Case Report. A Reticent Intraoral Growth - Peripheral Giant Cell Granuloma

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1 Medicine Case Report Dr. Abhay Kulkarni, Dr. Rajendra Birangane, Dr. Sanjeev Onkar, Dr.Pratik.C.Parkarwar Kulkarni A, Birangane R, Onkar S, Parkarwar PC. A Reticent Intraoral Growth - Peripheral Giant Cell Granuloma.J Periodontal Med Clin Pract 2015; 02:24-30 Affiliation 1. Assistant Professor, Department Of Oral Medicine and Radiology, PDU Dental College, Solapur, 2. Professor & Head, Department Of Oral Medicine and Radiology, PDU Dental College, Solapur, 3. Reader, Department Of Oral Medicine and Radiology, PDU Dental College, Solapur, Maharashtra, India. 4. PG Student, Department Of Oral Medicine and Radiology, PDU Dental College, Solapur, Corresponding Author: Dr. Abhay Kulkarni Assistant Professor, Department Of Oral Medicine and Radiology, PDU Dental College, Solapur, ABSTRACT Peripheral giant cell granuloma is the familiar exophytic benign lesion of the oral cavity. It occurs due to hyperplastic reaction that is occurring because of injury or inflammation.the origin is in the periosteium or periodontal membrane. It is seen frequently in females. Principally seen in the anterior region of the mandible. Alveolar crest is universal location in edentulous patients. The case reported here presents a middle aged woman with swelling in lower front region of jaw since two months, having fear of malignancy in the mouth. The lesion was diagnosed as peripheral giant cell granuloma by clinical and histopathological examination. The lesion was completely excised upto periosteal level and follow up of the patient was done. Early detection and excision of the lesion is important to prevent further dentoalveolar complication. The biopsy of lesion has to be done to rule out fear of malignancy. Key words : Peripheral giant cell granuloma, Exophytic, benign, Hyperplastic, detection INTRODUCTION Peripheral Giant cell granuloma is the frequently occuring extra-osseous and non neoplastic lesion. It is reactive in nature. The lesion is characteristically purple red coloured nodule and has consistent number of giant cells. [1, 2] The other names for the same lesion are Osteoclastoma, Giant cell hyperplasia, and Giant cell epulis. This entity is also called as Giant cell reparative 24

2 Medicine [3, 4] granuloma. The prevalence of Peripheral Giant cell granuloma is nearly about 7% in all benign tumors of jaw. [5] The major causative factors are trauma, tooth extraction, plaque, and calculus. The other ones are impacted food, poorly finished restorations and infection. The common locations [6] are on gingiva and alveolar ridge. The colour of the lesion may vary from deep red to purple. The easy bleeding may be another characteristic finding. The lesion may be sessile or pedunculated. Cells of mononuclear phagocytic [7] system may also play in the formation of lesion. The lesion on average occurs in lower jaws as compared to upper jaws. The common location is in between permanent first molar to incisor. [4, 9] size varies from 2cm -5cm. Some suggests that giant cell are influenced by hormones mainly oestrogen. [10] [8] It Proper clinical examination, radiographic examination and histopathological examination is required to confirm the diagnosis. Histo-pathological findings are non encapsulated mass with multi nucleated giant cells, intestinal haemorrhage, haemosiderin deposit and newly formed bone. The main element is fibroblast with multinucleated giant cells. It also shows inflammatory cells in the connective tissue. [11,12] The treatment of choice is surgical excision of the lesion. The lesion has to be excised up to periosteal level. The surgical exposure has to be followed by thorough scaling and extraction of mobile tooth. The removal of etiological factor should be considered to reduce the risk of [13] recurrence. CASE REPORT A middle aged woman came with swelling in lower front region of the mouth since last two months. She noticed a small peanut sized growth which gradually increased to present size [3 cm X 1.5 cm]. She noticed mobility of front teeth and lingual displacement of teeth recently. Since last 15 days, bleeding while cleaning of teeth from the same area was also present. The swelling was not associated with pain and any other complaints. In her dental history, History of extraction of teeth in lower jaw 15 years back and was operated for pus removal on right side of the face, extraorally. In her medical history, She was on medication for abdominal pain and taken medication for 15 days (the nature she was not aware of) and stopped medication after doctor suggestion on relieving of symptoms. On extraoral examination,scar of approximately 1.5 cm noted 3 cm anterior to angle of mandible. Right and left sub-mandibular lymph nodes were palpable of approximately 1cm in size mobile,soft, non-tender and not fixed to underlying tissue. In the intraoral examination on inspection growth was seen on gingiva in 31,32,41,42 region of 3cm X 1.5 cm, mesiodistally 1.5 cm labiolingually in size, [figure 1]. The shape of growth was irregular with lobulated surface. The color is pale pink, red & purple in some areas and edges wer well defined labially, diffuse lingually. No visible Pulsations were noted. The surrounding mucosa was normal. Pressure indentations of teeth & erythema are seen. Over all poor oral hygiene and halitosis was present. Generalised calculus and stains were present. Generalized pockets were present. 25

3 JPMCP Medicine Teeth missing- 36, 38, 46, 47, 48. Root stumps- 35, 37, 44, 45. Grade I mobility with - 12, 22, and 44. Grade II mobility with-11, 21, 23, 32, 41, and 42. Attrition was present in 11, 41. INVESTIGATION Blood investigation : Haemoglobin :- 9.0 gm% NEUTROPHILS :- 67% LYMPHOCYTES :- 29% MONOCYTES :- 02% EOSINOPHILS :- 02% BASOPHILS :- 00% RBC :- 4.8 million/cubic mm RBS : mg% BT :- 01 min 4 sec CT :- 03 min 51 sec The IOPA showing bone loss in relation with 31,41. In mandibular occlusal topographic showing soft tissue outline of the lesion, displaced 32, 41, [figure 2]. There is no expansion of cortical plates and no radiographic evidence of erosion of the bone. EXCISIONAL BIOPSY The biopsy was done in lower left front region of jaw with creamish brown colour of 2cm X 3cm in size. It was soft to firm in consistency with Fig 1: Profile picture 26 nodular appearance. HISTOPATHOLOGICAL REPORT The H & E stained section shows present of stratified squamous epithelium lining which is parakeratinised. The epithelial lining is thick and rete ridges are thin and elongated showing arcading and forking pattern. The basement membrane appears to be intact throughout section. The underlying connective tissue shows dense inflammatory cells infiltration. Numerous multinucleated cells showing 8-12 nucleoli, along with other inflammatory cells. Numerous blood engorged capillary seen. The overall histological picture is suggestive of peripheral giant cell granuloma. DIFFERENTIAL DIAGNOSIS Pyogenic granuloma, central giant cell granuloma, peripheral ossifying fibroma In rarities brown's tumor of hyperparathyroidism, kaposi sarcoma. TREATMENT The lesion was surgical excised under local anesthesia. Extraction of root stumps 35, 37, 44, 45, 31, 41. Oral hygiene prophylaxis. Restoration of carious teeth 26. Fig 2: Intraoral picture with pale pink over growth in mandibular anterior region

4 JPMCP Medicine Fig 3: Intraoral picture Fig 5 3: Histologic Picture DISCUSSION Giant cell granulomas are of two types one central and other is peripheral. Central giant cell granuloma is bone based lesion, has got origin in bone and peripheral giant cell granuloma is biologic tissue based, has got origin in the soft tissues. Central giant cell granuloma involves in maxilla, mandible, temporal bone and paranasal sinuses rarely it is seen in hard palate while peripheral giant in soft tissues of oral cavity mainly in gingival. [14-18] Jafee suggested term giant cell reparative granuloma to central growing lesion as these lesions are reparative and not neoplastic in nature,as he wanted to differentiate giant cell tumour from central growing lesion. As there is hyperplasia of gingiva and its exophytic 27 Fig 4: M andibular topographic view Fig 4: 6 Post operative picture growth worries the victims of been malignancy but is not so as it is non neoplastic. [19-21] It largely arises in 4-6 decade of living with male to female ratio of 1:1.5. [3, 22-24] It occurs in gingiva due to confined grievance.it is seen as 70% in mandible while 30% in maxilla.[25] It appears as smooth, irregular outline with multiple protuberances. It is in the range from red to purple in color with indentation. Occasionally ulcer may be seen. [4, 26, 27] It develops cupping superficial resorption of the underlying alveolar bone and can be seen as superficial erosion of bone radiographically. [11] Liu et al (2003) concluded that giant cell are fashioned from RANKL (receptor activator of NFKappa B Ligand), OPG (osteoprotegrin), RANK (receptor activator of NF-Kappa B

5 Medicine [28] Ligand). Recently Choi et al reported that there may be association of peripheral giant cell [29] granuloma with hyperparathyroidism. Rarely peripheral granuloma is a manifestation of hyperparathyroidism which is confirmed by blood chemistry. These suggest that osteoclastic brown tumor of hyperparathyroidism is allied with endocrine disease. It can be diagnosed by blood chemistry and by location (smith et al, 1988; Burkes & White 1989). According to study of Lim and Gibbins (1995) confirmed that the giant cells in peripheral giant cell granuloma [30] react strongly for monoclonal antibody. Some suggests that giant cell are influenced by hormones mainly estrogen. [10, 22, 31] Histopathologically peripheral giant cell granuloma shows non encapsulated mass with multi n u c l e a t e d g i a n t c e l l s, h a e m o r r h a g e, haemosiderin deposit and newly formed bone. T h e m a i n e l e m e n t i s fi b r o b l a s t w i t h multinucleated giant cells and eosinophilic cytoplasm. It shows inflammatory cells in the [11, 12] connective tissue. The treatment of choice is surgical excision of the lesion upto periosteal level followed by scaling and extraction of mobile tooth and removal of etiological factor and reduce the risk of [13] recurrence rate is 10 %. REFERENCES : recurrence. The 1. S.Moghe. Peripheral giant cell granuloma: A case report and review of literature.people's journal of scientific research. 2013; 6(2): Ajiravudh Subarnbhesaj, Peripheral giant cell granuloma: A case report and review literature. khon kaen university. 2005; 8(2): Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulou AP. Peripheral giant cell granuloma: clinicopathologic study of 224 new cases and review of 956 cases. Int J Oral Maxilofac surg. 1988; 17: Bodner L. Peist M. Gatot A. Flisss DM. Growth potential of Peripheral giant cell granuloma. Oral surg oral med oral pathol oral radiol endod. 1997; 83: Pour MAH, Rad M, Mojtahedi A. A survey of soft tissue tumor-like lesions of oral cavity: A clinicopathological study. Iranian Journal of pathology. 2008; 3: Satheesh Mannem, Vijay K Chava. Management of an unusual peripheral giant cell granuloma: A Diagnostic dilemma. Contemp Clin Dent. Jan Mar 2012; 3(1): Aslan M, Kaya GS, Day E, Demirci E. A peripheral giant cell granuloma in early age(case report). AtaturK Univ Dis Hek Fak Derg ;( 3): Kfir Y, Bucher A, Hansen I.S. Reactive lesions of gingival.a clinicopathological study of 741 cases. J Periodontol. 1980; 51: Nevville BW, Damm DD Allen CM, Bouquot JE. Soft tissue tumors.oral and maxillofacial pathology. St.louis saunders. 2009; 3: Giansanti JS, Waldron CA.Peripheral giant cell granuloma: review of 720 cases. J Oral surg. 1969; 27: Sidhi Passi et al. Peripheral giant cell granuloma: Innovative journal of 28

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