Oral cavity & oropharynx
Inflammatory / immune mediated (noninfectious)
Inflammatory fibrous hyperplasia
Author: Abberly Lott Limbach, M.D.
Editorial Board Member: Molly Housley Smith, D.M.D.
Deputy Editor-in-Chief: Kelly Magliocca, D.D.S., M.P.H.
Last author update: 24 July 2024
Last staff update: 24 July 2024
Copyright: 2019-2024, PathologyOutlines.com, Inc.
PubMed Search: Oral cavity inflammatory fibrous hyperplasia
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Lott Limbach A. Inflammatory fibrous hyperplasia. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/oralcavityinflamfibroushyperplasia.html. Accessed December 26th, 2024.
Definition / general
- Reactive inflammatory fibrous hyperplastic lesion that can be the result of chronic irritation, most frequently due to ill fitting dentures
Essential features
- Benign reactive inflammatory hyperplastic lesion that is the result of chronic irritation
- Histologically is composed of squamous mucosa overlying a dense collagen proliferation with focal chronic inflammation
- It is most commonly associated with ill fitting dentures
Terminology
- Epulis fissuratum, denture epulis, fibroepithelial hyperplasia, fibrous hyperplasia, fibroepithelial polyp, fibroma, fibrous epulis (Head Neck Pathol 2019;13:103, Tex Dent J 2009;126:172)
ICD coding
- ICD-10: K13.6 - irritative hyperplasia of oral mucosa
Epidemiology
- Middle aged and older adults, female predominance (Acta Histochem 2016;118:451, Head Neck Pathol 2019;13:103, Oral Surg Oral Med Oral Pathol 1974;37:401, Quintessence Int Dent Dig 1984;15:699)
- Denture wearers (Oral Surg Oral Med Oral Pathol 1974;37:401, Quintessence Int Dent Dig 1984;15:699)
Sites
- Oral cavity: gingiva, alveolar ridge (J Oral Maxillofac Pathol 2014;18:S86, Oral Surg Oral Med Oral Pathol 1974;37:401)
Pathophysiology
- Chronic trauma / irritation leading to exaggerated tissue repair with accumulation of collagen in the submucosal connective tissue (Acta Biomed 2022;93:e2022219, Med Oral Patol Oral Cir Bucal 2019;24:e305)
Etiology
- Chronic trauma (Tex Dent J 2009;126:172)
- Poorly fitting dental prosthesis (Oral Surg Oral Med Oral Pathol 1974;37:401, Med Oral Patol Oral Cir Bucal 2019;24:e305)
Clinical features
- Either single or multiple folds of flesh colored tissue (Tex Dent J 2009;126:172, Head Neck Pathol 2019;13:103, Oral Surg Oral Med Oral Pathol 1974;37:401)
- May be ulcerated (Tex Dent J 2009;126:172, Head Neck Pathol 2019;13:103, Oral Surg Oral Med Oral Pathol 1974;37:401)
Diagnosis
- Clinical diagnosis based on clinical features (folds of tissue) and the presence of a poorly fitting denture (Oral Surg Oral Med Oral Pathol 1974;37:401, Quintessence Int Dent Dig 1984;15:699)
Prognostic factors
- Benign lesion; does not recur if the irritation is resolved (Tex Dent J 2009;126:172)
Case reports
- 58 year old man with epulis fissuratum (SAGE Open Med Case Rep 2021;9:2050313X211063135)
- 70 year old woman with epulis fissuratum (Pan Afr Med J 2022;41:49)
- 81 year old man with epulis fissuratum (Clin Case Rep 2021;9:e04440)
- Case series of histopathologic findings of epulis fissuratum (Oral Surg Oral Med Oral Pathol 1974;37:401)
Treatment
- Surgical excision of tissue and remake or reline of ill fitting denture
- Submission of excised tissue is recommended, as malignancies (e.g., metastatic or primary) rarely may clinically mimic denture epulides
Clinical images
Contributed by Michael Piepgrass, D.M.D.
Redundant soft tissue folds
Images hosted on other servers:
Hyperplastic tissue maxillary alveolar ridge
Hyperplastic tissue mandibular alveolar ridge
Gross description
- Mucosal covered tissue with tan-white cut surface
Gross images
Images hosted on other servers:
Mucosal covered fibrous tissue
Microscopic (histologic) description
- Hyperplastic keratinized squamous mucosa overlying dense nodular connective tissue and variable inflammatory infiltrate (Acta Histochem 2016;118:451, Head Neck Pathol 2019;13:103)
- Underlying connective tissue is variably collagenized with scant bland spindled fibroblasts (Head Neck Pathol 2019;13:103)
- Pseudoepitheliomatous hyperplasia or secondary candidal colonization may be present
Microscopic (histologic) images
Contributed by Abberly Lott Limbach, M.D.
Squamous mucosa lined polypoid tissue
Squamous mucosa with chronic inflammation
Squamous mucosa, chronic inflammation and fibrosis
Squamous mucosal lined polypoid structure
Polypoid mucosal lined fibrous tissue
Sample pathology report
- Mandibular alveolar ridge, excision:
- Inflammatory fibrous hyperplasia (epulis fissuratum)
Differential diagnosis
- Pyogenic granuloma:
- Also known as lobular capillary hemangioma
- Pedunculated ulcerated gingival mass that bleeds easily
- Histologically a vascular proliferation resembling granulation tissue with surface ulceration
- Peripheral giant cell granuloma:
- Reactive lesion caused by irritation or trauma
- Histologically numerous multinucleated giant cells
- Background of ovoid to spindle shaped cells with extensive hemorrhage
- Drug induced gingival hyperplasia:
- Can be caused by calcium channel blockers, antiseizure meds or cyclosporine
- Can look identical to a denture epulis
Board review style question #1
A 50 year old woman presents with excessive tissue surrounding her denture (see image above). What is the best treatment?
- Immunotherapy
- Radiation therapy
- Stop all medications
- Surgery followed by revision of denture
Board review style answer #1
D. Surgery followed by revision of denture. This is inflammatory fibrous hyperplasia caused by trauma from the ill fitting denture. Answer C is incorrect because her hyperplasia is not related to medication. Answers A and B are incorrect because immunotherapy and radiation therapy are inappropriate for a benign condition.
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Board review style question #2
A 60 year old woman who wears dentures has excessive tissue removed from her mandible alveolar ridge (see image above). Based on the histology presented, what is the best diagnosis?
- Amyloidosis
- Giant cell fibroma
- Inflammatory fibrous hyperplasia
- Solitary fibrous tumor
Board review style answer #2
C. Inflammatory fibrous hyperplasia. The image shows squamous mucosa overlying a dense collagenous proliferation with focal chronic inflammation. Answer A is incorrect because amyloidosis is an accumulation of an acellular eosinophilic amorphous material in the submucosa. Answer B is incorrect because giant cell fibroma is not related to a history of chronic irritation. Morphologically the submucosa contains numerous stellate fibroblasts that can be multinucleated. Answer D is incorrect because solitary fibrous tumor is a cellular and vascular neoplastic proliferation; it does not have abundant reactive collagen.
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