Peripheral giant cell granuloma is a common benign and reactive gingival epulis in oral cavity. It is often difficult to make a

clinical diagnosis; thereby definitive diagnosis depends on histopathologic features. We report a case of a 4-year-old Caucasian

boy presenting with a five-month history a 20 × 15 × 12 mm pedunculated, lobular soft tissue mass of the left anterior maxilla

gingiva which was misdiagnosed and maltreated before his referral. An excisional biopsy of the lesion followed by histopathologic

examination of the biopsy specimen revealed distinctive features of peripheral giant cell granuloma. Early detection and excision

of this hyperplastic nodule especially in children are important to minimize potential dentoalveolar complications

Enshaei, Z.

Eshghi, A.

Jafarnejadi, P.

Nekouei, A.

PubMed

Peripheral giant cell granuloma is a common benign and reactive gingival epulis in oral cavity. It is often difficult to make a clinical diagnosis; thereby definitive diagnosis depends on histopathologic features. We report a case of a 4-year-old Caucasian boy presenting with a five-month history a 20 × 15 × 12 mm pedunculated, lobular soft tissue mass of the left anterior maxilla gingiva which was misdiagnosed and maltreated before his referral. An excisional biopsy of the lesion followed by histopathologic examination of the biopsy specimen revealed distinctive features of peripheral giant cell granuloma. Early detection and excision of this hyperplastic nodule especially in children are important to minimize potential dentoalveolar complications

Afsaneh Nekouei

Alireza Eshghi

Parisa Jafarnejadi

Zahra Enshaei

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Case Reports in Dentistry

A Review and Report of Peripheral Giant Cell Granuloma in a 4-Year-Old Child

shahrekord university of medical scinces

Case ReportA Review and Report of Peripheral Giant CellGranuloma in a 4-Year-Old ChildAfsaneh Nekouei, Alireza Eshghi, Parisa Jafarnejadi, and Zahra EnshaeiTorabinejad Dental Research Center and Department of Pediatric Dentistry, School of Dentistry,Isfahan University of Medical Sciences, Isfahan 73461-81746, IranCorrespondence should be addressed to Zahra Enshaei; zahraenshaei@ymail.comReceived 25 March 2016; Accepted 26 May 2016Academic Editor: Tommaso LombardiCopyright © 2016 Afsaneh Nekouei et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.Peripheral giant cell granuloma is a common benign and reactive gingival epulis in oral cavity. It is often difficult to make aclinical diagnosis; thereby definitive diagnosis depends on histopathologic features. We report a case of a 4-year-old Caucasianboy presenting with a five-month history a 20 × 15 × 12mm pedunculated, lobular soft tissue mass of the left anterior maxillagingiva which was misdiagnosed and maltreated before his referral. An excisional biopsy of the lesion followed by histopathologicexamination of the biopsy specimen revealed distinctive features of peripheral giant cell granuloma. Early detection and excisionof this hyperplastic nodule especially in children are important to minimize potential dentoalveolar complications.1. IntroductionSolitary gingival enlargements in children are relativelycommon and usually occur in reaction to local irritation orchronic trauma.One of these enlargements is peripheral giantcell granuloma (PGCG), a lesion unique to the oral cavity,occurring only on the gingiva. It is distinguishable fromsimilar lesion only on the basis of its unique histomorphol-ogy, which is essentially identical to that of central giant cellgranuloma, intrabony benign neoplasm of the jawbone [1].Peripheral giant cell granuloma originates from the inter-dental tissues (periosteum or periodontal membrane) [2,3]. Lesions can arise anywhere on the gingival or alveolarmucosa but most occur anterior to the molar teeth [2, 4].Although these lesions occur over a wide age range, thepeak incidence in males is in the second decade comparedto the fifth decade for females [5]. There is a nearly 2 : 1predilection of females to males, with the mandible beinginvolved more often than the maxilla [6]. While incipientlesions oftenpresent as painless, lobular, andulceratedmasseswith little complications and minor changes in gingivalcontour, progressive growth in some cases causes a significantswelling interfering normal oral function and resorption ofthe subjacent alveolar bone and teeth roots [2].Our study is aimed to report a case of PGCG in a youngchild which was misdiagnosed and neglected for more than5 months. We review histopathologic features and discusspossible differential diagnosis, based on the age of the patient,history, and clinical features.2. Case ReportA 4-year-old Caucasian boy was referred from a private officeto our pediatric dentistry clinic with a complaint of swellingin left anterior maxillary canine and lateral incisor teeth area.It was started about five months previously bilaterally in asmaller dimension. The right lesion subsided without anyintervention but the left lesion has been enlarging with par-ents and child manipulation. The central and lateral primaryincisors were extracted 3 months ago by a general dentistwith the diagnosis of periapical abscess but the lesion didnot heal and has been progressively growing. The lesion waspainless and with no associated spontaneous bleeding exceptfor occasional interference of the swelling with mastication.His medical history includes no complication.On clinical examination, he had slight extraoral facialswelling of his left anterior maxilla, without any palpableregional lymph nodes. An intraoral examination showed a 20Hindawi Publishing CorporationCase Reports in DentistryVolume 2016, Article ID 7536304, 4 pageshttp://dx.doi.org/10.1155/2016/75363042 Case Reports in DentistryFigure 1: Intraoral preoperative view of lesion: a painless redenlargement of themaxillary attached gingiva extends to the alveolarmucosa between teeth #52 and 53.Figure 2: Intraoral periapical radiograph, showing superficial ero-sion of the alveolar bone.× 15 × 12mm pedunculated, lobular soft tissue mass of his leftanterior maxillary gingiva related to his incisors (Figure 1).On palpation, the lesion had a firm consistency.The mucosalcovering of the lesion exhibited surface tan, red, and bluishareas with a focal area of ulceration. A periapical radiographof this area revealed superficial erosion of the alveolar bonewith no other significant findings (Figure 2).These clinical and radiographic findings indicated abenign lesion, and the following differential diagnoses wereconsidered: parulis, pyogenic granuloma, peripheral ossify-ing fibroma, PGCG, and peripheral odontogenic fibroma.Malignant entities such as squamous cell carcinoma, otherprimary malignant lesions, and metastatic lesions, althoughthought to be unlikely, were also considered.The patient was scheduled for surgical excision. Underlocal anaesthesia, the lesion was excised down to the perios-teum (Figure 3). After complete excision of the lesion, theexposed surface was cauterized to control the bleeding andthe entire specimen submitted for histopathologic examina-tion.Microscopic examination showsmultinucleated giant cellproliferation within a background of spindle-shaped andovoid mesenchymal cells. Areas of haemorrhage and acuteand chronic inflammatory cells are frequently present. A zoneFigure 3: Intraoral immediate postoperative view showing completesurgical removal.of dense fibrous connective tissue separates giant cell prolifer-ation frommucosal surface. Areas of dystrophic calcificationsand reactive bone formation are seen around (Figure 4). Thishistopathology confirmed the entity of PGCG.Follow-up visits were scheduled at three week intervals.No signs of recurrence of the lesion have been observedduring nine months after the excision.3. DiscussionWhile PGCG occurs mostly in adults, some cases havebeen described in children where a more aggressive clinicalbehaviour has been observed [7]. In a review of 720 cases,33%were seen in patients younger than 20 years of age, whichconcurs with the findings of another study in which 33 of 97cases (34%) occurred in individuals between 5 and 15 yearsof age [8, 9]. Studies show the clinical features of peripheralgiant cell granuloma in Iranian population are almost similarto those reported by other investigators with age ranged from6 to 75 years (mean 33 years) [10].The case we reported was 4years old and belowminimum threshold for PGCG commonage range.In children, PGCG similar to other reactive oral lesionsappears to have a rapid growth rate, be more aggressivewith infiltration of the interproximal crest area and boneresorption, interfere with eruption of adjacent teeth, produceminor to moderate tooth movement, and have multiplerecurrences [11]. Therefore considering the probability ofPGCG in gingival enlargements even in the children under5 years old reduces its consequences and prevents clinicians’misdiagnosis as in our case that lead to unreasonable extrac-tion of primary incisors. PGCG can be easily distinguishedfrom parulis, which is frequently associated with a necrotictooth or with periodontal disorder. Radiographs are essentialfor confirming the oral mucosa origin of the giant cell lesionand refusing a central bony lesion with cortical perforationand soft tissue extension. Early detection of the PGCG resultsinmore conservative surgery with less risk for tooth and boneloss [2].In differential diagnosis in the cases of gingival enlarge-ments in children we consider four main lesions: pyo-genic granuloma, peripheral giant cell granuloma, periph-eral ossifying fibroma, and peripheral odontogenic fibroma.Peripheral giant cell granuloma, like the peripheral ossifyingCase Reports in Dentistry 3Figure 4: Histopathologic section: hyperplastic granulation tissue, the presence of acute and chronic inflammatory cells, capillaries, andproliferation of multinucleated giant cells within haemorrhagic background showing histological appearance of the PGCG lesion (H&E stain10x and 40x).fibroma, is a lesion unique to the oral cavity, occurring onlyon the gingiva. Unlike peripheral ossifying fibroma, however,it may occur on the alveolar mucosa of edentulous areas.Like pyogenic granuloma and peripheral ossifying fibroma,peripheral giant cell granuloma may represent an unusualresponse to tissue injury. It is distinguishable from pyogenicgranuloma and peripheral ossifying fibroma only on the basisof its unique histomorphology, which is the same as centralgiant cell granuloma [8, 9]. Clinically, peripheral odontogenicfibroma (WHO type) must be considered in the differentialdiagnosis of dome-shaped or nodular, nonulcerated, growthson the gingiva like PGCG. Peripheral odontogenic fibromais characterized by a fibrous or fibromyxomatous stromacontaining varying numbers of islands and strands of odon-togenic epithelium that is clearly distinguishable from PGCGhistopathology [12].Clinically, PGCG features separate it from the fibrousand vascular epulides. It presents as a firm, soft, brightpedunculated or sessile nodule with various sizes that rangefrom small papules to enlarged masses, though they aregenerally less than 20mm in diameter with the color rangingfrom dark red to purple or blue commonly with ulceratedsurface [3, 13]. Pain is not a common characteristic, and lesiongrowth in most cases is induced by repeated trauma [1].The peripheral giant cell granuloma is best treated bycomplete surgical excision, with care taken to excise it atits base [14]. The treatment of PGCG comprises surgicalresection with elimination of the entire base of the lesion inaddition to the eradication of the underlying source of irritantfactors [2, 3]. If incomplete bone resection was done, thegrowth may recur [2]. To avoid recurrence after treatment, inaddition to complete simple excision with extensive clearingof the base of the lesion, the source of irritation needs to beremoved [4].Recurrence of PGCG is not common and ranges as littleas 5–11% [15, 16] but multiple recurrences with eventual lossof the adjacent teeth are a potential complication [2]. Earlydiagnosis based on clinical and radiological findings, con-firmed by pathological analysis especially in children, allowsfor conservative management with less risk of destruction forthe adjacent teeth and tissues.4. ConclusionPeripheral giant cell granuloma as relatively common lesionshould be considered in the cases of gingival enlargementsin children. Histopathology is the diagnostic tool for ejectingsimilar lesions. Surgical excision is a successful treatment ofchoice in minimizing the recurrence of lesion. Regardless ofthe surgical technique employed, it is important to eliminatethe etiological factors and to examine the tissues histo-logically for confirmation. Hence, the consideration shouldalso be given to correct diagnosis and proper treatmentplanning.ConsentWritten informed consent was obtained from the patient forpublication of this case report and accompanying images.Competing InterestsThe authors have no competing interests.References[1] B. W. Neville, D. D. Damm, C. M. Allen, and J. E. Bouquot,“Soft tissue tumors,” in Oral and Maxillofacial Pathology, B. W.Neville, D. D. Damm, C. M. Allen, and J. E. Bouquot, Eds., p.485, WB Saunders, Philadelphia, Pa, USA, 4th edition, 2015.[2] C. M. Flaitz, “Peripheral giant cell granuloma: a potentiallyaggressive lesion in children,” Pediatric Dentistry, vol. 22, no. 3,pp. 232–233, 2000.4 Case Reports in Dentistry[3] N. Katsikeris, E. Kakarantza-Angelopoulou, and A. P.Angelopoulos, “Peripheral giant cell granuloma. Clinico-pathologic study of 224 new cases and review of 956 reportedcases,” International Journal of Oral and Maxillofacial Surgery,vol. 17, no. 2, pp. 94–99, 1988.[4] Y. Kfir, A. Buchner, and L. S. Hansen, “Reactive lesions of thegingiva. A clinicopathological study of 741 cases,” Journal ofPeriodontology, vol. 51, no. 11, pp. 655–661, 1980.[5] J. V. Soames and J. C. Southam, “Hyperplastic, neoplastic andrelated disorders of oral mucosa,” in Textbook of Oral Pathology,J. V. Soames, Ed., p. 103, Oxford Medical Publications, Oxford,UK, 4th edition, 2000.[6] R. Nedir, T. Lombardi, and J. Samson, “Recurrent peripheralgiant cell granuloma associated with cervical resorption,” Jour-nal of Periodontology, vol. 68, no. 4, pp. 381–384, 1997.[7] E. Grand, E. Burgener, J. Samson, and T. Lombardi, “Post-traumatic development of a peripheral giant cell granuloma ina child,” Dental Traumatology, vol. 24, no. 1, pp. 124–126, 2008.[8] L. Andersen, O. Fejerskov, and H. P. Philipsen, “Oral giant cellgranulomas. A clinical and histological study of 129 new cases,”Acta Pathologica et Microbiologica Scandinavica A, vol. 81, no. 5,pp. 606–616, 1973.[9] J. S. Giansanti and C. A. Waldron, “Peripheral giant cellgranuloma: review of 720 cases,” Journal of Oral Surgery, vol.27, no. 10, pp. 787–791, 1969.[10] N. Shadman, S. F. Ebrahimi, S. Jafari, andM. Eslami, “Peripheralgiant cell granuloma: a review of 123 cases,” Dental ResearchJournal, vol. 6, no. 1, pp. 47–50, 2009.[11] P. J. Pandolfi, S. Felefli, C. M. Flaitz, and J. V. Johnson, “Anaggressive peripheral giant cell granuloma in a child,” Journalof Clinical Pediatric Dentistry, vol. 23, no. 4, pp. 353–355, 1999.[12] T. D. Daley and G. P. Wysocki, “Peripheral odontogenicfibroma,” Oral Surgery, Oral Medicine, Oral Pathology, vol. 78,no. 3, pp. 329–336, 1994.[13] L. Bodner,M. Peist, A. Gatot, andD.M. Fliss, “Growth potentialof peripheral giant cell granuloma,”Oral Surgery, OralMedicine,Oral Pathology, Oral Radiology, and Endodontics, vol. 83, no. 5,pp. 548–551, 1997.[14] J. S. McDonald, “Tumors of the oral soft tissues and cysts andtumors of bone,” in Textbook of McDonald and Avery’s Dentistryfor the Child and Adolescent, J. A. Dean, Ed., p. 606, Elsevier, St.Louis, Mo, USA, 10th edition, 2016.[15] L. R. Eversole and S. Rovin, “Reactive lesions of the gingiva,”Journal of Oral Pathology & Medicine, vol. 1, no. 2, pp. 30–38,1972.[16] A. J. Mighell, P. A. Robinson, andW. J. Hume, “Peripheral giantcell granuloma: a clinical study of 77 cases from 62 patients, andliterature review,” Oral Diseases, vol. 1, no. 1, pp. 12–19, 1995.Submit your manuscripts athttp://www.hindawi.comHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oral OncologyJournal ofDentistryInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014International Journal ofBiomaterialsHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Case Reports in DentistryHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oral ImplantsJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Anesthesiology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Radiology Research and PracticeEnvironmental and Public HealthJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Dental SurgeryJournal ofDrug DeliveryJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oral DiseasesJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineScientificaHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PainResearch and TreatmentHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Preventive MedicineAdvances inHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014EndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014OrthopedicsAdvances in

A review and report of peripheral giant cell granuloma in a 4-year-old child

Peripheral giant cell granuloma is a common benign and reactive gingival epulis in oral cavity. It is often difficult to make a clinical diagnosis; thereby definitive diagnosis depends on histopathologic features. We report a case of a 4-year-old Caucasian boy presenting with a five-month history a 20 × 15 × 12 mm pedunculated, lobular soft tissue mass of the left anterior maxilla gingiva which was misdiagnosed and maltreated before his referral. An excisional biopsy of the lesion followed by histopathologic examination of the biopsy specimen revealed distinctive features of peripheral giant cell granuloma. Early detection and excision of this hyperplastic nodule especially in children are important to minimize potential dentoalveolar complications.</jats:p

A review and report of peripheral giant cell granuloma in a 4-year-old child

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