Unusual gingivitis

Sir, as per the photograph enclosed (Fig. 1), I am writing this letter to bring this unusual form of gingivitis to the attention of our colleagues. I have only seen this condition twice in this form and I have not seen it written up in the literature or any specific reference to it. In the absence of any other name for it I refer to it as post-cancer lichenoid gingivitis. The two cases that I have seen had the following characteristics:

Figure 1

Post-cancer lichenoid gingivitis

• Post-menopausal females (both patients)

• Breast cancer (one full single mastectomy, the other partial single mastectomy)

• Clearance of local lymph nodes (one case and not the other)

• Post-surgical chemotherapy (both patients)

• Post-surgical radiotherapy (in one case but not the other)

• Concurrent hormone replacement therapy (Fosamax: one case and not the other).

The clinical features of the oral condition present as a characteristic painless marginal atrophic gingivitis with a straight and clearly defined demarcation line about 2-3 mm from the gingival margin. Other red patches are sometimes seen in the mucosa adjacent to the molar regions, reminiscent of physical trauma during function. Characteristically there are no Whickham's striae or other white lines/areas or other bullous lesions present either intra-orally or extra-orally. On close questioning one of these patients described a skin rash which presented as crops of ulcers 1-3 mm in diameter on her forearms. She could not recall these ulcers being preceded with blisters prior to forming.

In both cases the condition seemed to fade with time, taking approximately 18 months to disappear completely.

Management has included reassurance that it was not a new manifestation of the original cancer, regular reviews including palpating the head and neck regions for enlarged lymph nodes and checking intra-orally for any abnormalities in the soft tissues or any asymmetric enlargements of the peri-oral bone.

While one of the patients was taking a Fosamax (alendronate)-based tablet (an anti-osteoporosis bisphosphonate drug), and these are known to create a variety of side effects including urticaria and rashes, the other patient was not taking this medication and developed similar oral lesions. I have therefore concluded that this condition arises from some aspect of the cancer treatment that both of these ladies had received rather than being due to this medication.

I look forward to receiving comments from other colleagues who may have observed similar lesions and their views on what the causative agents may be.