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CASE REPORT
Year : 2013  |  Volume : 40  |  Issue : 1  |  Page : 49-51

Extragingival pyogenic granuloma: A rare case report


1 Department of Oral Medicine and Radiology, Al-Ameen Dental College and Hospital, Bijapur, India
2 Department of Anatomy, SSIMS and RC, Davangere, Karnataka, India
3 Department of Oral and Maxillofacial Surgery, Al-Ameen Dental College and Hospital, Bijapur, India
4 Department of Community Dentistry, Jaipur Dental College and Hospital, Jaipur, Rajasthan, India

Date of Web Publication28-Mar-2013

Correspondence Address:
Ningappa Chinnannavar Sangamesh
Department of Oral Medicine and Radiology, Al-Ameen Dental College and Hospital, Bijapur, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.109706

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  Abstract 

Pyogenic granuloma is a benign, localized mass of exuberant granulation tissue produced in response to various stimuli. It is inflammatory hyperplasia of oral cavity commonly seen on gingival and rarely on other parts of oral cavity such as lips, tongue, palate, and buccal mucosa. It is seen predominantly in second to third decade of life in young females. Clinically manifesting as a small red erythematous exophytic lesion must be biopsied to rule out other serious conditions. This article aims to present a case of extragingival pyogenic granuloma on buccal mucosa in a 40-year-old female patient which is comparatively a rare location.

Keywords: Buccal mucosa, extragingival pyogenic granuloma, hormonal changes, microtrauma, surgical excision


How to cite this article:
Sangamesh NC, Poornima B, Vidya KC, Sakri SB. Extragingival pyogenic granuloma: A rare case report. J Sci Soc 2013;40:49-51

How to cite this URL:
Sangamesh NC, Poornima B, Vidya KC, Sakri SB. Extragingival pyogenic granuloma: A rare case report. J Sci Soc [serial online] 2013 [cited 2019 May 23];40:49-51. Available from: http://www.jscisociety.com/text.asp?2013/40/1/49/109706


  Introduction Top


Pyogenic granuloma or granuloma pyogenicum is a relatively common benign mucocutaneous lesion.[1] It is believed to be reactive and not neoplastic in nature.[2],[3],[4] The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically.[5],[6]

Hullihen's description in 1844 was most likely the first pyogenic granuloma reported in the English literature,[7] but the term pyogenic granuloma or granuloma pyogenicum was introduced by Hartezell in 1904.[7] There are two kinds of pyogenic granuloma namely lobular capillary hemangioma (LCH) type and non-LCH type which differ histologically. Pyogenic granuloma when occurs on a rare location such as buccal mucosa, there is a critical need for its proper diagnosis and management.


  Case Report Top


A 40-year-old female patient presented with a chief complaint of growth on her left buccal mucosa. The lesion was of negligible size when the patient first noticed it 2 months ago. There was a gradual increase in size causing discomfort while eating and used to bleed on being traumatized. The patient was unaware of any initial trauma to site of the lesion. Her past medical history was noncontributory and her extraoral examination did not reveal any abnormalities.

Clinical examination revealed an exophytic, red pedunculated lesion measuring approximately 1.5 × 1.5 cm in size, having a smooth lobulated surface situated on left buccal mucosa below the line of occlusion in relation to 35 and 36 regions. The lesion was firm in consistency, nontender, noncompressible, and no pulsations were seen. There were two three bleeding points on the lesion and the lesion was easily bleeding on touch [Figure 1].
Figure 1: Photograph showing a exophytic lesion on the left buccal mucosa

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Hemogram of the patient was within the normal limits and the patient was taken for excisional biopsy under local anesthesia and histopathologic evaluation was recommended as the diagnostic approach. The wound healed uneventfully and the patient was followed up for a period of 6 months and no recurrence was found.

Photomicrograph [Figure 2] and [Figure 3] shows hematoxylin-eosin-stained sections showing hyperplastic stratified squamous parakeratinized epithelium with an underlying fibrovascular stroma. The stroma shows large number of budding capillaries, plump fibroblasts, and areas of extravasated blood and a dense chronic inflammatory cell infiltrate. The above histopathologic features are suggestive of pyogenic granuloma.
Figure 2: Photomicrograph showing hyperplastic stratified squamous parakeratinized epithelium

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Figure 3: Photomicrograph showing budding capillaries, plump fibroblasts, and areas of extravasated blood and a dense chronic inflammatory cell infiltrate

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  Discussion Top


The incidence of pyogenic granuloma has been described as between 26.8% and 32% of all reactive lesions.[1],[8],[9] Pyogenic granuloma was first thought to be mycotic infection contracted from horses.[1],[10],[11] Subsequently, it was claimed without scientific evidence that pyogenic granuloma results from purulent changes within benign oral tumors.[1],[10] Immunochemistry of pyogenic granuloma shows angiogenesis associated factors such as Tie2, angiopiotin1, angiopiotin2, ephrinB2, and EphB4.[1],[10],[12]

In oral cavity, pyogenic granuloma shows striking predilection for gingival with interdental papilla being the most common site in 70%. The maxillary anterior area is more commonly involved. Extragingival pyogenic granulomas are more commonly seen in the areas of frequent trauma.[2] Poor oral hygiene may be the precipitating factor.[7]

Some investigators regard pyogenic granuloma as benign neoplasm earlier but now considered it to be a reactive tumor like lesion which arises in response to various stimuli such as low grade local irritation,[6] injury, hormonal factors, or certain kinds of drugs such as cyclosporine.[7] Studies have also shown evidence of increased synthetic activity in the fibroblast of the granuloma. The ultra-structural study by Davies et al. found inclusion bodies in the fibroblast suggestive of disordered protein metabolism. They suggested that pyogenic granuloma constitute a lesion produced by primitive organizer resulting from gene depression in papillary fibroblast perhaps as a result of C-type virus infection.[13],[14]

Pyogenic granuloma occur in all ages but predominant in the second decade of life in young adult females, possibly because of vascular effects of female hormones.[7] Incidence is increased in pregnancy which is related to be increased level of estrogen and progesterone.[7],[15] Around 80% of extragingival pyogenic granuloma gave positive information about preceding injury to site[1] but in our case there was no history of truama. Some studies conclude initial traumatic conditions are main etiologic factors for the development of pyogenic granulomas.[1],[16]

Pyogenic granuloma usually appear as a localized solitary lump with sessile or pedunculated base and smooth or lobulated surface and is deep red or purplish in color. Development of the lesion is slow, asymptomatic, and painless but sometimes grows rapidly.[7],[17] Sometimes the surface may be ulcerated and friable, may be covered by a yellow fibrinous membrane. Older pyogenic granulomas resemble fibromas due to more fibrous appearance.[7]

In the present case the constant trauma either from the teeth or occlusion was not present as the lesion was below the line of occlusion. Initial microtrauma by hard foods may have initiated the lesion. The genesis and development of the lesion may also be attributed to the other etiological factors such as the estrogen and progesterone effect on the vasculature.

Such an atypical presentation like the case in discussion can be rather confusing and lead to erroneous diagnosis of other serious lesion such as hemangioma, kaposis sarcoma, squamous cell carcinoma, basal metastatic carcinoma, etc.

As pyogenic granuloma is a benign lesion, surgical excision is treatment of choice. Other conventional surgical modalities for treatment of pyogenic granulomas are cryosurgery, Nd:YAG, Co2 and flash lamp pulsed dye lasers have also been used.[1],[18] recurrence rate of 16% has been reported;[8] however, recurrences after surgery of extragingival pyogenic granuloma is uncommon.[2]


  Acknowledgments Top


We acknowledge Dr. Praveen G Kosti lecturer, Dr. Ikramuddin Patel lecturer, Dr. Suchitra Post Graduate Student, Dr. Mohammad Ali R. Patel Post graduate student for their support in completing the manuscript.

 
  References Top

1.Shenoy SS, Dinakar AD. Pyogenic granuloma associated with bone loss in an eight year old child: A case report. J Indian soc Pedod Prev Dent 2006;24:2013.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Amirchaghmaghi M, Falaki F, Mohtasham N, Mazafari PM. Extragingival pyogenic granuloma: A case report. Cases J 2008;1:3713.  Back to cited text no. 2
    
3.Ramire ZK, Bruce G, Carpenter W. Pyogenic granuloma: Case report in a 9 year old girl. Gen Dent 2002;50:2801.  Back to cited text no. 3
    
4.Neville BW, Pamm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. St Louis Missouri: W B Saunders. Co.; 2004. p. 4449.  Back to cited text no. 4
    
5.Patil K, Mahima VG, Lahari K. Extragingival pyogenic granuloma. Indian J Dent Res 2006;17:199202.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Regezi JA, Sciubba, James J, Jordan Richors CK. Oral pathology: Clinical pathologic correlation. 4th ed. St Louis Missouri: W B Saunders. Co.; 2003. p. 115.  Back to cited text no. 6
    
7.Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48:16775.  Back to cited text no. 7
    
8.Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingival. A clinicopathological study of 741 cases. J Periodontol 1980;51:65561.  Back to cited text no. 8
    
9.Buchner A, Calderon S, Raman Y. Localized hyperplastic lesions of the gingival: A clinicopathologic study of 302 lesions. J Periodontol 1977;48:1014.  Back to cited text no. 9
    
10.AlKhateeb T, Ababneh K. Oral pyogenic granuloma in Jordanians: A retrospective analysis of 108 cases. J Oral Maxillofac Surg 2003;61:12858.  Back to cited text no. 10
    
11.Kerr DA. Granuloma pyogenicum. Oral Surg Oral Med Oral Pathol 1951;4:15876.  Back to cited text no. 11
    
12.Yuan K, Jin YT, Lin MT. Expression of Tie2, angiopoietin1, angiopoietin2, ephrineB2 and EphB4 in pyogenic granuloma of the human gingival implicates their role in inflammatory angiogenesis. J Periodontal Res 2000;35:16571.  Back to cited text no. 12
    
13.Raut DL, Khedkar SA. Oral pyogenic granuloma: A case report. J Indian Acad Med Radiol 2007;19:3779.  Back to cited text no. 13
    
14.Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: Evaluation of oral conditions. Br J Oral Maxillofac Surg 1986;24:37682.  Back to cited text no. 14
    
15.Eversole LR. Clinical outline of oral pathology: Diagnosis and treatment. 3rd ed. Hamilton: BC Decker; 2002. p. 1134.  Back to cited text no. 15
    
16.Bhaskar SN, Jacoway JR. Pyogenic granuloma, clinical features, incidence, histology and result of treatment: Report of 242 cases. J Oral Surg 1981;24:3918.  Back to cited text no. 16
    
17.Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis 2006;12:702.  Back to cited text no. 17
    
18.Meffert JJ, Cagna DR, Maffert RM. Treatment of oral granulation tissue with flshlamp pulsed dye laser. Dermatol Surg 1998;24:8458.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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