J of IMAB. 2019 Jan-Mar;25(1) https://www.journal-imab-bg.org 2337

Case reports

PYOGENIC GRANULOMAS IN THE ORAL CAVITY:A SERIES OF CASES

Deyan Z. Neychev1, Radka B. Cholakova1, Tanya I. Sbirkova1, Stanimir N.Kisselov1, Svitlana Y. Bachurska2, Dimitar T. Atanasov1

1) Department of Oral Surgery, Faculty of Dental Medicine, Medical Universityof Plovdiv, Bulgaria2) Department of General and Clinical Pathology, Medical University of Plovdiv,Bulgaria.

Journal of IMAB - Annual Proceeding (Scientific Papers). 2019 Jan-Mar;25(1)Journal of IMABISSN: 1312-773Xhttps://www.journal-imab-bg.org

ABSTRACT Introduction: Pyogenic granulomas represent tumor-

like lesions affecting skin and the oral cavity. This classicdefinition can be somewhat misleading because such lesionis not associated with infection and lacks any clinical evi-dence of pus or histological evidence of actual granulationtissue. Scientific literature sources estimate its prevalenceto 1:25000 per capita, affecting females twice as often. Pyo-genic granuloma in the oral cavity affects the interdentalpapilla in 70% of the cases.

Purpose: The authors present a case series of pyo-genic granulomas in the oral cavity with varying localiza-tion and therapeutic approach.

Materials and methods: This article presents sixclinical cases of PG. Diagnosis is challenging due to simi-larities with number of tumorous and non-tumorous neo-plasms (formations) in the oral cavity. Two histological typesof pyogenic granuloma can be identified: lobular and non-lobular capillary hemangioma. Surgical excision is treat-ment method of choice, followed by deep curettage of thelesion toward the underlying bone. Such precautions arenecessary because 15,8% of the lesions tend to recur overtime.

Results: Alternative therapeutic approaches for re-moval of PG are explored, which are aimed at reducing therecurrences after surgical treatment. Such opportunity isprovided by utilization of Er:Yag laser, because its effectcan reach the underlying bone.

Conclusion: Pyogenic granuloma represents a diag-nostic challenge, specifically in cases of atypical localiza-tion. Effective surgical approach requires complete removalof the pathological process from the surrounding healthystructures in order to prevent recurrences.

Keywords: Oral, pyogenic granuloma, benign vas-cular tumors, Er-YAG laser,

INTRODUCTION:Pyogenic granuloma is common, usually solitary,

lobular formation of benign proliferation in the skin andmucous membrane of the oral cavity. It can be pedunculatedor sessile, predominantly developing in children and young

women [1, 2]. Hullihen was the first to report such case in1844, and Hartzel introduced the term “pyogenic granuloma”in 1904 [3, 4]. According to other authors, the condition isfirst described in 1879 by Ponect and Dor under the term“botryomycosis hominis” and later in 1903 Crocker pro-posed the name “pyogenic granuloma” or “Crocker andHàrtzel disease” [2]. PG is a type of inflammatory hyperpla-sia. This definition summarizes a number of nodularovergrowths of the oral mucosa, histologically presentedby inflammatory fibrous or granulation tissue [4]. Suchovergrowths include inflammatory fibrous hyperplasia(clinical fibroma, epulis fissuratum and pulp polyp), giantcell epulis, epulis gravidarum, papillary palatal hyperpla-sia and PGhyperplasia“.

Etiology of PG is yet unknown, however most asso-ciated factors are trauma, inflammation, infectious agents,tartar, foreign bodies, immunosuppression, hormonalchanges, medication [2, 3, 5]. Other causes can be gingivalinflammation due to poor oral hygiene and trauma due todeciduous teeth, failure of eruption, orthodontic patho-logies, dental implants [2, 6]. Pyogenic granuloma is usu-ally presented as red, painless formation that is often local-ized in the gingiva and grows quickly, it is easily trauma-tized causing bleeding [3]. Other typical localizations in-clude the tongue, lips, palate and buccal mucosa [7, 8, 9].

The treatment of PG is usually surgical excision, how-ever a tendency for recurrence is observed, especially infemale patients [3].

CASE PRESENTATIONCase 1:A 52 years old female patient in good general health

is referred to the Department of Oral surgery of FDM –Plovdiv because of formation on the back of the tongue(Fig. 1). The patient complaints of discomfort during talk-ing and eating are dated back 2-3 months. Clinical evalua-tion reveals the presence of 5-7mm large formation on theback of the tongue that is soft and painless with palpation.Periodontal status reveals tartar and plaque deposits. Treat-ment – the formation was surgically excised and there wasno recurrence during the 6 months follow-up period. Bi-opsy showed lobular capillary hemangioma.

https://doi.org/10.5272/jimab.2019251.2337

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Fig. 1. PG of the tongue Fig.3. Recurring PG

Case 2:A young male aged 17 without any comorbidities is

referred to the Department of Oral surgery of FDM – Plovdivbecause of suspicious formation, localized on the lingualfrenulum (Fig. 2). The patient’s complaints of bleeding dur-ing eating date back 4 months ago, the formation mean-while increased its size. Clinical evaluation revealed 10-6mm large, soft and painless formation localized on the lin-gual frenulum. Periodontal evaluation revealed plentifuldeposits of plaque.

A recurrence was discovered 1 month after surgicalexcision of the formation (Fig. 3). Healing process duringthe three month period after the second surgery was un-eventful. Histopathological diagnostics confirmed lobularcapillary hemangioma (Fig. 4).

Fig. 2. PG on the lingual frenulum

Fig. 4. Lobular capillary hemangioma

Case 3:A 36-years old male without comorbidities is referred

to the Department of Oral surgery because of estheticallydisconcerting formation localized on the lower lip that some-times bleeds when traumatized (Fig. 5). The formation datestwo months ago and the patient also reports having a do-mestic accident. Clinical evaluation reveals 7-5mm largeformation that is soft, painless and with a tendency for pro-voked bleeding. Histopathological analysis after surgicalexcision revealed lobular capillary hemangioma.

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Fig. 5. PG on lower lip Fig. 7. Non-lobular capillary hemangioma

Case 4:A 34-years old female in good general health with no

comorbidities, who gave birth two months ago, is referredto the Department of Oral surgery in FDM-Plovdiv with com-plaints of bleeding gums during brushing of teeth. Clinicalevaluation revealed multiple formations on the gingiva ofmaxilla from tooth 13 to tooth 23 and on the mandibulargingiva around tooth 43 (Fig. 6). Periodontal assessmentestablished deposits of plaque and tartar. The gingiva hadpasty and edematous look and was painful with palpation.Treatment included surgical excision and curettage deep inthe underlying tissues. There is no evidence of recurrencetwo months later. Biopsy results showed non-lobular capil-lary hemangioma (Fig. 7).

Fig. 6. PG on the maxillary gingiva of female patient

Case 5:A 33-years old male patient in good general health is

referred to the Department of Oral surgery because of 6-9mm sized formation in the region of teeth 33 and 34 (Fig.8). Patient’s complaints include bleeding in the mandibularregion when brushing the teeth, which started two monthsago. During clinical examination a soft-elastic formationthat bleeds upon mechanical provocation was discovered.Periodontal status established plaque deposits and multiplepathological pockets. Segment radiograph showed no evi-dence of pathology in the underlying bone structures (Fig.9). Excision with Er:Yag laser of the formation and lasertreatment of the adjacent soft tissues and the buccal corticalplate of tooth 34 was implemented (Fig. 10, Fig. 11 and Fig.12). Histopathological evaluation documented non-lobu-lar hemangioma. The patient received further instructionsfor personal oral hygiene. No recurrence was established inthe 6th month follow-up.

Fig. 8. PG on gingiva of tooth 34

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Fig. 9. Radiograph of tooth 34. No pathological find-ings in the bone

Fig. 12. Postoperative site

Fig. 10. Parameters of Er:Yag laser

Fig.11. Excision with Er:Yag laser

Case 6:A 39-years old female with no comorbidities com-

plained of bleeding and discomfort during eating and brush-ing her teeth in the anterior palatal region. She gave birthfour months prior to her visit in the Department of Oral sur-gery and she is currently lactating. Her complaints begantwo months ago. The patient also informed us about priorsurgery in the region associated with removal of cyst at theanterior teeth 10 years ago. Clinical evaluation foundgingival lesion between teeth 12 and 13 (Fig. 13). The pea-sized formation is soft and bleeds upon mechanic provoca-tion. Periodontal status revealed plaque and multiple peri-odontal pockets. Treatment included excision followed bydeep curettage of the underlying tissues. Diagnosis uponbiopsy was non-lobular capillary hemangioma. The follow-up after six months does not reveal any recurring lesions.

Fig. 13. PG on the palatal mucosa. Between teeth 22and 23

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DISCUSSION:Bhaskar et al. report that PG makes up for 1,85% of

all oral pathologies [2,10]. The term “PG” is somewhat in-accurate because such formations is not associated with in-fection, does not produce pus and there is no clinical orhistological evidence of true granulation tissue [3]. Instead,mild trauma or inflammation leading to quick connectivetissue overgrowth are associated with the majority of thereported cases [6]. The infection may be caused by strepto-cocci and staphylococci bacteria [11].

The presence of background infection and angioma-tous skin lesions is relatively uncommon. Most infectiousdiseases are associated with exanthema-like reaction. A com-bination of angiomatous lesion and infection can be ob-served in cases with Caposi sarcoma or Bartonella infec-tion. [11] Lately angiopoetin and efrin B2 in other tumorsof the blood vessels along with Bartonella hanselae,B.Quintana and HPV8 are found in recurring cases [12]. PGis additionally influenced by viral oncogenes, hormones,microscopic arterial malformations, as well as gene depres-sion in the fibroblasts. [13,14]

It was evident that pregnancy has a role in the devel-opment of PG in our patients. More than 5% of intraoral PGis observed in pregnancy, thus supporting the terms “preg-nancy tumor” and granuloma gravidarum. [3] Such lesionsare frequent occurrences in pregnancy in the light of in-creased progesterone and estrogen levels. Hosseini et al.establish that gingival hypertrophies are seen during preg-nancy and disappear in menopause. [15] Frequency of PGpeaks in teenagers and young patients, notably females.[3,16] Our findings confirm its prevalence in females andteenagers.

It was evident that pregnancy has a role in the devel-opment of PG in our patients. PG affects predominantly thegingiva (in 75% of cases)[6] but can also occur on the lips,tongue, oral mucosa and palate [2,7,8,14,17] which corre-sponds to our clinical experience.

Intraoral gingival forms are usually located in max-illa. [2,18] Extraoral presentations most often include theskin and seldom the GI tract. [2,4] Multiple PG developspontaneously or secondary to trauma, skin inflammationor immunosuppression, however such occasions are rela-tively rare. [1] The case of multiple PG we presented devel-oped on the background of poor oral hygiene and no pre-dating trauma. A vicious cycle is at play because of painduring brushing of teeth, which impairs the oral hygieneeven further. Our findings are in agreement with the conclu-sions of other authors [19] and we support the notion thatone possible reason for this uncommon pathology can bethe impaired oral hygiene.

Usually such lesions are clinically presented as sin-gle nodulus or pedunculated papula with smooth or lobularsurface, sometimes ulcerated, black color, various size fromfew mm to few cm. Matured lesions are characterized bypoorer vascularization, increased amount of collagen andpink color. The formations are usually painless, but bleedeasily when provoked or spontaneously due to increasedvascularization. [2] Angelopoulos described themhistologically as hemangiomatous granuloma, emphasiz-ing the abundance of blood vessels and inflammatory na-ture of the process [6]. There are two histological types ofPG: lobular capillary hemangioma and non-lobular capil-lary hemangioma [20]. The first type clinically presents assessile lesion in 66,4% of the cases and the second type – aspedunculated lesion in 77% of the cases. [6,16] Our experi-ence with the sessile, lobular PG on the lingual frenulumsupports this differentiation. The lobular region of the lobu-lar PG has more blood vessels of small diameter comparedto the central region of non-lobular PG. The central regionof non-lobular type has increased amount of blood vesselsthat are surrounded by mesenchymal cells non-reactive fora-smooth muscle actin and muscle-specific actin comparedto the lobular region of lobular PG. [16]

The diagnosis of PG can often be challenging be-cause of the similarities in the clinical presentation of manyother intraoral angiomatous lesions. Differential diagnosisincludes capillary hemangioma [21], periphery giant cellgranuloma, periphery ossifying fibroma, hyperplasticgingival inflammation, pregnancy tumor, Kaposi sarcoma,metastatic carcinoma, angiosarcoma, non-Hodgkin lym-phoma.

Surgical excision is treatment method of choice, fol-lowed by deep curettage of the lesion, combined with re-moval of the periosteum and granulation tissue around theadjacent teeth. [2,9,] Recurrence is observed in 15,8% ofthe cases. [10] A lot of authors explore alternative treatmentapproaches in order to prevent such recurrences, includingcryotherapy, laser excision, ethanol etc. [2] No recurrence 3months following Er:Yag laser excision was found in ourCase 5.

CONCLUSION:PG is relatively uncommon finding in the oral cavity.

Its diagnostics are hindered by the similarity to other tu-morous and non-tumorous formations. The clinical experi-ence we documented demonstrates different clinical pres-entations and therapeutical approaches in order to avoidrecurrences after surgical excision of the pyogenicgranuloma.

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Address for correspondence:Deyan NeychevDepartment of Oral Surgery, Faculty of Dental Medicine, Medical University -Plovdiv3 Hr. Botev blvd., 4000 Plovdiv, BulgariaE-mail: dneitchev@yahoo.com

Please cite this article as: Neychev DZ, Cholakova RB, Sbirkova TI, Kisselov SN, Bachurska SY, Atanasov DT. Pyogenicgranulomas in the oral cavity: a series of cases. J of IMAB. 2019 Jan-Mar;25(1):2337-2342.DOI: https://doi.org/10.5272/jimab.2019251.2337

Received: 18/08/2018; Published online: 29/01/2019