Pyogenic granuloma near the midline of the oral cavity: A series of case reports.

Pyogenic granuloma (PyG) is a common cause of swelling in the oral cavity during pregnancy and also as an exaggerated response to any minor trauma. The condition is frequently associated with periodontal pain and discomfort, in some cases interfering with mastication and creating esthetic problems. Six patients reported to the Department of Periodontics with gingival overgrowth in the lower anteriors. After recording the details of the patients' oral hygiene status, all the patients were provided initial therapy with scaling and were prescribed analgesics for the reduction of pain and discomfort. After 1 week, surgical excision of the overgrowth was performed and sent for histopathological analysis. The histopathological report is suggestive of PyG.

INTRODUCTION

Pyogenic granuloma (PyG) (also known as a “Eruptive hemangioma,” “Granulation tissue-type hemangioma,” “Granuloma gravidarum,” “Lobular capillary hemangioma,” “Pregnancy tumor” and “Tumor of pregnancy”[1] is primarily an oral disease which appears as an overgrowth of tissue due to irritation, physical trauma or hormonal factors.[2] PyG was first reported in the English literature by Hullihen in 1844.[3]

The term PyG or granuloma pyogenicum was introduced by Hartzell in 1904.[4] The name for PyG is misleading because it is not a true granuloma. In actuality, it is a capillary hemangioma of the lobular subtype, which is the reason they are often quite prone to bleeding. It is also not truly “pyogenic,” as the origin is mostly traumatic and not infectious.

PyG arises in response to various stimuli such as chronic low-grade irritation, traumatic injury and hormonal factors. It predominantly occurs in young females in the second decade of life, possibly because of a vascular effect due to hormonal changes. It occurs in 1% of pregnant women.[2] The appearance of PyG is usually a color ranging from red/pink to purple, and can be smooth or lobulated. Younger lesions are more likely to be red because of the high number of blood vessels. Older lesions begin to change into a pink color. PyG can be a pedunculated or sessile mass with a broad base. Its size ranges from a few millimeters to centimeters. It can be painful, especially if located in an area of the body where it is constantly disturbed. PyGs can grow rapidly and will often bleed profusely with little or no trauma. The most frequent intraoral site is the gingiva (approximately 75%). It can also occur on the lips, tongue, buccal mucosa, palate and floor of the mouth.[5] The diagnosis of PyG can be confirmed by preparing histological sections of the biopsy specimens. The treatment that has been widely used and often recommended is conservative surgical excision of the lesion, where the recurrence rates may vary from 0% to 16%.[6]

CASE REPORT

Six female patients with a common complaint of swelling of gums in the oral midline of the lower arch accompanied by pain and difficulty during mastication reported to the Department of Periodontics and Implantology, Drs. Sudha and Nageshwara Rao Siddhartha Institute of Dental Sciences, Chinnaoutpalli, Andhra Pradesh, India. Data regarding their age, sex, site, predisposing factors, clinical characteristics, histopathologic interpretation and treatment were duly recorded. On clinical examination, the size of the lesion varied from 1 cm in diameter up to 4 cm. In all the patients, the lesion was initially of a pin head size and then gradually increased to the present size. Local factors were present around the teeth corresponding to the lesion in all patients. We have found in our subjects a combination or superimposition of etiologies, like chronic low-grade irritation from local factors, traumatic injury and hormonal factors.

The treatment plan consisted of thorough oral prophylaxis comprising scaling and root planing to remove the local factors, followed by surgical excision using simple gingivectomy and histopathological examination of the excised mass.

Histopathology of the lesions in six cases

Stratified squamous epithelium covering the circumscribed areas of dilated capillaries and endothelial proliferation accompanied by formation of vascular spaces was seen in all the cases. Two of the lesions had an ulcerated surface with a zone of heavy infiltrate of neutrophils. Proliferation of fibroblasts was observed in all the cases, with a more pronounced effect on the longstanding lesions. The cellular infiltrates consisted of polymorphonuclear leukocytes (PMNs) and lymphocytes.

The histopathological report confirmed them as PyGs. The patients were examined periodically after 1 week, 1 month, 3 months and 5 months, and no evidence of recurrence of swelling was observed.

The clinical presentation of the six cases that reported to the Department of Periodontics and Implatology, Drs. Sudha and Nageshwara Rao Siddhartha Institute of Dental Sciences, Chinnaoutpalli, Andhra Pradesh, India, are summarized in Table 1 and Figures 1–13.

Table 1

Clinical presentation of the six cases

Figure 1

Case 1 - Pre-operative photograph

Figure 13

Case 6 - Post-operative

Case 1 - Immediate post-operative photograph

Case 1 - Three months post-operative

Case 2 - Pre-operative

Case 2 - Post-operative

Case 3 - Pre-operative

Case 3 - Post-operative

Case 4 - Pre-operative

Case 4 - Post-operative

Case 5 - Pre-operative

Case 5 - Post-operative

Case 6 - Pre-operative

DISCUSSION

PyG is a non-neoplastic growth in the oral cavity. It is a reactive inflammatory process filled with proliferating vascular channels, immature fibroblastic connective tissue and scattered inflammatory cells.

The surface usually is ulcerated and the lesion exhibits a lobular architecture. Gingiva is the most common site of occurrence, accounting for about 75% of the cases.[7] According to Vilmann et al., majority of the PyGs are found on the marginal gingival, with only 15% of the tumors on the alveolar part. Other common sites are lips, tongue and buccal mucosa.[8] Because it is a reactive tumor-like lesion, chronic low-grade irritation, traumatic injury, hormonal factors and certain kind of drugs could be considered as etiologic agents. Poor oral hygiene may be a precipitating factor in many patients.[2]

Many treatment techniques have been described for PyG. But, before treating any case, the etiology must be clearly identified and eradicated. Before attempting surgical excision of the lesion, a thorough oral prophylaxis should be performed because local factors such as plaque and calculus are the most important etiologic factors for PyG. If the lesion is small, painless and free of bleeding, oral prophylaxis, removal of causative irritants (foreign materials, source of trauma) and follow-up are advised. Lesions of large size are treated by a thorough oral prophylaxis followed by surgical excision using gingivectomy or flapsurgery procedures.

Other treatment protocols have also been suggested. Lasers such as Nd: YAG and CO2 Laser can also be used for surgical excision with minimal bleeding.[910] Ishida and Ramos-e-Silva believed that cryosurgery is a very useful technique for the treatment of PyG.[11] Moon et al. reported that sodium tetradecyl sulfate sclerotherapy successfully cleared the lesions in most patients without major complications.[12] Parisi et al. used a series of intralesional corticosteroid injections for the treatment of PyG, particularly highly recurrent lesions.[5]

A preventive measure consists of adequate home care measures with regular dental check up and oral prophylaxis, especially during pregnancy. Lesions removed during pregnancy may have a higher recurrence rate. After excision, recurrence occurs in up to 16% of the lesions. Recurrence is believed to result from incomplete excision, failure to remove etiologic factors or re-injury of the area. Some recurrences manifest as multiple deep satellite nodules that surround the site of the original lesion.

Differential diagnosis of PyG includes peripheral giant cell granuloma, peripheral ossifying fibroma, peripheral odontogenic fibroma, hyperplastic gingival inflammation, Kaposi's sarcoma, bacillary angiomatosis, angiosarcoma, metastatic cancer and hemangioma.

In our case reports, surgical excision of the lesion was curative, but one case of recurrence was reported in a pregnant woman in the second trimester, where the surgical procedure was repeated accompanied by thorough root planing that proved to be effective. This recurrence may be due to the effect of sex hormonal imbalances during pregnancy, which is one of the most common causes of PyG. In all the above cases, PyGs were found to occur close to the midline of the lower anteriors. Further observation of such cases will provide a better understanding of the occurrence of PyG in the midline of the lower anteriors.