Kristin K. McNamara

The role of direct visual fluorescent examination (VELscope) in routine screening for potentially malignant oral mucosal lesions

OBJECTIVE Direct visual fluorescent examination (DVFE) is a proposed adjunct to conventional oral examination (COE). We evaluate the benefit of DVFE in screening for potentially malignant mucosal lesions in a general population of patients presenting for dental care. STUDY DESIGN A total of 130 patients were evaluated by COE followed by DVFE. Areas clinically suspicious by COE or with positive DVFE (visual fluorescence loss [VFL]) underwent surgical biopsy. Association between COE and DVFE was assessed and compared with histopathology. RESULTS A total of 42 subjects had one or more areas of VFL, yet histologic evidence of premalignancy/malignancy was only identified in a single individual. Further, one lesion negative by DVFE exhibited epithelial dysplasia. DVFE was statistically different from scalpel biopsy (P = .0001). No difference was found between COE and scalpel biopsy (P = 1.0). CONCLUSIONS Results suggest that COE is more valid than DVFE at discriminating benign mucosal alterations from premalignancy and do not support use of DVFE as an oral cancer screening adjunct.

Non-calcifying Langerhans Cell-Rich Variant of Calcifying Epithelial Odontogenic Tumor: A Distinct Entity with Predilection for Anterior Maxilla

Calcifying epithelial odontogenic tumor (CEOT) is an uncommon locally invasive epithelial odontogenic tumor of the jaws associated with amyloid production. Intraosseous presentations are most common and they frequently occur in the posterior mandible. A non-calcifying Langerhans cell-rich variant of CEOT (NCLC CEOT) has been described with predilection for the anterior maxilla. Interestingly, all reported cases of NCLC CEOT have occurred in Asian population. We present a case of a 43-year old Caucasian female with a large radiolucent lesion involving the left anterior maxilla with histologic features of NCLC CEOT. This is the first reported case of this rare variant of CEOT in a Caucasian individual.

Clinical–Pathological Conference: Case 4

Clinical PresentationA 9-year-old male with a non-contributory medical historypresented with left mandibular swelling. His mother hadfirst noticed swelling in the area 2 months earlier, butstated that it seemed to resolve, only to develop again overthe last 2 weeks. The boy had no complaints of pain, ten-derness or altered sensation of his lower lip.Extraoral examination revealed mild facial asymmetrywith enlargement of the body region of the left posteriormandible. The overlying skin lacked erythema or warmthand no anesthesia or paresthesia of the left lower lip wasdetected. Intraoral examination showed marked bucco-lingual expansion of the mandible centered on tooth #19with vertical enlargement to the height of the occlusalplane; tooth #19 appeared ‘‘engulfed.’’ The mucosa wasintact and of normal color (Fig. 1).The panoramic radiograph showed a normal pattern oftooth development and eruption. A solitary 3.5 cm mixedradiolucent/radiopaque lesion was noted surrounding theroots of tooth #19 (Fig. 2a, b). The lesion was composed ofa central opacity exhibiting a fine, radiating trabecularpattern and a relatively well-defined radiolucent periphery.Expansion of the inferior border of the mandible as well asposterior displacement of teeth #18 and #19 was observed,without evidence of root resorption. Vertical extension oflesional tissue above the height of the surrounding alveolarbone was seen. A computed tomography (CT) imagerevealed prominent expansion of the left mandible withdiscontinuity of the buccal and lingual cortices but noevidence of soft tissue involvement (Fig. 3).Differential DiagnosisBased on the clinical history and radiographic findings, adiagnosis of osteoblastoma was favored. The differentialdiagnosis included osteosarcoma, juvenile active ossifyingfibroma, and calcifying epithelial odontogenic tumor.Osteoblastoma is a rare primary bone tumor that typi-cally occurs in patients under the age of 30, with a slightfemale predominance and a predilection for the mandible,particularly the posterior segments [1, 2]. Pain and swellingwith bone expansion are common clinical features [1, 3].While no discomfort was reported in the present case,recent literature indicates that significantly fewer patientsexperience pain associated with this neoplasm than waspreviously suggested [1]. The radiographic features ofosteoblastoma can vary from a well-demarcated to ill-defined osteolytic lesion with variable internal structurethat can range from entirely radiolucent to our finding of acentral radiopacity with radiolucent periphery [1–3].Osteosarcoma is a rare primary malignancy of bone thatmost often affects the long bones around the knee in teen-agers or young adults. While patients with jaw lesions areusually older, all age groups have been affected [4]. Apainful swelling is the most common clinical presentation,with paresthesia and loosening of teeth also frequent find-ings [5, 6]. Radiographically, the radiating pattern of tra-beculation noted within the current case supportedconsideration of osteosarcoma, although only 25% of gna-thic osteosarcomas demonstrate a radiating or ‘‘sunburst’’