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Inflammatory papillary hyperplasia of the palate: Treatment with carbon dioxide laser, followed by restoration with an implant-supported prosthesis
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British Journal of Oral and Maxillofacial Surgery 45 (2007) 658–660
Short communication
Inflammatory papillary hyperplasia of the palate: Treatment with carbon dioxide laser, followed by restoration with an implant-supported prosthesis P. Infante-Cossio a,∗ , R. Martinez-de-Fuentes b , E. Torres-Carranza a , J.L. Gutierrez-Perez a a
Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Avenue, 41013-Sevilla, Spain b Department of Prosthodontic, Faculty of Dentistry, University of Seville, Seville, Spain Accepted 30 August 2006 Available online 4 October 2006
Abstract Inflammatory papillary hyperplasia of the palate is a persistant non-neoplastic lesion that is normally caused by poorly fitting dentures and Candida infection. We describe a case that was managed primarily with topical miconazole, and complete removal of the old acrylic denture. A multidisciplinary approach between surgeon and prosthodontist was used that combined carbon dioxide laser followed by substitution of the old removable denture for a new implant-supported screw retained prosthesis. This avoided direct support of the prosthesis by the palatal mucosa and made oral hygiene easier. The treatment has resulted in complete remission and there has been no recurrence occurred during 3 years of follow-up. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Inflammatory papillary hyperplasia; Palate; Laser CO2 ; Dental implants; Denture stomatitis; Implant-supported dental prosthesis
Introduction
Case report
Inflammatory papillary hyperplasia of the palate is a benign epithelial proliferation that develops in patients who have complete acrylic maxillary dentures. These dentures are often old, ill-fitting, badly cleaned and worn all the time.1 The tumour is multiple and localised on the hard palate, over a substratum of evident mycotic mucositis, normally caused by Candida organisms. Less extensive lesions are resolved by improving hygiene and removing the dentures at night. Patients can also benefit from antifungal treatment.2 In irreversible lesions, eradication of the diseased mucosa is required.3–7
A 39-year-old woman was presented with an extensive papillomatous lesion of the palate. She had no teeth in the maxilla since she was 20 years old, and wore a complete acrylic maxillary denture all the time. She had smoked 20 cigarettes a day for 25 years. Intra-oral examination showed a granular lesion with numerous bulbous projections which varied between 1 and 5 mm deep, localised in the hard palate and confined to the limits of the denture (Fig. 1); it was biopsied. The histopathological study showed that the mucosa was covered by stratified squamous epithelium that was made up of numerous bulbous projections with connective tissue. The adjacent lamina propia contained a chronic inflammatory infiltrate. No fungal organisms were seen (Fig. 2). Treatment was started with 2% miconazole in gel for a month. However, despite her giving up smoking, the lesion
∗
Corresponding author. Tel.: +34 955 01 26 08. E-mail address: [email protected] (P. Infante-Cossio).
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.08.005
P. Infante-Cossio et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 658–660
659
Fig. 1. Inflammatory papillary hyperplasia of the palate on the first visit.
did not heal. The affected area was vaporised with carbon dioxide laser in defocused, continuous mode at 6 W. One month later, the mucosa had epithelialised and six implants were placed in the maxilla. Six months postoperatively an implant-supported, screw-retained, prosthesis was constructed. After 3 years, this treatment has resulted in complete remission and the lesion had not recurred (Fig. 3). Fig. 3. (A) Panoramic radiograph and (B) occlusal view of the upper implantsupported, screw-retained, prosthesis.
Discussion Inflammatory papillary hyperplasia of the palate is benign but persistent. In patients with extensive lesions or long papillae, and in those in whom conservative treatment has not healed the lesion, excision and replacement of dentures is the treatment of choice.2 Different techniques have been described, including supra-periosteal excision,5 the bladeloop technique,7 or electrosurgery,4 with or without soft tissue grafts, cryosurgery,3 and laser.6 The advantages of carbon dioxide laser are minimal bleeding, precise limits of the
surgical field, minimal trauma, relative absence of postoperative pain and accelerated healing.8 Once the lesion has been removed prognosis is good, and the lesion does not usually recur if the causative factors and associated risks are corrected, dentures are replaced and oral hygiene is maintained. As these cases are difficult to treat, the substitution of the old acrylic denture for a new implant-supported prosthesis solves the lack of retention and stability of dentures, avoids the support on the mucosa and makes hygiene easier. In addition, the screw-retained, implant-supported, prostheses can be dismantled when necessary and are of higher quality, and therefore, less likely to be colonised by Candida.
References
Fig. 2. Inflamed bulbous projection of mucosa composed of connective tissue covered by hyperplastic epithelium Haematoxylin and eosin original magnification ×125. A section through the papillary projections Haematoxylin and eosin original magnification ×50.
1. Damm DD, Fantasia JE. Red, bumpy palate. Inflammatory papillary hyperplasia. Gen Dent 2002;50:378–80. 2. Salonen MA, Raustia AM, Oikarinen KS. Effect of treatment of palatal inflammatory papillary hyperplasia with local and systemic antifungal agents accompanied by renewal of complete dentures. Acta Odontol Scand 1996;54:87–91. 3. Getter L, Perez B. Controlled cryotherapy in the treatment of inflammatory papillary hyperplasia. Oral Surg Oral Med Oral Pathol 1972;34:178–86. 4. Rathofer SA, Gardner FM, Vermileya SG. A comparison of healing and pain following excision of inflammatory papillary hyperplasia with electrosurgery and blade-loop knives in human patients. Oral Surg Oral Med Oral Pathol 1985;59:130–5. 5. Brown AR, Cobb CM, Dunlap CL, Manch-Citron JN. Atypical palatal papillomatosis treated by excision and full-thickness
660
P. Infante-Cossio et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 658–660
grafting. Compend Contin Educ Dent 1997;18:724–6, 728–32, 734. 6. Marei MK, Abdel-Meguid SH, Mokhtar SA, Rizk SA. Effect of lowenergy laser application in the treatment of denture-induced mucosal lesions. J Prosthet Dent 1997;77:256–64.
7. Antonelli JR, Panno FV, Witko A. Inflammatory papillary hyperplasia: supraperiosteal excision by the blade-loop technique. Gen Dent 1998;46:390–7. 8. Wlodawsky RN, Strauss RA. Intraoral laser surgery. Oral Maxillofacial Surg Clin North Am 2004;16:149–63.
British Journal of Oral and Maxillofacial Surgery 45 (2007) 658–660
Short communication
Inflammatory papillary hyperplasia of the palate: Treatment with carbon dioxide laser, followed by restoration with an implant-supported prosthesis P. Infante-Cossio a,∗ , R. Martinez-de-Fuentes b , E. Torres-Carranza a , J.L. Gutierrez-Perez a a
Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Avenue, 41013-Sevilla, Spain b Department of Prosthodontic, Faculty of Dentistry, University of Seville, Seville, Spain Accepted 30 August 2006 Available online 4 October 2006
Abstract Inflammatory papillary hyperplasia of the palate is a persistant non-neoplastic lesion that is normally caused by poorly fitting dentures and Candida infection. We describe a case that was managed primarily with topical miconazole, and complete removal of the old acrylic denture. A multidisciplinary approach between surgeon and prosthodontist was used that combined carbon dioxide laser followed by substitution of the old removable denture for a new implant-supported screw retained prosthesis. This avoided direct support of the prosthesis by the palatal mucosa and made oral hygiene easier. The treatment has resulted in complete remission and there has been no recurrence occurred during 3 years of follow-up. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Inflammatory papillary hyperplasia; Palate; Laser CO2 ; Dental implants; Denture stomatitis; Implant-supported dental prosthesis
Introduction
Case report
Inflammatory papillary hyperplasia of the palate is a benign epithelial proliferation that develops in patients who have complete acrylic maxillary dentures. These dentures are often old, ill-fitting, badly cleaned and worn all the time.1 The tumour is multiple and localised on the hard palate, over a substratum of evident mycotic mucositis, normally caused by Candida organisms. Less extensive lesions are resolved by improving hygiene and removing the dentures at night. Patients can also benefit from antifungal treatment.2 In irreversible lesions, eradication of the diseased mucosa is required.3–7
A 39-year-old woman was presented with an extensive papillomatous lesion of the palate. She had no teeth in the maxilla since she was 20 years old, and wore a complete acrylic maxillary denture all the time. She had smoked 20 cigarettes a day for 25 years. Intra-oral examination showed a granular lesion with numerous bulbous projections which varied between 1 and 5 mm deep, localised in the hard palate and confined to the limits of the denture (Fig. 1); it was biopsied. The histopathological study showed that the mucosa was covered by stratified squamous epithelium that was made up of numerous bulbous projections with connective tissue. The adjacent lamina propia contained a chronic inflammatory infiltrate. No fungal organisms were seen (Fig. 2). Treatment was started with 2% miconazole in gel for a month. However, despite her giving up smoking, the lesion
∗
Corresponding author. Tel.: +34 955 01 26 08. E-mail address: [email protected] (P. Infante-Cossio).
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.08.005
P. Infante-Cossio et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 658–660
659
Fig. 1. Inflammatory papillary hyperplasia of the palate on the first visit.
did not heal. The affected area was vaporised with carbon dioxide laser in defocused, continuous mode at 6 W. One month later, the mucosa had epithelialised and six implants were placed in the maxilla. Six months postoperatively an implant-supported, screw-retained, prosthesis was constructed. After 3 years, this treatment has resulted in complete remission and the lesion had not recurred (Fig. 3). Fig. 3. (A) Panoramic radiograph and (B) occlusal view of the upper implantsupported, screw-retained, prosthesis.
Discussion Inflammatory papillary hyperplasia of the palate is benign but persistent. In patients with extensive lesions or long papillae, and in those in whom conservative treatment has not healed the lesion, excision and replacement of dentures is the treatment of choice.2 Different techniques have been described, including supra-periosteal excision,5 the bladeloop technique,7 or electrosurgery,4 with or without soft tissue grafts, cryosurgery,3 and laser.6 The advantages of carbon dioxide laser are minimal bleeding, precise limits of the
surgical field, minimal trauma, relative absence of postoperative pain and accelerated healing.8 Once the lesion has been removed prognosis is good, and the lesion does not usually recur if the causative factors and associated risks are corrected, dentures are replaced and oral hygiene is maintained. As these cases are difficult to treat, the substitution of the old acrylic denture for a new implant-supported prosthesis solves the lack of retention and stability of dentures, avoids the support on the mucosa and makes hygiene easier. In addition, the screw-retained, implant-supported, prostheses can be dismantled when necessary and are of higher quality, and therefore, less likely to be colonised by Candida.
References
Fig. 2. Inflamed bulbous projection of mucosa composed of connective tissue covered by hyperplastic epithelium Haematoxylin and eosin original magnification ×125. A section through the papillary projections Haematoxylin and eosin original magnification ×50.
1. Damm DD, Fantasia JE. Red, bumpy palate. Inflammatory papillary hyperplasia. Gen Dent 2002;50:378–80. 2. Salonen MA, Raustia AM, Oikarinen KS. Effect of treatment of palatal inflammatory papillary hyperplasia with local and systemic antifungal agents accompanied by renewal of complete dentures. Acta Odontol Scand 1996;54:87–91. 3. Getter L, Perez B. Controlled cryotherapy in the treatment of inflammatory papillary hyperplasia. Oral Surg Oral Med Oral Pathol 1972;34:178–86. 4. Rathofer SA, Gardner FM, Vermileya SG. A comparison of healing and pain following excision of inflammatory papillary hyperplasia with electrosurgery and blade-loop knives in human patients. Oral Surg Oral Med Oral Pathol 1985;59:130–5. 5. Brown AR, Cobb CM, Dunlap CL, Manch-Citron JN. Atypical palatal papillomatosis treated by excision and full-thickness
660
P. Infante-Cossio et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 658–660
grafting. Compend Contin Educ Dent 1997;18:724–6, 728–32, 734. 6. Marei MK, Abdel-Meguid SH, Mokhtar SA, Rizk SA. Effect of lowenergy laser application in the treatment of denture-induced mucosal lesions. J Prosthet Dent 1997;77:256–64.
7. Antonelli JR, Panno FV, Witko A. Inflammatory papillary hyperplasia: supraperiosteal excision by the blade-loop technique. Gen Dent 1998;46:390–7. 8. Wlodawsky RN, Strauss RA. Intraoral laser surgery. Oral Maxillofacial Surg Clin North Am 2004;16:149–63.