Gingival and Papillary lesions

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Gingival and Papillary lesions
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Gingival Lesions

• Epulis (epulides) non-specific term for any
  solid growth arising from the gingiva or alveolar
  ridge area
• 3 Ps
• pyogenic granuloma
• peripheral giant cell granuloma
• peripheral ossifying fibroma

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Pyogenic Granuloma

• Benign growth of vascular, granulation tissue
• 75 occur on gingiva, but may occur anywhere in
  oral cavity or on skin
• Frequently seen in pregnant females (pregnancy
  tumor)
• Presents as painless reddish nodule, may be
  ulcerated, may grow rapidly and mimic a malignant
  process

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Pyogenic Granuloma

• Treat by local excision and removal of local
  irritants
• Lesions in pregnant females may resolve following
  delivery
• 10-15 recurrence, especially for gingival lesions

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Peripheral Giant Cell Granuloma

• Benign proliferation of vascular tissue, numerous
  giant cells, hemosiderin
• Alveolar/gingival mass only, adults 40-60 yrs
• Painless, bluish-red mass, may be ulcerated or
  associated with local irritants, may cause
  cupping of underlying bone
• Excision, remove irritants 10-15 recur

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Peripheral Ossifying Fibroma

• Proliferation of fibrovascular connective tissue
  with variable calcifications
• Thought to arise from PDL cells
• Gingival growth, young adults, anterior jaws,
  females (21), often ulcerated
• Excision, remove local irritants
• 10-15 recurrence

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Fibroma (irritation fibroma)

• Most common growth of the oral cavity
• Excess collagen deposition secondary to chronic
  trauma (biting)
• Buccal/labial mucosa, tongue
• Smooth-surfaced, dome-shaped nodule
• Dense fibrous connective tissue
  histopathologically
• Conservative excision, remove irritants

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Drug-Related Gingival Overgrowth

• Phenytoin (Dilantin) was first drug to be
  associated with gingival enlargement
• In the 1980s, nifedipine and the calcium
  channel-blocking agents were determined to cause
  gingival enlargement
• Cyclosporine was added to the list shortly after
  nifedipine

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Drug-Related Gingival Overgrowth

• Confirm the use of a causative drug
• Good oral hygiene, chlorhexidine rinses
• Discontinue drugs or replace if possible
• Some regression may be seen with discontinuation
  but not always (gingivectomy)
• Synergistic effects may be seen between 2
  different drugs

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Gingival Cyst of the Adult

• Uncommon cystic lesion, derived from dental
  lamina rests
• Middle-aged adults 40-60 yrs
• Mandibular canine/premolar region most common
• Bluish-translucent swelling, often centered in
  attached gingiva
• Can look like mucocele

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Gingival Cyst of the Adult

• Dx location excludes salivary gland origin
• Treat by local excision
• No tendency to recur

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Necrotizing ulcerative gingivitis(NUG, trench
mouth)

• Painful infectious disease of rapid onset,
  primarily affects gingiva (can spread)
• Certain bacteria (Fusobacterium nucleatum,
  Borrelia vincentii) together with predisposing
  factors
• stress, immunosuppression, poor oral hygiene,
  poor nutrition, smoking

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Necrotizing ulcerative gingivitis(NUG, trench
mouth)

• Adolescents, young adults
• Widespread involvement of superficial gingiva,
  especially interdental papillae
• punched-out papillae, bleeds easily
• Necrotic tissue gives a foul odor
• Low-grade fever, lymphadenopathy

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Necrotizing ulcerative gingivitis(NUG, trench
mouth)

• Dx clinical history and appearance
• Thorough gingival debridement with copious
  irrigation, improve oral hygiene
• Chlorhexidine or oral iodine rinses
• Systemic broad-spectrum antibiotics
• (i.e. tetracycline, metronidazole, erythromycin)
• Stop smoking, improve nutrition, evaluate immune
  function status

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Aggressive Periodontitis

• Rapid alveolar bone loss, often with little
  clinical signs of inflammation
• Any age, often first noted in teenage years
• Localized (often 1st molars and incisors) or
  generalized presentations
• Radiographic evidence of rapid bone loss,
  vertical defects common in localized cases
• Teeth may become mobile

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Aggressive Periodontitis

• Debridement, local and systemic antibiotic
  treatment, submit tissue for microscopic
  examination (biopsy) to rule out other pathologic
  conditions
• Extraction of hopeless teeth
• Majority of patients have a neutrophil
  dysfunction
• Prepubertal periodontitis associated with
  systemic leukocyte dysfunction
• A. actinomycetemcomitans, P.intermedia, P.
  gingivalis

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Periodontal Abscess

• Localized pus accumulation at base of periodontal
  pocket
• May be due to chronic periodontitis or acute
  obstruction of pocket by foreign material
  (popcorn husk)
• Often painful or tender, erythematous, foul taste
  may be reported, local pressure may release
  purulence
• Tooth usually vital

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Periodontal Abscess

• Drain purulence, debride area or remove foreign
  body, analgesics as needed
• Treat chronic periodontal disease, if present

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Parulis (sinus tract, gumboil)

• Associated with non-vital tooth (decay)
• Painless papule on gingiva or palate near apex,
  reddish with occasional yellow center, pressure
  may release pus
• Extraction or RCT of affected tooth
• Cutaneous sinus, rare complication

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Retrocuspid papilla

• Developmental papule(s), bilateral, lt 5mm
• Mandibular canine area, lingual gingiva
• Children, young adults (very common)
• Similar to giant cell fibroma microscopically
• Dx clinical appearance, no enlargement
• No Tx needed, may regress with time

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Inflammatory Fibrous Hyperplasia

• Also known as denture epulis, epulis fissuratum,
  or denture-induced fibrous hyperplasia
• Results from chronic, low-grade irritation from
  ill-fitting denture flange
• May have central fissure
• Conservative excision re-make denture

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Inflammatory Papillary Hyperplasia

• Denture papillomatosis maxillary complete
  denture
• Central region of hard palatal mucosa
• Numerous asymptomatic red papules
• Keeping denture out, red ? pink, but papules
  remain
• Excision may be needed

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Squamous Papilloma

• Most common benign epithelial neoplasm seen
  intraorally, associated with HPV infection
• Solitary lesion, typically found on soft
  palate/uvula, tongue, labial mucosa
• Finger-like fronds, usually pedunculated, but may
  be sessile
• Range of color (reddish to white)

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Papilloma - Treatment

• Conservative excision, including the base of the
  lesion
• Prognosis is excellent
• Recurrences are uncommon no risk of malignant
  transformation
• Very low transmission rate

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Verruca Vulgaris (common wart)

• Common, benign lesion caused by several strains
  of HPV
• Frequently affects children - hands and facial
  skin. Less frequent orally than sq. papilloma
• Can be transmitted, auto-inoculated
• Usually sessile, exophytic, papillary lesion
  often multiple on skin but solitary in the mouth
  (lips, gingiva, tongue, palate)

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Verruca Vulgaris

• spontaneous regression is common in kids
• excision, cryotherapy, keratolytic agents
• recurrence not common, but possible

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Condyloma Acuminatum

• also known as venereal warts
• benign epithelial proliferation caused by several
  strains of HPV, including types 6, 11, 16,18, 53
  and 54
• oral lesions - multiple, exophytic sessile
  mass(es), cauliflower surface, pink to white
• Lips, soft palate, lingual frenum

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Condyloma Acuminatum

• excision, cryotherapy, laser excision
• recurrence is common - 30 of patients have
  recurrent lesions after each treatment episode
• associated with squamous cell carcinoma of the
  uterine cervix

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Verrucous Carcinoma

• Uncommon, low-grade variant of oral squamous cell
  carcinoma
• Represents less than 1-10 of oral SCC
• Usually develops in elderly male patients
• Smokeless tobacco is often mentioned as a
  contributing factor, particularly in some
  southern states. These VCs arise in the area
  where the tobacco is placed. Can arise from the
  high risk precancerous condition PVL

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Verrucous Carcinoma

• Clinically presents as an extensive, exophytic,
  papillary mass or shaggy thick plaque, typically
  white, crisp borders
• Mandibular vestibule, gingiva, hard palate and
  buccal mucosa are most frequent sites
• Tends to grow slowly and laterally, not
  invasively

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Verrucous Carcinoma

• Wide surgical excision
• Rarely metastasizes
• Radiation therapy has been discouraged due to
  sporadic reports of transformation of verrucous
  carcinoma to a more aggressive squamous cell
  carcinoma

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Verrucous Carcinoma

• Prognosis fair-guarded - approximately 20-25 of
  verrucous carcinomas, upon complete excision,
  show foci of transformation to routine squamous
  cell carcinoma