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Answer & Explanation

Answer: D. Peripheral ossifying fibroma

This month’s case features a bump on the gum. The main differential diagnosis for these lesions include pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma.

The main entities in the differential diagnosis are all reactive lesions rather than true neoplasms. They represent a growth on the gingiva occurring in response to something such as calculus build up. In pathology, the word ‘peripheral’ means ‘on the gingivae’ – therefore, the only place one can encounter a peripheral ossifying fibroma or peripheral giant cell granuloma is the gingiva. Though 75% of pyogenic granulomas occur on the gingivae, they can also occur anywhere in the oral cavity. Pyogenic granulomas are also known as “pregnancy tumors” as they occur with higher frequency in pregnant women, though men and non-pregnant women can also get pyogenic granulomas.

The best treatment for these lesions is surgical excision with submission for histologic evaluation. This is the treatment for a couple of reasons – first, the lesions will not go away without a biopsy. Second, we do need to rule out the rare cases of malignancy presenting as reactive bumps on the gum. Inform the patient that all three have about a 10-15% recurrence rate.

Board pearls :

1. The main differential diagnosis for bump on the gum is pyogenic granuloma, peripheral ossifying fibroma, and peripheral giant cell granuloma
2. The pyogenic granuloma is known as the pregnancy tumor; it is the only one that can occur off the gingivae
3. Treatment is excisional biopsy with submission for histologic evaluation; the recurrent rate is 10-15%

Answer & Explanation

Answer: C. Candidiasis

Candidaisis is by far the most common oral fungal infection in humans and is caused by Candida albicans. There are four main clinical patterns:

1. Pseudomembranous
2. Erythematous
   • Median rhomboid glossitis (central papillary atrophy)
   • Chronic multifocal
   • Angular cheilitis
   • Chronic atrophic (Denture stomatitis)
   • Acute atrophic (Antibiotic sore mouth)
3. Chronic hyperplastic
4. Mucocutaneous

1. Pseudomembranous is the most easily recognizable and is often referred to as thrush. Removable white plaques are the hallmark of this infection.

2. Erythematous candidiasis is red rather than white and cannot be wiped away.
o Median rhomboid glossitis appears in adults as a red area in the midline posterior dorsal tongue and is directly anterior to the circumvallate papillae.
o Chronic multifocal presents as multiple red areas in the oral cavity.
o Angular cheilitis occurs at the corners of the mouth where saliva can pool. Edentulous adults with a decreased vertical dimension of occlusion are at most risk. This form occasionally has a bacterial component as well. Cheilocandidiasis can occur if a patient with angular cheilitis licks their lips or places a balm on the angular cheilitis and spreads the infection throughout the lips.
o Chronic atrophic candidiasis is striking redness under the denture-bearing area; the denture will harbor most of the organism.
o Finally, acute atrophic candidiasis may occur after a course of broad-spectrum antibiotics. It can cause loss of filiform papillae and a burning sensation. Many of the symptoms in acute atrophic candidiasis are similar to those noted in patients with xerostomia.

3. Chronic hyperplastic candidiasis is a white area that cannot be wiped away. Upon biopsy, numerous Candidal organisms are discovered. It typically occurs on the anterior buccal mucosa.

4. Mucocutaneous candidiasis presents as a severe form of oral candidiasis associated with immune dysfunction. The nails, skin, and other mucosal surfaces may also be involved. Associated systemic findings may include endocrine abnormalities or iron-deficiency anemia. Syndromic mucocutaneous candidiasis may also occur; these patients may be at an increased risk for malignancy.

Diagnosis can be made clinically. If histology is used, a PAS or GMS stain highlights the organisms. Treatment is with topical nystatin (a polyene agent) or clotrimazole (an imidazole agent). Systemic medications include fluconazole (a triazole). Ketoconazole is a systemic imidazole agent but should not be used for first round therapy for oral candidiasis as it requires an acidic environment for absorption and about 1 in 10,000 develop liver toxicity.

Answer & Explanation

Answer: B. Squamous papilloma

This month’s case features a squamous papilloma. These are very common benign lesions, occurring in 1 of 250 patients. Squamous papilloma’s are the most common epithelial tumor of the soft palate. They have a low virulence and infectivity rate, meaning they are not very contagious. Lesions tend to present as pedunculated, exophytic, white or mucosal-colored, wart-like growths and are typically about 0.5 cm in greatest diameter. These lesions are not considered sexually transmitted, nor do they have any association with HPV-driven oropharyngeal squamous cell carcinoma. Treatment is conservative surgical excision with an excellent prognosis.