Oral pyogenic granuloma: a review of 38 cases from Ibadan, Nigeria

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Oral pyogenic granuloma: a review of 38 casesfrom Ibadan, Nigeria J. 0. Lawoyin, J. T. Arotiba, 0.0.

Dosumu

Departments of Oral Medicine and PathologJl, Oral and Maxillofucial College of Medicine, University College Hospital, Ibadan, Nigeriu

Surgery and Restorative Dentistry,

SUMMARY. Thirty-eight cases of patients with histologically confirmed pyogenic granuloma of the oral cavity were treated at the University College Hospital Dental Centre during the period 1982-1993. The age of the patients at presentation ranged from 5 to 74 years (mean 33) and the male : female ratio was 1: 1.2. The main site was the gingiva (n-29, 74%). The clinical presentation was generally similar to that in other studies except that most of the lesions were large. All 38 cases were treated by excision and there were no recurrences among those with adequate follow-up.

INTRODUCTION

genie granuloma of the oral cavity especially in black Africans.7 The aim of this paper therefore is to describe our experience of pyogenic granuloma of the oral cavity in Africans and compare it with that of others.

Pyogenic granuloma or granuloma pyogenicum is a relatively uncommon, localised polypoid growth of the skin or mucous membrane. It was first thought to be a mycotic infection of horses that was transmitted to man,’ but later the result of tissue response to non-specific infection. It is now generally agreed, however, that it might be initiated by minor repetitive injury which predisposes to invasion by low virulent micro-organisms, resulting in a hyperplastic and exaggerated proliferation of highly vascular connective tissue.’ Recently Inagi et ~1.~stated that they thought that pyogenic granuloma was a purulent change associated with benign oral tumours although no scientific evidence was advanced to support this claim. Although the most common intra-oral site of pyogenie granuloma is the gingiva,4-6 other intra-oral sites are the lip, tongue, buccal mucosa, and palate. Extra-oral sites include the skin of the upper and lower extremities, head, face, mucous membrane of the nose, eyelids, and genitalia.7 Oral pyogenic granuloma presents as a painless, deep red or purplish, solitary oral lesion with a mean diameter of 20-30 mm but it may grow larger if left untreated. It can be pedunculated or sessile with a smooth lobulated or rough warty surface. The lesion, which is benign, has no age or sex predilection although some previous studies reported a slightly higher incidence in women.‘*4 Contact bleeding is common. The treatment is usually excision which, if adequate, should not lead to recurrence. In addition. a thorough scale and polish of the related teeth has been advocated.5 Recently, cryosurgery and laser surgery have been advocated for the treatment of pyogenic granuloma and other epulides, ‘-lo but there are few reports of the results of treatment of adequate number of cases. There is a paucity of published data on the epidemiology, clinical presentation, and management of pyo-

PATIENTS AND METHODS Patients with oral lesions histologically diagnosed as pyogenic granuloma between 1982 and 1993 were identified from the records of the oral pathology department and reviewed retrospectively. The slides were retrieved and reviewed by one of us (JO) to confirm the diagnosis. The case notes of these cases were then retrieved and the necessary information extracted. Thirty-eight cases were recorded as having oral pyogenic granulomas. Most of the cases were seen by one of the authors in the oral diagnosis or oral surgery clinic. The information collected included age, sex, size, site, and duration of lession, treatment and recurrences. RESULTS Incidence Thirty-eight out of 556 oral soft and hard tissue lesions in the histopathology records of our oral pathology department, between 1982 and 1993, were confirmed histologically to be pyogenic granuloma, giving an incidence rate of 7%. Age and sex The age of the patients at first presentation ranged from 5 to 74 years with a mean of 33 (Table 1). The age distribution showed a double peak occurrence at the second and sixth decades with 9 (24%) and 8 (21%) patients, respectively. There were 17 male and 18.5

1 -Age granuloma

Table

Age (years) O-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80

and sex distribution Total no. (%) 5 (13) 9 (24)

6 (16) 3 (8) 4 (11)

8 (21) 2 (5) 1 (3) 38 (100)

Total

of 38 patients with pyogenic

Table 3 -Oral pyogenic granuloma: lesions by quadrant

distribution

of 28 gingival Total %

Male

Female

Sex

4 4 3 1 2 2 1 -

1 5 3 2 2 6 1 1 21 (55)

Male

Female

2 1 2 2 3 2 0 0

4 1 3 0 5 0 3 0

17 (45)

Upper Upper Upper Upper Lower Lower Lower Lower

anterior anterior posterior posterior anterior anterior posterior posterior

labial gingivae palatal gingivae buccal gingivae palatal gingivae labial gingivae lingual gingivae buccal gingivae lingual gingivae

6 (21) 2 (7) 5 (18) 2 (7) 8 (29) 2 (7) 3 (11) 00

21 female patients giving a male: female ratio of 1: 1.2. The mean age 38 years for women was significantly higher than the mean age of 28 years for men. Site The gingiva was the main site (n = 29,74%) (Table 2). Other intra-oral sites were the tongue, the buccal mucosa of the cheek, and the alveolar mucosa. Site was not recorded for 3 (8%) patients while the lip was not involved in any of the 35 patients for whom the sites were record -’ ,- ” ’ ’ ^ _ within the gingiva s almost equal distribt upper (54”/0) and l( region (64%) was m region (36%) in bc common site was th no lesions were recor ual gingiva.

granuloma of the buccal mucosa in a 30-year-old

Clinical features (Fig. The lesions were raise or pedunculated, am bluish tinge. Althol 3x6x8mm to 65x’ large and quite a few rant of the jaw. A fe\ as a result of injury f chewing, biting, or frc _I_ VlU. “,~‘““W I,I~cIJUIcIJJULII as toothbrushing. These ulcerated lesions bled readily on slight provocation. Many of the patients did not give adequate information on the duration of these lesions, but in cases Table

2 -Age and site distribution

Age

Gingivae 3 8 4 1 3 6 2 1 28 (74)

Y

:xamination of specimens showed soft :times spongy, polypoid masses with SIIIUVLI~ roourated surfaces which were ulcerated in many cases. Their sizes ranged from 15-75 mm in the largest diameter. Most of the lesions showed the typical prominent areas of endothelial lined vascular spaces with plump

of pyogenic granuloma of the oral cavity Tongue

Buccal mucosa

Alveolar mucosa

Unspecified

Total

0 0 I 1 0 2 0 0

1 0 1 0 0 0 0 0

0 1 0 0 0 0 0 0

1 0 0 1 1 0 0 0

4 (11)

2 (5)

1 (3)

3 (8)

5 9 6 3 4 8 2 1 38 (100)

(years) O-10 1l-20 21-30 31-40 41-50 51-60 61-70 71-80 Total (%)

information was available it ranged s to 54 years. ‘the affected women had been pregnant.

Oral

pyogenic

fibroblasts, and vast areas of chronic and acute inflammatory cell infiltrates. About a third, however, showed spindle shaped fibroblasts emersed within a collagenous stroma of connective tissue with scanty inflamatory cells. Treatment All the lesions were excised en masse with the base under local anaesthesia using 2% xylocaine with adrenaline in a dental chair. Small wounds were closed primarily by undermining adjacent mucosa while in large lesions, the defects were allowed to granulate. Where bones were exposed-for example, in gingival lesions-a band of dressing such as whitehead varnish in gauze was sutured over the wound and left in place for about a week. An alternative gingival dressing such as peripac (De Trey Dentsply, ADOLF HAUPT & Co) was a satisfactory substitute in some cases. Penicillin and streptomycin were given intramuscularly or ampicillin and metronidazole were given orally for 5 days for prophylaxis in addition to oral analgesics such as piroxicam, aspirin, or paracetamol. Follow-up Patients were usually reviewed on the first day after operation, then weekly for the first month, monthly

Fig. 2 - Large pyogenic granuloma gingivae in a 56-year old woman.

of the mandibular

labial

1

Table 4 - Comparative First

sex distribution

author

Reference

of pyogenic

granuloma:

a review

of 38 cases from

* Pyogenic

granuloma

DISCUSSION The present series of 38 cases of oral pyogenic granulomas is to our knowledge the largest reported from West Africa so far. The fact that these 38 patients with pyogenic granuloma of the oral cavity were seen over an 1 l-year period suggests that this lesion is not common among Nigerian Africans. It has, however, been reported by various authors ‘i-l3 that patients do not usually present in the hospital for treatment unless their lesions are advanced and incapacitating, because of lack of awareness. This is further supported by our finding that quite a number of the cases have fairly large tumours (Fig. 2). The apparent rarity of oral pyogenic granuloma therefore may not be conclusive. Despite the fact that the number of patients may be too small to make conclusive deductions about the age and sex, we may safely infer that pyogenic granuloma affects people of all ages and both sexes. The mean age of 33 years in the current study is similar to that of 35 years reported by Angelopoulus in a White population.4 Our study also shows a higher mean age for women than men at 38 years and 28 years, respectively. This confirms Angelopoulus’s finding of a higher mean age for women (37 years) than for men (33 years). The higher female:male ratio is also in agreement with other studies (Table 4). Our findings as regards site confirm previous findings 4 that oral pyogenic granuloma of the gingiva is more common in the anterior than in the posterior regions in both jaws (Table 3). While the most common gingival site was the upper labial anterior region in Angelopoulus series, the lower anterior labial gingival region was the most common in the present study. Pyogenic granuloma is said to be an exaggerated soft tissue response to minor injury or low-grade irritation.““.i4 Calculus, overhanging edges or rough surfaces of restorations are possible sources.

Total no. of cases in which sex known

no.

Sex

Ill 20 67 17

x4* 46** 137* 3s*+ skin and mucous

187

granuloma

I 4 7

involving

Nigeria

for another 3 months and thereafter every 6 months. The period of follow-up ranged from a week to 6 years post-operatively. About a third of the patients did not keep their review appointments beyond a week post-operatively, and only nine patients came for review after a year, but no recurrence was noted in any of these nine patients.

Male Kerr Angelopoulus Nkanza Present study

Ibadan,

membranes;

**oral

cavity

only.

Female (41) (43) (49) (45)

153 16 70 31

(58) (57) (51) (55)

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British

Journal

of Oral

and Maxillofacial

Surgery

Microulcerations from these irritants might allow penetration into the submucosal connective tissue of low virulent micro-organisms that are normally resident in the oral cavity. This evokes an exaggerated, hyperplastic response from the connective tissue, particularly the vascular component. We think that this may explain the preponderance of gingival lesions in oral pyogenic granuloma. The clinical and histopathological features of oral pyogenic granuloma in this study are similar to those previously reported 1,4,6*7except that patients tend to present much later when their lesions are advanced and incapacitating. Chiong et al. Is reported a rare case of massive pyogenic granuloma of the gingiva in a 22-year old man, and commented that the case was an unusual presentation because it was so large, but most of our lesions in our series are large because they presented late (Fig. 2). Pyogenic granuloma is benign, so adequate excision should cure the lesion. Leopard I6 stated that excision is the treatment of choice for fibrous epulis and similar lesions but old age and recurrent or multiple lesions might be an indication for cryosurgery. Recurrent lesions could be a result of incomplete excision or treating pyogenic granuloma by cautery or laser.r7-r9 Our practice is to ensure adequate excision of the lesion with the tissue at its base. This practice has been highly successful and although most of the patients were quickly lost to follow-up, none of the few patients who were followed up beyond a year had any evidence of recurrent lesions. Cryosurgery and laser surgery have recently been introduced for the treatment of pyogenic granuloma 8*10,16,20but only a few reports have been documented, particularly of their use for oral pyogenic granuloma.‘0~2’ They have yet to gain widespread acceptance among surgeons because of their variable success. Good results have been reported, particularly for cutaneous lesions.9,‘0,22 Lee et aZ.,23 however, reported failure to cure two cases of pyogenic granuloma by laser surgery. In addition the development of cutaneous pyogenic granuloma as a complication of treating a previously existing pyogenic granuloma or similar lesions like port-wine stains, telangiectasia, superficial haemangiomas, and verruca vulgar-is, by laser or cryosurgery has been reported.‘g~24,25 The role of these new treatments, therefore, has not been fully evaluated because most of these studies reported only a few cases and there are few studies on oral pyogenic granuloma. More well planned prospective studies with adequate number of cases are necessary, therefore, before any conclusion could be reached on the adequacy and effectiveness of these new treatments of pyogenic granuloma of the oral cavity.

References 1. Kerr DA. Granuloma pyogenicum. Oral Surg 1951; 4: 158176. 2. Shafer WC, Hine MK, Levy BM. A textbook of oral pathology 4th ed. Philadelphia: W.B. Sanders and Company, 1983; 359-360. 3. Inagi K, Takahashi HO, Yao K, Kamata T. Study of pyogenic granuloma of the oral cavity. Nippon Jibiinkoka Gakkai Kaiho 1991; 94: 1857-1864. 4. Angelopoulus AP. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features. J Oral Surgery 1971; 29: 840-847. 5. Poonja LS, Bhatt AP. Case of the month: Pyogenic granuloma J Indian Dental Association 1983; 5: 2. 6. Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: evaluation of oral conditions. British J Oral Maxillofac Surg 1986; 24: 316-382. 7. Kanza NK, Hutt MSR. Pyogenic granuloma: A study of 181 cases from Malawi. East Afr Med J 1981; 58: 319-323. 8. Pogrel MA. Application of laser and cryosurgery in oral and maxillofacial surgery: Current Opinion in Dentistry 1991; 1: 263-270. 9. Glass AT, Milgraum S. Flashlamp-pumped pulsed dye laser treatment for pyrogenic granuloma. Cutis 1992; 49: 351-353. 10. Powell JL, Bailey CL, Coopland AT, Otis CN, Frank JL, Meyer I. Nd-YAG laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med 1994; 14: 178-183. 11. Daramola JO, Ajagbe HA, Oluwasanmi JO. Pattern of oral cancer in a Nigerian population Br J Oral Surg 1979; 17: 123-128. 12. Adekeye EO, Asamoa E, Cohen B. Intra-oral carcinoma in Nigeria: A review of 137 cases Ann Co11Surg Engl 1985; 67: 180-182. 13. Arotiba JT. Oral squamous cell carcinoma: Analysis of cases seen at the University College Hospital, Ibadan (1976-1990). Dissertation: National Postgraduate Medical College of Nigeria 1992, 109. 14. Gayford JJ, Haskell R. Clinical oral medicine. Bristol: John WrightandSons, 1979: 111-113. 15. Chiong AM Jr, Chiong CM, Dy AY, Pajarillo PR. A massive pyogenic granuloma in the gingiva. Auris Nasus Larynx 1990; 16: 2277231. 16. Leopard JP. Cryosurgery and its application in oral surgery. Br J Oral Surg 1975; 3: 1288152. 17. Eng AM, Hong HY. Recurrent granuloma: a form of lobular capillary haemangioma. Cutis 1993; 52: 101-103. 18. Patrice SJ, Will K, Mulliken JB. Pyogenic granuloma (lobular capillary haemangioma): a clinicopathologic study of 178 cases.Paediatr Dermatol 1991: 8: 267-276. 19. Blickenstaff RD, Roenigk RK; Peters MS, Goellner JR. Recurrent pyogenic granuloma with satellitoses. J Am Acad Dermatol 1989; 21: 1241-1244. 20. McDonald GA, Simpson GT. Transoral resection of lesions of the oral cavity with COZ laser: Otolaryngl Clin North Am 1983; 16: 8399847. 21. Modica LA. Pyogenic granuloma of the tongue treated with carbon dioxide laser: J Am Geriatr Sot 1988; 36: 1036-1038. 22. Goldberg DJ, Sciales EW. Pyogenic granuloma in children: Treatment with the Flashlamp-pumped pulsed dye laser. J Dermatol Surg Oncol 1991; 17: 960-962. 23. Lee CT, Tham SN, Tan T. Initial experience with CO2 laser in treating dermatological conditions: Ann Acad Med Singapore. 1987; 16: 713-715. 24. Beers BB, Rustad OJ, Vance JC. Pyogenic granuloma following laser treatment of a port-wine stain. Cutis 1988; 41: 266-268. 25. Kolbusz RV, O’Donoghue MN. Pyogenic granuloma following treatment of verruca vulgaris with cryotherapy and Duoplant. Cutis 1991; 47: 204.

Acknowledgements

The Authors

We thank Messrs A Adewoyin, GA Afolabi, and Mrs MI Omikunle for the secretarialwork, and the biomedicalillustration unit of the University College Hospital, Ibadan, for the photographs.

Dr J. 0. Lawoyin

DDS

(Howard),

MSc

(Glasgow)

Department of Oral Medicine and Pathology Dr J. T. Arotiba

BDS (Ibadan),

FMCDS

(Nig)

Oral pyogenic granuloma: a review of 38 cases from Ibadan, Nigeria Department of Oral and Maxillofacial Surgery Dr 0.0. Dosumu BDS (Ibadan), FMCDS (Nig) Department of Restorative Dentistry, College of Medicine University College Hospital Ibadan Nigeria

Correspondence and requests for offprints to Dr J.T. Arotiba, Department of Oral and Maxillofacial Surgery, Dental Centre, University College Hospital. PMB 5116, Ibadan. Nigeria Paper received 11 November 1994 Accepted 8 August I995

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