Case Presentation

1. CASE PRESENTATION
SaiVeena
Pg 1st Year

2. • Name: Sudhakar
• Age: 52
• Sex: Male
• Occupation: Private Employee
• Chief complaint:
Patient complaints of growth in the right upper back
tooth region since 3 months.

3. HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months back. Then he
noticed small growth in the right upper back tooth region which
initially was very small and gradually increased to present size.
H/O bleeding from that area was noticed at times during brushing.
H/O difficulty in chewing food
PAST MEDICAL HISTORY : No relevant medical history
PAST DENTAL HISTORY: He visited a private hospital at his
home town for the same reason where they advised OPG.

4. DRUG HISTORY: No known drug allergies
FAMILY HISTORY: No relevant history
PERSONAL HISTORY:
Diet: Mixed
Apetite: Regular
Sleep: Undisturbed
Bowel&Micturiton habit: Regular
Oral hygiene measures: Poor
Adverse habits: Occasional Alcoholic
No parafunctional habits

5. GENERAL EXAMINATION
Patient is conscious, coherent, cooperative and well
oriented with time and place.
Patient is moderately built and nourished.
No signs of pallor, icterus and cyanosis
Height: 6.0”
Weight:75kgs
VITALS: 18/3/19
BP- 140/80 mm of hg
Pulse : 76bpm
Respiratory rate : 16 cycles/min

6. EXTRA ORAL EXAMINATION
INSPECTION AND PALPATION:
• Face appears apparently symmetrical.
• Mouth opening: adequate (38mm)
• TMJ: No abnormality detected
• Lymph nodes : Not palpable

7. INTRAORAL EXAMINATION:
INSPECTION OF REGION OF INTEREST:
 A pinkish red exophytic kind of growth is seen along the
buccal and palatal gingiva irt 17 18 region.
 Antero-posteriorly extending from buccal groove region
of 17 to mid half of 18 buccally and palatally
 Medio-laterally from gingivobuccal sulcus to 2.5cm
(approx) over the palatal mucosa.
Other intraoral findings:
Tongue: No abnormality detected.
Oral hygiene status: Poor

8. • Missing 36
• No deranged occlusion
• Lingual tori irt 32 33 43 44 45
PALPATION:
• Soft in consistency, irregular surface,
lobulated
• Non tender
• Minute bleeding is noticed on palpation
• Pulsations are felt on the palatal growth.

9. PROVISIONAL DIAGNOSIS
Vascular lesion involving the right posterior
alveolus and palate

10. • DIFFERENTIAL DIAGNOSIS
Peripheral giant cell granuloma
Peripheral ossifying fibroma

11. INVESTIGATIONS
OPG
Complete blood picture
Bleeding time
Clotting time
ESR

14. • Local infiltrations were given in the region of the lesion buccally using as 2%
lignocaine HCL with 1:80000 adrenaline concentration.
• The buccal extension of the lesion measuring 1*0.5cm was excised and the
bleeding points were cauterised using monopolar and bipolar.
• Patient was kept under observation.
• Guaze packed soaked in adrenaline was placed.
• Inj.Tranexamic acid 2ml(IV) was given.
• Instructions and medications (Ethamsylate )were given.
• The excised specimen was sent for histopathological examination.

16. • FURTHER TREATMENT PLAN
• Injection of sclerosing agent sodium tetradecyl sulfate into
the lesion.
• Once the mass reduces in size excisional biopsy is adviced.
FINAL DIAGNOSIS
“PYOGENIC GRANULOMA”

17. • Vascular anomalies are a wide range of conditions that
result in an abnormal number, structure, or position of
blood vessels.
• Vascular lesions of the maxillofacial region are
classified by Mulliken and Glowacki (1982).
DISCUSSION

18. CLASSIFICATION

19.  Pyogenic granuloma (PG), also known as lobular capillary hemangioma, is a common, acquired,
benign vascular proliferation of the skin and mucous membrane.
 Oral PG is a common, tumor-like, exaggerated tissue response to a localized low-grade irritation
or minor trauma, or hormonal factors such as in lesions occurring during pregnancy and at
puberty.
 Clinically, a PG appears as a smooth mass, or the lesion exhibits a lobular architecture that is
usually pedunculated, although some lesions are sessile.
 The amount of vascularity determines the surface color and the age of the lesion. While newly
developed lesions tend to be highly vascular and bluish or purple in color with a tendency to
bleed and ulcerate even with minor trauma, older lesions are more fibrotic and pink in color.
 They vary from small growths only a few millimeters in size to larger lesions that may measure
several centimeters in diameter.
 Typically, the mass is painless, although it often bleeds easily because of its extreme
vascularity.

20. Oral PG shows a striking predilection for the gingiva.
The lip, tongue, and buccal mucosa are the next common sites.
It is most common in children and young adults with definite female predilection (female to
male ratio of 2:1), possibly because of the vascular effects of female hormones. Pyogenic
granuloma of the gingiva develops in pregnant women frequently; therefore, the terms
pregnancy tumor or granuloma gravidarum are often used.
The differential diagnosis of PG includes peripheral giant cell granuloma, peripheral
ossifying fibroma, and hemangioma. The final diagnosis is mainly based on biopsy and
histopathological examination.
Oral PG can be treated by conservative excision.
Local irritants or the source of trauma must be eliminated to minimize the risk of
recurrence. Although, surgical excision is considered a simple procedure, it might be
complicated by several complications such as intraoperative bleeding, and postoperative
infection that might delay the healing of the wound.
Other treatment modalities such as cryosurgery,Nd:YAG,Er:YAG,diode laser scan also be
used.

21. Case Report
A 51-year-old female, with a long history of uncontrolled type II diabetes
mellitus
complaint of a localized gingival growth for more than 2 years
Diagnosis: PYOGENIC GRANULOMA

22. MANAGEMENT
 Medical
Steroids:
-Intralesional
-Systemic
Interferon therapy
Sclerosing agents
Beta-blockers
 Surgical
Surgical excision
Pulsed dye lasers
Cryotherapy
Surgical ablation
Radiation

23. SCLEROTHERAPY:
 Percutaneous sclerotherapy is the first-line treatment.
 It is widely accepted to be well tolerated by patients,
is simple, fast, and cheap, and can be done in out
patients.

24.  Sterile technique usually performed under sedation or general
anesthesia.
 Sodium tetra decyl sulphate, sodium morrhuate, Absolute ethanol
(98%), boiling water, nitrogen mustard, sodium psylliate Bleomycin
and polidocanol are commonly used sclerosing agents.
The quantity of injected sclerosing agents and the number of
applications during the sclerotherapy treatment depend on the size
and location of the lesion and involvement of adjacent structures.

26. ETHANOL:
Most powerful sclerosing agent with the highest
toxicity.
Treatment with ethanol causes pain and swelling in all
patients, and the incidence of damage to adjacent skin,
nerves, and muscle, is higher than with other agents.

27. Sodium tetradecyl sulphate:
Sodiumtetradecylsulphate (STS) has been used as a
sclerosant since 1946, most commonly to treat varicose
veins of the lower limb.
Historically, it was injected directly in to a malformation
in liquid form but foam sclerotherapy has given better
outcomes because it increases contact with the
endothelium.
BLEOMYCIN:
Success rates of 88% have been reported.
Pain, nerve damage, and inflammation and necrosis of the
skin.

28. Advantages of sclerosing agent
• Simple and inexpensive
• No loss of blood
• No hospitalisation required
Disadvantages of sclerosing agent
• Postoperative pain and the patient must be managed
with moderate-level analgesic
• Anaphylactic reaction
• Tissue necrosis and sloughing (4%)
• Temporary myoglobinuria (2%)
• Airway compromise (1%)

29. POST SCLEROTHERAPY COMPLICATIONS:
 Pain, oedema, and localised inflammation as well as mild fever
are expected for 24 to 48 hours postsclerotherapy.
 Depending on the agent used,
-skin necrosis, nerve damage and cardiac arrhythmia (ethanol)
-skin erosion and infection
-alopecia, skin discolouration, and pulmonary fibrosis
(bleomycin)

30. 3% sodium tetradecyl sulphate was injected intralesionally
at multiple sites, first at the periphery and then into the
centre of the lesion with insulin syringe. 0.1–1 ml of STS
was injected in one sitting depending upon the size of
lesion.
Injection was repeated after an interval of 2 weeks. Up to
10 injections were given in larger lesions.
Sunita Agarwal. Treatment of Oral Hemangioma with 3% Sodium Tetradecyl Sulfate: Study
of 20 Cases. Indian J Otolaryngol Head Neck Surg (July–September 2012) 64(3):205–207

31. Parvathidevi M K, Shrinivas Koppal, Thriveni Rukmangada, Amit R Byatnal. Management of
haemangioma with sclerosing agent: a case report . BMJ Case Rep 2013.
Sclerotherapy is effective for small superficial vascular
lesions. In this study, the use of sclerosing agent as a
treatment resulted in complete regression of the lesion
without any collateral anastomosis.

32. THANK YOU