Juliane Pirágine Araújo

Malignant Transformation of an Odontogenic Cyst in a Period of 10 Years

Primary intraosseous carcinoma of the jaws (PIOSCC) might arise from odontogenic epithelium, more commonly from a previous odontogenic cyst. The aim of this case is to illustrate that the clinician should consider that an apparent benign dentigerous cyst can suffer malignant transformation and that all material removed from a patient must be evaluated histologically. A 44-year-old man presented in a routine periapical X-ray an impacted lower left third molar with radiolucency over its crown. Ten years later, the patient complained of pain in the same region and the tooth was extracted. After one month, the patient still complained of pain and suffered a fracture of the mandible. A biopsy was performed and carcinoma was diagnosed. The patient was treated surgically with adjuvant radio- and chemotherapy and after 8 years, he is well without signs of recurrences. This report describes a central mandibular carcinoma probably developed from a previous dentigerous cyst.

Syphilis related to atypical oral lesions affecting an elderly man. A case report

OBJECTIVE To present a case of oral syphilis in an old patient. BACKGROUND Syphilis seems to be resurging mainly in the young. However, in the last twenty years, the elderly have become more susceptive to infectious diseases due to a more frequent use of sildenafil. CLINICAL REPORT An 83-year-old man was referred to our clinic complaining of burning mouth. His medical history revealed papular lesions on chest and penis glans, which had been diagnosed and treated as scabiosis 2 months prior to our assessment. The intra-oral examination showed erosive and patch lesions on the bilateral lip commissures, the palate and the border of the tongue. Initially, oral herpes was suspected. However, both the serological test and the cytology were negative. Therefore, syphilis was hypothesised. Non-treponemic (VDRL) and treponemic tests (FTA-ABS) were reagent and secondary syphilis was confirmed. The treatment consisted of penicillin G benzathine 2.4 million IU/IM for 4 weeks. Both oral and skin lesions had complete remission. CONCLUSION The present case illustrates that syphilis should be suspected in old patients with oral atypical lesions.

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.

Rosai-Dorfman disease affecting the maxilla

Rosai-Dorfman disease (RDD), formerly called sinus histiocytosis with massive lymphadenopathy, is a non-neoplastic proliferative histiocytic disorder with behavior ranging from highly aggressive to spontaneous remission. Although the lymph nodes are more commonly involved, any organ can be affected. This study aimed to describe the features and the follow-up of a case of extranodal RDD. Our patient was a 39-year-old woman who was referred with an 11-month history of pain in the right maxilla. On clinical examination, some upper right teeth presented full mobility with normal appearance of the surrounding gingiva. Radiographic exams showed an extensive bone reabsorption and maxillary sinus filled with homogeneous tissue, which sometimes showed polypoid formation. An incisional biopsy demonstrated a diffuse inflammatory infiltrate rich in foamy histiocytes displaying lymphocytes emperipolesis. Immunohistochemistry showed positivity for CD68 and S-100, and negativity for CD3, CD20, and CD30. Such features were consistent with the RDD diagnosis. The patient was referred to a hematologist and corticotherapy was administrated for 6 months. RDD is an uncommon disease that rarely affects the maxilla. In the present case, the treatment was conservative, and the patient is currently asymptomatic after 5 years of follow-up.

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.

A comparison of conventional and diffusion-weighted magnetic resonance imaging in the diagnosis of sialadenitis and pleomorphic adenoma

OBJECTIVES The aim of this study was to compare the efficacy of conventional magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) in correctly identifying the presence of disease in the major salivary glands and correctly distinguish sialadenitis from pleomorphic adenoma. STUDY DESIGN Twenty-one patients diagnosed with unilateral sialadenitis or pleomorphic adenoma were selected. The nonaffected contralateral glands were also analyzed. T1- and T2-weighted MRI and DWI were obtained using spin-echo pulse sequences with a 1.5 Tesla MRI device. The diagnostic performance of 3 observers was evaluated for detection of salivary gland alterations and differentiation between sialadenitis and pleomorphic adenoma based on evaluation of MRI in comparison with DWI. RESULTS Intra-and interobserver reliability ranged from 0.86 to 0.94. DWI demonstrated greater sensitivity and accuracy values compared with MRI for both detection of disease and differentiation of sialadenitis from pleomorphic adenoma, with specificity values that were greater than or equal to those of MRI. DWI yielded significantly higher diagnostic odds ratios compared with MRI for both identification of disease and differentiation between lesions. CONCLUSIONS DWI demonstrated better diagnostic performance in the detection of alterations in the salivary glands and in differentiating between sialadenitis and pleomorphic adenoma compared with conventional T1 and T2-weighted MRI.

Gingival complex odontoma: a rare case report with a review of the literature

Odontomas are odontogenic tumors composed of a mixture of dental tissues. They are very common hamartomas of the jaws. However, their peripheral or gingival counterparts are extremely uncommon. The objective of this article is to report a rare case of gingival complex odontoma in an 11-year-old patient, and also to review all published cases of this type of lesion.

Mantle cell lymphoma: involvement of nodal and extranodal sites in the head and neck, with multifocal oral lesions

Mantle cell lymphoma (MCL) is a malignant B-cell neoplasm, which comprises monomorphic and small- to medium-sized mantle zone-derived lymphoid cells. It is characterized by chromosomal translocation t(11;14)(q13;q32) and CCND1 truncation, resulting in cell cycle deregulation. It is an aggressive type of non-Hodgkin lymphoma with a propensity to present with extranodal involvement. This study shows the case of an 80-year-old Caucasian male who complained of a 2-month progressive swelling on the right side of his face. The magnetic resonance imaging exam showed multifocal involvement of the head and neck, including oral manifestations, bilateral parotid glands, palate, tongue, and floor of the mouth. An incisional biopsy of the tumor mass was performed. The morphological and immunophenotypic findings were consistent with the diagnosis of MCL. The patient died 4 months later, without any chance of undergoing a therapeutic approach. Although MCL is a rare condition, it should be subjected to a differential diagnosis when affecting the maxillofacial area. Imaging exams and both immunohistochemical and morphological analyses are needed to reach the correct diagnosis. Here, we present an unusual MCL with multifocal involvement of the head and neck.

Extensive epidermoid cyst of the submental region.

Epidermoid cysts are malformations that are rarely observed in the submental region. Imaging has an important role in surgical planning according to the size and location of the cyst in relation to geniohyoid and mylohyoid muscles. This article reports the case of a 15-year-old female patient complaining of submental swelling. The differential diagnosis included infection, tumor, ranula, and abnormalities during embryonic development. The lesion was surgically excised using an extra-oral approach. The histopathological examination revealed a cyst wall lined with stratified squamous epithelium with the presence of several horny scales consistent with the diagnosis of an epidermoid cyst. No recurrences were found after 1 year of follow-up.