1) Pyogenic granuloma is a benign vascular growth that commonly occurs on the gingiva and presents as a painless reddish nodule that may ulcerate or bleed easily. 2) Aggressive periodontitis involves rapid alveolar bone loss with little clinical signs of inflammation and is treated with debridement, antibiotics, and extraction of hopeless teeth. 3) Verrucous carcinoma is a low-grade variant of oral squamous cell carcinoma that typically appears as an extensive white exophytic papillary mass, most often on the gingiva or hard palate of elderly males. It tends to grow slowly and laterally rather than invasively.

1. Gingival and
Papillary lesions

2. Gingival Lesions
 Epulis
(epulides): non-specific term for
any solid growth arising from the
gingiva or alveolar ridge area
 3 “P’s”
pyogenic granuloma
 peripheral giant cell granuloma
 peripheral ossifying fibroma


3. Pyogenic Granuloma
Benign growth of vascular, granulation
tissue
 75% occur on gingiva, but may occur
anywhere in oral cavity or on skin
 Frequently seen in pregnant females
(pregnancy tumor)
 Presents as painless reddish nodule, may
be ulcerated, may grow rapidly and mimic
a malignant process


10. Pyogenic Granuloma
Treat by local excision and removal of
local irritants
 Lesions in pregnant females may resolve
following delivery
 10-15% recurrence, especially for gingival
lesions


11. Peripheral* Giant Cell Granuloma
 Benign
proliferation of vascular tissue,
numerous giant cells, hemosiderin
 Alveolar/gingival mass only, adults 40-60
yrs
 Painless, bluish-red mass, may be
ulcerated or associated with local irritants,
may cause “cupping” of underlying bone
 Excision, remove irritants; 10-15% recur

17. Peripheral Ossifying Fibroma
 Proliferation
of fibrovascular connective
tissue with variable calcifications
 Thought to arise from PDL cells
 Gingival growth, young adults, anterior
jaws, females (2:1), often ulcerated
 Excision, remove local irritants
 10-15% recurrence

21. Fibroma (irritation fibroma)
Most common “growth” of the oral cavity
 Excess collagen deposition secondary to
chronic trauma (biting)
 Buccal/labial mucosa, tongue
 Smooth-surfaced, dome-shaped nodule
 Dense fibrous connective tissue
histopathologically
 Conservative excision, remove irritants


24. Drug-Related Gingival Overgrowth
Phenytoin (Dilantin) was first drug to be
associated with gingival enlargement
 In the 1980’s, nifedipine and the calcium
channel-blocking agents were determined to
cause gingival enlargement
 Cyclosporine was added to the list shortly after
nifedipine


28. Drug-Related Gingival Overgrowth
Confirm the use of a causative drug
 Good oral hygiene, chlorhexidine rinses
 Discontinue drugs or replace if possible
 Some regression may be seen with
discontinuation but not always (gingivectomy)
 Synergistic effects may be seen between 2
different drugs


30. Gingival Cyst of the Adult
 Uncommon
cystic lesion, derived from
dental lamina rests
 Middle-aged adults 40-60 yrs
 Mandibular canine/premolar region most
common
 Bluish-translucent swelling, often centered
in attached gingiva
Can
look like “mucocele”

36. Gingival Cyst of the Adult
 Dx:
location excludes salivary gland
origin
 Treat by local excision
 No tendency to recur

37. Necrotizing ulcerative gingivitis
(NUG, trench mouth)
Painful infectious disease of rapid onset,
primarily affects gingiva (can spread)
 Certain bacteria (Fusobacterium nucleatum,
Borrelia vincentii) together with predisposing
factors:

 stress,
immunosuppression, poor oral hygiene,
poor nutrition, smoking

38. Necrotizing ulcerative gingivitis
(NUG, trench mouth)
Adolescents, young adults
 Widespread involvement of superficial gingiva,
especially interdental papillae
 “punched-out” papillae, bleeds easily
 Necrotic tissue gives a foul odor
 Low-grade fever, lymphadenopathy


39. Necrotizing ulcerative gingivitis
(NUG, trench mouth)
Dx: clinical history and appearance
 Thorough gingival debridement with copious
irrigation, improve oral hygiene
 Chlorhexidine or oral iodine rinses
 Systemic broad-spectrum antibiotics

 (i.e.

tetracycline, metronidazole, erythromycin)
Stop smoking, improve nutrition, evaluate
immune function status

43. Aggressive Periodontitis
Rapid alveolar bone loss, often with little
clinical signs of inflammation
 Any age, often first noted in teenage years
 Localized (often 1st molars and incisors) or
generalized presentations
 Radiographic evidence of rapid bone loss,
vertical defects common in localized cases
 Teeth may become mobile


44. Aggressive Periodontitis





Debridement, local and systemic antibiotic treatment,
submit tissue for microscopic examination (biopsy) to
rule out other pathologic conditions
Extraction of hopeless teeth
Majority of patients have a neutrophil dysfunction
Prepubertal periodontitis associated with systemic
leukocyte dysfunction
A. actinomycetemcomitans, P.intermedia, P.
gingivalis

45. Periodontal Abscess
Localized pus accumulation at base of
periodontal pocket
 May be due to chronic periodontitis or
acute obstruction of pocket by foreign
material (popcorn husk)
 Often painful or tender, erythematous,
foul taste may be reported, local pressure
may release purulence
 Tooth usually vital


46. Periodontal Abscess
Drain purulence, debride area or remove
foreign body, analgesics as needed
 Treat chronic periodontal disease, if
present


47. Parulis (sinus tract, gumboil)
 Associated
with non-vital tooth (decay)
 Painless papule on gingiva or palate near
apex, reddish with occasional yellow
center, pressure may release pus
 Extraction or RCT of affected tooth
 Cutaneous sinus, rare complication

53. Retrocuspid papilla
Developmental papule(s), bilateral, < 5mm
 Mandibular canine area, lingual gingiva
 Children, young adults (very common)
 Similar to giant cell fibroma microscopically
 Dx: clinical appearance, no enlargement
 No Tx needed, may regress with time


56. Inflammatory Fibrous Hyperplasia
 Also
known as denture epulis, epulis
fissuratum, or denture-induced fibrous
hyperplasia
 Results from chronic, low-grade irritation
from ill-fitting denture flange
 May have central fissure
 Conservative excision; re-make denture

66. Inflammatory Papillary Hyperplasia
Denture papillomatosis – maxillary complete
denture
 Central region of hard palatal mucosa
 Numerous asymptomatic red papules
 Keeping denture out, red → pink, but papules
remain
 Excision may be needed


71. Squamous Papilloma
Most common benign epithelial neoplasm seen
intraorally, associated with HPV infection
 Solitary lesion, typically found on soft
palate/uvula, tongue, labial mucosa
 Finger-like fronds, usually pedunculated, but
may be sessile
 Range of color (reddish to white)


77. Papilloma - Treatment
 Conservative
excision, including the
base of the lesion
 Prognosis is excellent
 Recurrences are uncommon; no risk
of malignant transformation
 Very low transmission rate

78. Verruca Vulgaris (common wart)
Common, benign lesion caused by several
strains of HPV
 Frequently affects children - hands and facial
skin. Less frequent orally than sq. papilloma
 Can be transmitted, auto-inoculated
 Usually sessile, exophytic, papillary lesion; often
multiple on skin but solitary in the mouth (lips,
gingiva, tongue, palate)


83. Verruca Vulgaris
spontaneous regression is common in kids
 excision, cryotherapy, keratolytic agents
 recurrence not common, but possible


84. Condyloma Acuminatum
 also
known as “venereal warts”
 benign epithelial proliferation caused by
several strains of HPV, including types 6,
11, 16,18, 53 and 54
 oral lesions - multiple, exophytic sessile
mass(es), cauliflower surface, pink to white
 Lips, soft palate, lingual frenum

88. Condyloma Acuminatum
 excision,
cryotherapy, laser excision
 recurrence is common - 30% of
patients have recurrent lesions after
each treatment episode
 associated with squamous cell
carcinoma of the uterine cervix

89. Verrucous Carcinoma
Uncommon, low-grade variant of oral squamous
cell carcinoma
 Represents less than 1-10% of oral SCC
 Usually develops in elderly male patients
 Smokeless tobacco is often mentioned as a
contributing factor, particularly in some southern
states. These VC’s arise in the area where the
tobacco is placed. Can arise from the high risk
precancerous condition: PVL


90. Verrucous Carcinoma
 Clinically
presents as an extensive,
exophytic, papillary mass or shaggy thick
plaque, typically white, crisp borders
 Mandibular vestibule, gingiva, hard palate
and buccal mucosa are most frequent sites
 Tends to grow slowly and laterally, not
invasively

96. Verrucous Carcinoma
 Wide
surgical excision
 Rarely metastasizes
 Radiation therapy has been discouraged
due to sporadic reports of transformation
of verrucous carcinoma to a more
aggressive squamous cell carcinoma

100. Verrucous Carcinoma
Prognosis: fair-guarded - approximately 2025% of verrucous carcinomas, upon
complete excision, show foci of
transformation to routine squamous cell
carcinoma