Pyostomatitis Vegetans

Case report: In the present case, a 19-year-old female patient with no general medical history presented with multiple, small, pale yellow pustules in the area of the entire oral cavity. The changes had been present for 2 months. The greatest density of changes was found in the folds of the upper and lower jaw. Further symptoms were erythematous thickening of the gingiva and mucosa as well as hyperplastic cheek mucosa in places, especially in the buccal planum. There were no complaints. The microbiological examination of the mucosal swab was unremarkable. A biopsy of the left inframammary fold confirmed the clinical diagnosis.
A local combination therapy with a glucocorticoid-containing mouth rinse and an accompanying antimycotic and antibacterial treatment was administered. The therapy resulted in a significant reduction of the pustules in the area of the gingiva and mucosa.
Pyostomatis vegetans is often associated with inflammatory bowel diseases (Crohn's disease, ulcerative colitis). However, a colonoscopy with biopsies was negative. The patient is followed up regularly.
Discussion: The clinical presentation of pyostomatitis vegetans allows a reliable diagnosis. Typical clinical signs are: multiple pale yellowish spots and pustules, an erythematous thickened orange-red gingiva, and mucosa, erosions and ulcers, hyperplastic folds of the buccal mucosa and vestibule, a nodular mucosa and fissures on the mucosal surface. Pus discharges from the pinhead-sized pustules on pressure. The erosions may fuse. The lesions usually occur bilaterally symmetrically throughout the oral cavity. The aetiology is largely unexplained. There are no pathogenic bacteria, viruses or fungi, so the most likely cause is thought to be an immune reaction.
A frequent association with chronic inflammatory bowel diseases such as Crohn's disease or ulcerative colitis is known, but as in the present case, is not always present. Liver and biliary tract diseases are also associated with pyostomatitis vegetans. Other differential diagnoses are: Lichen ruber, oral pseudomembranous candidiasis, gingivostomtitis herpetica, bullous autoimmune dermatoses, or Fordyce spots.
Therapy can be local or systemic. The most effective therapy is the topical application of glucocorticoids. The use of tetracycline or tacrolimus is also described in the literature. Glucocorticoid therapy should be supported by preventive antifungal treatment.
Summary: Pyostomatitis vegetans is a rare oral mucosal disease with a very characteristic morphology. Typical are bass yellow mottled pustules on a reddened mucosa with erosions and thickening. Treatment is topical with glucocorticoids and antifungals. The general dentist should be familiar with the clinical picture, especially as it may be the first manifestation of a chronic inflammatory bowel disease.