EVALUATION HYPERPLASIA

CHARLES University

OF TREATMENT OF INFLAMMATORY OF THE PALATE

PAPILLARY

L.

BOLENDER,

AND GEORGE YAMANE,

D.D.S., MS.," RALPH D. D.D.S., Ph.D.*"*

School o/ Dentistry,

SWENSON,

D.D.S., M.S.,""

of Washington,

Seattle,

Wash.

have been suggested as being involved in the etiology and V treatment of inflammatory papillary hyperplasia of the palate. Poor oral hyARIOUS FACTORS

giene,r monilial infection,2 relief chambers,3movement of dentures in function,4 illfitting dentures, and faulty occlusion6 are some of the causesof this alteration in the tissues of the palate. These changes have been treated by the use of medicaments,2 removal of the dentures for varying lengths of time,ls fabrication of new, adequately fitting dentures, and different methods of surgical removal of the lesion.4p5,8 The purpose of this investigation was to evaluate the effects of the fabrication of new dentures with and without surgical removal of the lesion.
PATIENT INFORMATION

Twenty wearers of complete dentures exhibiting inflammatory papillary hyperplasia of the palate served as subjects. Four subjects were men and sixteen were women. Their ages ranged from 22 to 75 with a mean of 50 years. They had been wearing dentures from 6 to 30 years. They had been wearing their present dentures from 2 to 30 years with a mean of 10.3 years. All the maxillary dentures had palatal relief, with 11 of the 20 having a deep relief of more than .5 mm. in depth. The retention and stability of all the dentures were evaluated as poor. The oral hygiene of th,e subjects ranged from fair to poor with most of the subjects in the poor category. The overall size of the lesions ranged from 5 mm. by 15 mm. up to coverage of the entire palate. Multiple papillary projections that varied in diameter and depth were evident. The depth of the crevices between the projections observed ranged from 2 to 5 mm. as recorded by a periodontal probe. Erythema was present
Read before the I.A.D.R. in Pittsburgh, Pa.: Pacific Coast Society of Prosthodontists in Vancouver, B. C.; and The American Academy of Prosthetics in Chicago, Ill. *Associate Professor and Chairman, Department of Prosthodontics. **Clinical Associate, Department of Oral Surgery. ***Professor and Chairman, Departments of Oral Diagnosis, Oral Medicine and Oral Roent. genography, School of Dentistry, University of Minnesota, formerly Assistant Professor, Depart. ment of Oral Biology. 1013

BOLENDER,

SWENSON,

AND

YAMANE

J. Pros. Den. November-December, 1965

but varied in severity. Symptoms were reported by only 2 subjects; one symptom was a burning sensation, and the other was an itching sensation. Specimens for biopsy were secured, and clinical evaluation of the oral cavity was conducted. A positive histologic confirmation of the presence of inflammatory papillary hyperplasia was required before placing the subject in the study.
DESCRIPTION OF LESION

A representative lesion is shown in Fig. 1,A. The lesion is well demarcated from the surrounding tissue ; however, the papillary proj,ections are not clearly seen. A jet of air has been directed to the same palate in Fig. l,B, to demonstrate how the papillary projections become more evident. The use of an air syringe has proved to be the most useful diagnostic instrument to detect clinically the presence of this type of palatal lesion. Fig. 2. is a low magnification view of the lesion shown in Fig. 1. The typical features of an inflammatory papillary hyperplasia of the palate are evident. The epithelium was hyperplastic and thrown into several broad fingerlike projections. Keratinization was not a prominent feature, but many of the crevices were filled with parakeratin. The rete pegs were projecting deep into the underlying lamina propria. The basal cells were well organized, and were sharply demarcated from

Fig. 1.-A reprdsentative lesion from a subject in Group 1. A, are not clearly seen. B, The same palate after a jet of air was directed of distinct papillary projections.

The papillary on it. Note

projections the presence

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INFLAMMATORY

PAPILLARY

HYPERPLASIA

OF PALATE

101.5

the underlying lamina propria by a distinct basement membrane. The underlying lamina propria consisted of a loose fibrous connective tissue stroma with a variable amount of edema. The lamina propria was heavily infiltrated with lymphocytes and plasma cells.
OUTLINE OF STUDY

The subjects were evenly divided into two groups in regard to age, sex, and lesion size (Fig. 3). The therapy for the 10 subjects in Group I consisted of fabrication of nem complete dentures. The dentures were made by dental students under the direct supervision of one of the investigators (C.L.B.). No treatment of the lesions was attempted except to encourage the patients to leave the dentures out of the mouth as much as possible prior to making the final impressions. This was adopted fol Group I because it is a procedure commonly used in general practice. The neM dentures were processed in a methylmethacrylate acrylic resin with no relief chamber. Any necessary palatal relief was determined by the use of a disclosing paste following the insertion of the dentures. At 12 months following the insertion of the new dentures, the lesions were again clinically and histologically evaluated. The therapy for the 10 subjects in Group II consisted of supraperiosteal removal of the lesions with a high frequency electrical cutting current instrument. A temporary lining was placed in the existing dentures, immediately following the surgery, and changed at the two and three week postoperative intervals. The palate:; of the subjects were evaluated frequently until healing was complete. Following

Fig. hyperplastic

2.-A and

low

power thrown

microscopic
into broad,

view fingerlike

of

the lesion projections.

shown

in

Fig.

1. The

epithelium

is

1016

BOLENDER,

SWENSON,

AND

YAMANE

November-D&i%;

sufficient healing, new dentures were made and inserted following the same procedure as for Group I. At 12 months after operation, the palatal mucosa was again clinically and histologically evaluated.
PROCEDURE

Group I.-A representative lesion from Group I is shown in Fig. 1. The appearance of this same lesion is seen in Fig. 4 after new dentures had been worn for 12 months. Virtually no clinical change was evident for this subject. Following wearing of the new dentures for 12 months, a second biopsy was made. Care was taken to secure the biopsy specimen from an area away from the original biopsy site, yet remaining in the most involved part of the lesion. Fig. 5 is the histologic section of the lesion as shown in Fig. 4. The broad, fingeriike projections and inflammatory, cellular exudate are still present, indicating minimal change from the pretreatment biopsy (Fig. 2). Half the subjects in Group I showed no change in severity of the papillary
SUBJECTS I. Clinical 2. Biopsy (20) Evaluation (preop.)

GROUP

I I

(IO)

GROUP

II

(IO)

Surgery

f
I

New

Dentures

Clinical Biopsy

1 1

New

Dentures

Evaluation

Clinical Biopsy

Evaluation (I2 mo.)

(I2 mod

Fig.

3.-Outline

of the study.

Fig. I.-The of new dentures

clinical appearance for 12 months.

of the

same

lesion

shown

in Fig.

1 following

the wearhig

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INFLAMMATORY

PAPILLARY

HYPERPLASIA

OF PALATE

101.7

hyperplasia. The other half displayed a moderate reduction in erythema that was confirmed histologically, while the remainder of the microscopic and clinical features remained unchanged. Group II.-A representative lesion from Group II is shown in Fig. 6. The lesion covered a large portion of the palate. The histologic picture of the biopsy (Fig. 7) is very similar to those of the subjects in Group 1. Note the projections of epithelium and the inflammatory exudate. Using a wire loop, (Fig. S) one of the investigators (K.D.S.) performed the operation with a high-frequency electrical cutting current. The lesion was removed

Fig. 5.-A of new dentures biopsy.

low-power microscopic
for 12 months. Minimal

view of the lesion shown in Fig. change is evident in comparison

4 following the wearing with the pretreatment

three

Fig. 6.-A fourths

representative of the palate.

lesion from The maximum

a subject in Group II. The lesion covers approximately depth of the papillary projections was 3 mm.

1018

BOLENDER,

SWENSON,

AND

YAMANE

November-D:&%?,

?;%

Fig.

7.-A

low-power

microscopic

view

of the lesion

shown

in Fig. 6.

Fig. 8

Fig. 9

Fig. %-Half instrument. Fig. 9.-The

of the lesion

lesion has been

has

been

removed removed.

by

using

the

wire

loop

elLectrical

cu .tting

completely

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PAPILLARY

HYPERPLASIA

OF PALATE

1019

to a subepithelial level just beneath the grooves in the papillary hyperplasia and was always supraperiosteal. Local anesthesia was used. An outline of the preoperative biopsy site can be seen near the midline. Specimens for biopsy were removed by a scalpel. The operation is complete in Fig. 9. Bleeding was less with the cutting current wire loop than with sharp metal cutting instruments. Following surgery, a lining of hard-setting zinc oxide and eugenol impression paste was placed in the subjects old denture (Fig. 10). This lining was changed at the two and three week postoperative intervals. Discomfort of varying degrees, exhibited during the first week, was controlled most effectively by the application of a topical anesthetic ointment. No bleeding problems were encountered after operation. Considerable healing had occurred after 2 weeks (Fig. 1 1 ), and the soreness had gone. The healing was essentially complete at 4 weeks (Fig. 12). Several small erythematous areas can still be seen. The healing was complete at 4 weeks in nine subjects and at 3 weeks in one subject. At 4 weeks after operation, the old denture was relined by the usual procedures using acrylic resin. New dentures were made shortly thereafter. This procedure was followed for all subjects in Group II. Fig. 13 shows the palate maintaining a normal appearance at 3 months postoperative. At 12 months after operation, the palatal mucosa was again evaluated. Clinically, the palate was normal (Fig. 14). Histologically, the tissue appears to be similar to a normal palatal mucosa9 (Fig. 15). A similar result was seen in all subjects of Group II. The epithelium was well differentiated. The penetration of the rete pegs was fairly uniform and, for the most part, inflammatory cells were absent. In some instances, the epithelium showed a well-keratinized layer.
RESULTS

Group I.-Even after new dentures had been worn for twelve months, there was virtually no change in the clinical appearance of the palatal lesion of the subjects in Group I (2 men, 6 women). Half (4) of the subjects showed no clin-i-

Fig. 10.-A hard-setting zinc oxide denture immediately following surgery.

eugenol

impression

paste

lining

was

placed

in the

old

BOLENDER,

SWENSON,

AND

YAMANE

J. Pros. Den. November-December, 1965

Fig. 12

Fig. 14

Fig. Il.-The 2 week postoperative Fig. 12.-The 4 week postoperative right of the midline. Fig. 13.-The 3 month postoperative Fig. 14.-The 12 month postoperative evidence of the original lesion.

result. result. result. result,

Considerable healing has occurred. Note the localized area of inflammation The tissue is maintaining itself. There

to the is no

Fig.

15.-A

low-power

microscopic

view

of the 12 month

postoperative

result.

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PAPILLARY

HYPERPLASIA

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PALATE

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TABLE

I.

CLINICAL

AND

HISTOLOGIC

EVALUATION

GROUP

GROUP

II

SUBJECT

i
BEFORE AFTER SUBJECT PREOPERATIVE POSTOPERATI\E

______

: : 1 : :
+ Lesion present. - Lesion absent. Table I. Summary *Dyskeratosis postoperative

T: T z Not available Not available

FM

LItI MW

:: : : + + :: -* Not a&able Not available

E ww FD isk

of investigation present preoperatively biopsy-did not show

and 12 dyskeratosis.

months

postoperatively.

Subsequent

24-month

cal changes in the severity of the papillary hyperplasia. The size and color of the lesions remained the same. The other half (4) of the subjects displayed a moderate reduction in the erythema of the lesion but not in the size of the lesion. The microscopic examination confirmed these findings. It was impossible to maintain contact with 2 subjects in this group (Table I). Group II.-Where the lesions had been surgically removed, there was no clinical and histologic evidence of a return of the lesion in 7 subjects (2 men, 5 women). However, 2 of these subjects exhibited a small localized area about 3 to 4 mm. in diameter that was granular in appearance. In both instances, the lesions were located in the depression between two rugae. Because of this, it is speculated that these two areas were not entirely removed at the time of surgery. One subject (a woman), marked with the asterisk in Table I, showed a localized erythematous response at 12 months postoperatively which was not present following healing. This inflammatory response, however, disappeared clinically after relining and adjusting the occlusion of the dentures. This same subject was the only one of the entire study who displayed dyskeratosis preoperatively and 12 months postoperatively. Examination of a specimen taken for biopsy 24 months postoperatively did not show dyskeratosis. Also, at 24 months, the clinical and histologic appearance of the palate was well within normal limits. Two subjects were also lost from this group (Table I).
DISCUSSION

The treatment of inflammatory papillary hyperplasia by making new dentures alone did not cause a substantial change in the lesions. It was noted, however, that half the subjects experienced a reduction in the inflammatory response. This was found to be inadequate therapy.

1022

BOLENDER,

SWENSON,

AND

YAMANE

J. Pros. November-December,

Den. 1965

Surgical excision of the lesions by a high-frequency cutting current followed by making new dentures resulted in the lesions complete removal. This method proved to be adequate treatment and resulted in a normal mucosa. It is important to reline the old denture immediately following surgery and to maintain good contact of the denture with the palatal mucosa. One subject of the twenty showed dyskeratosis preoperatively. Conclusions cannot be drawn from the results of this study regarding dyskeratosis because of its incidence in only one subject. Supraperiosteal removal of inflammatory papillary hyperplasia is indicated and adequate treatment. Subperiosteal removal is not indicated except when one is dealing with a malignancy. This project is being continued in order to evaluate the therapy over a longer period of time. At the end of the third year, five subjects remained in Group I and four in Group II. The results so far indicate that the lesion still remained in the subjects in ,Group I, while it was not seen in the subjects in Group II, i.e., it seemed to indicate that similar results will be obtained to those reported at the end of twelve months.
SUMMARY

The results was not effective gical removal of eradication of the

REFERENCES

of this study indicated that the making of new dentures alone in eliminating inflammatory papillary hyperplasia. However, surthe lesion and the making of new dentures was effective in the lesion.

1. Fisher, A. K., and Rashid, P. J.: Inflammatory Papillary Hyperplasia of the Palatal Mucosa, Oral Surg., Oral Med. & Oral Path. 5:192, 1952. 2. Lyon, D. G., and Chick, A. 0. : Denture Sore Mouth and Angular Cheilitis : A Preliminary Investigation Into Their Possible Association With Candida Infection., D. Practitioner & D. Record 7:212-217, 1957. 3. Thoma, K. H., and Robinson, H. B.: Oral and Dental Diagnosis, ed. 4, Philadelphia, 1955, W. B. Saunders Company, pp. 323-324. 4. Robins;;5,H. B. G.: Diagnosis of Lesions Associated With Dentures, J. PROS. DEN. 7:338, 5. Nyquist, 6.: A Study of Denture Sore Mouth: An Investigation of Traumatic Allergic and Toxic Lesions of the Oral Mucosa Arising From the Use of Full Dentures, Acta Odont. Scandinavica 10, Suppl. 9:11-154, 1952. 6. Hickey, J. C., Boucher, C. O., and Woelful, J. B.: Responsibility of the Dentist in Complete Dentures. J. PROS. DEN. 12:638, 1962. 7. Friedman, Samuel: Effective Use of Diagnostic Data, J. PROS. DEN. 9:729, 1959. 8. Waite, D. E.: Inflammatory Papillary Hyperplasia, J. Oral Surg., Anesth. & Hosp. D. Serv. 19:210, 1961. 9. Ostlund, S. G.: Effect of Complete Dentures on the Gum Tissues. A Histological and Histopathological Investigation, Acta Odont. Scandinavica 16:l. 1958.
UNIVERSITY OF WASHINGTON, SEATTLE, WASH. 98155 SCHOOL OF DENTISTRY,