A 10 YEAR AUDIT OF PYOGENIC GRANULOMAS AT THE UNIVERSITY OF

NAIROBI DENTAL HOSPITAL

OMARI MICHAEL

V28/1947/2010

BDS LEVEL III

A COMMUNITY DENTISTRY RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE AWARD OF THE BACHELOR OF DENTAL SURGERY DEGREE,

UNIVERSITY OF NAIROBI

2013

ii

DECLARATION

I, Omari Michael, a third year student pursuing the Bachelor of Dental Surgery degree, do

solemnly swear that this is my original work and that it has not been presented by any other

person to any other institution.

Michael Omari

Signed………………………… Date…………………………

iii

SUPERVISORS’ APPROVAL

This research project has been submitted for examination with our approval as University of

Nairobi supervisors.

INTERNAL SUPERVISOR:

Dr. Bernard N. Mua BDS, MPH (Nbi), MBA (St Paul’s)

Department of Periodontology, Community and Preventive Dentistry

School of Dental Sciences

University of Nairobi

Signed………………….

Date…………………....

EXTERNAL SUPERVISOR

Dr. Hudson Alumera BDS, MDS (Nbi)

Department of Periodontology, Community and Preventive Dentistry

School of Dental Sciences

University of Nairobi

Signed…………………

Date……………………

iv

DEDICATION

To my mother, Joyce Kanini Omari, for her undying commitment to the success of her children.

v

ACKNOWLEDGEMENTS

I would like to thank Dr. B.N. Mua and Dr. H. Alumera for their support during this work, and

for their criticism through which I learnt the most.

I would also like to thank all my colleagues who provided assistance or moral support in any

way.

To the researchers whose works I have quoted and referred to, thank you for the inspiration.

Gratitude to Dr. Elizabeth Dimba for her advice and support during data collection. You deserve

more than a mention.

Mr. Desmond Tutu, for all the help provided during data analysis, I shall forever be grateful. I

learnt from scratch what data analysis is because of you.

Finally, to my family for all the support throughout the year, may you receive more than you

give.

May God bless you all.

vi

TABLE OF CONTENTS

DECLARATION .......................................................................................................................... ii

SUPERVISORS’ APPROVAL ................................................................................................... iii

DEDICATION ............................................................................................................................. iv

ACKNOWLEDGEMENTS ......................................................................................................... v

LIST OF TABLES AND FIGURES......................................................................................... viii

LIST OF ACRONYMS AND ABBREVIATIONS ................................................................... ix

DEFINITION OF TERMS .......................................................................................................... x

ABSTRACT .................................................................................................................................. xi

CHAPTER ONE: INTRODUCTION AND LITERATURE REVIEW .................................. 1

1.1 Introduction ........................................................................................................................... 1

1.2 Literature Review.................................................................................................................. 3

CHAPTER TWO: STATEMENT OF THE RESEARCH PROBLEM, STUDY

JUSTIFICATION AND OBJECTIVES ..................................................................................... 5

2.1 Statement of the Research Problem ...................................................................................... 5

2.2 Study Justification ................................................................................................................. 5

2.3 Study objectives .................................................................................................................... 5

2.31 General Objective ........................................................................................................... 5

2.32 Specific Objectives ......................................................................................................... 5

2.4 Study variables .................................................................................................................. 6

CHAPTER THREE: MATERIALS AND METHODS ............................................................ 7

3.1 Study Area ............................................................................................................................ 7

3.2 Study Population ................................................................................................................... 7

3.3 Study Design ......................................................................................................................... 7

3.4 Sample Size ........................................................................................................................... 7

3.5 Sampling Method .................................................................................................................. 8

3.6 Inclusion Criteria .................................................................................................................. 8

3.7 Exclusion Criteria ................................................................................................................. 8

3.8 Data Collection Instruments ................................................................................................. 9

3.9 Data Analysis And Presentation ........................................................................................... 9

3.10 Ethical Considerations ........................................................................................................ 9

3.11 Perceived Benefits .............................................................................................................. 9

vii

CHAPTER FOUR: RESULTS .................................................................................................. 10

4.1 Socio-demographic characteristics ..................................................................................... 10

4.11 Gender distribution ....................................................................................................... 10

4.12 Age distribution ............................................................................................................ 10

4.2 Site characteristics .............................................................................................................. 12

4.21 Gingival lesions ............................................................................................................ 12

4.22 Extra-gingival lesions ................................................................................................... 13

4.3 Size of the lesions ............................................................................................................... 14

CHAPTER FIVE: DISCUSSION OF RESULTS, CONCLUSION AND

RECOMMENDATIONS............................................................................................................ 15

5.1 Discussion ........................................................................................................................... 15

5.2 Conclusion .......................................................................................................................... 18

5.3 Recommendations ............................................................................................................... 18

REFERENCES ............................................................................................................................ 20

APPENDIX 1 : CHECKLIST .................................................................................................... 22

viii

LIST OF TABLES AND FIGURES

Table 1: Gender distribution of oral pyogenic granuloma

Figure 1: Mean age by gender

Figure 2: Year of diagnosis of OPG lesions

Figure 3: Location of OPG lesions

Figure 4: Location of gingival lesions along the sagittal plane

Figure 5: Location of gingival lesions along the sagittal plane

Figure 6: Site of gingival lesions

Figure 7: Number of Extra-gingival lesions

Figure 8: Largest Dimension of OPG lesions

ix

LIST OF ACRONYMS AND ABBREVIATIONS

BDS Bachelor of Dental Surgery

Fig. Figure

MDS Master of Dental Surgery

n Number

OPG Oral Pyogenic Granuloma

SPSS Statistical Package for the Social Sciences

UoN University of Nairobi

UoNDH University of Nairobi Dental Hospital

x

DEFINITION OF TERMS

Biopsy Tissue sample which is to be sampled

Epulis A term used to describe tumors on gingivae

Histopathology Studying of tissue under a microscope to check for disease

Oral Pyogenic Granuloma A reactive inflammatory lesion which occurs in the mouth

Pedunculated With a stalk

xi

ABSTRACT

Background: The normal periodontium and various parts of the oral mucosa are pink or very

slightly red in color, with some melanotic pigmentation that varies based mainly on the race of

an individual. Several diseases can cause a variation in this morphology including but not limited

to tumors and tumor-like lesions. Among them is oral pyogenic granuloma, also called

granuloma pyogenicum or granuloma gravidarum, which is a benign and relatively uncommon

reactive hyperplastic lesion. OPG is seen clinically as a red or pink tumor which almost always

has a stalk and bleeds either spontaneously or upon the slightest stimulation. It can be mistaken

for other lesions especially if clinical examination alone is used to arrive at a diagnosis, thus

diagnostic aids such as biopsies should be done together with adjuncts like radiographs to check

for osseous invasion.

Objective: To audit the histopathologic records of patients with oral pyogenic granuloma who

visited and were diagnosed with the condition at the UoNDH over a 10-year period (2003-2012).

Study Design: This was a descriptive cross-sectional study

Setting: Histopathology laboratory, University of Nairobi Dental Hospital

Materials and Methods: Data from a total of 89 files was obtained from the histolopathology

laboratory records and entered into a data sheet. This data included socio-demographic details,

clinical features of the lesions and sites of occurrence. Variables of interest included age, sex,

size of lesions, year of diagnosis and sites of occurrence. Data analysis was then done using a

SPSS version 16 and results tabulated.

Results: Data from a total of 89 patients was analysed, and of these, 59.77% were females and

40.2% were males. The male to female ratio was 2:3. The ages ranged between 5-92 with a mean

of 33.41 years. The peak age group affected by the lesion was that between 21-30 years i.e. it

xii

was most common in the third decade of life. Females affected by oral pyogenic granuloma were

older on average than males.

Most of the lesions were diagnosed in the year 2010 and 2011 with 15 each year (17%) while

2006, with 2 cases (2.3%), had the least number of lesions diagnosed. Most of the lesions

occurred on the gingivae of the upper jaw. They were 46 in number (52.3%), while those in the

gingivae of the lower jaw were 20 (22.7%). Among the gingivally located lesions, 55.7% were

on the facial aspect while 31.8% were on the linguo-palatal aspect. A total of 10 (11.4%) OPG

lesions were large to the extent of covering both the facial and lingual/palatal aspects. A majority

of the gingival lesions were located anteriorly, with 59.1% lesions, whereas 17% gingival lesions

were located posteriorly.

Conclusion:

1. Oral pyogenic granuloma was found to be more common in females than in males.

2. The lesion is more likely to occur on the labio-buccal aspect of the maxillary gingivae.

3. Extra-gingival lesions had a predilection for the lower lip.

Recommendations:

1. There is need to establish a link with the referring hospitals in order to facilitate patient follow

up and determination of treatment modality(ies) employed.

2. Another study should be carried out in Kenya to determine a more accurate incidence and

prevalence of oral pyogenic granuloma.

1

CHAPTER ONE: INTRODUCTION AND LITERATURE REVIEW

1.1 Introduction

Pyogenic Granuloma, a type of inflammatory hyperplasia, is a benign muco-cutaneous lesion

which may present intravascularly or subcutaneously, and whose most common site is the

gingivae. Other names used to refer to it include granuloma pyogenicum, granuloma gravidarum

and pregnancy epulis [1]

. It was first described in 1897 by Poncet and Dor, who named it

Botryomycosis Hominis. Its current name was coined by Hartzell in1904 [1,2]

. Pyogenic

Granuloma is actually a double misnomer [3]

, because no infection with pus is present, neither is

it a granuloma, which implies a lesion rich in chronic inflammatory immune cells, which are

few, if any [3, 4,]

.

OPG is more common in females than males, and occurs most frequently in the second decade of

life. The most common site of occurrence is the facial aspect of the maxillary gingivae [4]

.The

etiologyof pyogenic granuloma is low-grade local irritation, traumatic injury, hormonal factors

or some types of drugs e.g. cyclosporine, all of which cause capillary hemangiomas leading to

the appearance of a tumor. Risk factors include poor oral hygiene, pregnancy and the female

gender [5]

.

Clinically, it is characterized by a pink/red, smooth/lobulated and soft papule which bleeds

spontaneously or at the slightest stimulation. Older lesions tend to be pink due to collagenisation

and keratinisation while the younger ones are erythematous due to high vascularity [5, 6]

.

Radiographic findings often indicate invasion into alveolar bone, though this almost never

severe. Such invasion may mimic malignant disease.

Histologically, the lesion is composed of several dilated blood vessels in loose edematous

connective tissue stroma [6]

.Chronic inflammatory cell infiltrate is usually present but is sparse. It

appears similar to pregnancy epulis histologically hence the alternative name when the lesion

occurs in an expectant woman. Differential diagnoses include peripheral giant cell granuloma,

2

lymphoma, hemangioma, metastatic cancer, granulation tissue, Kaposi sarcoma and gingival

hyperplasia [5]

. Thus, a biopsy is invaluable in arriving at an accurate diagnosis [7,8]

.

Oral pyogenic granuloma usually resolves by its own, but more often than not, affected

individuals seek medical attention due to the tendency of the lesions to bleed spontaneously or

on slight stimulation. If the lesion is small, observation and patient follow up suffice, provided

any of the predisposing factors are eliminated or controlled. This includes complete periodontal

therapy with oral hygiene instructions in patients with poor oral hygiene. Large lesions usually

require excision, though alternative methods of tumor removal may be employed, including

intralesional corticosteroid therapy, cryosurgery, laser surgery and electrodessication. Injection

of absolute ethanol into lesions treated by means other than excision may be necessary to reduce

incidence of recurrence. The alternative methods are often employed where scars may form upon

excision of a large lesion. Treatment of pregnant mothers follows a more meticulous approach

which consists of removal of dental calculus and subsequent plaque control. Use of a soft tooth

brush is recommended to avoid gingival irritation. Excessive bleeding may indicate blood

transfusions or termination of pregnancy to save the patient. Usually resolves spontaneously

post-partum in women. Recurrence occurs in 16% of treated patients [4,5, 8]

.

3

1.2 Literature Review

Pyogenic granuloma is a benign lesion which affects the skin and mucosal surfaces. Oral

pyogenic granuloma is generally associated with periodontal disease, local inflammatory factors

and hormonal changes. The lesions are characterized by exophytic growths which are either

smooth or lobulated and are often ulcerated with spontaneous bleeding.Approximately 50% of

pregnant women develop gingival changes[9]

, though only5% are actually tumors[5, 7]

.

The incidence of pyogenic granuloma has been demonstrated to be higher in females than males,

and is more common in the second decade of life. 75% of lesions occurring in the oral cavity are

on the gingivae, and the maxillary gingiva is more affected than the mandibular. The facial

aspect of the gingivae is almost always the site of the lesion, with very few reported on the

linguo-palatal aspect [3, 4,5,10]

.A retrospective study on pyogenic granulomas done in Jordan

consisted of 108 patients over an 11-year period, with the age ranging from 3-85 years (mean 30

years). The male to female ratio was 1:1.7 and those in the second decade of life were most

affected (26.8%) [4]

.

In another study done in University of Ibadan’s Dental Hospital and Centre, Nigeria over a 12

year period, 38 cases were reviewed, and the ages ranged from 5-74 years (mean 33 years). The

male to female ratio was 1:1.2 and the most common site was the gingival [11]

. A similar study

done at the Discipline of Oral Pathology, Department of Dentistry of the Federal University of

Rio Grande do Norte, Brazil comprised 293 cases of OPG. Mean age was 27 years and the male

to female ratio was 1:2.38. The most prevalent site was the maxillary gingival [10]

.

Oral pyogenic granuloma is a reactive tumor-like lesion [1,5]

,though many regard it as a tumor [5]

.

Its etiology is chronic low-grade irritation, trauma, hormonal changes and certain drugs [5,10]

.

Risk factors include poor oral hygiene especially where calculus is present, the female gender

due to hormonal changes associated with puberty and pregnancy due to further profound

hormonal variations in estrogens and progesterone [5]

. The effects of increased hormones on

angiogenesis in subcutaneous capillaries and lymphatic microvasculature can be predicted but

the pathogenesis is not completely understood [5,10]

.

4

Clinico-pathological findings showed exophytic lesions with spontaneous bleeding, soft

consistency with an erythematous or pink color. 9.2% of lesions were ulcerated [4]

, and the

surface texture was either smooth or lobulated with a pedunculated or sessile base [1, 5, 6, 10, 12]

.

Its higher incidence in women can be attributed to the hormonal changes accompanying puberty

and pregnancy [5, 9, 13]

. Increased levels of estrogens and progesterone in pregnancy have a

profound effect on the structure and function of blood capillaries and lymphatic microvasculature

of the skin, which leads to the histopathological changes consistent with pyogenic granuloma [5]

.

These changes include dilated blood vessels which resemble granulation tissue [10]

, loose

edematous connective tissue stroma and engorgement with erythrocytes [6, 10]

.

Treatment modalities employed for pyogenic granulomas include excision, cryosurgery, intra-

lesional corticosteroid therapy, laser surgical removal and electrodessication [4,5]

. Cryosurgery is

done using liquid nitrogen or a cryoprobe [4]

and is a safe, cost-effective alternative to surgical

excision. The study done in University of Ibadan, Nigeria had 38 cases, all of which were treated

using surgical excision, and amongst the patients followed up, none had recurrence of the lesions

[11]. In another retrospective study carried out in the Faculty of Dentistry, Jordan University of

Science and Technology, 108 patients were treated using surgical excision. Of the 85 who

presented themselves for follow-up, 5 (5.8%) had a recurrence of the condition [4]

. In the study

done at the Federal University of Rio Grande do Norte, Brazil, a recurrence rate of 8.2% was

reported. In all cases, recurrence rate is low when the lesions are excised surgically [10]

.

However, a proper surgical technique must be employed in order to minimize the chance of

recurrence. This means excising down to the periosteum and the predisposing factors must be

eliminated where possible[3, 4,10]

. Margins of excision should be at least 2mm [3]

. Alternative

treatments to surgical excision are usually employed where a large lesion is present and would

thus cause formation of excessive scar tissue [5]

. To further reduce the chance of recurrence,

alternative treatments such as laser surgery should be followed by injection of absolute ethanol.

Inadequate cryosurgery where excision is contraindicated should also be followed by injection of

absolute ethanol to prevent recurrence [5]

.

5

CHAPTER TWO: STATEMENT OF THE RESEARCH PROBLEM, STUDY

JUSTIFICATION AND OBJECTIVES

2.1 Statement of the Research Problem

Oral pyogenic granuloma is a reactive tumor-like lesion which, though benign in nature, alarms

the patient due to its symptoms. Presence of the lesion in the oral cavity, especially on the

gingivae can impair oral hygiene practices due to its tendency to bleed spontaneously and this

can lead to subsequent complications such as dental caries and periodontal disease. Its

predilection for the labial aspect of the maxillary gingiva also has a bearing on patient aesthetics.

2.2 Study Justification

A review of literature reveals numerous studies on oral pyogenic granuloma. The demographic

characteristics, anatomical location as well as histological appearance have been well

documented in other geographical locations. However there is scarcity of data in Kenya. This

study therefore aims to audit the pattern of occurrence of pyogenic granuloma among patients

who visited a referral hospital in Nairobi county.

2.3 Study objectives

2.31 General Objective

To audit the characteristics and patterns of occurrence of OPG in laboratory records of patients

diagnosed with oral pyogenic granuloma at the UoNDH over a 10-year period (2003-2012).

2.32 Specific Objectives

1. To determine the gender and

age patterns of patients diagnosed with oral pyogenic granuloma in the UoNDH between

2003 and 2012.

6

2. To determine the anatomical

location of lesions among patients diagnosed with OPG at the UoNDH between 2003 and

2012.

2.4 Study variables

Variable Measurement

Socio-demographic Age Years

Sex Male or Female

Dependent Largest Diameter

Independent Anatomical Location Maxillary

Mandibular

Facial

Linguo-palatal

Facio-linguo-palatal

Anterior

Posterior

Other oral site

7

CHAPTER THREE: MATERIALS AND METHODS

3.1 Study Area

The study was conducted at the histopathology laboratory of the UoNDH which is located in

Upperhill, Nairobi County. Nairobi is the capital city of Kenya which is a metropolitan town.

UoNDH is a training institution for undergraduates pursuing the BDS degree. The hospital also

serves as a tertiary learning institution that awards postgraduate MDS degrees and as a referral

hospital for patients with conditions affecting their oral and maxillofacial region.

3.2 Study Population

The study included patients’ records at the UoNDH who were diagnosed with oral pyogenic

granuloma from January 2003 to December 2012.

3.3 Study Design

This was a descriptive cross-sectional study using histopathological records.

3.4 Sample Size

The sample size was calculated using the following formula:

Sample size, N=Z2P(1-P)

C2

Where N= Study population

Z= Z value (1.96)

P= Prevalence (50%)

8

C= 1-Confidence level (95%)

Thus N= 1.962x0.5(1-0.5)= 384.16

0.052

However, since the study population was less than 10 000, the sample size was calculated using

the following formula:

Where desired sample size from a population <10 000

= sample size derived from a population >10 000

and estimated size of the population under study

Therefore, since n=384, and N is approximately 150,

=

= 107.86

The sample size was thus determined to be 108 persons.

3.5 Sampling Method

All records of patients who had been diagnosed with oral pyogenic granuloma in UoNDH

between 2003 and 2012 was included in the study.

3.6 Inclusion Criteria

All records of patients who had been diagnosed with oral pyogenic granuloma between January

2003 and December 2012.

3.7 Exclusion Criteria

9

Records of patients with the condition (OPG) but outside the period between January 2003 and

December 2012.

Incomplete patient records.

3.8 Data Collection Instruments

Data was collected from patients’ histopathological records and confirmed using a predetermined

checklist.

3.9 Data Analysis And Presentation

Data collected was analysed using the Statistical Package for Social Sciences (version 16.0). The

final report was compiled and findings of the study presented in form of tables, graphs and

charts.

3.10 Ethical Considerations

Ethical approval was sought from KNH / UoN Ethics and Standards Committee

Permission was sought from UoNDH administration to carry out the study in the hospital

The information obtained has remained private and confidential

3.11 Perceived Benefits

The study provides clinicians with the necessary information on patterns of oral pyogenic

granuloma in Kenya as it addressed the paucity of data regarding the same in the country.

10

CHAPTER FOUR: RESULTS

4.1 Socio-demographic characteristics

4.11 Gender distribution

Data from a total of 89 patients’ records was analysed, and of these, 52 (59.77%) were females

and 35 (40.23%) were males [Table 1]. The male to female ratio was 2:3. The ages ranged

between 5-92 with a mean of 33.41 years.

Frequency Percentage

Male 35 40.23

Female 52 59.77

Total 87 100

Table 1: Gender distribution of oral pyogenic granuloma

4.12 Age distribution

Females affected by oral pyogenic granuloma were older on average (34.57) than males (31.89)

[Fig.1].

11

Figure 1: Mean age by gender

The peak age group affected by the lesion was that between 21-30 years, with 25 cases (30.49%)

while age groups 51-60 and >71 were the least affected with 3 each (3.66%) [Fig. 2].

Figure 2: Age group distribution of OPG

Most of the lesions were diagnosed in the years 2010 and 2011 with 15 cases each year (17%)

while 2006 had the least number (n-2, 2.3%) [Fig. 3].

12

Figure 3: Year of diagnosis of OPG lesions

4.2 Site characteristics

4.21 Gingival lesions

A majority of OPG lesions analysed occurred on the gingivae (n-66, 79%), whereas only 18

lesions were located at other oral sites (21%) [Fig. 4]. Of the gingival lesions, 46 (52.3%)

occurred on the maxilla while 20 (22.7%) occurred on the mandible.

Figure 4: Location of OPG lesions

13

Among these, 49 (55.7%) were on the facial aspect while 28 (31.8%) were on the linguo-palatal

aspect. A total of 10 (11.4%) lesions were large to the extent of covering both the facial and

lingual/palatal aspects [Fig. 5].

Most of the gingival lesions were located anteriorly, with 52 (59.1%) lesions, whereas 15 (17%)

gingival lesions were located posteriorly.

Figure 5: Location of gingival lesions along the sagittal plane

Figure 6: Site of gingival lesions

4.22 Extra-gingival lesions

Other oral sites affected by oral pyogenic granuloma included: the lower lip (10), ventral tongue

(2), lateral tongue (2), dorsal tongue (1), upper lip (1), buccal mucosa (1) and the oral

commissure (1).

14

Figure 7: Number of Extra-gingival lesions

4.3 Size of the lesions

The largest dimension of OPG lesions, ranged from 0.3-4.0cm, with the mean being 1.517 cm.

Fig 8: Largest Dimension of OPG lesions

15

CHAPTER FIVE: DISCUSSION OF RESULTS, CONCLUSION AND

RECOMMENDATIONS

5.1 Discussion

The data in the study was obtained from a total of 89 records, which was 82.41% of the intended

sample size over the 10 year period. 52 (59.77%) of the study subjects were female while 35

(40.23%) were male. The gender of two patients could not be verified from the records available.

The ratio of the gender distribution i.e. male to female was thus 2:3. This is almost similar to the

study done by Al Khateeb et al. where the male to female ratio was 1:1.7 [4]

. Another study done

by Saravana GH et al. demonstrated a male female ratio of 1:2.6 [14]

. All three studies show a

higher incidence of OPG in females.

Females affected by oral pyogenic granuloma were older on average (34.57 years) than males

(31.89 years). This pattern is similar to a study done by Krishnapillai R et al. in a Southern

Indian teaching hospital [15]

. It is also similar to the study conducted by Al-Khateeb T et al. [4]

. In

both studies, the average age of females affected by OPG was higher than males. The mean age

16

of both genders was 33.4 with a range of 5-92 years. In comparison, Zain RB et al. and Saravana

GH et al. found mean ages of 28.9 and 30.0 years respectively in their studies

[14, 16].

The highest number of cases were diagnosed in the third decade of life i.e. between 21-30 years.

This finding is similar to the study done by Krishnapillai et al. [15]

but differs from those done by

Al Khateeb et al., Gordón-Núñez et al. and Zain RB et al., all of whose peak incidences were in

the 2nd

decade of life [4, 10, 16]

. These differences could be attributed to cultural, geographic and

socio-economic factors which could have a bearing on oral hygiene practices and average ages

during pregnancy in females.

Most of the lesions were diagnosed in 2010 and 2011, both with 15 cases (17%) each, and 2006

had the lowest number (n-2, 2.3%). There is a general increase in the number of patients

diagnosed with OPG over the 10 period, overlooking the slump in 2006. This could be attributed

to factors such as: increased patient awareness on oral health, increased referrals from other

health practitioners and increase in the general public’s knowledge on the existence/whereabouts

of the UoNDH.

Oral pyogenic granuloma had a predilection for the gingivae, and out of 84 oral lesions, 66

(79%) occurred on the gingivae whilst 18 (21%) occurred at extra-gingival sites. The location of

5 lesions could not be verified from the records available. According to Gordón-Núñez et al.,

Lawoyin et al. and Al-Khateeb et al., the gingivae were the most common site with prevalences

of 83%, 74% and 44% respectively [4, 10, 11]

. The maxillary gingivae had a higher number of

lesions (n-46, 52.3%) compared to the mandibular gingivae (n-20, 22.7%). The predilection for

maxillary sites is comparable to the studies done by Zain RB et al., Krishnapillai et al., Gordón-

Núñez et al. and Al-Khateeb et al.

[4, 10, 15, 16].

Gingival OPG lesions were more common on the labio-buccal aspect (n-49, 55.7%) as compared

to 28 (31.8%) on the linguo-palatal aspect. 10 (11.4%) lesions extended through both the facial

and linguo-palatal aspects. The origin of lesions which covered both aspects could not be

determined, and thus implied long-standing lesions which grew over an extended period as

17

compared to those located at one aspect only. These findings are similar to those in the study

carried out by Al-Khateeb et al. in Jordan [4]

.

Both maxillary and mandibular lesions were more common anteriorly, with a combined total of

52 (59.1%) compared to 15 (17%) posteriorly. Krishnapillai et al. and Al-Khateeb et al. also

recorded a higher prevalence in the anterior region of both the upper and lower jaws [4, 15]

.

Other oral sites diagnosed with oral pyogenic granuloma included: the lower lip (10), ventral

tongue (2), lateral tongue (2), dorsal tongue (1), upper lip (1), buccal mucosa (1) and the oral

commissure (1). These represented 21% of all lesions, the commonest being the lower lips. The

reason for a relatively high occurrence on the lower lip could be chronic irritation by the incisal

edges of the upper anterior teeth, especially where they are the cause of incompetent lips [6]

.

The largest dimension of lesions in the current study ranged from 0.3-4.0cm with the mean being

1.52cm. In comparison, the studies conducted by Al-Khateeb et al., Zain RB et al., and Gordón-

Núñez et al. showed mean largest dimensions of 1cm, 1.08 cm and 1.3 cm respectively.

18

5.2 Conclusion

Based on the findings of this study, the following was concluded:

1. Oral pyogenic granuloma was found to be more common in females than in males, with a

male to female ratio of 2:3

2. The lesion was more likely to occur on the labio-buccal aspect of the maxillary gingivae.

3. Extra-gingival lesions had a predilection for the lower lip.

5.3 Recommendations

The following are the recommendations arrived at based on the study:

19

1. There is need to establish a link with the referring hospitals in order to facilitate patient follow

up and determination of treatment modality(ies) employed.

2. Another study should be carried out in Kenya to determine a more accurate incidence and

prevalence of oral pyogenic granuloma.

20

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(Pyogenic Granuloma) with Extensive Alveolar Bone Loss Mimicking a Malignant Tumor:

Case Report and Review of Literature. Int J Morphol. 2011; 29(1):164-7

3. S Dghoughi, W Elwady, Pyogenic granuloma (botryomycoma) of the tongue. Indian J

Dentistry 2012; 3 (4)

4. Al-Khateeb T, Ababneh K., Oral Pyogenic granuloma in Jordanians: A retrospective analysis

of 108 cases. J Oral Maxillofac Surg. 2003; 61 (11):1285–8.

5. H Jafarzadeh, M Sanatkhani, N Mohtasham, Oral pyogenic granuloma: A review. J Oral Sci

2006;48 (4): 167-75

6. RA Cawson, EW Odell, Essentials of Oral Pathology and Oral Medicine 2008; pp277

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APPENDIX 1 : CHECKLIST

a. Socio-demographic variables

Age

Sex

b. Dependent Variable

Largest Diameter

c. Independent Variables: Anatomical

location

Maxillary

Mandibular

Facial

Linguo-palatal

Facio-linguo-palatal

Anterior

Posterior

Other oral site