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 24-year-old man presents with an exophytic soft tissue mass involving the left anterior maxillary facial and palatal gingiva. The lesion is slow growing and asymptomatic, and the duration is unknown.The patient notes a significant history of alcohol and tobacco use.

QUESTION #1

Your clinical differential diagnosis should include:

a. Pyogenic granuloma b. Peripheral giant cell granuloma c. Peripheral ossifying fibroma d. Parulis

e. Fibroma

f. Mucous retention phenomenon (mucocele)

ANSWER #1

Your clinical differential diagnosis should include:

a. Pyogenic granuloma b. Peripheral giant cell granuloma c. Peripheral ossifying fibroma d. Parulis

e. Fibroma

All five of these lesions can present intraorally as an isolated gingival mass. The pyogenic granuloma (a) is a tumor-like growth of the skin and oral mucosa that is considered to be non-neoplastic in nature. This lesion represents an exuberant tissue response to local irritation or trauma. It typically presents as a smooth or lobulated mass that may exhibit a pedunculated or sessile base. The surface is characteristically ulcerated, and approximately 75% of the intraoral cases occur on the gingiva. This lesion has also been observed at other intraoral sites to include the lips, tongue, and buccal mucosa.

The peripheral giant cell granuloma (b) occurs exclusively on the gingiva or the edentulous alveolar ridge. It presents as a red or reddish-blue nodular mass, may or may not be ulcerated, and can exhibit a sessile or pedunculated base. The peripheral ossifying fibroma (c) is another non-neoplastic lesion that occurs exclusively on the gingiva. It presents as a nodular mass in young adults and usually involves the anterior regions of the jaws. The parulis (d) represents a mass of subacutely inflamed granulation tissue associated with the gingiva. It usually arises from an infection of pericoronal, pulpal, or periodontal origin and resolves spontaneously after the offending tooth erupts into occlusion, is extracted, or is endodontically treated. The fibroma (e) is the most common "tumor" of the oral cavity. This lesion is probably a reactive, hyperplastic response of fibrous connective tissue to local irritation or trauma and not a true neoplasm. It typically presents as a smoothsurfaced pink nodule and can occur anywhere in the mouth or on the skin. The mucous retention phenomenon (mucocele) (f) typically presents as a "dome-shaped" mucosal nodule. Because the gingiva and attached mucosa are devoid of minor salivary gland tissue, this would be a rare anatomic location to find this lesion that arises from the rupture of a salivary gland duct and spillage of mucus into the surrounding soft tissues.

QUESTION #2

Your treatment plan should consist of: a. Intraoral radiographic survey b. Biopsy of the lesion c. No surgical intervention; advise the patient that this probably represents an "irritation" fibroma and that unless the area becomes symptomatic, no treatment is necessary

QUESTION #3

Histologic examination of the excisional biopsy of this lesion reveals the following features: A nodular mass of very cellular fibrous connective tissue containing numerous islands of cementum and bone is observed. Considering the clinical appearance and microscopic description of this lesion, your diagnosis would be which of the following: a. Peripheral ossifying fibroma b. Epulis fissuratum c. Neurofibroma

d. Pyogenic granuloma e. Fibroma

ANSWER #3

The lesion is correctly diagnosed as peripheral ossifying fibroma (a) — see "Discussion" section. The other possibilities are not considered here because epulis fissuratum (b) and the fibroma (e) are both composed of a proliferation or hyperplastic mass of dense fibrous connective tissue without any evidence of a calcified product. The neurofibroma (c) is a neoplastic process composed of interlacing bundles of spindleshaped cells, which exhibit "wavy, commashaped" nuclei in association with delicate collagen fiber bundles. Lastly, the pyogenic granuloma (d) is composed of a highly vascular proliferation of granulation tissue which exhibits numerous endothelium-lined vascular channels that are engorged with erythrocytes.

DISCUSSION

The peripheral ossifying fibroma is a benign reactive (non-neoplastic) lesion that occurs exclusively on the gingiva. Most authorities believe this entity arises from fibers of the periodontal ligament or periosteum. The lesion usually presents clinically as a solid, firmly attached, gingival mass. The peripheral ossifying fibroma frequently causes separation of the adjacent teeth, and occasionally, minimal osseous resorption can be observed subjacent to the lesion. Frequently, the lesion is found to contain a calcified stalk or base at the time of surgery, and this, or other islands of calcified material, may be observed as radiopaque “flecks” or patches on a radiograph. This entity typically is slow growing and asymptomatic. Although often discovered by the patient, it usually does not receive professional attention until the patient presents for a routine examination. The peripheral ossifying fibroma has been observed in individuals between the ages of 10 and 20 years, with a peak incidence of 13 years. Females are more often affected than males, and the majority of the lesions occur anterior to the molar tooth region. There is a slight predilection for the maxillary arch. Microscopically, the peripheral ossifying fibroma consists of a markedly cellular proliferation of benign fibrous connective tissue. Calcified tissue may or may not be present. If found, it may consist of osteoid, bone, dentin, cementum, or dystrophic calcification. The presence of inflammation is quite variable. The lesion is treated by surgical excision. Because the peripheral ossifying fibroma probably arises from the periodontal ligament or periosteum, excision should be deep, down to the periosteum and including the associated periodontal ligament. Thorough root scaling of the adjacent teeth should be performed. Recurrence has been reported in 8%-16% of the cases.

REFERENCES

1. Childers ELB, Morton I, Fryer CE. Giant peripheral ossifying fibroma: a case report and clinicopathologic review of 10 cases from the literature. Head Neck Pathol. 2013; 7:356-360.

2. Zain RB, Fei YJ. Fibrous lesions of the gingiva; a histopathologic analysis of 204 cases. Oral Surg Oral Med Oral Pathol. 1990; 70:466-470.

3. Kenney JN, Kaugars GE, Abbey LM. Comparison between the peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral Maxillofac Surg. 1989; 47:378-382.

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