Pyogenic Granuloma
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Red gingival mass has ulcerated anterior surface.

Pyogenic granuloma of the oral and oropharyngeal region is similar to its counterparts in other parts of the body, although it may occur under rather unique circumstances.  During pregnancy, for example, hormonal excesses combine with poor oral hygiene to produce a generalized inflammatory enlargement of the gingiva, occasionally with one or more interdental papillae increasing to more than 2.0 cm. in size.   This pregnancy tumor (granuloma or epulis gravidarum) usually regresses after the birth of the child, possibly to reappear with the next pregnancy. It was most likely the first pyogenic granuloma reported in the English literature.

Another special pyogenic granuloma is the epulis granulomatosa (epulis haemangiomatosa), a hemorrhagic gingival mass of granulation tissue protruding from the poorly healing bony socket of a recently extracted tooth. A third unique presentation is a draining granulation tissue mass, or parulis, surrounding and often hiding the end of a fistulous tract from an underlying intraosseous dental infection.

The term pyogenic granuloma is not well chosen, as there is seldom pus production and there is never granuloma formation. It has, nevertheless, become entrenched in our vocabulary and is widely used today.  Population studies have determined a prevalence rate of 1 lesion per 25,000 adults (Table 1).

In addition to these special events, pyogenic granuloma can occur at any mucosal location of acute or chronic trauma, or infection. In the mouth the vast majority of these very common lesions occur on the gingiva (Figures 1 & 2), where they may develop as dumb-bell shaped masses on the facial and lingual surfaces of the dental arch, connected by a thin isthmus between adjacent teeth. Other sites of common involvement include the tongue, the lip mucosa and vermilion, and the buccal mucosa.

All ages and both genders are susceptible to this exuberant inflammatory response. The lesion is usually a pedunculated, bright red mass with or without white areas of surface ulceration; some lesions have a normal coloration. Rarely does pyogenic granuloma exceed 2.5 cm. in size and it usually reaches its full size within weeks or months, remaining indefinitely thereafter.

A newly identified and rather unique form of granulation tissue proliferation is the traumatic eosinophilic ulcer (traumatic eosinophilic granuloma). This lesion of young adults and middle-aged individuals appears to be trauma-induced and routinely demonstrates surface ulceration. It differs from the typical oral/pharyngeal traumatic ulcer in that it is larger (1.5-3.0 cm.), has often alarming proliferation of the granulation tissue of the ulcer bed (similar to pyogenic granuloma, but with a central indentation or crater), and has a much greater rate of recurrence.

Pyogenic granuloma is characterized by a rich profusion of anastomosing vascular channels, usually with plump endothelial cell nuclei, i.e. neovascularity (Figures   ). The background stroma is typically edematous, but fibroplasia is often active and older lesions may have undergone considerable fibrosis (fibrotic pyogenic granuloma). The fibroblasts are typically plumb and mitotic activity may be noted in the stromal cells. Older lesions demonstrate fewer and more mature cells, i.e. fibrocytes.

The blood vessels often show a clustered or medullary pattern separated by less vascular fibrotic septa, leading some authorities to consider the pyogenic granuloma to be a polypoid form of capillary hemangioma or nothing more than an inflamed lobular hemangioma occurring on the skin or mucosal surfaces, others prefer to use the term granulation tissue-type hemangioma (Figure ). A mixed chronic and acute inflammatory cell infiltrate is scattered throughout the stroma, with early lesions containing more neutrophils than older lesions. Occasional lesions demonstrate an extreme predominance of plasma cells, prompting some pathologists to call them plasma cell granuloma (Figure ) a term which is best avoided because of the potential confusion with mucosal solitary plasmacytoma or multiple myeloma. Rare examples of intravenous pyogenic granuloma have been reported.

The overlying stratified squamous epithelium may be atrophic or hyperplastic, and it is usually degenerated or ulcerated in large areas. When ulcerated, the ulcer bed is comprised of fibrinoid necrotic debris and regenerating epithelium at the ulcer edge may have a primitive or dysplastic appearance. The more aggressive variant, traumatic eosinophilic ulcer, shows considerable proliferation of granulation tissue, pushing the ulcer bed as much as a centimeter above the normal mucosal surface. The required diagnostic feature is a scattering of eosinophils, usually in deeper areas associated with chronic rather than acute inflammatory cells. The inflammatory changes in this lesion have a greater tendency to extend deeply into underlying tissues, including muscle, than do those of a more typical pyogenic granuloma.

The histopathologic differentiation of pyogenic granuloma from hyperplastic gingival inflammation is sometimes impossible, and the pathologist must depend on the surgeon's description of a distinct clinical mass to make the granuloma diagnosis. Usually, however, routine gingivitis has edema confined to the subepithelial regions of crevicular mucosa (facing the teeth) with more exposed epithelium demonstrating a normal or hyperplastic appearance without ulceration. Quite often the differentiation of pyogenic granuloma from inflamed capillary hemangioma is also impossible.

The reader is reminded that granulation tissue may be associated with many other oral soft tissue lesions, including peripheral ossifying fibroma, peripheral giant cell granuloma and mucocele. The older and more fibrotic pyogenic granuloma can be distinguished from irritation fibroma by the presence of plump endothelial cell nuclei in the stromal blood vessels, but this is probably an unnecessary distinction as we presume that at least some irritation fibromas begin life as pyogenic granulomas.

Kaposi's sarcoma, bacillary angiomatosis and epithelioid hemangioma must also be distinguished from pyogenic granuloma. Kaposi's sarcoma of AIDS shows proliferation of dysplastic spindle cells, vascular clefts, extravasated erythrocytes, and intracellular hyaline globules, none of which are features of pyogenic granuloma. Bacillary angiomatosis, also AIDS related, shows dense, extracellular deposits of pale hematoxyphilic granular material representing masses of bacilli which stain positive with the Warthin-Starry stain. Epithelioid hemangioma has more plump, histiocytoid, endothelial cell proliferation without an acute inflammatory cell infiltrate.

Pyogenic granuloma is treated by conservative surgical excision with removal of potential traumatic or infective etiologic factors. Recurrence occurs in approximately 15% of lesions thus removed, with gingival cases showing a much higher recurrence rate than lesions from other oral mucosal sites. Therefore, pyogenic granuloma of the gingiva, i.e. epulis granulomatosa, should not only be excised, but the surgical wound bed should be curetted and adjacent teeth should be scaled and root planed. If at all possible, removal in a pregnant woman should be postponed until after the birth. Lesional shrinkage at that time may make surgery unnecessary.

Hullihen SP. Case of aneurism by anastomosis of the superior maxillae. Am J Dent Sc 1844; 4:160-162.

Bhaskar SN, Jacoway JR. Pyogenic granuloma – clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg 1966: 24:391-398.

Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma: a study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol 1980; 4:471-479.

Vilmann A, Villmann P, Villmann H. Pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surg 1986; 24:376-382.

Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol 1991; 8:267-276.

Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral Surg Oral Med Oral Pathol 1991; 72:196-199.

Mooney MA, Janniger CK. Pyogenic granuloma. Cutis 1995; 55:133-136.

Silverstein LH, Burton CH, Singh BB. Oral pyogenic granuloma in pregnancy. Internat J Gynec Obstet 1995; 49:331-332.

Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reproduct Med 1996; 41:467-470.

Gerber ME, Myer CM. Eosinophilic ulcer of the tongue. Otolaryngol Head Neck Surg 1997; 117:715-716.

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Table 1: Gender-specific prevalence rates per 1,000 population for selected oral masses and surface alterations in U.S. adults, ranked by total frequency. Modified from Bouquot JE. Common oral lesions found during a mass screening examination. J Am Dent Assoc 1986; 112:50-57, and Bouquot JE, Gundlach KKH. Oral exophytic lesions in 23,616 white Americans over 35 years of age. Oral Surg Oral Med Oral Pathol 1986; 62:284-291.

Diagnosis	Number of lesions per 1,000 population*
	Males	Females	Total
Leukoplakia	43.2	20.9	28.9
Torus palatinus	13.2	21.7	18.7
Irritation fibroma	13.0	11.4	12.0
Fordyce granules	17.7	5.2	9.7
Torus mandibularis	9.6	7.9	8.5
Hemangioma	8.4	4.1	5.5
Erythema, inflammatory	4.5	4.8	4.7
Papilloma	5.3	4.2	4.6
Epulis fissuratum	3.5	4.4	4.1
Varicosities, lingual	3.5	3.4	3.5
Fissured tongue	3.5	3.1	3.2
Benign migratory glossitis	3.4	3.0	3.1
Aphthous ulcer	3.3	3.0	3.1
Papillary hyperplasia	1.7	3.8	3.0
Mucocele	1.9	2.6	2.5
Herpes labialis (herpes simplex)	2.4	2.6	2.5
Traumatic ulcer	2.1	2.1	2.1
Angular cheilitis	1.8	1.9	1.9
Smokeless tobacco keratosis	4.3	0.2	1.7
Hematoma or ecchymosis	2.0	1.4	1.6
Enlarged lingual tonsil	2.4	1.2	1.6
Chronic cheek bite	0.7	1.4	1.2
Lichen planus	1.2	1.1	1.1
Squamous cell carcinoma	2.5	0.1	0.9
Amalgam tattoo	0.6	1.0	0.9
Buccal exostosis	0.9	0.9	0.9
Leaf-shaped fibroma	0.4	1.2	0.9
Median rhomboid glossitis	0.8	0.5	0.6
Hairy tongue	1.2	0.3	0.6
Nicotine palatinus	1.2	0.2	0.6
Atrophic glossitis (smooth tongue)	0.6	0.5	0.6
Epidermoid cyst	0.7	0.4	0.5
Oral melanotic macule	0.5	0.3	0.4
Oral tonsils (except lingual)	0.5	0.3	0.4
Leukoedema	0.4	0.3	0.3
Lipoma	0.2	0.1	0.2
Ranula	0.2	0.1	0.2
Gingival hyperplasia	0.1	0.1	0.1
Buccinator node, hyperplastic	0.1	0.1	0.1
Pyogenic granuloma	0.0	0.07	0.04
Nasoalveolar cyst	0.0	0.07	0.04
Neurofibroma	0.0	0.07	0.04

* total examined population = 23,616 adults over 35 years of age 

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