Journal of Orthodontics, Vol.

38, 2011, 290–293

CLINICAL Pyogenic granuloma: a rare side

SECTION
complication from an orthodontic
appliance
Priti N. Acharya, Daljit Gill and Tim Lloyd
Eastman Dental Hospital UCLH NHS Trust, London, UK

This case report discusses a rare side effect associated with the use of a fixed quad helix orthodontic appliance. A 14-year-old
healthy girl presented with a painful enlarging mass on her tongue, which was causing distress to both her and her parents.
Investigations confirmed that the mass was a pyogenic granuloma and management involved surgical excision of the mass and
removal of the quad helix appliance. At least once previous case associated with an orthodontic quad helix appliance has been
reported in the literature.1

Key words: Pyogenic granuloma, orthodontics, quad helix, risks

Received 11 April 2011; accepted 22 September 2011

Introduction gingivae being the most common presenting site.2,4 The

A pyogenic granuloma is a ‘particular type of inflamma-
tory hyperplasia’2 which arises as a result of local
irritation or trauma. Although the vast majority of lesions
(62.4%) present in the head and neck region, they can also
be found on the trunk (19.7%), upper extremity (12.9%)
and lower extremity (5%). Also interestingly, 88.2% of
lesions occur on the skin, with the rest involving mucous
membranes of the oral cavity and conjunctivae.3 Despite
the name, a pyogenic granuloma is not a true granuloma,
as it is now thought to be unrelated to infection.4
Clinical presentation
The lesions usually appear as smooth or lobulated,
pedunculated masses with characteristically rough,
ulcerated surfaces. Their colour ranges from pink to
red or purple,4 with a fibrinous surface layer on the
ulcerated areas which may mimic pus.2 Established
lesions become increasing more collagenous and pink in
colour, while younger granulomas are more vascular.4
Their size varies from a few millimetres to several
centimetres in diameter; growth can be rapid and hence
cause distress in patients.4 Clinically, they are typically
painless and often bleed easily.3,4 A history of trauma
and knowledge of predisposed risk factors contribute to
the largely clinical diagnosis of such a lesion.
Three quarters of all oral pyogenic granulomas occur
on the gingivae,5 with the maxillary anterior labial
next most common sites are the lips, dorsal surface of
the tongue and buccal mucosa.2,4,5 Females aged 11–
40 years are particularly at risk of developing such
lesions due to hormonal influences.2,4 A commonly
known form is the ‘pregnancy epulis’4 that can occur
during pregnancy and is predisposed by high levels of
circulating progesterone and oestrogen.
Histopathology
Biopsy and microscopic examination of a pyogenic
granuloma reveals a ‘highly vascular proliferation that
resembles granulation tissue’. A more detailed descrip-
tion is of lobular aggregates of various sized endothelial-
lined channels which are filled with red blood cells —
this is sometimes termed a ‘lobular capillary heman-
gioma’ by pathologists when confirming the diagnosis.
The lesion surface is often ulcerated with a thick
fibrinopurulent membrane and mixed inflammatory cell
infiltrate consisting of neutrophils in the surface layers
and chronic inflammatory cells in the deeper layers.
More mature lesions, which have undergone fibrous
maturation, present as gingival fibromas.4
Differential diagnosis
The differential diagnosis for large pyogenic granulomas
should include a peripheral giant cell granuloma.2 A
peripheral giant cell granuloma also develops as a

Address for correspondence: Priti N. Acharya, Eastman Dental

Hospital UCLH NHS Trust, London, UK.
Email: pritinacharya@hotmail.com
# 2011 British Orthodontic Society DOI 10.1179/14653121141569
 JO December 2011 Clinical Section
benign hyperplastic tissue reaction to irritation or trau-
ma. Lesions can grow to a diameter of 2 cm, have a high
recurrence rate despite surgical excision and can displace
teeth and cause alveolar bone resorption.6
Management
Pyogenic granulomas occurring as a result of preg-
nancy-related hormonal fluctuations are known to
develop in the first trimester and gradually increase in
size until 7 months of pregnancy. Following childbirth
and ‘normalisation’ of hormone levels, lesions can either
resolve without treatment or undergo fibrous matura-
tion to resemble a fibroma. In pregnant individuals,
treatment should be deferred unless significant func-
tional or aesthetic concerns arise.4
Dental management should always include preventive
advice, consisting of a professional course of prophylaxis,
scaling and oral hygiene instruction. Additional use of
an antiseptic mouthwash may aid lesion regression.2
The treatment of choice for non-resolution involves
conservative surgical excision of the lesion.7 Histological
examination should be carried out to rule out other more
serious diagnoses.4
Case history
A 14-year-old female presented with a pyogenic
granuloma on the left dorsum of her tongue, caused
by chronic trauma from a fixed quad helix appliance. A
specialist practitioner in London fitted the quad helix in
May 2009. Soon afterwards, the patient experienced
soreness on the left side of her tongue. Symptoms
persisted and 2–3 weeks later, a lump appeared on her
tongue. The patient subsequently re-visited her ortho-
dontist, who adjusted the quad helix appliance to sit
closer to her palatal soft tissues. This did not result in
any pain relief and the lump on her tongue continued to
grow in size until September 2009. The patient regularly
saw the orthodontist and was told to rub the lesion with
a peach stone. Non-resolution of the lesion resulted in
her being referred to the Oral Surgery Department at the
Eastman Dental Hospital.
Clinical symptoms included soreness of the lesion
upon waking, during and after meals; this was
accompanied by erythema, a ‘film’ coating the lesion,
and occasional minor ulceration. No other masses had
appeared on her tongue. The patient also reported
speech difficulties, difficulty eating and occasionally
waking at night due to glossal discomfort. Her peers and
teachers had commented on her altered speech. Over-
the-counter non-steroidal anti-inflammatory medication
Pyogenic granuloma: rare orthodontic complications 291
Figure 1 Intra-oral photos of the patient’s dentition (a) In
occlusion; (b) upper arch showing quad helix appliance design
had partially helped with pain relief. Medically, she was
fit and well with a known amoxicillin allergy (rash); she
was pre-menstrual. Extra-oral examination confirmed
altered speech characteristic of a ‘blocked nose’ or cold.
The patient presented in her late mixed dentition with
a class I occlusion associated with bilateral cross-bites of
her lateral incisors (Figure 1). Oral hygiene was average.
The pyogenic granuloma measured approximately
1 cm2 and was located on the posterior left side of her
dorsal tongue. Its surface showed the clear indentation
of the left distal helix of the quad helix appliance with
associated ulceration and glossal keratosis/plaque accu-
mulation (Figure 2).
A provisional clinical diagnosis of a pyogenic granu-
loma was made.
Treatment involved surgical resection of the mass
under general anaesthetic followed by histological
confirmation of the clinical diagnosis. This was sup-
ported by oral hygiene instruction and the removal of
the quad helix appliance.
The lesion was causing significant discomfort to the
patient and was of a sufficient size to warrant surgical
excision. Pyogenic granulomas are associated with local
trauma to tissues, which subsequently become contami-
nated by oral flora.2 The patient’s oral hygiene was
average and hence, reinforcement was emphasized. It
could be suggested that the less than optimal oral hygiene
was a direct result, rather than a cause of the lesion.
Following surgical excision, the patient was reviewed
several weeks later. The surgical site was healing well
 292 Acharya et al.
Figure 2 Intra-oral photos of the pyogenic granuloma on the
patient’s tongue (a) full view of the dorsal tongue surface; (b) close
up view of the lesion
and oral hygiene advice was re-issued by the consultant
surgeon. The patient was hence discharged back to her
orthodontist for continuing care and monitoring.
Discussion
A quad helix appliance is an ‘efficient fixed slow
expansion device’ which allows differential anterior and
posterior expansion.8 It was described by Ricketts in
1979.9 It can also be used for passive retention once active
treatment is complete, or as an adjunctive reminder to
patients with oral habits such digit sucking.10
Risks associated with the use of such appliances are
common to most fixed orthodontic appliances and can be
divided into short- and long-term risks. Short-term risks
include altered speech, soft tissue irritation or ulceration
commonly involving the tongue, and discomfort due to
soft tissue irritation and dental movement following
appliance activation. Although quad helix appliances are
relatively easy to clean,10 oral hygiene aids are required to
ensure optimal plaque removal around the molar bands.
A commonly occurring long-term risk is gingivitis around
molar teeth and for individuals with cariogenic dietary
Clinical Section JO December 2011
habits and sub-optimal oral hygiene, caries risk is in-
creased. Other less common long-term risks include root
resorption and catastrophic dental tipping leading to loss
of overbite control.
With regard to the initial management of the lesion,
the physical abrasion of the lesion with the peach stone
would have reduced local bacterial counts by cleaning
the surface of the tongue on and around the lesion,
thus reducing bacteria-mediated inflammatory processes.
However, the mechanical irritation of the lesion by the
peach stone would also have had an adverse effect of
increasing localized trauma and hence been of little
overall benefit.
The management of a pyogenic granuloma should
always involve the elimination of any traumatic
stimulus, where feasible. A previously published case
report has demonstrated the spontaneous resolution of a
developing pyogenic granuloma by removal of the quad
helix appliance. The lesion measured approximately
166 mm and developed over a 6-month period.1 In the
case described above, the lesion was almost twice the
size and had developed over a 4-month period. Previous
adjustment of the appliance by the treating orthodontist
had failed to resolve the lesion; therefore, a decision was
made to excise the lesion, by the Oral Surgery
Department. The decision as to when to remove the
quad helix was left with her treating orthodontist. On
reflection, the appliance probably should have been
concurrently removed by the orthodontic team at the
Eastman Dental Hospital, and an explanation offered to
the referring orthodontist. Unfortunately, the patient
was not seen again by the orthodontic team at the
Eastman; hence, post-surgical photos were not obtained.
Conclusion
Tongue irritation is a common risk factor associated
with the placement of maxillary palatal orthodontic
appliances, including quad helix appliances. The small
but real risk of developing a pyogenic granuloma as a
result of chronic trauma must not be overlooked. This is
especially true given the risk factors associated with the
administration of a general anaesthetic as was required
in the treatment of this case and the risk of causing
distress within patients and their families as to the cause
of such ulcerated swellings.
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JO December 2011 Clinical Section
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