Female Predilected Disease: Pyogenic Granuloma

Journal of Dental Sciences and Oral Rehabilitation, October-December 2016;7(4):195-197 195

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Female Predilected Disease: Pyogenic Granuloma1Archana Chaurasia, 2Ramakant Dandriyal, 3KY Giri, 4Himanshu Pratap Singh, 5Vishakha Lal

ABSTRACT

Pyogenic granuloma is a reactive hyperplasia of connective tissue in response to local irritants. It is a tumor-like growth of the oral cavity, frequently located surrounding the anterior teeth. It usually arises in response to various stimuli, such as low-grade local irritation, traumatic injury, hormonal factors, or certain kinds of drugs. Histologically, the surface epithelium may be intact, or may show foci of ulcerations or even exhibit hyperkeratosis. It over-lies a mass of dense connective tissue composed of significant amounts of mature collagen. Gingiva is the most common site affected followed by buccal mucosa, tongue, and lips. Pyogenic granuloma, in general, does not occur when excised along with the base and its causative factors. This paper presents a case of a pyogenic granuloma managed by surgical intervention.

Keywords: Exophytic benign neoplasm, Hyperplastic lesion, Inflammatory hyplerplasia.

How to cite this article: Chaurasia A, Dandriyal R, Giri KY, Singh HP, Lal V. Female Predilected Disease: Pyogenic Granu-loma. J Dent Sci Oral Rehab 2016;7(4):195-197.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

The term pyogenic granuloma was coined only in 1904 by Hartzel, and the first case was reported in 1844 by Hullihen.1 The term pyogenic granuloma is a misnomer because the lesion does not contain pus and is not strictly speaking a granuloma.2 Approximately one-third of the lesion occurs due to trauma, and oral hygiene may also be one of precipitating factors. It often presents as a painless pedunculated or sessile mass of gingiva.3

Pyogenic granuloma is a hyperactive benign inflam-matory lesion that occurs mostly on the mucosa of females with high levels of steroid hormones. It is generally believed that female sex hormones play important role in its pathogenesis,4 possibly because of the vascular effects of female hormones.5 Pyogenic granulomas of

CaSe RepORt

1,4Senior Lecturer, 2Professor, 3Head and Professor, 5Postgraduate Student1-5Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

Corresponding Author: Archana Chaurasia, Senior Lecturer Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, Phone: +919451260999 e-mail: drarchanachaurasia@gmail.com

10.5005/jp-journals-10039-1141

the gingiva frequently develop in pregnant women; such lesions may begin to develop during the first trimester and their incidence increases up through the 7th month of pregnancy. The increased incidence of these lesions during pregnancy may be related to the increasing levels of estrogen and progesterone.5 After pregnancy and the return of normal hormone levels, some of these pyo-genic granulomas resolve without treatment or undergo fibrous maturation and resemble a fibroma.5 The peak prevalence is in teenagers and young adults with a female predilection.1

It is a tumor-like growth of the oral cavity or skin that is considered to be neoplastic in nature2 and repre-sents reactive focal fibrous hyperplasia, which appears in response to various stimuli, such as low-grade local irritation, traumatic injury, hormonal factors, or certain kinds of drugs.6 Clinically, these lesions usually present as single nodule or sessile papule with smooth or lobulated surface and may be seen in any size from few millimeters to several centimeters. As a lesion matures, the vascularity decreases and the clinical appearances are more collag-enous and pink.1 This paper presents a case of a pyogenic granuloma managed by surgical intervention.

CASE REPORT

An 18-year-old female patient reported to the Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bareilly Uttar Pradesh, India with a chief com-plaint of swelling in the lower left region of jaw since 3 months. The patient reported of a localized gingival swelling being present, which gradually increased in size from a small nodular swelling to approximately 4 × 3 cm in size with a clear sign of inflammation with respect to 35, 36, 37, 38 regions. There was also complaints of bleeding while chewing food (Fig. 2). The patient’s medical history was noncontributory and there was a dental history of extraction in relation to 36, 8 months back.

On extraoral examination, facial asymmetry was seen on left side of face due to swelling, which extended from 1 cm below the corner of the mouth to the angle of mandible (Fig. 1). Mouth opening was restricted to interincisal distance approximately of 30 mm. Regional lymph nodes were not palpable.

On intraoral examination, there was present a smooth, exophytic, irregular oval-shaped lesion manifested as a

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Fig. 1: Preoperative profile view Fig. 2: Intraoral preoperative view

Fig. 3: Preoperative OPG showing bony resorption Fig. 4: Periodontal dressing and suturing after excision

large erythematous nodule of size approximately 4 × 3 cm, which was soft, nonfluctuating, nontender, and noncom-pressible in nature with pedunculated base and dark pink in color, extending anteroposteriorly from distal aspect of canine to mesial aspect of third molar and inferiorly from lingual vestibule to buccalvestibule. Spontaneous bleeding on probing was present. The tongue movement was normal (Fig. 2). The lesion was painless and asympto-matic except for slight discomfort during mastication due to growth.

By considering all the above features, a provisional diagnosis was made of pyogenic granuloma and orthop-antomogram (OPG) was taken, which showed slight bony resorption (Fig. 3). Routine hematological investigations were normal. Excisional biopsy was planned under local anesthesia.

Lesion was excised up to the base of lesion and the extraction of 35, 37, and 38 was performed. It was ensured that the lesion was completely excised by trimming of the soft tissue and bone adjacent to the tooth to prevent recurrence of the lesion. Periodontal dressing was given

for 1 week. After excision, sutures were placed (Fig. 4). The excised tissue was sent for histopathogical evalua-tion. Based on histological findings, the final diagnosis of pyogenic granuloma was made (Figs 5A and B). Anti-biotics and analgesics were prescribed for 1 week with chlorhexidine mouthwash and patient was advised to maintain the oral hygiene.

DISCUSSION

Pyogenic granuloma is a kind of inflammatory hyperpla-sia, a large range of nodular growth of the oral mucosa that histologically represents inflamed fibrous and granu-lation tissue.1 There are two kinds of pyogenic granulo-mas, namely, lobular capillary hemangioma (LCH type) and non-LCH type, which differs in histological features. Poncet and Dor in 1897 first described pyogenic granu-loma.1 Over the years, various authors have suggested other names, such as granuloma gravidarum,5 pregnancy tumor,5 Crocker and Hartzell’s disease,1 vascular epulis,5 benign vascular tumor,1 hemangiomatosis granuloma,

Female Predilected Disease: Pyogenic Granuloma

Journal of Dental Sciences and Oral Rehabilitation, October-December 2016;7(4):195-197 197

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Figs 5A and B: Histopathological slides

A B

epulisteleangiectaticum granulomatosa,1 and lobular capillary hemangioma.1

Oral pyogenic granuloma is the most common gingi-val tumor accounting for 75% of all cases. The lips, tongue, and buccal mucosa are the next most common sites. In the oral cavity, pyogenic granulomas show a striking predilection for the gingiva, with interdental papillae being the most common sites in 70% of the cases. They are more common in the maxillary anterior area than any other areas in the mouth.5

Management of pyogenic granuloma depends on the severity of symptoms. If the lesion is small, painless, and free of bleeding, clinical observation and follow-up are advised. Other treatment modalities include laser surgery7 or electrodessication. Injections of absolute ethanol, sodium tetradecylsulfate (sclerotherapy), and corticosteroids have also been tried with successful results in cases with recurrent lesions.1 Recurrence occurs in up to 16% of the lesions, which might be due to incomplete excision, failure to remove etiologic factors, or due to re-injury to the area, making follow-up necessary.1

CONCLUSION

With the presentation of this paper, it can be concluded that the combinations of various etiological factors might have caused the inflammatory tissue to cross the

threshold from regular gingivitis to granuloma formation. Surgical excision is a successful treatment of choice in minimizing the recurrence of lesion. So, the consideration should also be given to correct diagnosis and proper treatment planning. A careful management of the lesion should be performed while preserving and improving the mucogingival complex.

REFERENCES

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6. Zain R, Khoo S, Yeo J. Oral pyogenic granuloma clinical analysis of 304 cases. Singapore Dent J 1995 Jul; 20(1):8-10.

7. White JM, Chaudhry SI, Kudler JJ, Sekandari N, Schoelch ML, Silverman S Jr. Nd: YAG and CO2 laser therapy of oral mucosal lesions. J Clin Laser Med Surg 1998 Dec;16(6):299-304.