Odontogenic keratocyst: Review of 256 cases for recurrence and clinicopathologic parameters

Odontogenic keratocyst (OKC) is of particular interest because of its high recurrence rate and aggressive behavior. Two hundred fifty-six cases of OKC were reviewed for the age of the patient at diagnosis, sex of the patient, OKC location, and radiographic findings, and 132 patients with OKC were observed to estimate recurrence, which was analyzed for age, sex, location, and several histopathologic findings. OKCs occurred more frequently in men (58.6%) than in women (41.4%), and they occurred in patients within a wide age range, most commonly in patients in the third decade of life (28.9%), followed by those in the second decade (25.0%); the mean age of patients with OKC was 30.8 years. One hundred ninety-six of the 256 cases (76.5%) occurred in the mandible, and the other 60 cases (23.5%) occurred in the maxilla. The mandibular molar and the premolar areas (51.2%) were the most common sites, and the most frequent clinical manifestations at first admission were swelling, pain, or both (82.4% of total cases). Radiographic impressions included dentigerous cyst (27.3%), OKC (25.4%), primordial cyst (14.8%), ameloblastoma (11.7%), residual cyst (9.8%), and radicular cyst (3.1%). The frequency of recurrence at the follow-up examination was 58.3%. There was no significant difference in the recurrence rate on the basis of the sex of the patient. However, OKCs had a significantly higher recurrence rate in patients in the fifth decade of life than in patients in the other age groups (P = .005).Recurrence rates were significantly dependent on the sites of involvement, and OKCs in the mandibular molar region had significantly higher recurrence rates than those in other sites (P = .001). The histopathologic presence of one or more daughter cysts was significantly related to recurrence (P = .03).

A review of clinical features in 13 cases of impacted primary teeth

AIM

The aim of this study was to review clinical findings in 14 impacted primary teeth in 13 cases treated at a Paediatric Dental Clinic over a period of 18 years.

METHOD

The retrospective study used clinical records, radiographs and oral photographs. Data included age, gender, presenting complaints, location, radiographic findings, aetiological factors, treatment and prognosis of impacted primary teeth and their permanent successors.

RESULTS

The patients included five males and eight females aged from one year two months to seven years five months. One case had impacted bilateral, mandibular primary central incisors and the remaining 12 cases each had one impacted tooth. The maxillary second primary molar was the tooth most frequently involved. Permanent successor tooth germs were identified in 12 teeth but not in two. Five cases were impacted because of odontomas, in the case with bilaterally affected mandibular primary central incisors these were malpositioned and were erupting ectopically. In seven cases, aetiology was unknown. Four impacted primary teeth were extracted because eruption was unlikely. In four cases, odontomas were surgically removed and the teeth kept under observation. The remaining six were surgically exposed. Traction was applied in two of the six. Eight of the teeth erupted. In two teeth in which traction was used, one was subsequently extracted, and one erupted. In the cases of seven, permanent successors erupted. These were hypoplastic teeth and were delayed in development and eruption.

CONCLUSIONS

Impacted primary teeth may be associated with defects in development and eruption of their permanent successors, long-term observation is therefore necessary until the permanent successors erupt.

Ameloblastoma: clinical features and management of 21 cases

A retrospective study of 21 patients with ameloblastoma, operated in Tikur Anbessa Hospital between September 1990 to August 1997, is reported. There were 14 male and 7 female patients. The mean age at diagnosis was 26 years. There were three paediatric patients aged 6,9 and 12 years. The average duration of illness was 4 years with a wide range of 3 months to 12 years. Complete medical record was recovered for 9 patients. Clinical features were pain on chewing in 7 out of 9 (78%) and mandibular swelling in 5 out of 9 (56%) of which there was ulceration with bloody and/or purulent discharge. Diagnosis was made by clinical presentation, x-ray of the mandible and fine needle aspiration cytology. Two patients had malignant ameloblastoma as confirmed by excisional biopsy. All patients were managed surgically. Of nine patients whose clinical records could be retrieved, five had hemimandibulectomy, two had segmental resection and two had local resection and curettage. Recurrences were seen in two patients. Post-operative stay was complicated by infection and salivary fistula in 55%; these patients were discharged after 29.6 days as compared to 14 days in those that were not complicated. One patient with malignant tumor needed tracheostomy and intensive care for one week. There were no deaths. Ameloblastoma is predominantly a benign disabling but curable disease. Radical excision is recommended to avoid recurrence.

Cytokeratin expression in the odontogenic keratocyst

PURPOSE

This study attempted to identify differential cytokeratin expression in cystic jaw lesions using immunohistochemical staining.

PATIENTS AND METHODS

The charts from selected patients treated between 1983 and 1994 for jaw cysts were evaluated. Twenty-four paraffinized specimens were selected randomly for investigation with 5 immunohistochemical stains. The 4 diagnostic categories included ameloblastoma, dentigerous cyst, odontogenic keratocyst (OKC), and recurrent odontogenic keratocyst in patients with nevoid basal cell carcinoma (NBCC) syndrome. The 5 immunohistochemical stains included antibodies to cytokeratins 13, 17, and 18; CAM 5.2; AE 1/3; and carcinoembryonic antigen (CEA).

RESULTS

Differential staining of OKCs from patients with and without NBCC syndrome was found only with the antibody to cytokeratin 17. Furthermore, staining of OKCs in syndromic patients appeared to be stronger and more uniform than in nonsyndromic patients.

CONCLUSIONS

These findings suggest that immunohistochemical staining for cytokeratin 17 may aid in the diagnosis of OKCs and may be used to further subdivide these lesions based on the presence or absence of NBCC syndrome.

A case of Burkitt's lymphoma that presented initially with resorption of alveolar bone

A 16-year-old male was evaluated for a 1-month history of alveolar bone resorption, which had been treated with endodontics by a neighborhood dentist. Intraoral examination showed slight gingival swelling and teeth mobility. However, no tumor mass was seen. The panoramic image showed resorption of alveolar bone and loss of teeth lamina dura. Because he complained of general fatigue, he was introduced to the internist. Biopsies of gingiva and bone marrow aspiration revealed a massive proliferation of lymphoblasts expressing CD10, 19, 20 and HLA-DR antigens on the surface. Their karyotypes were abnormal; 46, XY, t (8;14) (q24;q32). Accordingly, he was diagnosed as Burkitt's lymphoma, and received intensive chemotherapy which relieved his symptoms and decreased his tumor. However, his disease soon became refractory to chemotherapy, and he died 11 weeks after the onset.

A genotypic and histopathological study of a large Dutch kindred with hyperparathyroidism-jaw tumor syndrome

Familial primary hyperparathyroidism is the main feature of 2 familial endocrine neoplasia syndromes: multiple endocrine neoplasia type 1 (MEN 1) and hyperparathyroidism-jaw tumor syndrome (HPT-JT). The latter is a recently described syndrome that has been associated with ossifying fibroma of the jaw and various types of renal lesions, including benign cysts, Wilms' tumor, and hamartomas. To further illustrate the natural history of this syndrome, we describe a large, previously unreported Dutch kindred in which 13 affected members presented with either parathyroid adenoma or carcinoma; in 5 affected individuals, cystic kidney disease was found. Additionally, pancreatic adenocarcinoma, renal cortical adenoma, papillary renal cell carcinoma, testicular mixed germ cell tumor with major seminoma component, and Hürthle cell thyroid adenoma were also identified. Linkage analysis of the family using MEN1-linked microsatellite markers and mutation analysis excluded the involvement of the MEN1 gene. Using markers from the HPT-JT region in 1q2531, cosegregation with the disease was found, with a maximum logarithm of odds score of 2.41 obtained for 6 markers using the most conservative calculation. Meiotic telomeric recombination between D1S413 and D1S477 was identified in 3 affected individuals, and when combined with previous reports, delineated the HPT-JT region to 14 centimorgan. Combined comparative genomic hybridization and loss of heterozygosity data revealed complex genetic abnormalities in the tumors, suggesting different possible genetic mechanisms for the disease. In conclusion, we report a family with hyperparathyroidism linked to chromosome 1q, and exhibiting several types of renal and endocrine tumors that have not been previously described.

Odontogenic keratocyst: the northwestern USA experience

Odontogenic keratocyst (OKC) is a cyst of tooth origin with an aggressive clinical behavior including a high recurrence rate. OKC demographics in the northwestern United States are presented and compared to those reported elsewhere. A total of 430 cases were obtained from 393 patients of the northwest region over a period of 15 years. Data evaluated included: site, gender, age, race, and association with bifid-rib basal cell nevus syndrome (Gorlin syndrome). Site distribution of the northwest group was similar to that of international groups. For the northwest group, the most common lesion location was the body of the mandible. Gender distribution in the northwest group appeared similar to other reports made in Denmark, England, Japan, and other regions in the United States. However, when gender distribution was compared by decade of life, the northwest group had the largest cluster of males in the fourth decade and of females in the second decade. The greatest frequency in both genders occurred in the third decade. There were 18 of 258 (6.9%) male patients with OKC under age 10 in the northwest group and nearly 80% of the patients were Caucasian. The race factor is rarely described in other reports. Gorlin's syndrome was present in 5% of the patients, with a higher distribution in the first and second decades. In conclusion, this is the first report of OKC cases from the Pacific Northwest region of the United States of America.

Cemento-osseous dysplasia of the jaws in 54 Japanese patients: a radiographic study

OBJECTIVE

The aim of this study was to describe the radiographic patterns of cemento-osseous dysplasia.

STUDY DESIGN

Fifty-four patients affected with benign fibro-osseous jaw lesions that showed periapical radiopacities and/or radiolucencies in a focal or a multiplex form were studied. The clinical, radiographic, and histopathologic features of the patients with cemento-osseous dysplasia were retrospectively studied. Radiographic features of the cemento-osseous dysplasia lesions were classified according to the appearance of calcified bodies. Radiographic visibility of periodontal ligament spaces of related teeth was assessed.

RESULTS

Forty-nine (91 %) of the 54 patients were women. The mean age of the total group was 50.8 years, and that of the male group was 64.6 years. The cemento-osseous dysplasia lesions could be classified into 6 types radiographically. Eighteen patients had at least 2 or more types of cemento-osseous dysplasia lesions. Of 147 related teeth, 142 had periodontal ligament spaces clearly visible. Six of 9 patients who had a total of 25 teeth with active hypercementosis showed concomitant occurrence of other types of cemento-osseous dysplasia lesions. Biopsy specimens showed various amounts of bonelike and cementumlike tissues.

CONCLUSIONS

It is likely that cemento-osseous dysplasia consists of 3 variations of a single entity, all with the same unknown cause. In one variation, the entity originates from the periodontium; in another, it is of medullary bone origin; and in the third it results from the simultaneous involvement of both tissues.

Odontogenic keratocyst: a clinical experience in Singapore

The odontogenic keratocyst has been well documented and extensively studied. It is of particular interest because of its high recurrence rate and aggressive nature. The material for this study consisted of 70 cases of odontogenic keratocysts in predominantly ethnic Chinese patients who were treated from 1981 to 1996. The cases were retrospectively studied to compare characteristics of the lesion in this population with those in previous reports. Most of the patients in this series were 21 to 30 years of age. Association with an impacted mandibular third molar was found in more than 50% of the cases. The recurrence rate was 20% for 35 patients with a follow-up period of at least 5 years. The follow-up period for the whole series ranged from 1 to 16 years. Treatment was surgical enucleation with peripheral ostectomy. There were no significant differences in characteristics with respect to presentation and prognosis between this series and those described in previous publications.

Squamous cell carcinoma of gingiva and edentulous alveolar ridge: a clinicopathologic study

All oral squamous cell carcinomas were retrieved from the files of Temple University's Oral Pathology Laboratory from 1967 through 1994 for a clinicopathologic study of those occurring on the gingiva. A total of 1,193 cases had sufficient data for tabulation and statistical analysis, of which 300 (25%) arose on the gingiva or alveolar ridge. The largest number of these cases (211/300) occurred on the mandibular gingiva or alveolar ridge. The mean age of the patients was 66.66 years, with males accounting for 57% of cases. Many case comparison analyses of oral squamous cell carcinomas do not separate oral subsites or specifically address carcinoma of the gingiva. The results were compared with other published series and suggest that further studies are needed because of the wide range of reported figures on the incidence of gingival squamous cell carcinomas.

[Oral candidiasis following radiotherapy for neoplasms of the oromaxillofacial area]

The authors report the clinical and histopathologic factors of oral candidiasis in patients treated with irradiation for head and neck cancer and predisposing antimycotic related treatments.

Differential diagnosis of jaw pain in the elderly

While many diseases are marked by pain in the mandible or maxilla, a number of these conditions appear to be more prevalent in people 65 years and older. People in this age group often have a number of medical problems and take a variety of medications, so clear-cut diagnosis of jaw pain can be difficult. Memory deficits or concomitant somatic complaints can further complicate the diagnosis. This article presents a differential for jaw pain in the elderly and reports on a pertinent case.

[Familial hyperparathyroidism]

Recently, not only the multiple endocrine adenomatosis (MEN)-associated type but also the type which can be isolated from MEN syndrome have been widely accepted in the classification of familial hyperparathyroidism. Analysis of gene markers specific to MEN syndrome contributed markedly to the establishment of isolated familial hyperparathyroidism. We attempted an analysis of 15 pedigrees in the report of familial hyperparathyroidism in which MEN syndrome was actively ruled out. In 7 pedigrees, adenoma alone was seen while in 2 pedigrees was hyperplasia alone seen. In 6 pedigrees parathyroid carcinoma was also admitted (other members of the pedigree were affected with parathyroid adenoma or hyperplasia). There were 5 pedigrees in which cementifying fibroma or ossifying fibroma of the jaw was associated with familial hyperparathyroidism. The association of parathyroid carcinomas or benign jaw tumors should be paid attention.

Comparative study of inhibitory effects by murine interferon gamma and a new bisphosphonate (alendronate) in hypercalcemic, nude mice bearing human tumor (LJC-1-JCK)

The inhibitory effect of murine interferon gamma (muIFN gamma) on humoral hypercalcemia in nude mice bearing lower-jaw cancer (LJC-1-JCK), in which parathyroid-hormone(PTH)-related protein is responsible for causing humoral hypercalcemia by activating bone resorption, was examined in comparison with that of a new bisphosphonate, 4-amino-1-hydroxybutylidene-1,1-bisphosphonate (alendronate). muIFN gamma was injected into tumor-bearing nude mice for 5 days before the establishment of hypercalcemia. The increase of plasma calcium concentration was delayed and this effect continued for more than 6 days even after the injection was stopped. Alendronate markedly suppressed hypercalcemia in tumor-bearing nude mice but this inhibitory effect continued for less than 6 days. Neither muIFN gamma nor alendronate affected the tumor volume or serum PTH-related protein concentration. Injection of muIFN gamma into mice for 3 days almost completely abolished the formation of multinucleated osteoclast-like cells from bone marrow cells in vitro, whereas injection of alendronate into mice had no effect. These findings suggested that muIFN gamma suppressed the formation of osteoclasts, resulting in the prolonged decrease of plasma calcium concentration in hypercalcemic tumor-bearing nude mice, whereas alendronate is cytotoxic to functionally mature osteoclasts and inhibited osteoclastic bone resorption, resulting in a marked decrease in the plasma calcium concentration in tumor-bearing hypercalcemic nude mice.

[Secondary jaw deformities accompanying tumors and tumor-like formations in children and adolescents]

Clinical follow-up of children aged 2 to 14 with tumors and tumor-like formations permitted diagnose secondary deformations of maxillary bones in 44. Symptomatology of these deformations had signs which distinguished intraosteally growing tumors from extraosseous ones localized in soft tissues adjacent to jaw bones. Good results were attained with the use of protective labial and buccal plates which not only shielded bone formations from tumor pressure before surgery but created a support for compressive dressing during sclerosing therapy of vascular tumors in children. Reconstructive and orthodontic measures, implantation of prostheses are necessary in the active period of growth and formation of maxillofacial and dental system after organ-destroying surgery for tumors and tumors-like formations in order to not only repair the anatomical shape but more so to optimize the conditions for normal functioning of the growing and forming maxillofacial and dental system of a child.

Nutritional status of patients with oral and maxillofacial malignancies

A nutritional assessment battery consisting of the patient's history, anthropometric measurements, and laboratory tests was used to characterize the nutritional status of 127 patients with oral and maxillofacial malignancies. Forty-three percent of these patients had good nutrition, 21% fair, and 36% poor. The pattern of nutritional impairment was a protein-calorie deficiency. A close correlation with malnutrition was found for diminished oral intake and tumor stage. Gender, tobacco or alcohol consumption, job, and living place were not related to nutritional status.

Primary intraosseous carcinoma: review of the literature and diagnostic criteria

Twenty-four reports describing 39 cases of primary intraosseous carcinoma (PIOC) were reviewed and the clinicopathologic features were summarized. The mean age of the patients at the time of diagnosis was 51.0 years, and the male: female ratio was 2:3. The posterior mandible was the predominant site; in no patient was a lesion observed in the posterior maxilla. Twenty-five of 31 patients (80.6%) showed swelling of the oral mucosa. However, ulcer formation was observed in only 3 of 36 patients. Pain, sensory disturbances, and metastasis to regional lymph nodes were observed in 25 of 34 patients (73.5%), 9 of 15 patients (60%), and 13 of 33 patients (39.4%), respectively. Radiographically, most lesions produced bone resorption with ill-defined margins (51.6%) or with well-defined margins (19.4%). The diagnostic criteria proposed for PIOC are absence of ulcer formation, except when caused by other factors; histologic evidence of squamous cell carcinoma without a cystic component or other odontogenic tumor cells; and absence of another primary tumor on chest radiographs obtained at the time of diagnosis and during a follow-up period of more than 6 months.

Limitation of panoramic radiography in diagnosing adenomatoid odontogenic tumors

Adenomatoid odontogenic tumor is frequently not diagnosed preoperatively even when radiographs are available. This study evaluates radiographic findings with special emphasis on the characteristic radiopacities of adenomatoid odontogenic tumor. In correlating radiologic findings with pathologic findings, differences in diagnostic accuracy between intraoral periapical and panoramic radiographs were found. The intraoral periapical radiograph allows perception of the radiopacities in adenomatoid odontogenic tumor as discrete foci having a flocculent pattern within radiolucency even with minimal calcified deposits. Panoramic radiography was often unable to demonstrate radiopacities in adenomatoid odontogenic tumor when the calcification was minimal. The result indicates that intraoral radiographs may be essential for correct radiographic interpretation of an adenomatoid odontogenic tumor in the presence of minimal quantities of calcified deposits.

[Clinical nutrition in maxillofacial cancer surgery. A review of the literature]

The authors review the literature on problems of nutrition in patients with operable maxillofacial neoplasms. The causes of malnutrition in head-neck tumours will be particularly examined: metabolic alteration due to the presence of neoplasm; the tumour being situated in the first upper respiratory-digestive tracts; the side effects of chemotherapy and/or radiotherapy; the results of surgery and finally those of a late diagnosis. Once clinical nutrition has been indicated by both clinical and biochemical parameters, a plan for the most frequently used pre- postoperative treatments is drawn up. Reviewing the literature disagreement is found as the most effective method--enteral or parenteral--given that both solutions present advantages and disadvantages. The former is more physiological less expensive and simpler to carry out while the latter permits a more individualised form of treatment and the metabolic evaluation is simplified. The authors will go to present their own treatment plans: parenteral in the preoperative phase and in the postoperative patient a gradual weaning from parenteral to enteral treatment. The most important lines in both enteral and parenteral feeding are examined and the authors conclude by confirming that artificial nutritional therapy makes absolutely no difference to the prognosis but allows the patient to undergo the appropriate therapy.

Third molars confusing the diagnosis of carcinoma

The purpose of this study was to describe cases of oral cancer in which the initial presenting symptoms were considered to be due to third molars and in which the underlying carcinoma therefore escaped early diagnosis. Between 1986 and 1990 a total of five cases with squamous cell carcinoma associated with a third molar (impacted, partially or totally erupted, or recently extracted) were treated at our unit. Because of acute or chronic symptoms related to disturbed eruption of third molars, the detection of a simultaneous malignant change and referral were delayed. In conclusion, all third molars, especially impacted, partially erupted, or overerupted ones, should be examined critically, especially if the patient has symptoms.

North American Burkitt's lymphoma presenting with intraoral symptoms

A case is presented in which posterior tooth mobility and pain, bilateral intraoral swelling of the mandible, and anterior open bite following an incident of facial trauma were the presenting symptoms of a 4-year-old, white American male with Burkitt-type malignant lymphoma. Radiographic examination revealed multiple osteolytic lesions in the body of the mandible, with loss of osseous trabecular architecture, and generalized loss of lamina dura in both maxillary and mandibular arches. The patient also had bone marrow involvement at the time of diagnosis. Following the initial course of chemotherapy, the patient experienced a significant resolution of the bilateral mandibular swelling, anterior open bite, tooth mobility, and dental pain. Relapse occurred shortly after remission was achieved, with tumor metastasis to the central nervous system and testes. The tumor remained resistant to further chemotherapeutic treatments and radiation strategems. Because of renal and metabolic complications, Burkitt's lymphoma constitutes an oncologic emergency. If untreated, this rapidly growing tumor is fatal. Early interception and referral of these cases by the examining dentist is crucial.

[The ameloblastic fibroma. An odontogenic tumor in the growth period]

Nine cases of ameloblastic fibroma are described and compared with published data on this odontogenic tumour. The median age of the 7 male and 2 female patients was 11 years (range 2-17 yrs.). The tumour was localized in the posterior segment of the mandible and less often in the maxilla. The neoplasia was frequently associated with impaction and agenesis of teeth. Although recurrences of ameloblastic fibromas are rare, long-term follow-up is recommended.