CASE REPORT


https://doi.org/10.5005/djas-11014-0039
Dental Journal of Advance Studies
Volume 12 | Issue 1 | Year 2024

Pyogenic Granuloma with Calcification: An Enigmatic Case


Satinderpal Kaur1, Deepti Garg2, Swati Gautam3https://orcid.org/0000-0002-7810-6601, Nishat Sankhyan4

1–4Department of Oral Pathology and Microbiology, Bhojia Dental College and Hospital, Bhud (Baddi), Himachal Pradesh, India

Corresponding Author: Satinderpal Kaur, Department of Oral Pathology and Microbiology, Bhojia Dental College and Hospital, Bhud (Baddi), Himachal Pradesh, India, Phone: +91 7986148533, e-mail: satinder3096@gmail.com

How to cite this article: Kaur S, Garg D, Gautam S, et al. Pyogenic Granuloma with Calcification: An Enigmatic Case. Dent J Adv Stud 2024;12(1):70–72.

Source of support: Nil

Conflict of interest: Dr Deepti Garg is associated as the Editorial Board member of this journal and this manuscript was subjected to this journal´┐Żs standard review procedures, with this peer review handled independently of this editorial board member and her research group.

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Received on: 24 August 2023; Accepted on: 04 April 2024; Published on: 30 April 2024

ABSTRACT

Oral mucosa is one of the most common sites for reactive lesions as it is exposed to various internal and external stimuli. Pyogenic granuloma (PG) and peripheral ossifying fibroma (POF) are the most common reactive lesions associated with gingiva. Both lesions have similar clinical features and can be differentiated based on histopathology only. Pyogenic granuloma is a type of benign swelling and type of inflammatory hyperplasia that results in response to chronic irritation, trauma, and fluctuating hormones. Microscopically, ossification is a feature of POF and it is not seen in PG. This article aims to discuss the histopathology of PG in a young 18-year-old female patient, in which areas of ossification were seen that are not commonly encountered in this lesion.

Keywords: Case report, Gingiva, Peripheral ossifying fibroma, Pyogenic granuloma, Reactive lesions.

INTRODUCTION

Nonneoplastic growths are often seen in the oral cavity and could be inflammatory, reactive, developmental in origin, and could be some cyst or neoplasm. The reactive proliferative lesions manifest as benign growth or swellings.1 They occur as a result of chronic tissue injury and regress upon removal of the stimuli. Pyogenic granuloma (PG), being the second most common reactive growth encountered in the oral cavity is mostly seen on the gingiva (75%), followed by lips, tongue, buccal mucosa, and palate. Its etiology includes chronic trauma, hormonal changes, immunosuppressants, and oral contraceptives. Most commonly seen in young adults but with a predominant female predilection. Clinically, it is a well-circumscribed, reddish lobulated lesion, which could be sessile or pedunculated. It clinically mimics peripheral ossifying fibroma (POF) and can be differentiated histologically only. Microscopically, PG exhibits epithelium of variable thickness and sometimes ulceration. The Connective tissue closely resembles granulation tissue.1,2 However, ossification is a rare finding in PG.

This is a case presentation of PG with ossification mimicking the POF with a review of the current literature for the understanding of the etiology of the rare finding.

CASE DESCRIPTION

An 18-year-old female patient reported to the Department of Oral Pathology with a chief complaint of growth present on gums in the upper left front tooth region for 1 year. The growth was initially small in size, but it gradually increased. Upon examination, the growth was pedunculated, slightly tender on palpation, and soft to firm in consistency and measured 0.8 × 0.7 × 0.3 mm arising from gingiva and interdental papilla between teeth 21 and 22 (Fig. 1). There were no evident radiological findings. A provisional diagnosis of PG was made based on clinical and normal radiological features. Differential diagnoses included irritational fibroma, POF, and peripheral giant cell granuloma. An excisional biopsy was done for histopathological examination (Fig. 2).

Fig. 1: Soft tissue growth arising from gingiva and interdental papilla between teeth 21 and 22

Fig. 2: Gross specimen

The hematoxylin and eosin (H&E) stained section showed hyperplastic stratified squamous epithelium along with few ulcerated areas (Fig. 3). The connective tissue showed the presence of proliferating endothelial cells, several blood vessels, infiltration of dense chronic inflammatory cells chiefly lymphocytes and plasma cells (Fig. 4) and areas of calcification in the form of irregular bony trabeculae exhibiting osteocytes and osteoblastic rimming (Fig. 5). In few areas basophilic calcifications were also seen.

Fig. 3: The H&E stained section shows stratified squamous epithelium which is hyperplastic and ulcerated in a few areas

Fig. 4: Numerous blood vessels, proliferating endothelial cells, and dense chronic inflammatory cell infiltrate

Fig. 5: Areas of calcification in the form of bony trabeculae exhibiting osteocytes and osteoblastic rimming (black arrow)

DISCUSSION

The reactive lesions manifest as benign nodular swellings and occur as the result of chronic regress on the removal of the stimuli.1,2 Reactive lesions associated with gingiva are peripheral fibroma (56–61%), PG (19–27%), POF (10–18%), and peripheral giant cell granuloma (1.5–7%). Recently juvenile spongiotic gingival hyperplasia has been included in the category of these lesions.3,4

Pyogenic granuloma is a type of inflammatory hyperplasia and represents nodular growth of oral mucosa.2 The first case was described by Hulliken in 1844 and the term PG or granuloma pyogenicum was given by Hartzell in 1904.2,5 Histological types of PG are lobular and nonlobulated capillary hemangioma.2 The course of the lesion can be described as early (pink lesion), established (color similar to normal mucosa), and healing type (pinkish to white). In the present case, color of the lesion was pinkish with slight ulceration. The etiology of the lesion includes chronic irritation, trauma, hormonal imbalance, immunosuppressants and oral contraceptives, and secondary bacterial infection. Poor oral hygiene with accumulated plaque and calculus act as precipitating factors.6 Certain factors like inducible nitric oxide synthase, vascular endothelial growth factor (VEGF), basic fibroblast growth factor, or connective tissue growth factor are responsible for angiogenesis and rapid growth of PG.7 It is seen in the second decade and with female predilection due to the vascular effect of female hormones.7 The most common site is gingiva (75%) followed by lips, tongue and buccal mucosa. Frequently seen in maxillary anterior region.2,7

Though PG and POF share common etiology and clinical features but they can be distinguished histologically. Clinically POF is of normal mucosal color whereas PG is more red. Histologically, POF has features such as stratified squamous epithelium with hyperkeratosis, acanthosis, pseudoepitheliomatous hyperplasia and less inflammatory cell infiltration and connective tissue stroma is mainly collagenous with mineralized structure formation. This is in contrast to PG which consists of atrophic/hypertrophic stratified squamous epithelium and connective tissue stroma composed mainly of proliferation of granulation tissue, capillaries, venules, lobules of vascular neoformation, and predominant chronic inflammatory cell infiltration.6,7

In the present case, all the histopathological features of PG with some areas of calcifications in the form of bony trabeculae were seen. Calcification is the distinguishing feature of POF and is frequently found in PG.6 Calcification in PG can be due to the fluctuating levels of progesterone in young female patients which influences the osteoblast cells to form calcified tissue.8 Kim et al. noticed calcified areas in PG of skin because of the environment devoid of oxygen which leads to osteoblastic differentiation and could be a local tissue injury leading to dystrophic calcification. Local factors like pH, Ca, and P ions also affect ossification.9 Dermawan JK and Kilpatrick SE suggested that metaplastic bone formation in PG possibly represents a reactive or self-limited process, associated with trauma or injury.10 Elanagai R et al. revealed in their research that connective tissue fibroblasts within the PG expresses a protein named osteopontin.1 As it has a high Ca binding potential it influences calcification in PG.1 Narwal A and Bala S stated that cytokines produced due to inflammatory response stimulate the osteogenic differentiation of the cells.11 Sridhar et al. proposed persistent PG undergoes maturation and converts into POF so they are interrelated.12,13

In the reported case fluctuating levels of the female hormone “progestrone” could be the possible reason behind the unique presentation.7 So keeping all the factors in consideration the diagnosis of PG with calcification was given.

CONCLUSION

This is a case of PG with calcification which was a little enigmatic in diagnosing. Therefore, in the future, more such cases should be reported in the literature for a better understanding of varied histological patterns of the lesion.

ORCID

Swati Gautam https://orcid.org/0000-0002-7810-6601

REFERENCES

1. Elanagai R, Veeravarmal V, Nirmal RM. Osteopontin expression in reactive lesions of gingiva. J Appl Oral Sci 2015;23:26–32. DOI: 10.1590/1678-775720140122.

2. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48(4):167–175. DOI: 10.2334/josnusd.48.167.

3. Effiom OA, Adeyemo WL, Soyele OO. Focal reactive lesions of the gingiva: An analysis of 314 cases at a tertiary health institution in Nigeria. Nigerian Med J 2011;52(1):35–40. PMID: 21968923.

4. Chang JY, Kessler HP, Wright JM. Localized juvenile spongiotic gingival hyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(3):411–418. DOI: 10.1016/j.tripleo.2008.04.024.

5. Ganesan A, Kumar NG, Azariah E, et al. Oral pyogenic granuloma: A case report and a comprehensive review. SRM J Res Den Sci 2015;6(4):257–260. DOI: 10.4103/0976-433X.170284.

6. Godinho GV, Silva CA, Noronha BR, et al. Peripheral ossifying fibroma evolved from pyogenic granuloma. Cureus 2022;14(1):e20904. DOI: 10.7759/cureus.20904.

7. Dave A, Arora M, Saluja P, et al. An insight into pyogenic granuloma with ossification: Exploring a unique association. J Clin Diagn Res 2021;15(9):ZD01–ZD03. DOI: 10.7860/JCDR/2021/50298.15337.

8. Prior JC. Progesterone as a bone-trophic hormone. Endocrine Rev 1990;11(2):386–398. DOI: 10.7759/cureus.20904.

9. Kim ES, Kim KJ, Chang SE, et al. Metaplastic ossification in a cutaneous pyogenic granuloma: A case report. J Dermatol2004;31(4):326–329. DOI: 10.1111/j.1346-8138.2004.tb00679.x.

10. Dermawan JK, Kilpatrick SE. Ossifying pyogenic granuloma: A rare variant usually not recognized. J Cutaneous Pathol 2021;48(7):954–957. DOI: 10.1111/cup.14007.

11. Narwal A, Bala S. Osteopontin expression and clinicopathologic correlation of oral hyperplastic reactive lesions: An institutional 6-year retrospective study. J Oral Maxillofac Pathol 2017;21(3):382–386. DOI: 10.4103/jomfp.JOMFP_231_15.

12. Sridhar R, Wanjari S, Kanteshwari IK. Interrelationship between pyogenic granuloma and peripheral ossifying fibroma: A case report. J Dent Hyg 2012;86(3):179–184. PMID: 22947840.

13. Al Eid RA. Peripheral ossifying fibroma mimicking pyogenic granuloma: A case report and review of literature. J Surg 2020;6(1):1–4. DOI: 10.16966/2470-0991.204.

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