Retrospective analysis of the clinical features of 530 cases of reactive lesions of oral cavity

Journal of Advanced Clinical & Research Insights (2014), 1, 1 6 ORIGINAL ARTICLE Retrospective analysis of the clinical features of 530 cases of reactive lesions of oral cavity Santosh Hunasgi 1, Anila Koneru 2, M. Vanishree 2, Vardendra Manvikar 2, Ashwini M. Patil 3, Hamsini Gottipati 4 1 Oral and Maxillofacial Pathology Consultant, Raichur, Karnataka, India, 2 Department of Oral and Maxillofacial Pathology, Navodaya Dental College, Raichur, Karnataka, India, 3 Department of Conservative and Endodontics, Navodaya Dental College, Raichur, Karnataka, India, 4 General Dentist, Raichur, Karnataka, India Keywords Fibro-epithelial hyperplasia, inflammatory fibrous hyperplasia, inflammatory gingival hyperplasia, irritational fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, pyogenic granuloma, reactive lesions Correspondence Dr. Santosh Hunasgi, Santosh Dental Clinic, Near Mahaveer Chowk, Raichur - 584 101, Karnataka, India. Phone: +91-9448022496, Email: drsantosh31@gmail.com Received 02 May 2014; Accepted 10 July 2014 doi: 10.15713/ins.jcri.2 Abstract Background: Most common localized reactive lesions of oral cavity are focal fibrous hyperplasia, pyogenic granuloma (PG), irritational fibroma, peripheral giant cell granuloma (PGCG), peripheral ossifying fibroma (POF), fibro-epithelial hyperplasia/polyp, inflammatory fibrous hyperplasia and inflammatory gingival hyperplasia. Clinically, these reactive lesions often present diagnostic challenges because they mimic different groups of pathologic processes. The aim of this paper is to document the occurrence, distribution of clinical features of reactive lesions of oral cavity in 15 years of clinical practice in Raichur, Karnataka. Materials and Methods: This study is a retrospective archival review of 530 cases of focal reactive lesions of the oral cavity. The cases for inclusion in this study were PG, PGCG, POF, irritational fibroma, fibro-epithelial hyperplasia/polyp, inflammatory fibrous hyperplasia and inflammatory gingival hyperplasia. Clinical data of each patient such as age, gender, location, and treatment were retrieved from the records. Results: Inflammatory gingival hyperplasia was the most prevalent lesion and followed by PG. The age ranged from 7 to 63 years, with a mean age of 40.5 years. 261 cases were males and 269 cases were females. Male to female ratio being 1:1. With the exception of PG and inflammatory gingival hyperplasia, all reactive lesions were more common in males. Gingiva with 470 cases was the most frequent site of reactive lesions, followed by buccal mucosa and palate. Conclusion: Reported results on the age, gender, and location of the individual types of lesions are not consistent in different studies. Some of the differences may be attributed to the geographic or ethnic factors. Nevertheless, there is need for more epidemiological studies to establish a better and adequate program to educate general population. Inaddition an early diagnosis and elimination of such lesions may minimize possible dentoalveolar complications. Introduction Oral mucosa is always subjected to external and internal stimuli and thus manifests a spectrum of disease that range from developmental, inflammatory and reactive to neoplastic changes. [1] These lesions present as both generalized or localized. Reactive lesions constantly present clinically and histopathologically as non-neoplastic nodular swellings that increase in response to chronic recurring tissue injury which stimulates an exuberant or extreme tissue response. [2] Different types of localized reactive lesions of oral cavity are focal fibrous hyperplasia, pyogenic granuloma (PG), irritational fibroma, peripheral giant cell granuloma (PGCG), peripheral ossifying fibroma (POF), fibro-epithelial hyperplasia/polyp, inflammatory fibrous hyperplasia and inflammatory gingival hyperplasia. [2] They are commonly evident in gingiva and less commonly present in other intraoral sites such as buccal mucosa, tongue, palatal mucosa and floor of the mouth. [3] Reactive lesions are typically the response to chronic inflammation caused by various forms of low grade chronic irritations to the oral mucosa such as dental plaque and calculus, sharp edges of grossly carious teeth, faulty dental restorations, chronic biting habits, ill-fitting dental/oral appliances and food impactions. Apart from local chronic irritations, these lesions Journal of Advanced Clinical & Research Insights Vol. 1:1 Jul-Aug 2014 1

Reactive lesions of oral cavity Hunasgi, et al. also appear to be etiologically interrelated to systemic factors such as hormonal changes. [4] Clinically, oral reactive lesions frequently present diagnostic challenges since they mimic some pathologic processes. [2] The duration of these lesions is often weeks to months due to the slow growth and mild symptoms. They are rarely painful, but often interfere with adequate plaque control. While their duration is extensive, it is not atypical to see ulceration to the epithelial surface from trauma. [5] All reactive lesions of oral cavity can clinically be similar but possess diverse histopathological features. [2] This similarity is a complex matter for differential diagnosis. Thus the purpose of this paper is to document the occurrence, distribution of clinical features of reactive lesions of oral cavity in 15 years of clinical practice in Raichur, Karnataka. Materials and Methods The study was a retrospective archival review of focal reactive lesions of the oral cavity acquired from 15 years of clinical practice in Raichur, Karnataka, India. The cases included in the present study were PG, PGCG, POF, irritational fibroma, fibroepithelial hyperplasia/polyp, inflammatory fibrous hyperplasia and inflammatory gingival hyperplasia. Haematoxylin and eosin stained slides of all the above mentioned lesions were retrieved to verify the specific diagnosis. Clinical data of each patient such as age, gender, location, and treatment were retrieved from the records. Unfinished records and missed pathologic slides were expelled from the study. Data was analyzed using the SPSS for Windows (version 12) statistical software package and data was placed in descriptive and tabular forms. Results Inflammatory gingival hyperplasia was the most prevailing lesion (n = 268, 51%), which was followed by PG (n = 127, 24%), Fibro-epithelial hyperplasia/polyp (n = 47, 9%), irritation fibroma (n = 44, 8%), inflammatory fibrous hyperplasia (n = 24, 5%), POF (n = 18, 2.7%) and PGCG (n = 2, 0.3%). Age The age ranged from 7 to 63 years, with a mean of 40.5 years. PG, Irritational fibroma, Fibro-epithelial hyperplasia/polyp, inflammatory fibrous hyperplasia and inflammatory gingival hyperplasia were more frequent in the fourth decade, whereas PGCG and POF were more common in the third decade. Table 1 shows the incidence of focal reactive lesions of oral cavity in different ages. Gender In the present study 261 cases (49.24%) occurred in males and 269 cases (50.76%) in females. Male to female ratio for reactive lesions of oral cavity was 1:1. With the exclusion of PG and inflammatory gingival hyperplasia, all reactive lesions were more common in males. Table 2 shows the distribution of focal reactive lesions of oral cavity in different genders. Anatomic location Gingiva with 470 (88.67%) cases was the most frequent site of reactive lesions, followed by buccal mucosa (33 cases [6.22%]) and palatal mucosa (15 [2.83%]). Table 3 shows the occurrence of oral reactive lesions in different anatomic locations. Discussion Reactive lesions of the oral cavity are tumor-like non-neoplastic proliferations produced in involvement through chronic irritation or trauma. These proliferations are pedunculated or sessile masses and painless with different colors ranging from light pink to red. The surface is also variable, with a non-ulcerated smooth appearance to an ulcerated mass. The size of lesion ranges from a few millimeters to more than a few centimeters. [6] Intraoral reactive lesions are comparatively common lesions of the oral cavity in biopsies performed by pathological departments. Reactive lesions are comprised 6.4% of 20,228 biopsies in a study from Canada, 5% of 30,056 biopsies in a study from the United States and 3.6% of 66,957 biopsies in the study from China. [7] Table 1: Distribution of reactive lesions of oral cavity by different ages Lesions Age (years) Total (%) Mean Range (years) Pyogenic granuloma 33.3 8 60 127 (24) Irritational fibroma 37.3 9 85 44 (8) Fibro epithelial hyperplasia/polyp 34.5 15 62 47 (9) Inflammatory fibrous hyperplasia 35.7 7 58 24 (5) Inflammatory gingival hyperplasia 34.5 10 63 268 (51) Peripheral ossifying fibroma 21.8 15 48 18 (2.7) Peripheral giant cell granuloma 30 20 40 2 (0.3) Total 40.5 7 63 530 Table 2: Distribution of reactive lesions of oral cavity by gender Lesions Gender Males Females Pyogenic granuloma 51 76 Irritational fibroma 30 14 Fibro epithelial hyperplasia/polyp 28 19 Inflammatory fibrous hyperplasia 13 11 Inflammatory gingival hyperplasia 128 140 Peripheral ossifying fibroma 13 5 Peripheral giant cell granuloma 2 0 Total (%) 261 (49.24) 269 (50.76) 2 Journal of Advanced Clinical & Research Insights Vol. 1:1 Jul-Aug 2014

Hunasgi, et al. Reactive lesions of oral cavity Table 3: Distribution of reactive lesions of oral cavity by location Lesions Gingiva Tongue Buccal mucosa Palate Lip Total Pyogenic granuloma 104 0 13 10 0 127 Irritational fibroma 14 1 20 5 4 44 Fibro epithelial hyperplasia/polyp 47 0 0 0 0 47 Inflammatory fibrous hyperplasia 24 0 0 0 0 24 Inflammatory gingival hyperplasia 268 0 0 0 0 268 Peripheral ossifying fibroma 18 0 0 0 0 18 Peripheral giant cell granuloma 2 0 0 0 0 2 Total 470 (88.67) 5 (0.94) 33 (6.26) 15 (2.83) 7 (1.3) 530 In the present study of 650 cases of reactive lesions, inflammatory gingival hyperplasia was the most common reactive lesion, followed by PG, which is in accordance with the study done by Peralles et al. [8] and Seyedmajidi et al. [9] However Kashyap et al. [10] and Effiom et al. [2] in their study found that PG was most common lesion. Further Reddy et al. [1] and Ezirganl et al. [11] in their study found that focal fibrous hyperplasia as common lesion and Amirchaghmaghi et al. [12] showed traumatic fibroma as the most common lesion. Naderi et al. [6] found PGCG as the most prevalent lesion. In the present study, adults in fourth decade are most frequently affected, especially common in females, also in accordance with previous reports. Most frequent site for reactive lesions was gingiva. Other oral sites in the descending order of occurrence are buccal mucosa, palatal mucosa, labial mucosa and tongue. Inflammatory gingival hyperplasia Enlargements of gingiva may be inflammatory, noninflammatory, or a combination of the two types. [13] Usually, the hyperplasia occurs primarily because of local irritations such as buildup of dental plaque or calculus and mouth breathing leading to poor oral hygiene. A histological examination of gingival overgrowth is when inflammatory cell infiltration, vascular engorgement and edema predominate; such type of gingival enlargement is referred to as inflammatory gingival hyperplasia. When major component is represented by dense fibrous tissue, the lesion is referred to as fibrotic gingival hyperplasia. [14] In our study the most frequent histopathologically described gingival enlargement was inflammatory gingival hyperplasia (51%). The average age of occurrence was 34.5 with range being 10-63 years. Females are frequently affected than males. The most common site affected was gingiva [Figure 1]. PG The PG is mainly an increased tissue response to local irritation or trauma. The young lesions are extremely vascular, reddish purple, frequently elevated, ulcerated, and bleed easily. The PG can often exhibit rapid growth, appearing on the gingiva in 75% of reported cases with a female predilection. [5] In our study PG Figure 1: Inflammatory gingival hyperplasia located in maxillary and mandibular anterior gingiva presented 24% of all the reactive lesions with average age of occurrence being 33.3 and in the range of 8-60 years. Females are frequently affected than males and most common site affected was gingiva followed by buccal mucosa [Figure 2]. Irritational fibroma Focal fibrous hyperplasia is also known as irritational fibroma or oral fibroma. It is a connective tumor and most common benign soft tissue neoplasm occurring in the oral cavity. Most fibromas correspond to reactive focal fibrous hyperplasia which is always due to trauma or local irritation. A fibroma may arise in any site of oral cavity, but usually seen on buccal mucosa along the plane of occlusion. Other frequent sites are gingiva, labial mucosa, buccal mucosa, palatal mucosa and tongue. It is nearly always a well-defined lesion slowly growing lesion that occurs at any age but it is most familiar in third, fourth and fifth decade. Females are affected twice as frequently as male. [15] In the present study the prevalence of irritational fibroma was 8% of all reactive lesions. Irritational fibroma is common in third decade and in males with most common location being buccal mucosa [Figure 3]. Journal of Advanced Clinical & Research Insights Vol. 1:1 Jul-Aug 2014 3

Reactive lesions of oral cavity Hunasgi, et al. Inflammatory fibrous hyperplasia and fibro-epithelial hyperplasia The words inflammatory hyperplasia is used to describe a huge range of commonly occurring nodular growths of the oral mucosa that histopathologically stand for inflamed epithelium, fibrous or granulation tissues. The size of these reactive hyperplastic masses can be lesser or greater, depending on the severity to which the components of the inflammatory reaction and healing response are exaggerated in the particular lesion. A few are predominantly fibromatous overgrowths with only thin epithelial covering and inflammation called as inflammatory fibrous hyperplasia; others showing hyperplasia of both epithelium and connective-tissue stroma called fibroepithelial hyperplasia. [16] In the present study inflammatory fibrous hyperplasia and fibro-epithelial hyperplasia constituted about 9% and 5% respectively of all the total reactive lesions. Both these are more common in third decade and in males [Figures 4 and 5]. POF The POF is a frequent reactive gingival lesion displaying variable degrees of mineralization, and it could arise from the periodontal ligament or periosteum. The mineralization is found within a non-encapsulated proliferation of fibroblasts. Most lesions are located in the interdental papilla. Most of the lesions are sessile or pedunculated, and can have an ulcerated surface. The POF tends to be more widespread in females than males, and radiographic evidence of erosion of underlying bone can be seen. [5,17] In present study, POF constituted 2.7% of all the reactive lesions with average of 21 years. Males are more affected and gingiva being most commonly involved [Figure 6]. Figure 2: Pyogenic granuloma located in labial gingiva of lower anterior teeth Figure 4: Inflammatory fibrous hyperplasia located in mandibular labial and buccal gingiva Figure 3: Irritational fibroma located posterior to maxillary left 2 nd molar Figure 5: Fibro-epithelial hyperplasia located posterior to maxillary left 3 rd molar 4 Journal of Advanced Clinical & Research Insights Vol. 1:1 Jul-Aug 2014

Hunasgi, et al. Reactive lesions of oral cavity Figure 6: Peripheral ossifying fibroma located on labial interdental gingiva between of right central and lateral incisor PGCG The PGCG is less frequently seen of all the reactive lesions of the gingiva and reported in only 5% of the biopsy reports according to the published literature. It originates from the periosteum or periodontal ligament as a result of local irritation or chronic trauma. The PGCG is a sessile or pedunculated mass seen more commonly in the mandible. The lesion can develop at any age, but is most commonly reported in the fourth to sixth decade of life. Similarly in the present study PGCG constitutes only 0.3% of all reactive lesions. PGCG is seen in third decade and more prevalent in gingiva [Figure 7]. [18] The most common differential diagnosis of these reactive lesions of oral cavity is papilloma, giant cell fibroma, neurofibroma, mucocele, benign and malignant salivary gland tumor and peripheral odontogenic fibromas. Even though reactive lesions of oral cavity are benign in nature they do have a tendency towards recurrence with incomplete elimination of the lesion or incomplete removal of local irritants. The treatment in each case was surgical excision; however, diverse treatment modalities may offer better outcomes with less incidence of recurrence. [5] Conclusion The lesions affecting the oral cavity constitute a diverse group of pathologies. Of all the oral biopsies reported, reactive lesions were the most commonly reported pathologies. Records on the age distribution, gender, and location of the individual types of lesions are not consistent in different studies. Some of the differences may be attributed to the geographic or ethnic factors. Nevertheless, there is need for more epidemiological studies to establish a better and adequate program to educate general population. In-addition an early diagnosis and elimination of such lesions may minimize possible dento-alveolar complications. Figure 7: Peripheral giant cell granuloma located on labial gingiva of maxillary left lateral incisor References 1. Reddy V, Saxena S, Saxena S, Reddy M. Reactive hyperplastic lesions of the oral cavity: A ten year observational study on North Indian Population. J Clin Exp Dent 2012;4:e136-40. 2. Effiom OA, Adeyemo WL, Soyele OO. Focal Reactive lesions of the Gingiva: An Analysis of 314 cases at a tertiary Health Institution in Nigeria. Niger Med J 2011;52:35-40. 3. Zarei MR, Chamani G, Amanpoor S. Reactive hyperplasia of the oral cavity in Kerman province, Iran: A review of 172 cases. Br J Oral Maxillofac Surg 2007;45:288-92. 4. Awange DO, Wakoli KA, Onyango JF, Chindia ML, Dimba EO, Guthua SW. Reactive localised inflammatory hyperplasia of the oral mucosa. East Afr Med J 2009;86:79-82. 5. Rossmann JA. Reactive lesions of the gingiva: Diagnosis and treatment options. Open Pathol J 2011;5:23-32. 6. Naderi NJ, Eshghyar N, Esfehanian H. Reactive lesions of the oral cavity: A retrospective study on 2068 cases. Dent Res J (Isfahan) 2012;9:251-5. 7. Buchner A, Shnaiderman-Shapiro A, Vered M. Relative frequency of localized reactive hyperplastic lesions of the gingiva: A retrospective study of 1675 cases from Israel. J Oral Pathol Med 2010;39:631-8. 8. Peralles PG, Viana AP, Azevedo AL, Pires FR. Gingival and alveolar hyperplastic reactive lesions: Clinicopathological study of 90 cases. Braz J Oral Sci 2006;5:1085-9. 9. Seyedmajidi M, Hamzehpoor M, Bagherimoghaddam S. Localized lesions of oral cavity: A Clinicopathological study of 107 cases. Res J Med Sci 2011;5:7-72. 10. Kashyap B, Reddy PS, Nalini P. Reactive lesions of oral cavity: A survey of 100 cases in Eluru, West Godavari district. Contemp Clin Dent 2012;3:294-7. 11. Ezirganl S, Tasdemir U, Goze F, Kara M, Polat S, Muderris S. Intraoral localized reactive hyperplastic lesions in Sivas. ACU Saglık Bil Derg 2014;5:43-7. 12. Amirchaghmaghi M, Mohtasham N, Mosannen Mozafari P, Dalirsani Z. Survey of reactive hyperplastic lesions of the oral cavity in Mashhad, Northeast Iran. J Dent Res Dent Clin Dent Prospects 2011;5:128-31. Journal of Advanced Clinical & Research Insights Vol. 1:1 Jul-Aug 2014 5

Reactive lesions of oral cavity Hunasgi, et al. 13. Rajendran R, Sivapathasundharam B. Shafer s Textbook of Oral Pathology. 7 th ed. India: Elsevier; 2007. p. 543-8. 14. Janosi K, Popsor S, Ormenisan A, Martha K. Comparative study of hyperplastic lesions of the oral mucosa. Eur Sci J 2013;9:7-15. 15. Mathur LK, Bhalodi AP, Manohar B, Bhatia A, Rai N, Mathur A. Focal fibrous hyperplasia: A case report. Int J Dent Clin 2010;2:56-7. 16. Eversole LR. Benign tumors of the oral cavity. Burket s Oral Medicine Diagnosis and Treatment. 10 th ed. St. Louis, Mo: Elsevier; 2011. p. 137-9. 17. Neville BW, Damm DD, Allen CM. Oral & Maxillofacial Pathology. 2 nd ed. Philadelphia: W. B Saunders; 2001. p. 451-2. 18. Zhang W, Chen Y, An Z, Geng N, Bao D. Reactive gingival lesions: A retrospective study of 2,439 cases. Quintessence Int 2007;38:103-10. How to cite this article: Hunasgi S, Koneru A, Vanishree M, Manvikar V, Patil AM, Gottipati H. Retrospective analysis of the clinical features of 530 cases of reactive lesions of oral cavity. J Adv Clin Res Insights 2014;1:1-6. 6 Journal of Advanced Clinical & Research Insights Vol. 1:1 Jul-Aug 2014