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Case Report

Gingival enlargement unveiling Crohn’s

disease – A report of a rarefied case
Krishnamurthi Malathi,1 Arunachalam Muthukumaraswamy,1
MariaAntony PremBlaisie Rajula, Singh Arjun1

Department of Abstract:
Periodontics, SRM This article highlights a peculiar case of Crohn’s disease (CD) with the primary presenting symptom as localized
Kattankulathur Dental gingival overgrowth in the anterior region of maxilla. The patient underwent surgical treatment with external
College, Kanchipuram, bevel gingivectomy procedure. Follow‑up after 6 months revealed no recurrence. A final diagnosis of CD was
1
Department of made, after following histopathological evaluation of the gingival biopsy and other special investigations. It is
Periodontics, thus crucial to associate the localized granulomatous gingival overgrowth to systemic signs of CD. Intraoral
occurrence preceding intestinal involvement is very rare in CD with an incidence of about 8%–9% of patients.
Tamil Nadu Government
Therefore, precise diagnosis, treatment planning, and timely management are vital to the overall health and
Dental College and welfare of patients.
Hospital, Chennai,
Key words:
Tamil Nadu, India
Chronic granulomatous disease, Crohn’s disease, gingival overgrowth, gingivectomy

INTRODUCTION medical history. The patient experienced fatigue,

weakness, and loss of appetite for 6 months but

G ingival overgrowths are reasonably common

which can be induced by an array of
etiological factors and are aggravated by the
Access this article online
localized accumulation of bacterial plaque.
Website:
www.jisponline.com Gingival enlargements are classified into
several categories based on the etiologic factors
DOI:
10.4103/jisp.jisp_417_14 and pathologic changes. [1] Several systemic
diseases may develop oral manifestations that
Quick Response Code:
can result in gingival enlargement, but it is very
rare. Chronic granulomatous diseases such as
tuberculosis[2] and sarcoidosis[3] can manifest as
gingival enlargement in the oral mucosa.
This article highlights a rarefied case with
localized gingival enlargement diagnosed to
be related to Crohn’s disease (CD) which is
successfully managed by means of surgical
periodontal therapy. This case is unique because
intraoral occurrence is uncommon in CD with
an incidence of about 8%–9%.[4] In most of the
patients, intestinal involvement precedes the
Address for oral signs and symptoms.[5] However, in our
correspondence: case, gingival enlargement is seen without any
Dr. MariaAntony
intestinal symptoms. In 5%–10% of the affected
PremBlaisie Rajula,
Department of patients, oral lesion may be the initial presenting
sign before gastrointestinal symptoms.[6]
Periodontics, SRM
Kattankulathur Dental
College, Potheri, CASE REPORT
Kanchipuram,
Tamil Nadu, India.
A female patient, 45‑year‑old, came to the
E‑mail: premblaisierajula@
gmail.com
department of periodontics with a complaint
of pain and gingival overgrowth in the upper
Submission: 16‑10‑2014 front tooth region for the past 2 years. No
Accepted: 27‑11‑2017 systemic problems were revealed in patient’s
no cough with expectoration. The patient did
not give any history of other gastrointestinal
disturbances. The patient had average built
on general assessment; furthermore, the vital
signs were within normal range. On clinical
examination, the extraoral findings revealed
competent lips, and there was no lymph node
enlargement. Intraoral examination revealed
diffuse gingival overgrowth in the upper anterior
region covering more than two‑thirds of the tooth
surfaces with pseudo pockets of about 5–8 mm
[Figure 1]. The color of the gingiva appeared pale
pink. On palpation, it was firm and nontender.
Slight bleeding on provocation was noted.
Phase I therapy comprising of oral hygiene
maintenance instructions, scaling, and
root debridement was performed. During
re‑evaluation, the growth was persistent, and
hence, incisional biopsy was done. The tissue
was submitted for histopathological examination,
which was suggestive of chronic granulomatous
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How to cite this article: Malathi K,
Muthukumaraswamy A, Rajula MP, Arjun S.
Gingival enlargement unveiling crohn’s disease – A
report of a rarefied case. J Indian Soc Periodontol
2017;21:326-8.

326 © 2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow

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Malathi, et al.: Gingival enlargement unveiling Crohn’s disease
Figure 1: Intraoral photograph showing diffuse gingival enlargement
Figure 3: Postoperative picture showing well contour gingiva
diseases. The differential diagnosis considered is orofacial
granulomatosis, angioedema, tuberculosis, sarcoidosis,
and CD. Laboratory investigations were undertaken to
rule out various granulomatous diseases. Mantoux test and
sputum test were negative for tuberculosis and Kveim test
proved negative, which ruled out sarcoidosis. Complete
blood count reports revealed an increase in erythrocyte
sedimentation rate (33 mm/h) and her hemoglobin was 9%
and the red blood cell counts were 2.9 cells/Cumm. The serum
angiotensin‑converting enzyme levels were 39.2 U/L. The
X‑ray of chest revealed no abnormalities. Since the patient
was not willing to undergo further investigations, surgical
intervention by conventional gingivectomy was planned to
remove the excessive gingival tissue.
Surgical procedure
Informed consent was taken before the surgical procedure.
The surgical site was anesthetized by local infiltration with
2% lignocaine containing 1:80,000 adrenaline. The depths of
the pathological pockets were identified and at the level of
the bottom of the pocket bleeding points were produced by a
pocket marker. The primary incision (external bevel incision)
was made with a No. 15 BP blade or a Kirkland knife No. 15/16
at a level apical to the bleeding points. The secondary incision
through the interdental area was performed with the use of
Orban knife No. 1 or 2. The incised tissues were carefully
removed with curettes and tissue tags were removed and
periodontal dressing given [Figure 2].
The excised tissue was sent to pathology department for
histopathological analysis. Postoperative instructions,
Journal of Indian Society of Periodontology - Volume 21, Issue 4, July-August 2017 327
Figure 2: Intraoperative view showing external bevel gingivectomy
Figure 4: Histopathological picture showing stratified squamous epithelium with
pseudoepitheliomatous hyperplasia with diffuse multinucleated giant cells (×40)
including antibiotics and analgesics, were given. Uneventful
postoperative healing was observed. A 6‑month follow‑up
showed no recurrence [Figure 3].
Histopathological examination
Section stained with eosin and hematoxylin revealed stratified
squamous epithelium with pseudoepitheliomatous hyperplasia
and the underlying connective tissue shows diffuse chronic
inflammation with focal aggregates of noncaseating epithelioid
cell granulomas suggesting chronic granulomatous disease.
Multinucleate giant cells were evident throughout the
granuloma [Figure 4]. Since the histopathology once again
revealed chronic granulomatous disease, the patient was
referred back to the physician to rule out CD. The upper
gastrointestinal tract endoscopy results were normal, but
the colonoscopy report was suggestive of an early chronic
granulomatous disease. On the basis of colonoscopy report,
the case was finally diagnosed as CD. Its management is
mainly based on the extent, degree of disease severity, and
the individual patient situation. Since this patient had no
gastrointestinal symptoms, she was kept under physician’s
follow‑up with nutritional supplements alone.
DISCUSSION
CD also known as regional enteritis is a type of intestinal
inflammatory disease which may involve any part of the
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Malathi, et al.: Gingival enlargement unveiling Crohn’s disease
gastrointestinal tract. The main gastrointestinal symptoms
are pain in abdomen, vomiting, diarrhea, and weight loss.
However, other than gastrointestinal complications, it can
cause extraintestinal manifestations, namely skin rashes,
arthritis, lesions of the oral cavity, tiredness, and lack
of concentration. [7] Its incidence in the second and third
decades of life is high. Colonoscopy along with ileoscopy
and biopsy is worthy in the identification of CD. [8]. The
distinguishing diagnostic colonoscopy findings comprise
skip lesions, ulcerations, cobblestoning, and strictures.
The additional diagnostic tests valuable in the finding of
small bowel CD comprise capsule endoscopy, magnetic
resonance enterography, and computed tomography
enterography. [8]
Recent evidence showed a genetic  link to CD. Mutations in the
caspase‑activating recruitment domain 15 gene also named as
the nucleotide oligomerization domain 2 gene are linked with
CD and to certain phenotype susceptibility of disease location
as well as activity.[9] The intraoral findings related to CD were
at first delineated by Dyer et al. in 1969.[10]
In the majority of CD patients, oral findings along
with extraintestinal manifestations are more frequently
seen though Plauth et  al. did not support this in their
outstanding review[11] In 8%–9% of patients, intraoral signs
occur before intestinal involvement and oral signs may not
reflect the intestinal disease activity and severity. [5] Amid
the orofacial features have been mentioned in association
with CD firm, nontender and persistent overgrowth of
the labial or buccal mucosa is a common feature. [12] There
was also a report of an unusual, granulomatous‑appearing
gingivitis, which was hyperplastic in the anterior labial
or buccal mucosa with extension up to or above of the
mucogingival margin. [13]
CONCLUSION
Gingival enlargement may occur due to various etiological
factors. Diagnosis is often made with a careful history,
clinical examination, and relevant investigations. Even
though treatment of any gingival overgrowth is based on
the etiology implicated, the importance of local factors such
as plaque and calculus is considered as a modifying factor.
Gingival hyperplasia may be the first sign in CD patients
who are otherwise asymptomatic and may precede intestinal
involvement. Hence, the dentist is in a unique position in the
early diagnosis and treatment which is vital to the overall health
as well as the welfare of patients.
328 Journal of Indian Society of Periodontology - Volume 21, Issue 4, July-August 2017
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not be
published and due efforts will be made to conceal their identity,
but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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