Ranjana Desai*, Nalini Jangid**, Rashmi Sharma***, Kiran Mirdha****
(*Professor, **3rd year P.G. Resident, Department of Obstetrics and Gynaecology; ***Assistant Professor, Department of Pathology; ****Medical Officer, Department of Obstetrics and Gynaecology; Dr. Sampoornanand Medical College, Jodhpur)
Epulis of pregnancy is a benign growth of the gingiva with a rare occurrence during pregnancy. This is a report of a case of epulis during pregnancy which showed spontaneous regression after delivery.
Epulis fissuratum or Granuloma fissuratum is an oral pathologic hyperplastic condition that appears in the mouth as an overgrowth of fibrous connective tissue mainly from gingivial tissues. When it is associated with the edges of an ill fitting denture it is referred to as Inflammatory fibrous hyperplasia, Denture epulis or Denture induced fibrous hyperplasia. Epulis in a patient without dentures can also be diagnostic of Crohn's disease.Its occurrence in a pregnant woman is termed Epulis of Pregnancy or Granuloma gravidarum. Since it is rare during pregnancy and because its prevalence in pregnancy has not been well documented, the present case merits attention.
A 24 year old third gravida with two full term normal deliveries presented to our antenatal clinic with amenorrhea of 7 months duration. While taking her history it was noted that she had an irregular fleshy growth over her teeth. On everting her upper lip and examining the gums of the upper jaw, a 2 centimeters long irregular fleshy mass was detected arising from the gums and growing over and between her incisor teeth (figure 1). On examining the oral cavity the lesion extended 3 centimeters posteriorly on the soft palate (figure 2). The lesion was firm to touch, non-tender. History revealed that the growth had slowly evolved from a small size to the present one over a period of 2 months. The lesion was asymptomatic and the patient refused a biopsy. A clinical diagnosis of epulis of pregnancy was made. No surgical intervention was advised and only oral hygiene in the form of mouth wash with a commercially available over-the-counter mouth wash consisting of an aqueous solution containing bezoic acid, poloxamer 407, eucalyptol, thymol, sodium benzoate, and menthol mixed in alcohol twice a day and regular brushing of teeth twice daily was recommended. One month after delivery the mass had spontaneously regressed to half its size. And two months after delivery the lesion was one fourth its former size. After this the patient was lost to follow up.
Figure 1 : Anterior view of the epulis. Note the irregular fleshy growth emerging from between the incisors.
Figure 2 : Buccal view of the epulis. Note the dumbbell shape of the tumor displacing the incisors.
Epulis of pregnancy (synonyms: pregnancy tumor, granulaoma gravidarum, pyogenic Granuloma) is described as a gingival lesion that looks like a small, dome shaped hemangioma, often with a peripheral collarette of scales. The excess tissue is firm and fibrous; ulcerations may be present. It is usually pedunculated but may be sessile. It appears in gums around the alveolar vestibule, in either the mandible or maxilla (upper jaw) but is more commonly found in the frontal part of the maxilla during the third trimester. Often it has been referred to as pyogenic granulaoma in medical literature but the term is a misnomer, for this is not an infectious or pustular process.
The lesion is usually asymptomatic but appears cosmetically unsightly. It may interfere with mastication, closure of the oral cavity, brushing or flossing. The teeth adjacent to the epulis may loosen due to the pressure effect or may show migration. Sometimes there may be recurrent bleeding from the lesion resulting in life threatening hemorrhage requiring blood transfusion.
Etiologic factors responsible for epulis of pregnancy are improper maintenance of oral hygiene which leads to chronic gingivitis and the influence of hormones by a complex and partly understood mechanism on the gingival vasculature.[5,6]
Epulis has several histologic types. Granulomatous type is the prevalent type during pregnancy. It presents an inflammatory component characterized by lymphocytes, plasma cells and neutrophiles, an abundant vascular component with newly formed capillaries and a great proliferation of fibroblasts.
The lesion usually resolves partially or completely post partum within 1 to 4 months as it did in this case reported. Persistent lesion requires treatment by firstly removal of irritating factors and secondly surgical excision of the lesion, curettage, chemical or electric cauterization, cryo therapy or laser ablation.
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Desai R, Jangid N, Sharma R, Mirdha K. Epulis of Pregnancy. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/epulis-of-pregnancy.html