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CASE REPORT Table of Contents  
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Intraoral healing type of pyogenic granuloma (A benign vascular tumor): A case report


1 Department of Periodontology, I.T.S Dental College, Hospital & Research Centre, Uttar Pradesh, India
2 Department of Periodontology, Vinayaka Missions Sankarachariyar Dental College, Vinayaka Mission's Research Foundation [Deemed To Be University], Salem, Tamil Nadu, India
3 Junior Resident, I.T.S Dental College, Hospital & Research Centre, Uttar Pradesh, India

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Date of Submission23-Feb-2021
Date of Decision04-Apr-2021
Date of Acceptance03-May-2021
Date of Web Publication25-May-2022
 

   Abstract 


Pyogenic granulomas represent tumor-like lesions affecting the skin and the oral cavity. This classic definition can be somewhat misleading because such lesion is not associated with infection and lacks any clinical evidence of pus or histological evidence of actual granulation tissue. This case report describes a surgical excision of the growth to exclude angiomatous proliferation. The patient reported a chief complaint of localized gingival overgrowth since 4 months. Intraoral examination revealed an irregular, sessile exuberant growth in respect to labial aspect and interdental gingiva of 31, 32, and 33, measuring about 1.6 × 1.1 cm. Based on the clinical findings, the case was provisionally diagnosed as “pyogenic granuloma”. A treatment was planned for the patient. A surgical excision was done irt 31, 32, 33, and the tissue was sent for histopathological examination, which was suggestive of a healing type of pyogenic granuloma.

Keywords: Benign tumor, capillary hemangioma, growth, hyperplasia, pregnancy tumor, pyogenic granuloma


How to cite this URL:
Gupta N, Thangarasu V, Tihara P, ul Nisa T. Intraoral healing type of pyogenic granuloma (A benign vascular tumor): A case report. Indian J Pathol Microbiol [Epub ahead of print] [cited 2022 Sep 28]. Available from: https://www.ijpmonline.org/preprintarticle.asp?id=345859





   Introduction Top


Pyogenic granuloma is a benign vascular tumor. It is inflammatory hyperplasia affecting the oral tissues. Both mucous membranes and skin can be affected. The term “pyogenic granuloma” was introduced by Hartzell in 1904.[1] The lesion lacks infiltrative or potential of malignancy.

Oral pyogenic granuloma occurs over a wide age range of 4.5 to 93 years with the highest incidence in the second and fifth decades; females are slightly more affected than males. Gingiva was the predominant site followed by the lips, tongue, buccal mucosa, and hard plate. They usually appear as soft, rapid-growing mass, localized solitary nodule with a sessile or pedunculated base, and color varies from red, purplish, or pink, depending on the lesion's vascularity.[2] Etiology can be trauma, inflammation, infectious agents, tartar, foreign bodies, immunosuppression, hormonal changes, medication.[3]

Sternberg et al.[4] described the three distinct phases, namely, (i) cellular phase, (ii) capillary phase/vascular phase, and (iii) involutionary phase. Histopathologically, the pyogenic granuloma is classified into lobular capillary hemangioma (LCH) and noplobular capillary hemangioma (non-LCH).[5] The course of the lesion can be described as “early,” “established,” and “healing” type.

This article reports the case of a 32-year-old male patient with pyogenic granuloma successfully managed by surgical intervention followed by electrocautery for hemostasis.


   Case Report Top


A 32-year-old male patient reported to the Department of Periodontics with a complaint of growth in the lower front region of the mouth since 4 months. The growth was small in size initially and slowly attained the present size. The patient gave a history of a surgical excision 3 months back for a similar lesion. The patient reported discomfort while brushing. Medical history was not relevant. Intraoral examination revealed a solitary red exophytic, pedunculated growth on the gingiva measuring about 1.6 × 1.1 × 1 cm present in relation to 31, 32, and 33. [Figure 1] On palpation, inspectory findings were confirmed. The growth was firm on palpation, nontender with the absence of discharge. Bleeding on provocation was positive. Oral hygiene was poor with calculus and stains. The complete hemogram showed all blood counts within normal limits. No abnormality was detected in the Intraoral periapical radiograph irt 31, 32, and 33.
Figure 1: Preoperative image showing pyogenic granuloma

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Excisional biopsy was performed under local anesthesia using a scalpel and blade, followed by curettage and through scaling of the involved teeth and sent for histopathologic examination [Figure 2].
Figure 2: Histologic section of the growth - Densely packed inflamed stroma with numerous blood vessels and fibrous septa

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Histopathological examination showed keratinized stratified squamous epithelium overlying a highly cellular and densely packed inflamed stroma with abundant formed blood vessels and areas of fibrous septa. The blood vessels are thin, long, and well-formed. The stroma shows abundant plump fibroblasts and a dense amount of inflammatory cells predominantly lymphocytes, plasma cells, and neutrophils. Clinico- pathologically can be correlated with the healing/involutionary phase of pyogenic granuloma [Figure 3]. The histopathological examination confirmed the clinical diagnosis of pyogenic granuloma.
Figure 3: Postoperative (immediately after excision)

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The patient was recalled after a week, and the excised area was evaluated for healing. The healing was satisfactory. The patient was recalled periodically at 2 weeks, 1 month, 3 months and 6 months. Even after 1 year, there was no recurrence of the lesion.


   Discussion Top


Pyogenic granuloma is a kind of inflammatory hyperplasia. The name, “pyogenic granuloma” is a misnomer, as it does not represent a granuloma histologically and is not associated with pus. Some authors use the term, “lobular capillary hemangioma” on the basis of the histopathological picture or the terms, “vascular epulis,” “benign vascular tumor,” and “pregnancy tumor”, or “granuloma gravidarum” when it occurs in pregnant women. Angelopoulos described it as “hemangiomatous granuloma” due to the presence of numerous blood vessels and the inflammatory nature of the lesion that is seen histologically. Due to its vascularity, the term “telangiectatic granuloma” has also been proposed.[6]

Etiology is unknown but can be related to trauma, chronic irritation, drugs, hormones, gingivitis, chronic irritation related to exfoliation of deciduous teeth, an eruption of permanent teeth, faulty filling, food impaction, complete periodontitis, and trauma due to a toothbrush. Oral pyogenic granuloma arises as a result of infection by either staphylococci or streptococci.

Pyogenic granuloma is partly or completely covered by parakeratotic or nonkeratinized stratified squamous epithelium. The major bulk of the lesion is formed by a lobulated or a nonlobulated mass of angiomatous tissue. Usually, lobulated lesions are composed of solid endothelial proliferation or proliferation of capillary-sized blood vessels. The amount of collagen in the connective tissue of pyogenic granuloma is usually sparse. The surface can be ulcerated and in such ulcerated lesions, edema was a prominent feature, and the lesion is infiltrated by plasma cells, lymphocytes, and neutrophils.

Differential diagnosis of pyogenic granuloma includes peripheral giant cell granuloma, peripheral ossifying fibroma, metastatic cancer, hemangioma, bacillary angiomatosis and angiosarcoma, oral erythroplakia. Oral erythroplakia is a red or eythromatous patch of oral mucosa and is associated with a higher rate to develop dysplasia, carcinoma in situ.[7] Depending on the different stages of pyogenic granuloma, certain lesions come in as differential diagnoses. Younger lesions may be mistaken for conventional granulation tissue histopathologically or hemangioma, Kaposi's sarcoma, and bacillary angiomatosis clinically. Hemangioma generally presents in extragingival locations and is devoid of any inflammatory components, points, which help it in differentiating from pyogenic granuloma. Histopathologically, the absence of atypical cells and bizarre vascular channels helps to differentiate pyogenic granuloma from Kaposi's sarcoma, whereas the absence of any granular bacterial material differentiates it from bacillary angiomatosis. Similarly, older lesions can be mistaken for oral fibroma, peripheral giant cell granuloma, or peripheral ossifying fibroma. The older lesions show certain resemblances to oral fibroma or peripheral ossifying fibroma due to the presence of extensive fibrosis in the stroma. However, the increased vascular component and the inflammatory infiltrate are indicative of pyogenic granuloma and help in differentiating it from these lesions.[8]

Management of pyogenic granuloma is dependent 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 surgery, electrodessication. Injection of absolute ethanol, sodium tetradecyl sulfate (sclerotherapy), and corticosteroids, gel-containing timolol have also shown successful results.

After lesion excision, it is recommended to perform curettage of the underlying tissue, performing an excision with 2 mm margins in the periphery and at a depth that will include periosteum. Moreover, any foreign body, calculus, or restoration that might be associated with to onset of pyogenic granuloma must be removed.

An immunohistochemical study was done to compare the proliferation rate of LCH and non-LCH form of PG by an immunohistochemical method using anti-Ki-67 antibody as a proliferative marker and CD31 as an endothelial cell marker and concluded that there is a higher proliferation activity in endothelial cells of LCH PG than in non-LCH.[9]

Sangueza and Requena stated that pyogenic granuloma lesions express factor VIII-related antigen positivity in the endothelial cells lining large vessels, but are negative in the cellular areas, whereas Ulex europaeus I lectin binds to endothelial cells in both large vessels and cellular aggregates. Enhanced expression of the bFGF, Tie-2, anti-CD34, and anti-alpha SMA antibodies, and vascular morphogenesis factors such as angiopoietin-1, angiopoietin-2, ephrinB2, and ephrinB4. There is also an expression of inducible nitric oxide synthase, increased expression of vascular endothelial growth factor, low apoptotic rate expression of Bax/Bcl-2 proteins, and strong expression of phosphorylated mitogen-activated protein kinase.[10]

Recurrence occurs in up to 16% of the lesions, which might be due to incomplete excision, failure to remove etiologic factors, or reinjury to the area, making follow up necessary. Hence, due to its high recurrence rate, long-term follow ups are recommended. In order to minimize its recurrence, the lesion should be excised with a wider margin down to the periosteum or to the causing agent.

Clinical significance: Pyogenic granuloma is the most common entity responsible for causing soft tissue enlargement. Overall, a careful clinical and histopathological correlation is required to identify pyogenic granuloma. Complete knowledge about its etiology and careful management is helpful in decreasing the recurrence rate.


   Conclusion Top


A pyogenic granuloma is a harmless overgrowth of large numbers of tiny blood vessels on the skin and mucosa. From the present case report, it is concluded a thorough understanding of the lesion is prudent to differentiate it from similar clinical presentations with appropriate treatment modalities yielding excellent results. Careful management of the lesion also helps in preventing the recurrence of this benign lesion.

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.



 
   References Top

1.
Hartzell MB. Granuloma pyogenicum. J Cutan Dis Syph 1904;22:520-5.  Back to cited text no. 1
    
2.
Mubeen K, Vijaylakshmi KR, Abhishek RP. Oral pyogenic granuloma with mandible involvement: An unusual presentation. J Dent Oral Hyg 2011;3:6-9.  Back to cited text no. 2
    
3.
Kurian DB, Sasirekha D, Ebenezer D. Pyogenic granuloma - A case report and review. IJDSR 2014;2:66-8.  Back to cited text no. 3
    
4.
Sternberg SS, Antonioli DA, Carter D, Mills SE, Oberman H. Diagnostic Surgical Pathology. 3rd. Philadelphia, Pa, USA: Lippincott Williams & Wilkins; 1999.  Back to cited text no. 4
    
5.
Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: The underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol 1980;4:470-9.  Back to cited text no. 5
    
6.
Wollina U, Langner D, França K, Gianfaldoni S, Lotti T, Tchernev G. Pyogenic granuloma - A common benign vascular tumor with variable clinical presentation: New findings and treatment options. Open Access Maced J Med Sci 2017;5:423-6.  Back to cited text no. 6
    
7.
Jagtap SV, Warhate P, Saini N, Jagtap SS, Chougule PG. Oral premalignant lesions: A clinicopathological study. Int Surg J 2017;4:3477-81.  Back to cited text no. 7
    
8.
Marla V, Shrestha A, Goel K, Shrestha S. The histopathological spectrum of pyogenic granuloma: A case series. Case Rep Dent 2016;2016:1323798.  Back to cited text no. 8
    
9.
Rezvani G, Azarpira N, Bita G, Zeynab R. Proliferative activity in oral pyogenic granuloma: A comparative immunohistochemical study. Indian J Pathol Microbiol 2010;53:403-7.  Back to cited text no. 9
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10.
Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997;37:887-919.  Back to cited text no. 10
    

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Correspondence Address:
Neetika Gupta,
C-1/64 (Ground floor), Janak Puri New Delhi, 110058
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpm.ijpm_206_21



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