CASE PRESENTATIONPYOGENIC GRANULOMA

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INTRODUCTION

Exophytic gingival lesions represent some of the more frequently encountered lesions in the oral cavity.

Some of these lesions are reactive in nature.  PYOGENIC GRANULOMA :It is a tumor like growth that is

considered an exaggerated , conditioned response to minor trauma.

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CASE HISTORYA 30 -year- old lady presented at the Department of Oral Medicine and Radiology of School of Dental Sciences, Greater Noida, with a 3-months history of a painless gingival swelling in the left lower back tooth region which was interfering with her ability to speak and eat normally.

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HISTORY OF PRESENT ILLNESS

• Patient presented with the swelling in the left mandibular posterior tooth region from last 3 months.

• Swelling was not associated with any pain.• Swelling was localized & increasing in size with in the

time duration of 3 months & associated with 35 & 36.

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PAST MEDICAL HISTORYNo significant history.

PERSONAL HISTORY Appetite: NormalType of diet: Non-VegetarianAdverse habits: No adverse HabitsOTHER HISTORY

No history of any systemic illness.

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EXTRA ORAL EXAMINATION

No changes were observed in the extra oral examination.

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INTRA ORAL EXAMINATION The intraoral examination revealed a sessile nodule with

a smooth surface and a discrete ulcerated area, having fiery red color and measuring approximately 0.7 cm in maximum diameter.

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• Size – 0.7cm in maximum diameter• Shape – oval• Margins – regular • Colour – whitish reddish • Fluctuant/non fluctuant – non fluctuant• Consistency – firm • Number – 1• Extent – left posterior teeth region i.e 35,36• Swelling was not associated with pus discharge

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Clinical photograph

0.7cm in maximum diameter

oval

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Provisional Diagnosis Pyogenic granuloma

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INVESTIGATIONSHaemogram :- BT :- 1 min 10 sec CT :- 4 min 30 sec Hb :- 11 gm%

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Surgical excision done in PERIODONTAL department

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GROSSINGSingle soft tissue , firm in consistency , oval in shape , greyish

brown in color, measuring around 0.7 × 1.5 cm Received in 10% formalin.

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HISTOPATHOLOGYH & E stained section shows parakeratinized stratified

squamous epithelium with long slender rete –ridges and connective tissue stroma.

The underlined connective tissue stroma shows numerous endothelium lined blood vessel with extravasated RBCs.

Dense inflammatory infiltrate chiefly lymphocytes are seen.Moderately dense collagen bundle interspersed plump

fibroblast.Overall H/P features are suggestive of “PYOGENIC GRANULOMA”.

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Photomicrograph 10x

Stratified squamous epithelium with long slender rete –ridges

Connective tissue stroma

Numerous endothelium lined blood vessel

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Small proliferating blood vessels

Endothelium lined blood vessels with extravasated RBC’s

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Photomicrograph 40x

Dense inflammatory infiltrate

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DIAGNOSISThe microscopic feature were consistent with pyogenic

granuloma.

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MANAGEMENTSurgical excision was done.

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DISCUSSION

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Soft tissue enlargements of the oral cavity often present a diagnostic challenge because a diverse group of pathologic processes can produce such lesions.

An enlargement may represent a variation of normal anatomic structures, inflammation, cysts, developmental anomalies, and neoplasm.

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Pyogenic granuloma is of the most common entities responsible for causing soft tissue enlargements.

It is a tumor like growth that is considered an exaggerated , conditioned response to minor trauma.

Occurrence of pyogenic granuloma was first described in 1897 by Poncet and Dor. Hominis.

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Pyogenic granuloma has been referred to by a variety of other names such as:

Granuloma pediculatum benignum,Benign vascular tumor,Pregnancy tumor, Vascular epulis, Crocker and Hartzell's disease.

It was given its present name by Crocker in 1903

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INCIDENCE AND PREVALENCE

According to Cawson et al. oral pyogenic granuloma is relatively common. Represents 0.5% of all skin nodules in children.

Esmeili et al. in their review stated that hyperplastic reactive lesions represent as a group the most common oral lesions, excluding caries, periodontal, and periapical inflammatory disease.

Cawson R.A & Odell E.W. Cawson’s essentials of oral pathology & oral medicine, eighth edition, Chapter 19, Pages 316- 317.

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In an analysis of 244 cases of gingival lesions in South Indian population, Shamim et al. found that non neoplastic lesions accounted for 75.5% of cases with oral pyogenic granuloma being most frequent lesion, accounting for 52.71% cases.

Shamim T, Varghese VI, Shameena PM, Sudha S. A retrospective analysis of gingival biopsied lesions in south Indian population: 2001-2006. Med Oral Pathol Oral Cir Bucal. 2008;13:414–8. 

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ETIOPATHOGENESIS

Some authors regard pyogenic granuloma as an “infectious” entity.

Kerr has reported staphylococci and botryomycosis, foreign bodies, and localization of infection in walls of blood vessel as contributing factors in the development of the lesion.

Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: various concepts of etiopathogenesis. Journal of oral and maxillofacial pathology. 2012 Jan 1;16(1):79

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According to Shafer et al., oral pyogenic granuloma arises as a result of infection by either staphylococci or streptococci, partially because it was shown that these microorganisms could produce colonies with fungus-like characteristics.

They also stated that oral pyogenic granuloma arises as a result of some minor trauma to the tissues provide a pathway for invasion of nonspecific types of microorganisms.

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They explain the mechanism : any irritant applied to living tissue may act either as a stimulus or as a destructive agent or both.

If many cells are present in a small volume of tissue and there is a relative reduction of blood flow through the area as in inflammation, the concentration of the stimulating substance will be high and growth will be stimulated.

Shafer, Hine & Levy. Shafer’s textbook of oral pathology, sixth edition, Chapter 5, Pages 328-330.

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As differentiation and maturation are attained, the cells become widely separated and the concentration of the substance falls and little growth occurs.

In this type of inflammation that results in the formation of oral pyogenic granuloma, destruction of fixed tissue cells is slight but stimulus to proliferation of vascular endothelium persists and exerts its influence over a long period of time.

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Regezi et al. suggest that pyogenic granuloma represents an exuberant connective tissue proliferation to a known stimulus or injury like calculus or foreign material within the gingival crevice.

Hosseini et al. stated that there are clinical observations that gingiva may be enlarged during pregnancy and may atrophy during menopause. On basis of these observations, gingiva can be regarded as another “target organ” for direct action of estrogen and progesterone.

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Immunosuppressive drugs such as cyclosporine.wrong selection of healing cap for implants are some of

the other precipitating factors for pyogenic granulomas.

Bachmeyer C, Devergie A, Mansouri S, Dubertret L, Aractingi S. Pyogenic granuloma of the tongue in chronic graft versus host disease. Ann Dermatol Venereol. 1996;123:552–4

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CLINICAL FEATURES

Arises more frequently on the gingiva –75%of all cases.

 May occur on lips, tongue and buccal mucosa and occasionally on other areas.

Maxillary anterior region > posterior with the buccal surfaces being affected more than the lingual surfaces. 

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Appears as an elevated, smooth or exophytic, sessile or pedunculated growth covered with red hemorrhagic and compressible erythematous papules, which appear lobulated and warty showing ulcerations and covered by yellow fibrinous membrane.

The color varies from red, reddish purple to pink depending on the vascularity of the growth.

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Tendency for hemorrhage either spontaneously or upon slight trauma.

The size varies from a few millimeters to several centimeters and it is usually slow growing, asymptomatic, painless growth, but at times it grows rapidly.

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The case presented here showed a growth localized to the lingual surfaces of the lower left posterior mandibular, reddish in color, the growth was present since 3 month. It had gradually increased in size, it had started to bleed intermittently and it also interfered during mastication, which prompted the patient to seek treatment.

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MICROSCOPIC FEATURESMicroscopically, it consists

of many dilated blood vessels in a loose oedematous connective tissue stroma.

There is typically a dense acute inflammatory infiltrate, but this may be scanty or absent.

H & E stained section shows parakeratinized stratified squamous epithelium with long slender rete –ridges and connective tissue stroma.The underlined connective tissue stroma shows numerous endothelium lined blood vessel with extravasated RBCs.Dense inflammatory infiltrate chiefly lymphocytes are seen.Moderately dense collagen bundle interspersed plump fibroblast

Case presented here

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DIFFERENTIAL DIAGNOSIS

GINGIVAL REACTIVE FIBROUS LESION

Focal fibrous hyperplasia

Peripheral giant cell granuloma

Peripheral ossifying fibroma

Post extraction granuloma Hemangioma

Kaposi's sarcoma

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CONCLUSIONPyogenic granulomas are commonly encountered soft tissue

enlargements. However, etiopathogenesis of oral pyogenic granuloma is still debatable.

Careful diagnosis is essential to differentiate this lesion from vascular lesions.

Meticulous oral hygiene should be instituted. Surgical excision of the growth, along with curettage should be

done to prevent recurrences of this common lesion

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REFRENCES1. Shafer, Hine & Levy. Shafer’s textbook of oral pathology, sixth edition, Chapter 5, Pages

328-330.2. Cawson R.A & Odell E.W. Cawson’s essentials of oral pathology & oral medicine, eighth

edition, Chapter 19, Pages 316- 317.3. Neville B.W, Damm D.D & White D.K. Color atlas of clinical oral pathology, second edition,

Chapter 9, Pages 284-285.4. Bachmeyer C, Devergie A, Mansouri S, Dubertret L, Aractingi S. Pyogenic granuloma of the

tongue in chronic graft versus host disease. Ann Dermatol Venereol. 1996;123:552–45. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: various concepts of etiopathogenesis.

Journal of oral and maxillofacial pathology. 2012 Jan 1;16(1):796. Gomes SR, Shakir QJ, Thaker PV, Tavadia JK. Pyogenic granuloma of the gingiva: A

misnomer?-A case report and review of literature. Journal of indian society of periodontology. 2013 Jul 1;17(4):514.

7. Shamim T, Varghese VI, Shameena PM, Sudha S. A retrospective analysis of gingival biopsied lesions in south Indian population: 2001-2006. Med Oral Pathol Oral Cir Bucal. 2008;13:414–8.