Case #6
A 53-year-old female visited a general dentist for an initial exam and dental prophylaxis. Radiographic examination revealed diffuse radiopacities in the mandible.
Joen Iannucci Haring, DDS, MS
History
The patient was unaware of the areas in the mandible and denied any history of pain or swelling in the involved regions. At the time of the dental visit, the patient appeared to be in a general good state of health. Her past medical history included surgical removal of a thyroid tumor, appendectomy, and cholecystectomy. No medications were being taken by the patient at the time of the dental examination. The patient`s past dental history included sporadic dental examinations and routine dental treatment.
Examinations
The patient`s vital signs were all found to be within normal limits. A physical examination of the head and neck region revealed no enlarged or palpable lymph nodes. No abnormal extraoral findings were identified.
After a thorough intraoral examination, a panoramic radiograph was ordered and exposed. Examination of the panoramic radiograph revealed multiple, diffuse radiopacities throughout the mandible (see radiograph). In order to view the area more closely, periapical radiographs of the involved areas were also exposed. The radiopacities appeared well defined and were associated with the posterior areas.
The soft tissue of the mandibular area was examined, and the bone was evaluated for expansion. No bony or soft-tissue abnormalities were identified. All of the teeth in the posterior mandible were pulp tested for vitality; all tested vital. Further examination of the oral cavity revealed no unusual or abnormal findings.
Clinical diagnosis
Based on the clinical and radiographic information presented, which one of the following is the most likely diagnosis?
* Osteoma
* Condensing osteitis
* Ossifying fibroma
* Benign cementoblastoma
* Florid cemento-osseous dysplasia
Diagnosis
Florid cemento-osseous dysplasia
Discussion
Florid cemento-osseous dysplasia (formerly known as gigantiform cementoma) is a condition that only affects the jaws; no other portions of the skeleton are involved. The cause of florid cemento-osseous dysplasia is unknown, although it is suspected to represent a reactive process.
Clinical features
Up to 90 percent of florid cemento-osseous dysplasia cases are identified in middle-aged black women. The reason for this distinct gender and racial predilection is unclear. Florid cemento-osseous dysplasia occurs in either the maxilla or mandible, with most cases involving the posterior regions. The lesions often occur bilaterally and are often symmetrical in appearance.
This condition may be completely asymptomatic and discovered only when a radiograph is taken. In many cases, no symptoms or bony expansion are present. In symptomatic cases of florid cemento-osseous dysplasia, a dull pain is often the chief complaint, and bony expansion may be present. In some instances, a bone-like material is seen in the oral cavity through a mucosal defect.
Radiographic features
Florid cemento-osseous dysplasia typically appears as multiple, diffuse highly radiodense and lobular radiopacities. These densely radiopaque areas are often interspersed with less well-defined radiolucent areas. The mixed radiolucent-radiopaque areas tend to become more radiopaque over time. Both dentulous and edentulous areas may be involved. The presence or absence of teeth does not appear to be a factor.
Diagnosis and treatment
A diagnosis of florid cemento-osseous dysplasia is established based on the clinical, radiographic, and histologic features of the lesion. For the asymptomatic patient, management includes regular recall examinations and radiographic follow-up.
For the symptomatic patient, management is less than ideal. Once symptomatic, the process is essentially a chronic osteomyelitis involving dysplastic bone and cementum. Treatment includes debridement, drainage and antibiotics.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
