Hyperplastic, Neoplastic and Related Disorders of Oral Mucosa

LAB 1

Hyperplasia:
-Increase in number of cells (proliferation of cells) in a physiological manner which is responsive to a specific stimulus -Microscopically cells resemble normal cells but are increased in number -Results in the gross enlargement of tissue -Cells of hyperplastic growth remain subject to normal regulatory control mechanisms

Neoplasia:
-The process underlying cancer and benign tumors - Increase in number of cells (proliferation of cells) in a nonphysiological manner which is unresponsive to normal stimuli - Cells are genetically abnormal

Reactive hyperplasia
-Usually localized -Cause: chronic (low grade) irritation, such as:

Plaque & calculus Lip/cheek biting Ill-fitting/over-extended denture Sharp edge of a crown/bridge
-Clinical appearance: exophytic mass that is increasing in size -Histological appearance: granulation tissue with variable amounts of blood vessels and cells -Location: anywhere in the mouth

Reactive hyperplasia
Examples of localized hyperplastic lesions of oral mucosa: -Peripheral ossifying fibroma (considered as fibrous epulis) -Irritation fibroma focal fibrous hyperplasia (considered as fibrous epulis) -Pyogenic granuloma -Peripheral giant cell granuloma (giant cell epulis) -Giant cell fibroma -Retrocuspid papilla -Fibroepithelial polyp irritation fibroma, focal fibrous hyperplasia -Denture irritation hyperplasia epulis Fissuratum, inflammatory fibrous hyperplasia -Papillary hyperplasia of the palate inflammatory papillary hyperplasia

Epulides
Reactive localized tumor-like gingival enlargement Hyperplastic NOT neoplastic More common in females More common in maxilla More common in the anterior region of the oral cavity Main etiological factors are: subgingival plaque/calculus (chronic irritation) and trauma

Epulides
Treatment: Identification and removal of etiological factor if possible to allow lesion to regress by itself Excisional biopsy if required Causes of recurrence: Etiological factor persists Lesion incompletely excised (as in PGCG) Types: Fibrous epulis (Chronic hyperplastic gingivitis & peripheral ossifying fibroma) Vascular epulis (Pyogenic granuloma & pregnancy epulis) Giant cell epulis (Peripheral giant cell granuloma)

 50 years old patient attended the dental clinic for routine dental examination Upon examination we discovered an exophytic mass arising from gingiva palatal to upper right central & lateral incisors The lesion is painless (non-tender), pink in color, firm to palpation, and has a nonbleeding property Histopathological examination is shown below 1- What do we clinically call this localized gingival hyperplasia and how can we reach the definitive diagnosis?! 2- Whats the most likely diagnosis?! 3- What pathological variety is this?!

4- Whats the other pathological variety?!

5- Describe the usual histopathological appearance?!

6- Whats the treatment?!

Peripheral ossifying fibroma

Bone formation

Richly cellular fibrous stroma

Fibrous epulis
A B

The granulation tissue is highly cellular and showing signs of calcifications (figure B), here it is called peripheral ossifying fibroma

 25 years old non-pregnant female attended the dental clinic concerned about an exophytic mass arising from buccal interdental gingiva of upper right canine, 1st and 2nd premolars Upon examination we found that the lesion is painless (non-tender), red/purple in color, soft to palpation, and has a bleeding property on minor provocation The patient states that the lesion is of rapid growth & of 3 days duration only Histopathological examination is shown below
1- What do we clinically call this localized gingival hyperplasia and how can we reach the definitive diagnosis?! 2- Whats the most likely diagnosis?! 3- What clinical variety is this?! 4- Whats the other clinical variety?!

 25 years old non-pregnant female attended the dental clinic concerned about an exophytic mass arising from buccal interdental gingiva of upper right canine, 1st and 2nd premolars Upon examination we found that the lesion is painless (non-tender), red/purple in color, soft to palpation, and has a bleeding property on minor provocation The patient states that the lesion is of rapid growth & of 3 days duration only Histopathological examination is shown below 5- Whats the most likely cause?! 6- Does this clinical variety only affect the gingiva?! 7- Do the lesions elsewhere in the oral cavity differ from the ones arising on the gingiva?!

 25 years old non-pregnant female attended the dental clinic concerned about an exophytic mass arising from buccal interdental gingiva of upper right canine, 1st and 2nd premolars Upon examination we found that the lesion is painless (non-tender), red/purple in color, soft to palpation, and has a bleeding property on minor provocation The patient states that the lesion is of rapid growth & of 3 days duration only Histopathological examination is shown below 8- What are the clinical features of the other clinical variety?! 9- Describe the usual histopathological appearance?! 10- Whats the usual treatment?!

Vascular epulis
Vascular spaces

Pyogenic granuloma (lobular capillary Hemangioma)

NOT only on the gingiva

 40 years old male attended the dental clinic concerned about an exophytic mass arising from buccal interdental gingiva of upper left canine, 1st and 2nd premolars and recurring for the 3rd time Upon examination we found that the lesion is painless (non-tender), dark red in color Histopathological examination is shown below 1- What do we clinically call this localized gingival hyperplasia and how can we reach the definitive diagnosis?! 2- Whats the most likely diagnosis?! 3- What are the main clinical features of this lesion?! 4- Whats the main radiographic feature of this lesion?! 5- Why radiographs are usually needed in the definitive diagnosis of this lesion?!

 40 years old male attended the dental clinic concerned about an exophytic mass arising from buccal interdental gingiva of upper left canine, 1st and 2nd premolars and recurring for the 3rd time Upon examination we found that the lesion is painless (non-tender), dark red in color Histopathological examination is shown below 6- What other lesion to exclude?! And how to rule it out?! 7- Describe the usual histopathological appearance?! 8- What about the pathogenesis of the lesion?! 9- What are the possible diagnoses if there are multiple lesions?! 10- Whats the usual treatment?!

11- What about the prognosis?!

Peripheral giant cell granuloma

Collections of giant cells lying in richly vascular and cellular stroma

 PGCG vs. CGCG (take a radiograph)

CGCG

We need to exclude?! hyperparathyroidism

 35 years old female attended the dental clinic concerned about an exophytic mass arising on the right buccal mucosa Upon examination we found that the lesion is painless (non-tender), pink in color, firm to palpation, and has a nonbleeding property Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- What are the main clinical features of this lesion?! 3- Is it a true benign tumor?! 4- If the lesion occurs in the palate under a denture, what would it become?! 5- Describe the usual histopathological appearance?! 6- Whats the usual treatment?!

Fibroepithelial polyp

Hypocellular fibrous tissue

Fibroepithelial polyp
Chief Complaint: painless (non-tender), pink and firm swelling of the left posterior buccal mucosa of 2 months duration

Fibroepithelial polyp
Chief Complaint: painless (non-tender), pink and firm swelling of the right anterior buccal mucosa and the hard palate

Leaf Fibroma
In the palate under the denture, Fibroepithelial polyp becomes flattened and leaf-like

Fibroepithelial polyp
Management = Excisional biopsy

 20 years old female attended the dental clinic concerned about an exophytic mass arising on the dorsum of the tongue Upon examination we found that the lesion is painless (non-tender), pink in color, firm to palpation, and has a nonbleeding property Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- What are the differences between this lesion and Fibroepithelial polyp?! 3- Whats the usual treatment?!

Giant cell fibroma

A Fibroepithelial polyp in which a distinctive histopathological feature is found which is multinucleated fibroblasts Location (arises on keratinized mucosa gingiva, hard palate, and tongue)

Retrocuspid papilla
- Same histopathology as giant cell fibroma multinucleated fibroblasts

- Developmental lesion, lingual to mandibular canine on the interdental papilla

- 25-99% of young adults and children

 Some CLINICAL differential diagnoses for gingival

tumor-like enlargement:

1. 2. 3. 4. 5. 6.

Peripheral ossifying fibroma Irritation fibroma Pyogenic granuloma Peripheral giant cell granuloma Giant cell fibroma Retrocuspid papilla

 60 years old female attended the dental clinic concerned about multiple folds of tissue arising in the depth of vestibules on the facial aspect of upper complete denture flange Upon examination we found that the folds are painless (non-tender), pink in color, firm to palpation, and have a non-bleeding property They arent grossly inflamed but ulcerated at the base of the vestibule Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Whats the most likely cause?!

3- In whom/which this lesion is more common?!

4- Describe the Histopathological appearance?!

5- Whats the usual treatment?!

Denture irritation hyperplasia

Hyperplastic fibrous tissue

Hyperplastic epithelium

 55 years old female attended the dental clinic concerned about the pebbled appearance the hard palate shows under the fitting surface of upper complete denture Upon examination we found that the pebbles are painless (non-tender), red in color, and inflamed Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Whats the most likely cause?! 3- Describe the Histopathological appearance?! 5- Whats the usual treatment?!

Papillary hyperplasia of the palate

Pseudo-epithelomatous hyperplasia

 37 years old male attended the dental clinic complaining from pain arising from the lower right side Upon examination we found an ulcerated exophytic mass posterior to last molar tooth The lesion is indurated & fixed and regional lymph nodes are enlarged Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Whats the prognosis?!

 40 years old male attended the dental clinic concerned about a recurrent exophytic mass arising from lingual gingiva of lower left canine, 1st & 2nd premolars and 1st molar The lesion is slowly growing, locally aggressive & doesnt show any metastatic potential Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- What about the histopathological appearance?!

 40 years old female attended the dental clinic concerned about a swelling arising from the left buccal mucosa Upon examination the swelling is soft to palpation and yellowish in color Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Where does it more commonly arise?! 3- Describe the behavior of this lesion if dropped in formalin?! 4- Describe the histopathological appearance?!

Lipoma

Liposarcoma

Lipoblasts with Pleomorphic nuclei

 26 years old female attended the dental clinic concerned about an elevated dark reddish-purple lesion present on the left soft palate for the last 10 years Upon examination, we found the lesion to be diffuse, compressible (soft consistency) and painless (nontender) Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Is it a true tumor?! 3- Simple clinical test to confirm your diagnosis?! 4- Where do oral lesions most commonly arise?! 5- Are lesions usually solitary or multiple?! And if they are multiple then what syndrome should we think of?!

 26 years old female attended the dental clinic concerned about an elevated dark reddish-purple lesion present on the left soft palate for the last 10 years Upon examination, we found the lesion to be diffuse, compressible (soft consistency) and painless (nontender) Histopathological examination is shown below 6- If theres recent increase in size, then suspect what?! 7- Describe the histopathological appearance?! 8- What pathological variety is shown in here?! 9- Whats the usual treatment?!

Hemangioma

Blanching test
Hemangiomas blanch under pressure

Hemangioma

Hemangioma histopathology
Capillary (C) OR cavernous (D)

Cellular Hemangioma

Endothelial cells

Arteriovenous Malformation
Abnormal connection between arteries and veins, bypassing the capillary system

Thick walled blood vessel

Thin walled blood vessel

Venous lakes
- Local venous anomalies on the vermilion border of the lips

- Increase in frequency with age

Sublingual varicosities
-Dilatation of ranine veins -Increase in frequency with age

Kaposi Sarcoma

Commonly found in the mouth of patient with AIDS

 10 years old child was admitted to the dental clinic to consult about this clinical presentation he is present with Parents stated that he has frequent convulsions of the limbs on the right side 1- Whats the most likely diagnosis?! 2- Describe the clinical features of this condition?!

 70 years old male attended the dental clinic to consult about this clinical presentation she is present with She complains from frequent nose bleeding 1- Whats the most likely diagnosis?! 2- Describe the clinical features of this condition?!

Hereditary hemorrhagic telangiectasia

 10 years old male was admitted to the dental clinic with his parents who complained from a tongue lesion which has been present since their child was 6 months of age. The lesion is currently asymptomatic and slowly enlarging Upon examination, we found the lesion to be diffuse, compressible (soft consistency) and painless (nontender) Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Is it a true tumor?! 3- Where do oral lesions most commonly arise?! 4- Describe the histopathological appearance?! 5- What pathological variety is shown in here?!

Lymphangioma

Lymphatic fluid

Lymphangioma
Doesnt blanch

 8 years old male was admitted to the dental clinic with his parents who complained from a large swelling in the neck side of their child which has been present since birth Upon examination, we found the lesion to be fluctuant and more than 10 cm in diameter and extending to the base of the tongue & the floor of the mouth 1- Whats the most likely diagnosis?!

 28 years old female attended the dental clinic complaining from a swelling arising from the tip of the tongue Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- If there are multiple swellings of this lesion then suspect what?! 3- Describe the histopathological appearance?!

Neurofibroma

Neurofibroma

Wavy spindled cells

Neurofibroma

 35 years old male attended the dental clinic complaining from multiple large masses of the skin causing considerable disfigurement Upon examination, we found the patient to have some melanin pigmentation and Axillary freckling 1- Whats the most likely diagnosis?! 2- How many types are there of this condition?!

3- What mutation leads to this condition?!

4- What are the clinical features of this condition?! 5- What features of Neurofibroma are often found in this condition?!

 35 years old male attended the dental clinic complaining from a swelling arising from right buccal mucosa Upon examination, lesion is firm to palpation but movable (not fixed), somewhat Pedunculated and located about 5mm from Stensens duct It is of unknown duration and painless to palpation Histopathological examination is shown below

1- Whats the most likely diagnosis?!

2- Describe the histopathological appearance?!

3- What mutation leads to this condition?!

4- What are the clinical features of this condition?! 5- What features of Neurofibroma are often found in this condition?!

Schwannoma

Capsule

Schwannoma

Schwannoma

 65 years old male attended the dental clinic complaining from a small nodule arising just above the tissue covering the mental foramen and started to appear after a surgery performed in the area Patient stated that it is slowly growing in size Upon examination, lesion is firm to palpation, fixed to surrounding structures and painful to palpation Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Whats the cause behind this condition?! 3- If there are multiple lesions, then suspect what?! 4- What are the components of the condition suspected and what can be used to screen it?!

Traumatic neuroma

Nerve bundles

Multiple mucosal neuromas

 43 years old male attended the dental clinic concerned about a small swelling arising on the anterior 2/3s of dorsum tongue Patient stated that it is slowly growing in size Upon examination, lesion is firm to palpation, fixed to surrounding structures and painless to palpation Histopathological examination is shown below

1- Whats the most likely diagnosis?!

2- Whats the origin of this lesion?! Due to proliferation of what cell?! 3- How did they conclude the actual origin of this lesion?! 4- Where it more commonly occur in the oral cavity?! 5- Describe the histopathological presentation?!

Granular Cell Tumor

Hyperplastic epithelium

Pseudo Epithelomatous Hyperplasia

Granular cells

Granular Cell Tumor

Pseudo Epithelomatous Hyperplasia

Granular Cell Tumor

Pseudo Epithelomatous Hyperplasia

Granular Cell Tumor

Feeling of invasion because of the presence of striated skeletal muscle fibers between the granular cells but it is benign

 19 years old female was referred to the dental clinic by internal Medicine discipline to evaluate for possible odontogenic cause of right submandibular swelling Upon examination, right submandibular lymph nodes were enlarged & painless Histopathological examination is shown below 1- Whats the most likely diagnosis?! 2- Whats the most commonly affected age group?! 3- Where is this condition usually distributed?! 4- What lymph nodes are most commonly involved?! 5- Whats the etiology of this condition?! 6- What about the prognosis of this condition?!

 19 years old female was referred to the dental clinic by internal Medicine discipline to evaluate for possible odontogenic cause of right submandibular swelling Upon examination, right submandibular lymph nodes were enlarged & painless Histopathological examination is shown below 7- Whats the usual clinical presentation of this condition?! 8- The histopathological diagnosis depends on what??! 9- Describe the neoplastic component of this condition?!

Hodgkin's lymphoma

lymphocytes

Reed Sternberg cell

Hodgkin's lymphoma

Malignant lymphomas
lymphoma

Hodgkins

Non-Hodgkin B lymphoma (e.g. Burkitts) T lymphoma

 25 years old male attended the dental clinic concerned about a swelling arising from the right half of the palate Upon examination, swelling is large, diffuse, fleshy, soft & ulcerated Teeth in the area were mobile Radiographic examination suggested severe bone destruction Histopathological examination is shown below 1- What are the differential diagnoses?! 2- Whats the most likely diagnosis?! 3- Where is this condition usually distributed?! 4- When this condition is extra-nodal, what other tissues it may affect?! 5- Which lesions have better prognosis: nodal or extra-nodal?! 6- Based on cell of origin, how many types of this condition are there?!

 25 years old male attended the dental clinic concerned about a swelling arising from the right half of the palate Upon examination, swelling is large, diffuse, fleshy, soft & ulcerated Teeth in the area were mobile Radiographic examination suggested severe bone destruction Histopathological examination is shown below 7- Which variety is this?! 8- What are the different types of this variety and what are their clinical features?! 9- What is the genetic abnormality leading to this variety?! 10- Describe the histopathological presentation?!

Burkitts lymphoma Starry Sky

Malignant Blymphocytes

Non-neoplastic macrophages

Burkitts lymphoma Starry Sky

Malignant Blymphocytes

Non-neoplastic macrophages

Lethal midline granuloma T-cell lymphoma

- Also called nasal NK/T-cell lymphoma & Angiocentric Tcell lymphoma - Leads to extensive destruction of midfacial structures - EBV is found in some neoplastic cells

Case Report 1
13 years old female is referred for evaluation of an asymptomatic, 1 x 1.5 mm mass in the right buccal mucosa in the premolar area at the level of the occlusal plane. The patient wears full orthodontic appliances. She believes that the lesion was present before she started the orthodontic treatment one year ago The lesion seems localized, pink in color, fibrotic & firm to palpation

1- What are the differential diagnoses?!

Differential Diagnoses
Think of hyperplastic & benign neoplastic lesions causing Localized Soft Tissue Enlargements with a normal mucosa: 1) Fibroepithelial polyp irritation fibroma 2) Giant cell fibroma 3) Fibro-lipoma 4) Neurofibroma 5) Schwannoma 6) Mucosal neuroma 7) Granular cell tumor 8) Benign salivary gland tumors 9) Low grade salivary adenocarcinoma 10) Non-Vascular Leiomyoma (from blood vessels) 11) Rhabdomyoma (from Buccinator muscle)

Biopsy & Histopathological examination

Biopsy & Histopathological examination

Hyperplastic epithelium
Pseudo Epithelomatous Hyperplasia

Granular cells

Definitive Diagnosis

Granular cell tumor

Case Report 2
17 years old female is referred for evaluation of an asymptomatic mass in the left posterior buccal mucosa of 2 months duration The lesion seems localized, pink in color, fibrotic & firm to palpation

1- What are the differential diagnoses?!

Differential Diagnoses
Think of hyperplastic & benign neoplastic lesions causing Localized Soft Tissue Enlargements with a normal mucosa: 1) Fibroepithelial polyp irritation fibroma 2) Giant cell fibroma 3) Fibro-lipoma 4) Neurofibroma 5) Schwannoma 6) Mucosal neuroma 7) Granular cell tumor 8) Benign salivary gland tumors 9) Low grade salivary adenocarcinoma 10) Non-vascular Leiomyoma (from blood vessels) 11) Rhabdomyoma (from Buccinator muscle)

Biopsy & Histopathological examination

Hypocellular fibrous tissue

Definitive Diagnosis

Fibroepithelial polyp

Management

Excisional biopsy

Case Report 3
26 years old female is referred for evaluation of a diffuse, compressible, non-tender, purple surface lesion present on the left soft palate Patient stated it has been present for the last 10 years and didnt significantly increase in size

1- What are the differential diagnoses?!

Differential Diagnoses
Think of benign surface intravascular lesions: 1- Hemangioma 2- Varix or venous lake 3- Arteriovenous malformation 4- Vascular Leiomyoma EXCLUDE: - Pyogenic granuloma - Kaposis sarcoma

Biopsy & Histopathological examination

Definitive Diagnosis

Hemangioma

Management

No treatment

Case Report 4
18 years old female is referred for evaluation of a non-tender darkreddish gingival swelling recurring for the 3rd time

1- What are the differential diagnoses?!

Differential Diagnoses
Think of benign vascular lesions causing Localized Soft Tissue Enlargements with a dark-reddish mucosa: 1- Pyogenic granuloma 2- Peripheral giant cell granuloma 3- Central giant cell granuloma 4- Brown Tumor of hyperparathyroidism 5- Vascular Leiomyoma

Biopsy & Histopathological examination

With no radiographic abnormalities or abnormal chemical tests findings

Definitive Diagnosis

Peripheral giant cell granuloma

Case report 5
A 35 years-old male patient was referred to the dental clinic due to a nodule on the palate with more than 15 years of evolution In general physical examination we noticed the presence of papules and caf au lait (coffee with milk) pigmentation in many parts of the body In intra-oral examination we found a swelling in the hard palate, resilient on palpation with an intact surface epithelium, asymptomatic and measuring three centimeters in diameter The patient had poor hygiene condition, with many caries lesions, dental calculi and severe periodontal disease.

Panoramic radiography showed the bad oral condition described and an enlarged mandibular canal, mandibular foramen and mental foramen

What is the most likely diagnosis?!

Clinical Pictures

Radiographic Picture

Biopsy & Histopathological examination

Plexiform Neurofibroma

Definitive Diagnosis

Neurofibromatosis Type I syndrome

Case report 5
Adult male requests treatment of a soft tissue enlargement of the gingiva. The lesion has been present since two weeks and is progressively increasing in size. It is not painful and bleeds easily. The patient states that brushing his teeth or eating rough food makes the lesion bleed Medical History: The patient states that he smokes cigarettes, half a pack per day Dental History: No abnormalities are identified. Clinical Findings: The lesion is a well-circumscribed, 0.5 x 1.0 cm, erythematous soft tissue enlargement on the gingiva lingual to the maxillary central incisors. The lesion bleeds easily during gentle probing. The lesion is compressible and non-tender to palpation. It is fixed to the surface mucosa and underlying structures. The surface is smooth, but there is an area of ulceration covered by a fibrin clot. The lesion blanches upon pressure. Lymphadenopathy is not present Radiographs: reveal no associated bony abnormalities

What are the differential diagnoses?!

Clinical Picture

Differential Diagnoses
Think of benign & malignant vascular lesions causing Soft Tissue Enlargements with a dark-reddish mucosa: 1- Pyogenic granuloma 2- Peripheral giant cell granuloma 3- Central giant cell granuloma 4- Brown Tumor of hyperparathyroidism 5- Vascular Leiomyoma 6- Malignant vascular tumors

Lesions to exclude
Hyperplastic lesions that dont blanch on pressure e.g. fibrous epulis peripheral ossifying fibroma, irritation fibroma,giant cell fibroma Peripheral odontogenic fibroma (doesnt blanch) Hemangioma & Lymphangioma (because they are congenital or appear in childhood) Tumors of nerves (Schwannoma, Neurofibroma, mucosal neuroma, and granular cell tumor) as they dont blanch on pressure Tumors of adipose tissue: Angio-lipoma (extremely rare on the gingiva, mostly it doesnt blanch on pressure)

Tumors of muscles : - Rhabdomyoma (no skeletal muscles in the gingiva) - Non-vascular Leiomyoma
Salivary gland tumors (because salivary glands are not present on the gingiva and do not blanch)

Biopsy & Histopathological examination

Vascular spaces

Definitive Diagnosis

Pyogenic granuloma

Case report 6
Patient: Adult woman Chief Complaint: patient requests treatment of a soft tissue enlargement of the gingiva. The patient has been aware of the enlargement for five months, during which time it has slowly increased in size. It does not bleed and is non-painful except when traumatized while eating. The lesion has never been treated. Medical History: The patient states that she smokes occasionally. Dental History: The last time the patient received dental treatment was eight or nine months ago. Clinical Findings: The lesion is a well-circumscribed, 0.8 x 1.0 cm soft tissue enlargement labial and distal to tooth # 27. It is firm, non-tender, has a smooth surface, and is fixed to surface mucosa and underlying structures. The lesion has a normal mucosal color and does not blanch. All teeth in the area test vital to electrical and thermal stimulation. The lesion does not bleed during examination. There are no palpable lymph nodes Radiographs reveal no bony abnormalities in the area

What are the differential diagnoses?!

Clinical Picture

Differential Diagnoses
Think of hyperplastic & benign neoplastic lesions causing Localized Soft Tissue Enlargements with a normal mucosa:
1- Fibrous epulis peripheral ossifying fibroma 2- Irritation fibroma 3- Giant cell fibroma 4- Peripheral odontogenic fibroma 5- Neurofibroma 6- Schwannoma 7- Mucosal Neuroma 8- Granular cell Tumor 9- Non-Vascular Leiomyoma

Lesions to exclude
Hyperplastic lesions that blanch on pressure e.g. Pyogenic granuloma & peripheral giant cell granuloma Tumors of adipose tissue: Fibro-lipoma (extremely rare on the gingiva, mostly it doesnt blanch on pressure) Tumors of muscles : - Rhabdomyoma (no skeletal muscles in the gingiva) - Vascular Leiomyoma Salivary gland tumors (because salivary glands are not present on the gingiva and do not blanch)

Biopsy & Histopathological examination

Bone formation

Richly cellular fibrous stroma

Definitive Diagnosis

Fibrous epulis peripheral ossifying fibroma