GINGIVAL SWELLINGS

GINGIVAL SWELLINGS z Generalised

z Localised eg. Epulides, Abscess

Michael McCullough
BDSc MDSc PhD FRACDS (Oral Med)
Assoc. Professor, Oral Medicine,
School of Dental Science, University of Melbourne

Exostoses Localised Swellings

z Torus palatinus z Fibrous epulis
z Torus mandibularis
z Solitary z Pyogenic granuloma
z Multiple z Pregnancy epulis
z Gardners syndrome
• familial adenomatous z Peripheral giant cell granuloma
polyposis
• autosomal dominant z Gingival cyst of adults
• GI polyps
z Peripheral odontogenic neoplasms (rare)
• 100% undergo malignant
transformation

Fibrous Epulis Pyogenic Granuloma

z Firm fibrous mass z Soft, dark red-purplish
z gingival margin
swelling
z Pedunculated or sessile
z Pedunculated or sessile

z indistinguishable from
pregnancy epulis

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 Peripheral Giant Cell Granuloma Gingival Cyst of Adult
z Clinically resembles a z Uncommon
fibrous epulis or pyogenic
granuloma z Slow-growing

z Microscopically
indistinguishable from
• central giant cell granuloma
• brown tumours of z Most likely
hyperparathyroidism odontogenic in origin
(Glands of Serres)

GENERALISED GINGIVAL
Peripheral Odontogenic Neoplasms SWELLINGS

z Benign CAUSES:
z Developmental
z May recur if not completely removed
z Infective
z Histology is identical to that of their intra-
z Neoplastic
osseous counterparts
z Systemic Disease
• peripheral ameloblastoma • drug-induced
• peripheral odontogenic fibroma

DEVELOPMENTAL NEOPLASIA
GINGIVAL FIBROMATOSIS z Lymphoma
z autosomal dominant z Leukaemia
z multisystem syndrome
z Kaposi’s Sarcoma
z associated with
z Squamous Cell
• epilepsy Carcinoma
• hypertrichosis
• mental retardation

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 DRUG INDUCED GINGIVAL
SYSTEMIC DISEASE OVERGROWTH

z Scurvy z Over 20 medications

z Anticonvulsants
z Oral Crohns Disease • phenytoin
z Cyclosporin
z Wegener’s Granulomatosis
z Calcium Channel Blockers
z Drug Induced Gingival Overgrowth • Nifedipine, Verapamil, Diltiazem
z Cannabis

PIGMENTATION OF THE ORAL

MUCOSA
PIGMENTATION OF THE
ORAL MUCOSA z Intrinsic
z Extrinsic

Michael McCullough
BDSc MDSc PhD FRACDS (Oral Med)
Assoc. Professor, Oral Medicine,
School of Dental Science, University of Melbourne

EXTRINSIC HAIRY TONGUE

z superficial staining from z chromogenic
pigments/dyes bacteria trapped
e.g. foods, chlorhexidine within hyperplastic
mouthwash
filiform papillae
z subgingival calculus
• antibiotic therapy
z tobacco • Xerostomia
z black hairy tongue • Smoking
z amalgam tattoo • radiation therapy
z accidental implantation
z not oral candidosis
of foreign material

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 AMALGAM TATTOO Amalgam Tattoo
z Most common form of localised oral pigmentation
z painless bluish-black macules usually affecting
the gingivae or alveolar mucosa
z other frequent sites include floor of mouth and
buccal mucosa
z usually due to implantation of amalgam into
mucosal abrasions during restorative procedures
or fracture of an amalgam restoration during tooth
extraction

Amalgam Tattoo INTRINSIC

z Physiological / racial pigmentation

z Pathological pigmentation

RACIAL PIGMENTATION RACIAL PIGMENTATION

z Most common z Racial pigmentation does not alter the
z intensity and distribution
very variable normal anatomical architecture e.g.
• between races gingival stippling
• between individuals
z pigmentation is generally a function of
• in different areas of the
same mouth the activity of the melanocyte rather than
z gingivae most commonly the number of melanocytes
affected

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PATHOLOGICAL PIGMENTATION
z melanocytes are dendritic cells
• neuroectodermal origin
• migrate with the peripheral nerves
• to the basal layer of skin and oral mucosa
z they are a clear cell with a small dark
nucleus representing ~ 1/10 basal cells
LENTIGO SIMPLEX
z Resembles melanotic macule clinically
z however, there is a focal increase in the
number of melanocytes
z lentigo simplex is benign but malignant
lentigo can develop, particularly in
sunburnt skin
NAEVI
z A naevus cell is a physiologic relative of
the melanocyte
z lack dendrites
z oval shape
z tendency to nest
MELANOTIC MACULE
z an oral ephelis (“freckle”)
z brown to black macule
• commonly found on the lower
lip
• also buccal mucosa, gingivae
• more common in women than
men
z an overproduction of
melanin
• confined to the basal cell
layer
• or the immediately adjacent
keratinocytes
MELANOTIC NAEVI
z Developmental blemish (often called
“moles”)
z exceedingly common on the skin
z rare in the oral mucosa
z the amount of melanin they contain is
highly variable
JUNCTIONAL NAEVUS
z Focal proliferation of melanocytes in the
basal layer of the epithelium
z matures to become a compound naevus
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COMPOUND NAEVUS
z Junctional and connective tissue components
z groups of naevus cells in the connective tissue
which appear to have “dropped off” from the
epithelium
z some clusters of naevus cells remain in
contact with the basal keratinocytes
z matures to become an intramucosal naevus
BLUE NAEVI
z Form ~ 1/3 of all oral naevi
z resemble other intraoral naevi clinically apart
from their bluish tinge
z located deeper than intramucosal naevi
z covered by normal epithelium and well
separated from the basal layer by connective
tissue
z characterised by a proliferation of spindle-
shaped pigmented melanocytes and
melanophages loosely grouped together
ORAL MELANOMA
z Men slightly more frequently affected
z peak incidence 40-60 years
z lesions typically dark brown/bluish black
z may be a mixture of colours
z rarely non-pigmented (appear red)
z most often slightly raised or nodular with
irregular margins
INTRAMUCOSAL NAEVUS
z Junctional activity disappears
z lesion is located entirely within the
lamina propria
z CLINICALLY:- most common sites are
the buccal mucosa and palate
z well-circumscribed
z usually slightly raised, rarely polypoid
z brown, black, occasionally unpigmented
ORAL MALIGNANT MELANOMA
z Rare
z arises from neoplastic transformation of
either melanocytes or naevus cells
z aetiology of oral melanoma is unknown
z >70% of cases involve the maxilla
z ~50% of cases involve the hard palate
z ~25% of cases involve the gingivae and
alveolar ridge
ORAL MELANOMA
z Late presentation is
• long asymptomatic period
z rapid further growth
z ulceration, pain, bleeding, loosening of
teeth
z “Guestimated” that ~30% preceded by
oral pigmentation which has been
present for months or years
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ORAL MELANOMA SYSTEMIC
z Metastases are common z Peutz-Jeghers syndrome
• spread to regional lymph nodes, lungs, liver, z Neurofibromatosis (von
brain and bones Recklinghausens disease)
z 5 year survival rate is only 5% z McCune-Albrights disease
z Addisons diease
z tumour thickness is the single most z Heavy metal ingestion
important prognostic feature
z Drug-induced
z Metabolic