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Periodontics

Authors : Dr. Singh Rajbir , Dr. Srinivas S. Ramachandra , Dr. Umesh Chandra Prasad.

ABSTRACT:

Background:Squamous cell carcinoma (SCC) is the most frequent oral malignant neoplasm, which accounts for more than 90% of all malignant lesions in the mouth.Gingival SCC differs from oral SCC occurring in other areas of the oral cavity in many ways. Gingival SCCmay mimic common gingival inflammatory conditions resulting in delayed diagnosis or may even lead to misdiagnosis.

Methods: A male patient aged 65 years reported with a complaint of growth in the lower left back region of the jaw. On examination a soft gingival growth was noticed distal to the mandibular left second molar. Patient was consuming tobacco for the past 25-30 years. Patient wasalso brushing with tobacco containing dentifricefor the past 10 years. Excisional biopsy was done and the excised growth was sent for histo-pathological examination.

Results: Histopathologic examination, revealed hyperkeratotic stratified squamous epithelium that showed hyperplasia, invasive islands and sheets of atypical squamous cells extending into the underlying connective tissue stroma. The atypical squamous cells showed cellular and nuclear pleomorphism, hyperchromatism, altered nuclear cytoplasmic ratio, abnormal atypical mitotic figures and many dyskeratotic cells. Based on clinical, radiological and histopathologic features a diagnosis of SCC of the gingiva was made. Patient was referred for further treatment to regional cancer centre. However, follow-up was in-conclusive with patient’s relatives reporting death of the patient.

Conclusions:Gingival SCC has a higher chance of cure upon early diagnosis and treatment. This case demonstrates the importance of being highly suspicious of oral lesions, especially when they do not promptly respond to conventional therapy. In such instances dentists play an important role in early detection of such lesions.

BACKGROUND:

Squamous cellcarcinoma (SCC) is the most frequent malignant neoplasm affecting structures of the oral mucosa, whichaccounts for more than 90% of all malignant lesions in the mouth.1

Oral SCC is noticed in patients above 60 years of age, with buccal mucosa, tongue, floor of the mouth, soft palate and gingiva being the sites involved.1The exact etiology of oral SCC remains unknown, but predisposing risk factors include tobacco and alcohol use.2In South Asian countries, tobacco is used both in smoking and smokeless forms.2 Oral SCC have a gender predilection towards males. However, the gender predilection is equalling out in many populations owing to the increased trend of smoking in women.2

Gingival SCCdue to its rarity and aggressive nature forms a separate subset among oral SCC.3Gingival SCC is usually asymptomatic with variable clinical presentations.4The lesions present as common reactive lesions like pyogenic granulomas, simple ulcers or as an exophytic mass with a granular, papillary or verrucous surface. Since the lesion presents with a wide variety of clinical presentations, they can be easily misdiagnosed as benign tumors or other gingival/periodontal inflammatory conditions.5,6This delay in diagnosis or wrong diagnosis may lead to wrong treatment plan and worsening of the prognosis.7Gingival SCC is usually seen in the mandible than in the maxilla with more than 60% of the tumors seen posterior to the premolars. Cases of gingival SCC have poorer prognosis compared to other oral SCC, due to early invasion of bone.7Thus, early diagnosis and treatment of gingival SCC by health care providers is essential in achieving a goodprognosis.We report a patient with gingival SCC; which reminds us to keep the possibility of carcinoma in mind while examining growths seen on the gingiva.

CASE REPORT: A male patient aged 65 years reported to the Department of Periodontology with a chief complaint of growth in the lowerleft back region of the jaw.Patient reported of a painless growth of soft tissue noticedaround 10 days back. On intra oral examination, a soft gingival growth was noticed distal to mandibular 2nd molar on the left side (Figure 1). 

 
Fig. 1: Clinical image of gingival growth distal to left second molar.Inset at the top of the image shows the sharp and blunt projections seen in the growth

Growth was exophytic in nature and was present on the left retromolar region, extending anteriorly over the second molar and covering the tooth fully. Growth was 2-3 cm in size, whitish pink in color, firm in consistency, pedunculated with an irregular pebbly surface. Patient gave a history of pus extruding from the area distal to the left mandibular second molar. The gingival growth interfered during mastication causing discomfort to the patient. Past medical historyrevealed patient had tuberculosis few years back, for which he had taken medications for a period of one year.Patient gave a history of tobacco use for the past 25-30 years. Patient was consuming both smoking (20 beedis/day) and smokeless forms of tobacco(10 pouches of gutkha/day). Patient wasusing a tobacco containing dentifrice (Nirala) for brushing since 10 years (Figure 2).

 
Fig. 2: Image showing tobacco containing dentifrice sold illegally in rural portions of India.Inset shows the actual tobbacco containing dentifrice

Patient was also applying the tobacco containing dentifrice as a medicament in the area of the gingival growth since a week.Poor oral hygiene, halitosis, plaque and calculus deposition over the entire dentition, and gingival bleeding were noted. Orthopantomograph(OPG) showed impacted mandibular left third molar with bone loss present around third molar (Figure 3).

 
Fig. 3: Orthopantomogram showing an impacted third molar with surrounding bone loss

Differential diagnosis for the case included pyogenic granuloma, inflammatory hyperplasia, oral verrucous hyperplasia, proliferative verrucous leukoplakia, verrucous carcinoma,oral SCC, and gingival SCC. Complete hemogram, tests for bleeding time and clotting time revealed that all parameters were normal. A treatment plan comprising of scaling, root planing and excisional biopsy of the growth was done, informed to the patient and consent was obtained. Patient was informed about the ill-effects of tobacco and the potential of the growth to be a malignant one. Scaling and root planing was performed and patient was re-called after one week for excisional biopsy. After achieving adequate local anaesthesia, excisional biopsy was done using electrocautery (Figure 4).

 
Fig. 4: Clinical image after excision of the growth.Inset at the top of the image shows the excised growth.
 
Fig. 5: Figure 5:Histo pathology of the excised lesion showshyperkeratotic stratified squamous epithelium that showed hyperplasia, invasive islands and sheets of atypical squamous cells extending into the underlying connective tissue stroma. The atypical squamous cells show cellular and nuclear pleomorphism, hyperchromatism, altered nuclear cytoplasmic ratio, abnormal atypical mitotic figures and many dyskeratotic cells. (H&E,10 x).

Hemostasis was achieved with pressure pack and the excised tissue was sent for histopathologic examination.On histopathologic examination, hematoxylin and eosin(H and E) stained sections revealed hyperkeratotic stratified squamous epithelium that showed hyperplasia, invasive islands and sheets of atypical squamous cells extending into the underlying connective tissue stroma. The atypical squamous cells showed cellular and nuclear pleomorphism, hyperchromatism, altered nuclear cytoplasmic ratio, abnormal atypical mitotic figures and many dyskeratotic cells. The supporting stroma also showed the presence of epithelial and keratin pearls, many blood vessels and intense mononuclear inflammatory cell infiltrates (Figure 5).On the basis of clinical, radiological features and histopathologic examination of the tissue biopsy,the lesion was diagnosed as well differentiated gingival SCC. The patient was then referred to a regional cancer research centre for further treatment. Further follow-up of the patient was unsuccessful and patient’s relatives reported death of the patient.

DISCUSSION

SCC is defined as a malignant epithelial neoplasm exhibitingsquamous differentiation characterized by the formationof keratin and/or the presence of intercellular bridges.1Gingival SCC differs from oral SCC in other areas in many ways.Table 1 lists the differences between oral SCC in other areas and gingival SCC.4-7Gingival SCC is seen more commonly in female patients and in the age group of more than 60 years.4In our case patient was male and 65 years old. Gingival SCC is least associated with risk factors of tobacco and alcohol use.5However, in our case, patient was using both smoking and smokeless forms of tobacco for more than 25 years. Apart from this patient was also using a tobacco containing dentifrice from the past 10 years. In certain parts of rural India, tobacco containing dentifrices are marketed.8 Even though, it is illegal to produce and sell such tobacco containing dentifrices, unfortunately such products are still in use.8 Ironically patient was also using tobacco containing dentifrice as a medicament for the past one week before presentation. This highlights the lack of knowledge and awareness about the dangerous consequences of tobacco containing dentifrices especially among the rural illiterate population.8

Gingival SCCdoes not have the clinical appearance of a malignant neoplasm, and manifests initially as a reactive or inflammatory growth or an area of ulceration which may be a purely erosive lesion or may exhibit an exophytic, granular, or verrucous type of growth.4-7Malignant lesions usually show induration or an ulcerated surface. In our case the growth had papillary projections and was soft in consistency. Carcinoma of the gingiva because of its variable presentations is often misdiagnosed as one ofthe many inflammatory lesions of the periodontium such as pyogenic granuloma, periodontitis, papilloma, oreven inflammatory hyperplasia.6In our case, the list of lesions among the differential diagnosis was pyogenic granuloma and inflammatory hyperplasia of the gingiva. So, even in this case clinicians were confused with common gingival inflammatory conditions. The present case mimicked clinically a verrucous proliferative lesion, which is a premalignant lesion. Presence of bone loss seen distal to the second molar and the findings of the histopathologic examination ruled out the possibility of verrucous hyperplasia.Bone loss was seen beneath the lesion around the impacted mandibular third molar. In cases of gingival SCC bony invasion is seen earlier due to the close proximity to periosteum and bone compared to other oral SCC cases. Hence gingival SCC is more aggressive in nature due to the early local invasion of boneand probably is responsible for early lymphnode metastasis compared to oral SSCs of other areas.7The unfortunate end of our patient could probably be explained by the earlier invasion seen in the lesion. Thus the aggressive nature and metastasis as a common sequela followed by early death in gingival SCC makes it clinically significant lesion compared to SCCs of other areas.9,10

In well differentiated cases of SCC, malignant cells show resemblance to native squamous cells with abundance of keratin pearls. In moderately well differentiated cases of SCC, malignant cells show less resemblance to native squamous cells with lesser presence of keratin pearls. In poorly differentiated cases of SCC cells do not resemble the native squamous cells and there is no presence of keratin pearls. In our case, histopathologic picture showed malignant cells which were resembling the native squamous cells with abundance of keratin pearls. So, the diagnosis of this case was well differentiated gingival SCC.

Early detection of gingival SCC is vital as the prognosis is directlyrelated to the size of the lesion.9 Lesions measuring less than1 cm are amenable to cure and have a long-term prognosis.Thus, it is prudent to do biopsy of any unexplained lesion whichremains after 2 weeks following removal of any suspectedetiologic agent to avoid unnecessary delay in diagnosingsuch conditions. The overall survival rate for gingival SCC ispoor.9Gingival SCC is a condition wherein the chance of cure is higher and the prognosis would be better when carcinomatous lesions are diagnosed and treated early. In such instances dentists play an important role in early detection of gingival SCCsince these lesions can be misdiagnosed as common reactive or inflammatory gingival lesions in a routine general dental practice.9

REFERENCES

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  10. Kusafuka K, Onitsuka T, Miki T, Murai C, Suda T, Fuke T, Kamijo T, Iida Y, Nakajima T. Squamous cell carcinoma with rhabdoid features of the gingiva: a case report with unusual histology. Med MolMorphol. 2013 Dec 27.

More references are available on request.