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A Dental Tumor Associated with Dental Abnormality: Report of Case
G elpi— D ental Tum or Associated with D en tal Abnorm ality is graduated fr o m A n n apolis and, w ith out fu rther exam ination, is accepted into the U n ited States N a v y ; but he knows that, in due tim e, he w ill be ordered be fore a board o f exam iners fo r prom otion. A n d so he goes on all through his career from one grade to another, always w ith the k n ow led ge that, sooner o r later, he must stand an exam ination fo r prom o tion. T h u s , he is com pelled all his life to be a student o f his profession, and if he fails to pass his p rom otion examination, there com es a tim e w hen he ranks so far below the grade that he should occu py for the opportunities fo r advancem ent that he has had that he is dismissed from the service as u n w orth y to remain. T h e A r m y has a little different m ethod from the N a vy, but here also prom otion tests are constantly ahead o f one.
1031
SUM M ARY
T h e r e is need that som ething be done to insure that dentists keep up the quality o f their w o rk th rou gh ou t their profes sional life. I t is recom m ended that ( 1 ) all dental schools attain and maintain “ Class A ” efficien cy; ( 2 ) on ly graduates o f these schools be a llow ed to practice in this co u n tr y ; ( 3 ) in any part o f the U .S .A ., a degree fro m any o f these schools be ac cepted as evidence that the h older is fitted to begin p ra ctice; ( 4 ) all practicing den tists be com pelled to appear before a board o f dental examiners five years after graduation from the dental school and periodically thereafter, and ( 5 ) the pres ent state boards o f dental examiners be reorganized and have placed in their hands the operation o f these ideas. 655 C ongress Street.
A DENTAL TUMOR ASSOCIATED W ITH DENTAL ABNORMALITY: REPORT OF CASE B y F. JOSEPH GELPI, D .D .S., Denver, C olo.
S
IN C E , at the present time, classifica tion o f dental tum ors is not entirely satisfactory, an accurate discussion o f these path ologic conditions offers ob vious difficulties. W h e n the A n atom ic Society m et at Basle, S w itzerland, in 1869, to devise a scientific m edical no menclature, B roca in trodu ced the term “ odon tom a” to in clude all n ew grow ths having their origin in the dental organs, irrespective o f their physical character istics. T h is term has been accepted and n ow has the sanction o f universal usage. O f the various classifications attempted since B roca ’s tim e, that o f D ennis seems most satisfactory. It has the advantages not on ly o f brevity, bu t also o f descrip tion. H e divides odontom as according to Jour. A .D .A ., J une, 1935
origin and cellu lar structures as fo llo w s : ( 1 ) epithelial odon tom a, ( 2 ) fibrous odontom a, ( 3 ) cem entom a, ( 4 ) radicular odon tom a and ( 5 ) com posite odontom a. T h e epithelial odon tom a (D e n n is ) is analogous to B rop h y ’s “ enam elom a” and, accordin g to m ost authorities, arises from profileration o f the epithelium o f the enamel organ. M ech an ical, nutritional or any other fo rm o f irritation may be the etiologic factor. B enign in character, these lesions cause little if any pain or inconvenience, and w h ile there is no in filtration into adjacent structures, the e f fect o f pressure and expansion must o f necessity produce abnorm al changes in these tissues. E pithelial odontom as are not rare and are fou n d as frequ ently in
1032
T he Journal o f the American D ental Association
the m axillae as in the m andible. A g e ap parently is no fa ctor in their occurrence. T h e prognosis is favorable if the tum or is rem oved in its entirety. E a rly recog nition and rem oval are o f great im por tance as the fo llo w in g case report indi cates. REPORT OF CASE
July 2, 1933, a boy, aged 11, w ell nour ished and w ell developed, came in for a dental examination and consultation.
A b o v e : R oentgenogram s o f case. C enter: F lap la id back ex p osin g u n d e rly in g structure after rem oval o f bony process. B e lo w : 1, en am el ; 2, d e n tin ; 3, m yxom atous tissue.
Roentgenograms, as shown in the accom panying figure (above, left) and taken in February o f the same year, confirmed the condition found in the mouth. T h e upper central incisors had not erupted, and the tw o deciduous central incisors and the left cuspid w ere still attached to the soft tissues. T h is w as not the only important feature
o f the examination. F rom the boy’s actions, it became apparent that w e w ere dealing with a serious behavior problem or the lad was suffering from some incipient disease of the nervous system. Inquiry into this phase of the case revealed a history of violent hysterical outbursts or emotional storms of some type or another. These matters are noted because o f the subsequent course o f events and because they w ere of comparatively recent origin. T h e tw o deciduous central incisors and the one cuspid w ere removed. A week later, the patient was discharged, being instructed to return within three months for further observation. T h is he failed to do. O ra l examination and roentgenograms (above, right), a year later, indicated with out a doubt that the permanent incisors could not erupt normally. D igital examina tion revealed the incisal edges o f these teeth at the mucobuccal fold and the roentgeno grams suggested either supernumerary teeth or drifting second bicuspids, as the cuspids and first bicuspids w ere fully erupted. Surgical interference w as decided on. T h e illustration in the center represents the incision with the flap laid back and the underlying structures exposed after the bone process had been removed. T h e left incisor, lying in a parallel position with the posterior line o f occlusion, was firmly wedged at the dentino-enamel junction by a large irregular odontoma measuring 8 by 13 mm., which, by its position, exerted an upward pressure. T h is mass (as shown in the view below ) had adhering to its pos terior surface a small amount o f m yxo matous-like tissue. T h e right incisor, parallel with the left, w as wedged at the same point and subjected to a like pressure by a w ell-form ed cuspid measuring 5 by 14 mm. with a short hollow root containing the tissue previously described. A portion of this tissue w as cultured and incubated. N o growth was obtained. Retention stitches w ere removed in forty-eight hours and the flap firmly sutured with no medica tion of the cavity attempted. T h e patient made an uneventful recovery
Gelpi— D en tal T um or Associated with D en tal Abnorm ality and, fifteen days after the operation, the crow n o f the right incisor had appeared through the gum tissue. T h e mesial angle o f the left incisor erupted in normal posi tion six days after the right. Fulness, due to edema, which had been present over the low er portion o f the face and most marked under the nose before the tum or w as re moved, was now noticeably absent and the child rapidly returned to his normal state. The
im p o r ta n c e
o f e a r ly
r e c o g n itio n
an d rem ov a l o f d en ta l tu m ors m u st be
e m p h a s iz e d .
1033
E a r l y s u r g ic a l in t e r f e r e n c e
w i l l d e fi n it e l y e lim in a t e m a n y o f t h e a b n o r m a lit ie s n o w s e e n in t h e a d u lt .
A ls o ,
a t t e n t io n is d ir e c t e d t o t h e c o n d i t i o n o f th e n e r v o u s s y s te m , w h ic h m a y b e c a u s e d b y s o m e ir r it a t i v e f o c u s , as w a s t h e ca se in t h is in s t a n c e . T h i s c a s e t e n d s t o stres s t h e p o s s ib il it y o f d e n t a l ir r e g u la r it ie s as e t i o l o g i c f a c t o r s in a s m a ll p e r c e n t a g e o f t h e s o - c a ll e d
b e h a v io r p r o b le m s in c h i l
d re n o f s ch o o l age.
E x p l a in in g C
a l if o r n ia
A number of bills are before the California legislature, including six or seven bills for compulsory sickness insurance, one bill opening all the hospitals o f the state to all the people regardless o f ability to pay, and another licensing corporations to practice medicine in California. M oreover, the state is overrun with cultists o f various types and with all sorts of corporation practice, group practice, club practice, industrial practice and similar schemes. T h e survey made jointly by the California State M edical Association and the interim committee o f the senate, like most such surveys, hardly seems to have scratched the real surface of medical conditions, yet the results o f the survey are cited in support of the action to which the various bodies concerned in the legislation seem to have been rather largely committed before the survey was undertaken. It is clear that the M ilbank Fund and other foundations have been active in propaganda in California. As the onlooker from without, the editor w ould venture the prediction that all w ill not be so rosy in California as it may now seem to the bespectacled, rose-colored vision of some o f the proponents representing the California M edical Association. It should be obvious from the statements that have been made and the hearings that have been held that the very factors in medical care which the profession w ill demand w ill not be favorably received by the political group, w ho w ill eventually dominate the sickness insurance system in California. T h e dental profession, some assert, has received inadequate con sideration in the proposed legislation and w ill perhaps oppose the bill that has been offered. T h e medical profession w ill perhaps find itself ultimately in a situation in which it w ill have to oppose the legislation fo r which it is n ow responsible, mainly because it decided to compromise rather than to fight to the finish on the principle and the issue. A complete study o f all that has occurred in California indicates to any one w ho has some understanding o f our Am erican political system the difficult path which the leaders of California medicine are treading. Perhaps they w ill find their w ay successfully out o f the morass without engulfing their profession in a system which w ill lead to a low ering of the standards o f medicine and the quality o f medical care in that state.— J.A .M .A., M ay 4, 1935.
1031
SUM M ARY
T h e r e is need that som ething be done to insure that dentists keep up the quality o f their w o rk th rou gh ou t their profes sional life. I t is recom m ended that ( 1 ) all dental schools attain and maintain “ Class A ” efficien cy; ( 2 ) on ly graduates o f these schools be a llow ed to practice in this co u n tr y ; ( 3 ) in any part o f the U .S .A ., a degree fro m any o f these schools be ac cepted as evidence that the h older is fitted to begin p ra ctice; ( 4 ) all practicing den tists be com pelled to appear before a board o f dental examiners five years after graduation from the dental school and periodically thereafter, and ( 5 ) the pres ent state boards o f dental examiners be reorganized and have placed in their hands the operation o f these ideas. 655 C ongress Street.
A DENTAL TUMOR ASSOCIATED W ITH DENTAL ABNORMALITY: REPORT OF CASE B y F. JOSEPH GELPI, D .D .S., Denver, C olo.
S
IN C E , at the present time, classifica tion o f dental tum ors is not entirely satisfactory, an accurate discussion o f these path ologic conditions offers ob vious difficulties. W h e n the A n atom ic Society m et at Basle, S w itzerland, in 1869, to devise a scientific m edical no menclature, B roca in trodu ced the term “ odon tom a” to in clude all n ew grow ths having their origin in the dental organs, irrespective o f their physical character istics. T h is term has been accepted and n ow has the sanction o f universal usage. O f the various classifications attempted since B roca ’s tim e, that o f D ennis seems most satisfactory. It has the advantages not on ly o f brevity, bu t also o f descrip tion. H e divides odontom as according to Jour. A .D .A ., J une, 1935
origin and cellu lar structures as fo llo w s : ( 1 ) epithelial odon tom a, ( 2 ) fibrous odontom a, ( 3 ) cem entom a, ( 4 ) radicular odon tom a and ( 5 ) com posite odontom a. T h e epithelial odon tom a (D e n n is ) is analogous to B rop h y ’s “ enam elom a” and, accordin g to m ost authorities, arises from profileration o f the epithelium o f the enamel organ. M ech an ical, nutritional or any other fo rm o f irritation may be the etiologic factor. B enign in character, these lesions cause little if any pain or inconvenience, and w h ile there is no in filtration into adjacent structures, the e f fect o f pressure and expansion must o f necessity produce abnorm al changes in these tissues. E pithelial odontom as are not rare and are fou n d as frequ ently in
1032
T he Journal o f the American D ental Association
the m axillae as in the m andible. A g e ap parently is no fa ctor in their occurrence. T h e prognosis is favorable if the tum or is rem oved in its entirety. E a rly recog nition and rem oval are o f great im por tance as the fo llo w in g case report indi cates. REPORT OF CASE
July 2, 1933, a boy, aged 11, w ell nour ished and w ell developed, came in for a dental examination and consultation.
A b o v e : R oentgenogram s o f case. C enter: F lap la id back ex p osin g u n d e rly in g structure after rem oval o f bony process. B e lo w : 1, en am el ; 2, d e n tin ; 3, m yxom atous tissue.
Roentgenograms, as shown in the accom panying figure (above, left) and taken in February o f the same year, confirmed the condition found in the mouth. T h e upper central incisors had not erupted, and the tw o deciduous central incisors and the left cuspid w ere still attached to the soft tissues. T h is w as not the only important feature
o f the examination. F rom the boy’s actions, it became apparent that w e w ere dealing with a serious behavior problem or the lad was suffering from some incipient disease of the nervous system. Inquiry into this phase of the case revealed a history of violent hysterical outbursts or emotional storms of some type or another. These matters are noted because o f the subsequent course o f events and because they w ere of comparatively recent origin. T h e tw o deciduous central incisors and the one cuspid w ere removed. A week later, the patient was discharged, being instructed to return within three months for further observation. T h is he failed to do. O ra l examination and roentgenograms (above, right), a year later, indicated with out a doubt that the permanent incisors could not erupt normally. D igital examina tion revealed the incisal edges o f these teeth at the mucobuccal fold and the roentgeno grams suggested either supernumerary teeth or drifting second bicuspids, as the cuspids and first bicuspids w ere fully erupted. Surgical interference w as decided on. T h e illustration in the center represents the incision with the flap laid back and the underlying structures exposed after the bone process had been removed. T h e left incisor, lying in a parallel position with the posterior line o f occlusion, was firmly wedged at the dentino-enamel junction by a large irregular odontoma measuring 8 by 13 mm., which, by its position, exerted an upward pressure. T h is mass (as shown in the view below ) had adhering to its pos terior surface a small amount o f m yxo matous-like tissue. T h e right incisor, parallel with the left, w as wedged at the same point and subjected to a like pressure by a w ell-form ed cuspid measuring 5 by 14 mm. with a short hollow root containing the tissue previously described. A portion of this tissue w as cultured and incubated. N o growth was obtained. Retention stitches w ere removed in forty-eight hours and the flap firmly sutured with no medica tion of the cavity attempted. T h e patient made an uneventful recovery
Gelpi— D en tal T um or Associated with D en tal Abnorm ality and, fifteen days after the operation, the crow n o f the right incisor had appeared through the gum tissue. T h e mesial angle o f the left incisor erupted in normal posi tion six days after the right. Fulness, due to edema, which had been present over the low er portion o f the face and most marked under the nose before the tum or w as re moved, was now noticeably absent and the child rapidly returned to his normal state. The
im p o r ta n c e
o f e a r ly
r e c o g n itio n
an d rem ov a l o f d en ta l tu m ors m u st be
e m p h a s iz e d .
1033
E a r l y s u r g ic a l in t e r f e r e n c e
w i l l d e fi n it e l y e lim in a t e m a n y o f t h e a b n o r m a lit ie s n o w s e e n in t h e a d u lt .
A ls o ,
a t t e n t io n is d ir e c t e d t o t h e c o n d i t i o n o f th e n e r v o u s s y s te m , w h ic h m a y b e c a u s e d b y s o m e ir r it a t i v e f o c u s , as w a s t h e ca se in t h is in s t a n c e . T h i s c a s e t e n d s t o stres s t h e p o s s ib il it y o f d e n t a l ir r e g u la r it ie s as e t i o l o g i c f a c t o r s in a s m a ll p e r c e n t a g e o f t h e s o - c a ll e d
b e h a v io r p r o b le m s in c h i l
d re n o f s ch o o l age.
E x p l a in in g C
a l if o r n ia
A number of bills are before the California legislature, including six or seven bills for compulsory sickness insurance, one bill opening all the hospitals o f the state to all the people regardless o f ability to pay, and another licensing corporations to practice medicine in California. M oreover, the state is overrun with cultists o f various types and with all sorts of corporation practice, group practice, club practice, industrial practice and similar schemes. T h e survey made jointly by the California State M edical Association and the interim committee o f the senate, like most such surveys, hardly seems to have scratched the real surface of medical conditions, yet the results o f the survey are cited in support of the action to which the various bodies concerned in the legislation seem to have been rather largely committed before the survey was undertaken. It is clear that the M ilbank Fund and other foundations have been active in propaganda in California. As the onlooker from without, the editor w ould venture the prediction that all w ill not be so rosy in California as it may now seem to the bespectacled, rose-colored vision of some o f the proponents representing the California M edical Association. It should be obvious from the statements that have been made and the hearings that have been held that the very factors in medical care which the profession w ill demand w ill not be favorably received by the political group, w ho w ill eventually dominate the sickness insurance system in California. T h e dental profession, some assert, has received inadequate con sideration in the proposed legislation and w ill perhaps oppose the bill that has been offered. T h e medical profession w ill perhaps find itself ultimately in a situation in which it w ill have to oppose the legislation fo r which it is n ow responsible, mainly because it decided to compromise rather than to fight to the finish on the principle and the issue. A complete study o f all that has occurred in California indicates to any one w ho has some understanding o f our Am erican political system the difficult path which the leaders of California medicine are treading. Perhaps they w ill find their w ay successfully out o f the morass without engulfing their profession in a system which w ill lead to a low ering of the standards o f medicine and the quality o f medical care in that state.— J.A .M .A., M ay 4, 1935.