Thursday, January 30, 2014

Article 92

Oral Midazolam with and without meperidine for management of the difficult young perdiatric dental patient: a retrospective study

John E. Nathan, DDS, MDS
Kaaren G. Vargas, DDS, PhD
Pediatric Dentistry

Resident: Avani Khera

Purpose: To examine the effectiveness of different dosages of midazolam used with or without meperidine to manage the difficult pediatric dental patient.

Methods: 120 patient records with sedation logs were reviewed. The subjects were divided into six groups based on dosages of midazolam alone or in combination with meperidine. Ratings of the effectiveness of sedation, duration of action, need for restraint to accomplish treatment, and recovery times were made.

Higher doses of midazolam alone can produce better results in the severely apprehensive patient.
Children below the age of reason may require deeper levels of consciousness to permit invasive procedures
The addition of meperidine (1.0 mg/kg) doubled efficacy with 80% visits showing adequate or better ratings. In addition it also doubled working time from 8 to 18 minutes.
Higher doses of meperidine (1.0 mg/kg) did not show better results and warranted safety concerns for patients who were over sedated.

Conclusions: The addition of meperidine appears to enhance the effectiveness and duration of action of midazolam for managing difficult young pediatric patients.

Wednesday, January 29, 2014

Oral and Dental Findings in Children With Fanconi Anemia

Resident: Mackenzie Craik

Article: Oral and Dental Findings in Children With Fanconi Anemia

Journal: Pediatric Dentistry, May/June 2007.

Authors: Meryem Tekcicek, DDS, et al.

Overview: Fanconi Anemia (FA) is an autosomal and X chromosomal recessive DNA instability syndrome characterized by: 1) progressive bone marrow failure; 2) multiple congenital abnormalities; and 3) a predisposition to cancer.  Most FA patients have many physical abnormalities, including: 1) short stature 2) abnormal thumbs; 3) microcephaly; 4) cafe au lait; 5) hypopigmented and hyperpigmented spots; 6) a characteristic physical appearance.  Oral and dental findings in FA have been rarely reported in the literature.  The following have been previously reported in FA patients as oral findings: 1) generalized microdontia; 2) supernumerary teeth; 3) congenitally missing teeth; 4) periodontitis; and 5) gingivitis. 

Oral and dental injuries constitute a source of infection and facilitate development of infections in this patient group.  Additionally, the risk of squamous cell carcinoma is increased in the mucosal linings from the oral cavity to the anus, especially after the second decade.  

Purpose: The purpose of this study was to investigate the oral and dental findings in children with Fanconi Anemia (FA).  

Methods: The study included 26 FA patients.  Oral and radiological examinations and salivary collection were performed.  

Results: Among 26 FA children, 16 (62%) had never visited a dentist;, b) 6 (23%) had visited a dentist once; C) 4 (15%) had visited a dentist regularly.  The prevalence of dental caries was 35% in this study's patients.  Gingival examination showed about 35% of children had gingivitis, while 65% did not.  No leukoplakia or other precancerous lesion was detected in this patient group.  No patients had a salivary pH less than 5.  Radiological evaluation revealed that the most common congenital  dental abnormalities were 1)Microdontia 2) Congenitally missing teeth 3) transposition and 4) supernumerary teeth.

Conclusion: The results demonstrated that poor oral hygiene, dental decay, gingivitis, and congenital dental abnormalities (generalized microdontia, supernumerary teeth, transposition, and congenitally missing teeth) are common oral and dental findings in this group of Turkish children with Franconi Anemia.

Periodontitis as manifestation of Crohn's Disease in primary dentition: a case report

Resident: Todd Bushman

Title: Periodontitis as manifestation of Crohn's Disease in primary dentition: a case report
Journal: Journal of Dentistry for Children 2004
Author:Sigusch et al
Main purpose: To describe an initial perio manifestation of Crohn's disease

Background Info
-Crohn's disease is an inflammatory bowel disease of unknown etiology
-Crohn's disease can affect any part of the GI tract, but typically affects the terminal segment of the small intestines and first segment of the large intestines
-Crohn's disease often develops during childhood
-Oral lesions seen in 60% of all cases

Case Report
-6yo boy complains of diffuse swelling of the upper lip in the morning
IOE: bleeding on probing, edema, erythema
-Radiograph: no alveolar bone loss
-Actinobacillus actinomycetemcomitans was isolated from subgingival sites
-Dx of localized aggressive periodontitis was made based on AA
-Treatment: SRP and application of metronidazole and amoxicillin were unsuccessful
-Metabolic and immunological tests showed values WNL
-2 months after the first periodontal signs, the child suffered from severe malnutrition, diarrhea, and abdominal pain. Active colitis with multiple granulomas was detected with biopsies.
-Diagnosis of Crohn's disease was made by internalist

Good review of Crohn's disease. We need to faimilarize ourselves with these diseases that seem to be fairly common.  You never know when you will be the first health care provider to notice.

Giant Cell Fibroma in Children: Report of two cases and Literature Review.

Giant  Cell Fibroma in Children: Report of two cases and Literature Review.
Published: Journal of Oral and Maxillofacial Research, March 2013.

Case report 1
The patient, a 7 year-old Caucasian boy, was referred by a paediatric dentist for evaluation of a lesion on the free gingiva of the anterior mandible. The lesion was asymptomatic and had been present for 3 years remaining stable in size, shape and colour. The permanent right lateral incisor had uneventfully erupted 6 months ago. Medical history was uneventful except of the presence of allergic rhinitis treated with anthistamine nasal spray.
On oral clinical examination, a penduculated soft tissue nodule measuring 0.4 x 0.3 mm was noticed on the free gingiva distal to the permanent lower lateral incisor. The lesion was non-haemorrhagic, of firm consistency, covered by intact white mucosa. The rest of the oral mucosa was normal and the child's oral hygiene was satisfactory.
Based on the clinical appearance and the lesion's history, the differential diagnosis included primarily reactive and benign neoplastic lesions, such as traumatic fibroma, peripheral ossifying fibroma, peripheral odontogenic fibroma, giant cell fibroma and odontogenic hamartoma. The lesion was excised under local anaesthesia and haemorrhage control was achieved without need for suture application.
Microscopic examination of the excised specimen revealed fibrocollagenous connective tissue with dispersed spindle-shaped fibroblasts and bigger stellate cells with 1 or 2 nuclei (Figure 1). The overlying squamous epithelium was keratinized forming thin, elongated projections (Figure 2). The diagnosis of giant cell fibroma was rendered. No postoperative complications were noted and the healing process was good. The patient has been followed for 2 years since then without recurrence of the lesion.
Figure 1
Multiple stellate cells with one or two nuclei and basophilic cytoplasm within a fibrous connective tissue stroma (Case report 1, hematoxylin and eosin stain, original magnification x400).
Figure 2
Stellate giant cells in close proximity to the overlying epithelium, which forms elongated rete pegs (Case report 1, hematoxylin and eosin stain, original magnification x100).

Case report 2
A 6 year-old Caucasian boy was referred for dental restoration. Clinical examination revealed the presence of a hyperplastic lesion in the interproximal area between the left deciduous mandibular lateral incisor and canine; the lesion was extending both buccally (3 x 2 mm) and lingually (4 x 3 mm) (Figure 3A, B). The lesion was asymptomatic and non-hemorrhagic and appeared pedunculated, papillary surfaced, white and firm. The rest of the oral mucosa was normal. Deciduous, lower central incisors had exfoliated and permanent lower first molars had erupted without any complications. The medical history revealed moderate asthma episodes, controlled by medication, and allergy to amoxicillin.
Figure 3
A = buccal view and B = occlusal view of the nodular lesion of Case report 2 in the interproximal area between the deciduous lateral incisor and canine.
Based on clinical appearance differential diagnosis included traumatic fibroma, papilloma, peripheral ossifying fibroma, peripheral odontogenic fibroma and giant cell fibroma. The lesion was excised with electrocautery under local anaesthesia.
Microscopic examination of the excised lesion revealed connective tissue with thick collagenous fibres and presence of dispersed stellate giant cells with sizeable, vesicular nuclei, mainly in a subepithelial localization. The epithelium was keratinized squamous stratified forming thin, elongated projections (Figure 4A, B). The pathological findings were consistent with giant cell fibroma. Healing process was normal without any complications or evidence of recurrence of the lesion 4 years after the excision.
Giant cell fibroma is an uncommon lesion among young children. However, dentists should be aware of the existence of giant cell fibroma in children, which must be included in the differential diagnosis of nodular lesions of the gingiva along with irritation fibroma, papilloma, peripheral ossifying fibroma, peripheral odontogenic fibroma and odontogenic hamartoma. Following adequate diagnosis, lesions can be removed either with conservative surgical excision, electrosurgery or soft tissue laser and should be sent for histopathological examination.

I think this was a good article to remind us that though pathology is uncommon among children it does on occasion happen. Being familiar with the GCF is important to ensure that we properly and promptly diagnose our patients.

Molar Incisor Hypomineralization: Review and Recommendations for Clinical Management

Resident: Jeff Higbee
Article Info: Molar Incisor Hypomineralization: Review and  Recommendations for Clinical Management

Author: Vanessa William BDSc
Journal: Pediatric Dentistry 28:3 2006

Purpose: Review hypomineralization and give recommendations on how to manage patients with this condition

Key Points:
· Diagnosis is made by visual inspection of permanent first molars and incisors.
· Enamel can be severely discolored and teeth may be misformed and have unusual morphology.
· Mineral content decreases from the DEJ outwards which is opposite of normal enamel.
· The cause is unknown but seems to be linked to generalized poor health under the age of 3. Conditions implicated include malnourishment, brain injury, neurologic defects, cystic fibrosis, epilepsy, dementia, nephritic syndrome, atopia, lead poisoning, cleft lip and palate, radiation therapy, rubella, epidermolysis bullosa, ophthalmic conditions, celiac disease, and GI disorders.
· Preterm birth is also implicated due to common complications associated with it like hyperbilirubinaemia, metabolic disturbances, hypocalcemia, hypoglycemia, ductus arteriousus, and intracranial hemorrhage.
· Correlation may not be with these conditions but instead may be with the medications used to treat them.
· It is possible to have any number of teeth affected.
· Prevention is extremely important for management of these patients as caries develops extremely fast and often has destroyed a great amount of tooth structure as soon as the tooth erupts.
· Heavy fluoride regiment and MI paste can be used along with desensitizing tooth paste.
· Sealants are very important and glass ionomer should be utilized on partially erupted teeth
· Restoring these teeth is difficult. Chronic stimulation of pulp can make anesthesia difficult
· Children often need complex restorative soon after eruption and determination of sound tooth structure can be difficult due to abnormal color and consistency
· Amalgam is the worst restorative material to use because the prep is the most aggressive and relies on already compromised tooth to hold it in. Glass ionomers and composites are acceptable. Composites should be etched, bleached and re-etched before restoring. In badly affected teeth, SSCs are the recommended treatment.
· If teeth are badly broken down or fractured then extraction is indicated.

Assessment: No one knows what causes it and these teeth are very hard to anesthetize. The teeth generally require aggressive treatment early on in life which makes behavior a definite challenge. Because caries can progress so rapidly in patient with this condition, it is important for us to be on the lookout for these teeth so they can be properly managed.

Retrospective Review of Pediatric Oral Lesions from a Dental School Biopsy Service

Retrospective Review of Pediatric Oral Lesions from a Dental School Biopsy Service

Resident: Hofelich
Authors: Shah, et al
Journal: Pediatric Dentistry
Year: Jan/Feb 2009

  Purpose: To carry out the largest and most up to date U.S. survey of oral specimens from children.
Key Points:
  • evaluated records from Pacific Oral Pathology Laboratory from the University of the Pacific, San Francisco, California over a 15 year period
  •  5,457 (7% of the total number of cases) samples from infants to 16 yo
  • diagnoses were compiled into 4 categories following the MIND classification:
    • “M” stands for metabolic, which describes systemic diseases with oral manifestations
    • “I” stands for inflammatory and encompasses the area of reactive, trauma, infections, and immunologic conditions
    • “N” stands for neoplastic lesions that may be benign, potentially malignant, or malignant
    • “D” stands for developmental, which indicates a lesion that may be either genetic or acquired. 
  • largest category of diagnosis = inflammatory lesions, consisting of 2,758 cases (51%)
    • mucocele was the most frequently diagnosed lesion, comprising 21% of the total cases and 42% of all inflammatory lesions
    • Fibroma, the second most prevalent comprising 4% of all cases and 9% of the inflammatory category
    • periapical cyst, consisting of 4% of the total and 8% of this category
  • 2nd largest category = developmental lesions (1,928 cases, or 35%),
    • dentigerous cysts were most frequent and comprised 24% of the total cases and 67% of this category
    • hyperplastic dental follicle was the next most common finding, consisting of 5% of the total cases and 13% of the developmental lesions 
  • 3rd largest category = Neoplastic lesions, totaled 734 cases (13%), of which 726 (13%) were benign neoplasms
    • most common was odontoma comprised 6% of the total cases and 41% of neoplastic lesions
    • papilloma consisted of 3% of the total cases and 20% of the category
    • The malignant (8 cases total) or potentially malignant neoplasms were: neoplastic proliferations of surface epithelium (3); malignant melanoma (2); malignant bone tumor (1); and malignant salivary gland tumor (2)
  • Overall dentigerous cysts were the most common followed by mucoceles
  • pathoses increase with age
  • results from the study are similar to most other studies
  • more serious pathoses occur in some countries where there is limited access to care, resulting in patients seeking care only when symptomatic
  • oral malignancies are rare, but as with any malignancy, early diagnosis renders a more favorable prognosis



Oral Lesions

Riga-Fede disease and neonatal teeth.
Oral Implantol (Rome). 2012 Jan;5(1):26-30. Epub 2012 Jul 17.
Resident: Avani Khera

Purpose: Case study of Rega Fede disease.  It’s a benign and uncommon mucosal disorder, characterized by an ulceration of the tongue, often caused by repetitive traumatic injuries due to backward and forward movements of the tongue over the mandibular anterior incisors.  It is most commonly associated with the eruption of primary lower incisors in older infants or natal-neonatal teeth in newborns.

Case report: 2 month old infant was referred to a pediatric dental hospital for ulceration on the ventral surface of the tongue. The child had inadequate nutrient intake, difficulty in suckling and intermittent bleeding on the distal surface of the tongue.  The intra-oral examination revealed two crowns of neonatal teeth in the mandibular anterior region with grade II mobility and ulceration on the ventral surface of the tongue.  They opted to extract the teeth with topical anesthesia due to the infants grade II mobility, difficulty feeding, and potential for the teeth to be ingested or inhaled (ie aspiration risk). The teeth showed normal size-shape, whitish opaque color, and albescence of root formation.   The complete healing of the tongue lesion took 4 weeks.

Discussion: RFD is a reactive traumatic mucosal disease characterized by persistent ulcerations of the oral mucosa.   Possible management options such as cellulose film as protective appliances, oral disinfectants, corticosteroids, teething ring, smoothing the incisal edges, adding small increments of restorative material to the incisal edges, and dental extractions are indicated.  Literature has shown RFD to be associated with disorders such as Lesh-Nyhan syndrome, cerebral palsy, and Tourette’s syndrome.

Tuesday, January 28, 2014

An analysis of oral and maxillofacial pathology found in children over a 30-year period

Resident: Derek Nobrega
Title: An analysis of oral and maxillofacial pathology found in children over a 30-year period
Authors: Jones, A. V.; Franklin, C. D.
Journal: International Journal of Paediatric Dentistry, 2006, Volume 16(1): 19-30

Purpose: The vast majority of oral diseases are confined to oral tissues, but numerous underlying systemic conditions may present with signs and symptoms within the oral cavity. The authors carried out Europe's first pediatric-based survey of oral and maxillofacial pathology specimens submitted for diagnosis.

All entries for specimens from children between the ages of 0 and 16 years during the 30-year period from 1973 to 2002 were retrieved and compiled into 12 diagnostic categories.

Key Points:
- During the study period, 4406 (8.2%) specimens came from children between the ages of 0 and 16 years, with a male to female ratio of 1.01:1.
- The diagnostic category with the largest number of specimens was tooth pathology (22.1%), followed by salivary gland disease (19.1%) and mucosal pathology (12.1%).
- In all, there were 114 benign tumors of nonodontogenic origin, 43 odontogenic tumours and 31 malignant tumors.
- The most frequently diagnosed lesions were mucous extravasation cysts, which accounted for over 16% of cases.
- Periapical pathology in the form of a radicular cyst, residual cyst or chronic periapical granuloma formed almost 13% of all cases.
- This survey shows that, while nearly 10% of specimens submitted to the authors' laboratory are from children under 16 years of age, the majority of lesions are of a benign nature, requiring minimal intervention and less than 1% of cases comprise malignant lesions.
- Odontogenic tumours are relatively rare in this age group; however, certain lesions such as adenomatoid odontogenic tumour and ameloblastic fibroma occur predominantly in children and, therefore, remain an important diagnostic consideration.


Comprehensive, long-running study of oral lesions that shows that even though most cases are benign, we need to be aware of those malignant lesions that are more common in children and treat them appropriately.

Monday, January 27, 2014

Pinkham Chapter 2: Tables 2-5 through 2-8

Pediatric Dentistry: Infancy Through Adolescence. Fourth Edition, Chapter 2
Tables 2-5 through 2-8
CM Flaitz
Resident: Anna Abrahamian

Soft Tissue Enlargements
Papillary Lesions
Gender Predilection
Squamous Papilloma
Single pedunculated nodule with fingerlike projections, pink to white
Tongue, lips, soft palate (but can be anywhere)
Excisional biopsy
Verruca vulgaris
Multiple sessile or pedunculated papules and nodules with rough surface, white
Skin of hands and face, infrequently on lip, labial mucosa, and anterior tongue. Causative agents: HPV 2, 4, 6, 40
Excisional biopsy
Condyloma acuninatum
Multiple sicrete sessile nodules with blunted papillary surface, pink
Anogenital lesons. Causative agents: HPV 2, 6, 11, 53, 54, 16, 18
Excisional biopsy
Giant cell fibroma
10-20, female
Solitary sessile pedunculated nodule with pebbly surface, pink
Attached gingiva, dorsal tongue, hard palate
Excisional biopsy
Focal epithelial hyperplasia (Heck’s Disease)
Multifocal sessile papules and nodules with pink grainy surface, lesions coalesce
Labial and buccal mucosa and tongue. Causative agents: HPV 13, 32
Excisional biopsy
Inflammatory Papillary Hyperplasia
Multiple clustered papules and nodules with pink to red granular surface
Hard palate.
Remove and clean appliance, reline if needed, antifungal therapy
Acute Inflammatory Lesions
Gender Predilection
Soft tissue abscess (Parulis)
Solitary pink-white or red nodule with surrounding erythema, purulent drainage
Gingiva and alveolar mucosa. Caused by odontogenic infection.
Manage source of infection, antibiotics
Diffuse erythematous swelling of sudden onset, warm and painful tissue
Upper or lower face and neck. Caused by odontogenic infection.
Manage source of infection, antibiotics, incision and drainage
Diffuse swelling of sudden onset, soft and nontender
Lips, tongue, soft palate and face. Allergic reaction.
Antihistamines, steroids, epinephrine,
Fluid-filled nodule with smooth translucent red or blue surface
Lower labial mucosa, buccal mucosa, anterior ventral tongue
Excisional biopsy with removal of underlying minor salivary glands
Fluid-filled swelling with smooth translucent to blue surface
Floor of mouth, lateral to midline. Associated with sublingual gland
Excisional biopsy of sublingual gland/
Tumor and Tumor-like Lesions
Gender Predilection
Irritation fibroma
Pedunculated or sessile nodule with pink smooth surface
Buccal and labial mucosa, tongue, attached gingiva
Conservative excisional biopsy
Peripheral Ossifying Fibroma
10-20, female
Pedunculated or sessile nodule with pink to red surface, frequently ulcerated
Interdental of attached gingiva, anterior most common
Excisional biopsy down to periosteum and remove local irritation
Peripheral Giant Cell Granuloma
10-20, female
Pedunculated or sessile nodule with red or purple-blue surface, may be ulcerated
Attached gingiva or alveolar mucosa
Excisional biopsy down to periosteum and remove local irritation
Pyogenic Granuloma
0-20, female
Pedunculated or sessile nodule with smooth to irregular red surface, bleeds easily, soft and friable
Attached gingiva, also on lip, tongue, buccal mucosa
Excisional biopsy and remove local irritation
Gingival Fibromatosis (Hereditary or Idiopathic)
Localized or generalized gingival enlargements, pink, smooth to stippled
Attached gingiva and maxillary tuberosity
Gingivectomy and good oral hygiene
Infancy, female
Localized to diffuse, red, blue or purple lesion, flat or nodular, bleeds easily
60% head and neck, lips, tongue, buccal mucosa
Involution of lesion within first decade
Infancy, most detected by 2 years
Localized ot diffuse translucent to red or purple swelling, smooth or pebbly surface
75% in head and neck, tongue, lip, buccal mucosa
Surgical excision, recurrence common
Congenital Epulis (Congenital Granular Cell Tumor)
Infancy, female
Pedunculated or sessile nodule, pink to red smooth surface
Anterior alveolar ridge, usually maxilla
Surgical excision
Single or multiple nodules with smooth surface, discrete or diffuse. Café-au-lait macules
Tongue, buccal mucosa, vestibule, and palate
Surgical excision if solitary, selective excision of syndrome type
Mucosal Neuroma (Multiple Endocrine Neoplasia Syndrom, Type 2B)
Multiple pink papules and nodules, soft and non-tender, marfanoid body type
Labial and buccal mucosa, anterior tongue, gingiva
Surgical excision of neuromas for cosmetics
Pleiomorphic Adenoma (Benign Mixed Tumor)
10-20, female
Pink, dome shaped enlargement with smooth surface
Parotid gland most common, palate. Most common benign salivary gland neoplasm
Surgical excision with adequate margins
Juvenile Fibromatosis
Rapidly growing, pink firm mass with irregular surface, painless, large, facial disfigurement
Head and neck, paramandibular soft tissues
Surgical excision with wide margins

Radiolucent Lesions of Bone
Gender Predilection
Dentigerous Cyst
Well-defined, unilocular radiolucency around crown of unerupted tooth
Mandibular and maxillary third molar and canines
Enucleation, marsupialization if extensive
Odontogenic Keratocyst
10-20, male
Well-defined unilocular or multilocular radiolucency with corticated margins
Posterior body and ramus of mandible, maxillary 3rdmolar and canines
Surgical excision, 30% recurrence
Ameloblastic Fibroma
0-20, male
Well-defined unilocular or multilocular lesion with sclerotic margins
Posterior maxilla and mandible
Surgical excision, 18% recurrence
Well-defined unilocular or multilocular radiolucency, cortical perforation, root displacement
Mandibular molar and ramus. Unicystic ameloblastoma is most common in children
Enucleation, 15% recurrence
Melanotic Neuroectodermal Tumor of Infancy
Rapidly expanding bony lesion, displacement of tooth buds, “floating tooth” appearance
Anterior maxilla
Surgical excision or curettage, 15% recurrence
Central Giant Cell Granuloma
0-20, female
Well-defined unilocular or multilocular radiolucency with scalloped border
Mandible, anterior to first molar, may cross midline
Thorough curettage, 20% recurrence
0-5, males
Chubby face, bilateral, symmetric enlargement of jaws
All four quadrants frequently involved
Controversial, spontaneous regression during puberty
Simple Bone Cyst (Traumatic Bone Cyst)
10-20, male
Well-defined unilocular radiolucency with thin sclerotic border scalloping between teeth
Posterior and anterior body of mandible and ramus
Surgical exploration and curettage
Aneurysmal Bone Cyst
Painful swelling with rapid growth, unilocular or multilocular radiolucency with ballooning distension of buccal cortex
Posterior mandible
Curettage or enucleation, 60% recurrence
Periapical Abscess
Nonvital mobile tooth, tender to percussion, soft tissue swelling with purulence
Primary dentition most frequently in children
Endo or extraction
Periapical Granuloma and Cyst
Nonvital tooth, asymptomatic, well or poorly defined lucency at apex, root resorption
Adjacent to root apex and furcation
Endo or tooth extraction and gently curettage
Acute Osteomyelitis
0-20, male
Diffuse radiolucency with poorly defined margins, sequestra, fever, swelling, pain
Posterior mandible in children, anterior maxilla in infants
Incision and drainage with culture testing
Langerhans Cell Histiocytosis (Histiocytosis X)
0-10 Disseminated form, 10-20 Localized Form
Lymphadenopathy, rash, oral pain, gingivitis, ulcers, mobile teeth, punched out radiolucencies, “floating tooth”, premature tooth loss
Skull, mandible, ribs, vertebrae
Chemotherapy, radiotherapy, surgical curettage
Burkitt’s Lymphoma
0-20, males
Lymphadenopathy, facial swelling, tenderness, tooth mobility, extrusion and premature loss
Posterior mandible
Chemotherapy, malignancy with 5-year survival

Mixed Radiolucent and Radiopaque Lesions of Bone
Gender Predilection
Calcifying Odontogenic Cyst (Gorlin’s Cyst)
Well-defined unilocular radiolucency with irregular calcifications or tooth-like structures, most associated with odontoma
Incisior-canine region of maxilla and mandible
Enucleation, minimal risk of recurrence
Adenomatoid Odontogenic Tumor
10-20, female
Well-defined unilocular radiolucency with fine snowflake calcifications
Anterior maxilla, anterior mandible
Ameloblastic Fibro-odontoma
Well-defined unilocular radiolucency with calcified material and tooth-like structures
Mandibular molar and premolar
Conservative curettage
Ossifying Fibroma (Cemento-ossifying fibroma)
Painless swelling, circular growth pattern, well-defined unilocular lesion with sclerotic border
Premolar and molar region, usually mandible
Enucleation or resection
Osteomyelitis with proliferative periostitis (Garre’s Osteomyelitis)
Diffuse, poorly defined mixed radiolucent and opaque lesion, cortical bone duplication with onion skin pattern
Posterior mandible, usually 1st permanent molar
Endo or extraction

Radiopaque Lesions of Bone
Gender Predilection
Odontoma, Compound and Complex
Well-defined radiopacity surrounded by narrow lucent rim.
Compound = mini teeth. Complex = amorphous mass
Compound – anterior maxilla
Complex – posterior mandible
Local excision
Solitary, well-defined spherical opacity.
Gardner Syndrome – multiple osteomas, intestinal polyposis, supernumerary teeth
Body of mandible and condyle
Surgical excision
Fibrous Dysplasia
Unilateral, fusiform enlargement, ground glass opacity with ill-defined borders. McCune-Albright syndrome – polyostotic fibrous dysplasia, cafe-au-lait macules
Maxilla>mandible, buccal and lingual cortical expansion
Osseous recontouring
Condensing Osteitis (Focal sclerosing osteomyelitis)
Localized opacity at root apices of pulpally involved tooth, margins blend into surrounding bone
Mandibular premolar and molar area
No treatment of bony lesion, manage odontogenic infection
Opaque mass surrounded by thin radiolucent rim, fused to root of vital tooth, pain and swelling
Posterior mandible in molar and premolar region
Surgical extraction of tooth with attached tumor or RCT with root amputation
Idiopathic Osteosclerosis
Asymptomatic, non-expansile, uniformly opaque lesion that blends into surrounding bone
Molar-premolar mandible, usually by root apices
No treatment neessary