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EVALUATION OF TREATMENT OF INFLAMMATORY PAPILLARYHYPERPLASIA OF THE PALATECHARLES L. BOLENDER, D.D.S., MS.," RALPH D. SWENSON, D.D.S., M.S.,""AND GEORGE YAMANE, D.D.S., Ph.D.*"*University of Washington, School o/ Dentistry, Seattle, Wash.

V ARIOUS FACTORS have been suggested as being involved in the etiology andtreatment of inflammatory papillary hyperplasia of the palate. Poor oral hy-giene,r monilial infection,2 relief chambers,3movement of dentures in function,4 ill-fitting dentures, and faulty occlusion6 are some of the causesof this alteration inthe tissues of the palate. These changes have been treated by the use of medica-ments,2 removal of the dentures for varying lengths of time,ls fabrication of new,adequately fitting dentures, and different methods of surgical removal of thelesion.4p5,8The purpose of this investigation was to evaluate the effects of the fabricationof new dentures with and without surgical removal of the lesion.PATIENT INFORMATION

Twenty wearers of complete dentures exhibiting inflammatory papillary hyper-plasia of the palate served as subjects. Four subjects were men and sixteen werewomen. Their ages ranged from 22 to 75 with a mean of 50 years. They had beenwearing dentures from 6 to 30 years. They had been wearing their present denturesfrom 2 to 30 years with a mean of 10.3 years. All the maxillary dentures had palatalrelief, with 11 of the 20 having a deep relief of more than .5 mm. in depth. Theretention and stability of all the dentures were evaluated as poor. The oral hygieneof th,e subjects ranged from fair to poor with most of the subjects in the poorcategory.The overall size of the lesions ranged from 5 mm. by 15 mm. up to coverageof the entire palate. Multiple papillary projections that varied in diameter anddepth were evident. The depth of the crevices between the projections observedranged 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 inVancouver, 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.

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BOLENDER, SWENSO N, AND YAMANE J. Pros. Den.November-December, 1965

but varied in severity. Symptoms were reported by only 2 subjects; one symptomwas a burning sensation, and the other was an itching sensation.

Specimens for biopsy were secured, and clinical evaluation of the oral cavitywas conducted. A positive histologic confirmation of the presence of inflammatorypapillary 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 demarcatedfrom 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 howthe papillary projections become more evident. The use of an air syringe hasproved to be the most useful diagnostic instrument to detect clinically the presenceof this type of palatal lesion.Fig. 2. is a low magnification view of the lesion shown in Fig. 1. The typicalfeatures of an inflammatory papillary hyperplasia of the palate are evident. Theepithelium was hyperplastic and thrown into several broad fingerlike projections.Keratinization was not a prominent feature, but many of the crevices were f illedwith parakeratin. The rete pegs were projecting deep into the underlying laminapropria. The basal cells were well organized, and were sharply demarcated from

A

B

Fig. 1.-A reprdsentative lesion from a subjec t in Group 1. A, The papillary projectionsare not clearly seen. B, The same palate after a jet of air was directed on it. Note the presenceof distinc t papillary projections.

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ICE 6 INFLAMMATOR Y PAPILLARY HYPERPLASIA OF PALATE 101.5the underlying lamina propria by a distinct basement membrane. The underlyinglamina propria consisted of a loose fibrous connective tissue stroma with a variableamount of edema. The lamina propria was heavily infiltrated with lymphocytes andplasma cells.OUTLINE OF STUDY

The subjects were evenly divided into two groups in regard to age, sex, andlesion size (Fig. 3).

The therapy for the 10 subjects in Group I consisted of fabrication of nemcomplete dentures. The dentures were made by dental students under the directsupervision of one of the investigators (C.L.B.). No treatment of the lesions wasattempted except to encourage the patients to leave the dentures out of the mouthas much as possible prior to making the final impressions. This was adopted folGroup I because it is a procedure commonly used in general practice. The neMdentures were processed in a methylmethacrylate acrylic resin with no relief cham-ber. Any necessary palatal relief was determined by the use of a disclosing pastefollowing the insertion of the dentures. At 12 months following the insertion of thenew dentures, the lesions were again clinically and histologically evaluated.

The therapy for the 10 subjects in Group II consisted of supraperiosteal re-moval of the lesions with a high frequency electrical cutting current instrument. Atemporary lin ing was placed in the existing dentures, immediately following thesurgery, and changed at the two and three week postoperative intervals. The palate:;of the subjects were evaluated frequently until healing was complete. Following

Fig. 2.-A low power microscopic view of the lesion shown in Fig . 1. The epithelium ishyperplastic and thrown into broad, fingerlike projections.

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1016 BOLENDER, SWENSO N, AND YAMANE November-D&i%; %sufficient healing, new dentures were made and inserted following the same pro-cedure as for Group I. At 12 months after operation, the palata l mucosa was againclinically and histologically evaluated.PROCEDURE

Group I.-A representative lesion from Group I is shown in Fig. 1. Theappearance of this same lesion is seen in Fig. 4 after new dentures had been wornfor 12 months. Virtually no clinical change was evident for this subject.

Following wearing of the new dentures for 12 months, a second biopsy wasmade. Care was taken to secure the biopsy specimen from an area away from theoriginal biopsy site, yet remaining in the most involved part of the lesion. Fig. 5is the histologic section of the lesion as shown in Fig. 4. The broad, fingeriike pro-jections and inflammatory, cellular exudate are still present, indicat ing minimalchange from the pretreatment biopsy (Fig. 2).

Half the subjects in Group I showed no change in severity of the papillary

SUBJECTS (20)I. Clinical Evaluation

2. Biopsy (preop.)

GROUP I (IO) GROUP II (IO)I IfSurgery1 I

New Dentures New Dentures1Clinical EvaluationBiopsy (I2 mod

Clinical EvaluationBiopsy (I2 mo .)

Fig. 3.-Outline of the study.

Fig. I.-The clin ical appearance of the same lesion shown in Fig. 1 following the wearhigof new dentures for 12 months.

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iz%Z 6 INFLAMMATORY PAPILLARY HYPERPLASIA OF PALAT E 101.7hyperplasia. The other half displayed a moderate reduction in erythema that wasconfirmed histologically, while the remainder of the microscopic and clinical fea-tures remained unchanged.

Group II.-A representative lesion from Group II is shown in Fig. 6. Thelesion 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 projectionsof epithelium and the inflammatory exudate.

Using a wire loop, (Fig. S) one of the investigators (K.D.S.) performed theoperation with a high-frequency electrical cutting current. The lesion was removed

Fig. 5.-A low-power microscopic view of the lesion shown in Fig. 4 following the wearingof new dentures for 12 months. Minimal change is evident in comparison with the pretreatmentbiopsy.

Fig. 6.-A representative lesion from a subjec t in Group II. The lesion covers approximatelythree fourths of the palate. The maximum depth of the papillary projections was 3 mm.

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1018 BOLENDER, SWENSO N, AND YAMANE November-D:&%?, ?;%

Fig. 7.-A low-power micro scop ic view of the lesion shown in Fig. 6.

Fig. 8

Fig. 9

Fig. %-Half of theinstrument.

lesion has been removed by using the wire loop elLectrical cu .ttingFig. 9.-The lesion has been completely removed.

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Volume 15Number 6 INFLAMMATORY PAPILLARY HYPERP LASIA OF PALAT E 1019to a subepithelial level just beneath the grooves in the papillary hyperplasia andwas always supraperiosteal. Local anesthesia was used. An outline of the preopera-tive biopsy site can be seen near the midline. Specimens for biopsy were removedby a scalpel. The operation is complete in Fig. 9. Bleeding was less with the cuttingcurrent wire loop than with sharp metal cutting instruments.

Following surgery, a lin ing of hard-setting zinc oxide and eugenol impressionpaste was placed in the subjects old denture (Fig. 10). This lin ing was changedat the two and three week postoperative intervals.

Discomfort of varying degrees, exhibited during the first week, was controlledmost effectively by the application of a topical anesthetic ointment. No bleedingproblems were encountered after operation.

Considerable healing had occurred after 2 weeks (Fig. 1 1 ), and the sorenesshad gone. The healing was essentially complete at 4 weeks (Fig. 12). Severalsmall erythematous areas can still be seen. The healing was complete at 4 weeks innine subjects and at 3 weeks in one subject.

At 4 weeks after operation, the old denture was relined by the usual proceduresusing acrylic resin. New dentures were made shortly thereafter. This procedure wasfollowed for al l subjects in Group II.

Fig. 13 shows the palate mainta ining a normal appearance at 3 months post-operative.

At 12 months after operation, the palatal mucosa was again evaluated. Clini-cally, the palate was normal (Fig. 14). Histologically, the tissue appears to besimilar to a normal palatal mucosa9 (Fig. 15). A similar result was seen in al lsubjects of Group II. The epithelium was well differentiated. The penetration ofthe rete pegs was fairly uniform and, for the most part, inflammatory cells wereabsent. In some instances, the epithelium showed a well-keratinized layer.RESULTS

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

Fig. 10.-A hard-setting zinc oxide eugenol impress ion paste lining was placed in the olddenture immediately following surgery.

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BOLENDER, SWENSO N, AND YAMANE J. Pros. Den.November-December, 1965

Fig. 12

Fig. 14

Fig. Il.-The 2 week postoperative result. Considerable healing has occurred.Fig. 12.-The 4 week postoperative result. Note the localized area of inflammation to theright of the midline.Fig. 13.-The 3 month postoperative result.Fig. 14.-The 12 month postoperative result, The tissue is maintaining itself. There is noevidence of the original lesion.

Fig. 15.-A low-power micro scop ic view of the 12 month postoperative result.

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Volume 15Number 6 INFLAMMATO RY PAPILLARY HYPERPLASIA OF PALATE 1021

TA B LE I. CLINICAL AND HISTO LOG IC EVALUAT IONGROUP I GROUP II

ISUBJECT 1 BEFORE AFTERI I______ -: T-: :1 T: z:

Not availableNot available

iSUBJECT PREOPERATIVE POSTOP ERATI \ E

LItIMWFMEwwFDisk

:: -: -*: -+ -+::

Not a&ableNot available

+ Lesion present.- Lesion absen t.Table I. Sum mary of investigation

*Dyskeratosis present preoperatively and 12 month s postoperatively. Subsequent 24-monthpostoperative biopsy-did not show dyskeratosis.

cal changes in the severity of the papillary hyperplasia. The size and color of thelesions remained the same. The other half (4) of the subjects displayed a moderatereduction in the erythema of the lesion but not in the size of the lesion. The micro-scopic examination confirmed these findings. It was impossible to maintain con-tact with 2 subjects in this group (Table I).Group II.-Where the lesions had been surgically removed, there was noclinical and histologic evidence of a return of the lesion in 7 subjects (2 men, 5women). However, 2 of these subjects exhibited a small localized area about 3 to 4mm. in diameter that was granular in appearance. In both instances, the lesionswere located in the depression between two rugae. Because of this, it is speculatedthat these two areas were not entirely removed at the time of surgery.

One subject (a woman), marked with the asterisk in Table I, showed alocalized erythematous response at 12 months postoperatively which was not pre-sent following healing. This inflammatory response, however, disappeared clini-cally after relining and adjusting the occlusion of the dentures. This same subjectwas the only one of the entire study who displayed dyskeratosis preoperativelyand 12 months postoperatively. Examination of a specimen taken for biopsy 24months postoperatively did not show dyskeratosis. Also, at 24 months, the clinicaland histologic appearance of the palate was well within normal limits. Two subjectswere also lost from this group (Table I).DISCUSSION

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

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1022 BOLENDER, SWENSON, AND YAMANE J. Pros. Den.November-December, 1965Surgical excision of the lesions by a high-frequency cutting current followed

by making new dentures resulted in the lesions complete removal. This methodproved to be adequate treatment and resulted in a normal mucosa.

It is important to reline the old denture immediately following surgery andto 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 ofits incidence in only one subject.

Supraperiosteal removal of inflammatory papillary hyperplasia is indicated andadequate treatment. Subperiosteal removal is not indicated except when one isdeal ing with a malignancy.

This project is being continued in order to evaluate the therapy over a longerperiod of time. At the end of the third year, five subjects remained in Group I andfour in Group II. The results so far indicate that the lesion still remained in thesubjects in ,Group I, while it was not seen in the subjects in Group II, i.e., itseemed to indicate that similar results will be obtained to those reported at theend of twelve months.SUMMARY

The results of this study indicated that the making of new dentures alonewas not effective in eliminating inflammatory papillary hyperplasia. However, sur-gical removal of the lesion and the making of new dentures was effective in theeradication of the lesion.REFERENCES

1. Fisher, A. K., and Rashid, P. J.: Inflammatory Papillary Hyperplasia of the PalatalMucosa, Oral Surg., Oral Med. & Oral Path. 5:192, 1952.2. Lyon, D. G., and Chick, A. 0. : Denture Sore Mouth and Angular Cheilitis : A PreliminaryInvestigation Into Their Possible Association With Candida Infection., D. Practi-tioner & 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 o f Lesions Associated With Dentures, J. PROS. DEN. 7:338,5. Nyquist, 6.: A Study of Denture Sore Mouth: An Investigation of Traumatic Allergicand Toxic Lesions of the Oral Mucosa Arising From the Use of Full Dentures, ActaOdont. Scandinavica 10, Suppl. 9:11-154, 1952.6. Hickey, J. C., Boucher, C. O., and Woelful, J. B.: Responsibility of the Dentist in Com-plete Dentures. J. PROS. DEN. 12:638, 1962.7. Friedman, Samuel: Effect ive 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 o f Complete Dentures on the Gum Tissues. A Histological andHistopathological Investigation, Acta Odont. Scandinavica 16:l. 1958.

UNIVER SITY OF WASHINGTON, SCHOOL OF DENT ISTRY ,SEATTLE, WASH. 98155