Cases of GPA with oral symptoms were described in several reports [
2,
3,
7,
14‐
18]. However, a systematic search in PubMed generated by “granulomatosis with polyangiitis, Wegener’s granulomatosis, gingivitis, recurrent, recurrence” indicated only one report describing the recurrence of GPA without any oral symptoms in the initial presentation of the disease reported by Staines et al. [
14]. Comparable to our case, gingival hyperplasia was evident only on recurrence in this single reported case. The standard therapy of initial GPA consisted of glucocorticoids or cyclophosphamide, or a combination of both [
19]. Although standard therapy does improve the survival rate of the patients, there are also therapy-related malignancies like squamous cell carcinoma, Kaposi sarcoma or basal cell carcinoma which was also applicable to our patient [
20]. In contrast to the standard therapy of initial GPA, there are reports of successful treatment of refractory head and neck GPA with rituximab [
14]. Rituximab is a chimeric, monoclonal antibody targeting the CD20-antigen expressed by B-cells. Successful treatment with rituximab leading to full remission is reported in 62 % of all treated patients by Martinez et al. [
21]. About 15 % of all rare diseases show orofacial manifestations [
6,
22]. Typical oral manifestations in GPA are unspecific erosive lesions in the oral mucosa or hyperplastic gingivitis as reported here. Differential diagnosis for the gingival enlargement could be caused by medications [
2] (such as phenytoin, cyclosporine and some oral contraceptives), other granulomatous diseases like sarcoidosis and Crohn’s disease or blood dyscrasia like leukemia [
7]. Since oral lesions can be localized a long time before multiorgan involvement actually occurs [
15], the often overlooked oral manifestation may be interpreted as the first sign of GPA and could be pathognostic for the disease. Histopathological pattern of GPA include granulomatous inflammation, vasculitis, necrosis and multinucleated giant cells. Often, however, histopathological findings are less specific and cannot be considered as clinical diagnostics [
16]. Furthermore, it is known that rare diseases with oral components benefit more from an early diagnosis than rare diseases without oral components [
23]. Misdiagnosed oral manifestations which are often overlooked by physicans and by dentists may be interpreted as the first evidence of resurgent GPA in general and therefore could be pathognostic for the disease. A dental specialist has a high chance of identifying GPA based on the characteristics of the oral findings. Moreover, the dentist might be the first one being consulted by the patient with oral manifestations such as gingival hyperplasia. Gingival hyperplasia that is not associated with remission after periodontal therapy or with drug delivery should be investigated then with regard to internal diseases like GPA or leukemia. This example affirms why health professionals should be acquainted with orofacial manifestations of rare diseases such as GPA. As a consequence faster referrals to other medical specialists like rheumatologist, nephrologist, or pulmonologist will be possible and enable them to start with the treatment early on, on the one hand [
17]. On the other hand, dentists may receive referrals from physicans for evaluating oral symptoms.