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| 2010-22 |
| 22-1 |
ISSN (Print) 1013-9052
EISSN 1658-3558
P.O. Box 52500,
Riyadh 11563,
Kingdom of Saudi Arabia
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Pyogenic granuloma among Saudi females in an out-patient dental clinic
Hessa Al Wayli,* BDS, MSc, Hezekiah A. Mosadomi,** BS, MS, DMD, DABOP, FAAOP
* Al Yamama Hospital, Ministry of Health,
** Dept. of Maxillofacial Surgery & Diagnostic Sciences, College of Dentistry, King Saudi University, KSA
Objective: The aim of this study was to determine the prevalence of pyogenic granuloma among Saudi females who received dental care in an out-patient clinic of a Saudi Arabian Dental Center in Riyadh within a period of five years.
Pyogenic granuloma (PG) occurs most commonly on the gingiva and less frequently at other sites in the oral cavity and on the skin.1-4 It presumably arises secondary to minor injury and/or infection which stimulates the formation of an exuberant overgrowth of young highly vascular granulation tissue.4-6 The lesion is often associated with impacted food or a fragment of calculus which is presumed to be the causative agent.1,3,7 Pyogenic granuloma is histologically similar to capillary hemangioma and, on the gingiva is clinically and microscopically identical to the so-called pregnancy tumor.1, 8-10 An exaggerated response of the lesion has also been related to hormonal changes in women aged between ten and forty years. 8,10-12
On account of its vascular component, the pyogenic granuloma is red with a somewhat spongy consistency and bleeds readily following minor trauma. The gingival lesions typically have an ulcerated surface particularly along that portion of the surface in contact with adjacent or occluding teeth. Usually, a thick fibrinous exudate over the surface of the ulcer gives a whitish appearance to that area1,3,13-15 Although pyogenic granuloma is a benign exophytic lesion that can be treated by simple excision, sometimes it could be an alarming sign of visceral malignancy,16 or metastases of malignant tumors to the jaws.17 The term "pyogenic granuloma" is somewhat a misnomer in that the lesion is not pus-producing, as "pyogenic" implies. It is however, a tumor of granulation tissue, as granuloma implies. It has been called an epulis because it is located more frequently in the gingiva. Some other terms used are granuloma teleangiectaticum and "pregnancy tumor" also called epulis gravidarum.3 The term "hemangiomatous granuloma" was suggested by Angelopoulos3 to accurately reflect the characteristic histopathologic picture (hemangioma-like) and the inflammatory nature (granuloma) of the lesion. Clinically, pyogenic granuloma could present clinically as a lesion that is pedunculated or broad based, highly vascularized, smooth, edematous, hemorrhagic, soft, red with glossy surface and hardened when it had been longstanding. It could be a single or multiple well localized outgrowth, painless or dull-painful. The size could range from few millimeters to several centimeters. When ulcerated by secondary trauma, it may be covered by a yellow fibrinous membrane. The aim of this study was to determine the prevalence of pyogenic granuloma among Saudi female patients who received dental treatment in the Out-patient Clinic of the Dental Department of Al-Yamama Hospital between January 1999 and March 2005.
The patient population of this study consisted of 439 females seen in the Oral Medicine Out-patient Clinic at Al Yamama Hospital, Riyadh between January 1999 and March 2005.
A detailed classification was done on all the soft tissue lesions. All cases of pyogenic granuloma with detailed and complete information (age, address, type of specimen, site, consistency, size and duration), relevant medical history, photographs of the lesion, and histopathological reports of the lesion (confirmed diagnosis of PG) were included in this study. Cases with significant missing information were excluded. Clinical diagnosis was made in the Oral Medicine Clinic, Al Yamama Hospital. All the biopsies were sent to King Saud University, Dental College Histopathological Laboratory for histopathological diagnosis.
A total of 182 lesions were recorded in the study of which PG accounted for 45 (24.75%), the highest in the group (Table 1).Of the total PG cases, only 30 had full and detailed information. The highest prevalence of PG was found in patients aged 31-40 years, followed by age range 21- 30 years, and 41-50 years with 20% each (Fig. 1) respectively. Regarding relevant medical history, 80 percent of the caszes reported good health without any significant medical history. Three patients (10%) were pregnant, while diabetes and kidney transplant patients accounted for 6.66% and 3.33%, respectively. Anatomic locations of the PG were gingiva (87.09%), lips (9.67%) and buccal mucosa (3.22%) as shown in Figures 2 and 3a, b, c, d. In the upper jaw, 7 PGs were in the facial gingiva with none in the palatal gingiva, while in the lower jaw, 12 were in the facial and 8 in the lingual gingiva, respectively (Fig. 4). Most of the PG's were in the anterior gingiva in both the maxilla and mandible. Seventeen (62.94%) were in the anterior gingiva and ten (37.03%) were in the posterior gingiva (Fig. 4). The longest duration was found in lip lesions with a mean duration of 7.5 months followed by gingiva (6.5 months) and the buccal mucosa (3 months).
Pyogenic granuloma is an exophytic hyperplastic overgrowth occurring in a large number of patients with high prevalence in females.18 The results showed that PG was the most common intra-oral soft tissue lesion (hyperplastic overgrowth) with a prevalence of 24.75 %. This result is similar to results reported by Angelopoulos,3 Buchner,13 and Micheal et al.14 In this study, the highest prevalence was recorded between 31 and 40 years of age (40%) and this is in agreement with the report of Nartey et al.,19 but not with that of Micheal et al.14 who found that the highest prevalence (24.8%) was between 20 and 30 years of age or that of Angelopoulos3 who recorded the highest prevalence (23.9%) between 10 and 20 years of age. Our results showed that most of the patients (80 %) were free of medical problems, while 10% were pregnant. This observation is in agreement with the findings of Daley et al.,11 Papageorge and Doku,12 and, Elmustafa and Badie20. It is mentioned in the literature that oral contraceptive drug is an etiological factor of pregnancy tumor.21 The most frequent site of PG in the oral cavity was the gingiva at 87.09%. This result is similar to the results obtained by Angelopoulos,3 Micheal et al.,14 and Zain et al.22 followed by lip site with 9.67% and buccal mucosa with 3.22%. With respect to location, 44.5% of the PGs were in the anterior lower facial gingiva, followed in descending order by anterior lower lingual region (29.63%) and anterior upper facial region (25.9%). There were no reported lesions on upper anterior palatal region. This result is in disagreement with Angelopoulos3 who reported upper anterior facial gingival region with 40.9% followed by lower anterior facial 17.7%. Regarding duration of the lesion in months, the longest duration was found in the lip with a mean duration of 7.5 months. This result is not in agreement with Angelopoulos3 who reported the longest duration for gingiva with a mean duration of 8.6 months.The clinical data of 45 cases showed no differences from what the literature has reported. Since all the patients were females, there was no opportunity to compare the findings to male counterparts although literature reports consistently indicated that prevalence of pyogenic granuloma was higher in females than males. Pyogenic granuloma is a reactive non-neoplastic overgrowth that can be prevented by good oral hygiene measures and patient education. The lesion must be excised completely with the removal of local factors to prevent recurrence which is reported in the literature to be high when surgical excision is inadequate. Excised specimens should be sent for histopathological reports to exclude malignancy, which may be masked by what appears to be a pyogenic granuloma.
This present study revealed that PG was the commonest soft tissue lesion of the oral cavity among the studied group of 439 female patients in the Oral Medicine Clinic of Al Yamama Hospital, Riyadh. The lesion was observed most frequently in the lower facial gingiva, followed in descending order by the lower lingual and upper facial. No lesion was found in the upper palatal gingiva. The anterior region of the gingiva was affected more than the posterior region.
Table 1. Distribution of the total oral soft tissue lesions seen.
  
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