gave history of beedi smoking since 20 years, 4-5 times this type of lesion in the English literature. Hartzell a day and regular tobacco chewing since 14 years.
E:/Baba Farid University/Dental Journal/Case Report/17-Sunira Chandra.CDR
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BFUDJ, Volume 4, Number 2, June, 2013
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CASE REPORT EXTRAGINGIVAL PYOGENIC GRANULOMA: AN INTERESTING CASE REPORT
CHANDRA SUNIRA1 KELUSKAR VAISHALI2 KALE ALKA3 SAH KUNAL4
1
Reader Professor 3 Dean & Professor 4 Reader 2
ABSTRACT Pyogenic granuloma [PG] is a common tumor like growth of the oral cavity frequently localized to the gingiva. Histologically, it consists of stratified squamous epithelium overlying the fibrovascular inflammatory stroma. We report an interesting and rare case of PG occurring in a 70-year-old male patient on his lower labial mucosa and discuss its clinico-pathological features with a brief review of relevant literature. KEYWORDS: Oral cavity, extragingival, pyogenic granuloma, labial mucosa
Address for Correspondence :
DR. SUNIRA CHANDRA Reader Department of Oral Medicine & Radiology, Saraswati Dental College & Hospital, Faizabad Road, Lucknow - 227105, UP, India
INTRODUCTION
CASE REPORT
Pyogenic granuloma [PG] is a kind of inflammatory hyperplasia. It is a focal reactive growth of fibrovascular or granulation tissue with extensive endothelial proliferation. Hullihen's [1844] was first who reported this type of lesion in the English literature. Hartzell [1904] introduced the term 'pyogenic granuloma' or 'granuloma pyogenicum'. [1, 2] The term would imply that such lesions react to infection with pyogenic microorganisms. In fact, no relationship exists between bacteria and the emergence of these reactive proliferations. PG can occur anywhere in the body and are common on fingers and toes around the nail beds. PG of the oral cavity is commonly known to involve the gingiva, though it can also occur extragingivally which is extremely rare e.g. tongue, buccal mucosa, palate etc. In these location it is assumed that trauma to the tissue stimulates the hyperplastic response. [1, 3]
A 70-year-old male patient reported with the chief complaint of growth on his lower labial mucosal since 1 month, which gradually increased to present size. He gave history of beedi smoking since 20 years, 4-5 times a day and regular tobacco chewing since 14 years. He also gave history of chronic lip biting.
Over years, various authors have suggested various names for PG, such as granuloma gravidarum, pregnancy tumor, Crocker and Hartzell's disease, v a s c u l a r e p u l i s , b e n i g n v a s c u l a r t u m o r, hemangiomatosis granuloma, epulis teleangiectaticum granulomatosa, and lobular capillary hemangioma. [3, 4] In this paper, we present and discuss a case of extragingival pyogenic granuloma occurring in a 70year-old male patient on lower labial mucosa posing a diagnostic challenge.
No marked deformity was noted extra-orally. Intraoral examination revealed a pedunculated growth measuring about 1.5 X 1.5 cms in diameter present on his lower labial mucosa adjacent to 41 to 43 region. It was reddish in color and its surface characteristic appeared to be lobulated and smooth [Figure 1]. On palpation the growth was firm in consistency and nontender. The overall oral hygiene of the patient was poor with generalized stains and calculus. Slight attrition of 31, 41 and 42 was also observed. No other intraoral abnormality was noted. A differential diagnosis of hyperplasia, fibroma and pyogenic granuloma was considered. An excisional biopsy was advised under local anesthesia. The surgical specimen was lobular in appearance, brownish white in color, firm in consistency and was measuring about 1.5 cms X 1.5 cms in diameter. Specimen was cut into two halves, which also showed lobular pattern with intersepted septae [Figure 2]. The tissue was fixed in 10% neutral buffered formalin and was routinely processed. Cut surface was embedded in paraffin wax, sectioned at 4µm thickness
BFUDJ, Volume 4, Number 2, June, 2013 and slides were stained with Hematoxylin – Eosin [H & E] stain. Under low magnification section revealed stratified squamous epithelium overlying fibrovascular stroma consisting of nodules of inflamed tissue, separated by thin collagenous septa [Figure 3]. Stroma consisted of many vascular channels engorged with erythrocytes lined with proliferating vesicular to plump endothelial cells, interspersed between are loose intertwined collagen fibers with plump to stellate shape fibroblasts. Few of the endothelial cells showed pleomorphism. Inflammatory cells predominantly of neutrophills, lymphocytes and histiocytes were seen [Figure 4]. Based on these histopathological features, a diagnosis of pyogenic granuloma was given. Case was follow-up for a period of two years and no recurrence was noted.
DISCUSSION Pyogenic granuloma [PG] is a common tumor-like growth of the oral cavity that is considered to be nonneoplastic in nature. Etiology of PG is obscure. Originally, it was thought to be caused by pyogenic organism [botryomycosis] and now believed to be unrelated to infection. So, the term 'pyogenic granuloma', is a misnomer as the lesion does not contain pus. Some authors believed PG could possibly originate as a response of tissues to minor trauma or chronic low-grade local irritation or their combination, while others perceived that it was due to hormonal factors or certain kinds of drugs. [1, 2, 5] Although PG may occur in all ages, it is predominantly seen in the second decade of life with no racial predilection, with a prevalence rate of 1 lesion per 25,000 adults. [6 - 8] Lawoyin et al reviewed 38 cases and reported an average range of 5 to 75 years [mean age 33 years]. [9] In contrast, a recent study reported that an average patient age was 52 years with a peak incidence of occurrence in the sixth decade of life. [10] Most studies demonstrate a definite female predilection with a female to male ratio of 2:1 possibly because of the vascular effects of female hormone. It usually occurs during the second and third trimester of pregnancy and was referred to as 'pregnancy tumors'. [1, 5, 8, 11] Daley T D et al. in their study indicated that the clinical diagnosis of pregnancy tumor could be given when describing a pyogenic granuloma occurring in pregnancy, because it describes a distinct lesion not on the basis of histologic features but on etiology, biologic behavior, and treatment protocol. [12] PG of the oral cavity commonly is known to involve the gingiva as a result from poor oral hygiene, dental plaque, calculus and over-hanging restorations. In 70% of the cases interdental papillae is the most common site. It is slightly more common on maxillary gingiva than the mandibular gingiva. Anterior areas are more
92 frequently affected than posterior areas. Also, these are more common on facial aspect than lingual aspect of gingiva. [8] According to Vilmann et al. majority of PGs are found on marginal gingiva with only 15% of them occur on alveolar part. [15] Through it can also occur extragingivally e.g. tongue, buccal mucosa, palate etc. [2] In these location it was assumed that trauma to the tissue serves as an irritant that stimulates the hyperplastic response. [1] Clinically the PG appeared as a smooth or lobulated exophytic lesion manifesting as a small, red erythematous papule on a pedunculated or sometime sessile base. Color range from pink to red to purple depending upon its duration. Sometimes surface can also show ulceration. Size of this lesion varies from few millimeters to several centimeters. It is usually slow growing, asymptomatic and non-tender but it may also show rapid growth. Older lesions tend to become more collagenized and firm. [8] Clinical diagnosis of extragingival PG is a challenging task and differential diagnosis includes peripheral giant cell granuloma, peripheral ossifying fibroma, metastatic cancer, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi's carcinoma, capillary hemangioma, bacillary angiomatosis, spitz nevus, pigmented spindle cell tumor of Reed, nevocytic nevus, seborrheic keratosis, angiolymphoid hyperplasia with eosinophilia, furuncle, ecthyma contagiosum, and verruca vulgaris. [5, 6, 14] Bjork et al [1996] reported a similar case of a pyogenic granuloma occurring on the lip showing necrosis and collarette scale. [4] Souza et al [2003] reported a case of pyogenic granuloma occurring on the vermilion border of the lower lip, which had an unusual presentation of a cutaneous horn. [15] Karthikeya P et al. [2006] presented a case of extragingival PG occurring in the lower lip which also presented as a cutaneous horn. [16] Epivatianos et al. reported two types of PG which can be histologically differentiated from each other, namely lobular capillary hemangioma [LCH] and non-lobular capillary hemangioma [non-LCH]. They noted that these can also be clinically differentiated from each other as LCH PG occurred more frequently [66 %] as a sessile lesion, whereas non- LCH PG mostly occurred as pedunculated growth [77%]. [5, 10] Treatment of PG consists of conservative surgical excision with removal of causative irritants. [9, 17, 18] Although these are reactive hyperplasia's, they have a relatively high rate of recurrence after simple excision, especially in pregnant patients. A recurrence rate occurring up to 16% has been reported. [19] Recurrence is believed to result from incomplete excision, failure to remove etiologic factors, or recurrent trauma to that area. Gingival lesions showed a much higher
BFUDJ, Volume 4, Number 2, June, 2013 recurrence rate than any other oral mucosal site. [13] After surgical excision of gingival lesions, curettage of underlying tissue is recommended. Recurrences after surgery of extragingival pyogenic granuloma are uncommon. [8]
CONCLUSION Pyogenic granuloma is a non-neoplastic growth. Its proper diagnosis is helpful in its management and treatment. Oral PG is well documented in literature. However their occurrence on extragingival sites in the head and neck region are rare. Clinical diagnosis for the present case was a challenging task because of its occurrence on the extragingival site. Probable etiology for this case was chronic low-grade local irritation due to lip biting. Conservative surgical excision was done. Case was followed-up for two years and no recurrence was noted.
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10. Epivatianos A, Antoniades D, Zaraboukas T, Zairi E, Poulopoulos A, Kiziridou A, Iordanidis S. Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features. Pathol Int 2005; 55: 391-397. 11. Regezi JA, Sciubba JJ, Jordan RCK. Oral Pathology: clinical pathological considerations. 4th ed. Philadelphia: WB Saunders; 2003. pp 115-116. 12. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis, Oral Surg Oral Med Oral Pathol 1991; 72: 196199. 13. Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surg 1986; 24: 376-382.
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Bjork K, Hoede N, Korting GW, Burgdorf WHC, Young SK. Diseases of the oral mucosa and the lips. Philadelphia: WB Saunders; 1996. pp 229-230. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. Journal of Oral Science 2006; 48:167-75. Laskaris G. Colour atlas of oral diseases. 4th ed. New York: Thieme publishers, 1997. pp 400-401. Scully C, Flint SR, Porter SR, Moor KF. Oral and maxillofacial diseases. 3rd ed. London: Tylor and Francis; 2004. pp 370.
16. Patil K, Mahima VG, Lahari K. Extragingival pyogenic granuloma, Ind J Dent Res 2006; 17: 199-202. 17. Eversole LR. Clinical outline of oral pathology: diagnosis and treatment. 2nd ed. BC Decker, Hamilton; 2002. pp 113-114. 18. Esmeili T, Lozada-Nur F, Epstein J. Common Benign oral soft tissue masses. Dent Clin North Am 2005; 49: 223240. 19. Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma [pyogenic granuloma] with satellitosis. J Am Acad Dermatol 1992; 27: 297-300.
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LEGENDS
Figure 1 Intraoral photograph showing reddish color lobulated growth seen on lower labial mucosa.
Figure 2 Gross specimen cut into two halves showed lobular pattern with intersepted septae.
Figure 3 Photomicrograph showing proliferating stratified squamous epithelium overlying fibrovascular inflamed stroma. [H & E, x40]
Figure 4 Photomicrograph showing proliferating vascular channels engorged with erythrocytes and lined with vesicular to plump shape endothelial cells showing pleomorphism with inflammatory infiltrate. [H & E, x100]
Source of Support : Nil, Conflict of Interest: None Declared
