Introduction:
Oral cancers are one of the most common cancers in the world. In recent times the number of patients suffering from oral cancer has increased significantly. In such situations knowledge of various types of oral tissue growth is important. Granuloma pyogenicum is one of the most common types of oral tissue growth. So, it is essential to understand the causative factors behind this.
What Is Granuloma Pyogenicum?
Granuloma pyogenicum is an oral inflammatory lesion. The name "pyogenic granuloma" is colloquially used in medical and dental literature which is often considered a misnomer term in the field of oral pathology. This is because this condition is not actually associated with the release or accumulation of pus nor does it have any features of a granuloma on histologic examination. Pyogenic granuloma is a condition that is known to occur over a wide age range between the first decade and the eighth decade of life. The highest incidence is observed between the second and fifth decades of life. Females are more commonly affected than males.
What Is the Etiology of Granuloma Pyogenicum?
A history of trauma is often elicited from the patient upon questioning the oral or dental history by the dental practitioner or the surgeon. This would explain why pyogenic granuloma is common in a specific site (induced by trauma potentially). The etiology of the lesion though remains elusive in the dental literature. It was originally believed to be a botryomycosis infection. However, it is now hypothesized that the most common cause of pyogenic granuloma with the exception of pregnancy (in which it is induced by the rise in hormones) would be traced to the traumatic origin or as an oral tissue response to either minor trauma or due to chronic irritation in the oral cavity. This can open or create a pathway for the entry, invasion, and induction of nonspecific microorganisms and bacteria in the trauma site. Therefore, soft tissue enlargements caused due to microbial contamination remain a diagnostic challenge, more so because of the diverse pathologic processes by these bacterial groups that can cause such inflammatory lesions.
Soft tissue lesions also known as reactive hyperplasias are the lesions that usually develop in response to a chronic, recurring tissue injury. The tissue injury is responsible for either stimulating or exacerbating an excessive tissue repair response in the host immune system. Hence, the etiology of pyogenic granuloma is the same common process that occurs in the case of other soft tissue enlargements of the oral cavity. However, the differential diagnosis by the dentist plays a major role in the correct recognition and treatment of the lesions. Gingiva is considered to be the most affected site followed by lips, tongue, buccal mucosa, and hard palate. Intraorally, it can either appear as a sessile lesion or an inflamed and elevated tissue mass. It is a soft, painless lesion and appears as a swollen mass. Pyogenic granulomas are generally discovered by the dentist on clinical examination. It is often only of aesthetic concern to the patient. These lesions may appear deep red to reddish-purple in color.
What Is the Role of Bacteria in Granuloma Pyogenicum?
According to traditional research, oral pyogenic granulomas originate as a result of staphylococci or streptococci bacterial infections. These microorganisms, by virtue of their ability to produce colonies (colonization with the fungus-like character), are considered a major possibility for elucidation of the origin of these inflammatory infections. The other possibility as discussed above by many researchers is traced to traumatic origins like minor trauma to the tissues. This creates pathways for entry and invasion of inflammatory or pathogenic microbes. The tissues in the host usually respond in a specific manner to the organisms specifically of low virulent nature by the proliferation of a vascular type of connective tissue. This is a natural tissue response in the host. This tissue response is indicative of the fact that an irritant source upon the living tissue may act either just as a stimulus or destructive agent or both stimulus and destructive ability as part of natural host immunity. Also, clinical and histopathological observations show that granulation tissue in oral pyogenic granuloma is only contaminated by microbial flora of the oral cavity. The surface of the lesion is covered by fibrin that may rather mimic pus but does not actually contain pus which is a distinctive diagnostic feature of this condition. Supuration is hence not considered a clinical characteristic of oral pyogenic granuloma.
What Is the Cause of Granuloma Pyogenicum During Pregnancy?
In pregnancy, due to the dynamic changes and the marked increase in the levels of the female sex hormones like estrogen and progesterone, most hypotheses suggest that the endothelium of the oral cavity is affected causing pyogenic granuloma formations in the gingiva or in the oral mucous membranes. Studies have also shown that in pregnancy, there is an eventual migration of inflammatory cells and fibroblasts in the gingiva. Pregnancy regulates not only the metabolism of progesterone but may also influence the migration of inflammatory cells in tissue to the gingiva. This plays an important role in the pathogenesis of granuloma formation.
What Are the Diagnostic Features?
Pyogenic granuloma is diagnosed clearly by microscopic examination of the cells. These cells appear as parakeratotic or non-keratinized stratified squamous epithelial cells. The major bulk of the lesion appears either as a lobulated or a non-lobulated mass with the lobulated lesions composed of endothelial cell proliferation or proliferated capillary-sized blood vessels. The connective tissue in these lesions is pyogenic (pus-filled) and appears sparse. The surface can be ulcerated in cases where the edema remains a prominent feature. The lesion in ulcerated surfaces is characterized by infiltration of plasma cells, lymphocytes, and neutrophils.
Differential diagnoses of pyogenic granuloma by histopathologic examination can be various. These are peripheral giant cell granuloma, peripheral ossifying fibroma., fibroma, peripheral odontogenic fibroma, hemangiomas,
The final diagnosis or confirmatory diagnosis is based on histopathologic and clinical features of the disease by the dentist/maxillofacial surgeon
How to Treat Granuloma Pyogenicum?
Surgical excision is the only major treatment option of choice for eliminating granuloma pyogenicum. Considerations should be taken regarding pregnant patients unless it is a source of major oral discomfort. The oral surgeon would recommend surgical excision of the gingival lesion ideally along with the curettage of the underlying tissue to eliminate it completely. Care should be taken by the surgeon to eliminate foreign bodies, calculus, and restorations that are defective. All of these should be removed routinely as part of surgical excision. These Pyogenic granuloma lesions usually show a recurrence rate of 15.8. percent However, they are most often recurrent in the gingival sites only and they lack the potential to be either infiltrative or malignant. Recurrence in pregnancy is more common in spite of excision due to fluctuations in hormone levels and recurrence rates in extra gingival areas are also comparatively much lesser.
Conclusion:
The oral surgeon or the dentist should correctly identify the inflammatory soft tissue growths of the oral cavity by establishing an ideal differential diagnosis of which pyogenic granuloma/granuloma pyogenicum remains a common condition. It occurs due to trauma, bacterial infections, or due to inflammatory reactions created during pregnancy. Also, surgical excision remains the main treatment of choice to prevent the recurrence of these lesions
