control of pregnancy granuloma. [I]. Avaliação clínica de acompanhamento após dois anos de controle de granuloma gravídico. [A]. Luis Eduardo Rilling Nova. Palabras clave: Embarazo, gingivitis, periodontitis, granuloma En lo que respecta a lesiones de la mucosa bucal, Granuloma .. o granuloma gravídico. Clinical and Histological Evaluation of Granuloma Gravidarum: . Granuloma gravídico é uma lesão benigna comum da mucosa oral que ocorre na gestação.

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Pyogenic granuloma PG and peripheral giant-cell granuloma PGCG are two of the most common inflammatory lesions associated with implants; however, there is no established pathway for treatment of these conditions. This paper aims to illustrate the successful treatment of PG and PGCG and also report a systematic review of the literature regarding the various treatments proposed.

From the electronic granuuloma 16 case reports were found showing excision and curettage as the main successful treatment. As no clinical trials or observational studies were identified the authors agreed to present results from a review perspective.

Our review would suggest that PGCG associated with implants appears to have a more aggressive nature; however the level of evidence is very limited. Further cohort studies with representative sample sizes and standard outcome measures are necessary for better understanding of these conditions. Reactive lesions are characterized as excessive proliferation of connective tissue as a response to chronic irritation [ 1 ].

Among these types of lesions, those seen in the oral cavity include pyogenic granuloma PGperipheral fibroma, graunloma hyperplasia, peripheral ossifying fibroma, and peripheral giant-cell granuloma PGCG.

PG and PGCG appear to be the ones commonly associated with implants, as in the past few years multiple case reports have been published [ 12 ]. PG is defined as an inflammatory hyperplasia that usually appears as a response to irritants, trauma, hormonal changes, or certain medications [ 34 ]. Although classically it is called PG, a more correct name would be focal epithelial hyperplasia since the lesion is not strictly a granuloma or an infection [ 34 ].

Peripheral giant-cell granuloma PGCG is considered a reactive hyperplastic lesion, although its etiology is not entirely known. It is believed that its pathogenesis includes an excessive activation of osteoclasts, which is associated with a proliferation gravjdico macrophages, and possibly causes major bone resorption [ 25 ].

PG is more frequent in women in their 20s, with a ratio of 3: It is more common in the maxilla than grafidico the mandible and in anterior as opposed to posterior areas [ 4 ]. In contrast, PGCG usually appears in patients who are between their 40s and 60s, and it is slightly more frequent in women and tends to appear more often in the mandible than in graniloma maxilla Table 1 [ 45 ].

The treatment of these lesions generally involves eliminating the irritating factors as well as performing surgical removal [ 12 ]. Commonly associated with periodontal disease, where calculus is the irritating factor, surgical removal along with nonsurgical debridement is well described in the literature [ 6 ]. Summarizing the differential diagnosis between pyogenic granuloma and peripheral giant-cell granuloma.

Implant rehabilitation has become more common in the last decade and several factors have been studied which could interfere with osteointegration and longevity [ 7 ]. Factors such as smoking, diabetes, and periodontal disease have been studied [ 7 — 11 ].

However, with regard to reactive lesions such as PG and PGCG there is no clear pathway for intervention or treatment to manage these lesions and maintain grvaidico tissue around the implants [ 7 ]. The aim of this paper is to demonstrate the successful management of cases of PG and PGCG associated with implants and to review the literature for the various treatment options.

To collect all relevant information about previous published treatments for PG and PGCG involving implants, the authors carried out an electronic search vravidico to January to June Pubmed Central, National Library of Medicine’s Medline, Scielo, Scopus, and Cochrane Library for reactive lesions related to implants key words: These articles were obtained, and a hand search of gravidiico bibliographies identified any pertinent secondary references.

This process was repeated until no further new articles could be identified. The inclusion criteria included granuloa trials, cohort studies, case-controlled studies, case series, and case reports, published in English, Portuguese, French, and Gravidick, which included a clear description of the treatment employed. The search was limited to human studies and all articles which did not fit into the criteria were excluded. If there was insufficient information provided in the abstract or if there was a disagreement between reviewers, the authors reviewed the full text before reaching consensus through discussion.


Data extraction was then completed in duplicate by the same independent reviewers.

The following data were collected: The granuloja JLL prepared data extraction tables and all authors contributed to summary reports of the selected journal articles and review of the literature. The case reports protocol was carried out with patient informed consent following guidelines according to the Helsinki Declaration ofas revised in From the 55 articles initially selected, 39 studies were excluded as they were related to teeth gravieico not directly related to implants.

All 16 articles selected were case reports; these ranged from reports of a single case to articles describing up to a maximum of 3 cases, such that a total of 21 patients were reported.

As no experimental or observational studies were identified the authors agreed that it would not be reasonable to critically appraise the quality of the studies and consequently the results are presented from a review perspective.

Pyogenic Granuloma/Peripheral Giant-Cell Granuloma Associated with Implants

The majority of patients with PGCG were women 3: The average age of the population who suffered PGCG was The majority of published cases of PGCG associated with implants had suffered bone loss around the implant [ 2511 — 15 ], as only 4 of the published cases of PGCG did not experience bone loss [ 9101221 ] On the other hand bone loss did not occur in cases of PG [ 41417 — 20 ].

The six cases of PG were treated with excision of the lesion and curettage, though one case involved excision with Er-YAG Laser [ 18 ]. The cases of PGCG were treated with a number of different strategies. In all of the cases the lesion was surgically removed, but in addition to this, in nine cases curettage was also performed [ 2489111421 ], in two cases the prosthesis was graviidico [ 1011 ], in one case the prostheses were temporarily removed [ 15 ], in another case a graft was performed [ 13 ], and in four cases the implant was explanted [ 2512 ] Table 2.

The 6 cases which suffered relapse all were PGCG. Three of these were grvaidico with excision and curettage only [ 2912 ], while the other 3 also underwent explantation [ 2812 ] Table 2. In fact, from the ones that underwent explantation, one had a PGCG granluoma 8 times of recurrence [ 12 ] and the other case which had three times [ 2 ] was treated with curettage [ 2 ].

A year-old male came for consultation reporting two swellings intraorally adjacent to implants that had been placed three years earlier.

These lesions had developed over 6 months and were not painful but did bleed on brushing. With regard to his medical history, of interest, he was diagnosed with antiphospholipid syndrome in and suffered an acute myocardial infarction in August He also suffered from focal segmental glomerulosclerosis and chronic kidney failure since but did not require hemodialysis and could be linked to systemic lupus erythematosus.

With respect to his dental history, he suffered from advanced chronic generalized periodontal disease and had plaque and calculus deposits both supra- and subgingivally. Due to his advanced periodontal disease the remaining upper and lower teeth had been splinted two years earlier. No habits of substance abuse were reported. Oral examination revealed two nodular erythematous sessile lumps of 1. The presumptive diagnosis was that of pyogenic granuloma or peripheral giant-cell granuloma.

An excisional biopsy was performed along with curettage and irrigation with chlorhexidine 0. The microscopic description was that of ulcerated lesions covered by a fibrin and leukocyte membrane and made up of granulation tissue with a mixed inflammatory infiltrate with polymorphonuclears, together with vascular proliferation Figure 2. Squamous epithelium with parakeratosis, dyskeratosis, acanthosis, and elongation of the epithelial peaks was observed at the far extremes.

The epithelial maturation was conserved and no dysplasia-like phenomenon was observed. The results were compatible with a diagnosis of pyogenic granuloma, without any suggestion of malignancy. Postoperatively there were no further issues and there was no evidence of relapse at month follow-up Figure 3. A year-old male came for consultation regarding a day history of an exophytic mass associated with the buccal marginal gingiva of an implant supported dental prosthesis in the lower right quadrant.

This had been placed 8 years earlier. The lesion was asymptomatic, but the patient reported bleeding on brushing. The patient’s medical history revealed complete atrioventricular block, coronary atherothrombosis with acute myocardial infarction inleft ventricular dysfunction, pericarditis, and diabetes mellitus type 2.

The patient’s regular medicines included carvedilol 6. With respect to the patient’s dental history, he was partially dentate in the mandible as a result of periodontal disease and had multiple implant supported fixed prostheses, with a total of 10 implants placed 8 years earlier.

The lesion was reddish-purple in color and was well defined with an elastic consistency and an irregular texture.


It was not mobile and was sessile. Histopathology confirmed that it was an ulcerated peripheral giant-cell granuloma, without suggestion of malignancy Figure 5. Histologically it was described as a lesion covered by a parakeratinized stratified squamous epithelium, with areas of atrophy and ulceration in its thickness. A dense proliferation of multinucleated giant cells was dispersed on a stroma of the tissue, which was highly vascularized, with areas of hemorrhage, deposits of hemosiderin, and infiltrate due to accumulation of lymphoplasmacytic inflammatory cells.

Treatment involved complete excision of the lesion, curettage of the exposed implant threads, and irrigation with chlorhexidine 0.

Postoperative healing was good and at month follow-up there was no evidence of recurrence Figure 6. Peri-implantitis with progressive bone loss is reported to be the most frequent complication associated with implants [ 2 ]. Its treatment is challenging and to do so correctly we must identify the pathology leading to peri-implantitis [ 2 ]. In our view recognition of the soft tissue pathology by biopsy should be the first step for potential successful treatment. The etiology of these conditions when associated with implants is similar to that which is described when they are associated with teeth, where factors such as trauma, plaque deposits, or chronic infection have a major granukoma [ 1 ].

In cases associated with implants, incorrect or inadequate prosthesis implant cap or granyloma cap, poorly adjusted suprastructures, etc. With regard to inadequate prosthesis, Bischof et al. Another suggested potential cause, although controversial, is that an inflammatory response to titanium may lead to development of granulomas [ 1012 — 1522 ].

The clinical presentation and age group of the PG and PGCG cases described appeared to be similar when associated with teeth [ 23 gravidic 27 ].

Our data collection showed PGCG is more frequent in women and in the posterior mandible [ 2 ]. One could propose this may be due to greater plaque accumulation posteriorly due to difficult access for thorough oral hygiene. When associated with teeth, PG is also commonly seen in females [ 12 ].

This is in contrast with our findings which suggest that when associated with implants it is more granjloma in men. Nonetheless this may be an inaccurate conclusion and due to the small number of cases reported. In females, pregnancy can have a role in this condition. It has been suggested that the increase of estrogen and progesterone can gravdico gingival physiology, enhancing the granjloma response to the local microbiota, with a predominance of more pathogenic microorganisms [ 2027granulooma ].

Data from the selected articles suggests that bone loss from the implant site is more commonly associated with PGCG [ 25granupoma — 15 ] than PG.

Gravidarum granuloma associated to an osseointegrated implant: case report

This is also more prevalent when lesions present posteriorly. Again this could be related to difficult access for thorough oral hygiene though this may also be due to the greater occlusal load experienced posteriorly, as opposed to that experienced by the anterior teeth [ 2510 ]. Recurrence has been reported in 6 of the 15 published cases of PGCG associated with implants Table 2. Several possible explanations are considered, such as incomplete excision, but in addition these lesions may have been caused by combination of irritating factors, which therefore makes it challenging to granuloja all possible causes [ 258 ].


Pyogenic Granuloma/Peripheral Giant-Cell Granuloma Associated with Implants

This is consistent with normal convention when these lesions are associated granukoma teeth being granhloma relatively simple technique and with satisfactory results [ 1291012252629 ]. Other options have been described such as the use of Er-YAG Laser [ 18 ] or explantation of the implant and the provision of a new prosthesis granupoma 1011 ] or indeed temporary removal [ 15 ].

It is suggested that use of the Er-YAG Laser for granuloma excision offers advantages in comparison to conventional surgery techniques, especially by reducing the risk of bleeding, pain, and postoperative edema and also eliminating the need for sutures at the end of the procedure [ 18 ]. Given the small number of cases published, it is difficult to evaluate if explantation of the implant affects the number of recurrences or the granulomw of bone loss. Recurrences of PG and PGCG have been described when associated with bad plaque control but also due to hormonal imbalance during pregnancy, especially in PG cases [ 30 ].