Brown Tumors of the Jaws: A Retrospective Study.

Objectives: (1) Describe the clinical spectrum, imaging features, management, and outcome of brown tumors (BT) of the jaws. (2) Determine via a literature review the facts and controversies around the characteristics and management of this lesion. Materials and methods: Our study was approved by the institutional committee of Sahloul University Hospital in accordance with the ethical standards of the Declaration of Helsinki. Sixteen patients with BT in the context of a primary, secondary, and tertiary hyperparathyroidism were treated and followed up during their recovery. Results: This study reports 16 patients with a mean age of 48 years old. Brown tumor lesions were associated with primary hyperparathyroidism in 6 cases (38%), secondary hyperparathyroidism to chronic kidney failure in 5 cases (31%), and tertiary hyperparathyroidism in the context of a long lasting CRI in 5 cases. Their location was maxillary in 7 cases, mandibular in 5 cases, and bimaxillary in 4 cases. The treatment consisted of parathyroidectomy in 13 patients, maxillary resection in 3 cases, and vitamin D treatment in 2 cases. Favorable outcomes, characterized by tumor regression, were reported in 9 cases, whereas unfavorable evolution was observed among 7 patients. Conclusion: Parathyroidectomy is the gold standard treatment for primary hyperparathyroidism. It resulted in a total regression in all our cases. Regarding secondary hyperparathyroidism, blood screening and chronic renal insufficiency follow-up are critically valuable to detect this condition at an early stage, hence increasing the success rate of brown tumor regression. Our secondary and tertiary hyperparathyroidism results were miscellaneous; although it is important to emphasize the importance of the chronic renal insufficiency management to ensure a success. Clinical relevance: Brown tumors should be included in the differential diagnosis of giant cell lesions. Parathyroidectomy is usually sufficient to induce the total regression of the lesion in primary hyperparathyroidism cases. A more delicate approach is needed regarding secondary hyperparathyroidism. Meticulous control of chronic renal insufficiency is mandatory in addition to parathyroidectomy.

Incidental finding of a bilateral complete ossification of stylo-hyoid chain and thyro-hyoid ligaments.

Ossification of stylohyoid chain corresponds to the ossification of stylohyoid ligament that can vary from thin short to thick long ossification and can be associated with other calcifications. We report in this case a bilateral non painful complete ossification of the stylohyoid complex extended to the thyrohyoidien ligament.

Lateral luxation: Is root resorption an unavoidable complication?

Lateral luxation is defined as a traumatic displacement of a tooth in any direction other than axially. A laterally luxated tooth is often immobile because of its bony lock. It produces a high metallic sound during percussion. Pulp sensibility testing is likely to be negative during the initial follow-up. However, the tooth should be monitored until a definitive pulp diagnosis is made. Treatment includes local anesthesia, suturing soft tissue injuries, manual repositioning of the luxated tooth, and stabilization with a flexible splint for 4 weeks. Given the risk of pulp necrosis following lateral luxation, particularly in teeth with radiographically closed apices and severe displacement, an immediate (prophylactic) root canal treatment is recommended. The objective of this work was to report and discuss the management of a case of lateral luxation involving a permanent tooth treated by reduction, followed by contention with 0.4 steel wire and composite resin, and endodontic treatment, and which was complicated by root resorption 3 months later. We also highlighted the possible complications following lateral luxation, especially root resorption.

Direct pulp capping of carious immature tooth using bioactive material: A case report.

The management of deep carious lesions in immature tooth and the preservation of its pulp vitality is a real challenge in daily dental practice. Bioactive cements are of interest to deal with such cases. Our case report describes the immediate management and the follow-up of an extensive carious lesion on an immature first right mandibular molar with pulp exposure by direct pulp capping using Biodentine. A 6-month clinical and radiographic follow up showed that the tooth was vital, with dentine-bridge formation in the pulp chamber with continuous root formation. This procedure allowed the protection of pulp complex, preserving at the same time its functional and biologic activities due to the capacities of Biodentine as an effective pulp capping material to induce pulp cells to form hard tissue. The aim of this article is to discuss through the report of this clinical case, the indications, advantages and disadvantages of different procedures and biomaterials used for direct pulp capping.

Unicystic Ameloblastoma Mimicking Lateral Periodontal Cyst.

Intraosseous unicystic ameloblastoma (UA) is a rare subtype of a true neoplasm of odontogenic epithelial origin: ameloblastoma. Despite its rareness, dealing with UA is problematic. It is usually mistaken for an odontogenic cyst, and biopsy is rarely relevant because of its multiple growth patterns. The biggest challenge remains the treatment choice. When we are faced with a mural UA presenting strong similarities with a lateral periodontal cyst and having high rates of recurrence, how is the balance found between the young age, psychological fragility, postoperative process, and need for diagnostic biopsy? That was our dilemma. Our patient is a 23-year-old man with a mural unicystic ameloblastoma, diagnosed with general anxiety disorder. The final decision was to turn to a simple enucleation because of the small size of the lesion, and its radiological features strongly evoked a lateral periodontal cyst. Besides, his young age, psychological condition, and UA's proximity to the surrounding soft tissues guided us toward simple enucleation. Two years later, no sign of radiological recurrence was noted. However, we are aware of a later possibility of resection in case of recurrence.

Erosive cheilitis as an early manifestation in DRESS syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a distinct part of severe cutaneous adverse reactions (SCARs). It is characterized by fever, rash, hematologic abnormalities, lymphadenopathy, or/and different degrees of visceral organ involvement. Its diagnosis is particularly challenging due to the variability of its clinical presentations and its long latency period (2-6 weeks). Allopurinol, an uric acid-lowering drug, has been incriminated in several cases of allopurinol-induced DRESS syndrome. Through this paper, we present a case of allopurinol-induced DRESS syndrome with initial oral mucosal involvement. A 69-year-old female patient presented with an erosive cheilitis that started 1 week prior to his presentation. The cheilitis was associated with maculopapular rash and fever. She started taking allopurinol, as treatment of Gout, 6 weeks before hospitalization. The histologic findings obtained from skin biopsy were consistent with a toxic drug reaction. A complete blood count (CBC) showed a moderate eosinophilia. Alteration of renal function was also noted, and the diagnosis of allopurinol-induced DRESS syndrome was made. Systemic corticosteroid therapy was therefore started. The patient completely recovered and had been healthy for 3 years before developing a recurrence after re-challenge with allopurinol.

Management of cutaneous sinus tract of odontogenic origin: Eighteen months follow-up.

An odontogenic cutaneous sinus tract is a pathologic canal that initiates in the oral cavity but opens externally at the cutaneous surface of the face or neck. It is frequently misdiagnosed, leading to inappropriate treatment. A 44-year-old female patient referred to us with a chronically draining lesion on his chin. The lesion previously was misdiagnosed by medical doctors and had undergone cryotherapy and surgery with a focus on the skin lesion and had received antibiotic therapy for a prolonged period of time. After clinical and radiologic examination the dental origin of the lesion was evident and proper endodontic treatment was performed followed by surgical treatment after the recurrence of pus discharge 2 weeks after the conventionnel root canal treatment. Five months later, after the treatment, the lesion showed an obvious healing. After 18 months, the patient was comfortable and a significant healing of the sinus tract was noted, the periapical radiograph shows clear regression of the periapical lesion and an improvement in bone trabeculation. The key to successful treatment of cutaneous sinus tract of dental origin must be appropriate communication between the dentist and the physician in order to achieve correct diagnosis and therapy in such cases.

Simultaneous Oral and Umbilical Locations as a First Sign of Pemphigus Vulgaris.

The place of pemphigus vulgaris (PV) among autoimmune bullous diseases (AIBD) is well established. It is an acquired chronic, autoimmune, vesiculobullous disease in which IgG antibodies target desmosomal proteins to produce intraepithelial mucocutaneous blistering. The diagnosis is often challenging for the clinicians. It requires a combination of three major features: clinical, histopathological, and immunological. Clinically, oral lesions are the first manifestations of the disease in 50-90% of the patients with widespread blisters affecting the oral mucosa. On the skin, lesions are characterized by flaccid blisters that rapidly progress into erosions and crust formation. Umbilical lesions as a clinical manifestation of PV are peculiar and have rarely been reported, and they are not yet completely elucidated. Umbilical region involvement in patients with pemphigus was assessed in a limited study totalling just 10 patients. This localisation may be a valuable hint easing the diagnosis at the clinical level for patients with oral mucosal blisters. Dentists must be familiar with the clinical manifestations of PV to make an early diagnosis and start an early treatment which determines the prognosis of the disease. To the best of the authors' knowledge, the coexistence of these lesions with the oral lesions as a first sign of PV in the absence of skin involvement was reported in only one case of pemphigus vegetans (PVe). In this paper, we describe an observation of a female patient that was diagnosed with PV that begun with simultaneous oral and umbilical locations which coexisted for a period of 4 months before the appearance of other cutaneous lesions. We highlight the role of dentists, by being familiar with the clinical manifestations of PV, to make an early diagnosis to start an early treatment which determines the prognosis of the disease and to follow closely the evolution of lesions to change treatment if required. We also discuss the clinical, histological, and immunological features of the disease that enabled the differential diagnosis as well as the appropriate therapeutic management.

Surgical extrusion: A reliable alternative for saving fractured anterior teeth.

Crown-lengthening procedures are necessary to rehabilitate supracrestal insertion tissue and to guarantee a suitable dental restoration. The objective of this article was to report a surgical extrusion procedure as a treatment option for a fractured anterior tooth. A 24-year-old male patient presented to our department to rehabilitate his maxillary right lateral incisor. The tooth was fractured due to a trauma and presented a healthy periodontium. Endodontic treatment was performed before the surgical extrusion. A fixed crown was cemented after complete reduction of tooth mobility after 6 months. No complication was observed at 6 months post-operatively. A minimally traumatic surgical extrusion technique provided highly successful results in both functional and esthetic aspects, especially in the anterior region, where the latter is of great interest.

Central odontogenic fibroma of simple type: An original observation.

Central odontogenic fibroma is an uncommon, benign, slow-growing intraosseous mesenchymal odontogenic tumour. It presents a diagnostic dilemma to the clinician and the pathologist because its clinical and radiological features resemble other odontogenic and/or non-odontogenic tumours, and the differential diagnosis is based on histological examination. In this report, we describe our experience with a case of a 23-year-old female patient with central odontogenic fibroma of the mandible that was diagnosed as 'simple type'. Highlighting a subtype that was dropped from the last World Health Organization classification of head and neck tumours is important to accumulate more information about this lesion and to show its different features. Despite its rarity, central odontogenic fibroma should be included in the differential diagnosis of intrabony tumours of the jaws. These findings can better educate oral and maxillofacial surgeons about the unusual nature of this lesion, help establish a correct diagnosis and give the appropriate therapeutic management.

Periostitis Ossificans: Report of Two Cases Resolved with Endodontic Treatment.

Periostitis ossificans is a chronic disease characterized by an ossifying periostitis, occurring in children and young adults, commonly as a reaction to a mild infection or irritation. It is also characterized by the presence of lamellae of newly formed periosteal bone outside the cortex, giving the characteristic radiographic appearance of "onion skin." Aim. The aim of this paper was to present the clinical and radiographic findings, as well as the postoperative follow-up of two cases diagnosed with periostitis ossificans of dental origin, and to discuss the differential diagnosis and treatment modalities. Case Reports. In the first case, a 16-year-old adolescent was referred for a persistent mandibular swelling. Intraoral examination showed two sinus tracts in relation to the carious necrotic left mandibular first molar. The periapical radiograph showed a periapical lesion in relation to the two root canals of the left mandibular first molar. Occlusal radiographs revealed the "onion skin" bone formation aspect. In the second case, a 10-year-old girl presented to our department with a slightly painful mandibular swelling. The periapical radiograph showed a periapical lesion in relation to both the mesial and distal roots of the carious necrotic right mandibular first molar. Cone beam computed tomography (CBCT) showed a subperiosteal bone formation with an "onion skin" aspect. Diagnosis of periostitis ossificans in the two cases was confirmed and the lesion was resolved by simply an endodontic treatment. Conclusion. Specific attention should be given to clinical and radiographic exploration in case of children with mandibular swelling. As osteosarcoma can be misdiagnosed, additional examinations, such as computed tomography, can be useful in differential diagnosis and in searching malignancy signs.

Saliva diagnostic utility in patients with type 2 diabetes: Future standard method.

BACKGROUND: The purpose of the present study was to assess saliva reliability in diagnosis and monitoring type 2 diabetes instead of blood. METHODS: Blood and unstimulated whole saliva were collected from 300 type 2 diabetic subjects and 300 healthy controls in fasting. Then, the salivary flow rate was calculated. All parameters including glucose, urea, amylase, total protein, albumin, C-reactive protein (CRP), immunoglobulin A (IgA), potassium, calcium and chloride were assessed in the supernatant, using an autoanalyzer. Oral exam was conducted by a single examiner on full mouth excluding third molars. Statistical analysis was performed by the SPSS 20.0 version. RESULTS: Saliva screening showed that glucose, urea, amylase, total protein, potassium, calcium and chloride were significantly higher in patients compared to controls (p < 0.05). Whereas, the IgA level and salivary flow rate were significantly reduced in patients (p < 0.05). No significant difference was found in albumin and CRP levels (p > 0.05). There was a significant positive correlation between salivary and plasma glucose levels (r = 0.887, and r = 0.900, p < 0.001), as well as, salivary and blood urea (r = 0.586, and r = 0.688, p < 0.001) in patients and controls, respectively. CONCLUSIONS: From this study, saliva could be suggested as a useful diagnostic tool for type 2 diabetes.

Oral Lichen Planus and Polycythemia: Possible Association.

Oral lichen planus is a chronic inflammatory disease of established immune-mediated pathogenesis that affects the oral mucosa. Polycythemia is a nonaggressive myeloproliferative disorder, characterized by an increase in red blood cell mass, often with uncontrolled production of granulocytes and platelets. Their association was rarely mentioned in the scientific literature. The aim of this paper was to report their occurrence in a 52-year-old male patient. Although a casual connection cannot be excluded, both diseases share many similarities in the immune dysfunctions involved in their pathogenesis and their clinical features. Such a hypothesis remains to be demonstrated by further studies. The presence of oral lesions should alert the clinicians in the process of identifying and early diagnosing these diseases. Thus, complications can be prevented and treatment can be started at an early stage, avoiding further damage.

Gingival Bleeding in a Child with Fanconi Anemia: A Case Report and Literature Review.

Fanconi anemia (FA) is a rare autosomal recessive disorder characterized by multiple congenital abnormalities, bone marrow failure, and higher susceptibility to malignancies, especially to head and neck carcinomas. Only few reports about the oral manifestations of FA are available. The main reported oral conditions associated with FA are microdontia and advanced periodontitis. The aim of this paper was to report a case of a 10-year-old patient with FA presenting severe spontaneous gingival bleeding, as well as to discuss the role of the dentist in the management and treatment of this condition.

The Incidence of Complications of Dental Trauma and Associated Factors: A Retrospective Study.

OBJECTIVE: The aim of this work was to study the incidence of complications of dental traumatisms and look for associations between factors related to trauma and the occurrence of complications. Materials and Methods. It is a longitudinal retrospective study on a sample of 125 traumatized teeth. The sample is taken from patients consulting the dentistry service at the hospital Sahloul Sousse between 2014 and 2017. Criteria for including a patient were presence of a permanent incisor affected by a subluxation, intrusion, lateral luxation, extrusion, or avulsion injuries associated or not with concomitant dentoalveolar injuries. Data were collected using a questionnaire. The information about etiology of trauma, delay of consultation, orientation of the patient, kind of injury, and emergency treatment and complications were obtained from the patients' records. RESULTS: The incidence of complications was 8%: external root resorption was present in 70% of cases, surface resorption was observed in 10% of cases, and replacement resorption in 10%, ankylosis in 10%. About pulpal complications, pulp necrosis was found after 4 weeks of follow-up, as well as the internal root resorption after one year. The most common cause of the trauma was the fall (40%). The majority of patients came for emergency consultation within "1 to 3 days," and the coronary fracture without pulp exposure was the first diagnosis (20.60%). Statistical analysis showed no significant relationship between the cause of the trauma and the complication (P=0.577) and between the delay of consultation and complication (P=0.577) and between the delay of consultation and complication (P=0.577) and between the delay of consultation and complication (. CONCLUSION: Treatment of dental injuries is usually delayed and not given as much attention as general medical treatment that can explain the occurrence of pulpal and periodontal complications. Immediate consultation and treatment could improve long-term prognosis of the injured tooth.

Oral cancer: a major and growing public health problem towards a national policy of prevention and early detection in Tunisia.

Oral cancer is a growing public health problem, it is increasing worldwide since it is the sixth most common cancer overall. The highest rates of oral cancer occur in the most disadvantaged sections of the population. Early detection and screening have been shown to be effective in reducing mortality and morbidity caused by oral cancers. To ensure early detection of oral cancer measures such as mass screening or screening of high-risk group population; reducing the delay from patients´ side by creating awareness about signs and symptoms of oral cancer. Today, no national population-based screening programs for oral cancer have been implemented yet. The objectives of this project are to evaluate and educate Tunisian Dentists as well as health professionals to perform oral screening and early detection of suspicious oral lesions in order to reduce morbidity and mortality associated with oral cancer.

Mandibular non-Hodgkin's lymphoma: two observations of a challenging disease.

Lymphomas are a heterogeneous group of malignant tumours of the haematopoietic system characterized by an aberrant proliferation of mature lymphoid cells or their precursors and mainly represented by non-Hodgkin´s lymphomas (NHL). The aim of this paper was to report two cases of NHLs with mandibular locations by detailing their different clinical, radiological, and histopathological aspects, as well as the approach followed to diagnose these diseases and to provide patients with the appropriate therapeutic management. The first case is about a 72-year-old female patient who was diagnosed with a large B-cell lymphoma while the second one concerns a 16-year-old male patient who was diagnosed with a Burkitt's lymphoma. These observations represent the two highly aggressive known NHLs according to the WHO classification. The mandibular locations of these diseases are rare and represent only 0.6% of all the reported cases. It is important to note that only a deep and good quality tumour biopsy can provide a diagnosis of certainty. The reference treatment is medical consisting in the introduction of chemo-immunotherapy. As oral surgeons, we have an important role in the early diagnosis of these malignancies and in the patient's referral to specialized care in order to get the appropriate treatment.

Oral Lichen Planus and Lichenoid Lesions in Sjogren's Syndrome Patients: A Prospective Study.

OBJECTIVE: The aim of this study was to investigate the prevalence and characteristics of oral lichen planus (OLP) and oral lichenoid lesions (OLL) in Sjogren's syndrome (SS) patients. PATIENTS AND METHODS: A prospective clinical study was conducted at the Department of Oral Medicine and Oral Surgery in Sahloul Hospital, Sousse, from January 2012 to June 2018. The patients involved in this study were diagnosed with Sjogren's syndrome according to the AECG (American-European consensus group) diagnostic criteria. Among these patients, we searched for those affected by OLP or OLL as determined by the WHO (World Health Organisation) classification of 2003. Clinical variables such as age, sex, medical conditions and medications, type of SS (primary or secondary), clinical form of OLP, and treatment were analyzed. The assessment of the results was performed using SPSS software. RESULTS: We evaluated 30 patients (27 females and 3 males) diagnosed with SS (24 had primary SS) with a mean age of 55 years and 11 months (±11,714). Overall, 9 patients had oral lesions (30%). Two patients had OLP associated with secondary SS (25%). Primary Sjogren's syndrome patients had 6 OLP lesions and one erythematous lichenoid lesion. OLP was erosive in eight patients, among them two had vulvo-vaginal-gingival syndrome. OLP lesions showed improvement in symptoms after topical or general corticosteroids treatment, while OLL showed improvement only under antibiotic treatment. CONCLUSION: The results of our analysis suggest that patients with SS have 30% prevalence of OLP and OLL. This possible association shows the importance of screening for oral dryness in patients with OLP or OLL. Treatment includes topical or general corticosteroids for erosive forms associated or not with topical antifungal treatment to treat or prevent oral candidiasis.

The use of transillumination in detecting subclinical extensions of enamel opacities.

OBJECTIVE: Accurate detection of enamel opacities in reflected light is limited in terms of discriminating between affected and unaffected enamel. The aim of this study was to compare the ability of transilluminated photography in distinction between healthy and unhealthy enamel in comparison with reflected photography. MATERIALS AND METHODS: Patients presenting enamel opacities were selected during their regular dental visits and for each tooth, standardized photographs were taken in transmitted and reflected light. For each lighting condition, the ratio of the opacity surface area to the entire buccal enamel area was calculated. The difference in the ratio of the opacity surface area to the entire buccal enamel area was compared using the Wilcoxon paired test. RESULTS: The results of this study showed that the ratio of the opacity surface area to the entire buccal enamel area calculated in transilluminated photography is significantly higher in comparison with its calculation in reflected photography. The means ratios (SD) of the opacity to the entire buccal enamel area are in transmitted light and reflected light respectively 18% (12) and 15% (11). CONCLUSIONS: In comparison with reflected photography, transilluminated photography significantly increases the ratio of the opacity surface area to the entire buccal enamel area. Transilluminated photography allows better detection of enamel opacities on anterior teeth by aiding clinical discrimination between healthy an unhealthy enamel. CLINICAL SIGNIFICANCE: Being simple, noninvasive, painless and without any risk to the patient, transillumination represents a promising imaging method for detecting enamel opacities and for discriminating healthy and unhealthy enamel.

Endocrown: An Alternative Approach for Restoring Endodontically Treated Molars with Large Coronal Destruction.

Rehabilitation of endodontically treated molar still remains a challenge. After endodontic treatment, molars lost their mechanical characteristics. In fact, they became fragile and that is in relation with the removal of pulp and surrounding dentin tissues. Endocrown which is a single partial restoration could be considered as a good alternative for restoring molars having large coronal destruction and presenting endodontic treatment difficulties. Through this work, we discuss the indication and use of endocrown to replace single crowns with intraradicular retention and to present a clinical case report of an endocrown-type restoration, fabricated from lithium disilicate ceramic (IPS e.Max CAD) in a mandibular first molar with extensive coronal destruction.