|Year : 2015 | Volume
| Issue : 1 | Page : 75-78
Pyoenic granuloma with alveolar bone loss
Amitandra Kumar Tripathi, Vivek Kumar, Charanjeet Singh Saimbi, Jolly Sinha
Department of Periodontology, Career Postgraduate Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India
|Date of Web Publication||18-Mar-2015|
Dr. Charanjeet Singh Saimbi
Department of Periodontology, Career Postgraduate Institute of Dental Sciences and Hospital, H/No-C-17, Sector K, Aliganj, Lucknow - 226 024, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Pyogenic granuloma is an inflammatory hyperplasia of connective tissue which arises in response to various chronic low grade irritations. It is a tumor like growth of oral cavity and considers being non-neoplastic in nature. It predominantly occurs in the second decade of life in young females and rarely causes significantly alveolar bone loss. This paper present case of a pyogenic granuloma, the size of lesion was unusual large with severe alveolar bone loss in affected site and managed by surgical intervention.
Keywords: Gingival hyperplasia, hyperactive lesion, pyogenic granuloma
|How to cite this article:|
Tripathi AK, Kumar V, Saimbi CS, Sinha J. Pyoenic granuloma with alveolar bone loss. J Int Clin Dent Res Organ 2015;7:75-8
| Introduction|| |
Pyogenic granuloma is a smooth or lobulated exophytic lesions appears as small, red erythematous papules with pedunculated or some time sessile base. Hartzell in 1904 introduced term pyogenic granuloma or granuloma pyogenicum. 
Oral pyogenic granuloma is the most common gingival tumor. Gingiva is the most common site followed by lips, tongue and buccal mucosa.  They are more commonly located on facial surface of maxillary gingiva in anterior region.  They arise in response to various stimuli such as low grade local irritation, traumatic injury, hormonal factors or certain kinds of drugs. 
Higher frequency of pyogenic granuloma is observed in the second decade of life, especially among women, probably because of the vascular effects of female hormones. Females are more frequently affected, and the male to female ratio is 1:99.  The size of lesion varies in diameter from few millimeters to several centimeters, but rarely exceeds 2.5 cm. in size.
There are two histological types of pyogenic granuloma. The first type is characterized by proliferating blood vessels that are organized in lobular aggregates and called lobular capillary hemangioma (LCH type). The second type consists of highly vascular proliferation that resembles granulation tissue and called non lobular capillary hemangioma (non-LCH).
This paper present a case of pyogenic granuloma, the size of lesion was unusual large with severe alveolar bone loss in affected site and managed by surgical intervention.
| Case Report|| |
A 55-year-old male patient reported to the department of Periodontology with chief complaint of pain and swelling on gums at upper left side of jaw which caused esthetic deformities and masticatory problems on chewing foods.
On clinical examination a localized gingival swelling of 6 cm × 5.5 cm present in relation to facial aspect of upper anterior to posterior region of jaw [Figure 1] with moderate supra and sub gingival calculus. Lesion was solitary reddish pink, exophytic and pedunculated with broad base. Margin of lesion was irregular with ulcerated surface and present since last 2 year.
In this case medical history was not contributory and intraoral periapical radiograph showed severe alveolar bone loss in affected area [Figure 2]. On the basis of above features a provisional diagnosis of pyogenic granuloma was made.
Patient was informed about the procedure and consent was taken and oral prophylaxis was done. Thereafter, it was decided to further treat the lesion with a surgical approach. After local anaesthesia, the enlarged localized lesion was excised up to the base of the lesion by use of surgical blade and it was ensured that lesion was completely excised by trimming up the remnants of the soft tissue adjacent to the tooth to prevent recurrence of the lesion. The excised tissue [Figure 3] was sent for histopathological examination and histopathological feature showed hyperplastic, parakeratinized stratified squamous epithelium. The connective tissue was loose fibrillar and comprised of numerous proliferative capillaries with dense mixed inflammatory infiltrate [Figure 4]. The histopathological examination confirmed diagnosis of the lesion as pyogenic granuloma of lobular capillary hemangioma type (LCH type) because histopathological examination showed abundant capillary proliferation. In present case post operative 6 month recurrence was not found [Figure 5].
|Figure 4: Histopathological feature showed parakeratinized stratified squamous epithelium and connective tissue was loose fibrillar and comprised of numerous proliferative capillaries with dense mixed inflammatory infiltrate|
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| Discussion|| |
Pyogenic granuloma may occur at all age groups but mostly seen in the second decade of life in young adult female, due to the vascular effects of female hormones.  But according to Epivatianos et al. the average patient age was 52 year with a peak incidence of occurrence in the sixth decade of life.  In this case report, patient was male and his age is 50 years.
Pyogenic granuloma as a benign neoplasm, it is usually considered to be reactive tumor-like lesions which arises in response to various stimuli such as a chronic low grade local irritation, traumatic injury, hormonal factors or certain kinds of drugs. In present case report, poor oral hygiene was found in the case due to which abundant plaque and calculus accumulated which produced chronic irritation and contributed to development of pyogenic granuloma.
Clinically pyogenic granuloma seen as exophytic lesion with a pedunculated or sessile base and their size varies from few millimeters to several centimeters in size but rarely seen more than 2.5 cm  and rarely, may cause significant bone loss.  In present case the size of lesion attained unusual larger size which ranges from 5-6 cm and caused significant bone loss in affected area.
Possible mechanism in bone loss leading to production of granulocyte-macrophage-colony stimulating factor in keratinocytes (GM-CSF) and basic fibroblast growth factor (bFGF) and transforming growth factor beta1 (TGF-β1) in fibroblast, which form granulation tissue and leads to bone loss in pyogenic Granuloma.
Differential diagnosis of Pyogenic granuloma includes peripheral giant cell granuloma, pregnancy tumor, peripheral ossifying granuloma, metastasis of malignant tumors, hemangioma, inflammatory gingival hyperplasia, Kaposi sarcoma. ,
Peripheral giant cell granuloma is an exophytic lesion that is seen exclusively in gingiva, is more likely to cause bone resorption, with appearance of multinucleated giant cells. Diagnosis of pregnancy tumor is valid clinically in describing a pyogenic granuloma occurring in pregnancy, with no clinical or histological differences. Kaposi's sarcoma of AIDS shows proliferation of dysplastic spindle cells, vascular clefts, extravasated erythrocytes and intracellular hyaline globules, none of which are features of Pyogenic granuloma. It can be distinguished from Angiosarcoma by its lobular growth pattern, well defined vessels, and cytologically bland endothelial cells. 
On the basis of histology pyogenic granuloma are two types, first type is characterized by proliferative blood vessels that are organized in lobular aggregate although superficially the lesion frequently undergoes no specific changes including edema, capillary dilation.
From etiopathogensis of pyogenic granuloma various concept are related. Regezi et al. suggest that pyogenic granuloma represents an exuberant connective tissue proliferation to a known stimulus or injury like calculus or foreign material within the gingival crevice.  Several "etiologic factors" such as trauma, injury to a primary tooth, chronic irritation, hormones, drugs, gingival inflammation, preexisting vascular lesions, chronic irritation due to exfoliation of primary teeth, eruption of permanent teeth, defective fillings in the region of tumor, food impaction, total periodontitis, toothbrush trauma, etc. have been suggested as etiological factors where patients presented with these findings.  In Whitaker et al., study, it was suggested that the quantity of estrogen or progesterone receptors in oral pyogenic granuloma is not the determining factor in its pathogenesis of. Rather, such a role could be attributed to the levels of circulating hormones. The levels of estrogen and progesterone are markedly elevated in pregnancy and could therefore exert a greater effect on the endothelium of oral pyogenic granuloma. 
Treatment of pyogenic granuloma involves a complete surgical excision of the lesion, because after surgical excision recurrence has been reported in nearly 16% of cases. Excisional biopsy is indicated for treatment, except when procedure would produce marked deformity, in such cases Incisional biopsy is mandatory. Recurrence is believed to result from incomplete excision, failure to remove etiologic factors, or re-injury of the area.  In present case post operative 6 month recurrence were not found in both the cases.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]