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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 79-83

Management of perennial pyogenic granuloma by platelet-rich fibrin membrane in a 62-year-old patient


1 Department of Periodontics, Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College and Hospital, Hingoli, Maharashtra, India
2 Department of Oral Pathology, Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College and Hospital, Hingoli, Maharashtra, India
3 Department of Orthodontics, Vidya Shikshan Prasarak Mandal's Dental College and Hospital, Nagpur, Maharashtra, India

Date of Submission08-Feb-2020
Date of Acceptance19-Jun-2020
Date of Web Publication21-Aug-2020

Correspondence Address:
Dr. Namrata S Jajoo
Department of Periodontics, Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College and Hospital, Hingoli, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_3_20

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   Abstract 


Pyogenic granuloma (PG) is an inflammatory hyperplastic lesion of the oral cavity with common etiological factors such as low-grade local irritation, traumatic injury, or hormonal factors. The lesion is nonneoplastic in nature with the recurrence rate of 15.8%. Moreover, as it is a benign lesion, the choice of treatment is surgical excision with the removal of underlying cause if any. The present article highlights the use of platelet-rich fibrin (PRF) membrane in the management of PG. This case report presents a 62-year-old female patient who had reported with PG that recurred twice in 7-year period. The lesion appeared with a sessile base and was diagnosed clinically and histopathologically as PG. The PG was surgically excised exposing the underlying bone. The exposed bone surface was then covered with PRF membrane. At 6-month follow-up period, the patient did not show any further recurrence of the lesion.

Keywords: Gingiva, oral cavity, perennial, platelet-rich fibrin, pyogenic granuloma


How to cite this article:
Jajoo NS, Shelke AU, Deshpande KC, Bajaj RS. Management of perennial pyogenic granuloma by platelet-rich fibrin membrane in a 62-year-old patient. J Interdiscip Dentistry 2020;10:79-83

How to cite this URL:
Jajoo NS, Shelke AU, Deshpande KC, Bajaj RS. Management of perennial pyogenic granuloma by platelet-rich fibrin membrane in a 62-year-old patient. J Interdiscip Dentistry [serial online] 2020 [cited 2020 Sep 20];10:79-83. Available from: http://www.jidonline.com/text.asp?2020/10/2/79/292917




   Clinical Relevance to Interdisciplinary Dentistry Top


  1. Pyogenic granuloma (PG) is a nonneoplastic reactive tumor which occurs in response to low-grade local irritation and traumatic injury
  2. PG is more common in females
  3. Commonly found in the maxillary anterior region
  4. Large size of lesion may lead to bone loss in that area
  5. As it is commonly found in the maxillary anterior region, it leads to compromise esthetic
  6. The present case report demonstrates the treatment of PG using platelet-rich fibrin membrane.



   Introduction Top


Pyogenic granuloma (PG) is a smooth or lobulated exophytic lesion appears as small, red erythematous papules with pedunculated or some time sessile base. Hartzell in 1904 introduced the term PG or granuloma pyogenicum. Oral PG is the most common gingival tumor commonly seen in the maxillary gingiva, especially on the facial aspect of the anterior region of the gingiva than the posterior region and lingual side.[1]

PG is a nonneoplastic reactive tumor which occurs in response to varied stimuli such as low-grade local irritation, traumatic injury, hormonal factors, or certain kinds of drugs (e.g., oral contraceptives and isotretinoin).[2] PG is more common in females in the second decade of life, probably due to vascularization effect of estrogen and progesterone with male-to-female ratio of 1:99.[1]

Clinically, PG appears smooth or lobulated with sessile or pedunculated base. The lesion mainly develops slowly and is of asymptomatic nature.[2] The size of lesion varies from few millimeters to several centimeters in diameter, but rarely exceeds 2.5 cm in size.[1] Clinical behavior of the lesion depends on the total duration of the lesion. PG of short duration has high vascularity with hyperplastic granulation tissue while PG of long duration shows more collagenization.[3]

A number of treatment modalities have been described for PG, but, simple surgical excision of the lesion is the best treatment. Although PG does not show infiltrative tendency or malignant transformation potential, the recurrence rate is high up to 15.8%; thus, many times, re-excision of the lesion is required in future. The recurrence of the lesions can be due to many reasons such as deficient excision, failure to eliminate etiologic factors, re-injury of lesions, or due to the presence of multiple deep satellite nodules encircling the site of original lesions (Warner–Wilson Jones syndrome). To avoid the possibility of a recurrence, the lesion must be excised down to the underlying periosteum involving 2 mm of uninvolved healthy margin surrounding the lesion, and predisposing irritants must be removed.[2]

The present case report demonstrates the case of a 62-year-old female patient who had recurrent PG twice in a 7-year period. The patient was followed up for a 6-month period following the conservative excision procedure and placement of platelet-rich fibrin (PRF) membrane to check for the recurrence of the lesion.


   Case Report Top


A 62-year-old female patient reported to the department of periodontics with the chief complaint of intraoral painless swelling for 1½ years on the right maxillary front tooth region. At the initial stage, the lesion was of poppy seed in size. The patient ignored the swelling for 1½ years as it was painless and was not growing at a fast rate. However, for the past 2–3 months, the patient noticed increased in the size of the swelling which reached up to peanut size. She also noticed difficulty in chewing food, difficulty in closing the mouth, and bad esthetic appearance due to bulging of the lips. She stated that a similar type of growth in the same area was present 7 years before, and it was excised by the scalpel method as mentioned by the patient, and the histopathological examination was performed at that time for the excised lesion which confirmed the diagnosis of PG. On asking about the past medical history, the patient revealed that she is hypertensive and on medication for the past 10 years.

On intraoral examination, the lesion was present around the right labial maxillary anterior tooth region extending from the mesial aspect of the canine to the mesial aspect of the first premolar region. It measured approximately 9 mm × 6 mm in dimension. On visual examination, it appeared reddish pink, as observed in [Figure 1]. It was large and lobulated with a sessile base. On palpation, the lesion was firm and resilient with bleeding on slight provocation.
Figure 1: Preoperative view of pyogenic granuloma in the maxillary anterior tooth region

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The patient was informed about the procedure and consent was taken, and oral prophylaxis was done. Thereafter, it was decided to further treat the lesion with a surgical approach. After local anesthesia, the enlarged localized lesion was excised up to the base of the lesion by use of a surgical blade exposing the bony surface [Figure 2]. The excised lesion [Figure 3] was then transferred to a bottle of 10% formalin solution and was sent for histopathological evaluation. The denuded bone surface was then covered with PRF membrane. The PRF was prepared by withdrawing 10 ml of the patient's blood from the antecubital vein and was immediately transferred to the centrifugation machine within 30 s. It was centrifuged at 3000 rpm for 10 min [Figure 4].
Figure 2: Excision of the lesion caused exposure of the underlying bone

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Figure 3: Excised lesion

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Figure 4: Preparation of PRF membrane – a) Collection of blood b) Centrifuge machine c) PRF formed in the middle part of the tube d) PRF clot e) PRF clot is gently pressed between 2 piece of sterile dry gauze to form membrane f) PRF membrane

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The clot was then squeezed between a sterile gauze, and a PRF membrane was placed onto the exposed bone surface [Figure 5]. The membrane was further stabilized by direct interrupted sutures on the mesial and distal aspects [Figure 6]. The periodontal dressing was placed [Figure 7]. Postoperative instruction was given, and chlorhexidine mouthwash (0.12%) was prescribed to the patient.
Figure 5: Placement of platelet-rich fibrin membrane on the exposed bone surface

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Figure 6: Suturing of platelet-rich fibrin membrane with adjacent tissue

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Figure 7: Coe-Pak application

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Histopathological report [Figure 8] showed the presence of parakeratinized epithelium stretched in some areas with proliferation toward the base of the lesion. The underlying connective tissue stroma revealed dilated and engorged blood vessels with the presence of few inflammatory cells and extravasated red blood cells, angiogenesis, and bundles of collagen fibers. Thus, the diagnosis of PG was histologically confirmed. The patient was recalled at the 2-week follow-up period for suture removal where a complete epithelialization over the denuded bone surface was observed [Figure 9]. At 6-month follow-up period, recurrence of the lesion was not observed [Figure 10].
Figure 8: Histologic section of the growth

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Figure 9: Two-week follow-up period

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Figure 10: 6-month follow-up period

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   Discussion Top


It is now universally agreed that PG is formed as a result of exaggerated localized connective tissue reaction to a minor injury or any underlying irritation. Because of this irritation, the underlying fibrovascular connective tissue becomes hyperplastic, and there is a proliferation of granulation tissue which leads to the formation of PG.[4] PG may occur in all ages but is predominantly seen in the second decade of life in young adult females possibly because of vascular effects of female hormones. However, according to Epivatianos et al., the average patient age was 52 years with a peak incidence of occurrence in the sixth decade of life.[5]

A number of treatment modalities are present for the treatment of PG among which surgical excision is the most common method of treatment. The other treatment modalities for the treatment of PG are laser, cryotherapy, and electrocauterization, which have given successful results as it provides bloodless surgical field, less patient discomfort, less pain, and healing without scar formation, but they have their own disadvantages as laser and electrosurgery cause injury to the neighboring tissues and delayed wound healing which have been reported.[3]

In the present case, the scalpel method was chosen over the other mentioned techniques as the patient had reported about the recurrence of lesion in the same area. Asnaashari et al. in 2014,[6] reported about the 16% recurrence rate of lesion following conventional method. As the lesion had a sessile base and a history of recurrence, this treatment modality was preferred in this case. The aim was to completely excise the underlying soft tissue to prevent the recurrence of the lesion, which led to the exposure of bone surface.

Wilderman in 1964 stated that superficial necrosis occurs within 1–3 days in denuded bone, and osteoclastic resorption reaches at peak at 4–6 days resulting in loss of bone of about 1 mm3.[7] Hence, to prevent the sequence of events following exposure of the bone surface, PRF membrane was placed. PRF is the activated form of fibrinogen formed after the centrifugation of blood. It forms a protective wall along vascular breaches during coagulation. The fibrin architecture helps to entrap various numbers of leukocytes in the fibrin matrix, thus allowing an intense slow release of growth factors that favor the healing of wound borders and promote rapid epithelialization.[8] A systematic review by Miron et al. in 2017 has proven the immense potential of PRF on wound healing after regenerative therapy for the management of various soft-tissue defects.[9]

The present case showed the same result in terms of epithelialization and patient comfort following the placement of PRF over the denuded bone surface. No recurrence of the lesion was observed at 6-month follow-up period. A complete removal of the lesion, exposing the underlying bone surface was attributed to the success of the therapy. The use of PRF membrane following excision of recurrent PG also prevented the underlying bone resorption.

Further research should be done to perform the same in randomized controlled clinical trial design and with statistical evaluation of clinical and esthetic outcomes.


   Conclusion Top


Although PG is a nonneoplastic growth of the oral cavity, proper diagnosis, prevention, management, and treatment of the lesion are important to prevent recurrence. The use of the scalpel method for excision of PG is a safe technique. The recurrent lesions should be treated wisely with the aim of removing the etiological factors, if any and also take care that it should not have a detrimental effect on the underlying and adjacent soft and hard tissues. The biological activity of the PRF membrane in wound healing and regeneration has also played an important role in the success of the therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors express their thanks to the research team from the Department of Periodontics and Department of Oral Pathology, Dr. HSRSM's Dental College and Hospital, Hingoli, Maharashtra, India, for their support during data collection and analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Tripathi AK, Kumar V, Saimbi CS, Sinha J. Pyogenic granuloma with alveolar bone loss. J Int Clin Dent Res Organ 2015;7:75-8.  Back to cited text no. 1
  [Full text]  
2.
Debnath K, Chatterjee A. Management of recurrent pyogenic granuloma with platelet-rich fibrin membrane. J Indian Soc Periodontol 2018;22:361-4.  Back to cited text no. 2
    
3.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48:167-75.  Back to cited text no. 3
    
4.
Verma PK, Srivastava R, Baranwal HC, Chaturvedi TP, Gautam A, Singh A. Pyogenic granuloma – Hyperplastic lesion of the gingiva: Case reports. Open Dent J 2012;6:153-6.  Back to cited text no. 4
    
5.
Epivatianos A, Antoniades D, Zaraboukas T, Zairi E, Poulopoulos A, Kiziridou A, et al. Pyogenic granuloma of the oral cavity: Comparative study of its clinico-pathological and immune-histochemical features. Pathol Int 2005;55:391-7.  Back to cited text no. 5
    
6.
Asnaashari M, Bigom-Taheri J, Mehdipoor M, Bakhshi M, Azari-Marhabi S. Posthaste outgrow of lip pyogenic granuloma after diode laser removal. J Lasers Med Sci 2014;5:92-5.  Back to cited text no. 6
    
7.
Wilderman MN. Exposure of bone in periodontal surgery. Dent Clin North Am 1963;8:23.  Back to cited text no. 7
    
8.
Dohan Ehrenfest DM, Bielecki T, Jimbo R, Barbé G, Del Corso M, Inchingolo F, et al. Do the fibrin architecture and leukocyte content influence the growth factor release of platelet concentrates? An evidence-based answer comparing a pure platelet-rich plasma (P-PRP) gel and a leukocyte- and platelet-rich fibrin (L-PRF). Curr Pharm Biotechnol 2012;13:1145-52.  Back to cited text no. 8
    
9.
Miron RJ, Fujioka-Kobayashi M, Bishara M, Zhang Y, Hernandez M, Choukroun J, et al. Platelet-rich fibrin and soft tissue wound healing: A systematic review. Tissue Eng Part B Rev 2017;23:83-99.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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