J Biosci (2019) 44:78 Ó Indian Academy of Sciences DOI: 10.1007/s12038-019-9898-y (0123456789().,-volV)(0123456789().,-volV) Analysis of nine cases of oral foreign body granuloma related to biomaterials 1 1 1 LARISSA SANTOS AMARAL ROLIM ,CAIO CE´ SAR DA SILVA BARROS ,JULIANA CAMPOS PINHEIRO , 2 2 PATRI´CIA TEIXEIRA DE OLIVEIRA ,LE´ LIA BATISTA DE SOUZA and 3 PEDRO PAULO DE ANDRADE SANTOS * 1Oral Pathology Post-Graduation Program Student, Federal University of Rio Grande do Norte, Natal, RN, Brazil 2Oral Pathology Post-Graduation Program, Dentistry Department, Federal University of Rio Grande do Norte, Natal, RN, Brazil 3Oral Pathology Post-Graduation Program, Morphology Department, Federal University of Rio Grande do Norte, Natal, RN, Brazil *Corresponding author (Email, [email protected]) MS received 16 September 2018; accepted 10 April 2019; published online 2 August 2019 Foreign bodies can penetrate the interior of soft and, sometimes, hard, tissues in various ways, including through open wounds, lacerations and traumatic accidents. However over the years, evidence of links between the use of dental materials and lately, significant involvement of aesthetic filler materials as foreign bodies in the oral and perioral region have been reported. Foreign body granulomas (FBGs) may develop from this exogenous material, histopathologically characterized by the presence of chronic inflammation and a high amount of macrophages. This study presents nine FBG cases affecting the oral and perioral regions, and carries out a literature review on the main clinical, histopathological and material characteristics used in dental and dermatological procedures related to the appearance of this type of granuloma. Keywords. Cosmetic filler; endodontic filler; foreign body; foreign body granuloma 1. Introduction injectable materials have been developed in cosmetic dermatology to soften wrinkles, treat adipose tissue atrophy Giant cells related to foreign bodies develop from the fusion and promote increased soft face tissues, commonly injected of local macrophages that adhere to the surface of different into the dermis of perioral tissues, including the lips, naso- synthetic materials, acting in their degradation. The insertion labial sulcus, cheeks (Requena et al. 2011), mentolabial of foreign bodies into human oral and perioral tissues may groove, chin region and lip commissure (Bass 2015). Due to originate from traumatic events, postoperative dental pro- the variability of materials that can be inserted into tissues in cedures (Jham et al. 2009; Rai et al. 2015) and dermato- different ways, careful anamnesis and clinical evaluations logical aesthetic procedures (Jham et al. 2009; Lee et al. are necessary for accurate FBG diagnoses and appropriate 2017). The origin of foreign body granulomas (FBGs) treatment (Rai et al. 2015). In this context, this study reports remains unclear, and their development is unpredictable, nine FBG cases involving the oral cavity and perioral tis- although their establishment has been associated with host sues, highlighting their clinical and histopathological char- response variability and infection (Costa Miguel et al. 2009), acteristics and their relationship with different types of and may be related to pharmacological stimuli (Quirino et al. exogenous materials. 2012). FBGs in periapical oral tissues may develop due to the insertion of exogenous material, either accidentally or through iatrogenic dental procedures (Plascencia et al. 2. Materials and methods 2014). Over the years, an increase in the appearance of FBGs related to dermal filler cosmetic materials, such as The study protocol was approved by the Ethics Committee bovine collagen in the 1980s used to treat wrinkles and soft- of the Federal University of Rio Grande do Norte (UFRN) tissue defects, has been observed. Since then, many (number 1.883.170). The inclusion criteria were all cases of http://www.ias.ac.in/jbiosci 1 78 Page 2 of 8 Larissa Santos Amaral Rolim et al. oral FBGs diagnosed between January 1969 and December 2016, selected for this study among 14,000 oral lesions diagnosed in the Oral Pathology Service files at UFRN. Data regarding patient age, sex, duration, location, symptoma- tology, clinical presentation, size, staining, use aesthetic filling substances, cases were compiled from the clinical data sent together with the biopsy records. For histopathological analysis, all slides containing hematoxylin-eosin-stained 5-lm-thick sections were reas- sessed. Under light microscopy (Olympus CX31; Olympus Japan Co., Tokyo, JPN), oral FBGs were histologically fillers Biopsy reviewed by two previously trained examiners. Regarding histological findings, presence of giant cells, type of Dermal cosmetic inflammatory infiltrates and identification of the biomaterial related to each case. The data were tabulated and analyzed by descriptive statistics using the IBM SPSS Statistics (version 20.0; IBM Corp., Armonk, NY, USA). fillers Endodontic 3. Results The epidemiological and clinical data of our nine cases are summarized in table 1. Six cases were of female patients, three male patients, with mean age of 51.4 years for women and 39 years for men. With regard to FBG locations, five cases occurred in the lip region (two upper lip, two lower lip and one labial commissure. The lesion was presented in six cases (66.6%) as a fibrotic nodule, in three cases the duration ranged from 2 to 60 months and six cases were asymp- tomatic. The color of lesions was variable with a pale appearance in three cases. The use of filling material in Duration aesthetic facial procedure was reported by four patients and (months) Symptomatology Staining only one patient reported recent dental treatment with endodontic procedure. In six cases, excisional biopsy was chosen, one case of incisional biopsy and in two cases there Size was no such information in the clinical file. Histopathology (cm) features of oral FBGs are in table 2. Several multinucleated giant cells (figure 1A) was seen in all cases, predominantly lymphocytic inflammatory infiltrates in all nine cases (100%), asteroid bodies (figure 1B) related to polymethyl- Clinical methacrylate (PMMA) in three cases (33.3%) and vasculitis presentation (figure 1C) in five cases (55.5%) were observed. Regarding the biomaterials related to our cases of oral FBGs, we found in four cases PMMA (44.4%), two cases hyaluronic acid (22.2%), in the remaining three cases calcium hydroxylap- atite (11.1%), collagen hemostatic (11.1%) and nylon (11.1%). 4. Case reports Age 4.1 Case 1 (years)/sex Location Distribution of epidemiological and clinical aspects in nine cases of oral FBG During anamnesis, a 33-year-old female patient reported undergoing paraendodontic surgery, endodontic retreatment not available. Case Year Table 1. NA and calcium hydroxide (Ca(OH)2) dressing 18 months prior 123 20004 20065 2007 33/F6 2007 59/F7 2009 43/M Posterior8 jaw 2009 NA/F Lip9 commissure 2011 54/F Posterior jaw Fibrotic Cystic 2012 14/M Upper nodule lesion lip 2014 56/F Lower Soft 5.0 lip lesion 60/M Posterior jaw 1.0 55/F Upper lip Fibrotic nodule Lower lip Fibrotic nodule Fibrotic NA nodule Buccal NA 4.0 mucosa 10.0 NA 1.0 NA Fibrotic nodule Fibrotic nodule NA Asymptomatic 2.0 NA 1.0 NA 12 Pale white 48 Asymptomatic Asymptomatic 60 NA NA Pale 2 Symptomatic pink Pale red Symptomatic NA Pink Yellow Asymptomatic NA NA Asymptomatic Normal No NA White Asymptomatic No NA Yes NA No NA No NA Yes No No Yes Excisional No Excisional Yes NA Excisional NA Incisional Excisional excisional Yes Incisional Analysis of nine cases of oral FBG related to biomaterials Page 3 of 8 78 Table 2. Compatible material, category and histopathology features in nine cases of oral FBGs Case Compatible material Category Histopathology features 1 Calcium hydroxylapatite Resorbable within years Amorphous particles of black staining, presence of multinucleated giant cells, moderate and focal inflammatory infiltrate 2 PMMA microspheres Permanent Pseudocyst spaces of varying sizes permeated by multinucleated giant cells, forming lobes separated by septa of connective tissue 3 Collagen hemostatic Resorbable within months Eosinophilic particles of irregular shapes which are surrounded by numerous multinucleated giant cells 4 PMMA microspheres Permanent Pseudocyst spaces of varying sizes permeated by multinucleated giant cells, forming lobes separated by septa of connective tissue 5 PMMA microspheres Permanent Pseudocyst spaces of varying sizes permeated by multinucleated giant cells, forming lobes separated by septa of connective tissue 6 Hyaluronic acid Resorbable within months Amorphous particles of varying size of basophilic staining, permeated by multinucleated giant cells 7 PMMA microspheres Permanent Pseudocyst spaces of varying sizes permeated by multinucleated giant cells, forming lobes separated by septa of connective tissue 8 Suture material (Nylon) Non-absorbable Particles of varied morphology with crystalloid appearance, exhibiting grayish coloration and orange borders, circumscribed by an extensive area of inflammatory infiltrate 9 Hyaluronic acid Resorbable within months Amorphous particles of varied size of basophilic staining sometimes more bluish, permeated by multinucleated giant cells measuring approximately 1 cm in diameter, related to the dental element 46. The diagnostic hypothesis of a radicular cyst was formulated. An excisional biopsy was performed and the samples were sent to the Pathology Sector of the Dentistry Department of the UFRN. A mononuclear inflammatory infiltrate of moderate