Pyogenic granuloma. A case report

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PYOGENIC GRANULOMA – A CASE REPORT Swati Gotmare1, Avinash P. Tamgadge2, S . S .Bhalerao3, T. Pereira4, Mrs. S. Tamgadge5


Pyogenic granuloma is a fast growing reactive proliferation of endothelial cells commonly on the gingiva and usually in response to chronic irritation. It is a polypoid form of capillary hemangioma on the skin & mucosal surfaces. This paper present of case of pyogenic granuloma found on the cheek adjacent to retromolar region.

Introduction Pyogenic granuloma is a fast growing reactive proliferation of endothelial cells commonly on the gingiva and usually in response to chronic irritation. The term pyogenic granuloma is a misnomer in that it is not pus producing and it does represent granulomatous inflammation. In fact, no relationship exists between bacteria and emergence of this reactive proliferation3,4. This article describes a case of pyogenic granuloma and discusses the clinicopathological features of this tumor.

Case Report A 25 year old male was referred to the Pd. Dr. D.Y. Patil dental college and hospital for pain and swelling in the right cheek region. The patient noticed the swelling 2 months before, however he did not seek medical attention at that time. This lesion had gradually increased 1,




in size and he had bitten it many times. Intraoral examination revealed a 2 x 2 cm exophytic, yellowish white to red colour, soft nonmobile, oval lobulated swelling in the right cheek adjacent to retromolar region. Provisional diagnosis was given of fibroma. The lesion was excised through an intraoral approach under local anesthesia, after fixation in buffered formalin. The tissue was processed and stained with hematoxylin & eosin stain. Histopathological examination revealed a parakeratinized stratified squamous atrophied overlying epithelium. The tumor mass composed of lobular masses of hyper plastic granulation tissue, lots of endothelially – lined, vascular channels engorged with erythrocytes & nodules of endothelial cells in medullary patterns & moderation inflammatory cells infiltration. Based on these it was diagnosed as pyogenic granuloma.


Reader Professor , Professor , Professor , Professor Dept. of Oral Pathology Dr. D. Y. Patil Dental College & Hospital, Nerul Navi Mumbai.

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Pyogenic Granuloma …………………………………………………………………. Swati Gotmare et al

Fig :1 Clinical photograph of the lesion Fig:2

Discussion The so called pyogenic granuloma is a polypoid form of capillary hemangioma on the skin & mucosal surfaces. The inflammatory changes that often accompany theses tumors may be so pronounced that the lesion bears a striking resemblance to granulation tissue3. Poncet & Dor in 1897 described pyogenic granulomal granuloma pyogenicum. Over the year various authors have suggested other names such as granuloma gravidarum/ pregnancy tumors, Rocker & Hartzell’s disease, vascular epulis, benign vascular tumors, epulis telangectium granulomatousa, & lobular capillary hemangioma. An intravenous counterpart of pyogenic granuloma was recognized by cooper et al. This tumor is most common on the neck & upper extremity. It presents as a red-brown, intravascular polyp that can be easily mistaken for an organizing thrombus3,7. The pregnancy granuloma Gravidarum or ‘pregnancy tumor’ is a tumor specialized form of Pyogenic granuloma that occurs o the gingival surface during pregnancy1. The precise mechanism for the development of pyogenic granuloma is unknown. Trauma, hormonal influences, viral oncogens, underlying microscopic arteriovenous malformations, the production of angiogenic growth factors, & cytogenic abnormalities have all been postulated to play a role. The over expression of transcription factors, P- ATF2& STAT3 also may play role in tumorogenesis3,6. These tumors may occur on either the skin or mucosal surface, although the latter Scientific Journal

Hitopathological picture of the lesion(4x &10x) accounts for about 60% of all cases. In the extensive review of 289 cases by Kerr, the following were the most common sites, in descending order of frequency, gingival(64 cases 0, finger (44 cases ), lips (40 cases ), face (28 cases ), & tongue (20 cases ). Pyogenic granuloma of the oral cavity occurs at any age & in all populations with no racial prediction. Most studies demonstrate a definite female predilection with female to male ratio of 2:1. This is attributed to the vascular effect of Female hormones that occur in women during puberty, pregnancy & menopause. The lesions tend to occur more often during the second and third trimester of pregnancy & such lesions are referred to as pregnancy tumors4,5. In the oral cavity Pyogenic granuloma shows a striking predilection for the gingival with interdental papillae being the most common site in 70% of the cases. They are more common on maxillary anterior area than any other area in the mouth. Gingival irritation & inflammation that result from the poor oral hygiene, dental plaque & calculus or over-hanging restoration may be precipitating factors in many cases7. The typical clinical presentation of pyogenic granuloma is a small, deep red to reddish purple lesion occurring on the gingiva, which is either sessile or pedunculated. The surface may be smooth, lobulated or occasionally, warty which is commonly ulcerated & shows a tendency for hemorrhage either spontaneously or upon slight trauma. The lesion is painless & soft in consistency. Although older lesions tend to become more collagenized and firm. The Vol. III – 2009

Pyogenic Granuloma …………………………………………………………………. Swati Gotmare et al

size of the lesion usually ranges between 0.5 cm to 2 cms. They may grow at an alarming rate reaching that size within just 4 -7 days5,1. Although pyogenic granuloma can be diagnosed clinically with considerable accuracy radiographic and histopathological investigation are used for confirming the diagnosis and planning the treatment1. All clinically suspected pyogenic granuloma must be biopsied to rule out more serious condition. The hitopathological picture of the extra gingival pyogenic granuloma is quiet similar to the ones occurring on the gingiva or other parts of the body. The pathology is distinct consisting of a matrix of edematous connective tissue in which numerous thinned walled vascular channels can be seen. These vessels sometimes are organized in lobular aggregates, and some pathologists require this lobular arrangement for the diagnosis (lobular capillary hemangioma). There is also moderately dense mixed cellular infiltrate. The overlying stratified squamous epithelium may be atrophic or hyperplasic, and is usually degenerated or ulcerated in large areas; and the ulcer edge may have a primitive dysplastic appearance. Mitotic activity may be noted in the stromal cells. This histological picture can however be mistaken for less frequently occurring lesions like capillary hemangioma, epitheliod hemangioma, or epithelial cell histiocytoma1.2.3. Treatment of Pyogenic granuloma consists of conservative surgical excision, which is usually curative. Although these are reactive hyperplasias, they have a relatively high rate of recurrence after simple excision, especially in pregnant patients. A recurrence rate 15% has been noted. After surgical

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excisions of gingival lesions, curettage of underlying tissue is recommended. Recurrence after surgery of extra gingival Pyogenic granulomas is however 1,3 uncommon .

Summary In oral cavity pyogenic granuloma shows a striking predilection for the gingival with interdental papillae being the most common site in 70% of cases. Most studies demonstrate a definite female to male ratio of 2:1. In this case report we discussed a case of 25 yrs. Male patient diagnosed with pyogenic granuloma in the extra gingival location.

References 1. Shafer, Hine & Levy. Textbook of oral pathology 2006; 2. J. Philip Sapp, Lewis R. Eversole, George P. Wysock. Conteprary oral & maxillofacial pathology 2004;318-319 3. Sharon W. Weies, John R Goldblum. Enzinger’s & Weiss’s soft tissue tumors 864-865 4. Neville, Damm, Allen bouquet. Oral & maxillofacial pathology; 447-449 5. Regezi, Sciubba, Jordon. Oral pathology &clinical pathologic correlations 2003;115-117 6. G. H. L. Saravana. British journal of oral & maxillofacial surgery;47(2009)318-319 7. Karthikeya Patil, VG Mahima, K Lahiri. Indian J of dental research 17.4(2006)199-202

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