Oral Pyogenic Granuloma; Complete Case Series

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Oral Pyogenic Granuloma; Complete Case Series Oral Pyogenic granuloma, a frequent complaint that is reported to the clinic. This disease is most often presented by the young teenagers, young adults and pregnant females. Patients often consider this disease as cancerous lesion. However it is a reactive inflammatory disease which has no severe effect on the patient except for esthetics and comfort. 

In this case study we have included detailed history of the case as well as clinical, laboratory and histopathological examinations that are needed for correct diagnosis and treatment.

CASE: A 24-year-old male presents to a general dental clinic with a gingival swelling (Oral Pyogenic Granuloma).

Chief Complaint: The patient complains of a lump on the gum at the front of his mouth on the left side for 4 months.

History of presenting Illness: The swelling has been present for 4 months and has grown slowly during this period. It was never painful but now looks unsightly. It sometimes bleeds after brushing or eating hard food but it is not painful. The patient gives no history of other mucosal or skin lesions.

oral-Pyogenic-Granuloma

Medical History: Patient has no relevant medical history. No history of drug consumption is present.

Dental History: Restoration of anterior teeth 5 years back.

Personal History: He has no habit of chewing tobacco or smoking or alcohol consumption. Mouth breathing habit is also absent.

Examination of Oral Pyogenic Granuloma:

  • Extra-oral examination:
    • Bilaterally symmetrical face
    • No detectable cervical lymphadenopathy.
    • Mouth opening is normal(48 mm)
  • Intraoral examination:
    • An irregular rounded nodule like lesion appears to arise from the gingival margin of lateral incisor with following features on observation.
    • Site: Appears to arise from the gingival margin of the lateral incisor root or the interdental papilla mesially
    • Size: Approximately 7 mm× 5 mm in size
    • Shape and contour: Irregular rounded nodule like lesion appears to be pedunculated..
    • Colour: Reddish in colour
    • Surface: Slightly Ulcerated 
  • Palpation:
    • Soft lesion attached by a thin base to the gingival margin. Bleeding on probing was seen readily but it is not tender.

Possible Diagnosis with Justification of Oral Pyogenic Granuloma:

More likely:

  • Pyogenic granuloma: As the lesion is asymptomatic,soft and vascular, bleeds readily, and has an ulcerated surface.
  • Fibrous epulis: It is a nodule of more fibrous hyperplastic tissue. It is not usually ulcerated, is firmer on palpation and does not bleed so readily. Some fibrous epulides develop from pyogenic granulomas by maturation of the fibrous tissue and some arise de novo.

Less likely:

  • Peripheral giant cell granuloma: It is another hyperplastic lesion which seems to develop in response to a local irritant. Clinically it may have a deep red maroon or blue colour, but is otherwise indistinguishable from pyogenic granuloma or fibrous epulis. However, it can be distinguished by histological examination.
  • Sinus papilla (parulis):Sinus papilla (parulis) is essentially a pyogenic granuloma developing at the opening of a sinus. The usual site is on the alveolar mucosa and the lesion is usually no more than 4 or 5 mm across. This is an unlikely cause.

Unlikely:

  • Papilloma
  • Benign hamartoma or neoplasm
  • Malignant neoplasm.

Among these, most possible diagnosis on the basis of history, signs and symptoms is Oral Pyogenic Granuloma or Fibrous Epulis. 

The definitive diagnosis will require a biopsy, and excision is indicated.

Investigation for Oral Pyogenic Granuloma:

  1. Periodontal examination:To assess pocketing around the lesion and detect subgingival calculus, a common cause.
  2. Tests of vitality of the adjacent incisor and canine:To determine whether the cause could be irritation from a periapical infection draining into the pocket.
  3. Biopsy:The microscopic appearances of the biopsy specimen are the surface is ulcerated and covered by a slough of fibrin containing nuclei of inflammatory cells. Below the surface is a pale-stained tissue in which the endothelial lining of numerous small blood vessels stands out. The vessels have a radiating pattern and point towards the surface reflecting a pattern of growth outwards from the center. Between the vessels there is a little fibrin and the tissue is oedematous or myxoid or both. More deeply there is a cluster of inflammatory cells and collagen bundles are more prominent between the vessels.

FINAL DIAGNOSIS: Oral Pyogenic Granuloma

TREATMENT:

  • Excision biopsy
  • Removal of causative factors, i.e. plaque and calculus
  • Provide treatment for the generalized periodontitis
  • Extract or restore the lateral incisor root

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