Pyogenic granuloma manifests as a prevalent reactive lesion characterized by rapid development, easy bleeding, and ulceration, potentially leading to an incorrect clinical interpretation of malignancy. It is a clearly defined benign tumor of soft tissue, displaying an inflammatory as opposed to neoplastic character, and originates from mucous membrane or skin’s connective tissue 2,3. The term “epulis granulomatosa/epulis haemangiomatosis” denotes granulation tissue hyperplastic growths that sporadically arise in healing extraction sockets. The emergence of gingival pyogenic granuloma may be linked to gingival irritation caused by factors like rough restorations, overhanging edges, or calculus 5,11. Postulation revolves around the concept that microulcerations, stemming these irritants in an inflamed gingiva, allow lower-virulent oral microflora entry into gingival tissues. This mechanism minimizes exaggerated vascular hyperplastic responses inside the connective tissues, culminating in pyogenic granuloma development 12.
Pyogenic granuloma may manifest across various decades of human life. Nevertheless, prevailing research indicates a higher incidence of pyogenic granuloma in females compared to males, often linked to factors such as calculus accumulation, trauma, and the deterioration of oral tissues, thereby fostering gingival inflammation 13. Our clinicopathological investigation affirmed that the mandibular gingiva was frequently identified as an affected site. In clinical observations, the majority of documented cases exhibited sessile masses, with other instances displaying ulceration, while some presented with pedunculated masses 13,15.
Pyogenic granulomas of brief duration exhibit heightened susceptibility to bleeding due to increased vascularity and a lower concentration of collagen fibers, whereas more mature lesions possess reduced vascularity and a higher collagen content. The prevalence of pyogenic granulomas can increase to 5% during pregnancy, suggesting a possible association between gingival lesions and hormonal fluctuations during this period. Women’s routines have varied to comprize poor oral hygiene caused by situations like sleep and nausea disturbances, in addition to differencs in food or meal frequency 7,14,16. It additionally participated to the lesions emergence. The pyogenic granulomas raised prevalence in later-stages of pregnancy and subsequent drop in size after delivery highly recommend clear hormonal roles in the pyogenic granulomas pathogenesis 5,7.
This clinicopathological investigation emphasizes the impact of oral hygiene routines and socio-economic status and reveals that this lesion happened less frequently in urban populations than rural. Because of the high pyogenic granuloma prevalence throughout pregnancy, it is of utmost significance to pay close attention to treatment aspects, like regular follow-up and oral hygiene maintenance 2,4,10.
The pyogenic granulomas etiologies are immensely complicated to identify. Yet, it is developed as a reactive response to varying low-level stimuli or irritations, like recurrent trauma, aggression, specific medications, or hormonal factors. The heightened incidence throughout pregnancy is associated with elevated readings of estrogen and progesterone 1,5,7.
Examination under the microscope reveals pyogenic granuloma as having a highly vascularized proliferation resembling granulation tissue. The observation noted the existence of numerous small and large channels, replete with red cells and encompassed by conventional plump or flat endothelial cells. These endothelial cells may display mitotic activity. Blood vessels commonly display a clustered or medullary pattern, interspersed with fibrotic septa characterized by diminished vascularity. As a result, certain experts categorize pyogenic granuloma as a capillary hemangioma polypoid variant or merely an inflamed lobular hemangioma. On the contrary, others opt for the designation “hemangioma of the granulation tissue type.” In contrast, others emphasize the necessity of these vessels, occasionally arranged in lobular clusters, for a lobular capillary hemangioma (conclusive diagnosis) 11, 17,18.
Under decreased magnification, especially at the lateral perimeters, an evident lobular organization is discernible, where capillaries proliferate and abruptly halt. A slender collagen layer encases each lobule. This organized arrangement is interrupted at the base, where larger vascular channels of irregular shape are observed, probably related to proliferation. Currently, several interconnected ducts resembling angiosarcoma may be present, but their extent is limited and they are not an essential component of the lesion. Higher magnification reveals another hallmark of benign vascular lesions. The small spaces lined by capillary endothelial cells are surrounded by a layer of cells called pericytes or pericytes. Clonal angiosarcoma does not have the bilayer structure commonly seen in intramuscular angiomatosis 4,5.
The edematous stroma has a consistent presence of polymorphs and chronic inflammatory cells, accompanied by the formation of micro-abscesses. The fibroblasts within the stroma frequently showcase a plump morphology, and mitotic activity may be discernible in these stromal cells. In aged lesions, there is a decrease in cell density, and the cells tend to display a more mature, fibrocytic character 7,10,17. In certain instances, lesions manifest an overwhelming predominance of plasma cells, prompting certain pathologists to designate them as plasma cell granulomas. It is advised to refrain from using this term in order to prevent confusion with multiple myeloma or mucosal solitary plasmacytoma. Intravenous pyogenic granulomas have been reported on an episodic basis. In certain lesions, scarring may be seen, signifying the development of sporadic connective tissue repair mechanisms. The surface of the lesion may experience secondary, nonspecific changes, such as connective tissue swelling, small blood vessel widening, inflammation, and granulation tissue formation. Usually, the lesion's surface becomes ulcerated and is covered in a thick membrane that is purulent and fibrinous. An amalgam of inflammatory cells, mostly neutrophils, is typically located adjacent to the sore surface, while chronic inflammatory cells are located further down in the specimen 18,19, 20.
Rapidly advancing, laser technology has become a standard instrument for the removal of oral pathological lesions. Therefore, it is crucial for both the surgeon and the pathologist to enhance their understanding of its applications with increased effectiveness and efficiency21,22,23,24.