International J.

of Healthcare and Biomedical Research, Volume: 05, Issue: 02, January 2017, 53-58

Case Report
Peripheral Giant Cell Granuloma – A Review and Case Report
Dr. Somya Maheshwari * , Dr. Girish Bhutada, Dr Vaishakhi Baisane, Dr Devendra Palve

Name & Address of Institution: Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Waddhamna Road,
Wanadongri, Nagpur, Maharashtra.
Corresponding author*

ABSTRACT
Peripheral giant cell granuloma is among the reactive lesions of oral cavity present either on the gingiva or alveolar
ridge. It can occur due to local irritational factors, trauma, etc. This case report presents a peripheral giant cell
granuloma on the lingual aspect of mandibular premolars with hard bony consistency and a firm, consistent growth
seen in interdental region between left mandibular premolars in a 48 year-old female patient. Traditional surgical
excision was performed under local anesthesia.
Keywords: Peripheral Giant Cell Granuloma (PGCG), Excisional Biopsy, Gingival Overgrowth, Mandible

INTRODUCTION rapid painful growth with recurrence or slow

Oral cavity manifests a spectrum of lesions
which could be either reactive, developmental
and inflammatory to neoplastic. Constant
external or internal stimuli causes the lesion to
occur.1 Reactive hyperplastic lesions represent
the most frequently encountered oral mucosal
lesions in humans. Peripheral giant cell lesions
(PGCL) are reactive, extraosseous and exophytic,
located in the alveolar ridge in edentulous area
or in the gingiva. It usually occurs as a result of
local irritants such as bacterial plaque, calculus,
food retention, chronic infections, chronic
irritation, trauma related to poorly fit dental
prostheses, supernumerary teeth, poorly
finished fillings, occlusal forces and exodontia. If
the lesion is excised along with the elimination
of local factors, the recurrence rate is low.
Central giant cell lesions (CGCL) are
intraosseous nonproliferative lesions whose
etiology is unknown. It is less common than
PGCL and occurs exclusively in maxillary bones.
It has variable clinical manifestations with either
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asymptomatic growth with no recurrence.
PGCL are derived from periosteum and
periodontal ligament and occurs frequently in
young adults. It occurs in variable sizes, sessile
or pedunculated.2 PGCL appear as a reddish
purple or purplish blue lump with smooth shiny
or papillomatous surface. It is a well-defined
lesion with exophytic growth and rarely exceeds
3 cm in their greater dimension. Although they
are encountered at any age, the fourth to sixth
decades are more frequent with a slight female
predilection.3 A few cases have been reported
occurring in children, and in these cases the
lesion appeared to be more aggressive with
resorbtion of the interproximal crest area,
displacement of the adjacent teeth and multiple
recurrences. Previously, the lesion was called
peripheral giant cell reparative granuloma.
However, its reparative effect has not been
proved yet, hence osteoclast activity seems
doubtful.4,5,6 Although PGCL arise in soft tissues,
the “cup-shaped” resorption of the subjacent
alveolar bone may be occasionally observed.7,8
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Peripheral giant cell lesion can be differentiated
from other inflammatory hyperplastic lesions by
presence of multinucleated giant cells whose
origin is undetermined.
The differential diagnosis of peripheral giant cell
granuloma involves lesion with very similar
clinical and histopathological features such as
CGCL, fibrous hyperplasia, peripheral ossifying
fibroma, pyogenic granuloma, inflamed irritation
fibroma, hemangioma, lymphangioma,
amelanotic melanoma and metastatic tumors.12
Rarely a giant cell epulis may be due to
hyperparathyroidism, representing the so-called
osteoclastic “brown tumours” associated with
this endocrine disorder (Smith et al, 1988;
Burkes & White, 1989) and is also associated
with other lesions in bones and changes in the
blood chemistry. The gingiva in extra-osseous
lesions of cherubism appears very similar to
giant cell epulide. However, the other distinctive
clinical and radiological features of cherubism
indicate the correct diagnosis (Odell & Morgan,
1998).2
Early diagnosis based on clinical and radiological
findings and confirmed by pathological analysis
allows for conservative management with less
risk of destruction for the adjacent teeth and
tissues.13
CASE-REPORT
A female patient of 48 years presented with chief
complaint of soft to firm swelling in lower front
region of the jaw (inner aspect) since few
months.
On examination generalized deposits of calculus
and marginal recession of gingiva was also
present. Intra oral periapical radiograph
revealed bone resorption and widening of
Lamina dura with lower second premolar (Fig 1
and Fig 2). Generalized bleeding on probing of
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the periodontal pockets was present. The lesion
present was painless, as well as elastic on
palpation, sessile, extending from distal aspect of
left first premolar to mesial aspect of left first
molar covered by red-white mucosa and
measuring about 10 × 7 mm2 (Fig 3 and Fig 4).
The provisional diagnosis for the case was
moderate chronic periodontitis with pyogenic
granuloma. The differential diagnosis could be
Fibrous hyperplasia, inflamed irritational
fibroma and Hemangioma.
The patient underwent complete blood
investigations. Phase1 periodontal therapy was
performed, and patient was recalled after 15
days for excisional biopsy. The lesion was
excised under local anaesthesia, and flap of that
quadrant was raised for complete debridement
and root planing in order to prevent recurrence.
Obtained tissue specimens were sent for
histopathological examination.
On microscopic examination the excised
specimen shows single bits of tissues consisting
of epithelium and connective tissue. The
epithelium was parakeratinized stratified
squamous type (Fig 5). At one part of the
epithelium there were long pushing rete ridges
and at the other part it was flat. The lamina
propria adjacent to epithelium showed loosely
arranged collagen fibres, few chronic
inflammatory cells, many diffusely arranged
fibroblast and blood vessels which appeared
engorged as well as dilated with blood elements
in it. Deeper connective tissue showed many
multinucleated giant cells distributed evenly
with variable number of nuclei ranging from 4-
10 in number with mild to moderate chronic
inflammatory cells like plasma cells and
lymphocytes (Fig 6). The lesion was diagnosed
as Peripheral Giant Cell Granuloma.
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Fig 1 - Intra-oral peri-apical radiograph revealing reduction of the

level of crestal bone in premolar area.

Fig 2 – OPG revealing generalized bone loss

Fig 3 - Specimen removed by excisional biopsy (about 7 × 10 mm2)

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Fig 4- Showing overgrowth on lingual aspect below mandibular premolar

.
Fig 5 – Low Power Microscope showing Surface Epithelium

Fig 6 – High Power Microscope showing many Multinucleated Giant Cells

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 International J. of Healthcare and Biomedical Research, Volume: 05, Issue: 02, January 2017, 53-58

DISCUSSION Two members of the tumor necrosis factor

The present case was histopathologically (TNF) group: receptor activator of nuclear
diagnosed as peripheral giant cell granuloma. factor-β ligand (RANKL) and osteoprotegerin
The peripheral giant cell granuloma, also known (OPG) helps Stromal mononuclear cells
as giant cell epulis, PGCL or giant cell (monocytes and macrophages) to participate in
hyperplasia though is the most common giant the formation of multinucleated giant cells . The
cell lesion, it is not a true neoplasm, but rather a transmembrane molecule RANKL is produced by
reactive lesion caused by local irritation or osteoblasts/stromal cells and binds to its RANK
trauma. Moreover, its etiology is still receptor, which is situated on osteoclast
contentious. These lesions have been described progenitor cells surface. Differentiation of
as reddish or purple with a smooth surface and osteoclast progenitor cells into mature
consistency that varies from soft to firm. In the osteoclasts is promoted by RANK – RANKL
present case, the lesion was reddish in color in binding. OPG, also produced by stromal cells/
accordance to the literature. osteoblasts, competitively binds to RANKL
The preferential location of the lesion is thereby blocking and neutralizing its binding to
premolar and molar zone, though Shafer,9 the RANK receptor, resulting in the reduction of
Giansanti and Waldron10 suggest that it osteoclastogenesis.12
commonly occurred anterior to molars. The Treatment consists of local surgical excision
occurrence of PGCG is 2 times more common in down to the underlying bone, for extensive
females than males. When compared maxilla to clearing of the base (Neville et al, 2009).Removal
mandible, it is more frequent in latter.11 All the of local factors or irritants is also required
characteristic features present in our study were (Regezi et al, 2008). If resection is only
in accordance to the literature. superficial, the growth may recur. Exposure of
The characteristic histopathological features all bony walls following thorough surgical
include a non-encapsulated highly cellular mass resection responds satisfactorily most of the
with abundant giant cells, hemosiderin deposits, times. Recurrence rate of 5.0-70.6% (average
inflammation, mature bone or osteoid, 9.9%) has been reported in various
interstitial hemorrhage. Incipient lesions may epidemiologic studies (Mighell et al, 1996).2
bleed and induce minor changes in gingival CONCLUSION
contour but large ones adversely affect normal Early and precise diagnosis of the lesion can
oral function. Interference with occlusion may allow conservative management without
cause ulceration of the lesion due to which it destruction of tooth and adjacent bone.
becomes infected and painful.3 Treatment consists of local surgical excision
As the exact origin of the giant cells remains down to the underlying bone, with removal of
unclear, several hypotheses were generated to local factors or irritants. The growth may recur if
explain their proliferation: osteoclasts, spindle- superficially resected. So complete excision of
shaped mesenchymal cells, osteoblasts, foreign the lesion along with regular recall visits is the
body cells, phagocytes reacting to hemorrhage treatment of choice for Peripheral Giant Cell
and endothelial cells.5 Granuloma.
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ACKNOWLEDGEMENT Department of Oral and Maxillofacial Pathology ,

We would like to acknowledge all the staff of Swargiya Dadasaheb Kalmegh Smruti Dental
Department of Periodontology, Swargiya College and Hospital for performing histological
Dadasaheb Kalmegh Smruti Dental College and examination. The authors report no conflicts of
Hospital and Dr. Devendra Palve Professor, interest related to this study.

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