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2014 course two
GINGIVAL PATHOLOGY
The primary focus of this study centers on abnormal proliferations and
disease processes that can involve the gingiva, either exclusively or as a part
of their spectrum. While we are unable to discuss all of these entities, we will
limit the current discussion to some of the more common ones.
written by amber kiyani, dds
edited by rachel a. flad, bs
karen k. daw, mba, cecm
INTRODUCTION
Oral health professionals are given
the task of maintaining gingival
health. Gingivitis and periodontitis
are the most common gingival
pathology and, in most cases,
remediation can be simply achieved
by enforcing vigorous plaque
control measures. Considering the
extensive knowledge of dentists and
dental hygienists about plaque-
related pathology, we are excluding
the discussion on gingivitis and
periodontitis in this study.
Topics that will be covered in this
study include:
• Cysts and Tumors
• Reactive Proliferations
• Hyperplasia
• Infections
• Autoimmune Processes
• Pigmented Lesions
• Premalignant and Malignant
Processes
CYSTS AND TUMORS
GINGIVAL CYST:
A gingival cyst is classified as an
odontogenic cyst arising from
remnants of dental lamina, the band
of epithelial tissue which gives way
for developing teeth. It is
considered a soft tissue counterpart
of a lateral periodontal cyst, due to
remarking similarity in their
histopathologic features.
Clinical Features
Gingival cysts are usually identified
Page 2
in patients older than 50 years of
age. Facial gingiva of the
mandibular canine and premolar
region is more frequently
involved. They appear as small,
smooth surfaced, blue swellings
that are primarily asymptomatic.
Treatment
Conservative surgical excision is
the treatment of choice.
Recurrence rates are negligible.
FIBROMA:
Fibroma is a benign proliferation
of fibrous connective tissue
identified in areas undergoing
chronic irritation or trauma.
Clinical Features
Fibromas show no age or sex
predilection. They are commonly
identified in the buccal and labial
mucosa, tongue, and gingiva.
They appear as mucosal colored,
sessile nodules that are firm on
palpation. Presence of surface
ulceration may be accompanied
by some pain and discomfort.
Source: www.brown.edu Fibroma
Treatment
Conservative surgical excision with submission of
tissue for histopathologic examination is
recommended.
INFLAMMATORY FIBROUS HYPERPLASIA:
Inflammatory fibrous hyperplasia, or denture
epulis, are benign proliferations of fibrous
connective tissue that develop in association with
an ill-fitting dental prosthesis.
Clinical Features
This process is usually identified in older
individuals, and women tend to be more
commonly affected. It appears as mucosal colored
folds of hyperplastic tissue that correspond with
the ill-fitting flange of the denture. The
hyperplastic tissue is firm and fibrotic on
palpation. While most lesions are primarily
asymptomatic, occasional reports of pain and
discomfort may be noted when ulceration is
present. The size of the lesion can be highly
variable, ranging between a few millimeters to the
entire length of the vestibule.
Treatment
Surgical excision of hyperplastic tissue with
remaking or relining of the dental prosthesis is
recommended. The excised tissue should be
submitted for histopathologic examination to rule
out any significant pathology mimicking this
benign process.
GIANT CELL FIBROMA:
Giant cell fibroma is a benign fibrous neoplasm
that does not show an association with trauma.
Clinical Features
Giant cell fibromas are more frequently seen in
younger patients. A female predilection is noted
in some studies. Most lesions are identified on the
gingiva, but other sites of occurrence include the
tongue and the palate. The lesion appears as a
small, mucosal colored, papillary nodule that can
often be mistaken for a squamous papilloma.
Retrocuspid papilla is a name given to small,
mucosal colored nodules that appear on lingual
mandibular attached gingiva of canines. The
lesions are frequently bilateral and are mostly
identified in children. They tend to disappear as
the person ages. They show striking clinical and
histopathologic similarity to giant cell fibromas.
Treatment
The lesion requires conservative surgical excision
for treatment. The excised giant cell fibroma
should be submitted for histopathologic
examination to confirm diagnosis.
INTRA-OSSESOUS CYSTS AND TUMORS:
It is not uncommon for intra-osseous cysts and
benign and malignant tumors to erode through
the cortical bone and appear as soft tissue
masses. A radiograph is usually sufficient to
determine an osseous origin. Benign cysts and
tumors tend to exhibit distinct margin, while
malignancies are locally destructive with ill-
defined margins.
REACTIVE PROLIFERATIONS
PARULIS:
Parulis (gum boil) is a collection of granulation
tissue at the site of the sinus tract opening of a
dental abscess.
Clinical Features
Parulides can be seen in patients over a wide age
range. They present as small, red or yellow
colored nodules on the alveolar or palatal
mucosa. Patients usually report recurrent
episodes of enlargement and compression of the
nodule. Compression is accompanied by
discharge of foul-tasting pus.
Treatment
The offending tooth can be identified by pulp
testing the teeth in the vicinity. If pulp testing
does not yield favorable results, insertion of a
gutta percha point into the sinus tract followed by
radiographic imaging may aid in identifying the
responsible non-vital tooth. Endodontic
treatment or extraction of the offending tooth
leads to complete resolution of symptoms. Page 3
PERIPHERAL OSSIFYING FIBROMA:
Peripheral ossifying fibroma is a common, reactive
proliferation of fibroblasts that occurs exclusively
on the gingiva. Despite the similarity in names,
this lesion is distinct from a central ossifying
fibroma; a benign intraosseous neoplasm.
Clinical Features
The lesion is identified more commonly in women
in their 20s. Peripheral ossifying fibroma appears
as a smooth, pink, and sessile nodule. Surface
ulceration and erythema are frequently noted. It
is relatively smaller in size and rarely enlarge
beyond 2 centimeters. The lesion is firm to hard
in palpation depending on the amount of bone
formation.
Treatment
Conservative surgical excision is the treatment of
choice. Histopathologic examination is necessary
in order to establish diagnosis. A small
percentage of peripheral ossifying fibromas tend
to recur.
PERIPHERAL GIANT CELL GRANULOMA:
Similar to peripheral ossifying fibroma, peripheral
giant cell fibroma is also a reactive proliferation
that exclusively involves the gingiva. Some
studies have suggested that peripheral giant cell
granuloma is the soft tissue counterpart of central
giant cell granuloma.
Clinical Features
Peripheral giant cell granuloma can be seen in
individuals over a wide age range. A female
predilection is noted. Lesions tend to occur more
commonly in the mandible. They appear as a red-
blue, smooth-surfaced, and sessile nodules.
Surface ulceration is a common finding.
Peripheral giant cell granulomas remain relatively
small, rarely exceeding their dimensions by a
couple of centimeters. While this lesion does not
invade the underlying alveolar bone, it can cause
surface resorption leading to a “cupping” defect
that can be occasionally identified
radiographically.
Treatment
Surgical removal is the primary treatment. 10-
15% of the lesions may recur locally.
PYOGENIC GRANULOMA:
Despite the highly suggestive name, pyogenic
granuloma has no association with microbial
infections. It is a reactive proliferation of
granulation tissue, possibly induced due to low
grade irritation or trauma.
Clinical Features
Pyogenic granulomas can be seen in patients of
all ages. Some studies have suggested a strong
female predilection. Gingiva is the most frequent
site of involvement. The lesion may also be
identified on the tongue, lips, and buccal mucosa.
Cutaneous involvement with this process is
common. It appears as a red, lobulated growth
that is frequently ulcerated, and it tends to bleed
easily on manipulation. The ability of rapid
growth in pyogenic granulomas can occasionally
generate concerns about malignancy.
Pyogenic granulomas are a frequent finding on
the gingiva of pregnant women and may be
referred to as a pregnancy tumor. Hormonal
changes are considered an etiological factor in
the pathogenesis of this process. These lesions
tend to enlarge over the course of the pregnancy.
Once the child is delivered, remission is usually
noted.
Page 4
Source: Carl Allen, DDS
The Ohio State University
College of Dentistry
Oral Pyogenic Granuloma
Page 5
Treatment
Conservative surgical excision with submission of
tissue for histopathologic examination is usually
the preferred choice of treatment. Recurrence
rates are very similar to peripheral ossifying
fibroma and peripheral giant cell fibromas.
Excision of pregnancy tumors should be delayed
until the baby is delivered.
HYPERPLASIA
DRUG-RELATED GINGIVAL HYPERPLASIA:
Gingival growth has been known to occur
secondary with the use of certain medications:
• Phenytoin- an anti-seizure medication
• Cyclosporine- an immunomodulator
• Nifedipine- an antihypertensive drug
These drugs are likely to interfere with the
collagen remodeling process resulting in excess
accumulation of the protein in tissues.
Clinical Features
Gingival hyperplasia associated with medication
can be seen over a wide age range. Facial aspects
of anterior gingiva are more extensively involved.
Gingival enlargement initiates at the interdental
papillae and eventually covers the crowns of
teeth, either partially or completely. The enlarged
tissue has an irregular appearance and is firm on
palpation. If oral hygiene is not effectively
maintained, the hyperplastic gingiva may become
erythematous, edematous, and friable. Surface
ulceration may also be identified. Edentulous
areas are rarely affected. Patients using
cyclosporine can exhibit hyperplastic growth in
other oral soft tissues.
Treatment
Once the drug is identified as the offending agent,
the patient’s physician is requested to discontinue
the current medication. Significant improvement
in the condition is seen following cessation of the
offending drug. To improve esthetics, procedures
such as gingivectomy and gingivoplasty may be
performed.
INFECTIONS
HERPETIC INFECTION:
Herpes simplex virus has two subtypes, Type I
primarily affects the tissues above the diaphragm,
while Type II affects the tissues below the
diaphragm. The discussion in this section will
center around Type I. Herpes simplex virus Type I
spreads through saliva or contact with active
lesions. This virus has the ability to migrate to the
sensory ganglion following primary infection and
cause recurrent infections over subsequent years.
Clinical Features
Primary herpetic gingivostomatitis occurs more
commonly in children. Symptoms include fever,
malaise, lymphadenopathy, anorexia, and
irritability. Mucosal lesions begin as numerous
tiny vesicles that evolve into painful ulcers.
Adjacent lesions can coalesce to form larger
defects. Any part of the oral mucosa may be
involved. Gingiva appears erythematous and
swollen. Fingers, eyes, and the genitals can
acquire the virus through self-inoculation.
Complete resolution occurs within a week.
Adult infections are very similar to herpetic
gingivostomatitis except that the mucosal lesions
tend to occur in the pharyngotonsillar region.
Recurrent herpetic infection frequently presents
as herpes labialis or a cold sore. The onset of
blisters may be preceded by a prodromal phase
characterized by a tingling and burning sensation.
Recurrent lesions may also be identified on the
oral mucosa. In such instances, gingiva and the
palate are common sites of involvement.
Infections in immunocompromised patients tend
to be more frequent, severe, and persistent.
Treatment
The diagnosis can be made on the basis of clinical
presentation. Cytology can aid in establishing a
definitive diagnosis if it is performed within 72
hours of the onset of lesions.
Use of antivirals, such as acyclovir and valacyclovir,
earlier in the course of disease may lead to faster
resolution. Supportive treatment such as fluids,
process begins as generalized inflammation,
edema, and bleeding of the interdental papillae.
The papillae eventually undergo epithelial necrosis
to produce classic punched-out ulcerations. The
necrosed tissue is covered by an adherent white to
gray pseudomembrane. The condition is
extremely painful and emanates a foul odor.
Fever, malaise, and lymphadenopathy may
accompany the process.
Treatment
The condition is treated by local debridement and
use of topical and systemic antibiotics. Once the
offending bacteria are killed, regeneration of the
gingiva usually occurs. Supportive treatment may
be necessary if ancillary symptoms are also
present.
AUTOIMMUNE PROCESSES
MUCOUS MEMBRANE PEMPHIGOID:
Mucous membrane pemphigoid, also known as
cicatricial pemphigoid, is an autoimmune
blistering disease that primarily affects the oral
mucosa, skin, and conjunctiva. The body produces
antibodies against the proteins uniting the
epithelium with the underlying connective tissue
resulting in blister formation.
Clinical Features
The condition is more commonly seen in females
in their 50s and 60s. Oral lesions are seen in a
majority of patients affected by this condition.
They begin as small blisters that eventually rupture
to form painful ulcers that persist for several
weeks. Intact vesicles are rarely identified.
Gingival involvement presents as desquamative
gingivitis characterized by diffuse atrophy and
ulceration. Conjunctival and cutaneous lesions
heal by scarring (cicatrix). If conjunctival lesions
are not promptly managed, blindness may result.
Diagnosis and Treatment
Biopsy of lesional and perilesional tissue is
performed for establishing diagnosis. Lesional
t i s s u e is s u b mi t te d fo r h is to pa th olo gi c
examination, while perilesional tissue should be
submitted for immunofluorescent studies. Once
topical anesthetics and non-steroid anti-
inflammatory drugs can assist in alleviating
symptoms.
HERPES ZOSTER:
The varicella zoster virus causes both chickenpox
and herpes zoster. The virus becomes latent in the
geniculate ganglion following initial infection and
has the ability to reactivate in patients in advanced
age and immunocompromised states.
Clinical Features
Herpes zoster is rarely seen in immunocompetent
individuals under the age of 50. The reactivated
virus produces tingling or pain along the course of
a single dermatome. Elevated temperature,
fatigue, and body aches occur before the onset of
cutaneous lesions. As the virus travels through the
nerve, the pain intensifies and is followed by the
development of pustules along the nerve
pathway. The lesions do not cross the body’s
midline. The pustules rupture to form small ulcers
and eventually form a yellow colored crust. It
takes 2-3 weeks for complete healing to occur. A
significant degree of pain may persist up to several
months following recurrent infection. When the
trigeminal nerve is involved, intraoral lesions may
be seen. The lesions appear as white vesicles that
rupture to form shallow painful ulcers. The course
of the disease is very similar to cutaneous lesions.
Treatment
Early treatment with antivirals may limit the course
of disease. Supportive treatment with antipyretics
and antipruritics is usually beneficial.
NECROTIZING ULCERATIVE GINGIVITIS:
Necrotizing ulcerative gingivitis, also known as
trench mouth, is a bacterial infection precipitated
by stress, immunosuppression, nutritional
deficiency, and smoking. The process is linked to a
decrease in immune response against pathogenic
organisms due to stress hormones.
Clinical Features
Necrotizing ulcerative gingivitis is seen over a
wide age range. A higher prevalence is noted in
younger individuals in stressful situations. The Page 6
Page 7
the diagnosis is confirmed, the patient should be
referred to an ophthalmologist to rule out eye
involvement. If no eye involvement is identified,
topical corticosteroids are usually sufficient for
management. If scarring of conjunctival tissue is
noted, systemic therapy becomes mandatory.
LICHEN PLANUS:
Lichen planus is an immune-mediated process that
may involve the oral and genital mucosa, and the
skin. Oral lichen planus is relatively common. The
precipitating factor for this condition is currently
not known. It is broadly classified into reticular and
erosive forms.
Clinical Features
Lichen planus tends to affect people in their 40s
and 50s. Women appear to be more frequently
affected. Cutaneous lesions present as small,
pruritic, purple colored papules on the wrists,
ankles or the base of the spine. The papules
exhibit white, lace-like striation on the surface.
Reticular lichen planus is relatively more common
than the erosive form. It presents as symmetrically
bilateral, white lace-like striations primarily
involving the buccal mucosa. Tongue, palate, and
gingiva may also be affected. Most patients are
unaware of the presence of this condition.
Erosive lichen planus presents as bilateral,
symmetrical ulceration involving the buccal
mucosa and tongue. Around the margins of the
ulceration, erythema and lace-like striation, similar
to reticular lichen planus, can be identified. The
lesions are extremely painful forcing most patients
to seek help for the condition. Gingival
involvement presents as desquamative gingivitis.
Occasionally, gingival atrophy and ulceration may
be the only presentation of disease. Identification
of striation may be difficult in such cases.
Treatment
Diagnosis can usually be made on the basis of
clinical appearance. A biopsy of the erosive form
with submission of tissue for histopathologic and
immunofluorescent studies, is advised. This
prevents misdiagnosing cases of chronic ulcerative
stomatitis and lupus erythematosus as erosive
lichen planus.
Reticular lichen planus requires no treatment. The
patient should be reassured and monitored
periodically for changes in appearance. Erosive
lichen planus can be controlled by use of potent
topical steroids.
LICHENIOD MUCOSITIS:
Lichenoid mucositis is a term used to describe a
specific immune-mediated response of the body
against foreign material, drugs, artificial cinnamon
flavoring, and dental amalgam. While the clinical
presentation of these lesions can be quite diverse,
they bear a striking resemblance to lichen planus
histologically. Posterior buccal mucosa and the
tongue are frequently involved with drug-related
and contact mucositis. For amalgam reactions, the
changes are noted only in the mucosa coming into
contact with the restoration.
Lichenoid foreign material reaction primarily
involves the gingiva. It is considered to be an
abnormal response of mucosa against particles
originating from dental disks, polishing materials,
and dentifrices. It can present itself as isolated, as
generalized areas of erythema, or as an ulceration
resembling desquamative gingivitis. A biopsy
should be performed and submitted for
histopathologic examination. It is unlikely to
identify the foreign material during
histopathologic evaluation. Most cases resolve
spontaneously once the foreign material is
expelled. In chronic symptomatic cases, surgical
excision may be the only course of action.
PIGMENTED LESIONS
AMALGAM TATTOO:
Amalgam tattoo is discoloration of the oral mucosa
due to embedded amalgam particles. In most
instances the particles are incorporated following
placement or removal of an amalgam restoration.
Clinical Features
Amalgam tattoos are seen in patients over a wide
age range. Since it is not the preferred choice of
restoration material in pediatric patients, the
frequency of tattoos identified in this population is
low. They appear as grey colored macules most
Page 8
commonly involving the gingiva. Usually an
amalgam restoration can be identified in the
vicinity of the lesion. Since amalgam is also
employed as a retrograde filling material,
sometimes tattooing can be identified on the
attached labial gingiva of anterior teeth.
Diagnosis and Treatment
Clinical appearance is usually sufficient for
diagnostic purposes and no further intervention is
warranted. If the clinician is unsure about the
discoloration, radiographs may be helpful in
identifying amalgam particles in the mucosa.
When no particles are noted, or if the patient has
esthetic concerns, conservative surgical excision
followed by histopathologic examination should
be performed.
MELANOTIC MACULE:
Melanotic macule is a pigmented lesion that
results from focal deposition of melanin in oral soft
tissues. Some studies have implicated trauma as a
potential etiological factor.
Clinical Features
Melanotic macules occur over a wide age range.
Lips are the most common site of involvement.
Buccal mucosa, palate, and gingiva may also be
involved. They present as well-demarcated brown
to black macules. They tend to be less than one
centimeter in size.
Treatment
The diagnosis of melanotic macule can be made
on the clinical presentation. No treatment is
necessary. Dimensions of the lesion should be
documented at the initial visit. If any changes in
appearance and size are noted at the follow up
visit, an excisional biopsy of the lesion may be
mandated. Some patients may also request
removal due to esthetic reasons.
SMOKER’S MELANOSIS:
Smoker’s melanosis is pigmentation of oral tissues
in heavy smokers. Melanin is produced as a
protective response of oral mucosa against toxic
products of cigarette smoke.
Clinical Features
Smoker’s melanosis occurs more commonly in
Caucasians and shows a female predilection. It is
presented as diffuse, light brown pigmentation.
Anterior facial gingiva is more frequently involved.
Diagnosis and Treatment
A history of cigarette smoking or clinical evidence
of smoking is sufficient for diagnostic purposes.
The pigmentation usually disappears within a few
months of smoking cessation.
MELANOMA:
Melanoma is the malignant tumor of melanocytes.
It is primarily a cutaneous malignancy but can be
identified in the esophagus, small and large bowel,
eye, parotid gland, nasopharynx, and the mouth.
Acute damage by ultraviolet radiation is implicated
as an etiological factor in cutaneous lesions,
however definitive cause for mucosal lesions is
currently unknown. Oral melanomas are relatively
rare and accounts for less than 1% of all
melanomas. Oral melanomas tend to be more
aggressive than cutaneous melanomas.
Clinical Features
Oral melanomas occur in older individuals.
Maxillary gingiva and the hard palate are more
commonly involved. The lesion initially presents
as a large, brown to black macule, with irregular
borders. This macule rapidly evolves into an
exophytic lesion. Ulceration is a frequent finding.
The tumor is aggressive and can erode into the
Amalgam Tattoo Source: Amber Kiyani, DDS
The Ohio State University
College of Dentistry
Page 9
underlying bone creating a radiographically visible
defect. Some lesions may be devoid of
pigmentation and may appear mucosal colored.
Such lesions are difficult to diagnose clinically and
are referred to as amelanotic melanoma.
Diagnosis
Pigmented lesions involving the palate and
alveolar gingiva should always be biopsied. The
pathologist may need to perform a series of
immunohistochemical studies to establish
definitive diagnosis. Surgical excision with wide
margins is the preferred choice of treatment. For
deeper lesions, lymph node dissection, radiation,
and chemotherapy may also be needed.
PREMALIGNANT AND
MALIGNANT PROCESSES
LEUKOPLAKIA:
Leukoplakia is a clinical descriptor for white
patches, or plaques, in the oral cavity that have
distinct margins. While most leukoplakias may
represent a premalignant process, definitive
diagnosis of dysplasia can only be provided once
the lesion has been biopsied and has undergone
histopathologic examination.
Clinical Features
Leukoplakias are usually seen in patients over the
age of 40 and they exhibit a strong male
predilection. Use of tobacco products, alcohol and
sanguinaria are some of the common etiologic
factors associated with this process. Studies have
also implicated syphilis and candia as possible
etiologies.
Most lesions are identified on the lip, buccal
mucosa, and gingiva. The lesions can have variable
appearances; translucent, wrinkled, homogenous,
nodular, and speckled. Variations in size is also
noted. The lesions are crisply demarcated from the
adjacent normal tissue.
Sanguinaria is an herbal extract that was
extensively used in dentifrices in the 1970s.
Patients that used this product over a period of
time developed characteristically thin, white
plaques on the maxillary alveolar gingiva or
vestibule. Cessation of product did not lead to
resolution.
Treatment
If the lesion is small, complete surgical excision
extending to normal adjacent tissue is
recommended. Larger lesions require incisional
biopsies. The excised specimen should be
submitted for histopathologic evaluation. To
preserve the integrity of tissue for histopathologic
examination, use of lasers should be avoided
during excision. Lasers can compromise the tissue
sample, making it difficult for the pathologist to
establish diagnosis. Lesions with a diagnosis of
epithelial atypia and mild epithelial dysplasia
should be closely monitored at 3 to 6 month
intervals. If any changes are noted in appearance,
texture and size, the lesion should undergo
additional biopsies and the course of treatment
should be decided accordingly. Leukoplakias that
are diagnosed to be moderate to severely
dysplastic should be either surgically excised or
laser ablated completely. Since 30% of all
leukoplakias can recur, close clinical follow up is
recommended for all patients that have
leukoplakia surgeries.
PROLIFERATIVE VERRUCOUS LEUKOPLAKIA:
Proliferative verrucous leukoplakia is a condition
characterized by development of multiple
leukoplakic lesions in the oral cavity. Women tend
to be more frequently affected. Gingiva is a
common site of involvement. The leukoplakias
may evolve to verrucous carcinoma or squamous
c e l l c ar c i n o ma o ve r a pe r i od of ye ars .
Leukoplakia Source: Carl Allen, DDS
The Ohio State University
College of Dentistry
LYMPHOMA:
Lymphoma is a lymphoproliferative disorder. It is
broadly classified as Hodgkin’s and non-
Hodgkin’s lymphoma. Hodgkin’s lymphoma
primarily affects the lymph nodes, while non-
Hodgkin’s lymphoma is more frequently
identified in extralymphoid tissues.
Clinical Features
Hodgkin’s lymphoma presents with
lymphadenopathy commonly involving the
cervical, axillary, and mediastinal regions. Non-
Hodgkin’s lymphoma is characterized by fever,
malaise, night sweats, and weight loss, along with
lymphadenopathy. Non-Hodgkin’s lymphoma
can occasionally present as an intraoral mass
involving the jaws, palate, or gingiva. In some
instances, the soft tissue swelling may result from
malignant cells breaking out of bone. The mass is
erythematous and can be either smooth surfaced
or ulcerated. It tends to have a boggy
consistency. In case of intraosseous involvement,
a ragged radiolucency may be identified.
Diagnosis and Treatment
The diagnosis of lymphoma is established
through lymph node biopsy, flow cytometry,
immunophenotyping, and fluorescence in-situ
hybridization studies. If the oral mass is the only
presenting symptom, submission of tissue for
histopathologic examination and
immunohistochemical studies allows the
pathologist to render a definitive diagnosis.
LEUKEMIA:
Leukemia is a hematopoietic malignancy
characterized by abnormally increased levels of
immature leukocytes in bone marrow and blood.
It is broadly classified under myeloid and
lymphocytic types. Acute lymphocytic leukemia
is more common in children and follows an
aggressive clinical course. Newer forms of
chemotherapy have significantly improved the
prognosis for this process. Acute myelogenous
leukemia primarily affects adults and has
unfavorable survival rates despite chemotherapy.
Due to extensive involvement of the mucosa,
complete surgical excision of all leukoplakias is not
an option. These patients need to be closely
monitored for changes in size, texture and
appearances and regularly biopsied. If malignant
transformation is suspected, prompt laser ablation
or surgical excision of the area is recommended.
SQUAMOUS CELL CARCINOMA:
Squamous cell carcinoma accounts for over 90% of
oral malignancies. Cigarette smoking is associated
as the most common cause for this cancer. Other
etiological factors include smokeless tobacco, betel
quid, iron deficiency, microbial agents, chemical
agents and genetic influences.
Clinical Features
Oral cancer tends to occur in people between 40
and 80 years of age. Men appear to be more
frequently affected. It can present as a chronic
ulceration, an endophytic mass, a fungating tumor,
or as red-white patches. Ulceration, rolled border,
and induration are frequent findings. The surface
of the tumor is usually irregular and pain may be
occasionally noted. The size of the lesions vary
considerably. The tumor is locally destructive and
may erode into the underlying bone to create
radiographically identifiable changes.
Gingival lesions show a female predilection and are
not consistently associated with cigarette smoking.
They develop more commonly in the posterior
mandibular region and may appear deceptively
innocuous. They tend to mimic benign reactive
processes such as inflammatory fibrous hyperplasia
and pyogenic granulomas. Local growth
eventually results in invasion of the underlying
bone and tooth mobility.
Diagnosis and Treatment
All clinically suspicious lesions should be biopsied
and submitted for histopathologic examination.
Once the diagnosis is confirmed, the patient is
referred to an otolaryngologist. Surgical excision,
radiation, and chemotherapy are the available
treatment options.
Page 10
bone by the tumor results in loosening and
eventual loss of teeth in the vicinity.
Diagnosis and Treatment
A biopsy is mandated for rapidly enlarging
masses. The pathologist performs a series of
immunohistochemical studies to identify the
origin of the tumor. The prognosis for such
patients is usually poor with palliative treatment
as the only option.
CONCLUSION
This concludes our review on gingival pathology.
A few important points to remember:
• If it is not possible to diagnose a lesion
clinically, a biopsy is mandatory.
• Tissue from surgical excisions should always be
submitted for histopathologic examination.
• Patients with premalignant and malignant
lesions should be followed closely. Any
progression in lesional tissue should warrant
an immediate biopsy.
Chronic forms of both lymphocytic and myeloid
leukemia are common in adults and run an
indolent course.
Clinical Features
Fever, fatigue, weight loss, oral ulcers, and an
increased frequency of infections are some of the
initial symptoms at presentation. Easy bruising and
anemia slowly develop. Extramedullary disease
may involve the skin, central nervous system and
the gingiva. The gingiva appears ulcerated,
erythematous, and swollen. It is firm on palpation
and can sometimes be green, owing to the high
levels of myeloperoxidase in the tissues. This
presentation is referred to as granulocytic sarcoma
or chloroma.
Diagnosis and Treatment
The diagnosis of leukemia is usually made through
blood studies and bone marrow examination. If
the patient does not have a prior diagnosis of
leukemia and presents with gingival involvement,
the dentist should perform an incisional biopsy and
submit for histopathologic examination. The
pathologist will perform numerous
immunohistochemical studies in order to establish
definitive diagnosis. Once the diagnosis of
leukemia is confirmed, the patient is referred to a
hemeoncologist so chemotherapy can be initiated.
METASTATIC DISEASE:
Metastasis to the oral cavity is relatively rare and
accounts for only 1-1.5% of oral malignancies.
Tumors from lung, breast, prostate, kidney and
thyroid tend to metastasize to the oral cavity.
About 25% of patients are unaware of their primary
tumor prior to biopsy of their oral lesion.
Clinical Features
Metastatic disease of the oral cavity is more
commonly seen in individuals between the ages of
40-70. Men appear to be more frequently affected
than females. In oral soft tissues, 50% of tumors
occur on the gingiva. The lesions present as
nodular masses that vary in size considerably.
Surface ulceration is a common feature. The lesion
exhibits an aggressive growth potential and
enlarges rapidly. Destruction of the underlying Page 11
ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH
UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM.
GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE
UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL
AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE
INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH
DIAGNOSTIC AND TEACHING PURPOSES.
HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU
INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH
GASTROINTESTINAL DISEASES.
DR. AMBER KIYANI CAN BE CONTACTED
post-test instructions - answer each question ONLINE
- press “submit”
- record your confirmation id
- deadline is June 23, 2014
d i r e c t o r
john r. kalmar, dmd, phd
a s s i s t a n t d i r e c t o r
karen k. daw, mba, cecm
channel coordinator
rachel a. flad, bs
SUBMIT
ONLINE
SUBMIT
ONLINE
1 T F Peripheral ossifying fibromas frequently enlarge
beyond two centimeters.
2 T F Excision of pregnancy tumors should be
completed upon detection.
3 T F Cutaneous involvement is common with
pyogenic granuloma.
4 T F Cigarette smoking is associated with squamous
cell carcinoma, leukoplakia, and smoker’s
melanosis.
5 T F Oral melanomas tend to be more aggressive than
cutaneous melanomas.
6 T F Leukoplakias on the maxillary alveolar gingiva
and vestibule have been associated with
sanguinaria use in the past.
7 T F Melanotic macules are caused by a specific
immune-mediated response to artificial
cinnamon flavoring.
8 T F Erosive lichen planus is relatively less common
than reticular lichen planus.
Page 12
