Instructor: Dr. Heddie Sedano, D.D.S. Dr.Odont. PIC Courses PIC Homepage GINGIVAL CYSTS, NEOPLASMS and PSEUDO-NEOPLASMS Index | Part 2 | References

Part 1: CYSTS & PSEUDO-NEOPLASMS PSEUDO-NEOPLASMS Reactive gingival hyperplasias Reactive gingival hyperplasias represent a group of conditions which actually are an exuberant response most likely to trauma or a chronic stimulus. Therefore they have a varied etiology, some of them represent a response to a low grade chronic bacterial infection while some others, like in the case of leukemia, represent a response to the malignant process. They can be localized or generalized and in the case of the generalized ones if there is a lack of proper oral hygiene they may be accompanied by superimposed inflammatory symptomatology which may include marked erythema as well as bleeding. As the name implies they are characterized by an overgrowth which may be localized to an area of the gingiva or could be generalized to both maxillary and mandibular gingiva. The treatment varies according to the causative agent. Peripheral "Fibroma" (Fibrous epulis - Fibrous hyperplasia) The peripheral "fibroma" also called fibrous epulis or peripheral fibrous hyperpplasia is a localized mass of tissue that generally develops on the mandibular gingiva anterior to the molars and preferentially in women. The etiology could be related to a localized chronic trauma such as misuse of oral hygiene instruments and calculus deposits among others. This growth of variable size actually is not a fibroma, in the true sense of the word, but as the name implies, a hyperplastic reaction. The growth generally has the same color as the gingiva, it is painless and semi-hard on palpation. Some of them have a broad base of implantation while others are pedunculated. If the "fibroma" becomes too large, it could interfere with mastication and become traumatized and ulcerated. These hyperplasias could also be secondarily inflamed and acquire a deep erythematous color and become slightly painful. The differential diagnosis should include pyogenic granuloma and peripheral giant cell granuloma. As a rule both of these conditions present a deep red to magenta color which is different from the normal gingival hue. Histologically this "fibroma" is characterized by a proliferation of collagenic connective tissue with various degrees of a cellular inflammatory infiltrate. The surface of the lesion is covered by a stratified squamous epithelium. The treatment is surgical excision and subsequent biopsy in order to rule out other lesions such as the peripheral odontogenic fibroma and other benign neoplasias. Figure 5. This 34 year-old man presented this large mass on the anterior mandibular gingiva. The reflection on the mirror shows that the lesion is possibly of interdental origin, between lateral and central incisors. The patient had large amounts of calculus deposition associated to his anterior teeth. The diagnosis of fibrous peripheral hyperplasia ("fibroma") was established. Peripheral giant cell granuloma The peripheral giant cell granuloma (PGCG) is considered as an exuberant reactive response to trauma or some chronic inflammatory process. This granuloma occurs in the gingiva having a deep implantation and may form from cells originating in the periodontal ligament or the periosteum. PGCG can be sessile or pedunculated and generally is an exophytic mass with a purple-brown color due to its high vascularity. If traumatized it can be ulcerated. The size of the PGCG varies from very small to large lesions over 2.0 cm. in diameter. PGCG is seen slightly more frequently in women than in men, generally after the age of 30 and it is found with greater frequency in the mandibular gingiva rather than the maxillary gingiva. Radiographically there is generally no evidence of bone involvement but in some cases one can see a slight superficial bone erosion. Pyogenic granuloma and pregnancy tumor should be included in the differential diagnosis. Rarely will any other lesions of the gingiva present with this type of clinical appearance. It is important to determine if the lesion is in reality a PGCG or the exteriorization of a central giant cell granuloma. The differentiation is based on a careful clinical and radiological evaluation. Central lesions as a rule tend to occur before the age of 20 years and are radiologically characterized by marked bone involvement. Biopsy of PGCG reveals the presence of large numbers of multinucleated giant cells of the osteoclastic type. In addition one can observe a very well-vascularized connective tissue stroma and occasional areas of dystrophic calcification and formation of bone spicules. The treatment is surgical excision and care must be taken to eliminate the base of the lesion in the periodontal tissue. Possible causative agents such as tartar or foreign debris should also be eliminated to avoid recurrences. If the attachment to either periosteum or periodontal ligament is not properly eliminated, the lesion will tend to recur. If more than one tooth is involved it is some times necessary to extract those teeth in order to avoid recurrences. If these lesions recur, the surgical ablation needs to be less conservative. Figure 6. This 45 year-old male presented this large, erythematous mass on the maxillary molar-premolar area. According to the patient the mass had a slow growth and now it interferes with mastication. Surgical removal showed the mass deeply attached to the periodontal ligament. Biopsy revealed it to be a peripheral giant cell granuloma Figure 7. This is another example of a peripheral giant cell granuloma. Note the intense burgundy color as well as areas of erythema. This lesion was attached by a strong pedicle to the distal periodontal ligament of tooth #5. Pyogenic granuloma and pregnancy tumor Pyogenic granuloma (PG) is an exuberant overgrowth of neo-capillaries (due to extensive endothelial proliferation) and fibrous connective tissue caused by minor mechanical or plaque irritation. These growths are apparently prone to occur in the gingiva and in tooth sockets, during pregnancy or during pubrty in patients taking oral contraceptives simulating. The term pyogenic should be abandoned because these lesions are not related to neither microorganisms nor pus production. PG generally manifests as a rapidly growing, painless, easily bleeding, ulcerated, red, polypoid mass with a broad base, usually located on the marginal gingiva, but can also be found on the lips, tongue, buccal mucosa, palate, vestibule and even the alveolar mucosa of edentulous patients. PG is most common in young adult females. PG initially grows fairly rapidly to attain a size of a few millimeters to 2 cm. or more in diameter. It then tends to mature to a more fibrous and less ulcerated form and may finally become a dense peripheral fibrous hyperplasia. This maturation process is particularly marked postpartum in "pregnancy tumors" and many lesions will regress and the affected area return to normal after birth. The preferred site of occurrence is the interdental papilla and sometimes it may extend from the vestibular gingiva to the lingual gingiva. The majority of PG occur on the vestibular and labial side. Occasionally PGs can ulcerate and then they become covered with a yellowish pseudomembrane. Bleeding is a frequent finding. Radiographically there may be slight resorption of interdental septal bone. The terms pregnancy tumor and pregnancy gingivitis are used when a single PG or several of them occur during pregnancy, especially on the second or third trimester. Some authors have proposed that the lesions associated to pregnancy are related to hormonal changes and that they have a different histological appearance. Therefore, they should not be grouped with the non-pregnancy associated PG. Peripheral fibrous hyperplasia ("fibroma") and peripheral giant cell granuloma should be considered in the differential diagnosis as well as hemangioma. Extension to the maxillary sinus should be investigated if the lesion is in a maxillary tooth socket. Biopsy will reveal marked neo-capillary proliferation and superimposed inflammatory infiltrate in a fibrous connective tissue stroma. Surgical excision is the treatment of choice. In the highly vascular stage PG is prone to recur with an alarmingly rapid growth. Markedly fibrous PG are less likely to recur. Pregnancy tumors that persists should be removed after delivery. Plaque and tartar control is indicated in all cases. Figure 8. This 22 year-old non-pregnant woman had this 1.5 cm mass of several weeks duration. Note the redness of the surface. The patient admitted to repeatedly use a tooth pick in the area. The lesion was surgically excised and the biopsy report was pyogenic granuloma. Figure 9. This is another example of a pyogenic granuloma in a 9 year-old girl which had the habit of poking the gingiva of her left maxillary incisor with the rubber end of a pencil. Note the typical erythematous color. Figure 10. This 24 year-old pregnant woman developed these multiple, erythematous, easily bleeding nodes on her maxillary gingiva during the 7 month of pregnancy. Note the marked redness of this pregnancy gingivitis. Figure 11. Another example of pregnancy gingivitis (pregnancy tumor) in another woman. Note the intense red, granular surface and the extension of the lesion from the buccal to the palatal gingiva. These lesions should be treated after parturition if they develop during the last 2 months of pregnancy.

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