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مورد تشخیصی - ضایعه برجسته دهانی

مورد تشخیصی - ضایعه برجسته دهانی - 3.0 out of 5 based on 2 votes
2 Votes3.05 

استاد: خانم دکتر بهاروند

جایزه: پنجاه هزار تومان

History of the present illness
This 14-year-old white male was referred to the oral surgeon for surgical exposure of impacted teeth #s 6 and 11 and placement of brackets with gold chains to facilitate orthodontic eruption. The maxillary incisor teeth showed severe resorption. Surgical exposure with bracket placement was accomplished 3 months later. After 2 months, the bracket with gold chain on tooth #6 had come off and the patient was referred back for replacement (Figure 1). The alveolar mucosa overlying tooth #6 was swollen and inflamed; this tissue was debrided and a new bracket with chain was placed. The patient was referred again after 1 year to evaluate the gingival swelling between teeth #s 5 & 6 (Figure 2). The area was asymptomatic and the lesion was described to be 7 x 10 mm in size.

aban1

Figure 1 A small pinkish-red swelling is identified in the area of unerupted tooth #6.

 

aban2

Figure 2 One year after the small swelling in figure 1 was debrided. This is the recurrent lesion. The swelling on the buccal gingiva between teeth #s 5 & 6.

 

Past Medical History
The patient's past medical history is significant for hypersensitivity to sulfa drugs and penicillin. The patient is a non-smoker.

 

Clinical Findings
As described in the patient's present history, this lesion was present a year prior to the current lesion and was in the area of unerupted tooth #6 (Figure 1). It was debrided but it slowly recurred over a one-year period. The second lesion was an asymptomatic swelling (Figure 2) and was described as 7 x 10 mm in size.

 

Clinical challenge

What category of lesions does the swelling belong to

Mention 3 probable differential diagnoses based on clinical features of the lesion

What do you recommend for this patient

 

پاسخ استاد:

Peripheral oral exophitic lesions mainly consisting of inflammatory or reactive lesions.

 

A) Pyogenic granuloma
B) Peripheral Giant cell Granuloma
C) Peripheral Ossifying Fibroma

 

Excisional biopsy is mandatory to get a final diagnosis and treatment simultaneously.

 

نظر برتر: خانم فرناز رضایی پور

 

توضیحات تکمیلی درباره این مورد:

Treatment
Under local anesthesia, the lesion was excised sharply and the roots of teeth #s 5 and 6 were scaled to ensure complete removal of any local irritants. It was allowed to heal by secondary intention


Excisional Biopsy
Histologic examination reveals a hemisected piece of soft tissue composed of keratinized and ulcerated surface epithelium with an underlying granulation tissue mass with many giant cells (Figure 3). The surface also shows a large area of ulceration covered by fibrin and neutrophils. The underlying granulation tissue mass is loose and vascular and contains numerous giant cells of variable shapes and sizes (Figure 4). The giant cells are haphazardly arranged. The granulation tissue mass contains clusters of extravasated erythrocytes as well as clusters of hemosiderin pigment (Figure 5). This mass and the surrounding connective tissue are infiltrated by lymphocytes, plasma cells, and neutrophils.

 

aban11

Figure 3 Low power (x40) H & E stained histology shows a mass of vascular granulation tissue with many multinucleated giant cells and ulcerated surface epithelium.

 

aban12

Figure 4 Higher power (x100) H & E stained histology shows sheets of multinucleated giant cells suspended on a background of vascular granulation tissue.

 

aban13

Figure 5 High power (x200) H & E stained histology shows small clusters of hemosiderin pigment and clusters of extravasated erythrocytes in a background of granulation tissue and giant cells.

 


Peripheral Ossifying Fibroma

The second most common gingival swelling, especially in patients under the age of 20, is peripheral ossifying fibroma. This condition should therefore should be included on the differential diagnosis. The color of this swelling, however, is not supportive of this diagnosis since POFs tend to be pink in color unless extensively ulcerated. The histology is also not consistent with POF. Peripheral ossifying fibroma constitutes 10% of all reactive gingival swellings. It consists of a moderately cellular fibrous connective tissue mass with bony trabeculae and/or cementum-like hard tissue. It has been reported on the edentulous alveolar mucosa, albeit rarely. It originates from the periodontal ligament or the periosteum. This lesion is most common in young patients between 1 and 19 years of age and has a predilection for occurrence in females over males by a 3:2 ratio. It occurs exclusively on the gingiva, especially the anterior gingiva, with a slight predilection to the maxilla and rare presentation in primary teeth. It is usually sessile and exophytic and often ulcerated; it presents as well-demarcated sessile nodules, which are firm or hard depending on the amount of ossification and calcifications. Peripheral ossifying fibroma is usually pink but can be focally red if ulcerated. Histologically, peripheral ossifying fibroma is made up of a moderately cellular mass of fibrous connective tissue with calcifications ranging from cementum-like material to calcified bony trabeculae with viable osteocytes. The surface epithelium overlying the mass is usually ulcerated. Deep surgical excision to include the periodontal ligament is the preferred treatment, though laser removal has been used effectively. Deep surgery may lead to a gingival defect, which would require gingival grafting, especially if it is located on the anterior buccal gingiva. There is a 16-20% recurrence rate.

 

Pyogenic Granuloma
The most common gingival swelling, especially in patients under the age of 20, is pyogenic granuloma. For that reason, it should be high on the differential diagnosis list. The color of this lesion, the age of the patient, the association with orthodontic braces, and the location are all supportive of a clinical diagnosis of pyogenic granuloma. The histology, however, is not consistent with PG. Pyogenic granuloma constitutes 85% of all reactive gingival swellings. It presents as a profuse mass of vascular granulation tissue. It can be induced by local irritants such as excessive plaque, sharp fillings and dental calculus; it sometimes forms in an extraction socket in response to an irritant left in the socket. It can occur anywhere in the oral cavity and skin, especially the tongue, lips, fingers and nail beds. In the mouth, it occurs most commonly in the gingiva, especially the maxillary buccal and interproximal gingiva. Occasionally, it may surround the tooth. It is usually highly vascular, fast-growing, exophytic, lobular, sessile, and ulcerated or covered by pseudomembrane. The color changes from red to pink when it starts to heal. It occurs at any age and sex with a slight predilection for young females; it affects 1% of pregnant females. Pyogenic granuloma is usually painless except during eating, when bleeding and pain is described. Histologically, it presents as a mass of loose and vascular granulation tissue, usually with ulcerated or eroded surface epithelium and many inflammatory cells. A range of treatment modalities are available, including excision with removal of the local irritant, laser surgery, or intralesional injection with absolute alcohol, steroids or botulinum toxin. Scaling and polishing prior to surgical removal helps shrink the lesion. The prognosis is good, although recurrence is possible, especially during pregnancy.

 

Peripheral Giant Cell Granuloma
(The final diagnosis of this patient)
The third most common gingival swelling, especially in this age group, is peripheral giant cell granuloma (PGCG). The age of this patient, the location, and the color are all supportive of PGCG. So is the histology. Peripheral giant cell granuloma constitutes less than 5% of all reactive gingival swellings. It consists of a hyperplastic mass of vascular granulation tissue with many osteoclast-like multinucleated giant cells. It presents as a lobular, purplish-blue exophytic nodule exclusively on the gingiva, both edentulous and dentate, and usually anterior to the molars. It originates from either the periodontal ligament or the periosteum. It occurs across a wide age range, especially in children, young adults, and females (2:1 female to male ratio). It presents as either sessile or pedunculated and smooth surfaced or lobular; though usually painless, it can occasionally be ulcerated, painful and accompanied by bleeding. Like pyogenic granuloma, it is usually present either on the buccal or lingual gingiva or between teeth, but it can occasionally surround the teeth and act aggressively by displacing teeth much like a sarcoma. It can also resorb the underlying bone in a smooth and concave "saucer-like" manner. Complete excision including curettage of underlying bone is the preferred treatment. It has a good prognosis with a recurrence rate of approximately 10%.

 

 

 

دیدگاه‌ها

 
# Arash farzan 1391-08-04 19:32
Thanks to Prof. Baharvand for the great case, would you please also upload the radiographic images for the case?
 
 
# Admin 1391-08-05 13:30
آرش جان، متاسفانه تصویر رادیوگرافی بیمار در دسترس نیست. اما ضایعه اثری روی استخوان نداشته است.
 
 
# احمد محمدی 1391-08-20 16:39
ضایعات برجسته
پیوژنیک گرانولوما
PGCG
هماتوما

درمان:برداشت کامل ضایعه از طریق جراحی
 
 
# فرناز رضایی پور 1391-08-27 16:27
این یک ضایعه reactive است.
تشخیص افتراقی:
فیبروم تحریکی
پیوژنیک گرانولوما
PGCG
برای درمان باید تحریک حذف شود و در صورت نیاز ضایعه با جراحی برداشته شود.
 
 
# فرناز رضایی پور 1391-08-29 18:20
با تشکر از سوال جالب، این ضایعه در گروه ضایعات اگزوفیتیک قرار می گیرد. و تشخیص افتراقی آن می تواند ضایعات زیر باشد:
1- پیوژنیک گرانولوما
2- ژانت سل گرانولومای محیطی
3- فیبروم

پیشنهاد ما به بیمار می تواند بیوپسی اکسیژنال ضایعه برای تشخیص قطعی و درمان ضایعه باشد.
 
 
# zahra amini 1391-08-30 17:37
This is a reactive lesion
differential diagnosis:
irritation fibroma
periferal ossifying fibroma
traumatic neuroma

excitional biopsy
 
 
# Admin 1391-08-30 19:15
تشکر می کنیم از خانم دکتر بهاروند به خاطر این مورد جالب و پاسخ کاملی که در اختیار ما قرار دادند.
 

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