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Pyogenic granuloma: A case report and a comprehensive review

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DOI: 10.4103/jorr.jorr_47_20

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Case Report

Pyogenic granuloma: A case report and a comprehensive

review
Shivani Sharma, Sonali Singh, Lalita Yadav1, Sumit Tyagi2
Departments of Periodontics, 1Oral and Maxillofacial Pathology and 2Orthodontics and Dento‑Facial Orthopaedics, Kalka Dental College,
Meerut, Uttar Pradesh, India

Abstract Pyogenic granuloma (PG) is an inflammatory hyperplasia describing large range of nodular growths of
the oral mucosa. PG commonly occurs on the skin or oral cavity but seldom in the gastrointestinal tract.
It most commonly involves the gingiva. Extragingivally, it can occur on the lips, tongue, buccal mucosa,
and palate. It is caused due to low‑grade irritation, traumatic injury, or hormonal factors.    Various authors
have suggested other names for PG such as Crocker and Hartzell‘s disease, granuloma pyogenicum, benign
vascular tumor and during pregnancy as granuloma gravidarum. Because it is possible to misdiagnose PG as
peripheral ossifying fibroma, peripheral giant cell granuloma, hemangioma, and fibroma, its histopathological
examination is essential for accurate diagnosis. Differential diagnosis is important because of its tendency
to recur. This article presents a case of PG in a 17‑year‑old female along with a comprehensive review of
the lesion.

Keywords: Granuloma, hormonal, irritation, oral, pyogenic, vascular

Address for correspondence: Dr. Shivani Sharma, Department of Periodontics, Kalka Dental College, NH‑58, Partapur Bye‑Pass, Meerut ‑ 250 006,
Uttar Pradesh, India.
E‑mail: docshivaniperio@gmail.com
Submitted: 29‑May‑2020 Accepted: 22‑Jan‑2021 Published: 15-Feb-2021

INTRODUCTION extragingivally, it can occur on the lips, tongue, and buccal

Pyogenic granuloma (PG) is a common tumor‑like growth
of the oral cavity.[1] PG was first described by Hullihen
in 1844[2] as a common nonneoplastic growth of the
oral cavity; Hartzell in 1904[3] gave it the current term
of “PG” or “granuloma pyogenicum.” The name PG
is a misnomer as it is not associated with pus and does
not represent a granuloma histologically.[1] PG has been
described as “granuloma telangiectacticum” due to the
presence of numerous blood vessels seen in histological
sections.[4] Cawson et al.[4] described two forms of PGs, the
lobular capillary hemangioma (LCH) and the non‑LCH.
PG commonly involves the gingiva in 75%–85% of cases;
mucosa.[1]
PG can be found at any age but is more commonly seen
in children and young adults, especially females because
of vascular effects of hormones.[1] Various stimuli such as
trauma,[1] local irritation,[1] hormonal factors,[1] and certain
drugs[5] have been suggested in its development. Clinically,
these lesions usually present as a single nodule or sessile
papule with smooth or lobulated surface.[1,6] These vary in
size from few millimeters to several centimeters.[1] Older
PG resembles fibromas due to fibrous appearance.[7] A
detailed history, clinical examination, and proper treatment
plan are necessary to pinpoint PG as there are many lesions

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DOI: How to cite this article: Sharma S, Singh S, Yadav L, Tyagi S. Pyogenic
10.4103/jorr.jorr_47_20 granuloma: A case report and a comprehensive review. J Oral Res Rev
2021;13:53-9.

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Sharma, et al.: Pyogenic granuloma
in the oral cavity that have appearance similar to PG.
Surgical excision of the lesion with removal of irritants is
the treatment of choice.[1]
This article presents a case of PG of the gingiva in a
17‑year‑old female patient with a localized gingival growth in
the upper right quadrant of the jaw with review of literature.
CASE REPORT
A 17‑year‑old female patient was referred to the department
of periodontics with the chief complaint of a swelling in
gums in relation to the upper right back tooth region of
the jaw since the last 20 days. The swelling was of pinpoint
size when the patient first noticed it but had gradually
enlarged to attain the present size. Intraoral examination
of the patient revealed a poor oral hygiene with bleeding
on probing. Soft‑tissue examination showed a gingival
growth in relation to 17 and 18 region which was reddish
pink in color and had covered the entire crown of 17 up
to the occlusal surface (2 cm × 2.5 cm) in size [Figure 1].
The swelling was firm in consistency and nontender on
palpation. The patient’s medical and family history was
noncontributory, and general physical examination revealed
no other abnormalities. Intra-oral periapical radiograph.
[IOPAR] of the region showed no visible abnormalities,
and the alveolar bone in the region of growth appeared
normal [Figure 1 inset]. The hematological and biochemical
investigation of the patient was within normal limits.
A provisional diagnosis of PG was made. The differential
diagnosis included peripheral ossifying fibroma, peripheral
giant cell granuloma, hemangioma, and fibroma.
Oral prophylaxis was completed for the patient, and excisional
biopsy was planned. Excision of the lesion up to and
including the mucoperiosteum was carried out under local
anesthesia using a Bard Parker handle and blade, followed by
curettage in the involved teeth [Figure 2]. The excised tissue
was sent for histologic examination [Figure 2 inset].
Histopathological report showed parakeratinized
epithelium. The underlying connective tissue stroma
showed dilated and engorged small and large blood
vessels, extravasated red blood cells, angiogenesis, few
inflammatory cells, and bundles of collagen fibers. The
diagnosis PG was confirmed [Figure 3].
Patient was recalled periodically (Figure.4) to check for
possible recurrence and showed no recurrence of the lesion
at one year follow up (Figure.5).
54
DISCUSSION
Etiopathogenesis
PG has been regarded as an “infectious” entity. Shafer
et al.[8] suggested that oral PG 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 agreed
that oral PG is the result of minor trauma to the tissues
that allow nonspecific types of microorganisms to invade
the tissues. Bhaskar and Jacoway[9] have demonstrated
the presence of Gram‑positive and Gram‑negative bacilli
in superficial areas of ulcerated forms of oral PG. This
could justify the inclusion of the term “pyogenic” in PG.
However, oral PG shows predominance of capillary growth
within its granulomatous mass rather than the presence
of real pyogenic organisms and pus, so the term PG is a
misnomer and is not a granuloma in real sense.[1]
Other investigators consider PG as a “reactive” or
“reparative” tumor process. Regezi et al.[6] have suggested
that PG is an exuberant proliferation of connective tissue
to a known stimulus or injury like calculus or foreign
material within the gingival crevice. They also showed
histopathological findings of prominent capillary growth in
hyperplastic granulation tissue suggesting a strong activity
of angiogenesis in oral PG. Two angiogenesis enhancers,
i.e., vascular endothelial growth factor and basic fibroblast
growth factor, and two angiogenesis inhibitors, i.e.,
thrombospondin‑1 and angiostatin, have been implicated
in mechanism for angiogenesis. Vascular morphogenesis
factors Tie‑2, angiopoietin‑1, angiopoietin‑2, ephrinB2,
and ephrinB4 were also found to be upregulated in PG
compared to healthy gingiva.[10]
Yih et al.[11] suggested hormonal influence in the development
of PG on the basis of the observation that pregnancy
tumor that occurs in the pregnant women also arises from
the gingiva and has the same microscopic appearance. They
concluded that morphogenetic factors were higher in PG
as compared to normal gingiva and thus supported the
mechanism of angiogenesis in oral PG in pregnant females.
Due to its frequent occurrence in a pregnant female, PG
is also called granuloma gravidarum or pregnancy tumor.[1]
However, the role of hormones has been questioned by
Bhaskar and Jacoway,[9] since these lesions are found in
both males and females.
Cawson et al. [4] stated that PG represents vascular
proliferations and does not represent a stage in the
development of fibrous nodules or merely inflamed fibrous
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Sharma, et al.: Pyogenic granuloma
Figure 1: Preoperative view showing gingival growth in 17 and 18
region. Inset shows an intraoral periapical radiograph with no underlying
bone involvement in 17 and 18 region
Figure 3: Photomicrograph showing dilated and engorged blood
vessels, angiogenesis, and bundles of collagen fibers (H and E, ×10)
Figure 5: Clinical image of 17 AND 18 region at 1 year follow up
nodules. Thus, several “etiologic factors” such chronic
low grade irritation, hormonal factors, traumatic injury,
certain kinds of drugs, poor oral hygiene, injury to primary
Journal of Oral Research and Review | Volume 13 | Issue 1 | January-June 2021
Figure 2: Clinical image depicting excision of the lesion up to the
mucoperiosteum. Inset shows excised growth
Figure 4: One month follow up photograph showing uneventful healing’
tooth, aberrant tooth development, have been suggested in
patients presenting with pyogenic granuloma.[7]
In the present case, the patient was a 17‑year‑old healthy
female, the probable etiology included the presence
of large amount of calculus due to poor oral hygiene
habits,[6] repeated trauma, and occlusal interference while
eating due to the size and position of the lesion,[12] and
as described by Ainamo,[13] recurrent trauma occurring
during tooth brushing or function with the release of
various endogenous and angiogenic factors could be
contributing to the increased vascularity and development
of the lesion.
Clinical features
Oral PG occurs over a wide age range of 4.5–93 years
with the highest incidence in the second and fifth
decades, with females slightly more affected than males.[9]
It shows predilection for gingiva (75% of all the cases),
with interdental papilla being the most common site.
The maxillary gingiva is more commonly involved than
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Sharma, et al.: Pyogenic granuloma
mandibular gingiva, anterior areas are more frequently
affected than posterior areas, and the facial aspect of
the gingiva is more commonly involved than the lingual
aspect, followed by lips, tongue, and buccal mucosa.[1] The
incidence of PG has been described as between 26.8%
and 32% of all reactive lesions.[14] Intraorally, it appears as
an elevated sessile or pedunculated growth covered with
red hemorrhagic and erythematous papules. It also shows
ulcerations and is covered by a fibrinous membrane.[1,6]
Clinically, the lesion can be slow growing, asymptomatic,
and painless, but it may also grow rapidly sometimes.[6]
The color varies from pink to red to purple, depending
on the age of the lesion, with young PGs being highly
vascular, and older lesions tend to become collagenized
and pink.[1] The case presented here shows a large growth
localized to the buccal surface of the upper right posterior
maxilla, involving the interdental and marginal gingiva; it
was reddish pink in color and was present since 20 days. It
had gradually increased in size to cover the occlusobuccal
surface of the crown of 17, interfered with mastication,
and resulted in intermittent bleeding which prompted the
patient to seek treatment.
Histopathology
PG can be classified as the LCH type and non‑LCH type.
The non‑LCH type consists of a vascular core which
resembles a granulation tissue with foci of fibrous tissue.
The central area has a greater number of vessels with
perivascular mesenchymal cells which are nonreactive
for alpha‑smooth muscle actin as compared to LCH
type. The LCH type on the other hand has proliferating
blood vessels organized in lobular aggregates, and no
specific changes such as edema, capillary dilation, or
inflammatory granulation are seen. On comparison,
the lobular area of LCH type has greater number
of blood vessels with small luminal diameter than
non‑LCH type.[1,7] PG is partly or completely covered
by parakeratotic or nonkeratinized stratified squamous
epithelium. The amount of collagen in the connective
tissue of PG is usually sparse. The surface can be
ulcerated, and in such ulcerated lesions, edema is a
prominent feature and the lesion is infiltrated by plasma
cells, lymphocytes, and neutrophils.[9]
The biopsy in this case showed a non‑LCH type of
PG with high vascular proliferation that resembles a
granulation tissue along with numerous small and large
endothelium‑lined channels that are engorged with red
blood cells. A mixed inflammatory cell infiltrate is also
evident. The diagnosis of oral PG was confirmed from
these findings.
56
Radiographic findings
Although radiographic involvement is usually absent, large
and long‑standing gingival PGs can cause localized alveolar
bone resorption.[15] In this case, no obvious radiographic
findings could be seen.
Differential diagnosis
Differential diagnosis of PG includes peripheral
giant cell granuloma, peripheral ossifying fibroma,
fibroma, peripheral odontogenic fibroma, hemangioma,
conventional granulation tissue, hyperplastic gingival
inflammation, Kaposi’s sarcoma, bacillary angiomatosis,
and non‑Hodgkin’s lymphoma[16,17] [Table 1].
Treatment
The treatment of PG consists of conservative surgical
excision. For gingival lesions, excision should extend
down to the periosteum and adjacent teeth should be
thoroughly scaled to remove any source of continuing
irritation.[1] Various other treatment modalities, such as
use of neodymium‑doped yttrium aluminum garnet laser,
carbon dioxide laser, flash‑lamp pulsed‑dye laser, sodium
tetradecyl sulfate sclerotherapy and use of intralesional
steroids, and cryosurgery, have been used.[7] The treatment
of lesion that develops during pregnancy is deferred unless
significant functional or esthetic problems develop.[1] In the
present case, the lesion was surgically excised and was sent
for histopathologic examination. The scaling and curettage
of the involved teeth was completed to remove all the local
irritants, which could have been the primary etiologic factor
in the present case.
Recurrence
Recurrence rate of 16% has been reported for gingival
granuloma.[18] Incomplete excision, failure to remove
etiologic factors, or repeated trauma contributes to
recurrence of these lesions.[6] The recurrence rate is
higher for PGs removed during pregnancy, and some
resolve spontaneously after parturition.[1] Vilmann et al.[19]
emphasized the need of follow‑up, especially in PG of
the gingiva due to its much higher recurrence rate. The
present case was followed up for a period of 1 year, and
no recurrence was observed.
CONCLUSION
This article reports a case of PG in maxillary posterior
gingiva of a female patient with an overview on etiology,
clinical and histologic presentation, differential diagnosis,
treatment modalities, and recurrence of PG. Even though
PG is a common lesion of the oral cavity, especially the
gingiva, a thorough knowledge of the lesion is necessary
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Table 1: Differential diagnosis of gingival growths resembling pyogenic granuloma[17,18]
Gingival growth
PG: Distinct clinical entity
originating as a response of tissues
to nonspecific infection
Pregnancy tumor: Is an
inflammatory response to bacterial
plaque modified by patient’s
condition
Fibroma: True benign soft-tissue
neoplasm of connective tissue
origin
Peripheral giant cell granuloma:
Lesions are responses to local
injury and are not neoplasms.
They arise from deep in the tissues
compared to other superficial
lesions such as fibroma or PG
Peripheral odontogenic fibroma:
Mesodermal tumor of odontogenic
origin. Rare lesion as compared to
peripheral ossifying fibroma. In the
past, term was used synonymously
with peripheral ossifying fibroma
but is now considered to be a
distinct and separate entity
Peripheral ossifying fibroma:
Solitary gingival overgrowth
thought to arise from the
periodontal ligament. High degree
of cellularity in contrast to simple
fibroma. Vascularity is not as
prominent a feature of this lesion
as is for PG
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Sharma, et al.: Pyogenic granuloma
Clinical features (C/F)
Site: Most commonly gingiva may also be found on lips,
tongue, and buccal mucosa
Age/sex: Not definitive
C/F: Usually an elevated, pedunculated, or sessile
mass with a smooth, lobulated, or even warty surface.
Deep red or reddish purple color. Painless, rather soft in
consistency. Commonly ulcerated and has tendency for
hemorrhage either on slight trauma or spontaneously.
Old lesions may resemble typical fibroma
Site: Gingiva
Age/sex: Pregnant female after the 3rd month of
pregnancy
C/F: The lesion appears as a discrete, mushroom-
like, flattened spherical mass that protrudes from
the gingival margin or more commonly from the
interproximal space and is attached by a sessile or
pedunculated base. It is dusky red or magenta, and
has a smooth glistening surface that often exhibits
numerous deep-red, pinpoint markings. The mass is
usually semi-firm in consistency and painless unless its
shape and size interfere with occlusion, in which case
painful ulceration may occur
Site: Gingiva, buccal mucosa, tongue, lips, and palate
Age: Occurs at any age, most common in third, fourth
and fifth decades
C/F: Appears as an elevated nodule with smooth surface
and a sessile or pedunculated base. It may be small
or range up to several centimeters in diameter. Tumor
sometimes become irritated and inflamed showing
ulceration or hyperkeratosis
Site: Slight predilection for mandible over maxilla.
Occurs on gingiva interdentally/gingival margin or
alveolar process, most frequently anterior to molars
Age: Occurs at any age
Sex ratio: Female:male 2:1
Features: Vary in appearance from smooth, regularly
outlined masses to irregularly shaped, multilobulated
protuberances with surface indentations. Can be
pedunculated or a sessile, firm or spongy, color varies
from pink to deep red or purplish blue
Site: Gingiva, predilection of occurrence in the mandible
Age: 5–65 years
Features: Appears as a slow-growing, solid, firmly
attached gingival mass sometimes arising between teeth
or displacing teeth. May contain a calcified stalk or other
islands of calcified material
Site: Exclusively on gingiva: most commonly interdental
papilla
Age: Any age, common in children and young adults;
peak prevalence between the ages of 10–19. Predilection
for occurrence in maxilla
Sex ratio: Femle:male 3:2
Features: Well demarcated focal mass of tissue on the
gingiva, with a sessile or pedunculated base. Same color
as normal mucosa or slightly reddened. Surface may be
intact or ulcerated
Histopathologic feature
Features similar to that of granulation tissue
except that it is exuberant or well localized.
Startling features are occurrence of vast
number of endothelium-lined vascular spaces,
extreme proliferation of fibroblast, and
budding endothelial cells. If lesions is not
excised it assumes a fibrous appearances
due to obliteration of capillaries. Overlying
epithelium is thin or atrophic and may be
hyperplastic
Histopathologically, pregnancy tumor has
features similar to PG of gingiva
Composed of bundles of collagen fibers with
scattering of fibrocytes and variable vascularity
Nonencapsulated mass of tissue composed
of delicate reticular and fibrillar connective
tissue stroma containing large number of
ovoid or spindle-shaped connective tissue
cells and foci of multinuclear giant cells and
hemosiderin particles. The overlying epithelium
is hyperplastic, with ulceration at the base.
Bone formation occasionally occurs within the
lesion
Marked cellular fibrous connective tissues
stroma, sometimes vascularized. Myxomatous
changes may sometimes be found. The
epithelium is deep in the lesion, away from
the surface epithelium and is sometimes
found with “cuffing” calcification. Calcified
tissue may resemble trabeculae of bone or
osteoid, dentin, osteodentin, or cementum-like
material
Composed of an exceedingly cellular mass
of connective tissue comprising large
number of plump, proliferating fibroblasts
intermingled throughout a very delicate
fibrillar stroma. Surface epithelium is intact,
or appears as an ulcerated layer of stratified
squamous epithelium. Calcifications in the
lesion may be in the form of single or multiple
interconnecting trabeculae of bone or
osteoid, although less commonly globules of
calcified material closely resembling acellular
cementum or a diffuse granular dystrophic
calcification may be found
Contd...
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Sharma, et al.: Pyogenic granuloma

Table 1: Contd...
Gingival growth
Hemangioma: Hemangioma is
a benign proliferation of blood
vessels that primarily occurs
during childhood
Kaposi sarcoma: Common oral
malignancy associated with AIDS.
It is a rare multifocal, vascular
neoplasm. It is seen to be closely
associated with HHV-8 also called
“Kaposi sarcoma-associated
herpes virus”
Bacillary angiomatosis: Infectious
vascular proliferative disease
caused by rickettsia-like organism
(Bartonella henselae, Rochalimaea
quintana)
NHL - A heterogeneous group of
lymphoproliferative malignancies
which involve both lymph nodes
and lymphoid organs as well as
extranodal organs and tissues. It
includes B-cell neoplasm, T-cell/
NK cell neoplasm, and Hodgkin
lymphoma
PG: Pyogenic granuloma, C/F: Clinical features, H and E: Hematoxylin and Eosin, RBCs: Red blood cells, HHV-8: Human herpesvirus 8,
NHL: Non-Hodgkin lymphoma, NK: Natural killer Table 1. from: Sharma S, Anamika S, Ramachandra SS. Peripheral ossifying Fibroma: a clinical
report. Compend Contin Edu Dent 2011. June; 32 (5):E86-90. Copyright ©2020 to AEGIS Publications, LLC. All rights reserved. Used with
permission of publishers
Clinical features (C/F)
Site: Gingiva, rarely found in oral cavity
Age: Childhood
Features: Soft mass, smooth or lobulated, sessile
or pedunculated and may be seen in any size from a
few millimeters to several centimeters. The color of
the lesion ranges from pink to red purple and tumor
blanches on the application of pressure, and hemorrhage
may occur either spontaneously or after minor trauma.
They are generally painless
Site: Skin of lower extremities of older men
71% of HIV-infected individuals develop lesions of oral
mucosa, particularly palate and gingiva
Features: Classic form of Kaposi sarcoma is localized
and slow-growing lesion, where blue red nodules develop
on lower extremities. In HIV infected lesions, early stage
lesions are painless, reddish purples macules of the
mucosa, progressive lesions become nodular mimicking
PG or hemangioma
Site: Skin, gingiva
Age: More prevalent in HIV-positive individuals with low
CD4 cells
Clinical features: Red, purple, or blue edematous soft-
tissue lesions that may cause destruction of periodontal
ligament and bone. It may mimic Kaposi sarcoma and PG
clinically
Age: >50 years, subtypes of B-cell (NHL) more
commonly seen in children and young adults
Clinical features: Lymphadenopathy, organ specific
symptoms such as shortness of breath, chest pain,
cough, abdominal pain, bone pain. Oral lesions are
characterized by swellings which may grow rapidly and
then ulcerate. In some cases, these lesions become
large, fungating, necrotic, foul-smelling masses with pain
as a variable feature
Histopathologic feature
The H and E staining shows parakeratinized
stratified squamous epithelium associated
with fibrovascular connective tissue. Few
areas of epithelium show ulceration and
replacement by fibrinopurulent membrane.
The underlying connective tissue shows dense,
irregularly arranged collagen fibers. Many small
capillary with areas of marked endothelial
cell proliferation are evident. Sparse plasma
cells and lymphocytes are seen. Vascularity
increases with numerous large and small
capillaries filled with RBCs
Microscopically, it consists of perivascular
proliferation of spindle cells with proliferating
sheets of sarcomatous or atypical spindle
cells in advanced lesions, endothelial cell
proliferation of small veins and capillaries with
formation of atypical slit-like vascular channels
without a visible endothelial lining interspersed
with spindle cells in its advanced stages,
extravascular hemorrhage with hemosiderin
deposition, and a pronounced mononuclear
inflammatory cell infiltrate
Biopsy reveals an epitheloid proliferation
of angiogenic cells accompanied by acute
inflammatory cell infiltrate. Warthin–Starry
silver staining or electron microscopy is used
to identify the causative organism in biopsy
specimen
Histologic pattern is nodular or diffuse. Diffuse
pattern is characterized by a monotonous
distribution of cells with no evidence of
nodularity or germinal center formation. In
nodular pattern, the neoplastic cells aggregate
to form large clusters of cells

to differentiate it from similar presenting lesions and providing us the infrastructure and basic amenities to
appropriate treatment modality should be adopted to yield conduct this work.
excellent results.
Ethical clearance
Declaration of patient consent Study was conducted after approval from the Institutional
The authors certify that they have obtained all appropriate Ethics Committee.
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and Financial support and sponsorship
other clinical information to be reported in the journal. Nil.
The patients understand that their names and initials will
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