J. Adv Oral Research CASE REPORT

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Journal of Advanced Oral Research, Vol 2; Issue 3: October 2011 www.ispcd.org

Fibroepithelial hyperplasia: Rare, self-

limiting condition- Two case reports Jammula surya prasanna* Sangeeta Sehrawat

†

*M.D.S, Reader, †Post Graduate student, Department of Periodontics, Panineeya

Mahavidyalaya Institute of Dental sciences & Research Centre, Hyderabad, Andhra

Pradesh, India.

Email: Surya.prasanna@yahoo.com

Abstract:

Objectives: Fibro-epithelial hyperplasia is a

histological variant of fibroma and a proliferative

fibrous lesion of the gingival tissue that causes

esthetic and functional problems. Methods: This

article addresses the diagnosis and treatment of

two cases of fibro-epithelial hyperplasia. Results:

These lesions are a result of trauma/chronic

irritation, or arise from cells of periodontium,

periodontal ligament, or periosteum. Conclusion:

The cases demonstrate the need for awareness, and

role of biopsy and histologic evaluation in

management of these lesions KEYWORDS:

Fibroepithelial hyperplasia, ossifying fibroma,

traumatic , pyogenic granuloma, inflammatory

hyperplasia, neoplasia.

Key words: Oral mucosal lesions, Oral pathology,

Periodontal diseases

Introduction:

Oral mucosa is constantly subjected to

external and internal stimuli and therefore manifests a

spectrum of disease that range from developmental,

reactive, and inflammatory to neoplastic. 1 These

lesions present as either generalized or localized 1, 2

.

Reactive lesions are clinically and histologically non-

neoplastic nodular swellings that develop in response

to chronic and recurrent tissue injury which stimulates

an exuberant or excessive tissue response 3. They may

present as pyogenic granuloma, fibrous epulis,

peripheral giant cell granuloma, fibroepithelial polyp,

peripheral ossifying fibroma, giant cell fibroma,

pregnancy epulis; and commonly manifest in the

gingiva 2,3,4,5,6,7,8,9,10

. Such reactive lesions are less

commonly present in other intraoral sites such as

cheek, tongue, palate and floor of the mouth11, 12

.

Clinically, these reactive lesions often present

diagnostic challenges because they mimic various

groups of pathologic processes. They are clinically

similar but possess distinct histopathological features.

They may be termed 'epulides' when the connective

tissue proliferation which occurs is confined to the

gingiva 13, 14

. According to Romer, 13

the term epulis

was first employed by Galen to designate a tumor on

the gums. The term as used by him applied generally

to any kind of abnormal gingival growth. In more

recent times its use has been restricted, as a rule, to

certain types of growth found in this region of the

oral cavity, although some writers still use the word in

its more general meaning. Reactive lesions of the

gingiva have been classified on the basis of their

histology. 15,16

Kfir et al 8 have specifically classified

reactive gingival lesions into pyogenic granuloma,

peripheral giant cell granuloma, fibrous hyperplasia

and peripheral fibroma with calcification. A report of

more than 30,000 oral biopsies submitted for

diagnosis observed that nearly 13% were taken from

the gingiva. 17,18,19,20

Several authors 10,21,22,23

believed

that many of these lesions are true fibromas, whereas

Cooke 1956 24

believed that, they are reactive in

nature as the cause being local irritation. Barker and

Lucas 196725

examined 650 fibrous overgrowths of

the oral cavity and felt that only 2 could be considered

neoplasms. Daley et al.199013

suggested the term,

focal fibrous hyperplasia” which implies a reactive

tissue response, is preferable to the term, fibroma”

which implies incorrectly, a benign neoplastic

proliferative fibrous connective tissue.26, 27

Fibroma/fibro epithelial hyperplasia:

Almost all lesions in the oral cavity that are

called fibromas are not true neoplasms, but merely

fibrous overgrowths caused by chronic irritation.

Many authors therefore prefer the term fibroepithelial

polyp or fibrous hyperplasia for these type of

lesions26

. Axell (1976)23

encountered prevalence of

Serial Listing: Print ISSN (2229-4112) Online-ISSN (2229-4120) Formerly Known as Journal of Advanced Dental Research Bibliographic Listing : Indian National Medical Library, Index Copernicus, EBSCO Publishing Database,Proquest., Open J-Gate.

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Journal of Advanced Oral Research, Vol 2; Issue 3: October 2011 www.ispcd.org

3.25% for fibromas in the adult Swedish population.

They rarely occur before fourth decade and show no

preference for either sex23

.

Fibroma is the most common oral fibrous

growth. It represents focal fibrous hyperplasia due to

trauma or local irritation. Found in 1.2% of adults, it

is the most common oral mucosal mass submitted for

biopsy and is composed of Types I and III collagen28,

29. Gingival lesions are also common, although they

probably result from chronic infection rather than

trauma 2.The lesion presents as painless, sessile, round

or ovoid, broad-based swelling, lighter in colour than

surrounding tissue due to a reduced vascularity 3.The

surface may be ulcerated and diameter varies from 1

millimeter to several centimeters. Treatment is

surgical excision and a low recurrence rate is expected 30, 31

. Differential diagnosis of fibroma includes: giant

cell fibroma, neurofibroma, peripheral giant cell

granuloma, mucocele, lipoma, or salivary gland

tumor. Histologically, fibroblasts scattered in a dense,

collagenous matrix, mild chronic, inflammatory

infiltrate may be present, but is not a consistent

finding30, 31

.

Irritation fibroma, or traumatic fibroma, is a

common submucosal response to trauma from teeth or

dental prostheses and was first reported in 18469 as

fibrous polyp and polypus. Although at that location

they probably resulted from chronic infection rather

than trauma. A number of variations on the theme of

inflammatory fibrous hyperplasia are mentioned in the

following discussion.

Here we present two cases of fibroma manifesting

as inflammatory hyperplasia rather than a true

neoplastic lesion of connective tissue origin. They

exhibit a proliferative stratified squamous epithelium

different from a classic fibroma where a stretched and

flattened epithelium is observed. Thus, this indicates a

need to differentiate between hyperplasia and

neoplasia for correct therapeutic management.

Case report 1:

A 42 year old male patient (Figure 1) reported

with the chief complaint of swelling in the right front

region of the lower jaw since 5 years which was

unaesthetic and hindered the chewing from lower

front teeth. The swelling started as a small painless

growth 5 years back gradually increasing to the

present size. Medical history was non contributory.

He was a former smoker and had stopped smoking

since 6 years. No abnormality was detected on extra-

oral examination.

Intra-oral examination revealed fair oral

hygiene (OHI-S score 2.6) with Russell’s periodontal

index score 1.56 and moderate gingival inflammation

present near mandibular anteriors. 41, 42 and 43 had a

probing depth of 5mm and 42 had clinical attachment

loss of 2 mm. Interdental gingiva was bulbous and

marginal gingiva rolled in relation to 42 and 43 with

Grade III gingival enlargement. Enlargement was

sessile, ovoid and pinkish with minutely pebbled

surface, extending 2.2 cm buccolingually and 1.5cm

mesio distally (Figure 2). All the inspectory findings

were confirmed with palpation. It was non-tender,

firm, non reducible and non compressible with no

bleeding on probing.

Case report 2:

A 37 year old female patient (Figure3)

reported with the chief complaint of swelling in the

right front tooth region of the upper jaw (Figure 4)

since 4 years, hampering her aesthetics. It started as a

small painless growth 4-5 years back gradually

increasing to the present size. Her medical history was

non contributory. No abnormality was detected on

extra-oral examination. Intra-oral examination

revealed fair oral hygiene. 12 had a probing depth of

4mm with Grade III gingival enlargement. Lesion was

sessile and pinkish with smooth surface extending

1.1cm buccolingually and 2.4cm mesiodistally. All

inspectory findings were confirmed with palpation. It

was firm, non-tender, non-reducible and non-

compressible with no bleeding on probing.

In both the cases cross bite was present in

relation to 12 and 42 with Angle’s bilateral class I

molar relation. Based upon clinical findings, the

lesions were provisionally diagnosed as traumatic

fibroma. Differential diagnosis included inflammatory

hyperplasia and peripheral ossifying fibroma.

Intra-oral periapical radiograph (Figure 5),

and mandibular occlusal view (Figure 6) were taken

which showed moderate amount of bone loss in

relation to 42 and 43 with drifting of these teeth in

case 1 and no bone loss around 12 in case 2 (Figure

7).

Phase I therapy with supragingival scaling

was done. Patients were put on chlorhexidine

mouthwash twice daily for 1 week and were advised

complete blood investigations. All biochemical

investigations Complete Blood Picture (CBP),

Random Blood Sugar (RBS),Human Immuno

deficiency Virus (HIV) I&II-tridot method were

normal. Coronoplasty for lower anteriors with

excisional biopsy (Figure 8) of the lesions was

performed. Amoxycillin 500mg three times a day for

5 days was prescribed to the patients post-operatively.

(Figure 9, 10)

Histopathological examination revealed hyperplastic,

acanthotic parakeratinized, stratified squamous

epithelium (Figure 11) with elongated and

interconnected rete ridges. Underlying connective

tissue consisted of dense collagen bundles,

fibroblasts, blood vessels and inflammatory cells

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Journal of Advanced Oral Research, Vol 2; Issue 3: October 2011 www.ispcd.org

Fig 1: First patient facial view

Fig 2: First patient intra oral view with lesion

Fig 3: second patient facial view

Fig 4: Second patient intra oral view with lesion

Fig 5: First patient Intra Oral Peri Apical X-ray

Fig 6: First patient occlusal view X-ray

(Figure 12) mainly lymphocytes – suggesting “Fibro

epithelial Hyperplasia of Gingiva”

Discussion:

Fibrous growths of the oral soft tissues are fairly

common and include a diverse group of reactive and

neoplastic conditions. Tissue enlargement of the oral

cavity often presents a diagnostic challenge because a

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Journal of Advanced Oral Research, Vol 2; Issue 3: October 2011 www.ispcd.org

Fig 7: Second patient Intra Oral Peri Apical X-ray

Fig 8: Second patient excess ional surgery

Fig 9: First patient post surgical view

diverse group of pathologic processes can produce

such lesions. Within these lesions a group of reactive

hyperplasias which develop in response to a chronic,

recurring tissue injury stimulates an exuberant or

excessive tissue repair response 32

.The term “epulis”

is used clinically to describe any localized overgrowth

Fig 10: Second patient post surgical view

Fig 11: Histological view

Fig 12: Histological view

on the gingiva. Histological examination of epulides

indicates the vast majority are: Focal Fibrous

Hyperplasia (FFH), Peripheral Ossifying Fibroma

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(POF), Pyogenic Granuloma (PG) or Peripheral Giant

Cell Granuloma (PGCG)9.

Multiple polyps of the oral mucosa were described as

early as 1881 by March9. Cooke

24 called all the

pedunculated swelling from a mucosal surface as

“polyp” (fibro epithelial polyp), where maximum

number of lesions occurred on the mucosa in the line

of occlusion, and the entire pedunculated and sessile

lesion in the gingiva as “epulides” (fibrous epulides),

which commonly occurred in the maxillary anterior

region5. In certain cases the histology may reveal the

presence of spindle or stellate cells and

multinucleated giant cells both of which appear to be

of fibroblastic origin. These lesions have been termed

by several authors as “giant cell fibroma”. 33,34

. They

appear in the interdental papilla as a result of local

irritation from calculus, caries or restorations with

irregular margins. Histologically they are

characterized by a focal sub-epithelial mass of fibrous

connective tissue composed of interlacing or parallel

bundles of collagen, containing occasional vascular

channel and variable inflammatory infiltrate. The

fibroblast are apically narrow and elongated and

relatively few in number. Recurrences of this lesion

are uncommon or rare. However Cooke in his review

reported recurrence in 3 cases out of 78 biopsy

specimens.18,24,35

Fibro epithelial hyperplasias are reactive/

inflammatory conditions and they give rise to variety

of lesions named according to their clinical

presentation. For example, pyogenic granuloma or

fibrous epulis is named so due to the vascularity and

presence of ulceration. Most of these lesions arise on

gingiva, reflecting universal presence of inflammation

in the interdental papillae. Lesions are associated with

local predisposing factor like mal-aligned teeth, ill-

fitting restorations or calculus which prevent removal

of bacterial plaque and indirectly induce

inflammation. In both the present cases mal-aligned

teeth and sub-gingival deposits were present

explaining the possible etiologies.3,5,33

Histologically, these lesions vary from rapidly

growing granulation tissue to mature scar –like tissue,

depending on age and vascularity. Lesions are

collagenous, composed of mature fibrous tissue with

prominent vascular pattern. Epithelial changes also

correlate with the lesion’s age and degree of

inflammation. Fibro epithelial hyperplasias when

inflamed are covered by uniformly hyperplastic

epithelium, with arcading rete pattern when ulcerated.

Thin spiky or elongated bilaminar rete processes are

seen which may penetrate deeply into the connective

tissue. This rete hyperplasia is prominent when

marked inflammation is present, but in less inflamed

lesions epithelium becomes regular with flat basement

membrane, or may get atrophied 33

.These hyperplastic

conditions are considered self limiting. But since they

interfere with form and function, they need to be

excised. Also long standing hyperplastic lesions in the

presence of chronic irritation can get converted to

neoplasia 26

.

A substantial overlap exists between the

various histological types of reactive focal gingival

hyperplastic lesions. The frequent gingival site

occurrence supports an assertion that these

hyperplastic lesions are the same lesions at different

developmental stages. Daley et al13

suggested that the

vascular component of pyogenic granuloma is

gradually replaced by fibrous tissue with time and,

hence, diagnosed as a fibrous hyperplasia or fibroma.

In addition, Natheer Al- Rawi 6 observed that fibrous

hyperplasia on the gingiva not only have the same

female gender preponderance but occur in the same

age group and site as gingival pyogenic granuloma.

An inference that fibrous hyperplasia represents a

fibrous maturation of pyogenic granuloma especially

in lesions with long duration was therefore made to

support the assertion.

Identification of any reactive hyperplastic

gingival lesion requires the formulation of a

differential diagnosis to enable accurate patient

evaluation and management. These lesions must be

separated clinically and histologically from

precancerous, developmental and neoplastic lesions.

Differential diagnoses include metastatic tumours in

the oral cavity, angiosarcomas, gingival non-

Hodgkin's lymphoma, Kaposi's sarcoma and

haemangioma. Metastatic lesions in the oral cavity

may be the first indication of an undiscovered

malignancy at a distant site 27

. The clinical appearance

of these lesions in most cases has a striking

resemblance to reactive gingival lesions most

especially pyogenic granuloma. In addition, the

clinical appearance of non-Hodgkin’s lymphoma and

small haemangiomas may also be clinically

indistinguishable. Hodgkin's lymphoma in the gingiva

may present as an asymptomatic reactive gingival

lesion 2,3,7,20

.

Some authors reported that apart from

irritation some drugs can also induce fibro-

hyperplastic gingival overgrowth. George P.et al36

reported six patients with gingival fibrous hyperplasia

associated with cyclosporin A (CyA) therapy. Arvio

P.et al37

reported gingival overgrowth in patients with

Aspartylglucosaminuria (AGU). It is a lysosomal

storage disorder with main symptom as progressive

mental retardation. Of 16 oral mucosal lesions studied

histologically by them, 15 represented fibroepithelial

or epithelial hyperplasias and were reactive in

nature37

.

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Furthermore, the term fibro-epithelial hyper

plasia should not be confused with focal epithelial

hyperplasia which is caused by HPV virus. Focal

epithelial hyperplasia, all alterations occur in the

epithelial layer of the mucosa with virtually no

alteration in the underlying connective tissue38, 39,40

.

The histopathological features are quite distinct but

considerable overlap still exists among these lesions.

Conclusion:

The myriad histological entities that we

observe of reactive hyperplasia may be due to

connective tissue response to varied intensities of

gingival irritation. This response may be influenced

by the serum levels of certain endocrine hormones.

Distinction between hyperplasia and neoplasia needs

to be clearly defined as neoplasias are not self-

limiting conditions and long standing hyperplastic

lesions in presence of chronic irritation can get

converted to neoplasia. In addition to the physical

characteristics of the lesion, the patient’s

demographics, presence of associated symptoms,

related systemic disorders, and location and growth

patterns of the lesion all give clues to adequately

diagnose and treat their typical histopathologic

architecture.

A biopsy will ensure a better and a more ideal

treatment plan for the patient and prevent recurrence

of these lesions. Molecular analysis allows a more

conclusive diagnosis with polymerase chain reaction

(PCR) as a useful tool. Treatment modalities

commonly practised include scalpel surgery,

cryotherapy, cauterization. Laser therapy is currently

being undertaken and would soon become the norm,

as it has many advantages like hemostasis, more

patient comfort and better healing.

Because the condition described here, is of

both epithelial and connective origin, chances that it

may transform into neoplasia are quite high. Further

studies are needed to confirm this hypothesis with

longer follow up of the patients.

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Source of Support: Nil

Conflict of Interest: No Conflict of Interest

Received: January 2011

Accepted: April 2011

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