1 hyperplasia of oral mucosa

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1 hyperplasia of oral mucosa

  1. 1.  Who appreciates ART is NO LESS than who creates it  Hyperplasia of oral mucosa  Hyperplasia:  Hyperplasia means controlled proliferation of cells (increase in the number of cells) without any cytological abnormality It is a tumor-like enlargement of tissues due to certain stimulus (which if removed, the lesion will regress back to normal) ** Neoplasia or true tumor means uncontrolled proliferation of cells with cytological abnormality and it happens due to mutations  Hyperplasia of oral mucosa is usually localized  Cause of localized hyperplastic lesions of oral mucosa is chronic inflammation/irritation ** Chronic = continuous non-severing low-grade mild irritation ** Localized hyperplastic lesions that occur in response to chronic inflammation/irritation are the most common oral lesions and such type of hyperplasia is called “reactive hyperplasia” ** The most common causes of reactive hyperplasia are: 1- Plaque & calculus 2- Lip/cheek biting 3- Ill fitting/over-extended denture 4- Sharp edge of crown or bridge ** Localized hyperplastic lesions of oral mucosa are usually the result of chronic mild irritation which doesnt cause ulceration or bleeding but rather a chronic inflammation In chronic inflammation, Inflammation and repair occur simultaneously and granulation tissue is produced which is if excessive it present as an exophytic mass ** Many localized hyperplastic lesions of oral mucosa represent variation of the same disease process, clinically they present as exophytic mass that is increasing in size, histologically they range from richly cellular and vascular lesions to non-inflamed and avascular masses of dense collagen  Location of localized hyperplastic lesions of oral mucosa is anywhere in the mouth and if they arise on the gingiva, they are referred to as epulis (pleural is epulides) ** The term epulis is non-specific and it means a localized chronic inflammation on the gingiva  Examples of localized hyperplastic lesions of oral mucosa:  Epulides (fibrous epulis, vascular epulis, giant cell epulis)  Pyogenic granuloma  Giant cell fibroma  Retrocuspid papilla  Fibroepithelial polyp  Denture irritation hyperplasia (Epulis Fissuratum, inflammatory fibrous hyperplasia)  Inflammatory papillary hyperplasia (papillary hyperplasia of the palate) 1/8
  2. 2.  Who appreciates ART is NO LESS than who creates it   Epulides:  Epulides are reactive tumor-like gingival enlargement, which are hyperplastic BUT NOT neoplastic, and most of them arise from interdental tissues  Epulides are more common in females  Epulides are slightly more common in the maxilla than mandible  Epulides are more common in the anterior region of the oral cavity (anterior to the molar teeth)  The main etiological factors behind epulides are trauma and chronic inflammation/irritation particularly by subgingival plaque and calculus  For epulides to resolve the etiological factor should be identified and removed to allow lesion to regress by itself, and if after following the patient up, the lesion doesnt seem to regress by itself then surgical excision is required  Causes of recurrence of epulides after excision include persistence of etiological factor and /or incomplete excision of lesion  Types of epulides:  Fibrous epulis  the commonest type of epulis  Vascular epulis  the second commonest type of epulis  Giant cell epulis  relatively uncommon  A localized hyperplastic lesion on the gingiva is firstly described clinically as epulis until its definitive diagnosis (type) is proved microscopically  Fibrous epulis:  Peripheral ossifying fibroma & chronic hyperplastic gingivitis & irritation fibroma (focal fibrous hyperplasia) are considered as fibrous epulis in some textbooks  Clinical presentation:  Pedunculated or sessile lesion  Firm consistency (due to too much collagen)  Pink color usually similar to adjacent gingiva  Non-bleeding lesion  The surface of the lesion may/may not be ulcerated ** Pedunculated = constricted at the base ** Sessile = broad at the base  Histopathological presentation:  Fibrous epulis consists of granulation tissue with variable amounts of cells (fibroblasts) ** If the lesion seems to have highly cellular fibrous tissue (nuclei of fibroblasts are clearly seen) with some bone/cementum formation then it is called {Peripheral ossifying fibroma} 2/8
  3. 3.  Who appreciates ART is NO LESS than who creates it  - Peripheral = outside the bone (on gingiva) - Ossifying = bone/cementum formation in the fibrous tissue matrix - Fibroma = highly cellular fibrous tissue ** If the lesion seems to have avascular and acellular fibrous tissue (nuclei of fibroblasts are barely seen) without any bone/cementum formation then it is called {chronic hyperplastic gingivitis}  Mature collagen is usually present  Inflammatory infiltrate (mainly plasma cells) is present in most gingival biopsies because gingiva is exposed to plaque and calculus accumulation and their bacteria  Less commonly the lesion contain less cellular and less vascular fibrous tissue just like Fibroepithelial polyp  Treatment:  Identify and remove the cause (by scaling and polishing) to allow the lesion to regress by itself  If not, then surgical excision is required  Vascular epulis:  We have two types of vascular epulis: Pyogenic granuloma & pregnancy epulis ** The two lesions are clinically & histologically identical ** Pregnancy epulis is regarded as Pyogenic granuloma occurring in pregnant women  The peak incidence for these lesions occurs in females of child-bearing age  The term Pyogenic granuloma is historical, it was originally used because oral lesions resembled skin lesions that were thought to be caused by Pyogenic organisms Nowadays, Pyogenic granulomas are referred to as lobular capillary hemangiomas  Clinical presentation:  Pyogenic granuloma: - Pedunculated or sessile lesion - Soft consistency (due to too much blood vessels) - Red-purple lesion as it is highly vascular - The lesion bleeds easily after minor trauma or sometimes spontaneously - Lesions exhibit rapid growth so that they reach a very big size in a short period of time, which may rise the suspicion of malignant tumors - The surface of the lesion may/may not be ulcerated - Theres usually history of trauma ** Pyogenic granuloma occur on gingiva in 75% of the time or any other mucosal site (such as lips and tongue) and also on the skin  Pregnancy epulis: - Pedunculated or sessile lesion - Soft consistency (due to too much blood vessels) - Red-purple lesion (due to too much blood vessels) 3/8
  4. 4.  Who appreciates ART is NO LESS than who creates it  - The lesion bleeds easily after minor trauma or sometimes spontaneously - Lesions occur at any time during pregnancy, however they more commonly arise at the end of the first trimester - Lesions gradually increase in size because endothelial cells lining blood vessels in the gingiva are highly responsive to pregnancy hormones (estrogen and progesterone) - Lesions recur if excised during pregnancy - Lesions regress by themselves after delivery ** It is important NOT to rely on the clinical presentation alone to give a diagnosis since some chronic (mature, old) vascular epulides may undergo fibrosis and become firm and less vascular resembling fibrous epulides  Histopathological presentation:  Highly vascular proliferation  Lobular organization and that’s why some publishers call Pyogenic granuloma {lobular capillary Hemangioma}, which is a more descriptive term - Lobular = many lobules separated by fibrous septa - Capillary = small blood vessels - Hemangioma = endothelial cells proliferation  It has variable inflammatory infiltrate that predominate beneath areas of ulceration  Older and mature lesions may be more fibrous and less vascular  Treatment and prognosis:  Identify and remove the cause (by scaling and polishing) to allow the lesion to regress by itself  If not, then conservative surgical excision down to periosteum is required (since the lesion is highly vascular, bleeding after excision is very difficult to control)  Occasionally, it may recur  In case of pregnancy epulis, it is preferable to delay the excision until after delivery as the vascularity decreases and the lesion may regress or even resolve provided that the cause (mostly dental plaque and calculus) is removed  Giant cell epulis:  Giant cell epulis is also called peripheral giant cell granuloma (PGCG)  Clinical presentation:  Pedunculated or sessile lesion  Dark red lesion  It is commonly ulcerated  It occurs exclusively on the gingiva or the alveolar ridge in dentate or edentulous patients  In dentate patients the lesion usually arises interdentally with buccal and palatal parts joined together giving the lesion an hour- glass appearance 4/8
  5. 5.  Who appreciates ART is NO LESS than who creates it   It is slightly more in the mandible  We need to clinically distinguish peripheral giant cell granuloma (PGCG) that occur on gingiva and alveolar mucosa from central giant cell granuloma (CGCG) that arises inside bone - When CGCG perforates the bone it will appear on gingiva and alveolar mucosa just like PGCG - The two lesions can be distinguished radiographically - Radiographs may reveal superficial bone erosions in some cases of PGCG - In both PGCG and CGCG we should ask for parathyroid hormone level to exclude brown tumor of hyperparathyroidism  Pathogenesis:  The pathogenesis is unknown, but it is generally accepted that the lesion represents reactive hyperplasia  It is suggested that PGCG most likely arise from periosteum rather than gingiva as the lesion may cause superficial bone erosions and it occurs not only in dentate but also in edentulous patients  Giant cells are thought to originate from macrophages or osteoclasts  Histopathological presentation:  Collection of giant cells lying in richly vascular and cellular stroma  Giant cells vary in size, shape and number of nuclei  Stromal cells are spindled or ovoid, and they may be macrophage or fibroblasts or endothelial cells  Extravasated red blood cells and hemosiderine deposits are common (which give the lesion dark-brown or red color)  Occasionally slight bone formation may be found. ** Sometimes, there may be multiple giant cell lesions, here we should think of systemic disorders rather than local irritation (e.g. hyperparathyroidism or rarely neurofibromatosis type I)  Treatment:  Identify and remove the cause (by scaling and polishing) to allow the lesion to regress by itself  If not, then local surgical excision to underlying bone is required  Prognosis:  These lesions have the highest recurrence rate among epulides (Recurrence rate is 10%)  Lesions tend to recur if they havent been excised completely or the etiological factor persists  Pyogenic granuloma (NOT as an epulis):  Although the majority of Pyogenic granulomas in the oral cavity arise on the gingiva (as epulides), the lesion can occur at other sites (e.g. tongue, labial & buccal mucosa, or lips) as a result of trauma  The clinical & histological appearance of these Pyogenic granulomas is the same as for the gingival lesions 5/8
  6. 6.  Who appreciates ART is NO LESS than who creates it   Fibroepithelial polyp (irritation fibroma):  It is the commonest lesion of the oral cavity  It is a reactive non-neoplastic lesion  It is NOT a true tumor since it doesnt increase significantly in size with time  It is basically a fibrous epulis that occur in areas other than the gingiva  Chronic minor trauma appears to be an important initiating factor  Clinical presentation:  Pedunculated or sessile lesion  Pink color  Firm consistency (due to too much collagen)  Varies in size (from few millimeters to a centimeter or more)  Non-bleeding lesion  Ulceration is NOT a feature unless the patient has bitten it  The most common site is the buccal mucosa (particularly along the occlusal line) BUT it may also occur in the labial mucosa, tongue and gingiva ** If Fibroepithelial polyp occurs in the palate under the fitting surface of the denture, then the lesion becomes flattened and leaf-like and this is commonly referred to as "leaf fibroma"  Histopathological presentation:  The lesion is comprised of relatively avascular and acellular fibrous tissue  Collagen fibers are predominant  Fibroblasts are scanty (present in small amounts)  Typically there is little or no inflammatory infiltrate, so the lesion is sometimes regarded as formation of exuberant repair tissue  The surface epithelium varies in thickness and it may show areas of hyperkeratosis  Treatment:  Identify and remove the cause to allow the lesion to regress by itself  If not, then surgical excision is required 6/8
  7. 7.  Who appreciates ART is NO LESS than who creates it  ** Some CLINICAL differential diagnoses for gingival tumor-like enlargement: 1. Pyogenic granuloma 2. Peripheral giant cell granuloma 3. Peripheral ossifying fibroma 4. Chronic hyperplastic gingivitis 5. Irritation fibroma  Reactive non-neoplastic enlargement of fibrous connective tissue that arises on keratinized mucosa (e.g. gingiva, buccal mucosa, labial mucosa, tongue and hard palate) and occurs in the 4th to 6th decades of life 6. Giant cell fibroma  Occurs at a much younger age compared to irritation fibroma, it is NOT associated with trauma or irritation, and it is non-neoplastic enlargement that arises on keratinized mucosa (e.g. gingiva, buccal mucosa, labial mucosa, tongue and hard palate). The lesion is composed of multi-nucleated fibroblasts within fibrous connective tissue 7. Retrocuspid papilla  Developmental lesion arises lingual to mandibular canine on the interdental papilla and occurs in 25-99% of young adults and children Histologically it is the same as giant cell fibroma Note: in some textbooks lesions number 3, 4 and 5 are considered as fibrous epulis  Denture irritation hyperplasia (Epulis Fissuratum):  Clinical presentation:  Reactive non-neoplastic enlargement of mucosa related to the flange of an ill fitting denture  Most frequently appears as multiple folds of tissue arising in the depth of vestibules, commonly on the facial aspect of the flange, sometimes it may involve the inner surfaces of cheeks and lips or the posterior edge of an upper denture  Mucosa is firm, fibrous and not grossly inflamed  Mucosa may be ulcerated at the base of the vestibule  It is more common with lower dentures  It is more common in females 7/8
  8. 8.  Who appreciates ART is NO LESS than who creates it  ** Most studies indicate a clear predilection for denture irritation hyperplasia in females. The fact that women are more likely than men to wear their dentures for prolonged periods because of their reluctance to be seen without them probably plays a significant role. In addition, more women than men wear dentures and are more likely to seek treatment. Possibly, atrophic epithelial changes secondary to menopause may influence an increased reaction to trauma in older females  Histopathological presentation:  The epithelium may show hyperkeratosis and sometimes ulceration  The lesion is comprised of relatively avascular and acellular fibrous tissue that sometimes shows inflammatory cells beneath the ulcerative area.  Treatment:  Identify and remove the cause (by relining or remaking the denture) to allow the lesion to regress by itself  If not, then surgical excision is required  Papillary Hyperplasia of the Palate:  The exact etiology behind this condition is not fully understood, however there are some factors that are present in most of the cases, these include:  Ill-fitting denture (that causes chronic minor trauma)  Continuous denture wearing  Candida-associated denture stomatitis  Poor oral hygiene  Clinical presentation:  The hard palate shows pebbled appearance due to the numerous, small papillary projections  The mucosa is often red and inflamed especially if there is an accompanying candidal infection  Histopathological presentation:  Papillary projections of hyperplastic chronically inflamed granulation tissue  The overlying epithelium is also hyperplastic sometimes too much and in an irregular pattern to resemble carcinoma, and is called “pseudo- epithelomatous hyperplasia” but there is NO atypical cytological features  Treatment:  Identify and remove the cause (by removing the denture and maintaining good oral hygiene) to allow the lesion to regress by itself  If not, then surgical excision is required 8/8

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