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Table of Contents   
ORIGINAL RESEARCH  
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 41-45
An insight into diagnosis of a hidden entity: Impacted food material


1 Department of Oral and Maxillofacial Pathology, Microbiology and Forensic Odontology, School of Dental Sciences, Karad, Satara, Maharashtra, India
2 Department of Oral Pathology Microbiology, School of Dental Sciences, Karad, Satara, Maharashtra, India
3 Department of Pedodontics, School of Dental Sciences, Karad, Satara, Maharashtra, India
4 Department of Oral and Maxillofacial Surgery, School of Dental Sciences, Karad, Satara, Maharashtra, India

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Date of Web Publication12-Feb-2018
 

   Abstract 

Introduction: Foreign bodies and tissue reactions to foreign materials are commonly encountered in the oral cavity. Exogenous materials causing foreign body reactions may be metallic (amalgam) or nonmetallic (suture materials, vegetable matter). Implantation of food particles in the oral tissues has been known to cause reactive lesions such as oral pulse granuloma. Implantation could be through extraction sockets, deep periodontal pockets, associated with tumor growth, interdental areas of teeth, unfilled root canals, and grossly decayed teeth. These get rapidly digested and altered by host responses. Cellulose persists as hyaline material and invokes chronic granulomatous response. This change may mimic other pathologies. Materials and Methods: Representative specimens from commonly consumed food groups were selected, fixed in 10% neutral buffered formalin, processed, sectioned, stained with hematoxylin and eosin stain and observed under light microscope. Results: Each specimen revealed unique, distinct histology of each food type. The plant materials had a characteristic appearance of rigid double cell wall while rigid regular partitions containing nutrient material were revealed in seeds and beans. Starch-contained lentils exhibited clear spaces. Following is a brief description of some of the significant histological findings of each of the specimens processed and stained. Conclusion: Thus, the study of histological structure of vegetables and legumes will enable their easy recognition in oral biopsy samples and help in distinguishing them from other pathologies and artifact.

Keywords: Foreign body, hyaline material, reactive lesions, pulse granuloma.

How to cite this article:
Mulla HM, Vibhute N, Baad R, Shashikiran N D, Parker M, Parmod R C, Belgaumi U, Kadashetti V, Bommanawar S. An insight into diagnosis of a hidden entity: Impacted food material. Indian J Dent Res 2018;29:41-5

How to cite this URL:
Mulla HM, Vibhute N, Baad R, Shashikiran N D, Parker M, Parmod R C, Belgaumi U, Kadashetti V, Bommanawar S. An insight into diagnosis of a hidden entity: Impacted food material. Indian J Dent Res [serial online] 2018 [cited 2019 Oct 15];29:41-5. Available from: http://www.ijdr.in/text.asp?2018/29/1/41/225250

   Introduction Top


Foreign bodies implanted in tissues can often masquerade as different pathologies and can baffle both the clinicians and pathologists alike. The oral cavity has been reported to be susceptible to many foreign body implantations which may be metallic like amalgam restorations or nonmetallic like vegetable matter.[1]

The various morphological features provided by the teeth and soft tissues render many vulnerable sites for such foreign body implantations including extraction sockets, space associated with operculum, periapical sites of teeth associated with prolonged open drainage during endodontic therapy, deep periodontal pockets, and deep crevices within tumor growth.[1],[2]

The implanted organic matter can be partially digested and altered by action of the host response and the residual cellulose, and hyaline matter may act as a stimulus and trigger a reactive phenomenon.[1] These foreign body remnants can often mimic many human tissues and can cause erroneous interpretations in histological sections.

Thus, it is of paramount importance to be familiar and aware of the histological appearances of foods that are frequently encountered as impacted in oral tissues.[3] With this background in mind, the aim of our study was to observe the characteristic histologic structures of commonly impacted food materials.


   Materials and Methods Top


Representative specimens from commonly consumed food groups were selected. Leafy vegetables such as spinach and fenugreek, beans including ground nut, winged beans, Turkish grams, African spinach, cabbage, and papaya were included in the study.

All the specimens were fixed in 10% neutral buffered formalin, routinely processed, sectioned, and stained with hematoxilin and eosin stain.

All the slides were observed under light microscope.


   Results Top


Each specimen revealed unique, distinct histology of each food type. The plant materials had a characteristic appearance of rigid double cell wall while rigid regular partitions containing nutrient material were revealed in seeds and beans. Starch-contained lentils exhibited clear spaces.

Following is a brief description of some of the significant histological findings of each of the specimens processed and stained.

Groundnut

Arachis hypogaea, i.e., ground nut is a seed and consists of endosperm and cotyledon. The endosperm and cotyledon consist of parenchymal cells and nutrient material within the parenchymal cells. The amount of nutrient material within the cells of endosperm or cotyledon depends on the maturity of the seed.[4]

The hematoxylin and eosin-stained slide of groundnut revealed darkly stained parenchymal cells with nutrient material in the endosperm and comparatively lightly stained epidermal cells as well as the nutrient material in the cotyledon [Figure 1].
Figure 1: A: Endosperm B: Cotyledon a: Parenchymal cells b: Nutrient material (hematoxylin and eosin-stained section of groundnut under ×10)

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Winged beans

Winged beans, i.e., Psophocarpus tetragonolobus, is a fruit. Microscopically consists of parenchymal cells with nutrient material.[5],[6],[7] The hematoxylin and eosin-stained slide of winged beans in our sections revealed eosinophilic epidermal layer, few cells with indistinct cell wall, and others with nutrient material which take a darker hue of eosin [Figure 2].
Figure 2: a: Epidermal layer b: Nutrient material c: Indistinct cell walls (hematoxilin and eosin-stained section of winged beans under ×10)

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Turkish gram

Turkish gram, i.e., Vigna aconitifolia, microscopically consists of parenchymal cells revealing the nutrient material, plastids, or empty spaces depending on the amount of mature cotyledon.

It also consists of epidermal layer on the outer portion of parenchymal cells.[6],[7]

The hematoxylin and eosin-stained slide of Turkish gram in our section revealed few cells with nutrient material and other areas with clear spaces surrounded by the cells filled with nutrient material in the cotyledon, whereas the endosperm revealed epidermal layer and plastids [Figure 3].
Figure 3: a: Nutrient material b: Clear spaces containing starch c: Epidermis d: Plastid (hematoxilin and eosin-stained section of Turkish gram under ×40)

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Fenugreek

Fenugreek, i.e., Trigonella foenum graecum, histologically shows collenchyma cells, sieve tubes within the cluster of cells for the transport of nutrients, and nitrogen fixation nodules for nitrogen fixation.[6],[7]

The hematoxylin and eosin-stained slide of fenugreek in our section revealed all the structures such as collenchyma cells, sieve tubes, and nitrogen fixation nodules [Figure 4].
Figure 4: a: Collenchyma cells b: Sieve tubes c: Nitrogen fixation nodules (hematoxilin and eosin-stained section of fenugreek under ×10)

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African spinach

Synonym of African spinach is Amaranthus cruentus.[6],[7] The hematoxylin and eosin-stained slide of African spinach in our section revealed both the collenchyma cells and sieve tubes within the cluster of cells [Figure 5].
Figure 5: a: Collenchyma cells b: Sieve tubes (hematoxilin and eosin-stained section of African spinach under ×10)

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Chickpea

Chickpea, i.e., Cicer arietinumhi [6],[7] microscopically in the hematoxylin and eosin-stained section revealed seed coat and epidermal layer. Few cotyledonal cells containing nutrient material and others have empty spaces [Figure 6].
Figure 6: a: Seed coat b: Cotyledon cells c: Nutrient material d: Epidermal layer (hematoxilin and eosin-stained section of chick pea under ×40)

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Cabbage

Cabbage, i.e., Brassica oleracea variant capitata microscopically reveals the mesophyll layer, empty cells, and sieve tubes in the hematoxylin and eosin-stained slide [Figure 7].[6],[7]
Figure 7: A: Mesophyll layer B: Sieve tubes (hematoxilin and eosin-stained section of cabbage under ×10)

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Papaya

Papaya, i.e., Carica papaya is a fruit microscopically showing the parenchymal cells.[6],[7] The hematoxylin and eosin-stained slide of papaya in our section revealed numerous empty parenchymal cells [Figure 8].
Figure 8: a: Parenchymal cells (hematoxilin and eosin-stained section of papaya under ×40)

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   Discussion Top


Impacted food materials have been encountered in human tissues since many years and have been reported by many investigators.

The first description had been provided in 1971 by Levars et al. when he studied six cases of foreign body reaction in the mandible. He concluded that denture worn by patients may have resulted in food particles being driven into the mucosa which elicited a tissue response.[8]

About 4 years later, in 1975, Alkins et al. reported 15 cases with microscopic features consisting of rings of palely stained structure-less material which got incorporated and were surrounded by some multinucleated giant cells. He suggested that they represent foreign bodies that might be the unabsorbed residue of therapeutic agents inserted into extraction sockets and used the term granuloma in edentulous jaws.[8]

In the same year, provided a descriptive terminology for such lesions as chronic mandibular periostitis associated with vasculitis.[8]

Foreign body impactions and their subsequent tissue responses continued to be a source of interest to researchers. Various authors provided new terminologies for such lesions. These included Dunlop and Barker who in 1977 used the term giant cell hyaline angiopathy while King 1978, first used the term pulse granuloma. The pulse granuloma was thought to describe a granulomatous response, especially in lungs of infants or severely debilitated persons, after the aspiration of fragments of pulses. Similar lesions have been found in stomach.[8]

The hyaline ring-like appearance was considered by some investigators to be remnants of substances such as beans and peas. However, other researchers countered this view and instead thought that they were more indicative of degenerated blood vessels and degenerated collagen or even fibrosed extravasated serum proteins.[1],[8],[9],[10]

Further, some investigators did not endorse this view either and proposed the lesion to be due to infection by Fordlopusis Glabarata and stated that any of plant foods such as vegetables, cereals, and fruits comprising of cell walls could be responsible for the development of oral lesions.[8],[11]

Knoblich stated that leguminous cellulose compared to that of other vegetable food stuffs is particularly noxious because of its high resistance to digestion by tissue macrophages. Legumes and pulses are rich in phytohaemagglutinins, which have been shown to have granuloma enhancing properties.[9]

As can be seen in our slides, many of the sections can resemble normal or pathologic conditions. For example, winged beans can resemble columnar epithelium and hemorrhagic areas. Turkish gram and papaya can resemble adipocytes. Fenugreek can resemble fungal infection and helmenthic infection. Cabbage can resemble cyst wall whereas chickpea can resemble atypical cells.

Oral pathologist may be well served by a general knowledge of commonly impacted food histology. Many a times, the patient may or may not recollect history of trauma or impaction of a foreign vegetable matter in the oral cavity.[12] One significant factor to be taken into consideration is a documented difference between tissue responses in oral cavity compared with those at other body sites such as lungs and gut. Characteristically oral lesions often show the absence of starch cells as they are quickly digested, as well as the presence of giant cells compared to other intraoral sites.[13]

An important confounding factor is that the histologic aspects may vary with the time of evolution and location. Stomatologists' lack of experience of knowledge about these structures and consequent body responses may lead to inaccurate diagnosis and confusion.[14] In such cases, the pathologist can greatly assist the clinician in making the correct diagnosis by identifying the impacted vegetable matter in the sections.[12]

Awareness and familiarity of this entity help in avoiding an erroneous diagnosis of systemic inflammatory disease or infectious disease such as Crohn's disease or Sarcoidosis. The extraoral locations reported in the literature are lung, peridiverticular areas, gall bladder,  Fallopian tube More Details, periosteum, skin, appendix, colon, and rectum.[3],[15],[16]

This article highlights the histological aspects of some of the commonly encountered food impactions in the oral cavity. Further studies can be undertaken to unveil histology of other types of foods that may be encountered as foreign objects in oral tissues. The recognition of this vegetable matter is largely a microscopic diagnosis. The infrequency of this diagnosis may be attributed to sampling phenomenon. Another reason for the underdiagnosis may be that the tissue response to particular vegetable matter may be trivial, and in most cases, it does not lead to gross clinical lesion. To sum-up, experienced dental specialists should link together and provide guidance for the research studies using different impacted food material, special stains, different microscopic techniques, and histochemical analysis which will improve the precision for identification of such food materials.

A documented reference  Atlas More Details of the commonly impacted food material is currently being undertaken by us. This will be greatly useful to all the pathologists as a reference to avoid misinterpretation of the impacted food material and thus aid in accurate identification and definitive diagnosis.


   Conclusions Top


In summary, foreign body impaction may present a diagnostic challenge for clinician and pathologist alike. Therefore, it must be included in the differential diagnosis when a patient has a history of recurrent lung disease or acute apnea. Furthermore, a pathologist in surgical or postmortem practice may be well served by a general knowledge of commonly impacted food histology. Through awareness and familiarity, the pathologist may play a crucial role in diagnosis and aid in subsequent patient management.[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Naik SV, Ghousia S, Shashibhushan K, Benni D. Pediatric oral pulse granuloma: A rare entity. Dent Res J (Isfahan) 2012;9:812-5.  Back to cited text no. 1
[PUBMED]    
2.
Morrison A. Mandible-Maxilla Inflammatory Hyaline Ring-Like Strucures. Available from: http://www. Pathologyoutlines.com. [Last accessed on 2018 Jan 28].  Back to cited text no. 2
    
3.
Chidambharam C, Samuel P, Subramanian D, Hammed F. Colostomy site pulse granuloma: A case report and review of literature. Int J Prod Lifecycle Manage 2014;1:1-4.  Back to cited text no. 3
    
4.
Sehgal C, Varma B. Histology and histochemistry of endosperm of some legumes: Arachis hypogaea, Cyamopsis tetragonoloba and Pisum sativum. Proc Indian Natl Sci Acad 1991;57:303-10.  Back to cited text no. 4
    
5.
Jenkins W. A histological study of snap bean tissues affected with black root. J Agric Res 1941;62:683-90.  Back to cited text no. 5
    
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Shah B. Seth A. Textbook of Pharmacognosy and Phytochemistry.1st ed. New Delhi: Elsevier; 2010.  Back to cited text no. 6
    
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Barnes J. Fundamentals of Pharmacognosy and Phytotherapy. 2nd ed. Edinburgh: Churchill Livingstone; 2012.  Back to cited text no. 7
    
8.
Kotrashetti VS, Angadi PV, Mane DR, Hallikerimath SR. Oral pulse granuloma associated with keratocystic odontogenic tumor: Report of a case and review on etiopathogenesis. Ann Maxillofac Surg 2011;1:83-6.  Back to cited text no. 8
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9.
Madalli V, Basavaraddi S, Horatti P, Naikmasur V. Oral pulse granuloma – A rare entity. Iran J Pathol 2013;8:281-2.  Back to cited text no. 9
    
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Manjunatha BS, Kumar GS, Raghunath V. Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma. Indian J Dent Res 2008;19:74-7.  Back to cited text no. 10
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11.
Kumar H, Narasimha A, Prasad R, Deo R. Pulse granuloma of the parotid gland masquerading as carcinoma – A case report with review of literature. J Clin Biomed Sci 2011;1:25-9.  Back to cited text no. 11
    
12.
Pritt B, Harmon M, Schwartz M, Cooper K. A tale of three aspirations: Foreign bodies in the airway. J Clin Pathol 2003;56:791-4.  Back to cited text no. 12
    
13.
Gueiros LA, Santos Silva AR, Romañach MJ, Leon JE, Lopes MA, Jorge J, et al. Distinctive aspects of oral hyaline ring granulomas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e35-9.  Back to cited text no. 13
    
14.
Sato H, Miyate H, Fukuta Y, Satoh M. Hyaline ring granuloma of the mandibular periosteum. Oral Sci Int 2005;2:17-20.  Back to cited text no. 14
    
15.
Geramizadeh B, Seyed JM, Bananzadeh AM. Omental mass caused by pericolic vegetable granuloma: A rare case report. Ann Colorectal Res 2014;2:20233.  Back to cited text no. 15
    
16.
Yeo NK, Eom DW, Lim HW, Song YJ. Vegetable or pulse granuloma in the nasal cavity. Clin Exp Otorhinolaryngol 2014;7:334-7.  Back to cited text no. 16
    

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Correspondence Address:
Dr. Humeera M Mulla
Sanjiwani Nagar, 452 Shaniwar Peth, Karad - 415 110, Satara, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_746_16

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