Pearls and pitfalls in the diagnosis of small oral biopsies.

Pathologic processes affecting the oral and maxillofacial region include a heterogenous group of diseases with widely variable biologic behaviors. Proper patient management begins with the establishment of an accurate diagnosis, which often relies on histopathologic interpretation of small tissue samples from oral lesions. While confident diagnosis of small oral biopsies can be challenging, an understanding of oral and maxillofacial disease and consistent clinicopathologic correlation can help pathologists recognize inflammatory confounders and overcome common errors in specimen management, including insufficient sample size and non-representative biopsy samples.

Multiple Epithelial Origin Complications Following Subepithelial Connective Tissue Graft for Root Coverage.

INTRODUCTION: The subepithelial connective tissue graft (SCTG) and flap combination is a highly predictable root coverage procedure, with low complication rates. To our knowledge, this article reports the first case of two late SCTG complications, epithelial cell discharge, and subsequent epidermal inclusion cyst (EIC) formation. CASE PRESENTATION: A 35-year-old male presented with a 3-mm deep Miller Class II recession defect on the mandibular right canine and mesial root of mandibular right first molar. A mild discomfort was reported at 8 weeks after envelope flap+SCTG in #27. At 4 months after the procedure, the patient presented with persistent discomfort and minimally compressible recipient site diffuse swelling with discharge, which was cytologically diagnosed as normal epithelial cells. One year postoperatively, enlargement of the lesion was seen, and excisional biopsy was performed simultaneously with SCTG in #30. The lesion was diagnosed as EIC. At 8 months follow-up, the site healed uneventfully, the patient remained asymptomatic, and the site exhibited scar formation and no recurrence of the lesion. CONCLUSION: This report highlights epithelial cell discharge and EIC formation as a rare yet possible SCTG complication and emphasizes the importance of an excisional biopsy as the means to obtain a definitive diagnosis and manage this complication.

Unique Oral Presentations of Deep Fungal Infections: A Report of Four Cases.

Deep fungal infections rarely involve the oral cavity and most commonly affect immunocompromised patients. Oral deep fungal infections typically manifest as chronic mucosal ulcerations or granular soft tissue overgrowths. Since these lesions are non-specific and can mimic malignancy, it is crucial to obtain a thorough clinical history and an adequate biopsy to render the appropriate diagnosis. We report four new cases of deep fungal infections, diagnosed as histoplasmosis, blastomycosis and chromoblastomycosis, exhibiting unique oral and perioral presentations. Awareness of these unusual entities can help dental and medical practitioners expedite proper multidisciplinary care and minimize morbidity and mortality.

Expression of cornulin in oral premalignant lesions.

OBJECTIVE: The aim of this study was to evaluate expression of cornulin in oral mucosa as an adjunct to histopathologic grading of oral epithelial dysplasia (OED). STUDY DESIGN: Biomarker expression was assessed in normal oral mucosa, low-grade OED (LD), high-grade OED (HD), and oral squamous cell carcinoma (OSCC) by using immunohistochemistry. Photomicrographs were evaluated with Aperio Imagescope using a positive-pixel-counting algorithm. A histo-score (H-score) was calculated on the basis of staining intensity and the percentage of positive cells (%-staining). Intrarater reliability for H-score and %-staining was determined by calculating interclass correlation coefficients. Mean differences in H-scores and %-percent staining values were each analyzed by using an analysis of variance and Tukey's post hoc procedure. RESULTS: Cornulin expression progressively diminished with increasing grades of dysplasia and OSCC. Interclass correlation coefficients for H-score and %-staining were each greater than 0.99. Except for OSCC versus HD, all other pairwise comparisons were statistically significant (P < .0001) for H-score and %-staining. CONCLUSIONS: Cornulin expression helped differentiate between low-grade and high-grade oral epithelial dysplasia, making it a potential adjunct for grading oral OEDs and a potential biomarker for risk of lesion progression. Longitudinal studies evaluating risk stratification based on cornulin expression may be warranted.

Erythematous and Vascular Oral Mucosal Lesions: A Clinicopathologic Review of Red Entities.

Erythematous lesions of the oral mucosa are common and can reflect a variety of conditions, ranging from benign reactive or immunologically-mediated disorders to malignant disease. Together with vascular abnormalities, which can vary from reddish to bluish-purple in color, the differential diagnosis for erythematous oral mucosal change is quite diverse. This review focuses on salient clinical features and histopathologic findings of selected conditions which clinically present as red or vascular-like oral mucosal alterations, including oral vascular malformations and neoplasms, pyogenic granuloma, localized juvenile spongiotic gingival hyperplasia, denture stomatitis, benign migratory glossitis (geographic tongue), orofacial granulomatosis, granulomatosis with polyangiitis (Wegener granulomatosis), megaloblastic anemia, and erythroplakia. Recognition of the characteristic clinical features of these conditions, in conjunction with thorough patient history, will allow clinicians to narrow the differential diagnosis and guide appropriate clinical decision making, including the need for tissue biopsy, in order to complete the diagnostic process and initiate optimal patient care.

Non-calcifying Langerhans Cell-Rich Variant of Calcifying Epithelial Odontogenic Tumor: A Distinct Entity with Predilection for Anterior Maxilla.

Calcifying epithelial odontogenic tumor (CEOT) is an uncommon locally invasive epithelial odontogenic tumor of the jaws associated with amyloid production. Intraosseous presentations are most common and they frequently occur in the posterior mandible. A non-calcifying Langerhans cell-rich variant of CEOT (NCLC CEOT) has been described with predilection for the anterior maxilla. Interestingly, all reported cases of NCLC CEOT have occurred in Asian population. We present a case of a 43-year old Caucasian female with a large radiolucent lesion involving the left anterior maxilla with histologic features of NCLC CEOT. This is the first reported case of this rare variant of CEOT in a Caucasian individual.

The role of direct visual fluorescent examination (VELscope) in routine screening for potentially malignant oral mucosal lesions.

OBJECTIVE: Direct visual fluorescent examination (DVFE) is a proposed adjunct to conventional oral examination (COE). We evaluate the benefit of DVFE in screening for potentially malignant mucosal lesions in a general population of patients presenting for dental care. STUDY DESIGN: A total of 130 patients were evaluated by COE followed by DVFE. Areas clinically suspicious by COE or with positive DVFE (visual fluorescence loss [VFL]) underwent surgical biopsy. Association between COE and DVFE was assessed and compared with histopathology. RESULTS: A total of 42 subjects had one or more areas of VFL, yet histologic evidence of premalignancy/malignancy was only identified in a single individual. Further, one lesion negative by DVFE exhibited epithelial dysplasia. DVFE was statistically different from scalpel biopsy (P = .0001). No difference was found between COE and scalpel biopsy (P = 1.0). CONCLUSIONS: Results suggest that COE is more valid than DVFE at discriminating benign mucosal alterations from premalignancy and do not support use of DVFE as an oral cancer screening adjunct.

Buccal bifurcation cyst in a 7-year-old: surgical management and 14-month follow-up.

BACKGROUND: The buccal bifurcation cyst (BBC) is a paradental cyst that typically presents on the buccal aspect of mandibular permanent first molars in children 6 to 11 years of age. Histopathologic features are non-specific and closely resemble other inflammatory odontogenic cysts. The aim of this article is to report a case of a BBC and to review the management of such lesions. METHODS: A 7-year-old white male, complaining of lower right tooth pain and swelling, presented to the Nationwide Children's Hospital Dental Clinic. A clinical examination revealed no caries and swelling localized to the area approximating tooth #30 with a 15-mm probing depth on the buccal aspect. Radiographs revealed a radiolucency involving the bifurcation and root area of tooth #30, accompanied by the distal displacement of unerupted tooth #31. Therapy consisted of a simple surgical enucleation of the cyst. RESULTS: A microscopic evaluation revealed a chronically inflamed cyst lined by a non-keratinized stratified squamous epithelium. The immediate postoperative course was uneventful. At 14 months postoperatively, the development of teeth #30 and #31 was noted as normal. Probing depths around tooth #30 were