Written by Thomas J. Giusto, DDS Wednesday, 31 March 2004 19:00
Exophytic gingival lesions represent some of the more frequently encountered lesions in the oral cavity. Based on clinical appearance, different lesions are often indistinguishable from one another. A review of 15,783 oral lesions during a 17.5-year period found that fibromas, periapical granulomas, mucoceles, and radicular cysts were the most common.1,2 Data from several biopsy services have indicated that 77% of lesions are reactive in nature.1 These lesions are a result of trauma or chronic irritation, or they can arise from cells of the periodontium, periodontal ligament, or periosteum.
This article will review 3 exophytic gingival lesions that were encountered in a periodontal office setting. The cases demonstrate the need for awareness, and the role of biopsy and histologic evaluation in the management of these lesions.
EXOPHYTIC GINGIVAL LESIONS
Some of the most commonly encountered exophytic gingival lesions are the irritation fibroma, peripheral ossifying fibroma, pyogenic granuloma, and peripheral giant cell granuloma.3 A report of more than 30,000 oral biopsies submitted for diagnosis observed that nearly 13% were taken from the gingiva.4 Each of the previously mentioned lesions has been associated with or related to trauma or low-grade irritation as an etiologic factor, and these are generally considered to be reactive and/or nonneoplastic.3 The peripheral giant cell granuloma and peripheral ossifying fibroma generally occur more commonly in females,3,5 while there is no gender predilection for the irritation fibroma.6 The peripheral ossifying fibroma and peripheral giant cell granuloma have been reported in most age ranges, whereas fibromas have the highest incidence in the third through fifth decades.3 The treatment for each of these lesions is surgical excision. The peripheral giant cell granuloma and peripheral ossifying fibroma have a tendency to recur, while the irritation fibroma is unlikely to recur.3
The treatment of these lesions involves administration of local anesthesia and complete surgical excision. The excisional biopsy extends several millimeters beyond the border of the lesion down to bone. Once the entire lesion is removed, the underlying root surfaces of the teeth are debrided. If bone is underlying the lesion, and enough gingiva is remaining, a guided tissue regenerative procedure can be performed. Additionally, subsequent periodontal plastic surgical procedures can also be employed if aesthetics are a concern.
The fibroma is the most common oral fibrous growth.1,5 Of 1,453 lesions detected in more than 23,000 individuals over 35 years of age, the irritation fibroma was found at a prevalence rate of 12.0 lesions/1,000 people.7 Most fibromas represent focal fibrous hyperplasia due to trauma or local irritation. This lesion generally presents as a painless, sessile, round or ovoid, broad-based swelling that is lighter in color than surrounding tissue due to a reduced vascularity.6 The surface may be ulcerated. It is often seen on the buccal mucosa along the plane of occlusion. The diameter can vary from 1 mm to several centimeters.5 Treatment is surgical excision, and a low recurrence rate is expected.
The differential diagnosis of a fibroma includes the following: giant cell fibroma, neurofibroma, peripheral giant cell granuloma, mucocele, lipoma, or salivary gland tumor.5,6 Histologically, fibroblasts are scattered in a dense, collagenous matrix. A mild, chronic, inflammatory infiltrate may be present, but this is not a consistent finding.3,5,6
PERIPHERAL GIANT CELL GRANULOMA
The peripheral giant cell granuloma constitutes between 0.3 to 0.5% of all oral biopsies. It can appear as a sessile or pedunculated, somewhat firm mass that is red to reddish-blue in color.8,9 The lesion may arise from the periodontal ligament or periosteum. In some instances, it can cause resorption of alveolar bone.6,10 It has been reported more frequently in females than males, and radiographic involvement of underlying bone can be found.3
The etiology of peripheral giant cell granuloma is controversial, but is believed to result as a response to injury of the gingival tissues. A traumatic origin has been suggested due to the presence of hemosiderin deposits or erythrocytes found within the fibrous stroma or within the multinucleated giant cells.8,11 However, other reports have maintained that the peripheral giant cell granuloma represents a reactive lesion, stimulated by plaque and calculus. The formation of the giant cells may be due to the fusion of histiocytes, endothelial cells, fibroblasts, or pericytes.11-14
Treatment is surgical excision, and recurrences can be expected if the entire lesion is not completely removed. The differential diagnosis for a peripheral giant cell granuloma is peripheral ossifying fibroma, pyogenic granuloma, cyst, fibroma, mucocele, or hemangioma. Histologically, multinucleated giant cells are scattered throughout a vascular connective tissue.3
PERIPHERAL OSSIFYING FIBROMA
The peripheral ossifying fibroma is a common reactive gingival lesion displaying variable degrees of bone calcification and mineralization, and is believed to arise from the periosteum or periodontal ligament.3,15 The mineralization is found within a non-encapsulated proliferation of fibroblasts. A chronic inflammatory infiltrate is commonly seen around the periphery of the lesion.6 Most lesions have a diameter of less than 2 cm and are usually located in the papilla between adjacent teeth. The lesion can be sessile or pedunculated, and can have an ulcerated surface.5 It has been proposed that the ulcerated and non-ulcerated lesions represent a spectrum with different stages of maturation.16 The peripheral ossifying fibroma tends to be more prevalent in females than males, and similar to the peripheral giant cell granuloma, radiographic evidence of underlying bone involvement can be seen.3
As for the previously mentioned lesions, treatment consists of complete surgical excision. The recurrence rate approaches 20%.17 The differential diagnosis of a peripheral ossifying fibroma includes the following: peripheral giant cell granuloma, peripheral odontogenic fibroma, pyogenic granuloma, fibroma, or inflammatory gingival hyperplasia.5
Histologically, the peripheral ossifying fibroma consists of a fibrocellular component with focal deposits of bone, some cementum, as well as irregular amounts of dystrophic calcification.3
Case Report No. 1: Irritation Fibroma
|Figure 1. Irritation fibroma located on buccal mucosa near lower left lip.|
A healthy, 58-year-old, white female, who was referred for periodontal treatment, also exhibited a gingival mass that measured 5 x 5 mm (Figure 1). This sessile lesion had a smooth surface and was located on the buccal mucosa near her lower left lip. She stated it had been there for months, but recently it had been bothering her because of repeated trauma.
|Figure 2. Histology of fibroma shows dense collagenous matrix and little to no inflammatory response.|
A differential diagnosis included the following: irritation fibroma, mucocele, and salivary gland tumor. An excisional biopsy was performed, and the microscopic appearance (Figure 2) was a circumscribed, dense, collagenous matrix containing few fibroblasts and little or no inflammatory response. The diagnosis was an irritation fibroma.
Case Report No. 2: Peripheral Giant Cell Granuloma
A 75-year-old, white female with a noncontributory medical history presented with an asymptomatic swelling on the facial aspect of the gingiva adjacent to tooth No. 13. The patient had been aware of the swelling for 1 month. The lesion was a bluish-red nodule measuring 5 mm in diameter. It was firm in consistency and did not blanch on pressure. The affected tooth was nonvital, but not tender to percussion. There was 3 mm of gingival recession on the disto-facial aspect of tooth No. 13, and an isolated probing depth of 10 mm was detected on the direct facial surface. A moderate degree of mobility was present. No radiographic changes were detected on a periapical radiograph.
Figure 3. Gingival lesion mesial to tooth No. 13. Photograph was taken just prior to biopsy. The lesion had increased from 5 to 10 mm within 1 month.
One month after completion of endodontic therapy, the nodule had increased in size to 10 mm (Figure 3).
|Figure 4. Area of resorbed bone was present underneath lesion, mesial aspect of tooth No. 13.||Figure 5. Biopsied lesion seen following excision measured 11 x 10 mm.|
A differential diagnosis included the following: combined endodontic-periodontic lesion, root fracture, cyst, mucocele, peripheral ossifying fibroma, pyogenic granuloma, and peripheral giant cell granuloma. After the lesion was removed via an excisional biopsy, the bone underlying the lesion appeared to have been resorbed (Figure 4). The specimen measured 11 x 10 mm (Figure 5). After removal of the lesion, the root surface was then debrided.
|Figure 6. Histology of peripheral giant cell granuloma reveals a dense infiltrate of histiocytes and multi-nucleated giant cells within the subepithelial fibrous stroma.|
The histologic evaluation of the specimen revealed a dense infiltrate of histiocytes and multi-nucleated giant cells within the subepithelial fibrous stroma. The presence of extravasated erythrocytes and hemosiderin deposits was also noted (Figure 6). The diagnosis was a peripheral giant cell granuloma.
Case Report No. 3: Peripheral Ossifying Fibroma
|Figure 7. Exophytic gingival lesion noted on lingual aspect of teeth Nos. 28 and 29. The mass measured 12 x 7 mm and had increased in size over a 3-week duration.||Figure 8. Periapical radiograph of the region displayed a radiolucency between the apices of teeth No. 29 and 30.|
A healthy, 34-year-old, black female was referred by her restorative dentist for evaluation of a gingival lesion that measured approximately 12 x 7 mm (Figure 7).
The lesion was located on the lingual aspect of teeth Nos. 28 and 29, and according to the patient it had grown in size during the past 3 weeks. It was firm, painful, slightly ulcerated near its superior surface, and sessile in nature. A periapical radiograph displayed a radiolucency between the apices of teeth Nos. 29 and 30 (Figure 8). All teeth in the quadrant tested vital.
A differential diagnosis included the following: peripheral giant cell granuloma, pyogenic granuloma, and peripheral ossifying fibroma. The entire lesion was removed via an excisional biopsy down to the underlying bone, and the root surfaces were debrided.
|Figure 9. Histology of peripheral ossifying fibroma displays immature calcified foci of bone encapsulated within a proliferation of fibroblasts and chronic inflammatory cells.|
Histologically, immature calcified foci of bone encapsulated within a proliferation of fibroblasts were noted. Chronic inflammatory cells were also noted (Figure 9). The diagnosis was a peripheral ossifying fibroma. This lesion tends to recur at a rate of nearly 20%.17
These case reports illustrate that exophytic gingival lesions are commonly encountered by dental clinicians. An important rule to remember regarding exophytic, sessile, gingival lesions is the 4 Ps. The differential diagnosis should include peripheral fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, and pyogenic granuloma. Other gingival conditions, such as medication-influenced overgrowth, certain neoplasms, or a hemangioma, can clinically resemble the lesions described. However, the ability to formulate a differential diagnosis is contingent upon clinical appearance as well as location. Ultimately, though, the diagnosis is confirmed by biopsy and histologic evaluation.
The author wishes to thank Drs. John Fantasia and Steve McClain for their contributions to this article.
1. Weir JC, Davenport WD, Skinner RL. A diagnostic and epidemiologic survey of 15,783 oral lesions. J Am Dent Assoc. 1987;115:439-442.
2. Brannon RB, Carr RF, Weir JC. Oral pathology biopsy service at the Louisiana State University School of Dentistry: status report 1995. LDA J. 1997;56:7-9.
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8. Bhaskar SN, Cutright DE, Beasley JD III, et al. Giant cell reparative granuloma (peripheral): report of 50 cases. J Oral Surg. 1971;29:110-115.
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10. Ceravolo FJ, Verbin RS, Oakley CF. A peripheral giant cell granuloma associated with long-standing unusual gingival recession and labial radicular bone loss. Periodontal Case Rep. 1987;9:21-23.
11. Cooke BED. The giant cell epulis: histogenesis and natural history. Br Dent J. 1952;93:13-16.
12. Sapp JP. The ultrastructure and histogenesis of peripheral giant cell reparative granuloma of the jaws. Cancer. 1972;30:1119-1129.
13. Bartel H, Piatowska D. Electron microscopic study of peripheral giant-cell reparative granuloma. Oral Surg Oral Med Oral Pathol. 1977;43:82-96.
14. Anderson L, Arwill T, Fejerskov O, et al. Oral giant cell granulomas: an enzyme histochemical and ultrastructural study. Acta Pathol Microbiol Scand [A]. 1973;81:617-629.
15. Neville BW, Damm DD, Allen CM, et al. Oral & Maxillofacial Pathology. 2nd ed. Philadelphia, Pa: WB Saunders; 2001:451-452.
16. Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol. 1987;63:452-461.
17. Walters JD, Will JK, Hatfield RD, et al. Excision and repair of the peripheral ossifying fibroma: a report of 3 cases. J Periodontol. 2001;72:939-944.
Dr. Giusto has a practice limited to periodontics, including dental implants, in Clark and Watchung, NJ. He is a diplomate of the American Board of Periodontology and is president-elect of the Union County Dental Society. Additionally, he has a background in forensic dentistry. He can be reached at (732) 382-9090 or (908) 753-4427.
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