many types of localized reactive lesions may occur on gingiva , including focal fibrous hyperplasia , pyogenic granuloma , peripheral giant cell granuloma and peripheral cement - ossifying fibroma ( pcof ) peripheral cement - ossifying fibroma being a common gingival growth , it is thought to be either reactive or neoplastic in nature . it is widely accepted that this lesion may originate from the cells of periodontal ligament , and is often associated with irritants such as calculus , dental appliances , poor quality dental restorations , plaque or may occur as a result of trauma . the close proximity to the periodontal tissues pcofs are sessile or pedunculated , usually ulcerated , erythematous or may exhibit a color similar to the surrounding gingiva . most of these lesions are < 2 cm in size , although lesions > 10 cm are occasionally observed . female predilection as high as 4.3:1 has been reported with a peak incidence in the second decade and a declining incidence in later years . diagnosis of pcof based only on the clinical history is difficult and histopathological evaluation of the surgical specimen is necessary for an accurate diagnosis . the recurrence rate of pcof is considered to be high and is reported at 9% , 14% and 20% and hence regular follow - up is mandatory . we present here a recurrent case of pcof and also highlight the importance of early diagnosis with proper surgical excision and aggressive curettage of the adjacent tissues to prevent its recurrence . a 42-year - old male patient reported to our dental clinic at airoli , navi mumbai with complaint of a growth on his maxillary gingiva since 8 months . the patient gave a history of a similar growth 2 years back , which was then excised by a dentist but was not histopathologically evaluated . the patient was concerned about the pathogenesis of the lesion since it had recurred once again and had discussed the possibility of the lesion being a malignancy . intra - oral examination revealed a well circumscribed erythematous growth between maxillary right premolars , measuring approximately 1.2 cm  1 cm in diameter and originating from the interdental papilla [ figure 1 ] . intra - oral periapical radiograph in relation to the maxillary right premolars no showed no abnormality . intra - oral photograph showing growth between the maxillary right bicuspids clinical differential diagnosis included pcof , peripheral giant cell granuloma , traumatic fibroma and pyogenic granuloma . histopathological examination of the lesion revealed a parakeratinized stratified squamous epithelium with long and slender rete ridges . an 8 months postsurgical follow - up showed no evidence of recurrence [ figure 3 ] . epulis , peripheral fibroma with calcifications , calcifying fibroblastic granuloma , peripheral cementifying fibroma , peripheral ossifying fibroma , peripheral fibroma with cementogenesis and pcof are few of the many names given to similar lesions . the number of names used for fibroblastic gingival lesions indicates that there is a lot of controversy surrounding the classification of these lesions . although the etiopathogenesis of pcof is uncertain , some investigators consider it as a neoplastic process while others call it a reactive process . anyway , the lesion is thought to arise from the cells of the periodontal ligament due to trauma or local irritational factors such as plaque or ill - fitting or poor quality dentures . in the present case hormonal influences may play a role too , as these lesions have shown a female predilection , with an increased occurrence in the second decade and a declining incidence after the third decade . in a case published by kumar et al . , the presence of multicentric pcof at an edentulous site of a 49-year - old woman raises a question regarding the pathogenesis of this lesion . peripheral cement - ossifying fibroma is considered to arise from the cells of the periodontal ligament . as suggested by kumar et al . in 2006 , this may be due to the proximity of the gingiva to the periodontal ligament and the presence of oxytalon fibers within the mineralized matrix of the same lesions . excessive proliferation of the mature matrix , connective tissue is a response to gingival injury , subgingival plaque or calculus or a foreign body in the gingival sulcus . furthermore , chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue , which could initiate the formation of bone or dystrophic calcifications . it is therefore suggested that this lesion may be caused by fibrosis of granulation tissue . with respect to race , there is a predominance in whites ( 71% ) , as compared to blacks ( 36% ) . it may occur at any age but a peak incidence is seen in the second and third decade . approximately , 60% of the pcofs occur in the maxilla , and they occur more often in the anterior than in the posterior area with 5560% presenting in the incisor - cuspid region . in the present case , the patient was a 42-year - old male patient with the lesion seen in the maxillary bicuspid region . . they may show radio opaque foci of calcification , but not all lesions exhibit radiographic characteristics . the features observed during microscopic evaluation are a benign fibrous connective tissue stroma with a varying content of fibroblasts , myofibroblasts , and collagen . mineralized material varies in the form of lamellar or woven osteoid to cementum like material or dystrophic calcification . the recurrence rate of pcof is high and is probably due to incomplete removal of the lesion , repeated injury or persistence of local irritants . the rate of recurrence has been reported to vary from 8.9% to 20% ( bhaskar and jacoway 1966 ; kenny et al . recurrence in the present case was probably due to previous incomplete removal of the lesion and the presence of local irritants such as plaque and calculus . many cases will progress for long periods before the patient seeks treatment because of lack of symptoms associated with the lesion . we describe a case of pcof in a 42-year - old male , which recurred probably due to incomplete surgical removal along with the presence of local irritating factors . complete excision with aggressive curettage of the adjacent tissues is essential to prevent any recurrence . close postoperative follow - up is required because of the growth potential and 820% recurrence rate .
peripheral cement - ossifying fibroma ( pcof ) is a rare osteogenic neoplasm that ordinarily presents as an epulis - like growth . 
 it frequently occurs in maxillary anterior region in teenagers and young adults . 
 we report a case of pcof in a 42-year - old male , which was previously surgically excised and recurred after a period of 2 years . 
 pcof should be considered in the differential diagnosis of reactive hyperplastic lesions originating from gingiva . 
 hence , early diagnosis with proper surgical excision and aggressive curettage of the adjacent tissues is essential for prevention of recurrence .