All Topics (with details-not just images,tx,etiologies, more!) Flashcards

Question

What is the radiographic finding?

Answer 1

Paradental Cyst

Answer 2

Paradental Cyst

Answer 3

-Removal * Enucleation if small * Marsupialization if large * Note:* * Enucleation* means: removal of an organ or other mass intact from its supporting tissues *Marsupialization* means: surgical technique of cutting a slit into an abscess or cyst to empty its contents and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst or abscess. Promotes Decompressing and shrinkage.

Answer 4

Some controversy over this designation ‐ some think they are inflammatory cyst ‐ some think they are developmental cysts ▪ Etiology: _remains unclear_

Answer 5

* Radiolucent area noted * most frequently, along the distal aspect of an impacted or partially erupted third molar

Answer 6

**Buccal Bifurcation Cyst** *as seen in occlusal radiographs*

Answer 7

**Buccal Bifurcation Cyst** *as seen in occlusal radiographs*

Answer 8

**Paradental Cyst**

Answer 9

**Extraction** of the _tooth along with the lesion_

Answer 10

_Similar to **a paradental cyst**_ ‐ **EXCEPT**: location is _central on the buccal of mandibular first molars_

Answer 11

The eruption of ***the permanent first molar***

Answer 12

seen as * swelling * tenderness of soft tissue over involved area

Answer 13

_dentigerous cys_t b/c **\*attachment at CEJ**

Answer 14

**Dentigerous Cyst**

Answer 15

**dentigerous cyst**

Answer 16

**dentigerous cyst**

Answer 17

**dentigerous cyst**

Answer 18

Grossly image of ## Footnote **Dentigerous Cyst**

Answer 19

* **Decompression**: Try to open window in the jawand put tube into cyst lumen and have pt irrigate a few times a day for a few weeks ► release pressure and allows bone to grow back ► **cyst will shrink** * If get rid of whole area surgically► c_an risk_ _fracturing the jaw_

Answer 20

▪ Radiolucency best seen with **an occlusal radiograph**

Answer 21

▪ **Enucleation** **of cyst**; tooth extraction unnecessary ▪ Some cases _resolve w/o surgery_ ▪ Some resolve _w/ daily irrigation_ of buccal pocket with saline/hydrogen peroxide

Answer 22

**Follicular Cyst**

Answer 23

**Dentigerous Cyst**

Answer 24

**Eruption Cyst**

Answer 25

**Eruption Cyst**

Answer 26

*_Originates_*: by **the separation** of the _follicle_ from the _crown of an unerupted tooth_ *_Pathogenesis_*: **accumulation of fluid** between the tooth and the _reduced enamel epithelium_

Answer 27

▪ Small cysts typically asymptomatic and picked up on routine radiographic exam ▪ Large lesions may show expansion of bone ▪ Cysts may become infected, especially if partially erupted tooth

Answer 28

* Mostly **mandibular 3rd molars** (rarely unerupted deciduous teeth) * Most commonly present in **2nd and 3rd decades**

Answer 29

* **Attached to the tooth at the CEJ**

Answer 30

**enlarged/hyperplastic follicle** Rule of thumb: * If 4‐5mm or more of radiolucency ► _dentigerous cyst_ * If \<4mm of radiolucency► can be _hyperplastic follicle_

Answer 31

Cysts of the Newborn: Palatal cysts

Answer 32

Gingival cyst of the newborn/ Dental lamina cysts/Cysts of the Newborn-gingival

Answer 33

Eruption Cyst

Answer 34

_eruption hematoma_

Answer 35

* Results from accumulation of fluid in the follicular space when the tooth has erupted over the alveolar bone **\*NOT in bone\***

Answer 36

**Gingival Cyst of the Adult**

Answer 37

Gingival Cyst of the Adult

Answer 38

Gingival Cyst of the Adult notice the _bluish hue_

Answer 39

▪ Usually seen in **1st decade** *(children)* ▪ Most often involves **1st permanent molar** and **maxillary incisors**

Answer 40

Frequently _normal mucosal color_, BUT surface trauma (ex. chewing) may result in bleeding into the cystic space► may look **purple or blue** ▪ Usually **soft** or **fluctuant**(like a balloon) _upon palpation_

Answer 41

* Unless symptomatic, no treatment required, cysts resolve upon eruption of teeth

Answer 42

**Palatal cysts** or **Gingival cyst**

Answer 43

**‐ Bohn’s nodules:** scattered over HP (hard palate), often junction of HP and SP (soft palate) **‐ Epstein’s pearls:** along median palatal raphe

Answer 44

* Could be differential for lateral Odontogenic keratocyst, except this does not grow in size * Lateral radicular cysts from an accessory canal if tooth is non vital * or it could be Lateral Periodontal Cyst if tooth is vital!

Answer 45

**Lateral Periodontal Cyst**

Answer 46

**Lateral Periodontal Cyst**

Answer 47

**Lateral Periodontal Cyst** see the _alternating thin to thick epithelium_ ***a characteristic of these cysts***

Answer 48

**Lateral Periodontal Cyst**

Answer 49

* Seen in 60‐80% of neonates

Answer 50

* 1‐3 mm cream to white papules (keratin filled cysts) ## Footnote **\*NOT in bone\***

Answer 51

**No treatment is required** ‐ Resolve (degenerate or rupture) on their own in a few months ‐ Once baby eats solid foods, will go away

Answer 52

**Botryoid Odontogenic Cyst** well circumscribed, between 2 teeth (similar to lateral odontogenic cyst), multilocular

Answer 53

**Botryoid Odontogenic Cyst**

Answer 54

**Dental lamina cysts**

Answer 55

* Found superficially on the **alveolar ridge mucosa** * **MX** \> MD * Rarely seen after 3 mos. of age

Answer 56

▪ No treatment is necessary ▪ Spontaneously resolve (degenerate or rupture)

Answer 57

* 1‐3 mm creamy white papule (keratin filled cysts) * \*NOT in bone\*

Answer 58

**Gingival Cyst of the Adult**

Answer 59

**“Primordial” Cyst** Assuming histologically it is *different from OKC*

Answer 60

Derived from dental lamina rests **‐ Rests of Serres**

Answer 61

**▪Uncommon lesion** ▪ 60‐75% **mandibular canine/premolar area** ‐ most common location on the _facial or buccal aspect_ ▪ **5th and 6th decade** most common

Answer 62

* Painless, dome‐like swellings up to 5 mm in diamete * Often with a bluish or grayish hue

Answer 63

**lateral periodontal cyst**

Answer 64

* **simple surgical excision** * _Unlikely_ to recur/come back

Answer 65

Most of OKC in posterior region

Answer 66

**gingival cyst of the adult?**

Answer 67

* Developmental cyst believed to arise from **dental lamina rests**

Answer 68

* **an inflammatory origin cysts** or t**he diagnosis of odontogenickeratocyst** _have been excluded_

Answer 69

▪ Commonly **asymptomatic** and _found on routine radiographic exam_ ▪ Associated teeth tests **vital/responsive with electric pulp test**

Answer 70

‐ **If pulp alive**► **lateral periodontal cyst** or ***Lateral Okc ( if huge lesion)*** ‐ If pulp dead► **lateral radicular cyst**

Answer 71

▪ Most likely found after age 30 ▪ Males\>Females **▪ ~65% mandibular canine/premolar area** ‐ Can also be seen _between canine and lateral incisor_

Answer 72

**Odontogenic Keratocyst OKC**

Answer 73

**Odontogenic Keratocyst OKC**

Answer 74

**Odontogenic Keratocyst OKC**

Answer 75

**Odontogenic Keratocyst OKC**

Answer 76

similar to *lateral periodontal cyst* but is actually **OKC**

Answer 77

Odontogenic Keratocyst Histology Notice the daughter cysts

Answer 78

Present as **well circumscribed**, **unilocular** _radiolucencies between 2 teeth,_ located **lateral to tooth root** ▪ Most often **0.5‐1.0 cm** in diameter ▪ Radiographic features are **NOT** diagnostic

Answer 79

✎A patient who has **Nevoid Basal Cell Carcinoma Syndrome** ✎We can see **multiple cystics** areas and lesions in _the jaws, maxillary and mandible_ ✎**Both 3rd molar displaced** in the maxilla because of the cyst

Answer 80

✎**Multiple lesions**, impacted 3rd molar in mandible and displaced 3rd molar up into the sinus, ✎These too many lesions hard to manage the issue with a surgery ✎This large area on the left mandible – good example of why we do decompression because if you just remove this lesion and the entire area is left open, this would be an area risk for fracture

Answer 81

✎An example of the **pitting** that can be seen **palmar and plantar** ~ This is a side of a hand ✎This is an early stage of basal carcinoma which never goes on (like it is aborted)

Answer 82

* **thousands of basal cell carcinoma** is developing on the skin -very difficult to manage with surgery, ~ That’s why they remove the larger ones, the deeper ones ~ They leave the one that’s less as an issue until they get to a larger size to be removed

Answer 83

* consists of **conservative enucleation**

Answer 84

**Botryoid Odontogenic Cyst**

Answer 85

shows **a grape‐like cluster** of small individual cysts

Answer 86

▪ Either unilocular or multilocular on radiographs, depending on size of the lesion ▪ Cyst lining similar to lateral periodontal cyst

Answer 87

* **A rare odontogenic cyst** which exhibits features of _glandular differentiation within the epithelium_ * Presumably **represents the pluripotentiality of odontogenic epithelium**

Answer 88

▪ Wide age range from 2nd to 9th decades **‐** *_mean age 49_* **▪ ~ 80% of cases in mandible ▪ Anterior lesions** ‐ More common ‐ _May cross the midline_

Answer 89

▪ Uni‐ or (more often) multilocular radiolucency ▪ **Well‐defined** with **a sclerotic border**

Answer 90

(~ 25% recurrence rate) Can be locally aggressive

Answer 91

▪ Usually asymptomatic unless inflamed

Answer 92

``` **Calcifying Odontogenic Cyst (COC)** ``` * _in the mandible_ and you can see it **well circumscribed radiolucency** * a little bit of blunt root resorption in this area * _No calcifications_ in this one yet ►so this is still **unilocular radiolucency**

Answer 93

* Clinical finding for this patient was **Obliteration of the vestibule space**, because the mandible is showing expansion * radiographically:we see radiolucency going as far as the first molar * This is a **mixed radiolucent radiopaque lesion** in developing calcifications. * This is an example of **Calcifying** **Odontogenic Cyst (COC)**

Answer 94

* **Mixed up with OkC** * Originally meant to describe cyst which **develops in bone at a site where a tooth was meant to develop (usually a third molar)** * If this lesion exists, **it is truly rare and would have histology distinct from OKC** * * In the current literature, reference has been almost _nonexistent_

Answer 95

* lesion, *was actually some other type of cyst* * * it is now thought that most of the reported Primordial cysts were actually **OKCs**

Answer 96

**keratocystic odontogenic tumor (KOT)** -2005 WHO _but now it's back to **OKC**_

Answer 97

* **Growth and expansion** of this lesion due not only to osmotic effects/pressure, but to _unusual gene expressions_

Answer 98

* _Expresses **Ki‐67**_ (high rate of cell proliferation) * O_verexpression of **Bcl‐2**_ (antipoptotic protein) * _Overexpression of **MMP’s 2 and 9**_ (thought to allow growth into connective tissue) * _Mutation of **PTCH**_, a tumor suppressor gene * when PTCH is non‐functional → cell proliferation

Answer 99

* ~ **60%** present in **2nd and 3rd decade**, but can occur at any age * **Mandible** affected in 60‐80% of cases * tendency to occur in **posterior mandible and ramus** * **25‐40% of cases involve an unerupted tooth** * ‐ **5%** of patients have **_multiple cysts_**

Answer 100

**Odontogenic Keratocyst (OKC) :**grows in anterior to posterior manner before causing cortical expansion *while* **Meloblastoma:** causes **cortical expansion _early_**

Answer 101

**Odontogenic Keratocyst (OKC)**

Answer 102

**nevoid basal cell carcinoma syndrome**(*_**Gorlin syndrome**)_*

Answer 103

* **HIGH Recurrence Rate** * **Benign**, but _locally aggressive biologic behavior_ * _Solitary OKCs have_ ~**10% recurrence rate with appropriate treatment** * _Multiple OKCs hav_e ~ **30% recurrence rate**

Answer 104

**Syndrome OKC \> Multiple OKC \> Solitary OKC \> Conventional odontogenic cysts**

Answer 105

* Usually **a well‐circumscribed** *_radiolucency_* with **smooth, often** **corticated margins** ▪ Cysts may be ‐ **Unilocular** (most common) ‐ **Multilocular** (larger lesions)

Answer 106

▪ **Small cysts** are typically **asymptomatic** and picked up on routine radiographic exam ▪ **Larger cysts** may or may not be asymptomatic ▪ \*Cysts tend to grow in an antero‐posterior direction prior to lateral growth ►_therefore cysts are usually quite large when they start to expand the cortical plate_

Answer 107

* dentigerous cyst * ameloblastoma * and others

Answer 108

▪ **Marsupialization** (decompression) ▪ **Peripheral ostectomy** ‐ Carnoy’s solution ▪ **Resection** ▪ **Medications targeted to PTCH** ▪ ***Long term follow‐up***

Answer 109

**Basal Cell Nevus or Bifid Rib Syndrome** or **Gorlin syndrome**

Answer 110

**Odontogenic Keratocyst “OKC”**

Answer 111

**_Autosomal dominant_ inheritance**

Answer 112

* _Mutation_ of **PTCH** (tumor suppressor gene) * in the **Sonic Hedge Hog pathway**

Answer 113

■ Prognosis _depends on progression of skin tumors_

Answer 114

✎Surgery (typically MOHS) ✎Sometimes curette them ✎ Radiation therapy (RT) is typically not the first line of therapy with small lesions RT ✎Cryotherapy which means they just use a little liquid nitrogen and freeze them ✎Photodynamic therapy with photosensitizer and topical medications ■ New medication: **Vismodegib _inhibits sonic hedgehog pathway by binding smoothened (SMO)_** * *suppressive rather than curative cause it seems to work for short time and after ~7-8 months ..may also helps _suppress growth of OKC_*

Answer 115

It’s not the lesion themselves causing metastasis that’s the issue, it’s the lesion growing deeply and in affecting adjacent structures that really is the issue with basal carcinoma

Answer 116

**Basal Cell Carcinoma (BCC)**

Answer 117

* 2-3 million cases a year * About 3 out of 4 skin cancers are basal cell carcinomas

Answer 118

- Develop in the **lowest layer of the epidermis**, called the **basal Laye**r - Develops on sun-exposed areas: _cumulative DNA Damage_ **- Slow-growing** • If not treated, basal cell c**ancer can grow into nearby areas and invade the bone or other tissues beneath the skin**

Answer 119

within 5 years of being diagnosed with BCC►**35%-50%** of people _develop a new skin cancer_

Answer 120

* **Calcifying Cystic Odontogenic Tumor** * **_Gorlin Cyst_ ( don't confuse it with Gorlin syndrome)** * **Ghost Cell Tumor** *

Answer 121

1. **■ Cystic Unilocular COC** * COC with odontoma (~ 20%) * Extraosseous/peripheral – present in _older patients_ 2. **■ Solid COC (odontogenic ghost cell tumor)** * Often demonstrate _a more aggressive behavior_ * WHO once considered them all CCOT now back to COC 3. ■ **Odontogenic ghost cell carcinoma** * _very rare lesion_

Answer 122

* where you see **_both features_ of ameloblastoma with COC** or **adenomatoid odontogenic tumor with COC**

Answer 123

* **Odontomas** (a benign tumour linked to tooth development) * **Ameloblastomas** (rare, noncancerous (benign) tumor) * **Adenomatoid odontogenic tumor** (rare tumor of epithelial origin that is benign, painless, noninvasive, and slow-growing)

Answer 124

■ Peak in _second decade_, most **before age of 40** ■ Frequently presents **anterior to molars** ■ ~ **20% extraosseous (peripheral)**, found in **older age group** (~ 50 years of age) ■ Female \> Male ■ **~ 70% occur in MX** ■ One third are associated with **unerupted teeth**, usually a **canine**

Answer 125

■ Usually **a well-circumscribed unilocular radiolucency,** _infrequent multilocular cases_ ■ **One third to one half** show _radiopaque structures within the radiolucency_ ■ When you see **calcifications** within a lesion, you don't use the term uni or multi locular anymore, but they are called **_mixed radiolucent/radiopaque lesions_** ■ May cause **resorption or displacement of roots** **■** **_One third_** are associated with **unerupted** **Canine**

Answer 126

**_Ghost cells_** They have that sort of polygonal shape or roundish shape with the pink that looks like the cytoplasm, but in the location where the nucleus would have then, there's an empty spot

Answer 127

**_ameloblastic epithelium_**

Answer 128

■**Enucleation with peripheral ostectomy** ~ Very similar to odontogenic keratosis ■ **Follow up is long term** because s_ome of the solid tumors have a more aggressive behavior_ **■ Peripheral lesions are treated with excision**

Answer 129

■ the treatment is based on **the more aggressive tumor** **~** So you would treat the _ameloblastoma_. ~You wouldn't treat conservatively the COC though

Answer 130

**(5 year survival ~ 70%).** * It is _rare_ and shows _cytologic atypia histologically_ * It has an _unpredictable biologic behavior_

Answer 131

❑ Nasolabial cyst ❑ Globulomaxillary cyst (historic) ❑ Nasopalatine (incisive canal) cyst ❑ Incisive papilla cyst ❑ Median palatal cyst ❑ Median mandibular cyst (historic)

Answer 132

aka Nasoalveolar cyst

Answer 133

(1) That's the nasopalatine, which is sort of up in the labial nasal fold and it's in the soft tissue. (2) Sort of where the nasal alveolar cyst would occur. (3) Where the globular maxillary cyst would occur between the canine and the lateral sometimes between the lateral and the first premolar (4) The nasopalatine in the cyst of the nasopalatine papilla (5) Is the median palatal

Answer 134

■ Thought to be caused by: * either **epithelial remnants of the nasolacrimal duct** * or **cells left after fusion of the maxillary, medial and lateral nasal processe**s during _development of the midface_

Answer 135

_Rare_ **soft tissue cyst of the upper lip**, lateral to the midline (right under the ala of the nose) \*NOT in bone\* ■ Clinically see a swelling which can cause elevation of the ala of the nose ■ Intraorally see a swelling in the maxillary vestibule lateral to the midline (usually sort of in the canine area or just a little bit distal to the canine area) ■ Pain is uncommon, unless cyst becomes infected

Answer 136

■Clinically we see a **swelling** which _can cause elevation of the ala of the nose_ ■ Intraorally see **a swelling in the maxillary vestibule lateral to the midline** (usually sort of in the canine area or just a little bit distal to the canine area) ■ **Pain is uncommon,** _unless cyst becomes infected_

Answer 137

■ Peak in **4th and 5th decades** ■ **3 to 4 times** _more common in **females**_ ■ ~ **10%** of cases are **bilateral**

Answer 138

* **Surgical Excision** via i**ntraoral approach**, * usually do not recur ~ **very low risk of occurrence**

Answer 139

Nasolabial Cyst The lesion here just below the nose and you can tell that it's sort of raising the edge of the nose slightly

Answer 140

**Nasolabial Cyst** the lesion raising the edge of the nose slightly

Answer 141

either in the **sinus** or in the **nasopalatine ducts**

Answer 142

* we can see the **displacement of the root** * A **teardrop or pear shaped** radiolucency between the lateral and the canine * **Well circumscribed** maybe leaving **a little sclerotic edge** up here * ended up being in **a odontogenic keratocyst (OKC)**

Answer 143

~ it is kind of **a teardrop or pear shaped size** ~Little less well differentiated in this particular instance but again **unilocular radiolucency between the roots of two teeth** This one ended up being an **OKC**

Answer 144

* it's in quotations, because really there is no such thing as a globulomaxillary cyst * because it was thought that this was remnants _after fusion of the globular portion of the nasal process with the maxillary process,_ and now we know that **these two processes are always united from the start and that there is no fusion** * When biopsied these cysts are **odontogenic in origin**

Answer 145

✎This is term used to **describe a cyst in a particular anatomic location** _it is not a diagnosis_ ✎An odontogenic cyst (inflammatory cyst, lateral periodontal or even sometimes OKC) that forms in the area **between the maxillary lateral incisor and the canine roots** ~ It's really associated with a_n anatomic location **not** with any particular cyst._ ✎So it can be any of the odontogenic lesions such as **lateral granulomas or cysts, OKCs, COCs, etc.**

Answer 146

## Footnote ✎Presents as a **“inverted pear”** shaped **well-circumscribed radiolucency** ✎Frequently causes **displacement of the roots**

Answer 147

* *A**. It can either be _the cyst totally within bone_ * *B**. It can actually cause _widening of the orifice and causing the soft tissue expansion in this way_

Answer 148

**Nasopalatine Duct Cyst**

Answer 149

**incisive canal cyst** **nasopalatine canal cyst**

Answer 150

* arise **from epithelial remnants of the nasopalatine duct** which, _embryologically, connects the oral and the nasal cavities_

Answer 151

**Nasopalatine Duct Cyst** ## Footnote ✎This person is edentulous ✎ **an inverted pear shape** ✎The nasal spine is superimposed on your radiolucency ► **a heart shape**

Answer 152

**Nasopalatine Duct Cyst** ✎Between the roots of the two teeth, a well circumscribed radiolucency, not showing any changes to the adjacent structures ✎could be an enlargement of the incisive canal due to variation in size ~ **early lesions can be hard to diagnose** ✎**the treatment in such cases**: a follow up with another radiograph in six months to see if there's been any change in size **✎ No surgical intervention until you see the cyst expanding**

Answer 153

This is showing you the how the papilla can be enlarged if it's only in soft tissue or if there's a partial soft tissue partial bone expansion *Nasopalatine Duct Cyst*

Answer 154

* Peak presentation in the **4th to 6th decades**, _but can occur at any age_ ~ *because it takes a little bit of time for the cyst to grow within the bone* * commonly found on the **anterior palate** ~ typically in the _nasal area of the papilla._

Answer 155

**Median Palatine Cyst**

Answer 156

■ present with **swelling** o_f the anterior palate_ (in the nasal area of the papilla) ■ Most are **asymptomatic**, but _they may have pain or drainage_

Answer 157

Remember ## Footnote _Median Mandibular Cyst_ is a term used to describe a cyst in a **anterior mandible** not a definitive diagnosis So, this turned out to be an early ameloblastoma. It wasn’t a cyst The lesion radiolucency in the anterior mandible and again

Answer 158

■ a **well-circumscribed unilocular** **radiolucency** on _the midline of the anterior hard palate_ _between and apical to the central incisors_ ■ The radiolucency often have an oval or inverted pear shape with a sclerotic border ■ Superimposition with the nasal septum can create an appearance of the classic **“heart” shape**

Answer 159

Is a **soft tissue cyst** (no bone involvement) located in the same area as the **Nasopalatine Duct Cyst** _on the midline of the anterior hard palate between and apical to the central incisors_ . They may be symptomatic or asymptomatic and usually are not seen radiographically. some consider them to be uncommon variants of the nasopalatine duct cysts

Answer 160

* **surgical excision** * **recurrence is rare**

Answer 161

**Surgical Ciliated Cyst of the Maxilla** In this premolar shot (middle image) you can see a **well-circumscribed lesion** ✎Because the maxillary sinus is **radiolucent**, it almost looks like this is **radiopaque** but it's not ✎ If you did a CBCT you would see that **it's an empty space within the bone of the maxilla.** It's not actually radiopaque

Answer 162

**nasopalatine duct cyst** * it represents a more **posteriorly** placed nasopalatine duct cyst * ~ It's probably due to some sort of anatomic variation in the patients; that their palatine duct is just placed more posteriorly * So **instead of being between the roots of these two teeth, it's placed more posteriorly**

Answer 163

* **A controversial cysts** whose existence is questioned ~ similar to **the globulomaxillary cyst** ■ Originally *thought to arise from the fusion of the “halves” of the mandible, but current embryology finds that the mandible forms from a single bilobed process, therefore, no epithelial remnants would be found* ■ Now, it is thought that cysts in this area represent **odontogenic cysts or tumors** * **Median Mandibular Cyst is a** term used **to describe a cyst in a particular anatomic location not a definitive diagnosis** * ~ It is other lesions that occur in that particular location * **The Anterior Mandible**

Answer 164

■ Occurs after trauma or sinus surgery (iatrogenic - reactive not neoplastic)

Answer 165

■a portion of the sinus lining is **separated** from the sinus and forms an epithelial lined cavity in bone ■ Cavity f**ills with mucin** produced by the _mucous cells of the cyst lining_ ■ These cysts **enlarge** as the _intraluminal pressure increases_, causing **destruction of bone**

Answer 166

* after **a Caldwell-Luc procedure** * *sometimes with **difficult maxillary extractions***

Answer 167

* **They have no epithelial lining.** * They’re called cysts by convention just because that's what everybody is used to * **They're not true cysts.**

Answer 168

* Aneurysmal Bone Cyst * Antral Pseudocyst * Simple Bone Cyst * Osteoporotic Bone Marrow Defect * Stafne Bone Cyst

Answer 169

■ Most common site in the body is **long bones *or* vertebrae** _■ In the jaw_s, most frequently seen in the **1st and 2nd decade** **■ MD \> MX** ## Footnote *it's a pesudocyst*

Answer 170

* swelling, frequently a rather rapid swelling * often with **pain** and/or **paresthesia** (signs which can be suggestive of the presence of _a malignant or aggressive lesion_)

Answer 171

* Etiology is **unclear**, may result from **trauma** or a **vascular malformation** * most agree that it is a _**reactive** and ***not*** a neoplastic lesion_

Answer 172

■ **a radiolucency** which can be either **unilocular or multilocular** in appearance ■ **Borders are variable**, *often irregular in shape* and may be **ill-defined** (again, giving the suggestion of malignancy) ■ **Teeth may be displaced** ■ we may see **cortical expansion and thinning** ~ the cortex itself can become quite thin

Answer 173

- you might think that he has an odontogenic infection but he didn't. You can see that there's a pretty significant swelling on the left side of his face This is a **Aneurysmal Bone Cysts**

Answer 174

Aneurysmal Bone Cyst you can see that there is kind of a **multilocular radiolucency** in this particular area

Answer 175

**Aneurysmal Bone Cyst** ## Footnote ✎ There's a **radiolucency** involving _the second molar_ that's going as far anterior as the first molar and back to the third molar ✎ There is a little bit of **spiking root resorption** and _that's one of the signs that we associate with malignancy_ ✎ It's a little bit **ill-defined** *~ hard to say exactly where it begins and ends*

Answer 176

**Aneurysmal Bone Cyst** ✎ It looks like **a blood soaked sponge** ✎ There’s these **open sinusoidal spaces** and then fibrous connective tissue surrounding them. *✎The sinusoidal spaces can vary in size; some of them are fairly small and others are large*

Answer 177

■ Treatment is **surgical enucleation and curettage** ■ **lesions can recur** ~ Usually the recurrence is because you didn't get the entire thing out the first time around ■ Some surgeons follow **enucleation** with **cryotherapy** ■ **Irradiation** is _contraindicated_

Answer 178

■ No, **vascularity is predominantly “low flow”**, therefore not as much concern for bleeding upon surgical removal ■ As compared with **central hemangioma** where there is a concen for bleeding

Answer 179

They are different than **surgical ciliated cyst** in their lining, etiology, location and appearance!

Answer 180

**Antral Pseudocyst** * a **Dome-shape** **swelling** on the floor of the sinus. * _They can sometimes_ be **fairly subtle** **Antral Pseduocyst** are **NOT Mucoceles** **Mucoceles** would have more of **meniscus-like appearance**where it would come up to**the edge of the sinus**

Answer 181

_Not epithelial lined spaces_

Answer 182

**Aneurysmal Bone Cyst** ## Footnote ✎ A **dome shape swelling on the floor of the sinus** that’s associated with some _sort of inflammation of tooth of t_he **premolar** caused inflammation underneath the apex of the bone (right) and then that leads to accumulation of fluid which causes the sinus lining to elevate off the bone and fill with fluid ✎ After root canal therapy and once the infection gets under control, these will typically resolve on their own

Answer 183

Not within the bone **but are in the sinus**

Answer 184

develop a**s an accumulation of an inflammatory exudate** (often serum) _between the sinus epithelial lining and the bone_ -It develops because of an **inflammatory event in the jaw,** usually the **maxilla**, often from the roots of the maxillary teeth that cause inflammation

Answer 185

Appears as **a dome shaped elevation** _of the floor of the sinus_

Answer 186

aka **traumatic bone cyst**

Answer 187

**Simple Bone Cyst** ## Footnote ✎**A well-circumscribed with cortication** in the **body of the mandible**, affecting _the posterior aspect (premolars and the molars )_ ✎Note the **scalloping** that happens up **between the roots**. It doesn't cause root resorption and actually the lesion will grow up between the roots of the teeth

Answer 188

**Simple Bone Cyst** * **A well-circumscribed**showing **the scalloping up between the roots of the teeth radiolucency**

Answer 189

**Simple Bone Cyst** ## Footnote ✎Big lesion example: It’s going back to the molar area here. ✎You can see that the lesion extends _over to the canine on the other side_ ✎Most lesions are usually **in the anterior mandible**

Answer 190

* **A benign**, empty or fluid filled, cavity in bone which is devoid of an epithelial lining – **a pseudocyst** * Thought to be **reactive**, NOT *neoplastic*

Answer 191

_Etiology_ **ununcertain**, theories include: * **trauma** * **ischemic necrosis of medullary space** * **cystic degeneration of a primary bone lesion**

Answer 192

* In jaws, most likely in the **2nd decade** * Almost **exclusively the mandible** * **Twice** as common in **males**

Answer 193

* a **well-circumscribed radiolucency** with **an irregular outline** * Tendency to **“scallop” around and between roots** *_(highly suggestive_*, but *_not diagnostic of this lesion_*)

Answer 194

* **exploration** and **curettage** of space to create bleeding. Clot will organize and allow bone repair * **Recurrence** is **_rare_**

Answer 195

* You can see there's a little bit of radiolucency. * There happened to actually still be teeth in the area, but * when it was _biopsied_ it showed that it was a * **hematopoietic** or **osteopoietic bone marrow defect**

Answer 196

■ An **asymptomatic** focal _concavity_ of the cortical bone on the _lingual aspect of the MD_ ■ A *pseudocyst*, not a true cyst

Answer 197

■ _Uncommon finding_ ■ \> 75% of cases are in **females** ■ ~ 70% occur in the **posterior MD**, often in _an edentulous area_ it's a *pesydocyst*

Answer 198

* **Etiology unclear** * may be **hyperplasia of marrow** due to need for RBCs or * **abnormal regeneration of bone** after **an extraction or persistence of fetal marrow**

Answer 199

* it's a pesydocyst * a **radiolucency** in an area typically where tooth has been removed. Instead of filling in with bone, it fills in with marrow. * When we biopsy it, you’re seeing the hematopoietic elements. (fat, early stages of (the -blasts of) red cells, white cells. * We see basic **bone forming marrow** **content**

Answer 200

**Stafne Bone Cyst** _This is the classic look._ - a **well-circumscribed corticated radiolucency** - **below the inferior alveolar nerve**, away from the teeth. - They can be either **oval**, like this, or **round** in appearance

Answer 201

**Stafne Bone Cyst** Less common location Check if the teeth were vital with vitality test Get a CBCT in that area to see what was going on first and then once you saw the CBCT you'd be able to make the diagnosis.

Answer 202

**Hematopoietic bone marrow defect**

Answer 203

■ Typically **asymptomatic** and found on _routine_ radiographic exam

Answer 204

* **Irregularly shaped radiolucency** with _either_ **a well-defined or ill-defined border** (It can be in the _differential diagnosis with malignancy_)

Answer 205

■ **Must biopsy** to make a definitive diagnosis ■ **No further treatment is then necessary** ~ You don't have to remove it; you can just leave it as it is

Answer 206

**static bone cyst, Stafne defect**

Answer 207

* Most commonly found near **the angle of the mandible** **below the inferior alveolar nerve** (but also _seen in the anterior MD)_ * **\> 80% in Males** * usually noted **only in adults**

Answer 208

Oval round well-circumcribed radilucency Below the Inferior Alveolar Nerve

Answer 209

* Believed to be **developmental** in origin, *but usually noted only in **_adults_***

Answer 210

* lesions in the posterior MD are usually pathognomonic * **no further treatment is necessary**

Answer 211

* **Benign** developmental cystic lesion * Considered a form of teratoma Remember: _Teratomas_ have **all four embryologic** **layers** and so you can see these cysts that have **teeth, bone, hair, muscle, and nerves.** **Dermoid cyst** is sort of a lesser version of a teratoma in that **it just has dermis, rather than all the other layers**

Answer 212

* Depending on whether the cyst is above or below the mylohyoid muscle►the lesion will cause **swelling into the oral cavity elevating the tongue** or **under the chin in the submandibular area**, _respectively_ * Usually **found on the midline** * **Painless** and **slow growing,** _if not infected_ * _Upon palpation, cyst feels **doughy or rubbery**_ * _Usually **roundish to oval-ish swelling**_

Answer 213

* Most common in the 1st and 2nd decade ( young pts) * Can be found anywhere, but in the oral cavity they are ususally located i**n the anterior floor of the mouth (FOM) -** *usually* ***on the midline***

Answer 214

* **surgical excision** * _recurrence_ is ***rare***

Answer 215

_Dermoid Cyst_ a **dome shaped swelling**in _the floor of the mouth._ If these were left long enough, they could _cause issues with swallowing_

Answer 216

**Dermoid Cyst** ## Footnote ✎This is **a larger lesion on the floor of the mouth**, causing elevation of the tongue ✎If you let this go/grow, it would be similar to **Ludwig’s angina** where you would basically **eventually obstruct the airway** ✎**The difference** is this is **very slow growing** while **Ludwig’s happens** rather quickly. with **fever and other symptoms.**

Answer 217

**Dermoid Cyst** * This is showing you when they occur below the **mylohyoid muscle.** * You get **an elevation under the chin.** * This is **a fairly small on**e but they can get much larger

Answer 218

**infundibular cyst** **epidermal inclusion cyst** **“sebaceous” cyst** (laymen’s term, not really sebaceous) ~

Answer 219

* A very common skin cyst

Answer 220

similar to the dermoid cyst, except we don't see those **adnexal structures**

Answer 221

* Often occur after _***inflammation*** of a hair follicl_e

Answer 222

■ **_Males_** \> *Females* ■ **Young adults** _more likely to have cysts of the_ **fa**ce ■ **Older adults** _have cysts of the_ **back**

Answer 223

Associated with **Gardner’s syndrome** **Gardner syndrome** is associated with **polyps in the intestine**. **Gardner syndrome** is associated with **epidermoid cysts.**

Answer 224

Epidermoid Cyst **A dome-shaped swelling.** There’s **no change** in the overlying skin color, no redness, no pain

Answer 225

■ **Subcutaneous** ***nodular***, ***firm to fluctuant,* _papule_** ~ It tends to be **a subcutaneous, dome-shaped nodule that can be either firm to fluctuant**, _depending on how much stuff is within the lumen_

Answer 226

* The key difference between a dermoid and * epidermoid cyst, **is that there's no adnexal structures in an epidermoid cyst. _There are adnexal structures in a_** **_dermoid cyst._** * The adnexal structures are: **sebaceous glands, sweat glands, hair follicles, etc.**

Answer 227

■ Treatment is **_excision_** ■ _Recurrence_ is ***rare***

Answer 228

Thyroglossal Duct Cyst This is **NOT** a goiter. It looks like an enlargement of the thyroid, but this ended up being just a cyst, so they had a thyroglossal duct cyst

Answer 229

* _A developmental cyst_ that develops **from epithelial remnants of a tract which forms when the thyroid anlage descends into the neck** _from an area that later forms **the foramen caecum**_ * Follows a path that goes **anterior to the hyoid bone and ends below the thyroid cartilage**

Answer 230

■ Cysts are typically **painless fluctuant swellings,** _unless infected_ ■ **If the cyst remains attached to the hyoid bone or the tongue ►** i_t will move up and down when swallowing or protruding the tongue_ ■ **~ 1/3 will present with a fistulous tract** ~ _so they'll be draining._

Answer 231

■ **surgical excision** ■ _recurrence_ are ***not uncommon*** ■ *Rare cases* of **thyroid carcinoma** developing in these cysts have been reported

Answer 232

■ **60-80% of cysts** are _below the hyoid bone_ ■ **Most commonly present in the first 2 decades** (~ 50% prior to 20 years of age) ■ Cyst classically **forms at the midline** ■ _The most common developmental cyst of the neck_

Answer 233

Thyroglossal Duct Cyst

Answer 234

**cervical lymphoepithelial cysts**

Answer 235

Branchial Cleft Cyst **a small one in a child.** You can see that there's a small cystic lesion here on the neck

Answer 236

**Branchial Cleft Cyst** Then you can see it in an older person; this is getting to be maybe 4-5 centimeters at least in size. He left his for a little bit longer

Answer 237

■ Most commonly presents in the **3rd to 5th decades** ■Located on the **lateral aspect of the neck**, usually **anterior to the sternocleidomastoid muscle** ■**2/3** of the reported lesions have been **on the left side** ■Although cyst are uncommon in the parotid gland, can see multiple lymphoepithelial cysts bilaterally in **HIV positive patients** ■These cases present as painless uni- or bilateral swellings of the parotid glands

Answer 238

* presents as a **soft fluctuant swelling** ranging from **1 to 10 cm** _in diameter_

Answer 239

Etiology is _disputed_ * Some think it is _from_ **remnants of the branchial cleft** * Others think it is _cystic change of parotid gland epithelium_ which **became entrapped in a cervical lymph node during development**

Answer 240

**Oral Lymphoepithelial Cyst** **A pale dome-shape swelling in the floor of the mouth. **because the lesion is so close to the surface; you're seeing _little capillaries of the mucosa lining the lesion_

Answer 241

We can see _multiple Branchial Ceft cysts_ bilaterally on the parotid gland Painless swelling bilaterally or unilaterally on the parotid gland

Answer 242

surgical excision, recurrence is rare

Answer 243

■ **Uncommon lesion** ■ **The Most frequent location is _the floor of the mouth (FOM)_** (\> 50%)

Answer 244

■ Usually **less than 1 cm** _in diameter_ ■ May feel **firm or soft** _on palpation_ ■ Typically **creamy to yellow** _in color_ ■ **Painless** _unless infected_

Answer 245

* **Surgical Excision** * _Reccurance_ is ***Rare***

Answer 246

the more aggressive the biologic behavior, the higher risk of recurrence, and the longer the follow up needed for the patient

Answer 247

Things that have a very low rate of recurrence when you do a conservative excision or a nucleation ►they're going to be very benign and they're not going to be likely to be recurrent: ▪ **Odontoma and radicular cysts** are way down here near the benign side ▪ **AOT** (Adenomatoid Odontogenic Tumor) is benign. ▪ **COCs** (Calcifying odontogenic cyst) are benign. ▪ **OKCs** (Odontogenic keratocyst) ‐ they’re benign. ▪ Even **Ameloblastomas** are benign

Answer 248

But eventually you get over to the side over here where you can have something like an ***Ameloblastic carcinoma*** ‐ truly malignant --\> W*e know that it can metastasize and it can lead to death* ▪ Lesions like **Ameloblastomas and CEOTs** will need to be _managed more aggressively._ (**Not just curettage, aka surgical scraping or cleaning**) o You have **a resection ‐ either a portion of the mandible is removed or a segment of the mandible is removed.**

Answer 249

1. **Epithelial** 2. **Mesenchymal** 3. **Mixed**

Answer 250

**▪ Ameloblastoma ▪ Adenomatoid odontogenic tumor ▪ Calcifying epithelial odontogenic tumor ▪ Squamous odontogenic tumor** ▪ **Odontogenic keratocyst** (aka Keratocystic odontogenic tumor)

Answer 251

**▪ Odontogenic myxoma ▪ Central Odontogenic fibroma ▪ Cementifying fibroma ▪ Cementoblastoma ▪ Granular cell odontogenic tumor**

Answer 252

**▪ Odontoma** (complex and compound) **▪ Ameloblastic fibroma/odontoma ▪ Primordial odontogenic tumor ▪ Dentinogenic ghost cell tumor ▪ Calcifying cystic odontogenic tumor**(aka COC, ghost cell tumor)

Answer 253

* **An epithelial odontogenic neoplasm (**Tumor of Epithelial Origin) * with a close histologic **resemblance to the enamel organ**

Answer 254

**_Potential sources of epithelium include:_** **o Enamel organ** – look like they’re about to deposit a substance but never do **o Odontogenic rests (Malassez, Serres)** **o Reduced enamel epithelium** **o Epithelial lining of odontogenic cysts** ‐ can actually have an ameloblastoma arise within a dentigerous cyst

Answer 255

**-Osteolytic tumor** **(radiolucent – no hard tissue formed)** - **Well-circumscribed uni**- or **multilocular radiolucency** - Often with **sclerotic** or **corticated borders** - May see **blunt root** **resorption** and **displacement of teeth** - Frequently seen **in association with unerupted teeth**

Answer 256

* Rather **slow growing tumor** * Larger lesions present as ***painless*** ***expansion*** or ***swelling*** of bone * Smaller ones are ***asymptomatic***, can be seen on routine imaging * **Buccal and lingual cortical expansion is common** * May perforate cortical plate and invade surrounding soft tissue * Can arise in a dentigerous cyst (see transition from stratified * squamous to ameloblastic epithelium)

Answer 257

Conventional/multicystic/solid/ (~ 80%) * **Unicystic** (~6-15%) need entire specimen (excision) to know * **Desmoplastic** * **Peripheral** * **Malignant**

Answer 258

▪ **11‐18% of non‐cystic lesions** of the _maxillofacial bones_ ▪ **4th and 5th decade most common,** but occurs over a broad age range *(rare in first decade*) o Usually starts 2nd decade, can go up to 80‐90s. **Late 30s/early 40s are usually the peak** **▪ \> 80% occur in the mandibl**e _(most in molar/ramus area)_

Answer 259

**Ameloblastoma** _(after odontoma)_ o although ***odontomas*** are more _like hamartomas_

Answer 260

**Ameloblastoma** (we see transition from stratified squamous to ameloblastic epithelium)

Answer 261

▪ Almost 80% or a little over 80% (of ameloblasts) are down in the mandible. ▪ And the vast majority are in the posterior mandible ▪ Do occur in maxilla but at lower rate

Answer 262

**Unilocular and unicystic** ‐ An example of **a unilocular ameloblastoma** that is not associated with an impacted tooth ▪ Is between roots of two teeth, may be confused with lateral periodontal cyst. **Well‐circumscribed radiolucency**

Answer 263

▪ Typical appearance for **ameloblastoma** **Multilocular**, **very well‐circumscribed,** _associated with impacted tooth_. Can see bowing of _inferior aspect of mandible_ _lateral oblique radiograph.was used here_

Answer 264

**Ameloblastoma** **clinically:** Have expansion of the buccal plate, obliterating the vestibule in this area. **Radiographically:** Root resorption of molar, unilocular radiolucency in mandible

Answer 265

**Ameloblastoma** * **Small lesion** distal to impacted tooth. * **Unilocular radiolucency** with _elevation of alveolar ridge + some expansion of soft tissue_

Answer 266

**Ameloblastoma** ▪ **Well‐circumscribed radiolucency** with **a sclerotic or corticated margin**. ▪ If you had a CBCT, it would probably show you that there was a thin septa in this area of residual bone trabeculae. ▪ **Fracture could be caused by very large cysts.** ▪ **Resolve by decompressing unless with odontogenic tumor** – need to remove the mandible **1cm+** on either side of lesion

Answer 267

▪ Over expression of **Bcl‐2 (**anti‐apoptotic protein) ▪ **Expression of fibroblast growth factor (FGF)** ▪ **Over expression of matrix metalloproteinases (MMPs 9 and 20**) – like in OKC, allowing tumor to grow into surrounding area ▪ Surprisingly, _no significant increase in Ki‐67 expression_ (cell proliferation marker) **– ameloblastomas do NOT turn over rapidly**

Answer 268

▪Left mandible, **multilocular radiolucency associated with impacted tooth** ▪ It's **well circumscribed,** edge may be a little **bit sclerotic or corticated** ▪ It has _displaced an impacted tooth down_ towards the inferior aspect of the mandible ▪ Appears to be expanding the cortex of the mandible in areas ▪ There's **blunt resorption of the teeth adjacen**t (PMs and molar) **Ameloblastoma**

Answer 269

**Conventional/Solid Ameloblastoma**

Answer 270

▪ **Unicystic** (Simple or luminal) * lumina- confined to the surface lining of the cystic space ▪ **Plexiform** (intraluminal) * intralumina-one or more areas of the ameloblastic epithelial lining, proliferate into the lumen of the cystic space ▪ **Mural** – hard to distinguish from conventional, so pathologists think they should NOT be treated the same as unicystic (which would be a more conservative treatment) ▪ **Ameloblastoma arising in a cyst** ‐ can usually be treated in a similar way ***as unicystic ameloblastoma.***

Answer 271

**Unicystic Ameloblastoma** but could be **Dentigerous Cyst** based on clinical presentation! So radiograph is not diagonstic

Answer 272

Desmoplastic Ameloblastoma * **Spherical growth**. Within it, has both radiodense and radiolucent areas (is * **mixed radiolucent‐radiopaqu**e)– similar appearance to *_benign fibro‐osseous lesions._* * **Well‐circumscribed, corticated**.

Answer 273

* **Resection** (treatment depends on extent of the lesion and anatomy of involved bone) * **Segmental** * **Composite** * **Long term (decades) follow up** is needed for these patients

Answer 274

**Peripheral Ameloblastoma**

Answer 275

▪ **Younger initial presentation** (~ 50% in ***2nd decade***) ▪ **90% in MD (mandibular)** ▪ Typically _asymptomatic and found on routine radiographic exam_

Answer 276

* Commonly **a well‐circumscribed radiolucency** that _surrounds the crown of an unerupted tooth_ * Commonly accompanied by **_root resoprtion_**

Answer 277

* Radiographically can be confused with **dentigerous cyst** * **Presence of root resorption** should _increase your suspicion of ameloblastoma_

Answer 278

* Treatment is typically **enucleation and curettage** * Reports of lower rate of recurrence (10‐20%) than conventional ameloblastoma (50‐90%) with similar treatment * Some recommend decompression prior to surgery * Use of **Carnoy's solution** ***after enucleation- resulted in a recurrence rate _lower_***

Answer 279

* **Anterior jaws** (particularly **maxilla**)

Answer 280

Calcifying Epithelial Odontogenic Tumor (CEOT) **Clinically:** we see **a little expansion** on _inferior aspect of mandible + lingual_ too Radiographically: we see **well‐circumscribed**, **a little corticated/sclerotic edge**, **impacted tooth** ▪ we can see bowing of inferior aspect of mandible ▪ Within areas of radiolucency, see areas of opacity **(calcified lesions = classic CEOT)** ▪ _When smaller► could have looked ***unilocular***_

Answer 281

* looks **“fibro‐osseous”** due to **mixed radiolucentradiopaque** **appearance** * Mineralization of **dense collagen** * **Well‐circumscribed**, _corticated_.

Answer 282

**Calcifying Epithelial Odontogenic Tumor(CEOT)** * **flecks of calcifications.** * **Calcifications** all around crown is common

Answer 283

**Calcifying Epithelial Odontogenic Tumor(CEOT)** * **Multilocular radiolucency with calcifications**. * **an expansion** *up to PMs and back to 2nd molar* * as well as **bowing of mandible.**

Answer 284

**Calcifying Epithelial Odontogenic Tumor(CEOT**) * ***Fewer calcifications here***, **well‐circumscribed and corticated, impacted** tooth. * **periosteal reaction** _causing elevation_ at the bottom of image!

Answer 285

**Calcifying Epithelial Odontogenic Tumor(CEOT)** * **well‐circumscribed radiolucency with calcifications** *_in lower anteriors_*

Answer 286

* Thought to arise from **epithelial rests or basal cells in the gingiva** * *Uncommon* * **Does not invade underlying bone** * *Histology is the same as _conventional type_*

Answer 287

* Found on **gingiva or alveolar mucosa (**\*that's why it's named *peripheral* or extraosseous)

Answer 288

1. **Malignant ameloblastoma** 2. **Ameloblastic carcinoma**

Answer 289

* thought to arise from ***remnants of the dental lamina in the gubernacular cord /canal***

Answer 290

* **a primary lesion** has _atypical poorly‐differentiated_ * _neoplastic_(malignant) histology * **may metastasize**

Answer 291

**well‐circumscribed radiolucency at crown of an impacted canine** _Hard to tell if attaches at CEJ._ If further down, *less likely **a dentigerous cyst*** and more likely **AOT, ameloblastoma, or OKC**

Answer 292

we see **calcifications** forming, with both radiolucent and radiolucent areas. *▪ Dentingerous cyst, ameloblastoma, and OKC are NO LONGER in the* **differential diagnosis.** **_This is clearly AOT_** **_(_Adenomatoid odontogenic tumor)**

Answer 293

Adenomatoid odontogenic tumor (AOT) **Swelling in maxillary vestibule**

Answer 294

**Adenomatoid odontogenic tumor** **(AOT)** fibrous capsule of AOT is at least partially encapsulated. Easy to remove; “popped right out”.

Answer 295

**Adenomatoid odontogenic tumor** **(AOT)** An expansion _into lingual area_ as well as _into vestibule_

Answer 296

_Adenomatoid odontogenic tumor_ _(AOT)_ **Snowflake‐like calcifications** within ***mixed, well‐circumscribed radiolucency***

Answer 297

Adenomatoid odontogenic tumor (AOT) * **Teardrop shape / inverted pear** _between roots of teeth_. * **Well-circumscribed, corticated margin** & **snowflake‐like calcifications** *within*

Answer 298

▪ Malignant ameloblastoma o Primary lesion and metastasis have normal welldifferentiated ameloblastic (benign) histology o Most commonly to lung

Answer 299

**Pindborg Tumor**

Answer 300

▪ Uncommon (~1% of odontogenic tumors) ▪ Does not have inductive effect

Answer 301

o **2nd to 10th decade**s, peak **~ 4th decade** o **MD (mandibular) 2 : 1 MX (maxillary)** o Usually ***posterior mandible***

Answer 302

* Presents as **painless slowly expanding swellings** * sessile swellings **of the gingiva or alveolus** *( 2 times more on mandible than maxilla* * **Peripheral lesion** may be seen, but are **rare**

Answer 303

* *May be **unilocular***, but **most commonly as a multilocular lesion** * ***May be entirely radiolucent*** or ***a mixed radiolucent-radiopaque lesion*** * **Often associated with an unerupted tooth** * *MD third molar most common* * **Calcifications** in the lesion, if present, are typically *prominent around the crown of the impacted tooth.*

Answer 304

In addition to *fracture*, there is **semilunar loss of bone around the molars ►** (SOT) **Squamous Odontogenic Tumor**

Answer 305

**SOT** **Squamous Odontogenic Tumor** * ***Semilunar** loss of bone*. * **Alveolar bone** is gone due to **impacted canine** that is visible

Answer 306

* CEOT clinically is similar to **ameloblastoma** * Also**, CEOT** has potential _to be locally invasive_, if in the right anatomic location, *but has **a less aggressive biologic behavior** compared to **ameloblastoma***

Answer 307

▪ **Enucleation** _with peripheral ostectom_y ▪ **Resection** _with rim of normal bone_ ▪ _Recurrence_ rate is ***~12%*** ▪ **~ 2%** demonstrate *malignant transformation*

Answer 308

Central odontogenic fibroma (COF) * **well‐circumscribed radiolucency** *posterior to molar*

Answer 309

Central odontogenic fibroma (COF) round mass of opacity due to FCT. **Ground glass‐like appearance**

Answer 310

▪ 2/3 **anterior jaws** ▪ 2/3 **females** ▪ 2/3 associated with **an impacted canine** ▪ 2/3 **MX** ▪ 2/3 **2nd decade** – kids and teenagers\ That's why it's known as **the tumor of two thirds** ▪ ~ 3‐7% of all odontogenic tumors *New research showing more in **_ant md_** though*

Answer 311

* Frequently ***_asymptomatic_***, discovered upon routine radiographic exam or when lesion becomes large enough to expand bone * Tumor of *Epithelial Origin*

Answer 312

▪ ***~ 75%*** are **well‐circumscribed unilocular radiolucency** involving the **crown of an unerupted tooth** o ***less often,*** they are **found between the roots of teeth** **▪** ***Mixed radiolucent/radiopaque appearance*** is likened to **“snowflake” calcifications** *▪ May be totally radiopaque in some cases* **▪ Divergence of roots** _is frequently seen_

Answer 313

**a dentigerous cyst.**

Answer 314

**Odontogenic Myxoma** * Classic example of **enlargement of the mandible** caused by **multilocular radiolucency.** * Enlarged into oral cavity ‐ **alveolar ridge elevated**

Answer 315

**Odontogenic Myxoma**

Answer 316

**Clinically**: obliteration of vestibule on patient’s left mandible **Radiographically**:lesion running from posterior by third molar all the way anterior to canine. Well‐circumscribed, multilocular radiolucency is scalloping up between teeth, causing some root divergence **Grossly**: gelatinous appearance of myxoma makes it hard to remove **After treatment:** post‐surgery; had excised all the way to right 2nd PM This is **Odontogenic Myxoma**

Answer 317

* Treatment is usually **_enucleation_** * _recurrence_ is ***rare***

Answer 318

**CEMENTOBLASTOMA (True Cementoma)** * First molar has **tumor attached to the root.** * Mostly **radiopaque but has some less radiodense areas within** = *_classic for cementoblastoma._* * **Radiolucent halo** around region.

Answer 319

**Cementoblastoma** **Grossly** continuous growth from tumor to the root of the tooth. Brownish areas were more vascular. **Histologically:** tubular dentin in tooth, attached to mass of tissue with calcifications

Answer 320

▪ Typically _involves alveolar ridge_ **▪ Anterior \> Posterior jaws** ▪ Seen from 2nd to 7th decade (mean 40 years of age)

Answer 321

* Tumor of *Epithelial Origin* * ***Rare*** * Usually ***asymptomatic***, but _may present with tooth mobility and slight pain_ * **Multiquadrant** ~ 20-25% * A couple reported cases *in families*

Answer 322

* **Well‐circumscribed radiolucency** , often ***a semilunar radiolucency of alveolar ridge*** * Can mimic _periodontal disease_

Answer 323

* Thought to arise ***from epithelial rests (Malassez) in the periodontal ligament space***

Answer 324

* Treatment is **conservative local excision** * _Recurrence_ is ***rare***

Answer 325

**Compound Odontoma** * Mature normal appearing pulp, enamel and dentin * Organization like teeth, with enamel surrounding dentin which surrounds pulp ( Well developed rudimentary “tooth” forms) * appear as small tooth‐like structures in the Anterior jaws (esp. MX) **Complex Odontoma** * Mature pulp, enamel and dentin * No organization, mass of dentin and enamel matrix and pulp tissue (\*\*Poorly developed mass of calcified deposits) * appear as masses of radiopaque material with * variable densities in the Posterior jaws (esp. MD)

Answer 326

Classic appearance of **Odontoma** * **multiple tooth‐like shapes** *aggregated together* * Typically with some sort of **radiolucent halo around them**

Answer 327

**Compound Odontoma** _little teeth‐like structures_ blocking canine eruption

Answer 328

**Complex Odontoma** * _2‐2.5cm mass overlaying the molar_. * ***radiolucent rim/halo*** that is **mixed**, *mostly* **radiopaque**

Answer 329

* **Ameloblastoma** * **Squamous cell carcinoma (SCCa)**

Answer 330

* *Odontogenic Fibroma (central) **

Answer 331

- Tumors of Mesenchymal Origin - Some believe represents **the counterpart to the peripheral ossifying (odontogenic) fibroma** *(in soft tissue)*

Answer 332

Primordial Odontogenic Tumor (POT) **unilocular radiolucency**

Answer 333

* **MX ≈ MD** * lesions in **MX** tend to be **anterior to first molar** * those in **MD** **anterior ≈ posterior** * **1/3** associated with an **unerupted tooth**

Answer 334

*_-Small lesion_* tend to be **asymptomatic** -*_Larger lesions_* can cause **cortical expansion and tooth mobility**

Answer 335

* *Small lesions* tend to be **well-circumscribed unilocular radiolucencies** * **often periradicular** * can mimic periapical granulomas and cysts * *Larger lesions* tend to be **well-circumscribed multilocular radiolucencies** * ***Borders*** are usually **sclerotic** * **Root resorption** or **divergence** may be seen * ***~ 10- 15%*** will show **radiopaque flecks** _within the radiolucency_

Answer 336

**Ameloblastic Fibroma (AF)** 1‐3 potential locules, no impacted tooth associated

Answer 337

* **Enucleation** with **curettage** or **excision** * usually d**on’t recur**

Answer 338

**Ameloblastic Fibro-odontoma (AFO)** * _well‐circumscribed radiolucency_ * ***corticated edg***e + **calcification**

Answer 339

**Ameloblastic Fibro-odontoma (AFO)** has expansion into oral cavity. Flecks of calcification in lesion with impacted tooth = odontoma

Answer 340

**o Desmoplastic fibroma** ‐ *a more aggressive lesion* o **Fibromyxoma *‐*** *variant of odontogenic myxoma with abundant collagen* **o Hyperplastic tooth follicle** *‐ typically loose immature stroma, but when hyperplastic can have abundant collagen*

Answer 341

* Tumors of *Mesenchymal Origin* * Thought to arise from ***the tooth follicle or dental papilla***

Answer 342

* **~3-5%** of all odontogenic tumors * Wide age range, but **3rd decade most common** * Found anywhere in the ***MD or MX***

Answer 343

* *Small lesions* present as **asymptomatic radiolucencies** found upon routine exam * *Larger lesions* can cause **painless expansion of bone** * All are **radiolucent lesions**, but the appearance can vary from **well‐ circumscribed to irregular and diffuse** * ***Unilocular*** to, **more commonly, multilocular** _(“soap bubble” or “honeycomb”) radiolucency_ * **Borders** are often **scalloped**, can see sc_alloping around the roots of teeth_ * But can cause **displacement of teeth and resorption of the roots of teet**

Answer 344

**Ameloblastic Fibrosarcoma** in the mandible developed after two years from AF

Answer 345

* the tumor is described as **loose**, **soft** and **gelatinous**

Answer 346

* **Surgical excision** or **resection** * Because the lesion is not encapsulated and has a gelatinous loose consistency► it is difficult to remove completely * this is thought to be why myxoma **has a fairly high recurrence rate** * _**Maxillary posterior lesions** should be treated more aggressively_

Answer 347

* Tumor of *Mesenchymal* origin * **Benign tumor** of *cementoblasts*

Answer 348

* Typically present in **2nd and 3rd decade** (~75% prior to the age of 30) * **75% MD** * ▪ ~ 90% in **molar/premolar region** *

Answer 349

* **2/3** of cases have **pain and swelling** * Can cause **cortical expansion *_if large enough_***

Answer 350

* **Radiopaque mass** _fused to_ *the root of the affected tooth* * Usually has a **thin radiolucent halo or rim** _surrounding the radiopacity_

Answer 351

* **surgical extraction** _of the involved tooth with attached tumor_ * **Root amputation (with attached tumor) and endo** is an option *_for smaller lesions_* * _Recurrence_ is ***unlikely***

Answer 352

**osteoblastoma** Difference is Osteoblastoma is **NOT** a_ttached to the root of a tooth_ (whereas cementoblastoma must be)

Answer 353

They are tumors in which the _odontogenic epithelial componen_t causes **induction** of the _mesenchymal component_ **to produce a product** **Examples:** * Odontomas * Ameloblastic fibroma * (and Ameloblastic fibrosarcoma) * Ameloblastic fibro-odontoma

Answer 354

* Odontogenic Tumors of Mixed Origin (Epithelial and Mesenchymal * They are **_hamartomas_** *rather* than _true neoplasms_ * They are **_masses of enamel and dentin_** *with variable amounts* ***of*** **_pulp and cementum_**

Answer 355

**Odontoma**

Answer 356

▪ **First 2 decade** *_most common_* (mean age of ***14***) Location is based on *the type of Odontoma* * **Compound Odontoma** * _Anterior jaws (esp. MX)_ * \*\***Well developed rudimentary “tooth” forms** * **Complex Odontoma** * _Posterior jaws (esp. MD_) * **\*\*Poorly developed mass of calcified deposits**

Answer 357

* Often associated with _an unerupted tooth_ * Lesions **may prevent eruption of teeth** * Usually ***small* in size,** but ***rare cases of \> 6cm reported*** * *large lesions* **can cause bone expansion**

Answer 358

▪ Radiographically see **a radiopaque structure(s)** *surrounded by* **a radiolucent rim** ▪ As with any calcified lesion, those found *early in development* may appear _totally or *predominantly radiolucent*_ ▪ **Compound odontomas** *appear as* **small tooth‐like structures** ▪ **Complex odontomas** *look like* **masses of radiopaque material** *with* **variable densities**

Answer 359

▪ **Simple excision** or **enucleation** ▪ **Unlikely** *to* **recur**

Answer 360

* Tumor of mixed origin * Very rare! first reported in 2014 -**less than 30 cases so far**

Answer 361

* Most common in **1st and 2nd decades** * Mean age **12.5 years** * **MD:MX 6:1**

Answer 362

- **Asymptomatic** found on routine imaging - Can cause **tooth displacement** and **cortical expansion**

Answer 363

* **Well-defined radiolucency** _associated with_ **an impacted tooth** * Most commonly **a third molar**

Answer 364

* **conservative excision/enucleation** * So far ***no recurrence***

Answer 365

* _Uncommon_ ***benign* mixed** odontogenic neoplasms. * **Considered together b**ecause it is thought they are _variations of the same process_

Answer 366

* Typically presents in **first 2 decades** * mean is 12 years of age * **~ 70%** occur in **the posterior mandible** * **~ 75%** associated with **unerupted teeth**

Answer 367

* **Small lesions** are **asymptomatic** and found on routine exam * **Large lesions** _can cause bone expansion_ * **Smaller lesions are unilocular Radiolucencies** * **Large ones are multilocular radiolucencies** * **Border** is **well defined and often sclerotic** * ***Untreated***, _can grow to very large size_

Answer 368

- Clinical features similar to **Ameloblastic Fibroma AF** *(Small lesions are asymptomatic and found on routine exam & Large lesions can cause bone expansion)* Radiographically, we see **a mixed radiolucent/radiopaque lesion** _because of the formation of odontomas_

Answer 369

* **Conservative surgical excision** or **curettage**, _easily_ _removed from surrounding bone_ * _Prognosis_ is **excellent**, _recurrence_ is ***unusual*** * ▪ **Rare cases** reported of **development of ameloblastic fibrosarcoma** _in area of AF or AFO_

Answer 370

* _Malignant counterpar_t of **ameloblastic fibroma** * **Rare lesion** which may arise in the site of a previous AF/AFO or arise de novo

Answer 371

* **1.5 times** _more common_ in **males** * ~ **80% MD**

Answer 372

* **Pain**, **swelling** and **rapid growth** are *common presenting signs*

Answer 373

* presents as an **ill-defined destructive radiolucency** *with* **irregular borders**

Answer 374

- **Radical surgical excision** as the tumor is ***very aggressive*** *and* ***infiltrative*** - _Prognosis_ is *dependent on* **complete removal of tumor**

Answer 375

-**Ameloblastic carcinoma** **-Primary intraosseous carcinoma, NOS** **-Sclerosing odontogenic carcinoma** **-Clear cell odontogenic carcinoma** **-Ghost cell odontogenic carcinoma** All fairly rare lesions!

Answer 376

**MOCHA** * **M odontogenic **_M_**yxoma** * **O **_O_**dontogenic keratocyst** * **C **_C_**entral giant cell granuloma** * **H Central **_H_**emangioma** * **A _A_meloblastoma** **Others:** * Aneurysmal bone cyst * early CEOT * ameloblastic fibroma AF * central MECa

Answer 377

**Rapidly growing and infiltrative** –finger-like extensions into surrounding anatomy Remember: in some instances, a benign lesion can mimic a malignant one. Therefore we should be wary of all the information that is available.

Answer 378

ill-defined invasive borders followed by bone destruction

Answer 379

Destruction of the cortical boundary (floor of maxillary antrum) with an adjacent soft tissue mass (arrows)

Answer 380

Tumor invasion along the periodontal membrane space causing irregular thickening of this space

Answer 381

Multifocal lesions located at root apices and in the papilla of a developing tooth destroying the crypt cortex and displacing the developing tooth in an occlusal direction (arrow)

Answer 382

Four types of effects on cortical bone and periosteal reaction, from top to the bottom: •**cortical bone destruction** *without* **periosteal reaction** ***•laminated periosteal reaction*** *with* **destruction of the cortical bone and the new periosteal bone** **•destruction of cortical bone** *with* **periosteal reaction at the periphery** *forming* **Codman's triangles** **•a spiculatedor sunray** _type of periosteal reaction_

Answer 383

Bone destruction around existing teeth, producing an appearance of teeth floating in space.

Answer 384

**Chondrosarcoma** * its consistent widening as opposed to seen in periodontitis and inflammatory disease

Answer 385

**Chondrosarcoma** * Ill defined lesion of anterior maxilla * Areas of radiolucency * Classic area of moth‐eaten look * Circular area of radiolucency with trabecular * pattern * Patient left without surgery, not heeding medical advice Then patient came back ▪ Someone was willing to do the dentures for her ▪ CC‐ denture was not fitting ▪ Expansion of cortical plate ▪ Hyperkeratotic because of denture rubbing ▪ Still has malignancy ▪ Advise for surgery ▪ Refused again Then the lesion kept on Lesion still growing ▪ Metastasize to lungs ▪ Admitted to breathing issues ▪ About 5 ½ years from initial dx to pt passing away

Answer 386

**Chondrosarcoma** * Alveolar process and floor of mouth affected * **Limitations of movement of the tongue**

Answer 387

Can see in the anterior region there’s an elevation histology shows it's not chondrosarcoma because it contained **_Cutright lesion_** **papule or nodule on alveolar ridge** * Osseous and/or chondromatous metaplasia within the soft tissue of the gingiva o **Lesion is NOT central in bone or connected to bone** *_▪ NOT a malignant lesion_* o Thought to be **reactive metaplasia due to a poorly fitting denture**

Answer 388

* *Chondroma –** benign * *Chondrosarcoma**‐ malignant * Both are listed here _because_ * _a benign cartilaginous tumor central In the jaw is extremely rare_ (or may not exist) * _Lesions tend to recur many times_ and **eventually metastasize *( Basically chondromas are not really benign)***

Answer 389

* **Malignant tumor** that _forms cartilage_ * **10%** of all primary bone tumors, but ***rare in the jaws***

Answer 390

**Osteosarcoma** ## Footnote ▪ Swelling on left side of face ▪ Difficult opening

Answer 391

**Osteosarcoma** * See something in the operculum * Infection in third molar?

Answer 392

**Osteosarcoma** * AP Plain Film * Most of jaw was missing * Radiolucency affecting entire ramus and condyle

Answer 393

**Osteosarcoma** * Classic _sunburst pattern_ * **Fuzzy appearance** _on outer edges of cortex_

Answer 394

**Osteosarcoma** * _cloudy bone formation_ on surface of cortex on facial and lingual aspect

Answer 395

**Osteosarcoma** a patient with swelling with side of face

Answer 396

**Osteosarcoma** ▪ _Lytic lesion_ ▪ *Slightly* **ill defined** ▪ **Loss of bone** in the _inferior aspect of mandible_

Answer 397

* Patient’s chief complaint is **painless swelling,** *may be associated with tooth mobility* * **Symmetric widening of the PDL space** * Can be _initial presentation with chondrosarcoma and osteosarcoma_ * **Along radicular surface of the tooth** there is the _same rate of widening all the way down the tooth_ * ***In contrast to periodontal disease***, where there is _a triangular shaped loss of space_

Answer 398

* **Poorly defined radiolucency**, often with ***scattered radiopaque foci*** * Radiopaque foci can be seen since the cartilage in the tumor can ossify

Answer 399

* **Radical surgical excision** _on initial treatment_ * _Maxillectomy/Mandibulectomy_ * If anterior region they remove the entire anterior portion of the jaw * These lesions *don’t respond to radiation or chemotherapy* * ***Although used as adjuncts for lesions that can’t be treated surgically*** * *For example **a posterior sinus** **lesion** _since that is the base of the skull_* * *These patients have **poorer prognosis** than those with more accessible sites such as the mandible* * **Prognosis is poorer** *than for osteosarcoma* (which contrasts with the prognosis in extragnathicsites) * **Treatment failure** (and ***mortality***) is usually **due to uncontrolled local disease** *not metastasis*

Answer 400

* **Since 20% of chondrosarcomas of the jaw are initially misdiagnosed as chondromas** ► any diagnosis of chondromain the jaws should be viewed with suspicion * **All cartilaginous tumors arising in the jaws should be excised widely** * (\>60% of cartilaginous tumors of the jaw recur and ~7% metastasize to the lung and/or bone )

Answer 401

* **Most common malignant bone tumor in the jaws** is _metastatic disease_ * **Most commonly primary** (meaning started at this location) **malignant bone tumor in patients under 40 years old** * 2nd most common overall after *multiple myeloma* * _Mean age at presentation for jaw lesions_ is **33 years old,** *10‐15 years older than that for long bones* *

Answer 402

* **Swelling and pain** are the common presenting symptoms **(25% have “toothache”)** * Can also have ***loosening of teeth,** **paresthesia of lip** and **nasal obstruction*** * **Symmetric widening of the PDL** is often _an early radiographic change_ * Lesions vary from ***dense sclerotic, mixed sclerotic*** *and* ***radiolucent*** *to* ***all radiolucent***

Answer 403

* _Important to distinguish from chondrosarcoma as treatments are different_ * **_Osteosarcoma_** is currently treated with **pre-op multi-agent chemotherapy followed by surgery** * ***Radiation therapy*** alone is ***insufficient*** for cure * **_Favorable jaw site – MD symphysis_** * **_Worst site – MX sinus_** * **5 year survival is ~ 20%** (***_up to 80% if caught early_*** and *_treated with radical resection)_*

Answer 404

**Langerhans Cell Disease** Infant with _Acute disseminated type_ ▪ See lesions on head/ear

Answer 405

Langerhans Cell Disease we see _lesions on maxilla_

Answer 406

**Langerhans Cell Disease** ▪ Older child ▪ Chronic disseminated form ▪ Alveolar ridge involvement ▪ Lot of bone loss and mobility ▪ Painful to brush

Answer 407

**Langerhans Cell Disease** Torus and molar involvement

Answer 408

**Eosinophilic Granulations** Erythematous area

Answer 409

▪ Child with _disseminated form_ ▪ **Punched out radiolucency** in the skull

Answer 410

▪ Child with **bone loss** surround the teeth **▪ Floating teeth** _disseminated form_

Answer 411

▪ Floating teeth ▪ Only attached by soft tissue due to extensive bone loss _disseminated form_

Answer 412

**Eosinophilic granuloma**

Answer 413

* **Arise on the surface of the bone** (vs. medullary site for usual forms of osteosarcoma) * Usually **long bones**

Answer 414

**parosteal** – *_well differentiated_*, but will **recur** with less than an en bloc or radical surgery **periosteal** – _higher grade_ with prominent **cartilaginous** component

Answer 415

o **Mushroom like growth** on bone surface o **No** *elevation of periosteum* o **No** *new bone formation* o **Low grade**

Answer 416

o Usually **sessile** **growth** on bone surface o **Elevation of periosteum** o **New bone fills in** space under periosteum o **Prognosis is _better_** *than medullary osteosarcoma* ***but worse than**parosteal type*

Answer 417

* **Histiocytosis X (old name**) * **Langerhans cell granuloma** * **Eosinophilic granuloma** * **_Langerhans cell histiocytosis_**

Answer 418

Etiology unclear o Demonstration that LCH cells are **clonal**, along with the recent discovery of **activating BRAF mutations in LCH cells**, ►**strongly suggests that LCH is a neoplastic disease**

Answer 419

* **Males**\>\>\> Females * More than half of cases seen **under the age of 10** * **Jaw** affected in **10 ‐20% of cases**

Answer 420

* **Punched out** radiolucency * **Lytic** radiolucency *without cortication* MM Multiple Myeloma

Answer 421

* more punched out radiolucency in iliac crest in the image * Bone marrow biopsy usually done in this area since it’s frequently involved multiple Myeloma MM

Answer 422

Multiple Myeloma ## Footnote ▪ Radiolucency without sclerotic border ▪ Multiple and separated

Answer 423

Swelling of gingiva ## Footnote **▪ Plasmacytoma**

Answer 424

**_Clinically:_** Common sites: **skull, rib, vertebrae, and mandible** ▪ Often have associated **pain or tenderness** **_Radiographically:_** ▪ In jaws we see loss of alveolar bone in molar area o Mimics severe periodontitis

Answer 425

**▪ Acute disseminated form (Letterer‐Siwe disease) ▪ Chronic disseminated form (Hand‐Schuller‐Christian Disease, ▪ Eosinophilic Granuloma (chronic localized)**

Answer 426

* **Multisystem** (bone, skin, liver spleen and lymph nodes) * **Infants** * **high mortality** * **rapidly progressive**

Answer 427

* **Unisystem** (frequently *bone*, but _also skin and viscera)_ * **Children** * ***fairly* high mortality** * ***more* chronic progression**

Answer 428

**Ewing Sarcoma** ## Footnote ▪ Long bone ▪ Large expansion

Answer 429

**Ewing Sarcoma** * an _expansion of tissu_e * **Dissolution of bone** in that area

Answer 430

* **Solitary or multiple bone lesions** *without visceral involvement* * **Adults** * **very low mortality** * Some reports of **association with smoking marijuana** * In these cases ***the lungs are involved***

Answer 431

Site of involvement depends on clinical form * Neoplastic proliferation of Langerhans cells * Langerhans cells * Dendritic mononuclear cells normally *found in the epidermis and mucosa* * Antigen presenting cells to T lymphocytes

Answer 432

Metastatic Carcinoma to Jaw Bones ▪ A. Metastatic breast carcinoma surrounding the apical half of the second and third molar roots and extending inferiorly. It has destroyed the inferior border of the mandible.

Answer 433

Metastatic Carcinoma to Jaw Bones B. Bilateral metastatic lesions from the lung destroying the mandibular rami.

Answer 434

**Metastatic Carcinoma to Jaw Bones** D. Destruction of the left mandibular condyle (arrows) from a thyroid metastatic lesion

Answer 435

**Metastatic Carcinoma to Jaw Bones** A. Partial panoramic image of prostate metastatic lesions involving the body and ramus; note the sclerotic bone reaction (arrows).

Answer 436

**Metastatic Carcinoma to Jaw Bones** B. Occlusal image of prostate lesions causing sclerosis and spiculated periosteal reaction (arrows)

Answer 437

Metastatic Carcinoma to Jaw Bones C. Periapical image of a metastatic lesion of breast carcinoma; note the irregular widening of the periodontal membrane spaces and patchy sclerotic bone reaction, especially around the roots of the molars

Answer 438

* **Exophthalmus** * **Diabetes insipidus** * **Lytic defects of bone**

Answer 439

Clinically: * we see _mobility of teeth_ Radiographically: * picture of child with **“teeth floating in air”** * **Sharply punched out radiolucent lesion**s, *ill- defined radiolucency in some cases*

Answer 440

* **Elderly men** often present with **lung lesions** *_(increased incidence with smoking)_* * **Localized lesions,** usually affecting **one bone** * If found to be a*n accessible solitary lesion,* **treatment** is usually **curettage and possibly low dose RT** * in some instances it can be **initial presentation of systemic disease** – but that would _typically be in children or young adults_

Answer 441

**Birbeck granules**

Answer 442

**o Juvenile periodontitis** **o Langerhans cell histiocytosis** **o Papillon‐Lefevre syndrome** **o Cyclic neutropenia/agranulocytosis** **o Burkitt’s Lymphoma**

Answer 443

**Monoclonal Expansion of malignant plasma cells** * Plasma cells make a lot of immunoglobulin ► So we will see a lot of immunoglobulin

Answer 444

* Most common in **40‐70 year old** * Means 63 years old * Bones most commonly involved include **ribs, vertebrae and skull** * **70‐90%** will have ***_jaw involvement at some point_***

Answer 445

* Present with **bone pain (\>70%)** and **pathologic fractures** * ***Anemia, thrombocytopenia and neutropenia*** _due to crowding out of normal cells within bone marrow by proliferating malignant cells_ * _50‐60%_ have **Bence‐Jones proteins in urine** (light chains, usually kappa)

Answer 446

**▪ Solitary plasmacytoma** * *Individual lesion **in bone*** * When affecting oral cavity, ~95% of the cases are ramus and angle of the mandible * In many cases p_rogress to more systemic disease_ **Extramedullary plasmacytoma** * *individual **soft tissue** lesion* (not central In bone) **Multiple myeloma** * ***multifocal*** *disseminated disease*

Answer 447

* **“punched out” radiolucencies** (no sclerotic margin) often _with an irregular outline_

Answer 448

* **Elevated M spike in serum** * *Elevation of immunoglobulin in serum* (**hyperglobulinemia**) most **commonly IgG** * *Deposition of amyloid in tissues* (**macroglossia**)

Answer 449

Treatment can include : * **chemotherapy** _with or without Radtiaion Therapy_ * bone marrow transplant * interferon * antibodies made against tumor cells * thalidomide * Even with treatment, many patients do not survive more than 18‐24 months, however treatment modalities are improving * Older patients are treated less aggressively

Answer 450

▪ Highly malignant, undifferentiated, small round cell tumor/small blue cell tumor o The cell of origin is in question, may be of neural crest origin

Answer 451

* **Primarily a disease of children and adolescents (**90% of patients are between 5 and 30 years old) ▪ **\>60% males** ▪ * _Twice as common_ **in mandible** * **Caucasians\>\>\>\>Blacks and Asians** * Make up **~6% of primary malignant bone tumors** * In the jaws, the ratio of primary tumor to metastasis is 14 to 1 * **50%** of cases i**n the femur and pelvic bones** * **~1%** occur in the **jaw bones**

Answer 452

* Patients often present with **pain, swelling, fever and elevated ESR** (similar to signs of inflammation) * May be misdiagnosed as **an infection or osteomyelitis** * **Paresthesia** and **loosening of teeth** are _common findings with jaw lesions_

Answer 453

* **an irregular lytic lesion** *with* i**ll‐defined margins** * **Root resorption** _may be seen_ * May see **thickening of the periosteum** with a characteristic **“onion skinning” pattern** (like with peripheral periostitis) * seen more in long bones

Answer 454

* **Combined therapy with multi‐agent chemotherapy, radiation therapy and surgery** has led to 40% ‐ 80% survival rates * **Gnathic Ewing sarcoma** has *_a lower mortality rat_*_e_ than all other primary sites

Answer 455

The most common carcinomas to jaw: **B**reast **L**ung **T**hyroid and **C**olon **K**idney **P**rostate ▪ “B. L. T. and Cold Kosher Pickle”

Answer 456

Metastatic tumors to the jaw are more common than primary lesions ## Footnote ● Think osteosarcoma, chondrosarcoma, or osteoblastic metastasis (breast or prostate) if lesion radiographically looks malignant and has radiopaque internal pattern ● Ewing’s sarcoma is clinically accompanied by signs of inflammation ●Multiple myeloma characteristically presents as multiple, well‐ defined, punched‐out radiolucencies ● Bone affected by Non‐Hodgkin’s lymphoma radiographically appears to be dissolving ● Langerhans cell histiocytosis characteristically presents as scooped‐ out radiolucencies at the mid‐root level ● Remember to include metastatic carcinoma to jaw as a radiographic differential diagnosis for malignant lesions

Answer 457

Inflammatory bowel diseases associated with oral findings **▪ Crohn disease ▪ Ulcerative colitis ▪ Pyostomatitis vegetans ▪ Celiac Disease**

Answer 458

What areas does affect? ● Primarily affecting distal small intestine and proximal colon What are the symptoms? ● Symptoms include **abdominal cramping, pain, bloating, diarrhea**, and **nauseas** (*similar amongst the GI diseases*) ● Patients often have **weight loss and malnutrition** ● **20%** have **abrupt onset of symptoms** *resembling* **_acute appendicitis_** *or* **_bowel perforation_**

Answer 459

When it is diagnosed? ● Usually initially *diagnosed* **in adolescents** Etiology? **●** *Etiology* **unknown‐ immunologically mediated?** o Theory of being _too clean as a child and having a negative response as we grow older since we’re not used to normal bacteria_ Prevalence? ● *Prevalence* i**ncreasing, reason unknown** What are the oral implactions? ●Oral lesions can be first sign of disease

Answer 460

● **Superficial or deep ulceration** *with adjacent granulation tissue* extending into deep submucosa or below ● **A transmural granulomatous inflammation** o Sarcoid‐like, non‐caseating, poorly formed granulomas, in all tissue layers (50‐70% of cases) usually adjacent to blood vessels or lymphatics ● **Transmural inflammation with lymphoid aggregates** throughout bowel wall

Answer 461

* **Recurrent oral ulcerations** _can mimic those seen with_ **recurrent aphthous lesions** * **Diffuse or nodular swelling** of _the oral and perioral tissues_ * Can look like ***epulis fissuratum*** * **Deep linear granulomatous‐appearing ulcerations** (often in the buccal vestibule area) * ***_Cobblestone mucosal appearance_*** * **Polypoid tag‐like lesions** on _vestibular and retromolar mucosa_ * **Enlargement of lips** _caused by granulomatous inflammation:_ **orofacial granulomatosis**

Answer 462

* Current strategies aim for _deep and long‐lasting remission, with the goal of preventing complications_, such as *surgery, and blocking disease progression* * **_Immunosuppressant_** such as _cyclosporine_ * In more severe cases; * *high dose corticosteroids and** * **chemotherapeutics to induce a remission** * **Nutritional supplements** _(iron, folate)_ * Because _they are unable to absorb nutrients_ * If medical means do not keep patient under control► **surgical removal of a portion or all of the intestine** * When _intestinal symptoms are under control_►**oral ulcerations resolve**

Answer 463

Crohn Disease * Patients can also get **angular cheilitis** * Above the **Linear ulceration,** can see **a flap like structure** which is **the hyperplastic margin**

Answer 464

* we see the **ulceration** and **hyperplastic tissue** surrounding it.

Answer 465

**Crohn Disease** _Nodular appearance_ of **buccal mucosa**

Answer 466

_Crohn Disease_ we see **more nodules**

Answer 467

Crohn Disease _Linear granulomatous ulcerations_ But they are **not** *the aphthous ulcerations* **but the more linear type**

Answer 468

Unlike Crohn’s, lesions extend in a continuous fashion proximally from the rectum (no skip lesions) and histologically don’t have granulomas

Answer 469

Bactrial Overgrowth in the pseduomemberane (C.difficile Overgrowth) Causes: * **Clindamycin** prolonged use ~2 weeks _can cause the C. difficile overgrowth._ * _Always_ ***warn patients if you prescribe clindamycin about possible side effects*** and stop usage _since do not want them to develop untreatable strains_

Answer 470

What are the symptoms * A chronic inflammatory disease of the colon (mucosa and submucosa) presenting with **diarrhea, rectal bleeding, abdominal pain, weight loss and fever** What type of Cancer risk it presents? * Increased risk of **colon cancer**

Answer 471

● Treatment is n**ot well standardized**, fairly rare disease and good double blind studies rare ● Can **use topical corticosteroids** ● Werchniak et al had **good results with topical tacrolimus** ● **Sulfasalazine** or **Prednisone** *_for GI lesions_* ● If GI symptoms are under control► oral lesions will resolve

Answer 472

Pyostomatitis Vegetans

Answer 473

Pyostomatitis vegetans

Answer 474

**Pyostomatitis vegetans** *Snail track appearance*

Answer 475

● In some cases, patients get **recurrent oral ulcerations** (can have _aphthous‐like lesions_) ● **Papillary mucosal projections** with _deep linear ulcers_ and _fissures_ ● **Intraepithelial pustules of the mucosa** (_pyostomatitis vegetans_)

Answer 476

● Use of _anti‐inflammatory medications_ **o Sulfasalazine or Prednisone** ● If medical means do not succeed► then **removal of part or all of colon**

Answer 477

**● IBD** o Classified as a **_disease_** o Can cause **destructive inflammation and permanent harm to the intestines** o The disease can be _seen during diagnostic imaging_ o **Increased risk for colon cancer** ● IBS o Classified as a **_syndrome_**, a group of symptoms o Dose _**not cause** inflammation; rarely requires hospitalization or surgery_ o There is _**no sign of abnormality** during an exam of the colon_ ▪ Usually because it’s only _periodic_ o **No increased risk form colon cancer or IBD**

Answer 478

**What is it?** * Thought to be an unusual presentation of inflammatory bowel disease, especially ulcerative colitis (sometimes with Crohn’s)\ **Demographics** * In only a rare subset of patients * Typically present before 30 years of age **Symptoms onset** * **~25%** of cases seen in **absence of GI symptoms** * May see oral symptoms **before** the GI symptoms

Answer 479

**Oral Symptoms** ● **Recurrent oral ulcerations** _concurrent with, or prior to ***GI symptoms***_ ● Oral mucosa is **erythematous** and **thickened** with **multiple cream/yellow‐colored pustules**and**superficial erosions** ● *Linear* **“snail track**” _oral pustules_ **Most common sites in the mouth?** ● Most common sites include **buccal and labial mucosa, soft palate,** *and* **ventral tongue**

Answer 480

What is it? ● **Chronic disease** (diffuse enteritis) of **the small intestine** _which improves upon **withdrawal of gluten proteins**_ Which gene is involved? ● \>90% express **HLA‐B8** _histocompatibility antigen_ Symptoms? ● Patients present with **diarrhea, gas, weight loss, fatigue, impaired nutrient absorption, etc**

Answer 481

**Amyloidosis** Nodular “waxy” depositions in skin **deposition on the eyelid**

Answer 482

Amyloidosis orange, red, yellow tinge

Answer 483

Amyloidosis Macroglossis and crenation of tongue (indentation near the teeth area) _skin deposits_ on the comissure,

Answer 484

**Amyloidosis** _macroglossia_

Answer 485

**Amyloidosis** _Amyloid deposition_ on the tongue is amyloid, you have papule and nodule like area, can see the **crenation** of the tooth

Answer 486

Amyloidosis Submucosal amyloid deposit

Answer 487

**Amyloidosis** _Amyloid deposition_ with **ulceration** and **petechiae**

Answer 488

Amyloidosis ▪ different color compared to normal tongue with amyloid

Answer 489

● 10‐15% risk of **GI lymphoma**

Answer 490

● 10‐15% risk of GI lymphoma ● Oral symptoms include aphthous‐like ulceration of mucosa ● Patients can have enamel defects and pitting

Answer 491

**What is it?** * _Protein deposits in tissue_ * Paucicellular eosinophilic deposits amorphous eosinophilic deposit **From what does it form?** * Form **fibrillar β‐pleated sheets** within the tissue Seen with what disease? * **multiple myeloma**

Answer 492

1. **▪ _Primary amyloidosis_** is associated with **multiple myeloma** 2. **Reactive systemic amyloidosis** 3. **Hemodialysis** associated **amyloidosis kidney dysfunction** 4. **Hereditary amyloidosis** **(Familial Mediterranean Fever)**, present with **polyneuropathies, cardiac arrhythmias, renal failure, CHF** 5. **Localized dermal amyloidosis**

Answer 493

**multiple myeloma**

Answer 494

kidney dysfunction

Answer 495

* **Rare in oral cavity** * Amyloid _nodule_, **asymptomatic** submucosal deposit * **Not** associated with ***systemic symptoms***

Answer 496

* Older adults **\> 65yrs** * **Male** predilection * Amyloid deposits _lead to_ **_macroglossia, carpal tunnel_ syndrome, hepatomegaly, dry mouth** * **Skin lesions:** Waxy papules and plaques, **smooth surface (eyelid area, retroauricular, neck, lips), orangy, red appearance**

Answer 497

* Due to _chronic inflammatory process_ * *(osteomyelitis, TB,** **sarcoidosis)** * Affects **liver, kidney, spleen, adrenals** *but not heart* * can affect multiple organs, _heart is usually spared_

Answer 498

## Footnote o **Accumulation of normal protein** (beta‐2 microglobulin) in plasma _o Deposits in bones and joint_s **o Carpal tunnel syndrome, cervical spine pain** o **Tongue deposits** can have **macroglossia**

Answer 499

* **Deposition of an extracellular proteinaceous materia**l‐often **immunoglobulins** * all types have common feature of a _β‐pleated sheet molecular configuration_ * **Macroglossia** * **can be massive and exhibit dental indentations** (**crenation**) with _yellowish peripheral nodules_ * **Gingiva**: _usually normal in color,_ but *may be bluish, spongy and enlarged* * **Xerostomia** _if deposits in salivary glands_ * **Mucosal petechiae** can be seen

Answer 500

* **Medical work‐up** *to determine* **type of amyloidosis** * T**reat underlying disease** when possible * **No treatment available for most types** * **Chemo drugs** _(Colchicine, Prednisone, Melphalan, Thalidomide, Cyclophosphamide)_ for **multiple myeloma** * **Serum electrophoresis** – monoclonal gammopathy very complicated and time consuming treatment * **Renal transplant** for _dialysis‐associated type_ * *Death* **due to cardiac failure, arrhythmias or renal failure** *_is not uncommon_* within a few year of dx

Answer 501

Endocrine Disease * a group of metabolic disorders with one common manifestation**: hyperglycemia** * Basic problem is either _a decreased production of insulin_ or _tissue resistance to insulin_

Answer 502

▪ **Insulin** is hormone produced by ***beta cells of the pancreatic islets of Langerhans*** ▪ It is _required for the uptake of glucose by body cells_ ▪ **Insulin binds specific receptors which trigger** the _intracellular events necessary for glucose uptake_

Answer 503

Type 1 Type 2

Answer 504

_Definition_ insulin‐dependent diabetes mellitus (IDDM) _Demographics_ 5‐10% of cases **_Juvenile onset (avg age 14)_** _Symptoms_ * Severe **absolute lack of insulin** * **Hyperglycemia** and **ketoacidosis** * **Blood glucose levels of 200‐400 mg/dl** (70‐120 normal) * **Ketoacidosis** from using *protein* and *fat* for energy instead of glucose body _can’t use glucose_ * **Thin body habitus** _Etiology_ * **Autoimmune disease** * Thought to be possible viral infection as trigger to Islet cell antibody destruction of beta cells

Answer 505

_Definition_ * non‐insulin‐dependent diabetes mellitus (NIDDM) _Demographics_ * **About 90% of cases** * Onset in **older, obese adults (80‐90%)**; _ketoacidosis is rare_ _Symptoms_ * _Patients produce some insuli_n, can typically be treated with oral medication * **“insulin resistance”**‐ insulin levels appear WNL or elevated _Etiology_ * **Decreased number of insulin receptors or defective receptors** * *Genetic abnormalities, multifactorial* * _Growing percent_ of the **US population** as well as around the world

Answer 506

▪ **Decreased neutrophil chemotaxis** ►_do not fight off infections as well as you should_ ▪ **Peripheral vascular disease**►microangiopathy o Results in **ischemia**: kidney failure, gangrenous complications of lower limbs, retinal involvement leading to blindness o Amputations, CVA or MI o **Ketoacidosis** may lead to *_diabetic coma_*

Answer 507

* **Periodontal disease**‐ more frequent occurrence, more rapid progression * **Poor healing** _post oral surgery/extractions_ * **Enlargement and erythema of the attached gingiva** * **Increased risk of infections** * Candidiasis * **Xerostomia**‐ 1/3 of pts complain of dryness * **Diabetic Sialadenosi**s‐ both type I and type II * **Mucormycosis**‐ in uncontrolled disease and the tissue becomes necrotic because it is not getting any blood supply * **Dental Caries**o **Benign migratory glossitis** * Increased prevalence in type I

Answer 508

* **Insulin injections** * **Insulin shock**‐ _if blood glucose falls *below 40 mg/d*l_ * Treat with **dextrose**

Answer 509

* **Dietary modification** and **weight loss** * **Oral hypoglycemic agents** * ex. tolbutamide, glyburide, metformin * *Drugs may cause* **a lichenoid drug reaction**

Answer 510

**Diabetes Mellitus** Gingivitis = puffy red papillae here between the central and lateral incisors

Answer 511

**Diabetes mellitus** Anterior papillae are very puffy and red and fill of pus Posterior gingiva are very hyperplastic

Answer 512

Hyperplastic gingiva

Answer 513

Diabetes Mellitus Sialadenosis

Answer 514

Diabetes Mellitus diabetic patient who developed *Mucormycosis* Notice it is causing _necrosis_ in the palate

Answer 515

**Lichenoid mucositis looks like lichen planus** -same reticular white pattern, but there are areas of erosion and some ulceration as well -some diabetic medications can lead to this

Answer 516

* Treatment includes: * **Surgery** – complete or partial removal of thyroid gland * **Medications** * _Propylthiouracil_ and _methimazole_ block normal use of iodine by thyroid gland * **Radioactive iodine 131I** * Treatment often results in **hypothyroidism**

Answer 517

**Hyperthyroidism** * enlargement of the neck * characteristic stare

Answer 518

**Graves’ Disease is the most common form** o An autoimmune disease attacks thyroid (TSH receptor) o Leads to _elevated release of thyroxine_ o Most often a diffuse thyroid enlargement **(goiter)**

Answer 519

* **Serum T4** (thyroxine) is **_elevated_** and * **TSH is _decreased_**

Answer 520

▪ **5‐10X** more common in **females** ‐ 2% of women ▪ **3rd ‐ 4th** _decade of life_

Answer 521

▪ Treatment is **thyroid hormone replacement** ▪ Prognosis is **generally good** ▪ If children are not treated in a timely fashion ► **permanent CNS damage can occur (mental retardation)**

Answer 522

hypothyroidism woman who had hypothyroidism, lips are thickened, thick creases in the face

Answer 523

hypothyroidism, in child, still has deciduous teeth even though its an older child Radiographically we see the teeth have not erupted in the oral cavity

Answer 524

**Hypothyroidism** **Macroglossia** and **crenation** (scalloping) of the lateral tongue

Answer 525

hypothyroidism

Answer 526

**What patients might complain of?** * nervousness * heart palpitations * heat intolerance * muscle weakness * emotionally labile **What are the symptoms?** * weight loss, excessive perspiration, tachycardia, tremors, eyelid retraction and exophthalmos * **20‐40%** have **ocular involvement** o Early in the disease‐ **characteristic stare with eyelid retraction and lid lag** o **Exophthalmos or proptosis** ▪ **Oral findings** in children can include **early eruption of teeth**

Answer 527

**hyperthyroidism**

Answer 528

_What happens in Hypothyroidism?_ * Decreased levels of thyroid hormone _What it is called in children & adults?_ * **cretinism** in children * **myxedema** in adults _How it is diagnosed?_ * Diagnosed by **measuring T4** (free thyroxine) in serum

Answer 529

**▪ Primary Hypothyroidism** ‐ due to abnormality in thyroid gland o **T4** *_low_*, **TSH** *_elevated_* **▪ Secondary Hypothyroidism (less common)** ‐ pituitary gland doesn’t produce adequate amounts of TSH o **T4** *_low_*, **TSH** *_low_* or borderline

Answer 530

**Hypothyroidism**

Answer 531

_Symptoms_ * Symptoms include lethargy, dry skin, thinning hair, swelling (edema) of face and extremities, huskiness of voice, weakness and fatigue * ▪ Infants have failure to thrive _Symptoms_ o **Thickened lips** and **macroglossia** due to _accumulation of glycosaminoglycans (GAGs)_ o In children can see **failure of tooth eruption** even though teeth have normal development (enamel pitting can be seen)

Answer 532

Hyperparathyroidism in young children

Answer 533

o _Uncontrolled_ PTH production o 80‐90% caused by **parathyroid adenoma** o ~15% caused by hyperplasia o ~ 2% caused by parathyroid carcinoma

Answer 534

o PTH continuously produced in response to chronic low serum calcium (usually associated with chronic renal disease)

Answer 535

**bones, stones, and groans (& moans)** * **Bones** – Changes in the bones: * Subperiosteal resorption of distal phalanges (early in disease) * Loss of lamina dura around roots (early in disease) * Loss/blurring of trabecular density in bone with resultant “ground glass” appearance in radiographs * Brown tumor * **Stones** – renal calculi (especially with primary disease) due to elevated serum calcium basically kidney stones * **Groans** – duodenal ulcers * **Moans** – changes in mental status mild dementia

Answer 536

**Pseudohypoparathyroidism** pulp chambers are very elongated

Answer 537

**Pseudohypoparathyroidism** issues with eruption, no pulp stones present

Answer 538

Can be *Primary* or *Secondary* * Reduced amounts of PTH * Parathormone normally stimulates osteoclasts in bone and resorption in kidney, to bring serum levels of calcium back to normal with decreased parathyroid function, serum calcium levels drop → hypocalcemia * Lab findings ‐ PTH ↓, calcium ↓, phosphate↑, and normal renal function * Postive Chvostek’s sign ( sign of low Calcium) Females 2 to 4 times more than males

Answer 539

* **Subperiosteal resorption** of distal phalanges (early in disease) * **Loss of lamina dura** around roots (early in disease) * **Loss/blurring of trabecular density** _in bone with resultant_ * **“ground glass”** appearance in radiographs * **Brown tumor** * **Steitis fibrosa cystica**

Answer 540

Hereditary Hypophosphatemia/vitamin D‐resistant rickets teeth look fairly normal, have a draining abscess with ulcers and perilous

Answer 541

Hereditary Hypophosphatemia/vitamin D‐resistant rickets teeth look fairly normal, have a draining abscess with ulcers and perilous

Answer 542

 Enlarged pulp horns o Can extend up to DEJ  Abnormal globular dentin o Dentin may exhibit clefting  Enamel clefts  Bacteria noted in enamel, dentin and pulp o Pulpal involvement leads to necrosis and development of the periapical pathology

Answer 543

**Steitis fibrosa cystica** Where we see **central degeneration** and **fibrosis** of **longstanding brown tumors**

Answer 544

* **uni‐ or multilocular Radiolucency** (pelvis, ribs, mandible) * seen with _persistent disease_ * histology of **giant cell lesion** (**like CGCG**)

Answer 545

It is typically **surgical removal** of _a portion or all of the parathyroid glands_

Answer 546

▪ Can be due to **inadvertent surgical removal** when **thyroid gland** is _excised_ or to _autoimmine destruction._ ▪ **DiGeorge syndrome** (anomaly) and **endocrine‐candidiasis syndrome** can show this.

Answer 547

* The Chvostek sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. * This clinical sign refers to a twitch of the facial muscles that occurs when gently tapping an individual's when the facial nerve below the zygomatic process

Answer 548

* If develops in young children **tooth development can be affected** * **_pitting enamel hypoplasia_** and **_failure of eruption_** * **Persistent oral candidiasis** in a young patient may be a sign of the onset of **endocrine‐candidiasis syndrome** *(check for other endocrine abnormalities)*

Answer 549

* Oral vitamin D precursor * vitamin D2 (or ergocalciferol) * Dietary supplements of calcium * Teriparatide (a portion of PTH) injections twice daily

Answer 550

_Also known as?_ Albright hereditary osteodystrophy _What is it?_ ▪ **Normal parathyroid** and **PTH**, but activation of target cells is **dysfunctional** _How it appears clinically?_ ▪ Clinically, patient appears to have hypoparathyroidism o Based on **elevated serum levels of PTH seen with hypocalcemia,hyperphosphatemia** and **normal renal function** Lab findings **PTH ↑, calcium ↓, phosphate** ↑

Answer 551

*_Types_* Two broad disorders multiple subtypes **Type I and Type II** *_What causes it_* **Abnormal biochemical pathway**s that result in lack of target cell activation despite **normal levels of PTH** *_Type of inheritance_* Can be _autosomal dominant inheritance_ – **defective PTH** **receptor on the target cells**

Answer 552

- Vitamin D and calcium supplements - Serum and urinary calcium are monitored

Answer 553

* *- Generalized enamel hypoplasia** - **Widened pulp chambers** with **pulpal calcifications (“dagger” shaped pulp stones)** - _Oligodontia_ - _Delayed eruption_ - _Blunting of root apices_

Answer 554

**Also known as?** vitamin D‐resistant rickets looks like they have rickets. **What type of inheritance?** ▪ Most cases are X‐linked inheritance (males) **What mutation causes it?** o Mutation in PHEX ‐ zinc metalloproteinase gene ▪ phosphate regulating gene with endopeptidase activity on the X chromosome ▪ Mutation affects **metabolism of vitamin D precursors to the active metabolite** o Therefore _low or no absorption of calcium_ ▪ _Decreased capacity for reabsorption of phosphate from the renal tubules_

Answer 555

_Clinical Findings_ ▪ Clinical features similar to those of rickets, but resistant to treatment with vitamin D o **Short stature** (upper body fairly normal, lower body shortened) o **Lower limbs short and bowed** ▪ _Similar to Vitamin D‐dependent rickets except no hypocalcification of teeth_ ▪ **Teeth have enlarged pulp chambers and elongated pulp horns** (extend to DEJ) ▪ With **minor attrition of occlusal cusps, pulp is exposed to the oral cavity** ▪ Exposures are often very small and when note periapical radiolucencies, it appears that otherwise normal teeth have periapical pathology _Lab findings:_ **↓ serum phosphate**

Answer 556

**What is it?** Rare metabolic bone disease **Type of inheritance:** **_Autosomal recessive_** inheritance, generally the younger the age of onset the more severe the expression **Clincal findings:**  Bone abnormalities resemble rickets  Often presents with premature loss of primary teeth o not from periodontal disease, thought that marked reduction, or lack, of cementum allows exfoliation **Lab findings:** ↓ alkaline phosphatase, ↑ blood and urinary phosphoethanolamine

Answer 557

 Perinatal  Infantile  Childhood  Adult

Answer 558

o Most severe manifestations o Death in a few hours secondary to respiratory failure o Marked hypocalcification of skeleton

Answer 559

o Diagnosed ~4‐6 months due to failure to grow o Skeletal malformations  shortened bowed limbs, rib and skull abnormalities o Nephrocalcinosis, nephrolithiasis  Can have premature exfoliation of teeth

Answer 560

o Diagnosed at later age, variable clinical expression o Early sign is **premature loss of primary teeth, may be the only teeth affected** o **Large pulp chambers** *and* **alveolar bone loss** o P**remature fusion of cranial fontanels** can lead to _increase intracranial pressure and brain damage_

Answer 561

o Mild presentation o **Premature loss of primary or permanent dentition**; patient may be **edentulous** o **Stress fractures in _feet_** o Increased number of fractures assoc. with minor trauma

Answer 562

**Acromegaly** – excess production of growth hormone **after** closure of the epiphyseal plates **Gigantism** – excess production of growth hormone **before** closure of the epiphyseal plates

Answer 563

Etiology ▪ Usually due to _a pituitary adenoma_ Clinical signs ▪ _Renewed growth of small bones_ of the hands and feet as well as membranous bones of the skull and jaws ▪ Soft tissues are also affected Oral Findings ▪ Mandibular ***prognathism***, ***macroglossia***, and **diastema formation**

Answer 564

**Acromegaly**

Answer 565

**also known as** Hypoadrenocorticism **etiology** ``` Insufficient production of corticosteroid hormones due to destruction of adrenal cortex (autoimmune, infection, tumors, etc.) ``` **when do clinical symptoms appear?** ▪ Need ~90% destruction of gland before clinical symptoms

Answer 566

**Addison’s Disease**

Answer 567

**Addison’s Disease**

Answer 568

_Clincal symptoms_ * diffuse hyperpigmentation of skin (bronzing), fatigue, * irritability, depression, weakness, etc. * Oral mucosa shows **diffuse** *or* **patchy macular pigmentations flattened pigmentations** _Lab findings_ failure of cortisol to rise in response to a rapid ACTH stimulation

Answer 569

_Pellagra_ Deficience in Vitamine B3 (Niacin)

Answer 570

Pellagra Deficience in Vitamine B3 (Niacin) Dermititis of the skin

Answer 571

Pellagra Deficience in Vitamine B3 (Niacin) erythema of the tongue

Answer 572

**Deficiency** pellagra **Classic triad** **D**ermatitis, **D**ementia, **D**iarrhea **Oral symptoms** _stomatitis_ and _glossitis_

Answer 573

**Why it is a concern?** Premalignant process o ↑ incidence of oral and esophageal SCCa

Answer 574

**PLUMMER‐VINSON SYNDROME** denuded tongue and angular chelitis

Answer 575

_PLUMMER‐VINSON SYNDROME_ **Angular chelitis** (top) hard to get rid of them **Atrophic Glossitis** (bottom) red beefy tongue

Answer 576

**Top photo**: in Iron Deficiency Anemia, Plummer‐Vinson Syndrome, small area that is pale in the center **Bottom photo** : normal smear, center is not pale

Answer 577

**Charctersics of Anemia** a _hypochromic_, _microcytic_ anemia *decrease in color, smaller than normal* **Symptoms** fatigue, light headedness, lack of energy .

Answer 578

* **Angular cheilitis** (corner of the mouth ulceration) * **Dysphagia** (difficulty swallowing) * **Atrophic glossitis** (bald tongue, loss of papilla) beefy colored tongue * **Glossodynia** (burning tongue)

Answer 579

not biconcave

Answer 580

Treated with iron supplements, extreme cases with blood infusions

Answer 581

**Pernicious Anemia** glossitis, denuded papillae

Answer 582

**Pernicious Anemia** ## Footnote denuded tongue and then the papillae is back again after the treatment. You have to get injections for the rest of your life

Answer 583

**What is it ( assiosited with what difficiency)?** * Iron deficiency anemia with **glossitis** and **esophageal strictures** * _Similar signs and symptoms_ as iron deficiency **Demographics** * Mostly women 30‐50 years old * Northern European heritage more common

Answer 584

Uremic Stomatitis

Answer 585

* Treated with iron supplements * Need long term follow up for eval of SCCa

Answer 586

**Uremic Stomatitis** Before and After Tx with Dialysis changes on ventral and lateral side of the tongue, better outcome after dialysis

Answer 587

Reiter’s Syndrome (Reactive arthritis) This not actually a geogrpahic tongue!

Answer 588

Reiter’s Syndrome (Reactive arthritis) Top: erythema on the palate and areas of ulceration Bottom: classic look of geographic tongue, but it is not geo tongue. They are symptoms of Reiter’s

Answer 589

▪ Janeway lesions o Seen on palms of hands and soles of feet (tiny micro emboli that are causing lesions on the hands and feet) ▪ **Erythematous macule or petechiae** ▪ _Painless_ ▪ **Septic micro emboli**

Answer 590

Infective Endocardiatios Janeway lesions These are **Septic Emboli**

Answer 591

Hyperparathyroidism Here we see we see * _a granular appearance of the max and mand bone everywhere,_ it is **not localized**. * There is a **loss of bone density** and **the loss of definition of cortical bone.** * Here we see a **loss of definition of lamina dura** as well _because it is now granular, and is not as clear._

Answer 592

**Hyperparathyroidism**; this is the **brown tumor** which is sometimes **well or ill defined,** **multi or unilocular radiolucency** with **granular septation.** If you have a patient that is younger than 15-20 years old that has **a central giant cell granuloma** ► you have to check that patient for hyperparathyroidism, because it could be a brown tumor.

Answer 593

This is another medical CT scan. You see the granular appearance of the maxilla, skull, and well-defined multilocular radiolucency with granulation. We call this a brown tumor because it is associated with **hyperparathyroidism.** **( s**ystemic endocrine diseases)

Answer 594

Hyperparathyroidism ## Footnote On our intraoral radiographs, we see **loss of definition of lamina dura** because the bone now has **a granular appearance** which extends to the lamina dura. The teeth are usually normal, but there is a loss of lamina dura around the teeth. These teeth are not mobile.

Answer 595

a medical CT scan of a patient with **secondary hyperparathyroidism.** We see a **lack of cortical bone** – no normal cortical bone. Inside the skull we have **a granular appearance**, with **radiolucent and radiopaque dots**, we call this **a salt and pepper dots**. This is why we call this a salt and pepper appearance, _there is no normal cortical bone._ *( systemic endocrine diseases)*

Answer 596

_Type of Anemia?_ **_Megaloblastic_** Anemia _What difficiency?_ **Vitamin B₁₂ difficiency** _Causes?_ * Poor absorption of vitamin B12 (extrinsic factor, cobalamin) * These patients _lack intrinsic factor,_ usually **due to autoimmune destruction of parietal cells** * ***Intrinsic factor*** produced by parietal cells in the stomach is **needed for absorption of B12**

Answer 597

* Have **burning sensation of** *tongue, lips and buccal mucosa* * One of the things you need to rule out in patients with burning mouth syndrome * **50‐60% of patients** have **tongue symptoms,** see **atrophy** (papilla denuded) and **erythema**

Answer 598

we have 2 Pas of patients **with pseudohypoparathyroidism**. * hypoplasia of enamel, tooth material * hypoplastic tooth bud ( hypoplastic means arrested development) * delayed eruption, * external root resorption.

Answer 599

* monthly IM injections of **cyanocobalamin** * **cannot take **_**B12 orally**, you need injections_

Answer 600

1 – **Generalized weakness** 2 – **Painful tongue** 3 – **Numbness or tingling of the extremities**

Answer 601

What is it? * Uncommon complication of renal failure * Patients have markedly **elevated levels of urea** _in their blood stream_ **What causes the oral lesions?** * Cause of oral lesions is unclear, may be urease produced by normal flora degrades urea in saliva liberating free ammonia which damages mucosa

Answer 602

Most cases in patients with **acute renal failure** ▪ Abrupt onset of **white plaques or crusts** o _Bad taste_ and _burning_ also possible o **May be** *painful* ▪ Usually on the **buccal mucosa, tongue and floor of mouth** o If localized to the tongue can mimic ***oral hairy leukoplakia*** ▪ May detect **an odor of ammonia or urine** on the patients breath

Answer 603

▪ Usually clears within a few days _after renal dialysis has begun_ ▪ **Mildly acidic mouth rinses** seem to clear oral lesions *(ex. diluted hydrogen peroxide)* ▪ **Palliative treatment *_for pain_*** includes _ice chips or a topical anesthetic_

Answer 604

_also known as?_ **Reactive arthritis** _Corrlate with which antigen?_ Correlation with **HLA B27 (\> 70%)** _Associated with what?_ Typically seen after patient has either **a bacterial dysentery or an STD** sometimes **chlamydia**

Answer 605

_Etiology_ * Thought to be due to **an abnormal immune response to the infection** _Demographic_ * Almost **exclusively** seen ***in males*** _in their twenties_ _Clinical Presentation_ * Oral lesions (~ 20% of cases) include **painless oral ulcerations**, **erosions/erythema of mucosa**, as well as erosions of the tongue which can mimic geographic tongue (both clinically and histologically)

Answer 606

Reiter’s Syndrome **Classic Triad** ▪ 1 – Polyarthritis (lasting more than one month) ▪ 2 – Conjunctivitis or uveitis ▪ 3 – Urethritis

Answer 607

▪ **Stones, bones, moans, and groans** ▪ **Radiolucent appearance** (_generalized osteopenia_) What we see in the bones is one of the earliest radiographic features that we see = sudden erosions in the phalanges in the bones of the hands followed by mineralization of the skeleton including max and mand, skull base. As a result, you have generalized osteopenia. **10% of these patients have brown tumors** ▪ **Brown tumors:** Brown tumors are the same as central giant cell granulomas. When they are associated with hyperparathyroidism, we call them brown tumors. ▪ **Punctate or nodular calcifications** in the joints and kidneys =stones ▪ **Entire calvaria** has _a granular appearance_ classically known as the **“salt and pepper”** skull as a result of the generalized osteopenia, we have this granular appearance in the skull

Answer 608

What is Hypoparathyroidism: ## Footnote _Insufficient secretion of PTH o Damage or removal of the parathyroid glands during thyroid surgery_ Principal radiographic change: calcification of the basal ganglia Sometimes we have **pseudohypoparathyroidism.** This happens when we have a normal amount of PTH, but there is something wrong with the response of the target tissue. So, we have normal PTH but abnormal response to PTH. **dental enamel hypoplasia, external root resorption, delayed eruption, or root dilaceration**

Answer 609

_What is it?_ * Hyperfunction of the anterior lobe of the pituitary gland caused by a benign functioning tumor of the anterior lobe * it's a systemic endocrine disease _What is its types ?_ ▪ Types based _on age of onset_ * **Gigantism** happens in ***children***, **generalized overgrowth of most long bones, hard and soft tissue**. These patients are usually very tall. Proportion in these patients may be normal, but very large appearance. * **Acromegaly** Increased hyperfunction in **adult patients**. In these patients, the epiphysis of the long bones already closed, **you can see in the mand or max.** One of the observable features is **enlargement of the whole mandible/skull/sinuses/soft tissue.** Patients usually present with _“My hat is not fitting anymore, my denture is not fitting anymore”_

Answer 610

_What is it?_ * **Excess of circulating parathyroid hormone important in formation of osseous structures** * Increase bone remodeling but tips the balance of osteoblastic and osteoclastic activity in favor or osteoclastic resorption * it's a systemic endocrine disease _What are its types?_ **o Primary hyperparathyroidism Type** 1 ▪ Uncontrolled parathyroid hormone production by parathyroid neoplasm (adenoma \>\> hyperplasia \> adenocarcinoma) **o Secondary hyperparathyroidism Type 2** ▪ Continuous parathyroid hormone production in response to chronic low serum calcium levels ▪ Renal osteodystrophy

Answer 611

Hyperparathyroidism Here we see we see * _a granular appearance of the max and mand bone everywhere,_ it is **not localized**. * There is a **loss of bone density** and **the loss of definition of cortical bone.** * Here we see a **loss of definition of lamina dura** as well _because it is now granular, and is not as clear._

Answer 612

**Hyperparathyroidism**; this is the **brown tumor** which is sometimes **well or ill defined,** **multi or unilocular radiolucency** with **granular septation.** If you have a patient that is younger than 15-20 years old that has **a central giant cell granuloma** ► you have to check that patient for hyperparathyroidism, because it could be a brown tumor.

Answer 613

This is another medical CT scan. You see the granular appearance of the maxilla, skull, and well-defined multilocular radiolucency with granulation. We call this a brown tumor because it is associated with **hyperparathyroidism.** **( s**ystemic endocrine diseases)

Answer 614

Hyperparathyroidism ## Footnote On our intraoral radiographs, we see **loss of definition of lamina dura** because the bone now has **a granular appearance** which extends to the lamina dura. The teeth are usually normal, but there is a loss of lamina dura around the teeth. These teeth are not mobile.

Answer 615

a medical CT scan of a patient with **secondary hyperparathyroidism.** We see a **lack of cortical bone** – no normal cortical bone. Inside the skull we have **a granular appearance**, with **radiolucent and radiopaque dots**, we call this **a salt and pepper dots**. This is why we call this a salt and pepper appearance, _there is no normal cortical bone._ *( systemic endocrine diseases)*

Answer 616

we have 2 Pas of patients **with pseudohypoparathyroidism**. * hypoplasia of enamel, tooth material * hypoplastic tooth bud ( hypoplastic means arrested development) * delayed eruption, * external root resorption.

Answer 617

Acromegaly (Hyperpituitarism) * enlargement of the mandibular bone with a high degree of enlargement * a class III appearance * enlargement of sella tursica because of the pituitary gland enlargement

Answer 618

• **Definition**: mucocele-like lesion that forms unilaterally on the floor of the mouth • may break through the mylohyoid muscle & enter neck space = *“plunging ranula”* • **associated with:** the _ducts of the sublingual & submandibular glands_ **• clinical features:** - must be _on floor of the mouth_ for it to be considered a ***ranula*** - big & have deep blue color if exophytic - sometimes can grow downward/deep & won’t see blue as much **• treatment**: surgical excision

Answer 619

▪ **Stones, bones, moans, and groans** ▪ **Radiolucent appearance** (_generalized osteopenia_) What we see in the bones is one of the earliest radiographic features that we see = sudden erosions in the phalanges in the bones of the hands followed by mineralization of the skeleton including max and mand, skull base. As a result, you have generalized osteopenia. **10% of these patients have brown tumors** ▪ **Brown tumors:** Brown tumors are the same as central giant cell granulomas. When they are associated with hyperparathyroidism, we call them brown tumors. ▪ **Punctate or nodular calcifications** in the joints and kidneys =stones ▪ **Entire calvaria** has _a granular appearance_ classically known as the **“salt and pepper”** skull as a result of the generalized osteopenia, we have this granular appearance in the skull

Answer 620

_Osteoporosis_ * **reduction in bone density,** * **larger bone marrow spaces.** We **need more tests to confirm osteoporosis** besides dental radiographs.

Answer 621

What is Hypoparathyroidism: ## Footnote _Insufficient secretion of PTH o Damage or removal of the parathyroid glands during thyroid surgery_ Principal radiographic change: calcification of the basal ganglia Sometimes we have **pseudohypoparathyroidism.** This happens when we have a normal amount of PTH, but there is something wrong with the response of the target tissue. So, we have normal PTH but abnormal response to PTH. **dental enamel hypoplasia, external root resorption, delayed eruption, or root dilaceration**

Answer 622

medical CT scan with a patient with **osteopetrosis**- very dense. Not a nice definition of the cortical bone. We see decreased in size of skull foramina.

Answer 623

pt with Osteopetrosis we see **Hypovascular bones** so they are *more prone to osteomyelitis*. This is a sign of sequestrum which is a sign of osteomyelitis.

Answer 624

pt with Osteopetrosis * **Generalized increase in bone density,** increased trabeculation, loss of large bone marrow spaces. * These patients are more prone to **osteomyelitis** _because they are Hypovascular_. * We have to be careful in **extractions** because they don’t have the same vascularity as other healthy patients have. * We see an **onion skin appearance** by the white arrow.

Answer 625

_What is it?_ * Hyperfunction of the anterior lobe of the pituitary gland caused by a benign functioning tumor of the anterior lobe * it's a systemic endocrine disease _What is its types ?_ ▪ Types based _on age of onset_ * **Gigantism** happens in ***children***, **generalized overgrowth of most long bones, hard and soft tissue**. These patients are usually very tall. Proportion in these patients may be normal, but very large appearance. * **Acromegaly** Increased hyperfunction in **adult patients**. In these patients, the epiphysis of the long bones already closed, **you can see in the mand or max.** One of the observable features is **enlargement of the whole mandible/skull/sinuses/soft tissue.** Patients usually present with _“My hat is not fitting anymore, my denture is not fitting anymore”_

Answer 626

**▪ General features** * _Enlargement_ (ballooning) of the **sella turcica** * _Enlargement_ of the **paranasal sinuses** (especially the **frontal sinus**) * _Thickening_ of the outer table of the **skull** **▪ Jaws** * _Enlargement of the **jaws**,_ most notably the **mandible** * **Class III skeletal** as a result of the mandible enlargement with growth centering in the condylar head **▪ Teeth and associated structures** * _Spacing of the teeth, enlargement of tongue_, it could result in spacing of teeth in the anterior region o **Hypercementosis the forces** are higher now * so you may see H**_ypercementosis_** * Hypercementosis is **excessive deposition of non-neoplastic cementum over normal root cementum,** which alters root morphology. This cementum may be either hypocellular or cellular in natur*

Answer 627

Ricket / Osteomalacia hyperplasia or thinning of mineralization of teeth. We can see hyperplasia of enamel in patients.

Answer 628

_What is it?_ Reduced secretion of pituitary hormones it's a systemic endocrine disease _What is it called?_ **Dwarfism** _How it appears radiographically?_ ▪ Finding of the jaws o **Normal eruption of primary dentition** but _delayed exfoliation_ o **Small jaws -**\> crowding and malocclusion because there is not enough space for the teeth to erupt

Answer 629

**Renal Osteodystrophy 1** *Presentation is variable*. Sometimes you see **denser or granular appearance of bone.** You see _increase here_ but you sometimes will also see loss of definition of lamina dura, sometimes a sclerotic appearance and trabeculation.

Answer 630

**Renal Osteodystrophy 2** sometimes you see: * **increase in bone density** * **loss of definition of lamina** * **dura and cortical bone**

Answer 631

_What is it?_ ▪ **_Generalized decrease in bone mass_ i**n which the histologic appearance of bone is normal, it is a metabolic bone diseases (MBD) _Why it happens?_ * **Aging process (postmenopausal women)** bone mass usually increases until 30 years of age, and then there is a gradual decrease- about 8% loss in females and 3% loss in males * **Nutritional deficiencies** * **Hormonal imbalance** * **Inactivity** * **Corticosteroid or heparin therapy** _What the bone are like?_ ▪ **More prone to fracture** (distal radius, proximal femur, ribs, and vertebrae)

Answer 632

Hypophosphatasia

Answer 633

large root canal structures, large root chambers, premature loss of teeth = **hypophosphatasia.**

Answer 634

_What is it?_ **Defect in the differentiation and function of osteoclast**s, (osteoclasts that are used to resorb bone in the bone modeling process. They are not functioning properly ►so we have an increase in bone density.) It is a metabolic bone diseases (MBD) _How is the bone like?_ Bone is **dense, fragile, and _susceptible to fracture_** _and **infection ►**_we now have a_n osseous structure but small bone marrow spaces_ _What are the effects on other structures?_ It compromised vascular structures and cranial nerves

Answer 635

* Compression of the cranial nerves as they pass through the narrowed skull foramina -\> **blindness, deafness, vestibular nerve dysfunction, and facial nerve paralysis.** * Compromises hematopoiesis Poor vascularity -\> **osteomyelitis**

Answer 636

**Hypophosphatemia** * Periapical lesions with radiolucency but no caries on the crown. * There is loss of definition of cortical bone. * On the teeth, you have: * large pulp chambers * hypoplasia of enamel and dentin * periodontal and periapical lesions.

Answer 637

Progressive Systemic Sclerosis (scleroderma) ## Footnote sharp areas of resorption in the bones near muscles attached to the angle of the mandible= masseter and medial pterygoid. You see resorption at the coronoid process at the attachment of the temporal bone as well.

Answer 638

**Progressive Systemic Sclerosis (scleroderma)** * presence of **widening of the PDL space everywhere** around the root of the tooth.

Answer 639

***_What happens?_*** They are metabolic bone diseases (MBD) Inadequate serum and extracellular levels of ***calcium*** and ***phosphate***, ***failure of normal activity of vitamin D.*** There are different levels in the conversion from I,12- dihydroxy vitamin D that can have errors, not just the consumption of vitamin D. ***_Differences_*** **Rickets**: disease affects the growing skeleton in i**nfants and children** **Osteomalacia**: disease affects the **mature skeleton in adults** **Effects on bones:** A softening and weakening of bones

Answer 640

On a **sickle cell anemia** patient, you see: * **loss of this cortical bone area** * **the hair-on-end appearance on the skull**

Answer 641

Sickel Cell Anemia enlargement of bone marrow spaces, less trabeculation, more osteoporotic bone. You see periapical pathology associated with teeth with no obvious reason. You see the radioluscencies around the apex of the mandibular teeth.

Answer 642

o Lack of vitamin D in the diet o Gastrointestinal malabsorption problems o Lack of exposure to UV light o Liver disease o Kidney disease o Defect in the intestinal target cell response

Answer 643

_Rickets_ o Growth retardation o Short stature o **Bowing of long bones** of the legs, waddling gait o **Radiograph manifestations in the teeth** (especially \<3 years of age) **and jaws** _Osteomalacia_ o Weak fragile bone structure _o Diffuse skeletal pain_ o Susceptible to fracture with minor injury o _Radiographic manifestations in the jaws_ **are uncommon** o you may see **hyperplasia** *or* **thinning of mineralization of teeth. You can see hyperplasia of enamel in patients.**

Answer 644

**Thalassemia** * **osteopenic bone (***loss bone mass and bones get weaker*) * **radiolucent appearance of bone** * thinning of cortical bone around the mandible and maxilla. * Usually there is **hypoplasia of the paranasal sinuses.**

Answer 645

_What is it?_ **Chronic renal failure** produces **bone changes** by _interfering with the hydroxylation of vitamin D in the kidneys_ -\> _hypocalcemia_ -\> **inhibit the normal calcification of bone and teeth** *(it is a metabolic bone disease)* _what can it lead to?_ (secondary hyperparathyroidism) **level of calcium is low** leads to having **hyperparathyroidism secondary to osteodystrophy**

Answer 646

Dwarfism * hypopituitarism* * We see* multiple dental anomalies: **hypodontia, radicular fusion,** fused roots of left lateral incisor and left canine **and impacted permanent teeth.** * (from google)*

Answer 647

**_What is it?_** * Rare metabolic bone disease due to **lack of tissue-nonspecific alkaline phosphatase** **_What are its types?_** **Four types: prenatal, infantile, childhood, adult** * _The younger the age of onset, the more severe the_ * _manifestations_ * It may have premature loss of these patients because loss of function of the lungs in these patients

Answer 648

Common factors? * _Low levels_ of **tissue-nonspecific alkaline phosphatase** * **High** blood and urinary **phosphoethanolamine** * **Rickets-like skeletal malformations** Dental manfestations? * _Premature shedding_ of **primary incisors** * **Enamel hypoplasia** * _Enlarged_ **pulp chambers** and **root canals**

Answer 649

_What is it?_ * A **rare**, **heterogeneous** group of **inherited** metabolic disorders characterized by **decreased phosphate reabsorption** _in the distal renal tubules_

Answer 650

_Clinical Manifestations_ * **Rickets-like skeletal malformations** _Dental Manifestations_ * **Enlarged pulp chambers** and **root canals** * **Periapical and periodontal abscesses** of no obvious cause * **Enamel hypoplasia**

Answer 651

_What is it?_ * **Excessive collagen deposition** resulting in **hardening (sclerosis) of the skin and other tissues** can have involvement of _GI tract, heart, kidney,etc_ _Demographics?_ * Middle aged female

Answer 652

_Clinical Presentation_ * Thickened, leathery quality skin * joint pain * exaggerated response to cold (Raynaud's disease) * heartburn. * more prone for heart problems and respiratory insufficiencies, _Oral Manifestations_ * microstomia (small mouth) * Xerostomia (dry mouth) * telangietasia ("spider veins") * Increased decayed, missing and filled teeth. * higher Gingivitis scores (usually) * Deeper Periodontal Pockets

Answer 653

Treatment for generalized symptoms may involve: * **corticosteroids** * **immunosuppressants, such as methotrexate or Cytoxan** * **nonsteroidal anti-inflammatory drugs** Depending on your symptoms, treatment can also include: * blood pressure medication * medication to aid breathing * physical therapy * light therapy, such as ultraviolet A1 phototherapy * nitroglycerin ointment to treat localized areas of tightening of the skin *(from google)*

Answer 654

_What is it?_ **Chronic hemolytic blood disorder** _What causes it?_ ▪ **Abnormal hemoglobin, resulting in anemia** -\> by increasing the production of red blood cells -\> **requires compensatory hyperplasia of the bone marrow**

Answer 655

* loss of this cortical bone area * See the hair-on-end appearance on the skull * enlargement of bone marrow spaces * less trabeculation, more osteoporotic bone * periapical pathology associated with teeth with no obvious reason

Answer 656

What is it? * **Defect in hemoglobin synthesis** What causes it? * **RBC with reduced hemoglobin content** and _short life span_

Answer 657

* **Hyperplasia of the bone marrow** **component** of the bone which results _in fewer trabeculae per unit area and can **change the overall shape of the bone**_ * **Protrusive premaxilla** * **Radiographic appearance** very similar to _Sickle Cell Anemia_

Answer 658

generalized decrease in bone density of jaws (thin cortices; granular cancellous bone; loss of lamina dura). * Refer to physician for lab tests to make the diagnosis

Answer 659

o Localized focus of radiolucency► **think brown tumor and hyperparathyroidism** o Mandibular prognathism and incisor flaring► **think acromegaly** o Premature shedding of primary incisors► **think hypophosphatasia** o Enamel hypoplasia, enlarged pulp chambers and periapical abscesses of no obvious cause► **think hypophosphatemia**

Answer 660

* Tori are incredibly common, a normal of variant * Part of physical exam is to visualize as well as running index finger over the hard palate every time * Sometimes, torus palatinus is quite small and unnoticeable until you touch it (feel a hard bump and it’s just a bony growth) * Sometimes, they are pedunculated; Sometimes, they get so large they become traumatized; vascular supply on surface can sometimes form ulcerations and even get a little bone exposure. * If patient with history of use of bisphosphonates (bone modifying agents given to women who have osteoporosis or osteopenia and to prevent metastesis for certain cancers), he will remove that dead bone, and it will slowly heal. That’s one of the perils of having an enlarged palatine torus

Answer 661

Palatine Torus/Torus Palatinus

Answer 662

Palatine Torus/Torus Palatinus

Answer 663

Mandibular Torus: Torus Mandibularis

Answer 664

Mandibular Torus: Torus Mandibularis

Answer 665

Buccal Exostoses

Answer 666

- Sometimes pt’s tori are so large that the sublingual frenum gets stuck underneath - repeated irritation/trauma can create a little white rim on the tori - these tori are rock hard and may grow overtime, but we don’t really understand why people get them

Answer 667

Unencapsulated Lymphoid Aggregates

Answer 668

Lymphoepithelial cyst we see a tiny yellowish cyst. we see the blood vessels on the surface; this is quite characteristic.

Answer 669

**Unencapsulated Lymphoid Aggregates** **Post-tonsillectomy** Can even develop these on area of tonsils. (left pic) Red/salmon is a lymphoid aggregate (unencapsulated lymphoid tissue). This is someone who had a tonsillectomy , and you can see these lymphoid aggregates on posterior pharyngeal wall (salmon color).They move around the area. (right pic) It grew back even in post-tonsillectomy patients.

Answer 670

Fordyce Granules

Answer 671

Fordyce Granules

Answer 672

* Sometimes patient develops **exostoses** (another word for **torus**). * Can get buccal exostoses, all just bone. Can pick these up on radiograph, the _bone is a lot denser._ **Why does it happen?** * Maybe it’s related to parafunctional habits – but don’t really understand the * basis for the exostosis. * They’re going to be **bilateral**. If it’s unilateral, we start thinking about other bony diseases *a variant of normal*

Answer 673

**Fimbriated fold/Plica semiluminaris**

Answer 674

**Frenal tag**

Answer 675

* the lymphoid aggregates _are part of the foliate papillae_ (they contain some taste buds as well). * **This is lymphoid tissue -**- when you get a cold or upper respiratory tract infection, sometimes these areas can become **hyperplastic** _in response to infection_ – **can become** **a little enlarged.** * These are usually **bilateral.** * *a variant of normal*

Answer 676

Sublingual Varices

Answer 677

Sublingual Varices

Answer 678

Sublingual Varices

Answer 679

Circumvallate papillae

Answer 680

Parotid Papillia (Stenson duct)

Answer 681

Parotid Papillia (Stenson duct)

Answer 682

a cystic structure.develops in that area where there are already _unencapsulated lymphoid tissue._ **This is not normal – Pathologic** Sometimes when you get a cyst in this area -- because of lymphoid tissue, you can develop lymphoepithelial cyst – **a tiny yellowish cyst**. we see the blood vessels on the surface; this is quite characteristic.

Answer 683

Linea Alba

Answer 684

Leukoedema

Answer 685

* Occurs on the buccal labial mucosa, retro molar pad and tonsillar area and lips * They are white or yellow **ectopic sebaceous glands** * They can be present in small or large quantity * Why do we have sebaceous glands in mouth? we dont know, evolutionary advantage? we don’t really understand. * a variant of normal

Answer 686

Palatal Rugae

Answer 687

* Some patients have *_more obvious_* **fimbriated folds or plica semilunaris** in their mouths than others * When you look at the **ventral surface of the tongue**, you’ll sometimes be able to pick these up. * These are **duct opening from a series of salivary glands, minor glands,** but they’re a little bit different than other minor glands in the mouth. * They produce more of a **viscous type of saliva**, and they are **the glands of the Blandin and Nuhn** * a variant of normal

Answer 688

* Frenal attachments are **thin folds of mucous membrane with enclosed muscle fibers that attach the lips to the alveolar mucosa and underlying periosteum.** * Most often, during the oral examination of the patient the dentist gives very little importance to the frenum, for assessing its morpholology and attachment. * Sometimes occur; essentially normal of varient

Answer 689

* Tortuous dilated vessels (enlarged engourged veins) on the ventral surface of the tongue, and sometimes stretch onto lateral border * Appears bluish purple in color * More prominent with increasing age; we don't see it in younger pts. * Nothing to be concerned about, a variant of normal

Answer 690

* Located in the **posterior region of the tongue**; dividing the body from the base * They are mushroom shaped and arranged in V-shape formation * Although they are usually not apparent in most patients, you may be able to visualize them in some * a variant of normal

Answer 691

* **Located in right and left buccal mucosa** at the level of the occlusal plane close to the maxillary first and second molar. * This structure may appear a**s a small dot or have a prominent pink to red papillae presence.** * This is the **parotid papilla**, and It is the opening of the parotid duct which drains saliva from the parotid gland. *A normal of variant*

Answer 692

•a white line or keratotic area that present along occlusal plane in some patients * due to some friction In that area. (the buccal mucosa) * It varies in thickness and opacity * Can be seen in some patients who have bruxism * a variant of normal

Answer 693

* A bluish and white filmy opalescence of the mucosa is observed * In order to differentiate it from other white lesions à gently stretch the patient’s cheek forward and the leukoedema will disappear or partly fade and appears less apparent * It is commonly found in people of color and some smokers. * a variant of normal

Answer 694

* Raised ridges or folds * Located in the anterior palate on either side of the mid-palatine raphe behind the incisive papilla * They vary in number and size * May increase with age * a variant of normal

Answer 695

* AKA – **Fibroma, Traumatic Fibroma** * Composed of dense, scar-like, fibrous connective tissue * Occurs as a **result of chronic trauma** * **Clinical Features:** *Exophytic lesion* * Usually **less than a centimeter in diameter** * **Color**: lighter pink than surrounding mucosa,the surface can be white sometimes bc it’s rubbing and bumping into other oral structures (like teeth), so they get surface keratinization * **Locations**: buccal mucosa, tongue, lips, gingiva * Very common; **totally _benign soft lesion_** * _**Treatment**:_ _You don’t have to remove them, but the surgical Tx = to excise them_ _bc pts will stop biting them and they’ll heal and stop the irritation_

Answer 696

**Irritation Fibromas**

Answer 697

**Irritation Fibromas**

Answer 698

Chronic Hyperplastic Pulpitis (pulp polyp)

Answer 699

**Giant Cell Fibroma**

Answer 700

• **AKA:** pulp polyp • An e_xcessive proliferation of chronically inflamed dental pulp tissue_ – granulation tissue/ fibrous tissue with inflammatory cells *(like a little fibroma that occurs from pulp tissue) ( benign soft tissue leasion)* **• Location:** • Teeth with large, open carious lesions • Primary or permanent molars **• Age:** Children & young adults • **Clinical Appearance**: A red or pink nodule of soft tissue protruding from the pulp chamber and fills the entire cavity of the tooth • **Treatment**: RCT or extraction of tooth

Answer 701

* Very small form of fibrous tumour that show giant cells * Age: relatively rare in paediatric patients. * **Clinically** it is presented as a painless, sessile, or pedunculated growth which is usually confused with other fibrous lesions like ***irritation fibromas or Retrocuspid papilla*** * **Location**: Largely occur on lower gingivae and on palate\

Answer 702

**Tuberous sclerosis complex** we see A lot of gingival enlargement – is this overgrowth from disease or from seizure medication? Multi organ system involvement

Answer 703

**Epulis Fissuratum**

Answer 704

* **(multiple hamartoma and neoplasia syndrome)** * • **Autosomal dominant disorder** affecting multiple organ systems * • Caused by mutations in the phosphatase and tensin homolog gene (PTEN, a tumor suppressor gene) * • Oral and perioral findings include * *multiple papules on the lips and gingivae,** * **papillomatosis** (benign fibromatosis) of the buccal, palatal, faucial, and oropharyngeal * _mucosae_ often producing a **“cobblestone” effect**, and the _tongue_ may also present as **pebbly or fissured.** * • **Multiple papillomatous nodules** (histologically inverted follicular keratoses or * trichilemmomas) are often present on the perioral, periorbital, and perinasal skin, the pinnae of the ears, and neck. * • These nodules are often accompanied by **lipomas, hemangiomas, neuromas, vitiligo, café au lait spots, and acromelanosis .** * • A variety of neoplastic changes occur in the organs exhibiting hamartomatous lesions,with **an increased rate of breast and thyroid carcinoma and gastrointestinal malignancy.** * **Squamous cell carcinoma of the tongue** and **basal cell tumors of the perioral skin** have also been reported. * Incredibly rare ( board loves it)

Answer 705

Inflammatory Papillary Hyperplasia of the Palate

Answer 706

**Cowden Syndrome** *Very rare!*

Answer 707

• is an inherited disorder caused by mutations in the tuberous sclerosis complex (**TSC1 or TSC2) genes** • Characterized by **seizures** and **mental retardation** associated with **hamartomatous glial proliferations** and **neuronal deformity** in _the central nervous system._ • **Fine wart-like lesions** (adenoma sebaceum) occur in **a butterfly distribution over the cheeks and forehead**, and histologically similar lesions (vascular fibromas) have been described **intraorally.** • Characteristic **hypoplastic enamel defects** (pitted enamel hypoplasia) occur in 40 to 100% of those affected. • Rhabdomyoma of the heart and other hamartomas of the kidney,

Answer 708

• **AKA:** denture-induced fibrous hyperplasia, fibrous inflammatory hyperplasia • **Cause**: ill-fitting denture • **Location**: vestibule (maxilla or mandible), along the denture border •**Clinical presentation:** Arranged in elongated folds of tissue into which the denture flange fits; • Surface ulceration within the folds is common • **Composed of** _dense fibrous connective tissue_ • **Treatment**: **surgical excision** (scalpel vs CO2 laser -laser is better) and **reline then remake of denture**

Answer 709

**Pyogenic Granuloma** **We can see the corresponding radiograph;** -although the radiograph suggests generalized bone loss, there is a lot of calculus on the distal of #16 \> it makes sense that this is a pyogenic granuloma

Answer 710

**Pyogenic Granuloma:**

Answer 711

They are filled with blood vessels so they’re very very rich in vascularization \> they tend to bleed easily

Answer 712

**A parulis** ***It is not a pyogenic granuloma*** **A parulis** is a _proliferation of granulation tissue at the opening of a sinus tract_ When the infection breaks through the alveolar bone and presents itself, it will sometimes cause this proliferation of granulation tissue

Answer 713

* **Majority occur with** _denture stomatitis_ * **Associated with** a removable full or partial denture or orthodontic * appliance (Something you see in patients who wear denture all the time, don’t take it out, chronic denture wear) * **Clinical Appearance:** Palatal vault is covered by **multiple erythematous papillary projections** (fibrous connective tissue surfaced by epithelium) --(**papillary** but no papilla, instead it’s bumpy and bosselated) * ***Granular*** or **cobblestone appearance** * **Erythema** is usually _due to superinfection with candida_ * **Treatment:**Treat underlying candidiasis, fix denture. These bumps can be removed, take electrosurgery loop, and scrape off the bumps – heals well

Answer 714

**Peripheral Ossifying or Cementifying Fibroma** ## Footnote Lesion in the image is pedunculated – put a periodontal probe on normal gingiva and glide along underneath it, there’s a stalk

Answer 715

* When sessile, when removing it, take scalpel blade and just cut into it * If has a little bone or cementum formation inside it, you can feel the bone with the scalpel

Answer 716

**Peripheral Giant Cell Granuloma**

Answer 717

Giant cells inside the lesion

Answer 718

**• Pyogenic granuloma/pregnancy tumor • Peripheral _ossifying***_or_***cementifying_ fibroma • Peripheral giant cell granuloma • Peripheral fibroma (4P)** _Memorize these well!_ *All benign soft tissue lesions*

Answer 719

- if it’s on the gingival tissues, take a radiograph - always consider **SCC** as a differential diagnosis

Answer 720

Inflammatory Gingival Enlargement Example of someone with true hyperplastic gingivitis Maybe related to very poor plaque control In this case, either porcelain or porcelain fused to metal full coverage restorations that have very bulky margins, and that may play a role for food to pick up

Answer 721

* **What is it?** Reactive connective tissue hyperplasia - exuberant granulation tissue; Misnomer – not pyogenic and not a true granuloma * **Etiology:** Response to injury - calculus or overhang restoration * **Assosiated with**? Often occurs in **pregnant women (“pregnancy tumor”)**, also associated with **puberty** * **Treatment**: Excision and removal of irritant (eg calculus, overhanging restorations)

Answer 722

Acute Myelogenous Leukemia (AML) Wegener’s Granulomatosis Kaposi Sarcoma Plasma Cell Gingivitis **Generalized gingival enlargement – all different cases and diseases**

Answer 723

* They often occur in the gingival, but can occur in multiple areas * that’s the one thing that distinguishes this from the other 2 P’s: pyogenic granuloma can occur on ANY oral site, most commonly on the gingival tissues

Answer 724

Hereditary Gingivofibromatosis

Answer 725

**Infantile Hemangioma** **(“strawberry” hemangioma).** Infant with two red, nodular masses on the posterior scalp and neck *Neville Cr*

Answer 726

* **Clinical appearance** * Usually **ulcerated** * Soft exophytic lesion, either **sessile or pedunculated** * **Deep red to purple in color, bleeds easily** * **Location:** * **Most common – *gingiva*** * Also occurs in **other areas of the oral mucosa ( can happen anywhere)** * **Size**: small to large (millimeters to centimeters) * **Develop** rapidly and then remain static * **Age**: Any age

Answer 727

When you apply pressure to it, it evacuates the lesion (disappears!), when you pull away, it refills and you see it again – that tells you it’s a vascular lesion

Answer 728

**Capillary Malformation (Low flow)**

Answer 729

Venous malformation (Low flow) **No bruit, non-pulsatile** vs Arteriovenous or arteriolar malformations (High flow) **Bruit and pulsatile** **In other word, Venous lesion = Does not have pulse** **Histopathologically they look different too** **Treatment:** **-**Don't biopsy this unless it's rapidly growing, if it is rapidly growing then suspect ► *angiosarcoma*? ( unlikely) -can be surgically treated by oral surgeons -clamping off the blood vessel and dissecting it out, or putting a sclerosis agent

Answer 730

Venous malformation (low flow) *Many pts can live with this without treatment*

Answer 731

Osler-Weber-Rendu Syndrome

Answer 732

Sturge-Weber Angiomatosis Sturge-Weber syndrome

Answer 733

**Sturge-Weber Angiomatosis** **Sturge-Weber syndrome** Notice how the vascular malformation is only one side.. Remember: Vascular changes follow trigeminal nerve, so it doesn’t cross midline

Answer 734

**Lymphangioma**

Answer 735

**Cystic Hygroma** a type of Lymphangioma

Answer 736

* a reactive benign soft tissue lesion * **Clinical appearance:** Well-demarcated, sessile or pedunculated lesion that appears to originate from _the gingival interdental papilla_ * **Derived from:** cells of the periodontal ligament * **Age**: children and young adults * **Sex**: females more than males * **Recurrence rate** – about 16% * **Treatment**: Surgical excision

Answer 737

**Neuroma** **(Traumatic Neuroma)** Not a benign true neoplasm, it’s reactive lesion This is an edentulous patient, so resorbed bone, so flange of denture is impinging in the area of mental foramen – develop from repeated trauma Sometimes have to cut into nerve, peel the neuroma from nerve, careful not to sever nerve

Answer 738

Multiple Endocrine Neoplasia (MEN) Syndrome

Answer 739

neurofibroma -it looks like **lymphoepithelial cyst,** but this is further anterior and not where you would get lymphoid tissue – so it’s not lymphoepithelial cyst, it’s neurofibroma Yellow – nerves typically yellow

Answer 740

neurofibroma

Answer 741

* **What is it?** Probably a reactive lesion due to local irritating factors (giant cells develop inside the lesion which is a benign soft tissue lesion) * **Location**: _Gingiva_, usually anterior to the molars * **Age:** Most frequently seen between 40-60 years old * **Clinical appearance:** dusky purple, sessile or pedunculated, smooth-surfaced, dome-shaped papule or nodule. Most lesions are less than 1.5 cm in diameter, though infrequently, may grow as large as 5 cm in greatest dimension * **Radiographic Features:** Usually none, but superficial destruction of the alveolar bone may occur

Answer 742

**Neurofibromatosis syndrome** **von Recklinghausen’s Disease** * Lisch nodules on iris, pigmented (eye picture) * Neurofibromatosis in mouth (bottom left picture) * Café au lait (bottom right picture)

Answer 743

Schwannoma/ Neurilemoma

Answer 744

Schwannoma/ Neurilemoma

Answer 745

**Antoni A and Antoni B.** Streaming fascicles of spindle-shaped Schwann cells characterize Antoni A tissue. These cells often form a palisaded arrangement around central acellular, eosinophilic areas known as **Verocay bodies.** Antoni B tissue is less cellular and less organized; the spindle cells are randomly arranged within a loose, myxomatous stroma.

Answer 746

Granular Cell Tumor

Answer 747

Granular Cell Tumor

Answer 748

Has pseudoepitheliomatus hyperplasia of epithelium (seen on left picture) Characteristic feature are the granular cells on the right picture Infiltrate down into the muscle layers, that’s when pathologist confirms granular cell tumor

Answer 749

•**Diagnosis**: All 3 “P” lesions usually occur on gingival interdental papillae ( however pyogenic granuloma can occur anywhere) • Since they can look similar clinically, **excisional biopsy necessary to determine diagnosis** • **Treatment**: complete excision and removal of local irritant (scaling and root planing)

Answer 750

**Congenital Epulis**

Answer 751

- Response to chronic inflammation - Hormonal changes (pregnancy/puberty) - Immune-mediated/plasma cell gingivitis - Drug induced - Genetic/ Inherited NOTE: Gingival enlargement is not always ***hyperplastic tissue***

Answer 752

Neuroectodermal tumor of infancy look how they removed it here surgically *is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth.*

Answer 753

* **What is it:** Benign tumor of mature fat cells; Relatively rare * **Location:**Won’t see on gingival tissue, will see _on buccal mucosa, on the tongue, and floor of the mouth_ * **Clinically** appears as _a yellowish mass_ surfaced by thin overlying epithelium, When you feel it, it’s soft * **Histologically**: a well-delineated tumor composed of mature fat cells with a thin capsule * **Treatment**: surgical excision,does not recur

Answer 754

**Lipoma** Usually very orange looking lesion in site where there’s adipose tissue Very obvious, nothing as orange as lipoma

Answer 755

* **Phenytoin**: (or Dilantin) – the drug that used to be given to every single * person that had seizures * Calcium-channel blockers * Nifedipine *not as prescribed anymore* * Dilitiazem still prescribe * Amlodipine: is prescribed as one of the first line therapy for hypertension (very commonly prescribed); it doesn’t typically cause gingival overgrowth except in some selected patients, usually those with pretty poor oral hygiene * Cyclosporine A (used for for bone marrow transplant, graft vs host disease, solid organ transplant) * **Cyclosporine is universally recognized as causing gingival hyperplasia** * **Cyclosporine** is largely replaced with **Tacrolimus**, which typically doesn’t cause gingival overgrowth * Cyclosporine A is largely replaced with Tacrolimus, which typically doesn’t cause gingival overgrowth Some drugs have more connective tissue component, others have more epithelial component Not all identical under the microscope * Cyclosporine provides more epithelial change, Dilantin causes more of a connective tissue change

Answer 756

**Vascular leiomyoma** **High-power view showing spindle-shaped cells with bluntended nuclei. Immunohistochemical analysis shows strong positivity for smooth muscle actin (inset).**

Answer 757

**Rhabdomyoma** ## Footnote Will see the striated muscle Differential diagnosis… looks like granular cell tumor – don’t know til you remove it If patient presents with relatively slow growing tumor like this, will I get incisional biopsy or excisional biopsy? Hard to say If confident benign tumor and it’s this size and I don’t think it’s vascular (no pulse, can do aspiration), feels firm – try to excise it If it looks different, like you think it’s malignant minor salivary gland neoplasm (won’t find it in this site, but if it’s on hard palate) – incision?

Answer 758

**Leiomyosarcoma**

Answer 759

**What causes it?** * Various genes that are implicate (Putative inherited mutations are in the SOS1 or CAMK4 genes.) Linked to both autosomal dominant and recessive patterns of inheritance **How common?** * Very rare **what effects on oral cavity?** * Sometimes gingival overgrowth will completely obliterate the teeth, grow around entire tooth * Enlargement may be present at birth or may become apparent only with the eruption of the deciduous or permanent dentitions. * Tooth migration, prolonged retention of the primary dentition, and diastemata are common, and enlargement may completely cover the crowns of the teeth, resulting in compromised oral function. **Treatment** * Need surgical (usually laser) treatment – just grows back, so have to get it done periodically

Answer 760

Rhabdomyosarcoma In this case, hasn’t broken through epithelium They don’t all break through

Answer 761

* **_When do they appear?_** They are rarely present at birth, infants are Born with this in place. * **Rate of development:** the tumor will demonstrate rapid development that occurs at a faster pace than the infant’s overall growth in the first few weeks of life, * **Clinical presentation:** Either superficial or deeper tumors * Superficial tumors of the skin appear raised and bosselated with a bright-red color (“strawberry” hemangioma); They are firm and rubbery to palpation, and the blood, cannot be evacuated by applying pressure. * Deeper tumors may appear only slightly raised with a bluish hue. * May be left with a _pink or magenta macule_ in site where hemangioma occurred after its involute * **Treatment:** Typically will involute with time, Some cases don’t involute, so need to be removed * *It is a vascular Anomaly*

Answer 762

**Fibrosarcoma**

Answer 763

* a type of vascular anomaly * CMs are commonly known as port wine stains. * They look like a pink, red or purple patch of skin * occur in 1 in 300 newborns.

Answer 764

**Kaposi Sarcoma** Solitary vascular lesion on hard palate – it was so small so he decided to just excise it in this case^

Answer 765

**Kaposi Sarcoma** * Widespread Kaposi, can see cutaneous lesions * Oral images of this patient: on palate, starts with macule on patient’s left posterior palate –macular stage * Then in becomes proliferative – exophytic nodular stage (seen on patient’s right anterior palate,surrounding canine and some incisors) * Can see engorged blood vessels in area on histology slide

Answer 766

**Plasmacytoma in Multiple Myeloma** * They already had **multiple myeloma** then developed plasmacytoma * When you biopsy this, **it’s filled with plasma cells** bc they’re producing the abnormal immunoglobulins, which are the cause of the devastating issues of multiple myeloma

Answer 767

**Acute myelogenous leukemia***with* **granulocytic sarcoma** ## Footnote * *Complaining of lump inside of her cheek** * *Notsomuch worried about her gingiva**, despite her overgrowth – leukemic infiltrates that got into gingival tissues * *Left buccal mucosa**, kept biting on it, feeling incredibly fatigued though she was always working out * *Oral surgeon biopsied** her buccal mucosa and read by pathologist as pyogenic granuloma * *Physician** sent her for bloodwork, dental school sent her for bloodwork too

Answer 768

Lymphoma * Well circumscribed ulceration in area * Associated swelling in periphery * White change in the patient’s left area * Been there for 3 weeks * It’s lymphoma

Answer 769

Looks like it could be a salivary gland neoplasm, but it’s not It was another **lymphoma** Manifest in a number of different ways

Answer 770

**Do you think it’s a fibroma? No. Why?** Fibroma is covered with normal coloring epithelium – sometimes see a little white change on surface or see tiny traumatic ulcer on surface This is not like that, this is completely ulcerated Not fibroma; fibroma is a chronic bump that patient is aware of **Is it squamous cell carcinoma? Interesting, it is indeed very friable; but no** Sometimes SCC can develop and can be exophytic and don’t have deep invasion, But this is pedunculated, SCC would not be pedunculated History says there could be some kind of trauma, biting, or nick with bur – not squamous cell **Mucocele? No** Would you typically develop mucocele on lateral border of tongue? No Not going to be as many mucoceles in this area, but there are the glands of Blandin and Nuhn, so it’s possible to develop on ventral surface of tongue This bump doesn’t look like a fluid filled bump though, it has surface ulceration, redness ;Mucoceles have intact surface, would not bleed, or be red **Granular cell tumor? No** Granular cell tumor would have normal overlying epithelium (it’s pushing up from underneath) This does not have normal overlying epithelium **Hemangioma reserved for congenita**l; not a vascular malformation either **Neurofibroma? No, not the same surface** **Salivary gland neoplasms? Possible**, there are salivary glands in that area; keep this in differential The one that this is is **pyogenic granuloma**: usually red, ulcerated, and bleeds easily

Answer 771

**AKA** • _Hereditary Hemorrhagic Telangiectasia_ **What is it and its clinical appearance** • _disorder of development of the vasculature_ characterized by **telangiectases** and **arteriovenous malformations** in specific locations. These are essentially endothelial cell issue – get tafted area of abnormal blood vessels multiple different organ systems – causes complications **Type of Herditary and Etiology** •Autosomal dominant with mutations i_n at least five gene_s but mutations in two **genes (ENG and ACVRL1/ALK1)** cause approximately 85% of cases. **What can it cause?** • Can cause hemorrhage **Location?** often on fingers, lips,tongue, but always look at the fingers!

Answer 772

* Rare, non-hereditary developmental condition * **Vascular proliferation** involving tissues of the brain and face * Face: **Unilateral** distribution along one or more segments of the trigeminal nerve ( unilateral means don't cross the midline) known as **port wine stain/ nevus flammeus --** they are deep-purple color. * **Intracranial calcifications**; **neurological disorders** * **Intraoral involvement** _is common_

Answer 773

**What is it?** • Benign tumor of lymphatic vessels **Types** * Microcystic * Mixed * Cystic hygroma (macrocystic) **Location** * Most frequent extra-oral location: **posterior triangle of the nec**k; * intraoral location: **tongue** **Treatment**: monitor, surgery if needed, _recurrence common_

Answer 774

**AKA** * _traumatic neuroma_ **What is it?** * Reactive (ie not a true neoplasm) proliferation of nerve tissue after injury, usually extraction or other surgical procedure **Clinical presentation** * They are smooth-surfaced, nonulcerated nodules. * May be painful (30% of cases) and sometimes associated with altered nerve sensations that can range from anesthesia to dysesthesia to overt pain **Location** * mental foramen area, tongue, lower lip

Answer 775

***_What is it?_*** Group of rare conditions ***_Inhertiance type?_*** Autosomal dominant ***_Which type is associated with multiple mucosal neruoma?_*** **Type 2B associated with multiple mucosal neuromas (one of the first visual signs)** ***_What other presentations?_*** • Marfanoid features • Multiple tumors and hyperplasias of endocrine organs (ie pheochromocytoma) *_Increase risk of which cancer?_* **•** Increased risk for **medullary thyroid cancer (prophylactic thyroidectomy)** *_Common board questions_*

Answer 776

**What is it?** * A benign tumor arising from peripheral nerve tissue **Clinical presentation:** * Slow growing, painless lesion * Smooth-surfaced, nodular mass that varies in size * Skin more commonly involved than oral mucosa Location: * **Common oral mucosal sites:** tongue and buccal mucosa * May develop _centrally in bone_ **Treatment**: surgical excision **Malignant transformation** _reported, but rare_

Answer 777

_Most common form?_ Several forms, **type I** is **most common (von Recklinghausen’s Disease)** _intheritance type?_ • 85-97% of cases inherited as _autosomal dominant trait,_ c**hromosome 17 (NF1 gene)** **Clinical presentations:** * **Skin nodules** **(neurofibromas)** * **Café au lait** pigmentation on skin * **Lisch nodules** very diagnostic (a pigmented hamartomatou in the iris of the eyes) **Malignant transformation** * reported in 5% of cases (**neurofibrosarcoma**)

Answer 778

**What is it?** • Benign neoplasm of Schwann cell origin • Uncommon lesion: 28-48% occur in the head and neck **Age?** • Most common in young and middleaged adults **Location?** • Most common intraoral location: tongue **Clinical presentation?** • The **solitary** schwannoma is a slow-growing, encapsulated tumor that typically arises in association with a nerve trunk. • May present with pain **• Treatment** • surgical excision **malignant transformation** reported, but rare

Answer 779

**What is it?** Benign tumor derived from Schwann cells **Location?** • Oral cavity is the most common location • Vast majority of cases seen on dorsal tongue **Clinical presentation?** * Typically an **asymptomatic sessile nodule that is usually 2 cm or less in size (firm)** * The mass is typically **pink,** but some granular cell tumors appear **yellow**. * The granular cell tumor is usually solitary, although multiple, separate tumors sometimes occur, especially in black patients. * The lesion often has been noted for many months or years, although sometimes the patient is unaware of its presence. **Age**: 40-60, rare in children **Treatment** • Treated by surgical excision (Be careful with excision! no need to get all of it out, just most of it) rarely recurs

Answer 780

• **AKA**: Congenital epulis of the newborn • **Cells resemble** cells of the granular cell tumor **• Cell of origin** is unknown, not derived from nerve **• Clinical features:** * Sessile or pedunculated mass, usually found on * *the anterior** **gingiva/ alveolar mucosa** * Almost always occurs in baby girls * Present at birth **• Treatment:**Surgical excision, does not recur

Answer 781

**Location?** Often occur as soft tissue mass largely in _anterior maxilla_ **Rate of development?** So fast developing that it envelops and moves the teeth **Treatment?** Needs to be surgically excised **Origin?** Thought to be of **neuroectodermal source** **Clinical presentation?** Pigmented change in tissue

Answer 782

* Sometimes lipomas can be mixed with fibrous tissue, can be **lipofibromous** * Two lesions that look almost identical but one is **lipoma**, one is **lipofibroma** * Only difference is that **one has fibrous tissue in it, no other difference**

Answer 783

• **Leiomyoma** • Benign tumor of smooth muscle **• Vascular Leiomyoma** • Benign tumor of smooth muscle walls of blood vessels **• Rhabdomyoma** • Benign tumor of skeletal muscle They are SUPERRR rare If become malignant, they become leiomyosarcoma or rhabdomyosarcoma – malignant even more rare

Answer 784

* a type of rare cancer that grows in the smooth muscles. * So, so rare * Diseases that move rapidly, because they’re malignancies * You might see surface ulcerations, they’re moving so fast, they break through the epithelium

Answer 785

* is a type of sarcoma. * **Rhabdomyosarcoma** usually begins in muscles that are attached to bones and that help the body move, but it may begin in many places in the body

Answer 786

Sarcoma is cancer of soft tissue (such as muscle), connective tissue (such as tendon or cartilage), or bone.

Answer 787

**•What is it?** Malignant tumor of fibroblasts • **Age?** Most common in young adults and children • **Rate of growth?** Slow growing lesion that is usually not painful (Can be slow growing, can be rapidly growing – different criteria determining high or low grade) • **Treatment**: surgical excision, recurrence is common(Aren’t always easy to surgically remove, because already metastasized into other reservoirs, spread into contiguous areas) Aren’t always radiosensitive, don’t always respond to radiation treatment • 5-year **survival rates** range from 40-70%

Answer 788

**• Angiosarcoma** • Malignant tumor of blood vessels **• Lymphangiosarcoma** • Malignant tumor of lymphatic vessels **• Kaposi’s sarcoma** * Malignant neoplasm associated with endothelial cells * Seen predominantly in poorly controlled HIV infected patient population (not exclusively) * Elderly people can develop Kaposi

Answer 789

**Etiology**:Caused by **HHV-8 (human herpesvirus 8) /***part of herpes family* **Types:** * **Classic:** late adult life, Italian and Jewish men, skin of lower extremities * **Endemic:** African form * **Iatrogenic immunosuppression-associated:** most often occurs in recipients of organ transplants * **AIDS-related** **Treatment** * Surgical excision, radiation therapy or systemic chemotherapy for multiple nonoral lesions, if it gets large, dose-radiation therapy!

Answer 790

Presents as soft tissue lesion It is possible that a patient can present with plasmacytoma that would be the first sign of multiple myeloma (it would be a rare sign, but it can happen)

Answer 791

* **Lymphoma** is a general term for a complex group of heterogeneous lymphoreticular malignancies. * **Lymphoma** is the _sixth most common malignancy_ and the **second most common neoplasm of the head and neck after squamous cell carcinoma** and **accounts for 50-59% of head and neck neoplasms in children.** * They constitute approximately 3-5% of all known malignancies and are generally divided into two morphologically distinct types: **Hodgkin’s lymphoma (HL)** and **non-Hodgkin’s lymphoma (NHL).** * These malignancies typically **arise within the lymphatic tissues and can progress to extranodal disease as in NHL.** * **Cervical lymph node involvement can be present in any type of lymphoma**. * HL extends by means of contiguous nodal spread whereas NHL tends to disseminate hematogenously and is typically a systemic diagnosis. * Within the head and neck, **Waldeyer’s ring** is the most common site of involvement, accounting for more than half of all extranodal head and neck lymphomas. * **Oral involvement by lymphoma** may represent _a localized disease process_ but is _more often part of a systemic process that secondarily involves the cervical lymph nodes._ * **Lymphoma** arising within the oral cavity accounts for less than 5% of all oral malignancies, and **approximately 85% of these lesions involve the pharyngeal tonsil** and the **palate** * Extralymphatic sites include the **salivary glands, paranasal sinuses, oral cavity, and larynx.**

Answer 792

Lymphoma * Well circumscribed ulceration in area * Associated swelling in periphery * White change in the patient’s left area * Been there for 3 weeks * It’s lymphoma

Answer 793

Looks like it could be a salivary gland neoplasm, but it’s not It was another **lymphoma** Manifest in a number of different ways

Answer 794

**Do you think it’s a fibroma? No. Why?** Fibroma is covered with normal coloring epithelium – sometimes see a little white change on surface or see tiny traumatic ulcer on surface This is not like that, this is completely ulcerated Not fibroma; fibroma is a chronic bump that patient is aware of **Is it squamous cell carcinoma? Interesting, it is indeed very friable; but no** Sometimes SCC can develop and can be exophytic and don’t have deep invasion, But this is pedunculated, SCC would not be pedunculated History says there could be some kind of trauma, biting, or nick with bur – not squamous cell **Mucocele? No** Would you typically develop mucocele on lateral border of tongue? No Not going to be as many mucoceles in this area, but there are the glands of Blandin and Nuhn, so it’s possible to develop on ventral surface of tongue This bump doesn’t look like a fluid filled bump though, it has surface ulceration, redness ;Mucoceles have intact surface, would not bleed, or be red **Granular cell tumor? No** Granular cell tumor would have normal overlying epithelium (it’s pushing up from underneath) This does not have normal overlying epithelium **Hemangioma reserved for congenita**l; not a vascular malformation either **Neurofibroma? No, not the same surface** **Salivary gland neoplasms? Possible**, there are salivary glands in that area; keep this in differential The one that this is is **pyogenic granuloma**: usually red, ulcerated, and bleeds easily

Answer 795

benign tumor of glandular origin

Answer 796

 Encapsulated ‐ distinguishable from surrounding tissues  Freely movable ‐ not fixed  Slow growing  Non tender ‐ patients do not complain of pain

Answer 797

 **Pleomorphic adenoma** aka mixed tumor  **Monomorphic adenoma**s o **Canalicular adenoma** o **Basal cell adenoma**  **Warthin tumor** (papillary cystadenoma lymphomatosum)

Answer 798

* This tumor comes in many forms/shapes * **Most common salivary gland tumor** * **Painless, slowly growing, firm mass** * Adults (30‐50 years old) ; slight female predilection * Sites: * 50% to 77% of **parotid tumors** (most commonly found in parotid-2/3rd to 3/4th of parotid tumors) * Minor SG: **palate\>upper lip\>buccal mucosa\>** other site (most common intraoral site is the **palate**) * Malignant transformation possible in long standing lesions (about 5% cases) ‐\> called Ca ex PA

Answer 799

PLEOMORPHIC ADENOMA | (MIXED TUMOR)

Answer 800

PLEOMORPHIC ADENOMA Classic presentation: includes swelling in the parotid region | (MIXED TUMOR)

Answer 801

PLEOMORPHIC ADENOMA **Palatal presentation**: since salivary glands are only in lateral sides of the palate, **usually swellings are in one side and not the midline.** Lateral swelling is a clue that you are looking at a salivary gland lesion (left pics) On the right pic, it involved midline and crossed over to other side, so there are exceptions. But more commonly found in lateral side of the palate. | (MIXED TUMOR)

Answer 802

PLEOMORPHIC ADENOMA * Upper lip presentation: sometimes swelling can be seen extra orally and intraorally. * Remember the swelling will be movable, not tender, not fixed to underlying structures. | (MIXED TUMOR)

Answer 803

**Untreated pleomorphic adenoma** slow growing, but can grow to enormous sizes

Answer 804

This is a **mixed tumor** with myxoid component (right) and fibrous/epithelial component(left) This type of tumor can produce a lot of different tissues, since the origin is from myoepithelial cells aka plasmacytoid cells, which are pluripotent cells which means they can differentiate into many different lineages of cells such as

Answer 805

Canalicular Adenoma

Answer 806

**Canalicular Adenoma** * ***Mucocele*** might look this way, but what would make it lower on * differential diagnosis is the location of the swelling. Mucocele is mostly seen on lower lip and this pic shows upper lip. Salivary gland tumors and mucoceles * can have the same clinical presentation, so always do a biopsy for formal histopathology diagnosis.

Answer 807

* **Basaloid appearance of the tumor cells** * **Primarily parotid lesion** * **predominantly in women over 50 years of age**. It is uncommon in young adults.  (Basal cells are located in epithelium that is adjacent to interface with the connective tissue and they are separated from the CT by a basement membrane, stem cells of epithelium are located in basal cell layer)  Basal cells are typically Blue in appearance and cuboidal,

Answer 808

**Basal Cell Adenoma**

Answer 809

PAPILLARY CYSTADENOMA LYMPHOMATOSUM (WARTHIN TUMOR)

Answer 810

** Most common malignancy of salivary glands  Most common malignant SG tumor in children** **Locations**  **Palate**, most common intraoral site  Rare primary intrabony (jaws) tumors  Most common in **parotid**  **Minor SG: palate 2nd** **Clinical appearance in minor gland:** asymptomatic fluctuant swelling; blue or red colored ** Can be mistaken for mucocele**  **Histopathology**: note the cells growing into adjacent tissue, showing infiltration

Answer 811

**What is it?** Proliferation of 1 type of cell makes up the tumor. **Types? Includes:** o Canalicular Adenoma o Basal Cell Adenoma **Treatment** for all monomorphic adenomas is surgical excision & diagnosis is done with biopsy

Answer 812

MUCOEPIDERMOID CARCINOMA

Answer 813

MUCOEPIDERMOID CARCINOMA ## Footnote *Request all for biopsies!*

Answer 814

**CENTRAL MUCOEPIDERMOID CARCINOMA** * _Intrabony presentations_, may have extraoral swelling depending on the stage * Started as small swelling and progressed rapidly:, need to pick it up early! * Patient recovered, but might need radiation, lost salivary glands, needed reconstruction of palate

Answer 815

* Almost exclusively in **minor SG** * Striking predilection for **upper lip (\>75%)** * Nearly always occurs in **older adults** * **Slowly growing, painless mass** * One clue for visualization of soft tissue swellings is increased vascularity with **blue‐ish tint in the area.**

Answer 816

**ACINIC CELL ADENOCARCINOMA**

Answer 817

ACINIC CELL ADENOCARCINOMA blue‐ish tint

Answer 818

Untreated acinic cell adenocarcinoma ## Footnote  Because it is slow growing, and a low grade tumor, the patient is alive and not dead with a tumor this size.  Similar presentation to pleomorphic adenomas, but there is a lot of ulceration on the surface and prominent vascularization in acinic cell adenocarcinoma.

Answer 819

 **High grade salivary gland malignancy** ( very bad cancer to get)  Adults  **Palatal mass; ulcerations**  Spread through **perineural invasion** ‐ tumor wraps itself around nerves and spreads through perineural spaces  **Grows slowly in the beginning and then picks up speed**  **Histology**: Duct like proliferation with cystic spaces

Answer 820

Adenoid Cystic Carcinoma

Answer 821

Adenoid Cystic Carcinoma

Answer 822

Adenoid Cystic Carcinoma

Answer 823

Swiss cheese appearance, cribriform pattern (full of holes aka cystic spaces)

Answer 824

Perineural invasion: nerve nuble in the center and is wrapped by tumor

Answer 825

Polymorphous Adenocarcinoma

Answer 826

Polymorphous Adenocarcinoma

Answer 827

Carcinoma Ex Pleomorphic Adenoma

Answer 828

* **finger‐like projections, benign, cystic spaces, aggregates of****lymphocytes)** * Vast majority occur within **the parotid gland** * Very rare intraorally * **Predominantly in men** * Typically between **5th and 8th decades** * _Strong correlation with cigarette smoking_ * **Most common SG tumor to occur bilaterally** (bilateral parotid swelling), but can be unilateral * **Etiology:** Thought to arise within lymph nodes as a result of entrapment of * salivary gland elements early in development * **Clinical Features:** * **swelling that has** more subtle presentation * **Doughy to cystic mass** * In the inferior pole of the gland, adjacent and posterior to the angle of the mandible * **Treatment**: surgical excision, responds very well to it

Answer 829

 **Encapsulated, freely movable, not fixed to underlying structure, not tender, patients do not complain of pain, slow growing**  There is one tumor of the ones discussed that does have a risk of malignant transformation (only 5% and will take many, many years) and that is **Pleomorphic adenoma**

Answer 830

 Mucoepidermoid carcinoma  Acinic cell carcinoma  Adenoid cystic carcinoma  Carcinoma ex‐mixed tumor/malignant mixed tumor  Polymorphous adenocarcinoma

Answer 831

 Infiltrative  Fixed to underlying structures, not moveable  Rapid or slow growth, depending on grade and type of malignant salivary gland tumor  Larger, rapidly growing lesions may cause pain and/or paresthesia  Ulcerated overlying mucosa

Answer 832

**What are its compoenents?** Mixture of mucus‐producing cells and epidermoid or squamous cells May arise **within jaws** from odontogenic epithelium of dentigerous cysts • More common in the **mandible** than maxilla **• Molar‐ramus area** **Treatment**: Usually treated by surgical excision **Prognosis:** • Overall prognosis is _fairly good_ • 10% of patients die, due to local recurrence or metastasis  Low‐grade tumors have good prognosis (\>90% are cured)  High‐grade tumors the prognosis is guarded (Only 30% survive) **Therapy by gene?** *CRTC1–MAML2, CRTC3‐MAML2* gene fusions (targeted therapy)

Answer 833

*  Occurs **predominantly in major SGs,** *  Found in **all age group**s, peak incidence in 5th and 6th grade *  **No gender predilection** *  _Malignancy with serous acinar differentiation_ *  **Most common in the parotid** (since 90% serous acini) *  Variable microscopic appearance *  May even appear **encapsulated**, since it is SLOW growing *  **Better prognosis than salivary gland malignancies**

Answer 834

**Location**:  Approx. 50% occur within the minor SG ‐ palate most common site **Growth rate**  Usually a slowly growing mass **Clinical presentation**  Pain is a common and important early finding, occasionally occurring before there is noticeable swelling (described at annoying pain)  Tendency to show perineural invasion, corresponds to pain **Treatment**  Excision usually the treatment of choice ‐ but edges of tumor may have perineural invasion and remain undetected ‐ makes tumor dangerous **Prognosis**  5‐year survival rate as high as 70% (maybe 90%)  By 20 years, only 20% ‐ poor long term prognosis

Answer 835

* **Location:** * Almost exclusively in the **minor SG** * **60%** on the hard or **soft palate** * **Gender"** * *2/3rds in **females*** * **Appearance**: * Tumor cells have _deceptively uniform appearance_ * **Growth patterns:** * Different growth patterns – polymorphous * _Perineural invasion ‐ common_ ‐ but considered low grade tumor * **Treatment**: Wide surgical excision; overall prognosis relatively good, with 80% cure rate

Answer 836

**What is it?** (benign tumors that have underwent malignant transformation‐ takes a lot time, 15 to 20 years) **Mean age** about 15 years greater than benign counterpart **Growth patterns:** Mass present for many years with recent rapid growth with associated pain or ulceration **Treatment**: Best treated by wide excision, with local node dissection and radiation **Prognosis:** guarded, with 50% local recurrence or metastases and dying Prognosis is case to case scenario, may transform to high grade tumor

Answer 837

**o Mucocele o Mucoepidermoid Ca o Pleomorphic Adenoma**

Answer 838

**o Canalicular Adenoma o Salivary Duct Cyst\* o Pleomorphic Adenoma**

Answer 839

**o Pleomorphic adenoma o Warthin’s tumor o Basal cell adenoma o Mucoepidermoid ca o Acinic cell ca o Adenoid cystic ca o Ca ex mixed tumor**

Answer 840

**o Pleomorphic adenoma o Adenoid cystic ca o Mucoepidermoid ca o PLGA o Monomorphic adenoma**

Answer 841

 Involve both major and minor glands ** Benign and malignant tumors both have similar clinical presentation**  Most malignant salivary gland tumors do not show histopathologic characteristics associated with malignancy  Most occur in adults  Warthin Tumor seen in parotid, may be bilateral ** Mucoepidermoid carcinoma** o Can occur in children o May occur centrally in bone

Answer 842

* mucocele/mucous cyst * ranula * necrotizing sialometaplasia * sialolithiasis * sialadentitis

Answer 843

**• definition:** a lesion that forms when a salivary gland duct is severed & secretion spills into the adjacent CT • **a pseudocyst** (not lined by epithelium) — mucous builds up in the CT & causes a bump **• clinical features:** * swelling in the tissue that may increase & decrease in size * may have a bluish hue, fluctuant on palpation — fluid filled, soft, compressible **•** **location**: _lower lip most common site_, but may form in any area where there are minor salivary glands **• histologic features:** - a cyst-like space in soft tissue - lined by compressed granulation tissue - lumen filled with mucin, foamy macrophages & inflammatory cells **• treatment:** surgical excision, removal of associated minor salivary glands • may recur if don’t remove all associated injured minor salivary glands

Answer 844

**Mucocele**

Answer 845

**Mucous Cyst**

Answer 846

**Ranula** Notice how it's unilateral on the floor of the mouth

Answer 847

Ranula * Notice how it's unilateral* * on the floor of the mouth*

Answer 848

**• Definition:** locally destructive inflammatory condition — looks malignant but is _benign_ *• salivary gland ischemia* — “heart attack of the palate”; blood flow is interrupted **• predisposing factors:** - local trauma - palatal injection of local anesthesia - previous surgery - many are idiopathic.. • usually a clinical diagnosis based on history & how fast — palate uncommon for SCC **• clinical features:** - initially appears as a non-ulcerated swelling of the palate - often associated with pain or paresthesia - within 2-3 weeks, necrotic tissue sloughs off & becomes a crater-like ulcer - patient may say: “a chunk of the roof of my mouth fell out” **• histologic features:** - necrosis of the salivary glands — coagulative necrosis (green circles in histology —\>) - *salivary gland duct epithelium* is replaced by **squamous epithelium** — appear as islands of squamous epithelium deep in the CT & **resembles SCC** (arrows in histology —\>) • **Treatment**: no treatment, spontaneously resolves within 6 to 10 weeks • _irrigating & debriding the area_ can reintroduce vascularity & help healing

Answer 849

Necrotizing Sialometaplasia

Answer 850

**Definition:** lith = stone ;; sialolith: a salivary gland stone **Location:** occur in both major & minor salivary glands • floor of the mouth is most common location (Wharton’s duct is a common place) *• often causes obstruction of the duct* **Origin:** arise from _desposition of calcium salts around nidus of debris within the duct lumen_ * *clinical features:**- minor glands: hard yellowish structure in soft tissue - may be visible on a radiograph - recurrent swelling (due to the obstruction) - episodic pain & swelling during times of increased salivation - can be palpated if the stone is located toward the terminal portion of the duct * *Radiological features** : may be viewed as a radiopacity on an occlusal x-ray--well defined radiopacity * *Histological features-** concentric rings of calcification, color of it in stain depends on level of calcificatio * *Treatment**: promote passage of stone (massage, sialogogues, increase fluid intake) or surgical removal

Answer 851

Sialolithiasis

Answer 852

**Sialolithiasis** Notice how it can appear radiographically as a well defined radiolucency

Answer 853

**Sialolithiasis**

Answer 854

•_Definition:_ a pseudocyst • microscopicallly appears as an epithelial lined cystic structure that is actually a dilated duct • **clinically you CANNOT tell the difference between a mucocele & mucous cyst** **• clinical features:** - same as a mucocele **• histologic features:** - same as mucocele but will see an epithelial lining (but actually a dilated duct) **treatment**: same as mucocele; surgical excision

Answer 855

• **definition**: acute or chronic _inflammation in major or minor salivary glands_ **• causes:** • obstruction of a salivary gland duct (sialolith) • infection (mumps [viral], staph aureus [bacterial, most common], candida [fungal]) • decreased salivary flow (Sjogren’s, sarcoidosis) • parotid gland = parotitis **• clinical features:** **- acute:** most common in parotid, swollen & painful gland, erythematous & warm overlying mucosa/skin, purulent discharge, low-grade fever **-** **chronic**: caused by recurrent or persistent ductal obstruction, periodic swelling & pain **• histologic features:** - acute or chronic inflammatory cell infiltrate in the salivary gland - in chronic cases = salivary gland replaced by fibrous CT & fat - **cells: acute = neutrophils** ;; **chronic = lymphocytes, plasma cells, macrophages** **• Treatment:** antibiotics, rehydration, surgical drainage, or surgical removal of gland

Answer 856

**Sialadenitis** Acute: parotid papilla purulent discharge

Answer 857

Sialadenitis Chronic: caused fibrosis

Answer 858

**Mucocele** * fluctuant swelling * bluish hue * lower lip most common **Ranula** * fluctuant swelling * floor of mouth **Sialolithisis** • major glands: episodic pain & swelling of affected gland • minor glands: asymptomatic/ local swelling or tenderness • if superficial - firm to palpation & yellowish color **Necrotizing Sialometaplasia** • initial painful swelling • later necrotic ulcer • posterior lateral hard palate & soft palate **Sialadenitis** • painful swelling of affected gland • purulent discharge if acute infection

Answer 859

**‐ Debacterol** (sulfonated phenolics; sulfuric acid solution) **o Chemical cautery** o Label: one time application for 5‐10 seconds ‐ NOT recommended to patients with frequent outbreaks

Answer 860

**Topical anesthetic agents** o To numb the pain **‐ Surface protective agents/bioadhesives** o Cover the ulcer if small enough **‐ Anti‐inflammatory/immunomodulatory agents** o Applied to ulcer surface (corticosteroids) **‐ Anti‐microbials** o Some evidence that topical tetracycline may help **‐ Chemical/physical cautery Lasers** ‐ Over‐the‐counter (OTC) versus prescription (Rx **All essentially do the same thing:** o Numbing agent o Mucosal covering agent ‐ Bottomline: **o ALL canker sores will heal on their on with time**

Answer 861

**‐ Treatment to reduce pain ‐ vs. ‐ Abortive treatment to reduce healing time ‐ vs. ‐ Suppressive treatment to suppress recurrences ‐ Combination of all** Also Consider * Using Sodium Lauryl Sulfate‐Free Toothpastes * Remove Obvious Possible Causes

Answer 862

**‐ Treatment to reduce pain** Also Consider * using Sodium Lauryl Sulfate‐Free Toothpastes * Remove Obvious Possible Causes * ‐ Repair sharp teeth/restorations * ‐ Remove plaque * ‐ Optimize lubrication

Answer 863

‐ History of RAS ‐ Medical History o Medications o Review of Systems ‐ Social History ‐ Dental History ‐ Diet/Nutritional History ‐ Physical Examination ‐ LaboratoryTests

Answer 864

‐ Repair sharp teeth/restorations ‐ Remove plaque ‐ Optimize lubrication Ulcer

Answer 865

**Behcet’s Disease** ‐ Recalcitrant oral ulcers associated with Behcet’s Disease ‐ Later developed genital ulcers and other complications ‐ Image: o Sores in the labial mucosa have classic aphthae appearance o Other ulcers are major aphthae: ▪ Larger ▪ Irregular borders ▪ Intense proliferative erythema

Answer 866

**Behcet’s Disease** ‐ Recurrent inflammatory disorder of unknown cause: o Bacterial? ‐ Affects: o Middle Eastern Males o Asian Females ‐ Onset 3rd – 4th decade ‐ HLA‐B51 association Recurrent aphthous ulcers generally precede other signs: o Genital/skin/eye lesions & others (arthritis, Gl lesions, CNS symptoms, vascular lesions) ‐ Diagnosis based upon criteria (point system): no laboratory tests

Answer 867

**Hematinic Deficiencies** ## Footnote **‐ Superficial ulcers** o Not classic aphthous ulcers ‐ Equivocal associations with iron, Vit B1, B2, B6, B12, and folate. ‐ Blood tests are not recommended routinely in all patients with RAS. ‐ Indications for blood work (CBC): o Older patient with recent RAS history o Suspicious medical history/review of systems **o Strict vegetarian patients**

Answer 868

**HIV‐Associated Aphthous** * CD4 counts \<100 cells/mm3 are predisposed to major RAS * ‐ Other sites may be affected: * o Esophagus * o Genitals * o Anus/rectum * ‐ We see this **less frequently since ART** * ‐ Diagnosis is important, particularly if no prior history

Answer 869

**Inflammatory Bowel Diseases** * **Specific lesions:** * o Diffuse labial and buccal swelling * o Cobblestones * o Other specific lesions * ▪ Mucosal tags * ▪ Deep linear ulcerations * o Mucogingivitis * o Granulomatous cheilitis * * **Non‐specific lesions:** * o Aphthous ulcerations * o Pyostomatitis vegetans * o Dental caries * o Gingivitis and periodontitis * o Other non‐specific lesions

Answer 870

**Transient Lingual Papillitis** * ‐ Relatively rare * ‐ Canker sore meets **fungiform papilla** of tongue * Multiple papilla can become inflamed (above image) * **Very painful** * ‐ Ulcer Appearance: * Tiny * Transient * On fungiform papilla of tongue * **‐ Typically resolves in 7‐10 days**

Answer 871

**Herpetiform aphthous stomatitis** * Apppears like **herpesvirus but unrelated to it** * account for **5% of cases (**the least common) **Appearance**: * begin as multiple (up to 100) 1- to 3-mm crops of small, painful clusters of ulcers on an erythematous base. * They coalesce to form larger ulcers that last 2 weeks. * *A bunch of smaller ulcers that coalesce*

Answer 872

**‐ Minor Recurrent Aphthous Ulcers (RAS)‐ Rare Case** _o Keratinized Mucosal Site_ ‐ 11‐year‐old boy ‐ Canine is in process of erupting ‐ Canker sore present on his keratinized mucosa (RARE) **o 99% of canker sores occur on NON-KERATINIZED MUCOSA**

Answer 873

**Minor Recurrent Aphthous Ulcers (RAS)** * **aka‐ “Canker Sores”** * ‐ High prevalence: 5‐25% * ‐ Comprises the overwhelming majority of cases * o 75‐85% of ALL RAS cases * **‐ \<10 mm in diameter** * ‐ Ulcer appearance: * **o Shallow** * **o Round/Oval Shaped** * **o Yellow pseudomembrane** * ▪ Slightly raised margin * ▪ Erythematous Halo * **‐ Typically resolves in 7‐10 days** * o \*May take longer if in a “high‐traffic” site * **‐ No scarring** * ‐ Recurrence rates vary

Answer 874

**‐ Hallmarks:** o 1. Central ulceration o 2. Ring of erythema (erythematous border) ▪ Accentuated in right image

Answer 875

**‐ Aphthous Ulcer of the tongue** ‐ Aphthous ulcers can occur on specialized structures of the mouth

Answer 876

``` Aphthous ulcer (“The canker sore”) ``` What would it be like to have a canker sore on your uvula? o Painful to swallow ‐ The location of the canker sore will predict the symptoms

Answer 877

**‐ Dexamethasone elixir 0.5mg/5ml (ETOH base) or solution (H20 base)** ‐ Indicated for difficult to reach lesions to obtain access to all of them o Disp:600ml o Label: swish with 5‐10 ml for 5 minutes up to 0.5mg/5mL 4x/day and expectorate 00s preservalve.) May be used as suppressive therapy in selected patients with close surveillance o Prevent recurrences ‐ May buy an EXTRA DAY of healing time _dr. Kerr prefers the elixir_

Answer 878

**Major Recurrent Aphthous Ulcers (RAS)** * ‐ 10 – 15% of all RAS cases * **‐ \>10 mm in diameter** * ‐ Ulcer Appearance: * **o Deeper** * **o Irregular borders (usually)** * ‐ **Typically resolves in WEEKS or MONTHS** * ‐ May be associated with fever or malaise * o The associated cytokine release can induce a fever * ‐ Predilection for the throat * **‐ Often DOES leave scarring** * ‐ Recurrence rates vary

Answer 879

**‐ Triamcinolone acetonide** in Orabase 0.1% (intermediate) o Disp: 5g tube Dental Past o Label: apply a thin film over ulcer after meals and bedtime APOTHECON o Do not use for more than 2 weeks **‐ Fluocinonide gel or ointment** 0.05% (Potent) o Disp: 15g tube o Label: apply a thin film over o Do not use for more than 2 weeks ‐ Clobetasol ointment 0.05% (Ultra potent) o Disp: 15gtube Label: apply a thin film over ulcer bid

Answer 880

Topical Treatments ‐ Drug is easily washed away or rubbed off ‐ Topical anesthetics have a short‐lived effect ‐ Often difficult to apply due to location ‐ Cost may be a disincentive to buy OTC ‐ Once ulcers are established, these treatments are not as effective, therefore abortive treatment early on is preferred

Answer 881

**‐ Prednisone or systemic steroids were the one systemic treatment that Dr. Kerr has has success with in practice** **o 0.5 mg/kg of Prednisone would be prescribed for about 1 week** o Very successful in patients with frequent outbreaks of multiple canker sores ‐ In some limited cases Dr. Kerr has seen some success with: o Colchicine o Pentoxifylline

Answer 882

Large family of double stranded DNA viruses ## Footnote ❏ HHV‐1: HSV‐1‐Herpes simplex virus type 1 (most common in oral cavity) ❏ HHV‐2: HSV‐2‐Herpes simplex virus type 2 ❏ HHV‐3: VZV‐Varicella zoster virus ❏ HHV‐4: EBV‐Epstein Barr virus ❏ HHV‐5: CMV‐Cytomegalovirus ❏ HHV‐6: Sixth disease/Roseola (commonly seen in children, spreads through saliva and respiratory droplets) ❏ HHV‐7: Roseola ❏ HHV‐8: KSHV‐Kaposi sarcoma‐associated herpesvirus

Answer 883

Primary infection → Latency → Reactivationn → Recurrent infection

Answer 884

**Sensory ganglia**

Answer 885

**Sensory ganglia**

Answer 886

**Sensory ganglia (dorsal root ganglia)**

Answer 887

**B‐Lymphocytes**

Answer 888

**Myeloid cells, salivary gland cells, endothelium**

Answer 889

**CD4+ T‐Lymphocytes**

Answer 890

**CD4+ T‐Lymphocytes**

Answer 891

* *B‐lymphocytes (latency)**, **endothelial cells (Kaposi sarcoma) **

Answer 892

❏ **Type 1**‐ adapted to _oral, facial, and ocular areas_ (more common in oral cavity) ❏ **Type 2**‐ adapted to _genital area_ ❏ Other sites may also be affected ○ **Herpetic whitlow** (finger) ○ **Herpes gladiatorum** (wrestlers) ○ **Herpes barbae** (beard area)

Answer 893

○ Acute/Primary Herpetic Gingivostomatitis ○ The easy way to remember where the ulcerations occur? ➢ gingiva and oral cavity **gingivo** (=**gingiva** or _fixed_ keratinized mucosa) + **stoma** (= the **movable** part of the oral cavity where the CT is looser, including the **labial and buccal mucosa, and the tongue**).

Answer 894

two manifestations: 1. **Herpes labialis:** occurs on the vermillion border 2. **Intra‐oral herpes**: occurs ONLY on the fixed keratinized mucosa (mucosa that doesn't move around) MEMORIZE THIS

Answer 895

 They don’t have antibodies

Answer 896

 Children and young patients

Answer 897

HSV‐1: Primary Infection it is a raised blister/papule on the vermilion The bottom arrow pointing to a mucosal ulcer w/ tan pseudomembrane.

Answer 898

**HSV 1- Primary Herpetic Gingivostomatitis** Ulcer with an erythematous halo (top two arrows). We also have ulcerations that are irregular in shape on the gingiva (bottom two arrows). **❏ Clinical Features:** * Cervical lymphadenopathy * Chills * Fever * Nausea * Anorexia * Irritability * Sores in mouth * Ulcerations on fixed and movable mucosa * Variable number of lesions * Ulcers coalesce and form larger irregular ulcerations * Gingiva enlarged and painful * **Resolution in 5‐7 days**

Answer 899

**HSV‐1: Primary Infection** _pathogensis_ ❏ Usually young age ❏ Often asymptomatic ❏ Symptomatic = Primary herpetic gingivostomatitis ❏ In adults is usually pharyngotonsillitis (back of throat) ❏ Spread through infected saliva or active lesions ❏ Incubation period = 3‐9 days These photos represent **gingivostomatitis** **multiple irregularly shaped ulcers present on the fixed and movable mucosa, bilaterally**

Answer 900

HSV1: primary herpetic gingivostomatitis there are multiple irregularly shaped ulcers present on the fixed and movable mucosa --\> most likely diagnosis is primary herpetic gingivostomatitis since the patient has fever and malaise.

Answer 901

❏ Molding ❏ Margination ❏ Multinucleation ❏ Also Tzanck cells

Answer 902

HSV‐ Cytology‐ Papanicolaou Stain (PAP)

Answer 903

If you have **positive IgM** *and* **negative IgG** → that means it’s an acute recent infection. Then you have to wait 4‐6 weeks If you do the serology then and get **positive IgG** *and* **negative IgM** → that means the person has **the established infection.**

Answer 904

❏ Clinical diagnosis → based on putting all the features together ❏ Culture (may take 2 weeks) → not worth it ❏ Tissue biopsy → very invasive **❏ Cytologic smear (less invasive)** ○ easiest bc you take a popsicle stick to scrape an ulceration then you put those cells on a slide, you send it to a pathologist after fixing the cells with some alcohol then you can see the virally‐altered cells ❏ Serologic testing→ to look for antibodies 4‐8 days after they were exposed.

Answer 905

* ❏ Supportive/Palliative Treatment * ❏ Fluids, nutrition, rest, avoid spreading to others * ❏ Avoid touching eyes, genitals * ❏ Possible referral to MD if infant is not drinking because of pain * ❏ Medications: 1. Topical anesthetic (OTC vs Rx) 2. Mucosal coating (OTC) 3. Analgesic (OTC vs Rx) 4. Antiviral (Rx)

Answer 906

**❏ OTC Magic Mouthwash Formulation:** helps the person to actually be able to eat bc they have so many ulcerations ○ 1 Part‐ Diphenhydramine/ Benadryl (anticholinergic) 12.5mg/5mL elixir ○ 1 Part‐ Lidocaine (topical anesthetic) ○ 1 Part‐ Magnesium hydroxide/ Maalox (mucosal coating agent) ○ Disp: 4 oz bottle ○ Label: Rinse with 5mL every 2 hours for 30 sec. then spit out **❏ Rx‐Topical Anesthetic** ○ Lidocaine 2% viscous solution\* (viscous lidocaine) ○ Disp: 100mL bottle ○ Label: Rinse with 10 mL for 2 minutes and spit out \*May diminish the gag reflex therefore better suited for older patients‐ shouldn’t be prescribed to kids. Remember serious sideeffects of seizures and methemoglobinemia in pediatric population. **❏ OTC Analgesic** ○ Acetaminophen (Tylenol) OR ibuprofen (NSAID) suspension/ tablets as directed for body weight ❏ **Rx Antivirals** ○ Generally only indicated for immunocompromised or dehydrated patients ○ Limited evidence for other cases‐ see Cochrane Oral Health Group Review\* (\*Amended recently) ○ Oral acyclovir suspension (Zovirax) is typically used ○ 15 mg/kg up to adult dose of 200mg ○ Rinse and swallow, 5 times a day for 5‐7 days

Answer 907

* §**Secondary herpes** * §Mild, self-limiting * §Vermilion border * §Intraorally on **fixed keratinized mucosa** * §7-10 days * **§Unilateral** * § Prevalence‐15‐45% * 90% of adults have the antibodies, but 15‐45% of them can get recurrent herpes. Most of us have the antibodies, but we never exhibited the primary infection or a recurrent infection***.** * **§ 1‐6 outbreaks a year**

Answer 908

**trigeminal ganglion**

Answer 909

Prodrome►papules►vesicles►ulcer►crust►heals►no scar

Answer 910

**recurrent Hsv-1/Recurrent herpes** It is raised (papule), so it’s in the middle stage

Answer 911

* Old age, Allergy * UV light ,Trauma * Physical / emotional stress, Dental treatment * Fatigue, Respiratory illnesses * Heat, Fever * Cold, Menstruation * Pregnancy, Systemic Diseases * Malignancy

Answer 912

Recurrent HSV-1 Punctuate ulceration erythematous border, irregular shape, fixed mucosa, unilateral

Answer 913

Recurrent HSV-1 This is recurrent intraoral herpes. We have punctate (point‐like) ulcerations which sometimes have clusters of coalescing ulcers. That’s the words you wanna use Other features of the ulcers: ○ Erythematous border ○ Irregular shape ○ Fixed mucosa ○ Unilateral

Answer 914

Recurrent HSV-1 **Bilateral** \> THIS IS KEY -differential diagnosis with a Staph infection that occurs periorally with kids -\> impetigo

Answer 915

Recurrent HSV-1 Vesicle stage (unilateral)

Answer 916

Recurrent HSV-1 crust → later crust comes off and then you'll have epithelialization underneath

Answer 917

Recurrent HSV-1 papule bc its raised

Answer 918

**Recurrent HSV-1** healing stage cause you might see this one day

Answer 919

Asymptomatic shedding can occur in seropositive patients ❏ More common after surgical procedures and in immunocompromised patients ❏ We need to take Universal precautions

Answer 920

**❏** **Clinical**‐ if you see punctate ulcers unilaterally on the palate, it is usually recurrent herpes simplex. ❏ Culture (may take 2 weeks) ‐ takes too long ❏ Tissue biopsy‐ if it wasn't typical **❏ Cytologic smear**‐ the ideal way if you want a definitive diagnosis

Answer 921

**Atypical recurrent HSV** **❏ Immunocompromised host** Atypical recurrent HSV can have this appearance on the movable mucosa too, not just fixed

Answer 922

**HSV Associated Erythema Multiforme** ❏ Skin immune reaction in response to infection ❏HSV implicated in trigger for erythema multiforme where you get target lesions and crusted ulcerations on the lip ❏ need to prescribe :antiviral prophylaxis

Answer 923

_❏ **Depends on severity/frequency**_ _❏ **Preventive/suppressive vs episodic/abortive strategies** Two types of treatment:_ **Preventive/Suppressive: taking antivirals everyday to prevent an outbreak** **Episodic: taking antivirals here and there to abort the process; episodic: abortive. _❏ Drugs used:_** ❏ *Antiviral agents* ❏ *Antiviral‐steroid combination agents* **_❏ Avoid precipitating factors, like use sunscreens – avoid any triggers_**

Answer 924

❏ the **prodrome**, prodrome treatment is abortive \*\*remember this!\*\*

Answer 925

Topical like Acyclovir or Acylovir + steroid combination There are many OTC topical medications

Answer 926

: taking antivirals everyday to prevent those 6 outbreak/year. There is modest evidence that systemic **acyclovir or valacyclovir** prevents recurrent herpes labialis these drugs tend to only affect virally‐altered cells. They don’t affect the mammalian cells; they’re very safe.

Answer 927

❏ Episodic‐Occurring, appearing, or changing at usually irregular intervals ❏ Abortive‐Tending to cut short the course of a disease ○ Medication has to be taken during Prodrome ○ When the patient feels a burning, itching, and tingling

Answer 928

❏ Rx: **Acyclovir cream 5% (Zovirax)** Disp: 5g tube Label: dab on lesion every 2 hours for 4 days ❏ Rx: **Penciclovir cream 1% (Denavir)** Disp: 5g tube Label: dab on lesion every 2 hours for 4 days ❏ Rx: **Docosanal cream (Abreva) OTC** Disp: 2g tube Label: dab on lesion five times per day for 4 days **Acyclovir and Penciclovir should be taken during the prodrome stage** ❏ Rx: Acyclovir 5%/ hydrocortisone 1% cream (Xerese) Disp: 5g tube Label: dab on lesion 5 times a day for 5 days ❏ Rx: Acyclovir buccal tablets (Sitavig) 50mg Disp: 2 dose pack Label: apply to canine fossa within 1 hour of symptoms (single dose)

Answer 929

**❏ Rx: Valacyclovir 1g tablets** Disp: 4 tabs Label: 2 tabs stat PO, then again in 12 hours (ie 2 doses) *Given during prodrome.* **❏ Rx: Famciclovir 500mg tablets** Disp: 3 tabs Label: 3 tabs stat PO

Answer 930

❏ Ice ❏ L‐lysine ❏ Bioflavonoids ❏ Evaporants ‐ Desiccants ❏ Emollients ❏ Bioadhesives (Zilactin‐benzyl alcohol, topical pain reliever) ❏ Wound‐healing modification/ occlusive agents

Answer 931

❏ Primary infection **○ Varicella/ Chicken pox** ❏ Secondary infection **○ Zoster/ Shingles** ○ May affect oral cavity/ face if reactivation along distribution of V1/2/3

Answer 932

HHV3 Varicella (chickenpox) It is caused by Varicella Zoster Virus Infection a typical macular, papular, vesicular rash – it’s bilateral

Answer 933

**Herpes Zoster/ Shingles** * It is affecting the intraoral region * and the maxillary branch. * Picture on the far right looks like recurrent HSV (cluster of coalescing ulcers) * Looking at the picture on the left you can determine it is NOT a recurrent intraoral herpes **because we have vesicles that opened up and crusted over on** **the skin.** **VZV histopathology is the same as HSV.** **VZV remains latent in the dorsal root ganglion** travels down the sensory nerves to skin upon reactivation. ❏ The reactivation presents as **a painful rash in one or two adjacent dermatomes that does not cross the midline.** ❏ The rash is **maculopapular** and **develops into vesicles.** ❏ One complication of zoster is **post‐herpetic neuralgia**: pain that persists in the area where the rash once was present.

Answer 934

**HHV 5** **Cytomegalovirus Infection** Histopathology look like an owl eyes means the cells are affected- they are **nuclear inclusions and cytoplasmic inclusions.**

Answer 935

HHV 5 Cytomegalovirus Infection When a person is immunocompromised, particularly those who’ve had a transplant or HIV+ patients, only these people will present with ulcerations It's very hard to identify based on photo alone - it's very nonspecific

Answer 936

**Nasopharyngeal carcinoma** ❏ Associated w/ HHV‐4 (EBV) ❏ You might be one of the first people to detect this cancer – the first sign is the swelling of the lymph nodes In this case, these are late stages of the disease. *this photo from google*

Answer 937

**Oral hairy leukoplakia** Epstein‐Barr Virus induced disease ❏ Corrugated white keratotic lesion on the lateral tongue in HIV+ people

Answer 938

**Infectious mononucleosis** **Epstein‐Barr Virus/EBV‐induced disease** The virus spreads through saliva, which is why it's sometimes called "kissing disease." Mono occurs most often in teens and young adults. However, you can get it at any age. Symptoms of mono include: **Fever** **Sore throat** **Swollen lymph glands** * when you have salivary transfer, your lymph nodes get swollen * people feel fatigue and fever * they have tonsilitis * can lead to the secretion of white or gray‐ green tonsillar exudate * they can get petechiae on the palate too.

Answer 939

**Cytomegalovirus Infection** ❏ Usually **asymptomatic** ❏ Symptomatic infections are nonspecific: **chills, fever, sore throat** ❏ What’s interesting here: ❏ When the cells are affected, they form these owl eyes – they are **nuclear inclusions and cytoplasmic inclusions.** ❏ Disease states found predominantly in: * **○ pregnancy/neonates** (congenital infection) * **immunocompromised patients,** particularly **transplant and HIV+** **patients** **** ❏ Latency in **myeloid cells, salivary gland cells and endothelium**

Answer 940

**Burkitt Lymphoma** Epstein‐Barr Virus Infection * Fast growing tumor discovered by Dr. Burkitt * **High grade lymphoma B** **cells**‐ Usually affects the jaws of children. * **It is the fastest growing tumor/cancer**. * There is _translocation of c‐myc_

Answer 941

**EBV mucocutaneous ulceration** Very rare *Photos from google*

Answer 942

**Burkitt Lymphoma** *caused by **EBV***

Answer 943

**Kaposi sarcoma** HHV 8 Kaposi sarcoma on the skin: \>1cm Different color, so this is called a **patch**. Erythematous patches present on multiple areas of the face.

Answer 944

Histopathology shows **malignant endothelial cells proliferating.** There are tiny spaces. Extravasation of RBCs can be seen

Answer 945

**Kaposi Sarcoma (HHV‐8)** Right photo: we see Patch, slightly raised plaque stage ○ This is different from **hemangioma** because if you press on it, it doesn’t blanch (where all the blood goes away, and it looks white) Left photo: Nodular is when it becomes very exophytic You need to do a biopsy for this because it looks irregular.

Answer 946

**6, 11, 16, 18** ***(condyloma – can be malignant)***

Answer 947

**6 & 11**

Answer 948

**16, 18**

Answer 949

**Kaposi sarcoma--associated herpesvirus (KSHV)** **❏ Vascular neoplasm of endothelium** ❏ Associated with **immunosuppression** ❏ Usually evolves through 3 stages: **○ Patch►plaque►nodular** * **More commonly seen in patients with HIV infection.** * **Treated** with _topical agents and chemotherapy._

Answer 950

Incubation period: **3 weeks – 2yrs** ▪ Basic Explanation: Basal epithelial cell infection ► Genome replicates ► DNA released into stratum corneum ▪ Detailed Explanation: 1. HPV accesses and infects cells of the epithelial basal layer through breaks in the skin or mucosa 2. The virus becomes incorporated in the genome of the infected cell 3. The site of HPV integration into the cellular genome is in the general region of known oncogenes 4. The virus replicates during keratinocyte differentiation in the spinous and granular cell layers 5. A portion of the HPV genome encodes proteins that are capable of inducing cell proliferation and transformation **(E6, E7)**

Answer 951

1. Completely have infection go away or 2 .Stays and forms wart or affects maturation (becomes cancer, depending on strain)

Answer 952

▪ LCR: long control region ▪ P97: promoter protein ▪ E1‐E7: early region genes ▪ L1,L2: late region genes

Answer 953

**Epstein‐Barr Virus Infection** Latency in **lymphocytes** §Infectious mononucleosis §Oral hairy leukoplakia §Nasopharyngeal carcinoma §EBV mucocutaneous ulceration §Burkitt lymphoma §Other lymphomas (Hodgkin, post transplant)

Answer 954

§Small, non-enveloped **icosahedral DNA virus** that infects **skin or mucosal cells of humans.** **§Circular DNA** §198 types established **§High and low risk types** ## Footnote **‐ HIGH risk = CANCER ‐ LOW risk = WARTS**

Answer 955

▪ **Benign**: neoplasms of squamous epithelium ▪ **Pre‐malignant**: epithelial dysplasia – can lead to cancer ▪ **Malignant**: squamous cell carcinoma – infiltration of epithelial cells

Answer 956

▪ **Sexual/non‐sexual direct contact** ▪ **Salivary transfer** ▪ **Contaminated objects (fomite)** – not well established ▪ **Autoinoculation** – child puts finger into mouth ▪ **Perinatal/pre‐natal transmission**

Answer 957

``` **E6 = degrades p53 E7 = inactivates pRb** ``` ## Footnote 1. E2 = attachment location of Integrated HPV 2. transcription of E6 + E7 3. Binding of the viral E7 protein to pRb ► release of E2F and other proteins ► signals for the cell cycle to progress ▪ **As long as the E7 protein stays attached to pRb, uncontrolled cell proliferation will continue** HPV E6 protein is: ‐ A ubiquitin ligase ‐ contributes to oncogenesis by attaching ubiquitin molecules to p53 ► making p53 inactive and subject to proteasomal degradation ▪ **Normal function of p53 = to stop cell division + repair damaged DNA so that damaged cells do not reproduce (apoptosis)** ▪ _When p53 is inactive_, cells with changes in the DNA, such as integrated viral DNA, are not repaired ► destabilizes the cell ► increases the risk of malignant transformation

Answer 958

▪ Low‐risk types: clear faster, less likely to become persistent ▪ High‐risk types: clear slowly, more likely to become persistent

Answer 959

Overall: 6.9% (CI 6.7‐8.3) ▪ Gender: **Men (10.1%) \> Women (3.6%) – women clear faster** ▪ Age: **bimodal distributio**n – 30‐34yo and 60‐64yo (she says 30‐34 but Dr. Kerr’s graph shows mid‐20s ▪ High Risk HPV (3.7%) \> Low risk HPV (3.1%) ▪ **HPV‐16 infection most prevalent** (1% or 2.13 million Americans) ▪ Based on NHANES study w/ oral rinse sampling and PCR

Answer 960

▪ Ever had sex (7.6%) vs never had sex (0.9%) ▪ Male ▪ Increased number of sexual partners (vaginal or oral sex) ▪ Tobacco smoking ▪ HIV infection

Answer 961

HPV 16 = most prevalent

Answer 962

**Ppl w/ HIV+ and low CD4 T‐cells lvl** = higher risk of HPV **HPV 16+ higher if CD4 \<200**

Answer 963

**▪ HPV associated SCCa** ‐ Wild type TP53 ‐ Low pRb _‐ Increased p16_ **▪ Tobacco and Alcohol associated SCCa** _‐ \*Mutated TP53_ – mutated by carcinogens in tobacco and alcohol► cancer ‐ pRB overexpression ‐ Decrease p16

Answer 964

§_Appear_ as **single or multiple exophytic papules, either sessile and flat or pedunculated and papillary.** §_Color_ depends upon degree of keratinization, ranging **from white to pink.** §_Size_ of papules **generally \<10mm in diameter.** §_Histologically_, lesions may have **koilocytes.**

Answer 965

▪ Squamous papilloma ▪ Verruca vulgaris ▪ Condyloma acuminatum ▪ Focal epithelial hyperplasia ▪ Oral florid papillomatosis

Answer 966

SQUAMOUS PAPILLOMA Benign Oral Low Risk HPV Lesion **HPV 6+11** “finger‐like projections - The projections are almost feathery - exophytic lesion

Answer 967

▪ **Benign proliferation of stratified squamous epithelium resulting** ► p*_apillary, verruciform, rugose (ridged or wrinkled) mass_* ▪ **HPV types 6 + 11** – Low risk ▪ **M = F** ▪ **Any age** (more common in 30‐50s) ▪ Any oral mucosal surface (palate most common) ▪ **Soft, painless, usually pedunculated, exophytic lesion w/ numerous finger‐like projections** ▪ **HPV DNA detected in only ~50%** ▪ \*\*should remove from mouth – but WOULD NOT submit for HPV typing

Answer 968

SQUAMOUS PAPILLOMA Benign Oral Low Risk HPV Lesion **HPV 6+11** “finger‐like projections

Answer 969

***Oral Verruca Vulgaris*** HPV 2,4,6 Also “finger‐like projections” remember it's *contagious*

Answer 970

▪ HPV **2**, and others (1,**4,6**,7,11,26,27,29,41,57,65,75‐77) ▪ Benign, HPV‐induced focal hyperplasia of stratified squamous epithelium ▪ **Contagious** – transmitted by direct contact ▪ **Any age** – frequently seen in children ▪ More common **Anterior** \> Posterior part of mouth ▪ **Soft, painless, usually pedunculated, exophytic lesions w/ numerous fingerlike projections** (similar to squamous papilloma) ‐ _How to tell the difference? Under microscope_

Answer 971

**Condyloma Acuminatum** (Venereal Wart) HPV 6,11 – can be cancerous Genital warts “short, blunt, clusters” Characteristic clustering of multiple lesions

Answer 972

(Multifocal) Epithelial Hyperplasia/**Heck's Disease** HPV 13,32 **“Flat‐top papules”**

Answer 973

(Multifocal) Epithelial Hyperplasia/**Heck's Disease** HPV 13,32 **“Flat‐top papules”**

Answer 974

**HPV Types 6, 11** – _condyloma can turn cancerous_ ▪ Virually induced proliferation of stratified squamous epithelium – usually genital or anal mucosa ▪ **Contagious** – transmitted by direct contact ▪ Incubation period: 1‐3mo ▪ Considered **sexually transmitted disease** (if corroborated by history) ▪ **Oral lesions** – usually **anterior part of mouth** ▪ S**essile, pink, well‐demarcated, non‐tender exophytic mass ▪ Short, blunted surface projections ▪ Larger than papilloma or verruca vulgar** ## Footnote **▪ Characteristic clustering of multiple lesions**

Answer 975

**Oral Florid Papillomatosis** Very characteristic appearance - diffused, in multiple locations - papillary **"Multifocal, papillary lesions"** -if we biopsied these or had these removed for aesthetic regions, we’d see that the epithelium have become white, long, taller, and bumpy

Answer 976

-Since this is a sexually transmitted disease, we need to suspect sexcual child abuse and investigate further!

Answer 977

▪ HPV Types **13, 32** and others (1,6,11,16,18,55) ▪ **HPV‐induced localized proliferation of oral squamous epithelium ▪ “Flat‐top papules”** ▪ Endemic in some **Inuit/Alaskan native + Native American** **communities**, **Puerto Rican communities** ▪ _Crowded situations, malnutrition_ ▪ Usually seen in children ▪ May be seen in HIV + individuals ▪ **M = F** ▪ Histology: **focal epithelial acanthos**

Answer 978

IIt's benign HPV disease ▪ HIV infection ‐ Increased prevalence since advent of HAART therapy ‐ Multiple HPV types ▪ Down syndrome Oral Florid Characteristics: ‐ **Diffuse, multiple locations ‐ Papillary ‐ Bumpy and tall**

Answer 979

**§Acanthosis §Koilocytosis §Binucleated***and***multinucleated keratinocytes §Dyskeratosis §Mitosoid figures §Basilar hyperplasia**

Answer 980

HPV is thought to cause **70%** of oropharyngeal cancers in the US That's why we want to know if high risk HPV– better prognosis

Answer 981

_▪ Pathologists order it_ ▪ Only do testing if pathologist sees cancer **No HPV testing on low‐risk HPV lesions (warts)** ▪ No medical indication for **low‐risk HPV testing** b/c ‐ infection **NOT** associated w/ disease progression ‐ no treatment or therapy change indicated when low‐risk HPV is ID’ed ▪ HPV testing using p16 surrogate on **oropharyngeal squamous cell carcinoma** **(SCC)**

Answer 982

‐ Usually appear exophytic and papillary ‐ Excision is warranted ‐ Consider possible recurrence

Answer 983

▪ **Poxvirus** ▪ Presents as: ‐ pink, dome‐shaped, smooth‐surfaced or umbilicated (like belly‐button) papules ‐ with caseous plug involving skin, lips, buccal mucosa, and palate ▪ Florid cases seen in immunocompromised persons ▪ Children, young adults ▪ Histopathology characterized by: ‐ Large intracytoplasmic inclusion bodies – “Henderson‐Paterson bodies” ‐ Kids can have 6‐9mo and will go away

Answer 984

**Oral Molluscum Contagiosum** *multiple pink, dome‐shaped, smooth‐surfaced or umbilicated (like belly‐button) papules ‐ with caseous plug*

Answer 985

‐ Use high power evacuation to prevent transmission ‐ Treatment = controversial ‐ Excision/ablation vs Topical vs Intralesional therapy (or combo) ‐ Consider higher rate of recurrence

Answer 986

**Measles** **\*Characterized by Koplik’s spots** salts/grains

Answer 987

Excision/Ablation ▪ Scalpel ▪ Carbon dioxide laser – be cautious, don’t know what is burned away ▪ Electrosurgery

Answer 988

**_Hand, foot, and mouth disease_** caused by **Coxsackie Virus** affect children contagious The condition is spread by direct contact with saliva or mucus.

Answer 989

**Herpangina** casued by **_Coxsackie Virus_** *red macules and vesciles on the soft palate* a sudden viral illness in children. It causes small blisterlike bumps or sores (ulcers) in the mouth

Answer 990

**Acute lymphonodular pharyngitis** Caused by **Coxsackie Virus** *Affects children* Nodules on the soft palate. -distinctive, raised, micronodular lesions occur primarily in the pharynx and related structures and regressed without ulceration.

Answer 991

▪ Podophyllin resin ▪ Imiquimod (extra‐oral use only) ▪ Cidofovir ▪ Interferon

Answer 992

Rubella caused by Family: Togavirus; Genus: Rubivirus ``` Forchheimer sign (left) Palatal petechiae (right) ``` | (German Measles)

Answer 993

▪ Topical cytotoxic agent which arrests mitosis ▪ Genital warts and other papillomas ▪ Not FDA approved for oral warts ▪ Serious adverse reaction if absorbed systemically ▪ Pregnancy category X

Answer 994

▪ Induces cytokines + chemokines w/ resutlant anti‐virl (HPV) effects Not FDA approved for oral warts

Answer 995

**Newest is Gardsail 9** against many types for both men and women ▪ 2 doses recommended for boys/girls age 11‐12 and 6mo later ▪ Recommended for everyone \<26yo (MAX) ▪ NOT recommended for 26+yo unless risk for new infections (less benefit since most already exposed) ▪ Virus like particles (VLP) of L1 capsid protein present in vaccine Results of Vaccination ▪ Drops in infections w/ HPV types that cause most HPV cancers + genital warts in teen girls, young adult women ▪ Among vaccinated women – cervical precancers dropped by 40%

Answer 996

▪ 80% ppl will be infected in lifetime so better take the vaccine early!

Answer 997

**▪ Paramyxovirus** ▪ Spread through _respiratory droplets_ ▪ **Symptoms**: runny nose, red/watery eyes, cough, fever, rash, desquamation of skin ▪ \***Characterized by Koplik’s spots** ‐ Pathognomonic for measles ‐ Discrete, bluish white punctate mucosal macules ‐ Surrounded by rim of erythema ‐ Represent foci of epithelial necrosis ‐ Often precedes skin manifestations **▪ Most common location for Koplok’s spots:** _Buccal mucosa_ ‐ Lesions may resemble _“grains of salt sprinkled on erythematous background”_

Answer 998

**-Herpangina**‐soft palate, red macules ► fragile vesicles (back of throat) ‐ **Hand, foot, and mouth disease** – oral lesions more in anterior regions (aphthous‐like), hand/foot (vesicles) ‐ **Acute lymphonodular pharyngitis** – nodules on the soft palate ▪ Usually seen in children ▪ Self‐limiting

Answer 999

**▪ Family: Togavirus; Genus: Rubivirus** **▪ Respiratory droplets** **Symptoms:** ‐ Fever, headache, malaise, coryza (runny nose), anorexia, pharyngitis, lymphadenopathy ▪ Rash – **maculopapular w/ desquamation** * *▪ Forchheimer sign** * *▪ Palatal petechiae** ▪ **Congenital rubella syndrome** – pandemics in past ▪ Vaccine: **MMR** – so we barely see this anymore ▪ Diagnosis**: by serology**

Answer 1000

**Candida Species** ● Over 200 species exist ● At least 15 distinct Candida species cause human disease

Answer 1001

**Candida albicans**

Answer 1002

‐ C. albicans ‐ C. glabrata ‐ C. tropicalis ‐ C. parapsilosis ‐ C. krusei

Answer 1003

● **Commensalism**: ‐ “long‐term biological interaction (symbiosis) in which members of one species gain benefits while those of the other species neither benefit nor are harmed” ● \>50% of humans carry candida without harmful effects

Answer 1004

* Becomes an “infection” called **candidiasis** when environment changes and encourages growth * ● Defect in cell‐mediated immune response * ‐ Ranges from mild superficial mucosal infection ►(can be) fatal disseminated disease (usually with people with HIV and transplants)

Answer 1005

● A disrupted balance of the normal mucosal flora ● Impaired barrier functions ● Immunosuppression such as: ‐ Use of broad‐spectrum antibiotic ‐ Leukemia ‐ HIV ‐ Cancer chemotherapy ‐ Diabetes ‐ Xerostomia (what we deal with, candidiasis can persist here)

Answer 1006

Normally it is in the commensal state and once you reach a certain level where the fungal burden has increased, you increase the c‐FOS pathway ‐ This is when the organism forms **hyphae**; once these are formed, you see invasion into the **epithelial** cells.

Answer 1007

**● Commensalism** * **Fungus is tolerated** (threshold not reached) * I**mmune cells are not activated** **● Pathogenicity** * _Fungal burden is increased_ and **hyphae** form * Immune cells are recruited by cytokines, chemokines * Neutrophils are recruited and kill fungus * Dendritic cells present antigen to T‐cells * T‐cells also decrease fungal burden (IL‐22, IL‐17) * Innate and acquired clear fungus to levels below threshold

Answer 1008

1. **Dimorphism** (can be _spore_ and a _hyphae_‐ 2 forms) 2. **Phenotypic switching** (change shape) 3. **Adhesins/Invasins** (aid in attachment) 4. **Molecular mimicry of mammalian integrins** (helps to be avoided by the immune system) 5. **Secretion of hydrolytic enzymes** (aids in invasion) 6. **Phospholipase B contributes to degradation of host tissue** (aids in degradation to gain entry)

Answer 1009

SPORES‐ when they are in this form, they do NOT invade HYPHAE‐ when they begin their invasion

Answer 1010

Crosstalk: Candida **glycans** play an important role in the continuous interchange that regulates the balance between saprophytism and parasitism

Answer 1011

**● Superficial and localized‐more common (mild disease)** ‐ Intertrigo §Paronychia/Onychomycosis ‐ “Diaper Rash” ‐ Vulvovaginitis ‐ Esophageal Candidiasis §Oral Candidiasis (Candidosis) **● Invasive, disseminated and deep infection‐rare (moderate‐severe)** ‐ Affects blood (candidemia‐hospitalized), heart, brain, eyes, bones)

Answer 1012

**Onychomycosis** a type of candidiasis

Answer 1013

**Oral candidiasis** a type of candidiasis

Answer 1014

**Esophageal Candidiasis** a type of candidiasis

Answer 1015

**Vulvovaginitis** a type of candidiasis

Answer 1016

**“Diaper Rash”** a type of candidiasis

Answer 1017

**Intertrigo** a type of candidiasis

Answer 1018

**PSEUDOMEMBRANOUS CANDIDIASIS** *UNCONTROLLED DIABETIC* When you wipe away these plaques, you might see some Erythematous areas that causes some of the symptoms that the patient feels -This is **MILD DISEASE**

Answer 1019

* *Pseudomembranous Candidiasis‐** * Uncontrolled HIV* ● This can be mistaken with materia alba (this is just food) ‐ Should ask patient if they just ate ● This is **MODERATE DISEASE**

Answer 1020

**Pseudomembranous Candidiasis** *Topical Corticosteroid Use* Can be brought about from steroid use **(steroid inhaler example)** ‐ If you don’t rinse your mouth after using steroids, this can happen ■ _A proliferation of hyphae_

Answer 1021

PSEUDOMEMBRANOUS CANDIDIASIS **Severe dry mouth** **This is severe disease** we would want to use **systemic treatments/ intervention**

Answer 1022

**Angular Cheilitis** ● **Erythema**, _fissuring and scaling at angles of mouth_ and _commissures of mouth_ ● ***Loss of vertical dimension*** ● ***Pooling of saliva*** ● _May be mixed bacterial/fungal infection_ ● _Differential diagnosis_ can be **Vit B Deficiency** *a subtype of Erythematous Candidiasis*

Answer 1023

**Denture Stomatitis** ● _Chronic atrophic candidiasis_ ● **Erythema** in _denture bearing areas of maxilla_ ● **Petechiae** may be noted ● Usually, **asymptomatic** ● _Consider denture care/fit/allergy/inadequate curing of acrylic_ ● This can occur if the patient NEVER takes off their denture ● **Inflammatory papillary hyperplasia** is associated with condition ● **Treatment**‐**Nystatin** applied to intaglio surface of denture and wear denture and patient to remove denture at night *a subtype of Erythematous Candidiasis*

Answer 1024

**Median Rhomboid Glossitis** *a subtype of Erythematous Candidiasis* ● “**Central Papillary Atrophy”** ● _Well‐demarcated erythematous zone_ ● **Loss of papillae on midline posterior dorsal tongue** ● Usually, **asymptomatic** ● “**Kissing” palatal lesion** ‐ Because the tongue and the palate are in contact with each other ● Can have **a diamond shape**

Answer 1025

**ATROPHIC CANDIDIASIS** ● Erythematous on any mucosal surface **● “Bald Tongue”** ● Typically, painful ● (Chronic multifocal, looks familiar) ***a subtype of Erythematous Candidiasis***

Answer 1026

**C. albicans** * **Candidal sepsis** means that you have the fungal moving around in your body * **Life‐threatening event** in individual with severely deficient cell * mediated immunity * Most commonly involves urinary tract infection (women/men 4:1) * _Very rare_

Answer 1027

**HYPERPLASTIC CANDIDIASIS**

Answer 1028

● 30‐50% of people carry organism without infection (called candida carriage) ● Rate of carriage increases with age and risk factors ● 70‐80% of oral isolates are Candida albicans

Answer 1029

**Local** * denture wearing * smoking * atopic consitituion * steroid inhalation * hyperkeratosis * imblance of the oral microflora * quality and qunatity of saliva\ **General** * immunosupressive disease * impaired health status * immunosupressive drugs * endocrine disorders * hematinic deficiencies

Answer 1030

● “**Thrush**” ● KEY FEATURE: **Wipeable** _white plaques that resemble curdled milk_ ● Underlying mucosa is **erythematous** ● Asymptomatic usually ● Mild symptoms: burning, dysgeusia ● Seen in patients with: **HIV, broad‐spectrum antibiotics, leukemia, infants**

Answer 1031

**Chronic Mucocutaneous Candidiasis** Severe infection of mucosal surfaces, nails, and skin

Answer 1032

Mucocutaneous Candidiasis APECED Autoimmune Polyendocrinopathy Candidiasis Ectodermal Dystrophy Syndrome Biopsy of the tonuge revealed SCC

Answer 1033

* **Oral fluconazole, 100–200mg daily for 7–14 days** ● For **fluconazole‐refractory disease:** ‐ **Itraconazole suspension 200 mg once daily OR posaconazole** su**spension 400 mg twice daily for 3 days then 400 mg once dail**y, for up to **28 days**, are recommended *_Alternatives for fluconazole‐refractory disease include:_* ‐ **Voriconazole, 200 mg twice daily**, OR **AmB deoxycholate oral suspension, 100 mg/mL 4 times daily**(strong recommendation; moderate‐quality evidence). ‐ **Intravenous echinocandin** (caspofungin: 70‐mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200‐mg loading dose, then 100 mg daily) (weak recommendation; moderate‐quality evidence). § **Intravenous Amphotericin B** deoxycholate, 0.3 mg/kg daily, are other alternatives for refractory disease (weak recommendation; moderate‐quality evidence).

Answer 1034

* **Clotrimazole troches**, 10 mg 5 times daily or * **miconazole mucoadhesive buccal 50 mg tablet** applied to the mucosal surface over the canine fossa once daily for 7–14 days * Alternatives for mild disease include **nystatin suspension (100 000 u/mL) 4–6 mL** swished for \>1min then swallow **4 times daily.**

Answer 1035

● **Bleach‐**1 part bleach to 10 parts water (not for dentures with metallic clasps) ● **Polident** (NYU Carries Polident) ● **Microwave**? ( could be risky, careful not to ruin the denture) CLEANSERS FOR REMOVABLE PROSTHESIS- you have to use this everynight to avoid denture stomoatits **_NYU Carries Polident_** Formulation: **sodium bicarbonate, citric acid, potassium monopersulfate**, sodium carbonate, sodium carbonate peroxide, TAED, sodium benzoate, PEG‐180, sodium lauryl sulfate, VP/VA copolymer, flavor, cellulose gum, FD&C blue 2, blue 1 lake, yellow 5, yellow 5

Answer 1036

● **Clinical Findings:** * Red macules or patches * Can be due to multiple things **● Subtypes:** ‐ **Atrophic Candidiasis** (acute‐feels like mouth has been scalded) ‐ **Median Rhomboid Glossitis** (asymptomatic) ‐ **Denture Stomatitis** (asymptomatic) ■ HAS THE SHAPE OF THE DENTURE ‐ **Chronic multifocal (**asymptomatic) ■ THIS HAS BEEN THERE FOR A LONG TIME

Answer 1037

*a subtype of Erythematous Candidiasis*

Answer 1038

● Histopathology (H&E and special stain‐GMS) ● Culture ● Serology as for histology ● **Epithelioid macrophages containing histoplasma capsulatum** (white arrows) ● Lymphocytes ● Plasma cells

Answer 1039

**Histoplasmosis** ● This can be squamous cell carcinoma, shanker, ulcers ‐ Differentials for non healing ulcerations on the lateral tongue ● The white area is called the *pseudomembrane*

Answer 1040

● **Eastern half of US** which extends _farther north_ ● _Seen in the wild_

Answer 1041

● a Rare and controversial form of candidiasis ● Candidiasis superimposed on pre‐existing leukoplakic lesion ● White plaque which cannot be removed by scraping (NOT WIPEABLE) ● **Increased frequency of epithelial dysplasia** ● MUST **BIOPSY** then diagnose as hyperplastic candidiasis **if you see fungi post biopsy**

Answer 1042

● Group of rare disorders with immunologic pathogenesis ● Clinical: Severe infection of mucosal surfaces, nails and skin ● Oral‐ lesions‐thick white plaques that do not rub off but may see other forms

Answer 1043

‐ **A**: autoimmune ‐ **PE**: polyendocrinopathy ‐ **C**: candidiasis ‐ **E**: ectodermal ‐ **D**: dystrophy **Chronic Mucocutaneous Candidiasis** is also genetic associted with **AIRE** gene

Answer 1044

**Blastomycosis**

Answer 1045

● **Histopathology** (Granulomatous inflammation , Broad based budding , Double refractile cell wall) ● Cytology ● KOH ● Culture from sputum (3‐4 weeks) ● DNA probe (where you actively look for the DNA of the blastomycosis)

Answer 1046

● Increased risk of **squamous cell carcinoma**

Answer 1047

● Clinical signs ● Therapeutic diagnosis ● Cytologic smear: scrape cells and look at them under the microscope and stained with PAS stain ● Periodic Acid Schiff Stain (PAS stain) ● KOH float §Biopsy (esp. hyperplastic candidiasis) ● Culture

Answer 1048

● **Polyene‐Nystatin, Amphotericin B** (not absorbed; used for deep fungal infections) ● **Imidazole‐Clotrimazole, Ketoconazole** (GI absorption) ● **Triazole‐Fluconazole, Itraconazole, Posaconazole, Echinocandins**

Answer 1049

**this is when you keep the fungal infection under control for a long time** Usually **unnecessary in immunocompetent patients** ● For patients who have recurrent infections: ‐ **For HIV‐infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections** (strong recommendation; high‐quality evidence). ‐ **Fluconazole, 100 mg 3 times weekly, is recommended** (strong recommendation; high‐quality evidence). ● **Clotrimazole 10mg troches 1 week out of every month?** (no evidence

Answer 1050

YOU APPLY THE MEDICATION TO THE INTAGLIO PORTION antifungal medication (1) Topical Antifungal Agents ‐ Rx. Clotrimazole cream 1% vs OR ‐ Rx. Nystatin‐Triamcinolone Acetonide ointment or cream (why? To keep the inflammation down) ■ Disp: 15g tube ■ Label: apply to angles of mouth after meals and before bedtime (2) Denture adjustment, reline, remake YOU APPLY THE MEDICATION TO THE INTAGLIO PORTION

Answer 1051

Histoplasmosis

Answer 1052

**● Histoplasma capsulatum** ● **Dimorphic** (yeast at body temperature and mold in soil)

Answer 1053

● Endemic in **fertile river valleys** ‐ Seen in people who spend **a lot of time outside; near Ohio and Mississippi rivers** ● Bird and bat excrement ● Airborne spores enter lungs through inhalation ● Macrophage ingests fungusà**T‐lymphocyte immunity** ● Antibodies develop several weeks later ● **Macrophages may confine fungus** (express disease later)

Answer 1054

● **Acute**‐Supportive (analgesics and antipyretics) ● **Chronic**‐IV lipid preparation of amphotericin B or itraconazole ● **Disseminated**‐Lipid preparation of amphotericin B (2 weeks or more) followed by daily itraconazole for 6‐18 months

Answer 1055

● _Uncommon_ **fungal infection** ● **Blastomyces dermatitidis** ● **Dimorphic**

Answer 1056

● **Most** cases produce **no symptoms or only mild symptoms** ● Acute‐Self‐limited lung infection (similar to influenza; the flu) ● Chronic‐Lung infection similar to tuberculosis ● Disseminated‐Extrapulmonary spread in immunocompromised (spreads from the lungs) **● Tongue, palate, buccal mucosa ● Solitary ulcer with firm rolled borders** ● **Clinically appear indistinguishable from malignancy (squamous cell carcinoma)**

Answer 1057

● Airborne spores enter lungs through inhalation ● **M**\>F

Answer 1058

● **Acute**‐ Resembles pneumonia

Answer 1059

Chronic Resembles **tuberculosis**

Answer 1060

● Skin lesions‐extrapulmonary dissemination from lungs ● Oral lesions‐extrapulmonary dissemination or local inoculation ● Skin lesions ● Granular(rough looking) erythematous plaques which may become verrucous(wart‐like) or ulcerated ● Oral lesions ‐ Erythematous or white ‐ Intact surface or ulceration with rolled borders ‐ Painful ‐ Ddx‐Squamous cell carcinoma

Answer 1061

● Most cases **asymptomatic** ● **Itraconazole** (mild to moderate disease) ● **Systemic amphotericin B** (severe cases) ● There is a connection with people taking TNF‐alpha inhibitors

Answer 1062

A deep fungal infecion causes by: Paracoccidioidomycosis brasiliensis

Answer 1063

● South American blastomycosis

Answer 1064

**nine‐ringed armadillos**

Answer 1065

● More common in **males** ● _Agriculture workers_

Answer 1066

Pulmonary infection

Answer 1067

**Paracoccidio Mycosis** *looks like the three tail in **Naruto** lol*

Answer 1068

**Paracoccidioidomycosis** looks like strawberry gingiva but it is not

Answer 1069

● Histopathology (- Granulomatous inflammation, Epithelioid macrophages and multinucleated giant cells,GMS or PAS, Multiple daughter buds) ● Culture ● KOH

Answer 1070

●affects the Alveolar mucosa, gingiva and palate lesions with “Mulberry‐like” ulceration (little bumps around it) ● Looks like **strawberry gingivitis** (differential diagnosis)

Answer 1071

● **Trimethoprim/ sulfamethoxazole** (mild‐moderate) ● **IV Amphotericin B** (severe disease)

Answer 1072

deep fungal infection that present as Pulmonary infection

Answer 1073

**Valley Fever**

Answer 1074

* Coccidioides immitis * Coccidioides posadasii

Answer 1075

**Coccidioidomycosis**

Answer 1076

● Histopathology ( Round spherules with numerous endospores , Granulomatous inflammation, Suppurative neutrophils infiltrate, Special Stains used: GMS, PAS) ● Culture ● In situ hybridization (ISH) ● Cytology‐ scraping ulcers then stained with GMS ● Serology‐ check for antibodies ● Skin testing (limited value)

Answer 1077

**Dimorphic organism** (spores and hyphae)

Answer 1078

● Oral lesions **ulcerated granulomatous nodules** ● Skin lesions: **papules**(slightly raised), **abscesses**, **verrucous**(patchy), **plaques**, **granulomatous nodules**

Answer 1079

● Most cases are **asymptomatic** ~60% ● **Flulike** ● *Fatigue, cough, chest pain, myalgia, headache* ● May see a **hypersensitivity reaction** (_valley fever)_ ‐ When you are over responding; immune system is over reacting ● **Chronic**‐_mimics tuberculosis_ ● **Disseminated**‐ \<1% of cases

Answer 1080

● Biopsy ● Culture ● Serology Note: Histopathologically they appear as Granulomatous inflammation (epithelioid histiocytes trying to confide the infection) ● Yeast are surrounded by a clear halo (capsule)

Answer 1081

● **Mild symptoms**‐ no treatment usually ● **Amphotericin B** (‐ Immunosuppressed ‐ Severe pulmonary infection ‐ Disseminated disease ‐ Pregnant patients ‐ Life‐threatening situation ) ● **Itraconazole** or **fluconazole** (fewer side effects and complications)

Answer 1082

●Uncommon ● Cryptococcus neoformans ● Incidence increased due to AIDS epidemic in 1990s ● Pulmonary infection ● Meningitis

Answer 1083

pigeon excrement (poo)

Answer 1084

● Pulmonary infection ● Meningitis ( after it spreads from the lungs to the brain. )

Answer 1085

Mucormycosis‐ arrow refers to **ESCHAR**‐ always look for this and extreme-Black and necrotic ulcer ( we can see massive tissues destruction

Answer 1086

Mucormycosis‐ CT Sinus opacificatio ● First thing to do is to find out more about this lesion, how did this patient get this lesion?

Answer 1087

● Non‐septate hyphae with **90degrees branching** ● You see necrosis of tissue in the area because this attacks the blood vessels

Answer 1088

**Lung infection often asymptomatic** ● Flulike illness ● Dissemination *‐ Meninges ‐ Skin ‐ Bone ‐ Prostate ‐ Oral‐papillary/granular erythematous plaques*

Answer 1089

● Mild case: ***Fluconazole or Itraconazole*** ● Cryptococcal meningitis: ***amphotericin B + other antifungals***

Answer 1090

* **Infections** caused by **molds** belonging to the order **Mucorales** * _Grow in natural state on_ **decaying organic materials** (saprobic‐ recycling) * **Spores** may be _liberated into air and inhaled by humans_

Answer 1091

‐ Insulin dependent diabetics ‐ Bone marrow transplant recipients ‐ AIDS ‐ Patients receiving systemic corticosteroids ‐ Neutropenic patients (no white blood cells)

Answer 1092

**Aspergillosis** Histopathology includes: ●Branching septate hyphae ● Acute angle branching **● “Fruiting body**

Answer 1093

● Rhinocerebral form ● Nasal obstruction ● Bloody nasal discharge ● Facial pain ● Facial paralysis ● Facial swelling/cellulitis ● Visual disturbances ● Into cranial vault‐blindness, lethargy, seizures ● Oral swelling/ulceration of the maxillary alveolar process/palate as a result of sinus involvement ● Black and necrotic ulcer (eschar) ● Massive tissue destruction

Answer 1094

***Aspergillosis*** arrow points toward a violaceous‐ purple colour

Answer 1095

● Histopathology ● Culture

Answer 1096

● Surgical debridement (massive tissue destruction) ● High doses of lipid formation of amphotericin B ● Control underlying disease (main one) ● Prosthetic obturation of palatal defects

Answer 1097

* Saprobic (in an environment rich of oxygen) * it caused by Aspergillus flavus and Aspergillus fumigatus

Answer 1098

● Seen in **hospitals** and **construction sights** ●caused by _Aspergillus flavus_ and _Aspergillus fumigatus_ **● Spores** *are* **inhaled**

Answer 1099

**Necrotizing Gingivitis (NG)** o No periodontitis features o SIMILAR APPEARANCE to *_gonorrhea_* ▪ Distinguishing characteristic of NG **– Fetid Odor**

Answer 1100

**Necrotizing Periodontitis (NP)** o Bone loss of the periodontium seen

Answer 1101

● **Noninvasive** ‐ Allergic fungal sinusitis ‐ Aspergilloma (fungus ball, mycetoma [‐oma: like a tumour made of aspergillus]) ● **Invasive** ‐ Localized (possibly after tissue damage in oral cavity) ‐ Disseminated ‐immunocompromised

Answer 1102

● Histopathology ● Culture

Answer 1103

● Aspergilloma‐**debridement** ● Allergic fungal sinusitis‐**debridement and corticosteroid drugs** ● Localized invasive‐**debridement & voriconazole and amphotericin B** ● Disseminated invasive‐**consider poor prognosis even with treatment**

Answer 1104

Caries (streptococcus mutans) ‐ Gingivitis/Periodontitis ‐ Necrotizing Periodontal Diseases ‐ Noma (Cancrum Oris) Impetigo ‐ Erysipelas ‐ Streptococcal Tonsillitis and Pharyngitis Scarlet Fever ‐ Diphtheria ‐ Syphilis ‐ Gonorrhea ‐ Tuberculosis Leprosy Actinomycosis ‐ Cat Scratch Disease ‐ Bacillary Angioma

Answer 1105

Bacterial infection which presents with a spectrum of lesions ‐ Vary depending upon the localization of lesion and predisposing factors

Answer 1106

‐ Includes: **o Necrotizing gingivitis (NG):**rapidly destructive, non-communicable microbial disease of the gingiva **o Necrotizing periodontitis (NP)**:apidly progressing disease process that results in the destruction of the periodontium o **Necrotizing stomatitis (NS):**When the bacterial infection extends further to OTHER parts of the mouth o **NOMA** (extension to skin of face) ▪ Extreme disfigurement due to bacterial infection extending onto the skin of the face

Answer 1107

‐ The term "**acute**" has not been included since 1999 (ANUG=old name) o As the infections are ALWAYS acute ‐ The term "**ulcerative**" removed in 2017 World Workshop proposed classification "Necrotizing Periodontal Disease (NPD)" is term proposed in 2017 World Workshop for NG, NP and NS o There is ALWAYS ulceration as a result of necrosis

Answer 1108

‐ **Ulceration with necrosis of interdental papillae** o Results in a **"punched out" crater‐like appearance of the papilla** **‐ Gray pseudomembrane** o Dead tissue **‐ EXTREMELY Painful** **‐ Fetid odor** _‐ Spontaneous hemorrhage Fever, lymphadenopathy, malaise_

Answer 1109

**Young and middle‐aged adults** Prevalence \<0.1%

Answer 1110

Many related factors (Multifactorial etiology): o Psychological stress o Immunosuppression o Smoking o Local trauma o Poor nutritional status o Poor oral hygiene o Inadequate sleep

Answer 1111

**Necrotizing Periodontal Diseases** o During WW1, soldiers that were fighting in the trenches were under extreme stress o they commonly developed necrotizing periodontal diseases

Answer 1112

**o Treponema spp.** **o Selenomonas spp.** **o Fusobacterium spp.** **o Prevotella intermedia** o \*Also always present in healthy gingiva ▪ so, No, Microbiological testing is NOT used to form a diagnosis

Answer 1113

**o Removal of bacteria (scaling)** **o Chlorhexidine rinse** **o Antibiotics (fever or signs of systemic illness)** ▪ Metronidazole ▪ Penicillin **o Oral hygiene instruction** **o Supportive therapy** ▪ Rest ▪ Fluids ▪ Soft nutritious diet **o Predisposing (Immunosuppressive)factors** ▪ Smoking ▪ HIV?

Answer 1114

**cancrum oris**

Answer 1115

‐ **Rapidly progressive opportunistic infection caused by many bacteria** o More commonly seen in other parts of the world o Seen in the US in immunocompromised patients ▪ HIV ‐ WHO estimates the global yearly incidence = 140,000

Answer 1116

**‐ Polymicrobial etiology** ‐ Normal flora become pathogenic during immunocompromised states ***‐ Key bacteria:*** o **Fusobacterium necrophorum** **o Prevotella intermedium** ‐ Other common bacteria: **o Actinomyces pyogenes** o Bacillus cereus o Bacteroides fragilis o Fusobacterium nucleatum o Prevotella melaninogenica

Answer 1117

‐ Previous necrotizing periodontal disease Poverty ‐ Malnutrition or dehydration ‐ Poor oral hygiene ‐ Poor sanitation ‐ Unsafe drinking water ‐ Proximity to unkempt livestock ‐ Recent illness Malignancy ‐ Immunodeficiency disorder, including AIDS

Answer 1118

**NOMA** This is an aid patient Figure 2: Extension of infection onto the face ‐ Figure 3: Lost bone and gingiva ‐ Figure 4 & 5 Bone destruction

Answer 1119

**NOMA** This is an aid patient Figure 2: Extension of infection onto the face ‐ Figure 3: Lost bone and gingiva ‐ Figure 4 & 5 Bone destruction

Answer 1120

**‐ Polymicrobial etiology** ‐ Normal flora become pathogenic during immunocompromised states ***‐ Key bacteria:*** o **Fusobacterium necrophorum** **o Prevotella intermedium** ‐ Other common bacteria: **o Actinomyces pyogenes** o Bacillus cereus o Bacteroides fragilis o Fusobacterium nucleatum o Prevotella melaninogenica

Answer 1121

NOMA Development of NOMA from day 1 to day 15

Answer 1122

Children Adults with debilitating disease

Answer 1123

**Impetigo** ‐ “Cornflakes glued to Surface" Appearance o Little papules that can form little vesicles around the mouth o Vesicles burst open and dry up around the skin of the mouth ‐ Bilateral

Answer 1124

NOMA Development of NOMA from day 1 to day 15

Answer 1125

Gingiva (NG) ► Adjacent tissue (necrotizing stomatitis) + Non‐ contiguous tissue (trauma) ► Blue black discoloration of skin ‐ Spreads through muscle, bone (osteomyelitis) **‐ Other features:** _o Fetid odor_ ▪ Due to tissue necrosis _o Pain o Fever o Malaise_ o Tachycardia o Increased respiratory rate o Anemia o Leukocytosis o Regional lymphadenopat

Answer 1126

**Impetigo** ‐ “Cornflakes glued to Surface" Appearance o Little papules that can form little vesicles around the mouth o Vesicles burst open and dry up around the skin of the mouth ‐ Bilateral

Answer 1127

**Erysipelas** Superficial skin infection in immunosuppressed adults ‐ Group A beta‐hemolytic streptococci ‐ Painful ‐ Bright‐red, well‐circumscribed, swollen, indurated (firm) ‐ Warm to touch ‐ Systemic manifestations: o High fever o Swollen lymph nodes Diagnosis: Cultures not useful ‐ Treatment: **o Penicillin ‐ Complications without treatment**

Answer 1128

‐ Previous necrotizing periodontal disease Poverty ‐ Malnutrition or dehydration ‐ Poor oral hygiene ‐ Poor sanitation ‐ Unsafe drinking water ‐ Proximity to unkempt livestock ‐ Recent illness Malignancy ‐ Immunodeficiency disorder, including AIDS

Answer 1129

o **Antibiotics** ▪ Penicillin ▪ Metronidazole **o Local wound care** _▪ Conservative debridement_ to avoid iatrogenic tissue damage **o Consider nutrition, hydration and electrolyte imbalances** **o May cause significant morbidity**

Answer 1130

**Erysipelas** Superficial skin infection in immunosuppressed adults ‐ Group A beta‐hemolytic streptococci ‐ Painful ‐ Bright‐red, well‐circumscribed, swollen, indurated (firm) ‐ Warm to touch ‐ Systemic manifestations: o High fever o Swollen lymph nodes Diagnosis: Cultures not useful ‐ Treatment: **o Penicillin ‐ Complications without treatment**

Answer 1131

_Primary Syphilis_ **Chancre** at site of inoculation (3 – 90 days later) ‐ Papule ► Ulceration ‐ Most chancres occur in genital area (4% oral

Answer 1132

**Primary Syphilis** _Chancre_ at site of inoculation (3 – 90 days later) ‐ Papule ► Ulceration ‐ Most chancres occur in genital area (4% oral

Answer 1133

Gingiva (NG) ► Adjacent tissue (necrotizing stomatitis) + Non‐ contiguous tissue (trauma) ► Blue black discoloration of skin ‐ Spreads through muscle, bone (osteomyelitis) **‐ Other features:** _o Fetid odor_ ▪ Due to tissue necrosis _o Pain o Fever o Malaise_ o Tachycardia o Increased respiratory rate o Anemia o Leukocytosis o Regional lymphadenopat

Answer 1134

Secondary Syphilis ‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection ‐ Resolve in 3‐12 weeks **‐ Diffuse maculopapular (flat, raised) rash** o May involve oral cavity ‐ **Mucous patches** **o Most common on tongue and lip** _‐ Condylomata lata_ o **Resembles viral papillomas** ‐ Systemic symptoms

Answer 1135

Secondary Syphilis ( Rash) here we see **muscus patches** (right) and **Condylomata lata** (left) ‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection ‐ Resolve in 3‐12 weeks ‐ Diffuse maculopapular (flat, raised) rash **o May involve oral cavity ‐ Mucous patches** **o Most common on tongue and lip** **‐ Condylomata lata** **o Resembles viral papillomas** ‐ Systemic symptoms

Answer 1136

**Tertiary Syphilis** **Gumma** ‐ **Latent** period for **1 ‐ 30 years** **‐ 30% of patients develop tertiary syphilis** ‐ Serious complications develop: * Vascular system * Central nervous system * Ocular lesions What is "Gumma"? * o Granulomatous inflammation with tissue destruction * o Common on palate and tongue * o Causes a hole in the palate

Answer 1137

‐ Caused by: o Staphylococcus aureus o Streptococcal pyogenes _Damaged skin allows infection to enter_ **Usually affects kids**

Answer 1138

**Primary Syphilis** _Chancre_ at site of inoculation (3 – 90 days later) ‐ Papule ► Ulceration ‐ Most chancres occur in genital area (4% oral

Answer 1139

**Congenital Syphilis** ‐ Hutchinson Incisors (left image) ‐ Mulberry molars (right image) - not part of the triad

Answer 1140

Not specific ‐ Stage 1 and 2 similar o Ulceration o Hyperplasia (Stage 2) o Exocytosis of neutrophils into epithelium Intense Iymphoplasmacytic inflammatory infiltrate in superficial stroma and around deeper vascular channels (blood vessels)

Answer 1141

Stage 3 o Granulomatous inflammation o Ulceration may be present ‐ Special stain "**Warthin Starry"**, highlights _**corkscrew spirochetes** ‐_ **Immunohistochemical stain**

Answer 1142

**o Biopsy with histopathology** **o Dark field examination of a smear of active lesion** o Serologic screening lab tests * ▪ Venereal Disease Research Lab (VDRL), RPR (non‐ specific and not highly sensitive) * ▪ Fluorescent Treponemal Antibody Absorption (FTA‐ ABS), TPHA, TPPA, MHA‐TP (specific and sensitive)

Answer 1143

**Tertiary Syphilis** **Gumma** ‐ **Latent** period for **1 ‐ 30 years** **‐ 30% of patients develop tertiary syphilis** ‐ Serious complications develop: * Vascular system * Central nervous system * Ocular lesions What is "Gumma"? * o Granulomatous inflammation with tissue destruction * o Common on palate and tongue * o Causes a hole in the palate

Answer 1144

**Secondary Syphilis** Mucous Patch

Answer 1145

Secondary Syphilis ( Rash) here we see **muscus patches** (right) and **Condylomata lata** (left) ‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection ‐ Resolve in 3‐12 weeks ‐ Diffuse maculopapular (flat, raised) rash **o May involve oral cavity ‐ Mucous patches** **o Most common on tongue and lip** **‐ Condylomata lata** **o Resembles viral papillomas** ‐ Systemic symptoms

Answer 1146

Stage 3 o Granulomatous inflammation o Ulceration may be present ‐ Special stain "**Warthin Starry"**, highlights _**corkscrew spirochetes** ‐_ **Immunohistochemical stain**

Answer 1147

**o Biopsy with histopathology** **o Dark field examination of a smear of active lesion** o Serologic screening lab tests * ▪ Venereal Disease Research Lab (VDRL), RPR (non‐ specific and not highly sensitive) * ▪ Fluorescent Treponemal Antibody Absorption (FTA‐ ABS), TPHA, TPPA, MHA‐TP (specific and sensitive)

Answer 1148

**Gonorrhea** looks like necrotizing gingivitis (NG) but fetor oris not present

Answer 1149

Not specific ‐ Stage 1 and 2 similar o Ulceration o Hyperplasia (Stage 2) o Exocytosis of neutrophils into epithelium Intense Iymphoplasmacytic inflammatory infiltrate in superficial stroma and around deeper vascular channels (blood vessels)

Answer 1150

**Secondary Syphilis** Mucous Patch

Answer 1151

**Congenital Syphilis** ‐ Hutchinson Incisors (left image) ‐ Mulberry molars (right image) - not part of the triad

Answer 1152

Secondary Syphilis ‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection ‐ Resolve in 3‐12 weeks **‐ Diffuse maculopapular (flat, raised) rash** o May involve oral cavity ‐ **Mucous patches** **o Most common on tongue and lip** _‐ Condylomata lata_ o **Resembles viral papillomas** ‐ Systemic symptoms

Answer 1153

**Gonorrhea** looks like necrotizing gingivitis (NG) but fetor oris not present

Answer 1154

_Primary Syphilis_ **Chancre** at site of inoculation (3 – 90 days later) ‐ Papule ► Ulceration ‐ Most chancres occur in genital area (4% oral

Answer 1155

**o Recurrent Herpes Labialis** ▪ Resemblance to initial impetigo stages when still unilateral **o Perioral Dermatitis** ▪ Triggered by cosmetics and other substances on the skin **o Exfoliative Cheilitis (chapped lips)**

Answer 1156

Diagnosis: o Presumptive from clinical features _‐ Treatment:_ **o Topical mupirocin** **o Systemic antibiotics**

Answer 1157

‐ Tuberculosis

Answer 1158

‐ Tuberculosis

Answer 1159

o **Antibiotics** ▪ Penicillin ▪ Metronidazole **o Local wound care** _▪ Conservative debridement_ to avoid iatrogenic tissue damage **o Consider nutrition, hydration and electrolyte imbalances** **o May cause significant morbidity**

Answer 1160

**o Systemic Lupus Erythematosus (SLE)** ▪ Due to sparing of nasolabial folds ▪ Butterfly rash in SLE resembles erysipelas **o Cellulitis (dental infection induced):** ▪ Tooth infection burrowing through the tissues rather than forming an abscess **o Actinomycosis**

Answer 1161

* Chronic infection * caused by *_spirochete_* **Treponema pallidum**

Answer 1162

Three stages 1. o Primary (**chancre**) 2. o Secondary (**rash**) 3. o Tertiary (**gumma**)

Answer 1163

TB Ulceration (tongue ulceration most common)

Answer 1164

**Miliary TB** compared to miliary seeds

Answer 1165

‐ Tuberculosis

Answer 1166

‐ Tuberculosis

Answer 1167

Diagnosis: o Presumptive from clinical features _‐ Treatment:_ **o Topical mupirocin** **o Systemic antibiotics**

Answer 1168

Three stages 1. o Primary (**chancre**) 2. o Secondary (**rash**) 3. o Tertiary (**gumma**)

Answer 1169

**Miliary TB** compared to miliary seeds

Answer 1170

TB Ulceration (tongue ulceration most common)

Answer 1171

1. **SCC** 2. **Fungal Ulcer** 3. **Trumatic Ulcer**

Answer 1172

* Chronic infection * caused by *_spirochete_* **Treponema pallidum**

Answer 1173

1. **SCC** 2. **Fungal Ulcer** 3. **Trumatic Ulcer**

Answer 1174

**o Systemic Lupus Erythematosus (SLE)** ▪ Due to sparing of nasolabial folds ▪ Butterfly rash in SLE resembles erysipelas **o Cellulitis (dental infection induced):** ▪ Tooth infection burrowing through the tissues rather than forming an abscess **o Actinomycosis**

Answer 1175

Differential Diagnosis: 1. ▪ T‐cell Lymphoma 2. ▪ Cocaine abuse 3. ▪ Granulomatosis 4. ▪ Polyangiitis 5. ▪ Mucor

Answer 1176

‐ Pathognomonic features in **Hutchinson triad**: **o 1. Hutchinson teeth** **o 2. Ocular interstitial keratitis** **o 3. Eighth nerve deafness** ‐ Other Features: o High arched palate o Saddle nose o Frontal bossing **Clinical changes secondary to fetal infection**

Answer 1177

**o Recurrent Herpes Labialis** ▪ Resemblance to initial impetigo stages when still unilateral **o Perioral Dermatitis** ▪ Triggered by cosmetics and other substances on the skin **o Exfoliative Cheilitis (chapped lips)**

Answer 1178

‐ Pathognomonic features in **Hutchinson triad**: **o 1. Hutchinson teeth** **o 2. Ocular interstitial keratitis** **o 3. Eighth nerve deafness** ‐ Other Features: o High arched palate o Saddle nose o Frontal bossing **Clinical changes secondary to fetal infection**

Answer 1179

Differential Diagnosis: 1. ▪ T‐cell Lymphoma 2. ▪ Cocaine abuse 3. ▪ Granulomatosis 4. ▪ Polyangiitis 5. ▪ Mucor

Answer 1180

‐ Caused by: o Staphylococcus aureus o Streptococcal pyogenes _Damaged skin allows infection to enter_ **Usually affects kids**

Answer 1181

_o Single dose of parenteral long_‐ acting **benzathine penicillin G** (primary, secondary, early latent) o **Intramuscular penicillin** weekly for three weeks (late latent and tertiary

Answer 1182

Children Adults with debilitating disease

Answer 1183

‐ a Sexually transmitted (F\>M) caused by **‐ Neisseria gonorrhoeae**

Answer 1184

‐ Genital area usually‐**purulent discharge** ‐ **Systemic bacteremia** (myalgia, arthralgia, polyarthritis, dermatitis) ‐ **Pelvic inflammatory disease** in women (affects pregnancies) ‐ **Gonococcal ophthalmia neonatorum** (infection of infant's eyes)

Answer 1185

‐ Oral lesions ‐ **similar to aphthous** o Very rare _‐ Tonsils edematous and erythematous_ ‐ May **simulate necrotizing gingivitis (NG)** but _fetor oris not present_

Answer 1186

**‐ Gram stain** **‐ Culture of** _endocervical swab_ ‐ **Nucleic acid amplification tests** (NAATs)‐_detect DNA, RNA_

Answer 1187

Many cases of resistance with antibiotics §Cephalosporins *Adults with gonorrhea are treated with antibiotics. Due to emerging strains of drug-resistant Neisseria gonorrhoeae, the Centers for Disease Control and Prevention recommends that uncomplicated gonorrhea be treated with the antibiotic ceftriaxone* — given as an injection — with oral azithromycin (Zithromax)

Answer 1188

**Chlamydia trachomatis**

Answer 1189

**Reactive arthritis (reiter)** _o Can’t see, Can’t Pee, Can’t Climb a Tree_ ▪ _Causes_: **● Conjunctivitis ● Urethritis ● Arthritis** Remember: **Chlamydia trachomatis** coininfect with **Neisseria gonorrhoeae**

Answer 1190

- _Chronic granulomatous infectious disease_ - Caused by **Mycobacterium tuberculosis** §Direct person-to-person spread through **airborne droplets**

Answer 1191

_affects previously unexposed, lungs - They breathe in the organisms that someone is coughing out_ 1st: C_hronic inflammatory reaction_ ► Next, **a fibrocalcific nodule** (_Ghon focus)_ forms at initial site of infection

Answer 1192

Only **5%-10%** infections lead to active disease i

Answer 1193

* Leads to **disseminated TB** (miliary TB) * True, active TB

Answer 1194

_o Single dose of parenteral long_‐ acting **benzathine penicillin G** (primary, secondary, early latent) o **Intramuscular penicillin** weekly for three weeks (late latent and tertiary

Answer 1195

‐ Oral lesions ‐ **similar to aphthous** o Very rare _‐ Tonsils edematous and erythematous_ ‐ May **simulate necrotizing gingivitis (NG)** but _fetor oris not present_

Answer 1196

* Immunosuppressive medications * Diabetes * Old age * Crowded living conditions * AIDS

Answer 1197

* Lymphatics * Skin * Skeletal system * CNS * Kidney * GI tract * **Oral cavity (uncommon)**

Answer 1198

Usually asymptomatic

Answer 1199

o Typically see lung lesions (productive cough) o _Fever, malaise, anorexia, night sweats_

Answer 1200

§Ulceration (tongue ulceration most common) §Mucosal granularity §Diffuse inflammation §Non-healing extraction socket

Answer 1201

* Leads to **disseminated TB** (miliary TB) * True, active TB

Answer 1202

Only **5%-10%** infections lead to active disease i

Answer 1203

Usually asymptomatic

Answer 1204

o Typically see lung lesions (productive cough) o _Fever, malaise, anorexia, night sweats_

Answer 1205

§Ulceration (tongue ulceration most common) §Mucosal granularity §Diffuse inflammation §Non-healing extraction socket

Answer 1206

* Lymphatics * Skin * Skeletal system * CNS * Kidney * GI tract * **Oral cavity (uncommon)**

Answer 1207

* Immunosuppressive medications * Diabetes * Old age * Crowded living conditions * AIDS

Answer 1208

_affects previously unexposed, lungs - They breathe in the organisms that someone is coughing out_ 1st: C_hronic inflammatory reaction_ ► Next, **a fibrocalcific nodule** (_Ghon focus)_ forms at initial site of infection

Answer 1209

- _Chronic granulomatous infectious disease_ - Caused by **Mycobacterium tuberculosis** §Direct person-to-person spread through **airborne droplets**

Answer 1210

**Reactive arthritis (reiter)** _o Can’t see, Can’t Pee, Can’t Climb a Tree_ ▪ _Causes_: **● Conjunctivitis ● Urethritis ● Arthritis**

Answer 1211

**Chlamydia trachomatis**

Answer 1212

Many cases of resistance with antibiotics §Cephalosporins *Adults with gonorrhea are treated with antibiotics. Due to emerging strains of drug-resistant Neisseria gonorrhoeae, the Centers for Disease Control and Prevention recommends that uncomplicated gonorrhea be treated with the antibiotic ceftriaxone* — given as an injection — with oral azithromycin (Zithromax)

Answer 1213

**‐ Gram stain** **‐ Culture of** _endocervical swab_ ‐ **Nucleic acid amplification tests** (NAATs)‐_detect DNA, RNA_

Answer 1214

‐ Genital area usually‐**purulent discharge** ‐ **Systemic bacteremia** (myalgia, arthralgia, polyarthritis, dermatitis) ‐ **Pelvic inflammatory disease** in women (affects pregnancies) ‐ **Gonococcal ophthalmia neonatorum** (infection of infant's eyes)

Answer 1215

‐ a Sexually transmitted (F\>M) caused by **‐ Neisseria gonorrhoeae**

Answer 1216

**Granulomas** * o Epithelioid histiocytes * o Multinucleated giant cells * ▪ \* Langhans giant cells * ● Nuclei along the periphery * o Central caseous necrosis

Answer 1217

Primary Oral TB Oral Primary TB clinical manifestation is very rare TB is directly in the **_epithelial cells._** Person coughs ⇒ organism enters broken skin somewhere in the oral mucosa ⇒directly causing TB in the mouth -this person would NOT have any issues in their lungs **-**primary TB = infection went directly into their mucosa from another person

Answer 1218

**Primary Oral TB** tongue ulceration

Answer 1219

Special stain Epithelioid o Ziehl‐Neelson or AFB o Consider scarcity of organisms **o MAY NOT VISUALIZE ORGANISMS WITH STAIN** **_▪ NEGATIVE RESULT DOES NOT RULE OUT TB INFECTION_**

Answer 1220

**o TB o Deep fungal infections o Traumatic ulcer o SCC o Major Aphthous ulcer**

Answer 1221

o TB‐Test **§Delayed type hypersensitivity (Type 4)** §Checks if developed an immune response to TB §**PPD (purified protein derivative)** *(what they inject under the skin)* §**T cells** are attracted by immune system to the skin site §**Lymphokines** induce _hard raised area with clear margins_ §Need to check 48-72 hours later (measure area)

Answer 1222

**Scrofula**

Answer 1223

**§Multiagent therapy for active infection to prevent mutation and resistance** §8 week course §Pyrazinamide §Isoniazid §Rifampin §Ethambutol **§Followed by 16 week course** §Isoniazid §Rifampin **‐ Chemoprophylaxis** ‐ For positive PPD but no active infection **‐ BCG vaccine** o Not used in US due to controversy regarding effectiveness

Answer 1224

**Mycobacterium bovis** **Infected milk** leads to **scrofula** **RARE** today _as milk is pasteurized_

Answer 1225

o Enlargement of oropharyngeal lymphoid tissues and cervical nodes o Significant caseous necrosis may occur and cause sinus tracts to skin

Answer 1226

**LEPROSY** _Clinical features_ * *§Bone destruction** ( hole in the palate) * *§Nodular** will become **nectortic** and then **destruction** will follow

Answer 1227

**Diagnosis:** o Clinical presentation o Acid fast stain Histopahology No well‐formed granulomas o Lepromatous leprosy diffuse presentation

Answer 1228

**Hansen disease**

Answer 1229

**Mycobacterium leprae**

Answer 1230

**1. Tuberculoid leprosy** ▪ High immune reaction ▪ Oral manifestations are **RARE** **2. Lepromatous leprosy** ▪ Reduced cell‐mediated response

Answer 1231

**EXTREMELY RARE** o 80% of cases occur in: ▪ Brazil ▪ India ▪ Indonesia ▪ Madagascar ▪ Myanmar ▪ Nepal ▪ Nigeria

Answer 1232

**Actinomycoses** it's an external Sinus

Answer 1233

Clinical features: **o Leonine facies** ▪ Appearance of a lion **● Loss of eyebrows** ● **Scarring (fibrosis)** from infection prevents hair growth o **\* Oral Manifestations seen in areas of mouth with lower** temperatures: ▪ Hard/soft palate ▪ Maxillary gingiva ▪ Tongue ## Footnote **Oral‐enlarging papules ► ulcer ► necrosis**

Answer 1234

‐ Colony of actinomycotic organisms surrounded by neutrophils ‐ Grocott‐Gomori methenamine silver stain (GMS) In this histo slide, we see: \* Sulfur Granule o 1. Collection of actinomycoses israelii organisms o 2. MANY neutrophils surround the periphery o BOTH are requirements for a TRUE diagnosis of actinomycoses

Answer 1235

* **Culture** * o \< 50% of cases are positive * ▪ Due to various types of bacteria in the culture * **Presumptive diagnosis from biopsy** **in this histology: GMS stain was used** o Correlates with top H&E histopathology o Filamentous branches are the actinomycotic organisms

Answer 1236

§Rifampicin, clofazimine, dapsone

Answer 1237

‐ Infection caused by filamentous branching gram positive anaerobic bacteria ‐ Normal component of oral flora

Answer 1238

‐ Associated Bacteria: **o Actinomyces israelii o Actinomyces viscosus** ‐ Normal component of oral flora -gram positive anaerobic bacteria

Answer 1239

can be Acute or chronic ‐ **Hard indurated swelling** o Result of injury / trauma ▪ Tooth extraction o Erythematous o Formation of **external sinus** ▪ Drains into the skin **‐ "Sulfur granules"** o May be present in suppuration o Indurated area of fibrosis

Answer 1240

**‐ 55% in cervicofacial area** ‐ Hard indurated swelling o Result of injury / trauma/tooth extraction o Erythematous **‐ Area overlying angle of mandible** o Formation of external sinus ▪ Drains into the skin ‐ Other locations include: **o Abdomen o Pelvis o Lungs**

Answer 1241

‐ **Enters tissue through an area of prior trauma** o Soft tissue injury o Periodontal pocket o Non‐vital tooth o Extraction socket o Infected tonsil ‐ **Direct extension through soft tissue to the surface**

Answer 1242

‐ **Clinical features:** o Presence of a cat ▪ Presumptive diagnosis can be made ‐ Serology (antibody detection) ‐ Histopathology (biopsy) (Stellate suppurative necrosis surrounded by a band of histiocytes and neutrophils) and the use of Immunohistochemistry and Warthin‐Starry silver stain to identify the organism Left o Histiocytes on the periphery o Stellate necrosis in the center ‐ Middle Immunohistochemistry o Antibodies allow for visualization of Bartonella henselae (red little dots) ‐ Right : Warthin‐Starry silver stain o Silver stain allows for visualization of Bartonella henselae (black areas)

Answer 1243

colonies of bacteria (o Actinomyces israelii o Actinomyces viscosus) found in suppuration (pus) which means Suppuration (pus) is dead tissue, bacteria, dead white blood cells, and other products of tissue breakdown.. Sulfur granules found in Actinomycoses yellow in color

Answer 1244

Cat‐Scratch Disease

Answer 1245

o Erysipelas

Answer 1246

‐ Tongue ‐ Tonsillar crypts ‐ Salivary gland involvement ‐ Osteomyelitis ‐ Periapical inflammatory lesions

Answer 1247

* \* **Prolonged high dose antibiotics for _cervicofacial actinomycosis_** * Due to the fibrosis that occurs * Early cases 5‐6 weeks * Deep‐seated infections up to 12 months * **Abscess drainage** * **Sinus tract excision** * **Penicillin**

Answer 1248

‐ Infectious disease which is seen in _lymph nodes_

Answer 1249

‐ Causative organism: o Bartonella henselae ‐ Previous contact with a cat (scratch or saliva)

Answer 1250

‐ 80% in patients **_younger than 21_**

Answer 1251

Cat Scratch Disease

Answer 1252

**‐ o Swellings in the lymph node** **o Unilateral swellings of the neck**

Answer 1253

‐ Initial **scratch** ‐ **Papule** at _inoculation site_ (3‐14 days later) **‐ Papule ► erythematous ► vesicular ►crusted** ‐ **Healing** (1‐3 weeks) ‐ **Lymph node enlargement** with _fever and malaise_

Answer 1254

o **Self‐limiting (resolves within 4 months)** o Local heat o Analgesics o Mechanical removal of suppuration (aspiration) o May use antibiotics for severe cases ▪ Azithromycin

Answer 1255

1. Fibrous Dysplasia 2. Cemento-osseous Oysplasia 3. Ossifying Fibroma

Answer 1256

Type of Bone Dysplasia

Answer 1257

Benign neoplasm

Answer 1258

** Monostotic  Polystotic  McCune‐Albright Syndrome  Craniofacial  Mazabraud Syndrome**

Answer 1259

Monostotic

Answer 1260

a Fibrous dysplasia involving **one bone** o Ex: when only the mandible involved or only the maxillae (Most common type (70%)

Answer 1261

a Fibrous dysplasia involving **more than one bone**

Answer 1262

Polystotic Fibrous dysplasia

Answer 1263

** Jaffe Type  McCune‐Albright Syndrome** (involving multiple bones with endocrine abnormalities)

Answer 1264

-a Fibrous dysplasia limited to **Skull and Facial Bones.**..

Answer 1265

-Fibrous dysplasia with **intramuscular myxomas**

Answer 1266

an aberrations in osteoblastic/osteoclastic function ► normal bone turn over affected ► normal bone structure will be affected!

Answer 1267

Developmental lesion characterized by substitution of normal bone by poorly organized woven bone and fibrous tissue.

Answer 1268

**_GNAS1 gene mutation_** in fibrous dysplasia is a potential diagnostic adjuvant, as it is not found in normal bone tissue (etiolog

Answer 1269

* No gender predilection * commonly seen in pediatric patients and young adults

Answer 1270

* Clinically, it causes **bone expansio**n and **asymmetry** * most typical presentation of monostotic fibrous dysplasia is **a slow growing painless enlargement in the affected area.** * so the patient may notice a slight asymmetry that won’t bother them intially, but over time~months to years ►they’ll notice that this area is slowly and steadily growing more and more ( slow and painless)

Answer 1271

• Most common sites of FD include the **ribs, femur, tibia, maxillae and mandible**  the **Maxillae** is affected more than the mandible

Answer 1272

**FD** Radiographically: you have altered trabecular pattern Clinically: Painless mass slowly growing over time is is typical presntation of Fibrous Dysplasia

Answer 1273

**Fibrous Dysplasia** * ill‐defined radiolucent/radiopaque/mixed radiolucent‐radiopaque entities that blend with normal bone. * The left side is affected. Left body of the mandible and the ramus. * The cortical outlines have been expanded near the inferior border of the mandible.

Answer 1274

**• Maxillae affected more than mandible** • **Ill‐defined borders, blends in with the surrounding bone (not necessary to be corticated)** • **Variable density and orientation of the trabecular pattern** (radiolucent, radiopaque or a combination) * *• Ground‐glass appearance** (common) * *• Peau d'orange (surface of an orange)** (common) * *• Cotton wool appearance** (common) * *• Fingerprint pattern** ( uncommon pattern) • Typically the lesionss in the **maxillae are more homogenous and radiopaque,** whereas they may appear **more heterogenous and mixed in the mandible.** *\*typically you’ll see the ground glass appearnce and Peau d’orange on the maxilla as they are homogenous the cotton wool appearance more commonly found in the mandible since it is heterogenous.*

Answer 1275

**Fingerprint pattern** The arrow indicating the inter‐radicular area of this molar. You can see the trabecular bone has been altered into a fingerprint pattern. This is a case of localized fibrous dysplasia. Very uncommon.

Answer 1276

**Cotton wool appearance** Irregullary shaped and outlined radiopacities blending in with adjacent bone

Answer 1277

**Peau d'orange** surface of an orange – the bone shows a “pitting” appearance.

Answer 1278

**Ground Glass Pattern** it appears granular in nature. (Grainy)

Answer 1279

**Fibrous dysplasia on the right mandible.** Note the superior displacement of the IAN Canal This is not odontogenic ( as they are usually above the canal) **Anything below th canal ►think of it as originiating from the bone itself**

Answer 1280

Fibrous Dysplasia in the left of the maxillae. Always compare both side left and right * We see granular/glass appearance of the bone ( blue arrow) and compare it to the contralateral maxillae. The trabucular pattern has changed signficantly. * Also compare the maxillary sinus space. The left maxillary sinus appears radiopaque. * That is because the maxillae has been enlarged to the point where it is pushing the floor of the maxillary sinus superiorly and reducing the total volume of the sinus. * The purple arrows indcate the displaced floor of the maxillary sinus.

Answer 1281

**FD** Note the normal left maxillary sinus and the obliterated space of the right maxillary sinus ( blue arrows). **A ground glass appearing entity** (humogenous radiopaque lesion) has obliterated the space secondary to expansion of the right maxilla. These findings are consistent and quiet common in **advanced cases Firbous dysplasia**

Answer 1282

* **May have no effect** ( especially if it hasn’t reached the cortical outlines) * **Expansion and thinning of cortical walls** * **Displacement of teeth** ( espically in advanced cases) * One of the few entities that cause **SUPERIOR displacement** of the mandibular canal

Answer 1283

Periapical COD green arrow Simple bone cysts may develop in regions of COD ( periapical or florid type) So look for areas void of trabucular bone and has scalopping of the lesion. Red arrow

Answer 1284

mature Periapical COD Coronal cross section of the posterior mandible in the region of the premolar ~ mixed radiolucent/radiopaque entity, the center is radiopaque and the periphery is radiolucent.

Answer 1285

mature Periapical COD You can have these lesions in endentulous areas as well. So this is is an endeulous area, but if there was a tooth here, this would be in the periapicel region or near it with mixed radiolucent/radiopaque entity  the differential diagonsis of this area could include Periapical COD.

Answer 1286

mature Periapical COD You see a nice radiolucent rim and radiopaque center  so mixed radiolucent/radiopaque entity in the periapical region of tooth #31  most likely diagonsis would be Periapical COD.

Answer 1287

A very mature Periapical COD ( purple arrow) Well‐defined radiopacity in the periapical region. Sometimes you may or may not be able to differentiate a very thin radiolucent line as in this case. you might include ddx of other lesions which might present with radiopacity in the preapical region There are certain tests you can do clinically to differentiate too. or do clinical tests

Answer 1288

Periapical COD Sagital cross section of the anterior Mandible. Mixed radiolucent/radiopaque area (green circle)

Answer 1289

Early & mature Periapical COD **Preapical radiographs of the anterior mandible of the same patient at different times.** Note the differnece in density between the two radiolecency: Note the internal structure of the radiopacity is quite radiolucent ( purple arrow) The Preapical radiographs of the same region taken at a later time shows a more radiopaque internal structure (pink arrow). This reflect the maturing of the COD lesion. The lesion with Pink arrow can be described as well‐defined mixed radiolucent/radiopaque entity. ( because you have radioleucent part and radipaque part)

Answer 1290

Early Periapical COD well defined radiolucency surrounding the apeces of these two central When looking at such cases, it is also imporant to: 1. look at the crowns to look for carious lesions. If there is no restorations or no evidence of caries, it is likely that these lesions are arising from the bone and not secondary to pulpal involvement. 2. It also important to look at the PDL and Lamina dura, typically in COD lesions they should be visisulized and intact ( but because this is a 2D image and this area may superimpose on this region and obsecure the visulizing of the lamina dura and the PDL) **what’s the difference between COD and Inflammatory lesion?** COD won’t have effect on the PDL space itself, because it orginates from the bone! Vitality testing can help us differntiate between inflmmatory lesion and something that happeing inside of the bone.

Answer 1291

Florid COD Axial section of the mandible. * Notice **mixed radiolucent/radiopaque entity on the patient right side**. And **on the left the area is more radiopaque centrally and has a thin radioluceny around it.** * The arrows indicate **well‐defined radiopacities immedietly surrounded by radiolucent rims.** * Note that **the radiolucent rim on the left side is thin when compared to the lesion on the right. This likely means that the lesion on the left is more mature** ( more time has passed for the entity to produce more woven bone).

Answer 1292

Florid COD ## Footnote Two periapical radiographs of the left and right posterior mandible of the same patient.  In this case, note **the areas of radiolucency and radiopacity are rather ill defined but widepsread** to affect most of the teeth. Most of the teeth noted here are restored.  So even if the radiographs suggest a cemento‐osseous process, it is important to keep an eye for these teeth in term of vitality and prevent a periapical infections which would otherwise **secondarily infect** the altered bone of COD.

Answer 1293

Florid COD Multiple regions of COD. Notice the wide areas of scelortic/radiopaque areas on mandible and also on maxillae

Answer 1294

**Generalized FD** * Metabolic bone diseases (hyperparathyroidism) (any disease that incrase trabacular bone density) * Paget's disease **Localized FD** * Osteomyelitis * Osteosarcoma

Answer 1295

* Consultation with an OMFR is advisable. Monitoring of the area is also advised. * Typically treatment is not needed unless there are clinical symptoms or patients present with cosmetic concerns if clinical symptoms are severe * Implants and surgical intervention should be avoided when possible as these areas are void of blood supply

Answer 1296

There are two types: **classic and juvenile form** -**juvenile** seen in younger patients and tend to be more aggressive in nature ( both radiographically and clinically aggressive features) • Young adults and females affected mostly • Bony expansion and displacement of teeth can be seen in many cases ( not suprising since it acts like a neoplasm) • _More commonly_ seen i**n the mandible and in posterior regions**

Answer 1297

**Cemento‐ossifying Fibroma** ## Footnote Note **the internal granular appearance of the trabucular bone** ( black arrows) The purple arrows shows the wall of the expanded buccal/facial and lingual cortical plates caused by the neoplastic entity. This was a confirmed cased of **ossifying fibroma\*** mainly because of two things: **1. siginficant cortical expansion on buccal and lignual side 2. altered trabacular pattern.** **ddx of fibrous dysplasia b**ut you should look for a radiolucent rim if you can and if not, they maybe considered under the same differential diagosnsis. Note that may help you in differentiating : **** The **maxilla** is affected more in **_Fibrous dysplasia_** **** The **mandible** is affected more in **_Ossifying fibroma_**

Answer 1298

Cemento‐ossifying Fibroma Axial section of the mandible * The granular radiopacity immediately surrounded by a radiolucent rim ( purple arrow) * **Also note the extent of the expansion of the buccal and lingual cortical plates, a feature which is common of ossifying fibroma.** * This is more clear radiographically where we see a radiolucent rim surrouding a mixed radiolucent/radiopaque center and there is a siginficant expansion of the buccal and lingual plates. ► **very common in ossifying fibroma**

Answer 1299

Classified as **a benign neoplasm** ## Footnote Because _it acts like a benign neoplasm_. Once you examine it under microscope, you’ll see features _resmeble_ **benign fibrous osseous lesions.** You’ll see: ** Fibrous connective tissues  cementum like material  even altered bone material (woven bone)**

Answer 1300

* **Well‐defined, round or oval lesion** * **Periphery of the lesion is corticated** and may **exhibit a radiolucent periphery** (sometimes referred to as **a soft tissue capsule**) * Internally, the lesion is typically **granular or radiopaque** but may show variations (**mixed radiolucent/radiopaque**) * _Strong tendency to_ **displace teeth and cortical outlines**

Answer 1301

Cropped Panaromic showing **a case of** Cemento‐ossifying Fibroma * Appreciate the **radiolucent rim** indicated by the black arrows. * Also note the internal structure of the trabucular bone and compare it to adjacent unaffected areas. It is **more granular and radopaque** compared to adjacent areas. * Another important feature to appreciate is **the displacement of the anterior teeth** **(diverging roots)** * These features are usually seen **in lesions with benign neoplastic characterstics.**

Answer 1302

Dysplastic lesions that are confined to the jaws.

Answer 1303

**Cleido-Cranial Dysplasia** **Treatment:** For children, facial reconstructive surgery on the bones of the face to reshape the forehead or cheekbones. Spinal fusion procedures to support the spinal column. Lower leg surgery to correct knock knees (knees that bend inward toward the center of the body)

Answer 1304

Gardner's Syndrome Synonym: Familial Multiple Polyposis. Remember this:  GarDENse Bone Island.  GARDEN-FOREST:  F- Familial adenomatous polyposis.  O- Osteomas.  RE- Retinal epithelial hypertropy.  ST- Supernumerary teeth. Treatment: Because people with Gardner’s syndrome have a higher risk of developing colon cancer, treatment is usually aimed at preventing this. Medications such as an NSAID (sulindac) or a COX2 inhibitor (celecoxib) may be used to help limit the growth of colon polyps. Treatment also involves close monitoring of the polyps with lower GI tract endoscopy to make sure they do not become malignant (cancerous). Once 20 or more polyps and/or multiple higher risk polyps are found, removal of the colon is recommended in order to prevent colon cancer. If dental abnormalities are present, treatment may be recommended to correct problems.

Answer 1305

**Osteopetrosis** **Osteomyelitis** is a complication in patients with **osteopetrosis** as can be seen in pan image! Treatment: Bone marrow transplant (to stimulate osteoclast formation).

Answer 1306

Paget's disease stages ## Footnote Early Linear lines: The bone is being resorbed in a very distinct pattern \> linear patterns of trabeculation Middle -MAY see the "cotton wool" appearance (but this is more pronounced in the third stage) -the trabecular pattern may or may not be slightly affected Late - There is MORE bone deposition -the "cotton wool" appearance is very very clear in this stage! Also-hypercementosis and spacing of teeth.

Answer 1307

Paget's Disease Also Known As: **Osteitis Deformans.** **Skeletal disorder involving osteoclasts** **_Treatment:_** Osteoporosis drugs (bisphosphonates) are the most common treatment for Paget's disease of bone

Answer 1308

Cherubism **Treatment**: Usually not needed as the cyst-like lesions fill in with granular bone during adolescence- conservative surgical procedures may follow for cosmetic reasons.

Answer 1309

Idiopathic Osteosclerosis AKA: Dense Bone Island  Not associated with any dysplastic, neoplastic, inflammatory or systemic disorder.  **Common incidental finding.**  Slow growing, typically stops growing by the time of skeletal maturity.  Peak prevalence in the third decade of life. ** No treatment required; monitoring is suggested.**

Answer 1310

**PCOD** ## Footnote **Differentiating factor:** Radiolucent zone surrounding the radiopacities of COD lesions. No such radiolucent areas for idiopathic osteosclerosis.  Important: The root of the tooth #28 appears to be resorbed but is likely not. Look at the root of #29. These teeth are still undergoing development in a young patient.  Left is showing dense bone island.  Right is showing Periapical COD- this is intermediate stage, not fully mature. You should see a radiolucent rim.  Another more obvious radiographic feature: you see radiolucent areas surrounding in both images, the common feature is: because PCOD and dense bone island do not affect the PDL spaces – you should be able to see the PDL spaces.  Sometimes it’s not the case. Look for the PDL, look for radiolucent area surrounding possible central radiopacity, idiopathic osteosclerosis can cause resorption; PCOD hasn’t been associated with root resorption.

Answer 1311

**_Hypercementosis_** ## Footnote  **Differentiating Factor:** A well-defined radiolucent border that is continuous with the PDL of the tooth, in the case of hypercementosis. This means that whatever is happening is within the confines of the tooth-bearing region. In this case, the cementum.  Hypercementosis- Cementum is overraeacting, so there’s enlargement of cementum.  If cementum is larger, it should be pushing the PDL out (black arrow). So the PDL is enlarged meaning you should be able to see a radiolucent rim around the area. And the radiolucent rim should be continuous with the PDL of the remaining root structure.

Answer 1312

**Cementoblastoma** ## Footnote ** Differentiating Factor:** A well-defined radiolucent border that is continuous with the PDL of the tooth, similarly seen in the previous case of hypercementosis. (sometimes it is difficult to differentiate hypercementosis and cementoblastoma, in this case, the beige arrow indicates the resorbed root surface, which normally occurs in benign neoplastic cases, such as cementoblastoma.  Cementoblastoma is more of a heterogenous radiopacity- meaning you may see gaps, like radiolucent voids, in between the areas.  See radiolucent rim.  But more common feature include root resorption because it’s a neoplastic condition. It should act like a neoplasms in which it’s destroying some of the root structure.

Answer 1313

 For condensing osteitis, look for heavily restored or carious teeth. Condensing osteitis typically surrounds the initial rarefying osteitis lesion. The teeth in these cases are non-vital as they represent a condition that is secondary to pulpal necrosis.  Open necrosis, eventual PDL space widening and then once the infection reaches the bone, you have bone loss.  Now you have an overreaction or inflammatory reaction surrounding the initial inflammation.

Answer 1314

**Focal Osteoporotic Marrow Defect** A large marrow defect that may mimic a cystic/neoplastic radiolucency in the jaw. common incidental finding a variation of normal anatomy within trabecular bone.

Answer 1315

Simple Bone Cyst Also known as  1.) Solitary Bone Cyst.  2.) Traumatic Bone Cyst.  3.) Idiopathic Bone Cyst.  4.) Hemorhhagic Bone Cyst. Remember radiographic feature tend to Scalop between teeth  Treatment includes surgical curettage- spontaneous healing has been reported.

Answer 1316

Sometimes, simple bone cysts should be differentiated from odontogenic keratocysts (OKCs)

Answer 1317

brown tumor.

Answer 1318

central giant cell granuloma CGCG

Answer 1319

Aneurysmal Bone Cyst

Answer 1320

1) Periapical COD 2) Focal COD ( not covered) 3) Florid COD Two types of COD instead of three Perapical COD & Florid COD

Answer 1321

cancellous bone is replaced with fibrous tissues & cementum‐like material.

Answer 1322

* Typically **asymptomatic**, almost always captured as incidental finding * Generally, no bony expansion but is not uncommon in the florid type

Answer 1323

• Commonly seen in middle‐aged patients female predilection * more commonly seen in the **Black population** * also frequently seen in **Asian population**

Answer 1324

* Usually **well‐defined borders** in perapical type (may be ill‐defined in florid type). * **Early lesions show radiolucent features** in the periapical area of the teeth _As times progresses, the lesion matures =_t**he entity may become radiopaque.** ‐ as a result there is also **an intermideate mixed phase** **• The lesions mature from the center outwards** ‐ as a result, **_a radiolucent rim surrounding the lesion is commonly noted._** • Typically **the periodontal ligament space** of affected areas are intact but my not be _visualized_ because _they are superimposed over the region._

Answer 1325

Widespread form of periapical COD ## Footnote There is some discreppency on how to consider a lesion a florid COD Some people say the radiopacity entities have to be on at least 2 qudarants And other says if you have the radiopacity entities crossing the midline of the bone. If it is in 3 quadrant ► then you can defentitly say it’s the Florid type, but even if you see itone bone and it has crossed the midline ► you may consider it Florid COD

Answer 1326

Florid COD ## Footnote  **Rarefying osteitis** (radiolucent lesions) ( it would differentiate in the more early stages of the COD ( the radiolucent stage)  **Condensing osteitis** (considered in the differential when the lesion is more mature and more radiopaque lesions)  **Cementoblastoma** ( benign neoplasm of the cementum so we should be able to see certain features that reflect benign neoplastic lesions )  **Dense bone islands** ( a common differential when considering COD)

Answer 1327

* **Paget's disease** ( t generalized areas) * **Osteomyelitis** ( localized area because we have mixed radioluecent/radiopaque areas)

Answer 1328

* Typically, no treatment is required **unless these regions show clinical/radiographic** * Ex if patient complain of some pain of that area –\> we want to follow up that region

Answer 1329

* Surgical excision ( need to send to **biopsy** in order to confirm the diagosnsis of that) * Wider resection with bone maybe necessary in soma larger or more clincally aggressive cases.

Answer 1330

**Leukemia** o Dilantin hyperplasia (drug induced gingival hyperplasia) – fibrotic looking o Has to an addition of thromocytopenia

Answer 1331

**Leukomia** ## Footnote o Leukemic infiltrate – have areas of erthema o Looks like gingival hyperplasia, but in gingivail hyperplasia you don’t have the same amount of redness. Leukemia has significant hyprotophy of gingivial papilla and areas that look like they have ptechia in them. With gingival hyperplasia drug induced they are very fibrotic

Answer 1332

**Leukemia** ## Footnote ▪ Oral findings include **gingival hyperplasia, spontaneous bleeding of gingiva, mucosal ulcerations, candidiasis, recurrent herpetic lesions, etc**. ▪ Leukemic infiltrate in soft tissues (ex. gingiva) produces a diffuse, boggy, nontender swelling that may or may not ulcerate **o most common with myelo‐monocytic types** ▪ May create a tumor‐like mass in soft tissue o granulocytic sarcoma/chloroma (clinically looks green) ▪ mass infiltrate into soft tissue If you see children and notice they have prominent areas of redness or red/purple and know the child has decent oral hygiene, leukemia should be in your differential. Need to be aware of that cause patients need to be treated in a fairly quick fashion.

Answer 1333

**Leukemia** Acute and chronic myelo‐monocytic leukemia are the most likely types of leukemia to exhibit oral manifestations o Generalized gingival hypertrophy May create a tumor‐like mass in soft tissue o granulocytic sarcoma/chloroma (clinically looks green) ▪ mass infiltrate into soft tissue

Answer 1334

**Agranulocytosis** Oral findings: * include multiple ragged ulcerations of the oral mucosa * can mimic recurrent aphthous (but often no erythematous halo) * Gingiva is a common site due -can resemble NUG)

Answer 1335

**Agranulocytosis** **Oral findings:** * include multiple ragged ulcerations of the oral mucosa * o can mimic recurrent aphthous depending on sites involved * (but often no erythematous halo) – more like neutropenic ulcer * **Gingiva is a common site** due to the minor trauma caused bymastication (can resemble NUG)

Answer 1336

**Cyclic Neutropenia** **_o Teeth floating in air_**

Answer 1337

**Cyclic Neutropenia** ▪ Gingiva is most severely affected with periodontal bone loss and tooth mobility

Answer 1338

**Cyclic Neutropenia** ▪ Depending on surface involved, can mimic recurrent aphthous ulcerations o Usually do not see erythematous halo that is so typical of aphthous

Answer 1339

**Cyclic Neutropenia** ## Footnote **▪ Oral ulcerations on any mucosal surface exposed to minor trauma (L,T, BM and oropharynx) last 5‐7 days** ▪ Depending on surface involved, **can mimic recurrent aphthous ulcerations** o Usually do not see erythematous halo that is so typical of aphthous ▪ **Gingiva is most severely affected with periodontal bone loss and tooth mobility**

Answer 1340

**Cyclic Neutropenia** ## Footnote Oral ulcerations on any mucosal surface exposed to minor trauma & can mimic recurrent aphthous ulcerations without the erythematous halo that is so typical of aphthous ▪ Gingiva is most severely affected with periodontal bone loss and tooth mobility

Answer 1341

**Hematoma** because of THROMBOCYTOPENIA or Trauma

Answer 1342

Hematoma because of THROMBOCYTOPENIA orTrauma

Answer 1343

o hematoma because of THROMBOCYTOPENIA orTrauma THROMBOCYTOPENIA:▪ Markedly decreased numbers of circulating blood platelets (severe cases \< 10,000/mm³) Etiology: Can be from: o Decreased production (malignancy, drugs) o Increased destruction (immunologic, drugs) o Sequestration in the spleen (splenomegaly) ▪ Clinically see spontaneous gingival bleeding, petechiae, ecchymosis and hematomas o Clinically see some type of bleeding ▪ Treatment is usually platelet transfusion

Answer 1344

o hematoma because of THROMBOCYTOPENIA or Trauma

Answer 1345

**Aplastic Anemia** ## Footnote ▪ Failure of the **hematopoietic precursor cells to produce adequate numbers of all types of blood components** ▪ Rare, but life threatening ▪ **_Associated with_** **environmental toxins (benzene), certain drugs (antibiotic chloramphenicol), or infection with certain viruses (non‐A, non‐B, non‐C, non‐G hepatitis)** ▪ **Fanconi’s anemia and dyskeratosis congenita patients** _have an increased risk of developing this_ **Oral signs:** are associated with the **thrombocytopenia** and include **spontaneous gingival hemorrhage, mucosal petechiae, purpura,** *and* **ecchymoses** ▪ **Nonspecific oral ulcerations** **(neutropenic ulceration)** may also be seen on any mucosal surface, but especially in areas of trauma (even minor trauma, ex. gingiva) **o Neutropenic = low neutrophils**

Answer 1346

**Sickle Cell Anemia** Can see prominent trabeculae left, looks like steps on a ladder

Answer 1347

**Sickle Cell Anemia** Radiographic findings include: o decreased trabecular pattern in the mandible (due to increased extramedullary hematopoiesis) o laddering of inter‐radicular trabeculae o “hair‐on‐end” appearance of skull films (less prominent than with thalassemia) Can see spontaneous pulpal necrosis in the absence of trauma or caries

Answer 1348

**Beta‐thalassemia** ▪ Two defective genes – **thalassemia major (Cooley’s anemia, Mediterranean fever)** o Disease detected when fetal hemoglobin ceases to be made (~3‐4 months old) o Extramedullary hematopoiesis cause hepatosplenomegaly, bone marrow hyperplasia, and lymphadenopathy o In jaws, painless enlargement of maxilla and mandible (“chipmunk” facies) o Skull films show “hair‐on‐end” appearance o Untreated, patient dies by about one year of age o Treatment is repeated blood transfusions or bone marrow transplant this pt was treated with

Answer 1349

**Macrocytic (megaloblastic) Anemias:** **▪ Folic acid and B12 deficiencies** * _Glossitis_ * Denuded dorsal surface * Burning, stinging pain Seen in older patients and seen in patients with poor nutrition **_Etiology:_** alcoholism, malabsorption, medications (trimethoprim, oral contraceptives, anticonvulsants

Answer 1350

Iron deficiency anemias Microcytic hypochromic ▪ **Atrophic glossitis** – tongue has been a little denuded of papilla ▪ **Angular cheilitis** – white and redness at angle of mouth/ commissure **▪ Plummer‐Vinson Syndrome**: type of iron deficiency anemia o Chronic iron def, dysphagia (esophageal webs), atrophic glossitis. * **Significantly increased risk of esophageal cancer (SCC)** * More commonly seen in European women * Have difficulty swallowing

Answer 1351

**microcytic, hypochromic anemias (iron deficiency):** Pallor ▪ **Anemia**: reduction in O2 carrying capacity ▪ **Diagnosis**: RBC counts, Hg, HCT, red cell indices for dx of type of anemia ▪ Normal upper labial mucosa ▪ Pale lower labial mucosa

Answer 1352

**Aplastic Anemia** * One of the main differences between and neutropenic ulcer and an empthis ulcer? Is the red halo, the mucosa surroundingneutropenic ulcer Is pale and not red. * The center of a neutropenic ulcer has granulation tissue with a little bit of white

Answer 1353

``` supportive care initially, attempts to stimulate bone marrow (androgenic steroids), and bone marrow transplants for severe cases (prognosis is guarded at best) ```

Answer 1354

Multiple Myeloma Elevated M spike in serum ‐ abnormal increase in immunoglobulin (**hyperglobulinemi**a), most commonly IgG ▪ Reversal of normal albumin/globulin ratio

Answer 1355

**Symptoms** * ▪ Initial symptoms include non‐specific symptoms of infection **malaise, sore throat, swelling, fever, chills, etc.** * Oral findings include multiple ragged ulcerations of the oral mucosa, o can mimic recurrent aphthous but no erythematous halo, Gingiva is a common site & can resemble NUG **Treatment** * Remove offending drug, numbers should replenish in 10‐14 days * Agranulocytosis secondary to cancer therapy ‐ meticulous oral hygiene, chlorhexidine rinse (non alcohol type) , etc.

Answer 1356

Non‐Hodgkins Lymphoma (NHL) o Typically presents with painless lymphadenopathy (often unilateral) ▪ up to 40% are extranodal ▪ 5‐10% arise in Waldeyer’s ring ▪ _Inflamatory or reactive enlarged lymph nodes_ tend to be * *soft, tender, and movable** * *▪** _Lymph nodes associated with malignancy_ tend to be * *hard/firm, fixed, and non‐tender**

Answer 1357

Non‐Hodgkins Lymphoma (NHL) o The most common of the lymphoproliferative diseases o Uncontrolled proliferation of B or T cell origin derived from a single cell (or clone) o Typically presents with painless lymphadenopathy (often unilateral) ▪ up to 40% are extranodal ▪ 5‐10% arise in Waldeyer’s ring

Answer 1358

**Non‐Hodgkins Lymphoma (NHL)** ## Footnote o The most common of the lymphoproliferative diseases o Uncontrolled proliferation of B or T cell origin derived from a single cell (or clone) o Typically presents with painless lymphadenopathy (often unilateral) ▪ up to 40% are extranodal ▪ 5‐10% arise in Waldeyer’s ring

Answer 1359

Adult acute myeloid leukemia (AML) is a type of cancer in which the bone marrow makes a large number of abnormal blood cells. We see in these images: o Hemorrhagic ulcer right vestibule o Ulcers are deep and can go down to bone o Ulcers resolved after treatment

Answer 1360

leukomia o Multifocal bony destruction o Widened PDL with leukemic infiltrate ▪ Symmetric widening of PDL space in a patient that doesn’t have that normal vertical bone loss that you associate with periodontal disease. ▪ If see symmetrical bone loss in PDL space think malignancy, neoplastic **● Lymphomas, leukemias, osteocarcoma, chondro scaroma can do this**

Answer 1361

leukomia Cause of infiltrate they has bone loss

Answer 1362

**Leukemia** This is **Chloroma**, inflitrate gets so dense they look green. On buccal or lingual mucosa chloroma are more of a solitary mass, gingival it more diffuses

Answer 1363

**Hodgkins lymphoma**

Answer 1364

**Hodgkin Lymphoma** **o Begins in lymph nodes o 70‐75% cervical/supraclavicular o Painless but unresolving,** **o Night fevers/sweats**

Answer 1365

**Hodgkin Lymphoma** ## Footnote **▪ Cell of origin is unknown** ▪ Often begins as a unifocal disease above diaphragm and then spreads to other sites ▪ Present with painless cervical lymphadenopathy in 60‐80% of cases ▪ **Bimodal ‐ late twenties and after 50 years old** ▪ In North America and Europe, **EBV positivity has been noted in over 50 percent of mixed cellularity cases and 10 to 50 percent of nodular sclerosis cases**

Answer 1366

**T cell Lymphoma** _Less common than B cell lymphomas_ ▪ One variant associated with **palatal perforation** o Old name **midline lethal granuloma**

Answer 1367

**Burkitt’s Lymphoma** Scattered throughout the lymphocytes are macrophages containing nuclear debris (tingible body macrophages) o Creates **a “starry sky”** appearance

Answer 1368

Burkitt’s Lymphoma * **North American type (sporadic)** * Typically older children (mean of 11 years) * Involves abdomen as a mass * uncommon in the jaws * No association with EBV * More localized disease * **HIV type** * Adults * 25% associated with EBV * GI, marrow and CNS **Teeth floating** as shown in the image

Answer 1369

* **Low grade B cell** (disseminated but slow growing) * Small lymphocytic, Mantle cell, Marginal zone * Follicular center (35‐40 % of all B cell lymphomas) * **Moderate** (aggressive) * Diffuse B‐cell, Peripheral T‐cell * **High Grade B cell** (disseminated and rapidly progressive) * Anaplastic large cell, lymphoblastic * Large cell (25‐30 % of all B cell lymphomas) * Burkitt’s * Immunoblastic (increasingly seen in AIDS) * As AIDS patients live longer we see this more * **T cell lymphoma** (less common than B cell, associated with **palatal perforation** [midline lethal granuloma]) (in differntial with deep fungal infections/candidiasis, TB, use of cocaine * Precursor T‐lymphoblastic, T cell chronic lymphocytic, * **Hodgkin’s** (bimodal ‐ late twenties and after 50 years old)

Answer 1370

**Burkitt’s Lymphoma** **African type (endemic**) * More common * Peak incidence 3‐8 years of age * _Twice as common in males_ * **~95% associated with the Epstein‐Barr virus** * North american or non edemic type is not associated * with EBV * ~88% under 3 yrs of age have jaw lesions * Only 25% of those older than 15 do * Typically involves: * MD, MX, (often affects all 4 quadrants) * Mandible or maxilla * Abdomen * grow quickly

Answer 1371

Multiple Myeloma **Pathological fracture**

Answer 1372

Multiple myeloma

Answer 1373

Multiple Myloma ## Footnote **Punched out translucency in crest**

Answer 1374

**Multiple Myeloma** Monoclonal expansion of malignant plasma cell ▪ Most common in 40‐70 year old (mean 63 yo.) ▪ Present with bone pain (\> 70%) and pathologic fractures Punched out radilucency

Answer 1375

**Plasma Cell Disorders** Clock face nucleaus

Answer 1376

**Plasma cell gingivitis** ▪ Allergen causes mass infiltrate into gingival ▪ Benign ▪ Diet log to identify allergen, allergy testing

Answer 1377

**▪ Diet log** to **identify allergen,** allergy testing ▪ Ideally **eliminate offending substance** ▪ **Can manage with topical steroids**

Answer 1378

**Plasma cell gingivitis** ▪ Allergen causes mass infiltrate into gingival ▪ Benign

Answer 1379

**Multiple Myeloma** Deposition of amyloid in soft tissues o Can cause macroglossia if tongue is involved

Answer 1380

**Plasmacytoma** **▪ Unifocal, monoclonal neoplastic ▪ proliferation of plasma cells** **▪ 30% develop into MM over 10 yrs ▪ 50% disseminate w/in 2‐3 yrs ▪ Central Bone lesion o Unilocular radiolucency o Swelling or bone pain o Non‐tender soft tissue mass** **▪ 90% occur in Head and neck**

Answer 1381

Multiple Myeloma

Answer 1382

* **Cyclic** **neutropenia** * **aggressive periodontitist** * **pamiona fav** * **burkitts lymphoma** * **langerhan cell histocytosis** **o All these things can occur in children and lead bone destructions and look like teeth are floating**

Answer 1383

* **Chemotherapy** with or without RT * **Bone marrow transplant,** interferon, antibodies made * against tumor cells, thalidomide, bisphosphonates, * corticosteroids, melphalan, etc. * Even with treatment, most patients do not survive more than * 18‐24 months * older patients – better prognosis * younger patients – more aggressive and worse prognosis * IV bisphosphonate therapy puts patients at increase risk for MRONJ

Answer 1384

**microcytic, hypochromic anemias (iron deficiency):** Pallor ▪ **Anemia**: reduction in O2 carrying capacity ▪ **Diagnosis**: RBC counts, Hg, HCT, red cell indices for dx of type of anemia ▪ Normal upper labial mucosa ▪ Pale lower labial mucosa

Answer 1385

fungal (candidiasis) --\> mucosal smear/ Empirically can give antifungals (to figure out if it is candidiasis can do a smear or give antifungal) If not candidiasis order cbc ▪ Order CBC with diff ▪ Order blood levels on Fe, Folate, B12, zinc ▪ Rule out : diabetic neuropathy If not candidiasis and blood work didn’t show anything abnormal patient has **burning mouth syndrome** ▪ **TIBC tests** to see if theres too much or too little FE in the blood, measures the bloods capacity to bind fe with transferrin ▪ **B12 def can be from pernicious anemia** ( **Schilling test for Pernicious Anemia**) lack intrinsic factor to allow proper absorption, malnutrition or malabsorption from GI conditions can lead to this as well.

Answer 1386

**Pernicious – “highly injurious or deadly”** ▪ Lack of intrinsic factor protein in stomach decreases absorption of vitamin B12 **Etiology** is usually the body making antibodies against parietal cells which make intrinsic factor o Autoimmune disease effecting parietal cells leads to decreased intrinsic factor ▪ More common in **elderly** ▪ More common in patients of **Northern European and African decent** _This anemia can lead to death_

Answer 1387

▪ Partial thromboplastin time (PTT), prothrombin time (PT), bleeding time (BT) and platelet counts, as well as consultation with physician, should be done prior to any dental treatment ▪ (PT is like INR, Normal INR between 0.8 and 1.2) ▪ Clotting factor replacement therapy (synthetic) given as indicated ▪ Avoid aspirin

Answer 1388

Beta‐thalassemia ▪ Two defective genes – thalassemia major (Cooley’s anemia, Mediterranean fever) Hyperplasia of maxilla, body is trying to make more rbc so bone marrow enlarges to support space of those red blood cells but rbc are abnormal so spleen keeps destroying them

Answer 1389

* Sickle cell trait ‐ one allele is affected, only 40‐50% of hemoglobin will be abnormal, no significant clinical manifestations * **Sickle cell disease** ‐ both alleles affected, close to 100% of hemoglobin is abnormal**, significant clinical problems** ▪ **Abnormal gene** confers **resistance to malaria,** therefore**, sickle cell trait is seen most frequently in populations from areas endemic for malaria (Africa, the Mediterranean, and Asia)**

Answer 1390

**▪ Increase in the number of circulating red blood cells**

Answer 1391

* *of MI or CVA (cerebral vascular accident or stroke) **

Answer 1392

**▪ Types** * **Primary polycythemia:** polycythemia vera * **Secondary polycythemia:** response to low O2 environment such as sleep apnea, living in high elevations, smoking * **Relative polycythemia** * Dehydration, diuretics, vomiting

Answer 1393

**Secondary Polycythemia** Oral manifestation ▪ Oral mucosa appears deep red ▪ Glossitis ▪ Gingiva appears edematous and bleeds easily ▪ Consequent “crowding out” of WBCs and platelets may result in other manifestations

Answer 1394

▪ **Failure** of the **hematopoietic precursor cells to produce adequate numbers of all types of blood components** ▪ Rare, but life threatening ▪ **_Associated with_** **environmental toxins (benzene), certain drugs (antibiotic chloramphenicol), or infection with certain viruses (non‐A, non‐B, non‐C, non‐G hepatitis)** ▪ **Fanconi’s anemia and dyskeratosis congenita patients** _have an increased risk of developing this_

Answer 1395

**o Hemophilia A** ▪ **A patient with only 25% of normal clotting factor VIII levels may function normally, but less than 5% will likely manifest as bruising and bleeding problems** ▪ Deep hemorrhage in joints is a major complication resulting in **arthritis, ankylosis and deformity** **▪ Oral findings include bleeding** (often uncontrolled) upon scaling and root planing, tooth extractions and any oral lacerations **▪ Pesudotumor of hemophilia** o Tissue hemorrhage can result in a submucosal tumor‐like mass **o Bone hemorrhage can result in intraosseous radiolucency**

Answer 1396

Markedly decreased numbers of circulating blood platelets (severe cases \< 10,000/mm³) Etiology: Can be from: o Decreased production (malignancy, drugs) o Increased destruction (immunologic, drugs) o Sequestration in the spleen (splenomegaly)

Answer 1397

▪ Treatment is usually **platelet transfusion**

Answer 1398

▪ Clinically see spontaneous gingival bleeding, petechiae, ecchymosis and hematomas o Clinically see some type of bleeding

Answer 1399

**Agranulocytosis** ## Footnote Decrease in the number of cells from the granular cell lineage (neutrophils, eosinophils, basophils, etc.) o Decreased production or increased destruction ▪ Some cases are idiopathic, most are drug induced ▪ Anticancer chemotherapeutics ‐ inhibit mitotic division and maturation of hematopoietic stem cells. ▪ In rare cases, agranulocytosis is a congenital syndrome. ▪ Increase risk of **infections**

Answer 1400

* Probably caused by **a combination of environmental and genetic factors** * Some leukemias have specific genetic alterations (ex. **CML –** * **Philadelphia chromosome)** * t(9;22)(q34;q11) fusion gene BCR‐ABL1) * **Translocation of 9 and 22 and fusion gene BCRABL1** * **Environmental factors include**: * ionizing radiation * pesticides * benzene * viruses (ex. HTLV‐1)

Answer 1401

**▪ Represents several types of malignancies derived from hematopoietic stem cells** **▪ ~ 2.5% of all cancers in US**e

Answer 1402

**Divided into acute and chronic, myeloid and lymphoid** o Acute myeloid, chronic myeloid, acute lymphoid, and chronic lymphoid **▪ Acute leukemia** o Typical course under 6 mos o Untreated, runs an aggressive course often causing death **▪ Chronic leukemia** o 2‐6 or more years o More indolent course, although, they too often result in death **▪ Leukemia, like lymphoma, can cause bone destruction and the radiographic appearance of “teeth floating in air” in children**

Answer 1403

``` **▪ Acute myeloid leukemia** o Adult (and children) ``` **▪ Chronic myeloid leukemia** o Peak 3rd ‐ 5th decade

Answer 1404

Acute lymphoblastic leukemia (ALL) Success in treatment of a previously fatal disease Children age 1‐10 years have higher success with treatments than teenager do (10‐20yrs) o And infants (under 1yr) do the worst Chemotherapy that are given for curing ALL actaully causes problems when they are older.

Answer 1405

▪ related to crowding out of normal hematopoietic stem cells in the bone marrow o ↓ in normal WBC, RBC, and platelets ▪ See **fatigue, bleeding, bruising, fevers and infections, etc.**

Answer 1406

**Chronic lymphocytic leukemia** o Elderly o Most common type o Considered incurable at this time o unchecked proliferation of B‐cells o no good treatment

Answer 1407

* **Treatment** depends on specific type of leukemia, but includes multi‐agent chemotherapy (often an initial high dose induction and then a lower maintenance dose) * And for lymphoma * **Bone marrow transplant** has been used with limited success

Answer 1408

**▪ Usually a 21 day cycle** **o Dx –** when count falls below 500/ul for 4‐5 days every 21 days **▪ Patients experience recurrent fever, mallaise, anorexia, cervical lymphadenopathy, oral ulcerations, etc.** ▪ Treatment can be just supportive in mild cases, granulocyte colony‐stimulating factor for more severe cases

Answer 1409

▪ **Bones** most commonly involved include **ribs, vertebrae and skull** **o 70‐90% will have jaw involvement at some point** ▪ **Anemia, thrombocytopenia and neutropenia** due to crowding out of normal cells within bone marrow by proliferating malignant cells ▪ **50‐60% have Bence‐Jones proteins in urine** (light chains, usually kappa) **o Due increased plasma cells ⇒ plasma cells make antibodies ⇒ antibodies/proteins gets excreted** **Solitary plasmacytoma can be the first sign of multiple myeloma** ▪ Radiographically, see **punched out radiolucencies** (no sclerotic margin) often with an irregular outline

Answer 1410

▪ Stage I and II – localized disease curable with RT ▪ Stage III and IV – more widespread and treated with chemo and RT, worse prognosis ▪ Stage determined by sites involved o Above diaphragm – stage 1 and 2 o Above and Below diaphragm – stage 3 and 4 having it above diaphragm is bette than having it below so stage 1 and 2 are better than stage 3 and 4

Answer 1411

* Midline lethal granuloma (T cell Lymphoma) * deep fungal * malignancy * TB * tertiary syphilis gumma, * cocaine abuse (necrotizing sialometaplasia‐ soft * tissue)

Answer 1412

▪ Tx: **radiation**, better prognosis than MM ▪ Solitary better prognosis than disseminated MM

Answer 1413

* Immune cell tumors primarily involving bone marrow and peripheral blood are classified as leukemias * while those of lymph nodes are classified as lymphomas, * however there is often overlap of these entities

Answer 1414

**– environmental**

Answer 1415

**o Folic Acid def o Vit B12 def (pernicious anemia)**

Answer 1416

* *menstruation, pregnancy, malabsorption diseases (eg. Celiac)**

Answer 1417

**– environmental, things like bensin**

Answer 1418

**Genetic**

Answer 1419

**inflammatory conditions, malignancy – organ disease**

Answer 1420

**low levels of erythropoietin – organ disease**

Answer 1421

* 1mg IM injections weekly for 1‐2 months * Monitored for lifetime

Answer 1422

o 1mg PO, 5mg in malabsorptive disease o Pregnant women given folic acid to decrease spina bifida o Can be given IM injections if have malabsorption

Answer 1423

▪ Ferrous sulfate 325 mg TID between meals o can cause Constipation ▪ add on fiber to diet, green leafy vegetables o IV doses for absorptive problems ▪ 125mg in 100ml saline infused over 1 hour

Answer 1424

▪ A group of disorders of hemoglobin synthesis characterized by decreased synthesis of either the alpha‐globin or beta‐globin chains of the hemoglobin molecule Patients get a microcytic, hypochromic anemia ▪ People with the abnormal gene have a resistance to malaria ▪ People who have the trait rather than the disease are more likely to live and not die from malaria and spread that gene to their children ▪ Severity depends on the specific genetic alteration and whether it is homozygous (severe) or heterozygous (no clinical sign to mild manifestations)

Answer 1425

When there are **Four defective genes – Hb Bart’s hydrops fetalis** o Lethal in utero or within a few hours of birth o Not compatible with life **▪ Estimated that 5% of world population carries a variant of Alpha‐thalassemia (over 100 genetic forms)** ▪ One defective gene – o no disease detected ▪ Two defective genes – **alpha‐thalassemia trait** o Mild degree of anemia (usually not clinically significant) ▪ Three defective genes – Hb (hemoglobin) H disease **o Hemolytic anemia and splenomegaly**

Answer 1426

Areas with a lot of malaria

Answer 1427

▪ Genetic disorder of hemoglobin synthesis (one of the hemoglobinopathies) **▪ Autosomal recessive pattern** ▪ **Mutation in DNA of *thymine* for adenine causes alteration of codon resulting in the substitution of the amino acid valine for glutamic acid in the beta‐globin chain of hemoglobin** ▪ This transformed hemoglobin is prone to molecular aggregation and polymerization to form a rigid and curved shape (sickle shape)

Answer 1428

* ▪ Transcranial Doppler scan used to evaluate blood flow in brain ▪ **Hydroxyurea** may be used as a therapy o Induces Hb F formation (doesn’t sickle) o But can be carcinogenic and teratogenic

Answer 1429

* sickling of the RBCs becomes severe * precipitated by such things as **hypoxia, infection, hypothermia, or dehydration** * Symptoms include **pain (**which may be severe) due to ischemia and infarction of affected tissues ▪ Long bones, lungs and abdomen are common sites of occurrence for “crises” ▪ Episodes last from 3‐10 days, some patients have monthly crises, some may go a year or more between ▪ May need **pre‐medication prior to dental treatment** * **infections** are the most common cause of death in sickle cell patients (in the US) ▪ Patients also have impaired kidney function and CNS involvement (strokes in 5‐8%, often prior to age of 10)

Answer 1430

Bleeding disorders associated with a genetic deficiency of any one of the clotting factors **o Hemophilia A (classic type, most common type )** ▪ Factor VIII deficiency ▪ X‐linked recessive ▪ Abnormal PTT **o Hemophilia B (Christmas disease)** ▪ Factor IX deficiency, ▪ X‐linked recessive, Abnormal PTT **o Von Willebrand’s disease** ▪ Abnormal von Willebrand’s factor, abnormal platelets ▪ Autosomal dominant ▪ Abnormal BT, abnormal PTT

Answer 1431

**Cyclic Neutropenia** ## Footnote ▪ A rare idiopathic disorder characterized by regular periodic reductions in the neutrophil population **_Etiology:_** Underlying cause is a defect in hematopoietic stem cells in the marrow _▪ Symptoms_ usually _begin in childhood_ ▪ Most symptoms when neutrophil count is at its lowest point (nadir), usually lasts 3‐6 days (even when neutrophil counts are at their highest, it’s often lower than normal) **▪ Patients have repeated problems with infections** Oral ulcerations on any mucosal surface exposed to minor trauma & can mimic recurrent aphthous ulcerations without the erythematous halo that is so typical of aphthous ▪ Gingiva is most severely affected with periodontal bone loss and tooth mobility

Answer 1432

**Mucositis** Thickening of the mucous of the sinus - normally we don’t see mucosa because it is very thin membrane 10 to 15 times thicker. Most common incidental findings that we can see on radiographs

Answer 1433

**Sinusitis** Sinus mucosa becomes inflamed and thickened from infection or allergen, which may lead to ciliary dysfunction, retention of sinus secretions and blockage of sinus drainage ● 10% of maxillary sinusitis are related to dental infections

Answer 1434

**Sinusitis** In this cone beam CT scan, we can see opacification of the sinus + sometimes we see gaseous bubbles. It is fluid that is forming inside the sinus.

Answer 1435

**Sinusitis** Sinusitis can be secondary to oral antral communication (communication between maxillary sinus and oral cavity) this can happen due to extraction

Answer 1436

``` Antral Pseudocyst (Retention Pseudocyst) ``` Localized, submucosal accumulation of fluid forming a sessile, domeshaped swelling along a sinus border ● Common incidental radiographic finding on panoramic ● Well-defined, non-corticated and dome shape radiopacity mostly along the floor of maxillary sinus

Answer 1437

``` Antral Pseudocyst (Retention Pseudocyst) ```

Answer 1438

``` Antral Pseudocyst (Retention Pseudocyst) ```

Answer 1439

**Antrolith** ## Footnote Deposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous (due to blood, pus or mucous) nidus ● Pediatric and adult population ‐ **Small antroliths** – incidental radiographic finding ‐ **Large antroliths** – sinus obstruction, sinusitis, nasal discharge, pain ● Mostly adjacent to the floor of the maxillary sinus ● We see combination of radiopacity and radiolucency due to layers of calcification.

Answer 1440

One of the ways to differentiate antral pseudocyst from radicular cyst is by the presence of cortication. ‐ Reticulosis is a cystic lesion that happens around the apex of the nonvital tooth. ‐ They have a round and domed shaped appearance too, but they are from a different origin 􀀀 happening inside the alveolar processes

Answer 1441

**Antrolith** ## Footnote Deposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous (due to blood, pus or mucous) nidus We see a presence of radiopacity which is antrolith inside the maxillary sinus

Answer 1442

**Foreign Body in Maxillary Sinus**

Answer 1443

Foreign Body in Maxillary Sinus

Answer 1444

**Periostitis** ## Footnote **•**Lamellar, periosteal reaction **from periapical inflammatory disease** •**Exudate** from infected tooth diffuses through the cortical bone, (elevation of periosteum) lifts and stimulates the periosteal lining to produce layer(s) of new bone **•Floor of maxillary sinus** •Inferior, buccal, lingual mandibular cortices

Answer 1445

**Homogeneous leukoplakia** ○ Thickened leathery, White plaque ○ Well-demarcated, Deepened fissures ○ Non-wipeable white patch

Answer 1446

Homogeneous leukoplakia. *○ Non-wipeable white patch*

Answer 1447

**homogenous leukoplakia** Just white color

Answer 1448

**Non-homogenous leukoplakia** Nodular leukoplakia ~ Largely white Verrucous leukoplakia ~ Largely white Erythroleukoplakia ~ Red and white Speckled and verrucous leukoplakia have a greater risk for malignant transformation than the homogeneous form

Answer 1449

**Speckled leukoplakia.** **Non-homogenous leukoplakia**

Answer 1450

**Hairy Leukoplakia** corrugated white lesion on the lateral tongue. **• It only occurs on the lateral tongue**

Answer 1451

**Hairy Leukoplakia**

Answer 1452

**Proliferative Verrucous Leukoplakia** Patient with proliferative verrucous leukoplakia but manifesting more as an erythroplakia in multiple sites than a leukoplakia **Proliferative verrucous leukoplakia has very high risk (49.5% in malignant transformation)** almost 10% risk for malignant transformation every year

Answer 1453

**Proliferative Verrucous Leukoplakia** **Location** ○ Gingiva (Frequent) ○ Buccal Mucosa ○ Palatal Mucosa

Answer 1454

**Proliferative Verrucous Leukoplakia** Multifocal

Answer 1455

**Oral lichen planus** White lacy appearance, with a network reticular appearance (Wickham’s striae) sometimes punctate or plaque‐like lesions predominate o **Wickham’s striae**→ very characteris► white wispy changes

Answer 1456

**Oral lichen planus** on the buccal mucosa (most common site reticular form.

Answer 1457

Oral lichen planus slightly more **red** as you move to the left of the picture ● The white lines have small sunburst effect at the periphery ○ Very very characteristic of lichen planus ○ Will never see this in a leukoplakia

Answer 1458

**Oral lichen planus** Lichen planus of the dorsum of the tongue this is a hypertrophic form.

Answer 1459

**Etiology** The exact etiology remains unknown. Tobacco, alcohol, chronic local friction, and Candida albicans are important predisposing factors. Human papilloma virus (HPV) may also be involved in the pathogenesis of oral leukoplakia.

Answer 1460

* Biopsy to rule out malignancy * Elimination or discontinuation of predisposing factors, * systemic retinoid compounds. * Smoking cessation (leukoplakias often disappear or become smaller within first year of smoking cessation) * Complete removal with surgical excision, electrocautery, cryosurgery, or laser ablation

Answer 1461

**Lichenoid Reactions** **Contact Lesions** a sensitivity in contact with a **dental amalgam** ▪ When you replace these amalgams, the lichenoid reaction will typically disappear

Answer 1462

**Oral Lichenoid** **Contact lesion** chenoid reaction to dental amalgam and cold: white and erythematous lesions on the buccal mucosa.

Answer 1463

Oral Lichenoid Drug Reaction

Answer 1464

Oral Lichenoid Drug Reaction

Answer 1465

* Lichenoid reactions may develop after exposure to a medication for periods of \> 1 year * May develop very slowly after the problem is initiated so it can be very challenging to connect the dots **Many different medications that can lead to lichenoid reactions** * Beta blockers, ACE inhibitors, Rituxumab etc… * A number of new targeted agents “mabs” and “nibs” can cause lichenoid reactions * In cancer centers, this has become quite a problem because they are taking disease‐modifying drugs

Answer 1466

**Nicotinic Stomatitis** also known as Smoker’s keratosis smoker’s palate * the palatal mucosa becomes diffusely gray or white; numerous slightly elevated papules are noted, usually with punctate red centers

Answer 1467

**Nicotinic Stomatitis** These papules represent _inflamed minor salivary glands_ and their ductal orifices.

Answer 1468

Nicotine Stomatitis.

Answer 1469

Epstein–Barr virus seems to play an important role in the pathogenesis.

Answer 1470

* Not required * however, in some cases aciclovir or valaciclovir * can be used with success. * Topical retinoids or podophyllum resin for temporary remission

Answer 1471

**Pseudomembranous candidiasis** on the palate. usually caused by Candida albicans Predisposing factors are local (poor oral hygiene, xerostomia, mucosal damage, dentures, antibiotic mouthwashes)

Answer 1472

Geographic tongue/ areata migrans Multiple, well-demarcated zones of erythema (due to filiform atrophy) surrounded by slightly elevated, yellow-white, serpentine/ scalloped border annular - serpiginous - atrophic - Fissured

Answer 1473

Geographic tongue/ areata migrans

Answer 1474

Geographic tongue/ areata migrans

Answer 1475

Geographic tongue/ areata migrans

Answer 1476

Geographic tongue, localized lesion.

Answer 1477

**Fordyce’s granules** on the buccal mucosa. a normal anatomical variation. ectopic sebaceous glands of the oral mucosa.

Answer 1478

Leukoedema of the buccal mucosa. Laskaris,

Answer 1479

White Sponge Nevus Diffuse, thickened white plaques of the buccal mucosa

Answer 1480

White Sponge Nevus | (Canon disease)

Answer 1481

complete removal: excision, electrocautery, cryosurgery, or laber ablation ## Footnote *Lesions rarely regress despite therapy*

Answer 1482

**Verrucous Carcinoma** Early verrucous carcinoma of the buccal mucosa.

Answer 1483

**Verrucous Carcinoma** Large, exophytic, papillary mass of the maxillary alveolar ridge.

Answer 1484

**Verrucous Carcinoma** Large, exophytic, papillary mass of the maxillary alveolar ridge.

Answer 1485

Verrucous Carcinoma Extensive papillary, white lesion of the maxillary vestibule

Answer 1486

Traumatic Erythema /Traumatic Hematoma on the lower lip.

Answer 1487

Geographic tongue: well-demarcated red patch on the tongue.

Answer 1488

Median rhomboid glossitis. a Chronic hyperplastic, erythematous candidiasis

Answer 1489

Denture stomatitis.

Answer 1490

Although the cause is not well known, T cell-mediated autoimmune phenomena are involved in the pathogenesis of lichen planus.

Answer 1491

**Erythroplakia** of the buccal mucosa Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 1492

Erythroplakia of the buccal mucosa.

Answer 1493

**Erythroplakia** of the lateral margin of the tongue. Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 1494

Erythroplakia Firey red Well-demarcated patch or plaque with soft velvety texture transformed into SCC

Answer 1495

* Incisional biopsy on non-keratinized, non-ulcerated mucosa ○ Asymptomatic → no tx ○ Symptomatic → 0.5mg/ml Dexamethasone Elixir.

Answer 1496

Erythroplakia. Well-circumscribed red patch on the posterior lateral hard and soft palate

Answer 1497

Erythroplakia. Erythematous macule on the right floor of the mouth. Biopsy-- Turned out to be early invasive squamous cell carcinoma.

Answer 1498

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Smokeless Tobacco–related Gingival Recession. Extensive recession of the anterior mandibular facial gingiv

Answer 1499

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Severe

Answer 1500

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Mild. A soft, fissured, gray-white lesion of the lower labial mucosa located in the area of chronic snuff placement.

Answer 1501

**Pemphigus Vulgaris.** . Multiple erosions affecting the marginal gingiva.

Answer 1502

**Pemphigus Vulgaris.** Multiple erosions of the left buccal mucosa and soft palate.

Answer 1503

**Pemphigus Vulgaris.** Large, irregularly shaped ulcerations involving the floor of the mouth and ventral tongue.

Answer 1504

**Pemphigus Vulgaris.**

Answer 1505

**Pemphigus vulgaris** ● Multiple, chronic, mucocutaneous ulcers ● Many patients also have ● Relatively non‐specific ● Very superficial, only in epithelium ● Occur on any mucosal surface: oral, ocular, nasal, GI, esophageal, genital

Answer 1506

**Pemphigus vulgaris** PV Lesions can affect virtually any mucosal surface (oral, nasal, ocular, pharyngeal, esophageal, genital)

Answer 1507

**Pemphigus vulgaris** **usually suffer from Desquamative gingivitis (DG)** More superficial erosion of the marginal gingiva, typically with an intense erythema and inflammation, and very often in the absence of local factors that would typically cause a gingivitis o Hurts to brush their teeth Immediately look for areas where there are no local factors and look for inflammation there o To check the possibility of systemic factors causing local gingivitis

Answer 1508

**Pemphigus vulgaris** Combination of PV inflammation and gingival inflammation accumulating local factors can result in advanced loss of attachment and tooth loss

Answer 1509

Mucous membrane pemphigoid

Answer 1510

Mucous membrane pemphigoid SEVERE/HIGH RISK FORMS OF MMP ▪ Ocular ▪ Esophageal can result in functional blindness

Answer 1511

Mucous membrane pemphigoid Oral Hygiene: Plaque related gingival inflammation contributing to continued VB desquamative gingivitis

Answer 1512

Mucous membrane pemphigoid REMEMBER: ▪ Plaque and calculus can be the consequence of painful MMP lesions ▪ When assessing MMP lesions/desquamative gingivitis, look for areas of intense inflammation WITHOUT local factors as evidence of VB disease

Answer 1513

**Hypersensitivity** to * dental restorative materials, amalgam or other metal, composite resins * Foods, oral products * Especially cinnamon * dental plaque accumulation are the most common

Answer 1514

take two different sites ○ For H&E, still must be perilesional ○ If you get only ulcer just because the clinician thinks ○ that is the pathology → there is no epithelium! ○ The sample is useless and no diagnosis can be made

Answer 1515

Actinic cheilitis (Solar cheilosis) Early presetation: Smooth, blotchy, pale, dry areas Diffuse, irregular white plaque around line of the lip Crusted, Scaly ****

Answer 1516

Actinic cheilitis (Solar cheilosis) Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 1517

**Insicional biopsy Mandated to distinguish from OLP** ○ Biopsy white areas on non-keratinized mucosa NOT ulcerated OR red areas Treatment Replacement of the restorative material, polishing and smoothing, and good oral hygiene are recommended. Topical steroid treatment for a short time is also helpful.

Answer 1518

**_SCC_** arising from **Actinic Cheilitis**

Answer 1519

**Oral Melanoma** Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 1520

Amalgam tattoo This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 1521

**Oral Melanoma** a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 1522

**Oral Melanoma** an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 1523

**Oral Melanoma** patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient's fingers are depicted.)

Answer 1524

Oral melanoacanthoma. the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 1525

**Oral melanotic macule** an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 1526

Smoking Cessation. * Nicotine stomatitis is completely reversible, even when it has been present for many decades. * The palate usually returns to normal within 1 to 2 weeks of smoking cessation.

Answer 1527

Oral Melanoma

Answer 1528

Oral Melanoma

Answer 1529

Traumatic Granuloma (traumatic ulcertaive granuloma)

Answer 1530

Oral Melanoma

Answer 1531

The elevated temperature, rather than the tobacco chemicals, is responsible for this lesion.

Answer 1532

Traumatic ulcer Most often on tongue, lips, buccal mucosa Any sites that may be injured by dentition

Answer 1533

Traumatic ulcer a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 1534

Traumatic ulcer caused by sharp or puncturing food stuff

Answer 1535

Traumatic Granuloma

Answer 1536

**Traumatic Granuloma** | ( Traumatic Ulcerative Granuloma)

Answer 1537

Squamous cell carcinoma on the buccal mucosa)

Answer 1538

**Erythroplakia and Squamous Cell Carcinoma** Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 1539

Leukoplakia and Squamous Cell Carcinoma Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 1540

**Graphite tattoo** Gray, black, or blue-ish macule

Answer 1541

**Graphite tattoo** Most common location on the palate and gingiva Gray, black, or blue-ish macule

Answer 1542

* Generally no treatment is indicated * Reassuring the patient that the condition is completely benign is often all that is necessary. * In case of tenderness or a burning sensation that is so severe --topical corticosteroids, such as fluocinonide or betamethasone gel, may provide relief

Answer 1543

The exact etiology remains unknown. It may be genetic.

Answer 1544

Etiology It is due to increased thickness of the epitheliumand intracellular edema of the prickle-cell layer. Treatment No treatment required

Answer 1545

**Autosomal dominant skin disorder** Etiology: ● This condition is due to a defect in the normal keratinization of the oral mucosa in the 30-member family of keratin filaments, the pair of keratins known as **keratin 4 and keratin 13** is specifically expressed in the spinous cell layer of mucosal epithelium.

Answer 1546

a low-grade variant of squamouscell carcinoma. Etiology Leading theories include * human papillomavirus (HPV) infection * chemical carcinogenesis induced by smoking and chewing tobacco * alcohol consumption * betel nut chewing (oral lesions), * chronic inflammation

Answer 1547

○ Surgical Excision ○ Radiotherapy

Answer 1548

No treatment is required.

Answer 1549

**Atrophy of central filiform papillae** Presumably developmental. Candida albicans may also be involved. but smokers, people with xerostomia , who use inhalation steroids and denture wearers are **at increased risk**

Answer 1550

Erythroplakia is a high risk for malignant transformation. So, if you encounter an erythroplakia, it's probably already a cancer or it's fast‐tracking towards a cancer

Answer 1551

○ Biopsy required for diagnosis ○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal ○ Complete excision

Answer 1552

typically resolves weeks after cessation ○ if persists 6+weeks -\> biopsy to rule out dysplasia + SCC

Answer 1553

Pemphigus vulgaris is not fully understood. Experts believe that it's triggered when a person who has a genetic tendency to get this condition comes into contact with an environmental trigger, such as a chemical or a drug. In some cases, pemphigus vulgaris will go away once the trigger is removed.

Answer 1554

Treatment has 3 stages: **● Stage 1: Control** ○ Suppress inflammation / lesion activity with Systemic **Corticosteroid: Remains initial / 1st‐line treatment…** ○ Then quickly add steroid‐sparing agents (mycophenolate mofetil) to minimize dose and duration of corticosteroid treatment as well as improve disease control **● Stage 2: Consolidation** ○ Reducing auto‐antibody production with the addition of Immunosuppressants ○ Assessed by the lack of development of NEW lesions **● Stage 3. Remission / Maintenance:** ○ achieving complete remission of lesion activity OFF medication is the GOAL ○ When lesion activity OFF medications cannot be achieved, principle of MINIMALLY effective therapy is the goal, typically with combination of immunosuppressant medications **○ RITUXIMAB has become the FIRST CHOICE treatment after ○ the consolidation phase to achieve DISEASE REMISSION** _● TOPICAL / INJECTABLE CORTICOSTEROID MEDICATIONS_ ○ o Can be used to help control limited number of lesions resistant to systemic therapy: it treats ONLY the disease ○ outcome (lesions) and not the systemic illness / pathologic antibody production **○ ex:clobetesol 0. 05% , halbetesol 0.05% (most potent)**

Answer 1555

Mucocutaneous autoimmune disease characterized by sub‐epithelial blisters (bullae) which ruptures to form large, non‐healing ulcerations

Answer 1556

o Approach is similar to PV – but generally not as aggressive unless hi‐risk areas ( ocular, esophageal ) where more intense immunosuppression indicated ▪ NON‐immunosuppressive treatments uniquely effective: * *o** **Dapsone** * *o Tetracycline + nicotinamide**

Answer 1557

Actinic cheilitis has **2 times** of risk for developing SCC of the lip. SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 1558

due to chronic ultraviolet light exposure.

Answer 1559

* avoid sun exposure * Laser ablation is preferred for severe actinic cheilitis * surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia * Lip Shaving” (Vermilionectomy) * can also use cryotherapy, electrodesiccation It requires long term follow up and **prognosis is good if caught early**

Answer 1560

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma **Acute sun damage** can cause it more than chronic exposure

Answer 1561

Fair skin A history of sunburn Excessive ultraviolet (UV) light exposure. Living closer to the equator or at a higher elevation Having many moles or unusual moles A family history of melanoma Weakened immune system.

Answer 1562

* Surgical excision * Radiotherapy * Chemotherapy

Answer 1563

**Etiology** * typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep. * Chronic mucosal trauma from adjacent teeth * Some adjacent source of irritation

Answer 1564

Traumatic ulcer Post-anaesthesia traumatic ulcer on lower lip.

Answer 1565

**Remove cause of irritation** Topical anesthetic or film for pain relief If there is no obvious cause then ► **biopsy**

Answer 1566

**HPV + SCC** Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue) Younger pts, 3:1 Males to females ratio, high socio-eco status Incidence is decreasing less aggressive → higher survival rates ( Better than HPV negative SCC) **HPV - SCC** The chief risk factors for oral squamous cell carcinoma are Smoking (especially \> 2 packs/day) Alcohol use Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men. ( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva) mostly men, low socio-economic factors Incidence is decreasing Very aggressive → lower survival rates

Answer 1567

Early stage: Radiation and/or Surgical removal Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 1568

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 1569

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 1570

**Hemangioma of Infancy** a relatively common benign proliferation of blood vessels that primarily develops during childhood. display a rapid growth phase with endothelial cell proliferation, followed by gradual involution.

Answer 1571

Hemangioma of Infancy

Answer 1572

Traumatic ulcer of the tongue.

Answer 1573

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 1574

**Necrotizing Sialadenometaplasia** *we see two ulcers on the palate* *Mostly ● Palatal salivary glands ○ Possible for parotid ● 75% of case on posterior palate ● Hard\>Soft palate ● 2/3rd are unilateral*

Answer 1575

Necrotizing Sialadenometaplasia an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands. *Here it is on the palate*

Answer 1576

**Xerostomia-related Caries** **Or** **Dry Mouth** . Extensive cervical caries of mandibular dentition secondary to radiation-related xerostomia.

Answer 1577

*The cause is uncertain, although the hypothesis of ischemic necrosis after vascular infarction seems acceptable.*

Answer 1578

No Treatment Needed but we need to biopsy to rule out other diseases

Answer 1579

**Xerostomia** The subjective experience of a dry mouth (ie a symptom) **Salivary Hypofunction** The objective measurement of a reduction in salivary flow (a sign)

Answer 1580

**300 ml/day ▪ Flow rate: mean 0.3 ml/min**

Answer 1581

**Stimulated Saliva Production** **▪ 200+ ml/day ▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min** o “Normal” range is very wide

Answer 1582

* **Dehydration** * **Medical conditions** * **Body posture** * **Lighting conditions** * **Circadian/circannual rhythm (lowest during)** * **Medications** Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 1583

**dry‐mouth** from radiation Note the Ropy, frothiness on the palate. - The tissues are red and irritated due to candida infection as well.

Answer 1584

**dry‐mouth** patient a classic example **• Classic fissuring • depapillation of the tongue papilla • some white changes on the tongue.**

Answer 1585

**dry Mouth** Cervical caries related to radiation. The patient is a smoker and coffee drinker --\> explains the staining

Answer 1586

dry Mouth Incisal caries in a radiation patient: **Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction**

Answer 1587

* **Mechanical stimuli** * **Vomiting** * **Gustatory/olfactory stimuli (acid/smell)** * **Gland size** Age is an independent factor for whole saliva (but not for parotid and minor gland secretions)

Answer 1588

Central inhibition as a result of connections between the primary salivary centers and the higher centers of the brain.

Answer 1589

* **May be a reduction in baseline sialometry which is still above “normal.”** * *If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.* * **Saliva film thickness** * *Palatal mucous gland secretions?* * *Anterior dorsum of tongue?* * **Relative contributions by glands** * Mucins, proteins? * **Alterations in sensory perception?** * **Mental status/central inhibition?**

Answer 1590

**● Dehydration ● Medications (Rx & OTC)** * *Direct damage to glands* * *Head and neck radiotherapy* * *As a result of radiation it’s irreversible damage to the glands* * *Chemotherapy (reversible)* * *Autoimmune diseases* * *Primary vs Secondary Sjögren’s Syndrome, GVHD* * *HIV disease* **● Decreased mastication (tooth loss, soft diet) ● Conditions affecting the CNS:** * Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 1591

**SJÖGREN’S SYNDROME** _Dry Mouth_ very severe cervical disease & very dry lips

Answer 1592

a patient with a **_bacterial sialadenitis_** who has **_SJÖGREN’S SYNDROME_** When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 1593

Depapillated & Fissured Tongue ## Footnote **SJÖGREN’S SYNDROME**

Answer 1594

**Sjögren Syndrome** * bilateral enlargement of the submandibular glands * angular cheilitis, dry and cracked lips and fissured and despapilated tongue * severe ocular lesions.

Answer 1595

These patients **LOW USFR, no response to stimulation (aka abnormal USFR/SFR)** * Rehydrate if dehydrated * Treat underlying conditions (i.e. DM) * Salivary substitutes (glycerin) * Minimize damage to glands from radiation * Prevention of complications & palliative treatment * Optimal hygiene * Restore caries * Smooth sharp edges in oral cavity * Fluoride therapy * Antifungals * Chlorhexidine rinses w/o alcohol * Sialendoscopy * Salitron - salivary pacemaker * ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 1596

**Abnormal unstimulated USFR= \<0.1–0.2ml/min** **Abnormal stiumated SFR = \<0.5ml/min**

Answer 1597

* Salivary stimulation (OTC) to stimulate their glands * Salivary lubrication ( to improve it) * Humidification ( like a humidifier in the room at night) * Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a * diuretic and lead to dehydration). * Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 1598

* If dehydrated ► rehydrate or treat underlying condition * People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back. * All we can do is offering Salivary substitutes (sprays, gels, rinses ) * For patients with high dose radiation treatment ► makes sure they get the INRT * Minimizing damage to salivary glands ( there are other strategies for that) * Prevention and treatment of oral complications

Answer 1599

* Look for possible causes (major cause will be medications & can dehydration or others) * Restore chewing function (Masticatory issues) * Reduce medication‐induced salivary hypofunction * Prescribe Salivary stimulation OTC, Rx medications, others * Prescribe Salivary lubrication * Humidification ‐use humidifiers * Hydration/prevent dehydration (ie avoid alcohol, caffeine) * Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 1600

– Muscarinic agonists: – **Pilocarpine** 5‐7.5mg tid & qhs (can go as high as 10mg qid) – **Cevimeline** 30mg tid (can go as high as 60mg tid) _Contradicated for_ : **CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma** **Pilocarpine affects M1 & M3** _side effects_ (sweating, flushing, rhinitis, increased urination, weakness and some experience the shakes. ) **Cevimeline affects M3 only** fewer side effects

Answer 1601

Frictional keratosis on the tongue

Answer 1602

**Frictional Keratosis** **the white surrounding a a traumatic ulcer** Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 1603

Leukoplakia Linea alba Chronic cheek chewing (bite injury) Candidiasis Oral Lichen planus Squamous cell carcinoma

Answer 1604

**Frictional Keratosis.** There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”), because this area is now edentulous and becomes traumatized from mastication. **Such frictional keratoses should resolve when the source of irritation is eliminated and should not be mistaken for true leukoplakia.**

Answer 1605

* Trauma from Sharp cusp & ortho appliance * Chronic mechanical irritation (chronic biting) * Masticatory function * Normal hyperplastic response * Dentures/missing teeth

Answer 1606

* Remove the cauative factor that caused the trauma * observe large lesion regularly excellent prognosis

Answer 1607

**SJÖGREN’S SYNDROME** Autoimmune exocrinopathy Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary glands due to retrograde infections.) **increased risk of lymphoma (MALT type)**

Answer 1608

**Nicotine Patch Generic Name-Nicodern CQ/Habitrol** * 21 mg/24 hr\> 10 dgs/d * 14 mg/24 hr or 7 mg/24 hr \<10 mg cig/d or \<100 lbs **Nicotine Gum Generic Name -Nicorette** 2 mg \< 25 cig/d 4 mg \> 25 cig/d **Nicotine lozenge - Commit** 2 mg if smoke 1st cig more than 30 minutes after waking 4 mg 4 mg if smoke 1st cig within 30 minutes after waking ( no more than 20 a day) **Nicotine Inhaler -Nicotrol lnholer** 6-16 cartridges/ d Use 1 cartridge/hour **Nicotine Nasal Spray- Nicotrol NS** Mox 40 doses/d (1 dose = 1 spray per nostril}

Answer 1609

Sustained release buprorpion **Zyban or Wellbutrin** Can be used w/NRT Start 1-2 weeks before quit date. Option 1 : 150 mg/ day for 3 days then 150 mg BID (doses at least 8 hrs apart) Option 2: 150 mg q AM is recommende~ Fewer adverse eff eds better tolerated iin older adult) **Varenidine tartrate** **Chontix** Start 1 week before quit date 0. 5 mg/ d for 3 days then 0.5 mg BID for next 4 days (one in AM, and one in PM). After firs1 7 days 1 mg/810

Answer 1610

* Mouth and throat irritation * Cough • Side effem generally caused by inappropriate use

Answer 1611

* Nasal irrttation * Sneezing * Cough * Teary eyes

Answer 1612

* local skin irritation * insomonia

Answer 1613

* hiccups * Dyspepsia * mouth sorness

Answer 1614

* Dyspepsia * local irrttation mouth & throat * Rarely causes coughing & hiccups

Answer 1615

* Insomnia * Dry mouth * Anxiety

Answer 1616

* Nausea * Insomnia * Abnormal dreams

Answer 1617

**Urticaria** Well defined erythematous papules/plaques which are pruritic (itchy) We’ll see them on the skin ‐ Not found intraorally

Answer 1618

**Urticaria** (HIVES) this person was exposed to extreme temperature developed hives ( not really red but very itchy) no skin scarring is noted it goes in about a day

Answer 1619

**Angioedema** ❖ **Diffuse edematous swelling** of the soft tissues that most commonly involves the subcutaneous and submucosal connective tissues ❖ Results from local vasodilatation and increased vascular permeability of DEEPER blood vessels

Answer 1620

**Angioedema**

Answer 1621

❖ Medications ► causing rash ❖ Foods ► like peanuts ❖ Airborne allergens ► pollen ❖ Physical stimuli ► ex cold weather

Answer 1622

❖Avoid known triggers avoid the penicillin, any of the triggers ❖ Antihistamines ( to prevent it from happening in the first place) Corticosteroids (prevents the inflammatory effect)

Answer 1623

**Cinnamon Contact Stomatitis** * It can present similar to leukoplakia * So you’d think it is pre‐malignant lesion * But after asking the patients ► you’ll realize they are chewing like 10 cinnamon gums every day.

Answer 1624

**Allergic Contact Stomatitis** ## Footnote ❖ Mild‐severe redness, edema, vesicles, erosions, ulcerations ❖ Burning, itching, stinging, tingling *●We can't know what is this right away.* *Patients may say it burns, tingles, there could be peeling (desquamation). We might think it’s a **vesiculobullous diseases.** ● So these cases require more consulative‐investigative work.*

Answer 1625

**Allergic Contact Stomatitis‐Clinical** * slight vesicales and diffused erythemya * we wouldn’t always know this is Allergic contact stomatitis * This occured due to allumnium chloride on gingival retraction cord.

Answer 1626

**Exfoliative cheilitis** Allergic Contact Reactions‐ Non‐ Mucosal dry, scaly, fissured, cracking lips This is a mild case that affect the non‐mucosal around the the skin

Answer 1627

**Exfoliative Cheilitis** *caused by titanium implants and some mercury in amalgam.*

Answer 1628

**Perioral Dermatitis** Allergic Contact Reactions‐ Non‐ Mucosal erythematous papules/vesicles – papules ( raised) & vesicles (actual blisters)

Answer 1629

**Erythema Multiforme** Rapidly rupturing vesicles/bullae forming erosions/ulcerations and hemorrhagic encrusted lip lesions, with greyish pseudomembrane Fast expansion, ► the skin is just peeling off. Type 4 hypersensitivity. Has prodrome phasesudden *Rapid onset, crusted hemorrhagic swollen lips, and desquamative gingivitis.*

Answer 1630

**Granuloma** This is a granuloma. It’s composed of histeocytes that looks epithelioid. This is a collection of epithelioid histeocytes **Found in:** * TB (**They’ll be holding TB inside. But in TB you have caseous necrosis of granuloma.** * Deep fungal infections (**they holding? fungal organisms)** * GRANULOMATOUS DISEASES **( if with Asteroid bodies & Schaumann Bodies)** **In these granulomas we don’t know why they are forming.**

Answer 1631

Orofacial Granulomatosis **Cheilitis granulomatosa=Involvement of lips alone** Non‐tender, persistent swelling NEED To BIOPSY to RULE OUT angioedema

Answer 1632

**Orofacial Granulomatosis** Papules, slightly raised areas, fissures, cobblestone appearance **DDx** We could suspect a traumatic injury early signs of Crohn’s

Answer 1633

Orofacial Granulomatosis

Answer 1634

❖ Discover cause ( we need to find out the cause.) ❖ Topical or intralesional corticosteroids (maybe try steroids) ❖ Other (topical tacrolimus, sulfazalazine, methotrexate, etc) ❖ Some cases resolve spontaneously *(This photo shows a person has puffiness because of granulomas. Sometimes it goes away on its own. We can use injection steroids on the lips too.)*

Answer 1635

**Sarcoidosis‐Organ Systems** ❖ Lungs ❖ Lymph Nodes (bilateral hilar lymphadenopathy) ❖ Skin (25% of time) ❖ Eyes ❖ Salivary Glands ❖ Other (endocrine, gastrointestinal, heart, kidney, liver, nervous system, spleen, skeletal

Answer 1636

Sarcoidosis‐Hilar Lymph Node Enlargement popcorn‐like calcifications in the hilar lymph nodes. granulomas from sarcoidosis being inside .

Answer 1637

**Sarcoidosis**‐Skin Lesions **Lupus pernio** (nose, ears, lips and face) ‐ when we have these erythematous indurated, hard on face.

Answer 1638

**Sarcoidosis** **DDX** in the oral cavity. It could be one of the three P’s: ❖ pyogenic granuloma ❖ peripheral ossifying fibroma ❖ peripheral giant cell granuloma.

Answer 1639

**❖ This is Strawberry gingivitis** Granulomatosis with Polyangiitis "Wegener’s” Orally ❖ Ulceration, ❖ Mucosal nodules ❖ Facial paralysis ❖ Enlarged major gland from granulomas * we need to biopsy, as this also looks like a deep fungal infection. *

Answer 1640

**Granulomatosis with Polyangiitis** Orally We want to biopsy to confirm because it Could be contact mucositis.

Answer 1641

**‐ Cinnamon contact mucositis** This could be oral hairy leukoplakia. It could be hyperplastic candidiasis it could be tongue chewing it could be a leukoplakia. We’ll know what it is by biopsy and investigate

Answer 1642

Urticaria.

Answer 1643

Erythema multiforme

Answer 1644

\* Erythema multiforme

Answer 1645

**‐ Orofacial granulomatosis.** We make sure there’s no tb, no fungal, no foreign material in the granulomas

Answer 1646

Sarcoidosis \*Erythemous papules (grey circle) Asteroid bodies ( blue arrow) Hilar lymph nodes (green circle)

Answer 1647

**orofacial granulomatosis.** What is the common way to describe this? **Cobblestone**. This is the classic cobblestone. Cobblestone and fissuring DDx: people with Crohn’s with oral manifestations it looks like this too.

Answer 1648

**Sarcoidosis**

Answer 1649

angioedema

Answer 1650

**Fixed Drug Eruption** –This case has both the skin and oral appearance. This happened every time this person took NSAIDs that’s not used in the USA. A person gets a reaction to a medication they take. It occurs at the same place each time because there’s s**ome memory T cell at these sites.**

Answer 1651

Causes include: ❖ **IgE mediated** ( most common types are allergy related) * Hypersensitivity reaction * drugs, foods, plants, dust * Contact allergic reactions * foods, cosmetics, topical medications, rubber dam * Physical stimuli * heat, cold, exercise, emotional stress, solar exposure, vibration ❖ Drug reaction to **ACE inhibitors** * Does not respond well to **antihistamines** ❖ Hereditary or acquired activation of the complement pathway ❖ Other (high levels of antigen‐antibody complexes and in elevated blood eosinophil counts) * Complexes in lupus, viral and bacterial infections * Patients with grossly elevated blood eosinophilia

Answer 1652

❖ **Antihistamine/IM epinephrine/IV corticosteroids** ( typical treatment for allergy) ❖ **Intubation and tracheostomy** ( if the patient can’t breathe, so we can get air in) ❖ **Avoid medications in ACE Inhibitor class of drugs** ( for people who has Ace inhibitor induced angieodema) ❖ **C1 esterase inhibitor** concentrate and esterase inhibiting drugs

Answer 1653

**Granulomatosis with Polyangiitis** extra-oral Joint pain, weakness, tiredness ❖ Known as **Saddle nose deformity** ❖ First signs may be recurrent respiratory infection, cough or runny nose ❖ Oral lesions initial presentation in 2% of patients

Answer 1654

**First line: oral prednisone** ❖ After remission immunosuppressive drugs: ❖ Methotrexate ❖ Cyclosporine ❖ Rituximab ❖ Treatment induces prolonged remission ❖ May have relapses

Answer 1655

● pseudomembranous candidiasis ● Mucosal sloughing‐ Allergic Contact Stomatitis ● Food particles

Answer 1656

**Mucosal sloughing** **Allergic Contact Stomatitis** caused by tooth paste (Colagate Total) white area‐like a film peeling out slowly **Wipeable** *could be confused with candidasis*

Answer 1657

Medications, lipsticks, sunscreens, toothpaste floss, cosmetics

Answer 1658

**Erythema Multiforme** Acute, vesiculobullous, ulcerative mucocutaneous disorder Immunologically mediated **_Target lesions on skin_** (typical board question) Healthy young adults in 20‐40’s

Answer 1659

❖ 50% of cases precipitating cause is identified * Infectious Agents: Herpes simplex virus, Mycoplasma pneumonia, Adenovirus, Enterovirus, Coccidiomycosis * **Most of the time, erythema multiforme is related to a previous infection with herpes simplex virus.** * Drugs: Penicillin, Cephalosporins, Sulphonamides, NSAID’s, Phenytoin * Other: Foods (Benzoates, Nitrobenzene), Chemicals (Perfumes) ❖ it’s not an infection, it’s our body reacting to the infectious organism or pieces of it in a wrong way

Answer 1660

**Sarcoidosis** discrete clear granulomas. 2nd schaumann body in a giant cell (3rd to the right) Asteroid bodies ( right)

Answer 1661

**Erythema Multiforme** Focal hemorrhagic crusting of the lips is seen in conjunction with diffuse shallow ulcerations and erosions involving this patient’s mandibular labial mucosa

Answer 1662

**Erythema multiforme** The concentric erythematous pattern of the cutaneous lesions on the fingers resembles a target or bull’s-eye.

Answer 1663

**Sarcoidosis** large red nodule on the lower lip.

Answer 1664

**Urticaria** developed after bites from an imported fire ant.

Answer 1665

**Erythema multiforme** multiple erosions on the lips and tongue.

Answer 1666

(Granulomatosis with polyangiitis) *formerly Wegener Granulomatosis.* Hyperplastic and hemorrhagic mucosa of the facial mandibular gingiva on the left side. ((strawberry gingivitis).

Answer 1667

**❖ Idiopathic** **❖ Abnormal immune reaction** ❖ in orofacial granulomatosis, people form granulomas and it’s idiopathic ❖ we don’t know why they’re forming them so that’s an abnormal immune reaction.

Answer 1668

Depends on the case! ❖ 60% of cases resolve within 2 years ❖ Initial diagnosis 3‐12 mo. observationàactive intervention as needed ❖ First line tx: corticosteroids ❖ Refractory dx: * Cytotoxic drugs (methotrexate, azithioprne) * TNF blockers * Hydroxychloroquine ❖ 4‐10% die of pulmonary, cardiac or CNS complications

Answer 1669

❖ **Granulomatous disorder** ❖ Multisystem ❖ Unknown cause

Answer 1670

First line: oral prednisone ❖ After remission immunosuppressive drugs: ❖ Methotrexate ❖ Cyclosporine ❖ Rituximab ❖ Treatment induces prolonged remission ❖ May have relapses

Answer 1671

* erythema multiforme * morbilliform drug eruption

Answer 1672

* Oral hairy leukoplakia * hyperplastic candidiasis

Answer 1673

❖ Foods ❖ Food additives ❖ Chewing gums ❖ Candies ❖ Dentifrices ❖ Mouthwashes ❖ Gloves ❖ Rubber dam material ❖ Topical anaesthetics ❖ Restorative metals ❖ Acrylic denture materials ❖ Dental impression materials ❖ Denture adhesive preparations ❖ Cinnamon (mainly artificial flavoring)

Answer 1674

* *❖ Remove the suspected antigen** * *❖** **Severe cases‐Antihistamine** (combined with a topical anaesthetic) ( because it’s an allergy) * *❖** **Chronic cases‐Apply topical corticosteroid** **❖ Recommendations to AVOID:** * ❖ Mouthwash * ❖ Gum/mints * ❖ Cinnamon * ❖ Excessive salty, spicy, acidic ❖ **Patch testing** (we send them to allergist )

Answer 1675

❖Self‐limiting, resolves in a few weeks (It will go away on its own, you just have to manage symptomatically.) ❖Symptomatic management, IV rehydration, corticosteroids (topical and oral), antivirals in recurrent cases (We may use antivirals if they tell us they get cold sores every now and then this means they do have a history of herpes simplex.) ❖ Avoid causative drug (If drug‐related) ❖ Other second‐line systemic therapies (like cyclosporin, azathioprine and other serious drugs) ❖ Usually not life threatening unless in major form.

Answer 1676

Reactive Airway Disease

Answer 1677

Reactive Ariway diseases Not recomended for pts with Chronic Nasal diseases ( nasal polyps & sinusitis)

Answer 1678

* Seizure disorders * Current use of bullrin or MAO inhibitor * Eating disorder (bulimia, anorexia) * Alcohol * Head trauma ## Footnote *Moniter Blood presssure*

Answer 1679

* women breasfeeding should avoid * pt with kidney problems -adjust dose

Answer 1680

* Caution with 6 months of MI

Answer 1681

* poor dentition * maybe inappropriate for use for pts with compelete or partial denture (hard for them to chew)

Answer 1682

* Xerostomia

Answer 1683

Yes ## Footnote •New York State Education Department has deemed that treating tobacco use is part of the scope of practice for dentistry, this includes prescribing smoking cessation products.

Answer 1684

* Combination long- and-short acting **Nicotine Replacement Therapy (NRT) (e.g., patch and gum, patch and inhaler)** * **Varenicline alone** * **Bupropion SR** with **NRT** (long- or short-acting)

Answer 1685

**•What is NRT at the POC?** –Distribution of a free starter pack of NRT to all smokers by clinic staff during the clinic visit **•Rationale for NRT at the POC** –NRT doubles the success rate of patients’ quit attempts –Inconvenience of purchasing RNT or filling a prescription creates barriers –The clinic is an opportune time to intervene **•Who will hand the patient NRT?** –Dental Students **•What kind of NRT will be on stock?** •Nicotine Patch, Gum, and Lozenge **•How to distribute NRT at POC?** –Take faculty-approved NRT request form to dispensary, where NRT is stored.

Answer 1686

**a combination of pharmacotherapy and counseling**

Answer 1687

■Irritability/frustration/anger ■Anxiety ■Difficulty concentrating ■Restlessness/impatience ■Depressed mood/depression ■Insomnia ■Impaired performance ■Increased appetite/weight gain ■Cravings

Answer 1688

* **Ask** about tobacco use and secondhand smoke exposure * **Advise** to quit * **Assess** interest in quitting * **Assist** in quit attempt (referral and or pharmacotherapy) * **Arrange** for a follow-up

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