ODA FEATURE
DIFFERENTIAL DIAGNOSIS: SOLITARY GINGIVAL MASS
By: Glen D. Houston, DDS, MSD | Diplomate, American Board of Oral and Maxillofacial Pathology | gdhdds@heartlandpath.com HISTORY A 32-year-old male presented with a large fluctuant mass involving the mandibular gingiva. The patient noted that the area in question had been present for “a while” and would “bleed when I eat any food.” He reported a lengthy history of cigarette and marijuana use. The remainder of his health history was unremarkable. Clinical examination revealed extremely poor oral hygiene and a soft tissue mass that was quite hemorrhagic. QUESTION #1 An appropriate clinical differential diagnosis for this lesion might include: a. Gingival cyst of the adult b. Peripheral giant cell granuloma c. Histoplasmosis d. Squamous cell carcinoma e. Peripheral ossifying fibroma f. Pyogenic granuloma
ANSWER #1 Your differential diagnosis should include: peripheral giant cell granuloma (b), peripheral ossifying fibroma (e), and pyogenic granuloma (f). All three of these lesions can present intraorally as an isolated gingival mass. The peripheral giant cell granuloma (b) occurs exclusively on the gingiva or the edentulous alveolar ridge presenting as a red or reddish-blue nodular mass. The lesion can be sessile or pedunculated and may or may not be ulcerated. The peripheral giant cell granuloma may develop at any age, is more common in females than males, and affects the mandible more often than the maxilla. Much like the peripheral giant cell granuloma, the peripheral ossifying fibroma (e) also occurs exclusively on the gingiva. It presents as a nodular mass with a pedunculated or sessile base. It is pink to red in color and frequently ulcerated. The peripheral ossifying fibroma is a lesion of teen-agers and young adults with the majority observed in females. Over 50 percent of the reported cases have occurred in the anterior regions of the jaws. The pyogenic granuloma (f) typically presents as a smooth, lobulated mass that usually exhibits surface ulceration. This lesion exhibits a predilection for the gingiva. However, unlike the peripheral giant cell granuloma and the peripheral
36 journal | January/February 2022
ossifying fibroma, it has also been observed on the lips, tongue, and buccal mucosa as well as other mucosal and cutaneous surfaces. The gingival cyst of the adult (a) would not be included in the differential diagnosis even though it is invariably located on the facial gingiva or alveolar mucosa. This lesion is often bluish or bluish-gray in color and presents as a tense, fluid filled swelling. Likewise, histoplasmosis (c) is not a consideration here. This is the most common systemic fungal infection observed in the United States today. Although primarily a pulmonary infection, it may manifest intraorally as a solitary, painful, firm ulceration with a rolled margin involving the tongue, palate, or buccal mucosa. Squamous cell carcinoma (d) can also be ruled out in this differential diagnosis. Although it is the most common malignancy observed intraorally (approximately 30,000 cases annually; three percent of all cancers in the United States), only about four to six percent occur on the gingiva or alveolar mucosa. This neoplasm typically presents as an area of erythroplakia, leukoplakia, or ulceration with rolled borders in this location. QUESTION #2 Your treatment plan should include: a. Intraoral radiographic survey b. Oral smear of the lesion for microscopic examination c. Excisional biopsy of the lesion d. No surgical intervention; follow closely for 3-6 months ANSWER #2 Your treatment plan should include intraoral radiographic survey (a) and excisional biopsy of the lesion (c). The intraoral radiographic survey (a)
