Plasma cell gingivitis and gingival erythema

Introduction, leading question, aim
The aim of this literature review is to provide an overview of the two separate clinical entities plasma cell gingivitis (PCG) and gingival erythema (gE) according to the current knowledge. The leading question therefore is formulated as the following: What is the current scientific knowledge (August/September 2015) in terms of prevalence, aetiology, clinical and histopathological features, diagnosis and possible therapies for plasma cell gingivitis and gingival erythema? Another aim of this overview consists in clearly defining overlaps and the differences between various synonyms among these oral pathologies.

Methods
The systematic literature research for this overview was built upon four major levels, in order to get a widespread and representative overview of the current knowledge. These consisted of the research in dental e-journals provided by the library of the University of Zurich, the research within the online database PubMed, the selection of a leading/editorial article including the study of its secondary literature and the consultation of specialized textbooks. The selection of the relevant articles, which made a contribution towards answering a part of the leading question, was conducted based on two steps: First the review of the title and the abstract and in a second step the study of the full text.

Discussion PCG
PCG is a benign inflammation of the gingiva.4,32 It is characterized by an erythematous and oedematous swelling as well as a diffuse reddening of the gingiva. During histopathological examination one can see the typical massive infiltration of plasma cells in the subepithelial tissue.4,21,32,36,47,55 As the name suggests, these lesions particularly affect the gingiva and are mostly located in the anterior maxillary dental arch. Further localisations of PCG can be observed in the whole oral cavity and they can spread far over the oral boarder. The triade of gingivitis, glossitis and cheilitis is frequently encountered in patients suffering from PCG.23 Within the course of PCG the clinical picture is characterized by episodes of exacerbation and remission.4,20,23,38 The aetiology of this pathology is heavily discussed among scientists. There are three major groups which trigger a PCG: allergens, neoplasia or unknown causes.32,42,55 Most often one can read about a hypersensitivity reaction to certain ingredients in food products or oral hygiene devices such as flavouring, colouring or additive agents (for example cinnamon, clove, chillies, peppers or mint).49,53 In order to examine the cause of this disease one has to find out about certain eating as well as oral hygiene habits.49 The accumulation of bacterial plaque as an aetiological factor for PCG is controversial and discussed in scientific literature. The performance of the diagnostic analysis varies throughout the case reports. Some of the crucial examinations are the histopathological screening which include a gingival biopsy, the haematological screening, the evaluation of the medical history and certain eating and oral hygiene habits of the patient. The process of diagnosis is especially important in order to exclude possible malignant differential diagnoses. As heterogeneous as the aetiological and diagnosing attempts, one can find various therapeutic options in professional literature to treat patients suffering from PCG. The most commonly used are the optimization of oral hygiene, the detection and elimination of potential allergens and the use of locally applied corticosteroids. The subject literature also describes controversial therapies as for instance the use of antibiotics or antimycotics.

Discussion gE
The research concerning gE turned out sparingly. Indeed, it is possible to encounter the term gE in various scientific articles, but it is used mainly as a descriptive and phenotypical term in order to characterize other, mainly periodontal, pathologies. Additionally, this term is used as a measuring parameter in clinical studies for the purpose of assessing the level of inflammation of periodontal diseases or for the purpose of characterizing comorbidities of periodontal diseases. Therefore, we can sum up, that current scientific literature provides sparse information to aspects such as aetiology, clinics, histology, diagnostics, differential diagnostics and therapeutic options. Only the article written by Mueller et al. outlines some characteristics of the gE. Clinically, the gE manifests itself as a sharply locally restricted, obviously reddend and indolent swelling.35 The gE can be attributed to both local and systemic aetiological factors. All aetiological triggers are accompanied by the accumulation of bacterial plaque and therefore an exaggerated inflammation of the human organism is observed. A strictly performed plaque reduction and plaque control present the base of the therapeutic attempts. It is extremely important for a clinician to observe the gE regularly and to precisely evaluate its differential diagnostics in order to prevent malignant entities. This is due to ascribing the character of the gE to various oral pathologies, benign and malignant ones.

Conclusion
The clinical picture of PCG is represented profoundly in the current scientific literature, even though heterogeneous and contrasting views on certain aspects exist. Compared to the results of the literature research concerning the clinical picture of PCG one can barely find adequate research results for the term gE which would allow us to answer the leading question. The term gE does appear in several articles, but it is exclusively used to characterize other, most of the time periodontal, pathologies. That?s why one has to assume that the gE is not an autonomous clinical entity but rather a descriptive term which was added to the specialized literature. In order to receive clarification, one aims for a clear definition and description of the term gE which would include aspects like aetiology, clinical and histopathological appearance, diagnosis and possible therapies. One also needs to classify and demarcate this term between similar differential diagnoses in pursuance of guaranteeing a coherent diagnostic analysis. Masterthesis 'Plasmazellgingivitis und gingivales Erythem: Literaturreview. Beitrag zu Stomatopedia, Online Based Color Atlas of Oral Diseases in Children and Adolescents.' from Sandrine Lasance. University of Zurich. back