October 21, 2018

Case Study 7

 22 year old male patient

 Came for routine exam to the dental office
 Vitals: within normal limits
 Generally, in good health
 Receives regular cleaning; some restorative treatment

 Extraoral finding:
 No palpable lymph nodes
 No associated pain/tenderness

 Intraoral findings:
 Slight bony swelling
 Location: near the Mandibular 1st molar.

 Radiographic finding:
 showed a large, round radiopacity.
 It is well defined and surrounded by a radiolucent rim
 obliterating distal root of the mandibular 1st molar.

 Differential Diagnosis:

1. complex odontoma,
2. periapical cemental dysplasia,
3. osteoblastoma,
4. cementoblastoma,
5. focal sclerosing osteomyelitis.

 Here is a summary of those particular pathologies for each one and our
reasoning behind why or why not they are suitable and match our patient’s
particular diagnoses.

1. Complex Odontoma:
October 21, 2018

consists of a mast of enamel and dentin, cementum and pulp that does not
resemble a normal tooth. Most odontomas are detected in adolescents and
young adults. (This made us believe okay, maybe because our patient is 22 he
would fall into this category.) Upon further reading we discovered that the
compound odontoma is usually located in the maxillary anterior and the
complex occurs in the posterior mandible. (which also relates to the patient)
but then the information said that the most common clinical manifestation of
this is the failure of a permanent tooth to erupt and that radiographically it
appears as a cluster of numerous miniature teeth surrounded by a radiolucent
halo. This excerpt of information was what persuaded us to pick another
choice.

2. Periapical cemental dysplasia:

is asymptomatic and usually discovered during a routine radiographic
examination.(So this bit of info related to our patient so we thought maybe it
could be this one.) Further reading again indicated It occurs commonly in the
anterior mandible of patients older than 30 years old. Which doesn’t describe
the characteristics of our patient who is only 22 years old. Early lesions are
well circumscribed and radiolucent and may mimic periapical inflammatory
disease. The bone at the apical area of many teeth may be involved. Well this
definitely doesn’t fit the symptoms of our patient because it only deals with his
mandibular 1st molar and not numerous teeth so we decided on yet another
choice.

3. Osteoblastoma:
is an uncommon osteoid tissue forming primary neoplasm of the bone. It has
clinically and histologic manifestations similar to those of osteoid osteoma.
Osteoblastoma is categorized as a benign bone tumor, it is a bone forming
lesion that may be found within the cortex, medullary canal or periosteal
tissues. Usually occurs between ages of 10-25 so our patient could possibly
still fall into that category. Once again upon further reading it states that
patients usually will experience pain and swelling as well as tenderness, well
our patient’s symptoms stated none of those, so we disregarded this one as
well as a plausible choice.

4. Cementoblastoma:
October 21, 2018

This is also a rare benign periapical lesion, it represents less than 1% of all
odontogenic tumors. Cementoblastomas appear as a periapical, sclerotic,
sharply marginated lesion with a low- attenuation halo and directly fuse to the
root of the tooth. This usually occurs in people under the age of 25. The most
common site of this tumor is the mandibular molar area with 50% of cases
occurring on the mandibular 1st molar. These symptoms seem to match our
patients thus far, but its rare. So, the chances of cementoblastoma being the
culprit is rather rare as well. This tumor presents with no pain and is usually
asymptomatic. What made us believe that this couldn’t be our patients
diagnoses is that the radiographic appearance of this is well defined
radiopaque mass with a radiolucent peripheral line which overlies and
obliterates the tooth root. It is described as having a rounded of sunburst
appearance. There is also usually apparent external resorption of the root
where the tumor and the root join. This doesn’t match our patients symptoms,
so this is not the correct choice.

5. Focal sclerosing osteomyelitis:

is also called condensing osteitis, is a change in bone near the apices of teeth
that may be a reaction to low grade infection. The tooth most commonly
associated with this is mandibular 1st molar which matches our patient’s
inflicted tooth. Radiographically this appears as a radiopaque area in the
periapical area of teeth. The borders may be diffused or well defined. (our
patients is well defined) in some cases a central radiolucency surrounded by
the radiopacity is seen, similar to the halo that appears around our patients
radiographic image. This is sometimes associated with a carious or restored
tooth and our patient in his medical history did state that he had numerous
restorative work done. This can be present at any age but it is usually seen
first on young adults, and our patient matches that description because he is
only 22 years old. Treatment of this disease is not necessary, the sclerotic bone
remains even after treatment of the involved teeth, on occasion such as our
patient a biopsy was taken to help eliminate certain pathology that it could be.
We believe based on the description of this condition in comparison to our
patients that this would be the most likely answer.

We attempted to pick the best possible answer, hopefully this paper allows you to
see our thought process and reason of deduction 😊
October 21, 2018

References

Bell, J. D., & Gaillard, F. (1, 11 2005). cementoblastoma. Retrieved 10 19, 2018, from Radiopaedia:
https://radiopaedia.org/articles/cementoblastoma

Cruz, A., Hegde, S., & Shetty, U. (2013, 05). Large Complex Odontoma a report of rare entity. Retrieved
10 19, 2018, from NCBI: https://www.ncbi.nlm.ni

Cure, J. K., Vattoth, S., & Shah, R. (2012, November 1). Radiopaque Jaw Lesions: An approach to the
differential diagnosis. Retrieved October 19, 2018, from RadioGraphics:
https://pubs.rsna.org/doi/full/10.1148/rg.327125003

De Oliveira, B. H., Campos, V., & Marcal, S. (2000, May 18). Compound Odontoma-diagnosis and
treatment three case reports. Retrieved October 19, 2018, from oral pathology:
https://www.aapd.org/assets/1/25/dolivera-23-02.pdf

desimpel, j., posadzy, m., & vanhoenacker, f. M. (2017, 05 11). The many faces of osteomyelitis a
pictorial review. Retrieved 10 19, 2018, from journal of the belgian society of radiology:
https://www.jbsr.be/articles/10.5334/jbr-btr.1300/

Ibsen, O. A., & Phelan, J. A. (2014). Oral Pathology for the Dental Hygienist with General Pathology
Introductions (7 ed.). Elsevier.

milani, c. m., thorne, c. a., sage, r. s., DaSilva, m. d., & machado, M. A. (2012, 03). Mandibular
Cementoblastoma: case report. Retrieved 10 19, 2018, from Open Journal of Stomatology:
https://file.scirp.org/pdf/OJST20100011_96205381.pdf

Roghi, M., Scapparone, C., Crippa, R., Silvestrini-Biavati, A., & Angiero, F. (2014, 03 12). Retrieved 10 19,
2018, from Anticancer Research: international journal of cancer research and treatment:
https://ar.iiarjournals.org/content/34/5/2533.full

weerakkody, y. (2005, 1 12). Sclerosing osteomyelitis of Garre. Retrieved 10 19, 2018, from radiopaedia:
https://radiopaedia.org/articles/sclerosing-osteomyelitis-of-garre

Here’s our Pathology quote of the day:

“Objection, evasion, joyous distrust, and love of irony are signs of health;
everything absolute belongs to pathology.”
― Friedrich Nietzsche, Beyond Good and Evil