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Though pyoginic granuloma is a common occurrence in the oral cavity, it has got particular significance because of its unexpected clinical course.Here a case of large pyogenic granoloma is presented in a 30-year-old female reported at the dental OPD of VSS Medical College and Hospital, Burla with the complaint of a growth in the mouth from the right upper last tooth since one and half years associated with difficulty in swallowing and breathing. The lesion was excised under local anaesthesia along with extraction of upper right second molar. The patient recovered without any complication and there was no recurrence even after one year. [J Indian Med Assoc 2007; 105: 90 & 98]
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Key words : Pyogenic granuloma.
The pyogenic granuloma is also called granuloma pyogenicum1, telangiectactic granuloma, epulis granulomatosa. It
does not produce any pus ie, pyopus. It is a misnomer. Originally it was believed to be a botryomycotic infection, an infection in horses thought to be transmitted to man. Subsequently it was suggested that the lesion was due to infection by either staphylococci or streptococci, because these micro-organisms produce colonies with fungus like characteristics. But now it is agreed that it arises as a result of some minor trauma to the tissues, which provides a pathway for the invasion of non-specific types of micro-organisms. The tissues respond to these organisms of low virulence by the overzealous proliferation of a vascular type of connective tissue.As it is associated with trauma sometimes called traumatic fibroma.
Case Report
A 30-year-old female came to the dental OPD of VSS Medical College and Hospital, Burla with complaint of a growth in the mouth from the right upper last tooth since one and half years. The growth gradually increased in size to its present form. She was having difficulty in swallowing for the last two months. She had to sleep in lateral position because of difficulty in breathing in supine position and was having pain in the right upper last tooth.
Examination— On intra-oral examination a large (5cm x 4cm x 3cm) pedunculated growth originating from the distal side of the upper right second molar extending towards the tonsil was found (Fig 1). It was non-tender, fibrous in consistency and having ulcerated surface.
Investigations — Her haemoglobin, total count, differential count, bleeding time, clotting time and peripheral smear were within normal limits. X-ray (PNS view) showed right sinus decreased in size. Intra-oral peri-apical x-ray showed bone loss distal to upper right second molar. Fine needle aspiration cytology smear showed few small groups of plumpy spindle cells with heavy inflammatory cells of both acute and chronic types in a haemorrhagic background, compatible with pyogenic granuloma.
Treatment — Under local anaesthesia the growth was excised along with extraction of upper right second molar. The growth was sent for histopathological examination.
Histopathology — Most important features are the occurrence of vast numbers of endothelium lined vascular haemorrhagic spaces and extreme proliferation of fibroblasts and budding endothelial cells. There is moderately infiltration of polymorphonuclear leucocytes, lymphocytes and plasma cells. The connective tissue stroma is typically delicate, although frequently fascicule of collagen fibres are noted coursing through the tissue mass.
Follow-up — Patient was followed up regularly and even after one year there was no recurrence. Prognosis is good.
Discussion
The tumour has no apparent predilection for any age but 60% of the lesions occur between 11 and 40 years. There is no significant difference in sex but Angelopoulos2 stated 70% cases of females are involved.
The most frequently site found is gingiva. It may also occur on the lips, tongue and buccal mucosa. Maxilla is affected more than mandible. The tumour may develop rapidly, reach full size and then remain static.Ulcerated surface is a common feature. It shows a tendency for haemorrhage either spontaneously or by slight trauma. Its colour is deep red or reddish purple, depending upon its vascularity. It is painless,soft in consistency and associated with halitosis.
An intravenous pyogenic granuloma occurring on the neck and upper extremities has been reported by Cooper et al3, but not reported in oral cavity. These lesions occurs due to intravascular papillary endothelial hyperplasia.
Pyogenic granuloma is best treated by surgical excision. As the lesion is not encapsulated and there is difficulty in determining its limits the surgeon may have difficulty in excising it adequately. That is why the lesion recurs sometimes.
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Reference
1 Kerr DA — Granuloma pyogenicum. J Oral Maxillofac Surg 1951; 4:158-76.
2 Angelopoulous AP — Pyogenic granuloma of the oral cavity: statistical analysis of its clinical features. J Oral Maxillofac Surg 1971; 29: 840-7.
3 Cooper PH, McAllister HA, Helwig EB — Intravenous pyogenic granuloma: a study of 18 cases. Am J Surg Pathol 1979; 3: 221-8.
Department of Dental Surgery,VSS Medical College and Hospital, Burla 768017
*MDS, Assistant Professor
**MDS, Lecturer
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