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many types of localized reactive lesions may occur on the gingiva , including focal fibrous hyperplasia , pyogenic granuloma , peripheral giant cell granuloma and peripheral cemento - ossifying fibroma [ pcof ] .
pcof is a common gingival growth that is thought to be either reactive or neoplastic in nature .
it is widely considered that this lesion originates from the cells of the periodontal ligament,[26 ] and is often associated with trauma or local irritants , such as subgingival plaque , calculus , dental appliances , and poor - quality dental restorations .
clinically , pcof 's are sessile or pedunculated , usually ulcerated , and erythematous or exhibiting a color similar to the surrounding gingiva .
diagnosis of the pcof based only on clinical aspects can be difficult and histopathological examination of the surgical specimen is mandatory for an accurate diagnosis .
recurrence rate of the pcof has been considered high . in the series of cundiff ,
16% of the cases recurred , while in a series of 50 cases reported by eversole and rovin , the recurrence rate was 20% .
the purpose of this article is to present a recurrent case of pcof and to highlight the importance of early diagnosis with proper surgical excision and aggressive curettage of the adjacent tissues to prevent its recurrence .
a 13 year old male reported with a slow growing asymptomatic growth on the anterior region of his hard palate .
the growth was then surgically excised by the dentist , and histopathologically diagnosed as peripheral ossifying fibroma . after a period of 9 months he noticed another asymptomatic growth on the same region again started as a peanut size growth and
he also gave history of trauma to the same region by fish bone 1 year back .
intraoral examination revealed a well - circumcised , erythematous sessile growth on the hard palate adjacent to 11 and 12 , measuring about 2.5  2 cm in diameter and originating from interdental papilla .
[ figures 1 and 2 ] it was firm in consistency and non - tender .
maxillary occlusal and iopa in relation to 11 & 12 were done and no radiological sign of bone involvement was noted . clinical intraoral image of the growth [ frontal view ] clinical intraoral image of the growth [ lateral view ] clinically , differential diagnosis included traumatic fibroma , peripheral cemento - ossifying fibroma , peripheral giant cell granuloma and pyogenic granuloma . under local anesthesia ,
[ figure 3 ] histopathological examination of the lesion revealed stratified squamous epithelium overlying the cellular connective tissue stroma with calcifications .
[ figure 4 ] many round to oval haematoxophillic calcified masses were seen resembling cementum like material .
excised specimen measuring about 2.5  2 cm in diameter photomicrograph of histopathological examination of the lesion showing bony trabeculae within fibrocellular connective tissue stroma covered by stratified squamous epithelium [ hematoxylin and eosion stain , 10 ]
many names have been given to similar lesions , such as epulis , peripheral fibroma with calcification , peripheral ossifying fibroma , calcifying fibroblastic granuloma , peripheral cementifying fibroma , peripheral fibroma with cementogenesis and peripheral cemento - ossifying fibroma [ pcof ] .
the sheer number of names used for fibroblastic gingival lesions indicates that there is much controversy surrounding the classification of these lesions . although the etiopathogenesis of pcof is uncertain some investigators consider it a neoplastic process , while other argue it is a reactive process ; however , in either case , the lesion is thought to arise from the cells of the periodontal ligament due to trauma or local irritantation such as by dental plaque , microorganisms , masticatory forces , ill - fitting and poor quality dentures . the etiology behind present case can be trauma due to fish bone .
origin from the periodontal ligament has been suggested by kumar et al . in 2006 .
their reasons for such hypothesis include occurrence of the peripheral ossifying fibroma in the gingiva [ interdental papilla ] , the proximity of the gingiva to the periodontal ligament and the presence of oxytalan fibers within the mineralized matrix of some lesions .
excessive proliferation of mature fibrous connective tissue is a response to gingival injury , gingival irritation , subgingival calculus or foreign body in the gingival sulcus .
chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue which initiates formation of bone or dystrophic calcification .
it has therefore been suggested that the lesion may be caused by fibrosis of granulation tissue .
hormonal influences may play a role too , as the lesions have shown a female predilection , with increasing occurrence in the second decade of age and declining incidence after the third decade . in one isolated case of multicentric pcof , kumar et al . noted the presence of such a lesion at an edentulous site in a 49-year - old woman , which once again raises questions regarding the pathogenesis of this type of lesion .
according to cuisia and brannon , the prevalence of this tumor in children aged 5 to 9 years is 10% .
in contrast , kenney et al . reported a 1.9% prevalence in children aged 0 to 9 years .
with respect to race , there is a predominance in whites [ 71% ] , compared to blacks [ 36% ] .
it may occur at any age range , but exhibits a peak incidence between the second and third decade .
however neville et al . sated that pcof predominantly affects adolescents and young adults , with peak prevalence between 10 to 19 years of age , as seen in the present case .
clinically , pcof manifests as a pedunculated or a sessile nodular mass , which usually originates in the interdental papilla .
most tumors measure less than 2 cm in diameter , although lesions larger than 10 cm are occasionally observed .
about 60% of the tumors occur in the maxilla and more than 50% of all cases affect the region of the incisors and canines .
pcof can show diffuse radiopaque calcifications , but not all lesions exhibit these radiographic characteristics .
a case of severe destruction of adjacent bone structures has been reported in the literature .
benign fibrous connective tissue with varying content of fibroblasts , myofibroblasts and collagensparse to profuse endothelial proliferationmineralized material which may represent mature , lamellar or woven osteoid , cementum like material or dystrophic calcifications . acute or chronic inflammation related findings can also be identified in lesions . 
 
benign fibrous connective tissue with varying content of fibroblasts , myofibroblasts and collagen sparse to profuse endothelial proliferation mineralized material which may represent mature , lamellar or woven osteoid , cementum like material or dystrophic calcifications . acute or chronic inflammation related findings can also be identified in lesions .
orkin and aimadas emphasized the importance of histopathological examination to confirm the diagnosis of pcof , which clinically resembles a pregnancy tumor , epulis fibrosa , inflammatory hyperplasia , or peripheral and central giant cell granuloma .
the recurrence has been attributed to incomplete initial removal , repeated injury , and/or the persistence of the local irritants .
the rate of recurrence has been reported to vary from 8.9% to 20% [ ( bhaskar and jacoway , 1966 ; kenney et al . , 1989 ; eversole and rovin , 1972 ) ] .
the average time interval for the first recurrence is 12 months [ das and azhar , 2009 ] .
recurrence in the present case can be due to previous incomplete surgical removal of the lesion . to conclude , peripheral cemento - ossifying fibroma is a non - neoplastic enlargement of the gingiva that is classified as a reactive hyperplastic inflammatory lesion .
it is possible to misdiagnose pcof from the other reactive lesions arising from the gingiva .
we describe a case of pcof in a 13-year - old male , recurred probably due to an inappropriate surgical excision .
complete excision with aggressive curettage of the adjacent tissues are essential for prevention of its recurrence .
peripheral cemento - ossifying fibroma [ pcof ] is a reactive gingival overgrowth occurring frequently in the maxillary anterior region in teenagers and young adults . here 
 , we report a case of pocf in a 13-year - old male , which was previously surgically excised and had recurred after a period of 9 months . 
 pcof should be considered in differential diagnosis of such reactive hyperplastic lesions originating from the gingiva . 
 hence , early diagnosis with proper surgical excision and aggressive curettage of the adjacent tissues are essential for prevention of recurrence .