Difference between central offifying granuloma and peripheral ossifying granuloma
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Abstract
Peripheral ossifying fibroma (POF) is one of the inflammatory reactive hyperplasia of gingiva. It represents a separate clinical entity rather than a transitional form of pyogenic granuloma and shares unique clinical characteristics and diverse histopathological features. We present a case of POF in a 65-year-old male patient in the posterior maxillary gingiva, the clinical presentation of which differs from the usual presentation. Differential diagnosis and some interesting facts of POF are discussed.
Keywords: Calcifications, gingival hyperplasia, ossifying fibroma
INTRODUCTION
Peripheral ossifying fibroma (POF) is a non-neoplastic entity, which occurs on the gingiva in response to trauma or irritation. It is a reactive lesion of connective tissue and is not the soft-tissue counterpart of central ossifying fibroma. It is reported under bewildering array of terms in literature, which includes peripheral cementifying fibroma, calcifying or ossifying fibroid epulis, mineralizing ossifying pyogenic granuloma, peripheral fibroma with calcifications and calcifying fibroblastic granuloma.[1]
POF was first reported by the Shepherd in 1844 as alveolar exostosis.[1] Eversol and Robin in 1972, later coined the term peripheral ossifying fibroma.[1] It occurs in the younger age group with a female preponderance. It has a predilection for maxillary arch and most of them occur in the incisor-cuspid region. It presents as a painless mass on gingiva or alveolar mucosa measuring not exceeding 3 cm. It can be pedunculated or sessile. Earlier lesions appear irregular and red and older lesions have a smooth pink surface. Surface ulceration may be present.[2]
POF occurring in an older age group in male patient involving posterior maxilla is rare and an unusual clinical presentation. We attempt to report one such rare case with emphasis on compilation of interesting facts pertaining to POF.
CASE REPORT
A 65-year-old man visited the Department of Periodontics, Hasanambha Dental College and Hospital with a history of a swelling that had gradually increased in size during previous 2 years. He had no history of previous swelling in the oral cavity. Past medical and family history was non-contributory.
Intra oral examination revealed a solitary, pedunculated mass involving buccal interdental papilla and attached gingiva in relation to 26 and 27 [Figure 1]. Mass was pink in color with a smooth surface, measuring approximately 1.5 cm × 2 cm. No surface ulceration was noted. On palpation, it was non-tender and firm in consistency.

Figure 1
Intra oral picture showing gingival mass with respect to 26 and 27
Intra oral periapical radiograph showed no significant bony changes. Provisional diagnosis of POF was considered.
Thorough scaling and root planning was performed to eliminate the irritating factors and after a week, complete surgical excision of the lesion was performed under local anesthesia. To prevent recurrence, complete removal of the lesion and gingival curettage is ensured followed by oral hygiene maintenance instructions to the patient.
Microscopic examination showed fibro-cellular connective tissue interspersed with plump fibroblasts in between the collagen bundles, surfaced by parakeratinzed stratified squamous epithelium [Figure 2]. Stroma showed large trabeculae of lamellar bone [Figure 3] and scattered basophilic, cementum like substances [Figure 4]. The histopathological features were diagnostic of peripheral ossifying fibroma.

Figure 2
Photomicrograph showing fibro-cellular stroma with surface epithelium, (H and E, ×10)

Figure 3
Trabeculae of lamellar bone, (H and E, ×40)

Figure 4
Scattered basophilic material, (H and E, ×10)
Healing was uneventful [Figure 5] and patient is followed-up for 12 months without any recurrence.

Figure 5
Post-operative view with 10 months follow-up
DISCUSSION
Gingiva is one of those anatomical regions in the oral cavity with the broadest array of lesions occurring ranging from inflammatory to neoplastic. POF is one such reactive lesion, which occurs exclusively on gingiva. It accounts for 9.6% of gingival lesions.[3]
Histogenesis remains controversial and there are two schools of thought proposed to understand the histogenesis
of POF.
POF may initially develop as pyogenic granuloma that undergoes subsequent fibrous maturation and calcification. It represents the progressive stage of the same spectrum of pathosis.[4]
Peripheral ossifying fibroma (POF) is one of the inflammatory reactive hyperplasia of gingiva. It represents a separate clinical entity rather than a transitional form of pyogenic granuloma and shares unique clinical characteristics and diverse histopathological features. We present a case of POF in a 65-year-old male patient in the posterior maxillary gingiva, the clinical presentation of which differs from the usual presentation. Differential diagnosis and some interesting facts of POF are discussed.
Keywords: Calcifications, gingival hyperplasia, ossifying fibroma
INTRODUCTION
Peripheral ossifying fibroma (POF) is a non-neoplastic entity, which occurs on the gingiva in response to trauma or irritation. It is a reactive lesion of connective tissue and is not the soft-tissue counterpart of central ossifying fibroma. It is reported under bewildering array of terms in literature, which includes peripheral cementifying fibroma, calcifying or ossifying fibroid epulis, mineralizing ossifying pyogenic granuloma, peripheral fibroma with calcifications and calcifying fibroblastic granuloma.[1]
POF was first reported by the Shepherd in 1844 as alveolar exostosis.[1] Eversol and Robin in 1972, later coined the term peripheral ossifying fibroma.[1] It occurs in the younger age group with a female preponderance. It has a predilection for maxillary arch and most of them occur in the incisor-cuspid region. It presents as a painless mass on gingiva or alveolar mucosa measuring not exceeding 3 cm. It can be pedunculated or sessile. Earlier lesions appear irregular and red and older lesions have a smooth pink surface. Surface ulceration may be present.[2]
POF occurring in an older age group in male patient involving posterior maxilla is rare and an unusual clinical presentation. We attempt to report one such rare case with emphasis on compilation of interesting facts pertaining to POF.
CASE REPORT
A 65-year-old man visited the Department of Periodontics, Hasanambha Dental College and Hospital with a history of a swelling that had gradually increased in size during previous 2 years. He had no history of previous swelling in the oral cavity. Past medical and family history was non-contributory.
Intra oral examination revealed a solitary, pedunculated mass involving buccal interdental papilla and attached gingiva in relation to 26 and 27 [Figure 1]. Mass was pink in color with a smooth surface, measuring approximately 1.5 cm × 2 cm. No surface ulceration was noted. On palpation, it was non-tender and firm in consistency.

Figure 1
Intra oral picture showing gingival mass with respect to 26 and 27
Intra oral periapical radiograph showed no significant bony changes. Provisional diagnosis of POF was considered.
Thorough scaling and root planning was performed to eliminate the irritating factors and after a week, complete surgical excision of the lesion was performed under local anesthesia. To prevent recurrence, complete removal of the lesion and gingival curettage is ensured followed by oral hygiene maintenance instructions to the patient.
Microscopic examination showed fibro-cellular connective tissue interspersed with plump fibroblasts in between the collagen bundles, surfaced by parakeratinzed stratified squamous epithelium [Figure 2]. Stroma showed large trabeculae of lamellar bone [Figure 3] and scattered basophilic, cementum like substances [Figure 4]. The histopathological features were diagnostic of peripheral ossifying fibroma.

Figure 2
Photomicrograph showing fibro-cellular stroma with surface epithelium, (H and E, ×10)

Figure 3
Trabeculae of lamellar bone, (H and E, ×40)

Figure 4
Scattered basophilic material, (H and E, ×10)
Healing was uneventful [Figure 5] and patient is followed-up for 12 months without any recurrence.

Figure 5
Post-operative view with 10 months follow-up
DISCUSSION
Gingiva is one of those anatomical regions in the oral cavity with the broadest array of lesions occurring ranging from inflammatory to neoplastic. POF is one such reactive lesion, which occurs exclusively on gingiva. It accounts for 9.6% of gingival lesions.[3]
Histogenesis remains controversial and there are two schools of thought proposed to understand the histogenesis
of POF.
POF may initially develop as pyogenic granuloma that undergoes subsequent fibrous maturation and calcification. It represents the progressive stage of the same spectrum of pathosis.[4]
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