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The 34-year-old man presented to our observation for a persistent exophytic crust on the right lower lip. Five years before he underwent allogenic bone marrow transplantation for an acute myeloid leukaemia. After transplantation, he developed a severe graft versus host disease with cutaneous and hepatic involvement. He was treated with steroids, mycophenolate mofetil and photopheresis. Crusty lesions on the lower lip appeared about 6 months before our observation and were treated with antiviral drugs assuming an herpetic infection. An incisional biopsy was performed revealing a squamous cell carcinoma. The lesion was surgically excised in general anaesthesia and a vermilion reconstruction with buccal musculomucosal flap combined with V-Y plasty was performed after malignant tumor excision. Hematopoietic stem cell transplant (HCT) recipients have a well-known substantial risk of developing secondary solid cancers frequently involving the lip and the oral cavity, particularly beyond 5 years after HCT. Several factors as chronic GVHD and prolonged immunosuppressive treatment beyond 24 months are well-documented risk factors for many types of secondary cancers.

In August 2011 a 11-year-old girl had the extraction of the first inferior right permanent molar as a result of an odontogenic infection non responsive to antibiotics nor to endodontic treatment. One month later she was referred to our clinic for delay in healing even in absence of any symptom. The extra oral examination revealed right submandibular lymphadenopathy, right mandibular swelling, facial asymmetry; on intra oral examination a pink-strawberry granulating mucosa without any purulent exudate or emission of granular sulfur compounds was observed. The child was hospitalized and underwent a 21-days antibiotic infusion therapy: Tazocin and Clindamycin. No evidence of recurrence was reported in a 20-months follow-up. In presence of a granulomatous disease both infective and non-infective etiologies have to be ruled out; this a challenging case of granulomatous osteitis and lymphadenitis from unknown cause.

The objectives of the \"Bisphosphonate related oral pathology Service\" are: 1. to evaluate the oral condition of the oncologic patients before the beginning of the therapy with bisphosphonate in order to reduce as less as possible the oral risk factors, 2. to follow up the patients during all the period of treatment in order to intercept as soon as possible the onset of the disease and 3. to treat the patients affected from bisphosphonate related osteonecrosis of the jaw (BRONJ). The researchers wanted to compare their population of patients taking bisphosphonates and their results with literature data. BRONJ occurred in 23% of this population, 16,6% were oncologic patients. Prevalence of BRONJ described in literature varies from 1,2% to 28%, although in a study with follow-up it is attested to 13.3%. About 60% of the BRONJ was localized in the mandible, 35% in the maxilla, and 5% in both mandible and maxilla.

A 37-year-old female was referred to the authors' clinic for a single, slow-growing, painless, fibrous, upper gingival swelling. Intraoral examination revealed a 20 mm sessile mass involving the left alveolar process and displacing the lateral incisor and the canine which were vital and not mobile. The overlying mucosa showed an ulcer due to chronic dental trauma from the lower teeth. Panoramic radiographs did not indicate any bone involvement. An incisional biopsy was consistent with peripheral calcifying epithelial odontogenic tumor. After a CT assessment showing bone resorption with maintenance of the vestibular cortical bone, the mass was excised under general anesthesia with a conservative surgical approach, comprehending the displaced teeth. They generally occur as single, painless, non-bleeding, gingival masses mainly located in the anterior and premolar regions, that commonly resemble oral hyperplastic or reactive lesions. The significant bone resorption observed in the present case underlines the importance of reconstructive surgery for a proper management and rehabilitation.

BACKGROUND: Amyloidosis is a rare disease with multifactorial pathogenesis. Localized amyloidosis affecting the head and neck region is an uncommon and benign process, which has almost no clinical consequences. The most reported characteristic features of localized oral amyloidosis appear as multiple soft nodules of the tongue, lip and cheek. METHODS: We report the case of a 68-year-old woman suffering from a primary localized amyloidosis presenting as a purple patch on the palate. CONCLUSIONS: The presence of systemic amyloidosis or underlying plasma cell dyscrasia have to be ruled out in patients presenting with a diagnosis of amyloidosis of the oral mucosa. If a primary localized amyloidosis is proven, the surgical therapy may be useful to eliminate a functional impairment.

Several known autosomal dominant hereditary syndromes involve the head and neck region. Most of them just involve one single subsite such as the skin, the endocrine system or the gastro-digestive tract. In a minority of cases there is a multi-organ involvement as in Cowden Syndrome (CS) or Multiple hamartoma Syndrome, a rare condition with important implications represented by an increased risk of malignancies, particularly breast, thyroid and endometrium cancers. The disorder take origin from the mutation of the tumour suppressor gene PTEN located at 10q22-23. From a review of literature the PTEN protein product promote cell death and the alteration of cells' proliferation, resulting in hamartomatous growths. Mucocutaneous lesions are present on almost 100% of affected individuals. The prevalence of the Cowden Syndrome is estimated approximately 1:200 000, and usually it develops during the I - II decade of life. A 52-year-old female patient with a mild mental handicap was referred to our Oral Medicine and Oral Oncology Clinic with a chief complaint of irregularity on her gums. The patient gave a history of thyroidectomy 7 years before because of a recurrent toxic nodular struma. In 2014 a CT scan revealed the presence of a myelo-lipoma of the left adrenal gland and an adenoma of the right suprarenal gland. Moreover, the patient was repeatedly treated for multiple cutaneous fibromas. Finally, the mother and the father of the patient were first cousins and they both came to death, the mother died of diabetes complications, while the father died of heart attack. Malformation and mental handicap were not known in the family of the patient. At the clinical observation, the gums showed several papules with a warty aspect on the attached gingiva. An incisional biopsy was performed revealing papillomatosis, negative for p16. Based on the medical history, clinical examination, and histopathological findings a diagnosis of CS was considered and the patient was referred for a genetic assessment. The genetic analysis disclosed an heterozygosis of the mutation of c.562delT, p. (Tyr188Ilefs· 11) of the gene PTEN, which was never highlighted in healthy or ill subject affected by CS, but the protein produced by this gene was pathogenetic with CS. The finding of mutation c.562delT, p. (Tyr188Ilefs· 11) in the PTEN gene confirmed the clinical suspect of CS. Consequently, patients with such diagnosis have to follow periodic controls and instrumental examinations: colonscopic, dermatological, breast and gynaecological evaluations are fundamental for early diagnosis of neoplasms in such anatomic sites; CT jr MR of the abdomen together with urine examination are recommended every 2 years to evaluate the progression of renal lesions, finally, MR of the brain is mandatory to detect malignancies of this district. The diagnosis of CS should reflect specific major and/or minor clinical criteria that are periodically renewed; in this case, the team approach of several specialist, including the general dental practitioner, is fundamental to reach the correct diagnosis.

Malignant lymphomas represent approximately 5% of all malignant neoplasm of the head and neck area. This heterogeneous group of tumours is classically divided in two subgroups, Hodgkin's lymphomas (HL) and Non-Hodgkin's lymphomas (NHL), depending on the presence or absence of Reed-Stenberg cells. Non-Hodgkin's lymphoma is the most frequent type of haematological malignancy of the head and neck, representing about 75% of lymphomas in this area. It's well known that some variants of NHL are more common that others in the oral and maxillofacial region. The haematological disorders with an highest prevalence are: B-lymphoblastic leukaemia/lymphoma, chronic lymphocytic leukaemia/small lymphocytic lymphoma, extranodal marginal-zone B-cell lymphoma of MALT, follicular lymphoma, mantle cell lymphoma, diffuse large B-cell lymphoma and Burkitt's Lymphoma/leukaemia. The most frequent T-cell and NK-cell nHL is the extranodal NK/T cell lymphoma, nasal type. Extranodal NHL represent 20-30% of all the NHL. Among the NHL that occur in the oral cavity 10%-26% arise in the maxilla and mandible. The upper maxilla (11%) and the gum (7%) are involved more frequently by NHL. Isolated mandibular NHL accounts for only 0.6% of all the NHL. A 44-year-old female smoker without any significant anamnestic report, was admitted to our Oral Medicine and Oral Oncology Clinic on September 2015 with a chief complaint of swelling and pain at the left mandible, with a sense of numbness of the left inferior lip. About 6 months before, the patient underwent extraction of the first inferior left molar, because of a periodontal abscess, with an inadequate healing. A revision surgery of the alveolus with histological sampling was performed resulting in a diagnosis of osteitis. After the surgical revision the patient disclosed intermittent pain and swelling in the area of the tooth extraction with constant paraesthesia of the left part of the lower lip. On examination the left mandible showed a soft swelling with an overlying ulcerated mucosa. A CT scan showed a non homogeneous structure of the alveolar bone with a lithic aspect in the area of the extraction. An incisional biopsy was performed. The haematoxylin and eosin-stained sections revealed the presence of an ulcer of the oral mucosa in relation to sporadic bone fragments with inflammatory aspects of bone marrow, compatible with osteitis. The surgical wound completed the healing but in January 2017 the swelling reappeared, three more biopsies were performed revealing a status of chronic periostitis. A more aggressive surgical approach was carried out. The result of the histological examination showed a lymphoma of B small lymphocytes with aspects of secretive differentiation of kappa chains. Haematological examination, total body CT and bone marrow biopsy were performed. CT and bone marrow biopsy ruled out a systemic involvement. A PeT was required, and the only site strongly enhanced was the mandible, consequently she was addressed to the local radiotherapy. In contrast to the vast majority of NHL involving the jaws, our case of NHL presented with a generalized sclerotic radiographic appearance and pain which most often are related to chronic inflammation. Primary extranodal NHLs of the oral cavity are rare lesions. Early diagnosis is essential to achieve optimal treatment results, nevertheless deep sampling is mandatory to obtain adequate tissue for diagnosis.

Keratoacanthoma (KA) is a benign epithelial tumor normally presenting as a solitary and proliferating dome-shaped keratin-filled crater. It often occurs on sun-exposed sites in light-skinned persons of middle age or older. It is considered the prototype of cutaneous pseudo-malignancies because it is a rapidly growing tumor with histologic pattern resembling squamous cell carcinoma (SCC). This premalignant lesion in all probabilities arises from ectopic sebaceous glands and not hair infundibulum. It's often found in the head and neck area, including the lip. Management is controversial: some Authors suggest surgical removal while others prefer monitoring to allow for spontaneous resolution. Nevertheless, the rate of malignant transformation of KA is around 32.6%, thus supporting an active treatment. A 56-year-old male patient came to our Oral Medicine and Oral Oncology Clinic in April 2017, because of the onset of an exophytic lesion on the lower right vermilion. He was smoking more than 20 cigarettes/day and was drinking beer during every meal. Clinical examination revealed an ulcerate and nodular growth measuring approximately 10x5 mm on the lower lip, with no report of local trauma. An incisional biopsy was performed in order to rule out the presence of dysplasia or carcinoma. Histopathological report just showed the presence of keratosis with lichenoid infiltrate and verrucous hyperplasia. A surgical excision was scheduled. The lesion in the following weeks did not regress, indeed it worsened structuring like a horn. The histopathological report was consistent with keratoacanthoma showing a keratinic esophytic lesion with hyperkeratotic, hyperplastic epithelium with untouched adipose tissue. After surgery a complete histolopathological healing was achieved. KA is a common benign cutaneous lesion occasionally involving the mucous membrane. The clinical appearance of KA could resemble SCC, so that incisional biopsy is mandatory to clarify the diagnosis.

Surgical treatment of medication-related osteonecrosis of the jaw (MRONJ), especially in presence of wide volume of necrotic bone can be quite aggressive, with an important impact for the quality of life, especially in aged patients. We describe the non-surgical management of an osteoporotic patient with a stage 3 MRONJ. A 80-year old woman was treated for 8 years with alendronate per os (Fosamax®, Merck Sharp & Dhome, White House Station, NJ, USA) for osteoporosis and developed MRONJ in 2012 after the extraction of maxillary teeth. The computed tomographic (CT) imaging was consistent with the clinical diagnosis of MRONJ, showing extensive osteonecrosis of the left side of the hard palate, and the medial and infero lateral walls of the maxillary sinus. In view of the age of the patient and in view of the morbidity of a surgical approach, a conservative management was undertaken. The presence of infection was managed by antibiotic therapy according to In- ternational guidelines: amoxicillin/clavulanate (1000 mg orally three times a day for 10 days), metronidazole (250 mg orally three times a day for 10 days) and Chlorhexidine rinse 0.12% three times a day for 30 seconds. Adjunctive treatment with subcutaneous teriparatide (Forteo®) at a dose of 20 |ag a day for 2 months was administered.After 6 weeks of treatment, symptoms and purulent drainage resolved, with substantial improvement of the quality of life of the patient and closure of the oro-antral fistula. In 2017, a spontaneous sequestrectomy of bone affected by necrosis was observed, with subsequent healing of soft tissues. In the present case a surgical management would have required an extensive maxillectomy resulting in a wide oro-nasal communication; then an obturator prosthesis would have been needed in order to allow the patient to feed. Aiming to avoid such a surgical treatment and its sequelae, we first performed an only medical treatment which, in this case, succeeded in resolving symptoms and improving the quality of life of the patient. During the following years, in absence of new infective episodes, a self-limitation of the necrosis was achieved. Management of MRONJ continues to be controversial. The literature highlights that about 71-80% of MRONJ patient improved or remained asymptomatic with a non-surgical approach. Recently, some Authors have promoted early extensive surgical intervention and found treatment to be successful in over 85%. However, these reports did not consider the severity, morbidity, or the cost of the treatment. Teriparatide could successfully be used as adjunct therapy for osteonecrosis in osteoporotic patients, because it has an anabolic effect and potential role in accelerating bone healing. Even if surgery is the most frequently selected option to treat MRONJ, the present case shows that in piesence of a successful medical treatment limiting infection, surgery could be not mandatory in order to gain a good quality of life for patients.

A 55-year-old female patient presented with a complaint of swelling on the right side of mouth floor since 1 month. The swelling was initially small and a gradual increase in size was observed. On examination there was a solitary well-defined, tender and non-fluctuant swelling with smooth borders, localized over the right lingual caruncola, measuring approximately 4 x 3 mm. It was supposed to be a gallstone of the sublingual gland, but ultrasound scan of the salivary glands and radiographic exams were both negative. An incisional biopsy was performed. The hematoxylin and eosin-stained sections revealed cellular proliferation of polygonal cells with abundant granular cytoplasm. No mitotic figures were observed. A diagnosis of granular cell tumor was rendered. A panel of markers were used: S-100, vimentin. Positivity was observed with vimentin, S-100. Benign mesenchymal neoplasms usually present a swelling on the tongue. This lesion though uncommon should be considered in the differential diagnosis of benign and malignant swellings of the oral cavity and a regular follow up of patients is mandatory.