Differential Diagnosis: Solitary Gingival Mass

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 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)

will supplement your clinical observations and will complete a thorough intraoral examination. An isolated, asymptomatic gingival mass is best managed by an excisional biopsy (c). An intraoral cytologic smear (b) is of limited value in the diagnosis of a gingival mass. It is primarily useful in the diagnosis of certain viral conditions, vesiculo-bullous disorders, and a limited number of infections. It is an adjunct to, but not a substitute for, a surgical biopsy procedure. No surgical intervention; follow closely for 3-6 months (d) is also of no benefit in this case. There is nothing to be gained in the management of a gingival mass by following this lesion by observation.

QUESTION #3

The lesion was composed of a hyperplastic mass of granulation tissue covered with a layer of unremarkable ulcerated squamous epithelium. Numerous inflammatory cells were dispersed throughout the lesion. Based upon this description and the history, the diagnosis for the lesion is: a. Epulis fissuratum b. Pyogenic granuloma c. Peripheral giant cell granuloma d. Gingival cyst of the adult

ANSWER #3

The lesion is correctly diagnosed as pyogenic granuloma (b). The other possibilities are not considered here because epulis fissuratum (a), also known as inflammatory fibrous hyperplasia, is composed of a proliferation or hyperplastic mass of dense fibrous connective tissue with hyperkeratotic surface stratified squamous epithelium and a chronic inflammatory cell infiltrate. The peripheral giant cell granuloma (c) reveals a soft tissue lesion composed of multinucleated giant cells within a background of plump, ovoid, and spindle-shaped mesenchymal cells. The gingival cyst of the adult (d) consists of a thin, flattened, luminal, epithelial lining (keratinized or non-keratinized) in association with a fibrous connective tissue capsule.

DISCUSSION

The pyogenic granuloma (b) is a distinctive clinical entity representing a response of the soft tissue to a nonspecific infection, lowgrade trauma, or irritation. In the oral cavity this lesion occurs most commonly on the gingiva followed by the lips, tongue, and buccal mucosa. The pyogenic granuloma usually presents as an elevated, sessile mass with a smooth, lobulated surface that is usually ulcerated and shows a tendency for hemorrhage. It is usually deep red or reddish purple in color, asymptomatic, and soft in consistency. It may vary considerably in size, ranging from a few millimeters to a centimeter or more in diameter. Cases have been observed in both young people and adults with no apparent gender or age group predilection. Microscopically, the pyogenic granuloma is composed of a localized exuberant proliferation of granulation tissue. The overlying surface epithelium is quite atrophic and ulcerated. The most prominent features of this lesion are the numerous endotheliumlined vascular spaces enmeshed with immature fibrous connective tissue. There is also an infiltrate of acute and chronic inflammatory cells dispersed throughout the lesion.

The pyogenic granuloma is treated primarily by surgical excision. Following the excision, care should be taken to examine the adjacent teeth to ensure that they are free of calculus or foreign material, since this may act as an irritant leading to recurrence or persistence of the lesion.

REFERENCES

Gordόn-Núñez MA, Vasconcelos Carvalho M, Benevenuto TG, et al: Oral pyogenic granuloma: a retrospective analysis of 293 cases in a Brazilian population, J Oral Maxillofac Surg 68:2185-2188, 2010.

Epivatianos A, Antoniades D, Zaraboukas T, et al: Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features. Pathol Int 55:391-397, 2005.

Bhaskar SN and Jacoway JR: Pyogenic granuloma— clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg 24:391-398, 1966