Epulis

Epulis is a benign tumor and non-neoplastic growth is above the gingiva (interdental papillae) are
derived from the periodontal tissues and periosteum. This can be fibrous epulis, hyperplastic, and
granulatif. In this epulis growth could not be stemmed or so-called sensile and can also stemmed
(peduncullated).
The types of epulis
I. Granulomatous epulis
This epulis occurs from a reaction network granulomatik because of chronic irritation due to residual
roots, caries edge, tumpatan the overhanging, or klamer sharp. Frequency was statistically epulis is
rarely found. Clinical picture is of a reddish color dungkul stemmed with or about the same as the
granular surface, soft consistency can be accompanied by tenderness and sometimes can diseratai
an ulcerated. Digingiva most locations but can also occur throughout the oral cavity, such as the
lower lip, tongue and palate On histological examination showed epithelial coated dungkul inlaid
under which consisted of granulation tissue with proliferation of capillaries and connective tissues of
young and sebukan chronic inflammatory cells. Elimination of the causes and excision can give a
good prognosis for this type of epulis perwatan.
II. Epulis fissuratum
a. Definition
Growth in excess fibrous connective tissue in the mucosa in contact with the edge of the denture is
usually too fixed and suppress mucosa. Epulis fissuratum also often called inflammatory fibrous
hyperplasia, or denture epulis.
This epulis fibrous tissue folds appear as one or more of the vestibule is not accompanied by signs of
inflammation, is painless unless there is secondary infection, fibrous hyperplasia, proliferation of
epithelial / ulcers. Chronic irritation caused by the use of denture inadequate in the long term in this
case due to the base / wing prosthesis. Epulis fissuratum a reactive hyperplastic lesions that chewy
consistency. Histological appearances may vary, and frequency most seemingly benign fibrous. If
there is an inflammatory reaction will appear fibroblasts and vascular proliferation. Mucosal gland
always appear in the specimen and will lead to chronic sialadenitis. Sometimes gland will have a
relationship with lymphoid hyperplasia and ductal papillary hyperplasia. The atrophic or hyperplastic
epithelium and sometimes raises pseudoepitheliomatous hyperplasia. Ulceration can occur at the
base of the folds. Kondroid or bone metaplasia may develop as the emergence of a bump.
The connective tissue growth caused by chronic irritation due to the use of artificial teeth, denture
where the edge of the gums pressing areas bordering the inner cheek (vestibular alveolar mucosa).
The suppression of bone causes the area is constantly changing due to loss of bone, resulting in bone
support for the denture base becomes unstable. This gradually leads to the protrusion of the epulis
fissuratum.

Fig. Epulis fissuratum protrusion which appears to be a vestibule in contact with the edge of the
denture
This condition is most common in older people because the patients in the age group of many who
use denture. However, this problem tends to diminish with the growing technology of dentistry and
the increasing awareness of the patient to maintain the integrity and health of your teeth and mouth
so that dentures will need to be reduced. It seems this condition is more common in women than
men
b. Symptom
Lesions composed of redundant network is generally in the form of pink hyperplastic folds, hard and
fibrous. The inside and outside of lesions separated by basins (groove) in which signifies the place
where the edge of the denture pressing mucosa.
Epulis fissuratum rare in the lingual (tongue facing part), and is more often found in the front of the
jaw (anterior). The lesion size varied. There is a small lesions, but there are also extensive and
involve the whole region mucosa (mucosa vestibule) in contact with the edge of the denture.
Sometimes it can be quite severe irritation causing redness and visible mucosal ulceration,
particularly at the base edge of the basin in which the artificial tooth into contact with mucous.
c. Treatment
These lesions can be removed by excision. In addition, the artificial tooth into the onset of these
lesions should be improved to be able to have good dexterity but puts pressure on the mucosa in
order to prevent a more severe irritation.
Although these lesions are very rarely associated with squamous cell carcinoma, but as a preventive
action should be carried out on a microscopic examination of the excised lesion.
III. Giant Cell epulis
a. Definition
Epulis type is also often referred to as peripheral giant cell granuloma, giant cell reparative
granuloma, osteoclastoma and myeloid epulis. The exact cause is unknown, but is expected to giant
cell epulis occurs in response to an injury. In addition, many cases where patients express surface
receptors for the hormone estrogen, which raised speculation that hormonal influences may play a
role in the development of these lesions.
Epulis gigantoselulare caused by trauma to the gingival soft tissue which can be caused by tooth
extraction, denture irritation, and chronic infections are more common in women and children.
Clinically this can epulis the periodontal tissues or in edentulous ridge areas with varying diameter
sizes between 0.5 to 1.5 even bigger and can also ulcerated this Dungkul wide-stemmed with dark
red to purple, soft consistency and easy bleed so sometimes accompanied by pain. On
histopathologic examination obtained fibroblast cells which is undergoing proliferation and form a
stroma that contains a lot of giant cells of foreign body.
Giant cell epulis can occur at any age but most cases are diagnosed in patients in the age group 40-
60 years, and especially in women.
Image. Giant Cell epulis

insisif teeth on the palatal region
b. Symptom
Lesions appear as enlarged gums that appear in between two teeth, rich vascularity so easily bleed
to the touch and are generally purplish red.
Its size varies, most cases usually less than 2 cm but no case exceed the size of 4 cm diameter. These
lesions can grow into masses of irregular shape that can become ulcerated and bleed easily. In some
cases of giant cell epulis can invade underlying bone so that the picture will be visible radiographic
bone erosion.
c. Treatment
Epulis giant cell treatment involves surgical excision and curettage of bone involved. Teeth adjacent
to the epulis also need to be removed when it is not tenable, or made tartar cleaning (scaling) and
smoothing the root (root planing). Reported recurrence rate of 10% so that the necessary action
excision back.
IV. Congenital epulis
a. Definition
The cause of the occurrence of congenital epulis is uncertain but scientists believe that the epulis is
derived from primitive mesenchymal cells that originate from the neural crest.
This is the type of epulis congenital condition that is very rare, and occurs in infants at birth. Of the
research found that congenital epulis more common in babies of women than men with a ratio of
8:1, and most occur in the maxilla (upper jaw) than the mandible (lower jaw).

Image. Baby girl with congenital epulis, which was first reported case in 1871 and up to now only
about 200 incidents have been reported.
b. Symptom
In the newborn baby bulge mass found in the mouth, usually on the upper jaw bone anterior (front).
10% of reported cases, lesions which occur are multiple lesions but can also be a single lesion. Lesion
size varied from 0.5 cm to 2 cm, but there are cases where the size of epulis reach 9 cm. This lesion
soft, stemmed and sometimes in the form of lobes of the alveolar mucosa. When epulis is too large,
it can disrupt the respiratory tract and make it difficult for the baby while feeding.
Histologically, congenital epulis similar to granular cell tumor that occurs in adults. The difference
was not recurrent and congenital epulis not seem potentially lead to malignancy. This disorder can
be found at an early stage when the mother checked the content through tools sonography but a
definitive diagnosis can not be enforced.
c. Treatment
In most cases, epulis tend to shrink and disappear by itself when the baby reaches the age of about 8
months. Thus the small-sized lesions do not require treatment. Larger lesions can interfere with
breathing and / or breastfeeding so that unnecessary surgery with general anesthesia. Reported the
successful use of carbon dioxide laser to operate on a large epulis lesions. Of existing cases, this
incident does not seem to interfere with the process of tooth growth.
V. Epulis Gravidarum (Tumor Pregnancy)
a. Definition
Epulis gravidarum is a growing reaction granulomatik tissue of the gums during pregnancy. This
tumor is a benign proliferative lesions in the oral soft tissues incidence ranging from 0.2 to 5% of
pregnant women.
This type of epulis expanding rapidly, and it is likely recur in subsequent pregnancies. Pregnancy
tumors are usually present in the first trimester of pregnancy, but there are patients who reported
this incident in the second trimester of pregnancy. Rapid development in line with the increase in
estrogen and progesterone during pregnancy. Greater influence of progesterone on the
inflammatory process / inflammation. Gingival enlargement will decrease the 9th month of
pregnancy and the few days after giving birth. The situation will be back to normal as before
pregnancy.
Epulis gravidarum appears as a bulge on the gingiva with a variety of colors ranging from pink, dark
red to purplish-colored papules, most often found in the anterior maxillary gingiva. Generally,
patients do not complain of pain, but these lesions bleed easily when chewing or brushing teeth. In
general, this lesion diameter not more than 2 cm but in some cases reported that lesion size is much
larger, making it difficult patient clenched lips. Factor causes epulis gravidarum can be divided into 2.
That is the cause of primary and secondary causes:
a. Primary causes
Local irritants like plaque is the primary cause of epulis gravidarum as well as in non-pregnant
women, but hormonal changes that accompany pregnancy can aggravate inflammatory reactions by
local irritation of the gums. The local irritation is calculus / plaque that has undergone calcification,
leftover food, poor fillings, dentures that are less good.
b. Secondary causes
Pregnancy is a physiological condition that causes hormonal balance changes, particularly changes in
the hormones estrogen and progesterone. Increased concentrations of the hormones estrogen and
progesterone during pregnancy have varied effects on the network, including the widening of blood
vessels resulting in increased blood flow to the gingiva becomes red, swollen, and bleed easily.


Image. Epulis gravidarum in pregnant women
b. Symptom
The pregnancy tumor appears as a bulge on the gums with a variety of colors ranging from pink, dark
red to purplish-colored papules, most often found in the upper jaw. Generally, patients do not
complain of pain, but these lesions bleed very easily when chewing or brushing teeth. In general, this
lesion diameter not more than 2 cm, but in some cases reported that lesion size is much larger,
making it difficult patient clenched lips.
c. Treatment
Generally, these lesions will shrink and disappear by itself as soon as the mother had the baby, so
the treatment is associated with lesions should be postponed until after delivery unless there is pain
and bleeding continues to occur that interfere with optimal tooth brushing and daily routine.
But in cases where epulis persisted after the baby is born, the lesions required biopsy for histological
examination. Spontaneous recurrence was reported in 75% of cases, after 1 to 4 months after giving
birth.
When a large bulge mass and disrupt mastication and speech, the bulge can be removed with a
conservative surgical excision. But sometimes this pregnancy tumor can be removed with Nd: YAG
laser because it gives the advantage that a little bleeding.
VI. Angiomatosa epulis (epulis Telangiecticum)
An excessive granulation response is endothelial reaction (proliferation) and the etiology due to
trauma or unknown but suspected as hemangioma gingiva. Said to be an exaggerated response due
to rapid growth, bounded clear, soft spongy consistency, bright red and bleed easily. Angiomatosa
epulis is often in the differential diagnosis with granulomatous epulis and epulis gravidarum.

VII. Epulis Fibromatosa
This epulis occurs in the oral cavity, especially on the edge of the gingiva and is also common in the
cheek and tongue. Etiology derived from chronic irritation that causes hyperplasia of fibrous tissue
reaction. Clinical signs are seen, among others, stemmed, or may not, pale pink, rubbery consistency
and a solid, well defined, solid and sturdy. Epulis is not easy to bleed and painless.

Classification epulis
Based on histopathologic, epulis classified into conditions that mimic tumor as mentioned below:
The conditions that mimic tumor
Verruca vulgaris
Papillary hyperplasia
Limphoepitelial Benign Lesions
Mukokel
Overgrowth of fibrous tissue
Congenital fibromatosis
Santogranuloma
Granuloma piogenikum
Epulis gigantosellulare
Traumatic neuroma
Neurofibromatosis

Diagnosis, Prognosis
For diagnosis epulis to do some checks, as well as supporting both routine examination to determine
prognosis and appropriate treatment plan.
Diagnosis epulis
Epulis Diagnosis is made by anamnesis, clinical examination and radiographic examination,
laboratory and histopathologic. Differential diagnosis of epulis is a benign tumor or other neoplasm
that occurs in the gums such as fibroma, mixoma, mioblastoma and central giant cell tumors.
Anamnesis epulis
Generally, people are not aware of epulis lesions during not cause any complaints in the oral cavity,
but when it becomes larger epulis to interfere with the function of mastication, dental occlusion and
esthetics, new patients feel the need to seek treatment. In some cases, epulis which has been
enlarged and ulcerated can cause pain.

Clinical Examination epulis
Clinical symptoms were found on physical examination epulis is as follows:
a) Mass is a bulge on the gums
b) Localized with firm boundaries
c) Konsistesi hard or soft
d) Can be stemmed or not stemmed
e) Can ulcerated
f) Sometimes berlobus
g) Colored pink to purplish red
h) can bleed spontaneously or on slight trauma
i) The size varies from a few millimeters to several centimeters and can reach a very large size.
Radiography Examination epulis
In patients with epulis radiographic examination to determine the extent of tissue damage and
supporting bone structure. On inspection found some erosion at the edges or tops that are
superficial alveolar bone in the interdental area.
Laboratory epulis
Laboratory tests are done which is taking a biopsy is part of the network that includes pathological
tissue and healthy tissue. The network then fixed with formal saline and sent to the Pathology
section to be diagnosed.

Histopathologic examination epulis
On histopathologic examination found epulis connective tissue covered with squamous epithelium-
lined-cell infiltration of round and spindle-shaped cells and inflammatory PMN cells, leukocytes and
plasma cells. It also found multinucleated giant cells that is the hallmark of giant cell epulis. Some
epulis contains many blood vessels and fibroblast proliferation as well as a number of collagen
fibers.
Examination immunocytochemistry epulis
This can also be done while immunocytochemistry examination, the examination that utilizes
antigen antibody reaction to determine the immune response to an antigen cells.
Prognosis epulis
Epulis prognosis is generally good if the patient always keep his mouth after excision perfect.
Surgical excision is carried out should take up the entire basis of the epulis around the gum tissue
even though derived from alveolar bone periosteum to prevent recurrence.
Gingival tissue overgrowth
(Celsus/Galen: "disease on the gingival surface"; Axhausen: "no epulis without a tooth")
These tumour-like lesions, designated as epulis, are rather:
Due to chronic trauma or inflammation
Usually of connective-tissue origin and only rarely of epithelial origin
Non-neoplastic

Classification
Histopathological classification (Axhausen):
(German-speaking countries)
WHO classification
- Epulis granulomatosa - Pyogenic granuloma
- Epulis fibromatosa - Fibrous hyperplasia
- Epulis gigantocellularis - Peripheral giant-cell granuloma
- Epulis fissurata - Inflammatory fibrous dysplasia
- Epulis gravidarum - Pyogenic granuloma
Pyogenic granuloma
Synonyms: Lobular capillary hemangioma, granulation tissue-like hemangioma, epulis
granulomatosa, epulis gravidarum, granuloma teleangiectaticum, epulis angiomatos
Definition and clinical picture : - Local reactive connective-tissue proliferation of skin and mucosa.
Localised most frequently on the gingival surface or in the vestibule, the tongue, or the cheek. Women
are more frequently affected than men. Marginal periodontitis is of causal significance in its
aetiology; microtrauma is also a possible cause. Often a short case history and a tendency for
recurrence.
Special form: Pyogenic granuloma (Epulis gravidarum)
Morphology : - Broad-based or pedicled red overgrowth with a diameter of a few millimetres to 2 cm
- Frequently superficial ulceration or white coating
- Often bleed when touched
Histology :Granulation tissue with various degrees of inflammation and development of collagen
fibres. In case of prominent capillary proliferation: "Granuloma teleangiectaticum". Strictly speaking,
they are not granulomas.
Treatment : -Surgical removal with resection of periosteum and bone and the affected periodontal
ligaments down to healthy tissue
- In case of relapse: Extraction of the adjacent tooth
Fibrous hyperplasia
Synonym: Epulis fibromatos
Definition and clinical picture
Polypoid, usually broad-based, rough, pale overgrowth of the gingival mucosa; pedicled forms also
occur. Marginal periodontitis and microtrauma can also be significant in the aetiolog
Special forms:
1. I nflammatory fibrous dysplasia
Localisation in the area of the denture flange, often multiple. The surface may be ulcerated.
Aetiology: Ill-fitting denture; inflammation secondary to functional activity (speech and mastication).
2. Traumatic fibromas
Ubiquitous in the oral cavity, often at the level of the occlusal plane. Broad-based or pedicled mucosal
protrusion. Usually reactive, irritative, localised lesions; clinically and histologically similar to
fibromas (true neoplasias)
Histology : Polypoid protruding mucosa, subepithelial nodular and dense deposition of collagen fibre
bundles with sparse small blood vessels, usually without inflammatory infiltrate.
Treatment : Excision (and send for histological examination)
Improvement of the denture fit, if necessary
Peripheral giant-cell granuloma
Definition and clinical picture : Localised on the gingival margin as a dark-red to bluish "epulis";
only occurs on the gingiva; a non-neoplastic, localised, reactive cell proliferation with tendency for
recurrence.
Histology : Histologically analogous to what is referred to as central giant-cell granuloma (the
designation of "peripheral" or "central" depends on their localisation: peripheral =on the gingiva,
central =intra-osseous). Vascular connective tissue, mononucleated cells and multinucleated giant
cells.
Treatment: - Surgical removal with excision of the underlying periosteum and adjacent bone and
affected parts of the periodontal ligaments of the teeth involved in the lesion
- In case of relapse: extraction of the tooth