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Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 47-51

Clinical Study of Squamous Cell Carcinoma as a Result of a Fissured Epulis in Upper Total Edentulous Patient: A Case Report

Department of Investigation, Faculty of Dentistry, University of Guayaquil, Guayaquil, Guayas Province, Ecuador

Date of Web Publication6-Sep-2019

Correspondence Address:
William Ubilla-Mazzini
Department of Investigation, Faculty of Dentistry, University of Guayaquil, Guayaquil, Guayas Province
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_7_19

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Introduction: The fissured epulis is a reactive tissue growth that develops underneath a dental prosthesis. Its etiology is related to removable of partial or total dentures and other irritative or traumatic factors. Oral cancer (CAB) is a malignant neoplasm of aggressive behavior, and it has become one of the most serious health problems worldwide. Currently, squamous cell carcinoma is considered a disease with a high mortality rate. This article aims to describe the clinical management of a squamous cell carcinoma, as a result of a fissured epulis in upper total edentulous patient. Case Report: A female patient, 58 years of age, with no systemic or family history, went for a lower removable prosthesis. The clinical examination in the maxilla presented an enlargement of soft tissue in the bottom of the vestibule on the left side, asymptomatic, compatible with a fissured epulis. Two surgical procedures were performed to remove the pathology and a sample was taken to perform a biopsy, which resulted in a squamous cell carcinoma. The patient was referred to a center specialized in cancer treatments (Society for the Fight Against Cancer) where she currently is receiving the attention of the case. Conclusions: The lack of knowledge of this injury on the part of the patient, and the lack of symptomatology, absence of periodic controls, maladjustment, and incorrect prosthetic design were the risk factors that triggered the injury.

Keywords: Fissured epulis, removable prosthesis, squamous cell carcinoma, total edentulous

How to cite this article:
Guzman-Gallardo H, Ubilla-Mazzini W, Mazzini-Torres F, Plúas-Robles C. Clinical Study of Squamous Cell Carcinoma as a Result of a Fissured Epulis in Upper Total Edentulous Patient: A Case Report. Dent Hypotheses 2019;10:47-51

How to cite this URL:
Guzman-Gallardo H, Ubilla-Mazzini W, Mazzini-Torres F, Plúas-Robles C. Clinical Study of Squamous Cell Carcinoma as a Result of a Fissured Epulis in Upper Total Edentulous Patient: A Case Report. Dent Hypotheses [serial online] 2019 [cited 2023 Jun 2];10:47-51. Available from:

  Introduction Top

Removable prostheses are a very good alternative to the loss of dental pieces. However, despite being a good solution, they are not free to cause injuries in the oral cavity, which, together with the susceptibility of tissues produced by aging or inadequate lifestyles, can generate important mucous membrane changes, the bones of the oral cavity, and, above all, the appearance of injuries that can vary from the simplest to the malignant and cause a great health problem for people and the society.[1] The reason why, at present, removable prostheses are considered risk factors.

On the other hand, there is an important relationship between the time of use of the prosthesis, hygiene, and its state with the increase of oral mucosal injuries. The current situation in Ecuador on the use of prostheses, the oral injuries caused by those that are being used as well as the relationship between their characteristics and oral injuries in the population, is not visibly quantified. It is also not known for sure the risk that a person has of oral injuries with a long time of use or with a mismatched or damaged prosthesis. It is important to deepen this problem, and it is of great importance for the planning of medical services and to establish adequate policies for the benefit of the population. Therefore, this research was carried out with the objective of describing the characteristics of the removable prostheses used in the population of 60 years of age and older and its relationship with oral mucosal injuries.

The term “epulis” was used by Virchoff in 1864 and comes from the Greek words “epi” (on) and “oulon” (gum). Later, in 1887, Désir de Forturnet defined epulis as any solid tumor located near the alveolar ridge, which is not accompanied by lymph node involvement, without tendency to ulceration and which does not recur, generally after complete ablation.[2] Currently, the term “epulis” is not accepted by several authors such as Dechaume,[2] Grinspan,[3] and Shafer,[2] among others, as it only indicates a growth on the gum without specifying the nature of the injury, considering that this histological study is essential to establish a diagnosis of certainty. Borguelli clinically defines the epulis as an abnormal growth, circumscribed and of chronic evolution, located in the gum or near the alveolar ridge. On the other hand, Donado[4] considers the term epulis from a clinical point of view and defines it as a chronic, granulomatous inflammatory mass on the gum and in dependence on the periosteum or the periodontium.[2] According to some studies, it occurs more frequently after the fifth and sixth decade of life of patients with incongruent removable of prostheses; the incidence is variable from 1% to 12%, with predominance in the female sex.

Oral cancer (CAB) is a malignant neoplasm of aggressive behavior, which comprises 4% to 5% of all tumors that affect humans and has become one of the most serious health problems worldwide, due to the increased incidence in recent years and its high mortality rate.[5] Most of the CABs are of the oral squamous cell carcinoma (CEB) type, which represents 91% of all oral cancers.

Currently, squamous cell carcinoma (CEB) is considered a disease with a high mortality rate and ranks sixth among the causes of death.[6] In recent years, it has been reported that its incidence increased especially in young people and women, due to the exposure to risk factors such as smoking and alcohol,[7] according to epidemiological data from countries such as Japan, EE.UU., Brazil, and Thailand.

Squamous cell carcinoma has a series of different clinical presentations. In the early stage, it may appear as an asymptomatic erythematous (erythroplastic) injury or a white injury (leukoplastic), or both (erythroleukoplastic). It can also appear as an erosion, a small ulcer, an exophytic mass, or a periodontal injury. In advanced stages, it can present as a large exophytic mass with or without ulcerations, deep ulcer with an irregular vegetative surface, raised borders, and a hard infiltrate of the buccal tissues.[8],[9]

This case report aims to describe the clinical management of a buccal squamous cell carcinoma (CEB) from an inflammatory fibrous hyperplasia (fissured epulis) diagnosed in a patient who attended the dental office to replace a dental prosthesis.

  Case Report Top

In January 2017, a female patient, 58 years old, of mestizo race, without presenting systemic or family background, went to the Adult Integral Clinic and the Senior Adult I, Removable Prosthetic Area, School of Dentistry of the University of Guayaquil. She mentions her reason for consultation as “I want them to make a plaque down, up if I have and it looks good, and I cannot eat because I do not have teeth.”

When performing the oral clinical examination, we observed a maxillary edentulous total in the patient, and mandibular partial edentulism identified as Kennedy class I, bacterial plaque, and caries. A thorough examination of the soft and hard tissues was carried out, and when the lips were lifted, it could be seen that at the bottom of the vestibule on the left maxillary side, there was an enlargement of soft tissue compatible with a fissured epulis. The patient, if she knew of that injury, to which she stated that she did, but that she did not remember exactly from when she presented it. Besides, she never felt any discomfort or pain, so she did not give the importance of the case [Figure 1].
Figure 1 (A) Upper prosthesis. (B) Fissured epulis with the prosthesis. (C) Fissured epulis without the prosthesis.

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In the clinical history, important data were obtained to determine the etiology of the injury and the state of the total prosthesis; the frequency of use of the prosthesis was day and night. The time of use of the prosthesis was 7 years, when the advisable is from 4 to 5 years. The prosthesis presented an incorrect design due to the extension of the flanks in the vestibular area, a poor hygiene, and the occlusal anatomy of the artificial teeth preserved. All these factors, along with the clinical characteristics that it presented, determined the presumptive diagnosis of a cleft pulp immediately proceeded with the removal of the total maxillary prosthesis; surgery was recommended, which was performed 10 days after the first consultation, in the Maxillofacial Surgery Clinic, with a favorable prognosis until then. In addition, a biopsy of the tissue removed during surgery was ordered [Figure 1].

Approximately 2 weeks after having undergone surgery, the patient was presented, to continue prosthetic rehabilitation, stating that the requested biopsy had not been performed, because she did not have the financial resources.

When performing the clinical examination for the prosthetic rehabilitation, at the bottom of the vestibule, a small enlargement of the mucosa in the intervened area was observed, which caused surprise, and we proceeded to suspend the rehabilitation. Despite the first surgical act and not using the total prosthesis, there was a relapse of the injury. They performed the respective examinations and was intervened for the second time in mid-February 2017, requesting family members to perform an urgent biopsy of the injury [Figure 2].
Figure 2 (A) First recurrence fissured epulis. (B and C) Second surgery. (D and E) Apparent improvement of the injury. (F) Biopsy results. (G) Moderately differentiated cancer cells. (H) Programmed death-1 ligand (I) Strong expression in tumoral cells. (J) Strong expression in stromal cells.

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Six days after the second surgery, she went to the first postoperative control, and there was a noticeable improvement in the affected area, and she also delivered the results of the biopsy [Figure 2].

Approximately after 15 days, she went to the second control, and the injury recurred for the second time, this confirmed our suspicion with the results of histopathological examination, which determined the diagnosis of “well differentiated and infiltrating squamous cell carcinoma,” whereupon it was sent to the Society for the Fight Against Cancer so that she receives the corresponding treatment. In addition, the patient’s prosthesis was worn to avoid contact with the injury [Figure 3].
Figure 3 (A and B) Second recurrence fissured epulis. (C) New upper prosthesis. (D) Wear on the prosthesis.

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At the moment, the patient is under chemotherapy in the specialized health center, but did not present satisfactory results, now she is continuing with radiotherapy. Despite the treatment received, the patient has not shown a favorable prognosis in her health.

  Discussion Top

At present, fibrous inflammatory hyperplasia or fissured epulis, one of the injuries that occurs relatively frequently in the stomatology practice, is observed as an excessive growth of soft tissue around the edges of poorly fitted prostheses.[10] In a study carried out by Guzmán y cols at the Faculty of Dentistry of the University of Guayaquil in 100 patients with removable prostheses, it was presented with a frequency of 2%.[11] This differs with other studies in that it presents an incidence that ranges from 1% to 12%.[12] In Cuba, in a study conducted by Castañeda et al. (2018), it presents a frequency of 21.4%.[13] Based on epidemiological studies, and the significant increase of them, it is important to have knowledge of the different injuries that affect the oral cavity, and its relation with the removable prosthesis, to prevent them, and avoid that they can affect the oral and general health of the patients.

The clinical case presented, due to its clinical characteristics, is compatible with a fissured epulis. The treatment is usually surgical, based on alternative techniques such as cryosurgery.

In this clinical case, it was possible to demonstrate that the prosthetic bad adjustment, the lack of periodic controls, absence of symptomatology, and total ignorance of the injury by the patient contributed significantly in the presence of this. We must emphasize that at the first surgical act, the patient was informed that he had to perform the biopsy of the excised tissue, which was not performed, indicating lack of economic resources. Fortunately, in the second surgical intervention, he agreed to perform the biopsy, with the results already described above, and which was diagnosed in squamous cell carcinoma.

Sharma et al., in 2010, investigated correlation of microvascular density with mast cell proliferation and revealed that positive correlation was observed in moderately differentiated injuries but not in well or poorly differentiated types.[14] On the other hand, another study stated that there was significant correlation in mast cell and microvessel density in normal oral mucosa but not in oral squamous cell carcinoma, regardless of the histological grade. In our study, the histopathological results showed that there was a considerable density of mast cells and microvessels in the oral mucosa.Studies in the United States and Ecuador have reported disparate trends in incidence for cancers arising from various anatomic sites in the oral cavity and oropharynx, whereas the incidence of oral cavity cancers has decreased and oropharyngeal cancer incidence has increased, specifically among younger age groups.[15]

Oral squamous cell carcinoma has a remarkable incidence worldwide and a fairly onerous prognosis, encouraging further research on factors that might modify disease outcome. In this clinical study, the authors approach the factors that may exert influence on the prognosis and eventually guide the selection of patients for more aggressive therapies.[16]

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Conflicts of interest

There are no conflicts of interest.

  References Top

García B, Benet M, Castle E. Dental prosthesis and mucous lesions in the elderly: a concern for everyone. Medi Sur 2010;8:36-41.  Back to cited text no. 1
Tamarit M, Delgado E, Berini L, Gay-Escoda C. Exeresis of hyperplastic lesions of the oral cavity: retrospective study of 128 cases. Oral Med Oral Pathol Oral Surg 2005;10151-62.  Back to cited text no. 2
Grinspan D. Diseases of the mouth. Semiology, pathology, clinical and therapeutic of the oral mucosa. Buenos Aires Mundi 1977;2:808-12.  Back to cited text no. 3
Donado M. Introduction to oral and maxillofacial tumor lesions. In: Donado M, editor. Oral Surgery Pathology and Technique. Madrid: Masson 1998. pp. 559-63.  Back to cited text no. 4
Cotran RS, Kumar V, Collins T. Neoplasia. In: Robbin’s Pathologic Basis of Disease. 6th ed. Pennsylvania: Mosby 1999. pp. 260-325.  Back to cited text no. 5
Patton LL. The effectiveness of community based visual screening and utility of adjunctive diagnostic aids in the early detection of oral cancer. Oral Oncol 2003;39:708-23.  Back to cited text no. 6
Llewelyn CD, Linklater K, Bell J, Johnson NW, Warnakulasuriya S. An analysis of risk factors for oral cancer in young people: a case-control study. Oral Oncol 2004;40:304-13.  Back to cited text no. 7
De Souza LN, Albuquerque A, Rodrigues C, Gomez R, Da Costa P, López R. Squamous cell carcinoma diagnosed early. Rev Cubana Estomatol 2010;47.3.  Back to cited text no. 8
Guzmán H, Briones M, Suarez J, Loza D, Plúas C. Subprotic stomatitis: a silent enemy. Report of Clinical Case. In: Ubilla W, Vintimilla UW, Saez PR. editors. II International Congress of Research and Scientific Production in the Stomatology Field. 2nd ed. Guayaquil, Ecuador: University of Guayaquil; 2018. pp. 77-82.  Back to cited text no. 9
Díaz Guzmán LMGZO, Gay-Zarate O. Series in oral medicine X. Quality dentistry for elderly patients. Revista ADM 2005;LXII:36-39.  Back to cited text no. 10
Guzmán H, Suárez J, Romero D, Loza D. Prevalence of oral cavity lesions related to the use of dental prostheses. In: Vintimilla UW, Saez PR, editors. I International Congress of Research and Scientific Production in the Stomatology Field. 1st ed. Guayaquil, Ecuador: University of Guayaquil; 2018. pp. 205-2011.  Back to cited text no. 11
Mandali G, Damla SI, Turker SB, Ülgen H. Factors affecting the distribution and prevalence of oral mucosal lesions in complete denture wearers. Gerodontology 2011;28:97-103.  Back to cited text no. 12
Castañeda S. Effectiveness of cryosurgery in oral lesions in the elderly. Stomatol Clin 2018;47:347-54.  Back to cited text no. 13
Sharma B, Sriram G, Saraswathi TR, Sivapathasundharam B. Immunohistochemical evaluation of mast cells and angiogenesis in oral squamous cell carcinoma. Indian J Dent Res 2010;21:260-5.  Back to cited text no. 14
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Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirusrelated and-unrelated oral squamous cell carcinomas in the United States. J Clin Oncol 2008;26:612-9.  Back to cited text no. 15
Massano J, Regateiro FS, Januário G, Ferreira A. Oral squamous cell carcinoma: review of prognostic and predictive factors. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2006;102:67-76.  Back to cited text no. 16


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