|Year : 2013 | Volume
| Issue : 1 | Page : 49-51
Extragingival pyogenic granuloma: A rare case report
Ningappa Chinnannavar Sangamesh1, Bellguppa Poornima2, Kodige Chandrashekar Vidya3, Santosh Bhopal Sakri4
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 Publication||28-Mar-2013|
Ningappa Chinnannavar Sangamesh
Department of Oral Medicine and Radiology, Al-Ameen Dental College and Hospital, Bijapur, Karnataka
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
Pyogenic granuloma or granuloma pyogenicum is a relatively common benign mucocutaneous lesion. It is believed to be reactive and not neoplastic in nature.,, The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically.,
Hullihen's description in 1844 was most likely the first pyogenic granuloma reported in the English literature, but the term pyogenic granuloma or granuloma pyogenicum was introduced by Hartezell in 1904. 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|| |
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|| |
The incidence of pyogenic granuloma has been described as between 26.8% and 32% of all reactive lesions.,, Pyogenic granuloma was first thought to be mycotic infection contracted from horses.,, Subsequently, it was claimed without scientific evidence that pyogenic granuloma results from purulent changes within benign oral tumors., Immunochemistry of pyogenic granuloma shows angiogenesis associated factors such as Tie2, angiopiotin1, angiopiotin2, ephrinB2, and EphB4.,,
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. Poor oral hygiene may be the precipitating factor.
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, injury, hormonal factors, or certain kinds of drugs such as cyclosporine. 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.,
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. Incidence is increased in pregnancy which is related to be increased level of estrogen and progesterone., Around 80% of extragingival pyogenic granuloma gave positive information about preceding injury to site 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.,
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., 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.
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., recurrence rate of 16% has been reported; however, recurrences after surgery of extragingival pyogenic granuloma is uncommon.
| Acknowledgments|| |
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.
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[Figure 1], [Figure 2], [Figure 3]