|Year : 2013 | Volume
| Issue : 2 | Page : 90-93
Peripheral giant cell granuloma
Pushpendra Kumar Verma1, Ruchi Srivastava1, Akhilesh Chandra1, Anju Gautam1, Pramod Yadav2
1 Department of Dentistry, I.M.S, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh, India
2 Department of Preventive and Community Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow - 226 025, Uttar Pradesh, India
|Date of Web Publication||22-Oct-2013|
Pushpendra Kumar Verma
Service Senior Resident, Faculty of Dental sciences, I.M.S, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
Gingival overgrowth is one of the most undesirable consequences that often lead to severe aesthetic changes and compromised oral hygiene maintenance. Giant cell granuloma is among the localized growths, considered to be reactive rather than neoplastic in nature. It is relatively a benign, nonodontogenic lesion of oral cavity. It is a reactive response to local irritations and trauma that may be of central or peripheral type. The purpose of this article is to report the clinical, histopathological features and treatment of a case of peripheral giant cell granuloma arising from maxillary anterior alveolus in a 37-year-old male. The lesion was completely excised to the periosteum level and there was no recurrence or bony defect apparent in the area of biopsy after a follow-up period of 8 months. Proper plaque control and effective oral hygiene can reduce its severity or prevent its occurrence.
Keywords: Benign nonodontogenic lesion, gingival overgrowth, giant cell granuloma
|How to cite this article:|
Verma PK, Srivastava R, Chandra A, Gautam A, Yadav P. Peripheral giant cell granuloma. SRM J Res Dent Sci 2013;4:90-3
| Introduction|| |
The peripheral giant cell granuloma (PGCG) is a common benign reactive lesion, originating from the periosteum or the periodontal ligament. Localized hyperplastic lesions of the gingiva are also commonly known as "Epulides". The word "epulis" is derived from Greek "epi" and "elon"; meaning "on the gingiva". This term may not give any indication about the nature of the lesion.  It is also known as giant cell epulis, osteoclastoma, giant cell reparative granuloma or giant cell hyperplasia. Jaffe first suggested the term "giant cell reparative granuloma" for the similar central lesion of the jaw bones to help differentiate them from the giant cell tumor as he believed the former lesion to represent a local reparative reaction rather than being a true neoplasm.  Bernier and Cahn proposed the term "peripheral giant cell reparative granuloma" for the lesion.  The latter terminology is currently not being used as the reparative nature of the lesion has not been proved. Today, the term PGCG is universally accepted. Other terms used to describe this lesion include peripheral cementifying fibroma, peripheral fibroma with cementogenesis, peripheral fibroma with osteogenesis, peripheral fibroma with calcification, calcified or ossified fibrous epulis and calcified fibroblastic granuloma.  PGCG is believed to be stimulated by local irritation or trauma, which resulted in gingival or mucosal hemorrhage.  The aggressive factors include trauma, tooth extraction, badly finished restorations, plaque, calculus, chronic infections, and impacted food.  Many of these lesions are difficult to be identified clinically and can be identified only on the basis of histopathology. It accounts for 7% of all benign tumors of the jaw.  PGCG is more common in the mandible than in the maxilla and common in the anterior region than in the posterior region.  Radiographs are important to determine if the lesion is of gingival origin or of central origin with extension to the surface. At times lesion may become large, some attaining 2 cm in size. Most lesions of PGCG respond well to thorough surgical curettage that exposes all bony walls. A careful scaling and root planing should be done in the adjacent teeth to remove any source of irritation and to minimize the risk of recurrence. When the periodontal membrane is involved, the associated teeth may require extraction to accomplish complete removal. This article reports a case of PGCG arising at the maxillary anterior alveolus in a 37-year-old male. The lesion was completely excised to the periosteum level and there was no bony defect apparent in the area of biopsy after a follow-up period of 8 months.
| Case Report|| |
A 37-year-old male patient presented to the Faculty of Dental Sciences, BHU, Varanasi, India with a chief complaint of swelling on gums at upper front region since 3 months. On clinical examination, a well circumscribed gingival swelling of 2 × 1 cm size was present in relation to 21, 22 [Figure 1]. The lesion was soft in consistency, sessile, and bled readily on probing. No radiological signs of involvement of alveolar ridge were observed. Patient's medical history was uneventful. After considering the dental history, scaling and root planing was performed, followed by surgery for excision of the lesion. The surgical technique was explained to the patient and informed consent was obtained. After local anesthesia, lesion was excised with 15 no. B.P. blade up to the base of lesion [Figure 2] and [Figure 3]. It was ensured that the lesion was completely excised by trimming the remnants of soft tissue adjacent to the tooth to prevent recurrence of lesion and the sample was sent for histopathology [Figure 4] and [Figure 5]. Periodontal dressing was applied to prevent the wound from trauma and to enhance healing for 1 week. Antibiotics and analgesics were prescribed for 1week. Patient was monitored on weekly schedule postoperatively, to ensure good oral hygiene in the surgery performed area [Figure 6]. The histopathology of specimen confirmed the diagnosis of PGCG. On histologic examination, the reddish-purple exophytic lesion showed an ulcerated overlying epithelium composed of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells (×100 magnification) [Figure 4]. Higher magnification (×400) demonstrated multinucleated giant cells dispersed within spindle-shaped mesenchymal stromal cells [Figure 5]. At 8 months recall, gingival tissues were healthy with successful healing and no more recurrence.
| Discussion|| |
The clinical appearance of PGCG is similar to pyogenic granuloma, but the PGCG is often more bluish-purple as compared with pyogenic granuloma, which is bright-red in color. The differential diagnosis of PGCG includes central giant cell granuloma, oral pyogenic granuloma, fibroma, kaposi sarcoma, metastatic neoplasms of the oral cavity, oral malignant and other nodular melanomas, metastatic tumors of gingiva, nevi, and other inflammatory hyperplastic lesions. The lesion may be sessile or pedunculated, spreading through penetration of the periodontal membrane and it may or may not be ulcerated. Occasionally the lesions arise from the periosteum overlying edentulous areas. PGCG may also be associated with dental implants, which has been reported.  Also PGCG seems to be influenced by hormonal stimulus, especially estrogen.  PGCG is the least commonly diagnosed among the various hyperplastic gingival lesions, but a common giant cell lesion found in the oral cavity. The origin of multinucleated giant cells is unknown but some believe that they show immunohistochemical features of osteoclasts, while others suggest them to arise from mononuclear phagocyte system.  Other possible sources include osteoblasts, endothelial cells, and spindle cells. Histologically, fibroblasts are also the basic elements. Scattered among the fibroblasts are abundant multinucleated giant cells. Islands of metaplastic bone occasionally may be seen. Numerous capillaries may be seen along with areas of hemorrhage, hemosiderin, and inflammatory cells throughout the cellular connective tissue. Rarely, ulcerations are associated features. Vascular proliferation, especially capillary, was found in a study by Peralles et al.  The nonulcerated lesions are typically identical to the ulcerated type except for the presence of surface epithelium. Clinically it is difficult to differentiate between most of the reactive gingival lesions particularly in the initial stages. Calcified tissue, which is found in some of the lesions, varies from small amorphous foci to well developed trabeculae. The PGCG has a close resemblance to central giant cell granuloma microscopically, and it may represent a soft tissue counterpart of the central bony lesion.  At times, it is difficult to determine whether the lesion arose as a peripheral lesion or a central giant cell granuloma eroding through the cortical plate into the gingiva.  There may be a little radiographic difference of some lesions in teeth-bearing areas because these lesions may be small and primarily in the soft tissues. Larger lesions exhibit a superficial erosion of the cortical bone surface and may demonstrate some widening of the adjacent periodontal space. In edentulous areas, the cortical bone exhibits a concave area of a resorption beneath the lesion, often referred to as "saucerisation". Treatment requires proper surgical intervention that ensures deep excision of the lesion including periosteum and affected periodontal ligament. In this case report after a period of 8 months, no residual or recurrent, swelling or bony defect apparent in the area of biopsy. The successful integration of esthetics and function is a result of the meticulous development of clearly defined anatomic parameter and their subsequent incorporation into the final result. Periodontal surgery is generally perceived as excisional in nature being the treatment goal.
| Conclusion|| |
The lesion was painless as nerves do not proliferate within the reactive hyperplastic tissue. Surgical excision is a successful treatment of choice in minimizing the recurrence of lesion. Regardless of the surgical technique employed, it is important to eliminate the etiological factors and to examine the tissues histologically for confirmation. Hence, the consideration should also be given to correct diagnosis and proper treatment planning.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]