J Periodontal Implant Sci.  2015 Apr;45(2):76-80. 10.5051/jpis.2015.45.2.76.

Extensive gingival necrosis and sequestration of the alveolar bone caused by methimazole-induced neutropenia and three-year follow-up

• Kim EC
• Park JB
• Hong JY
• Kang KL

• KMID: 2329659
• DOI: http://doi.org/10.5051/jpis.2015.45.2.76

Abstract

PURPOSE
Methimazole is an anti-thyroid drug that can cause life-threatening neutropenia in rare situations. The aim of this case report is to describe a set of oral complications associated with methimazole-induced neutropenia and the healing of the gingiva after proper treatment.
METHODS
A 31-year-old female patient hospitalized for systemic symptoms of sore throat and fever and showing extensive gingival necrosis with pain was referred to the Department of Periodontics from the Department of Endocrinology. Methimazole-induced neutropenia was diagnosed based on blood test results and her medical history. Methimazole was discontinued and a range of treatments was administered, including the injection of granulocyte colony stimulating factor.
RESULTS
After systemic treatment, the gingiva began to heal as the neutrophil count increased. Approximately one year later, the gingiva had returned to a normal appearance. Twenty-one months after treatment, sequestra of the alveolar bone that had broken through the gingiva were removed. Periodic supportive periodontal treatment has been continued uneventfully.
CONCLUSIONS
The oral manifestations of gingival necrosis and ulcerations, in combination with systemic symptoms such as fever and sore throat, are the critical signs presented in the early stages of drug-induced neutropenia. Therefore, dentists need to be aware of these oral complications in order to make an accurate diagnosis and to ensure that prompt medical intervention is provided.

Keyword

Complications; Hyperthyroidism; Methimazole; Neutropenia

MeSH Terms

Adult
Colony-Stimulating Factors
Dentists
Diagnosis
Endocrinology
Female
Fever
Follow-Up Studies*
Gingiva
Granulocytes
Hematologic Tests
Humans
Hyperthyroidism
Methimazole
Necrosis*
Neutropenia*
Neutrophils
Oral Manifestations
Periodontics
Pharyngitis
Ulcer
Colony-Stimulating Factors
Methimazole

Figure

• 

  Figure 1 At the first dental visit (A1, A2, A3), a wide zone of whitish necrotic lesions was found in the gingiva, extending across almost the entire dentition. An erythematous margin limiting the necrotic gingival zone was formed at the alveolar mucosa. A crust was present on the left side of the lower lip. Five days after the first dental visit (B1, B2, B3), the necrotic area decreased remarkably and re-epithelialization had started. Two weeks after the first dental visit (C1, C2, C3), pale and pink gingiva, reddish gingival margins, and exposed root surfaces were observed.

• 

  Figure 2 Eight weeks after the first dental visit (A), the gingiva was reddish-pink and much more epithelialized. At 18 weeks of follow-up (B), the gingival margins were re-epithelialized and the size of the interdental spaces had decreased. At a nine-month follow-up (C), the embrasure spaces were almost completely filled with gingival tissue, even though some calculus and plaque were present. At one year of follow-up (D), the upper and lower gingiva showed a normal appearance.

• 

  Figure 3 Necrotic alveolar bones protruding out of the marginal gingiva (arrow) were found around the maxillary left central incisor and canine at a 21-month follow-up visit (A, C) and the sequestra of the bone were removed (B, D, E). At a three-year follow-up visit, the gingiva were found to have a normal appearance (F).

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