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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 27-31

Esthetically displeasing and recurrent gingival enlargement: A report of two cases


1 Department of Periodontics, University of Benin, Benin City, Nigeria
2 Department of Periodontics, University of Benin Teaching Hospital, Benin City, Nigeria
3 Department of Oral Surgery and Oral Pathology, University of Benin, Benin City, Nigeria

Date of Web Publication17-Jul-2017

Correspondence Address:
Clement Chinedu Azodo
Room 21, 2nd Floor, Department of Periodontics, Prof. Ejide Dental Complex, University of Benin Teaching Hospital, P.M.B. 1111, Ugbowo, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_8_17

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  Abstract 

Two cases of esthetically displeasing and recurrent gingival enlargement were reported. A case of 26-year-old female with gingival enlargement in the maxillary anterior region which has been excised twice by General Dental Practitioners and another case of 42-year-old female with gingival enlargement in the maxillary anterior region that caused displacement and mobility of associated tooth. Both cases had radiologic evidence of bone loss. Excisional biopsy was carried out and the histologic diagnosis was peripheral ossifying fibroma (POF). Healing of the surgical site was uneventful. POF should be considered as the diagnosis in cases of esthetically displeasing and recurrent maxillary anterior region gingival enlargement.

Keywords: Gingival enlargement, periodontal care, recurrent


How to cite this article:
Azodo CC, Uche IE, Ojehanon PI, Ehizele AO, Omoregie OF. Esthetically displeasing and recurrent gingival enlargement: A report of two cases. Indian J Oral Health Res 2017;3:27-31

How to cite this URL:
Azodo CC, Uche IE, Ojehanon PI, Ehizele AO, Omoregie OF. Esthetically displeasing and recurrent gingival enlargement: A report of two cases. Indian J Oral Health Res [serial online] 2017 [cited 2023 Jan 29];3:27-31. Available from: https://www.ijohr.org/text.asp?2017/3/1/27/210927


  Introduction Top


Gingival enlargements are frequently encountered in the oral cavity. These enlargements may be inflammatory, noninflammatory, or a combination of the two type.[1] Gingival enlargement may be esthetically displeasing, cause speech disturbances, masticatory disturbance, and impede effective tooth cleaning. It may also cause abnormal tooth movement or force the teeth out of alignment.

Some of these enlargements are localized reactive lesions which include focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma (POF).[2],[3],[4] The lesions are considered reactive because they are nonneoplastic in nature and not implicated with drug involvement. The duration of the lesion is often weeks to months due to the slow growth with mild symptoms, rarely painful but often interfere with adequate plaque control. Since their duration is long, it is not uncommon to see ulceration to the epithelial surface from trauma.[5]

These lesions may arise as a result of such irritants as microorganisms in plaque or from trauma, defective restorations, dental calculus, and iatrogenic factors.[4],[5] They are not considered neoplasms and have distinctive histopathology for identification. Although benign in nature, they do have a tendency toward recurrence with incomplete removal of the lesion or the local irritants involved at the site.[5] The ability of the clinician to obtain a good outcome involves proper planning with complete removal of the lesion and one of the treatment option is surgical excision.[5]

POF is a focal, reactive, nonneoplastic tumor-like growth of the soft tissue that often arises from the interdental papilla.[6] Literature reveals that various terminologies have been used to name POF, namely, peripheral fibroma, fibrous epulis, ossified fibrous epulis, peripheral cementifying fibroma, calcifying fibroblastic granuloma, or peripheral fibroma with calcification.[7] Ossifying fibromas of oral cavity can be divided into central type which arises from the endosteum or periodontal ligament and peripheral type which arises from the soft tissue.[7] About 60% of these gingival growth occur in the maxilla and more than 50% of all cases of maxillary POFs are found in the incisors and canine areas.[8] POF is an occasional growth of the anterior region of mandible and accounts for 3.1% of all tumors and 9.6% of the gingival lesions.[9] Due to their histopathological as well as clinical resemblance, POFs are thought to arise as pyogenic granuloma which undergoes fibrous maturation and subsequent calcification.[10] It affects both gender, but female predilection is more than male.[10] Racial predominance is 71% in white in contrast to 36% in black. The peak incidence occurs in the second and third decade of life.[11]

The clinical presentation of POF is sometimes confused with pyogenic granuloma, but it can be very well differentiated from other fibrous proliferative lesions by the presence of different types of calcifications such as mature lamellar bone, immature bone, and dystrophic calcification which are more common in initial lesions and even lamellar bone may be present in older lesions.[12]


  Case Reports Top


Case 1

A 26-year-old female seamstress presented to the Periodontology Clinic of University of Benin Teaching Hospital, Benin City, Edo State, Nigeria, with a slow growing, painless gingiva growth that was present in her left maxillary anterior region. The lesion started as a small nodule 2 years earlier and gradually increased in size with a history of slight bleeding on brushing. The patient did not give a history of trauma, injury, or food impaction. Patient history revealed that excision had been done twice before presentation. The first excision was a year after the onset of growth and the second excision was 6 months before presentation. Both excisions were done in different clinics by General Dental Practitioners in same location, but no histology report was requested of the excised lesion. The growth reoccurred in same area after the excisions. The patient also gave a history of use of oral contraceptives and been pregnant 6 months before presentation and had an evacuation done due to health reasons.

An intraoral examination revealed a nodular growth, pinkish red, nontender, firm in consistency, sessile in nature, arising on the labial gingiva of the interdental papilla of 21 and 22, measuring 1 cm by 1.5 cm [Figure 1]. The growth caused spacing between 21 and 22 and associated bleeding on probing. Radiography showed horizontal bone loss between the 21 and 22 and slight widening of periodontal space of 21 [Figure 1]. Based on the clinical and radiographic features, a provisional diagnosis of pyogenic granuloma was made. Differential diagnosis of peripheral giant cell granuloma and POF was considered. After performing oral prophylaxis, consent for the surgical procedure was obtained from the patient after proper counseling was done. Under local anesthesia, the lesion was completely excised, underlying surface was thoroughly curetted up to deepest possible tissue. Hemostasis was achieved and a periodontal dressing was placed. Medications prescribed included diclofenac 50 mg BD X 3/7, amoxicillin 500 mg TDS X 5/7, and metronidazole 400 mg TDS X 5/7. Postoperative instruction was given to the patient. The excised tissue was submitted to the Oral Pathology Department for histologic diagnosis. The patient was recalled after 1 week for the removal of the periodontal dressing and site showed uneventful healing.
Figure 1: Preoperative buccal, palatal, and radiographic view

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Histology section showed a reactive lesion with a covering of parakeratinized stratified squamous epithelium with foci of epithelial hyperplasia. There was underlying proliferation of fibrocollagenous connective tissue with infiltrates of chronic inflammatory cells and focal aggregates of basophilic calcific islands surrounded by cellular fibrous connective tissue [Figure 2]. A histologic diagnosis of POF was made. Periodic review was done at 1 week, 2 weeks, 1 month, 3 months, 6 months, 12 months, and 24 months [Figure 3] after treatment and revealed no recurrence of the lesion.
Figure 2: Histology slide low and high magnification

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Figure 3: One week 6 months and 24 months postoperative view

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Case 2

A 42-year-old female teacher presented in the Periodontology Clinic with a slow-growing gingival enlargement present in her left maxillary anterior region. The lesion started as a small nodule 4 years earlier and gradually increased in size, with no pain initially but with associated pain on presentation. The patient did not give a history of trauma, injury, or food impaction. The patient medical history was insignificant.

An intraoral examination revealed a nodular growth which was interfering with upper and lower lip seal and displacing 21 and 22, pinkish red, well demarcated, tender with firm pressure, firm in consistency, sessile in nature arising on the labial gingival of the interdental papilla of 11, 21, and 22 [Figure 4]. Measuring 2 cm × 2 cm, with associated mobility of 21 (Grade 1). Radiography showed horizontal bone loss of 11, 21, and 22 and associated widening of periodontal ligament space of 21 and 22 [Figure 4]. After performing oral propylaxis, consent for the surgical procedure was obtained from the patient after proper counseling was done. Under local anesthesia, the lesion was completely excised, intraoperatively revealed bony involvement, and 21 was extracted. Hemostasis was achieved and a periodontal dressing was placed. The excised tissue was submitted to the Oral Pathology Department for histologic diagnosis. Medications were analgesic: tablet diclofenac 50 mg BD X 3/7; antibiotics: capsule amoxicillin 500 mg TDS X 5/7 and tablet metronidazole 400 mg TDS X 5/7. Postoperative instruction was given to the patient. The patient was recalled after 1 week for the removal of the periodontal dressing and site showed uneventful healing. Histologic examination revealed a benign lesion composed of a covering parakeratinized stratified squamous epithelium and underlying dense fibrocollagenous connective tissue within which were trabeculae of bone. There was peripheral residual bone. There were areas with dense chronic inflammatory infiltrate [Figure 5]. A diagnosis of POF was made. Follow-up visits were arranged after 1 week, 1 month, 2 months, 3 months, 6 months, 12 months, and 24 months [Figure 6] to rule out recurrence. Removable denture was fabricated to replace the missing teeth [Figure 6].
Figure 4: Preoperative extraoral, intraoral, and radiographic views

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Figure 5: Histology slide low and high magnification

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Figure 6: Two months and 24 months postoperative view and removable denture in situ

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  Discussion Top


Localized gingival enlargements represent a group of lesions with distinctive clinical manifestations. They are reactive lesions emanating from the superficial fibers of periodontal ligaments. Different lesions with similar clinical presentations make it difficult to arrive at a correct diagnosis. POF is a nonneoplastic enlargement of the gingiva that is thought to be reactive in nature.[2],[4] Local irritants such as dental plaque, calculus, masticatory forces, ill-fitting dentures, and poor quality restorations have been implicated in the etiology of POF.[13]

There are two types of ossifying fibromas: the central type and the peripheral type. The central type arises from the endosteum or the periodontal ligament adjacent to the root apex and causes the expansion of the medullary cavity. The peripheral type occurs solely on the soft tissues covering the tooth-bearing areas of the jaws.[14] Pathogenesis of POF is uncertain, they are thought to arise from periosteal and periodontal membrane.[15],[16] There are two school of thoughts regarding the histogenesis of POF. The first one explains that POF develops from the cells of periodontal ligament or periosteum. Chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue and results in the initiation of formation of bone or dystrophic calcification. According to the second school of thought, POF lesions were simply a more mature variant of pyogenic granuloma.[17]

POF most often occurs in the second decade of life with a female predilection, with peak occurrence in the second and third decade of life,[18] and this occurrence suggests hormonal influences.[19] The female to male ratio described in the literature varies from 1.22:1 to 4.3:1.[6] In this case report, case #1 was 26 years which was within the prevalent age group and case #2 was 42 years and both cases were females.

Approximately, 60% of POF occurs in the maxilla where >50% occurs in the anterior region [8],[19] and this was seen in both case #1 and case #2 occurring in the anterior maxilla region [Figure 1] and [Figure 4]. POF exclusively occurs on the gingiva.[20] Most of the time, the underlying bone will not be affected. Several cases of tooth migration and bone destruction have been reported.[21] This was seen in our report in case #1 showing bone destruction [Figure 1] and case #2 showing tooth migration and bone destruction [Figure 4].

Clinically, the lesion appears as a nodular mass which may be pedunculated or sessile, pink to red and surface is usually but not always ulcerated. In the both cases reported, the lesion occurred in female patients, in anterior maxilla region, and appeared as a nodular pink to red growth without ulceration.

Radiographically, the features of POF tend to vary. Foci of calcifications have been reported to be scattered in the central area of the lesion but not in all lesions. Underlying bone involvement is usually not visible on a radiograph; however, in rare instances, superficial erosion of bone can be seen.[22]

Periodontal care of gingival enlargement entails a thorough history and examination, and it is important to establish a differential diagnosis. In case #1, a differential diagnosis of pyogenic granuloma, peripheral giant cell granuloma, and POF was performed, while in case #2, a differential diagnosis of POF and peripheral cementifying fibroma was performed. Because the clinical appearance of these various lesions can be remarkably similar, classification is based on their distinct histologic differences.

POF is definitively diagnosed through a histopathological examination. The histopathological examination usually shows the following features: benign fibrous connective tissue with varying fibroblast, myofibroblast and collagen content, sparse to profuse endothelial proliferation, and mineralized material that may represent mature, lamellar or woven osteoid, cementum-like material, or dystrophic calcifications. Acute or chronic inflammatory cell infiltration can also be observed in these lesions.[23] In our report, histopathological result showed parakeratinized stratified squamous epithelium with fibrocollagenous connective tissue with chronic inflammatory infiltrate which confirm the diagnosis of lesion as POF in both case #1 [Figure 2] and case #2 [Figure 5].

Some authors believe that POF initially develops as pyogenic granuloma, which undergoes fibrous maturation and then calcification.[17] Treatment consists of the removal of the local irritants by way of scaling and root planing and surgical intervention that ensures thorough excision of the lesion including the involved periosteum and the periodontal ligament. Early recognition and definitive surgical intervention result in less risk of tooth and bone loss.[19] In case #2, the lesion was excised with extraction of involved tooth [Figure 6]. It is important to obtain complete removal of gingival lesions down to normal underlying tissue to reduce recurrence as well as thorough debridement of stem cells in the periodontal ligament space and periosteum to reduce recurrence rate.[5]

After the removal of these gingival enlargements, a follow-up is required to ensure the early diagnosis of any recurrence.[24] POF has a very high rate of recurrence ranging from 8% to 20% and repeated recurrences are not uncommon, with studies reporting 16%–20% recurrence.[25] Due to the high rate of recurrence, close postoperative monitoring is required in all cases of POF.[6] POF recurs due to (1) the incomplete removal of the lesion as seen in case #1; (2) the 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, usually an interdental area.[26] Both cases did not show clinical signs of recurrence after nearly 2 years of follow-up.


  Conclusion Top


Apart from gingival enlargement being esthetically displeasing, causing pathological migration of teeth and hindering ability to maintain a good oral hygiene, a higher chance of recurrence mandates histopathologic examination and frequent recall visits. POF should be considered as one of the diagnoses in cases of esthetically displeasing and recurrent maxillary anterior region gingival enlargement. This report reinforces the importance of arriving at definitive diagnosis to provide proper treatment and for adequate monitoring protocols.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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