Strawberry gingivitis is a rare but highly characteristic oral finding strongly associated with granulomatosis with polyangiitis (GPA), formerly known as Wegener’s granulomatosis.
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Early identification by dental professionals can play a decisive role in prompt diagnosis and referral, potentially preventing severe renal, pulmonary, and systemic complications.
✅ Etiology
Strawberry gingivitis is not an independent disease. It is a direct oral manifestation of granulomatosis with polyangiitis, an autoimmune condition characterized by:
▪️ Necrotizing vasculitis of small- and medium-sized vessels
▪️ Granulomatous inflammation
▪️ Dysregulated immune response, often associated with c-ANCA (PR3-ANCA) positivity
The gingival changes result from vascular damage, capillary proliferation, and inflammatory cell infiltration within the gingival tissues.
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Yes. Strawberry gingivitis is considered a highly specific and sometimes pathognomonic oral manifestation of granulomatosis with polyangiitis.
➤ Key clinical facts:
▪️ Appears in less than 5–10% of GPA patients
▪️ Can precede systemic signs
▪️ Often does not respond to conventional periodontal therapy
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Typical features include:
▪️ Bright red to violaceous gingival enlargement
▪️ Granular, friable surface resembling a strawberry
▪️ Spontaneous bleeding
▪️ Diffuse or localized involvement, commonly affecting the marginal and attached gingiva
The appearance is disproportionate to plaque levels, which should immediately raise suspicion of a systemic etiology.
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➤ Oral signs
▪️ Diffuse erythematous gingival swelling
▪️ Petechial hemorrhages
▪️ Pain or tenderness
▪️ Rapid progression despite good oral hygiene
➤ Systemic symptoms (may be absent initially)
▪️ Chronic sinusitis or nasal ulcers
▪️ Epistaxis
▪️ Cough or hemoptysis
▪️ Fatigue, fever
▪️ Renal involvement (hematuria, proteinuria)
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Diagnosis requires a multidisciplinary approach:
▪️ Detailed clinical examination
▪️ Gingival biopsy showing granulomatous inflammation and vasculitis
▪️ Serologic testing (c-ANCA / PR3-ANCA)
▪️ Medical evaluation by rheumatology or internal medicine
The dentist’s suspicion is often the first step toward diagnosis.
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The main challenge is distinguishing strawberry gingivitis from common inflammatory or reactive gingival conditions.
馃搳 Comparative Table: Key Differences in Strawberry Gingivitis
| Aspect | Strawberry Gingivitis (GPA) | Plaque-Induced Gingivitis |
|---|---|---|
| Etiology | Systemic autoimmune vasculitis | Dental plaque and biofilm |
| Appearance | Red, granular, friable (“strawberry-like”) | Smooth erythematous gingiva |
| Response to periodontal therapy | Poor or absent | Good |
| Bleeding | Spontaneous and profuse | Bleeding on probing |
Local periodontal treatment alone is insufficient. Management focuses on systemic control of GPA, typically including:
▪️ Corticosteroids
▪️ Immunosuppressive agents (e.g., cyclophosphamide, rituximab)
▪️ Supportive oral care to reduce secondary infection
Gingival lesions usually improve once systemic disease is controlled.
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Strawberry gingivitis is a diagnostic red flag. Its rarity often leads to misdiagnosis as aggressive gingivitis or pyogenic lesions, delaying appropriate care.
Dental professionals must recognize that:
▪️ Not all gingival enlargements are periodontal
▪️ Unusual gingival presentations require systemic consideration
▪️ Early referral can be life-saving
馃幆 Clinical Recommendations
▪️ Suspect GPA in atypical, hemorrhagic gingival enlargements
▪️ Avoid repeated periodontal therapy without response
▪️ Request biopsy when clinical features are unusual
▪️ Refer promptly for medical evaluation
▪️ Maintain supportive oral hygiene during systemic treatment
✍️ Conclusion
Strawberry gingivitis is a distinctive and clinically significant oral manifestation of granulomatosis with polyangiitis. Although rare, its recognition by dentists is crucial, as it may be the earliest sign of a severe systemic disease. Early diagnosis and interdisciplinary management significantly improve patient outcomes.
馃摎 References
✔ AlJohani, K., Moles, D. R., Hodgson, T. A., Porter, S. R., & Fedele, S. (2010). Oral manifestations of granulomatosis with polyangiitis. Journal of Oral Pathology & Medicine, 39(9), 629–634. https://doi.org/10.1111/j.1600-0714.2010.00915.x
✔ Suresh, L., & Radfar, L. (2004). Oral manifestations of Wegener’s granulomatosis: A review of the literature. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 97(4), 484–492. https://doi.org/10.1016/j.tripleo.2003.10.015
✔ Patil, S., Khandelwal, S., Doni, B., & Rahman, F. (2015). Strawberry gingivitis: A diagnostic clue to granulomatosis with polyangiitis. Journal of International Oral Health, 7(Suppl 1), 71–73.
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