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Keller E, Clocchiatti S, Rupel K, Ottaviani G, Ratti C, Canton G, Di Lenarda R, Murena L, Biasotto M. Chronic Diffuse Sclerosing Osteomyelitis of the Mandible: The Use of Bisphosphonates as a Treatment for a Rare and Challenging Condition. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:917. [PMID: 38929534 PMCID: PMC11205509 DOI: 10.3390/medicina60060917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024]
Abstract
Chronic diffuse sclerosing osteomyelitis is a very rare condition, described as a non-suppurative, inflammatory disease of the bone and characterized by a proliferative endosteal reaction, which clinically reveals itself with cyclic pain of the jaw and swelling. We reported two clinical cases, where patients suffered recurrent swelling and pain at the mandible irradiating to the preauricular area, denying any previous trauma or significant medical history. Odontogenic causes were excluded. An initial treatment with antibiotics and NSAIDs temporarily relieved the symptoms without complete resolution, prompting further investigations. After a comprehensive array of diagnostic tools (X-rays, CT scans, scintigraphy, bone biopsy, serum markers), both patients were diagnosed with chronic diffuse sclerosing osteomyelitis of the mandible. Bisphosphonates (clodronate and zolendronate) with different treatment schemes were used to treat the condition, until a full recovery from symptoms was reported. Bisphosphonates could therefore represent an effective option in managing this rare but impactful condition. Further research is warranted to better understand the underlying mechanisms of the disease and to optimize treatment strategies.
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Affiliation(s)
- Edgar Keller
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy; (E.K.); (K.R.); (R.D.L.); (M.B.)
| | - Susanna Clocchiatti
- Clinica Ortopedica e Traumatologica, Ospedale di Cattinara, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34100 Trieste, Italy; (S.C.); (C.R.); (G.C.); (L.M.)
| | - Katia Rupel
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy; (E.K.); (K.R.); (R.D.L.); (M.B.)
| | - Giulia Ottaviani
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy; (E.K.); (K.R.); (R.D.L.); (M.B.)
| | - Chiara Ratti
- Clinica Ortopedica e Traumatologica, Ospedale di Cattinara, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34100 Trieste, Italy; (S.C.); (C.R.); (G.C.); (L.M.)
| | - Gianluca Canton
- Clinica Ortopedica e Traumatologica, Ospedale di Cattinara, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34100 Trieste, Italy; (S.C.); (C.R.); (G.C.); (L.M.)
| | - Roberto Di Lenarda
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy; (E.K.); (K.R.); (R.D.L.); (M.B.)
| | - Luigi Murena
- Clinica Ortopedica e Traumatologica, Ospedale di Cattinara, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), 34100 Trieste, Italy; (S.C.); (C.R.); (G.C.); (L.M.)
| | - Matteo Biasotto
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy; (E.K.); (K.R.); (R.D.L.); (M.B.)
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Togninalli D, Antonarakis GS, Schatz JP. Condylar resorption following mandibular advancement or bimaxillary osteotomies: A systematic review of systematic reviews. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e948-e955. [PMID: 35263683 DOI: 10.1016/j.jormas.2022.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/04/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
Several systematic reviews have been published on the effects of mandibular surgery on condylar remodeling without reaching a consensus. The purpose of this systematic review of systematic reviews was to assess the impact of mandibular advancement or bimaxillary surgeries on condylar resorption. A literature search, using several electronic databases, was carried out by two reviewers independently. Article preselection was based on titles and abstracts, and final article selection based on full-text analysis of preselected studies. After final study selection, the quality of studies was assessed using the AMSTAR 2 tool. A decision algorithm was subsequently established to choose the best body of evidence. From an initial yield of 1'848 articles, 23 systematic reviews were identified for further analysis, with ten studies being included in the final selection. Despite the generally low quality of the reviews, certain associations could be made: young patients, female patients, and those with a high mandibular plane angle are more prone to condylar resorption following mandibular advancement osteotomies, especially if anterior rotation of the mandible is performed during surgery. Patients undergoing bimaxillary surgery also appear to have a higher risk of developing condylar resorption. In conclusion, these results confirm the multi-factorial nature of condylar resorption, stressing the need for well-controlled prospective studies with long-term follow-up to clearly identify potential risk factors associated with orthognathic surgery.
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Affiliation(s)
- David Togninalli
- Department of Orthodontics, University Clinic of Dental Medicine, Faculty of Medicine, University of Geneva, Switzerland
| | - Gregory S Antonarakis
- Department of Orthodontics, University Clinic of Dental Medicine, Faculty of Medicine, University of Geneva, Switzerland
| | - Jean-Paul Schatz
- Department of Orthodontics, University Clinic of Dental Medicine, Faculty of Medicine, University of Geneva, Switzerland
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van de Meent MM, Appelman-Dijkstra NM, Wetselaar-Glas MJM, Pichardo SEC, van Merkesteyn JPR. Bisphosphonate therapy in chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible: Retrospective case series. J Craniomaxillofac Surg 2022; 50:599-604. [PMID: 35768318 DOI: 10.1016/j.jcms.2022.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 04/26/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022] Open
Abstract
This study aims to evaluate short-term and long-term results of bisphosphonate therapy in patients with diffuse sclerosing osteomyelitis/tendoperiostitis (DSO/TP) of the mandible. Eighteen patients (12 female, 6 male) aged 34.8 ± 22.2 years with DSO/TP of the mandible that were treated with bisphosphonates were included. In 16 patients, the bisphosphonate treatment led to remission with decrease of symptoms (pain, swelling of the cheek, trismus, tenderness of masticatory muscles) with a follow-up period of 4.5 (0.8-11.9) years between start of bisphosphonate treatment and latest follow-up consult. Of these, three patients were still in need of regular bisphosphonate therapy. Two patients were lost to follow-up. Bisphosphonate therapy is a treatment option for DSO/TP of the mandible that is associated with a high chance of remission of symptoms. Within the limitations of the study it seems that this treatment might be an effective second step in DSO/TP refractory to conservative treatment.
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Affiliation(s)
- Marieke M van de Meent
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Natasha M Appelman-Dijkstra
- Centre for Bone Quality, Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Sarina E C Pichardo
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J P Richard van Merkesteyn
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
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4
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Waldman S, Shimonov M, Yang N, Spielman D, Godfrey KJ, Dean KE, Phillips CD, Helman SN. Benign bony tumors of the paranasal sinuses, orbit, and skull base. Am J Otolaryngol 2022; 43:103404. [PMID: 35246319 DOI: 10.1016/j.amjoto.2022.103404] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/13/2022] [Indexed: 11/15/2022]
Abstract
Benign bony tumors of the skull base and paranasal sinuses are uncommon entities, with an overall higher incidence in males. Benign bony tumors may lead to local expansion with resultant mass effect of potentially critical structures. Some benign bony tumors may undergo malignant transformation. This article reviews the presentation and management of benign bone tumors of the skull base and paranasal sinuses with special consideration to involvement of the adjacent orbit, intracranial and critical neurovascular structures. This review covers tumor incidence, location, gross and histologic appearance as well as radiographic findings, treatment, and recurrence rates. Tumors discussed in this article include osteochondromas, osteomas, osteoid osteomas, aneurysmal bone cysts, fibrous dysplasia, giant cell tumors, cemento-ossifying fibroma, ameloblastic fibro-odontoma, ecchordosis physaliphora, chondromyxoid fibroma, primary chronic osteomyelitis, primary chronic osteomyelitis, osteochondromyxoma, and dense bone islands.
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Affiliation(s)
- Spencer Waldman
- SUNY Downstate, College of Medicine, 450 Clarkson Ave, Brooklyn, NY 11203, United States of America.
| | - Menachem Shimonov
- SUNY Downstate, College of Medicine, 450 Clarkson Ave, Brooklyn, NY 11203, United States of America.
| | - Nathan Yang
- Weill Cornell Medical College, Department of Otolaryngology - Head and Neck Surgery, 2315 Broadway, 3rd Floor, New York, NY 10024, United States of America.
| | - Daniel Spielman
- Weill Cornell Medical College, Department of Otolaryngology - Head and Neck Surgery, 2315 Broadway, 3rd Floor, New York, NY 10024, United States of America.
| | - Kyle J Godfrey
- Weill Cornell Medical College, Department of Ophthalmology--1305 York Ave, 12(th) Floor New York, NY 10021, United States of America.
| | - Kathryn E Dean
- Weill Cornell Imaging at New York-Presbyterian 1305 York Avenue,3rd Floor, New York, NY 10021, United States of America.
| | - C Douglas Phillips
- Weill Cornell Imaging at New York-Presbyterian 1305 York Avenue,3rd Floor, New York, NY 10021, United States of America.
| | - Samuel Nathaniel Helman
- Weill Cornell Medical College, Department of Otolaryngology - Head and Neck Surgery, 2315 Broadway, 3rd Floor, New York, NY 10024, United States of America.
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Cheng W, Li F, Tian J, Xie X, Chen JW, Peng XF, Tang Q, Ge Y. New Insights in the Treatment of SAPHO Syndrome and Medication Recommendations. J Inflamm Res 2022; 15:2365-2380. [PMID: 35444448 PMCID: PMC9013916 DOI: 10.2147/jir.s353539] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare autoinflammatory disease characterized by dermatological disorders and osteoarticular inflammatory lesions. This article reviews the application of biologics and other treatments based on the therapeutic target and the size of molecules in SAPHO syndrome. We found that drugs, especially biologics, have different effects on bone, joint, and skin damage. This may relate to the different inflammatory pathways involved in the osteoarticular and cutaneous symptoms in SAPHO patients. In this study, we provide stratified medication recommendations for SAPHO syndrome. Patients with osteoarticular symptoms can consider tumor necrosis factor blockers, JAK inhibitor, interleukin (IL)-1 inhibitor, and IL-17 inhibitor. Patients with cutaneous symptoms should consider IL-17 and JAK inhibitors. Apremilast, Tripterygium wilfordii Hook F, and bisphosphonates are other effective treatments.
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Affiliation(s)
- Wei Cheng
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Fen Li
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Jing Tian
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Xi Xie
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Jin-Wei Chen
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Xiao-Fei Peng
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Qi Tang
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Yan Ge
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China
- Correspondence: Yan Ge, Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People’s Republic of China, Email
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Long-Term Follow-Up of SAPHO Syndrome for 15 Years Led to a Diagnosis of Temporomandibular Joint Pain and Trismus. Case Rep Dent 2021; 2021:3102037. [PMID: 34868689 PMCID: PMC8642013 DOI: 10.1155/2021/3102037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/19/2021] [Indexed: 11/17/2022] Open
Abstract
Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a systemic disease with symptoms of pustular skin disease and sterile osteoarticular lesions. This disease rarely involves the temporomandibular joint (TMJ). Although it is a disease with a good long-term prognosis, its treatment remains challenging. We describe a case with long-term follow-up of SAPHO syndrome for 15 years in which TMJ pain and trismus led to the diagnosis. A 30-year-old woman with TMJ pain and trismus was referred to our department. Her medical history included palmoplantar pustulosis. Sterile inflammation in the left TMJ and diffuse sclerosing osteomyelitis of the mandible were observed. Thus, she was diagnosed with SAPHO syndrome. The symptoms of severe TMJ pain, trismus, and left cheek swelling presented three times in the 15 years. Symptomatic treatment with nonsteroidal anti-inflammatory drugs, antibiotics, corticosteroids, and bisphosphonates was administered several times. There has been no relapse of symptoms over the past nine years. The patient must be continuously kept under observation to look for the relapse of symptoms.
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Leerling AT, Cañete AN, Ramautar AIE, Appelman-Dijkstra NM, Winter EM. Sternocostoclavicular Hyperostosis: Positive Clinical and Radiological Response on Pamidronate. Front Endocrinol (Lausanne) 2021; 12:621604. [PMID: 33679619 PMCID: PMC7930901 DOI: 10.3389/fendo.2021.621604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Sternocostoclavicular hyperostosis (SCCH) is a rare disease, constituting a chronic sterile osteomyelitis with elevated bone turnover in the axial skeleton, causing pain and shoulder dysfunction. SCCH severely interferes with daily activities, work, and quality of life. SCCH has a relapse-remitting disease course, but inflammatory-induced sclerotic transformation in the affected area is slowly progressive. Here we present two patients with clinical and radiological diagnosis of SCCH treated with intravenous pamidronate, leading to clinical remission in both, but complete resolution of sclerosis in one of them, which is a novel finding in our experience. CASE PRESENTATION Two adult female SCCH-patients presented with longstanding pain, swelling of the anterior chest wall, and compromised shoulder function. Subsequent single photon emission computed tomography-computed tomography (SPECT/CT) illustrated elevated bone activity and sclerosis in the SC region, with hyperostosis, confirming the diagnosis of SCCH. As symptoms in both patients were eventually refractory to standard painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs), intravenous pamidronate treatment in 3-month cycles was started. Pamidronate was effective in reducing pain and improving shoulder function and also led to decreased bone turnover on skeletal scintigraphy. Sclerosis in the first patient persisted. In the second patient, however, a complete resolution of sclerosis was observed. CONCLUSIONS SCCH remains a rare bone disorder for which no evidence-based therapies are yet available. While disease burden is high, SCCH lacks recognition and is often diagnosed long after symptomatic presentation. As for the cases in this report, pamidronate was successful in reducing symptoms, and in the second case even led to regression of sclerotic changes on CT-imaging.
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Affiliation(s)
- Anne T. Leerling
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Ana Navas Cañete
- Center for Bone Quality, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Ashna I. E. Ramautar
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Natasha M. Appelman-Dijkstra
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Elizabeth M. Winter
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Elizabeth M. Winter,
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Jia K, Li X, An J, Zhang Y. Comparing Clinical and Radiographic Characteristics of Chronic Diffuse Sclerosing Osteomyelitis and Craniofacial Fibrous Dysplasia in the Mandible. J Oral Maxillofac Surg 2020; 79:1053-1061. [PMID: 33345814 DOI: 10.1016/j.joms.2020.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Differential diagnosis of chronic diffuse sclerosing osteomyelitis of the mandible (DSOM) and craniofacial fibrous dysplasia (CFD) involving the mandible is challenging. The purpose of this study was to explore the differences of the clinical and radiographic characteristics between these 2 conditions. PATIENTS AND METHODS In this retrospective cross-sectional, blinded, comparative study, clinical and imaging data of patients with DSOM and CFD at the Peking University Hospital of Stomatology from 2012 to 2018 were retrieved. Clinical characteristics, mainly pain, swelling, and trismus, and radiographic findings, including sclerosis, lysis, and subperiosteal bone formation, were evaluated. The t test, χ2 test, and Fisher-Freeman-Halton test were used to determine differences. RESULTS Thirty-seven patients with DSOM and 32 patients with CFD were included (mean ages, 24.2 and 28.4 years, respectively); both groups showed a female predilection. DSOM (91.9%) and CFD (84.4%) were mainly unilateral. Patients with DSOM mainly presented with pain (94.6%), soft-tissue swelling (100.0%), and trismus (54.1%), whereas those with CFD did not experience pain (90.6%) and showed bone enlargement (87.5%) without trismus (6.3%). Panoramic radiographs and computed tomography scans of patients with DSOM showed subperiosteal bone formation, cortex lysis, and poorly demarcated cortex, whereas those patients with CFD mainly showed moderate-to-severe bone expansion, well-demarcated cortex, and tooth and mandibular canal displacement. CONCLUSIONS These findings emphasize the importance of clinical and radiographic features in differentiating between DSOM and CFD. Pain, soft-tissue or bone-tissue swelling, subperiosteal bone formation, clarity of the boundary of the cortex and medulla, and continuity of the cortical bone are key points facilitating differentiation.
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Affiliation(s)
- Kuankuan Jia
- Resident, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - Xiaoli Li
- Resident, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - Jingang An
- Associate Professor, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China.
| | - Yi Zhang
- Professor, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
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Orofacial manifestations of SAPHO syndrome: a systematic review of case reports. Clin Rheumatol 2020; 39:3277-3286. [DOI: 10.1007/s10067-020-05084-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/12/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
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The effectiveness of treatments for patients with SAPHO syndrome: a follow-up study of 24 cases from a single center and review of literature. Clin Rheumatol 2020; 40:1131-1139. [PMID: 32789818 DOI: 10.1007/s10067-020-05322-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 07/10/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of current treatments for SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) by delineating the therapeutic choices and the outcome of patients in a medical center of China and review of the literature. METHOD An observational study was performed on patients diagnosed as SAPHO syndrome in the Peking University First Hospital from 2009 to 2015. Clinical data including osteoarticular and cutaneous manifestations, laboratory and medical imaging findings, treatments, and outcomes were analyzed retrospectively. A literature detailing the usage of medicines and SAPHO syndrome patient responses to treatment were selected. RESULTS Clinical data of 24 patients were analyzed in this study. The mean age was 42.4 ± 15.5 years old at the time of diagnosis. Of a total of 17 patients that received the combination treatments of NSAIDs and DMARDs, 15 of them experienced an improvement in their symptoms. Bisphosphonates were given to 18 patients. Four patients were treated with TNF blockers, and one of them had adalimumab ineffective and then improved by add-on of DMARDs. The mean follow-up period was 2.5 years. Twenty-one patients (87.5%) had a favorable outcome and exhibited improved disease condition in the last follow-up. CONCLUSIONS The majority of patients with SAPHO syndrome respond well to combination therapy of NSAIDs, DMARDs, and bisphosphonates. TNF blockers are effective in a patient refractory to NSAID and DMARDs. However, in case TNF blockers are ineffective, add-on of DMARDs may be effective. Thus, the proper application of conventional DMARDs is still worth a position in the treatment of SAPHO syndrome. Key Points •NSAIDs and DMARDs and/or bisphosphonates can alleviate symptoms of the majority of patients with SAPHO syndrome. •TNF blockers are effective in patients who do not respond well to NSIADs and DMARDs. •In case TNF blockers are ineffective, add-on of conventional DMARDs may be effective.
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11
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Application of pamidronate disodium for the treatment of diffuse sclerosing osteomyelitis of the mandible: A clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:616-624. [PMID: 32771415 DOI: 10.1016/j.oooo.2020.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/31/2020] [Accepted: 06/30/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical effectiveness of using pamidronate disodium to treat patients with diffuse sclerosing osteomyelitis of the mandible (DSOM ). STUDY DESIGN Patients with DSOM who were hospitalized in the Department of Oral and Maxillofacial Surgery, Peking University Hospital of Stomatology (Beijing, China), between March 2018 and March 2019 were included. All patients were treated with intravenous administration of pamidronate disodium for 3 days. Pain intensity, mouth opening, blood workup findings, imaging examination findings, and incidence of complications before and after treatment and during the follow-up period, were recorded and compared. RESULTS Forty-three patients were treated with pamidronate disodium. Adverse reactions, including fever, hypocalcemia, hypokalemia, and diarrhea, were observed during treatment. Fourteen patients had moderate to severe pain before treatment, and the pain was markedly alleviated after days 2 and 3 of treatment. Pain and swelling were found to have disappeared at the 6-month follow-up in 39 patients (90.7%). Mean mouth opening increased from 28.5 mm to 38.1 mm. Imaging examinations showed that the bone mass in the affected area had markedly improved in 32 patients (74.4%). CONCLUSIONS Pamidronate disodium alleviated pain and swelling and improved mouth opening in patients with DSOM. Follow-up after 6 to 18 months demonstrated stable treatment effectiveness.
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Matharu J, Taylor H, Sproat C, Kwok J, Brown J, Patel V. Diffuse sclerosing osteomyelitis: a case series and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 129:437-446. [DOI: 10.1016/j.oooo.2019.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/17/2019] [Accepted: 11/21/2019] [Indexed: 11/16/2022]
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Outcome of different treatments for chronic diffuse sclerosing osteomyelitis of the mandible: a systematic review of published papers. Br J Oral Maxillofac Surg 2020; 58:385-395. [DOI: 10.1016/j.bjoms.2020.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 01/13/2020] [Indexed: 01/19/2023]
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Hameed M, Horvai AE, Jordan RCK. Soft Tissue Special Issue: Gnathic Fibro-Osseous Lesions and Osteosarcoma. Head Neck Pathol 2020; 14:70-82. [PMID: 31950477 PMCID: PMC7021863 DOI: 10.1007/s12105-019-01094-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/29/2019] [Indexed: 12/29/2022]
Abstract
Gnathic fibro-osseous lesions are a diverse group of disease processes which share overlapping microscopic features characterized by fibroblastic stroma with variable cellularity and a range of bone forming pathological processes leading to woven, sclerotic and cementum-like structures. Some of the lesions are unique to craniofacial location and a combination of clinical, radiological and pathological correlation is often necessary for diagnostic accuracy. Gnathic osteosarcomas are rare tumors with differences in age distribution and behavior as compared to osteosarcoma of long bones. This review will discuss the clinicopathological and radiological features of gnathic fibro-osseous lesions and osteosarcoma with updates on current genetics and molecular pathogenesis.
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Affiliation(s)
- Meera Hameed
- Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 USA
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15
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Non-surgical treatment of adults with chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible. J Craniomaxillofac Surg 2019; 47:1922-1928. [PMID: 31810841 DOI: 10.1016/j.jcms.2019.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/31/2019] [Accepted: 11/20/2019] [Indexed: 11/20/2022] Open
Abstract
Non-surgical therapy has proved to be effective in chronic diffuse sclerosing osteomyelitis (DSO) of the mandible in children. Therefore we aimed to investigate the effect of non-surgical therapy in adult DSO patients. We included consecutive patients with DSO who received non-surgical therapy in our center. They all received occlusal splint therapy, counselling about the disease, and/or physiotherapy by a specialised team. The use of analgesics, preferably nonsteroidal anti-inflammatory drugs, was advised for symptomatic control during periods of exacerbation. Sixteen patients (11/5 female/male) aged 39.9 ± 15.0 years with DSO of the mandible were included. The mean duration of symptoms was 39.7 ± 26.3 months before referral to our center. Patients were treated with a broad range of treatments before referral. All patients underwent non-surgical treatment. In 12 patients this led to remission. Four patients still had complaints after 12 months of non-surgical therapy and started with intravenous bisphosphonate therapy. In our center, DSO of the mandible was successfully treated with non-surgical therapy, despite a long duration before referral and extensive pre-treatment. Considering this high success rate, we recommend this non-surgical approach as the first treatment option for DSO of the mandible. In case of persistence, alternative treatments such as bisphosphonates should be explored.
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Sacco R, Shah S, Leeson R, Moraschini V, de Almeida Barros Mourão CF, Akintola O, Lalli A. Osteonecrosis and osteomyelitis of the jaw associated with tumour necrosis factor-alpha (TNF-α) inhibitors: a systematic review. Br J Oral Maxillofac Surg 2019; 58:25-33. [PMID: 31645276 DOI: 10.1016/j.bjoms.2019.09.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
Tumour necrosis factor-α (TNF-α) inhibitors are increasingly being used as immunomodulators to manage inflammatory conditions such as rheumatoid arthritis and Crohn's disease. Reported serious side effects include an increased incidence of lymphoma and greater susceptibility to infections such as tuberculosis. The aim of this systematic review was to find out whether there is an associated risk of medication-related osteonecrosis of the jaw (MRONJ). Three authors independently searched PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials for published reports of oral osteonecrosis (ONJ) or osteomyelitis (OM) in patients who took anti TNF-α drugs and had no history of antiangiogenic agents or antiresorptive treatment. All types of studies on humans treated with TNF-α inhibitors were considered. Only six were eligible for analysis, and all were independently assessed for risk of bias. They included six patients with ONJ or OM that was attributed solely to TNF-α inhibitors. The most common site of ONJ was the posterior mandible (n=5). The mean (SD) duration of anti-TNF-α treatment before the development of bony lesions was 62.5 (47.4) months. Invasive surgery was reported as a precipitating factor in five cases, and the ONJ/OM resolved with conservative management in five. Although all the studies were judged to be at high risk of bias, the limited data suggest that some patients will potentially develop ONJ/OM as a result of treatment with TNF-α inhibitors. Studies of higher quality are now needed to establish the relative risk of MRONJ in patients who take them.
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Affiliation(s)
- R Sacco
- Oral Surgery Department, Barts and the London School of Medicine and Dentistry, London E1 2AT, UK; Eastman Dental Institute - University College of London, London, WC1X 8LT, UK; King's College Hospital, London, SE5 9RW, UK.
| | - S Shah
- King's College Hospital, London, SE5 9RW, UK.
| | - R Leeson
- Eastman Dental Institute, London WC1X 8LT, UK.
| | - V Moraschini
- Fulminense Federal University, Rio De Janeiro, Brazil; Salgado de Oliveira University, R. Lambari, 10 - Trindade, São Gonçalo, RJ, Rio De Janeiro, 24456-570, Brazil.
| | - C F de Almeida Barros Mourão
- Estácio de Sá University, R. Raul Pompéia, 231 - Copacabana, Rio de Janeiro - RJ, 22080-000, Rio de Janeiro, Brazil.
| | - O Akintola
- King's College Hospital, London, SE5 9RW, UK.
| | - A Lalli
- Centre for Oral Immunobiology and Regenerative Medicine Barts and The London School of Medicine and Dentistry, London, E1 4NS, UK.
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Figueiredo ASB, Oliveira AL, Caetano A, Moraes-Fontes MF. SAPHO: has the time come for tailored therapy? Clin Rheumatol 2019; 39:177-187. [PMID: 31312988 DOI: 10.1007/s10067-019-04675-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 12/13/2022]
Abstract
SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome is a heterogeneous condition combining osteoarticular and cutaneous manifestations. Conventional treatments are mostly ineffective. We hereby report two patients, the first with an aggressive form of disease and the second with an incomplete response to two different anti-TNF-α agents. Both were successfully treated with tocilizumab and ustekinumab, respectively, over a long period of time. A narrative review of a biological therapy in SAPHO syndrome yielded very little information on the specific use of these agents. We highlight the advantages of personalising therapy and describe emerging promising treatments for this disease.
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Affiliation(s)
- Adelaide Sofia Batalha Figueiredo
- Unidade de Doenças Auto-imunes/Serviço Medicina 7.2, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal. .,Serviço de Medicina IV, Hospital de Santarém EPE, Av. Bernardo Santareno, 2005-177, Santarém, Portugal.
| | - Ana Luísa Oliveira
- Unidade de Doenças Auto-imunes/Serviço Medicina 7.2, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,Serviço de Medicina I, Unidade Local de Saúde do Baixo Alentejo, Hospital José Joaquim Fernandes, Beja, Portugal
| | - António Caetano
- Serviço de Radiologia do Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Maria Francisca Moraes-Fontes
- Unidade de Doenças Auto-imunes/Serviço Medicina 7.2, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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18
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Campana SC, Canceill T, Esclassan R. Oral care of a patient with a SAPHO syndrome and a nickel allergy. SPECIAL CARE IN DENTISTRY 2019; 39:231-235. [PMID: 30761569 DOI: 10.1111/scd.12362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 01/29/2023]
Abstract
SAPHO is an acronym for Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis. The syndrome is difficult to diagnose because it may present many different manifestations in adults and children. Its origin is still unknown, although some infectious, genetic and immune hypotheses have been put forward. We report the case of a 49-year-old woman with SAPHO syndrome, who developed a serious cutaneous allergy following the insertion of a removable partial denture (RPD). The oral care and treatment of this patient are described.
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Affiliation(s)
- Sophie-Caroline Campana
- Dental Faculty of Toulouse, Université Paul Sabatier, Hôpitaux de Toulouse, Toulouse Cedex 9, France
| | - Thibault Canceill
- Dental Faculty of Toulouse, Université Paul Sabatier, Hôpitaux de Toulouse, Toulouse Cedex 9, France.,CIRIMAT, University of Toulouse, CNRS, INPT, UPS, PPB Team, Université Paul Sabatier, Faculté de Pharmacie, Toulouse Cedex 9, France
| | - Rémi Esclassan
- Dental Faculty of Toulouse, Université Paul Sabatier, Hôpitaux de Toulouse, Toulouse Cedex 9, France.,Laboratoire AMIS UMR 5288 CNRS, Toulouse, France
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Daoussis D, Konstantopoulou G, Kraniotis P, Sakkas L, Liossis SN. Biologics in SAPHO syndrome: A systematic review. Semin Arthritis Rheum 2019; 48:618-625. [DOI: 10.1016/j.semarthrit.2018.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/30/2018] [Accepted: 04/16/2018] [Indexed: 02/08/2023]
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20
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Antao CJ, Dinkar AD, Khorate MM, Raut Dessai SS. Chronic Diffuse Sclerosing Osteomyelitis of the Mandible. Ann Maxillofac Surg 2019; 9:188-191. [PMID: 31293951 PMCID: PMC6585216 DOI: 10.4103/ams.ams_257_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Chronic diffuse sclerosing osteomyelitis (CDSO) is a disease that presents a rather unusual clinicoradiographic picture creating diagnostic and therapeutic problems. Involvement of the temporomandibular joint is not frequently observed in CDSO. We report a unique case of a 37-year-old male with cyclic episodes of insidious swelling and progressive trismus for the past 4 years. Each episode was followed by spontaneous remission after 2 weeks. Radiographic examination detected unilateral coarse trabeculae with ground-glass appearance of the left hemimandible and resorption of ipsilateral condyle. Computed tomography demonstrated endosteal sclerosis, cortical thickening, and condylar resorption, while magnetic resonance imaging revealed altered marrow intensity with postcontrast enhancement of the surrounding musculature. Bone histopathology was consistent with the diagnosis of osteomyelitis. Palliative antibiotic therapy and regular follow-up were recommended. Of particular interest in the present case is ipsilateral condylar resorption not associated with any dermato-skeletal conditions, which is uncommon in CDSO of the mandible.
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Affiliation(s)
- Candice Jacinta Antao
- Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim, Goa, India
| | - Ajit Dattatray Dinkar
- Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim, Goa, India
| | - Manisha Maruti Khorate
- Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim, Goa, India
| | - Sapna S Raut Dessai
- Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim, Goa, India
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21
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Mandibular osteomyelitis related to SAPHO syndrome following dental implant surgery: A case report. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2018. [DOI: 10.1016/j.ajoms.2018.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Shirai T, Hanaoka R, Goto Y, Kojima I, Ishii Y, Hoshi Y, Fujita Y, Shirota Y, Fujii H, Ishii T, Harigae H. Takayasu Arteritis Coexisting with Sclerosing Osteomyelitis. Intern Med 2018; 57:1929-1934. [PMID: 29434141 PMCID: PMC6064701 DOI: 10.2169/internalmedicine.0329-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a rare case of a 27-year-old woman with Takayasu arteritis (TAK) complicated by diffuse sclerosing osteomyelitis. She first presented with sclerosing osteomyelitis of the right mandible without evidence of arteritis in the carotid arteries. Eight months later, she complained of left neck pain, and imaging studies revealed the presence of arteritis in the left carotid artery. She was diagnosed with TAK, and immunosuppressive treatment was initiated, which was effective for both the arteritis and the osteomyelitis. Osteomyelitis is an important complication of TAK and bone scintigraphy is useful for its detection.
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Affiliation(s)
- Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Riiza Hanaoka
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Yusuke Goto
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Ikuho Kojima
- Department of Oral Diagnosis, Tohoku University Graduate School of Dentistry, Japan
| | - Yusho Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Yousuke Hoshi
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Yoko Fujita
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Yuko Shirota
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
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Julien Saint Amand M, Sigaux N, Gleizal A, Bouletreau P, Breton P. Chronic osteomyelitis of the mandible: A comparative study of 10 cases with primary chronic osteomyelitis and 12 cases with secondary chronic osteomyelitis. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:342-348. [DOI: 10.1016/j.jormas.2017.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 06/02/2017] [Accepted: 08/08/2017] [Indexed: 11/26/2022]
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24
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Conservative treatment of children with chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible. J Craniomaxillofac Surg 2017; 45:1938-1943. [DOI: 10.1016/j.jcms.2017.09.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 08/14/2017] [Accepted: 09/25/2017] [Indexed: 11/21/2022] Open
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25
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Otto S, Burian E, Troeltzsch M, Kaeppler G, Ehrenfeld M. Denosumab as a potential treatment alternative for patients suffering from diffuse sclerosing osteomyelitis of the mandible-A rapid communication. J Craniomaxillofac Surg 2017; 46:534-537. [PMID: 29510893 DOI: 10.1016/j.jcms.2017.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/27/2017] [Accepted: 10/09/2017] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Diffuse sclerosing osteomyelitis (DSO) is a rare disease of the jaw bone. Its treatment is challenging. Different medical and surgical treatment protocols have been proposed; however, none of these treatment protocols produce reliable results. Recently, ibandronate administration has been attempted as a treatment alternative in acute cases of DSO. Due to the similar antiresorptive effect, we sought to explore the application of the human monoclonal antibody to the receptor activator of nuclear factor kappaB ligand (RANKL), denosumab, in the treatment of DSO. MATERIALS AND METHODS One female patient with histologically verified DSO received subcutaneous injections of denosumab (Prolia® 60 mg). The further course of the disease was followed clinically and by radiography and scintigraphy. RESULTS In this case, the use of denosumab displayed promising results in aiding pain relief and reducing inflammatory activity. CONCLUSION We suggest that antiresorptive treatment with denosumab can be considered as an alternative treatment for patients suffering from DSO. However further studies, with respect to clarifying the mechanisms of action and defining the necessary medication dose as well as application intervals, have to be conducted.
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Affiliation(s)
- Sven Otto
- Department of Oral- and Maxillofacial Surgery (Head: Prof. M. Ehrenfeld), Ludwig-Maximilians-University, Munich, Germany.
| | - Egon Burian
- Department of Oral- and Maxillofacial Surgery (Head: Prof. M. Ehrenfeld), Ludwig-Maximilians-University, Munich, Germany
| | - Matthias Troeltzsch
- Department of Oral- and Maxillofacial Surgery (Head: Prof. M. Ehrenfeld), Ludwig-Maximilians-University, Munich, Germany
| | - Gabriele Kaeppler
- Department of Oral Radiology (Head: Prof. G. Kaeppler), Ludwig-Maximilians-University, Munich, Germany
| | - Michael Ehrenfeld
- Department of Oral- and Maxillofacial Surgery (Head: Prof. M. Ehrenfeld), Ludwig-Maximilians-University, Munich, Germany
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27
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Otto S, Troeltzsch M, Burian E, Mahaini S, Probst F, Pautke C, Ehrenfeld M, Smolka W. Ibandronate treatment of diffuse sclerosing osteomyelitis of the mandible: Pain relief and insight into pathogenesis. J Craniomaxillofac Surg 2015; 43:1837-42. [DOI: 10.1016/j.jcms.2015.08.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 07/14/2015] [Accepted: 08/26/2015] [Indexed: 11/17/2022] Open
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28
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Idahosa CN, Boggess WJ, Levin LM, Alawi F. Unilateral enlargement of the mandible in a child. Oral Surg Oral Med Oral Pathol Oral Radiol 2015. [PMID: 26212558 DOI: 10.1016/j.oooo.2015.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Chizobam N Idahosa
- Resident, Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA
| | - William J Boggess
- Resident, Department of Oral and Maxillofacial Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lawrence M Levin
- Chief, Division of Dentistry, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Faizan Alawi
- Associate Professor of Dermatology, Section of Oral and Maxillofacial Pathology, Division of Dermatopathology, Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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