This lesion is found on the gingiva or edentulous alveolus and is thought to originate from elements of the peri-odontal ligament. It is seen across a wide age range, but the peak incidence is between 30 and 50 years. Lesions tend to affect the area anterior to the permanent molars and are slightly more frequent in the mandible. The giant cell epulis usually forms a fleshy, bluish swelling that may be sessile or broadly pedunculated and the surface is often ulcerated. There may be erosion of the underlying bone or periodontium.
Microscopically, there is usually an uninvolved zone of fibrous tissue between the lesion and the overlying epithelium, but this is lost if there is inflammation or ulceration. The lesion consists of a matrix of plump, spindle-shaped cells with interspersed multinucleated and osteoclast-like giant cells. These can be numerous and may be confluent, blurring the distinction between each other and the stromal cells. The multinucleated cells are large and contain about 10-20 nuclei. There are two types: the most common have lightly eosinophilic cytoplasm and large vesicular nuclei with prominent nucle-oli while the other type has much more densely stained cytoplasm, and pyknotic and densely haematoxyphil-ic nuclei. The latter are probably a degenerative form of the first type. The multinucleated cells are thought to be formed by fusion of bone marrow-derived mononuclear pre-osteoclasts [84, 101]. The lesion is usually very vascular and giant cells may be seen within the dilated vascular spaces. Red blood cell extravasation and haemo-siderin deposition is common. Mitoses can often be seen in stromal and endothelial cells, but this observation has
Pyogenic granulomas are most common on the gingivae and less frequently in other intraoral sites, particularly the lip and tongue. They form solitary, soft, red and friable nodules that bleed readily. They frequently ulcerate and are covered by a fibrinous slough. Gingival lesions may be seen in pregnancy and appear to be a focal exacerbation of pregnancy gingivitis . Pregnancy epuli-des ("pregnancy tumour") usually manifest towards the end of the first trimester. They have a strong tendency to recur if removed before parturition and may show partial or complete spontaneous resolution if left following delivery. Occasionally, similar lesions are seen in other parts of the mouth during pregnancy, particularly the dorsum of the tongue, and they are termed granuloma gravidarum .
Microscopically, oral pyogenic granulomas consist of numerous large, thin-walled, anastomosing blood vessels in a loose, oedematous and moderately cellular stroma. Older lesions may show some fibrosis. Inflammation is very variable and can be minimal or absent. However, if the lesion ulcerates there may an intense inflammatory infiltration. Foci of papillary endothelial hyperplasia are an occasional feature.
Although excision is usually curative, rare cases can show repeated recurrences and require more extensive surgery for their eradication.
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