Case #38 Discussion

Summary: The patient complains of a soft tissue enlargement that bleeds easily, has been present for two weeks, and is progressively increasing in size.  The lesion is a well-circumscribed, 0.5 x 1.0 cm, erythematous soft tissue enlargement on the gingiva lingual to the maxillary central incisors.  The lesion is compressible, nontender to palpation, and is fixed to the surface mucosa and underlying structures.  The lesion blanches upon pressure and has a smooth surface with an area of ulceration covered by a fibrin clot.   Lesions to Exclude from the Differential Diagnosis: This lesion is described as a soft tissue enlargement.  Reactive soft tissue enlargements can be excluded from differential diagnosis because the lesion in this case is persistant, progressive, and nontender. Within the category of tumors, malignant tumors and soft tissue cysts can be excluded.  Although the lesion has a rapid growth and ulcerated surface, the lesion is asymptomatic and is well circumscribed and thus it is not described as a malignant tumor.  Soft tissue cysts can be eliminated because they are very slow growing and they do not blanch. From the category of benign tumors, epithelial lesions and salivary gland tumors can be excluded.  Epithelial lesions can be excluded because they are firm to palpation, white, have a rough or cauliflower surface, and they do not blanch.  Salivary gland tumors can be excluded because salivary glands are not present on the gingiva and do not blanch. Within the category of benign mesenchymal tumors, the following lesions can be excluded.  Fibroma, lipoma, rhabdomyoma, schwannoma, neurofibroma, neuroma, and granular cell tumor can be excluded because they are not vascular lesions and do not blanch.  In addition, rhabdomyoma can be excluded because skeletal muscle is not present in the gingiva.  Hemangioma, lymphangioma, and congenital epulis can be excluded because they are congenital or appear in childhood.    Lesions to Include in the Differential Diagnosis:  Pyogenic granuloma is the most likely diagnosis because it is compressible, easily bleeding, blanches on pressure, and is rapidly growing.  Pyogenic granuloma is most commonly found on the gingiva, but it can be present on any oral mucosal surface.  It is commonly seen in pregnant females or children going through puberty, but it can present in either sex and at any age.  Other vascular lesions, especially peripheral giant cell granuloma and peripheral ossifying fibroma are also likely possibilities.  The vascular form of leiomyoma can also be included in the differential diagnosis. Management: Excisional biopsy is recommended because it will remove the lesion and allow for microscopic diagnosis.  Final Diagnosis: Pyogenic granuloma.  Pyogenic granuloma has a good prognosis although it may recur.