oprm-web-case-op-st-39

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 nonpainful 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, nontender, has a smooth surface, and is fixed to surface mucosa and underlying structures. The lesion has a normal mucosal color and does not blanch. Radiographs reveal no bony abnormalities in the area. 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, other palpable masses, or areas of tenderness.

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
The patient complains of a soft tissue enlargement of the gingiva that is slowly increasing in size and is of five months duration.  The lesion is firm, nontender, well-circumscribed, 0.8 x 1.0 cm in size, and labial and distal to tooth #27.  The lesion has a normal mucosal color, does not blanch, has a smooth surface and is fixed to surface mucosa and underlying structures.  It does not bleed and is nonpainful except when traumatized while eating.

Lesions to Exclude from the Differential Diagnosis:
The lesion is described as a soft tissue enlargement.  Reactive lesions can be excluded because the lesion in this case is persistent and progressive.

Within the category of tumors, malignant tumors and soft tissue cysts can be excluded.  Malignant tumors may be eliminated from the differential diagnosis because the lesion in this case is well-circumscribed, slowly growing, nonpainful, and not ulcerated.  Soft tissue cysts can be excluded because these are compressible to palpation.

Epithelial lesions and salivary gland tumors may be excluded from the category of benign tumors.  Epithelial lesions can be excluded because the lesion in this case does not have a yellow or white, rough surface.  Salivary gland tumors can be excluded because salivary gland tissue is not located in the gingiva.

From the category of benign mesenchymal tumors, the following lesions may be excluded.  Epulis fissuratum is excluded because it is associated with the flange of a denture.  Rhabdomyoma is excluded because skeletal muscle is not present in the gingiva.  The lesion in this case is not vascular because it has normal colored mucosal surface, does not bleed easily, and is not compressible; thus we can exclude peripheral giant cell granuloma, hemangioma, and pyogenic granuloma.  Lymphangioma and lipoma can be excluded because these are compressible.  Neuroma may be excluded because these are painful to palpation.  Congenital epulis is excluded because they are present at birth or appear in early childhood.

Lesions to Include in the Differential Diagnosis:
The lesions included in the differential diagnosis include: irritation fibroma, peripheral ossifying fibroma, the non-vascular form of leiomyoma, neurofibroma, schwannoma, and granular cell tumor.  All of these lesions are well-circumscribed, firm and not vascular.

Management:
Treatment is excisional biopsy which will remove the lesion and allow for microscopic diagnosis.

Final Diagnosis:
Peripheral ossifying fibroma.  The prognosis is good although recurrence is a possibility.