|Year : 2019 | Volume
| Issue : 2 | Page : 89-94
Clinical and histopathological study of four diverse cases of peripheral ossifying fibroma: A case series
Nishat Sultan, Zeba Jafri, Madhuri Sawai, Anika Daing
Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
|Date of Web Publication||30-Sep-2019|
Dr. Nishat Sultan
Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia, New Delhi - 110 025
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Peripheral ossifying fibroma (POF) is an inflammatory reactive hyperplasia of gingiva. It presents as a diverse lesion with respect to the size, site, gender, age of incidence, clinical appearance, histological, and radiographic presentations. Here, we present a case series of four cases of POF. All the four cases show the clinical, histological, and radiographic diversity of POF posing a diagnostic dilemma. Local excisional biopsy was performed in all the four cases, and the specimens were subjected to histopathological examination which revealed Case 1 to be peripheral cemento-ossifying fibroma, whereas, Case 2, 3, and 4 came out to be POF. Clinically, it becomes difficult to differentiate between the various reactive lesions of the gingiva. This emphasizes upon the role of biopsy for all such lesions. All the local etiological factors should be completely removed, and patients must be put on regular follow-up for evaluation of any recurrences.
Keywords: Biopsy, differential diagnosis, gingival overgrowth, laser, peripheral cemento-ossifying fibroma, peripheral ossifying fibroma
|How to cite this article:|
Sultan N, Jafri Z, Sawai M, Daing A. Clinical and histopathological study of four diverse cases of peripheral ossifying fibroma: A case series. J Interdiscip Dentistry 2019;9:89-94
|How to cite this URL:|
Sultan N, Jafri Z, Sawai M, Daing A. Clinical and histopathological study of four diverse cases of peripheral ossifying fibroma: A case series. J Interdiscip Dentistry [serial online] 2019 [cited 2019 Dec 8];9:89-94. Available from: http://www.jidonline.com/text.asp?2019/9/2/89/268370
| Clinical Relevance to Interdisciplinary Dentistry|| |
Peripheral ossifying fibroma is a non-neoplastic reactive lesion of gingiva which is many times misdiagnosed as pyogenic granuloma. A case series comprising of four cases demonstrates the diverse nature of POF. A thorough diagnostic work up is essential for the operator so that such cases could be managed and followed up well.
| Introduction|| |
Fibrous growths of oral soft tissues are very common, and they include a diverse group of neoplastic and non-neoplastic reactive lesions. One such non-neoplastic enlargement of gingiva which is usually thought to be reactive in nature is peripheral ossifying fibroma (POF) and is believed to arise from periodontal ligament. There are two types of ossifying fibromas: Central and peripheral. The central variant arises from the endosteum or periodontal ligament adjacent to the root apex and expands from the medullary cavity of the bone. The peripheral-type occurs solely on the soft tissues overlying bone. It is a relatively uncommon solitary gingival growth which usually arises in the interdental papillary region. POF accounts for 9.6% of gingival lesions. Trauma or local irritants such as plaque, calculus, microorganisms, trauma, poor quality restorations, and ill-fitting dentures have been implicated in its etiology. Clinically, POF resembles to other common benign gingival lesions making it mandatory to follow a thorough diagnostic sequence, radiographic examination, and biopsy of the lesion for histopathological examination.
The article describes a case series of POF comprising of four cases showing a wide difference in the clinical, radiographic, and histopathological presentation. A detailed description of POF along with etiopathogenesis, differential diagnosis, and treatment plan are also discussed describing the diverse behavior of POF posing a diagnostic dilemma.
| Case Reports|| |
A 15-year-old female patient reported with a gingival growth in relation to lower front teeth of 1-year duration. The patient had discomfort and pain while eating because of the growth. There was a solitary discrete 2.5 cm × 2.0 cm large pedunculated fibrotic gingival growth on the lingual aspect of lower central and lateral incisors [Figure 1]. The growth was pale pink, firm, minutely lobulated and covered with mucinous discharge. It was non-tender with no frank pus/blood discharge. The associated teeth were not mobile, non-tender and were covered with plaque and calculus. Intraoral periapical radiograph revealed interdental bone loss and widening of periodontal ligament space [Figure 2]. Routine blood investigations were advised which were within normal limits. Phase I therapy was performed; excisional biopsy was done under local anesthesia followed by gingivoplasty [Figure 3]. The biopsy site was covered with periodontal dressing. The patient was given postoperative instructions, an analgesic and 0.2% chlorhexidine mouthwash were prescribed twice daily for 1 week. The hematoxylin and eosin (H and E) stained section of the soft tissue showed parakeratinized stratified squamous epithelium which was hyperplastic at places [Figure 4]. The underlying connective tissue was densely cellular with numerous plump fibroblasts and chronic inflammatory cells predominantly lymphocytes. The histopathologic diagnosis was suggestive of a peripheral cemento-ossifying fibroma.
|Figure 1: Clinical image of Case 1 shows the preoperative view at initial presentation|
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|Figure 2: Radiographic image of Case 1 showing a slight interdental bone loss and widening of periodontal ligament space|
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|Figure 4: Histopathological image of Case 1 shows peripheral cemento-ossifying fibroma (H and E, original magnification ×10)|
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A 15-year-old male patient presented with a gingival growth following discomfort while eating from upper back teeth. He first noticed it around 5 months back. It was slightly tender with occasional bleeding and pus discharge. No other abnormality was recorded locally or systemically. On examination, two gingival growths were present interdentally in relation to upper left first and second molar, buccally and palatally [Figure 5]. The buccal growth was fibrous 1.0 cm × 1.0 cm in size, pedunculated, with erythematous surface. The palatal growth was fibrotic, 0.5 cm × 0.5 cm in size, sessile with the reddish pink surface. There was bleeding on probing at the site of growth. The associated teeth were clinically normal. An intraoral periapical radiograph revealed interdental bone loss in relation to upper left first and second molar; slight radiolucency in furcation, area of upper left first molar due to bone loss and the periodontal ligament space was widened along mesial root. No change in the trabecular pattern was seen [Figure 6]. Routine blood investigations were advised which came within normal limits. After the Phase I therapy, excisional biopsy was performed under local anesthesia using diode laser (DenLase, Diode Laser Therapy System, Daheng Group Inc., China; wavelength-810 nm, output power: 0.5W–7W, continuous wave, contact mode) and the specimen was subjected to histopathologic examination. Routine postoperative instructions were given to the patient. The submitted H and E stained section of buccal specimen showed fibrocellular connective tissue with a central area of ossification and smaller ossicles towards the periphery. Foci of chronic inflammatory cells predominantly plasma cells and lymphocytes were also noted along with few blood vessels. The H and E stained palatal tissue specimen showed hyperorthokeratinized epithelium which was hyperplastic in nature. The report was confirmatory of “POF” [Figure 7].
|Figure 6: Radiographic image of Case 2 shows interdental bone loss in relation to #26 and 27; slight radiolucency in furcation area of 26 and widened periodontal ligament space|
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|Figure 7: Histopathological image of Case 2 shows peripheral ossifying fibroma (H and E staining, original magnification ×10)|
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A 40-year-old systemically healthy female reported with a gingival growth in relation to lower left front teeth of 3 months' duration. The patient gave a history of trauma to the gums in that region with the sewing thread she was trying to break with her teeth. She otherwise had no local discomfort or pain. On local examination, there was a single, isolated, ovoid, firm, non-tender sessile, gingival growth present interdentally between lower left lateral incisor and canine, size 1.5 cm × 3 cm × 1.5 cm [Figure 8]. There was blanching on the digital pressure with no blood or pus discharge. Labially, the gingiva was pink with reddish pink areas on lingual aspect of the growth. The growth had caused displacement of associated teeth and was reaching up to the occlusal plane. Radiographically, it showed interdental bone loss, reduction of the trabecular spaces, presence of hazy increase in the radiodensity between lower left lateral incisor and canine [Figure 9]. Excisional biopsy was performed under local anesthesia followed by routine postoperative instructions. Histopathological examination was confirmatory of “POF.”
|Figure 9: Radiograph image of Case 3 shows displacement of #32 and 33, reduction in trabecular space and hazy radiodensity at the local site|
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A 32-year-old systemically healthy female reported with a gingival growth between her lower front teeth for 1 month. It was accompanied with mild pain while eating. On examination, there was a single, 1.5 cm × 1.5 cm non-tender, and fibrotic, pedunculated growth interdentally in relation to lower left lateral incisor and canine on lingual aspect [Figure 10]. The surface was erythematous, minutely lobulated and covered with mucinous layer. No significant change was seen on a radiograph. Excisional biopsy was done under local anesthesia. The histopathologic examination was suggestive of “POF.” The patient reported with a recurrent growth at the same site, smaller in size than before within a year of excision [Figure 11]. The oral hygiene was very poor. Again oral prophylaxis was performed, and re-biopsy was done with the same result of “POF” The patient was reinforced about the importance of very good oral hygiene.
Healing after biopsy was good in all the four cases and there were no recurrences seen within 2 years of postoperative phase except Case 4.
| Discussion|| |
Intraoral ossifying fibroma was first documented in 1844 by Shepherd who reported this entity as “alveolar exostosis.” The term POF was coined by Eversole and Rovin. POF is a solitary, slow growing nodular mass that is either pedunculated or sessile. Over the years, various terminologies have been considered for its description, and it includes peripheral odontogenic fibroma, peripheral cemento-ossifying fibroma, peripheral cementifying fibroma, ossifying fibro-epithelial polyp, peripheral fibroma with osteogenesis, peripheral fibroma with cementogenesis, peripheral fibroma with calcification, fibrous epulis, calcifying or ossifying fibrous epulis, and calcifying fibroblastic granuloma., The term cemento-ossifying fibroma is scientifically invalid, as there is no histomorphic or biochemical difference between bone and cementum. Whereas peripheral odontogenic fibroma is a true neoplasm of odontogenic origin, and it is the counterpart of central odontogenic fibroma;, the POF, however, does not represent the soft tissue counterpart of the central ossifying fibroma, as the latter arise from the endosteum and causes expansion of the medullary cavity.
The pathogenesis of POF is uncertain. Some consider it to be a fibrotic variant of pyogenic granuloma as it appears clinically and histologically similar to it. The role of hormones has also been questioned as it occurs mostly in females as compared to males (3:2) in the second decade of life., Of the four cases presented here, three were females (Case 1, 3, and 4). The most widely accepted histogenesis of POF is inflammatory hyperplasia of cells of periosteum or periodontal ligament., The inflammatory reaction could be secondary to trauma from local irritants. This hypothesis appears valid as the lesion appears exclusively on gingiva, in proximity to the periodontal ligament, and there is decline in the number of cases with the progress of age as loss of periodontium occurs with tooth loss as age advances. Only patient in Case 3 could give a history of possible trauma to the gingiva in that area, whereas others were unaware of the cause how it started. However, in all the reported cases here, there were local irritants in the form of plaque and calculus present which could be attributed to the causation of the gingival hyperplasia.
POF can occur at any age but peak incidence is seen in the second decade of life, and it declines after the third decade. Again, the cases presented here were unique as the patients in Case 1 and Case 2 were adolescents, 15-year-old patients; whereas, Case 3 was a 40-year-old patient, and Case 4 was a 32-year-old female.
In all the four cases presented here, surgical excision was planned a week after thorough scaling and root planing. During the removal of the lesions, complete removal of the lesion along with gingival curettage was performed to prevent recurrence. The patients were advised to follow strict oral hygiene measures.
Clinically, POF occurs as a solitary nodular. It occurs most commonly in the interdental papillary region. All the four cases presented as discrete gingival growths causing discomfort and pain while eating. Case 1 and 4 had single growth whereas Case 2 and 3 had communication through the interdental areas and presented with a lingual growth at the same site as well.
POF has a greater preponderance to occur in the maxillary arch than the mandibular arch in the incisor-cuspid region. Again, Case 2 presented as maxillary growth, in relation to molars and the rest three growths were present in mandible in incisor-cuspid region. Case 1 and Case 2 and Case 4 presented as pedunculated growths while Case 3 had sessile growth. The color ranges from pink to red, and the surface is frequently but not always ulcerated.
Most lesions are usually 1–2 cm in size, however, lesions of size >2 cm have also been reported. Case 1 presented as a growth size >2 cm. POF are usually solitary; rarely, multicentric lesions are also seen. Occasionally, multicentric variants are seen in association with nevoid basal cell carcinoma syndrome, multiple endocrine neoplasia Type II, neurofibromatosis and Gardner's syndrome. Usually, the associated teeth are unaffected, but rarely, it may cause mobility, migration, and delay in the eruption of permanent teeth. Case 3 showed the marked migration of associated teeth and Case 4 displayed mild displacement of the associated tooth. The radiographic features of POF may vary from no changes to erosive changes of bone. Underlying bone changes are usually not visible on routine radiographs. In certain cases, superficial erosion of bone is seen, cupping defects of the bone may be present and radiopaque focal areas of calcification may be evident scattered in the center of the lesion., Depending on the size of the lesion and the radiographic findings on plain radiography, additional imaging methods are rarely required. In the four cases presented here, all showed interdental bone loss, slight widening of the periodontal ligament space. Case 2 showed slight radiolucency in the furcation area also. Case 3 depicted displacement of the associated teeth along with increase in the radiodensity at the site of the growth. Histopathologically, POF can exhibit an intact or ulcerated superficial stratified squamous epithelium. The deeper fibroblastic component is highly cellular with variable mineralized component, sparse endothelial proliferation and few chronic inflammatory cells mainly lymphocytes and plasma cells. In areas of ulceration, the endothelial proliferation can be profuse which can be misleading as the lesion may appear like a pyogenic granuloma. The mineralized components may consist of bone, cementum-like material or dystrophic calcifications. Usually, the bone is woven, lamellar or trabecular in type and rarely contains unmineralized osteoids and multinucleated giant cells. Histopathologic examination revealed Case 1 to be peripheral cemento-ossifying fibroma, whereas, Case 2, 3, and 4 came out to be POF.
POF should be differentiated from other reactive lesions of gingival such as pyogenic granuloma, peripheral giant cell granuloma, and peripheral odontogenic fibroma. Pyogenic granuloma presents as rapidly growing red mass which bleeds profusely when touched, usually seen in pregnant women. Histologically, it is highly proliferative vascular lesion resembling granulation tissue. Peripheral giant cell granuloma appears clinically similar to POF but has a purple or bluish colored growth and histologically presents numerous giant cells scattered in fibrous stroma. Peripheral odontogenic fibroma contains prominent islands of odontogenic epithelium.
The treatment of choice is surgical intervention with deep surgical excision of the lesion including periosteum and periodontal ligament and complete removal of all the irritants including plaque and calculus.
The prognosis of POF is good, but POF has a recurrence rate of about 7%–20% according to various authors. It probably occurs due to incomplete removal of initial irritants, repeated injury or persistence of local irritants. All the four cases presented here were followed for more than 2 years and showed no signs of recurrence except Case 4 with recurred after a year of excision; however, the local etiological factors, i.e., plaque and calculus were present in abundance in the absence of patient's proper oral hygiene maintenance.
Various surgical procedures such as lateral sliding flap (full thickness or partial thickness), subepithelial connective tissue graft or coronally repositioned flap may be used later on to manage the defect and minimize esthetic concerns of the patient. If surgical intervention is not done, POF can become large, causing destruction to adjacent teeth and bone and significant functional and esthetic alterations., In Case 1 and 2, the associated teeth were clinically normal, but in Case 3 and 4, the gingival growth had caused migration of associated teeth. However, this could be attributed to the local factors present also.
| Conclusion|| |
POF is a slowly progressing gingival enlargement that is non-neoplastic and is considered reactive in nature. Most of the times, it is misdiagnosed as pyogenic granuloma based on its clinical features. There is a substantial overlap between the various reactive lesions of gingiva. POF demonstrates a diverse clinicopathological variation from the usual presentation. Surgical excision followed by histopathological examination is mandatory to differentiate it from other non-neoplastic and reactive lesions of gingiva. Although it has a low recurrence rate, a complete excision of the lesion with the underlying periosteum prevents its recurrence. The patient should be followed up regularly for any recurrences, and local etiological agents should be regularly removed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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