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CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 3  |  Page : 269-274
 

Bismuth subnitrate iodoform parafin paste used in the management of inflammatory follicular cyst – Report of two cases


M.A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, India

Date of Web Publication31-Jul-2017

Correspondence Address:
Mayuri Kale
503, B.N. No. 5 Vakil Nagar, Erandwane, Pune - 411 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_328_16

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   Abstract 

Dentigerous cyst or follicular cyst is a type of odontogenic cyst which encloses the crown of an unerupted tooth and is attached to the amelocemental junction and is the second most common odontogenic cyst contributing about 16.6% to 21.3% of all odontogenic cysts. Occurrence of Dentigerous cysts according to Shear is usually in 3rd and 4th decade in contrast to this finding Shibata et al showed that the age of discovery of the dentigerous cyst was generally 9–11 years. The treatment indicated for dentigerous cysts are surgical enucleation of the cyst, along with removal of the involved tooth; or the use of a marsupialization technique, which removes the cyst while preserving the developing tooth. The present case report describes the management of dentigerous cysts in children with the use of Bismuth Subnitrate Iodoform Paste.


Keywords: Bismuth subnitrate iodoform paste, dentigerous cyst, enucleation


How to cite this article:
Morawala A, Shirol D, Chunawala Y, Kanchan N, Kale M. Bismuth subnitrate iodoform parafin paste used in the management of inflammatory follicular cyst – Report of two cases. J Indian Soc Pedod Prev Dent 2017;35:269-74

How to cite this URL:
Morawala A, Shirol D, Chunawala Y, Kanchan N, Kale M. Bismuth subnitrate iodoform parafin paste used in the management of inflammatory follicular cyst – Report of two cases. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jul 21];35:269-74. Available from: http://www.jisppd.com/text.asp?2017/35/3/269/211853



   Introduction Top


Dentigerous cyst or follicular cyst is a type of odontogenic cyst which encloses the crown of an unerupted tooth and is attached to the cementoenamel junction. It is the second most common odontogenic cyst after radicular cyst contributing about 16.6%–21.3% of all odontogenic cysts.[1],[2] In children, the frequency of odontogenic cysts is relatively low and about 9% of dentigerous and 1% of radicular cysts occur in the first decade of life. The frequency of dentigerous cyst formation has been calculated as 1.44 in every 100 unerupted teeth.[3],[4],[5]

As evident from the literature, an inflamed follicular cyst occurs more frequently in boys than girls. It occurs between 6 and 12 years of age and is ten times more likely to occur in the lower jaw than the upper. Cysts occur most frequently in the premolar region, while primary molars are destroyed by caries. A cyst is usually associated with the roots of a nonvital primary tooth and the crown of an unerupted permanent successor.[6]

Exact mechanism of dentigerous cyst formation remains unclear. Benn and Altini suggest that periapical inflammation from a nonvital primary tooth may spread to involve the follicle of the permanent successor and the inflammatory exudate leads to the formation of a dentigerous cyst and designated such cysts as inflammatory follicular cysts.[7],[8] Hence, treatment of carious deciduous teeth plays an important role in the prevention of formation of dentigerous cyst. Most dentigerous cysts are solitary. Bilateral and multiple cysts are usually found in association with a number of syndromes including cleidocranial dysplasia and Maroteaux–Lamy syndrome.[9]

While a normal follicular space is 3–4 mm, a dentigerous cyst can be suspected when the space is more than 5 mm.[10] As long as the cyst remains small, it is asymptomatic and usually only found by chance, for example, during routine radiography for orthodontic reasons. In general, a large cyst causes an intraoral buccal swelling; while at the same time, it may cause a springiness of the bone. It has the potential to expand the bone, displacing adjacent teeth and may cause root deformation of developing permanent teeth. A round or void, well-demarcated unilocular, radiolucency within the corpus of the mandible showing a sclerotic border is seen on radiograph suggestive of infl ammatory dentigerous cyst.[6],[10]

The treatment indicated for dentigerous cysts is surgical enucleation of the cyst along with removal of the involved tooth or the use of a marsupialization technique which removes the cyst while preserving the developing tooth.[11] The present case report describes the management of dentigerous cysts in children with the use of bismuth subnitrate iodine paraffin paste.

Bismuth subnitrate iodine paraffin paste is routinely used to pack nasal cavities. James Morrison Rutherford used bismuth iodoform paraffin paste (BIPP) to dress First World War soldier's wounds. BIPP Pack is sterile gauze (ribbon) impregnated with a paste containing one part bismuth subnitrate, two parts iodoform, and one part sterile liquid paraffin by weight.


   Case Reports Top


Case report 1

A 10-year-old girl reported to the Department of Preventive and Pediatric Dentistry with a chief complaint of a painless swelling in the mandibular right posterior region for 5 months.

On general examination, the patient was apparently healthy. Intraoral examination revealed a bony swelling which had caused a slight bulging of the buccal cortical bone of the mandibular right molar region. The swelling was ill defined, firm in consistency, painless on palpation. There were no signs of any acute periodontal condition or carious lesions. Radiographic examination revealed a well-circumscribed, unilocular, radiolucent lesion with sclerotic borders around the crown of unerupted mandibular second premolar [Figure 1].
Figure 1: Preoperative orthopantogram

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Based on clinical and radiological examination, a provisional diagnosis of dentigerous cyst was concluded. Aspiration biopsy revealed yellow straw-colored fluid, favoring the diagnosis of dentigerous cyst. Routine blood and urine investigations were within normal limits. Surgical enucleation of the dentigerous cyst and extraction of unerupted mandibular second premolar were done followed by packing the cavity with bismuth subnitrate iodoform paraffin paste since the defect was too large for a primary closure. Histological examination revealed that cyst was attached to the neck of the involved tooth. It showed granulation tissue with foreign body granulomas, inflammatory cell infiltration in the connective tissue lined by nonkeratinized squamous epithelium [Figure 2]. Dressing was changed once in every 10 days for over a period of 2 months. An uneventful rapid healing was observed with the use of BIPP [Figure 3]. Postoperative 6-month follow-up shows healthy healing as well accelerated bone formation radiographically [Figure 4].
Figure 2: Two months follow-up

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Figure 3: Histology investigation – H and E staining of the lesion

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Figure 4: Six months follow-up

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Case report 2

A 9-year-old female patient was referred to Department of Pedodontics and Preventive Dentistry with a chief complaint of pain and swelling in lower right back teeth region of jaw for 6 months.

The patient's medical history was nonsignificant except for thyroid problem at the time of birth. There were no associated syndromes present. Clinical examination revealed the presence of deep proximal caries and large swelling with respect to mandibular right primary first and second molar. Swelling was well defined, tender, afebrile, and bony hard on palpation. For further investigation, intraoral periapical radiograph, occlusal radiograph, panoramic radiograph, and cone beam computed tomography (CBCT) of the right side of the mandible were taken.

Radiographic examination carried out with the help of panoramic radiograph [Figure 5] revealed a well-circumscribed, unilocular, radiolucent lesion with sclerotic borders around the crown of unerupted right mandibular second premolar. The lesion was associated with a periapical area of the lower right second deciduous molar that exhibited deep occlusal caries involving enamel, dentin, and pulp, intrafurcal radiolucency, and considerable amount of root resorption in distal root.
Figure 5: Preoperative orthopantogram of Case 2

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Lower right first deciduous molar showed the presence of proximal caries involving enamel, dentin, and approaching pulp. The lesion extended laterally from the distal face of the first premolar to the mesial root of the lower left first permanent molar. The lower limit of the lesion was in proximity to the mandibular canal. For investigation purpose, CBCT was preferred as the extent of the cystic lesion could be precisely estimated. CBCT revealed the mesial and lateral displacement of the second premolar. CBCT revealed thinning of lingual cortical plate and perforating buccal cortical plate. The left lower premolar showed one-third root formation without any cystic formation [Figure 6], [Figure 7], [Figure 8].
Figure 6: Preoperative cone beam computed tomography of Case 2

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Figure 7: Preoperative cone beam computed tomography of Case 2

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Figure 8: Preoperative cone beam computed tomography horizontal section of Case 2

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Based on clinical and radiological examination, a provisional diagnosis of infected follicular cyst was made. Routine blood and urine investigations were within normal limits. Extraction of primary mandibular first and second molar was carried out. Surgical enucleation of the dentigerous cyst and extraction of unerupted mandibular second premolar were done followed by packing the cavity with bismuth iodoform paraffin paste since the defect was too large for a primary closure. The cyst was seen attached to the neck of the involved tooth. Dressing was changed once in every 10 days for over a period of 2 months.

Histological features show the presence of connective tissue stroma made up of delicate-to-dense arrangement of collagen fibers laid down haphazardly, interspersed fibroblasts, extravasated RBCs, and moderate number of inactive odontogenic islands suggestive of a dental follicle with moderate-to-abundant number of chronic inflammatory cells [Figure 9].
Figure 9: Histology investigation – H and E staining of the lesion of Case 2

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An uneventful rapid healing was observed with the use of BIPP [Figure 10]. Postoperative 6-month follow-up shows healthy healing as well as accelerated bone formation radiographically [Figure 11].
Figure 10: Two months follow-up of Case 2

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Figure 11: Six months follow-up of Case 2

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   Discussion Top


Occurrence of dentigerous cysts according to Shear is usually in the third and fourth decade in contrast to this finding. Mervyn showed that the age of discovery of the dentigerous cyst was generally 9–11 years. Dentigerous cyst is seen associated with unerupted mandibular second premolar, and the same finding was reported by Mervyn, where lower premolars are the most common site of occurrence of dentigerous cyst.[3],[12],[13]

Histopathogenesis of dentigerous cyst is unknown. It can be developmental in origin. The dentigerous cyst arises from the pooling of inflammatory exudate, which is derived from the obstructed follicular veins of an unerupted tooth and accumulates between the reduced enamel epithelium and the crown of the tooth. It enlarges by unicentric expansion from the hydrostatic pressure of its contents.[14] It can also occur due to inflammation present in surrounding environment of unerupted tooth. The inflammation at the apex of a deciduous tooth can lead to the development of another type of follicular cyst around the permanent successor, which has been termed inflammatory follicular cyst. Benn and Altini found clinical and histological evidence for this process and concluded that inflammatory exudate is induced by infection that spreads to the dental follicle, causing separation of the reduced enamel epithelium from the enamel.[8] In few cases, there is possibility of eruption of tooth within the radicular cyst associated with deciduous tooth resulting in the formation of an extrafollicular dentigerous cyst.[15],[16]

In above cases, the inflammatory reaction associated with the apex of the primary molar probably stimulated the proliferation of the reduced enamel epithelium of the adjacent developing premolar leading to cyst formation, as previously demonstrated by Benn and Altini [8] and Lustig et al.[17] Because of which, it has been diagnosed as inflammatory follicular cyst in relation with mandibular right second premolar.

The choice of treatment for a dentigerous cyst should be based on the size of the lesion, location of the cyst, age of the patient, dentition affected, and relationship with surrounding vital structures. Larger cysts are treated by marsupialization or decompression technique and are indicated for growing children and adolescents.[18] This procedure relieves the pressure of the cystic fluid, thus reducing the cystic space and allows the spontaneous eruption of the unerupted/impacted tooth.[6],[19],[20],[21] Conservative treatment of a dentigerous cyst in a permanent mandibular molar using erbium lasers has been reported. Enucleation of the cyst along with removal of the involved tooth has been favored by many authors which was the treatment of choice in the present case.[22],[23]

It has been suggested that marsupialization of the cyst lining is the treatment of choice for dentigerous cyst in children to give a chance to the unerupted tooth to erupt.[24] In both the cases, the cystic sac was surrounded by the unerupted premolar and was firmly attached to it; hence, enucleation of the cyst along with the extraction of premolar was carried out.

Rutherford Morrison introduced BIPP in 1916. It contains two parts of iodoform and one part of bismuth subnitrate or carbonate in a liquid paraffin base. It has many applications particularly in oral, maxillofacial, ear, nose, and throat, and neurosurgical practices. The use of BIPP makes impregnated gauze impervious to blood and body fluids ensuring little nutrition for bacteria to thrive in its interstices.[18] Bismuth has topical antiseptic properties and can be used as an astringent. This property contributes to the antibacterial properties of BIPP by releasing dilute nitric acid on hydrolysis iodoform (chemical name - triodomethane). This is another component of BIPP. It has a distinctive color as well as smell. Iodoform decomposes to release iodine which is an antiseptic. Paraffin is added into BIPP as a lubricant which aids in atraumatic placement and removal of pack. It also has the ability to stimulate granulation tissue. Its stability in the presence of necrotic tissue resulting in clean manageable cavities is remarkable in our experience. BIPP was used in the form of dressing since the defect was too large to hold the sutures given during primary closure. The cavity was packed with ribbon gauge impregnated with bismuth iodoform paste. The dressing was changed once every 10 days till 2 months until satisfactory healing was observed radiographically.


   Conclusion Top


Although it is recommended to manage large dentigerous cyst by conservative methods, enucleation alone is still so far an effective method of treatment especially in the case of inflammatory dentigerous cysts where complete specimen is retrieved for histopathological examination and appropriate diagnosis. BIPP as a dressing material in packing the cystic cavity proved effectual with rapid healing of the defect, less patient discomfort, and its compatibility to use. Its short-term application showed no systemic or local harmful effects on the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Waldron CA. Odontogenic cysts and tumours. In: Neville BW, Damn DD, Allen CM, Bouquot JE, editors. Oral and Maxillofacial Pathology. Philadelphia: W B Saunders; 1995. p. 493-540.  Back to cited text no. 1
    
2.
Kawamura JY, de Magalhães RP, Sousa SC, Magalhaes MH. Management of a large dentigerous cyst occurring in a six-year-old boy. J Clin Pediatr Dent 2004;28:355-7.  Back to cited text no. 2
    
3.
Mourshed F. A roentgenographic study of dentigerous cysts. I. Incidence in a population sample. Oral Surg Oral Med Oral Pathol 1964;18:47-53.  Back to cited text no. 3
    
4.
Shear M. Cysts of the Oral Regions. 3rd ed. Oxford: Write; 1992.  Back to cited text no. 4
    
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Main DM. Epithelial jaw cysts: 10 years of the WHO classification. J Oral Pathol 1985;14:1-7.  Back to cited text no. 5
    
6.
Kozelj V, Sotosek B. Inflammatory dentigerous cysts of children treated by tooth extraction and decompression – Report of four cases. Br Dent J 1999;187:587-90.  Back to cited text no. 6
    
7.
Donath K. Odontogenic and nonodontogenic jaw cysts. Dtsch Zahnarztl Z 1985;40:502-9.  Back to cited text no. 7
    
8.
Benn A, Altini M. Dentigerous cysts of inflammatory origin. A clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:203-9.  Back to cited text no. 8
    
9.
Gorlin RJ. Cysts of the jaws, oral floor and neck. In: Gorlin RJ, Goodman HW, editors. Thoma's Oral Pathology. 6th ed., Vol. 1. St. Louis: Mosby; 1970.  Back to cited text no. 9
    
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Goaz PW, Stuart CW. Cysts of the jaws. In: Oral Radiology, Principles and Interpretation. 3rd ed. St. Louis: Mosby; 1994. p. 400.  Back to cited text no. 10
    
11.
O'Neil DW, Mosby EL, Lowe JW. Bilateral mandibular dentigerous cysts in a five-year-old child: Report of a case. ASDC J Dent Child 1989;56:382-4.  Back to cited text no. 11
    
12.
Mervyn S. Speight Paul Cysts of the Oral and Maxillofacial Regions. 4th ed. Australia: Blackwell Publishing; 2007.  Back to cited text no. 12
    
13.
Daley TD, Wysocki GP, Pringle GA. Relative incidence of odontogenic tumors and oral and jaw cysts in a Canadian population. Oral Surg Oral Med Oral Pathol 1994;77:276-80.  Back to cited text no. 13
    
14.
Browne RM. The pathogenesis of odontogenic cysts: A review. J Oral Pathol 1975;4:31-46.  Back to cited text no. 14
    
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Shear M. Developmental odontogenic cysts. An update. J Oral Pathol Med 1994;23:1-11.  Back to cited text no. 15
    
16.
Wood RE, Nortjé CJ, Padayachee A, Grotepass F. Radicular cysts of primary teeth mimicking premolar dentigerous cysts: Report of three cases. ASDC J Dent Child 1988;55:288-90.  Back to cited text no. 16
    
17.
Lustig JP, Schwartz-Arad D, Shapira A. Odontogenic cysts related to pulpotomized deciduous molars: Clinical features and treatment outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:499-503.  Back to cited text no. 17
    
18.
Neville BW, Damm DD, Allen CM, Bouquot JE. Odontogenic cysts and tumors. In: Neville BW, editor. Oral and Maxillofacial Pathology, 2nd ed. Philadelphia, PA: W.B. Saunders; 2002. p. 589-642.  Back to cited text no. 18
    
19.
Martínez-Pérez D, Varela-Morales M. Conservative treatment of dentigerous cysts in children: A report of 4 cases. J Oral Maxillofac Surg 2001;59:331-3.  Back to cited text no. 19
    
20.
Desai RS, Vanaki SS, Puranik RS, Tegginamani AS. Dentigerous cyst associated with permanent central incisor: A rare entity. J Indian Soc Pedod Prev Dent 2005;23:49-50.  Back to cited text no. 20
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21.
Motamedi MH, Talesh KT. Management of extensive dentigerous cysts. Br Dent J 2005;198:203-6.  Back to cited text no. 21
    
22.
Gondim JO, Neto JJ, Nogueira RL, Giro EM. Conservative management of a dentigerous cyst secondary to primary tooth trauma. Dent Traumatol 2008;24:676-9.  Back to cited text no. 22
    
23.
Muthray E, Desai J, Suleman Y, Meer S. Inflammatory dentigerous cyst in a 3 year old South African black male: A case report. SADJ 2006;61:252, 254-5.  Back to cited text no. 23
    
24.
Scott-Brown Otolaryngology. 6th ed. Australian journal of otolaryngology. Butterworth-Heinemann; 1996.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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