Peripheral Giant Cell Granuloma

Peripheral giant cell granuloma is a reactive, gingival or alveolar mucosal swelling made of multinucleated giant cells in a vascular stroma. It is the commonest giant cell lesion of the oral cavity.

It is found at any age, most often in the fifth and sixth decades, in women more than men, and on the gingiva or edentulous ridge of the mandible more than the maxilla, anterior to the molars. The giant cell epulis is another name.

Pathophysiology. A hyperplastic response of the periosteum or periodontal ligament to local irritation: plaque, calculus, ill fitting dentures, extractions, poor restorations and trauma.

Cells are osteoclast like, and the lesion has no neoplastic potential. It can erode the underlying bone and produce a shallow cupped defect.

A soft or firm, red, purple or bluish nodular mass on the gingiva or alveolar ridge, sessile or pedunculated, from a few millimetres to several centimetres, with a smooth or ulcerated surface that bleeds easily. Usually painless, and growing slowly or in rapid bursts.

Teeth may be displaced or mobile, and the lesion can recur after incomplete excision. Multiple lesions need metabolic assessment.

• Clinical diagnosis with a biopsy for confirmation.
• Periapical or panoramic radiograph to look for cupping of the alveolar bone, which separates the lesion from a central giant cell granuloma that has broken through.
• Histology: multinucleated giant cells in a vascular fibroblastic stroma with haemorrhage and haemosiderin, separated from the surface by a zone of connective tissue.
• Serum calcium, parathyroid hormone and alkaline phosphatase for recurrent or multiple lesions, to exclude hyperparathyroidism.

Differential diagnosis.

• Pyogenic granuloma
• Peripheral ossifying fibroma
• Fibrous epulis and irritation fibroma
• Peripheral odontogenic fibroma
• Central giant cell granuloma with soft tissue extension
• Haemangioma
• Gingival carcinoma, melanoma and lymphoma

• Local excision down to the periosteum, with curettage of the underlying bone, scaling of adjacent teeth and removal of local irritants (calculus, restorations, denture flanges). Extraction of an affected tooth is needed when the lesion cannot otherwise be cleared.
• Recurrence is about 10 to 18% and is treated by re-excision with a wider margin and removal of the cause.
• Send the specimen for histology to exclude malignancy.
• Antibiotics are not needed. Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily) with ibuprofen 400 mg every 8 hours with food for 2 to 3 days.
• Treat hyperparathyroidism when found, with endocrine input.

Monitoring. Review at 2 weeks and 3 months, then 6 monthly for 2 years. Radiographs for bone defects.

Referral and escalation. Refer to oral surgery or periodontology for excision. Refer to endocrinology for abnormal calcium. Urgent referral for rapid growth, bone destruction, multiple lesions or histology that does not match.