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Necrotizing Sialometaplasia: Report of an Ulcerative Case
C L IN IC A L
REPORTS
absorption of nitroglycerin through the skin of the hands of persons en gaged in the m anufacture or handling of nitroglycerin, is am ple evidence of the pharm acologic potency of nitro glycerin.910 The nitroglycerin causes an increase in intracranial pressure w hen the blood vessels dilate against the cpnfining bony cranial vault. The patient whose case is reported h a d no h is to r y of b le e d in g i r regularities; th e d en tal p ractitio n er had, in fact, extracted several teeth for the patient before the m yocardial in farction w ithout incident. The accu racy of the previous m edical labora tory test for prothrom bin level was rechecked, and found precise. The expi ration of the effect of th e epinephrine in the local anesthesia was considered as a factor, but discounted as a cause of the hem orrhage because of the u n in terrupted sym ptom s of anesthesia, and because the onset of bleeding was so sudden.
Summary A case of hem orrhage of the tooth socket, p o ssibly in d u c e d by n itro g ly c e rin , has b een p re se n te d . A l though physiological evidence in this case strongly suggests nitroglycerin as a factor in the bleeding, any conclu sions drawn from this report m ust be speculative; additional investigation m ust be done before the theory that nitroglycerin induces hem orrhage can be substantiated. The blood-clotting m echanism is delicate and com plex,11 and the use of nitroglycerin tablets by p a tie n ts im m ed iately after surgery should be restricted. The dental practi tioner should be aware of the danger of hem orrhage and be prepared to react in such an emergency.
The authors thank Dr. A nthony G. W esson for his help. Dr. M anne is associate p rofessor, an d Dr. Kramer is instructor, New York University Dental Center, M odule 2 B, 342 E 24th St, New York,
10010. A d d re ss req u e sts for re p rin ts to Dr. Manne. 1. Wood, N., and Goaz, P. Differential diag nosis of oral lesion, St. Louis, C. V. Mosby Co., 1975, p 13. 2. Physician’s desk reference, ed 33. Oradell, NJ, M edical Economics Co., 1979, p 1390. 3. P hysician’s desk reference, ed 30. Oradell, NJ, M edical Economics Co., 1976, pp 933-944. 4. Seegers, W. (ed.). Blood clotting enzymology. New York, A cademic Press, 1967, p 2. 5. G oodm an, L., and G ilm an, A. T he p har m acological basis of therapeutics, ed 4. London, MacMillan P ublishing Co., 1970, pp 746-747. 6. Fam, W., and McGregor, M. Effect of nitro glycerin and dipridam ole in regional vascular re sistance. Circ Res 22:649-659,1964. 7. M ason, P., and Braunwald, E. The effects of nitroglycerin and amyl nitrite in arteriolar and venous tone in the hum an circulation. Circ Res 32:755-766, 1965. 8. Neidle, E., and others (eds.). Pharmacology and therapeutics for dentistry. St. Louis, C. V. Mosby Co., 1980, p 429. 9. Hogstecht, C., and others. Nitroglycerin ex p o su re in d y n a m ite w o rk ers. J O ccu p M ed 19(10):675-680, 1973. 10. Schwartz, A. The cause, relief and preven tion of headache arising from contact w ith dyna mite. N Engl J Med 235(15):541-544,1946. 11. L eh rer, T ., an d L obichevsky, N. T he b lood-clotting m echanism . Hem Res 5:11361139,1968.
Necrotizing sialometaplasia: report of an ulcerative case
Howard Birkholz, DDS Carl L. Brownd, DDS
A case is reported o f necrotizing sialom etaplasia, a benign condition that is often m isdiagnosed, m ainly affecting the m inor salivary glands.
N
ecrotizing sialom etaplasia is a self-lim iting, variably ulcerated, be n ig n d is e a s e p ro c e s s in v o lv in g , prim arily, the m inor salivary glands. A bram s1 first described this lesion in 1973, and it has since been reported by m any authors. It m ost frequently oc 48 ■ JADA, Vol. 103, July 1981
curs in the palate, but cases have been reported involving the nasopharynx,2 lip ,3 retromolar pad,4 and major sali vary glands.5 The lesion has been m is diagnosed as m ucoepiderm oid and squamous cell carcinom a because of the histologic findings and the sever ity of ulceration and tissue destruction over a relatively short period. The re sem blance to a m alignant process and re su ltin g m isd iagnosis have som e tim es led to u n n e c e ssa ry su rg ica l tre a tm e n t. A case of n e c ro tiz in g sialom etaplasia of the hard palate is d e s c rib e d , in w h ic h su rg e ry w as avoided because of the ap p aren tly spontaneous resolution of the lesion.
Report of case A 41 -year-old w hite m an w as referred to the hospital on A pril 26, 1978, because of an
u lcer on the palate. It had been noticed two weeks previously and had not changed in size. The patient was not able to w ear his dentures because of the painful ulceration. His history disclosed th at he underw ent a craniotom y and clipping of a left internal carotid artery aneurysm in July 1971. He had had a su d d en subarachnoid hem or rhage from this u n su sp ected aneurysm . Postoperatively, there was a residual right hem iplegia, a dense aphasia, and obtunded level of consciousness, after w hich his physical and m ental status rem ained rela tively unchanged; he was occasionally re sponsive to verbal stim uli. In February 1973, his teeth were extracted because of severe caries; a deeply im pacted maxillary third m olar was not removed. The patient was then able to w ear dentures satisfactor ily. Physical exam ination show ed a wellnourished, edentulous w hite m an w ho was confined to a w heelchair. He was com pletely aphasic and had severe bilateral and
C L IN IC A L
upper and low er extremity flexion contrac tures. On the posterior left side of the hard palate, there was an ulcer 2 cm in diameter, w ith raised borders (Fig 1). The surround ing tissue was inflam ed and indurated. Im m ediately lateral to this, was a partially erupted third molar. There were no palpa ble nodes, and radiographic exam ination disclosed norm al underlying bony archi tecture. Laboratory results w ere w ith in norm al limits. A n incisional biopsy was done, w ith a tentative diagnosis of squam ous cell car cinoma. Because of the unknow n duration, necrotizing sialom etaplasia was also con sidered. A histopathologic diagnosis of in vasive squam ous cell carcinoma was re ported. A dditional surgery, consisting of a w ide resection of soft tissue and bony hard palate, was planned. By the day of surgery, the lesion had de creased significantly in size (Fig 2). The in flam m ation had subsided, and the lesion appeared to be healing spontaneously. Be cause of the serious diagnosis, it was de cided to do a soft tissue excision dow n to the bone and remove the im pacted molar. T his w as perform ed w ithou t com plica tions, and a soft liner was placed in the den ture. Healing was uncom plicated, and the defect gradually filled in. A photograph taken six m onths later shows that this area healed well (Fig 3). After 14 m onths, there has been no evidence of residual disease or recurrence.
Fig 3 ■ Photograph of p a l ate six m onths later show s com plete healing of area. Residual defect is also evi dent from extraction of th ird m olar.
H is to p a th o lo g y The specim en from the hard palate was fixed in 10% buffered formalin and pro cessed by standard m ethods. Microscopic e x a m in a tio n s h o w e d fo c a l p s e u d o epitheliom atous hyperplasia of the mucosa w ith necrosis of the m inor salivary glands in the underlying tissue (Fig 4). There was distinct squam ous metaplasia of the ducts and a chronic inflammatory reaction in the su p p o rtin g stro m a (Fig 5). T he b a sic patho lo g ic fin d in g s ap p eared to be in flammatory reaction, necrosis of the m inor salivary g land lobules, an d sig n ifican t squam ous metaplasia of the various-sized ducts.
Discussion
Fig 1 ■ Preoperative photograph of p alatal le sion and p artially erupting m axillary left third m olar in buccal version.
Fig 2 ■ P reoperative photograph of resolving p alatal lesion three weeks after incisional bi opsy.
REPO RTS
Currently, there have been fewer than 60 cases of necrotizing sialometaplasia in the literature.1 12 It m ust be em phasized that it is a self-limiting dis ease, and a diagnostic biopsy and care ful follow-up are the only treatm ent necessary. The patients involved with this disease range in age from 18 to 68 years and have various sym ptom s.7Al th o u g h it is m ore prevalent in the white, m iddle-aged man, the patient sam ple is not large enough to draw conclusive evidence. The etiology remains obscure. Even though there is a liberal blood supply to the areas most commonly affected, many authors have suggested a com prom ise of this blood supply, either m echanical, chem ical, or traum atic. Atherosclerosis has been proposed as a contributing factor, as has the ulcera tive or term inal stage of leukokeratosis nicotine palati. Coincidental findings of alcohol or drug abuse, smoking, and d iab etes m e llitu s have been m e n tioned. In the case presented, it can be postulated that the im pingem ent of the denture on the partially erupted third m olar compromised the blood supply,
resulting in necrotizing sialom etap lasia. The condition is characterized m icroscopically by the presence of lobular necrosis, bland nuclear m or p h o lo g y , sq u am o u s m e ta p la sia of ducts and m ucinous acini, prom inent granulation tissue and inflam m ation and, especially, m aintenance of lobu lar m orphology.6 The usual clinical appearance is a deep, irregular ulcer of the hard palate, 1 to 3 cm in diameter, that may be bilateral. It may also ap pear as a n o n u lc erated h y p erem ic m ucosal elevation. It is unlikely that this is a new dis ease process; it may be a recent recog nition of a process previously diag nosed as low-grade m ucoepidem oid carcinoma or other neoplastic lesions. In the past, even a biopsy of these may not have resulted in a specific diag nosis of necrotizing sialometaplasia. W hen the c o n d itio n reso lv ed , the clinician and pathologist may not have pursued the investigation further and, therefore, no specific diagnosis of nec rotizing sialom etaplasia w ould have been made. In this era w hen fear of cancer is prevalent, caution in diag nosis and restraint in treatm ent are es sential for the proper m anagem ent of this benign disease process.
Summary A report of an ulcerative case of nec rotizing sialom etaplasia of the hard palate is presented. Initially, the diag nosis w as reported as an invasive squam ous cell carcinoma. At the time of surgery, the size of the ulceration had decreased, and extensive surgery was delayed. An additional biopsy and a review of the results of original bi opsy show ed them to be consistent w ith necrotizing sialometaplasia. This benign disease process resolves spon-
B irkholz-B row nd : NECROTIZING SIALOMETAPLASIA ■ 49
Fig 4 ■ Photomicrograph shows pseudoepitheliomatous hyperplasia of mucosa (top left) and necrotic lobule of minor salivary gland (bottom right) (hematoxylin and eosin, original magnification x 100).
taneously in three to ten weeks, and the only treatm ent required is a diag nostic biopsy.
Dr. Birkholz is staff dentist, Olin E. Teague Vet eran s’ Center, Tem ple, Tex 76501; Dr. Brownd, form erly general practice resident in dentistry, Olin E. Teague V eterans’ Center, is currently a first-year resident in prosthodontics, University of Texas Health Sciences Center at San Antonio. A ddress requests for reprints to Dr. Birkholz. 1. Abram s, A.M.; M elrose, R.J.; and Howell, F.V. N ecro tizin g sia lo m etap la sia. A d ise ase sim ulating m alignancy. Cancer 32:130-135,1973.
Fig 5 ■ Photomicrograph shows squamous metaplasia of ducts with inflammatory reaction (hematoxylin and eosin, original magnification x 200).
2. M a isel, R .H ., a n d o th e rs. N e c ro tiz in g s ia lo m e ta p la sia in v o lv in g th e n asal cavity. Laryngoscope 87(3):429-434, 1977. 3. M a tilla , A ., a n d o th e r s . N e c r o tiz in g sialom etaplasia affecting the m inor labial glands. Oral Surg 47(2):161-163,1979. 4. F o rn e y , S.K., an d o th e rs. N e c ro tiz in g sia lo m e ta p la sia of th e m an d ib le. O ral S urg 43(5):720-726, 1977. 5. Batsakis, J.G. Letter: Sialom etaplasia. Arch Otolaryngol 102(3):191, 1976. 6. L ynch, D.P.; Crago, C.A.; and M artinez, M.G., Jr. Necrotizing sialom etaplasia. A review of the literature and report of 2 additional cases. Oral Surg 47(l):63-69, 1979. 7. Birkholz, H.; M inton, G.A.; and Yuen, Y.L. Necrotizing sialom etaplasia: review of the litera
ture and report of nonulcerative case. J Oral Surg 37(8):588-592, 1979. 8. W lodarkiewicz, A. Necrotizing m etaplasia of salivary glands of hard palate. Czas Stomatol 31(7):629-633, 1978. 9. Sparks, R.P., and D uncan, D.G. Necrotizing sialom etaplasia. A self-lim ited pseudotum oral palatal ulcer. A nn Otol Rhinol Laryngol, 87(3 Pt 1):409-411, 1978. 10. Suckiel, J.M., and others. Early and late m anifestations of necrotizing sialom etaplasia. J Oral Surg 36(11):902-905,1978. 11. Dunley, R.E., and Jacoway, J.R. Necrotizing sialom etaplasia. Oral Surg 47(2):169-172,1979. 12. Samit, A.M.; M ashberg, A.; and Greene, G.W., Jr. Necrotizing sialom etaplasia. J Oral Surg 37(5):353-356, 1979.
Hypoxic encephalopathy after the administration of alphaprodine hydrochloride D avid M. O kuji, DDS
The adverse reaction of a 34-month-old boy to alphaprodine hydrochloride, adm inistered for dental surgery, is described, and the literature is reviewed.
A
.dverse reactions resulting from the a d m in istratio n of a th erap eu tic agent are of concern to all dental pro fessionals. It is im portant, therefore, that reports of adverse reactions be ad dressed to the profession. The follow
50 ■ JADA, Vol. 103, July 1981
ing report describes the case of a 34m onth-old boy who was adm itted to the hospital for rehabilitative therapy. Hypoxic encephalopathy after receiv ing alphaprodine hydrochloride was diagnosed. This report reviews the lit erature pertinent to this case and de scribes the events and circum stances that led to the p atien t’s condition. R e v ie w o f the literature A lp h a p r o d in e h y d r o c h lo r id e is a s y n th e tic , n a rc o tic analgesic that is rapid-acting and of H IS T O R Y .
short duration.1 It was first synthe sized in 1947 by Ziering and Lee.2 Its clinical use was initially applied, in 1949, in obstetric m edicine.3,4 After 1950, the sedative and analgesic ef fects of alphaprodine were applied in anesthesia, pulm onary m edicine, and urology.5'7 Its application in dentistry was first described by DeLapa,8 who studied its influence on intravenous b a rb itu rate in d u c tio n in a d u lt p a tients. Burbank9 and Shane10 also de scrib ed d e n tal an e sth esia-am n esia produced by intravenous adm inistra tion of alphaprodine. An early report
REPORTS
absorption of nitroglycerin through the skin of the hands of persons en gaged in the m anufacture or handling of nitroglycerin, is am ple evidence of the pharm acologic potency of nitro glycerin.910 The nitroglycerin causes an increase in intracranial pressure w hen the blood vessels dilate against the cpnfining bony cranial vault. The patient whose case is reported h a d no h is to r y of b le e d in g i r regularities; th e d en tal p ractitio n er had, in fact, extracted several teeth for the patient before the m yocardial in farction w ithout incident. The accu racy of the previous m edical labora tory test for prothrom bin level was rechecked, and found precise. The expi ration of the effect of th e epinephrine in the local anesthesia was considered as a factor, but discounted as a cause of the hem orrhage because of the u n in terrupted sym ptom s of anesthesia, and because the onset of bleeding was so sudden.
Summary A case of hem orrhage of the tooth socket, p o ssibly in d u c e d by n itro g ly c e rin , has b een p re se n te d . A l though physiological evidence in this case strongly suggests nitroglycerin as a factor in the bleeding, any conclu sions drawn from this report m ust be speculative; additional investigation m ust be done before the theory that nitroglycerin induces hem orrhage can be substantiated. The blood-clotting m echanism is delicate and com plex,11 and the use of nitroglycerin tablets by p a tie n ts im m ed iately after surgery should be restricted. The dental practi tioner should be aware of the danger of hem orrhage and be prepared to react in such an emergency.
The authors thank Dr. A nthony G. W esson for his help. Dr. M anne is associate p rofessor, an d Dr. Kramer is instructor, New York University Dental Center, M odule 2 B, 342 E 24th St, New York,
10010. A d d re ss req u e sts for re p rin ts to Dr. Manne. 1. Wood, N., and Goaz, P. Differential diag nosis of oral lesion, St. Louis, C. V. Mosby Co., 1975, p 13. 2. Physician’s desk reference, ed 33. Oradell, NJ, M edical Economics Co., 1979, p 1390. 3. P hysician’s desk reference, ed 30. Oradell, NJ, M edical Economics Co., 1976, pp 933-944. 4. Seegers, W. (ed.). Blood clotting enzymology. New York, A cademic Press, 1967, p 2. 5. G oodm an, L., and G ilm an, A. T he p har m acological basis of therapeutics, ed 4. London, MacMillan P ublishing Co., 1970, pp 746-747. 6. Fam, W., and McGregor, M. Effect of nitro glycerin and dipridam ole in regional vascular re sistance. Circ Res 22:649-659,1964. 7. M ason, P., and Braunwald, E. The effects of nitroglycerin and amyl nitrite in arteriolar and venous tone in the hum an circulation. Circ Res 32:755-766, 1965. 8. Neidle, E., and others (eds.). Pharmacology and therapeutics for dentistry. St. Louis, C. V. Mosby Co., 1980, p 429. 9. Hogstecht, C., and others. Nitroglycerin ex p o su re in d y n a m ite w o rk ers. J O ccu p M ed 19(10):675-680, 1973. 10. Schwartz, A. The cause, relief and preven tion of headache arising from contact w ith dyna mite. N Engl J Med 235(15):541-544,1946. 11. L eh rer, T ., an d L obichevsky, N. T he b lood-clotting m echanism . Hem Res 5:11361139,1968.
Necrotizing sialometaplasia: report of an ulcerative case
Howard Birkholz, DDS Carl L. Brownd, DDS
A case is reported o f necrotizing sialom etaplasia, a benign condition that is often m isdiagnosed, m ainly affecting the m inor salivary glands.
N
ecrotizing sialom etaplasia is a self-lim iting, variably ulcerated, be n ig n d is e a s e p ro c e s s in v o lv in g , prim arily, the m inor salivary glands. A bram s1 first described this lesion in 1973, and it has since been reported by m any authors. It m ost frequently oc 48 ■ JADA, Vol. 103, July 1981
curs in the palate, but cases have been reported involving the nasopharynx,2 lip ,3 retromolar pad,4 and major sali vary glands.5 The lesion has been m is diagnosed as m ucoepiderm oid and squamous cell carcinom a because of the histologic findings and the sever ity of ulceration and tissue destruction over a relatively short period. The re sem blance to a m alignant process and re su ltin g m isd iagnosis have som e tim es led to u n n e c e ssa ry su rg ica l tre a tm e n t. A case of n e c ro tiz in g sialom etaplasia of the hard palate is d e s c rib e d , in w h ic h su rg e ry w as avoided because of the ap p aren tly spontaneous resolution of the lesion.
Report of case A 41 -year-old w hite m an w as referred to the hospital on A pril 26, 1978, because of an
u lcer on the palate. It had been noticed two weeks previously and had not changed in size. The patient was not able to w ear his dentures because of the painful ulceration. His history disclosed th at he underw ent a craniotom y and clipping of a left internal carotid artery aneurysm in July 1971. He had had a su d d en subarachnoid hem or rhage from this u n su sp ected aneurysm . Postoperatively, there was a residual right hem iplegia, a dense aphasia, and obtunded level of consciousness, after w hich his physical and m ental status rem ained rela tively unchanged; he was occasionally re sponsive to verbal stim uli. In February 1973, his teeth were extracted because of severe caries; a deeply im pacted maxillary third m olar was not removed. The patient was then able to w ear dentures satisfactor ily. Physical exam ination show ed a wellnourished, edentulous w hite m an w ho was confined to a w heelchair. He was com pletely aphasic and had severe bilateral and
C L IN IC A L
upper and low er extremity flexion contrac tures. On the posterior left side of the hard palate, there was an ulcer 2 cm in diameter, w ith raised borders (Fig 1). The surround ing tissue was inflam ed and indurated. Im m ediately lateral to this, was a partially erupted third molar. There were no palpa ble nodes, and radiographic exam ination disclosed norm al underlying bony archi tecture. Laboratory results w ere w ith in norm al limits. A n incisional biopsy was done, w ith a tentative diagnosis of squam ous cell car cinoma. Because of the unknow n duration, necrotizing sialom etaplasia was also con sidered. A histopathologic diagnosis of in vasive squam ous cell carcinoma was re ported. A dditional surgery, consisting of a w ide resection of soft tissue and bony hard palate, was planned. By the day of surgery, the lesion had de creased significantly in size (Fig 2). The in flam m ation had subsided, and the lesion appeared to be healing spontaneously. Be cause of the serious diagnosis, it was de cided to do a soft tissue excision dow n to the bone and remove the im pacted molar. T his w as perform ed w ithou t com plica tions, and a soft liner was placed in the den ture. Healing was uncom plicated, and the defect gradually filled in. A photograph taken six m onths later shows that this area healed well (Fig 3). After 14 m onths, there has been no evidence of residual disease or recurrence.
Fig 3 ■ Photograph of p a l ate six m onths later show s com plete healing of area. Residual defect is also evi dent from extraction of th ird m olar.
H is to p a th o lo g y The specim en from the hard palate was fixed in 10% buffered formalin and pro cessed by standard m ethods. Microscopic e x a m in a tio n s h o w e d fo c a l p s e u d o epitheliom atous hyperplasia of the mucosa w ith necrosis of the m inor salivary glands in the underlying tissue (Fig 4). There was distinct squam ous metaplasia of the ducts and a chronic inflammatory reaction in the su p p o rtin g stro m a (Fig 5). T he b a sic patho lo g ic fin d in g s ap p eared to be in flammatory reaction, necrosis of the m inor salivary g land lobules, an d sig n ifican t squam ous metaplasia of the various-sized ducts.
Discussion
Fig 1 ■ Preoperative photograph of p alatal le sion and p artially erupting m axillary left third m olar in buccal version.
Fig 2 ■ P reoperative photograph of resolving p alatal lesion three weeks after incisional bi opsy.
REPO RTS
Currently, there have been fewer than 60 cases of necrotizing sialometaplasia in the literature.1 12 It m ust be em phasized that it is a self-limiting dis ease, and a diagnostic biopsy and care ful follow-up are the only treatm ent necessary. The patients involved with this disease range in age from 18 to 68 years and have various sym ptom s.7Al th o u g h it is m ore prevalent in the white, m iddle-aged man, the patient sam ple is not large enough to draw conclusive evidence. The etiology remains obscure. Even though there is a liberal blood supply to the areas most commonly affected, many authors have suggested a com prom ise of this blood supply, either m echanical, chem ical, or traum atic. Atherosclerosis has been proposed as a contributing factor, as has the ulcera tive or term inal stage of leukokeratosis nicotine palati. Coincidental findings of alcohol or drug abuse, smoking, and d iab etes m e llitu s have been m e n tioned. In the case presented, it can be postulated that the im pingem ent of the denture on the partially erupted third m olar compromised the blood supply,
resulting in necrotizing sialom etap lasia. The condition is characterized m icroscopically by the presence of lobular necrosis, bland nuclear m or p h o lo g y , sq u am o u s m e ta p la sia of ducts and m ucinous acini, prom inent granulation tissue and inflam m ation and, especially, m aintenance of lobu lar m orphology.6 The usual clinical appearance is a deep, irregular ulcer of the hard palate, 1 to 3 cm in diameter, that may be bilateral. It may also ap pear as a n o n u lc erated h y p erem ic m ucosal elevation. It is unlikely that this is a new dis ease process; it may be a recent recog nition of a process previously diag nosed as low-grade m ucoepidem oid carcinoma or other neoplastic lesions. In the past, even a biopsy of these may not have resulted in a specific diag nosis of necrotizing sialometaplasia. W hen the c o n d itio n reso lv ed , the clinician and pathologist may not have pursued the investigation further and, therefore, no specific diagnosis of nec rotizing sialom etaplasia w ould have been made. In this era w hen fear of cancer is prevalent, caution in diag nosis and restraint in treatm ent are es sential for the proper m anagem ent of this benign disease process.
Summary A report of an ulcerative case of nec rotizing sialom etaplasia of the hard palate is presented. Initially, the diag nosis w as reported as an invasive squam ous cell carcinoma. At the time of surgery, the size of the ulceration had decreased, and extensive surgery was delayed. An additional biopsy and a review of the results of original bi opsy show ed them to be consistent w ith necrotizing sialometaplasia. This benign disease process resolves spon-
B irkholz-B row nd : NECROTIZING SIALOMETAPLASIA ■ 49
Fig 4 ■ Photomicrograph shows pseudoepitheliomatous hyperplasia of mucosa (top left) and necrotic lobule of minor salivary gland (bottom right) (hematoxylin and eosin, original magnification x 100).
taneously in three to ten weeks, and the only treatm ent required is a diag nostic biopsy.
Dr. Birkholz is staff dentist, Olin E. Teague Vet eran s’ Center, Tem ple, Tex 76501; Dr. Brownd, form erly general practice resident in dentistry, Olin E. Teague V eterans’ Center, is currently a first-year resident in prosthodontics, University of Texas Health Sciences Center at San Antonio. A ddress requests for reprints to Dr. Birkholz. 1. Abram s, A.M.; M elrose, R.J.; and Howell, F.V. N ecro tizin g sia lo m etap la sia. A d ise ase sim ulating m alignancy. Cancer 32:130-135,1973.
Fig 5 ■ Photomicrograph shows squamous metaplasia of ducts with inflammatory reaction (hematoxylin and eosin, original magnification x 200).
2. M a isel, R .H ., a n d o th e rs. N e c ro tiz in g s ia lo m e ta p la sia in v o lv in g th e n asal cavity. Laryngoscope 87(3):429-434, 1977. 3. M a tilla , A ., a n d o th e r s . N e c r o tiz in g sialom etaplasia affecting the m inor labial glands. Oral Surg 47(2):161-163,1979. 4. F o rn e y , S.K., an d o th e rs. N e c ro tiz in g sia lo m e ta p la sia of th e m an d ib le. O ral S urg 43(5):720-726, 1977. 5. Batsakis, J.G. Letter: Sialom etaplasia. Arch Otolaryngol 102(3):191, 1976. 6. L ynch, D.P.; Crago, C.A.; and M artinez, M.G., Jr. Necrotizing sialom etaplasia. A review of the literature and report of 2 additional cases. Oral Surg 47(l):63-69, 1979. 7. Birkholz, H.; M inton, G.A.; and Yuen, Y.L. Necrotizing sialom etaplasia: review of the litera
ture and report of nonulcerative case. J Oral Surg 37(8):588-592, 1979. 8. W lodarkiewicz, A. Necrotizing m etaplasia of salivary glands of hard palate. Czas Stomatol 31(7):629-633, 1978. 9. Sparks, R.P., and D uncan, D.G. Necrotizing sialom etaplasia. A self-lim ited pseudotum oral palatal ulcer. A nn Otol Rhinol Laryngol, 87(3 Pt 1):409-411, 1978. 10. Suckiel, J.M., and others. Early and late m anifestations of necrotizing sialom etaplasia. J Oral Surg 36(11):902-905,1978. 11. Dunley, R.E., and Jacoway, J.R. Necrotizing sialom etaplasia. Oral Surg 47(2):169-172,1979. 12. Samit, A.M.; M ashberg, A.; and Greene, G.W., Jr. Necrotizing sialom etaplasia. J Oral Surg 37(5):353-356, 1979.
Hypoxic encephalopathy after the administration of alphaprodine hydrochloride D avid M. O kuji, DDS
The adverse reaction of a 34-month-old boy to alphaprodine hydrochloride, adm inistered for dental surgery, is described, and the literature is reviewed.
A
.dverse reactions resulting from the a d m in istratio n of a th erap eu tic agent are of concern to all dental pro fessionals. It is im portant, therefore, that reports of adverse reactions be ad dressed to the profession. The follow
50 ■ JADA, Vol. 103, July 1981
ing report describes the case of a 34m onth-old boy who was adm itted to the hospital for rehabilitative therapy. Hypoxic encephalopathy after receiv ing alphaprodine hydrochloride was diagnosed. This report reviews the lit erature pertinent to this case and de scribes the events and circum stances that led to the p atien t’s condition. R e v ie w o f the literature A lp h a p r o d in e h y d r o c h lo r id e is a s y n th e tic , n a rc o tic analgesic that is rapid-acting and of H IS T O R Y .
short duration.1 It was first synthe sized in 1947 by Ziering and Lee.2 Its clinical use was initially applied, in 1949, in obstetric m edicine.3,4 After 1950, the sedative and analgesic ef fects of alphaprodine were applied in anesthesia, pulm onary m edicine, and urology.5'7 Its application in dentistry was first described by DeLapa,8 who studied its influence on intravenous b a rb itu rate in d u c tio n in a d u lt p a tients. Burbank9 and Shane10 also de scrib ed d e n tal an e sth esia-am n esia produced by intravenous adm inistra tion of alphaprodine. An early report