Román‑Quesada et al. BMC Oral Health (2021) 21:204 https://doi.org/10.1186/s12903‑021‑01566‑4 RESEARCH ARTICLE Open Access An analysis of the prevalence of peripheral giant cell granuloma and pyogenic granuloma in relation to a dental implant Nieves Román‑Quesada1, Beatriz González‑Navarro2,3, Keila Izquierdo‑Gómez2,3, Enric Jané‑Salas2,3, Antonio Marí‑Roig3,4, Albert Estrugo‑Devesa2,3* and José López‑López2,3,5* Abstract Background: The aim of the present investigation was to evaluate the literature recurrence of peripheral giant cell granuloma and pyogenic granuloma associated with dental implants. It’s important to know the characteristics pre‑ sent in these lesions and possible efects on the prognosis of dental implants. Methods: An electronic search without time restrictions was done in the databases: PubMed/Medline. With the keywords "Granuloma" OR "Granuloma, Giant Cell" OR "peripheral giant cell" OR "Granuloma, Pyogenic” AND "Dental implants" OR "Oral implants”. Results: After applying the inclusion and exclusion criteria, a total of 20 articles were included, which reported 32 lesions (10 pyogenic granulomas, 21 peripheral giant cell granulomas and one peripheral giant cell granuloma com‑ bined with peripheral ossifying fbroma, all associated with implants). According to our review, these lesions are more frequent in males and in the posterior region of the mandible. Both excision and curettage of the lesion, compared to only excision, presented similar recurrences (40%). Explantation of the implant was performed in 41% of cases without additional recurrences. The results are not statistically signifcant when comparing one lesion to the other in terms of explantation (p 0.97), recurrence (p 0.57) or bone loss (p 0.67). = = = Conclusions: The main therapeutic approach is tissue excision. The lesions show a high recurrence rate (34.4%), which often requires explantation of the associated implant. This recurrence rate is not afected by curettage after excision. Keywords: Dental implant, Oral implant, Pyogenic granuloma, Peripheral giant cell granuloma, Reactive oral lesions Background biological and technical complications [3, 4]. Te most Te replacement of missing teeth with dental implants prominent biological complications are peri-implant has a high success rate, but it is still a technique which mucositis and peri-implantitis [3, 5, 6]. In a 2017 system- involves risks and requires good evaluation and planning atic review, Lee et al. [7] demonstrated that the rates of to minimize failures [1, 2]. However, the increasing num- mucositis and peri-implantitis were 29.48% and 9.25%, ber of dental implants used leads the dentist to encounter respectively. Te appearance of so-called peri-implant reactive *Correspondence: [email protected]; [email protected] lesions is another complication that must be taken into 2 Department of Odontoestomatology, Faculty of Medicine and Health consideration. Despite its lower incidence, its presence Sciences (Dentistry), Bellvitge Campus, University of Barcelona, Barcelona, could imply the need for explantation [2, 3, 8]. Reactive Spain Full list of author information is available at the end of the article lesions are characterized by excessive proliferation of © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Román‑Quesada et al. BMC Oral Health (2021) 21:204 Page 2 of 11 connective tissue in response to chronic irritation [9]. in the maxilla than in the mandible, and in the anterior Among these lesions, those most frequently observed in areas when associated with teeth [9]. Histologically, PG is the oral cavity are pyogenic granuloma (PG), traumatic composed of proliferating blood vessels and granulation fbroma, fbroepithelial hyperplasia, peripheral ossifying tissue, often organized in lobular aggregates, hence the fbroma and peripheral giant cell granuloma (periheral name capillary lobular hemangioma [3]. It is character- giant cell lesion, -PGCG-) [4, 9]. PG and PGCG are the ized by prominent capillary growth in hyperplastic gran- reactive lesions most frequently associated with teeth and ulation tissue, suggesting high angiogenic activity. Blood implants [2, 9]. Some factors such as chronic infamma- vessels often show a grouped or separated pattern by less tion, the accumulation of foreign bodies or corrosion of vascular fbrotic septa, leading some authors to consider the implant surface could cause a chronic irritative pro- PG as a polypoid form of capillary hemangioma [12]. cess and act as contributing factors not only for mucositis PGCG is believed that its pathogenesis includes an and peri-implantitis but also for PG and PGCG [3, 4, 10]. excessive activation of osteoclasts, which is associated Several factors have been studied that could interfere with a proliferation of macrophages and can cause sig- with osseointegration and therefore the survival of the nifcant bone resorption [9]. Clinically, PGCG may pre- placed implant. Factors such as smoking, diabetes and sent as a frm or soft, sessile or pedunculated nodule, periodontal disease have been studied [9, 11]. However, color ranging from bluish to purple, with a frequently with regard to reactive lesions, such as PG and PGCG, ulcerated surface, confned to the alveolar and/or gingival the prevention technique is the maintenance of healthy mucosa. Swelling is the most frequent sign and its clinical peri-implant tissue [9] (Fig. 1). course is usually asymptomatic [4, 13]. It tends to show PG can occur in response to irritants, trauma, hormo- a progressive increase in size and can cause pressure on nal changes or certain medications. Although classically the adjacent teeth, which could lead to malocclusion or called PG, the most correct name would be capillary interference with mastication. Erosion of the underlying lobular hemangioma, since the lesion is not strictly a bone or periodontium can also occur and in edentulous granuloma or an infection [9, 10]. Clinically, oral PG is areas, it can often cause a radiolucent cup-shaped image characterized as an exophytic mass with a smooth or in intraoral radiography [4]. PGCG does not have an age lobulated appearance that can be sessile or peduncu- predilection. It seems to have a greater predilection in lated. Te epithelium is frequently ulcerated and varies women and tends to appear more frequently in the molar in color from pink to red and/or purple, depending on area [4, 9, 11]. It consists of a non-encapsulated lobulated the evolution time and the vascularization of the lesion. tumor of proliferating vascular connective tissue with a Te lesion tends to grow rapidly in a short period of time, large number of osteoclast-type multinucleated giant with a tendency to bleed spontaneously or after a minor cells. It is common to fnd signs of bleeding and hemosi- trauma [10, 12]. Its incidence varies between 3.81 to 7% derin deposits inside the lesion. Fibroblastic proliferation of the histopathological results of biopsies performed and/or signifcant formation of osteoid material and even in the oral cavity [3, 12]. According to the literature, it bone is common. Blood biochemistry shows no altera- is more frequent in young women (3:2), more common tions [3, 13]; however, if alteration of phosphorus-cal- cium metabolism appears, hyperparathyroidism should be suspected and a brown parathyroid tumor should be ruled out [14–16]. Te treatment of both PG and PGCG includes com- plete surgical excision until bone level and complete curettage, as well as removal of the causative agent if identifed [17]. Since it is rarely reported it’s important to know the characteristics present in these lesions and pos- sible efects on the prognosis of dental implants in order to take the appropriate course of action in the clinical practice. Te aim of the present study was to search the associa- tion of the available data published in the literature on PG and PGCG associated with dental implants, analyzing their recurrences, associated etiological factors and dif- ferent treatment options. For this we asked ourselves the following PICO question: What is the prevalence, recur- Fig. 1 Pyogenic granuloma associated with a dental implant rence, etiological factors and treatment of PG and PGCG Román‑Quesada et al. BMC Oral Health (2021) 21:204 Page 3 of 11 around dental implants? P: Dental implants; I: develop- recurrence of lesions and bone loss. All reported values ment of a reactive lesion; C: PG vs. PGCG, type of treat- (P values) were compared to a signifcance level of 5%. ment carried out (excision vs. excision and curettage); O: Prevalence of PG and PGCG around dental implants, Results recurrence of the lesions and bone loss around dental 141 articles were obtained with the search strategy implants associated with the lesions. used. After excluding duplicate articles, 91 articles were selected and reading the title and abstract, 32 were left. Methods Out of 32 articles, 4 were excluded because they were not Search strategy written in English or Spanish, 6 due to lack of data and Te present study followed the Preferred Reporting Items 2 because data was related to teeth instead of implants.