Peripheral Ossifying Fibroma

Peripheral ossifying fibroma is a reactive gingival growth of fibrous tissue that contains mineralised material (bone, cementum like tissue or dystrophic calcification). It is not a neoplasm and arises from the periodontal ligament or periosteum.

It is found mostly in teenagers and young adults, in women more than men, and in the anterior maxilla, from the interdental papilla. It accounts for a notable share of gingival reactive lesions.

Pathophysiology. Chronic irritation from plaque, calculus, overhanging restorations or trauma stimulates proliferation of fibroblasts and mineralisation. Hormonal influences may contribute, given the female predominance.

Progression from a pyogenic granuloma with mineralisation has been proposed.

A firm, pink or red, sessile or pedunculated, smooth or ulcerated gingival nodule, usually under 2 cm, arising from the interdental papilla, which can bleed. Pain is minimal. It may displace or loosen teeth, and bone loss under the lesion is usually slight.

Rapid growth, large size, bone destruction or tooth migration suggests another lesion.

• Clinical diagnosis with histological confirmation of all excised tissue.
• Radiograph: usually normal, with occasional small radiopaque foci in the lesion, and slight alveolar bone loss.
• Histology: a cellular fibrous connective tissue with mineralised foci (woven or lamellar bone, cementum like globules, dystrophic calcification), often with ulceration and acute inflammation over the surface.
• Pregnancy test where relevant, and review of gingival lesions during pregnancy.

Differential diagnosis.

• Pyogenic granuloma (including pregnancy epulis)
• Peripheral giant cell granuloma
• Fibrous epulis and irritation fibroma
• Peripheral odontogenic fibroma
• Squamous cell carcinoma and other malignancy
• Lymphoma and metastasis
• Kaposi sarcoma

• Surgical excision down to the periosteum, with scaling and root planing of the adjacent teeth and removal of local irritants. Extraction of the tooth is needed only when the lesion is not controlled.
• Recurrence is about 8 to 20% and is managed by re-excision with a wider margin and attention to plaque control. Incomplete removal is the main cause.
• Send all specimens for histology.
• Do not remove a lesion during pregnancy unless it bleeds or interferes with eating. Excision of pregnancy related lesions is delayed until after delivery when possible, since many regress.
• Antibiotics are not needed. Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily) with ibuprofen 400 mg every 8 hours with food for 2 to 3 days (avoid ibuprofen from 28 weeks of pregnancy).
• Oral hygiene instruction and professional plaque control to prevent recurrence.

Monitoring. Review at 2 weeks, 3 months and 6 months, then annually. Recurrence prompts re-biopsy.

Referral and escalation. Refer to periodontology or oral surgery for excision, and to oral medicine for multiple or atypical lesions. Urgent referral for rapid growth, bone destruction or histology that suggests malignancy.