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CR0349 Concurrence of methotrexate-associated lymphoproliferative disorder and bisphosphonate-related osteonecrosis of the jaw in a patient with rheumatoid arthritis
ORAL MEDICINE e348 Abstracts nonpruritic erythematous rash on her right arm and leg. The remainder of her review of systems was not significant. Physical examination found an upper lip swelling with a doughy consistency, and a chronic ulcer on the right upper lip vermilion. Also noted were gingival erythema and significant edema extending from the maxillary right canine to the maxillary left canine. An empiric trial of Medrol dose pack was recommended and resulted in significant improvement (85%) but without complete resolution. A biopsy of the lip and the gingival tissue was performed, and the gingival biopsy found granulomatous inflammation. The biopsy did not find a foreign body under polarized light. The patient is presently being evaluated for Crohn disease and sarcoidosis. Conclusions: Having not identified foreign material by microscopic means, it is important that other causes of granulomatous inflammation be considered.
CR0262 A CASE SERIES OF VASCULAR MALFORMATIONS IN PEDIATRIC PATIENTS Carly Harrison, Meena Rudralingam, Oral Medicine, Manchester Dental Hospital, Manchester, United Kingdom Background: Vascular malformations are congenital aberrancies affecting the skin and mucosa, often affecting the head and neck region, recorded in 1 in 22 neonates. Vascular malformations consist of progressively enlarging aberrant and ectatic vessels composed of a particular vascular architecture. Hemangioma is the most common neoplasm consisting of localized developments, owing to the marked increase in growth factor, denoted histologically by endothelial proliferation and hypercellularity. Most true hemangiomas involute in time; however, some cases present late. These can be alarming owing to local disfigurement, and the treatment options are not without serious complications. Summary: We report a series of 4 clinical cases of vascular and lymphangiomatous oral malformations in pediatric patients. These were originally misdiagnosed as dental and herpes infections by dental practitioners. Failure to respond to the antibiotic and antiviral therapy prescribed led to persistence, enlargement, and local disfigurement. The local morbidity caused by the malformations eventually alerted urgent referral to oral medicine. The clinical diagnoses are as follows: (1) lymphangioma localized to the palate, causing ulceration and bleeding; (2) microcystic lymphangioma in the buccal mucosa infiltrating into the subcutaneous tissues, causing drooping of the lip and distortion of the cheek; (3) capillary hemangioma in the maxillary alveolus, causing occlusal disharmony and facial discoloration; and (4) hemangioma in the submandibular region, causing facial swelling. Clinical photographs of the cases were taken. Investigations to confirm the diagnosis and the range of multimodal therapy were performed. Conclusions: The cases demonstrate an interesting documented journey of pediatric referrals with inaccurate diagnoses. The effects on patients’ quality of life and parental concerns were explored. Highlighting such cases’ correct classification and accurate diagnosis is imperative to ascertain prognosis and direct treatment. This reflects on the management strategies and how they have varied in each case of vascular malformations.
CR0349 CONCURRENCE OF METHOTREXATE-ASSOCIATED LYMPHOPROLIFERATIVE DISORDER AND BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW IN A PATIENT WITH RHEUMATOID ARTHRITIS Massaki Miyakoshi, Misa Yanagiya, Jun Sato, Hironobu Hata,
OOOO May 2014 Chiharu Sato, Yutaka Yamazaki, Yoshimasa Kitagawa, Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan Background: Although methotrexate (MTX) is used as the first choice of medication for rheumatoid arthritis (RA), it has the risk of MTX-associated lymphoproliferative disorder (MTXLPD). Additionally, to prevent steroid-induced osteoporosis, bisphosphonates (BPs) are administered in many RA cases. BPrelated osteonecrosis of the jaw (BRONJ) is reported worldwide. We report a case of concurrence with MTX-LPD and BRONJ in a RA patient. Summary: A 54-year-old woman visited her general dental clinic with a chief complaint of bilateral upper gum pain around the molar teeth. At the clinic, intraoral steroid ointment was administrated for an ulcer. The lesion failed to heal. She was referred to our hospital, and intraoral examination found a 20-mm necrotic ulcer and bone exposure of the peripheral gingiva of the inside of the upper second molar. Contrast-enhanced computed tomography found osteonecrosis in the posterior cortex. Furthermore, fluorodeoxyglucose-labeled positron emission tomographye computed tomography (FDG-PET/CT) found strong uptake bilaterally. A clinical diagnosis of malignant lymphoma was suspected, and blood examination was performed. This showed a slightly raised C-reactive protein level, a raised monocyte count, and a low lymphocyte count; however, the soluble interleukin 2 receptor level was within the reference range. Histology suggested MTXLPD. With hematologist liaison, MTX was stopped, as well as BP (risedronate sodium), which she had taken for more than 3 years. After drug cessation, the ulcers disappeared. Ipsilaterally, bone exposure and FDG abnormal uptake remained. The lesion was diagnosed as BRONJ, and osteonecrotomy was performed. Postoperatively, healing of the lesions was good, and there was no recurrence. Conclusions: Combination therapy may be required to treat drug-induced disease.
CR0416 CEREBELLOPONTINE ANGLE TUMOR: TRIGEMINAL NEURALGIA AS A CRITICAL SIGN Imad Elimairi, A. Sami, Oral and Maxillofacial Surgery, Oral Pathology and Oral Medicine, Ribat University Hospital and Nile College, Khartoum, Sudan Background: Cerebellopontine angle (CPA) tumor can manifest with similar symptoms to trigeminal neuralgia (TN). Summary: Chief complaint: A 26-year-old woman presented to the Facial Pain Clinic, Ribat Hospital, with severe rightsided facial pain. Each episode lasted for several seconds. Examination: There was hyperesthesia to digital palpation along the right maxillary division of the trigeminal nerve and the right temporal region. Diagnostic investigations: We requested contrast-enhanced magnetic resonance imaging (MRI) of the brain and brain stem and a brain magnetic resonance angiogram (MRA) to rule out any tumorous lesion or cranial neuropathy. Therapeutics: A tentative diagnosis of trigeminal neuralgia was reached. She was empirically started on oxcarbazepine 150 mg 3 times daily, with reexamination planned in 10 days. Three days after, the patient complained of increased intensity, frequency, and duration of each pain episode. The oxcarbazepine dose was increased to 150 mg 4 times daily, and clonazepam 0.5 mg 2 times daily was also prescribed. She reported pain improvement but remarkable hyperesthesia to the maxillary division of the trigeminal nerve and loss of sensation on the right half of the upper lip on 10-day review. Results: MRI of the brain and brain stem found a space-occupying lesion at the CPA that was mostly
CR0262 A CASE SERIES OF VASCULAR MALFORMATIONS IN PEDIATRIC PATIENTS Carly Harrison, Meena Rudralingam, Oral Medicine, Manchester Dental Hospital, Manchester, United Kingdom Background: Vascular malformations are congenital aberrancies affecting the skin and mucosa, often affecting the head and neck region, recorded in 1 in 22 neonates. Vascular malformations consist of progressively enlarging aberrant and ectatic vessels composed of a particular vascular architecture. Hemangioma is the most common neoplasm consisting of localized developments, owing to the marked increase in growth factor, denoted histologically by endothelial proliferation and hypercellularity. Most true hemangiomas involute in time; however, some cases present late. These can be alarming owing to local disfigurement, and the treatment options are not without serious complications. Summary: We report a series of 4 clinical cases of vascular and lymphangiomatous oral malformations in pediatric patients. These were originally misdiagnosed as dental and herpes infections by dental practitioners. Failure to respond to the antibiotic and antiviral therapy prescribed led to persistence, enlargement, and local disfigurement. The local morbidity caused by the malformations eventually alerted urgent referral to oral medicine. The clinical diagnoses are as follows: (1) lymphangioma localized to the palate, causing ulceration and bleeding; (2) microcystic lymphangioma in the buccal mucosa infiltrating into the subcutaneous tissues, causing drooping of the lip and distortion of the cheek; (3) capillary hemangioma in the maxillary alveolus, causing occlusal disharmony and facial discoloration; and (4) hemangioma in the submandibular region, causing facial swelling. Clinical photographs of the cases were taken. Investigations to confirm the diagnosis and the range of multimodal therapy were performed. Conclusions: The cases demonstrate an interesting documented journey of pediatric referrals with inaccurate diagnoses. The effects on patients’ quality of life and parental concerns were explored. Highlighting such cases’ correct classification and accurate diagnosis is imperative to ascertain prognosis and direct treatment. This reflects on the management strategies and how they have varied in each case of vascular malformations.
CR0349 CONCURRENCE OF METHOTREXATE-ASSOCIATED LYMPHOPROLIFERATIVE DISORDER AND BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW IN A PATIENT WITH RHEUMATOID ARTHRITIS Massaki Miyakoshi, Misa Yanagiya, Jun Sato, Hironobu Hata,
OOOO May 2014 Chiharu Sato, Yutaka Yamazaki, Yoshimasa Kitagawa, Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan Background: Although methotrexate (MTX) is used as the first choice of medication for rheumatoid arthritis (RA), it has the risk of MTX-associated lymphoproliferative disorder (MTXLPD). Additionally, to prevent steroid-induced osteoporosis, bisphosphonates (BPs) are administered in many RA cases. BPrelated osteonecrosis of the jaw (BRONJ) is reported worldwide. We report a case of concurrence with MTX-LPD and BRONJ in a RA patient. Summary: A 54-year-old woman visited her general dental clinic with a chief complaint of bilateral upper gum pain around the molar teeth. At the clinic, intraoral steroid ointment was administrated for an ulcer. The lesion failed to heal. She was referred to our hospital, and intraoral examination found a 20-mm necrotic ulcer and bone exposure of the peripheral gingiva of the inside of the upper second molar. Contrast-enhanced computed tomography found osteonecrosis in the posterior cortex. Furthermore, fluorodeoxyglucose-labeled positron emission tomographye computed tomography (FDG-PET/CT) found strong uptake bilaterally. A clinical diagnosis of malignant lymphoma was suspected, and blood examination was performed. This showed a slightly raised C-reactive protein level, a raised monocyte count, and a low lymphocyte count; however, the soluble interleukin 2 receptor level was within the reference range. Histology suggested MTXLPD. With hematologist liaison, MTX was stopped, as well as BP (risedronate sodium), which she had taken for more than 3 years. After drug cessation, the ulcers disappeared. Ipsilaterally, bone exposure and FDG abnormal uptake remained. The lesion was diagnosed as BRONJ, and osteonecrotomy was performed. Postoperatively, healing of the lesions was good, and there was no recurrence. Conclusions: Combination therapy may be required to treat drug-induced disease.
CR0416 CEREBELLOPONTINE ANGLE TUMOR: TRIGEMINAL NEURALGIA AS A CRITICAL SIGN Imad Elimairi, A. Sami, Oral and Maxillofacial Surgery, Oral Pathology and Oral Medicine, Ribat University Hospital and Nile College, Khartoum, Sudan Background: Cerebellopontine angle (CPA) tumor can manifest with similar symptoms to trigeminal neuralgia (TN). Summary: Chief complaint: A 26-year-old woman presented to the Facial Pain Clinic, Ribat Hospital, with severe rightsided facial pain. Each episode lasted for several seconds. Examination: There was hyperesthesia to digital palpation along the right maxillary division of the trigeminal nerve and the right temporal region. Diagnostic investigations: We requested contrast-enhanced magnetic resonance imaging (MRI) of the brain and brain stem and a brain magnetic resonance angiogram (MRA) to rule out any tumorous lesion or cranial neuropathy. Therapeutics: A tentative diagnosis of trigeminal neuralgia was reached. She was empirically started on oxcarbazepine 150 mg 3 times daily, with reexamination planned in 10 days. Three days after, the patient complained of increased intensity, frequency, and duration of each pain episode. The oxcarbazepine dose was increased to 150 mg 4 times daily, and clonazepam 0.5 mg 2 times daily was also prescribed. She reported pain improvement but remarkable hyperesthesia to the maxillary division of the trigeminal nerve and loss of sensation on the right half of the upper lip on 10-day review. Results: MRI of the brain and brain stem found a space-occupying lesion at the CPA that was mostly