A pyogenic granuloma is a relatively common tumorlike, exuberant tissue response to localized irritation or trauma.[1, 2] The term pyogenic granuloma, though commonly used, is in fact a misnomer, in that the condition does not give rise to pus and does not resemble a granuloma histologically. It is a reactive inflammatory process filled with proliferating vascular channels, immature fibroblastic connective tissue, and scattered inflammatory cells. The surface usually is ulcerated, and the lesion exhibits a lobular architecture. (See the image below.)
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Typical appearance of pyogenic granuloma involving buccal gingiva of teeth 20 and 21. Note extreme vascularity.
Two other lesions, peripheral ossifying fibroma and peripheral giant cell granuloma, are clinically identical to pyogenic granuloma when they occur on the gingiva. If 100 biopsy specimens from gingival lesions appearing to be pyogenic granuloma are submitted for histologic examination, approximately 75% will be pyogenic granulomas, 20% will be peripheral ossifying fibromas, and 5% will be peripheral giant cell granulomas. Pyogenic granulomas can occur anywhere in the oral cavity, whereas peripheral ossifying fibromas and peripheral giant cell granulomas occur only on the gingiva or the alveolar mucosa. The clinical appearance, treatment, and prognosis are the same for all three entities.
Oral pyogenic granulomas most frequently develop on the buccal gingiva in the interproximal tissue between teeth. Three quarters of all such lesions occur on the gingiva, with the lips, tongue (especially the dorsal surface), and buccal mucosa also affected. The pathogenesis is not well defined.[3, 2, 4]
A history of trauma is common in extragingival sites, whereas most lesions of the gingiva arise in response to response to irritation.[5] Individuals with poor oral hygiene and chronic exposure to oral irritants (eg, overhanging restorations, calculus) are most commonly affected. Pregnancy exacerbates the tendency to develop a pyogenic granuloma.
Cases of pyogenic granuloma developing around a dental implant have been reported; such cases are likely to become more common as the number of implants and the incidence of associated peri-implantitis continues to increase.[6, 7] Oral pyogenic granuloma associated with a fixed quad helix orthodontic appliance has been reported.[8]
Lesions have a similar frequency throughout the world.
Pyogenic granulomas occur at any age, but they most frequently affect young adults. Incidence peaks in the second and fifth decades have been cited.[2]
Females are more susceptible than males because of the hormonal changes that occur in women during puberty, pregnancy, and menopause.[3, 9] Pyogenic granuloma has been called a "pregnancy tumor" and does occur in 1% of pregnant women. It is advisable, when possible, to wait until after delivery to remove the lesion in pregnant women because of the greater tendency for recurrence during pregnancy. In a number of cases, mastication on the lesion causes bleeding and pain and necessitates surgical intervention before parturition.[10] Some pyogenic granulomas regress after childbirth without surgical intervention.
The prognosis is excellent. After surgical removal, the lesion usually does not recur unless it was inadequately removed. Lesions removed during pregnancy may have a higher recurrence rate. For lesions of the gingiva, removal of potential irritants (eg, plaque and calculus) is indicated to prevent recurrence. For lesions associated with pregnancy, surgical intervention before parturition may be required to manage bleeding and pain caused by mastication on the lesion.[10]
Oral pyogenic granuloma is a benign reactive/inflammatory process that can be avoided (even in pregnancy) by using good oral hygiene and not allowing plaque and calculus to build up on the teeth, and patients should be instructed accordingly.
Early lesions bleed easily as a consequence of their extreme vascularity. Pyogenic granulomas can have a rapid growth pattern that may cause alarm. If left alone, a number of pyogenic granulomas undergo fibrous maturation and resemble or become fibromas.
The typical lesion involves the interproximal gingiva and increases in size to cover a portion of the adjacent teeth. The maxillary gingiva (especially in the anterior region) is involved more frequently than the mandibular gingiva; the facial gingiva is involved more than the lingual gingiva. A number of lesions affect both the facial and lingual gingivae.
Pyogenic granulomas usually present as smooth or lobulated red-to-purple masses that may be either pedunculated or sessile. As lesions mature, the vascularity decreases and the clinical appearance is more collagenous and pink. Pyogenic granulomas vary in size from a few millimeters to several centimeters and are painless. These tumors are soft to palpation. (See the images below.)
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Pyogenic granuloma of anterior maxilla showing small amount of involvement on buccal gingiva of teeth 8 and 9 with most of lesion on lingua. Note that....
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Pyogenic granuloma of dorsal tongue in 52-year-old Black woman. Area of geographic tongue is adjacent to pyogenic granuloma.
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Pyogenic granuloma associated with teeth 20 and 21 in 27-year-old White woman who is 8 months pregnant. Lesion was excised without curettage of area t....
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Same patient as in preceding image (27-year-old White woman, 8 months pregnant), with lesion that recurred almost immediately. Picture was taken 1 mon....
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Rapidly growing pyogenic granuloma in area of teeth 20 and 21 in 13-year-old Black girl. Notice calculus and plaque on tooth 22. Lesion was soft to pa....
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Pyogenic granuloma on facial gingiva of teeth 7 and 8. This is long-standing lesion that is becoming fibrosed and less vascular. Note pink coloration ....
In the case of lesion that has the appearance of pyogenic granuloma and involves the teeth, a periapical radiograph of the associated teeth should be obtained. If the lesion is a pyogenic granuloma, radiography findings will be negative. If calcifications are present, then the lesion probably is a peripheral ossifying fibroma, which is clinically identical to a pyogenic granuloma and requires the same treatment (removal with scaling of the adjacent teeth).
Histologic examination reveals sectioned soft tissue consisting of a lesion composed of ulcerated mucosa covering a core of cellular fibrous connective tissue admixed with proliferating vascular channels and a mixed inflammatory infiltrate. This lesion is a reactive/inflammatory process.
Although surgical excision is the preferred treatment, other therapies have been suggested as potential options, including cryotherapy, sclerotherapy, and corticosteroids.[2, 11] Some authors have suggested that laser therapy may be an effective and less invasive method of managing oral pyogenic granuloma and other benign oral soft-tissue lesions.[12, 13]
The treatment of choice for oral pyogenic granuloma is conservative surgical excision. In the case of a gingival lesion, excising the lesion down to the periosteum and scaling adjacent teeth to remove any calculus and plaque that may be a source of continuing irritation is recommended.
Pyogenic granuloma occasionally recurs, rendering reexcision necessary. The recurrence rate is higher for pyogenic granulomas removed during pregnancy.
John A Svirsky, DDS, MEd, Director of Oral Pathology Diagnostic Service, Professor of Oral and Maxillofacial Pathology, Virginia Commonwealth University School of Dentistry
Disclosure: Nothing to disclose.
Specialty Editors
Michael J Wells, MD, FAAD, Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology
Disclosure: Nothing to disclose.
Chief Editor
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates
Disclosure: Nothing to disclose.
References
Pyogenic granuloma. Neville BW, Damm DD, Allen CM, Chi AC, eds. Oral and Maxillofacial Pathology. 5th ed. St Louis, MO: Elsevier; 2024.
Typical appearance of pyogenic granuloma involving buccal gingiva of teeth 20 and 21. Note extreme vascularity.
Pyogenic granuloma of anterior maxilla showing small amount of involvement on buccal gingiva of teeth 8 and 9 with most of lesion on lingua. Note that indentations from lower teeth are on surface of tumor.
Pyogenic granuloma of dorsal tongue in 52-year-old Black woman. Area of geographic tongue is adjacent to pyogenic granuloma.
Pyogenic granuloma associated with teeth 20 and 21 in 27-year-old White woman who is 8 months pregnant. Lesion was excised without curettage of area to remove irritants.
Same patient as in preceding image (27-year-old White woman, 8 months pregnant), with lesion that recurred almost immediately. Picture was taken 1 month after birth of her child.
Rapidly growing pyogenic granuloma in area of teeth 20 and 21 in 13-year-old Black girl. Notice calculus and plaque on tooth 22. Lesion was soft to palpation.
Pyogenic granuloma on facial gingiva of teeth 7 and 8. This is long-standing lesion that is becoming fibrosed and less vascular. Note pink coloration at base of lesion.
Typical appearance of pyogenic granuloma involving buccal gingiva of teeth 20 and 21. Note extreme vascularity.
Pyogenic granuloma of anterior maxilla showing small amount of involvement on buccal gingiva of teeth 8 and 9 with most of lesion on lingua. Note that indentations from lower teeth are on surface of tumor.
Pyogenic granuloma of dorsal tongue in 52-year-old Black woman. Area of geographic tongue is adjacent to pyogenic granuloma.
Pyogenic granuloma associated with teeth 20 and 21 in 27-year-old White woman who is 8 months pregnant. Lesion was excised without curettage of area to remove irritants.
Same patient as in preceding image (27-year-old White woman, 8 months pregnant), with lesion that recurred almost immediately. Picture was taken 1 month after birth of her child.
Rapidly growing pyogenic granuloma in area of teeth 20 and 21 in 13-year-old Black girl. Notice calculus and plaque on tooth 22. Lesion was soft to palpation.
Pyogenic granuloma on facial gingiva of teeth 7 and 8. This is long-standing lesion that is becoming fibrosed and less vascular. Note pink coloration at base of lesion.
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