Moving beyond clinical appearance: The need for accurate histological diagnosis
By Ghousia Fatima, MDS
Nagarajappa Sandesh, MDS
S. Ravindra, MDS
Sudhindra Kulkarni, MDS
Featured in General Dentistry, September/October 2009
Pg. 472-477
Posted on Friday, September 04, 2009
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This study considered 120 cases of localized gingival overgrowths that had been clinically diagnosed, surgically excised, and submitted for histopathological examination from 2000–2006. Data regarding the patient’s age and gender and the lesion’s anatomical location, clinical diagnosis, and recurrence were retrieved from case records. The percentage of concurrence and discrepancy between clinical and histopathological diagnosis was calculated using a discrepancy index. In 46.60% of cases, the diagnoses were in total agreement; discrepancies were noted in 53.40% of cases. The diagnosis of peripheral giant cell granuloma showed a high discrepancy (88.89%). Recurrence was seen in five cases.
The high discrepancy between the clinical and histopathological diagnosis of localized gingival overgrowths indicates the need for a confirmatory histological examination for diagnosis and complete management of the lesion.
Received: February 11, 2009
Accepted: May 5, 2009
Plaque-induced gingival and periodontal inflammatory conditions are the most commonly encountered oral problems in clinical practice; these conditions affect more than 90% of the population.1 Gingival enlargements or overgrowths are generalized or localized clinical conditions characterized by an increase in the size of the gingiva.
In most cases of localized gingival overgrowths, the etiology may be inflammatory due to local irritation from plaque, calculus, or poorly adapted restorations. Eliminating these causes usually results in spontaneous regression. Sometimes, overgrowths are unrelated to plaque and can be considered either reactive lesions (like pyogenic granuloma, pregnancy tumor (pyogenic granuloma in pregnant women), peripheral giant cell granuloma, and fibrous hyperplasia) or benign tumors (such as peripheral odontogenic fibroma or peripheral ossifying fibroma).2 Certain developmental lesions like lymphangioma and salivary gland choristoma or metastatic tumors also can manifest as gingival swellings.3
Localized gingival overgrowths resemble each other clinically and can be misdiagnosed (Fig. 1 and 2). Fibroma with a superimposing inflammation may resemble pyogenic granuloma. Both fibrous hyperplasia and fibroma appear clinically as a firm, pale, and painless mass but each has a different histological appearance (Fig. 3 and 4).1
Peripheral giant cell granuloma is an infrequent, reactive, exophytic lesion that originates from the connective tissue of the periosteum or from the periodontal membrane in response to local irritation or chronic trauma.4 The condition is basically asymptomatic; however, repeated trauma (as can occur due to occlusion) leads to ulceration and infection, causing it to resemble pyogenic granuloma.5,6
Some benign tumors, including peripheral ossifying fibroma and cemento-ossifying fibroma, appear as exophytic growth.7 Although oral metastatic tumors are uncommon and account for approximately 1% of malignant oral neoplasms, metastatic lesions also may appear as a localized gingival overgrowth.8,9 The clinical appearance of isolated gingival metastasis from hepatocellular carcinoma mimics pyogenic granuloma.
Some of these exophytic growths have an increased tendency for recurrence; according to the literature, pyogenic granuloma lesions have shown a recurrence rate of approximately 15%.10-12 Studies have shown that peripheral giant cell granuloma has a recurrence rate ranging from 5–11%.13,14
Most often in clinical practice, general dentists overlook pyogenic granuloma and pregnancy tumor as simple localized gingival overgrowth. Routine protocol involves eliminating the inflammatory source or, if swelling persists, excising the gingival overgrowth surgically, either for the purpose of a biopsy or as the complete treatment. Excised tissues are not always submitted for histo-pathological examination. There are some gingival overgrowths, such as epithelioid angiosarcoma or isolated gingival metastasis from hepatocellular carcinoma mimicking a pyogenic granuloma, that even specialists find difficult to diagnose clinically.8,9 It is possible that the histopathologic diagnosis may vary from the clinical diagnosis. The present study sought to evaluate the discrepancy (in %) between the clinical and histological diagnosis of localized gingival overgrowths and to find the rate of recurrence among gingival overgrowths that were excised based on clinical diagnosis.
Materials and methods
A retrospective study of records from the Department of Periodontics, SDM College of Dental Sciences, Dharwad, was conducted after ethical clearance was obtained from the institutional review board. The authors considered 120 cases of localized gingival overgrowths that were diagnosed clinically, treated by complete surgical excision, and submitted for histopathological examination from 2000–2006.
The histopathological diagnosis was compared with the clinical diagnosis and the percentage of agreement was calculated using the following equation: Discrepancy index = Number of incompatible diagnoses/Number of total samples x 100 (see Table 3).15 For cases in which the clinical diagnosis and histopathological diagnosis did not match, an incompatible diagnosis was recorded.
Results
The distribution of the lesions according to patient age, patient gender, and site is shown in Table 1.
The seven-year record of 120 cases of localized gingival overgrowths (median patient age = 25) showed that pyogenic granuloma occurred most frequently (40.0%), followed by fibroepithelial hyperplasia (21.7%), inflammatory hyperplasia (6.7%), peripheral ossifying fibroma (4.2%), peripheral giant cell granuloma (1.7%), myxofibroma (0.8%), and supraperiosteal osteoma (0.8%). Women accounted for 68% of the overgrowths (see Table 1).
The clinical and histological diagnoses were compared by using the percentage of agreement and the percentage of discrepancy between the two methods (see Table 3). There was 46.6% total agreement between the clinical and histopathological diagnoses, with a discrepancy index of 53.4%.
A discrepancy of 28.3% was observed in cases of pyogenic granuloma, indicating an agreement of 71.7%. Pregnancy tumor showed a discrepancy index of 66.67%. For fibroma cases, the discrepancy index was 78.95%. The highest discrepancy index (88.89%) involved cases that were clinically diagnosed as peripheral giant cell granuloma.
In five cases, a recurrence of gingival overgrowth was seen. All five recurrences were diagnosed clinically as pyogenic granuloma and excised completely. Histopathological examination of the recurring lesions revealed one case to be a pregnancy tumor while the remaining four were pyogenic granuloma.
Discussion
Based on the authors’ experience, localized gingival overgrowths are one of the most common lesions in day-to-day practice. Interestingly, patients with localized gingival overgrowth suffer primarily from esthetic complications and secondarily from bleeding and pain. Accurate diagnosis and appropriate treatment is necessary to prevent recurrence and any future complications. For that purpose, this retrospective study was conducted to determine the discrepancy between the clinical and histopathological diagnoses.
In the present study, the clinical and histopathological diagnoses were in total agreement 46.60% of the time, a rate identical to that reported by Czerninski et al in 2007.16
The discrepancy index was 28.30% for pyogenic granuloma, 66.67% for pregnancy tumor, 78.95% for fibroma, and 88.89% for peripheral giant cell granuloma, the highest among all lesions. Localized gingival overgrowths were most common among younger women (that is, 15–28 years of age) and in the anterior region. Both the clinical and histopathological diagnoses showed that pyogenic granuloma was the most common type of localized gingival overgrowth, found predominantly in women aged 15–25.10 Fibroma was the second most common clinically diagnosed lesion, in keeping with previous data on the subject.3
Histopathological examination of pyogenic granuloma shows increased endothelial proliferation with little fibrous stroma; the stroma increases in quantity during the healing phase, thus resembling a fibroma (Fig. 4 and 5).10-12 Sometimes the vascular pattern in pyogenic granuloma will mimic a capillary hemangioma.17,18 Approximately 20% of the cases clinically diagnosed in this study as pyogenic granuloma were histologically benign tumors like fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, supraperiosteal osteoma, or inflammatory hyperplasia.
Inflamed fibroma resembles pyogenic granuloma. The characteristic histological features help to differentiate fibroma from other lesions: fibroma shows atrophic epithelium with increased proliferation of connective tissue fibers, whereas fibrous hyperplasia shows hyperplastic epithelium with an increased proliferation of both connective tissue fibers and chronic inflammatory cells.3,19
The discrepancy was highest in cases that were clinically diagnosed as peripheral giant cell granulomas; only one of these nine cases was confirmed histologically. Peripheral giant cell granuloma is a nodular lesion with a rubbery-to-soft consistency similar to that of fibroma or pyogenic granuloma. It is more common in the mandibular premolar and molar regions and can be differentiated based on the histopathological examination, which shows the characteristic presence of giant cells (Fig. 6).3
Pyogenic granuloma occurs in 5% of pregnant women and thus can be diagnosed as pregnancy tumor or granuloma gravidarum.20 Histologically, pregnancy tumors are not different from granulomas that appear in nonpregnant patients; it should be diagnosed based on the clinical findings and the patient’s history. Such tumors may recur following incomplete excision or poor oral hygiene after a complete excision.3,20
Exophytic lesions are non-specific in terms of their appearance and are difficult to diagnose on a clinical basis alone. A metastatic deposit also may appear as a painless localized gingival overgrowth; as a result, the histopathological examination would be helpful in making a diagnosis.8,9
Some exophytic growths have an increased tendency for recurrence. Previous studies have shown a recurrence rate of 15% for pyogenic granuloma and 5–11% for peripheral giant cell granuloma.13,21 Similarly, the present study found a high recurrence rate of cases diagnosed as pyogenic granuloma. Recurrence occurred in one case of pregnancy tumor, which recurs if it is not excised completely.20
Conclusion
The high discrepancy between the clinical and histopathological diagnoses of localized gingival overgrowths found in this study necessitates a confirmatory histological examination of the lesion. If the size of the overgrowth permits, an incisional biopsy should be performed prior to complete excision of the lesion. A biopsy will ensure a better and a more ideal treatment plan for the patient and prevent recurrence of these lesions.
Acknowledgements
The authors would like to thank the staff of the Department of Oral Pathology, SDM College of Dental Sciences, Dharwad, for providing the histopathological reports in this study.
Author information
Dr. Fatima is an assistant professor, Department of Periodontics, Saraswati Dhanwantari Dental College, Parbhani, Maharastra, India. Dr. Sandesh is an assistant professor, Department of Community Dentistry, Kanti Devi Dental College and Hospital, Mathura, U.P., India. Dr. Ravindra is principal, Hassanamba Dental College, Hassan, Karnataka, India. Dr. Kulkarni is a reader, Department of Periodontics, SDM College of Dental Sciences, Dharwad, Karnataka, India.
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General Dentistry, September/October 2009 , Volume 57 , Issue 5
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