Intra-observer and inter-observer variability in two grading systems for oral epithelial dysplasia: A multi-centre study in India.

BACKGROUND: The presence and grading of oral epithelial dysplasia (OED) are considered the gold standard for predicting the malignant risk of oral potentially malignant disorders. However, inter-observer and intra-observer agreement in the context of reporting on OED grading has been reputedly considered unreliable. METHODS: We undertook a multi-centre study of six Indian oral pathologists to assess variations in reporting OED using the World Health Organization (WHO; 2005) system and also the recently introduced binary system. The observer variability was assessed with the use of kappa statistics. RESULTS: The weighted kappa intra-observer agreement scores improved (κw  = 0.5012) on grouping by two grades as no and mild dysplasia versus moderate and severe dysplasia compared to binary grading system (κ = 0.1563) and WHO grading system (κw  = 0.4297). Poor to fair inter-observer agreement scores were seen between the principal investigator (PI) and the other five observers using the WHO grading system (κ = 0.051-0.231; κw  = 0.145 to 0.361; 35% to 46%) and binary grading system (κ = 0.049 to 0.326; 50 to 65%). CONCLUSIONS: There is considerable room for improvement in the assessment of OED using either system to help in standardised reporting. The professional pathology organisations in India should take steps to provide external quality assessment in reporting OED among oral and general pathologists who are engaged in routine reporting of head and neck specimens.

Determining the best anti-microbial properties of dental cements used for pulp capping procedures using deep dentinal carious material.

Introduction: The exposure of the healthy pulp in cases of deep dentinal caries (DDC) that contain carious microorganisms can be prevented by placing a layer of pulp capping agent on the affected dentin. The cements used for pulp-capping should also ensure good anti-microbial properties. The present study was carried out to detect the antimicrobial efficacy of the commonly used cements by culturing the samples directly from DDC. Aims: To determine the efficacy of dental cements in the growth inhibition of microorganisms involved in DDC using direct contact anaerobic culture test. Method: 100 samples of DDC were collected in RTF. Ten microliters of the specimen containing RTF was incubated in thioglycolate broth consisting of 1 mm3 cement blocks of GIC, CaOH2, ZnOE and MTA anaerobically for 24 hours. This was further sub-cultured using selective media for streptococcus mutans, lactobacillus and bifidobacterium. Growth inhibition was measured by calculating the number of CFUs and statistically analysed using ANOVA and Tukey's post-hoc tests. Results: Tests showed variation in the anti-microbial effects of the cements and was highly significant at P < 0.001. Bifidobacterium showed most number of CFUs. MTA was the most effective pulp capping agent exhibiting 87.13% reduction in microbial growth, followed closely by ZnOE (84.6%). Conclusion: A conservative approach to treat DDC is the need of the hour which calls for the use of pulp capping cements of good antimicrobial efficacy. The current study revealed bifidobacterium to be the most prevalent in DDC and the cement that would best inhibit the mixed culture growth was MTA followed closely by ZnOE.

Clear cell adenomatoid odontogenic tumour and dentigerous cyst: an uncommon hybrid combination - case and review.

Odontogenic tumours and cysts have a characteristic presentation, histopathologically and clinically. The diagnostic criteria and nomenclature are distinct as elaborated in 2017 WHO classification. But one can occasionally and infrequently find an association between different odontogenic tumours and cysts, like calcifying epithelial odontogenic tumour (CEOT) and adenomatoid odontogenic tumour (AOT), CEOT and ghost cell tumour. Some of the odontogenic tumours and cysts share the site of occurrence, intraosseous location, teeth involved/quadrant involved and histopathology too. Hence these lesions are considered for differential diagnoses in most cases. But some instances report hybrid or associated tumours and cyst cases. Here we present a case of dentigerous cyst in association with AOT that showed variation in cell type, pattern and induction pattern.

Peripheral adenomatoid odontogenic tumour.

The Adenomatoid Odontogenic Tumour (AOT) is more than 100 years old, known by different names and the term AOT was coined in 1969 by Philipsen and Birn. AOT frequently occurs in intra-osseous location in gnathic skeleton and rarely seen in peripheral forms. These are rare odontogenic tumours, accounting for 2.2--7.1% of all odontogenic tumours, whereas the central or intraosseous variant of AOT in follicular and extra-follicular presentation, accounts for 95.6% of all AOTs. The peripheral variant presents as a gingival mass, which may cause slight saucerization of alveolar bone or might not affect the bone at all. These peripheral variants constitute 4.4% or less, of all AOTs of the gnathic skeleton. Here, we present a rare case of a peripheral variant of AOT in a 35-years-old female, 1.5 to 2 cm in dimension seen on the labial gingiva in right canine-premolar area. The lesion showed marked bone loss in 13 and 14 teeth region, causing mobility of 13. Histopathology showed a well encapsulated tumour mass with metaplastic bone in the capsule. A conventional AOT with ductal and rosette pattern was seen with tumour droplets and amyloid like material. The case clinically presented a moderately aggressive behaviour.

Case of labial sclerosing polycystic adenoma with ductal carcinoma in situ (DCIS).

Minor salivary gland tumours are enigmatic in their behaviour and presentations. Histopathological diagnosis of these tumours encompasses a large spectrum. Conventionally, small nodular tumours of the upper lip or the labial mucosa are generally adenomas, frequently pleomorphic adenomas. Here, we describe a case of a solitary nodular tumour, occurring in the upper labial mucosa, diagnosed as sclerosing polycystic adenoma (SPA) with intraductal epithelial proliferation of high grade. This is a rare lesion, which has entered into the category of salivary gland tumours recently in the 2017 WHO categorisation. We report a case of paucicystic SPA with intraductal epithelial proliferations in the labial minor salivary gland of a 56-year-old woman, which might be the first report of a case occurring in the upper labial mucosa.

Odontogenic keratocyst with granular cell changes: A distinctive finding.

Odontogenic keratocyst (OKC) originates from the dental lamina and is more commonly seen in the posterior mandible than in the maxilla. OKC is the most aggressive cyst of the oral cavity and is known for its rapid growth and its tendency to invade bone of the adjacent tissues. The recurrence rate of OKC is very high due to various reasons debated upon. Cases of OKC have shown the presence of calcifications, dentinoid formation and ossification. Here, we report the first case of OKC in a 27-year-old male showing granular cell changes.

"SKILL TO KILL" - Oral cancer and potentially premalignant oral epithelial lesions (PPOELs): A survey approach. Emerging of a new system and professionals.

BACKGROUND: Oral cancer is said to be the 6th most common cancer in men and 12th in women. Potentially malignant disorders/potentially premalignant oral epithelial lesion (PMDs/PPOELs) have shown an increased risk of progressing to cancer. In this regard, lack of awareness about identification of oral PMDs among healthcare providers in general and oral pathologists in particular is said to be responsible for the diagnostic delay. Oral cancer is said to be the most common cancer in men and 3rd most common in women in the Indian subcontinent. PMDs have shown an increased risk of progressing to cancer. The various rates of conversion include 14%-51% for erythroplakia, 60%-100% for proliferative verrucous leukoplakia and 7%-26% for oral submucous fibrosis (OSMF). In this regard, early detection at PPOEL level will lead to prevention of malignant transformation. AIMS AND OBJECTIVES: The purpose of this survey was: 1. To determine if awareness among professionals is essential/key to challenge the progression of PMDs of the oral cavity. 2. To examine and/ordiscern if oral pathologists felt enough was being done to address the issue of early detection and prevention and how the scenario could be improved further. MATERIALS AND METHODS: A survey was designed to assess the interest, zeal, knowledge and skill of healthcare providers in general and oral pathologists in particular in careful examination of the oral cavity and early detection of PMDs. A questionnaire with 18 questions was designed to address these issues/points and distributed among post-graduate students and practicing oral pathologists on online platforms. RESULTS: The results of the esurvey were collected, analyzed and the results discussed question wise. The validity and reliability of the questionnaire was assessed and confirmed with Aiken's index for validity and Cronbach's alpha for reliability. Inferential statistical analysis was performed using Chi square test with P = 0.05 being statistically significant. CONCLUSION: On evaluation of the survey, we found that 85% of the surveyees are on agreement that PPOELs should be registered in a standard format and should be included in the list of recognizable diseases. 89.2% and 87.8% of the respondents would like to be part of an active body for early detection and diagnosis and for Cancer screening in our country respectively. In conclusion, the oral pathology fraternity is eager to work for and tackle these PPOELs head on, provided the right opportunities and training are meted out to them.

Determination of epigenetic age through DNA methylation of NPTX2 gene using buccal scrapes: A pilot study.

CONTEXT: DNA methylation (DNAm) age can be used to evaluate the chronological age of individuals often called "epigenetic age." In this study, buccal scrape samples were used for the determination of epigenetic age. AIMS: To examine if epigenetic age could be determined using neuronal pentraxin 2 (NPTX2) gene in buccal cells. SETTING AND DESIGN: This cohort study was designed to validate the use of buccal cells for epigenetic age estimation. Sanger sequencing was used to determine the genetic sequence of the gene of interest postamplification. Nucleotide base sequence for NPTX2 gene was obtained for each case using this protocol. SUBJECTS AND METHODS: The study was conducted on buccal scrapes obtained from 26 subjects of both genders, whose age varied from 1 to 65 years. The samples, collected by wooden spatulas, were placed in cell suspension buffer and stored at 4°C until transported to the laboratory. RESULTS: Methylation levels of 5'-C-phosphate-G-3' located in the gene NPTX2 of 26 subjects were studied and analyzed by bisulfate sequencing. The percentage of methylation in this study falls in the range between 15% and 51%. CONCLUSION: In this study, a sufficient amount of gDNA was retrieved from the buccal cells, thus confirming that buccal scrape was a feasible technique to obtain ample DNA. This study also showed that DNAm-polymerase chain reaction method was a feasible method for the evaluation of methylation pattern of NPTX2 gene.

Periosteal desmoid tumour: a rare finding in the oral cavity.

A 55-year-old female patient reported with an intraoral well-localised asymptomatic swelling on the right side of the mandible in relation to the right mandibular first molar along with a history of trauma 6 months back. Panoramic radiograph revealed normal trabecular bone pattern in relation to the lesion. The lesion was excised along with the associated buccal cortical plate and tooth. The microscopic examination revealed a well-circumscribed lesion consisting of spindle cells arranged in storiform pattern associated with the buccal cortical plate. The key feature to note was presence of reactive periosteum, which was in continuum with the lesion. Immunohistochemistry (IHC) revealed faint nuclear positivity for ß-catenin. The above findings led to our diagnosis of periosteal desmoid, which is rarely reported in the head-and-neck region. The major challenge in the diagnosis of such lesions is good clinicopathological correlation as the differential diagnosis of spindle-cell lesions is vast and needs IHC confirmation.

Ameloblastic Fibrodentinoma: A Case with Varied Patterns of Dysplastic Dentin.

Ameloblastic fibrodentinoma is a benign odontogenic tumor belonging to the category of "odontogenic epithelium with odontogenic ectomesenchyme" along with recognition of induction in the form of dentin in atypical or dysplastic forms. The biological behaviour of ameloblastic fibrodentinoma is not very different from ameloblastic fibroma; hence, it is treated similarly by conservative procedures. It is important to understand the histopathogenesis of these rare tumors. Though rare, they are an independent entity awaiting recognition. Here, we report a case of amelobalstic fibrodentinoma in a 14-year-old female patient.

Intramuscular sinusoidal haemangioma with secondary Masson's phenomenon.

Intramuscular haemangiomas (IMHs) are rare benign vascular neoplasms that account for approximately 0.8% of all haemangiomas. The histology of IMHs can reveal cavernous dilated spaces. We report an interesting case of haemangioma in the deep skeletal muscle of the right labial mucosa in a young man involving the orbicularis oris muscle which showed additional features of sinusoidal arrangement with a secondary Masson's phenomenon.

Fallacious Carcinoma- Spindle Cell Variant of Squamous Cell Carcinoma.

Spindle cell carcinoma is a unique, rare and peculiar biphasic tumour of head and neck which is not frequently observed in the oral cavity. This variant of squamous cell carcinoma although of monophasic epithelial origin, simulates a sarcoma and is an aggressive carcinoma with high frequency of recurrence and metastasis. A correct and timely diagnosis is of paramount importance. Most of the tumours require an Immunohistochemistry (IHC) panel for confirmation or diagnosis. We report a case of spindle cell carcinoma with varied histopathological morphology and clinical presentation in a middle aged female with a brief review of literature.

Compound composite odontoma.

The term odontoma has been used as a descriptor for any tumor of odontogenic origin. It is a growth in which both epithelial and mesenchymal cells exhibits complete differentiation. Odontomas are considered as hamartomas rather than true neoplasm. They are usually discovered on routine radiographic examination. Odontomas, according to the World Health Organization, are classified into complex odontoma and compound odontomas. The present paper reports a case of compound composite odontomas.

Quantification of Porphyromonas gingivalis in chronic periodontitis patients associated with diabetes mellitus using real-time polymerase chain reaction.

INTRODUCTION: Periodontal diseases, if left untreated, can lead to tooth loss and affect at least one tooth in 80% of adults worldwide, with the main cause being a bacterial plaque. Among subgingival plaque bacterial species, Porphyromonas gingivalis has been implicated as a major etiological agent causing tooth loss. Diabetics and smokers are two patient groups at high risk for periodontal disease. The increase in the number of this organism with the coexistence of other pathogenic microbes leads to rapid destruction of the periodontium, premature loss of teeth and also because of its virulence has implications in systemic pathology. Our aim was to observe the involvement of P. gingivalis in diabetes mellitus (DM) patients associated with periodontitis with and without tobacco-associated habits and to compare them with periodontitis patients having no other systemic pathologies. MATERIALS AND METHODS: Subgingival plaque samples from a total of seventy subjects were included in the study. DNA was isolated from the collected sample and was quantified using spectrophotometer for standardizing the polymerase chain reaction. The quantity of the isolated DNA was checked in a ultraviolet-visible spectrophotomer. STATISTICS: One-way ANOVA and Tukey's multiple post hoc procedures were carried out. RESULTS: The maximum score of P. gingivalis was seen in periodontitis patients having DM, whereas the least score was seen in periodontitis patients having DM with tobacco smoking habit compared to the other groups. CONCLUSION: P. gingivalis count is significantly reduced in periodontitis patients having DM with smoking habit; it is concluded that P. gingivalis might not be a key causative organism responsible for the periodontal destruction in case of smokers despite the DM condition. The decrease in counts may be attributed to change in the local environment like chemical (tobacco nitrosamines) and physical changes preventing the growth of P. gingivalis.

Survivin expression in oral lichen planus: Role in malignant transformation.

CONTEXT: Oral lichen planus (OLP) is a potentially malignant disease with a prevalence rate of 0.5-2.2%. It is a T-cell-mediated autoimmune disease, in which cytotoxic CD8+ T-cells trigger apoptosis of the basal cells of oral epithelium. The reported progression of OLP to oral squamous cell carcinoma (OSCC) ranges from 0.4% to 6.5%. Apoptosis plays a major role in the maintenance of tissue homeostasis. The evasion of apoptosis in the form of dysregulation of inhibitors of apoptosis proteins (IAPs) may lead to malignant transformation. Survivin belongs to the second gene family of IAPs, which is overexpressed in many tumors such as OSCC and gastric carcinomas, and its expression is widely involved in apoptosis as well as in tumor metastasis. MATERIALS AND METHODS: Sections were obtained from the paraffin-embedded archival blocks of patients diagnosed histologically as OLP, and cases with normal epithelium were used for comparison whereas cases with OSCC were used as positive control. RESULTS: We analyzed the expression of survivin in OLP and normal epithelium. Survivin expression with moderate intensity was seen in the cells of basal layer with nuclear positivity in cases of OLP, whereas mild to nil expression was seen in normal epithelium with nuclear and cytoplasmic positivity in different layers. CONCLUSIONS: Survivin positivity was seen predominantly in the basal cells of OLP suggesting increased longevity of these cells which in turn might acquire dysplastic changes leading to increased risk of malignant transformation of this premalignant condition. Although the conversion rate may be low, the potential exists in the indolent course of the disease.

Analysis of the invasive edge in primary and secondary oral squamous cell carcinoma: An independent prognostic marker: A retrospective study.

BACKGROUND AND OBJECTIVES: Oral squamous cell carcinoma (OSCC) is one of the most common head and neck carcinomas and corresponds to 95% of all oral cancers with an increasing morbidity and mortality. Its prognosis is affected by several clinicopathologic factors, one of which is pattern of invasion (POI). The histological features of OSCC may differ widely, but there is general agreement that the most useful prognostic information can be deduced from the invasive front of the tumor. In this retrospective study, our aim was to compare the POI, the status of connective tissue and the status of inflammation at the tumor-host interface in primary and recurrent (secondary) OSCC and test the validity of POI, to serve as a potential marker to assess the prognosis of the patient. MATERIALS AND METHODS: Differentiation of tumors, POI, status of connective tissue and inflammation was assessed in 168 cases of primary and recurrent cases of OSCC. STATISTICAL ANALYSIS: Fisher's exact test was used to determine the statistical significance and P < 0.05 was considered to be statistically significant. RESULTS: Our study showed that majority of the primary and secondary tumors were well differentiated, 117 [95.9%] and 34 [73.9%], respectively. Predominant POI in the primary and secondary tumor group was Pattern II and least was Pattern V. Worst pattern in primary tumor and highest distribution was seen for Pattern III (53.3%), and least for Pattern V (0.00%). In secondary tumors, the predominant worst pattern was Pattern IV (50.0%) and least distribution was seen for Pattern I (0.00%). Connective tissue status for both primary and secondary tumors showed the predominance of loose type (85.2% and 79.2%) and least was variable type (0.8% and 0.6%), respectively. Status of inflammation in the primary tumor group showed a predominance of moderate grade of inflammation (50.0%) and very mild grade of inflammation (6.6%) was the least type. In the secondary tumor group, moderate grade (43.5%) of inflammation was predominant and very mild grade (5.4%) was the least. All the parameters showed a statistically significant difference on the application of Fisher's exact test between the two groups. CONCLUSION: Our study showed that POI could serve as an individual prognostic marker irrespective of the histologic differentiation of tumor. Tumor desmoplasia could be considered as an important reflection of the tumor-host interaction, especially in aggressive cancers. Host immune defense, especially tumor infiltrating lymphocytes must be noted as critical factors related to survival rate in OSCC patients. Assessment of mentioned parameters may lead to sound prognostic assessment and appropriate treatment planning thus reducing the possibility of recurrence or relapse. Hence, the parameters evaluated in our study could serve as independent or interdependent prognostic markers.

Congenital epulis of the newborn.

Congenital epulis, a benign tumor of the oral cavity, is an extremely rare condition in newborn. It may lead to mechanical obstruction, therefore resulting in respiratory distress and difficulty in feeding. Addressing the problem may need a multidisciplinary team approach at the time of birth. Antenatal ultrasonography and perinatal magnetic resonance imaging are an adjunct to treatment planning. Prenatal diagnosis remains difficult as the findings are nonspecific due to the late development of the tumor. Surgical excision is, therefore, the treatment of choice. Our report discusses this condition and the treatment thereafter on a newborn, with an epulis originating from the upper alveolar ridge discovered at birth. Histological examination confirmed the diagnosis of large polygonal granular cells. The mass was excised under general anesthesia, and the outcome was good after surgery allowing regular feeds on the second postoperative day.

A Large Extragnathic Keratocystic Odontogenic Tumour.

Odontogenic keratocysts (OKCs) are developmental cysts which occur typically in the jawbones. They present more commonly in the posterior mandible of young adults than the maxilla. OKCs have been reclassified under odontogenic tumours in 2005 by the WHO and have since been termed as keratocystic odontogenic tumours (KCOTs). Here we report a case of a recurrent buccal lesion in a 62-year-old man which was provisionally diagnosed as a space infection (buccal abscess) but surprisingly turned out to be a soft tissue KCOT in an unusual location on histopathologic examination.

Chondromyxoid fibroma of zygoma: A rare case report.

Chondromyxoid fibroma (CMF) is a rare benign mesenchymal tumor of the bone. Clinically, it is characterized by a lobular growth pattern and histologically by chondroid and myxoid differentiation. The tumor is rare in the craniofacial bones with only 2% of all reported cases. Extragnathic location in the facial skeleton is extremely rare. Most of the cases reported either originate from gnathic sites or in the cranium. A case of CMF in a 3½-year-old male is presented here, which arose from the root of zygomatic arch. A detailed clinical history and histopathological picture of one more case is added to the literature. It is important to document such cases so that better light can be shed on future reviews and conclusions. This shall facilitate better treatment approaches and prognosis. This case is the first reported case of involvement of the zygomatic arch in a pediatric patient.

Solid blue dot tumour: minor salivary gland acinic cell carcinoma.

Acinic cell adenocarcinoma (ACC) is a low-grade malignant salivary neoplasm that constitutes approximately 17% of all primary salivary gland malignancies. In the head and neck region, the parotid gland is the predominant site of origin and ACC is usually more frequent in women than men. Previous radiation exposure and familial predisposition are some of the risk factors for ACC. ACCs rarely involve minor salivary glands constituting only 13-17% of all minor salivary gland tumours. Generally, a slowly enlarging mass lesion in the tail of the parotid gland is the most frequent presentation. ACC has a significant tendency to recur, metastasise and may have an aggressive evolution. Therefore, a long-term follow-up is mandatory after treatment. Here we report the case of a woman in her 60s with an ACC in association with the labial minor salivary gland, presenting in the post-treatment period of squamous cell carcinoma of the tongue.