|Year : 2017 | Volume
| Issue : 1 | Page : 5-7
Oral pulse or hyaline ring granuloma: A bird's eye view
Arpan K Shah
Department of Oral Pathology and Microbiology, Manubhai Patel Dental College, Hospital and Oral Research Institute, Vadodara, Gujarat, India
|Date of Web Publication||18-Aug-2017|
Arpan K Shah
Department of Oral Pathology and Microbiology, Manubhai Patel Dental College, Hospital and Oral Research Institute, Vishwajyoti Ashram, Munjmahuda, Vadodara - 390 011, Gujarat
Source of Support: None, Conflict of Interest: None
Pulse granuloma or hyaline ring granulomas as frequently encountered while histopathological examination of various oral as well as extraoral lesions. There was a great deal of uncertainty about the pathogenesis of these structures. Many confusing terminologies were also suggested and used for pulse granulomas. However, now it is clear that pulse granuloma is fundamentally a lesion arising due to chronic granulomatous inflammation in response to implantation of foreign particles in the submucosal connective tissue. Appearance of multiple pulse granulomas may create diagnostic confusion. The purpose of this paper is an attempt to revisit the clarified pathogenesis and terminology of pulse granulomas.
Keywords: Angiopathy, giant cell, granuloma, hyaline, oral, pulse
|How to cite this article:|
Shah AK. Oral pulse or hyaline ring granuloma: A bird's eye view. Int J Histopathol Interpret 2017;6:5-7
| Introduction|| |
Hyaline ring granuloma is an unusual form of chronic granulomatous inflammation towards the implanted foreign particles within the tissues. The oral pulse or hyaline ring granuloma (OPHRG) is frequently encountered while histopathological examination of oral lesions. However, they are not commonly reported and discussed. OPHRGs may present as enigmatic structures, especially when they are unusually large or multiple in number. Correct identification of OPHRG can prevent such diagnostic dilemma. Although the pulse granulomas occur most frequently in oral tissues, there are reports describing their occurrence beyond the oral cavity, the extraoral pulse or hyaline ring granuloma (EOPHRG). Most frequent sites for EOPHRG are lungs and gastrointestinal tract.,, Here, we have restricted our discussion to OPHRG. We have also discussed the details of its pathogenesis.
| Microscopic Appearance of Oral Pulse or Hyaline Ring Granuloma|| |
In haematoxylin- and eosin-stained sections, hyaline ring or pulse granulomas appear as rings of amorphous, pale eosinophilic material with corrugated periphery. The eosinophilic material is thought to be pooled inflammatory exudate [Figure 1] and [Figure 2]. The foreign body giant cells are drawn to the site for removal of insoluble haemosiderin granules [Figure 1] and [Figure 2]. Chronic inflammatory cells within and around the rings are usually present [Figure 1] and [Figure 2]. Necrotic debris and dystrophic calcification may also be present. The connective tissue surrounding pulse granuloma may show fibrosis.
|Figure 1: Hyaline ring granulomas in sections of periapical granuloma. Rings of pooled inflammatory exudate (white arrows), multinucleated giant cells (green arrows) and chronic inflammatory cells in surrounding connective tissue (black arrows) (H and E stain, ×100)|
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|Figure 2: Hyaline ring granulomas in sections of inflamed follicular connective tissue associated with mandibular third molar. Rings of pooled inflammatory exudate (white arrows), multinucleated giant cells (green arrows), chronic inflammatory cells in surrounding connective tissue (black arrows) and chronic inflammatory cells within the rings (H and E stain, ×100)|
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Histopathologically, pulse or hyaline ring granuloma resembles hyaline degenerative changes in vessel walls seen in hypertension, diabetes mellitus or amyloidosis. However, this microscopic resemblance is considered more important when it is encountered in extraoral, extrapulmonary and extragastrointestinal lesions because, in oral cavity, gastrointestinal tract and lungs, the most probable aetiology of pulse granuloma is implantation (aspiration in case of lungs) of food particles.
We encountered OPHRGs in chronically inflamed dental follicle of impacted mandibular third molar, which was removed due to recurrent pericoronitis.
| Terminologies Used in the Past for Oral Pulse or Hyaline Ring Granuloma|| |
- Chronic mandibular periostitis 
- Hyaline rings and giant cell hyaline angiopathy 
- Hyaline bodies ,,
- Oral vegetable granuloma.
| Etiopathogenesis of Oral Pulse or Hyaline Ring Granuloma|| |
Two opposing theories have been described in literature regarding the development of hyaline ring granulomas:
Hyaline ring granulomas were initially described by Lewars as 'chronic periostitis'. They suggested that minute food particles are pushed into the submucous connective tissue beneath the mandibular dentures. These food particles provoke a granulomatous foreign body reaction. Later, King described these structures as foreign body reaction to the fragments of pulses or edible seeds of legumes and coined the term OPHRG. Amongst two theories, the exogenous theory is the most accepted.
Legumes as culprits of granulomatous tissue reaction
It is suggested that formation of hyaline ring granulomas is provoked by the cellulose moiety of leguminous foodstuffs such as peas, beans and lentils. Seeds of legumes contain starch, cellulose and considerable amounts of proteins. Cellulose, unlike starch, is indigestible and thus may incite foreign body response. Lectins, phytates and lathyrogens present in legumes are able to disturb the collagen metabolism. Legumes are rich in phytohaemagglutinin which cause agglutination of erythrocytes and leucocytes and may provoke and enhance the granulomatous host response.,
Portals of entry of legume particles in the tissues
Open carious lesion with pulp necrosis or tooth left open without interim restoration between visits of endodontic treatment may become a patent pathway for food particles to reach the periapical tissues. Opercula around the partially erupted third molars also allow the entry of food particles to periodontium. Minute food particles may also be pushed into the submucosal connective tissue of edentulous alveolar ridge due to the pressure exerted by denture. Extraction sockets and open wounds may also become passive portals of entry for foodstuffs to the tissues.
Dunlap and Barker put forward an 'endogenous theory' for the development of pulse granulomas. They introduced the term 'hyaline rings'. The endogenous theory stated that hyaline rings represent hyaline degenerative changes in the walls of blood vessels initiated by acute vasculitis. This concept brought the term 'giant cell hyaline angiopathy'.
'Hyaline bodies': A confusing terminology
The term 'hyaline bodies' is used to describe OPHRG in few reports.,, However, this terminology is more appropriate to describe hyaline bodies of Rushton, which are usually seen in the epithelial linings of inflamed odontogenic cysts. These structures are etiologically, structurally and morphologically different from OPHRG. Rushton bodies are derived from products of epithelia of odontogenic cysts, whereas OPHRGs are foci of granulomatous inflammation in response to foreign bodies. Thus, the two terminologies (hyaline bodies and hyaline rings) should not be used interchangeably to avoid confusion.
| Conclusion|| |
OPHRG is a form of chronic granulomatous inflammatory lesion, which most probably arises due to implantation of particles of leguminous food stuff in the submucosal connective tissues. It can be encountered in any lesion of chronic inflammation, most commonly intraosseous inflammation. They should not be misinterpreted as Rushton bodies observed in epithelia of odontogenic cysts or hyaline degenerative vasculitis associated with systemic diseases to avoid diagnostic confusion.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]