Inflammatory overgrowths All new growths of the oral tissues should be treated with suspicion and must be fully investigated. There are some well-defined conditions (for instance, denture granulomas) of which the clinical diagnosis can be accurate in practically all cases, but appearances can be misleading and it cannot be too strongly stressed that absolute certainty as to the nature of any lesion can only come after histological examination

Epulides An epulis (plural, epulides) is defined as a soft-tissue swelling of the gingival margin. The term is more specifically used to describe a range of hyperplastic inflammatory lesions arising from the periodontal tissues. They represent an exaggerated inflammatory response of the periodontium, although the source of irritation is not always obvious

inflammatory The inflammatory process arises initially in the interdental tissues, and there is often an associated loss of alveolar crest-bone that may become severe in advanced cases

There are Three types, Three types, the fibrous epulis, the pyogenic granuloma (pregnancy epulis), and the giant-cell epulis, are commonly seen, reflecting differing stages of the inflammatory and bone-resorbing process. Most epulides are more common in females than males and usually occur anterior to the molar teeth.

Fibrous epulis The fibrous epulis presents as a pedunculated or sessile swelling on the gingivae and essentially consists of heavily fibrosed granulation tissue. Its content of collagen fibres gives it a firm, rubbery texture and its colour is usually pale pink.

The degree of fibrosis depends, however, on the stage of maturity of the epulis, and a lesion in its early stages may be soft in texture and with a histological appearance that shows very many cells. In a longstanding lesion, focal mineralization and/or bone formation may occur.

Epulis

Pyogenic granuloma and pregnancy epulis These are both vascular epulides and present clinically as reddish-purple swellings on the gingivae. A pregnancy epulis is histologically identical to the pyogenic granuloma but occurs in pregnancy

pyogenic granuloma In the pyogenic granuloma and pregnancy epulis the granulation tissue remains vascular and immature. It is much redder in colour than the fibrous epulis proper and has a tendency to bleed easily because of its high vascular content

The giant-cell epulis (peripheral giant-cell granuloma) The giant-cell epulis is a lesion in which the granulation tissue is osteogenic in nature. Its predominant histological feature is the presence of multinucleated giant cells dispersed in a vascular stroma. With maturity the lesion may become less vascular and more fibrosed and may include some areas of bone formation. In its immature form, this epulis is characteristically red-purple in colour.

Epulides Fibrous epulis Vascular epulides Pyogenic granuloma Pregnancy epulis Giant cell epulis (peripheral giant-cell granuloma)

Management Treatment of all of these forms of epulis is by local excision. The origin of the lesion is often interdental and, in more advanced cases, the periodontal membrane may be quite deeply involved. If excision is not complete, there may be recurrence of the lesion and so, although radical surgical techniques are not called for, the initial removal should include all affected tissue

Rag qowlbaa xira Dumarna!! With repeated recurrence, it is sometimes necessary to remove the adjacent teeth in order to secure the elimination of the tissue of origin. In their tendency to recur, epulides may appear to be neoplasms, but the recurrence is due only to persistence of the conditions that caused the initial abnormal response. The timing for the excision of a pregnancy epulis is further discussed in Chapter 13.

Although the clinical diagnosis Although the clinical diagnosis may be a confident one, it should always be confirmed by histological examination. Occasionally, a neoplasm may present in a form resembling a simple epulis and in a likely site for one. It should also be remembered that a central giant-cell granuloma may perforate alveolar bone and appear as an epulis

Dhug uyeelo Appropriate investigations (including blood tests for plasma calcium, phosphorus, and alkaline phosphatase) should be carried out on all patients presenting with a histologically confirmed giant-cell epulis to exclude hyperparathyroidism. Any symptoms or history that might imply undiagnosed hyperparathyroidism (such as renal calculi) should be taken into consideration

Fibroepithelial polyp This lesion, similar in structure to the mature fibrous epulis, is essentially scar tissue produced as a response to trauma, such as repeated irritation of the buccal or labial mucosa, along the occlusal plane of the teeth, often caused by a bite. It is usually seen in adults and there is no sex differentiation

The lesion appears as a pedunculated swelling and is quite free of symptoms unless secondarily traumatized. The usual size of such a lesion when the patient presents for treatment is of the order of 1 cm in diameter, but occasional longstanding lesions are seen that are very much larger. The colour of the lesion is pink and the texture varies from soft to rubbery, depending on the maturity of the constituent fibrous tissue

Treatment treatment need only be conservative, excision to the limit of the swelling or to the base of the pedicle being all that is required. Recurrence will occur only if trauma is repeated and is, in fact, uncommon. As with all other tissue overgrowths, absolute certainty of diagnosis can come only after histological examination, although a clinical diagnosis can often be made with a fair degree of confidence

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Denture granuloma This is a lesion essentially similar to the fibroepithelial polyp, the irritating factor in this case being the flange of an overextended or ill-fitting denture. As in the case of the polyp, proliferative scar tissue is formed following chronic trauma

. The typical fissured shape of the denture granuloma results from the indentation caused by the flange of the denture These lesions are rarely painful and, indeed, often cause astonishingly little trouble to the patient. This being so, occasional lesions are seen that are very large indeed, with multiple folds of proliferative tissue

denture granuloma The denture granuloma is a benign lesion and is treated by simple excision after removing the offending denture or drastically trimming it away from the affected area. The removal of the source of chronic irritation is in many cases sufficient to reduce considerably the size of the lesion within a relatively short time and even to make excision unnecessary.

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Squamous cell papilloma This benign epithelial neoplasm is relatively common. It may appear anywhere on the oral mucosa, but is most commonly found at the junction of the hard and soft palates. Its typical appearance is pedunculated with a pale colour varying from that of normal mucosa to white. It is a painless lesion that rarely gives trouble.

Malignant transformation has not been described in these lesions and, in this respect, the oral lesions behave quite differently from those in the lower parts of the gastrointestinal tract, which have a definite tendency to undergo malignant change.

Treatment of a papilloma Treatment of a papilloma is by local excision. This, however, must be sufficiently wide and deep to include any abnormal cells that may extend beyond the area of the pedicle. It is not sufficient

Traumatic keratoses Traumatic keratoses on the oral mucosa are caused by a local reaction to earlier physical, mechanical, electrical, or thermal causes and are reversible. Chemical trauma caused by an irritant substance, such as topical use of an aspirin, can cause either oral ulceration or hyperkeratosis, which manifests as a white lesion on the oral mucosa.

Acute chemical insults, such as ingestion of acid substance, tend to cause oral ulceration. Lesions seen on the oral mucosa of individuals who smoke cigarettes, cigars, or pipes are due to a combination of chemical and thermal insults.

Nicotinic stomatitis (pipe-smokers' palate)

Nicotinic stomatitis Nicotinic stomatitis is usually found, as the name implies, in pipe-smokers, but also, occasionally, in cigarette- and cigar-smokers. The characteristic histological feature of this condition is the combination of epithelial acanthosis and hyperkeratosis with inflammatory changes in the mucous glands of the palate

As a result of these changes, the palate becomes white and a number of nodules project from the surface, each representing the site of a mucous gland and individually bearing a small red spot at the centre that marks the opening of the duct of the gland

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In advanced cases the mucous glands may break down to form quite large chronic ulcers. The condition usually appears most marked on the hard palate, although the soft palate may also be involved. It has been suggested that the site of involvement depends upon the projection of pipe smoke directly on to the palate, but this is not easy to prove.

Melanotic pigmentation of oral mucosa The significance of oral pigmentation in endocrine disturbances, and particularly in Addison's disease, is discussed in An association between oral melanosis (particularly of the soft palate), smoking, and bronchogenic carcinoma has also been reported. Oral melanosis may occur in HIV infection

A number of drugs may also stimulate increased pigmentation including oral contraceptives, antimalarials, and major tranquillizers. There have been recent reports of minocycline causing pigmention of the skin and oral mucosa

Oral melanoma Intraoral melanomas are highly malignant oral tumours that usually occur as isolated dark brown or black patches on the oral mucosa. Amelanotic melanomas can manifest as red lesions. Oral melanomas are rare malignancies and tend to occur on the palate. In the early stages they may be symptomatic

The appearance is usually of a nodular or macular lesion that is firm to palpate. This ultimately ulcerates and causes discomfort or bleeds

Early diagnosis Early diagnosis of any lesion suspected of being a malignant melanoma is essential as metastasis to the lymph nodes and other organs (lungs, liver, and bone) occurs early. The prognosis for oral melanoma is poor. Superficial spreading melanomas are rarely seen in the mouth and their appearance can be quite spectacular

Oral melanoma

Melanotic pigmentation of the oral mucosa: principal causes Racial Addison's disease HIV disease Reactive    Lichen planus and leukoplakia

Drug-related Peutz–Jegher syndrome Isolated melanotic lesions    Idiopathic melanotic macule    Melanotic naevus    Malignant melanoma

Human immunodeficiency virus and AIDS Ibtaadu yeeysan IIL kugeeyn