Electrocautery-Assisted Management of Unilateral Pyogenic Granuloma: A Case Report

Pyogenic granuloma (PG) refers to an acquired benign proliferation most commonly seen within the oral cavity involving lips, palate, and gingiva. The term is misleading since it is a type of lobular capillary haemangioma but not an infection. It frequently recurs but lacks the capacity for malignant alteration. Depending on where the PG is located, one may experience discomfort or irritation. PGs often lead to differential diagnoses by clinicians, which include capillary hemangioma, neurofibroma, melanoma, and hyperplasia. Therefore, one must confirm a PG by diagnosing and analysing it by clinical and histopathological examinations, and treatment options should be formulated according to the evaluation. Sometimes, a biopsy of the lesion can be taken for final diagnosis. Various treatment approaches are available, including conventional scalpel excision, laser, electrocautery, and cryotherapy. Surgical excision is preferable due to the likelihood of malignancy, as it provides the best cosmetic appearance and produces a specimen for pathologic assessment. After confirming all the clinical evaluatory parameters and routine haematological examinations, which proved satisfactory and within normal ranges, this case of a 45-year-old female with soft tissue growth of the gingival origin was managed by electrocautery, and the PG was confirmed by a clinical-histopathological examination.


Introduction
A reactive proliferation of connective tissue from local irritants is known as a pyrogenic granuloma (PG).It is a tumour-like development of the oral cavity, thought to be neoplastic.It is typically found around the anterior teeth or gingival margin.The term PG can be deceptive because the lesion does not contain pus and is not technically a granuloma [1].In 1904, Hartzell coined the term "pyogenic granuloma."The term "hemangiomatous granuloma," which was introduced by Angelopoulos, appropriately describes the inflammatory nature of oral pyogenic granuloma and its histopathologic appearance (hemangioma-like) [2].While PGs can affect anyone at any age, it is most common in children and young adults between the ages of 11 and 40, with over 70% of cases involving females.The vascular effects of female hormones are the source of the preference towards women.As a PG rarely alleviates on its own and frequently bleeds heavily and repeatedly, surgery usually becomes necessary [1,2].
It is assumed that the primary etiologic component is unrelated to infection despite pyogenic organisms being suspected of causing it.Gingiva is reported to be affected mainly by PG.In addition to gingiva, the lips, tongue, buccal mucosa, and palate may be impacted.PGs are typically deep red to reddish-purple gingival masses that are soft, painless, pedunculated, or sessile [3].According to Bhaskar and Jacoway, 1.85% of all oral diseases are caused by PGs [4].Excision is the most common treatment for PGs and has the lowest recurrence rate.Alternative treatment options include curettage, traditional scalpel technique, electrocautery, radiosurgery, cryosurgery, sclerotherapy, and laser treatment, depending on the patient's need and the size of the lesion, where large lesions are managed by surgical excision approaches [5].

Case Presentation
A 45-year-old female patient reported to the Department of Periodontics with a complaint of soft tissue growth associated with the lower right anterior region of the jaw for seven months.Past medical history and dental history were non-significant.A clinical examination revealed soft tissue growth, which was edematous, pedunculated, and unilateral, which was present on the facial and lingual aspect of the lower right lateral incisor and canine, as appreciated in Figure 1.

FIGURE 1: Pre-operative view after oral prophylaxis of the pyogenic granuloma lesion which was soft, pedunculated and edematous in origin
The lesion was insidious in onset and gradually progressive, having a size of 13 mm in width and 11 mm in height, as shown in Figure 2, and was painless, but pain aggravated on mastication and brushing.Oral prophylaxis was carried out before attempting the surgical procedure.

mm, respectively
The patient was advised surgical excision of the lesion.Informed written consent was obtained.After one week of oral prophylaxis, surgical excision intervention was carried out using electrocautery.Under local anaesthesia, the lesion was excised with the electrosurgical unit setting on the cutting electrode, which was set to a power supply of 230V and frequency of 50Hz, 1.25 A, with power output kept at 50W, as seen in Figure 3.

FIGURE 3: Surgical excision of the lesion was carried out with the electrosurgical unit
Hemostasis was achieved, and a periodontal pack was administered at the surgical site, as shown in Figure 4.
The patient was instructed about the postoperative instructions and medication, with recall after seven days for pack removal.

FIGURE 4: Periodontal pack was administered after excision
Patients were reviewed after seven days for pack removal and after three months from the date of surgery.
After seven days of follow-up examination, satisfactory healing of the surgical site and maintaining aesthetics at the concerned area with no pain and discomfort is appreciated in Figure 5.

FIGURE 5: Post-operative view after seven days showing complete satisfactory healing of the lesion
A follow-up examination after three months showed no recurrence of the lesion, no scar formation, and completely satisfactory healing, as appreciated in Figure 6.Under low magnification (4x to 10x), the H&E-stained tissue section showed overlying keratinised stratified squamous epithelium and underlying connective tissue stroma.The connective tissue stroma was highly vascular with dense inflammatory cell infiltrate, whereas, at higher magnification, the connective tissue stroma showed endothelium-lined blood capillaries engorged with RBCs.Dense inflammatory cell infiltration was seen predominantly in plasma lymphocytes, as shown in Figure 8 (low magnification) and Figure 9 (high magnification).By clinicopathologic correlation, features suggestive of PG confirmed the same.

FIGURE 2 :
FIGURE 2: Measurements of the lesion were obtained with a University of North Carolina (UNC)-15 probe of width and height 13 mm and 11

FIGURE 6 :
FIGURE 6: Postoperative view of the lesion after three months showing no recurrence and completely satisfactory healing

FIGURE 7 :
FIGURE 7: Excised specimen of the lesion, which was sent for a histopathological examination

FIGURE 8 :FIGURE 9 :
FIGURE 8: Histopathological examination under low magnification revealed epithelium and highly vascular connective tissue stroma infiltration