Oral manifestations in Cowden's syndrome. Report of four cases

An unusual case of the congenital mesenchymal hamartoma of the neck associated with the midline cervical cleft in neonate

Objectives

Hamartomas are non-neoplastic developmental anomalies, mostly congenital, characterized by uncontrolled, disorganized proliferation of local endogenous tissue, which can normally be found at the site of origin and are very often mesodermally derived. It is well known that hamartoma can be associated with congenital midline cervical cleft and therefore cause a variety of symptoms. In general, they are benign and indolent, but they can be the cause of complex morbidity if they are localized within specific regions, such as the head and neck, which represent highly sensitive and vulnerable areas.

Case presentation

The reported case is unusual because of the presence of a congenital mesenchymal hamartoma along with the median cervical cleft, in a 1-day-old neonate, without the presence of any respiratory symptoms or associated congenital features. Although extremely rare, hamartomas should be included in the differential diagnosis of congenital neck masses, with emphasis on diagnostic approach, to avoid overly aggressive treatment and possible complications, such as infection, further mass growth, malignant transformation and compression of the adjacent neck structures.

Conclusions

Appropriate and timely treatment of the hamartoma of the neck in neonates, with further follow-up is necessary to avoid an overly aggressive treatment and to distinguish benign from malignant lesions, which is necessary for successful curative outcome.

Clinical manifestations of gastrointestinal diseases in the oral cavity

Aim

In this review, several gastrointestinal diseases that dentists may encounter in practice are highlighted and discussed.

Materials and methods

Using MEDLINE (PubMed), a comprehensive review of gastrointestinal diseases and their oral cavity manifestations was performed.

Results

Many gastrointestinal diseases present with oral symptoms that are detectable by dentists and dental hygienists. Often, oral manifestations of the disease may appear before systemic signs and symptoms. Managing patients with these conditions requires dentists to adjust their treatment and/or involve other health professionals.

Conclusion

Care must be taken when providing periodontal therapy or dental implants to patients suffering gastrointestinal diseases who are at high risk of bleeding, infection, or malnutrition, for example. Also, pharmacological therapy for these patients may need to be customized.

Orofacial Manifestations Assisting the Diagnosis of Cowden Syndrome in a Middle-Aged Patient: Case Report and Literature Overview

Middle-aged and old adults (≥ 50 years) diagnosed with Cowden syndrome (CS) with orofacial manifestations are uncommon. We describe a case of CS in a 53-year-old female showing "narrow bird-like" face, macrocephaly, acral keratoses, oral candidiasis, burning in the mouth, and multiple asymptomatic papillomatous lesions with a cobblestone pattern distributed on the alveolar ridge, tongue, buccal mucosa, and commissure. The histopathological features of lesions of the oral mucosa were those of papillary fibroepithelial hyperplasia. Immunohistochemistry revealed strong positivity for PTEN and p53 in most epithelial cells, while the expression of Bcl-2, S-100, and Ki-67 was weak/negative. According to a review conducted in PubMed, Web of Science, Embase, and Scopus for the analysis of reports of CS individuals ≥ 50 years with orofacial manifestations, 56 cases have been described in literature. Predilection for women was observed, with a female:male ratio of 2.3:1. Thirty-five (62.5%) individuals developed some malignant neoplasms. Oral health providers should be aware of the orofacial aspects of CS, including multiple papillomatosis, which can be an important criterion for diagnosis. Since malignancies may occur in older adults with CS, the need for strict surveillance is necessary. The present case has been under follow-up for 7 years without evidence of other manifestations.

Benign and Malignant Oral Lesions in Children and Adolescents: An Organized Approach to Diagnosis and Management

Oral lesions in children encompass a wide range of etiologies, including idiopathic entities as well as those related to an underlying systemic illness. In addition, oral masses include benign entities harboring locally destructive behavior and even malignancies in rare cases. Thorough patient history and detailed and efficient physical examination are critical for determining which lesions can be closely observed versus those require further diagnostic work-up. Understanding normal oral cavity anatomy is crucial for performing appropriate evaluation. This review describes the appropriate diagnostic and therapeutic strategies for oral cavity lesions and reviews the broad differential diagnosis of oral cavity masses.

Gingival fibromatosis: clinical, molecular and therapeutic issues

Gingival fibromatosis is a rare and heterogeneous group of disorders that develop as slowly progressive, local or diffuse enlargements within marginal and attached gingiva or interdental papilla. In severe cases, the excess tissue may cover the crowns of the teeth, thus causing functional, esthetic, and periodontal problems, such as bone loss and bleeding, due to the presence of pseudopockets and plaque accumulation. It affects both genders equally. Hereditary, drug-induced, and idiopathic gingival overgrowth have been reported. Hereditary gingival fibromatosis can occur as an isolated condition or as part of a genetic syndrome. The pathologic manifestation of gingival fibromatosis comprises excessive accumulation of extracellular matrix proteins, of which collagen type I is the most prominent example. Mutation in the Son-of-Sevenless-1 gene has been suggested as one possible etiological cause of isolated (non-syndromic) hereditary gingival fibromatosis, but mutations in other genes are also likely to be involved, given the heterogeneity of this condition. The most attractive concept of mechanism for drug-induced gingival overgrowth is epithelial-to-mesenchymal transition, a process in which interactions between gingival cells and the extracellular matrix are weakened as epithelial cells transdifferentiate into fibrogenic fibroblast-like cells. The diagnosis is mainly made on the basis of the patient's history and clinical features, and on histopathological evaluation of affected gingiva. Early diagnosis is important, mostly to exclude oral malignancy. Differential diagnosis comprises all pathologies in the mouth with excessive gingival overgrowth. Hereditary gingival fibromatosis may present as an autosomal-dominant or less commonly autosomal-recessive mode of inheritance. If a systemic disease or syndrome is suspected, the patient is directed to a geneticist for additional clinical examination and specialized diagnostic tests. Treatments vary according to the type of overgrowth and the extent of disease progression, thus, scaling of teeth is sufficient in mild cases, while in severe cases surgical intervention is required. Prognosis is precarious and the risk of recurrence exists.

Oro-facial-digital syndrome type II with otolaryngological manifestations

We present a case of oro-facial-digital syndrome type II (Mohr's syndrome) which is characterized by malformations of the oral cavity, face and digits. The facial and oral features include tongue nodules, cleft or high-arched palate, missing teeth, broad nose; cleft lip. The digital features include clinodactyly, polydactyly, syndactyly, brachydactyly and duplication of the hallux.

Cowden's disease—its importance for otolaryngologists

Cowden's disease is a rare predominantly inherited disease, characterized bymucocutaneous lesions, gastrointestinal polyposis and benign or malignant thyroid and breast tumours. The report deals with a typical case of this disease with emphasis on its importance forotolaryngologists.

Bannayan-Riley-Ruvalcaba syndrome: report of a family

Bannayan-Riley-Ruvalcaba (BRR) syndrome is a rare inherited condition. We describe the protean orofacial manifestations of this syndrome in one family and consider their management. The dental surgeon should be aware of this entity, its orofacial connotations and the possible association with Cowden's syndrome.

Otolaryngologic aspects of oral-facial-digital syndrome

The oral-facial-digital (OFD) syndromes are a heterogeneous group of hereditary disorders which have in common the findings of oral abnormalities, facial dysmorphism, and hand/feet malformations. We report the case history of an 18-month-old male with cerebellar cysts, hydrocephalus, tongue hamartomas, and polydactyly. These findings are most consistent with OFD VI. The clinical features of eight different types of OFD are discussed, with particular attention to the characteristics of the most interest to the otolaryngologist.

Multiple hamartoma syndrome presenting with oral lesions

Multiple hamartoma syndrome (Cowden's syndrome), a rare genodermatosis with predominant mucocutaneous features, particularly hamartomas, and Cowden/Lhermitte-Duclos disease, the combination of multiple hamartomas with cerebellar hypertrophy, typically present with cutaneous and oral papillomatosis as major features of both uncommon disorders. This article details the clinical features of three patients with multiple hamartoma syndrome and one with both disorders.

Early diagnosis of multiple hamartoma and neoplasia syndrome (Cowden disease). The role of the dentist

A typical case of Cowden disease is presented. This is rare mucocutaneous disease, genetically determined, with multiple organ system involvement in which a malignancy, particularly of breast and thyroid gland, may develop. The disease can be diagnosed in its early stages by gingival and cutaneous manifestations. We emphasize that the dentist may be the first health care professional who recognizes the syndrome, which is a crucial step to prevent and cure the predictable malignancy.

Cowden's disease: a rare but important manifestation of oral papillomatosis

A case of Cowden's disease is reported, and possible differential diagnosis for the oral lesions is suggested.

Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer

Oral submucous fibrosis (OSF) is a chronic disease of the oral mucosa characterized by inflammation and a progressive fibrosis of the lamina propria and deeper connective tissues. It is a condition predominantly seen among people of Indian origin, and an epidemiologic survey done a decade ago showed no less than 250,000 cases in India, a figure that must have increased sharply. OSF is a condition with a high risk of malignant transformation; to date, no conclusive etiologic agent has been identified, although plenty of data have been generated on various aspects of the disease. These include genetic, carcinogenic, immunologic, viral, nutritional, and autoimmune possibilities, all of which also have been implicated in the development of oral cancer. This article reviews existing evidence on the pathogenesis of OSF and its relation to oral cancer and suggests a possible multifactorial model to explain the disease process.

Heterogeneity in the gingival fibromatoses

Forty-nine cases of isolated familial and idiopathic gingival fibromatoses, consisting of 12 cases from six families and 37 cases of idiopathic gingival fibromatosis, were reviewed. Pedigrees of five families revealed various penetrances and genetic heterogeneity as suggested by the presence of both autosomal dominant and autosomal recessive inheritances. Ultrastructurally, the lesions were composed of fibroblast-like cells and myofibroblast-like cells, with the former being the predominant cell type. The 267 cases of familial and idiopathic gingival fibromatoses were analyzed, and they with or without hypertrichosis, mental retardation, and/or epilepsy. These included 49 cases seen by the authors, 50 cases from the Japanese literature, and 168 cases from non-Japanese literature. Isolated gingival fibromatosis occurred more frequently after age of 12 years (P less than 0.0074). There was no significant difference in age of onset between generalized and localized forms of the idiopathic gingival fibromatosis. Gingival fibromatosis with hypertrichosis and mental retardation and/or epilepsy occurred frequently before 12 years (P less than 0.069). It has been shown that heterogeneity of the gingival fibromatosis is a result of either histologic heterogeneity, genetic heterogeneity, or a combination with other systemic disorders.

Cowden's disease: a case report and literature review

Cowden's disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 51-year-old man with hyperplastic polyposis of the entire alimentary tract as the most prominent feature of this disease. We also present a review of 85 cases of this entity as reported in the English medical literature, and summarize the pertinent findings.