PREVALENCE OF ORAL REACTIVE HYPERPLASTIC LESIONS AND ASSOCIATED RISK FACTORS IN A SAMPLE OF YEMENI DENTAL PATIENTS IN SEVERAL UNIVERSITIES AND PUBLIC HOSPITALS 

Shaima’a Abdulraqeeb Yahya Rajeh1image, Hassan Abdulwahab Al-Shamahy2image, 

Taghreed Ahmed Al-Kibsi3image

1Department of Basic Sciences, Faculty of Dentistry, Sana’a University, Republic of Yemen.

2Medical Microbiology and Clinical Immunology Department, Faculty of Medicine and Health Sciences, Sana’a University.

3Oral and maxilla-facial surgery Department, Faculty of Dentistry, Sana’a University, Republic of, Yemen.

 

Abstract

Background and aims: Reactive lesions may result from the oral mucosa's continuous exposure to endogenous and external stimuli. The nature of these lesions is not cancerous. They display a variety of pathologies, from neoplasms to reactive, inflammatory, and developmental abnormalities. Dental plaque and tartar, sharp edges of severely carious teeth, defective dental fillings, chronic biting habits, ill-fitting dental/oral appliances, and food impaction are just a few examples of the various forms of chronic, low-grade irritation of the oral mucosa that can cause reactive lesions. Benign neoplastic proliferations and oral reactive lesions look a lot alike. Investigating the frequency of reactive periodontal lesions and the characteristics that are linked to them in a sample of adult Yemeni dentistry patients in Sana'a City was the goal of this study.

Method: An observational cross-sectional study of 1197 Yemeni dental patients attending the Faculty of Dentistry, Sana’a University, Alrazi University, Alyemenia University, Aljomhori and Althawra hospitals were examined for the presence of reactive hyperplastic lesions.

Results: A total of 48 (4%) patients were found to have reactive hyperplastic lesions. Focal fibrous hyperplasia is the most common type representing (91.7%). Peripheral giant cell granuloma was the second most common type representing (6.3%). The most risk factors were qat chewing, teeth grinding, cheek biting and poor oral hygiene.

Conclusion: In the current study, irritant fibroma and pyogenic granuloma were the most and least common oral reactive hypertrophic lesions, respectively. Compared with males, the prevalence of lesions in female patients was equal, and older age groups were more probable to grow oral reactive hypertrophic lesions. The most frequent location for lesions was the gingiva.

Keywords: Focal fibrous hyperplasia, peripheral giant cell granuloma, peripheral ossifying fibroma, pyogenic granuloma, reactive hyperplastic lesions. 

 

INTRODUCTION

 

The oral cavity is constantly exposed to a wide range of exogenous and endogenous stimuli, including physical, chemical, and microbial agents. Chronic, low-grade inflammatory stimuli, in particular, have been found to induce a heightened repair response, resulting in what are collectively known as reactive hypertrophic lesions (RHLs). These lesions generally resemble tumors and may be symptomatic or discovered incidentally during routine dental visits1.  Various factors influence the clinical presentation of these lesions, such as age, trauma, gender, or degree of irritation, and the extent and features of the lesion. It is well documented that rheumatoid gingivitis is caused by chronic, mild inflammation caused by plaque and tartar, sharp edges of rigorously carious teeth, defective fillings, chronic biting habits, ill-fitting dental or oral appliances, and food impaction. It has also been reported that some of these lesions may be directly influenced by female hormone levels in females2. Clinically, these proliferations are generally painless, have a pedicled or firm base, and range in color from pale pink to red. Some of these lesions may bleed easily when touched, depending on their vascularity. The upper surfaces of RHLs may be ulcerated or non-ulcerated, and a few millimeters to several centimeters is their size range. Furthermore, the onset of RHLs often rapid, with potential size fluctuations, and they may regress over time3.

RHLs have been classified by Eversole into peripheral (extraosseous) lesions that occur on the soft tissues of the oral cavity such as gingiva, tongue etc., or central (intraosseous) occur inside the jaws. RHLs are more frequently seen on the gingiva and alveolar ridge followed by tongue, and buccal mucosa. Less common sites of involvements are hard palate and floor of the mouth. Though these lesions can occur across wide age groups and both genders, they are predominantly found in the females with a ratio of 2.5:1 to males, and with a high incidence in 5th, 6th and 7th decades of life4,5. 

The most common localized reactive lesions of oral cavity include focal fibrous hyperplasia (FFH), pyogenic granuloma (PG), peripheral giant cell granuloma (PGCG), and peripheral ossifying fibroma (POF) 6. Histologically, RHLs consist of one or more of the connective tissue components, including collagen fibers, bone, endothelial cells, and multinucleated giant cells. This distinctive feature aids in their histopathological differentiation from each other7. It is interesting that the prevalence of RHLs has been estimated to vary from 5.6%8 to 48%9. Several factors have been proposed in the literature to explain this variation, including geographical and lifestyles differences; diverse nomenclatures used to these lesions; racial factors; and the study population involved10. 

Indeed, the close resemblance in the clinical manifestation of the RHLs to the neoplastic lesions is a challenging matter for diagnosis and optimal treatment. Additionally, these lesions are painless, which often leads to them being overlooked for an extended period of time11. The aim of this study was to find out how common RHLs are and what factors were associated with them in a sample of adult Yemeni dental patients in Sana'a city.

 

METHODS

 

Study design: An observational cross-sectional clinical study. 

Study population: A sample of Yemeni dental patients attending the Faculty of Dentistry, Sana’a University, Alrazi University, Alyemenia University, Aljomhori and Althawra hospital dental clinics. 

Inclusion criteria: Adults and children over 5 years Yemeni dental patients. 

Exclusion criteria: Children below 5 years, edentulous patients and non-Yemeni patients.

Sample size calculation: All patients visiting the oral medicine department of the three universities between February 2024 and June 2024 were included, according to the predetermined inclusion criteria.

Method of data collection: A total of 1,197 Yemeni patients, 724 males and 473 females, who attended the selected dental clinics were examined. All participants gave their informed consent, and each patient's relevant data was recorded using a data collecting routine. Risk factors and demographic information were gathered before the clinical assessment. Dental history was also verified, including data on previous dental treatments, any previous poor restorations, and their location. Habits such as cheek biting, teeth grinding, smoking, snuff use, qat chewing, and poor oral hygiene were also recorded. Participants underwent an additional clinical examination and an intraoral examination in a dental chair. An intraoral examination of soft tissues was performed, and if any oral lesions were found, the patient was referred to hospitals for histological examination to determine the tumor type. After collecting the information and laboratory results, the data were analyzed and tabulated.

Ethical considerations:  Formally, ethical approval was achieved from the Medical Ethics Committee in the Faculty of Dentistry at Sana’a University No. (263). Permission was sought to examine the patients and agreement was obtained from all subjects that participated in the study.

 

RESULTS

 

he number of females was 473 (39.6%) and males 724 (60.4%), with 679 (56.7%) of patients aged ≤ 25 years, and 518 (43.3%) of patients aged ≤ 25 years (Table 1). Married patients comprised 431 (36%), while single patients comprised 766 (64%). Regarding occupations, most patients were students (724) (60.5%), followed by laborers (245) (20.5%), and housewives (144) (12%), while other occupations were less common. 

Based on medical history, 201 patients (16.8%) had systemic diseases, such as diabetes, hypertension, rheumatoid arthritis, and others (Table 2). Most RHLs occurred in the age group >25 years, with 34 cases (70.8%) of the total, while only 14 cases (29.2%) were in the age group ≤25 years. Regarding gender, most RHLs occurred in males, with 29 cases (60.4%) of the total, while only 19 cases (39.6%) were in females (Table 3). The correlation between age, sex, and the prevalence of reactive hypertrophic lesions (RHLs) is displayed in Table 3. In both sexes, the frequency of RHLs was almost equal.  For females, it was 4.7%, with an associated odds ratio (OR) of 1, a confidence interval (CI) of 0.53–1.9, and X2=0.0, with a p-value of 0.99. Males also had the same results.

This indicates that the correlations and ORs were similar for both sexes, concluding that there is no association between RHLs and sex.

Regarding age, the prevalence of RHLs was higher in the older age group (>25 years), reaching 6.6%, with an associated OR of 3.3 times, a CI of 1.7–6.6, with a significant X2 of 15.5, and a p-value of <0.0001. Younger ages showed a significant protective OR of 0.3. 

The association between occupation, marital status, and the prevalence of reactive hypertrophic lesions (RHLs) in patients who visit oral medicine departments for RHL examination is displayed in Table 4. Regarding marital status, the prevalence of RHLs was higher in the married group, reaching 6.7%, with an associated odds ratio (OR) of 2.8 times, a confidence interval (CI) of 1.5–5.3, a significant X2 coefficient of 12.9, and a p value of 0.0003. Meanwhile, single individuals showed a lower prevalence of RHLs, with an OR of 0.5. Regarding occupations, the prevalence of RHLs was higher among housewives, reaching 9.03%, with an associated OR of 2.9 times, a CI of 1.4–5.8, a significant X2 coefficient of 10.7, and a p value of 0.001. While other occupations had no association with the occurrence of reactive hypertrophic lesions. Table 5 illustrates the correlation between the occurrence of oral and dental disorders and reactive hypertrophic lesions as well as personal activities like smoking, qat usage, oral cleanliness, and Shammah. An associated odds ratio (OR) of 3.8 times, a confidence interval (CI) of 2.02–7.14, a significant X2 coefficient of 22, and a p value of less than 0.0001 were found when qat chewing was examined as a risk factor for RHLs. Also, smoking was an associated risk factor for developing RHLs, in which the OR was 2.4 times, with a confidence interval (CI) of 1.2–4.6, with a significant X² coefficient of 7.5 and a p value of 0.006.  Tooth grinding was a risk factor associated with the development of RHLs with an OR of 9.4 times, confidence interval (CI) of 2.8 to 29.7, with a significant X² coefficient of 24.9 and p value < 0.0001. Cheek biting was a risk factor associated with the development of RHLs with an OR of 13 times, confidence interval (CI) of 5.11 to 32.6, with a significant X² coefficient of 56, p value < 0.0001. Poor hygiene status of the mouth was a risk factor associated with the development of RHLs with an OR of 1.9 times, confidence interval (CI) of 1.01 to 3.5, with a significant X² coefficient of 4.6 and p value of 0.03. Clicking of the mouth was a risk factor associated with the development of RHLs with an OR of 9.4 times, confidence interval (CI) of 2.8 to 29.7, with a significant X² coefficient of 24.9, p value < 0.0001. The presence of pigmented and white lesions in the mouth of patients was a risk factor associated with the development of RHLs with an OR of 11.5 times, confidence interval (CI) of 5.3 to 24.8.

Also, the presence of white lesions alone in the mouths of patients was a risk factor associated with the development of RHLs with an OR of 9.9 times, confidence interval (CI) of 5.2 to 18.9, with a significant X² coefficient of 69.7, p value < 0.0001. A history of gingivitis was a risk factor associated with the development of RHLs with an OR of 14.2 times, confidence interval (CI) of 6.8 to 29.5, with a significant X² coefficient of 94.2, p value < 0.0001. A strong association of periodontitis with the development of RHLs was found in which OR was 63.7 times, confidence interval (CI) of 30.4 to 134, with a significant X² coefficient of 325, p value < 0.0001. The various reactive hypertrophic lesion types and their sites in patients who come to oral medicine departments for clinical examinations are displayed in Table 6. 

Only one (2.1%) of the reactive hypertrophic lesions were pyogenic granulomas, whereas the majority (44, 91.7%) were irritating fibromas, followed by peripheral giant cell granulomas (3, 6.3%). Regarding the locations of the lesions in the oral cavity, the oral mucosa was the most common site, with 17 (35.3%), followed by the lower labial mucosa, with 13 (27%), the lateral border of the tongue, with 9 (18.8%), and the alveolar mucosa, with 6 (12.6%). The tip of the tongue, dorsum of the tongue, and the upper labial mucosa each accounted for only one case (2.1%).

The physical features of reactive hypertrophic lesions in patients who come to the oral medicine department for a clinical evaluation are displayed in Table 7. Nine (18.7%) of the lesions were bigger than 1 cm, while 39 (81.3%) were less than 1 cm. Only one (2.1%) multi-nodular lesion was discovered based on its morphology, whereas the other lesions (97.9%) were solitary nodules. All lesions had smooth surfaces. Most lesions had well-defined and regular margins (47 (97.9%)), and only 1 had ill-defined and irregular margins. Considering color, most lesions were pink (42 (87.5%), followed by reddish-pink (4 (8.3%), while pink-white and whitish-white were present in one case each. The necks of all lesions were sessile, and the texture of the lesions was firm (consistent) in all (48/48). Table 8 shows the duration, onset, pain, and bleeding of reactive hypertrophic lesions, and their distribution among our patients. Examining the duration of the lesions, 38 (79.2%) lesions had been present for 5 years or less, while 10 (20.8%) had been present for more than 5 years. The progressive course of the lesions was steady in 46 (95.8%) cases, while two (4.2%) cases were progressive. The onset of the lesions was gradual in all (48/48, 100%), all lesions were painless, bleeding occurred in only one case, and all lesions were localized and isolated.

 

DISCUSSION 

 

Oral neoplastic lesions, including reactive benign prosthetic hyperplasia (BPH), are frequently observed in the oral mucosa in routine dental clinics and hospitals in Yemen4,11-14. These lesions may be symptomatic or encountered incidentally when a patient visits an outpatient dental clinic for routine treatment. The clinical presentation of these lesions depends on various factors such as age, degree of irritation or trauma, gender, distribution, and nature of the lesion5. The most common predisposing factors are persistent low-grade chronic inflammation, recurrent chronic irritation due to plaque and tartar accumulation, cheek biting, hormonal disorders, and trauma from exogenous factors such as sharp edges of broken teeth, loose fillings, and ill-fitting dentures4, 15. Numerous studies have been conducted to collect epidemiological data on neoplastic lesions in general or on oral cavity lesions in Yemen4, 11-13, 16-22. However, little attention has been paid to collecting statistics on benign hypertrophic lesions of the oral mucosa, which may cause recurrent problems such as aesthetic dissatisfaction or impaired masticatory function.

In the current study the prevalence of RHLs was approximately equal in both sexes. For females, it was 4.7%, with an OR of 1, and p-value of 0.99. This indicates that the correlations and ORs were similar for both sexes, concluding that there is no association between RHLs and sex. This current finding differs from that reported in Brazil, where these hyperplastic reactive oral lesions are found mainly in females contrasted to males, with a ratio of 2.5:1 as described by - Kamile LD et al.,23. Our sex distribution also differs from that described by Da Saliva et al., in Nigeria24 and Soyele OO et al.,25 in Brazil, where most hyperplastic reactive oral lesions were described in females contrasted to males, with a ratio of 2:1, 1.8:1, and 1.4:1, respectively24, 25. Also, in studies conducted by Sangle et al.,26 , Kadeh H et al.27, and Ala Aghbali9, the lesions were obtained to be more prevalent in women than in men (2.2 times higher), which is coherent with the findings of all the previous studies mentioned9, 26-27. The higher incidence of these lesions among female patients worldwide may be attributed to the role of hormones as a predisposing factor in their development. What is more, this latter difference may be attributed to women's greater concern for oral hygiene in places other than Yemen, as they visit dental clinics for examinations and treatment more often than men in Iran, Nigeria, and Pakistan. However, in Yemen, men's concern for oral health may be equal or even better than that of women.

In our age-related study, the prevalence of RHLs was higher in the older age group (>25 years), reaching 6.6%, with an associated odds ratio of 3.3 times, a confidence interval of 1.7–6.6, a significant X2 of 15.5, and a p-value <0.0001. This result is similar to that reported by Ayaz M et al., in Pakistan28, Kadeh et al., in Iran29, Kumar et al.,30 in India, Halikiri et al.31, and Awange et al., in India32 in where a high incidence of oral reactive hypertrophic lesions in the second and third decades and with a mean age of 30 years. However, our result is different from that reported by Soyele O et al.25, in their studies, they found that RHLs appear in a wide age range from 10 to 70 years, with a higher incidence in the fifth, sixth, and seventh decades of life.

In the current study, prevalence of RHLs was higher in the married group, reaching 6.7%, with an associated odds ratio (OR) of 2.8 times, a confidence interval (CI) of 1.5–5.3, a significant X2 coefficient of 12.9, and a p value of 0.0003. Regarding occupations, the prevalence of RHLs was higher among housewives, reaching 9.03%, with an associated OR of 2.9 times, a CI of 1.4–5.8, a significant X2 coefficient of 10.7, and a p value of 0.001. While other occupations had no association with the occurrence of reactive hypertrophic lesions. The higher frequency of these lesions in married and housewives persons did not mentioned or tested in previous studies and no clear reasons for these results.

When khat chewing was tested as a risk factor of RHLs, there was an associated odds ratio (OR) of 3.8 times, a confidence interval (CI) of 2.02–7.14, a significant X² coefficient of 22, and a p value of <0.0001. Also, smoking was an associated risk factor for developing RHLs, in which the OR was 2.4 times, with a confidence interval (CI) of 1.2–4.6, with a significant X² coefficient of 7.5 and a p value of 0.006. This association can be confirmed that Qat chewing and smoking are important stimulating factors, to developed RHLs.  DaSilva et al.24, reported that the smoking rate is higher in patients with RHLs, compared to other reactive lesions. To prevent recurrence, a careful histopathological evaluation and confirmation of the absence of an infected lesion base are essential. Furthermore, dentists and patients should try to reduce controllable triggers, such as khat chewing and smoking.

In this study, tooth grinding was a risk factor associated with the development of RHLs with an OR of 9.4 times, confidence interval (CI) of 2.8 to 29.7, with a significant X² coefficient of 24.9 and p value < 0.0001. Cheek biting was a risk factor associated with the development of RHLs with an OR of 13 times, confidence interval (CI) of 5.11 to 32.6, with a significant X² coefficient of 56, p value < 0.0001. Poor hygiene status of the mouth was a risk factor associated with the development of RHLs with an OR of 1.9 times, confidence interval (CI) of 1.01 to 3.5, with a significant X² coefficient of 4.6 and p value of 0.03. Clicking of the mouth was a risk factor associated with the development of RHLs with an OR of 9.4 times, confidence interval (CI) of 2.8 to 29.7, with a significant X² coefficient of 24.9, p value < 0.0001. The presence of pigmented and white lesions in the mouth of patients was a risk factor associated with the development of RHLs with an OR of 11.5 times, confidence interval (CI) of 5.3 to 24.8, with a significant X² coefficient of 67.3, p value < 0.0001. Also, the presence of white lesions alone in the mouths of patients was a risk factor associated with the development of RHLs with an OR of 9.9 times, confidence interval (CI) of 5.2 to 18.9, with a significant X² coefficient of 69.7, p value < 0.0001. A history of gingivitis was a risk factor associated with the development of RHLs with an OR of 14.2 times, confidence interval (CI) of 6.8 to 29.5, with a significant X² coefficient of 94.2, p value < 0.0001. A strong association of periodontitis with the development of RHLs was found in which OR was 63.7 times, confidence interval (CI) of 30.4 to 134, with a significant X² coefficient of 325, p value < 0.0001. Benign oral lesions primarily represent hypertrophic tumor-like proliferations, but they do not have any neoplastic features on histology33. These lesions are small reactive growths that can develop as a result of persistent irritation or trauma to the oral soft tissues34. The most common sources of persistent irritation of the oral mucosa are teeth grinding, cheek biting, poor oral hygiene, mouth picking, the presence of pigmented and white oral lesions, and periodontitis. These factors are the most significant risk factors for RHLs in previous studies33,34. This may be explained by the fact that poor oral hygiene leads to heavy plaque and tartar deposition, and local traumatic injuries such as cheek biting and foreign bodies lead to mucosal irritation35,36.

In the current study most of the reactive hypertrophic lesions were irritant fibromas, with 44 (91.7%), followed by peripheral giant cell granulomas, with 3 (6.3%), and only one (2.1%) was a pyogenic granuloma.  Hallikeri K et al.31, Hunasgi S et al.35, and Koneru A et al.36, they reported roughly similar to our results with predominant of  irritant fibromas.

According to research by Santosh Hunasgi et al., and Binita Gandhi et al., oral reactive hyperplastic lesions frequently appear in the mandible, especially in the posterior region31,35-36. They state that the alveolar ridge and gingival tissue are the most often affected areas by these lesions36. Compared to the maxillary, the mandibular arch typically had the lesions (80%). Santosh Hunasgi et al. and Binita Gandhi et al., research, which found that oral reactive hyperplastic lesions are frequently seen in the mandible, especially in the posterior area, is also consistent with this31,35-36.

Rather of being cancerous, the benign reactive hyperplastic oral lesions are mostly reactive and inflammatory in nature. The fibrous lesion, also known as a fibrous epulis or fibroma, is the most common and frequently occurring of all the reactive hyperplastic lesions of the oral cavity37,38. Mandeep Kaur and colleagues discovered that up to 33% of people in Jammu and Kashmir State had traumatic fibroma, while 27% and 25% of people had inflammatory papillary hyperplasia and pyogenic granuloma of the oral mucosa, respectively39. According to Maturana-Ramirez et al., the largest incidence of localized fibrous lesion (71.1%) in the Chilean population is followed by pyogenic granuloma (21.1%), which is consistent with the findings of the aforementioned research40.

Gingiva was the most often impacted area (44.2%), as in all of the earlier research27. Chronic stimulations from bacterial plaque buildup and poor dental restorations may be the reason of the increased frequency of these lesions in the gingiva. Furthermore, the periodontal ligament, gingival connective tissue, or periosteum may be the source of several of these diseases, such as POF and PGCG9. The idea that RHLs are identical in nature but at various stages of evolution is supported by the fact that gingiva is the most common site of RHLs. According to Daley et al.41, fibrous hyperplasia, or IF, is caused by the progressive replacement of PG's vascular texture by fibrotic tissue. The aforementioned notion is supported by the current analysis, which found that the mean age of patients afflicted by IF was greater than that of PG cases. Other studies, nevertheless, did not note this variation42. In the present study, the majority of lesions were 1 cm or less in size (39 (81.3%)), while 9 (18.7%) were larger than 1 cm. considering the morphology of the multi-nodular the lesions, only 1 (2.1%) was found, while the remaining lesions were solitary nodules (97.9%). All lesions had smooth surfaces. Just one lesion had irregular and poorly defined margins, whereas the majority (47, or 97.9%) had regular and well-defined margins. In terms of color, the majority of lesions were pink (42, or 87.5%), followed by reddish-pink (4, or 8.3%), and there was one instance of each of pink-white and whitish-white. The lesions had a hard (consistent) texture and all of them had sessile necks (48/48). The oral reactive hyperplastic lesions in the current study are essentially the same as those previously described by Neville B.W. et al.1, and Regezi J et al.43, where they appeared sessile, had a pedunculated appearance due to the small number of lesions attached to the stalk, and ranged in size and color from pink to reddish, bleeding at the slightest touch. Table 3 shows the duration, onset, pain, and bleeding of reactive hypertrophic lesions, and their distribution among patients presenting to the oral medicine department for clinical examination. Examining the duration of the lesions, 38 (79.2%) lesions had been present for 5 years or less, while 10 (20.8%) had been present for more than 5 years. The progressive course of the lesions was steady in 46 (95.8%) cases, while two (4.2%) cases were progressive. The onset of the lesions was gradual in all (48/48, 100%), all lesions were painless, bleeding occurred in only one case, and all lesions were localized and isolated. Our results are roughly similar that reported in literatures4,23-25,44.

Limitation of the study

Cross-sectional methodology makes it difficult to infer causal links because exposure and outcome are measured only once. Given the short time frame for data collection and the fact that the study is limited to one region of Yemen, this type of study is susceptible to some bias.

 

CONCLUSIONS

 

Given the increasing prevalence of oral reactive hypertrophic lesions in the Yemeni population as well as globally, decisive action is now required to halt their occurrence and progression. This can be achieved simply by providing awareness sessions on proper oral hygiene to patients who come to the dental clinic for routine checkups or any type of dental treatment. People who lack access to dental treatment are generally unaware of the importance of maintaining proper oral hygiene and superior aesthetics for a better and healthier life. In conclusion, in the current study, irritational fibroma and pyogenic granuloma were the most and least common oral reactive hypertrophic lesions (RHLs), respectively. Furthermore, compared to male individuals, female patients had an equal prevalence of the lesions, and older age groups were more susceptible with higher incidence rate of oral reactive hypertrophic lesions. The gingiva was the most common site of the lesions. 

 

ACKNOWLEDGEMENTS 

 

The authors would like to thank the National Public Health Laboratories, Al-Mamoon Center, and Al-Awlaqy Lab Centers in Sana’a city for their kind cooperation.

 

AUTHOR’S CONTRIBUTIONS 

 

Rajeh SAY: formal analysis, conceptualization, data organization to obtain a clinical MSc degree in Dental Sciences. Al-Shamahy HA: supervision. Al-kibsi TA: supervision. Final manuscript was checked and approved by all authors. 

 

DATA AVAILABILITY

 

The accompanying author can provide the empirical data that were utilized to support the study's conclusions upon request.

 

CONFLICT OF INTEREST 

 

There are no conflicts of interest in regard to this project.

 

REFERENCES

 

  1. Neville, BW, Damm DD, Allen CM, et al. Oral and maxillofacial pathology-e-book, Elsev Health Sci 2023.
  2. Alhindi NA, Sindi AM, Binmadi NO, et al. A retrospective study of oral and maxillofacial pathology lesions diagnosed at the faculty of dentistry, King Abdulaziz University. Clin Cosmet Investig Dent 2019 Mar 4; 11:45-52. http://doi.org/10.2147/CCIDE.S190092.
  3. Naderi NJ, Eshghyar N, Esfehanian H. Reactive lesions of the oral cavity: A retrospective study on 2068 cases. Dent Res J (Isfahan) 2012 May;9(3):251-5.PMID: 23087727; PMCID: PMC3469888.
  1. Al-Sayadi AS, Al-Rahbi LM, Al-Shamahy HA, et al. Clinical and histopathological analysis of biopsied oral and maxillofacial lesions: A retrospective study in Sana’a, Yemen. Universal J Pharma Res 2025; 10(1): 11-19.http://doi.org/10.22270/ujpr.v10i1.1272
  1. Soyele OO, Ladeji AM, Adebiyi KE, et al. Pattern of distribution of reactive localised hyperplasia of the oral cavity in patients at a tertiary health institution in Nigeria. Afr Health Sci 2019 Mar; 19(1):1687-1694.http://doi.org/10.4314/ahs.v19i1.45. PMID: 31148999; PMCID: PMC6531947.
  1. Nair BM, Basavaraju SM, Pachipulusu B. Reactive hyperplastic lesions of oral cavity: A review of literature. J Health Sci Res 2020; 10: 42-46. http://doi.org/10.5005/jp-journals-10042-1085
  1. Damasceno S, Gonçalves FDS, Zenóbio EG, et al. Stromal myofibroblasts in focal reactive overgrowths of the gingiva. Brazil Oral Res 2012; 26, 373-377.
  2. Effiom OA, Adevemo WL, Omitola OG, et al. Oral squamous cell carcinoma: A clinicopathologic review of 233 cases in Lagos, Nigeria. J Oral Maxi Surg 2008; 66:1595-1599.http://doi.org/10.1016/j.joms.2007.12.025.
  3. Ala Aghbali A, Vosough Hosseini S, Harasi B, et al. Reactive hyperplasia of the oral cavity: A survey of 197 cases in tabriz, northwest iran. J Dent Res Dent Clin Dent Prosp 2010 Summer; 4(3):87-9. PMID: 22991605http://doi.org/10.5681/joddd.2010.022.
  1. Patil SR, Maheshwari S, Khandelwal S, et al. Prevalence of reactive hyperplastic lesions of the gingiva in the Western Indian population. J Orofac Sci 2014; 6: 41-45.
  2. Gandhi, DB, Johnson DA, Dhuvad DJ, et al. (2018). Reactive lesions of oral cavity: reactive lesions of oral cavity. Natio J Integ Res Med 7(4), 154–157.https://doi.org/10.70284/njirm.v7i4.1122
  1. Al-Maweri SA, Alaizari NA, Al-Sufyani GA. Oral mucosal lesions and their association with tobacco use and qat chewing among Yemeni dental patients. J Clin Exp Dent 2014, 6(5):e460. https://doi.org/10.4317/jced.51706
  2. Al-Kibsi TAM, Qirshi HGMAA, Al-Shamahy HA. Prevalence of parotid tumors among Yemeni patients in Sana’a city, Yemen. Universal J Pharm Res 2024; 9(4): 54-59. https://doi.org/10.22270/ujpr.v9i4.1156
  3. Al-Thobhani SS, Da'er SAA, AL-Haddad KA, et al. Ameloblastoma in population of Yemen: Analyzing the prevalence and clinic pathologic features of amelo-blastoma in a Yemeni population. Universal J Pharm Res 2024; 9(5): 24-29.http://doi.org/10.22270/ujpr.v9i5.1195
  1. Głowacka B, Konopka T. Prevalence of oral mucosal lesions in young seniors in the Wrocław region. Dent Med Probl 2018 Oct-Dec;55(4):405-410.http://doi.org/10.17219/dmp/97310. PMID: 30648365.
  1. Almohya GAM, El-Zine MAY, Al-Shamahy HA, et al. Prevalence and risk factors associated with Hepatitis B virus infection among oncology patients. Universal J Pharm Res 2024; 9(6): 5- 13.http://doi.org/10.22270/ujpr.v9i6.1233
  1. Al-Shiabani RK, Al-Jaufy AY, Al-Moyed KA, et al. Correlation of epstein-barr virus with breast cancer: A case control study. Universal J Pharm Res 2024; 9 (1):1-6. https://doi.org/10.22270/ujpr.v9i1.1063
  2. El-Zine MAY, Ali MAA, Al-Shamahy HA. Prevalence of CNS tumours and histological recognition in the operated patients: 10 years experience in Yemen. Universal J Pharm Res 2021; 6(2): 20-27.https://doi.org/10.22270/ujpr.v6i2.563
  1. El-Zine MAY, Dawood YAS, Al-Shamahy HA, et al. Hepatitis C virus and leukemia patients: Prevalence and risk factors associated with infection among leukemia patients who achieve long-term remission after chemotherapy. Universal J Pharm Res 2024; 9(4): 21-27.http://doi.org/10.22270/ujpr.v9i4.1150
  1. Okbah AA, Al-Ankoshy AAM, Al-Shamahy HA. Bladder cancer: Differentiation of types, age, sex distribution and associated variants with gradation. Universal J Pharm Res 2022; 6 (6): 1-8. https://doi.org/10.22270/ujpr.v6i6.701
  2. Okbah AA, Al-Shamahy HA, Al-Shamahi EH, et al. Renal lesions: Differentiation of malignant and benign tumors, sex and age distribution and variables associated with renal cell carcinoma. Universal J Pharm Res 2022; 7(2):1-8. https://doi.org/10.22270/ujpr.v7i2.754
  3. El-Zine MAY, Alhadi AM, Ishak AA, et al. Prevalence of different types of leukemia and associated factors among children with leukemia in children’s cancer units at Al-Kuwait Hospital, Sana’a City: A cross sectional study. Glob J Ped Neonatol Car. 3(4): 2021.http://doi.org/10.33552/GJPNC.2021.03.000569
  1. Dutra KL, Longo L, Grando LJ, et al. Incidence of reactive hyperplastic lesions in the oral cavity: A 10-year retrospective study in Santa Catarina, Brazil. Braz J Otorhinolaryngol 2019 Jul-Aug; 85(4):399-407.http://doi.org/10.1016/j.bjorl.2018.03.006. Epub 2018 Apr 17. PMID: 29705120; PMCID: PMC9443062.
  1. DaSilva FC, Piazzetta CM, Torres-Pereira CC, et al. Gingival proliferative lesions in children and adolescents in Brazil: A 15-year-period cross-sectional study. J Indian Soc Periodontol. 2016 Jan-Feb;20(1):63-6. PMID: http://doi.org/10.4103/0972-124X.168493
  2. Soyele OO, Ladeji AM, Adebiyi KE, et al. Pattern of distribution of reactive localised hyperplasia of the oral cavity in patients at a tertiary health institution in Nigeria. Afr Health Sci 2019 Mar;19(1):1687-1694. PMID: 31148999. http://doi.org/10.4314/ahs.v19i1.45.
  3. Sangle VA, Pooja VK, Holani A, et al. Reactive hyperplastic lesions of the oral cavity: A retrospective survey study and literature review. Indian J Dent Res 2018 Jan-Feb;29(1):61-66. PMID: 29442089http://doi.org/10.4103/ijdr.IJDR_599_16
  1. Kadeh H, Saravani S, Tajik M. Reactive hyperplastic lesions of the oral cavity. Iran J Otorhinolaryngol 2015 Mar;27(79):137-44. PMID: 25938085; PMCID: PMC4409958.
  2. Mehwish Ayaz, Sapeedeh Afzal, Hasan Mehdi. Prevalence of reactive hyperplastic oral lesions. Pakistan Oral Dental J 2020;40(3):162-166.
  3. Kadeh H, Saravani S, Tajik M. Reactive hyperplastic lesions of the oral cavity. Iran J Otorhinolaryngol. 2015 Mar;27(79):137-44. PMID: 25938085; PMCID: PMC4409958.
  4. Kumar S. Prevalence of oral soft tissue lesions in Assam – India. Int J Sci Res 2017; 6(6): 1775-78
  5. Hallikeri K, Naikmasur V, Guttal K, et al. Prevalence of oral mucosal lesions among smokeless tobacco usage: A cross-sectional study. Indian J Cancer 2018 Oct-Dec;55(4):404-409. PMID: 30829279.http://doi.org/10.4103/ijc.IJC_178_18.
  1. Awange DO, Wakoli KA, Onyango JF, et al. Reactive localised inflammatory hyperplasia of the oral mucosa. East Afr Med J. 2009 Feb;86(2):79-82. PMID: 19894472http://doi.org/10.4314/eamj.v86i2.46939.
  1. Hunasgi S, Koneru A, Vanishree M, et al. Retrospective analysis of the clinical features of 530 cases of reactive lesions of oral cavity. J Adv Clin Res Insights 2014; 1(1):1–6.
  2. Sangle VA, Pooja VK, Holani A, et al. Reactive hyperplastic lesions of the oral cavity: A retrospective survey study and literature review. Indian J Dent Res 2018 Jan-Feb;29(1):61-66. PMID: 29442089http://doi.org/10.4103/ijdr.IJDR_599_16..
  1. Hunasgi S, Koneru A, Vanishree M, et al. Assessment of reactive gingival lesions of oral cavity: A histopathological study. J Oral Maxillofac Pathol. 2017 Jan-Apr;21(1):180.http://doi.org/10.4103/jomfp.JOMFP_23_16. PMID: 28479713; PMCID: PMC5406807.
  1. Gandhi B, Dhuvad J, Johnson A et al. Reactive lesions of the oral cavity. Natl J Integr Res Med 2016; 7(4): 154-57.
  2. Amadori F, Bardellini E, Conti G, et al. Oral mucosal lesions in teenagers: A cross-sectional study. Ital J Pediatr 2017 May 31;43(1):50. PMID: 28569171http://doi.org/10.1186/s13052-017-0367-7.
  1. Kansky AA, Didanovic V, Dovsak T, et al. Epidemiology of oral mucosal lesions in Slovenia. Radiol Oncol 2018 Sep 11;52(3):263-266. PMID: 30210036http://doi.org/10.2478/raon-2018-0031.
  1. Mandeepk, Singh S,Singh R, et al. Reactive hyperplastic lesions of the oral cavity: A Retrospective analysis in Jammu region of Jammu and Kashmir state, India. Int J Sci Study 2016; 4(4): 92-96.
  2. Maturana-Ramírez A, Adorno-Farías D, Reyes-Rojas M, et al. A retrospective analysis of reactive hyperplastic lesions of the oral cavity: study of 1149 cases diagnosed between 2000 and 2011, Chile. Acta Odontol Latinoam 2015;28(2):103-7. PMID: 26355878.http://doi.org/10.1590/S1852-48342015000200002  
  1. Daley TD, Wysocki GP, Wysocki PD, et al. The major epulides: clinicopathological correlations. J Can Dent Assoc 1990 Jul;56(7):627-30. PMID: 2397424.
  2. Reddy V, Saxena S, Saxena S, Reddy M. Reactive hyperplastic lesions of the oral cavity: A ten-year observational study on North Indian Population. J Clin Exp Dent 2012 Jul 1;4(3):e136-40. PMID: 24558543http://doi.org/10.4317/jced.50670.
  1. Regezi J, Sciubba J, Jordan R. Oral pathology. 7th ed. United States: Elsevier Saunders; 2016.
  2. Al-Mobeeriek A, AlDosari AM. Prevalence of oral lesions among Saudi dental patients. Ann Saudi Med 2009 Sep-Oct;29(5):365-8. http://doi.org/10.4103/0256-4947.55166.