Oral telangiectatic granuloma with an intrabony defect.

Oral telangiectatic granuloma is a benign hyperplastic lesion occurring in response to trauma or chronic irritation in the oral cavity. The characteristic histological appearance comprises of typical granulation tissue with a proliferation of small thin-walled blood vessels in the loose connective tissue. We describe a case of a 36-year-old female who had a swelling in the left maxillary region which was associated with the intrabony defect. An internal bevel gingivectomy was performed, and the histopathological report was suggestive of telangiectatic granuloma. The intrabony defect was managed with the placement of platelet rich fibrin plug in the defect. A follow-up at 6 months showed no recurrence and no loss in the width of keratinized tissue. The aim of this case is to highlight the rare association of intrabony defect with telangiectatic granuloma and the need for histopathological diagnosis in such lesions.

INTRODUCTION

Oral telangiectatic granulomas (OTGs) constitute a group of oral lesions which are benign and hyperplastic in nature, occurring in response to trauma or chronic irritation. Earlier, these lesions were synonymous with “pyogenic granulomas.” However, this term has been found to be a misnomer as it does not adequately reflect the characteristics of this lesion, that is, it does not contain pus and is not, strictly speaking, a true granuloma.[1] OTGs may occur in any age group, appear to have a female predilection and are commonly seen as red tumorous lesions affecting the vestibular gingiva of the maxillary anterior segment.[2] The etiology has been related to aspects such as the presence of bony spicules, use of orthodontic appliances, root fragments, gingival irritation, plaque, calculus, and trauma.[2] The term telangiectatic granulomas are attributed to its histological appearance which comprises of typical granulation tissue with inflammatory cell infiltrates and a characteristic subepithelial proliferation of small thin-walled blood vessels in the loose connective tissue.[3] This case report describes the clinical and histological appearance as well as the management of an OTG associated with chronic irritation.

CASE REPORT

A 36-year-old female patient reported to Department of Periodontology, Dr. D.Y Patil Dental College and Hospital, Pimpri, Pune with the chief complaint of a swelling in maxillary left front tooth region of the jaw since 1-year. The patient had noticed a small growth in the anterior region 1-year back, which had gradually increased to the present size, and it was associated with pain due to food lodgement. Past dental history revealed incomplete root canal treatment initiated 6 months earlier in the maxillary left lateral incisor. There was no contributory medical or drug history and no associated deleterious habits.

The intraoral examination revealed a swelling that measured 2.4 cm × 1 cm in size, extending from vestibule to gingival margin apico-coronally and from distal aspect of maxillary right central incisor to mesial aspect of maxillary left canine mesiodistally [Figure 1]. It was a firm, nontender growth, pale pink in color with a reddish component on attached gingiva of the maxillary left lateral incisor. The surface of the lesion appeared to be nodular, and the swelling was sessile. There was minimal bleeding on probing, and there was no purulent discharge from the gingival sulcus. Periodontal probing was performed and a pocket depth of 5 mm mesially, and 8 mm distally of the maxillary left lateral incisor was recorded.

Figure 1

Preoperative lesion

An intraoral periapical radiograph [Figure 2] revealed periapical radiolucency at the apex of the tooth and an intrabony defect distal to the maxillary left lateral incisor. Laboratory investigations (complete blood profile) revealed no abnormalities in the blood counts.

Figure 2

Preoperative radiograph with intrabony defect (thin arrow) distal to maxillary left lateral and periapical radiolucency (thick arrow)

A provisional diagnosis of pyogenic granuloma secondary to chronic irritation was given based on the clinical and radiographic investigations.

The initial phase of treatment consisted of nonsurgical periodontal therapy-scaling, root planing, and oral hygiene instructions. An endodontic consultation was taken and on pulp vitality testing tooth was found to be nonvital. The provisional diagnosis given was primary endodontic lesion with secondary periodontal involvement. The root canal treatment of the involved maxillary left lateral incisor was planned and completed. At 3 months recall, clinical examination showed neither a significant change in the size of the gingival growth nor a significant reduction in probing depth. However, no periapical radiolucency was detected at this time.

As the swelling involved the attached gingiva and was located in the esthetic zone, an excisional biopsy would have lead to considerable loss of keratinized tissue. Since, there was combined pocket due to swelling, therefore we did not raise conventional flap. Keeping in mind that there was also an intrabony defect associated with maxillary left lateral incisor, an internal bevel gingivectomy was planned in order to conserve keratinized tissue and facilitate access to the underlying bone defect. Under local anesthesia (2% LOX, Neon Labs lignocaine with 1:80,000 adrenaline), a mucoperiosteal flap was raised by giving internal bevel, sulcular, and interdental incisions. The intrabony defect adjacent to the maxillary left lateral incisor was debrided, and the root surfaces of the teeth were planned [Figure 3]. The tissue on the undersurface of the gingival swelling was curetted and sent for histopathological examination. Management of the intrabony defect comprised of placement of platelet rich fibrin (PRF) into the defect [Figure 4]. For preparation of PRF, 20 ml of blood was drawn from the antecubital vein and centrifuged in two glass tubes (10 ml each) at 3000 rpm for 12 min. Two plugs of PRF were obtained in separate test tubes. One plug was used as a graft material, and the other was compressed and used as a membrane.[4] The flap was then sutured back to its original position, and a periodontal dressing was given. The patient was prescribed amoxicillin (500 mg thrice a day for 5 days), diclofenac (50 mg twice a day for 5 days) and was instructed to follow standard postoperative instructions. Ten days later the periodontal pack and sutures were removed, and the healing was found to be satisfactory. At 3 and 6 months follow-up [Figures 5 and 6], there was complete soft tissue healing with no recurrence of the lesion. At 6-month recall, the pocket depth was 1 mm mesially and 3 mm distally of the maxillary left lateral incisor. Radiographic evaluation at 6 months also showed good bone fill [Figure 7].

Figure 3

Intrabony defect seen after flap reflection and debridement

Figure 4

Defect filled with platelet rich fibrin as a graft material and a membrane

Figure 5

Postoperative healing after 3 months with final restoration in place

Figure 6

Postoperative healing after 6 months with no recurrence

Figure 7

Postoperative radiograph after 6 months

Hematoxylin and eosin, stained section stratified squamous epithelium of the tissue specimen showed a hyperplastic parakeratinized. A highly cellular connective tissue with the plump proliferation of the endothelial cells and fibroblasts, with evidence of multiple budding capillaries was seen. Chronic inflammatory cells in a collagenous matrix, predominantly lymphocytes, and plasma cells were also noted. These findings were consistent with the histopathological diagnosis of a telangiectatic granuloma [Figure 8].

Figure 8

Photomicrograph showing characteristic proliferation of the endothelial cells, fibroblasts, multiple budding capillaries and chronic inflammatory cells in a collagenous matrix, predominantly lymphocytes, and plasma cells

DISCUSSION

The literature is replete with reports on pyogenic granuloma but very few authors have referred to such lesions as OTG.[35] The term OTG has been used as an alternative term for pyogenic granuloma as there are numerous blood vessels seen in the oral lesions.[5]

Telangiectatic granuloma is described as a localized reactive lesion caused by a given stimulus that produces excessive connective tissue; it is frequently found in the oral cavity, usually affecting areas such as gingiva, lips, and alveolar mucosa.[2] In a retrospective study conducted by Gordon et al.[6] a Brazilian population that included 293 cases of oral pyogenic granuloma showed a higher prevalence in women, with a 2.38:1 ratio. The most frequent target was the gingiva (83%), most cases were asymptomatic and presented spontaneous bleeding. The lesions were described as having a red surface (73.2%), soft consistency (62.3%), and a pedicular base (61.1%); the average lesion size was 1.3 cm. The lesion in our case, however, did not have the typical red surface which may be probably attributed to excessive fibrosis which could have occurred due to the chronic nature of the disease process and also to the thickness of the hyperplastic parakeratinized stratified squamous epithelium. Various etiological factors such as local irritants like dental plaque and calculus, chronic trauma, foreign bodies in the tissues, overhanging margins of the crowns have been described in the literature.[3] In the present case, the interplay of the above factors, mainly chronic periapical infection, and local irritants, could have initiated the gingival growth.

Bone loss has been reported infrequently in association with such lesions.[789101112] In this case, an intrabony defect on the mesial aspect of left maxillary lateral incisor beneath the granuloma was seen. The pressure from the granuloma and local irritants could be responsible for bone resorption and subsequent development of an intrabony defect. In the presence of bone loss with such a lesion, a differential diagnosis of giant cell granuloma, metastatic tumor, peripheral ossifying fibroma, and Kaposi's sarcoma was considered. However, the histopathological report, which is the gold standard for making the diagnosis of such lesions, confirmed a diagnosis of telangiectatic granuloma.[1]

The management of oral telangiectatic granuloma involves maintaining good oral hygiene, curettage of the lesion base, surgical excision to decrease the frequency of recurrence, accompanied by antibiotic and analgesic therapy.[3] In accordance with the available literature, our treatment plan consisted initially of scaling, root planing, and curettage along with antibiotics and analgesics. After 3 months follow-up, the persistence of pocket depths and swelling justified the need for a surgical intervention. The surgical procedure was aimed at the elimination of the granuloma and management of the intrabony defect concomitantly. Thus, an internal bevel gingivectomy which allows for reshaping of the gingival contour and facilitates access to the underlying defect was performed.[13] In cases where the etiology is obscure, the use of nonautogenous regenerative materials may be associated with a foreign body reaction. Consequently, the bone defect, in this case, was filled with a completely autologous biomaterial, PRF, without the use of any synthetic grafts. PRF has been shown to improve and accelerate soft tissue as well as bone healing and has shown tremendous potential for periodontal regeneration. There are many advantages of using PRF, a second-generation platelet concentrate. PRF does not use bovine thrombin or other exogenous activators in the preparation process. It forms a gel-like matrix that contains high concentrations of nonactivated, functional, intact platelets, contained within a fibrin matrix, that release, a relatively constant concentration of growth factors over a period of 7 days. In the form of a membrane, it can be used as fibrin bandage serving as a matrix to accelerate the healing of wound edges. Being autologous in nature, it is relatively inexpensive as no additional cost for synthetic membranes is incurred to the patients. Furthermore, the chair side preparation of PRF is quite easy, and processing is fast and simple.[4]

CONCLUSION

Even today, the occurrence of oral lesions presents a clinical enigma and diagnostic dilemma. It is difficult, in many instances, to classify and differentiate gingival growths based on etiology and clinical presentation alone. Thus, a gingival biopsy and subsequent histopathological examination are the sine qua non for establishing a definitive diagnosis. For gingival growths associated with underlying bone loss, the management may be aimed at treating both lesions simultaneously. Here, we present the management of a case of OTG associated with an underlying intrabony defect. The diagnosis of the lesion was based principally on the results of the biopsy which helped to characterize the nature of the lesion. Thus, with this report we reiterate the need to carry out a histopathologic examination for such lesions in order to reach a more accurate diagnosis.

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Conflicts of interest

There are no conflicts of interest.