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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 211-217

Management of a periodontally compromised grade III mobile tooth associated with pyogenic granuloma


1 Department of Periodontology and Oral Implantology, Pandit Deendayal Upadhyay Dental College, Solapur; Department of Periodontology and Oral Implantology, Dr. D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India
2 Department of Periodontology and Oral Implantology, The Oxford Dental College, Bengaluru, Karnataka, India

Date of Submission05-Jul-2021
Date of Acceptance10-Jul-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Shravanthi Raghav Yajamanya
43555 Grimmer Blvd, Apt A202, Fremont, California 94538
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_27_21

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  Abstract 


With current advancements in the field of dentistry, the dental treatments today are focused more on conserving the tooth and supporting the concept of “nothing serves better than the natural tooth itself.” This case report presents a multidisciplinary treatment approach adopted in retaining a Grade III mobile periodontally compromised permanent maxillary left central incisor in a 32-year-old female patient who reported to the Department of Periodontics and Oral implantology with the chief complaint of intraoral swelling, pus discharge, bleeding gums, and tooth mobility in the upper front tooth region. At 1-year follow-up, the tooth was periodontally stable and functional.

Keywords: Autologous platelet-rich fibrin, coronally advanced flap, Grade III tooth mobility, periodontal intrabony defect, PerioGlas®, pyogenic granuloma


How to cite this article:
Yajamanya SR, Chatterjee A, Hussain AM, Das S. Management of a periodontally compromised grade III mobile tooth associated with pyogenic granuloma. Niger J Exp Clin Biosci 2021;9:211-7

How to cite this URL:
Yajamanya SR, Chatterjee A, Hussain AM, Das S. Management of a periodontally compromised grade III mobile tooth associated with pyogenic granuloma. Niger J Exp Clin Biosci [serial online] 2021 [cited 2022 Jan 21];9:211-7. Available from: https://www.njecbonline.org/text.asp?2021/9/3/211/331556




  Introduction Top


Vascular anomalies as per the 2014 International Society for the Study of Vascular Anomalies guidelines are classified as vascular tumors and vascular malformations. Vascular tumors are subclassified as benign, locally aggressive/borderline, or malignant based on cellular behavior. Benign vascular tumors include a broad group of lesions called reactive proliferative vascular lesions which in response to stimuli such as trauma, local thrombosis, and hormones exhibit hyperplasia. Pyogenic granuloma is the most common of these reactive proliferative vascular lesions.[1]

An array of lesions associated with oral mucosa are of developmental, reactive, inflammatory, and neoplastic types and can be localized or generalized.[2] Reactive lesions of gingiva according to Kfir et al. are classified into pyogenic granuloma, peripheral giant cell granuloma, fibrous hyperplasia, and peripheral fibroma with calcification.[3]

Characteristic features of pyogenic granuloma include a more common involvement of maxillary anterior labial attached gingiva with rare alveolar bone association[4],[5],[6] however, its destructive forms might be related to labial cortex erosion.[7] The PG lesions may present itself as a painless pedunculated or sessile polyploidy mass with bleeding or as a painless ulcerative rapid growth arising from the gingival papilla.[7]

Pyogenic granuloma is one such lesion that has the tendency to show considerable variations in terms of size (ranging from a few millimeters to a centimeter or more in diameter),[8] occurrence at uncommon sites,[9] and the extent to which underlying alveolar bone loss may be involved. Considering the noted distinctions in its clinical and radiographic presentation, it is important to record the unique presentations of various pyogenic granuloma cases for a better understanding of the lesion and hence provide suitable treatment.

Thus, the rationale for this case report is to present an uncommon case of pyogenic granuloma lesions associated with a periodontally compromised tooth and related severe bone loss and Grade III mobility and the multidisciplinary treatment approach considered in saving a tooth with poor prognosis.


  Case Report Top


A 32-year-old female patient reported to the Department of Periodontology and Oral Implantology with a chief complaint of swelling in gums with associated pus discharge, bleeding, and increasing tooth mobility for 5–6 months in the upper front tooth region. She also noticed spacing between her upper front teeth in the past 6 months. On extraoral examination, no facial asymmetry was noted. No contributory medical history was noted. She was not on any medication. Intraoral examination revealed the presence of two independent gingival lesions both limited to the maxillary anterior region. First gingival lesion - site: tooth number 21 (as per FDI notation); extent: limited to labial gingiva involving marginal and attached gingiva with slight extension beyond the mucogingival junction; size: small, 8.5x8mm (approximately); elevated, sessile, round, vascular mass, bright red color, soft consistency, smooth surface, friable in nature, circumscribed margins, and well-demarcated from the surrounding gingival and tendency to bleed on provocation [Figure 1].
Figure 1: Labial view - Pyogenic granuloma lesions in association with tooth number 21 and IDP between tooth numbers 21-22. Palatal view - pyogenic granuloma lesion in association with tooth numbers 21-22

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Second gingival lesion - site and extent: labial gingiva-marginal and attached along with the IDP between teeth numbers 21 and 22, covering the mesial 1/3rd of the labial aspect of tooth number 22. Palatally-from the IDP distally, involving marginal and attached gingiva of tooth number 21 and limiting itself to the base of the palatal IDP mesially between teeth numbers 21 and 11; size: labially-9 mm × 12 mm (approximately) palatally-9 mm × 5mm (approximately); elevated, sessile, soft, smooth, pinkred vascular mass, circumscribed, tendency to bleed on provocation with labially being lobulated and palatally exhibiting pus discharge [Figure 1].

Periodontal tissue examination -Teeth numbers 11, 21, and 22 - Gingiva was soft, edematous, bleeding on probing, painful on touch, and periodontal probing was done using William periodontal probe under local anesthesia. Deep periodontal pockets in the range of 8-9 mm were noted with teeth numbers 21, 22; moderate plaque and calculus (supra and subgingival).

Hard tissue examination - severe extrinsic stains on the palatal and lingual aspects of all teeth with moderate plaque and calculus accumulation. Tooth number 21 exhibited[1] Grade III mobility (simple method such as holding the tooth firmly between the handles of two metallic instruments and an effort was made to move it in all directions was used and grading was based on ease and extent of tooth movement),[2],[10] tenderness on percussion[3] Pathologic migration - facial flaring, diastema, extrusion. Spacing between teeth numbers 11, 21, and 22.

Oral habits - Tobacco chewing for 3-4 years, 1-2 packets a day. After chewing the tobacco for some time, she spits it out.

Poor oral hygiene status noted.

Dental history - This was her first dental visit.

Radiographic examination - Radiovisiography of teeth numbers 11, 21, 22 (partial) revealed periodontal IBD in relation to tooth number 21 and periodontal ligament widening extending up to the tooth apex [Figure 2].
Figure 2: Radiovisiography showing angular bone loss with tooth number 21. IOPA of 1 year follow up

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According to the case history and clinical presentation of the gingival lesions recorded, a provisional diagnosis of pyogenic granuloma was noted. A differential diagnosis of irritational fibroma and hemangioma were considered for the gingival lesions.

Treatment plan followed - 1st appointment included: thorough recording of case history, advised to stop the habit of chewing tobacco, performing Phase I periodontal therapy which included through scaling and root planing performed under local anesthesia administration of 2% lignocaine HCL solution with adrenaline 1:80,000 followed by giving oral hygiene instructions. Patient was advised for blood investigation to be performed at the Department of Oral Pathology.

Second appointment was scheduled 4 weeks after the phase I periodontal therapy when her blood investigation report was studied and was within the normal range. Although a marked reduction was observed in the gingival inflammation, the presence of the gingival lesions and periodontal pockets was noted [Figure 3]. Hence, excisional biopsy of the gingival lesions and phase II periodontal therapy was executed. A written consent was obtained for the same. A local anesthesia of 2% lignocaine HCL solution with adrenaline 1:80,000 was administered. A complete excision of the 1st gingival lesion was done with the scalpel [Figure 4]. Crevicular incisions were placed from the mesial aspect of tooth number 11 to the mid of tooth number 23. and gingivectomy was performed for the 2nd gingival lesion involving the IDP between teeth numbers 21 and 22 [Figure 5] followed by elevation of full-thickness buccal and palatal periodontal flaps [Figure 6]. Granulation tissue was removed using Gracey curettes (HU-Friedy). Residual debris and calculus were removed with ultrasonic scalers. The periodontal IBD site was presutured (3-0 silk) and autologous platelet-rich fibrin (PRF) clot was placed palatally and autologous PRF as a membrane was placed labially at the 1st gingival lesion excised site in relation to tooth number 21 [Figure 7]. Autologous PRF preparation protocol - intravenous blood was obtained from the antecubital vein was centrifuged immediately without anticoagulant in a centrifugation machine for 10 min at 3000 revolutions. This resulted in acellular plasma at the top, autologous PRF in the middle of the disposable vacuum test tube, and red blood cells (RBCs) at the bottom.[11],[12] PRF along with a small RBC layer was obtained using a sterile tweezers and scissors and then transferred to the periodontal IBD site. Periodontal dressing was used to cover the surgical site. Patient was prescribed capsule amoxicillin 500 mg thrice daily for 5 days and tablet diclofenac sodium 50 mg thrice a day for 3 days. Postoperative instructions were given. The two excised gingival lesions were sent to the Department of Oral Pathology for biopsy in 10% formalin solution.
Figure 3: Labial and palatal views of clinical outcome 2 weeks after phase I periodontal therapy

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Figure 4: Surgical site after excision of pyogenic granuloma lesion and the excised lesion associated with tooth number 21

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Figure 5: Palatal view of incisions placed during periodontal surgical procedure and excised PG lesion associated with IDP between tooth numbers 21-22

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Figure 6: Labial and palatal views of full-thickness periodontal flap elevated and the yellow circle shows autologous Platelet Rich Fibrin (PRF) placed in the intrabony defect related to tooth no 21

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Figure 7: Labial view - autologous platelet-rich fibrin membrane placed at the 1st pyogenic granuloma excised site. Palatal view-autologous platelet-rich fibrin clot placed in the IBD with tooth number 21

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Third appointment included suture removal and healing assessment of the surgical site after 7 days of surgical procedure [Figure 8]. A single visit intentional root canal treatment (RCT) with tooth number 21 was scheduled at the Department of Conservative Dentistry and Endodontics. The biopsy report confirmed the diagnosis of pyogenic granuloma.
Figure 8: 1 week follow-up after periodontal flap surgery

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Fourth appointment - After RCT, patient reported back to the Department of Periodontology and Oral Implantology. Incisal reduction with tooth number 21 and splinting with Ribbond bondable reinforcement was carried out lingually involving teeth numbers 11, 12, 21, 22, 23 [Figure 9].
Figure 9: Labial and palatal views after incisal reduction of tooth number 21 and periodontal splinting

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Fifth appointment - PG lesions showed no signs of recurrence at 6 months. Coronally advanced flap (CAF) with PerioGlas® was performed on tooth number 21. Two percent lignocaine HCL solution with adrenaline, 1:80,000 was administered. Two apically divergent vertical incisions were placed including the mesial and distal IDPs in the flap and extending beyond the mucogingival junction. Apical to the receded soft-tissue margin, full-thickness flap was raised and 3mm (approximately) apical to the bone defect, a horizontal incision was made through the periosteum followed by blunt dissection into the vestibular lining mucosa to release the muscle tension. PerioGlas® mixed with patient's own blood was placed in the periodontal IBD [Figure 10] and the flap was coronally positioned tension free and sutured (4–0 suture). Periodontal dressing was given along with postoperative instructions.
Figure 10: Coronally advanced flap and Perioglas placement with tooth number 21

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Sixth appointment - Suture removal was done after 7 days of CAF procedure. Surgical site was inspected for gingival condition and no signs of recurrence of PG lesions were noted.

Seventh appointment - Tooth number 21 was assessed at 2 months recall after CAF procedure for periodontal condition [Figure 11]. Periodontal splint was removed, tooth mobility was noted to be Grade I. Patient was referred to the Department of Prosthodontics for further treatment.
Figure 11: Before and after comparison of free gingival margin level of tooth number 21 compared to tooth number 11

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Eighth appointment - 1 year clinical and radiographic picture of tooth number 21 revealed a periodontally and functionally stable tooth [Figure 2].


  Discussion Top


Pyogenic granuloma is a tumor-like gingival enlargement with minor trauma,[13] poor oral hygiene,[5],[6] drugs such as cyclosporine,[14],[15] presence calculus, and foreign material in the gingival crevice may its precipitating factors.[4],[5],[6] In our case, the cause for the development of pyogenic granuloma could be poor oral hygiene, long-standing plaque, and calculus. Formation of pyogenic granuloma and its painful presentation with tendency to bleed, tobacco chewing habit, and delay in dental treatment, chronic periodontitis may have further deteriorated the periodontal condition resulting in severe periodontal attachment and alveolar bone loss.

In periodontitis bone loss is due to neutrophils, Th1-lymphocytes, B-cell macrophages related upregulated proinflammatory mediator production, and receptor activator of nuclear factor-κB ligand expression pathway expression.[16] Whereas the explanation for granulation tissue formation and thus, bone loss in pyogenic granuloma can be explained due to the production of basic fibroblast growth factor and transforming growth factor beta1 in fibroblast and granulocyte-macrophage-colony stimulating factor in keratinocytes.[17] Thus, the reason of severe alveolar bone loss in our case report may be the dual effect of periodontitis and pyogenic granuloma.

In our case report, considering the severity of clinical periodontal parameters associated with the PG lesions, a treatment plan of simultaneous surgical excision of PG lesions and periodontal flap surgery with placement autologous PRF in the IBD with tooth number 21 was chosen.

We choose to treat the tooth number 21 with regenerative therapy instead of extraction because IBDs after periodontal regenerative treatment presented with stabilized attachment and preservation of compromised teeth on medium to long term basis[18],[19] and up to 88% survival of teeth with hopeless prognosis noted at 10 years.[20]

Autologous PRF was a biomaterial of choice in our case report in treating the tooth number 21 related IBD was due to its ability to[1] accelerate physiologic healing because of its organized fibrin matrix which allows for efficient mesenchymal stem cell harnessing and support for obtaining osseous defect regeneration,[21],[22],[23] (2) promote the phosphorylated extracellular signal-regulated protein kinase expression and osteoprotegerin production resulting in osteoblast proliferation[24] (3) release transforming growth factor and platelet-derived growth factor promoting periodontal regeneration.[25],[26]

Autologous PRF was used as a membrane at the excised site of 1st pyogenic granuloma lesion in our case report because (1) during coagulation it forms a protective wall along the vascular breaches[27] (2) the fibrin mesh favors healing and encourages faster reepithelialization by steady release of growth factors[27] (3) prevents underlying bone resorption at the excised sites of PG lesions.[28],[29]

RCT was performed for tooth number 21 considering the drastic tooth reduction that was performed due to extrusion, the occurrence of definite vital pulp involvement when prosthetic crown placement was carried out, and to eliminate the chances for root canal contamination and bacterial re-growth during appointments.[30]

Periodontal splinting was performed on tooth number 21 considering the advantages such as faster healing, assistance in periodontal health regeneration, improved comfort and function,[31] and prevention of further tooth extrusion.[32] Ribbond combined with composite resin presented with benefits such as durability and better resistance to load-bearing occlusal and masticatory forces than most alternative splinting materials.[33] Hence was considered in this case report.

Tooth number 21 presented with a Miller's class IV gingival recession. As per the available literature, treating Miller's class III and IV gingival recession cases may not achieve root coverage or predictable outcome.[34] We attempted gingival recession treatment for tooth number 21 in our case report for the following reasons (1) the presence of asymmetric free gingival margin compared to tooth number 11 (2) affected tooth number 21 looked longer than tooth number 11 (3) final crown placement was to be planned for tooth number 21 with the presence of predisposing factors.[35] CAF was considered for this case report for it being the most common treatment approach for the maxillary gingival recession defects.[36] Bioactive glass (PerioGlas®) was combined with CAF for the following added advantages such as (1) relapse prevention and long term gingival recession management due to its ability of hard tissue formation[37] (2) good confinement in various osseous defects resulting in significant clinical attachment level gain and bone fill.

Our case reports gingival recession treatment clinical outcome was in accordance with long-standing observation that, least root coverage is expected in Miller's class IV gingival recession.[35],[38] However, we achieved a close to complete symmetry between free gingival margin of tooth number 21 as compared to the free gingival margin of adjacent tooth number 11 [Figure 9] which posed with the benefit of acceptable esthetic outcome on completion of the final crown placement.

During the course of periodontal treatment, we observed a marked improvement in clinical parameters such as a significant reduction in gingival inflammation, reduction in bleeding on probing, reduction in probing pocket depth, and radiographic evidence of bone fill with gradual reduction in mobility from Grade III to Grade I with tooth number 21 which is in accordance with the available literature.[30],[39] There exists a positive correlation between probing pocket depth, clinical attachment loss, and alveolar bone loss and the presence and grade of tooth mobility[40] which may explain the influence of significant improvement in the periodontal clinical parameters on the reduction of mobility with tooth number 21 in our case report.

Limitation includes follow-up of only 1 year. A longer follow-up period would provide a better assessment of the long-term success rate of the treatment plan provided in this case report, and thus instil greater confidence in clinicians to implement the said treatment in their routine dental practice.


  Conclusion Top


Our case report highlights that a periodontally compromised tooth of severe nature (1) with the presence of pyogenic granuloma can be treated with a multidisciplinary approach giving priority to the patient comfort and expectation from the treatment planned (2) can respond favorably with no signs and symptoms of further periodontal tissue deterioration if periodontal regenerative therapy is meticulously implemented with regularly maintaining follow-up visits resulting in keeping the decision of tooth extraction, especially in the anterior region on hold or eliminating that option altogether.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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