Incidental Finding of Phlebolith in a Patient
with Chronic Inflammatory Gingival
Enlargement – A Case Report
Roshni Ramesh1*, Arun Sadasivan2 and Pradheesh Sathyan3
1Department of Periodontics, Government Dental College, India
2Department of Periodontics, Government Dental College, IndiDepartment of Periodontics, Sree Mookambika Institute of Dental Sciences, Indiaa
3Department of Oral Pathology, Government Dental College, India
Submission: April 13, 2017; Published: May 23, 2018
*Corresponding author: Roshni Ramesh, Professor, Department of Periodontics, Government Dental College, Trivandrum-695011, Kerala, India,
Tel: 9198475230052; Email: [email protected]
How to cite this article: Roshni R, Arun S, Pradheesh S. Incidental Finding of Phlebolith in a Patient with Chronic Inflammatory Gingival Enlargement – A Case
Report. Adv Dent & Oral Health. 2018; 9(1): 555753. DOI: 10.19080/ADOH.2018.09.555753
The aim of this case report is to alert clinicians to the possibility of occurrence of vascular thrombi in the mouth. Phleboliths (calcified thrombi) are a common finding, especially in the pelvic veins. They are usually associated with vascular malformations and are generally multiple. Here in we report an incidental finding of a phlebolith associated with chronic inflammatory gingival enlargement and not associated with any other vascular lesion. Although phleboliths not associated with other vascular lesions are not a common finding in the oral cavity, clinicians should be aware of the existence of such lesions. Phleboliths associated with gingival enlargements even though rare do occur. Dentists need to be aware of the existence of such lesions and should rule out the possibility of vascular lesions in such cases.
Phleboloths are calcified thrombi that occur in vascular channels associated with hemangiomas and other vascular lesions as venolymphatic malformations and are caused by blood stasis  or even trauma . They are usually multiple and may vary in number from several to dozens within the affected area. They are most commonly seen in the pelvic area within prostatic, uterine or intestinal veins. Phleboliths are not unusual in the head and neck region, but only a few cases of phleboliths not associated with other vascular anomalies have been reported in the literature [3-5].
Phleboliths are commonly found on routine radiographs of cases diagnosed as vascular malformations although they are better detected by computerized tomography [6,7].
Besides imaging techniques, biopsy followed by microscopic examination can help in the final diagnosis.
Even though phleboliths are not rare in the head and neck, buccal soft tissues rarely contain lesions that include calcifications. Here in we report an incidental finding of calcification within a chronic inflammatory gingival enlargement. To the best of our knowledge, this could be the first reported instance of occurrence of phlebolith in a case of gingival enlargement. By presenting this case, we aim to alert clinicians regarding the importance of biopsy
in all cases of gingival enlargements to rule out the possibility of vascular malformations.
A 32 – year old woman was referred to our clinic presenting with generalised gingival enlargement. She reported difficulty in mastication and speech. Patient’s medical history was non-contributory.
On intraoral examination, generalised, diffuse, fibroedematous
overgrowth of gingival tissues of both the maxillary and
mandibular teeth was seen. The severity of enlargement was more
in relation to posterior teeth (Figure 1a-1d). The probing depth in
the posterior region ranged from 4 to 6mm. Plaque accumulation
was moderate and the gingiva was inflamed with a pale red colour.
The condition was not painful, but there was mild bleeding on
probing. The teeth were not mobile.
Intraoral periapical and panoramic radiographs were taken.
Radiographs revealed generalised mild bone loss with slight
interproximal bone loss (Figure 2). Radiographs did not reveal any
bony lesion. General examination and blood investigations were
done to rule out any medical involvement. Serum calcium level
and routine biochemical tests were normal. Results of complete
blood count indicated no significant abnormalities. Based on the
above findings, a provisional diagnosis of chronic inflammatory
gingival enlargement was made.
After completion of oral prophylaxis, internal bevel
gingivectomy with open flap debridement was done first in the
mandibular left posterior quadrant. The excised gingival tissue
was sent for histopathological examination.
Microscopic examination revealed parakeratinized,
hyperplastic stratified squamous epithelium in association with
a fibrovascular connective tissue stroma (Figure 3). Acanthosis
was noted in some foci while in other areas the epithelium
showed long rete pegs. The connective tissue was mild to
moderately collagenous. The connective tissue showed diffuse,
mixed inflammatory cell infiltrate with numerous engorged blood
vessels, endothelial proliferation and extravasated red blood cells.
The histopathological examination of the excised tissues from the mandibular left posterior region showed calcified structures
within the vascular spaces in addition to the above findings. The
presence of the calcified structure seen intravascularly as well as
its structure seems to indicate a phlebolith rather than any other
type of calcification (Figure 4 & 5).
Internal bevel gingivectomy with open flap debridement
was completed in all the other quadrants. Histopathological
examination of the excised tissues in the rest of the quadrants did
not show any calcification. The patient was followed without any
complication after surgery. At the end of one year no evidence of
recurrence was observed.
Phleboliths are calcified thrombi commonly seen as multiple
calcifications associated with vascular malformations or
hemangiomas [1,2 ,6,7,8-19]. Phleboliths not associated with
other vascular lesions are uncommon [3-5]. We have reported here
in a case of chronic inflammatory gingival enlargement but with
an unusual finding of an intravascular phlebolith. As the familial,
medical and drug histories were not contributory, a diagnosis
of chronic inflammatory gingival enlargement was made. The
histopathological evaluation results of the biopsied tissues in this
case were similar to that of any inflammatory hyperplasia. The
presence of calculi with characteristic concentric lamination was
suggestive of phlebolith. No vascular anomalies were seen in the
The pathogenesis of phleboliths usually involves an organized
thrombus produced when the peripheral blood flow slows.
The thrombus calcifies, forming the core of the phlebolith. The
fibrinous component undergoes secondary calcification and
becomes attached. Repetition of this process causes enlargement
of the phlebolith . In the present case, the enlargement had
an inflammatory component that was responsible for increase
in vascularity and blood flow to the area. The chronicity of
the condition may have led to a decrease in this inflammatory
component as the lesion got fibrosed. As a result, the newly formed
vascular channels may have had a relative stagnation in blood flow
giving rise to conditions favouring the formation of phlebolith.
This finding is unique in a case of gingival enlargement and hence
cannot be explained further until more cases are encountered or
Medline and Web of Science databases were searched for
articles reported in the English literature from 1970 to 2015
describing cases of phleboliths in the oral region. There were
only five articles reported with multiple and four with solitary
phleboliths not associated with other vascular lesions. The
reviewed literature showed that phleboliths of the oral cavity
can be found in infants to elderly individuals, but it mainly occurs
between the first and third decades of life. The search of literature
for the presence of phlebolith within a gingival enlargement did
not yield any result.
Phleboliths are diagnosed by physical and imaging
examinations and confirmed by microscopy (HE stain). However
in our case the presence of phlebolith within the gingival
enlargement was an incidental finding when the excised tissue
was examined histopathologically. To the best of our knowledge,
this could be the first reported instance of occurrence of phlebolith
in a case of gingival enlargement.
All gingival enlargements should be subjected to
histopathological examinations. Findings such as phleboliths
are usually associated with vascular malformations. Although
phleboliths not associated with other vascular lesions are not a
common finding in the oral cavity, clinicians should be aware of
the existence of such lesions.
When you evaluate an oral soft tissue mass with a calculus
like body, it will usually be a phlebolith associated with a vascular
lesion. Cases of phleboliths not associated with other vascular
lesions are rarely reported in the literature. Despite the rarity of
the condition, dentists need to be aware of the existence of such
conditions in the oral cavity.