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CASE REPORT
Year : 2013  |  Volume : 17  |  Issue : 4  |  Page : 523-526  

Gingival squamous cell carcinoma masquerading as an aphthous ulcer


Department of Periodontics, Government Dental College and Hospital, Hyderabad, Andhra Pradesh, India

Date of Submission21-Apr-2012
Date of Acceptance08-Jul-2013
Date of Web Publication17-Sep-2013

Correspondence Address:
Gudi Pavan Kumar
H. No. 207/3RT, Near Ramalayam, Saidabad Colony, Hyderabad - 500 059, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.118329

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   Abstract 

Gingival squamous cell carcinoma (GSCC) is an uncommon condition of the oral cavity. It is seldom associated with classic risk factors of oral cancer and shows a predilection for females. It's close clinical resemblances to various lesions of the oral cavity may make it go unnoticed. This may lead to diagnosis at advanced stages and coupled with the proximity to underlying alveolar bone may result in subsequent morbidity and mortality. A case of GSCC camouflaged as an aphthous ulcer in a middle aged woman is presented. The article highlights the importance of early diagnosis resulting in conservative treatment approaches.

Keywords: Early diagnosis, gingiva, squamous cell carcinoma


How to cite this article:
Kumari PS, Kumar GP, Bai YD, Reddy EB. Gingival squamous cell carcinoma masquerading as an aphthous ulcer. J Indian Soc Periodontol 2013;17:523-6

How to cite this URL:
Kumari PS, Kumar GP, Bai YD, Reddy EB. Gingival squamous cell carcinoma masquerading as an aphthous ulcer. J Indian Soc Periodontol [serial online] 2013 [cited 2019 Oct 23];17:523-6. Available from: http://www.jisponline.com/text.asp?2013/17/4/523/118329


   Introduction Top


Squamous cell carcinoma (SCC) is the most common malignant tumor of the oral cavity and constitutes 90% of all oral neoplasms. The incidence of oral SCC (OSCC) is evidencing an upward trend signaling an increase in incidence and mortality rates. Around 300,000 patients are annually estimated to have oral cancer globally. It accounts for 4% of cancers in men and 2% of cancers in women and the stage at diagnosis determines the prognosis to a large extent. [1]

The relative incidence of OSCC is reported as 35% for the lower lip, 25% for ventral surface of the tongue, 20% for floor of the mouth, 15% for the soft palate, 4% for gingiva/alveolar ridge and 1% for the buccal mucosa. [2] Gingival SCC (GSCC) is an uncommon condition with a likely predilection for females. [3] It clinically presents as an exophytic mass with a granular, papillary, or verrucous surface or as an ulcerative lesion. [4]

GSCC is an insidious lesion that is usually asymptomatic and is commonly misdiagnosed as one of the many inflammatory lesions of the periodontium such as periodontitis, pyogenic granuloma, papilloma or an inflammatory hyperplasia. [5] It typically arises from the keratinized mucosa, commonly in a posterior site destroying the underlying alveolar bone leading to tooth mobility. [6] Unlike tobacco and alcohol consumption, which are significant risk factors for OSCC, [3] GSCC is weakly or least associated with them. [6] It is generally agreed that GSCC is more common in the mandible than the maxilla [7] and 60% of those are located posterior to premolars. [8]

Although GSCC is amenable to early detection due to its direct visibility and the ease of clinical examination, it can easily be misinterpreted and overlooked as a periodontal lesion or an ulcer resulting in the delay of diagnosis and treatment affecting the prognosis. [9] A case of GSCC affecting the mandibular anterior lingual gingiva masquerading as an aphthous ulcer is presented which buttresses the above viewpoint.


   Case Report Top


A 38-year-old Indian woman reported to the Department of Periodontics, Government Dental College and Hospital, Hyderabad, India in July 2011 with a chief complaint of burning sensation and itching in relation to mandibular anterior lingual gingiva for past 1 month. Patient had provided informed consent to be profiled. Past dental history revealed that the patient had visited a couple of private general dental practitioners where the lesion was misdiagnosed as an aphthous ulcer and palliative care was provided for the same. As there was no improvement in her complaint, she decided to come to the dental school for an additional opinion. She was referred for diagnosis and treatment in post-graduate periodontics clinic. There was no contributing medical or family history except that the patient had undergone hysterectomy and appendectomy 10 years back. Patient was in good health and denied any deleterious habits like smoking, alcohol consumption or recreational drug use. No lymph nodes were palpable or tender in a head and neck examination.

Intraoral examination revealed a clean mouth with good gingival health and minimal deposits with the full complement of teeth. Clinical examination of the lingual gingiva revealed a 1 cm × 1 cm ulcer extending mesiodistally from mid lingual surface of 41 to mesiolingual surface of 43 and corono-apically from the gingival margin to the floor of the mouth, not extending beyond the anterior part of lingual frenum. The surface of the lesion appeared to be ulcerated and pebbly with isolated areas of erythema and had well-defined borders that were found to be in level with the adjacent tissue. The ulcerated part of the lesion had rhomboid appearance. The surface of lesion toward the lingual frenum appeared to have a shaggy base covered with slough and there was no exudation [Figure 1]. Intraoral periapical X-ray showed bone loss extending up to the apical 3 rd in relation to 41, 42 [Figure 2]. Since the clinical findings of the existing lesion didn't correlate with any of the features of periodontal lesions and the fact that it has been present for the past 1 month was enough to suspect a malignant ulcer. At this stage, a provisional diagnosis of GSCC was made and after obtaining the patient's consent, an incisional biopsy was taken immediately. The specimen was then sent for histopathological examination.
Figure 1: Clinical lingual view showing the ulcerative lesion

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Figure 2: Intraoral periapical showing bone loss in relation to 41, 42

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Histopathology

The histological examination of the soft-tissue specimen revealed severe dysplastic changes of the epithelium. There were many sheets and clusters of cells, which were polygonal in shape and contained moderate to abundant pale acidophilic cytoplasm and sharp cellular margins. The nucleus was round to oval in shape and showed moderate pleomorphism, disorganization, coarse chromatin clumping and prominent nucleoli. Mitotic activity was high. There were patchy dense infiltrates of lymphocytes, plasma cells and neutrophils [Figure 3]. A clear and prominent feature was the presence of multiple, keratin pearls in connective tissue [Figure 4]. The above clinical and histological features are conclusive of invasive keratinizing GSCC.
Figure 3: Histopathological examination showing proliferation of basal cell layer and neoplastic epithelial cells in the connective tissue (H and E, 40)

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Figure 4: Keratin pearls inside the connective tissue seen in higher magnification (H and E, 100)

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The patient was immediately referred to a specialty hospital for cancer (Indo-American Cancer Institute, Hyderabad, India) where a computed tomography scan was taken to evaluate any alveolar bone invasion. Subsequently, the lesion was staged as T 1 N 0 M 0 . The involved teeth 41, 42 were extracted and the lesion was treated with radiation therapy alone (intensity modulated radiation therapy, 6600 U/33 fractions using ×6 photons). Six months follow-up revealed uneventful healing and no recurrence.


   Discussion Top


SCC being a common neoplasm is a well-documented lesion in the dental literature in terms of its pathogenesis, sites affected, diagnosis, treatment and prognosis. [10] Despite this, the literature on GSCC is scarce. The authors admit that this lacuna in literature is due to the fact that this entity is considered as a part of oral cancers in general. [11],[12],[13] There is a need to document GSCC as a separate entity as it exhibits features different from general OSCC. These include its direct invasion of the bone, [14] its predilection for females unlike OSCC which is generally seen in males [3] and the least association with the classic risk factors of tobacco and alcohol consumption. [6] The fact that it resembles periodontal disease [15] or an endo-perio lesion [14] or an ulcer as in the present case may make it go unnoticed by a complacent or casual examiner. This in turn could lead to diagnosis at advanced stages with poorer prognosis and possible life threatening complications.

Henceforth, dentists in general and periodontists in particular must stress on a thorough intraoral examination and it is wise to lay special emphasis on lesions that remain after the elimination of local factors such as plaque, calculus etc., The need for biopsy in these lesions must not be underestimated as histopathological examination is the gold standard to conclude the final diagnosis. This view of the authors is identical with the observations of Khan et al. [16] and Seoane et al. [17]

The present case report is unique in terms of its anatomic location, i.e., the lingual gingiva of mandibular region near the lingual frenum. It could have easily been misinterpreted as an aphthous ulcer. It is uncommon for an aphthous ulcer to present on the attached gingiva but such cases have been documented in the literature. [18] Earlier studies on GSCC have reported the lesion on posterior mandible, [16],[19],[20],[21] posterior maxilla, [14],[22] anterior maxilla [15],[23] and anterior mandible. [24] To the best of our knowledge, this is the first case report on the above mentioned anatomic location.

GSCC is a rare human neoplasm with direct bone invasion and most of the cases are diagnosed at an advanced stage [17] requiring treatment procedures such as radical neck dissection, rim or segmental resection of mandible or maxilla. This calls for an early diagnosis and management of the lesion to decrease morbidity and subsequent mortality resulting from GSCC.

The present case can be termed as an early diagnosis as it was diagnosed within 40 days. This total diagnostic time (relative time from when patients first become aware of the problem to histopathological diagnosis) is well within the limits of 45 days [17] and 46 days [25] diagnostic time intervals. The conservative treatment approach of radiation therapy alone in this case can be solely attributed to early diagnosis. The fact that these oral lesions are more likely to be diagnosed in a dental setting by a general dental practitioner or periodontist during routine dental appointments [26] necessitates the need for an astute eye during intraoral examinations.


   Conclusions Top


Lesions of the gingiva and oral soft-tissues not responding to conventional therapy should alert the dentist regarding the possible chances of encountering a neoplasm. A biopsy to confirm the diagnosis and prompt referrals can significantly improve the prognosis and decrease the morbidity and mortality.

 
   References Top

1.Hoffman HT, Karnell LH, Funk GF, Robinson RA, Menck HR. The National Cancer Data Base report on cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124:951-62.  Back to cited text no. 1
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2.Sapp JP, Eversole LR, Wysocki GP. Contemporary Oral and Maxillofacial Pathology. St. Louis: CV Mosby; 1997. p. 174-94.  Back to cited text no. 2
    
3.Barasch A, Gofa A, Krutchkoff DJ, Eisenberg E. Squamous cell carcinoma of the gingiva. A case series analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:183-7.  Back to cited text no. 3
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4.Lee JJ, Cheng SJ, Lin SK, Chiang CP, Yu CH, Kok SH. Gingival squamous cell carcinoma mimicking a dentoalveolar abscess: Report of a case. J Endod 2007;33:177-80.  Back to cited text no. 4
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5.McClatchy KD, Zarbo RJ. The jaws and oral cavity. In: Sternberg SS, editor. Diagnostic Surgical Pathology. 3 rd ed. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 822.  Back to cited text no. 5
    
6.Neville BW, Damm DD, Allen CM. Epithelial pathology. In: Oral and Maxillofacial Pathology. 2 nd ed. Philadelphia: WB Saunders; 2002. p. 356-67.  Back to cited text no. 6
    
7.Shafer WG, Hine MK, Levy BM. Textbook of Oral Pathology. 4 th ed. Philadelphia: WB Saunders; 1983. p. 124-6.  Back to cited text no. 7
    
8.Holmstrup P, Peiber J. Tumors and cysts of periodontium. In: Lindhe J, editor. Clinical Periodontology and Implant Dentistry. 3 rd ed. Copenhagen: Munksgaard; 1998. p. 368-9.  Back to cited text no. 8
    
9.Holmes JD, Dierks EJ, Homer LD, Potter BE. Is detection of oral and oropharyngeal squamous cancer by a dental health care provider associated with a lower stage at diagnosis? J Oral Maxillofac Surg 2003;61:285-91.  Back to cited text no. 9
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10.Casiglia J, Woo SB. A comprehensive review of oral cancer. Gen Dent 2001;49:72-8.  Back to cited text no. 10
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11.Chen JK, Katz RV, Krutchkoff DJ. Intraoral squamous cell carcinoma. Epidemiologic patterns in Connecticut from 1935 to 1985. Cancer 1990;66:1288-96.  Back to cited text no. 11
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12.Keller AZ, Terris M. The association of alcohol and tobacco with cancer of the mouth and pharynx. Am J Public Health Nations Health 1965;55:1578-85.  Back to cited text no. 12
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13.Krolls SO, Hoffman S. Squamous cell carcinoma of the oral soft tissues: A statistical analysis of 14,253 cases by age, sex, and race of patients. J Am Dent Assoc 1976;92:571-4.  Back to cited text no. 13
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14.Levi PA Jr, Kim DM, Harsfield SL, Jacobson ER. Squamous cell carcinoma presenting as an endodontic-periodontic lesion. J Periodontol 2005;76:1798-804.  Back to cited text no. 14
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15.Molina AP, Cirano FR, Magrin J, Alves FA. Gingival squamous cell carcinoma mimicking periodontal disease. Int J Periodontics Restorative Dent 2011;31:97-100.  Back to cited text no. 15
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16.Khan SM, Gossweiler MK, Zunt SL, Edwards MD, Blanchard SB. Papillary squamous cell carcinoma presenting on the gingiva. J Periodontol 2005;76:2316-21.  Back to cited text no. 16
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17.Seoane J, Varela-Centelles PI, Walsh TF, Lopez-Cedrun JL, Vazquez I. Gingival squamous cell carcinoma: Diagnostic delay or rapid invasion? J Periodontol 2006;77:1229-33.  Back to cited text no. 17
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18.Mintz GA, Smidansky ED. Aphthous stomatitis with involvement of attached gingiva. J Clin Pediatr Dent 1994;18:309-12.  Back to cited text no. 18
    
19.Wallace ML, Neville BW. Squamous cell carcinoma of the gingiva with an atypical appearance. J Periodontol 1996;67:1245-8.  Back to cited text no. 19
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20.Li PY, Auyeung L, Huang SC. Squamous cell carcinoma of the mandibular gingiva. Chang Gung Med J 2004;27:777-81.  Back to cited text no. 20
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21.Indira AP, David P, Roopashri G, Vaishali MR. Gingival carcinoma in a non-tobacco user. J Dent Sci Res 2010;1:67-74.  Back to cited text no. 21
    
22.Veeresh M, Rai BA. Squamous cell carcinoma of maxillary gingival buccal sulcus: A case report. Int J Dent Clin 2010;2:52-3.  Back to cited text no. 22
    
23.Cabral LA, Carvallo LF, Salgado JA, Brandão AA, Almeida JD. Gingival squamous cell carcinoma: A case report. J Oral Maxillofac Res 2010;1:e6.  Back to cited text no. 23
    
24.Alsharif MJ, Jiang WA, He S, Zhao Y, Shan Z, Chen X. Gingival squamous cell carcinoma in young patients: Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:696-700.  Back to cited text no. 24
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25.Jovanovic A, Kostense PJ, Schulten EA, Snow GB, van der Waal I. Delay in diagnosis of oral squamous cell carcinoma; a report from The Netherlands. Eur J Cancer B Oral Oncol 1992;28B: 37-8.  Back to cited text no. 25
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26.Gellrich NC, Suarez-Cunqueiro MM, Bremerich A, Schramm A. Characteristics of oral cancer in a central European population: Defining the dentist's role. J Am Dent Assoc 2003;134:307-14.  Back to cited text no. 26
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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