Q U I N T E S S E N C E I N T E R N AT I O N A L
GENERAL DENTISTRY
Nathalie Frumkin
Nonsurgical treatment of recurrent gingival pyogenic granuloma: A case report Nathalie Frumkin, DMD1*/Rizan Nashef, DMD2*/Lior Shapira, DMD, PhD3**/Asaf Wilensky, DMD, PhD4** Gingival pyogenic granuloma is a relatively common benign form of mucocutaneous lesion. Although surgical excision is considered to be the standard care, several reports have demonstrated a high recurrence rate of the lesion. In this case report a nonsurgical protocol to treat recurring gingival pyogenic granuloma and prevent further recurrence is
suggested. The protocol includes strict oral hygiene instructions, scaling, root planing, and maintenance treatment. To the best of our knowledge, this is the first report of conservative nonsurgical management of recurrent gingival pyogenic granuloma lesions. (Quintessence Int 2015;46:539–544; doi: 10.3290/j.qi.a33992)
Key words: pyogenic granuloma, nonsurgical treatment
Pyogenic granuloma or granuloma pyogenicum is a relatively common benign mucocutaneous lesion. The term pyogenic granuloma is a misnomer in that, contrary to what the name implies, the lesion does not contain pus and is not a granuloma.1 The incidence of pyogenic granuloma has been described as between 26.8% to 32% of all reactive lesions.2 Although it has been reported in all age groups, it occurs mainly between the ages of 11 and 40 years, with peak incidence in the third decade.3 Females are more susceptible.1 Oral sites of pyogenic granuloma 1
Postgraduate Student, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
2
Clinical Instructor, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
3
Associate Professor and Head, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
4
Lecturer, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
*NF and RN contributed equally to the study. **AW and LS contributed equally to the study. Correspondence: Dr Asaf Wilensky, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Ein Kerem, Jerusalem 91120, Israel. Email: [email protected]
VOLUME 46 • NUMBER 6 • JUNE 2015
can include the gingiva, lips, tongue, buccal mucosa, and palate.4 The lesion usually appears as a localized elevated lump with a sessile or pedunculated appearance. The surface may be smooth or lobulated, and when exposed to traumatic irritation it becomes ulcerated. The color may range from pink to red or purple.5 The lesion is wellvascularized (hyperplastic response), with a tendency for bleeding in response to even minor injury. Insofar as its etiology is related to minor injury or irritation (for example plaque), it is a reactive form of lesion.1,5 Gingival irritation resulting from calculus, plaque, overhanging edges, or rough restoration may represent the predisposing factors in the development of gingival pyogenic granuloma.5 It is possible that microulceration from these irritants in an already inflamed gingiva facilitates the ingress into the gingival connective tissue of low virulent oral microflora.5 The lesion generally develops rapidly, causing the erroneous clinical impression of a malignant tumor.6 It is, however, a benign soft tissue lesion of an inflammatory rather than neoplastic nature, arising from the connective tissue of the skin or mucous membrane.7
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Q U I N T E S S E N C E I N T E R N AT I O N A L Frumkin et al
The clinical features of pyogenic granuloma are indicative but not specific. A definitive diagnosis can therefore be made only by histopathologic examination of biopsy.1 Histopathologically, the lesion shows a highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed, lined with endothelium. The surface is usually ulcerated and replaced by a thick fibrino-purulent membrane, but it may also be lined with a layer of stratified squamous epithelial cells. A mixed inflammatory cell infiltrate of neutrophils, plasma cells, and lymphocytes is evident. Neutrophils are more prevalent near the ulcerated surface, with chronic inflammation evident in deeper layers.8 Since gingival pyogenic granuloma represents a benign lesion, surgical excision is today considered the treatment of choice.1 In order to prevent a possible recurrence, the gingival lesion must be excised down to the underlying periosteum, and predisposing irritants must be removed.8 According to the Journal of Periodontology, pregnancy-associated pyogenic granuloma may be categorized under the definition of “plaque-induced gingival diseases”; for this specific subgroup of gingival pyogenic granuloma another primary cause may be dental plaque, which can be predisposed by systemic factors (hormonal changes).9 The pregnancy-associated pyogenic granuloma has been reported to occur in 0.5% to 5% of pregnant women, usually regressing or completely disappearing following parturition. The etiology of pregnancy-associated pyogenic granuloma is thought to be related to changes in levels of sex hormones during pregnancy.7 These changes are frequently associated with functional and structural alterations of blood and lymph microvasculature of the mucosa.10 Although it may be regarded as a common procedure, the surgical resection of a gingival pyogenic granuloma may have ramifications. The possible negative outcomes, as for any other periodontal surgery, of surgical resection include impaired esthetics, dental sensitivity, postoperative swelling, infection, and recurrence of the lesion and incidental attachment loss due to the resective nature of the procedure.11 After excision, recurrence occurs in up to 16% of the lesions;
540
recurrence/persistence is believed to result from incomplete excision.2,4 It should be emphasized that gingival cases show a much higher recurrence rate than lesions from other oral mucosal sites.7 We hypothesize that since gingival pyogenic granuloma is actually an inflammatory lesion that is highly vascularized, an antiinflammatory/anti-infective therapy aimed at eliminating irritants and lowering infection may be an effective treatment which obviates the need for secondary surgical procedures, along with their potential consequences. In this case report, a nonsurgical treatment and maintenance protocol for the treatment of recurrent gingival pyogenic granuloma lesions is presented. This minimally invasive protocol eliminated the need for repeated surgery and prevented recurrence for 12 to 24 months following treatment. To the best of our knowledge, having reviewed the literature, this appears to be the first report of conservative nonsurgical management of a recurrent gingival pyogenic granuloma.
CASE 1 A 26-year-old healthy woman presented with a growth located in the mandibular anterior region (central incisors) (Fig 1a) which had recurred after having been excised and the area cleaned 6 months earlier by an oral and maxillofacial surgeon. The specimen was histologically diagnosed as pyogenic granuloma. The lesion had recurred 4 months after surgery. The patient noticed a gradual increase in size followed by tooth movement, and the condition caused her discomfort while eating. The treatment plan offered by the maxillofacial surgeon at that point was to extract the relevant mandibular central incisors, which were mobile, along with the excision of the lesion, which measured 10 mm. Upon referral to the Department of Periodontology, an intraoral examination revealed a pedunculated growth measuring 10 to 12 mm, bluish to red in color, multi-nodular, surrounding the mandibular incisors. The mandibular central incisors were mobile to the second degree, and the mandibular lateral incisors
VOLUME 46 • NUMBER 6 • JUNE 2015
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a
b
c
d
Figs 1a to 1d Follow up pictures of patient 1. The initial presentation (a) is significant for an exophytic cauliflower-shaped lesion on the lingual gingiva between the mandibular central incisors. A month later (b) the exophytic lesion is reduced in size. The roots of the involved teeth are more exposed with recession of the surrounding gingiva, which is also less erythematous and edematous. Two months later (c) there is substantial shrinkage of the lesion, and a minimal erythema and edema is still noticeable. Four months following the treatment (d) the gingiva appears healthy.
were mobile to the first degree according to the Miller index.12 Calculus and plaque were noticed on the lingual aspect of the relevant teeth (Fig 1a) and was thought to be the etiologic factor. A periapical radiograph (Fig 2) revealed localized horizontal bone loss extending along the roots of the mandibular central incisors, leaving minimal bone support for the apical third of the relevant roots, with no other areas of bone or attachment loss. The patient was made aware of the decision to change the treatment plan from surgical excision of the lesion and extraction of the mandibular central incisors, to nonsurgical treatment of the lesion and maintenance of the central incisors. The patient was given strict oral hygiene instructions, including the use of regular and single-tufted toothbrushes and an interdental brush until the achievement of optimal oral hygiene (full mouth plaque scores of 8% to 14% were measured during the phase of therapy and maintenance). A splint, extending bilaterally between the mandibular canines, was made 3 weeks after the first
VOLUME 46 • NUMBER 6 • JUNE 2015
Fig 2 Pretreatment periapical radiograph of the mandibular central and lateral incisors. There is a horizontal, localized bone loss surrounding the relevant teeth.
examination in order to stabilize the periodontally relevant teeth. One week after splinting the teeth, the treatment protocol began. The patient underwent three cycles of debridement in the following 2 months. These treatments were done under local anesthesia, in combination with an adjunctive chlorhexidine rinse. Following the treatment, the patient was followed up every 2 weeks for the first 2 months (Fig 1b), full-mouth plaque
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Fig 3 Periapical radiograph of the mandibular central and lateral incisors after treatment for 3 months, showing stability in the bone support around the mandibular central and lateral incisors.
scores were recorded, and oral hygiene instructions were modified according to the state of the lesion. Three months following the treatment, the lesion had reduced in size significantly and a minimal erythema and edema were still noticeable (Fig 1c); the periapical radiograph showed stability in bone level, pronounced periodontal ligament, and bone mineralization (Fig 3). Following the disappearance of the lesion, 4 months after the beginning of treatment (Fig 1d), a supportive treatment protocol which included reinforcement of oral hygiene instructions and deplaquing was performed every 2 months for the first year. No recurrence of the lesion was noticed during the following 24 months and the teeth were maintained. During this period the patient became pregnant but continued to show up regularly for followup and maintenance visits every 3 months (Fig 4).
radiograph revealed horizontal bone loss which extended to the middle third of the root of the mandibular right canine (Fig 6). The etiologic factor was considered to be plaque and the lesion was found to be suitable for nonsurgical treatment based on the protocol used in the Department of Periodontology for the treatment of pyogenic granuloma. The patient was advised of the prognosis for the teeth involved, and made aware of the suggested treatment plan. The patient was given strict oral hygiene instructions as mentioned above (Case 1). Once she achieved optimal oral hygiene (full mouth plaque score < 15%) the treatment protocol began. Following the treatment the patient was followed up every 2 weeks for the first 2 months (Fig 5b), and full-mouth plaque scores were recorded. Eight months following the treatment, the lesion disappeared and the space between the relevant teeth was diminished (Fig 5c). After the disappearance of the lesion, a supportive treatment protocol which included reinforcement of oral hygiene instructions and deplaquing was performed every 2 months. No recurrence of the lesion (Fig 5d) and no significant changes in bone support (Fig 7) were observed around the relevant teeth during the follow-up period, which lasted 14 months. Inspection continues and the patient attends maintenance appointments every 3 months.
DISCUSSION CASE 2 A 65-year-old healthy woman was referred by the Department of Prosthodontics after presenting with a growth located in the mandibular right canine region (Fig 5a). The lesion had been excised by an oral surgeon 12 months earlier. The specimen was histologically diagnosed as pyogenic granuloma. The patient claimed that the lesion had gradually recurred 12 months after surgery. Clinical examination revealed a 5-mm red nodular lesion, located between the mandibular right lateral incisor and canine. The mandibular right canine exhibited a state of second-degree mobility based on the Miller index.12 The mandibular right central and lateral incisors were splinted together. A periapical
542
Pyogenic granuloma originates from a response of the tissues to various stimuli such as low-grade local irritation, traumatic injury, and sex hormones.13 Intraoral pyogenic granuloma most commonly arises in the gingivae, with this situation accounting for 75% of all cases.13 Pyogenic granuloma has distinct clinical and histopathologic features. While clinical diagnosis is often difficult due to lesions that are similar in appearance (for instance peripheral giant cell granuloma, fibroma, and vascular lesions), the histopathology shows distinctive features, including a highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed, lined with endothelium, and these are engorged with red blood cells. These vessels
VOLUME 46 • NUMBER 6 • JUNE 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Frumkin et al
a
b
a
b
c
d
Figs 4a and 4b Two years post treatment: (a) labial and (b) lingual view. Notice the healthy-looking gingiva and the stability of the soft tissues.
Figs 5a to 5d Follow-up pictures of patient 2. The initial presentation (a) is significant for an exophytic erythematous lesion on the gingiva between the mandibular right lateral incisor and canine. Two months later (b) the exophytic lesion is reduced in size and is less erythematous and edematous. Eight months later (c) there is no evidence of the lesion; however, a minimal edema of the papilla in between the involved teeth is still noticeable. Fourteen months later (d) the gingiva appears healthy.
Fig 6 Pretreatment periapical radiograph showing localized bone loss of the relevant tooth (mandibular right canine).
Fig 7 Periapical radiograph taken during follow-up; no significant changes in the bone support were observed around the relevant teeth.
are sometimes organized in lobular aggregates, and some pathologists require this lobular arrangement for the diagnosis.8 The surface is usually ulcerated and replaced with a fibrinopurulent membrane. A mixed inflammatory cell infiltrate of neutrophils, plasma cells, and lymphocytes is evident.8 The older lesions are more fibrous in appearance.8
The two cases presented in the present study had an official histopathologically confirmed diagnosis insofar as the two lesions had previously been resected. In both cases, bone loss was diagnosed. In the first case, bone loss was limited solely to the area of the relevant lesion, with no evidence of bone loss in other sites. This is an unusual presentation, reported in only a few case
VOLUME 46 • NUMBER 6 • JUNE 2015
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reports,14-16 and it might be explained by the excisional biopsy that was done in the area. Surgical excision of pyogenic granuloma lesions is currently considered to be the treatment of choice.2,5,7 Several reports have demonstrated a high rate of recurrence following the surgical approach. Recurrence is believed to result from incomplete excision. Gingival cases show a much higher recurrence rate than lesions from other oral mucosal sites.7 It is suggested that various irritants such as plaque and calculus are the major cause of the lesion’s high recurrence rate.1 Based on this hypothesis, we established a conservative nonsurgical protocol for treating the lesion and preventing recurrence; this involved removal of the irritating factors with debridement under local anesthesia, in combination with strict oral hygiene instructions and adjunctive chlorhexidine treatment. It must be emphasized that the oral hygiene phase included model and in-mouth demonstration.17 A similar protocol was previously described in a case report.18 To the authors best knowledge, this is the first case report in which recurrent pyogenic granuloma lesions were treated by means of a conservative approach. By specifically targeting the etiologic factor the lesion may disappear and the concept of cause-related therapy was implemented.19 The follow-up protocol included repeated visits to the clinic, every 2 weeks, for the first 2 months. These were followed by a maintenance appointment once every 2 months. The lesion disappeared in the two patients, and they were free of the lesion for the followup period, which lasted from 12 to 24 months.
benefit from using this protocol are medically compromised patients, owing to the prevention of surgical intervention.
REFERENCES 1. Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology: clinical pathologic correlations. St. Louis: Elsevier Saunders, 2012. 2. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol 1980;51:655–661. 3. Leyden JJ, Marples RR. Ecologic principles and antibiotic therapy in chronic dermatoses. Arch Dermatol 1973;107:208–211. 4. Bhaskar SN, Jacoway JR. Pyogenic granuloma – clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg 1966;24:391–398. 5. Al-Khateeb T, Ababneh K. Oral pyogenic granuloma in Jordanians: a retrospective analysis of 108 cases. J Oral Maxillofac Surg 2003;61:1285–1288. 6. Correll RW, Wescott WB, Siegel WM. Rapidly growing, nonpainful, ulcerated swelling in the posterolateral palate. J Am Dent Assoc 1983;106:494–495. 7. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci 2006;48:167–175. 8. Neville BW. Oral and Maxillofacial Pathology. Philadelphia, London: Saunders, 1995. 9. Mariotti A. Dental plaque-induced gingival diseases. Ann Periodontol 1999;4:7–19. 10. Henry F, Quatresooz P, Valverde-Lopez JC, Pierard GE. Blood vessel changes during pregnancy: a review. Am J Clin Dermatol 2006;7:65–69. 11. Lindhe J, Lang PN, Karring T (eds). Clinical Periodontal and Implant Dentistry. Oxford: Blackwell Munksgaard, 2008. 12. Miller SC. Textbook of Periodontia: oral medicine. London: Henry Kimpton, 1950. 13. Krishnapillai R, Punnoose K, Angadi PV, Koneru A. Oral pyogenic granuloma: a review of 215 cases in a South Indian Teaching Hospital, Karnataka, over a period of 20 years. Oral Maxillofac Surg 2012;16:305–309. 14. Goodman-Topper ED, Bimstein E. Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case. ASDC J Dent Child 1994;61:65–67. 15. Kirkham DB, Hoge HW, Bell WA. Severe alveolar bone loss associated with a pyogenic granuloma: a case report. J Wis Dent Assoc 1982;58:17–19. 16. Shenoy SS, Dinkar AD. Pyogenic granuloma associated with bone loss in an eight year old child: A case report. J Indian Soc Pedod Prev Dent 2006;24:201–203. 17. Ashkenazi M, Kessler-Baruch O, Levin L. Oral hygiene instructions provided by dental hygienists: results from a self-report cohort study and a suggested protocol for oral hygiene education. Quintessence Int 2014;45:265–269. 18. Chandrashekar B. Minimally invasive approach to eliminate pyogenic granuloma: a case report. Case Rep Dent 2012;2012:909780. 19. Kwon T, Levin L. Cause-related therapy: a review and suggested guidelines. Quintessence Int 2014;45:585–591.
CONCLUSION The results of a conservative nonsurgical treatment procedure for recurring pyogenic granuloma lesions in the present case report suggests that an alternative approach to the traditional surgical excision can be used for selected compliant patients, specifically those with large lesions located in an esthetic region. Using the present protocol in such cases would keep the soft tissue intact with no defects. Other patients who would
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VOLUME 46 • NUMBER 6 • JUNE 2015
GENERAL DENTISTRY
Nathalie Frumkin
Nonsurgical treatment of recurrent gingival pyogenic granuloma: A case report Nathalie Frumkin, DMD1*/Rizan Nashef, DMD2*/Lior Shapira, DMD, PhD3**/Asaf Wilensky, DMD, PhD4** Gingival pyogenic granuloma is a relatively common benign form of mucocutaneous lesion. Although surgical excision is considered to be the standard care, several reports have demonstrated a high recurrence rate of the lesion. In this case report a nonsurgical protocol to treat recurring gingival pyogenic granuloma and prevent further recurrence is
suggested. The protocol includes strict oral hygiene instructions, scaling, root planing, and maintenance treatment. To the best of our knowledge, this is the first report of conservative nonsurgical management of recurrent gingival pyogenic granuloma lesions. (Quintessence Int 2015;46:539–544; doi: 10.3290/j.qi.a33992)
Key words: pyogenic granuloma, nonsurgical treatment
Pyogenic granuloma or granuloma pyogenicum is a relatively common benign mucocutaneous lesion. The term pyogenic granuloma is a misnomer in that, contrary to what the name implies, the lesion does not contain pus and is not a granuloma.1 The incidence of pyogenic granuloma has been described as between 26.8% to 32% of all reactive lesions.2 Although it has been reported in all age groups, it occurs mainly between the ages of 11 and 40 years, with peak incidence in the third decade.3 Females are more susceptible.1 Oral sites of pyogenic granuloma 1
Postgraduate Student, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
2
Clinical Instructor, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
3
Associate Professor and Head, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
4
Lecturer, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Jerusalem, Israel.
*NF and RN contributed equally to the study. **AW and LS contributed equally to the study. Correspondence: Dr Asaf Wilensky, Department of Periodontology, Faculty of Dental Medicine, Hebrew University and Hadassah Medical Center, Ein Kerem, Jerusalem 91120, Israel. Email: [email protected]
VOLUME 46 • NUMBER 6 • JUNE 2015
can include the gingiva, lips, tongue, buccal mucosa, and palate.4 The lesion usually appears as a localized elevated lump with a sessile or pedunculated appearance. The surface may be smooth or lobulated, and when exposed to traumatic irritation it becomes ulcerated. The color may range from pink to red or purple.5 The lesion is wellvascularized (hyperplastic response), with a tendency for bleeding in response to even minor injury. Insofar as its etiology is related to minor injury or irritation (for example plaque), it is a reactive form of lesion.1,5 Gingival irritation resulting from calculus, plaque, overhanging edges, or rough restoration may represent the predisposing factors in the development of gingival pyogenic granuloma.5 It is possible that microulceration from these irritants in an already inflamed gingiva facilitates the ingress into the gingival connective tissue of low virulent oral microflora.5 The lesion generally develops rapidly, causing the erroneous clinical impression of a malignant tumor.6 It is, however, a benign soft tissue lesion of an inflammatory rather than neoplastic nature, arising from the connective tissue of the skin or mucous membrane.7
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Q U I N T E S S E N C E I N T E R N AT I O N A L Frumkin et al
The clinical features of pyogenic granuloma are indicative but not specific. A definitive diagnosis can therefore be made only by histopathologic examination of biopsy.1 Histopathologically, the lesion shows a highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed, lined with endothelium. The surface is usually ulcerated and replaced by a thick fibrino-purulent membrane, but it may also be lined with a layer of stratified squamous epithelial cells. A mixed inflammatory cell infiltrate of neutrophils, plasma cells, and lymphocytes is evident. Neutrophils are more prevalent near the ulcerated surface, with chronic inflammation evident in deeper layers.8 Since gingival pyogenic granuloma represents a benign lesion, surgical excision is today considered the treatment of choice.1 In order to prevent a possible recurrence, the gingival lesion must be excised down to the underlying periosteum, and predisposing irritants must be removed.8 According to the Journal of Periodontology, pregnancy-associated pyogenic granuloma may be categorized under the definition of “plaque-induced gingival diseases”; for this specific subgroup of gingival pyogenic granuloma another primary cause may be dental plaque, which can be predisposed by systemic factors (hormonal changes).9 The pregnancy-associated pyogenic granuloma has been reported to occur in 0.5% to 5% of pregnant women, usually regressing or completely disappearing following parturition. The etiology of pregnancy-associated pyogenic granuloma is thought to be related to changes in levels of sex hormones during pregnancy.7 These changes are frequently associated with functional and structural alterations of blood and lymph microvasculature of the mucosa.10 Although it may be regarded as a common procedure, the surgical resection of a gingival pyogenic granuloma may have ramifications. The possible negative outcomes, as for any other periodontal surgery, of surgical resection include impaired esthetics, dental sensitivity, postoperative swelling, infection, and recurrence of the lesion and incidental attachment loss due to the resective nature of the procedure.11 After excision, recurrence occurs in up to 16% of the lesions;
540
recurrence/persistence is believed to result from incomplete excision.2,4 It should be emphasized that gingival cases show a much higher recurrence rate than lesions from other oral mucosal sites.7 We hypothesize that since gingival pyogenic granuloma is actually an inflammatory lesion that is highly vascularized, an antiinflammatory/anti-infective therapy aimed at eliminating irritants and lowering infection may be an effective treatment which obviates the need for secondary surgical procedures, along with their potential consequences. In this case report, a nonsurgical treatment and maintenance protocol for the treatment of recurrent gingival pyogenic granuloma lesions is presented. This minimally invasive protocol eliminated the need for repeated surgery and prevented recurrence for 12 to 24 months following treatment. To the best of our knowledge, having reviewed the literature, this appears to be the first report of conservative nonsurgical management of a recurrent gingival pyogenic granuloma.
CASE 1 A 26-year-old healthy woman presented with a growth located in the mandibular anterior region (central incisors) (Fig 1a) which had recurred after having been excised and the area cleaned 6 months earlier by an oral and maxillofacial surgeon. The specimen was histologically diagnosed as pyogenic granuloma. The lesion had recurred 4 months after surgery. The patient noticed a gradual increase in size followed by tooth movement, and the condition caused her discomfort while eating. The treatment plan offered by the maxillofacial surgeon at that point was to extract the relevant mandibular central incisors, which were mobile, along with the excision of the lesion, which measured 10 mm. Upon referral to the Department of Periodontology, an intraoral examination revealed a pedunculated growth measuring 10 to 12 mm, bluish to red in color, multi-nodular, surrounding the mandibular incisors. The mandibular central incisors were mobile to the second degree, and the mandibular lateral incisors
VOLUME 46 • NUMBER 6 • JUNE 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Frumkin et al
a
b
c
d
Figs 1a to 1d Follow up pictures of patient 1. The initial presentation (a) is significant for an exophytic cauliflower-shaped lesion on the lingual gingiva between the mandibular central incisors. A month later (b) the exophytic lesion is reduced in size. The roots of the involved teeth are more exposed with recession of the surrounding gingiva, which is also less erythematous and edematous. Two months later (c) there is substantial shrinkage of the lesion, and a minimal erythema and edema is still noticeable. Four months following the treatment (d) the gingiva appears healthy.
were mobile to the first degree according to the Miller index.12 Calculus and plaque were noticed on the lingual aspect of the relevant teeth (Fig 1a) and was thought to be the etiologic factor. A periapical radiograph (Fig 2) revealed localized horizontal bone loss extending along the roots of the mandibular central incisors, leaving minimal bone support for the apical third of the relevant roots, with no other areas of bone or attachment loss. The patient was made aware of the decision to change the treatment plan from surgical excision of the lesion and extraction of the mandibular central incisors, to nonsurgical treatment of the lesion and maintenance of the central incisors. The patient was given strict oral hygiene instructions, including the use of regular and single-tufted toothbrushes and an interdental brush until the achievement of optimal oral hygiene (full mouth plaque scores of 8% to 14% were measured during the phase of therapy and maintenance). A splint, extending bilaterally between the mandibular canines, was made 3 weeks after the first
VOLUME 46 • NUMBER 6 • JUNE 2015
Fig 2 Pretreatment periapical radiograph of the mandibular central and lateral incisors. There is a horizontal, localized bone loss surrounding the relevant teeth.
examination in order to stabilize the periodontally relevant teeth. One week after splinting the teeth, the treatment protocol began. The patient underwent three cycles of debridement in the following 2 months. These treatments were done under local anesthesia, in combination with an adjunctive chlorhexidine rinse. Following the treatment, the patient was followed up every 2 weeks for the first 2 months (Fig 1b), full-mouth plaque
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Q U I N T E S S E N C E I N T E R N AT I O N A L Frumkin et al
Fig 3 Periapical radiograph of the mandibular central and lateral incisors after treatment for 3 months, showing stability in the bone support around the mandibular central and lateral incisors.
scores were recorded, and oral hygiene instructions were modified according to the state of the lesion. Three months following the treatment, the lesion had reduced in size significantly and a minimal erythema and edema were still noticeable (Fig 1c); the periapical radiograph showed stability in bone level, pronounced periodontal ligament, and bone mineralization (Fig 3). Following the disappearance of the lesion, 4 months after the beginning of treatment (Fig 1d), a supportive treatment protocol which included reinforcement of oral hygiene instructions and deplaquing was performed every 2 months for the first year. No recurrence of the lesion was noticed during the following 24 months and the teeth were maintained. During this period the patient became pregnant but continued to show up regularly for followup and maintenance visits every 3 months (Fig 4).
radiograph revealed horizontal bone loss which extended to the middle third of the root of the mandibular right canine (Fig 6). The etiologic factor was considered to be plaque and the lesion was found to be suitable for nonsurgical treatment based on the protocol used in the Department of Periodontology for the treatment of pyogenic granuloma. The patient was advised of the prognosis for the teeth involved, and made aware of the suggested treatment plan. The patient was given strict oral hygiene instructions as mentioned above (Case 1). Once she achieved optimal oral hygiene (full mouth plaque score < 15%) the treatment protocol began. Following the treatment the patient was followed up every 2 weeks for the first 2 months (Fig 5b), and full-mouth plaque scores were recorded. Eight months following the treatment, the lesion disappeared and the space between the relevant teeth was diminished (Fig 5c). After the disappearance of the lesion, a supportive treatment protocol which included reinforcement of oral hygiene instructions and deplaquing was performed every 2 months. No recurrence of the lesion (Fig 5d) and no significant changes in bone support (Fig 7) were observed around the relevant teeth during the follow-up period, which lasted 14 months. Inspection continues and the patient attends maintenance appointments every 3 months.
DISCUSSION CASE 2 A 65-year-old healthy woman was referred by the Department of Prosthodontics after presenting with a growth located in the mandibular right canine region (Fig 5a). The lesion had been excised by an oral surgeon 12 months earlier. The specimen was histologically diagnosed as pyogenic granuloma. The patient claimed that the lesion had gradually recurred 12 months after surgery. Clinical examination revealed a 5-mm red nodular lesion, located between the mandibular right lateral incisor and canine. The mandibular right canine exhibited a state of second-degree mobility based on the Miller index.12 The mandibular right central and lateral incisors were splinted together. A periapical
542
Pyogenic granuloma originates from a response of the tissues to various stimuli such as low-grade local irritation, traumatic injury, and sex hormones.13 Intraoral pyogenic granuloma most commonly arises in the gingivae, with this situation accounting for 75% of all cases.13 Pyogenic granuloma has distinct clinical and histopathologic features. While clinical diagnosis is often difficult due to lesions that are similar in appearance (for instance peripheral giant cell granuloma, fibroma, and vascular lesions), the histopathology shows distinctive features, including a highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed, lined with endothelium, and these are engorged with red blood cells. These vessels
VOLUME 46 • NUMBER 6 • JUNE 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L Frumkin et al
a
b
a
b
c
d
Figs 4a and 4b Two years post treatment: (a) labial and (b) lingual view. Notice the healthy-looking gingiva and the stability of the soft tissues.
Figs 5a to 5d Follow-up pictures of patient 2. The initial presentation (a) is significant for an exophytic erythematous lesion on the gingiva between the mandibular right lateral incisor and canine. Two months later (b) the exophytic lesion is reduced in size and is less erythematous and edematous. Eight months later (c) there is no evidence of the lesion; however, a minimal edema of the papilla in between the involved teeth is still noticeable. Fourteen months later (d) the gingiva appears healthy.
Fig 6 Pretreatment periapical radiograph showing localized bone loss of the relevant tooth (mandibular right canine).
Fig 7 Periapical radiograph taken during follow-up; no significant changes in the bone support were observed around the relevant teeth.
are sometimes organized in lobular aggregates, and some pathologists require this lobular arrangement for the diagnosis.8 The surface is usually ulcerated and replaced with a fibrinopurulent membrane. A mixed inflammatory cell infiltrate of neutrophils, plasma cells, and lymphocytes is evident.8 The older lesions are more fibrous in appearance.8
The two cases presented in the present study had an official histopathologically confirmed diagnosis insofar as the two lesions had previously been resected. In both cases, bone loss was diagnosed. In the first case, bone loss was limited solely to the area of the relevant lesion, with no evidence of bone loss in other sites. This is an unusual presentation, reported in only a few case
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reports,14-16 and it might be explained by the excisional biopsy that was done in the area. Surgical excision of pyogenic granuloma lesions is currently considered to be the treatment of choice.2,5,7 Several reports have demonstrated a high rate of recurrence following the surgical approach. Recurrence is believed to result from incomplete excision. Gingival cases show a much higher recurrence rate than lesions from other oral mucosal sites.7 It is suggested that various irritants such as plaque and calculus are the major cause of the lesion’s high recurrence rate.1 Based on this hypothesis, we established a conservative nonsurgical protocol for treating the lesion and preventing recurrence; this involved removal of the irritating factors with debridement under local anesthesia, in combination with strict oral hygiene instructions and adjunctive chlorhexidine treatment. It must be emphasized that the oral hygiene phase included model and in-mouth demonstration.17 A similar protocol was previously described in a case report.18 To the authors best knowledge, this is the first case report in which recurrent pyogenic granuloma lesions were treated by means of a conservative approach. By specifically targeting the etiologic factor the lesion may disappear and the concept of cause-related therapy was implemented.19 The follow-up protocol included repeated visits to the clinic, every 2 weeks, for the first 2 months. These were followed by a maintenance appointment once every 2 months. The lesion disappeared in the two patients, and they were free of the lesion for the followup period, which lasted from 12 to 24 months.
benefit from using this protocol are medically compromised patients, owing to the prevention of surgical intervention.
REFERENCES 1. Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology: clinical pathologic correlations. St. Louis: Elsevier Saunders, 2012. 2. Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol 1980;51:655–661. 3. Leyden JJ, Marples RR. Ecologic principles and antibiotic therapy in chronic dermatoses. Arch Dermatol 1973;107:208–211. 4. Bhaskar SN, Jacoway JR. Pyogenic granuloma – clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg 1966;24:391–398. 5. Al-Khateeb T, Ababneh K. Oral pyogenic granuloma in Jordanians: a retrospective analysis of 108 cases. J Oral Maxillofac Surg 2003;61:1285–1288. 6. Correll RW, Wescott WB, Siegel WM. Rapidly growing, nonpainful, ulcerated swelling in the posterolateral palate. J Am Dent Assoc 1983;106:494–495. 7. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci 2006;48:167–175. 8. Neville BW. Oral and Maxillofacial Pathology. Philadelphia, London: Saunders, 1995. 9. Mariotti A. Dental plaque-induced gingival diseases. Ann Periodontol 1999;4:7–19. 10. Henry F, Quatresooz P, Valverde-Lopez JC, Pierard GE. Blood vessel changes during pregnancy: a review. Am J Clin Dermatol 2006;7:65–69. 11. Lindhe J, Lang PN, Karring T (eds). Clinical Periodontal and Implant Dentistry. Oxford: Blackwell Munksgaard, 2008. 12. Miller SC. Textbook of Periodontia: oral medicine. London: Henry Kimpton, 1950. 13. Krishnapillai R, Punnoose K, Angadi PV, Koneru A. Oral pyogenic granuloma: a review of 215 cases in a South Indian Teaching Hospital, Karnataka, over a period of 20 years. Oral Maxillofac Surg 2012;16:305–309. 14. Goodman-Topper ED, Bimstein E. Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case. ASDC J Dent Child 1994;61:65–67. 15. Kirkham DB, Hoge HW, Bell WA. Severe alveolar bone loss associated with a pyogenic granuloma: a case report. J Wis Dent Assoc 1982;58:17–19. 16. Shenoy SS, Dinkar AD. Pyogenic granuloma associated with bone loss in an eight year old child: A case report. J Indian Soc Pedod Prev Dent 2006;24:201–203. 17. Ashkenazi M, Kessler-Baruch O, Levin L. Oral hygiene instructions provided by dental hygienists: results from a self-report cohort study and a suggested protocol for oral hygiene education. Quintessence Int 2014;45:265–269. 18. Chandrashekar B. Minimally invasive approach to eliminate pyogenic granuloma: a case report. Case Rep Dent 2012;2012:909780. 19. Kwon T, Levin L. Cause-related therapy: a review and suggested guidelines. Quintessence Int 2014;45:585–591.
CONCLUSION The results of a conservative nonsurgical treatment procedure for recurring pyogenic granuloma lesions in the present case report suggests that an alternative approach to the traditional surgical excision can be used for selected compliant patients, specifically those with large lesions located in an esthetic region. Using the present protocol in such cases would keep the soft tissue intact with no defects. Other patients who would
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