the gingiva is often the site of localized growths that are considered to be reactive rather than neoplastic in nature . many of these lesions are difficult to be identified clinically and can be identified as specific entity only on the basis of typical and consistent histomorphology . pyogenic granuloma ( pg ) or granuloma pyogenicum is a well - known oral lesion . the name pyogenic granuloma ( pg ) is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically . the majority remains small and lesions more than 1 cm in diameter are rare on the cheeks , tongue , and floor of the mouth possibly because masticatory trauma restricts their size through necrosis and ulceration . pg is a benign lesion ; therefore , surgical excision is the treatment of choice . to avoid the possibility of recurrence the lesion must be excised down to the underlying periosteum and predisposing irritant must be removed . a 30-year - old systemically healthy male patient presented with a chief complaint of growth in the mouth involving lower - left back teeth region of the jaw . the patient had noticed a small painless growth about few years back . there was a very gradual increase in size , which led to discomfort while eating as the extent of growth had reached the occlusal plane [ figure 1 ] since 3 months . there was no history of intake of any hormonal supplements , but the patient was given antibiotics by some dentist for the same . intraoral examination revealed a solitary diffused growth , pale bluish red in color , measuring around 21.5 cm seen in the interdental region in relation to the left first molar and second molar region that did not extend lingually [ figure 1 ] . the superior surface of lesion showed indentation of the upper teeth as a result of surface ulceration . there was no mobility or pathological migration of any of the molars was not present . abscess drainage with help of a periodontal probe the intraoral periapical radiograph of teeth 46 and 47 region revealed widening of the periodontal ligament space , marked interdental bone loss with change in the trabecular pattern of bone . roots of the involved teeth did not show any signs of resorption [ figure 3 ] . intraoral periapical radiograph showing interdental bone loss and change in the trabecular pattern in between first and second molars blood examination revealed normal values . the treatment comprised of oral prophylaxis and surgical excision of the growth by gingivectomy procedure under local anesthesia . although many treatment techniques have been described for pg , when it is large or occurs in a surgically difficult surgically area , choosing an appropriate treatment modality can be difficult . excisional biopsy is indicated for the treatment of pg . except when the procedure would produce marked deformity : in such a case , incisional biopsy is mandatory . conservative surgical excision and removal of causative irritants ( plaque , calculus , foreign materials , and source of trauma ) are the usual treatments for gingival lesions . here , local anesthesia 1 : 80,000 given to the patient and abscess was drained with the help of the periodontal probe . in this case , pg was associated with periodontal abscess and bone loss , so interval bevel gingivectomy was performed . periosteum reflected and exposed the underlying bone [ figure 4 ] . exposing the underlying bone after excision of growth after complete degranulation and scaling , root planning angular defect was filled with g - bone bone alloplast ( defect filled with g - bone bone alloplast ten days later , periodontal pack and suture were removed and satisfactory healing of the gingiva was seen . complete healing of the operated area was observed at 3 month follow - up visit [ figure 6 ] . complete healing after 3 months of operation radiograph also shows sign of bone fill after 3 months histopathological findings in the photomicrograph shows hematoxilin  eosin - stained section showing the overlying epithelium had hyperplastic parakeratinized stratified squamous epithelium exhibiting areas of pseudoepitheliomatous hyperplasia [ figure 8 ] . highly vascular connective tissue exhibiting numerous small and large endothelium - lined channels engorged with red blood cells . thickened wall of blood vessels , proliferating endothelial cells and few lymphatic vessels were evident . mixed inflammatory cell infiltrate consisting predominantly of neutrophils and lymphocytes were also seen [ figure 9 ] . photomicrograph shows hyperplastic parakeratinized stratified squamous epithelium exhibiting areas of pseudoepitheliomatous hyperplasia photomicrograph showing endothelium lined channels , mixed inflammatory cell infiltrate consisting predominantly of neutrophils and lymphocytes although many treatment techniques have been described for pg , when it is large or occurs in a surgically difficult surgically area , choosing an appropriate treatment modality can be difficult . excisional biopsy is indicated for the treatment of pg . except when the procedure would produce marked deformity : in such a case , incisional biopsy is mandatory . conservative surgical excision and removal of causative irritants ( plaque , calculus , foreign materials , and source of trauma ) are the usual treatments for gingival lesions . here , local anesthesia 1 : 80,000 given to the patient and abscess was drained with the help of the periodontal probe . in this case , pg was associated with periodontal abscess and bone loss , so interval bevel gingivectomy was performed . periosteum reflected and exposed the underlying bone [ figure 4 ] . exposing the underlying bone after excision of growth after complete degranulation and scaling , root planning angular defect was filled with g - bone bone alloplast defect filled with g - bone bone alloplast ten days later , periodontal pack and suture were removed and satisfactory healing of the gingiva was seen . complete healing of the operated area was observed at 3 month follow - up visit [ figure 6 ] . complete healing after 3 months of operation radiograph also shows sign of bone fill after 3 months histopathological findings in the photomicrograph shows hematoxilin  eosin - stained section showing the overlying epithelium had hyperplastic parakeratinized stratified squamous epithelium exhibiting areas of pseudoepitheliomatous hyperplasia [ figure 8 ] . highly vascular connective tissue exhibiting numerous small and large endothelium - lined channels engorged with red blood cells . thickened wall of blood vessels , proliferating endothelial cells and few lymphatic vessels were evident . mixed inflammatory cell infiltrate consisting predominantly of neutrophils and lymphocytes were also seen [ figure 9 ] . photomicrograph shows hyperplastic parakeratinized stratified squamous epithelium exhibiting areas of pseudoepitheliomatous hyperplasia photomicrograph showing endothelium lined channels , mixed inflammatory cell infiltrate consisting predominantly of neutrophils and lymphocytes the incidence of pg has been describe between 28.8% to 32% of all reactive lesions . as reported by buchner et al . in study of 302 consecutive localized gingival outgrowths it was found pg occurred in all ages but mainly in youngsters . more in the third decade pg was thought to be a mitotic infection contracted from horses . it was claimed by inagi k ( 1991 ) without any scientific evidence that pg results from purulent change within benign oral tumors . recently , angiogenesis - associated factors tie2 , angiopoietin-1 , angiopoietin-2 , ephrin b2 , and eph b4 have been detected in pg in immunohistochemistry . it is now generally accepted that the lesion is exaggerated localized connective tissue reaction to minor trauma or irritation . other oral sites are the lower lip , tongue , buccal mucosa , upper lip , and palate . gingival pg is more common in the maxilla than in the mandible and in the anterior region than in the posterior regions of both jaws . gingival irritation as a result of calculus , overhanging edges or rough restorations might be the predisposing factor for the development of gingival pg . it is possible that microulceration from these irritants in an already inflamed gingiva allows the ingress into the gingival connective tissue of low virulent oral microflora . this evokes an exaggerated vascular hyperplastic response in the connective tissue resulting in the formation of pg . pg is a common reactive lesion that generally develops rapidly , bleeds easily , and ulcerates causing the erroneous clinical impression of the malignant tumor . it is however a well - circumscribed benign soft tissue tumor of innammatory rather than the neoplastic nature arising from the connective tissue of the skin or mucous membrane . clinically , pg is a smooth or lobulated exophytic lesion manifesting as small , red erythematous papules on a pedunculated or sometimes sessile base , which is usually hemorrhagic and compressible . rarely pg exceeds 2.5 cm in size and it usually reaches its full size within weeks or months , remaining indefinitely thereafter . clinical development of the lesion is slow , asymptomatic , and painless , but it may also grow rapidly . the surface is characteristically ulcerated and friable which may be covered by a yellow , fibrinous membrane and its color ranges from pink to red to purple , depending on the age of the lesion . young pgs are highly vascular in appearance because they are composed predominantly of hyperplastic granulation tissue in which capillaries are prominent . thus , minor trauma to the lesion may cause considerable bleeding , due to its pronounced vascularity , whereas older lesions tend to become more collagenized and pink . differential diagnosis of pg includes parulis , peripheral giant cell granuloma , peripheral ossifying fibroma , hemangioma , peripheral fibroma , leiomyoma , hemangioendothelioma , hemangiopericytoma , bacillary angiomatosis , kaposis sarcoma , metastatic tumor , pregnancy tumor and post extraction granuloma . numerous small and larger endothelium- lined channels are formed that are engorged with red blood cells . these vessels sometimes are organized in lobular aggregates and some pathologists require this lobular arrangement for the diagnosis ( lobular capillary hemangioma ) . a mixed inflammatory cell infiltrate of neutrophils , plasma cells , and lymphocytes is evident . neutrophils are more prevalent near the ulcerated surface ; chronic inflammatory cells are found deeper in the specimen . pg is a benign lesion ; therefore , surgical excision is the treatment of choice . other conventional surgical modalities for the treatment of pg reported is cryosurgery in form of either liquid nitrogen spray or a cryoprobe , which has been used for eradication of the lesion . it is a safe , easy , and inexpensive technique suited for out patient 's clinic setting . nd : yag and co2 , and flash lamp pulsed dye lasers have also been used for the pg . lasers have shown to be a successful option for the excision of pg with advantages of minimal pain and invasiveness and the lack of need for suturing or packing .
a diverse group of the pathologic process can produce the enlargement of soft tissues in the oral cavity and often present a diagnostic challenge . 
 this soft tissue enlargement may represent a variation of the normal anatomic structure , inflammatory reaction , cyst , neoplasm , and developmental anomalies . 
 a group of reactive hyperplasias , which develop in response to chronic recurring tissue injury that stimulates an excessive tissue repair response . 
 the pyogenic granuloma ( pg ) is a reactive enlargement that is an inflammatory response to local irritation such as calculus , a fractured tooth , rough dental restoration , and foreign materials or hormonal ( pregnancy tumor ) and rarely associated with bone loss . 
 this paper presents a rare case of pg associated with periodontal abscess and bone loss in a 30-year - old male .