CASE STUDY #3
Ms. Taylor, a 39-year-old woman, presented to Dr. L. with a chief complaint of swollen and bleeding gums subsequent to brushing her teeth. This had started about two months before and she reported recent fatigue as her work schedule had increased over the past month. Ms. Taylor’s medical history was negative and she was not taking any medications. She did report that her mother and older sister had gingival problems and that their respective dentists saw both for three-month recalls. Ms. Taylor presented with generalized enlarged gingiva on the buccal, lingual, and palatal regions of all teeth, more pronounced in the anterior. There was loss of stippling and the color was pale pink. Bleeding was evident upon probing, and the tissue was firm. Ms. Taylor’s oral hygiene was poor. Poor oral hygiene, systemic conditions, and genetic or hematological disorders may be causes of gingival enlargement, and in some cases, the cause may be idiopathic. Differential diagnoses for Ms. Taylor’s gingival condition include: 1. Inflammation: Plaque is usually the primary cause of gingival inflammation, with symptoms of swelling, bleeding, and color change from pink to red. Fibrosis may be apparent after long-standing inflammation. 2. Genetic (familial): There is a rare condition of gingival enlargement that usually presents upon eruption of the dentition (primary or permanent) and is seen in other family members. This familial condition is hereditary gingival hyperplasia or congenital familial fibromatosis. Some common terms used are idiopathic fibromatosis, gingivomatosis, and elephantiasis. 3. Drug-induced: Medications may cause gingival enlargement that is generalized and present on the marginal and attached gingiva of the lingual and facial surfaces. The gingiva will usually appear firm, pink, and irregularly shaped. Medications that may cause gingival changes are calcium channel blockers, anticonvulsants, and some immunosuppressive drugs. The gingival changes will present after the drug is administered and in most cases subside when the patient stops taking the medication. 4. Hormonal/Vitamin C deficiency: Generalized gingival hyperplasia is common during pregnancy because of the increased levels of hormones causing the tissue to become more sensitive to local factors such as plaque. Increased levels of progesterone and estrogen lead to gingival inflammation and edema subsequent to the vascular permeability changes. This condition is seen more in the interproximal areas than on other surfaces, and the gingiva is smooth with a soft, shiny, bright red surface. Bleeding is spontaneous or caused by minimal manipulation. After the pregnancy, decreasing of the enlargement occurs but removal of the local factors and any irritants is needed for complete resolution of the hyperplasia. Vitamin C deficiency causes a similar appearing gingival hyperplasia, except that the gingival color may be a bluish red. The bleeding pattern is similar to pregnancy gingival hyperplasia but may include a necrotic surface with formation of a pseudomembrane. 5. Systemic conditions: Leukemia causes generalized gingival swelling from gingival infiltration that may present clinically as gingival inflammation. Gingival hyperplasia, oral ulceration, spontaneous bleeding, petechiae, herpetic infections, and candidiasis are other possible oral findings. One of the most serious conditions exhibiting enlargement of the gingiva is acute myeloid leukemia (AML). AML patients often present with ecchymoses, night sweats, infections, and lethargy, which are bone marrow failure symptoms. Quick and simple diagnosis of AML can be Dental malpractice charges Professional liability insurance companies have frequently claimed that errors or inadequacies in the patient record hinder their
made with a full blood count. Crohn’s disease, Wegener granulomatosis, and sarcoidosis are other conditions that can be associated with enlargement of gingival tissue. The appearance of the gingiva is usually pink in color, with a firm consistency that is almost leathery. A pebbled surface is often associated with these conditions. Patients presenting with these gingival changes should always be further evaluated. Gingival enlargement that is not genetic or drug-induced may be a secondary inflammatory response or neoplastic in nature. There are many causes for overgrowth of gingival tissue, and there are definite characteristics for each condition. Inflammation caused by local factors may overlay the definitive condition characteristics. Biopsy and blood work may be necessary to make a definitive diagnosis in cases concerning systemic conditions, and physician/specialty referral is warranted. Dr. S.’s evaluation of Ms. Taylor’s oral condition was that she had generalized fibrotic enlargement of the gingival tissue. Her past medical history was negative and she did not report any drug history that would be a cause of her gingival condition; however, her mother and older sister did have gingival concerns. Ms. Taylor was working long hours, which Dr. S. considered to be the reason for her fatigue. His definitive diagnosis based on clinical presentation and reported patient family history was hereditary gingival hyperplasia or congenital familial fibromatosis. He prescribed periodontal scaling and curettage and an oral rinse including chlorhexidine for her, with follow-up in three months. After the initial three-month recall, minimal improvement was noted. Periodontal recall was completed and Ms. Taylor was scheduled for another three-month recall. Dr. S. told her that it might take some time for her condition to resolve. Nine months passed and Ms. Taylor’s gingival condition remained unchanged. She complained of increased fatigue and “felt drained and not right.” She scheduled an appointment with her primary care physician. Blood tests were completed and her results revealed a low hemoglobin level (6.8 g/dL), low platelet count (30 × 109/L), an elevated total white cell count (19.4 × 109/L), increased bleeding time (12 minutes), and a high erythrocyte sedimentation rate (160 mm/h). Microscopic evaluation of her peripheral blood showed that myeloblasts with large nuclei accounted for 70% of the sample. These hematologic findings are indicative of acute myeloid leukemia (AML). Her oral condition and physical symptoms, combined with her blood work, are conclusive for a definitive diagnosis of AML. Discussion Ms. Taylor’s oral condition appearing to be fibrotic enlargement of her gingiva and her reports of family members with similar gingival problems may have influenced Dr. S.’s misdiagnosis. AML is a life-threatening disease, and the failure to promptly diagnose or refer Ms. Taylor caused a delay in her chemotherapy treatment. This delay may have affected Ms. Taylor’s medication response and survival prospects. Although gingival enlargement is caused by multiple conditions, it may be an early sign in AML patients. Dentists need to be aware of this serious systemic condition and its oral sign. When there were no signs of improvement after the first three-month recall, and especially after the second three-month recall, Dr. S. should have reevaluated his diagnosis. It is easy to make errors in diagnosis. Dentists need to look at the patient’s overall health and medical history, not just at his or her presenting oral condition.
POSSIBLE LEGAL AND ETHICAL IMPLICATIONS OF MEDICAL/DENTAL ERRORS
efforts to defend dentists against unsubstantiated accusations of malpractice effectively. The ADA Council on Members Insurance
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