UW School of Dentistry
COM Jan. 2006 Diagnosis
Gingival swelling of the lingual anterior aspect of the mandible.
Can you make the correct diagnosis?
This is a 23-year-old pregnant Vietnamese female who presented with this lesion that had been present for two months at the the time of her examination.
1. Pyogenic granuloma
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Given that this patient is seven months pregnant, the extensive dental calculus and the clinical presentation of exophytic and red lesion on the gingiva, it is most likely that this lesion represents a pyogenic granuloma (pregnancy tumor). Pyogenic granuloma accounts for 85% of all reactive gingival swellings, representing a profuse mass of vascular granulation tissue (1). Local irritants such as excessive plaque, sharp fillings and dental calculus can induce it. It can occur anywhere in the oral cavity and skin, especially the tongue, lips, fingers and nail beds (1). In the mouth, it occurs most commonly in the gingiva in about 75% of the cases, especially the maxillary buccal and interproximal gingiva (1-2). Occasionally, it may surround the tooth. It is usually highly vascular, fast-growing, exophytic, lobular, sessile, and ulcerated or covered by psuedomembrane. The color changes from red to pink when it starts to heal. It occurs at any age and sex with a slight predilection for young females; it affects 1% of pregnant females. Pyogenic granulomas occurring in pregnant females are called pregnancy tumors, or granuloma gravidarum. They are usually evident in the last trimester, around the seventh month of pregnancy, as was the case in this patient. However, they may start developing earlier in the pregnancy. Unlike in this patient, many of the pyogenic granulomas in pregnant females regress after delivery and some undergo fibrosis. Pyogenic granulomas can also occur in an extraction socket in response to an irritant left in the socket; this type is known as epulis granulomatosa.
Pyogenic granuloma in general is painless except during eating, when bleeding and pain is described (1). Histologically, pyogenic granulomas present as a mass of loose and vascular granulation tissue, usually with ulcerated or eroded surface epithelium and many inflammatory cells. A range of treatment modalities are available, including excision with removal of the local irritant, laser surgery, or intralesional injection with absolute alcohol, steroids and botulinum toxin (1-2). Scaling and polishing prior to surgical removal helps shrink the lesion. The prognosis is good, although recurrence is possible, especially during pregnancy.
As mentioned before, the surgical removal of this lesion was deferred to two months after the birth of the baby. The lesion was then conservatively excised under local anesthesia. The adjacent teeth and entire mouth were thoroughly scaled of the dental calculus in a visit prior to the surgical removal. It has been four months since the lesion was the removed and the area appears to be within normal limits with no evidence of recurrence.
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2. Peripheral Ossifying fibroma
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Peripheral ossifying fibroma constitutes 10% of all reactive gingival swellings. It consists of a moderately cellular fibrous connective tissue mass with bony trabeculae and/or cementum-like hard tissue. It has been reported but rarely on edentulous alveolar mucosa. It originates from the periodontal ligament or the periosteum. This lesion is most common in young patients between 1 and 19 years of age and has a predilection for females over males by a 3:2 ratio (3-5). It occurs exclusively on the gingiva, especially the anterior gingiva, with slight predilection to the maxilla and rare presentation in primary teeth (5). It is usually sessile and exophytic and often ulcerated; it presents as well-demarcated sessile nodules, which are firm or hard depending on the amount of ossification and calcifications (3-5). Peripheral ossifying fibroma is usually pink but can be focally red if ulcerated. Histologically, peripheral ossifying fibroma is made up of a moderately cellular mass of fibrous connective tissue with calcifications ranging from cementum-like material to calcified bony trabeculae with viable osteocytes. The surface epithelium overlying the mass is usually ulcerated. Deep surgical excision to include the periodontal ligament is the preferred treatment, though laser removal has been used effectively. Deep surgery may lead to a gingival defect, which would require gingival grafting, especially if it is located on the anterior buccal gingival (5). There is a 16-20% recurrence rate (5). The clinical presentation of an exophytic red lesion on the gingiva are consistent with a peripheral ossifying fibroma; however, the histology is not supportive of this diagnosis.
3. Peripheral giant cell granuloma
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Peripheral giant cell granuloma constitutes less than 5% of all reactive gingival swellings, and consists of a hyperplastic mass of vascular granulation tissue with many osteoclast-like multinucleated giant cells. It presents as a lobular, purplish-blue exophytic nodule exclusively on the gingiva, both edentulous and dentate, and usually anterior to the molars (7-8). It originates from the periodontal ligament or the periosteum. It occurs across a wide age range, commonly in children, young adults, and in females (2:1 female to male ratio) (7-8). It presents as sessile or pedunculated and smooth surfaced or lobular, and though usually painless it can occasionally be ulcerated, painful and accompanied by bleeding (7-9). Like pyogenic granuloma, it is usually present either on the buccal or lingual gingiva or between teeth, but it can occasionally surround the teeth (6-8) and act aggressively by displacing teeth much like a sarcoma (7). It can also resorb the underlying bone in a smooth and concave “saucer-like” manner. Complete excision including curettage of underlying bone is the preferred treatment. It has a good prognosis with recurrence rate of approximately 10% (8-9). The clinical presentation of an exophytic red lesion on the gingiva are consistent with a peripheral giant cell granuloma; however, the histology is not supportive of this diagnosis.
4. Metastatic malignancy
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Cancer metastasis (from meta, “travel,” and stasis, “stay”) to the oral cavity is neither specific nor common. Although it constitutes less than 1% of all oral malignant neoplasms, it may have a devastating consequence for the patient: usually, metastasis to other sites has already developed or is inevitable (10). Theoretically, any malignant neoplasm can metastasize to the oral cavity, but in actuality few do and out of the ones that do, the majority are carcinomas rather than sarcomas. The most common malignant neoplasms that metastasize to the mouth are from the breast, lung, kidney and prostate (10-12). Malignant neoplasms from the thyroid, pancreas, colon, and liver have also been described. Breast cancer is the most common neoplasm to metastasize to the oral cavity regardless of gender. Among men in particular, lung and prostate cancers are the most common neoplasms to metastasize to the oral cavity. In most cases, the oral presentation is a secondary diagnosis where the primary diagnosis of the distant organ has been already made and the patient has had or is undergoing treatment for it. On rare occasions, the oral lesion is the first manifestation of the disease (10-12). The most common location for cancer metastasis is the posterior mandible, followed by the gingiva and tongue. It is mostly described in adults over the age of 30 and rarely in children. Pain and swelling are the most common clinical symptoms (11-12). They may also present as asymptomatic, simulating a periapical gingival swelling like a pyogenic granuloma. However, they frequently cause bone destruction, tooth loosing and displacement—behavior that is unusual for a pyogenic granuloma. Given the lack of a history of significant medical problems in this patient, it is highly unlikely that this lesion would represent a metastatic neoplasm. Therefore, neither the clinical history nor the histology is supportive of this diagnosis.