Exophytic gingival lesions represent some of the more frequently

encountered lesions in the oral cavity. Based on clinical

appearance, different lesions are often indistinguishable from one
another. A review of 15,783 oral lesions during a 17.5-year period
found that fibromas, periapical granulomas, mucoceles, and
radicular cysts were the most common. 1,2 Data from several
biopsy services have indicated that 77% of lesions are reactive in
nature.1 These lesions are a result of trauma or chronic irritation,
or they can arise from cells of the periodontium, periodontal
ligament, or periosteum.
This article will review 3 exophytic gingival lesions that were
encountered in a periodontal office setting. The cases
demonstrate the need for awareness, and the role of biopsy and
histologic evaluation in the management of these lesions.
EXOPHYTIC GINGIVAL LESIONS
Some of the most commonly encountered exophytic gingival
lesions are the irritation fibroma, peripheral ossifying fibroma,
pyogenic granuloma, and peripheral giant cell granuloma. 3 A
report of more than 30,000 oral biopsies submitted for diagnosis
observed that nearly 13% were taken from the gingiva. 4 Each of
the previously mentioned lesions has been associated with or
related to trauma or low-grade irritation as an etiologic factor, and
these are generally considered to be reactive and/or
nonneoplastic.3 The peripheral giant cell granuloma and
peripheral ossifying fibroma generally occur more commonly in
females,3,5 while there is no gender predilection for the irritation
fibroma.6 The peripheral ossifying fibroma and peripheral giant
cell granuloma have been reported in most age ranges, whereas
fibromas have the highest incidence in the third through fifth
decades.3 The treatment for each of these lesions is surgical
excision. The peripheral giant cell granuloma and peripheral
ossifying fibroma have a tendency to recur, while the irritation
fibroma is unlikely to recur.3
The treatment of these lesions involves administration of local
anesthesia and complete surgical excision. The excisional biopsy
extends several millimeters beyond the border of the lesion down
to bone. Once the entire lesion is removed, the underlying root
surfaces of the teeth are debrided. If bone is underlying the
lesion, and enough gingiva is remaining, a guided tissue
regenerative procedure can be performed. Additionally,
subsequent periodontal plastic surgical procedures can also be
employed if aesthetics are a concern.
FIBROMA
The fibroma is the most common oral fibrous growth.1,5 Of 1,453
lesions detected in more than 23,000 individuals over 35 years of
age, the irritation fibroma was found at a prevalence rate of 12.0
lesions/1,000 people.7 Most fibromas represent focal fibrous
hyperplasia due to trauma or local irritation. This lesion generally
presents as a painless, sessile, round or ovoid, broad-based
swelling that is lighter in color than surrounding tissue due to a
reduced vascularity.6 The surface may be ulcerated. It is often
seen on the buccal mucosa along the plane of occlusion. The
diameter can vary from 1 mm to several centimeters.5 Treatment
is surgical excision, and a low recurrence rate is expected.
The differential diagnosis of a fibroma includes the following:
giant cell fibroma, neurofibroma, peripheral giant cell granuloma,
mucocele, lipoma, or salivary gland tumor. 5,6 Histologically,
fibroblasts are scattered in a dense, collagenous matrix. A mild,
chronic, inflammatory infiltrate may be present, but this is not a
consistent finding.3,5,6
PERIPHERAL GIANT CELL GRANULOMA
The peripheral giant cell granuloma constitutes between 0.3 to
0.5% of all oral biopsies. It can appear as a sessile or
pedunculated, somewhat firm mass that is red to reddish-blue in
color.8,9 The lesion may arise from the periodontal ligament or
periosteum. In some instances, it can cause resorption of alveolar
bone.6,10 It has been reported more frequently in females than
males, and radiographic involvement of underlying bone can be
found.3
The etiology of peripheral giant cell granuloma is controversial,
but is believed to result as a response to injury of the gingival
tissues. A traumatic origin has been suggested due to the
presence of hemosiderin deposits or erythrocytes found within the
fibrous stroma or within the multinucleated giant
cells.8,11 However, other reports have maintained that the
peripheral giant cell granuloma represents a reactive lesion,
stimulated by plaque and calculus. The formation of the giant
cells may be due to the fusion of histiocytes, endothelial cells,
fibroblasts, or pericytes.11-14
Treatment is surgical excision, and recurrences can be expected if
the entire lesion is not completely removed. The differential
diagnosis for a peripheral giant cell granuloma is peripheral
ossifying fibroma, pyogenic granuloma, cyst, fibroma, mucocele,
or hemangioma. Histologically, multinucleated giant cells are
scattered throughout a vascular connective tissue. 3
PERIPHERAL OSSIFYING FIBROMA
The peripheral ossifying fibroma is a common reactive gingival
lesion displaying variable degrees of bone calcification and
mineralization, and is believed to arise from the periosteum or
periodontal ligament.3,15 The mineralization is found within a non-
encapsulated proliferation of fibroblasts. A chronic inflammatory
infiltrate is commonly seen around the periphery of the lesion.6
Most lesions have a diameter of less than 2 cm and are usually
located in the papilla between adjacent teeth. The lesion can be
sessile or pedunculated, and can have an ulcerated surface. 5 It
has been proposed that the ulcerated and non-ulcerated lesions
represent a spectrum with different stages of maturation. 16 The
peripheral ossifying fibroma tends to be more prevalent in
females than males, and similar to the peripheral giant cell
granuloma, radiographic evidence of underlying bone
involvement can be seen.3
As for the previously mentioned lesions, treatment consists of
complete surgical excision. The recurrence rate approaches
20%.17 The differential diagnosis of a peripheral ossifying fibroma
includes the following: peripheral giant cell granuloma, peripheral
odontogenic fibroma, pyogenic granuloma, fibroma, or
inflammatory gingival hyperplasia.5
Histologically, the peripheral ossifying fibroma consists of a
fibrocellular component with focal deposits of bone, some
cementum, as well as irregular amounts of dystrophic
calcification.3
CASE REPORTS
Case Report No. 1: Irritation Fibroma

Figure 1. Irritation
fibroma located on
buccal mucosa near
lower left lip.
A healthy, 58-year-old, white female, who was referred for
periodontal treatment, also exhibited a gingival mass that
measured 5 x 5 mm (Figure 1). This sessile
lesion had a smooth surface and was
located on the buccal mucosa near her
lower left lip. She stated it had been there
for months, but recently it had been
bothering her because of repeated trauma.
A differential diagnosis included the
following: irritation fibroma, mucocele, and Figure 2. Histology
salivary gland tumor. An excisional biopsy of fibroma shows
was performed, and the microscopic dense collagenous
appearance (Figure 2) was a circumscribed, matrix and little to
dense, collagenous matrix containing few no inflammatory
fibroblasts and little or no inflammatory response.
response. The diagnosis was an irritation
fibroma.
Case Report No. 2: Peripheral Giant Cell Granuloma
A 75-year-old, white female with a noncontributory medical history presented with an asymptomatic
swelling on the facial aspect of the gingiva adjacent to tooth No. 13. The patient had been aware of the
swelling for 1 month. The lesion was a bluish-red nodule measuring 5 mm in diameter. It was firm in
consistency and did not blanch on pressure. The affected tooth was nonvital, but not tender to
percussion. There was 3 mm of gingival recession on the disto-facial aspect of tooth No. 13, and an
isolated probing depth of 10 mm was detected on the direct facial surface. A moderate degree of
mobility was present. No radiographic changes were detected on a periapical radiograph.

Figure 3. Gingival
lesion mesial to tooth
No. 13. Photograph
was taken just prior
to biopsy. The lesion
had increased from 5
to 10 mm within 1
month.
One month after completion of endodontic therapy, the nodule had increased in size to 10 mm (Figure
3).

Figure 4. Area of Figure

resorbed bone was 5. Biopsied
present underneath lesion seen
lesion, mesial aspect of following
tooth No. 13. excision
measured 11 x
10 mm.
A differential diagnosis included the following: combined endodontic-periodontic lesion, root fracture,
cyst, mucocele, peripheral ossifying fibroma, pyogenic granuloma, and peripheral giant cell granuloma.
After the lesion was removed via an excisional biopsy, the bone underlying the lesion appeared to have
been resorbed (Figure 4). The specimen measured 11 x 10 mm (Figure 5). After removal of the lesion,
the root surface was then debrided.

Figure 6. Histology
of peripheral giant
cell granuloma
reveals a dense
infiltrate of
histiocytes and multi-
nucleated giant cells
within the
subepithelial fibrous
stroma.
The histologic evaluation of the specimen revealed a dense
infiltrate of histiocytes and multi-nucleated giant cells within the
subepithelial fibrous stroma. The presence of extravasated
erythrocytes and hemosiderin deposits was also noted (Figure 6).
The diagnosis was a peripheral giant cell granuloma.
Case Report No. 3: Peripheral Ossifying Fibroma

Figure 7. Exophytic Figure 8. Periapical

gingival lesion noted radiograph of the
on lingual aspect of region displayed a
teeth Nos. 28 and radiolucency
29. The mass between the apices
 measured 12 x 7 mm of teeth No. 29 and
and had increased in 30.
size over a 3-week
duration.
A healthy, 34-year-old, black female was referred by her
restorative dentist for evaluation of a gingival lesion that
measured approximately 12 x 7 mm (Figure 7).
The lesion was located on the lingual aspect of teeth Nos. 28 and
29, and according to the patient it had grown in size during the
past 3 weeks. It was firm, painful, slightly ulcerated near its
superior surface, and sessile in nature. A periapical radiograph
displayed a radiolucency between the apices of teeth Nos. 29 and
30 (Figure 8). All teeth in the quadrant tested vital.
A differential diagnosis included the following: peripheral giant cell granuloma, pyogenic granuloma, and
peripheral ossifying fibroma. The entire lesion was removed via an excisional biopsy down to the
underlying bone, and the root surfaces were debrided.

Figure 9. Histology
of peripheral
ossifying fibroma
displays immature
calcified foci of bone
encapsulated within
a proliferation of
fibroblasts and
chronic inflammatory
cells.
Histologically, immature calcified foci of bone encapsulated within
a proliferation of fibroblasts were noted. Chronic inflammatory
cells were also noted (Figure 9). The diagnosis was a peripheral
ossifying fibroma. This lesion tends to recur at a rate of nearly
20%.17
CONCLUSION
These case reports illustrate that exophytic gingival lesions are
commonly encountered by dental clinicians. An important rule to
remember regarding exophytic, sessile, gingival lesions is the 4
Ps. The differential diagnosis should include peripheral fibroma,
peripheral ossifying fibroma, peripheral giant cell granuloma, and
pyogenic granuloma. Other gingival conditions, such as
medication-influenced overgrowth, certain neoplasms, or a
hemangioma, can clinically resemble the lesions described.
However, the ability to formulate a differential diagnosis is
contingent upon clinical appearance as well as location.
Ultimately, though, the diagnosis is confirmed by biopsy and
histologic evaluation.
Acknowledgments
The author wishes to thank Drs. John Fantasia and Steve McClain
for their contributions to this article.