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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 1  |  Page : 41-44

Carbon dioxide laser-assisted management of pregnancy tumor: A case report


Department of Periodontology and Implantology, M.C.E Society's M.A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Dr. Waqas Naseer Ansari
306 Ashrafi Manzil, Badlu Rangari, Byculla, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdl.jdl_12_18

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  Abstract 

Pyogenic granuloma (PG) is an inflammatory hyperplasia of the tissues that occurs as a result of various stimuli such as low-grade local irritation, traumatic injury, or hormonal factors. The term used is a misnomer since it is unrelated to infection and does not contain pus. Clinically, oral PG develops as a solitary, granuloma-like, pedunculated, and easily bleeding tumor which mostly affects the gingiva followed by buccal mucosa, tongue, lips, and palate. It is also known as granuloma pyogenicum, granuloma gravidarum, telangiectatic granuloma, pregnancy tumor, vascular epulis, benign vascular tumor, and hemangiomatous granuloma. Females are affected more commonly mainly during puberty, pregnancy, and menopause probably due to the vascular effects of the hormones. The lesions are known as “pregnancy tumor” and tend to occur more frequently during the second and third trimesters. Commonly involved treatment protocols include conventional surgical excision, electrocautery, and lasers. The purpose of this article is to report the laser-assisted management of an unusual case of PG in a 22-year-old female patient in her 9th month of pregnancy.

Keywords: Carbon dioxide laser, pregnancy tumor, pyogenic granuloma, telangiectatic granuloma


How to cite this article:
Sigtia SH, Hegde R, Ansari WN, Gudakuwala A. Carbon dioxide laser-assisted management of pregnancy tumor: A case report. J Dent Lasers 2018;12:41-4

How to cite this URL:
Sigtia SH, Hegde R, Ansari WN, Gudakuwala A. Carbon dioxide laser-assisted management of pregnancy tumor: A case report. J Dent Lasers [serial online] 2018 [cited 2021 Oct 25];12:41-4. Available from: https://www.jdentlasers.org/text.asp?2018/12/1/41/235375


  Introduction Top


Pyogenic granuloma (PG) is a common reactive neoformation of the oral cavity, described as a painless, exophytic mass that has either a sessile or pedunculated base extending from the gingival margin. It is mainly composed of granulation tissue and develops in response to low-grade local irritation, hormonal factors, certain medication, or trauma.[1] The term “PG” is a misnomer because the lesion does not contain pus and does not represent a true granuloma.[2] It is more suitably named “Telangiectatic Granuloma” as it is highly vascular.

The management of PG in pregnancy depends on the size of the lesion and severity of the symptoms. If the lesion is small, painless, and free of bleeding, clinical observation, removal of local factors, oral hygiene maintenance, and follow-up are advised.[3] During pregnancy, surgery should be recommended if bleeding or pain from the lesion impedes daily or after delivery if the lesion has not regressed completely.

Various treatment modalities have been proposed for the treatment of this lesion. Laser therapy using Carbon dioxide (CO2) lasers is one of the best treatment modality, as they carry the advantage of being less invasive, excellent hemostasis, and sutureless procedures that produce only minimal postoperative pain.

This report presents management of a case of PG in a 22-year-old female patient who was in her 9th month of pregnancy.


  Case Report Top


A 22-year-old female patient in her 36th week of pregnancy reported to the Department of Periodontology and Implantology, with a soft-tissue overgrowth in the lower right region of the mouth. The patient complained of pain that was dull and aching in nature with difficulty in speech and mastication [Figure 1].
Figure 1: Preoperative photo

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On examination, the overgrowth was approximately 1.8 cm (length) ×0.9 cm (width) centimeters in size extending from the distal surface of mandibular right canine to mesial surface of the mandibular right first molar [Figure 2]. It was lobulated, red-to-pink mass, pedunculated, with irregular borders and bleed spontaneously on provocation. There was no mobility of the related teeth.
Figure 2: Overgrowth measurement (a) 0.9 cm (width) (b) 1.8 cm (length)

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Oral prophylaxis was performed on the same visit, followed by oral hygiene instructions. Following routine blood investigations, a written informed consent was obtained from the patient. On second visit, excisional biopsy was performed using a CO2 laser under all laser safety precautions such as wearing wavelength-specific glasses, minimizing reflective surfaces in the operating site, and use of plume evacuator. CO2 laser 10,600 nm was operated at 2.5 Watt, continuous wave in noncontact mode with long-pulse hollow waveguide under 2% lignocaine infiltration (local anesthesia) following which routine scaling and curettage of the area were carried out. The excised tissue was sent for histopathological examination [Figure 3]. The patient was given complete postoperative instructions and was put on a maintenance protocol till the end of pregnancy [Figure 4] and [Figure 5]. In sequential visits up to 18 months, postoperatively no recurrence of the lesion was seen [Figure 6].
Figure 3: Excision of the lesion using carbon dioxide laser

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Figure 4: Immediate postoperative photo

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Figure 5: Postoperative photo after 2 weeks

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Figure 6: Postoperative photo after 18 months

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Histopathological examination revealed parakeratotic stratified squamous epithelium of variable thickness from atrophic to hyperplastic. Foci also showed that ulcerated area covered by fibro purulent membrane. The underlying connective tissue stroma revealed abundance of capillaries of variable shape and sizes, some of them filled with red blood cells, numerous budding endothelial cells and dense chronic inflammatory cell infiltrate chiefly lymphocytes, plasma cells, and macrophages.


  Discussion Top


Telangiectatic granuloma is a reactive tumor-like lesion that tends to occur more often during the second and third trimester of pregnancy.[4] The exact mechanism for its development is unknown; however, factors such as chronic low-grade irritation, hormonal influences, viral oncogenes, and the presence of angiogenic growth factors have been seen to play a role in the etiology.

Increased incidence during pregnancy is attributed to the increased level of estrogen and progesterone that evokes the activity of pro-inflammatory cytokines. Estrogen regulates cellular proliferation, differentiation, and keratinization, and thus, estrogen seems to stimulate matrix synthesis, along with progesterone, enhances the localized production of inflammatory mediators especially prostaglandin E2. However, bacterial plaque and gingival inflammation are necessary for subclinical hormone alteration leading to gingivitis.

Management of patients with such lesions involves conventional surgery along with the control of local factors.[3] Other protocols also include the use of flash-lamp dye laser, cryosurgery, injection of ethanol, sodium tetradecyl sulfate sclerotherapy, intralesional corticosteroid injection, and lasers.[5]

PG is a highly vascular lesion. Thus, the use of laser provides an additional advantage to achieve hemostasis by sealing blood vessels which in turn helps to give a better control incision. Thus, the contour of the tissues is well maintained. It also seals the lymphatics and nerve endings thus reducing the postoperative pain and swelling. Postoperatively, the healing was satisfactory with no signs of any thermal damage to the adjacent tissues. Thus, taken into consideration the late stage of pregnancy and clinical features of the lesion, CO2 laser served as a good treatment procedure as compared to other invasive surgical treatment options and also treatment with laser was very well accepted by the patient, without any adverse effects.[6]

Choice of treatment during pregnancy is important as lesions removed during this period have a higher chance of recurrence. Although PG is a nonspecific, sharply marked off, nonneoplastic growth in the oral cavity, proper diagnosis, prevention, and management of the lesion are very important. However, complete removal of local factors by the clinician along with good oral hygiene maintenance by the patient with proper and regular follow-ups might prevent the occurrence and recurrence of the disease.

In conclusion, the utilization of lasers has added a new dimension to the previous treatment procedures for management of highly vascular lesions, either as monotherapy or as adjunctive therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Brahmankar UA, Gadgil RM, Bhoosreddy AR. Telangiectatic granuloma: A case report and review. Int J Sci Stud 2014;2:246-8.  Back to cited text no. 1
    
2.
Limmonthol S, Sayungkul C, Klanrit P. Oral pyogenic granuloma presenting as an atypically large soft tissue mass: A case report. J Oral Maxillofac Surg Med Pathol 2014;26:258-61.  Back to cited text no. 2
    
3.
Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med 1996;41:467-70.  Back to cited text no. 3
    
4.
Ricardo JH, Alvarez AL, Gomez KR. Oral telangiectatic granuloma. Caseseries presentation. Rev Fac Odontol Univ Antioq 2012;23:366-75.  Back to cited text no. 4
    
5.
Epivatianos A, Antoniades D, Zaraboukas T, Zairi E, Poulopoulos A, Kiziridou A, et al. Pyogenic granuloma of the oral cavity: Comparative study of its clinicopathological and immunohistochemical features. Pathol Int 2005;55:391-7.  Back to cited text no. 5
    
6.
Venkatasubramanyam A, Hegde R, Sigtia S, Muglikar S, Shourie V. Laser assisted management of telangiectatic granuloma in third trimester of pregnancy – A case report. J Clin Diagn Res 2018;12:7-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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