Introduction: Pyogenic granuloma (PG) is a prevalent inflammatory hyperplasia of skin and oral mucosa which is often caused by constant low-grade local irritation, traumatic injury or hormonal factors. In many cases, gingival irritation and inflammation due to poor oral hygiene are precipitating factors. Oral PG occurs predominantly on the gingiva, but it is also encountered on the lips, tongue, buccal mucosa and rarely on the hard palate. Although surgical excision is the first choice of treatment, many other treatment modalities could be counted such as cryosurgery, sodium tetradecyl sulfate sclerotherapy, intralesional steroids, flash lamp pulsed dye laser, neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, carbon dioxide (CO2) laser, erbium-doped yttrium aluminum garnet (Er:YAG) lasers and diode laser have been suggested. After surgical excision recurrence occurs up to 16% of these lesions. It is believed that recurrence ensues as a result of incomplete excision, failure to eliminate etiologic factors or repeated trauma.
Case Report: A 50-year-old female was referred to the Department of Oral Surgery, Gazi University, School of Dentistry, complaining of a swelling and growth on the right side of the hard palate for four months. Patient reported a similar growth in the same area about two years earlier, which had turned out to be a PG by histopathology. The treatment plan included surgical excision of the lesion using diode laser.
Results: The patient reported no pain after the surgery. She was discharged with a prescription of chlorhexidine mouthwash and necessary post-operative instructions. At 7 days follow up visit, immediate recurrence of the lesion was observed, and it was excised by diode laser with 2 mm margins at its clinical periphery, to a depth up to the periosteum, by the same operator. No recurrence or scarring was observed in 14 months follow-up.
Conclusion: Although diode laser is a secure and efficient technique for the treatment of intraoral PG, in order to minimize its recurrence, the lesion should be excised with a wider margin down to the periosteum or to the causing agent. Also due to its high recurrence rate, long-term follow-up is recommended.
Rai S, Kaur M, Bhatnagar P. Laser: a powerful tool for treatment of pyogenic granuloma. J Cutan Aesthet Surg. 2011;4:144-147. doi:10.4103/0974-2077.85044.
Asnaashari M, Mehdipour M, MoradiAbbasabadi F, Azari- Marhabi S. Expedited removal of pyogenic granuloma by diode laser in a pediatric patient. J Lasers Med Sci. 2015; 6:40-44.
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; 5:92-95.
Hullihen SP. Case of aneurysm by anastomosis of the superior maxilla. Am J Dent Sc. 1844; 4:160-162.
Hartzell MB. Granuloma pyogenicum. J Cutan Dis Syph. 1904; 22:520-525.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48:167-175. doi:10.2334/josnusd.48.167.
de Giorgi V, Sestini S, Nardini P, Carli P. A 42-year-old man with a rapidly growing lesion of the soft palate. CMAJ. 2005;173:367. doi:10.1503/cmaj.050242.
Kocaman G, Belduz N, Erdogan C, Ozbek E, Sadik E, Kara C. The use of surgical Nd:YAG laser in an oral pyogenic granuloma: a case report. J Cosmet Laser Ther. 2014;16:197- 200. doi:10.3109/14764172.2014.910078.
Fekrazad R, Nokhbatolfoghahaei H, Khoei F, Kalhori KA. Pyogenic granuloma: surgical treatment with Er:YAG Laser. J Lasers Med Sci. 2014;5:199-205.
Gomes SR, Shakir QJ, Thaker PV, Tavadia JK. Pyogenic granuloma of the gingiva: A misnomer? A case report and review of literature. J Indian Soc Periodontol. 2013;17:514- 519. doi:10.4103/0972-124x.118327.
Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012;16:79-82. doi:10.4103/0973-029x.92978.
Regezi JA, Jordan RC, eds. Oral Pathology: Clinical Pathologic Considerations. Philadelphia: WB Saunders; 2003.
Esmeili T, Lozada-Nur F, Epstein J. Common benign oral soft tissue masses. Dent Clin North Am. 2005;49:223-240. doi:10.1016/j.cden.2004.07.001.
Lebwohl MG, Heyman W, Berth-Jones J, Coulson I, eds. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Saunders; 2013.
Aguilo L. Pyogenic granuloma subsequent to injury of a primary tooth. A case report. Int J Paediatr Dent. 2002;12:438-441. doi:10.1046/j.1365-263x.2000.00388.x.
Milano M, Flaitz CM, Bennett J. Pyogenic granuloma associated with aberrant tooth development. Tex Dent J. 2001;118:166-172.
Muench MG, Layton S, Wright JM. Pyogenic granuloma associated with a natal tooth: case report. Pediatr Dent. 1992;14:265-267.
Alomar MJ. Pyogenic granuloma successfully treated with electric cautarization - case study. J Basic Clin Pharm. 2011; 3:229-234. doi:10.4103/0976-0105.103830.
Gupta R, Gupta S. Cryo-therapy in granuloma pyogenicum. Indian J Dermatol Venereol Leprol. 2007;73:141.
Ishida CE, Ramos-e-Silva M. Cryosurgery in oral lesions. Int J Dermatol. 1998;37:283-285.
Samatha Y, Reddy TH, Jyothirrmai, Ravikiran A, Sankar AJ. Management of oral pyogenic granuloma with sodium tetra decyl sulphate. A case series. N Y State Dent J. 2013; 79:55-57.
Deore GD, Gurav AN, Patil R, et al. Sclerotherapy: a novel bloodless approach to treat recurrent oral pyogenic granuloma associated with port-wine stain. Ann Vasc Surg. 2014;28(1564):9-14. doi:10.1016/j.avsg.2014.01.009.
Ichimiya M, Yoshikawa Y, Hamamoto Y, Muto M. Successful treatment of pyogenic granuloma with injection of absolute ethanol. J Dermatol. 2004;31:342-344.
Quitkin HM, Rosenwasser MP, Strauch RJ. The efficacy of silver nitrate cauterization for pyogenic granuloma of the hand. J Hand Surg Am. 2003;28:435-438.
Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis. 2006;12:70-72. doi:10.1111/j.1601-0825.2005.01158.x.
Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser. Pediatrics. 1997;99:368-370.
Goldberg DJ, Sciales CW. Pyogenic granuloma in children. Treatment with the flashlamp-pumped pulsed dye laser. J Dermatol Surg Oncol. 1991;17:960-962.
Glass AT, Milgraum S. Flashlamp-pumped pulsed dye laser treatment for pyogenic granuloma. Cutis. 1992;49:351-353.
Gonzalez S, Vibhagool C, Falo LD Jr, Momtaz KT, Grevelink J, Gonzalez E. Treatment of pyogenic granulomas with the 585 nm pulsed dye laser. J Am Acad Dermatol. 1996;35:428- 431. doi:10.1016/s0190-9622(96)90610-6.
Meffert JJ, Cagna DR, Meffert RM. Treatment of oral granulation tissue with the flashlamp pulsed dye laser. Dermatol Surg. 1998;24:845-848. doi:10.1111/j.1524-4725.1998.tb04261.x.
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. 1994;14:178- 183.
Lindenmuller IH, Noll P, Mameghani T, Walter C. CO2 laser-assisted treatment of a giant pyogenic granuloma of the gingiva. Int J Dent Hyg. 2010;8:249-252. doi:10.1111/ j.1601-5037.2010.00449.x
Akbulut N, Kursun ES, Tumer MK, Kamburoglu K, Gulsen U. Is the 810-nm diode laser the best choice in oral soft tissue therapy? Eur J Dent. 2013;7:207-211. doi:10.4103/1305- 7456.110174.
Azma E, Safavi N. Diode laser application in soft tissue oral surgery. J Lasers Med Sci. 2013;4:206-211.
Bhaskar SN, Jacoway JR. Pyogenic granuloma--clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg. 1966;24:391-398.
Adusumilli S, Yalamanchili PS, Manthena S. Pyogenic granuloma near the midline of the oral cavity: A series of case reports. J Indian Soc Periodontol. 2014;18:236-239. doi:10.4103/0972-124x.131339.
White JM, Chaudhry SI, Kudler JJ, Sekandari N, Schoelch ML, Silverman S Jr. Nd:YAG and CO2 laser therapy of oral mucosal lesions. J Clin Laser Med Surg. 1998;16:299-304.
Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004;48:861- 888.
Coluzzi DJ. Fundamentals of dental lasers: science and instruments. Dent Clin North Am. 2004;48:751-770.
Coleton S. Lasers in surgical periodontics and oral medicine. Dent Clin North Am. 2004;48:937-962.
Janda P, Sroka R, Mundweil B, Betz CS, Baumgartner R, Leunig A. Comparison of thermal tissue effects induced by contact application of fiber guided laser systems. Lasers Surg Med. 2003;33:93-101. doi:10.1002/lsm.10199.
Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol. 1980;51:655-661. doi:10.1902/jop.19188.8.131.525.
Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol. 1992;27:297-300. doi:10.1016/0190- 9622(92)70184-h.
Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surg. 1986;24:376-382. doi:10.1016/0266-4356(86)90023-9.
Moon SE, Hwang EJ, Cho KH. Treatment of pyogenic granuloma by sodium tetradecyl sulphate sclerotherapy. Arch Dermatol. 2005;141:644-646. doi:10.1001/ archderm.141.5.644.
Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis. 2006;12:70–72. doi:10.1111/j.1601-0825.2005.01158.x.