Pyogenic Granuloma of Tongue in a 14-year-old Child: A Case Report
Corresponding Author: Veena Arali, Department of Pediatric and Preventive Dentistry, GSL Dental College & Hospital, Rajahmundry, Andhra Pradesh, India, Phone: +91 7760748787, e-mail: firstname.lastname@example.org
Received on: 23 January 2023; Accepted on: 11 March 2023; Published on: 22 April 2023
Introduction: Pyogenic granuloma (PG) is also known by various names such as granuloma pyogenicum or lobular capillary hemangioma. It is a well-known benign vascular oral lesion which commonly presents on skin and mucosa with an unknown etiology. Although the gingiva is the site of occurrence of most of pyogenic granulomas of the oral cavity, literature reports rare presentations in other sites, including the lips, tongue, palate, and oral mucosa.
Case details: 14-year-old male patient presented to the department of Pediatric and preventive dentistry with the chief complaint of growth on the tongue since three months. The growth was slow, and initially it began as a pea-sized lesion which grew to its present size gradually. A solitary, exophytic, palpable, nontender, pedunculated growth was found intraorally on examination in the anterior two thirds of dorsum of tongue. Electrocautery was done to remove the entire lesion.
Discussion: PG is diagnosed clinically based on characteristic history and clinical findings. It is a rapidly growing lesion with either smooth or lobulated surface, pedunculated or sessile, with erythematous surface which becomes pale on maturation and varies in size. Long standing trauma and gingival irritation caused by faulty tooth brushing may be one among the contributing factors. Though many treatment modalities exist, such as laser ablation, excision using Nd:YAG laser, cryosurgery, curettage, electrical cautery, chemical cauterization, surgical excision of the lesion, involving 1–2 mm of surrounding normal tissue, remains the treatment of choice.
How to cite this article: Mavuri PP, Arali V, Rapala H, et al. Pyogenic Granuloma of Tongue in a 14-year-old Child: A Case Report. J South Asian Assoc Pediatr Dent 2023;6(1):45-48.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
Keywords: Benign lesions of oral cavity in children, Granuloma pyogenicum, Pyogenic granuloma, Tongue.
Pyogenic granuloma (PG) is a tumor-like growth that is considered an inflammatory response to minor trauma or trauma to the oral tissue. The term PG is based on heterogeneous skin lesions thought to be caused by pyogenic organisms.1 Though the term PG means a lesion associated with infection or pus formation, it does not actually resemble a true granuloma histologically.2 Although the etiology of PG is not yet explained clearly in literature, it is considered an exaggerated inflammatory hyperplastic reaction in response to any stimuli, physical or mechanical trauma, or hormonal factors. Any age group may be at risk of being affected by PG, but young adults and adolescents are among the most frequently affected, with a greater proportion of females than males (female: male = 2:1).3 It is quite common for the occurrence of PG in females at puberty and pregnancy due to hormonal changes combined with an increased response of marginal gingiva to any local irritants like plaque and calculus. PG is rarely present on the lips, tongue, oral mucosa, and palate, with the gingiva accounting for the majority of documented instances.
Usually slow-growing and asymptomatic, oral PG is a frequent hemorrhagic lesion that is raised, pedunculated, or sessile and ranges in size from a few millimeters to several centimeters. However, ulceration and bleeding may develop.4 Clinically, these lesions present as dull red soft single nodules with smooth or lobulated surfaces. This is a case report that presents a case of PG, a condition that seldom affects the tongue.
A 14-year-old male patient presented to the department of pediatric and preventive dentistry with the chief complaint of growth on the tongue for 3 months. The present history of the lesion revealed that the growth was slow, and initially, it began as a pea-sized lesion which grew to its present size gradually. The patient had no symptoms except for periods of intermittent bleeding from the growth during mastication. The medical and family history was not significant. The face was bilaterally symmetrical, and there was no evidence of swelling extra orally. A solitary exophytic, palpable growth was found intraorally on examination in the anterior two-thirds of the dorsum of the tongue (Fig. 1). On clinical examination, the growth was found to be pale with a lobulated surface and greyish-white borders. The growth was nontender and pedunculated, and the dimensions were about 1.2 × 0.8 cm in diameter. Its consistency varied from soft to firm, showing no signs of blanching under pressure, but there was bleeding slightly on provocation. Pus discharge was not evident from the growth, and no regional lymphadenopathy was observed. The history and clinical findings led to a provisional diagnosis of traumatic fibroma. Traumatic fibroma, PG, and capillary hemangioma were considered under provisional diagnosis.
After routine laboratory blood investigations, an excisional biopsy of the lesion was done. Around 3 mL of 2% lidocaine with 1:200000 adrenaline was administered at the base of the lesion. Electrocautery was done after retraction of the tongue to remove the entire lesion (Fig. 2). The entire lesion was removed in three bits of tissue. The tissue which was preserved in formalin solution was transferred to the histopathological lab for examination (Fig. 3). Wound edges were sutured using 3–0 black silk sutures (Fig. 4). Proper wound healing was observed, and suture removal was done after 1-week postoperatively. Follow-up after 1 month postoperatively, the mucosa of the tongue at the site of the lesion was absolutely normal and continuous with the adjacent mucosa with no signs of inflammation (Fig. 5).
On histopathological examination, the soft tissue sections showed highly vascularized fibrous connective tissue stroma exhibiting numerous dilated blood capillaries and areas of stromal eosinophilia. The overlying surface epithelium was stratified squamous epithelium with areas of ulceration. Fibro purulent membrane was noted. Correlating the clinical picture and histological results as a guide, PG was made as the final diagnosis (Fig. 6).
Differential diagnoses included traumatic fibroma, hyperplastic gingival inflammation, peripheral ossifying fibroma, postextraction granuloma, peripheral giant cell granuloma, hemangioma, and Kaposi’s sarcoma. A traumatic fibroma consists of dense, collagenous connective tissue stroma with few blood vessels in histopathological sections, unlike PG, which is characterized by numerous blood capillaries. Hyperplastic gingival inflammation is a generalized condition of gingiva with chronic inflammatory cells, edema, and fibrosis, whereas PG appears in a localized area. Postextraction granuloma is characterized by granulation tissue formation both clinically and histologically postextraction. Peripheral ossifying fibroma occurs most commonly on the gingiva with minimal vascular component and is characterized by the presence of calcified structures within the fibrous connective tissue, unlike PG. Peripheral giant cell granuloma was diagnosed histologically due to the presence of numerous multinucleated giant cells and the lack of a source of infection. Endothelial cell proliferation without acute inflammatory cell infiltrate differentiated hemangioma from PG. As Kaposi’s sarcoma commonly occurs in acquired immune deficiency syndrome due to the proliferation of dysplastic spindle cells, and intracellular hyaline bodies, PG was differentiated.1,14
The term “PG” was first introduced in 1904 by Hartzell as “GP.”5 Although a great number of cases of PG occurring in the oral cavity are predominant in the gingiva, it is not uncommon to involve other sites in the oral cavity, such as lips, tongue, and buccal mucosa. Tongue involvement was found to be about 4% of all PG.6 Saravana, in his study, reviewed 137 cases of PG, of which only 23 reported cases were located extra gingivally, and the mean age of occurrence was 30 years.6 In a case report by Verma et al., PG was the most common hyperplastic lesion occurring on the gingiva.15 Peters et al., in their case report, reported that the occurrence of PG is more in females.3 However, the present case was reported in a male patient at a rare location, such as the tongue.
Though uncertainty exists on the etiology of PG in literature, however, it is typically believed to manifest as an overgrowth of granulation tissue following trauma or as a reaction to a foreign body.7 PG is diagnosed clinically based on characteristic history and clinical findings. It is a rapidly growing lesion with either a smooth or lobulated surface, pedunculated or sessile, with an erythematous surface that becomes pale on maturation and varies in size.8 The lesions are painful and have a tendency to bleed when located in areas of irritation such as the tongue, buccal mucosa, and gingiva.9
The exact pathogenesis of the PG is not yet explained clearly. Trauma, infection, and hormonal influences were suggested to have a role in its causation. Chronic irritation may cause granulation tissue formation in large amounts.10 In our case also, there was local irritation due to biting of the tongue could have been the cause of the lesion. As gingiva overlying the mandibular anterior teeth is where PG most frequently manifests itself, long-standing trauma and gingival irritation caused by faulty tooth brushing may be one among the contributing factors.11 There are two types of PG, differentiated clinically and histologically. They are LCH and nonlobular capillary hemangioma. LCH type often presents as a sessile lesion with diffuse blood capillaries, whereas non-LCH presents as a lesion with a stalk and fibrosis. Non-LCH could be a lesion of long-standing irritation of the mucosa. Ours is a case of LCH because of the rich invasion of blood capillaries.12 On histopathological examination, the surface epithelium is stratified squamous epithelium with plenty of blood vessels with dilatations in the connective tissue stroma. These blood vessels are sometimes organized, giving the appearance of lobules, called a lobular hemangioma.13 PG can be differentiated from clinically similar conditions based on etiology and histopathological picture.14
Surgical excision of the lesion, involving 1–2 mm of surrounding normal tissue, remains the treatment of choice to prevent the recurrence of PG.15 Other conservative treatment modalities include excision by CO2 laser ablation, excision using Nd:YAG laser, cryosurgery, curettage, electrical cautery, and chemical cauterization. In our case, we have done surgical excision using electrocautery after the administration of local anesthesia. A total of 1 mm of the surrounding tissue was also removed along with the lesion to prevent a recurrence.
Despite being benign nonneoplastic lesions of the oral cavity, PG is threatening to patients, especially in children, because of its rapid growth, pain, and discomfort caused to the child. In our case, PG presented in an unusual location of the dorsal tongue. There is a possibility that PG to recur until the source of irritation is entirely eliminated. Proper diagnosis and medical intervention at the right time are required to prevent further interference with normal mastication and oral function in the child.
Padma Praveena Mavuri https://orcid.org/0000-0002-4609-4976
Veena Arali https://orcid.org/0000-0002-6614-3405
Harika Rapala https://orcid.org/0000-0002-9043-9783
A S Kumar https://orcid.org/0009-0007-3149-5789
Swapnika Vegi https://orcid.org/0000-0001-9641-2613
1. Rajendran R, Sivapathasundaram B. Bacterial infections of the oral cavity. Shafer, Hine, Lavy, editors Shafer’s Textbook of Oral Pathology India: Elsevier 2009:328–330.
5. Akamatsu T, Hanai U, Kobayashi M, et al. Pyogenic granuloma: a retrospective 10-year analysis of 82 cases. Tokai J Exp Clin Med 2015;40(3):110–114.
10. Epivatianos A, Antoniades D, Zaraboukas T, et al. Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features. Pathol Int 2005;55(7):391–397. DOI: 10.1111/j.1440-1827.2005.01843.x
12. Alaoui ML, Tabbai S, Benkarroum FZ, et al. Management of a pyogenic granuloma of the tongue a case report and review of the literature. Int J Appl Dent Sci 2019;5(1):107–110.
14. Sachdeva SK. Extragingival pyogenic granuloma: an unusual clinical presentation. J Dent (Shiraz) 2015;16(3 Suppl):282–285.
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