|Year : 2013 | Volume
| Issue : 1 | Page : 65-69
Biopsy the gold standard in the final diagnosis of solitary gingival enlargements: Case reports and an overview
Archana Devanoorkar1, Nagappa Guttiganur1, CD Dwarakanath2, AN Savitha3
1 Department of Periodontics and Oral Implantology, A.M.E's Dental College and Hospital, Raichur, Karnataka, India
2 Department of Periodontics and Oral Implantology, Vishnu Dental College and Hospital, Bhimavaram, Andhra Pradesh, India
3 Oxford Dental College Hospital and Research Centre, Bengaluru, Karnataka, India
|Date of Web Publication||26-Nov-2013|
Department of Periodontics and Oral Implantalogy, AME's Dental College and Hospital, Bijengere, Raichur - 584 103, Karnataka
Source of Support: None, Conflict of Interest: None
Solitary gingival enlargements are the commonly occurring soft-tissue tumors of the oral cavity. These lesions occur in response to local irritation or may occur as exaggerated tissue response to underlying systemic conditions. Commonly occurring solitary gingival enlargements include the pyogenic granuloma, peripheral giant cell granuloma, fibroma, peripheral ossifying fibroma, exophytic squamous cell carcinoma, abscesses, hemangioma, Kaposi's sarcoma etc., When present, they result in the diagnostic dilemma when the diagnosis is entirely based on clinical findings, in such conditions proper history and histopathological examination may aid in proper diagnosis and case management. This article is intended to address the importance of histopathological examination of various solitary enlargements that resemble clinically alike though they are different histpathologically. Biopsy results in turn will dictate the further treatment depending on the recurrence rate and the nature of the lesion. This article also focuses on few case reports of solitary gingival enlargements.
Keywords: Biopsy, peripheral ossifying fibroma, pyogenic granuloma
|How to cite this article:|
Devanoorkar A, Guttiganur N, Dwarakanath C D, Savitha A N. Biopsy the gold standard in the final diagnosis of solitary gingival enlargements: Case reports and an overview. Int J Oral Health Sci 2013;3:65-9
|How to cite this URL:|
Devanoorkar A, Guttiganur N, Dwarakanath C D, Savitha A N. Biopsy the gold standard in the final diagnosis of solitary gingival enlargements: Case reports and an overview. Int J Oral Health Sci [serial online] 2013 [cited 2020 Sep 25];3:65-9. Available from: http://www.ijohsjournal.org/text.asp?2013/3/1/65/122137
| Introduction|| |
In the differential diagnosis of tumors, experience has shown how little one can depend on purely clinical methods for accuracy. Proper management of a patient with solitary oral lesion starts with an accurate diagnosis. Clinical examination, trans-illumination, X-ray examination, or X-ray in combination with the injection of radiopaque substances have been discussed in the past, however in the final analysis, we must turn to the oral pathologist because the current gold standard for diagnosis of such lesions is the histopathologic assessment of a tissue biopsy of the suspicious lesion. Thus, biopsy still remains the gold standard. This article focuses on cases with solitary gingival enlargements and the importance of biopsy in the management of such cases.
| Case Reports|| |
A 45-year-old female patient reported to the Department of Periodontics of The Oxford Dental College Hospital and Research Center Bangalore with a chief complaint of overgrowth in the left-upper front teeth region [Figure 1]. On intraoral examination, there was localized gingival overgrowth between 22 and 23 on the labial aspect extending interdentally to involve the palatal aspect [Figure 2]. The lesion originated from interdental region, it was sessile, oval in shape measuring roughly about 1 cm × 1 cm, with lobulated and erythematous surface, soft in consistency, with bleeding on slight provocation. Patient had poor oral hygiene with generalized attachment loss ranging from 5 to 9 mm. Associated teeth exhibited pathologic migration and mobility.
Following investigations were done. Complete hemogram, orthopantomograph, intraoral periapical (IOPA) X-ray. No abnormalities were detected in hemogram. Radiographic examination showed the presence of bone loss in relation with left lateral incisor and canine [Figure 3]. Excisional biopsy was advised. After scaling and root planing surgical excision was carried out under local anesthesia [Figure 4]. Biopsy specimen was collected in formalin and sent to department of oral pathology [Figure 5]. Histopathological examination revealed granulation tissue with the proliferation of endothelial cells with blood cell formation and infiltration of acute and chronic inflammatory cells in the collagenous matrix. Surface of the lesion was consistent with stratified squamous epithelium with areas of atrophy and ulcerated membrane [Figure 6]. These findings were consistent with a histopathological diagnosis of pyogenic granuloma. Patient was recalled every month and was kept under constant follow-up. No recurrence was observed over a period of 6 months [Figure 7].
A 19-year-old male patient reported with a chief complaint of swelling in the upper anterior palatal region since 5 months [Figure 8]. General examination revealed no significant medical history. On intraoral examination, there was a localized ovoid gingival overgrowth between maxillary central incisors on the palatal aspect extending interdentally to involve the labial aspect. The lesion originated interdentally it was sessile, oval in shape measuring roughly about 1.5 cm × 1 cm, with lobulated and erythematous surface, soft in consistency, with bleeding on slight provocation. He had fair oral hygiene with moderate gingival inflammation. Investigations done were complete hemogram, IOPA X-ray. No radiographic signs of involvement of the alveolar ridge were observed and no abnormalities were detected in hemogram. Excisional biopsy was advised. After scaling and root planing surgical excision was done [Figure 9]. Biopsy specimen was collected in formalin and sent to department of oral pathology. Based on the histopathological observations the final diagnosis was peripheral ossifying fibroma [Figure 10]. 3 months post-operative photograph showing uneventful healing [Figure 11].
| Discussion|| |
This article mainly focuses on the clinical and the histopathological features and the differential diagnosis of various intraoral solitary lesions that aids in the proper diagnosis and accurate treatment plan.
It is also known as a "granuloma gravidarum" and "pregnancy tumor." Primarily, it is a solitary oral lesion resulting from the inflammatory tissue response to local irritation such as plaque, calculus, trauma and other local factors or exaggerated tissue response to hormonal changes. ,, The name for pyogenic granuloma is misleading because it is not a true granuloma. , Histologically, it is a reactive inflammatory process filled with proliferating vascular channels, immature fibroblastic connective tissue and scattered inflammatory cells. Some authors use the term lobular capillary hemangioma for this lesion. ,
Clinically, these lesions usually present as a single nodule or sessile papule with smooth or lobulated surface. These may be seen in any size from a few mm to several cm. As lesions mature, the vascularity decreases and the clinical appearance are more collagenous and pink. The peak prevalence is in teenagers and young adults, with a female predilection of 2:1. 
The increased incidence of these lesions during pregnancy may be related to the increasing levels of estrogen and progesterone.  Pyogenic granuloma of the oral cavity is known to involve the gingiva commonly (75% of all cases). Uncommonly it can occur on the lips, tongue, buccal mucosa, palate and so on.  Although pyogenic granuloma can be diagnosed clinically with considerable accuracy, radiographic and histopathological investigations, aid in confirming the diagnosis and treatment. Radiographs are advised to rule out bony destruction suggestive of malignancy or to identify any foreign body.
Treatment of pyogenic granuloma consists of conservative surgical excision, which is usually curative. There is a relatively high rate of recurrence (about 15%) after simple excision. 
Peripheral ossifying fibroma
It is a solitary, non-neoplastic gingival overgrowth usually arises from the interdental papillae.  Over the years, various terminologies have been considered for its description which includes: Peripheral odontogenic fibroma, peripheral cemento-ossifying fibroma, peripheral cementifying fibroma, ossifying fibro-epithelial polyp, peripheral fibroma with osteogenesis, peripheral fibroma with cementogenesis, peripheral fibroma with calcification. ,
The pathogenesis of peripheral ossifying fibroma (POF) is uncertain. As they resemble clinically and histopathologically to pyogenic granuloma, some consider POF to develop secondary to fibrosis of granulation tissue.  The inflammatory reaction is believed to occur secondary to trauma from local irritants such as plaque, calculus, restorations or ill-fitting dental appliances. ,,,
It has the predilection for the females during the second decade of their life because of which the role of hormones has also been considered.  POF is the inflammatory hyperplasia of the cells and it is thought to originate from the cells of the periosteum or periodontal ligament. POF clinically appears as a solitary nodular mass, either pedunculated or sessile and arise from the interdental papilla. ,
The color ranges from pink to red and the surface is frequently, but not always ulcerated.  Most lesions are usually 1-2 cm in size; however, cases ranging more than 2 cm have also been reported.  POF's are usually solitary, rarely, it can be multi-centric. 
The peak incidence of POF is between second and third decades and almost two-thirds of all cases are reported in females.  There is a slight predilection for the maxillary arch and are frequently observed in the incisor-cuspid region. , Usually the teeth are unaffected; rarely, it may cause migration and mobility. The radiographic features may range from no changes to destructive changes. 
A confirmatory diagnosis is mainly by the microscopic examination of the biopsy specimen which may exhibit the epithelium that can be intact or ulcerated. If ulcerated, superficial areas of fibrinopurulent membrane with a subjacent zone of granulation tissue can be noticed. Abundant fibroblastic proliferations, variable mineralized component, sparse endothelial proliferation and few inflammatory cells are other predominant findings of POF. The mineralized components may consist of bone, cementum like material or dystrophic calcifications. Less frequently, ovoid droplets of basophilic cementum - like material are formed. Usually, the bone is woven, lamellar or trabecular in type and rarely contains unmineralized osteoids and multinucleated giant cells. 
The treatment of choice is local surgical excision.  POF has a high recurrence rate of about 8% to 16%; hence, the mass should be excised deep into the periosteum with complete removal of all irritants and the patient should be kept under long-term follow-up with regular oral hygiene maintenance. In extensively destructive cases, repositioned flaps or connective tissue grafts may be necessary to repair the gingival defects. 
| Conclusion|| |
The study of the various soft-tissue tumors of the oral cavity and adjacent structures constitutes an important part of orofacial examination. Various soft-tissue tumors may exhibit similar clinical features which may range from fibroma to a life-threatening condition such as oral cancers. However, the definitive diagnosis may in turn be dependent on the histopathological examination of the biopsy specimen.
The two cases reported here which look similar on clinical examination were diagnosed to be different on histopathological (H/P) examination. H/P examination not only helps in proper diagnosis but also dictates the accurate treatment plan for the specific conditions that is, a conservative or a more aggressive approach required for case management. Although tumors usually constitutes only a small minority of the oral pathological conditions seen by the dentist, they are of great significance especially in the differentiation of malignant lesions from the benign and inflammatory gingival enlargements since they have potential ability to jeopardize the health and longevity of the patient. Thus, biopsy still remains the irreplaceable diagnostic tool in the diagnosis of solitary gingival enlargements.
| References|| |
|1.||Nevile BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2 nd ed. Philadelphia: W.B. Saunders Co.; 2004. p. 444-9. |
|2.||Patil K, Mahima VG, Lahari K. Extragingival pyogenic granuloma. Indian J Dent Res 2006;17:199-202. |
|3.||Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48:167-75. |
|4.||Svirsky J. Oral pyogenic granuloma website, 2007. (10 pages), Web med. Available from: http://www.emedicine.medscape.com/article/1077040-overview. [Last accessed on 2007 Mar 10]. |
|5.||Regezi JA, Sciubba JJ, Richors CK. Oral Pathology, Clinical Pathologic Correlation. 4 th ed. Philadelphia: Saunders Company; 2003. p. 115-76. |
|6.||Akyol MU, Yalçiner EG, Doðan AI. Pyogenic granuloma (lobular capillary hemangioma) of the tongue. Int J Pediatr Otorhinolaryngol 2001;58:239-41. |
|7.||Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8. |
|8.||Zain RB, Fei YJ. Fibrous lesions of the gingiva: A histopathologic analysis of 204 cases. Oral Surg Oral Med Oral Pathol 1990;70:466-70. |
|9.||Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg 1993;51:828-35. |
|10.||Yadav R, Gulati A. Peripheral ossifying fibroma: A case report. J Oral Sci 2009;51:151-4. |
|11.||Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60. |
|12.||Neville BW, Damm DD, Allen CM, Bouquot JE. Soft tissue tumors. Oral and Maxillofacial Pathology. 3 rd ed. Missouri: Elsevier. p. 521-3. |
|13.||Delbem AC, Cunha RF, Silva JZ, Soubhia AM. Peripheral cemento-ossifying fibroma in child. A follow-up of 4 years. Report of a case. Eur J Dent 2008;2:134-7. |
|14.||Moon WJ, Choi SY, Chung EC, Kwon KH, Chae SW. Peripheral ossifying fibroma in the oral cavity: CT and MR findings. Dentomaxillofac Radiol 2007;36:180-2. |
|15.||Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-43. |
|16.||Das UM, Azher U. Peripheral ossifying fibroma. J Indian Soc Pedod Prev Dent 2009;27:49-51. |
|17.||Poon CK, Kwan PC, Chao SY. Giant peripheral ossifying fibroma of the maxilla: Report of a case. J Oral Maxillofac Surg 1995;53:695-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]