A Clinical Report of Solitary Gingival Overgrowth in a Young Female Patient.

Pyogenic granuloma is a type of inflammatory hyperplasia. The term "inflammatory hyperplasia" is used to describe nodular growths of oral mucosa that histologically contain inflamed fibrous and granulation tissues. It is nonneoplastic. It is predominant in second decade of life in young adult females. Oral pyogenic granuloma is the most common gingival tumor with a striking predilection to gingiva. About one-third of the lesions occur following trauma. Poor oral hygiene may be a precipitating factor as 75% of all cases show calculus or foreign material in gingival sulcus. Lesions are more common in maxillary than mandibular gingiva; lesions are more common on the facial aspect of gingiva than gingival aspect. Clinically, pyogenic granuloma is a smooth, lobulated, exophytic lesion seen as small, red, and erythematous papules on a pedunculated or sessile base that is usually hemorrhagic. Clinical development of the lesion is slow, asymptomatic, and painless but may also grow rapidly; surface is characteristically ulcerated and friable, covered by yellow, fibrinous membrane with its color ranging from pink to red to purple depending on the age of the lesion. Pyogenic granuloma develops in about 5% of pregnancy, called as "pregnancy tumor'' or "granuloma gravidarum." Hormonal imbalance in pregnancy exaggerates the body's response to bacterial irritation. Sometimes, pregnancy gingivitis may show a tendency for localized hyperplasia, which is called "pregnancy granuloma." Generally, it appears in about second-to-third month of pregnancy. Although pyogenic granuloma is a nonneoplastic growth in the oral cavity, proper diagnosis, prevention, management, and treatment of the lesion is very important. Excisional surgery is the treatment of choice whereas cryosurgery, excision by Nd:YAG laser, and sclerotherapy are alternative therapies. Though pyogenic granuloma in pregnancy is because of the effect of sex hormonal imbalances, taking careful oral hygiene measures is important to avoid recurrence of the lesion. This article is a case report of a 22-year-old female patient with pyogenic granuloma in the buccal aspect of maxillary gingiva managed by surgical excision.

INTRODUCTION

The term “pyogenic granuloma” or “granuloma pyogenicum” was introduced by Hartzell in 1904.[1] Pyogenic granuloma is a nonspecific conditioned gingival enlargement. In response to the local factors such as plaque and calculus, a highly vascularized granulation tissue is formed. Any minor trauma to the tissues may also provide route for the invasion of specific types of microorganism. Recurrent trauma during tooth brushing, trauma to deciduous teeth,[2] occlusal interferences, and trauma during chewing may also contribute to the development of the lesion.[3] Oral pyogenic granuloma is predominant in the second decade of life in young adult females.[4] It may also occur during the first and second trimesters of pregnancy in about 2% of women.[5] Oral pyogenic granuloma shows a predilection to gingiva accounting for approximately 75% of all cases followed by buccal mucosa, tongue, and lips.[6] The term “inflammatory hyperplasia” is used to describe nodular growths of oral mucosa that histologically contain inflamed fibrous and granulation tissue. It is nonneoplastic. Pyogenic granuloma is referred by various other names such as granuloma, pediculatum benignum, benign vascular tumor, pregnancy tumor, vascular epulis, and Crocker and Hartzell’s disease. Besides oral cavity, pyogenic granuloma can also occur in other regions such as head and neck, trunk, and extremities.[7] This article reports a case of a 22-year-old female patient with oral pyogenic granuloma successfully treated with surgical excision.

CASE REPORT

A 22-year-old female patient reported with the complaint of a growth in her left upper back tooth region. The growth had started about 6 months ago and reached the present size. Patient had no pain, but discomfort during chewing. Her medical history was insignificant. On clinical examination, no extraoral changes were observed. Intraoral examination revealed a single, pedunculated growth measuring about 1.5 cm × 1.5 cm, in the buccal aspect of gingiva in relation to left upper molar (27, 28) region. The growth was soft, smooth, erythematous and friable, and had a tendency to bleed easily on palpation. Heavy calculus deposits were present beneath the growth [Figure 1]. On examination with a William’s periodontal probe, periodontal pocket of approximately 4 mm was elicited. Intra oral periapical radiograph was taken in relation to 27, 28, which revealed no significant bony changes. Under local anaesthesia, surgical excision of the growth was carried out. To remove the local factors and remnants of the lesion, a full thickness flap was raised; debridement of granulation tissue was performed; flap was closed with 3-0 black silk simple interrupted sutures; and hemostasis was achieved. Histopathologic examination of the excisional biopsy was performed. The hematoxylin and eosin–stained sections showed stratified squamous epithelium and fibrovascular connective tissue [Figure 2]. The epithelium appeared atrophic. The underlying connective tissue exhibited numerous dilated blood vessels and budding capillaries, inflammatory infiltrates suggestive of pyogenic granuloma. The patient was recalled for review. Following excision, healing was uneventful [Figure 3]

Figure 1

Pre-operative view

Figure 2

Hematoxylin and eosin (H&E) stain showing numerous dilated blood vessels and budding capillaries, inflammatory infiltrates

Figure 3

Post-operative view

DISCUSSION

The lesions are more common in the facial aspect of maxillary gingiva.[8910] Pyogenic granuloma is a smooth or lobulated exophytic lesion seen as a small erythematous papules on a pedunculated or a sessile base, size of which may vary from few millimeters to several centimeters. Some of the important etiologic factors of gingival enlargement other than pyogenic granuloma are inflammation, hormonal imbalance, nonspecific conditioned enlargement, and systemic involvement such as leukemia and Wegener’s granulomatosis.[11] The superficial areas of the ulcerated form of pyogenic granuloma is predominated by gram-positive and gram-negative bacilli possibly contaminated from the oral cavity.[12] Growth of the lesion may be slow, asymptomatic, and painless,[1314] but may be rapid. The color of the lesion may be pink, red, or purple. Rapid growth of the lesion may be influenced by growth factors such as vascular endothelial growth factor 2, angiopoietin-2, and a nitric oxide synthase. Younger lesions are highly vascular causing bleeding to minor trauma whereas older lesions are more collagenized and pink.[910] Pyogenic granuloma rarely causes any bone loss,[15] though chronic lesions may cause localized alveolar bone resorption. Pyogenic granuloma develops in approximately 5% of pregnancy, called as “pregnancy tumor’’ or “granuloma gravidarum.” Hormonal imbalance in pregnancy exaggerates the body’s response to bacterial irritation. Sometimes, pregnancy gingivitis may show a tendency for localized hyperplasia that is called pregnancy granuloma.[16] Histopathologically, the lesion is usually well localized and resembles more of granulation tissue with a picture of high vascular proliferation.[9] Formation of small and large channels engorged with RBCs occurs.[89] These blood vessels sometimes organize in lobular aggregates and pathologists consider it as a lobular capillary hemangioma.[17] The overlying epithelium is generally thin and atrophic. Fibrinous exudates are seen over the surface in ulcerated lesion. Extensive proliferation of fibroblasts is observed. Endothelial-lined vascular spaces with budding endothelial cells are present. Infiltration of inflammatory cells is seen.[89] Polymerase chain reaction investigations for human papilloma virus and human herpes virus type have yielded negative results.[18] Differential diagnosis of pyogenic granuloma includes peripheral giant cell granuloma, peripheral ossifying fibroma, fibroma, peripheral odontogenic fibroma, hemangioma, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi’s sarcoma, pregnancy tumor, bacillary angiomatosis, angiosarcoma, non-Hodgkin’s lymphoma,[18] and metastatic tumors. Treatment of choice for pyogenic granuloma is surgical excision of gingival lesions followed by curettage of underlying tissue.[19] Any foreign body, calculus, and defective restoration should also be removed.[20] Laser therapy[13] and cryosurgery[21] have proved worthwhile in the treatment of pyogenic granuloma. Intralesional corticosteroids have been used in the treatment of some of the multiple recurrences.[22] The use of Nd:YAG laser for the excision of pyogenic granuloma lesion also proves worthwhile owing to its lower risk of bleeding compared to surgical technique. In a study by Powell et al.,[23] Nd:YAG laser proved better than CO2 laser for its superior coagulation characteristics. White et al.[13] proposed that laser excision is a better treatment of choice with no adverse effects. Additional precautionary measures need to be taken during pregnancy. Maintenance of meticulous oral hygiene and regular follow-ups are recommended. Surgical and periodontal treatment must be completed during second trimester.[14] Postpartal shrinkage of the gingival lesion may make surgery nonmandatory. Lawoyin et al.[24] observed no recurrence in cases treated by surgical excision. Following surgery, recurrence may be expected in approximately 16% of lesions, which may be because of incomplete excision, reinjury, or improper removal of etiologic factors.[25]

Al-Khateeb and Ababneh[26] observed a recurrence rate of 5.8% in their study.

CONCLUSION

Pyogenic granuloma is a common lesion of gingiva, the causative agents of this lesion being an array of etiologic factors such as local irritants, the dental plaque and calculus, overhanging restoration, and trauma. An exaggerated inflammatory response to minor trauma leads to granuloma formation. Moreover, pyogenic granuloma is a misnomer as the lesion has nothing to do with pus formation. Though it is a noninvasive tumor-like growth, it needs early diagnosis and prompt intervention to prevent recurrence of the lesion.

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Nil.

Conflicts of interest

There are no conflicts of interest.