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Image Challenge

October 2016

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A 47-year-old male was referred to the Department of Oral & Maxillofacial Medicine and Diagnostic Sciences to acquire a panoramic image. No significant medical history was elicited during clinical examination. The panoramic radiograph showed a well-defined radiolucent region in the left mandibular region. The lesion is curvilinear in shape and measures approximately 11.13 mm x 9.03 mm in its greatest dimensions. The internal content is homogeneous, radiolucent in nature. No bony reaction noted. Identify the abnormality (green arrows) and provide your diagnosis.

 

INCORRECT.

Ossifying fibroma (OF) affects middle-aged females and is more predominant in the premolar-molar area. It is usually described as a mixed density lesion with concentric expansion of the cortical plate. Lack of these radiographic features precludes this entity.

 

CORRECT.

SBD is asymptomatic and may be noted as an incidental finding in routine dental imaging.

It is relatively easy to diagnose, especially if typical radiographic features are present. These features include a round to oval radiolucent region with an intact cortical bone. The location is another key factor for diagnosis; SBD is located below IAC and near the angle of the mandible. The radiographic impression should suffice the diagnosis and this should preclude any surgical exploration. Radiographic follow-up is recommended.

 

INCORRECT.

Residual cysts occur as a result of incomplete removal of radicular or other inflammatory cyst. The location is pathognomonic for this lesion, i.e. they tend occur in the edentulous ridge and are usually located above the inferior alveolar canal (IAC). This panoramic view shows the lesion to be below the IAC.

 

October 2016 References

White, Stuart C., and Michael J. Pharoah. Oral Radiology: Principles and Interpretation, 7th Edition. Mosby, 2014. VitalBook file.

 

September 2016

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A 55-year-old female presents with an asymptomatic, solitary white lesion of the left buccal mucosa. The patient had been unaware of its presence. The patient’s medical history is non-contributory and she does not take any medications. What is the most likely diagnosis?

 

INCORRECT.

Chronic nibbling produces lesions most frequently located on the buccal mucosa. It may be found in people under stress, but also in patients entirely unaware of their parafunctional habit. Clinically, it can be bilateral or unilateral. It appears as thickened, shredded, white areas combined with intervening zones of erythema, erosion or focal traumatic ulceration. Areas of white mucosa show an irregular ragged surface. The altered mucosa is located in the mid-portion of the anterior buccal mucosa along the occlusal plane. No treatment is required.

 

CORRECT.

Leukoplakia is the most common precursor lesion to squamous cell carcinoma of the oral cavity. There is a male predilection, presumably due to the commonly implicated risk factors, smoking and alcohol. It presents as a white plaque with generally well-demarcated borders. Early lesions present as homogenously smooth and thin, and more advanced lesions may present with nodular, verrucous, or even partially erythematous components (erythroplakia). The area of hyperpigmentation located posteriorly may represent a coexisting melanotic macule or an unusual example of post-inflammatory hyperpigmentation (PIH), which is most characteristically associated with lichen planus.

 

INCORRECT.

Lichen planus is an immunologically mediated mucocutaneous disorder. It tends to occur in middle-aged patients with female predominance. Skin lesions appear as purple, pruritic, polygonal papules. Oral lesions may be white, red, or ulcerative. The reticular type presents with classic Wickham striae, typically on the posterior buccal mucosa bilaterally, and is frequently asymptomatic. Other common surfaces involved are the ventrolateral tongue and the gingiva. Erythematous and ulcerative presentations may be symptomatic. For asymptomatic cases, no treatment is required. Topical or systemic corticosteroids are recommended for symptomatic patients. Disease course is variable but my be waxing or waning.

 

September 2016 References

Neville BW, Damm DD, Chi AC, Allen CM. Oral and maxillofacial pathology. Elsevier Health Sciences; 2015.

Greenberg MS, Glick M (2003). Burket's oral medicine diagnosis & treatment (10th ed.). Hamilton, Ont.: BC Decker. pp. 87,88,90–93,101–105. ISBN 1-55009-186-7.

Thongprasom, K; Carrozzo, M; Furness, S; Lodi, G (Jul 6, 2011). Interventions for treating oral lichen planus. The Cochrane database of systematic reviews (7): CD001168. doi:10.1002/14651858.CD001168.pub2. PMID 21735381.

August 2016

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A 65-year-old male complains of food impaction in the lower left mandibular region. Clinical examination reveals a fixed partial denture. Bitewing radiographs show an increased density of the bone under the pontic (green arrows). Identify the abnormality and provide your diagnosis.

 

CORRECT.

There is a well-defined radiopaque entity noted at the crest of the edentulous alveolar ridge. Occasionally, irritation from the pontic could produce excessive bone formation, which would appear as a radiopaque entity under the pontic. Hence the entity noted in the bitewing is termed a subpontic hyperostosis. 

 

INCORRECT.

Mandibular tori are located on the lingual aspect; on radiographs they appear to superimpose over the roots of the premolar and molar teeth. However, in the bitewing radiographs shown, the radiopaque entity noted is below the pontic.

 

August 2016 References

Koenig. Diagnostic Imaging: Oral and Maxillofacial. 1st Edition. Amirsys.

White, Stuart C., and Michael J. Pharoah. Oral Radiology: Principles and Interpretation, 7th Edition. Mosby, 2014. VitalBook file.

 

July 2016

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A 58-year-old female’s routine panoramic interpretation showed a well-defined radiolucency in the interradicular region (between #28 and 29). The lesion is well corticated, round to ovoid in shape. No evidence of root resorption or expansion is noted. Clinical examination proved that teeth are vital. Identify the abnormality and provide your diagnosis.

 

INCORRECT.

Radiographically there is no evidence of loss of lamina dura and PDL space. Both lamina dura and PDL appears to be WNL. Coronally, no evidence of pulpal involvement is observed on the radiographs. Clinical examination should reveal teeth to be nonvital.

 

CORRECT.

Based on the location and radiographic presentation, this fits the description of lateral periodontal cyst. The clinical exam should reveal vital teeth. Lateral periodontal cysts typically are noted in mandible, canine- premolar region. They are more prevalent in 5th or 6th decade. Lateral periodontal cyst if they are multiple they are termed as botryoid type. 

 

INCORRECT.

They are usually asymptomatic and are usually noted as an incidental finding. The radiographic appearance shows relatively smaller number of trabeculae in the cancellous bone. Periodic radiographic follow-up should shows no change.

July 2016 References

Koenig. Diagnostic Imaging: Oral and Maxillofacial. 1st Edition. Amirsys.

White, Stuart C., and Michael J. Pharoah. Oral Radiology: Principles and Interpretation, 7th Edition. Mosby, 2014. VitalBook file.