Delayed Eruption of Tooth Due to Peripheral Giant-Cell Granuloma: An Unusual Presentation and Treatment in 15-Year-Old Child Patient.

Peripheral giant-cell granulomas (PGCGs) are reddish color lesions of the gingiva which are frequently diagnosed on a routine basis by many dentists in the regular dental practice. Most of the lesions of PGCG are slow-growing, nonaggressive with asymptomatic, and tend to recur. Here, we exhibit a case of PGCG of the upper jaw in a 15-year-old girl child. She presented with a chief complaint of a lump on her upper anterior tooth region for 2-3 months. A well-defined painless, sessile exophytic growth, measuring about 1 cm × 0.5 cm in dimension with pinkish red in color with a firm consistency, was noted. Moreover, no secondary changes were seen. On the radiograph also, no changes in the bone/tooth were observed. The provisional diagnosis was identified as benign lesions such as pyogenic granuloma, peripheral ossifying fibroma, and PGCG and was made based on the clinical history and radiographic findings, and the confirmative diagnosis was given after histopathological examination. To improve the esthetic and function of teeth as well as psychological problems in the young patient, we tend to manage the case more simply by conservative surgical procedure at the earliest to prevent a recurrence. Copyright:

INTRODUCTION

The most important reactive lesions seen in the oral cavity are pyogenic granuloma, fibrous hyperplasia, peripheral ossifying fibroma, and peripheral giant-cell granuloma (PGCG). Jaffe was the first person who described PGCG in 1953, and he termed the lesion as “reparative giant-cell granuloma.”[1] Later, it was coined as “peripheral giant-cell reparative granuloma” by Bernier and Cahn.[2] The main goal of this case presentation was to demonstrate a girl child presenting an upper swelling of peripheral giant-cell lesions which is interfering with the eruption of the upper canine and to discuss the distinct technique of treating this lesion.

CASE REPORT

A female child patient aged 15 years with presenting a complaint of a swelling on her upper front tooth region for 2–3 months. A well defined painless, sessile exophytic growth, measuring about 1 cm × 0.5 cm in dimension with pinkish red in color, and there are no secondary changes. It was extending from the distal aspect of the left maxillary permanent lateral incisor to the mesial aspect of the first deciduous molar of the same side. On palpation, the lesion showed a smooth surface, soft to a firm consistency, and no tendency toward bleeding. The patient did not have any other medical or dental history [Figure 1]. There were no remarkable radiographic changes. Based on clinical and radiographic findings, the provisional diagnosis is a benign lesion or cyst. All the hematological findings and parathyroid hormone levels of the patient were within the normal values.

Figure 1

Photomicrography showing an intraoral clinical presentation of gingival swelling in a 9-year-old female child

Informed consent was attained from the patient before the surgical treatment procedure. Excisional biopsy was carried out under local anesthesia, and the specimen was sent for histopathological examination. On microscopic examination, there were ample multinucleated giant cells arranged in dense fibrous connective tissue with fibroblast cells. The lesion was enveloped with stratified squamous keratinized epithelium with hyperplastic. The above features are characteristic of PGCG [Figure 2].

Figure 2

Photomicrography showing dense fibrous connective tissue with numerous multinucleated giant cells arranged in foci

The electrocautery scalpel surgical procedure was carried out and the resected area was sutured with periodontal/surgical dressing to be protected by the external environment [Figure 3]. After 7 days, recall the patient for removal of the surgical dressing as the lesion was in the healing phase. There was no mark of pathology or recurrence, and the permanent canine was erupting normally within 3 months. The patient was advised to maintain oral hygiene with Betadine solution until the perfect tissue healing. The follow-up was done for 3 years, and the lesion was uneventful postoperative recovery.

Figure 3

Photomicrography showing the patient had undergone a surgical procedure with surgical dressing

DISCUSSION

The etiology of peripheral giant-cell granuloma exhibits an unknown, with some controversy as to whether this lesion illustrates a reactive or neoplastic. It is a benign hyperplasic lesion but not a true neoplasm.[345] Palacios et al. suggested that the origin of giant cells in this lesion by the fusion of histiocytes, endothelial cells, pericytes, and fibroblasts gives rise to giant cell formation, but the source of giant cells origin has still been controversial.[6] The current research work was carried out by Bo Liu et al. to detect the multinucleation of osteoclasts and macrophage-derived giant cells from mononuclear precursor cells through in situ hybridization.[7] On clinical presentation, the majority of the cases manifest that PGCG is more common in the mandible compared to the anterior maxilla and observed in elderly people in the 4th–6th decade of life.[3] The lesion represents a rubbery or firm, smooth-surfaced nodule or growth with red, purple, or blue. Other clinical findings such as surface ulceration, bleeding, and displacement of the teeth can be seen. The size of the lesion varies from a small papule to a massive enlargement, i.e., <2 cm diameter in size. In our case, PGCG may also hinder the eruption of succeeding teeth, i.e., canine was observed. On radiographic features, there will be bone involvement under the lesion, i.e., superficial bone resorption like concave resorption which is a typical feature of PGCG is known as “leveling” effect[3] or “cupping” resorption of alveolar bone.[8] The differential diagnosis of PGCG based on clinical and radiographic findings are fibrous epulis, peripheral odontogenic fibroma, hemangioma, lymphangioma, and metastatic tumors of the gingiva. Therefore, careful histopathological examination is the key point to arrive at a final diagnosis and focus on an exact treatment plan.[9] The histologic features of PGCG included a stratified squamous keratinized epithelium and the connective tissue has a high cellular mass. The connective stroma consists of abundant multinucleated giant cells “osteoclasts like” or larger than typical osteoclasts, inflammatory cells, thin walled, small sized vessels, hemosiderin laden macrophages with extravasated RBCs, and collagen bundle with fibroblasts.[310] As per the proposed treatment of peripheral giant-cell granuloma, it is recommended to excise the entire lesion by the surgical procedure with scaling of adjacent teeth, if any local irritating factors.[9] Here, we used the different techniques of treatment, i. e., electrocautery scalpel surgery was used to excise the lesion.

Sometimes, the recurrence of the lesion was seen due to:[9]

The lack of inclusion of the periosteum or periodontal ligament in the excised lesion

A superficial excision or incomplete removal of the lesion

Lack of cooperation of the child

Conservative management.

Various authors have reported recurrence rates ranging from 1.4%–22%.[1011] Therefore, early detection and diagnosis of the PGCG should be treated by an electrocautery scalpel surgery along with less risk for tooth and bone loss.

CONCLUSION

Numerous reactive lesions are enlisted, but peripheral giant-cell granuloma is a reasonably rare lesion in children, and the clinician should be considered as one of the clinical differential diagnoses for the gingival lesion. Hence, the histopathological examination is one of the most important procedures to arrive at a final diagnosis. The electrocautery scalpel surgery is the line of treatment for the PGCG along with the cessation of underlying any etiologic factor. The early observation and correct diagnosis can be done, based on clinical and radiographic findings as well as the histological examination, to minimize any dentoalveolar complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the father has given his consent for images and other clinical information to be reported in the journal. The father understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.