Fig. 3.15. Fibrous epulis showing osseous metaplasia
The majority of fibrous and fibroblastic lesions within the mouth appear to be reactive rather than neoplastic. They are the most common tumour-like swelling of oral mucosa. Although these lesions are considered to be a response to low-grade irritation, the source of such irritation may not be immediately apparent. Fibroepithelial polyps tend to form smooth nodules or swellings that may be soft or firm and are usually covered by normal, pink mucosa unless ulcerated. The polypoid swellings may be sessile or pedunculated.
Fibrous overgrowths of the gingiva are a type of epulis (lit. - swelling of the gum). They can arise from the interdental papilla or gingival margin and tend to affect the anterior part of the mouth. They can grow to several centimetres in diameter. Fibrous epulides are frequently associated with local irritation from dental calculus, sharp edges of restorations or carious teeth. A very characteristic form of hyperplasia is associated with the edges of loose dentures. Such denture-induced fibrous hy-perplasia has been termed denture granuloma and epu-lis fissuratum. The rocking backwards and forwards of the denture causes extensive overgrowth of fibrous tissue on either side of the edges, or flanges, of the denture. This often leads to the formation of a series of linear folds of hyperplastic tissue and the base of the grooves so formed is often ulcerated by the denture's edge. Other common sites for fibrous overgrowths are along the occlusal line of the buccal mucosa and lateral border of the tongue, and related to spaces where teeth have been extracted.
Microscopically most of these nodules consist of interlacing bundles of sparsely cellular fibrous tissue. The
Fig. 3.15. Fibrous epulis showing osseous metaplasia overlying epithelium is often hyperplastic with irregular rete processes extending sometimes deeply into the underlying fibrous tissue. There may be candidal infestation of the superficial epithelium. The degree of inflammatory infiltration is very variable, but tends to be mild unless there has been ulceration.
The microscopical appearances of fibrous epulides can differ from fibrous overgrowths seen elsewhere in the mouth. They typically show much more evidence of cellular fibroblastic proliferation. These lesions may consist predominantly or focally of a vascular stroma containing plump fibroblasts with large, vesicular nuclei and prominent nucleoli. There can be brisk mitotic activity. Ulceration is common and the lesions are often heavily inflamed. Calcifications are common in fibrous epulides and there may be florid osseous metaplasia or dystrophic calcification (Fig. 3.15). Sometimes the calcified masses are basophilic and they can also be laminated and resemble cementicles. Such lesions have been termed "peripheral ossifying fibromas", but there is no evidence that they are neoplastic or have any relationship with central ossifying fibromas (see Chap. 4). Mineralisation tends to be uncommon in extra-gingival oral fibrous overgrowths.
Most fibrous overgrowths respond to conservative surgical removal, but a minority of fibrous epulides can recur, sometimes repeatedly.
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