Granuloma gravidarum associated with pregnancy: A case report.
Granuloma gravidarum, commonly known as "pyogenic granuloma," is a reactive inflammatory hyperplasia that occurs in response to various stimuli such as low-grade local irritation or trauma, hormonal factors or certain kinds of drugs. Occasionally it develops during pregnancy because of the hyper-responsiveness of the oral tissues to increased levels of pregnancy hormones. This case study describes a persistent pregnancy tumour postpartum and discusses its management using electrocautery. Simple oral hygiene measures are highly effective in preventing both the initial occurrence and persistence of such lesions postpartum. Pregnant clients should be educated about the risk for developing pyogenic granulomas and counselled on the importance of maintaining good oral hygiene.
Le botriomycome, communement appele le << granulome pyogenique >> est une hyperplasie inflammatoire reactive qui se presente en reponse a divers stimuli tels que l'irritation ou le traumatisme mineur local, les facteurs hormonaux ou certaines sortes de medicaments. Occasionnellement, il se developpe pendant la grossesse en raison de l'hyperreactivite des tissus buccaux en reponse a la hausse du niveau des hormones de grossesse. La presente etude de cas decrit une tumeur de grossesse qui persiste apres l'accouchement et se penche sur sa gestion au moyen de l'electrocauterisation. De simples mesures d'hygiene buccale sont grandement efficaces pour la prevention a la fois de l'occurrence initiale et de la persistance de telles lesions postpartum. Les clientes enceintes devraient etre renseignees sur les risques de developper des granulomes pyogeniques et devraient recevoir des conseils sur l'importance de maintenir une hygiene buccale optimale.
Key words: electrocautery, granuloma gravidarum, oral hygiene maintenance during pregnancy, pregnancy tumour, puerperal period, pyogenic granuloma
CDHA Research Agenda category: risk assessment and management
Oral soft tissue enlargements often present a diagnostic challenge since a diverse group of pathologic processes can produce such lesions and thus complicate their management. Such enlargements may be deviations from normal anatomy, developmental anomalies, cysts, inflammation or neoplasms. Among these lesions is a group of highly reactive hyperplasias, which develop in response to a chronic, recurrent tissue injuiy that initiates an unruly reparative tissue response. (1,2) Granuloma gravidarum, commonly known as "pyogenic granuloma," is one of the most common oral soft tissue enlargements. It is a benign, fast-growing, focal reactive growth, fibrovascular in nature, with extensive endothelial proliferation. The lesion was originally described in 1897 by Poncet and Dor, who named this lesion "botiyomycosis hominis." The term "pyogenic granuloma" was proposed by Hartzell in 1904. (2) This name, however, is a misnomer since the lesion is neither associated with pus nor does it represent a true granuloma.
Gingival pyogenic granuloma develop in up to 5% of pregnancies. Hence the terms "pregnancy tumour" and "granuloma gravidarum" are often used interchangeably to describe this lesion. (3,4) Periodontal pathogens, local irritants, and circulating hormones in the pregnant woman contribute to the origin of this lesion. The principal oral site affected by pregnancy tumours is the gingiva. Other sites in the oral cavity include the lower lip, tongue, buccal mucosa, upper lip, and the palate. The true prevalence of pregnancy tumours is not well established since not all affected women seek professional care for these lesions. (5) The overall reported prevalence is 0.2% to 9.6%. Pregnancy tumours generally appear in the 2nd or 3rd month of pregnancy and show a tendency to gradually increase in size. The lesion typically regresses following childbirth. (5)
This short communication presents a case report of a pregnancy tumour that persisted postpartum and was managed by surgical excision using electrocautery together with vestibuloplasty to increase the depth of the vestibule in the same region.
A 22-year-old female client reported to the Department of Periodontics at KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India, with a chief complaint of a swelling in her gums in the area of her lower front teeth. She reported that the lesion appeared approximately 8 months earlier during the 3rd month of her pregnancy. The lesion was of negligible size when the client first noticed it, but it gradually increased in size. This growth was accompanied by an increase in tooth mobility. Eventually, the condition began to cause discomfort during mastication due to the large size of the lesion and was also esthetically unpleasing.
The client's medical history revealed that she underwent a normal delivery 3 months prior to presenting to this institution. The client reported visiting a local dentist in the 3rd month of her pregnancy when she perceived that the lesion was increasing in size. Supragingival ultrasonic scaling was performed at that time, and oral hygiene instructions were given. However, the client was advised against any surgical intervention and was asked to report postpartum.
The extraoral examination showed no facial asymmetry. The intraoral clinical examination revealed a roughly oval, exophytic, sessile lesion, attached to the labial surface of the gingiva between the mandibular left central and lateral incisors (Figure 1A). The lesion measured approximately 13 mm X 9 mm x 6 mm (Figures 2A, 2B, 2C). The lesion also extended onto the lingual side as a small mass measuring 2mm x 2mm (Figure IB). The surface of the lesion was lobulated and reddish-pink in colour. On paipation the growth was soft to firm in consistency and non-tender. The lesion was quiescent and showed no signs of spontaneous bleeding. It involved the interdental papilla, marginal and attached gingiva and, when retracted from the teeth, its attachment to the interdental papilla was visible (Figure 1C).
The mandibular central and lateral incisors had Grade I mobility. The oral hygiene status of the client was poor, with a score of 4.49 on the Simplified Oral Hygiene Index. (6) Laboratory investigations, including hemoglobin, bleeding, and clotting times, were ordered and reported to be within normal limits. Radiographic examination revealed approximately 20% to 30% horizontal bone loss in the mandibular anterior region (Figure 3). Thus, based on the client's medical history and clinical examination, a differential diagnosis of pregnancy tumour (granuloma gravidarum), peripheral giant cell granuloma, and peripheral ossifying fibroma was made.
At the initial visit, the local irritating factors (plaque and calculus) were eliminated by thorough ultrasonic scaling followed by root planing performed with Gracey Curettes after application of a local anesthetic. The client was instructed on maintaining her oral hygiene, and a treatment plan was presented to her which included surgical excision of the lesion. The procedure was scheduled for 1 week following her phase-I therapy as the client complained of a lot of discomfort during mastication and refused to follow the standard 6-week re-evaluation protocol.
At the subsequent appointment, one week later, the lesion had a pale pink surface, most likely resulting from the reduction in inflammation due to the phase-I therapy (Figure 4A). Hence, a decision was made to proceed with the excision of the lesion using an electrocautery unit in order to minimize the anticipated intraoperative bleeding, which is a common occurrence with such lesions. After an injection of local anesthesia, the lesion was excised using a unipolar electrocautery device mounted with a needlelike active electrode, up to 2 mm beyond the involved margins (Figure 4B). The lesion bled minimally during the excision. A ball electrode was later used to achieve complete hemostasis.
After the lesion was excised, an inadequate depth of the vestibule was noted in the same region, thus a decision to perform a frenotomy along with vestibular deepening was made. The mandibular labial frenum was held using a hemostat, and a number 15 blade was used to excise the tissue along the upper and lower borders of the hemostat until the hemostat was free and the wedge-shaped tissue was removed. The edges of the frenotomy incision were extended laterally by making an incision in the depth of the vestibule (Figure 4C). A periodontal dressing was placed to protect the raw area corresponding to the excised lesion and to prevent reattachment at the site where the vestibuloplasty was performed. The client was recalled after 1 week for dressing removal and evaluation of the surgical site. The excised tissue (Figure 4D) was sent to the Department of Oral Pathology for histological examination.
One week later, at the follow-up visit, the surgical site had healed uneventfully although some amount of redness was noticed at the interdental papilla between the mandibular left central and lateral incisors (Figure 5). This redness had subsided at a subsequent follow-up visit without any further intervention. When the vestibular depth measurements recorded before and after the procedure were compared, a gain of 3 mm of vestibular height was noted (Figures 6A, 6B). The case was followed for 1 year and no signs of recurrence or discomfort were reported.
The histopathologic examination revealed stratified squamous parakeratinized epithelium. The underlying connective tissue was delicate and loose with plum- to spindle-shaped fibroblasts and focal aggregates of chronic inflammatory infiltrate comsisting of lymphocytes and plasma cells. Numerous endothelial lined vascular spaces and budding endothelial cells were identified. Several endothelial lined blood vessels were engorged with RBCs and few extravasated RBCs were also noted. These findings were consistent with the diagnosis of pyogenic granuloma (Figures 7A, 7B, 7C).
Granuloma gravidarum has been referred to by a variety of other names, such as "granuloma pediculatum benignum," "benign vascular tumour," "pregnancy tumour," "vascular epuli," and "Crocker and Hartzell's disease." Angelopoulos proposed the term "hemangiomatous granuloma," which accurately expresses the histopathologic picture, i.e., the hemangioma-like and inflammatory nature of oral pyogenic granuloma. (7)
Gingival inflammation in the initial months of pregnancy is induced by the persistence of plaque that serves as a base for the development of granuloma gravidarum.5 Later, in the subsequent months, it is controlled by the cumulating hormonal stimuli. Broad investigations have been carried out to study the molecular mechanisms contributing to the development of granuloma gravidarum during pregnancy as a result of the increased leves of female sex hormones, namely progesterone and estrogen.2 Progesterone functions as an immunosuppressant in the gingival tissues of pregnant women, preventing a rapid, acute inflammatory reaction against plaque, but allowing an increased chronic tissue reaction. This clinically results in an exaggerated appearance of inflammation. (4,5)
Estrogen enhances granulation tissue formation, which accelerates wound healing by stimulating the following factors (4,5,8,9):
* basic fibroblast growth factor (bFGF) and transforming growth factor beta-1 (TGF-B1) production in fibroblasts
* granulocyte-macrophage colony-stimulating factor (GM-CSF) production in keratinocytes
* vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) production in macrophages
The changes in the function and structure of the blood and lymph microvasculature of mucosa is brought about by the profound endocrine turmoil during pregnancy. However, it should be noted that the pregnancy tumour typically regresses following childbirth but the mechanism for such regression remains unclear. This finding may be explained partially by the fact that, in the absence of VEGF, angiopoietin-2 (Ang-2) causes blood vessels to regress. The amount of VEGF has been found to be high in granulomas associated with pregnancy and almost undetectable after childbirth. (4,9,10)
In the present case, the client's poor oral hygiene habits and persistent band of supra and subgingival calculus and plaque most likely acted as a chronic stimulus causing the lesion to persist postpartum. This result could potentially have been avoided by proper maintanence of oral hygiene during pregnancy. Management of granuloma gravidarum depends on the severity of symptoms. If the lesion is small, painless, and free of bleeding, eradication of the etiology, clinical observation, and follow up are advised. Because pyogenic granuloma is a benign lesion, surgical excision is the treatment of choice for larger lesions that are painful or tend to interfere with mastication. Surgical intervention is generally avoided during pregnancy since these lesions usually regress postpartum. (7,9)
During management in the puerperal period, teeth should be thoroughly scaled to remove any source of continuing irritation. The excision should extend down to the periosteum and include excision of up to 2 mm of the adjacent tissue collar in order to avoid recurrence. The majority of cases typically show a tendency to bleed excessively during excision with a scalpel. (11,12) Thus, an electrocautery device was used to excise the lesion in the current case which avoided any such complications. Other novel treatment options include the flashlamp pulsed dye laser (13), cryosurgery (14), and sodium tetradecyl sulfate sclerotherapy (15). Intralesional injection of absolute ethanol and corticosteroids has been used particularly for highly recurrent lesions. (16) Recurrence has been reported in up to 16% of these types of lesions, which might be due to incomplete excision or failure to remove the etiologic factors. (17)
The diagnosis of granuloma gravidarum is complex, and it is important to differentiate this type of lesion from inflammatory tumours and true neoplasms. Careful management also helps in preventing the recurrence of these benign lesions. Often, oral health may be neglected during pregnancy, leading to the development of such reactive lesions. Thus, during pregnancy, oral hygiene maintenance should be reinforced and made a priority, since the increased levels of progesterone and estrogen in the presence of dental plaque can promote the development of these lesions in the oral cavity. From this case report, it can be concluded that pregnancy tumours can be adequately treated with the correct diagnosis and proper treatment planning.
WHY THIS ARTICLE IS IMPORTANT TO DENTAL HYGIENISTS
* Poor oral hygiene may lead to the development of reactive lesions, such as granuloma gravidarum, during pregnancy. These lesions usually develop in the first trimester and regress postpartum.
* If the lesions persist, they may compromise maternal health.
* Educating clients about the importance of maintaining good oral hygiene during pregnancy can help to prevent the occurance of such lesions and the need for surgical excision postpartum.
The authors extend their sincere gratitude to the Department of Oral Pathology, KLE VK Institute of Dental Sciences, Belagavi, India, for its support, and to Dr. Priyanka Iyer for her thoughtful guidance.
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(11.) Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral Surg Oral Med Oral Pathol. 1991 Aug 1;72(2):196-99.
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(16.) Ichimiya M, Yoshikawa Y, Hamamoto Y, Muto M. Successful treatment of pyogenic granuloma with injection of absolute ethanol. J Dermatol. 2004 Apr 1;31(4):342-44.
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Murtaza A Kaderi *, BDS; Aditi B Mahajani *, BDS; Neelamma A Shetti ([section]), MDS; Renuka M Metgud (dagger]), MDS; Jyoti M Ajbani *, BDS
* Postgraduate student, Department of Periodontics, KAHE's KLE VK Institute of Dental Sciences, Belagavi, Karnataka, INDIA
([section]) Reader, Department of Periodontics, KAHE's KLE VK Institute of Dental Sciences, Belagavi, Karnataka, INDIA
([dagger]) Professor and head of department, Department of Periodontics, KAHE's KLE VK Institute of Dental Sciences, Belagavi, Karnataka, INDIA
Correspondence: MA Kaden; firstname.lastname@example.org
Manuscript submitted 17 August 2017; revised 24 November 2017; accepted 5 December 2017
Caption: Figure 1A. Lesion attached to labial surface of the gingiva in relation to mandibular left central and lateral incisors
Caption: Figure 1B. Extension of the lesion on the lingual side
Caption: Figure 1C. Attachment of the lesion primarily to the interdental papilla
Caption: Figure 2. Images showing size of the lesion
Caption: Figure 3. Intraoral periapical radiograph showing horizontal bone loss in the mandibular anterior region
Caption: Figure 4A. Slightly reduced size and pale pink surface of the lesion 1 week after phase I therapy
Caption: Figure 4B. Electrocautery device used for excision of the lesion
Caption: Figure 4C. Vestibular deepening
Caption: Figure 4D. Excised lesion sent for histopathological examination
Caption: Figure 5. Postoperative image (1 week following surgery)
Caption: Figure 6A. Vestibular depth measurements at the time of the procedure
Caption: Figure 6B. Vestibular depth measurements 1 week after surgery
Caption: Figure 7A. Histopathologic section at 4x magnification
Caption: Figure 7B, 7C. Histopathologic section at 10x magnification
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|Title Annotation:||SHORT COMMUNICATION|
|Author:||Kaderi, Murtaza A.; Mahajani, Aditi B.; Shetti, Neelamma A.; Metgud, Renuka M.; Ajbani, Jyoti M.|
|Publication:||Canadian Journal of Dental Hygiene|
|Article Type:||Medical condition overview|
|Date:||Feb 1, 2018|
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