The clinical picture of PCG features gingival erythema and edema, which may expand to the mucogingival junction [1] [2] and even to the palate. The involved regions are the anterior maxillary and mandibular segments. The gums may be friable and hence prone to bleeding during chewing, brushing teeth or flossing.

Although rare, PCG may be accompanied by cheilitis [3], which is characterized by lip swelling, dryness, atrophy, and the formation of fissures. PCG may also be associated with glossitis, which is marked by tongue enlargement and erythema as well as the development of furrows and crenations.

Patients report mouth soreness and burning, which is exacerbated by consumption or usage of certain products. While the etiology has not been determined [3], it is strongly suggested that this condition arises from a hypersensitive reaction to allergens such as certain toothpaste ingredients, chewing gum, khat, cinnamon, or other spices [4] [5].

Complications

There is a case report describing a young adult with PCG who developed gingival enlargement and generalized aggressive periodontitis (GAP) [6]. However, it was unclear whether PCG or GAP occurred first.

Oral exam

Notable findings include red colored marginal and attached gingiva with swelling and diffuse enlargement [3]. There may be granule-like formations as well. If cheilitis is present, then the lip(s) will be dry, swollen, and fissured.

• Hyperthermia

  The following effects have been reported after the use of khat: euphoria, anorexia, insomnia (lack of fatigue), hyperactivity, excitation, hyperthermia, increased respiration, mydriasis, arrhythmias, hypertension, and constipation. 1, 2, 3 The first of [nature.com]

• Sputum

  The workup consists of a complete blood count (CBC), a complete biochemistry panel (CMP), erythrocyte sedimentation rate (ESR), thyroid function tests, HIV screening, acid-fast bacilli (AFB) sputum smear, and peripheral blood smear. [symptoma.com]

• Sore Mouth

  mouth can develop, and if so pain is sometimes made worse by toothpastes, or hot or spicy food. [7] The lesions can extend to involve the palate. [7] Plasma cell cheilitis appears as well defined, infiltrated, dark red plaque with a superficial lacquer [en.wikipedia.org]

• Macroglossia

  […] wart Tongue Ankyloglossia Black hairy tongue Caviar tongue Crenated tongue Cunnilingus tongue Fissured tongue Foliate papillitis Glossitis Geographic tongue Median rhomboid glossitis Transient lingual papillitis Glossoptosis Hypoglossia Lingual thyroid Macroglossia [en.wikipedia.org]

• Hairy Tongue

  tongue Caviar tongue Crenated tongue Cunnilingus tongue Fissured tongue Foliate papillitis Glossitis Geographic tongue Median rhomboid glossitis Transient lingual papillitis Glossoptosis Hypoglossia Lingual thyroid Macroglossia Microglossia Rhabdomyoma [en.wikipedia.org]

• Nikolsky's Sign

  A negative Nikolsky’s sign ruled out pemphigus, other cutaneous diseases like pemphigoid, lichen planus and discoid lupus erythematosus. [casereports.in]

  Nikolsky's sign was negative. A provisional diagnosis of desquamative gingivitis secondary to lichen planus was given. In addition, a differential diagnosisof atypical gingivitis and leukemia-associated gingivitis were considered. [jiaomr.in]

• Hyperactivity

  The following effects have been reported after the use of khat: euphoria, anorexia, insomnia (lack of fatigue), hyperactivity, excitation, hyperthermia, increased respiration, mydriasis, arrhythmias, hypertension, and constipation. 1, 2, 3 The first of [nature.com]

• Mydriasis

  The following effects have been reported after the use of khat: euphoria, anorexia, insomnia (lack of fatigue), hyperactivity, excitation, hyperthermia, increased respiration, mydriasis, arrhythmias, hypertension, and constipation. 1, 2, 3 The first of [nature.com]

• Excitement

  The following effects have been reported after the use of khat: euphoria, anorexia, insomnia (lack of fatigue), hyperactivity, excitation, hyperthermia, increased respiration, mydriasis, arrhythmias, hypertension, and constipation. 1, 2, 3 The first of [nature.com]

During the clinical assessment of an individual with the above manifestations, the clinician should obtain a family history and a list of known allergens. Additionally, a detailed medical history is necessary to rule out differential diagnoses, which include leukemia, myeloma, HIV infection, and connective tissue diseases such as discoid lupus erythematosus, pemphigoid, and lichen planus [7] [8]. Furthermore, other diseases that should be excluded are tuberculosis, Crohn disease, and Wegener granulomatosis. The clinician must also determine whether the patient is using antiseizure medications that cause gingival hyperplasia, which includes phenytoin and phenobarbital [9] [10].

Another critical component of the evaluation is a thorough oral exam of the gums, teeth, mouth, tongue and lips. Additionally, a physical exam including inspection of the skin is important.

The workup consists of a complete blood count (CBC), a complete biochemistry panel (CMP), erythrocyte sedimentation rate (ESR), thyroid function tests, HIV screening, acid-fast bacilli (AFB) sputum smear, and peripheral blood smear [6]. Serology is done if needed. Biopsy of the affected tissue is also useful, especially if the condition is refractory to therapy. Allergen tests should be considered as well.

Histopathology

When a biopsy is taken, the histopathological analysis reveals the presence of diffuse plasma cell infiltration of the connective tissue. This finding confirms the diagnosis.

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2. Gargiulo AV, Ladone JA, Ladone PA, Toto PD. Case report: Plasma cell gingivitis A. CDS Rev. 1995; 88(3):22–3.
3. Janam P, Nayar BR, Mohan R, Suchitra A. Plasma cell gingivitis associated with cheilitis open link: A diagnostic dilemma! J Indian Soc Periodontol. 2012; 16(1):115-9.
4. Marker P, Krogdahl A. Plasma cell gingivitis apparently related to the use of khat: Report of a case. Br Dent J. 2002; 192(6):311–313.
5. Al-Meshal IA. Effect of (alpha) chationone, an active principle of Catha edulis Forssk (khat) on plasma amino acid levels and other biochemical parameters in male wistar rats. Phytother Res. 1988; 2(2):63–66.
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8. Lamey PJ, Lewis MA, Rees TD, et al. Br Dent J. 1990; 168(3):115-8.
9. Hassell T, O'Donnell J, Pearlman J, et al. Phenytoin induced gingival overgrowth in institutionalized epileptics. J Clin Periodontol. 1984;11(4):242–53.
10. Cornacchio AL, Burneo JG, Aragon CE. The effects of antiepileptic drugs on oral health. J Can Dent Assoc. 2011; 77:b140.