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| Year : 2006 | Volume
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| Issue : 4 | Page : 199-202 |
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| Extragingival pyogenic granuloma |
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Karthikeya Patil, VG Mahima, K Lahari
Dept. of Oral Medicine & Radiology, JSS Dental College and Hospital, Mysore, Karnataka- 570 015, India
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 Abstract | | |
Pyogenic granuloma is a well-known localized granulation tissue overgrowth in reaction to mild irritation. Although it is known to show a striking predilection for the gingiva, it can be found extragingivally with varying clinical features that sometimes may mimic more serious lesions such as malignancies. The clinical diagnosis of such an uncommon extragingival pyogenic granulomra can be quite challenging. The purpose of this article is to report an unusual case of extragingival pyogenic granuloma occurring on the lower lip, which presented as a cutaneous horn. Keywords: pyogenic granuloma, extragingival, cutaneous horn, granuloma pyogenicum.
How to cite this article:
Patil K, Mahima V G, Lahari K. Extragingival pyogenic granuloma. Indian J Dent Res 2006;17:199-202 |
| Introduction | |  |
Pyogenic granuloma or granuloma pyogenicum is a well-known oral lesion. It is a localized granulation tissue overgrowth in reaction to mild irritation [1]. The name pyogenic granuloma' is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically [2]. Pyogenic granuloma of the oral cavity is known to involve the gingiva commonly. Extragingivally it can occur on the lips, tongue, buccal mucosa, palate, and the like. A history of trauma is common in such sites [1],[3]. This article describes a case of extragingival pyogenic granuloma occurring on the lower lip with an unusual presentation, posing a diagnostic challenge.
| Case report | | |
A 50-year-old female patient presented with a swelling on the lower lip of one-month duration. The swelling was of negligible size when the patient first noticed it, but had grown rapidly over the past one month to attain the present size. Apart from mild tenderness, there were no other symptoms. The patient's medical history was unremarkable.
Examination revealed an exophytic, sessile, conical shaped, brownish-black swelling centered over the lower lip, measuring roughly 1 x 0.5cm 2 in size. The surface of the swelling was thick and keratotic with crustation, giving it the appearance of a hom. The swelling was non-tender, with a firm base that bled minimally. The surface felt rough and hard on palpation. Intraoral hard tissue examination showed both the upper central incisors having sharp margins due to abrasion of their facial surfaces [Figure - 1],[Figure - 2].
Excisional biopsy of the swelling with a wide margin was performed. The histopathological section showed stratified squamous epithelium with hyperkeratosis and acanthosis. The connective tissue stroma showed marked inflammation consisting of neutrophils, plasma cells, and lymphocytes. The lesion was comprised of proliferating capillaries that were arranged in a lobular fashion. Distinct capillary lumina lined by flattened endothelium were seen beneath the surface epithelium. Mitotic activity was evident. There was no evidence of malignancy. These findings were consistent with a histopathological diagnosis of pyogenic granuloma [Figure - 3],[Figure - 4]
| Discussion | | |
Poncet and Dor in 1897 first described pyogenic granulomal granuloma pyogenicum. Over the years various authors have suggested other names such as granuloma gravidarum/pregnancy tumour, Crocker and Hartzell's disease, vascular epulis, benign vascular tumour, hemangiomatosis granuloma, epulis teleangiectaticum granulomatosa, and lobular capillary hemangioma [4],[5].
The etiology of the lesion is not known, though it was originally believed to be a botryomycotic infection. It is theorized that pyogenic granuloma possibly originates as a response of tissues to minor trauma and/or chronic irritation, thus opening a pathway for invasion of non-specific microorganisms, although microorganisms are seldom demonstrated within the lesion [2].
Pyogenic granuloma of the oral cavity occurs at any age and in all populations with no racial predilection. Population studies have determined a prevalence rate of 1 lesion per 25,000 adults [1],[3],[6],[8]. Lawoyin et al (1997) reviewed 38 cases from Ibadan, Nigeria and reported an average range of 5 to 75 years (mean age 33 years) (7). Most studies demonstrate a definite female predilection with a female to male ratio of 2:1. This is attributed to the vascular effect of female hormones that occur in women during puberty, pregnancy, and menopause. The lesions tend to occur more often during the second and third trimester of pregnancy and such lesions are referred to as 'pregnancy tumours' [8],[9]. Daley TD et al (1991) in their study indicated that the clinical diagnosis of 'pregnancy tumour' can be given when describing a pyogenic granuloma occurring in pregnancy, because it describes a distinct lesion not on the basis of histologic features but on etiology, biologic behaviour, and treatment protocol [10].
Pyogenic granulomas may occur anywhere in the body surface and excepting the oral cavity, they are common around the fingers and toes [11]. In the oral cavity pyogenic granulomas show a striking predilection for the gingiva, with interdental papillae being the most common site in 70% of the cases. They are more common in the maxillary anterior area than any other area in the mouth. Gingival irritation and inflammation that result from poor oral hygiene, dental plaque, and calculus or over-hanging restorations may be precipitating factors in many cases [1],[8].
The typical clinical presentation of pyogenic granuloma is a small, deep red to reddish-purple lesion occurring on the gingiva, which is either sessile or pedunculated. The surface may be smooth, lobulated or occasionally, warty which is commonly ulcerated and shows a tendency for hemorrhage either spontaneously or upon slight trauma. The lesion is painless and soft in consistency; although older lesions tend to become more collagenized and firm [8]. The size of the lesion usually ranges between 0.5cm and 2cm, and they may grow at an alarming rate reaching that size within just 4 to 7 days [9].
Pyogenic granulomas of head and neck are uncommonly seen extragingivally in areas of frequent trauma such as the lower lip, tongue, buccal mucosa, and palate [1],[9]. Such lesions may resemble their gingival counterparts or can show atypical presentations. Some lesions have a brown cast if hemorrhage has occurred into the lesion [2]. Epulis granulomatosa/epulis hemangiomatosa is a term used to describe hyperplastic growths of granulation tissue that sometimes arises in healing extraction sockets. These lesions are pyogenic granulomas, which arise as a reaction to bony sequestra in the socket [8]. Lee et al in 1994 reported three cases ofintraoral pyogenic granuloma occurring as an oral complication after allogenic bone marrow transplant [12].
Souza et al in 2003 reported a case of pyogenic granuloma occurring on the vermilion border of the lower lip, which had an unusual presentation of a cutaneous horn, quite similar to the case in discussion [13]. Bjork et al in 1996 reported a similar case of a pyogenic granuloma occurring on the lip, and described it as showing necrosis and collarette scale [5]. In the present case, the constant trauma inflicted by the sharp incisal edges of the attrited upper central incisors upon the lower lip could have been the etiology behind the growth on the lip.
Such atypical presentations, like the case in discussion can be rather confusing, and can lead to erroneous diagnoses of other more serious lesions, which can also be thought of as clinical differential diagnosis. These include sqaumous cell carcinoma, basal cell carcinoma, keratoacanthoma, Kaposi's sarcoma, AIDS related complex, amelanotic melanoma, acrolentiginous melanoma, nodular melanoma, and metastatic carcinomas. Capillary hemangioma, bacillary angiomatosis, Spitz nevus, fibromaofmucosa,pigmented spindle cell tumour of Reed, nevocytic nevus, seborrheic keratosis, angiolymphoid hyperplasia with eosinophilia, furuncle, ecthyma contagiosum, and verruca vulgaris are benign lesions that can be considered in the differential diagnosis [1],[14],[15]. Thus the clinical diagnosis of an extragingival pyogenic granuloma can be a challenging task. Peripheral giant cell granuloma and peripheral ossifying fibroma are two intraoral lesions that may look clinically similar to gingival pyogenic granulomas [1],[14].
Although pyogenic granuloma can be diagnosed clinically with considerable accuracy, radiographic, and histopathological investigations aid in confirming the diagnosis and planning the treatment. Radiographs are advised to rule out bony destruction suggestive of malignancy or to identify a foreign body or sharp restorative margin that would need to be removed with the lesion [16]. Long-standing pyogenic granulomas, like other irritation hyperplasias can show dystrophic calcifications. The radiographic appearances of such calcifications varies from barely perceptible, fine grains of radiopacities to larger, irregular radiopaque particles that rarely exceed 0.5cm in diameter [17].
All clinically suspected pyogenic granulomas must be biopsied to rule out more serious conditions as mentioned previously. The histopathological picture of the extragingival pyogenic granuloma is quite similar to the ones occurring on the gingiva or other parts of the body. The pathology is distinct consisting of a matrix of edematous connective tissue in which numerous thin walled vascular channels can be seen. These vessels sometimes are organized in lobular aggregates, and some pathologists require this lobular arrangement for the diagnosis (lobular capillary hemangioma) [8]. There is also moderately dense mixed cellular infiltrate [8]. The overlying stratified squamous epithelium may be atrophic or hyperplastic, and is usually degenerated or ulcerated in large areas; and the ulcer edge may have a primitive dysplastic appearance. Mitotic activity may be noted in the stromal cells. This histological picture can however be mistaken for other less frequently occurring lesions like capillary hemangioma, epitheloid hemangioma, or epithelial cell histiocytoma [8],[9],[14],[18],[19].
Treatment of pyogenic granulomas consists of conservative surgical excision, which is usually curative. Although these are reactive hyperplasias, they have a relatively high rate of recurrence after simple excision, especially in pregnant patients. A recurrence rate of 15% has been noted [6]. After surgical excision of gingival lesions, curettage of underlying tissue is recommended. Recurrences after surgery of extragingival pyogenic granulomas is however uncommon [9]. The present case was followed up for one year after excision. The wound healing was complete and no recurrence was noted.
| Conclusion | | |
Oral pyogenic granulomas are well documented in literature. However their occurrence on extragingival sites in the head and neck region is rare and often has atypical presentation. Eyes cannot see what the mind does not know! Such is a situation when a clinician, not cognizant with the possibility of this reactive lesion in its unusual site mistakes it for the more serious ones. This is easily overcome by histopathology which confirms its innocuous nature.
| References | | |
| 1. | Laskaris G: Colour atlas of oral diseases, 4th ed, Thieme publishers, New York, pages 400-401,1997.  |
| 2. | Shafer WG, Hine MK, Levy BM: A textbook of oral pathology, 4th ed, WB Saunders, Philadelphia, pages 359-60,1983. |
| 3. | Scully C, Flint SR, Porter SR, Moor KF: Oral and maxillofacial diseases, 3rd ed. Tylor and Francis, London, page 370, 2004. |
| 4. | Graham RM: Pyogenic granuloma: an unusual presentation, Dental Update 26(1): 240-1,1996. |
| 5. | Bjork K, Hoede N, Korting GW, Burgdorf WHC, Young SK: Diseases of the oral mucosa and the lips. WB Saunders, Philadelphia, pages 229-30,1996. |
| 6. | Pierson JC, Pierson DM: Pyogenic Granuloma (Lobular Capillary Hemanigioma), http://www. emedicine. com/derm/topic368.htm (12 November 2005) |
| 7. | Lawoyin JO, Arotiba JT, and Dosumu 00: Oral pyogenic granuloma: a review of 38 cases from Ibadan, Nigeria. Br J Oral Maxillofac Surg 35:185-9,1997 |
| 8. | Neville BW, Damm DD, Allen CM, Bouquot JE: Oral and maxillofacial pathology, 2nd ed. Elsevier, Philadelphia, pages 447-49,2002. |
| 9. | Sapp JP, Eversole LR, Wysocki GP: Contemporary oral and maxillofacial pathology, 2nd ed, Mosby, Missouri, pages 318-19,2004. |
| 10. | Daley TD, Nartey NO, Wysocki GP: Pregnancy tumour: an analysis, Oral Surg Oral Med Oral Pathol 72:196-9,1991. |
| 11. | Marks K: Roxburgh's common skin diseases, 17th ed, Arnold, London, page 197, 2003. |
| 12. | Lee L et al: Intraoral pyogenic granuloma after allogeic bone marrow transplant, Oral Surg Oral Mod Oral Pathol 78: 607-10,1994. |
| 13. | Souza LN, Martin CR and De Paula AMB: Cutaneous horn occurring on the lip of a child, Int J Paed Dent 13:365-67,2003. |
| 14. | Wood NK, Goaz PW: Differential diagnosis of oral and maxillofacial lesions, 5th ed, Mosby, Missouri, 549-550,1997. |
| 15. | http://dermis.net/dermisroot/en/27156/ diagnose.htm |
| 16. | Marx RE, Stem D: Oral and maxillofacial pathology-A rationale for diagnosis and treatment, Quintessence publishing co, inc., Chicago, pages 21-23,2003. |
| 17. | White SC, Pharoah MJ: Oral radiology principles and interpretation, 5th ed., Mosby, Missouri, page 598, 2004. |
| 18. | Sampurna Roy, Path Quiz Case-70: Pyogenic granuloma - [lobular capillary hemangioma], http://wwwhistopathology-india.com/PG.htm, (12 November2005) |
| 19. | Rawal YB et al: Presentation of an epithelial cell histiocytoma on the ventral tongue, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 75-83,2005. |
Correspondence Address:
Karthikeya Patil
Dept. of Oral Medicine & Radiology, JSS Dental College and Hospital, Mysore, Karnataka- 570 015
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.29864
Figures
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4] |
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