Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management

ORALand maxillofacial pathology diagnosis and management—from page 245

Pyogenic Granuloma (Pregnancy Tumor, Granuloma Gravidarum) Discussion

Pyogenic granuloma, is considered to be a reactive vasoproliferative tumorlike growth that is most often the result of local stimulating or irritating factors. The name itself is deceiving as the lesion is not pyogenic, as there is no association with any pyogenic organisms, nor does it consist of granulomatous inflammation. Pyogenic granulomas can affect the mucosa as well as the skin, and while it can affect both the attached and unattached tissues in the oral cavity, the most common intraoral location is the gingiva.1,2 The lesion has a tendency to affect females more often than males and is more commonly seen in children and young adults.1-4 Female predilection is thought to be related to the fluctuating effects of sex hormones, specifically estrogen and progesterone, which have been observed to play a role in angiogenesis as well as have an effect on vascular smooth muscle and vasodilation.5,6

Clinically, pyogenic granulomas most often present as a nodular or lobular exophytic lesion with a pedunculated or sessile base. The lesions can vary in size from a few millimeters to as large as several centimeter. The surface can appear smooth, but often shows evidence of ulceration or has a hemorrhagic appearance with variation in red-bluepurple coloration.1,3 While lesions can be painless, they may have a tendency to produce some local discomfort and many lesions do bleed easily upon manipulation.1,3 The typical duration of a lesion can vary, but in a large study previously published, the mean duration of the lesion was shown to be 4 months.3

Pyogenic granulomas have a longstanding history with pregnancy, given the increased susceptibility of these individuals, and the association with the rising levels of both estrogen and progesterone. The term “pregnancy tumor” or “granuloma gravidarum” has been used historically to describe epulides in pregnant females and is used synonymously for pyogenic granulomas in this clinical setting.7,8 These lesions have been observed developing more frequently within the second and third trimester, which correlates with increasing hormone levels.7,8 While the increased levels of hormones are a contributing factor, a stimulus is still thought to be necessary in many cases, such as preceding trauma or a local irritating factor, such as plaque. On occasion, some lesions have been shown to undergo resolution after childbirth as the hormonal levels drop.

Another common clinical presentation of a pyogenic granuloma, termed “epulis granulomatosa”, is observed in the setting of an extraction socket.1 Clinically, the lesion will present as a vascular ulcerated mass protruding

from the site of a recent extraction. Often, a nidus, such as a boney spicule is found to be the stimulating factor. The clinical presentation does warrant some concern as malignancies, both primary and metastatic can mimic this process.

Treatment of pyogenic granulomas typically consists of complete excision, while being cognizant of the initiating factors. Therefore, procedures such as scaling and root planing around gingival tissues is typically helpful in reducing the risk of recurrence. In cases of pregnancy, if an incisional biopsy is performed, there is value in waiting until after childbirth, knowing that some lesions may regress. The recurrence rates vary from 3%-23% and have been shown to be higher in those studies looking at pyogenic granulomas in the setting of pregnancy.1,3,4,8 Given the current American Dental Association recommendations, it is safe for pregnant women to receive some degree of routine preventive, diagnostic and restorative dental treatment, as long as proper safety measures and guidelines are followed. In cases of complicated pregnancies or if any questions should arise, contact with the patient’s obstetrician should be considered. Preventative care and oral hygiene should be made a priority amongst pregnant females, who may be more susceptible to developing these lesions.

When reviewing your differential diagnosis for an exophytic lesion of the gingiva, most cases are definitively diagnosed as one of four entities, pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma, or fibrous hyperplasia (fibroma, inflammatory fibrous hyperplasia)11. All four entities are reactive in nature, and are typically treated and managed the same. While all of the aforementioned lesions have clinically overlapping characteristics, it is prudent to be aware that metastases to the oral cavity also have a predilection for the gingiva, second only to the gnathic bones. While most individuals are aware of their primary disease, an oral metastasis may be the first sign of the underlying malignancy in 25% of cases.11 Metastatic lesions involving the gingival tissues are known to clinically mimic the common reactive lesions, such as a pyogenic granuloma. Therefore, proper clinical evaluation with treatment and submission of tissue for histopathologic evaluation is necessary to ensure that patients are adequately managed.

References

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Nascimento AO, Milhan NVM, Anbinder AL. Oral pyogenic granuloma: An 18-year retrospective clinicopathological and immunohistochemical study. J Cutan Pathol. 2021 Jan 23. doi: 10.1111/ cup.13970. Epub ahead of print. PMID: 33486806. 3. Gordon-Nunez MA, de Vasconcelos

Carvalho M, Benevenuto TG, Lopes MF,

Silva LM, Galvao HC. Oral pyogenic granuloma: a retrospective analysis of 293 cases in a Brazilian population. J Oral Maxillofac Surg. 2010;68(9):2185–8. 4. Saravana GH. Oral pyogenic granuloma: a review of 137 cases. Br J Oral Maxillofac Surg. 2009;47(4):318–9 5. Losordo DW, Isner JM. Estrogen and angiogenesis: A review. Arterioscler Thromb Vasc Biol. 2001 Jan;21(1):612. doi: 10.1161/01.atv.21.1.6. PMID: 11145928. 6. Barbagallo M, Dominguez LJ, Licata

G, Shan J, Bing L, Karpinski E, Pang

PK, Resnick LM. Vascular Effects of Progesterone: Role of Cellular Calcium

Regulation. Hypertension. 2001 Jan;37(1):142-147. doi: 10.1161/01. hyp.37.1.142. PMID: 11208769. 7. Cardoso JA, Spanemberg JC, Cherubini K,

Figueiredo MA, Salum FG. Oral granuloma gravidarum: a retrospective study of 41 cases in Southern Brazil. J Appl Oral Sci. 2013;21(3):215-218. doi:10.1590/1679775720130001 8. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral

Surg Oral Med Oral Pathol. 1991 Aug;72(2):196-9. doi: 10.1016/00304220(91)90163-7. PMID: 1923399. 9. American Dental Association. Current Policies: Adopted 1954-2016. Chicago:

American Dental Association; 2017. 10. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol. 1980 Nov;51(11):655-61. doi: 10.1902/ jop.1980.51.11.655. PMID: 6936553. 11. Hirshberg A, Shnaiderman-Shapiro A,

Kaplan I, Berger R. Metastatic tumours to the oral cavity - pathogenesis and analysis of 673 cases. Oral Oncol. 2008 Aug;44(8):743-52. doi: 10.1016/j. oraloncology.2007.09.012. Epub 2007 Dec 3. PMID: 18061527.