Case 1:

Differential Diagnosis:
Inflammatory Hyperplasias

 Fibrous epulis/pyogenic granuloma

Neoplasias/Tumors

 Congenital epulis/granular cell tumor of infancy

 Melanotic neuro-ectodermal tumor of infancy
 Congenital epithelial tumor

Developmental Anomalies/Harmatomas
 Eruption cyst/hematoma
 Bohn’s nodules/dental laminar cysts
 Dentigerous cyst/odontogenic keratocyst
 Lymphangioma
 Hemangioma
 Vascular malformation
 Natal/neonatal teeth

Why its not any of the other diagnosis

 Fibrous epulis: The most common clinical aspect of the fibrous epulis is the growth of well-
delimited tissue, of a smooth surface, usually with normal colored mucosa, sessile or
pedunculated base, of hard consistence, usually located on the anterior maxillary, in the
interdental papilla.
 Vascular lesions: Vascular lesions tend to blanch in response to the application of a firm pressure
by a flat transparent instrument –for example, a glass slide–, during 1 or 2 minutes. When the
instrument is removed, the lesion remains pale for a few seconds; then, it slowly starts refilling
again from the feeder vessels
 MNTI is an osteolytic pigmented neoplasm primarily affecting jaws of newborns. However, MNTI
and CGCL are distinctly different as MNTI is infiltrating, contains melanin pigment and tumor
mass comprises of alveolar spaces lined by cuboidal or large polygonal cells having pale
cytoplasm. Hemangioma is primarily a vascular lesion with budding endothelial cells and
essentially not present at birth; whereas, CGCLs manifest within the 1 st month of life. Fibroma is
more common in 5th, 6th and 7th decade. It consists of bundles of interlacing collagen fibers and
no granular cells. Embryonal rhabdomyosarcoma is a malignant tumor of striated muscle and
uncommon in the oral cavity. Granuloma is primarily a focal collection of epithelioid cells,
lymphocytes and giant cells. Malignant granular cell myoblastoma is commonly seen between
30 and 60 years of age. 
Provisional Diagnosis and Problem List Provisional Diagnosis
• Eruption cysts

• Natal/neonatal teeth

BACKGROUND INFORMATION:

Natal and Neonatal Teeth

A natal tooth is present at birth whereas the neonatal tooth erupts within a month of delivery. In
almost every case, it is the normal primary tooth that has appeared early and not a supernumerary
tooth. Therefore, the loss of a natal or neonatal tooth represents the loss of the primary tooth, but
that will not affect the development of the permanent successor.
The incidence of natal teeth is between 1:2,000 and 1:3,500 live births. There are no accurate
figures on the incidence of neonatal teeth. Treatment options depend on the degree of mobility of
the tooth and the risk that the tooth will exfoliate. It is important to remember that only five-
sixths of the crown of a primary incisor has formed at birth; hence, the mobility of the tooth.
Despite the theoretical risk, there has never been a reported case of aspiration of natal or
neonatal teeth. If the tooth is excessively mobile or there are feeding difficulties, then it may be
extracted. When extracting natal or neonatal teeth, it is essential to remove the dental papilla
(pulp). If this is left behind, hard tissue or even a root may form. Local anesthesia is usually not
required and the airway must always be protected.

FUNDAMENTAL POINT:

Diagnosis of Eruption Cysts

The eruption cyst or hematoma is an extremely common variation of normal eruption and not
considered to be pathological unless the lesion is infected. The cyst represents an enlargement of
the follicle around a newly erupting tooth. Because natal and neonatal teeth are common, it is not
unusual to see an eruption cyst in a newborn infant. An eruption cyst must not be confused with
a vascular lesion.
To test this, apply pressure to the lesion to determine whether the area changes in color due to
any blood emptying. Lesions that are bilateral and symmetrical are almost invariably benign and
histopathology is not required.
The most common lesions that may mimic eruption cysts in a newborn include vascular
anomalies (hemangiomas or lymphangiomas), neuroectodermal tumors of infancy, or other
odontogenic cystic lesions. A case has been reported of an odontogenic keratocyst mimicking an
eruption cyst in a 19-month-old infant. (Chiang and Huang 2004)
Case 2

Differential Diagnosis:

• Drug-induced gingival enlargement: cyclosporine, nifedipine, phenytoin (Dilantin)

• Hereditary gingival fibromatosis

• Other localized gingival enlargements such as epulides

Why its not HGF:

When HGF is suspected, the first step is to rule out medication or a medical or systemic history that
could explain the gingival enlargement. A similar history in other members of the family points to a
hereditary etiology but is not an exclusive diagnostic criterion for HGF, so the anatomopathologic
diagnosis and the progress of the case are indispensable for establishing this diagnosis.

Provisional Diagnosis and Problem List:

 Gingival enlargement induced by cyclosporine and nifedipine

BACKGROUND INFORMATION

Gingival Enlargement

Gingival enlargement, independent of gingivitis, is invariably related to medications or several

hereditary conditions of which gingival fibromatosis is the most important. Clearly, if a child is
on an immunosuppressive medication such as cyclosporine or a calcium channel blocker such as
nifedipine, then the diagnosis is straightforward.
Phenytoin induced gingival enlargement depends on oral hygiene, whereas cyclosporine
enlargement appears to have a particular threshold dose for some individuals. In all cases, the
maintenance of meticulous oral hygiene is essential, although it must be realized that it is often
extremely difficult for children to maintain their oral health in the presence of such enlarged
tissues.
A number of treatment options exist, such as changing the medication. This is obviously done in
consultation with the physician, and general medical requirements always take precedence over
oral considerations. In the case of cyclosporine, tacrolimus is often used as a substitute and there
are drugs such as sodium valproate (Epilim) or carbamazepine (Tegretol) can be used as
alternatives to phenytoin without the complications of gingival enlargement. The differential
diagnosis in cases of enlargement should also include isolated gingival lesions such as epulides,
of which the most common is the pyogenic granuloma.

Mechanisms of Gingival Overgrowth

The precise mechanisms by which cyclosporine causes overgrowth of gingival tissues has yet to
be fully determined. Nonetheless, there is increasing risk in younger children, those who express
HLA-A24 antigen, and those with poor oral hygiene. The question of dose relationship is
contentious, although it appears that a threshold may exist above which enlargement may occur.
Cyclosporine causes an increase in fibroblast proliferation, possibly in response to elevated IL-6 and TGF-
β1. There is an increase in the volume of extracellular collagen and decreased collagen loss. There is
little doubt that oral hygiene is very important in reducing overgrowth and in some studies the use of
antibiotics such as metronidazole was beneficial in controlling the gingival growth.
Management of Gingival Enlargement Surgical Resection of Gingival Overgrowths
The choice of surgical procedure depends on the degree of overgrowth in each patient. No one
procedure is better than another. The use of a diathermy or soft tissue lasers (diode, Nd:YAG, or
CO2) are useful when only minor work is required.
The classical gingivectomy may be indicated when a major resection of the all of the gingiva is
required. The disadvantage of this technique (using a bevel incision) is the large amount of open
tissue that is left, making the post-operative period extremely uncomfortable for the patient and
increasing the risk of infection. Flap surgery with apically repositioned flaps ensures primary
closure of the wounds, less bleeding, and a better post-operative recovery period. Orthodontic
Treatment in Children Following Organ Transplantation.
There is no contraindication to orthodontic treatment in the post-transplant patient. Indeed, in
these cases, orthodontics is impossible without removal of the excessive soft tissue which will
also allow for better oral hygiene practices. It is important to observe the displacement of the
teeth secondary to the growth of the gingival tissues and intervene where there is tooth
movement. Importance of Dental Care for the Transplant Recipient Dental care for transplant
recipients is an essential part of their medical well- being. Immunosuppressed children are
susceptible to infections from even minor wounds. It should be noted that pulp therapy in
primary teeth is contraindicated in these children.

Pre-transplant care:
Excellent oral hygiene and preventive protocols (fluoride, fissure sealants, etc.) Aggressive
removal of any present and/or potential pathology that may compromise the child during
immunosuppression.

Post-transplant care:
Continuation of excellent oral hygiene practices, including regular reviews and preventive
monitoring. Avoid elective dental treatment during immunosuppression periods. In consultation
with the patient’s cardiologist, use antibiotic prophylaxis if the patient is immunosuppressed and
the dental treatment cannot be postponed. Although similar dosages may be used as in
prophylaxis against endocarditis, the antibiotics are targeting secondary infections principally in
the surgical site (not distant sites). Organ transplantation does not put the child at a greater risk of
developing endocarditis, except if valvulopathy develops.
Protocols for the use of antibiotics for prophylaxis against endocarditis are constantly changing
and the reader is advised to consult the most up-to-date protocols for their jurisdiction, such as
those published by the American Heart Association and the National Institute for Health and
Clinical Excellence (NICE) in the United Kingdom.