Case report

1. PYOGENIC
GRANULOMA

2. CASE HISTORY
◦41 years old Malay Male
◦U/L
1.Hypertension
-Tab Hovacs 10 mg

3. CHIEF COMPLAINT:
Swelling on tongue since 3 weeks

4. HISTORY OF PRESENTING ILLNESS
-Bleeding on tongue surface , stop after few
-Swelling gradually increase in size
-No altered sensation/pain/pus discharge/foul
smell

5. SOCIAL HISTORY
Was a tobacco cigarette smoker
Stop 3 years ago
Started to smoke vape
Stop vape after diagnosed with hypertension
No adverse habits

6. ◦EXTRA ORAL EXAMINATION
1. No gross facial asymmetry
2. TMJ :No abnormality detected
3. Lymph Nodes : Non palpable

7. ◦INTRA ORAL EXAMINATION
1. Poor oral hygiene
2. Multiple dental caries
3. Mouth opening : normal
4. Tongue : Can perform all tongue movements

8. ◦LESION ON TONGUE
1. Solitary pedunculated growth with well defined margin
2. Site : Dorsum , just anterior to sulcus terminalis
3. Size : 1cm x 1.5 cm
4. Shape : Oval
5. Colour of overlying mucosa : Pale pink
6. Surface : Smooth
7. Consistency :Firm
8. On palpation : Non tender

9. ◦DIFFERENTIAL DIAGNOSIS
1. Pyogenic granuloma
2. Irritational fibroma
3. Peripheral giant cell granuloma

10. ◦TREATMENT
1. Excisional biopsy under General Anaesthesia

11. HISTOPATHOLOGY
EXAMINATION

12. GROSS
1. A lobulated greyish tissue measuring 18 x 10 x 9
mm
2. Cut section shows greyish tissue with area of
hemorrhage
3. Entirely submitted in 1 block

13. ◦MICROSCOPY
1. Fragments of fibrocollagenous tissue covered by stratified squamous epithelium with areas of
ulceration filled with acute inflammatory exudate.
2. Tissue is composed of lobules of proliferating capillary-sized vascular channels lined by plump
endothelial cells with bland looking nuclei
3. Surrounding stroma is edematous and shows dense lymphoplasmacytic cells infiltrate mixed
neutrophils
4. Bacterial colonies also present
5. No atypia of endothelial cell,abnormal mitosis or malignancy seen.

14. FINAL DIAGNOSIS
Overall H/P features suggestive of Pyogenic
Granuloma

15. ◦ Soft tissue enlargements of oral cavity often present a diagnostic challenge because a diverse group
of pathologic process can produce such lesions.
◦ An enlargement may represent as
◦ Variation of normal anatomic structures
◦ Inflammation
◦ Cysts
◦ Developmental anomalies
◦ Neoplasm

16. ◦ Pyogenic granuloma is a common tumourlike growth of oral cavity that traditionally has been
considered to be non neoplastic in nature
◦ Although it was originally thought to be caused by pyogenic granuloma,it is now believed to be
unrelated to infection.
◦ In spite of its name,it is not a true granuloma

17. PYOGENIC GRANULOMA
Other names
1. Lobular Capillary Hemangioma
2. Pregnancy epulis/tumour
3. Benign vascular tumour
Its present name given by Crocker in 1903

18. ◦ETIOPATHOGENESIS
1. Unknown etiology
2. Local irritation or chronic trauma to tissue – provide pathway for invasion of non-specific types of
microorganism
3. Poor oral hygiene
4. Hormone :gingival enlargement during pregnancy

19. ◦CLINICAL FEATURES
1. Site : Gingiva (75% of all cases)
-lips , tongue , buccal mucosa and occasionally on other areas
-Maxillary anterior > posterior ;Buccal > lingual
2. Appears as sessile / pedunculated growth
3. Surface :smooth / lobulated / ulcerated
4. Colour :red – purple – pink
5. Size – few mm to several cm in diameter

20. 6. Painless
7. Easily bleed
8. Rapid growth

21. ◦ HISTOPATHOLOGIC FEATURES
1. Highly vascular proliferation – resembles granulation tissue
-Organised in lobular aggregates ; Lobular capillary hemangioma
2. Ulcerated surface – replaced by thick fibrinopurulen membrane
3. Mixed inflammatory cell infiltrate of neutrophils,plasma cells and
lymphocytes.
4. More fibrous appearance-in older lesion

22. ◦TREATMENT
Conservative surgical excision
-For gingival lesions :excision should extend down to periosteum and adjacent tooth :thoroughly
scaled
-Should include few mm of healthy tissue
Pregnancy epulis :Treatment is deferred as it will resolve spontaneously after parturition