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Case of the Month Archives

COM Nov 2019 Diagnosis

Single large gingival swelling left maxilla; area of retained root of tooth #13

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This patient is a 62-year-old white female who presented with a very large gingival swelling.


Case of the Month Summary

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The exophytic, pink, sessile and firm nature of this lesion are all clinical features consistent with those of a benign and reactive gingival swelling. The gender is also consistent with POF. The age and site however argue against POF since they tend to occur in younger patients and more anterior jaws. The histology is that of POF.

POFs tend to present on the anterior gingiva of both jaws in form of a sessile firm nodule, often ulcerated, but sometimes smooth surfaced and pink as is the case with this patient. POFs are more common on the buccal gingiva but can occur on the lingual (palatal) gingiva or between teeth as is the case in this patient.

POFs are more common in young females at a ratio of 3:2 with a typical age range of 10-20 years. They are surgically removed and have a 16-20% recurrence rate.

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Exophytic, sessile, pink and firm gingival swellings may also be benign neoplasms of tooth (odontogenic) origin that solely occur on the gingiva. It is however important to note that peripheral odontogenic neoplasms are rare. The clinical presentation of an exophytic, sessile, pink, and smooth-surfaced swelling on the posterior mandibular gingiva is consistent with the clinical presentation of peripheral ameloblastoma. The age is on the older age range of peripheral ameloblastoma but the gender is.

Almost 99% of ameloblastomas are intra-osseous (central/within bone) and about 1% are present completely outside the bone, usually on the gingiva known as peripheral ameloblastomas. They are slow-growing and non-aggressive compared to the solid and desmoplastic intra-osseous ameloblastomas. They present as small, well-circumscribed, firm nodules on the gingiva, mainly of the posterior mandible in patients around 50 years of age. They are slightly more common in males. They are usually asymptomatic, pink like the surrounding mucosa, smooth surfaced, and sessile. The histology in this case is not consistent with peripheral ameloblastoma or any other peripheral odontogenic neoplasms.

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The pink, exophytic swelling with and non-ulcerated surface should make one think of solitary neurofibroma or leiomyoma but not vascular leiomyoma (the more common variant in the mouth). The site and age argue against both of these soft tissue neoplasms.

In general, benign soft tissue neoplasms such as solitary neurofibromas and leiomyomas are rare in the mouth. If they do occur, the gingiva is not a common site. On the rare occasions that leiomyomas occur in the mouth, they tend to be of the vascular type (angiomyoma). Vascular leiomyomas are slightly reddish-gray in color and they, too, rarely occur on the gingiva.

Solitary neurofibromas (NF) of the oral cavity can occur between 20 and 30 years of age. Some studies suggest that NFs are slightly more common in females, while others report an equal gender predilection. They usually occur on the buccal mucosa, tongue, palate and, rarely, on the gingiva. They are non-tender, smooth surfaced, slow-growing swellings that may be soft or firm. The age, gender and site are not consistent with solitary NF and neither is the histology.

Leiomyomas of the oral cavity tend to originate from the smooth muscle cells around blood vessels. These are known as vascular leiomyomas (or angiomyomas) and account for 75% of oral leiomyomas. Patients tend to be over 30 years of age and are predominantly males. They more commonly occur on the posterior tongue, palate, cheeks and lips. They are slow growing, painless, sessile or pedunculated; smooth surfaced, and normal colored or slightly bluish nodules. The site, age and color are not consistent with leiomyoma and neither is the histology.

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The clinical presentation of a slow-growing gingival lesion of four-month duration is unusual for metastatic disease but cannot be excluded. The patient has no history of breast or lung cancer-two most commonly known to metastasize to the mouth. However, 30% of metastatic disease in the mouth occurs in patients with no prior history of cancer and that the mouth lesion was the first manifestation of the disease. Gingiva is the second most common site of metastasis proceeded by the posterior mandible. The histology is not consistent with a malignant neoplasm, primary or metastatic.

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