1.

Interpretasi gambaran klinis:

Ekstraoral:

Secara ekstra oral tidak tampak adanya asimetris wajah

Tidak ditemukan adanya pembengkakan, semua dalam batasan normal

Daerah labial dalam kondisi baik

Keadaan lymph normal

Tidak ada pembesaran kelenjar ludah

Intraoral:

Pada bagian lingual gigi 43 dan 44 terdapat nodul sebesar mulberry

Ukuran tumor seluas sekitar 1x1cm dan bertangkai

Bentuk tidak beraturan

Permukaan kilat/glossy

Daerah eritema

Warnanya hampir sama dengan jaringan sekitar tetapi agak pucat

Tidak ada lesi ulseratif

Warna lidah dalam keadaan baik (tidak ada hairy tongue/coated tongue)

Tidak sakit, permukaan berlobus.

PGs present clinically as exophytic, not well-delimited, widely based or pedunculated

lesions. The surface is smooth or rough and deep red in colour and the consistency is
softer than the rest of the mucosa. Ulceration is a frequent finding, sometimes covered
by a fibrinous pseudomembrane, which imparts a whitish appearance. This white
necrotic material may resemble pus, but, in the absence of a bacterial infection, no
actual pus is produced. Depending on the duration and degree of fibrosis, the lesion
may be firmer and paler. The size of PG is usually between 1-3 cm, although much
larger lesions are not uncommon.
The majority of PGs are asymptomatic; however, lesions with an intense
inflammatory component can be rather painful. Bleeding following mild trauma, or
even spontaneously, is frequent. When PGs occur in the gingivae, they are also
complicated with specific periodontal alterations (bleeding, periodontal pocket
formation, gingival retraction, and tooth mobility).

2. Diagnosis kasus dan diagnosis bandingnya?

Epulis gravidarum is a quite rare gingival disorder occurring 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 arises in the 2nd
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.

Identical lesions with the same histologic structure occur in association with the florid
gingivitis and periodontitis that may complicate pregnancy17 and are referred to as
pregnancy epulis or pregnancy tumor. The prevalence of pregnancy epulides increases
toward the end of pregnancy (when levels of circulating estrogens are highest), and
they tend to shrink after delivery (when there is a precipitous drop in circulating
estrogens). This suggests that hormones play a role in the etiology of the lesion,18
secondary to an increase in angiogenic factor expression and a reduction in the
apoptosis of granulation tissue.19 Similar to pregnancy gingivitis, these lesions do not
occur in mouths that are kept scrupulously free of even minor gingival irritation, and
local irritation is clearly also an important etiologic factor. Both pyogenic granulomas
and pregnancy epulides may mature and become less vascular and more collagenous,
gradually converting to fibrous epulides. Small isolated pregnancy tumors occurring
in a mouth that is otherwise in excellent gingival health may sometimes be observed
for resolution following delivery, but the size of the lesion or the presence of a
generalized pregnancy gingivitis or periodontitis supports the need for treatment
during pregnancy.
The peripheral ossifying or cementifying fibroma is found exclusively on the gingiva;
it does not arise in other oral mucosal locations. Clinically, it varies from pale pink to
cherry red and is typically located in the interdental papilla region (Figure 9). This
reactive proliferation is named because of the histologic evidence of calcifications
that are seen in the context of a hypercellular fibroblastic stroma. Peripheral ossifying
or cementifying fibromas occur in teenagers and young adults and are more common
in women. The existence of these lesions indicates the need for a periodontal
consultation, and treatment should include the elimination of subgingival irritants and
gingival pockets throughout the mouth, as well as excision of the gingival growth.

DD:
Differential diagnosis includes

peripheral giant cell granuloma,

epulis,

peripheral ossifying fibroma

metastatic cancer,

hemangioma

conventional granulation tissue

hyperplastic gingival inflammation

angiosarcoma,

kaposis sarcoma

non-hodgkins lymphoma.

pyogenic granuloma,

peripheral giant cell granuloma, peripheral ossifying

fibroma and metastatic cancer.

3. Etiologi dan patofisiologi kasus?

There is a higher incidence of pyogenic granuloma in women during pregnancy
termed as pregnancy epulis. Clinically, the pregnancy epulis appears as a smooth or
lobulated and ulcerated mass that is usually pedunculated or sometimes sessile.
Younger tumors are soft in consistency, progressing to a rubbery texture
on maturation. The color may range from pink to bright red to purple or brown.4 Such
lesions begin to develop in first trimester and their incidence increases upto 7th month
of pregnancy. The cause for the pyogenic granuloma in pregnancy is the raised levels
of progesterone and estrogen and it is seen that the tumor usually regresses post
parturition.4
The hormonal imbalance coincident with pregnancy heightens the organisms
response to irritation7 however, bacterial plaque and gingival inflammation
are necessary for subclinical hormone alterations leading to gingivitis.8 The
development of this particular kind of gingivitis, typical in pregnancy, not
different from that appearing in nonpregnant women, suggests the existence of a
relationship between the gingival lesion and the hormonal condition observed in

pregnancy. Sometimes pregnancy gingivitis can show a tendency towards localized

hyperplasia, which is called pregnancy granuloma. Generally, it appears in the
2nd - 3rd month of pregnancy, the persistent influence of plaque induces catarrhal
inflammation of the gingiva that serves as a base for development of hyperplastic
gingivitis during the last months, modulated by the cumulating hormonal stimuli. In
uncontrolled cases, pyogenic granuloma may arise. This lesion is rarely observed in
women with poor oral hygiene in areas with local irritating factors such as improperly
fitting restorations or dental calculus. During pregnancy, pyogenic grenuloma when
treated by surgical excision may reappear due to incomplete excision or inadequate
oral hygiene.9
The molecular mechanism behind the development and regression of

pyogenic

granuloma during pregnancy is due to changes associated with the functions and
structure of the blood and lymph microvasculature of the skin and mucosa due to
profound endocrine upheaval.10 Recent studies have revealed that sex hormones
manifest a variety of biological and immunological effects. Estrogen accelerates
wound healing by stimulating nerve growth factor (NGF) production in macrophages,
granulocyte-macrophagecolony stimulating factor (GM-CSF) production in
keratinocytes and basic fibroblast growth factor (bFGF) and transforming growth
factor beta 1 (TGF-1) production in fibroblasts, leading to granulation tissue
formation. Estrogen enhances vascular endothelial growth factor (VEGF) production
in macrophages, an effect that is antagonized by androgens and which may
be related to the development of pyogenic granuloma during pregnancy. The
molecular mechanism for the regression of pyogenic granuloma after the pregnancy
is not clear. It is proposed that in the absence of VEGF, the Angiopoietin (Ang-2)
causes the blood vessels to regress and VEGF, which was found high in pregnancy
was found undetectable after parturition.

Indian journal:
The exact etiology of pyogenic granuloma is unknown. Many factors have been
suggested, including hormonal influences, as many of the lesions, though not all
which appear during pregnancy resolve soon after delivery. Hormonal influences
(specifically of progesterone) almost certainly play a role in the pathogenesis of
pyogenic granuloma because these lesions commonly develop in pregnant women or
in those taking oral contraceptives. Elevated levels of estrogen during pregnancy may

play a role by direct hormone action as estrogen receptor was found weakly positive
in a case reported by Demir 3. Others have suggested that other regnancy related
angiogenic factors might play a role. A viral origin has also been hypothesized but
seems unlikely because the most common types of human papilloma virus have been
ruled out as etiologic agents by polymerase chain reaction (PCR) testing 4.

4. Prosedur dan rencana terapi pasien?

a. Scaling dan root planning
b. Eksisi

Indian journal:
Treatment during pregnancy is only needed if the lesion causes irritation or bleeding.
Therapeutic alternatives can be in the form of a destructive technic using a laser,
electro-cautery, cryocautery, or chemical cautery Gonzalez et al5 report on
treatment by 585 nm pulsed dye laser. Surgical treatment for removal is very
occasionally required. Surgical removal with electrodessication and silver nitrate
cautery of the base may be done. Some cases resolve spontaneously after delivery. In
both our cases, good results were obtained with cryocautery.

Possible treatment modalities are excision, curettage, cryotherapy, chemical and

electric cauterization, and the use of lasers. The lasers commonly used are argon
lasers, continuous wave (CW) Nd:YAG laser, pulsed dye laser and CW carbon
dioxide laser, which permits rapid, minimally invasive surgical treatment, but the
nonspecific coagulation may lead to scars. The management of pyogenic granuloma
depends on the severity of symptoms. Excisional biopsy is indicated for treatment of
pyogenic granuloma, except when the procedure would produce marked deformity.12
Recurrence rate after excision ranges from 0% to 16%. Pyogenic granuloma of
pregnancy often regresses postparturition, they need not be excised unless
symptomatic.4 As the patient presented with huge painful mass, which was ulcerated
and bleeding we decided to excise completely.
Treatment considerations during pregnancy are very important as it is considered that
there is a biological plausibility that periodontal diseases in pregnancy are associated
with pregnancy complications like preterm births, preterm low birth weight (LBW)

babies or even pre-eclampsia.13 Surgical and periodontal treatment should be

completed, when possible.

Dalam hal ini, maka pasien dilakukan tindakan eksisi terhadap epulis, Hal ini
dilakukan karena:
keberadaan epulis di rongga mulut akan menyebabkan asupan nutrisi ibu
hamil terganggu sehingga gizi yang akan diterima oleh bayi menjadi
terhambat.
Keadaan yang dibarengi dengan periodontitis ini akan mengakibatkan
berbagai defek terhadap kelahiran bayi.
Penggunaan teknik electrocautery/ cryosurgery/ laser belum dimungkinkan
dilakukan di RSGMP FKG USU pada saat ini

5. Jelaskan prognosis gigi tersebut?

Prognosis gigi baik. Hal ini apabila didukung oleh hal berikut:
Perawatan lesi periodontal yang adekuat dengan cara menyingkirkan faktor
etiologi yaitu plak dan kalkulus
Perawatan bone graft yang adekuat. Tambahan: jurnal.
Terjadinya proses regenerasi , repair dan terbentuk new attachment dalam
perawatan GTR
Proses penyembuhan daerah periodontal bukan reattachment
kontrol plak adekuat
lakukan splint periodontal apabila diperlukan

Hasil penyembuhan saku periodontal yang dicapai sangat tergantung pada

sekuens proliferasi sel-sel yang terlibat pada stadium penyembuhan. Apabila epitel
berproliferasi lebih dahulu sepanjang permukaan akar gigi sebelum jaringan
periodonsium lainnya mencapai daerah tersebut, maka bentuk penyembuhan yang
dicapai adalah berupa epitel penyatu yang panjang. Bila sel-sel dari jaringan ikat
gingiva yang terlebih dahulu mempopulasi daerah tersebut, hasilnya adalah
serabut-serabut yang sejajar dengan permukaan akar gigi dan remodeling tulang
alveolar, tanpa perlekatan serabut ke sementum. Apabila sel-sel tulang yang lebih
dulu mencapai daerah tersebut, bisa terjadi resorpsi akar dan ankilosis. Sebaliknya

bila sel-sel dari ligamen periodontal proliferasi lebih dulu ke daerah tersebut, baru
akan terjadi pembentukan sementum dan ligamen periodontal baru.

Prognosis dikatakan baik karena lesi ini hanya bersifat lokal dan pola kehilangan
tulang adalah vertical. Dengan perawatan yang adekuat serta sifat kooperatif pasien,
maka dapat diharapkan terjadinya penyembuhan jaringan periodontal yang baik
(karena notabene kehilangan vertical memiliki penyembuhan dan outcome yang lebih
baik).
Mobiliti pasien juga masih derajat 2 di mana keadaan ini masih memungkinkan untuk
mempertahankan gigi ybs.

6. Apakah diindikasikan bone graft?

Ya, alasan: di jurnal.

7. Komplikasi pasca terapi?

Elimination of the causative traumatic factors followed by complete surgical excision
of the lesion constitutes the basis for definitive treatment and prevention of
recurrences. However, according to some authors, recurrences occur in almost 20% of
cases. During surgical removal, special attention should be paid to complete removal
of the base of the lesion to avoid possible recurrences.
Complications of treatment include haemorrhage, which can be prevented through
previous reduction of the amount of inflamed granulation tissue by means of
elimination of the irritating factors. Use of LASER allows control of haemorrhage
through induction of coagulation. On the other hand, extirpation of anterior large
lesions can produce a wide range of gingival defects, which pose important aesthetic
problems. In these cases, a more laborious and meticulous surgical approach will
contribute to a cosmetically-acceptable result.
There is a general consensus that HT regresses after childbirth, although it rarely
disappears completely. In our experience, the HTs persisted one month after
childbirth, although smaller in size. Surgical excision and periodontal management
were carried out without subsequent recurrences.

Tambahan; jurnal.