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A 6-year-old girl was referred for assessment of an oral soft tissue swelling in the anterior maxilla. An asymptomatic, large, erythematous soft tissue mass developed on the alveolar ridge following the loss of the deciduous upper central incisor. Following excision of the lesion, a diagnosis of pyogenic granuloma was confirmed. This case demonstrates the unusual presentation of a pyogenic granuloma in a younger child. These lesions can arise as a reactive response to various stimulating factors and can grow rapidly. Management often involves excision but recurrence risk can be high.
CPD/Clinical Relevance: Dentists should not only be aware of the common oral soft tissue changes but should also familiarize themselves with lesions that can occur atypically in children.
Article
Introduction
Clinical features
A pyogenic granuloma (PG) is a benign, vascular growth of the skin and mucous membranes.1,2 They are commonly found on the skin but rarely in the gastrointestinal tract, with the exception of the oral cavity,3 where they usually arise on the gingiva.4 PGs are typically soft, red-purple swellings which can display ulceration and bleed readily. They often present as smooth or lobulated lesions and can be either sessile or pedunculated.1 PGs are more likely to occur in the maxilla than the mandible, and anteriorly more often than posteriorly.5 They can increase in size rapidly and some have reported significant bone loss in the area of the lesion,6 with no malignant potential.
Incidence
Higher incidence in females2 during the second decade of life;7
Bhaskar et al8 reported an incidence for PGs of 1.85%, whilst Kadeh et al9 reported PGs to constitute 37% of all oral lesions in the adult populations studied;
Limited data reporting incidence rates for children.
Histopathology
PGs show vascular proliferation with an oedematous cellular fibrous stroma and areas of inflammatory cell infiltration.2 Two distinct histological types of pyogenic granuloma have been described; Lobular Capillary Haemangioma (LCH) and non-Lobular Capillary Haemangioma (non-LCH).1 LCH is characterized by proliferation of capillaries into lobes, whilst the non-LCH type consists of areas of vascular proliferation.10
Aetiology
The exact aetiology of PG is unclear but is believed to develop as an exaggerated, localized response to several aggravating factors including:
Repeated trauma;
Certain drugs;
Plaque or calculus;
Hormonal factors.
PGs are also commonly associated with pregnancy and higher levels of oestrogen and progesterone.10 In one case report, a PG had developed in a 19-month-old child, following trauma to a deciduous incisor.11
Diagnosis
Upon identifying any soft tissue abnormalities, it is important to consider a range of differential diagnoses. A biopsy is valuable not only in providing a definitive diagnosis, but also aids management. Clinically, PG can mimic several other lesions.5,12 Some of these have been listed in Table 1.
Peripheral giant cell granuloma
Peripheral ossifying fibroma
Metastatic cancer
Haemangioma
Pregnancy tumour
Conventional granulation tissue
Hyperplastic gingival inflammation
Kaposi's sarcoma
Bacillary angiomatosis
Angiosarcoma
Non-Hodgkin's lymphoma
Treatment
Treatment involves biopsy by surgical excision of the lesion at its base and removal of causative factors (including plaque, calculus, trauma source and foreign bodies). Nd YAG laser has been used with success, particularly in control of haemostasis of these vascular lesions.13 A flash lamp pulsed dye laser14 and cryosurgery15 can also be used to treat oral PGs. Maintenance of good oral hygiene and prevention of aggravating factors must be encouraged in the post-operative period to prevent recurrence.
Recurrence
Reported recurrence rates following surgical excision vary from 5.8%16 to 23.3%;2
Recurrence is influenced by the following factors; incomplete excision, failure to remove causative factors, re-injury of the area and pregnancy.
Case report
The case of an unusual presentation of PG in a paediatric patient is described. A 6-year-old girl was referred, on an urgent basis, by her General Dental Practitioner (GDP) to the Paediatric Dentistry Department at King’s College London Dental Institute for assessment of a soft tissue swelling on the anterior maxilla gingivae (Figure 1). Her medical history was unremarkable and there were no known drug allergies.
Figure 1. Pyogenic granuloma at initial presentation.
The upper left primary central incisor had exfoliated two weeks prior to referral being made, and the patient’s mother reported a history of a ‘growth of the gum’ following loss of the tooth.
Examination revealed a soft tissue mass, which displayed gingival enlargement over the alveolar ridge in the region of the upper central incisors, measuring approximately 15 x 10 mm in diameter (Figure 2). The mass was red-purple in colour, well-defined and lobulated. It was erythematous with keratinized tissue, showing sloughing on the surface in contact with opposing lower incisors. There was no cervical lymphadenopathy.
Figure 2. Occlusal view of upper arch demonstrating size of lesion and occlusal trauma from lower incisors
Interestingly, the patient reported no pain or discomfort and her mother reported that there had been no episodes of bleeding, despite its position. Both deciduous upper central incisors had exfoliated and the permanent successors had not yet erupted. Multiple carious deciduous teeth, evidence of tooth surface loss and an increased overbite were also noted. The lower incisors appeared to be traumatizing the soft tissue mass when in occlusion. The patient’s oral hygiene was poor. Her mother reported twice daily brushing with a fluoride-free toothpaste.
An OPG was taken to assess the developing dentition. Caries was evident in all of the primary molars, with a periapical radiolucency associated with the grossly carious lower right first and second deciduous molars. An upper standard occlusal was taken to ensure that there was no pathology related to the hard tissues in the area of the soft tissue mass, which revealed no apparent abnormalities (Figure 3).
Figure 3. Pre-operative upper standard occlusal radiograph revealed no apparent bony or dental abnormalities.
The opinion of Oral Medicine colleagues was sought and, with a likely diagnosis of a pyogenic granuloma, excisional biopsy was agreed. Based on the history and clinical examination, the following differential diagnoses were considered:
Pyogenic granuloma;
Fibrous epulis.
Due to the age of the child and the number of carious teeth present, treatment under general anaesthetic was agreed with the parent. Consent was taken for excisional biopsy of the soft tissue mass, along with extraction of the carious deciduous teeth under general anaesthetic. The risks discussed included potential increased bleeding at the biopsy site and risk of recurrence of the lesion.
The treatment was carried out on a comprehensive care list in the day surgery unit three weeks after initial presentation. Intra-operatively, the soft tissue mass was found to be pedunculated and so, with careful excision, the lesion was removed. Haemostasis was achieved with pressure using gauze and tranexamic acid topically. No sutures were required, as had initially been anticipated.
A follow-up appointment was arranged three weeks post-operatively. On review, the patient reported no post-operative complications. Both upper central incisors were partially erupted and the gingiva had healed well, with the gingival margins around the erupted teeth appearing healthy (Figure 4).
Figure 4. Post-operative view taken at review shows eruption of permanent incisors and healing of gingival tissues following excision of lesion
The histopathology report of the excised lesion described a nodular mucosa covered by stratified squamous epithelium with focal ulceration. The underlying stroma contained a proliferation of capillaries and was densely infiltrated by mixed acute and chronic inflammatory cells. There was no evidence of dysplasia or malignancy and a diagnosis of a pyogenic granuloma was confirmed.
Discussion
The parent of the child was understandably alarmed by the sudden appearance of the lesion and its rapid rate of growth. Despite the atypical presentation in a young child, a likely diagnosis of PG was confirmed by an Oral Medicine specialist, which provided some reassurance for the parent. This emphasizes the importance of general dentists’ familiarity with both common and uncommon oral pathology that can present in paediatric patients, in order to be able to provide some degree of reassurance and certainly to avoid any undue distress. Similarly, awareness of local referral pathways for lesions that warrant an urgent assessment.
Surgically, the intra-operative bleeding risk and post-operative haemostasis were potential challenges due to the high vascularity of the lesion and the initial appearance, pointing to a sessile rather than pedunculated lesion. The potential use of diathermy and suturing were anticipated and prepared. Rigorous post-operative instructions regarding bleeding were reinforced.
The family were made aware of the recurrence risk and potential need for further surgery. There was more than one potential aetiological factor in this case, including prolonged mobility of the deciduous tooth and/or trauma from the lower incisors due to the increased overbite.
Conclusion
General Dental Practitioners should not only be aware of common soft tissue changes and lesions, but also familiarize themselves with the less common changes that can be seen in paediatric patients. This will help in providing some reassurance to the family. It is important that GDPs are able to identify local referral pathways to secondary care and identify cases that warrant an urgent referral.
