LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Ray Murphy Date: 7/24/09 Region: Providence
Article title: Gingival Enlargement Associated With a Partially Erupted Mandibular Molar
Author(s): Catherine Flaitz, DDS,MS
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 23:5, 3
Year: 2001
Major topic: Peripheral odontogenic fibroma (PodF)
Minor topic(s): -
Type of Article: Case Report
Main Purpose: Discuss the clinical and microscopic features of a PodF in a 13yo male.
Overview of method of research: 13yo male evaluated for soft tissue growth overlying his mandibular second molar.
Findings: A POdF is a rare tumor that exclusively exists in the soft tissues covering the tooth bearing areas of the jaws. It is described as a firm, sessile enlargement of the soft tissue with a pink, smooth, nonulcerated mucosal surface. They range in size from approx. .5cm-3.5cm. It is found throughout the dental arches with an affinity for the buccal gingival of the mandible. It typically presents as a solitary lesion. This 13 yo male patient presented with an asymptomatic fibrous overgrowth on his mandibular second molar. IOE revealed a 2cm x 1.5 cm firm, pinkish gray, smooth, dome shaped lesion arising from the posterior lingual gingival/retromolar pad. The lesion was delaying the second molar from fully erupting. Also, the maxillary second molar was displaced lingually into a cross-bite as a result of occluding on the lesion. Radiographically the second molar had normal root development and open apices. No bone involvement was noticed. EOE revealed multiple hypertrophic scars and keloids on the patients extremities. Treatment of the lesion was excisional biopsy to allow the second molar to completely erupt. Histologically, the lesion was comprised of well vascularized, fibrous connective tissue with multinucleated giant cells. There was no evidence of calcifications in the stroma. Ten months after the excision of the lesion there was no recurrence.
Key points in the article discussion: The POdF is an uncommon gingival tumor that is similar to the central odontogenic fibroma. Whether the lesion is a true neoplasm, or a reactive hyperplasia has not yet been decided. People of all ages are susceptible to PodF’s, with the largest occurrence being before the age of 20(although this may be underestimated b/c not an operculum are submitted for histological differentiation). Treatment of choice is surgical excision. While the prognosis of the lesion after excision is excellent, it’s behavior is not totally understood. Recurrence happens 38% of the time, usually within 1-4 years. It is suspected that recurrence following the first year after excision is due to incomplete removal of the entire lesion initially. Differential diagnosis is extensive, including reactive hyperplasias, hamartomas, neoplasms, irritation fibromas, POF, pericoronal hamartoma, etc. The most common gingival enlargement overylying a molar is focal fibrous hyperplasia of the operculum. The difference between an operculum and a PodF is that a PodF will hinder the complete eruption of the affected molar, an operculum does not.
Summary of conclusions: In conclusion, the PodF is a soft tissue lesion that can affect the eruption of whichever tooth it is associated with. The differential diagnosis are extensive, but a diagnosis can be narrowed down by thorough IOE and histological differentiation. Histologically, the PodF and the pericoronal hamartoma are extremely similar, which could possibly mean that they represent a clinical spectrum of the same disease, ESPECIALLY when it occurs in children. The treatment of choice is excisional biopsy to allow the affected molar to continue erupting. Following excision, normal eruption of the affected molar was noted in 95% of cases.
Assessment of article: Good article. Clinically relevant. Listed numerous differential diagnosis of PodF and why it was different. Overall a good case report.
Thursday, July 23, 2009
Palatal Blue Nevus In Children 7/24/09
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Murphy Date:7/24/09 Region: Prov.
Article title: Palatal Blue Nevus In Children
Author(s): Flaitz, Catherine, DDS
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 23:4, 2
Year: 2001
Major topic: Palatal Blue Nevus
Minor topic(s): Other soft tissue pigmentations
Type of Article: Case Report
Main Purpose: Review a case of blue nevus(BN) in a child
Overview of method of research: N/A
Findings: Except for vascular entities, blue lesions are relatively uncommon in a child’s oral cavity. They are mostly found on the skin. In this case, a 7 yo female presented with an asymptomatic, non-blanching, smooth, bright blue oval macule measuring 7mm x 4mm on her palate. There was no history of trauma. Treatment was excisional biopsy. Histologically, there was heavily pigmented spindle shaped cells with dendritic extensions aligned parallel to the epithelium.
Key points in the article discussion: Oral nevi are farely rare, with a prevalence of .1% in the general population. The BN is the second most common type of nevi, accounting for 36% of all nevi found. BN present as a solitary blue-gray macule that’s slightly raised, less than 6mm in size, regular margins, and a smooth surface. The most common site for a BN is the palate, accounting for 75% of the cases, followed by the labial mucosa. There’s a slight female predilection, but mostly in the third and forth decades. Only 2% of BN are seen in children. While the treatment of choice is surgical excision, this pratice is somewhat controversial. It’s recommended because the lesion is constantly subjected to trauma, which makes it hard to monitor changes in size and appearance, which may mimic melanoma. While malignant transformation of BN has been implicated in children, there are no intra oral examples of this. Some risk factors of malignant transformation include a new or changing nevus, the presence of multiple nevi, fair skin, family history of melanoma, congenital nevus, and immunosuppression. Differential diagnosis of BN includes amalgam tattoo, melanotic macule, and various vascular anomalies. In terms of amalgam tattoo, a good history of trauma and past dental procedures is important.
Summary of conclusions: In summary, the BN is an extremely rare lesion seen in the oral cavity of a child. Take a good medical history to rule out other possible causes and diagnosis, and when in doubt, excise the entire lesion. This is because should the lesion turn malignant, the overall 5 year survival rate for oral melanomas is less then 15%.
Assessment of article:Good article. It was quick to the point. Easy to read. Good summary.
Dental Residency Program
Literature Review Form
Resident: Murphy Date:7/24/09 Region: Prov.
Article title: Palatal Blue Nevus In Children
Author(s): Flaitz, Catherine, DDS
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 23:4, 2
Year: 2001
Major topic: Palatal Blue Nevus
Minor topic(s): Other soft tissue pigmentations
Type of Article: Case Report
Main Purpose: Review a case of blue nevus(BN) in a child
Overview of method of research: N/A
Findings: Except for vascular entities, blue lesions are relatively uncommon in a child’s oral cavity. They are mostly found on the skin. In this case, a 7 yo female presented with an asymptomatic, non-blanching, smooth, bright blue oval macule measuring 7mm x 4mm on her palate. There was no history of trauma. Treatment was excisional biopsy. Histologically, there was heavily pigmented spindle shaped cells with dendritic extensions aligned parallel to the epithelium.
Key points in the article discussion: Oral nevi are farely rare, with a prevalence of .1% in the general population. The BN is the second most common type of nevi, accounting for 36% of all nevi found. BN present as a solitary blue-gray macule that’s slightly raised, less than 6mm in size, regular margins, and a smooth surface. The most common site for a BN is the palate, accounting for 75% of the cases, followed by the labial mucosa. There’s a slight female predilection, but mostly in the third and forth decades. Only 2% of BN are seen in children. While the treatment of choice is surgical excision, this pratice is somewhat controversial. It’s recommended because the lesion is constantly subjected to trauma, which makes it hard to monitor changes in size and appearance, which may mimic melanoma. While malignant transformation of BN has been implicated in children, there are no intra oral examples of this. Some risk factors of malignant transformation include a new or changing nevus, the presence of multiple nevi, fair skin, family history of melanoma, congenital nevus, and immunosuppression. Differential diagnosis of BN includes amalgam tattoo, melanotic macule, and various vascular anomalies. In terms of amalgam tattoo, a good history of trauma and past dental procedures is important.
Summary of conclusions: In summary, the BN is an extremely rare lesion seen in the oral cavity of a child. Take a good medical history to rule out other possible causes and diagnosis, and when in doubt, excise the entire lesion. This is because should the lesion turn malignant, the overall 5 year survival rate for oral melanomas is less then 15%.
Assessment of article:Good article. It was quick to the point. Easy to read. Good summary.
Wednesday, July 22, 2009
Traumatic herniation of the buccal fat pad
Resident: Tyler Roberts
Article: Traumatic herniation of the buccal fat pad
Author: Horie. et al
Journal: Pediatric Dentistry
Volume # 23:3, pages: 249 - 251
Year: 2001
Major topic: Traumatic herniation of the buccal fat pad
Type of article: case review
Purpose: To diagnose and treat this rare truamatic lesion found most commonly in children
Kep pts/findings
The buccal fat pad consist of 4 segments: the ptergoid, buccal, superficial and deep temporal areas. It lies wedged between the masseter and the buccinator. It extends on one end from the anterior region of the masseter through to the retromolar region of the mandible. Up until the year 2000, only 31 cases of traumatic herniation of the buccal fat pad has ever been reported.
Case 1
A 10 month old reportedly fell down while holding chopsticks in his mouth. The chopsticks did not break and minimal bleeding was noted at the time of injury. On examination a laceration was found present on his right buccal mucosa, inferior and distal to the parotid papilla. From the laceration a reddish-yellow soft pedunculated mass measuring 1.0 x .5 x.5 cm was protruding. The working diagnoses was given. The treatment included irrigating and reapproximating the margins and placing 4-0 nylong sutures while under local anesthesia. An antibiotic was given for four days and in two weeks the lesion had completely healed.
Case 2
A 1 year 9 month old had fallen while holding her toothbrush in the mouth. The tooth brush was not broken and minimal bleeding was present. The following morning a large mass extended from the right buccal mucosa into the oral cavity. The pedunculated mass appeared to be reddish brown in color with the dimension of 1.5 x 1.0 x 1.0 cm. and located just inferior to the parotic papilla. The working diagnosis was given. Three days later the mass was excised at the hospital under general anesthesia. The patient recieved. 4-0 nylon sutures and was placed on antibiotics for 5 days. One month later everything appeared to be healed with no cosmetic defects.
summary of conclusions:
Almost all cases of buccal herniation of the fat pad have been due to a traumatic injury. It most frequently occurs in infants and small children under the age of 4. The site of the lesion is almost always along the oclussal table near the parotid papilla. Histologically this lesion is not capsulated and composed of mature adipose tissue. Treatment includes excision or reaprroximation of the pad depending on size. No history of recurrence has been reported after treatment.
Article: Traumatic herniation of the buccal fat pad
Author: Horie. et al
Journal: Pediatric Dentistry
Volume # 23:3, pages: 249 - 251
Year: 2001
Major topic: Traumatic herniation of the buccal fat pad
Type of article: case review
Purpose: To diagnose and treat this rare truamatic lesion found most commonly in children
Kep pts/findings
The buccal fat pad consist of 4 segments: the ptergoid, buccal, superficial and deep temporal areas. It lies wedged between the masseter and the buccinator. It extends on one end from the anterior region of the masseter through to the retromolar region of the mandible. Up until the year 2000, only 31 cases of traumatic herniation of the buccal fat pad has ever been reported.
Case 1
A 10 month old reportedly fell down while holding chopsticks in his mouth. The chopsticks did not break and minimal bleeding was noted at the time of injury. On examination a laceration was found present on his right buccal mucosa, inferior and distal to the parotid papilla. From the laceration a reddish-yellow soft pedunculated mass measuring 1.0 x .5 x.5 cm was protruding. The working diagnoses was given. The treatment included irrigating and reapproximating the margins and placing 4-0 nylong sutures while under local anesthesia. An antibiotic was given for four days and in two weeks the lesion had completely healed.
Case 2
A 1 year 9 month old had fallen while holding her toothbrush in the mouth. The tooth brush was not broken and minimal bleeding was present. The following morning a large mass extended from the right buccal mucosa into the oral cavity. The pedunculated mass appeared to be reddish brown in color with the dimension of 1.5 x 1.0 x 1.0 cm. and located just inferior to the parotic papilla. The working diagnosis was given. Three days later the mass was excised at the hospital under general anesthesia. The patient recieved. 4-0 nylon sutures and was placed on antibiotics for 5 days. One month later everything appeared to be healed with no cosmetic defects.
summary of conclusions:
Almost all cases of buccal herniation of the fat pad have been due to a traumatic injury. It most frequently occurs in infants and small children under the age of 4. The site of the lesion is almost always along the oclussal table near the parotid papilla. Histologically this lesion is not capsulated and composed of mature adipose tissue. Treatment includes excision or reaprroximation of the pad depending on size. No history of recurrence has been reported after treatment.
Highly Aggressive Brown Tumor in the Jaw Associated with Tertiary Hyperparathyroidism
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 7/24/2009
Article title: Highly Aggressive Brown Tumor in the Jaw Associated with Tertiary Hyperparathyroidism
Author(s): Pinto LP, Cherbinim K, Salum FG, et al.
Journal: Pediatric Dentistry
Volume (number): 28(6)
Date: 2006
Major topic: Brown Cell tumor diagnosis and management
Type of Article: Case Report
Main Purpose: This case report describes a 12 year old female with an aggressive brown tumor associated with tertiary hyperparathyroidism and treated medically with calcitonin and corticosteroids.
Review of Case: Brown tumors are central giant cell granulomas which develop as a result of untreated hyperparathyroidism. The tumor affects mainly children and young adults with a female predilection. It represents less than 7% of all benign jaw lesions. The primary form of hyperparathyroidism relates of a hyperplastic or neoplastic parathyroid gland. Secondary occurs due to chronic renal insufficiency and tertiary is secondary with spread of parathyroid glands to other sites. Brown tumors occur in 1.5-1.7% of patients with chronic renal insufficiency. Treatment is focused around solving the underlying endocrine abnormatlity. The brown color is derived from hemorrhay and hemosiderin infiltration of the lesion.
The 12 yewar old female presented with right buccal lesion noted 3 months ago, and had a firm consistency. The panorex revealed a large osteolytic lesion. Blood tests revealed elevated blood creatinine levels, parathyroidhormone and alkaline phosphatase. Histology confirmed the diagnosis. Other radiographs showed lesions on the left humerus, pelvis, and right femur. Dialysis controlled the creatinine levels and a parathyroidectomy of the upper left gland reduced the PTH levels. Due to the extension of the lesions, treatment with inhaled salmon calcitonin, and intralesional triancinolone once per week was undertaken. After 12 weeks, the lesion became calcified. A renal transplant was performed and the patient is free of clinical and radiographic signs of relapse.
Discussion: In patients with renal insufficiency, PTH contrations become elevated in response to hypocalcemia, hyperphosphatemia, and vitamin D defiency. Parathyroid gland increases in size and may enlarge or develp neoplasia. In some cases partial to complete parathyroidectomy is effective in reducing PTH concenctration and treating the lesion. This study illustrates the first casein which both calcitonin and intralesional corticosteroid injections. The calcitonin blocks the effects of PTH and the corticosteroids prevent osteoclastic giant cell activity.
Key points/Summary : Brown tumors are central giant cell granulomas with an underlying parathyroid disorder. Non-surgical intervention using a combination of inhaled calcitonin and intra-lesional injections successfully treated this case
Assessment of article: Good article.
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 7/24/2009
Article title: Highly Aggressive Brown Tumor in the Jaw Associated with Tertiary Hyperparathyroidism
Author(s): Pinto LP, Cherbinim K, Salum FG, et al.
Journal: Pediatric Dentistry
Volume (number): 28(6)
Date: 2006
Major topic: Brown Cell tumor diagnosis and management
Type of Article: Case Report
Main Purpose: This case report describes a 12 year old female with an aggressive brown tumor associated with tertiary hyperparathyroidism and treated medically with calcitonin and corticosteroids.
Review of Case: Brown tumors are central giant cell granulomas which develop as a result of untreated hyperparathyroidism. The tumor affects mainly children and young adults with a female predilection. It represents less than 7% of all benign jaw lesions. The primary form of hyperparathyroidism relates of a hyperplastic or neoplastic parathyroid gland. Secondary occurs due to chronic renal insufficiency and tertiary is secondary with spread of parathyroid glands to other sites. Brown tumors occur in 1.5-1.7% of patients with chronic renal insufficiency. Treatment is focused around solving the underlying endocrine abnormatlity. The brown color is derived from hemorrhay and hemosiderin infiltration of the lesion.
The 12 yewar old female presented with right buccal lesion noted 3 months ago, and had a firm consistency. The panorex revealed a large osteolytic lesion. Blood tests revealed elevated blood creatinine levels, parathyroidhormone and alkaline phosphatase. Histology confirmed the diagnosis. Other radiographs showed lesions on the left humerus, pelvis, and right femur. Dialysis controlled the creatinine levels and a parathyroidectomy of the upper left gland reduced the PTH levels. Due to the extension of the lesions, treatment with inhaled salmon calcitonin, and intralesional triancinolone once per week was undertaken. After 12 weeks, the lesion became calcified. A renal transplant was performed and the patient is free of clinical and radiographic signs of relapse.
Discussion: In patients with renal insufficiency, PTH contrations become elevated in response to hypocalcemia, hyperphosphatemia, and vitamin D defiency. Parathyroid gland increases in size and may enlarge or develp neoplasia. In some cases partial to complete parathyroidectomy is effective in reducing PTH concenctration and treating the lesion. This study illustrates the first casein which both calcitonin and intralesional corticosteroid injections. The calcitonin blocks the effects of PTH and the corticosteroids prevent osteoclastic giant cell activity.
Key points/Summary : Brown tumors are central giant cell granulomas with an underlying parathyroid disorder. Non-surgical intervention using a combination of inhaled calcitonin and intra-lesional injections successfully treated this case
Assessment of article: Good article.
Dentigerous Cysts in Primary Dentition: Report of 2 cases
Resident: Tyler Roberts
Author: Delbem et al
Journal: Pediatric Dentistry
Volume # 28:3, pages 269-271
Year: 2006
Major topic: Dentigerous cyst in children/adolescents
Type of article: case review
Kep pts/findings:
Dentigerous cyst are benign odontogenic cysts associated with the crowns of unerupted permanent teeth. They are usually single in occurrence and located in the mandible. They are the second most common type of odontogenic cyst, accounting for 49% of all cystic lesions. They are most common in male patients and frequently occur during the second or third decade of life. These lesions are usually asymptomatic and discovered at the time of routine radiographic examination. If the cyst is greater than 2cm in diameter swelling, mild sensitivity, tooth mobility and displacement may be observed. Radiographically these lesions are symmetric, well-defined, unilocular surrounding the crown of the unerupted tooth. Possible complications include: permanent bone deformation or fracture, expansive bone destruction, loss of permanent teeth, development of squamous cell carcinoma
Case 1
A 10 year old presented with swelling on the left side of his jaw. An intraoral examination revealed bulging along the cortical bone that extended from his mandibular left first bicuspid to the distal of the permanent mandibular left first molar and a radiographic lesion that appeared unilocular, radiolucent and was associated with the dental crown of the bud of the mandibular left second molar. A differential diagnosis suggested a dentigerous cyst. Marsupialization was chosen as treatment. The primary mandibular left second molar was extracted, the lesion was decompressed and a space maintenance appliance was inserted. The parents were told to irrigate the lesion with listerine solution and clean the appliance daily. A histopathologic examination revealed that the lesion was indeed a dentigerous cyst.
Case 2
An 8 year old boy, was found to have a volumetric increase of the lingual cortical plate in the region of the primary mandibular right lataeral incisor which showed prolonged retention. Radiographically a well-defined, unilocular, radiolucent lesion was present surrounding the bud of the permanant mandibular right lateral incisor. The lesion appeared to be causing root resportion of the primary lateral incisor and canine. The working diagnosis was a dentigerous cyst. Treatment included extraction of the primary mandibular right lateral incisor and primary canine as well as total enucleation of the cyst due to the small size. Stitches were placed and removed seven days later and seven months later eruptive movements of the permanent right lateral incisor was present along with new bone neoformation was visible in the area.
Summary of conclusions: Dentigerous cysts are benign and asymptomatic. Because they are common among cyst they should not be overlooked at the time of routine radiographic examination. Small cyst are most likely to undergo complete enucleation while larger cyst may require decompression for healing to take place.
Author: Delbem et al
Journal: Pediatric Dentistry
Volume # 28:3, pages 269-271
Year: 2006
Major topic: Dentigerous cyst in children/adolescents
Type of article: case review
Kep pts/findings:
Dentigerous cyst are benign odontogenic cysts associated with the crowns of unerupted permanent teeth. They are usually single in occurrence and located in the mandible. They are the second most common type of odontogenic cyst, accounting for 49% of all cystic lesions. They are most common in male patients and frequently occur during the second or third decade of life. These lesions are usually asymptomatic and discovered at the time of routine radiographic examination. If the cyst is greater than 2cm in diameter swelling, mild sensitivity, tooth mobility and displacement may be observed. Radiographically these lesions are symmetric, well-defined, unilocular surrounding the crown of the unerupted tooth. Possible complications include: permanent bone deformation or fracture, expansive bone destruction, loss of permanent teeth, development of squamous cell carcinoma
Case 1
A 10 year old presented with swelling on the left side of his jaw. An intraoral examination revealed bulging along the cortical bone that extended from his mandibular left first bicuspid to the distal of the permanent mandibular left first molar and a radiographic lesion that appeared unilocular, radiolucent and was associated with the dental crown of the bud of the mandibular left second molar. A differential diagnosis suggested a dentigerous cyst. Marsupialization was chosen as treatment. The primary mandibular left second molar was extracted, the lesion was decompressed and a space maintenance appliance was inserted. The parents were told to irrigate the lesion with listerine solution and clean the appliance daily. A histopathologic examination revealed that the lesion was indeed a dentigerous cyst.
Case 2
An 8 year old boy, was found to have a volumetric increase of the lingual cortical plate in the region of the primary mandibular right lataeral incisor which showed prolonged retention. Radiographically a well-defined, unilocular, radiolucent lesion was present surrounding the bud of the permanant mandibular right lateral incisor. The lesion appeared to be causing root resportion of the primary lateral incisor and canine. The working diagnosis was a dentigerous cyst. Treatment included extraction of the primary mandibular right lateral incisor and primary canine as well as total enucleation of the cyst due to the small size. Stitches were placed and removed seven days later and seven months later eruptive movements of the permanent right lateral incisor was present along with new bone neoformation was visible in the area.
Summary of conclusions: Dentigerous cysts are benign and asymptomatic. Because they are common among cyst they should not be overlooked at the time of routine radiographic examination. Small cyst are most likely to undergo complete enucleation while larger cyst may require decompression for healing to take place.
07/24/09 Mucoepidermoid carcinoma of the palate in a child
Resident: Adam J. Bottrill
Date: 24JUL09
Region: Providence
Article title: Mucoepidermoid carcinoma of the palate in a child
Author(s): Flaitz, Catherine M. DDS, MS
Journal: Pediatric Dentistry
Volume #: Number; Page #s): 22: 292-293
Year: 2000
Major topic: Mucoepidermoid carcinoma of the palate
Minor topic(s): Salivary gland tumors
Type of Article: Case review
Main Purpose: Discussion and differential diagnosis for salivary gland tumors
Overview of method of research: Case study
Findings: 8 y.o. white boy presented with soft tissue enlargement of the palate. Increasing in size for 9 months. Localized, submucosal nodule of Rt posterior hard palate. Mucosa smooth, intact and faintly blue. Soft, compressible and fluctuant. No mobility or displacement of adjacent teeth. No other abnormalities.
Key points in the article discussion: Due to slow growth and location, salivary gland tumor should be considered. 1st most common is the pleomorphic adenoma followed by mucoepidermoid carcinoma.
A. Mucoepidermoid carcinoma:
1. Malignant tumor occurring most frequently in the parotid gland followed by submandibular gland. When involving MINOR salivary glands, palatal region is most common.
2. Most diagnosed withw girls between age 10 and 16
3. Painless, persistent enlargement present for about a year. With Major glands or tongue involved, pain, parasthesia and difficulty with swallowing most common. Intraoral lesions are localized, fluctuant nodule with bluish or reddish smooth mucosa. Some may drain through sinus tract. Most are soft and compressible but the higher grade tumors may be firm. More aggressive tumors may exhibit ulceration, bone resorption.
4. Most pediatric tumors are diagnosed as low or intermediate grade. Present case Dx as low grade with multicystic spaces and duct-like structures in fibrous connective tissue.
5. Tx: Wide local excision with adequate, tumor-free margins. Higher grade tumors require more aggressive surgery with possible radiation or chemotherapy. Low grade: > 90% cure rate. High grade: 20-30% cure rate.
B. DDX: Abscess (more sudden with tooth symptoms), mucocele (uncommon site), hemangioma (gingival sulcular bleeding and uncommon site), neurofibroma, schwannoma.
Summary of conclusions: Though this is a rare oral lesion in children, it should be ruled out when dealing with a mucocele-like lesion on the hard palate. Tx as a mucocele may result in spread of the carcinoma. This tumor has also presented as a secondary malignancy after therapy of a more aggressive primary malignancy. In pediatric pts, these rare malignancies are MORE likely to be malignant when they arise in minor salivary glands. Prompt differential diagnosis, referral and therapy is important.
Assessment of article: A concise DDX and discussion for mucoepidermal carcinoma of the palate.
Date: 24JUL09
Region: Providence
Article title: Mucoepidermoid carcinoma of the palate in a child
Author(s): Flaitz, Catherine M. DDS, MS
Journal: Pediatric Dentistry
Volume #: Number; Page #s): 22: 292-293
Year: 2000
Major topic: Mucoepidermoid carcinoma of the palate
Minor topic(s): Salivary gland tumors
Type of Article: Case review
Main Purpose: Discussion and differential diagnosis for salivary gland tumors
Overview of method of research: Case study
Findings: 8 y.o. white boy presented with soft tissue enlargement of the palate. Increasing in size for 9 months. Localized, submucosal nodule of Rt posterior hard palate. Mucosa smooth, intact and faintly blue. Soft, compressible and fluctuant. No mobility or displacement of adjacent teeth. No other abnormalities.
Key points in the article discussion: Due to slow growth and location, salivary gland tumor should be considered. 1st most common is the pleomorphic adenoma followed by mucoepidermoid carcinoma.
A. Mucoepidermoid carcinoma:
1. Malignant tumor occurring most frequently in the parotid gland followed by submandibular gland. When involving MINOR salivary glands, palatal region is most common.
2. Most diagnosed withw girls between age 10 and 16
3. Painless, persistent enlargement present for about a year. With Major glands or tongue involved, pain, parasthesia and difficulty with swallowing most common. Intraoral lesions are localized, fluctuant nodule with bluish or reddish smooth mucosa. Some may drain through sinus tract. Most are soft and compressible but the higher grade tumors may be firm. More aggressive tumors may exhibit ulceration, bone resorption.
4. Most pediatric tumors are diagnosed as low or intermediate grade. Present case Dx as low grade with multicystic spaces and duct-like structures in fibrous connective tissue.
5. Tx: Wide local excision with adequate, tumor-free margins. Higher grade tumors require more aggressive surgery with possible radiation or chemotherapy. Low grade: > 90% cure rate. High grade: 20-30% cure rate.
B. DDX: Abscess (more sudden with tooth symptoms), mucocele (uncommon site), hemangioma (gingival sulcular bleeding and uncommon site), neurofibroma, schwannoma.
Summary of conclusions: Though this is a rare oral lesion in children, it should be ruled out when dealing with a mucocele-like lesion on the hard palate. Tx as a mucocele may result in spread of the carcinoma. This tumor has also presented as a secondary malignancy after therapy of a more aggressive primary malignancy. In pediatric pts, these rare malignancies are MORE likely to be malignant when they arise in minor salivary glands. Prompt differential diagnosis, referral and therapy is important.
Assessment of article: A concise DDX and discussion for mucoepidermal carcinoma of the palate.
07/24/09 Delayed tooth eruption associated with an ameloblastic firbro-odontoma
Resident: Adam J. Bottrill
Date: 24JUL09
Region: Providence
Article title: Delayed tooth eruption associated with an ameloblastic firbro-odontoma
Author(s): Flaitz, Catherine M. DDS, MS; Hicks, John MD, DDS, PhD
Journal: Pediatric Dentistry
Volume #: Number; Page #s): 23: 253-254
Year: 2001
Major topic: Delayed eruption associated with ameloblastic fibro-odontoma
Minor topic(s): Differential diagnosis for delayed eruption
Type of Article: Case review
Main Purpose: Discussion and differential diagnosis for delayed eruption
Overview of method of research: Case study
Findings: Healthy 31 month-old Hispanic boy presented with unerupted primary left mandibular canine. Bony, hard mass at site of unerupted tooth. Facial asymmetry. Pt occluding on soft tissue covering bony swelling. PA revealed RL with dilacerations of M root of 1st primary molar and displacement of developing premolar. RL lesion is expansile, mixed radiolucent/ radiopaque lesion surrounds crown of unerupted canine. Histo eval revealed cords and islands of odontogenic epithelium, conglomerate foci of enamel and dentin and small tooth-like structures. Connective tissue in the sample resembled the dental papilla. DX: Ameloblastic Fibro-Odontoma (AFO)
Key points in the article discussion: Odontogenic cysts and neoplasms are an uncommon reason for delayed eruption of primary teeth but should be included in the DD. Odontomas are the most common associated lesion, but presence of bony expansion should lead us to explore other etiologies.
A. AFO: Uncommon odontogenic tumor.
1. Resembles ameloblstic fibroma and complex odontoma. Slow growing, painless swelling. Delayed eruption. Unilocular or multilocular. Well-defined margins. Varied radiopacities. Central opacity resembles the same density as a tooth. Can displace teeth. Several cm large.
2. Mean age: 8-11.
3. Occurs equally in both jaws
a. anterior when in maxilla
b. posterior when in mandible
4. Tx: conservative curettage with possible splint. Recurrence following conservative surgery is uncommon.
B. DDX: AOT, COC, CO (most common)
1. CO: asymptomatic developmental abnormality (hamartoma)
a. pericoronal molar region.
b. delayed eruption
c. typically opaque with thin margin of lucency, a developing odontoma may actually resemble AF-O.
d. minimally expansile
2. AOT: benign tumor usually found during second decade.
a. anterior maxilla
b. no bony expansion
c. well-defined, unilocular RL around crown tooth.
3. COC: uncommon with varying clinical behavior.
a. in children, typically cystic type.
b. anterior region
c. peak in 2nd and 3rd decade
d. unilocular/multilocular associated with unerupted tooth
e. 50% associated with tooth-like opacities.
f. Tx: enucleation with uncommon recurrence.
Summary of conclusions: Delayed eruption of a SINGLE primary tooth is very uncommon. After ruling out trauma, neoplasms and odontogenic tumors become the most common etiology. This article outlined a short DDX of the condition.
Assessment of article: A concise DDX for delayed eruption of single primary tooth in the absence of traumatic event. This article could use a conclusion paragraph. Builds up to a real cliffhanger and then leaves the audience with no closure!
Date: 24JUL09
Region: Providence
Article title: Delayed tooth eruption associated with an ameloblastic firbro-odontoma
Author(s): Flaitz, Catherine M. DDS, MS; Hicks, John MD, DDS, PhD
Journal: Pediatric Dentistry
Volume #: Number; Page #s): 23: 253-254
Year: 2001
Major topic: Delayed eruption associated with ameloblastic fibro-odontoma
Minor topic(s): Differential diagnosis for delayed eruption
Type of Article: Case review
Main Purpose: Discussion and differential diagnosis for delayed eruption
Overview of method of research: Case study
Findings: Healthy 31 month-old Hispanic boy presented with unerupted primary left mandibular canine. Bony, hard mass at site of unerupted tooth. Facial asymmetry. Pt occluding on soft tissue covering bony swelling. PA revealed RL with dilacerations of M root of 1st primary molar and displacement of developing premolar. RL lesion is expansile, mixed radiolucent/ radiopaque lesion surrounds crown of unerupted canine. Histo eval revealed cords and islands of odontogenic epithelium, conglomerate foci of enamel and dentin and small tooth-like structures. Connective tissue in the sample resembled the dental papilla. DX: Ameloblastic Fibro-Odontoma (AFO)
Key points in the article discussion: Odontogenic cysts and neoplasms are an uncommon reason for delayed eruption of primary teeth but should be included in the DD. Odontomas are the most common associated lesion, but presence of bony expansion should lead us to explore other etiologies.
A. AFO: Uncommon odontogenic tumor.
1. Resembles ameloblstic fibroma and complex odontoma. Slow growing, painless swelling. Delayed eruption. Unilocular or multilocular. Well-defined margins. Varied radiopacities. Central opacity resembles the same density as a tooth. Can displace teeth. Several cm large.
2. Mean age: 8-11.
3. Occurs equally in both jaws
a. anterior when in maxilla
b. posterior when in mandible
4. Tx: conservative curettage with possible splint. Recurrence following conservative surgery is uncommon.
B. DDX: AOT, COC, CO (most common)
1. CO: asymptomatic developmental abnormality (hamartoma)
a. pericoronal molar region.
b. delayed eruption
c. typically opaque with thin margin of lucency, a developing odontoma may actually resemble AF-O.
d. minimally expansile
2. AOT: benign tumor usually found during second decade.
a. anterior maxilla
b. no bony expansion
c. well-defined, unilocular RL around crown tooth.
3. COC: uncommon with varying clinical behavior.
a. in children, typically cystic type.
b. anterior region
c. peak in 2nd and 3rd decade
d. unilocular/multilocular associated with unerupted tooth
e. 50% associated with tooth-like opacities.
f. Tx: enucleation with uncommon recurrence.
Summary of conclusions: Delayed eruption of a SINGLE primary tooth is very uncommon. After ruling out trauma, neoplasms and odontogenic tumors become the most common etiology. This article outlined a short DDX of the condition.
Assessment of article: A concise DDX for delayed eruption of single primary tooth in the absence of traumatic event. This article could use a conclusion paragraph. Builds up to a real cliffhanger and then leaves the audience with no closure!
Tuesday, July 21, 2009
07/24/09 Palatal Erythema in Patients Using Listerine Cool Mint PocketPaks
Resident: Jason Hencler Date: 07/24/09
Article title: Palatal Erythema in Patients Using Listerine Cool Mint PocketPaks Oral Care Strips: Case Reports
Author(s): Chris L. Pham, DDS; A. Jeffrey Wood,DDS; Michael B. Lambert, DMD; William Carpenter, DDS, MS
Journal: Journal of Dentistry for Children
Volume #72; Number 2; Page #52-55
Year: 2005
Major topic: Palatal Erythema
Minor topic(s):
Type of Article: Case Report
Main Purpose: Present 2 cases of similar erythematous lesions in patients using Listerine Cool Mint PocketPaks Oral Care Strips
Overview of method of research: Review of 2 similar cases including diagnosis, treatment, and outcome.
Findings: Case 1: 44yo Caucasian female presents with asymptomatic rectangular lesion on mid-hard palate. Patient was unaware of lesion. Upon questioning patient revealed frequent use of strips. When patient discontinued strips, erythematous lesion was not present at next evaluation. Patient was asked to resume use of strips and at the next appointment the lesion had returned. An exfoliative cytology specimen was obtained to rule out suspicion of Candida albicans. Periodic acid-schiff test was negative for C. albicans. Case 2: 7 yo Hispanic female with no significant med history, no systemic diseases, and age appropriate dental development. Patient had no unusual habits. A very symmetrical square shaped lesion was located on the mid palate. The anterior border was feathered with subtle gradation toward the anterior 1/3 of the palate. Lesion was almost identical to case 1. After discontinuation of cool strips the lesion disappeared.
Key points in the article discussion: Possible differential diagnosis for erythematous lesions of th epalate include: 1) Chemical or Physical allergy/irritation 2) yeast infection (C. albicans) 3) sexual abuse 4) foreign object trauma. With evidence gathered from removing and reapplying Listerine cool strips, there is support for these strips to be the causative agent. These oral aids adhere to the palate after applications, so prolonged exposure to these strips and the various chemical compositions they contain, was a likely suspect. The lesion’s feathered anterior border is consistent with use of this agent due to the swallowing reflex. It is unlikely that this is a case of allergy contact dermatitis. Past studies indicate menthol, thymol, and propylene glycol as possible causative agents. Shape of the lesions found in this study indicate that Listerine cool strips. Type III hypersensitivity is implied which may take 48hrs to develop.
Summary of conclusions: Patients presenting with asymptomatic, square shaped, erythematous macular lesions on the mid-hard palatal gingival who report use of Listerine strips, a differential diagnosis of sensitivity to this oral aid should be considered. These cases presented here provide clinicians with one more differential diagnosis to consider.
Assessment of article: Article presented some good points but not particularly groundbreaking. I thought after patients revealed using strips, characteristics of lesion, especially shape, made the diagnosis quite obvious.
Article title: Palatal Erythema in Patients Using Listerine Cool Mint PocketPaks Oral Care Strips: Case Reports
Author(s): Chris L. Pham, DDS; A. Jeffrey Wood,DDS; Michael B. Lambert, DMD; William Carpenter, DDS, MS
Journal: Journal of Dentistry for Children
Volume #72; Number 2; Page #52-55
Year: 2005
Major topic: Palatal Erythema
Minor topic(s):
Type of Article: Case Report
Main Purpose: Present 2 cases of similar erythematous lesions in patients using Listerine Cool Mint PocketPaks Oral Care Strips
Overview of method of research: Review of 2 similar cases including diagnosis, treatment, and outcome.
Findings: Case 1: 44yo Caucasian female presents with asymptomatic rectangular lesion on mid-hard palate. Patient was unaware of lesion. Upon questioning patient revealed frequent use of strips. When patient discontinued strips, erythematous lesion was not present at next evaluation. Patient was asked to resume use of strips and at the next appointment the lesion had returned. An exfoliative cytology specimen was obtained to rule out suspicion of Candida albicans. Periodic acid-schiff test was negative for C. albicans. Case 2: 7 yo Hispanic female with no significant med history, no systemic diseases, and age appropriate dental development. Patient had no unusual habits. A very symmetrical square shaped lesion was located on the mid palate. The anterior border was feathered with subtle gradation toward the anterior 1/3 of the palate. Lesion was almost identical to case 1. After discontinuation of cool strips the lesion disappeared.
Key points in the article discussion: Possible differential diagnosis for erythematous lesions of th epalate include: 1) Chemical or Physical allergy/irritation 2) yeast infection (C. albicans) 3) sexual abuse 4) foreign object trauma. With evidence gathered from removing and reapplying Listerine cool strips, there is support for these strips to be the causative agent. These oral aids adhere to the palate after applications, so prolonged exposure to these strips and the various chemical compositions they contain, was a likely suspect. The lesion’s feathered anterior border is consistent with use of this agent due to the swallowing reflex. It is unlikely that this is a case of allergy contact dermatitis. Past studies indicate menthol, thymol, and propylene glycol as possible causative agents. Shape of the lesions found in this study indicate that Listerine cool strips. Type III hypersensitivity is implied which may take 48hrs to develop.
Summary of conclusions: Patients presenting with asymptomatic, square shaped, erythematous macular lesions on the mid-hard palatal gingival who report use of Listerine strips, a differential diagnosis of sensitivity to this oral aid should be considered. These cases presented here provide clinicians with one more differential diagnosis to consider.
Assessment of article: Article presented some good points but not particularly groundbreaking. I thought after patients revealed using strips, characteristics of lesion, especially shape, made the diagnosis quite obvious.
Monday, July 20, 2009
07/24/09 Oral Abnormalities in Taiwanese Newborns
Resident: Jason Hencler
Article title: Oral Abnormalities in Taiwanese Newborns
Author(s): Ming-Hui Liu, DDS; Wen-Hsi Huang, DDS
Journal: Journal of Dentistry for Children
Volume #71; Number 2; Pg: 118-120
Year: 2004
Major topic: Oral Abnormalities in Newborns
Type of Article: Observational
Main Purpose: Investigate the frequency of oral abnormalities in newborns in Taiwan
Overview of method of research: Study included 420 infants born between February and April 2000. Babies with craniofacial abnormalities and systemic conditions were excluded. One dentist examined all newborns within 3 days of birth. Authors segmented each arch into 12 separate areas to record oral abnormalities. They also recorded natal and neonatal teeth.
Findings: All 420 newborns were of East Asian ethnicity and consisted of 231 males and 189 females. 4 kinds of oral abnormalities were found: 1) natal teeth 2) neonatal teeth 3) palatal cyst of the newborn 4) gingival cyst of the newborn. Frequency of natal and neonatal teeth was 1%. All teeth were located in the mandibular anterior area. Among the subjects examined, 86% had palatal cysts, 79% had gingival cysts. Overall the frequency was 94%.
Key points in the article discussion: Oral abnormalities of newborns include: 1) inclusion cyst 2) alveolar lymphangioma 3) median alveolar notches 4) natal teeth 5) neonatal teeth 6) congenital epulis 7) commissural lip pits 8) ankyloglossia. The terms natal and neonatal refer only to the time of eruption but not the origin of tooth germ. Crowns are either well formed or discolored with irregular surface and are mostly mobile due to short or missing roots. Histologically they have hypoplastic enamel and some have irregular dentin and enlarged interlobular areas in the dentin tubules. Most have large vascular pulp and may fail to form cementum. Other studies reported a slightly lower frequency of natal and neonatal teeth. Larger sample sizes in the other studies may explain this difference. Most natal and neonatal teeth occur in the mandible incisor region except in the case of cleft lip and palate, where they occur in the maxillary cleft areas. Gingival cysts near the surface appear as white masses. They don’t increase in size with age and they are rarely seen after 3 months of age. Frequency of cysts (94%) in this study was higher than recorded in any other published reports. Palatal cysts (84%) and gingival cysts (79%) were not low. This variance with past data may be due to racial difference, examination methods, and different definitions of cysts. This study found no significant correlation between gender, body weight, and gestational age.
Summary of conclusions: Palatal cyst frequency was highest. Of the gingival cysts, buccal aspects of the maxillary arch and lingual aspects of the mandibular arch were more pronounced. Frequency of palatal and gingival cysts of the newborn was not significantly affected by gender, body weight, gestational age, or delivery pattern variables. One natal tooth in 1 newborn and 2 neonatal teeth in another were located in the mandibular anterior for an incidence less than 1%.
Assessment of article: Data from this study could be useful to a Pediatric dentist when treating a patient population that included patients of East Asian ethnicity. Compared with other races, East Asian newborns may have higher incidence of the oral abnormalities considered in this study. The high frequency of oral cysts found in this study may be due to small sample size when compared with other past studies.
A clinicopathologic and immunohistochemical analysis of melanotic neuroectodermal tumor of infancy
Resident’s Name: Brian Schmid DMD
Author(s): A.W. Barrett et al.
Journal: Oral Surg Oral Med Oral Path
Month, Year: 2002
Major topic: A small retrospective, histological study of melanotic neuroectodermal tumors in infants (MNTI)
Type of Article: Retrospective
Findings: MNTI’s are quite rare and usually considered benign with only 250 reported cases, typically as a single or paired lesion but also in clusters of 5 or more. The membrane can be intact or ulcerated, blue, brown or red and can even resemble an eruption cyst. There is no sex predilection and presentation is typically less than 1y.o. The treatement of choice is surgical removal with a conservative lymph node dissection to rule out metastasis. Radiotherapy and chemotherapy are ineffective and would be contraindicated in such young patients anyhow.
Searching through pathology department archives, 8 cases of melanotic neuroectodermal tumors were found; 7 in males and 7 affected the maxilla. The cases ranged from 1963-1999. The age of presentation was 2.5-14 months and all were treated with excision. Three of the cases “involved the whole maxilla” and 2 crossed the midline but only 1 case required a radical bilateral maxillectomy. Radiographically the lesions could present a radiopaque or radiolucent state and moth single and multilocularity. Histologically the lesions present as small melanocyte-like cells mixed with smaller neuroblast-like cells. There is good evidence that these lesions are of neural crest origin. The purpose of this study as to elucidate a histological/immunological assay that could be performed to successfully predict aggression and malignancy of a given tumor. NB84 is a reliable marker for childhood neuroblastoma but was negative on all account in this study. While the most aggressive case was the only one positive for CD99 and Ki67, this is inconsistent with many previous findings. There is a small chance of recurrence which can be monitored with regular intra-oral exams.
Key points/Summary: While this study did not specify any immunohistological markers which could help identify the more malignant episodes of this tumor, further study is necessary and in the meantime it is in the best interest of the patient to perform proper soft tissue exams at regular intervals in all patients. Erythroplakic and pigmented lesions are of particular importance to note, monitor and treat.
Assessment of article: Chock full of biochemistry goodness but with some valuable clinical peppering. They included no photos of the study patients, which may not have been available, or even stock photos of an MNTI.
Author(s): A.W. Barrett et al.
Journal: Oral Surg Oral Med Oral Path
Month, Year: 2002
Major topic: A small retrospective, histological study of melanotic neuroectodermal tumors in infants (MNTI)
Type of Article: Retrospective
Findings: MNTI’s are quite rare and usually considered benign with only 250 reported cases, typically as a single or paired lesion but also in clusters of 5 or more. The membrane can be intact or ulcerated, blue, brown or red and can even resemble an eruption cyst. There is no sex predilection and presentation is typically less than 1y.o. The treatement of choice is surgical removal with a conservative lymph node dissection to rule out metastasis. Radiotherapy and chemotherapy are ineffective and would be contraindicated in such young patients anyhow.
Searching through pathology department archives, 8 cases of melanotic neuroectodermal tumors were found; 7 in males and 7 affected the maxilla. The cases ranged from 1963-1999. The age of presentation was 2.5-14 months and all were treated with excision. Three of the cases “involved the whole maxilla” and 2 crossed the midline but only 1 case required a radical bilateral maxillectomy. Radiographically the lesions could present a radiopaque or radiolucent state and moth single and multilocularity. Histologically the lesions present as small melanocyte-like cells mixed with smaller neuroblast-like cells. There is good evidence that these lesions are of neural crest origin. The purpose of this study as to elucidate a histological/immunological assay that could be performed to successfully predict aggression and malignancy of a given tumor. NB84 is a reliable marker for childhood neuroblastoma but was negative on all account in this study. While the most aggressive case was the only one positive for CD99 and Ki67, this is inconsistent with many previous findings. There is a small chance of recurrence which can be monitored with regular intra-oral exams.
Key points/Summary: While this study did not specify any immunohistological markers which could help identify the more malignant episodes of this tumor, further study is necessary and in the meantime it is in the best interest of the patient to perform proper soft tissue exams at regular intervals in all patients. Erythroplakic and pigmented lesions are of particular importance to note, monitor and treat.
Assessment of article: Chock full of biochemistry goodness but with some valuable clinical peppering. They included no photos of the study patients, which may not have been available, or even stock photos of an MNTI.
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