Background

• Oral pyogenic granuloma is a typical benign vascular lesion in the oral cavity. It is characterized by forming a red or pink, rapidly growing, and friable mass of granulation tissue. Despite its name, oral pyogenic granuloma is not correlated with pus and doesn’t portray granuloma. 
• Microscopically, oral pyogenic granuloma typically shows a lobular architecture, with the lesion composed of multiple lobules separated by fibrous septa. Each lobule contains a central core of proliferating blood vessels, often called “granulation tissue,” surrounded by fibroblasts and a variable number of inflammatory cells such as neutrophils, lymphocytes, and plasma cells. The blood vessels within the lesion are often dilated and lined by endothelial cells. 

Epidemiology

• The epidemiology of oral pyogenic granuloma indicates that it is a relatively common oral lesion.  
• Although it affects individuals of any age, oral pyogenic granuloma is most commonly observed in young adults, with a peak incidence between the second and third decades of life. 
• Oral pyogenic granuloma has a higher incidence during pregnancy, affecting approximately 1-5% of pregnant women. The exact cause of this increased prevalence during pregnancy is not fully understood, but hormonal changes and increased vascularity are believed to play a role. 

Anatomy

Pathophysiology

• The pathophysiology of oral pyogenic granuloma involves a complex interplay of inflammatory and angiogenic processes in response to local irritation or trauma.
• The 3 parts of the mouth that get affected by the granuloma are the lips, gums, and tongue. The mechanisms involved in the pathophysiology of this condition include chronic irritation, inflammatory response, angiogenesis, granulation tissue formation, imbalance between angiogenesis & pro-angiogenic factors, and epithelial changes. Pregnancy makes granuloma more vulnerable. 

Etiology

The etiology of oral pyogenic granuloma, known as lobular capillary hemangioma, involves several factors. 

• Chronic irritation or trauma: Chronic irritation or trauma to the oral tissues significantly contributes to developing oral pyogenic granuloma. This can result from poor oral hygiene, dental plaque, sharp teeth, ill-fitting dental appliances, repetitive mechanical injury, or chronic low-grade infections. 
• Hormonal factors: Hormonal changes, especially during pregnancy, correlate with an increased incidence of oral pyogenic granuloma. The higher levels of hormones, such as estrogen and progesterone, during pregnancy, may contribute to the development of the lesion. It is often called as a “pregnancy tumor” or “granuloma gravidarum” due to its frequent occurrence in pregnant individuals. 
• Local factors: Local factors within the oral cavity, including dental calculus (tartar), dental plaque, and periodontal disease, have been implicated in developing oral pyogenic granuloma. These factors can lead to chronic inflammation, tissue injury, and irritation, triggering lesion formation. 
• Genetic predisposition: Although not well-established, a genetic predisposition may influence an individual’s susceptibility to developing oral pyogenic granuloma. Further research is required to get through the genetic factors involved. 
• Inflammatory and angiogenic factors: Inflammatory mediators and angiogenic factors play a role in developing oral pyogenic granuloma. The inflammatory response triggered by local irritants or trauma leads to the release of cytokines and growth factors, promoting the proliferation of blood vessels and the formation of granulation tissue. 

Genetics

Prognostic Factors

• Regression and resolution: With appropriate treatment and removal of local irritants, oral pyogenic granuloma often regresses and resolves completely. After the lesion is excised or treated, the area usually heals without complications. 
• Recurrence: Although oral pyogenic granuloma has a low recurrence rate, there is a small possibility of recurrence if the underlying causes and local irritants are not adequately addressed. It is essential to maintain good oral hygiene, address any oral health issues, and follow the advice of the healthcare professional to minimize the chances of recurrence. 
• Pregnancy-related lesions: In cases where oral pyogenic granuloma occurs during pregnancy, the lesion commonly regresses and resolves postpartum without further intervention. However, if the lesion persists or causes significant discomfort or bleeding, treatment during pregnancy may be necessary. 

Clinical History

Age Group:  

• Young adults 
• Pregnant individuals 
• Children 
• Adolescents 
• Older adults 

Physical Examination

• During the physical examination of a patient suspected of having bacterial sepsis, healthcare providers will assess various signs & symptoms that may indicate the presence of infection and sepsis.
• The examination will thoroughly assess the patient’s vital signs, general appearance, and specific physical findings.

Age group

Associated comorbidity

Certain local factors or activities may contribute to the development or persistence of the lesion.

Here are some factors that can be associated with oral pyogenic granuloma are: 

• Poor oral hygiene 
• Trauma/chronic irritation 
• Periodontal disease 
• Hormonal changes 
• Presence of orthodontic appliances 

Associated activity

• In some cases, oral pyogenic granuloma can present acutely, meaning it develops rapidly over a short period. This may occur due to a recent traumatic event or sudden exposure to an irritant. The lesion may appear as a red or pink raised mass on the oral mucosa, and it may cause symptoms such as pain, tenderness, or bleeding. 
• Subacute presentation: Most oral pyogenic granulomas have a subacute presentation, where the lesion develops gradually over weeks to months. In these cases, the lesion may start as a small bump or ulceration that slowly enlarges and becomes more prominent. There may be intermittent bleeding or discomfort associated with the lesion. 
• Chronic presentation: In some instances, oral pyogenic granuloma may have a chronic presentation, indicating that the lesion has lasted longer. These chronic lesions may be larger and have a more fibrotic appearance. They may exhibit recurrent bleeding or ulceration due to persistent irritation or trauma. 

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Observation: Small pyogenic granulomas that are asymptomatic and not causing any functional or aesthetic concerns may be observed without intervention. 
• Conservative Management: Maintaining good oral hygiene practices, including regular brushing and flossing, can help prevent further irritation and promote healing. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-oral-pyogenic-granuloma

• Oral Hygiene: Maintaining good oral hygiene is essential to prevent further irritation and inflammation of the granuloma. 

To prevent plaque and food particles that can irritate teeth, brush your teeth at least two times a day with fluoride toothpaste.  

• Avoidance of Irritants: Identifying and avoiding potential irritants can help prevent exacerbation or recurrence of oral pyogenic granulomas.  
• Dietary Modifications: Certain foods and beverages which are spicy and acidic can aggravate oral lesions. Advising patients to avoid such foods or beverages may help alleviate discomfort and promote healing. 
• Orthodontic Evaluation: In cases where orthodontic appliances contribute to irritation of oral tissues, referral to an orthodontist for evaluation and adjustment of appliances may be necessary to minimize friction and pressure on the granuloma. 

Use of Vasoconstrictors

Epinephrine: By narrowing blood vessels and lowering blood flow to the afflicted location, it may be used to momentarily shrink the size of the granuloma. This can help control bleeding during surgical procedures or provide symptomatic relief in certain cases. 

Use of Nonsteroidal Anti-Inflammatory Drugs

Ibuprofen: It may be recommended to alleviate pain and reduce inflammation associated with oral pyogenic granulomas. Prostaglandins are mediators of inflammation and pain, and these drugs function by preventing their production. 

use-of-intervention-with-a-procedure-in-treating-oral-pyogenic-granuloma

• Excisional Biopsy: Surgical excision is often recommended for larger or persistent lesions. This involves complete removal of the granuloma along with a margin of normal tissue to prevent recurrence. 
• Sclerotherapy: Injection of sclerosing agents into the lesion can cause thrombosis of the blood vessels feeding the granuloma, leading to its regression. 
• Laser Therapy: Laser ablation can be an effective alternative to traditional surgical excision, offering precise removal of the lesion with minimal damage to surrounding tissues. 

use-of-phases-in-managing-oral-pyogenic-granuloma

• Diagnostic Phase: The first step in managing oral pyogenic granuloma involves a thorough clinical examination by a dentist or oral healthcare professional.  
• Treatment Planning Phase: Once the diagnosis is confirmed, the next phase involves developing a comprehensive treatment plan tailored to the individual patient’s needs. 
• Acute Management Phase: In cases where the pyogenic granuloma is causing significant symptoms such as bleeding, pain, or functional impairment, immediate intervention may be necessary to alleviate discomfort and address any urgent concerns. 
• Intervention Phase: The mainstay of treatment for oral pyogenic granuloma is surgical excision, which involves removing the lesion along with a margin of healthy tissue to reduce the risk of recurrence. 
• Rehabilitation Phase: Following surgical intervention, patients may require postoperative care and rehabilitation to promote healing and restore optimal oral health.  
• Monitoring and Follow-up Phase: Regular follow-up appointments are essential to monitor healing progress, evaluate treatment outcomes, and detect any signs of recurrence or complications. 

Medication

Future Trends

Media Gallary

References

Oral Pyogenic Granuloma: A Narrative Review – PMC (nih.gov) 

Oral pyogenic granuloma: Various concepts of etiopathogenesis – PMC (nih.gov)