Peripheral ossifying fibroma: Clinical and histopathological insights from a case report

INTRODUCTION

Peripheral ossifying fibroma (POF) is a reactive lesion that accounts for 3.1% of all oral tumors and 9.6% of gingival lesions occurring in the oral cavity. POF is a non-neoplastic, slow-growing lesion which appears to be pinkish or reddish in color, ranging from ≥2 cm and it can be occasionally larger in size, which may in few instances lead to tooth displacement accompanied by interdental bone loss.^[1] POF is common in 2^nd and 3^rd decades of life, especially in females.

The etiological causes include trauma, local elements such as the presence of calculus and plaque, and impingement by dental appliances or restorations.^[2] Although the etiopathogenesis is uncertain, an origin from cells of the periodontal ligament has been suggested.^[3]

POF tends to reoccur, therefore it is necessary to eliminate any potential local irritants as well as treating the affected periodontal ligament of the adjacent teeth to decrease the likelihood of the recurrence of the lesion.^[4]

This report highlights the crucial role of clinical assessment and histological investigation for accurate diagnosis of POF and emphasizes the need for its complete removal down to the periosteum using a diode laser to reduce the potential recurrence risk.

CASE REPORT

A 12-year-old female was referred to the department of Periodontics, from the department of Paedodontics, School of Dental Sciences, Sharda University, with a chief complaint of swelling in her upper front tooth region for the past 2 months that had gradually increased with time. She had a history of the same for which she had previously undergone surgical excision, but the lesion had recurred. No relevant past medical and family history was found.

An isolated, sessile overgrowth mass including the buccal interdental papilla and connected gingiva in relation to 11 and 12 was discovered during clinical intraoral examination [Figure 1a]. It had a smooth surface, was pink in color, and was around 0.9 cm × 0.7 cm in size with no surface ulceration or discharge. On palpation, the growth was nontender and was firm in consistency. Intraoral periapical radiograph showed no significant bony changes. There was a widespread buildup of calculus and subgingival plaque in the region, which depicted the poor oral hygiene maintenance by the patient. Considering the age, gender, clinical, histopathologic and radiographic findings, the provisional diagnosis of POF was considered.

Close

Figure 1:

(a) Clinical photograph depicting a erythematous sessile lesion in labial surface extending i.r.t 11 and 12 (b) surgical excision of the lesion carried out by using 810 nm diode laser (c) immediate post-operative photograph after the excision (d) post-operative clinical photograph after 10 days.

Export to PPT

After completion of phase 1 therapy, the patient was given an appointment 1 week after, for re-evaluation. Blood tests were advised. Surgical excision was planned by a soft-tissue diode laser of 810 nm [Figure 1b].

Before surgery, the patient was instructed to use a mouthwash containing 0.2% chlorhexidine gluconate to reduce the amount of bacteria in the oral cavity. At the injection site, a 15% lignocaine topical anesthetic spray was used. Local infiltration with 2% lignocaine and 1:1,00,000 adrenaline was given. After obtaining the right level of anesthesia, the lesion was removed [Figure 1c], promptly preserved in 10% formalin, and then transferred for additional histopathologic analysis. Coe-pack was applied to the surgical site to protect it, and the periodontal dressing was removed after 10 days [Figure 1d].

Histopathologic examination with hematoxylin and eosin stain showed the presence of proliferative stratified squamous epithelium at places and the underlying connective tissue shows dense collagen fibers with plump fibroblasts, hemosiderin pigments with chronic inflammatory cells, and reactive bone formation in some areas [Figure 2]. Overall, the histopathologic features are indicative of POF.

Close

Figure 2:

Histopathological (H & E) stained sections at (a) 10x, (b) 40x showing connective tissue stroma with proliferating fibroblasts marked with blue arrow and reactive bone formation is marked with black arrow. H & E: Hematoxylin & eosin.

Export to PPT

DISCUSSION

Menzel originally provided a clinical description of the lesion known as a “ossifying fibroma” in 1972, and Montgomery coined the word in 1927.^[5] POF has also been called as peripheral odontogenic fibroma, peripheral cementoossifying fibroma, peripheral fibroma with calcification, peripheral fibroma with osteogenesis, calcifying fibroblastic granuloma, fibrous epulis, etc.^[6]

Eversole and Rovin earlier noted that POFs exhibit a variable histologic response to irritation in comparison to pyogenic granuloma and peripheral giant cell granuloma, which share the same sex, site predilection, and clinical presentation.^[5]

According to Rallan et al., POF normally has a diameter of <1.5 cm, although there have also been reports of gigantic POFs up to 9 cm in diameter.^[7]

The prevalence of POF is higher in female patients during the second decade of life because of the hormonal effect, particularly of estrogen and progesterone. POF is common in females than in males because of the variations in hormonal levels during puberty and pregnancy. Alveolar and gingival mucosa is more frequently linked to POF. In the incisor and cuspid region, more than 50% of cases have been reported.^[1]

To prevent occlusal alterations and tooth loosening, POF should be removed at an early stage. Furthermore, it is recommended to thoroughly clean the neighboring teeth, particularly the PDL and periosteum, to eliminate any potential local irritation and lower the likelihood of the lesion returning.^[8]

Since many oral lesions have an identical clinical presentation, it is challenging to diagnose POF solely based on its clinical presentation. Microscopically, POF shows vascular growth that resembles granulation tissue.^[9] It is composed of a gingival mass comprising islands or trabeculae of woven or lamellar bone in a cellular fibrous connective tissue stroma. Chronic inflammatory cells have also been found in the periphery of the lesion.^[1]

Pyogenic granuloma, peripheral fibroma, POF, and peripheral giant cell granuloma are all possible diagnoses for POF.^[10]

Hence, the diagnosis of POF is based not only on the clinical signs but also on the radiographic and histopathologic findings.

CONCLUSION

To confirm the diagnosis of POF, a histopathological study is required along with the detailed clinical and radiographic findings because there are several other gingival reactive lesions such as PGCG, pyogenic granuloma, and irritant fibroma which have similar clinical presentations and also share the same etiological factors such as trauma, presence of plaque and calculus, irritation caused due to a dental appliance or over hanging restoration, etc. Due to this reason it is critical to have a thorough understanding of the challenging diagnosis of these particular lesions to reach a proper conclusion so that appropriate necessary treatment can be provided to the patient.