Malignant neoplasm in association with dental osseointegrated implants Song-Hee Oh Yoon-Joo Choi, Hwa-Young Choi, Sae-Rom Lee, Jae-Jung Yu*, Gyu-Tae Kim, Yong-Suk Choi, Eui-Hwan Hwang Dept. of Oral and Maxillofacial Radiology, School of Dentistry, Kyung Hee University Institute of Oral Biology, School of Dentistry, Kyung Hee University *Dep. of Oral and Maxillofacial Radiology, Kangdong SacredHeart Hospital, Hallym Medical Center Good afternoon, My name is Oh Song Hee. I am honored by the invitation to present my research findings to you. My presentation today describes two case reports of the malignant neoplasm in association with dental implant.

CONTENTS Introduction Case report Literature Review Discussion Conclusion

INTRODUCTION Dental implants have become a routine procedure in the clinical practice of dentistry. Dental implants have become a routine procedure in the clinical practice of dentistry.

INTRODUCTION However, the number of associated complications such as peri-implantitis, maxillary sinusitis, osteomyelitis, and neoplasm has risen in proportion to the increased demand for implant treatment. The number of associated complications have risen in proportion to the increased demand for implant treatment. ex) peri-implantitis, sinusitis, ostemyelitis and neoplasm etc.

INTRODUCTION Although severe complications are uncommon, in recent years several cases of malignant tumors such as oral squamous cell carcinoma have been reported to develop around dental implants. Although severe complications are uncommon, in recent years, several cases of malignant tumors, such as oral squamous cell carcinoma, have been reported to develop around dental implants. Today, I will present two such cases of malignant neoplasm around dental implants referred to the Kyung-Hee University dental hospital in Seoul, South Korea.

The First Case

75-year-old-Male Chief Complain Dental histroy Paresthesia on the left lower lip & a firm mass in the left cheek area. (onset : 1 month ago) Dental histroy extraction on #36 (onset : 7 months ago) Implant surgery after extraction #36 (onset : 4 months ago) explantation due to peri-implantitis (onset : 1 month ago) Medical history : N/S The first case involved a 75-year-old male patient who was referred by a local clinic for evaluation of paresthesia on the left lower lip and a firm mass in the left cheek area manifesting approximately one month prior. According to the dental history of the patient, extraction of the first molar of the left mandible was performed due to a periapical abscess. Following the extraction, the patient had implant surgery approximately 4 months ago. However, he had to undergo explantation one month ago due to peri-implantitis.  

Present Illess Facial swelling (+) & a firm mass on Lt side with tenderness to palpation(-), induration (+), local heat (-) Erythematous enlarged mass (+) on #36 lingual side with tenderness to palpation(+), pus discharge (-) Paresthesia (+) on Lt lower lip area At the time of the first visit to our hospital, he had facial swelling and a firm mass on left cheek area. And in the intra-oral examination, there was an erythematous enlarged mass on the lingual side. A B Figure 1. The clinical extra & intra-oral finding. Facial swelling on the left cheek area (A) and erythematous enlarged mass on lingual side(B).

First visit to local clinic (7 months ago) The patient visited his local clinic 7 months ago with the chief complaint of pain in the first molar of the left mandible  and panoramic and periapical radiographs were taken. This revealed a monolocular radiolucent lesion and sclerotic bone change. The dentist diagnosed this lesion as a periapical abscess and decided to extract the tooth. 치료과정에서의 첫번째 실수 : 치료방법으로 재신경치료를 시도했었어야 했다. Figure 2. The panoramic and periapical radiographs were taken 7 months ago. The image a monolocular radiolucent lesion and sclerotic bone change.

3 months after the extraction Three months after the extraction, the patient had implant surgery However, the range of bone destruction was more extensive than that observed on the initial periapical view. 두번째 실수 : 임플란트 수술 전에 골의 상태나 치유정도를 확인하기 위한 영상검사를 실시 하지 않았다. Figure 3. The panoramic and periapical radiographs were taken 3 months after the extraction. The image shows more extensive bone destruction than that observed on the initial periapical view.

3 months after implant surgery Three months after implant surgery, the patient revisited the clinic, complaining of gingival swelling around the surgery site. The dentist removed the implant because he thought that the surgery had failed due to peri-implantitis. However, following explantation, the patient began to experience paresthesia on the left lower lip and gingiva. Figure 4. The panoramic radiograph was taken 3 months after implant surgery.

Referred to our hospital Finally, he was referred to our hospital, and panoramic radiography was performed. There was diffuse and infiltrative bone destruction in the apical area of involved tooth. (from second premolar to second molar) Compared with the panoramic view in the local clinic, at the time he visited our hospital, the lesion had already extended to the mandibular canal. Thus, the mandibular canal cortication appeared indistinct. Figure 5. The panoramic radiograph shows diffuse and infiltrative bone destruction in the apical area. And the mandibular canal cortication appeared indistinct.

On the periapical view, there was infiltrative bone destruction and an enlarged soft tissue shadow. Figure 6. Periapical view shows infiltrative bone destruction and the arrow indicate an enlarged soft tissue shadow.

On an occlusal view, we were unable to detect erosive change of the buccal and lingual cortical plates. Figure 7. Occlusal cross view doesn’t show erosive change of the buccal and lingual cortical plates.

Figure 8. CBCT image (Sagittal view) shows invasive bone destruction in the apical area of tooth and loss of mandibular canal were observed. On sagittal view CBCT, invasive bone destruction in the apical areas of tooth and loss of mandibular canal cortication were observed. On a cross-sectional view, there was partial perforation and erosion of the buccal and lingual cortical plates. Figure 9. CBCT image (Cross-sectional view) the arrow line indicates perforation and erosion of the buccal and lingual cortical plates.

A. H&E staining, x100. B. H&E staining, x1000. Figure 10. Final soft tissue specimen showing solitary plasmacytoma lesion. A. H&E staining, x100. B. H&E staining, x1000. The patient diagnosed as Solitary plasmacytoma finally according to histopathological findings, and the patient is currently receiving radiation treatment.

The Second Case

43-year-old-Male Chief Complain Dental histroy Medical history : N/S Painful gingival swelling on peri-implant (#47i) area (onset : 7 month ago) Dental histroy Implant installation after extraction #47 (onset : 1 year ago) Medical history : N/S Present Illess Ulcerative gingival enlargement (+) on #46i, 47i area with tenderness to palpation (+), redness (+), pus discharge (-) Lymphadenopathy(+) on Rt. sub mandibular area The second case involved a 43-year-old man who was referred with a painful ulcerative lesion around the implant area. According to his dental history, he underwent the implant surgery a year prior and begun to experience the pain approximately seven months ago. Upon oral examination, it was discovered that he had an ulcerative gingival hyperplasia on the alveolar ridge around the implant. However, there was no sign of inflammation, such as pus discharge.

The following are panoramic and periapical images taken at his first visit to our hospital. The image shows bony destruction with an ill-defined border around the dental implant fixture as well as an enlarged soft tissue shadow. Figure 1. The panoramic radiograph shows bony destruction with an ill-defined border around the dental implant fixture as well as periapical radiograph shows enlarged soft tissue shadow.

Sonography revealed a well-demarcated heterogeneous echogenic mass with peripheral feeding vessels. Figure 2. Sonography revealed a well-demarcated heterogeneous echogenic mass with peripheral feeding vessels.

A B Well-differentiated squamous cell carcinoma was diagnosed on the basis of histopathologic analysis. C D Figure 3. Final soft tissue specimen showing squamous cell carcinoma (SCC) lesion. A. H&E staining, x100 B. H&E staining, x400 C. H&E staining, x100 D. H&E staining, x400

LITERATURE REVIEW As mentioned earlier, although severe complications due to dental implant surgery such as malignant tumor are uncommon, a small number of cases of malignancy have been reported. Valle et al. reported on a patient who had primary oral squamous cell carcinoma arising around dental implants mimicking peri-implantitis. Valle et al. reported on a patient who had primary oral squamous cell carcinoma arising around dental implants mimicking peri-implantitis.

LITERATURE REVIEW Multiple myeloma adjacent to the dental implant has also been reported by Junquera et al. Multiple myeloma adjacent to the dental implant has also been reported by Junquera et al.

Is it indeed the implant itself that is the cause of the cancer? This raises the question: is it indeed the implant itself that is the cause of the cancer?

DISCUSSION Asier E et al. healthy periodontal tissue acts as a natural barrier, preventing the progression of a malignant tumor, while dental implants provide a suitable environment that assists rapid growth and bone infiltration of malignant lesions . 4 Hussein et al. hypothesized that the trauma to the skeletal system could cause the release of cytokines leading to clonal proliferation and accumulation. Similary, the dental implants itself would be a trauma to the jaws that could cause an increase in inflammatory cytokines. 5 According to Asier, healthy periodontal tissue acts as a natural barrier, preventing the progression of a malignant tumor, while dental implants provide a suitable environment that assists rapid growth and bone infiltration of malignant lesions. Hussein et al. hypothesized that the trauma to the skeletal system could cause the release of cytokines leading to clonal proliferation and accumulation. Similarly, the dental implant itself would constitute a trauma to the jaws that could cause an increase in inflammatory cytokines.

DISCUSSION Recently, a number of studies regarding the relevance of inflammation in terms of cancer have been reported in several organ systems. 2,3 Chronic inflammation impacts decisive celluar processes such as proliferation, adhesion, apoptosis, angiogenesis and transfomation. 2,3 Recently, a number of studies regarding the relevance of inflammation in terms of cancer have been reported in several organ systems. Chronic inflammation impacts decisive  cellular processes such as proliferation, adhesion, apoptosis, angiogenesis, and transformation.

DISCUSSION Inflammation: important in cancer, important in symptoms Mantovani described inflammation as the 7th hallmark of cancer, (Nature 2008) it is also known to play a critical role in the pathogenesis of malignancy. It is also known to play a critical role in the pathogenesis of malignancy.

CONCLUSION Even though a clear cause-effect relationship cannot be established, there is a possibility that the implant treatment may be a risk factor for developing malignant neoplasm. As demonstrated in our two case reports, the potential for mucosal hyperplasia and bone destruction around dental implants means that it is imperative to carry out an exhaustive differential diagnosis to rule out malignancy. Delayed diagnosis for malignant neoplasm results in extended destruction of surrounding tissues and result in a poor prognosis for the patient. In conclusion, even though a clear causal relationship cannot be established, there is a possibility that dental implant treatment may be a risk factor for developing malignant neoplasm. As demonstrated in our two case reports, the potential for mucosal hyperplasia and bone destruction around dental implants means that it is imperative to carry out an exhaustive differential diagnosis to rule out malignancy. Thus, it is important to bear in mind that a delayed diagnosis of malignant neoplasm results in extended destruction of surrounding tissues and results in a poor prognosis for the patient.

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Thank you for your attention!