Peripheral
Giant Cell Granuloma: A Case Report
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Yunus Feyyat Sakin, MD,
Department of Otorhinolaryngology, Varto State
Hospital, Mus, Turkey
Serdal Ugurlu, MD,
Department of Internal Medicine
Hakan Cankaya, MD,
Department of Otorhinolaryngology, Yuzuncu Yil
University Faculty of Medicine, Van, Turkey
Mustafa Kosem, MD,
Department of Pathology, Yüzuuncü
Yil University Faculty of Medicine, Van, Turkey
Correspondence:
Yunus Feyyat Sakin, MD
Department of Otorhinolaryngology, Varto State
Hospital, Mus, Turkey
49600 Varto, Mus, Turkey
Tel: +90 5065063365
E-mail: feyyats@hotmail.com
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ABSTRACT
Objective:
Peripheral giant cell granuloma (PGCG),
also known as osteoclastoma, giant cell
reperative granuloma, or giant cell hyperplasia,
is a reactive exophytic lesion observed
in the oral cavity. We report an extremely
rare case of PGCG.
Method:
The case is discussed in light of the
information in the literature.
Results:
A 30-year-old female patient admitted
to our clinic with the complaints of painless
swelling and gingival growth underwent
total excision of an exophytic lesion
causing purplish-red colored gingival
growth found during clinical examination
in the upper jaw in the region of right
vestibular 1st molar tooth. Histopathological
examination revealed PGCG.
Conclusion:
We wish to stress that effective treatment
of PGCG requires not only complete excision
of the lesion, but also elimination of
irritating factors.
Keywords:
Peripheral giant cell granuloma, gingival
hyperplasia, gingival mass, benign tumor,
aggressive periodontitis.
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Giant cell granulomas of
the jaw develop in two forms, namely the peripheral
giant cell granulomas (PGCGs) and central giant
cell granulomas. The peripheral type develops
in the gingiva and alveolar process, while the
central type originates from the bone. Both
lesion types are observed most commonly in females,
and in the mandible. Etiologically, they have
been proposed to have hormonal, traumatic or
neoplastic origins(16).
The PGCGs, also known as
osteoclastomas, giant cell reperative granulomas,
or giant cell hyperplasias, are reactive exophytic
lesions found in the oral cavity. Although irritants
or aggressive factors such as trauma, tooth
extractions, badly finished fillings, plaques,
dental calculi, chronic infections, or the effects
of nutrients may be the causes, their etiology
is not completely known(5,6,9,10). The lesion,
being more commonly encountered in adulthood,
may recur following excisions unless the local
traumatic factors and infections in its etiology
are eliminated. The PGCGs are observed frequently
in the oral mucosa, forming tumor-like masses.
Rather than being genuine tumors, they are pathological
reactive hyperplasic lesions developing as a
result of abnormal repair(8). They are also
known as giant cell epulis or myeloid epulis(15).
In this case report, our
aim is to describe a patient with gingival swelling
originating in the upper jaw.
A 30-year-old female patient
was admitted to the Otorhinolaryngology Outpatient
Clinic in Varto State Hospital with the complaints
of painless swelling and gingival growth in
the anterior region of upper jaw. The swelling
had been present for 2 months, and had grown
progressively.
Intraoral examination revealed a purplish-red
colored, stalked exophytic lesion with a hard
appearance extending from the midline of palate
and alveolar crest in the region of the right
vestibular 1st molar tooth in the upper jaw,
accompanied by dense dental stones, while the
gingiva were found to be hyperemic, edematous
and inflamed. The mucosa overlying the lesion
was found to be ulcerated due to trauma caused
by the lower teeth (Figure 1). Palpation of
the mass revealed no fluctuations. The patient
had insufficient oral hygiene. Anamnesis of
the patient revealed no systemic diseases. Examination
of the lymph nodes in the head-and-neck region
revealed no lymphadenopathy. Her blood tests
including complete blood count, thyroid function
tests, liver function tests, and serum calcium,
phosphorus, ionized calcium and parathormone
levels revealed normal results.
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Figure 1: The
appearance of lesion on first admission
in the 2nd month of pregnancy |
The patient was informed regarding the diagnosis
and treatment plan, educated about oral hygiene,
and recommended to use chlorhexidine (CHX) 0.02%
for 7 days (Figure 2). At the end of the treatment
period, the case advanced to the surgical phase,
in which the aforementioned mass was completely
excised with the aid of scalpels and monopolar
cauterising under local anesthesia (Figures
3 and 4). Postoperatively, the patient was recommended
to use CHX 0.02% shaking solution and to apply
regularly for control visits.
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Figure 2: The
preoperative appearance in the 3rd month
of pregnancy |
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Figure 3: The
appearance of the location of the mass following
its removal |
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Figure 4: Macroscopic
appearance of the lesion. |
Four months later, the lesion
region was found to have recovered. Biopsy of
the lesion revealed the typical histological
appearance of PGCG (Figure 5).
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Figure 5: Numerous
giant cells, some with osteoclast-like appearance,
within the stroma that appear to be hemorrhagic
and covered with squamous epithelium (H-E
×125). |
Giant cell lesions have a wide distribution
spectrum, ranging from slowly growing asymptomatic
radiolucent lesions to rapidly growing aggressive
lesions, which are characterized by pain and
root resorption and have a high recurrence potential(1,7,16). PGCGs are lesions of the gingiva and
oral mucosa that are thought to arise from the
periodontal ligament or periosteum. These lesions
have been reported to have a rate of being encountered,
ranging from 5.1% to 43.6% among all reactive
growths(9). Such lesions are observed at a
rate of 40% between 40 and 60 years of age,
and at a rate of 20-30% between 10 and 20 years
of age. The PGCGs have been reported to be two
times more common in females than males, and
more frequent in the lower jaw than the upper(1,17). In our case, the female sex and age of
patient were compatible with the literature.
Although Pindborg(13) has described that giant
cell lesions are localized in the premolar and
molar regions, these lesions are observed generally
in the gingiva and alveolar regions of incisor
and canine teeth. In our case, the lesion was
observed between the central and premolar-molar
teeth in the upper jaw.
In our patient, absence of pain associated
with the lesion may have arisen from the fact
that the lesion might not have reached the level
of occlusion and therefore might have not been
affected by traumatic forces arising during
chewing. Bodner et al(2) have found an inverse
correlation between the level of oral hygiene
and size of PGCG. The patient presented in this
report had had complaints of gingival hemorrhage
beginning in her thirties, and had not brushed
her teeth at all. These factors might have rendered
the periodontal picture more dramatic. Likewise,
it may be proposed that insufficient oral hygiene
of the case and the presence of periodontitis
might have been effective in development of
PGCG.
As PGCGs originate from soft tissues, it has
been suggested that radiographic findings are
not notable(17). However, irritating factors
in occasional cases may give significance to
radiographic findings. Our PGCG case did not
undergo X-ray examination as she was in the
second month of pregnancy, and as the teeth
in the region of lesion were not loose, the
lesion had a stalk, and the patient attended
at an early stage, suggesting that the lesion
was benign.
The maximum capacity of PGCGs to enlarge is
currently unknown; however, Kfir et al(10)
have reported that the lesions may enlarge from
0.1 cm to 3 cm, and 94% of these lesions are
smaller than 1.5 cm. In our case, the lesion
had a size of 2.5-3 cm and was evaluated as
giant cell epulis.
It has been reported that PGCGs may cause mobility
and/or displacement in neighboring teeth(3).
As our case was encountered at an early stage,
no displacement or luxation was observed in
the teeth associated with the lesion.
Though the etiology of PGCGs is not precisely
known, local irritating factors such as tooth
expulsion, maladapting prostheses and restorations,
plaques, calculi, and nutrient debris play significant
roles(2,11,15). In our patient, the oral
hygiene level was considerably low, and in her
personal history she had tooth expulsion 2 months
prior to her initial admission. Also, she had
local irritating factors such as debris, plaques,
and calculi.
Lesions similar to PGCGs may rarely be encountered
in patients with hyperparathyroidism. These
lesions are named Brown tumors. However, Brown
tumors associated with hyperparathyroidism are
more commonly localized within bones, and display
similarity to central giant cell granulomas(12). The patient in our case has been found
to be systemically healthy. In a few cases,
giant cell granulomas have been reported to
be oral findings of hyperparathyroidism. In
their PGCG case studies, Giansanti et al(6)
have found no association between hyperparathyroidism
and PGCGs.
Overall, hyperparathyroidism has been observed
in less than 10% of all cases(14). Likewise,
the tests in our case revealed no such disease.
On the other hand, Gunhan et al(8) have proposed
that these lesions might be affected by sex
hormones. According to these authors, giant
cells are potential targets for estrogen activation.
In our case, the patient was in the 2nd/3rd
months of pregnancy, and the lesion had a progressive
growth, both indicating a possibility of estrogen
activation (comparison of figures 1 and 2).
The therapeutic approach has been reported
in several cases to be excision of the PGCG
with scalpels or CO2 lasers(4). Although treatment
with laser has limited applications in lesions
neighboring the bone structures, it has advantages
such as less hemorrhage in the site of surgery,
absence of pain, and increasing sight. Eversole
et al(5) have reported that the risk of recurrence
ranges from 5 to 11%. In our case, the priority
in our therapeutic approach was towards eliminating
the growth in the gingiva, and the lesion was
surgically completely excised, followed by curetting
the neighboring structures. As a result of a
4-month follow-up, no recurrence was observed.
Giant cell granuloma lesions should be carefully
diagnosed and excised in an as early as possible
stage, via a careful treatment plan, and should
be histopathologically distinguished from similar
lesions. Our case was caught at an early stage,
and a successful result was obtained with performing
the required tests, therapy, and follow-up.
In conclusion, we wish to stress the importance
of not only successful treatment of these lesions
that can be encountered in the oral cavity,
but also their follow-up regarding the risk
of recurrence.
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