Oral cavity & oropharynx

Soft tissue tumors & proliferations

Pyogenic granuloma


Editorial Board Member: Bin Xu, M.D., Ph.D.
Deputy Editor-in-Chief: Kelly Magliocca, D.D.S., M.P.H.
Molly Housley Smith, D.M.D.

Topic Completed: 30 August 2021

Minor changes: 30 August 2021

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PubMed Search: Pyogenic granuloma[TI] oral "last 5 years"[DP]

Molly Housley Smith, D.M.D.
Page views in 2020: 9,168
Page views in 2021 to date: 8,560
Cite this page: Smith MH. Pyogenic granuloma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/oralcavitypyogenicgranuloma.html. Accessed October 15th, 2021.
Definition / general
  • Benign and often reactive vascular proliferation of the oral mucosa, most commonly found on the gingiva
Essential features
  • Benign red / vascular soft tissue proliferation, most commonly found on the anterior maxillary gingiva
  • Associated with poor oral hygiene, chronic trauma, pregnancy, medications
  • Form of capillary hemangioma that is most often considered reactive and may demonstrate a lobular architecture histopathologically
  • May demonstrate rapid growth and clinically mimic malignancy (Clin Case Rep 2018;6:690, Case Rep Dent 2021;2021:5575896)
  • Constitutes 3.8 - 7% of oral biopsy diagnoses (J Oral Maxillofac Surg 2010;68:2185)
Terminology
  • Lobular capillary hemangioma, subtype
  • Pregnancy tumor
  • Epulis gravidarum / granuloma gravidarum: pyogenic granuloma occurring in a setting of pregnancy
  • Epulis granulomatosum: pyogenic granuloma located in an extraction socket
ICD coding
  • ICD-10:
    • K06.8 - pyogenic granuloma of the gingiva
    • K13.4 - granuloma and granuloma-like lesions of the oral mucosa
    • K13.6 - irritative hyperplasia of the oral mucosa
Epidemiology
Sites
Pathophysiology
  • Largely unknown, although in pregnancy, estrogen enhances vascular endothelial growth factor (VEGF) production in macrophages, likely contributing to the development of pyogenic granulomas (J Dermatol Sci 2005;38:1)
  • Also in pregnancy, progesterone may function as an immunosuppressant in gingiva, preventing an acute inflammatory reaction against oral bacteria and resulting in proliferative gingival inflammation (J Clin Periodontol 1991;18:262)
  • Increased estrogen and progesterone in pregnancy increases concentrations of Prevotella intermedia in the subgingival biofilm, decreases the host response to the bacteria and increases the vascular permeability and infiltration of fluids into the gingival tissues, contributing to formation of pyogenic granulomas (J Appl Oral Sci 2013;21:215)
  • 2018 International Society for the Study of Vascular Anomalies (ISSVA) Classification of Vascular Anomalies lists BRAF, RAS and GNA14 as causal genes for the lobular capillary hemangioma (pyogenic granuloma) (ISSVA: ISSVA Classification for Vascular Anomalies [Accessed 11 August 2021])
Etiology
  • Associated with chronic irritation (J Oral Maxillofac Surg 2010;68:2185, Head Neck Pathol 2019;13:4)
    • Poor oral hygiene
    • Ill fitting oral appliances or overhang margins of dental restorations
    • Persistent bite trauma
  • May be seen in patients with drug induced gingival overgrowth from use of calcium channel blockers, calcineurin inhibitors, antiseizure medications or anticancer medications (e.g. TNF alpha antagonists, BRAF inhibitors, tyrosine kinase inhibitors, epidermal growth factor receptor inhibitors, mTOR inhibitors, taxanes, pyrimidine analogs) (Case Rep Dent 2021;2021:5575896, Pediatr Transplant 2020;e13947)
Clinical features
Diagnosis
  • Made upon histopathological examination of the excisional specimen
Prognostic factors
Case reports
Treatment
Clinical images

Contributed by Brittany Camenisch, D.M.D., Nehal Almehmadi, B.D.S., Sana Naheed, B.D.S., Evan Lynch, M.D., Ph.D.,
Justin Kolasa, M.D., D.M.D., Molly Housley Smith, D.M.D. and Susanna Goggin, D.M.D.

Gingival pyogenic granuloma

Reactive pyogenic granuloma

Pedunculated vascular nodule

Red ulcerated pyogenic granuloma


Nodular red pebbly masses

Epulis granulomatosum

Ulcerated gingival pyogenic granuloma

Gross description
  • Tan / brown mass, often pedunculated or lobulated
  • May demonstrate hemorrhagic foci on cut surface (Case Rep Dent 2016;2016:1323798)
  • Often exhibits ulcerated surface
Gross images

Contributed by Molly Housley Smith, D.M.D.

Lobulated and hyperkeratotic mass

Lobulated and hyperkeratotic mass, sectioned

Deep inflammatory infiltrate

Ulcerated pyogenic granuloma

Ulcerated pyogenic granuloma, sectioned

Microscopic (histologic) description
  • Highly vascularized proliferation of granulation tissue (J Oral Maxillofac Surg 2010;68:2185)
  • Often demonstrates surface ulceration and a subacute inflammatory cell infiltrate comprised of neutrophils, lymphocytes and plasma cells
  • May demonstrate a lobular arrangement of capillary vessels and proliferating endothelial cells delineated by fibrous septae (termed lobular capillary hemangioma)
  • May be pedunculated
  • May show brisk mitotic rate (up to 10 mitotic figures per high power field); however, lacks pleomorphism (Ann Diagn Pathol 2020;46:151506)
Microscopic (histologic) images

Contributed by Molly Housley Smith, D.M.D.

Pedunculated mass

Prominent vasculature

Prominent blood vessels

Acute inflammation


Lobular arrangement

Lobular and exophytic architecture

Capillary proliferation

Virtual slides

Images hosted on other servers:

Pyogenic granuloma of the skin

Positive stains
Videos

Histopathology of pyogenic granuloma

Clinical and etiologic features

Sample pathology report
  • Gingiva, excision:
    • Pyogenic granuloma
Differential diagnosis
  • Peripheral ossifying fibroma:
    • May be clinically identical
    • Only on the gingiva / alveolar ridge
    • Differentiated based on histopathologic examination
      • Peripheral ossifying fibroma demonstrates the presence of bone, at least focally, within the mesenchymal stroma
  • Peripheral giant cell granuloma:
    • May be clinically identical
    • Only on the gingiva / alveolar ridge
    • Differentiated based on histopathologic examination
      • Presence of osteoclast type multinucleated giant cells
  • Parulis:
    • May be clinically identical, although may express red-yellow fluid on palpation
    • Associated with an adjacent nonvital tooth or inflamed periodontal pocket
    • Can be traced using gutta percha to reveal the inflammatory origin
    • Differentiated based on histopathologic examination
      • Accumulations of neutrophils arranged in a linear fashion
  • Metastatic disease:
    • May be clinically identical
    • Differentiated based on histopathologic examination
  • Gingival squamous cell carcinoma:
  • Spongiotic gingival hyperplasia / localized juvenile spongiotic gingival hyperplasia:
    • Papillary / pebbly surface architecture
    • Recalcitrant to oral hygiene measures
    • < 1 cm in size (J Cutan Pathol 2019;46:839)
    • Traditionally localized, although multifocal examples have been noted
    • Histopathologic examination reveals papillary proliferation of spongiotic, nonkeratinized squamous epithelium with elongation of rete ridges, intermixed capillary vessels and neutrophilic exocytosis
  • Angiosarcoma:
  • Kaposi sarcoma:
Board review style question #1


The above mass is found on the gingiva. What is true regarding this diagnosis?

  1. This entity is more commonly found in pregnant women
  2. This entity is more commonly found in men
  3. This entity is more commonly found in patients who are taking long term steroids
  4. No treatment is indicated for this particular entity; clinical diagnosis is sufficient
Board review style answer #1
A. This entity is more commonly found in pregnant women

Comment Here

Reference: Pyogenic granuloma
Board review style question #2

The above images are of a pedunculated red, lobulated mass on the dorsal tongue. What is the diagnosis?

  1. Angiosarcoma
  2. Epithelioid hemangioendothelioma
  3. Granular cell tumor
  4. Lobular capillary hemangioma (pyogenic granuloma)
Board review style answer #2
D. Lobular capillary hemangioma (pyogenic granuloma)

Comment Here

Reference: Pyogenic granuloma
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