbation and remission
Age/gender  * Mean age is 49
tendency    * Frequently in ages 30 to 707
            * Occurs more frequently in females
            * No hormonal influences
Treatment   * Free gingival grafts can be used for atrophic sites (7)
            * Management of symptoms and monitoring for dysplastic
              changes
            * Reticular types are asymptomatic; no treatment required
            * Erosive types typically respond to topical steroids
            * Good oral hygiene is essential and can enhance healing;
              plaque and calculus associated with a significantly higher
              incidence of erythematous and erosive gingival OLP
              lesions (6,8)

Table 1. Foreign body gingivitis and oral lichen planus compared