BBOP Forum

Bulletin Board of Oral Pathology

Forum for Clinical and Surgical Oral Pathology

Case BBOPF 16-1

Dr. Mitzi J. Palazzolo (Maj USAF AETC AFMOA/SGDS) is seeking your suggestions to manage a case of recurrent gingival lesions that have been diagnosed as pyogenic granulomas, peripheral ossifying fibromas, generalized gingival hyperplasia..etc. More specifically, she is seeking advise on any non-surgical approach that would benefit this patientPlease send your comments in the window located below the images. This case will be posted until October 11, 2016. A summary of the responses will then be posted.

Clinical History

A 52 yo caucasian female presents with a medical hx that includes migraine headaches, granuloma annulare, and menopause. Past medications include topomax, nortriptilyne, Maxaltprn, multivitamins, fish oil, and botoxinjq 12 weeks.

Pt initially noticed lesions summer 2012 and was referred by her general dentist in Feb 2013 for evaluation/biopsy. In March of 2013 the patient was diagnosed as menopausal based on blood work, but was not placed on any medication. In June 2013, her neurologist changed her migraine management from topomax and nortriptilyne (which she had been taking for 2-3 years) and placed her on inderal, which she had taken previously. These medication changes did not alter the presentation of the gingival lesions or their recurrence, so in Feb 2014 she was placed back on topomax and Nortriptilyne. In Nov 2013, the pt was placed on estrogen and progesterone, again with no change in lesions; she was then taken off the hormones in May 2014.

Pt was placed on a strict periodontal maintenance schedule and returned every 2-3 months. Pt had gingivectomies and biopsies performed in July, Nov, Dec 2013 and Feb, Mar 2014. Trays were made and pt was prescribed lidex 0.05% ointment Dec 2013, with recurrence noted. Medication was switched to Clobetasol 0.05% (apply to trays and wear 30 min qid) in Feb 2014. Also prescribed 0.12% chx. Re-evaluation at the maintenance appointment 31 Jul 14 revealed recurrence of lesions despite superior plaque control. Biopsy was taken of distal papilla and gingival margin #20. The patient has been off of topomax since July 2015, she is not diabetic. The patient comes in quarterly for gingivectomy/biopsy and debridment.