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Case A case report of pregnancy tumor and its

Report
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

Abstract
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.

Key words
Diode, laser, pyogenic granuloma, pregnancy

Introduction base extending from the gingival margin or, in most

Pregnancy tumor is a pyogenic granuloma  (PG) that
occurs on the gingiva during pregnancy.[1] 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.[2]
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.[3] 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.[4]

These lesions have been described as a painless, Pregnancy tumor usually occurs at the end of the
exophytic mass that has either a sessile or pedunculated first trimester and rapid growth usually accompanies
the steady increase of circulating estrogens and
Access this article online progestrones. Partial or complete regression is
Quick Response Code: Website: common after child birth. Repeated mild irritation
www.jdentlasers.org with gestational steroid changes may subsequently
exacerbate inflammatory response, leading to
DOI: development of this proliferating lesion.[3]
10.4103/0976-2868.106666

Various modalities of treatment have been documented

Correspondence:
Dr. Namazi Esmaeil, Department of Periodontology and Implantology, M. A. Rangoonwala College of Dental Sciences and Research
Centre, Pune - 411 001, Maharashtra, India. E-mail: r1u2m3i@yahoo.com

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Namazi, et al.: Pregnancy granuloma and diode laser
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.[4]
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].
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,
Figure 1: Gingival overgrowth between maxillary right central and
lateral incisors
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Journal of Dental Lasers July - December 2012 Issue 2 Vol 6
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
Figure 2: Three weeks after phase I therapy
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Namazi, et al.: Pregnancy granuloma and diode laser
Figure 3: Histologic section of the excised tissue
factor and cytogenic abnormalities have all been
postulated to play a role.[5]
According to Tumini, et al., pregnancy tumor is a result of
gingivitis that leads to local hyperplasia.[6] 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.[1]
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.[7]
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Figure 4: One week post‑operative view
Histologically, it is a reactive inflammatory processes
filled with proliferating vascular channel, immature
fibroblastic connective tissue and scattered
inflammatory.[8] 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.[7]
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.[3] During pregnancy, surgery should be
recommended if bleeding or pain from the lesion
impedes daily activities,[1] or after delivery, if the lesion
has not regressed completely.[9] Other procedures like
cryosurgery,[10] laser therapy, sclerotherapy with sodium
tetra decyl sulfate and monoethanolamineoleate,[11]
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 36th week of pregnancy because of the lower
risk of bleeding compared to other surgical techniques
and found that it was tolerated well.[12] Rai, et al. (2011)
reported the beneficial effect of diode laser in excision
of the PG.[4]
The wavelength of the diode laser is absorbed by the
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Namazi, et al.: Pregnancy granuloma and diode laser
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.[13] 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.[14]
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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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.
Source of Support: Nil, Conflict of Interest: None declared.
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