Simultaneous occurrence of pyogenic granuloma at multiple sites associated with bone loss: Report of a rare case.

Pyogenic granuloma (PG) is a reactive hyperplasia of connective tissue that occurs in response to low-grade local irritation, traumatic injury, foreign materials, or hormonal causes and rarely associated with bone loss. Although solitary PG is a common lesion in the orofacial region, presence of multiple such lesions at the same time with associated bone loss is rare. In addition, repeated recurrences of such lesions sometimes frustrate the clinician. This article presents a rare case of simultaneous occurrence of PG at multiple sites associated with bone loss in a young female and its management.

INTRODUCTION

Some of the most frequently encountered lesions in oral cavity are exophytic and gingival in nature. These lesions are also reactive. One such relatively common benign mucocutaneous lesion that occurs either extraorally or intraorally is pyogenic granuloma (PG). This term is often considered inapt as it is not associated with pus-forming infection and the fact that it occurs as a reactionary response to various types of stimuli such as trauma, local irritation, and hormonal imbalances.[1]

Sometimes, destructive PG might be associated with bony erosion of labial cortex and present as painless and bleeding pedunculated or sessile polyploidy mass or an ulcerative painless growth of skin arising from gingival papilla showing rapid growth.[2] Nearly 75% of these masses are seen in gingiva but they can also affect lips, mucosa, tongue, etc. It is believed to originate from periosteum or periodontal ligament as a manifestation of injury or chronic irritation and typically appear as reddish purple nodule invading either gingiva or adjacent edentulous alveolar bone margins. This can lead to cupping resorption of the underlying bone which is also found to be associated with odontogenic tumors which originate in gingiva of tooth-bearing areas of jaws and present as traumatic, ulcerated exophytic growths.[3] However, final diagnosis can only be made by combining histopathological and clinical findings. We report a rare case of simultaneous occurrence of PG at multiple sites associated with bone loss in a young female and its management.

CASE REPORT

A 21-year-old female patient reported to us with the chief compliant of swelling in gums in the upper and lower anterior tooth region. These swellings were increasing in size for the past 15 days and were associated with bleeding gums, purulent discharge, and intermittent pain that were increased on chewing food. She had also noticed increase in gaps between her front upper teeth with slight mobility with the same. The patient was concerned for her compromised esthetics. Her medical history was suggestive of abnormal menstrual cycles and her drug history revealed that she was on hormonal supplements for reducing her body weight. She had a waist circumference of 102 cm and weighed 91 kg. All her vitals were within normal limits.

The patient was cooperative and had no reported tissue abuse habits. No abnormality was detected during her extraoral examination. Her intraoral clinical examination revealed soft and edematous gingiva which bled spontaneously on probing. It was associated with purulent discharge with a marked halitosis. There were multiple reddish granulomatous swellings in relation to tooth no. 12, 11, and 21 in the upper arch and 31, 41, and 42 in the lower arch [Figure 1]. There was an associated localized gingival overgrowth covering at least one-third of the clinical crown height on the labial surfaces of teeth. Lesions had pedunculated base, varying from 4 mm × 3.5 mm in 11 and 21 regions to 5 mm × 4 mm in 12 region. A provisional diagnosis of PG was made. The differential diagnosis of the lesion included fibroma, irritational fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, and hemangioma.

Figure 1

Preoperative clinical view

The gingiva was painful to touch and the associated teeth were tender on percussion. Periodontal probing was done after administration of local anesthesia. Anterior teeth revealed deeper probing depth measuring around 9–10 mm [Figure 2]. Grade I mobility was also seen with 11 and 21. Radiograph showed presence of angular bone loss in all anterior teeth [Figure 3]. The hematological findings were observed to be within the normal range.

Figure 2

Preoperative probing view of lesion at multiple sites (a) at 11, (b) 21, (c) 12, and (d) 31

Figure 3

Orthopantomogram

An immediate drainage of abscess under local anesthesia was done and suitable antimicrobial and analgesic agents were prescribed. Phase 1 therapy was carried out after a week and was followed for 8 weeks. A significant reduction in gingival inflammation was observed after 8 weeks [Figure 4]. However, there was persistence of localized gingival overgrowth and periodontal pockets. Therefore, an excisional biopsy of the lesion along with surgical pocket therapy was planned and explained to the patient, and written consent was obtained.

Figure 4

Lesions after scaling and root planing

Complete excision of the gingival overgrowth was done with scalpel under local anesthesia and the tissue was sent to the department of oral and maxillofacial pathology for histopathology. Histopathological report revealed hyperplastic, parakeratotic, stratified squamous epithelium with an underlying fibrovascular stroma that consisted of large number of dilated and budding capillaries, plump fibroblasts, and areas of extravasated blood and mixed modified inflammatory cell infiltrate [Figure 5]. The observed features confirmed the diagnosis of PG. Postexcisional biopsy healing was uneventful [Figure 6].

Figure 5

Histopathological picture: (A) Hyperplastic stratified squamous epithelium (B) Proliferating endothelial cells (C) Chronic inflammatory cells (D) Capillary

Figure 6

Healing after excisional biopsy

Surgical pocket therapy included elevation of full-thickness flap for access [Figure 7]. A papilla preservation flap was planned in relation to 21 and 11 and extended to 16. Surgical sites were thoroughly debrided. An autologous platelet-rich fibrin (PRF) membrane was prepared according to the following protocol: 10 ml of intravenous blood was withdrawn by venipuncture from antecubital fossa into a sterile tube. The tube was immediately centrifuged at 3000 rpm for 10 min. It yielded a fibrin clot in between the top layer of acellular plasma and bottom layer of erythrocytes. PRF membrane was used along with osseous grafts in sites with two or three walled angular osseous defects. Primary closure was achieved with 4-0 nonabsorbable black silk sutures (Ethicon, Johnson and Johnson, Somerville, NJ, USA) and periodontal dressings (Coe-Pak, GC America, Alsip, IL, USA) were placed.

Figure 7

Periodontal surgery: (a) osseous defects and (b) placement of bone grafts

Postoperatively, the patient was prescribed with antimicrobials and analgesics. Verbal oral hygiene instructions were given in detail. No complaints were reported at 48 h postoperative visit and progress of healing was satisfactory. She was recalled after 7 days, sutures were removed, and postoperative maintenance care was continued at regular interval.

Clinical re-evaluation after 1 year revealed an improvement in clinical parameters [Figure 8], reduced mobility, and significant bone fill in relation to 11 and 12 [Figure 9].

Figure 8

Postoperative 1-year follow-up

Figure 9

Comparative intraoral periapical radiographs: (a) preoperative (b) postoperative

DISCUSSION

Solitary PG of the gingiva is a common lesion which results from a reactive inflammatory response of the local tissues to local irritants or hormonal changes. However, simultaneous occurrence of multiple PGs is rare. In addition, the lesions presented with associated alveolar bone loss. Majority of lesions have been seen in the anterior maxillary marginal gingiva on the facial side, with only 15% tumors involving the alveolar bone. Although PG is a nonneoplastic soft tissue lesion, recurrence after treatment has been observed in some cases.[4]

Occurrence of multiple PGs has been described as satellitosis which may manifest as a complication of removal of tumor or trauma.[5] However, in the present case, there was no such history of trauma or tumor removal. The traumatic etiology provides an opportunity for nonspecific microbes such as staphylococci and streptococci to invade and the tissue responds with low virulence by proliferation of vascular type of connective tissue.[6] PGs are rarely associated with significant bone loss unlike this case with significant bone loss in all the teeth where PGs were located.

The patient presented with poor oral hygiene and local irritants contributing to chronic periodontitis. A painful oral lesion often hinders regular oral hygiene which is the most likely explanation of the oral hygiene status of the patient. Periodontitis is a microbiological and inflammatory disease, and untreated periodontal disease results in extension of the disease to deeper structures resulting in loss of attachment and bone loss which appears to have been occurred in the present case. PGs exhibiting neo-angiogenesis as a reactionary inflammatory response are influenced by several cytokines and proteins which play a role in the pathogenesis of this lesion. Angiogenesis is a crucial step in the pathogenesis of PG and the development of PG is dependent on the deregulation in the balance between angiogenic and anti-angiogenic effects.[7]

Prostaglandin E2 may be a possible common mediator of inflammatory process involved in the pathogenesis of PG and chronic periodontitis. In addition, obesity itself has been shown to influence systemic inflammatory mediators and local chronic inflammation.[8] There appears to be a possibility of local influence of systemic inflammatory mediators.

Oral manifestations of hormonal contraceptives are similar to those associated with oral changes in pregnancy such as pronounced vascular gingiva, hyperplastic gingivitis, and PG. In the present case, the patient was under medical treatment for weight loss suggesting a possibility of an underlying hormonal etiological influence in exacerbation of the local inflammatory condition. There are contrasting reports on the effect of female steroid hormones on PG. While Nichols et al.[9] reported that since periosteum lacks receptors for steroid hormone, estrogen and progesterone may be indirectly involved in the pathogenesis of this lesion. Yuan et al.[10] suggested that female steroid hormones might not only enhance the expression of angiogenic factors including vascular endothelial growth factor and basic fibroblast growth factor in inflamed tissue of PG, but also antagonize apoptosis of granuloma cells resulting in the prolonged course of angiogenic effect.

Effective treatment modality for solitary PG includes excision by scalpel or lasers, sclerotherapy, electrodessication, ligation, curettage, or a combination of techniques. In a small painless bleeding-free lesion, the treatment of choice is excision. Lasers substantially reduce the risk of bleeding, lessen operator time, and lessen postoperative pain. In the present case, presence of multiple PGs along with angular bone loss demanded both excision of the lesion and management of periodontal disease at the same site.

The primary objective of periodontal therapy is to gain access to the diseased sites and reduce pocket depth, arrest disease progression and restore the periodontal tissues lost due to disease process, and achieve tangible benefits such as improved esthetics. This could be obtained by regeneration. However, in this type of challenging clinical situation such as angular bone loss in relation to 11 and 12 regions, associated with Grade I mobility, regeneration proves to be an elusive goal. A conventional papilla preservation flap technique was used for the anteriors which preserves interdental soft tissues, helps in maximum protection of the bone graft and the PRF membrane, and results in esthetically pleasing gingival contours following the regenerative therapy. PRF is a second-generation platelet concentrate and aims at improving wound healing following surgical procedures. In addition, PRF stimulates the growth of osteoblasts and periodontal ligament cells, both of which are significant for the regeneration of hard and soft tissues at the periodontal defect sites.

CONCLUSION

PGs are common nonneoplastic oral findings; however, multiple such lesions along with bone loss are rare. Here, successful excision was followed by regenerative periodontal flap surgery using PRF and bone grafts as a regenerative mixture. A successful management of the lesion with no recurrence till 1 year was encouraging. This emphasizes the importance of thorough history taking, proper investigation, correct diagnosis, treatment planning, and regular maintenance phase to prevent recurrence of such lesions.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.