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Inflammatory Papillary Hyperplasia of the Oral Mucosa: Report of 341 Cases
Inflammatory papillary hyperplasia of the oral mucosa: report of
341
c a se s
Surindar N. Bhaskar, DDS, PhD Joe D. Beasley, III, DDS Duane E. Cutright, DDS, PhD, Washington, DC
A study was made of inflammatory papillary hyper plasia. The purpose was to describe the natural history of this lesion, to determine if it is capable of malignant change, and to suggest a method of therapy. Clinical features of the lesion and micro scopic findings are discussed.
Inflam m atory papillary hyperplasia (IP H ) is a le sion o f oral m ucosa. In a recent study it w as found in 1.5 % o f all b iopsy specim ens taken in a dental o f fic e .1 A lthough the clinical features o f this lesion are w ell know n, there is disagreem ent concerning its m alignancy potential.2-5 B ecause the lesion is histologically associated with pseudoepitheliom atous hyperplasia and keratinization, it is not u n usual that som e pathologists not fam iliar with oral lesions consider it grade I squam ous-cell carcino ma. C linically, IP H may b e seen under an upper or lower, partial or com p lete denture; how ever, the m ajority o f cases occur on the hard palate and are associated w ith the com plete denture.6 A p p roxi m ately 20% o f the patients who wear the dentures 2 4 hours a day show IPH , and am ong all denture wearers it has a prevalence rate o f 10% . T he lesion occurs ten tim es m ore frequently in patients w ho sleep w ith dentures than in those w ho do not;7 its occurrence is directly related to oral hygien e.2-6 T he prevalence o f IP H has also been related to the type o f m aterial used in the dental prosthesis; it is five tim es m ore com m on in patients w earing acryl ic dentures than in patients with m etallic dentures. IP H is characterized by the presence o f num er ous sm all, w artlike, edem atous, red, papillary
growths o f the affected m ucosa. Pain is not a d om i nant feature. Since there is a disagreem ent concerning the m alignancy or infiltration potential o f the IPH , the treatment o f this lesion varies w id ely.3-8_ 11 Som e reports only recom m end rem oval o f the d en ture as a m ode o f therapy8; others have suggested electrocauterization,3 cryotherapy,9 surgical re m oval o f the lesio n ,10 or a com p lete excision and stripping o f the lesion to include the periosteum o f the underlying b o n e.11 T h e present clinicopathologic study w as under taken to describe the natural history o f this co m m on oral lesion, to determ ine if it is capable o f m alignant transformation, and to suggest a m ethod o f therapy. T he report is based on the evaluation o f 341 surgical specim ens from the files o f the d iv ision o f oral pathology, U n ited States A rm y In-
Table 1 ■ C linical fe a tu re s * of in fla m m a to ry p a p illa ry h yp e rp la sia . A ge d is tr ib u tio n : Age 110 1 1 -2 0 2 1 -3 0 3 1 -4 0 4 1 -5 0 5 1 -6 0 6 1 -7 0 7 1 -8 0 8 1 -9 0
No. of cases 1 8 71 77 61 41 15 6 2
Sex d is tr ib u tio n : M ale, 1 6 0 ; fe m a le , 1 2 2 Race d is tr ib u tio n : W hite, 2 5 1 ; N e g ro , 21 Location + : Site P alate M a x illa ry a lv e o la r m ucosa M a n d ib u la r a lv e o la r m ucosa U n s p e c ifie d P a late and m a x illa ry a lv e o la r m ucosa
No. o f cases
P e rc e n t
282
8 2 .7
33
9 .1
4 21
1.1 6 .2
3
0 .9
• C lin ic a l in fo rm a tio n was n o t s u b m itte d in a ll cases. + In th re e cases le sion w as lo c a te d on th e p a la te as w e ll as th e m a x illa ry a lv e o la r m ucosa.
949
Fig 3 ■ Pseudoepitheliom atous hyperplasia in I PH
stitute o f D ental Research, W alter R eed Arm y M edical C enter. A ll specim ens w ere fixed in 10% form alin, sectioned step serially at 5/x, and stained w ith hem atoxylin and eosin.
Findings
Fig 1 ■ C linical features o f inflam m atory pa p illa ry hyper plasia. Note m u ltip le p apillary lesions on palates o f edentu lous patients.
y •...
Fig 2 ■ Inflam m atory p apillary hyperplasia showing m u lti ple w a rtlik e excrescences.
950 ■ JADA, Vol. 81, October 1970
■ C linical fe a tu re s: T he clinical features o f the inflam m atory papillary hyperplasia are sum m a rized in T able 1. In the present study this lesion occurred in patients w ho ranged in age from 7 to 8 6 years; the majority were in the third, fourth, and fifth decades o f life and the average age w as 4 0 .2 years. L esions were slightly m ore com m on in the m ale, show ed no racial predilection, and w ere m ost frequently (m ore than 9 2 .7 % ) located in the palate. T he clinical appearance o f the lesion w as d e scribed as papillary, “scotch grained,” “raspberry-lik e,” “grape-cluster-like,” warty, or co n sist ing o f m ultiple “lum ps” (Fig 1). T he m ucous m em brane surrounding the papillary growths w as red, boggy, spongy or flabby, but there w as little pain. On the palate the region o f special predilection is the hard palate w here the deepest portion o f the vault is m ost often involved. In som e instances, if the patient had left the dentures out o f the mouth or slept w ithout them, the lesion regressed; in none did the lesion disappear com pletely. ■ M icro sco p ic fin d in g s: T he m icroscopic features o f inflam m atory papillary hyperplasia are co n sis tent. T he lesion shows num erous papillary growths o f the oral m ucosa that are covered usually by parakeratotic stratified squam ous epithelium (Fig 2, 3). C om p lete keratinization is rare and in this study occurred in only 39 instances. T he deeper
Fig 4 ■ Pseudoepitheliom atous hyperplasia w ith dyskera^ to tic appearance. Areas such as th a t seen here often lead to a m isdiagnosis of squamous-cell carcinoma.
Fig 5 ■ Pseudoepitheliom atous hyperplasia w ith form ation of m icrocysts.
aspects o f the epithelium show p seu doepith elio m atous hyperplasia as w ell as the form ation o f keratin pearls and m icrocysts (Fig 4, 5). C alcifica tion o f the keratin pearls som etim es m ay be seen (Fig 6). U lceration is seen only rarely. T h e con n ec tive tissue form ing the cores o f the papillary growths shows edem a, m yxom atous degeneration, and plasm a cell and lym phocytic infiltration. Rarely, polym orphonuclear leukocytes, ca lcifica tion, or cartilage m ay also be seen in the corium (Fig 7). In regions w here the lesion approaches the m ucous glands o f the palate, secondary changes in the glandular parenchym a and stroma are com m on. T h ese changes are atrophy o f the acini, interstitial fibrosis, lym phocytic infiltration, squam ous m etaplasia o f the ducts, and accum ula tion o f sm all p ools o f m ucoid secretions (Fig 8). T h ese latter features give these areas a superficial resem blance to the m ucoepiderm oid tum or, a d i agnosis that is som etim es rendered by the p ath ol ogist. In none o f the 341 cases exam ined was there any evidence o f dyskeratosis (prem alignant change). T able 2 gives som e o f the h istologic fea tures o f this lesion.
fibrous com ponent. T h e rem oval o f the dentures and im proved oral h ygiene can elim inate the ed e m a and the cellular infiltrate; how ever, the co n n ec tiv e tissue cannot be rem oved w ithout surgical in tervention. H istologic study reveals that IP H usually shows
Fig 6 ■ C a lcifica tio n in keratin cyst.
Discussion IP H occurs m ost frequently in the third, fourth, and fifth decades o f life, is m ost com m on in the m axilla, is associated with dentures, and is slightly m ore com m on in the m ale. A lthough rem oval o f the denture can lead to som e im provem ent, com p lete regression is not likely to occur. T h is is b e cau se alm ost all cases o f this lesion (except in the very early phase) con sist o f an inflam m atory and a
Fig 7 ■ D iffe re n tia tio n o f focus of hyalin ca rtilag e in case of IPH.
Bhaskar—Beasley—Cutright: INFLAMMATORY PAPILLARY HYPERPLASIA ■ 951
lous oral hygiene, and the need for rem oving the denture at night should be em phasized.
Summary
Fig 8 ■ In te rs titia l fibrosis, lym phocytic in filtra tio n , squa mous m etaplasia.
Table 2 ■ H is to p a th o lo g y of in fla m m a to ry p a p illa ry h y p e rp la s ia .
No. o f cases
P e rc e n t of in c id e n c e
341 339 325 93 39 20 8 6 5
100 9 9 .7 9 5 .3 2 7 .3 1 1 .4 5 .8 2 .3 1.7 1 .5
In fla m m a tio n P s e u d o e p ith e lio m a to u s h y p e rp la s ia P a ra k e ra to s is In tr a e p ith e lia l k e ra tin iz a tio n K e ra tin iz e d s u rfa c e M y x o m a to u s d e g e n e ra tio n S ia la d e n itis M ic ro c y s ts U lc e ra tio n
prom inent p seudoepitheliom atous hyperplasia and in severe cases can be diagnosed erroneously as squam ous-cell carcinom a. H ow ever, it does not show dyskeratosis and m alignant transform ation w as not observed. Form ation o f keratin cysts and “pearls” is com m on, and there is a superficial re sem blance to a w ell-differentiated carcinom a. In instances w here the inflam m atory papillary hyperplasia approaches a m ucous gland, seconda ry changes in the acini and the strom a m ay resem ble a m ucoepiderm oid tumor. For this reason such a diagnosis in a clinical case o f what appears to be inflam m atory papillary hyperplasia should be look ed on with suspicion. T reatm ent o f this lesion by excision to include the periosteum , electrocauterization, or cryother apy are n ot the ideal m ethods o f therapy. T he treatm ent o f ch oice is curettage with periodontal k nives, or uterine or other curets, to the point w here the papillary configuration o f the tissues is changed to a sm ooth, even surface. A fter curet tage o f the 1PH, a better fitting denture should be m ade, the patient should be instructed in m eticu
952 ■ JADA, Vol. 81, October 1970
A study w as m ade to describe the natural history o f inflam m atory papillary hyperplasia. It repre sents the largest series o f cases reported in the lit erature. T he follow in g con clusions were made: ■ T his lesion o f oral m ucosa occurs m ost often in the m axilla. ■ T he majority o f cases are associated with den tures. ■ T he average age o f patients suffering from 1PH is 4 0 .2 years. ■ T he lesion shows p seudoepitheliom atous h y perplasia, keratin cysts, and keratin pearls. ■ D yskeratosis is not show n, and m alignancy does not develop. ■ Salivary glands can be involved, giving a su perficial resem blance to a m ucoepiderm oid tumor. ■ IP H is best treated by conservative curettage, fabrication o f a better adapting prosthesis, and a regim e o f m eticulous oral hygiene.
Doctor Bhaskar, colonel, USA Dental Corps, is director; Doctor Beasley, major, is a resident; Doctor C utright, lie u tenant colonel, is ch ie f, division of oral pathology, United States Arm y In s titu te o f Dental Research, W alter Reed Army Medical Center, W ashington, DC 20012.
1. Bhaskar, S.N. Oral pathology in th e dental office: sur vey o f 20,575 biopsy specimens. JADA 76:761 April 1968. 2. Yrastorza, J.A. Inflam m atory p apillary hyperplasia of the palate. J Oral Surg 21:330 Ju ly 1963. 3. Guernsey, L.H. Reactive in fla m m a to ry papillary hy perplasia of the palate. Oral Surg 20:814 Dec 1965. 4. Lambson, G.O. Papillary hyperplasia of the palate. J Prosth Dent 16:636 July-Aug 1966. 5. Robinson, H.B.G. Diagnosis of lesions associated w ith dentures. J Prosth Dent 7:338 May 1957. 6. Lambson, G.O., and Anderson, R.R. Palatal papillary hyperplasia. J Prosth Dent 18:528 Dec 1967. 7. Love, W.D.; Goska, F.A.; and Mixson, R.J. The etiology of mucosal infla m m a tio n associated w ith dentures. J Prosth Dent 18:515 Dec 1967. 8. Fisher, A.K., and Rashid, P.J. Inflam m atory papillary hyperplasia of the palatal mucosa. Oral Surg 5:191 Feb 1952 9. Amaral, W.J., and others. Cryosurgery in the treatm ent of inflam m atory pa p illa ry hyperplasia. Oral Surg 25:648 A pril 1968. 10. Uohara, G.I., and Federbusch, M.D. Removal of p a p il lary hyperplasia. J Oral Surg 26:463 July 1968. 11. Waite, D.E. Inflam m atory p a pillary hyperplasia. J Oral Surg 19:210 May 1961.
341
c a se s
Surindar N. Bhaskar, DDS, PhD Joe D. Beasley, III, DDS Duane E. Cutright, DDS, PhD, Washington, DC
A study was made of inflammatory papillary hyper plasia. The purpose was to describe the natural history of this lesion, to determine if it is capable of malignant change, and to suggest a method of therapy. Clinical features of the lesion and micro scopic findings are discussed.
Inflam m atory papillary hyperplasia (IP H ) is a le sion o f oral m ucosa. In a recent study it w as found in 1.5 % o f all b iopsy specim ens taken in a dental o f fic e .1 A lthough the clinical features o f this lesion are w ell know n, there is disagreem ent concerning its m alignancy potential.2-5 B ecause the lesion is histologically associated with pseudoepitheliom atous hyperplasia and keratinization, it is not u n usual that som e pathologists not fam iliar with oral lesions consider it grade I squam ous-cell carcino ma. C linically, IP H may b e seen under an upper or lower, partial or com p lete denture; how ever, the m ajority o f cases occur on the hard palate and are associated w ith the com plete denture.6 A p p roxi m ately 20% o f the patients who wear the dentures 2 4 hours a day show IPH , and am ong all denture wearers it has a prevalence rate o f 10% . T he lesion occurs ten tim es m ore frequently in patients w ho sleep w ith dentures than in those w ho do not;7 its occurrence is directly related to oral hygien e.2-6 T he prevalence o f IP H has also been related to the type o f m aterial used in the dental prosthesis; it is five tim es m ore com m on in patients w earing acryl ic dentures than in patients with m etallic dentures. IP H is characterized by the presence o f num er ous sm all, w artlike, edem atous, red, papillary
growths o f the affected m ucosa. Pain is not a d om i nant feature. Since there is a disagreem ent concerning the m alignancy or infiltration potential o f the IPH , the treatment o f this lesion varies w id ely.3-8_ 11 Som e reports only recom m end rem oval o f the d en ture as a m ode o f therapy8; others have suggested electrocauterization,3 cryotherapy,9 surgical re m oval o f the lesio n ,10 or a com p lete excision and stripping o f the lesion to include the periosteum o f the underlying b o n e.11 T h e present clinicopathologic study w as under taken to describe the natural history o f this co m m on oral lesion, to determ ine if it is capable o f m alignant transformation, and to suggest a m ethod o f therapy. T he report is based on the evaluation o f 341 surgical specim ens from the files o f the d iv ision o f oral pathology, U n ited States A rm y In-
Table 1 ■ C linical fe a tu re s * of in fla m m a to ry p a p illa ry h yp e rp la sia . A ge d is tr ib u tio n : Age 110 1 1 -2 0 2 1 -3 0 3 1 -4 0 4 1 -5 0 5 1 -6 0 6 1 -7 0 7 1 -8 0 8 1 -9 0
No. of cases 1 8 71 77 61 41 15 6 2
Sex d is tr ib u tio n : M ale, 1 6 0 ; fe m a le , 1 2 2 Race d is tr ib u tio n : W hite, 2 5 1 ; N e g ro , 21 Location + : Site P alate M a x illa ry a lv e o la r m ucosa M a n d ib u la r a lv e o la r m ucosa U n s p e c ifie d P a late and m a x illa ry a lv e o la r m ucosa
No. o f cases
P e rc e n t
282
8 2 .7
33
9 .1
4 21
1.1 6 .2
3
0 .9
• C lin ic a l in fo rm a tio n was n o t s u b m itte d in a ll cases. + In th re e cases le sion w as lo c a te d on th e p a la te as w e ll as th e m a x illa ry a lv e o la r m ucosa.
949
Fig 3 ■ Pseudoepitheliom atous hyperplasia in I PH
stitute o f D ental Research, W alter R eed Arm y M edical C enter. A ll specim ens w ere fixed in 10% form alin, sectioned step serially at 5/x, and stained w ith hem atoxylin and eosin.
Findings
Fig 1 ■ C linical features o f inflam m atory pa p illa ry hyper plasia. Note m u ltip le p apillary lesions on palates o f edentu lous patients.
y •...
Fig 2 ■ Inflam m atory p apillary hyperplasia showing m u lti ple w a rtlik e excrescences.
950 ■ JADA, Vol. 81, October 1970
■ C linical fe a tu re s: T he clinical features o f the inflam m atory papillary hyperplasia are sum m a rized in T able 1. In the present study this lesion occurred in patients w ho ranged in age from 7 to 8 6 years; the majority were in the third, fourth, and fifth decades o f life and the average age w as 4 0 .2 years. L esions were slightly m ore com m on in the m ale, show ed no racial predilection, and w ere m ost frequently (m ore than 9 2 .7 % ) located in the palate. T he clinical appearance o f the lesion w as d e scribed as papillary, “scotch grained,” “raspberry-lik e,” “grape-cluster-like,” warty, or co n sist ing o f m ultiple “lum ps” (Fig 1). T he m ucous m em brane surrounding the papillary growths w as red, boggy, spongy or flabby, but there w as little pain. On the palate the region o f special predilection is the hard palate w here the deepest portion o f the vault is m ost often involved. In som e instances, if the patient had left the dentures out o f the mouth or slept w ithout them, the lesion regressed; in none did the lesion disappear com pletely. ■ M icro sco p ic fin d in g s: T he m icroscopic features o f inflam m atory papillary hyperplasia are co n sis tent. T he lesion shows num erous papillary growths o f the oral m ucosa that are covered usually by parakeratotic stratified squam ous epithelium (Fig 2, 3). C om p lete keratinization is rare and in this study occurred in only 39 instances. T he deeper
Fig 4 ■ Pseudoepitheliom atous hyperplasia w ith dyskera^ to tic appearance. Areas such as th a t seen here often lead to a m isdiagnosis of squamous-cell carcinoma.
Fig 5 ■ Pseudoepitheliom atous hyperplasia w ith form ation of m icrocysts.
aspects o f the epithelium show p seu doepith elio m atous hyperplasia as w ell as the form ation o f keratin pearls and m icrocysts (Fig 4, 5). C alcifica tion o f the keratin pearls som etim es m ay be seen (Fig 6). U lceration is seen only rarely. T h e con n ec tive tissue form ing the cores o f the papillary growths shows edem a, m yxom atous degeneration, and plasm a cell and lym phocytic infiltration. Rarely, polym orphonuclear leukocytes, ca lcifica tion, or cartilage m ay also be seen in the corium (Fig 7). In regions w here the lesion approaches the m ucous glands o f the palate, secondary changes in the glandular parenchym a and stroma are com m on. T h ese changes are atrophy o f the acini, interstitial fibrosis, lym phocytic infiltration, squam ous m etaplasia o f the ducts, and accum ula tion o f sm all p ools o f m ucoid secretions (Fig 8). T h ese latter features give these areas a superficial resem blance to the m ucoepiderm oid tum or, a d i agnosis that is som etim es rendered by the p ath ol ogist. In none o f the 341 cases exam ined was there any evidence o f dyskeratosis (prem alignant change). T able 2 gives som e o f the h istologic fea tures o f this lesion.
fibrous com ponent. T h e rem oval o f the dentures and im proved oral h ygiene can elim inate the ed e m a and the cellular infiltrate; how ever, the co n n ec tiv e tissue cannot be rem oved w ithout surgical in tervention. H istologic study reveals that IP H usually shows
Fig 6 ■ C a lcifica tio n in keratin cyst.
Discussion IP H occurs m ost frequently in the third, fourth, and fifth decades o f life, is m ost com m on in the m axilla, is associated with dentures, and is slightly m ore com m on in the m ale. A lthough rem oval o f the denture can lead to som e im provem ent, com p lete regression is not likely to occur. T h is is b e cau se alm ost all cases o f this lesion (except in the very early phase) con sist o f an inflam m atory and a
Fig 7 ■ D iffe re n tia tio n o f focus of hyalin ca rtilag e in case of IPH.
Bhaskar—Beasley—Cutright: INFLAMMATORY PAPILLARY HYPERPLASIA ■ 951
lous oral hygiene, and the need for rem oving the denture at night should be em phasized.
Summary
Fig 8 ■ In te rs titia l fibrosis, lym phocytic in filtra tio n , squa mous m etaplasia.
Table 2 ■ H is to p a th o lo g y of in fla m m a to ry p a p illa ry h y p e rp la s ia .
No. o f cases
P e rc e n t of in c id e n c e
341 339 325 93 39 20 8 6 5
100 9 9 .7 9 5 .3 2 7 .3 1 1 .4 5 .8 2 .3 1.7 1 .5
In fla m m a tio n P s e u d o e p ith e lio m a to u s h y p e rp la s ia P a ra k e ra to s is In tr a e p ith e lia l k e ra tin iz a tio n K e ra tin iz e d s u rfa c e M y x o m a to u s d e g e n e ra tio n S ia la d e n itis M ic ro c y s ts U lc e ra tio n
prom inent p seudoepitheliom atous hyperplasia and in severe cases can be diagnosed erroneously as squam ous-cell carcinom a. H ow ever, it does not show dyskeratosis and m alignant transform ation w as not observed. Form ation o f keratin cysts and “pearls” is com m on, and there is a superficial re sem blance to a w ell-differentiated carcinom a. In instances w here the inflam m atory papillary hyperplasia approaches a m ucous gland, seconda ry changes in the acini and the strom a m ay resem ble a m ucoepiderm oid tumor. For this reason such a diagnosis in a clinical case o f what appears to be inflam m atory papillary hyperplasia should be look ed on with suspicion. T reatm ent o f this lesion by excision to include the periosteum , electrocauterization, or cryother apy are n ot the ideal m ethods o f therapy. T he treatm ent o f ch oice is curettage with periodontal k nives, or uterine or other curets, to the point w here the papillary configuration o f the tissues is changed to a sm ooth, even surface. A fter curet tage o f the 1PH, a better fitting denture should be m ade, the patient should be instructed in m eticu
952 ■ JADA, Vol. 81, October 1970
A study w as m ade to describe the natural history o f inflam m atory papillary hyperplasia. It repre sents the largest series o f cases reported in the lit erature. T he follow in g con clusions were made: ■ T his lesion o f oral m ucosa occurs m ost often in the m axilla. ■ T he majority o f cases are associated with den tures. ■ T he average age o f patients suffering from 1PH is 4 0 .2 years. ■ T he lesion shows p seudoepitheliom atous h y perplasia, keratin cysts, and keratin pearls. ■ D yskeratosis is not show n, and m alignancy does not develop. ■ Salivary glands can be involved, giving a su perficial resem blance to a m ucoepiderm oid tumor. ■ IP H is best treated by conservative curettage, fabrication o f a better adapting prosthesis, and a regim e o f m eticulous oral hygiene.
Doctor Bhaskar, colonel, USA Dental Corps, is director; Doctor Beasley, major, is a resident; Doctor C utright, lie u tenant colonel, is ch ie f, division of oral pathology, United States Arm y In s titu te o f Dental Research, W alter Reed Army Medical Center, W ashington, DC 20012.
1. Bhaskar, S.N. Oral pathology in th e dental office: sur vey o f 20,575 biopsy specimens. JADA 76:761 April 1968. 2. Yrastorza, J.A. Inflam m atory p apillary hyperplasia of the palate. J Oral Surg 21:330 Ju ly 1963. 3. Guernsey, L.H. Reactive in fla m m a to ry papillary hy perplasia of the palate. Oral Surg 20:814 Dec 1965. 4. Lambson, G.O. Papillary hyperplasia of the palate. J Prosth Dent 16:636 July-Aug 1966. 5. Robinson, H.B.G. Diagnosis of lesions associated w ith dentures. J Prosth Dent 7:338 May 1957. 6. Lambson, G.O., and Anderson, R.R. Palatal papillary hyperplasia. J Prosth Dent 18:528 Dec 1967. 7. Love, W.D.; Goska, F.A.; and Mixson, R.J. The etiology of mucosal infla m m a tio n associated w ith dentures. J Prosth Dent 18:515 Dec 1967. 8. Fisher, A.K., and Rashid, P.J. Inflam m atory papillary hyperplasia of the palatal mucosa. Oral Surg 5:191 Feb 1952 9. Amaral, W.J., and others. Cryosurgery in the treatm ent of inflam m atory pa p illa ry hyperplasia. Oral Surg 25:648 A pril 1968. 10. Uohara, G.I., and Federbusch, M.D. Removal of p a p il lary hyperplasia. J Oral Surg 26:463 July 1968. 11. Waite, D.E. Inflam m atory p a pillary hyperplasia. J Oral Surg 19:210 May 1961.