Abdulkareem Hussain Alwan¹, Faraedon M. Zardawi², Sarhang  S. Gul² and Afnan Abdulkareem Hussain³  

¹Department, Dentistry department,  Al-Rafidain  university College, Baghdad, Iraq.

²Department, College of Dentistry, Sulaimani University, Iraq.

³First specialized dental center in Baquba, Diyala health directorate, Ministry of Health, Iraq.

Correspondent Author E-mail: dr_alsady @yahoo.co.uk

DOI : https://dx.doi.org/10.13005/bpj/1352

Abstract

Pyogenic granuloma is an inflammatory hyperplastic lesion seen in the oral cavity. It is commonly appear in the gingiva. The objectives of the research were to determine the percent of gingival  pyogenic granuloma  in the  population  of Sulaimani city -Iraq   in relation to gender, age,  pregnancy ,systemic diseases ,oral hygiene and site of occurrence of pyogenic granuloma. Materials and Methods:  In this study the total stratified sample [1136 (568 male +568 female] and the randomly selected sample [248 (124 male and 124 female their age range (from 10 to 70 year) .They were examined orally for inspection of gingival pyogenic granuloma and determination of oral hygiene. The percent of the total sample with gingival pyogenic granuloma was (11.3%). The most of patients with gingival pyogenic granuloma was in females in their Second decade.  The high percent of gingival pyogenic granuloma was found in buccal gingiva in upper jaw. Highly significant relationship was found between gingival pyogenic granuloma and its’ history. There was significant correlation between gingival pyogenic granuloma and oral hygiene status and systemic condition.

Keywords

Gingival; Granuloma Pyogenicum; Pyogenic Granuloma; Prevalence; Pregnancy Tumor Tumor;

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Copy the following to cite this article: Alwan A. H, Zardawi F. M, Gul S. S, Hussain A. A. Prevalence and Distribution of Gingival Pyogenic Granuloma in Sulaimani population - Kurdistan Region - Iraq. Biomed Pharmacol J 2018;11(1).

Copy the following to cite this URL: Alwan A. H, Zardawi F. M, Gul S. S, Hussain A. A. Prevalence and Distribution of Gingival Pyogenic Granuloma in Sulaimani population - Kurdistan Region - Iraq. Biomed Pharmacol J 2018;11(1). Available from: http://biomedpharmajournal.org/?p=19568

Introduction

Pyogenic granuloma (“Granuloma gravidarum”, “pregnancy tumor”) is nonmalignant lesion that affect skin and mucosa ,which may occur inside or outside the oral cavity.¹  The accurate  etiology and pathogenesis of pyogenic granuloma (PG) is still not obvious although, many researchers mentioned that pyogenic granuloma occurred due to  an intensive reaction of localized connective tissue to a little irritating factor.² Many etiological factors for pyogenic granuloma have been reported for instance, primary teeth exfoliation, eruption  of  adult teeth ,traumatic factors, hormonal change, gingival  inflammation, chronic irritant factor, medications, vascular lesions, defective restoration, food accumulation or strange object and calculus in the gingiva and poor oral hygiene status.^3,4,5

Sometime pyogenic granuloma (PG) inside the oral cavity is associated with pregnancy.⁵ gingival pyogenic granuloma (GPG) occurs up to 5 percent  of pregnancies,⁶ however, bacterial plaque and infection of gingiva are essential for hormonal alteration which result in gingivitis.⁷

Oral pyogenic granulomas shows tendency for the gingiva, 75 percent of the cases of pyogenic granulomas may occur in the gingiva,⁸ but it may be also located in the oral mucosa, lips, palate and tongue⁵. It is painful” pedunculated”, “sessile”, “resilient”, “exophytic”, “nodule  or papule” with more than one lobe or smooth surface that bleed easily, it has more tendency to females ⁵. Pyogenic granuloma may be found in any age, though it is commonly seen in young females (20-30 years), this may be due to the hormonal alterations in this period⁹. The color of pyogenic granuloma may vary from pink to red or purple.¹⁰      

Diagnosis of pyogenic granuloma (PG)  depend on clinical, Histopathological and  Radiographical  examinations. “peripheral giant cell granuloma”, “hyperplastic gingival  inflammation”, “Kaposi’s  sarcoma” “peripheral odontogenic fibroma”, “peripheral ossifying fibroma”, “angiosarcoma” and “hemangioma” should be consider in differential diagnosis of pyogenic  granuloma.¹¹ Surgical excision which combined with removal of irritant local factors is the treatment of pyogenic granuloma.⁵ Pyogenic granuloma is associated with recurrence rates which ranged (from 0- to 16) percent. ^5,12

This study was performed in order to determine the prevalence of gingival pyogenic granuloma (GPG) in Sulaimani city population -Kurdistan region-Iraq; to find its ’percent in maxilla and mandibula and to detect if there is any correlation between gingival pyogenic granuloma (GPG) and (systemic diseases and oral hygiene status).

Materials and Methods

The total stratified sample of the studied population was comprised of [1136 (568 male +568 female)] and the randomly selected sample include [248 (124 male and 124 Female), aged (from  10 to 70 year). The subjects were recruited from patients attending to college of Dentistry – Sulaimani university. Disposable dental mirrors and” Williams” graduated periodontal probes (Marking at 1, 2,3,5,7,8,9,10 mm) were used for oral inspection of gingival pyogenic granuloma and determination of oral hygiene condition (poor ,fair, good). The pregnant sample was divided according to the trimesters into 3 subgroups: Subgroup 1: includes women at First trimester; Subgroup 2: includes women at Second trimester; Subgroup 3 includes women at Third trimester.

A questionnaire was taken from all sample including their names, ages, sex, marital status, medical history and history of presence and duration of  gingival pyogenic granuloma, pregnancy trimester and number of deliveries. This research was approved by the ethical committee from medical Factuality–Sulaimani University. However, these patients were not included in the study : Edentulous patients and those taking immunosuppressives, anticonvulsants or calcium channel blockers.

The Histopathological  test was done in Oral Pathology branch – College of Dentistry – Medical Factuality –Sulaimani University . SPSS version 19 was used to analyzed data .Associations between gingival pyogenic granuloma (GPG) and different variables was tested by using Chi-square test. Non-significant  P > 0.05, Significant 0.05 ≥ P > 0.01, highly significant P ≤ 0.0.

Results

The percent of females group was (49.2 %), male group was (50.2%); male and female (10-20 years) and (40-50 years) was (17.4%); (21-30 years) and (31-40 years) age groups were (24.3%) and (23.1%) respectively. (51-60 years) and (61-70 years) the percent were (9.7%) and (8.1%) respectively as shown in table (1).

The percent of the total sample with gingival pyogenic granuloma was (11.3%). The percent of patients with history of gingival pyogenic granuloma (GPG) was (2.8%). Most of patients with (GPG) was in female age group (21-30 year). Regarding the oral hygiene status  the percent of poor oral hygiene was (45.3%), fair (49.4%) and good (5.3%)  as shown in table (2).

In terms of systemic condition  the percent of patients with systemic diseases was (22.7%).; hypertension was (7.3%); Type II diabetes mellitus (4.5 %) ; renal stone (1.6 %); cardiac disease ,stomach ulcer, backache, and migraine were (1.2%); Thyrotoxicosis, irritable colon and stone in gallbladder ( 0.8%); Type I diabetes mellitus, hypoglycemia, rheumatism, hypotension, psychological (0.4 %) as shown in table (3). The percent of married patients was (66%). The percentage of patients with  first trimester of  pregnancy was (1.2 %), third trimester was (0.8%) as  shown in table (4). The percent of gingival pyogenic granuloma in buccal gingiva between right upper central and lateral incisors, buccal gingiva between maxillary right lateral incisor and canine, buccal gingiva between right lower canine and lateral incisor were (1.2%). The percent of gingival pyogenic granuloma in buccal gingiva between left central, lateral incisors and canine in mandible, buccal gingiva between mandibular left and right central incisors were (0.8%). The percent of gingival pyogenic granuloma in buccal gingiva between lower left lateral incisor and canine  was (0.6%). The percentage of gingival pyogenic granuloma in buccal gingiva between lower right First and Second molars; buccal  gingiva between upper right and left central incisors; buccal  gingiva between upper left central and lateral incisors; buccal gingiva of upper right lateral incisor; buccal gingiva between upper right First and Second premolars; palatal gingiva between upper left  lateral incisor and canine; buccal gingiva between lower right central, lateral incisor and canine; buccal gingiva between upper left canine and First premolar; palatal gingiva between upper right lateral incisor and canine; palatal gingiva between upper left central and lateral incisors was (0.4%) as shown in table (5).

The percent  of duration of gingival pyogenic granuloma of one month was (1.6%); two month (2.8%); three months (1.6%), four and six and 12 months (1.2%), 24 months (0.8%), eight and 36 months (0.4%) as shown in table (6).

A highly significant correlation was found between gingival pyogenic granuloma (GPG) and history of (GPG). There was significant relationship between gingival pyogenic granuloma and (oral hygiene status; and systemic condition). While there were  no significant correlation between gingival pyogenic granuloma (GPG) and (age groups; Pregnancy complications; type of systemic disease; marital status; pregnancy trimester; number of boys; number of girls) as shown in table (7).

Table 1: frequency and percent of gingival pyogenic granuloma according to age group

Variable		frequency	Percent
Gender	Total males	124	50.2
	Total Females	123	49.2
Male and female in each age group (Years)	10-20	43	17.4
	21-30	60	24.3
	31-40	57	23.1
	41-50	43	17.4
	51-60	24	9.7
	61-70	20	8.1

 

Table 2: frequency and percent of gingival pyogenic granuloma in total sample, pregnancy complication, history of gingival pyogenic granuloma and oral hygiene status

Variable		frequency	Percent
Gingival pyogenic granuloma(GPG)	No GPG	219	88.7
	GPG	28	11.3
Pregnancy complications(PC)	NO PC	228	92.3
	Abortion	15	6.1
	Low term birth	3	1.2
	Preterm birth	1	0.4
History of Gingival pyogenic granuloma(GPG)	No history of(GPG)	240	97.2
	History of (GPG)	7	2.8
Oral hygiene status	Poor	112	45.3
	Fair	122	49.4
	Good	13	5.3

 

Table 3: Frequency and percent of systemic diseases

Variable		frequency	Percent
Systemic condition	No  systemic diseases	190	77.3
	With systemic diseases	57	22.7
Type of systemic diseases	Type I diabetes mellitus	1	0.4
	Type II diabetes mellitus	11	4.5
	Hypoglycemia	1	0.4
	Hypertension	18	7.3
	cardiac disease	3	1.2
	Thyrotoxicosis	2	0.8
	Irritable colon	2	0.8
	Stomach ulcer	3	1.2
	Migraine	3	1.2
	Renal stone	10	1.6
	Stone in gallbladder	2	0.8
	Rheumatism	1	0.4
	Backache	3	1.2

 

Table 4: frequency and percent of material status, pregnancy trimester

Variable	frequency	Percent
Material status Unmarried	84	34.0
Married	163	66.0
non-pregnant	242	98.0
pregnant  first trimester	3	1.2
pregnant third trimester	2	0.8

 

Table 5: Frequency and percent of the sits of distribution of gingival pyogenic granuloma

Variable		frequency	Percent
Sites  of pyogenic granuloma	Buccal gingiva between lower right First and Second molars	1	0.4
	Buccal gingiva between lower left lateral incisor and   canine	4	0.6
	Buccal  gingiva between upper right & left central incisors	1	0.4
	Buccal gingiva between maxillary left lateral  & central incisors	1	0.4
	Buccal gingiva between  left  mandibular central  & lateral incisors & canine	2	0.8
	Buccal  gingiva between   maxillary  right central & lateral incisors	3	1.2
	Buccal gingiva of right  maxillary lateral incisor	1	0.4
	Buccal gingiva  between upper right First and Second premolars	1	0.4
	Palatal  gingiva between upper left  lateral incisor and canine	1	0.4
	Buccal gingiva   between lower right and left central incisors	2	0.8
	Buccal gingiva between upper  right lateral incisor and canine	3	1.2
	Buccal gingiva between  lower right central and lateral incisor s and canine	1	0.4
	Buccal gingiva between upper left canine and First premolar	1	0.4
	Buccal   gingiva between  lower right lateral incisor s and canine	3	1.2
	Palatal   gingiva between upper right lateral incisor s and canine	1	0.4
	Palatal   gingiva between upper left central and lateral incisors	1	0.4

 

Table 6: Duration of gingival pyogenic granuloma

Variable		frequency	Percent
Duration of Gingival pyogenic granuloma	1 month	4	1.6
	2 month	7	2.8
	3Months	4	1.6
	4 months	3	1.2
	6 months	3	1.2
	8 months	1	0.4
	12months	3	1.2
	36 months	1	0.4

 

Table 7: (Chi-square) correlation between Gingival pyogenic granuloma and variables

Gingival pyogenic granuloma(GPG)	Variables	Chi-square
	Age groups	0.47
GPG	Pregnancy complications	0.452
GPG	History of GPG	0.000
GPG	Oral hygiene status	0.006
GPG	Systemic condition	0.037
GPG	Type of systemic disease	0.898
GPG	marital status	0.058
GPG	pregnant trimester	0.722
GPG	Number of boys	0.733
GPG	Number of girls	0.277

 

Discussion

In this study the percent of patients with gingival pyogenic granuloma (GPG) was (11.3%) , while  other studies found it  (35%),¹³  (49.2%)¹⁴ and (57%).¹⁵ These variations between researches may be due to the   differences   in design and performance of the studies.

The result of this study showed that gingival pyogenic granuloma could be develop in all age but , the most of patients with (GPG) were females in  age group (21-30 year), this because   of rising  in  estrogen” and “progesterone”. This  result was  in agreement with,^10,12,16 they found that  although (GPG) may develops in all ages, but they were more commonly appeared in females age group (21-30 year). Hormonal change lead to physiological  alteration  in gingival tissue, which contain  “steroid hormones” receptors, that  could increase the reaction of  tissue to irritating factors and alter the “microbiota” and lead to more  predominance  of pathogenic bacteria. However, other study   demonstrated   that there was no effect of female hormones on oral pyogenic granulomas, because they found that pyogenic granuloma occurred in both males and females without gender preference.

While the result of this study was in disagreement   with¹⁶ who   found that Pyogenic granulomas occur in all age groups, but they  were common in  age group (10-20 year). This study was inconsistent with¹⁵; they mentioned   that pyogenic granuloma was periodomently  found in    second decade of males , this because of the impact of elevation of sex hormones to  the maximum level   with obvious poor oral hygiene in  male in this age. This   lead   to initiate excessive increase in size of gingiva in presence of irritating factor for example, plaque and calculus.

Pyogenic granuloma develops up to 5 percent in pregnancy. The presence of this lesion in pregnancy suggests the possible correlation   between gingival lesions and the hormonal status during this period.¹⁸There were some changes occur in women during pregnancy   such as, food habits and frequency  of meal take, oral hygiene is affected  due to nausea and sleepless.⁹ The raise in prevalence of PG in the third trimester and the tendency to reduction in size after delivery indicate a clear hormonal association in the etiology of pyogenic granuloma.¹⁴

This   study was agreed with the findings of,^13,14 they showed that pyogenic granuloma had maxillary predominance. In addition this study was in agreement with¹⁹ who found that the gingiva was the most common affected site   and the maxilla more affected than mandible .While this   study was   in disagreement with²⁰ who revealed that GPG were slightly more commonly found  on the buccal mandibular gingival region of .

This study demonstrated that frontal regions of maxillary and mandibular gingiva are more frequently affected than posterior areas   and most of GPG were showed on the gingival margin, this result was in agreement with,²¹ they noticed similar findings.

Conclusions                                                                                                                                                       

This study showed that the percentage of the total sample with gingival pyogenic granuloma was (11.3%). Although pyogenic granuloma (GPG) may occurs at any age ,  the most of patients with GPG was in females  age group (21-30 year).  In addition, the high percentage of gingival pyogenic granuloma was  found  in  maxillary buccal  gingiva . Moreover, there was highly significant correlation between gingival pyogenic granuloma (GPG) and history of (GPG) .Furthermore, there was significant correlation between gingival pyogenic granuloma and( oral hygiene status and systemic condition). While there were  no significant correlation between gingival pyogenic granuloma (GPG) and  (age groups, pregnancy complications, type of systemic disease ,marital status ,pregnancy trimester and number of kids).

Acknowledgements

We are thankful to staff of Periodontics Department, College of Dentistry, Sulaimani University for their valuable help and made the success of this study. In addition, a great thanks and warmth appreciation to the patients for their participation in this research.

Conflict of interest

There is no conflict of interest.

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