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eMedicine - Oral Pyogenic Granuloma : Article by

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Peripheral Giant Cell Granuloma




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AUTHOR AND EDITOR INFORMATION

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Author: John Svirsky, DDS, Director of Dental Diagnostic Services, Professor, Department of Oral Pathology, Virginia Commonwealth University School of Dentistry

John Svirsky is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association

Editors: Kelly M Cordoro, MD, Fellow and Clinical Instructor, Department of Pediatric Dermatology, University of California at San Francisco; Assistant Professor (On Educational Leave), Assistant Program Director for Resident Medical Education, Department of Dermatology, University of Virginia School of Medicine; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

Author and Editor Disclosure

Synonyms and related keywords: pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma, pregnancy tumor

INTRODUCTION

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Background

The pyogenic granuloma is a relatively common, tumorlike, exuberant tissue response to localized irritation or trauma. The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically. It is a reactive inflammatory process filled with proliferating vascular channels, immature fibroblastic connective tissue, and scattered inflammatory cells. The surface usually is ulcerated, and the lesion exhibits a lobular architecture.

Two lesions, peripheral ossifying fibroma and peripheral giant cell granuloma, are clinically identical to the pyogenic granuloma when they occur on the gingiva. If 100 biopsies of pyogenic granuloma–appearing lesions of the gingiva are submitted for histologic examination, approximately 85% will be pyogenic granulomas, 10% will be peripheral ossifying fibromas, and 5% will be peripheral giant cell granulomas. The pyogenic granuloma can occur anywhere in the oral cavity, whereas the peripheral ossifying fibroma and peripheral giant cell granuloma only occur on the gingiva or alveolar mucosa. The clinical appearance, treatment, and prognosis are the same for all 3 entities.

Pathophysiology

The pyogenic granuloma most frequently develops on the buccal gingiva in the interproximal tissue between teeth. Three quarters of all oral pyogenic granulomas occur on the gingiva, with the lips, tongue (especially the dorsal surface), and buccal mucosa also affected. A history of trauma is common in extragingival sites, whereas most lesions of the gingiva are a response to irritation. Individuals with poor oral hygiene and chronic oral irritants (eg, overhanging restorations, calculus) most frequently are affected.

Frequency

International

Lesions have a similar frequency throughout the world.

Mortality/Morbidity

Mastication on the lesion can cause bleeding and pain and can require surgical intervention before parturition in lesions associated with pregnancy.1

Race

No racial predilection is reported.

Sex

Females are far more susceptible than males because of the hormonal changes that occur in women during puberty, pregnancy, and menopause. The pyogenic granuloma has been called a "pregnancy tumor" and does occur in 1% of pregnant women. (The Medscape Pregnancy Resource Center may be of interest.)

  • When possible, wait until after delivery to remove the lesion in pregnant women because of a greater tendency for recurrence during pregnancy.
  • In a number of cases, mastication on the lesion causes bleeding and pain and requires surgical intervention before parturition.
  • Some pyogenic granulomas regress after childbirth without surgical intervention.

Age

Pyogenic granulomas occur at any age, but they most frequently affect young adults.


CLINICAL

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History

  • Early lesions bleed easily due to extreme vascularity.
  • Pyogenic granulomas can have a rapid growth pattern that can cause alarm.
  • If left alone, a number of pyogenic granulomas undergo fibrous maturation and resemble and/or become fibromas.

Physical

  • The typical lesion involves the interproximal gingiva and increases in size to cover a portion of the adjacent teeth.
  • The maxillary gingiva (especially in the anterior region) is involved more frequently than the mandibular gingiva; the facial gingiva is involved more than the lingual gingiva.
  • A number of lesions affect both the facial and lingual gingivae.
  • Pyogenic granulomas usually present as smooth or lobulated red-to-purple masses that may be either pedunculated or sessile.
  • As lesions mature, the vascularity decreases and the clinical appearance is more collagenous and pink.
  • Pyogenic granulomas vary in size from a few millimeters to several centimeters and are painless.
  • These tumors are soft to palpation.

Causes

  • A history of trauma is common in extragingival sites, whereas most lesions of the gingiva are a response to irritation.2
  • Individuals with poor oral hygiene and chronic oral irritants (eg, overhanging restorations, calculus) most frequently are affected.


DIFFERENTIALS

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Peripheral Giant Cell Granuloma

Other Problems to be Considered

Peripheral ossifying fibroma


WORKUP

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Imaging Studies

Obtain a periapical radiograph of the associated teeth in lesions that involve the teeth. Radiography findings are negative if the lesion is a pyogenic granuloma. If calcifications are present, then the lesion probably is a peripheral ossifying fibroma, which is clinically identical to the pyogenic granuloma and requires the same treatment of removal with scaling of the adjacent teeth.

Histologic Findings

Histologic examination reveals sectioned soft tissue consisting of a lesion composed of ulcerated mucosa covering a core of cellular fibrous connective tissue admixed with proliferating vascular channels and a mixed inflammatory infiltrate. This lesion is a reactive/inflammatory process.


TREATMENT

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Surgical Care

The treatment of choice is conservative surgical excision.

  • For gingival lesions, excising the lesion down to the periosteum and scaling adjacent teeth to remove any calculus and plaque that may be a source of continuing irritation is recommended.
  • Pyogenic granuloma occasionally recurs, and a reexcision is necessary.
  • The recurrence rate is higher for pyogenic granulomas removed during pregnancy.


FOLLOW-UP

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Further Outpatient Care

  • The only outpatient care is observation of the surgical healing 1 week after removal.

Deterrence/Prevention

  • Prevention consists of routine dental cleanings and home care, especially during pregnancy.

Complications

  • No complications are anticipated with removal of this lesion other than the chance of a cosmetic gingival defect.

Prognosis

  • The prognosis is excellent, and the lesion usually does not recur unless inadequately removed.
  • Lesions removed during pregnancy may have a higher recurrence rate.

Patient Education

  • Focus patient education on better oral hygiene, and consider recommending pulsating mechanical toothbrushes with timers. These toothbrushes encourage better hygiene.


MISCELLANEOUS

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Medical/Legal Pitfalls

  • No medical/legal concerns exist with this lesion because it always is benign and does not undergo malignant change; however, the lesion must be biopsied to prove the diagnosis and to exclude more serious conditions. A related eMedicine article is Cancers of the Oral Mucosa.


MULTIMEDIA

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Media file 1:  Typical appearance of a pyogenic granuloma involving the buccal gingiva of teeth numbers 20 and 21. Note the extreme vascularity.
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Media type:  Photo

Media file 2:  Pyogenic granuloma of the anterior maxilla showing a small amount of involvement on the buccal gingiva of teeth numbers 8 and 9 with most of the lesion on the lingua. Note that indentations from the lower teeth are on the surface of the tumor.
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Media type:  Photo

Media file 3:  Pyogenic granuloma of the dorsal tongue in a 52-year-old black woman. An area of geographic tongue is adjacent to the pyogenic granuloma.
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Media type:  Photo

Media file 4:  Pyogenic granuloma associated with teeth numbers 20 and 21 in a 27-year-old white woman who is 8 months pregnant. The lesion was excised without curetting the area to remove irritants.
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Media type:  Photo

Media file 5:  Same patient as in Image 4 with a lesion that recurred almost immediately. This picture was taken 1 month after the birth of her child.
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Media type:  Photo

Media file 6:  Rapidly growing pyogenic granuloma in the area of teeth numbers 20 and 21 in a 13-year-old black girl. Notice the calculus and plaque on tooth number 22. The lesion was soft to palpation.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 7:  Pyogenic granuloma on the facial gingiva of teeth numbers 7 and 8. This is a long-standing lesion that is becoming fibrosed and less vascular. Notice the pink coloration at the base of the lesion.
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Media type:  Photo


REFERENCES

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  1. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. Jul 1996;41(7):467-70. [Medline].
  2. Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surg. Oct 1986;24(5):376-82. [Medline].
  3. Bhaskar SN, Jacoway JR. Pyogenic granuloma--clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg. Sep 1966;24(5):391-8. [Medline].
  4. Eisen D, Lynch DP. The Mouth: Diagnosis and Treatment. St. Louis, Mo: Mosby; 1998:58-60.
  5. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & Maxillofacial Pathology. Philadelphia, Pa: WB Saunders; 2002:447-9.
  6. Neville BW, Damm DD, White DK. Color Atlas of Clinical Oral Pathology. Baltimore, Md: Lippincott Williams & Wilkins; 1999:284-5.
  7. Sapp JP, Eversole LR, Wysocki GP. Contemporary Oral and Maxillofacial Pathology. 2nd ed. St. Louis, Mo: Mosby; 2003.

Oral Pyogenic Granuloma excerpt

Article Last Updated: Oct 28, 2008