Inflammatory Hyperplastic Lesions of the Oral Cavity

The causes and the course of the disease

Inflammatory hyperplastic lesions have similar causes like the purpuric macule except that the main insults are normally chronic irritants.  These insulting agents include calculus, sharp-edge cavities, overhanging restorations, overextended denture, sharp extension of bone, and chronic biting of lip and cheek.  The prolonged chronic insults cause the body to produce abnormal healing tissues, called granulation tissues.  Examples of these include pyogenic granuloma, hormonal tumor, traumatic hemagioma, fibroma, epulis fissuratum, epulis granulomatosum, papillary hyperplasia, and peripheral fibroma with calcification.

An inflammatory hyperplastic lesion typically begins as a pile of inflamed granulation tissue.  At this initial stage it appears quite soft and very red.  Later, as more fibrous tissues are formed, the lesion becomes harder and less reddish.  If the irritant is eliminated at this stage, the inflammation disappears and the lesion shrinks noticeably.  The final scar has a pale hue and the tissue gradually returns to its original softness.

The features

 The key features of the inflammatory hyperplastic lesions include: (1) very red; (2) fairly soft; and (3) polypoid or modular masses.  Microscopically, the lesion reveals granulomatous tissue covered with an intact layer of stratified squamous non-keratinized epithelium.   If the covering of the lesion is traumatized, a white necrotic area usually forms in the area of the injury, and the lesion is now considered as a pyogenic granuloma.

The differential diagnosis

Your dentist has to differentiate the early inflammatory hyperplastic lesion from hemangioma, a metastatic tumor, a primary malignant tumor, a papilloma, condylomas, and verrucae.  It is important to note that most inflammatory hyperplastic lesions, in their early stages of development, have some identifiable irritants.  This characteristic irritant strengthens the impression and confirms the working diagnosis.

However, if such irritant is not apparent, the possibility that the lesion is either a primary or second malignant tumor beginning below a normal epithelium should be considered in the differential diagnosis.   A history of medical treatment and symptoms of a primary tumor else where may prompt the possibility of a metastatic tumor. Primary malignant tumors of the oral soft tissue are rare.  Similarly, it is uncommon for a squamous cell carcinoma to appear as a small exophytic red lesion with a smooth un-ulcerated surface. In the case of lesions are located next to the jaw bone, it is most important to differentiate the inflammatory hyperplastic lesions from malignant tumors.

A congenital hemangioma is present from birth, whereas a traumatic hemangioma is really a type of inflammatory hyperplastic lesion.   Papilloma, condylomas, and verrucae are included here for the completeness; however, since inflammatory hyperplastic lesions are red and have basically smooth surfaces, they should be readily differentiated from the epithelial growths that are frequently white with cauliflower-like skins.

The recommended management

Excisional biosy combining with the elimination of the irritant is the treatment of choice for lesions of substantial size.  Some small red lesions may also shrink to a size that precludes treatment when irritant is eliminated.