NTSM: a non-salient target segmentation model for oral mucosal diseases

BACKGROUND

Oral mucosal diseases are similar to the surrounding normal tissues, i.e., their many non-salient features, which poses a challenge for accurate segmentation lesions. Additionally, high-precision large models generate too many parameters, which puts pressure on storage and makes it difficult to deploy on portable devices.

METHODS

To address these issues, we design a non-salient target segmentation model (NTSM) to improve segmentation performance while reducing the number of parameters. The NTSM includes a difference association (DA) module and multiple feature hierarchy pyramid attention (FHPA) modules. The DA module enhances feature differences at different levels to learn local context information and extend the segmentation mask to potentially similar areas. It also learns logical semantic relationship information through different receptive fields to determine the actual lesions and further elevates the segmentation performance of non-salient lesions. The FHPA module extracts pathological information from different views by performing the hadamard product attention (HPA) operation on input features, which reduces the number of parameters.

RESULTS

The experimental results on the oral mucosal diseases (OMD) dataset and international skin imaging collaboration (ISIC) dataset demonstrate that our model outperforms existing state-of-the-art methods. Compared with the nnU-Net backbone, our model has 43.20% fewer parameters while still achieving a 3.14% increase in the Dice score.

CONCLUSIONS

Our model has high segmentation accuracy on non-salient areas of oral mucosal diseases and can effectively reduce resource consumption.

Potential use of optical coherence tomography in oral potentially malignant disorders: in-vivo case series study

BACKGROUND

Evidence confirms that the use of Optical Coherence Tomography (OCT) in oral medicine can be a reliable aid for the diagnosis and management of Oral Potentially Malignant Disorders (OPMDs). Several authors described the ability of this system to detect the structural changes of the epithelia involved by the OPMDs. The purpose of this case series is to provide a suggestion for interpretation of OCT images from different OPMDs, compared to OCT images of healthy tissues.

METHODS

A sample of 11 OPMDs patients was recruited and analyzed with OCT. The images obtained were then compared with an OCT repertoire image. In this work the reflectance degree was considered, together with the analysis of the increased/decreased thicknesses of the various layers. Keratin Layer (KL), Epithelial Layer (EP), Lamina Propria (LP), Basal Membrane (BM) assessment, for each lesion, was performed.

RESULTS

OCT measurements of KL, EP and LP layers, together with BM assessing, should aid the physicians to recognize and describe different oral lesions, relating them to the corresponding oral pathology.

CONCLUSION

More studies like this, on larger samples, are needed to validate the results and provide, in the future, a kind of manual that could guide clinicians to correctly interpret the OCT images in relation to the causing pathologies.

TRIAL REGISTRATION

The present trial has been registered with ISRCTN (#17,893,224).

Evaluation of treatment response in oral chronic graft-versus-host patients by power doppler ultrasound: a prospective study

OBJECTIVE

To date, imaging and non-invasive examination methods for evaluating the oral tissue of patients who with oral chronic graft-versus-host disease (GVHD) are still lacking. Herein, we assessed the ultrasonography imaging characteristics of chronic GVHD patients' buccal soft tissue and evaluated the response to treatment using gray-scale and power Doppler (PD) ultrasound. The overall objective of the study was to determine the potential of ultrasonography to provide an early and objective indication of a therapeutic response to treatment intervention in oral chronic GVHD.

METHODS

Buccal mucosa in 21 patients with clinically diagnosis of oral chronic GVHD were assessed before and after 14 day treatment between 2016 and 2018. Ultrasonography assessment included thickness and echogenicity evaluation, and PD. Echogenicity and PD were measured and scored according to a semi-quantitative method. Ultrasonography parameters were compared with clinical activity assessments of disease activity and patient-reported measures.

RESULTS

Following 14 day therapy, a significant decrease in PD scores and patient-reported measures was observed (p < 0.01), and clinical assessment scores also decreased (p < 0.05). Changes from baseline PD scores correlated significantly with patient-reported measures (r = 0.85, p < 0.01). Changes in PD scores correlated moderately with the changes in the clinical assessments from baseline (r = 0.46, p < 0.05). A significant decrease in PD scores was observed in the buccal soft tissue of patients that responded clinically to the treatment. A significant decrease in PD scores was also observed in patients that were failed to show clinical improvement (p < 0.05).

CONCLUSION

Ultrasonography is a novel and feasible imaging technique for measurement of the response of oral chronic GVHD to therapy. Ultrasonography yields additional information about buccal mucosa and is a complementaty to clinical examination.

Potential role of autofluorescence imaging in determining biopsy of oral potentially malignant disorders: A large prospective diagnostic study

Autofluorescence examination of oral tissues using the VELscope has been suggested as an adjunctive tool for cancer detection and diagnosis. This study aimed to determine the diagnostic value of VELscope in a large prospective study of 517 patients with oral potentially malignant disorders (OPMD). For the outcome assessments of discrimination of carcinoma form general OPMD and distinguishing high-risk lesions (moderate/severe dysplasia and carcinoma) from low-risk lesions (no/mild dysplasia), high sensitivity (100% and 95.9% respectively) and negative predictive value (100% and 98.2% respectively) were observed. All the carcinoma and showed loss of autofluorescence (LAF) and only 3 (0.6%) moderate/severe dysplasia were observed without LAF. These data indicate that the cases without LAF using VELscope substantially rule out the presence of high-risk lesions including cancer. This may prove to be useful specially to alleviate patient anxiety regarding a clinically suspicious oral lesion without the LAF, and to avoid a unnecessary biopsy for these cases. Collectively, a perspective to highlight was that a no biopsy strategy may be appropriate for OPMD without LAF using VELscope after conventional oral examination.

A novel fetal sequence patogenesis resulting in oral meningoencephalocele

OBJECTIVES

To analyze a rare triad of intracranial fetal pathologies and clinical study of the novel defined sequence pathogenesis based on prenatal and postmortem findings.

METHODS

Complex multidisciplinary clinical analysis and review of up-to-date literature.

RESULTS

In an 18-gestational-week fetus the screening ultrasound scan resembled the semilobar type of holoprosencephaly and oral tumor. After the indicated termination of pregnancy, the histopathology results confirmed another pathologies - oral meningoencephalocele, teratoma of the sellar area and large arachnoidal cyst of the anterior cerebral fossa. The surprising final results were evaluated by specialists in prenatal diagnosis, histopathology, genetics, neurology, and radiology.

CONCLUSION

We defined the final diagnosed triad oral meningoencephalocele - intracranial sellar teratoma- arachnoidal cyst as a novel sequence defect malformation. In the detailed sequence pathogenesis, the intracranial sellar teratoma created an aperture for meningoencephalocele in the cranial base and the arachnoidal cyst facilitated, by its growth and pressure, the protrusion of the brain tissues (Fig. 4, Ref. 10). Text in PDF www.elis.sk.

Development of an integrated multimodal optical imaging system with real-time image analysis for the evaluation of oral premalignant lesions

Oral premalignant lesions (OPLs), such as leukoplakia, are at risk of malignant transformation to oral cancer. Clinicians can elect to biopsy OPLs and assess them for dysplasia, a marker of increased risk. However, it is challenging to decide which OPLs need a biopsy and to select a biopsy site. We developed a multimodal optical imaging system (MMIS) that fully integrates the acquisition, display, and analysis of macroscopic white-light (WL), autofluorescence (AF), and high-resolution microendoscopy (HRME) images to noninvasively evaluate OPLs. WL and AF images identify suspicious regions with high sensitivity, which are explored at higher resolution with the HRME to improve specificity. Key features include a heat map that delineates suspicious regions according to AF images, and real-time image analysis algorithms that predict pathologic diagnosis at imaged sites. Representative examples from ongoing studies of the MMIS demonstrate its ability to identify high-grade dysplasia in OPLs that are not clinically suspicious, and to avoid unnecessary biopsies of benign OPLs that are clinically suspicious. The MMIS successfully integrates optical imaging approaches (WL, AF, and HRME) at multiple scales for the noninvasive evaluation of OPLs.

Incidental Findings in Small Field of View Cone-beam Computed Tomography Scans

INTRODUCTION

The use of cone-beam computed tomography (CBCT) in endodontics has increased in recent years. In clinical application of small field of view (FOV) CBCTs, these scans are not reviewed routinely by a radiologist. Studies of large FOV CBCT scans show the prevalence of incidental findings to be greater than 90%. The purpose of this study was to evaluate the prevalence of missed findings by endodontic residents as compared with a radiologist on small FOV CBCT scans.

METHODS

Two hundred three small FOV CBCTs obtained for endodontic purposes were analyzed by an endodontic resident and a medical radiologist. The reported findings of each practitioner were compared to evaluate for missed incidental findings by the endodontic resident.

RESULTS

The radiologist reported abnormalities in 176 of the 203 subjects (87%), with a total of 310 abnormalities reported. The endodontic resident reported abnormalities in 102 of the 203 subjects (50%), with a total of 126 abnormalities reported. The percentage of scans with any abnormality reported by the radiologist was significantly greater than the endodontic resident (P < .001). There was no significant difference between jaw locations in percentage of missed findings for the 3 most common types of finding-rarefying osteitis, sinusitis/mucosal lining thickening, and excess restorative material in the periapical area. Rarefying osteitis was missed significantly less than the other 2 types of findings (P < .001).

CONCLUSIONS

A radiologist is significantly more likely to identify incidental findings in small FOV CBCT scans than an endodontic resident. Scan location had no significant association with the rate of missed findings.

Detection of Monckeberg Medial Sclerosis on Conventional Dental Imaging

Vascular calcification occurs with aging, and several risk factors including diabetes, hyperlipidemia, and disorders of calcium metabolism have been identified. M6nckeberg medial sclerosis (MMS) is the most common variant of medial calcification. M6nckeberg sclerosis can lead to significant adverse cardiovascular outcomes such as arterial stiffness, increased pulse and left ventricular hypertrophy. Here we report two cases of MMS involving facial vasculature, diagnosed incidentally on radiographs during their routine dental evaluation. They appear as convoluted "railroad tracks" patterns of the facial artery calcification. We believe that a better understanding and identification of these calcifications can lead to appropriate patient follow-up with medical providers and interventions to reduce morbidity and mortality by potentially predicting possible cardiovascular events.

Interpretation of cone beam computed tomography volumetric data: How to report findings?

Cone beam computed tomography (CBCT) was introduced to the dental profession at the beginning of the new millennium and has become an integral part of dental practice, especially within the surgical specialties. With advances in technology and the introduction of new-generation digital detectors, the concomitant increase in pixel resolution provided the ability to discern fine details of the anatomy. This article focuses on the methodology of CBCT interpretation and reporting. Details of reviewing the volume thoroughly are described with relevant citations. The article summarizes the overall methodical interpretation of CBCT data that is essential to every dentist who uses the technology.

A Rare Case of Labial Myiasis caused by Dermatobia hominis

The aim of this article is to present a rare case of myiasis caused by Dermatobia hominis. Myiasis is a disease caused by invasion of tissues of animals and humans by larval stages of dipterous (2-winged) flies. There are few reports of oral myiasis in the literature, mostly related to Cochliomyia hominivorax larvae. We present a case of a 53-year-old man with painful swelling of the left lower lip that was confirmed to be myiasis caused by D. hominis. Though more common in tropical and subtropical regions of North and South America, myiasis should be considered in the differential diagnosis of subcutaneous masses among residents or travelers in endemic areas.

Assessment of oral mucosal lesions with autofluorescence imaging and reflectance spectroscopy

BACKGROUND

The aim of this prospective study was to evaluate the efficacy of a new form of autofluorescence imaging and tissue reflectance spectroscopy (Identafi, DentalEZ) in examining patients with oral mucosal lesions.

METHODS

The authors examined 88 patients with 231 oral mucosal lesions by conventional oral examination (COE) using white-light illumination and ×2.5 magnification loupes, followed by examination using Identafi. The authors noted fluorescence visualization loss, the presence of blanching, and diffuseness of vasculature. They performed incisional biopsies to provide definitive histopathologic diagnosis.

RESULTS

Identafi's white light produced lesion visibility and border distinctness equivalent to COE. Identafi's violet light displayed a sensitivity of 12.5% and specificity of 85.4% for detection of oral epithelial dysplasia (OED). The authors noted visible vasculature using the green-amber light in 40.9% of lesions.

CONCLUSIONS

Identafi's intraoral white light provided detailed visualization of oral mucosal lesions comparable with examination using an extraoral white-light source with magnification. A high level of clinical experience is required to interpret the results of autofluorescence examination as the violet light displayed low sensitivity for detection of OED. The green-amber light provided additional clinical information in relation to underlying vasculature and inflammation of lesions.

PRACTICAL IMPLICATIONS

Examination using Identafi can provide clinicians with more clinical data than a standard COE with yellow incandescent light, but the clinical and optical findings should be interpreted as a whole and not in isolation. Clinicians should use the light features of Identafi in a sequential and differential manner.

Nasopalatine duct cyst mimicking an endodontic periapical lesion: a case report

Lesions of nonendodontic origin, such as nasopalatine or globulomaxillary cysts, may mimic periapical radiolucencies associated with pulpal pathosis, and incorrect diagnosis may lead to unnecessary endodontic treatment. Horizontal root fractures most commonly affect the maxillary central and lateral incisors. Prognosis depends largely on the level of fracture; fractures in the apical third have the best prognosis, and those in the cervical third have the worst. This case report discusses surgical and restorative management of a patient who had a nasopalatine cyst that had been misdiagnosed and treated as an endodontic lesion of the maxillary right central incisor as well as a midroot horizontal fracture of the adjacent lateral incisor.

Comparison of physical quality assurance between Scanora 3D and 3D Accuitomo 80 dental CT scanners

BACKGROUND

The use of cone beam computed tomography (CBCT) in dentistry has proven to be useful in the diagnosis and treatment planning of several oral and maxillofacial diseases. The quality of the resulting image is dictated by many factors related to the patient, unit, and operator.

MATERIALS AND METHODS

In this work, two dental CBCT units, namely Scanora 3D and 3D Accuitomo 80, were assessed and compared in terms of quantitative effective dose delivered to specific locations in a dosimetry phantom. Resolution and contrast were evaluated in only 3D Accuitomo 80 using special quality assurance phantoms.

RESULTS

Scanora 3D, with less radiation time, showed less dosing values compared to 3D Accuitomo 80 (mean 0.33 mSv, SD±0.16 vs. 0.18 mSv, SD±0.1). Using paired t-test, no significant difference was found in Accuitomo two scan sessions (p>0.05), while it was highly significant in Scanora (p>0.05). The modulation transfer function value (at 2 lp/mm), in both measurements, was found to be 4.4%. The contrast assessment of 3D Accuitomo 80 in the two measurements showed few differences, for example, the grayscale values were the same (SD=0) while the noise level was slightly different (SD=0 and 0.67, respectively).

CONCLUSIONS

The radiation dose values in these two CBCT units are significantly less than those encountered in systemic CT scans. However, the dose seems to be affected more by changing the field of view rather than the voltage or amperage. The low doses were at the expense of the image quality produced, which was still acceptable. Although the spatial resolution and contrast were inferior to the medical images produced in systemic CT units, the present results recommend adopting CBCTs in maxillofacial imaging because of low radiation dose and adequate image quality.

Central giant cell lesion: diagnosis to rehabilitation

Central giant cell lesion (CGCL) is a benign bone lesion of unknown etiology that primarily affects the mandible, with a predilection for female children and young adults. This article describes a case of a 16-year-old boy with a palatal swelling of approximately 18 months duration. Clinical, radiographic, histopathological, and hematological examinations led to a diagnosis of CGCL. Treatment involved a complete enucleation of the lesion and the removal of several teeth. A subsequent esthetic/functional rehabilitation was performed using a removable prosthesis. The patient was submitted to rigorous clinical and radiographic follow-ups, with no signs of recurrence over a 7-year period.

A comparative study of three imaging modalities currently used in the assessment of patients for maxillofacial surgery

Diagnostic imaging is pivotal in clinical maxillofacial evaluation. This study evaluated and compared the use of conventional radiographs (CR) with two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) in patients requiring maxillofacial surgery. Pre-surgical records of sixty five patients who had undergone routine CR, 2D CT and 3D CT were selected and classified into the categories of traumatic injury, pathology and deformities. The accuracy of image analysis, diagnosis and treatment planning were scored and the data statistically analysed. 2D CT scanning was more effective diagnostically and is preferred for cases of traumatic injury (44%, SD=0.54, p>0.05) and pathology (34%, SD=0.47, p>0.05) whilst 3D CT imaging was indicated for the deformity category (22%, SD=0.58, p>0.05). Linear comparisons between radiographic modalities within each clinical group revealed significant differences (p<0.05). Multiplanar reformatted (MPR) 2D cross sectional CT views offered additional imaging information.

CONCLUSION

2D CT scanning is an excellent imaging modality for the majority of craniomaxillofacial surgical cases. 3D CT scanning is also recommended for cases of trauma and pathology. Both 2D CT and 3D CT scanning are vital in craniomaxillofacial deformities and reconstructive surgery.

Extensive sublingual epidermoid cyst--diagnosis by immunohistological analysis and proof by podoplanin

AIM

We present the case of a surgically treated 39-year-old man with diagnosis of a giant sublingual internal epidermoid cyst. Usually, such dermoid or epidermoid cysts are caused by aberrant ectodermal tissues or by acquired aberrant epithelial tissues arising from the foetal period, or from trauma or surgery. The incidence of oral dermoid or epidermoid cysts is about 1.6%; most occur at the mouth floor but they nevertheless are very rare.

CASE REPORT

The patient presented with a history of progressive swelling of the sublingual region with dysphagia, progressive snoring during sleep and occasional shortness of breath. The suspected clinical diagnosis of a giant sublingual dermoid or epidermoid cyst was supported by the radiological finding after performing magnetic resonance imaging. The cyst was surgically removed under general anaesthesia through an intraoral approach. The immunohistological analysis of the specimen with a monoclonal antibody against podoplanin (D2-40) showed a positive reaction in the basal epithelial layer, exclusively in areas with secondary inflammation, but not in the remaining cyst wall.

CONCLUSION

Sublingually situated extensive epidermoid cysts are rare findings in the oral cavity. In such cases, surgical excision remains the only treatment. We demonstrated that cystic epithelia were normally not immunoreactive for D2-40 but strong immunoreactivity was observed in the basal epithelial cell layer, in areas of ruptured cyst wall associated with secondary inflammatory changes.

Oral and radiographic findings in patients undergoing continuous ambulatory peritoneal dialysis

OBJECTIVE

To compare the oral status, cortical and spongy bone density of the mandible, and dental pulp calcification between the patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and age- and sex-matched healthy controls.

MATERIAL AND METHOD

Thirteen end stage renal disease patients undergoing CAPD and 17 age- and sex- matched healthy volunteers were enrolled. The questionnaires, oral radiography, and intraoral examination, including number of decayed teeth, filled teeth, missing teeth, plaque index, gingival index, calculus index, and oral hygiene index were performed in both groups. Two views of oral radiology, comprising panoramic and bite-wing radiographs, were taken to evaluate mandibular bone density and pulp calcification. The data were analyzed with t-test and Mann-Whitney U tests.

RESULTS

Both groups were similar in baseline demographics, including age, sex, and education. Plaque index, calculus index, and oral hygiene index of the CAPD patients were significantly worse than the controls' (p = 0.025, 0.015, and 0.014, respectively). Percentage of decayed teeth and missing teeth of the CAPD patients had a trend to be higher than control. The percentage of filled teeth, decayed missing filling tooth (DMFT) index, sum of percentage DMFT, gingival index, average of spongy and cortical bone densities, and the percentage of pulp calcification were comparable in both groups.

CONCLUSION

CAPD had poorer oral hygiene than the healthy; however; DMFT pulp calcification, and bone density were not differenct from the healthy. This urges the medical personnel to examine all CAPD patients in order to prevent hematogenous spreading of occult oral infection.

Cone beam computed tomography in the diagnosis of dental disease

Conventional radiographs provide important information for dental disease diagnosis. However, they represent 2-D images of 3-D objects with significant structure superimposition and unpredictable magnification. Cone beam computed tomography, however, allows true 3-D visualization of the dentoalveolar structures, avoiding major limitations of conventional radiographs. Cone beam computed tomography images offer great advantages in disease detection for selected patients. The authors discuss cone beam computed tomography applications in dental disease diagnosis, reviewing the pertinent literature when available.

[Application of ultrasonography in diagnosis and treatment of acute inflammation of soft tissues in maxillofacial region and neck]

We investigated the value of ultrasonography (USG) and ultrasound-guided aspirations in diagnosis and treatment of acute inflammation of soft tissues in maxillofacial region and neck. We performed 174 USG in 136 patients (73 with abscesses and phlegmons, 27 with acute lymphadenitis, 16 with inflamed cysts, 12 with parotitis, 3 with sialolithiasis and 5 with diseases, simulated acute inflammation). Ultrasound-guided aspirations performed in 35 patients. We considered USG to be useful diagnostic tool in acute inflammation of soft tissues in maxillofacial region and neck. USG allowed to determine localization and stage of inflammation, discriminate it from non-inflammatory diseases and improve assessment of its dynamics. Ultrasound-guided aspirations was a valuable tool for diagnostic and treatment purposes in inflamed cysts.

Oral and maxillofacial pathology in three dimensions

It is clear that the dental profession has entered a new age of radiographic diagnostic imaging. A number of examples have shown that being able to visualize oral and maxillofacial pathologic entities in three dimensions assists in diagnosing and planning the appropriate treatment. The technology is an improvement for our profession and for the patients it serves.

What's in your mouth? The CT appearance of comestible intraoral foreign bodies

BACKGROUND AND PURPOSE

Comestible or chewable intraoral foreign bodies (IOFB), such as candies, gum, and chewing tobacco, are seen incidentally on many CT scans of the head and neck. If these foreign bodies are misinterpreted as pathology, patients may be subjected to unnecessary distress or unneeded radiation from additional imaging. The purpose of this study was to characterize the CT appearance of comestible IOFBs and to find characteristics that distinguish them from true pathology.

MATERIALS AND METHODS

With institutional review board approval, 30 patients who were already scheduled to undergo CT examinations of the head and neck were enrolled in this study. Nine typical IOFBs with different physical characteristics were selected for inclusion. Each patient placed 1 IOFB in his or her mouth before the initiation of the routine clinical scan. The resulting scans were evaluated by 2 head and neck radiologists. In vivo and ex vivo attenuation measurements were obtained for each IOFB.

RESULTS

The attenuation of comestible IOFBs ranged from 184 to 475 Hounsfield units. Large, hard IOFBs were most easily distinguished from mucosal lesions, but might be mistaken for odontogenic or bone tumors. Small, hard IOFBs could be mistaken for calculi, tooth fragments, or enhancing vessels. Soft IOFBs generally had more confusing configurations and more heterogeneous densities and, thus, might be mistaken for enhancing mucosal lesions. Foci of gas were often identified within chewable IOFBs, mimicking an abscess. Because all of the IOFBs had higher densities than soft tissue, they could all be mistaken for calcified, enhancing, or bony lesions.

CONCLUSION

Radiologists frequently encounter IOFBs on CT examinations of the head and neck. Familiarity with the expected appearance of these incidental pseudolesions is important to prevent misdiagnosis as a true pathologic process.

Oral paracoccidioidomycosis: a case without lung manifestations

AIM

The aim of this article is to present a case of Paracoccidioidomycosis with involvement of the oral cavity but without pulmonary manifestations.

BACKGROUND

Paracoccidioidomycosis is a fungal infection caused by Paracoccidioides brasiliensis. It is an endemic disease representing a serious health problem for Latin American countries, especially Brazil. This infection primarily affects the lungs of adult men and is acquired through inhalation or accidental inoculation of the fungus. It can spread to other organs and tissues, mainly the oral cavity. Administration of antifungal medication always resolves the disease.

REPORT

A 58-year-old black male presented with three painless, ulcerated, mulberry-like granulomatous lesions located in the floor of the mouth, on the superior alveolar ridge, and on the hard palate, which had evolved over a period of two years. Facial asymmetry was observed due to edema in the lower lip and lymphadenopathy. He had smoked for more than six years but showed no evidence of lung alterations, productive cough, or fever. Panoramic radiography showed no signs of a bone lesion in the jaws. Both a radiograph and a CT scan of the thorax showed no areas of nodular infiltration. Fibrobronchoscopic examination of the entire respiratory tract was normal. Biopsies of the oral lesions were performed, and tissue sections exhibited oral mucosa coated with non-keratinized stratified squamous epithelium with acanthosis and focal areas of exocytosis. The underlying connective tissue showed an intense lymphocytic and polymorphonuclear infiltrate in addition to multinuclear giant cells and coagulation necrosis. A special stain used for fungus (the Grocott-Gomori method) was positive. Pulmonary biopsy exhibited aerial spaces containing macrophages, dark granular hemossiderin, and absence of fungus. This was considered normal. In agreement with the recommendation of pneumologists 400 mg/day of ketoconazole was prescribed for the patient. After two months of treatment, even though the oral lesions had resolved completely, the therapy was maintained for six months more. One year after following treatment the patient was in good health and free of any signs of a recurrent infection.

SUMMARY

Based on clinical, radiographic, and histologic findings the differential diagnosis included paracoccidioidomycosis and squamous cell carcinoma. Following clinical and biopsy examinations of the oral lesions and the lungs a final diagnosis of paracoccidioidomycosis was made. This is a prime example of oral manifestations of a systemic disease in which the dentist is the initial health care professional to evaluate the patient due to the location of the lesions.

Odontogenic focal infection could be partly involved in the pathogenesis of atopic dermatitis as exacerbating factor

BACKGROUND

A focal infection has been reported to be associated with the pathogenesis of various skin diseases, but, to date, not atopic dermatitis (AD). The objective of the study was to clarify whether the odontogenic focal infection (OFI) could be recognized as one of the exacerbating factors in AD.

METHODS

Forty-three patients with AD whose skin conditions were resistant to conventional therapy were examined. An OFI was evaluated by using radiographs. Serum IgE/sCD30 levels were also examined. Skin condition was evaluated by the eczema area and severity index (EASI).

RESULTS

Odontogenic focal infection was detected in 13 patients (30%) and this incidence was higher than in the normal population. Moreover, a 3-month therapy including dental care improved the skin conditions of patients with OFI better than those without OFI.

CONCLUSION

The study concluded that OFI could be involved in the pathogenesis of some types of AD as exacerbating factors.

Oral mucormycosis in children with leukemia: report of 2 cases

Mucormycosis is a rare acute opportunistic infection caused by a saprophytic fungus, which belongs to the order Mucorales. This report describes intraoral mucormycosis in 2 children with acute leukemia who were undergoing chemotherapy and had febrile neutropenia. A 7-year-old boy with acute myeloid leukemia and a 9-year-old boy with acute lymphoblastic leukemia were referred to the Department of Pediatric Dentistry at Cukurova University for their intraoral soft tissue lesions, which were diagnosed as mucormycosis by histologic examination. While, for the first case, the lesion was debrided under general anesthesia and medical antifungal therapy was performed, only medical management was done, without any debridement, for the second case. Early recognition of mucormycosis is necessary to limit the spread of infection, which can lead to high morbidity and mortality. Therefore, health practitioners should be familiar with the signs and symptoms of the disease.

[Useful imaging in maxillofacial surgery. Part II: practical applications]

Various pathologic patterns are discussed with advice on appropriate radiographic imaging. The choice of the most suitable modality for each condition depends on the need to obtain the most accurate results. Panoramic radiography remains a basic and low cost method. Choice of CT or MR as the principal or only modality depends on anatomic patterns: CT being preferred for bone and cavities, MR for soft tissue and cavity content. Much progress has been made in MR machines and the variety of sequences enables high discrimination between normal and pathologic tissues.

Herniation of the buccal fat pad into the maxillary antrum: CT findings in three cases

We report the first 3 cases in which CT disclosed herniation of the body of the buccal fat pad into the maxillary antrum. Only 20 cases of traumatic herniation of the buccal fat pad have been described in the literature. In all except one instance, the buccal fat pad herniated into the oral cavity. The only previous report of herniation of the buccal fat pad into the maxillary antrum is in an article published before modern cross-sectional imaging, and the diagnosis was not made preoperatively in that case.

Ectopic submandibular gland presenting as a swelling in the floor of mouth

The authors describe a patient who presented with a left sublingual swelling. Ultrasonic and sialographic investigation showed no salivary tissue in the expected left submandibular region, but a large salivary gland in the left floor of the mouth deep to the mylohyoid muscle. This is likely to represent an ectopically positioned submandibular gland.

Oral sarcoidosis: a review of literature

Sarcoidosis is a common systemic granulomatous disease affecting multiple organs. Oral involvement is relatively rare and, to our knowledge, there have been only 64 cases reported in the English literature. Most cases of oral sarcoidosis present with mobility of the teeth due to rapid alveolar bone loss. Other oral manifestations include asymptomatic swelling of the involved mucosa, gingivitis and ulcers. Diagnosis of sarcoidosis is by exclusion as no specific test is available. Radiographic, biochemical and histological findings are non-specific, but helpful. All cases of sarcoidosis do not require treatment. Corticosteroids are the treatment of choice in patients requiring treatment. Other drugs such as chloroquine, methotrexate, infliximab and thalidomide are also used in the treatment of sarcoidosis. In most of the oral cases reported, systemic steroids and surgery were the preferred treatment.

Kieferknochennekrosen als mögliche unerwünschte Wirkung von Bisphosphonaten

BACKGROUND

Bisphosphonates are widely used in the treatment of cancer patients with hypercalcemia and bone metastases or in osteoporosis therapy. Current reports have focused on therapy-resistant osteonecrosis of the jaws as a possible side effect of bisphosphonates. Official German drug committees have recently warned about the possibility of these side effects in the publication organs Deutsches Arzteblatt and Deutsche Apotheker Zeitung.

CASE REPORTS

So far we have had experience with seven patients showing therapy-resistant osteonecrosis of the mandible under bisphosphonate medication. The presentation of these cases is intended to call attention to this clinically important side effect of bisphosphonate medication.

Periodontoid pseudotumor: CT and MRI imaging

Periodontoid pseudotumor (PP) can be a severe and disabling disease. This disease process typically presents in elderly patients with a longstanding history of myelopathy. We reviewed four cases of PP in order to summarize the clinical and imaging features.

The value of scintigraphy in the evaluation of oropharyngeal dysphagia

Healthy adults can swallow boluses of 20 ml water in a single swallow. Individuals with impaired swallowing, however, may be unable to do so, instead requiring two or more swallows; this phenomenon is called "piecemeal deglutition". The term "dysphagia limit" refers to the volume at which piecemeal deglutition occurs. The aim of our study was to investigate the potential value of scintigraphic evaluation of piecemeal deglutition and dysphagia limit in patients with dysphagia, based on correlation with the results of submental electromyography (SM-EMG) and laryngeal sensor monitoring (LS). The study population comprised 24 patients with dysphagia secondary to neurological disorders and ten normal adults, who formed a control group. In the scintigraphic evaluation, subjects underwent four separate dynamic studies using 5, 10, 15 and 20 ml of water containing 0.5 mCi technetium-99m labelled sulphur colloid, and time-activity curves (TACs) were created for each study. Static thoracic images were also recorded in order to detect airway aspiration Observation of two or more peaks on TACs within the 10-s acquisition period was considered a sign of piecemeal deglutition. If piecemeal deglutition occurred at or below 20 ml, this volume was regarded as the dysphagia limit. Piecemeal deglutition was not found in any normal subjects; by contrast, it was observed in 14 of the 24 (58%) patients on scintigraphy and in 17 (71%) patients on EMG and LS. In three patients, signs of the airway aspiration were observed on static thoracic images. Scintigraphic and electrophysiological findings were in agreement in 19 patients (79%), and the correlation between scintigraphy and the electrophysiological methods for the evaluation of dysphagia was statistically significant (r=0.57, P=0.003). The novel finding of this study is the demonstration of piecemeal deglutition and dysphagia limit on scintigraphic studies in patients with neurogenic dysphagia. Based on this finding we consider that scintigraphic evaluations of piecemeal deglutition and dysphagia limit could be of value especially in centres which do not have electrophysiological test facilities. The technique should be added to the list of standard scintigraphic methods for the evaluation of patients with oropharyngeal dysphagia.

Factitial oral lesions in an autistic paediatric patient

Self Injurious Behaviour (SIB) is a deliberate harm to the body that may lead to factitial injuries. Its origin may be functional or biological and it has a higher prevalence in females and in psychologically impaired individuals. Seventy per cent of autistic patients have SIB. Seventy-five per cent of factitial injuries are located in the head and neck region. A paediatric case report concerning a 4-year-old autistic female is presented. Detailed medical history, physical examination, clinical intraoral and radiographic examination, incisional biopsy, neuropaediatrical, psychological and speech evaluation were undertaken. Diagnosis included hypochromic macrocytic anaemia, caries, coronal fracture, factitial ulcer, factitial periodontitis, self-extraction of primary teeth and permanent teeth buds, non-specific oral ulcer with inflammatory reaction, mild mental retardation, speech impairment, autistic syndrome and self injurious behaviour consisting of putting fingers and foreign objects in the gingiva, fingernail biting and hair pulling. Differential diagnosis included hystiocitosis X, prepuberal periodontitis and leukocyte adhesion deficiency. Dental preventive and restorative treatment was performed. Non-contingent reinforcement therapy was successfully used to diminish SIB. Treatment of factitial oral injuries must be interdisciplinary and requires cooperation of the patient, the parents, health care providers, and medical team.

Bone scintigraphy as an adjunct for the diagnosis of oral diseases

Bone scintigraphy is a very sensitive method for the detection of osteoblastic activity of the skeleton. The technique consists of imaging the uptake of bone-seeking radiopharmaceuticals, particularly technetium-99m labeled diphosphonates, in the mineral component of bone, which consists of hydroxyapatite crystals and calcium phosphate, as well as in the organic matrix such as collagen fibers. Plain radiographs, computed tomography, and magnetic resonance imaging are classified as structural imaging modalities, whereas bone scintigraphy is a functional method. In many cases, radionuclide imaging techniques are the only means by which early physiologic changes that are a direct result of biochemical alteration may be assessed, before significant bone mineral changes can be detected by other means. Since many oral diseases may cause metabolic changes in the oromaxillofacial complex, it would be of great value to use bone scintigraphy to evaluate more completely some conditions involving the bones in the region to formulate more appropriate treatment plans. Based upon the current literature, the authors discuss the possible applications of bone scintigraphy as a diagnostic and treatment planning adjunct for oral diseases. Bone scintigraphy has proven particularly useful in the study of malignant lesions and in the evaluation of vascularized bone grafts used for maxillofacial reconstructions.

Application of dynamic CT for various diseases in the oral and maxillofacial region

OBJECTIVE

To investigate whether dynamic CT enables quantitative differentiation between inflammation, benign tumors, and malignant tumors in oral and maxillofacial regions.

METHODS

Sixteen malignant tumors (14 squamous cell Ca, one adenoid cystic Ca, one mucoepidermoid Ca), six benign tumors (one Warthin tumor, two pleomorphic adenomas, one lipoma, one Schwanoma, one hemangioma), and seven inflammation cases (three submandibular adenitis, two osteomyelitis, two perimandibular inflammations) were examined. Contrast agent (0.8 ml/kg) was injected intravenously at 5 ml/s. CT (Toshiba TCT 900S) scanning was performed at the time of the beginning of contrast medium injection. Parameters from the time-density curve were investigated: peak height (PH), relative CT value from the base CT value when the curve reached peak point; peak time (PT), the time when the curve reaches the peak point from contrast medium infusion; transit time (TT), time between two transit points on the time-density curve; and peak time ratio (PR), the ratio of peak time from the lesion to the artery and peak time from the vein to the artery.

RESULTS

PH was highest in inflammation, followed by malignant tumors and benign tumors. TT was significantly longer in benign tumor cases compared with malignant tumor and inflammation cases. PR for malignant tumor and inflammation were between the artery and vein phase, and that for benign tumor was beyond the vein phase.

CONCLUSION

Parametrical analysis of a contrast enhanced dynamic CT study may serve to differentiate the lesions in the oral and maxillofacial region.

Oral and clinical characteristics of a group of patients with Turner syndrome

OBJECTIVE

The loss of the X chromosome in girls with Turner syndrome (TS) affects the shape and the size of craniofacial structures. Few studies have been reported on female patients with TS in South America. Records of odontologic alterations of 23 Argentinian patients with TS were compared with those of 25 girls in a control group, and associations were made with medical indications.

STUDY DESIGN

Oral clinical diagnoses were completed with periapical, occlusal, panoramic, and orthopantomograms; urine and blood determinations were performed by conventional methods.

RESULTS

Blood phosphorus and calcium levels were altered, and osteoporosis was detected. In some patients, TS was associated with autoimmune thyroiditis. Control subjects had normal blood and urine values. The decayed, missing, and filled permanent surfaces index for temporary teeth was statistically higher for the control group. About 78% of the patients had hypoplasia, 65% had reduced root length and bifurcated roots, and 100% had high arch palate. Incisor asymmetry was also observed.

CONCLUSIONS

Medical and laboratory indexes are essentially indicative of hormone alterations. TS patients have a particular oral anatomy that could be closely related to an alteration in calcium and phosphorus metabolism.

A case of buccal abscess; originating from an ectopic accessory parotid gland?

We report a case of an abscess from an 'ectopic' accessory parotid gland in the cheek demonstrated by sialography and computed tomography (CT). The accessory parotid gland was ectopically located anterolateral to the masseter muscle and isolated from the main parotid gland. The orifice and ductal system of the ectopic accessory parotid gland were separated from those of Stensen's duct. The abscess developed from this ectopic accessory gland, and the main parotid gland was free of inflammation. Using sialography and CT, we confirmed the presence of this ectopic accessory gland.