|Year : 2016 | Volume
| Issue : 4 | Page : 259-263
Peripheral giant cell granuloma: An unusual presentation in pediatric patient: A report of two cases
Deepak Khandelwal, Amit Khatri, Namita Kalra, Rishi Tyagi, Amresh Banga, Gaurav Panwar
Department of Paedodontics and Preventive Dentistry, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
|Date of Web Publication||13-Dec-2016|
Department of Paedodontics and Preventive Dentistry, University College of Medical Sciences (Delhi University) and Guru Teg Bahadur Hospital, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
The peripheral giant cell granuloma (PGCG) is a relatively common tumor-like growth of the oral cavity. It is also known as giant cell epulis. PGCG is an oral, nonneoplastic, tumor-like growth that occurs exclusively on the gingiva and the alveolar mucosa. It affects both sexes, with a slight predilection for females, especially after puberty. It is not a true neoplasm but rather benign hyperplasic lesion. It is probably caused by local irritation or trauma which resulted in gingival or mucosal hemorrhage.
Keywords: Epulis, oral cavity, peripheral giant cell granuloma
|How to cite this article:|
Khandelwal D, Khatri A, Kalra N, Tyagi R, Banga A, Panwar G. Peripheral giant cell granuloma: An unusual presentation in pediatric patient: A report of two cases. SRM J Res Dent Sci 2016;7:259-63
|How to cite this URL:|
Khandelwal D, Khatri A, Kalra N, Tyagi R, Banga A, Panwar G. Peripheral giant cell granuloma: An unusual presentation in pediatric patient: A report of two cases. SRM J Res Dent Sci [serial online] 2016 [cited 2022 May 24];7:259-63. Available from: https://www.srmjrds.in/text.asp?2016/7/4/259/195677
| Introduction|| |
The peripheral giant cell granuloma (PGCG) is an oral, non neoplastic, tumor-like growth that occurs exclusively on the gingiva and the alveolar mucosa. , It is also known as giant cell epulis or peripheral giant cell reparative granuloma, peripheral giant cell tumor, giant cell hyperplasia, reparative giant cell granuloma. , It accounts for 7% of all benign tumors of the jaw.  It is a common giant cell lesion found in the oral cavity.  It usually originates from connective tissues of periosteum or periodontal membrane. 
It has been reported to account for 5.1%-43.6% of reactive gingival overgrowths. ,, It affects both sexes, with a slight predilection for females, especially after puberty. PGCG is usually found in adults with peaks in incidence in the age group of 30-40 years. , The most common site for PGCG is incisor and canine region with slight predilection for mandible.  It is not a true neoplasm but rather benign hyperplasic lesion. It is probably caused by local irritation or trauma which resulted in gingival or mucosal hemorrhage. ,, Local irritating factors such as tooth extraction, poorly adapted restorations, food impaction, plaque, and calculus are said to be etiological factors although the mechanisms through which they act are not completely known. ,, Possible hormonal influences for some PGCG have been postulated. 
In rare cases, PGCG may be sole expression of hyperparathyroidism.  Children with hypophosphatemic rickets, a condition associated to subclinical hyperparathyroidism, are also at increased risk of developing such lesion. 
Radiographic evaluation of any gingival lesion, including the PGCG, is a prudent measure to determine the extent and origin of the lesion. In addition, a widened periodontal ligament space and tooth mobility may extend the lesion around the root. ,,, The final diagnosis, however, relies on the histological diagnosis.  The treatment is usually local surgical excision down to underlying bone along with scaling of adjacent teeth to remove any source of irritation and to minimize risk of recurrence. Recurrence rate has been reported to be 5% by Giansanti and Waldron. 
The purpose of this study was to illustrate a case series of two cases of peripheral giant cell lesion in child patient and to discuss the differential diagnosis and the importance of treating this lesion in children.
| Case Reports|| |
This was a first case of 5-year-old boy presented to the Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, with the chief complaint of swelling in the upper gum region.
History revealed that swelling had appeared about 15 days back which was not associated with any pain or bleeding. The patient also reported history of self-extraction of tooth from same region. No other relevant history of trauma or any other systemic illness was obtained.
Clinical examination revealed that 51 and 52 were missing. A reddish blue nodular swelling was present 2-2.5 cm in diameter in the right maxillary incisor region obliterating the vestibule [Figure 1]. Swelling was soft, fluctuant, sessile, and nontender. The surface was smooth except for ulcerated surface on the occlusal side which was due to trauma with lower incisors. Excision of lesion was planned under general anesthesia [Figure 2]. Radiograph did not reveal any erosion of alveolar bone [Figure 3]. After clinical examination, differential diagnosis of PGCG, pyogenic granuloma, or peripheral ossifying fibroma was made. Fine needle aspiration cytology (FNAC) and incisional biopsy were carried out. FNAC demonstrated giant cells and incisional biopsy depicted numerous variously shaped multinucleated giant cells in proximity to blood vessels [Figure 4]. Hence, diagnosis of PGCG was made.
|Figure 3: Orthopantomogram did not reveal any erosion of alveolar bone and bony changes|
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|Figure 4: Photomicrograph depicting numerous variously shaped multinucleated giant cells in proximity to blood vessels (H and E, ×400). Arrow indicates blood vessel and circle represent giant cells|
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Electrocautery was used for incision and whole lesion was removed and curettage was done up to the base. Excised specimen measuring about 2 cm × 2.5 cm in dimension [Figure 5]. The patient had uneventful postoperative recovery. The patient has been under regular follow-ups [Figure 6] and [Figure 7]. During this period, the patient did not report any complaints.
A 10-year-old girl presented to the Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, with the chief complaint of swelling in the gums in lower jaw.
History revealed the presence of swelling for 6 months not associated with any pain or bleeding. Initially, swelling was small which increased to present size insidiously. Poor oral hygiene was present due to which patient could not brush her teeth because of pain. No other relevant history of trauma or any other systemic disorder was obtained.
On clinical examination, reddish swelling was present 1-1.5 cm in diameter in the right mandibular canine region [Figure 8]. Swelling appeared to be fibrous and nontender. Excision of lesion was planned under local anesthesia. Radiograph did not reveal any erosion of alveolar bone. Differential diagnosis of PGCG, pyogenic granuloma, or peripheral ossifying fibroma was made. Lesion was removed and complete curettage was done up to the base. Histopathological report depicted a highly cellular connective tissue stroma with many multinucleated giant cells and moderate vasculature [Figure 9]. Hence, diagnosis of PGCG was made. The patient had uneventful postoperative recovery [Figure 10].
|Figure 9: Photomicrograph depicting a highly cellular connective tissue stroma with many multinucleated giant cells and moderate vasculature (H and E, ×100) circle represent giant cells|
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| Discussion|| |
PGCG is a reactive, nonneoplastic lesion formed by granuloma-like tissue dominated by multinucleated giant cells.  Highest incidence (40%) is in the fourth to the sixth decades of life. ,, A female predilection of 60% has been reported. , Giansanti and Waldron noted the prevalence rate of 20%-30% in the first and second decade of life.  Peak prevalence is in the fifth and sixth decade of life. , In this case series, we have reported one case in 5-year-old male child and other in a 10-year-old female child. Similar case reports have been reported earlier with similar presentation. ,,
A reactive nature of origin has been found in several immunohistochemical and ultrastructural studies. The presence of S-100 positive cells, which are evidence of Langerhans cells or their precursors, and the presence of fibroblasts, endothelial cells, and myofibroblasts point toward a reactive nature of the PGCG. ,
PGCG varies in appearance from smooth, well demarcated regularly outlined mass to irregularly shaped, multilobulated protuberance with surface indentation. Ulceration of the margin is occasionally seen. , The color can range from dark red to purple or blue.  The lesion appears bluish-purple due to extensive hemorrhagic areas and hemosiderin deposition at the periphery. , On palpation, one may note a lesion that is either soft or hard, depending on the composition of collagen and/or inflammatory components.  However, in our case, the lesion was found in the anterior maxillary arch, the lesion was an exophytic, sessile nodular growth which was bluish-pink, firm in consistency and was found on the gingiva in relation to the right maxillary incisors. Histopathology of our case shows lesional connective tissue stroma with numerous multinucleated giant cells and blood vessels with an overlying keratinized epithelium. These features were suggestive of PGCG. The absence of lymphocyte, plasma cell, and polymorph nuclear cell was suggestive of the absence of bacterial infection.
Routine blood tests were found normal. Serum alkaline phosphatase, calcium, phosphate, alkaline phosphatasem and parathyroid hormone were in normal limit. In rare case, giant cell granuloma is an oral manifestation of hyperparathyroidism. 
Radiographs are important diagnostic tool to confirm that so-called giant cells lesion arises within oral mucosa and does not represent giant central body lesion with perforation and soft tissue extension. ,, Although the PGCG develops within soft tissue, "cupping" resorption of the underlying alveolar bone is sometimes seen radiographically. , No significant radiographic evidence of superficial erosion of bone was evident in our case.
There are no pathognomonic clinical features whereby these lesions can be differentiated from other forms of gingival enlargement including pyogenic granuloma, fibrous epulis, peripheral ossifying fibroma, inflammatory fibrous hyperplasia, peripheral odontogenic fibroma, hemangioma, and papilloma. , Generally, pyogenic granuloma presents as a soft, friable nodule that bleeds freely with minimal manipulation. Peripheral ossifying fibroma is often ulcerated and inflamed and lacks bluish-purple often associated with PGCG, and on radiograph, small flecks of calcification with tumefaction were present. Hemangioma which is also reddish-blue soft nodule can be differentiated as are congenital lesions, brisk bleeding, and blanching upon palpations are characteristic.  Microscopic examination is required for definitive diagnosis.  The most characteristic histologic features included a nonencapsulated highly cellular mass with abundant giant cells, inflammation, interstitial hemorrhage, hemosiderin deposits, mature bone, or osteoid.  Fibroblasts are the basic element of PGCGs. 
Treatment consists of local surgical excision down to the underlying bone, for extensive clearing of the base.  Removal of local factors or irritants is also required.  If resection is only superficial, lesion may recur.  A recurrence rate has been reported to be 5% by Giansanti and Waldron  and 11% by Eversole and Rovin. 
Recurrences are believed to be related to lack of inclusion of the periosteum or periodontal ligament in the excised specimen.  Removal of local factors or irritants is also required.  Various treatment options modalities that have been established are use of cold scalpel, electrocautery, carbon dioxide laser, etc., No difference between cold scalpel and carbon dioxide laser resection of PGCG was reported. 
The treatment rendered in both the cases was surgical excision to the bone and curettage followed by oral prophylaxis. The follow-up has shown no recurrence indicating that the given treatment along with maintenance of a good oral hygiene is sufficient to treat PGCG.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]