Periodontological disease of pregnancy: pregnant tumor

Objective

Our aim was to discuss the treatment and management of pregnant tumor.

Case(s)

The pregnant tumor is a periodontological disease similar the benign hyperplastic tumor of gingiva. It is seen in approximately 5 of the pregnants.A 26year old G1P0 patient was admitted to the Mount and Tooth Health Clinic with the complaints of swelling and bleeding in gingiva in the 18th pregnancy week.In oral examination, in the adherent gingiva in the region between right lower 1st and 2nd molar teeth was observed an exsophitic lesion in the diameter of about 4 cm. lesion was removed by the excisional biopsy and the diagnosis of the pyogenic granuloma was established.

Conclusion

There is no difference in histopathological features between pregnant tumor and pyogenic granuloma. Elevated hormone levels is one of the most important cause in the etiology. Treatment is generally expectant. Rarely, the surgery is neccessary.

Keywords

Pregnancy, pregnancy tumor, piyogenic granuloma

Introduction

The pregnant tumor which is a periodontological disease, is a lesion resembling the benign hyperplastic tumor of gingiva (1). Apart from the fact that it occured with the effects of hormonal changes during the pregnancy, in fact its difference in the hystopathological level with pyogenic granuloma observed in males, and the females who are not pregnant,was not demonstrated (2,3). The greatest difference from pyogenic granuloma is to occur in response to the hormonal changes in pregnancy and to slow down itself within the several weeks after the hormonal changes eliminated together with the end of the pregnancy (4,5). It is seen in approximately 5% of the pregnants and frequently after the first trimester (6). In its etiology, it has been demonstrated that elevated progesteron levels, local irritants and the bacteria have been effective (7). Treatment is generally expectant. Rarely, the surgery is neccessary (6). As the reccurency risk after the surgery performed during the pregnancy is already high, it is not the preferable treatment (8,9). Under the light of literature, we evaluated a case which we followed up with the pregnancy tumor diagnosis and which we applied the excisional surgery as the bleeding complication developed.

Case(s)

A 26-year old G1P0 patient was admitted to the Mount and Tooth Health Clinic with the complaints of swelling and bleeding in gingiva in the 18th pregnancy week. In oral examination, exsophitic lesion in the diameter of about 4 cm lying from interdental papilla to vestibular sulcus in the adherent gingiva in the region between right lower 1st and 2nd molar teeth was observed (figure 1). Oral hygiene training was provided for the patient whose oral hygiene was not in a good condition. Tartars occuring the irritation around the lession were cleaned. Despite this process, lesion kept up with growing in the following two weeks. Spontaneous bleedings were realized to present in the patient expressing that speech and chewing functions were impaired. For this, by applying the oral surgical process to the patient within the 21st pregnancy week, lesion was removed by the excisional biopsy. After the pathological assessment, the diagnosis of the pyogenic granuloma was established. The reccurancy was not detected in the patient observed by the periodical intervals during the pregnancy.

Discussion

Even if they are the same lesions as pyogenic granulomas in the hystopathological level, the etiology should be established as the definition of pregnancy tumor in the pregnant patients because they have displayed the specific differences as the biological behaviour character and the treatment regimen (5). This condition is hyperplastic gingivitis and gingival hyperplasy occuring in pregnancy. For this reason, it is also known as the pregnancy gingivitis. It is benign. Its greatest difference from pyogenic granuloma is to be seen in pregnancy and to slow down spontaneusly for a short time as a result of eliminating the hormonal changes after the delivery (4,5). Even if it may be seen at any age,it is seen in generally young females at the age of reproduction and especially in the ones having bad hygiene. It is observed in approximately 5% of the pregnants and frequently after the first trimester (6). In its etiology, it was demonstrated that elevated progesteron levels, local irritants and bacteria were effective (7). In our case, the patient is 26 years old and is in the 18th pregnancy week. As seen in figure 1, the patient’s oral hygiene is not in a good condition. It was reported as the pyogenic granuloma as a consequence of pathology examination.
Pyogenic granuloma is a tumor-like reactive inflammatory tissue reaction which occurs depending on the localised trauma and irritation. It is mostly seen in the individuals having bad oral hygiene. Because of the hormonal changes, this disease is seen in females more than the males. In fact, the name of pyogenic granuloma is wrong. Because lesion does not include granuloma and pus. Its surface is generally ulcerative. When peripherical ossified fibrom and peripherical giant cell granuloma occur on gingiva, two lessions are the same clinically as pyogenic granuloma.
While pyogenic granuloma may occur in any place of the oral cavity, peripherical ossified fibrom or peripherical giant cell granuloma only occurs on gingiva or alveolar mucosa in oral cavity. Pyogenic granuloma commonly develops on buccal gingiva in interproximal tissue among the teeth. But the diagnosis, clinical picture and the treatment of these three clinical conditions are the same. While the treatment regimen is scheduled, pregnancy must be in the foreground. In treatment, an expectant attitude is generally followed. But the fact that the lession bleeds and impairs the chewing functions and does not slow down after the pregnancy causes the indications for the surgical approach (6). As the surgery performed during the pregnancy has a higher reccurency risk, the surgery during the pregnancy is not preferrable treatment aproach (8,9). But in the conditions which may complicate with the serious bleedings,the treatment method is really difficult in pregnancy. The treatment method in the patient group which the bleeding complication developed is identified by the intensity of the clinical picture. While mouth hygen,locally compression and the drugs stopping the local bleeding may be sufficient in the mild bleedings, the blood transfussion may even be neccessary in the severe bleedings. If the surgery is definitive, the treatment should be stopped within the second trimester of the pregnancy if possible and the patient should be observed in regular intervals (4). In reccurency or in the group which the surgery can not performed and in the condition which the disease progressed increasingly, the pregnancy is ended that the lung maturation is provided (10). In our case, the impairments of the patient’s speech and chewing functions based on the mass were seen with the progression of the pregnancy week. Subsequently,as the bleedings started, the mass was completely removed by the surgical excision in the 21st pregnancy week. Oral hygiene training was provided for the patient during the pregnancy. And perhaps depending on this, the reccurency was not observed in a long run after the ending and ongoing pregnancy.
In general, prognosis is good. Although it is benign, it is customary for the mass to be removed for both diagnosis and treatment if the long period does not pass following the ending of the pregnancy. Although there is a possibility of reccurency in those which were removed during the pregnancy, there is no generally possibility of reccurency after ending the pregnancy if it is completely removed. And also, oral hygiene should be provided in order to reset the recurrency rate after such treatments. For this, the patient training is definitely essential by the physician. Soft tooth brushes and palatine massage must be definitely recommended.

Conclusion

Consequently, the fact that pregnancy tumor,one of the diseases of the pregnancy period, having serious complications is known by the gynecologists is invaluable for the attention which should be given by assessing accurately the symptoms related to the mouth health of the patients. The importance of the oral hygiene and the usage of the soft tooth brushes must be taught all pregnants by the jynecologist physicians so that the development of the disease could be prevented rather than provided the treatment and the diagnosis of the disease.

References

1) Regezi JA, Sciubba JJ, Jordan RCK.Oral pathology: clinical pathologic considerations.4th ed. WB Saunders, Philadelphia 2003: 115–6.
2) Ojanotko-Harri AO, Harri MP, Hurttia HM, Sewon LA.Altered tissue metabolism of progesterone in pregnancy gingivitis and granuloma.J Clin Periodontol 1991: 18; 262-66.
3) Daley TD, Narley NO, Wysocki GP.Pregnancy tumor: an analysis.Oral Surg Oral Med Oral Pathol 1991: 72; 196–9. . 4) Greenberg MS, Glick M.Burket’s oral medicine: diagnosis and treatment.10th ed, BC Denker, Hamilton 2003: 141–2. . 5) Sonis ST, Fazio RC, Fang LST.Principles and practice of oral medicine. .2nd ed. WB Saunders, Philadepia 1995: 416. 6) Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. .Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). .J Reprod Med 1996: 41; 467–70.  
7) Neville BW, Damm DD, Alen CM, Bouquot JE. .Oral and maxillofacial pathology.2nd ed, WB Saunders, Philladelphia 2002: 437–95.
8) Boyarova TV, Dryankova MM, Bobeva AI, Gebadiev GI.Pregnancy and gingival hyperplasia..Folia Med 2001 43; 53–6. 9) Taira JW, Hill TL, Everett MA..Lobular capillary hemangioma (pyogenic granuloma) with saellitosis..J Am Acad Dermatol 1992: 27; 297–300.
10) Wang PH, Chao HT, Lee WL, Yuan CC, Ng HT. .Severe bleeding from a pregnancy tumor. A case report..J Reprod Med 1997: 42; 359–62..

	File/Dsecription
	Figure 1: A typical pregnancy tumor in view exsophitic lesion in the diameter of about 4 cm lying from interdental papilla to vestibular sulcus in the region between right lower 1st and 2nd molar teeth.