Pyogenic Granuloma of The Cheek: A Rare Case Report

Headnote

Abstract

Pyogenic granuloma (PG) is an inflammatory hyperplasia arising in the oral cavity in response to various stimuli, such as local irritation, traumatic injury and hormonal factors Oral PG is the most common gingival tumour with greater predilections in gingiva followed by lip, tongue, and buccal mucosa occurring in 2nd decade of life in young females. Although surgical excision is the treatment of choice, other modalities of treatment are also used. Here with we present a rare case report of pyogenic granuloma of the cheek

Keywords: Pyogenic granuloma; pregnancy tumour; hyperplasia.

Introduction

Pyogenic granuloma (PG) is a benign exophytic hyperplastic overgrowth occurring most commonly on the gingiva and less frequently at other sites in the oral cavity and on the skin, with high prevalence in females. It arises in response to various stimuli such as chronic low-grade local irritation, traumatic injury, hormonal factors, certain kinds ofdrugsandinfectionwhichstimulatestheformationofan exuberant overgrowth of young highly vascular granulation tissue.1 Clinically the lesion varies from a discrete spherical, tumour like mass that is pedunculated or broad based, highly vascularized, smooth, edematous, soft, and red with glossy surface, which is usually hemorrhagic and compressible. It may develop as dumb-bell-shaped hardened masses when it is longstanding. It could be single or multiple well localized outgrowths, which may be painless or dull-painful. The size could range from few millimeters to several centimeters.2 Here we present a case of pyogenic granuloma of the cheek.

Case report

A 44-year-old female patient reported with a chief complaint of swelling present on the leftside of her cheek which was interfering with speech and mastication. The patient revealed that the swelling started as a small nodule a month back and developed to attain its present size. Intraoral examination revealed a swelling measuring about 3x1.5x lcm present on the leftlower buccal mucosa extending from the premolar region to the retromolar pad (Figure 1). The swelling was in relation to the edentulous site on the leftlower quadrant where the molars were missing. The swelling was red, lobulated, and firm and it was attached with a broad base. It showed the indentations of the upper molars on its superior surface. The patient gave no history of pain. The treatment procedure was explained to the patient and informed consent was obtained. The patient was subjected to complete haemogram which revealed all parameters to be within normal range. The swelling was surgically excised under local anesthesia. The specimen was placed in 10% formalin and sent for histopathological examination. The patient was recalled and reviewed after a month (Figure 2). Histopathology revealed hyperparakera-totic stratified squamous epithelium associated with a fibrovascular connective tissue. The epithelium was hyperplastic and exhibited acanthosis. The reteridges were thin and elongated with inter and intra cellular edematous changes. The lesional connective tissue consisted of thin irregularly arranged collagen fibers with spindle shaped fibroblasts. Numerous blood capillaries of varying sizes lined by endothelial cells were present with chronic inflammatory cell infiltrate composed predominantly of lymphocytes (Figure 3,4).

Discussion

Pyogenic granuloma was first reported in literature by Hullihen in 1844, but the term "pyogenic granuloma" or "granuloma pyogenicum" was introduced by Hartzell in 1904.34 The term pyogenic granuloma is misleading because the lesion is not pus-producing, as "pyogenic" implies and it is not a true granuloma. In actuality, it is a capillary hemangioma of lobular subtype, quite prone to bleeding.5 It has been called an epulis because it is located more frequently on the gingiva. Some other terms used are reactive localized inflammatory hyperplasia, granuloma teleangiectaticum or pregnancy tumor" also called epulis gravidarum. In pregnant women, it occurs as a reactive non-neoplastic overgrowth mostly observed during the first trimester, till the seventh month of pregnancy. PG of the gingiva develops in up to 5% of pregnancies, hence the terms "pregnancy tumor" and "granuloma gravidarum" are often used.2

They usually occur as a response to chronic inflammation caused by various forms of low grade chronic irritations to the oral mucosa such as dental plaque and calculus, faulty dental restorations, sharp edges of grossly carious teeth, chronic biting habits, ill-fitting dental/oral appliances, food impaction and systemic factors such as hormonal changes.5 An essential feature of chronic inflammation is that the processes of inflammation and repair occur simultaneously with the resultant production of granulation tissue and, therefore, most of these lesions represent exuberant production of granulation tissue in chronic inflammatory reactions. The clinical features of these lesions, therefore, appear to reflect the various stages of development as in the early stages they appear red, raw with ulcerated surfaces and bleed on slight touch or spontaneously, while in the late stages, they appear as firm, mature and avascular fibrous growfh which may be sessile, pedunculated or leaf-like in shape.2

A thorough literature search and review reveals that the prevalence of PG on the buccal mucosa has not been widely reported. The most frequent site of PG in the oral cavity is the gingiva at 87.09% which is in accordance to the results obtained by Angelopoulos, Micheal et al., and Zain et al., followed by lip site with 9.67% and buccal mucosa with 3.22%.68 Wayli et al., have also reported similar results. With respect to location, 44.5% of the PGs were in the anterior lower facial gingiva, followed in descending order by anterior lower lingual region (29.63 %) and anterior upper facial region (25.9%).' The uniqueness of this case report is that it had developed on the buccal mucosa adjacent to an edentulous site. The size of this lesion was 3.0xl.5xlcm and a lesion of this size has not been reported on the buccal mucosa. This case has been followed up for the past 18 months and there has been no recurrence as of now. Differential diagnosis of PG includes peripheral giant cell granuloma, peripheral ossifying fibroma, metastatic cancer, hemangioma, pregnancy tumor, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi's sarcoma, bacillarV angiomatosis, angiosarcoma, and Non-Hodgkin's lymphoma.2 Histopat-hological findings gave us a conclusive diagnosis of pyogenic granuloma and did not favor the other conditions. Excisional surgery is the treatment of choice for pyogenic granuloma, but some new approaches for treatment such as cryosurgery, excision by Nd:YAG laser, flash lamp pulsed dye laser, inj ection of ethanol or corticosteroid and sodium tetradecyl sulfate sclerotherapy have been reported as alternative therapies.2

Conclusion

Pyogenic granuloma is an inflammatory non-neoplastic growth seen in the oral cavity. This term is misnomer because the lesion is unrelated to infection and in reality it arises in response to various stimuli such as low-grade local irritation, traumatic injury, sex hormones or certain kinds of drugs, so removal of causative irritants (plaque, calculus, foreign materials and source of trauma) is the major line of treatment. Therefore proper diagnosis, prevention, management and treatment of the lesion are very important.

References

References

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3. Hullihen SP Case of aneurism by anastomosis of the superior maxillae. Am J Dent Sci 1844;4:160-62.

4. Hartzell MB. Granuloma pyogenicum. J Cutan Dis Syph 1904;22:520-25.

5. Awange DO, Wakoli K, Onyango JF, Chindia ML, Dimba EO, Guthua SW: Reactive localised inflammatory hyperplasia of the oral mucosa. East African Medical J 2009; 86:79-82.

6. Angelopoulos AP. Pyogenic granuloma of the oral cavity: statistical analysis and its clinical feature. J Oral Surg 1971; 29:84.

7. Micheal, Stablein MJ, Silverglade LB. Comparative analysis of biopsy specimens from gingival and alveolar mucosa. JPeriodontol 1985;56:671-76.

8. Zain RB, Khoo SP, Yeo JF. Oral pyogenic granuloma (excluding pregnancy tumour)-A clinical analysis of 304 cases. Singapore Dent J 1995;20:08-10.