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CLINICOPATHOLOGIC CASE REPORT Table of Contents  
Ahead of print publication
Electro-surgical management of a traumatic fibroma with clinical assessment of re-epithelialization using methylene blue assay: A clinico-histopathological case report


1 Department of Periodontology, PMNM Dental College and Hospital, Bagalkot, Karnataka, India
2 Department of Periodontology, Bapuji Dental College and Hospital, Davangere, Karnataka, India

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Date of Submission30-Apr-2021
Date of Acceptance22-Jan-2022
Date of Web Publication15-Jun-2022
 

   Abstract 


This article addresses the clinical presentation, diagnosis, histological features, and management of a case of fibroma. Fibroma is proliferative fibrotic lesions of the gingiva and oral mucosa, which may cause aesthetic and functional problems. Fibrous hyperplasia and fibroepithelial hyperplasia are histological alternates of these nonneoplastic lesions. The case demonstrated an overgrowth in the lower back tooth region. The growth was pale in color, sessile, painless, and firm in consistency. The lesion caused discomfort when chewing food, the lesion was excised using dental electrocautery and sent for histopathological assessment. This lesion was caused by trauma or persistent irritation, and histological examination indicates that the cells in the lesion are from the oral mucous membrane. This case demonstrates the need for proper diagnosis, the role of biopsy, and histologic evaluation in the management of fibrotic lesions.

Keywords: Case report, electrocautery, fibroepithelial hyperplasia, traumatic fibroma


How to cite this URL:
Manjunatha VA, Vemanaradhya GG, Kulkarni M, Machetty L. Electro-surgical management of a traumatic fibroma with clinical assessment of re-epithelialization using methylene blue assay: A clinico-histopathological case report. Natl J Maxillofac Surg [Epub ahead of print] [cited 2022 Dec 10]. Available from: https://www.njms.in/preprintarticle.asp?id=347403





   Introduction Top


Fibroma is deliberated as the utmost common benign growth in the oral cavity.[1] They may arise from the gingival connective tissue or the periodontal ligament and are slow-growing, oval tumors[1],[2] that are firm and nodular, but few cases have been reported to be soft and vascular. Found in 1.2%[1] of adults, this inflammatory hyperplasia is the most common tissue biopsy[2] arising from the oral cavity and is usually composed of Types I and III collagen.

Gingival lesions are also communal, predominantly a consequence of enduring infection rather than trauma.[2] The most communal clinical facet is the growth of a well-delimited smooth-surfaced tissue, typically of a normal-colored mucosa, sessile or pedunculated base, of hard consistency,[3] and lesser than 1.5 cm at its largest diameter,[4],[5] The term “focal fibrous hyperplasia,” as suggested by Daley et al. 1990,[6] implies “a combative tissue response, is desirable to the term, fibroma” which entails erroneously, a benign neoplastic proliferative fibrous connective tissue.[7]

The lesion presents as painless, sessile, round, or ovoid broad-based swelling, lighter in color than the surrounding tissue due to reduced vascularity.[8] Treatment of the fibroma involves surgical excision using scalpel, electrocautery, and laser. Recurrence is rare. This article explains the diagnosis and treatment planning of traumatic fibroma.


   Case Report Top


A 53-year-old male patient reported to the department of periodontics, with a chief complaint of swelling in the right lower back tooth region for 2 months. History revealed a systemically healthy male with no family history of gingival epulis. The lesion was first noticed 2 months ago and the size gradually increased. There is no history of trauma to the hard and soft tissues; upon palpation, the lesion was painless. No antiquity of bleeding. Good oral hygiene was found with the oral hygiene index- score of 1.

On intraoral examination

The lesion was on the distal aspect of 48 with a dimension of about 7 mm × 6 mm in size, sessile, pink in color. The lesion was firm inconsistency. The radiographic image showed no bony involvement [Figure 1].
Figure 1: Preoperative view upon intraoral examination

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Further clinical examination revealed a sharp palatal cusp concerning 18 posteriorly, which was suspected to be the etiological factor for this fibrous outgrowth due to the irritation caused at the line of occlusion concerning 18 and 48.

Based on both the clinical and radiographic findings, the provisional diagnosis was made to be irritational fibroma on the distal aspect of 48. Possible differential diagnoses included giant cell granuloma, pyogenic granuloma, neurofibroma, or a benign salivary gland tumor.[9] The differential diagnosis including hyperplastic fibroma, peripheral giant cell granuloma, peripheral ossifying fibroma, pyogenic granuloma, papilloma, the gingival cyst was considered,[10] which would further be investigated the biopsy through histomorphometric analysis.

Treatment plan

The treatment was thus planned to surgically excise the lesion completely followed by correction of the sharp palatal cusp irt 18 through odontoplasty to prevent further recurrence of the lesion.

The treatment protocol was explained prior and written consent was obtained from the patient. The recommended routine blood tests were performed, and the reports acquired were within the normal range. At the first visit, the treatment plan started with scaling (Woodpecker Scaler®) and root planing (2R-2 L Columbia, universal curettes Hu-Friedy) was planned, the patient was kept in the maintenance phase for a week to subside the inflammation in gingival tissue in relation with 48. Following oral prophylaxis, it was decided to perform an excisional biopsy of the growth under local anesthesia using Dental Electrocautery (Medical Equipment India). Local infiltration anesthesia (2% lidocaine 1:80,000 adrenaline) was given in the area of interest. The electrocautery unit was set to cutting mode and the growth was excised en masse using the scalpel point T2 electrode with normal saline for irrigation [Figure 2]. Hemostasis was achieved using the hemostasis ball C3 electrode in the coagulation mode [Figure 3].[11],[12],[13]
Figure 2: Growth was excised en masse using the scalpel point T2 electrode

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Figure 3: Hemostasis was achieved using the hemostasis ball C3 electrode in the coagulation mode

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The sample was then transferred to a vial containing 10% formalin and sent for histopathological evaluation. Before discharge, postoperative instructions were given to the patient with the advice to take ibuprofen 400 mg thrice a day for 3 days and 0.2% chlorhexidine mouthwash twice daily for 14 days.

The patient was assessed every day for a week and the degree of epithelialization was evaluated via methylene blue stain [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]. The patient was indorsed to rinse with dye and immediately wiped the stained area with wet gauze to remove the dye on the surface of the normal epithelium, in order to stain the infeasible tissue and granulation tissue at the same time.
Figure 4: Healing checked on 2nd day. Note the increased uptake of dye by the damaged tissue

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Figure 5: Healing checked on 4th day. Note the gradual decrease in uptake of the dye by the healing tissue

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Figure 6: Healing checked on the 5th day

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Figure 7: Healing checked on the 6th day showing little or no uptake of the dye by tissues thus indicating re-epithelialization

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Figure 8: Day 7 postoperative view

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   Results Top


The uptake of methylene blue dye by the tissue gradually decreased indicating complete reepithelialization within 1 week [Figure 8].

Histopathology H and E

Stained section showed epithelium and connective tissue. The epithelium was orthokeratinized stratified squamous epithelium of varying degrees. Underlying fibrous connective tissue stroma showed mild chronic inflammatory infiltrate and few blood vessels. These features are suggestive of the fibroma [Figure 9].
Figure 9: Histopathology H and E

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   Discussion Top


A diverse group of pathologic processes can produce tissue enlargement of the oral cavity. Thus, those lesions often present as a diagnostic challenge. Within these lesions, a group of reactive hyperplasia that develops in response to a lingering repeated tissue damage can stimulate a violent or excessive response to tissue repair.[8] Reactive gingival lesions have been classified into pyogenic granuloma, peripheral giant cell granuloma, fibrous hyperplasia, and peripheral fibroma with calcification by Kfir et al.[4] As the most common nonneoplastic growth in the oral cavity, much has been written about the fibroma.

It has been known as irritation fibroma, traumatic fibroma, fibrous hyperplasia, focal fibrous hyperplasia, localized hyperplasia, fibrous polyp and fibroepithelial polyp.[9] The clinical presentation and epidemiology of most nonneoplastic growths in the oral cavity are quite similar; thus, identification is dependent on histopathological differentiation. Histologically, these lesions vary from granulation tissue to mature scar-like tissue, depending on age and vascularity.[10]

Lesions are collagenous and composed of mature fibrous tissue with a prominent vascular pattern. Epithelial changes are also related to the age of the lesion and the degree of inflammation. Fibroepithelial hyperplasias, when inflamed, are covered by uniformly hyperplastic epithelium, with an arcading rete pattern when ulcerated.[1],[2],[3],[4]

This case report is the first to describe a defined histopathological diagnostic criterion, as well as clinical and demographic information, and to propose the diagnostic name “Gingival Fibroma” (GF) for such lesions. We described and distinguished the key clinical and histologic characteristics of other common gingival lesions that might be included in the differential diagnosis of GF [Table 1].[3],[6]
Table 1: Differential diagnosis of “gingival fibroma”

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In the present case report, the lesion was excised by electrosurgery. Notable advantages of electrosurgery over the surgical scalpel include rapid dissection, precise tissue cutting with the self-disinfecting tip without the use of manual pressure, immediate and consistent hemostasis that does not obscure the operative field, reduced overall operative blood loss and scar-free wound healing.[11],[12] Atraumatic tissue cleavage and wound-sterilization eliminate the unfavorable postoperative sequelae common to scalpel surgery, contributing to rapid, uneventful postoperative healing.[12]

When compared to dental lasers, electrosurgery provides a number of advantages. It provides excellent cutting performance and is much cheaper than laser therapy. Furthermore, the electrode can cut on its side as well as the tip and can be angulated, thereby enabling easy contouring of the tissue, especially in areas difficult of access.[11] All of the above considerations made us choose electrosurgery as the preferred mode of treatment over the scalpel and laser.

Like all other devices, electrocautery has many disadvantages, including the necessity of preoperative anesthesia, the inevitable burning smell, poor tactile sensitivity, and increased thermal damage to surrounding tissues (including bone). Patients with pacemakers or implants cannot use electrosurgery.[11],[13]

Methylene blue is a vital dye that has been used to assess the progress of wound healing.[14] It is also effectively used as an early diagnostic marker for oral precancerous lesions and cancerous lesions.[15],[14] It stains the negatively-charged molecules, including the DNA, within damaged cells but does not stain the nonabsorptive epithelia. This makes it a simple yet effective technique to track the course of re-epithelialization.[16] As seen in the present case, methylene blue dye uptake gradually dwindled over 1 week and an indicative of re-epithelialization.


   Conclusion Top


Chairside evaluation of postoperative methylene blue re-epithelialization can be a routine procedure. It is a simple, inexpensive, and quick procedure that can assist doctors in determining the cure rate and degree of cure due to its minimal toxicity. More refined approaches are required to determine the specific timing of re-epithelialization and its relationship to the disappearance of methylene blue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Esmeili T, Lozada-Nur F, Epstein J. Common benign oral soft tissue masses. Dent Clin North Am 2005;49:223-40.  Back to cited text no. 1
    
2.
Newman MG, Takei H, Klokkevold PR, Carranza FA. Newman and Carranza's Clinical Periodontology E-Book. Beverly Hills, California: Elsevier Health Sciences; 2018.  Back to cited text no. 2
    
3.
Baumgartner JC, Stanley HR, Salomone JL. Zebra Hunt. Peripheral ossifying fibroma. J Endod 1991;17:182-5.  Back to cited text no. 3
    
4.
Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol 1980;51:655-61.  Back to cited text no. 4
    
5.
Kendrick F, Waggoner WF. Managing a peripheral ossifying fibroma. ASDC J Dent Child 1996;63:135-8.  Back to cited text no. 5
    
6.
Daley TD, Wysocki GP, Wysocki PD, Wysocki DM. The major epulides: Clinicopathological correlations. J Can Dent Assoc 1990;56:627-30.  Back to cited text no. 6
    
7.
Krahl D, Altenburg A, Zouboulis CC. Reactive hyperplasias, precancerous and malignant lesions of the oral mucosa. J Dtsch Dermatol Ges 2008;6:217-32.  Back to cited text no. 7
    
8.
Barot VJ, Chandran S, Vishnoi SL. Peripheral ossifying fibroma: A case report. J Indian Soc Periodontol 2013;17:819-22.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Gusterson BA, Greenspan JS. Multiple polypoid conditions of the oral mucosa. Br J Oral Surg 1974;12:91-5.  Back to cited text no. 9
    
10.
Kolte AP, Kolte RA, Shrirao TS. Focal fibrous overgrowths: A case series and review of literature. Contemp Clin Dent 2010;1:271-4.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Funde S, Baburaj MD, Pimpale SK. Comparison betweenlaser, electrocautery and scalpel in the treatment of drug-induced gingival overgrowth – A case report. IJSS Case Rep Rev 2015;1:27-30.  Back to cited text no. 11
    
12.
Sharma N, Sachdeva SD. A comparative study of electro-surgery and scalpel surgery. Heal Talk 2012;5:36-8.  Back to cited text no. 12
    
13.
Loh SA, Carlson GA, Chang EI, Huang E, Palanker D, Gurtner GC. Comparative healing of surgical incisions created by the PEAK PlasmaBlade, conventional electrosurgery, and a scalpel. Plast Reconstr Surg 2009;124:1849-59.  Back to cited text no. 13
    
14.
Lejoy A, Arpita R, Krishna B, Venkatesh N. Methylene blue as a diagnostic aid in the early detection of potentially malignant and malignant lesions of oral mucosa. Ethiop J Health Sci 2016;26:201-8.  Back to cited text no. 14
    
15.
Gupta M, Shrivastava K, Raghuvanshi V, Ojha S, Gupta A, Sasidhar S. Application of in vivo stain of methylene blue as a diagnostic aid in the early detection and screening of oral cancerous and precancerous lesions. J Oral Maxillofac Pathol 2019;23:304.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Milyavsky M, Dickie R. Methylene blue assay for estimation of regenerative re-epithelialization in vivo. Microsc Microanal 2017;23:113-21.  Back to cited text no. 16
    

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Correspondence Address:
Vinayaka Ambujakshi Manjunatha,
Room No. 4, Department of Periodontology, PMNM Dental College and Hospital, Bagalkot, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njms.njms_376_21



    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

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