| Epulis is a kind of localized hyperplasia commonly seen in the gingiva.Although with tumor-like appearance,epulis is considered to be non-neoplastic in nature.Some studies indicate that epulis in reality arises in response to various stimuli such as low-grade local irritation,traumatic injury,hormonal factors or some drugs.Excisional biopsy is indicated for treatment of epulis,which mainly has two disadvantages.Firstly,postoperative recurrence should not be ignored,the main reason for which is incomplete resection,resulting in failure to remove local stimulation factors throughly,or secondary injury in the surgical area.In addition,in anterior areas,soft tissue deformity will cause aesthetic defects.In the posterior,the soft tissue deformity may result in insufficient width of the attatched gingiva and the horizontal food impaction.To prevent postoperative recurrence,multiaspect may take effect.Radical initial therapy can remove local micro stimulation factors in preoperative phase.Besides,improving surgical skills leads to complete surgical treatment.Moreover,strict medical orders contribute to avoiding secondary injury in the surgical area.However,the periodontist could not prevent the soft tissue defect after ectomy of epulis.Therefore,the study has been committed to explore a treatment,which could treat epulis through the minimally invasive method based on the elimination of local chronic micro stimulation.The improved treatment will try to avoid soft tissue defect by the maximized retention of soft tissue.This study contains three parts.In the first part,the histological changes of the epithelium and connective tissue of epulis are analyzed after initial therapy,which provids a theoretical basis for the treatment of epulis.The second part is designed to explore a kind of improved treatment,namely partial removal peiodonatal surgery in the therapy of epulis,which can retain more keratinized gingiva.The third part is aimed to explore a non-surgical treatment of pregnancy epulis,especially for lactating patients who could not accept surgical treatment.According to the above studies,the strategy of clinical treatment for epulis was presented.Part oneThe histological changes of the epulis after initial therapyObject:Evaluate the histological changes of the epithelium and connective tissue of epulis after initial therapyMethods:From October 2012 to October 2014,we collected clinical diagnosis of patients with epulis granulomatosa and fibrous hyperplasia in Huizhou Stomatological Hospital.There were 15 cases in each class,with 30 cases in total.In the epulis granulomatosa group,male 6,female 9,agedl8y?45y,with an average age of 29.8±1.8y.In the fibrous hyperplasia group,male 8,female 7,aged21y?53y,with an average age of 34.5±2.4y.The patients were randomly devided into three groups,with 5 patients in each group:Surgical excision was performed in the first group;the second group underwent surgical resection after 1?2 months of initial therapy.The third group underwent surgical resection after initial therapy for 2?3 months.Following indexes were detected for all teeth:1.baseline information(1)Bleeding index,the exact site of epulis,the diameter of epulis during initial diagnosis;2.morphological examination(2)Changes in the epithelium width and epithelial cells after HE staining;(3)Microvessel density counts in connective tissue;(4)Collagen fiber area in connective tissue;3.Inflammatory cell examination(5)CD45 positive inflammatory cells expression in connective tissue;(6)Macrophage expression in connective tissue;4.Immunohistochemistry(7)TNF-a expression in epithelial tissue and connective tissue;(8)IL-10 expression in epithelial tissue and connective tissue;(9)TGF-?1 expression in epithelial tissue and connective tissue.Import the data into spss 16.0,making data analysis.The baseline information,which are distribution site of epulis,bleeding index,the diameter of epulis during initial diagnosis,adopt the homogeneity test of variance,P>0.05,present that variance of each group is considered.There are no significant differences between the three groups,which were compared by one-way anova,P>0.05.The immunohistochemistry after surgery:the CD45 positive inflammatory cells expression,the macrophage expression,the TNF-a expression,the TGF-?1 expression,the microvessel density,the collagen fiber area and the epithelial width,adopt one-way anova,P<0.05,was a significant difference.Results:1.Comparison of baseline information during initial diagnosis1.1 Distribution site of epulisThere is no significant difference between the epulis granulomatosa group and the fibrous hyperplasia group.1.2 Comparison of the diameter of epulisThere is no significant difference between the epulis granulomatosa group and the fibrous hyperplasia group.1.3 Comparison of bleeding indexThere is no significant difference between the epulis granulomatosa group and the fibrous hyperplasia group.2.Postoperative index2.1 HE staining result2.1.1 Morphologic descriptionIn the epulis granulomatosa group,the histopathology of epithelium before the treatment showed:there are many layers of epithelial cells,mainly spinonum layer cells;the edema eccures among in the interepithelial,and the gap of the stratum spinosum is Widened,which is expressed as "spongiosis";The stratum spinosum was irregular and the epithelium spikes was prolonged;the basal cells are not aligned.When ulceration occured on the surface of the epulis,the epithelial cells of the ulcer area were completely exfoliated,with a large number of proliferating vascular endothelial cells below.After 1?2 months of periodontal treatment,the number of epithelial cells decreased,and the stratum spinosum cells decreased;the basal cells are dense.After 2?3 months of periodontal treatment,the number of epithelial cells decreased,and the basal cells were more dense;the epithelium spikesis is superficial.In the fibrous hyperplasia group,the histopathology of epithelium before the treatment showed:the edema eccures amongin the interepithelial,and the gap of the stratum spinosum is widened,which is expressed as "spongiosis";The basal cells are dense,and the stratum spinosum is located at the shallow layer of the basal cells layer,with the most layers.and the nucleus of the stratum granulosum is concentrated and hyperchromasia.the number of cells in each layer is normal;after the periodontal treatment,the intercellular space is normal,and the morphology of each layer cells are regular.2.1.2 Epithelial width measurementIn the epulis granulomatosa group,the epithelial width gradually decreased after initial therapy,the differences between those three groups was statistically significant.In the fibrous hyperplasia group,there was no significant change of the epithelial width during initial diagnosis,1?2months after initial therapy and 2?3months after initial therapy.There was no statistically significant difference between the three groups.2.2 Microvessel densityAfter initial therapy,the microvessel density of epulis granulomatosa group and fibrous hyperplasia group gradually decreased,showed statistic difference.2.3 Collagen fiber areaAfter initial therapy,there was a gradual increase in the area of collagen fibers of epulis granulomatosa and fibrous hyperplasia,there was statistical significance between three groups.After 2?3 months of the initial periodontal treatment,the collagen fiber area of the epulis granulomatosa group was lower than that of normal gingiva,the fibrous hyperplasia is higher than that of normal.2.4 CD45 positive inflammatory cells expression in connective tissue.After initial therapy,the CD45 positive inflammatory cells expression in connective tissue of epulis granulomatosa and fibrous hyperplasia decreased,there was statistically significant before and after therapy.2.5 Macrophage expression in connective tissueAfter initial therapy,the macrophage expression in connective tissue of epulis granulomatosa and fibrous hyperplasia decreased,there was statistically significant before and after therapy.During the inflammation period,the macrophages in connective tissue of epulis granulomatosa and fibrous hyperplasia,are expressed a large number of TNF alpha and IL-10,suggested that macrophages M1 and M2 phenotypes were increased,and M2 phenotypes switched to M1 phenotype;After periodontal treatment,the expression of macrophages in the connective tissue of epulis granulomatosa and fibrous hyperplasia decreased,and the expression of TNF-was gradually decreased,and the expression of IL-10 was not significantly changed.suggested that during the recovery period,macrophages M1 and M2 phenotypes are lower,Ml phenotype switched to M2 phenotypes.2.6 TNF-a expression in epithelial tissue and connective tissueAfter initial therapy,the TNF-aexpression in connective tissue of epulis granulomatosa and fibrous hyperplasia decreased,there was statistically significant before and after therapy.2.7 IL-10 expression in epithelial tissue and connective tissueIn the epithelial tissue and connective tissue of epulis granulomatosa,the IL-10 expression of 1-2months after initial therapy was lower than that during initial diagnosis,showed statistical significance;there was no statistical significance between the IL-10 expression of 1-2months and 2-3months after initial therapy.In the epithelial tissue and connective tissue of fibrous hyperplasia,the IL-10 expression of 1-2months after initial therapy was lower than that during initial diagnosis,showed statistical significance;there was no statistical significance between the IL-10 expression of 1-2months and 2-3months after initial therapy.2.8 TGF-(3 1 expression in epithelial tissue and connective tissueAfter initial therapy,the TGF-?1 expression in the epithelial tissue and connective tissue of epulis granulomatosa decreased,there was statistically significant before and after therapy.In the epithelial tissue and connective tissue of fibrous hyperplasia,the TGF-?1 expression of 1-2months after initial therapy was lower than that during initial diagnosis,showed statistical significance;there was no statistical significance between 1-2months arid 2-3months after initial therapy.Conclusion:1.During the inflammation period,macrophages M1 and M2 phenotypes were increased;After periodontal treatment,the expression of macrophages in the connective tissue of epulis granulomatosa and fibrous hyperplasia decreased,macrophages M1 and M2 phenotypes are lower.2.The restoration of epithelial histology provides a theoretical basis for partial removal periodontal surgery in the therapy of epulis.3.After initial therapy,the microvessel density of epulis granulomatosa group and fibrous hyperplasia group gradually decreased when collagen fiber area gradually increased.Part twoClinical evaluation of partial removal periodontal surgery in the therapy of epulisObject:Evaluate the clinical effect of treating epulis by traditional surgery and partial removal periodontal surgery,which reserves epithelium.Methods:33 cases of patients match the inclusion and exclusion standard,clinical diagnosis of patients with epulis granulomatosa and fibrous hyperplasia in Huizhou Stomatological Hospital.The patients were randomly devided into two groups,in the control group,male 7,female 11,with an average age of 35.3±3.2y;in the experimental group,male 6,female 9,with an average age of 39.7±1.9y.All patients had periodontal initial therapy before surgery.Traditional surgery was used to remove the epulis in the control group,while partial removal periodontal surgery was used in the experimental group.The concrete operation of the experimental group is:local infiltration anesthesia of epulis area,make crevicular incision at the tumor body and the surrounding gingiva,turn the full thickness flap,exposure the dental root and alveolar bone,remove the surrounding granulation tissue completely,remove pericementum and local irritants,root planning,alveolar bone profile modification,recontour the tumor body by Minimally invasive tissue scissors,reserve the tumor epithelium and partial connective tissue,with the thickness of 0.5 mm,so that the retained epithelium and connective tissue can cover the surgical area,tight suture.Following indexes were detected:1.The exact site of gingival tumor2.The diameter of the lesions3.Visual analogue scale to evaluate the pain after surgery4.BI and PLI before surgery and 12 weeks after surgery5.Gingival recession at 12 weeks after surgery6.Gingival papilla filling index at 12 weeks after surgery7.Changed width of keratinized gingiva at 12 weeks after surgery8.Visual analogue scale to evaluate the satisfaction after surgery9.Relapse at 1?3 years after surgeryImport the data into spss 16.0,making data analysis.The baseline data of the experimental combination were:the patient's age adopt the chi-square test,P<0.05 was a significant difference;the diameter of the tumor adopt the t-test,P<0.05 was a significant difference;The rank and test were used for the sex of the patient,P<0.05 was a significant difference;The distribution of the tumor sites was based on the chi-square test,and P<0.05 was a significant difference.The data after the operation:the changes in the width of the keratinized gingiva and the gingiva receding,adopt the t-test,P<0.05,was a significant difference.Gingival papilla filling index after surgery,preoperative and postoperative plaque index,and preoperative and postoperative bleeding index,postoperative pain VAS,postoperative satisfaction,adopt rank and test,P ? 0.05 was a significant difference.Results:1.There is no statistical difference of baseline data between experiment group and control group,as the age and gender of patients,exact site of the lesions,the diameter of the tumor,BI and PLI before surgery,as follows:(1)7 males and 11 females in the control group;6 males and 9 females in the experimental group.Through the chi-test of two independent samples,P>0.05,shows that there is no significant difference in gender composition between the experimental group and the control group.(2)The mean age of the experimental group was 35.3±3.2 years old,and the mean age of the control group was 39.7±1.9 years old,with the T test of the two independent samples,P>0.05,indicating no significant difference in age between theexperimental group and the control group.(3)In the control group,11 cases tumors located in the upper jaw,7 cases located in the lower jaw;Maxillary anterior teeth 9 cases;Maxillary posterior teeth 4 cases;Mandible posterior teeth 4 cases;Lip buccal 15 cases,the tongue palatal side 5 cases.In the experimental group,10 cases tumors located in the upper jaw,5 cases located in the lower jaw;Maxillary anterior teeth 8 cases;Maxillary posterior teeth 3 cases;Mandible posterior teeth 4 cases;Lip buccal 10 cases,the tongue palatal side 7 cases.The rank and test of the two groups shows no significant difference.(4)The average diameter of the tumor in the control group was 11.4±0.9mm.The average diameter of the tumor in the experimental group was 10.5±1.1mm,after T test,P>0.05,shows no significant difference in diameter between the two groups.(5)Preoperative bleeding index and plaque index of experimental group and control group,adopt rank and test shows no significant difference.2.There is a statistical difference that surgery in experiment group was less painful than control group(P<0.01).3.12 weeks after surgery,the gingival bleeding index and the plaque index of the control group and experimental group are much lower than preoperative,shows the statistical differences(P<0.05).4.After 12 weeks,gingival recession in the control group is 2.69±0.48mm,and the experiment group is 0.77±0.16mm,which is statistically lower than the control group,shows the statistical differences(P<0.05).5.After 12 weeks,gingival papilla filling index in experiment group is statistically higher than control group,shows the statistical differences(P<0.05).6.In the experimental group,the width of preoperative keratinized gingiva is 1.50±0.25mm,and the width of keratinized gingiva at 12 weeks after surgery is 4.68±0.30 mm,3.00±0.28 mm more than preoperative.The width of keratinized gingiva in experiment group grew more than that in control group,shows the statistical differences(P<0.05).7.There is a statistical difference that surgery for experiment group was more satisfied than control group(P<0.01).8.No recurrence of epulis was noted during subsequent follow-up 1?3 years after surgery.Conclusion:Partial removal periodontal surgery makes less gingival recession,better gingival papilla filling,and no recurrence in the 1?3 years of observation period.In conclusion,under the condition of strict indications and the standard operation guidance,Partial removal periodontal surgery which reserves tumor epithelium has got a better effect than the traditional surgery.It can be widely applied in clinic after large sample studies and long-term follow-up.Part threeClinical evaluation of non-suigical treatment in the therapy of pregnancy tumorPurpose:To evaluate the clinical efficacy of periodontal initial therapy of gingival pregnancy tumor.Methods:25 patients diagnosed with gingival tumors of pregnancy,matched the inclusion and exclusion standard,were enrolled in this study.The patients admitted 2 to 6 months after childbirth,and the tumor were not healed.The time of tumor,preoperative bleeding index,plaque index(PLI),size of tumors were observed.All cases received periodontal initial therapy first,then received supportive periodontal therapies every 3?6 months.The data of bleeding index(BI)and plaque index(PLI)was taken at 3rd,6th,12th month after surgery.All patients were followed up for 1?5 years.Import the collected data into SPSS for statistical description and statistical analysis.The age,duration of pregnancy,the tumor site,the diameter of the tumor,and the time of the tumor regression were described.The BI and PLI of preoperative and 3rd,6th 12th month after surgery,two independent samples,respectively adopt rank and inspection,a=0.05,P<0.05 for significant differences.The correlation of the disappear time,the diameter of the tumor,the tumor site and the age of the patient,was tested by Spearman linear correlation.Results:Patients were aged from 22 to 38 years old,27.1 years old on average.Two cases occurred during pregnancy between 1 and 3 months,18 in 4 to 6 months of pregnancy and 5 during pregnancy between 8 and 10 months.18 cases were located at the maxillary.After oral hygiene instruction,plaque control,supragingival scaling,subgingival scaling and root planning,the tumors were gradually eliminated without surgery.In 3 cases,the tumors with the size<5 mm disappeared with a mean time of 3.6 months,7.5 months for tumors with a diameter of 5?10 mm in 4 patients,10.2 months for masses with the size of 10?15 mm in 11,15 months for tumors with a diameter of 15?20 mm in 6 and 22.0 months for the tumor with a diameter>20 mm in only 1 case.The bleeding index(BI)and plaque index(PLI)were significantly reduced at 3rd,6th,12th month after surgery,compared with the preoperative period,and there was a statistical difference.Through correlation analysis,the disappear time of the tumor body was directly related to the diameter of the tumor and had no correlation with the tumor site and the age of the patient.No recurrence of gingival pregnancy tumors was noted during subsequent follow-up 1?5 years.Conclusion:Periodontal initial therapy after pregnancy can obtain the good effect of complete disappearance of the tumor.It is suitable for breastfeeding women,who are not willing or inconvenienced to have a surgical treatment for the removal of gingival tumor,and the disadvantage of soft tissue defect caused by traditional surgical method is avoided effectively.According to analyzing the histologic changes before and after the treatment,and observing the clinical effects of partial removal periodontal surgery in the therapy of epulis and the clinical effects of non-surgical treatment in the therapy of pregnancy tumor,the clinical treatment strategies for epulis is presented:1.The initial periodontal treatment is required before surgical treatment.2.Partial removal periodontal surgery in the therapy of epulis should be done when the connective tissue inflammatory is controlled.3.Non-surgical treatment is suitable for epulis granulomatosa unable/willing to undergo surgery,This method can eliminate the epulis granulomatosa,but the treatment duration is longer.4.Surgical treatment is still needed for fibrous hyperplasia that are difficult to eliminate. |
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