a rare case of irritation fibroma assosiated with leukoplakia

Archives of Oral Sciences & Research
A RARE CASE OF IRRITATION FIBROMA ASSOSIATED
WITH LEUKOPLAKIA OF ORAL MUCOSA
B Harshavardhana*, SK Rath*, Manish Mukherjee*
ABSTRACT:
Isolated soft tissue enlargements seen in the oral cavity are generally a reactive hyperplasia and rarely neoplastic. Diagnosis
of these enlargements are always a challenge to the dentist. Gingiva is a common site for either neoplastic or non neoplastic
lesions. Non neoplastic lesions are usually inflammatory or represent a reaction to some kind of irritation or low grade
injury.
Oral cavity is an ideal niche for manifestation of various precancerous lesions. Out of these lesions leukoplakia is a very
important one. But it is generally rare to find both the above mentioned lesions at a same time in the oral cavity. This case
report is one such rare manifestation wherein the patient presented to us with both leukoplakia and irritation fibroma and were
subsequently managed successfully.
AOSR 2012;2(1):34-36.
Key Words: Leukoplakia, Irritational Fibroma, Inflammation.
* Div of Periodontology and Oral Implantology, Dept of Dental Surgery, Armed Forces Medical College, Sholapur Road,
Pune, India.
INTRODUCTION:
Diseases of the oral cavity can be either of soft tissue or of
hard tissue in origin. One such manifestation of soft tissue
lesions are the soft tissue tumor. Intraoral soft tissue tumor
like lesion is said to be any pathologic growth that projects
above the normal contour of the oral surface. Different
mechanisms may lead to the development of a soft tissue
tumor like lesion in the oral cavity. The most common
mechanism included reactive hyperplasia and neoplasia.
The great majority of localized overgrowths of the oral
mucosa are considered to be reactive rather than neoplastic
in nature.1 The diagnosis of these soft tissue tumours
have always been a challenge to the dentists. Many of
these lesions are common and relatively characteristic in
presentation, leaving the dentist a very little doubt about the
diagnosis. In certain instances however, unusual findings
may leave the dentist with certain diagnostic uncertainty.2
The localised lesions of the oral cavity have been broadly
documented as: Irritation fibroma, Peripheral osssifying
fibroma, Squamous papilloma, Giant cell fibroma,
Pyogenic granuloma and Peripheral giant cell granuloma.3
The fibroma, is the most common oral fibrous tumor like
growth. Most if not all fibromas represent reactive focal
fibrous hyperplasia due to trauma or local irritation.4
Gingiva is a common site for either neoplastic or non
neoplastic lesions. Non neoplastic lesions are usually
inflammatory or represent a reaction to some kind of
irritation or low grade injury.5
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Leukoplakia is the most common precancerous lesion in
oral cavity. The term Leukoplakia simply means a “white
patch”, and it has been used in a sense to describe any white
lesion in the mouth.6 Tobacco use is the most important
etiologic factor for leukoplakia. WHO in 2005, has defined
of leukoplakia as: “a white plaque of questionable risk
having excluded other known diseases or disorders that
carry no increased risk of cancer”.7 This case report is a
rare one where in both the lesions introduced above were
manifested in the same patient.
Case report:
A 62 years old female reported to the OPD of Department
of Dental surgery, AFMC with a chief complaint of growth
in lower front region and associated white patches in the
lips and cheeks within the oral cavity (Fig 1). On eliciting
the history of the presenting illness, patient was apparently
normal six months back. She initially observed a small
patch in her lower lip which grew in size over a period of
time. There was no associated pain or burning sensation
experienced. Five months before she noticed a small nodule
in the region of lower central incisors. There was associated
bleeding from the lesion especially on brushing.
The medical history given by the patient was that she is a
known diabetic and is presently on Tab Glibenclamide 5
mg twice daily. The past dental history of the patient was
very critical, wherein she gave a history of extraction of
both the lower central incisors three years back and got
Irritational Fibroma Assosiated with Leukoplakia- A Rare Case
the teeth replaced by an acrylic fixed partial denture in a
local civil clinic. The patient also gave information that she
had a habit of mishri (tobacco) for the last thirty five years
and used to place it in the region of both the labial and
buccal mucosa. She had stopped the habit a year back on
the advice of a local doctor.
On extra oral examination, there was no abnormalities
detected and the regional lymph nodes were not palpable.
Intra orally there was presence of a solitary, pendunculated,
pale white coloured lesion originating underneath the
denture and extending both labially and lingually in
relation to the same denture (Fig 2). The lesion measured
roughly 2cm X 1 cm X 1 cm on the labial side and roughly
1.5 cm X 1 cm X 0.5 Cm on the lingual side. The lesion
was mobile, very hard in consistency and did not blanch
on pressure. There was presence of calculus in abundance
underneath the denture. The associated whitish plaque like
lesion extended distally to the third molars on both the sides
and covered the entire lower labial mucosa. Bilaterally it
extended superiorly from the mid buccal portion to the
depth of the vestibule and further extending to the attached
gingiva. The lesion was non scrapable, and no tenderness
was elicited. The denture was mobile due to the mobility
of the supporting lateral incisors. On correlating the chief
complaint, the medical history and the clinical features a
provisional diagnosis of irritation fibroma associated with
leukoplakia was arrived upon.
An Intraoral periapical radiograph of the lower anterior
reveled no bony abnormalities but elicited few islands
of bone present within the lesion (Fig 3). An incisional
biopsy was taken from both the enlargement and of
the white lesion from the left mid buccal portion for
histopathological analysis. The histopathological report
in relation to the enlargement revealed hyperplasia of
the gingival epithelium associated with spindle shaped
fibroblasts and dense collagen fiber infiltrate within the
connective tissue. Diffuse white calcifications resembling
bone were also recognized (Fig 5). The report of the white
lesion revealed presence of ulceration and acanthosis of the
epithelial layer and associated dense inflammatory infiltrate
in the connective tissue.
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B Harshavardhana et al.
On correlating with the investigations, a final diagnosis of
Irritation fibroma associated with leukoplakia was arrived
upon. The patient was recalled and complete excision of
the lesion was performed along with the removal of the
denture and the two lateral incisors supporting the denture
(Fig 4). The patient is presently on local triamcenolone
acetonide application for leukoplakia and on follow up,
the final decision on the surgical treatment modality will be
decided seeing the progress rendered in the patient.
though both the lesions are common in the oral cavity,
manifestation of both the lesions with different aetiologies
at the same time is a very rare one. The aetiological factor
is both iatrogenic as well as abnormal habit oriented. Such
cases have to be managed with utmost care after arriving at
the correct diagnosis since they involve multiple aetiologies
and different treatment modalities.
DISCUSSION:
1.
Most of the localised overgrowths of the gingiva and the
oral mucosa are naturally considered to be more reactive
than neoplastic. It is possible to diagnose the lesions based
on the histopathological picture, wherein it can be divided
into fibrous and vascular types. These fibrous growths can
occur either as sessile or pedunculated. On gingiva any
such growth is normally termed as epulis. Most of these
lesions do not grow more than one centimetre.5 The lesion
diagnosed in this case is an exception since the growth was
more than two centimetres and that it originated due to
a faulty design of the denture which was provided to the
patient.
The associated leukoplakia was mainly due to the tobacco
habit of the patient for the past thirty five years. Leukoplakia
is very common in the oral cavity but the leukoplakia
presented in this case was quite alarming since it involved
both the buccal as well as the complete labial mucosa.
Generally the patient is treated by a local therapy and
seeing the progression it will be further decided whether to
go in for surgical intervention or not.
CONCLUSION:
The irritation fibroma due to a faulty denture rings us a bell
that the proper designing of a denture is very important
and a crucial step in the overall treatment plan. Even
REFERENCES:
Maryam Assadat Hashemi Pour, Rad M, Mojtahedi
A. A Survey of Soft Tissue Tumor-Like Lesions of Oral
Cavity: A Clinicopathological Study. Iranian Journal of
Pathology 2008;3:81-87.
2. Coleman GC, Flaitz CM, Vincent SD. Differential
diagnosis of oral soft tissue lesions. Tex Dent J 2002;
199:484-499.
3. Vilmann A, Vilmann P, Vilmann H. Pyogenic
granuloma:evaluation of oral conditions. Br J Oral
Maxillofac Surg 1986;24:376-382.
4. Kolte AP, Kolte RA, Shrirao TS. Focal fibrous
overgrowth- A case series and review of literature.
Contemp Clin Dent 2010;1:271-274.
5. Zain R. Fibrous lesions of the gingiva- a histopathological
analysis. Oral Surg Oral Med Oral Pathol 1990;70:466 470.
6.
Pindborg JJ, Renstrup G, Poulsen HE, Silverman S
Jr. Studies in Oral Leukoplakias: Clinical and Histologic
Signs of Malignancy. Acta Odont Scand 1963;21:407414.
7.
George A, Sreenivasan BS, Sunil S, Varghese SS,
Thomas J, Devi G, Mani V. Potentially malignant
disorders of oral cavity. Oral Maxillofac Pathol J 2011;
2:95-99.
CORRESPONDENCE:
Maj B Harshavardhana
Postgraduate Resident, Div of Periodontology and Oral Implantology, Dept of
Dental Surgery, Armed Forces Medical College, Sholapur Road, Pune-411040
E Mail: dr_harshavardhana@rediffmail.com
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