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Systemic Lupus Erythematosus

Oral and Maxillofacial Pathology Review for NBDE Part 2


2010

Clinical
Autoimmune Young adult females Butterfly rash of face

Michael A. Kahn, DDS Professor and Chairman Department of Oral and Maxillofacial Pathology Tufts University School of Dental Medicine
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Sun exposure worsens it Heart endocarditis Kidney renal glomeruli (glomerulonephritis)

Systemic involvement complications



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Cavernous sinus thrombosis

Ludwigs angina

Can arise from an infection - - a subcutaneous abscess of the upper lip or a intrabony abscess of an anterior maxillary tooth t th
Valveless facial veins

Submandibular space infection Most serious complication is edema of the glottis

Treacher Collins Syndrome

Scarlet fever

Has external ear changes

White coating of the tongue that sloughs off leaving a deep red surface with swollen hyperplastic fungiform papillae (strawberry tongue) tongue )

Fordyce granules

Turner tooth

Ectopic sebaceous glands yellow papules/plaques

Due to local trauma or infection associated with the developing tooth bud

Intrinsic tooth stain

Recurrent Aphthous Stomatitis

Tetracycline deposition within the dentin

Clinical

Moveable mucosa

Ex. Uvula, labial mucosa

Recurrent NOT PRECEDED BY VESICLE Associated with certain HLA types

NOT caused by a virus, bacteria, fungus Corticosteroids are often prescribed Many small

Treatment

Herpetiform type Minor and major types



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Very painful Size, depth, time to heal (minor 55-10 days) Minor small, shallow ulcer with red halo
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Benign Mucous Membrane Pemphigoid (cicatricial)

Clinical
Autoimmune

Condyloma Acuminatum

Antibody reaction at the epithelialepithelial -connective tissue interface (BMZ) Subepithelial split

Clinical
Venereal wart Extensive Etiology

Vesiculoerosive, l ulcers l > women - middle aged Skin and eye Oral

Human papilloma virus (HPV)

Any site: gingiva, soft palate, etc. Ulcers, erosions following vesicles, bulla

Histology
Subepithelial separation at basement membrane zone
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Candidiasis pseudomembranous

Candidiasis Chronic

Median rhomboid glossitis


Clinical

Clinical
Opportunistic infection (yeast)

Immature or deficient immune system Antibiotics usage C ti t id usage Corticosteroids May be diagnosed by cytology smear

Hyphae and spores

Red atrophy of filiform papillae Midline tongue, junction of anterior 2/3 and posterior 1/3 at tuberculum impar Not a developmental disorder as once thought Treatment
Antifungal agents are sometimes effective, such as nystatin or clotrimazole

White, wipeable patch with red, underling base; palate and buccal mucosa are often involved Thrush

Denture sore mouth


Clinical

Newborns and infants

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Red Patient does not remove or clean denture NOT acrylic allergy Tx rinse mouth and soak denture with antifungal

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Recurrent (Secondary) Herpes Simplex

Recurrent (Secondary) Herpes Simplex

Clinical
U.S. incidence estimate of herpes infection is 80 8085%

Most M t cases are subclinical b li i l Reactivation from nerve cells of trigeminal ganglion Skin or vermilion Vesicle ruptures - - -> ulcer that heals in 7 7-10 days (not present for weeks or months if immunocompetent person)
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Lip

Recurrent Herpes Simplex Infection

Traumatic Neuroma

Clinical
HSV Type 1 in humans, most often Intraoral

Clinical
Wandering transected nerve with scar tissue Painful or tender, firm lump or nodule Oral site
O Occurs at t sites it of f chronic h i trauma t Ex. mandibular alveolar ridge in denture wearer, especially near mental nerve, denture flange trauma Ex. tongue

Hard palate and gingiva = nonmoveable, overlying bone Small coalescing shallow ulcers preceded by small vesicles Can be subclinical even though person has primary infection U Usually ll history hi t of f trauma, t stress, t UV exposure, as triggering ti i event several days earlier (ex. restorative procedure) No history of allergy or chemical burn

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Pyogenic Granuloma

Peripheral Giant Cell Granuloma

Clinical
Occur at any age Any location but usually on gingiva Most common is interdental papilla Local reactive growth Irritation Bleeds readily Exophytic Not painful Grows very fast like malignancies Proliferative

Clinical
Somewhat similar in appearance to pyogenic granuloma Moderate soft mass Often liverliver-colored [brownish purple] Distinctive histology

Multinucleated giant cells

Limited to alveolar ridge/ gingiva

Usually anterior to first molar region


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Central Giant Cell Granuloma

Squamous Papilloma (Papilloma)

Clinical
Etiology - epithelium White to white white-pink usually but can be reddened Rough surface (cauliflower) Elevated lesion (papule, nodule) Common sites

Clinical
Intrabony Same histology as:
Peripheral giant cell granuloma Brown tumor of hyperpara hyperparathyroidism

Facial or lingual gingiva Soft or hard palate Tongue

No effect on saliva production Bone destruction secondary to chronic renal disease


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More frequent than some other omas


Rhabdomyoma Leiomyoma Lymphangioma Neurofibroma

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Fibroma

(fibrous nodule, focal fibrous hyperplasia, traumatic fibroma, irritation fibroma)

Granular Cell Tumor

Clinical
Most common connective tissue tumor Reactive, Reactive not true tumor Hyperplasia; NOT neoplasia, anaplasia, dysplasia, etc. Firm, smooth, pink, elevated papule/nodule Common site is tongue (due to trauma)
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Clinical
Dorsum of tongue #1 site Nodule with smooth or papillated surface Histology distinct

Granular cells - cytoplasm 50% of time exhibit pseudoepitheliomatous hyperplasia


Resembles squamous cell carcinoma histologically
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Leukoplakia

Erythroplakia and Erythroleukoplakia (speckled) Clinical


Red plaque that does not wipe off Studies show that it is likely to have severe dysplasia or worse and undergo malignant transformation to carcinoma Treatment

Clinical
White patch that does not wipe off Cytology smear does not help determine specific diagnosis Appropriately managed by biopsy Floor of mouth hyperkeratosis most common site to exhibit dysplasia If two separate areas in persons mouth then both areas should have incisional biopsy
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Initial incisional biopsy

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Squamous Cell Carcinoma

Clinical
Lower lip

Can be preceded by actinic cheilitis Firm, indurated ulcer; painless with v. good prognosis Submental node is most common lymph node involved by metastasis MidMid -lateral border of tongue Hard palate

Most common oral site

Least likely oral site

Site with greatest likelihood or risk of developing squamous cell carcinoma

Floor of mouth worse prognosis when lung mets (not size, local spread or anaplastic cells) Most likely to a lymph node
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Metastasis

Squamous Cell Carcinoma

Staging vs. Grading


Stage III has a worse prognosis than I or II

Metastatic Disease to the Jaws

Clinical and Radiographic


Most common site is posterior mandible Does not cause a shift of patients occlusion Usually a poorly defined lucency without sclerotic border

Radiographic
When invasive into the alveolar ridge it will appear poorly defined lucencies without a reactive sclerotic border

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Monomorphic Adenoma (Canalicular Adenoma)

Leukoedema

Clinical
Most common site

Clinical
Intracellular edema of cells More often seen in AfricanAfrican-Americans Common, bilateral on buccal mucosa Diagnostic test chairside

Upper lip > Women W May be multinodular Asymptomatic Do not confuse with mucocele of the lower lip
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Pull on buccal mucosa - - - -> disappears or dissipates

Normal mucosa variation so no treatment required


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Leukemia

Clinical/Lab
Red, swollen (hyperplastic), boggy, bleeding gingiva (interdental papilla) with ulcers Lab tests ordered Complete blood count White blood count differential Decreased neutrophils Leukemic infiltrate leaves blood and into soft tissue (esp. acute monocytic type) Red macules on skin (purpura (purpura = extravasated blood) & skin infections Decreased platelets Tired feeling (malaise) Anemia (decreased RBCs) RBCs)

Verrucous Carcinoma

Clinical
Very well differentiated form of squamous cell carcinoma Large, elevated, papillary often associated with smokeless tobacco habit Most common site is buccal vestibule No tendency to metastasize

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Chief difference from typical squamous cell carcinoma

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Field Cancerization Squamous Cell Carcinoma

Salivary Gland Tumors

Patient diagnosed and treated for squamous cell carcinoma of the tongue Much more likely y to have future p premalignant g or malignant lesions anywhere in the oral cavity
Ex. speckled leukoplakia of the floor of mouth likely to be a second primary lesion

Most common tumor of salivary gland origin is the pleomorphic adenoma


Benign Most common intraoral site is p palate

Major and minor salivary glands potential sites


Neoplasm most likely to arise in the parotid Neoplasm most likely to arise in the palate

p53 tumor suppressor gene is most common associated


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Adenoid cystic carcinoma


Characteristic perineural invasion most likely

Parotid facial nerve involvement but no upper lip paresthesia

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Physiologic Pigmentation (Racial Pigmentation)

Lateral Periodontal Cyst

Clinical
Darkens with time; present most of a person persons s lifetime African African-American patients
Upper or lower lip vermilion, attached gingiva, tongue, buccal mucosa Series of splotchy brown macules

Clinical
True cyst (epithelial lining), not p pseudocyst y

Radiographic appearance
Well circumscribed radioluceny between the roots of adjacent, erupted, vital teeth (most commonly seen at mandibular premolars) Radiographic differential diagnosis does NOT include dentigerous cyst (impacted tooth)

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Ameloblastoma

Ameloblastic Fibroma

Clinical
Average age is 34 Most common in posterior mandible but anterior mandible also a so (ca (can c cross oss midline) d e)

Clinical

Radiographic
Most common true odontogenic tumor Multilocular radiolucency Superimposed over posterior teeth (> mand.) Often associated with impacted tooth
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Radiographic

Young person More often in posterior jaws, esp. mandible Slight g pain, p , swelling; g; not aggressive gg Ameloblastic fibro fibro-odontoma is similar except for odontoma component

Histology
Reverse polarization of the nuclei of the tall, columnar cells of the periphery

Pure lucency; no radiopaque component AFO also has radiopaque component (i.e., the odontoma) 40

Odontoma

Clinical primarily first two decades of life (young persons) Radiographic Radiopacity with radiolucent rim (= follicle) Compound vs. Complex types Compound - identifiable toothlets > Anterior maxilla Complex unidentifiable mass > Posterior of jaws

Adenomatoid Odontogenic Tumor (AOT)

Clinical
Young person (child or teenager) Unerupted tooth of the anterior maxilla (#6, #11) Snow flake calcifications in the radiolucency surrounding the crown and a portion of the impacted tooths root

Radiographic

Treatment simple enucleation


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Amelogenesis Imperfecta

Dentinogenesis Imperfecta

Clinical
Teeth lack enamel; Dentin and cementum unaffected Shapes of root and crown are normal

Clinical
Opalescent dentin blue/gray Often associated with osteogenesis imperfecta

Blue sclera Multiple bone fractures

Radiographic
Enamel is missing Pulp chambers and root canals normal
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Radiographic
BWXs and PAs demonstrate classic lack of pulp chambers and root canals Bell Bell-shaped crown with constricted cervical region

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Cherubism

Radiographic
Multilocular, bilateral lucencies

Fibrous Dysplasia
Clinical
Unilateral mandibular or maxillary expansion; onset before puberty; C.C. of teeth do not fit Painless swelling, usually ceases at age 20 Root canal therapy will not help since non non-infectious process (i.e., fibro fibro-osseous lesion) Caf au lait pigmentation

Clinical
Bilateral jaws Young persons Jaw expansion - - ceases after childhood

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Polyostotic form McCune Albright syndrome

Radiographic
Ground glass appearance

Treatment
After age 20 when stabilized Cosmetic bone shaving
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Condensing Osteitis
(Sclerosing Osteitis)

Clinical
Associated with pulpitis (ex. very carious posterior mandibular tooth); nonvital tooth Associated tooth will test nonvital or signs and symptoms or tooth destruction will support nonvital status

Idiopathic Osteosclerosis

Clinical
No apparent reason including no pulpitis in adjacent tooth No expansion, p , pain p

Radiographic
Periapical opacity so does NOT mimic a periapical granuloma radiographically Does not connect with root

Radiographic
Radiopacity without peripheral lucent rim Not connected to tooths root

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Treatment
None
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Traumatic Bone Cyst

Clinical

(Simple Bone Cyst; Idiopathic Bone Cavity; Unicameral Cyst; Hemorrhagic Cyst)

Pagets Disease of Bone

Clinical
Older age group Bilateral maxilla affected Involved bone can undergo malignant (sarcomatous) transformation (i.e., osteosarcoma) Cranial nerve deficits as foramen compressed, narrowed d Does NOT have hyperglobulinemia or premature exfoliation of primary teeth

Undergoes spontaneous healing without treatment following exploratory surgery Pseudocyst

Radiographic
Radiolucent with scalloped margins

Radiographic
Cotton wool appearance 50% - hypercementosis

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Histology
Reversal lines with a mosaic pattern
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Langerhans Cell Disease (Histiocytosis X)

Benign vs. Malignant Bone Involvement

Clinical
Composed of Langerhans cells, not histiocytes Etiology is still unknown Eosinophilic granuloma

Clinical
Ominous malignant sign

Spontaneous paresthesia of the lower lip

Solitary lesion, young adults Diabetes insipidus Exophthalmos Bone lesions


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Hand Hand-Schuller Schuller-Christian triad


Radiographic - Benign
Cortex remains intact thinned or expanded

Radiographic
Tooth floating in air or space
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Central Neural Lesions


Nasolabial Cyst

Neurofibroma and Schwannoma Radiographic


Enlargement of canals and foramina

Clinical
Mucolabial Mucolabial, , smooth swelling adjacent to a maxillary lateral incisor Soft tissue involvement; not bone

Histology
Pseudostratified squamous epithelium cystic lining

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Odontogenic Keratocyst Lymphoepithelial Cyst

Clinical

Clinical
Commonly on ventral tongue/floor of mouth Well circumscribed swelling g Pale, yellowish at times

Radiographic

High recurrence! Intrabony, posterior mandible but anywhere; BCNS association Radiolucent, usually multilocular May M mimic i i many other h types of lucent cysts and odontogenic tumors including ameloblastoma

parakeratin
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surface

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Nevoid Basal Cell Carcinoma Syndrome (Gorlin syndrome; basal cell nevus syndrome)

Clinical
Onset is childhood Cysts of the jaws = odontogenic keratocysts

Hi h recurrence rate High t Face especially

Basal cell carcinomas

Bifid rib

Radiographic
Keratocysts - unilocular or multilocular lucencies Calcification of the falx cerebri

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Cheek Nibbling (Morsicatio Buccarum)

Gardner Syndrome

Clinical
Multiple facial osteomas & skin nodules Hyperdontia; unerupted teeth Multiple GI (colon) polyps [familial intestinal polyposis] - - - -> colon carcinoma

Clinical Buccal mucosa site White, rough, tissue tags above and below the occlusal plane (line alba) Other sites lip and tongue

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Odontoma

Epidermoid cyst

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Bells Palsy

Clinical
7th nerve paralysis - - - -> unilateral lip droop at corner, inability to close or wink eyelid Last usually less than one month

Temporomandibular Dysfunction (TMD)


Clinical
Pain and tenderness of palpated TMJ Deviation of jaw toward painful side upon opening TMJ disc moves anterior and medially due to contraction of the lateral pterygoid muscle Popping and clicking indicate internal derangement with reduction Does not cause dizziness Reduce opening to ~ 45 mm Will get neuritis of VII cranial nerve
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Erythema Multiforme

StevensStevens -Johnson syndrome


(Erythema Multiforme Major)

Clinical
Young adult males Sudden, explosive onset Triggered by drug or viral infection Crusted, bleeding, vesicles, ulcers of vermilion of lips; intraoral sites excluding gingiva Target, iris, or bulls bulls-eye lesions of the hands and feet
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Eye (conjunctiva), mouth (labial mucosa, tongue, etc.), genitalia


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Pemphigus Vulgaris

Pemphigus Vulgaris

Clinical/Lab Vesiculoerosive (oral and skin) Demonstrates immunoglobulin fluorescence intraepithelial ( (supraepithelial supraepithelial) ) cementing substance

Most often immunoglobulin type G (IgG (IgG) )

Positive Nikolsky sign Common sites lips, palate, gingiva

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Progressive Systemic Sclerosis (Scleroderma)

Clinical
Demonstrates induration of the soft tissue (mask(mask-like) and generalized widening of the PDL space Trismus

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Benign Migratory Glossitis (Geographic Tongue, Erythema Migrans) Migrans) Clinical


Red and white

Aspirin Burn (Chemical Burn)

Clinical
White = coagulative necrosis of the surface, NOT hyperkeratosis

Red = flat, depapillated areas of tongue (filiform papillae atrophied) White = keratin, epithelial cell debris

White rubs off with difficulty, hyperkeratosis does not wipe off

Periodically appears Can cause soreness or burning occasionally Treatment

Corticosteroid rinse (dexamethasone (dexamethasone) )

Moves around from day to day Dorsum of tongue most often

Also lateral, ventral surfaces

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Basal Cell Carcinoma


Clinical
Painless ulcer of upper lip, elsewhere on sunsun -exposed face (UV); raised margins Does NOT occur intraorally Begins as pearly papule; assoc. g telangiectasia Can be highly destructive if not treated Usually does not metastasize

(mucus retention phenomenon, mucus extravastion phenomenon) Clinical


Children and young adults Trauma Lower lip is most common site Vesicle/bulla, dome dome-shaped Bluish often History of recurrence

Mucocele

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phenomenon, mucus extravastion phenomenon)

Ranula (mucocele, mucus retention

Antral Pseudocyst (Mucous Retention Pseudocyst)


Clinical Asymptomatic No treatment necessary Radiographic Slight radiopaque, radiopaque domedome -shaped, emanating from floor of maxillary sinus

Clinical
Floor of mouth swelling
Looks like a frogs belly (Gk ranu = frog) Bluish usually; history of recurrence several times Mucin will yield viscous aspirate Microscopic histiocytes visible in mucin

MUCIN GW MSG
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Ankyloglossia

Dentigerous Cyst

Congenital abnormality tonguetongue - tied

Clinical
Most common site is posterior mandible Impacted third molars U i ti ameloblastoma Unicystic l bl t can arise i from f it Malignant transformation of the lining is possible

Histology
Epithelial lining - - - -> ameloblastoma, ameloblastoma, squamous cell carcinoma, mucoepideromoid carcinoma Other impacted teeth besides 3rd molars

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Dentigerous Cyst (contd)

Radiographic
Pericoronal radiolucency attached at CEJ of unerupted tooth Radiographic differential diagnoses
Ameloblastoma Residual cyst Odontogenic keratocyst Odontogenic myxoma

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Varices

Parulis (Gum Boil)

Lingual and Lip


Dilated veins - blue Seen typically in the elderly Lip varices may thrombose and subsequently calcify (i.e. phlebolith)

Clinical
Incomplete root canal therapy with intermittent sensitivity Elevated reddishreddish-yellow

Clinical evidence of a draining fistula

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Tuberculosis

Clinical
Incidence is increasing worldwide and in the U.S. Chest radiograph May M spread d by b infected i f t d sputum t to t oral l lesions (e.g., ulcer mimicking cancer on the tongue)

Extravasated Blood

Clinical spontaneously resolve


Purpura generalized term Petechia Petechia- pinpoint bleeding Ecchymosis larger area of involvement Hematoma large, elevated areas

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Allergic Mucositis

Eagle Syndrome

Clinical
Typically due to flavoring agents in toothpastes, candies, and chewing gums (cinnamon ( i flavoring fl i is i a common culprit) l it)

Clinical
Elongation and/or calcification of the stylohyoid ligament Head and neck pain is elicited by chewing, yawning, opening mouth

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Herpes Zoster

Primary Herpes Gingivostomatitis

Clinical
Crop of vesicles - - - > ulcers with pain Striking unilateral distribution on skin and oral l

Clinical
Inflamed, enlarged marginal gingiva; gingival bleeding Vesicles - - - -> ulcers throughout the mouth and lips with significant pain Malaise Low grade fever Sore throat, lymphadenopathy

ex. palate, tongue

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Primary Herpes Gingivostomatitis

Crohns Disease

Clinical
Granulomatous gingivitis Aphthous Aphthous-like ulcers Rectal bleeding

Intestinal skip lesions of small intestine, and to a lesser degree, large intestine and other regions of the GI tract

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Dermoid Cyst

Multiple Endocrine Neoplasia Syndrome, Type IIB (III)

Clinical
Slightly compressible (doughy) Midline distribution usually

Clinical
Multiple mucosal neuromas (e.g., tongue) Medullary y thyroid y carcinoma Adrenal pheochromocytoma

Example - anterior floor of mouth

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Incisive Canal Cyst (Nasopalatine Duct Cyst)

White Sponge Nevus

Clinical
Most common developmental nonnon -odontogenic cyst Teeth vital; max. max midline True cyst (epithelial lining)

Clinical
A genodermatosis

Autosomal dominant

Often bilateral buccal mucosa; other mucosa Moderately extensive thick, white folds of tissue - No eye involvement Often heartheartshaped lucency

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Cleft Palate

Trigeminal Neuralgia

Clinical
Between lateral incisor and canine

Clinical
Age of onset typically > 35 years old; trigger points

Radiographic
Lucent line Maxillary occlusal film

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Neuritis

Actinic Cheilitis

Clinical
Lips vermilion becomes indistinct Great potential for dysplasia to undergo malignant transformation into squamous cell carcinoma

Clinical
Intense pain for one week duration Unilateral

At forehead and around eye

Therefore, a premalignant condition

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Cheilitis Glandularis

Clinical
Mucous minor salivary glands of lips are inflamed Mucus secretions Premalignant condition - - - - > squamous cell carcinoma

Post-Developmental Loss of Tooth PostStructure


Attrition - physiological Abrasion - pathological
Mechanical wear at cervical region g most typically yp y Habits / occupations

Erosion
Chemical loss of tooth structure exclusive of acidogenic theory of caries

Chlorinated pools Hiatal hernia, bulimia


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Gastric regurgitation and GERD


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Post-Developmental Loss of Tooth PostStructure

Post-Developmental Loss of Tooth PostStructure

Abrasion

Erosion

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Periapical Cemento Cemento-osseous Dysplasia

Oral Hairy Leukoplakia

(Periapical cemental dysplasia; periapical osseous dysplasia)

Clinical
White, rough plaque on lateral border of tongue (#1 site) Seen in HIVHIV-positive individuals that are progressing to AIDS Caused by Epstein Epstein-Barr virus

Clinical
MiddleMiddle-aged black women Mandibular anterior vital teeth No pain or expansion - - asymptomatic

Radiographic
Diagnosed by characteristic findings Multifocal periapical lucencies which mature over time; become mixed lucent/opaque and finally mainly opaque

Time

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Florid CementoCemento-osseous Dysplasia (florid osseous dysplasia)

Florid Osseous Dysplasia

Clinical
Multiquadrant FibroFibro -osseous intrabony lesion Hard product produced is avascular so . . Most likely complication is a secondary osteomyelitis

Radiographic
Radiolucent and radiopaque

Treatment
None necessary after dx

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Lichen Planus

Clinical
Skin and/or oral condition Middle aged women most often Skin

Lichen Planus

Purple, polygonal, pruritic papules White papules and coalescing papules = Wickams striae Does not wipe off any oral site Reticular form; often asymptomatic Erosive form On tongue may be mistaken for geographic tongue Sensitive, painful Most common site Buccal mucosa Ex. dorsum of tongue White plaques, individual papules and striae Hyperplastic form - - plaque plaque-like Does not wipe off

Oral

Reticular

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Cutaneous

Hyperplastic

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Erosive Lichen Planus

Peripheral Ossifying Fibroma


Clinical
Soft tissue lesion, not in bone but makes osteoid/bone Occurs on gingiva, especially interdental papilla area Product may be seen on dental radiographs as scattered light opacities

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Cleidocranial Dysplasia

Clinical
Multiple unerupted supernumerary teeth Retention of primary teeth Delayed eruption of permanent teeth Missing clavicles, frontal bossing, large head

Neurofibromatosis, type 1 (von Recklinghausens disease of skin)


Clinical
Multiple neurofibromas (nodules) of the skin and oral cavity (especially tongue) Caf au lait pigmentation (abnormal macules or spots p of the skin) )

Brown macules

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Calcifying Odontogenic Cyst (Gorlin Cyst)

Histology
Ghost cells Calcifications

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Nicotine Stomatitis

Melanotic Neuroectodermal Tumor of Infancy


Clinical Rapid onset, destructive in newborns Increase of vanillylmandelic acid ( (VMA VMA) ) Anterior maxilla, soft and hard tissue Mobile teeth Radiographic Intrabony, lucent, destructive Malignant looking but benign usually

Clinical
Hard palate Red, inflamed minor salivary gland ducts with background of leukoplakic change Tobacco use Pipe smokers most often Cigarettes

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Auriculotemporal syndrome (Frey syndrome)

Aspiration

Clinical
Often after parotid gland surgery Sweating of unilateral facial skin just prior to eating Does not affect cranial nerve VII (rather V)

Always aspirate an anterior maxillary/mandibular radiolucency prior to biopsy to rule out vascular nature

Starch Iodine Test


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Actinomycosis

Chronic Osteomyelitis

Radiographic
Often best seen in lateral oblique radiographic view Radiolucent and radiodense

Clinical
Soft tissue swelling (woody consistency) with multiple draining fistulas sulfur granules = colonies of bacterial organism
PMNs

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Condylar Hyperplasia

DensDens -in in-dente (dens invaginatus)

Clinical
Irregular, elongated condyle Chin deviates away y from affected side upon p closure

Clinical
Most often found in anterior jaw, especially maxillary lateral incisor

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Periapical Cyst and Granuloma


Clinical
Nonvital tooth, at apex

Dentin Dysplasia

Clinical
Dentin abnormal with exposure Draining fistulas Misshapen teeth

Radiographic
Periapical lucency with thin radiopaque line = reaction to apical inflammatory disease

Radiographic
Type 1 rootless teeth
Periapical lucencies

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(Hypohydrotic) Ectodermal Dysplasia


Epulis Fissuratum

Exhibits hypodontia (anodontia) Hypohidrotic - common type


Lack of skin appendages and hair Heat intolerance

Clinical
Hyperplastic connective tissue like fibroma Associated with illill-fitting denture flange Treatment does NOT include antibiotic therapy

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Gingival Cyst of the Adult

Clinical
Soft tissue Facial attached gingiva Mandibular anterior most often Elevated, fluid containing so a vesicle

Heavy Metal Systemic Intoxication

Clinical
Lead line

Blue line that parallels free marginal gingiva

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Hemangioma

Lymphangioma

Clinical
Lymph Lymph-filled superficial vessels Most common cause of macroglossia

Clinical Hamartoma Red to blue elevated lesions Blanches, compressible Histology Collection of small or large vessels filled with red blood cells

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Hypercementosis

Infectious Mononucleosis

Clinical
Vital mandibular first molar Generalized in acromegaly Also seen, at times, in Pagets

Clinical
Cervical swelling, lateral Sore throat Teenagers most often Positive monospot test Epstein Epstein-Barr virus association

Radiographic
Radiopacity with intact PDL Attached to root surface

palatal petechiae
Cementoblastoma
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Internal vs. External Tooth Resorption

Irradiation Therapy

Clinical pink tooth when crown involved with internal type Radiographic
Cannot tell difference early in the process Round or ovoid radiolucency

Clinical
Causes cervical caries secondary to inducement of xerostomia Does D not t result lt i in pulp l necrosis i

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Acquired Melanocytic Nevus (common mole; nevus)

Kaposis Sarcoma

Clinical
Particular malig. malig. seen in HIV positive individual that progress to AIDS Etiology

Clinical
Junctional type

Most likely to undergo malignant transformation (i.e., melanoma)

Herpes virus virus, type 8; not HIV, HIV EBV EBV, , CMV CMV, , HPV

Intramucosal type

Most common oral type Called intradermal type on skin

Compound type
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Keratoacanthoma

Clinical
Difficult to differentiate from squamous cell carcinoma of the face and lip (and its histology) Sun Sun-exposed skin Present for many months; spontaneously resolve in ~ 4 months Keratin plug in the center of the ulceration

Keratoacanthoma

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Xerostomia

Warthins tumor
(papillary cystadenoma lymphomatosum)

Clinical
Dry mouth (subjective) Can result in retrograde infection of the salivary glands; baldish, inflamed tongue

Clinical
Primary site overwhelmingly is parotid

Not in oral cavity; y; >> males

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Vitamin C Deficiency

Stafne Defect (salivary gland depression defect)

Clinical
Scurvy Does NOT cause xerostomia

Clinical
Developmental More in males Asymptomatic Teeth vital

Radiographic
Well demarcated lucency found near the angle of the mandible beneath the mandibular canal

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Sjgrens Syndrome

Sarcoidosis

Clinical
Bilateral hilar lymphadenopathy (chest xx-ray) Cutaneous lesions - violaceous Treatment corticosteroids

Clinical
Autoimmune disease; NOT infectious (e.g., herpes) Elderly women Dry eyes, dry mouth = sicca Parotid P tid swelling lli Often other autoimmune diseases lupus, rheumatoid arthritis

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Proliferative Periostitis (Garres)

PeutzPeutz -Jeghers Syndrome

Clinical
Young person; swelling visible

Clinical
Oral and Paraoral

Radiographic
Inferior border of posterior mandible is common site - Onion skin pattern (radiographic appearance) Bands of radiopaque lines that parallel cortical surface

Pigmented macules (brown)


Lips, tongue, buccal mucosa Vermilion and skin of lip

Intestinal polyposis

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Osteosarcoma

Clinical
Swift onset of localized pain and swelling; tingling lower lip Onset in late 20s, early 30s

Osteoporosis

Most common primary malignancy of bone in persons less than 2525-years years-old

Clinical
Decrease in serum estrogen and calcium Older females

Radiographic - early lucency then opacity; trabeculae changes; PDL symmetrical widening

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Osteopetrosis

Clinical
Massive overproduction of dense, nonvital bone of both jaws Young persons or adults Expansion Frequent complication Secondary osteomyelitis

Osteopetrosis

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Osteoma

Mandibular Fracture

Clinical
Most common site is angle of mandible

Radiographic
Well Well-circumscribed radiopacity

Clinical
Often diagnosed with two radiographs

Panoramic and occlusal

149

150

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Mandibular Malignant Ominous Sign

Mandibular Torus

Clinical
Spontaneous paresthesia of the lower lip

Radiographic
May be superimposed over periapical region as radiodensities

151

152

Malignant Melanoma

Multiple Myeloma

Clinical
Most common oral sites

Clinical
Elderly males (high median age)

Hard palate and gingiva

Lab Findings
Bence Bence-Jones proteinuria Immunoglobulin spike

Radiographic
Multiple bone sites

Calvaria, spine, pelvic girdle, jaws

Punched Punched-out lucencies


153 154

Necrotizing Sialometaplasia

Cervical emphysema

Clinical
Rapid onset Deep ulceration of the palate (most common site) it ) after ft i initial iti l swelling; lli self selflf-resolving l i

Introduction of air into oral soft tissues with resulting sudden painless swelling and crepitance
Ex. air/water syringe

155

156

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Odontogenic Myxoma

Miscellaneous Facts

Clinical
Young adult onset

Radiographic
Closely resemble ameloblastoma

Multilocular lucency with soap bubble pattern


Primordial cyst forms in place of a tooth Enamel hypoplasia is a temporary suspension of amelogenesis Fusion one less than normal compliment of teeth; primary tooth of ant. mandible; separate root canals Gemination can be confused with fusion Pleomorphic adenoma (benign mixed tumor) most common salivary gland tumor
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157

Miscellaneous Facts

Miscellaneous Facts (contd)


The parotid gland body is the most likely salivary gland tissue to have a neoplasm Osteoradionecrosis major factor is damage to the vascular supply Prognosis best for sq cell ca of lower lip compared to osteosarcoma, osteosarcoma, melanoma, adenocarcinoma Most common jaw metastasis site is posterior mandible Onion skin radiograph pattern is also seen in Ewings sarcoma Desquamative gingivitis includes pemphigoid, pemphigoid, pemphigus and erosive lichen planus
159

Autoimmune diseases more common in women Oncocytoma = parotid swelling (tumor) Gingival hyperplasia drugs such as cyclosporine, nifedipine (Procardia) phenytoin (Dilantin) Malignant jaw lesions destroy the cortical plates of bone Gingival condition with no improvement after two months should be biopsied Dysplasia abnormal maturation of the epithelium
160

Epithelial Dysplasia

Radiology Facts
X-ray has the shortest wavelength and the highest energy; high voltage has the same characteristics When milliamperage is doubled the intensity of an xx-ray beam is doubled Kilovoltage (kVP) primarily controls contrast and is the penetrating characteristic of an x x-ray X-ray penetration is determined by kVP Focal spot size primarily influences resolution
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Radiology Facts (contd)

Radiology Facts (contd)

First sign of damage from acute radiation exposure (4 Gy) is erythema Most radioresistant tissue is nerve and muscle cell; most sensitive is hematopoetic Basic shadow casting principle with the paralleling technique does not fulfill the physics requirement of the distance from the object to the recording surface should be as short as possible
163

The density of processed film is not affected by overfixation but is affected by Increase mA Increase exposure time Decreased objectobject-thickness distance Decreased targettarget-object distance B Best i imaging i film fil for f viewing i i internal i l derangement d of f the TMJ (e.g., articular disc) is an MRI Identify Normal:
Zygomatic process and base; intermaxillary suture Lingual foramen; incisive foramen; genial tubercles Mylohyoid ridge; nutrient canals Inverted Y of Ennis Maxillary sinus Tuberosity; hyoid bone; nose shadow (ant. periapical film) 164 Hard palate; tori; anterior nasal spine; stylohyoid ligament

Radiology Facts (contd)


Radiology Facts (contd)

Intensifying screens are used to decrease exposure time, reduce radiation exposure 8-bit digital image would have 256 shades of gray Complication p of radiation treatment in children does NOT include supernumerary teeth but does include:
Stunted roots Micrognathia Condylar hyperplasia Malocclusion
165

Double the distance from the radiation source then the radiation becomes diminished by a factor of 4 (i.e., inverse square law) Latent period = radiobiology time between exposure and biologic onset of symptoms; not cell exposure and free radical formation Radiograph is rinsed with water to accomplish getting rid of chemicals (not remove emulsion, diminish silver particles, remove latent image) Artifact
Bitewing radiograph with a curved dark line through contact points of adjacent crowns = a break in the166 emulsion from film bending

Coin tests
Used for detection of light leakage

Radiology Facts (contd)


Radiology Facts (contd)


A light radiograph is NOT caused by a long process time An MRI is narrow frequency radiation of the electromagnetic spectrum The filter in a dental x x-ray machine is made of aluminum A charged coupled device (CCD) converts xxrays to electrical signals but does NOT result in the same average absorbed dose as conventional radiology (less absorbed dose) Effective dose =comparison of the radiation risk in humans from different radiographic exams and doses/sources
167

Collimating an xx-ray beam results in an x-ray photons increase of the penetration of xRadon is the greatest source of background radiation ad at o o on ea earth t Basic components of an xx-ray cathode ray tube consists of a filament and a focusing cup To change from long scale intensity (low contrast) to short scale intensity (high contrast) but maintain image density, the operator should decrease kVp and increase mAs

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Radiology Facts (contd)

Radiology Facts (contd)

Panoramic radiograph with one second of movement by patient results in wavy inferior border of the mandible and unsharp image vertically across the image at that site Major biologic damage from ionizing radiation is primarily due to radiolysis of the water molecules Electrons flow from cathode to anode with the energy converted to heat Recognize MRI and CT films Recognize technical errors Incorrect beam centering (cone cut) Blurring due to patient movement 169

Penumbra the geometric unsharpness with a fuzzy area surrounding the contours of the teeth and osseous tissues An intensifying screen is used with external radiographs to decrease the radiation exposure The oil unit of an xx-ray tube housing functions to dissipate heat from the target
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