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

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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

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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

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Recurrent Aphthous Stomatitis

Tetracycline deposition within the dentin

!

Clinical
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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
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Herpetiform type Minor and major types

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9

Very painful Size, depth, time to heal (minor 5-10 days) 5Minor small, shallow ulcer with red halo
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Benign Mucous Membrane Pemphigoid (cicatricial)

!

Clinical
Autoimmune
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Condyloma Acuminatum
!

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

Clinical
Venereal wart Extensive Etiology
!

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

Clinical
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Clinical
Opportunistic infection (yeast)
!

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

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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
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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

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Recurrent (Secondary) Herpes Simplex

Clinical
U.S. incidence estimate of herpes infection is 808085%
! !

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

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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
Occurs at sites of chronic trauma O t it f h i 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 Usually history of trauma, stress, UV exposure, as triggering U ll hi t ft t 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

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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 liver-colored [brownish purple] liver Distinctive histology
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Multinucleated giant cells

Limited to alveolar ridge/ gingiva

!

Usually anterior to first molar region

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Central Giant Cell Granuloma

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Squamous Papilloma (Papilloma)

!

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

Clinical
Intrabony Same histology as:
Peripheral giant cell granuloma ! Brown tumor of hyperparahyperparathyroidism
!

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

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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, not true tumor Reactive 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

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Least likely oral site

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Site with greatest likelihood or risk of developing squamous cell carcinoma

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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
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Squamous Cell Carcinoma

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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)

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Leukoedema
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Clinical
Most common site
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Clinical
Intracellular edema of cells More often seen in African-Americans African Common, bilateral on buccal mucosa Diagnostic test chairside
!

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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

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Salivary Gland Tumors

!

Patient diagnosed and treated for squamous cell carcinoma of the tongue Much more likely to have future premalignant y p 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 palate p

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
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Parotid facial nerve involvement but no upper lip paresthesia

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Physiologic Pigmentation (Racial Pigmentation)

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Lateral Periodontal Cyst

!

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

Clinical
True cyst (epithelial lining), not pseudocyst p 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 (can cross midline) a so (ca c oss 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 p , swelling; not aggressive g pain, g; gg Ameloblastic fibro-odontoma fibrois 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-shaped crown with constricted Bellcervical region

44

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-infectious nonprocess (i.e., fibro-osseous lesion) fibro 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, pain p ,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
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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-Schuller-Christian triad Hand-Schuller! ! !

Radiographic - Benign
Cortex remains intact thinned or expanded

Radiographic
Tooth floating in air or space
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Central Neural Lesions

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Nasolabial Cyst
!

Neurofibroma and Schwannoma Radiographic

Enlargement of canals and foramina

Clinical
Mucolabial, smooth swelling adjacent to a Mucolabial, 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 M mimic many other May i i 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
!

High Hi h recurrence rate 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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10

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-eye lesions bullsof 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) cementing substance (supraepithelial)
!

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-like) and (maskgeneralized 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-shaped domeBluish often History of recurrence

Mucocele

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12

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
73 74

Ankyloglossia
! !

Dentigerous Cyst
!

Congenital abnormality tonguetongue- tied

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

Histology
Epithelial lining - - - -> ameloblastoma, squamous ameloblastoma, 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
! !
77 78

13

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 reddish-yellow reddish!

Clinical evidence of a draining fistula

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Tuberculosis
!

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

Extravasated Blood
!

Clinical spontaneously resolve

Purpura generalized term Petechia- pinpoint bleeding Petechia 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 flavoring is a common culprit) ( i fl i i 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-like ulcers Aphthous 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 thyroid carcinoma y y 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. midline max 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
! !

PostPost-Developmental Loss of Tooth Structure

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

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

Chlorinated pools Hiatal hernia, bulimia

98

Gastric regurgitation and GERD

97

PostPost-Developmental Loss of Tooth Structure

PostPost-Developmental Loss of Tooth Structure

Abrasion

Erosion

99

100

Periapical Cemento-osseous Dysplasia Cemento-

Oral Hairy Leukoplakia

!

(Periapical cemental dysplasia; periapical osseous dysplasia)

!

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

Clinical
Middle-aged black women Middle 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

101

102

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Florid Cemento-osseous Dysplasia Cemento(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-like plaque Does not wipe off

Oral
! !

Reticular

105

Cutaneous

Hyperplastic

106

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

107

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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 of the skin) p )
!

Brown macules

109

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Calcifying Odontogenic Cyst (Gorlin Cyst)

!

Histology
Ghost cells Calcifications

111

112

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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19

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

115 116

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

117

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Condylar Hyperplasia
!

Dens-inDens-in-dente (dens invaginatus)

!

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

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

119

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20

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

121

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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 ill-fitting denture flange ill Treatment does NOT include antibiotic therapy

123

124

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

125

126

21

Hemangioma

Lymphangioma
!

Clinical
Lymph-filled superficial vessels Lymph 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

127

128

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-Barr virus association Epstein-

Radiographic
Radiopacity with intact PDL Attached to root surface

palatal petechiae
Cementoblastoma
129 130

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 D Does not result i pulp necrosis t lt in l i

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132

22

Acquired Melanocytic Nevus (common mole; nevus)

!

Kaposis Sarcoma
!

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

Clinical
Junctional type
!

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

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

Intramucosal type
! !

Most common oral type Called intradermal type on skin

Compound type
133 134

Keratoacanthoma
!

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

Keratoacanthoma

135

136

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; >> males y;

137

138

23

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

139

140

Sjgrens Syndrome
!

Sarcoidosis
!

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

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

141

142

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

143

144

24

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 25-years-old 25-years-

Clinical
Decrease in serum estrogen and calcium Older females

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

145

146

Osteopetrosis
!

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

Osteopetrosis

147

148

Osteoma
!

Mandibular Fracture
!

Clinical
Most common site is angle of mandible

Radiographic
Well-circumscribed radiopacity Well-

Clinical
Often diagnosed with two radiographs
!

Panoramic and occlusal

149

150

25

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-Jones proteinuria Bence Immunoglobulin spike

Radiographic
Multiple bone sites
!

Calvaria, spine, pelvic girdle, jaws

Punched-out lucencies Punched153 154

Necrotizing Sialometaplasia
!

Cervical emphysema
!

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

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

155

156

26

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
158

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, melanoma, adenocarcinoma osteosarcoma, 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 x-ray beam is doubled x! Kilovoltage (kVP) primarily controls contrast and is the penetrating characteristic of an x-ray x! X-ray penetration is determined by kVP ! Focal spot size primarily influences resolution
161 162

27

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 object-thickness distance object Decreased target-object distance targetBest i B imaging film for viewing internal derangement of i fil f i i i ld 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 of radiation treatment in children p 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-ray machine is made of xaluminum 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 x-ray beam results in an xxincrease of the penetration of x-ray photons Radon is the greatest source of background radiation o ea t ad at o on earth Basic components of an x-ray cathode ray xtube 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

168

28

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 x-ray tube housing xfunctions to dissipate heat from the target
170

29