Working in pediatric dentistry, we see unique cases on a somewhat regular basis. Recently we had two different cases where a child presented with a sizable pyogenic granuloma. Pyogenic granuloma growths are very interesting as the growths can present themselves so differently each time. Some are flat, some are strawberry-like, and some look like cysts or round smooth lesions depending on the location. Recommended treatment is to excise the growth and to biopsy. Pyogenic granulomas occasionally recur, so patients (or their parents) are advised to monitor the area where the growth was removed.

What is pyogenic granuloma?

Pyogenic granuloma is reactive hyperplasia of connective tissue that can happen when exposed to local irritants. It is a tumor-like growth of the oral cavity, frequently located surrounding the anterior teeth or skin, considered neoplastic. Pyogenic granuloma is the most common of all oral tumor-like growths. While the terminology implies a benign neoplasm, most if not all fibromas represent reactive focal fibrous hyperplasia due to trauma or local irritation.¹

Research has found that the growths can form after exfoliation of a primary tooth as well. Pyogenic granulomas are highly vascular and bleed very easily. Cauterizing the tissue after removal will help reduce bleeding and recurrence.

Histology of pyogenic granuloma

Pyogenic granuloma is histologically classified into lobular capillary haemangioma (LCH) type and non-LCH type. LCH pyogenic granuloma is characterized by proliferating blood vessels that are organized in lobular aggregates. The non-LCH pyogenic granuloma shows vascular proliferation that resembles granulation tissue. The foci of fibrous maturation were seen in 15% of non-LCH pyogenic granuloma but were totally absent in LCH type of pyogenic granuloma.²

Clinical appearance

Pyogenic granulomas are usually a small red, oozing, and bleeding bump that looks like raw hamburger meat. The growths often seem to follow a minor injury and proliferates over a period of a few weeks to an average size of a half an inch. (3) How they look can vary depending on length of time the growth’s been present, location of the growth, and if the patient is constantly touching and playing with the growth. Pyogenic granulomas are often described as strawberry-like, as well, and have a lobulated base that makes them moveable. The growths are usually hard when palpated.

Who is most likely to get a pyogenic granuloma?

Pyogenic granuloma can occur at any age but is least common in the very young and the very old. It is seen most often in children, pregnant women ("pregnancy tumor"), and those taking the drugs Indinavir, Soriatane, Accutane, and oral contraceptives.³

The growths can form after exfoliation of a primary tooth, as well.

Our patients with pyogenic granuloma

We saw an 11-year-old boy with 20mm by 15mm by 13mm growth on his palate. The growth was pushing number 11 buccally, and it wasn’t present at the patient’s last visit six months ago. He had no pain and said it is just annoying when he eats. His mom was hoping the growth would go away on its own, but the dentist explained that since the growth has been progressively getting bigger it wasn’t likely that the growth would disappear. The dentist referred the patient to an oral surgeon for removal and biopsy and stressed to the patient’s mom the importance of addressing the issue of the growth before it creates any pain or issues with surrounding teeth. It is not common for pyogenic granuloma to be malignant, but best practice is to biopsy and remove the growth to make sure.

The other case was a 14-year-old girl who had a growth that was thin and bright red on the buccal of number seven right at the gingival margin; it was flat, and a flap-like growth of tissue. The patient didn’t even realize the growth was there until she was shown in a mirror. The growth appeared to have a very vascular tissue and bleed easily when touched. The patient said it didn’t bother her when the growth was being moved around and evaluated. The dentist thought the pyogenic granuloma was induced by trauma or hormone, and referred the patient to an oral surgeon for evaluation and removal.

References

1. Verma PK, Srivastava R., Baranwal HC, Chaturvedi TP, Gautam A, Singh A. Pyogenic granuloma - Hyperplastic lesion of the gingiva: Case reports. J. Open Dent. 2012. doi:10.2174/1874210601206010153
2. Veena R, Vasantha K, Chitra G, Seema G, Manoj S, Tharun V. Atypical Presentation of Capillary Hemangioma in Oral Cavity- A Case Report. JCDR. 2015. doi:10.7860/JCDR/2015/14276.6691
3. Pyogenic granuloma. American College of Dermatology. https://www.aocd.org/page/PyogenicGranuloma