Analysis of the Frequency and Nature of Hyaline Ring Granulomas in Inflammatory Odontogenic Cysts

7/29/2019 Analysis of the Frequency and Nature of Hyaline Ring Granulomas in Inflammatory Odontogenic Cysts

1/10

Analysis of the frequency and nature of hyaline

ring granulomas in inflammatory odontogenic

cysts

A. C. G. Henriques1, J. S. Pereira1, C. F. W. Nonaka2, R. A. Freitas1, L. P. Pinto1 &

M. C. C. Miguel1

1Department of Dentistry, Federal University of Rio Grande do Norte, Natal, RN, Brazil; and 2Department of Dentistry, State

University of Paraba, Campina Grande, PB, Brazil

Abstract

Henriques ACG, Pereira JS, Nonaka CFW, Freitas RA,

Pinto LP, Miguel MCC. Analysis of the frequency and nat-

ure of hyaline ring granulomas in inflammatory odontogeniccysts. International Endodontic Journal, 46, 2029, 2013.

Aim To determine the prevalence of hyaline ring

granulomas (HRGs) in a large case series of inflam-

matory odontogenic cysts, and to investigate the nat-

ure of these structures.

Methodology All records from the patients diag-

nosed with inflammatory odontogenic cysts between

January 1970 and April 2009 were reviewed. Histo-

logic sections were evaluated by light microscopy and

cases with HRGs for which sufficient biological mate-

rial was available were submitted to histochemical

analysis (Massons trichrome) and immunohistochem-istry (CD34, CD68 and collagen IV).

Results Twenty-two (3.3%) of the 661 cases of

inflammatory odontogenic cysts diagnosed during the

study period presented HRGs. The relative frequency

of HRGs was higher amongst residual radicular cysts

(6.1%), followed by paradental cysts (5.6%) and

radicular cysts (3.0%). HRGs appeared as roughly

circular homogeneous/fibrillar masses in 14 (63.6%)

cases and as round structures enclosing amorphous

material in 3 (13.6%) cases. Most (77.8%) roughly

circular homogeneous/fibrillar masses were positive

for collagen, whereas all (100.0%) round structures

enclosing amorphous material were negative for this

protein. Immunohistochemistry showed that most

mononucleated cells and all multinucleated giant cells

were positive for CD68, but negative for CD34, in all

cases. In addition, collagen IV immunostaining was

negative in amorphous structures and weakly positive

in homogeneous/fibrillar masses.

Conclusions The present results suggest a very

low frequency of HRGs in inflammatory odontogenic

cysts and support the hypothesis that these structures

arise from the implantation of foreign material, most

likely food particles of plant or vegetable origin. Thediverse microscopic features of HRG possibly represent

different developmental stages of this structure.

Keywords: histochemistry, hyaline ring granu-

loma, immunohistochemistry, inflammatory odonto-

genic cysts.

Received 16 October 2011; accepted 19 May 2012

Introduction

Hyaline ring granuloma (HRG) is an uncommon histo-

pathologic finding characterized by hyaline rings or

ovoid homogeneous/fibrillar hyaline masses lying

within fibrous connective tissue, which contain vari-

able numbers of inflammatory cells and multinucleat-

ed giant cells (Talacko & Radden 1988a, Zhai &

Maluf 2004). This microscopic finding has been

reported in lesions located in the oral cavity, lung,

intestine, skin, gallbladder and uterine tube (Knoblich

1969, Zhai & Maluf 2004, Rhee & Wu 2006, Gueiros

et al. 2008). In the oral cavity, HRGs have been

found in extraosseous lesions such as inflammatory

Correspondence: Marcia Cristina da Costa Miguel, Universid-

ade Federal do Rio Grande do Norte, Departamento de

Odontologia, Av. Senador Salgado Filho, 1787, Lagoa Nova,

Natal, RN, CEP 59056-000 Brasil (Tel./Fax:

+55 84 3215 4138; e-mail: [email protected]).

2012 International Endodontic JournalInternational Endodontic Journal, 46, 2029, 2013

doi:10.1111/j.1365-2591.2012.02086.x

20


2/10

fibrous hyperplasia (Gueiros et al. 2008) and in

intraosseous lesions such as periapical granulomas

(Pola et al. 2003, Gueiros et al. 2008) and odonto-

genic cysts (Chen et al. 1981, Talacko & Radden

1988a, Marcussen et al. 1993).

Oral HRG was initially described by Lewars (1971)

as chronic periostitis, which was characterized bythe presence of palely stained eosinophilic structure-

less material, so-called hyaline rings. Since then, a

variety of terms have been used to describe this

entity, including giant-cell hyaline angiopathy

(Dunlap & Barker 1977, McMillan et al. 1981,

Ferguson & Smillie 1986), pulse granuloma (Mincer

et al. 1979, McMillan et al. 1981), granuloma tissue

with giant cells and hyaline change (McMillan et al.

1981), oral vegetable granuloma (Harrison & Martin

1986), food-induced granuloma (Brown & Theaker

1987) and le granulome alimentaire des maxillares

(Iriarte Ortabe et al. 1991). In addition, some authors

have caused confusion by mixing up the term hyaline

rings with hyaline bodies (Chen et al. 1981, Keirby &

Soames 1985, Yang & Barnett 1985). The latter

structures, also called Rushton bodies, are morpho-

logically and aetiologically different from hyaline

rings (Philipsen & Reichart 2010).

Two opposing theories regarding the aetiopatho-

genesis of HRGs have been proposed (Philipsen &

Reichart 2010). The exogenous theory suggests that

these structures arise from the implantation of foreign

material (food particles of plant or vegetable origin,

therapeutic agents) (Lewars 1971, Mincer et al.

1979, Talacko & Radden 1988a, LaMear et al. 1994).The endogenous theory proposes that HRGs represent

hyaline degeneration of the walls of blood vessels

(Dunlap & Barker 1977). Although the origin of these

structures is not clear, the use of the descriptive term

HRG has been suggested, which seems more suitable

and also avoids misunderstanding (Chou et al. 1990,

Gueiros et al. 2008).

Data on the occurrence of HRGs in inflammatory

odontogenic cysts are basically limited to case reports

(Chen et al. 1981, Yang & Barnett 1985, Lin et al.

1993, Keskin et al. 2000, Pola et al. 2003), and only

a few retrospective studies are available (Talacko &

Radden 1988a, Marcussen et al. 1993, Philipsen &

Reichart 2010). Therefore, the objective of the present

investigation was to determine the frequency of HRGs

in a large case series of inflammatory odontogenic

cysts. In addition, histochemical and immunohisto-

chemical analyses were performed to gain insights

into the nature of these structures.

Materials and methods

Clinical analysis

After approval of the study by the Research Ethics

Committee of the Federal University of Rio Grande do

Norte (UFRN), case records from 661 patients with

inflammatory odontogenic cysts (594 radicular cysts,

49 residual radicular cysts and 18 paradental cysts)

diagnosed between January 1970 and April 2009

were retrieved from the archives of the Oral Pathol-

ogy Service at UFRN. Data regarding age, gender and

anatomic location were compiled from the clinical

data sent together with the biopsy reports.

Histopathologic analysis

For histopathologic analysis, all slides containing

haematoxylin-/eosin-stained 5-lm-thick sections were

reassessed. The tissue sections were examined under alight microscope (Olympus CX31, Tokyo, Japan) by

three observers, and cases were classified according to

the presence or absence of HRGs. In addition, HRGs

were classified according to the following morphologic

patterns of the hyaline material: round structures

enclosing eosinophilic amorphous material (Gueiros

et al. 2008) or roughly circular homogeneous/fibrillar

masses (Philipsen & Reichart 2010). The presence of

calcification (Talacko & Radden 1988a, Philipsen &

Reichart 2010), metaplastic bone formation (Talacko

& Radden 1988a) and haemosiderin pigmentation

(Chen et al. 1981) were also analysed.

Histochemical and immunohistochemical analysis

To evaluate the nature of the material composing the

hyaline rings, 5-lm-thick sections were cut from paraf-

fin-embedded tissue blocks and stained with Massons

trichrome (EasyPath; Bio-Optica Milano SpA, Milan,

Italy). Three observers then examined the reactivity of

the hyaline material to Massons trichrome stain under

a light microscope (Olympus CX31) according to the

morphologic pattern of these structures.

Immunohistochemical staining for CD34 and CD68

was used to elucidate the nature of mononucleated

cells and multinucleated giant cells associated with

HRGs, and staining for collagen IV to gain insights into

the nature of the hyaline ring material. Briefly, 3-lm-

thick sections were cut from paraffin-embedded tissue

blocks, deparaffinized and immersed in 3% hydrogen

peroxide to block endogenous peroxidase activity. The

Henriques et al. Hyaline ring granulomas in odontogenic cysts

2012 International Endodontic Journal International Endodontic Journal, 46, 2029, 2013 21


3/10

sections were then washed in phosphate-buffered saline

(PBS) and submitted to antigen retrieval (Table 1).

After treatment with normal serum, the sections were

incubated with the primary anti-CD34, anti-CD68 and

anti-collagen IV antibodies in a moist chamber

(Table 1). The sections were then washed twice in PBS

and incubated at room temperature with the labelledstreptavidin biotin complex (LSAB+ System-HRP; Dako,

Carpinteria, CA, USA) for anti-CD34 and anti-CD68

antibodies and with a polymer-based complex (Advan-

ceTM HRP; Dako) for anti-collagen IV antibody. Peroxi-

dase activity was visualized by immersing the tissue

sections in diaminobenzidine (Liquid DAB+ Substrate;

Dako), which resulted in a brown reaction product.

Finally, the sections were counterstained with Mayers

haematoxylin and coverslipped. Blood vessels and

macrophages present in all specimens served as inter-

nal positive controls for CD34 and CD68, respectively.

Immunostaining of blood vessels in the basement mem-

brane was used as internal positive control for collagen

IV. As negative control, the samples were treated as

described above, except that the primary antibody was

replaced with a solution of bovine serum albumin in

PBS.

The slides were analysed by three observers under

a light microscope (Olympus CX31). Positive or

negative staining for CD34 and CD68 was evaluated

in mononucleated cells and multinucleated giant cells

present inside and adjacent to HRGs. For collagen IV,

positive or negative staining was evaluated in the

hyaline material of HRGs.

The results were tabulated and analysed by descrip-tive statistics using the Statistical Package for the Social

Sciences, version 17.0 (SPSS, Inc., Chicago, IL, USA).

Results

Clinical analysis

A total of 661 cases of inflammatory odontogenic cysts

were identified during the study period. Of these, 594

(89.9%) were radicular cysts, 49 (7.4%) were residual

radicular cysts and 18 (2.7%) were paradental cysts.

HRGs were observed in 22 (3.3%) cases. Of these, 18

(81.8%) were radicular cysts, 3 (13.6%) were residual

radicular cysts and 1 (4.5%) was a paradental cyst.

Analysis of the distribution of cases according to the

type of inflammatory odontogenic cyst revealed a

higher relative frequency of HRGs amongst residual

radicular cysts (3/49; 6.1%), followed by paradentalcysts (1/18; 5.6%) and radicular cysts (18/594; 3.0%)

(Table 2).

With respect to gender, cysts containing HRGs were

commonly diagnosed in women (63.6%), with a

female-to-male ratio of 1.75 : 1. Similarly, most cysts

without HRGs were also diagnosed in women

(59.8%), with a female-to-male ratio of 1.49 : 1

(Table 2). The mean patient age for cases with and

without HRGs was 26.76 years (range 667) and

32.41 years (range 486), respectively (Table 2).

Information regarding the anatomic location of

cysts containing HRGs was available for 20 cases. Of

these, 11 (55.0%) were located in the maxilla and 9

(45.0%) in the mandible (Table 2). Maxillary lesions

were commonly located in the anterior region

(81.8%), whereas mandibular lesions were usually

found in the posterior region (88.9%) (Table 2).

Histopathologic analysis

Both morphologic patterns of hyaline material could

be observed in the present series of inflammatory

odontogenic cysts: round structures enclosing eosino-

philic amorphous material consistent with degener-

ated starch cells (Fig. 1a,b) and roughly circularhomogeneous or fibrillar masses exhibiting a

corrugated border (Fig. 1c,d). In both morphologic

patterns, the hyaline material was found lying in

chronically and, less often, acutely inflamed fibrous

connective tissue. In addition, mononucleated cells

and multinucleated giant cells were observed inside

and adjacent to the hyaline material (Fig. 1ad).

Three (13.6%) cases exhibited only round structures

enclosing amorphous material, 14 (63.6%) cases

showed only roughly circular homogeneous or

fibrillar masses and both morphologic patterns were

Table 1 Manufacturer, clone, antigen retrieval, dilution and incubation period of the primary antibodies

Antibody Manufacturer Clone Antigen retrieval Dilution Incubation

CD68 Dako KP1 Citrate, pH 6.0, Pascal, 121 C, 3 min 1 : 50 Overnight

CD34 Dako QBEnd10 Tris/EDTA, pH 9.0, Pascal, 121 C, 3 min 1 : 50 Overnight

Collagen IV Dako CIV22 Citrate, pH 6.0, Pascal, 121 C, 3 min 1 : 25 Overnight

Hyaline ring granulomas in odontogenic cysts Henriques et al.



4/10

present in 5 (22.7%) cases (Table 3). One case (4.5%)

presented calcifications in the form of small, coalesced

basophilic droplets inside the hyaline material

(Fig. 1e, Table 3). In one case (4.5%), haemosiderin

pigmentation was found scattered within the hyaline

material and in the cytoplasm of mononucleated andmultinucleated giant cells (Fig. 1f, Table 3). None of

the cases showed metaplastic bone formation.

Histochemical and immunohistochemical analysis

Analysis of tissue sections stained with Massons

trichrome revealed the presence of hyaline material in

the form of roughly circular homogeneous or fibrillar

masses in nine cases and in the form of round

structures enclosing amorphous material in three

cases. Seven (77.8%) of the cases of roughly circular

homogeneous or fibrillar masses exhibited variable

amounts of collagen (Fig. 2a,b), and 2 (22.8%) were

negative for collagen (Fig. 2c). On the other hand, all

HRGs characterized by round structures enclosing

eosinophilic amorphous material were negative for

collagen (Fig. 2d).

All cysts containing HRGs were submitted to immu-

nohistochemistry. However, because of the small size

of some HRGs, these structures could be identified in

only 15 of the 22 cases treated with the anti-CD68

antibody, in 12 of the 22 cases treated with the anti-

CD34 antibody and in eight of the 22 cases treated

with the anti-collagen IV antibody. Most mononucle-

ated cells and all multinucleated giant cells inside andadjacent to HRGs were positive for CD68 in all cases

(Fig. 3a). In contrast, most mononucleated cells and

all multinucleated giant cells inside and adjacent to

HRGs were negative for CD34 (Fig. 3b). In fact, CD34

highlighted the presence of small blood vessels near

the HRGs. No significant difference in the immuno-

expression of CD68 or CD34 was observed between

the two morphologic patterns of hyaline material

(Fig. 3c,d). Furthermore, all HRGs appearing in the

form of roughly circular homogeneous or fibrillar

masses were weakly positive for collagen IV (Fig. 3e).

On the other hand, all HRGs characterized by round

structures enclosing eosinophilic amorphous material

were negative for this protein (Fig. 3f).

Discussion

HRGs have been described in both extraosseous and

intraosseous oral lesions (Lewars 1971, Dunlap &

Table 2 Number of cases, gender, age and anatomic location according to the presence or absence of hyaline ring granulomas

in inflammatory odontogenic cysts

Group n (%)

Gender

Age (years); mean (range)

Anatomic location

Female Male

Maxilla Mandible

A P A/P A P A/P

Radicular cystsa

Absence 576 (97.0) 349 227 31.59 (486) 186 137 7 34 152 6

Presence 18 (3.0) 11 7 24.78 (660) 9 1 0 0 7 1

Total 594 (100.0) 360 234 31.38 (486) 195 138 7 34 159 7

Residual radicular cysta

Absence 46 (93.9) 20 26 44.23 (1678) 14 9 2 6 10 2

Presence 3 (6.1)b 2 1 47.50 (2867) 0 1 0 0 0 0

Total 49 (100.0) 22 27 44.37 (1678) 14 10 2 6 10 2

Paradental cysta

Absence 17 (94.4)c 13 3 28.07 (1768) 0 1 0 0 14 0

Presence 1 (5.6) 1 0 0 0 0 0 1 0

Total 18 (100.0) 14 3 27.63 (1768) 0 1 0 0 15 0

All cysts

Absence 639 (96.7) 382 256 32.41 (486) 200 147 9 40 176 8

Presence 22 (3.3) 14 8 26.76 (667) 9 2 0 0 8 1

Total 661 (100.0) 396 264 32.22 (4

86) 209 149 9 40 184 9

A, anterior; P, posterior; A/P, anterior and posterior.aInformation regarding anatomic location was not available for 54 radicular cysts, five residual radicular cysts and two paradental

cysts.bInformation regarding age was not available for one case.cInformation regarding gender was not available for one case.




5/10

Barker 1977, Chen et al. 1981, Talacko & Radden

1988a, Marcussen et al. 1993, Pola et al. 2003,

Gueiros et al. 2008). Despite these reports, the aetio-

pathogenesis of these unusual histopathologic findings

remains a matter of discussion and data regarding

their prevalence in inflammatory odontogenic cysts

are scarce. Therefore, this study determined the fre-

quency of HRGs in a large case series of inflammatory

odontogenic cysts. In addition, histochemical and

immunohistochemical analysis was performed to gain

insights into the nature of these structures.

In a retrospective study of oral HRGs, Talacko & Rad-

den (1988a) only found minimal evidence of these

structures in odontogenic cysts and periapical lesions

and suggested that HRGs in these lesions might have

been overlooked in the past. In the present study, HRGs

were usually small and inconspicuous. Nevertheless,

even after careful and thorough microscopic examina-

tion, HRGs were found in only 22 (3.3%) of the 661

cases of inflammatory odontogenic cysts studied,

suggesting a very low frequency of these microscopic

features in these lesions.

The age range of affected individuals was 667 years

in the present series and in 36 previous reports of

HRGs in inflammatory odontogenic cysts (Table 4),

with a slight predominance amongst females (54.8%).

In a review of 173 cases of oral HRGs, Philipsen &

Reichart (2010) observed that more than two-thirds

of the lesions occurred in the mandible, particularly

in the posterior region where food stagnation is

(a) (b)

(c) (d)

(e) (f)

Figure 1 (a) Hyaline ring granuloma (HRG) appearing as round structure enclosing eosinophilic amorphous material (HE,

9400). (b) HRGs lying in fibrous connective tissue densely infiltrated by acute and chronic inflammatory cells (HE, 9400). (c)

HRGs in the form of roughly circular homogeneous or fibrillar masses exhibiting a corrugated border (HE, 9400). (d) Multinu-

cleated giant cells inside and adjacent to hyaline material (HE, 9400). (e) Calcification in the form of small, coalescing baso-philic droplets inside the hyaline material (HE, 9400). (f) Haemosiderin pigmentation scattered within the hyaline material

and in the cytoplasm of mononucleated cells and multinucleated giant cells (HE, 9400).




6/10

common. However, when only inflammatory odonto-

genic cysts are analysed (Table 4), there is a slightly

higher percentage of HRGs in the maxilla (55.4%).

Nevertheless, in the present sample, most (88.9%) of

the inflammatory odontogenic cysts with HRGs

located in the mandible were found in the posterior

region, in agreement with Philipsen & Reichart

(2010).

Amongst the 22 inflammatory odontogenic cysts

with HRGs found in this study, 18 (81.8%) were

radicular cysts, 3 (13.6%) were residual radicular

cysts and 1 (4.5%) was a paradental cyst. As radicu-

Table 3 Microscopic features of hyaline ring granulomas according to the type of inflammatory odontogenic cyst

Microscopic features

Cyst type

Radicular

cyst

Residual

radicular cyst

Paradental

cyst

Morphological pattern

Round structures enclosing eosinophilic amorphous material 3 0 0

Roughly circular homogeneous or fibrillar masses 11 2 1

Round structures enclosing eosinophilic amorphous material

and roughly circular homogeneous or fibrillar masses

4 1 0

Calcification

Presence 1 0 0

Absence 17 3 1

Haemosiderin pigmentation

Presence 1 0 0

Absence 17 3 1

Metaplastic bone formation

Presence 0 0 0

Absence 18 3 1

(a) (b)

(c) (d)

Figure 2 (a) Focal positivity for collagen in hyaline ring granuloma (HRG) presenting as roughly circular homogeneous mass

(Massons trichrome, 9400). (b) Diffuse positivity for collagen in HRGs presenting as roughly circular homogeneous masses

(Massons trichrome, 9400). (c) Negativity for collagen in HRGs appearing as roughly circular homogeneous masses (Massons

trichrome, 9400). (d) Negativity for collagen in HRG appearing as round structure enclosing amorphous material (Massons

trichrome, 9400).




7/10

lar cysts are the most frequent type of odontogenic

cyst and residual radicular cysts and paradental cysts

are relatively uncommon (de Souza et al. 2010), the

frequency of HRGs was determined according to the

type of cyst to avoid bias. There was a higher relative

frequency of HRGs amongst residual radicular cysts

(6.1%), followed by paradental cysts (5.6%) and radic-

ular cysts (3.0%). As extraction sites and pericoronitis

around the lower third molars, associated with food

stagnation in the area, are possible pathways for the

implantation of foreign bodies, especially food parti-

cles, the present findings support the concept of an

exogenous origin of oral HRGs (Lewars 1971, Mincer

et al. 1979, Talacko & Radden 1988a, LaMear et al.

1994). Moreover, in view of the low relative

frequency of HRGs in radicular cysts, it may be sug-

gested that carious teeth or root canals left open to

the oral cavity are less efficient portals of entry for

food particles than extraction sites and pericoronitis.

Nevertheless, further studies including large series of

residual radicular cysts and paradental cysts are

needed to confirm this hypothesis.

Microscopically, oral HRGs can manifest as round

structures enclosing eosinophilic amorphous material

(Gueiros et al. 2008) or as roughly circular homo-

geneous/fibrillar masses (Philipsen & Reichart

(a) (b)

(c) (d)

(e) (f)

Figure 3 (a) Positivity for CD68 in mononucleated and multinucleated giant cells inside and adjacent to hyaline ring granulo-

mas (HRGs) in the form of roughly circular homogeneous masses (LSAB method, 9400). (b) Negativity for CD34 in mono-

nucleated and multinucleated giant cells inside and adjacent to HRGs in the form of roughly circular homogeneous masses

(LSAB method, 9400). (c) Positivity for CD68 in mononucleated and multinucleated giant cells inside and adjacent to HRGappearing as round structure enclosing amorphous material (LSAB method, 9400). (d) Negativity for CD34 in mononucleated

and multinucleated giant cells inside and adjacent to HRG appearing as round structure enclosing amorphous material (LSAB

method, 9400). (e) Weak positivity for collagen IV in HRGs in the form of roughly circular homogeneous masses (Advance

method, 9400). (f) Negativity for collagen IV in HRG in the form of round structure enclosing amorphous material (Advance

method, 9400).




8/10

2010). Both patterns may be found in the same tis-

sue section (Talacko & Radden 1988a). The present

results suggest that roughly circular homogeneous

or fibrillar masses are the most common morpho-

logic pattern of oral HRGs in inflammatory odonto-

genic cysts. According to Talacko & Radden

(1988a), the hyaline material can also present a

rod-like shape or appear in the form of long,

branching filaments. None of these features were

observed in the HRGs studied here.

Calcifications are relatively uncommon in oral

HRGs and appear in the form of small basophilicdroplets either inside the hyaline material or inside

the almost empty circular structures (Dunlap &

Barker 1977, Chen et al. 1981, Ide et al. 1982,

Talacko & Radden 1988a). Occasionally, calcification

of the entire hyaline structure is observed (McMillan

et al. 1981, Ide et al. 1982, Talacko & Radden

1988a, Philipsen & Reichart 2010). In the present

series, calcification was seen in only one case (4.5%)

of radicular cyst, confirming the low frequency of this

microscopic feature in oral HRGs.

Haemosiderin pigmentation was found scattered

within the hyaline material and in the cytoplasm of

mononucleated and multinucleated giant cells in only

one case (4.5%) of radicular cyst. These findings are

in agreement with those reported by Chen et al.

(1981). Metaplastic bone formation is very uncom-

mon in oral HRGs, with only one case described in the

literature (Ide et al. 1982). Coherently, this feature

was not observed in the present series of HRGs.

The aetiopathogenesis of oral HRG is still unclear

(Gueiros et al. 2008). Dunlap & Barker (1977) sug-

gested that oral HRGs represent hyaline degeneration

of the walls of blood vessels precipitated by localized

acute vasculitis. According to other studies, oral HRGs

may be formed by pooling and coagulation of extra-

vasated serum proteins (Chen et al. 1981) or degener-

ated collagen (El-Labban & Kramer 1981). In contrast,

evidence from an experimental animal model (Talacko

& Radden 1988b) and the results of histopathologic

(Marcussen et al. 1993, Sato et al. 2005, Gueiros et al.

2008) and ultrastructural (Harrison & Martin 1986,Pola et al. 2003, Sato et al. 2005, Gueiros et al. 2008)

studies support the viewpoint that exogenous foreign

material, especially from leguminous food, is responsi-

ble for the formation of oral HRGs. As the cellulose part

of plant foods is indigestible, it may persist in human

tissues in the form of hyaline material that elicits a

chronic granulomatous response (Talacko & Radden

1988a, Philipsen & Reichart 2010).

In the present study, most mononucleated cells and

all multinucleated giant cells inside and adjacent to

HRGs were positive for CD68 in all cases, regardless of

the morphologic pattern of the hyaline material. On

the other hand, these cell types were negative for CD34

in all cases, irrespective of the morphologic pattern of

the hyaline material. This negative staining for CD34

near the hyaline structure rules out a possible endo-

genous origin as a result of hyaline degeneration of the

vessel wall. Positive staining for CD68 indicates the

presence of cells of the macrophage lineage, which is

Table 4 Distribution of the cases of inflammatory odontogenic cysts with hyaline ring granulomas reported in the literature

according to cyst type, age, gender and anatomic location

Author No. of cases Cyst type Age (years)

Gender Anatomic location

Male Female M axilla Mandible

Chen et al. (1981) 1 Residual radicular cyst 59 1 1

Yang & Barnett (1985) 1 Radicular cyst 67 1 1

Talacko & Radden (1988a) 27 Radicular cyst (13) NS NS NS 10 3

Residual radicular cyst (12) NS NS NS 5 7

Paradental cyst (2) NS NS NS 2

Lin et al. (1993) 1 Residual radicular cyst 20 1 1

Marcussen et al. (1993) 3 Residual radicular cyst 30, 34 and 57 2 1 2 1

Keskin et al. (2000) 2 Radicular cyst 18 and 38 2 1 1

Pola et al. (2003) 1 Radicular cyst 16 1 1

Current study 22 Radicular cyst (18) 660 7 11 10 8

Residual radicular cyst (3)a 28 and 67 1 2 1

Paradental cyst (1) 21 1 1

NS, not stated.aInformation regarding anatomic location was not available for two cases. Information regarding age was not available for one

case.




9/10

compatible with a foreign body granulomatous reac-

tion. In fact, CD34 highlighted the presence of small

blood vessels near the HRGs. These small vascular

structures found near the hyaline ring, but not inside,

would participate in the granulomatous reaction

together with macrophages. Taken together, these

findings do not lend support to the endogenous theoryproposed by Dunlap & Barker (1977), but rather rein-

force the exogenous theory, which suggests that oral

HRGs arise from the implantation of foreign material,

most likely leguminous foods (Lewars 1971, Mincer

et al. 1979, Talacko & Radden 1988a, LaMear et al.

1994, Philipsen & Reichart 2010).

The different microscopic features of oral HRGs

have been suggested to be related to distinct

evolutionary stages (Gueiros et al. 2008). In this

respect, the round structures enclosing eosinophilic

amorphous material may represent a more recent

stage in the development of oral HRGs when com-

pared with the roughly circular homogeneous/fibrillar

masses (Gueiros et al. 2008). The present histochemi-

cal findings support this suggestion because all HRGs

characterized by round structures enclosing eosino-

philic amorphous material were negative for collagen,

whereas most HRGs in the form of roughly circular

homogeneous or fibrillar masses exhibited variable

amounts of this protein. According to Harrison &

Martin (1986), hyaline rings sometimes contain both

vegetable cell wall and collagen, a fact that might

explain the variable staining of these structures with

different collagen stains (e.g. van Giesons and

Mallorys) seen in previous studies (Chen et al. 1981,Harrison & Martin 1986, Talacko & Radden 1988a)

and in the present investigation.

Pola et al. (2003) detected no immunoreactivity to

basement membrane proteins, such as laminin or type

IV collagen, in an HRG present in the wall of a radic-

ular cyst. Coherently, all HRGs characterized by

round structures enclosing eosinophilic amorphous

material were negative for collagen IV in the present

study. However, all HRGs that appeared as roughly

circular homogeneous or fibrillar masses were weakly

positive for collagen IV, suggesting that small

amounts of this protein might be incorporated into

HRGs during their development. The fact that weak

collagen IV staining was only observed in structures

that represent a more advanced developmental stage

of oral HRG does not support the endogenous theory

proposed by Dunlap & Barker (1977).

In the case series of Gueiros et al. (2008), HRGs

appearing as round structures enclosing eosinophilic

amorphous material exhibited stronger periodic acid

Schiff and diastase-resistant staining than those

appearing in the form of roughly circular homoge-

neous/fibrillar masses. Taken together, these findings

and the present histochemical and immunohisto-

chemical results suggest that vegetable material

undergoes progressive degenerative changes, whereascollagen is deposited during the progression of oral

HRGs. Gueiros et al. (2008) highlighted that inflam-

mation can be responsible for a distinct and persistent

evolution of HRGs, especially at an intraosseous site.

According to these authors, chronic exposure to

inflammatory enzymes probably modifies the

morphologic aspects of the hyaline rings without

compromising their antigenic potential.

Conclusion

The present results suggest a very low frequency ofHRGs in inflammatory odontogenic cysts and support

the hypothesis that these structures arise from the

implantation of foreign material, most likely food par-

ticles of plant or vegetable origin. In addition, the

diverse microscopic features of HRG possibly represent

different developmental stages of this structure.

References

Brown AM, Theaker JM (1987) Food induced granuloma

an unusual cause of a submandibular mass with observa-

tions on the pathogenesis of hyaline bodies. British Journalof Oral & Maxillofacial Surgery 25, 4336.

Chen SY, Fantasia JE, Miller AS (1981) Hyaline bodies in the

connective tissue wall of odontogenic cysts. Journal of Oral

Pathology 10, 14757.

Chou L, Ficarra G, Hansen LS (1990) Hyaline ring granu-

loma: a distinct oral entity. Oral Surgery Oral Medicine Oral


Dunlap CL, Barker BF (1977) Giant-cell hyalin angiopathy.

Oral Surgery Oral Medicine Oral Pathology 44, 58791.

El-Labban NG, Kramer IR (1981) The nature of hyaline

rings in chronic periostitis and other conditions: an ultra-

structural study. Oral Surgery Oral Medicine Oral Pathology

51, 50915.

Ferguson JW, Smillie AC (1986) Giant cell hyaline angiopa-thy presenting as a facial sinus in a patient with undiag-

nosed diabetes mellitus. New Zealand Dental Journal 82,

14951.

Gueiros LA, Santos Silva AR, Romanach MJ, Leon JE, Lopes

MA, Jorge J (2008) Distinctive aspects of oral hyaline ring

granulomas. Oral Surgery Oral Medicine Oral Pathology Oral

Radiology and Endodontics 106, e359.




10/10

Harrison JD, Martin IC (1986) Oral vegetable granuloma:

ultrastructural and histological study. Journal of Oral

Pathology 15, 3226.

Ide F, Kusama K, Saito I, Umemura S (1982) Pulse granu-

loma in the wall of a dentigerous cyst. Journal of Oral and

Maxillofacial Surgery 40, 65962.

Iriarte Ortabe JI, Laka A, Marbaix E, Reychler H (1991)

Food granuloma of the jaws. Presentation of a new case

and review of the literature. Actualites Odonto-Stomatologi-

ques 45, 2531.

Keirby FA, Soames JV (1985) Periostitis and osteitis associ-

ated with hyaline bodies. British Journal of Oral & Maxillo-

facial Surgery 23, 34650.

Keskin A, Duran S, Alkan A, Gunhan O (2000) Hyaline ring

granuloma in inflammatory odontogenic cysts: report of two

cases. Journal of Oral and Maxillofacial Surgery 58, 1158.

Knoblich R (1969) Pulmonary granulomatosis caused by

vegetable particles. So-called lentil pulse pneumonia.

American Review of Respiratory Disease 99, 3809.

LaMear WR, Estrem SA, Spollen LE (1994) Pulse granuloma

presenting as a facial mass. Otolaryngology Head and NeckSurgery 111, 5223.

Lewars PH (1971) Chronic periostitis in the mandible under-

neath artificial dentures. British Journal of Oral Surgery 8,

2649.

Lin SK, Chiang CP, Ou SH, Wang JT, Liu BY, Lan WH

(1993) Hyaline ring granuloma: a case report with histo-

chemical and polarized microscopic studies. Journal of the

Formosan Medical Association 92, 10013.

Marcussen LN, Peters E, Carmel D, Mickleborough M, Robin-

son C (1993) Legume associated residual cyst. Journal of

Oral Pathology & Medicine 22, 1414.

McMillan MD, Kardos TB, Edwards JL, Thorburn DN, Adams

DB, Palmer DK (1981) Giant cell hyaline angiopathy or

pulse granuloma. Oral Surgery Oral Medicine Oral Pathology52, 17886.

Mincer HH, McCoy JM, Turner JE (1979) Pulse granuloma

of the alveolar ridge. Oral Surgery Oral Medicine Oral


Philipsen HP, Reichart PA (2010) Pulse or hyaline ring

granuloma. Review of the literature on etiopathogenesis of

oral and extraoral lesions. Clinical Oral Investigations 14,

1218.

Pola JG, de la Cruz A, Bustillo F, Gallas M, Leston JS

(2003) Pulse granuloma in the wall of an inflammatory

radicular cyst. Otolaryngology Head and Neck Surgery 129,

4412.

Rhee DD, Wu ML (2006) Pulse granulomas detected in gall-

bladder, fallopian tube, and skin. Archives of Pathology &

Laboratory Medicine 130, 183942.

Sato H, Miyate H, Fukuta Y, Satoh M (2005) Hyaline ring

granuloma of the mandibular periosteum. Oral Science

International 2, 1720.

de Souza LB, Gordon-Nunez MA, Nonaka CF, de Medeiros

MC, Torres TF, Emiliano GB (2010) Odontogenic cysts:

demographic profile in a Brazilian population over a 38-

year period. Medicina Oral Patologa Oral y Cirugia Bucal15, e58390.

Talacko AA, Radden BG (1988a) Oral pulse granuloma: clin-

ical and histopathological features. A review of 62 cases.

International Journal of Oral & Maxillofacial Surgery 17,

3436.

Talacko AA, Radden BG (1988b) The pathogenesis of oral

pulse granuloma: an animal model. Journal of Oral Pathol-

ogy 17, 99105.

Yang ZP, Barnett F (1985) Hyaline bodies and giant cells

associated with a radicular cyst. Endodontics & Dental Trau-

matology 1, 857.

Zhai J, Maluf HM (2004) Peridiverticular colonic hyaline

rings (pulse granulomas): report of two cases associated

with perforated diverticula. Annals of Diagnostic Pathology8, 3759.



Documents

Analysis of the Frequency and Nature of Hyaline Ring Granulomas in Inflammatory Odontogenic Cysts