Oral pulse granuloma associated with keratocystic odontogenic tumor: Report of a case and review on etiopathogenesis
A 56-year-old female patient reported with pain and difficulty in chewing food in the mandibular posterior region since one and a half months. Intraoral examination revealed bony hard swelling extending from alveolar ridge of mandibular first premolar to third molar with obliteration of vestibule. The mucosa over the swelling was normal. Right submandibular lymphnodes were enlarged []. Patient gave past history of similar swelling eight months ago in the same region, for which she consulted a general dental practitioner. The right mandibular 1st and 2nd molars were extracted and enucleation of the cyst was done by the practitioner. Later patient did not report back to the practitioner as healing was uneventful and she was unaware of the previous diagnosis. The swelling reoccurred in the same area after four weeks. The alveolar mucosa appeared apparently normal with no change in color.\nOrthopantomograph revealed a well defined radiolucency involving right mandibular body extending from mandibular first premolar to third molar region distally []. A differential diagnosis of odontogenic keratocyst and ameloblastoma was considered and incisional biopsy was done.\nMicroscopic examination revealed a cystic epithelium overlying an inflammatory connective tissue. The epithelium was parakeratinised stratified squamous type with palisaded cuboidal basal cells. The epithelium demonstrated separation from underlying connective tissue in few areas []. An interesting finding was presence of homogenous, pale, eosinophilic material resembling vegetable matter was seen dispersed in the cyst wall. It demonstrated a double layered refractile hyaline membrane surrounded with prominent chronic inflammatory cells and few foreign body giant cells [].\nA diagnosis of keratocystic odontogenic tumor with pulse granuloma was made. The lesion was subsequently excised and application of Carnoy's solution was done with no evidence of recurrence since six months. The excised specimen confirmed the diagnosis of keratocystic odontogenic tumor and no vegetable matter was observed.\nHistochemical staining with Periodic acid Schiff (PAS) without diastase, van Gieson and Alcian blue at pH 2.5 were performed. PAS [] and alcian blue [] demonstrated positivity for hyaline material confirming it to be vegetable matter. The surrounding condensed collagen stained reddish in color with van Gieson suggestive of matured collagen [].\nVegetable matter presented as birefringent refractile material under polarized microscopy [].