Rare disease

CASE REPORT

Gingival squamous cell carcinoma presenting

as periodontal lesion in the mandibular
posterior region
Renu Gupta,1 Nitai Debnath,2 Prathibha Anand Nayak,3 Vishal Khandelwal4
1
Department of Public Health SUMMARY
Dentistry, Nair Hospital and Gingival squamous cell carcinoma (GSCC) is a relatively
Dental College, Mumbai,
Maharashtra, India rare malignant neoplasm of the oral cavity. It represents
2
Department of Prosthetic less than 10% of diagnosed intraoral carcinoma.
Dentistry, Dental College, Because of its close proximity to the teeth and
RIMS, Imphal, India periodontium, the tumour can mimic tooth-related
3
Department of Periodontics,
benign inflammatory conditions. This case report
NIMS Dental College &
Hospital, Jaipur, Rajasthan, describes a patient diagnosed with GSCC presenting as
India localised periodontitis.
4
Department of Pedodontics,
Index Institute of Dental
Science, Indore, Madhya
Pradesh, India BACKGROUND
Gingival squamous cell carcinoma (GSCC) is an
Correspondence to infrequent oral tumour.1–3 It represents less than Figure 1 Intraoral lesion.
Dr Prathibha Anand Nayak, 10% of diagnosed intraoral carcinoma.4 Early
drprathibha_an@[Link]
detection is crucial, as survival is most significantly
Accepted 27 July 2014 linked to the stage of disease.5 In general, the main palpation. Pocket probing depth ranging from 6 to
risk factors for oral squamous cell carcinoma (SCC) 8 mm was present in relation to teeth 44 and 45.
are tobacco and alcohol consumption.6 In contrast The teeth were not mobile. There was no tender-
to oral SCC, GSCC is weakly associated with these ness on lateral and vertical percussion on teeth 44
risk factors and its aetiology is not yet well estab- and 45. The gingiva and alveolar mucosa at the
lished. The most common area to be affected with adjacent sites were clinically normal with minimal
SCC is the lateral part of tongue followed by the plaque accumulation. Extraoral palpation revealed
floor of the mouth. Clinically, GSCC usually no lymph nodes involvement.
appears as an exophytic mass with a granular, pap- A provisional diagnosis was carried out as loca-
illary or verrucous surface or it presents as an lised chronic periodontitis with respect to teeth 44
ulcerative lesion.7 Gingival pain is the most pre- and 45.
dominant symptom but in the early stages, the
disease may be asymptomatic.3 4 Because of its INVESTIGATIONS
various appearances and similarity to common peri- Intraoral periapical radiographic examination
odontal lesions, GSCC may be misdiagnosed on revealed moderate horizontal bone loss in relation
clinical examination.8 9 to teeth 44 and 45 and bony involvement of the
lesion (figure 2).
CASE PRESENTATION DIFFERENTIAL DIAGNOSIS
A 46-year-old woman presented to the department
Gingivitis, chronic localised periodontitis, pyogenic
of periodontics with pain and swelling in the lower
granuloma, or benign conditions like verruciform
right back teeth region for the last 15 days. The
patient had no history of tobacco consumption in
any form. She was found to be systemically healthy.
The intraoral examination revealed a swelling on
the buccal and lingual aspect of teeth 44 and 45,
extending from the mesial aspect of tooth 44 to
the distal aspect of tooth 45. The gingival lesion
appeared erythematous with speckled non-
scrapable white patches and the surface was eroded
and ulcerated. Clinically, the lesion confined to
attached gingiva and interdental papilla of teeth 44
To cite: Gupta R,
Debnath N, Nayak PA, et al.
and 45. The margins of the lesion were well-
BMJ Case Rep Published defined with raised edges (figure 1). The lesion was
online: [ please include Day firm to hard on palpation with a fixed broad base.
Month Year] doi:10.1136/ Periodontal examination revealed bleeding on
bcr-2013-202511 probing with no exudation and tenderness on Figure 2 lntraoral periapical of the affected region.

Gupta R, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202511 1

 Rare disease

xanthoma, erythroleucoplakia, deep fungal infections (blasto-

mycosis, histoplasmosis, coccidioidomycosis, cryptococcosis)
and chronic traumatic ulcer.

TREATMENT
Routine periodontal phase I therapy including scaling and root
planning was performed in relation to teeth 44 and 45 with sys-
temic antibiotics. The patient was advised to take amoxicillin
250 mg+clavulanic acid 125 mg three times a day, diclofenac
50 mg+paracetamol 500 mg twice daily for 5 days and clorhexi-
dine mouthwash twice daily for 7 days.

OUTCOME AND FOLLOW-UP

On recall after 7 days, the patient reported with severe pain and
discomfort on the right side of the mandible with referred pain
to neck and shoulder on the same side. Clinical examination
revealed an extensive erythematous and granular appearing
hyperplastic tissue on the facial and lingual aspect of teeth 44 Figure 4 Lesion 1-week postoperatively after incisional biopsy.
and 45. A deep linear ulcer measuring about 2 cm was noticed
at the depth of the vestibule on the lingual aspect, correspond-
DISCUSSION
ing to teeth 44 and 45 (figure 3). The lesion was tender on pal-
SCC is an epithelial tumour and the most common malignant
pation. Tablet tramadol 50 mg three times a day for 3 days was
tumour of the oral cavity.10 Gingival SCC accounts for <10%
prescribed and incisional biopsy was planned.
of all intraoral SCC and the majority of gingival SCCs occur in
Multiple incisional biopsies were performed on the right man-
the mandible.5
dibular buccal (0.5×0.5×0.5 cm) and lingual (1.0×0.5×0.5 cm)
Over the past 40 years, despite advances made in diagnosis,
gingiva in relation to teeth 44 and 45 the next day. the overall 5-year survival rate for oral SCC has remained rela-
One week after incisional biopsy, the intraoral picture tively constant at around 50%.11 Several reasons may account
revealed incomplete healing of the gingival tissue (figure 4). for this: high-risk patients do not seek medical attention, oral
Histological examination of the incised tissue with H&E stain cancer examinations are not frequently performed and existing
revealed hyperplastic surface epithelium with a prominent endo- lesions are often overlooked by the general dentist, and delays
phytic growth pattern. The squamous proliferation showed to the onset of signs/symptoms to clinical diagnosis are also
focal epithelial detachment, individual cell keratinisation and common.12
keratin pearls (figure 5). Based on the histological findings, the
final diagnosis was carried out as GSCC.
The patient was referred to the department of oncology for
further needful management. Based on the histopathological
examination and lymph node biopsy, she was diagnosed with
moderately differentiated gingival SCC (T1N1M0). The patient
underwent right-sided marginal mandibulectomy of the teeth 44
and 45 region with level 5 radical neck dissection.

Figure 5 Histopathological view of the lesion showing the loss of the

Figure 3 Lesion after phase I therapy. epithelial-connective tissue (H&E stain).

2 Gupta R, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202511

 Rare disease

GSCC is often asymptomatic and the initial symptoms are In the present case, the patient had no history of tobacco con-
usually an intraoral mass or swelling, ulceration, pain, ill fitting sumption in any form. Gingival SCC is rarely associated with
dentures, mobility of teeth or unhealed extraction wounds. tobacco consumption, despite the main risk factors for oral SCC
These tumours frequently resemble inflammatory lesions affect- being smoking or consumption of any chewable form of
ing the periodontium such as pyogenic granuloma, gingivitis, tobacco and drinking of alcohol.1
periodontitis or benign conditions such as verruciform xan-
thoma. At the early stage, the lesion often closely simulates
advanced periodontitis associated with minimal pain and may Learning points
lead to a diagnostic delay.8 13 Other differential diagnosis could
be erythroleucoplakia, deep fungal infections and chronic trau-
matic ulcer. ▸ Gingival squamous cell carcinoma (SCC) is quite different
Chronic traumatic/reactive ulcers are usually covered by a from other SCCs, mimicking localised periodontal disease.
yellow membrane and are surrounded by elevated margins that ▸ It can be misdiagnosed as localised chronic periodontitis,
may show hyperkeratosis or induration due to scar formation. speckled erythroplakia, deep fungal infection, chronic
They are most frequently seen on the tongue and show chronic traumatic ulcer, SCC or metastatic carcinoma (from the
cell infiltration on histopathological evaluation.14 lungs and vestibule).
Deep fungal infections (blastomycosis, histoplasmosis, coc- ▸ Appropriate oral cancer screening and appropriate referral is
cidioidomycosis, cryptococcosis) may also present as a chronic important.
erythematous ulcerated area with indurated margins, but they ▸ Gingival verrucous, white patches and persistent ulcers and
are characterised by primary involvement of the lungs and swellings should be biopsied promptly.
microscopic examination reveals granulomatous inflammation
with organism, which was ruled out in this case.15
Erythroplakia mostly present as well demarcated red lesions
Competing interests None.
of flat, macular and velvety appearance. Most of the clinically
Patient consent Obtained.
diagnosed erythroplakia re-present as severe dysplasia or carcin-
oma in histopathological examination. If left untreated, 90% of Provenance and peer review Not commissioned; externally peer reviewed.
the cases transform into cancer. Among them 51% into grade-I
oral squamous cell carcinoma, 40% into carcinoma in situ or
severe epithelial dysplasia and 9% mild to moderate epithelial REFERENCES
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Gupta R, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202511 3

 Rare disease

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4 Gupta R, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202511