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Year : 2006  |  Volume : 24  |  Issue : 4  |  Page : 201-203

Pyogenic granuloma associated with bone loss in an eight year old child: A case report

Oral Medicine, Department of Diagnosis and Radiology, Goa Dental College and Hospital, Bambolim, Goa - 403 202, India

Correspondence Address:
S S Shenoy
Oral Medicine, Diagnosis and Radiology Dept, Goa Dental College and Hospital, Bambolim, Goa - 403 202
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.28078

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Soft tissue enlargements of the oral cavity often present a diagnostic challenge because a diverse group of pathologic processes can produce such lesions. An enlargement may represent a variation of normal anatomic structures, inflammation, cysts, developmental anomalies and neoplasm. Within these lesions is a group of reactive hyperplasias, which develop in response to a chronic, recurring tissue injury that stimulates an exuberant or excessive tissue repair response. The pyogenic granuloma is a reactive enlargement that is an inflammatory response to local irritation such as calculus, a fractured tooth, rough dental restoration and foreign materials. This article aims to present a case of pyogenic granuloma in 8 year old child patient associated with resorption of bone in relation to the tooth.

Keywords: Angiogenesis, granuloma pyogenicum, lasers, microulceration

How to cite this article:
Shenoy S S, Dinkar A D. Pyogenic granuloma associated with bone loss in an eight year old child: A case report. J Indian Soc Pedod Prev Dent 2006;24:201-3

How to cite this URL:
Shenoy S S, Dinkar A D. Pyogenic granuloma associated with bone loss in an eight year old child: A case report. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2023 Jan 28];24:201-3. Available from: http://www.jisppd.com/text.asp?2006/24/4/201/28078

   Introduction Top

Pyogenic granuloma or granuloma pyogenicum is a relatively common benign mucocutaneous lesion. The term pyogenic is a misnomer in that, contrary to what the name implies, the lesion does not contain pus. Pyogenic granuloma is a benign lesion; therefore surgical excision is the treatment of choice. To avoid the possibility of recurrence the lesion must be excised down to the underlying periosteum and predisposing irritants must be removed.

   Case Report Top

An eight-year-old female child patient presented with a complaint of growth in the mouth involving lower left posterior region, which bled frequently and interfered with eating. Her medical history was non contributory. The patient's parent noticed the growth two and half month back, which was slightly smaller, then the size at the time of presentation. The patient couldn't recall the exact time of initiation of the growth. There was a gradual increase in size causing discomfort while eating as the extent of the growth had reached the occlusal plane and used to bleed on being traumatized.

Extraoral examination didn't reveal any facial asymmetry. Left submandibular lymph nodes were palpable, nontender and mobile.

Intraoral examination revealed a solitary growth measuring 2 x 1 x 1 cm, in lower left vestibule in relation to lower left deciduous second molar and permanent first molar [Figure - 1]. It had a smooth surface laterally in relation to buccal mucosa, while superior surface showed occlusal indentation of upper teeth resulting in surface ulceration. The growth was pedunculated attached to the marginal gingiva interproximally between the two teeth. Lower second deciduous seemed to be grade II mobile.

Intraoral periapical radiograph of teeth # 75 and # 36 region [Figure - 2] revealed loss of alveolar crestal bone interproximally with a cup shaped defect (white arrow). Roots of # 75 did not show any signs of resorption.

The hemogram of the patient was within normal limits and she was taken for excisional biopsy under local anaesthesia. The excised specimen is shown in [Figure - 3]. Patient was discharged on complete stoppage of bleeding with all post-operative instruction. Patient revisited after 5 days for checkup but failed to keep further appointments.

Photomicrograph [Figure - 4] shows Hematoxylin-Eosin stained section showing hyperplastic stratified squamous parakeratinized epithelium with an underlying fibrovascular stroma. The stroma shows a large number of budding capillaries, plump fibroblasts and areas of extravasated blood and a dense chronic inflammatory cell infilterate. The above histopathologic features are suggestive of pyogenic granuloma.

   Discussion Top

The incidence of the pyogenic granuloma has been described as between 26.8% to 32% of all reactive lesions[1],[2] Although it has been reported in all age groups, it occurs mainly between the ages of eleven and forty years with the peak incidence in the third decade.[3] Females are more frequently affected, a study by Skinner et al revealed a 3:2 predilection for females over males.[4]

Pyogenic granuloma was first thought to be a mycotic infection contracted from horses.[5],[6] Subsequently it was claimed without scientific evidence that pyogenic granuloma results from a purulent change within benign oral tumours.[5],[7] Recently, the angiogenesis-associated factors Tie2, angiopoietin-1, angiopoietin-2, ephrin B2 and Eph B4 have been detected in pyogenic granuloma by immunochemistry.[5],[8] It is now generally accepted that the lesion is an exaggerated localized connective tissue reaction to minor injury or irritation. Oral sites of pyogenic granuloma can include the gingivae, lips, tongue, buccal mucosa and palate.[5]

The granuloma usually appears as a localized solitary lump with a sessile or pedunculated base. The surface can be smooth or lobulated with a deep red or purplish colour. It is a well vascularized lesion with propensity for bleeding after any minor form of injury. Some studies concluded that some initial traumatic conditions are the main etiologic factor for development of pyogenic granuloma.[9],[10] Around 80% of patients with extragingival oral pyogenic granuloma gave positive information about preceding injury to the site.[11] Gingival irritation as a result of calculus, overhanging edges or rough restoration might be the predisposing factor for the development of gingival pyogenic granuloma. It is possible that microulceration from these irritants in an already inflamed gingiva allows the ingress into the gingival connective tissue of low virulent oral microflora. This evokes an exaggerated vascular hyperplastic response in the connective tissue resulting in the formation of pyogenic granuloma.[12] Pyogenic granuloma is a common reactive lesion that generally develops rapidly, bleeds easily and ulcerates causing the erroneous clinical impression of malignant tumour.[13] It is however a well circumscribed benign soft tissue tumour of inflammatory rather than neoplastic nature arising from the connective tissue of the skin or mucous membrane.[14]

Differential diagnosis of pyogenic granuloma includes parulis, peripheral giant cell granuloma, peripheral ossifying fibroma, hemangioma, peripheral fibroma, leiomyoma, hemangioendothelioma, hemangiopericytoma, bacillary angiomatosis, kaposis sarcoma, metastatic tumour, pregnancy tumor and post extraction granuloma.[15]

Definitive diagnosis of pyogenic granuloma can only be made by histopathologic examination of biopsied tissue. Pyogenic granuloma histologically shows a highly vascular proliferation that resembles granulation tissue. Numerous small and larges endothelium- lined channels are formed that are engorged with red blood cells. These vessels sometimes are organized in lobular aggregates and some pathologists require this lobular arrangement for the diagnosis (lobular capillary hemangioma). The surface is usually ulcerated and replaced by a thick fibrinopurulent membrane. A mixed inflammatory cell infiltrate of neutrophils, plasma cells and lymphocytes is evident. Neutrophils are more prevalent near the ulcerated surface; chronic inflammatory cells are found deeper in the specimen. Older lesions may have areas with a more fibrous appearance. Many gingival fibromas probably represent pyogenic granulomas that have undergone fibrous maturation.[15]

Pyogenic granuloma is a benign lesion; therefore surgical excision is the treatment of choice. Other conventional surgical modalities for the treatment of pyogenic granuloma reported is cryosurgery in form of either liquid nitrogen spray or a cryoprobe, which has been used for eradication of the lesion. It is safe, easy and inexpensive technique suited for out patient's clinic setting.[16],[17] Nd: YAG and CO 2 and flashlamp pulsed dye lasers have also been used for the treatment for oral pyogenic granuloma[18],[19] Lasers have shown to be a successful option for the excision of pyogenic granuloma with advantages of minimal pain and invasiveness and the lack of need for suturing or packing. Dermal pyogenic granuloma has been treated with electrodessication and sclerotherapy.[20] A recurrence rate of 16 % however has been reported[1]

   Acknowledgement Top

Heartfelt thanks to Dr. Anita Spadigam, Professor and Head, Dept of Oral and Maxilloafacial Pathology, Dr. Sandeep Lawande, Lecturer, Dept of Periodontia, Goa Dental College and Hospital, Bambolim, Goa for their help rendered.

   References Top

1.Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva: A clinicopathologic study of 471 cases. J Periodontol 1980;51: 655-61.  Back to cited text no. 1  [PUBMED]  
2.Buchner A, Calderon S, Raman Y. Localized hyperplastic lesion of the gingival: A clinicopathologic study of 302 lesions. Periodontol 1977;48:101-4.  Back to cited text no. 2    
3.Leyden JJ, Master GH. Oral cavity pyogenic granuloma. Arch Dermatol 1973;108:226-8.  Back to cited text no. 3  [PUBMED]  
4.Skinner RL, Davenport WD Jr, Weir JC, Carr RF. A survey of biopsied oral lesions in pediatric dental patient. Pediatric Dent 1986;8:163-7.  Back to cited text no. 4  [PUBMED]  
5.Al-Khateeb T, Ababneh K. Oral pyogenic granuloma in Jordanians: A retrospective analysis of 108 cases. J Oral Maxillofac Surg 2003;61:1285-8.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Kerr DA. Granuloma pyogenicum. Oral Surg Oral Med Oral Pathol 1951;4:158-76.  Back to cited text no. 6  [PUBMED]  
7.Inagi K, Takahashi HO, Yao K, Kamata T. Study of pyogenic granuloma of the oral cavity. Nippon Jibinkoka Gakkai Kaiho 1991;94:1857-64.  Back to cited text no. 7  [PUBMED]  
8.Yaan K, Jin YT, Lin MT. Expression of Tie 2, angiopoietin-1, angiopoietin-2, ephrin B2 and EphB4 in pyogenic granuloma of the human gingival implicates their role in inflammatory angiogenesis. J Periodontal Res 2001;35:165.  Back to cited text no. 8    
9.Bhaskar SN, Jacoway JR. Pyogenic granuloma, clinical features, incidence, histology and result of treatment: Report of 242 cases. J Oral Surg 1981;24:391-8.  Back to cited text no. 9    
10.Jalek BW, Wood RP, Dion M. Granuloma pyogenicum. Ear Nose Throat J 1979;56:228.  Back to cited text no. 10    
11.Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: Evaluation of oral condition. Br J Oral Maxillofac Surg 1986;24:376-82.  Back to cited text no. 11  [PUBMED]  
12.Lawoyin JO, Arotiba JT, Dosumic OO. Oral pyogenic granuloma: A review of 38 cases from Jbadan, Nigeria. Br J Oral Maxillofac Surg 1997;35:185-9.  Back to cited text no. 12    
13.Correll RW, Wescott WB, Siegel WM. Rapidly growing nonpainful, ulcerated swelling in the posterolateral palate. J Am Dent Assoc 1983;106:494-5.  Back to cited text no. 13  [PUBMED]  
14.Angelopolous AP. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features. J Oral Surg 1971;29:840-7.  Back to cited text no. 14    
15.Fowler EB, Cuenin MF, Thompson SH, Kudryk VL, Billman MA. Pyogenic granuloma associated with guided tissue regeneration: A case report. J Periodontol 1996;67:1011-5.  Back to cited text no. 15  [PUBMED]  
16.Pogrel MA. Application of lasers and cryosurgery in the oral and maxillofacial surgery. Curr Opin Dent 1991;1:263-70.  Back to cited text no. 16  [PUBMED]  
17.Ishida CE, Ranos-e-Silva M. Cryosurgery in oral lesions. Int J Dermatol 1998;37:283-5.  Back to cited text no. 17    
18.Meffert JJ, Cagna DR, Meffert RM. Treatment of oral granulation tissue with the flashlamp pulsed dye laser. Dermatol Surg 1998;24:845-8.  Back to cited text no. 18  [PUBMED]  
19.White JM, Chaudhary SI, Kudle JJ, Sekandari N, Schoelch ML, Silverman S Jr. Nd: YAG and CO2 laser therapy of oral mucosal lesions. J Clin Laser Med Surg 1998;16:299-304.  Back to cited text no. 19    
20.Matsumoto K, Nakanishi H, Seike T, Koizumi Y, Mihara K, Kubo Y. Treatment of pyogenic granuloma with a sclerosing agent. Dermatol Surg 2001;27:521-3.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]


[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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