The peripheralgiant cell granuloma (PGCG), also known as peripheral giant cell epulis. PGCGor giant cell hyperplasia, is the most common giant cell lesion in the oralcavity with the incidence rate varying from 5.1% to 43.
6%. Since its reparativeeffect has not been proved till date; the osteoclast activity appears to bedoubtful.1-3 CASEREPORT A 40 years old female patient with a chief complain of painlessswelling in lower back right region of jaw since 6 months. Theswelling was initially small in size and then gradually increased up to thepresent size. The patient gavea history of mild localized intermittent pain in relation to the same regionwhile having meals and also slight bleeding on brushing teeth. There was nohistory of trauma, neurological deficit, fever, loss of appetite, loss ofweight. There was no similar swelling present in any parts of the body.
Patientwas systemically healthy. Past medical, family histories were non-contributory. Extra-orally,there was no abnormality detected. Intra-orally, a solitary ovoid swelling waspresent in the right lower buccal vestibule measuring approximately 2× 3 cmextending from distal aspect of 45 to mesial aspect of 47 with significantvestibular obliteration in relation to 45–47. The overlying mucosa appearedpink to erythematous. The surface ofthe swelling was smooth, showed no secondary changes,& was covered bynormal mucosa with mild focal hyper pigmented areas and had a pedunculatedbase.
On palpation, the swelling was soft to firm in consistency, slightlytender, and blanched on pressure. Orthopantomogram, intraoral periapical radiographsshowed no bone resorption. Fig 1. A firm, smoothswelling, extending from mandibular premolar to mesial aspect of mandibular 2ndmolar. Surgery (excisional biopsy) was plannedunder local anaesthesia.
The overlying mucosa was incised and undermined.Lesion was separated from adjacent tissue by blunt dissection and removed inone piece. There is no sign of reoccurrence after 6 months follow up. Fig2. After surgical exicision of lesion Histopathology reveals it consists ofnon-encapsulated mass of tissue composed of a delicate reticular and fibrillarconnective tissue stroma containing tissue cells and multinucleated giant cells,containing 8-15 nuclei. Area of haemorrhage and acute and chronic inflammatorycells are frequently present. Microscopic examination of the section shows thepresence of hyperplastic parakertinized stratified squamous epithelium.Presence of numerous young proliferating fibroblasts.
(Fig 3&4) Fig 3&4. Histologicalappearance of the PGCG lesion (in various magnifications) showing features ofhyperplastic granulation tissue, and proliferation of multinucleated giantcells within haemorrhagic background(H&E stains20X & 10X) Fig 5. Exicisedtissue Fig 6. 1 week post operatively DISCUSSION A case of a PGCGis described, which originallyappeared to be agingival overgrowth.
The word epulisderives from theGreek words “epi” and “ulon” meaning”on thegingiva”. Since the term “epulis” indicates onlythe location ofa lesion, as an insufficient term it is notused in diagnosis nowadays.5,6 PGCG is alocalized tumor-like hyperplastic gingival enlargement which usually evolvesfrom the interdental tissues (which may include the periosteum or periodontalmembrane) as a consequence of chronic irritation from local factors viz. sub-gingivalplaque and calculus or trauma.Chronic localirritation of the gingivaisresponsible for the occurrence of most of the reactive lesions, one of which isPGCG.Although theselesions occur over a varied age group? the peak incidence observed in males isthe second decade in contrast to the fifth decade for females.
Moreover, PGCGlesions are more common in mandible when compared to maxilla (2:1). Lesions areseen to arise from anywhere on the gingiva or alveolar mucosa in either dentateor edentate patients, but most occur anterior to the molar teeth. Theinterdental papilla is mostly affected in dentate patients.7 Lesions canbecome large, sometimes attaining a size upto 2 cm. The clinical appearance issimilar to the more common pyogenic granuloma, although the PGCG is often morebluish-purple as compared with the bright-red colour of a typical pyogenicgranuloma.Recently, thePGCG associated with dental implants has been reported (Hirshberg et al, 2003).Although the PGCG develops within soft tissue, superficial resorption of theunderlying alveolar bony crest is sometimes seen. On occasion, it may bedifficult to determine whether the mass arose as a peripheral lesion or acentral giant cell granuloma eroding through the cortical plate into thegingival soft tissues (Chadwick et al, 1989; Giansanti & Waldrom, 1969).
Differentialdiagnosis among multifocal location, should be between leukaemia (it ischaracterized by gingival swelling) and gingival hyperplasia due to medication(ie: nifedipine, phenytoin and cyclosporine A).Surgery remains the mainstay oftreating PGCG wherein resection of the lesion with the elimination of itsentire base is performed. To prevent the recurrence after treatment, it isnecessary to correct or eradicate the underlying source of irritation.8 CONCULSION of PGCG involvingthe mandibular alveolar mucosa and gingiva. The case report has substantiatedthe provisional diagnosis by means of radiologic and histopathologic picture.
Most of thereactive oral lesions including PGCG may rapidly grow to reach a significantsize within several months of initial diagnosis. Radiographs are important toshow the origin of this particular giant cell lesion from the periphery withinthe oral mucosa and thus help in its diagnosis. PGCG is not an aggressivelesion. If not diagnosedearly & properly managed, these soft tissue growths may cause discomfortwhile performing daily routine such as eating, speaking, etc and also destroyoral tissues.