|Year : 2016 | Volume
| Issue : 1 | Page : 30-34
Angiogranuloma in pregnancy: A case series and mini review
PS Divya Gayatri, MG Triveni, Sapnil Gaidhankar, DS Mehta, GV Gayathri
Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||21-Jul-2016|
P S Divya Gayatri
Room No. 5, Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
Women go through several stages in their life as directed by their hormonal responses and the environmental factors. Pregnancy is considered as one of those golden phases of a woman's life cycle in which they seem to be very sensitive to stimulants. Pregnancy tumor is one of the most common oral manifestations in pregnant females wherein a gingival enlargement resembling pyogenic granuloma arises even due to minor stimuli. Here, it is a report of four cases of pregnancy tumor in different sextants of the oral cavity presenting in diverse fashions, which resolved after professional care.
Keywords: Gingival enlargement, pregnancy, pyogenic granuloma
|How to cite this article:|
Divya Gayatri P S, Triveni M G, Gaidhankar S, Mehta D S, Gayathri G V. Angiogranuloma in pregnancy: A case series and mini review. Int J Oral Health Sci 2016;6:30-4
|How to cite this URL:|
Divya Gayatri P S, Triveni M G, Gaidhankar S, Mehta D S, Gayathri G V. Angiogranuloma in pregnancy: A case series and mini review. Int J Oral Health Sci [serial online] 2016 [cited 2019 Dec 9];6:30-4. Available from: http://www.ijohsjournal.org/text.asp?2016/6/1/30/186663
| Introduction|| |
The life cycle of a woman unfolds into different phases as the hormonal response influences it. It can be divided into many stages such as childhood, puberty, reproductive phase, pregnancy, and menopause. The periodontium of a woman is sensitive in all these stages as the hormones produce a conditioned response to the existing gingival status. Pregnancy tumor is a gingival enlargement commonly initiated due to conditioned response of hormones in pregnant women. This angiogranulomatous lesion is believed to be owing to excessive female hormones, i.e., estrogen, which increases cellular proliferation in the blood vessels and progesterone, which increases vascular dilatation and permeability.
The gingival enlargements in pregnancy are called as pregnancy tumors, which fall into a distinctive clinical entity called pyogenic granuloma. The first description of pyogenic granuloma in English literature dates back to 1844 by Hullihen, and the term "pyogenic granuloma" or "granuloma pyogenicum" was given by Hartzell in 1904.  In general, these lesions grow aggressively and spread laterally. They tend to bleed profusely on simple provocation.
| Case Report|| |
A 23-year-old pregnant female reported to the Department of Periodontics as referred by her gynecologist in the 8 th month of gestation period. The chief complaint was swelling over gums in the upper right back tooth region toward cheek side, which was noticed 4 weeks back [Figure 1]a. The patient gave a history of rapid growth within 3 weeks. No difficulty was experienced during speech but masticatory ability was impaired for the past 2 weeks as the overgrowth was impinging on the occlusal surface and blocking the right buccal corner of her oral cavity [Figure 1]b. The patient seems to be worried about the rapid growth and its effects on the developing fetus. Her medical history was nonsignificant.
|Figure 1: Case 1: (a) Preoperative profile view; (b) preoperative occlusal view; (c) intraoral periapical radiograph in relation to 14, 15, and 16; (d) excision of the lesion; (e) excised lesion; (f) immediate postoperative view; (g) histopathologic picture of lesion black arrow- representing dialation of blood vessels, red arrow- red blood cells within the vessel lumen, blue arrow- chronic inflammatory cell infiltrate; (h) 1-month postoperative view|
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On intraoral examination, a solitary erythematous pedunculated gingival overgrowth of 20 mm × 20 mm × 22 mm was observed. It was roughly triangular in shape, which was extended from the mesiobuccal aspect of 14 to distobuccal aspect of 16. The apex of the triangle was directed downward with the base of the peduncle attached interdentally between 15 and 16. On palpation, the overgrowth was found to be fragile on the lateral aspect and firm on the medial aspect with bleeding on slight provocation. Lymph nodes were nonpalpable. No significant bone loss was observed in the radiograph in relation to 14, 15, and 16 [Figure 1]c. A provisional diagnosis of pregnancy tumor was made.
The marginal inflammatory component had subsided after 1 week of phase-I therapy. Then, the patient was prepared for surgical excision of the lesion under proper stress reduction protocol  and strict aseptic environment. During excision, 2 mm of the adjacent healthy gingiva was included to prevent the recurrence [Figure 1]d-f. Paracetamol 500 mg 8 hourly was prescribed for 3 days and postoperative instructions were given. The excised tissue was sent for histopathological examination. It revealed the presence of parakeratinized stratified squamous epithelium which was ulcerated in few areas. Dense fibrous connective tissue was identified beneath the epithelium consisting of numerous budding capillaries with plump of endothelial cells and chronic inflammatory cell infiltrate, predominantly consisting of lymphocytes and plasma cells. Dilated blood vessels and hemorrhagic areas were evident suggesting of pregnancy tumor supporting the clinical findings [Figure 1]g. Complete gingival healing was observed one moth post-operatively [Figure 1]h. Three other patients with variable clinical features were also treated in a similar fashion and the healing was uneventful [Figure 2].
|Figure 2: Case 2: (a) Preoperative view, (b) 1-month postoperative; Case 3: (c) Preoperative view, (d) 1-month postoperative; Case 4: (e) Preoperative view, (f) 1-month postoperative|
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| Discussion|| |
Any overgrowth or increase in the size of the gingiva is called as gingival enlargement.  Conditioned gingival enlargements occur when the systemic condition of the patient exaggerates or distorts the usual gingival response to dental plaque. Bacterial plaque is necessary for the initiation of this type of enlargement. However, plaque is not the sole determinant of the nature of the clinical features.
The conditioned gingival enlargements [Figure 3]  occurring during pregnancy resemble pyogenic granulomatous gingival enlargements and are called as angiogranulomas. It is a localized, painless protuberant, exophytic gingival mass that is attached to a sessile or pedunculated base from the gingival margin or more commonly from an interproximal space.  They are also called as "Pregnancy tumor" or "pregnancy epulis." Their prevalence is 0.2-9.6% of pregnancies. They are clinically and histologically indistinguishable from their counterparts in men and nonpregnant women.
The lesion generally appears about 3 months of gestation period or later and gradually increases in size. Minor trauma, tissue irritation, or reactions are manifested as an enlargement by the intensifying action of endocrine alterations during pregnancy. The first recorded case of "pregnancy gingivitis" was in 1877 by Pinard.  The term "pregnancy tumor" was proposed by Blum in 1912.  The gingival manifestations in pregnancy are basically attributed to two major factors which include underlying plaque and overwhelming host tissue response due to hormonal changes.
Pregnancy gingivitis has been briefly classified into five classes by Ziskin and Ness in 1946. 
- Class I: Characterized by bleeding gingiva with more or less, no other manifestations
- Class II: Characterized by changes in the interdental papillary edema and swelling with subsequent blunting of interdental papilla
- Class III: Characterized by involvement of the free gum margin, which takes on the color and general appearance of a raspberry
- Class IV: Generalized hypertrophic gingivitis of pregnancy
- Class V: The pregnancy tumor.
Kornman and Loesche 1980  observed a significant increase in gingivitis between 13 th and 28 th week of gestation which then decreased gradually. Cross-sectional studies , also described a gradual increase in gingivitis during pregnancy with an apparent resolution following parturition. During the early stages of pregnancy, i.e., 13-16 weeks, the anaerobe/aerobe ratio increased significantly and remained high until the third trimester. Bacteroides melaninogenicus ss. intermedius is the microbe which seems to be associated with elevated levels of estradiol and progesterone. Culture studies proved that estradiol and progesterone can replace menadione, an essential growth factor for B. melaninogenicus ss. intermedius and ss. melaninogenicus but not in Bacteroides asaccharolyticus or Bacteroides (Capnocytophaga) ochraceus (Kornman and Loesche 1980). 
Ovarian hormones are effective in stimulating the mediators of inflammation, particularly prostaglandin E1 and E2. Prostaglandin being an immunosuppressant, gingival inflammation increases when the mediator level is high.  High progesterone levels during pregnancy influenced plasminogen activator inhibitor type 2 (PAI-2) and disturbed the balance of the fibrinolytic system as PAI-2 is an important inhibitor of tissue proteolysis.  Estrogen is believed to be the regulator of cellular proliferation, differentiation, and keratinization, whereas progesterone influences the permeability of the microvasculature, , which alters the rate and pattern of collagen production and increases the metabolic breakdown of folate. 
In women, estrogen is the major causative factor for alterations in the blood vessels such as increasing blood volume, flow rate, hyperemia, and enlarged microvascular surface. Endothelial cells are known to synthesize estrogen, in turn their vessel function is modulated by both estrogen receptor-α and estrogen receptor-β. The mechanisms by which estrogens control blood vessel tone include (i) voltage sensitive calcium channels of uterine arteries after metabolic conversion to catechol estrogens, (ii) increase capillary permeability by stimulating the release of various mediators (e.g., adenosine, bradykinin, vasoactive intestinal polypeptide, etc.), (iii) nitric oxide-induced vasodilation, (iv) reendothelialization, and (v) angiogenesis. On the other hand, several studies have implied that progesterone was primarily responsible for a reduction in corpuscular flow rate, increased vascular permeability and vascular proliferation. ,, Although estrogens are primarily responsible for vascular changes reported in reproductive target tissues like the uterus, literature suggests that increased vascular permeability in the gingiva was essentially the result of progesterone.  Although the presence of receptors for estrogen and progesterone was revealed by Whitaker et al., no such receptors were identified in the histopathologic section of the lesions (initial and reccurred) observed by Oettinger-Barak et al. 
A study states that pregnant woman receiving preventive and professional dental care had better birth outcomes compared with their counterparts.  During the first trimester, treatment should include preventive therapy with personified homecare instructions. If there is periodontal inflammation, it is safe and effective to provide periodontal care. Early phase of the second trimester is the safest period for providing routine dental care. During this period, treatment is emphasized on controlling active diseases if any and eliminating potential problems that could complicate in late pregnancy. In the third trimester, a hazard for premature delivery exists because the uterus is very sensitive to external stimuli. Prolonged chair time should be avoided because women are most uncomfortable at this time, and elective dental care is advised to ensure minimal complications. Surgical excision of the gingival enlargement is indicated in any trimester to improve the ease of maintaining oral hygiene, comfort of the patient along with masticatory efficiency.  Surgical management could be either conventional using scalpel or with advanced modalities such as LASER. , Following the above-mentioned treatment considerations and protocols, treatment was advocated to these four pregnant women. The recurrence rate of these pregnancy tumors is about 16% and believed to be as a result of incomplete excision. 
| Conclusion|| |
Although the gingival enlargements in pregnancy are rapidly growing and fragile in nature, the histopathological picture depicts a benign inflammatory cellular infiltrate. Thus, we can conclude that these angiogranulomatic lesions are seemingly ferocious; however, they are knowingly innocuous. All the four patients were followed up for more than 1 year and no recurrence was observed. Thus, we conclude that angiogranuloma during pregnancy, if conditionally managed, could preserve and restore the oral health during the golden period of pregnancy.
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[Figure 1], [Figure 2], [Figure 3]