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Epulis

Epulis is the general term for distinct types of benign gingival hyperplasia. Persistent irritation and subsequent inflammation is usually assumed to be the cause of epulis.


Presentation

Characteristic morphologies of EFis, EFib, GCE and CE differ. Nevertheless, macroscopic appearance may not allow a reliable diagnosis and histopathological analysis of excised tissue is generally recommended. The latter may not be required in cases of spontaneously remitting CE.

  • EFis are usually located in close proximity to an ill-fitting dental prosthesis. The latter may also cause discomfort or pain while chewing solid foods and in rare cases, it may interfere with articulation. Most patients carrying a denture that is no longer well adjusted to their jaws are asymptomatic, though. EFis are soft, bright red lesions whose surface may be ulcerated. Inflammation may change the epulis' appearance, it may become darker due to intense vascularization, and it may tend to bleed. EFis develop within rather short periods of time.
  • EFib are of fibrous texture and indeed, pathohistological analysis of these epulides reveals large numbers of collagen fibers but few cells. These tumors are rather pale.
  • GCE, in contrast, are usually deep red or even purple.
  • CE resemble EFis. They may grow to astonishing sizes and fill out large parts of the child's oral cavity.

For some types of epulides, predilection for mandibular or maxillary gingiva, for alveolar mucosa or vestibules, has been reported. However, information to this end varies largely. It is therefore not included in this description.

In general, epulides don't cause additional symptoms. However, they may disturb while eating and are often considered esthetic flaws. In infants, mechanical obstruction may cause feeding difficulties or even interfere with breathing.

Cheilitis
  • In addition, clinical presentation of denture stomatitis and angular cheilitis was observed. Medical history was not contributory, and she did not use any medications except for vitamins and minerals.[dentalhypotheses.com]
  • PMID 19262247 . v t e Oral and maxillofacial pathology ( K00–K06, K11–K14 , 520–525, 527–529 ) Lips Cheilitis Actinic Angular Plasma cell Cleft lip Congenital lip pit Eclabium Herpes labialis Macrocheilia Microcheilia Nasolabial cyst Sun poisoning Trumpeter's[en.wikipedia.org]
Ankylosis
  • Plasmoacanthoma Stomatitis Aphthous Denture-related Herpetic Smokeless tobacco keratosis Submucous fibrosis Ulceration Riga–Fede disease Verruca vulgaris Verruciform xanthoma White sponge nevus Teeth ( pulp , dentin , enamel ) Amelogenesis imperfecta Ankylosis[en.wikipedia.org]
Xanthoma
  • […] papillomatosis Oral melanosis Smoker's melanosis Pemphigoid Benign mucous membrane Pemphigus Plasmoacanthoma Stomatitis Aphthous Denture-related Herpetic Smokeless tobacco keratosis Submucous fibrosis Ulceration Riga–Fede disease Verruca vulgaris Verruciform xanthoma[en.wikipedia.org]
Angioedema
  • Mucoepidermoid carcinoma Sclerosing polycystic adenosis Sialadenitis Parotitis Chronic sclerosing sialadenitis Sialectasis Sialocele Sialodochitis Sialosis Sialolithiasis Sjögren's syndrome Orofacial soft tissues – Soft tissues around the mouth Actinomycosis Angioedema[en.wikipedia.org]
Dermatitis
  • […] around the mouth Actinomycosis Angioedema Basal cell carcinoma Cutaneous sinus of dental origin Cystic hygroma Gnathophyma Ludwig's angina Macrostomia Melkersson–Rosenthal syndrome Microstomia Noma Oral Crohn's disease Orofacial granulomatosis Perioral dermatitis[en.wikipedia.org]

Workup

Although a patient's medical history and macroscopic appearance of gingival nodes usually prompts a strong suspicion for epulides, it may not be easy to rule out differential diagnoses without further analysis. This applies particularly to eroded or ulcerated epulides, a condition frequently found in patients presenting with EFis. However, such analyses are rarely conducted before surgical excision of the nodular lesion since it is not necessary to define safety margins based on the results of histopathological examination of fine-needle aspirates or biopsy samples. Workup may be different if physical examination implies squamous cell carcinomas or other forms of cancer. The latter require much more aggressive surgical removal and dictate another time schedule.

Histopathological analysis typically reveals hyperplastic lesions with varying cell density (for instance, cell density in EFis and CE is much higher than in EFib), predominance of characteristic cell types (fibroblasts, histiocytes, giant cells and granular cells), possibly infiltration with inflammatory cells and vascularization. Findings indicating neoplasia, i.e., elevated numbers of mitotic figures and chromosomal anomalies, should not be present.

Treatment

Surgical excision is the method of choice for treatment of EFis, EFib and GCE. CO(2) laser radiation has recently been reported as a valuable alternative to traditional surgery [11]. Great care should be taken to achieve complete excision without damaging the underlying dental alveoli, particular in cases of GCE.

In order to avoid recurrence, the cause of chronic irritation should be removed. Replacement of poorly-fitting dentures will prevent relapses; if identification and subsequent removal of the trigger are not feasible, recurrence is likely.

Surgical excision may be indicated in CE. However, if the tumor does not interfere with breathing or feeding, spontaneous remission should be awaited.

Prognosis

Epulides are benign hyperplasias. Prognosis is usually excellent. If a precise cause can be identified, in case of EFis developing in close proximity to possibly ill-fitting dental prostheses, it should be remedied. Otherwise, recurrence of EFis is likely after surgical removal of the initial lesion. Excision is also indicated for EFib and GCE. Since the latter may infiltrate underlying bones, permanent damage to dental alveoli should be considered as a possible complication of this disease [8].

With regards to CE, spontaneous remission has repeatedly been reported [9] [10]. However, if the tumor interferes with breathing and/or feeding, it should be removed instead of awaiting remission.

Etiology

In general, gingival hyperplasia may be induced by chronic mechanical and/or inflammatory stimuli. Formation of EFis can be explained with that hypothesis and are commonly detected in patients who received a dental prosthesis some time ago. An ill-fitting prosthesis causes persistent irritation of the adjacent gingiva and while this may result from insufficient adaption of dentures, most EFis patient don't claim discomfort and epulides until years later [4]. Remodelling processes taking place in the respective dental alveoli may serve as an explanation for that observation: Prostheses may have been well adapted although they are now recognized as poorly-fitting.

Of note, EFis are frequently diagnosed in pregnant women. In these cases, they are designated epulis gravidarum. Its etiology is less clear than that of denture-induced EFis. Elevated levels of progesterone have not yet been related with epulis formation. In contrast, molecular biological analysis of GCE have demonstrated an increased expression of estrogen receptors and it is assumed that this observation explains increased incidence rates of GCE among women in general.

Similarly, additional research is required to clarify etiological factors triggering formation of CE. Presumably, this benign oral tumor originates from odontogenic cells. If excised tumors are analyzed histopathologically, such cells may even be recognized [5]. However, fibroblasts and histiocytes may also give rise to CE [3]. CE typically develop during the second half of pregnancy and may be recognized during prenatal sonographic exams.

Epidemiology

In general, epulides are benign tumor-like lesions that result from hyperplasia rather than from neoplasia. Therefore, mortality associated with epulides is very low. Morbidity may result from epulides being a space-occupying mass that may interfere with breathing, feeding and eating. Most epulides don't reduce the quality of life of the affected individual.

These individuals are preferentially females. Distinct hypotheses have been proposed to explain that observation. On the one hand, hormonal differences between men and women may account for higher incidence among the latter. As has been stated above, GCE have been shown to express estrogen receptors and hyperplasia may be stimulated by such hormones. However, most epulides are diagnosed in patients older than 40 years and post-menopausal women present significantly decreased estrogen levels. This fact argues against the theory of hormonal induction of epulides. On the other hand, post-menopausal changes in osseous structure may account for displacement of dental prostheses and subsequent formation of EFis. Female predilection has also been observed with regards to CE. Here, male-to-female ratios of 1:10 have been reported [3].

Of note, epulides may be diagnosed in patients of any age and have been described in children [6]. Dentures are more frequently worn by the elderly which may partially explain the above mentioned age peak in the second half of life.

Sex distribution
Age distribution

Pathophysiology

Little is known about epulis pathogenesis. While the theory of chronic mechanical and inflammatory stimuli is widely accepted, it does neither explain why distinct types of epulides are developed by different patients nor why epulides form prenatally. Presumably, the hypothesis of persistent irritation is suitable for EFis and granuloma-like variants of epulides, i.e., EFib and GCE. These epulides may be considered macroscopic equivalents of reactive hyperplasia, a concept that has already been proposed for other tissues, particularly for lymph nodes. With regards to CE, enhanced estrogen production by female fetuses had once been proposed, but resected epulides don't necessarily express receptors for these hormones [7].

Prevention

Because of significant knowledge gaps regarding etiology and pathogenesis of epulides, few recommendations can be given to prevent formation of this type of gingival hyperplasia, with the exception of denture-induced hyperplasia. Here, regular dental examination, realignment or replacement of ill-fitting dental prostheses and general measures to avoid reduction of bone density and osteoporosis may be of help to prevent EFis.

Summary

Epulis describes an isolated tumor-like lesion of the gingiva that usually results from mesenchymal hyperplasia, rarely from epithelial proliferation. Thus, the underlying pathophysiological events are of benign nature. Epulides have to be distinguished from oral neoplasms like squamous cell carcinomas. According to current knowledge, most epulides are induced by persistent mechanical irritation or chronic inflammation of the gingiva or surrounding tissues. However, causes of an individual case of epulis can often not be identified.

Epulides may measure only a few millimeter in diameter or may grow to considerable nodes that measure up to four centimeters. They may be of soft or rather hard texture, differ in color from healthy gingiva or not, and their surface may be smooth or become ulcerated. The medical term epulis is descriptive and does not reveal additional information regarding etiology, histological structure and morphology of the tumor-like lesion. These parameters are used to differentiate between distinct types of epulides:

  • Epulis fissuratum (EFis). Epulis granulomatosa and inflammatory fibrous hyperplasia are synonyms of epulis fissuratum. Sometimes this type of epulis is also referred to as denture-induced hyperplasia and this name indicates its most common cause: a poorly-fitting dental prosthesis [1]. Therefore, EFis are frequently located in close proximity to the neck of a tooth carrying a prosthesis. EFis develop within rather short periods of time.
  • Epulis fibromatosa (EFib) is sometimes described as an own entity, whereas others describe it as a mature variant of EFis.
  • Giant cell epulis (GCE), previously also referred to as epulis gigantocellularis, corresponds to an oral giant cell granuloma. It originates from the periodontal ligament rather than from the gingiva itself. The etiology of this lesion is not known, although local irritation or trauma have been proposed as possible triggers [2]. Molecular biological findings implied that female sex hormones may play a role in GCE pathogenesis. GCE is characterized by rather aggressive growth and possible infiltration of adjacent osseous tissue. GCE are sometimes regarded as a specific form of granulomatous epulides like EFis and EFib.
  • Congenital epulis (CE). While its name only indicates that it's present at birth, CE differs largely from the aforementioned epulides regarding tissue structure. Large polygonal granular cells are typically observed upon histopathological analysis of this type of epulis [3]. CE may also be referred to as congenital granular cell tumor, congenital granular cell fibroblastoma or congenital granular epulis.

Patient Information

The medical term epulis is derived from the Greek language and means "growing on the gums". It is used to describe distinct, benign, tumor-like lesions that are characterized by tissue hyperplasia, i.e., proliferation of cells located within the oral cavity. Epulides are not a form of cancer.

Causes

Little is known about the precise causes of epulides. The most widely accepted hypothesis is that of epulides being a form of reactive hyperplasia: Chronic mechanical or inflammatory stimuli may induce cell proliferation and formation of these nodular lesions. In some cases, an ill-fitting dental prosthesis may act as such as stimulus. However, in most patients, no precise cause can be identified.

Epulides may be diagnosed in patients of any age and may even be present at birth. The latter finding corresponds to what is designated congenital epulis.

Symptoms

Epulides constitute mechanical obstructions. They may cause problems with chewing solid food, eating in general and articulation. In infants, feeding difficulties are often reported and in some cases, large epulides may interfere with breathing.

Otherwise, epulides usually don't cause any complaints.

Diagnosis

Diagnosis is often based on the macroscopic aspect of the nodular lesion. However, histopathological analysis after surgical removal (see Treatment) is recommended to resolve any doubts as to differential diagnoses.

Treatment

Surgical excision is the treatment of choice and is generally associated with an excellent prognosis. If a poorly-fitting denture accounted for epulis formation, it needs to be realigned or replaced.

References

Article

  1. Mohan RP, Verma S, Singh U, Agarwal N. Epulis fissuratum: consequence of ill-fitting prosthesis. BMJ Case Rep. 2013; 2013.
  2. Tandon PN, Gupta SK, Gupta DS, Jurel SK, Saraswat A. Peripheral giant cell granuloma. Contemp Clin Dent. 2012; 3(Suppl 1):S118-121.
  3. Kumar RM, Bavle RM, Umashankar DN, Sharma R. Congenital epulis of the newborn. J Oral Maxillofac Pathol. 2015; 19(3):407.
  4. Coelho CM, Zucoloto S, Lopes RA. Denture-induced fibrous inflammatory hyperplasia: a retrospective study in a school of dentistry. Int J Prosthodont. 2000; 13(2):148-151.
  5. Childers EL, Fanburg-Smith JC. Congenital epulis of the newborn: 10 new cases of a rare oral tumor. Ann Diagn Pathol. 2011; 15(3):157-161.
  6. Ghadimi S, Chiniforush N, Najafi M, Amiri S. Excision of epulis granulomatosa with diode laser in 8 years old boy. J Lasers Med Sci. 2015; 6(2):92-95.
  7. Lapid O, Shaco-Levy R, Krieger Y, Kachko L, Sagi A. Congenital epulis. Pediatrics. 2001; 107(2):E22.
  8. Etoz OA, Demirbas AE, Bulbul M, Akay E. The peripheral giant cell granuloma in edentulous patients: report of three unique cases. Eur J Dent. 2010; 4(3):329-333.
  9. Küpers AM, Andriessen P, van Kempen MJ, et al. Congenital epulis of the jaw: a series of five cases and review of literature. Pediatr Surg Int. 2009; 25(2):207-210.
  10. Kadlub N, Galliani E, Oker N, Vazquez MP, Picard A. [Congenital epulis: refrain from surgery. A case report of spontaneous regression]. Arch Pediatr. 2011; 18(6):657-659.
  11. de Arruda Paes-Junior TJ, Cavalcanti SC, Nascimento DF, et al. CO(2) Laser Surgery and Prosthetic Management for the Treatment of Epulis Fissuratum. ISRN Dent. 2011; 2011:282361.

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Last updated: 2017-08-09 18:22