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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 96-101

Inflammatory and reactive lesions of the orofacial region in an African tertiary health setting


1 Department of Maxillofacial Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Dental and Maxillofacial, Jos University Teaching Hospital, Jos, Nigeria
3 Department of Dental and Maxillofacial Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Submission23-May-2017
Date of Acceptance23-Oct-2017
Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. Benjamin Fomete
Department of Maxillofacial Surgery, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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DOI: 10.4103/smj.smj_35_17

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  Abstract 


Background: Chronic inflammatory and reactive lesions are tumor-like hyperplasia that are produced in association with chronic local irritation or trauma. These proliferations are painless pedunculated or sessile masses in different colors, from light pink to red. The surface appearance is variable from nonulcerated smooth to ulcerated growth, and they from a few millimeters to several centimeters in size. Common examples in the oral cavity include pyogenic granuloma (PG), epulis, traditional clinical name for gingival reactive proliferations, Irritation fibroma, epulis fissuratum, and giant cell granulomas which could either be of peripheral or central origin. Objective: To describe the pattern of inflammatory and reactive lesions of orofacial region. Materials and Methods: A retrospective study of patients attending the oral and maxillofacial clinic between January 2006 and December 2014 was undertaken. Results: One hundred and twelve patients, comprising 61 (54.5%) males and 51 (45.5%) females were seen over the period of study. Their age ranged from 1 to 80 years with a median age of 26.5 years. PG was the most frequently reported lesion accounting for 32 (28.6%). This was followed by nonspecific chronic inflammation (n = 23; 20.5%), epulis/peripheral giant cell granuloma (n = 13; 11.6%), granulation tissue (n = 10; 8.9%), and central giant cell granuloma, (n = 8; 7.1%). Conclusion: The results of the study show that inflammatory and reactive lesions are common in the study population.

Keywords: Giant cell, inflammatory lesions, pyogenic granuloma, reactive


How to cite this article:
Fomete B, Agbara R, Adeola DS, Osunde DO. Inflammatory and reactive lesions of the orofacial region in an African tertiary health setting. Sahel Med J 2019;22:96-101

How to cite this URL:
Fomete B, Agbara R, Adeola DS, Osunde DO. Inflammatory and reactive lesions of the orofacial region in an African tertiary health setting. Sahel Med J [serial online] 2019 [cited 2019 Sep 23];22:96-101. Available from: http://www.smjonline.org/text.asp?2019/22/2/96/260837




  Introduction Top


Chronic inflammatory and Reactive lesions are tumor-like hyperplasia that are produced in association with chronic local irritation or trauma.[1] These proliferations are painless pedunculated or sessile masses in different colors, from light pink to red.[2] The surface appearance is variable from nonulcerated smooth to ulcerated growth, and they from a few millimeters to several centimeters in size.[1] Common examples in the oral cavity include PG, epulis, a traditional clinical name for gingival reactive proliferations, irritation fibroma, epulis fissuratum, and giant cell granulomas which could either be of peripheral or central origin. Although cemento-ossifying fibroma is a reactive lesion, it is traditionally classified under another distinct pathological entity referred to as the fibro-osseous lesions, which is outside the scope of the present study but presented in another study.[3]

Pyogenic granuloma (PG) is a pedunculated or sessile hemorrhagic nodule that occurs most frequently on the gingiva with a strong tendency to recur after simple excision. It is a response of tissue to nonspecific infection.[4],[5] It arises due to minor trauma to the tissue, therefore, making a pathway to nonspecific types of microorganisms. Its surface most especially the ulcerated areas present with colonies of saprophytic organisms.[4],[5] Apart from the gingivae, PG may also be found on the lips, tongue, and buccal mucosa.[4] It is said to be common in females (70%) and 60% occurring between 11 and 40 years.[4] The treatment is by surgical excision.

Giant cell granuloma occurs either as a peripheral exophytic lesion on the gingiva (giant cell epulis, osteoclastoma, peripheral giant cell reparative granuloma) or as a centrally located lesion within the jaw, skull, or facial bones.[6] Central lesions occur preferentially in the mandible, anterior to the first molar, and often cross the midline.[5],[6] Although not normally considered an odontogenic lesion, the fact that it only occurs in the jawbones probably indicates some relationship to the teeth or tooth-bearing structures.[5],[6] It occurs primarily in the anterior parts of the jaws in people in the second and third decades of life, but it has been recorded in all sites at all ages.[6] Radiographically, the central giant cell granuloma can take a number of forms from a well-defined radiolucency, a more ill-defined radiolucency or a multilocular radiolucency. Teeth can be displaced by the lesion, although resorption of teeth is uncommon.[6]

Peripheral giant cell granuloma has trauma implicated in its etiology and chiefly tooth extraction has been pointed out although others such as denture irritation or a low-grade infection may be implicated.[4] It occurs anterior to the molars and presents itself as pedunculated or sessile lesion on the gingivae or alveolar process.[4] It is common in the mandible (55%) than the maxilla (45%) and females (65%) than males (35%).[4]

Both peripheral and central lesions are histologically similar and are considered to be examples of benign inflammatory hyperplasia in which cells with fibroblastic, osteoblastic, and osteoclastic potentials predominate. Peripheral giant cell granulomas are five times as common as the central lesions.[6]

Denture-induced hyperplasia otherwise called epulis fissuratum is a hyperplastic condition of the oral mucosa caused by low-grade chronic trauma from ill-fitting dentures.[7] It is a reactive lesion of the oral mucosa to excessive mechanical pressure on the mucosa.[8] Resorption of residual alveolar bone leads to overextension of denture border which if not attended to causes chronic irritation of the oral mucosa in the region of the sulcus.

Granulation tissue is the result of initial response to a wound and consist of a richly vascular connective tissue.[9] It comprises a dense population of macrophages, fibroblasts, capillary networks, fibronectin, hyaluronic acid, and endothelial cells.[10],[11] Macrophages, fibroblasts, and endothelial cells are interdependent during granulation tissue formation.[10],[11]

The similarity in clinical appearance of chronic inflammatory and reactive lesions to oral neoplastic proliferations makes them an important consideration in the differential diagnosis of oral tumors. The aim of this study was to determine the frequency and distribution of chronic inflammatory and reactive lesions involving the orofacial region in our environment.


  Materials and Methods Top


This was a retrospective study of patients attending the oral and maxillofacial clinic of the Ahmadu Bello University Teaching Hospital, Zaria between January 2006 and December 2014 was undertaken. Records of patients were retrieved manually. Data collected were age, sex, site (s), type of lesion, histopathology results where needed, other ancillary results and types of treatment given. Continuous data were presented as percentages and compared using Chi-squared test. A P value < 0.05 was considered significant. Ethical approval was provided by Health Research Ethical Committee of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria (Protocol no ABUTHZHREC/D-U-S 954524802; Date: 10/12/205).


  Results Top


One hundred and twelve patients, distributed as 61 (54.5%) males and 51 (45.5%) females were seen over the period of study. This gives an approximate male to female ratio of 1:1.2. The age ranged from 1 to 80 years with a median age of 26.5 years. PG was the most frequently reported lesion accounting for 32 (28.6%). This was followed by nonspecific chronic inflammation (n = 23; 20.5%), epulis/peripheral giant cell granuloma (n = 13; 11.6%), granulation tissue (n = 10; 8.9%), and central giant cell granuloma, represented by a frequency of 8 (7.1%) [Table 1]. The distribution of the lesions according to gender was not significant (χ2 = 11.941; df = 11; P = 0.368).
Table1:Distributionofinflammatory andreactivelesionsaccording to gender (n=112)

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There was a wide age distribution of the lesions with occurrence across all the age groups represented; but the 21–30 years of age category was the most frequently affected with a frequency of 25 (22.3%). This was followed by the 11–20 years and 31–40 years of age brackets with frequency occurrence of 24 (21.4%) and 23 (20.5%), respectively. The age distribution of other lesions is displayed in [Table 2]. The distribution of the lesions according to age was not significant (χ2 = 93.129; df = 77; P = 0.102).
Table2:Distributionofreactiveandinflammatory lesionsaccordingtoage

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The gingivae were the most frequently involved site accounting for 30 (26.8%). This was followed by the mandible and the tongue each represented by 16 (14.3%), and the maxilla with a frequency of 12 (10.7%). The orbit and upper buccal sulcus were the least involved sites with a frequency of 1 (0.9%) each. The distribution of the granulomatous lesions according to site was significant (χ2 = 173.159; df = 121; P = 0.001).

The majority (60%) of the lesions were pedunculated while the rest were sessile. Lesions were ulcerated in about 65% of cases and pain was not a complaint. All our patients had a poor oral hygiene some had (30%) had retained root closed to the lesion. Five of our patients stated that the lesion was present when they were pregnant.


  Discussion Top


In this study, 61 (54.5%) were males and 51 (45.5%) females giving a ratio of 1.2:1 The age ranged from 1 to 80 years with a median age of 26.5 years. PG was the most frequently reported lesion accounting for 32 (28.6%). This was followed by nonspecific chronic inflammation (n = 23; 20.5%), epulis/peripheral giant cell granuloma (n = 13; 11.6%), granulation tissue (n = 10; 8.9%), and central giant cell granuloma, represented by a frequency of 8 (7.1%).

PG [Figure 1] caused 28.6% of inflammatory and reactive lesions. It constituted 6.6% in Skinner et al.[12] study and 30% in South Korea.[13] It appears mostly in children and young adults.[14] In this study, the majority were in the second decade followed by three decades. This agree with Abdulai et al.[15] in Ghana; Al-Shiaty et al.[16] in Egypt and Koo et al.[13] in South Korea. Epivatianos et al.[17] found more females than males with a peak of age in sixth and seventh decades. In our study, there were more males than females which is contrary to the result of Abdulai et al.[15] in Ghana and that of Al-Shiaty et al.[16] who reported more females than males in the ratio of 1.2:1 and 1.5:1, respectively. They advanced hormonal changes in puberty, menopause, administration of contraceptive and pregnancy as reason for high female preponderance. Our result also contrast those of Skinner et al.[12] who found a female predilection in the ratio of 3:2, Saravana[18] who observed 77% females as well as that of Koo et al.[13] from South Korea who similarly reported more female than male. Our male predominance was in agreement with Katamatsu et al.[19] in Japan.
Figure 1: A female patient with pyogenic granuloma

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The most common site of PG was the gingivae with 17 (53.1%) followed by the tongue with 6 (18.7%). This was lower than the 58.33% in Ghana,[15] the 75% in Egypt,[16] and the 83% in India.[18] Skinner et al.[12] also found the gingivae to be the most common site of occurrence. The most common site in Japan[19] was the tongue (69%). Histology reports were as follow: Sections showed fragment of tissue composed of ulcerated stratified squamous epithelium exhibiting marked pseudoepitheliomatous hyperplasia. This overlies some lobules of thin-walled vascular channels that are intensely infiltrated by lymphoplasma cells and polymorphs. Foci of dystrophic calcification and bony trabeculae are noted. The stroma is fibrocollagenised. An occasional reactive multinucleate giant cell is noted.

Treatment of PG includes cryosurgery, surgical excision, shave excision, or curettage followed by electrocauterization. A recurrence rate of 3.7%–5.8% when treated by surgical excision has been reported.[19]

Nonspecific chronic inflammation caused 20.5% of inflammatory and reactive lesions in this study. It constituted 14.2% in Skinner et al.[12]'s study. Males were affected more than females in the ratio of 1.3–1 (M:F; 1.3:1) with a peak in age at the 4th decade of life followed by 1st and 3rd.

Histology report was that of a section showing tissue fragments composed of fibroconnective tissue showing numerous mononuclear infiltrates including plasma cell, macrophages, and multinucleated giant cell with few thin wall vascular channels admix bony trabeculae.

Giant cell granulomas occurring within the bone are called central giant cell granuloma while those occurring on edentulous alveolar processes or gingivae are called peripheral giant cell granuloma.[6],[20] Peripheral giant cell [Figure 2] represented 11.6% of all the lesions in this study which is within the range of 5.1%–43.6%.[20] It was majorly (61.5%) in the 2nd and 3rd decade of life which is contrary to the findings of Patil et al.,[20] 2014 where the majority (40%) was found in the 4–6th decade. It was also found to be more in females than males in the ratio of 1.5–1 (1.5:1) which agrees with the literature.[14],[20] Furthermore, it had a predilection for the mandible (76.9%) compare to maxilla (23.1%), and this again agrees with the literature.[20] About 90% of the cases in this study presented with poor oral hygiene and the size could be as big as shown in [Figure 2]. Histologically, it presented as a hyperplastic stratified squamous epithelium overlying collagenous tissues infiltrated by dense mononuclear inflammatory cells that extended in areas into the overlying mucosa with granulation tissue formation. Features were consistent with those of epulis.
Figure 2: A female patient with peripheral giant cell granuloma showing biopsied site

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Treatment varies from conventional to cryosurgery using liquid nitrogen or cryoprobe and lasers.[20] In our center, conventional method with saucerization and removal of the irritant has been used with a recurrence rate of 10%. This is within the range (5.0%–70.6%) of recurrence reported in the literature.[20]

Central giant cell granuloma constituted 7.1% of all the lesions in this study, common in the 3rd decade followed by the 2nd decade without sex predilection. According to Vasconcelos et al.,[21] the lesion has a female predilection, and it is common below 30 years. The age of occurrence agrees with our findings in which 75% occurred below 30 years. The mandible was the predominant site with 62.5% which agrees with Vasconcelos et al.[21] Plain radiographs were taken by our patients and about 62.5% showing multilocular radiolucencies with perforation of bone. Histologically, it presented as a tumor composed of numerous osteoclast-like multinucleate giant cells embedded diffusely within a cellular fibrovascular stroma. Areas of old hemorrhages and fibrosis are noted. The features are those of a giant cell lesion of the jaw and central giant cell was favored. Treatment done on our patients ranged from conservative curettage to resection depending on the behavior of the lesion. This agrees with the recommended modes of treatment in the literature.[21]

Fibroma constituted 5.4% with a male predominance of 2-1 (2:1) and an age decade which peaks at 5th followed by 1st decade. Fibroepithelial polyps are pedunculated fibrohyperplastic lumps arising from the mucous membrane lining the oral cavity.[14] They represented 4.5% and common in females in the ratio of 1-1.5 (M:F). They may develop on the cheek, lip, tip of the tongue, and hard palate.[14] In this study, they were more from the nasal mucosa (3 cases) followed by the mandible and hard palate (1 each). Treatment is by excision and closure with interrupted sutures.

Hamartomas are commonly observed in lung, pancreas, spleen, liver, and kidney. They are rare in the head and neck region.[22] Within the oral cavity, indigenous tissues that might result in hamartomatous growths include odontogenic and nonodontogenic epithelial derivatives, smooth and skeletal muscle, bone, vasculature, nerve, and fat.[23] In the present series, hamartoma comprised 3 (2.7%) of the cases and was found predominantly in male. It occurred twice in the maxilla than the mandible. Microscopy was that of a section showing fragments of tissue composed of disorganized lobules of mature adipocytes entrapped within fibrocollagenous and skeletal muscle tissues. There are numerous vascular channels with associated perivascular inflammation.

Granulation tissue made up 8.9%, more in males than females in the ratio of 3-2 (M:F) and expanded from 1st to 4th decade of life with a pick at the 4th decade. They were found in a patient who had disturbances in their wound healing. The histology was that of tissues composed of proliferating thin-walled vascular channels containing RBC (red blood cell). The stroma is edematous with marked infiltration of inflammatory cells predominantly lymphocytes, plasma cells, and polymorphs.

Epulis fissuratum (Denture-induced hyperplasia) may be the result of ill-fitting dentures, poor oral hygiene, wearing dentures all day and all night, smoking, age-related changes, and systemic conditions. Irritation and trauma to the palatal salivary glands and inappropriate relief chambers in dentures are also considered as etiological factors.[8] In contrast to the commonly reported female predilection,[24],[25] more male occurrence was seen in the present study. This study, being retrospective, is constrained by missing data.


  Conclusion Top


The results show that inflammatory and reactive lesions are common with pyogenic granuloma, non-specific chronic inflammation and peripheral giant cell granuloma being the frequent types in the study population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Seward GR, Harris M, McGowan DA. Pyogenic granuloma. Swellings of the oral mucosa. Soft tissue swellings of the oral mucosa. Killey and Kay's Outline of Oral Surgery: Part 1. 2nd ed. Indian Edition. Dadar, Bombay: Varghese Publishing House, Hind Rajasthan Building; 1992. p. 301-2.  Back to cited text no. 14
    
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  [Full text]  
21.
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Allon I, Allon DM, Hirshberg A, Shlomi B, Lifschitz-Mercer B, Kaplan I, et al. Oral neurovascular hamartoma: A lesion searching for a name. J Oral Pathol Med 2012;41:348-53.  Back to cited text no. 23
    
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Macedo Firoozmand L, Dias Almeida J, Guimarães Cabral LA. Study of denture-induced fibrous hyperplasia cases diagnosed from 1979 to 2001. Quintessence Int 2005;36:825-9.  Back to cited text no. 24
    
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Veena K, Jagadishchandra H, Sequria J, Hameed S, Chatra L, Shenai P, et al. An extensive denture-induced hyperplasia of maxilla. Ann Med Health Sci Res 2013;3:S7-9.  Back to cited text no. 25
    


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