Epulis

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Epulis
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Epulis (Greek : ἐπουλίς; plural epulides) is any tumor-like enlargement (i.e. lump) situated on the gingival or alveolar mucosa. [1] [2] The word literally means "(growth) on the gingiva", [3] [4] and describes only the location of the mass and has no further implications on the nature of the lesion. [5] There are three types: fibromatous, ossifying and acanthomatous.[ medical citation needed ] The related term parulis (commonly called a gumboil) refers to a mass of inflamed granulation tissue at the opening of a draining sinus on the alveolus over (or near to) the root of an infected tooth. [2] Another closely related term is gingival enlargement, which tends to be used where the enlargement is more generalized over the whole gingiva rather than a localized mass.

Contents

Epulis fissuratum

This is a fibrous hyperplasia of excess connective tissue folds that takes place in reaction to chronic trauma from an ill fitting denture. It usually occurs in the mandibular labial sulcus. The clinical appearance of these lesions can vary, from erythematous mucosa that is prone to bleeding (a manifestation of hyperaemia), to lesions of more dense connective tissue, appearing more pale and firm. [6] Sometimes the term epulis is used synonymously with epulis fissuratum, [2] but this is technically incorrect as several other lesions could be described as epulides.

This condition typically affects middle-aged and elderly patients. It is causes when a denture irritates the mucosa forming an ulcer. In time, this ulcer may develop into an elongated fibro-epithelial enlargement. Several leaflets may develop. [7]

Management of this condition includes trimming the denture flange or areas causing irritation to the mucosa. Should modification of the denture not cause the lesion to decrease in size after 2–3 weeks, the swelling should be biopsied and examined histologically. [7]

Pyogenic granuloma

This type of epulis is neither pyogenic ("pus producing") nor a true granuloma, but it is a vascular lesion. About 75% of all pyogenic granulomas occur on the gingiva, [2] growing beneath the gingival margin, [8] although they may also occur elsewhere in the mouth or other parts of the body (where the term epulis is inappropriate). This common oral lesion is thought to be a reaction to recurrent trauma or a response to non-specific infection. [9] It is more common in younger people and in females, and appears as a red-purple nodular swelling and bleeds easily. Small lesions can vary from a few millimetres up to two or three centimetres. Larger lesions can be attached to the gingiva with or without a stalk. [10] This type of epulis may also penetrate interdentally and present as bilobular, i.e. present both buccally and lingually. [8]

Pregnancy epulis

Also termed a "pregnancy tumor" or "granuloma gravidarum", [2] this lesion is identical to a pyogenic granuloma in all respects apart from the fact that it occurs exclusively in pregnant females. [3] Hormonal changes during pregnancy causes an increased inflammatory response to plaque and other irritants, which in turn causes the development of the epulis. [9] There is usually pregnancy gingivitis also. [3] Pregnancy epulis commonly occurs during the third trimester of pregnancy. [11]

Fibrous epulis

In adults, this type of epulis is characterised as a firm, pink mass that is not inflamed. It seems to grow from below the free gingival margin/interdental papilla. [8] This epulis most commonly occurs on the gingiva near the front of the mouth between two teeth. [3] When gingival hyperplasia is confined to one area of the jaw, this is when it is termed an epulis fibrosa, caused by an increase in collagenous tissue with varying cellularity. [12] It may be sessile or pedunculated and is composed of fibrosed granulation tissue. Fibrous epulides are firm and rubbery, and pale pink in color. Over time, bone may form within the lesion at which point the term peripheral ossifying fibroma may be used (in some parts of the world), despite having no relation to the ossifying fibroma of bone and it is not a fibroma. [13] : 315  This type of epulis is most often painless, but pain may be associated due to secondary trauma, via brushing, flossing or chewing. [8] Diagnosis of a fibrous epulis is based firstly upon clinical features. A variety of common presentations exist including: painless, round and pedunculated swellings, rarely exceeding 2 cm in diameter, swelling sometimes next to areas of irritation, rarely involve attached gingiva and they can be red or pale. The diagnosis is confirmed by an excisional biopsy. [14]

Ossifying fibroid epulis

Not to be confused with ossifying fibroma. This is a long-standing fibrous epulis in which bone has begun to form. It is believed that irritants and trauma cause the growth. Dental appliances, poor restorations and subgingival plaque and calculus are all examples of possible causes. It is seen most commonly in young adults and teenagers but can occur at any age, with the majority of cases occurring in females. In a clinical point of view, they are sessile or pedunculated, typically ulcerated and erythematous or are similar to the surrounding gingiva in colour. they are usually <2 cm in size. Ossifying fibroid epulis should be excised and examined make a definitive diagnosis. However, recurrences are common. [15]

Giant cell epulis

This epulis contains giant cells and is usually found on the gum margin between teeth which are anterior to the permanent molars. [13] : 317  The development of a giant cell epulis may be related to the recent loss of baby teeth, extraction or trauma. [13] : 319  The swelling is round, soft and commonly maroon or purplish in colour. [13] : 317  It is also termed peripheral giant cell granuloma. Children are typically mainly affected, with females being affected more than males [16]

Diagnosis of giant cell epulis usually requires a biopsy and radiographs should be taken of the area. [17]

Epulis granulomatosa

An epulis granulomatosa is a granuloma which grows from an extraction socket (the hole left after a tooth has been removed), and as such can be considered to be a complication of healing after oral surgery. [18]

Congenital epulis

This rare epulis (also called granular cell tumor, congenital gingival granular cell tumor or Neumann's tumor) presents at birth, and is not acquired, [19] in contrast to most other epulides which tend to be reactive lesions to tissue irritation. Congenital epulides mainly affect females and every so often, the growth is so large that it can obstruct breathing and feeding. [13] : 322  On rare occasion, it may arise on the tongue, or be multifocal.

Clinically, congenital epuli are usually found on the alveolar ridge, and are typically pink, pedunculated, firm, have a smooth or lobulated surface and the size varies from a few to 9 mm. They are usually found in solitary with multiple growths only in 10% of cases. It is commonly a pedunculated lesion in the incisor region. A diagnoses can usually be made based on clinical findings. [20]

Histologically, congenital epuli are benign and thought to have a mesenchymal origin. When examined, cells with abundant granular eosinophilic and small eccentric nuclei are found. A delicate fibrovascular network can be found between the cells. It has an unusual resemblance to granular cell myoblastoma and is more common in the maxilla than the mandible. [21]

A congenital Epulis can potentially involute, therefore, if it is not interfering with feeding and breathing, monitoring the lesion is advised. Otherwise, the lesion is removed with a simple excision and it does not have a tendency to recur. [20] Diagnosis is typically based upon clinical features but a biopsy confirms this. [22]

Related Research Articles

<span class="mw-page-title-main">Stomatitis</span> Inflammation of the mouth and lips

Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration.

The oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed lamina propria. The oral cavity has sometimes been described as a mirror that reflects the health of the individual. Changes indicative of disease are seen as alterations in the oral mucosa lining the mouth, which can reveal systemic conditions, such as diabetes or vitamin deficiency, or the local effects of chronic tobacco or alcohol use. The oral mucosa tends to heal faster and with less scar formation compared to the skin. The underlying mechanism remains unknown, but research suggests that extracellular vesicles might be involved.

Epulis fissuratum 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, epulis fissuratum 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. Treatment is by simple surgical removal of the lesion, and also by adjustment of the denture or provision of a new denture.

Inflammatory papillary hyperplasia (IPH) is a benign lesion of the oral mucosa which is characterized by the growth of one or more nodular lesions, measuring about 2mm or less. The lesion almost exclusively involves the hard palate, and in rare instances, it also has been seen on the mandible. The lesion is mostly asymptomatic and color of the mucosa may vary from pink to red.

<span class="mw-page-title-main">Pyogenic granuloma</span> Vascular tumor on both mucosa and skin

A pyogenic granuloma or lobular capillary hemangioma is a vascular tumor that occurs on both mucosa and skin, and appears as an overgrowth of tissue due to irritation, physical trauma, or hormonal factors. It is often found to involve the gums, skin, or nasal septum, and has also been found far from the head, such as in the thigh.

Peripheral giant-cell granuloma (PGCG) is an oral pathologic condition that appears in the mouth as an overgrowth of tissue due to irritation or trauma. Because of its overwhelming incidence on the gingiva, the condition is associated with two other diseases, pyogenic granuloma and peripheral ossifying fibroma. These three diseases are associated because they appear frequently on gingiva. Due to its similar microscopic appearance, peripheral giant-cell granuloma is considered to be the soft tissue equivalent of central giant-cell granuloma.

A peripheral ossifying fibroma, also known as ossifying fibrous epulis, is “a gingival nodule which is composed of a cellular fibroblastic connective tissue stroma which is associated with the formation of randomly dispersed foci of mineralised products, which consists of bone, cementum-like tissue, or a dystrophic calcification. The lesion is considered part of an ossifying fibroma, but that is usually considered to be a jaw tumor. Because of its overwhelming incidence on the gingiva, the condition is associated with two other diseases, though not because they occur together. Instead, the three are associated with each other because they appear frequently on gingiva: pyogenic granuloma and peripheral giant cell granuloma. Some researchers believe peripheral ossifying fibromas to be related to pyogenic fibromas and, in some instances, are the result of a pyogenic granuloma which has undergone fibrosis and calcification.

An oral medicine or stomatology doctor/dentist has received additional specialized training and experience in the diagnosis and management of oral mucosal abnormalities including oral cancer, salivary gland disorders, temporomandibular disorders and facial pain, taste and smell disorders; and recognition of the oral manifestations of systemic and infectious diseases. It lies at the interface between medicine and dentistry. An oral medicine doctor is trained to diagnose and manage patients with disorders of the orofacial region.

Stomatitis nicotina is a diffuse white patch on the hard palate, usually caused by tobacco smoking, usually pipe or cigar smoking. It is painless, and it is caused by a response of the palatal oral mucosa to chronic heat. A more pronounced appearance can occur with reverse smoking, sometimes distinguished from stomatitis nicotina by the term reverse smoker's stomatitis. While stomatitis nicotina that is caused by heat is not a premalignant condition, the condition that is caused by reverse smoking is premalignant.

Giant-cell fibroma is a benign localized fibrous mass. It often mimics other fibroepithelial growths and can be distinguished by its histopathology. The exact cause of giant-cell fibromas is unknown however there is no evidence to show that it can be caused by irritation. Giant-cell fibromas can be removed by surgical incision, electrosurgery, or laser excision.

Orofacial granulomatosis (OFG) is a condition characterized by persistent enlargement of the soft tissues of the mouth, lips and the area around the mouth on the face, causing in most cases extreme pain. The mechanism of the enlargement is granulomatous inflammation. The underlying cause of the condition is not completely understood, and there is disagreement as to how it relates to Crohn's disease and sarcoidosis.

<span class="mw-page-title-main">Central giant-cell granuloma</span> Medical condition

Central giant-cell granuloma (CGCG) is a localised benign condition of the jaws. It is twice as common in females and is more likely to occur before age 30. Central giant-cell granulomas are more common in the anterior mandible, often crossing the midline and causing painless swellings.

<span class="mw-page-title-main">Calcifying odontogenic cyst</span> Medical condition

Calcifying odontogenic cyst (COC) is a rare developmental lesion that comes from odontogenic epithelium. It is also known as a calcifying cystic odontogenic tumor, which is a proliferation of odontogenic epithelium and scattered nest of ghost cells and calcifications that may form the lining of a cyst, or present as a solid mass.

Peripheral odontogenic fibroma(PFO) is a fibrous connective tissue mass that is exophytic and covered in surface epithelium that contains odontogenic epithelium. The World Health Organization (WHO) classifies peripheral odontogenic fibroma as a fibroblastic neoplasm with variable amounts of odontogenic epithelium that appears to be dormant. Dentine and/or cementum-like material may be present.

<span class="mw-page-title-main">Gingival enlargement</span> Increase in size of the gums

Gingival enlargement is an increase in the size of the gingiva (gums). It is a common feature of gingival disease. Gingival enlargement can be caused by a number of factors, including inflammatory conditions and the side effects of certain medications. The treatment is based on the cause. A closely related term is epulis, denoting a localized tumor on the gingiva.

Dental pertains to the teeth, including dentistry. Topics related to the dentistry, the human mouth and teeth include:

<span class="mw-page-title-main">Plasma cell gingivitis</span> Medical condition

Plasma cell gingivitis is a rare condition, appearing as generalized erythema (redness) and edema (swelling) of the attached gingiva, occasionally accompanied by cheilitis or glossitis. It is called plasma cell gingivitis where the gingiva (gums) are involved, plasma cell cheilitis, where the lips are involved, and other terms such as plasma cell orifacial mucositis, or plasma cell gingivostomatitis where several sites in the mouth are involved. On the lips, the condition appears as sharply outlined, infiltrated, dark red plaque with a lacquer-like glazing of the surface of the involved oral area.

Cysts of the jaws are cysts—pathological epithelial-lined cavities filled with fluid or soft material—occurring on the bones of the jaws, the mandible and maxilla. Those are the bones with the highest prevalence of cysts in the human body, due to the abundant amount of epithelial remnants that can be left in the bones of the jaws. The enamel of teeth is formed from ectoderm, and so remnants of epithelium can be left in the bone during odontogenesis. The bones of the jaws develop from embryologic processes which fuse, and ectodermal tissue may be trapped along the lines of this fusion. This "resting" epithelium is usually dormant or undergoes atrophy, but, when stimulated, may form a cyst. The reasons why resting epithelium may proliferate and undergo cystic transformation are generally unknown, but inflammation is thought to be a major factor. The high prevalence of tooth impactions and dental infections that occur in the bones of the jaws is also significant to explain why cysts are more common at these sites.

Plasma cell granulomas (PCGs) are uncommon, non-neoplastic lesions of unknown etiology and are considered an entity of IgG4-related diseases.

<span class="mw-page-title-main">Amalgam tattoo</span> Common discoloration of tissue in the mouth

Amalgam tattoo is a grey, blue or black area of discoloration on the mucous membranes of the mouth, typically on the gums of the lower jaw. It is a healthcare caused lesion, due to entry of dental amalgam into the soft tissues. It is common, painless, and benign, but it can be mistaken for melanoma.

References

  1. ↑ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: Clinical Dermatology. Saunders Elsevier. ISBN   978-0-7216-2921-6.
  2. 1 2 3 4 5 Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2nd ed.). Philadelphia: W.B. Saunders. pp.  440–442, 447–448. ISBN   978-0721690032.
  3. 1 2 3 4 Cawson RA, Odell EW (2002). Cawson's essentials of oral pathology and oral medicine (7th ed.). Edinburgh: Churchill Livingstone. pp. 275–278. ISBN   978-0443071065.
  4. ↑ ἐπουλίς . Liddell, Henry George ; Scott, Robert ; A Greek–English Lexicon at the Perseus Project.
  5. ↑ Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. (2012). Carranza's clinical periodontology (11th ed.). St. Louis, Mo.: Elsevier/Saunders. pp.  93. ISBN   978-1-4377-0416-7.
  6. ↑ Cutright, Duane E. (1974-03-01). "The histopathologic findings in 583 cases of epulis fissuratum". Oral Surgery, Oral Medicine, Oral Pathology. 37 (3): 401–411. doi:10.1016/0030-4220(74)90113-3. ISSN   0030-4220. PMID   4591192.
  7. 1 2 Scully, Crispian (1999). Handbook of Oral Disease. London: Martin Dunitz. pp. 120–121.
  8. 1 2 3 4 Agrawal, Amit Arvind (September 2015). "Gingival enlargements: differential diagnosis and review of literature". World Journal of Clinical Cases. 3 (9): 779–788. doi: 10.12998/wjcc.v3.i9.779 . PMC   4568527 . PMID   26380825.
  9. 1 2 Mitchell, David; Mitchell, Laura (July 2014). Oxford Handbook of Clinical Dentistry. Oxford University Press. doi:10.1093/med/9780199679850.001.0001. ISBN   9780199679850.
  10. ↑ R Pramod, John (2014). Textbook of Oral Medicine. doi:10.5005/jp/books/12196. ISBN   9789350908501.
  11. ↑ Rabinerson, D; Kaplan, B; Dicker, D; Dekel, A (September 2002). "[Epulis during pregnancy]". Harefuah. 141 (9): 824–6, 857, 856. PMID   12362490.
  12. ↑ Slootweg, Pieter. J (2013). Dental pathology: a practical introduction. Springer. p. 91. ISBN   9783642367137.
  13. 1 2 3 4 5 Cawson, RA; Odell, EW (2008). Cawson's essentials of oral pathology and oral medicine (8th ed.). Edinburgh: Churchill Livingstone. ISBN   9780702040016.
  14. ↑ Scully, Crispian (1999). Handbook of Oral Disease. London: Martin Dunitz. p. 285.
  15. ↑ Azher, U.; Das, U. M. (2009-01-01). "Peripheral ossifying fibroma". Journal of Indian Society of Pedodontics and Preventive Dentistry. 27 (1): 49–51. doi: 10.4103/0970-4388.50818 . ISSN   0970-4388. PMID   19414975.
  16. ↑ Scully, Crispian (1999). Handbook of Oral Disease. London: Martin Dunitz. p. 286.
  17. ↑ Scully, Crispian (1999). Handbook of Oral Disease. Martin Dunitz Ltd. p. 287.
  18. ↑ Leong, R; Seng, GF (May–Jun 1998). "Epulis granulomatosa: extraction sequellae". General Dentistry. 46 (3): 252–5. PMID   9693538.
  19. ↑ Eghbalian, F; Monsef, A (March 2009). "Congenital epulis in the newborn, review of the literature and a case report". Journal of Pediatric Hematology/Oncology. 31 (3): 198–9. doi:10.1097/mph.0b013e31818ab2f7. PMID   19262247.
  20. 1 2 Küpers, A. Marlijn; Andriessen, Peter; van Kempen, Muriel J. P.; van der Tol, Ignaz G. H.; van der Waal, Isaäc; Baart, Jacques A.; Dumans, Antoine G. (Feb 2009). "Congenital epulis of the jaw: a series of five cases and review of literature". Pediatric Surgery International. 25 (2): 207–210. doi:10.1007/s00383-008-2304-8. hdl: 1871/23572 . PMID   19082830. S2CID   6828136.
  21. ↑ Bosanquet, David; Roblin, Graham (November 2009). "Congenital Epulis: A Case Report and Estimation of Incidence". International Journal of Otolaryngology. 2009: 508780. doi: 10.1155/2009/508780 . PMC   2809329 . PMID   20130770.
  22. ↑ Scully, Crispian (1999). Handbook of Oral Disease. London: Martin Dunitz. p. 280.
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