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Oral mucosal lesions: A retrospective review of one institution’s 13-year

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DOI: 10.3906/sag-1312-9

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 Turkish Journal of Medical Sciences Turk J Med Sci
(2014) 44:
http://journals.tubitak.gov.tr/medical/
© TÜBİTAK
Research Article doi:10.3906/sag-1312-9

Oral mucosal lesions: a retrospective review of one institution’s 13-year experience

Burcu SENGÜVEN*, Emre BARIŞ, Benay YILDIRIM, Alaa SHUIBAT, Özlem OZER YÜCEL,
Farid MUSEYIBOV, Yeşim YILDIZ, Özkan BÜYÜK, Sibel Elif GÜLTEKIN
Department of Oral Pathology, Faculty of Dentistry, Gazi University, Ankara, Turkey

Received: 02.12.2013 Accepted: 05.03.2014 Published Online: 00.00.2014 Printed: 00.00.2014

Background/aim: To investigate the relative frequency of biopsied nonneoplastic oral mucosal lesions in Ankara, Turkey.
Materials and methods: Biopsy records of a single center from 2000–2012 were retrospectively collected. Diagnosis was recorded and
evaluated with respect to patient demographics (age, sex) and location of the lesion.
Results: Of 11,980 biopsies, 1732 (14.5%) were mucosal nonneoplastic lesions. Hyperplastic lesions (n = 1000, 57.7%) with fibroepithelial
hyperplasia in 30.9% of patients were the most common type of oral nonneoplastic lesions. The mean age of patients differed with
respect to type of mucosal lesion, tending to be lower in patients with reactive lesions. Dermatoses showed a female predominance.
Conclusion: Our findings revealed that hyperplastic lesions were the most common among nonneoplastic oral mucosa lesions.
Geographic and ethnic differences of patients with various types of oral mucosal lesions require further investigation.

Key words: Epidemiology, hyperplastic lesions, oral mucosa, reactive lesions

1. Introduction frequently present as painless masses of variable size. Since

The oral mucosa, including the gingiva, retromolar area,
and buccal and palatal mucosa, is subjected to various
local acute and chronic irritants and may be affected
by more than 600 different systemic diseases (1). Since
mucosal lesions are relatively common in oral pathology
practice, oral tissue biopsies are frequently taken for
pathologic examination. Except for extracted teeth,
extirpated dental pulp tissue, and clinically normal tissue,
all tissues removed from the oral and maxillofacial region
should be submitted for histopathological examination as
the gold standard for final diagnosis (2,3). Dentists and
maxillofacial surgeons may encounter serious mucosal
lesions, including leukoplakia/erythroplakia, oral lichen
planus, vesiculobullous lesions, and oral candidiasis (4,5).
Most oral mucosal biopsies are taken from patients
with reactive and/or inflammatory conditions. The oral
mucosa may respond to a wide variety of local irritations
by epithelial and/or fibrotic overgrowth (6). Nonneoplastic
lesions, including peripheral giant cell granuloma,
peripheral ossifying fibroma, pyogenic granuloma, and
fibrous and/or epithelial hyperplasia, also called reactive
lesions of the oral cavity, are the most common type of
clinical entities (7). Hormonal changes may also affect the
development of some of these lesions, including pyogenic
granuloma, also called pregnancy tumor (8). Lesions
* Correspondence: senguvenb@yahoo.com
this anatomical region is open to trauma, most lesions
have ulcerated surfaces, which may give rise to suspicion
of a malignant tumor in appearance (9).
The oral mucosa is also one of the most common
locations for dermatoses, pigmented lesions, and viral
diseases. Infection by oncogenic or nononcogenic viruses
can cause several lesions in the oral mucosa. For example,
human papilloma virus is responsible for papillomatous
lesions, especially in the palatal mucosa (10,11). Immune-
mediated vesiculobullous diseases, including lichen
planus, are also not rare in the oral mucosa and may be
malignant (12). Pigmented lesions of the oral mucosa may
be iatrogenic, as in amalgam tattoo; congenital, as in ethnic
pigmentation; or neoplastic, as in nevus and melanoma
(13,14).
Understanding the distribution of oral mucosal lesions
should be useful for better diagnosis and treatment. Ankara
is the capital and the second largest city in Turkey, with 5
faculties of dentistry and more than 6 state dental hospitals
serving as reference centers for all of Anatolia. The present
study was therefore designed to evaluate relative frequency
of biopsied nonneoplastic oral mucosal lesions in relation
to patient demographics and localization of the lesion
based on a retrospective review of the 13-year experience
of a single center in Ankara.
1
 SENGÜVEN et al. / Turk J Med Sci
2. Materials and methods
This retrospective study evaluated the records of all
patients who underwent oral mucosal biopsies at the
Department of Oral Pathology, Faculty of Dentistry, Gazi
University, Ankara, Turkey, between 2000 and 2012. The
majority of specimens were stored at the Department of
Maxillofacial Surgery of Gazi University, though some
were stored at various state and private dental facilities in
Ankara and nearby cities. All biopsies were diagnosed in
our department, the only oral pathology laboratory in the
region. Biopsies of gingiva, vestibule and buccal mucosa,
palatine mucosa, and retromolar area were included in
the study, whereas biopsies of the tongue and lips were
excluded.
Data collected from medical records included patient
age and sex and the site and type of the biopsy. Descriptive
diagnoses were evaluated by 2 oral pathologists, who
determined the final diagnosis.
A total of 1732 cases were added to current study with a
mean patient age of 44.4 ±17.4 years, including 855 female
and 877 male cases.
2.1. Classification of oral lesions
Reactive oral lesions were histologically classified using
Neville’s classification of common mucosal overgrowth
(15). Lesions were classified as hyperplastic, reactive, and
nonneoplastic pigmented lesions, and as dermatoses,
lichen planus, and lichenoid reactions.
Hyperplastic lesions included fibroepithelial
hyperplasia, irritation fibroma, epulis fissuratum, fibrous
polyps, and cheek-biting lesions. Reactive lesions included
peripheral giant cell granuloma, pyogenic granuloma,
peripheral ossifying fibroma, and giant cell fibroma.
Nonneoplastic pigmented lesions included amalgam tattoo,
melanosis, and melanotic macule. Dermatosis included
pemphigus vulgaris, mucous membrane pemphigoid,
lupus erythematosus, and bullous pemphigoid. Lichen
planus included all subtypes, such as bullous or erosive
lichen planus and lichenoid reactions. Nonspecific
inflammatory lesions such as epulis granulomatosa were
excluded, as were benign and malignant tumors.
2.2 Statistical analysis
Due to the design of study, descriptive statistics were
used to summarize the lesions’ characteristics. Mean
and standard deviation (SD) were used for quantitative
variables; count and percentage were used for qualitative
variables.
3. Results
3.1. Type of lesions
During the 13-year study period, 11,980 biopsies were
evaluated, with 1732 (14.46%) of the lesions being
nonneoplastic lesions of the oral mucosa. The remaining
10,248 lesions were diagnosed as nonspecific inflammatory
2
processes, odontogenic cysts or tumors, jaw lesions,
salivary gland lesions, and other benign and malignant
tumors.
Hyperplastic lesions were the most common (n = 1000,
57.7%), followed by reactive lesions (n = 472, 27.3%),
lichen planus and lichenoid reactions (n = 206, 11.9%),
pigmented lesions (n = 35, 2.0%), and dermatoses (n = 19,
1.1%). Fibroepithelial hyperplasia (30.9%) was the most
common hyperplastic lesion, whereas peripheral giant cell
granuloma (13.4%) was the most common reactive lesion
(Table).
3.2. Lesion distribution by patient demographics
The distribution of lesions by sex and age is shown in the
Table. Mean (SD) age of the overall 1732 patients with
lesions was 44.4 (17.4) (range: 5–92) years. Females (F)
and males (M) accounted for 49.4% (n = 855) and 50.6%
(n = 877) of the study population, respectively, with an
M/F ratio of 1.02:1. Except for epithelial hyperplasia, all
other mucosal lesions were more common in females. The
mean age of the patients with reactive lesions was lower
than those of the other groups.
3.3. Lesion distribution by location
Lesion distribution by location was known for 1674 of
the 1732 lesions (Table). The most common site was the
gingiva, accounting for 674 (38.9%) lesions, whereas the
retromolar area (2.9%) was the least affected region. The
buccal mucosa was the most frequent site of dermatosis
and lichen planus when compared to other locations.
4. Discussion
The present retrospective cross-sectional study surveyed
the biopsy records of histologically diagnosed oral mucosal
lesions obtained by the Department of Oral Pathology of
our institution over a 13-year period. Although several
studies have assessed the prevalence of different types of oral
mucosal lesions in different geographic areas (6,14,16,17),
few studies have documented the range of histologically
diagnosed lesions affecting the oral mucosa (18,19).
Since definitive diagnosis requires histopathological
examination (5), studies based on biopsy examination may
be more reliable. Thus, the results presented here reflect
the profile of histologically diagnosed oral mucosal lesions
in the Turkish population. Moreover, earlier surveys only
assessed specific oral lesions or syndromes, such as oral
lichen planus or Behçet’s disease (20,21), whereas the
present survey included several categories of oral mucosal
lesions.
Given that only 3 previous studies to date have
included more than 10,000 patients (3,19,22), the much
larger scale of lesions surveyed (11,980) in the present
study as compared to past studies (3,18,23,24) seems
notable. Consistent with the data from previous studies
(14), our findings indicated mucosal pathologies as the
 SENGÜVEN et al. / Turk J Med Sci

Table. Patients’ demographics and lesion locations.

Age (years), Females, Location, n (%)* Total,

Buccal and Retro-molar Palatal

mean (SD) n (%) Gingiva Missing n (%)**
vestibular mucosa area mucosa
Hyperplastic lesions 46.8 (16.9) 555 (55.5) 501 (50.1) 353 (35.3) 40 (4.0) 70 (7.0) 36 (3.6) 1000 (57.7)
Fibroepithelial hyperplasia 48.8 (16.8) 309 (57.6) 231 (43.1) 231 (43.1) 15 (2.8) 23 (4.3) 36 (6.7) 536 (30.9)
Fibrous hyperplasia 45.2 (16.2) 161 (57.5) 176 (62.9) 73 (26.1) 14 (5.0) 17 (6.1) 0 (0) 280 (16.2)
Epithelial hyperplasia 42.6 (17.3) 85 (46.2) 94 (51.1) 49 (26.6) 11 (6.0) 30 (16.3) 0 (0) 184 (10.6)
Reactive lesions 36.1 (18.3) 268 (56.8) 134 (28.4) 287 (60.8) 2 (0.4) 27 (5.7) 22 (4.7) 472 (27.3)
Giant cell fibroma 32.6 (16.9) 10 (52.6) 9 (47.4) 9 (47.4) 0 (0) 1 (5.3) 0 (0) 19 (1.1)
Peripheral ossifying fibroma 31.8 (15.2) 86 (65.2) 125 (94.7) 0 (0) 0 (0) 6 (4.5) 1 (0.8) 132 (7.6)
Pyogenic granuloma 37.7 (17.2) 55 (61.8) 0 (0) 74 (83.1) 1 (1.1) 11 (12.4) 3 (3.4) 89 (5.1)
Peripheral giant cell
38.6 (20.3) 117 (50.4) 0 (0) 204 (87.9) 1 (0.4) 9 (3.9) 18 (7.8) 232 (13.4)
granuloma
Lichen planus and lichenoid
46.7 (15.4) 120 (58.3) 182 (88.3) 14 (6.8) 7 (3.4) 3 (1.5) 0 (0) 206 (11.9)
reactions
Pigmented lesions 49.9 (15.0) 19 (54.3) 14 (40.0) 16 (45.7) 1 (2.9) 4 (11.4) 0 (0) 35 (2.0)
Dermatoses 46.7 (15.5) 13 (68.4) 15 (78.9) 4 (21.1) 0 (0) 0 (0) 0 (0) 19 (1.1)
Total 36.3 (22.9) 855 (49.4) 846 (48.8) 674 (38.9) 50 (2.9) 104 (6) 58 (3.3)*** 1732 (100)

*: Percentage in lesion subgroup total.

**: Percentage in the entire group (1732 patients).
***: Location details of 58 patients were not available in the database.
n: Patient count, SD: standard deviation.

most common type of oral mucosal nonneoplastic lesions.
Although several retrospective studies have assessed
the prevalence of oral mucosal lesions, few did so using
the recorded files of biopsies obtained from patients in oral
surgery and oral pathology departments (14,17,25). Few
studies have assessed the epidemiology of oral lesions in
Turkey; these include one study in a pediatric population
(1) and a second in patients with lesions throughout the
entire oral cavity (16).
While previous studies included either reactive lesions
or gingiva lesions, aiming to evaluate the relative frequency
of oral mucosal lesion in Turkey, all mucosal regions and
all nonneoplastic reactive lesions were included in the
present survey. Among the oral biopsy specimens that were
obtained over the 13-year period, 14.5% were classified as
nonneoplastic lesions of the oral mucosa. In comparison,
other surveys have reported that 75.5% (17), 6.7% (25),
and 41.6% (7) of lesions were nonneoplastic lesions of the
oral mucosa. The percentage of these lesions tended to
decrease as the number of lesions increased.
We found that the most frequent lesions in our
population were hyperplastic lesions, including reactive
hyperplasia of fibrous connective tissue and/or epithelia in
response to local irritation or trauma. Traumatic fibroma
and denture epulis occur beneath dentures (15). In this
group, fibroepithelial hyperplasia, which is characterized
by hyperplasia of fibrous connective tissue under an
acanthotic epithelium, was the most common lesion
(30.9%), followed by fibrous hyperplasia or fibrous polyp
(16.2%). Focal fibrous hyperplasia accounted for 6.4% of
20,228 biopsies in Israel (25) and 61.05% of 1489 biopsies
from China (9), but both included only gingival lesions
(3). In contrast, we included buccal/vestibular lesions as
well as gingival lesions, which may have accounted for the
wider distribution of locations that we observed.
Focal, reactive lesions included peripheral giant cell
granuloma, pyogenic granuloma, peripheral ossifying
fibroma, and giant cell fibroma. These lesions are
nonneoplastic but microscopically specific, developing
in response to acute or chronic trauma, and appear as
relatively common tumor-like growths of the oral mucosa.
Peripheral giant cell granuloma, which originates from
the periodontal ligament or mucoperiosteum, is the most
common lesion of this type (26,27). Notably consistent
with the fact that hyperparathyroidism may cause central
giant cell lesions but not peripheral giant cell granuloma,
it was determined that none of the 232 patients with
peripheral giant cell granuloma had primary or secondary

3
 SENGÜVEN et al. / Turk J Med Sci
hyperparathyroidism. Dental restoration followed by
poor oral hygiene was reported to be the primary cause
of peripheral giant cell granuloma. Similar to previous
findings, we observed a female predominance of peripheral
ossifying fibroma and pyogenic granuloma (6,17).
Pyogenic granuloma has been associated with hormonal
imbalance, with gingival pyogenic granuloma reported
in up to 5% of pregnant women. Oral contraceptives and
postmenopausal hormone replacement may also induce
oral pyogenic granuloma (28). High concentrations of
estrogen are thought to induce macrophages to secrete high
levels of vascular endothelial growth factor (28). Although
excision of these lesions is both simple and sufficient, and
their etiology and pathogenesis are frequently known,
differential diagnoses are important to exclude a real
benign or malignant tumor of the oral mucosa (29).
Lichen planus is a well-known mucocutaneous
chronic inflammatory condition. Its primary etiology
remains unknown, but it may be due to irritation of the
oral mucosa (30,31). A recent metaanalysis from Greece
reported that the incidence of oral lichen planus in the
general population was 1.27% (32). Of our biopsied
patients over 13 years, 1.71% had lichen planus or lichenoid
reactions, with women being affected more frequently
than men (58.3%) and the buccal/vestibular mucosa
being the most common area (88.3%), findings similar
to previous data from Turkey (20). The mean age of our
patients with lichen planus (46.7 (15.4) years) was younger
than that reported in other populations (20,33,34). The
suggestion that oral lichen planus may be associated with
hepatitis C infection in patients from Mediterranean
countries was not supported by the results of controlled
epidemiological studies. Genetic influences may affect the
clinical manifestations of the disease. Oral lichen planus is
considered a premalignant condition and more resistant to
therapy than skin lesions (35).
Dermatoses accounted for only 1.1% of all mucosal
lesions, with pemphigus vulgaris being the most
common, followed by mucous membrane pemphigoid,
lupus erythematosus, and bullous pemphigoid. The
mechanisms underlying these autoimmune processes are
unclear but oral lesions may be the initial presentation
before skin lesions and may frequently be severe (33).
Due to their fragile nature, mucosal blisters are difficult
to biopsy, preventing a histopathological diagnosis.
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