# Refractory Gingival Enlargement: A Critical Oral Clue to Early‐Stage Granulomatosis With Polyangiitis—A Case Report and Literature Review

## TL;DR

A rare case of granulomatosis with polyangiitis (GPA) presented solely through oral symptoms, highlighting the importance of early dental recognition for timely diagnosis and treatment.

## Contribution

This case report highlights GPA's rare oral-only presentation and proposes a diagnostic and management protocol for oral GPA.

## Key findings

- Oral GPA can present with strawberry gingivitis and resolve completely with systemic and topical therapy.
- Early diagnosis and multidisciplinary management prevented progression to other organs in this patient.
- Effective treatment required concurrent management of comorbid conditions like diabetes and hypothyroidism.

## Abstract

Granulomatosis with polyangiitis (GPA), formerly known as Wegener′s granulomatosis, is a rare, systemic small‐vessel vasculitis characterized by necrotizing granulomatous inflammation. It classically affects the upper airway, lungs, and kidneys. Oral manifestations are infrequent, occurring in approximately 6%–13% of cases, and represent the initial presentation in only about 2%.

A 55‐year‐old female was presented with a two‐month history of painful, bleeding gingival hyperplasia unresponsive to routine periodontal therapy. Intraoral exam revealed “strawberry gingivitis”—diffuse, friable, erythematous granular gingival enlargement. Comprehensive workup showed elevated inflammatory markers and positive cytoplasmic ANCA (c‐ANCA). Gingival biopsy demonstrated granulomatous inflammation with necrotizing vasculitis, confirming localized GPA confined to oral tissues. Multidisciplinary management was initiated with systemic immunosuppression (oral azathioprine and deflazacort) and topical therapy, alongside optimization of the patient’s comorbid conditions. An antifungal and antibiotic prophylaxis regimen was also provided.

Following the commencement of therapy, the gingival lesions exhibited complete resolution within 3 weeks. Over a 12‐month follow‐up period, there was no evidence of progression to other organ involvement. The concurrent management of the patient′s diabetes and hypothyroidism was instrumental in facilitating optimal healing and overall patient recovery.

This case distinctly underscores that GPA can present solely with oral symptoms, making early recognition by dental clinicians paramount for prompt diagnosis. The presence of “strawberry gingivitis” serves as a crucial, pathognomonic clinical sign. We propose a diagnostic and management protocol for oral GPA to improve patient outcomes.