Received 05 March 2021; Accepted 01 April 2021
Unusual Presentation Of Pyogenic Granuloma On The Buccal Mucosa In A 9- Year-Old Girl – A Case Report.
Shankar Paulindraraj,1 Nancy Solomon,2 Madhu Narayan,3 Shanmuga Priya,4 Senthil D,5 Trophimus Gnanabagyan Jayakaran.6
1,5Reader, Department of Pediatric and Preventive Dentistry, SRM Dental College and Hospital, Ramapuram, Chennai – 600089.
2,6Senior Lecturer, Department of Pediatric and Preventive Dentistry, SRM Dental College and Hospital, Ramapuram, Chennai – 600089.
3Senior Lecturer, Department of Oral and Maxillofacial Pathology and Microbiology, SRM Dental College and Hospital, Ramapuram, Chennai – 600089.
4Post graduate student, Department of Oral and Maxillofacial Pathology and Microbiology, SRM Dental College and Hospital, Ramapuram, Chennai – 600089.
ABSTRACT
BACKGROUND: Pyogenic granuloma is a benign tumour-like lesion that affects the skin and the oral mucosa, that occurs as a local tissue response to irritation or trauma with highest rate of occurrence in the gingiva. The aim of the present case report is to document the unusual occurrence of pyogenic granuloma on the buccal mucosa
CASE DESCRIPTION: A rare case of pyogenic granuloma of buccal mucosa, an extra- gingival site, in a 9-year- old female child following extraction of grossly decayed 64 under local anaesthesia. The soft tissue growth increased over a period of 10 days associated with mild bleeding from the same region. The diagnosis was made after meticulous clinical observation and histopathological investigation.
CONCLUSION: Surgical excision was planned towards treating the lesion with a primary objective of preventing its recurrence in the future.
CLINICAL SIGNIFICANCE: This case report reached the pinnacle to be a rare type of pyogenic granuloma of buccal mucosa that was ascertained clinically and histologically. This paper intends the clinicians to be acquainted with the rare phenomena of the lesion and to construct a treatment plan pertinent to the condition.
KEYWORDS: Benign tumour-like lesion, Extra-gingival site, Pyogenic granuloma, Surgical excision.
BACKGROUND:
The term 'Pyogenic granuloma' refers to non-neoplastic inflammatory hyperplasia representing inflamed fibrous and granulation tissue. Clinically, the lesion usually presents as solitary lobular formation in the skin and mucous membrane of the oral cavity which can be sessile or pedunculated.1,2 Histologically, the lesion can be classified as capillary lobular haemangioma, where capillary vessels are organized into granulomatous tissue lobes surrounded by thin collagen band; and non-lobular capillary haemangioma when vascular formations are interwind in tissue without order.3
The first case was reported by Hullihen in 1844. The condition was first described and termed as 'botryomycosis hominis' by Ponect and Dor in 1879. Later, Croker proposed the name 'Pyogenic granuloma' or 'Croker and Hartzell disease' in 1903. In 1904, Hartzell introduced the term pyogenic granuloma otherwise known as granuloma pyogenicum.4
Although the etiology is unclear, the associated factors include low-grade local irritation,5 aggression, traumatic injury, hormonal factors,6 or certain kinds of drugs.7 It is predominantly seen during the second decade of life with a female predilection.8 Clinically, the lesion presents as a well- circumscribed, erythematous, pedunculated, polypoid growth with a definite predilection for the maxillary anterior gingival region.9 Other sites of occurrence of the lesion are lips, tongue, buccal
Received 05 March 2021; Accepted 01 April 2021
mucosa, hard palate, and to a lesser extent occurred in cheeks, mesiobuccal fold and frenum.10 Their clinical presentation mimics other benign soft tissue growth or even malignancy.
The present case report deals with one such case of pyogenic granuloma with rare site of occurrence as a result of severe cheek biting.
CASE DESCRIPTION
CLINICAL PRESENTATION
A 9-year-old female patient reported to the clinic with the chief complaint of growth on the left buccal mucosa in the past 10 days. The patient had undergone extraction of upper left deciduous first molar under local anaesthesia following which the patient had developed severe cheek biting towards the left side. The patient began developing a soft tissue growth in her left buccal mucosa which increased in size over a period of 10 days with associated bleeding from the same region.
CLINICAL EXAMINATION
On clinical examination, it was found that the lesion extended from the angle of the mouth towards the left buccal mucosa.(Figure 1) It was irregularly shaped, exophytic, pedunculated, well- circumscribed, and greyish white in colour. The lesion presented as exophytic 2 lobulated masses and measured approximately 1cm x 0.7cm and 0.6cm x 0.5cm respectively. On palpation, the lesion was fibrous, firm in consistency, non-tender with minimal bleeding.
DIFFERENTIAL DIAGNOSIS:
As the lesion often gets associated with bleeding, it is frequently confused with vascular malformation like haemangioma or any malignancy due to rapid progression rate in which case, excision should be planned with precaution. Other differential diagnosis includes peripheral giant cell granuloma, fibroma, conventional granulation tissue, Kaposi's sarcoma, bacillary angiomatosis, angiosarcoma, and non-Hodgkin's lymphoma.(11,12)
TREATMENT
Based on the clinical features, an excisional biopsy was planned for treating the lesion. After detailed explanation to the parent, an informed consent was obtained and surgical excision was carried out using no.15 scalpel and the lobules were removed separately. The region was inspected for any granulation tissue remnant. The excised lesion was collected and stored in a bottle containing 37% formalin and sent for histopathological examination for investigation. Sutures placed using 3-0 silk following thorough irrigation.(Figure 2) Post- operative instructions were given, medications prescribed and the patient recalled after a week for suture removal.(Figure 3) The patient was asked to report after a month for review.
MICROSCOPIC FEATURES:
Microscopically the lesion exhibited areas of acanthosis and parakeratosis with hyperplasticity.
The epithelium was of a stratified squamous type, ulcerated in few areas whereas few other regions showed fibrinopurulent membrane with evidence of microbial colonies. (Figure 4) The connective tissue showed small thin-walled blood vessels arranged in lobules with endothelial proliferation.
(Figure 5) Inflammatory cell infiltration with neutrophils, lymphocytes, and histiocytes was also observed.
DISCUSSION
Pyogenic granulomas are benign non-specific soft tissue lesions that occur as a localized mass of
Received 05 March 2021; Accepted 01 April 2021
granulation tissue or connective tissue overgrowth. It is often said to occur as a result of an exaggerated response to long term irritation or trauma. The lesion can rarely get infected by Streptococci or Staphylococci species. Vascular association with the lesion such as haemangioma is a rare occurrence. Most often, the pyogenic granuloma is seen associated with pregnancy during the second or third trimester owing to increased levels of progesterone and oestrogen hormones during that time.13 Hence it is also termed as pregnancy tumours or granuloma gravidarum.14
In the present case, the child had undergone extraction of left maxillary deciduous first molar under local anaesthesia 10 days before she presented with pyogenic granuloma. The child had apparently developed a cheek biting habit under the influence of local anaesthesia that caused continuous irritation of the soft tissue in that region. A part of the lesion at the time of presentation was greyish white in colour and an increased amount of collagen.15 While the rest of the lesion was slightly more vascularized with intermittent bleeding. This confirmed the presence of an abundance of blood vessels and the inflammatory nature of that part of the lesion.16
Considering the mixed nature and the location of the lesion, the diagnosis of pyogenic granuloma was quite challenging and could easily misguide us towards vascular lesions like haemangioma, Kaposi's sarcoma, or squamous cell carcinoma.17 After routine haematological investigations, an excisional biopsy was planned for this case. The excision was carried out surgically followed by deep curettage of the lesion as pyogenic granuloma has a greater rate of recurrence of about 15.8%,18 the surgical site was inspected thoroughly for any remnants, granulation tissue in the buccal mucosa. Histopathologically, the lesion was identified to be a lobular capillary haemangioma (LCH) type which is more aggressive than non-LCH type. The characteristic feature of LCH type include proliferating blood vessels with small luminal diameter organized in lobular aggregates. The increased vascularity and inflammatory cells are differentiating features of pyogenic granuloma as compared to giant cell granuloma however the presence of multinucleated giant cells is unique to peripheral giant cell granuloma. Vascular lesions with a greater affinity for extra- gingival locations without the presence of any characteristic inflammatory components represent haemangioma. Pyogenic granuloma can be differentiated from Kaposi’s sarcoma by the absence of atypical cells and haphazardly placed blood vessels within the lesion.13,17
The patient was put under at-home palliative care and post-operative instructions were given and analgesics prescribed. The patient was reviewed at an interval of 1 month for a period of 3 months.
No evidence of recurrence was observed. A similar observation was reported by Deyan et al in his case where the surgical site following the excision of pyogenic granuloma healed uneventfully at the end of 3 months.
CONCLUSION
Pyogenic granuloma can present in different clinical forms making it more challenging for diagnosing the lesion. The treatment of pyogenic granuloma should always be directed towards excision of the lesion, removal of the etiological factor that causes irritation if any, proper guidance and recommendation if the lesion has occurred due to hormonal changes, finally preventing its recurrence. Therefore, it is the utmost responsibility of the dentist to be certain with all the special cases and plan accordingly preventing its recurrence as well.
ACKNOWLEDGEMENT Nil
CONFLICT OF INTEREST
There is no conflict of interest.
FIGURE 1: Exophytic lobulated lesion on left buccal mucosa
Received 05 March 2021; Accepted 01 April 2021
Received 05 March 2021; Accepted 01 April 2021
FIGURE 2: Surgical excision done and 3-0 silk suture placed
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FIGURE 3: Post-operative image after 1 week follow-up
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FIGURE 4: Ulcerated epithelium covered with fibropurulent membrane with microbial colonies
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FIGURE 5: Numerous small thin-walled blood vessels arranged in lobules
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