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Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 98-103

Incidence of chronic inflammatory hyperplasia and radicular cyst: A rare case report with review of literature

Department of Oral Medicine and Radiology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Date of Submission18-Jul-2018
Date of Acceptance31-Aug-2019
Date of Web Publication13-Nov-2019

Correspondence Address:
Dr. Gadadasu Swathi
Senior Lecturer, Department of Oral Medicine and Radiology, Anil Neerukonda Institute of Dental Sciences, Sangivalsa, Thagarapuvalasa, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_34_19

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Chronic inflammatory hyperplasia is a reactive soft-tissue lesion. These lesions represent a reaction to some kind of irritation or low-grade injuries such as chewing, trapped food, calculus, fractured teeth, and iatrogenic factors, including overextended flanges of dentures and overhanging dental restorations. Treatment includes surgical excision of lesion and regular follow-up for the recurrence. Radicular cysts are the most common of all jaw cysts and comprise about 52%–68% of all the cysts affecting the human jaws. Radicular cysts arise from the epithelial residues in the periodontal ligament as a result of inflammation. They generally result due to pulpal infection following dental caries. Treatment comprises enucleation of cyst and endodontic treatment of tooth. These are two entities were irrelevant, and occurrence of these two entities in a single individual was an averment of patients' negligence and lack of oral hygiene awareness among patients of lower social economy. A complete case report accompanied with emphasis on hygiene awareness was depicted in this present case report.

Keywords: Diagnosis, inflammatory hyperplasia, prognosis, radicular cyst, treatment

How to cite this article:
Swathi G, Ramesh T, Reddy R. Incidence of chronic inflammatory hyperplasia and radicular cyst: A rare case report with review of literature. Int J Oral Health Sci 2019;9:98-103

How to cite this URL:
Swathi G, Ramesh T, Reddy R. Incidence of chronic inflammatory hyperplasia and radicular cyst: A rare case report with review of literature. Int J Oral Health Sci [serial online] 2019 [cited 2021 Jan 16];9:98-103. Available from: https://www.ijohsjournal.org/text.asp?2019/9/2/98/270879

  Introduction Top

Inflammatory fibrous hyperplasia is an active, inflammatory hyperplastic lesion of the connective tissue. It presents usually as a yellowish-white or mucosal colored, sessile, smooth-surfaced, asymptomatic, soft nodule. The surface may be hyperkeratotic or ulcerated, owing to repeated trauma.[1] Definitive diagnosis is based on the histological analysis to rule out the possibility of lesions that may have a similar appearance, such as pyogenic granuloma, peripheral giant-cell granuloma (PGCG), and peripheral ossifying fibroma.[2] A radicular cyst is generally defined as a cyst arising from epithelial residual (cell rests of Malassez) in the periodontal ligament as consequence of inflammation, usually following the death of dental pulp.[3] Herein, we report a case report of the incidence of inflammatory fibrous hyperplasia and radicular cyst in a 42-year-old male patient.

  Case Report Top

A 42-year-old male patient was reported to the Department of Oral Medicine and Radiology, with a chief complaint of swelling in the right upper tooth region for 1 year. On eliciting the history of present illness, the patient reported that swelling was initially smaller in size, which later increased day by day and reached present size. The patient reported a history of trauma while driving bike, in which one tooth was broken, since then, he noticed development of swelling. Detailed family history was taken which revealed that he was the second born child of his parents. There were no abnormal findings reported among any of the siblings or near relatives. On general examination, all the vital signs were in normal limits. Medical history was noncontributory.

On extraoral examination, solitary diffuse swelling was seen in the right half of face in middle one-third of face which was of size 1 cm × 3 cm roughly oval in shape, extending anteroposteriorly 0.5 cm away from ala of nose to 1 cm away from tragus of ear, superioinferiorly from 1 cm away from outer canthus of eye to 2 cm away from corner of mouth. Skin over swelling is similar to adjacent normal skin. On palpation, it is nontender, firm in consistency. Skin over swelling is pinchable [Figure 1].
Figure 1: Profile (straight and lateral) picture of the patient

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On intraoral examination, hard tissue examination revealed dental caries of 38, 18, 27, grossly decayed tooth of 14, 15, 16, 26, 46, and partially edentulous of teeth 36, 37, 47. On soft-tissue examination, solitary swelling was seen of size 1 cm × 1 cm, oval in shape, extending over buccal vestibule of 15, 14. It was soft in consistency, nontender, and fluctuant in nature [Figure 2]. There was an ulceroproliferative growth seen of size 2 cm × 2 cm in size with irregular margins with indurated border extending 1 cm away from the mesial aspect of 15 to mesial aspect of 17 involving attached gingiva, marginal gingiva, and mucogingival junction and also extending up to palatal surface of 16, 17, 15 with red friable epithelium with necrotic slough with indentations of opposing tooth [Figure 3].
Figure 2: Intraoral swelling

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Figure 3: Intraoral growth developed with the presence of indentations from opposing teeth

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Based on the clinical picture and history given by the patient, provisional diagnosis was given as periapical abscess for swelling and irritational fibroma for which the growth was situated posteriorly.

The patient was subjected to radiographic investigations. Orthopantamograph revealed root stumps in relation to 15, 16, 26, 28, 36, and 46, granuloma in the periapical region of 45, and partially edentulous in relation to 47.37 [Figure 4]. Cone-beam computed tomography was performed in relation to 15 using FOV 6 × 4, which revealed oval-shaped hypodense area in periapical region of 14 with internal structure completely hypodense with partial erosion of buccal cortical plate, there is displacement of 16 root and mild resorption of distal root tip [Figure 5]. The lesion is in close proximity to floor of maxillary sinus. There was evidence of hyperdense area in floor of maxillary sinus, suggestive of maxillary sinusitis. Radiographic diagnosis was given as radicular cyst in relation to 15.
Figure 4: Orthopantamograph of the patient

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Figure 5: Cone-beam computed tomography image of swelling

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Fine-needle aspiration was performed for swelling in relation to 15 reveled blood-tingled fluid [Figure 6]. The histopathological report stated that there is the presence of numerous mixed inflammatory cells predominantly of neutrophils and lymphocytes. In some areas, nucleus of neutrophils showing degenerative changes, few plasma cells, and numerous red blood cells were also found. They gave an impression of infected dental cyst or granuloma [Figure 7].
Figure 6: Straw-colored liquid drawn as fine-needle aspiration from swelling

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Figure 7: Histopathological picture of fine-needle aspiration cytology

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Next step was planned for excision of lesion. The procedure was performed under local anesthesia. Specimens were sent for histopathological report revealing parakeratinized stratified squamous epithelium with varying rete ridges patterns showing spongiosis, acanthosis, and basilar hyperplasia. Dense fibrocellular with inflammatory cell infiltrate predominantly comprising of lymphocytes, plasma cells, macrophages, mast cells, and neutrophils [Figure 8].
Figure 8: Histopathological picture of intraoral growth

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The second specimen revealed that 5–10-layered nonkeratanized stratified squamous epithelium in arcading pattern along with acute inflammatory cells and vacuolated cells. Underlying connective tissue is dense fibrocellular with parallely arranged collagen bundles intermixed with inflammatory cell infiltrate, predominantly comprising of lymphocytes, plasma cells, macrophages, mast cells, and neutrophils. Areas of hyalinization were seen [Figure 9]. On histopathological examination, we arrived to final diagnosis as inflammatory fibrous hyperplasia in relation to 16 and radicular cyst in relation to 15.
Figure 9: Histopathological picture of intraoral swelling

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  Discussion Top

The term “inflammatory hyperplasia” is used to describe a large range of commonly occurring nodular growths of the oral mucosa that histologically represent inflamed fibrous and granulation tissue.[4] The size of these reactive hyperplastic masses may be greater or lesser, depending on the degree to which one or more of the components of the inflammatory reaction and healing response are exaggerated in the particular lesion. On the gingiva, a similar lesion is often referred to as an epulis. It is nearly always a well-defined lesion slowly growing lesion that occurs at any age, but it is most common in the third, fourth, and fifth decade. Females are affected twice as frequently as male.[5] The differential diagnosis of fibrous inflammatory hyperplasia should include consideration of the possibility that the lesion is a true papilloma (a cauliflower-like mass made up of multiple finger-like projections of stratified squamous epithelium with a central core of vascular connective tissue) or a small verrucous carcinoma. Other differential diagnosis includes giant cell fibroma, neurofibroma, PGCG, mucocele, benign, and malignant salivary gland tumor.[1]

Localized overgrowths of fibrous tissues are of frequent occurrence in the oral mucosa. Many of these lesions are true fibromas,[2] whereas some believed that the cause being local irritation as they are reactive in nature.[4] They appear in the interdental papilla as a result of local irritation from calculus; caries or restorations with irregular margins. Approximately 60% of irritation fibromas occur in the maxilla, and they are found more often in the anterior region, with 55%–60% presenting in the incisor-cuspid region.[5]

These lesions are called reactive since they are due to some kind of reaction to low-grade injury, irritation, calculus, improperly contoured, and designed prosthetic appliances or restorations. In early stage, chronic irritant stimulates the formation of granulation tissue later the tissue begins to undergo a process of fibrosis.[6] The presence of irritative factors in the mucosa triggers a chronic inflammatory process leading to the formation of hyperplastic asymptomatic fibrous tissue. Lesion is usually slow-growing and asymptomatic, considered a nonneoplastic cell proliferative increase in response to the action of constant physical agents.[5]

Histologically, it is characterized by an unencapsulated, solid, nodular mass of dense, and sometimes hyalinized fibrous connective tissue. The surface epithelium is usually atrophic but may show signs of continued trauma, such as excess keratin, intracellular edema of the superficial layers, or traumatic ulceration.[7] About 1% of the cases present stellate and giant cells. Similar histological features were seen in both the present cases without ulceration in the surface epithelium with the occasional vascular channel and variable inflammatory infiltrate in connective tissue. The fibroblast is apically narrow and elongated and relatively few. Simple excision is the treatment of choice, and recurrence is unlikely unless the inciting trauma continues or is repeated.[8]

Radicular cysts are the most common odontogenic cystic lesions of inflammatory origin affecting the jaws. They are most commonly found at the apices of the involved teeth, however, they may also be found on the lateral aspect of the roots in relation to lateral accessory root canals. Most of the radicular cyst are symptomless and are discovered when periapical radiograph are taken of teeth with nonvital pulps.[3] The patient often complains of slowly enlarging swellings. Quite often a radicular cyst remains behind in the jaws after removal of the offending tooth and this is referred to as a residual cyst. They are most commonly associated with permanent teeth and are rare in the primary teeth. Radicular cysts are the most common of all jaw cysts and comprise about 52%–68% of all the cysts affecting the human jaws. Actual prevalence of cysts is only about 15% of all apical periodontitis lesions. Their prevalence is highest among patients in their third decade of life, and higher among men than women.[9]

Most of the radicular cysts are symptomless and are discovered when periapical radiographs are taken of teeth with nonvital pulp.[10] The patient often complains of slowly enlarging swellings. At first, the enlargement is bony hard, but as the cyst increases in size, the covering bone becomes very thin despite subperiosteal bone deposition and the swelling then exhibits springiness. Only when the cyst has completely eroded the bone, there will be fluctuation.[11] In the maxilla, there may be buccal or palatal enlargement, whereas in the mandible, it is usually labial or buccal and only rarely lingual. Pain and infection are other clinical features of some radicular cysts. It is often said that radicular cysts are painless unless infected.[12]

Some patients with these lesions, however, complain of pain although no evidence of infection is found clinically and no evidence of acute inflammation is seen histologically after the cyst has been removed.[10] Likewise, some patients have clinically infected and histologically inflamed cysts which are not painful. Occasionally, a sinus may lead from the cyst cavity to the oral mucosa. Quite often, more than one radicular cyst may be found in a patient.[13]

Radiographically, most radicular cysts appear as round or pear-shaped unilocular radiolucent lesions in the periapical region. The cysts may displace adjacent teeth or cause mild root resorption. Radiographically, distinguishing between a granuloma and a cyst is impossible, although some say that if the lesion larger than 2 cm is more likely to be a cyst.[3],[11]

The treatment options for radicular cyst can be conventional nonsurgical root canal therapy when lesion is localized[14] or surgical treatments such as enucleation, marsupialization, or decompression when lesion is large.[15] The choice of treatment may be determined by the factors such as the extension of the lesion, relation with noble structures, origin and the clinical characteristics of the lesion and cooperation and systemic condition of the patient. The treatment of these cysts, in general, is conservative approach by means of endodontic technique. However, in large lesions, the endodontic treatment alone is not efficient and it should be associated to a decompression or a marsupialization or even to enucleation.[14],[15]

Illiteracy and faulty beliefs have led to innumerable oral diseases. Failure to treat these diseases with the right treatment modality, results in the increase in its severity. This case report has expressed concern over the low awareness and poor oral hygiene habits among people, which has resulted in a sharp rise in the dental problems. Preventive dental care is almost nonexistent in the rural areas and very limited in urban areas of developing countries. This can be reinforced by health education and motivation.

The National Oral Health Program, an initiative of the indian dental association (IDA), affirms that oral health is essential for general health and well-being. This program crystallizes the IDA's aim for optimal oral health by 2020, which addresses the “silent epidemic of oral diseases.”[16] The National Oral Health Care Program was launched as a pilot project in 1999, to reduce the increasing morbidity due to orodental problems in the country. The main focus of this program is primary prevention through a generation of awareness. The project was reviewed by the National Institute of Health and Family Welfare in 2004.[17]

The strategies proposed for the 11th 5-year plan include oral health education, formulation of a Basic Package on Oral Health for the country, and its implementation, workforce and infrastructure development and capacity building, and monitoring of dental public health, as well as research, through the National, State, and District Oral Health Cells.

Occurrence of these soft- and hard-tissue lesions in middle-aged patients depicts negligence of the patient. In spite of swelling for 1 year, the patient seeking medical assistance was lacking in this present case. Although these lesions can be conservatively treated, they were found to be in chronic severe condition. Dental awareness of these lesions has to be elicited in all income classes to make these lesions less incident. Oral hygiene awareness programs have to be conducted more in rural areas where people visit a dentist only on the occurrence of pain.

  Conclusion Top

Fibrous hyperplasia is a slowly progressing lesion, the growth of which is generally limited. Many cases will progress for long periods before patients seek treatment because of the lack of symptoms associated with the lesion. Discussion of the differential diagnosis should be done tactfully. Long-term follow-up of the case is required to prevent reoccurrence of the lesion. Since inflammatory hyperplasia is a chronic lesion, local irritants such as calculus and plaque should be removed. Radicular cyst is the result of dental caries leading to pulp death. Dental professionals should provide good counseling to provide awareness of importance of all oral prophylactic techniques that can prevent such conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Effiom OA, Adeyemo WL, Soyele OO. Focal reactive lesions of the gingiva: An analysis of 314 cases at a tertiary health institution in Nigeria. Niger Med J 2011;52:35-40.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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