Puberty Blues and Pyogenic Granuloma In
Females- A Report Of Two Cases
Afaf Zia1*, Huda Zubair1, Shagufta Qadri2, Mukhtar Andrabi1, Masood Khan1 and Afshan Bey1
1*Dr Z A Dental College, Aligarh Muslim University, Aligarh, India
2Department of Pathology, JNMCH, Aligarh Muslim University, Aligarh, India
2Department of Pathology, JNMCH, Aligarh Muslim University, Aligarh, India
*Corresponding author: Afaf Zia, Assistant Professor, Department of Periodontology, Dr Z A Dental College, Aligarh Muslim University, Aligarh, India,
00919897789011, E-mail: afafzia@gmail.com
Received: August 29, 2016; Accepted: September 12, 2016; Published: September 30, 2016
Citation: Zia A, Zubair H, Qadri S, Andrabi M, Khan M, et al. (2016) Puberty Blues and Pyogenic Granuloma In Females- A Report Of
Two Cases. J Dent Oral Disord Ther 4(3): 1-3. DOI: http://dx.doi.org/10.15226/jdodt.2016.00162
Abstract
Pyogenic Granuloma is a commonly occurring tumor-like hyper
plastic growth on the skin and the mucous membrane. There is
markedly prominent angiogenesis which is a contributing factor to its
typically red color. Its absolute etiological factors are still unknown,
although minor trauma and endocrinal imbalances have known to
play an important role. In the literature there is a well established
relationship between the estrogen group of hormones and the
angiogenetic factors like vascular endothelial growth factor and
basic fibroblast growth factor. In this report, we have discussed and
highlighted the apparent attribution of pyogenic granuloma to raised
female sex hormones in pubertal young females of ages ranging
from 12-18 years. In conclusion we suggest hormonal imbalance
and pubertal changes can also be counted as an etiological factor for
pyogenic granulomas in young females.
Introduction
Pyogenic Granuloma is considered to be the most common
tumour of the oral cavity. It may be sessile or pedunculated, of
various shades from pink to red or dark brown depending on its
type or histogenesis. A ratio of 1:1.5 has been mentioned as the
epidemiological occurrence among males and females1. Females
of second decade being affected the most [2,3,4]. Although local
irritating factors, hormonal disturbances (as in pregnancy) and
poor oral hygiene are considered to be its etiological factors but
its absolute causes are still obscure. In this report we discuss
the occurrence of pyogenic granuloma in non-pregnant healthy
young females of 12-18 years with good oral hygiene falling in
the category of pubertal ages. Through this report we will shed
some light on mildly raised estrogen group of hormones or other
pubertal changes leading to such tumor like growth through
various angiogenetic factors.
Case Report 1
A 15 year old female reported in the OPD of Dr Ziauddin
Ahmad Dental College with a growth on her gums. The patient
complained of painless slowly growing nodule on her gums since
two weeks. History revealed that the swelling was pin point sized
2 weeks back which gradually grew large enough to bring her to seek medical care. The oral hygiene maintenance of the patient
was commendable. There was no history of any kind of trauma in
the recent past. The patient brushed twice daily with horizontal
brushing strokes.
On examining clinically, there was a solitary growth seen with respect to the upper left lateral incisor. The growth involved the marginal gingival, was pedunculated, pink in color measuring about 1.8 cm in diameter, round in shape, with smooth surface. (Figure 1)
On the basis of history, clinical presentation and examination, a provisional diagnosis of pyogenic granuloma was made. An excisional biopsy was performed after the necessary investigations that are the complete blood picture, bleeding time and clotting time under local anaesthesia. The excisied tissue was sent for biopsy. (Figure 2) The patient wound healed uneventfully and was recalled every three months for one year. (Figure 3) Recall appointments till 1 year showed no recurrence of the lesion
The biopsy showed neocapillaries separated by edematous stroma infiltrated with inflammatory cells. Surface stratified epithelium was thickened and ulcerated focally confirming pyogenic granuloma. (Figure 4)
On examining clinically, there was a solitary growth seen with respect to the upper left lateral incisor. The growth involved the marginal gingival, was pedunculated, pink in color measuring about 1.8 cm in diameter, round in shape, with smooth surface. (Figure 1)
On the basis of history, clinical presentation and examination, a provisional diagnosis of pyogenic granuloma was made. An excisional biopsy was performed after the necessary investigations that are the complete blood picture, bleeding time and clotting time under local anaesthesia. The excisied tissue was sent for biopsy. (Figure 2) The patient wound healed uneventfully and was recalled every three months for one year. (Figure 3) Recall appointments till 1 year showed no recurrence of the lesion
The biopsy showed neocapillaries separated by edematous stroma infiltrated with inflammatory cells. Surface stratified epithelium was thickened and ulcerated focally confirming pyogenic granuloma. (Figure 4)
Case Report 2
A young female of 18 years reported to the periodontics OPD
of Dr Ziauddin Ahmad Dental College with a swelling on her gums
Figure 1: Preoperative picture showing growth with respect to upper
left lateral incisor
that had gradually increased within a span of three weeks. She
complained of mild pain and difficulty in speaking or chewing.
She gave no history of trauma. The patients brushed in vertical
strokes twice a day.
Intraoral examination revealed a large firm polyploid mass with a broad base and smooth pink surface, measuring 10 x 7 mm in size in relation to the gingiva of mandibular right canine. The peculiar feature of this growth was its unusual growth on the lingual surface of the lower anteriors. Over all calculus and plaque accumulation was negligible. Other systemic involvement was non contributory with no lymphadenopathy. (Figure 5a and 5b)
After preliminary investigation which included complete hemogram, bleeding time and clotting time, the growth was excised under local anaesthesia and sent for biopsy. (Figure 6) The patient was kept on recall visits every month for a year. (Fig 7) There was no recurrence of the lesion and the patient showed excellent recovery.
The histopathological report showed lobular growth lined by stratified squamous epithelium, while underlying deeper tissues shows proliferating capillaries and dense inflammatory infiltrates like neutrophils, lymphocyte and plasma cells.
Intraoral examination revealed a large firm polyploid mass with a broad base and smooth pink surface, measuring 10 x 7 mm in size in relation to the gingiva of mandibular right canine. The peculiar feature of this growth was its unusual growth on the lingual surface of the lower anteriors. Over all calculus and plaque accumulation was negligible. Other systemic involvement was non contributory with no lymphadenopathy. (Figure 5a and 5b)
After preliminary investigation which included complete hemogram, bleeding time and clotting time, the growth was excised under local anaesthesia and sent for biopsy. (Figure 6) The patient was kept on recall visits every month for a year. (Fig 7) There was no recurrence of the lesion and the patient showed excellent recovery.
The histopathological report showed lobular growth lined by stratified squamous epithelium, while underlying deeper tissues shows proliferating capillaries and dense inflammatory infiltrates like neutrophils, lymphocyte and plasma cells.
Discussion
Pyogenic granuloma represents an exuberant connective
tissue proliferation to a known stimulus or injury [5]. Originally it
was believed to be a pyogenic growth but there is enough evidence
against it as it does not contain pus neither is it a granuloma in
a strict sense. Hamid Jaferzadeh, et al. have mentioned in their
review that about one third of the cases occur after any trauma
Figure 2: Excised tissue.
Figure 3: Postoperative picture showing complete healing after excision.
Figure 4: Histological section of the growth under 10X (4a), 40X (4b)
& 100X (4c)
Figure 5: Preoperative picture showing the lesion labially (5a) and lingually
(5b)
Figure 6: Excised tissue
Figure 7: Postoperative picture showing complete healing after excision
or injury [6]. According to Vilmann, et al. majority of the pyogenic
granulomas are found on the marginal gingiva with only 15 %
of the tumors on the alveolar part [8]. Regezi, et al. mention that
it is seen mostly common in the second life of females [5,9]. It
occurs more commonly in the females and seen in upto 5% of
pregnancies. Yuank, et al. has demonstrated a strong relationship
between the angiogenetic factors especially vascular endothelial
growth factor and basic fibroblastic growth factors and pyogenic
granuloma [7]. There is also an undisputed relationship between
these factors and their directly dependant relationship between
female sex hormones. The gradual but marked rise in the levels
of female sex hormones; associated with puberty and specifically
menarche; especially the estrogen group of hormones may play
an important role in initiating or promoting the occurrence of
pyogenic granuloma. In a study done by Michael D. Graubert, et
al. they demonstrated that VEGF expression peaks during days 1
to 3 of the endometrial cycle. In addition, they provide evidence
that physiological hypoxia in conjunction with TGF-α and IL-1β
are most likely responsible for the induction and sustained levels
of VEGF during menstruation [11].
In the cases presented here the female patients were of the age group corresponding to the pubertal age contrary to the common incidence in the second decade of life in females. Also the presenting females were not pregnant and rather healthy. The oral hygiene in all the above cases does not direct the etiology towards local irritation or poor oral hygiene. There was also absence of history of trauma. Thus the abrupt hormonal rise in corresponding to the pubertal spurt might have played a role in the development of pyogenic granuloma in these cases.
Bhaskar SN, Jacoway JR observed in their study [10] that pyogenic granuloma is partly or completely covered by parakeratinased or non-keratinised stratified squamous epithelium. Major bulk of the lesion is formed by a lobulated or a non lobulated mass of angiomatous tissue. Usually, lobulated lesions are composed of solid endothelial proliferation or proliferation of capillary sized blood vessels. The amount of collagen in the connective tissue of pyogenic granuloma is usually sparse. Surface can be ulcerated and in such ulcerated lesions, edema was a prominent feature and the lesion is infiltrated by plasma cells, lymphocytes and neutrophils.
Various other benign soft tissue lesions need to be differentiated from pyogenic granuloma. Few to name include peripheral giant cell granuloma, pregnancy tumor; conventional granulation tissue etc [6].
Surgical excision is the treatment of choice. After surgical excision of gingival lesions, curettage of underlying tissue is recommended. Bhaskar SN, Jacoway JR has reported one recurrence after conservative excision with a recurrence rate of 15.8 %. They also stated that pyogenic granuloma lacks infiltrative or malignant potential [10].
In the cases presented here the female patients were of the age group corresponding to the pubertal age contrary to the common incidence in the second decade of life in females. Also the presenting females were not pregnant and rather healthy. The oral hygiene in all the above cases does not direct the etiology towards local irritation or poor oral hygiene. There was also absence of history of trauma. Thus the abrupt hormonal rise in corresponding to the pubertal spurt might have played a role in the development of pyogenic granuloma in these cases.
Bhaskar SN, Jacoway JR observed in their study [10] that pyogenic granuloma is partly or completely covered by parakeratinased or non-keratinised stratified squamous epithelium. Major bulk of the lesion is formed by a lobulated or a non lobulated mass of angiomatous tissue. Usually, lobulated lesions are composed of solid endothelial proliferation or proliferation of capillary sized blood vessels. The amount of collagen in the connective tissue of pyogenic granuloma is usually sparse. Surface can be ulcerated and in such ulcerated lesions, edema was a prominent feature and the lesion is infiltrated by plasma cells, lymphocytes and neutrophils.
Various other benign soft tissue lesions need to be differentiated from pyogenic granuloma. Few to name include peripheral giant cell granuloma, pregnancy tumor; conventional granulation tissue etc [6].
Surgical excision is the treatment of choice. After surgical excision of gingival lesions, curettage of underlying tissue is recommended. Bhaskar SN, Jacoway JR has reported one recurrence after conservative excision with a recurrence rate of 15.8 %. They also stated that pyogenic granuloma lacks infiltrative or malignant potential [10].
Conclusion
Pyogenic granuloma is a common oral lesion occurring in
females. Although numerous factors are responsible for its
causes, its proper diagnosis and management is essential to
prevent its recurrence. In this case report we highlighted the role
of hormonal imbalance in the absence of local deposits as one
of the cause of pyogenic granuloma in healthy young females of
pubertal age and their successful management.
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