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Oral Pathology Flashcards

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1
Q

Define cyst

A

Pathological cavity filled with fluid, semi-fluid or gas freq. lined by epithelium
Never filled with pus

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2
Q

Classification of cysts

A

Epithelial
- odontogenic
- non-odontogenic
Non-Epithelial

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3
Q

Sub classification of odontogenic cysts

A

Inflammatory

  • radicular; apical, lateral
  • residual

Developmental

  • odontogenic keratocyst
  • dentigerous; follicular, eruption
  • lateral periodontal
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4
Q

Sub-classification of non-odontogenic cysts

A

Fissure (developmental)

  • nasopalatine
  • nasolabial
  • median palatine

Soft tissue

  • mucous extravasation
  • mucous retention
  • dermoid
  • lymphoepithelial
  • thyroglossal duct
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5
Q

Non-epithelial cysts

A

Bone

  • simple; solitary, haemorrhagic, traumatic
  • aneurysmal
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6
Q

3 requirements for cyst pathogenesis

A
  1. Epithelial source
  2. Stimuli for cavitation + epithelial proliferation
  3. Mechanism(s) for continued growth + bone resorption
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7
Q

Discuss epithelial source of cysts

A

Inflammatory Cysts
- remnants of Hertwig’s Epithelial Root Sheath
— ensheath’s root dentine
- form epithelial cell rests of Malassez
- throughout PDL, entrapped in periapical granuloma

Dentigerous
- reduced enamel epithelium 
— forms epithelial ‘cover’ for enamel 
— protects enamel during development + eruption 
- split b/w REE + enamel -> cyst

Odontogenic keratocyst
- remnants of dental lamina
— initial buds of oral epithelium
- Glands of Serres

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8
Q

Discuss stimulus for cavitation and epithelial proliferation of cysts

A

Inflammation
- inflammatory cysts usually stim. by inflammation
- site specific: pulp necrosis -> periapical granuloma -> cyst
- PD pocket -> lat. PD inflammatory cyst
- cytokines + growth factors stim. epithelial proliferation
— IL-1+6, TNF, EGF, TGF-beta

Genetic

  • possible genetic defect in tumour suppressor gene
  • odontogenic keratocyst linked to Gorlin’s syndrome
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9
Q

Discuss mechanisms for continued epithelial growth and bone resorption

A

Hydrostatic: inflammatory + dentigerous

  • protein accumulation in cyst
  • wall acts as semi-permeable membrane
  • fluid accumulates in cyst lumen creating +ve pressure in cyst

Bone Resorption

  • cyst releases cytokines stim. bone resorption
  • IL1, TNF, PGE2

Epithelial Growth Factors
- EGF + TGF-beta May cause pronounced epithelial proliferation
- odontogenic keratocyst: pronounced mural growth
— epithelial cells over proliferate
— don’t have lots of expansion

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10
Q

General radiographic presentation of cysts

A

Well defined round/oval radiolucency
- keratocyst: scalloped margin
Usually, well corticated margin (radiopaque)
- except solitary bone cyst
- infection = loss of definition
Shape
- round due to hydrostatic growth
- keratocyst (+ solitary bone) grow through bone cf expand jaw
Locularity
- true (multiple cavities): keratocyst
- large cysts appear multilocular due to ridges in bony wall

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11
Q

General clinical findings of cysts

A 
Swelling
Pain 
Fluctuance 
Eggshell cracking
Tooth displacement/loosening
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12
Q

Clinical + radiographic findings of radicular cyst

A

Clinical

  • S: non-viral tooth, UIs common
  • develop within periapical granuloma (>10mm = cyst)
  • regular growth limited; B expansion late
  • long standing: displacement + loosening

Radiographic

  • unilocular, oval/round
  • well corticated
  • @ apex non-vital tooth
  • continuous w/ lamina dura
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13
Q

Epidemiology + Tx of radicular cyst

A

Epidemiology: 4-5th decade

Most common cyst; 65%

Tx: RCT, XLA

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14
Q

Discuss residual cysts

A

Epithelial odontogenic inflammatory cyst
Derived from rests of Malassez

S: edentulous area; retained radicular cyst post-XLA
Radiographic: well defined, oval/round

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15
Q

Histology of radicular/residual cysts

A

Lumen

  • pale pink serious exudate (white if removed)
  • macrophages, desquamated epithelial
  • inflammatory cells
  • cholesterol clefts + foreign body giant cells (if RF; GP, amalgam)

Epithelial

  • non-keratinised stratified squamous
  • variable thickness, often arcading (hyperplastic rete processes)
  • long-standing: thin, attenuated

Capsule: thick wall fibrous + granulation tissue

Inflammatory infiltrate: acute + chronic cells

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16
Q

Clinical + radiographic findings of dentigerous cysts

A

Clinical
- S: 3s, 8s common
- attached @ CEJ surrounding crown of UE tooth
— confirmed surgically/pathologically (not X-ray)
- envelop crown symmetrically
- late B expansion

Radiographic

  • unilocular, well corticated
  • crown associated lies centrally in cyst
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17
Q

Epidemiology + Tx of dentigerous cysts

A

Epidemiology: 3-4th decade

20% of jaw cysts

Tx: uncover tooth, XLA
- no recurrence

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18
Q

Histology of dentigerous cysts

A

Lumen

  • pink serious exudate
  • cholesterol clefts

Epithelial

  • non-keratinised stratified squamous
  • flat basement membrane
  • thin (2-5 cells), uniform
  • resembles REE

Cyst Wall

  • variably thick
  • blueish myxoid appearance (like dental follicle)

If becomes inflamed, indistinguishable from inflammatory cyst

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19
Q

Clinical + radiographic findings of odontogenic keratocyst

A

Clinical: S: Md; angle, ramus

Radiographic 
- usually multilocular 
- poss. associated w/ UE tooth
- little expansion 
- grows through medullary bone; late B expansion 
— root resorption possible
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20
Q

Epidemiology and Tx of odontogenic kerarocyst

A

Epidemiology: 2-3rd decade

5% jaw cysts

Tx: XLA
- recurrence common due to daughter cysts

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21
Q

Histology of odontogenic keratocyst

A

Lumen: pink, keratin filled

Epithelial 
- para/keratinised corrugated surface 
- flat basement membrane (developmental)
- basal cells
— reverse nuclear polarity (towards lumen)
— darkly staining

Wall: thin, fibrous
Small daughter cysts poss. in wall
- due to epithelial growth grows into marrow spaces
- lots = syndromic

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22
Q

Discuss lateral periodontal cysts

A

Any cyst in lat. PD area
Epithelial: derived from remnants dental lamina

Clinical: lat. roots vital teeth

Radiographic

  • unilocular, well corticated
  • round, small (<1cm)
  • B expansion if v large
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23
Q

Histology of lat. PD cyst

A

Epithelial

  • non-keratinised stratified squamous
  • thin (2-5 cells), not uniform
  • thickened areas for swirled plaques
  • flat basement membrane

Wall

  • thin, fibrous
  • scattered glycogen rich clear cells
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24
Q

Clinical + radiographic findings of nasopalatine cyst

A

Clinical

  • S: midline, ant. Mx; vital UIs
  • size: >6mm
  • asymptomatic

Radiographic

  • unilocular, well corticated
  • round/oval
  • apices of U1s
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25
Histology of nasopalatine cyst
Lumen - serous exudate - variable inflammatory infiltrate Epithelium - non-keratinised stratified squamous - ciliated pseudo-stratified respiratory - both Wall - fibrous - neurovascular bundles
26
Discuss solitary bone cyst
Non-epithelial non-odontogenic cyst Usually <20y Aetiology: unknown, poss. trauma Clinical - S: Md body - asymptomatic Radiographic - unilocular, well corticated - irregular outline; extend b/w roots
27
Histology of solitary bone cyst
Fibrovascular tissue only Lumen: usually empty Epithelial: none Wall: none/thin fibrous - occ. giant cells - haemosiderin pigment; blood vessels were present
28
Discuss aneurysmal blood cyst
Epidemiology: child, young adult Aetiology: unknown Soft tissue lesion; also classified as giant cell lesion - blood filled cystic spaces Clinical: S: Md Radiographic - multilocular, well corticated - cortical expansion (ballooning) - partially cystic, partially solid
29
Histology of aneurysmal bone cyst
Giant cell lesion Giant cells in hypervascular, hypercellular background Localised proliferative lesion of vascular tissue w/ giant cells + granulation tissue Blood filled cystic spaces
30
Discuss mucous extravasation and retention cysts
``` Extravasation - younger - aetiology: trauma - S: L lip - histology — lumen: extravasated mucin — epithelial: none — wall: granulation tissue ``` ``` Retention - older - S: L lip less common - related to duct obstruction - histology — dilated salivary duct filled w/ mucin — has epithelial lining ```
31
Discuss lympho-epithelial cyst
Epidemiology: late childhood, early adulthood Epithelial: remnants within lymphoid tissue - stimuli for proliferation unknown Clinical - unilateral, fluctuant swelling - S: lat. neck, ant. sternocleidomastoid Histology - attenuated epithelium surrounded by lymphoid stroma
32
Discuss dermoid cyst
Developmental anomaly Rare - F=M - 15-35; may present earlier/later Clinical: S: midline FoM, above mylohyoid Histology - epithelial: epidermis - wall: skin appendages (sebaceous glands, hair follicles)
33
Discuss thyroglossal cyst
Developmental Occurs when thyroglossal tract left from descent of thyroid doesn’t breakdown Clinical: S: midline Histology - epithelium: attenuated or respiratory - wall: thyroid follicles (req. for Dx)
34
Briefly describe tooth development
Neural crest cells (from ectoderm) migrate + clump beneath oral ectoderm - induce formation 1ry epithelial band - gives rise to tooth germs Pre-ameloblast induce odontoblasts - form dentine which induce ameloblasts - form enamel of crown Following fragmentation of Hertwig’s root sheath, dentine formation during root development induce cementoblasts
35
General features of odontogenic tumours
Derived: odontogenic epithelium (oral ectoderm) +/- mesenchyme Neoplasm - abnormal/uncontrolled growth/proliferation - unrelated to stimuli - benign or malignant Hamartoma - developmental malformation - normal tissue, incorrect proportion or morphological arrangement Most odontogenic tumours are benign - more hard tissue content (mature) = more benign
36
Classification of odontogenic tumours
Epithelium only Epithelium + mesenchyme +/- hard tissue Mesenchyme only
37
Odontogenic epithelium only tumours
``` Ameloblastoma: benign, v aggressive Calcifying epithelial: benign Squamous: benign Clear cell: malignant Adenomatoid: enamel, cystic ```
38
Odontogenic epithelial + mesenchyme tumours
Ameloblastic fibroma: no hard tissue, both epithelium + mesenchyme neoplastic Calcifying odontogenic cyst: dentine + enamel like material, cystic Odontoma: all hard tissues formed
39
Odontogenic mesenchyme only tumours
Benign cementoblastoma Odontogenic fibroma: only mesenchyme neoplastic Myxoma: destructive potential
40
Epidemiology, freq., origin + Tx ameloblastoma
Benign odontogenic neoplasm Epidemiology: 20-50y Freq.: 1% all tumours Origin: cell rests of enamel organ or dental lamina Tx - surgical removal w/ margin (invasive) - long term follow up due to recurrence
41
Clinical + radiographic findings of ameloblastomas
Clinical - S: Md 80% (angle); Mx 20% - behaviour: slow growing, locally aggressive - late Dx + incidental finding as mucosa appears normal - early: asymptomatic - late — expansion of cortical plates, egg shell cracking — extension into soft tissues — root resorption, painless — if left: destruction of Md Radiographic - multilocular ‘soap bubble appearance’ - well corticated; slow growing, Mx less so - round/oval, scalloped edge
42
Histology of ameloblastoma
Solid/cystic/both Epithelium: resembles ameloblasts - tall, columnar - reverse nuclear polarity (prominent basal cells) Follicular - epithelial islands - filled w/ loose stellate reticulum-like cells - some cystic degeneration (not true cyst) Plexiform - interlacing epithelial strands - less stellate-like cells
43
Discuss unilocular ameloblastoma
Freq.: 10-15% of ameloblastomas Radiographic: unilocular - resembles dentigerous/radicular cyst Often associated w/ crown UE8
44
Epidemiology, freq., origin + Tx of calcifying epithelial odontogenic tumours
Benign, solid neoplasm Epidemiology: 20-60 Freq.: rare, 1% of odontogenic tumours Origin: odontogenic epithelium, poss. cells of stratum intermedia Tx: surgical excision w/ margin
45
Clinical + radiographic features of calcifying epithelial odontogenic tumours
Clinical - S: Md body 75% (P/M) - behaviour: slow growing, locally invasive — usually small; v. large if undetected - early: asymptomatic - late: cortical plate expansion, root resorption Radiographic - uni/multilocular - scatter radiopacities; esp. around UE crown - often associated w/ UE tooth - ill/well defined, irregular/round
46
Histology of calcifying epithelial odontogenic tumours
Epithelial - islands - pleomorphic, hyperchromatic, prominent nucleoli - bizarre atypia - no mitosis, no necrosis Calcifications - concentric circles - laminated - basophilic - no pre-dentine layer; abrupt
47
Epidemiology, freq., origin + Tx ameloblastic fibroma
Benign neoplasm Epidemiology: <20 Freq.: rare;
48
Clinical + radiographic findings of ameloblastic fibroma
Clinical - S: Md body 80% - behaviour: slow growing - asymptomatic - B+L expansion w/ tooth displacement - 50% associated w/ UE (mistaken for dentigerous) Radiographic - resembles ameloblastoma - small: unilocular, smooth, well corticated - large: multilocular
49
Histology of ameloblastic fibroma
Similar to ameloblastoma Epithelial - tall, columnar basaolid (ameloblast-like) - islands + strands - filled w/ stellate-like cells Hypercellular mesenchyme in connective tissue (fibroma); usually dominant feature - looks primitive; too many cells for mature cell No hard tissues
50
Epidemiology, freq., origin + Tx of adenomatoid odontogenic tumour
Benign lesion, epithelium + variable hard tissue Epidemiology: <30 Freq.: v rare Origin: odontogenic epithelium Tx: curettage
51
Clinical + radiographic findings of adenomatoid odontogenic tumour
Clinical - S: Mx ant., usually associated w/ UE - behaviour: slow growing, locally expansive - early: asymptomatic - late: root resorption, displacement, bony destruction (expansion) Radiographic - unilocular, round/oval - well corticated - early: resemble dentigerous cyst, extends apical to CEJ - late: small radiopacities within lesion
52
Histology of adenomatoid odontogenic tumour
Solid or cystic Intra-osseous or extra-osseous (gingival swelling-like) Epithelium - tall, columnar cells resemble ameloblasts - from duct-like structures + rosettes (whirls of cells) Calcifications - abrupt, basophilic deposits within epithelium - immature enamel, dentine - like calcifying epithelial odontogenic tumour
53
Epidemiology, freq., origin + Tx of calcifying odontogenic cyst
Benign cystic tumour; epithelium + hard tissue Epidemiology: <40 Freq.: rare Origin: odontogenic epithelium Tx: enucleation
54
Clinical + radiographic findings of calcifying odontogenic cyst
Clinical - S: Md ant. 80% - behaviour: slow growing - early: asymptomatic - late: local expansion Radiographic - unilocular, well corticated - occ. associated w/ UE/odontome - radiopacities within lesion
55
Histology of calcifying odontogenic cyst
Cystic (majority), some solid 75% intra-osseous Epithelium - tall, columnar, reverse nuclear polarity - ameloblast-like ``` Suprabasal: loose stellate reticulum-like layer Ghost cells (lack nuclei), may calcify ``` Calcifications: dysplastic dentine Resembles ameloblasts, diff. by ghost cells + calcifications
56
Epidemiology, freq., origin, Tx of odontomes
Hamartoma, developmental abnormality (WHO) Epidemiology: <20 Freq.: most common Origin: odontogenic epithelium Tx: XLA
57
Type of odontome
Compound - small tooth-like denticles - tooth shapes of normal radiodensity Complex - irregular, haphazard mass - similar radiopacity to normal
58
Clinical + radiographic findings of odontomes
Clinical - S: Mx - behaviour: slow growing - asymptomatic, delay eruption/impacted - local expansion Radiographic - similar radiopacity to normal tissue - associated w/ UE/impacted tooth - radiolucent line around lesion
59
Histology of odontome
Resemble developing teeth - enamel space (white) - dentine + pre-dentine - pulp tissue Compound: organised, separated structures Complex: irregular, haphazard arrangement
60
Epidemiology, freq., origin, Tx of odontogenic myxoma
Benign neoplasm, mesenchymal Epidemiology: young adult, F>M Freq.: rare Origin: mesenchyme (fibroblasts) Tx: excision
61
Clinical + radiographic findings of odontogenic myxoma
Clinical - S: Md (angle) > Mx - behaviour: locally invasive + expansive - early: asymptomatic - late: expansion ``` Radiographic - multi/unilocular — poss. soap-bubble appearance - occ. associated w/ UE - smooth, well defined ```
62
Histology of odontogenic myxoma
Hypercellular myxoid ground substance - contains spindle/stellate cells - stellate reticulum-like Epithelium: scattered rests, not neoplastic
63
Epidemiology, freq., origin + Tx of benign cementoblastoma
Benign neoplasm, mesenchymal Epidemiology: 10-70; 50% <20 Freq.: rare Origin: cementoblasts Tx: excision/enucleation
64
Clinical + radiographic findings of benign cementoblastoma
Clinical - S: Md > Mx; P/M - behaviour: slow growing - local enlargement + expansive - root resorption Radiographic - well defined dense mass @ apex - radiolucent margin - continuous w/ root
65
Histology of benign cementoblastoma
``` Cellular cementum - attached to root - resting + reversal lines — mark changes in growth direction — usually indicate fast growing lesion ``` Fibrous capsule
66
Histology of alveolar osteitis
Dry socket Excessive acute inflammatory infiltrate - lots of neutrophils - localised to socket wall Bacterial aggregates Irregular necrotic bone
67
Histology of osteomyelitis
``` Acute - acute inflammatory infiltrate — densely packed neutrophils form pus - necrotic bony islands; acellular — resorbed by osteoclasts ``` Chronic - mixed inflammatory infiltrate - fibrosis
68
Radiographic findings of osteomyelitis
Ill defined/poorly corticated; loss of cortication Mottled/moth eaten appearance Bony sequestra floating Mixed radio-density
69
Histology of ORN
Completely acellular bone - lacunae empty; lack osteocytes - no osteoblasts on periphery Bacterial aggregates - periphery - bone marrow spaces Mixed inflammatory infiltrate Necrosis Fibrin
70
Epidemiology and aetiology of fibrous dysplasia
Benign skeletal anomaly Normal bone replaced by immature disorganised bone + fibrous tissue Epidemiology - children, young adults (bones growing) - F>M
71
Clinical + radiographic findings of fibrous dysplasia
``` Clinical: depends on bone(s) affected - S: Mx > Md - behaviour: slow growing, self limiting — stops once bones stop growing - facial asymmetry - tooth displacement + malocclusion ``` Radiographic - ground-glass appearance - ill defined; extends to cortex - roots + bone appear continuous (not) - loss of lamina dura - narrowing of PDL - early: radiolucent (fibrous) - late; radiopaque (calcified)
72
Histology of fibrous dysplasia
Highly cellular fibrous stroma Bony islands deposited in fibrous tissue - immature, woven bone - no osteoblast rim; secreted by fibroblasts - irregular, curved, haphazard morphology
73
Epidemiology, freq. and Tx of cemento-ossifying fibromas
Benign neoplasms of jaws + craniofacial skeleton Epidemiology: 40-59, F>M Freq.: rare Tx: excision; recurrence rare
74
Clinical + radiographic findings of cemento-ossifying fibroma
``` Clinical - S: Md (P/M) - behaviour: slow growing — no malignant transformation - B+L expansion - painless ``` Radiographic - well corticated - mixed radiodensity - no fusion b/w roots + bone
75
Histology of cemento-ossifying
Highly cellular fibrous stroma Pseudo-capsule: reactive bone Mineralised tissue deposited within stroma - reactionary, woven bone - lamellar bone - cementum-like tissue
76
Epidemiology of cemento-osseous dysplasia
Non-neoplastic fibro-osseous condition affecting alveolar bone Epidemiology - middle aged - F - Afrocaribbean
77
Types of cemento-osseous dysplasia
PA: PA region, Md, ant. Focal: single tooth Florid: multiple sites, multi-Qs Familial gigantiform cementoma: autosomal dominant, multifocal
78
Clinical + radiographic findings of cemento-osseous
Clinical - PA/Focal: asymptomatic, incidental finding - Florid: minor bony expansion - FGC: bony expansion, facial deformity Radiographic - well defined - thin radiolucent rim - mixed radiodensity - no fusion w/ roots
79
Mx of cemento-osseous dysplasia
``` PA/Focal: none, monitor Florid: risk osteomyelitis, regular recall FGC: surgery - risk recurrence - 2ry infection ```
80
Histology of cemento-osseous dysplasia
``` High cellular fibrous stroma Mineralised deposits - woven/lamellar/cementum-like - haphazard, irregular - fuse to from islands - many reversal lines ```
81
Epidemiology, freq., aetiology + Mx of Paget’s disease
``` Epidemiology: >40 Freq.: 1.5-8% popn Aetiology: unknown - genetic - environmental: paramyxovirus ``` Mx: bisphosphonates
82
Phases of Paget’s disease
1. Osteoclastic: excessive resorption, fibrovascular tissue deposited 2. Osteoblastic: new bone formation within fibrous tissue 3. Osteosclerotic: bone coalesces -> dense, sclerotic bone
83
Clinical presentation of Paget’s disease
Jaws rare: Mx > Md Mx - widening of alveolar process - palate flattening - malocclusion: retroclination UIs, P tipping post. Md: expansion -> facial deformity ``` Enlargement Pathological # (weak) Deformity of weight bearing bones Compression of cranial nerves - deafness - visual disturbance - vertigo ```
84
Radiographic findings of Paget’s disease
1. Radiolucent 2. Mixed radiodensity, cotton wool appearance, ill defined 3. Very dense, radiopaque
85
Dental implications of Paget’s disease
Early: highly vascular stroma -> inc. risk post-XLA bleeding Late: irregular bone + min. vascularity -> inc. risk infection Hypercementosis: difficult XLA
86
Histology of Paget’s disease
Mosaic pattern - haphazard, irregular arrangement of bone Prominent, basophilic reversal lines Mature: less vascular
87
Aetiology of cherubism
Benign, autosomal dominant disorder of childhood Aetiology: mutation of binding protein gene
88
Clinical presentation of cherubism
Presents: 2-4y, usually normal @ birth ``` S: Md > Mx Behaviour: slow growing, self limiting Bilateral, symmetrical expansion Facial deformity - characteristic retracted skin, upwards gaze ``` Tooth displacement + loosening Delayed eruption + premature loss Speech + visual impairments
89
Radiographic findings + Mx of cherubism
Radiographic - hypercellular + hypervascular fibrous stroma — replaces bone — numerous multinucleate osteoclast giant cells - abundant haemosiderin (b/d of RBC) - perivascular hyalinisation ``` Mx - detect + Tx UE - OH - orthognathic: facial deformity + malocclusion — once stopped growing ```
90
Aetiology/types of hyperparathyroidism
1ry - adenoma (benign tumour) 80% - carcinoma (malignancy) 5% - idiopathic hyperplasia 15% 2ry: hyperplasia 2ry to renal disease/intestinal malabsorption 3ry: hyperplasia, gland behaves as autonomous adenoma following removal
91
Pathogenesis of hyperparathyroidism
Parathyroid glands detect + regulate serum Ca2+ conc. Excess PTH prod. from adenoma/hyperplasia Stim. osteoclasts -> Ca2+ mobilised from bone Ca2+: tubular re-absorption, intestinal absorption PO4-: renal excretion PTH: inc. ALP: inc.
92
Clinical features of hyperparathyroidism
``` Bone - brown tumours (giant cell lesions) - osteoporosis - joint pain Renal stones GIT irregularity Depression Fatigue, nausea Muscle weakness ```
93
Radiographic findings + Mx of hyperparathyroidism
Radiographic - well defined - variable: radiolucent -> densely sclerotic - irregular radiopacities Mx - 1ry: removal - 2ry: Tx underlying cause
94
Histology of hyperparathyroidism
Similar to cherubism Hypercellular, hypervascular fibrous stroma - multinucleate osteoclast giant cells Haemosiderin Bony destruction, modular appearance
95
Types of giant cell granuloma
Central | Peripheral
96
Epidemiology + Mx of central giant cell granuloma
Localised, benign osteolytic lesion of jaws Epidemiology: F > M ``` Mx - curettage - intralesional/systemic medication — steroid — calcitonin — interferone — RANKL inhibitors ```
97
Clinical + radiographic findings of central
``` Clinical - S: Md > Mx, ant. - behaviour: slow growing, expansile - asymptomatic - 30% locally aggressive — pain — resorption + displacement — perforate cortex, involve soft tissue ``` Radiographic - well defined radiolucency - advanced: multilocular
98
Histology of central giant cell granuloma
Hypercellular, hypervascular fibrovascular stroma Numerous multinucleate osteoclast giant cells Haemosiderin
99
Aetiology of peripheral giant cell granuloma
Localised reactive proliferation of gingiva/alveolar mucosa Aetiology - 2ry reactive process - localised mucoperiosteum/coronal PDL irritation - plaque/calculus/overhanging restoration
100
Clinical + radiographic findings, Mx of peripheral giant cell granuloma
Clinical - S: Md > Mx, gingiva, edentulous ridge - sessile/pedunculate soft pink/purple-blue lump - smooth/ulcerated/papillomatous surface Radiographic: no bony invasion (poss. erosion of alveolar bone) Mx: surgical removal, recurrence low
101
Syndromes that may lead to central giant cell granulomas
Neurofibromatosis type 1 Noonan LEOPARD (noonan w/ lentigines)
102
General features of abscesses
Develop @ apices of tooth w/ necrotic/infected RC May occur in deep PPD along affected tooth Presents: pain + swelling, poss. discharge - spread along fascial/muscle planes -> cellulitis, Ludwig’s angina
103
Causes of pulpitis/abscess
``` Caries Trauma # Deep PPD: lat. +/- accessory canals Extension of PA infection from adjacent tooth Blood stream (anachoresis) ```
104
Sequelae of pulpitis
Pulpitis -> acute chronic - > PA periodontitis -> acute chronic - > dento-alveolar abscess PA granuloma - > inflammatory dental cyst -> abscess -> distant spread
105
Obligate anaerobes commonly associated w/ pulpitis
Gram- rods - porphyromonas gingivalis - prevotella intermedia - fusobacterium nucleatum Gram+ rods - eubacterium - lactobacillus - actinomyces Gram+ cocci: peptostreptococci Gram- cocci: veillonella
106
Facultative anaerobes commonly associated w/ pulpitis
Gram+ cocci - strep. mitis, oralis, intermedius - enterococcus faecalis Gram- cocci: neisseria Gram+ rods - corynebacterium - lactobacillus
107
Tx of pulpitis
Debridement: remove necrotic + infected tissue from RC Antimicrobial: RC dressing, occ. systemic RCT Apicoectomy: if infection persists
108
Clinical features of abscesses
``` Pain: rapid onset Erythema Swelling Tenderness: TTP, palpation Mobility ```
109
Routes for pus drainage from abscess
RC/PDL Cancellous bone + perforate cortex Into OC/facial skin through sinus tract Palate: discrete swelling due to dense mucoperiosteum
110
Mx of periapical abscess
``` Drainage Remove source (RCT) AB - req. — no drainage — spread to soft tissues — pt febrile - amoxicillin - metronidazole: failure to respond within 48h ```
111
What is a periodontal abscess?
Abscess caused by acute/ bronco destructive process in periodontium Results in localised formation of pus communicating w/ OC through PDL and/or periodontal sites Doesn’t arise from necrotic pulp
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Classification of periodontal abscesses
Gingival: localised soft gingival tissues; margin, interdental papilla Periodontal: larger, extends apically Pericoronal: associated gingiva of UE/E tooth (usually periocoronitis)
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What causes periodontal abscesses to form? Mx?
Occlusion or trauma to PPD orifice causing bacteria to become trapped - infection spread; pocket -> soft tissues Mx - drainage - debridement - AB: if pyrexia or cellulitis
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Define abscess
Pathological cavity w/ pyogenic membrane + pus filled
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Local + systemic signs of inflammation
Local - pain - swelling - redness - heat - loss of function - lymphadenopathy ``` Systemic - fever - inc. HR - altered bloods — Inc.: WBC (PMN), serum protein, ESR ```
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Clinical presentation of acute abscess
Soft tissue swelling - usually B - U2/6 P Pain: poorly localised - affected tooth painful if post-PA PD Mobility (post-PD) X-ray changes: may take few days
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Tx for acute abscesses
Drain pus Remove cause - RCT/XLA/incise + drain
118
What can happen if abscesses are left unTx’d?
Spontaneous drainage will occur -> chronic abscess
119
Why may an infection to spread? What determines direction of spread?
Cause - host usually maintain balance b/w defence + bacteria - imbalance -> spread — opportunistic infection — inadequate/no Tx — immunocompromised: cold, fatigue, insomnia Direction - can spread in any direction - take path of least resistance
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Stages of infection/abscess
Cellulitis - diffuse swelling due to tissue oedema - red + shiny - firmness depends on amount of fluid - spreading in potential connective tissue spaces - suppurations @ source, accumulates if unTx’d ``` Suppurative - once infection peaked - pus accumulation @ centre - position depends on — gravity — pressure — heat — muscle activity ```
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Source of dental infections
Odontogenic infections: any dental infectious disease - abscess: PA, PD - pericoronitis Less common - AUG - infected cysts - MRONJ/ORN/osteomyelitis - fungal infection - cancrum oris
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Potential maxillary spaces for spread of infection
``` Buccal space: sup. to buccinator Buccal sulcus: inf. to buccinator Palatal Lat. pharyngeal Sinus Canine fossa ```
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Potential mandibular spaces for spread of infection
``` Sublingual Submandibular Submental Labial sulcus Submasseteric Pytergomandibular Lat. pharyngeal Peritonsillar Buccal space Buccal sulcus ```
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Differentiate b/w sublingual + submandibular space
Sublingual: sup. to mylohyoid Submandibular: inf. to mylohyoid Mylohyoid is lower ant., higher post. - most post. infection will be sublingual
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What are the submasseteric and pytergomandibular spaces?
Submasseteric: b/w lat. border ramus (lat., post.) + masseter (ant., medial) Pytergomandibular: b/w medial border ramus (lat., ant.) + medial pterygoid (post., medial’)
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What are the peritonsillar and lat. pharyngeal spaces?
Lat./parapharyngeal - b/w carotid sheath (post., lat.) + medial pterygoid (ant., medial) - sup. to constrictor Peritonsillar: inf. to constrictor
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Differentiate b/w submental + labial sulcus space and buccal space + sulcus in Md
Submental - chin - inf. to mentalis Labial sulcus: sup. to mentalis Buccal - space: inf. to buccinator - sulcus: sup. to buccinator
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What factors affect the spread of infection?
Ability to - bacteria: no., virulence - failure to drain - pt health Anatomical - site - drainage site - natural barriers
129
Discuss Ludwig’s angina
Bilateral submental, submandibular, sublingual infections Clinical - raised, swollen tongue - pyrexia - dysphagia - dyspnoea - dysarthria Tx - drainage - IV AB - poss. tracheostomy for airway
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Indications urgent referral to hospital is req. for abscess
``` Rapidly swelling Pyrexia Raised FoM: dysphagia, dysarthria, dyspnoea (Ludwig’s) Deviated uvula: Ludwig’s Immunocompromised/DM Severe trismus High pulse, raised WBC Toxic appearance Malaise ```
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Difference b/w premalignant lesion and condition
Lesion: morphologically altered tissue in which cancer more likely cf normal counterpart Condition: generalised state associated w/ significantly inc. risk developing cancer
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What is leukoplakia?
Pre-malignant lesion characterised by white patches w/ questionable risk having excluded know diseases/disorders w/ no inc. risk
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Epidemiology + aetiology of leukoplakia
Epidemiology - middle age, inc. age - M>F Aetiology - smoking: 90% - idiopathic: 10%
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Clinical presentation of leukoplakia
``` White patches S - B mucosa: 25% - Md gingiva: 20% - tongue: 10% - FoM: 10% ```
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Discuss the two types of leukoplakia
Homogenous: no malignant change - uniform flat appearance - may have shallow cracks - smooth/wrinkled/corrugated surface - consistent texture Non-homogenous: 26% malignant transformation - predominately white or white/red lesion (erythroleukoplakia) - irregularly flat/nodular/exophytic — nodular: raised, rounded, red and/or white excrescences — exophytic: irregular blunt or sharp projections
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What is erythroplakia?
High risk pre-malignant lesion Always associated w/ dysplasia/carcinoma 80% malignant transformation
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Aetiology of erythroplakia
Tobacco + smoking Snus: 60% users get keratoses - associated w/ oral epithelial dysplasia - rarely dysplastic - malignancy: 0-1.2%/10y Candida albicans: 30% associated - chronic hyperplastic candidiasis - dysplasia, speckled/nodular = high risk - lesion may regress w/ Candida Tx
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Clinical presentation of erythroplakia
Brightly red velvety plaque | Can’t be characterised as any other lesion
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Oral signs of syphilis
1ry: oral chancre (rare, 2% extragenital) 2ry - leukoplakia: D tongue - condyloma lata - mucosal patches - ulcers 3ry - gumma - syphilitic leukoplakia - atrophied glossitis
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Malignancy risk of syphilis
2.5% pt have leukoplakia | 10% OSCC
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Clinical presentation of Plummer-Vinson syndrome and associated risk
``` Clinical - Fe anaemia — strophic glossitis — aphthous-like ulcers — mucosal pallor — sore tongue - post-cricoid oesophageal web - dysphagia ``` Risk factor for OSCC and oesophageal carcinoma
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Discuss oral submucous fibrosis
Pre-malignant condition Aetiology: Paan/Betel quid chewers Clinical - mucosal fibrosis + marbling - trismus - leukoplakia - staining + attrition 30% develop OSCC
143
Discuss actinic keratosis
Aetiology: sunlight damage Clinical - speckled, rough scaly patch - obliterates vermillion border - lip crusting - peri-oral freckles Risk: 1%/yr SCC - 60% SCC from AK
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Cancer risk of LP
0.5-2.0%/5yr OSCC | Controversial
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Define: keratosis, hyperkeratosis, orthokeratosis, parakeratosis
Keratosis: keratinisation of epithelium not normally keratinised Hyperkeratosis: thickening of keratinised layer Orthokeratosis: flat, anucleate superficial cells w/ homogenous eosinophilic cytoplasm Parakeratosis: flat, homogenous eosinophilic cells w/ pyknotic nuclei
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Define: acanthosis, atrophy, atypia, dysplasia
Acanthosis - inc. no. cells in prickle cell layer - inc. epithelial thickness - broadening of Rete ridges Atrophy - dec. thickness due to less cells - loss of Rete ridges - epithelium uniform Atypia: changes to individual cell Dysplasia: changes to whole epithelium
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Features of dysplasia
``` Nuclear hyperchromatism Nuclear + cellular pleomorphism Inc. nuclear:cytoplasm Inc. no. + bizarre mitoses Mitosis in prickle layer Premature keratinisation in prickle layer Loss of polarity of basal cells Loss of cell adherence Drop shaped Rete ridges Loss of epithelial stratification ```
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Grading of dysplasia
None: epithelium normal Mild: few epithelial cells in basal layer show atypia Mod.: atypia in most basal cells + few suprabasal cells Severe: almost all cells show atypia, basement membrane intact (no invasion)
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Histology of leukoplakia
``` Para/hyperkeratosis (clinically white) Variable: hyperplasia, acanthosis Atrophy Candidal hyphae Inflammation Poss.: 1/+ dysplasia features ```
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Histology of erythroplakia
Atrophy (clinically red) Dysplasia Inflammation
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Management of dysplasia
Mild: review, advice, biopsy (repeat if req.) Mod - small: surgical excision - large: multiple biopsies, review + monitor, repeat biopsy Severe: excision
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Relative freq., incidence, prevalence + death rate of oral cancer in UK
Freq.: % all malignancies - WW: 10% - UK: 1-2% - India: 30-50% - geographical variation due to aetiological factors Incidence: new cases / 100000/yr - UK: 4 Prevalence: cases within popn. @ T - 0.05-0.1% (1 in 1000) Mortality: 60% 5yr survival - comparable to breast cancer - > malignant melanoma, cervical Ca
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Predisposing factors for oral cancer
Elderly M M:F 3:1 - lip: 5-20:1 - tongue: 1:1 - other: 2:1 Age: 60-70 - >50 85% - >40 98%
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Prognosis of oral cancer
Poor prognosis depends on staging Early: >80% 5 yr Node involvement: >40% Distant mets: <20%
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Aetiology of oral cancer
``` Tobacco Alcohol Diet Viral infection Other infections ```
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Discuss tobacco as risk factor for oral Ca
Smoking - hydrocarbons in cigarettes broken down by salivary enzymes - benzopyrene carcinogen of cigarette (tar) - 80-90% oral Ca pt long term smokers, 2x risk Smokeless: - India, HK, Sri Lanka, SEA: buccal Ca — association b/w site of betel quid + lesion — dose T related — Areca nut: oral submucous fibrosis, Ca not clear - chewing: nitrosonornicotine (carcinogen)
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Discuss alcohol as risk factor for oral Ca
80-90% oral Ca pt drink Ethanol: inc. permeability of mucosa to carcinogens - not carcinogen itself Contaminants, colourants poss. carcinogenic
158
Discuss how diet can be risk factor for oral Ca
Fe2+ deficiency - mucosal atrophy -> more susceptible to carcinogen - Plummer-Vinson syndrome: Fe2+ deficiency + oesophageal web VitA - req. for normal epithelial differentiation - may be factor in neoplasia - retinoid Tx can cause remission of white lesions
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What virus are associated w/ oral Ca? How may viruses cause Ca?
Mechanism - activate cellular oncogenes by — initiation of mutations OR — inserting own genome close to oncogene Associated - HPV16/18: oropharyngeal, cervical - EBV: nasopharyngeal, Burkitt’s lymphoma
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What other infections may be involved in oral Ca?
Syphilis - limited evidence - leukoplakia D tongue -> Ca D tongue Candida - associated w/ premalignant white patches - leukoplakia w/ Candida more freq. malignant transformation - tumour promoter - enzymes prod. catalyse: nicotine -> nitrosamines
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3 factors influence mortality rate of oral Ca
Site Size Stage
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Discuss impact of size on oral Ca survival
Further ant. better Lip: 90% 5yr survival FoM: 45% Tongue: 40% B mucosa: 40%
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Discuss impact of size of tumour on mortality
Larger: inc. risk metastases, worse prognosis Depth invasion worse cf surface size + pattern Perineural + vascular spread poor prognosis
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Most common sites for oral Ca
Gutter: 80% Tongue: 30% FoM: 15% Retromolar: 15%
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Regional features of oral Ca
Lymphadenopathy Metastatic deposits cause enlargement Firm, painless Fixed if spread beyond capsule Infected nodes: painful soft/firm, not fixed
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Local features of oral Ca
Leukoplakia Speckled leukoplakia Erythroplakia Ulceration Fungation (exophytic tumour) Fixation Destruction Painless Loss of function
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Ix may be req. for oral Ca
Biopsy: fine needle aspirate of lumps X-ray: bony involvement CT: soft/hard tissue involvement for staging + Tx plan MRI: soft tissue, better resolution cf CT MET: shows ‘hot spots’ of activity, detect occult 1rys
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Systemic features of oral Ca
Weight loss Cachexia Symptoms due to distant metastases - lung: coughing blood, shortness of breath
169
Discuss pathology of oral Ca
Epithelial malignancy Malignant cells invade underlying CT Spread via lymphatics to regional lymph nodes - becomes established within node - replace normal structure - may spread out of capsule into neck tissue Rare: vascular spread to distant sites
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Histology of oral Ca
Epithelial island invasion of - connective tissue - muscle - salivary glands - bone Cellular atypia - nuclear hyperchromatism - nuclear + cellular pleomorphism - inc. nuclear:cytoplasm - inc. + abnormal mitoses Inflammatory infiltrate: lymphocytes, plasma cells
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Principles of Ca surgery
Resection - remove Ca - 1cm clear margin Reconstruction - reshape damaged/destroyed structures - skin graft: radial forearm flap, pectoralis major flap - microvascular surgery Rehabilitation - speech + language therapist - oral competence - chewing - palatal competence - dental rehabilitation: teeth, implants etc
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How does radiotherapy work?
X-ray beams directed at site which cause damage to cells w/ high turnover
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Adverse affects of radiotherapy
Acute - mucositis - dysgeusia - weight loss - fatigue Late: >90d post-Tx - xerostomia - oedema - ORN - telangiectasia - fibrosis - atrophy
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Difference b/w palliative and curative surgery
Palliative - doesn’t remove Ca - alleviate pain/discomfort - improve QoL Curative - removes malignant tissue - aims to cure Ca
175
Aetiology + risk factors for acute bacterial sialadenitis
Aetiology - Strep. pyogenes - Staph. aureus Predisposing - red. salivary flow - dehydrated - immunocompromised - acute exacerbation of chronic
176
Clinical features + Mx of acute sialadenitis
Clinical - S: parotid, submandibular (common), unilateral - gland: tender, swelling - erythema: skin, mucosa - suppurative - fever, malaise, trismus - lymphadenopathy Mx - antimicrobial: Tx infection - target predisposing factor
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Discuss chronic sialadenitis
Non-specific inflammation of gland Associated w/ red. saliva flow -> low-grade ascending infection Clinical - S: submandibular, unilateral - recurrent tenderness + swelling - duct orifice: erythema, suppurative (acute exacerbation) - early: enlarged - late: small, firm, no saliva prod. when massaged Ix: US, sialography - determine predisposing: calculus, stricture
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Histology of sialadenitis
Progressive glandular atrophy - acinar destruction - fibrous replacement - ductal ectasia Inflammatory infiltrate
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Discuss sialolithiasis
``` Salivary gland stones Predisposing - red. saliva flow - dehydration - chronic sialadenitis - Sjögren’s ``` Clinical - S: submandibular (80-90%) - pain + swelling associated w/ meal times Mx - Tx acute infection (if present) - surgical removal — strategy depends on site
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Aetiology, epidemiology + Mx of mumps associated sialadenitis
Aetiology: paramyxovirus Epidemiology: childhood usually, any age poss. Mx - supportive: hydration, OH, analgesic - vaccine: 88% effective — immunity long lasting thus recurrence low
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Clinical presentation + complications of mumps associated sialadenitis
Clinical - S: parotid (70% bilateral) - prodromal: fever, malaise - painful swelling 1/+ glands Complications - orchitis - meningoencephalitis - pancreatitis - arthritis
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Histology of mumps sialadenitis
Dense interstitial lymphoplasmacytic infiltrate Acinar destruction Duct dilation
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Discuss cytomegalic inclusion disease
Aetiology: CMV (HHV5) Clinical - asymptomatic - neonates, immunocompromised: severe disseminated disease - salivary disease usually incidental finding Histology: viral inclusions in epithelial nucleus + cytoplasm
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Clinical features of HIV sialadenitis
Diffuse cystic enlargement of major salivary glands ``` S: bilateral Gradual, non-tender enlargement 1/+ Cervical lymphadenopathy Nasopharyngeal swelling Xerostomia ```
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Histology of HIV sialadenitis
``` Cystic spaces - lined by squamous epithelium Associated w/ reactive lymphoid stroma Florid follicular hyperplasia Loss of mantle zones Lymphoepithelial islands ```
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Epidemiology + aetiology of necrotising sialometaplasia
Epidemiology: middle age Aetiology: unknown - local ischaemia (trauma) -> minor gland infarction
187
Clinical features + Mx of necrotising sialometaplasia
Clinical - S: hard palate - deep crater-like ulcer - erythematous edge - preceded: indurated swelling - mistaken for malignancy Mx - reassure - supportive - spontaneous resolution: 4-10/52
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Histology of necrotising sialometaplasia
``` Mucosal ulceration - lobular necrosis minor glands Reactive squamous metaplasia Ductal hyperplasia Mucus extravasation -> inflammation ```
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What is sarcoidosis? Clinical features
Mutlisystem, systemic granulomatous disorder Clinical - S: parotid (bilateral), minor glands - painless, persistent enlargement - indurated swellings: gingiva, tongue - multiple asymptomatic submucosal nodules - xerostomia
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Mx of sarcoidosis
Medications - steroids - azathioprine - methotrexate - cyclophosphamide May remain stable/regress spontaneously/progressively worsen - mortality: <5%
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Histology of sarcoidosis
Non-necrotising granulomatous inflammation Hyalinisation Calcification
192
Aetiology, Mx + histology of tuberculosis
Aetiology: mycobacterium tuberculosis Mx: anti-mycobacterial Histology: necrotising granulomatous inflammation
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Clinical features of oral TB
``` S: parotid Mycobacterial lymphadenitis - peri/intra-parotid lymph node enlargement - due to lymphatic drainage Painless, discrete nodule(s) in gland Deep, punched-out ulcers - erythema - swelling ```
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Histology of Sjögren’s syndrome
Lymphocytic infiltrate - formation of punctate lymphocytic foci - peri-acini/ductal/vascular distribution Exocrine gland atrophy
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What is Küttner tumour? Epidemiology, risk factors + Mx
IgG4-related salivary gland disease Chronic sclerosing sialadenitis Benign, fibroinflammatory process affecting submandibular gland in pt w/ IgG4 disease Epidemiology: >50, M Mx: surgical excision
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Clinician features of Kuttner tumour
S: submandibular common Non-tender firm swelling Mimics neoplasia
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Histology of Kuttner tumour
Dense lymphoplasmacytic infiltrate Storiform pattern of fibrosis Obliterative phlebitis
198
Clinical features of pleomorphic adenoma
Benign epithelial salivary gland neoplasm Clinical - S: parotid, minor glands - behaviour: slow growing - asymptomatic - smooth, mobile mass
199
Mx + prognosis of pleomorphic adenoma
Mx: excision - incomplete capsule makes difficult - may req. parotidectomy Prognosis - low of complete removal - recurrence aggressive - malignant transformation: 6%
200
Histology of pleomorphic adenoma
Pleomorphism: epithelial, connective tissue Formation bilayered ducts - ductal epithelium: inner layer - myo-epithelium: outer layer Stroma: myxochondroid/myxoid/chondroid + mucin
201
Clinical features of Warthin’s tumour
Benign epithelial salivary gland tumour Clinical - S: parotid, peri-parotid lymph nodes - behaviour: slow growing - asymptomatic, fluctuant swelling - multifocal, bilateral
202
Mx + prognosis Warthin’s tumour
Mx: excision w/ margin Prognosis - recurrence low (5%): incomplete removal, multifocal - malignant transformation: rare
203
Histology of Warthin’s tumour
Double layer epithelial cells Lymphoid stroma Cystic spaces Oncocytic columnar cells w/ discontinuous basal cells
204
Epidemiology + clinical features mucoepidermoid carcinoma
Epidemiology: <20 ``` Clinical - S: parotid — P, submandibular, minor - cystic, mimic mucocele - soft/firm circumscribed/infiltrative mass ```
205
Difference b/w low + high grade of mucoepidermoid carcinoma
Grading based on epidermal:mucous cells Low/intermediate - less aggressive - good prognosis - Tx: surgical excision High Grade - aggressive - regional metastases - Tx: resection +/- neck dissection + post-op radiotherapy - 10y survival 25%
206
Histology of mucoepidermoid carcinoma
Mucinous, epidermoid + intermediate cells in varying amounts Solid -> cystic growth pattern Cysts mucin filled High grade - less mucous cells - solid/infiltrative growth - perineural spread - vascular invasion - cytological anaplasia - necrosis
207
Discuss adenoid cystic carcinoma
Malignant epithelial salivary gland neoplasm ``` Epidemiology: >50, elderly Clinical - S: major glands — most common submandibular tumour - behaviour: slow growing, locally invasive - painless relentless swelling/mass - ulceration: skin, mucosa - numbness/paraesthesia/pain ``` Mx: excision +/- radiotherapy Prognosis - distant metastases common: >50% - 10y survival: 50-70%
208
Histology of adenoid cystic carcinoma
Biphasic: ductal epithelial + albuminal myoepithelial - myoepithelial: basaloid appearance; dark, angulated nucleus + scant cytoplasm Architecture: cribriform (myoepithelial w/ globules), tubular (tubules) or solid (sheets of basaloid cells) Acellular basophilic + hyalinised matrix incorporeal into micro-cystic islands Peri/intraneural spread High grade - solid growth - cellular atypia - inc. mitoses - necrosis
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Epidemiology + Mx of acinic cell carcinoma
Malignant salivary gland neoplasm Epidemiology: 50, F Mx - excision - high grade: neck dissection +/- radiotherapy
210
Clinical features of acinic cell carcinoma
S: parotid Behaviour: slow growing, infiltrative Solitary, unfixed mass Poss. multi-nodular +/- fixed
211
Histology of acinic cell carcinoma
Usually sheets of neoplastic acinar cells Non-encapsulated Pushing or frankly infiltrative Prominent lymphoid stroma,basophilia Aggressive: perineural invasion, stromal hyalinisation
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Indications for salivary gland surgery
Overproduction -> drooling Neoplasia Obstruction Trauma -> cyst
213
What is Wilkie’s procedure?
Surgical rerouting of parotid and/or subMd ducts | Indicated: overproduction of saliva -> drooling
214
Tx of benign salivary gland tumour
Surgical excision Minor glands: local excision Superficial parotidectomy Total parotidectomy; if deep Extracapsular dissection
215
Discuss parotidectomy; structures + complications
Structures - CN7 - great auricular nerve (sensory) - retromandibular vein ``` Complications - sensory disturbance — CN7: temp 30%, perm 1-3% - facial hollowing - sialocele - Frey’s syndrome ```
216
What is Frey’s syndrome?
Disorder associated w/ parotid gland and great auricular nerve Clinical - erythema + sweating of cheek adjacent to ear — distribution of great auricular nerve - usually associated w/ meal times
217
What is extracapsular dissection?
Surgical technique for Tx gland tumours aims to preserve CN7 Dissection outside of tumour capsule Benefits - red. CN7 weakness - red. Frey’s syndrome Not suitable for all tumours
218
Discuss Mx of malignant salivary gland tumours
Surgical excision w/ wide margin CN7 preserved if poss. May req. neck dissection + removal of other structures - ear, skin, Md
219
Difference b/w mucous extravasation cyst and mucous retention cyst
Extravasation - damaged duct - spillage of mucous into surrounding tissues Retention - duct obstruction/stricture - red. mucous secretion from gland
220
Tx for mucocele and ranula
Mucocele: excision + closure Ranula - marsupialisation: suture edges open to allowing drainage - resection: sublingual/subMd, OE approach - sclerotherapy: inject drug to shrink vessel, red. production
221
Tx options for submandibular gland obstruction
``` Papillotomy Endoscopic removal Duct removal Gland removal Hilar exploration Extracorporeal lithotripsy Radiographically assisted basket removal ```
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Complications of submandibular gland removal
Sensory alteration - CN7, Md branch: lip/chin muscles - CNV3: lingual branch, sensory ant. 2/3 tongue - CN12: muscles of tongue Sialolithiasis Scarring

BDS4 (10 decks)

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