|Year : 2015 | Volume
| Issue : 2 | Page : 107-109
Diode laser for treatment of peripheral giant cell granuloma
Jafri Zeba1, Nafis Ahmad2, Deepika Shukla3
1 Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia University, New Delhi, India
2 Department of Prosthodontics, Faculty of Dentistry, Jamia Millia Islamia University, New Delhi, India
3 Department of Oral Pathology, Babu Banarsi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||26-Nov-2015|
Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia University, Jamia Nagar, New Delhi - 110 025
Source of Support: None, Conflict of Interest: None
Peripheral giant cell granuloma (PGCG) is not a true neoplasm but an exophytic benign growth of gingival tissues which has an origin either from periodontal ligament or mucoperiosteum. Clinically, it appears as a solitary nodule which may be sessile or pedunculated, color may vary from pale pink to deep red or purplish blue. The lesion varies widely in size, but usually is between 0.5 to 2 cm in diameter. The treatment is complete surgical excision which can be done either by a scalpel, electrocautery or lasers. This case report presents use of a diode laser aluminum gallium arsenide (denlase 810 nm) in contact mode for the treatment of PGCG. Use of lasers has shown various advantages over the conventional method and is a good treatment option.
Keywords: Diode laser, excision, peripheral giant cell granuloma
|How to cite this article:|
Zeba J, Ahmad N, Shukla D. Diode laser for treatment of peripheral giant cell granuloma. J Dent Lasers 2015;9:107-9
| Introduction|| |
Peripheral giant cell granuloma (PGCG) is an exophytic growth exclusively seen on the gingiva. Despite, classified under benign tumor of the oral cavity, it is not a true neoplasm. The lesion was thought to be reparative in reaction earlier hence Bernier and Cahn proposed the term "peripheral giant cell reparative granuloma" for the lesion. But the terminology is currently not being used as the reparative nature of the lesion has not been proved. Other names to PGCG includes giant cell epulis, osteoclastoma, or giant cell hyperplasia. At present, the term PGCG is universally known and accepted. Although the reason for the growth of PGCG is not known, it is considered to arise in response to local injury. Local irritating factors such as ill-fitting prosthesis, poor restorations, microbial dental plaque, calculus, chronic infection, and lack of nutrients may have a role in the etiology. It is believed to be originated from the periodontal ligament and also from the mucoperiosteum because it may be found associated with the edentulous area and dental implants  as well where periodontal ligament is not present. The clinical picture varies in appearance from smooth, regularly outlined masses to irregularly shaped, multilobulated protuberances with surface indentations. The lesions are painless, vary in size but usually between 0.5 to 2 cm in diameter. PGCG larger than 2 cm are seen more commonly in females, with poor oral hygiene and xerostomia. In some cases, PGCG is locally invasive and causes destruction of the underlying bone. Radiographically, "cupping" resorption of the underlying alveolar bone on edentulous ridge  or superficial destruction of the crest of the alveolar bone in interdental areas may be seen, but these radiographic signs may not be invariably present. The color of the lesion varies from pale pink to deep red or purplish blue depending on the composition of collagen and/or inflammatory components. There are no characteristic clinical features whereby these lesions can be differentiated from other forms of solitary gingival growth. A microscopic examination is required for a definitive diagnosis.
| Case Report|| |
A female patient aged 52 years reported to the Department of Periodontics with a complaint of localized swelling in relation to lower right anterior teeth.
History and examination
The growth had initiated around 4 years back and slowly progressed. Patient gave the history of taking an ayurvedic medicine orally for its treatment which failed to help her. Her medical history was noncontributing. An intraoral examination revealed a solitary growth, which originated in the interdental area in between lower right lateral incisor and canine extending from buccal to the lingual side and to adjacent teeth [Figure 1]a and [Figure 1]b. Heavy deposits of plaque and calculus were found. The growth was pink in color with firm consistency. Patient's blood investigation had showed the blood counts within normal limits. An intraoral radiograph of the region showed superficial destruction of the alveolar crest in the interdental area. A provisional diagnosis of pyogenic granuloma was made, and a sitting of full mouth scaling was planned followed by excisional biopsy of the growth.
Surgical excision by diode laser
Patient was given local infiltration of 2% local anesthesia and a diode laser aluminum gallium arsenide (denlase 810 nm) with delivered optical power of 4.9 W maximum, with an initiated fiberoptic core diameter tip of 400 µm in pulse mode with pulse length 1 ms and pulse interval of 1 ms delivering an average power of 2.4 W [Figure 2] in contact mode was used to excise the growth from [Figure 3]a base up to the periosteum and curettage of the area of origin was done. Adjacent roots were thoroughly scaled, and hemostasis was achieved by diode laser on coagulation mode [Figure 3]b. Surgical area was irrigated by betadine and periodontal pack was placed. The excised nodule was about 2 cm in diameter [Figure 4]. There was periodontal bone loss interdentally between lateral incisor and canine. Patient was advised medication and was recalled on 10th day [Figure 5]a and 3 months [Figure 5]b for follow-up and review. Healing was satisfactory with no recurrence even after 3 months follow-up.
|Figure 3: (a) Intraoperative using diode laser. (b) Intraoperative after excision|
Click here to view
Histopathologic examination of biopsied specimen (hematoxylin and eosin Stain) revealed aggregates of multinucleated giant cells in a background of mononuclear stromal cells. The connective tissue stroma was highly cellular, consisting of proliferating plump fibroblasts. Extravasated erythrocytes and deposits of hemosiderin were seen with few inflammatory cells. A diagnosis of PGCG was thus made [Figure 6].
| Discussion|| |
Although PGCG may not clinically be differentiated from other forms of gingival enlargement including pyogenic granuloma, fibrous epulis, peripheral ossifying fibroma, inflammatory fibrous hyperplasia, peripheral odontogenic fibroma, hemangioma caverosum, and papilloma  but the histopathological finding can lead to the correct diagnosis. The characteristic histologic features of PGCG include presence of a nonencapsulated highly cellular mass with abundant giant cells, fibroblasts, interstitial hemorrhage, hemosiderins, mature bone or osteoid. The definite origin of multinucleated giant cells is still not known and it appears to be nonfunctional in the usual sense of phagocytosis and bone resorption despite its striking resemblance to osteoclasts. The histogenesis of PGCG and the nature of the lesion remain controversial despite intense studies. A reactive nature of origin has been found in several immunohistochemical and ultrastructural studies. The mononuclear cells stain positive with histiocyte markers (lysozyme and alpha 1-antichemotrypsin) as well as show a positive reaction with CD-68, a macrophage-associated antigen. The presence of S-100 positive cells, which are evidence of Langerhans cells or their precursors, and the presence of fibroblasts, endothelial cells, and myofibroblasts point toward a reactive nature of the PGCG.
The treatment of PGCG always includes excision of the growth down to the periosteum with scalpel, electrocautery or lasers and also eliminating any local irritating factors associated with it. Lasers, nowadays, are a good option to perform excision of such growths because they provide excellent hemostasis, bactericidal effect, precision, short healing time, better postoperative pain perception, and less discomfort to the patient. The present case had a considerable big growth, so the diode laser was useful in its excision in toto with good bleeding control and at the same time providing coagulation. A superficial resection or incomplete removal of local irritating factors may sometimes result in recurrence of growth, but it is a rare occurrence.
| References|| |
Carranza FA, Hogan EL. Gingival enlargements. In: Newman MG, Takei HH, Klokkevold PR, editors. Carranza's Clinical Periodontology. 10th
ed. St. Louis: Saunders; 2009. p. 373-90.
Hirshberg A, Kozlovsky A, Schwartz-Arad D, Mardinger O, Kaplan I. Peripheral giant cell granuloma associated with dental implants. J Periodontol 2003;74:1381-4.
Bodner L, Peist M, Gatot A, Fliss DM. Growth potential of peripheral giant cell granuloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:548-51.
Regezi JA, Sciubba JJ, Jordan RC, editors. Red-Blue lesions. In: Oral Pathology. Clinical Pathologic Correlations. 5th
ed. St. Louis: Saunders; 2009. p. 107-25.
Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulos AP. Peripheral giant cell granuloma. Clinicopathologic study of 224 new cases and review of 956 reported cases. Int J Oral Maxillofac Surg 1988;17:94-9.
Carvalho YR, Loyola AM, Gomez RS, Araújo VC. Peripheral giant cell granuloma. An immunohistochemical and ultrastructural study. Oral Dis 1995;1:20-5.
Pirnat S. Versality of an 810nm diode laser in dentistry: An overview. J Laser Health Acad 2007;4:1-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]