eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Peripheral Giant Cell Granuloma

Updated: Jan 20, 2009

Introduction

Background

The peripheral giant cell granuloma has an unknown etiology, with some dispute as to whether this lesion represents a reactive or neoplastic process. However, most authorities believe peripheral giant cell granuloma is a reactive lesion.

Frequency

United States

Peripheral giant cell granuloma is uncommon but not rare. Precise estimates of its incidence and prevalence in the general population have not been definitively determined.

Mortality/Morbidity

No mortality is associated with peripheral giant cell granuloma, and the lesion has minimal morbidity. Malignant transformation has never been reported.

Race

No known racial predilection is associated with peripheral giant cell granuloma.

Sex

Most reports describe a slight female predilection.

Age

A wide age range of patients can be affected, although most patients are in the fourth to sixth decades of life at the time of diagnosis of this lesion. The mean age of patients at the time of diagnosis is typically 38-42 years.

Clinical

History

Peripheral giant cell granuloma has a relatively rapid growth rate, often attaining a size of 1 cm within a few months.
Lesions are generally asymptomatic.

Physical

Clinical examination shows a dusky purple, sessile or pedunculated, smooth-surfaced, dome-shaped papule or nodule.
Most lesions are less than 1.5 cm in diameter, though infrequently, a peripheral giant cell granuloma may grow as large as 5 cm in greatest dimension.¹
The lesion is always located on the alveolar mucosa or the gingiva, and 70% are found in the anterior segments of the jaws, such as in the premolar, canine, and incisor regions. A slight predilection for the mandible is observed in most reported series.
Surface ulceration is often present.

Causes

The cause of peripheral giant cell granuloma is unknown, although local irritation due to dental plaque or calculus, periodontal disease, poor dental restorations, ill-fitting dental appliances, or dental extractions has been suggested to contribute to the development of the lesion.
Recent reports have described the development of the peripheral giant cell granuloma in association with dental implants. This appears to represent an uncommon complication of implant placement, developing from a few months to several years after placement of the dental implant.^2,3,4

Differential Diagnoses

Kaposi Sarcoma
Metastatic Neoplasms to the Oral Cavity
Oral Malignant Melanoma
Oral Pyogenic Granuloma

Workup

Laboratory Studies

Laboratory studies are generally not necessary, although a serum calcium level or a parathyroid hormone assay may be indicated to rule out the rare possibility of brown tumor for lesions that are particularly large, recurrent despite adequate surgery, multiple, or associated with systemic signs suggestive of hyperparathyroidism.

Imaging Studies

Periapical radiographs typically demonstrate a cupping out or saucerization of the alveolar bone that underlies a peripheral giant cell granuloma.

Histologic Findings

Intact or ulcerated surface epithelium covers peripheral giant cell granulomas. The underlying connective tissue contains a benign proliferation of granulationlike tissue that supports numerous benign multinucleated giant cells. Abundant extravasated blood is typically noted, and deposits of hemosiderin are seen at the periphery of the lesional tissue. Spicules of woven or lamellar bone may be observed in approximately 35% of peripheral giant cell granulomas.⁶

Treatment

Surgical Care

Conservative excision is typically curative, although the lesion must be completely removed to prevent recurrence. In areas such as the maxillary gingivae where surgical removal may have a negative esthetic impact, the clinician may want to consider a gingival graft in conjunction with the excision of the lesion.⁷

Follow-up

Prognosis

Peripheral giant cell granuloma has an excellent prognosis. A recurrence rate of 10-15% has been reported in most series; however, recurrences are typically managed easily with additional surgery.

Multimedia

Media file 1: A 10-year-old boy developed this painless purple papule of the maxillary facial alveolar process over a 3-month period. Biopsy helped confirm the diagnosis of peripheral giant cell granuloma.

Media file 2: This peripheral giant cell granuloma involved the maxillary gingiva associated with an erupting central incisor of a 6-year-old girl. The referring doctor had suggested a diagnosis of eruption cyst; however, an eruption cyst would immediately collapse once the tooth had disrupted its roof.

Media file 3: This asymptomatic bluish-purple nodule developed on the edentulous mandibular alveolar ridge of a 76-year-old man.

References

Bodner L, Peist M, Gatot A, Fliss DM. Growth potential of peripheral giant cell granuloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. May 1997;83(5):548-51. [Medline].
Bischof M, Nedir R, Lombardi T. Peripheral giant cell granuloma associated with a dental implant. Int J Oral Maxillofac Implants. Mar-Apr 2004;19(2):295-9. [Medline].
Hirshberg A, Kozlovsky A, Schwartz-Arad D, Mardinger O, Kaplan I. Peripheral giant cell granuloma associated with dental implants. J Periodontol. Sep 2003;74(9):1381-4. [Medline].
Cloutier M, Charles M, Carmichael RP, Sandor GK. An analysis of peripheral giant cell granuloma associated with dental implant treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:618-622. [Medline].
Choi C, Terzian E, Schneider R, Trochesset DA. Peripheral giant cell granuloma associated with hyperparathyroidism secondary to end-stage renal disease: a case report. J Oral Maxillofac Surg. May 2008;66(5):1063-6. [Medline].
Dayan D, Buchner A, Spirer S. Bone formation in peripheral giant cell granuloma. J Periodontol. Jul 1990;61(7):444-6. [Medline].
Sahingur SE, Cohen RE, Aguirre A. Esthetic management of peripheral giant cell granuloma. J Periodontol. Mar 2004;75(3):487-92. [Medline].
Grand E, Burgener E, Samson J, Lombardi T. Post-traumatic development of a peripheral giant cell granuloma in a child. Dent Traumatol. Feb 2008;24(1):124-6. [Medline].
Martins MD, Pires F, Daleck F, Myaki SI, Friggi MN, Martins MA. Peripheral giant cell granuloma in anterior maxilla: case report in a child. J Clin Pediatr Dent. Winter 2005;30(2):161-4. [Medline].
Pandolfi PJ, Felefli S, Flaitz CM, Johnson JV. An aggressive peripheral giant cell granuloma in a child. J Clin Pediatr Dent. Summer 1999;23(4):353-5. [Medline].
Warrington RD, Reese DJ, Allen G. The peripheral giant cell granuloma. Gen Dent. Nov-Dec 1997;45(6):577-9. [Medline].

Keywords

peripheral giant cell epulis, peripheral giant cell reparative granuloma

Contributor Information and Disclosures

Author

Carl Allen, DDS, Director, Oral and Maxillofacial Pathology, Professor, Department of Oral and Maxillofacial Surgery and Pathology, Ohio State University College of Dentistry; Professor, Department of Pathology, Ohio State University College of Medicine
Carl Allen, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Dental Association, American Society for Microbiology, International Association for Dental Research, and International Association of Oral Pathologists
Disclosure: Nothing to disclose.

Medical Editor

Terry L Barrett, MD, Clinical Professor of Dermatology and Pathology, University of Texas Southwestern School of Medicine; Director, ProPath Dermatopathology, Dallas, Texas
Terry L Barrett, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.

Further Reading