|
|
Year : 2006 | Volume
: 17
| Issue : 3 | Page : 139-42 |
|
Mucormycosis presenting as palatal perforation. |
|
S Jayachandran, C Krithika
Department of Oral Medicine and Radiology, Tamilnadu Govt Dental College and Hospital, Chennai, India
Click here for correspondence address and email
|
|
 |
|
Abstract | | |
Mucormycosis is an opportunistic fungal infection that is caused by normally saprobic organism of the class Zygomycetes. The main form of mucormycosis are pulmonary and rhinocerebral. Rhinocerebral mycormycosis typically starts in the maxillary antrum, particularly in poorly controlled diabetics. Invasion of surrounding tissue can cause necrotizing ulceration of palate with a blackish slough and exposure of bone. A case of mucormycosis presenting as palatal performation is discussed in this article. Keywords: Mucormycosis, palatal perforation, diabetics
How to cite this article: Jayachandran S, Krithika C. Mucormycosis presenting as palatal perforation. Indian J Dent Res 2006;17:139 |
Introduction | |  |
Fungal pathogens are subdivided into those that remain superficial (i.e restricted to the epithelial surface) and those that invade deep organs and tissues (deep fungi). Most important by some species are considered opportunistic (infecting only immuno compromised hosts) and others truly pathogenic (i.e capable of infecting normal persons). Mucormycosis is an opportunistic deep fungal infection caused by "bread mold fungi" of the genera Mucor, Absidia, Rhizopus and Cunninghamella, also collectively known as Phycomycetes [1].
Case report | |  |
A 48-year-old male patient reported to the Department of Oral Medicine and Radiology, Tamil Nadu Government Dental College and Hospital, with the complaint of nasal regurgitation of food, associated with a purulent discharge from the nasal cavity and left lower eyelid for the past 15 days. History revealed that he had his left upper tooth extracted 1 month back, following which he noticed a small painless hole in the palate. He also gave a history of fever for the previous 10 days. There was no history suggestive of visual disturbances or altered mental status.
Past medical history revealed the patient to be a diabetic with a history of poor drug compliance. He had not been on any antidiabeticmedication over the previous two years.
General examination revealed the patient to be febrile with mild tachycardia and inflammatory submandibular lymphadenitis. Extra oral findings included right sided periorbital eel lulitis and ectropion of the left lower eyelid with an infra orbital sinus. A purulent discharge was seen from the sinus [Figure - 1].
Intraorally, a 3x3 cm' circular perforation was noticed in the anterior region of the hard palate [Figure - 2]. A blackish, necrotic, hemorrhagic mass was seen through the perforation. Based on the history and clinical presentation, a provisional diagnosis of a deep fungal infection was made.
Occlusal radiograph ofthemaxillashowedanilldefined radiolucent area in the anterior region of the hard palate [Figure - 3]. CT sections [Figures 4, 5 and 6] demonstrated a lesion of soft tissue density in the nasal cavity, causing destruction of the nasal septum centrally, destruction of the medial walls of the antra bilaterally and perforation of the palate inferiorly. Partial destruction of the floor of the orbit and ethmoidal sinus could be seen on the coronal CT images. CT scan of the brain was apparently normal. Haemogram showed polymorphonuclear leucocytosis [Pa, L12E] and elevated ESR [36 mm/lhr]. Biochemical investigations revealed alarmingly high blood glucose of 426 mg/dl, associated with glycosuria and ketonuria. ENT, ophthalmologic and neurosurgical consults concurred with the diagnosis of rhinocerebral mucormycosis, secondary to diabetic ketoacidosis. Emergency medical management of diabetic ketoacidosis resulted in optimal glycaemic control, following which an incisional biopsy of the lesion was accomplished. The tissue was sent for histopathological examination, as well as fungal culture and sensitivity. Histopathological examination [Figure - 6] showed broad, non-septate hyphae with acute right angle branchings suggestive of Mucor species. Although fungal culture showed no growth, a final diagnosis ofmucormycosis was made since cultures are frequently negative in a majority of cases, caused by Mucor species.
The patient was started on intravenous amphotericin B 60mg in 4 divided doses, cefotaxime lg bd and metronidazole 500mg tds. He was monitored closely for signs of amphotericin induced nephrotoxicity. Fortunately, his recovery was uneventful. Surgical debridement of the necrotic tissues was done under general anesthesia and a temporary palatal obturator was given. The patient is planned to be taken up for definitive palatoplasty after 6 months.
Discussion | |  |
Organisms of the class Zygomycetes or Phycomycetes were first noted to cause disease in humans since 1800. Platauf is credited with the first description of Zygomycosis in his paper entitled. 'Mycosis mucorina' [3]. The class 'Zygomycetes' is subdivided into two orders, which contain the agents of human Zygomycosis, the Mucorales and the Entomophthorales. Among the Mucorales, Rhizopus (most common), Mucor, Absidia, Rhizomucor, Cunninghamella, Saksenaea, Cokeromyces and Apophysomyces [4] have been implicated in causing human disease [2]. The hallmarks of disease with these organisms are angioinvasion, thrombosis, infarction and necrosis of the involved tissue.
Mucorales are considered to be opportunistic pathogens that require a break down in host immune defenses, particularly disease processes that lead to neutropenia or neutrophil dysfunction [5].
The predisposing factors for mucormycosis are as follows:
1. Diabetes is the single most common predisposing factor especially when associated with ketoacidosis. Mucor thrives in an acid pH and glucoserich medium. Hyperglycemia enhances fungal growth and impairs neutrophil chemotaxis,while lactic acidosis decreases phagocytosis[5],[7].
2. Hematological malignancies (Leukemia [8], Lymphoma[9])
3. Solidorgan[10] or Bone marrow transplants[11]
4. Corticosterioduse[12]
5. Deferroxamine therpay [13] (Rhizopus species prefersaniron rich environment)
6. Severe and prolonged neutropenia[6]
7. DeficientT Cell immunity[14]
8. Immaturity andlow birthweight [15].
Zygomycosis presents as a spectrurn of diseases, depending on the portal of entry and the predisposing risk factors of the patient. The 5 major clinical forms are as follows [16]:
1. Rhinocerebral
2. Pulmonary
3. Abdominal pelvic and gastrointestinal
4. Prunary cutaneous and
5. Disseminatedforms
Rhinocerebral mucormycosis represents one-third to onehalf of all cases of zygomycosis [17]. It manifests itself in a setting of poorly controlled diabetes in about 70% of the cases [18]. The process originates in the paranasal sinuses following inhalation of the fungal spores. Disease begins with symptoms consistent with sinusitis-sinus pain, nasal discharge and soft tissue swelling [2]. Then, it becomes rapidly progressive, extending into neighbouring tissues. Involved tissues become red, then violaceous and finally black as vessels are thrombosed and tissues undergo necrosis. Extension into the orbital region can lead to perimbital oedema, proptosis, tearing and ocular or optic nerve involvement [19]. Spread along the cribriform plate can result in intracranial involvement.
The most common oral sign of mucormycosis is ulceration of the palate, which results from necrosis due to invasion of a palatal vessel [20]. Extension from the sinuses into the mouth causes painful, black necrotic ulcerations in the hard palate [2]. The lesion is characteristically large and deep, causing denudation of the underlying bone [21]. Ulcers from mucormycosis have also been reported on the gingiva, lip and alveolar ridge.
Differential diagnosis of a lesion presenting as palatal perforation should include tertiary syphilis [22], leprosy, tantrum oris, mechanical trauma, intranasal cocaine abuse [23], malignancies, especially nasal T cell lymphomas, Wegener's granulumatosis and midline non-healing granuloma [24]. But, evidence of diabetes or immunosuppression in a patient presenting with necrotic lesions of the nasal cavity and palate strongly favours the diagnosis of a deep fungal infection.
Plain radiographs of sinuses and orbits may demonstrate sinus mucosal thickening, with or without air-fluid levels, but this is not specific. CT scan with contrast or MRI may demonstrate erosion or destruction of bone or sinuses and help delineate the extent ofthe disease [22].
Key features associated with zygomycetes on direct examination of cytologic specimens is the presence of wide, ribbon like aseptate, hyaline, hyphal elements, often in the setting of extensive necrotic debris. The special stains used for this purpose include calcofluor white stain; Gomori methenamine silver stain (GMS), periodic acid schiff (PAS) and Papanicolai stains [2].
Diagnosis of zygomycosis is easily made on tissue sections. Involved tissue demonstrates focal areas of infection, necrosis and haemorrhage. Demonstration of aseptate hyphae with wide angle branching (45°sub to 90°sub ) with angioinvasion is characteristic ofMucor species [2].
Fungal selective media are used to suppress the growth of bacterial elements (inhibitory mold agar) but, results are frequently negative, despite positive histopathology. In fact fungal cultures are positive in only 15-25% of the cases [22]. As the disease progresses with alarming rapidity, prompt and aggressive therapy is essential [25]. Treatment of Zygomycosis requires several simultaneous approaches:
1. Surgical debridement
2. Antifungal therapy
3. Medical management or correction of the underlying Condition that predisposes the patient to the disease. Amphotericin B is the first line drug of choice for most cases of zygomycosis [1],[2],[21], but its use may be associated with adverse effects such as nephrodoxicity (30-50%) that may prevent maintenance of effective doses andhence, monitoring serum creatinine, potassium, magnesium levels and blood urea nitrogen (BUN) is very important. Recently, liposomal amphotericin B (where the drug has been inserted into liposomes) is claimed to produce lesser nephrodoxicity, even at higher doses [25]. Fluconazole may be of benefit in treating Zygomycetes infection, [26] although some reports indicate an increase in resistant organisms to fluconazole [27]. Hyperbaric oxygen therapy is believed to improve neutrophilic killing by higher oxygen delivery and delaying or totally inhibiting the growth of fungal spores and mycelium [28].
Correction of the underlying diabetic ketoacidosis, improving neutropenia either with granulocyte infusions or by enhancing endogenous neutrophil production with growth factors [29] and discontinuation of iron chelation therapy orcorticosteroids is oftenwarranted.
Prognosis depends on several factors such as infection site, rapidity of diagnosis, type and severity of immunosupression and the like. The mortality rates were nearly 85% in earlier days; however after the introduction of combined therapy, more than 80% of the patients can be expected to survive [30]. Hope for cure, however lies in early recognition and aggressive treatment.
References | |  |
1. | Cotran, Kumar, Robbins Robbins' pathologic basis of disease, (4'° sub ed.) WB Saunders and Co, Philadelphia, 356,1989. |
2. | Ribes JA, Vanover CL, Baker DJ: Zygomycetes in human disease, Clinical Microbiological Reviews, 13:236-301,2000. |
3. | Platauf,AP:Mycosis Mucorina,VirchowsArch, 102: 543-564,1885. |
4. | Wieden MA, Steinbronn KK, PadhyeAA, Ajello L, Chander FW: Zygomycosis caused by Apophysomyces elegans, J C1inMicrobiol, 22: 522526,1985. |
5. | Mowat AG, Baum J: Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus, New Engl J Med, 284: 621- 627, 1971. |
6. | Meyers BR, Wormser G, Hirschman SZ, Blitzer A: Rhinocerebral Mucormycosis Pre-mortem diagnosis and therapy Arch Intern Med, 139: 557560,1979. |
7. | Sheldon WH and Bauer H: The development of acute inflammatory response to experimental cutaneous mucormycosis in normal and diabetic rabbits, J Exp Med,110:845-852,1959. |
8. | Pagano L, Ricci P, Tonso A, Nosari AN: Mucormycosis in patients with haematological malignancies: A retrospective clinical study of 37 cases, BrJHaemato1,99:33-37,1997. |
9. | Mir N, Edmonson R, Yeghen T, Rausund H: Gastrointestinal mucormycosis complicated by arterio-enteric fistula in a patient with non Hodgkin's lymphoma, Clinical and Laboratory Haematology, 22: 41-45, 2000. |
10. | Jones MWR, Tosoline FA, Marzec A, Angus P, Grayson ME: Cure of Rhizopus sinusitis in a liver transplant recipient with liposomal amphotericin B, Clin InfectDis,16: 183 -186,1993. |
11. | Nomura J, Ruskin J, Sahebi F, Kogut N, Falk PM Mucormycosis of the vulva following bone marrow transplant, Bone Marrow Transplant, 19:859-860, 1997. |
12. | fain JK, Markowitz A, Khilanani PV: Case report of localized mucormycosis following intramuscular corticosteroid, Am J Med Sci, 275: 209-216,1978. |
13. | Daly AL, Velazquez LA, Barkley SF, Kauff CA: Mucormycosis: association with deferroxamine therapy Am JMed, 87:468-471,1989. |
14. | Vesa J, Bielsa O, Arango O, Llado C, GelabertA Massive renal infarction due to mucormycosis in ALDS patients, Infection, 20: 234-236,1992. |
15. | Mitchell SL Gray J, Morgan MEI, Hocking MD, Durbin GM: Nosocomial infection with Rhizopus no crosporus in pre-term infants: association with wooden tongue depressors, Lancet, 348: 441-443, 1996. |
16. | Prabhu RM and Patel R: Mucormycosis and entomophtharomycosis: A review of clinical manifestations, diagnosis and treatment, Clinical MicrobiolInfection, 10:31-36,2000. |
17. | Pillsbury HC and Fischer ND: Rhinocerebral mucormycosis, Arch Otolaryngol, 103: 600-604, 1977. |
18. | McNulty JS: Rhinocerebral mucormycosis: Predisposing factors, Laryngoscope, 92: 1140-1143, 1982. |
19. | Le Compte PM and Meissner WA: Mucormycosis of CNS associated with haemochromatosis, Am J Patho1,23:673-676,1947. |
20. | Jones AC,BeutsenTY,Freedman PD:Mucormycosis ofthe oral cavity oral Surg, 75:455, 1993. |
21. | Greenberg MS, Glick M: Barker's oral medicine diagnosis and treatment, (10th ed.) BC Decker Inc, ElsevierIndia, 78-79,2001. |
22. | VazquezJA: Zygomycosis, e.Medicine, 2002. |
23. | Seyer B, Grist W, Miller S: Palatal perforation in long term intranasal cocaine abuse oral Surg Oral Med Oral Pathol Oral Radiol Endod, 94: 465-470, 2002. |
24. | Loudon JA, Marsh WE, Allen CM: Destructive midline palatal lesion oral Sorg Oral Med Oral PatholOral RadiolEndod, 89:134-136,2000. |
25. | Cagatay AA, Oncu SS, Calanger SS, Yildermak TT, Ozust HH, Eraksoy HH: Rhinocerebral mucormycosis treated with 32 gram liposomal amphotercin B and incomplete surgery: Acase report, BMCInfectiousDis,1:22,2001. |
26. | Kocak R, Tetiker T, Kocak M: Fluconazole in the treatment of three cases of mucormycosis, Ear J Clin Microbiol InfectDis,14: 559-561,1995. |
27. | Samaranayake LP, Cheung LK, Samaranayake YH: Candidiasis and other fungal diseases of the mouth, Dermatologic Therapy, 5: 251-255,2002. |
28. | Couch L, Theilen F, Mader JT: Rhinocerebral mucormycosis with cerebral extension successfully treated with adjuvant hyperbaric oxygen therapy J Otolaryngol HeadNeckSorg,114:791-794,1988. |
29. | Liles WE, Huang JE, Van Bank JH, Bowden RA and Dale DC: Granulocyte colony-stimulating factor administered in-vivo augments neutrophil mediated activity against opportunistic fungal pathogens, J InfectDis,175: 1012-1015,1997. |
30. | Pafrey NA: Improved diagnosis and prognosis of mucormycosis, Medicine, 65:113-123,1986. |

Correspondence Address: S Jayachandran Department of Oral Medicine and Radiology, Tamilnadu Govt Dental College and Hospital, Chennai India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.29873

Figures
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7] |
|
This article has been cited by | 1 |
A retrospective analysis for the management of oromaxillofacial invasive mucormycosis and systematic literature review |
|
| Chen-xi Li, Zhong-cheng Gong, Parekejiang Pataer, Bo Shao, Chang Fang | | BMC Oral Health. 2023; 23(1) | | [Pubmed] | [DOI] | | 2 |
A Comprehensive Review on the Management of COVID-19-Associated Mucormycosis (CAM): The New Basics |
|
| Divyam Girdhar, Ekta Manocha | | BioMed. 2022; 2(2): 181 | | [Pubmed] | [DOI] | | 3 |
Role of dentist: COVID19 and mucormycosis |
|
| FarisJaser Almutairi, ZiyadAhmad Alsuwaydani, AbdulSalam Thekkiniyakath Ali, MohammedAbdullah M. Alraqibah, BaderMassad A. Alharbi, RayanSuliman A. Alyahya, SalehMohammed N. Alrudhayman, RemaOthman Albisher | | Journal of Pharmacy And Bioallied Sciences. 2022; 14(5): 2 | | [Pubmed] | [DOI] | | 4 |
Postextraction Mucormycosis in Immunocompromised-Patient Management and Review of Literature |
|
| Omri Emodi, Chaim Ohayon, Amir Bilder, Tal Capucha, Amir Wolff, Adi Rachmiel | | Journal of Oral and Maxillofacial Surgery. 2021; 79(7): 1482 | | [Pubmed] | [DOI] | | 5 |
Non-invasive Mucormycosis Associated with Ameloblastoma of the Mandible in Liver Transplant Patients |
|
| Tae Min You, Hyun Sil Kim, Woong Nam | | The Korean Journal of Oral and Maxillofacial Pathology. 2020; 44(5): 135 | | [Pubmed] | [DOI] | | 6 |
Recurrent mucormycosis – Better understanding of treatment and management |
|
| Karthika Panneerselvam, MSathish Kumar, Karthikeyan, AMathan Mohan | | Journal of Family Medicine and Primary Care. 2020; 9(12): 6279 | | [Pubmed] | [DOI] | | 7 |
Differential diagnosis of Osteomyelitis of Maxilla in a long standing Diabetic Patient – A Rare Case Report |
|
| Vennila P,Sidra Bano,Rizwaana Parveen | | Clinical Dentistry. 2019; : 23 | | [Pubmed] | [DOI] | | 8 |
Rhino-orbital mucormycosis with palatal involvement in a child with type 1 diabetes mellitus |
|
| Shyam Sundar Meena,T.V. Ram Kumar,Obeid Shafi,Sunil Garg | | Indian Journal of Medical Specialities. 2016; 7(1): 46 | | [Pubmed] | [DOI] | | 9 |
Rhino-orbital mucormycosis with palatal involvement in a child with type 1 diabetes mellitus |
|
| Shyam Sundar Meena,T.V. Ram Kumar,Obeid Shafi,Sunil Garg | | Indian Journal of Medical Specialities. 2016; 7(1): 46 | | [Pubmed] | [DOI] | | 10 |
Palate Perforation |
|
| Neha Patel,Chandrashekar Bohra,Ganesh Gajanan,Ramon L. Sandin,John N. Greene | | Infectious Diseases in Clinical Practice. 2016; 24(2): 83 | | [Pubmed] | [DOI] | | 11 |
Palate Perforation |
|
| Neha Patel,Chandrashekar Bohra,Ganesh Gajanan,Ramon L. Sandin,John N. Greene | | Infectious Diseases in Clinical Practice. 2016; 24(2): 83 | | [Pubmed] | [DOI] | | 12 |
Rhinocerebral mucormycosis: a devastating rhinological condition |
|
| Paul Grant,Christopher J Skilbeck | | Practical Diabetes. 2014; 31(1): 37 | | [Pubmed] | [DOI] | | 13 |
Mucormycosis in a diabetic ketoacidosis patient |
|
| G. Sree Vijayabala,Rajeshwari G Annigeri,Ramachandran Sudarshan | | Asian Pacific Journal of Tropical Biomedicine. 2013; 3(10): 830 | | [Pubmed] | [DOI] | | 14 |
Rhinocerebral Mucormycosis Presenting as Oroantral Fistula |
|
| Rajashri Shailendra Mane, Balasaheb Chougonda Patil, Anjana Avinash Mohite | | An International Journal Clinical Rhinology. 2012; 5(3): 135 | | [Pubmed] | [DOI] | | 15 |
Mucormycosis of the Hard Palate Masquerading As Carcinoma |
|
| Bhari Sharanesha Manjunatha, Nagarajappa Das, Rakesh V. Sutariya, Tanveer Ahmed | | Clinics and Practice. 2012; 2(1): 66 | | [Pubmed] | [DOI] | | 16 |
Rhinocerebral mucormycosis presenting as oroantral fistula |
|
| Mane, R.S. and Patil, B.C. and Mohite, A.A. | | Clinical Rhinology. 2012; 5(3): 135-137 | | [Pubmed] | | 17 |
Fungal infections of the oral mucosa |
|
| Anitha Krishnan, P. | | Indian Journal of Dental Research. 2012; 23(5): 650-659 | | [Pubmed] | | 18 |
Rhinocerebral mucormycosis in a diabetic patient with cranial nerve involvement |
|
| Javadzadeh Bolouri, A. and Delavarian, Z. and Dalirsani, Z. and Tonkaboni, A. | | Pakistan Journal of Medical Sciences. 2011; 27(4): 911-914 | | [Pubmed] | | 19 |
Sequence of oral manifestations in rhino-maxillary mucormycosis |
|
| Doni, B.R. and Peerapur, B.V. and Thotappa, L.H. and Hippargi, S.B. | | Indian Journal of Dental Research. 2011; 22(2): 331-335 | | [Pubmed] | | 20 |
Mandibular Mucormycosis in Immunocompromised Patients: Report of 2 Cases and Review of the Literature |
|
| Mutan Hamdi Aras, Muhammed Isa Kara, Suna Erkiliç, Sinan Ay | | Journal of Oral and Maxillofacial Surgery. 2011; | | [VIEW] | [DOI] | | 21 |
Rare mycoses of the oral cavity: a literature epidemiologic review |
|
| Roberta Iatta,Christian Napoli,Elisa Borghi,Maria Teresa Montagna | | Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009; 108(5): 647 | | [Pubmed] | [DOI] | | 22 |
Hard palate perforation in acute lymphoblastic leukemia due to mucormycosis - A case report |
|
| Samanta, D.R. and Senapati, S.N. and Sharma, P.K. and Shruthi, B.S. and Paty, P.B. and Sarangi, G. | | Indian Journal of Hematology and Blood Transfusion. 2009; 25(1): 36-39 | | [Pubmed] | | 23 |
Rare mycoses of the oral cavity: a literature epidemiologic review |
|
| Iatta, R., Napoli, C., Borghi, E., Montagna, M.T. | | Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology. 2009; 108(5): 647-655 | | [Pubmed] | | 24 |
Hard palate perforation in acute lymphoblastic leukemia due to mucormycosis — a case report |
|
| Dipti R. Samanta,Surendra N. Senapati,Praveen K. Sharma,B. S. Shruthi,Prajna Bimoch Paty,Gitanjali Sarangi | | Indian Journal of Hematology and Blood Transfusion. 2009; 25(1): 36 | | [Pubmed] | [DOI] | | 25 |
Palatal mucormycosis: a rare clinical dilemma |
|
| Shetty, SR and Punnya, VA | | Oral Surgery. 2008; 1(3): 145-148 | | [Pubmed] | | 26 |
Mucormycosis in immunochallenged patients |
|
| Pak, J. and Tucci, VT and Vincent, AL and Sandin, RL and Greene, JN | | Journal of Emergencies, Trauma, and Shock. 2008; 1(2): 106 | | [Pubmed] | | 27 |
Invasive rhinomaxillary mucormycosis: a case report with a review of the literature |
|
| Sanjeev Jindal,Sunita Kulkarni,Soheyl Sheikh,Vinod V. Chandar,Dipti Bhatnagar,Amit Aggarwal | | Oral Radiology. 2008; 24(1): 42 | | [Pubmed] | [DOI] | | 28 |
Invasive rhinomaxillary mucormycosis: a case report with a review of the literature |
|
| Jindal, S. and Kulkarni, S. and Sheikh, S. and Chandar, V.V. and Bhatnagar, D. and Aggarwal, A. | | Oral Radiology. 2008; 24(1): 42-48 | | [Pubmed] | | 29 |
Palatal zygomycosis: experience of 21 cases |
|
| A Bonifaz, B Macias, F Paredes-Farrera, P Arias, RM Ponce, J Araiza | | Oral Diseases. 2008; 14(6): 569-574 | | [Pubmed] | [DOI] | | 30 |
Palatal mucormycosis: a rare clinical dilemma |
|
| S.R. Shetty,V.A. Punnya | | Oral Surgery. 2008; 1(3): 145 | | [Pubmed] | [DOI] | |
|
|
 |
 |
|
|
|
|
|
|
Article Access Statistics | | Viewed | 17545 | | Printed | 1091 | | Emailed | 16 | | PDF Downloaded | 0 | | Comments | [Add] | | Cited by others | 30 | |
|

|