CASE REPORT

Giant granuloma gravidarium of the oral cavityBalasubramanian Krishnan, Gnanasekaran Arunprasad, Balasubramanian Madhan

Department of Dentistry,Jawaharlal Institute ofPostgraduate MedicalEducation and Research,Pondicherry, Pondicherry, India

Correspondence toDr Balasubramanian Krishnan,krishident@yahoo.co.uk

Accepted 12 March 2014

To cite: Krishnan B,Arunprasad G, Madhan B.BMJ Case Rep Publishedonline: [please include DayMonth Year] doi:10.1136/bcr-2014-204057

SUMMARYOral health is affected by hormonal changes duringpregnancy but is usually neglected by both theobstetrician and the patient during follow-up visits.Gingival enlargement is one of the most common orallesions seen during pregnancy. Rarely, gingivalenlargement can be very big, significantly affectingmaternal nutrition and impairing haemodynamic status.A giant granuloma gravidarium and appropriatemanagement strategies are discussed. Patients must beencouraged to undergo regular dental check-ups duringpregnancy. Simple oral hygiene measures are highlyeffective in mitigating most oral lesions of pregnancy.

BACKGROUNDThis case highlights the possible consequences ofneglecting oral hygiene during pregnancy. Largegingival enlargements can cause significant discom-fort to the patient and can complicate an unevent-ful pregnancy. Obstetricians must encourage theirpatients to visit their dentist and follow oralhygiene instructions. Most pregnancy related gin-gival lesions are easily managed with simple oralhygiene measures.

CASE PRESENTATIONA 26-year-old prima gravida woman who was28 weeks pregnant, was referred to the Departmentof Dentistry for evaluation of a progressivelyincreasing mass in the mandibular teeth region. Onexamination, a large proliferative gingival growth(approx 5×3 cm) was observed enveloping theocclusal surfaces of all posterior teeth with bothbuccal and lingual extensions. The lesion was mod-erately firm on palpation, non-tender and coatedwith plaque and debris. Some degree of mobilitywas suggestive of a pedunculated lesion. Onmanipulation, a sluggish bleed was observed, whichhowever ceased spontaneously in a few minutes.The patient had stopped using a toothbrush for thepast several weeks owing to the increased bleedingduring tooth brushing. The large lesion was alsoaffecting mastication and speech and bled spontan-eously several times a day. Poor oral hygiene withsignificant materia alba and plaque deposits on alltooth surfaces was recorded. The surface of thelesion had multiple traumatic indentations corre-sponding to the opposing tooth surfaces (figure 1).A single right submandibular inflammatory lymphnode was palpable. The medical history was posi-tive for gestational diabetes mellitus which wasmanaged satisfactorily with insulin therapy. A pro-visional diagnosis of pregnancy pyogenic granu-loma (PG) was made and treatment options werediscussed.

INVESTIGATIONSAn orthopantomogram revealed no intraosseouspathology of the mandible. Bone loss with patho-logical migration of teeth 43, 44 and 45 wasobserved (figure 2).

DIFFERENTIAL DIAGNOSISThe differential diagnosis of a large gingival massin the oral cavity includes peripheral giant cellgranuloma, peripheral ossifying fibroma, haemangi-oma, conventional granulation tissue, Kaposi’ssarcoma, angiosarcoma and non-Hodgkin’s lymph-oma. Biopsy and histology is definitive in ruling outthese lesions.

TREATMENTAlthough the large lesion and its associated discom-fort favoured surgical excision, in view of theadvanced pregnancy and the unwillingness of thepatient to accept the risks of the proposed surgery,the procedure was deferred until parturition. Thepatient underwent ultrasonic supragingival scalingto reduce the plaque and calculus deposits, and oralhygiene instructions were reinforced. Chlorhexidinegluconate (0.12%) mouthwash was prescribed toimprove oral hygiene and regular follow-up wasadvocated. The patient reported 8 weeks later for

Figure 1 Giant granuloma gravidarium covering theocclusal surfaces of mandibular posterior teeth.

Figure 2 Preoperative panoramic X-ray.

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further management of the gingival lesion following intrauterinefetal death 4 weeks earlier. The lesion appeared to show noregression in size or in symptoms. A surgical excision was per-formed down to the periosteum under general anaesthesia alongwith extraction of periodontally weakened teeth associated withthe gingival growth (figures 3 and 4).

OUTCOME AND FOLLOW-UPThe patient withstood the procedure well and the intraoperativeand postoperative periods were uneventful. Histological featuresof prominent endothelial proliferation with capillary formationand associated inflammation confirmed the clinical diagnosis(figure 5). No recurrence of the lesion was observed at a2-month follow-up visit.

DISCUSSIONOral health can be affected by hormonal changes duringpuberty, menstruation, pregnancy and the menopause. Gingivitisin pregnancy usually increases during the first trimester whengonadotropins are overproduced, and during the third trimesterwhen oestrogen and progesterone levels are at their highest.1

Localised gingival enlargements are often seen in pregnantpatients (granuloma gravidarium) and are categorised as ‘condi-tioned enlargements’ as the systemic condition of the patientexaggerates or distorts the normal gingival response to dentalplaque.2 Although commonly used, the term ‘pyogenic

granuloma’ is a misnomer since the condition is not associatedwith pus and does not represent a granuloma histologically.

Pregnancy PG is usually seen as a reddish, semi-firm, discrete,mushroom-like, flattened spherical mass that protrudes from thegingival margin and is attached by a sessile or pedunculatedbase. It is generally associated with bleeding either spontan-eously or during tooth brushing and mastication. Female sexhormones affect the gingiva by altering the effectiveness of theepithelial barrier to bacterial insult and by interfering with colla-gen maintenance and repair.3

The correlation between gingivitis and the quality of plaque isgreater after parturition than after pregnancy, which suggeststhat pregnancy introduces other features that aggravate the gin-gival response to local irritants. Ojanotko-Harri et al4 suggestedthat progesterone functions as an immunosuppressant in thegingival tissues of pregnant women, preventing a rapid acuteinflammatory reaction against plaque but allowing an increasedchronic tissue reaction, resulting clinically in an exaggeratedappearance of inflammation. Increased levels of progesteroneproduce dilatation and tortuosity of the gingival microvascula-ture, circulatory stasis and increased susceptibility to mechanicalirritation, all of which favour leakage of fluid into the perivascu-lar tissues.5 Depression of the maternal T lymphocyte responseand destruction of gingival mast cells by increased sex hormoneswith resultant release of histamine and proteolytic enzymes, andchanges in subgingival flora may all contribute to the exagger-ated inflammatory response to local irritants and plaque.6

Microscopic examination of gingival PG shows prominentendothelial proliferation with capillary formation and associatedinflammation. The capillary formation exceeds the usual gingivalresponse to chronic irritation and accounts for the enlargement.However, these microscopic features are not pathognomicbecause they cannot be used to differentiate pregnant and non-pregnant patients. Daley et al7 indicated that a diagnosis of‘pregnancy tumor’ is valid clinically in describing a PG occur-ring in pregnancy because it describes a distinct lesion not onthe basis of histological features but on aetiology, biologicalbehaviour and treatment protocol.

Most gingival disease during pregnancy can be prevented bythe removal of local irritants and the institution of fastidiousoral hygiene at the outset. Regular follow-up appointments witha dental surgeon should be recommended and any surgical orperiodontal treatment is best performed in the second trimester.It is easier to treat early carious lesions rather extensive dental

Figure 3 Excision of the lesion down to the periosteum.

Figure 4 Excised gingival lesion.

Figure 5 Acanthotic stratified epithelium with subepithelium showingproliferating capillaries and fibroblasts (H&E ×40).

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decay needing dental extractions during the later stages of preg-nancy. Dental extractions and postoperative pain managementcan be challenging and will require coordination with theobstetrician. Management of pregnancy PG depends upon theseverity of the symptoms. If the lesion is small, painless and freeof bleeding, regular follow-up and emphasis on oral hygienemaintenance is usually recommended. Surgical intervention isgenerally not considered during pregnancy as potential risksmust be carefully considered prior to any surgical proceduresince these lesions have a tendency to bleed heavily and mayresult in serious morbidity or fetal mortality.8 Surgical excision,the use of lasers/cautery and cryosurgery are among the modal-ities described for the management of these gingival lesions.2

Care must be taken to ensure that the excision extends down tothe periosteum and that the adjacent teeth are thoroughly scaledto remove the source of continuing irritation (plaque, calculus,foreign material). In pregnancy, treatment of gingival growthsthat is limited to the removal of tissue, without complete elimin-ation of local irritants, is usually associated with recurrence. Thehigh rates of recurrence observed have prompted a few investi-gators to suggest waiting until parturition before initiating surgi-cal management as spontaneous reduction commonly followsthe end of pregnancy and often makes surgery superfluous. Inthis case, although the lesion was interfering with masticationand worsening oral hygiene and surgical intervention was there-fore indicated, a conservative approach was instead preferred asthere was a risk of significant intraoperative bleeding duringattempted excision of such a large PG. The lesion appeared toshow no signs of regression even 4 weeks following the end ofthe patient’s pregnancy and so surgical intervention was neces-sary for the alleviation of symptoms.

CONCLUSIONOral health is afforded little importance at follow-up visitsduring pregnancy. although there is evidence that there is adirect relationship between maternal periodontal health andfetal outcome.9 Often, gingival enlargements are detected onlywhen they reach a considerable size and cause persistent bleed-ing and difficulty masticating. Management of such large PGsremains a challenge as the size of the lesion significantly impactson oral hygiene. In addition, such patients tend to prefer softand sugary foods, which hinders the control of gestational dia-betes mellitus. Pregnant patients must be encouraged to visit thedentist at regular intervals to minimise the occurrence of suchlesions. During pregnancy, instructions for oral hygiene main-tenance, removal of dental plaque, and the use of soft

toothbrushes are simple and effective measures to minimise theoccurrence of PG.

Learning points

▸ The gingiva in a pregnant patient often shows anexaggerated proliferative response to local irritants due tothe effect of hormonal variations during pregnancy.

▸ Most patients and obstetricians do not consider oral healthassessment during pregnancy to be important but regularoral health check-ups should be encouraged duringpregnancy.

▸ Most pregnancy gingival enlargements are self-limiting, canbe prevented by simple oral hygiene measures, and regressspontaneously following parturition.

▸ Gingival enlargements in pregnancy may rarely requiresurgical excision so the risk–benefit ratio must be carefullyassessed before surgery.

Contributors BK: concept and principal role in manuscript preparation. GA:preparation of the manuscript and literature review. BM: concept, and manuscriptpreparation and final approval.

Competing interests None.

Patient consent Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES1 Figuero E, Carrillo-de-Albornoz A, Herrera D, et al. Gingival changes during

pregnancy I. Influence of hormonal variations on clinical and immunologicalparameters. J Clin Periodontol 2010;37:220–9.

2 Durairaj J, Balasubramanian K, Rani PR, et al. Giant lingual granuloma gravidarum.J Obstet Gynaecol 2011;31:769–70.

3 Mascarenhas P, Gapski R, Al-Shamman K, et al. Influence of sex hormones on theperiodontium. J Clin Periodontol 2003;30:671–81.

4 Ojanotko-Harri AO, Harri MP, Hurttia HM, et al. Altered tissue metabolism ofprogesterone in pregnancy gingivitis and granuloma. J Clin Periodontol1991;18:262–6.

5 Henry F, Quatresooz P, Valverde-Lopez JC, et al. Blood vessel changes duringpregnancy: a review. Am J Clin Dermatol 2006;7:65–9.

6 Taylor D, Sullivan A, Eblen C, et al. Modulation of T cell CD3-Zeta chain expressionduring normal pregnancy. J Reprod Immunol 2002;54:15–31.

7 Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral Surg Oral MedOral Pathol 1991;72:196–9.

8 Wang PH, Chao HT, Lee WL, et al. Severe bleeding from a pregnancy tumor. A casereport. J Reprod Med 1997;42:59–62.

9 Kumar A, Basra M, Begum N, et al. Association of maternal periodontal health withadverse pregnancy outcome. J Obstet Gynaecol Res 2013;39:40–5.

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