A guide to common oral lesions part 3

Peripheral giant cell granuloma
DESCRIPTION: The peripheral giant cell granuloma appears as a nodular soft tissue mass arising from
gingival or alveolar mucosa. The color may be red but is often a blue-grey. Most are approximately a
centimeter in size, although they may be larger. The peak age is around 40 years but they occur in all
ages with a female prevalence. There is almost equal distribution between maxillary and mandibular
gingival. The term “peripheral” is included in the name to separate this lesion from a histologically similar
lesion which occurs inside the jaws. Jaw lesions are referred to as the “central” giant cell granuloma. The
peripheral granuloma may cause pressure resorption of underlying alveolar bone and less commonly
resorption of the adjacent tooth. They are not painful. Histologically this lesion consists of fibroblasts and
multinucleated giant cells.
ETIOLOGY: Unknown
TREATMENT: Conservative excision. The recurrence rate is approximately 10%.
PROGNOSIS: Good.
DIFFERENTIAL DIAGNOSIS: Pyogenic granuloma and peripheral ossifying fibroma.

Drug-induced gingival hyperplasia (Dilantin hyperplasia)
DESCRIPTION: Drug-induced gingival enlargement was first described almost 50 years ago with the use
of the anticonvulsant Dilantin (phenytoin). Other drugs especially calcium channel blockers such as
Procardia (nifedipine) and cyclosporine have also been implicated. Dilantin causes gingival enlargement
in almost 50% of those that regularly take it, while only about 25% of patient talking cyclosporine and
calcium channel blockers have enlargement. Poor oral hygiene and especially dental plaque accentuate
the enlargement. Superimposed gingivitis also causes boggy and red tissues that mask the true nature of
the enlargement.
ETIOLOGY: Drug induced. As stated above, the condition may become aggravated by superimposed
gingivitis and periodontitis. There is evidence that associated drugs may impair the secretion of
collagenase by gingival fibroblasts permitting the accumulation of excessive gingival collagen.
TREATMENT: The inflammatory component may be reduced by good dental hygiene. The fibrous
overgrowth requires surgical removal. Discontinuance of associated drugs may result in gradual
regression of the overgrowth within one year.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: Hereditary gingival fibromatosis, hyperplastic gingivitis from dental neglect,
and leukemic infiltrates of the gingiva.

Traumatic ulcer
DESCRIPTION: An ulcer by definition is a localized area on the skin or mucosa in which the surface
epithelium has been destroyed. The shape and size of traumatic ulcers are so variable as to defy a simple
description. They are usually painful and of short duration.
ETIOLOGY: Common causes of traumatic ulcers include: denture irritation, biting injuries, burns and
friction irritation from sharp or fractured teeth.
TREATMENT: The treatment is to remove the cause if it is known. Relief of pain can be achieved with
topical agents such as Orabase-B® with Benzocaine, Zilactin® or Soothe-N-Seal.
PROGNOSIS: The ulcer should heal if the cause is removed. An ulcer which does not heal within two to
three weeks should be biopsied to rule out malignancy.
DIFFERENTIAL DIAGNOSIS: Traumatic ulcers must be differentiated from squamous carcinoma,
bacterial, fungal and viral diseases, and other oral mucosal diseases.

Geographic tongue
(benign migratory glossitis, erythema migrans)
DESCRIPTION: The lesions of this disease on the tongue are so characteristic that recognition should be
instantaneous. The dorsal tongue displays map-like areas that are smooth and red with a whitish-yellow
perimeter. The disease may involve any oral mucosal surface in which case the name erythema migrans
is more appropriate. Atrophy of the filliform papillae is usually a finding on the dorsal tongue.
All ages are affected. We have seen it in a child six months old. The number of lesions varies from one to
many. Old lesions heal and new ones form, waxing and waning in rhythm with most due to unknown
forces. Some complain of a burning sensation.
ETIOLOGY: Unknown although a hypersensitivity reaction to unknown antigens has been suspected.
TREATMENT: None is usually required. In those with symptoms, topical steroid ointment or gel may be
beneficial. Secondary fungal colonization should also be suspected in symptomatic lesions.
PROGNOSIS: This is a chronic disease lasting months to years with periods of remission and
exacerbation.
DIFFERENTIAL DIAGNOSIS: Typical lesions are diagnostic. Variable clinical presentation may suggest
lichen planus or candidiasis.

Condensing osteitis
DESCRIPTION: Condensing osteitis is a reaction to infection. It differs from other periapical inflammatory
diseases in that there is a bone production rather than bone destruction. The result is a radiopaque lesion.
This sclerotic reaction is apparently brought about by good patient resistance coupled with a low degree
of virulence of the offending bacteria. It is more commonly seen in the young and seems to show special
predilection for the periapical region of lower molars. The associated tooth is carious or contains a large
restoration. We are reluctant to state the reaction of the tooth to pulp testing because of lack of sufficient
personal experience and paucity of published information. Theoretically, the results should be abnormal.
Current level of knowledge suggests that the pulp is irreversibly inflamed. Uncommonly, condensing
osteitis occurs as a reaction to periodontal infection rather than dental infection.
ETIOLOGY: Infection of periapical tissues by organisms of low virulence.
TREATMENT: Vitality of the overlying tooth should be investigated. If the pulp is inflamed or necrotic,
endodontics or extraction are the options.
PROGNOSIS: In those cases in which the offending tooth is extracted, the area of condensing osteitis may
remain in the jaws indefinitely, and is termed osteosclerosis or bone scar.
DIFFERENTIAL DIAGNOSIS: Idiopathic osteosclerosis and cementoblastoma. An abnormal result with
pulp testing strongly suggests condensing osteitis and tends to rule out osteosclerosis and
cementoblastoma.

Peripheral ossifying fibroma
DESCRIPTION: This lesion appears as a mass arising from the gingiva adjacent to teeth or between
teeth. It favors teenagers and young adults. Those arising between teeth may separate the teeth and
produce pressure resorption of the interdental bone. It’s not unusual to see a “saddle” lesion straddling
the ridge with a labial and lingual lobe. Color is normal or slightly red. Histologically the bulk of this
lesion is moderately cellular fibrous connective tissue frequently containing foci of bone, cementum, or
dystrophic calcification. When inflammation is present, plasma cells frequently predominate.
ETIOLOGY: Unknown
Treatment: Excision. The recurrence rate is about 15%. Extraction of the adjacent teeth is seldom
necessary.
Prognosis: Good
Differential Diagnosis: Peripheral fibroma bears a great resemblance to pyogenic granuloma and
peripheral giant cell granuloma. Histologic examination is necessary to distinguish between them.