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Head and Neck Pathology > D2 Fall PAR 8 > Flashcards

D2 Fall PAR 8 Flashcards

(101 cards)

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1
Q

Erythematous Definition

A

Red in color due to dilation and congestion of capillaries, increased blood flow; implies injury, infection, or inflammatory process

“Red” does NOT always mean erythematous

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2
Q

Fibroma

A

(aka irritation fibroma, traumatic fibroma, hyperplastic scar)

reactive fibrous hyperplasia (connective tissue)

people 40-60 years old

most are 1.5cm or less

smooth surfaced papule/nodule

similar color to surrounding tissue

common at buccal mucosa along line of occlusion

MUST BIOPSY

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3
Q

Epulis Fissuratum/Inflammatory Fibrous Hyperplasia

A

fibrous hyperplasia developing because of an ill-fitting removable prosthesis (denture or partial)

IFH can also occur WITHOUT a prosthesis because of inflammatory factors like plaque and calculus– cannot call this epulis fissuratum

firm and fibrous

usually on FACIAL ASPECT

Good prognosis when the ill-fitting prosthesis is fixed

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4
Q

Bumps on the Gums– 4 P’s

A
  1. Pyogenic Granuloma
  2. Peripheral ossifying fibroma
  3. Peripheral giant cell granuloma
  4. Peripheral odontogenic fibroma
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5
Q

Pyogenic Granuloma

A

Anywhere on oral mucosa

LOCAL IRRITANT causes granulation tissue response

may have rapid/alarming growth rate

  • smooth or lobulated mass
  • pedunculated
  • Very vascular (red/blue color, may blanche with pressure)
  • compressible, spongy
  • surface frequently ulcerated

several mm to several cm

PREGNANT WOMEN common– may resolve after delivery

May recur if local irritant isn’t removed

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6
Q

Peripheral Ossifying Fibroma

A

ONLY ON GINGIVA/EDENTULOUS ALVEOLAR RIDGE

TEENS AND YOUNG ADULTS

  • nodular mass
  • varying degrees of calcified material (“ossifying”)
  • pedunculated or sessile
  • reactive
  • red/pink color
  • often ulcerated

Most are less than 2 cm

Tx: excision to periosteum

Recurrence rate is low, 8-16%

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7
Q

Peripheral Giant Cell Granuloma

A

Reactive lesion caused by LOCAL IRRITATION or TRAUMA

ONLY ON GINGIVA/EDENTULOUS ALVEOLAR RIDGE

  • Red/Purplish nodular mass
  • most less than 2cm
  • may or may not be ulcerated

ANY AGE

Tx: excision to underlying bone

10-18% recurrence rate

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8
Q

Recurrent Aphthous Stomatitis

A

likely IMMUNOLOGICAL
- HIV
- HLA types
- trauma, food, stress

Tx: Topical corticosteroids
- augmented betamethasone dipropionate 0.05% gel
- clobetasol propionate 0.05% gel

can use elixirs/syrups with corticosteroids for ulcerations that are hard to reach

Three types: (detailed in other cards)
1. Minor recurrent aphthous stomatitis
2. Major recurrent aphthous stomatitis
3. Herpetiform recurrent aphthous stomatitis

All three forms are on UNATTACHED GINGIVA

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9
Q

MINOR Recurrent Aphthous Stomatitis

A

Ulcer with yellow-white membrane

Erythematous halo

Small (3-5mm)

Unattached mucosa, usually on the ANTERIOR

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10
Q

MAJOR Recurrent Aphthous Stomatitis

A

Can be associated with HIV or other immunocompromised states

Larger (up to 3cm) and longer duration (2-6 weeks)

usually a deeper ulcer– may SCAR once healed

Unattached mucosa, usually on the POSTERIOR

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11
Q

HERPETIFORM Recurrent Aphthous Stomatitis

A

Numerous, small lesions

NON-KERATINIZED unattached mucosa

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12
Q

Herpes Simplex Virus

A

Self limiting (resolves itself if not immunocompromised)

Primary infection that can be reactivated (secondary infection)

Most orofacial infections caused by HSV-1 (remainder by HSV-2)

Primary HSV infection usually ages 2-4 (TODDLERS)

80-90% asymptomatic

The symptomatic cases are called ACUTE HERPETIC GINGIVOSTOMATITIS

Spread by saliva and direct contact with active perioral lesions

Multiple vesicles and ulcers ANYWHERE ON SKIN OR ORAL CAVITY

Unattached AND attached mucosa

Quickly rupture and leave shallow, painful ulcers

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13
Q

HSV remains latent in regional ganglia, and can be reactivated by…

A
  • UV light
  • physical trauma
  • upper resp. tract infection
  • pregnancy and menstruation
  • immunosuppression
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14
Q

Herpes labialis

A

Cold sore/fever blister

Secondary HSV form

prodromal signs and symptoms 6-24 hrs before lesions develop

Vesicles rupture and crust within 2 days– minimal risk for infection after lesions crust

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15
Q

Intraoral Secondary HSV

A

KERATINIZED MUCOSA bound to bone in immunocompetent patients (attached gingiva and hard palate)

Less intense symptoms

Healing in 7-10 days

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16
Q

Treatment for acute herpetic gingivostomatitis

A

must treat within first 3 symptomatic days to be effective

Systemic valacyclovir (preferred) or acyclovir

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17
Q

Treatment for herpes labialis

A

initiation of treatment during prodromal period has maximum benefit

systemic valacyclovir, acyclovir, or penciclovir cream

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18
Q

Treatment for recurrent intraoral herpes

A

usually no treatment necessary

Chlorhexidine rinse with or without valacyclovir/acyclovir

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19
Q

Candida albicans (general microbiology)

A

Most common fungal infection in humans

common dimorphic yeast

yeast form = commensal
hyphae = pathogen

yeast can undergo transformation to hyphae form, producing germinative or “germ tubes”

Candida hyphae never penetrate deeper than the keratin layer

Microabscesses may be seen on superficial spinous layer

acanthosis often present (benign thickening of stratum spinosum)

chronic inflammation of the connective tissue

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20
Q

Candidiasis Spectrum of Disease

A

(most mild to most serious):

  • Carrier state
  • superficial mucosal/cutaneous infection
  • localized invasive candidiasis
  • disseminated candidiasis
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21
Q

Candida infections are more prevalent in…

A

(remember it is opportunistic)

  • infants
  • pts who had recent abx tx
  • pts on corticosteroids
  • immunodeficiency
  • people with RPD
  • pregnancy
  • overweight/diabetes
  • zinc or iron deficiency
  • hypothyroid conditions
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22
Q

Candida Diagnosis

A

often clinical signs and symptoms are enough

Culture– may not distinguish between carrier and infection

Exfoliative cytology

Biopsy usually NOT NEEDED

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23
Q

Candidiasis Treatment

A

Superficial oral mucosal infections can be treated with milder topical or systemic antifungals:

  • clotrimazole 10mg troches
  • nystatin oral susp. (100,000 units/mL)
  • fluconazole 100mg tablets

Life threatening infections:
- IV amphotericin B

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24
Q

Erythematous candidiasis

A

Common on TONGUE

area of redness, variable borders

diffuse atrophy of dorsal tongue papillae, particularly after broad-spectrum antibiotics… causes “burning sensation”

2 forms of erythematous candidiasis:
- central papillary atrophy
- denture stomatitis

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25
4 types of Oral Candidiasis
1. Erythematous candidiasis (two types-- central papillary atrophy and denture stomatitis) 2. Angular cheilitis 3. Acute pseudomembranous candidiasis 4. Hyperplastic candidiasis
26
Central Papillary Atrophy
One of the 2 types of Erythematous Candidiasis previously called "median rhomboid glossitis" Most caused by chronic candidiasis Well-defined area of redness, mid-posterior dorsal tongue Usually asymptomatic
27
Denture Stomatitis
One of the 2 types of Erythematous candidiasis May be called "chronic atrophic candidiasis" Denture is often contaminated with candida organisms, but NO INVASION OF MUCOSA is seen Erythema of palatal denture-bearing area Usually asymptomatic
28
Angular Cheilitis
Usually related to candidiasis, but may have other cutaneous bacterial microflora Redness, cracking of corners of the mouth Often waxes and wanes Usually required topical anti-fungal therapy
29
Treatment for angular cheilitis
Angular cheilitis with intramural candidiasis: - clotrimazole troches-- have pts lick corners of mouth while using troches Isolated or severe: topical anti fungal creams - 1%/1% iodoquinol/hydrocortisone - nystatin/triamcinolone cream - OTC 1% clotrimazole
30
Pseudomembranous Candidiasis
Also called "thrush" White "curdled milk" or "cottage cheese-like" plaques that CAN BE WIPED OFF and leave an erythematous base BUCCAL MUCOSA PALATE TONGUE May be asymptomatic - burning or unpleasant taste occasionally noted
31
Hyperplastic Candidiasis
also known as "candidal leukoplakia" White patch that CANNOT be rubbed off ANTERIOR BUCCAL MUCOSA May be problematic because a true leukoplakia may have superimposed candidiasis (leukoplakia is premalignant and you may not recognize it due to the candida growth) should resolve with anti fungal therapy
32
Leukoplakia
white patch or plaque that cannot be characterized as any other disease considered PREMALIGNANT (most common precancerous oral lesion--may transform to SCC) Well-defined with crisp margins May be homogenous, variably thick, or speckled Common areas: "soft areas" - lateral/ventral tongue - floor of mouth - soft palate hyperkeratosis with or without acanthosis most do NOT show dysplasia
33
Possible etiologies of leukoplakia (there are 3)
1. tobacco smoking 2. sanguinaria (blood root) [this is a flower] 3. betel nut use Alcohol is NOT necessarily associated with leukoplakia
34
5 Lesions that ARE NOT LEUKOPLAKIA:
"Frick, This is Not A Leukoplakia" Frictional keratosis Tobacco pouch keratosis Nicotine stomatitis Amalgam reactions Lichen Planus
35
Prognosis and Tx of Leukoplakia
BIOPSY MANDATORY (premalignant.. duh) Tx: clinical monitoring, excision, laser ablation Small risk of transformation to SCC Follow-up appt is essential, with or without removal Recurrences COMMON (1/3 of patients)
36
Proliferative Verrucous Leukoplakia (PVL)
More than 1 precancerous lesion in the mouth OR a single lesion greater than 3cm no definite etiology OLDER FEMALES (mean age = 67) Malignant transformation in more than 70% of patients almost guaranteed recurrence (87-100%) Prognosis is GUARDED Management: - 3-6 month recall with excellent documentation - biopsy at least every 12-18 months, sooner if it changes or a new lesion appears.
37
Erythroplakia
Red patch that cannot be clinically or pathologically diagnosed as any other condition MUCH MORE DYSPLASIA upon biopsy than leukoplakia - 90% of erythroplakia shows dysplasia (CIS) Same etiology as SCC (tobacco, alcohol) OLDER MALES Same locations as leukoplakia (very soft areas) - floor of mouth - ventral tongue - soft palate Well-demarcated velvety, red plaque May be adjacent to areas of leukoplakia Epithelial atrophy with lack of keratin production Chronic inflammation BIOPSY and close follow-up are MANDATORY Tx depends on how severe the dysplasia is Recurrence, developing separate lesions, and malignant transformation are all common
38
Most common oral cancer? Most common demographic for this cancer?
Oral Squamous Cell Carcinoma Most common in BLACK MALES
39
OSCC Risk Factors
Tobacco (especially combustible)--75-85% have OSCC association Alcohol (not directly a carcinogen here, but works synergistically with tobacco) Betel quid Radiation Plummer Vinson Syndrome - iron deficiency anemia - glossitis - dysphagia Immunosuppression High-risk HPV strains - not a major risk factor for oral cavity cancer - associated more with OROPHARYNX cancers (base of tongue, tonsillar pillars, back of throat)-- usually attributed to HPV16 ** 20-25% of OSCC present with NO IDENTIFIABLE RISK FACTORS
40
How long is OSCC usually present before pt seeks medical attention?
4-8 months longer (8-24 months) in lower socioeconomic classes denial, lack of pain, and insufficient education play a role
41
OSCC has highly varied features that may include:
exophytic (growing out from tissue) endophytic (growing down into tissue ulcerated erythroplakic leukoplakic ** it doesn't have all these features at once, these are just possible appearances
42
OSCC histologic features
islands and strands of malignant squamous epithelial cells Pleomorphism, hyperchromatism, increased nuclear:cytoplasmic ratio, increased mitotic rate
43
OSCC most common locations
Tongue more than 1/2 of cases (ventral and lateral... very rarely dorsal) Floor of mouth and soft palate 2nd most common Gingiva Buccal mucosa Labial mucosa Hard palate
44
Metastasis of OSCC
spread through LYMPHATICS Firm nodes, moveable or fixed distant spread to lungs, liver, bones Stage at diagnosis is the most important prognostic factor!!
45
OSCC Treatment and Prognosis
Surgical excision/resection radiation usually chemotherapy does NOT respond well Prognosis: - carcinoma of LIP has a much better prognosis stage 1 has okay prognosis, stage 4 has very bad prognosis "Field cancerization"-- person with one carcinoma are at increased risk of a second mucosal tumor
46
SCC of the LIP
Cause: chronic UV light MALES (usually light skinned with outdoor occupations) Slowly growing, indurated (hardened) ulceration
47
Verrucous Carcinoma
first reported as a smoke-less tobacco related lesion SCC is much more common, even among smokeless tobacco users May be associated with proliferative verrucous leukoplakia (PVL) MALES older than 55 white, warty plaque mandibular vestibule buccal mucosa hard palate VERY RARE METASTASIS GOOD PROGNOSIS - up to 20% have foci of SCC
48
Branchial Cleft Cyst (Cervical Lymphoepithelial Cyst)
arise from remnants of the branchial clefts--95% from the 2nd arch swelling ANTERIOR to the sternocleidomastoid more likely on the LEFT side Fixed position on the neck (doesn't move around) stratified squamous epithelial lining lymphoid tissues present in wall, with germinal center formation Recurrence is RARE
49
Thyroglossal Duct Cyst
CHILDREN 10-12 Fluctuant midline swelling from foramen cecum to suprasternal notch 80% located BELOW the HYOID BONE Cysts often move up and down upon swallowing columnar and/or stratified squamous epithelial lining Often with thyroid tissue present in cyst wall TX: Sistrunk Procedure (removal of cyst with midline segment of hyoid bone and muscle... less than 10% recurrence)
50
Xerostomia is most common in which demographic
ELDERLY FEMALES
51
Medications associated with xerostomia are...
Antihistamines Decongestants Antidepressants Antipsychotics Antihypertensives Anticholinergics
52
Xerostomia Treatments
- continuous hydration - artificial saliva - fluoride application - Pilocarpine (Salagen) or cevimeline (Evoxac), but they have side effects - Chlorhexidine/other antimicrobial mouthrinse
53
Mucocele (Mucous Extravasation Phenomenon)
blockage or rupture of salivary gland duct and spillage of mucin into surrounding tissue usually children or young adults usually by local trauma, like a lip bite Usually on lower lip, followed by floor of mouth (ranula), anterior ventral tongue, buccal mucosa, and palate RARE in upper lip-- submucosal nodule in upper lip is probably a neoplasm-- not a mucocele!! Dome shaped submucosal swelling 2mm to several cm in size Bluish translucence to normal color Fluctuant or firm on palpation
54
Ranula
Mucocele that is on the floor of the mouth
55
Sialolithiasis
Salivary stone - calcified structures that develop within salivary ductal system Etiology: deposition of calcium salts around nidus of debris (bacteria, etc) usually SUBMANDIBULAR gland duct-- because duct is long and has a tortuous uphill course Increased pain and swelling at mealtime Firm (rock-hard) mass in floor of mouth or cheek Smooth surfaced radiopaque mass, can see concentric rings on radiograph Surrounded by salivary duct epithelium
56
Most salivary gland tumors involve the ______ gland
Parotid (most are benign)
57
2nd most common site for salivary gland tumors? What percent are malignant here?
Minor salivary glands about 50% are malignant here
58
Sublingual gland tumors are rare, but they are usually _____________ when present
MALIGNANT (around 90%)
59
Features of BENIGN salivary gland tumors
slow growth painless firm most have normal surface
60
Features of MALIGNANT salivary gland tumors
fast growth pain or paresthesia firm ulcerated surface
61
Pleomorphic Adenoma (Benign Mixed Tumor)
MOST COMMON salivary gland tumor arises from ductal epithelium and myoepithelial elements ADULT FEMALES slowly growing, rubbery-firm mass If in the parotid gland, it is usually the superficial lobe If in a minor salivary gland, it is usually seen in the palate or upper lip well circumscribed, encapsulated tumor tumors may be completely composed of myoepithelial cells GOOD PROGNOSIS with adequate surgical excision small amount will undergo malignant transformation
62
Papillary Cystadenoma Lymphomatosum (Warthin Tumor)
BENIGN tumor of PAROTID almost exclusively in the parotid gland (slow growing in tail of parotid) strong association with SMOKING OLDER MALES very small percent is bilateral relatively low recurrence rate VERY RARE malignant transformation
63
Mucoepidermoid Carcinoma
Most common MALIGNANT salivary gland tumor mucous and squamous differentiation Wide age range, but peak is in pt's 30s FEMALES parotid and minor salivary glands of the palate most common may present as intraosseous jaw tumor Low grade-- very good prognosis High grade-- bad prognosis Children have better prognosis than adults
64
Intraosseous Mucoepidermoid Carcinoma
MALIGNANT central tumor, possibly arising from entrapped, ectopic salivary gland tissue or odontogenic epithelium histologically identical to soft tissue tumor (mucoepidermoid carcinoma) MIDDLE AGED FEMALES MANDIBLE more common Swelling, pain, paresthesia Unilocular or multilocular radiolucency GOOD PROGNOSIS--90% cure rate
65
Odontogenic ________ are relatively common in dental practice, but odontogenic __________ are uncommon.
Cysts-- common Tumors-- uncommon
66
Odontogenic Cysts (general definition)
epithelium-lined cysts in bone, seen only in the jaws (rare exceptions) subcategorized into developmental and inflammatory cysts
67
Dentigerous Cyst
Cyst originating around the crown of an unerupted tooth MOST COMMON DEVELOPMENTAL ODONTOGENIC CYST usually MAND. 3RD MOLARS other common sites: - maxillary canines - maxillary 3rd molars - mandibular 2nd premolars usually PERMANENT TEETH may cause root resorption of adjacent teeth usually between ages 10-30 Well-defined, unilocular radiolucency around crown of unerupted tooth
68
Treatment/Prognosis for Dentigerous Cyst
surgical enucleation of cyst with removal of unerupted tooth tooth may be left in place if eruption is deemed feasible (orthodontic assistance may be necessary) EXCELLENT PROGNOSIS - rare recurrence
69
Odontogenic Keratocyst (OKC)
arise from cell rests of the dental lamina Multiple OKCs are associated with nevoid basal cell carcinoma syndrome (Gorlin syndrome) Any age, but mostly between ages 10-40 MANDIBLE usually - posterior body and ramus sometimes involves unerupted teeth small vs. large lesions described in another card stratified squamous epithelial lining, 6-8 cells thick Tx: enucleation and curettage Recurrence is 30%
70
OKC Small vs. Large Lesions
SMALL OKC LESIONS: - well defined, unilocular radiolucency - NO clinical expansion - asymptomatic LARGE OKC LESIONS: - well defined multilocular radiolucency - pain, swelling, drainage - occasional clinical expansion
71
Odontoma
type of mixed odontogenic tumor MOST COMMON ODONTOGENIC TUMOR Developmental anomaly (hamartoma) Compound and complex types composed mostly of enamel and dentin, variable amounts of pulp and cementum KIDS AND TEENS (median is 14) asymptomatic and small, but some can be 6+ cm in size may cause clinical expansion Radiograph: calcified mass or tooth-like structures surrounded by well-defined, narrow radiolucent border EXCELLENT PROGNOSIS
72
Ameloblastoma
most common clinically significant odontogenic tumor odontogenic epithelial origin slow-growing, locally invasive tumor 3rd-7th decade MANDIBLE - molar/ascending ramus small lesions are asymptomatic, pain and paresthesia are UNCOMMON may slowly enlarge to massive proportions Radiograph, histology, tx described in another card
73
Ameloblastoma Radiograph Characteristics
Well-defined, multilocular radiolucency, but could be unilocular Resorption of roots of adjacent teeth Buccal and lingual expansion Common association with unerupted tooth
74
Ameloblastoma Histologic Patterns
6 histologic patterns... these are the shared features: - columnar ameloblast-like cells with hyper chromatic nuclei - nuclei of these cells orient away from the basement membrane (reverse polarity) appearance reminiscent of PIANO KEYS
75
Treatment of Ameloblastoma
if you only do removal and curettage, there is usually recurrence. Marginal resection is more commonly used - less chance of recurrence some surgeons advocate 1-2cm margins past radiographic limits
76
When the odontoma is made up of toothlets, it is ______________
Compound
77
Most tumors arriving from this salivary gland are malignant
Sublingual (about 90% are malignant)
78
Percent of salivary gland tumors that are benign
75%
79
Most common salivary gland tumor: parotid, palate, upper lip are most common sites
pleomorphic adenoma
80
Most common odontogenic cyst?
Periapical cyst
81
Typical treatment for ameloblastoma
Marginal resection
82
Approximate recurrence rate for odontogenic keratocysts treated with enucleation and curettage?
30%
83
Most common odontogenic tumor that is a hamartoma of dental hard and soft tissue
Odontoma
84
Most common developmental odontogenic cyst; develops around the crown of an unerupted tooth
Dentigerous cyst
85
Percent of pleomorphic adenomas that will undergo malignant transformation
5%
86
Prognosis for intraosseous mucoepidermoid carcinoma
GOOD
87
Most common location for mucoceles
Lower lip
88
Odontoma made up of a disorganized mass of dental hard/soft tissue
Complex
89
Fluctuant midline swelling that tends to move up and down upon swallowing
Thyroglossal Duct Cyst
90
Most common clinically significant odontogenic tumor; slow growing and locally invasive
ameloblastoma
91
Dental consideration for patients with xerostomia that may be combated with supplemental fluoride
Root caries
92
Characteristic histologic appearance of ameloblastoma resembles these
Piano keys
93
Second most common site for salivary gland tumors; about half of these tumors are malignant
Minor salivary glands
94
Benign tumor of the parotid gland strongly associated with tobacco smoking
Papillary cystadenoma lymphomatosum
95
Most common site for dentigerous cyst
Mandibular 3rd molars
96
Surgical procedure to treat thyroglossal duct cysts
Sistrunk procedure
97
Most cases arise in mandible of teens/younger adults; may be multilocular, typically without clinical expansion
Odontogenic keratocyst
98
Most common location for a salivary gland stone
Submandibular gland duct
99
Most common malignant salivary gland tumor
mucoepidermoid carcinoma
100
Most cases arise in the mandible in adults, may be multilocular, and large lesions show clinical expansion
ameloblastoma
101
Cyst appearing clinically as swelling anterior to the sternocleidomastoid
branchial cleft cyst

Head and Neck Pathology (3 decks)

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