OP: Inflammatory and reactive lesions

Describe briefly what Inflammatory and reactive lesions of the oral mucosa result from?

Chronic irritation to oral mucosa leading to, chronic (persistent) inflammation and excess granulation tissue or fibrous connective tissue formation.

Classify inflammatory and reactive lesions

Generalised: Chronic hyperplastic gingivitis & Drug-related gingival hyperplasia.

Localised: Pyogenic granuloma, Fibrous epulis, fibro-epithelial polyp, Denture epulis / epulis fissuratum, Papillary hyperplasia of the palate

What is a polyp, a pedunculated polyp and a sessile polyp?

Polyp: A localised mass of tissue protruding from the lining of the oral mucosa.

Pedunculated polyp: When the polyp is attached to the lining of the oral mucosa by a stalk.

Sessile polyp: the polyp is attached to the lining of the oral mucosa by a broad base i.e. without a stalk

What are the causes/aetiology of a PYOGENIC GRANULOMA?

Causes / aetiological factors

- It represents an exuberant proliferation of gingival fibrovascular connective tissue

- initiated by plaque and/or calculus within the gingival crevice, local injury or trauma

- modified by hormones or drugs

What is the clinical presentation of a pyogenic granuloma?

Clinical presentation

- A red, painless, pedunculated or sessile soft polyp thats pedunculated or sessile, often bleeds easily

- can occur at any age

- mostly occurs on the gingiva, in other areas: eg. tongue, lip, buccal mucosa

- An important clinical differential diagnosis is Kaposi sarcoma.

1. During pregnancy called a “pregnancy epulis”.

2. Hormonal changes during pregnancy modify the gingival response to local irritants.

What are the histopathological features of a pyogenic granuloma?

1. Lesion is made up of small blood vessels (capillaries), that are arranged in lobules. Which are separated by fibrous connective tissue septae

2. Overlying mucosa is typically ulcerated and the surface is covered by fibrinopurulent exudate.

3. Accompanying inflammatory cell infiltrate

4.Intact surface squamous mucosa usually present at the base of the lesion, forms a “collarette.”

What is the treatment of a localised pyogenic granuloma?

- local surgical excision

- remove local aetiological factors: plaque, calculus or source of trauma

- sometimes the pyogenic granuloma recurs:

• Failure to remove aetiological factors

• incomplete excision

• re-injury of the area

What are the causes/aetiological factors of a Fibrous epulis/Fibrous epithelial polyp?

1.Localised, chronic low-grade trauma to oral mucosa (also called traumatic fibroma).

2.Sometimes arises from a pre-existing pyogenic granuloma as explained below. Explanation: where local irritants have been eliminated to some degree causing the vascularity of the lesion to decrease with maturation to a fibrous polyp

What is the clinical representation for a fibrous epulis vs fibroepithelial polyp?

1.Smooth, surfaced firm polyp, covered by intact mucosa - pale pink - usually painless. Occuring on the gingiva vs Occurs on the mobile mucosa, common sites: tongue, lip, buccal mucosa

2.Covered by intact mucosa - pale pink - painless

3. (Commonly occurs anteriorly in the mouth). At any age.

Give the histopathological features of a Fibrous epulis/ Fibrous epithelial polyp

- the nodule is covered by epithelium that is usually hyperplastic

- the fibrous nodule consists of irregular, intersecting collagenous connective tissue fibres

- the nodule is relatively hypovascular and hypocellular, with bone formation occuring in long-standing lesions, called Ossifying fibrous epulis

Treatment for a fibrous epulis

1. Local surgical excision, and for lesions on gingiva, underlying bone should be curretted

2. There should be no recurrence if done thoroughly and the source of irritation is removed

What is the aetiology of a denture epulis?

1. As bony ridges of the maxilla and mandible resorb with long-term denture use. The denture flanges gradually extend deeper & further into the vestibule, where chronic irritation and trauma incite an overexuberant fibrous connective tissue reparative response.

Give the clinical presentation for a denture epulis

Painless fold of fibrous tissue that is firm and pale, in the buccal mucosa, surrounding the over-extended denture flange

What is the treatment for a denture epulis?

- local surgical excision

- construction of a new denture or relining of the old one is also required

What is the aetiology of papillary hyperplasia?

- Low-grade trauma beneath an ill-fitting upper denture and poor denture hygiene

- Wearing the denture 24-hours a day, candidiasis is sometimes superimposed. Mild forms of papillary hyperplasia of the palate are sometimes seen in non-denture wearers, HIV pt

Papillary hyperplasia of the palate

- painless nodules, erythematous mucosa clustered together

- nodules are ovoid-spherical and 2-3mm in diameter

Papillary hyperplasia of the palate treatment is done how?

- poor-fitting dentures should be relined, should be kept clean and not worn overnight

- candidal infection should be treated with topical anti-fungal medication

What is the aetiology of chronic hyperplastic gingivitis?

Local factors:

1. plaque and/or calculus within the gingival crevice

2. irregular tooth surfaces

3. restorations or dental appliances that cause stagnation areas

4. mouth-breathing

Systemic factors:

1. hormonal factors (puberty, pregnancy)

2. poorly controlled diabetes mellitus

Give the clinical presentation of hyperplastic gingivitis?

- gingiva bleeds easily, appears red and swollen

- plaque is readily detectable along the gingival margins

- dental probing shows absence of pocketing

- intact crestal alveolar bone (radiographs)

What is the treatment of chronic hyperplastic gingivitis?

- plaque and calculus removal, effective tooth brushing, interdental cleaning habits

- Usually reversible by effective oral hygiene measures

Give the aetiological factors/causes of drug related gingival hyperplasia

Anti-epileptic drugs - Epinutin/Dilantin/Phenytoin

Calcium-channel blockers – Nifedipine

Immunosuppressive drug - Cyclosporine

How does drug related gingival hyperplasia present itself?

- interdental papillae become bulbous and overlap the teeth

- gingiva is usually firm and pale, however stippled texture of the gingiva is exaggerated

- plaque accumulation contributes to overgrowth of the gingiva

What is the treatment of drug related gingival hyperplasia?

- may regress 6-12 months after withdrawal of the drug by the attending physician and substituting with another drug if possible

- phenytoin-induced gingival hyperplasia requires surgical removal of the hyperplastic gingiva

- rigorous oral hygiene measures are mandatory in all cases