endodontics Editor: MILTON
SISKIN,
DDS
Suite 339 Union Plaza Building 1835 Union Avenue Memphis, Tennessee 38104
Periapical lesions of mandibular bone: Difficulties in early diagnostics Karin Wannfors and Lars Hammarstriim.
Stockholm, Sweden
DEPARTMENT OF ORAL PATHOLOGY, SCHOOL OF DENTISTRY, KAROLINSKA INSTITUTET It is oflen difficult to establish a correct diagnosis on the basis of initial clinical and roentgenologic symptoms in mandibular bone disease. In this paper these problems are discussed, and some suggestions are made to overcome them. The discussion is based on cases of osteogenic sarcoma, histiocytic lymphoma, and chronic osteomyelitis. The patients were a boy and two middle-aged women, all of them with primary clinical symptoms of pain and swelling, diffuse roentgenologic changes in mandibular bone, uncertain response to treatment, and an unusual progress of the disease. (ORAL SURG ORAL MED ORIL PATHOL 1990;70:483-9)
D
estructive bone lesions surrounding dental roots are usually infective and inflammatory, but benign and malignant tumors and certain developmental anomalies and metabolic diseasesmay also appear as radiolucencies of bone.I-3 The clinical signs of malignant tumors of bone might be obvious but are often vague or might even be lacking, mainly becauseof the location of the tumor and the rapidity of its growth. The osteosarcoma often runs a rapid course, sometimes causing lossof teeth,4-8whereas the lymphomas of bone grow slowly and cause insignificant discomfort if not interfering with important structures such as the inferior alveolar nerve (which interference might lead to anesthesia).9-13 Chronic osteomyelitis, defined as a widespread inflammation of bone, might express very uncharacteristic clinical symptoms as well.iW3In early stages of these conditions, there seldom are positive roentgenologic proofs for a specific diagnosis, especially since the roentgenologic signs often appear several weeks after the onset of the disease.2*3 Bone scintigraphy might be helpful in detecting a lesion that is diffusely engaging the bone, but it can by no meansbe used for differential diagnostics. Computerized tomography has proven to be a useful adjunct to conventional radiologic techniques in diagnostics of bone diseases,but since teeth, especially 7/15/12658
metallically restored teeth, disturb the computerized tomography scan, .only selected patients could be considered for this examination.15-l7 Another factor complicating the examination of patients is the difficulty in obtaining a representative biopsy specimen when the lesion is located in the mandible, adjacent to dental roots.7vl4 The purpose of this article is to discuss these diagnostic difficulties and to review the commonly applied clinical, roentgenologic and histologic criteria for primary malignancy of bone and chronic osteomyelitis. The discussion will be based on three cases in which we encountered serious problems in arriving at a correct diagnosis. CASEREPORTS CASE 1
An otherwisehealthy 12-year-oldboy visited his dentist becauseof a swelling in his right lower jaw. He also had somepain and wasfeverish.Six daysearlier he had had a blow to the jaw while swimmingin a pool with his friends. The dentistdiagnosedan infection arounda movablemolar tooth, a probable complication of the former trauma. The boy was given antibiotics, but there was no response. An incision was made, but there was no pus drainage. The boy was then referred to the Clinic for Oral Surgery. Examination revealed a large semisoft swelling lingual to the mobile right first mandibular molar and an enlarged submandibular lymph node. The teeth and the oral mucosa were other483
484
‘annfors1and Hammarstriim
ORAL SURG ORAL M IED OR AL PA THOI OC:tober 1990
Fig. 1. Destruction of bone surrounding roots of mandibular first molar. Periodontal spacesof adjiacent roots :are widened.
Fig. 2 . Atypical osteoid with scattered areasof calcification. Tumor cells of varying size are seer1; t heirr nuclei are often hyperchromatic, and several are undergoing mitosis.
wise healthy. Results of blood tests were normal. The roentgenologic examination revealed diffuse destruction of bone around the roots of the molar tooth, with a total loss of the lamina dura (Fig. 1). A biopsy specimen was taken from the swelling, including the previous incision. Histologic examination gave rise to a suspicion of malignancy, but more tissue was neededto ensure the diagnosis because an inflammatory infiltrate all over the biopsy material made the pathologic examination difficult. A new biopsy specimen was taken that included some of the underlying bone. The histologic examination of the new biopsy revealed atypical ostoid with large osteoblast-like cells and basophilic calcifications surrounded by abnormal cells, someof which were undergoing mitosis. The diagnosis was now indisputable: osteogenic sarcoma (Fig. 2). The boy was admitted to the regional oncologic center, where he was treated by radical surgery and chemotherapy. At present, 2 years later, he is alive and has no signs of recurrence or metastasis.
CASE 2
A 4Cyear-old woman had pain in the left lower jaw. Her dentist treated the left first molar tooth endodontically by extirpating necrotic pulp tissue and by filling up the pulp cavity with calcium hydroxide. This measuredid not result in relief of pain. There was a slowly progressing swelling in the region, and the pain increased. Various antibiotics were prescribed, but there was no obvious improvement. She was admitted to the clinic of oral surgery. Except for nauseaher general status was normal. The oral examination revealed a firm swelling located in the buccal vestibulum of the left mandible. The teeth and oral mucosa were otherwise healthy. A limited sensoryperception was noted within the area supported by the mental nerve. Results of routine blood tests were normal except for a slightly raised sedimentation rate. Roentgenologic examination showedwidened periodontal spacesaround the roots of the endodontically treated molar tooth. A descending
Mandibular
Volume70 Number 4
bone lesions
485
Fig. 3. Endodontic treatment of mandibular first left molar has been started. Descending bone destruction can be seen. Margins of mandibular canal are diffuse, and lytic areas are seenin the bone inferior to the canal.
Fig. 4. Bone trabeculae have lost their osteoblastoma,and soft tissue of marrow spacesis invaded by fymphocytes, plasma cells, and some polymorphonuclear leukocytes.
diffuse destruction of bone surrounding the mandibular canal and involving the basal cortical bone was seen (Fig. 3). The patient was prescribed 2 gm penicillin and 1 gm metronidazole a day. After a week the lesion was explored. A fibrotic mucoperiosteal flap was raised and a soft, pathologically changed cortical bone was exposed. The mental nerve was surrounded by granulomatous tissue. Softened bone and pads of granulation tissue were easily removed. The tissue sample was sent for histologic examination. Both the bone and the soft tissue were infiltrated by lymphocytes and plasma cells. No atypical cells were seen.There were areas of necrotic bone, remodeled bone, and new immature bone. The histologic diagnosis was chronic osteomyelitis (Fig. 4). The patient continued treatment with metronidazole for 6 months. An adequateendodontic treatment was carried out, and after 6 months the bone was almost reorganized. No
subjective symptoms of diseasewere present, and a normal sensory perception returned. CASE 3
A 45year-old woman was seenwith symptoms similar to those of the previous patient. The right first molar tooth of the lower jaw was thought to be the cause of pain and intermediate diffuse swelling in the area. The tooth was endodontically treated without relief of pain. She was examined by her family physician becauseher genera1condition was weakened. She had also lost the normal sensory perception of the right side of the lower lip and jaw. Results of routine blood tests and spinal fluid examination were within normal limits. The physician favored the diagnosis of a viral infection and therefore prescribed only some rest. However, there was no improvement, and the periodic swelling became more significant.
486
Wannfors and Hammarstrijm
ORAL SURG ORAL
MED ORAL PATHOL. October 1990
Fig. 5. Area of changed bone structure in right mandibular molar-premolar region. Cortical margins of alveoli are diffuse. In front region interdental bone is damaged.
Fig. 6. Damaged bone trabeculae with lymphocyte and plasma cell infiltration in marrow spaces.Some large histiocytic cells are seen.
When the patient was examined at the clinic of oral surgery, two firm and diffusely demarcated swellings were found, located at the buccal side of the right mandible and at the labial aspectof the frontal mandibular alveolar ridge. The swellings were covered by an edematousmucous membrane with a marked capillary induration. The oral status was otherwise normal, and there were no signs of periodontal disease.Lymph nodeswere nontender on palpation and of normal size. Routine laboratory tests showed normal results. The roentgenologic examination indicated diffuse bone destruction. There was a peculiar, loose trabecular
pattern of the bone in the premolar-molar area of the right mandible. The periodontal spacesof the frontal teeth were widened, and the septal bone between the two mandibular medial lower incisors was almost lost (Fig. 5). A surgical exploration of the suspectedbone areas was performed. Biopsy specimenswere taken. Histologic examination showed partly necrotic bone trabeculae, some remodeling of bone, and a heavy infiltration of lymphocytes in the bone and in the soft tissues. Large histiocytic cells could be seen scattered among the lymphocytes in the marrow spacesof the bone. The presenceof these atypical cells was somewhat
Volume70 Number 4
Mandibular
bone lesions
487
confusing, but since no abnormal mitotic activity was seen, malignancy was not suspected (Fig. 6). The patient was treated for an osteomyelitis. She had an antibiotic prescription of penicillin and metronidazole. The responsewas satisfying at first, but after a month her condition worsened. The swellings grew bigger, and there were no periods of regression. The lower incisors became loose.Additional roentgenogramsshoweddivergent roots of the incisors and a total lossof septal bone in the region (Fig. 7). The bone destruction in the molar area was also more extensive than previously. A new biopsy specimen was obtained. Raising a mucoperiosteal flap exposeda white, fish meat-like tumor that surrounded the mental nerve. The pathologist’s report this time was indisputable. Histiocytic lymphoid cells were predominating, and frequent mitoses were seen. Reticular fibers could be demonstrated, proved by the silver staining method. The diagnosis was histiocytic lymphoma (Fig. 8). The patient was treated with radiation. After irradiation with 40 Gy there were no clinical symptoms. In 3 months the bone pattern was normalized, as seen in a roentgenogram. No recurrence was observedduring the first year after treatment, but after 6 months a new tumor was discovered in the colon region. DISCUSSION
It is remarkable that the initial diagnosis of primary bone tumors is often wrong,9-14,18-20probably becauseof nonspecific clinical symptoms and diffuse roentgenologic changes. Pain and swelling are primary symptoms of chronic inflammatory disease of bone and of malignant bone tumors. Numbness of the jaw and anesthesia of the lip are signs of nerve involvement. Displacement and rapid loosening of the teeth are signs of an advanced disease. Although alarming, these symptoms are not specific enough for a current diagnosis.8-11The roentgenologic expression of a bone lesion varies with the amount of cortical bone involved. Lesions that are limited to cancellous bone are not visible on the radiograph. Changes involving well-known structures such as the lamina dura of the periodontal spacesor the mandibular canal are often seenearlier than loss of cancellous bone tissue.2*3,21 Infections and neoplasms spread in the direction that has the least resistance. In the maxilla this process results in early destruction of the thin cortical layer and an early soft tissue engagement. The cortical layer of the mandible is considerably thicker than that of the maxilla, and there is therefore a tendency for the lesion to spread within the cancellous bone and along the mandibular canal. To some extent this tendency explains why the roentgenologic characteristics of malignant and inflammatory bone disease are so diffuse, especially when the disease engages the mandible.3T7,16*21The descriptions of roentenologic signs in malignant bone diseaseare commonly rather
Fig. 7. Separated roots of frontal lower incisors. Total loss of interdental bone in the region.
vague. Terms such as “sunburst expression,” “mouse-eaten appearance,” and “cotton wool destruction’.’ describe roentgenologic signs seldomfound in casesthat are not advanced.5,6 lo, l l The present casesindicate the importance of coordinating the clinical, roentgenologic, and histologic diagnostic criteria. Neither the initial clinical and roentgenologic signs nor the histologic examination of the first biopsy in the histiocytic lymphoma casecontradicted the diagnosis of osteomyelitis. To a practicing dentist, who often has a vast experience of infectious diseasesbut perhaps just once in his lifetime is confronted with a bone malignancy, the initial clinical and roentgenologic behavior of the sarcoma lesion is not alarming. A proliferation of lymphocytes due to infection is sometimesdifficult to distinguish from an increase of malignant lymphatic cells. Further, the malignant changes in tumors are often accompanied by an inflammatory infiltration confusing the picture.97 11,14,15319 W e h ave been reminded of the importance of a representative biopsy and of being alert to a lack of responseto therapy. There should be no hesitation to perform a new biopsy in such cases. The roentgenologic expressian in our osteogenic sarcoma case was strictly destructive; no abnormal formation of bone spicule could be seen. The roentgenologic appearance of the histiocytic lymphoma
488 Wannfors and Hammarstriim
ORAL SURG ORAL MED ORAL PATHOL October 1990
Fig. 8. Pleomorphic neoplastic IymphoidaI tumor tissue with dominant histiocytic element. Silver staining outlines abundant reticulum fibers between cells.
was diffusely radiolucent. No specific structural changes could be seen. The tumor had probably developed from the cells of the bone marrow and was therefore not visible on the radiograph until the endosteal layer of cortical bone was engaged. The roentgenologic appearance of the histiocytic lymphoma was very similar to that of the osteomyelitis, probably becausean equivalent amount of bone was decalcified in both cases.In the malignant casesdescribed, further circumstances were complicating the diagnostics. First, the histiocytic lymphoma started multifocally, not a common behavior of malignant tumors with the exception of the lymphomas. However, this behavior is often associated with chronic osteomyelitis.3v7,9*16,22 Second, a young boy was the victim of a malignancy. Malignant diseasesare
most frequently found among elderly people. Exceptions are the sarcomas, which are found in children. An unusual reaction to trauma in young people, should always be alarming, since trauma is supposed to be a trigger factor in the development of a sarcoma.5~6,8 Three casesare reported. They all started with pain and swelling. The general condition of the patients was affected. The roentgenologic signs in all cases were diffuse. The responseto antibiotic treatment was not satisfying in any of the patients. Despite correct examination routines, we had problems with the diagnosis, but after reevaluation of anamnestic, clinical, and roentgenologic criteria supplemented by new biopsy procedures, the current diagnoseswere finally established.
Volume 70 Number 4 REFERENCES
1. Eversole R, Sabes WR, Rovin S. Fibro-osseouslesions of the jaws. J Oral Pathol 1972;189-220. 2. Stafne EC, Gibilesco JA. Oral roentgenographic diagnoses. Philadelphia: WB Saunders Company, 1975:79-85, 169-229. 3. Worth HM, Stoneman DW. Osteomyelitis, malignant disease and fibrous dysplasia. Dent Radiogr Photogr 1977;SO:1- 14. 4. Chuong R, Kaban L. Diagnosis and treatment of jaw tumors in children. J Oral Maxillofac Surg 1985;43:323-32. 5. Garrington G, Scofield H, Cornyn J, Hooker S. Osteosarcoma of the jaws. Cancer 1967;3:377-91. 6. Kragh L, Dahlin D, Erich J. Osteogenic sarcoma of the jaws and facial bones. Am J Surg 1958;96:496-505. 7. Looser K, Kuehn P. Primary tumors of the mandible. Am J Surg 1976;132:608-14. 8. Potdar G. Osteogenic sarcoma of the jaws. ORAL SURG ORAL MED ORAL PATHOL 1970;3:381-9.
9. Barclay JK. Reticulum cell sarcoma. J Oral Surg 1971;19: 734-6. 10. Campbell RL, Kelly DE, Jefferson E. Primary reticulum-cell sarcoma of the mandible. ORAL SURG ORAL MED ORAL PATHOL 1977;39:918-28.
11. Cline RE, Stenger TG. Histiocytic lymphoma. ORAL SURG ORAL MED ORAL PATHOL 1977;43:422-35.
12. Kayavis J, Papanyotuo P, Antoiadis D. Reticulum cell sarcoma of the mandible. J Oral Surg 198&38:210-l. 13. Stoopack J. Reticulum cell sarcoma of the mandible. J Oral Surg 1959;17:73-8. 14. Mincey D, Warnock M. Primary malignant lymphoma of mandible. J Oral Surg 1974:32:221-4.
Mandibular bone lesions
489
15. Hernandez R, Conway J, Poznanski A, Tachdjian M, Dias L, Kelikian A. The role of computer tomography and radionucleide scintigraphy in the localization of osteomyelitis in flat bones. J Pediatr Orthop 1985;5:151-4. 16. JacobssonS, Hollender L, Lundberg S, Larsson A. Chronic sclerosing osteomyelitis of the mandible. ORAL SURG ORAL MED ORAL PATHOL 1978;45:167-74.
17. Van Sickels JE, Plotkin R, Hershman D. Histiocytic lymphoma of the mandible. J Oral Surg 1980;38:359-60. 18. Lindqvist C, Teppo L, Sane J, Holmstrijm T, Wolf J. Osteosarcomaof the mandible. J Oral Maxillofac Surg 1986;44:75964. 19. Taylor C, Alexander R, Kramer H. Primary reticulum cell sarcoma of the mandible. J Oral Surg 1970;28:218-21. 20. Wing V, Jefferey B, Federle M, Helms C, Trafton P. Chronic osteomyelitis examined by CT. Radiology 1985;154:171-4. 21. Van Der Steldt R. Periapical bone lesions. Stafne and Tholen BU-Alpen aan den Rijd, 1979:46, 140-4. 22. JacobsonS, Heyden G. Chronic sclerosingosteomyelitis. ORAL SURG ORAL MED ORAL PATHOL 1977;43:357-64.
Reprint requests to: Karin Wannfors Department of Oral Pathology School of Dentistry P.O. Box 4064 S-141 04 Huddinge, Sweden
SISKIN,
DDS
Suite 339 Union Plaza Building 1835 Union Avenue Memphis, Tennessee 38104
Periapical lesions of mandibular bone: Difficulties in early diagnostics Karin Wannfors and Lars Hammarstriim.
Stockholm, Sweden
DEPARTMENT OF ORAL PATHOLOGY, SCHOOL OF DENTISTRY, KAROLINSKA INSTITUTET It is oflen difficult to establish a correct diagnosis on the basis of initial clinical and roentgenologic symptoms in mandibular bone disease. In this paper these problems are discussed, and some suggestions are made to overcome them. The discussion is based on cases of osteogenic sarcoma, histiocytic lymphoma, and chronic osteomyelitis. The patients were a boy and two middle-aged women, all of them with primary clinical symptoms of pain and swelling, diffuse roentgenologic changes in mandibular bone, uncertain response to treatment, and an unusual progress of the disease. (ORAL SURG ORAL MED ORIL PATHOL 1990;70:483-9)
D
estructive bone lesions surrounding dental roots are usually infective and inflammatory, but benign and malignant tumors and certain developmental anomalies and metabolic diseasesmay also appear as radiolucencies of bone.I-3 The clinical signs of malignant tumors of bone might be obvious but are often vague or might even be lacking, mainly becauseof the location of the tumor and the rapidity of its growth. The osteosarcoma often runs a rapid course, sometimes causing lossof teeth,4-8whereas the lymphomas of bone grow slowly and cause insignificant discomfort if not interfering with important structures such as the inferior alveolar nerve (which interference might lead to anesthesia).9-13 Chronic osteomyelitis, defined as a widespread inflammation of bone, might express very uncharacteristic clinical symptoms as well.iW3In early stages of these conditions, there seldom are positive roentgenologic proofs for a specific diagnosis, especially since the roentgenologic signs often appear several weeks after the onset of the disease.2*3 Bone scintigraphy might be helpful in detecting a lesion that is diffusely engaging the bone, but it can by no meansbe used for differential diagnostics. Computerized tomography has proven to be a useful adjunct to conventional radiologic techniques in diagnostics of bone diseases,but since teeth, especially 7/15/12658
metallically restored teeth, disturb the computerized tomography scan, .only selected patients could be considered for this examination.15-l7 Another factor complicating the examination of patients is the difficulty in obtaining a representative biopsy specimen when the lesion is located in the mandible, adjacent to dental roots.7vl4 The purpose of this article is to discuss these diagnostic difficulties and to review the commonly applied clinical, roentgenologic and histologic criteria for primary malignancy of bone and chronic osteomyelitis. The discussion will be based on three cases in which we encountered serious problems in arriving at a correct diagnosis. CASEREPORTS CASE 1
An otherwisehealthy 12-year-oldboy visited his dentist becauseof a swelling in his right lower jaw. He also had somepain and wasfeverish.Six daysearlier he had had a blow to the jaw while swimmingin a pool with his friends. The dentistdiagnosedan infection arounda movablemolar tooth, a probable complication of the former trauma. The boy was given antibiotics, but there was no response. An incision was made, but there was no pus drainage. The boy was then referred to the Clinic for Oral Surgery. Examination revealed a large semisoft swelling lingual to the mobile right first mandibular molar and an enlarged submandibular lymph node. The teeth and the oral mucosa were other483
484
‘annfors1and Hammarstriim
ORAL SURG ORAL M IED OR AL PA THOI OC:tober 1990
Fig. 1. Destruction of bone surrounding roots of mandibular first molar. Periodontal spacesof adjiacent roots :are widened.
Fig. 2 . Atypical osteoid with scattered areasof calcification. Tumor cells of varying size are seer1; t heirr nuclei are often hyperchromatic, and several are undergoing mitosis.
wise healthy. Results of blood tests were normal. The roentgenologic examination revealed diffuse destruction of bone around the roots of the molar tooth, with a total loss of the lamina dura (Fig. 1). A biopsy specimen was taken from the swelling, including the previous incision. Histologic examination gave rise to a suspicion of malignancy, but more tissue was neededto ensure the diagnosis because an inflammatory infiltrate all over the biopsy material made the pathologic examination difficult. A new biopsy specimen was taken that included some of the underlying bone. The histologic examination of the new biopsy revealed atypical ostoid with large osteoblast-like cells and basophilic calcifications surrounded by abnormal cells, someof which were undergoing mitosis. The diagnosis was now indisputable: osteogenic sarcoma (Fig. 2). The boy was admitted to the regional oncologic center, where he was treated by radical surgery and chemotherapy. At present, 2 years later, he is alive and has no signs of recurrence or metastasis.
CASE 2
A 4Cyear-old woman had pain in the left lower jaw. Her dentist treated the left first molar tooth endodontically by extirpating necrotic pulp tissue and by filling up the pulp cavity with calcium hydroxide. This measuredid not result in relief of pain. There was a slowly progressing swelling in the region, and the pain increased. Various antibiotics were prescribed, but there was no obvious improvement. She was admitted to the clinic of oral surgery. Except for nauseaher general status was normal. The oral examination revealed a firm swelling located in the buccal vestibulum of the left mandible. The teeth and oral mucosa were otherwise healthy. A limited sensoryperception was noted within the area supported by the mental nerve. Results of routine blood tests were normal except for a slightly raised sedimentation rate. Roentgenologic examination showedwidened periodontal spacesaround the roots of the endodontically treated molar tooth. A descending
Mandibular
Volume70 Number 4
bone lesions
485
Fig. 3. Endodontic treatment of mandibular first left molar has been started. Descending bone destruction can be seen. Margins of mandibular canal are diffuse, and lytic areas are seenin the bone inferior to the canal.
Fig. 4. Bone trabeculae have lost their osteoblastoma,and soft tissue of marrow spacesis invaded by fymphocytes, plasma cells, and some polymorphonuclear leukocytes.
diffuse destruction of bone surrounding the mandibular canal and involving the basal cortical bone was seen (Fig. 3). The patient was prescribed 2 gm penicillin and 1 gm metronidazole a day. After a week the lesion was explored. A fibrotic mucoperiosteal flap was raised and a soft, pathologically changed cortical bone was exposed. The mental nerve was surrounded by granulomatous tissue. Softened bone and pads of granulation tissue were easily removed. The tissue sample was sent for histologic examination. Both the bone and the soft tissue were infiltrated by lymphocytes and plasma cells. No atypical cells were seen.There were areas of necrotic bone, remodeled bone, and new immature bone. The histologic diagnosis was chronic osteomyelitis (Fig. 4). The patient continued treatment with metronidazole for 6 months. An adequateendodontic treatment was carried out, and after 6 months the bone was almost reorganized. No
subjective symptoms of diseasewere present, and a normal sensory perception returned. CASE 3
A 45year-old woman was seenwith symptoms similar to those of the previous patient. The right first molar tooth of the lower jaw was thought to be the cause of pain and intermediate diffuse swelling in the area. The tooth was endodontically treated without relief of pain. She was examined by her family physician becauseher genera1condition was weakened. She had also lost the normal sensory perception of the right side of the lower lip and jaw. Results of routine blood tests and spinal fluid examination were within normal limits. The physician favored the diagnosis of a viral infection and therefore prescribed only some rest. However, there was no improvement, and the periodic swelling became more significant.
486
Wannfors and Hammarstrijm
ORAL SURG ORAL
MED ORAL PATHOL. October 1990
Fig. 5. Area of changed bone structure in right mandibular molar-premolar region. Cortical margins of alveoli are diffuse. In front region interdental bone is damaged.
Fig. 6. Damaged bone trabeculae with lymphocyte and plasma cell infiltration in marrow spaces.Some large histiocytic cells are seen.
When the patient was examined at the clinic of oral surgery, two firm and diffusely demarcated swellings were found, located at the buccal side of the right mandible and at the labial aspectof the frontal mandibular alveolar ridge. The swellings were covered by an edematousmucous membrane with a marked capillary induration. The oral status was otherwise normal, and there were no signs of periodontal disease.Lymph nodeswere nontender on palpation and of normal size. Routine laboratory tests showed normal results. The roentgenologic examination indicated diffuse bone destruction. There was a peculiar, loose trabecular
pattern of the bone in the premolar-molar area of the right mandible. The periodontal spacesof the frontal teeth were widened, and the septal bone between the two mandibular medial lower incisors was almost lost (Fig. 5). A surgical exploration of the suspectedbone areas was performed. Biopsy specimenswere taken. Histologic examination showed partly necrotic bone trabeculae, some remodeling of bone, and a heavy infiltration of lymphocytes in the bone and in the soft tissues. Large histiocytic cells could be seen scattered among the lymphocytes in the marrow spacesof the bone. The presenceof these atypical cells was somewhat
Volume70 Number 4
Mandibular
bone lesions
487
confusing, but since no abnormal mitotic activity was seen, malignancy was not suspected (Fig. 6). The patient was treated for an osteomyelitis. She had an antibiotic prescription of penicillin and metronidazole. The responsewas satisfying at first, but after a month her condition worsened. The swellings grew bigger, and there were no periods of regression. The lower incisors became loose.Additional roentgenogramsshoweddivergent roots of the incisors and a total lossof septal bone in the region (Fig. 7). The bone destruction in the molar area was also more extensive than previously. A new biopsy specimen was obtained. Raising a mucoperiosteal flap exposeda white, fish meat-like tumor that surrounded the mental nerve. The pathologist’s report this time was indisputable. Histiocytic lymphoid cells were predominating, and frequent mitoses were seen. Reticular fibers could be demonstrated, proved by the silver staining method. The diagnosis was histiocytic lymphoma (Fig. 8). The patient was treated with radiation. After irradiation with 40 Gy there were no clinical symptoms. In 3 months the bone pattern was normalized, as seen in a roentgenogram. No recurrence was observedduring the first year after treatment, but after 6 months a new tumor was discovered in the colon region. DISCUSSION
It is remarkable that the initial diagnosis of primary bone tumors is often wrong,9-14,18-20probably becauseof nonspecific clinical symptoms and diffuse roentgenologic changes. Pain and swelling are primary symptoms of chronic inflammatory disease of bone and of malignant bone tumors. Numbness of the jaw and anesthesia of the lip are signs of nerve involvement. Displacement and rapid loosening of the teeth are signs of an advanced disease. Although alarming, these symptoms are not specific enough for a current diagnosis.8-11The roentgenologic expression of a bone lesion varies with the amount of cortical bone involved. Lesions that are limited to cancellous bone are not visible on the radiograph. Changes involving well-known structures such as the lamina dura of the periodontal spacesor the mandibular canal are often seenearlier than loss of cancellous bone tissue.2*3,21 Infections and neoplasms spread in the direction that has the least resistance. In the maxilla this process results in early destruction of the thin cortical layer and an early soft tissue engagement. The cortical layer of the mandible is considerably thicker than that of the maxilla, and there is therefore a tendency for the lesion to spread within the cancellous bone and along the mandibular canal. To some extent this tendency explains why the roentgenologic characteristics of malignant and inflammatory bone disease are so diffuse, especially when the disease engages the mandible.3T7,16*21The descriptions of roentenologic signs in malignant bone diseaseare commonly rather
Fig. 7. Separated roots of frontal lower incisors. Total loss of interdental bone in the region.
vague. Terms such as “sunburst expression,” “mouse-eaten appearance,” and “cotton wool destruction’.’ describe roentgenologic signs seldomfound in casesthat are not advanced.5,6 lo, l l The present casesindicate the importance of coordinating the clinical, roentgenologic, and histologic diagnostic criteria. Neither the initial clinical and roentgenologic signs nor the histologic examination of the first biopsy in the histiocytic lymphoma casecontradicted the diagnosis of osteomyelitis. To a practicing dentist, who often has a vast experience of infectious diseasesbut perhaps just once in his lifetime is confronted with a bone malignancy, the initial clinical and roentgenologic behavior of the sarcoma lesion is not alarming. A proliferation of lymphocytes due to infection is sometimesdifficult to distinguish from an increase of malignant lymphatic cells. Further, the malignant changes in tumors are often accompanied by an inflammatory infiltration confusing the picture.97 11,14,15319 W e h ave been reminded of the importance of a representative biopsy and of being alert to a lack of responseto therapy. There should be no hesitation to perform a new biopsy in such cases. The roentgenologic expressian in our osteogenic sarcoma case was strictly destructive; no abnormal formation of bone spicule could be seen. The roentgenologic appearance of the histiocytic lymphoma
488 Wannfors and Hammarstriim
ORAL SURG ORAL MED ORAL PATHOL October 1990
Fig. 8. Pleomorphic neoplastic IymphoidaI tumor tissue with dominant histiocytic element. Silver staining outlines abundant reticulum fibers between cells.
was diffusely radiolucent. No specific structural changes could be seen. The tumor had probably developed from the cells of the bone marrow and was therefore not visible on the radiograph until the endosteal layer of cortical bone was engaged. The roentgenologic appearance of the histiocytic lymphoma was very similar to that of the osteomyelitis, probably becausean equivalent amount of bone was decalcified in both cases.In the malignant casesdescribed, further circumstances were complicating the diagnostics. First, the histiocytic lymphoma started multifocally, not a common behavior of malignant tumors with the exception of the lymphomas. However, this behavior is often associated with chronic osteomyelitis.3v7,9*16,22 Second, a young boy was the victim of a malignancy. Malignant diseasesare
most frequently found among elderly people. Exceptions are the sarcomas, which are found in children. An unusual reaction to trauma in young people, should always be alarming, since trauma is supposed to be a trigger factor in the development of a sarcoma.5~6,8 Three casesare reported. They all started with pain and swelling. The general condition of the patients was affected. The roentgenologic signs in all cases were diffuse. The responseto antibiotic treatment was not satisfying in any of the patients. Despite correct examination routines, we had problems with the diagnosis, but after reevaluation of anamnestic, clinical, and roentgenologic criteria supplemented by new biopsy procedures, the current diagnoseswere finally established.
Volume 70 Number 4 REFERENCES
1. Eversole R, Sabes WR, Rovin S. Fibro-osseouslesions of the jaws. J Oral Pathol 1972;189-220. 2. Stafne EC, Gibilesco JA. Oral roentgenographic diagnoses. Philadelphia: WB Saunders Company, 1975:79-85, 169-229. 3. Worth HM, Stoneman DW. Osteomyelitis, malignant disease and fibrous dysplasia. Dent Radiogr Photogr 1977;SO:1- 14. 4. Chuong R, Kaban L. Diagnosis and treatment of jaw tumors in children. J Oral Maxillofac Surg 1985;43:323-32. 5. Garrington G, Scofield H, Cornyn J, Hooker S. Osteosarcoma of the jaws. Cancer 1967;3:377-91. 6. Kragh L, Dahlin D, Erich J. Osteogenic sarcoma of the jaws and facial bones. Am J Surg 1958;96:496-505. 7. Looser K, Kuehn P. Primary tumors of the mandible. Am J Surg 1976;132:608-14. 8. Potdar G. Osteogenic sarcoma of the jaws. ORAL SURG ORAL MED ORAL PATHOL 1970;3:381-9.
9. Barclay JK. Reticulum cell sarcoma. J Oral Surg 1971;19: 734-6. 10. Campbell RL, Kelly DE, Jefferson E. Primary reticulum-cell sarcoma of the mandible. ORAL SURG ORAL MED ORAL PATHOL 1977;39:918-28.
11. Cline RE, Stenger TG. Histiocytic lymphoma. ORAL SURG ORAL MED ORAL PATHOL 1977;43:422-35.
12. Kayavis J, Papanyotuo P, Antoiadis D. Reticulum cell sarcoma of the mandible. J Oral Surg 198&38:210-l. 13. Stoopack J. Reticulum cell sarcoma of the mandible. J Oral Surg 1959;17:73-8. 14. Mincey D, Warnock M. Primary malignant lymphoma of mandible. J Oral Surg 1974:32:221-4.
Mandibular bone lesions
489
15. Hernandez R, Conway J, Poznanski A, Tachdjian M, Dias L, Kelikian A. The role of computer tomography and radionucleide scintigraphy in the localization of osteomyelitis in flat bones. J Pediatr Orthop 1985;5:151-4. 16. JacobssonS, Hollender L, Lundberg S, Larsson A. Chronic sclerosing osteomyelitis of the mandible. ORAL SURG ORAL MED ORAL PATHOL 1978;45:167-74.
17. Van Sickels JE, Plotkin R, Hershman D. Histiocytic lymphoma of the mandible. J Oral Surg 1980;38:359-60. 18. Lindqvist C, Teppo L, Sane J, Holmstrijm T, Wolf J. Osteosarcomaof the mandible. J Oral Maxillofac Surg 1986;44:75964. 19. Taylor C, Alexander R, Kramer H. Primary reticulum cell sarcoma of the mandible. J Oral Surg 1970;28:218-21. 20. Wing V, Jefferey B, Federle M, Helms C, Trafton P. Chronic osteomyelitis examined by CT. Radiology 1985;154:171-4. 21. Van Der Steldt R. Periapical bone lesions. Stafne and Tholen BU-Alpen aan den Rijd, 1979:46, 140-4. 22. JacobsonS, Heyden G. Chronic sclerosingosteomyelitis. ORAL SURG ORAL MED ORAL PATHOL 1977;43:357-64.
Reprint requests to: Karin Wannfors Department of Oral Pathology School of Dentistry P.O. Box 4064 S-141 04 Huddinge, Sweden
