CASE 1

PRESENTATION
Resource faculties:
Prof. Jyotsna Rimal
Dr. Iccha Kumar Maharjan Presenter :
Dr. Pragya Regmee Dr. Sagar Adhikari
JR- I

Department of Oral Medicine and Radiology

 Demographic Details

• Name: Pinky Devi Marital status: Married

• Age/ Gender: 31/F Patient ID number: 2938270
• Address: Banarkulla-8,
Phone number: 9861677337
Saptari
SES: Upper middle
• Occupation: Housewife
• Religion: Hindu
• Date: 8th Feb 2018 2
 Chief complain
• Complains of mass in upper surface of tongue since 4 months

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 History of presenting illness

• Apparently well 4 months back when she noticed growth of mass in upper
surface of tongue.
• Insidious onset, it was gradually progressive in nature (Initially it was small
and has progressed to present size).
• No known history of trauma. No history of tongue bite.
• No history of pain associated with mass.

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• No history of ulceration over the mass. No history of discharge from the
mass.
• No history of similar mass present in other part of the mouth/body.
• No history of similar mass present in other members of the family.
• No history of functional disturbances due to presence of mass.

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• No history of regression and recurrence of the mass in between.
• No history of altered bowel and bladder habit.
• No history of any medical/ dental consultation done for the same.

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Medical History: No relevant medical history reported.

Family History: No relevant family history reported.

Past Dental History: First dental visit.

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Personal History:

• Diet history: Mixed diet, 2 major (rice, pulses, vegetables) + 2 minor (tea,
snacks) meals/day.

• Oral hygiene: Brushes twice daily with medium bristle toothbrush and
fluoridated toothpaste for 3-4 minutes in vertical/horizontal stroke motion.
Changes her toothbrush every 2-3 months. Occasional use of tooth pick.

• Deleterious habit: Not present. 8

General examination

• Vitals: Peripheral Signs:

• Pulse: 74 beats/minute Pallor

• Respiratory rate: 18 cycles/ minute, abdominothoracicIcterus

• Blood pressure: 120/ 80 mmHg in right arm in supine Cyanosis
Absent
position Clubbing
• Temperature: Afebrile to touch Edema
Dehydration 9
• Height: 4 feet 8 inch (as said by patient)
• Weight: 41 kg
• Body mass index: 20.3 kg/sq m

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Extraoral examination:
No abnormality detected in:
Face
Skin
Hair
Eyes
Ears
Nose 11
Body Examination

Her general body examination was done to check for presence of

any mass/swelling in the body.

No any mass/ swelling was present in the body.

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 Temporomandibular Joint (TMJ)
• Inspection:
Bilateral pre-auricular area appeared symmetrical.
• Palpation:
• Extra-auricular: Bilateral well coordinated synchronous movement of
condyle felt. No tenderness present at rest, occlusion, right/left lateral
excursion, protrusion and mouth opening. No joint noise felt
• Intra-auricular: No tenderness present at rest, occlusion, right/left lateral
excursion, protrusion and inter-incisal opening.
• Auscultation: No joint noise heard.
• Range of motion: Interincisal opening: 42mm, Right/left lateral excursion:
8mm 13
• Protrusion: 7mm, No deflection/deviation present.
Muscles of Mastication

• Primary muscles of mastication: Bilateral temporalis and masseter

appeared symmetrical with adequate bulk of masseter on palpation.
Bilateral lateral and medial pterygoid are non-tender on functional and non-
functional manipulation.
• Accessory muscles of mastication: Bilateral digastric, sternocleidomastoid
and trapezius appeared clinically normal.

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Lymph Node:
• Submental, bilateral submandibular and cervical nodes not palpable

Cranial Nerve Examination:

• No abnormality detected in bilateral trigeminal and facial nerve
examination.

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 Intraoral examination
• Halitosis: Not present

Soft tissue:
• Right/left buccal mucosa, upper/lower labial mucosa, hard/soft palate, ventral
surface of tongue, floor of mouth, anterior/posterior faucial pillars, bilateral tonsils
and posterior pharyngeal walls appeared clinically normal.
• Maxillary and mandibular labial frenum has mucogingival level of attachment.
• Bilateral parotid and submandibular gland salivary flow is clear, copious and watery.

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 Local Examination: Dorsal surface of Tongue
Inspection: On dorsal
surface of tongue, left side
of midline, single, well
defined, roughly ovoid,
sessile mass, pink in color
with smooth surface
measuring about 5 mm in
maximum diameter. No
ulceration over the mass,
discharge from the mass.
Overlying and surrounding
mucosa appeared normal. 17
 Local Examination: Dorsal surface of Tongue
Palpation: All the inspectory
findings were confirmed.
Firm in consistency, non
reducible, non compressible
and non pulsatile and non
tender. Peripheral
induration was absent. Size
of the mass was 6 mm in
maximum diameter
measured with periodontal
probe. 18
Gingiva:
• Color: pink with generalized diffused gingival pigmentation
• Contour: scalloping margin
• Consistency: firm
• Size: not enlarged
• Stippling: present
• Bleeding on probing: absent
• Position: at the level of CEJ
• Periodontal pocket: absent
• Furcation involvement : absent 19
 Hard tissue

• Generalized plaque and

stains deposits.
• Occlusal pit caries: 47
• Overjet: 2mm
• Overbite: 3mm
Molar relation: Bilateral Angle’s Class I
Canine relation: Bilateral class I 20
 Case summary
• A 31 years female presented to the Department of Oral Medicine and
Radiology with chief complaint of growth of mass on upper surface of
tongue since 4 months.

• Insidious in onset, it was gradually progressive in nature (Initially it was

small and has progressed to present size). No any other relevant history
of presenting illness was present.
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On local examination
Inspection: On dorsal surface of tongue, left side of midline, single, well
defined, roughly ovoid, sessile mass, pink in color with smooth surface
measuring about 5 mm in maximum diameter. No ulceration over the mass,
discharge from the mass. Overlying and surrounding mucosa appeared
normal.

Palpation: All the inspectory findings were confirmed. Firm in consistency,

non reducible, non compressible and non pulsatile and non tender.
Peripheral induration was absent. Size of the mass was 6 mm in maximum
diameter measured with periodontal probe.
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 Provisional diagnosis
Fibroma, dorsal surface of tongue

• History
• Clinical examination

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 Differential diagnosis: Fibroma

Disease Points for Points against

Giant cell fibroma Size, age, Nodular surface, most

appearance common in gingiva
Neurofibroma Clinical appearance, Usually multinodular,
site associated with pain
or tingling sensation

Fibrolipoma Site, size, age, Soft to firm

appearance consistency, slippery,
yellowish hue, 24
presence of fat cells
 Differential diagnosis: Fibroma

Disease Points for Points against

Squamous papilloma Small isolated growth and Usually on palate,

color pedunculated, lobulated
surface
Pyogenic granuloma Soft tissue mass, smooth Usually pedunculated,
surface, sessile common in gingiva, red
color, blanches on
pressure, bleeds on
provocation
Minor salivary gland Painless swelling, Lymph nodes, ulceration,
tumor duration, no signs of induration, fixity,
inflammation paresthesias, no rapid 25
growth
 Investigations
• Complete blood count
• Serology
• Random blood sugar

 Excisional biopsy of mass on dorsal surface of tongue

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Systemic phase:
Treatment plan
• Not required
Initial phase:
• Oral prophylaxis and oral hygiene instructions (Dept. of Periodontology and Oral
Implantology)
Corrective phase:
• Excision of mass on dorsal surface of tongue (Dept. of Oral Medicine and
Radiology)
• Restoration of 47 (Dept. of Conservative dentistry and Endodontics)
Maintenance phase: Maintain good oral hygiene, follow up with investigation
report for excisional biopsy. 27
Follow up:

SN Parameters Values Reference range

1 Hemoglobin 12.3 gm/dL 11-16
2 TLC 8200 cells/mm cube 4000-11000
3 DLC N 52, L 38, M 06, E05 N 40-75, L 20-45, M 2-10, E 1-
6
4 Platelets 333000 cells/ mm cube 150000- 400000
5 Serology HIV, HBsAg, HCV (Negative)
6 Random Blood 100 mg/dL < 140
Sugar
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SN Parameters Values Reference range

7 Bleeding time 3 minute 3-6 minute

8 Clotting time 7 minute 6-10 minute

9 Prothrombin time/INR 14 sec/1 14-16 sec

10 Activated partial 29 sec 26-45 sec

thromboplastin time

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 Excisional biopsy
• Excision of the mass on dorsal surface of tongue was done under local
anesthesia under aseptic condition.
• 1 surgical knot was made with 3-0 silk suture.
• Hemostasis was achieved.
• Post-operative instructions given.
Rx
1. Tab Flexon 1 tab PO x TID x 1 day and then SOS.
Advice: 30
Maintain good oral hygiene and follow up after 7 days for suture removal.
 Follow up after 10 days of Excision

Sutures removed, healing wound present, patient asked to follow up on 15 31

days.
Histopathological picture:

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Follow up after 25 days of excision
Asked to follow up on 3 months 33
Follow up after 3 months
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BEFORE AFTER

1st Visit 2nd Visit: After 10 days

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3rd Visit: After 3 months
 Discussion: Oral Fibroma
 Most common benign soft tissue lesion of oral cavity.

Most of them are reactive focal fibrous hyperplasia due to trauma or local
irritation.

The term “Focal fibrous hyperplasia” more accurately describes the clinical
appearance and pathogenesis.
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Epidemiology:

• South India: 0.84% (Mathew 2007)

• Malaysia: 16% (Halim 2010)

• Spain: 53% (Domingo 2008)

• This significant variation in prevalence of fibroma can be attributed to the

type and duration of the study as well as sample size that was involved in
the study. 37
 Clinical features:
 Age: May occur at any age, common in 3rd, 4th and 5th decade.
 Gender: no specific gender predilection.
 Site: May occur at any site , most commonly on buccal mucosa along the
occlusal plane.
Features:
Round to ovoid, asymptomatic, smooth surfaced, firm, sessile or
pedunculated mass.
Diameter may range from few mm to cms.
Surface may be hyperkeratotic or ulcerated due to trauma. 38
 Histopathology

• Hyperkeratotic, atrophic or ulcerated epithelium.

• Hyalinized fibrous connective tissue.
• Bundles of collagen fibres often arranged in haphazard fashion.
• Multiple endothelial lined blood vessels.
• Scant chronic inflammatory cells infiltrate.

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 Management:
 Conservative surgical excision is the best treatment of choice.
 Recurrence is very rare but possible if offending irritant is still present.

Advances:
Soft tissue laser: Nd:YAG laser excision; non-contact, 250 mJ/15 Hz,
average power 3.75 W

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Condition associated with multiple fibromas
Cowden syndrome (multiple hamartoma and neoplasia syndrome)

Autosomal dominant {mutations in the phosphatase and tensin homolog gene

(PTEN)}
 Oral/ perioral findings: multiple papules on the lips and gingivae, papillomatosis
(benign fibromatosis) of buccal, palatal, faucial, and oropharyngeal mucosa producing
a “cobblestone” effect, tongue is also pebbly or fissured. 41
Tuberous sclerosis

Inherited disorder caused by mutations in the tuberous sclerosis complex (TSC1 or

TSC2) genes.
Fine wart-like lesions (adenoma sebaceum) occur in a butterfly distribution over
the cheeks and forehead.
Intraorally multiple fibromas with characteristic hypoplastic enamel defects (pitted
enamel hypoplasia) occur. 42
 Variants:
Fibrolipoma: histological variant of lipoma, mostly affect the buccal
mucosa and causes functional and cosmetic disabilities.

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Pereira T, Shetty S, Sapdhare S, Tamgadge A. Oral fibrolipoma: A rare histological variant . Indian J
Dent Res 2014;25:672-4
Fibrosarcoma: malignant mesenchymal tumour derived from fibrous
connective tissue and characterized by the presence of immature
proliferating fibroblasts or undifferentiated anaplastic spindle cells in a
storiform pattern.

Daroit N, Maraschin B, Carrard V, Rados V, Visioli F. Submucosal nodule in buccal mucosa. Oral Surgery, Oral 44
Medicine, Oral Pathology and Oral Radiology. 2016; 122(6): 660-665
 Angiofibroma: Angiofibromas are highly vascular, histologically
benign but locally aggressive tumours.

Thakur RK, Madan E, Tomar A, Arora M. Angiofibroma on cheek mucosa: a rare entity and its management 45
with laser. Journal of cutaneous and aesthetic surgery. 2014;7(4):227-8.
 Conclusion
Oral fibroma is a common soft tissue lesion occurring in patients without
very specific age and gender predilection.
The true fibroma is very rare and majority of cases corresponds to a fibrous
hyperplasia caused by chronic irritation or trauma.
To arise at a definitive diagnosis, these soft tissue growths and swellings,
must be diagnosed clinically and histopathologically.

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 References
 Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015
 Neville B., Damm DD , Allen CM , Bouquot J and Neville BW. 2009. Oral And Maxillofacial Pathology, 3rd ed.
United Kingdom: Saunders Elsevier.
 Shafer WG, Hine MK, Levy BM, Rajendran R, Sivapathasundharam B. A textbook of oral pathology.
Philadelphia: Saunders; 1983 Sep 20.
 Torres-Domingo S, Bagan JV, Jiménez Y, Poveda R, Murillo J, Díaz JM, Sanchis JM, Gavaldá C, Carbonell E.
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cases. Oral Med Pathol;6:91-94.
 Halim D, Pochi A, Yi P. The Prevalence of Fibroma in Oral Mucosa Among Patient Attending USM Dental Clinic
Year 2006-2010. The Indonesian J Dent Res. 2010; 1(1): 61-66
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 References
• Pereira T, Shetty S, Sapdhare S, Tamgadge A. Oral fibrolipoma: A rare histological variant . Indian J Dent Res 2014;25:672-4
 Parker s. Lasers and soft tissue: ‘loose’ soft tissue surgery. British Dental Journal. 2007; 202: 185-191
 Sanchana VB, Brundha MP. INFLAMMATORY FIBROMA OF ORAL CAVITY- review. International Journal of Recent Advances in
Multidisciplinary Research. 2016; 3(9): 1808-1810.
 Thakur RK, Madan E, Tomar A, Arora M. Angiofibroma on Cheek Mucosa: A Rare Entity and its Management with
Laser. Journal of Cutaneous and Aesthetic Surgery. 2014;7(4):227-228.
 Khubchandani M, Thosar NR, Bahadure RN, Baliga MS, Gaikwad RN. Fibrolipoma of buccal mucosa. Contemporary Clinical
Dentistry. 2012;3(Suppl1):S112-S114.
 Mathew A, Pai K, Sholapurkar A, Venqal M. The prevalence of oral mucosal lesions in patients visiting a dental school in
Southern India. IJDR. 2008; 19(2): 99-103.
 Krishnan V, Shunmugavelu K. A clinical challenging situation of Intra oral fibroma mimicking pyogenic granuloma. The Pan
African Medical Journal. 2015;22:263.
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