Background: The gingiva is part of the periodontium supporting structures surrounding the teeth and commonly involved in gingival and periodontal conditions. Assessing the distribution of gingival lesions is important for evaluating the prevalence of periodontal disease in the population to optimize the oral health care services. The purpose of this study is to report the frequency and distribution of gingival lesions biopsied from 1996?2016. Material and Methods: This cross-sectional retrospective study retrieved data from all gingival lesions biopsied from 1996?2016 and sent to the King Abdulaziz University Dental Hospital oral pathology laboratory. Histologic sections were reviewed in a blinded manner by a certified oral pathologist to confirm the initial histologic diagnosis. Results: Of the 1,248 oral-maxillofacial lesions, 119 (9.5%) gingival lesions were diagnosed. The mean age was 41.58 years. Gingival lesions were more prevalent in female patients than male patients (53.8%). The most common diagnoses were reactive lesions (41.2%). Pyogenic granuloma was the predominant lesion in the category (n=26, 21.8%), and followed by inflammatory conditions (24.4%), benign neoplasm (9.2%), malignant neoplasm (7.6%), epithelial lesions (7.6%), miscellaneous (5%), and immune-mediated diseases (5%). Squamous cell carci noma was the only malignant neoplasm reported (7.6%; mean age, 57.44 years) and more common in male than female patients (2:1). Most biopsies were sent from oral and maxillofacial surgeons (55.6%) followed by general dentists (22.2%) and periodontists (12.8%). Conclusions: Pyogenic granuloma was the most common gingival lesion. Squamous cell carcinoma was the only malignant lesion in which histologic examination was the definitive diagnostic measure. This study provides information about the frequencies and distributions of gingival lesions over 20 years.