Introduction

Pyogenic granuloma is a benign neoplastic vascular proliferation that occurs on the skin and in the oral cavity. It is wrongly called pyogenic because it is not an infectious process and does not produce purulent drainage. It has also been called a benign pedunculated granuloma, lobular capillary hemangioma, vascular epulis, or gravid granuloma and pregnancy tumor when it occurs in pregnant patients^(1-3.

Background

Pyogenic granuloma can grow anywhere in the head and neck, torso, and limbs. When it occurs in the oral cavity, it is called oral pyogenic granuloma (OPG). The gingival area is the main site of onset, but it can also occur in the oral mucosa, cheeks, palate, lips, and, less frequently, the tongue^(4-6. Its etiology is still unknown, but it is believed to be associated with chronic trauma, local irritants, tartar irritation due to poor oral hygiene, medications such as cyclosporine, and hormonal changes^7-8.

Clinically it is usually a reddish lesion, which can show ulcerations and bleed easily, with a soft and lobular surface, and a pedunculated base⁹. It is usually a small lesion (<2 cm) and does not alter the alveolar bone⁽¹⁰. It has no age or sex predilection but appears more frequently in the second decade of life and in women^(11-13. Histologically, it can be classified as lobular and non-lobular capillary hemangioma. However, the lobular type has an endothelial lining and a layer of smooth muscle that is characteristic of venules and not of capillaries. Therefore, the best name would be lobular hemangioma ⁽¹⁴.

Its characteristics lead to a diversity of differential diagnoses such as peripheral odontogenic fibroma, hemangioma, inflammatory gingival hyperplasia, peripheral giant-cell granuloma, non-Hodgkin’s lymphoma, angiosarcoma, peripheral ossifying fibroma, Kaposi sarcoma^3,5.

The treatment of choice is surgical excision; some authors report no recurrence with this method^(15-16. However, recurrence is between 5.8% and 16%^(1,17. Conversely, follow-up studies after one year have shown no lesion recurrence when a modified excision with deep curettage is performed⁽¹⁸.

This study aims to report the case of a 9-year-old female patient who underwent oral pyogenic granuloma excision in the maxilla. The following year, she presented a possible lesion recurrence with alveolar bone loss and the mobility of an adjacent tooth. An excisional biopsy was taken, and thorough curettage was performed, confirming the diagnosis of oral pyogenic granuloma.

Clinical case

A 9-year-old female patient with no systemic history sought care at the Oral and Maxillofacial Surgery Service of the Teaching Dental Center of Universidad Peruana Cayetano Heredia for an apparent lesion recurrence at the posterior maxilla. The patient reported seeking care a year before and undergoing an excisional biopsy. The pathology report described a pyogenic granuloma. Clinical check-ups were carried out until she was discharged.

The intraoral clinical examination showed a tumor-like lesion that was painful to palpation and chewing at the marginal and alveolar gingiva level of teeth 1.4 and 1.5 (Fig. 1), approximately 3x3x3 cm in diameter, covering the buccal and palatal areas, and part of the clinical crown. Its consistency was firm, lobular, and pedunculated. It had a rough and bleeding texture when stimulated, with grade II mobility in tooth 1.4 (Fig. 2). The radiographic examination showed the alveolar crest’s effacement between teeth 1.5 and 1.4, with mesioangular and widened periodontal space 1.4 (Fig. 3). The presumptive diagnosis was pyogenic granuloma or peripheral giant-cell granuloma based on the evolution and clinical characteristics.

A rotation flap, excisional biopsy, and thorough curettage of healthy tissue were performed by removing 2 to 3 mm of the adjacent periosteum, and then the wound was sutured.

Clinical check-ups were performed after seven days (Fig. 4) and then after a week. The surgical wound had no dehiscence or secretions; it underwent a good healing process with stable sutures. The pathology report described a pyogenic granuloma, which confirmed its recurrence.

Fig. 1: Front view of mouth in occlusion showing lesion in quadrant I 

Figure 2: A: Front view of the lesion covering the buccal faces of teeth 1.4 and 1.5. B: Occlusal view of the lesion covering the palatal faces and part of the clinical crown of teeth 1.4 and 1.5 

Figure 3: Periapical radiography of the lesion-affected region showing clear horizontal alveolar bone loss between teeth 1.4 and 1.5. In addition, the mesioangular position of tooth 1.4 is clear 

Figure 4: The clinical check-up after seven days of evolution shows no dehiscence or secretions and a normal and favorable healing process 

Discussion

The diameter of the recurrent OPG (3 cm) was greater than that published in the literature. However, Rebolledo et al.⁽¹⁹ report that it can measure up to 4.5 cm in diameter.

Depending on the age, the oral pyogenic granuloma is more common in adult women than in men. However, OPG develops in boys more frequently than in girls ²⁰, so this case does not fit the epidemiological age and sex characteristics.

Root resorption caused by oral pyogenic granuloma is a rare condition, which usually occurs in cases with long evolution⁽²¹. Extensive alveolar bone loss and tooth mobility are observed in 3% of patients^(22). Shenoy et al.²³ reported the case of an 8-year-old boy with oral pyogenic granuloma associated with bone resorption. Goodman-Topper et al.⁽²⁴ also reported a case of oral pyogenic granuloma with alveolar bone loss in a 12-year-old boy. In addition, Ababneb et al.⁽²⁵ reported the case of a 28-year-old pregnant woman with the same lesion and alveolar bone loss. In this case, we observe alveolar bone loss in a recurrent lesion, a rare feature of OPG. Such resorption is likely to have occurred at the time of recurrence.

Differential diagnosis of OPG includes peripheral odontogenic fibroma, hemangioma, inflammatory gingival hyperplasia, peripheral giant-cell granuloma, non-Hodgkin lymphoma, angiosarcoma, peripheral ossifying fibroma, Kaposi sarcoma, lymphangioma, syphilis, tuberculous ulcer, and traumatic ulcer^(3,5,26. In this case, the OPG clinically simulated most of the above pathologies as differential diagnoses. Added to bone loss and tooth mobility, this makes diagnosis a real challenge. Therefore, pathological analysis was essential to reach an accurate diagnosis and treatment.

Recurrence occurs at intervals of 10 months to 1 year ⁽¹⁸, which coincides with this case. It is also known that recurrence would be associated with multiple factors, most prominently poor oral hygiene rather than systemic compromise. Our patient had good oral hygiene habits, so that factor was not decisive. However, emphasis was placed on improving oral hygiene also to prevent other oral diseases. Removing 2 mm of normal tissue and deep curettage help prevent lesion recurrence⁽¹⁸. Therefore, we performed thorough curettage by removing 2 to 3 mm of adjacent periosteum.

Conclusions

Oral pyogenic granuloma is a well-known benign lesion. However, when it does not present its most common characteristics, such as average size, evolution, and radiographic features, it becomes a challenge for diagnosis because a malignant lesion must be ruled out.

The safe diagnosis and treatment of oral pyogenic granuloma include excisional biopsy and thorough curettage, eliminating 2 to 3 mm of adjacent periosteum, thus preventing potential recurrence.

Recurrence of oral pyogenic granuloma may result in alveolar bone loss with tooth mobility. Therefore, the clinician should provide the proper treatment early to prevent lesion progression.