Diagnostic Discussion

DRS. SAJA ALRAMADHAN*, DONALD M. COHEN, NEEL BHATTACHARYYA AND NADIM M. ISLAM Read, Learn and Earn! A 12-year-old female presented to periodontist Dr. Ana L. Roca for evaluation of a lesion on the maxillary gingiva. The Visit floridadental.org/online-ce for this FREE, MEMBERS-ONLY BENEFIT. You will be given the patient was receiving orthodontic treatment and her health opportunity to review the “Diagnostic Discussion” and its accompanying photos. Answer five history was unremarkable. The lesion was painless and was first noted by the patient around two months after initiatmultiple choice questions to earn one hour of CE. ing the orthodontic treatment. Clinical examination revealed a red, exophytic, papillomatous and ulcerated lesion on the facial interdental papillae of teeth Nos. 6 and 7 (Fig. 1). An excisional biopsy was performed and submitted to the University of Florida Oral Pathology Laboratory Biopsy Service for a diagnosis. Contact FDC Marketing Coordinator Brooke Martin at bmartin@floridadental.org or 800.877.9922. Question:

Based on the above history and clinical presentation what is the most likely diagnosis?

A. Pyogenic granuloma

B. Peripheral ossifying fibroma

C. Gingival fibroma

D. Localized juvenile spongiotic gingival hyperplasia

Fig. 1: Localized erythematous, velvety, ulcerated lesion on the facial interdental papillae of teeth Nos. 6-7.

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A. Pyogenic granuloma Incorrect. Pyogenic granuloma is however a great choice, as it is most common in children and young adults. There is a female preponderance. Pyogenic granuloma is considered to be an exuberant healing response to chronic irritation or trauma. Therefore, it is considered to be reactive in nature rather than a true neoplasm. The name pyogenic granuloma is a misnomer because these lesions are not related to pus formation (pyogenic) nor true granulomas (like tuberculosis with epithelioid giant cells). They are composed of well-vascularized fibrous connective tissue and eventually mature into a dense fibrous connective tissue mass. Two-thirds of pyogenic granulomas occur on the gingiva, mostly on the anterior maxilla. Clinically, they appear as red or pink exophytic growths that vary in size from a few millimeters to several centimeters. Also, 95% of pyogenic granulomas are ulcerated and covered by a whitish yellow fibrino-purulent exudate as seen in this patient. As pyogenic granulomas age, they tend to get more fibrous and less vacular and can appear as smooth, mucosal-colored nodules. Finally, the histology would be a match except for the finding of intercellular edema (spongiosis) with neutrophils exocytosis seen in this patient’s biopsy sample.

B. Peripheral ossifying fibroma Incorrect, but peripheral ossifying fibroma is a great guess. Peripheral ossifying fibroma is a common hyperplastic growth occurring exclusively on the gingiva. Like the other bumps on the gum, it is considered to be reactive in nature rather than a true neoplasm. Frequently caused by chronic irritation (i.e., calculus, ill-fitting crown, orthodontic appliances) and/ or trauma. Half of all cases occur in the incisor-cuspid area of the maxillary arch. Children and young adults are commonly affected with the peak incidence range between 10-19 years. These lesions tend to occur much more frequently in females. Clinically, peripheral ossifying fibroma appears as red/pink sessile or pedunculated nodular mass that is firm or hard on palpation. Microscopically peripheral ossifying fibroma is composed of inflamed fibrous connective tissue and/or granulation tissue containing foci of calcified material such as cementum, osteoid and/or bone, in which this feature was not seen in the present case. The recurrence rate is estimated to be up to 20%. Therefore, it is advisable to treat these lesions with excision down to the periosteum since recurrence is more likely if the base of the lesion is allowed to remain.

C. Gingival fibroma Incorrect. Gingival fibroma is a relatively common gingival growth that is considered reactive rather than neoplastic in nature. The pathogenesis of this lesion is uncertain. Gingival fibroma is very similar to peripheral ossifying fibroma, however, many pathologists consider this lesion to represent a “pre-peripheral ossifying fibroma” or a peripheral ossifying fibroma-like lesion. These lesions probably arise from the periosteum or periodontal ligament and therefore, exhibit a modest rate of recurrence in the range of 10% to 20%. They occur exclusively on the gingiva and are usually seen on the anterior facial aspects of both the maxillary and mandibular gingiva. It presents as a nodular mass, either pedunculated or sessile with the surface being frequently, but not always, ulcerated. It is predominantly seen in children and young adults with an almost equal gender predilection. Microscopically, a highly cellular fibrous proliferation with a myxomatous background rich in acid mucopolysaccharides is noted with a variable number of inflammatory cells. It is advisable to treat these lesions with excision down to the periosteum since recurrence is more likely if the base of the lesion is allowed to remain.

D. Localized juvenile spongiotic gingival hyperplasia Correct. Localized juvenile spongiotic gingival hyperplasia (LJSGH) was first introduced in 2007 as non-plaque-induced gingival overgrowth that affects children and young adults. LJSGH has distinct clinical and microscopic features. Although the exact etiology is unclear, it has been hypothesized that a disruption in the junctional or sulcular epithelium by local factors, such as mouth breathing or orthodontic bands, as seen in our case can cause LJSGH. Clinically, LJSGH appears on the attached gingiva as a localized, bright red velvety, with a slight papillary, granular or ulcerated surface. LJSGH exhibits an affinity for the facial aspect of the anterior maxillary gingiva. The majority of cases are isolated; however, multifocal

involvement has been reported. LJSGH can affect both sexes, however, significant female predominance has been reported. Most of the cases are diagnosed in patients under the age of 20. The lesion is generally biopsied because of the lack of resolution with conservative oral hygiene therapeutic measures and aesthetic concerns. Microscopically, the epithelium is similar to the junctional or sulcular region. The epithelium is hyperplastic with a papillary surface. Intercellular edema (spongiosis) with neutrophils exocytosis are diagnostic features of LJSGH. Conservative excision is the treatment of choice, however, a recurrence rate of 6% to 16.7% has been documented.

References:

Bawazir M, Islam MN, Cohen DM, Fitzpatrick S, Bhattacharyya I. Gingival Fibroma: An Emerging Distinct Gingival Lesion with Well-Defined Histopathology. Head Neck Pathol. 2021;15(3):917-922. doi:10.1007/s12105021-01315-7

Neville, BW, Damm DD, Allen CM, and Chi AC. (2016) Oral and Maxillofacial Pathology. 4th edition, WB Sanders, Elsevier

Ribeiro JL, Moraes RM, Carvalho BFC, Nascimento AO, Milhan NVM, Anbinder AL. Oral pyogenic granuloma: An 18-year retrospective clinicopathological and immunohistochemical study. J Cutan Pathol. 2021;48(7):863-869. doi:10.1111/cup.13970

Theofilou VI, Pettas E, Georgaki M, Daskalopoulos A, Nikitakis NG. Localized juvenile spongiotic gingival hyperplasia: Microscopic variations and proposed change to nomenclature. Oral Surg Oral Med Oral Pathol Oral Radiol. 2021;131(3):329-338. doi:10.1016/j.oooo.2020.10.024 DR. COHEN Diagnostic Discussion is contributed by UFCD professors, Drs. Don Cohen, Indraneel Bhattacharyya and Nadim Islam who provide insight and feedback on common, important, new and challenging oral diseases.

The dental professors operate a large, multi-state biopsy service. The column’s case studies originate from the more than 12,000 specimens the service receives every year from all over the United States.

Clinicians are invited to submit cases from their own practices. Cases may be used in the “Diagnostic Discussion,” with credit given to the submitter.

DR. BHATTACHARYYA Drs. Cohen, Bhattacharyya and Islam, can be reached at oralpath@dental.ufl.edu.

Conflict of Interest Disclosure: None reported for Drs. Cohen, Bhattacharyya, and Islam.

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* Fellow in Oral and Maxillofacial Pathology University of Florida College of Dentistry

DR. ISLAM