Myxoid Change in Oral Pyogenic Granuloma: A Rare Histologic Finding in a Common Oral Lesion

Headnote

Abstract

Pyogenic granuloma is a relatively common reactive lesion occurring in the oral cavity. This clinical entity is seen more com- monly on the gingiva. Histopathology of this lesion comprises of large and small blood vessels resembling a granulation tissue. Though pyogenic granulomas undergo fibrous maturation, myxoid change in these lesions is relatively uncommon. This article highlights the rare histopathologic feature of a common oral lesion.

Keywords: Pyogenic granuloma; histopathology; myxoid change.

Introduction

Oral cavity is commonly associated with various types of local reactive focal overgrowths occurring on the gingiva, like focal fibrous hyperplasia, pyogenic granuloma, perip- heral giant cell granuloma and peripheral ossifying fibro- ma (POF). Local irritants like plaque, calculus, overhangi- ng margin, chronic persistent trauma and even dental app- liances have been postulated to be the causative etiologies. Pyogenic granuloma is an inflammatory hyperplasia seen as a response to underlying irritating factor. Gingiva is the most common site affected followed by buccal mucosa, tongue and lips.12

Case report

A 23-year-old female reported with a chief complaint of pain and swelling in the inner aspect of the lower left back teeth region since 2 years. History revealed that the swel- ling which was initially small of peanut size occurred 2 ye- ars back when the patient was in the first trimester of her pr- egnancy. The swelling gradually increased in size with no history of remission. Clinical examination revealed an fir- m, tender exophytic mass of size 2cmx2.5cm, with smooth lobulated surface, reddish in color extending in the lingual vestibule region from the mesial aspect of the permanent mandibular first premolar upto the distal aspect of the sec- ond molar (Figure 1 ). A provisional diagnosis of pyogenic granuloma with a differential diagnosis of other reactive overgrowths such as peripheral giant cell granuloma and peripheral ossifying fibroma was considered. Intra oral pe- riapical radiograph was normal. An excisional biopsy was performed (Figure 2). Histopathologic examination revea- led circumscribed tissue partly covered by stratified squa- mous parakeratinised epithelium with elongated rete ridg- es. Superficial part of the connective tissue underlying the epithelium showed numerous blood capillaries along with inflammatory cells (Figure 3). The deeper aspect of the co- nnective tissue showed fibrous proliferation, inflammation and the central area exhibited myxomatous change(Figure 4). Discrete irregularly shaped eosinophilic areas were also present within the connective tissue. Alcian blue staining showed alcinophilia at pH l(Figure 5). The lesion healed uneventfully and the patient had no recurrence after a 6 months follow-up period.

Discussion

The pyogenic granuloma is a relatively common, tumor li- ke, exuberant tissue response to localized irritation or trau- ma.3 Literature review suggests that Hullihen was the first person to describe the first case in 1844, but the term was introduced by Hartzell in 1904.4 The name pyogenic granu- loma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologica- lly.5 The classical clinical presentation is a smooth or lobu- lated exophytic lesion manifesting as small, red erythema- tous papules on a pedunculated or sometimes sessile base, which is usually hemorrhagic and compressible and may develop as dumb-bell shaped mass. Their size varies in dia- meter from millimeters to centimeters. The common site on the gingiva is on the facial/buccal aspect which is in co- ntrast in the present case where it was observed lingually. The jaw preference being in the maxillary anterior area th- an any other area in the mouth with 15% recurrence rate."

One of the feature is its association with pregnancy and he- nce the terms 'pregnancy tumor' or granuloma gravidarum are often used. It generally appears in the 2nd and 3rd month of pregnancy. The endocrinal changes in the body during pregnancy cause changes in the function and structure of the blood and lymph microvasculature of the skin and mu- cosa. Estrogen enhances vascular endothelial growth fact- or (VEGF) production in macrophages that may be related to the development ofthis lesion during pregnancy.

Histologically, it is characterized by vascular proliferation of small and large channels engorged with red blood cells and lined by flat or plump endothelial cells that may be mi- totically active. 2 histological entities representing 2 disti- nct entities have been observed. The lobular capillary hae- mangioma type exhibiting capillaries in a lobular arrange- ment and the non lobular capillary haemangioma type sh- owing vascular proliferation in the form of granulation tis- sue. Among the 2 types non lobular type shows fibrous ma- turation. In the present case areas of fibrous maturation al- ong with areas showing myxoid change especially in the central aspect of the lesion were observed. Alcian blue stai- ning at a pH of 1 revealed the positive staining of the myx- omatous change. An increase in the mucoid ground subst- ance of connective tissue, so that it comes to resemble my- xoid tissue of the fetus and umbilical cord, is termed myxo- matous or myxoid change. Oral lesions of myxomatous na- ture are relatively rare. The lesions include nerve sheath myxoma, soft tissue myxoma, oral focal mucinosis and od- ontogenic myxomas. Trauma has been suggested as the eti- ology for the mucoid change in case of oral focal mucino- sis.7 The long standing duration and subjection of chronic trauma to the mucosa in the present case may also be sug gested as the cause for the degenerative changes resulting in the overproduction of hyaluronic acid by the fibroblasts giving the myxomatous appearance to the tissue. Inthepre- sent case there was no recurrence, and also the treatment was that of simple excision. The long duration of the lesion resulting in myxoid degeneration can be considered as one of the histopathologic variation which has not been report- ed previously.

References

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