Rapidly Recurrent Fibrous Gingival Enlargement in a Geriatric Patient: Clinical Significance of Recurrence Timing

Abstract

Localized gingival enlargement (epulis) demonstrates variable recurrence rates, yet the clinical significance of recurrence timing has received limited attention. Regrowth may occur gradually due to persistent irritation or more rapidly when residual periodontal ligament or periosteal tissue remains after excision. A 74-year-old female with systemic comorbidities presented with fibrous epulis in the lower left anterior region. Histopathological examination following initial periodontal therapy and gingivectomy confirmed the diagnosis. The lesion recurred at the same site within 4 months. Management was modified to include open flap debridement with thorough curettage and repeat excision, after which no recurrence was observed during 1 year of follow-up. Early relapse may reflect persistence of the residual lesion rather than irritation-related regrowth. This case suggests recurrence timing may assist clinicians in considering the extent of surgical management and potentially reduce repeated interventions, particularly in geriatric patients.

Introduction

Gingival enlargement is an abnormal condition characterized by the excessive growth of the gingival tissue around the teeth. A localized form of gingival enlargement is referred to as epulis.[1,2,3] Clinically, epulis manifests as smooth or ulcerated bright pink/red swellings, either sessile or pedunculated, which are typically painless and can vary in size from a few millimeters to several centimeters.[1,4] Histologically, the currently accepted classification divides epulis into four subtypes: focal fibrous hyperplasia (FFH), peripheral ossifying fibroma, pyogenic granuloma (PG), and peripheral giant cell granuloma.[1,2,4,5]

Several factors have been linked with the occurrence of epulis, including dental plaque and calculus, microorganisms, trapped food, trauma, and iatrogenic factors such as ill-fitting dental appliances and restorations.[1,2,6] Although generally benign, recurrence after excision is well-documented and has been associated with local inflammatory factors and incomplete removal of the lesion base.[2,4,7]

Previous studies have primarily evaluated recurrence rates and associated risk factors, whereas the clinical implication of recurrence timing has rarely been discussed. Recurrence of reactive gingival lesions may arise either from persistent stimulation from local irritants or from residual periodontal ligament or periosteal tissue after excision.[8] Because these mechanisms differ biologically, the pattern of regrowth may also differ. Very early postoperative recurrence may raise the possibility of persistent lesion base rather than delayed inflammatory regrowth.

In a study conducted by Zhao et al., the recurrence rate of epulis varies significantly, ranging from 1.68% to 60.92%.[1] However, recurrence rate alone does not explain the clinical behaviour of regrowth or assist in determining the appropriate surgical approach. Consequently, clinicians often face uncertainty when deciding whether a conservative excision is sufficient or whether deeper tissue removal is required.

This issue becomes particularly relevant in geriatric patients, in which epulis recurrence raises concern about underlying pathology and repeated surgical procedures increase treatment burden and healing challenges.[8,9,10] Recognizing the timing of recurrence may therefore provide a practical clinical indicator of lesion origin and guide treatment planning. This report describes an unusual case of rapidly recurrent fibrous epulis in a geriatric patient and highlights how early recurrence may signal persistence of the lesion base and may support consideration of deeper surgical management.

Case Report

A 74-year-old female patient presented with gingival enlargement in the lower left anterior region. The painless swelling began a year earlier and gradually impaired mastication, speech, and oral hygiene maintenance [Figure 1a]. She had diabetes mellitus for 2 years, treated with metformin, glimepiride, and acarbose, and hypertension for 3 years, managed with amlodipine and candesartan. There was no family history of gingival overgrowth, and she denied picking her gingiva with toothpick.

Figure 1.

(a) The epulis had approximate dimension of 4 cm × 3 cm on the buccal site, (b) Epulis extended to the lingual site with a diameter of one cm, (c) Panoramic radiograph revealed mild to moderate alveolar bone loss, indicating periodontitis, (d) First Biopsied Lesion with chronic inflammatory cells, shown in black arrow (H and E, ×100), (e) Proliferation of fibroblast, shown in black arrow (H and E, ×400), (f) Intraoral findings 2 weeks after excisional biopsy

Intraoral examination revealed irregular gingival overgrowth between teeth 32 and 33 [Figure 1b]. The lesion was dense, fibrous, lobulated, and well-demarcated. Periodontal evaluation showed mild plaque and calculus with a 5 mm buccal periodontal pocket. No tooth mobility was found. A panoramic radiograph is shown in Figure 1c.

A provisional diagnosis of localized idiopathic gingival fibromatosis was initially considered. Initial therapy included dental health education, scaling, and root planing. She was referred to internal medicine to exclude any other systemic causes, but no abnormalities were found. A gingivectomy was performed, and the tissue was sent for biopsy. Examination revealed polypoid tissue with locally proliferative, stratified squamous epithelium and hyperplastic growth. Numerous chronic inflammatory cells, especially lymphocytes, were present [Figure 1d]. The stroma consisted of extensively distributed and densely packed collagenous connective tissue [Figure 1e]. Findings were consistent with fibrous epulis (FFH) with no malignancy.

At a 2-week follow-up, the patient reported no complaints. The gingiva between 32 and 33 was slightly swollen, hyperemic, and showed minor bleeding [Figure 1f]. Despite scheduling another recall, the patient did not attend the appointment.

The patient returned after 4 months with recurrent epulis at the same site. Her medical status and medications were unchanged. Intraoral examination showed gingival enlargement between teeth 32 and 33 that was hyperemic, firm, and smooth, measuring 8 mm × 12 mm labially and 3 mm width lingually [Figure 2a and b]. The gingiva bled easily. Radiographs showed no changes, with intact cortical bone between the teeth [Figure 2c]. A provisional diagnosis of PG was made. The patient was scheduled for open flap debridement and excisional biopsy, and the specimen was sent for histopathology. The underlying gingival surface was meticulously curetted, and the interproximal bone between 32 and 33 was smoothed.

Figure 2.

(a) Clinical findings at 4 months postgingivectomy. Hyperemic and firm gingival enlargement with smooth surface between teeth 32 and 33, (b) The enlargement was measured at 8 mm × 12 mm on the labial site and three mm on the lingual site, (c) Radiographic examination revealed bone loss extending up to the middle third of the root 32 and 33, (d) Clinical findings 2 weeks after the second biopsy, (e) Polypoid benign lesion covered by stratified squamous epithelium, shown in yellow arrow (H and E, ×100), (f) Clusters suggestive of colonies of microorganisms within the connective tissue, shown in yellow arrow (H and E, ×1000)

At 2 weeks, the patient reported no discomfort. The gingiva between 32 and 33 showed mild hyperemia and bleeding [Figure 2d]. Histology revealed a stratified squamous epithelium showing localized hyperplasia, atrophy, erosion, and contained narrow fissures harboring colonies of unidentified microorganisms [Figure 2e and f]. The stroma consisted of locally swollen, mildly hyperemic, and fibrotic thick collagenous connective tissue, densely infiltrated by chronic inflammatory cells. Findings indicated chronic inflammation, possibly attributed to microbial colonies. The diagnosis of FFH, nonneoplastic, was confirmed.

At the 1-year follow-up, the patient reported no complaints. The gingiva around teeth 31–33 remained slightly swollen and hyperemic [Figure 3a and b], with minimal plaque and calculus. Radiographs showed stable bone levels [Figure 3c]. She was advised to maintain oral hygiene and attend annual reviews.

Figure 3.

(a) Clinical findings after 1 year. The gingiva displayed mild swelling and hyperaemia on the buccal site, (b) Intraoral condition on the lingual site showed no abnormality, (c) Intraoral radiograph depicted a similar bone level up to the middle third of the roots

Discussion

A provisional diagnosis of localized idiopathic gingival fibromatosis was initially considered because the lesion presented as a slowly progressive fibrous gingival enlargement involving both the marginal and attached gingiva, with relatively minimal local irritants and no obvious systemic contributing factors.[11] However, the absence of family history, the localized nature of the lesion, and subsequent histopathological findings showing a reactive fibrous lesion with chronic inflammatory infiltrate were ultimately more consistent with fibrous epulis (FFH) rather than true gingival fibromatosis.[1,5]

In this case, a histologically confirmed fibrous epulis (FFH) recurred within 4 months following excisional biopsy. Histopathological examination from both biopsies showed similar features, consisting of dense collagenous connective tissue with chronic inflammatory cell infiltration, supporting the diagnosis of nonneoplastic reactive fibrous lesion.[1,5] Although the recurrent lesion showed additional epithelial erosion and superficial microbial colonies, no atypia or malignant transformation was identified in either specimen. The persistence of a similar microscopic pattern in both biopsies may indicate that part of the lesion base remained after the first excision. In cases showing atypia or unusual histopathological findings, additional investigations such as proliferating cell nuclear antigen or Ki67 immunohistochemical analysis may be considered to further evaluate the proliferative activity of the lesion.[12]

According to Xu et al., recurrence of epulis after surgery is reported at 14.2%, but typically occurs at a longer interval, with an average recurrence time of 17.6 months.[2] In this case, the unusually early relapse is therefore clinically significant, and few reports have discussed the clinical significance of such early postoperative recurrence.[13] This pattern of regrowth may suggest a mechanism different from delayed irritation-related recurrence commonly associated with reactive gingival lesions.

Early relapse after simple excision has been associated with persistence of reactive tissue originating from the periosteum and periodontal ligament.[4,6,13] During the first procedure, only soft tissue removal was performed, which is consistent with the commonly employed conservative approach for fibrous epulis.[14] Following recurrence, surgical management was modified to include flap elevation with thorough curettage of the underlying tissue,[5,6,15] after which no regrowth was observed during 1 year of follow-up. This clinical course may support the possibility that residual lesion tissue remained after the initial excision and that deeper surgical management contributed to the more definitive outcome.

In this case, drug-induced gingival overgrowth (DIGO) caused by amlodipine was unlikely to be the primary etiologic factor for the initial overgrowth and its recurrence. DIGO typically presents as a generalized enlargement involving the marginal and papillary gingiva that develops within months of medication exposure.[14,16] In this patient, the lesion remained localized despite long-term amlodipine use and recurred without any change in medication.

Age-related alterations in healing may also contribute to tissue response. Aging is associated with a prolonged inflammatory phase that delays tissue remodeling, which may have influenced healing after the first excision.[9] Such changes may increase tissue susceptibility to reactive proliferation. However, they generally modify lesion progression rather than account for rapid postoperative recurrence.

The management strategy should therefore consider the timing of recurrence in addition to histologic diagnosis. While conservative excision is generally adequate for fibrous epulis,[17] early recurrence after surgery may indicate incomplete elimination of the underlying reactive tissue and support consideration of a deeper surgical approach, even in geriatric patients.[4,5,6,15] In such situations, flap elevation with curettage of the lesion base to the periosteal/periodontal ligament level may help reduce the likelihood of repeated interventions. This approach may also help establish a more favorable gingival contour and mucogingival architecture for improved oral hygiene maintenance.[18]

Conclusion

This unusually early relapse of fibrous epulis is clinically significant and suggests persistence of the initiating tissue, representing a mechanism different from the more commonly reported irritation-related recurrence described in the literature.[2] In such situations, deeper surgical management including flap elevation and curettage to the periosteal/periodontal ligament level may provide more definitive resolution, even in geriatric patients. Recognition of recurrence timing as a clinical indicator may assist clinicians in selecting appropriate surgical depth and reducing repeated interventions. However, as this report describes a single case, the proposed relationship between recurrence timing and surgical depth should be interpreted cautiously and requires validation in larger studies.

Declaration of patient consent

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

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.