International Journal of Clinical Case Reports, 2016, Vol.6, No.15, 1-9
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POF more commonly occurs in females and in the second decade, hence the role of hormones has also been
questioned. Multicentric POF can also occur in the oral and maxillofacial region, and have been observed in
conditions associated with known genetic mutations, such as, Nevoid basal cell carcinoma syndrome, multiple
endocrine neoplasia type II, neurofibromatosis and Gardner syndrome (Ramu et al., 2012). Also, recently an
immunohistochemical study done by Marcos A Jose et al., (2010) showed that the proliferating cells of
connective tissue in POF are of myo-fibroblastic nature (i.e.cells sharing morphological characteristics with
fibroblasts and muscle cells). An immuno-histochemical study made to determine the nature of these
proliferating spindle shaped cells showed the cells to be positive to vimentin and actin further confirming its
myo-fibroblastic nature.
The findings of the study, thereby, raised suspicion regarding the interlink between PG and POF (Mathur et al.,
2014).
Clinically, POF commonly presents as a pedunculated or sessile localized overgrowth on the gingiva. On
palpation, it appears to be firm, non-tender and attached to the inderdental gingiva. The overlying mucosa may
show foci of ulceration or it may be non-ulcerated with normal overlying mucosa.
10
It is a slowly growing lesion
which attains mostly the size of 1-2 cm in diameter; rarely, larger lesions up to the size 9 cm have also been
reported.
11
POF may occur at any age but exhibits a peak incidence between the second and third decades. Almost
60% of the lesions occur in the maxilla and are seen usually anterior to the first molars, mostly, in
incisor-cuspid region and during the second decade of life. The lesion affects females more commonly than
males (5:1 respectively) (Mathur et al.,
2014)
. Due to the marked female predilection, the role of hormones is
also postulated in the pathogenesis of POF (Ramu et al., 2012). The lesions usually are solitary however,
multi-centric lesions have also been reported rarely. One such case has been reported by Kumar K S et al where
the lesion involved both the maxillary and mandibular gingivae and both sides of the jaws were affected
(Kumar et al., 2006). POF has to be differentiated clinically from other reactive pathologies occurring on the
gingiva. Radiographic changes in POF are not routinely seen; however, sometimes small amount of
radioopaque material is seen, specifically in larger lesions or long standing lesions with much amount of
mineralization to produce radiographic changes (Kumar et al., 2006)
These lesions are known to cause cupping resorption of the adjacent superficial alveolar bone. Other bone
changes that can be noted are, widening of the periodontal ligament space along with thickened lamina dura.
Pathologic migration of the involved teeth is noted due to resorption of the interdental bone. Because of the
huge clinical spectrum to which POF can mimic, confirmatory diagnosis has to be established by
histopathology of the lesion. Gardner (1982) stated that cellular connective tissue of POF is so characteristic
that a histological diagnosis can be made with confidence, regardless of the presence or absence of
calcification. This feature holds significance as the mineralized component of peripheral ossifying fibroma
varies from 23% to 75 %. The mineralization can contain following components:Lamellar or woven osteoid
tissue;Cementum like material; and Dystrophic calcification (Reddy et al., 2011). Dystrophic calcification is
mostly seen in ulcerated lesions (Buchner et al., 1987). Cundiff stated that mineralization is an inherent
potential of periodontal ligament/periosteum. The same lesion that shows minute dystrophic calcification may
also show other type of mineralization, if left long enough (Gardner et al., 1982). Along with the above
mentioned two important features, other histological features include intact or ulcerated surface epithelium,
connective tissue comprising of plump fibroblasts which are proliferating and other components which are
mesenchymal in origin and less to highly profuse endothelial cell proliferation. This may cause bleeding in
POF further making clinical diagnosis confusing (Reddy et al., 2011).
Treatment requires proper surgical intervention that ensures deep excision of the lesion including periosteum and
affected periodontal ligament. Thorough root planing of the adjacent teeth and/or removal of other sources of
irritants should be accomplished. Due to the high rate of recurrence (8% to 20%), post-operative follow-ups are
required. POF recurs due to 1) incomplete removal of the lesion, 2) failure to eliminate local irritants and 3)
difficulty in accessing the lesion during surgical manipulation as a result of the intricate location of the lesion
