Celso Augusto Lemos

Abordagem do câncer da boca : uma estratégia para os níveis primário e secundário de atenção em saúde

Progress in cancer management by health systems involves improvements in surveillance, organization of healthcare services, specific programs focused on primary and secondary prevention, and scientific and technical advances in diagnosis and treatment. Despite well-known progress in the management of malignant neoplasms in all the above areas, oral cancer displays persistently high morbidity and mortality rates, apparently failing to reflect the accumulated scientific knowledge on the disease. The current article discusses the reasons for this mismatch, the need for redefining priorities in oral cancer management, and the implementation of such priorities as a public health policy.

Treatment of painful and recurrent oral mucoceles with a high-potency topical corticosteroid: a case report.

Single mucoceles are a relatively common disorder of the oral mucosa, but the occurrence of multiple mucoceles is considered an uncommon event. There are only a few reports in the literature. 1-6 Although no etiologic factor has been associated with multiple mucoceles, some authors reported on this condition in patients with oral lichen planus and in association with graft-versus-host disease. 1,6,7 There is a hypothesis that an inflammatory process may play a role in the pathogenesis of recurrent mucoceles, 6,7 although it was also argued that changes in minor salivary-gland function may contribute to the development of these lesions. 2

Psoriasiform mucositis on the gingival and palatal mucosae treated with retinoic-acid mouthwash.

mucosae treated with retinoic-acid mouthwash A 35-year-old African-American female sought our clinic for evaluation of a burning sensation on the palate and gingival bleeding of one-year duration. Oral examination showed diffuse erythema on the upper gingival mucosa, resembling a desquamative gingivitis (Fig. 1a), and erythematous patches on the hard and soft palatal mucosa (Fig. 1b,c). No other lesion was reported either on the skin or on other mucosal surfaces. The patient was neither a smoker nor an alcohol abuser; otherwise she was in good health. Her family history presented nothing noteworthy. The diagnostic procedure began with microscopic examination of biopsies taken from the palatal and gingival mucosae, which were consistent with psoriasiform lesion (Fig. 2a–d). Periodic acid-Schiff staining of the histopathological slide sections was negative for Candida infection. A serological test for syphilis was non-reagent, and a complete blood cell count was within normal limits.

The relevance of clinical and radiographic features of jaw lesions: A prospective study.

The study was carried out in a Brazilian population and the aim was to describe the prevalence and the clinic-radiographical features of jaw lesions. In addition, a comparison between the main diagnosis hypothesis and final diagnosis was accessed. A prospective study which evaluated all patients with jaw lesions diagnosed in an Oral Diagnosis Center, between August 2013 and October 2014. A total of 450 patients were observed for the first time, and 130 had some type of jaw lesion. The mean age of the patients was 35.2 years ± 17.86. Among these, 71 were women (54.62%) and 87 were Caucasian (66.92%). The mandible was affected more frequently (71.43%) than the maxilla (28.57%). Swelling and pain were the most frequent clinical signs and symptoms and were observed in 60 (42.85%) and 38 (27.14%) cases, respectively. The panoramic x-ray was the main radiographic exam utilized (88.57%). Radiolucent lesions accounted for 89 cases (63.57%) and the unilocular form was present in 114 cases (81.43%). A total of 93 cases had histopathological analyses and the periapical cyst was the most frequent lesion. In the other 47 lesions, the diagnosis was conducted by clinical and radiographic management. Bone lesions were frequent, being noted on first visit in approximately 30% of patients; in 1/3 of the cases, the diagnoses were completed with a combination of clinical and radiographic exams.

Bilateral mandibular osteomyelitis mimicking periapical cysts in a patient with sickle cell anemia

Sickle cell anemia (SCA) is a hemoglobin disorder that occurs more commonly among Afro-descendants. The authors report the case of a 28-year-old Afro-descendent male patient with the diagnosis of homozygotic sickle cell disease (SCD) referred for evaluation of mandibular lesions. The patient’s main complaints included pain and bilateral teeth mobility. An intraoral examination revealed gingiva recession affecting the lower molars with extensive root exposure. A panoramic x-ray showed two radiolucent symmetrical periapical lesions evolving both the first and the second lower molars, bilaterally. The diagnostic hypotheses comprised odontogenic infection, among others. Besides antimicrobial therapy, the two molars of both sides were extracted and bone was collected for histopathological and microbiological analyses. Osteomyelitis was diagnosed, and Streptococcus viridans was recovered from the culture media. Mandibular osteomyelitis should be considered as a diagnosis in patients with SCD. The present case offers an alert to clinicians about the importance of knowing jaw lesions related to SCA.

Ameloblastic Fibroma: a Case Report

| Ameloblastic fibroma is a rare benign odontogenic tumor in which both epithelial and ectomesenchymal components are neoplastic. A 24-year-old male patient was referred to the Stomatology Department with difficulty to chew and swelling in the right posterior region of the mandible. The panoramic radiograph showed a well-circumscribed, unilocular radiolucent lesion with partially radiopaque borders involving first and second unerupted molars. Computed tomography imaging presented a hypodense image with well-delimited isodense content, bulging and rupture of cortical bones. The patient underwent an incisional biopsy. Microscopically, the lesion was composed of many mesenchymal tissue cells in strand form, arranged in cords, islands and nests of odontogenic epithelium; the diagnostic was ameloblastic fibroma. The patient was referred to the hospital for enucleation and curettage of the lesion and extraction of the associated teeth. After 8 months of follow-up, no recurrence was observed. This case emphasizes the importance of differential diagnosis, anatomopathological exam, and both clinical and imaging follow-up, since this kind of tumor can recur and progress to malignancy. DESCRIPTORS | Odontogenic Tumors; Oral Pathology; Ameloblastic Fibroma. RESUMO | Fibroma ameloblástico: um estudo de caso • O fibroma ameloblástico é um tumor odontogênico benigno raro no qual os componentes epiteliais e ectomesenquimais são neoplásicos. Paciente de 24 anos de idade foi encaminhado à clínica de Estomatologia devido à dificuldade de mastigar e edema na região posterior direita da mandíbula. A radiografia panorâmica evidenciou uma lesão radiolúcida unilocular, circunscrita, com bordas parcialmente radiopacas envolvendo o primeiro e segundo molar não irrompidos. A tomografia computadorizada apresentou imagem hipodensa, com conteúdo isodenso, bem delimitada, com abaulamento e rompimento das corticais ósseas. O paciente foi submetido a uma biópsia incisional. Microscopicamente, a lesão foi composta por tecido mesenquimal rico em células, formando cordões, ilhas e ninhos de epitélio odontogênico, cujo diagnóstico foi de fibroma ameloblástico. O paciente foi encaminhado ao hospital para enucleação e curetagem da lesão com extração dos dentes associados. Após 8 meses de acompanhamento, não se observou recorrência. Este caso enfatiza a importância do diagnóstico diferencial, exame anatomopatológico, e acompanhamento clínico e radiográfico, uma vez que este tumor pode recidivar e evoluir para malignidade. DESCRITORES | Tumores Odontogênicos; Patologia Oral; Fibroma Ameloblástico. CORRESPONDING AUTHOR | • Juliane Piragine Araujo Department of Radiology, School of Dentistry, University of São Paulo • Av. Professor Lineu Prestes, 2227, Cidade Universitária São Paulo, SP, Brazil • 05508-000 Email: jupiragine@usp.br • Received Aug 20, 2015 • Accepted Oct 13, 2015 • DOI http://dx.doi.org/10.11606/issn.2357-8041.clrd.2015.12951 251 Ameloblastic fibroma: a case report 252 ● Clin Lab Res Den 2015; 21 (4): 251-257 INTRODUCTION Ameloblastic fibroma (AF) is a rare benign odontogenic tumor, originating from the odontogenic epithelium and odontogenic mesenchyme,1 and it is classified as a true mixed tumor.2 According to Barnes et al.,2 mixed odontogenic tumors include: ameloblastic fibrodentinoma (AFD), ameloblastic fibro-odontoma (AFO), odontoma complex and compound, odontoameloblastoma, calcifying cystic odontogenic tumor, dentinogenic ghost cell tumor, and ameloblastic fibroma. To some authors, mixed odontogenic tumors are different developmental stages of the same lesion.1 The incidence of odontogenic tumors in a study by Nalabolu et al. was 2.17% of a total 7,400 oral biopsies. The AF corresponded to 0.6% of all odontogenic tumors.3 The mean age was 14.8 years (ranging from 7 weeks to 62 years).2 AF occurs more frequently in the mandible and the posterior region is more affected than the anterior region.1,4 Clinical and radiographic features of odontogenic tumors, as well as their prognosis and malignant transformation are conflicting.1 The radiographic features include well-defined, unior multilocular radiolucency, and, in most cases, a radiopaque boundary.2,4 This case report describes the case of a young man affected by mandibular AF, associated with first and second molars on the right side. CASE REPORT A 24-year old male was referred to the Stomatology Department of the School of Dentistry, University of São Paulo, complaining of difficulty chewing and a progressive, asymptomatic increase in the size of his right mandible, which he noticed about 15 days before examination. The patient had no relevant medical history. Extraoral examination revealed facial asymmetry, bulging of the right lower third of the face, intact skin, no palpable lymphonodes, and no paresthesia. The intraoral examination revealed a tumor in the right mandible, with an ulcerated surface, a reddish color, well-defined borders, and measuring approximately 3 cm. Absence of the second premolar and the first and second molars was noted in the region of the tumor. Figure 1 | Extraoral examination revealed facial asymmetry with bulging of the lower third of the face and intact skin, on the right side. Carvalho EM • Horikawa FK • Guimaraes L • Viveiros SK • Lemos CA • Araujo JP • Clin Lab Res Den 2015; 21 (4): 251-257 ● 253 A panoramic radiograph (PR) revealed a unilocular, radiolucent lesion with a partially defined radiopaque boundary, associated to non-erupted first and second molars displaced towards the base of the mandible. Helicoidal computed tomography (HCT) soft window image revealed a hypodense image with isodense content, and cortical bulging with rupture of alveolar crest. Figure 2 | A,B: An ulcerated tumor due to chewing, affecting the posterior right mandible and causing expansion of the cortical bone. Figure 3 | A: A panoramic radiograph shows a well-delimited radiolucent lesion with partially radiopaque borders. B, C: HCT coronal and axial view of tissues shows a well-delimited, unilocular, hypodense lesion with isodense content, with cortical expansion and rupture, affecting the posterior right mandible. Ameloblastic fibroma: a case report 254 ● Clin Lab Res Den 2015; 21 (4): 251-257 INVESTIGATION, HISTOPATHOLOGY AND TREATMENT The patient was submitted to an incisional biopsy under local anesthesia, and the tissue was sent for histopathological analysis. Microscopically, the tumor consisted of odontogenic epithelium lying in mesenchymal tissue resembling embryonic tooth pulp. The odontogenic epithelium consisted of short and long narrow cords or islands, usually two cells thick, with cuboidal or columnar cells sometimes in anastomosing arrangement. The final histopathological diagnosis was ameloblastic fibroma. Therefore, surgery was indicated and performed under general anesthesia, with curettage of the lesion and tooth extraction (Figure 5). AF diagnosis was confirmed. A helicoidal tomography was performed 8 months after surgery (Figure 6). The patient has been followed-up with no evidence of recurrence, and has been asymptomatic ever since (Figure 7). Figure 4 | Benign neoplasm consisting of mesenchymal tissue associated with odontogenic epithelium arranged in short and long, narrow cords or islands (H&E 200x). Figure 5 | A-C: Trans-surgical procedure: enucleation with curettage of the surrounding bone and removal of the affected tooth. D: An extracted specimen. Carvalho EM • Horikawa FK • Guimaraes L • Viveiros SK • Lemos CA • Araujo JP • Clin Lab Res Den 2015; 21 (4): 251-257 ● 255 Figure 6 | A: Five months after surgery, the patient presented symmetry. B, C: Intraoral examination revealed normal alveolar ridge and intact surface. Figure 7 | A, B: HCT coronal view shows an area of bone defect from surgery, with no evidence of lesion. C, D: HCT axial view shows a hyperdense area, suggesting a process of bone repair in the right mandible. Ameloblastic fibroma: a case report 256 ● Clin Lab Res Den 2015; 21 (4): 251-257 DISCUSSION Ameloblastic fibroma of the jaw is a benign, relatively rare, mixed odontogenic tumor, whose epithelial and mesenchymal components are neoplastic.2,4 This tumor is usually diagnosed in the first and second decades of life (72.4%), when odontogenesis is complete (80% of cases), and affects mainly the mandible.1,4 In this case, the lesion was diagnosed in the third decade of life, and occurred in the posterior region of the mandible. However, some cases of AF in the maxilla have also been reported.1,5 AF does not have a specific sign or symptom, and it is often observed in a routine radiograph, in the form of cysts and other odontogenic tumors.2 In this case, the patient never complained about the absence of his right lower molars. His chief complaint was just difficulty chewing due to the large mass of tissue in this region. Most cases of AF present painless swelling, or are discovered due to disturbances of tooth eruption. Radiographically, the tumor presents a welldemarcated radiolucency, often associated with a malpositioned tooth.2 In addition, a multilocular pattern often characterizes larger tumors (75% of the cases), and a unilocular pattern is more common in smaller lesions (up to 4 cm),6 as was this case. Differential diagnosis of AF lesions must be made, distinguishing ameloblastoma, odontogenic myxoma, dentigerous cysts, odontogenic keratocysts, central giant cell granuloma, and histocytosis.7 Histological examination of AF showed strands, cords, and islands of odontogenic epithelium in a primitive connective tissue stroma closely resembling the dental papilla. No hard tooth structures were detected in any of the primary tumors.4 Tumors with AF histomorphology may form dysplastic dentin; in this case, they are called ameloblastic fibrodentinoma.2 Some authors state that AF is a separate, specific neoplastic entity that does not develop into a more differentiated odontogenic tumor.

Noninferiority trials in oral medicine

More than a century ago, Greenwood and Yule (1915) published a seminal paper explaining the epidemiological assessment of vaccine effectiveness. To illustrate their argument, they compared the incidence of typhoid fever among vaccinated and non-vaccinated British troops stationed in France and Belgium, based on the previously available information.Little consideration was given to issues that we would care so much afterward; nothing was said about why and how some were, and others were not vaccinated. This article is protected by copyright. All rights reserved.

Evaluation of fine needle aspiration biopsy in oral cavity and head and neck region with different stains techniques

The present study aimed to evaluate the Fine Needle Aspiration Biopsy in different staining techniques in nodular lesions of the oral cavity and head and neck region, as their sensitivity, specificity and accuracy, staining with Panoptic, Papanicolaou and Hematoxylin-Eosin (H&E) stains. 46 patients who sought the Clinic of the Discipline of Clinical Stomatology at FOUSP were selected consecutively, with nodular lesions in the oral cavity and head and neck region. The material obtained by FNAB was sent on 6 different slides, stained by the method of Panoptic, Papanicolaou and H&E, to the same pathologist only with the clinical diagnosis. After the final report of FNAB, the biopsy report was issued, serving as gold standard. After the calculations, the results of sensitivity, specificity and accuracy for Panoptic staining were 28.6%, 76% and 15.4%, respectively. The result of sensitivity, specificity and accuracy for Papanicolaou staining were 71.4%, 76.7% and 23.3%, respectively. The result of sensitivity, specificity and accuracy for H&E staining were 82.1%, 23.3%, 28.6%, respectively. We can conclude, according to the methodology of this study that, H&E and Papanicolaou stains showed the same sensitivity of diagnosing malignant neoplasms. H&E stain showed a better specificity for diagnosing benign neoplasms, compared with Papanicolaou and Panoptic stains. H&E stain showed better accuracy, to give definitive diagnosis, followed by Papanicolaou and Panoptic stains.