Clinical and Histological Evaluation of Granuloma Gravidarum:
Case Report


Yara Teresinha Corrêa SILVA-SOUSA1
Claudia Mendonça Pinto COELHO1
Luiz Guilherme BRENTEGANI2
Mara Lucia Senna Oliveira VIEIRA1
Marcelo Leipner de OLIVEIRA3

1Faculdade de Odontologia, Universidade de Ribeirão Preto
2Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo
3Dental Surgeon Ribeirão Preto, SP, Brasil


Braz Dent J (2000) 11(2): 135-139 ISSN 0103-6440

Introduction | Case Report | Discussion | Resumo | References


Granuloma gravidarum is a benign lesion of the oral mucosa which occurs during pregnancy. This case report presents the clinical and histological evaluation and treatment of a granuloma gravidarum in a patient in the 9th month of pregnancy.


Key Words: granuloma gravidarum, pregnancy tumor, pyogenic granuloma, pregnancy complications.


Introduction

Granuloma gravidarum (pregnancy tumor) is a pyogenic granuloma which develops on the gingiva during pregnancy. This benign hyperplastic lesion of the oral mucosa occurs in up to 5% of pregnancies. This rapidly growing lesion is typically a painless sessile or pedunculated gum mass, of varied diameter. Spontaneous hemorrhage or bleeding following brushing is observed in some cases. Maxillary tumors are more common than mandibular (Sills et al., 1996). Although less common, this lesion may appear on the tongue (Fenton et al., 1996).

Histologically, granuloma gravidarum presents loose granulation tissue rich in capillary vessels and proliferation of endothelial cells, typically accompanied by a mixture of infiltrated inflammatory cells. A thin epithelial layer overlies the lesion and is often ulcerated due to trauma associated with eating or tooth brushing (Sills et al., 1996).

Management of granuloma gravidarum depends on the severity of the symptoms. If the lesion is small, painless and free of bleeding, clinical observation and follow-up are advised (Sills et al., 1996). Steelman and Holmes (1992) reported that maintenance of oral hygiene and regular follow-up appointments while pregnant should be recommended. During pregnancy, surgery should be recommended if bleeding or pain from the lesion impedes routine brushing or other daily activities (Sills et al., 1996), or after delivery if the lesion has not regressed completely (Butler and Macintyre, 1991; Tumini et al., 1998).

Powell et al. (1994) reported the use of Nd:YAG laser for the excision of this tumor in a patient in the 36th week of pregnancy because of the lower risk of bleeding compared to other surgical techniques.

This report presents a case of granuloma gravidarum in a patient in the last month of pregnancy.


Case Report

This 19-year-old Negro woman in the 9th month of pregnancy was examined at the Stomatology Clinic of the Faculty of Dentistry (UNAERP, Ribeirão Preto, SP, Brazil) presenting a polypoid sessile gum mass, with intense reddish color, and bleeding on touch. This mass involved both buccal and lingual regions of the maxillary pre-molars and molars on the right side at the muco-gingival line (Figure 1) and there was bacterial plaque and calculus present.

Basic periodontal treatment, including scraping and prophylaxis, and instructions on oral hygiene were carried out at the first visit. The patient returned to the Clinic after delivery for follow-up. The lesion had decreased in size (Figure 2, top). A program of supervised oral hygiene to improve gingival status and lesion regression was carried out.

Because the lesion did not regress completely, five months after parturition the lesion was re moved surgically (Figure 2, bottom). One week before the surgical excision of the lesion, basic periodontal treatment, including scraping and root planing and instructions on oral hygiene were preformed to decrease gingival inflammation. After tissue excision, residual calculus was removed and root planing done. To obtain better gingival contour, a gingivoplasty was performed. The patient was encouraged to maintain normal hygiene and to rinse her mouth with 0.2% chlorhexidine solution, twice a day for 7 days.

Microscopic examination revealed lobular contour tissue, partially covered by epithelium and ulceration of the external lobule, with the epithelium replaced by a fibrin pseudomembrane densely infiltrated by inflammatory cells, mainly polymorphonuclear neutrophils. The connective tissue in the deepest parts of the lesion was granulomatous, with a large number of blood vessels at several developmental stages. The inflammatory infiltrate was abundant in most of the tissue (Figure 3, top and bottom).

The patient was followed-up for 18 months after surgical excision of the lesion. Healing occurred normally and no recurrence was observed.


Discussion

Granuloma gravidarum usually appears in the first trimester and rapid growth accompanies the steady increase of circulating estrogens and progestins. Repeated mild gingival inflammation secondary to plaque, calculus and trauma are sufficient to initiate lesion development. Gestational steroid changes do not independently trigger development of granuloma gravidarum but seem to aggravate previously latent gingivitis and the subsequent exacerbated inflammatory tissue response leads to the development of this proliferative lesion (Sills et al., 1996). According to Tumini et al. (1998), granuloma gravidarum is a result of gingivitis that leads to local hyperplasia. Pregnancy gingivitis results from the increase of progesterone and can induce substantial microvascular alterations in the gingiva. However, bacterial plaque and gingival inflammation are necessary for subclinical hormone alterations to lead to gingivitis (Sooriyamoorthy and Gower, 1989). Ojanotko-Harri et al. (1991) suggested that progesterone functions as an immunosuppressant in the gingival tissues of pregnant women, preventing a rapid acute inflammatory reaction against plaque, but allowing an increased chronic tissue reaction, resulting clinically in an exaggerated appearance of inflammation.

The size and location of the granuloma gravidarum may interfere in mastication, affecting nutrition and consequently fetal development. The lesion also provides a site for bacterial growth, contributing to periodontal disease and affecting esthetics (Sills et al., 1996). In the present case, because of the volume of the lesion and difficulty in oral hygiene, the patient presented difficulty in alimentation, indicating the need for surgical removal. However, because the patient was in 38th week of pregnancy, it was decided not to do surgical excision at that time. After parturition, a supervised oral hygiene program for the regression of the lesion was carried out until the lesion was reduced and surgically excised 5 months later.

The histopathologic examination revealed similar characteristics to those described by Sills et al. (1996): loose granulation tissue, rich in capillary vessels, and proliferation of endothelial cells, being typically accompanied by a mixture of infiltrated inflammatory cells. According to Ojanotko-Harri et al. (1991), there is no clinical and histological difference between pregnancy granuloma and pyogenic granuloma that occurs in "non-pregnant" patients.

In conclusion, preventive follow-up of the pregnant patient is necessary to avoid periodontal diseases related to hormonal alterations.


Resumo

Silva-Sousa YTC, Coelho CMP, Brentegani LG, Vieira MLSO, Oliveira ML: Avaliação clínica e histológica de granuloma gravídico: relato de caso. Braz Dent J 11(2): 135-139, 2000.

Granuloma gravídico é uma lesão benigna comum da mucosa oral que ocorre na gestação. Este trabalho descreve o aspecto clínico, o tratamento e a avaliação histológica de um granuloma gravídico presente em uma paciente no último mês de gestação.


Unitermos: granuloma gravídico, tumor de gravidez, granuloma piogênico, complicações da gravidez.


References

Butler EJ, MacIntyre DR: Oral pyogenic granulomas. Dent Update 18: 194-195, 1991
Fenton JE, Timon CI, McShane DP: Lingual granuloma gravidarum. Otolaryngol Head Neck Surg 114: 682-683, 1996
Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewon LA: Altered tissue metabolism of progesterone in pregnancy gingivitis and granuloma. J Clin Periodontol 18: 262-266, 1991
Powell JL, Bailey CL, Coopland AT, Otis CN, Frank JL, Meyer I: Nd:YAG laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med 14: 178-183, 1994
Sills ES, Zegarelli DJ, Hoschander MM, Strider WE: Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reproductive Medicine 41: 467-470, 1996
Sooriyamoorthy M, Gower DB: Hormonal influences on gingival tissue: relationship to periodontal disease. J Clin Periodontol 16: 201-208, 1989
Steelman R, Holmes D: Pregnancy tumor in a 16-year-old: case report and treatment considerations. J Clin Pediatr Dent 16: 217-218, 1992
Tumini V, Di Placido G, D'Archivio D, Del Giglio Matarazzo A: Hyperplastic gingival lesions in pregnancy. I. Epidemiology, pathology and clinical aspects. Minerva Stomatol 47: 159-167, 1998


Correspondence: Yara T. C. Silva-Sousa, R. Cav. Torquato Rizzi 1638, Apt. 43, 14020-3000 Ribeirão Preto, SP, Brasil.


Accepted July 18, 2000
Eletronic publication october, 2000


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