|Year : 2014 | Volume
| Issue : 1 | Page : 41-45
Prevalence of reactive hyperplastic lesions of the gingiva in the Western Indian population
Santosh R. Patil1, Sneha Maheshwari2, Suneet Khandelwal3, Richa Wadhawan1, Santosh Bankur Somashekar4, Abhijeet Deoghare5
1 Department of Oral Medicine and Radiology, Jodhpur National University, Jodhpur, Rajasthan, India
2 Department of Intern, Jodhpur Dental College, Jodhpur National University, Jodhpur, Rajasthan, India
3 Department of Oral Pathology and Microbiology, Desh Bhagat Dental College, Muktsar, Punjab, India
4 Department of Oral and Maxillofacial Surgery, Chattisgarh Dental College and Research Institute, Rajnandgaon, Chattisgarh, India
5 Department of Oral Medicine and Radiology, Chattisgarh Dental College and Research Institute, Rajnandgaon, Chattisgarh, India
|Date of Web Publication||15-May-2014|
Santosh R. Patil
Department of Oral Medicine and Radiology, Jodhpur Dental College, Jodhpur National University, Jodhpur - 342 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Aim: The aim of the present study was to study the prevalence of reactive hyperplastic lesions of the gingiva in the western Indian population. Materials and Methods: A review of biopsy records of localized reactive hyperplastic lesions of the gingiva during the period from September 2007 to December 2013 was conducted from the Department of Oral and Maxillofacial Pathology. The lesions were studied according to the available clinical data regarding patient's age, sex, location, and size of the lesion. Results: The prevalence of reactive gingival lesions was 17.4%. The majority of the lesions were focal fibrous hyperplasia (FFH) (40.9%), followed by pyogenic granuloma (30%) with a female predominance. The lesions were commonly seen during the 2 nd and 3 rd decades of life. The lesions were equally distributed in both the jaws and the anterior region was the most commonly involved site. Conclusion: Focal reactive lesions are rather uncommon lesions of the oral cavity. The present study showed some difference in age and gender distribution, with FFH being the most common lesion in the north Indian population
Keywords: Focal fibrous hyperplasia, gingiva, localized reactive lesions, prevalence
|How to cite this article:|
Patil SR, Maheshwari S, Khandelwal S, Wadhawan R, Somashekar SB, Deoghare A. Prevalence of reactive hyperplastic lesions of the gingiva in the Western Indian population. J Orofac Sci 2014;6:41-5
|How to cite this URL:|
Patil SR, Maheshwari S, Khandelwal S, Wadhawan R, Somashekar SB, Deoghare A. Prevalence of reactive hyperplastic lesions of the gingiva in the Western Indian population. J Orofac Sci [serial online] 2014 [cited 2020 Feb 26];6:41-5. Available from: http://www.jofs.in/text.asp?2014/6/1/41/132585
| Introduction|| |
Overgrowth of the oral cavity soft-tissues often presents a diagnostic dilemma for the clinician since a diverse group of pathologic processes may produce these lesions. These may be the result of any underlying systemic disease, due to certain drugs, local iatrogenic factors or plaque-induced. These may be localized or generalized. Within these different lesions, group of reactive hyperplasias are present which are nonneoplastic in nature and develop in response to a chronic, recurring tissue injury that stimulates an exuberant or excessive tissue repair response. These reactive lesions may present as pyogenic granuloma (PG), fibrous epulis, peripheral giant cell granuloma (PGCG), fibroepithelial polyp, peripheral ossifying fibroma, giant cell fibroma and pregnancy granuloma.  Kfir et al.  classified reactive gingival lesions into PG, PGCG, fibrous hyperplasia and peripheral ossifying fibroma. ,, These lesions are less commonly seen in the cheek, tongue, palate and floor of the mouth. Clinically, the lesions often present as diagnostic challenges, as they are clinically similar to various pathologic processes but possess specific histopathological features.
The aim of the present study was to study the relative prevalence of the focal reactive gingival lesions namely, focal fibrous hyperplasia (FFH), PG, PGCG and ossifying fibrous epulis (OFE) in the western Indian population in relation to gender, age, and site of occurrence and review the clinicopathological features of these lesions.
| Materials and methods|| |
A review of 398 biopsy records of localized reactive hyperplastic lesions of the gingiva during the period from September 2007 to March 2013 from the Department of Oral and Maxillofacial Pathology was conducted. Reports with adequate case histories and of all the age groups were included for the study. Ethical clearance was obtained from the Institutional Ethical Committee. However, edentulous patients and those taking immunosuppressives, anticonvulsants or calcium channel blockers were excluded from the study. The glass slides of the above mentioned lesions were studied and the histological diagnosis was made according to the criteria of Daley et al. to confirm the clinical diagnosis.  The lesions were studied according to the available clinical data from biopsy records regarding patient's age, sex, location, and size of the lesion. Data were analyzed using the Chi-square test and entered using SPSS 12 (SPSS Inc., Chicago, USA). P < 0.05 were considered to be significant.
| Results|| |
The mean age of the patients was 33.5 years with a standard deviation of 13.7 years. A total of 398 reactive hyperplastic lesions were diagnosed from 2277 biopsy records, with a prevalence rate of 17.4%. The majority of the lesions were FFH (40.9%), followed by PG (30%). There were 77 cases of PGCG and 39 cases of OFE. The lesions were predominantly seen in females (222 cases, 55.7%), while 166 cases (44.3%) were seen in males [Table 1]. The ratio of male:female was 1:1.3 which was statistically significant (P < 0.05). OFE was more common in males while all the other three lesions showed a female predominance. The distribution of the lesions according to age is shown in [Table 2]. The lesions were commonly seen during the 2 nd (24.2%) and 3 rd decade (27.3%) of life and least in the older age groups. PG was more common in the 2 nd decade (40 cases) and FFH (43 cases), PCGC (23 cases) and OFE (14 cases) were commonly seen in the 3 rd decade. [Table 3] shows the distribution of the lesions according to the site. The lesions were equally distributed in both the maxilla (186 cases, 46.7%) and the mandible (212 cases, 53.3%) and the mandibular anterior region was the most commonly involved site. PG was most commonly seen in the maxilla (69 cases) while FFH, PGCG and OFE were commonly seen in the mandible (92 cases, 46 cases and 24 cases respectively). The average size of the lesion was 0.5-6 cm. All the lesions were surgically excised and recurrence was noted in 18 cases of PG and six cases of PGCG. FFH and OFE showed no recurrence.
| Discussion|| |
The reactive lesions are commonly observed in the oral cavity due to the high frequency of tissue injuries and are clinically not easily distinguished. A review of 15,783 oral lesions during a 17.5-year period by Weir et al.  in the US found that fibromas, periapical granulomas, mucoceles, and radicular cysts were the most common reactive lesions observed in the oral cavity. It has been shown that 77% of lesions observed in the oral cavity are reactive in nature. , The present study is the largest study in western India of the four histological variants of reactive hyperplastic gingival lesions. Reactive hyperplastic lesions represent the most common oral lesions and reactive gingival lesions rank second in this group of lesions.  According to Peralles et al.  the most reactive gingival lesion is FFH (41%) followed by PG (30%), similar to the findings of the present study (40.9% and 27%, respectively). Reddy et al.  also observed similar results in the north Indian population, but the prevalence was comparatively low (12.6%) when compared with the present study (17.4%). They observed FFH in 57.4% cases and PG in 18.7% cases.
The prevalence of reactive lesions of the gingiva is reported to be rather common with the peripheral fibroma being the most common category (56-61%) followed by PG (19-27%), peripheral ossifying fibroma (10-18%), and PGCG (1.5-7%) based on over 3000 cases studied. , The prevalence of gingival reactive lesions in the present study was 17.4% which is higher than the findings of Effiom et al.  who reported prevalence of 5.6%. While Al-Rawi  had reported prevalence of 15.79%. All of these lesions are more commonly seen in females with only the PGCG having no consistent sex predilection.  This high prevalence in females could reflect a greater concern and compliance toward oral hygiene and the role of female hormones. In the present study, all the lesions except OFE were commonly seen in females. While Ramu and Rodrigues  showed a male predominance for FFH in the south Indian population. The exact reason for this difference is not known, but it may be due to geographical variation.
Focal fibrous hyperplasia is a localized reactive response of the oral mucosa to injury or chronic irritation.  This term was preferred over fibroma, which refers to a benign neoplastic proliferative fibrous connective tissue by Daley et al.  The lesion is a slow growing, painless, firm, nodular mass with a smooth surface.  The prevalence of FFH in the present study was 40.9%, which is higher than the findings of Al-Rawi (21.5%)  and Effiom et al.  (19.4%). It may occur at any oral site, but it is seen mostly on buccal mucosa. It is more commonly seen in the maxilla, as in the present study. It is more common in the 2 nd and 3 rd decade. This finding is consistent with the finding of Al-Rawi.  However, the study of Ramu and Rodrigues  showed a predominance of FFH in the 4 th decade. The lesion is seen in the same age groups, location and with a female predilection as seen in PG. This finding is also evident in the present study and could support the fact that inflammatory or reactive hyperplasia of gingiva may be the same lesion at different stages of histological maturation. Therefore, it can be said that FFH could represent a fibrous maturation of PG in long standing cases.
Pyogenic granuloma was the second most common lesion with a prevalence of 30% and occurring over a wide age range with a peak incidence in the 2 nd decade of life. The lesion was predominantly seen in the females (67 cases) as compared to males (52 cases), similar to the findings of Kfir et al.  and Angelopoulous  and other similar studies. ,, The prevalence of the lesion was low when compared with the findings of Al-Rawi,  who reported a prevalence of 49.2% and Effiom et al.  who reported an even higher prevalence of 57%. The results of the present study were similar to the findings of Ramu and Rodrigues  who showed a prevalence of 35%.
Pyogenic granuloma develops in up to 5% pregnancy. The development of this particular lesion, typical in pregnancy suggests the possible relationship between the gingival lesions and the hormonal condition during pregnancy. The female hormones render the gingival tissue more susceptible to chronic irritation due to plaque and calculus. , The sex hormones manifest a variety of biological and immunological effects, such as enhanced vascular endothelial growth factor (VEGF) production in macrophages, due to estrogen. This effect is antagonized by androgens and may be the reason for the development of PG during pregnancy.  Increased prevalence of PG in the third trimester and the tendency to shrink after delivery indicate a clear hormonal relation in the etiology of the lesion.  The lesion has is also seen commonly in the age group of 11-20 years in males. This may be due to the effect of male sex hormones which reaches the peak during puberty with remarkable poor oral hygiene in this age group. This renders the gingival tissue more prone to develop exuberant tissue growth in response to plaque and calculus. 
Pregnancy epulis on the basis of clinical presentation and histologic appearance is said to represent a PG according to same authors, whereas others believe that this lesion due to the apparent influence of female sex hormones, is unique in itself.  Poor oral hygiene may be a precipitating factor in many patients. The vascular nature and the rapid growth of PG may be due to the effect of some factors like inducible nitric oxide synthase, VEGF, basic fibroblast growth factor or connective tissue growth factor.  The present investigation revealed that PGs were slightly more common on the buccal aspect of mandibular gingiva, which is not consistent with the findings of Al-Rawi  and Ramu and Rodrigues  who showed a maxillary predominance. Anterior areas are more frequently affected than posterior areas. Similar findings were recorded by Vilmann et al. 
Peripheral giant cell granuloma is an exophytic lesion, clinically similar to PG. It can be differentiated histologically due the presence of numerous multinucleated giant cells seen in the gingiva. Its site of occurrence also supports a possible histogenic derivation from superficial periodontal ligament. The prevalence of PGCG in the present study was 19.4%, which was higher than the findings of Effiom et al.  (3.2%), but lower than that of Al-Rawi  (23.58%). The wide age distribution of PGCG in the present study is similar with the previous studies as mentioned in the literature. ,, PGCG appears to have a mandibular site predilection (46 cases) with majority of the cases being reported in the buccal posterior region, similar to previous studies. ,, Kfir et al.  have reported no sex predilection for PGCG, while the present study showed a female predominance (38 cases), similar to the findings of Al-Rawi  and Effiom et al. 
Ossifying fibrous epulis or peripheral fibroma with calcification showed a prevalence of 9.7% which is higher than the findings of Al-Rawi,  who noted a prevalence of 5.66%. It was seen more commonly in males than in females in the present study, as opposed by the findings of other similar studies which showed a female predominance. ,, It was common during the 2 nd and 3 rd decades of life, which is consistent with the findings of previous reported studies. , It has been indicated by Eversole and Rovin  that the loss of periodontium with tooth loss in advancing age could explain the higher prevalence of OFE in the younger age group. They also suggested that the site location of OFE supports a superficial periodontal ligament histogenic derivation. The periodontal ligament contains cementoblasts and osteoblasts, which explains the presence of bone or cementum in OFE.
Although benign in nature these lesions do have a tendency toward recurrence with incomplete removal of the lesion or the local irritants involved at the site. The treatment in each case is surgical excision; however, different treatment modalities may offer better outcomes with less frequency of recurrence. In the present study, 12 cases of PG and two cases of PGCG showed recurrence.
A substantial overlap does exist between the various histological types of reactive gingival hyperplastic lesions. The frequent site of occurrence of these lesions supports the fact that these are the same lesions at different developmental stages. The vascular component of PG is gradually replaced by fibrous tissue over a period of time and diagnosed as a fibrous hyperplasia or fibroma, as suggested by Daley et al.  Al-Rawi  observed that fibrous hyperplasia on the gingiva have similar female predilection, site of occurrence and also occur in the same age as seen in PG. The present study however, did not show a definite age grouping for the various histologic variants. Therefore whether or not the focal reactive gingival lesions represent the same lesion at different developmental stages is questionable.
Hence, it can be concluded that the above mentioned lesions are mucosal responses to chronic low grade irritation caused by plaque, and calculus or any other irritant. It is helpful to know the frequency and presentation of the most common oral lesions in order to develop a clinical impression of such lesions met in practice. The present retrospective study can pose limitations on getting clinical information, since the results are solely based on available laboratory records. Successful treatment involves obtaining an accurate diagnosis through histopathologic identification and analysis, complete removal of the gingival lesion, and addressing the local irritants with follow-up care, as well as dental hygiene maintenance to prevent or treat recurrence.
| Conclusion|| |
The present study indicates some differences in the gender, age, and site distribution among the four reactive hyperplastic lesions. The authors also opine that these lesions are a result of chronic irritation due to plaque and calculus or other irritants. Though these lesions can be differentiated based on the clinical and histologic appearance, yet these are the variations of a single entity which may be influenced by the irritant, duration of the lesion or possible hormonal changes.
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[Table 1], [Table 2], [Table 3]