Oral Pyogenic Granuloma: A Review

Resident: Swan

Article Title: Oral Pyogenic Granuloma: A review

Author: Jafarzadeh, et al.

Journal: Journal of Oral Science

Volume (Number): Vol 48, No. 4 pgs 167-175, 2006

Major Topic: A complete review of published information about pyogenic granulomas, including the most recent approaches for treatment

Key Points/Summary:

In General: Pyogenic granuloma is a type of inflammatory hyperplasia (made up of inflamed fibrous and granulation tissues histologically). It’s title is a misnomer because it doesn’t have pus and isn’t a granuloma. It is a common tumor-like growth that is non-neoplasitc, and is usually found on keratinized tissue in the mouth. It is especially common in pregnant women.

Etiology: PG is generally considered to be a reactive tumor-like lesion that arises in response to different stimuli like chronic low-grade irritation, trauma (1/3 of all PGs), hormonal factors, or certain drugs (Cyclosporine). Poor oral hygiene can be a precipitating factor for PGs. They have been reported as being a result of injury to a primary tooth, iatrogenic therapies (GTR), and after bone marrow transplantation. It may occur in all ages but is most common in females in their second decade (probably hormonally related). Gingival lesions account for 75% of all PGs, followed by the lips, tongue, and buccal musoca. Max>Mand, Ant>Post. Mostly found on marginal gingival

Clinical Features: PG is a smooth, lobulated, exophytic lesion. It manifests as small, red, usually pedunculated but sometimes sessile, with a base that is hemorrhagic and compressible. Size is anywhere from a few mm to several cm. Clinical development is slow, asymptomatic, and painless, although it can grow rapidly. Its surface is usually ulcerated and friable, and it may be covered by a yellow, fibrinous membrane. It’s color ranges from pink to red to purple. Younger lesions are more vascular and appear more reddish-purple; they will bleed a lot if traumatized. Older lesions are more collagenized and pink.

Pregnancy Correlation: Gingival PGs develop in about 5% of pregnancies (pregnancy tumor). They come about as a result of hormonal imbalances that promote pregnancy gingivitis. If the cases go uncontrolled, PGs may develop. The reasons behind the regression of PGs after childbirth are unclear.

Histology: PGs show a highly vascular make up that resembles granulation tissue. There are two types of PG—Lobular Capillary Hemangioma type (LCH) and non-LCH type.

Differential Diagnosis: Biopsy confirms PG, but the differential would include peripheral giant cell granuloma, peripheral ossifying fibroma, metastatic cancer, hemangioma, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi’s sarcoma, angiosarcoma, and NH Lymphoma. PCCG is more bluish-purple compared to the typical bright red PG. Ossifying fibromas are generally much lighter in color (not much vasculature). Metastatic tumors to the mouth are rare, but the attached gingiva is the most common affected soft tissue (30%). These are usually diagnosed much later in life. PGs may be clinically indistinguishable from hemangiomas, so biopsy is the only definitive way to differentiate. However, hemangiomas typically occur on the tongue, are multinodular, and bluish red.

Treatment: Excisional biopsy is the treatment of choice, unless it would produce a large deformity. Excision should extend down to the periosteum. Recently, successful excision of PGs using a Nd:YAG laser has been described.The laser has superior coagulation ability and results in less chance of bleeding. Other successful techniques that have been described include cryogenesis and injection of ethanol or sodium tetradecyl sulfate into the lesion. After surgery, recurrence is about 16%.

Assessment of Article: Great comprehensive review of the literature on PGs. I especially liked how it went down the list of differential diagnoses and described how PGs are different from each of the listed lesions.