SOPS Differential – August 2017 by Lee Slater, DDS, MS

Case submitted by Dr. Peter Nordland, La Jolla, CA

A 73 year-old woman had a painless gingival swelling between the right maxillary central and lateral incisors (#7-8).  General dentists had attempted to surgically remove it several times, but it repeatedly recurred.
The tissue was submitted for pathological evaluation.  

Cords and islands of odontogenic epithelium scattered in lesional connective tissue

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Cords and islands of odontogenic epithelium.

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What Is Your Clinical Diagnosis?

  1. Pyogenic granuloma
  2. Peripheral fibroma
  3. Metastatic carcinoma
  4. Peripheral ossifying fibroma
  5. Peripheral odontogenic fibroma

Clinical Differential Diagnosis

Based on relative frequency, the most likely diagnosis would be peripheral (gingival) fibroma, which probably represents a reactive nodular fibrous hyperplasia; it occurs more often than any other gingival mass.  The classic “three Ps” of gingival swellings include: pyogenic granuloma, peripheral ossifying fibroma, and peripheral giant cell granuloma.  Of the 3Ps, peripheral ossifying fibroma occurs more frequently than pyogenic granuloma (peripheral giant cell granuloma is least frequent).  Biopsy is necessary to establish the definitive diagnosis; but varying clinical features can cause the clinician to place a diagnosis at the top of the clinical differential diagnosis list.  An ulcerated tan nodule of interdental papilla suggests a peripheral ossifying fibroma.  An elevated red lesion suggests gingival fibroma or pyogenic granuloma.  A broad-based purplish-brown mass suggests peripheral giant cell granuloma.  A slightly-elevated red lesion with a papillomatous surface suggests juvenile spongiotic gingival hyperplasia.  For completeness, a wider range of diagnostic categories might be considered: infectious (histoplasmosis); inflammatory (parulis, granulomatous inflammation); neoplastic (peripheral odontogenic tumor, monocytic leukemia, metastatic carcinoma). 

 Histopathologic diagnosis:  Peripheral odontogenic fibroma

The biopsy demonstrated a nodule of fibrous connective tissue exhibiting scattered islands and cords of odontogenic epithelium, indicative of peripheral odontogenic fibroma. 

 

Discussion

Peripheral odontogenic fibroma is typically treated by surgical excision.  Ritwik and Brannon found that 50% of peripheral odontogenic fibromas recurred.  If this gingival swelling were associated with a radiolucent lesion, then the designation “central odontogenic fibroma” (with an extraosseous component) would be appropriate. 

References:

  1. Ritwik P, Brannon RB: [50% of peripheral odontogenic fibromas recur.] Oral Surg 110:357, 2010.
  2. Eversole LR: Peripheral odontogenic fibroma, n = 40. Head Neck Pathol 5:335, 2011.
  3. Darling MR, et al: Juvenile spongiotic gingivitis. J Periodontol 78:1235, 2007.
  4. Chang JY, et al: Localized juvenile spongiotic gingival hyperplasia [n = 52]. Oral Surg 106:411, 2008. [15% related to orthodontic treatment.]