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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 82-85

Diode laser excision of pyogenic granuloma


1 Associate Professor, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh, India
2 Professor and HOD, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh, India
3 Post Graduate Student, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh, India
4 Lecturer, Department of Oral Pathology and Microbiology, Government Dental College, Raipur, Chhattisgarh, India

Date of Submission26-Aug-2022
Date of Acceptance03-Aug-2022
Date of Web Publication28-Sep-2022

Correspondence Address:
Dr. Shirish Kujur
Associate Professor, Department of Periodontology, Government Dental College, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpcdr.ijpcdr_19_22

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  Abstract 


Pyogenic granuloma is a commonly occurring inflammatory hyperplasia of the skin and oral mucosa in females. It is a misnomer that is characterized histologically by angiomatous proliferation rather than a granulomatous lesion. This tumor-like growth is considered to be nonneoplastic in nature and has a varied clinical presentation. We present one such case of pyogenic granuloma, which was excised with a diode laser along with a relevant review of the literature.

Keywords: Diode laser, granuloma, inflammatory hyperplasia, pyogenic granuloma


How to cite this article:
Kujur S, Gupta V, Sreeraj V S, Kerketta RC, Jhawar B. Diode laser excision of pyogenic granuloma. Int J Prev Clin Dent Res 2022;9:82-5

How to cite this URL:
Kujur S, Gupta V, Sreeraj V S, Kerketta RC, Jhawar B. Diode laser excision of pyogenic granuloma. Int J Prev Clin Dent Res [serial online] 2022 [cited 2022 Dec 7];9:82-5. Available from: https://www.ijpcdr.org/text.asp?2022/9/3/82/357308




  Introduction Top


Pyogenic granuloma is a common inflammatory hyperplastic lesion also known as Crocker and Hartzell's disease, granuloma pyogenicum, granuloma pediculatum benignum, benign vascular tumor, and during pregnancy as granuloma gravidarum.[1] The word “epulis” is derived from the Greek “epi” and “elon,” meaning “on the gingiva” and represents any lesion that appears on the gingiva, not necessarily implicating the true nature of the lesion. The term “pyogenic granuloma” is a misnomer because the lesion does not contain pus and is not strictly speaking a granuloma. The lesion can develop owing to chronic irritation, which is a cause of “excess” proliferative tissue repair. Several factors are involved in the etiology of pyogenic granuloma associated with dental restorations and infectious agents,[2] including trauma, hormonal factors, and dental plaque. Bhaskar and Jacoway[1] and Kamal et al.[3] observed that pyogenic granuloma represents 1.85% of all oral pathologies and Esmeili et al.[4] underlined in their review that reactive hyperplastic lesions represent the most common group of lesions after caries, periodontal disease, and periapical inflammatory disorders.

Clinically, these lesions appear as soft mass, smooth or lobulated, and sessile or pedunculated and may vary in size from a few millimeters to several centimeters. Vascular malformations of the oral cavity, although uncommon, are a discomforting and potentially serious clinical problem. Patients often present with complaints of recurrent hemorrhage, biting of oral tissue, pain, difficulty with speaking, mastication, and deglutition.[5]

Many different modalities for treatment of vascular lesions have been used so far: surgical, cryosurgery, electrodesiccation, intralesional administration of corticosteroids or sclerosant (sodium tetradecyl), radiotherapy, and embolization with steel coil, gel foam, silicone beads, or cyanoacrylate.[3],[6]


  Case Report Top


A 20-year-old female patient came to our department with a chief complaint of swelling in the upper left back region for 3 months [Figure 1]. She gave a history of a pea-sized swelling initially, which gradually increased to the present size and was associated with physical interference while chewing but not bleeding. She did not recollect any history of trauma or was not under gestation. General physical examination revealed no other abnormalities, and there was no generalized lymphadenopathy. On clinical examination, a single, well-defined reddish granular, roughly spherical gingival growth of size 2.5 cm × 3 cm was seen arising from a buccal gingival area of 262,728. The surface was smooth without ulceration. On palpation, it was found to be pedunculated, soft to firm in consistency, nontender, and compressible, but not reducible or fluctuant [Figure 2]. Based on history and clinical findings, a provisional diagnosis of pyogenic granuloma was made, and a differential diagnosis of peripheral ossifying fibroma, fibroma, and peripheral giant cell granuloma was considered. Excisional biopsy with diode laser was planned. After local anesthesia, the lesion was excised with a 980-nm diode laser using an initiated tip in continuous mode with a 1 W setting. It was ensured that the lesion was completely excised by trimming up the remnants of the soft tissue adjacent to the tooth to prevent the recurrence of the lesion [Figure 3]. The excised tissue was sent for histopathologic examination, which revealed angiomatous tissue with endothelial cell proliferation and inflammatory cell infiltrate in the form of a few neutrophils, lymphocytes, and plasma cells covered by parakeratinized epithelium, based on which a final diagnosis of pyogenic granuloma was established. The patient was recalled after 1 week, and her postoperative healing was uneventful [Figure 4].
Figure 1: Preoperative

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Figure 2: After phase I therapy

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Figure 3: Immediate postoperative with laser

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Figure 4: Postoperative after 1 week

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Scanning power showed discontinuous parakeratinized stratified squamous epithelium and underlying stroma revealed numerous vascular spaces [Figure 5]a. A high-power view showed numerous dilated capillaries engorged with red blood cells and proliferating capillaries in a loose inflammatory stroma [Figure 5]b.
Figure 5: (a) Scanning power view (b) High-power view

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The microscopic picture of pyogenic granuloma, in general, shows exuberant granulation tissue which is covered by atrophic/hyperplastic epithelium that may be ulcerated at times and reveals fibrinous exudates. The presence of numerous endothelium-lined vascular spaces and the proliferation of fibroblasts and budding endothelial cells are the characteristic features of pyogenic granuloma. The presence of mixed inflammatory cell infiltration is also observed.


  Discussion Top


Hullihen's description in 1844 was most likely the first “pyogenic granuloma” reported in the English literature; however, it was named so only in 1904 by Hartzell. Pyogenic granuloma occurs in all age groups, from children to older adults, but is more frequently encountered in females in their second decade due to the increased levels of circulating hormones, estrogen, and progesterone. Have reviewed the correlation between oral pyogenic granuloma, pregnancy, and the role of oral hormonal contraceptives in detail.

Clinically, it presents as an elevated, smooth or exophytic, lobulated, sessile, or pedunculated growth that may show ulcerations or may be covered by a yellow fibrinous membrane. Gingiva, especially the marginal gingiva, is affected more than the alveolar part, but in our patient, marginal and attached gingiva are affected. Its size varies from a few millimeters to several centimeters, and it is usually slow growing, asymptomatic, and painless, but at times it grows rapidly. The color varies from red to reddish purple to pink depending on the vascularity of the growth.[1] Our patient presented with a slow-growing well-defined reddish granular, roughly spherical gingival growth of the buccal gingiva.

Radiographic findings are absent in pyogenic granuloma as in our case. Differential diagnosis of pyogenic granuloma includes peripheral giant cell granuloma, peripheral ossifying fibroma, fibroma, peripheral odontogenic fibroma, hemangioma, conventional granulation tissue, hyperplastic gingival inflammation, Kaposi's sarcoma, bacillary angiomatosis, angiosarcoma, and non-Hodgkin's lymphoma. Histologically, pyogenic granuloma shows prominent capillary growth within a granulomatous mass.

Although the conventional treatment for pyogenic granuloma is surgical excision, a recurrence rate of 16% has been reported.[7] Rai et al. introduced laser as a powerful tool for the treatment of pyogenic granuloma. They used a diode laser with the following specifications: wavelength 808 nm (±10), output energy 0.1–7.0 W, and input power 300 VA for the removal of pyogenic granuloma.[8] Diode lasers have the advantages of being less invasive, sutureless procedures over conventional excision. Rapid healing can be observed within a few days of treatment, and as blood vessels are sealed, there is a reduced need for postsurgical dressings. It also depolarizes nerves, thus reducing postoperative pain, and also destroys many bacterial and viral colonies that may potentially cause infection. Reduced postoperative discomfort, edema, scarring, and shrinkage have all been associated with its use.[9] Akbulut et al. stated that diode lasers are useful for oral soft-tissue surgical procedures because their specific wavelength (810–980 nm) is absorbed by water (although less than the carbon dioxide laser wavelength) and also other chromophores, such as melanin, and in particular, oxyhemoglobin. Moreover, the exclusive use of this laser by contact or at an extremely close distance avoids damage, due to “beam escape,” in an open field, which makes it much safer than other laser sources. Furthermore, the diode laser has a higher tissue ablation capacity and enough hemostatic properties compared to most laser systems.[10] It has also been documented in numerous studies that laser creates locally sterile conditions, which would result in the reduction of bacteremia concomitant to the operation.[11]


  Conclusion Top


Surgical excision is the criterion standard treatment for pyogenic granuloma. Among the techniques used for surgical excision of the lesion, the diode laser has shown the following advantages: less invasiveness, absence of intra and postoperative discomfort and pain, effective hemostasis with better bleeding control, absence of scarring, and better postoperative management. In addition, greater patient compliance is observed because the operation is rapid, and, in most cases, suturing the wound is not necessary.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Kurian B, Sasirekha D, Ebenezer D. Pyogenic granuloma – A case report and review. Int J Dent Sci Res 2014;3:66-8.  Back to cited text no. 2
    
3.
Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol 2012;16:79-82.  Back to cited text no. 3
  [Full text]  
4.
Esmeili T, Lozada-Nur F, Epstein J. Common benign oral soft tissue masses. Dent Clin North Am 2005;49:223-40.  Back to cited text no. 4
    
5.
Açikgöz A, Sakallioglu U, Ozdamar S, Uysal A. Rare benign tumours of oral cavity--capillary haemangioma of palatal mucosa: A case report. Int J Paediatr Dent 2000;10:161-5.  Back to cited text no. 5
    
6.
Shapshay SM, David LM, Zeitels S. Neodymium-YAG laser photocoagulation of hemangiomas of the head and neck. Laryngoscope 1987;97:323-30.  Back to cited text no. 6
    
7.
Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's Clinical Periodontology. 10th ed. The Netherlands: Elsevier Publication Amsterdum; 2006. p. 176-7.  Back to cited text no. 7
    
8.
Rai S, Kaur M, Bhatnagar P. Laser: A powerful tool for treatment of pyogenic granuloma. J Cutan Aesthet Surg 2011;4:144-7.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Kirschner RE, Low DW. Treatment of pyogenic granuloma by shave excision and laser photocoagulation. Plast Reconstr Surg 1999;104:1346-9.  Back to cited text no. 9
    
10.
Akbulut N, Kursun ES, Tumer MK, Kamburoglu K, Gulsen U. Is the 810-nm diode laser the best choice in oral soft tissue therapy? Eur J Dent 2013;7:207-11.  Back to cited text no. 10
  [Full text]  
11.
Asnaashari M, Azari-Marhabi S, Alirezaei S, Asnaashari N. Clinical application of 810nm diode laser to remove gingival hyperplasic lesion. J Lasers Med Sci 2013;4:96-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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