Epulis

Epulis is a benign tumor and non-neoplastic growth is above the gingiva (interdental papillae) are derived from the periodontal tissues and periosteum. This can be fibrous epulis, hyperplastic, and granulatif. In this epulis growth could not be stemmed or so-called sensile and can also stemmed (peduncullated).The types of epulisI. Granulomatous epulisThis epulis occurs from a reaction network granulomatik because of chronic irritation due to residual roots, caries edge, tumpatan the overhanging, or klamer sharp. Frequency was statistically epulis is rarely found. Clinical picture is of a reddish color dungkul stemmed with or about the same as the granular surface, soft consistency can be accompanied by tenderness and sometimes can diseratai an ulcerated. Digingiva most locations but can also occur throughout the oral cavity, such as the lower lip, tongue and palate On histological examination showed epithelial coated dungkul inlaid under which consisted of granulation tissue with proliferation of capillaries and connective tissues of young and sebukan chronic inflammatory cells. Elimination of the causes and excision can give a good prognosis for this type of epulis perwatan.II. Epulis fissuratuma. DefinitionGrowth in excess fibrous connective tissue in the mucosa in contact with the edge of the denture is usually too fixed and suppress mucosa. Epulis fissuratum also often called inflammatory fibrous hyperplasia, or denture epulis.This epulis fibrous tissue folds appear as one or more of the vestibule is not accompanied by signs of inflammation, is painless unless there is secondary infection, fibrous hyperplasia, proliferation of epithelial / ulcers. Chronic irritation caused by the use of denture inadequate in the long term in this case due to the base / wing prosthesis. Epulis fissuratum a reactive hyperplastic lesions that chewy consistency. Histological appearances may vary, and frequency most seemingly benign fibrous. If there is an inflammatory reaction will appear fibroblasts and vascular proliferation. Mucosal gland always appear in the specimen and will lead to chronic sialadenitis. Sometimes gland will have a relationship with lymphoid hyperplasia and ductal papillary hyperplasia. The atrophic or hyperplastic epithelium and sometimes raises pseudoepitheliomatous hyperplasia. Ulceration can occur at the base of the folds. Kondroid or bone metaplasia may develop as the emergence of a bump.The connective tissue growth caused by chronic irritation due to the use of artificial teeth, denture where the edge of the gums pressing areas bordering the inner cheek (vestibular alveolar mucosa). The suppression of bone causes the area is constantly changing due to loss of bone, resulting in bone support for the denture base becomes unstable. This gradually leads to the protrusion of the epulis fissuratum.

Fig. Epulis fissuratum protrusion which appears to be a vestibule in contact with the edge of the dentureThis condition is most common in older people because the patients in the age group of many who use denture. However, this problem tends to diminish with the growing technology of dentistry and the increasing awareness of the patient to maintain the integrity and health of your teeth and mouth so that dentures will need to be reduced. It seems this condition is more common in women than menb. SymptomLesions composed of redundant network is generally in the form of pink hyperplastic folds, hard and fibrous. The inside and outside of lesions separated by basins (groove) in which signifies the place where the edge of the denture pressing mucosa.Epulis fissuratum rare in the lingual (tongue facing part), and is more often found in the front of the jaw (anterior). The lesion size varied. There is a small lesions, but there are also extensive and involve the whole region mucosa (mucosa vestibule) in contact with the edge of the denture. Sometimes it can be quite severe irritation causing redness and visible mucosal ulceration, particularly at the base edge of the basin in which the artificial tooth into contact with mucous.c. TreatmentThese lesions can be removed by excision. In addition, the artificial tooth into the onset of these lesions should be improved to be able to have good dexterity but puts pressure on the mucosa in order to prevent a more severe irritation.Although these lesions are very rarely associated with squamous cell carcinoma, but as a preventive action should be carried out on a microscopic examination of the excised lesion.III. Giant Cell epulisa. DefinitionEpulis type is also often referred to as peripheral giant cell granuloma, giant cell reparative granuloma, osteoclastoma and myeloid epulis. The exact cause is unknown, but is expected to giant cell epulis occurs in response to an injury. In addition, many cases where patients express surface receptors for the hormone estrogen, which raised speculation that hormonal influences may play a role in the development of these lesions.Epulis gigantoselulare caused by trauma to the gingival soft tissue which can be caused by tooth extraction, denture irritation, and chronic infections are more common in women and children. Clinically this can epulis the periodontal tissues or in edentulous ridge areas with varying diameter sizes between 0.5 to 1.5 even bigger and can also ulcerated this Dungkul wide-stemmed with dark red to purple, soft consistency and easy bleed so sometimes accompanied by pain. On histopathologic examination obtained fibroblast cells which is undergoing proliferation and form a stroma that contains a lot of giant cells of foreign body.Giant cell epulis can occur at any age but most cases are diagnosed in patients in the age group 40-60 years, and especially in women.Image. Giant Cell epulis

insisif teeth on the palatal regionb. SymptomLesions appear as enlarged gums that appear in between two teeth, rich vascularity so easily bleed to the touch and are generally purplish red.Its size varies, most cases usually less than 2 cm but no case exceed the size of 4 cm diameter. These lesions can grow into masses of irregular shape that can become ulcerated and bleed easily. In some cases of giant cell epulis can invade underlying bone so that the picture will be visible radiographic bone erosion.c. TreatmentEpulis giant cell treatment involves surgical excision and curettage of bone involved. Teeth adjacent to the epulis also need to be removed when it is not tenable, or made tartar cleaning (scaling) and smoothing the root (root planing). Reported recurrence rate of 10% so that the necessary action excision back.IV. Congenital epulisa. DefinitionThe cause of the occurrence of congenital epulis is uncertain but scientists believe that the epulis is derived from primitive mesenchymal cells that originate from the neural crest.This is the type of epulis congenital condition that is very rare, and occurs in infants at birth. Of the research found that congenital epulis more common in babies of women than men with a ratio of 8:1, and most occur in the maxilla (upper jaw) than the mandible (lower jaw).

Image. Baby girl with congenital epulis, which was first reported case in 1871 and up to now only about 200 incidents have been reported.b. SymptomIn the newborn baby bulge mass found in the mouth, usually on the upper jaw bone anterior (front). 10% of reported cases, lesions which occur are multiple lesions but can also be a single lesion. Lesion size varied from 0.5 cm to 2 cm, but there are cases where the size of epulis reach 9 cm. This lesion soft, stemmed and sometimes in the form of lobes of the alveolar mucosa. When epulis is too large, it can disrupt the respiratory tract and make it difficult for the baby while feeding.Histologically, congenital epulis similar to granular cell tumor that occurs in adults. The difference was not recurrent and congenital epulis not seem potentially lead to malignancy. This disorder can be found at an early stage when the mother checked the content through tools sonography but a definitive diagnosis can not be enforced.c. TreatmentIn most cases, epulis tend to shrink and disappear by itself when the baby reaches the age of about 8 months. Thus the small-sized lesions do not require treatment. Larger lesions can interfere with breathing and / or breastfeeding so that unnecessary surgery with general anesthesia. Reported the successful use of carbon dioxide laser to operate on a large epulis lesions. Of existing cases, this incident does not seem to interfere with the process of tooth growth.V. Epulis Gravidarum (Tumor Pregnancy)a. DefinitionEpulis gravidarum is a growing reaction granulomatik tissue of the gums during pregnancy. This tumor is a benign proliferative lesions in the oral soft tissues incidence ranging from 0.2 to 5% of pregnant women.This type of epulis expanding rapidly, and it is likely recur in subsequent pregnancies. Pregnancy tumors are usually present in the first trimester of pregnancy, but there are patients who reported this incident in the second trimester of pregnancy. Rapid development in line with the increase in estrogen and progesterone during pregnancy. Greater influence of progesterone on the inflammatory process / inflammation. Gingival enlargement will decrease the 9th month of pregnancy and the few days after giving birth. The situation will be back to normal as before pregnancy.Epulis gravidarum appears as a bulge on the gingiva with a variety of colors ranging from pink, dark red to purplish-colored papules, most often found in the anterior maxillary gingiva. Generally, patients do not complain of pain, but these lesions bleed easily when chewing or brushing teeth. In general, this lesion diameter not more than 2 cm but in some cases reported that lesion size is much larger, making it difficult patient clenched lips. Factor causes epulis gravidarum can be divided into 2. That is the cause of primary and secondary causes:a. Primary causesLocal irritants like plaque is the primary cause of epulis gravidarum as well as in non-pregnant women, but hormonal changes that accompany pregnancy can aggravate inflammatory reactions by local irritation of the gums. The local irritation is calculus / plaque that has undergone calcification, leftover food, poor fillings, dentures that are less good.b. Secondary causesPregnancy is a physiological condition that causes hormonal balance changes, particularly changes in the hormones estrogen and progesterone. Increased concentrations of the hormones estrogen and progesterone during pregnancy have varied effects on the network, including the widening of blood vessels resulting in increased blood flow to the gingiva becomes red, swollen, and bleed easily.

Image. Epulis gravidarum in pregnant womenb. SymptomThe pregnancy tumor appears as a bulge on the gums with a variety of colors ranging from pink, dark red to purplish-colored papules, most often found in the upper jaw. Generally, patients do not complain of pain, but these lesions bleed very easily when chewing or brushing teeth. In general, this lesion diameter not more than 2 cm, but in some cases reported that lesion size is much larger, making it difficult patient clenched lips.c. TreatmentGenerally, these lesions will shrink and disappear by itself as soon as the mother had the baby, so the treatment is associated with lesions should be postponed until after delivery unless there is pain and bleeding continues to occur that interfere with optimal tooth brushing and daily routine.But in cases where epulis persisted after the baby is born, the lesions required biopsy for histological examination. Spontaneous recurrence was reported in 75% of cases, after 1 to 4 months after giving birth.When a large bulge mass and disrupt mastication and speech, the bulge can be removed with a conservative surgical excision. But sometimes this pregnancy tumor can be removed with Nd: YAG laser because it gives the advantage that a little bleeding.VI. Angiomatosa epulis (epulis Telangiecticum)An excessive granulation response is endothelial reaction (proliferation) and the etiology due to trauma or unknown but suspected as hemangioma gingiva. Said to be an exaggerated response due to rapid growth, bounded clear, soft spongy consistency, bright red and bleed easily. Angiomatosa epulis is often in the differential diagnosis with granulomatous epulis and epulis gravidarum.

VII. Epulis FibromatosaThis epulis occurs in the oral cavity, especially on the edge of the gingiva and is also common in the cheek and tongue. Etiology derived from chronic irritation that causes hyperplasia of fibrous tissue reaction. Clinical signs are seen, among others, stemmed, or may not, pale pink, rubbery consistency and a solid, well defined, solid and sturdy. Epulis is not easy to bleed and painless.

Classification epulisBased on histopathologic, epulis classified into conditions that mimic tumor as mentioned below:The conditions that mimic tumor Verruca vulgaris Papillary hyperplasia Limphoepitelial Benign Lesions Mukokel Overgrowth of fibrous tissue Congenital fibromatosis Santogranuloma Granuloma piogenikum Epulis gigantosellulare Traumatic neuroma Neurofibromatosis

Diagnosis, PrognosisFor diagnosis epulis to do some checks, as well as supporting both routine examination to determine prognosis and appropriate treatment plan. Diagnosis epulisEpulis Diagnosis is made by anamnesis, clinical examination and radiographic examination, laboratory and histopathologic. Differential diagnosis of epulis is a benign tumor or other neoplasm that occurs in the gums such as fibroma, mixoma, mioblastoma and central giant cell tumors. Anamnesis epulisGenerally, people are not aware of epulis lesions during not cause any complaints in the oral cavity, but when it becomes larger epulis to interfere with the function of mastication, dental occlusion and esthetics, new patients feel the need to seek treatment. In some cases, epulis which has been enlarged and ulcerated can cause pain.

Clinical Examination epulisClinical symptoms were found on physical examination epulis is as follows:a) Mass is a bulge on the gumsb) Localized with firm boundariesc) Konsistesi hard or softd) Can be stemmed or not stemmede) Can ulceratedf) Sometimes berlobusg) Colored pink to purplish redh) can bleed spontaneously or on slight traumai) The size varies from a few millimeters to several centimeters and can reach a very large size. Radiography Examination epulisIn patients with epulis radiographic examination to determine the extent of tissue damage and supporting bone structure. On inspection found some erosion at the edges or tops that are superficial alveolar bone in the interdental area. Laboratory epulisLaboratory tests are done which is taking a biopsy is part of the network that includes pathological tissue and healthy tissue. The network then fixed with formal saline and sent to the Pathology section to be diagnosed.

Histopathologic examination epulis On histopathologic examination found epulis connective tissue covered with squamous epithelium-lined-cell infiltration of round and spindle-shaped cells and inflammatory PMN cells, leukocytes and plasma cells. It also found multinucleated giant cells that is the hallmark of giant cell epulis. Some epulis contains many blood vessels and fibroblast proliferation as well as a number of collagen fibers. Examination immunocytochemistry epulisThis can also be done while immunocytochemistry examination, the examination that utilizes antigen antibody reaction to determine the immune response to an antigen cells. Prognosis epulisEpulis prognosis is generally good if the patient always keep his mouth after excision perfect. Surgical excision is carried out should take up the entire basis of the epulis around the gum tissue even though derived from alveolar bone periosteum to prevent recurrence.Gingival tissue overgrowth(Celsus/Galen: "disease on the gingival surface"; Axhausen: "no epulis without a tooth")These tumour-like lesions, designated as epulis, are rather: Due to chronic trauma or inflammation Usually of connective-tissue origin and only rarely of epithelial origin Non-neoplastic

Classification Histopathological classification (Axhausen):(German-speaking countries)WHO classification

- Epulis granulomatosa - Pyogenic granuloma

- Epulis fibromatosa - Fibrous hyperplasia

- Epulis gigantocellularis - Peripheral giant-cell granuloma

- Epulis fissurata - Inflammatory fibrous dysplasia

- Epulis gravidarum - Pyogenic granuloma

Pyogenic granulomaSynonyms: Lobular capillary hemangioma, granulation tissue-like hemangioma, epulis granulomatosa, epulis gravidarum, granuloma teleangiectaticum, epulis angiomatosDefinition and clinical picture : - Local reactive connective-tissue proliferation of skin and mucosa. Localised most frequently on the gingival surface or in the vestibule, the tongue, or the cheek. Women are more frequently affected than men. Marginal periodontitis is of causal significance in its aetiology; microtrauma is also a possible cause. Often a short case history and a tendency for recurrence. Special form: Pyogenic granuloma (Epulis gravidarum)Morphology : - Broad-based or pedicled red overgrowth with a diameter of a few millimetres to 2 cm- Frequently superficial ulceration or white coating- Often bleed when touchedHistology :Granulation tissue with various degrees of inflammation and development of collagen fibres. In case of prominent capillary proliferation: "Granuloma teleangiectaticum". Strictly speaking, they are not granulomas.Treatment : -Surgical removal with resection of periosteum and bone and the affected periodontal ligaments down to healthy tissue - In case of relapse: Extraction of the adjacent toothFibrous hyperplasiaSynonym: Epulis fibromatosDefinition and clinical picturePolypoid, usually broad-based, rough, pale overgrowth of the gingival mucosa; pedicled forms also occur. Marginal periodontitis and microtrauma can also be significant in the aetiologSpecial forms:1. Inflammatory fibrous dysplasiaLocalisation in the area of the denture flange, often multiple. The surface may be ulcerated. Aetiology: Ill-fitting denture; inflammation secondary to functional activity (speech and mastication).2. Traumatic fibromasUbiquitous in the oral cavity, often at the level of the occlusal plane. Broad-based or pedicled mucosal protrusion. Usually reactive, irritative, localised lesions; clinically and histologically similar to fibromas (true neoplasias)Histology : Polypoid protruding mucosa, subepithelial nodular and dense deposition of collagen fibre bundles with sparse small blood vessels, usually without inflammatory infiltrate.Treatment : Excision (and send for histological examination)Improvement of the denture fit, if necessaryPeripheral giant-cell granulomaDefinition and clinical picture : Localised on the gingival margin as a dark-red to bluish "epulis"; only occurs on the gingiva; a non-neoplastic, localised, reactive cell proliferation with tendency for recurrence.Histology : Histologically analogous to what is referred to as central giant-cell granuloma (the designation of "peripheral" or "central" depends on their localisation: peripheral =on the gingiva, central =intra-osseous). Vascular connective tissue, mononucleated cells and multinucleated giant cells.Treatment: - Surgical removal with excision of the underlying periosteum and adjacent bone and affected parts of the periodontal ligaments of the teeth involved in the lesion- In case of relapse: extraction of the tooth