PYOGENIC GRANULOMA: CLINICAL FEATURES, HISTOLOGY AND TREATMENT
Author: Sanketh DS, MDS
Pyogenic granuloma, is a relatively common tumor like growth occurring in the oral mucosa. This lesion is considered to be non-neoplastic in nature and is known to be an exaggerated granulation tissue response to local irritation or trauma.
Though, called pyogenic granuloma, it is not pus filled, neither caused by pyogenic organisms nor is it a granulomatous infection.
Pyogenic granuloma was once thought to be a botryomycotic infection and then with subsequent work was suggested to be a lesion caused by streptococci and staphylococci. It is now, however generally agreed that these are reactive lesions and arise due to trauma to the tissues. The tissues then respond in an exaggerated manner and proliferate in excess giving rise to a localised growth of granulation tissue/fibro-vascular tissue.
Pyogenic granuloma manifests most commonly on the gingiva, on the maxillary anterior region accounting for 75% -85% of the cases. Poor oral hygiene or chronic irritants like overhanging restorations or calculus may be precipitating factors in patients developing these lesions. Biting on extra-gingival locations like lips, tongue and buccal mucosa could stimulate the growth of this lesion in these locations.
Pyogenic granuloma may range from a few millimetres to several centimetres in size. The lesion is elevated and is usually pedunculated or sometimes sessile. It is deep red or red-purple in colour, painless and soft in consistency. The surface may be lobulated or smooth and may be frequently ulcerated due to trauma. The lesion may bleed easily due to its extreme vascularity. Older lesions may be less vascularised, pink in colour and tend to be more fibrosed and firmer than early lesions. Pyogenic granulomas may tend to have a rapid growth at times and can be a source of alarm for the patients and the clinician.
The lesions on the gingiva more often appear on the buccal aspect of the gingiva than the lingual or palatal aspect and may also extend through the inter-dental areas to expand bucally and lingually.
The lesion demonstrates a female predilection especially during the first trimester . This has been attributed to the female hormones estrogen and progesterone. It occurred so often during pregnancy, that it was thought to be a lesion then named as pregnancy tumor or granuloma gravidarum. But it is now known that both pyogenic granuloma and pregnancy tumor are the same and hence the term pregnancy tumor is better avoided.After pregnancy, these lesions may subside and resolve or may remain static and become fibrous and resemble a fibroma.
Histology is similar to a granulation tissue except that it is much exaggerated. The epithelium may be thinned or more often hyperplastic. Epithelium may be ulcerated in focal areas with a fibrinous exudate covering the surface.
The characteristic feature is the excess proliferation of numerous endothelial lined capillaries engorged with red blood cells and fibroblasts in a stroma that may be chronically inflamed and mildly-moderately fibrous. The inflammation is mixed with infiltration of neutrophils, lymphocytes and plasma cells. These proliferating capillaries may have a lobular arrangement and are hence refered to as lobular capillary hemangiomas by some pathologists.
Remember that pyogenic granuloma most often appears on the gingiva. And the first set of differentials to be considered when diagnosing a soft tissue lump on the gingiva are the 3 “P”s i.e – Pyogenic granuloma, Peripheral giant cell granuloma and Peripheral ossifying fibroma. An irritational fibroma could also be considered although fibromas are mostly pink in appearance as compared to the deep red to red-blue appearance of the other lesions.
Metastatic tumors occurring on the gingiva are sometimes indistinguishable from a pyogenic granuloma although they are very rare. Hemangioma and squamous cell carcinoma could also be considered.
These lesions are treated by surgical exicision. The lesion has a tendency to recur rarely if the precipitating factors are not eliminated along with removal of the lesion. Hence, there has to be considerable care taken to scale and remove calculus and restore good hygiene in addition to excision.
These lesions show evidence of healing and tend to become fibrosed with time. It is likely possible that many fibromas diagnosed could have possibly been healed pyogenic granulomas.
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