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Squamous cell carcinoma and piercing of the tongue – A case report
Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 329e331
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Case report
Squamous cell carcinoma and piercing of the tongue e A case report Peter Stanko a, *, Dusan Poruban a, Jozef Mracna a, Dusan Holly a, Branislav Janicek a, Zuzana Pinakova b, Miriam Porubska c, Stefan Galbavy d a
Department of Oral and Maxillofacial Surgery Department of Radiotherapy (Head: Dr. Elena c Department of Chemotherapy (Head: Prof. Dr. d Institute of Forensic Medicine (Head: Prof. Dr. b
(Head: Prof. Dr. Vladimir Javorka, CSc), Comenius University, Bratislava, Slovakia Boljesikova, CSc), St Elisabeth Hospital, Bratislava, Slovakia Stanislav Spanik, PhD), St Elisabeth Hospital, Bratislava, Slovakia Stefan Galbavy, PhD, MSc), Comenius University, Bratislava, Slovakia
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 30 July 2010 Accepted 11 May 2011
Tongue piercings can be associated with local and systemic complications. Local complications occur frequently immediately after the surgery but also long-term local effects can cause problems such as speech and swallowing difficulties. Aspiration, transmission of infectious diseases, hypersensitivity reaction belong to the systemic complications. In the presented paper an unusual case of cancer development in a 26-year-old man who had a metal piercing inserted for 5 years in the right anterior third of the tongue. Despite of intense concommitant chemoradiotherapy the patient died 18 months from the first symptoms. In prevention of various complications it would be the best solution spread information about the risks of the tongue piercing especially within teenage population. Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Tongue piercing Complications Squamous cell carcinoma
1. Introduction With respect to jewellery in oral soft tissue lip and tongue piercings are of significance to dentists, oral and maxillofacial surgeons since they can be associated with various local and systemic complications (Garcia-Pola et al., 2008; Jeger et al., 2009; Ziebolz et al., 2009). Local complications occur frequently immediately after the surgery i.e. pain, swelling as well as hemorrhages or haematomas and infections can be observed. Transmission of infectious diseases such as hepatitis B or C, HIV, EBV, tetanus, tuberculosis are also at risk (Hayes and Harkness, 2001; EscuderoCastano et al., 2008). A hypersensitivity reaction to metal in the sense of contact allergy can occur in susceptible people. Long-term local effects can cause problems, e.g. periodontal recession can be discerned mainly in the case of lip piercings (Antoszewski et al. 2009; Vilchez-Perez et al., 2009), the loss of hard tooth substance or broken teeth, speech impediments and swallowing difficulties in the case of tongue piercings. Dangerous breathing problems may occur by aspiration when the barbell comes un-screwed and winds up in a lung. Lethal complications are quite rare. In the presented
* Corresponding author. Department of Stomatology & Maxillofacial Surgery, Comenius University, St Elisabeth Hospital, Heydukova 10, 812 50 Bratislava, Slovakia. Tel./fax: þ421 2 59249 742. E-mail address: [email protected] (P. Stanko).
paper an unusual case of cancer development in the site of tongue piercing is introduced. 2. Case report A 26-year-old man was referred to the Department of Oral and Maxillofacial Surgery with 2 months lasting painful ulcer on right margin of the tongue associated with diminished ability to articulate. He had a metal piercing inserted there 5 years earlier which was removed at start of the pains by his dentist. Regarding abuses he was smoker of 10e15 cigarettes about 8 years. On our evaluation the ulcer revealed size 15 5 mm without bleeding tendency, defect in the piercing insertion site was observable. Because the right first lower molar with large amalgam filling had had lingual inclination an extraction was performed, antibiotics prescribed and patient invited to recall. At second presentation after 3 weeks the ulcer had enlarged and by autofluorescence imaging (Svistun et al., 2004; Lane et al., 2006) a suspicion for cancer was considered. The biopsy confirmed squamous cell carcinoma grading II (Fig. 1). Subsequent sonography of the neck revealed lymph node involvement till 20 mm on the right and till 13 mm on the left side respectively. On CT scans size of the tongue infiltration was 29 19 41 mm (AP LL CC) with small bubbles of unknown origin. The staging T3N1M0 was established and a concommitant external radiotherapy and chemotherapy started immediately. The radiotherapy included LINAC 6 MV X beams to the face and neck in total doses TD ¼ 60 Gy. The used chemotherapy protocol included
1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2011.05.005
330
P. Stanko et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 329e331
metal one. This fact provides a suspicion for participation of possible electrogalvanic potential arising within the metal piercing and the amalgam filling in the close neighbourhood. The negative role of the potentials leading to the malignant transformation during the 5-year period of the piercing wearing can be considered. Unclear remains the rapid progress of the disease. Smoking in the anamnesis was of mild degree and it was stopped immediately after getting the histological result of carcinoma. A previous illegal drug abuse may be on question. An increasing incidence of oral carcinoma among young adults has been reported in the U.S. and Europe (Llewellyn et al., 2004; Shiboski et al., 2005). Although the role of human papillomaviruses is very important (Furniss et al., 2007; Hennessey et al., 2009), in our case the HPV analysis was not performed for technical reasons. 4. Conclusion
Fig. 1. Histology of the squamous cell carcinoma obtained from the suspect region.
three cycles of cisplatin (CDDP doses 40 mg/m2) and five of Erbitux (400 mg/m2 initially, then 4 250 mg/m2). The radiotherapy was interrupted after two cycles of the CDDP and four cycles of the Erbitux due to second-degree radiomucositis. A short temporary partial remission ended by locoregional progression and cachexia. Despite of the intense therapy the patient died 18 months from the first symptoms. 3. Discussion Some studies reported the prevalence of oral piercing ranging from 3.4% to 20.3% (Levin and Zadik, 2007). Among evaluated group of teenage students there was a slight predominance of males (54.55%) compared with females (45.45%), the tongue was the most common location for piercing (66.6%) (Firoozmand et al., 2009). Oral piercings are not a harmless fashion trend. Straight barbells with either plastic or metal beads are commonly worn in tongue piercings. A lack of hygiene with accumulation of plaque may lead to acute deep infections of the tongue (Sands et al., 1993; Fehrenbach, 1998; Olsen, 2001) or chronic infections of the piercing insertion site. A higher susceptibility to mechanical pressure of the mucous membrane than of the skin was observed especially in cases of short barbells. In these situation growth into the soft tissues was published (Jurkovic et al., 1999). Barbells that are too thin are prone to migration, long-term unmentioned playing or suctioning of the piercing results in further mechanical irritation. Because the risk of aspiration is highest by intubation, removal of piercing is recommended before every general anaesthesia (Roth and Plotz, 1998). Rare lethal complication was described as a sequel of severe general herpetic infection (Lakhan and Harle, 2008). Perkins et al. (1997) reported a nonlethal case of Ludwig’s angina in 25-year-old patient due to insertion of the tongue piercing. The treatment included extraoral incision and combined antibiotics. Extubation was performed after several days later due to massive oedema of the tongue and floor of the mouth. Other problems related to tongue piercing include endocarditis (Tronel et al., 2001; Harding et al., 2002) and cerebellar brain abscess (Martinello and Cooney, 2003). In our case the patient could not provide the piercing to an analysis but he confirmed surely that the total material used was
Patients with oral piercing should be regularly followed up by dentists or oral surgeons because of possible development of different types of the adverse effects. In prevention of the complications it would be the best solution to spread information about the risks especially within the teenage population. The tongue piercings are an unnecessary and potentially dangerous surgical procedure that should be avoided. The aim not to insert tongue piercing at all is an ideal one but unexpectable indeed. Conflict of interest None, no support in the form of grants. References Antoszewski B, Szychta P, Fijalkowska M: Are we aware of all complications following body piercing procedures? Int J Dermatol 48(4): 422e425, 2009 Escudero-Castano N, Perea-García MA, Campo-Trapero J, Cano-Sánchez, BasconesMartínez A: Oral and perioral piercing complications. Open Dent J 4(2): 133e136, 2008 Fehrenbach MJ: Tongue piercing and potential oral complications. J Dent Hyg 72: 23e25, 1998 Firoozmand LM, Paschotto DR, Almeida JD: Oral piercing complications among teenage students. Oral Health Prev Dent 7(1): 77e81, 2009 Furniss CS, McClean MD, Smith JF, Bryan J, Nelson HH, Peters ES, et al: Human papillomavirus 16 and head and neck squamous cell carcinoma. Int J Cancer 120: 2386e2392, 2007 Garcia-Pola MJ, Garcia-Martin JM, Varela-Centelles P, Bilbao-Alonso A, CereroLapiedra R, Seoane J: Oral and facial piercing: associated complications and clinical repercussion. Quintessence Int 39(1): 51e59, 2008 Harding PR, Yerkey MW, Deye G, Storey D: Methicillin resistant Staphylococcus aureus (MRSA) endocarditis secondary to tongue piercing. J Miss State Med Assoc 43: 109, 2002 Hayes MO, Harkness GA: Body piercing as a risk factor for viral hepatitis e an integrative research review. Am J Infect Control 29(4): 271e274, 2001 Hennessey PT, Westra WH, Califano JA: Human papillomavirus and head and neck squamous cell carcinoma: recent evidence and clinical implication. J Dent Res 88: 300e306, 2009 Jeger F, Lussi A, Zimmerli B: Oral jewelry: a review. Schweiz Monatsschr Zahnmed 119(6): 615e631, 2009 Jurkovic R, Satko I, Kubisova J: Piercing of the tongue and possible complications. Ces Stomat 99(6): 240e244, 1999 Lakhan SE, Harle L: Fatal fulminant herpes simplex hepatitis secondary to tongue piercing in an immunocompetent adult e a case report. J Med Case Reports 2: 356, 2008 Lane PM, Gilhuly T, Whitehead P, Zeng H, Poh CF, Ng S, et al: Simple device for the direct visualization of oral cavity tissue fluorescence. J Biomed Opt 11: 24006e24007, 2006 Levin L, Zadik Y: Oral piercing: complications and side effects. Am J Dent 20(5): 340e344, 2007 Llewellyn CD, Linklater K, Bell J, Johnson NW, Warnakulasuriya S: An analysis of risk factors for oral cancer in young people: a case-control study. Oral Oncol 40(3): 304e313, 2004 Martinello RA, Cooney EL: Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis 36(2): e32ee34, 2003 Olsen JC: Lingual abscess secondary to body piercing. J Emerg Med 20: 409, 2001 Perkins CS, Meisner J, Harrison JM: A complication of tongue piercing. Br Dent J 182(4): 147e148, 1997
P. Stanko et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 329e331 Roth R, Plotz J: Zungenpiercing (Ein Modenphänomen nicht ohne anästhesiologische Bedeutung). Anaesthetist 47(8): 690e691, 1998 Sands M, Pepe J, Brown RB: Tongue abscess e case report and review. Clin Infect Dis 16: 133e135, 1993 Shiboski CH, Schmidt BL, Jordan RCK: Tongue and tonsil carcinoma. Increasing trends in the U.S. population ages 20e44 years. Cancer 103: 1843e1849, 2005 Svistun E, Alizadeh-Naderi R, El-Naggar A, Jacob R, Gillenwater A, RichardsKortum R: Vision enhancement system for detection of oral cavity neoplasia based on autofluorescence. Head Neck 26(3): 205e215, 2004
331
Tronel H, Chaudemanche H, Pechier N, Doutrelant L, Hoen B: Endocarditis due to Neisseria mucosa after tongue piercing. Clin Microbiol Infect 7: 275e276, 2001 Vilchez-Perez MA, Fuster-Torres MA, Figueiredo R, Valmaseda-Castellón E, GayEscoda C: Periodontal health and lateral lower lip piercings e a split-mouth cross-sectional study. J Clin Periodontol 36(7): 558e563, 2009 Ziebolz D, Stuehmer C, van Nüss K, Hornecker E, Mausberg RF: Complications of tongue piercing e a review of the literature and three case reports. J Contemp Dent Pract 10(6): 1065e1071, 2009
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Case report
Squamous cell carcinoma and piercing of the tongue e A case report Peter Stanko a, *, Dusan Poruban a, Jozef Mracna a, Dusan Holly a, Branislav Janicek a, Zuzana Pinakova b, Miriam Porubska c, Stefan Galbavy d a
Department of Oral and Maxillofacial Surgery Department of Radiotherapy (Head: Dr. Elena c Department of Chemotherapy (Head: Prof. Dr. d Institute of Forensic Medicine (Head: Prof. Dr. b
(Head: Prof. Dr. Vladimir Javorka, CSc), Comenius University, Bratislava, Slovakia Boljesikova, CSc), St Elisabeth Hospital, Bratislava, Slovakia Stanislav Spanik, PhD), St Elisabeth Hospital, Bratislava, Slovakia Stefan Galbavy, PhD, MSc), Comenius University, Bratislava, Slovakia
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 30 July 2010 Accepted 11 May 2011
Tongue piercings can be associated with local and systemic complications. Local complications occur frequently immediately after the surgery but also long-term local effects can cause problems such as speech and swallowing difficulties. Aspiration, transmission of infectious diseases, hypersensitivity reaction belong to the systemic complications. In the presented paper an unusual case of cancer development in a 26-year-old man who had a metal piercing inserted for 5 years in the right anterior third of the tongue. Despite of intense concommitant chemoradiotherapy the patient died 18 months from the first symptoms. In prevention of various complications it would be the best solution spread information about the risks of the tongue piercing especially within teenage population. Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Tongue piercing Complications Squamous cell carcinoma
1. Introduction With respect to jewellery in oral soft tissue lip and tongue piercings are of significance to dentists, oral and maxillofacial surgeons since they can be associated with various local and systemic complications (Garcia-Pola et al., 2008; Jeger et al., 2009; Ziebolz et al., 2009). Local complications occur frequently immediately after the surgery i.e. pain, swelling as well as hemorrhages or haematomas and infections can be observed. Transmission of infectious diseases such as hepatitis B or C, HIV, EBV, tetanus, tuberculosis are also at risk (Hayes and Harkness, 2001; EscuderoCastano et al., 2008). A hypersensitivity reaction to metal in the sense of contact allergy can occur in susceptible people. Long-term local effects can cause problems, e.g. periodontal recession can be discerned mainly in the case of lip piercings (Antoszewski et al. 2009; Vilchez-Perez et al., 2009), the loss of hard tooth substance or broken teeth, speech impediments and swallowing difficulties in the case of tongue piercings. Dangerous breathing problems may occur by aspiration when the barbell comes un-screwed and winds up in a lung. Lethal complications are quite rare. In the presented
* Corresponding author. Department of Stomatology & Maxillofacial Surgery, Comenius University, St Elisabeth Hospital, Heydukova 10, 812 50 Bratislava, Slovakia. Tel./fax: þ421 2 59249 742. E-mail address: [email protected] (P. Stanko).
paper an unusual case of cancer development in the site of tongue piercing is introduced. 2. Case report A 26-year-old man was referred to the Department of Oral and Maxillofacial Surgery with 2 months lasting painful ulcer on right margin of the tongue associated with diminished ability to articulate. He had a metal piercing inserted there 5 years earlier which was removed at start of the pains by his dentist. Regarding abuses he was smoker of 10e15 cigarettes about 8 years. On our evaluation the ulcer revealed size 15 5 mm without bleeding tendency, defect in the piercing insertion site was observable. Because the right first lower molar with large amalgam filling had had lingual inclination an extraction was performed, antibiotics prescribed and patient invited to recall. At second presentation after 3 weeks the ulcer had enlarged and by autofluorescence imaging (Svistun et al., 2004; Lane et al., 2006) a suspicion for cancer was considered. The biopsy confirmed squamous cell carcinoma grading II (Fig. 1). Subsequent sonography of the neck revealed lymph node involvement till 20 mm on the right and till 13 mm on the left side respectively. On CT scans size of the tongue infiltration was 29 19 41 mm (AP LL CC) with small bubbles of unknown origin. The staging T3N1M0 was established and a concommitant external radiotherapy and chemotherapy started immediately. The radiotherapy included LINAC 6 MV X beams to the face and neck in total doses TD ¼ 60 Gy. The used chemotherapy protocol included
1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2011.05.005
330
P. Stanko et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 329e331
metal one. This fact provides a suspicion for participation of possible electrogalvanic potential arising within the metal piercing and the amalgam filling in the close neighbourhood. The negative role of the potentials leading to the malignant transformation during the 5-year period of the piercing wearing can be considered. Unclear remains the rapid progress of the disease. Smoking in the anamnesis was of mild degree and it was stopped immediately after getting the histological result of carcinoma. A previous illegal drug abuse may be on question. An increasing incidence of oral carcinoma among young adults has been reported in the U.S. and Europe (Llewellyn et al., 2004; Shiboski et al., 2005). Although the role of human papillomaviruses is very important (Furniss et al., 2007; Hennessey et al., 2009), in our case the HPV analysis was not performed for technical reasons. 4. Conclusion
Fig. 1. Histology of the squamous cell carcinoma obtained from the suspect region.
three cycles of cisplatin (CDDP doses 40 mg/m2) and five of Erbitux (400 mg/m2 initially, then 4 250 mg/m2). The radiotherapy was interrupted after two cycles of the CDDP and four cycles of the Erbitux due to second-degree radiomucositis. A short temporary partial remission ended by locoregional progression and cachexia. Despite of the intense therapy the patient died 18 months from the first symptoms. 3. Discussion Some studies reported the prevalence of oral piercing ranging from 3.4% to 20.3% (Levin and Zadik, 2007). Among evaluated group of teenage students there was a slight predominance of males (54.55%) compared with females (45.45%), the tongue was the most common location for piercing (66.6%) (Firoozmand et al., 2009). Oral piercings are not a harmless fashion trend. Straight barbells with either plastic or metal beads are commonly worn in tongue piercings. A lack of hygiene with accumulation of plaque may lead to acute deep infections of the tongue (Sands et al., 1993; Fehrenbach, 1998; Olsen, 2001) or chronic infections of the piercing insertion site. A higher susceptibility to mechanical pressure of the mucous membrane than of the skin was observed especially in cases of short barbells. In these situation growth into the soft tissues was published (Jurkovic et al., 1999). Barbells that are too thin are prone to migration, long-term unmentioned playing or suctioning of the piercing results in further mechanical irritation. Because the risk of aspiration is highest by intubation, removal of piercing is recommended before every general anaesthesia (Roth and Plotz, 1998). Rare lethal complication was described as a sequel of severe general herpetic infection (Lakhan and Harle, 2008). Perkins et al. (1997) reported a nonlethal case of Ludwig’s angina in 25-year-old patient due to insertion of the tongue piercing. The treatment included extraoral incision and combined antibiotics. Extubation was performed after several days later due to massive oedema of the tongue and floor of the mouth. Other problems related to tongue piercing include endocarditis (Tronel et al., 2001; Harding et al., 2002) and cerebellar brain abscess (Martinello and Cooney, 2003). In our case the patient could not provide the piercing to an analysis but he confirmed surely that the total material used was
Patients with oral piercing should be regularly followed up by dentists or oral surgeons because of possible development of different types of the adverse effects. In prevention of the complications it would be the best solution to spread information about the risks especially within the teenage population. The tongue piercings are an unnecessary and potentially dangerous surgical procedure that should be avoided. The aim not to insert tongue piercing at all is an ideal one but unexpectable indeed. Conflict of interest None, no support in the form of grants. References Antoszewski B, Szychta P, Fijalkowska M: Are we aware of all complications following body piercing procedures? Int J Dermatol 48(4): 422e425, 2009 Escudero-Castano N, Perea-García MA, Campo-Trapero J, Cano-Sánchez, BasconesMartínez A: Oral and perioral piercing complications. Open Dent J 4(2): 133e136, 2008 Fehrenbach MJ: Tongue piercing and potential oral complications. J Dent Hyg 72: 23e25, 1998 Firoozmand LM, Paschotto DR, Almeida JD: Oral piercing complications among teenage students. Oral Health Prev Dent 7(1): 77e81, 2009 Furniss CS, McClean MD, Smith JF, Bryan J, Nelson HH, Peters ES, et al: Human papillomavirus 16 and head and neck squamous cell carcinoma. Int J Cancer 120: 2386e2392, 2007 Garcia-Pola MJ, Garcia-Martin JM, Varela-Centelles P, Bilbao-Alonso A, CereroLapiedra R, Seoane J: Oral and facial piercing: associated complications and clinical repercussion. Quintessence Int 39(1): 51e59, 2008 Harding PR, Yerkey MW, Deye G, Storey D: Methicillin resistant Staphylococcus aureus (MRSA) endocarditis secondary to tongue piercing. J Miss State Med Assoc 43: 109, 2002 Hayes MO, Harkness GA: Body piercing as a risk factor for viral hepatitis e an integrative research review. Am J Infect Control 29(4): 271e274, 2001 Hennessey PT, Westra WH, Califano JA: Human papillomavirus and head and neck squamous cell carcinoma: recent evidence and clinical implication. J Dent Res 88: 300e306, 2009 Jeger F, Lussi A, Zimmerli B: Oral jewelry: a review. Schweiz Monatsschr Zahnmed 119(6): 615e631, 2009 Jurkovic R, Satko I, Kubisova J: Piercing of the tongue and possible complications. Ces Stomat 99(6): 240e244, 1999 Lakhan SE, Harle L: Fatal fulminant herpes simplex hepatitis secondary to tongue piercing in an immunocompetent adult e a case report. J Med Case Reports 2: 356, 2008 Lane PM, Gilhuly T, Whitehead P, Zeng H, Poh CF, Ng S, et al: Simple device for the direct visualization of oral cavity tissue fluorescence. J Biomed Opt 11: 24006e24007, 2006 Levin L, Zadik Y: Oral piercing: complications and side effects. Am J Dent 20(5): 340e344, 2007 Llewellyn CD, Linklater K, Bell J, Johnson NW, Warnakulasuriya S: An analysis of risk factors for oral cancer in young people: a case-control study. Oral Oncol 40(3): 304e313, 2004 Martinello RA, Cooney EL: Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis 36(2): e32ee34, 2003 Olsen JC: Lingual abscess secondary to body piercing. J Emerg Med 20: 409, 2001 Perkins CS, Meisner J, Harrison JM: A complication of tongue piercing. Br Dent J 182(4): 147e148, 1997
P. Stanko et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 329e331 Roth R, Plotz J: Zungenpiercing (Ein Modenphänomen nicht ohne anästhesiologische Bedeutung). Anaesthetist 47(8): 690e691, 1998 Sands M, Pepe J, Brown RB: Tongue abscess e case report and review. Clin Infect Dis 16: 133e135, 1993 Shiboski CH, Schmidt BL, Jordan RCK: Tongue and tonsil carcinoma. Increasing trends in the U.S. population ages 20e44 years. Cancer 103: 1843e1849, 2005 Svistun E, Alizadeh-Naderi R, El-Naggar A, Jacob R, Gillenwater A, RichardsKortum R: Vision enhancement system for detection of oral cavity neoplasia based on autofluorescence. Head Neck 26(3): 205e215, 2004
331
Tronel H, Chaudemanche H, Pechier N, Doutrelant L, Hoen B: Endocarditis due to Neisseria mucosa after tongue piercing. Clin Microbiol Infect 7: 275e276, 2001 Vilchez-Perez MA, Fuster-Torres MA, Figueiredo R, Valmaseda-Castellón E, GayEscoda C: Periodontal health and lateral lower lip piercings e a split-mouth cross-sectional study. J Clin Periodontol 36(7): 558e563, 2009 Ziebolz D, Stuehmer C, van Nüss K, Hornecker E, Mausberg RF: Complications of tongue piercing e a review of the literature and three case reports. J Contemp Dent Pract 10(6): 1065e1071, 2009