Overview

Pyogenic granuloma is a benign non-cancerous vascular growth that affects the skin and mucous membrane. It is not an alarming condition, but its benign nature should not be confused with the more dangerous growth, as it can mimic some other lesions, such as cancer, due to its high proliferative potential. It easily bleeds and is often confused with some major vascular lesion,s such as hemangiomas.¹

The condition can be diagnosed easily by the physician through taking and reviewing a detailed patient history, as well as through clinical diagnosis. Pyogenic granuloma is predominantly found in the oral cavity and especially in assigned females at birth (AFAB).

The term PG (short for Pyogenic granuloma) is a misnomer; it is not caused due to any infectious agents, nor does it cause a granuloma formation. It has always been a controversy regarding its true pathological nature, it is given several names such asvascular epulis, fibroangioma, polypoid capillary hemangiomar and Hartzell’s disease.

It is usually caused by irritants, possibly as a result of side effects from certain drugs or it can even be due to oestrogen sensitivity during puberty and pregnancy. As it is not an alarming condition, physicians can educate the patient and reduce the apprehension of the affected individuals.²

Etiology 

The aetiology is usually due to some irritant or even trauma. One main originator could be a plaque, overhanging restoration, periodontitis or toothbrush trauma, which all cause this reactive type of growth. It could also be from hypersensitivity reactions to medication like cyclosporine, nifedipine, and phenytoin.

Additionally, as mentioned previously, hormonal levels, namely levels of oestrogen and progesterone, have been found to be elevated at the time of pregnancy and puberty. In pregnant individuals it is usually seen in the 2nd and 3rd trimesters. It is usually called pregnancy tumour or pyogenic gravidarum. It also exhibits the same histopathological features of PG. There is an imbalance in the angiogenic and anti-angiogenic factors, and it may also trigger some other important growth factors. These may eventually lead to proliferation of endothelial cells, blood vessels and fibroblasts.

PG is usually considered as a reactive lesion and it may lead to increased inflammatory activity, these inturn may cause increased remodelling and repair activity. So there is increased activity of inflammatory mediators, vascular endothelial cells and extracellular proliferation.^2,3

Clinical examination

PG is a benign non-neoplastic vascular proliferation of the skin and mucous membrane. It is found as a hyperplastic proliferation mainly in the form of granulation tissue in response to some insult or irritant. It usually responds to low-grade stimuli trauma, hormonal factors and certain drugs. Clinically, PG appears soft, often pedunculated, sometimes lobulated, reddish and ulcerated and bleeds easily due to its high vascularity.¹

Figure 1 shows the intraoral lesion of pyogenic granuloma in the interdental gingiva and tongue⁴

History

Patient history reveals a rapid proliferation, and bleeding easily. The patient might have experienced some hormonal changes recently, like onset of puberty, or the individual might be pregnant. As a result, some of the PG is often called pregnancy tumour. The patient might have had a recent trauma, poor oral hygiene with plague, overhanging restoration or periodontitis. They might give a history of taking medication, cyclosporine, phenytoin or even contraceptive pills. Drug history should always be considered.

Intraoral findings

Intraorally, it is usually seen in gingiva (75%) and less frequently in other areas like lip, oral mucosa, oral mucosa, tongue and palate. It can occur in the interdental area, that is, between the teeth and also anteriorly. Initially, it is reddish in colour, and later it turns to pale pink as fibrosis occurs.

Radiographic examination 

Radiographic examination is of least use in diagnosing PG. Intraoral periapical radiograph (IOPA) is often used for intraoral lesions. There will not be any specific radiographic findings except for some erosion. If the lesion occurs in the interdental area then mild bone loss is noted in relation to it.³

Biopsy and histopathological confirmation

The course of the lesion is mainly 3 phases early, called cellular phase, established called capillary/vascular phase and healing, called involutionary phase. The colour of the lesion also varies according to the phase of the lesion: pink/pinkish-white initially, then turns into reddish purple and at the end, pinkish-white.

Indication for biopsy

PG is a benign condition usually confused with aggressive lesion. In the initial stages, it can be confused with hemangiomas as well as Kaposi's sarcoma. The late stages can resemble fibroma, peripheral ossifying fibroma and peripheral giant cell granuloma, so that with a biopsy can a definitive diagnosis be ascertained.⁵

Histological features

There are two main types of PG, and it is called lobular capillary hemangioma (LCH) and non-lobular capillary hemangioma (NLCH). These terms should be used only histopathologically, and it should not be used as a clinical diagnosis. Furthermore, it should not be confused with the hemangioma, which is caused by the benign proliferation of blood vessels or endothelial cells. LCH is a term used when there is proliferation of capillaries in a lobular pattern, the epithelium, the outer portion of the connective tissue, is thinned out or even breaks can be observed, which bleeds easily. The second type, NLCH, does not have this specific arrangement; it is just seen as a granulation tissue and does not have any lobular arrangement⁶.

Figure 2 shows the biopsy finding in a histopathologically stained section with proliferation of endothelial cells and capillaries with inflammatory cells intervening.⁴

Treatment 

PG, when small or related to hormonal, can regress on its own. The larger lesions usually include complete surgical excision and the most acceptable one. The other treatment options are laser, sclerotherapy, shaving, curettage, corticosteroid injection and cryosurgery. In case of surgical excision root planing or complete removal of supra and subgingival calculus done and it should be important to remove the irritant. Oral hygiene management should also be considered.⁷

FAQs

How fast does a pyogenic granuloma grow?

It usually enlarges very fast and can reach half an inch within a week.

What is the risk of pyogenic granuloma? 

It does not cause any alarming risk except for hindrance in chewing and biting or it can cause bleeding as it is fragile.

What happens if we do not treat pyogenic granuloma?

It may cause frequent bleeding, and it can cause pain. 

PG in pregnancy be treated or not?

Usually, it resolves on its own when the hormonal imbalance is fixed and it regresses. If it is to be removed, the acts of shaving, excision or curettage should not be performed. Instead, complete surgical excision is necessary to avoid recurrence.

Should we treat all pyogenic granulomas?

All PG should not be treated as some of them, especially the smaller ones, resolve on their own, but the larger lesions would cause problems while having food and it can cause a disturbance in day-to-day activities. So it should be surgically removed, it is usually advisable to perform a complete surgical excision.

Summary 

PG is not an alarming condition, and usually, proper history and clinical diagnosis can arrive at a diagnosis. It is usually caused due to irritation, some medicine or due to hormonal changes in pregnancy and puberty. PG is the proliferation of capillaries or endothelial cells, and it can cause bleeding if bruised. It can be seen both in skin and mucous membranes. The oral cavity is the most commonly affected area, especially the gingiva. Biopsy should be done to rule out other lesions that mimic PG. Proper removal or excision of the lesion should be done to avoid its recurrence.