Introduction PTEN-hamartoma tumor syndrome (PHTS) is due to phosphatase and tensin homolog gene (PTEN, located on 10q23.3) deletion or mutation. This results in the loss of function of PTEN tumor suppressor inhibitory effects and regulation of cell proliferation, leading to the development of hamartomas and benign and malignant tumors. Methods and Materials Two preadolescent females presented with markedly enlarged thyroids, which upon ultrasound examination demonstrated multiple nodules of variable sizes. Thyroid function tests were not abnormal. Fine needle aspirations of the thyroid nodules demonstrated benign follicular lesions. Total thyroidectomies identified numerous multifocal follicular adenomas ranging from macroscopic to microscopic in size, with no malignant features. Results Molecular testing identified PTEN mutation with thyroid tissue, and subsequently identified germline PTEN mutation in both patients. Upon follow-up screening examination, a benign lipoma and hamartomatous ductal hyperplasia with PASH (pseudoangiomatous stromal hyperplasia) were identified in one patient; while the other patient had a breast intraductal papilloma and PTEN hamartoma of soft tissue (PHOST) involving an extremity. Both patients will be followed long-term for the development of other lesions. Conclusion PTEN-hamartoma tumor syndrome (PHTS) is primarily comprised of Cowden Syndrome and Bannayan–Riley–Ruvalcaba syndrome, and less often by Proteus-like syndrome, autism with macrocephaly, and other syndromes. A variety of thyroid diseases occurs in at least 75% of children with PHTS, with multiple adenomatous nodules being the hallmark, as in the present cases. Other thyroid diseases include lymphocytic thyroiditis, multinodular hyperplasia, and C-cell hyperplasia. The major long-term concern is the development of malignant tumors. Lifetime risk of cancer in individuals with PTEN mutations is significant and involves many organ systems (85% breast, 35% thyroid, 30% endometrium, 30% kidney, 12% colorectum, 5% melanoma). Multiple adenomatous nodules in a child may lead to the discovery of PHTS and reinforce the need for tumoral genetic testing in such instances.

Introduction ALK-rearranged histiocytosis was first described in 2008 in 3 infants with liver and hematopoietic involvement. Subsequently, this entity has been further defined in case reports and series (majority pediatric cases) with the identification of ALK and histiocytic immunohistochemical marker expression and recurrent ALK fusions (majority KIF5B::ALK). Less common ALK rearrangements have been described (CLTC::ALK, TPM3::ALK, TFG::ALK, EML4::ALK, DCTN1::ALK, COL1A2::ALK, SQSTM1::ALK). Materials and Methods ALK-rearranged histiocytosis in 8 patients (age range: 18 months to 17 years; 4M:4F) involved the head and neck region (4 cervical neck; 2 periparotid; 2 peritonsillar). The masses were freely movable on palpation. The children were without symptoms. Clinical and radiologic impression was lymph node with Langerhans cell histiocytosis, lymphoma, or sarcoma. Results Upon gross examination, the masses were relatively well-circumscribed, fleshy, and without necrosis, resembling lymphoma/sarcoma (tumor size: 1.6 to 5.6 cm in greatest dimension). These tumors had variable epithelioid to spindled morphology with a high degree of cellularity. ALK, CD68, and CD163 were uniformly strongly positive, only focally positive for S100, and negative for CD1a and CD207 (Langerin). Electron microscopy on limited cases demonstrated epithelioid cells with prominent infolding of nuclei and no Birbeck pentalaminar granules. Molecular fusion panel identified ALK fusions (4 KIF5B::ALK, 1 COL1A2::ALK, 1 CLTC::ALK, 1 EML4::ALK; 1 MSN::ALK). Conclusions ALK-rearranged histiocytosis is a relatively rare subtype of histiocytosis, characterized by histiocytic and ALK immunohistochemical expression and ALK rearrangements. There are distinct clinical groups: Group 1A - infants with multisystemic disease with liver and hematopoietic involvement; Group 1B – other individuals with multisystemic disease; Group 2 - individuals with single-system disease. With epitheloid to spindled lesions with ALK immunoexpression, additional histiocytic marker immunostaining is required for the diagnosis of ALK-rearranged histiocytosis, with subsequent molecular characterization. It is important to identify this entity because ALK and MAP-kinase inhibitors have therapeutic benefits.

Abstract Aim The aim of this case series is to provide a detailed account of pediatric cases with bifid mandibular canal (BMC) along with clinical implications. Background The prevalence of BMC on panoramic radiographs has been reported to be 0.03–1.90% in adults. Only one study reported prevalence of BMC in children based on cone-beam computed tomography (CBCT) images. As CBCT images are not routinely prescribed in children, it is important to understand if panoramic radiographs provide a valuable tool to diagnose BMC in children. Case description This case series provides a review of three cases of nonsyndromic, bilateral BMC, and associated radiculomegaly affecting mandibular permanent first molars in children during the mixed dentition stage. An overview of clinical implications of BMC in children is also discussed to help clinicians provide appropriate dental care and anticipatory guidance. Conclusion Bifid mandibular canal (BMC) has never been reported in children during mixed dentition stage based on panoramic radiographs. This is the first case series reporting BMC and associated dental anomalies in children. Clinical significance This case series will help clinicians in diagnosing BMC during mixed dentition stage and understand its clinical implications. Additionally, this case series will help define future cross-sectional studies evaluating BMC and associated dental anomalies in children. How to cite this article Puranik CP, Chandki R, Mladenovic R, et al. Bifid Mandibular Canals: A Pediatric Case Series with Clinical Implications. Int J Clin Pediatr Dent 2023;16(3):547-549.

Objectives This quality improvement and safety project assessed the coronavirus disease 2019 (COVID-19) risk factors of the patient population at the University of Colorado School of Dental Medicine for the purpose of developing an operational strategy for modifying patient care protocols and clinic infrastructure during the pandemic. Study Design The data consist of retrospectively collected information on all patients treated at the University of Colorado School of Dental Medicine between March 1, 2019, and March 31, 2020, retrieved from the electronic dental health record. Variables of interest focused on patients treated by predoctoral students and included age group, race/ethnicity, and major comorbidities for COVID-19 risk. Patients were placed into 3 risk categories based on age and health status: Minimal (no comorbidities), high (comorbidities), and highest (>65 years and comorbidities). Descriptive statistics were calculated on the cohort. No hypothesis testing or statistical inference was employed. Results A total of 10,958 patients, with a median age of 53 (interquartile range, 34, 67) and equal sex distribution (F = 50%; M = 49.8%), treated by predoctoral students were identified. White, Hispanic, black, and mixed race accounted for 58.4%, 20.9%, 13.1%, and 2.2%, respectively. Regarding major comorbidities, 29.9% had 1, 14.8% had 2, and 9.1% had ≥3 (median = 1; interquartile range, 0, 1), with 53.5% of those ≥65 years having 3+ diseases. The most common comorbidities were cardiovascular disease (24.5%); diabetes (9.9%); immunocompromised, including HIV; and chronic corticosteroid use (9.5%), cancer (8.2%), and pulmonary disease (7.9%). The prevalence of tobacco smoking was 26.5%. Most patients were defined as high (30.9%) or highest (23%) risk, with 77.5% of those ≥75 years in the highest risk category. Stratifying by race/ethnicity, those with ≥1 comorbidities were distributed as follows: white = 62.3%, black = 56.8%, Hispanic = 40.4%, and mixed race = 64.4%. Conclusions Most patients treated by predoctoral dental students in the main clinic were classified as high or highest risk for COVID-19 infection, and this risk increased with age. Information from this quality improvement project was critical for understanding the medical complexity of the patient pool and justifying major scheduling and infrastructure changes for safe delivery of clinical care in an academic environment.

A wide variety of oral lesions and soft tissue anomalies are detected in children, but the low frequency at which many of these entities occur makes them challenging to clinically diagnose. The purpose of this chapter is to highlight selected oral lesions that are most commonly found in children and pathologic entities that primarily develop in this age group. In addition, oral lesions associated with several genetic disorders and specific malignancies, which may mimic benign or inflammatory conditions, are included to broaden the disease scope. The material is outlined in tables to make this comprehensive subject more succinct and easier to review. The brief description for each entity summarizes the most important clinical information that is relevant to the child patient. Representative examples of these conditions are included to illustrate the characteristic clinical or radiographic features.

Oral health is integral to general health. The oral cavity may harbor manifestations of systemic disease and can be the harbinger of early onset. Primary care providers (PCPs) can therefore use the oral cavity to support working diagnoses. Conversely, systemic diseases and treatments can affect oral health and require interactions between PCPs and dental providers. Acute oral manifestations of systemic disease may involve teeth and/or gums. This article reviews oral and systemic disease connections for some diseases, identifies issues that benefit patients through medical-dental collaboration, and highlights some nondental oral injuries that might confront PCPs or emergency medical providers.

Purpose: Few data exist on combining pediatric surgical procedures under a single general anesthetic encounter (general anesthesia). We compared perioperative outcomes of combining dental surgical procedures with tonsillectomy during one anesthetic vs separate encounters. Methods: We classified elective tonsillectomy +/- adenoidectomy and restorative dentistry as combined (group C) or separate (group S). Outcomes included anesthesia time, recovery duration, the need for overnight hospital stay, and postoperative complications. Results: Patients aged 4 +/- 1 years underwent tonsillectomy and dental surgery in combination (n=7) or separately (n=27). No differences were noted in total anesthesia time (C: median: 150, interquartile range [IQR]: 99, 165 vs S: median: 109, IQR: 92, 132; 95% CI of difference in median: -58, + 10 minutes; P=0.115) and total recovery time (C: median: 54, IQR: 40, 108 vs S: median: 72, IQR: 58, 109; 95% CI of difference in median: -16, +48 minutes; P=0.307). The need for overnight stay (C: 4 of 7, S: 20 of 27; P=0.394) did not differ between the groups. No postoperative complications were noted in either group. Conclusion: These preliminary data support the potential feasibility of combining dental procedures with tonsillectomy during a single anesthetic encounter. Such care may not only reduce costs but also limit parental work absences and increase convenience for patient families. When compared with procedures performed separately, combined procedures did not result in increased morbidity or significant changes in postoperative outcomes.

The Archives of Pathology & Laboratory Medicine acknowledges the following individuals for volunteering to review abstract and case study submissions for the CAP17 meeting.

Purpose: The purpose of this study was to assess the caries experience in the primary dentition of children born with cleft lip and palate (CLP). Methods: A retrospective chart review was conducted on subjects between two and six years old recruited from a university-based pedi-atric dentistry residency clinic. The number of dental visits and professional fluoride applications, the plaque index and treatment modality, and the presence/location of caries, white spot lesions, and enamel hypoplastic lesions were compared between CLP patients and healthy age-and gender-matched controls. Descriptive statistics, Student's t test, Mann-Whitney U test, and regression analysis were completed. Results: A total of 183 charts were reviewed. Compared to healthy children, CLP children had increases in number of dental visits (P<0.001), decayed-missing-filled surfaces (dmfs; P<0.001), decayed-missing-filled teeth (dmft; P<0.001), enamel hypoplastic lesions (P=0.003), treatment completed under general anesthesia (P<0.001), plaque score (P<0.001), and caries increment between baseline and most recent oral examination (P=0.003). Regression analysis revealed a positive association between age and dmft scores within the CLP group (P=0.018). The caries experience of unilateral and bi-lateral CLP cases was the same (P>0.05). Conclusions: Children with cleft lip and palate are at a greater risk of enamel hypoplasia and dental caries. No significant caries experience difference was found between unilateral or bilateral CLP cases.

This case report describes a recently identified round cell sarcoma, BCOR-ITD URCSI, involving the head and neck in an infant and reviews the clinicopathologic and molecular genetic features of this tumor.

PURPOSE:To characterize traditional Chinese medicine (TCM) use, emphasizing herbal remedies, for oral conditions among two Chinese pediatric populations in the United States.METHODS:318 unique ethnic Chinese parental units in Houston and Boston with children younger than 12 years old were interviewed for themselves and their children. Questionnaire included age, gender, duration in the United States, frequency of TCM use, and the five selected oral conditions for which TCM agents might be used.RESULTS:Parents (45.6 percent) and children (19.1 percent) used TCM for oral conditions, most commonly for aphthous ulcers (64.2 percent). Most commonly used TCM agents included watermelon frost (37.4 percent), niuhuang jiedu pian (15.5 percent), and honey/propolis (9.9 percent). Chi-square tests with logistic regression (P<0.05) showed duration of U.S. residency significantly affected (P=0.002), parental TCM usage, age group (P=0.003), and birth location (P=0.02) related to child use. Parental TCM use increased child likelihood of use (P<0.0001).CONCLUSIONS:In this study, traditional Chinese medicine was widely used for oral conditions by Chinese immigrants. Factors such as duration of U.S. residency, age, birth location, and parental use affect utilization of TCM in this population. Future studies are needed to explore the therapeutic properties of the various components of TCM.

Purpose: The purpose of this in vitro pilot study was to evaluate the effects of xylitol and sodium fluoride containing dentifrices on the surface topography of sound human enamel following acid-etching, using scanning electron microscopic (SEM) techniques. Methods: Enamel surfaces from caries-free human molar teeth (n=10) underwent debridement, and dental prophylaxis. Each tooth was sectioned into 5 portions, with each tooth portion assigned to a specific treatment group: 1) acid-etching (35% phosphoric acid gel, 60 seconds); 2) acid-etching followed by synthetic saliva rinsing; 3) acid-etching followed by treatment with Fluoride Free Xylitol Toothpaste (25% xylitol) and synthetic saliva rinsing; 4) acid-etching followed by treatment with Fluoride and Xylitol Toothpaste (31% xylitol, 0.243% sodium fluoride) and synthetic saliva rinsing; and 5) acid-etching followed by treatment with Sodium Fluoride Toothpaste with No Xylitol (0.243% sodium fluoride) and synthetic saliva rinsing. Enamel surfaces from an additional 10 caries-free human teeth served as untreated control teeth that only underwent soft tissue debridement and prophylaxis. Dentifrice treatment was performed for 120 seconds twice daily with synthetic saliva rinsing between dentifrice applications followed by synthetic saliva rinsing at 37°C for 7 days with fresh synthetic saliva replenished on a daily basis. Following the experimental period, the tooth portions were prepared for scanning electron microscopy using standardized techniques. Results: Acid-etching alone created type 1 etching patterns with a finely porous enamel surface. With acidetching followed by synthetic saliva rinsing, the effects of acid-etching were obscured by a finely granular surface coating with fine porosities. With acid-etching followed by xylitol only dentifrice treatment and synthetic saliva rinsing, enamel surfaces showed fine granular coatings with no obvious porosities. Enamel surfaces that were acid-etched then treated with the xylitol with fluoride dentifrice and rinsed with synthetic saliva possessed homogenous surface coatings with areas with finely granular to globular deposits. Acid-etched enamel surfaces that were treated with the fluoride dentifrice without xylitol and rinsed with synthetic saliva had surface coatings with numerous relatively large globoid deposits, morphologically resembling calcium fluoride deposits. Clinical significance: The clinical application of the results from the current in vitro pilot study relate to the procedure of acid-etching teeth for adhesive dental materials. With acid-etching, there is a residual exposed etched enamel surface following sealant, restoration or orthodontic bracket placement. Application of xylitol containing fluoridated dentifrice may facilitate fluoride uptake from the dentifrice and calcium and phosphate uptake from saliva, aid in the elimination of the surface effects of acid-etching, and allow for remineralization of the acid-damaged enamel surface that was not protected by adhesive resin placement.

Purpose: The purpose of this study was to document the amount of wear caused by ceramic materials to opposing enamel in primary teeth using an in vitro model. Methods: The localized wear by two different ceramic materials (alumina and zirconia) on primary tooth enamel was accomplished using a Leinfelder style in vitro wear test apparatus on 15 samples for 800,000 cycles each. The maximum wear height, width, and depth were measured with a traveling 20X microscope. Descriptive statistics, student's t test, and Mann-Whitney test were used to analyze enamel wear by the dental ceramics. Results: The height, width, and depth of the alumina samples were 1186.7 mu m, 10975 mu m, and 123.0 mu m, respectively. The height, width, and depth of the zirconia samples were 1113.4 mu m, 1082.2 mu m, and 192.7 mu m, respectively. No statistical difference was observed between the alumina and zirconia in this wear test (P>0.05). Conclusion: Although enamel wear was documented in both groups, the amount of in vitro wear was minimal, suggesting that ceramic crowns can be used without resulting in excess enamel loss to occluding primary teeth.

Nodular Fasciitis (NF) is a rapidly growing benign myofibroblastic proliferation that may mimic a spindle cell sarcoma. Although a history of trauma is often elicited, recently NF has been proven to be clonal with rearrangement of USP6 by FISH, and fusion of MYH9 with USP6 [t(17p13)(22q12,3-q13)].

PURPOSE:To investigate postdischarge events occurring in children during the 24 hours following sedation for dentistry.METHODS:A convenience sample of 50 children undergoing sedation with combinations of midazolam, hydroxyzine, and meperidine were included. Parents received a standardized timesheet to record child's behavior, alertness, activity level, motor imbalance, emesis, and soft tissue trauma every two hours from discharge until bedtime. A questionnaire asked about transportation, supervision, and return to normal activity. Families were telephoned after 24 hours to collect the information.RESULTS:Sixty-six percent of children slept in the car; of these, 30 percent were supervised by only the driver, and 12 percent were difficult to awaken. Agitation was observed in 22 percent, restlessness in 10 percent, withdrawn behavior in 16 percent, and soft tissue trauma in 18 percent. Motor imbalance was significantly associated with midazolam (P=.002), as was restlessness (P=.004). Eighty-two percent slept between discharge and bedtime, with 16 percent sleeping for greater than four hours. Return to normal activity was greater than four hours in 36 percent, and was inversely correlated with age (P=.02).CONCLUSIONS:Postdischarge sleepiness, drug-specific motor imbalance, sleep during transit, and recovery times greater than four hours were common and warrant vigilant adult supervision.