FIGURE 1: Ulcerated, erythematous, dome-shaped pyogenic granuloma of the anterior maxillary palatal gingiva.
FIGURE 2: Pink, dome-shaped peripheral ossifying fibroma of the right posterior maxilla. Note the severe periodontal disease and heavy plaque and calculus deposits. Such irritants are commonly associated with development of reactive gingival lesions.
PYOGENIC GRANULOMA
Pyogenic granulomas( PGs) are benign vascular growths that can arise anywhere in the oral cavity, but approximately 80 percent occur on the gingiva. 1 A study of 302 reactive fibrous lesions of the gingiva found approximately one-third to consist of PGs. 2 Most lesions occur in female patients and maintain a multifactorial etiology including irritation, inflammation, trauma, or hormonal influences during pregnancy. 1, 2 Because the lesion has been found in 5 percent of pregnancies due to hormonal imbalances, PGs are sometimes referred to as“ oral pregnancy tumors.” 3 Younger PGs have an erythematous, vascular appearance, while older lesions can appear more pink due to the deposition of collagen. 1 Given the vascular nature of the lesion, bleeding is the predominant sign. Ulceration of the overlying epithelium is also present in a number of cases( Figure 1). Histopathologically, PGs appear as highly vascular proliferations, which are sometimes arranged in a lobular pattern. 1 If this is the case, they may also be referred to as“ lobular capillary hemangiomas.” Surgical excision with clear margins constitutes the treatment of choice. However, the literature reports recurrence rates of 14.8 percent after surgery for PGs. 4 Of note, PGs occurring during pregnancy have a higher rate of recurrence than sporadic cases; and, moreover, they may regress spontaneously following childbirth. 1 For this reason, excision should be deferred in most cases.
PERIPHERAL FIBROMA
Peripheral fibromas, similar to pyogenic granulomas, have been reported in all locations in the oral cavity and frequently develop in the context of physical irritation. 2 Clinically, most peripheral fibromas are enveloped by a smooth, pink surface. Histopathologically, they appear as well-defined, asymptomatic lesions composed of fibrocollagenous tissue with variable vascularity. One common variant that has a propensity for palatal tissues is the“ giant cell fibroma” which retains a more roughened, papillary surface. Histopathologically, the giant cell fibroma is comprised of multinucleated, stellate-shaped cells interspersed amidst fibrils of collagen. 1 Conservative surgical excision is the treatment of choice.
PERIPHERAL OSSIFYING FIBROMA AND PERIPHERAL GIANT CELL GRANULOMA
Peripheral ossifying fibromas( POF) and peripheral giant cell granulomas( PGCG) comprise approximately one-quarter of non-odontogenic reactive hyperplasias on the gingiva. Unlike PGs, both PGCGs and POFs only occur on the gingiva or edentulous alveolar ridge. 1 POFs arise primarily in the anterior gingiva of both the maxilla and mandible, while PGCGs mostly occur on the mandibular gingiva anterior to the molars. 2 They may present clinically with surface ulceration. PGCGs often have a purplishhemorrhagic appearance. Longstanding POFs frequently can appear pink( Figure 2). 1 Histologically, POFs have a conspicuously cellular stroma along with hard tissue deposition that may be prominent or subtle in young lesions and are correspondingly, firmer to palpation. Histopathologically, PGCGs are notoriously vascular with red blood cell extravasation and hemosiderin pigmentation. Additionally, multinucleated giant cells, composed of greater than 10 nuclei, dominate the stroma. 1 PGCGs have the potential for cupping bone resorption of the area underlying the lesion leading to mobility of the teeth. 1 POFs and PGCGs are more aggressive and possess a higher recurrence rate( 12-20 %) compared to pyogenic granulomas and peripheral fibromas. Nonetheless, surgical excision with clear margins down to the underlying bone is curative in the majority of cases and represents the standard of care for these lesions. 5-7
MAY / JUNE 2018 | PENNSYLVANIA DENTAL JOURNAL 25