Peripheral giant cell granuloma of maxilla.

It is often documented that chronic irritation could be an etiology of oral cancer; yet out of negligence little heed is paid to any sort of discomfort until it grows to a sizable mass where it is difficult to go unnoticed. Intraorally, the source of irritation could vary from a jagged tooth edge to a chronic cheek bite. Furthermore, the removable prosthesis and orthodontic appliances can lead to alteration of the oral mucosal tissue. This case report represents one such sequelae of an ill-fitting dental prosthesis. Surprisingly and unfortunately, the broken denture was still in use by the patient until the damage caused by it could no further be ignored, it is then that the patient sought medical help. A histopathological diagnosis of reparative giant cell granuloma was made, and the patient was treated by successful excision of the same. Copyright:

INTRODUCTION

Reparative giant cell granulomas (RGCGs) are tumor-like nonneoplastic lesions of gingiva and alveolar ridge which indicate an exuberant hyperplastic response of periosteum or periodontal ligament to a chronic irritation or trauma. It is a nonodontogenic and rare bony lesion in the head-and-neck region; never seen in any other bone of the skeleton.[12]

Also known as giant-cell reparative granuloma, giant-cell epulis, osteoclastoma, or giant-cell hyperplasia have to be differentiated from hemangioma, lymphangioma, metastatic tumors of gingiva, nevi, other nodular melanomas, peripheral giant cell granuloma (PGCG), and other inflammatory hyperplastic lesions.[3]

It most commonly affects maxilla followed by the mandible and can be seen at any age but is more common in the fifth and sixth decades of life, with a slight predilection toward females.[4] RGCGs are classified, according to location, as central (bone) and peripheral (gingival tissues).[5]

Clinical presentation can vary from nodular or polyploid lesions, primarily bluish red in color with a smooth shiny or lobulated surface, stalky or sessile base, small and well demarcated.[6] This lesion has a higher recurrence rate as compared to other reactive lesions and thus has to be treated with caution with complete excision and clearing of the lesion.

CASE REPORT

A 60-year-old male patient reported with a chief complaint of growth in the right gum region [Figure 1]. The patient was a denture wearer for 15 years with a history of denture fracture. The patient continued to wear the broken denture for approximately 2.5 months and maintained a soft diet. The growth was initially small in size which the patient ignored and sought treatment once it reached the present size. The patient did not experience any pain or bleeding from the same.

Figure 1

Intraoral view of the growth

The patient visited a private practitioner who repaired the denture and referred the patient to our hospital. Medical history revealed the patient to be a known diabetic and had a raised glycosylated hemoglobin level.

On examination, it was a firm sessile growth in relation to the gingivobuccal sulcus of the right maxillary posterior region. The surface was lobulated with areas of ulceration; color was dark red with areas of bluish discoloration.

Investigations

Orthopantomogram [Figure 2] revealed edentulous maxilla with pneumatization of the maxillary sinus. No significant bony changes were seen.

Figure 2

Orthopantomogram

Routine blood investigations, including complete blood count, bleeding time, and clotting time, were in the normal range.

Following a workup on the blood profile, glycemic control evaluation and radiologic investigation; surgical excision of the fibrous growth was done under local anesthesia. Hemostasis was achieved by radio cautery. The excised sample [Figures 3 and 4] was sent for the histopathologic examination. Grossly, the globular growth measured 2.5 cm × 1.8 cm × 0.8 cm.

Figure 3

Excised growth

Figure 4

Undersurface of excised growth

Histopathology

Microscopic examination revealed tissue lined by stratified squamous epithelium. The underlying fibrocollagenous tissue showed a large number of multinucleated giant cells, cellular vascular stroma, and areas of new bone formation within the tumor mass. The multinucleated giant cells were patchily distributed in a background showing hemosiderin-laden macrophages along with chronic inflammatory infiltrate [Figures 5 and 6].

Figure 5

Microphotograph showing an outer stratified squamous epithelium beneath which well vascularised fibrocollagenous stroma (black arrow) and multinucleated giant cell seen (red arrow) (H and E, ×10)

Figure 6

Microphotograph showing high power view of evenly distributed multinucleated giant cells (arrow) in a background of fibrocollagenous stroma (H and E, ×40)

DISCUSSION

Reparative giant cell granuloma (RGCG) comprises the category of neoplasms which clinically may look aggressive but histologically are not a true neoplasm rather a reactive hyperplastic process of periosteum or the periodontal membrane to local irritation or chronic trauma arising from a sharp tooth edge, ill-fitting dental prosthesis, foreign-body lodgement in gingiva, dental restoration, calculus.[7] Association with periodontal bony defects and dental implants is also cited in the literature.[89]

Of all the reactive growths found intraorally incidence of PGCG is reported to vary from 5.1% to 43.6%.[10]

Although an equal predilection of its occurrence in both the genders is reported, there are studies which show preponderance in females explained by the hormonal influence of estrogen on the multinucleated giant cells[1112] and males, respectively.[1314]

Differential diagnosis of PGCG is important since there are various other lesions which resemble PGCG but have a different line of treatment and prognosis. Focal proliferative gingival lesions which mimic PGCG are pyogenic granuloma, central giant cell granuloma (CGCG), peripheral ossifying fibroma (POF), brown tumor, and metastatic carcinomas.[15]

Pyogenic granuloma usually presents a soft nodular growth which tends to bleed easily. Since it is very difficult to differentiate this lesion from PGCG clinically, final diagnosis rests on histopathological evaluation. POFs usually occur on the maxillary arch in the incisor cuspid region. X-ray shows radio-opaque calcification at the center of the lesion.

Radiographically, PGCG is a soft-tissue lesion that infrequently affects the underlying bone, although it may cause superficial erosion of the underlying bone and less commonly underlying teeth. These lesions are not painful unless they are traumatized.[16]

CGCG with a peripheral extension presents as an expansile lesion in center of the jaw. The lesions appear centrally in bone and are referred to as brown tumors, these intrabony lesions grow centrifugally perforating the cortical layer, spreading toward the soft tissues and imitating a peripheral lesion.

Radiographs show radiolucent lesion often crossing the midline. This condition is often associated with hyperparathyroidism and the patient demonstrates multiple lesions and recurrences in spite of adequate treatment.[615]

Metastatic carcinomas usually present as exophytic growth leading to irregular bony destruction, below the lesion and usually have an indurated margin.

In a review of 123 cases by Shadman et al.[7] determining the clinical characteristics of PGCG, it was reported that PGCG was seen more in the mandible (64.6%) and in the anterior region “canine to canine region” (57.7%) more than in the posterior region.

The ulceration seen on the surface is attributed to trauma. Although in our case the site was posterior maxilla, the growth was sessile and painless. The common site of occurrence is the interdental papilla, edentulous alveolar margin or at the marginal gingival level.[615] Both sessile[1] and pedunculated[7] are reported in the literature.

In our patient, the consistency of lesions was firm which could be attributed to the chronicity of the lesion which contributed to an increase in collagenous component.

The bluish red discoloration is ascribed to extravasated deoxygenated erythrocytes at the periphery and various amounts of hemosiderin pigment.[3]

The local cause of irritation could be extended wearing of an ill-fitting denture and the diabetic profile of the patient; which surprised the family and the dentist alike as to how the patient could even manage with the broken prosthesis.

The treatment of PGCG comprises surgical resection with elimination of the entire base of the lesion and suppression of the etiologic factor. If resection is only superficial, the growth may recur. Most lesions respond satisfactorily to thorough surgical resection [Figure 7].

Figure 7

Healed surgical site

CONCLUSION

The presented case is an eye-opener for the dental community. The responsibility of the dentist cannot be overemphasized. Despite the awareness programs, advertisements on social media regarding general and oral health the resultant laxity on the part of patients resurfaces. Although there is no dearth of such cases reported in the literature but what makes our case distinct from those reported is the etiology that despite knowing the prosthesis was faulty it was still in use by the patient though at an expense of compromised dietary intake.

Therefore, patient education videos in the reception area as well as reinforcement of good oral hygiene and the interrelationship between oral health and systemic health at each patient visit should be an integral part of the treatment plan. Detailed knowledge and identification of cause and behavior of this lesion will lead to a reduction in occurrence and recurrence rates of PGCG. Furthermore, the extension of this to the adjacent dentition and the underlying bone could be avoided. Therefore, all the more essential that the importance of visiting a dentist bi annually and not to ignore even the slightest of an aberrancy more so when the patient has risk factor of diabetes need to be reinforced.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.