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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 3  |  Page : 230-234

Sclerotherapy in pyogenic granuloma and mucocele


Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat, India

Date of Submission09-Jul-2018
Date of Acceptance27-Oct-2018
Date of Web Publication18-Oct-2018

Correspondence Address:
Dr. Ashish F Ranghani
Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_118_18

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   Abstract 


Aim and Objective: To evaluate the effect of intralesional injection of polidocanol for treating pyogenic granuloma and mucocele that commonly in the oral cavity. This study also aimed to analyze the effect of polidocanol in both lesions of various sizes. Materials and Methods: Fifteen clinically diagnosed cases of oral pyogenic granuloma (8 cases) and mucocele (7 Cases) were included in the study. After topical anesthesia application, 0.5–1 ml of polidocanol was injected using an insulin syringe into the lesion till the solution leaked out. Each patient was recalled after 1 week and evaluated; if the lesion did not resolve, second and third injections were given consecutively. Results: All 15 patients showed complete regression of the lesion after 1–3 consecutive injections in a weekly interval. Recurrence of one case of mucocele occurred. Conclusion: Sclerotherapy is simple, minimally invasive, economical, and of minimal discomfort to the patient; there is negligible blood loss, and less surgical expertise is required. Size of the lesion determines the number of weekly injections of sclerotherapy required for complete resolution of the lesion; however, numbers of injections do not depend on age, sex, and site of the lesion.

Keywords: Mucocele, polidocanol, pyogenic granuloma, sclerotherapy


How to cite this article:
Shah JS, Ranghani AF. Sclerotherapy in pyogenic granuloma and mucocele. J Indian Acad Oral Med Radiol 2018;30:230-4

How to cite this URL:
Shah JS, Ranghani AF. Sclerotherapy in pyogenic granuloma and mucocele. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2019 Jan 23];30:230-4. Available from: http://www.jiaomr.in/text.asp?2018/30/3/230/243650




   Introduction Top


Sclerotherapy is defined as the targeted elimination of small vessels, varicose veins, and vascular anomalies by the injection of a sclerosant. When injected into or adjacent to blood vessels, the sclerosing agent causes vascular thrombosis and endothelial damage, leading to endofibrosis and vascular obliteration. The most commonly used sclerosants are polidocanol, sodium tetradecyl sulfate, sodium morrhuate, sodium sylliate, pingyangmycin (PYM), OK-432, ethanolamine oleate, and ethanol. Sclerotherapy is indicated in the treatment of mucocele, ranula, pyogenic granuloma, hemangioma, vascular malformations, and lymphatic malformations.[1],[2],[3],[4],[5]

Pyogenic granuloma can be managed by surgical excision or laser surgery. However, when the lesion is large or develops in a surgically difficult area, it is not easy to choose a suitable treatment modality. Excision can leave an apparent scar, and treatment with a laser, which is inappropriate for a thicker lesion, requires specialized training and a staged procedure. Although these are reactive hyperplasias, they have a relatively high rate of recurrence after simple excision. Therefore, sclerotherapy has evolved as an effective alternative approach.[1],[2]

There are various treatment modalities available for the treatment of mucocele including surgery, laser ablation, cryosurgery, micromarsupialization, laser surgery, and intralesional injection of corticosteroid and sclerosing agent. Although surgery is widely used, it has several disadvantages such as lip disfigurement and damage to adjacent ducts with further development of satellite lesions.[6]

The advantages of sclerotherapy are that it is a simple, safe, effective, and minimally invasive procedure, with minimal discomfort to the patient and minimal complications compared to surgery. There is negligible blood loss and no requirement for any postoperative dressing or specific care.[1],[2]

Polidocanol is a widely used nonionic detergent sclerosant that was first developed as an anesthetic. It acts through endothelial overhydration, vascular injury, and closure. Sclerosing agents cause permanent damage to the endothelial vessels resulting in necrosis. The maximum recommended dose according to the European guidelines is 2 mg/kg (10 ml 1% solution for a 50 kg individual). A toxic level can produce cardiotoxicities such as bradycardia and hypotension.[7]

Sodium tetradecyl sulfate is a synthetic, surface-active substance composed of sodium 1-isobutyl-4-echyloctyl sulfate plus benzoyl alcohol 2% (as an anesthetic agent) that is phosphate buffer and pH of this solution is 7.6. Pingyangmycin (PYM), the single component of bleomycin A5, is an anticancer agent that is refined from Streptomyces pingyangensis. Ethanol injection, which is recognized as the most effective sclerosing agent, can result in severe pain and soft tissue edema, with the treatment usually performed under general anesthesia. OK-432 is a lyophilized mixture of low-virulence group A S. pyogens with penicillin G potassium.[1],[2],[3],[4],[8]

Matsumoto K et al. treated 9 cases of pyogenic granuloma by local injection of the monoethanolamine oleate solution with no recurrence.[9] Khaitan T et al. successfully treated 40 cases of pyogenic granuloma. All 40 patients showed complete regression of the lesion after 1–4 consecutive shots in a weekly interval.[1]

Cai et al. administered PYM in 40 cases of mucocele showing complete resolution with no recurrence. Chen et al. investigated the efficiency of PYM for treatment of ranula. In total, 3 cases of ranula were treated without any recurrence. Cai et al. attempted PYM sclerotherapy in 785 cases ofthe sublingual cyst; 756 patients were cured completely and othershad significant improvement. The authors concluded that it isa safe and effective therapy for a sublingual cyst.[3],[10]

Hence, the present study was conducted to evaluate the effect of intralesional injection of polidocanol for treating pyogenic granuloma and mucocele that commonly in the oral cavity. This study also aimed to analyze the effect of polidocanol in both lesions of various sizes.


   Materials and Methods Top


The study was carried out among 15 patients visiting the Department of Oral Medicine & Radiology, Govt. Dental College & Hospital between 2017 and 2018. Written informed consent was obtained from all patients. Irrespective of age, sex, and site, 7 cases of mucocele (mucous extravasation cyst) and 8 cases of pyogenic granuloma cases were included in the study, whereas patients suffering from mucous retention cyst, pregnancy tumor, hemangioma, vascular malformations, and lymphatic malformations were excluded from the study. Complete case history and diagnosis of lesions was documented based on the following clinical findings.

Mucocele[6],[10]

  • Typically appear as dome-shaped, bluish, translucent mucosal swellings
  • It can range from 1 or 2 mm to several centimeters in size
  • It is fluctuant, but some mucocele feel firmer to palpation.


Pyogenic granuloma[1],[4],[5],[9],[11],[12]

  • Painless
  • Usually found in the interdental gingiva
  • Smooth or lobulated red-to-purple masses
  • It may be either pedunculated or sessile
  • It varies in size from a few millimeters to several centimeters
  • Soft to palpation
  • Early lesions bleed easily due to extreme vascularity.


For all cases of pyogenic granuloma, radiographic evaluation was done to rule out any bony involvement due to pressure resorption, and under local anaesthesia, incisional biopsies were performed for histopathologic confirmation.

Patients were subjected to a patch test to rule out any hypersensitivity reaction to the sclerosing agent [3% polidocanol (60 mg/2 mL)]. Patients with any allergy to sclerosant were excluded from the study. In our study, no patient had an allergy to polidocanol. Armamentarium required for sclerotherapy were 3% of polidocanol, insulin syringe, mouth mirror, gauze and tweezer [Figure 1]. First, surface local anesthesia was applied over the lesion, and under aseptic conditions, 0.5–1 mL of 3% polidocanol (Asklerol) was slowly injected by insulin syringe in a circumferential manner around the lesion until the solution leaked out from the surface of the lesion. The puncture site was gently compressed for 5 min with a gauze [Figure 2] and [Figure 3].
Figure 1: Armamentarium used for sclerotherapy

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Figure 2: Mucocele treated by sclerotherapy (a) Preoperative. (b) During procedure. (c) Postprocedure after 10 min. (d) Follow-up after 7 days. (e) Second time intralesional sclerotherapy. (f) Complete removal of lesion

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Figure 3: Pyogenic granuloma treated by sclerotherapy (a) Preoperative. (b) Postprocedure after 10 min. (c) Follow-up after 7 days

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Regular follow ups were done at 24 h, 7 days, and 15 days at weekly intervals up to 1 month to evaluate the response until the lesions became necrotic and exfoliated. During follow-up, the size of the lesions was measured with the help of a digital Vernier calliper. If the lesion resolved after the first injection, the treatment was stopped, but, if the lesion persisted, then the second, third, and fourth injections were planned and given at weekly intervals till complete regression. After completion of treatment, all patients were recalled at 1, 3, and 6 months intervals to check for recurrence. The result of all cases was entered in the table as below.


   Results and Discussion Top


Sclerosing agents are basically irritants that injure the endothelial surfaces, ultimately resulting in the obliteration of space between the surfaces. The resultant endovascular obliteration of low-flow venous anomalies results in a satisfactory outcome. Several sclerosing agents, sodium tetradecyl sulphate, sodium morrhuate, ethanolamine oleate, OK 432, PYM and other chemical irritants are used in dentistry. Among all, ethanol has been considered as an effective agent. However, ethanol sclerotherapy is a significant risk, and complications such as neuropathy and skin necrosis have been reported. Moreover, it causes pain during injection; therefore, measures such as general anesthesia are often required to control pain. In contrast to ethanol, polidocanol has an advantage due to its anesthetic effect and less postoperative complications. Considering the advantage of polidoconal over other sclerosing agents, it was preferred in our case.[1],[2],[3],[4],[5],[8]

Polidocanol consists of 95% hydroxypolyethoxydodecane and 5% ethyl alcohol. The former, an urethrane local anesthetic that differs from the more classic ester and amide anesthetic agents by its lack of an aromatic ring, is the active component of the product. Its detergent action induces a rapid over-hydration of endothelial cells, leading to vascular injury. The latter is added as a preservative. The action of polidocanol is summarized below [Figure 4].[2],[8]
Figure 4: The action of polidocanol

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A total of 15 clinically diagnosed cases of pyogenic granulomas and mucocele were selected for the study. The incidence of pyogenic granuloma has been depicted as 26.8%–32% of all reactive lesions, with a peak incidence in the third decade and age ranging from 11 to 40 years. Females are found to be more frequently affected with a predilection of 3:2 over males.[1] In this study, out of 8 cases of pyogenic granuloma, 4 cases were found in females and 4 cases in the males. Four cases were found in the 31–41-year age group, 2 cases were found in the 21–30-year age group, and only one case was found in 11–20-year age group and 41–50-year age group. Gingiva being the most common site (all 8 cases). The size of the lesions was measured with the help of dental calliper. The average size of the lesion was 2.5 cm. For mucocele, 3 cases were found in the 11–20-year age group, 2 cases were found in the 21–30-year age group, and only one case found in the 1–10-year and 31–40-year age groups with female predominance; lower lip was the most common site (4 lesions out of 7 cases). The average size of the lesion was 1.71 cm [Table 1] and [Table 2].
Table 1: Age and sex-wise distribution of the lesions

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Table 2: Site-wise distribution of the lesions

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Out of 8 cases of pyogenic granuloma, 6 cases having size <2 cm were completely treated by only one injection while 1 case (2–4 cm) underwent 2 times weekly interval injection, and 1 large case of pyogenic granuloma (>4 cm) required 3 times weekly interval injections [Table 3]. Out of 7 cases of mucocele, 5 cases having size <2 cm were completely treated by only one injection while 1 case (2–4 cm) underwent 2 times weekly interval injection and 1 large case of mucocele (>4 cm) required 3 times weekly interval injections [Table 4]. Therefore, the size of the lesion determines the numbers of injection of sclerotherapy. If the size of the lesion is less than 2 cm then only a single injection of polidocanol is sufficient. If it is between 2 to 4 cm then two injections (one at each appointment) has to be given with an interval of 1 week in between, and if the size is greater than 4 cm then 3 injections have to be given with weekly interval. Though the size of the lesion dictated the number of injections but were unaffected by age, sex and site of the lesion.
Table 3: Size-wise distribution of pyogenic granuloma along with the number of injection required for treatment with follow-up

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Table 4: Size-wise distribution of mucocele along with the number of injection required for treatment with follow-up

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Samantha et al. (2013) presented a case series on oral pyogenic granulomas wherein four cases showed complete resolution and one fibrosed on treatment with the sclerosing agent.[1] Similarly, this study also proved to be successful showing 100% results (15 cases). Out of the 15 subjects, 14 (90%) showed complete regression of the lesion with no recurrence. One case of mucocele in relation to the ventral surface of the tongue showed recurrence due to trauma at the same site during eating [Table 5]. All patients received a maximum of 1–3 consecutive intralesion injections at weekly intervals. No postoperative complications were observed except for local discomfort, and mild bleeding and mild swelling was reported by few cases which resolved within an hour. The swelling was evident due to the inflammatory response induced by polidocanol.[7]
Table 5: Recurrence of the lesion

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A dose of 3% polidocanol preferred is approximately 2 ml per injection to a maximum of 4 ml, repeated every 1 week to a maximum of 3–4 injections. In our cases, no complications were noted. Significant reduction in the size of the lesion was reported with the use of polidocanol. There were no recurrences during follow up of 3 months.


   Conclusion Top


Sclerotherapy is simple, minimally invasive, economical, and results in minimal discomfort to the patient; there is negligible blood loss, and less surgical expertise is required. There is no requirement of postoperative dressing or specific care, and patients can resume their daily activities immediately.

Surgical resection of the lesion is the mainstay treatment of mucocele and pyogenic granuloma. However intraoperative bleeding, postoperative infection and recurrence chances are more with surgical technique. In addition, surgical therapy might be difficult for infants and children under local anesthesia. To avoid complications associated with surgical procedures, sclerotherapy has been reported to have the advantages of minimal scarring, little recurrence, and few complications in the treatment of mucocele and pyogenic granuloma compared with other procedures.

  • If the size of the lesion is less than 2 cm, only one injection of polidocanol is required
  • If the size ranges from 2 to 4 cm, two injections of polidocanol are required
  • If the size is more than >3 cm, three injections of polidocanol are required for complete resolution of the lesion.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Khaitan T, Sinha R, Sarkar S, Kabiraj A, Ramani D, Sharma M. Conservative approach in the management of oral pyogenic granuloma by sclerotherapy. J Indian Acad Oral Med Radiol 2018;30:46.  Back to cited text no. 1
  [Full text]  
2.
Reddy GS, Reddy GV, Reddy KS, Priyadarshini BS, Sree PK. Intralesional sclerotherapy – A novel approach for the treatment of intraoral haemangiomas. J Clin Diagn Res 2016;10:ZD13-4.  Back to cited text no. 2
    
3.
Chen Z, Zheng J, Zhang S. Intralesional pingyangmycin injection sclerotherapy for oral ranulas. Open J Stomatol 2013;3:359.  Back to cited text no. 3
    
4.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: A review. J Oral Sci 2006;48:167-75.  Back to cited text no. 4
    
5.
Moon SE, Hwang EJ, Cho KH. Treatment of pyogenic granuloma by sodium tetradecyl sulfate sclerotherapy. Arch Dermatol 2005;141:644-6.  Back to cited text no. 5
    
6.
Sinha R, Sarkar S, Khaitan T, Kabiraj A, Maji A. Nonsurgical management of oral mucocele by intralesional corticosteroid therapy. Int J Dent 2016;2016:2896748.  Back to cited text no. 6
    
7.
Kadhum SI, Lateef TA. The efficacy of polidocanol foam sclerotherapy in treatment of infantile hemangioma and slow-flow vascular malformation. J Baghdad Coll Dent 2016;28:116-20.  Back to cited text no. 7
    
8.
Mimura H, Kanazawa S, Yasui K, Fujiwara H, Hyodo T, Mukai T, et al. Percutaneous sclerotherapy for venous malformations using polidocanol under fluoroscopy. Acta Med Okayama 2003;57:227-34.  Back to cited text no. 8
    
9.
Matsumoto K, Nakanishi H, Seike T, Koizumi Y, Mihara K, Kubo Y, et al. Treatment of pyogenic granuloma with a sclerosing agent. Dermatol Surg 2001;27:521-3.  Back to cited text no. 9
    
10.
Cai Y, Wang R, Yang SF, Zhao YF, Zhao JH. Sclerotherapy for the mucoceles of the anterior lingual salivary glands with pingyangmycin. Oral Dis 2014;20:473-6.  Back to cited text no. 10
    
11.
Rahman H. Pyogenic granuloma successfully cured by sclerotherapy: A case report. J Pak Assoc Dermatol 2016;24:361-4.  Back to cited text no. 11
    
12.
Cai Y, Sun R, He KF, Zhao YF, Zhao JH. Sclerotherapy for the recurrent granulomatous epulis with pingyangmycin. Med Oral Patol Oral Cir Bucal 2017;22:e214-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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