Oral and Maxillofacial Pathology Services - OraLab

06/07/2023

Registration Date extended

21/06/2023

13/02/2023

https://forms.gle/mGD3VcfVrsuKyUz57

29/01/2022

Introducing the new educational series...
Case credits: Zeeshan Baig

15/06/2021

Details on yesterday's video...

A 24-year-old male was seen at the Oral and Maxillofacial Surgery Clinics at Islamabad Medical and Dental Clinics for a swelling in left mandible present for over 2 years. The mass had been progressively increasing in size.

Panoramic film showed a lytic, multilocular radiolucency extending from the first molar region to the ramus of mandible. The lesion was causing resorption of the distal root of the first mandibular molar. CT scan revealed an expansile lesion arising in the left mandible. It had a significant component pushing in to the soft tissue.

At this point an incisional biopsy was performed. The biopsy showed an odontogenic neoplasm with tumor cells arranged in nests. The neoplastic nests exhibit tall, columnar cells at the periphery of the nests. These cells are arranged in a palisaded arrangement and demonstrate reverse nuclear polarity. The cells in the center were more loosely arranged and resembled stellate reticulum. Based on these features a diagnosis of ameloblastoma was made.

Management required wide surgical resection. The final excision measured about 250g in weight and was about 12 cms in greatest dimension. The portion of mandible that was removed was replaced by a titanium plate.

Ameloblastoma is a benign odontogenic neoplasm that affects the jaws. It is believed that it arises from the dental lamina. It gradually increases in size but is locally invasive. There are 3 known variants of this tumor; cystic, solid and peripheral.

Solid ameloblatoma, like our case, is common in the 3rd and 4th decade of life. They present as painless swellings in the jaw favoring the posterior region. The expansile tumor can cause resorption of roots. Larger tumors can compress against nerves and result in pain.

Radiographically the tumors present as well defined radiolucencies, usually multilocular in nature. The appearance of the locations are often referred to as "soap-bubble" or "honey-combed". While radiology helps in establishing a differential diagnosis, microscopy is essential for definitive diagnosis. Ameloblastic cells have a characteristic appearance; they are tall, columnar in morphology, demonstrate palisading and reverse nuclear polarity. Depending on addition of other features, ameloblastomas can be classified into 6 independent categories; follicular, acanthomatous, desmoplastic, granular cells, plexiform and basal cell types. It is rare to see a single histologic type in any tumor. All tumors are combinations of multiple histologic types.

Given the locally aggressive nature of this neoplasm, simple curettage is accompanied by recurrence rates as high as 90%. Wide surgical resection has much lower recurrence rates (less then 15%) and is therefore a preferred mode of management.

Case Credits: Muhammad Jamal Awan Anzish Iman

04/06/2021

A 51-year-old female was seen by a general dentist for a rapidly enlarging painful mass in the anterior maxilla. Although the clinical image is not that great, you can appreciate this growth in the image. The medical history was unremarkable. A panoramic radiograph was taken, the growth, with bone-like radio-density and ill-defined margins can be appreciated on the film. The dentist performed a biopsy and the tissue was sent in.

Histopathologic examination showed a proliferation of pleomorphic, mesenchymal cells exhibiting angular nuclei, multi nucleation and frequent mitoses. They were also laying down osteoid and cartilage-like material. Based on these features a diagnosis of osteosarcoma, chondroblastic type, was made.

Osteosarcoma, or osteogenic sarcoma, is the most common primary malignancy of bone. Majority of the osteosarcomas arise from the medullary bone, but a juxtacoritical variant has also been recognized. Osteosarcomas involving long bones is usually diagnosed within the second decade of life and rarely over the age of 50. Secondary osteosarcoma may be seen in older individuals with a history of Paget's disease, fibrous dysplasia or radiation exposure.

Osteosarcoma of the jaws has a wide age range. The mean age of diagnosis is about 33 years. The maxilla and mandible are equally affected. One of the first symptoms is a painful swelling involving either of the jaws. Tooth mobility, exfoliation, paresthesia and nasal blockage may also be seen.

Radiographic findings can range from a radiolucent defect to radio-opaque changes. The margins of the lesion are ill-defined and adjacent teeth may show widening of the periodontal ligament space. The classic “sunburst” appearance is rarely seen in the jaw region. Computed tomography scans are necessary to establish the extent of the lesion.

Histopathology can classify osteosarcoma of the jaw into three processes: fibroblastic, osteoblastic and chondroblastic. In each of these subtypes, pleomorphic mesenchymal cells depositing osteoid is necessary for diagnosis. Depending on the type and quantity of the osteoid production, further classification can be done. Given the presence of malignant cartilage in our case, the tumor was classified as chondroblastic osteosarcoma.

Management requires radical surgery, followed by chemotherapy. Risk of recurrence and metastasis is high. Survival rates are between 30 to 70% for jaw lesions.

Case Credit: Dr. Danial Qasim and Dr. Saad Akbar

01/06/2021

Details on yesterday's case of Herpes Labialis (Post by Dr. Rabia Masood:

A 38-year-old patient was seen in the Oral Surgery clinics at Islamic International Dental Hospital for removal of his sutures from the site of his 10-day old extraction. The resident on duty noticed red crusting at the corner of the patient's lip extending down to the skin. The patient said that blisters appeared at this site 2 days following the extraction procedure. These blisters had ruptured and crusted over the next few days. Given the patient's history of the recent extraction procedure and the course of the lesions, a diagnosis of Herpes labialis or secondary Herpes was made. Since the lesions had healed by the time we saw the patient, we chose not to give any medications.

Acute Herpetic gingivo-stomatitis is the primary infection caused by the Herpes simplex virus.It is usually seen in children between the ages of 6 months and 5-years.This infection causes fever, malaise, lymphadenopathy and generalized ulceration within the oral cavity. The lesions can take about 7-14 to heal completely.

Following this primary infection the virus become latent in our sensory or autonomic ganglia. It can be reactivated by triggers such as old age, ultraviolet light, physical and emotional stress, fatigue, heat, cold, pregnancy, allergy, trauma, dental treatment, respiratory illnesses, fever, menstruation, systemic diseases and malignancy. Dental procedures are a frequent cause for reactivation of the virus. The stress created during the procedure causes release of adreno-cortical hormones, resulting in a period of decreased immunity, hence a safe environment for the virus to return. In our case, the surgical procedure became the trigger.

Herpes labialis is accompanied by a prodromal phase that can present as pain, itching, burning, tingling, localized warmth, or erythema of the involved skin. This usually occurs 6-24 hours before the lesion develop. Symptoms are usually severe in the first 8 hours. After the prodrome, multiple small erythematous papules develop and form clusters of fluid filled vesicles. The vesicles rupture and crust within 2-3 days. Complete healing can take 7 to 10 days.

While the diagnosis is mostly clinical, a cytological smear, viral culture or PCR may help in establishing definitive diagnosis. Out of these the quickest results are received from a cytological smear that shows HSV-infected cells exhibiting acantholysis, nuclear clearing, nuclear enlargement and multinucleation.

Patients with active lesions can spread the virus to others so patients are often directed to avoid kissing and sharing of utensils. They can also be prescribed acyclovir cream to be applied multiple times daily. Use allows the lesions to heal much more quickly.

31/05/2021

Details in tomorrow's post...