Case #138

A 70-year-old African-American female was referred to a dental clinic for the radiographic evaluation and diagnosis of an apical mixed radiolucent-radioopaque lesion of anterior mandibular teeth (Figure #1). The lesion has been asymptomatic and the patient was not aware of it. There was no evidence of bony expansion.

Final diagnosis: Periapical cemental dysplasia

Periapical cemental dysplasia is a form of benign fibro-osseous lesions of the jaws that until recently was being considered as “Cementoma”, an odontogenic tumor of connective tissue origin.

PCD is not a true neoplasm, but a dysplastic lesion in which the normal bone is replaced by a cellular fibrous connective tissue (osteolytic phase), and later undergoes cementification and ossification process (cementoblastic and maturation phases). Radiographically the lesions are radiolucent in early phase and gradually become radioopaque. Cemental dysplasia is usually discovered accidentally during routine evaluation of the radiograph. The lesion is asymptomatic and not associated with the expansion of the bone. These lesions are more frequently associated with young or middle-aged African-American females. The most common site for the development
of these lesions is apical region of mandibular incisors, but can be more widely distributed. The teeth are vital and there is no sign of lingual or buccal expansion. After diagnosis of
PCD is made no further treatment is required, unless the associated tooth has to be removed for other reasons.

Acknowledgement: This case was contributed by Dr. Schuyler Session, a Marquette University School of Dentistry graduate.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414-805-8440.

#137

A 27-year-old male was referred to the Marquette University School of Dentistry clinic for evaluation of an exophytic and papillary lesion of tonsilar pillar region (Figure #1). This lesion of unknown duration was asymptomatic.The patient was a cigarette smoker and had been smoking half a pack a day for almost eight years. He was otherwise healthy and on no medications.

Final diagnosis: Oral Squamous Papilloma

Squamous papilloma is a benign epithelial tumor caused by Human Papilloma Virus. Papilloma is the most common papillary (verrucous) lesion of oral cavity. While papilloma may be found at any intraoral sites, soft and hard palate and uvula are the most common locations for their development. The size of papilloma may vary and are generally less than 1 centimeter in greatest dimension. The lesions are usually presented as a sessile or pedunculated papillary (cauliflower-like) nodule. They are generally solitary and asymptomatic in their presentation. The differential diagnosis should include verrucous xanthoma, papillary hyperplasia, Condyloma acuminatum (venereal wart) and verrucous carcinoma. Surgical removal is the treatment
of choice either by routine excision or laser ablation. The lesion must be histologically evaluated to confirm the diagnosis.

Acknowledgement: This case was contributed by Michael Brammeier, a Marquette University School of Dentistry student.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414-805-8440.

#136

A 62-year-old female was referred to an oral surgery clinic for the diagnosis and treatment of a well-defined and asymptomatic radiolucent lesion of left mandible (figure #1). The duration of the lesion was unknown and there was no clinical evidence of bone expansion.

Final diagnosis: Odontogenic keratocyst

Odontogenic keratocyst is a very active odontogenic cyst that has high growth potential resulting in huge bone destruction. The OKC shows high rate of recurrence comparing with other odontogenic cysts. Most odontogenic keratocysts are found in molar region of mandible. The maxillary OKC occur primarily in the posterior or in canine-lateral incisor regions. Radiographically the OKC appears as a well defined unilocular or multilocular radiolucent lesion.Surgical enucleation is the treatment of choice for the smaller odontogenic keratocyst. The large OKC with extensive perforation must be resected. The surgical specimen must be evaluated histologically to confirm the diagnosis. Malignant transformation of the cystic epithelial wall to squamous cell carcinoma has been reported in the literature.

Acknowledgement: This case was contributed by Dr. John J. Rydlewicz
(Appleton), an oral surgeon.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414-805-8440.

#135

A 60-year-old female was referred to an oral surgery clinic for the diagnosis and treatment of a polypoid soft tissue lesion of anterior midline maxilla (figure #1). This lesion of several weeks duration was asymptomatic and would easily bleed upon touch. The patient was otherwise healthy.

Final diagnosis: Pyogenic granuloma

Pyogenic granuloma is a reactive fibro-vascular or granulation tissue growth with remarkable endothelial and capillary proliferation. The term pyogenic granuloma, which implies that the lesion is a reaction to a pyogenic microorganism, is a misnomer. Indeed, there is no relationship between these lesions and bacteria. While pyogenic granuloma in the oral cavity mostly involves gingival tissue, it can occur anywhere in the mouth. A chronic trauma or introduction of a foreign substance like calculus in the gingival sulcus is responsible for the development of a pyogenic granuloma. A remarkable female predilection exists, and pregnant women in their second or third trimesters are more prone to develop pyogenic granuloma which is also referred to as “pregnancy tumor”. Total surgical excision is the treatment of choice. To prevent recurrence, curettage of the underlying tissue and root planning is required. To rule out other diagnostic possibilities, the surgical material should be evaluated histologically.

Acknowledgement: This case was contributed by Dr. Chris Bergstrom (Appleton), an oral surgeon.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414-805-8440.

#134

A 45-year-old white male was seen in a dental clinic for the routine dental examination. Radiographic evaluation of the patient revealed a well-defined apical radioopacity of tooth #27 (figure #1). An additional radiopaque lesion was also found in the extraction site of tooth #17. The lesions were asymptomatic and there was no evidence of cortical bone expansion. The patient was otherwise healthy.

Final diagnosis: Idiopathic osteosclerosis

Idiopathic osteosclerosis also known as focal periapical osteopetrosis and dense bone island is a circumscribed radiopaque lesion commonly found at the apical area of posterior
mandibular teeth. Most of the patients are adult and the teeth are asymptomatic and test vital, and free of caries or restorations. Because of the location periapical cemento-osseous dysplasia, focal sclerosing osteomyelitis, benign cementoblastoma and cemento-ossifying fibroma should be considered in the differential diagnosis. The etiology of this lesion is not known and no treatment is required.

Acknowledgement: This case was contributed by Drs. George Pano (Milwaukee) and Patrick F. Sweeney (Milwaukee).

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414-805-8440.

#133

A 36-year-old male was referred to an oral surgery clinic for the diagnosis and treatment of two leukoplakic lesions of right lateral and ventral surface of tongue (figure #1). The lesions were asymptomatic and the duration was unknown.

Final diagnosis: Hyperkeratosis with moderate to severe dysplasia

Leukoplakia is a clinical term for white and asymptomatic mucosal patch that cannot be characterized as any other lesion, and does not imply any histopathological tissue change. Although leukoplakia is considered a premalignant lesion, the use of this clinical term does not suggest that the histological features of dysplasia are present in all leukoplakic lesions.

In fact, biopsy specimens in only five to 25 percent of the leukoplakic lesions show dysplasia. The risk of dysplastic change increases if the lesion is located in certain areas of the oral cavity like lateral aspect of the tongue or floor of the mouth.

Although the exact cause of leukoplakia is not known tobacco, alcohol, ultraviolet radiation and friction and trauma may contribute in the development of leukoplakia. Leukoplakia is usually found in individuals older than 40 years of age and clinically may be presented as thin, thick, nodular and verrucous.

At the present time careful clinical evaluation of leukoplakic lesions and conventional biopsy is the most accurate way of assessing oral leukoplakic lesions. When there is a concern about malignancy noninvasive screening methods like brush biopsy should not replace conventional (incisional) biopsy. The lesions which show mild cellular atypia must be monitored clinically in a regular interval.

Leukoplakia in patients who are smokers and or drink alcoholic beverages excessively must be taken more seriously and these patients should be advised to quit their smoking or drinking habits. Severe dysplastic lesions must be excised totally.

Acknowledgement: This case was contributed by Dr. Jeff Casperson (Appleton), an oral surgeon.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414-805-8440.

#132

A 52-year-old female was referred to an oral surgery clinic for the diagnosis and treatment of a leukoplakic lesion of right lateral and ventral surface of tongue (figure #1). The lesion was asymptomatic and the duration was unknown.

Final diagnosis: Hyperkeratosis with mild to moderate dysplasia

Leukoplakia is a clinical term for white and asymptomatic mucosal patch that cannot be characterized as any other lesion, and does not imply any histopathological tissue change. Although leukoplakia is considered a premalignant lesion, the use of this clinical term does not suggest that the histological features of dysplasia are present in all leukoplakic lesions.

In fact biopsy specimens in only 5 percent to 25 percent of the leukoplakic lesions show dysplasia. The risk of dysplastic change increases if the lesion is located in certain areas of the oral cavity like lateral aspect of the tongue or floor of the mouth. Although the exact cause of leukoplakia is not known tobacco, alcohol, ultraviolet radiation and friction and trauma may contribute in the development of leukoplakia. Leukoplakia is usually found in individuals older than 40 years of age and clinically may be presented as thin, thick, nodular, and verrucous. At the present time careful clinical evaluation of leukoplakic lesions and conventional biopsy is the most accurate way of assessing oral leukoplakic lesions. When there is a concern about malignancy noninvasive screening methods like brush biopsy should not replace conventional (incisional) biopsy. The lesions which show mild cellular atypia must be monitored clinically in a regular interval. Leukoplakia in patients who are smokers and or drink alcoholic beverages excessively must be taken more seriously and these patients should be advised to quit their smoking or drinking habits. Severe dysplastic lesions must be excised totally.

Acknowledgement: This case was contributed by Dr. Philip Hawkins (Milwaukee), an oral surgeon.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414- 805-8440.

#131

A 28-year-old female was referred to a dental clinic for the diagnosis and treatment of a reticular leukoplakic and erosive lesion of oral cavity. The lesion was painful and involved the dorsal and ventral surfaces of tongue and labial mucosa (figure #1 & 2).

Final diagnosis: Erosive lichen planus

Lichen planus is a chronic mucocutaneous lesion of unknown etiology, but it is generally considered to be an immunologically mediated process that resembles histologically to a hypersensitivity reaction. It presents various clinical forms in oral cavity, and reticular lichen planus with typical white lesion is the most common type.

In the erosive form of lichen planus, the central area of the lesion is ulcerated and is usually covered by a Pseudomembranous plaque that can be easily detached from the underlying tissue. A reticular white component is closely associated with ulcerated and the erythematous part lesion. This lesion is usually painful and sensitive to touch.

Lichenoid drug reaction is a hypersensitivity reaction to various medications that mimics erosive lichen planus.

Lichen planus cannot be generally cured, but some drugs can provide relief and satisfactory control. Topical application and intralesional injection of corticosteroids are the most beneficial and widely used methods of treatment for the intra oral lichen planus.

It appears that there is a very small percentage of oral lichen planus particularly the erosive and the bullous types that change into squamous cell carcinoma, but the risk is very low.

Acknowledgement: This case was contributed by Dr. Benjamin Cope, a general dentist in Utah and graduate of the Marquette University School of Dentistry.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414- 805-8440.

#130

A 55-year-old female was referred to an oral surgery clinic for the diagnosis and treatment of an ulcerated and papillary mucosal lesion of her left lateral tongue (figure #1). The lesion was asymptomatic and has been present for past four months. The patient had history of heavy smoking and was otherwise healthy.

Final diagnosis: Early Invasive squamous cell carcinoma

Squamous cell carcinoma is the most common primary malignancies of the mouth (90 percent of all oral cancers). Tobacco habits and drinking alcoholic beverages are implicated as the main causative factors in development of the oral squamous cell carcinoma. Actinic radiation, immunosupression, and chronic irritation may also contribute in formation of this type of cancer in the oral cavity. Lower lip and lateral tongue and floor of the mouth are the most common locations for the development of oral squamous cell carcinoma. Clinically the lesions may be presented as a leukoplakic, erythroplakic, ulcerated and fungating and expanding lesions. Any mucosal lesion in the mouth that does not disappear after initial treatment must be biopsied in order to rule out malignancy. Treatment of the oral squamous cell carcinoma may include surgery, radiation therapy and chemotherapy depending on the size, location and the stage of the tumor.

Acknowledgement: This case was contributed by Dr. John Rydlewicz (Appleton), an oral surgeon.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414- 805-8440.

#129

A 45-year-old female was referred to a dental clinic for the evaluation and treatment of a polypoid and papillary lesion of labial mucosa (figure #1). The lesion was asymptomatic and the patient could not remember the duration of the lesion.

Final diagnosis: Squamous Papilloma

Squamous Papilloma is a benign proliferation of stratified squamous epithelial tissue. The lesion is caused by a DNA virus called Human Papilloma Virus. Various types of HPV are associated with lesions of mucosa and skin including Papilloma condyloma acuminatum (venereal wart), verrucous vulgaris and focal epithelial hyperplasia. The squamous papilloma is an asymptomatic, exophytic, pedunculated or sessile lesion of soft tissue that is covered by numerous small finger-like projections. The projections may be pointed or blunted and depends on the degree of keratinization the lesion may appear red, white or have a normal color. The lesions are usually small, but large sized papillomas have been reported in the literature. Papilloma can be easily mistaken with verrucous vulgaris, venereal wart and other [papillary] lesions. Conservative surgical excision is the treatment of choice and histological examination of the lesion would confirm the clinical diagnosis.

Acknowledgement: This case was contributed by Dr. Laura Benesh, a Marquette University School of Dentistry alumna.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414- 805-8440.

#128

A 56-year-old male was referred to an oral surgery clinic for the diagnosis and treatment of a papillary and leukoplakic lesion of left posterior lateral tongue (figure #1). The lesion was asymptomatic and the patient was not aware of this lesion.

Final diagnosis: Oral Squamous Papilloma

Squamous papilloma is a benign epithelial tumor caused by Human Papilloma Virus (HPV). Papilloma is the most common papillary (verrucous) lesion of oral cavity. While papilloma may be found at any intraoral sites but soft and hard palate and uvula are the most common locations for their development. The size of papilloma may vary and are generally less than 1 centimeter in greatest dimension. The lesions are usually presented as a sessile or pedunculated papillary (cauliflower-like) nodule. They are generally solitary and asymptomatic in their presentation. The differential diagnosis should include verrucous xanthoma, papillary hyperplasia and Condyloma acuminatum (venereal wart). Surgical removal is the treatment of choice either by routine excision or laser ablation.

Acknowledgement: This case was contributed by Dr. Christopher Bergstrom (Appleton), an oral surgeon.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414- 805-8440.

#127

A 58-year-old white male was referred to an oral surgery clinic for the diagnosis and treatment of an asymptomatic and ulcerated lesion of right lateral and ventral tongue (figure #1). The patient was a cigarette smoker and the duration of this lesion was not known.

Final diagnosis: Invasive Squamous cell carcinoma

Squamous cell carcinoma is the most common primary malignancies of the mouth (90 percent of all oral cancers). Tobacco habits and drinking alcoholic beverages are implicated as the main causative factors in development of the oral squamous cell carcinoma. Actinic radiation, immunosupression, and chronic irritation may also contribute in formation of this type of cancer in the oral cavity. Lower lip and lateral tongue and floor of the mouth are the most common locations for the development of oral squamous cell carcinoma. Clinically the lesions may be presented as a leukoplakic, erythroplakic, ulcerated and fungating and expanding lesions. Any mucosal lesion in the mouth that does not disappear after initial treatment must be biopsied in order to rule out malignancy. Treatment of the oral squamous cell carcinoma may include surgery, radiation therapy and chemotherapy, depends on the size, location and the stage of the tumor.

Acknowledgement: This case was contributed by the Oral & Maxillofacial Surgery Associates in Appleton, Wis.

Ezedin M. Sadeghi, DDS, MS Oral & Maxillofacial Pathologist Associate Professor, Marquette University School of Dentistry Referral and Consultation: 414-288-6559. Biopsy Service: 414- 805-8440.

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