Tehran University of Medical Sciences Journal of Craniomaxillofacial Research 2345-5489 13 1 2026 05 12 129 133 EN Elaheh Hoseini Department of Oral and Maxillofacial Medicine, School of Dentistry, Kashan University of Medical Sciences, Kashan, Iran. Seyed Mohammad Torabi DDS, Private Practice, Fars, Jahrom, Iran. Hassan Ehteram Department of Pathology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran. Bahareh Fattahi Department of Oral and Maxillofacial Pathology, School of Dentistry, Kashan University of Medical Sciences, Kashan, Iran. Arash Esmaeili Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran. 2025 12 16 2026 04 09 This report details a complex oral manifestation of SARS-CoV-2 infection in a 50-year-old female recovering from moderate COVID-19. The patient presented with severe mandibular pain, which upon comprehensive clinical, radiographic, and histopathological evaluation was diagnosed as concurrent advanced pyogenic granuloma and acute osteomyelitis with sequestration in the same jaw quadrant, accompanied by severe bilateral facial paresthesia. The diagnostic process was protracted, with osteomyelitis only confirmed following a subsequent presentation with exposed bone. Management necessitated sequential surgical debridement, targeted antibiotic therapy, and neuropathic pain control with Gabapentin, culminating in eventual resolution. This singular co-occurrence of a reactive vascular lesion and an invasive bony infection suggests a unified pathophysiological model wherein SARS-CoV-2-induced endotheliopathy, cytokine dysregulation, and immune dysfunction collectively establish a permissive local environment for both aberrant angiogenic proliferation and bacterial invasion of bone. The case underscores the imperative for heightened clinical suspicion of complex, co-existing maxillofacial pathologies in post-COVID patients and illuminates the potential therapeutic dilemmas inherent in managing such intertwined inflammatory and infectious sequelae.  Keywords: COVID-19; Osteomyelitis; Pyogenic granuloma; Oral manifestations. https://jcr.tums.ac.ir/index.php/jcr/article/view/606 https://jcr.tums.ac.ir/index.php/jcr/article/download/606/489