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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 49-52

Discrete gingival enlargement resulting from artificially created maxillary midline diastema


1 Department of Periodontics, University of Benin, Benin City, Edo State, Nigeria
2 Department of Periodontics, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication30-Jan-2017

Correspondence Address:
Clement Chinedu Azodo
Room 21, 2nd Floor, Department of Periodontics, Prof Ejide Dental Complex, University of Benin Teaching Hospital, P.M.B. 1111 Ugbowo, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-6859.199165

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  Abstract 

A case of discrete gingival enlargement as a long-term consequence of artificially created midline diastema by a dental quack in an otherwise healthy 33-year-old female was reported. The patient and her husband were bothered by the gingival enlargement and requested treatment. The patient was unconcerned about the associated discolored tooth. The lesion was diagnosed as fibrous epulis and was treated by surgical excision after which the patient was referred to the restorative dentist for endodontic treatment. To conclude, discrete gingival enlargement occurring as a long-term consequence of artificially created midline diastema by a dental quack should be considered as fibrous epulis until proven otherwise.

Keywords: dental quackery, fibrous epulis, gingival enlargement, midline diastema


How to cite this article:
Azodo CC, Erhabor P. Discrete gingival enlargement resulting from artificially created maxillary midline diastema. J Clin Sci 2017;14:49-52

How to cite this URL:
Azodo CC, Erhabor P. Discrete gingival enlargement resulting from artificially created maxillary midline diastema. J Clin Sci [serial online] 2017 [cited 2021 Apr 11];14:49-52. Available from: https://www.jcsjournal.org/text.asp?2017/14/1/49/199165


  Introduction Top


The description of pleasing tooth color, size, and arrangement in the languages of the multiple ethnic groups that make up Nigeria emphasizes the cultural values attached to the dental appearance. This perception of dental appearance has obvious impact on acceptance, full integration, social interaction, friendship, marriage, achievement, schooling, and employment. The individuals with dental appearance who deviate from the acceptable norm usually seek care to restore it to culturally accepted norm or close to it. However, the drive to achieve the culturally accepted state may sometimes result in tooth modification and mutilation. This is the case with artificial creation of maxillary midline diastema in Nigeria because of its consideration as a sign of beauty and as such, accorded a lot of compliments in the society.[1] This pursuit of beauty occurs in younger age groups because of the intense concern about their appearance. Midline diastema is enormously valued in Nigerian society as 29.7% of the respondents in a study on midline diastema in Nigeria expressed interest in having artificially created diastema.[1] Umanah et al.[2] reported a 34% prevalence of artificially created maxillary midline diastema in their study in South Eastern part of Nigeria.

Individuals who desire maxillary midline diastema, seek such care from dental quacks and beauty salon operators as more than three-quarters of Nigerian dentists do not support artificial creation of maxillary midline diastema.[3] The association of diastema with fashion makes individuals, ignorant of the adverse consequences, to seek artificial diastema creation services in both dental and nondental environment.[2] Other reasons for seeking artificial diastema include peer pressure, increased chances of getting a spouse, and cultural practices.[2] This form of tooth mutilation is commonly associated with complications as 72% of the Nigerian dentists in a study attested to treating patients with various forms of complications arising from artificially created diastema.[3] The complications from artificially created diastema include tooth sensitivity, tooth fracture, pulpitis, and pulp necrosis which may progress to an abscess, cellulitis, and probably loss of the tooth.[2],[4] Although rare, wide diastema may cause speech defect by making proper pronunciations of words, difficult. There seems to be no report of gingival enlargement as a consequence of artificially created diastema in the literature. Hence, we report a case of discrete gingival enlargement as a long-term consequence of artificially created maxillary midline diastema by dental quack.


  Case Report Top


A 33-year-old female, retail kerosene seller from the Bini speaking part of Edo State, presented with a 2-month history of a painless localized swelling of the gingiva in the maxillary anterior region of the mouth [Figure 1]. The swelling was progressively increasing in size. The patient also complained of cavities in her posterior teeth which was associated with pain, disturbed her sleep and mastication, but claimed that the pain subsided on its own. She is married in a monogamous setting with one child and is not on any form of contraceptive. She reported having a diastema created for her in a private dental clinic ran by a dental technologist, some 12 years ago on her request. She noticed that the maxillary right central incisor became discolored some years later following the creation of the artificial diastema. She cleans her teeth twice daily with a nonfluoride containing toothpaste. On examination, there was a discrete sessile firm, maxillary midline gingival swelling, which was pink and blanches on digital pressure. The swelling measured about 10 mm by 7 mm and was located between the two maxillary central incisors which were mutilated to artificially create a diastema. Plaque score was 0.3, calculus score was 0.3, and oral hygiene was 0.6, which was good oral hygiene status using the oral hygiene index-simplified index. Periapical radiograph shows slight bone loss between the two upper central incisors. The upper right central incisor has evidence of pulpal involvement on radiograph.
Figure 1: Midline gingival enlargement

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Surgical excision of the swelling was done under local anesthesia using a size no. 15 surgical blade on a bald parker holder. Reshaping of the alveolar bone underneath the mass was done with a bone file [Figure 2]. A periodontal pack placed after hemostasis was achieved [Figure 3]. The mass was placed in a formalin solution and sent to the laboratory for histological diagnosis. Postoperative periodontal instructions were given, oral doses of amoxicillin (500 mg 8 hourly for 5 days), metronidazole (400 mg 8 hourly for 5 days), acetaminophen (50 mg 12 hourly for 3 days), and Vitamin C (100 mg 8 hourly for 14 days) were prescribed and a week appointment was given for review. The histological report showed a reactive (inflammatory) lesion consisting of a covering made of hyperplastic stratified squamous parakeratinized epithelium with underlying proliferation of fibrous connective tissue with marked chronic inflammatory cell infiltration of the stroma. with underlying proliferation of fibrous connective tissue with marked chronic inflammatory cell infiltration of the stroma. There was no evidence of malignancy. The histological diagnosis of fibroepithelial hyperplasia was made. On recall visit, the surgical site was clean and free of any plaque deposit and devoid of any symptoms. The patient was referred to the restorative clinic for management of the pulpally involved maxillary right central incisor.
Figure 2: Surgical site after complete excision of the fibrous epulis

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Figure 3: Surgical site with periodontal dressing in situ

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  Discussion Top


Gingival enlargement is a common feature of gingival disease and therefore, is a common presenting complaint in periodontal practices.[5] Gingival enlargement which may be of inflammatory and noninflammatory origins include retrocuspid papilla, fibrous nodule, gingival cyst, focal mucinosis, focal epithelial hyperplasia, gingival epithelial hamartoma, Cowden's syndrome, neoplasm, peripheral giant cell granuloma, peripheral fibroma, hemangioma, pyogenic granuloma, pregnancy tumor, periodontal granulation tissue, Kaposi sarcoma, bacillary angiomatosis, neurofibromas, leiomyomas, nonHodgkin's lymphoma, and metastatic tumor.[6],[7],[8],[9] The most common discrete gingival enlargements are fibrous epulis, pyogenic granuloma, peripheral giant cell granuloma, and peripheral fibroma.[10],[11]

Fibrous epulis also known as fibroepithelial polyp or fibrous hyperplasia that occurs most commonly on the interdental papilla and on the gingiva near the anterior part of the mouth, especially that of the maxillary anterior region.[12],[13] They are usually pedunculated, firm and rubbery, and pale pink colored swelling.[5] Fibrous epulis affect more females than males and can attain giant size if they do not present on time to the clinician.[14],[15],[16] Over time, bone, cementum-like material, and dystrophic calcification may form within the lesion at which point the term peripheral ossifying fibroma may be used.[5] In some instances, when fibrous epulis contain multinucleated giant fibroblast, it is called giant cell fibroma.[5] Fibrous epulis is considered one of the reactive gingival lesions. Reactive lesions are products of exuberant or heightened tissue in response to chronic and recurring tissue injuries.[10],[17] In this report, the patient is an adult female which is in tandem with report that this form of gingival enlargement is found dominantly in adults with female predilection. It has been stated that fibrous epulis occurs more in females than males, and is the most prevalent in of 21–30-year-old dental population and decline with aging.[16]

Fibrous epulis usually emanates from under the free gingival margin or interdental papilla. When gingival enlargement arises from the interdental papilla without a stalk, it is considered a sessile growth instead of the commonly known pedunculated nature.[5] Fibrous epulis usually occur as a result of local irritation from plaque, calculus, dental caries, irregular margins of restorations, and minor trauma from accidental biting.[10],[18] Chronic irritation is known to serve as a local trigger for fibrous epulis as they stimulate an exuberant or heightened tissue repair response.[10],[17] The artificial creation of diastema of both maxillary central incisors resulted in sharp mesial surfaces. These sharp mesial surfaces constituted the source of irritation and difficult to clean stagnation area. The chronicity of this irritation explained why the enlargement became obvious after 10 years. It can therefore be justified to document discrete gingival enlargement as a long-term complication of tooth mutilation in the form of artificially created maxillary midline diastema. The gingival enlargement is usually asymptomatic with a variable growth rate.[9] As with the patient in this report, the swelling was painless, but the obvious negative impact on the appearance and her husband's concern about the gingival swelling prompted the dental visit.

The artificial creation of maxillary midline diastema also resulted in discoloration of maxillary right central incisor which did not respond to electric pulp testing giving impression of pulpal death. Pulp consequences of artificially created maxillary midline diastema have been reported in Nigeria. Nearly, three-quarters of Nigerian dentists in a previous study reported treating patients with various forms of complications arising from artificially created diastema.[3]

The receipt of artificially created maxillary midline diastema in a dental clinic owned by a dental technologist amounts to dental quackery, since quackery is professionally or publicly pretence of possession of specific skill, knowledge, or qualifications. The procedures carried out by quacks have been reported to be very undesirable, harmful, and sometimes dangerous to the patients, and so was the finding in the reported patient.[19] The stakeholders in dental healthcare delivery should set up necessary strategies to protect the citizens, stop dental quackery, and enhance qualitative dental healthcare delivery.


  Conclusion Top


Discrete gingival enlargement occurring as a long-term consequence of artificially created midline diastema by a dental quack should be considered as fibrous epulis until proven otherwise.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Omotoso G, Kadir E. Midline diastema amongst South-Western Nigerians. Internet J Dent Sci 2009;8:2.  Back to cited text no. 1
    
2.
Umanah A, Omogbai AA, Osagbemiro B. Prevalence of artificially created maxillary midline diastema and its complications in a selected Nigerian population. Afr Health Sci 2015;15:226-32.  Back to cited text no. 2
    
3.
Oboro HO, Umanah AU, Chukwumah NM, Sede M. Creation of artificial midline maxillary diastema: Opinion of Nigerian dentists. 2008. Available from: http://www.iadr.confex.com/iadr/pef08/techprogram/abstract_109649.htm. [Last accessed on 2015 Apr 15].  Back to cited text no. 3
    
4.
Arigbede AO, Adesuwa AA. A case of quackery and obsession for diastema resulting in avoidable endodontic therapy. Afr Health Sci 2012;12:77-80.  Back to cited text no. 4
    
5.
Newman MG, Takei HH, Kokkevold PR, Carranza FA. Carranza's Clinical Periodontology. 11th ed. Missouri, USA: Elsevier Limited; 2012. p. 84-96.  Back to cited text no. 5
    
6.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48:167-75.  Back to cited text no. 6
    
7.
Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumours to the oral cavity – Pathogenesis and analysis of 673 cases. Oral Oncol 2008;44:743-52.  Back to cited text no. 7
    
8.
Savage NW, Daly CG. Gingival enlargements and localized gingival overgrowths. Aust Dent J 2010;55 Suppl 1:55-60.  Back to cited text no. 8
    
9.
Choudhari P, Kamble P, Jadhav A. Gingival epulis: Report of two cases. IOSR J Dent Med Sci 2013;7:40-4.  Back to cited text no. 9
    
10.
Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol 1980;51:655-61.  Back to cited text no. 10
    
11.
Effiom OA, Adeyemo WL, Soyele OO. Focal reactive lesions of the gingiva: An analysis of 314 cases at a tertiary Health Institution in Nigeria. Niger Med J 2011;52:35-40.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.
Cawson RA, Odell EW. Essentials of Oral Pathology and Oral Medicine. 7th ed. Edinburgh: Churchill Livingstone; 2002. p. 275-8.  Back to cited text no. 12
    
13.
Regezi JA, Sciubba JJ. Connective tissue lesions. Oral Pathology: Clinical Pathologic Correlations. 5th ed. St. Louis: Saunders, Elsevier; 2008. p. 155-78.  Back to cited text no. 13
    
14.
Ajagbe HA, Daramola JO. Fibrous epulis: Experience in clinical presentation and treatment of 39 cases. J Natl Med Assoc 1978;70:317-9.  Back to cited text no. 14
    
15.
Fonseca GM, Fonseca RM, Cantín M. Massive fibrous epulis – A case report of a 10-year-old lesion. Int J Oral Sci 2014;6:182-4.  Back to cited text no. 15
    
16.
Al-Rawi N. Localized reactive hyperplastic lesions of the gingiva: A clinico-pathological study of 636 lesions from Iraq. Internet J Dent Sci 2008;7:1.  Back to cited text no. 16
    
17.
Rajanikanth BR, Srinivas M, Suragimath G, Pai J, Walvekar A, Kumar R. Localized gingival enlargement – A diagnostic dilemma. Indian J Dent 2012;3:44-8.  Back to cited text no. 17
    
18.
Agnihotri A, Sharma R, Sandhu AP, Gulati A. Giant fibroepithelial polyp: A rare case report. Indian J Multidiscip Dent 2013;3:817-9.  Back to cited text no. 18
  Medknow Journal  
19.
Sandesh N, Mohapatra AK. Street dentistry: Time to tackle quackery. Indian J Dent Res 2009;20:1-2.  Back to cited text no. 19
[PUBMED]  Medknow Journal  


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