Soft young adults, with a female predilection

Soft tissue enlargements of the oral cavity are often
a diagnostic challenge because of the diverse group of pathologic processes
associated with such lesions. An enlargement could represent a variation of
normal anatomic structures, inflammation, cysts, developmental anomalies or
neoplasm. Amongst these lesions is a group of reactive hyperplasias, which
develop in response to a chronic, recurring tissue injury, which stimulates an
exuberant tissue response. Pyogenic granuloma is of the most common entities
causing soft tissue enlargements.1 It is a benign, non-neoplastic,
mucocutaneous lesion. However the name ‘pyogenic granuloma’ is a misnomer,
since this condition is not associated with pus and as it does not represent a
granuloma histologically.2 It was originally described in 1897 by two French
surgeons, Poncet and Dor.3 They are now known as Angiomatous Granuloma. In
south Indian population, Shamim et al 
found that non neoplastic lesions accounted for 75.5% of cases with oral
Angiomatous granuloma being most frequent lesion, accounting for 52.71%
cases.4  Clinically, these lesions
present as single nodule or sessile papule with smooth or lobulated surface and
are red, elevated and sometimes ulcerated.5,6 
The peak prevalence is in teenagers and young adults, with a female
predilection of 2:16.6,7 A higher frequency 
is observed in the second decade of life8, especially among women,
probably due to the vascular effects of female hormones9. The gingiva is the
most commonly affected site  accounting
for almost 75% of all cases9, although occurrence of these lesions on the
lips, tongue, oral mucosa, palate10 and fingers11 has also been reported.

 

This paper
presents an unusual presentation of Angiomatous granuloma of the upper lip
where many lesions of the oral mucosa with similar clinical characteristics
were considered before arriving at a final diagnosis through biopsy. Being a
non-neoplastic growth, excisional therapy is the treatment of choice but some
alternative approaches such as cryosurgery, excision by diode Laser, flash lamp
pulsed dye laser, injection of corticosteroid or ethanol, and sodium tetradecyl
sulfate sclerotherapy have been reported to be effective.3 In this report, we
used a Diode Laser for excision of the lesion since Lasers are effective, well
tolerated by the patients with no adverse consequences.

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Case history:

A 39-year-old male patient reported to the Department
of Periodontology, Saveetha dental college with a chief complaint of a growth
in the upper lip for the past one-year. The patient noticed a small growth on
the upper labial mucosa one year ago that had gradually increased to the
present size. The patient was systemically healthy. His medical, dental and
drug histories were non-contributory. On Physical examination, he appeared to
be healthy and of normal size and weight. Intraoral examination revealed solitary,
exophytic growth on the upper labial mucosal surface measuring 1 cm x 0.5 cm in
diameter with a lobulated surface. (Figure-1) The growth was bluish red in
colour,firm in consistency and non-tender and also not associated with any
bleeding on palpation. When the patient closed his mouth, the growth touched
the upper sharp incisal edge of left canine. Based on the history and clinical
examination we arrived at a provisional diagnosis of Traumatic Fibroma with a
differential diagnosis of Angiomatous Granuloma. An excisional Biopsy was
performed with Diode laser .(    nm , in
the continuous mode with a power of 1.0 w).The excised specimen was placed in
10% Formalin and then sent for histopathologic examination. The histopathologic
examination showed parakeratinized stratified squamous epithelium of variable
thickness with and area of ulceration exhibiting fibrinopurulent membrane. The
underlying connective tissue stroma shows intense vascularity and numerous
proliferative endothelial cells associated with intense mixed inflammatory cell
infiltrate and areas of haemorrhage.These findings were consistent with
histopathologic diagnosis of Angiomatous Granuloma. Post excision period was
uneventful with a regular follow?up of 1-month
interval, which showed no evidence of recurrence for the past 3 months.

 

Discussion:

Angiogranuloma
is a well-recognized inflammatory hyperplastic oral lesion, which comprises
about 1.85% of all oral patholo­gies. 12 Usually the growth is neither
symptomatic nor painful but minor trauma can induce significant bleeding and
may also cause functional problems with mastication, swallowing, speaking as
well as esthetic problems. 13&14 Even though Angiogranuloma is seen in
a wide age range, the incidence culminates during the second decade of life,
and shows a female predilection, common site is on the gingiva, but can also be
encountered on the lips, tongue, buccal mucosa and rarely like this case, it
may appear on the upper labial mucosa. 13, 15, 16 it is most commonly treated by surgical excision; but numerous
other treatment modalities, including excision by lasers, have also been
successfully used.
14, 15, 17-23, 25, 26 Laser application offers various advantages such as
relatively bloodless surgery as it seals the blood vessels and nerve bundles
while cutting thereby aiding in better visualization of the site and a
sutureless procedure with very minimal postoperative pain. Additionally, also
provides instantly disinfection of the surgical wound with minimal chances of
postoperative infection, minimal edema, better aesthetics and faster healing.
6 Meffert et al 22 used
flash lamp pulsed dye laser to treat an intraoral mass of granulation tissue.
Powell et al 27 and Kocaman et al used Nd: YAG laser for excision of
Angiomatous granuloma, and reported su­perior coagulation characteristics.
White et al 26 used Nd: YAG and CO2 lasers for the excision, which was well endured by
patients without intraoperative or postopera­tive side effects. Fekrazad et al
18 preferred Er: YAG laser for excision stating that it causes less damage to
the lesion, hereby the remaining tissue has more pathological value. Rai et al
28 used diode laser for excision. Iyer and Sasikumar 29 highlighted
the effectiveness of 940 nm Diode laser over conventional treatment modalities
for excision. Diode laser wavelengths
are highly absorbed by pigment­ed tissue whereas they are poorly absorbed by
hard tissues such as the teeth and bones; furthermore they can be used in
continuous or gated pulse mode in contact or at an extremely close distance to
the tissue thereby avoiding damage, because it prevents the ‘beam escape’ in an
open field and makes this laser safer than other laser sources. Since the
angiomatous granuloma was present in the upper labial mucosa, aesthetics are of
prime importance and hence we chose diode laser for excision because of its
above mentioned benefits, and also because it ensures a relatively bloodless
surgical field, which is a crucial factor in these haemorrhagic le­sions,
improves haemostasis and coagulation, and leaves minimal swelling and scarring
after surgery. Several studies have reported recurrence rates of up to 16 %
with simple excision. 1, 12, 30, 31 Recur­rence can be due to
insufficient excision, failure to eliminate etiologic factors or repetitive
trauma. Re­cently, angiopoietin 1, 2 and agents in other vascular tumors such
as Bartonella henselae, B. Quintana and human herpesvirus-8, are
presumed to play a role in recurrence of Angiomatous granuloma. Various Viral
oncogenes, hormonal in­fluences, microscopic arteriovenous malformation and
gene depression in fibroblasts, have also been implicated for recurrence.
Generally the recur­rence rate is much higher in gingival cases than other oral
mucosal sites. 15, 28, 32