Workup for Gingivitis with Gingival Hyperplasia and Fever
In a patient presenting with gingivitis, gingival hyperplasia, and fever, immediately obtain at least 3 sets of blood cultures before starting any antibiotics to rule out infective endocarditis, then perform comprehensive dental and systemic evaluation to identify the source of infection. 1
Immediate Diagnostic Steps
Blood Cultures and Infectious Workup
- Obtain at least 3 sets of blood cultures before initiating any antibiotic therapy to avoid culture-negative endocarditis, as emphasized by the American Heart Association 2, 1
- Do not prescribe antibiotics for undefined febrile illnesses without obtaining blood cultures first 2
- Assess for systemic involvement including fever, lymphadenopathy, and signs of infection extending to cervicofacial tissues 3, 1
Comprehensive Dental Examination
- Perform thorough intraoral examination focusing on periodontal inflammation, pocketing around teeth, and caries that may result in pulpal infection 2, 1
- Obtain a full series of intraoral radiographs to identify caries, periodontal disease, bone loss, tooth fractures, and other pathology not evident on physical examination 2, 1
- Inspect for sources of trauma including ill-fitting prostheses and fractured teeth 2
- Evaluate gingival hyperplasia characteristics: localized versus generalized, papillary versus diffuse, presence of bleeding 4
Cardiac Evaluation
- Obtain echocardiography to evaluate for infective endocarditis, particularly given the strong association between poor oral hygiene, periodontal disease, and bacteremia from IE-related species 2, 1
- This is critical because poor oral hygiene and periodontal diseases are responsible for the vast majority of oral-origin infective endocarditis cases 2
Medication History Review
Drug-Induced Gingival Hyperplasia Assessment
- Review current medications, specifically cyclosporine (CsA) and calcium channel blockers, which are known causes of gingival hyperplasia 2
- Consider switching from cyclosporine to tacrolimus if drug-induced hyperplasia is identified, as tacrolimus is not associated with gingival hyperplasia 2
- Document any immunosuppressive therapy that may increase infection risk 2
Differential Diagnosis Considerations
Age-Specific Presentations
- In younger patients (average age 11.8 years), consider localized juvenile spongiotic gingival hyperplasia, which presents as papillary, often pedunculated, red and easily bleeding gingival overgrowth predominantly on anterior maxillary gingiva 4
- In adults, consider inflammatory hyperplasia secondary to local irritants, systemic factors, or medication effects 5
Systemic Disease Evaluation
- Assess for systemic conditions that may manifest as gingival lesions, as non-plaque-induced gingival diseases can be manifestations of systemic disorders 6, 7
- Evaluate immune status, as immunocompromised patients have higher infection risk 2, 3
Laboratory Studies
- Complete blood count to assess for leukopenia, which increases infection risk 2
- Consider inflammatory markers (ESR, CRP) if systemic involvement is suspected 1
Common Pitfalls to Avoid
- Never initiate empirical antibiotics before obtaining blood cultures, as this leads to culture-negative endocarditis and diagnostic difficulty 2, 1
- Do not overlook the possibility of infective endocarditis in patients with fever and periodontal disease, as this can have serious consequences 1
- Avoid prescribing antibiotics without proper surgical intervention for dental infections, as this leads to poor treatment outcomes 3, 1
- Do not delay dental consultation; early assessment by a dentist familiar with oral sources of systemic infection is essential 2
Risk Stratification
High-Risk Features Requiring Hospitalization
- Systemic involvement with fever and lymphadenopathy 3, 1
- Suspected infective endocarditis based on clinical presentation and risk factors 2, 1
- Diffuse swelling or infections extending to cervicofacial tissues 3
- Immunocompromised status 3