Gingival Tumor in Young Female Patient: A Case Report

    

    

    Figure 4: Histopathological features shows proliferation of vascular channel
with ulcerated area under 40x.
    

Discussion

Pyogenic Granuloma (PG) is a kind of inflammatory hyperplasia. The term “inflammatory hyperplasia” is used to describe a large range of nodular growths of the oral mucosa that histologically represent inflamed fibrous and granulation tissues [2]. It includes fibrous inflammatory hyperplasia (clinical fibroma, epulis fissuratum, and pulp polyp), palatal papillary hyperplasia, giant cell granuloma, pregnancy epulis and Pyogenic granuloma [1]. Pyogenic granuloma is a common tumor-like growth of the oral cavity or skin that is considered to be non-neoplastic in nature [5]. Hullihen’s description in 1844 was most likely the first Pyogenic granuloma reported in English literature, but the term “pyogenic granuloma” or “granuloma pyogenicum” was introduced by Hartzell [6] in 1904. Although it is a common disease in the skin, it is extremely rare in the gastrointestinal tract, except for the oral cavity where it is often found on keratinized tissue. There are two kinds of Pyogenic granuloma namely Lobular Capillary Hemangioma (LCH type) and non-LCH type, which differ in their histological features [7].

Pyogenic Granuloma (PG) occurs in patients of all ages with a peak incidence in the second and third decades of life [3]. In children, the average age at diagnosis is 6 to 10 years and there is a predilection for males. Mucosal Pyogenic granuloma is more common in adult women than in men or children. About 2% of pregnant women develop an intraoral Pyogenic granuloma in the first five months of pregnancy [4]. Gingiva was the predominant site followed by lips, tongue, buccal mucosa, and hard plate. Other sites were the cheek, lips, tongue, palate, mucobuccal fold, and frenum [8].

The exact aetiopathogenesis of oral pyogenic granuloma is not known. At present it is regarded as an endothelial proliferation of unknown cause. pyogenic granuloma as an “infectious” entity. Kerr has reported staphylococci and botryomycosis, foreign bodies, and localization of infection in walls of blood vessel as contributing factors in the development of the lesion [8]. Regezi et al. suggested that pyogenic granuloma is caused by a known stimulant or injury such as calculus or foreign material within the gingival crevice resulting in exuberant proliferation of connective tissue.

Pyogenic Granuloma is a smooth or lobulated exophytic lesion manifesting as small, red erythematous papules on a pedunculated or sometimes sessile base, which is usually hemorrhagic and compressible [9] and may develop as dumb-bell-shaped masses. However, Epivatianos et al. reported that the two types of PG were clinically different. They found that LCH PG occurred more frequently (66%) as a sessile lesion, whereas non-LCH PG mostly occurred as pedunculated (77%). The size varies in diameter from a few millimeters to several centimeters. Rarely does Pyogenic granuloma exceed 2.5 cm in size and it usually reaches its full size within weeks or months, remaining indefinitely thereafter [10]. Clinical development of the lesion is slow, asymptomatic and painless but it may also grow rapidly. The surface is characteristically ulcerated and friable which may be covered by a yellow, fibrinous membrane and its color ra because they are composed predominantly of hyperplastic granulation tissue in which capillaries are prominent. Thus minor trauma to the lesion may cause considerable bleeding, due to its pronounced vascularity, whereas older lesions tend to become more collagenized and pink. Rarely, Pyogenic granuloma may cause significant bone loss [11].

Microscopic examination of Pyogenic granuloma shows a highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed which are engorged with red blood cells and lined by banal flat 170 or plump endothelial cells that may be mitotically active. The blood vessels often show a clustered or medullary pattern separated by less vascular fibrotic septa, leading some authorities to consider Pyogenic granuloma as a polypoid form of capillary hemangioma or nothing more than an inflamed lobular hemangioma; others prefer to use the term granulation tissue-type hemangioma. Some pathologists require these vessels, which are sometimes organized in lobular aggregates, for diagnosis (lobular capillary hemangioma) [12]. At low magnification, particularly at the lateral edges, a lobular arrangement is noted wherein groups of capillaries proliferate but abruptly stop. Each lobule is surrounded by a thin collagen layer. This arrangement is disrupted at the base, where irregularly shaped larger vascular channels reside and presumably communicate with the proliferation. It is here that some anastomosing channels (resembling angiosarcoma) can occasionally be identified, but they are focal rather than an integral part of the lesion. At higher magnification, another discriminating feature of benign vascular lesion is found: the small capillary endothelial-lined spaces are themselves surrounded by a perithelial or pericytic layer of cells. This double layer of cells, also seen in intramuscular angiomatosis, is not seen in the clonal angiosarcoma [13].

Radiographic findings are usually absent. However, that in some cases long standing gingival pyogenic granulomas caused localized alveolar bone resorption. Differential diagnosis of pyogenic granuloma includes peripheral giant cell granuloma, peripheral ossifying fbroma, fbroma, peripheral odontogenic fbroma, hemangioma, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi’s sarcoma, bacillary angiomatosis, angiosarcoma, and non-Hodgkin’s lymphoma.

Surgical excision is the treatment of choice. After surgical excision of gingival lesions, curettage of underlying tissue is recommended. Excision with 2 mm margins at its clinical periphery and to a depth to the periosteum or to the causative agent. Any foreign body, calculus, or defective restoration should be removed as part of the excision. Nevertheless, prognosis for intra-oral pyogenic granulomas is good. Satisfactory outcome has been reported with Laser therapy and Cryosurgery for oral pyogenic granulomas. Interestingly, multiple recurrences of intraoral pyogenic granuloma have been reportedly treated with intra-lesional corticosteroids [14]. Incomplete excision, failure to remove etiologic factors or repeated trauma contributes to recurrence of these lesions. No recurrence in cases treated by surgical excision [15] but few studies observed a recurrence rate of 5.8% [16].

Conclusion

Although pyogenic granuloma is a non-neoplastic growth in the oral cavity, proper diagnosis, prevention, management and treatment of the lesion are very important. Pyogenic granuloma arises in response to various stimuli such as lowgrade local irritation, traumatic injury, sex hormones or certain kinds of drugs, so removal of causative irritants (plaque, calculus, foreign materials, and source of trauma) is the major line of treatment. Excisional surgery is the treatment of choice for pyogenic granuloma.

References

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