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Exophytic and Focally Ulcerated Mass on the Mandibular Gingiva
Exophytic and Focally Ulcerated Mass on the Mandibular Gingiva
Abrar Shamim, D.D.S., M.A.; Scott Peters, D.D.S.; Shahid R. Aziz, D.M.D., M.D.; Gregg Jacob, D.M.D.
ABSTRACT
The pyogenic granuloma is a benign vascular proliferation which may present either on the skin or intraorally. While the majority of oral pyogenic granulomas remain less than 1 cm in size, they can grow to large sizes if care is neglected. Herein, we report a case of a large pyogenic granuloma on the mandibular alveolar ridge gingiva which grew to 10 cm x 10 cm in size due to failure to seek treatment.
The pyogenic granuloma, also referred to as the lobular capillary hemangioma, is a benign vascular proliferation commonly seen on the skin and in the oral cavity.[1] While cutaneous lesions represent benign neoplasms, intraoral pyogenic granulomas are considered non-neoplastic, reactive entities. The term pyogenic granuloma is somewhat of a misnomer, as it is not related to any known infectious agents and, therefore, not pyogenic in nature. Nor is it histologically similar to inflammatory granulomas.
Pyogenic granulomas of the oral cavity most often form in response to local irritation or trauma. A subset of intraoral pyogenic granulomas is seen in pregnant individuals and are believed to result from hormonal factors.[2] These are sometimes referred to as pregnancy tumors or granuloma gravidarum.
Oral pyogenic granulomas are seen more commonly in females. While they may present at any age, they are often seen in younger adults. The most common clinical presentation of an intraoral pyogenic granuloma is a pedunculated smooth or lobulated erythematous exophytic lesion. The gingiva is most commonly affected, and various irritants, such as chronic food impaction and overhanging dental restorations, may serve as etiologic factors. Other less commonly affected sites include the lips, tongue and buccal mucosa.[3]
Oral pyogenic granulomas are often less than one centimeter in size. They are typically treated by surgical excision, and the recurrence rate is low. Higher recurrence rates have been reported in women who are pregnant or in cases in which an irritative causative agent has not been identified and managed appropriately. Although non-neoplastic, pyogenic granulomas can increase in size if they are not treated.
Herein, we report a case of a large gingival pyogenic granuloma for which treatment had been neglected for several years.
Case Report
A 59-year-old female presented to an oral and maxillofacial surgeon for evaluation of a growth involving the left mandibular gingiva. She stated that it had been present for three years and had slowly increased in size over this time. She did not seek treatment initially but now presented because the lesion prevented her from eating and drinking properly. The patient’s past medical history was not significant. She reported a familial history of oral squamous cell carcinoma. The extraoral examination was unremarkable for any facial asymmetries, lymphadenopathy, trismus or swellings.
On intraoral examination, a 10 cm x 10 cm pedunculated mass lesion of the left mandibular gingiva was observed (Figure 1). Panoramic radiograph demonstrated no intraosseous pathologies in the underlying area of the soft-tissue growth. An incisional biopsy of the specimen was performed for diagnostic purposes and demonstrated ulcerated surface epithelium and connective tissue containing granulation tissue composed of small-to-mediumsized blood vessels arranged in lobular aggregates (Figure 2). A diagnosis of a pyogenic granuloma was rendered, and the patient returned for excision of the remaining lesion.
The lesion was excised via electrocautery under local anesthesia with no complications and sutures were placed. There was proper healing and no sign of recurrence.
Discussion
The intraoral pyogenic granuloma is a reactive hyperplasia in response to various stimuli,[4,5] but it has also been classified as a benign tumor composed of capillary endothelial cells in extraoral locations[6] and, therefore, may sometimes be referred to as lobular capillary hemangioma. The oral pyogenic granuloma most commonly involves the gingiva, with the maxillary arch affected more often than the mandible.[7] Other less common oral sites include the lips, tongue, buccal mucosa and hard palate.[3,8] Some reports have found this is the most common gingival growth; however this may depend largely on the population.[9]
The pyogenic granuloma is a relatively common pathology affecting approximately 1% of the population, notably, younger patients in the third and fourth decades of life, with a slight female predilection.[10] The gender predilection becomes less apparent in older patients. Pregnancy is associated with increased incidence of these lesions, potentially related to angiogenic hormone release.[11]
The pyogenic granuloma often presents as an exophytic growth that may be smooth or lobulated, with either a pedunculated or sessile base. The color may range from purple to red to pink, and may be related to the age and vascularity of the lesion.[12,13] It can present with an overlying yellow fibrinous membrane and may also be ulcerated.[14] Pyogenic granulomas tend to range from a few millimeters to a few centimeters in size but do not often surpass 1 cm in greatest dimension, rarely exceeding 2.5 cm in size.[5,13,15-17] The pyogenic granuloma we describe in this case report grew to several centimeters in size as a result of failure to seek treatment.
The clinical differential diagnosis for a pyogenic granuloma includes the “three Ps,” all of which can manifest on the gingiva or alveolar ridge. These consist of the pyogenic granuloma, peripheral ossifying fibroma and peripheral giant cell granuloma. Among these, pyogenic granuloma is the most common.[18] All three of these lesions are benign, reactive entities that form as a result of local irritation or trauma. While there may be some subtle clinical findings which can help differentiate them, histopathology is required to ascertain a definitive diagnosis.
The clinical differential diagnosis may also include malignant entities. Gingival malignancies such as squamous cell carcinoma, metastatic carcinoma to the oral cavity and Kaposi Sarcoma may closely resemble the clinical appearance of benign, reactive gingival pathologies.[19-23] Many of these entities require a well-informed medical history, and biopsy is often indicated for definitive diagnosis.
A presumptive diagnosis of pyogenic granuloma can be made based on the clinical appearance of the lesion; however, histopathological confirmation is indicated for confirmation of the diagnosis. Microscopic examination of a pyogenic granuloma will demonstrate collections of small-to-medium-sized blood vessels often arranged in lobular aggregates. Ulceration of the surface epithelium is frequently observed. Histologic analysis of this patient’s lesion confirmed the diagnosis.
Pyogenic granulomas (PGs) are primarily soft-tissue lesions; while they may occasionally cause superficial cupping of bone, they do not cause bony destruction. In rare instances, PGs may lead to bone loss.[24] Definitive treatment of pyogenic granuloma involves a complete surgical excision[12] with removal of any potential irritants. In nonvisible areas, such as the mouth, without concern of scarring, complete excision is the preferred treatment, as it likely provides the least chance of recurrence. Alternative medical treatments have been suggested for recurrent lesions.[8,25] Excision of granuloma gravidarum in pregnant patients is not always indicated since they may regress after delivery.[26]
Of the various potential etiologic factors of oral pyogenic granuloma, there were none that warranted this patient’s presentation. The patient did not seek treatment over a period of years, which permitted its growth to significantly expand beyond the average size reported in the literature.[5,13,15-17] The patient was partially edentulous in the mandibular quadrant and similarly edentulous in the left maxillary arch opposing it, which may have permitted continued growth of the lesion, as excisional treatment was neglected.
Queries about this article can be sent to Dr. Aziz at Shahid.aziz@hmhn.org or Dr. Shamim at ashamim@mgh.harvard.edu.
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Shahid R. Aziz, D.M.D., M.D., FACS, FRCSEd, is professor of otolaryngology, Hackensack Meridian School of Medicine, Division Director, Oral and Maxillofacial Surgery, Hackensack University Medical Center, New Jersey, and clinical professor, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ.
Gregg Jacob, D.M.D., FACS, is assistant clinical professor of surgery, Division of Oral and Maxillofacial Surgery, New York Hospital—Weill Cornell Medical College, New York, NY. He is affiliated with Northeast Facial and Oral Surgery Specialists, Florham Park, NJ.
Scott M. Peters, D.D.S., is former assistant professor of dental medicine at Columbia University Irving Medical Center, Division of Oral and Maxillofacial Pathology. He now holds the title of associate professor, Oral and Maxillofacial Pathology, Geisinger Health Systems, Danville, PA.
Abrar Shamim, D.D.S., M.A., is a 2024 graduate of Columbia University College of Dental Medicine and Columbia University Teachers College. He is a resident in oral and maxillofacial surgery at Massachusetts General Hospital and an MD candidate at Harvard Medical School.
