DEPARTMENT OF ORAL AND MAXILLOFACIAL

PATHOLOGY AND MICROBIOLOGY

PRESENTED BY:
Shivangi Singla
BDS III Year
Roll No.- 870

S.G.T. Dental College and Research Centre,

Budhera, Gurgaon
Department of Oral and Maxillofacial Pathology & Microbiology
OP File No. - 194937

Case No. -

Biopsy No. - 216/13

Referred by: - Oral Surgery

I.

PERSONAL DATA

Name:-Ram Kumar
Sex:-Male
Age:- 65 years
Address:- Daryapur
Contact No. :- -Occupation:- Retired government employ
Religion:- Hindu
II.
CHIEF COMPLAINT
Patient complains of swelling in the upper right front region of jaw since 15 days.

1.
2.

Pain
Swelling

3.
4.
5.

Ulcer
White Patch / Red Patch
Restricted mouth
opening
Burning Sensation
Teeth mobility
Bleeding gums
Any Other

6.
7.
8.
9.

Area
Upper right region of jaw w.r.t
13, 14
Bleeding from swelling while
eating.

Duration
15 days
-

III.

HISTORY OF PRESENT ILLNESS :a. Onset :- Patient was apparently well before 15 days when he noticed a pea sized swelling in the upper
right front region.
b. Associated Symptoms:- Bleeding is present.
c. Aggravating Factors & Relieving factors:- None
d. Any earlier test been performed:- None
e. Any earlier medical opinion:- None

IV.

PAST MEDICAL HISTORY

a. Serious illness:- None
b. Hospitalization:- None
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c.
d.
e.
f.
g.
V.

1.
2.
3.
4.
5.
6.
7.
8.

Transfusions:- None
Allergies:- None
Medications:- None
Pregnancy / Miscarriage:- -Any Other:- None

PERSONAL HISTORY
a. Married / Unmarried:- Married
b. Educational Status:- 10+2 (Intermediate)
c. Spouse / Children / Parents:- Wife and 3 children
d. Death in the family (cause & age):- Not contributory
e. Menstruation:- -f. Lactation:- --

g. Habits
Tobacco + Lime quid
Tobacco chewing
Areca nut
Areca nut + Lime + Tobacco
Pan
Pan masala/ Gutka / Kharra/ mava
Bidi/ Cigarette smoking
Teeth cleaning with tooth power/ paste
/mishri / tobacco/ datum / neem / coal & lime

9. Alcohol
10. Snuff Dipping
11. Any Other

Frequency/ Day
12-15 bidis/day
Brushes teeth with tooth brush
and tooth paste once in a day.

Duration
30 years
5-7 minutes

VI.

EXAMINATION OF PATIENT
A. General Examination:- Patient is cooperative, conscious, well built, well nourished with no
pallor and no cyanosis.
Vital Signs:Normal
Test Value
Respiratory Rate
14-16 beats/min
17 beats/min
Normal temp
Oral 98.6O F / 37.0O C
98.2 F
Pulse
60-100 beats/ min
80 beats/min
B.P.
<120/<80mmHg
110/74 mmHg

B. Oral & Maxillofacial Examination

1. Facial Features
-Skin - Colour, moles, pigmentation, vascular abnormality: - Brownish color with moles on
forehead and right corner of right eye. No pigmentation and vascular abnormality seen.
- Ulcers, pustules, modules, swelling, growth: - Absent
- Muscles of mastication: - No abnormality detected
- Scars: - Absent
- Any other: - None
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2.
-

Lips:Color: - Normal
Textures: - Smooth with minimal fissuring
Commisures of lip Lt/Rt: - Normal
Scar: - Absent
Any other: - None

Cheeks (intraoral)
Pigmentation: - Absent
Movability: - Under physiological limits
Linea alba: - Absent
Hyperkeratotic patches: - Absent
Swelling/ growth: - Absent
Ulcer: - Absent
Nodules: - Absent
Red/white/mixed patches: - Absent
Opening of stensons duct: - Normal
Any other: - None

3.

4.

Maxillary & Mandibular mucobuccal fold

- Colour: - Pink
- Texture: - Normal
- Ulcer: - Absent
Tenderness of roots: - Absent
- Swelling/ growth: - Absent
Fistula: - Absent
- Any other: - None

5.

Hard & Soft Palate:- Texture: - Smooth

- Ulcer: - Absent
- Colour: - Brownish
- Depth: - Normal
- Swelling/ growth: - Absent
- Any other: - None

6.

The Tongue:Size: - Normal

Colour: - Pinkish in color
Papillae: - Normal
Mobility : - Under physiological limits
Lateral border: - Normal
Ulcer: - Absent
Swelling/ growth: - Absent
Any other : - None

7.
8.

Floor of Mouth:Opening of whartons duct: - Normal

Salivary Pool: - Normal
Swelling/ growth: - Absent
Ulcer: - Absent
Red/ White patches: - Absent
Any other: - None

Gingiva:Colour, texture, contour: - Reddish pink in color, stippling absent, generalized recession
present
Frenal attachment: - Normal
Inflammation: - Present
Hyperplasia: - Absent
Swelling/ growth: - Present w.r.t 13,14
Fistulae: - Absent
Any other: - None

Alveolar Process (edentulous patient):- NOT APPLICABLE

Colour, texture
- Hyperplasia
Contour
- Swelling/ growth
Frenal attachment
- Fistulae
Inflammation
- Any other

9.

10. Teeth & Periodontium:- No of teeth present: - 20

- Missing teeth: - 16, 18, 26, 27, 48
- Supernumerary teeth: - Absent
- Mobility: - Present w.r.t 34, 45 (grade II), 32 (grade I)
- Tenderness: - Absent
- Caries: - Present w.r.t 17, 26
- Restorations: - None
- Plaque, Calculus: - Present
- Any other: - Root stumps w.r.t 18, 48
11. Tonsils & Oropharynx:No abnormality detected
12. Salivary Glands:- Swelling/ growth: - Absent
- Pain on mastication: - Absent
- Consistency of saliva : - Thin and watery
- Any other: - None
13. TMJ movements:- Clicking: - Absent
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- Deviation: - Absent
- Any other: - None
14. Lymph nodes: - NO ABNORMALITY DETECTED
- Consistency
- Size (if enlarged & Palpable)
- Number
- Pain
- Mobility
- Any other
C. Local Examination
1. Swelling:- Size: - 1x1 cm
- Shape: - Triangular
- Margins: - Well defined
- Color: - Erythematous
- Fluctuant/ non fluctuant: - Non-fluctuant
- Tenderness/ Pain : - Non-tender
- Consistency: - Soft
- Discharge: - Absent
- Number: - One
- Extent: - Extending from 13-14 on the buccal side
- Any other: - Non- compressible and sessile; bleeding is present due to rupture.
2. Ulcers:- NOT PRESENT
- Margins
- Number
- size
- shape
- base
- colour
- induration
- associated finding
- any other
3. Patch:- NOT PRESENT
- White/ red / mixed
- Number
- Size
- Bleeding
- Shape
- Location & extent
- Margins
- Any other
4. Any other:- None
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VII.

PROVISIONAL DIAGNOSIS:Pyogenic granuloma

INVESTIGATIONS:1.

Radiographic features:Ring the radiolucency

Shade the radiopacity

(IOPA/ OPG/ Any other) Adviced IOPA w.r.t 13,14 No finding

2.

Haemogram:BT :- 3 min,
DLC:-

CT:- 5 min,
M:- 1 %,

Hb :- 15 mg/dl

E:- 5 %,

B:- 0 %,

L:- 33 %,

N:- 65 %

TLC:- --- /mm3

ESR (WESTERGREEN METHOD):- --- mm/h
BLOOD SUGAR:-

R:- 96 mg,

F:- -- mg, PS:- -- mg

Any other hemogram:- --3.

URINE EXAMINATION:- ---

4.

BIOCHEMICAL EXAMINATION:- ---

5.
6.

MICROBIOLOGICAL EXAMINATION:- --Previous biopsy report (if any):- ---

7.

BIOPSY:- (mark the site of biopsy)

8

Type of biopsy:- FNAC/ Scrape cytology/ Incisional (area) / Excisional / Punch / Wedge / Intraosseous:
- Excisional biopsy
-

Nature of tissue: - Soft tissue specimen

8.

MACROSCOPY: - Soft tissue specimen from buccal side gingival, soft in consistency,
erythematous, measuring 1x1 cm.

9.

MICROSCOPY: - The H&E section shows epithelium and connective tissue stroma. Epithelium
is stratified squamous showing atrophy at few foci. The underlying connective tissue is
fibrovascular with blood vessels and inflammatory cell infiltrate.

10. REPORT: - Suggestive of INFLAMMATORY HYPERPLASIA.

Follow up
Date:
21-10-2013

Finding & improvement/ remarks:Inflammatory hyperplasia

INTRAORAL PHOTOGRAPH

Signature

EXTRAORAL PHOTOGRAPH

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RADIOGRAPH (IF ANY)

SIGNATURE:(Staff Incharge)

SIGNATURE:( H.O.D.)

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INFLAMMATORY HYPERPLASIA
ABSTRACT:
Oral inflammatory hyperplasia is the most common oral abnormalities. It manifests as diverse signs
and symptoms. It may occur in any part of the oral cavity. They occur mainly due to reactive
stimulus hence these lesions are called reactive hyperplasia. Distinguishing these entities and
removal of etiological factors are essential.
DEFINITION:
INFLAMMATORY HYPERPLASIA is a benign hyperplasia of fibrous connective tissue which
develops as a reactive lesion to chronic mechanical irritation produced by the flange of a poorly
fitting denture. More simply, it is where excess folds of firm tissue form inside the mouth, as a
result of rubbing on the edge of dentures that do not fit well. It is a harmless condition and does not
represent oral cancer.
Such hyperplasia of oral mucosa is not restricted to this location but occurs in many other areas
where chronic irritation of any type may exists, such as on the gingival, buccal mucosa, and the
angle of the mouth.
OTHER NAMES:
- Denture injury tumor
- Epulis fissuratum
- Redundant tissue
- Inflammatory fibrous hyperplasia
- Denture-induced fibrous inflammatory hyperplasia
- Denture epulis
- Denture-induced granuloma
- Granuloma fissuratum
CLASSIFICATION:
Epulis (literally, 'on the gingiva') is a general term for any gingival or alveolar tumor (i.e.
lump). This term describes only the location of a lump and has no implication on the
histological appearance of a lesion. Epulis is also sometimes used synonymously with epulis
fissuratum; however other conditions are classified as epulides, e.g.
-

Giant cell epulis (peripheral giant cell granuloma)

Ossifying fibroid epulis (peripheral ossifying fibroma)

Congenital epulis.
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EPIDEMIOLOGY:
This condition occurs in association with denture wearing, and so those affected tend to be middle
aged or older adults. 66-75% is estimated to occur in women. Epulis fissuratum is the third most
common reactive lesion that occurs in the mouth, after peripheral giant cell granuloma and
pyogenic granuloma.
CAUSES:
The cause is usually pressure from the flange of a denture which causes chronic irritation and a
hyperplastic response in the soft tissues. Women during pregnancy can also present with an epulis,
which will resolve after birth. Fibroepithelial polyps, pedunculated lesions of the palate beneath an
upper denture, are associated with this condition. A cobble-stone appearance similar to an epulis
fissuratum in a patient without dentures can be diagnostic of Crohn's disease. Epulis fissuratum can
also appear around dental implants.
CLINICAL FEATURES:
Inflammatory fibrous hyperplasia as a result of denture injury is characterized by the development
of elongated rolls of tissue in the mucolabial or mucobuccal fold area into which the denture flange
conveniently fits. This proliferation of tissue is usually slow in developing and probably is as much
a result of the resorption of the alveolar ridge as of the trauma of the loose dentures.
This excess fold of tissue is not usually highly inflamed clinically, although there may be irritation
or even ulceration in the base of the fold into which the denture flanges fits. The lesion is firm to
palpation.
The lesion is usually painless. The usual appearance is of two excess tissue folds in alveolar
vestibule/buccal sulcus, with the flange of the denture fitting in between the two folds. It may occur
in either the maxillary or mandibular sulci, although the latter is more usual. Anterior locations are
more common than posterior. Less commonly there may be a single fold, and the lesion may appear
on the lingual surface of the mandibular alveolar ridge.
The swelling is firm and fibrous, with a smooth, pink surface. The size of the lesion varies from less
than 1 cm to involving the entire length of the sulcus.
HISTOLOGIC FEATURES:
The hyperplastic mass of the tissue is composed of an excessive bulk of fibrous connective tissue
covered by a layer of stratified squamous epithelium which may be normal thickness or show
acanthosis. Pseudoepitheliomatous hyperplasia is often found. Hyperkeratosis is frequently present.
The connective tissue is composed chiefly of coarse bundles of collagen fibers with few fibroblasts
or blood vessels unless there is an active inflammatory reaction present. Such a reaction is
frequently seen, however, in the base of the fissure adjoining the denture flange, especially if the
tissue is superficially ulcerated.
One additional histologic finding often seen in the surface epithelium of inflammatory fibrous
hyperplasia is mucopolysaccharide keratin dystrophy, also referred to as plasma pooling. Its
occurrence is not confirmed to inflammatory hyperplasia but may also be found in oral epithelium
under a wide variety of other conditions, especially those involving irritated epithelium.
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This mucopolysaccharide keratin dystrophy consists histologically of homogenous, eosinophilic

pools of material in the superficial spinous layer of epithelium, where it appears to have replaced
individual cells. Its significance is unknown.
DIAGNOSIS:
The diagnosis is made clinically, and usually this is clear cut if the lesion is associated with the
flange of a denture. Tissue biopsy is not usually indicated before removal of the lesion, since the
excises surgical specimen is usually sent for histopathologic examination and the diagnosis is
confirmed retrospectively. Rarely, incisional biopsy may be indicated to rule out neoplasia, e.g. in
the presence of suspicious ulceration. The appearance may also be confused with pyogenic
granuloma.
The excessive tissue is composed of cellular, inflamed fibrous connective tissue. The appearance of
an epulis fissuratum microscopically is an overgrowth of cells from the fibrous connective tissue.
The epithelial cells are usually hyperkeratotic and irregular; hyperplastic rete ridges are often seen.
TREATMENT AND PROGNOSIS:
Inflammatory fibrous hyperplasia should be surgically excised, and either new dentures constructed,
or the old dentures rebased to provide adequate retention. If the denture is replaced or repaired, the
lesion should not recur. Complete regression, even after construction of new dentures, will not
occur, although subsidence of the inflammatory reaction may produce some clinical improvement
of the condition.

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