Introduction

Pyogenic granuloma is a vascular growth occurring on skin and mucous membrane. The term pyogenic granuloma is a misnomer as it is neither associated with pus nor it represents granuloma histologically (Shafer WG, Hine MK, and Levy BM, 1983). Oral pyogenic granuloma commonly occurs on gingiva but can also occur on lips, palate, tongue and buccal mucosa. Extra-orally, fingers and toes are commonly affected areas (Marks K, 2003). Clinically, pyogenic granuloma occurs as a painless, soft mass, smooth or, lobulated, sessile or, pedunculated with the color varying from pink to reddish purple and with a tendency to bleed spontaneously or, after minute provocations in the form of physical trauma. Pyogenic granuloma was first described by Poncet and Dor in 1897 (Graham RM, 1996; Bjork K, et al., 1996). The term pyogenic granuloma or, granuloma pyogenicum was coined by Hertzell (Hertzell MB, 1904). Other names for pyogenic granuloma include pregnancy tumor, Crocker and Hertzell’s disease, granuloma gravidrum, vascular epulis and epulisgranulomatosa. Epulisgranulomatosa is a specific variant of pyogenic granuloma consisting of hyperplastic growth of granulation tissue arising in the healing extraction sockets as a response to bony sequestra in the socket (Neville BW, Damm DD, Allen CM, and Bouquot JE, 2002). Based on histological features, two variants of pyogenic granuloma are known: lobular capillary hemangioma (LCH) and non- lobular capillary hemangioma (non-LCH) variants (Epivatianos A, et al., 2005). In this case report, we are reporting a case of lobular capillary hemangioma variant of pyogenic granuloma that is relatively rare in its occurrence.

Case Report

A 30 year old female patient (Figure 1) reported with a chief complaint of swelling on gum in upper right back jaw region. It was small in size when the patient first noticed it but went on increasing to the present size over a span of one month. Intra-oral clinical examination revealed a 1.5X0.9X0.6cms, ovoid, reddish brown, pedunculated, homogenous growth on the palatal aspect of maxillary right second premolar and first molar interdentally (Figure 2). It was non-tender on palpation and bleeding was minimal. The margins were smooth and firm in consistency. Intra-oral hard tissue examination revealed significant amount of calculus and plaque which might be the etiologic factor in this case reported. Also, the patient gave history of using toothpick to remove food particles stuck in that particular region which may have caused injury to the tissues in this region responsible for the growth. Based on the said history and clinical features, a provisional diagnosis of pyogenic granuloma was arrived-at while peripheral giant cell granuloma was considered to be the first differential. Excisional biopsy was carried-out followed by flap surgery and extraction of 17 was done which was grade III mobile. Suturing was done using 3-0 black silk suture (Figure 3). The excised specimen was sent for histopathological analysis. Histopathologically, H and E stained section revealed a hyperparakeratotic, stratified squamous epithelium which was discontinuous, proliferative, with multiple connective tissue entrapments, and with basal cell hyperplasia in some areas. Underlying connective tissue stroma was fibro-cellular in nature with moderate chronic inflammatory cell infiltration, chiefly, composed of lymphocytes. Several endothelial-lined blood vessels, some of them, were dilated and with extravasated RBCs, were seen. Numerous areas showed endothelial cell proliferation (Figure 4). All these features were consistent with the diagnosis of lobular capillary hemangioma variant of pyogenic granuloma that is relatively rare in its occurrence.

Discussion

Pyogenic granuloma can occur at any age although it is more commonly seen during the 2^nd and 3^rd decades of life with no specific racial predilection. It, however, is said to have a definite female predilection with a female to male ratio for occurrence of 2:1. It was originally thought to be caused by pyogenic microorganisms including Bartonella quintana, Bartonella henselaea and Human Herpes Virus type 8 which were, also, said to have a role in the frequent recurrence of the lesion seen, however, there is no confirming evidence regarding the same (Janier M, 1999). A pre-existing vascular lesion, chronic irritation to the soft tissues by proximal overhangs of the restorations, fractured restorations and grossly damaged tooth structures, food impaction, chronic periodontitis, hormonal changes during pregnancy, drugs-like cyclosporine, indinavir sulphate, isotretinoin, oral contraceptive pills are all considered to be the important pre-disposing, if not, etiologic factors for the lesion. Iatrogenic factors like Guided Tissue Regeneration (GTR) using Decalcified Freeze-Dried, Bone Allografts (DFDBAs) with expanded poly-tetra-fluoro-ethylene membranes, have, also, been seen to lead to the occurrence of pyogenic granulomas (Fowler EB, et al., 1996). Factors-like inducible nitric oxide synthase, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (b-FGF), connective tissue growth factors, involved in angiogenesis, are considered responsible for the rapid growth of pyogenic granulomas seen in few cases (Hamid Jafarzadeh, et al., 2006). Pyogenic granulomas are, also, reported to occur after bone marrow transplants (Kanda Y, 2000). The important differential diagnoses of pyogenic granulomas include peripheral giant cell granulomas, peripheral ossifying fibromas, peripheral odontogenic tumors, and Kaposi’s sarcoma, and non-Hodgkin’s lymphomas, to add in the end (Wood NK, and Goaz PW, 1997). Treatment of pyogenic granulomas involves surgical excision along with the removal of the underlying etiologic factors, if recognizable, with maintenance of a good oral hygiene and avoidance of trauma to the soft tissues in that area, as it is considered to be, principally, a reactive tumor in nature (Shafer WG, Hine MK, and Levy BM, 1983). New modalities like cryosurgery, excision by Nd: Yag laser, injection of absolute alcohol, ethanol or, corticosteroids, sodium tetradecyl sulphate sclerotherapy, can, also, be used. Topical application of timolol gel has, also, been found to be effective in few cases without side effect as reported in few studies (Hamid Jafarzadeh, et al., 2006). With surgical excision of pyogenic granulomas, a recurrence rate, as high as 15%, has been reported. This high recurrence rate observed might be, attributed to incomplete excision or, failure to remove the underlying etiologic factors of the lesion or, re-injury to the area. Sometimes, recurrence manifests as Warner-Wilson Jones syndrome, where multiple satellite nodules, surrounding the original lesion, are seen (Reichart PA, and Philipsen HP, 2000). Also, the recurrence rate of gingival lesions reported is higher than the lesions from other oral mucosal sites (Sapp JP, Eversole LR, and Wyoscki GP, 1997).

Conclusion

Pyogenic granuloma is a common lesion occurring in oral cavity which frequently occurs on the buccal aspect of attached gingival tissues. In this case, we came across a highly vascular variant of pyogenic granuloma, named on histopathological background, as lobular capillary hemangioma that is relatively rare in occurrence. Also, the lesion was seen as a growth in relation to the palatal aspect of the gingiva. The treatment included surgical excision of the lesion with flap surgery after a thorough debridement in the affected region. No recurrence was reported when the patient was followed-up after 1-year of excision, despite being suspected with recurrence, being a purely vascular lesion.

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