1 hyperplasia of oral mucosa

Who appreciates ART is NO LESS than who creates it

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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

doesn't 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)


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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 doesn't 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}


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- 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


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

- There's 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)


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- 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


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)



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


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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


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 haven't 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


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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 doesn't 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



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"


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



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** 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):


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


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** 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


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


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


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


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


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1 hyperplasia of oral mucosa