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CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 129-132

Peripheral giant cell granuloma


Department of Periodontics, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Submission28-Apr-2021
Date of Decision11-May-2021
Date of Acceptance13-May-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Surbhi Gautam
Dr. R. Ahmed Girls and Boys Hostel, Kolkata - 700 014, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_14_21

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  Abstract 


Peripheral giant cell granuloma (PGCG) has been given various names over the years such as peripheral giant cell tumor, reparative giant cell granuloma, giant cell epulis, giant cell hyperplasia, and osteoclastoma. It is the most commonly occurring lesion of the jaw developing from periosteum's connective tissue or periodontal membrane. It is predominantly seen in females in the mandibular region and usually in their late 40s. However, we hereby present a rare case of PGCG found in a male, in the maxillary posterior region, and in his early 20s.

Keywords: Connective tissue, giant cells, maxillary, peripheral giant cell granuloma


How to cite this article:
Gautam S, Banerjee S, Datta S, Bagchi S. Peripheral giant cell granuloma. Niger J Exp Clin Biosci 2021;9:129-32

How to cite this URL:
Gautam S, Banerjee S, Datta S, Bagchi S. Peripheral giant cell granuloma. Niger J Exp Clin Biosci [serial online] 2021 [cited 2021 Dec 4];9:129-32. Available from: https://www.njecbonline.org/text.asp?2021/9/2/129/323667




  Introduction Top


The most common giant cell lesion of the jaws is peripheral giant cell granuloma (PGCG), which develops from the periosteum's connective tissue or the periodontal membrane in response to local insult or persistent trauma that manifests as a reactive hyperplasia overgrowth.[1],[2] Peripheral giant cell tumor, reparative giant cell granuloma, giant cell epulis, giant cell hyperplasia, and osteoclastoma are terms given to this lesion.[3]

Here, we present an unusual case of PGCG lesion seen in a male patient in his early 20s. The lesion was seen in his maxilla in its posterior region. The PGCG is less likely to be found in males as compared to female patients, and it occurs in the fourth to sixth decades of life. The mandible is usually a more predictable site for the lesion.[4]

Clinically, it manifests as a single purplish-red nodule with vascular or hemorrhagic presentation, which may be with or without surface ulceration originating from the interdental tissues (periosteum or periodontal membrane). It may be sessile or pedunculated. Lesions can appear anywhere on the gingival or alveolar mucosa, but the majority happen in front of the molar teeth.[5],[6]

The stimulus for the lesion is chronic irritation or trauma but not certain. The diagnosis of PGCG is usually confirmed by a histopathological study based on the presence of the densely cellular mass with multiple multinucleated giant cells and chronic inflammatory cells. The basic component of PGCG is formed by fibroblast.


  Case Report Top


A 20-year-old male was referred to the Outpatient Department of Periodontics and Implantology, Dr. R. Ahmed Dental College and Hospital, Kolkata, with a chief complaint of painless swelling located in the left upper first molar since 5–6-months. The patient also complained of occasional bleeding while chewing and brushing. History showed that the swelling was at first small in size but progressively increase in size. However, there was no similar swelling present in any other part of the body. The patient was systemically healthy. Extraoral examination detected no facial asymmetry or lymphadenopathy.

The swelling was localized buccally to the left upper first molar, reddish pink in color, well defined, smooth, pedunculated, and nonulcerated [Figure 1]. It is also firm, nontender on palpation with bleeding on probing, and nonfluctuant of size 14 mm × 12 mm extending from mesial to distal aspect of first molar in the second quadrant. On further examination, trauma indentation from occlusion with that same first molar was also seen.
Figure 1: A lesion seen with respect to 26 region

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Generalized deposits of plaque and calculus were seen with a Simplified Oral Hygiene Index score of 3.9 indicating poor oral hygiene. Routine blood tests were found normal. Radiological examination revealed widening of periodontal ligament space in relation to first molar in the second quadrant with no evidence of bone involvement [Figure 2].
Figure 2: A radiograph of the 26 region showing no bone loss

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Based on the history and clinical and radiographic findings, provisional diagnosis was made as PGCG. Pyogenic granuloma and peripheral fibroma were considered for differential diagnosis due to the similarity of their clinical presentation.

After obtaining a written informed consent from the patient prior to the surgery, the growth was excised under local anesthesia using a Bard-Parker handle and blade, followed by curettage in the involved teeth [Figure 3]. The patient was given postoperative instructions along with medications and oral hygiene instructions were reinforced. Histological analysis of the excised tissue was performed. The patient was followed up regularly up to 6 months postsurgically, and no evidence of recurrence was observed [Figure 4] and [Figure 5].
Figure 3: A surgically excised mass which was sent for histopathological examination

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Figure 4: Clinical appearance of the 26 region after 10 days of follow-up

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Figure 5: Clinical appearance of the 26 region after 6 months of follow-up

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Histopathological report

Histopathological report revealed the presence of surface stratified squamous epithelium which was backed by dense fibrous connective tissue. Multinucleated giant cells were noted in the deeper area to the connective tissue. Areas with chronic inflammatory infiltrate were also noted. The histopathological features confirmed the diagnosis as “PGCG” [Figure 6].
Figure 6: Histological report showing presence of multinucleated giant cells

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  Discussion Top


PGCG is a benign exophytic lesion, initially thought to be of reparative nature, and was named giant cell reparative granuloma by Jaffe.[7] In contrast, Waldron and Shafer described that histologically this lesion showed features of benign giant cell tumors of bone with no reparative characteristics.[8] Bhaskar et al. divided giant cell granuloma into central and peripheral. Central giant cell granuloma occurs within the bone, while PGCG originates in gingiva or edentulous alveolar processes.[9]

The clinical features of the lesion were same as that described in the literature previously, and no unusual findings were observed. The cause and nature of PGCG (giant cell epulis) are unknown. PGCG has been related to a number of local attributes such as difficult dental extractions, improper dental restorations, food impaction, plaque and calculus, ill-fitting dentures, and so on. A possible hormonal influence for some PGCG has been postulated.[4] Some hormones (estrogen and progesterone) may suppress the immune system and promote to the progression of the lesion.[10] In our case, it might be the chronic irritation due to plaque and calculus as the patient had poor oral hygiene status and trauma from occlusion might have led to the progression of the lesion.

The incidence rate of PGCG ranges from 5.1% to 43.6% among all reactive growths detected orally.[11] PGCG can appear at any age, but it is common (40%) in people in their fourth to sixth decades of life. Females (65%) are more likely than males (35%) to have PGCG.[11],[12] According to the literature, the male-to-female ratio is estimated to be around 1:1.5 or 1:2.1.[13] The mandible is more affected by PGCG (55%) than the maxilla; the ratio of mandibular-to-maxillary predisposition is 2.4:1.1.21.[14] The case report here presents the case of a male patient in his early 20s, and the lesion was seen in the maxilla.

Bone resorption can be evident in some cases of PGCG but is limited superficially only while widening of the periodontal ligament followed by tooth mobility can be seen in some cases.[1] The present case showed widening of periodontal ligament space in relation to first molar in the second quadrant but no insight for bone loss with respect to that region.

The differential diagnosis of PGCG includes pyogenic granuloma, fibrous epulis, peripheral ossifying fibroma, inflammatory fibrous hyperplasia, peripheral odontogenic fibroma, hemangioma cavernosum, and papilloma.

There are many treatment options available for treating PGCG. The conventional surgical blade excision was chosen because of the site where lesion was present and the ease of availability of the instruments to treat the present case. Other treatment modalities available are an electric scalpel, cryosurgery using liquid nitrogen or a cryoprobe, and lasers.[15],[16]

Giansanti and Waldron[17] registered a 5% recurrence rate, while Eversole and Rovin found an 11% recurrence rate over a study of 7 years in their analysis. The incomplete removal of the periosteum or periodontal ligament along with the lesion is thought to be the cause of recurrences.[18] However, in the present case, there was no recurrence observed over a period of 6 months.


  Conclusion Top


An accurate diagnosis of gingival overgrowth through clinical, radiographic, and histopathological examination is vital for its management. Postsurgical regular follow-up is essential to prevent recurrence of the growth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chaparro-Avendano AV, Berini-Aytes L, Gay-Escoda C. Peripheral giant cell granuloma. A report of five cases and review of the literature. Med Oral Patol Oral Cir Bucal 2005;10(1): 53-57.  Back to cited text no. 1
    
2.
Wood NK, Goaz PW. 5th ed. St.Louis: Mosby; 1997. Differential Diagnosis of Oral and Maxillofacial Lesions; pp. 141–2.  Back to cited text no. 2
    
3.
Kfir Y, Buchner A, Hansen L. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol 1980;51:655-61.  Back to cited text no. 3
    
4.
Gunhan M, Gunhan O, Celasun B, Mutlu M, Bostanci H. Estrogen and progesterone receptors in the peripheral giant cell granulomas of the oral cavity. J Oral Sci 1998;40(2):57-60.  Back to cited text no. 4
    
5.
Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 6th ed. Philadelphia: WB Saunders Co 1983.  Back to cited text no. 5
    
6.
Hernandez G, Lopez-Pintor RM, Torres J, et al. Clinical outcomes of peri-implant peripheral giant cell granuloma: A report of three cases. J Periodontol 2009; 80:1184-91.  Back to cited text no. 6
    
7.
Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibro-oseous) dysplasia of the jawbones. Oral Surg Oral Med Oral Pathol 1953; 6:159-75.  Back to cited text no. 7
    
8.
Waldron CA, Shafer WG. The central giant cell reparative granuloma of the jaws. An analysis of 38 cases. Am J Clin Pathol 1966; 45:437-47.  Back to cited text no. 8
    
9.
Bhaskar SN, Bernier JL, Godby F. Aneurysmal bone cyst and other giant cell lesions of the jaws: Report of 104 cases. J Oral Surg Anesth Hosp Dent Serv 1959; 17:30-41.  Back to cited text no. 9
    
10.
Parbatani R, Tinsley GF, Danford MH. Primary hyperparathyroidism presenting as a giant-cell epulis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:282-84.  Back to cited text no. 10
    
11.
Yadalam U, Bhavya B, Kranti K. Peripheral giant cell granuloma: A case report. Int J Dent Case Rep 2012;2:30-4.  Back to cited text no. 11
    
12.
Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 4th ed. Philadelphia: W B Saunders Company; 1983. p. 185-6.  Back to cited text no. 12
    
13.
Shirani G, Arshad M. Relationship between circulating levels of sex hormones and peripheral giant cell granuloma. Acta Med Iran 2008;46:429-33.  Back to cited text no. 13
    
14.
Prabhat MP. Recurrent peripheral giant cell granuloma of the gingival: A case report. Ann Essences Dent 2010;2:65-7.  Back to cited text no. 14
    
15.
Soames JV, Southam JC. Oral Pathology. 3rd ed. New York: Oxford University Press; 1998. p. 119-23.  Back to cited text no. 15
    
16.
Ishida CE, Ramos-e-Silva M. Cryosurgery in oral lesions. Int J Dermatol 1998;37:283-5.  Back to cited text no. 16
    
17.
Giansanti JS, Waldron CA. Peripheral giant cell granuloma: Review of 720 cases. J Oral Surg 1969;27:787-91.  Back to cited text no. 17
    
18.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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