Forum for Clinical and Surgical Oral Pathology

Case BBOPF 06-5

Dr. George Gallagher (Boston University, USA) is requesting your advice for the following case. This case will be posted from June 16 to June 23, 2006. A summary of the responses will be posted in BBOP.

Clinical History

The patient is a 33 year-old woman, a periodontist, in excellent general health. She takes no medications, does not smoke, and uses commercial toothpaste with whiteners but without tarter control additives. There was no history of skin abnormalities.

About 2 months ago she became conscious of a localized labial gingival swelling in the region of tooth #8 (upper central incisor). She described the swelling as otherwise asymptomatic and obviously fluid-filled. It enlarged slowly, and on 2 occasions seemed to drain a tasteless fluid. She thinks that the swelling began in a more apical location and enlarged toward the marginal gingiva as it grew, but the lesion has always been confined to the attached gingiva.

Upon examination, the patient presented no abnormalities of the head, neck or visible skin. The teeth are heavily restored, but there are no restorations of teeth 7 and 8. There is a veneer on tooth #9, which has been endodontically treated for a number of years. #9 is asymptomatic and recent radiographs seem W.N.L. Oral hygiene is good, with no areas of gingivitis and no tooth mobility or pockets. Specifically, there is no attachment loss around #s 7 and 8, and gingival probing depths are normal, without bleeding. A photograph of the swelling is shown below.

Upon palpation the lesion is fluctuant, and fluid can be seen to move back and forth within the lesion as pressure is moved from mesial to distal and back. The fluid seems clear. The borders of the lesion are sharply circumscribed, and moderately heavy pressure neither causes emptying nor extension of the vesicle. No signs of mucosal fragility are present. There seems to be little, if any, inflammation.

The patient is distracted by the swelling and concerned about its cause. Were the lesion to be excised, there are concerns about esthetics and the need for complicated surgery to maintain attached gingiva. The vesicle seems to me too robust and stable to be caused by the "usual suspects" and there are no other signs of oral or systemic conditions that I associate with blistering.

I would appreciate any ideas about possible causes for this condition.

Dr. George Gallagher

Images