Introduction: To report the treatment and follow-up (24 months) of a periodontal plastic surgery for excisionof a maxillary pyogenic granuloma. Case report: This case report describes a patient who presented a lesion diagnosed as a pyogenic granuloma in the region of maxillary incisors and was submitted to surgical excision. The study emphasizes the clinical follow-up after the treatment of patients that present pyogenic granuloma that should be based on surgical excision and histopathological confirmation of clinical diagnosis combined with the treatment of the specific periodontal disease. Conclusion: Follow-up over two years of surgical procedures demonstrated the maintenance of a periodontal health

Cruz, Luis Eduardo Rilling Nova

Martos, Josué

Silva, Gabrielle de Carli da

Silveira, Juliana Cortês da

Portuguese

Portal de Peritódicos da PUCPR (Pontifícia Universidade Católica do Paraná)

Arch Oral Res. 2012 Jan./Apr.;8(1):81-5ISSN 2236-8035Archives of Oral Research, v. 8, n. 1, p. 81-85, Jan./Apr. 2012Licensed under a Creative Commons License [T]Clinical evaluation at two-year follow-up control of pregnancy granuloma[I]Avaliação clínica de acompanhamento após dois anos de controle de granuloma gravídico[A]Luis Eduardo Rilling Nova Cruz[a], Josué Martos[b], Juliana Cortês da Silveira[c], Gabrielle de Carli da Silva[c][a] DDS, MS, PhD, associate professor, Department of Semiology and Clinic, Faculty of Dentistry, Federal University of Pelotas, Pelotas, RS - Brazil. [b] DDS, PhD, associate professor, Department of Semiology and Clinic, Faculty of Dentistry, Federal University of Pelotas, Pelotas, RS - Brazil, e-mail: josue.sul@terra.com.br[c] Graduate students, Faculty of Dentistry, Federal University of Pelotas, Pelotas, RS - Brazil.[R]AbstractIntroduction: To report the treatment and follow-up (24 months) of a periodontal plastic surgery for exci-sion of a maxillary pyogenic granuloma. Case report: This case report describes a patient who presented a lesion diagnosed as a pyogenic granuloma in the region of maxillary incisors and was submitted to surgical excision. The study emphasizes the clinical follow-up after the treatment of patients that present pyogenic granuloma that should be based on surgical excision and histopathological confirmation of clinical diagno-sis combined with the treatment of the specific periodontal disease. Conclusion: Follow-up over two years of surgical procedures demonstrated the maintenance of a periodontal health. [#] [P]Keywords: Periodontics. Pyogenic granuloma. Treatment. Follow-up. [#][B]ResumoIntrodução: Relatar o tratamento e o acompanhamento clínico de 24 meses de uma cirurgia plástica perio-dontal para excisão de um granuloma piogênico maxilar. Relato de caso: Este relato clínico descreve uma pa-ciente que apresentava uma lesão diagnosticada como granuloma piogênico na região de incisivos superiores Arch Oral Res. 2012 Jan./Apr.;8(1):81-5Cruz LERN, Martos J, da Silveira JC, da Silva GC.82Figure 1 - Approximate clinical aspect of pyogenic granulomaFigure 2 - Palatal aspect of pyogenic granulomarevealed an area with gingival hyperplasia of a red-dish color with irregular surface and pedunculated mass lesion extending to the buccal and palatal area of the permanent maxillary left incisors (Figure 2). Periodontal examination revealed a 5-mm pocket on the buccal and proximal aspects of 21/22 and bleed-ing on probing. Light presence of dental plaque was detected during initial clinical examination of the gingival margin, especially around the incisor area.We observed a significant distance (diastema) between 21 and 22; however, the patient reported IntroductionThe pyogenic or gravidarum granuloma is a be-nign lesion of the gingival mucosa that affects the skin and mucosa. These are generally associated with periodontal disease inflammatory and hormonal fac-tors such as pregnancy (1-4). This lesion is charac-terized by localized polypoid growth, which is exo-phytic, sessile or pedunculated erythematous to brownish, and usually ulcerated with spontaneous bleeding. The surface of the oral pyogenic granulo-ma ranges from pink to red to purple, depending on the age of the lesion (5).Hormones and other factors may modify the re-sponse and promote development of hyperplastic tissue or granulation. Hormonal changes in both the gestational period and puberty modify the clinical course (6), since the levels of estrogen and proges-terone is high, exerting a markedly enhanced pro-liferative effect at the level of the endothelium (2).The treatment usually used is surgical excision of the lesion, including all tissue where the disease appears. This is performed in combination with the removal of local irritating factors such as dental plaque and calculus (4, 5, 7-10). However, recogni-tion and identification of these factors are not al-ways possible and the rate of recurrence of the in-jury is relatively high due to incomplete removal of the lesion or failure due to the intervention of etio-logical factors (11).Case reportA 22-year-old female in the fourth month of preg-nancy was referred to the Dental Clinics of our in-stitution. She presented a polypoid sessile gingival mass on the palatal and buccal aspect of teeth 21 and 22. She also complained of gingival bleeding upon brushing (Figure 1). Clinical intraoral examination e que foi submetida à excisão cirúrgica. O trabalho enfatiza o acompanhamento clínico após o tratamento de pacientes que apresentem granuloma piogênico, e que deve basear-se na excisão cirúrgica e na confirma-ção histopatológica do diagnóstico clínico, combinado com o tratamento da doença periodontal específica. Conclusão: O acompanhamento clínico de dois anos dos procedimentos cirúrgicos indicou a manutenção da saúde periodontal. [#] [K]Palavras-chave: Periodontia. Granuloma piogênico. Tratamento. Acompanhamento. [#]Arch Oral Res. 2012 Jan./Apr.;8(1):81-5Clinical evaluation at two-year follow-up control of pregnancy granuloma83Figure 3 - Initial incision of the lesion with Kirkland scalpelFigure 4 - Surgical access by buccal aspect with 15c bladeFigure 5 - Appearance and dimensions of excised tissueFigure 6 - Microscopic view of pyogenic granuloma with hy-perplastic epithelium and fibrous connective tis-sue with chronic inflammatory cells (hematoxylin-eosin stain)that diastema existed before appearance of the le-sion. She also reported that this lesion was relaps-ing (recurrent) because she had the same type of le-sion removed a year ago. The patient was sufficient-ly informed about her oral health status, as well as the proposed treatment, and signed a consent form that outlined the ethical and legal principles of clini-cal care.After basic periodontal treatment, the main body of the gingival mass, which also involved the inter-proximal and buccal aspects of teeth 21 and 22, was completely excised and submitted for histopatho-logic examination (Figures 3 and 4). At the time of the procedure under local anesthesia with Mepiva-caine 2% and 1:100,000 epinephrine, incisions were made in the external bezel by removing the lesion. The lesion appeared macroscopically as a fragment measuring 21.0 × 10.0 × 7.0 mm, which was smooth, shiny, and elastic, covered with whitish mucosa with small ulcers in some parts (Figure 5). After removal of the lesion, the scraping technique was performed with castroviejo surgical scissors and with the back of a scalpel blade, to restore the aesthetic contour of the affected gingival region.After surgical excision, the area was protected with surgical cement. The patient was advised to use 0.2 percent chlorhexidine digluconate solution twice a day for ten days for periodontal maintenance. Histological analysis revealed the presence of vascu-lar proliferation, and similar to granulation tissue, numerous small and large canals lined by endothe-lium, and obliterated by hematic and inflammatory cell infiltrate comprising neutrophils, plasma cells and lymphocytes (Figure 6). Arch Oral Res. 2012 Jan./Apr.;8(1):81-5Cruz LERN, Martos J, da Silveira JC, da Silva GC.84Figure 7 - Two-year follow-up of the clinical casemade after histopathological examination which, in this case, confirmed the diagnosis (4).In the case of a benign lesion, adequate excision usually leads to cure (9, 10). To avoid the possibility of recurrence, the lesion should be excised under the periosteum and the predisposing factors for the le-sion should be removed (4).Periodic preventive maintenance is essential for periodontal health in the long-term. Therefore, one can conclude that the therapy used in this case has the potential to achieve a framework of periodontal health. Therefore the patient was fully treated to fa-cilitate the control of systemic conditions, surgical removal of the lesion and appropriate periodontal treatment.ConclusionGranuloma gravidarum is a frequent injury of the mouth where the gingival tissue in females is affect-ed. The clinical treatment protocol is based on sur-gical excision and histopathological confirmation of clinical diagnosis combined with the treatment of any periodontal disease present.AcknowledgementsThe authors gratefully thank to Mr. Sam Mahfoudh for the assistance with the specific permission from Elsevier.After three weeks, the gingival tissue showed a beginning of healing within the expected normality. After two months of the periodontal surgery was noted the symmetry and tissue pigmentation with the right side; it was determined that the patient could maintain adequate plaque control. After six months of healing, the patient was pleased with the aesthetic results that addressed and at the 2-years postoperative visit, the periodon-tium and anterior dentition appeared to be healthy, and there was no recurrence of the pyogenic granu-loma (Figure 7). A follow-up examination showed satisfactory resolution of the clinical case and sug-gested a favorable progression in the periodontal tis-sues involved.DiscussionGranuloma gravidarum (pregnancy tumor) is a term used to describe a pyogenic granuloma that de-velops in pregnant women. The condition typically occurs in the first trimester of pregnancy and rapid growth follows the steady increase in circulating es-trogen and progesterone (1-4).Granuloma gravidarum has a preference for gin-gival tissue, in the anterior maxilla, presumably due to the presence of biofilm and calculus. About 50% of pregnant women have gingival changes, although only a small proportion develop tumors in the gingi-val tissue (12). Atypical situations may be observed, such as a pyogenic granuloma concomitant with drug-induced gingival hyperplasia in renal trans-plant patients under cyclosporin therapy or, alter-nately, in association with external dental resorp-tion (13, 14).Studies show that the gingival tissue has recep-tors for steroid hormones (2) and thus the increase in estrogen and progesterone can cause changes in the physiology of gingival tissue (1). Such changes can enhance the response of gingival tissues to local irritants such as plaque and calculus.In this case, the clinical examination showed low, however present, accumulation of plaque and a small amount of tartar on the teeth, mainly related to the lesion. Presumptive clinical diagnosis was pyogenic granuloma, taking into account the clinical features of the lesion. It should be noted that the definitive diagnosis of lesions in oral soft tissues can only be Arch Oral Res. 2012 Jan./Apr.;8(1):81-5Clinical evaluation at two-year follow-up control of pregnancy granuloma859. Bosco AF, Bonfante S, Luize DS, Bosco JM, Garcia VG. Periodontal plastic surgery associated with tratment for the renoval of gingival overgrowth. J Periodontol. 2006;77(5):922-8.10. Santana RB, Furtado MB, Mattos CML. Plástica perio-dontal para excisão cirúrgica estética de granuloma piogênico. Rev Bras Odont. 2008;65(2):165-8. 11. Lopez-Labady J, Lazarde J, Arreaza AA. Granuloma Piogénico de gran tamaño en paciente embarazada: presentación de un caso. Acta Odontol Venez. 2003; 41(3):240-3.12. Silverstein LH, Burton CH, Garnick JI, Singh BB. The late development of oral pyogenic granuloma as a complication of pregnancy: a case report. Compend Contin Educ Dent. 1996;17(2):192-8.13. Vélez LMA, Souza LB, Pinto LP, Al-Zayer M, Fonseca M, Ship JA. Pyogenic granuloma in a renal transplant patient: case report. Spec Care Dentist. 2001;21(5): 187-90.14. Vossoughi R, Takei H. External cervical resorption associated with traumatic occlusion and pyogenic granuloma. J Canad Dent Assoc. 2007;73(7):625-8. Received: 04/09/2012Recebido: 09/04/2012Approved: 06/01/2012Aprovado: 01/06/2012References1. Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewon LA. Altered tissue metabolism of progesterone in preg-nancy gingivitis and granuloma. J Clin Periodontol. 1991;18(4):262-6.2. Whitaker SB, Bouquot JB, Alimaro AE, Withaker TJ. Identification and semiquantification of estrogen and progesterone receptors in pyogenic granulomas of pregnancy. Oral Surg Oral Med Oral Pathol. 1994; 78(6):755-60.3. Fowler EB, Cuenin MF, Thompson SH, Kudryk VL, Billman MA. Pyogenic granuloma associated with guided tissue regeneration: a case report. J Periodon-tol. 1996;67(10):1011-5.4. Cruz LE, Martos J. Granuloma gravidarum (pyogenic granuloma) treated with periodontal plastic surgery. Int J Gynaecol Obstet. 2010;109(1):73-4.5. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyo-genic granuloma: a review. J Oral Sci. 2006;48(4): 167-75.6. Yuan K, Wing LY, Lin MT. Pathogenic roles of angio-genic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones. J Periodontol. 2002;73(7):701-8.7. Terezhalmy GT, Riley CK, Moore WS. Pyogenic gran-uloma (pregnancy tumour). Quintessence Int. 2000; 31(6):440-1.8. Silva-Sousa YTC, Coelho CMP, Brentegani LG, Vieira MLSO, Oliveira ML. Clinical and histological evalu-ation of granuloma gravidarum: case report. Braz Dent J. 2000;11(2):135-9.

Clinical evaluation at two-year follow-up control of pregnancy granuloma

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Clinical evaluation at two-year follow-up control of pregnancy granuloma

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