|Year : 2018 | Volume
| Issue : 1 | Page : 47-50
Oral pregnancy tumor
Swet Nisha1, Avinash Bettahalli Shivamallu1, Usha Hedge2
1 Department of Periodontology, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
2 Department of Oral pathology and Microbiology, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
|Date of Web Publication||11-Jun-2018|
Dr. Swet Nisha
Department of Periodontology, Room No. 9, JSS Dental College and Hospital, JSS University, S.S. Nagar, Bannimantap, Mysore - 570 015, Karnataka
Source of Support: None, Conflict of Interest: None
Oral health care in pregnancy is a critical issue which needs to be addressed by the patient, gynecologist and dentist. There are hormonal changes which occur during the pregnancy and leads to changes in oral flora making the oral cavity more susceptible to oral infections and inflammation. Timely referral by the gynecologist to the dentist can minimize the oral health issues related to pregnancy. Patient education and oral prophylaxis are beneficial for both the patient and fetal care. This case report highlights pregnancy tumor in the second trimester of pregnancy which was excised after parturition due to its persistence.
Keywords: Inflammatory hyperplasia, Oral pregnancy tumor, pregnancy, pyogenic granuloma
|How to cite this article:|
Nisha S, Shivamallu AB, Hedge U. Oral pregnancy tumor. J Dent Allied Sci 2018;7:47-50
| Introduction|| |
The hormonal changes during pregnancy are linked to changes in oral health. Periodontal health is of great concern as literature reviews focuses on pregnancy-induced gingival and periodontal changes such as pregnancy gingivitis and pregnancy tumor. Low birth weight baby, risk of preterm are the systemic health issues in pregnancy related to periodontal health.
Pregnancy tumor is a pyogenic granuloma that occurs during pregnancy. The term was first coined by Blum in 1912. Hartzell proposed the term pyogenic granuloma although it is not a true granuloma as it is not associated with pus and hence the term itself is a misnomer. It is present in up to 5% of pregnancies. Saravana demonstrated that 55% of PG lesions involved the maxilla, and 83% occurred in the gingiva.
Etiological factor triggering the inflammation can be chronic low-grade irritation, hormonal factors, or drugs. This rapidly growing tumor usually appears during the 2nd or 3rd month of pregnancy. Clinically, it represents a tumor-like growth, reddish–purplish red depending on the vascularity of the lesion, tendency to bleed and most common origin is the interdental papilla of maxillary anterior teeth. The most common site of appearance is gingiva followed by tongue, lip, palate, and oral mucosa.
In 1946, Ziskin and Ness compiled a clinical classification of pregnancy gingivitis as follows:
- Class I – Characterized by bleeding gingiva with more or less no other manifestations
- Class II – Characterized by changes in interdental papilla-edema and swelling with exhibits a tendency to recur. Subsequent blunting of interdental papilla
- Class III – Characterized by the involvement of the free gingival margin, which takes on the color and general appearance of a raspberry
- Class IV – Generalized hypertrophic gingivitis of pregnancy
- Class V – The pregnancy tumor.
The treatment modalities include removal of irritating agent, oral prophylaxis, and oral hygiene reinforcement. When patient's oral hygiene condition improves postpartum some lesions resolves on its own. Persisting lesions can be removed by surgical excision with a scalpel, radiosurgery, laser surgery, cryosurgery, and intralesional injections of ethanol, sodium tetradecyl sulfate sclerotherapy, or corticosteroid.
| Case Report|| |
A 20-year-old woman in the 17th week of pregnancy reported to the Department of Periodontology with a chief complain of a swelling in upper right maxillary back tooth region for 4 weeks. The patient had bleeding on brushing and while mastication. On examination revealed a 5 cm × 4 cm sessile nodular mass covered by smooth red mucosa with bleeding tendency. The mass was extending from canine region to the second molar region covering both the buccal and palatal area [Figure 1] and [Figure 2]. On palpation, it was soft in consistency, bleeding on palpation was present without ulceration. Intraoral periapical radiograph revealed no bone loss.
|Figure 2: Extension of the soft-tissue mass from buccal aspect to the palatal aspect of involving 13–17 region|
Click here to view
The patient had extracted the first premolar for orthodontic correction and space closure was uncompleted. The origin of the sessile mass was observed from the space between the canine and first premolar indicating difficulty in maintaining this area clean. A provisional diagnosis of pyogenic granuloma was made. Treatment plan included phase I therapy-oral prophylaxis after routine hematological investigation and oral hygiene instruction. Follow-up visits were scheduled for the next 5 months. Postpartum, the patient, reported with persisting lesion and surgical excision of the lesion was planned.
Local anesthesia 1:80,0000 maxillary nerve block and greater palatine nerve block was given. Scalpel technique was used for excision of the growth [Figure 3] and [Figure 4]. The growth was excised, and root planing and curettage of the area was done. The site was irrigated with normal saline. Periodontal pack was placed.
The excised mass was sent for histopathological examination [Figure 5]. The h and E stained sections showed stratified squamous surface epithelium. Lobular pattern of vascular proliferation with inflammation was seen with sparsely arranged collagen in the connective tissue. Angiomatous tissue with endothelial cell proliferation, inflammatory cell infiltrate is seen in the form of neutrophils, lymphocytes, and plasma cells. Based on a clinicopathological correlation, a final diagnosis of pregnancy tumor was reached. The patient was recalled after 1 week for pack removal and oral hygiene reinforcement was done [Figure 6] and [Figure 7]. No recurrence has been observed for 6 months' follow-up.
|Figure 5: Stratified squamous epithelium with an underlying fibrovascular stroma including large number of budding capillaries, dense chronic inflammatory cell infiltrate|
Click here to view
| Discussion|| |
Pyogenic granuloma is very common skin lesion. In oral cavity, it is seen in keratinized tissue. There are two types – lobular capillary hemangioma and nonnodular capillary hemangioma, which differ in their histologic features. The molecular mechanisms involved in the development of pyogenic granuloma lies in the endocrinal changes leading to changes in blood and lymph microvasculature of skin and mucosa. Ojanotko-Harri et al. suggested possible role of progesterone in pregnancy gingivitis and granuloma. This hormone acts as an immunosuppressant in the gingival tissues of pregnant women, thereby preventing a rapid acute inflammatory reaction against plaque and allowing an increased chronic tissue reaction, resulting in chronic inflammatory state. Besides pregnancy, the lesion could be being secondary to a local cause, systemic illness, or drug reaction. Several drugs, such as phenytoin, cyclosporine, and calcium channel blockers, have been reported to have an adverse effect on gingival hyperplasia. Recognized side effects of oral contraceptives are similar to the oral changes associated with pregnancy, such as the pronounced hyperemia of the gingiva, hyperplastic gingivitis, and PG. Systemic illnesses such as leukemia, Wegener's granulomatosis, sarcoidosis, Crohn's disease, acromegaly, and Vitamin C deficiency have also been described in association with gingival enlargement.
Blood tests should be performed, and a thorough history and physical assessment are essential to reach a correct diagnosis. Differential diagnosis of a pregnancy tumor includes peripheral giant cell granuloma, peripheral ossifying fibroma, metastatic cancer, and hemangioma. Biopsy findings have an important role and a definitive effect on correct diagnosis.
A study on angiogenesis-associated factors in pyogenic granuloma suggested increased expression of vascular endothelial growth factor and basic fibroblast growth factor in pyogenic granuloma than healthy periodontium.
During pregnancy the normal oral microbiota changes to anaerobic flora mainly Prevotella intermedia predominance which is associated with an increase in estradiol and progesterone levels systemically. This can act as a substitute for menadione (Vitamin K) essential growth factor for P. intermedia and coincide with gingival bleeding.
Recurrence of lesion even after excision occurs up to 16% of the lesions. Some lesions manifests as multiple deep satellite nodules that surround the site of original lesion (Warner-Wilson Jones Syndrome). Incomplete removal of lesion or poor oral hygiene are attributable to recurrence rate.
O'Neil in 1979 reported that pregnancy can lead to depression of maternal T-lymphocytes, diminishing the mother's immunity. This may also act as a factor in the exuberant tissue response to the plaque microorganisms.
Maintenance of oral hygiene and regular follow up appointments should be recommended for pregnant patients. Surgical intervention should be done in case of esthetic or functional problems safely in the second trimester. However, surgical intervention should be planned with patient and physician consent and after routine hematological test. Oral prophylaxis and oral hygiene reinforcement should be done in all the cases as some lesions may resolve after parturition and still if persists surgical excision can be planned.
In the present case, though the lesion was causing functional problem, patient hematological report revealed hemoglobin – 7.6%, and with physician consent, nonsurgical management along with maintenance therapy was planned. Surgical therapy was planned postpartum as lesion did not resolve.
| Conclusion|| |
Oral health education for pregnant woman should be focused by gynecologist and dentist. Pregnancy tumor is nonneoplastic lesion and patient should be reassured. Timely oral prophylaxis and maintenance can prevent gingival inflammation and its subsequent consequences.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
López NJ, Da Silva I, Ipinza J, Gutiérrez J. Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol 2005;76:2144-53.
Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med 1996;41:467-70.
Saravana GH. Oral pyogenic granuloma: A review of 137 cases. Br J Oral Maxillofac Surg 2009;47:318-9.
Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: Evaluation of oral conditions. Br J Oral Maxillofac Surg 1986;24:376-82.
Stark MM, Zarka FJ. Gingival tumors of pregnancy; review of pregnancy tumors and a report of two cases. Obstet Gynecol 1956;8:597-600.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48:167-75.
Fowler EB, Cuenin MF, Thompson SH, Kudryk VL, Billman MA. Pyogenic granuloma associated with guided tissue regeneration: A case report. J Periodontol 1996;67:1011-5.
Epivatianos A, Antoniades D, Zaraboukas T, Zairi E, Poulopoulos A, Kiziridou A, et al.
Pyogenic granuloma of the oral cavity: Comparative study of its clinicopathological and immunohistochemical features. Pathol Int 2005;55:391-7.
Henry F, Quatresooz P, Valverde-Lopez JC, Piérard GE. Blood vessel changes during pregnancy: A review. Am J Clin Dermatol 2006;7:65-9.
Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewón LA. Altered tissue metabolism of progesterone in pregnancy gingivitis and granuloma. J Clin Periodontol 1991;18:262-6.
Yuan K, Jin YT, Lin MT. The detection and comparison of angiogenesis-associated factors in pyogenic granuloma by immunohistochemistry. J Periodontol 2000;71:701-9.
Kornman KS, Loesche WJ. The subgingival microbial flora during pregnancy. J Periodontal Res 1980;15:111-22.
Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol 1992;27:297-300.
O'Neil TC. Maternal T-lymphocyte response and gingivitis in pregnancy. J Periodontol 1979;50:178-84.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]