ABSTRACT:Peripheral giant cell granuloma (PGCG) is areactive,proliferative,exophytic lesion developing on the gingiva and alveolar ridge, originating fromthe periosteum or periodontal membrane.
The lesion develops mostly in adults,commonly in the lower jaw, with slight femalePS1 . INTRODUCTIONTheperipheral giant cell granuloma (PGCGPS2 ), also known asperipheral giant cell epulis, peripheral gaint cell reparative granulomaPS3 . PGCL or giantcell hyperplasia, is the most common giant cellPS4 lesion in the oralcavity with the incidence rate varying fromPS5 5.1% to 43.6%.
Since its reparative effect has not been proved till date; the osteoclastactivity appears to be doubtful.1-3 CASEREPORTA female patient of age 40 yearsreported to Department of Periodontology of Sardar Patel Post graduateInstitute of Dental Sciences. Chief complain of patient was painless swellingin lower back right region of jaw since 6 months.
History revealed swellingstarted as small one and progressively increased to the present size over 6months. The patient gave a history of mild localized intermittent pain inrelation to the same region while having meals and also slight bleeding onbrushing teeth. There was no history of trauma, neurological deficit, fever,loss of appetite, loss of weight. There was no similar swelling present in anyparts of the body. Patient was systemically healthy. Past medical, familyhistories were non-contributory.
Extraorally, there was noabnormality detected. Intraorally, a solitary ovoid swelling was present in theright lower buccal vestibule measuring approximately 2× 3 cm extending fromdistal aspect of 45 to mesial aspect of 47 with significant vestibular obliterationin relation to 45–47. The overlying mucosa appeared pink to erythematous. Thesurface of the swelling was smooth. The swelling was firm in consistency,showed no secondary changes. The swelling was covered by normal mucosa withmild focal hyperpigmented areas and had a pedunculated base. On palpation, theswelling was soft to firm in consistency, slightly tender, and blanched onpressure.
Orthopantomogram, intraoral periapical radiographs showed no boneresorption. Surgery(exicisional biopsy) was planned under local anaesthesia. The overlying mucosawas incised and undermined. Lesion was separated from adjacent tissue by bluntdissection and removed in one piece.
There is no signs of reoccurrence after 3months follow up. Histopathologyreveals it consists of nonencapsulated mass of tissue composed of a delicatereticular and fibrillar connective tissue stroma containing tissue cells andmultinucleated gaint cells DISCUSSION A case of a PGCG is described,which originallyappeared to be a gingivalovergrowth. The word epulisderives from the Greek words”epi” and “ulon” meaning”on the gingiva”. Since the term”epulis” indicates onlythe location of a lesion, as aninsufficient term it is notusedin diagnosis nowadays.5,6 PGCG is a localized tumor-likehyperplastic gingival enlargement which usually evolves from the interdentaltissues(which may include the periosteum or periodontal membrane) as a consequenceof chronic irritation from local factors viz. subgingival plaque and calculusor trauma.Chronic local irritation of thegingivaisresponsible for the occurrence of most of the reactive lesions, one of which isPGCG.Although these lesions occur overa varied age group? the peak incidence observed in males is the second decadein contrast to the fifth decade for females.
Moreover, PGCG lesions are morecommon in mandible when compared to maxilla (2:1). Lesions are seen to arisefrom anywhere on the gingiva or alveolar mucosa in either dentate or edentatepatients, but most occur anterior to the molar teeth. The interdental papillais mostly affected in dentate patients.7 Lesions can become large, sometimesattaining a size upto 2 cm. The clinical appearance is similar to the morecommon pyogenic granuloma, although the PGCG is often more bluish-purple ascompared with the bright-red colour of a typical pyogenic granuloma.Recently, the PGCG associatedwith dental implants has been reported (Hirshberg et al, 2003). Although thePGCG develops within soft tissue, superficial resorption of the underlyingalveolar bony crest is sometimes seen. On occasion, it may be difficult to determinewhether the mass arose as a peripheral lesion or a central giant cell granulomaeroding through the cortical plate into the gingival soft tissues (Chadwick etal, 1989; Giansanti & Waldrom, 1969).
PGCG is most commonly a unifocallesion, so it must be differentially diagnosed among unifocal gingivalovergrowth8,9 Fibroma: itdiffers from PGCG in consistency and Colour8,9.Also, unlike PGCG, it typically causes irritation 9;Pyogenicgranuloma: it is usually softer, more bright red in colour and bleeds more readilywith minimal manipulation 8,9;· Peripheralossifying fibroma (POF): it may be similar to PGCG but it does not havethe bluish-red colouring, which is characteristic of aPGCG 8,9. Also shows predominance in young women. X-ray typically reveals calcificationspots 9,10;· Pregnant tumour:it is similar with pyogenic granuloma, and the diagnosis isestablished due to pregnancy11;· Kaposi’ssarcoma: where immunosuppression exists (characteristic lesion in patients withHIV infection) and may provoke irregular bonedestruction below the exophytic lesion8, so itcan be easily diagnosed due to patient’s history;· Benign neoplasmlike haemangioma: it disappears under pressure 9;· Malignantneoplasm like metastatic tumour: it may provoke irregular bone destructionbelow the exophytic lesion 8,9 andpresents very rarely 12,13;· A brown tumourof hyperparathyroidism can perforate the alveolus at the cervicalregion of a tooth and it may mimic PGCG 8,9. Differential diagnosis amongmultifocal location, should be between leukaemia (it is characterized bygingival swelling) and gingival hyperplasia due to medication (ie: nifedipine,phenytoin and cyclosporine A).Surgery remains the mainstay of treating PGCGwherein resection of the lesion with the elimination of its entire base isperformed. To prevent the recurrence after treatment, it is necessary tocorrect or eradicate the underlying source of irritation.
14CONCULSION This case report shows theclinical presentation of PGCG involving the mandibular alveolar mucosa andgingiva. The case report has substantiated the provisional diagnosis by meansof radiologic and histopathologic picture.Most of the reactive oral lesionsincluding PGCG mayrapidly grow to reach a significantsize within several months of initial diagnosis. Radiographs are important toshow the origination of this particular giant cell lesion from th peripherywithin the oral mucosa and thus help in its diagnosis.If not managed timely, these softtissue growths may destroy the oral tissues; causing discomfort and toothmovement by resorbing bone.