Oral to the entity ‘pyogenic granuloma’. Most commonly
Oral Telangiectatic Granuloma: A Case Report ABSTRACTTelangiectatic Granuloma usually evolves as a solitary, pediculated, granuloma-like, easily bleeding tumor. It is one of the other names given to the entity ‘pyogenic granuloma’. Most commonly involves gingiva in the oral cavity. Extragingivally, it can be manifested on the tongue, palate, floor of the mouth, lips. Generally, it appears as a small pinkish soft tissue swelling, ranging from few millimeters to few centimeters in size.
Rapid growth of these granulomas can be alarming. If left untreated, numerous telangiectatic granulomas undergo fibrous maturation to resemble or form fibromas. Here, a case of telangiectatic granuloma and its management has been presented.
Key words: Telangiectatic Granuloma, Pyogenic Granuloma, Oral, Human botryoomycosisINTRODUCTIONSoft tissue growths in the oral cavity often creates a diagnostic challenge for the dentists as a huge variety of pathologic processes can create such lesions. A soft tissue growth can be characterized by a variation of normal anatomic structures, developmental anomalies, inflammation, cysts as well as neoplasm. These lesions comprises of a group of reactive hyperplasias, which appear as an exuberant or excessive tissue repair response to a chronic, recurring tissue injury.1Oral telangiectatic granulomas constitute a group of oral lesions which are benign and hyperplastic in nature, occurring in response to trauma or chronic irritation. Earlier, these lesions were synonymous with “pyogenic granulomas.
” However, this term has been found to be a misnomer as it does not wholly reflect the features of this lesion, due to absence of pus, thus can’t be considered as a true granuloma.2It is considered as an exaggerated tissue response to a local irritation or trauma. Various terms have been used for this lesion such as, ‘hemangiomatous granuloma’, ‘lobular capillary hemangioma’, ‘vascular epulis’, ‘benign vascular tumour’ and ‘pregnancy tumour’ in pregnant women. Sometimes, a recent extraction socket can be a source of this nonspecific granulation tissue resembling a pyogenic granuloma.
Such lesions are termed as “epulis granulomatosum”.3-5CASE REPORTA 46?year?old male patient reported to our department with the chief complaint of a swelling in mandibular front tooth region of the jaw since 4 months. The patient had noticed a small growth on the lingual aspect of the mandibular anterior teeth 4 months back, which had suddenly increased to the present size. The patient did not have any deleterious habits or systemic disease. His medical, dental and drug histories were non-contributory. On physical examination, he appeared to be healthy and of normal size and weight.
Other general physical examinations were within normal range. The clinical examination Figure-1 revealed an exophytic, round pedunculated lesion in lingual vestibule in relation to mandibular anterior teeth region that measured 2 cm in diameter. It was a firm, nontender growth, pale pink in color with smooth overlying surface. There was minimal bleeding on probing, and no purulent discharge. Figure -1: Preoperative lesionAn intraoral periapical radiograph Figure-2 revealed no periapical radiolucency and horizontal bone loss in relation to mandibular anterior teeth. Laboratory investigations (complete blood profile) revealed no abnormalities in the blood counts.
Poor oral hygiene was also observed. On the basis of clinical examination and history, a provisional diagnosis of telangiectatic granuloma was made with a differential diagnosis of a fibroma. Figure-2: Intraoral radiograph in relation to teeth involvedThe initial phase of treatment comprised of nonsurgical periodontal therapy? oral hygiene instructions, scaling and root planing. It was then followed by an excisional biopsy, along with a histopathologic evaluation for final diagnosis purpose. Figure-3. Figure-3: Gross Specimen of the lesion and intraoral view after surgical excisionThe histopathologic examination Figure-4 revealed granulation tissue with a non malignant proliferation of the endothelial cells, with formed blood cells and acute, chronic inflammatory cells infiltration in a collagenous matrix. The surface of the lesion was smooth with parakeratinized stratified squamous epithelium and areas of atrophy.
These findings were suggestive of a telangiectatic granuloma. Figure-4: Photomicrograph (H ; E stained) The patient was recalled every 3rd month for maintenance and to evaluate any recurrence. The case was followed up for a duration of 1 year and no recurrence has been observed till now Figure-5. Figure-5: Post operative view after 1 yearDISCUSSIONDental surgeons frequently encounter pyogenic granuloma of the oral cavity in their daily clinical practice. However, very few have referred to such lesions as Oral Telangiectatic granuloma. This term has been used as an alternative term or synonym for pyogenic granuloma as a number of blood vessels are seen in these lesions.
6These lesions were first reported by Poncet and Dor in 1897 and was referred as botryomycosis hominis. A variety of other names have been given to this lesion till then such as granuloma pediculatum benignum, benign vascular tumor, pregnancy tumor, vascular epulis, Crocker and Hartzell’s disease. Its present name was given by Crocker in 1903.7 Hartzell in 1904 introduced the term “pyogenic granuloma” that is widely used by researchers, although, it does not express accurately the clinical or histopathologic features.8Due to the presence of numerous blood vessels in oral pyogenic granuloma, alternative term for pyogenic granuloma is suggested as granuloma telangiectacticum.6The differential diagnosis of telangiectatic granuloma includes irritation fibroma, hemangioma, benign salivary gland tumours and tumours of the oral soft tissues, Kaposi’s sarcoma and leiomyoma. Although it can be diagnosed clinically with considerable accuracy, radiographic and histopathological investigations aids.
9The management of oral telangiectatic granuloma involves maintaining good oral hygiene, curettage of the lesion base, surgical excision to decrease the frequency of recurrence, accompanied by antibiotic and analgesic therapy. The other conventional surgical modalities include cryosurgery, Nd: YAG and CO2, and flash lamp pulsed dye lasers.10 In accordance with the available literature, our treatment plan consisted initially of oral hygiene instructions, scaling, root planing along with antibiotics and analgesics. It was then followed by surgical excision of the lesion, its biopsy and subsequent histopathological examination.
CONCLUSIONThe occurrence of oral lesions presents a diagnostic dilemma for dentists. The correct diagnosis of these lesions is often challenging due to their clinical resemblance to other inflammatory tumours, as well as to some true neoplasms of the oral cavity. Therefore, it is very necessary to make a proper diagnosis for adequate treatment.
REFERENCES1) Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012; 16(1): 79–82.2) Regezi JA, Sciubba JJ, Jordan RC, editors. Red?blue lesions. In: Oral Pathology: Clinical Pathologic Correlations.
4th ed.Philadelphia: WB Saunders; 2003. p. 115?6.3) Karthikeya P, Mahima VG, Lahari K. Exragingival pyogenic granuloma.
Indian J Dent Res. 2006;17(4):199–202.4) Akyol MU, Yalciner EG, Dolan AI. Pyogenic granuloma (lobular capillary hemangioma) of the tongue. Int J Pediatr Otorhinolaryngol. 2001;58(3):239–41.
5) Graham RM. Pyogenic granuloma: an unusual presentation. Dent Update.
1996;23:240–41. 6) Cawson RA, Binnie WH, Speight PM, Barrett AW, Wright JM, editors. Benign fibrous tumors. In: Lucas Pathology of Tumors of Oral Tissues. 5th ed. Missouri: Mosby; 1998.
p. 252?4.7) Bhaskar SN, Jacoway JR. Pyogenic granuloma – clinical features, incidence, histology, and result of treatment: Report of 242 cases. J Oral Surg.
1966;24:391–8.8) Angelopoulos AP. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features. J Oral Surg. 1971;29:840–7.9) Ramirez K, Bruce G, Carpenter W. Pyogenic granuloma: case report in a 9-year-old girl.
General Dentistry. 2002;50(3):280–81.10) Ricardo JH, López A, Romero K. Oral telangiectatic granuloma.
Case series presentation. Rev Fac Odontol Univ Antioq 2012;23:366?75.