Diagnostic Information

History of Present Illness Jimmy is a 38-year-old patient of record who has just returned home from a two year overseas assignment in Costa Rica. He reports that while out of the country, he had his teeth cleaned once and now needs a comprehensive check-up. He has no complaints and relates no problems in the past two years. Medical History - Adverse drug effects: none

- Medications: Naproxen as needed for shoulder soreness

- Pertinent medical history: osteoarthritis, prior BCG vaccination (completed a 9 month regimen of prophylactic isoniazid 15 years ago)

- Pertinent family history: paternal - fatal MI age 65 (long-term smoker), maternal - DM type 2 managed with diet. Siblings are healthy

- Social history: denies tobacco or alcohol exposure and denies recreational drug exposure Clinical Findings Extraoral examination reveals normal TMJ function, no facial muscle tenderness, and no cervical lymphadenopathy. Intraoral examination reveals an intact dentition in good repair with no evidence of caries or periodontal disease. There is well-defined, firm, smooth surfaced papule noted on the lingual alveolar ridge interproximal to #22/23 (Figure 1). The lesion is broadly attached and blanches with pressure (Figure 2). A periapical radiograph of the area is within normal limits, with no evidence of alveolar bone loss or osseous involvement. The lesion is excised and submitted for histologic assessment.

Figure 1. Smooth surfaced papule on the lingual alveolar ridge interproximal to #22/23.

Figure 2. Blanching noted with applied lateral pressure.

Histopathologic Findings The biopsy of the gingival mass shows a submucosal proliferation of nests, cords and islands of odontogenic epithelium. The epithelium displays peripherally palisaded columnar epithelial cells with nuclear polarization away from the basement membrane, nuclear hyperchromasia, subnuclear cytoplasmic clearing, and central keratinization. A supporting fibrovascular connective tissue stroma is present. There is a patchy acute and chronic inflammatory infiltrate. No bone involvement is identified.

Figure 3. Low-power histologic image showing an infiltrative submucosal proliferation of nests and strands of odontogenic epithelium. Mild inflammation is present.

Figure 4. High-power histologic image of the odontogenic epithelial islands exhibiting peripherally palisaded columnar epithelial cells with nuclear polarization away from the basement membrane, nuclear hyperchromasia, subnuclear cytoplasmic clearing, and central keratinization. There is a supporting fibrovascular stroma.