Epulis fissuratum is a benign

hyperplasia Hyperplasia (from ancient Greek ὑπέρ ''huper'' 'over' + πλάσις ''plasis'' 'formation'), or hypergenesis, is an enlargement of an organ or tissue caused by an increase in the amount of organic tissue that results from cell proliferati ...

of fibrous

connective tissue Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...

which develops as a reactive

lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classifi ...

to chronic mechanical irritation produced by the flange of a poorly fitting

denture Dentures (also known as false teeth) are prosthetic devices constructed to replace missing teeth, and are supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable (removable partial denture or ...

. More simply, epulis fissuratum is where excess folds of firm tissue form inside the mouth, as a result of rubbing on the edge of dentures that do not fit well. It is a harmless condition and does not represent

oral cancer Oral cancer, also known as mouth cancer, is cancer of the lining of the lips, mouth, or upper throat. In the mouth, it most commonly starts as a painless white patch, that thickens, develops red patches, an ulcer, and continues to grow. When on ...

. Treatment is by simple surgical removal of the lesion, and also by adjustment of the denture or provision of a new denture. It is a closely related condition to inflammatory papillary hyperplasia, but the appearance and location differs.

Signs and symptoms

The lesion is usually painless. The usual appearance is of two excess tissue folds in alveolar vestibule/buccal sulcus, with the flange of the denture fitting in between the two folds. It may occur in either the maxillary or mandibular sulci, although the latter is more usual.

Anterior Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...

locations are more common than posterior. Less commonly there may be a single fold, and the lesion may appear on the lingual surface of the mandibular alveolar ridge. The swelling is firm and fibrous, with a smooth, pink surface. The surface may also show

ulceration An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing o ...

erythema Erythema (from the Greek , meaning red) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not assoc ...

. The size of the lesion varies from less than 1 cm to involving the entire length of the sulcus.

Causes

The cause is usually pressure from the flange of a denture which causes chronic irritation and a hyperplastic response in the soft tissues. Women during pregnancy can also present with an epulis, which will resolve after birth. Fibroepithelial polyps,

pedunculated A peduncle is an elongated stalk of tissue. Sessility is the state of not having a peduncle; a sessile mass or structure lacks a stalk. In medicine, a mass such as a cyst or polyp is said to be ''pedunculated'' if it is supported by a peduncle ...

lesions of the palate beneath an upper denture, are associated with this condition. A cobble-stone appearance similar to an epulis fissuratum in a patient without dentures can be diagnostic of

Crohn's disease Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea (which may be bloody if inflammation is severe), fever, abdominal distension ...

. Epulis fissuratum can also appear around dental implants.

Diagnosis

The diagnosis is made clinically, and usually this is clear cut if the lesion is associated with the flange of a complete denture. Tissue

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...

is not usually indicated before removal of the lesion, since the excises surgical specimen is usually sent for

histopathologic Histopathology (compound of three Greek words: ''histos'' "tissue", πάθος ''pathos'' "suffering", and -λογία ''-logia'' "study of") refers to the microscopic examination of tissue in order to study the manifestations of disease. Spec ...

examination and the diagnosis is confirmed retrospectively. Rarely, incisional biopsy may be indicated to rule out

neoplasia A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

, e.g. in the presence of suspicious ulceration. The appearance may also be confused with

pyogenic granuloma A pyogenic granuloma or lobular capillary hemangioma is a vascular tumor that occurs on both mucosa and skin, and appears as an overgrowth of tissue due to irritation, physical trauma, or hormonal factors. It is often found to involve the gums, ...

. The excessive tissue is composed of cellular, inflamed fibrous connective tissue. The appearance of an epulis fissuratum microscopically is an overgrowth of

cells Cell most often refers to: * Cell (biology), the functional basic unit of life Cell may also refer to: Locations * Monastic cell, a small room, hut, or cave in which a religious recluse lives, alternatively the small precursor of a monastery w ...

from the fibrous connective tissue. The

epithelial cells Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellula ...

are usually hyperkeratotic and irregular, hyperplastic rete ridges are often seen.

Classification

Epulis Epulis ( gr, ἐπουλίς; plural ''epulides'') is any tumor like enlargement (i.e. lump) situated on the gingival or alveolar mucosa. The word literally means "(growth) on the gingiva", and describes only the location of the mass and has no fu ...

(literally, 'on the gingiva') is a general term for any

gingiva The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lini ...

l or

alveolar Alveolus (; pl. alveoli, adj. alveolar) is a general anatomical term for a concave cavity or pit. Uses in anatomy and zoology * Pulmonary alveolus, an air sac in the lungs ** Alveolar cell or pneumocyte ** Alveolar duct ** Alveolar macrophage * ...

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

(i.e. lump on the gum). This term describes only the location of a lump and has no implication on the

histologic Histology, also known as microscopic anatomy or microanatomy, is the branch of biology which studies the microscopic anatomy of biological tissues. Histology is the microscopic counterpart to gross anatomy, which looks at larger structures vis ...

appearance of a lesion. ''Epulis'' is also sometimes used synonymously with epulis fissuratum, however other conditions are classified as epulides, e.g. giant cell epulis (

peripheral giant cell granuloma Peripheral giant-cell granuloma (PGCG) is an oral pathologic condition that appears in the mouth as an overgrowth of tissue due to irritation or trauma. Because of its overwhelming incidence on the gingiva, the condition is associated with tw ...

), ossifying fibroid epulis (

peripheral ossifying fibroma A peripheral ossifying fibroma, also known as ossifying fibrous epulis, is “a gingival nodule which is composed of a cellular fibroblastic connective tissue stroma which is associated with the formation of randomly dispersed foci of mineralised p ...

), and

congenital epulis Congenital epulis is a proliferation of cells most frequently occurring on the alveolar ridge of the upper jaw at birth. Less frequently, the mass may arise from the mandibular alveolus. Rare cases can arise from the tongue. This lesion is more ...

Treatment

Treatment is by surgical excision (complete removal) of the fibrous tissue overgrowth and addressing the causative factor to prevent recurrence of the lesion. Other sources suggest that surgical excision may not be required in all cases. Common techniques for removal of the excess tissue include traditional removal with a surgical

scalpel A scalpel, lancet, or bistoury is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, podiatry and various arts and crafts (either called a hobby knife or an X-acto knife.). Scalpels may be single-use disposa ...

, electrical scalpel, or laser excision with a

laser scalpel A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fir ...

, e.g. a

carbon dioxide laser The carbon-dioxide laser (CO2 laser) was one of the earliest gas lasers to be developed. It was invented by Kumar Patel of Bell Labs in 1964 and is still one of the most useful types of laser. Carbon-dioxide lasers are the highest-power continuou ...

, erbium:YAG laser, Neodymium-YAG laser, or

diode laser The laser diode chip removed and placed on the eye of a needle for scale A laser diode (LD, also injection laser diode or ILD, or diode laser) is a semiconductor device similar to a light-emitting diode in which a diode pumped directly with e ...

. The poorly fitting denture can be adapted to fit better (a "reline") or a new denture constructed. Alternatively, the section of flange that is sharp/over-extended can be smoothed and reduced with a drill.

Prognosis

If the causative factor persists, tissue will become more fibrous over time.

Epidemiology

This condition occurs in association with denture wearing, and so those affected tend to be middle aged or older adults. 66-75% are estimated to occur in women. Epulis fissuratum is the third most common reactive lesion that occurs in the mouth, after

and

References

* Kahn, Michael A. Basic Oral and Maxillofacial Pathology. Volume 1. 2001.

External links

{{Oral pathology Conditions of the mucous membranes Oral mucosal pathology