COM Sept. 2009 Diagnosis

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One of the most common gingival swellings is pyogenic granuloma; for that reason, it should be high on the differential diagnosis list. PG can recur, reach large sizes and be persistent, as in this case. The histology, however, is not consistent with PG.

Pyogenic granuloma constitutes 85% of all reactive gingival swellings, representing a profuse mass of vascular granulation tissue (1). It can be induced by local irritants such as excessive plaque, sharp fillings and dental calculus; it sometimes forms in an extraction socket in response to an irritant left in the socket. 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, 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 pseudomembrane. 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 granuloma is usually painless except during eating, when bleeding and pain is described (1). Histologically, it presents 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 or botulinum toxin (2-3). Scaling and polishing prior to surgical removal helps shrink the lesion. The prognosis is good, although recurrence is possible, especially during pregnancy.

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Peripheral giant cell granuloma constitutes fewer 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 (4-6). 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) (6). 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 (4-6). Like pyogenic granuloma, it is usually present either on the buccal or lingual gingiva or between teeth, but it can occasionally surround the teeth (5) and act aggressively by displacing teeth much like a sarcoma (4). 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 a recurrence rate of approximately 10% (4-6).

References

1. Fantasia JE, Damm DD. Red nodular lesion of tongue. Pyogenic granuloma.
   Gen Dent. 2003 Mar-Apr;51(2):190-194.
2. Ichimiya M, Yoshikawa Y, Hamamoto Y, Muto M. Successful treatment of pyogenic granuloma with injection of absolute ethanol. J Dermatol. 2004 Apr;31(4):342-4.
3. Pham J, Yin S, Morgan M, Stucker F, Nathan CA. Botulinum toxin: helpful adjunct to early resolution of laryngeal granulomas. J Laryngol Otol. 2004 Oct;118(10):781-5.
4. Flaitz CM, Peripheral giant cell granuloma: a potentially aggressive lesion in children.
   Pediatr Dent. 2000 May-Jun;22(3):232-3.
5. Chaparro-Avendano AV, Berini-Aytes L, Gay-Escoda C. Peripheral giant cell granuloma. A report of five cases and review of the literature. Med Oral Patol Oral Cir Bucal. 2005 Jan-Feb;10(1):53-7; 48-52.
6. Neville BW, Damm DD, Allen CM, Bouquot JE. Peripheral giant cell granuloma. In: Oral and Maxillofacial Pathology, 2nd edition. Philadelphia: W.B. Saunders, 2002. p. 449-451.
7. Bundgaard T, S Bentzen, et al. Histopathologic, stereologic, Epidemiologic, and clinical parameters in the prognostic evaluation of squamous cell carcinoma of the oral cavity. Head & Neck. 18:142-152 (1996).
8. Barasch A, DE Morse, et al. Smoking, gender, and age as risk factors for site-specific intraoral squamous cell carcinoma. Cancer 73:509-513 (1994).
9. Syrjanen SM, KJ Syrjanen et al. Human papillomavirus (HPV) DNA sequences in oral precancerous lesions and squamous cell carcinoma demonstrated by in situ hybridization. J Oral Pathol. 17:273 (1988).
10. Neville BW, Damm DD, Allen CM, Bouquot JE. Metastasis to the oral soft tissue. In: Oral and Maxillofacial Pathology, 3rd edition. Philadelphia: W.B. Saunders, 2007.
11. Ogunyemi O, Rojas A, Hematpour K, Rogers D, Head C, Bennett C. Metastasis of genitourinary tumors to the head and neck region. Eur Arch Otorhinolaryngol. 2009

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The persistence, the recurrence, the fungating and the asymptomatic clinical presentation in this case are supportive of malignant neoplasm behavior; therefore, squamous cell carcinoma should be included on the differential diagnosis. The histology, however, is not supportive of SCC.

Squamous cell carcinoma of the gingiva is uncommon, especially in a non-smoker and social alcohol user. Oral squamous cell carcinoma of the mouth is a highly aggressive neoplasm that currently ranks as the fifth most common malignant neoplasm worldwide and accounts for an estimated 90% of oral malignancies (7). Oral SCC occurs predominantly in males over the age of 40 years, with an observed male-to-female ratio of 2:1 generally and 1.4:1 in the USA (7-9).

Excluding the outer lip, the most common sites (in decreasing order) are the ventral and lateral surfaces of the tongue (25-50%), floor of mouth (15%), gingiva (12%) and palate (9%). The buccal mucosa and retromolar pad areas (3%) have a relatively low incidence of occurrence (8) unless the patient is a chronic smokeless tobacco user. Oral SCC varies in presentation from deceptively innocent-looking to obviously malignant. It may present as a non-healing ulcer, or as red, white or mixed red-and-white lesions. Characteristic signs of oral SCC are non-healing ulcer, ulcer with rolled borders, fungation, fixation and induration. Rarely, oral SCC may present as unexplained asymptomatic lateral neck lymphadenopathy (7-9). Oral SCC is most commonly associated with chemically induced mutagenesis, specifically tobacco and alcohol use (9).

Tobacco use is described in over 75% of oral SCC patients (7-9). Tobacco and alcohol have been shown to act synergistically in the development of oral SCC. Human papilloma virus (HPV) has also been found to have a high prevalence in oral cancer, especially in younger patients with no history of tobacco use. Other factors include poor oral hygiene, syphilis, chronic candidiasis, iron and dietary deficiencies, herpes simplex and various other immunologic factors, and lichen planus—especially persistent erosive lichen planus.

Determination of the prognosis of oral SCC is based on its clinical stage and histological classification (7-9). Although oral SCC is a diagnosis made by histology, surgeons tend to depend exclusively on the TNM classification system for clinical staging and treatment decisions. Prognosis is dependent on the TNM staging system; the most important prognostic sign is the presence or absence of metastases at the time of diagnosis. The prognosis thus improves when the lesion is detected early. Oral SCC patients die mainly of infection due to lowered resistance or of hemorrhage if the tumor erodes through one of the main blood vessels.

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In this case, the history of recurrence and persistence and the fungating, asymptomatic clinical presentation even when bit should make a clinician consider possibilities beyond benign lesions.

There are many malignant neoplasms that can afflict the oral cavity, including the gingiva; the most common primary malignant neoplasms of the mouth is squamous cell carcinoma (7). Other primary malignant neoplasms include malignant lymphomas and a number of sarcomas, including osteosarcoma and chondrosarcoma, although bone malignancy, can present as lobular gingival swellings with bony component that would be more ominous in radiographic presentation.

The gingiva is also a frequent location for metastatic neoplasms such as metastatic breast, lung and colon cancer (10-11). In this case, since the patient has a history of a thyroid “tumor” (although the patient does not recall the specifics), it is reasonable to consider the potential of metastatic disease. However, the radiographic findings of a smooth surface and superficial alveolar ridge resorption do not support a diagnosis of any malignant neoplasm; neither does the histology.