Fibrous Lesions
Fibroma (“Bite” or “Irritation” Fibroma, Fibroepithelial or Fibrovascular Polyp), and Giant Cell Fibroma
Clinical Findings
- •
Fibroma: This consists of a dome-shaped nodule or papule that may be white/keratotic, mucosa-colored, or ulcerated; it is located in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower lip mucosa) or on the gingiva where plaque accumulates ( Fig. 5.1A–D ).
FIG 5.1 (A) Fibroma of right buccal mucosa. (B) Cut surfaces of fibroma, dense and white. (C) Fibroma of the lower lip mucosa. (D) Sclerotic fibroma of the palate. (E) Giant cell fibroma on the palatal mucosa.(Courtesy Dr. Carl Allen, The Ohio State University, Columbus, Ohio.) - •
Giant cell fibroma: This often has a papillary surface and 90% are located on the gingiva (50% of cases), tongue, and palatal mucosa; a similar histopathologic condition is referred to as the retrocuspid papilla, which occurs on the lingual attached gingiva of the mandibular cuspids, usually bilaterally ( Fig. 5.1E ).
- •
Multiple fibromas of the gingiva, buccal mucosa, and tongue are often seen in tuberous sclerosis complex (associated with a mutation in TSC1 or TSC2 ), while sclerotic fibromas are seen in Cowden syndrome (part of PTEN hamartoma tumor syndrome).
Etiopathogenesis and Histopathologic Features
Conventional fibroma is a reactive fibrosis/scar (similar to a hypertrophic scar on the skin) from bite trauma and is not a true neoplasm.
- •
Fibroma: the nodule consists of a proliferation of fibrocollagenous tissue associated with variable vascularity, neurovascular hyperplasia, parakeratosis or hyperkeratosis, ulceration, inflammation, and epithelial hyperplasia or atrophy ( Figs. 5.2 to 5.4 ); myxoid/mucinous change may be present ( Fig. 5.5 ).
Fig 5.2 (A) Fibroma with frictional keratosis. (B) Dense collagenous tissue with dilated capillaries.
Fig 5.3 (A) Fibroma with frictional parakeratosis. (B) Fibroma with frictional parakeratotic chevrons.
Fig 5.4 (A) Fibroma with frictional hyperkeratosis. (B) Parakeratosis and bacterial colonies typical for frictional/factitial keratosis.
Fig 5.5 (A) Fibroma with focal myxoid/mucinous change. (B) Areas of dense collagen interspersed with myxoid/mucinous areas with mild chronic inflammation. - •
Giant cell fibroma: nodules often have a papillary or bosselated surface with acanthosis forming spiky, saw-tooth shaped rete ridges; there are many giant, stellate, bi- and multinucleate fibroblasts that sometimes show cytoplasmic positivity for smooth muscle actin, suggesting differentiation toward myofibroblasts; some of these cells have been shown to be factor XIIIa+; dense collagen and mast cells are often present similar to fibrous papule of the nose ( Figs. 5.6 and 5.7 ).
Fig 5.6 Giant cell fibroma. (A) Fibrous nodule with spiky rete ridges and dense collagen. (B) Stellate and multinucleate fibroblasts. (C) Nodule with bosselated surface and tapered interlacing rete ridges. (D) Stellate and multinucleate fibroblasts.
Fig 5.7 Giant cell fibroma. (A) Fibrous nodule with papillary surface. (B) Giant and binucleate fibroblast-like cells and dense collagen. - •
Solitary sclerotic fibroma (storiform collagenoma): the nodule contains hyalinized bands of dense collagen with a storiform pattern, usually demarcated from the surrounding soft tissue; there are stellate and fusiform fibroblasts, and clusters of stellate mononuclear cells appearing as multinucleate cells; clefts between collagen fibers are a distinctive feature; a giant cell version is recognized that contains bizarre, true multinucleate giant cells ( Fig. 5.8 ); lesions are positive for CD34, CD99, and occasionally factor XIIIa; multiple sclerotic fibromas are associated with Cowden syndrome.
Fig 5.8 Sclerotic fibroma. (A) Well-demarcated nodule of dense, hyalinized collagen. (B) Stellate and fusiform fibroblasts with tissue clefts. - •
Fibromas of the anterior hard palatal mucosa often contain cartilage and branches of the nasopalatine neurovascular bundle ( Fig. 5.9 ).
Fig 5.9 Fibroma of anterior palatal mucosa. (A) Nodule containing hyaline cartilage and neurovascular bundles. (B) Mature hyaline cartilage.
Differential Diagnosis
- •
Desmoplastic fibroblastoma (collagenous fibroma) contains spindled and stellate fibroblasts but in an edematous to fibromyxoid stroma, and are likely true neoplasms because gene rearrangements have been identified.
Management and Prognosis
- •
Excision is curative although continued irritation and trauma may lead to recurrence.
References
Fibroma (“Bite” or “Irritation” Fibroma, Fibroepithelial or Fibrovascular Polyp), and Giant Cell Fibroma
Clinical Findings
- •
Fibroma: This consists of a dome-shaped nodule or papule that may be white/keratotic, mucosa-colored, or ulcerated; it is located in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower lip mucosa) or on the gingiva where plaque accumulates ( Fig. 5.1A–D ).
FIG 5.1 (A) Fibroma of right buccal mucosa. (B) Cut surfaces of fibroma, dense and white. (C) Fibroma of the lower lip mucosa. (D) Sclerotic fibroma of the palate. (E) Giant cell fibroma on the palatal mucosa.(Courtesy Dr. Carl Allen, The Ohio State University, Columbus, Ohio.) - •
Giant cell fibroma: This often has a papillary surface and 90% are located on the gingiva (50% of cases), tongue, and palatal mucosa; a similar histopathologic condition is referred to as the retrocuspid papilla, which occurs on the lingual attached gingiva of the mandibular cuspids, usually bilaterally ( Fig. 5.1E ).
- •
Multiple fibromas of the gingiva, buccal mucosa, and tongue are often seen in tuberous sclerosis complex (associated with a mutation in TSC1 or TSC2 ), while sclerotic fibromas are seen in Cowden syndrome (part of PTEN hamartoma tumor syndrome).
Etiopathogenesis and Histopathologic Features
Conventional fibroma is a reactive fibrosis/scar (similar to a hypertrophic scar on the skin) from bite trauma and is not a true neoplasm.
- •
Fibroma: the nodule consists of a proliferation of fibrocollagenous tissue associated with variable vascularity, neurovascular hyperplasia, parakeratosis or hyperkeratosis, ulceration, inflammation, and epithelial hyperplasia or atrophy ( Figs. 5.2 to 5.4 ); myxoid/mucinous change may be present ( Fig. 5.5 ).
Fig 5.2 (A) Fibroma with frictional keratosis. (B) Dense collagenous tissue with dilated capillaries.
Fig 5.3 (A) Fibroma with frictional parakeratosis. (B) Fibroma with frictional parakeratotic chevrons.
Fig 5.4 (A) Fibroma with frictional hyperkeratosis. (B) Parakeratosis and bacterial colonies typical for frictional/factitial keratosis.
Fig 5.5 (A) Fibroma with focal myxoid/mucinous change. (B) Areas of dense collagen interspersed with myxoid/mucinous areas with mild chronic inflammation. - •
Giant cell fibroma: nodules often have a papillary or bosselated surface with acanthosis forming spiky, saw-tooth shaped rete ridges; there are many giant, stellate, bi- and multinucleate fibroblasts that sometimes show cytoplasmic positivity for smooth muscle actin, suggesting differentiation toward myofibroblasts; some of these cells have been shown to be factor XIIIa+; dense collagen and mast cells are often present similar to fibrous papule of the nose ( Figs. 5.6 and 5.7 ).
Fig 5.6 Giant cell fibroma. (A) Fibrous nodule with spiky rete ridges and dense collagen. (B) Stellate and multinucleate fibroblasts. (C) Nodule with bosselated surface and tapered interlacing rete ridges. (D) Stellate and multinucleate fibroblasts.
Fig 5.7 Giant cell fibroma. (A) Fibrous nodule with papillary surface. (B) Giant and binucleate fibroblast-like cells and dense collagen. - •
Solitary sclerotic fibroma (storiform collagenoma): the nodule contains hyalinized bands of dense collagen with a storiform pattern, usually demarcated from the surrounding soft tissue; there are stellate and fusiform fibroblasts, and clusters of stellate mononuclear cells appearing as multinucleate cells; clefts between collagen fibers are a distinctive feature; a giant cell version is recognized that contains bizarre, true multinucleate giant cells ( Fig. 5.8 ); lesions are positive for CD34, CD99, and occasionally factor XIIIa; multiple sclerotic fibromas are associated with Cowden syndrome.
Fig 5.8 Sclerotic fibroma. (A) Well-demarcated nodule of dense, hyalinized collagen. (B) Stellate and fusiform fibroblasts with tissue clefts. - •
Fibromas of the anterior hard palatal mucosa often contain cartilage and branches of the nasopalatine neurovascular bundle ( Fig. 5.9 ).
Fig 5.9 Fibroma of anterior palatal mucosa. (A) Nodule containing hyaline cartilage and neurovascular bundles. (B) Mature hyaline cartilage.
Differential Diagnosis
- •
Desmoplastic fibroblastoma (collagenous fibroma) contains spindled and stellate fibroblasts but in an edematous to fibromyxoid stroma, and are likely true neoplasms because gene rearrangements have been identified.
Management and Prognosis
- •
Excision is curative although continued irritation and trauma may lead to recurrence.
Clinical Findings
- •
Fibroma: This consists of a dome-shaped nodule or papule that may be white/keratotic, mucosa-colored, or ulcerated; it is located in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower lip mucosa) or on the gingiva where plaque accumulates ( Fig. 5.1A–D ).
FIG 5.1 (A) Fibroma of right buccal mucosa. (B) Cut surfaces of fibroma, dense and white. (C) Fibroma of the lower lip mucosa. (D) Sclerotic fibroma of the palate. (E) Giant cell fibroma on the palatal mucosa.(Courtesy Dr. Carl Allen, The Ohio State University, Columbus, Ohio.) - •
Giant cell fibroma: This often has a papillary surface and 90% are located on the gingiva (50% of cases), tongue, and palatal mucosa; a similar histopathologic condition is referred to as the retrocuspid papilla, which occurs on the lingual attached gingiva of the mandibular cuspids, usually bilaterally ( Fig. 5.1E ).
- •
Multiple fibromas of the gingiva, buccal mucosa, and tongue are often seen in tuberous sclerosis complex (associated with a mutation in TSC1 or TSC2 ), while sclerotic fibromas are seen in Cowden syndrome (part of PTEN hamartoma tumor syndrome).
Etiopathogenesis and Histopathologic Features
Conventional fibroma is a reactive fibrosis/scar (similar to a hypertrophic scar on the skin) from bite trauma and is not a true neoplasm.
- •
Fibroma: the nodule consists of a proliferation of fibrocollagenous tissue associated with variable vascularity, neurovascular hyperplasia, parakeratosis or hyperkeratosis, ulceration, inflammation, and epithelial hyperplasia or atrophy ( Figs. 5.2 to 5.4 ); myxoid/mucinous change may be present ( Fig. 5.5 ).
Fig 5.2 (A) Fibroma with frictional keratosis. (B) Dense collagenous tissue with dilated capillaries.
Fig 5.3 (A) Fibroma with frictional parakeratosis. (B) Fibroma with frictional parakeratotic chevrons.
Fig 5.4 (A) Fibroma with frictional hyperkeratosis. (B) Parakeratosis and bacterial colonies typical for frictional/factitial keratosis.
Fig 5.5 (A) Fibroma with focal myxoid/mucinous change. (B) Areas of dense collagen interspersed with myxoid/mucinous areas with mild chronic inflammation. - •
Giant cell fibroma: nodules often have a papillary or bosselated surface with acanthosis forming spiky, saw-tooth shaped rete ridges; there are many giant, stellate, bi- and multinucleate fibroblasts that sometimes show cytoplasmic positivity for smooth muscle actin, suggesting differentiation toward myofibroblasts; some of these cells have been shown to be factor XIIIa+; dense collagen and mast cells are often present similar to fibrous papule of the nose ( Figs. 5.6 and 5.7 ).
Fig 5.6 Giant cell fibroma. (A) Fibrous nodule with spiky rete ridges and dense collagen. (B) Stellate and multinucleate fibroblasts. (C) Nodule with bosselated surface and tapered interlacing rete ridges. (D) Stellate and multinucleate fibroblasts.
Fig 5.7 Giant cell fibroma. (A) Fibrous nodule with papillary surface. (B) Giant and binucleate fibroblast-like cells and dense collagen. - •
Solitary sclerotic fibroma (storiform collagenoma): the nodule contains hyalinized bands of dense collagen with a storiform pattern, usually demarcated from the surrounding soft tissue; there are stellate and fusiform fibroblasts, and clusters of stellate mononuclear cells appearing as multinucleate cells; clefts between collagen fibers are a distinctive feature; a giant cell version is recognized that contains bizarre, true multinucleate giant cells ( Fig. 5.8 ); lesions are positive for CD34, CD99, and occasionally factor XIIIa; multiple sclerotic fibromas are associated with Cowden syndrome.
Fig 5.8 Sclerotic fibroma. (A) Well-demarcated nodule of dense, hyalinized collagen. (B) Stellate and fusiform fibroblasts with tissue clefts. - •
Fibromas of the anterior hard palatal mucosa often contain cartilage and branches of the nasopalatine neurovascular bundle ( Fig. 5.9 ).
Fig 5.9 Fibroma of anterior palatal mucosa. (A) Nodule containing hyaline cartilage and neurovascular bundles. (B) Mature hyaline cartilage.
References
Gingival Masses
Gingival nodules may represent one of the following:
- •
Reactive/inflammatory gingival nodules, solitary or diffuse; these are by far the most common
- •
Peripheral (extraosseous) odontogenic cysts and tumors (see Chapters 14 and 15 )
- •
Soft tissue tumors (such as nerve sheath or smooth muscle tumors discussed in Chapter 6 )
- •
Extension of intrabony lesions into the gingiva
- •
Metastatic tumors to the gingiva
Reactive/Inflammatory Gingival Nodules
Clinical Findings
- •
Peripheral ossifying fibromas and pyogenic granulomas tend to occur in young patients in the second to fourth decades, but all occur as nodular masses on the marginal gingiva adjacent to teeth or dental implants, often in the maxillary anterior region; fibromas are pink, while pyogenic granulomas and peripheral giant cell granulomas are dusky purple; they may be painful if ulcerated, and if vascular will bleed; the underlying bone may show “saucerization” (especially with peripheral giant cell granuloma) ( Fig. 5.10 ).
Fig 5.10 (A) Gingival fibroma. (B) Peripheral ossifying fibroma. (C) Pyogenic granuloma with ulceration. (D) Pyogenic granuloma of the mandibular ridge at an extraction site. (E) Peripheral giant cell granuloma. (F) Peripheral giant cell granuloma causing saucerization of bone ( arrow ).( A , Courtesy Dr. Greg Sarka, private practice, Waterville, Me; B , Courtesy Dr. David Feinerman, private practice, Boynton Beach, Fla; C , Courtesy Dr. Jeffrey Freedman, private practice, Lexington, Mass; E , Courtesy Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.) - •
Peripheral giant cell granuloma is the least common and tends to occur in older adults > 50 years.
- •
Parulis (“gum boil” or sinus tract) occurs on the attached gingiva and has a punctum and an underlying tract that leads to the infected tooth.
- •
Up to 5% of pregnant women develop gingival pyogenic granulomas (granuloma gravidarum or oral pregnancy tumor).
- •
Multiple gingival fibromas may be seen in tuberous sclerosis complex and Cowden syndrome (usually sclerotic fibromas).
Etiopathogenesis and Histopathologic Features
Multipotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or the presence of implants) differentiate toward endothelial cells, fibroblasts, osteoblasts, or osteoclast-like cells, giving rise to four distinct histologic entities or combinations thereof. Estrogen and progesterone causes overexpression of vascular endothelial growth factor in granuloma gravidarum. See Table 5.1 and Figs. 5.11–5.19 for histopathologic features.
- •
A parulis (sinus tract) consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils ( Figs. 5.20 and 5.21 ).
Fig 5.20 Parulis (sinus tract) of the gingiva with gutta-percha tracer.
Fig 5.21 Parulis. (A) Edematous granulation tissue with linear tract communicating with the surface. (B) Edematous granulation tissue with linear spaces/tracts. (C) Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as a mucocele. (D) Tract filled with and lined by neutrophils ( arrows ).
| Diagnosis | Histopathology |
|---|---|
| Fibroma (fibrovascular hyperplasia/polyp) Giant cell fibroma |
|
| Pyogenic granuloma (see also Chapter 6 ) |
|
| Peripheral ossifying fibroma (fibroma with osseous metaplasia) |
|
| Peripheral giant cell granuloma |
|
Differential Diagnosis
- •
A parulis may be mistaken for a mucocele (which does not occur on the attached gingiva) if the edematous tissue is mistaken for extravasated mucin.
- •
Infantile hemangioma may look similar to pyogenic granuloma but it is a developmental malformation and is almost always positive for glucose transporter-1 (GLUT-1) ( Fig. 5.22 ).
Fig 5.22 Infantile hemangioma of buccal mucosa. (A) Proliferation of endothelial cells that surround minor salivary glands. (B) Cellular proliferation of endothelial cells and capillaries. (C) Occasional mitoses noted. (D) Cytoplasmic positivity for glucose transporter-1 (GLUT-1).( A , Courtesy Dr. Harry Kozakewich, Harvard Medical School, Boston, Mass.) - •
Peripheral odontogenic fibroma produces dentinoid rather than cementum, and epithelial islands are always present distinguishing this from peripheral ossifying fibroma (see later).
- •
Aggressive central (intraosseous) giant cell granuloma may erode through bone and radiographs differentiates it from a peripheral (extraosseous) lesions (see Chapter 17 ).
Management and Prognosis
- •
Excision is the treatment of choice, although if underlying irritating factors such as dental plaque are not removed the recurrence rate is 15% to 20%; anecdotal data suggests that pyogenic granulomas in teenagers may exhibit multiple recurrences.
- •
Granuloma gravidarum may resolve postpartum but may also sclerose and become a gingival fibroma.
References
Reactive/Inflammatory Gingival Nodules
Clinical Findings
- •
Peripheral ossifying fibromas and pyogenic granulomas tend to occur in young patients in the second to fourth decades, but all occur as nodular masses on the marginal gingiva adjacent to teeth or dental implants, often in the maxillary anterior region; fibromas are pink, while pyogenic granulomas and peripheral giant cell granulomas are dusky purple; they may be painful if ulcerated, and if vascular will bleed; the underlying bone may show “saucerization” (especially with peripheral giant cell granuloma) ( Fig. 5.10 ).
Fig 5.10 (A) Gingival fibroma. (B) Peripheral ossifying fibroma. (C) Pyogenic granuloma with ulceration. (D) Pyogenic granuloma of the mandibular ridge at an extraction site. (E) Peripheral giant cell granuloma. (F) Peripheral giant cell granuloma causing saucerization of bone ( arrow ).( A , Courtesy Dr. Greg Sarka, private practice, Waterville, Me; B , Courtesy Dr. David Feinerman, private practice, Boynton Beach, Fla; C , Courtesy Dr. Jeffrey Freedman, private practice, Lexington, Mass; E , Courtesy Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.) - •
Peripheral giant cell granuloma is the least common and tends to occur in older adults > 50 years.
- •
Parulis (“gum boil” or sinus tract) occurs on the attached gingiva and has a punctum and an underlying tract that leads to the infected tooth.
- •
Up to 5% of pregnant women develop gingival pyogenic granulomas (granuloma gravidarum or oral pregnancy tumor).
- •
Multiple gingival fibromas may be seen in tuberous sclerosis complex and Cowden syndrome (usually sclerotic fibromas).
Etiopathogenesis and Histopathologic Features
Multipotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or the presence of implants) differentiate toward endothelial cells, fibroblasts, osteoblasts, or osteoclast-like cells, giving rise to four distinct histologic entities or combinations thereof. Estrogen and progesterone causes overexpression of vascular endothelial growth factor in granuloma gravidarum. See Table 5.1 and Figs. 5.11–5.19 for histopathologic features.
- •
A parulis (sinus tract) consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils ( Figs. 5.20 and 5.21 ).
Fig 5.20 Parulis (sinus tract) of the gingiva with gutta-percha tracer.
Fig 5.21 Parulis. (A) Edematous granulation tissue with linear tract communicating with the surface. (B) Edematous granulation tissue with linear spaces/tracts. (C) Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as a mucocele. (D) Tract filled with and lined by neutrophils ( arrows ).
| Diagnosis | Histopathology |
|---|---|
| Fibroma (fibrovascular hyperplasia/polyp) Giant cell fibroma |
|
| Pyogenic granuloma (see also Chapter 6 ) |
|
| Peripheral ossifying fibroma (fibroma with osseous metaplasia) |
|
| Peripheral giant cell granuloma |
|
Differential Diagnosis
- •
A parulis may be mistaken for a mucocele (which does not occur on the attached gingiva) if the edematous tissue is mistaken for extravasated mucin.
- •
Infantile hemangioma may look similar to pyogenic granuloma but it is a developmental malformation and is almost always positive for glucose transporter-1 (GLUT-1) ( Fig. 5.22 ).
Fig 5.22 Infantile hemangioma of buccal mucosa. (A) Proliferation of endothelial cells that surround minor salivary glands. (B) Cellular proliferation of endothelial cells and capillaries. (C) Occasional mitoses noted. (D) Cytoplasmic positivity for glucose transporter-1 (GLUT-1).( A , Courtesy Dr. Harry Kozakewich, Harvard Medical School, Boston, Mass.) - •
Peripheral odontogenic fibroma produces dentinoid rather than cementum, and epithelial islands are always present distinguishing this from peripheral ossifying fibroma (see later).
- •
Aggressive central (intraosseous) giant cell granuloma may erode through bone and radiographs differentiates it from a peripheral (extraosseous) lesions (see Chapter 17 ).
Management and Prognosis
- •
Excision is the treatment of choice, although if underlying irritating factors such as dental plaque are not removed the recurrence rate is 15% to 20%; anecdotal data suggests that pyogenic granulomas in teenagers may exhibit multiple recurrences.
- •
Granuloma gravidarum may resolve postpartum but may also sclerose and become a gingival fibroma.
Clinical Findings
- •
Peripheral ossifying fibromas and pyogenic granulomas tend to occur in young patients in the second to fourth decades, but all occur as nodular masses on the marginal gingiva adjacent to teeth or dental implants, often in the maxillary anterior region; fibromas are pink, while pyogenic granulomas and peripheral giant cell granulomas are dusky purple; they may be painful if ulcerated, and if vascular will bleed; the underlying bone may show “saucerization” (especially with peripheral giant cell granuloma) ( Fig. 5.10 ).
Fig 5.10 (A) Gingival fibroma. (B) Peripheral ossifying fibroma. (C) Pyogenic granuloma with ulceration. (D) Pyogenic granuloma of the mandibular ridge at an extraction site. (E) Peripheral giant cell granuloma. (F) Peripheral giant cell granuloma causing saucerization of bone ( arrow ).( A , Courtesy Dr. Greg Sarka, private practice, Waterville, Me; B , Courtesy Dr. David Feinerman, private practice, Boynton Beach, Fla; C , Courtesy Dr. Jeffrey Freedman, private practice, Lexington, Mass; E , Courtesy Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.) - •
Peripheral giant cell granuloma is the least common and tends to occur in older adults > 50 years.
- •
Parulis (“gum boil” or sinus tract) occurs on the attached gingiva and has a punctum and an underlying tract that leads to the infected tooth.
- •
Up to 5% of pregnant women develop gingival pyogenic granulomas (granuloma gravidarum or oral pregnancy tumor).
- •
Multiple gingival fibromas may be seen in tuberous sclerosis complex and Cowden syndrome (usually sclerotic fibromas).
Etiopathogenesis and Histopathologic Features
Multipotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or the presence of implants) differentiate toward endothelial cells, fibroblasts, osteoblasts, or osteoclast-like cells, giving rise to four distinct histologic entities or combinations thereof. Estrogen and progesterone causes overexpression of vascular endothelial growth factor in granuloma gravidarum. See Table 5.1 and Figs. 5.11–5.19 for histopathologic features.
- •
A parulis (sinus tract) consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils ( Figs. 5.20 and 5.21 ).
Fig 5.20 Parulis (sinus tract) of the gingiva with gutta-percha tracer.
Fig 5.21 Parulis. (A) Edematous granulation tissue with linear tract communicating with the surface. (B) Edematous granulation tissue with linear spaces/tracts. (C) Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as a mucocele. (D) Tract filled with and lined by neutrophils ( arrows ).
| Diagnosis | Histopathology |
|---|---|
| Fibroma (fibrovascular hyperplasia/polyp) Giant cell fibroma |
|
| Pyogenic granuloma (see also Chapter 6 ) |
|
| Peripheral ossifying fibroma (fibroma with osseous metaplasia) |
|
| Peripheral giant cell granuloma |
|
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