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Case report DeNtal tribuNe | april-June, 2010
Epulis gravidarum mimicking a neoplasm
A case report by Dr Deepak Chopra, Dr Mayur Kaushik, Dr Deepak Kochar, and Dr Sidharath Malik, India
Introduction
aled granulation tissue with
Pregnancy is a delicate condi-
non-neoplastic proliferation of
tion, involving complex physi-
endothelial cells, suggestive of
cal and physiological changes. 1
epulis gravidarum.
Modification of metabolism,
immunology, and high level of
Case Description
hormones make it possible for
A 26-year-old female was refer-
fetus to grow & develop, ending
red with the chief complaint of an
up with labor. Variations of these
extensive gingival enlargement
hormones cause some changes
on the lower right anterior tooth
on skin and oral mucosa. 2
region. The lesion was of negligi-
The changes progress due to
ble size when the patient first
increased level of sex hormones
in blood and saliva. These hor-
noticed it three weeks ago, but
had grown rapidly over the past
Fig. 1: Pre-operative view
Fig. 2: Excised lesion
mones are thought to be the
twenty days to attain the present
reasons for occurrence of infla-
size. The patient’s medical
mmatory process and the epulis
history revealed that she was
gravidarum. 3
at five months of gestation with
no systemic disease.
The progesterone & estrogen
receptors are situated in basal
Clinical examination reve-
and spinous stratum of the ep-
aled an isolated exophytic,
ithelium, and in the connective
pedunclated lesion on the man-
tissue. That is why those cells
dibular right buccal side bet-
are influenced by a high level of
ween the interdental gingival of
pregnancy hormones. 4
Proges-
lateral incisor and canine. It
terone dilates blood vessels,
makes them more permeable,
measured approximately 2.5
cm in diameter with some areas
Fig. 3: Sutured with 6-0 silk sutures
Fig. 4: Post-operative view
and increases proliferation of
capillary vessels. Estrogen regulates
the proliferation, differentiation,
and keratinization of
the gingival tissue. These hormones
increase gingival bleed-
of erythema. The lesion was
rough and firm in consistency
on palpation that bled minimally
(Fig. 1). The swelling also interfered
with eating and speech.
On examination, patient’s oral
in that the lesion is not pus
producing as “pyogenic” implies.
It is however, a tumor of granulation
tissue, as granuloma
implies. 1 It has been called an
epulis, because it is located
sarcoma, kaposi’s sarcoma and
non-hodgkins lymphoma. 10
Conclusion
Epulis gravidarum represents
an important differential diag-
7. Ababneh K, Khateeb T. Aggressive
pregnancy tumor mimicking
a malignant neoplasm:
a case report. J Contemp Dent
Pract. 2009 Nov 1; 10(6): E072-8.
8. Angelopoulos AP. Pyogenic
granuloma of the oral cavity:
ing, cause gingival growth, and
lead to deepening of periodontal
pockets as well. 5
Epulis gravidarum is a quite
rare gingival disorder occurring
hygiene was found good.
Excisional biopsy of the
swelling with a wide margin
was performed (Figs. 2 & 3). The
histopathological examination
more frequently in the gingiva.
Some other terms used are
“granuloma telangiectaticum”
and “pregnancy tumor”. The
term “hemangiomatous granuloma”
was suggested by An-
nosis of oral masses and can
behave in a very aggressive
fashion, mimicking a malignant
tumor. Excised specimens
should be sent for histopathological
reports to exclude malig-
Statistical analysis and its clinical
feature. J Oral Surg. 1971;
29, 84-9.
9. Daley TD, Nartey NO, Wysocki
GP. Pregnancy tumor: an analysis.
Oral Surg Oral Med Oral
Pathol. 1991; 72(2): 196-99.
in 1.8 to 5% of pregnant women,
and it affects more commonly
the anterior region of the upper
jaw. 6 It is a smooth or lobulated
exophytic lesion and manifests
as a pink, red, or purple erythematous
papule with pedunculated
or sessile base. 1 It usually
revealed young granulation
tissue with non-neoplastic proliferation
of endothelial cells
and the enlargement of blood
capillaries. Infiltration of acute
and chronic inflammatory cells
in a collagenous matrix was also
present. Surface of the lesion
gelopoulos to accurately reflect
the characteristic histopathologic
picture (hemangioma-like)
and the inflammatory nature
(granuloma) of the lesion. 8
Clinically it presents as a
lesion that is pedunculated or
nancy. It is acceptable practice
to excise aggressive variants
of this lesion during pregnancy
to avoid distressing side effects.
References
1. Jafarzadeh H, Sanatkhani M,
Mohtasham N. Oral pyogenic
granuloma: a review. J Oral
10. Czerninski R et al. Comparison
of clinical and histological diagnosis
in lesions of oral mucosa.
Oral Surg Oral Med Oral Pathol
Oral Radiol Endond. 2007; 103
(4): e20. DT
arises in the 2 nd trimester, grows
gradually over a few months
time, and it also tends to bleed.
After delivery of the child, it may
regress and disappear entirely. 7
The purpose of this article is
to describe a gingival swelling
in a five months pregnant 26-
year-old woman, which grew
very rapidly unlike for this kind
of tumor mimicking a malignant
neoplasm.
The lesion was not painful
and grew very rapidly over a
three week period. The histopathological
examination reve-
showed hyperplastic parakeratinised
stratified squamous epithelium
with areas of atrophy
and ulcer. These findings were
consistent with a histopathological
diagnosis of epulis
gravidarum.
After three weeks of postoperative
followup, clinical
appearance of normal gingiva
was present at the site of the
lesion (Fig. 4).
Discussion
Epulis gravidarum is also known
as “Pyogenic granuloma”. The
term is somewhat a misnomer
broad based, highly vascularized,
smooth, edematous, hemorrhagic,
soft, red with glossy
surface and hardened when it
had been longstanding. It could
be a single or multiple well
localized outgrowth, painless
or with dull pain. It usually
is not bigger than 2 cm in the
diameter. 9
Differential diagnosis includes
peripheral giant cell granuloma,
epulis, peripheral ossifying
fibroma, metastatic cancer,
hemangioma, conventional granulation
tissue, hyperplastic
gingival inflammation, angio-
Sci. 2006; 48: 167-75.
2. Erickson CV, Matus NR. Skin
disorders of pregnancy. Am
Fam Physic. 1994; 3: 602-10.
3. Laine MA. Effect of pregnancy
on periodontal and dental
health. Acta Odontol Scand.
2002; 60: 257-64.
4. Zeeman GG, Veth O, Dennison
D. Focus on primary care on
periodontal disease. Implications
on women’s care. Obst
Gynecol Survey. 2001; 56: 43-9.
5. Henry F, et al. Blood vessel
changes during pregnancy: a
review. Am J Clin Dermatol.
2006; 7: 65-9.
6. Paradowska A, Slawecki K,
Chojak EG. Pregnancy tumor:
review of literature. Dent Med
Probl. 2008; 45(1): 51-4.
About the authors
Dr Deepak Chopra is a reader in
the department of periodontology
at Inderprastha Dental College
at Ghaziabad, India. He can be
contacted at deepakchopra2010
@gmail.com.
Dr Mayur Kaushik is a reader in
the department of periodontology
at Subharati Dental College at
Meerut, India.
Dr Deepak Kochar is an assistant
professor in the department of
periodontology at Inderprastha
Dental College at Ghaziabad,
India.
Dr Sidharath Malik is an assistant
professor in the department of
periodontology at Inderprastha
Dental College at Ghaziabad,
India.