Inflammatory papillary hyperplasia

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Inflammatory papillary hyperplasia
Other namesPalatal papillomatosis, [1] palatal epithelial hyperplasia, [2] denture papillomatosis [3] papillary hyperplasia of the palate
Specialty Dentistry, ENT surgery

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. [4] [5] 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.

Contents

In general, IPH is associated with the use of removable upper dentures, although it also has been found in dentulous patients with no history of a dental prosthesis. [4]

The majority of lesions are found beneath ill-fitting dentures of long use and in patients who do not take their dentures out overnight. The lesion seems to result from a combination of chronic, mild trauma which permit frictional irritation. A poor fitting denture never acquires papillomatosis. However, there must be some unidentified predisposing factors present in those patients who develop the lesion. [5] It is also induced by low-grade infection by bacteria or Candida yeast. [5] It is occasionally seen in patients without dentures but with high palatal vaults or those with habit of breathing through the mouth. [5]

Signs and symptoms

Papillary hyperplasia is seen in middle-aged and older persons, and there is a strong female predilection (2:1). The disease occurs on the bone-bound oral mucosa of the hard palate and alveolar ridges. Inflammatory papillary hyperplasia is usually asymptomatic. It presents as a cluster of individual papules or nodules that may be erythematous, somewhat translucent, or normal in surface coloration. Mucosa is erythematous and has a pebbly or papillary surface. Many cases are associated with denture stomatitis. [6]

Often the entire vault of the hard palate is involved, with the alveolar mucosa being largely spared. White cottage cheese–like colonies of Candida may be seen in clefts between papules. There is seldom pain, but a burning sensation may be produced by the yeast infection. Early papules are more edematous, whereas older ones are more fibrotic and firm, being individually indistinguishable from irritation fibroma. [5]

Candida -associated palatal papillary hyperplasia also has been reported in dentate patients with human immunodeficiency virus (HIV) infection. [6]

Cause

The origin of the lesion is unclear. This condition appears to be of an inflammatory nature. [7]

An excessive denture palatal relief area, creating a void between the denture base and the tissue of the palate, encourages food entrapment and so encouraging bacterial and fungal growth between the two surfaces. This was demonstrated in 80 per cent of the patients. [8]

The other causes may include ill-fitting or poorly contoured dentures, [9] [10] irritation of the palatal salivary glands [11] poor oral hygiene [10] and continuous day and night denture use. [12] [10]

ll-fitting or poorly contoured dentures can result in excessive frictional movement of the denture bases on the oral mucosa, [13] creating the chances of developing inflammatory papillary hyperplasia.

Inflammatory papillary hyperplasia is commonly associated with Candida infection. [14] Strong correlation between denture stomatitis and poor hygiene in the use of prostheses have been found in a few studies in Brazil. [15] [16] Denture stomatitis is the most frequent denture related mucosal lesion and is always associated with Candida albicans. Colonization of Candida albicans is caused by poor oral hygiene. However, Candida albicans infection is an opportunistic event and  is not consequential for developing denture stomatitis and inflammatory papillary hyperplasia. [17] [18]

Gender was also found to be another significant factor from studies in Brazil. [19] Females usually live longer than men, causing more tooth loss to happen among women and more women wear dentures (and for longer periods) than men. Hence, women have higher chance of getting inflammatory papillary hyperplasia. Oral mucosa of women is more susceptible to hyperplastic change than that of men due to postmenopausal changes to the oral mucosa,

Diagnosis

Classification

This has been generally based on the clinical appearance of the inflamed mucosa seen under maxillary complete dentures. The classification of Newton (1962) has been the most widely used. He proposed three types: (1) Pinpoint hyperaemic foci, (2) Diffuse hyperaemia of denture-supporting tissues, and (3) Papillary hyperplasia. Budtz-Jorgensen & Bertram (1970) used different terminology for the same changes: (1) Simple localized inflammation, (2) Simple diffuse (generalized) inflammation, and (3) Granular inflammation. Bergendal (1982) included only diffuse and papillary varieties and referred to atrophic or hyperplastic denture stomatitis.

Inflammatory papillary hyperplasia is a hyperplasia (overgrowth) of soft tissue, usually beneath a denture. It is associated with poor denture hygiene, denture overuse, and ill-fitting dentures.

It is a closely related condition to inflammatory fibrous hyperplasia (epulis fissuratum), but the appearance and location differs. [20]

Histopathology

Epithelium is able to grow into the subjacent connective tissue in response to chronic inflammation. [21] [7] Mild trauma, and constant irritation to the oral mucosa histologically manifests as acanthosis and hyperparakeratosis. This defensive thickening is a primary function of epithelium.

Histopathologically, numerous papillary projections are usually covered by hyperplastic stratified squamous epithelium with or without chronic inflammation. [22] Pseudoepitheliomatous appearance can be seen In advanced cases, this hyperplasia is pseudoepitheliomatous in appearance. [23]

A chronic inflammatory cell infiltrate containing lymphocytes and plasma cells is usually seen, Rarely, polymorphonuclear leukocytes are also present. Proliferation of fibrovascular tissue occurs in nodules with a variable lymphoplasmacytic infiltrate.

Differential diagnosis

Treatment

For early lesions of inflammatory papillary hyperplasia, cessation of denture use for 2 to 4 weeks may allow the lesion to completely subside. This may be aided by use of topical antibiotic or antifungal therapies. [25] Small lesions are also typically treated with mouthrinses such as chlorhexidine mouthrinse at 0.12% or antifungal mouthrinse/ gels. [4]

For more advanced and large lesions, excision of the hyperplastic tissue may be required before fabricating a new denture. Several surgical methods have been used, including: [26]

Lesions removed by electrosurgery require an average of 30 to 33 days to heal, whereas lesions removed by surgical curettage require around 21 to 23 healing days. [27] During healing interval, the existing denture can be lined with a temporary tissue conditioner that acts as a palatal dressing and provides greater comfort. [26] Surgical removal of the lesion and the making of new dentures are effective in eradication of the lesion. [28]

Good oral hygiene practice is very important in preventing repetition of events leading to the condition again. [29] Proper denture hygiene care should be carried out as instructed by your dentist and nocturnal use of dentures should be eliminated.

Epidemiology

Due to the strong association with denture-wearing, the lesion tends to occur more in adults than children. There is no gender predilection. [1] In people who wear dentures 24 hours a day, its incidence is around 20%.

Inflammatory papillary hyperplasia almost exclusively involves the hard palate, specifically the vault of the palate. Extension of the lesion to the mucosa of the residual ridges have also been observed. 11% to 13.9% of  patients who wear maxillary complete dentures with complete palatal coverage has been reported to have IPH. [22]

Related Research Articles

Dentures Prosthetic devices constructed to replace missing teeth

Dentures are prosthetic devices constructed to replace missing teeth, and are supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable. However, there are many denture designs, some which rely on bonding or clasping onto teeth or dental implants. There are two main categories of dentures, the distinction being whether they are used to replace missing teeth on the mandibular arch or on the maxillary arch.

Oral candidiasis Fungal infection

Oral candidiasis, also known as oral thrush among other names, is candidiasis that occurs in the mouth. That is, oral candidiasis is a mycosis of Candida species on the mucous membranes of the mouth.

Leukoplakia Medical condition

Oral leukoplakia is a potentially malignant disorder affecting the oral mucosa. It is defined as "essentially an oral mucosal white lesion that cannot be considered as any other definable lesion." Oral leukoplakia is a white patch or plaque that develops in the oral cavity and is strongly associated with smoking. Leukoplakia is a firmly attached white patch on a mucous membrane which is associated with increased risk of cancer. The edges of the lesion are typically abrupt and the lesion changes with time. Advanced forms may develop red patches. There are generally no other symptoms. It usually occurs within the mouth, although sometimes mucosa in other parts of the gastrointestinal tract, urinary tract, or genitals may be affected.

<span class="mw-page-title-main">Dental implant</span> Surgical component that interfaces with the bone of the jaw

A dental implant is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodontic anchor. The basis for modern dental implants is a biologic process called osseointegration, in which materials such as titanium or zirconia form an intimate bond to bone. The implant fixture is first placed so that it is likely to osseointegrate, then a dental prosthetic is added. A variable amount of healing time is required for osseointegration before either the dental prosthetic is attached to the implant or an abutment is placed which will hold a dental prosthetic/crown.

Stomatitis Medical condition

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.

Angular cheilitis Cheilitis characterized by inflammation of one or both of the corners of the mouth

Angular cheilitis (AC) is inflammation of one or both corners of the mouth. Often the corners are red with skin breakdown and crusting. It can also be itchy or painful. The condition can last for days to years. Angular cheilitis is a type of cheilitis.

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.

An oral medicine or stomatology doctor 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, essentially as a "physician of the mouth."

Toothlessness Lacking teeth

Toothlessness or edentulism is the condition of having no teeth. In organisms that naturally have teeth, it is the result of tooth loss.

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.

Oral and maxillofacial pathology refers to the diseases of the mouth, jaws and related structures such as salivary glands, temporomandibular joints, facial muscles and perioral skin. The mouth is an important organ with many different functions. It is also prone to a variety of medical and dental disorders.

Median rhomboid glossitis Medical condition

Median rhomboid glossitis is a condition characterized by an area of redness and loss of lingual papillae on the central dorsum of the tongue, sometimes including lesions of the tongue and palate. It is seen in patients using inhaled steroids and smokers, and is usually a kind of chronic atrophic oral candidiasis, but hematinic deficiency and diabetes should be excluded.

Oral pigmentation is asymptomatic and does not usually cause any alteration to the texture or thickness of the affected area. The colour can be uniform or speckled and can appear solitary or as multiple lesions. Depending on the site, depth, and quantity of pigment, the appearance can vary considerably.

Epulis is any tumor like enlargement situated on the gingival or alveolar mucosa. The word literally means "(growth) on the gingiva", and describes only the location of the mass and has no further implications on the nature of the lesion. There are three types: fibromatous, ossifying and acanthomatous. The related term parulis refers to a mass of inflamed granulation tissue at the opening of a draining sinus on the alveolus over the root of an infected tooth. 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.

Denture-related stomatitis is a common condition where mild inflammation and redness of the oral mucous membrane occurs beneath a denture. In about 90% of cases, Candida species are involved, which are normally a harmless component of the oral microbiota in many people. Denture-related stomatitis is the most common form of oral candidiasis. It is more common in elderly people, and in those who wear a complete upper denture. Denture-related stomatitis is more likely to develop when the denture is left constantly in the mouth, rather than removing it during sleep, and when the denture is not cleaned regularly.

Gingival cyst Medical condition

Gingival cyst, also known as Epstein's pearl, is a type of cysts of the jaws that originates from the dental lamina and is found in the mouth parts. It is a superficial cyst in the alveolar mucosa. It can be seen inside the mouth as small and whitish bulge. Depending on the ages in which they develop, the cysts are classified into gingival cyst of newborn and gingival cyst of adult. Structurally, the cyst is lined by thin epithelium and shows a lumen usually filled with desquamated keratin, occasionally containing inflammatory cells. The nodes are formed as a result of cystic degeneration of epithelial rests of the dental lamina.

Alveoloplasty is a surgical pre-prosthetic procedure performed to facilitate removal of teeth, and smoothen or reshape the jawbone for prosthetic and cosmetic purposes. In this procedure, the bony edges of the alveolar ridge and its surrounding structures is made smooth, redesigned or recontoured so that a well-fitting, comfortable, and esthetic prosthesis may be fabricated or implants may be surgically inserted. This pre-prosthetic surgery which may include bone grafting prepares the mouth to receive a prosthesis or implants by improving the condition and quality of the supporting structures so they can provide support, better retention and stability to the prosthesis.

A complete denture is a removable appliance used when all teeth within a jaw have been lost and need to be prosthetically replaced. In contrast to a partial denture, a complete denture is constructed when there are no more teeth left in an arch, hence it is an exclusively tissue-supported prosthesis. A complete denture can be opposed by natural dentition, a partial or complete denture, fixed appliances or, sometimes, soft tissues.

Overdenture Removable dental prosthesis

Overdenture is any removable dental prosthesis that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and/or dental implants. It is one of the most practical measures used in preventive dentistry. Overdentures can be either tooth supported or implant supported. It is found to help in the preservation of alveolar bone and delay the process of complete edentulism.

References

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  15. ↑ Ferreira RC, Magalhães CS, Moreira AN (September 2010). "Oral mucosal alterations among the institutionalized elderly in Brazil". Brazilian Oral Research. 24 (3): 296–302. doi: 10.1590/s1806-83242010000300007 . PMID   20877966.
  16. ↑ da Silva HF, Martins-Filho PR, Piva MR (September 2011). "Denture-related oral mucosal lesions among farmers in a semi-arid Northeastern Region of Brazil". Medicina Oral, Patologia Oral y Cirugia Bucal. 16 (6): e740-4. doi: 10.4317/medoral.17081 . PMID   21196849.
  17. ↑ Altarawneh S, Bencharit S, Mendoza L, Curran A, Barrow D, Barros S, Preisser J, Loewy ZG, Gendreau L, Offenbacher S (January 2013). "Clinical and histological findings of denture stomatitis as related to intraoral colonization patterns of Candida albicans, salivary flow, and dry mouth". Journal of Prosthodontics. 22 (1): 13–22. doi:10.1111/j.1532-849x.2012.00906.x. PMC   3541428 . PMID   23107189.
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  21. ↑ Cutright DE (April 1975). "Morphogenesis of inflammatory papillary hyperplasia". The Journal of Prosthetic Dentistry. 33 (4): 380–5. doi:10.1016/s0022-3913(75)80033-3. PMID   1054416.
  22. 1 2 Orenstein NP, Taylor T (April 2014). "A nonsurgical approach to treating aggressive inflammatory papillary hyperplasia: a clinical report". The Journal of Prosthetic Dentistry. 111 (4): 264–8. doi:10.1016/j.prosdent.2013.07.020. PMID   24360006.
  23. ↑ Emami E, Taraf H, de Grandmont P, Gauthier G, de Koninck L, Lamarche C, de Souza RF (February 2013). "The association of denture stomatitis and partial removable dental prostheses: a systematic review". The International Journal of Prosthodontics. 25 (2): 113–9. doi:10.1016/s0022-3913(13)60029-3. PMID   22371829.
  24. ↑ Woo S (November 2016). Oral Pathology (2nd ed.). Elsevier. ISBN   978-0-323-39054-5.
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  26. 1 2 Oral and Maxillofacial Pathology (4th ed.). Elsevier.
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  29. ↑ Cutright DE (April 1975). "Morphogenesis of inflammatory papillary hyperplasia". The Journal of Prosthetic Dentistry. 33 (4): 380–5. doi:10.1016/S0022-3913(75)80033-3. PMID   1054416.
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