|
 
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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 7
| Issue : 1 | Page : 35-40 |
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Peripheral ossifying fibroma: Revisited
Vikram S Amberkar, KP Mohankumar, Sarabnoor Kaur Chawla, GS Madhushankari
Department of Oral Pathology, College of Dental Sciences, Davangere, Karnataka, India
| Date of Web Publication | 3-Jul-2017 |
Correspondence Address:
Sarabnoor Kaur Chawla
Department of Oral Pathology, College of Dental Sciences, Davangere, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijohs.ijohs_26_17
Peripheral ossifying fibroma (POF) is one of the few reactive lesions of the gingiva which are clinically similar in presentation. The lesion occurs over a wide age range with females being affected more often than males. Furthermore, the POF has a propensity to occur in the incisor cuspid area affecting maxilla more than the mandible. POF is known to arise as a focal exophytic mass exclusively on the gingiva commonly appearing to originate from the interdental gingiva and does not commonly involve the underlying bone. Irritation to the gingiva by calculus, plaque, ill-fitting dentures, and hormonal influence has been considered in the etiopathogenesis. The recurrence has been found to be as high as 16% making it important for the clinician to identify the lesion and treat accordingly.
Keywords: Exophytic mass, ossifying fibroma, peripheral ossifying fibroma, reactive lesions
How to cite this article:
Amberkar VS, Mohankumar K P, Chawla SK, Madhushankari G S. Peripheral ossifying fibroma: Revisited. Int J Oral Health Sci 2017;7:35-40 |
| Introduction | |  |
Gingival mucosa is constantly under mild irritation due to various factors such as the masticatory forces, entrapment of food debris, poor restorations and prosthesis, plaque and calculus, and a vast variety of microorganisms which may become pathogenic under altered conditions. More often than not, the gingiva reacts to these irritants by forming a hyperplastic growth in a localized area.[1] These localized reactive lesions include the peripheral giant cell granuloma (PGCG), pyogenic granuloma, fibrous hyperplasia (fibrous epulis), one of relatively common entities encountered is a gingival overgrowth that is usually composed of cellular fibroblastic tissue and contains one or more mineralized tissues is the peripheral ossifying fibroma (POF).[2] POF is a focal, reactive, nonneoplastic tumor-like growth of the soft tissue that often arises from the interdental papilla. POF is a distinct entity, unlike central ossifying fibroma, which is not the central counterpart of POF but is instead a true neoplasm with significant growth potential.[3],[4]
It has been known by various synonyms in literature. Shepherd first reported this entity as “alveolar exostosis” in 1844.[5] Epulis, peripheral fibroma with calcification, calcifying fibroblastic granuloma, peripheral cementifying fibroma, peripheral fibroma with cementogenesis, and peripheral cemento-ossifying fibroma are the names that have been used in the literature.[6] Lee KW in 1968 proposed the term calcifying fibroblastic granuloma, but the term is not popular among researchers.[7] The term POF was coined by Eversole and Rovin in 1972.[1]
POF has been used interchangeably with peripheral odontogenic fibroma in the literature. However, the peripheral odontogenic fibroma is now put under the extraosseous counterpart of the neoplastic central odontogenic fibroma by the WHO which has distinctive histopathological features and therefore is not used synonymously with POF.[8] Gardner suggested that of the various names mentioned in the literature, only the term POF should be retained.[7]
| Epidemiological Data | | |
In a study done by Buchner et al., over a 17 years period, from 1969 to 1986, the POF accounted for 0.44% of the total cases accessioned.[2] In a more recent study, incidence of POFs stood at 1.5% of the total cases accessioned.[8] Among the reactive lesions of gingiva, the incidence of POF is 10%–18%.[9]
The POF has a propensity to occur in the maxilla with almost 60% of the growths being reported in the maxilla and more than 50% lesions involving the incisor cuspid area and premolar region being the least frequently involved.[2],[8]
Females are affected 1.3–1.7 times more than males.[2],[8],[10] Eversole and Rovin reported females to outnumber males at 4.3:1.[1]
| Clinical Presentation | | |
The clinical appearance of POF is characteristic but not pathognomonic. Frequently, POF arises as a solitary, focal exophytic mass exclusively on the gingiva commonly appearing to originate from the interdental gingiva. Occasionally, edentulous alveolar ridges are also involved. POF is a slow-growing progressive lesion which seldom presents with any symptom. The growth can be sessile or pedunculated, smooth surfaced, usually firm and nontender to palpation in most of the cases. The color may range from being the same as that of surrounding mucosa to red or reddish-blue. The surface may be intact or ulcerated depending if there has been trauma to the overgrown tissue.[3],[4],[11] Miller et al. stated that immature lesions are soft and bleed easily; older lesions become firm and fibrotic. Immature lesions can therefore be confused with pyogenic granuloma.[2],[12] Various studies show that the lesions occurred within a wide age range with the peak incidence in the second decade followed by a decrease in incidence with ensuing age.[3],[4] Eversole and Robin suggested that in the old age, there is loss of periodontium accompanying tooth loss which may explain its greater occurrence in the younger age group.[1] There is a wide variation seen in the reported age range with a phenomenal case in a 2-hour-old female, associated with an anterior mandibular neonate tooth.[8] On the other end, a 3 cm POF has been seen in a 70-year-old female.[5]
Kumar et al. 2006 reported a unique case of POF presenting as multicentric lesions affecting both maxilla and mandible with a recurrent nature despite good oral hygiene and routine periodontal care. The lesions ranged from 3 mm to 5 cm and were painful.[13]
Most POF are smaller than 2 cm in diameter.[3] Kfir et al. reported the size to be <1.5 cm in most of the cases [10] but a size of up to 9 cm of the growth, disfiguring the face has been reported in the literature.[14]
Clinical photographs of two recently encountered cases of gingival overgrowths in our department show lesions of approximate measurement 1 cm in breadth and 1.5 cm in length present on the mandibular anterior region and 2.5 cm in breadth and 1 cm in length in the mandibular posterior region. The lesions were reported to be of duration 1.5 months and 3.5 months, respectively. As can be seen, both lesions were sessile, almost the same color of the mucosa with a smooth-surface, firm, and nontender to palpation. The lesions were subsequently diagnosed as POF s histopathologically [Figure 1] and [Figure 2]. | Figure 1: Clinical presentation of peripheral ossifying fibroma as a sessile, slightly reddish gingival swelling in the anterior mandible
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 | Figure 2: Clinical presentation of peripheral ossifying fibroma as a sessile, firm, non tender, gingival swelling in the posterior mandible
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| Radiographic Features | | |
In most cases, there is no apparent underlying bone involvement seen on the radiograph. On very rare occasions, there can be superficial erosion of the bone or migration and loosening of adjacent teeth.[3],[4] In a case reported by Yadav R, radiographic examination of POF showed a radiolucent lesion displacing the root of second premolar with resorption of crest bone mesial to the involved tooth.[15] When taking a radiograph, a minor adjustment of exposure settings (decrease of kilovolt peak; increase of milliampere) is recommended as it is helpful for showing the tiny radiopaque foci.[14]
| Etiopathogenesis | | |
Apparently, the name POF is a misnomer and its use could evoke confusion. The term fibroma etymologically means tumor of fibrous connective tissue (from Latin fibra, “fiber” + Greek oma, “tumor”), POF is not considered a true neoplasm.[16]
The etiology and histogenesis of the POF is uncertain, but inflammatory hyperplasia of superficial periodontal ligament (PDL) origin has been suggested by Eversole and Rovin and Bhaskar and Jacoway [1],[17] The theory of PDL origin is based on several factors including the exclusive occurrence on the gingiva, the proximity to the PDL, the age distribution of the lesions correlated inversely with the number of lost permanent teeth and their corresponding PDL, and the similarity of the fibrocellular response to other reactive lesions of PDL derivation.[12]
It is strongly suggested that since POF is not seen in edentulous areas, its origins must lie with the connective tissue elements of the PDL. Since lamina dura and cementum are a part of the PDL complex, the presence of ossifications in POF should not be surprising.[18]
Orikin and Amaidas suggested that chronic irritation of periosteal and periodontal membrane causes metaplasia of the connective tissue which initiates the formation of bone and dystrophic calcification.[19]
Dental calculus, plaque, microorganisms, masticatory forces, ill-fitting dental appliances, and restorations are likely the chronic irritants responsible for this reactive growth.
Hormonal influences may contribute to the growth because of a higher incidence in women, the rare occurrence before age 10, and the steady decline in incidence after the third decade suggest that hormonal influence may contribute to the growth of this lesion.[12]
In a study of immunohistochemical profile of POF, lesion specimen from 4 healthy women, two of which were pregnant, were studied. The results indicated the myofibroblastic nature of proliferating cells, i.e., cells with morphological characteristics of both muscle cells and fibroblasts. Although hormonal influence has been widely suggested, this study did not demonstrate estrogen or progesterone receptor positivity in the proliferating cellular component. The authors suggested that the failure to demonstrate these receptors may be due to low level of increment in the receptors, or an endocrine mechanism that does not involve these receptors.[20]
Studies have also shown the reactive nature of the lesion as a response to inflammation as demonstrated by CD68 positivity and other cell proliferation markers such as proliferating cell nuclear antigen, whose levels are lower than benign neoplasms but similar to other reactive neoplasms such as inflammatory fibrous hyperplasia.[20],[21]
| Histopathology | | |
The histologic appearance of the POF is a nonencapsulated mass of very cellular fibroblastic connective tissue covered by stratified squamous epithelium which is commonly discontinuous due to ulceration. Ulcerated lesions have a surface covered with fibrinopurulent membrane with a subjacent zone of granulation tissue. In some cases, there can be a band of relatively acellular fibrous connective tissue separating the cellular connective tissue from the intact epithelium. Gardener stated that the cellular connective tissue is so characteristic that the diagnosis of POF can be made with confidence, even if no calcifications are found.
Randomly distributed calcifications are dispersed throughout the cellular connective tissue. This mineralized component may consist of bone, cementum-like material, or dystrophic calcifications. They vary in number and in some sections may be absent. Usually, the bone is woven and in the form of single or multiple interconnecting trabeculae. Less frequently, globular basophilic cementum-like material is formed. Dystrophic calcifications can vary from multiple tiny globules to large irregular masses of basophilic mineralized material. Vascularity is not a prominent feature of POF as it is in the pyogenic granuloma. Finally, foci of giant cells, similar to those of the PGCG, may be present but are not a prominent feature.[3],[4],[7]
The histopathological features found in various studies are presented in [Table 1]. | Table 1: Year-wise summary of histologic features of few of the reported cases of peripheral ossifying fibroma
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As stated, bone, cementum, and spheroidal calcifications are found in POF, which has prompted the use of term cementifying fibroma, when spheroidal calcifications or curvilinear trabeculae predominate. Another term, “cement ossifying fibroma,” is used when both cementum-like and bony tissues are observed. The term cement ossifying fibroma is not used because of several reasons, for example, the two may be clinically and radiographically impossible to separate and the histopathological picture of oral cemento-ossifying fibroma is similar to that from skull, femur, and tibia where no cementum is formed. Another reason suggested that there is no biochemical and histologic difference between bone and cementum.[15],[18]
Photomicrographs of POF from the archives of our department show a highly cellular connective tissue with ossifications in the form of mature lamellated bone, osteoid, woven bone, cementum-like material, and dystrophic calcifications [Figure 3],[Figure 4],[Figure 5],[Figure 6]. | Figure 3: H and E-stained sections reveal a highly cellular connective tissue with ossifications in the form of irregular trabeculae of woven bone, osteoid, and acellular basophilic cementum-like material
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 | Figure 4: Higher magnification of Figure3 showing irregular trabeculae with osteocytic lacunae
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 | Figure 5: H and E-stained sections reveal a highly cellular connective tissue with ossifications in the form acellular basophilic cementum-like material
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 | Figure 6: H and E-stained sections reveal a highly cellular connective tissue with ossifi cations in the form of irregular trabeculae of woven bone and osteoid
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| Differential Diagnosis of a Localized Gingival Growth | | |
A differential diagnosis of POF, pyogenic granuloma, PGCG, peripheral odontogenic fibroma, and fibrous hyperplasia is usually considered for such localized growths on the gingiva.
Pyogenic granuloma
Usually, the pyogenic granuloma presents as a soft, friable localized mass that bleeds with minimal manipulation and is often associated with pregnancy. Gingiva is the most common location, but it can occur on lips, tongue, and buccal mucosa also.[11] No tooth displacement or alveolar bone resorption is observed on radiographs. Histopathological features reveal endothelium-lined vascular channels engorged with red blood cells and chronic inflammatory cells.[11],[23]
Peripheral giant cell granuloma
Clinical features are similar to those of POF, but PGCG has a purple-blue hue and occurs most commonly during 4–6th decade.[11],[25] Histopathologically, a large number of multinucleated giant cells in vascularized fibro cellular stroma with inflammatory cell infiltration can be seen.[23]
Irritation fibroma
With no definitive age range, irritation fibroma is the most common of the localized gingival growths and commonly affects buccal mucosa, lips, and gingiva. Histopathologically, atrophic epithelium with dense collagenous matrix containing few fibroblasts and little or no inflammatory response is seen.
Peripheral odontogenic fibroma
This uncommon lesion occurs in a wide range of ages, from 5 to 65 years. It is known to sometimes displace the surrounding teeth. Histopathological features are characterized by the presence of odontogenic epithelium and dysplastic dentine.[11],[23],[24],[25]
| Treatment | | |
Total excision is the preferred management of POF is total excision. This should include the involved PDL and periosteum. Any etiologic agent seen, such as calculus, ill-fitted dental appliances, and rough restorations have to be removed. However, extraction of the adjacent teeth is seldom necessary in the early stages. Although POF is a benign, reactive lesion, the recurrence rate is fairly high. High recurrence rates of upto 16%, has been seen by studies from Buchner & Hansen, and various other authors making postoperative follow-up mandatory.[2],[14]
| Conclusion | | |
Plethora of lesions occurs in the oral cavity with similar clinical findings and nearly resembling histological features. Especially the reactive lesions pose such a dilemma to clinicians and pathologists. There is a need to individualize these lesions not only from academic stand point but also from clinical perspective. As a lesion-like POF can be recurrent and needs continuous monitoring, understanding of histogenesis, presentation, and clinical outcome of POF can help a clinician to approach the lesion in a perspective to improve the quality of life of the patient.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1]
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