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2014 course two GINGIVAL PATHOLOGY The primary focus of this study centers on abnormal proliferations and disease processes that can involve the gingiva, either exclusively or as a part of their spectrum. While we are unable to discuss all of these entities, we will limit the current discussion to some of the more common ones. written by amber kiyani, dds edited by rachel a. flad, bs karen k. daw, mba, cecm INTRODUCTION Oral health professionals are given the task of maintaining gingival health. Gingivitis and periodontitis are the most common gingival pathology and, in most cases, remediation can be simply achieved by enforcing vigorous plaque control measures. Considering the extensive knowledge of dentists and dental hygienists about plaquerelated pathology, we are excluding the discussion on gingivitis and periodontitis in this study. Topics that will be covered in this study include: Cysts and Tumors Reactive Proliferations Hyperplasia Infections Autoimmune Processes Pigmented Lesions Premalignant and Malignant Processes CYSTS AND TUMORS GINGIVAL CYST: A gingival cyst is classified as an odontogenic cyst arising from remnants of dental lamina, the band of epithelial tissue which gives way for developing teeth. It is considered a soft tissue counterpart of a lateral periodontal cyst, due to remarking similarity in their histopathologic features. Gingival cysts are usually identified Fibroma in patients older than 50 years of age. Facial gingiva of the mandibular canine and premolar region is more frequently involved. They appear as small, smooth surfaced, blue swellings that are primarily asymptomatic. Conservative surgical excision is the treatment of choice. Recurrence rates are negligible. FIBROMA: Fibroma is a benign proliferation of fibrous connective tissue identified in areas undergoing chronic irritation or trauma. Source: www.brown.edu Fibromas show no age or sex predilection. They are commonly identified in the buccal and labial mucosa, tongue, and gingiva. They appear as mucosal colored, sessile nodules that are firm on palpation. Presence of surface ulceration may be accompanied by some pain and discomfort. Page 2

Conservative surgical excision with submission of tissue for histopathologic examination is recommended. INFLAMMATORY FIBROUS HYPERPLASIA: Inflammatory fibrous hyperplasia, or denture epulis, are benign proliferations of fibrous connective tissue that develop in association with an ill-fitting dental prosthesis. This process is usually identified in older individuals, and women tend to be more commonly affected. It appears as mucosal colored folds of hyperplastic tissue that correspond with the ill-fitting flange of the denture. The hyperplastic tissue is firm and fibrotic on palpation. While most lesions are primarily asymptomatic, occasional reports of pain and discomfort may be noted when ulceration is present. The size of the lesion can be highly variable, ranging between a few millimeters to the entire length of the vestibule. Surgical excision of hyperplastic tissue with remaking or relining of the dental prosthesis is recommended. The excised tissue should be submitted for histopathologic examination to rule out any significant pathology mimicking this benign process. GIANT CELL FIBROMA: Giant cell fibroma is a benign fibrous neoplasm that does not show an association with trauma. Giant cell fibromas are more frequently seen in younger patients. A female predilection is noted in some studies. Most lesions are identified on the gingiva, but other sites of occurrence include the tongue and the palate. The lesion appears as a small, mucosal colored, papillary nodule that can often be mistaken for a squamous papilloma. Retrocuspid papilla is a name given to small, mucosal colored nodules that appear on lingual mandibular attached gingiva of canines. The lesions are frequently bilateral and are mostly identified in children. They tend to disappear as the person ages. They show striking clinical and histopathologic similarity to giant cell fibromas. The lesion requires conservative surgical excision for treatment. The excised giant cell fibroma should be submitted for histopathologic examination to confirm diagnosis. INTRA-OSSESOUS CYSTS AND TUMORS: It is not uncommon for intra-osseous cysts and benign and malignant tumors to erode through the cortical bone and appear as soft tissue masses. A radiograph is usually sufficient to determine an osseous origin. Benign cysts and tumors tend to exhibit distinct margin, while malignancies are locally destructive with illdefined margins. REACTIVE PROLIFERATIONS PARULIS: Parulis (gum boil) is a collection of granulation tissue at the site of the sinus tract opening of a dental abscess. Parulides can be seen in patients over a wide age range. They present as small, red or yellow colored nodules on the alveolar or palatal mucosa. Patients usually report recurrent episodes of enlargement and compression of the nodule. Compression is accompanied by discharge of foul-tasting pus. The offending tooth can be identified by pulp testing the teeth in the vicinity. If pulp testing does not yield favorable results, insertion of a gutta percha point into the sinus tract followed by radiographic imaging may aid in identifying the responsible non-vital tooth. Endodontic treatment or extraction of the offending tooth leads to complete resolution of symptoms. Page 3

PERIPHERAL OSSIFYING FIBROMA: Peripheral ossifying fibroma is a common, reactive proliferation of fibroblasts that occurs exclusively on the gingiva. Despite the similarity in names, this lesion is distinct from a central ossifying fibroma; a benign intraosseous neoplasm. The lesion is identified more commonly in women in their 20s. Peripheral ossifying fibroma appears as a smooth, pink, and sessile nodule. Surface ulceration and erythema are frequently noted. It is relatively smaller in size and rarely enlarge beyond 2 centimeters. The lesion is firm to hard in palpation depending on the amount of bone formation. Conservative surgical excision is the treatment of choice. Histopathologic examination is necessary in order to establish diagnosis. A small percentage of peripheral ossifying fibromas tend to recur. PERIPHERAL GIANT CELL GRANULOMA: Similar to peripheral ossifying fibroma, peripheral giant cell fibroma is also a reactive proliferation that exclusively involves the gingiva. Some studies have suggested that peripheral giant cell granuloma is the soft tissue counterpart of central giant cell granuloma. Surgical removal is the primary treatment. 10-15% of the lesions may recur locally. PYOGENIC GRANULOMA: Despite the highly suggestive name, pyogenic granuloma has no association with microbial infections. It is a reactive proliferation of granulation tissue, possibly induced due to low grade irritation or trauma. Pyogenic granulomas can be seen in patients of all ages. Some studies have suggested a strong female predilection. Gingiva is the most frequent site of involvement. The lesion may also be identified on the tongue, lips, and buccal mucosa. Cutaneous involvement with this process is common. It appears as a red, lobulated growth that is frequently ulcerated, and it tends to bleed easily on manipulation. The ability of rapid growth in pyogenic granulomas can occasionally generate concerns about malignancy. Pyogenic granulomas are a frequent finding on the gingiva of pregnant women and may be referred to as a pregnancy tumor. Hormonal changes are considered an etiological factor in the pathogenesis of this process. These lesions tend to enlarge over the course of the pregnancy. Once the child is delivered, remission is usually noted. Peripheral giant cell granuloma can be seen in individuals over a wide age range. A female predilection is noted. Lesions tend to occur more commonly in the mandible. They appear as a redblue, smooth-surfaced, and sessile nodules. Surface ulceration is a common finding. Peripheral giant cell granulomas remain relatively small, rarely exceeding their dimensions by a couple of centimeters. While this lesion does not invade the underlying alveolar bone, it can cause surface resorption leading to a cupping defect that can be occasionally identified radiographically. Oral Pyogenic Granuloma Source: Carl Allen, DDS The Ohio State University College of Dentistry Page 4

Conservative surgical excision with submission of tissue for histopathologic examination is usually the preferred choice of treatment. Recurrence rates are very similar to peripheral ossifying fibroma and peripheral giant cell fibromas. Excision of pregnancy tumors should be delayed until the baby is delivered. HYPERPLASIA DRUG-RELATED GINGIVAL HYPERPLASIA: Gingival growth has been known to occur secondary with the use of certain medications: Phenytoin- an anti-seizure medication Cyclosporine- an immunomodulator Nifedipine- an antihypertensive drug These drugs are likely to interfere with the collagen remodeling process resulting in excess accumulation of the protein in tissues. Gingival hyperplasia associated with medication can be seen over a wide age range. Facial aspects of anterior gingiva are more extensively involved. Gingival enlargement initiates at the interdental papillae and eventually covers the crowns of teeth, either partially or completely. The enlarged tissue has an irregular appearance and is firm on palpation. If oral hygiene is not effectively maintained, the hyperplastic gingiva may become erythematous, edematous, and friable. Surface ulceration may also be identified. Edentulous areas are rarely affected. Patients using cyclosporine can exhibit hyperplastic growth in other oral soft tissues. Once the drug is identified as the offending agent, the patient s physician is requested to discontinue the current medication. Significant improvement in the condition is seen following cessation of the offending drug. To improve esthetics, procedures such as gingivectomy and gingivoplasty may be performed. HERPETIC INFECTION: INFECTIONS Herpes simplex virus has two subtypes, Type I primarily affects the tissues above the diaphragm, while Type II affects the tissues below the diaphragm. The discussion in this section will center around Type I. Herpes simplex virus Type I spreads through saliva or contact with active lesions. This virus has the ability to migrate to the sensory ganglion following primary infection and cause recurrent infections over subsequent years. Primary herpetic gingivostomatitis occurs more commonly in children. Symptoms include fever, malaise, lymphadenopathy, anorexia, and irritability. Mucosal lesions begin as numerous tiny vesicles that evolve into painful ulcers. Adjacent lesions can coalesce to form larger defects. Any part of the oral mucosa may be involved. Gingiva appears erythematous and swollen. Fingers, eyes, and the genitals can acquire the virus through self-inoculation. Complete resolution occurs within a week. Adult infections are very similar to herpetic gingivostomatitis except that the mucosal lesions tend to occur in the pharyngotonsillar region. Recurrent herpetic infection frequently presents as herpes labialis or a cold sore. The onset of blisters may be preceded by a prodromal phase characterized by a tingling and burning sensation. Recurrent lesions may also be identified on the oral mucosa. In such instances, gingiva and the palate are common sites of involvement. Infections in immunocompromised patients tend to be more frequent, severe, and persistent. The diagnosis can be made on the basis of clinical presentation. Cytology can aid in establishing a definitive diagnosis if it is performed within 72 hours of the onset of lesions. Use of antivirals, such as acyclovir and valacyclovir, earlier in the course of disease may lead to faster resolution. Supportive treatment such as fluids, Page 5

topical anesthetics and non-steroid antiinflammatory drugs can assist in alleviating symptoms. HERPES ZOSTER: The varicella zoster virus causes both chickenpox and herpes zoster. The virus becomes latent in the geniculate ganglion following initial infection and has the ability to reactivate in patients in advanced age and immunocompromised states. Herpes zoster is rarely seen in immunocompetent individuals under the age of 50. The reactivated virus produces tingling or pain along the course of a single dermatome. Elevated temperature, fatigue, and body aches occur before the onset of cutaneous lesions. As the virus travels through the nerve, the pain intensifies and is followed by the development of pustules along the nerve pathway. The lesions do not cross the body s midline. The pustules rupture to form small ulcers and eventually form a yellow colored crust. It takes 2-3 weeks for complete healing to occur. A significant degree of pain may persist up to several months following recurrent infection. When the trigeminal nerve is involved, intraoral lesions may be seen. The lesions appear as white vesicles that rupture to form shallow painful ulcers. The course of the disease is very similar to cutaneous lesions. Early treatment with antivirals may limit the course of disease. Supportive treatment with antipyretics and antipruritics is usually beneficial. NECROTIZING ULCERATIVE GINGIVITIS: Necrotizing ulcerative gingivitis, also known as trench mouth, is a bacterial infection precipitated by stress, immunosuppression, nutritional deficiency, and smoking. The process is linked to a decrease in immune response against pathogenic organisms due to stress hormones. Necrotizing ulcerative gingivitis is seen over a wide age range. A higher prevalence is noted in younger individuals in stressful situations. The process begins as generalized inflammation, edema, and bleeding of the interdental papillae. The papillae eventually undergo epithelial necrosis to produce classic punched-out ulcerations. The necrosed tissue is covered by an adherent white to gray pseudomembrane. The condition is extremely painful and emanates a foul odor. Fever, malaise, and lymphadenopathy may accompany the process. The condition is treated by local debridement and use of topical and systemic antibiotics. Once the offending bacteria are killed, regeneration of the gingiva usually occurs. Supportive treatment may be necessary if ancillary symptoms are also present. AUTOIMMUNE PROCESSES MUCOUS MEMBRANE PEMPHIGOID: Mucous membrane pemphigoid, also known as cicatricial pemphigoid, is an autoimmune blistering disease that primarily affects the oral mucosa, skin, and conjunctiva. The body produces antibodies against the proteins uniting the epithelium with the underlying connective tissue resulting in blister formation. The condition is more commonly seen in females in their 50s and 60s. Oral lesions are seen in a majority of patients affected by this condition. They begin as small blisters that eventually rupture to form painful ulcers that persist for several weeks. Intact vesicles are rarely identified. Gingival involvement presents as desquamative gingivitis characterized by diffuse atrophy and ulceration. Conjunctival and cutaneous lesions heal by scarring (cicatrix). If conjunctival lesions are not promptly managed, blindness may result. Diagnosis and Biopsy of lesional and perilesional tissue is performed for establishing diagnosis. Lesional tissue is s u b mi t ted for h is to pa th ologi c examination, while perilesional tissue should be submitted for immunofluorescent studies. Once Page 6

the diagnosis is confirmed, the patient should be referred to an ophthalmologist to rule out eye involvement. If no eye involvement is identified, topical corticosteroids are usually sufficient for management. If scarring of conjunctival tissue is noted, systemic therapy becomes mandatory. LICHEN PLANUS: Lichen planus is an immune-mediated process that may involve the oral and genital mucosa, and the skin. Oral lichen planus is relatively common. The precipitating factor for this condition is currently not known. It is broadly classified into reticular and erosive forms. Lichen planus tends to affect people in their 40s and 50s. Women appear to be more frequently affected. Cutaneous lesions present as small, pruritic, purple colored papules on the wrists, ankles or the base of the spine. The papules exhibit white, lace-like striation on the surface. Reticular lichen planus is relatively more common than the erosive form. It presents as symmetrically bilateral, white lace-like striations primarily involving the buccal mucosa. Tongue, palate, and gingiva may also be affected. Most patients are unaware of the presence of this condition. Erosive lichen planus presents as bilateral, symmetrical ulceration involving the buccal mucosa and tongue. Around the margins of the ulceration, erythema and lace-like striation, similar to reticular lichen planus, can be identified. The lesions are extremely painful forcing most patients to seek help for the condition. Gingival involvement presents as desquamative gingivitis. Occasionally, gingival atrophy and ulceration may be the only presentation of disease. Identification of striation may be difficult in such cases. Diagnosis can usually be made on the basis of clinical appearance. A biopsy of the erosive form with submission of tissue for histopathologic and immunofluorescent studies, is advised. This prevents misdiagnosing cases of chronic ulcerative stomatitis and lupus erythematosus as erosive lichen planus. Reticular lichen planus requires no treatment. The patient should be reassured and monitored periodically for changes in appearance. Erosive lichen planus can be controlled by use of potent topical steroids. LICHENIOD MUCOSITIS: Lichenoid mucositis is a term used to describe a specific immune-mediated response of the body against foreign material, drugs, artificial cinnamon flavoring, and dental amalgam. While the clinical presentation of these lesions can be quite diverse, they bear a striking resemblance to lichen planus histologically. Posterior buccal mucosa and the tongue are frequently involved with drug-related and contact mucositis. For amalgam reactions, the changes are noted only in the mucosa coming into contact with the restoration. Lichenoid foreign material reaction primarily involves the gingiva. It is considered to be an abnormal response of mucosa against particles originating from dental disks, polishing materials, and dentifrices. It can present itself as isolated, as generalized areas of erythema, or as an ulceration resembling desquamative gingivitis. A biopsy should be performed and submitted for histopathologic examination. It is unlikely to identify the foreign material during histopathologic evaluation. Most cases resolve spontaneously once the foreign material is expelled. In chronic symptomatic cases, surgical excision may be the only course of action. PIGMENTED LESIONS AMALGAM TATTOO: Amalgam tattoo is discoloration of the oral mucosa due to embedded amalgam particles. In most instances the particles are incorporated following placement or removal of an amalgam restoration. Amalgam tattoos are seen in patients over a wide age range. Since it is not the preferred choice of restoration material in pediatric patients, the frequency of tattoos identified in this population is low. They appear as grey colored macules most Page 7

commonly involving the gingiva. Usually an amalgam restoration can be identified in the vicinity of the lesion. Since amalgam is also employed as a retrograde filling material, sometimes tattooing can be identified on the attached labial gingiva of anterior teeth. Diagnosis and Clinical appearance is usually sufficient for diagnostic purposes and no further intervention is warranted. If the clinician is unsure about the discoloration, radiographs may be helpful in identifying amalgam particles in the mucosa. When no particles are noted, or if the patient has esthetic concerns, conservative surgical excision followed by histopathologic examination should be performed. MELANOTIC MACULE: Melanotic macule is a pigmented lesion that results from focal deposition of melanin in oral soft tissues. Some studies have implicated trauma as a potential etiological factor. Melanotic macules occur over a wide age range. Lips are the most common site of involvement. Buccal mucosa, palate, and gingiva may also be involved. They present as well-demarcated brown to black macules. They tend to be less than one centimeter in size. The diagnosis of melanotic macule can be made on the clinical presentation. No treatment is necessary. Dimensions of the lesion should be documented at the initial visit. If any changes in appearance and size are noted at the follow up visit, an excisional biopsy of the lesion may be mandated. Some patients may also request removal due to esthetic reasons. SMOKER S MELANOSIS: Smoker s melanosis is pigmentation of oral tissues in heavy smokers. Melanin is produced as a protective response of oral mucosa against toxic products of cigarette smoke. Amalgam Tattoo Smoker s melanosis occurs more commonly in Caucasians and shows a female predilection. It is presented as diffuse, light brown pigmentation. Anterior facial gingiva is more frequently involved. Diagnosis and A history of cigarette smoking or clinical evidence of smoking is sufficient for diagnostic purposes. The pigmentation usually disappears within a few months of smoking cessation. MELANOMA: Melanoma is the malignant tumor of melanocytes. It is primarily a cutaneous malignancy but can be identified in the esophagus, small and large bowel, eye, parotid gland, nasopharynx, and the mouth. Acute damage by ultraviolet radiation is implicated as an etiological factor in cutaneous lesions, however definitive cause for mucosal lesions is currently unknown. Oral melanomas are relatively rare and accounts for less than 1% of all melanomas. Oral melanomas tend to be more aggressive than cutaneous melanomas. Source: Amber Kiyani, DDS The Ohio State University College of Dentistry Oral melanomas occur in older individuals. Maxillary gingiva and the hard palate are more commonly involved. The lesion initially presents as a large, brown to black macule, with irregular borders. This macule rapidly evolves into an exophytic lesion. Ulceration is a frequent finding. The tumor is aggressive and can erode into the Page 8

underlying bone creating a radiographically visible defect. Some lesions may be devoid of pigmentation and may appear mucosal colored. Such lesions are difficult to diagnose clinically and are referred to as amelanotic melanoma. Diagnosis Pigmented lesions involving the palate and alveolar gingiva should always be biopsied. The pathologist may need to perform a series of immunohistochemical studies to establish definitive diagnosis. Surgical excision with wide margins is the preferred choice of treatment. For deeper lesions, lymph node dissection, radiation, and chemotherapy may also be needed. PREMALIGNANT AND MALIGNANT PROCESSES LEUKOPLAKIA: Leukoplakia is a clinical descriptor for white patches, or plaques, in the oral cavity that have distinct margins. While most leukoplakias may represent a premalignant process, definitive diagnosis of dysplasia can only be provided once the lesion has been biopsied and has undergone histopathologic examination. vestibule. Cessation of product did not lead to resolution. If the lesion is small, complete surgical excision extending to normal adjacent tissue is recommended. Larger lesions require incisional biopsies. The excised specimen should be submitted for histopathologic evaluation. To preserve the integrity of tissue for histopathologic examination, use of lasers should be avoided during excision. Lasers can compromise the tissue sample, making it difficult for the pathologist to establish diagnosis. Lesions with a diagnosis of epithelial atypia and mild epithelial dysplasia should be closely monitored at 3 to 6 month intervals. If any changes are noted in appearance, texture and size, the lesion should undergo additional biopsies and the course of treatment should be decided accordingly. Leukoplakias that are diagnosed to be moderate to severely dysplastic should be either surgically excised or laser ablated completely. Since 30% of all leukoplakias can recur, close clinical follow up is recommended for all patients that have leukoplakia surgeries. Leukoplakias are usually seen in patients over the age of 40 and they exhibit a strong male predilection. Use of tobacco products, alcohol and sanguinaria are some of the common etiologic factors associated with this process. Studies have also implicated syphilis and candia as possible etiologies. Most lesions are identified on the lip, buccal mucosa, and gingiva. The lesions can have variable appearances; translucent, wrinkled, homogenous, nodular, and speckled. Variations in size is also noted. The lesions are crisply demarcated from the adjacent normal tissue. Sanguinaria is an herbal extract that was extensively used in dentifrices in the 1970s. Patients that used this product over a period of time developed characteristically thin, white plaques on the maxillary alveolar gingiva or Leukoplakia Source: Carl Allen, DDS The Ohio State University College of Dentistry PROLIFERATIVE VERRUCOUS LEUKOPLAKIA: Proliferative verrucous leukoplakia is a condition characterized by development of multiple leukoplakic lesions in the oral cavity. Women tend to be more frequently affected. Gingiva is a common site of involvement. The leukoplakias may evolve to verrucous carcinoma or squamous c e l l c arcinoma o ve r a pe ri od of years. Page 9

Due to extensive involvement of the mucosa, complete surgical excision of all leukoplakias is not an option. These patients need to be closely monitored for changes in size, texture and appearances and regularly biopsied. If malignant transformation is suspected, prompt laser ablation or surgical excision of the area is recommended. SQUAMOUS CELL CARCINOMA: Squamous cell carcinoma accounts for over 90% of oral malignancies. Cigarette smoking is associated as the most common cause for this cancer. Other etiological factors include smokeless tobacco, betel quid, iron deficiency, microbial agents, chemical agents and genetic influences. Oral cancer tends to occur in people between 40 and 80 years of age. Men appear to be more frequently affected. It can present as a chronic ulceration, an endophytic mass, a fungating tumor, or as red-white patches. Ulceration, rolled border, and induration are frequent findings. The surface of the tumor is usually irregular and pain may be occasionally noted. The size of the lesions vary considerably. The tumor is locally destructive and may erode into the underlying bone to create radiographically identifiable changes. Gingival lesions show a female predilection and are not consistently associated with cigarette smoking. They develop more commonly in the posterior mandibular region and may appear deceptively innocuous. They tend to mimic benign reactive processes such as inflammatory fibrous hyperplasia and pyogenic granulomas. Local growth eventually results in invasion of the underlying bone and tooth mobility. Diagnosis and All clinically suspicious lesions should be biopsied and submitted for histopathologic examination. Once the diagnosis is confirmed, the patient is referred to an otolaryngologist. Surgical excision, radiation, and chemotherapy are the available treatment options. LYMPHOMA: Lymphoma is a lymphoproliferative disorder. It is broadly classified as Hodgkin s and non- Hodgkin s lymphoma. Hodgkin s lymphoma primarily affects the lymph nodes, while non- Hodgkin s lymphoma is more frequently identified in extralymphoid tissues. Hodgkin s lymphoma presents with lymphadenopathy commonly involving the cervical, axillary, and mediastinal regions. Non- Hodgkin s lymphoma is characterized by fever, malaise, night sweats, and weight loss, along with lymphadenopathy. Non-Hodgkin s lymphoma can occasionally present as an intraoral mass involving the jaws, palate, or gingiva. In some instances, the soft tissue swelling may result from malignant cells breaking out of bone. The mass is erythematous and can be either smooth surfaced or ulcerated. It tends to have a boggy consistency. In case of intraosseous involvement, a ragged radiolucency may be identified. Diagnosis and The diagnosis of lymphoma is established through lymph node biopsy, flow cytometry, immunophenotyping, and fluorescence in-situ hybridization studies. If the oral mass is the only presenting symptom, submission of tissue for histopathologic examination and immunohistochemical studies allows the pathologist to render a definitive diagnosis. LEUKEMIA: Leukemia is a hematopoietic malignancy characterized by abnormally increased levels of immature leukocytes in bone marrow and blood. It is broadly classified under myeloid and lymphocytic types. Acute lymphocytic leukemia is more common in children and follows an aggressive clinical course. Newer forms of chemotherapy have significantly improved the prognosis for this process. Acute myelogenous leukemia primarily affects adults and has unfavorable survival rates despite chemotherapy. Page 10

Chronic forms of both lymphocytic and myeloid leukemia are common in adults and run an indolent course. Fever, fatigue, weight loss, oral ulcers, and an increased frequency of infections are some of the initial symptoms at presentation. Easy bruising and anemia slowly develop. Extramedullary disease may involve the skin, central nervous system and the gingiva. The gingiva appears ulcerated, erythematous, and swollen. It is firm on palpation and can sometimes be green, owing to the high levels of myeloperoxidase in the tissues. This presentation is referred to as granulocytic sarcoma or chloroma. Diagnosis and The diagnosis of leukemia is usually made through blood studies and bone marrow examination. If the patient does not have a prior diagnosis of leukemia and presents with gingival involvement, the dentist should perform an incisional biopsy and submit for histopathologic examination. The pathologist will perform numerous immunohistochemical studies in order to establish definitive diagnosis. Once the diagnosis of leukemia is confirmed, the patient is referred to a hemeoncologist so chemotherapy can be initiated. bone by the tumor results in loosening and eventual loss of teeth in the vicinity. Diagnosis and A biopsy is mandated for rapidly enlarging masses. The pathologist performs a series of immunohistochemical studies to identify the origin of the tumor. The prognosis for such patients is usually poor with palliative treatment as the only option. CONCLUSION This concludes our review on gingival pathology. A few important points to remember: If it is not possible to diagnose a lesion clinically, a biopsy is mandatory. Tissue from surgical excisions should always be submitted for histopathologic examination. Patients with premalignant and malignant lesions should be followed closely. Any progression in lesional tissue should warrant an immediate biopsy. METASTATIC DISEASE: Metastasis to the oral cavity is relatively rare and accounts for only 1-1.5% of oral malignancies. Tumors from lung, breast, prostate, kidney and thyroid tend to metastasize to the oral cavity. About 25% of patients are unaware of their primary tumor prior to biopsy of their oral lesion. Metastatic disease of the oral cavity is more commonly seen in individuals between the ages of 40-70. Men appear to be more frequently affected than females. In oral soft tissues, 50% of tumors occur on the gingiva. The lesions present as nodular masses that vary in size considerably. Surface ulceration is a common feature. The lesion exhibits an aggressive growth potential and enlarges rapidly. Destruction of the underlying ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH DIAGNOSTIC AND TEACHING PURPOSES. HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH GASTROINTESTINAL DISEASES. DR. AMBER KIYANI CAN BE CONTACTED AT: KIYANI.1@OSU.EDU Page 11

post-test instructions - answer each question ONLINE - press submit - record your confirmation id - deadline is June 23, 2014 Peripheral ossifying fibromas frequently enlarge beyond two centimeters. 1 T F SUBMIT 2 T F Excision of pregnancy tumors should be completed upon detection. 3 ONLINE T F 4 T F Cutaneous involvement is common with pyogenic granuloma. Cigarette smoking is associated with squamous cell carcinoma, leukoplakia, and smoker s melanosis. SUBMIT 5 T F 6 T F Oral melanomas tend to be more aggressive than cutaneous melanomas. Leukoplakias on the maxillary alveolar gingiva and vestibule have been associated with sanguinaria use in the past. ONLINE 7 T F 8 T F Melanotic macules are caused by a specific immune-mediated response to artificial cinnamon flavoring. Erosive lichen planus is relatively less common than reticular lichen planus. d i r e c t o r john r. kalmar, dmd, phd kalmar.7@osu.edu a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm daw.37@osu.edu channel coordinator rachel a. flad, bs flad.4@osu.edu Page 12