Removal of hyperplastic lesions of the oral cavity.
A retrospective study of 128 cases
Exéresis de las lesiones hiperplásicas de la cavidad bucal.
Estudio retrospectivo de 128 casos

 

Meritxell Tamarit Borràs ⁽¹⁾, Esther Delgado Molina ⁽²⁾, Leonardo Berini Aytés ⁽³⁾, Cosme Gay Escoda ⁽⁴⁾

(1) Odontóloga. Alumna del Máster de Cirugía Bucal e Implantología Bucofacial.
Facultad de Odontología de la Universidad de Barcelona
(2) Odontológa. Profesora del Máster de Cirugía Bucal e Implantología Bucofacial.
Profesora Asociada de Cirugía Bucal. Facultad de Odontología de la Universidad de Barcelona
(3) Profesor Titular de Patología Quirúrgica Bucal y Maxilofacial. Profesor del Máster de Cirugía Bucal e Implantología Bucofacial.
Facultad de Odontología de la Universidad de Barcelona
(4) Catedrático de Patología Quirúrgica Bucal y Maxilofacial. Director del Máster de Cirugía Bucal e Implantología Bucofacial.
Facultad de Odontología de la Universidad de Barcelona. Servicio de Cirugía Bucal, Implantología Bucofacial y Cirugía Maxilofacial del
Centro Médico Teknon. Barcelona

Address:
Dr. Cosme Gay Escoda.
Centro Médico Teknon.
C/Vilana 12. 08022 Barcelona.
E-mail: cgay@bell.ub.es
http://www.gayescoda.com

Received: 18-11-2003. Accepted: 20-11-2004

 

 

INTRODUCTION

The term "epulis" was first used by Virchoff in 1864, and derives from the Greek words "epi" (over) and "oulon"(gums) (1). Posteriorly, in 1887, Désir de Forturnet defined epulis as any solid tumor lesion located close to the alveolar margin in the absence of lymph node involvement, and with no tendency to ulcerate or generally relapse following total ablation (2). At present, the term "epulis" is not accepted by some authors such as Dechaume (2), Grinspan (3) and Shafer (1) among others, since it only refers to growth over the gums, without specifying the nature of the lesion. In this sense, they consider a histological study to be essential for definitive diagnosis. Borguelli (1) clinically defines epulis as an abnormal, circumscribed and chronic growth located in the region of the gums or close to the alveolar margin. On the other hand, Donado (4) contemplated the term "epulis" from a clinical perspective - defining it as a chronic, granulomatous tumor lesion located in the gums and exhibiting dependency on the periosteum or periodontium.

Epulis is usually classified among the group of benign tumors of the oral mucosa (Figure 1) (1,5-7). However, some authors disagree on this point and prefer to refer to epulis as granulomas - differentiating the lesions into subtypes according to the histological characteristics involved (8). The classification proposed by Anneroth and Sigurdson (9) in 1983 divides epulis into three large groups, based on histological criteria: granulomatous, fibromatous and giant cell lesions. These authors prefer the term "hyperplasia" instead of "epulis", since the latter only designates the topographic location of the lesion. Hyperplasia in turn constitutes an increase in the number of cells present in a given tissue or organ (10). This term comprises all self-limiting lesions produced by some stimulus or irritative mechanism, and that tend to disappear following resection and elimination of the underlying causal factors.

From the clinical perspective these lesions do not possess specific features. In general, oral hyperplastic lesions present a common course, originally manifesting as an intensely red and soft mass of inflamed granulation tissue. Posteriorly, if the causal factor persists, the tissue becomes more fibrous over time (7,11). Differences are in turn observed in terms of the location and consistence of the lesions, and their relation to the surrounding tissues. According to Anneroth and Sigurdson (9), genuine "epulis" is a giant cell lesion - since the latter is the only presentation to manifest exclusively in the gums and alveolar bone. The classification proposed below follows the above mentioned histological criteria (1,9), with some modifications:

1. Granulomatous hyperplasia. This includes epulis in pregnancy, pyogenic granuloma, angiomatous epulis, telangiectatic epulis, capillary hemangioma and hemangioma cavernosum. The histology of these lesions corresponds to low density granulation tissue containing abundant capillaries and more or less intense proliferation of endothelial cells, immature fibroblasts, lymphocytes, plasma cells and polymorphonuclear (PMN) cells. Gingivitis in pregnancy has been excluded, since it does not correspond to a single proliferative lesion located in the gums, and because it does not represent a proprietary entity as such (Figure 2)(12,13).

2. Fibrous hyperplasia. This term comprises fibrous epulis, fissured epulis, fibroepithelial lesions and primary odontogenic fibroma. Histologically, the condition is characterized by dense collagen, with a chronic inflammatory reaction and slight vascularization. It should be pointed out that fissured epulis consists of pseudotumor growth located over the soft tissues of the vestibular sulcus (vestibular fundus), produced by the edges of poorly fitting complete dentures, and with variable degrees of hypertrophy and hyperplasia. The lesion manifests in the form of folds or elongated tissue growths in the region of the mucovestibular sulcus to which the dentures are fitted (Figure 3) (1,3,14).

3. Giant cell hyperplasia. This is represented by peripheral giant cell granuloma. Histologically the condition is characterized by the presence of giant cells similar to osteoclasts and presenting phagocytic activity. These cells are located within a mesenchymal stromal component containing fibroblasts. The giant cells are usually associated to osteoblasts and undergo metaplastic transformation to give rise to osteogenic tissue or osteoid trabeculation. The stroma in turn can evolve towards tissue rich in fibroblasts or osteoblasts (Figure 4).

The prevalence of these lesions is relatively high in the general population, particularly among older individuals. Mallo et al. (15) recorded a prevalence of 12.7% in elderly patients without dentures, versus 8.2% in denture wearers, in a global series of 3282 patients.

The etiology of epulis is multifactorial. In this sense, mention should be made of irritative factors such as chronic gingivitis, periodontal disease, excessive dental fillings, poorly fitting dentures, poor oral hygiene and tobacco smoking. Hormonal influences have also been suggested (during pregnancy, due to an increase in estrogen and progesterone levels), as well as certain blood dyscrasias (anemias or hemostatic alterations) (4,7).

The treatment of these lesions aims to eliminate the underlying etiologic agents, and comprises surgical resection. The present study evaluates and discusses the indications, advantages and inconveniences of oral cavity epulis resection using the carbon dioxide laser (CO₂) versus the Erbium:YAG laser (Er:YAG), diode laser and cold scalpel, and presents our own experience with the treatment of 120 patients (128 hyperplastic lesions).

MATERIAL AND METHODS

In the context of the Master of Oral Surgery and Implantology (School of Dentistry of the University of Barcelona, Spain), a total of 128 lesions (in 120 patients) clinically diagnosed as epulis were surgically removed. The surgical options comprised use of the CO₂ laser, Er:YAG laser, diode laser and the surgical scalpel. While the most commonly used option was the CO₂ laser (108 cases), the other treatment options were also included to afford an improved description of the global series. All removed lesions were subjected to histological study to establish the definitive diagnosis.

Prior to surgery, an anamnesis was compiled and the patients were examined, with documentation of the following data of interest in relation to the oral lesions: patient age and sex, the presence or absence of dentures of some kind, buccodental health, toxic habits, fillings, lesion duration and location, previous resection attempts and, in the case of women, lesions developing during pregnancy. Complementary tests comprised systematic orthopantomography and periapical X-rays of the affected zone to assess the loss of periodontal bone support. The teeth related to the lesion and presenting periodontal problems were rasped, smoothed and polished, or extracted in those cases where the prognosis was poor.

For surgical removal of the lesions using one of the three types of laser system, the teeth in proximity to the target lesion were protected with a plastic instrument (metal instruments are to be avoided, due to the risk of laser beam reflection at the surface, resulting in possible eye and skin damage, for example). The lesions were removed under supraperiosteal and perilesional infiltrating local anesthesia. The anesthetic solutions used were 4% articaine with 1:100.000 adrenalin, or 3% mepivacaine. Following anesthesia of the surgical zone, a laser power rating of 4-6 W was selected, focalizing the beam for mucosal sectioning, and defocalizing when tissue vaporization was required. The surgical specimens were subsequently immersed in 10% formalin solution, processed and stained with hematoxylin-eosin. In general, no antibiotic or antiinflammatory-analgesic medication was prescribed. The patients were advised to use chlorhexidine both as bioadhesive gel applied to the surgical zone and as a mouthrinse - emphasis being placed on the need to maintain good postoperative oral hygiene.

In those cases where resection was carried out with a surgical scalpel, a number 12 blade was used to work the palatal / lingual zone, and a number 15 blade when working on the vestibular side (in all cases using a number 3 handpiece).

Postoperative controls were carried out after 7, 15 and 30 days to evaluate healing and wound evolution, and after 3, 6 and 12 months to assess possible relapse.

RESULTS

The 128 epulis lesions were classified into two large groups according to the clinical and etiopathogenic characteristics involved. Thus, 77 (60.2%) corresponded to gingival hyperplastic lesions and 51 (39.8%) to fibromatous hyperplasia.

Of the 76 patients with gingival hyperplasia, 52 were females (68.4%) and 24 males (31.6%). The mean patient age was 56.7 years (range 10-85 years).

The highest incidence of hyperplastic lesions corresponded to the mandible, with 40 cases (51.9%) - though the difference versus the upper jaw (37 cases; 48.1%) was not statistically significant.

Of the 77 gingival hyperplastic lesions removed, 65 (84.4%) were resected with the CO₂ laser, 11 (14.3%) with the surgical scalpel and 1 with the Er:YAG laser (1.3%). Following exeresis of the lesions, the latter were subjected to histological study. In this sense, fibrous hyperplasia was the most frequent presentation, with 49 cases (63.6%), followed by granulomatous hyperplasia (19 cases; 24.7%) and giant cell hyperplasia (8 cases; 10.4%). Only one malignancy was identified, corresponding to infiltrating squamous cell carcinoma (1.3%). Of the global cases of gingival hyperplasia, 7 were seen to relapse (9.1%). Of these lesions, 5 histologically corresponded to fibrous hyperplasia, and were again removed using the CO₂ laser - with no further relapse to date (Table 1).

On the other hand, of the 44 patients with fissured epulis, 31 were females (70.5%) and 13 males (29.5%), with a mean age of 68.1 years (range 38-84 years). The upper jaw presented the greatest incidence of this type of lesions, with 30 cases (58.8%), while 21 were located in the mandible (41.2%).

Of the 51 lesions treated, 43 (84.3%) were removed using the CO₂ laser, while only 7 (13.7%) were removed with the surgical scalpel. One case was operated upon with the diode laser (2%). Posterior histological analysis showed all these lesions to correspond to fibrous hyperplasia. Relapse occurred in 10 cases (19.6%).

The two groups of lesions treated showed good healing, regardless of the surgical technique used. Relapse, where present, occurred within the first 30 days after removal of the lesions.

DISCUSSION

The terminology used to designate gingival lesions is typically confusing, diverse and nonspecific. In our opinion, and in coincidence with other authors (5,7,9), the term "hyperplasia" is more appropriate, since it refers to tissue growth, probably attributable to an increase in cellularity.

In addition to the term "hyperplasia", mention must also be made of the predominant type of cells or tissues found in the lesion. A detailed clinical description of the lesion is required, as well as determination of the duration of the lesion and the underlying etiological factors - since the greater or lesser chronicity of the lesion in turn conditions the magnitude of the existing fibrous or vascular component. This was confirmed by Zain and Fei (16), who conducted a histopathological analysis of 204 cases of gingival hyperplastic lesions.

On the other hand, the histopathological study of all these lesions is essential, even if the appearance is benign, since only the histological features of the lesion can yield a firm diagnosis (7,14).

Despite the low incidence of metastatic lesions in the jaws and oral mucosa, such lesions represent 1-8% of all malignancies of the oral cavity. Most of them are located within the bone, while 14% are found in the soft tissues - fundamentally the gums (54.8%) and tongue (27.4%). In these cases the primary tumors are usually located in the lungs, breast, kidney, liver and stomach (17-19). In 20.4% of cases, oral metastases are the first manifestation of systemic neoplastic disease. Such lesions can be confused with pyogenic granulomas, fibromas or peripheral giant cell granulomas, among other pathologies, since the clinical appearance is very similar (20-22). The treatment of these metastases is essentially palliative; 70% of the affected patients die within the first year after diagnosis of the oral metastatic disease (17,21). In order to confirm gingival metastasis, the lesion must confirm the following criteria: existence of a primary tumor, histological confirmation of its malignant nature, histopathological similarity between the primary lesion and the gingival metastasis, and the absence of direct contact-extension between the two lesions (17, 23).

In some cases, the dentist may be the first health care professional to detect an oral lesion related to systemic disease. Before deciding any therapeutic measures, complementary tests are required, such as orthopantomography, occlusal X-rays, or a periapical X-ray study to assess the extent and implication of the hard tissues in proximity to the lesion.

On the other hand, in the present study a distinction has been made between gingival hyperplasia of non-prosthetic origin and caused by dentures or fibromatous hyperplasia. This distinction was made because such hyperplasias depend on circumstances such as for example the patient population involved (fissured epulis appearing in elderly subjects and in patients wearing removable dentures) or the underlying causal factor, since although irritation is involved in both cases, patients with gingival hyperplasia do not usually present associated dentures. Fibromatous hyperplasia appears at the margins of poorly fitting and over-extended dentures secondary to alveolar bone resorption and/or incorrect fitting. The lesions are usually exophytic, asymptomatic, often elongated, and present at least one fissure produced by fitting of the denture margins - with tissue proliferation at either side. The most frequently affected location is the anterior region of the upper jaw (Figure 5) (13,14).

A number of surgical options are available for removing gingival hyperplastic lesions. The most widely used are the surgical scalpel, the electrical scalpel, the CO₂ laser, the Erbium:YAG (Er:YAG) laser, the Neodymium:YAG (Nd:YAG) laser, and the diode laser. El Wady et al. (24) have proposed the intra- and perilesional injection of 1,000,000 IU of penicillin G, on the grounds that the antibiotic induces sclerosis and posterior necrosis of the lesion, which ultimately becomes detached. These authors recommend this technique as a complement to surgery, since it seems to avoid relapses.

The CO₂ laser operates at a wavelength of 10,600 nm, and is fully absorbed by water. The CO₂ laser is normally applied without direct contact with the target tissue. On the other hand, the beam can impact in focalized or defocalized form. Beam focalization affords surgical sectioning, while defocalization induces tissue vaporization. Since 80% of soft tissue mass is composed of water, the CO₂ laser beam is intensely absorbed at surface level, i.e., it has limited penetration capacity and is therefore a good surgical option for oral soft tissue treatments (4,25-31). According to España et al. (25), the recommended power rating is 5-10 W in most cases, since higher ratings cause fibrous cicatricial reactions or tissue destruction phenomena.

One of the advantages of surgical removal with the CO₂ laser is the comparatively lesser pain induced during removal of the lesion and in the postoperative period. Laser irradiation causes sectioning and sealing of the nerve endings in the surgical field (32-34), and the thin denaturalized collagen layer formed on the surface of the surgical wound serves to isolate the latter from irritation by the oral fluids (32). Pogrel et al. (35) attributed the lesser postoperative pain to the fact that the inflammatory reaction associated with CO₂ laser application is likewise of lesser intensity, since blood and lymphatic vessel sealing occurs, with prevention of the extravasation of fluids responsible for inflammation and pain (30,32,33,35,36). Komori et al. (37), in a study involving 7 patients, proposed epulis removal using the laser CO₂ without any type of locoregional anesthesia. In our opinion, however, it is better to inject prior perilesional submucosal or supraperiosteal infiltrating anesthesia (25).

Following fibromatous hyperplasia treatment with the CO₂ laser, it is essential to ensure immediate denture fitting. In our Service, fibrous hyperplastic lesions caused by poorly fitting dentures are removed using the CO₂ laser. Posteriorly, the dentures are refitted using a soft tissue conditioner (Viscogel^®). In this way the vestibular mucosa is able to re-adapt to the new situation, while avoiding further loss of vestibular depth. Fisher et al. (32,38) indicate application of the CO₂ laser to fibroepithelial hyperplasias of prosthetic origin located in the vestibular fundus region, since second intention healing was seen to cause scant tissue alteration and little loss of vestibular depth. Other authors (26,27,33,38) coincide that vestibular loss occurs when the surgical wound heals by first intention or when a graft is placed. Pogrel (33,35) applied the CO₂ laser for the resection of hyperplastic tissue caused by poorly fitting dentures in 11 patients, with healing by second intention. The dentures were examined, readjusted and placed immediately after the intervention. Tissue re-epithelization occurred after 14 days. Loss of vestibular depth was 20% after 6 weeks, when the new prostheses were prepared. According to Basu et al. (39), healing of the lesions produced by the CO₂ laser involves the development of a fibrino-purulent membrane after 72 hours, which replaces the superficial necrotic layer of the irradiated tissue. After two weeks, epithelial growth begins at the periphery and covers the wound surface. The epithelium thus formed is thinner and parakeratotic compared with the epithelium formed after excision with the surgical scalpel (32). Pogrel (33) concluded that hyperplasia secondary to poorly fitting dentures should be removed with laser, based on his experience with these 11 patients.

In our study, this type of lesion manifested in patients wearing old and poorly fitting dentures for prolonged time periods. Following lesion removal with the CO₂ laser, denture replacement or re-fitting was recommended. In the cases where relapse was observed (19.61%), the patients had failed to replace or re-fit their dentures.

Abt et al. (30) proposed the CO₂ laser for treating gingival hyperplasia, due to the low relapse rate involved. These authors used this technique to eliminate fissured epulis in the lower left vestibular zone, manifesting as a tissue reaction to over-extended and poorly fitting dentures. The authors also described a case of removal of hyperplastic granulomatous tissue formed as a consequence of the healing of an ulceration caused by lower removable partial dentures. Following excision with a surgical scalpel, the lesion relapsed within a week. Vaporization was therefore decided, under local anesthesia and using the CO₂ laser defocalized at a power rating of 10 W. No posterior relapse was observed.

The United States FDA (Food and Drug Administration) only accepts the use of CO₂, argon and Nd:YAG laser for the removal of soft tissue lesions of the oral cavity (26,28,29). The more recent studies published in the literature make use of the Nd:YAG laser, with a wavelength of 1060 nm, as an alternative to the CO₂ laser for the removal of benign tumors of the oral cavity, since it has great affinity for pigmented tissues with a high protein content (40). Use of the Nd:YAG laser has mainly been confined to medical practice, though Nd:YAG laser systems have also been developed for oral surgery, with a maximum power of 3 W at a frequency of 10-30 pulses per second (each pulse lasting 6 msec.). Due to these short pulses and their low power rating, some authors consider that surgery can be performed without the need for local anesthesia - applying only topical anesthesia in the form of a gel or aerosol (41).

The Nd:YAG laser possess greater mucosal penetrating power than the CO₂ laser, since the latter is absorbed by water, and comparatively less by hemoglobin. Differences between the two systems also exist in terms of the duration of treatment, since the CO₂ laser has great affinity for the oral soft tissue cells, and sections and vaporizes tissue much more easily than the Nd:YAG laser - thereby shortening the surgical time (25,28,40). It is also important to take into account that although the CO₂ laser is approximately half as expensive as the Nd:YAG laser, it is still more costly than conventional surgery (4,41-43).

Another factor to be taken into account is that these lasers produce sterile incision, as a result of which the risk of spreading cancer cells or germs in the wound, or of causing bacteremia, is zero (30,32,33,44,45).

Consideration is also required of the hemostatic effect afforded by the selected surgical technique. In cases where an important vascular component of the lesion is suspected intraoperatively, the electrical scalpel and CO₂ laser are theoretically the instruments of choice, since they afford a bloodless surgical field. However, it must be taken into account that the CO₂ laser is only able to coagulate vessels measuring under 0.5 mm in diameter - i.e., it is useful in the presence of such vessels, but not when larger caliber vessels are involved (33,39-41,46). For this reason, some authors (47) advocate the Nd:YAG or argon laser for removing hemangioma cavernosum, since vessels with a caliber of over 7 mm are effectively coagulated - thus affording good visibility and improved precision in the removal of soft tissues. They recommend power ratings of 20-30 W, with intermittent exposures lasting 0.2-0.5 seconds at a distance of 2-3 cm from the target lesion. In their article, Convissan et al. (34) cite Hylton, who treated a patient with Sturge-Weber syndrome using the Nd:YAG laser, with good control of bleeding. However, Argüero et al. (48) used the CO₂ laser to treat a patient with Rendu-Osler-Weber disease, with satisfactory control of bleeding.

In oral surgery a laser system with lesser application to soft tissues is the Er:YAG laser, which produces rapid healing as a result of the limited lateral thermal effect generated. An inconvenience, however, is that the surgical field is not free of blood (unlike with the CO₂ laser); consequently, upon concluding surgery, compression of the treatment zone is required to ensure adequate hemostasia.

Another treatment option is the electrical scalpel, which used high-frequency alternating current which is rectified and transmitted to a small heat-generating electrode. The heat thus formed is able to section, coagulate and desiccate tissues. The frequencies most commonly used in dental practice are in the range of 2-4 MHz. The effects obtained vary according to the type of current used. Thus, fully rectified and filtered, totally rectified, and partially rectified currents are useful for soft tissue exeresis, since they allow sectioning, sectioning-coagulation, and coagulation, respectively.

It is also important to adequately select the active electrode tip configuration, since the therapeutic effect obtained is largely dependent upon the latter. Thus, for sectioning, use is made of fine needle electrodes, while coagulation makes use of sphere electrode configurations. The advantages offered comprise clean and exact sectioning, rapidity, a bloodless surgical field, and sterile incision (45,47,49).

In the literature examined, Nixon et al. (50). cite Pope, who argues that this type of scalpel induces an increase in osteoclastic activity when incision is carried out very close the periosteum. In the comparative histological study conducted by Nixon et al. (50), an important inflammatory exudate was observed, resulting in a delay in healing - with important implication of the periosteum. However, authors such as Schieda and Eiseman (50) consider that there are no differences between the electrical scalpel and the surgical scalpel.

On the other hand, Convissan et al. (34) contraindicate the use of this instrument when the patient carries some intraoral metallic element, e.g., fixed prostheses, since pulp necrosis of the teeth in proximity to the treatment zone may result. Another contraindication would correspond to patients with old pacemakers, since the electromagnetic waves emitted can interfere with their function. In this context, newer generation pacemakers are coated with material designed to prevent such interferences. The cardiologist treating the patient should always be consulted to determine the kind of pacemaker implanted and the possible associated risks (49).

Based on our experience, we recommend the surgical scalpel in combination with the electrical scalpel, since the former affords more effective and less damaging sections, while the latter ensures improved control of intraoperative bleeding. In addition, the economic costs are relatively low, and the option is a good alternative when no CO₂ laser is available.

All hyperplastic gingival lesions should be treated by eliminating the underlying etiology and removing the lesion. If this protocol is followed, the risk of relapse should be negligible. In our series, 19.6% of all fibromatous hyperplasias relapsed because no immediate denture fitting was performed, or because the patient failed to report for the programmed postoperative controls. As to gingival hyperplasia, the relapse rate was 9.1%. The cause in this case may have been deficient oral hygiene, since the persistence of bacterial plaque is a decisive factor for the relapse of these lesions. If tartar removal with rasping-smoothing and root polishing is carried out, but correct periodontal health is not ensured, then these lesions are very likely to reappear. The only type of lesion described in the literature with a greater tendency to relapse is giant cell hyperplasia (10%) (11). It is therefore advisable to amplify the margins when resecting these lesions. In our series no relapse was recorded.

Fortunately, most of these gingival lesions were seen to be benign - with the exception of a single case of infiltrating squamous cell carcinoma. The present study stresses the need for a detailed clinical history and patient examination - with histological evaluation of all removed oral tissues being an essential consideration for establishing a definitive diagnosis.

Lastly, it can be concluded that the CO₂ laser is a good option for the removal of gingival hyperplasia, and affords multiple intra- and postoperative advantages. Nevertheless, the CO₂ laser should not be viewed as the sole treatment option. Combination of the surgical scalpel and the electrical scalpel also affords intraoperative convenience for the oral surgeon in removing these lesions. Since our patient series was not balanced in terms of the number of cases operated upon with each of the different surgical instruments, we consider that further research is required in patients with such lesions, using different treatment modalities, to adequately assess the advantages and inconveniences of each technique.

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