Foreign body gingivitis: An iatrogenic disease? Tom D. Daley, DDS, MSc, FRCD(C),” Ontario, Canada DIVISION

OF ORAL PATHOLOGY,

and George P. Wysocki, DDS, PhD,b London,

DEPARTMENT

OF PATHOLOGY,

THE UNIVERSITY

OF WESTERN

ONTARIO. Gingival biopsy specimens from eight patients exhibiting a localized, erythematous, or mixed erythematous/leukoplakic gingivitis that was refractory to conventional periodontal therapy were examined histologically and by energy-dispersive X-ray microanalysis. Histologic examination revealed variable numbers of small, usually subtle, sometimes equivocal, and occasionally obvious foci of granulomatous inflammation. Special stains for fungi and acid-fast bacilli were consistently negative. In all cases, the granulomatous foci contained particles of foreign material that were often inconspicuous and easily overlooked during routine histologic examination. Energy-dispersive X-ray microanalysis of these foreign particles disclosed Ca, Al, Si, Ti, and P in most lesions. However, other elements such as Zr, V, Ag, and Ni were found only in specific biopsy specimens. By comparing the elemental analyses, clinical features, and history of the lesions, strong evidence for an iatrogenic source of the foreign material was found in one case, and good evidence in five cases. In the remaining two patients, the source of the foreign particles remains unresolved.

(ORALSIJRCORALMEDORALPATHOL~~~O;~~:~O~-12)

G

ranulomatous gingivitis can result from a number of causesranging from infectious diseasessuch as tuberculosis and brucellosis’ to diseases of uncertain etiology such as sarcoidosis2 and Crohn’s disease.3 Foreign materials may also elicit a granulomatous reaction in gingival tissues,4 but the nature and the source of the foreign material are usually unknown. This study of eight cases of foreign body gingivitis, which exhibited characteristic clinical features, was undertaken to identify the elements in the foreign materials and to attempt to determine their source. MATERIAL

AND METHODS

Hematoxylin and eosin, Ziehl-Neelsen (ZN), and periodic acid-Schiff (PAS) stained tissue sections from eight casesof granulomatous gingivitis from the files of the Oral Pathology Diagnostic Service, at the University of Western Ontario, and from the Surgical Pathology Service of University Hospital,London, Ontario, were examined microscopically and by polarized light microscopy to determine the presenceof fcrcigz matcria!. Detailed clinical histories for all aAssociate Professor. bProfessor and Chairman 7-14-18832 708

Fig. 1. This photograph of the patient from case 7 shows erythematous gingivitis of interdental papillae between maxillary lateral and central incisors bilaterally (arrows~. (Magnification, X2.)

caseswere obtained, and two patients were examined clinically by one of us (T. D. D.). Serial tissue sections were examined by scanning electron microscopy and energy-dispersive X-ray microanalysis (EDXM) by means of a previously described technique.5 Control tissue samples examined by EDXM included five focal fibrous hyperplasias from age-matched patients,

Foreign body gingivitis

Volume 69 Number 6

709

Fig. 2. A, Foreign material sometimes consisted of easily identifiable large angular particles such as those illustrated in this photomicrograph (arrows). (Hematoxylin and eosin stain. Original magnification, X 140.) B, By means of polarized light microscopy on the same field as Fig. 2, A, many more foreign particles are visible. Some of these are very small (circles) and not apparent in Fig 2, A, (Hematoxylin and eosin stain. Original magnification, x 140.) C, The foreign particles more frequently consisted of fine powder-like particles such as those in and around the circle, scattered in focal concentrations within the granulomatous chronic inflammatory infiltrate. These foreign particles can easily be overlooked during routine light microscopic examination. (Hematoxylin and eosin stain. Original magnification, X220.)

sections of paraffin before and after deparaffinization, and 10 samples of dust obtained from the laboratory in which the tissues were prepared for EDXM. RESULTS Clinical features

(Table

I)

The eight patients ranged in age from 34 to 62 years with a mean of 49.1 years. Seven patients were female. The lesions appeared as red or red and white macules varying in size from 5 to 15 mm, solitary in six cases and multifocal in two cases. The maxillary gingiva was involved in five cases with a predilection for the anterior segment (Fig. I), and the mandibular gingiva in five cases with no apparent site predilection. The interdental papillae were usually affected; however, the lesions also involved the marginal and attached gingiva. The lesions were often sore and had persisted for up to 2 years despite conventional periodontal therapy and excellent oral hygiene. One pa-

tient noticed the onset of multifocal lesions shortly after her daughter, a dental hygiene student, had performed a dental prophylaxis; another patient noticed the onset of lesions after the placement of full crown dental restorations; and a third patient had a lesion adjacent to the clasp of a removable partial denture. Histologic

features

Microscopically,

the lesions consisted of granulothat varied from focal collections of histiocytes that were largely obscured by an intense lymphocytic infiltrate to well-formed granulomas sometimes containing multinucleated giant cells. Foreign particles in the granulomas varied from angular fragments that polarized easily to a fine powder scattered in focal areas (Fig. 2, A, B, and C), which could easily be overlooked during light microscopic examination. matous

inflammation

710

Daley and Wysocki

Table

I. Clinical

ORAL

and EDXM

features of eight cases of granulomatous

Case

Age

Sex

1

34 44 52 40 52 53 62 56

M F F F F F F F

2 3 4 5 6 I 8 Elements listed case each. MY., maxilla;

by frequency Md,

mandible;

of appearance: Ant,

anterior;

Gingival

Ant Mx Ant Mx, L Post Md Ant Md R Post Md Ant Mx RMd Ant Mx, R Post Md R Mx

L, left;

II. EDXM of control tissue sections, paraffin, solvents, and dust /

Diagnosis

#l*

FFH

#2 #3 #4 #5 Paraffin Solvents Dust

FFH FFH FFH FFH -

FFH, focal fibrous Mercurochrome.

1

found

by EDXM

Ca, Al, Hg, Zn, P, Si, Cl, Fe Zn, Si, Ca, S, Cl Ca, P, Si, Al, Fe, S Al, Sn, Ca, P Al, Cl, Fe, S, Si Al, Si, Ti, Ca, P, S, Zn, Fe, Cl, K

-

hyperplasia.

Elements

*This

tissue

was painted

on one side with

The overlying stratified squamous epithelium was typically nonulcerated. No acid-fast bacilli or fungi were detected in the tissue sections stained by the ZN and PAS techniques. EDXM

containing Elements

Ca, Zr, Si, Si, Si, Ca, Ca, Ca,

found

foreign material by EDXM

Al, Ti, P Si, Al, Zn, Ca, Sn. Fe, Cu, P Al, Ca, Zn, Ti, Cu Ca, P, Ti, Fe, Al, Ni Ti, Al, Ca, V, Ag, P P, S, Si, V, Ti, Fe Si Fe, P, Ti, Al, Si

Fe in 4 cases; Zn, Cu, V in 2 cases; Zr, Sn, Ni, S, Ag in cm

R, right

Table

Stub

site

Ca in all 8 cases; Si in 7 cases; Al, P, Ti in 6 cases; Post, posterior;

gingivitis

SURG ORAL MED ORAL PATHOL June 1990

features

Table I lists the results of the elemental analyses of the foreign material found in the eight cases of granulomatous gingivitis. Table II lists the elements found in the EDXM of the control tissues, paraffin, solvents, and dust samples. Table III lists elements found by EDXM of selected dental products. Elemental constituents of numerous dental products are listed in textbooks on dental materials.6, ’ DISCUSSION

This study was undertaken to determine the etiology of a persistent erythematous or erythematous/ leukoplakic localized gingivitis that was refractory to ~on~renfinnat periodontal therapy and dental hygiene techniques. Histologically, these lesions were characterized by granulomatous inflammation, often containing foreign material that was sometimes very fine and difficult to detect by routine light microscopy. An

attempt was made to determine the source of the foreign materials by comparing their elemental analyses to those of suspected sources. Particles containing various elements including Ca, P, Si, Al, Fe, and Zn were found in control tissue sections of focal fibrous .hyperplasias. These particles were in low concentration and randomly scattered throughout the tissue sections, including the epithelium. Similar particles were found beside the tissues on the carbon stubs, small disks of pure carbon upon which tissue sections are mounted for EDXM. Similar elements had been found in the lesional tissues. However, the random distribution suggested contamination of the stubs by particles in the paraffin, tissue-processing fluids such as xylenes and alcohols, or from the air. No significant contamination was found from an analysis of sections of paraffin before and after deparaffinization. To rule out the possibility of contamination from airborne particles, 10 samples of laboratory dust were analyzed, and found to contain Ca, P, Al, Si, S, Cl, Ti, Zn, Fe, and K. These were assumed to be the source of the tissue section contamination. To rule out misinterpretation caused by dust contamination, lesional tissue sections were reexamined with the scanning electron microscope and with field scanning EDXM of local concentrations of foreign particles corresponding to those present in serial sections of the tissues examined by light microscopy. By means of this technique, particles in the lesional tissues were found to contain a spectrum of elements, commonly Ca, Si, Al, Ti, and P. Elements such as V, Zr, Ag, and Ni were present in only specific cases. Inasmuch as particulate matter of the elements and sizes found in these cases have been documented to cause granulomatous or chronic inflammatory reactions,4 it was assumed that these particles were the etiologic agents of the clinical lesions. An iatrogenie source of these particles was considered. The analyses of selected dental products revealed many elements that were found in the particles of the

Volume 69 Number 6 Table

Foreign body gingivitis

111.EDXM

7 11

ZlR23

of selected dental products

Zr

Product

Prophylaxis paste 1 (n = 72) Prophylaxis paste 2 (n = 31) Polishing bur (n = 1) Sand paper disk (n = 1) Hand instrument (n = 2) Zinc oxide (n = 1) Amalgam (n = 100) Burs-701 (n = 1) -Jet carbide (n = 1) n. number

of

I

Elements

found

Si, Ti, Ba, Al, Zr Zr, Si, Sn, Al Si, Al Al Fe, Cr Zn, Ca, P Hg, Ag, Cu. Sn, Zn W, Co, core: Fe, Ni W, core: Fe, Ni, P

Range

= IO 230

keV

samplesanalyzed. , S3224-888

lesions. Of particular interest were the elements found in prophylaxis pastes examined: Si, Al, Ti, and Zr. Since many of the elements of dental materials and products that may be impacted into the gingiva are also found in a wide variety of nondental products, and even in dust, it is difficult to prove an iatrogenic cause based on elemental constituents alone. However, the combined historical, clinical, histologic, and EDXM features provide sufficient information on which to draw conclusions. One case was interpreted to be iatrogenic. A 44-year-old woman acted as a patient for her daughter, who was a dental hygiene student. The erythematous gingivitis appeared shortly after the daughter had scaled and polished her mother’s teeth. EDXM of some of the fine particles found by light microscopy showed the presence of zirconium silicate (Fig. 3, B). Identical and near identical spectra were obtained from a commercially available prophylaxis paste (Fig. 3, A). Zr was not found in dust nor in controls. The elements found in five other cases could support an iatrogenic cause. However, the historical evidence is missing (although one of these patients noticed the onset of the gingivitis after the insertion of full-crown dental restorations), and common elements such as Si, Al, Ca, and P may be derived from various sources. Nevertheless, a dental source is possible and even probable for gingival tissues, considering the high frequency with which these elements are found in dental products including porcelains, abrasives, polishes, and even toothpaste. Two cases could not be ascribed an iatrogenic cause because of the presence of V in many particles. We know of no common use of V in dental materials. Periodontal disease is very common,* especially in middle-aged and older adults. It frequently involves ulceration of the sulcular epithelium, producing minute wounds that may be exposed to the oral environment after plaque removal. Furthermore, dental personnel frequently injure the sulcular epithelium during subgingival scaling. These wounds are avenues

-5G

2I

!

s, I

Zra;, B -0000

N-fL._ Range

= 20460

keV

20 220-

Fig. 3. A, Spectra of some particles from samples of a commercially available prophylaxis paste contained a high concentration of Zr and Si. Compare this spectra to Fig. 3, B. B, Spectra of some particles found in the gingiva of the patient from case 2 are illustrated in this printout. The high concentration of Zr was unique to this case in which the gingivitis occurred after the patient had received a thorough scaling and prophylaxis. The emission energies were analyzed over a range of 0 to 20.460 keV to detect the highenergy emissions from Zr “K orbital” reactions. This technique differentiates Zr “L orbital” reactions from P “K orbital” reactions, which have overlapping emission energies.

by which foreign materials from the oral cavity may be introduced into the gingival tissues. Ironically, it is during

the time when

wounds

are exposed

that dental

personnel spin abrasives into the gingival sulcus while performing a dental prophylaxis after scaling of the teeth. To reduce the risk of iatrogenic foreign body gingivitis, it would seem prudent to postpone the dental polishing

and prophylaxis

for at least 2 days after

scaling. TREATMENT

The only successful treatment for foreign body gingivitis found to date is surgical excision of the affected tissue, if periodontal considerations are suitable and if it is indicated for the relief of symptoms or for cosmetic purposes.

7 I2

Daley and Wysocki

ORAL

SURG

ORAL

MED

ORAL

PATHOL

June 1990

SUMMARY

A persistent refractory, usually erythematous localized gingivitis that exhibits obvious or subtle granulomas may contain foreign particles, which may be so small that they can be easily overlooked during routine histologic examination. Evidence indicates that at least some of these lesions are iatrogenic in nature. REFERENCES 1. Nolte WA, ed. Oral microbiology with basic microbiology and immunology. 4th ed. St. Louis: CV Mosby Co, 1982:352,436. 2. Regezi JA, Sciubba JJ. Oral pathology. Clinical-pathologic correlations. Philadelphia. WB Saunders Co, 1989:241-3. 3. Robbins SL, Cotran RS. Pathologic basis of disease. 2nd ed. Philadelphia: WB Saunders Co, 1979:905,958-62.

4. Peters E. Surgical materials in tissues [MSc thesis]. London, Ontario: University of Western Ontario, 1984. 5. Daley TD, Gibson D. Practical applications of energy-dispersive X-ray microanalysis in diagnostic oral pathologv, ORAL SURG

ORAL

MED

ORAL

PATHOS

1990;69:339-44.

-I

6. Combe EC. Notes on dental materials. 5th ed. New York: Churchill Livingstone, 1986. 7. Phillips RW. Skinner’s science of dental materials. 8th ed. Philadelphia: WB Saunders Co., 1982. 8. Lindhe J, ed. Textbook of clinical periodontology. Philadelphia: WB Saunders Co, 198567-84. 154-85. Reprint requests to: Dr. Tom D. Daley Associate Professor Division of Oral Pathology The University of Western London, Ontario, Canada,

Ontario N6A 5Cl

Foreign body gingivitis: an iatrogenic disease?

Gingival biopsy specimens from eight patients exhibiting a localized, erythematous, or mixed erythematous/leukoplakic gingivitis that was refractory t...
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