An unusual case of oral phleboliths without evidence of associated vascular anomalies.

Phleboliths are calcified thrombi found within a dilated blood vessel. When located in the maxillofacial region, they are commonly associated with hemangiomas or vascular malformations. This article reports an unusual case of a 59-year-old woman presenting with noncalcified phleboliths without evidence of associated vascular anomalies. Therefore, although a radiographic finding of phleboliths in the soft tissues of the head and neck represents evidence that a vascular malformation may be present, these lesions can occur without associated vascular anomalies. The association between the estimated age and elemental composition of the phleboliths in the present case suggests that the calcification process is relatively slow.

Could diet composition modulate pathological outcomes in schistosomiasis mansoni? A systematic review of in vivo preclinical evidence.

Schistosomiasis and malnutrition are often overlapped in poor communities, resulting in disproportionately high mortality rates. Currently, fragmented data make it difficult to define the relationship between diet and schistosomiasis. Thus, we systematically review the preclinical evidence on the impact of diet in Schistosoma mansoni infection. From a structured search, we recovered 27 original articles. All studies used mice and most of them investigated hypoproteic (70.37%), hyperlipidic (22.22%) or vitamin-deficient (7.41%) diets. Diets based on carbohydrate, zinc or milk supplementation were investigated at a reduced frequency (3.70% each). Hypoproteic diets attenuated parasitic load and granulomatous inflammation, but also reduced host resistance to S. mansoni infection, determining higher mortality rates. By stimulating steatohepatitis, parasitic load and granulomatous inflammation, hyperlipidic diets increase organ damage and mortality in infected animals. Although a high-sugar diet and vitamin restriction potentiate and zinc supplementation attenuates S. mansoni infection, the current evidence for these diets remains inconclusive. Analysis of methodological quality indicated that the current evidence is at high risk of bias due to incomplete characterization of the experimental design, diet composition and treatment protocols. From the bias analysis, we report methodological limitations that should be considered to avoid systematic reproduction of inconsistent and poorly reproducible experimental designs.

Conservative surgical treatments for nonsyndromic odontogenic keratocysts: a systematic review and meta-analysis.

OBJECTIVES: This manuscript presents a systematic review of the clinicopathologic features and outcomes of conservative surgical treatments for nonsyndromic odontogenic keratocysts (OKCs) and assesses the recurrence rates through a meta-analysis, in order to indicate the best conservative approach. MATERIALS AND METHODS: PRISMA guidelines for systematic reviews were followed, and the protocol was registered (PROSPERO/Nr.: CRD42017060964). An electronic search was conducted using the PubMed/MEDLINE, Science Direct, Web of Science, Scopus, and The Cochrane Library databases, and relevant articles were selected based on specific inclusion criteria. The PICOS criteria (Population: nonsyndromic patients of any age with OKC, with histopathological diagnosis and minimum follow-up of 12 months; Intervention and Comparison: marsupialization or decompression with or without enucleation, and enucleation alone; Outcome: recurrence rates; Study design: clinical trials, controlled trials, retrospective studies, and case series containing at least 10 cases of OKC) were employed. A pooled odds ratio (OR) was computed through the Mantel-Haenszel test (M-H) with 95% confidence intervals (CI). RESULTS: One thousand nine hundred OKCs were analyzed; the age of the patients varied from 6 to 90 years (mean of 38.6 years); a male to female ratio of 1.57:1 was observed; 74.5% of the lesions occurred in the mandible; 75.7% of OKCs were unilocular; the association with impacted tooth was reported for 344 OKCs; and the mean follow-up was 60.1 months. One thousand three hundred thirty-one OKCs were treated by conservative surgical treatments, and 261 cases (19.8%) presented recurrence. Nonetheless, minor total recurrence rates were observed after decompression followed by enucleation (11.9%) and marsupialization followed by enucleation (17.8%). In contrast, enucleation alone showed a total recurrence rate of 20.8%. CONCLUSION: The results suggest a significant superiority of success for OKC treatments that use decompression followed by enucleation, instead of an initial enucleation (M-H, OR = 0.48; 95% CI = 0.22 to 1.08; P = 0.0163). CLINICAL RELEVANCE: No consensus exists concerning the best management for OKCs. More aggressive treatments (ostectomy, resection, or use of adjunctive therapies like Carnoy's solution and liquid nitrogen) can have many disadvantages and risks. Therefore, it is necessary to identify the conservative approach for OKCs that results in a lower recurrence rate.

Estrogen Receptor-α Correlates with Higher Fungal Cell Number in Oral Paracoccidioidomycosis in Women.

BACKGROUND: Paracoccidioidomycosis is a neglected tropical fungal infection with great predilection for adult men, indicating the participation of female hormone estrogen in preventing paracoccidioidomycosis development in women. Estrogen has an immunologic effect leading to polarization toward the Th2 immune response, which favors the disease evolution. OBJECTIVES: To evaluate estrogen and progesterone receptors in oral paracoccidioidomycosis lesions and to verify any association with tissue fungi counting in women and men. METHODS: Thirty-two cases of chronic oral paracoccidioidomycosis were included. Immunohistochemical analyses for anti-estrogen receptor-α, anti-progesterone receptor and anti-Paracoccidioides brasiliensis antibodies were performed. The differences between women and men and the relations among the immunomarkers for each gender were also evaluated. RESULTS: A significant positive correlation was observed between estrogen receptor-α and the amount of fungi in women. In addition, estrogen receptor-α was mildly expressed in the inflammatory cells of female patients, while progesterone receptor was expressed in both genders, with similar expression between women and men. Moreover, fungi counting revealed no differences between genders. CONCLUSIONS: Estrogen receptor-α was expressed only in women and showed a positive correlation with the amount of fungi in oral paracoccidioidomycosis, while progesterone receptor was observed in both genders and exhibited no correlation with estrogen receptor-α or fungi counting.

Fatal primary diffuse large B-cell lymphoma of the maxillary sinus initially treated as an infectious disease in an elderly patient: A clinicopathologic report.

OBJECTIVE: To report a case of primary diffuse large B-cell lymphoma (DLBCL) of the maxillary sinus in an 82-year-old Caucasian woman. BACKGROUND: Diffuse large B-cell lymphoma of the maxillary sinus has non-specific signs and symptoms that may be confused with benign inflammatory conditions and upper respiratory infections. METHODS: An incisional biopsy was performed. CD20+ /CD3- /Ki-67: 95% cells were observed. CONCLUSION: A good medical history, clinical and imaging evaluations and immunohistochemical reactions are crucial to establish a correct and early diagnosis of DLBCL.

M2 macrophages and inflammatory cells in oral lesions of chronic paracoccidioidomycosis.

BACKGROUND: Paracoccidioidomycosis (PCM) is a systemic fungal infection caused by Paracoccidioides brasiliensis (Pb) and associated with deficient cellular immune response, which is modulated by inflammatory cells, mainly macrophages, and cytokines. Recently, the comprehension of the macrophage polarization mediated by Th1 and Th2 cytokines has contributed to elucidate the immune response that takes part in some diseases. Thus, the aim of this study was to assess the presence of Th1- and Th2-immune response and also Pb counting in oral lesions of chronic PCM. METHODS: Forty-eight cases of chronic PCM oral lesions were included. All cases were classified as loose or dense granulomas. S100 protein, IL-1ß, IL-6, TNF-α, CD163 and CD68 immunoexpressions, and Pb localization were evaluated. The fungi present in the tissue were quantified by anti-Pb antibody. RESULTS: Most patients were white men with mean age of 47 years old and showed higher incidence of multiple lesions. Loose granulomas were predominant and exhibited a great amount of M2 macrophages, which were visualized with anti-CD163 antibody. The expression for CD163 and CD68 was similar (P = 0.05), highlighting the predominance of M2 macrophages in PCM. IL-1ß, IL-6, and TNF-α immunoexpression did not significantly change with CD163, CD68, and S100 protein. The number of fungi was significantly higher in cases with intense IL-1ß immunoexpression (P = 0.003). CONCLUSIONS: M2-activated macrophages were the majority among inflammatory cells in chronic PCM, characterizing the action of a Th2-immune response. Nevertheless, Th1 cytokines were also found; mainly IL-1ß, which was associated with fungi counting in oral lesions.

Oral Paracoccidioidomycosis Granulomas are Predominantly Populated by CD163+ Multinucleated Giant Cells.

Multinucleated giant cells (MGC) are considered to be a hallmark of granulomatous inflammation; thus, they may play an essential role in the host response against pathogens, particularly Paracoccidioides brasiliensis. This study characterizes the MGC found in oral paracoccidioidomycosis and assesses the correlation of MGC with the amount of fungi within oral tissues. Twenty-six cases were included. They were classified as loose or dense granulomas, and the total MGC, including foreign-body and Langhans giant cells, besides the total and intracellular fungi, were taken into consideration. CD163 immunoexpression was performed, and CD163+ multinucleated giant cells were also quantified. Dense granulomas revealed more foreign-body type and total giant cells than loose granulomas (P < 0.05). Total giant cells showed a positive linear correlation with the CD163+ cells (P = 0.003; r = 0.56) and intracellular fungi quantification (P = 0.045; r = 0.40). Oral paracoccidioidomycosis lesions contain MGC that mainly belong to a CD163+ phenotype, also showing both Langhans and foreign-body arrangements. Additionally, the higher the presence of MGC, the higher the amount of phagocytized fungi.

Extensive Mandibular Ameloblastic Fibro-Odontoma.

Ameloblastic fibro-odontoma (AFO) is a mixed odontogenic tumor that presents epithelial and mesenchymal components. Ameloblastic fibro-odontoma is generally diagnosed between the first and second decades of life and normally shows a slow clinical growth in the posterior portion of the maxilla or mandible, being mostly associated with 1 or more impacted teeth. Radiographic features of AFO show a radiolucent well-defined, uni, or multilocular defect due to containing variable amounts of calcified material. The enucleation of the tumor is the usual conduct and should be followed up for a long period of time. Here, the authors report the case of 17-year-old male patient who presented an extensive AFO on the right posterior side of the mandible. The panoramic radiograph and the tomographic examination revealed a multilocular radiolucent lesion with impacted teeth. Histological examination revealed connective tissue resembling the dental papilla along with epithelial strands or islands, as well as dental hard tissue such enamel and dentin. Enucleation and curettage was performed and led to good outcome. There was no recurrence after an 8-year follow-up, and oral rehabilitation was performed with dental implants.

Giant keratoacanthoma of the lower lip: case report and review of the published literature.

Keratoacanthoma (KA) is an epithelial tumor mainly located on the sun-exposed skin of the face and hands of elderly patients. The giant form of KA affecting the lower lip is relatively rare, and only 2 of 9 recently reported cases were in women. This report describes a case of giant KA of the lower lip in a 62-year-old white woman and discusses clinical and histologic diagnosis and the therapeutic approach to this lesion. The patient reported a 2-month evolution of a nodule characterized by a brownish central plug of keratin and measuring approximately 2.0 cm in its greatest diameter. Keratoacanthoma may present some histopathologic features similar to those of squamous cell carcinoma, and careful attention is required to avoid an incorrect diagnosis. Following histopathologic confirmation of giant KA, complete excision of the lesion was performed. A 17-month follow-up examination revealed complete healing of the area and no signs of recurrence. Because giant KA of the lower lip may impair normal function and esthetics, surgical excision is the best choice for treating this lesion.

Serum antibody levels correlate with oral fungal cell numbers and influence the patients' response to chronic paracoccidioidomycosis.

Paracoccidioidomycosis (PCM) is a neglected fungal disease that elicits an important granulomatous inflammatory reaction which aims to isolate the fungi and resolve the infection; besides the innate cellular response, the patients' sera may contain different levels of antibodies directed against PCM's pathogenic agent: Paracoccidioides brasiliensis (Pb). The aim of the study was to assess the distinct serum antibody levels of 19 chronic PCM patients and to associate these levels to the granulomatous inflammatory response and presence of fungi in oral lesions caused by Pb. The presence of Pb was detected and counted within oral tissues using immunohistochemistry; antibody levels were classified as negative, low-grade, moderate or high-grade groups. The Kruskal-Wallis and Dunn's test were used to verify possible associations among the groups. Interestingly, lower antibody titres were associated with lesser numbers of Pb, which favours the cellular response over the humoral response to fight PCM. On the other hand, negative serological results were linked to a higher presence of Pb in the tissues, indicating that a deficient humoral response supports the fungal proliferation. The number of Pb was conveniently associated with the level of serum antibodies, showing that the humoral immune response is required, however, not solely responsible to restrain the dissemination of Pb.

Cyclin D1 and Ki-67 expression correlates to tumor staging in tongue squamous cell carcinoma.

BACKGROUND: The immunohistochemical expression of Cyclin D1 and Ki-67 were analyzed in tongue squamous cell carcinomas (SCC), relating them to the clinical and morphological exhibition of these tumors. MATERIAL AND METHODS: Twenty-nine patients fulfilled the inclusion criteria; clinical data included gender, age, ethnicity and use of licit drugs such as alcohol and tobacco. The TNM staging and histopathological differentiation grading was assessed for each case. In addition, T1 patients were gathered with T2 patients; and T3 patients were gathered with T4 patients to assemble two distinct groups: (T1/T2) and (T3/T4). RESULTS: The mean follow-up time was 24 months and 30% of the patients died as a consequence of the disease, while 23.3% lived with the disease and 46.7% lived lesion-free. T1 and T2 tumors showed statistically lesser Ki-67 and Cyclin D1 staining when compared to T3 and T4 tumors. CONCLUSIONS: Ki-67 and Cyclin D1 pose as auxiliary tools when determining the progression of tongue SCC at the time of diagnosis.

Rare oral cartilaginous choristoma: a case report and review of the literature.

Cartilaginous choristomas are extraosseous benign tumors. They occur in abnormal sites that usually do not contain chondrocytes. The oral variant of this entity is considered to be very rare, with only 38 cases currently published in the literature. This article presents a case of an oral cartilaginous choristoma lesion. In addition to presenting clinical and histological diagnoses, this article compares the present case to recently reported cases. Special attention was given to analyzing cells of the oral cartilaginous choristoma, which appear as well-differentiated chondrocytes with a pale blue cytoplasm surrounded by a light basophilic stroma and no evidence of malignity. Following surgical excision, the lesion did not recur, which is similar to other reported cases of oral cartilaginous choristomas.

Paracoccidioidomycosis mimicking squamous cell carcinoma on the dorsum of the tongue and review of published literature.

INTRODUCTION: Paracoccidioidomycosis is a disease that is endemic to southern and southeastern Brazil, caused by the fungus Paracoccidioides brasiliensis. The most common clinical oral manifestation is the presence of multiple granulomatous ulcers with hemorrhagic dots, located mainly on the lips, palate, and buccal mucosa. However, the disease can manifest atypically as a single ulcer, mimicking oral squamous cell carcinoma (SCC) or tuberculosis. CASE REPORT: A 65-year-old male patient presented with a complaint of a single ulcerated lesion on the dorsum of the tongue; the lesion had evolved over 6 months. The diagnostic hypotheses were SCC and oral manifestation of tuberculosis. An incisional biopsy was performed, and histopathological analysis of the specimen revealed pseudoepitheliomatous hyperplasia, a granulomatous structure of epithelioid histiocytes, multinucleated giant cells, and lymphocytes in the connective tissue. Grocott staining confirmed the presence of the fungus in the lesion, and a diagnosis was made of paracoccidioidomycosis. The patient was treated with 200 mg/day of itraconazole for 12 months and now shows no signs or symptoms of recurrence of the disease. CONCLUSION: Correct diagnosis is essential for a successful therapeutic approach and resolution of the lesion.

Noninvasive treatment choice for an aged down syndrome patient presenting a residual periapical cyst.

AIM: This is the first report to illustrate the marsupialization as an effective treatment for a Down Syndrome (DS) patient presenting a residual periapical cyst. BACKGROUND: These cysts occur within the alveolar ridge, usually at the local site of a previously extracted tooth that did not received proper curettage; usually the surgical excision of a cyst and also the vigorous curettage of a socket is very simple, if not for the fact that mentally disabled patients require rapid and non-stressful procedures. CASE DESCRIPTION: The 54-year-old DS patient represented herein received a minimally invasive marsupialization under local anesthesia. Due to the large extent of the lesion, the acrylic resin drain was maintained for 30 days. Through the following period, a daily irrigation of the cystic cavity with saline solution was carried out to prevent a secondary infection within the cystic cavity. A follow-up of 16 months showed no signs of recurrence. CONCLUSION: Marsupialization of residual periapical cyst is completely effective and safe, even for a DS patient that is considered to be at an advanced age. CLINICAL SIGNIFICANCE: Marsupialization poses as a minimally invasive choice for mentally disabled patients, even when presenting advanced ages; treatment success was stated by the easy clinical conduct, uneventful postoperative situation and the lack of recurrence along 16 months of follow-up.

Conservative surgical treatment of an aggressive calcifying cystic odontogenic maxillary tumor in the young permanent dentition.

Calcifying cyst odontogenic tumor (CCOT) is a rare benign cystic neoplasm of odontogenic origin whose treatment depends on the lesion's localization and histological type. The purpose of this report was to describe a case of extensive calcifying cyst odontogenic tumor involving the maxilla of a 12-year old female patient and the treatment option adopted. The lesion was associated with an impacted first premolar, and the roots of the canine and second premolar were divergently displaced. An incisional biopsy revealed the presence of a highly cellular, densely fibrous connective tissue, with diffuse infiltration of mononuclear inflammatory cells. Cystic marsupialization and extraction of the impacted premolar were performed. No signs of lesion recurrence were noted after 28 months. Therefore, marsupialization should be considered when planning CCOT treatment, primarily in young patients with large lesions, to avoid mutilations and tooth loss.

Primordial odontogenic tumor: report of 2 new cases.

Primordial odontogenic tumor (POT) is a recently described benign odontogenic tumor, with only 16 cases reported in the literature. We present 2 new cases of POT affecting the mandible. Case 1 is that of 12-year-old girl with an asymptomatic, slow-growing mass, causing facial asymmetry. Radiography showed a well-defined unilocular radiolucency surrounding an impacted second premolar. Case 2 is that of a 13-year-old girl with a mass involving the crown of the unerupted third molar and showing similar radiographic features. Microscopically, both lesions were composed of variably cellular fibromyxoid tissue surrounded by thin ameloblastic epithelium, with stellate reticulum-like areas, but no mineralized tissue, yielding the diagnosis of POT. Immunohistochemical analysis showed diffuse expression of CK14 in epithelial cells, whereas CK19 was expressed mainly in the basal layer. Syndecan-1 (CD138) was expressed in the stellate-like regions and in the subepithelial zone. Both patients were treated surgically, with no signs of recurrence seen after 15 and 60 months, respectively.

Epidemiologic profile and quality of life of patients treated for oral cancer in Juiz de Fora, Minas Gerais, Brazil.

OBJECTIVES: To assess the quality of life of patients treated for oral cancer, analyzing their physical, social/family, functional and emotional well-being; to identify socioeconomic and clinical functional variables that may potentially influence their quality of life; to describe the patients' epidemiologic profile (sex and age) and tumor features (histopathology, anatomical location and stage); to identify the frequency of risk factors associated with the malignancy. STUDY DESIGN: Observational cross-sectional study-case series study undertaken in 2 cancer treatment institutions in Juiz de Fora, Minas Gerais, Brazil, between 2000 and 2007. RESULTS: Of the 88 registered oral cancer patients, 16 were selected for the study sample. The majority of the study sample (87%) included males, with a mean age of 57.06 years; 43.8% were retired; 50% had not completed elementary education. Most (56.3%) had a monthly income of less than the minimum wage. Most (83.7%) smoked before cancer diagnosis and 43.8% from this sample continued to smoke after treatment. In addition, those who drank alcohol before treatment continued drinking (31.3%). The tongue was the predominant anatomic site (37.5%). The patients' quality of life score was fair; the best result was for emotional well-being. CONCLUSIONS: Despite the limitations imposed by low survival, it was possible to evaluate the quality of life of these patients. Patients having a family income higher than the minimum monthly wage scored significantly better in final indexes FACT-G and FACT-HN than those with a lower income.

New WHO odontogenic tumor classification: impact on prevalence in a population.

OBJECTIVES: This study approaches the history of reclassifications and redefinitions around the odontogenic keratocyst (OK), as proposed by the World Health Organization (WHO), and aims to understand the impact of those changes on the prevalence and epidemiology of odontogenic tumors (OTs). METHODOLOGY: Cases of OTs diagnosed in an Oral Pathology service between January 1996 and December 2016 were reviewed. Demographic data of patients such as age, gender and site of lesions were retrieved from their respective records. RESULTS: Within the studied period, 7,805 microscopic reports were elaborated and 200 (2.56%) of these were diagnosed as OTs. Out of these 200, between 1996 and 2005, prior to the 2005 WHO classification, there were 41 (20.5%) OTs cases, being odontoma the most frequent (23; 56.09%), followed by ameloblastoma (8; 19.51%) and myxoma (03; 7.31%). Between 2006 and 2016, after the previous 2005 WHO classification there were 159 (79.5%) OTs, being odontogenic keratocystic tumor (KCOT) the most frequent (68; 42.76%), followed by odontoma (39; 24.52%) and ameloblastoma (21; 13.20%). CONCLUSIONS: As of today, the most recent WHO classification to be followed brings KCOT back to the cyst category, which will impact on the prevalence and epidemiology of OTs; thus, this study was able to identify a considerable increase (287.80%) in the prevalence of OTs when the 2005 WHO classification was utilized. Despite being an important academic exercise, classifying odontogenic lesions and determining whether to place the odontogenic keratocyst in a cyst or tumor category is crucial to establish the correct diagnosis and treatment to follow, whether by oral medicine or oral surgery specialist, or by the general practitioner.

Oral Manifestation of Lymphomatoid Granulomatosis.

Lymphomatoid granulomatosis (LYG) is a rare B-cell lymphoproliferative disorder driven by Esptein-Barr virus (EBV) that most commonly affects the lungs, although extra pulmonary sites like the central nervous system, skin, liver and kidney can also be involved. It is microscopically characterized by an angiocentric and angiodestructive growth pattern, predominantly composed by small T-cells, although a smaller population of atypical large B-cells is considered the true neoplastic component. Oral cavity involvement of LYG has rarely been described and the diagnosis of this neoplasm is very difficult. The aim of this report is to present a rare case of LYG affecting an 86-year-old female patient that was diagnosed due to an extensive, ulcerated and painful oral lesion affecting the hard palate. Detailed microscopic evaluation together with a large immunohistochemical study were necessary to achieve the correct diagnosis of LYG.

Gingival involvement in oral paracoccidioidomycosis.

BACKGROUND: Paracoccidioidomycosis, a deep mycosis endemic in parts of Latin America, often presents with oral lesions involving the gingiva. Nevertheless, the periodontal literature is devoid of references to oral paracoccidioidomycosis. The purpose of this study was to characterize the gingival involvement in oral paracoccidioidomycosis and to contrast clinical and histopathologic diagnosis of the disease. Differential diagnosis and management of oral paracoccidioidomycosis were reviewed. METHODS: From January 1995 to October 2006, the files of the Oral Pathology Laboratory, School of Dentistry, Alfenas Federal University, were reviewed to identify cases referred because of a clinical diagnosis of oral paracoccidioidomycosis. Data collected included patient demographics (age, gender, race, and occupation), clinical information (oral lesion location), and histopathologic diagnosis. RESULTS: Forty-six cases were identified, and 34 were histopathologically confirmed as paracoccidioidomycosis. Of the remaining 12 cases, one-half were diagnosed as either carcinoma or dysplastic leukoplakia. Of the 34 confirmed paracoccidioidomycosis cases, 45% presented with multiple site involvement, whereas the gingiva/alveolar process was the most prevalent site overall (52%). The gingiva/alveolar process was the most prevalent site in both multiple and single site cases. The majority of patients were men (88%), white (75%), and in their fourth decade of life (47%). Statistical analysis revealed that patients with gingival/alveolar process involvement were demographically indistinguishable from those without. CONCLUSIONS: Oral paracoccidioidomycosis has a strong predilection for the gingiva, whereas patients with gingival lesions do not differ from patients lacking such involvement. Early diagnosis of gingival/oral lesions may prevent life-threatening complications of this mycosis.