|Year : 2017 | Volume
| Issue : 4 | Page : 258-263
Reactive lesions of oral cavity: A retrospective study of 659 cases
Biji Babu, Kaveri Hallikeri
Department of Oral and Maxillofacial Pathology and Microbiology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India
|Date of Submission||09-May-2017|
|Date of Acceptance||30-Sep-2017|
|Date of Web Publication||29-Jan-2018|
Dr. Kaveri Hallikeri
Department of Oral and Maxillofacial Pathology, SDM College of Dental Sciences and Hospital, Dhaval Nagar, Sattur, Dharwad - 580 009, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: This study reviews, analyzes, and compares the demographic data, histopathological features and discusses the treatment and prognosis of reactive lesions (RLs). Materials and Methods: Retrospective study was performed on the departmental archives from July 2006 to July 2016 (total 5000 cases) comprising of 659 cases of RLs of the oral cavity. The recorded data included age, gender, size, site, duration, habits, etiology, histopathological diagnosis, treatment, and prognosis. Results: The most common lesion was found to be inflammatory fibrous hyperplasia (47%) followed by pyogenic granuloma (PG) (27.16%) and the least cases were of peripheral giant cell granuloma (1.6%). The mean age for the occurrence was 4th–5th decade in all the RL's exceptperipheral ossifying fibroma (POF) which presented in the third decade. Female predominance was noted in all lesions except irritational FIB. The sizes of majority of the lesions were approximately 0.5–1 cm. The common sites were anterior maxilla followed by posterior mandible and least in tongue with no associated habits (82.2%). The duration of all the lesions was seen to be <1 year. Majority of them presented with poor oral hygiene status (87.2%). Recurrences were present in 13.5% of surgically excised lesions. Conclusion: The RLs present commonly in oral cavity secondary to injury and local factors which can mimic benign to rarely malignant lesions. The clinical and histopathological examination helps to categorize the type of lesions. The complete removal of local irritants with follow-up and maintenance of oral hygiene helps to prevent the recurrences of such lesions.
Keywords: Etiology, oral hygiene, reactive lesions, recurrence
|How to cite this article:|
Babu B, Hallikeri K. Reactive lesions of oral cavity: A retrospective study of 659 cases. J Indian Soc Periodontol 2017;21:258-63
| Introduction|| |
Reactive lesions (RLs) are clinicopathologically benign, reactive, solitary, swelling occurring due to chronic and recurrent tissue injury leading to extreme or exuberant tissue response., They are commonly evident in gingiva, and sometimes, other sites are involved. RLs are typically developed in response to chronic inflammation caused by various forms of low-grade chronic irritations to the oral mucosa. Even though the lesion is benign, it has a tendency of recurrence with incomplete excision and inability to remove local irritants. The usage of CO2 laser is preferred over surgical excision with minimal recurrence rate followed by maintenance of oral hygiene and regular follow-ups. This study reviews, analyzes, and compares the demographic data, histopathological features and discusses the treatment and prognosis of RLs.
| Materials and Methods|| |
A retrospective study was performed on the departmental archives of SDMCDSH, Dharwad from the year July 2006 to July 2016. Patient's records were assessed to select those with the RLs of the oral cavity. RLs were classified on the basis of histopathological diagnosis into inflammatory fibrous hyperplasia (IFH), pyogenic granuloma (PG), fibroma (FIB), IF, peripheral ossifying FIB (POF), and peripheral giant cell granuloma (PGCG). Data included the type of lesion, age, gender, site, size, duration, habit, and oral hygiene status. The age groups were subdivided into 7 decades (for example, 0–10 years as first decade, 11–20 as second decade etc.) [Table 1]. The site involvement was categorized into gingiva which was further divided into anterior and posterior quadrants of maxilla and mandible, buccal mucosa, lip, tongue, palate whether single or multiple sites [Figure 1]. The size of the lesions was subdivided into 3 groups; <2 cm, 2–4 cm, and >4 cm [Figure 2]. Duration of the lesion were distributed into 3 groups, i.e., <1 year, 1–3 years, and > 3 years [Figure 3]. Habit associations were divided into 4 groups such as no association, smokeless form, smoking, and both [Figure 4]. Oral hygiene status was subdivided into poor, fair, and good [Figure 5].
|Figure 1: Graph depicts the site distribution of reactive lesions. IFH: Inflammatory fibrous hyperplasia; PG: Pyogenic granuloma; FIB: Fibroma; POF: Peripheral ossifying fibroma; IF: Irritational fibroma; PGCG: Peripheral giant cell granuloma|
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|Figure 2: Graph describes the size of the reactive lesions. IFH: Inflammatory fibrous hyperplasia; PG: Pyogenic granuloma; FIB: Fibroma; POF: Peripheral ossifying fibroma; IF: Irritational fibroma; PGCG: Peripheral giant cell granuloma|
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|Figure 3: Graph describes the duration of the reactive lesions in the oral cavity. IFH: Inflammatory fibrous hyperplasia; PG: Pyogenic granuloma; FIB: Fibroma; POF: Peripheral ossifying fibroma; IF: Irritational fibroma; PGCG: Peripheral giant cell granuloma|
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|Figure 4: Graph shows the habit association with the occurrence of reactive lesions. IFH: Inflammatory fibrous hyperplasia; PG: Pyogenic granuloma; FIB: Fibroma; POF: Peripheral ossifying fibroma; IF: Irritational fibroma; PGCG: Peripheral giant cell granuloma|
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|Figure 5: Graph denotes the oral hygiene status of the patients with reactive lesions. IFH: Inflammatory fibrous hyperplasia; PG: Pyogenic granuloma; FIB: Fibroma; POF: Peripheral ossifying fibroma; IF: Irritational fibroma; PGCG: Peripheral giant cell granuloma|
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|Table 1: Depicts the type, number of cases, mean age, gender distribution, and recurrence rate of reactive lesions of oral cavity|
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Further these parameters were correlated between recurrent and nonrecurrent RLs in which recurrent group included both single and multiple recurrences to evaluate the statistical significance (P< 0.05). The treatment protocol for such lesions included excisional biopsy using scalpel and knife or laser followed by oral hygiene maintenance with regular follow-ups. Data were entered into Microsoft excel and assessed using the SPSS.version 20.0 (SPSS Inc. Chicago, IL, USA).
| Results|| |
Of the 5000 cases reviewed, 659 cases were confirmed cases of RLs of oral mucosa with a prevalence of 13.18%. The most common lesion was found to be IFH (47%) followed by PG (27.16%), and the least cases were of PGCG (1.6%). The mean ages for the occurrence were 4th–5th decade except POF which presented mostly in 3rd decade. Female predominance was noted in all lesions except irritational FIB (IF). The sizes of majority of the lesions were approximately 0.5–1 cm. The common sites were anterior maxilla followed by posterior mandible and least in tongue with no associated habits (82.2%). The duration of all the lesions was seen to be <1 year. Majority of them presented with poor oral hygiene status (87.2%).
Among 659 cases, 72 (10.9%) cases have recurred [Table 1] of which 12 (16%) showed multiple recurrences. Parameters between nonrecurrent and recurrent RLs were correlated to evaluate the statistical significance. A statistical significance was noted in IFH between site and habit with recurrence (P = 0.016, P = 0.000) and in PG between gender and habits (P = 0.038, P = 0.028). PGCG showed significance when correlated with duration of lesion, oral hygiene status, and recurrence. Duration and recurrence gave a statistical significance in POF while habit and recurrence in IF [Table 2].
|Table 2: Describes the significant correlation between the lesions and the parameters in the recurrent and nonrecurrent reactive lesions|
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| Discussion|| |
In the present study, RLs are categorized based on the histopathological features into fibrous and inflammatory types. The inflammatory group constitutes IFH, PG, IF, PGCG, and the fibrous group constitutes FIB and POF. Inflammatory lesions comprise of inflammatory cells predominantly of chronic type and varying degree of vascularity in an edematous to cellular to fibrous stroma depending on the stage of the lesion. This is important as the recurrence rates in these lesions are different. Various case series have shown varying distribution of RLs in oral cavity owing to various classifications and terms used to describe the lesions. These lesions are primarily due of local factors such as plaque and calculus followed by the presence of ill-fitting denture, orthodontic treatment, and drug-induced acting as a form of chronic irritation which produces granulation tissue. It comprises of budding capillaries with endothelial cells admixed with chronic inflammatory cells and later are replaced with fibroblastic proliferation which manifests as an overgrowth called reactive hyperplasia. Accurate diagnosis of RLs becomes important for appropriate treatment and to prevent recurrences to minimize further complications.
Inflammatory fibrous hyperplasia
IFH comprised 47.64% of cases in the present study, and similar finding has been recorded by Jaffrey. Histologically, IFH consists of predominantly inflammatory cell infiltration, vascular engorgement, and edema.
While gingival overgrowth secondary to orthodontic treatment were paler in color with thick gingiva in contrast to inflammatory induced which were red and fragile gingival outgrowth. Orthodontically induced such gingival enlargements seem to be temporary and resolve following the therapy. However, Ramadan's study concluded that resolution may not be complete. A study done by Gursoy et al. concluded that continuing low dose of nickel is known to cause Type IV hypersensitivity reaction. In the present study, 12 (3.8%) cases were noted during orthodontic treatment while others associated with trauma 51 (16%) in the form of denture-related lip biting and cheek biting. Since these lesions are derived from periodontal tissues, it becomes mandatory to excise deeply and examine the same histopathologically for clear margin to further prevent recurrences [Figure 6]a,[Figure 6]b,[Figure 6]c. Mucoperiosteally raised flaps help to excise lesion adequately followed by curettage and debridement of underlying bone and adjacent tooth root surfaces. Laser excision is preferred as it has minimal postsurgical pain and requires no suturing. A recurrence rate of 8.9% was noted in our case, and poor oral hygiene was the major contributing factor [Figure 7].
|Figure 6: Photomicrograph showing the excised specimen of (a) irritation fibroma; (b) fibroma; (c) pyogenic granuloma, arrows indicate the extension of the lesion up to the base of surgical margin (H and E, ×4)|
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|Figure 7: Plaque and calculus deposition leading to poor oral hygiene adjacent to the growth|
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It is the second predominant lesion among the RLs in accordance with the study done by Peralles et al. Various synonyms include pregnancy tumor, benign vascular tumor, and vascular epulis. Recently, it is been also called lobular capillary hemangioma owing to the presence of well-circumscribed and distinct lobular arrangement, with central large vessels and peripheral aggregates of well-formed capillaries. If PGs are left untreated over time, it undergoes fibrous maturation with ossification and develops into POF. The main etiological factors are the presence of plaque, calculus, and pregnancy. Daley et al. reported the definite correlation between serum estrogen and progesterone hormone and PG during pregnancy. These render tissues of gingiva more vulnerable to chronic inflammation secondary to plaque and calculus; PGs should be excised deep up to periosteum and/or PDL and removal of local irritants. The hemorrhagic nature of the lesion poses difficulty during treatment; therefore, laser is recommended over scalpel to excise the lesion. The present study showed a recurrence rate of 15.6% in accordance with the studies done by Bhaskar and Jacoway and Vilmann et al., The increased recurrence rate is contributed by hormones, deep-seated lesions, poor oral hygiene, and presence of local irritants. Excision of PG during pregnancy is indicated in the 1st trimester and should be avoided in other two trimesters unless it causes functional impairment. In the present study, 57% of cases recurred in females. In addition to surgical excision, various authors have tried several treatment modalities such as Nd: YAG laser, CO2 laser, flash lamp pulse dye laser, cryosurgery, electrodessication, sodium tetradecyl sulfate sclerotherapy, and use of intralesional steroids to minimize recurrences. Excision using lasers has shown lesser recurrence rates. PG is a mysterious common lesion as it mimics certain group of lesions such as vascular tumors, metastatic cancer, granulation tissue, bacillary angiomatosis, and Kaposi's sarcoma. In our study, one case of PG mimicked a vascular tumor due to its clinical aggressive behavior [Figure 8].
|Figure 8: Clinical photograph showing a growth extending from labial to lingual aspect and laterally to incisors, erythematous with bone loss|
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IF was first noted in 1846 and coined as fibrous polyp occurring as submucosal reaction to trauma from teeth or dental prosthesis. According to various authors, males showed predominance in occurrence than females in consistent with our study. Denture-related FIB are named as Epulis fissuratum which occur adjacent to alveolar ridge secondary to ill-fitting denture, and in the present study, 16.6% of the IF cases had an association with ill-fitting denture. Only 1 case recurred in the present study, but in the literature, the recurrence is very rare unless the provoking factors remain following a conservative surgical excision. For epulis fissuratum, the treatment intended is surgical removal with the relining or remaking of the offending denture.
Peripheral giant cell granuloma
PGCG is the accepted terminology; it is known to arise from the cells of periodontal ligament (PDL) or periosteum of bone. The exact etiology is unknown. Possible factors considered are chronic irritation, tooth extractions, hormones, and xerostomia. The cells of PGCG shows high proliferative potential which owes for its higher recurrence rate. PGCG is a worldwide designated and acknowledged terminology, but still certain parameters regarding this lesion such as its etiology, recurrent nature, proliferative potential and derivative roots of multinucleated giant cells and mononuclear stromal cells remain obscure. We recorded least percentage of cases of PGCG among Rl, i.e., 1.66% comparable to the study done by Buchner et al. and by Hunasgi et al., PGCG consists of numerous multinucleated giant cell and fibrocellular stroma. PGCG is thought to originate peripherally from periodontal ligament and periosteum. The origin of giant cell is controversial and known to be originated from phagocytosis, foreign body, osteoclasts, and endothelial blood cells. CD68 immunohistochemical positivity suggests the multinucleated giant cells (MNG) cells are derived from monocyte/macrophage lineage. The cells of stroma are considered to be the proliferative compartment and are related to the clinical behavior of lesion. The treatment of PGCG comprises of excision and suppression of underlying etiological factors with elimination of the entire base of the lesion. Recurrence rates of 18.18% have been noted in our study similar to study reported by Eversole and Rovin. Recurrences could be due to lack of inclusion of the periosteum or PDL in the excised specimen. PGCG lesions are self-limiting. The treatment of choice of PGCG is to eliminate the entire base of lesion and also local factors.
FIB constitutes the third most common RL and is a benign connective tissue neoplasm of oral mucosa. Most of the FIBs present as reactive hyperplasia secondary to trauma or local factors. Clinical appearance and pathogenesis is described by the term focal fibrous hyperplasia more accurately. In the present study, the most common site recorded was buccal mucosa at the line of occlusion and similar finding is noted by Hunasgi et al. [Figure 1]. Clinically, FIBs mimic various lesions such as giant cell FIB, neuro FIB, PGCG and can be differentiated from the conventional FIBs with the help of histologic appearance. However, a great number of lesions are diagnosed as FIBs and are, in reality, simply examples of focal or localized hyperplasia resulting from inflammation, and the true FIBs are much rarer than presently believed. In the present study, the recurrence rate noted was 7% even though rarely does it recur and preferred treatment is complete excision.
Peripheral ossifying fibroma
POF is a peripheral RL of gingiva which was first coined by Eversole and Rovin in 1972. In our study, 3rd decade was the predominant age group noted and these findings were consistent with the study by Meherwade et al. Clinically, POF presents as either sessile or pedunculated solitary mass with variation in the color ranging from erythematous to normal. The POF originates from the undifferentiated mesenchymal cells of PDL and associated causative agents are local irritants. The presence of oxytalan fibers within POF supports its origin from PDL. A conclusive diagnosis of POF is made by histopathology, comprising of atrophic epithelium and dense connective tissue stroma with fibroblastic proliferation and minimal vascular proliferation. Intense chronic inflammatory cell infiltrates with foci of cementum and dystrophic calcifications are evident.
In the present study, recurrence was noted in 18.5% cases; similarly, higher recurrence rate is been noted up to 20%. The possible contributing factors are inadequate surgical excision, failure to eradicate the local factors, and difficulty to gain access to excise the lesion if the interdental site is affected.
| Conclusion|| |
In the present study, RL were grouped into inflammatory and fibrous; we observed inflammatory group of lesions recurred more frequently. Of all the oral biopsies reported, RLs were the commonly encountered pathologies secondary to injury and local factors. The clinical and histopathological examination is important to categorize the type of RL to predict the recurrence rate and evaluate the base for clearance. The complete removal of local irritants with follow-up and maintenance of oral hygiene helps to prevent the recurrences of such lesions.
- We observed that the excised specimen's base consisted of the lesional tissue with very minimal clear margin which could be a cause for the recurrences. 90 cases from our study showed the base with lesional tissue with minimum clearance
- Nickel released from the orthodontic brackets is considered one of the etiological factors in association with poor oral hygiene for the causation of such lesions
- The inflammatory groups of RL have been reported with high recurrence rates 61 (84.72%) as compared to the fibrous group 13 (18.05%).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]