Non-resolving periapical inflammation: a malignant deception

Hematolymphoid neoplasm mimicking endodontic lesions: case series and review of the literature

Hematolymphoid neoplasms originating in the periapical region of a tooth are rare occurrences. Their signs, symptoms, and radiographic findings can also mimic lesions of endodontic origin. History-taking and clinical examination provide clues to determine the possibility of a non-endodontic lesion, although the definitive diagnosis can only be rendered based on histologic examination. In our case series, we present four cases of hematolymphoid neoplasms that radiographically mimicked endodontic lesions. All the cases initially underwent endodontic treatment, but the lesions failed to resolve. In one case, the clinician suspected a diagnosis of lymphoma based on the patient's history. In the other cases, the clinicians' impression was that the lesions originated from endodontic issues. We present two cases of diffuse large B-cell lymphoma, a case of a plasma cell neoplasm, and a case of Langerhans cell histiocytosis, along with a literature review of three entities when found in the oral cavity as well as review of hematolymphoid neoplasm mimicking endodontic lesion previously reported in literature.

Oral manifestations of extranodal lymphomas - a review of the literature with emphasis on clinical implications for the practicing dentist

OBJECTIVE

Lymphoma is a heterogenous group of malignant tumours with proliferation of lymphoid cells or their precursors. Lymphomas in the head and neck region are usually found in Waldeyer's ring. Intraoral lymphomas are rare and the clinical presentation and roentgenological appearance may resemble other and benign conditions, entailing a risk for diagnostic delay. The objective of the present literature review was to identify subjective symptoms, clinical presentations and roentgenological appearances which should raise suspicion of lymphoma.

MATERIALS AND METHODS

The literature review identified 41 case series with head and neck lymphomas (n = 3880) and 384 case reports (n = 567 cases) of intraoral lymphomas. Information of demographics, clinical presentation, subjective symptoms and roentgenological appearance was registered.

RESULTS

The most common clinical presentation was a broad-based swelling or bulging mass with or without simultaneous ulceration, frequently with a relatively rapid growth pattern. Subjective symptoms varied considerably. Intraosseous lymphomas were frequently associated with paresthaesia or numbness. The most common roentgenological finding was a radiolucency with diffuse demarcation.

CONCLUSIONS

The clinical presentation, symptomatology and roentgenological appearance of intraoral lymphomas varied. Diagnostic delay was usually associated with a lymphoma initially misdiagnosed as a lesion of dental aetiology or a reactive lesion. Inadequate healing after tooth extraction or symptoms of numbness or pain without obvious dental origin should merit further clinical and roentgenological examination. Biopsy is indicated when there is the slightest doubt of the true nature of mucosal lesion.

The quality of root canal treatment and periapical status of permanent teeth in Turkish children and teens: a retrospective CBCT study

OBJECTIVE

This study aimed to assess the quality of root canal fillings and the prevalence of periapical radiolucencies in the permanent teeth of 6-18 year-old Turkish children.

METHODS

CBCT images of 150 patients' 235 teeth with a mean age of 16.0 ± 2.06 years were included. Root development stage, quality of root canal filling, the presence and severity of periapical radiolucencies, and their relationship with anatomical structures were recorded. Correlations between the quality of root canal filling, periapical lesion, and lesion size were assessed using regression analyses.

RESULTS

A total of 235 teeth (528 root canals) were evaluated. 65.5% of root canals had periapical lesions. Immature roots and mandibular teeth had the highest prevalence and the largest size of periapical radiolucencies (p < 0.05). Overfilling (n = 52), underfilling (n = 93), unfilled (n = 46), inhomogeneously filled (n = 113) root canals and poor coronal restoration (n = 85 teeth) were observed in terms of technical failures of endodontic treatment. The quality of endodontic treatment was associated with the presence of periapical lesion and lesion size (p < 0.05). Teeth with under-filled, overfilled or inhomogeneously filled root canals and poor coronal restoration had a periapical lesion larger than 5 mm (p < 0.05). Immature teeth were most associated with the presence of lesion (OR = 4.07) and the lesion size > 5 mm (OR = 3.71).

CONCLUSION

The prevalence of periapical radiolucencies in young permanent teeth showed an increase when the tooth was an incisor, had incomplete root development, or the root filling had technical errors.

Non-Hodgkin Lymphoma Mimicking Endodontic Lesion: A Case Report with 3-dimensional Analysis, Segmentation, and Printing

Non-Hodgkin lymphoma (NHL) of the oral cavity can present with pain, swelling and radiolucent lesion mimicking endodontic diseases. This article reports on a case of diffuse large B-cell lymphoma initially diagnosed and treated as periodontal disease and then endodontic disease in the maxillary anterior and premolar area of a 40-year old female. A cone beam computed tomography (CBCT) image of the lesion was taken. The lesion was segmented using Mimics software (Materialise NV, Lueven, Belgium). Three-dimensional models of the tumor were printed. During the surgical phase teeth #4, 6, and 7 were extracted and biopsy samples were obtained. Histopathologic examination showed invasive sheets of large, atypical, basophilic cells strongly and diffusely positive for CD20. Three-dimensional analysis, segmentation, and printing of radiolucent lesions of the jaws assists with differential diagnosis and efficient treatment. Oral health professionals can play a crucial role in the early detection and diagnosis of oral NHL, thereby preventing extensive loss of function and esthetics, and even saving lives.

Unusual cause of tooth mobility

We describe a case of a 71-year-old otherwise healthy man who presented to the dental clinic with the chief complaint of mobility involving his upper left molar teeth. The patient was a febrile, and clinical oral examination revealed localised grade II mobility and absence of gingival swelling, erythema or sinus tract. Orthopantogram revealed a poorly defined radiolucency involving the upper left second and third molar teeth. Surgical exploration of the involved area was performed and revealed the presence of a 'jelly like' brown tissue that fragments easily. Pathological examination confirmed the diagnosis of diffuse large B cell lymphoma.

Malignant Lesions Mimicking Endodontic Pathoses Lesion: A Systematic Review

INTRODUCTION

Malignant nonendodontic periapical lesions represent a rare diagnosis, in which few case have been reported about this condition. Due to the low occurrence and little exploration of this subject, serious errors of diagnosis are observed in the oral medicine services. In this sense, the purpose of the present review was to integrate the information on the record published on malignant lesions that mimic endodontic pathoses into a comprehensive analysis of their clinical, radiologic, and histopathologic features.

METHODS

An online search was made in March 2020 in the following databases: Pubmed, Web of Science, and Scopus. Eligibility criteria included publications having enough clinical, radiologic, and histopathologic information to confirm the diagnosis. Data were assessed descriptively.

RESULTS

Forty-nine publications from 16 countries comprising 60 cases were included. There is a nearly equal occurrence rate between males and females (male/female ratio is 49.15%/50.84%) with a mean age of 46.56 years. The lesions were more prevalent in the posterior mandibles (40.69%), and, radiographically, they were unilocular radiolucent. Histopathologic analysis showed metastasis (26.67%) as the most prevalent lesion followed by salivary gland malignant disease (25%).

CONCLUSIONS

The present systematic review revealed several histologic types of malignant periapical lesions that could be mimicking endodontic pathoses. Because these lesions usually do not show clinical or radiologic features of malignant alteration, clinicians should consider these hypotheses in their routine.

Periapical lymphoma: Review of reported cases in the literature

Oral lymphoma can resemble clinically to other pathologic entities such as periapical radiolucencies, or dental abscess. The aim of this study was to review the literature related to misdiagnosed periapical lymphomas and discuss their characteristics. In this review study, authenticated search engines and databases such as Google Scholar, PubMed, PubMed Central, Science Direct, and Scopus were surfed to find articles related to the topic by using related keywords. Out of more than 100 articles approximately, 50 were closely relevant to the title, and ultimately 43 well-documented English articles were chosen. Out of 45 reported cases, 63% were male and 37% were female with mean age of 41.22 years. The majority of such lesions have been detected in the mandible (61%) with a mandibular to maxillary involvement ratio of 1.58:1. The most frequent type of lymphoma was diffuse large B cell lymphoma (DLBCL) (53%). Noteworthy, 49% of periapical lymphoma has been misdiagnosed as pulpal pathology and treated through root canal therapy. The mean time lapse before making the correct diagnosis was 4.3 months. Although rare, periapical lymphoma should be ranked in the differential diagnosis of a periapical lesion especially when vitality pulp tests are positive.

Extranodal lymphoma arising within the maxillary alveolus: a systematic review

Objectives

Extranodal lymphomas affecting the head and neck infrequently arise within the jaw bones. Although clinical examination and conventional radiography may initially suffice for such lesions arising within the mandible, those arising within the maxillary alveolus generally require cross-sectional imaging because of the complex anatomy of this region. This study was performed to determine the prevalence, demographic characteristics, and clinical presentations of these lesions and the imaging modalities used for their diagnosis.

Study design

A systematic review (SR) on case series and another SR on case reports were performed to investigate the demographic, clinical, and radiological features of extranodal lymphomas arising within the maxillary alveolus.

Results

Most case series were derived from just four nations, whereas the case reports were derived from a wider range of ethnicities. The more detailed case reports significantly reported at least one imaging modality. Most patients were aware of their lesions for nearly 2 months before presentation. The most frequent symptom was swelling. Most case reports included a provisional diagnosis, the most frequent of which was dental infection followed by squamous cell carcinoma.

Discussion

Extranodal lymphomas arising within the maxillary alveolus were sufficiently frequent in four communities to be reported in two or more case series, and the occasional single case report indicated that such lesions are more widespread globally. Although the SR on case series revealed differences in the relative period prevalence and maxillary/mandibular ratio, the SR on case reports revealed details of the clinical presentation and imaging modalities used.

T-Cell/Histiocyte-Rich Large B-Cell Lymphoma: Report of the First Case in the Mandible

T-cell/histiocyte-rich large B-cell lymphoma (THRBCL) is an uncommon subtype of non-Hodgkin's lymphoma. It is a predominant nodal neoplasm; however, extranodal sites, such as the spleen, liver and bone marrow, can be involved at diagnosis. However, only one case of primary THRLBCL in the jaws have been reported. We herein describe a 29-year-old female patient who presented with a swelling of the right mandible that had grown rapidly over the previous 2 months. Periapical and panoramic radiographs showed a multilocular osteolytic lesion located in the mandibular periapical region of the canine and premolar teeth and molar region. Preoperative examination and incisional biopsy were performed. Immunohistochemistry was applied to confirm the diagnosis of THRBCL in the jaw. The treatment consisted of CHOP therapy and radiotherapy. After complete tumor remission following initial treatment, additional sites of the disease appeared in the lung, abdomen and long bones. The patient died within 2 months. THRLBCL is an uncommon and aggressive malignant neoplasm that can involve the jaws, mimicking a periapical disease.

Follicular Lymphomas of Oral Region Treated by Rituximab Monotherapy: About Two Cases

Lymphomas represent the second most common malignant lesions of the head and neck. Among them, follicular lymphomas (FLs) are the second most frequent B-cell non-Hodgkin’s lymphomas. However, their incidence is rare in the oral cavity. We describe here two cases of FL with initial intra-oral presentation. The first patient was 81 years old and presented a palatal hyperplasia, covering the posterior edge of her dental removable prosthesis. After surgical excision of the lesion, the pathological diagnosis was an extra-nodal low-grade follicular lymphoma. Medical imaging assessment found a widespread but non-bulky involvement. The second patient was 38 years old and referred for asymptomatic swelling of the lower vestibule evolving for 4 months. Surgical exploration revealed a cheek lymphadenopathy infiltrated by a grade 3 FL; this patient did not have any other localization. Both patients were treated by a rituximab monotherapy with excellent response after 2 years of follow-up. Most of the time, FL affecting the oral cavity presenting as unspecific swelling, can mimic other frequent and benign oral lesions. In the absence of biopsy, both diagnosis and proper onco-hematological management may be delayed. The introduction of monoclonal antibody rituximab represents a major advance in the management of FL: it can be used as monotherapy or may be combined with chemo-immunotherapy according to histological grading, initial staging (extent, tumor mass or bulk), age and co-morbidities. These two observations show the importance of an early diagnosis regarding a chronic lesion in the oral cavity. Painless lymphadenopathy, asymptomatic swelling, aspecific mucosal lesions, or subprosthetic lesions should draw attention of any oral specialist.

Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis

Patients undergoing radiation therapy for the head and neck are susceptible to a significant and often abrupt deterioration in their oral health. The oral morbidities of radiation therapy include but are not limited to an increased susceptibility to dental caries and periodontal disease. They also include profound and often permanent functional and sensory changes involving the oral soft tissue. These changes range from oral mucositis experienced during and soon after treatment, mucosal opportunistic infections, neurosensory disorders, and tissue fibrosis. Many of the oral soft tissue changes following radiation therapy are difficult challenges to the patients and their caregivers and require life-long strategies to alleviate their deleterious effect on basic life functions and on the quality of life. We discuss the presentation, prognosis, and management strategies of the dental structure and oral soft tissue morbidities resulting from the administration of therapeutic radiation in head and neck patient. A case for a collaborative and integrated multidisciplinary approach to the management of these patients is made, with specific recommendation to include knowledgeable and experienced oral health care professionals in the treatment team.

Delayed diagnosis in the maxillofacial region: Two case reports

While conventional CT scan has historically been used for maxillofacial bone imaging. The introduction of cone beam CT (CBCT) in the new millennium has revolutionized the use of CT for dental and maxillofacial diagnoses. This paper presents two clinical examples of delayed diagnoses associated with maxillofacial imaging, describes the reasons for the delays and offers potential preventive measures. The first case involves a delay in the diagnosis of non-Hodgkin's lymphoma in a 49-year-old female who was being treated for an odontogenic problem. In the second case, a 9-year-old female who presented with a limited ability to open her mouth was mistakenly diagnosed with muscles spasm. Subsequently, she was found to have an elongation of the right lateral pterygoid plate that interfered with her right mandibular body, which restricted the degree to which she could open her mouth. A thorough clinical examination and accurate radiographic interpretation combined with a complete medical history can minimize these types of diagnostic delays. If the dentist is unable to conclusively reach a diagnosis, the patient should be referred immediately to a specialist who can better manage the specific medical problem.