An unusual presentation of a pyogenic granuloma in a paediatric patient.

Abstract

A 12-year-old boy was urgently referred to our dental hospital Accident and Emergency department by his general practitioner following discovery of an irregular exophytic growth on his hard palate. The patient was unaware of its presence although he described a history of thermal trauma to the roof of his mouth some months previously. No pain or bleeding was reported in the recent past. The patient's medical history was non-contributory, and he was otherwise fit and healthy. Clinical examination demonstrated the presence a regular-shaped, well-circumscribed, exophytic pedunculated growth on the hard palate measuring approximately 1x1cm. The growth was red and white in colour, with a thinly sloughed surface. It was soft and non-tender and demonstrated no discharge. Adjacent tissue appeared healthy, there were no other mucosal lesions, and oral hygiene was fair. No lymphadenopathy was detected, and a maxillary occlusal radiograph confirmed no underlying bony involvement (Fig. 1). The differential diagnosis for such a clinical profile includes oral squamous papilloma, peripheral ossifying fibroma, pyogenic granuloma (PG), reactionary granulomatous tissue, peripheral odontogenic fibroma, capillary haemangioma, Kaposi's sarcoma and non-Hodgkin's lymphoma. Although this patient would be otherwise stratified as low risk, this unusual presentation demonstrated some worrisome signs. In light of these findings, an excisional biopsy was completed under local anaesthetic. Histological analysis confirmed the presence of an ulcerated PG. The unusual anatomic position in this case, in addition to atypical clinical findings including hyperkeratosis and mixed ulceration, compounded the diagnostic challenge (Fig. 1). The term PG was coined by Hartzell in 1904.1 Originally believed to be caused by pus-producing micro-organisms, it is now known that the lesion is not caused by infection but an exaggerated inflammatory tissue response.2 In the oral cavity, PGs tend to occur on the gingiva, with the interdental papilla being the most frequent site in 70% of cases, followed by the lips, tongue and buccal mucosa.3 Low-grade inflammation due to poor oral hygiene and plaque, as well as local traumatic injury and hormonal factors, has been documented as a potential contributory factor leading to the reactionary overgrowth of tissues.4 We advocate that colleagues pay close attention to and document all abnormalities of intraoral tissues. Cases causing any concern should be referred to the local oral and maxillofacial department for further investigation.