I before E, especially after T

J Oral

Maxillofac 1999

Surg

.57:2 19,

CLARIFICATIONOF DIAGNOSTIC CRITERIA FOR AMELOBLASTICFIBROMA To the Editor-The case report of Kusama et al entitled “Peripheral Ameloblastic Fibroma of the Mandible: Report of a Case” in the March 1998 issue’ describes a peripheral gingival mass in a 4@year-old woman consisting of cellular fibromatous tissue and strands and/or islands of odontogenic epithelium. However, their description and illustrations are much more suggestive of odontogenic fibroma (OF) than ameloblastic fibroma (AF). Naturally, the presence of large amounts of nonactive odontogenic epithelium in a peripheral OF is to be expected.” The epithelial components in AF are apparently more active, and are composed of a peripheral layer of columnar cells that may enclose a variable number of cells resembling stellate reticulum6; most of them exhibit classic Vickers and Gorlin criterza for the diagnosis of ameloblastoma.7 In contrast to OF, the connective tissue components in AF are characterized by an embryonic, cell-rich fibromyxoid mesenchyme suggestive of dental papilla? This immature stroma should be sufficient to distinguish the AF from OF. Such a pathognomonic finding was not seen in their photomicrogmphs. Therefore, we believe that their case is, in fact, an example of peripheral OF (World Health Organization type) with a high odontogenic epithelial compo nent.>s Tmuo

DDS, PhD NORIOHORIE,DDS, PhD FUMIO bE, DDS, PhD Saitama, Japan

In Re$+-Drs Shimoyama, Hone, and Ide point out that our first case1 is an example of peripheral odontogenic fibroma (OF) with a high odontogenic epithelial component rather than peripheral ameloblastic fibroma (AP), because the epithelial components are apparently more active and the connective tissue components are characterized by an embryonic, cell-rich, fibromyxoid mesenchyme resembling dental papilla, in contrast to OF. In the recent World Health Organization classification of odontogenic tumors,2 the OF is defined as a fibroblastic neoplasm containing varying amounts of apparently inactive odontogenic epithelium. Regarding the peripheral OF, it is mentioned that sometimes the proliferation of odontogenic epithelium is so marked that it may be diflicult to distinguish the lesion from a peripheral ameloblastoma.2 According to the present classification by the World Health Organization, the histologic diagnosis for our case may be peripheral OF. However, the lesion was histologically composed of a cell-rich mesenchy ma1 tissue resembling the dental papilla or dental follicle, admixed with proliferating active odontogenic epithelium. These findings suggest that it should be considered a true mixed tumor in which the epithelial and mesenchymal elements are both neoplastic, and not an OF containing inactive odontogenic epithelium. KAORU

SHIMOYAMA,

References K, Miyake M, Moro I: Peripheral ameloblastic fibroma of the mandible: Report of a case.J Oral Maxillofac Surg 56:399,1998

1. Kmama

2. Gardner DG: The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Path01 54:40, 1982 3. Buchner A, Ficarra G, Hansen LS: Peripheral odontogenic fibroma. Oral Surg Oral Med Oral Path01 64:432, 1987 4. de Vllers Slabbert H, Altini M: Peripheral odontogenlc fibroma: A clinicopathologic study. Oral Surg Oral Med Oral Path01 72:86, 1991 5. Daley TD, Wysocki GP: Peripheral odontogenic tibroma. Oral Surg Oral Med Oral Path01 78:329,1994 6. Philipsen HP, Reichart PA, Praetorius F: Mixed odontogenic tumours and odontomas. Considerations on interrelationship. Review of the literature and presentation of 134 new cases of odontomas. Oral Oncol33:86, 1997 7. Vickers RA, Gorlin RJ: Ameloblastoma: Delineation of early histopathologic features of neoplasia. Cancer 26:699, 1970

KUSAMA, DDS, PhD Tokyo, Japan

References 1. Kusama K, Miyake M, Moro I: Peripheral ameloblastic fibroma of the mandible: Report of a case. J Oral Maxillofac Surg 56399,199s 2. Kramer IRH, Pindborg JJ, Shear M: Histological Typing of Odontogenic Tumours (ed 2). International Histological Classilication of Tumours, Geneva, Switzerland, World Health Orgamzation, 1992, p 22

I BEFOREE, ESPECIALLY AFTERT To the Editor-1 enjoyed reading the study published by Parworth et al on propofol and fentanyl that appeared in the April 1998 issue (56:453, 1998). I also found Dr Candelaria’s discussion helpful. My criticism relates to two items. My name was mispelled twice in the article and there was no reference to my original article. On the other hand, Dr Candelaria spelled it right but also gave no reference citation. The original article, authored by Newman et al was published in Anesthesia and Analgesia 48:1,136-140, 1969 and it was subsequently published in Anesthesia Progress (Trieger N, Newman MG, Miller JG: An objective measure of recovery. Anesth Prog 16:4, 1969). In regard to the JOMS article, the psychomotor scores were comparable mainly because both the effect of midazolam and propofol has a time-limited influence. If the dot tests were administered earlier than at 45 minutes, greater differences from baseline would have been evident. It should also be noted that low-dose opioids produce very minimal change in this dot test. I agree with Dr Candelaria that adding midazolam to the propofol/fentanyl regimen will provide more desirable sedation than if the drugs are individually titrated, taking advantage of their specific synergistic effects. NORMAN

TRIEGER,

DMD, Bronx,

MD NY