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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 3  |  Page : 131-4
Florid cemento-osseous dysplasia : Review and report of two cases.


Department of Oral Medicine Dental College and Hospital, Bagalkot, Kamataka, India

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   Abstract 

Only three Indian patients of florid cemento-osseous dysplasia have been reported (less than 2%), according to the review of recent literature (2003). This makes the occurrence of FCOD a relatively rare phenomenon. The age group may vary from 19-76 years and typically presents in the fourth and fifth decade. In most of the cases, patients do not have family history of the disease. We report two cases showing classic radiologic features. The diagnosis of our cases were made radiographically.

Keywords: Florid cemento-osseous dysplasia, India, radiology

How to cite this article:
Mangala M, Ramesh D N, Surekha P S, Santosh P. Florid cemento-osseous dysplasia : Review and report of two cases. Indian J Dent Res 2006;17:131

How to cite this URL:
Mangala M, Ramesh D N, Surekha P S, Santosh P. Florid cemento-osseous dysplasia : Review and report of two cases. Indian J Dent Res [serial online] 2006 [cited 2019 Dec 16];17:131. Available from: http://www.ijdr.in/text.asp?2006/17/3/131/29875

   Introduction Top


The term florid cement-osseous osseous dysplasia (FCOD) was first suggested by Melrose et al in 1976 to describe a condition of exuberant multi quadrant masses of cementura and/or bone in both jaws and in some cases, simple bone cavity like lesions in affected quadrant [1]. The word 'florid' was introduced to describe the wide spread, extensive manifestations of the disease in the jaws. Florid cemento­osseous dysplasia (FCOD) is not associated with any other extragnathic abnormalities and there are no abnormalities in blood chemistry of patients [2]. The disease has a striking tendency for bilateral occurrence, often presenting symmetrically in the jaws [2],[3]. When the lesions are large, jaw expansion may be noted and symptoms of dull pain or drainage may be noted in the involved area [3].

In the asymptomatic patient, it is probably wise to keep the patient under observation without surgical intervention because the radiologicfeatures are diagnostic [3],[4].

The rationale of reporting these two interesting cases is to illustrate the alteration of the normal radiographic appearance. Lesions of FCOD is most of the times an incidental finding. Hence an oral physician must be well aware of such a possibility when there is any cortical bone expansion/ localized infection with drainage.

Differential diagnosis can be a crucial process specially when there is a coincidental findings like odontogenic infections or chronic diffuse osteomyelitis, neoplasia, bone dysplasia that can cause changes in the mandible with similar radiographic characteristics. Hence we must consider all the available diagnostic information, the radiographic characteristics which would contribute significantly to the diagnosis [5].

The cases we report here are rare, specially in the Indian population. In a systemic review done, only 2% cases have been reported in the Indians in the literature [4],[6].

Also FCOD can make the jaws susceptible to osteomyelitis and pathological fracture. This sequelae make the cases all the more significant as regular follow up becomes mandatory.


   CASE 1 Top


A 30-year-old female patient reported to the out patient department with a complaint of a mild swelling in the right back region of the mandible. The patient noted the swelling one-year back and since then it has not shown any changes. Swelling was not painful. No relevant family and social history was elicited. On clinical examination, there was no evidence of dental decay or periodontal disease. Teeth were vital (response to ethyl chloride). There was expansion of buccal plate clinically in relation to 46 [Figure - 1]. On palpation, the area was bony hard and non-tender. Teeth were non-tender to percussion. Orthopantomograph showed globular radio opaque masses, scattered in both the quadrants of the lowerj aw. Thin radiolucentrims were seen with most of the sclerotic areas. A few scattered sclerotic areas were also seen in the maxillary right and left quadrants [Figure - 2].

Biopsy was not done as the case was diagnosed on the basis of the characteristic features seen on the radiographs. Case is being followed up since the last six months. Patientis asymptomatic.


   CASE 2 Top


A38-year-old Indian femalereported to the departmentof oral diagnosis and medicine with the chief complaint of swelling and dull aching pain in the lower left posterior tooth since 1 month. She presented with a history of pus discharge in relation to her left molar region. Family and medicalhistorywerenon-contributory.

On oral examination, tooth 35 was carious and an intraoral sinus was present. The tooth was non vital. IOPA radiograph showed periapical rarefaction and certain rounded sclerotic areas in the molar and premolar region. Since extent of lesion could not be entirely covered, an OPGwastaken.

OPG showed ovoid sclerotic areas with a radiolucent rim in theperiapical areas of all the molars and leftpremolars in both the quadrants of the mandible [Figure - 2]. Solitary radio opaque foci was also seen in both maxillary quadrantsinpremolarregion.

Tooth 35 was endodontically treated and patient is asymptomatic till date. Thus a diagnosis of FCOD with a chronic periapical infection was made on the basis of clinical and radiographic findings. The patient is being followed up since the last two years and the lesions have not undergone any change in size, number and behavior. We didnotperformbiopsy aspatienthasremained


   Discussion Top


Cemento-osseous dysplasias are usually classified depending on their extent and radiological appearances into three main groups; periapical (surrounds the periapical region of the teeth and are bilateral), florid (sclerotic symmetrical masses). and focal (single lesion) cemental dysplasias [4]. This disorder is strictly localized to tooth bearing areas and not associated with any other skeletal disease [2],[3],[4].

However the etiopathogenesis is not clear. Waldron et al [2],[3] haveproposed thatreactive or dysplasiac changes in theperiodontalligament mightbeacauseforthedisease. The term'cementosseous dysplasia' is a histopathological term, yet diagnosis can be decided by clinical and radiographic flndings. These lesions are characterized by replacement of bone by connective tissue matrix, the matrix displaying varying degrees ofmineralization inthe form of woven bone or cementum-like round basophilic acellular structures [6]. The affected area undergoes changes fromvascularboneinto auricular cementum-like lesion. Clinically, FCOD are asymptomatic but sometimes there may be localized expansion of the corticalplates [4]. (as inthefirst case) or symptoms of dull aching pain or drainage (as in the second case). A systematic review on FCOD conducted showed only three Indian patients (less than 2%) identified from the whole series that combined most of the cases reported around the world [6]. Thus the report of two cases in Indian women (same geographical area) make this report a rare one. The age group may vary from 19-76 years. Our cases also fall in the fourth decade. Our cases are non­familial as also reported by other authors [9],[10],[11],[12],[13],[14]. There are reported instances of familial involvement, although in many of the cases, the mode of genetic transmission remains unclear [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17]. Thus investigators have suggested that familial FCOD be regarded as a separate form of the disease as some differences were noted between the two variants. The radiographic appearance of FCOD depends on the degree of maturation of the lesion. The lesion may appear as radiolucent, mixed or lobulated dense radiopaque masses with radiolucent halo, usually located in tooth bearing areas [18). Most of the times, these lesions are diagnosed incidentally on routine radiographic examination [4],[6],[8],[10],[18]. FCOD have a striking tendency towards bilateral often quite symmetrical location and it is not unusual to find extensive lesions in all four posterior quadrants of the jaws [2],[3],[4],[7],[10].

We have diagnosed our cases as FCOD based on the clinical and characteristic radiographic features. Since our patients have remained asymptomatic, we have not subjected the lesions for biopsy procedures. And as reassuring a biopsy might be in this condition, it may precipitate infection that is difficult to control without extensive surgical intervention. Many authors have observed that patients presented with poor socket healing and even sequestrum formation following extraction of teeth. It is recommended that every effort should be made to avoid extraction or even elective surgical procedures [2],[3],[4],[7],[12].

A biopsy is thus not required to confirm the diagnosis as this condition can usually be diagnosed radiographically and managed accordingly [4],[6],[10],[18].

FCOD lesions must be differentiated from Paget's disease, Gardner's syndrome and chronic diffuse osteomyelitis. FCOD has no other skeletal changes, skin tumors and dental anamolies thus can be differentiated from Gardner's syndrome. Paget's disease is polyostotic and shows raised alkaline phosphatase levels which is not a consistent feature of FCOD. Chronic difuse osteomyelitis is not confined to tooth bearing areas. It is a primary inflammatory condition of the mandible with cyclic episodes of unilateral pain and swelling. The affected region of the mandible exhibits a diffuse opacity with poorly defined borders

The current methods of management of FCOD are not discussed satisfactorily. The onset of symptoms is usually a sign that there may be an inflammation. In such cases, the tooth can be managed endodontically. Administration of antibiotics is also indicated. Extraction must be avoided due to poor socket healing (impaired blood circulation in the affected area of bone). Extensive surgical resection and saucerization are proposed treatment options when lesions become extensive and symptomatic [7],[12].

Reconstruction of the surgical defect (vascularised grafts) have been reported to have 95% success. An implant supported prosthesis would improve the functional efficiency[12].

The lesion is usually benign and requires no treatment unless cosmetically concerning or becomes symptomatic; However treatment of secondary infection of this lesion can be difficult and complicated [6].

This condition is usually diagnosed by radiographs. Computed tomography (CT) because of its ability to give axial, saggital and frontal view, is useful in the evaluation of these lesions. [10],[18] Scintigraphy of FCOD reveals an increased uptake of the radio tracer [14].

We look forward for investigative methods like biopsy procedures without surgical mutilation to bone and advanced imaging modalities like 3D Computed tomography and scintigraphy with lesser radiation doses to the patient, since Our FCOD patients will require frequent scans for periodic assessment of the lesions. A future which will see more convincing management options, like intralesional injections of certain biologicals that will dissolve the sclerotic masses and also enhance healing process is eagerly awaited. We look forward to more acceptable, affordable rehabilitative measures, esthetically pleasing and functionally long lasting, with no further consequences.


   Conclusion Top


Most cases of florid cemento osseous dysplasias are asymptomatic and are found during routine radiographic examination. The radiographic and histologic spectrum is similar to other benign fibro osseous lesions. One needs to have knowledge about the disease process and its managamentoptions.[19]



 
   References Top

1.Brown KE: Fabrication of ear prosthesis, J Prosthet Dent, 21: 670-676,1969.  Back to cited text no. 1    
2.Melrose RJ, Abrams AM and Mills BG: Florid osseous dysplasia,Oral Surg,41[1]:62-82,1976.   Back to cited text no. 2    
3.Waldron CA: Fibrosseous lesions of thejaws, J Oral Maxillofac Surg,43:249-262,1985.  Back to cited text no. 3    
4.Waldron CA: Fibro-osseous-lesions of the jaws, J Oral Maxillofac Surg, 51: 828-35,1993.  Back to cited text no. 4    
5.Jeres W, Banu B, Winson B and Hopper C: Florid cemento-osseous dysplasia in young Indian women. A case report, Brit Dent J,198: 477-78, 2005.  Back to cited text no. 5    
6.Singer SR, Muralidhar M, Renaggio J: Florid cemento-osseous dysplasia and diffuse osteomyelitis, JArn DentAssoc,136: 927-31, 2005.   Back to cited text no. 6    
7.Jakowski MD: Florid cemento-osseous dysplasia: A systemic review, Dentomaxillofac Radiol, 32: 141-149,2003.  Back to cited text no. 7    
8.Waldron CA, Giasanti IS and Brawand BC: Sclerotic cemental masses of the jaws (so called chronic Sclerosing osteomyelitis, Sclerosing osteitis,multiple enostosis and gigantiform cementoma) oral Surg, 4:590-604,1975.  Back to cited text no. 8    
9.Reichart PA and Hans PP: Florid cementoosseous dysplasia in odontogenic tumours and allied lesions, Quintessence publishing, London P:301-308,2004.   Back to cited text no. 9    
10.MiyauchiM,Ogawa1,TakataT, Him H,NikalIand Tanimoto: Florid cementoosseous dysplasia with concomitant simple bone cysts:a case in a Japanese woman, J Oral Pathol Med, 24: 285-87,1994.   Back to cited text no. 10    
11.Beylouni 1, Farge P, Mazoyer JF, Coudert L: Florid cementoosseous dysplasia oral Sorg Oral Med Oral Pathol Oral Radiol Endod, 85: 707-11,1998.   Back to cited text no. 11    
12.Schneider LS and Mesa MI: Differences between florid osseous dysplasia and chronic diffuse sclerosing osteomyelitis oral Surg Oral Med Oral Pathol Oral Radiol Endod, 70:308 -12,1990.  Back to cited text no. 12    
13.Bencharit S, Schardt-Sacco D, Zuniga JR and Minsley GE: Surgical and prosthodontic rehabilitation for a patient with aggressive florid cemento-osseous dysplasia: a clinical report, JProst Dent, 90:220-4,2003.  Back to cited text no. 13    
14.Winer Elf, Goepp RA and Olson RA: Gigantiform cementoma, report of case, J Oral Sung, 30, 517-519, 1972.  Back to cited text no. 14    
15.Miyake M, Nagahate S: Florid cementoosseous dysplasia, report of a case, J Oral Maxillofac Sung, 28:56-57,1999.  Back to cited text no. 15    
16.Young SK, Markowitz R, Sullivan S, Seale TW, Hirschi R: Familial Gigantiform cementoma:classification and presentation of a large pedigree oral Sung Oral Med Oral Pathol Oral Radiol Endod, 68:740-7,1989.  Back to cited text no. 16    
17.MusellaAE and Slater LJ: Familial florid osseous dysplasia: A case report, J Oral Maxillofac Sorg, 47: 636-40,1989.  Back to cited text no. 17    
18.Oikarinen K, Altonen M, Pekka R: Gigantiform cementoma affecting a Caucasian family Brit J Maxillofac S org, 29:194-97,1991.  Back to cited text no. 18    
19.Ariji Y, Ariji E, Higuchi Y Kubo S, Nakayama E and Kanda S: Florid cementoosseous dysplasia oral Sung Oral Med Oral Pathol Oral Radiol Endod, 78:391-6,1994.  Back to cited text no. 19    

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Correspondence Address:
M Mangala
Department of Oral Medicine Dental College and Hospital, Bagalkot, Kamataka, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.29875

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[Figure - 1], [Figure - 2], [Figure - 3]

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    Abstract
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