G

Case
10
A lump on the gingiva
SUMMARY
A 48-year-old man presents to you in general dental
practice with a gingival swelling. What is the cause
and what would you do?
Examination
Extraoral examination
He is healthy looking but slightly overweight. There are no
palpable cervical lymph nodes.
Intraoral examination
The patient is partially dentate and has relatively few
and extensively restored teeth. He wears an upper partial
denture. The root of the upper lateral incisor is present and
its carious surface lies at the level of the alveolar ridge. The
teeth on each side of the lesion are restored with metal
ceramic crowns.
There is a mild degree of marginal gingivitis. Most of
the interdental papillae are rounded and marginal inam-
mation is present around crowns. Flecks of subgingival
calculus are visible.
The appearance of the lesion is shown in Figure 10.1.
Describe its features.
Fig. 10.1 Appearance of the swelling.
History
Complaint
The patient complains of a lump on the gum at the front of
his mouth on the left side. It sometimes bleeds, usually after
brushing or eating hard food but it is not painful.
History of complaint
The swelling has been present for 4 months and has grown
slowly during this period. It was never painful but now
looks unsightly. The patient gives no history of other
mucosal or skin lesions.
Medical history
The patient has hypertension, controlled with atenolol
50 mg daily.
Feature Appearance
Site Appears to arise from the gingival margin of the lateral
incisor root or the interdental papilla mesially
Size Approximately 10 7mm
Shape and contour Irregular rounded nodule. It is not possible to say
whether it is pedunculated or sessile, though from its
size and the fact that it overlies the lateral incisor root,
it is probably pedunculated
Colour Patchy red and pink with a thin grey translucent sheen.
The surface is almost certainly ulcerated
If you were able to palpate the lesion you would nd that
it is eshy and soft and attached by a thin base to the gin-
gival margin. It bleeds readily from between the tooth and
lesion when pressed with an instrument but it is not tender.
From the information in the history and examination so far,
what is your diferential diagnosis?
Likely:
Pyogenic granuloma (if the patient had been female,
pregnancy epulis might have been considered)
Fibrous epulis
Less likely:
Peripheral giant cell granuloma
Sinus papilla (parulis)
Unlikely:
Papilloma
Benign hamartoma or neoplasm
Malignant neoplasm.
Justify your diferential diagnosis.
A very wide range of lesions may afect the gingiva and many
possible causes cannot be excluded on the basis of the
information given so far. However, the gingiva is the site of
predilection for a number of infammatory hyperplastic
lesions comprising fbrous tissue and epithelium. All are
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associated with poor oral hygiene and the lesion is almost
certainly one of this type on statistical grounds.
Pyogenic granuloma is a localized proliferation of
granulation tissue or very vascular fbrous tissue. It arises in
association with a local irritant such as poor oral hygiene,
calculus or the margin of a restoration. The present lesion has
many features of the pyogenic granuloma: it is asymptomatic,
soft and vascular, bleeds readily, and has an ulcerated surface.
If the patient had been female, a pregnancy epulis (a variant
of pyogenic granuloma arising during pregnancy) would have
been possible.
Fibrous epulis (gingival fbroepithelial polyp/nodule) is
a nodule of more fbrous hyperplastic tissue. It is not usually
ulcerated, is frmer on palpation and does not bleed so
readily. Some fbrous epulides develop from pyogenic
granulomas by maturation of the fbrous tissue and some
arise de novo. They are usually associated with a local irritant
in the same manner as pyogenic granulomas. The current
lesion could well be a fbrous epulis, though its vascularity
and red colour are more suggestive of pyogenic granuloma.
These two names are really no more than convenient labels
for lesions at opposite ends of a spectrum ranging from
granulation tissue to dense fbrous tissue. All are
hyperplastic.
Peripheral giant cell granuloma is another hyperplastic
lesion which seems to develop in response to a local irritant.
Clinically it may have a deep red maroon or blue colour, but is
otherwise indistinguishable from pyogenic granuloma or
fbrous epulis. However, histologically it is distinctive,
containing numerous multinucleate osteoclast-like giant cells
lying in a very cellular vascular stroma. The giant cell epulis is
commoner in children, though it can arise in an adult. While it
cannot be excluded, it is a less likely diagnosis for the present
lesion.
Sinus papilla (parulis) is essentially a pyogenic granuloma
developing at the opening of a sinus. Infection and
infammation are the stimuli inducing hyperplasia. If the sinus
heals, the sinus papilla may disappear or it may mature and
shrink into a small fbrous nodule. The usual site is on the
alveolar mucosa and the lesion is usually no more than 4 or
5mm across. This is an unlikely cause.
Papillomas are lesions of proliferating epithelium. Their exact
cause is not always clear though it is generally considered
that most are caused by human papilloma virus infection.
Others do not appear to contain virus and may be benign
neoplasms. Papillomas may arise at any site in the oral cavity
but are often seen at the gingival margin and lips. Sometimes
patients have warts on their fngers as well. Papillomas usually
have a white spiky or frond-covered surface or a smoother
caulifower-like surface and neither is seen in the present
lesion. Papillomas do not bleed easily and this seems an
unlikely diagnosis.
It would not be useful to list the many other possible causes,
but a few groups of lesions might also be considered.
Hamartomas and benign neoplasms can arise at all sites.
If this were such a lesion a haemangioma would be likely in
view of the vascularity. A haemangioma could appear very
similar to a pyogenic granuloma.
Odontogenic tumours can occasionally arise extraosseously
in the gingiva but usually form uninfamed sessile nodules.
Malignant neoplasms occasionally present in the gingiva.
Metastatic deposits are commoner than primary lesions and
leukaemia is the most likely cause. Kaposis sarcoma might
also be considered in an HIV-positive individual. Both these
lesions are vascular, may bleed on pressure and ulcerate.
Further examination and
investigations
What further examinations and investigations would you
perform? Explain why.
The defnitive diagnosis will require a biopsy, and excision is
indicated. However a number of other investigations (Table
10.1) need to be performed to identify possible causes. If the
cause is left untreated the lesion may recur after excision.
The results of these further examinations are shown in
Table 10.1.
Diferential diagnosis
What is the most likely diagnosis?
On the basis of the clinical appearance and the results of the
tests in Table 10.1 the lesion is almost certainly a pyogenic
granuloma or fbrous epulis.
Treatment
What treatment would you provide?
Excision biopsy
Removal of causative factors, i.e. plaque and calculus
Provide treatment for the generalized periodontitis
Extract or restore the lateral incisor root.
Table 10.1 Investigations and fndings
Test Reason Findings in this patient
Periodontal examination To assess pocketing around the lesion and detect
subgingival calculus, a common cause
There is generalized chronic adult periodontitis with loss of attachment of 34mm.
There is a 5-mm probing depth adjacent to the lesion, most of which is false pocket
below the lesion. This pocket and others contain subgingival calculus
Tests of vitality of the adjacent incisor
and canine
To determine whether the cause could be irritation from a
periapical infection draining into the pocket
Both teeth are vital on electric pulp testing
Periapical view of the incisor and canine Not useful for diagnosis but might be indicated on the
basis of probing or vitality tests
Not indicated
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Table 10.2 Obtaining a report on a biopsy specimen
Aim Procedure
Avoid distortion or crushing of specimen If a suture has been placed through the lesion to hold it and prevent it being lost in the vacuum, do not remove it. Cut the thread a
centimetre or so from the lesion
Ensure rapid and efcient fxation Place immediately in 10 times the tissue volume of 10% formol saline (available in biopsy containers from pharmacies, hospital suppliers
and some pathology departments). In the absence of fxative, postpone the biopsy if possible. Spirits and other solutions used in dental
surgeries are inefective. An unfxed specimen will autolyse (rot) on the way to the laboratory
Provide the pathologist with sufcient clinical
information to enable diagnosis
Fill in a request form or write a letter including the patients name, age and sex, a complete clinical description of the lesion, the diferential
diagnosis and medical history. Include any details of previous lesions or lesions elsewhere in the mouth. Do not forget your own name and
practice address and phone number
Protect those handling the specimen in transit Package the specimen according to the Post Ofce regulations for sending hazardous materials through the post. Make sure the container is
labelled with a hazard sticker identifying the contents as formalin. Place the specimen container in either an unbreakable second container
or box with padding. Include enough absorbent material (e.g. tissue) to soak up all the formalin in the pack in the event of breakage. Label
the package Pathology specimen handle with care and send by frst-class post
Would you perform this biopsy in general dental practice?
What complications might develop?
Yes: this amounts to no more than the removal of a fap of
gingiva, and ideally this would be performed in general
practice. The only signifcant complication might be bleeding
because this is a very vascular lesion. However, haemostasis
should not prove a problem because pressure can be readily
applied to the gingival margin.
How would you obtain a report on the biopsy specimen?
Most histopathology departments, either specialized oral
pathology departments associated with dental schools, or
departments in district general or other hospitals, provide
postal or courier pathology services for the dentists and/or
medical practitioners in their area.
The steps to be taken after removal are shown in Table 10.2.
Diagnosis
The microscopic appearances of the biopsy specimen are
shown in Figures 10.2 and 10.3. What do you see and how
do you interpret them?
The surface is ulcerated and covered by a slough of fbrin
containing nuclei of infammatory cells. At higher power you
would be able to identify these as neutrophils. Below the
surface is a pale-stained tissue in which the endothelial lining
of numerous small blood vessels stands out. The vessels have
a radiating pattern and point towards the surface refecting a
pattern of growth outwards from the centre. Between the
vessels there is a little fbrin and the tissue is oedematous or
myxoid or both. More deeply there is a cluster of
infammatory cells and collagen bundles are more prominent
between the vessels.
The lesion is a nodule of ulcerated maturing granulation and
fbrous tissue.
What is the diagnosis?
Pyogenic granuloma.
Other possibilities
Is a more conservative approach to treatment ever
justifed?
Fig. 10.2 Histological appearance of the surface layers of the
excision specimen.
Fig. 10.3 The deeper tissue of the specimen.
Yes: elimination of the causative factors may induce
considerable resolution. However, the degree of resolution
varies; softer more vascular lesions shrink most and frmer
more fbrous lesions hardly at all. Removal of calculus and
improved oral hygiene may cause partial resolution and leave
a smaller lesion which is easier to excise and bleeds much
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less. Such a course of action is often appropriate for treatment
of pregnancy epulis, both because of the wish to avoid the
procedure during pregnancy and because excision during
pregnancy carries a risk of recurrence. Defnitive excision may
then be delayed until after parturition. Occasionally resolution
is almost complete and no further treatment is required.
If, on removing the lesion, you felt bone within it, what
would this signify?
Woven and lamellar bone, sometimes quite large pieces, can
lie within fbrous epulides and pyogenic granulomas. Bone
may be noted on excision or on histological examination.
Sometimes such lesions are referred to as mineralizing
epulides (or peripheral ossifying fbroma in the US). The
presence of bone seems to be of no great signifcance and it
may indicate that such lesions arise by proliferation of the
deep fbrous tissue of the periosteum. Some consider lesions
containing bone more likely to recur than those without but
there is no good evidence to support this belief.