Adjunctive Treatment of Recurrent Oral Pyogenic Granuloma With Platelet‐Rich Fibrin and Diode Laser: A Case Report With Two Years' Follow‐Up

ABSTRACT

A multimodal treatment approach combining conventional surgery, diode laser, and PRF membrane application can enhance healing and reduce recurrence in severely recurrent pyogenic granuloma, offering a promising protocol for the management of these lesions.

1. Introduction

Pyogenic granuloma is a reactive inflammatory lesion that occurs frequently in the skin and mucous membranes [1]. The reactive process may be triggered by local irritants (dental calculus, biofilm, defective restorations, food impaction, and occlusal interferences), traumatic influences (tooth injury, eruption of primary teeth, and tooth brushing trauma), and chronic irritation or preexisting vascular lesions, often in association with periodontitis [2]. The Gingiva is predominantly affected; however, it may occur in other sites of the oral cavity, including the lips, tongue, buccal mucosa, hard palate, and peri‐implant sites [3, 4]. The name of this lesion is inappropriate since it is not related to pus formation. Furthermore, histologically, it resembles an angiomatous lesion rather than a granulomatous lesion [5]. Some researchers have adopted the designation of lobular capillary hemangioma, which more accurately reflects the histopathological characteristics of this lesion [6]. It also called pregnancy tumor, vascular tumor, and lobular capillary tumor [7]. The lesion is commonly more seen in females, particularly in their second decade of life. This can be explained by the increased circulating levels of both estrogen and progesterone. The male‐to‐female ratio is approximately 1:99 [8].

The clinical appearance of pyogenic granuloma is that of an asymptomatic mass. It presents as a smooth or lobulated mass, which may be pedunculated or sessile. It often bleeds upon minor trauma. The lesion gradually increases in size, ranging from a few millimeters to multiple centimeters [9]. Because of its vascular nature and tendency to recur if predisposing factors are not eliminated, several treatment modalities have been proposed. These modalities include cryosurgery [10], corticosteroid injection [3], sclerotherapy, and lasers using different wavelengths [11]. The standard treatment modality is the traditional surgical excision; however, some researchers have applied platelet‐rich fibrin to enhance healing outcomes and reduce the recurrence rate [9]. Moreover, other researchers have used diode lasers to achieve effective hemostasis, to ensure better visualization, and reduce postoperative complications. Furthermore, it was used to decontaminate periodontal pockets to reduce microbial overload [12, 13].

In the following case, we present a severely recurrent pyogenic granuloma in a female patient. The lesion had relapsed ten times over a period of three years. The lesion was managed by complete surgical excision using the conventional approach. Adjunctively, diode laser was employed for hemostasis, to provide a clear work field, and for decontamination of the periodontal pocket. This was followed by the application of a platelet‐rich fibrin membrane. The patient was followed for two and a half years to evaluate recurrence and assess the clinical healing of the lesion. To the best of our knowledge, this is the first case to highlight a multimodal strategy for the management of a severely recurrent pyogenic granuloma.

2. Case History/ Clinical Examination

A 33‐year‐old female was referred to the Department of Oral Medicine, Faculty of Dental Medicine, Damascus University with a chief complaint of a frequent occurrence of a bleeding mass in the lower premolars. The patient reported 10‐times recurrences of the lesion, with varying sizes at the same site following surgical intervention. On each occasion, the mass was excised using conventional surgery. Medical history revealed no previous or current systemic diseases or medication intake. However, the patient mentioned a previous mild hormonal disturbance. Before clinical assessment, written informed consent was obtained for documentation and publication of the clinical findings. Intraoral examination revealed a sessile, pink‐colored mass with a smooth surface between teeth 34 and 35. This mass was painless and bled upon minor trauma (Figure 1A). Calculus was evident at the same site.

FIGURE 1.

Clinical stages of lesion excision, (A) preoperative view showing the mass between the two mandibular premolars, (B) intraoperative view showing the traditional removal of the lesion, (C) intraoperative view directly after diode laser hemostasis, and (D) direct postoperative view showing the PRF membrane in place.

3. Methods

After administration of local anesthesia using lidocaine 2% with epinephrine 1:80,000, the tumor was excised down to the periosteum (Figure 1B). Any granulation tissue and subgingival calculus were removed using Gracey curettes. The excised mass was immersed in 10% formalin and sent for histopathological evaluation. Gingival debridement of the root surface was performed. Diode laser was used to provide hemostasis (wavelength of 810 nm, continuous mode, fiber diameter of 300 μm, and power of 3 watts) where bleeding was evident. In addition, the periodontal pocket was decontaminated using the following parameters: wavelength of 810 nm, pulsed mode, fiber diameter of 300 μm, and power of 1.5 watts (Figure 1C). PRF membrane was prepared and was positioned at the surgical site and secured with interrupted silk (3/0) sutures (Figure 1D).

The PRF membrane was previously prepared using the following protocol: 20 mL of the patient's blood was withdrawn and distributed into two tubes. No substances or anticoagulants were added. Immediately, they were transferred to the centrifuge, which was set at a speed of 2700 rpm for a total of 10 min. Following centrifugation, a dense fibrin network was formed in the middle layer of the centrifuge tube. This layer containing the platelet‐rich fibrin clot, was carefully separated from the tube and placed on a sterile surface. It was then compressed between two sterile gauze pads to obtain the PRF membrane. The PRF membrane preparation procedure is shown in (Figure 2).

FIGURE 2.

Preparation of PRF membrane, (A) blood withdrawal from the patient, (B) formation of the dense fibrin network in the middle layer after centrifugation, (C) extraction of platelet‐rich fibrin clot prior to compression into the final membrane, and (D) The final membrane after compression between two pads of gauze.

The patient was prescribed antibiotics (amoxicillin 500 mg three times daily for three days), and paracetamol 500 mg as needed. Moreover, she was instructed to avoid vigorous rinsing on the surgical side, and to adhere strictly to oral hygiene instructions. Follow‐up sessions were scheduled at two days, two weeks, one month, and six months postoperatively. The patient was subsequently followed after one year and two and a half years to ensure stability of the outcome and confirm the absence of recurrence.

3.1. Histopathological Findings

Histopathological evaluation revealed a hyperplastic gingival epithelium with no dysplastic changes. The connective tissue showed numerous blood vessels, either dilated or newly formed. A dense inflammatory infiltration was evident. The histopathological features were consistent with oral pyogenic granuloma.

3.2. Follow‐Up and Outcomes

Postoperative complications were negligible. Neither pain, edema, nor bleeding was reported. The 14‐day follow‐up evaluation revealed merged incision lines, nearly complete epithelialization, and an absence of bleeding or redness along the wound lines.

The patient was followed for two and a half years; in each recall session, she received scaling. No recurrence was observed during the follow‐up sessions (six months, one year, and two and a half years postoperatively), as shown in (Figure 3A–D).

FIGURE 3.

Patient follow‐up, (A) fourteen‐day postoperative view showing nearly merged incision margins, without inflammation signs, (B) six‐month postoperative view showing healthy gingival appearance with no recurrence, and (C, D) one‐year and two‐and‐a‐half‐year postoperative views, respectively, showing no recurrence at the surgical site, (images B, and D were taken after scaling).

4. Discussion

The presented case highlights a multimodal strategy for the management of a severely recurrent PG. In order to accelerate healing and reduce postoperative complications, the PRF membrane was applied directly after the surgery. In addition, the advantages of diode laser application were utilized in achieving hemostasis and decontaminating the pocket surface. Since pyogenic granuloma has a high rate of recurrence (nearly 16% [14]), we used three treatment modalities to ensure complete removal of the lesion and eliminate the predisposing factors. The originality of this case report lies in the implementation of a multimodal therapeutic protocol for the management of recurrent pyogenic granuloma. Unlike conventional approaches that rely on a single treatment modality, our protocol integrates three complementary techniques within a single case. This combined approach aimed to ensure complete lesion removal, to enhance hemostasis and decontamination, and to promote accelerated wound healing. To our knowledge, the use of three modalities in the management of recurrent pyogenic granuloma has not been previously documented, which underscores the novelty and clinical relevance of this approach.

Platelet‐rich fibrin (PRF) membrane is the activated form of fibrinogen resulting from blood centrifugation. It forms a protective wall along the capillaries during the coagulation process. The fibrin architecture helps entrap varying numbers of leukocytes within the fibrin network. This allows a slow and sustained release of growth factors that enhance wound edge healing and promote faster epithelialization [15]. PRF application promotes faster healing. This can be attributed to the release of pro‐inflammatory cytokines (for instance, TNF‐α, Interleukin‐1β, and Interleukin‐6). In addition, many growth factors such as vascular endothelial growth factor (VEGF), platelet‐derived growth factor, fibroblast growth factor, transforming growth factor, and insulin‐like growth factor are also released [9, 15]. A recent systematic review reported the numerous advantages of PRF in accelerating healing after regeneration surgeries in the management of soft tissue defects [16]. A recent case report used PRF after surgical removal of PG in the anterior region of the mandible. The study reported a good patient tolerance and minimal postoperative complications. In addition, follow‐up recalls revealed the absence of recurrence [9]. This was in alignment with our results.

Diode laser produces near‐infrared wavelengths. These wavelengths are well known for their high absorption in body pigments such as melanin and hemoglobin [17]. Thus, it was used to provide complete hemostasis in areas where bleeding was still ongoing. This provided good vision, helped to eliminate all predisposing factors, and provided a clear work field in order to apply the PRF membrane. In addition, since diode laser has bactericidal effects on periodontopathic pathogens, it was placed in the periodontal pocket to disinfect the region [18].

Previous recurrence of PG in this case can be attributed to many factors. These include the previous hormonal disturbance, failure to eliminate the predisposing factors, and incomplete removal of the lesion. Furthermore, the surgery was restricted to the traditional removal. Although the latter remains the standard treatment, the accompanied uncontrolled intraoperative bleeding may hinder complete removal of the lesion. Hence, diode laser was later used for hemostasis. The success of the presented treatment can be attributed to the multimodal strategy of traditional surgery, diode laser, and PRF membrane application.

The use of PRF is limited by the need for additional preparation steps, which may prolong the overall procedure duration. Moreover, diode laser application is restricted by its high cost, requirement for specialized training, and the potential risk of thermal damage if parameters are not properly adjusted [19, 20]. In addition, as this article represents a single case report, the findings cannot be generalized to broader clinical practice. These limitations may affect the generalizability and routine application of the proposed protocol. Hence, well‐organized randomized controlled trials with long follow‐up periods are warranted to confirm our claims. The patient reported her satisfaction with the treatment provided. At two‐and‐a‐half years' follow‐up, the healing outcome was favorable, and no recurrence was noted.

5. Conclusion

Pyogenic granuloma is known for its high recurrence rate, often resulting from incomplete excision or failure in eliminating predisposing factors. In this article, we proposed a multimodal treatment strategy that improved postoperative outcomes and was not associated with recurrence during the follow‐up visits. Nevertheless, as this study presents a single case, the findings remain limited in scope and cannot be generalized or routinely applied without further evidence.

Author Contributions

Omar Hamadah: conceptualization, supervision, writing – review and editing. Raneem Darkazali: writing – review and editing, conceptualization. Razan Hafez: writing – original draft, conceptualization, investigation, methodology, data curation.

Funding

The authors have nothing to report.

Ethics Statement

Ethics approval was obtained from the ethics committee of Damascus University.

Consent

Written informed consent was obtained from the patient to publish clinical details and photographs.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.