|Year : 2010 | Volume
| Issue : 4 | Page : 293-296
Peripheral giant cell granuloma
VK Adlakha1, P Chandna1, U Rehani2, V Rana3, P Malik4
1 Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Subharti Dental college, Meerut, India
2 Professor and Head, Department of Pedodontics and Preventive Dentistry, Subharti Dental college, Meerut, India
3 Reader, Department of Pedodontics and Preventive Dentistry, Subharti Dental college, Meerut, India
4 Resident, Department of Pedodontics and Preventive Dentistry, Subharti Dental college, Meerut, India
|Date of Web Publication||25-Jan-2011|
V K Adlakha
J-58, Shastri Nagar, Meerut - 250 004
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Peripheral giant cell granuloma is a benign reactive lesion of gingiva. It manifests as a firm, soft, bright nodule or as a sessile or pedunculate mass. This article reports the management of peripheral giant cell granuloma in a 12-year-old boy by surgical excision.
Keywords: Giant cell, granuloma, treatment, jaw
|How to cite this article:|
Adlakha V K, Chandna P, Rehani U, Rana V, Malik P. Peripheral giant cell granuloma. J Indian Soc Pedod Prev Dent 2010;28:293-6
| Introduction|| |
Peripheral giant cell granuloma is a relatively uncommon lesion of the oral cavity,  arising mainly from the connective tissue of the gingiva, periodontal membrane, periosteum of alveolar ridge, or in response to local irritation.  Initially, similar central lesions of the jaw were referred to as reparative lesions.  Since the reparative response was quite rare, the term "peripheral giant cell granuloma" is currently preferred and universally accepted.
The etiology of this lesion is still not precisely defined. In 1962, Gottsegen  suggested the development of peripheral giant cell granuloma often after periodontal surgery. However, some investigators consider it to arise in response to local irritating factors such as tooth extractions, ill-fitting prostheses, poor restorations, collections of food remnants, and calculus. , Low socioeconomic status of the patients and unfavorable oral hygiene also seem to be predisposing factors to peripheral giant cell granuloma.  Recently, Choi reported the association of peripheral giant cell granuloma with hyperparathyroidism secondary to renal failure. 
The peripheral giant cell granuloma occurs exclusively on the gingiva or edentulous alveolar ridge, presenting as a red or reddish nodular mass.  The peripheral giant cell granuloma is more common in the mandibular arch than in the maxillary arch and frequently occurs anterior to the permanent first molars. 
Clinically, peripheral giant cell granuloma manifests as a firm, soft, bright nodule or as a sessile or pedunculate mass.  Pyogenic granulomas are benign reactive lesions usually treated with surgical resection with extensive clearing of the base of the lesion and elimination of the local etiologic factor. Malignant transformation of these lesions has never been reported. The recurrence rate after local excision is around 10%. 
The histological features consist of a nonencapsulated highly cellular mass with abundant multinucleated giant cells dispersed throughout. Chronic inflammatory cells are present, and neutrophils are mainly encountered in the ulcerated base of the lesions. Fibroblasts form the basic element of the peripheral giant cell granuloma.  The radiographs exhibit evidence of superficial destruction of the alveolar margin or crest of the interdental bone. 
| Case Report|| |
A 12-year-old boy reported to the Department of Pedodontics and Preventive Dentistry, Subharti Dental College, Meerut, with a chief complaint of swelling in upper anterior region of the mouth for the last 2 years. The patient was treated with antibiotics by a local dentist. Since no relief was noted, the patient was referred to our pedodontic department. On intraoral examination, a 2.0 Χ 1.5 cm, reddish pink, soft, tender, gingival growth was noted which showed bleeding on palpation. It extended from the free gingival margin on the labial side of maxillary central incisors to the attached gingiva on the palatal surface. Deposits of calculus were seen on the teeth related to the lesion. Diastema was present with respect to teeth # 11 and 21. There was no associated lymphadenopathy [Figure 1] and [Figure 2].
Intraoral periapical radiograph and occlusal radiograph revealed loss of crestal bone and periodontal ligament widening at the apex of the maxillary central incisors [Figure 3] and [Figure 4]. No systemic abnormalities were detected. Hematological reports were noncontributory. A decision was thus made to excise the lesion.
The growth was excised under local anesthesia with a cold scalpel. Care was taken to remove the entire base, and the excised lesion [Figure 5] was stored in 10% formalin and sent for histopathological examination.
The histopathological section showed parakeratinized stratified squamous epithelium, which was hyperplastic and underlying fibrocellular connective tissue showing numerous vascular channels and intense acute and chronic inflammatory infiltrates. Collections of multinucleated giant cells were evident in certain areas [Figure 6]. The presence of these features was suggestive of peripheral giant cell granuloma with superadded infection. The lesion did not reoccur during the 1-week and 6-month follow-up period [Figure 7],[Figure 8],[Figure 9].
|Figure 6 :Microscopic view of excised specimen showing the presence of giant cells|
Click here to view
| Discussion|| |
Peripheral giant cell granuloma is seen in the young as well as in the elderly population with highest incidence in the 4th to 6th decades of life.  However, 20-30% of cases manifest in the 1st and the 2nd decades of life.  The preferential location of the lesion according to Pindborg  is the premolar and molar zone, though Shafer  and Giansanti  suggest that it generally occurs in the incisor and canine region.
Radiographic features are generally nonspecific. However, sometimes they reveal superficial destruction of the alveolar margin or crest of the interdental bone when the granuloma is seen associated with the teeth. In cases where the granuloma is associated with the edentulous ridge, it characteristically exhibits superficial erosion of the bone with peripheral "cuffing" of the underlying bone.  In our case, the intraoral periapical radiograph revealed the loss of crestal bone and periodontal ligament widening in the maxillary central incisors.
The differential diagnosis of peripheral giant cell granuloma includes pyogenic granuloma,  fibrous epulis, peripheral ossifying fibroma, inflammatory fibrous hyperplasia, peripheral odontogenic fibroma, and papilloma, all of which present with similar clinical and radiographic findings. Thus, in such cases a definitive diagnosis can only be established through histopathological examination.
The histopathological study centers on three points:
- Ulcerative changes in epithelium
- Connective tissue with abundant small-caliber blood vessels
- Presence of giant cells in the medullary or the core region 
The presence of giant cells has been attributed to a number of causes. It may be a phagocytic response to hemorrhage in a preexisting granulation tissue,  or it may arise from the endothelial cells of the capillaries, periosteum, periodontal ligament, or connective tissue of the gingiva. ,,
Recommended management of peripheral giant cell granuloma aims at elimination of the entire base of the growth accompanied by eliminating any local irritating factors, as was followed in our case. The various modalities used to excise the lesion are cold scalpel, electrocautery, lasers, etc. The literature shows no difference between cold scalpel and CO 2 laser resection of peripheral giant cell granuloma. 
| Conclusions|| |
Early and definite diagnosis of peripheral giant cell granuloma on the basis of clinical, radiographic, and histopathological examination allows conservative management with minimal risk to the adjacent hard tissues.
| References|| |
|1.||Ragezi JA, Sciubba JJ, Jordan RC. Oral pathology: Clinical pathological considerations. 4 th ed. Philadelphia: W B Saunders; 2003 p. 115-6. |
|2.||Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulo AP. Peripheral giant cell granuloma: Clinicopathologic study of 224 new cases and review of 956 reported cases. Int J Oral Maxillofac Surg 1988;17:94-9. |
|3.||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. |
|4.||Gottsegen R. Peripheral giant cell granuloma following periodontal surgery. J Periodontol 1962;33:190-4. |
|5.||Bernier JL, Cahn LR. Peripheral giant cell reparative granuloma. J Am Dent Assoc 1954;49:141-8. |
|6.||Eronat N, Aktug M, Glinbay T, Unal T. Peripheral giant cell granuloma: Three case reports. J Clin Pediatr Dent 2000;24:245-8. |
|7.||Choi C, Terzian E, Schneider R, Trochesset DA. Peripheral giant cell granuloma: Associated with hyperparathyroidism secondary to end-stage renal disease: A case report. J Oral Maxillofac Surg 2008;66:1063-6. |
|8.||Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Pennysylvania: W B Saunders Company; 2004. p. 449-50. |
|9.||Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 4 th ed. Philadelphia, W B Saunders Company; 1983. p. 144-6. |
|10.||Bhat SS, Jayakrishnan A, Rao BH, Kudva S. Peripheral giant cell granuloma: A case report. J Indian Soc Pedod Prev Dent 1999;17:93-6. |
|11.||Giansanti JS, Waldron CA. Peripheral giant cell granuloma: A review of 720 cases. J Oral Surg 1969;27:787-91. |
|12.||Pindborg JJ. Atlas deenfermedades de la Mucosa Oral. 5 th ed. Barcelona: Ediciones Cientificas Tecnicas; 1994.p. 186. |
|13.||Chaparro-Avendaso 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;10:48-57. |
|14.||Sapp JP. Ultrastructure and histogenesis of peripheral giant cell granuloma. Cancer 1972;30:1119-29. |
|15.||Flaitz CM. Peripheral giant cell granuloma: A potentially aggressive lesion in children. Pediatr Dent 2000;22:232-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
|This article has been cited by|
||Peripheral giant cell granuloma: A case report
| ||Banthia, R. and Maheshwari, S. and Banthia, P. and Mantri, K. |
| ||General Dentistry. 2013; 61(1): e12-e14 |