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Home , Pyogenic granuloma

Pyogenic associated with a natal tooth: case report Maureen G. Muench, DDS Steve Lay ton, DDS, MSD John M. Wright, DDS, MS

Introduction The pyogenic granuloma is a clinical entity which development and rapid clinical growth of a pyogenic originates as an overexuberant connective tissue re- granuloma. sponse to a stimulus or .^ Trauma and local irrita- tion have a significant impact on the development of the Case Report pyogenic granuloma.2 This lesion is particularly impor- A 6-day-old male patient was referred to a Piano, tant to dentists because of its common intraoral occur- Texas, pediatric dentist's office by a pediatrician for rence and sometimes alarming clinical course.1 evaluation of an enlarging mass on the patient's ante- The pyogenic granuloma is seen most frequently on rior mandibular alveolar ridge (Fig 1, next page). The the gingiva, but occasionally is found elsewhere in the patient was a healthy, Caucasian, 6-lb, 12-oz product of mouth in areas of frequent trauma such as the , the a normal, uncomplicated full-term , and was buccal mucosa, and the . Previous dental extrac- the first-born tions, exfoliating primary teeth, bone spicules, root rem- child to a healthy nants, toothbrush trauma, and gingival irritation from 17-year-old bacterial plaque and have been reported as mother and a possible etiologic factors of pyogenic granuloma at gin- healthy 21-year- gival sites. It now generally is agreed that the pyogenic old father. The granuloma is not a response to any specific infective single unusual agent. finding after The lesion is usually an elevated, pedunculated, or birth was a man- sessile mass. The surface may be smooth, lobulated, or dibular anterior even warty. The pyogenic granuloma is typically deep natal tooth. red or reddish-purple due to its vascularity, but may The parents have a brown cast of hemorrhage. These lesions usually reported an ex- are ulcerated, and subsequently become covered by a tremely mobile yellow-tan fibrinous exudate. Pyogenic do tooth attached not produce pus, as the term "pyogenic" implies.1'3 to a mass on The pyogenic granuloma may develop rapidly, reach the lower jaw. full size, then remain static. Hormonal changes of pu- The parents berty and pregnancy may modify the clinical course. followed their Pyogenic granulomas are associated so frequently with pediatrician's pregnancy that the term "pregnancy tumor" has been advice and Fig 1. Six-day-old patient with a pyogenic removed the used. The lesions range in size from a few millimeters to granuloma affecting the mandibular several centimeters in diameter. They have no apparent anterior alveolar ridge. Three days tooth with their predilection for any age group, but tend to occur in previously, a mandibular anterior natal fingers a few females more frequently than males.1'3 tooth was extracted by the patient's days after birth. Treatment for the pyogenic granuloma involves con- parents. Note the patient's grand mother's They reported ungloved finger in photograph. servative local excision, except in cases of hormonal no unusual or (e.g., pregnancy) tumors.4 In cases of "pregnancy tu- prolonged mors," the lesions usually are left untreated until post- bleeding after the tooth was extracted. The parents partum when they may resolve, or lessen in severity. noted that the mass had begun to enlarge rapidly fol- Because the lesions are not encapsulated, their limits lowing removal of the natal tooth. are hard to define. The surgeon must be careful to excise At 16 days of age, the patient was placed under local the connective tissue from which the lesion arises, and anesthesia, and the lesion was excised. The lesion was to remove any etiologic factors.1' 3 Pyogenic granulo- 0,6 cm x 0.4 cm x 0.4 cm. Histologic examination re- mas recur occasionally, probably due to incomplete vealed a mass of , acute and chronic inflam- excision, failure to remove etiologic factors, or reinjury.3 matory cells, fibrin, and delicate fibrous tissue. The Our case report presents a pyogenic granuloma asso- capillaries, although small, were numerous and promi- ciated with a natal tooth. This case suggests that the nent in areas of the specimen (Fig 2, next page). The extraction of a natal tooth may have stimulated the diagnosis of pyogenic granuloma was made.

PEDIATRIC DENTISTRY: JULY/AUGUST, 1992 ~ VOLUME 14, NUMBER 3 265 in females eight times as often as in males, and in the three times as often as in the .^ Due to the location of the lesion, an eruption cyst also was considered as part of the differential diagnosis. Erup- tion cysts in neonates usually are located at the man- dibular central incisor region. However, in contrast to this lesion, eruption cysts generally resolve with erup- tion of the tooth, and need no surgical intervention.6 Additionally, a was considered because of the color and vascular nature of the lesion, and most are present at birth or arise at an early age. However, most hemangiomas occur on the lips, tongue, buccal mucosa, and .1 Pyogenic granulomas in newborns have not been Fig 2. Photomicrograph demonstrating granulation tissue stroma reported as occurring frequently. Jorgenson et al. (1982) with prominentvascularity. Arrows indicate the most prominent areas of proliferating blood vessels. H & E stain, original examined 2,258 neonates. They reported a high fre- magnification x33. quency of gingival and palatal cysts of the newborn, and a significantly lower frequency of alveolar .7 However, lymphangiomas of the al- Ten days after surgery, the excision site was healing veolar ridge of neonates have been reported to occur adequately, and there were no signs of recurrence. The almost exclusively in African Americans, and postsurgical course was uneventful. One month later, lymphangiomas in the mandibular arch are most often the patient returned for a follow-up evaluation. The limited to the posterior lingual surface of the mandibu- excision site had healed fully, with no recurrence of the lar ridge.7"9 Additionally, gingival cysts of the new- lesion. A raised area at the surgical site was normal in born are not reactive lesions, are not associated with color and there was no increased vascularity, as would erupting teeth, and are generally approximately 1 mm be seen with a recurring pyogenic granuloma (Fig 3). in diameter.6' 7 Discussion In cases of natal teeth, a radiograph may be exposed to determine the This case report suggests that a natal tooth, and/or amount of root extraction of this tooth, may have stimulated develop- development, ment of a pyogenic granuloma, a relationship not re- the relationship ported previously. The parents reported that before of a prematurely extracting the natal tooth, they noticed a small mass erupted tooth to underlying the tooth. The microtrauma of the gingival its adjacent tissue associated with an erupting tooth has been shown teeth, and to be associated with the development of pyogenic whether the granulomas. If the pyogenic granuloma existed before tooth is a super- the extraction, then the trauma associated with the numerary tooth extraction of the natal tooth by the parent probably or one of the pri- contributed to the rapid growth of the lesion. If the mary teeth.10 pyogenic granuloma did not exist before extraction, the Because of the parents may have irritated the gingival tissue attached size, history, and to the natal tooth while attempting extraction, or left a appearance of portion of the tooth or a bony spicule, thus producing the lesion, a ra- the lesion. diograph might The differential diagnosis of reactive lesions of the have been indi- gingiva should include: pyogenic granuloma, fibrous cated in this case, (fibrous ), peripheral giant cell granu- 4 but none was ex- loma, and peripheral odontogenic . These le- posed. Recur- Fig 3. Intraoral photograph of patient one sions, though, are not normally present in neonates. In rence of the le- month after surgical excision of pyogenic this case, of the newborn also was granuloma. The raised area at the surgical sion would sug- considered due to the age of the patient and the clinical site was determined to be a result of gest radio- appearance of the lesion. However, it should be noted normal healing. graphic exami- that the congenital gingival granular cell tumor occurs nation.

266 PEDIATRIC DENTISTRY: JULY/AUGUST, 1992 ~ VOLUME 14, NUMBER 4 Although this case represents an extreme outcome of 2. VilmannA, VilmannP, VilmannH: Pyogenicgranuloma: evalu- a natal tooth extraction, previous re-ports have docu- ation of oral conditions. Br J Oral MaxillofacSurg 24:376-82, 1986. mented that tooth extraction may stimulate develop- 3. Regezi JA, Sciubba JJ: Red-BlueLesions in Oral Pathology: ment2 of a pyogenic granuloma. Clinical-Pathologic Correlations. Philadelphia: WBSaunders, Pediatric dentists should make every effort to edu- 1989, pp 131-32. cate parents and the medical community on the pre- 4. Moriconi ES, Popowich LD: Alveloar pyogenic granuloma: review and report of a case. Laryngoscope94:807-9, 1984. ferred treatment for natal teeth. If extraction of a natal or 5. Fuhr AH,Krogh PHJ: Congenital epulis of the newborn: cen- neonatal tooth is indicated, then it should be performed tennial reviewof the literature and a report of case. J Oral Surg by a dentist to avoid unnecessary trauma to the area. 30:30-35,1972. 6. Peters RA,Schock RK: Oral cysts in newborninfants. Oral Surg 32:10-14,1971. Dr. Muenchis assistant professor, Departmentof Pediatric Dentistry, 7. Jorgenson RJ, Shapiro SD, Salinas CF, Levin LS: Intraoral Dr. Laytonis clinical assistant professor, Departmentof Pediatric findings and anomaliesin neonates. Pediatrics 69:577-82,1982. Dentistry, and Dr. Wrightis professor and director, Divisionof Oral 8. WilsonS, Gould AR, Wolff C: Multiple lymphangiomasof the Pathology, Departmentof Diagnostic Sciences, Baylor College of alveolar ridge in a neonate: case study. Pediatr Dent8:231-34, Dentistry, Dallas, Texas. 1986. Shafer WG,Hine MK,Levy BM:Bacterial, Viral and Mycotic 9. Levin LS, Jorgensen RJ, Jarvey BA:Lymphangiomas of the alveolar ridges in neonates. Pediatrics 58:881-84,1976. Infections, in A Textbookof Oral Pathology, 4th ed. Philadel- phia: WBSaunders, 1983, pp 359~1. 10. McDonaldRE, AveryDR: Eruption of the teeth: local, systemic, and congenital factors that influence the process, in Dentistry for the Child and Adolescent, 5th ed. Philadelphia: CVMosby Co, 1987, pp 198-200.

PEDIATRICDENTISTRY: JULY/AUGuST, 1992-- VOLUME14, NUMBER3 267