This is a repository copy of Lumps and bumps of the gingiva : a pathological miscellany. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/145057/ Version: Published Version Article: Brierley, D.J., Crane, H. and Hunter, K.D. orcid.org/0000-0002-7873-0877 (2019) Lumps and bumps of the gingiva : a pathological miscellany. Head and Neck Pathology, 13 (1). pp. 103-113. ISSN 1936-055X https://doi.org/10.1007/s12105-019-01000-w Reuse This article is distributed under the terms of the Creative Commons Attribution (CC BY) licence. This licence allows you to distribute, remix, tweak, and build upon the work, even commercially, as long as you credit the authors for the original work. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing [email protected] including the URL of the record and the reason for the withdrawal request. [email protected] https://eprints.whiterose.ac.uk/ Head and Neck Pathology (2019) 13:103–113 https://doi.org/10.1007/s12105-019-01000-w SPECIAL ISSUE: COLORS AND TEXTURES, A REVIEW OF ORAL MUCOSAL ENTITIES Lumps and Bumps of the Gingiva: A Pathological Miscellany Daniel J. Brierley1 · Hannah Crane1 · Keith D. Hunter1,2 Received: 16 October 2018 / Accepted: 2 January 2019 / Published online: 29 January 2019 © The Author(s) 2019 Abstract Lesions of the gingivae are amongst the commonest lesions seen in patients and the vast majority are reactive hyperplasias, related to a number of chronic irritant stimuli. However, there are a number of entities that have a predilection for the gin- givae, which are much less common in other parts of the oral cavity. The purpose of this paper is to discuss the clinical and histological diferential diagnoses when presented with a lump on the gingivae, including the approach to diagnosis and diagnostic pitfalls. Keywords Epulis · Gingiva · Fibrous hyperplasia · Giant cell granuloma · Pyogenic granuloma · Ligneous gingivitis · Granulomatosis with polyangiitis · Benign tumor · Malignant tumor Introduction A Word on Terminology Lesions of the gingiva are very common and provide a sig- As in many areas of histopathology, terminology is variably niicant proportion of the diagnostic workload of any oral used and those used in the description of clinical and histo- pathology practice. The majority of these lesions are reac- logical lesions of the gingivae are no diferent. Some use of tive (with varied appearance), but other developmental and terminology is, strictly, inaccurate, but has, for a number of neoplastic conditions can also present in the gingiva, giv- reasons, become well established as common usage. This ing rise to areas of clinical and histological uncertainty in includes, but is not limited to, the terms ‘polyp’ and ‘epulis’ diagnosis. In this review, we aim to address the main entities as histological diagnoses, the use of the term ‘ibroma’ in which may present as “lumps and bumps” in the gingiva. As the context of these lesions, and the common usage in some with all common diagnoses, there is variability in the clini- parts of the world of the term ‘peripheral ossifying ibroma’, cal presentation of such lesions of the gingivae and to some which causes confusion in others [1, 2]. Whilst it is not help- extent, in the histological appearances. As such, it is not ful to be dogmatic about which terms should or should not possible to describe every possible presentation. However, be used, it is important that histopathologists and referring the descriptions below will cover the most salient features clinicians have a common understanding of the terminology, of a range of diferent pathologies of the gingival tissues. to ensure efective communication of diagnosis and resulting treatment strategies. Where appropriate, synonyms will be indicated in the text. Reactive Lesions Fibrous Hyperplasia of the Gingiva * Keith D. Hunter [email protected] Epidemiology 1 Academic Unit of Oral and Maxillofacial Medicine and Pathology, School of Clinical Dentistry, University Nodules of inlammatory ibrous hyperplasia (syn. ibroepi- of Sheield, Claremont Crescent, Sheield S10 2TA, UK thelial polyp, ibroma; on gingivae, ibrous epulis) are very 2 Department of Oral Pathology and Biology, University common, with ibrous hyperplasia accounting for up to 40% of Pretoria, Pretoria, South Africa Vol.:(0123456789)1 3 104 Head and Neck Pathology (2019) 13:103–113 of mucosal pathology in large series [3]. Lesions occur over granuloma and peripheral giant cell granuloma. Considera- a wide age range and are more common in females. tions in more generalised lesions include hereditary gingival ibromatosis, which may occur as an isolated lesion or as Clinical Presentation and Diferential Diagnosis part of a syndrome. A number of genetic lesions, including mutations of the Son-of-Sevenless-1 (SOS1) gene have been In dentate patients, these lesions most commonly occur associated with the isolated from of this condition [6]. on the interdental papilla, but may also include the facial surface of the tooth (Fig. 1a). When large, lesions may Histology and Histological Diferential Diagnosis extend through the contact point to appear in the papilla on both sides of arch, with a rather “dumb-bell” appear- Histology shows hyperplastic and usually keratinized epithe- ance, although this appearance is more commonly seen in lium overlying nodular ibrous connective tissue (Fig. 1c). peripheral giant cell granuloma (see below). The lesions The extent of collagenisation and vascularity of the body are most commonly mucosal colored, but may be focally of the lesion will depend on its maturity and the presence ulcerated. More extensive lesions occur in patients taking or absence of inlammation. The ibroblast component is certain medications, for example: phenytoin, nifedipine (and bland and in most cases comprises ine spindle shaped cells, other calcium channel blockers) or cyclosporine [4]. This with most lesions relatively paucicellular. However, in some drug-induced gingival hyperplasia is an exaggerated form cases, the ibroblasts may be large and stellate in morphol- of the more focal reactive lesions described above (Fig. 1b). ogy, and occasionally multinucleated, albeit cytologically In edentulous/partially dentate patients, similar lesions can bland (Fig. 1d). These lesions have been termed “giant cell occur on the alveolus in relation to the presence of ill-itting ibroma” and are most common on the gingiva of young prostheses, often termed denture irritation hyperplasia or adults. denture hyperplasia [5]. These lesions are most common in Up to a third of such lesions on the gingiva contain tra- the mucosa in contact with the periphery of a denture and beculae of metaplastic bone, particularly those on the max- are usually broad based leaf-like folds of mucosa. illary labial gingiva, and which are or have been ulcerated The clinical diferential diagnosis most often includes [1, 7]. Such lesions are termed peripheral ossifying ibroma other reactive lesions of the gingiva including pyogenic (synonym: mineralizing ibrous epulis). The use of this Fig. 1 a A large ibrous epulis on maxillary gingiva. b Widespread ibroma (H&E, overall magniication × 200). e An ulcerated vascular ibrous gingival enlargement on a patient on cyclosporine therapy. c lesion on the maxillary gingiva of a pregnant patient in mid-trimester. Histological image of a nodule of ibrous hyperplasia of the gingiva f The histology of a vascular epulis/pyogenic granuloma shows atten- (H&E, Overall magniication × 20). In this case, the collagen varies uated or ulcerated epithelium with an underlying endothelial prolif- from supericially hyalinised to more edematous in deeper tissues. d eration. This may have a lobular pattern (H&E, overall magniication Histological image showing large stellate ibroblasts in a giant cell × 200) 1 3 Head and Neck Pathology (2019) 13:103–113 105 terminology varies geographically, as does the viewpoint Peripheral Giant Cell Granuloma that this represents a separate diagnostic entity. In their sur- vey of reactive gingival lesions, Eversole and Rovin indi- Epidemiology cated that this lesion most likely represents a variation in response to chronic irritation [8]. Histologically, the min- The peripheral giant cell granuloma (PGCG) (syn. giant cell eralizing component consists of trabeculae or drop-like cal- epulis) accounts for approximately 10% of epulides [11]. They ciications resembling woven bone or cementum in a back- occur over a wide age range with a lower age peak incidence ground of active cellular stroma. The recurrence rate of such for males than females, and a female predilection. These lesions is higher than for other forms of ibrous epulis [7]. lesions can occur in any part of the gingiva in dentate patients or on the alveolar ridge in edentulous patients, but most occur anterior to the molar region and are slightly more common in Vascular Epulis the mandible [12]. Epidemiology Clinical Presentation and Diferential Diagnosis The vascular epulis (syn. pyogenic granuloma) is a reac- PGCG are most often deep red/purple colored sessile swell- tive vascular lesion, which, in the mouth, is most common ings that may reach an appreciable size (Fig. 2a). They may on the gingiva. These lesions develop as a result of trauma extend through the contact point between teeth in a dumb-bell or recurrent irritation, most commonly