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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Pediatric oral pulse granuloma: A rare entity</title><author><name sortKey="Naik, Saraswathi Vishnu" sort="Naik, Saraswathi Vishnu" uniqKey="Naik S" first="Saraswathi Vishnu" last="Naik">Saraswathi Vishnu Naik</name><affiliation><nlm:aff id="aff1">Department of Pedodontics Preventive Dentistry, SJM Dental College, Chitradurga, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Ghousia, Syed" sort="Ghousia, Syed" uniqKey="Ghousia S" first="Syed" last="Ghousia">Syed Ghousia</name><affiliation><nlm:aff id="aff2">Department of Pedodontics Preventive Dentistry, AECS Maaruthi College of Dental Sciences and Research Center, Bangalore, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Shashibhushan, Kamalaksharappa" sort="Shashibhushan, Kamalaksharappa" uniqKey="Shashibhushan K" first="Kamalaksharappa" last="Shashibhushan">Kamalaksharappa Shashibhushan</name><affiliation><nlm:aff id="aff3">Department of Pedodontics Preventive Dentistry, College of Dental Sciences, Davengere, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Benni, Deepa" sort="Benni, Deepa" uniqKey="Benni D" first="Deepa" last="Benni">Deepa Benni</name><affiliation><nlm:aff id="aff4">Department of Pedodontics Preventive Dentistry, Maratha Mandal Dental College, Belgaum, Karnataka, India</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23559964</idno><idno type="pmc">3612236</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612236</idno><idno type="RBID">PMC:3612236</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">001C52</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001C52</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Pediatric oral pulse granuloma: A rare entity</title><author><name sortKey="Naik, Saraswathi Vishnu" sort="Naik, Saraswathi Vishnu" uniqKey="Naik S" first="Saraswathi Vishnu" last="Naik">Saraswathi Vishnu Naik</name><affiliation><nlm:aff id="aff1">Department of Pedodontics Preventive Dentistry, SJM Dental College, Chitradurga, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Ghousia, Syed" sort="Ghousia, Syed" uniqKey="Ghousia S" first="Syed" last="Ghousia">Syed Ghousia</name><affiliation><nlm:aff id="aff2">Department of Pedodontics Preventive Dentistry, AECS Maaruthi College of Dental Sciences and Research Center, Bangalore, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Shashibhushan, Kamalaksharappa" sort="Shashibhushan, Kamalaksharappa" uniqKey="Shashibhushan K" first="Kamalaksharappa" last="Shashibhushan">Kamalaksharappa Shashibhushan</name><affiliation><nlm:aff id="aff3">Department of Pedodontics Preventive Dentistry, College of Dental Sciences, Davengere, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Benni, Deepa" sort="Benni, Deepa" uniqKey="Benni D" first="Deepa" last="Benni">Deepa Benni</name><affiliation><nlm:aff id="aff4">Department of Pedodontics Preventive Dentistry, Maratha Mandal Dental College, Belgaum, Karnataka, India</nlm:aff></affiliation></author></analytic><series><title level="j">Dental Research Journal</title><idno type="ISSN">1735-3327</idno><idno type="eISSN">2008-0255</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>A pulse granuloma is nothing but a reaction of the foreign body to any vegetable which is characterized by a collection of the hyaline; a hyaline is a transparent substance that is formed from the pathological degeneration of the tissue. These granulomatous rings may be oral or extra-oral. It is important to recognize such a type of granuloma because it may resemble serious pathological processes or may clinically stimulate neoplasia. It might also be confused morphologically with hyaline vasculopathy. The following manuscript presents a rare case of oral pulse granuloma. As going by the literature-search, the following being the only case to have been occurred in a pediatric patient. The authors therefore aim to bring awareness amongst the pediatric dentists about its etiology, occurrence, clinical features and thereby management of the same.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Watson, Re" uniqKey="Watson R">RE Watson</name></author><author><name sortKey="Stewart, C" uniqKey="Stewart C">C Stewart</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Manjunatha, Bs" uniqKey="Manjunatha B">BS Manjunatha</name></author><author><name sortKey="Kumar, Gs" uniqKey="Kumar G">GS Kumar</name></author><author><name sortKey="Raghunath, V" uniqKey="Raghunath V">V Raghunath</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chou, L" uniqKey="Chou L">L Chou</name></author><author><name sortKey="Ficarra, G" uniqKey="Ficarra G">G Ficarra</name></author><author><name sortKey="Hansen, Ls" uniqKey="Hansen L">LS Hansen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kotrashetti, Vs" uniqKey="Kotrashetti V">VS Kotrashetti</name></author><author><name sortKey="Angadi, Pv" uniqKey="Angadi P">PV Angadi</name></author><author><name sortKey="Mane, Dr" uniqKey="Mane D">DR Mane</name></author><author><name sortKey="Hallikerimath, Sr" uniqKey="Hallikerimath S">SR Hallikerimath</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gueiros, La" uniqKey="Gueiros L">LA Gueiros</name></author><author><name sortKey="Santos Silva, Ar" uniqKey="Santos Silva A">AR Santos Silva</name></author><author><name sortKey="Roma Ach, Mj" uniqKey="Roma Ach M">MJ Romañach</name></author><author><name sortKey="Leon, Je" uniqKey="Leon J">JE Leon</name></author><author><name sortKey="Lopes, Ma" uniqKey="Lopes M">MA Lopes</name></author><author><name sortKey="Jorge, J" uniqKey="Jorge J">J Jorge</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Harrison, Jd" uniqKey="Harrison J">JD Harrison</name></author><author><name sortKey="Martin, Ic" uniqKey="Martin I">IC Martin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Philipsen, Hp" uniqKey="Philipsen H">HP Philipsen</name></author><author><name sortKey="Reichart, Pa" uniqKey="Reichart P">PA Reichart</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Talacko, Aa" uniqKey="Talacko A">AA Talacko</name></author><author><name sortKey="Radden, Bg" uniqKey="Radden B">BG Radden</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Talacko, Aa" uniqKey="Talacko A">AA Talacko</name></author><author><name sortKey="Radden, Bg" uniqKey="Radden B">BG Radden</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Scivetti, M" uniqKey="Scivetti M">M Scivetti</name></author><author><name sortKey="Lucchese, A" uniqKey="Lucchese A">A Lucchese</name></author><author><name sortKey="Ficarra, G" uniqKey="Ficarra G">G Ficarra</name></author><author><name sortKey="Giuliani, M" uniqKey="Giuliani M">M Giuliani</name></author><author><name sortKey="Lajolo, C" uniqKey="Lajolo C">C Lajolo</name></author><author><name sortKey="Maiorano, E" uniqKey="Maiorano E">E Maiorano</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Dent Res J (Isfahan)</journal-id><journal-id journal-id-type="iso-abbrev">Dent Res J (Isfahan)</journal-id><journal-id journal-id-type="publisher-id">DRJ</journal-id><journal-title-group><journal-title>Dental Research Journal</journal-title></journal-title-group><issn pub-type="ppub">1735-3327</issn><issn pub-type="epub">2008-0255</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23559964</article-id><article-id pub-id-type="pmc">3612236</article-id><article-id pub-id-type="publisher-id">DRJ-9-812</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Pediatric oral pulse granuloma: A rare entity</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Naik</surname><given-names>Saraswathi Vishnu</given-names></name><xref ref-type="aff" rid="aff1">1</xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Ghousia</surname><given-names>Syed</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Shashibhushan</surname><given-names>Kamalaksharappa</given-names></name><xref ref-type="aff" rid="aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Benni</surname><given-names>Deepa</given-names></name><xref ref-type="aff" rid="aff4">4</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Department of Pedodontics Preventive Dentistry, SJM Dental College, Chitradurga, Karnataka, India</aff><aff id="aff2"><label>2</label>Department of Pedodontics Preventive Dentistry, AECS Maaruthi College of Dental Sciences and Research Center, Bangalore, Karnataka, India</aff><aff id="aff3"><label>3</label>Department of Pedodontics Preventive Dentistry, College of Dental Sciences, Davengere, Karnataka, India</aff><aff id="aff4"><label>4</label>Department of Pedodontics Preventive Dentistry, Maratha Mandal Dental College, Belgaum, Karnataka, India</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Saraswathi V. Naik, Department of Pedodontics Preventive Dentistry, SJM Dental College, Chitradurga, Karnataka, India. E-mail: <email xlink:href="drsaru1976@yahoo.com">drsaru1976@yahoo.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Nov-Dec</season><year>2012</year></pub-date><volume>9</volume><issue>6</issue><fpage>812</fpage><lpage>815</lpage><history><date date-type="received"><month>2</month><year>2012</year></date><date date-type="accepted"><month>6</month><year>2012</year></date></history><permissions><copyright-statement>Copyright: © Dental Research Journal</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>A pulse granuloma is nothing but a reaction of the foreign body to any vegetable which is characterized by a collection of the hyaline; a hyaline is a transparent substance that is formed from the pathological degeneration of the tissue. These granulomatous rings may be oral or extra-oral. It is important to recognize such a type of granuloma because it may resemble serious pathological processes or may clinically stimulate neoplasia. It might also be confused morphologically with hyaline vasculopathy. The following manuscript presents a rare case of oral pulse granuloma. As going by the literature-search, the following being the only case to have been occurred in a pediatric patient. The authors therefore aim to bring awareness amongst the pediatric dentists about its etiology, occurrence, clinical features and thereby management of the same.</p></abstract><kwd-group><kwd>Giant cell angiopathy</kwd><kwd>hyaline rings</kwd><kwd>multinuclear giant cells</kwd><kwd>oral pulse granuloma</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>INTRODUCTION</title><p>Foreign bodies and tissue reactions to foreign materials are commonly encountered in the oral cavity. Exogenous materials most commonly causing foreign body reactions are metallic in origin (usually amalgam). Of the non-metallic materials seen during biopsies, suture materials and vegetable matter are most often observed.[<xref ref-type="bibr" rid="ref1">1</xref>] For the tissue reactions involving vegetable matter, Oral pulse granuloma has been used most often.</p><p>Oral Pulse Granuloma has been described in literature under variety of names. It appears to be closely related to Periapical Granuloma.[<xref ref-type="bibr" rid="ref2">2</xref>] It was originally described, by Lewars in 1970, as inflammatory lesions in the buccal sulcus of lower denture wearers. In 1975, Rannie described these kinds of lesions as “chronic mandibular periostitis associated with vasculitis”, Dunlap and Barker (1977) used the terminology ‘<italic>Giant cell Angiopathy</italic>’, King (1978) first termed it as “Pulse granuloma”, for the lesions occurring in the oral cavity.[<xref ref-type="bibr" rid="ref3">3</xref>]</p><p>Chou <italic>et al</italic>. proposed the descriptive term ‘Hyaline Ring Granuloma ’ (HRG), ‘Chronic Periostitis’, ‘Granuloma in edentulous jaws’, and ‘Oral Vegetable Granuloma ’ or ‘Food Induced Granuloma’. He further, described these lesions as a distinct entity and classified them into central and peripheral according to the location. Central lesions are asymptomatic, whereas peripheral lesion present as painless sub-mucosal swellings.[<xref ref-type="bibr" rid="ref2">2</xref><xref ref-type="bibr" rid="ref4">4</xref>]</p><p>Based on the histochemical and immunohistochemical analyses, it was concluded that oral lesions are caused by traumatic implantation of vegetable particles in the extraction socket or oral ulcer with cellulose being responsible for granuloma formation. In order of descending frequency, the commonest sites where the lesions of Oral Pulse Granuloma were found in:</p><p><list list-type="order"><list-item><p>Edentulous portions of the alveolar ridge which had history of extraction,</p></list-item><list-item><p>In periapical lesions, associated with teeth which had been subjected to endodontic therapy or which had a history of prolonged open drainage</p></list-item><list-item><p>In the walls of dentigerous, residual and nasopalatine cysts,</p></list-item><list-item><p>In association with retained tooth roots, impacted lower third molar teeth with history of pericoronitis and</p></list-item><list-item><p>As a complication of periodontal surgery.[<xref ref-type="bibr" rid="ref5">5</xref>]</p></list-item></list></p><p>The following case is a rare entity in itself as a lesion. It is the most unusual and rarest of its kind in pediatric cases till date as per the available literature is concerned. More so, also the site of occurrence being the lower lip in the present case makes it more unique and significant.</p></sec><sec id="sec1-2"><title>CASE REPORT</title><p>An 8 year old young boy patient reported to our department of Pedodontics and Preventive Dentistry in College of Dental Sciences, Davangere, with a chief complaint of swelling on the lower lip region and interference in closing of mouth.</p><p>Case history revealed the growth to be initiated as a small nodule over the lower lip, which gradually increased in size within 3 weeks. The patient's parents also revealed a failed attempt for removal of the growth by tying a horse's tail hair around it - a popular superstitious belief [<xref ref-type="fig" rid="F1">Figure 1</xref>]. Clinical examination, intra-orally revealed, a nodule on the right side of lower lip measuring about 1 × 0.8 cm, which was round in shape with a pedunculated base, non-tender on palpation. The growth was reddish brown in color, firm in consistency with smooth borders. Secondary infection was seen with pus discharge due to the tying of horse's tail hair [<xref ref-type="fig" rid="F2">Figure 2</xref>]. The other intra-oral clinical findings revealed generalized hypoplasia of the teeth.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Pre-op</p></caption><graphic xlink:href="DRJ-9-812-g001"></graphic></fig><fig id="F2" position="float"><label>Figure 2</label><caption><p>Secondary infection with pus discharge</p></caption><graphic xlink:href="DRJ-9-812-g002"></graphic></fig><p>After complete haemogram, surgical excision of the nodule [<xref ref-type="fig" rid="F3">Figure 3</xref>] was done followed by curettage of the excised area [<xref ref-type="fig" rid="F4">Figure 4</xref>] followed by prescription of antibiotics and anti-inflammatory drugs.</p><fig id="F3" position="float"><label>Figure 3</label><caption><p>Excised nodule for biopsy</p></caption><graphic xlink:href="DRJ-9-812-g003"></graphic></fig><fig id="F4" position="float"><label>Figure 4</label><caption><p>Curettage of the lesion</p></caption><graphic xlink:href="DRJ-9-812-g004"></graphic></fig><p>Based on history and clinical features, a provisional diagnosis of Irritational Fibroma was made. Upon histological examination of the excised lesion, the slide exhibited compartmentalized spaces with enveloping giant cells. Polarized lenses were used to detect the foreign material which was not readily identifiable otherwise [<xref ref-type="fig" rid="F5">Figure 5</xref>].</p><fig id="F5" position="float"><label>Figure 5</label><caption><p>Histopathological slide</p></caption><graphic xlink:href="DRJ-9-812-g005"></graphic></fig><p>The patient was recalled after a week. The excised area exhibited complete healing with proper lip seal [<xref ref-type="fig" rid="F6">Figure 6</xref>].</p><fig id="F6" position="float"><label>Figure 6</label><caption><p>Post-op healing</p></caption><graphic xlink:href="DRJ-9-812-g006"></graphic></fig></sec><sec sec-type="discussion" id="sec1-3"><title>DISCUSSION</title><p>Pulse granuloma is a rare oral inflammatory lesion histologically characterized by the presence of giant cells, foreign body type, associated with hyaline rings and chronic inflammatory fibrous tissue.[<xref ref-type="bibr" rid="ref6">6</xref>] The pathogenesis of oral pulse granuloma is very controversial; thus, this condition has received numerous terms over time (1971-2008).[<xref ref-type="bibr" rid="ref2">2</xref><xref ref-type="bibr" rid="ref3">3</xref>] One hundred seventy-three cases of oral hyaline ring granuloma have been retrieved from the literature. In the mandible, 72.3% occurred, most commonly in the posterior region due to common site for food stagnation.[<xref ref-type="bibr" rid="ref7">7</xref>]</p><p>Clinically, it appears as a nonspecific mass, with an inflammatory aspect, that is asymptomatic, firm or fluctuating, painful to touch, and located in the oral cavity.</p><p>Two theories for <italic>etiopathogenesis</italic> have been proposed:</p><p><list list-type="bullet"><list-item><p>The origin of the hyaline rings is due to a foreign material (pulse and legumes) having penetrated the oral mucosa or gastrointestinal tract and lungs (exogenous theory) and</p></list-item><list-item><p>The rings are due to hyaline degenerative changes in walls of blood vessels, degraded collagen or fibrosed extravasated serum proteins of these lesions. (Endogenous theory).[<xref ref-type="bibr" rid="ref7">7</xref>]</p></list-item></list></p><p>Based on the suggestion of implantation of food particles of plant origin, through extraction sockets, deep periodontal pockets, unfilled root canals and grossly decayed teeth, animal experiments have lent evidence to this concept.[<xref ref-type="bibr" rid="ref8">8</xref>] It is further suggested that, implanted food particles in Pulse Granuloma or Vegetable Granuloma get rapidly digested and also g<italic>et al</italic>tered by host responses. The cellulose part of plant foods being indigestible persists in the form of hyaline material, whereas the starch matter gets digested. This cellulose moiety invokes chronic granulomatous response.[<xref ref-type="bibr" rid="ref9">9</xref>]</p><p>The histopathological features of Oral Pulse Granuloma described in the literature were similar, irrespective of clinical manifestations. Constant features were the presence of hyaline rings or amorphous hyaline masses lying within a fibrous connective tissue stroma of varying maturity and vascularity with variable numbers of acute and chronic inflammatory cells and foreign-body giant cells. The giant cells were seen at the periphery of the hyaline structures and within the lumen of the hyaline rings. Connective tissue and inflammatory cells were observed within the rings.[<xref ref-type="bibr" rid="ref10">10</xref>]</p><p>Other features inconsistently noted were, the presence of small, round calcified basophilic bodies within the amorphous hyaline material, calcification of the entire hyaline structure, and clearly identifiable vegetable cells.</p></sec><sec sec-type="conclusion" id="sec1-4"><title>CONCLUSION</title><p>Pulse or hyaline ring granulomas are rare but are well-defined oral and extraoral lesions due to implantation of the cellulose moiety of plant foods in contrast to the starch components.</p><p>In the pediatric population, a rapidly growing polypoidal lesion requires a thorough clinical and radiological assessment and prompt histological diagnosis in order to exclude the possibility of a malignant lesion. Oral pulse granuloma should be also considered in the differential diagnosis of children presenting with polypoidal lesions of the lower lip.</p></sec></body><back><ack><title>ACKNOWLEDGMENT</title><p>The authors would like to acknowledge the Department of Oral Pathology, College of Dental sciences, Davengere in Karnataka for their generous support in tissue specimen collection as well as in the histological investigations of the same.</p></ack><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> Nil</p></fn><fn fn-type="conflict"><p><bold>Conflict of Interest:</bold> None declared</p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Watson</surname><given-names>RE</given-names></name><name><surname>Stewart</surname><given-names>C</given-names></name></person-group><article-title>Experimental oral foreign body reactions: Vegetable materials</article-title><source>Oral Surg Oral Med Oral Pathol</source><year>1991</year><volume>71</volume><fpage>312</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">1707151</pub-id></element-citation></ref><ref id="ref2"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Manjunatha</surname><given-names>BS</given-names></name><name><surname>Kumar</surname><given-names>GS</given-names></name><name><surname>Raghunath</surname><given-names>V</given-names></name></person-group><article-title>Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma</article-title><source>Indian J Dent Res</source><year>2008</year><volume>19</volume><fpage>74</fpage><lpage>7</lpage><pub-id pub-id-type="pmid">18245929</pub-id></element-citation></ref><ref id="ref3"><label>3</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Chou</surname><given-names>L</given-names></name><name><surname>Ficarra</surname><given-names>G</given-names></name><name><surname>Hansen</surname><given-names>LS</given-names></name></person-group><article-title>Hyaline ring granuloma: A distinct oral entity</article-title><source>Oral Surg Oral Med Oral Pathol</source><year>1990</year><volume>70</volume><fpage>318</fpage><lpage>24</lpage><pub-id pub-id-type="pmid">1699192</pub-id></element-citation></ref><ref id="ref4"><label>4</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kotrashetti</surname><given-names>VS</given-names></name><name><surname>Angadi</surname><given-names>PV</given-names></name><name><surname>Mane</surname><given-names>DR</given-names></name><name><surname>Hallikerimath</surname><given-names>SR</given-names></name></person-group><article-title>Oral pulse granuloma associated with keratocystic odontogenic tumor: Report of a case and review on etiopathogenesis</article-title><source>Ann Maxillo Fac Surg</source><year>2011</year><volume>1</volume><fpage>83</fpage><lpage>6</lpage></element-citation></ref><ref id="ref5"><label>5</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gueiros</surname><given-names>LA</given-names></name><name><surname>Santos Silva</surname><given-names>AR</given-names></name><name><surname>Romañach</surname><given-names>MJ</given-names></name><name><surname>Leon</surname><given-names>JE</given-names></name><name><surname>Lopes</surname><given-names>MA</given-names></name><name><surname>Jorge</surname><given-names>J</given-names></name></person-group><article-title>Distinctive aspects of oral hyaline ring granulomas</article-title><source>Oral Surg Oral Med Oral Pathol Oral Radiol Endod</source><year>2008</year><volume>106</volume><fpage>e35</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">18554949</pub-id></element-citation></ref><ref id="ref6"><label>6</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Harrison</surname><given-names>JD</given-names></name><name><surname>Martin</surname><given-names>IC</given-names></name></person-group><article-title>Oral vegetable granuloma: Ultrastructural and histological study</article-title><source>J Oral Pathol</source><year>1986</year><volume>15</volume><fpage>322</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">2428961</pub-id></element-citation></ref><ref id="ref7"><label>7</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Philipsen</surname><given-names>HP</given-names></name><name><surname>Reichart</surname><given-names>PA</given-names></name></person-group><article-title>Pulse or hyaline ring granuloma. 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