Oral cavity & oropharynx
Soft tissue tumors & proliferations
Peripheral ossifying fibroma
Editorial Board Member: Molly Housley Smith, D.M.D.
Deputy Editor-in-Chief: Kelly Magliocca, D.D.S., M.P.H.
Last author update: 8 November 2022
Last staff update: 8 November 2022
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PubMed Search: Peripheral ossifying fibroma
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Negative stains | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Fielder T, Gupta R. Peripheral ossifying fibroma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/oralcavityperipheralossifyingfibroma.html. Accessed January 3rd, 2025.
Definition / general
- Reactive gingival proliferation characterized by spindle cell proliferation with calcification or ossification
Essential features
- Reactive gingival lesion; thought to be associated with chronic irritation
- Spindle cell proliferation with calcification or ossification within gingival connective tissue
Terminology
- Other terms include peripheral cementifying fibroma, peripheral cemento-ossifying fibroma, ossifying fibrous epulis, calcifying fibrous epulis (J Indian Soc Periodontol 2014;18:527)
- Should not be confused with odontogenic / central bone tumors, such as ossifying fibroma and cemento-ossifying fibroma
ICD coding
Epidemiology
- More common in females (F:M = ~2:1) (Oral Surg Oral Med Oral Pathol 1987;63:452, Med Oral Patol Oral Cir Bucal 2022;27:e460, J Indian Soc Periodontol 2015;19:83, Pediatr Dent 2001;23:245)
- Second to fourth decades (children and young adults) (Oral Surg Oral Med Oral Pathol 1987;63:452, Med Oral Patol Oral Cir Bucal 2022;27:e460, Br J Oral Maxillofac Surg 2019;57:1081)
- Can occur at any age, reports range from 2 months to 87 years (Oral Surg Oral Med Oral Pathol Oral Radiol 2020;130:e74, Med Oral Patol Oral Cir Bucal 2022;27:e460)
- ~5% of oral hyperplastic lesions (Braz J Otorhinolaryngol 2019;85:399, Indian J Dent Res 2018;29:61, Acta Odontol Latinoam 2015;28:103)
- ~20% of gingival hyperplastic lesions (Quintessence Int 2007;38:103, J Oral Pathol Med 2010;39:631)
Sites
- Arise exclusively on the gingiva
- Maxilla more common than mandible (Oral Surg Oral Med Oral Pathol 1987;63:452, Pediatr Dent 2001;23:245)
- ~67% in incisor cuspid region (Oral Surg Oral Med Oral Pathol 1987;63:452, Med Oral Patol Oral Cir Bucal 2022;27:e460, J Indian Soc Periodontol 2015;19:83)
Pathophysiology
- Unknown, likely a reaction to chronic irritation (J Indian Soc Periodontol 2015;19:83)
- Hormonal influence has been proposed since the lesion is common in adolescents and young women (Niger Med J 2011;52:35)
- However, lesional cells do not express estrogen or progesterone receptors (ER / PR) (J Oral Sci 2010;52:95)
Etiology
- Associated with chronic irritation, poor dentition and dental prosthetics, especially if poorly fitted (J Indian Soc Periodontol 2015;19:83)
- Thought to arise from the periodontal ligament (Ann Diagn Pathol 2020;46:151510)
Clinical features
- Slow growing nodule with a mean time to presentation of 16 months (Med Oral Patol Oral Cir Bucal 2022;27:e460)
- Generally painless or causing mild discomfort (J Indian Soc Periodontol 2015;19:83)
- May ulcerate (Oral Surg Oral Med Oral Pathol 1987;63:452)
- Indolent clinical course but in some cases, the size and location may interfere with normal oral function, displace teeth and distort local anatomy (Int J Surg Case Rep 2021;84:106127, Ann Maxillofac Surg 2016;6:300, Head Neck Pathol 2013;7:356)
- Recurrence in ~15% despite surgical excision (Oral Surg Oral Med Oral Pathol 1987;63:452, Br J Oral Maxillofac Surg 2019;57:1081, J Indian Soc Periodontol 2015;19:83)
- Multifocal disease is rare (Indian J Dent Res 2014;25:220)
Diagnosis
- Difficult to distinguish clinically from other entities (pyogenic granuloma, oral irritation fibroma, giant cell fibroma, peripheral giant cell granuloma, metastatic lesions)
- Readily diagnosed histologically with high interobserver concordance (Med Oral Patol Oral Cir Bucal 2022;27:e460)
Radiology description
- May show irregular radiopacity due to calcification / ossification or show mild alveolar bone resorption (Dentomaxillofac Radiol 2007;36:180, Med Oral Patol Oral Cir Bucal 2022;27:e460, Head Neck Pathol 2013;7:356)
Radiology images
Contributed by Molly Housley Smith, D.M.D.
Visible ossification
Prognostic factors
- Benign but may recur
- Recurrence is more likely if offending irritant is not removed (J Indian Soc Periodontol 2015;19:83)
Case reports
- 2 month old girl with peripheral ossifying fibroma (Oral Surg Oral Med Oral Pathol Oral Radiol 2020;130:e74)
- 24 year old man with multifocal disease (Indian J Dent Res 2014;25:220)
- 25 year old woman with 4 cm tumor interfering with oral function (Int J Surg Case Rep 2021;84:106127)
Treatment
- Surgical excision (J Indian Soc Periodontol 2015;19:83)
- Removal of irritants including plaque / calculus or poorly fitted prosthetics (J Indian Soc Periodontol 2015;19:83)
Clinical images
Contributed by Molly Housley Smith, D.M.D.
Nodular mass
Multilobular red growth
Images hosted on other servers:
Typical clinical appearance
17 year old boy
21 year old man
25 year old man
26 year old man
31 year old man
Gross description
- Exophytic mass that may be sessile or pedunculated (Med Oral Patol Oral Cir Bucal 2022;27:e460, J Indian Soc Periodontol 2015;19:83)
- Mean size of < 2 cm but sizes up to 10 cm have been reported (Med Oral Patol Oral Cir Bucal 2022;27:e460, J Indian Soc Periodontol 2015;19:83, Ann Maxillofac Surg 2016;6:300)
Gross images
Contributed by Molly Housley Smith, D.M.D.
Partially calcified mass
Microscopic (histologic) description
- Variably cellular fibroblastic spindle cell proliferation in subepithelial connective tissue in variably collagenous background (J Indian Soc Periodontol 2015;19:83)
- Collagen deposition is more prominent in the deep aspect (J Indian Soc Periodontol 2015;19:83)
- Dystrophic calcification, lamellar or woven bone formation is essential for diagnosis (J Indian Soc Periodontol 2015;19:83)
- Overlying hyperplastic epithelium with hyperkeratosis (J Indian Soc Periodontol 2015;19:83)
- Surface epithelium may be ulcerated (J Indian Soc Periodontol 2015;19:83, Oral Surg Oral Med Oral Pathol 1987;63:452)
- Background contains variable chronic inflammatory infiltrate, predominantly lymphoplasmacytic and proliferating small capillary sized vessels (J Indian Soc Periodontol 2015;19:83, Med Oral Patol Oral Cir Bucal 2022;27:e460)
Microscopic (histologic) images
Contributed by Timothy Fielder, M.B.B.S., B.Med.Sci., Ruta Gupta, M.D. and Molly Housley Smith, D.M.D.
Well demarcated mucosal lesion
Ulceration
Metaplastic ossification
Ossification and calcification
Lamellar bone
Collagenous matrix
Woven bone
Peripheral cemento-ossifying fibroma
Cementum-like bone
Positive stains
- Not used in routine diagnosis
- SMA in 73% (Br J Oral Maxillofac Surg 2019;57:1081)
- CD68 in 54% (Br J Oral Maxillofac Surg 2019;57:1081)
- SATB2 in 100% (Head Neck Pathol 2022;16:339, Ann Diagn Pathol 2020;46:151510)
- Positive for osteoblastic / cementoblastic proteins RUNX2, BMP2, CAP in one study and osterix (OSX) in another (J Oral Pathol Med 2015;44:628, Braz Oral Res 2017;31:e53)
Negative stains
Sample pathology report
- Gingiva, excision:
- Peripheral ossifying fibroma (see comment)
- Comment: Sections include oral squamous mucosa with underlying connective tissues and show features of a peripheral ossifying fibroma. The mucosa shows focal ulceration with organizing granulation tissue. The submucosal tissues show a well demarcated but unencapsulated lesion composed of areas of fibrosis and metaplastic ossification. There is no dysplasia or malignancy.
Differential diagnosis
- Oral irritation fibroma:
- Clinically difficult to distinguish
- Histologically lacks calcification or bone formation
- Peripheral giant cell granuloma:
- Clinically difficult to distinguish
- Stromal multinucleated giant cells are seen on histology
- Pyogenic granuloma:
- Clinically difficult to distinguish
- Lobulated vascular proliferation on histology
- Giant cell fibroma:
- Clinically difficult to distinguish
- Lacks bone formation
Board review style question #1
Which of the following is true regarding peripheral ossifying fibroma?
- It is a reactive gingival proliferation thought to occur in response to irritation or trauma
- It is histologically characterized by lobulated growth of capillary sized vessels with a central feeder vessel
- It is molecularly characterized by recurrent internal tandem duplication of BCOR
- It is most common in males over 50
Board review style answer #1
A. It is a reactive gingival proliferation thought to occur in response to irritation or trauma
Comment Here
Reference: Peripheral ossifying fibroma
Comment Here
Reference: Peripheral ossifying fibroma
Board review style question #2
A 24 year old woman presents with a 1 cm anterior maxillary gingival nodule. What is the favored diagnosis?
- Central ossifying fibroma
- Oral irritation fibroma
- Peripheral ossifying fibroma
- Pyogenic granuloma
Board review style answer #2
