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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 42-46

Lobulated capillary hemangioma: A series of 3 cases with review of literature


1 Department of Oral Medicine and Radiology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Pathology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Harshal Varpe
Department of Oral Medicine and Radiology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdas.jdas_38_17

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  Abstract 


Enlargements of soft tissue of the oral mucosa often present a diagnostic challenge because a diverse group of pathologic processes can produce such lesions. Lobulated capillary hemangioma of oral mucosa is a well-known benign lesion occurring most commonly on gingiva. Diagnosis of such lesions becomes difficult many times as an enlargement may represent a variation of normal anatomic structures, inflammation, cysts, developmental anomalies, and neoplasm. Some of these lesions are reactive in nature. This article focuses on a series of three similar cases on gingiva, clinically diagnosed as “pyogenic granuloma” and histopathologically as “lobulated capillary hemangioma.”

Keywords: Benign vascular lesions of oral mucosa, gingival overgrowth, lobulated capillary hemangioma, pyogenic granuloma, swelling on gingiva


How to cite this article:
Varpe H, Mhapuskar A, Jadhav S, Hiremutt D, Gaikwad S, Deshmukh A. Lobulated capillary hemangioma: A series of 3 cases with review of literature. J Dent Allied Sci 2018;7:42-6

How to cite this URL:
Varpe H, Mhapuskar A, Jadhav S, Hiremutt D, Gaikwad S, Deshmukh A. Lobulated capillary hemangioma: A series of 3 cases with review of literature. J Dent Allied Sci [serial online] 2018 [cited 2019 Oct 21];7:42-6. Available from: http://www.jdas.in/text.asp?2018/7/1/42/234187




  Introduction Top


Pyogenic granuloma or lobulated capillary hemangioma is a tumor-like growth that is considered an exaggerated, conditioned response to minor trauma. Exophytic gingival lesions represent some of the more frequently encountered lesions in the oral cavity.

As the name pyogenic granuloma suggests pus, this term is a misnomer as it is not associated with any kind of pus neither does it represent granuloma histologically. These benign vascular lesions are commonly occurring lesion in the oral mucosa especially the gingiva

The actual etiology of the lesion is not known, but it is believed to be a botromycotic infection. Theories also suggest that it is a response of tissues for minor trauma or a persistent irritation resulting in opening a path for the invasion of nonspecific microorganisms.

Benign tumors such as hemangiomas consists of blood vessels and are classified based on histology as capillary, mixed or cavernous

Among all the cases 75% occur on gingiva. Other sites include tongue, buccal mucosa, and lips. Maxillary anterior region is affected more than posterior and buccal surface involvement is more than lingual.[1],[2],[3],[4],[5]


  Case Reports Top


Case report 1

A 34-year-old male patient reported to the Department of Oral Medicine and Radiology with a chief complaint of growth on the lingual surface of gingiva for 2 months [Figure 1]. The growth was initially peanut size when he noticed it for the first time, but the growth has rapidly increased over the past 1 month to attain present size. The growth was asymptomatic; the patient's medical history was unremarkable.
Figure 1: Pedunculated, nodular growth on lingual aspect of 43 and 44, with a smooth overlying surface appearing fiery red

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The patient gives a history of similar growth 17 years ago which he had then got excised.

On examination of the present growth, it was single, pedunculated, nodular growth on the lingual aspect of 43 and 44, with a smooth overlying surface appearing fiery red, measuring approximately 1 cm × 1 cm in size. On palpation, all inspectory findings are confirmed, blanching on pressure is seen, no bleeding on provocation was reported [Figure 1].

Intraoral periapical (IOPA) of the region revealed mild horizontal bone loss in relation 42 and 43.

Based on clinical signs and symptoms, a provisional diagnosis of pyogenic granuloma was given, but as differential diagnosis fibrous hyperplasia and capillary hemangioma were considered, the patient was advised routine blood investigations which were within normal limits after which an excisional biopsy with curettage was performed under local anesthesia and patient was kept under follow-up.

The H and E stained section showed parakeratinized stratified squamous epithelium with long slender rete – ridges and connective tissue stroma. The underlined connective tissue stroma showed numerous endothelium-lined blood vessel with extravasated red blood cells (RBCs). Dense inflammatory infiltrate chiefly lymphocytes were seen. Moderately dense collagen bundle interspersed plump fibroblast.

The histopathological diagnosis of lobulated capillary hemangioma was given [Figure 2].
Figure 2: Histopathology image under ×40 showing H and E stained section shows parakeratinized stratified squamous epithelium with long slender rete - ridges and connective tissue stroma, dense inflammatory infiltrate chiefly lymphocytes are seen

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Case report 2

A 24-year-old female patient reported to the Department of Oral Medicine and Radiology with a chief complaint of growth and swelling on the lingual surface of gingival region on the right side for 2 months [Figure 3]. The growth was initially peanut size when she noticed it for the first time, but the growth has rapidly increased over the past 15 days to attain the present size. The growth was asymptomatic, and the patient's medical history was unremarkable.
Figure 3: Single, pedunculated, nodular growth on lingual aspect of 42, 43, 44, and 45 measuring approximately 2 cm × 2 cm

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On examination of the present growth single, pedunculated, nodular growth on the lingual aspect of 42, 43, 44 and 45 with a smooth overlying surface appearing fiery red, measuring approximately 2 cm × 2 cm in size was seen. On palpation, all inspectory findings are confirmed, the growth was firm in consistency and nontender, no bleeding on provocation. Pathological migration of the teeth, i.e., 43 and 44 was seen in association with the growth with mild crowding in the same region.

IOPA and mandibular occlusal radiographs of the patient were made with area of interest into consideration which did not reveal any significant changes except mild bone loss between 42, 43, and 44 along with pathological migration of 46.

Based on clinical signs and symptoms, a provisional diagnosis of fibrous hyperplasia was given. The differential diagnosis of pyogenic granuloma and peripheral ossifying fibroma were considered, the patient was advised routine blood investigations which came out to be within normal limits after which patient was advised an excisional biopsy with curettage under local anesthesia [Figure 4].
Figure 4: Excised soft tissue from the lingual aspect measuring approximately 2 cm × 2 cm

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The H and E section showed epithelium and connective tissue; the epithelium is stratified squamous parakeratinized in nature with variable thickness, the thin long test tube like rete ridges present in some areas. The underlying connective tissue shows loose fibrillar connective tissue collagen fibers interspersed with fibroblast, chronic inflammatory infiltrate chiefly lymphocytes, macrophages, plasma cells, and few neutrophils are present. Dystrophic calcification is seen in some areas.

The histopathological diagnosis of lobulated capillary hemangioma was given.

Case report 3

A 32-year-old male patient reported to the Department of Oral Medicine and Radiology with a chief complaint of bleeding gums in lower anterior region for 8 months [Figure 5]. The growth was initially small in size when he noticed it for the first time, but the growth has rapidly increased over the past one 1 month to attain the present size. The growth bleeds on provocation but is not associated with pain. The patient's medical history was unremarkable. The patient gave history of tissue abuse habit that is tobacco chewing for 1 year twice a day, and he used to keep the pouch of tobacco in the lower anterior region. Since he noticed the growth, he has changed the place for placement of the pouch and now places in the left posterior region.
Figure 5: Single pedunculated growth was in 31, 32 region attached to the normal gingival and measuring approximately 1 cm × 1 cm in dimension

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On examination, a single pedunculated growth was in 31, 32 region attached to the normal gingival and measuring approximately 1 cm × 1 cm in dimension. The overlying mucosa was pinkish and had a smooth surface. On inspection, all inspectory findings were confirmed. The growth was soft to firm in consistency, nontender, bleeding on provocation was present. No pus discharge.

Based on clinical signs and symptoms, a provisional diagnosis of irritational fibroma was given. The differential diagnosis of lobulated capillary hemangioma was considered. The patient was advised routine blood investigations, the report of which came within the normal limit. The patient was advised an excisional biopsy with curettage under local anesthesia.

The H and E stained section showed stratified parakeratinized squamous epithelium layers with long slender rete – ridges and connective tissue stroma. The underlined connective tissue stroma showed numerous endothelium-lined blood vessel with extravasated RBCs. Dense inflammatory infiltrate chiefly lymphocytes were seen. Dense collagen bundle interspersed plump fibroblast.

The histopathological diagnosis of lobulated capillary hemangioma was given.


  Discussion Top


Seven percent of total benign lesion tumors of infancy and childhood are hemangiomas.[4] These type of hemangiomas in head and neck region are common but those occurring in oral cavity especially on the soft tissues are uncommon and less frequently encountered by the dental professionals.[6] These lesions are very much similar to other lesions such as inflammatory hyperplasias and nodular growth in their clinical appearance.

In an analysis of 244 cases of gingival lesions in South Indian population, Shamim et al. found that non-neoplastic lesions accounted for 75.5% of cases with lobulated capillary hemangioma being most frequent lesion, accounting for 52.71% cases.[7]

Taking etiopathogenesis into consideration, some authors regard lobulated capillary hemangioma as an “infectious” entity. Kerr has reported staphylococci and botryomycosis, foreign bodies, and localization of infection in walls of blood vessel as contributing factors for the development of the lesion.[8] According to Shafer et al., oral pyogenic granuloma arises as a result of infection by either staphylococci or streptococci, partially because it was shown that these microorganisms could produce colonies with fungus-like characteristics. They also stated that lobulated capillary hemangioma arises as a result of some minor trauma to the tissues providing a pathway for the invasion of nonspecific types of microorganisms. They explain the mechanism that any irritant applied to living tissue may act either as a stimulus or as a destructive agent or both. If many cells are present in a small volume of tissue and there is a relative reduction of blood flow through the area as in inflammation, the concentration of the stimulating substance will be high, and growth will be stimulated. As differentiation and maturation are attained, the cells become widely separated and the concentration of the substance falls and little growth occurs. In this type of inflammation that results in the formation of lobulated capillary hemangioma, destruction of fixed tissue cells is slight, but stimulus to proliferation of vascular endothelium persists and exerts its influence over a long period.[1]

Regezi et al. suggest that lobulated capillary hemangioma represents an exuberant connective tissue proliferation to a known stimulus or injury like calculus or foreign material within the gingival crevice.[9]

Extragingival causes of Lobulated Capillary Hemangioma can be a history of trauma, whereas gingival causes can be chronic oral irritants such as overhanging restoration, poor oral hygiene, and even hormonal changes.[10]

Immunosuppressive drugs such as cyclosporine, wrong selection of healing cap for implants are some of the other precipitating factors for lobulated capillary hemangioma.[11]

Lobulated capillary hemangiomas in the early stages bleed easily, are highly vascular as whereas the vascularity decreases as the lesion matures and becomes more collagenous and pink. Sometimes, the mature lesions have fibrous maturation resemble and/or become fibromas. Sometimes, they can have a rapid growth pattern. The mean duration time of diagnosis is approximately 3 months. If the lesion is present longer than 6 months, the possibility of cutaneous malignancy increases.[12]

Lobulated capillary hemangiomas are most of the times clinically similar to peripheral ossifying fibroma and peripheral giant cell granuloma. However, peripheral ossifying fibroma and peripheral giant cell granuloma typically occur only on gingival and alveolar mucosa unlike lobulated capillary hemangioma which can occur on other sites including the gingiva.

Also to be site-specific, peripheral giant cell granuloma is bluish purple and histopathologically it shows the presence of multinucleated giant cells.

Peripheral ossifying fibromas are larger lesions, clinically more than 1.5 cm in dimensions. There is radiographic evidence of ossification (calcification present within the lesion), and histopathologically, it shows minimal vascular component.

Lobulated capillary hemangioma does not show any radiographic findings.

Two histological variants of pyogenic granuloma are seen lobulated capillary hemangioma and nonlobulated capillary hemangioma. Lobulated capillary hemangioma shows proliferating blood vessels organized in lobular aggregates, superficially the lesion most of the times shows no specific change, including edema, capillaries dilation or inflammatory granulation tissue.[2],[10]

Recurrence of lobular capillary hemangiomas in the same location after treatment is common with rates ranging from 3.7% to 43.5%.[13]


  Conclusion Top


Lobulated capillary hemangiomas are commonly encountered soft-tissue enlargements. However, etiopathogenesis is still debatable. Careful diagnosis is essential to differentiate this lesion from vascular lesions. Meticulous oral hygiene should be instituted. Surgical excision of the growth, along with curettage should be done to prevent recurrences of this common lesion. Proper diagnosis and treatment of the lesion are very important. It arises in response to various stimuli such as low grade local irritation, traumatic injury, sex hormones, and certain kinds of drugs, so surgical excision is the treatment of choice.

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.
Shafer WG, Hine MK, Levy BM. Shafer's Textbook of Oral Pathology. 5th ed. Amsterdam: Elsevier Health Sciences; 2006. p. 459-61.  Back to cited text no. 1
    
2.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Surgery. 2nd ed. Philadelphia: Saunders; 2002. p. 447-9.  Back to cited text no. 2
    
3.
Cawson RA, Binnie WH, Speight PM, Barrett AW, Wright JM. Lucas Pathology of Tumors of Oral Tissues. 5th ed. Missouri: Mosby; 1998. p. 252-4.  Back to cited text no. 3
    
4.
Rachappa MM, Triveni MN. Capillary hemangioma or pyogenic granuloma: A diagnostic dilemma. Contemp Clin Dent 2010;1:119-22.  Back to cited text no. 4
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5.
Gomes SR, Shakir QJ, Thaker PV, Tavadia JK. Pyogenic granuloma of the gingiva: A misnomer? – A case report and review of literature. J Indian Soc Periodontol 2013;17:514-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Angelopoulos AP. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features. J Oral Surg 1971;29:840-7.  Back to cited text no. 6
[PUBMED]    
7.
Shamim T, Varghese VI, Shameena PM, Sudha S. A retrospective analysis of gingival biopsied lesions in South Indian population: 2001-2006. Med Oral Patol Oral Cir Bucal 2008;13:E414-8.  Back to cited text no. 7
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8.
Kerr DA. Granuloma pyogenicum. Oral Surg Oral Med Oral Pathol 1951;4:158-76.  Back to cited text no. 8
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9.
Regezi JA, Sciubba JJ, Jordan RC. Oral Pathology: Clinical Pathologic Considerations. 4th ed. Philadelphia: WB Saunders; 2003. p. 115-6.  Back to cited text no. 9
    
10.
Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: The underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol 1980;4:470-9.  Back to cited text no. 10
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11.
Bachmeyer C, Devergie A, Mansouri S, Dubertret L, Aractingi S. Pyogenic granuloma of the tongue in chronic graft versus host disease. Ann Dermatol Venereol 1996;123:552-4.  Back to cited text no. 11
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12.
Fortna RR, Junkins-Hopkins JM. A case of lobular capillary hemangioma (pyogenic granuloma), localized to the subcutaneous tissue, and a review of the literature. Am J Dermatopathol 2007;29:408-11.  Back to cited text no. 12
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13.
Lee J, Sinno H, Tahiri Y, Gilardino MS. Treatment options for cutaneous pyogenic granulomas: A review. J Plast Reconstr Aesthet Surg 2011;64:1216-20.  Back to cited text no. 13
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    Figures

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



 

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