|Year : 2012 | Volume
| Issue : 2 | Page : 68-71
A case report of pregnancy tumor and its management using the diode laser
Namazi Esmaeil, Baliga Sharmila, Muglikar Sangeeta, Kale Rahul
Department of Periodontology and Implantology, M A Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||31-Jan-2013|
Department of Periodontology and Implantology, M. A. Rangoonwala College of Dental Sciences and Research Centre, Pune - 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Pyogenic granuloma (PG) is a tumor-like growth in the oral cavity. It is manifested as a painless sessile or pedunculated, erythematous, exophytic and specific papular or nodular with a smooth or lobulated surface, which may have a fibrinous covering. The lesion usually bleeds easily on a slight provocation. PG is considered to be a non-neoplastic in nature. It is a reactive lesion, also classified in pregnancy associated gingival diseases. It occurs due to irritation or physical trauma from calculus or cervical restorations as also some contribution by hormonal factors and usually affects the gingiva, but can be seen in areas of frequent trauma such as lower lip, tongue, oral mucosa, and palate. The growth is typically seen on or after the third month of pregnancy and may grow rapidly to acquire a large size, thus, requiring surgical removal. The diode laser has also been used as an alternative treatment modality. This is a case report of PG in a patient treated with the diode laser.
Keywords: Diode, laser, pyogenic granuloma, pregnancy
|How to cite this article:|
Esmaeil N, Sharmila B, Sangeeta M, Rahul K. A case report of pregnancy tumor and its management using the diode laser. J Dent Lasers 2012;6:68-71
| Introduction|| |
Pregnancy tumor is a pyogenic granuloma (PG) that occurs on the gingiva during pregnancy.  It was first described in 1897 by two French surgeons Poncet and Dor, and is also known as epulis gravidarum.
The term of PG is misleading, because the lesion is unrelated to infection and it is not a true granuloma. It arises as a result of various stimuli, such as low-grade local irritation, trauma, or hormonal factors. 
These lesions have been described as a painless, exophytic mass that has either a sessile or pedunculated base extending from the gingival margin or, in most instances, from the interproximal tissues in the maxillary anterior.
The pregnancy tumor most frequently develops on the buccal gingiva in the interproximal tissue between teeth. This benign hyperplastic lesion of the oral mucosa occurs in up to 5% of pregnancies.  It rarely reaches more than 2 cm in size and has a tendency to recur, if not completely removed. The gingiva is involved in 70% of cases, followed by the tongue, lips, and buccal mucosa. 
Pregnancy tumor usually occurs at the end of the first trimester and rapid growth usually accompanies the steady increase of circulating estrogens and progestrones. Partial or complete regression is common after child birth. Repeated mild irritation with gestational steroid changes may subsequently exacerbate inflammatory response, leading to development of this proliferating lesion. 
Various modalities of treatment have been documented for treatment of this lesion. It has been reported that laser excision is well tolerated by patients with no adverse effects. Diode laser has shown excellent results in cutaneous PGs with only minimal pigmentary and textural complications. 
This report presents a case of PG in a patient in the second trimester of pregnancy, which was excised with the help of the diode laser.
| Case Report|| |
A 26-year-old female in her second trimester of pregnancy was referred to the Department of Periodontology at the M. A. Rangoonwala College of Dental Sciences and Research Center, Pune, with a complaint of gingival overgrowth and bleeding on slight provocation in the maxillary right central and lateral incisor region [Figure 1].
|Figure 1: Gingival overgrowth between maxillary right central and lateral incisors|
Click here to view
The patient noticed a growth on the gum and bleeding 2 months before, however, did not seek medical attention at that time. This lesion had gradually increased in size to attain present dimensions.
Conventional periodontal treatment, including scaling and root planing was performed to decrease gingival inflammation. Patient was given oral hygiene instructions and correct brushing technique was demonstrated as also a 0.12% chlorhexidine mouthwash was prescribed.
Three weeks later, it was noticed that the lesion did not regress completely as shown in [Figure 2]. The lesion was excised with the help of diode laser (980 nm, continuous wave, 200 μm optical fiber, 6W) and sent for histopathological examination. After tissue excision, residual calculus was removed and root planing done. Gingivoplasty was carried out with the help of the diode laser to obtain better gingival contour.
The patient was prescribed Paracetamol (500 mg) to be taken, if and when there is pain. She was further prescribed 0.12% chlorhexidine mouthwash. Although, the patient was prescribed analgesics, she reported that since she experienced no pain post-operatively, she had not taken the analgesics.
As shown in [Figure 3], histopathological section showed loose granulation tissue rich in capillary vessels and proliferation of endothelial cells, typically accompanied by a mixture or infiltrated inflammatory cells. A thickened stratified squamous epithelium layer overlaid the lesion and was ulcerated due to the trauma associated with eating or tooth brushing. There was no evidence of malignancy. These findings were consistent with the histopathological findings of PG.
One week post-operatively, the lesion had completely healed and gingiva was clinically healthy [Figure 4]. The patient was followed up for 2 months post-operatively. There was no recurrence of the lesion.
| Discussion|| |
PG is an inflammatory hyperplastic lesion. The pregnancy granuloma or pregnancy tumor is a specialized form of PG that occurs on the gingiva during pregnancy.
The precise mechanism for the development of PG is unknown. Trauma, hormonal influences, viral oncogenes, underlying microscopic arteriovenous malformation, the production of angiogenic growth factor and cytogenic abnormalities have all been postulated to play a role. 
According to Tumini, et al., pregnancy tumor is a result of gingivitis that leads to local hyperplasia.  The increase of progesterone can induce substantial microvascular alteration in certain areas, most commonly in the gingiva. The etiologic means by which female sex steroid hormones may influence the periodontium of women, especially during pregnancy, are varied and differ from those ordinarily associated with plaque-induced gingivitis. Human gingiva contains receptors for estrogen and progesterone, and increased plasma levels result in an increase in accumulation of these hormones in gingival tissues. Estrogen regulates cellular proliferation, differentiation and keratinisation and thus estrogen seems to stimulate matrix synthesis, along with progesterone, enhances the localized production of inflammatory mediators, especially prostaglandin E2, a potent inducer of osteoclastic activity. Progesterone compromises tissue homeostasis by reducing fibroblast proliferation, altering the pattern of collagen production and reducing the level of plasminogen activator inhibitor type 2, which is an important inhibitor of tissue proteolysis.
However, bacterial plaque and gingival inflammation are necessary for subclinical hormone alteration to lead to gingivitis. There is an increase in the selective growth of P. Intermedia, P. Gingivalis and Tannerella species has been demonstrated in sub gingival plaque during the onset of pregnancy gingivitis. This is likely to be a result of these species being able to use the pregnancy hormones, particularly progesterone, as a source of nutrition. 
Ojanotko-Harri, et al., (1991) suggested that progesterone functions as an immunosuppressant in the gingival tissue 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. 
Histologically, it is a reactive inflammatory processes filled with proliferating vascular channel, immature fibroblastic connective tissue and scattered inflammatory.  These events result in the accumulation of collagen within the connective tissue, thereby, providing a possible additional mechanism for the dramatic gingival enlargement of pregnancy granuloma, and the vascular effects account for the bright red appearance, and hyperemia and edema for the gingival enlargement.
According to Ojanotko-Harri, et al., (1991) there is no clinical and histological difference between pregnancy granuloma and PG that occurs in non-pregnant patient. 
Management of pregnancy granuloma depends on the severity of the symptoms. If the lesion is small, painless and free of bleeding, clinical observation and follow-up are advised.  During pregnancy, surgery should be recommended if bleeding or pain from the lesion impedes daily activities,  or after delivery, if the lesion has not regressed completely.  Other procedures like cryosurgery,  laser therapy, sclerotherapy with sodium tetra decyl sulfate and monoethanolamineoleate,  which have been documented
Powell, et al. (1994) proposed the use of Neodymium: Yttrium Aluminium Garnet (Nd: YAG) laser for the excision of this tumor. They used the Nd: YAG laser in a patient in the 36 th week of pregnancy because of the lower risk of bleeding compared to other surgical techniques and found that it was tolerated well.  Rai, et al. (2011) reported the beneficial effect of diode laser in excision of the PG. 
The wavelength of the diode laser is absorbed by the hemoglobin, which leads to tissue coagulation and formation of charred layer. The diode laser leads to thermocoagulation of the blood vessels, which is responsible for its hemostatic effect.  This property of the diode laser contributes to lower-risk of bleeding of the granuloma intraoperatively during excision. The diode laser is also known or its bactericidal effect, which is contributory to the reduction of the bacteria. Post-operative discomfort is also less compared to conventional surgical procedures, which is evident from the current report. 
In the present report, we can see that there was no adverse effect from the use of the laser. Intraoperative bleeding was also less compared to conventional surgical excision. The advantages of the diode laser therapy are the lesser time taken for treatment, lesser pain, lesser operator fatigue and better patient acceptance. We can thus conclude that the diode laser is a safe tool for excision of the PG.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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