Authors: Dr. Santosh Patil(Senior lecturer), Dr. Nitin Kalla.(Lecturer), Dept. of oral medicine and radiology, Jodhpur Dental College, Jodhpur National University, Jodhpur, India

Introduction

A common characteristic of gingival lesions is that they are located on the gingiva and present as a submucosal enlargement covered by normal epithelium. The swellings may be either localized or generalized.
Localized

1. Fibroma
2. Pyogenic granuloma
3. Peripheral giant cell granuloma (PGCG)
4. Peripheral ossifying fibroma (POF)
5. Metastatic lesions

Generalized

1. Drug-induced gingival hyperplasia
2. Leukemic infiltrate
3. Scurvy

Case Series

1. Pyogenic granuloma

Pyogenic granuloma has been described as a benign exophytic lesion, which manifests as small erythematous papules that enlarge and may become pedunculated (Figure 1). The clinical development is slow and asymptomatic. The condition develops predominantly in females in the second decade of life, and is most often found in the maxillary labial gingiva. It is a hyperplastic inflammatory tissue response associated with minor injury or nonspecific local irritation. Excisional surgery is the treatment of choice for pyogenic granulomas1.

2. Peripheral giant cell granuloma (PGCG)

PGCG is an exophytic soft tissue lesion originating from periodontal ligament and periosteum2. It characteristically arises interdentally, adjacent to permanent teeth as a sessile or pedunculated swelling (Figure 2). Classically, the most notable feature is the deep red colour and the hemorrhagic tendency of the lesion. These lesions may occur more commonly in 5th and 6th decade of life with female predominance. This lesion is usually elastic in consistency on palpation. Biopsy is usually required to establish the diagnosis. Treatment is surgical excision down to the underlying bone, adjacent teeth should be carefully scaled to minimize the risk of recurrence1.

3.Peripheral ossifying fibroma (POF)

It is a relatively common, reactive non-neoplastic enlargement of gingiva. It commonly occurs in females in second and third decades of life. The lesion is exclusively seen on the gingiva in the region of incisors and canines. It manifests as pinkish red, well-defined, firm nodular mass which may be sessile and pedunculated and usually covered by normal mucosa (Figure 3). The surface of the swelling will be ulcerated in majority of the cases. These lesions are commonly mistaken for pyogenic granuloma because of similar presenting features. The treatment of choice for peripheral ossifying fibroma is local surgical excision. The mass should be excised down to the periosteum to prevent the recurrence3.

4. Drug induced gingival enlargement

Drugs associated with gingival enlargement are anticonvulsants, calcium channel blockers, and immunosuppressants. Clinical manifestation of gingival enlargement frequently appears within 1 to 3 months after the initiation of the offending agent. Gingival overgrowth normally begins at the interdental papillae and is more frequently found in the anterior segment of the labial surfaces (Figure 4). Gradually, gingival lobulations are formed that may appear inflamed or more fibrotic in nature, depending on the degree of local factor induced inflammation. The fibrotic enlargement normally is confined to the attached gingiva but may extend coronally interfering the mastication, or speech. This condition may be managed by discontinuing the offending drug in consultation with the patient’s physician. Gingivectomy and chemosurgical techniques may be helpful in some cases4.

5. Inflammatory gingival enlargement

Inflammatory gingival enlargements are characterized by swelling or edema, redness, and a tendency to bleed upon periodontal probing (Figure 5). Longstanding inflammatory enlargements can have a fibrotic component as well. A patient history helps establish the inflammatory enlargement as acute or chronic. Chronic enlargements are generally painless and slow to progress, whereas acute enlargements are characterized by a painful, rapid onset5.

6. Hereditary gingival fibromatosis (HGF)

HGF develops as a localized or generalized enlargement of keratinized gingiva which is slow growing. The condition is obvious during the transition from deciduous to permanent dentition6. The changes involve the papillae and later the attached gingiva. If the enlargement is gross, it may move or cover the teeth and bulge out of the mouth. The affected gingiva is usually of normal colour but firm in consistency, and the surface, although initially smooth, becomes coarsely stippled (Figure 6). Diagnosis is based on history and clinical clinical features. This condition is usually managed by surgical procedures7.

7. Gingival carcinoma

Gingival squamous cell carcinoma represents less than 10% of diagnosed intraoral
carcinoma. Many unique features of gingival squamous cell carcinoma clearly delineate it from oral squamous cell carcinoma arising in other sites8. It appears as painless, slow growing swelling, as the lesion enlarges it may become an exophytic mass with a fungating or papillary surface (Figure 7). The diagnosis will be confirmed after histopathologic examination, which will reveal dysplastic features. Surgery or radiation therapy is the treatment options depending upon the size and location of the tumor9.

Conclusion

It is well understood that the gingival mass can pose a difficult diagnostic dilemma for the clinician. The swelling may present with the common characteristics and may be indistinguishable clinically. Emphasis is placed on the importance of obtaining a thorough and comprehensive history and collecting relevant laboratory information. Finally, a biopsy of the gingival mass may be necessary to arrive at definitive diagnosis and determine the optimal treatment and management of the patient.

References

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