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

Ludwig’s angina
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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

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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”)

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Fordyce granules

Turner tooth

Ectopic sebaceous glands – yellow papules/plaques

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

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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
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– Herpetiform type – Minor and major types
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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

Condyloma Acuminatum

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

Clinical
– Venereal wart – Extensive – Etiology

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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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. as triggering U ll hi t ft t ti i event several days earlier (ex. denture flange trauma  Ex. mandibular alveolar ridge in denture wearer.Candidiasis – pseudomembranous  Candidiasis – Chronic  Median rhomboid glossitis – Clinical   Clinical – Opportunistic infection (“yeast”)    Immature or deficient immune system Antibiotics usage Corticosteroids C ti t id usage May be diagnosed by cytology smear   – Hyphae and spores   Red – atrophy of filiform papillae Midline tongue. 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 . stress. 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.-> ulcer that heals in 7-10 days 7(not present for weeks or months if immunocompetent person) 15 16 – Lip   Recurrent Herpes Simplex Infection  Traumatic Neuroma  Clinical – HSV Type 1 in humans.S. restorative procedure) No history of allergy or chemical burn 17 18 3 . such as nystatin or clotrimazole – White. palate and buccal mucosa are often involved – “Thrush”  Denture sore mouth – Clinical   Newborns and infants 13  Red Patient does not remove or clean denture – NOT acrylic allergy Tx – rinse mouth and soak denture with antifungal 14 Recurrent (Secondary) Herpes Simplex  Recurrent (Secondary) Herpes Simplex Clinical – U. underling base. especially near mental nerve. firm “lump” or nodule – Oral site Occurs at sites of chronic trauma O t it f h i t Ex. tongue    Hard palate and gingiva = nonmoveable. wipeable “patch” with red. most often – Intraoral     Clinical – Wandering transected nerve with scar tissue – Painful or tender. UV exposure. overlying bone Small coalescing shallow ulcers preceded by small vesicles Can be subclinical even though person has primary infection Usually history of trauma.

pink.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 “liver-colored” [brownish purple] “liver– Distinctive histology  Multinucleated giant cells – Limited to alveolar ridge/ gingiva  Usually anterior to first molar region 20 19 Central Giant Cell Granuloma  Squamous Papilloma (Papilloma)  Clinical – – – – – Etiology .epithelium White to white-pink usually but can be reddened whiteRough surface (cauliflower) Elevated lesion (papule. smooth. elevated papule/nodule – Common site is tongue (due to trauma) 23  Clinical – Dorsum of tongue #1 site – Nodule with smooth or papillated surface – Histology distinct   Granular cells . traumatic fibroma. etc. focal fibrous hyperplasia. 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 21 – More frequent than some other “omas”     Rhabdomyoma Leiomyoma Lymphangioma Neurofibroma 22 Fibroma (fibrous nodule. anaplasia. not true tumor Reactive – Hyperplasia.cytoplasm 50% of time exhibit pseudoepitheliomatous hyperplasia – Resembles squamous cell carcinoma histologically 24 4 . dysplasia. NOT neoplasia. irritation fibroma)  Granular Cell Tumor Clinical – Most common connective tissue tumor – Reactive. – Firm.

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.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 person’s mouth then both areas should have incisional biopsy 25 Initial – incisional biopsy 26 Squamous Cell Carcinoma  Clinical – Lower lip    Can be preceded by actinic cheilitis Firm. 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 patient’s 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 29 30 5 . indurated ulcer. painless with v. local spread or anaplastic cells) Most likely to a lymph node 27 28 – Metastasis  Squamous Cell Carcinoma  Staging vs.

bilateral on buccal mucosa – Diagnostic test chairside    Upper lip > Women W May be multinodular Asymptomatic Do not confuse with mucocele of the lower lip 31 Pull on buccal mucosa . 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. boggy. papillary often associated with smokeless tobacco habit – Most common site is buccal vestibule – No tendency to metastasize  33 Chief difference from typical squamous cell carcinoma 34 Field Cancerization – Squamous Cell Carcinoma  Salivary Gland Tumors   Patient diagnosed and treated for squamous cell carcinoma of the tongue Much more likely to have future p y premalignant g or malignant lesions anywhere in the oral cavity – Ex. elevated.-> disappears or dissipates – Normal mucosa variation so no treatment required 32 Leukemia  Clinical/Lab – Red. – 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 35  Adenoid cystic carcinoma – Characteristic perineural invasion – most likely  Parotid – facial nerve involvement but no upper lip paresthesia 36 6 .Monomorphic Adenoma (Canalicular Adenoma)  Leukoedema  Clinical – Most common site    Clinical – Intracellular edema of cells – More often seen in African-Americans African– Common. 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. swollen (hyperplastic)...

Complex types – Compound . swelling.e. the odontoma) 40 Odontoma    Clinical – primarily first two decades of life (young persons) Radiographic – Radiopacity with radiolucent rim (= follicle) Compound vs.Physiologic Pigmentation (Racial Pigmentation)  Lateral Periodontal Cyst  Clinical – Darkens with time. erupted. esp. #11) – Snow flake calcifications in the radiolucency surrounding the crown and a portion of the impacted tooth’s root  Radiographic Treatment – simple enucleation 41 42 7 . present most of a person s lifetime person’s – African-American patients AfricanUpper or lower lip vermilion. gg Ameloblastic fibro-odontoma fibrois similar except for odontoma component  Histology – Reverse polarization of the nuclei of the tall. g. buccal mucosa  Series of splotchy brown macules  Clinical – True cyst (epithelial lining). columnar cells of the periphery – Pure lucency.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. no radiopaque component – AFO – also has radiopaque component (i. tongue. attached gingiva. not aggressive g p . not pseudocyst p y  Radiographic appearance – Well circumscribed radioluceny between the roots of adjacent.) Often associated with impacted tooth 39  Radiographic Young person More often in posterior jaws. vital teeth (most commonly seen at mandibular premolars) – Radiographic differential diagnosis does NOT include dentigerous cyst (impacted tooth) 37 38 Ameloblastoma  Ameloblastic Fibroma Clinical – Average age is 34 – Most common in posterior mandible but anterior mandible also (ca c oss midline) a so (can cross d e)  Clinical – – – –  Radiographic – – – – Most common true odontogenic tumor Multilocular radiolucency Superimposed over posterior teeth (> mand.. mandible Slight pain.

onset before puberty. bilateral lucencies  Fibrous Dysplasia Clinical – Unilateral mandibular or maxillary expansion. – 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 43  Radiographic – BWXs and PAs demonstrate classic lack of pulp chambers and root canals – Bell-shaped crown with constricted Bellcervical region 44 Cherubism  Radiographic – Multilocular. 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 tooth’s root  47 Treatment – None 48 8 ..C..e. fibro-osseous lesion) fibro– Café au lait pigmentation   Clinical – Bilateral jaws – Young persons – Jaw expansion . usually ceases at age 20 – Root canal therapy will not help since non-infectious nonprocess (i. 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. very carious posterior mandibular tooth). C.Amelogenesis Imperfecta  Dentinogenesis Imperfecta Clinical – Teeth lack enamel. of “teeth do not fit” – Painless swelling.ceases after childhood   45 Polyostotic form – McCune Albright syndrome Radiographic – Ground glass appearance Treatment – After age 20 when stabilized – Cosmetic bone shaving 46 Condensing Osteitis (Sclerosing Osteitis)  Clinical – Associated with pulpitis (ex.

maxillary lateral incisor – Soft tissue involvement. Idiopathic Bone Cavity. Hemorrhagic Cyst) Paget’s Disease of Bone  Clinical – Older age group – Bilateral maxilla affected – Involved bone can undergo malignant (sarcomatous) transformation (i. Malignant Bone Involvement  Clinical – Composed of Langerhans cells. smooth swelling adjacent to a Mucolabial. Unicameral Cyst. osteosarcoma) – Cranial nerve deficits as foramen compressed.hypercementosis  49 Histology – Reversal lines with a mosaic pattern 50 Langerhans Cell Disease (Histiocytosis X)  Benign vs. not histiocytes – Etiology is still unknown – Eosinophilic granuloma  Clinical – Ominous malignant sign  Spontaneous paresthesia of the lower lip Solitary lesion.Benign – Cortex remains intact – thinned or expanded  Radiographic – Tooth “floating in air or space” 52 Central Neural Lesions   Nasolabial Cyst  Neurofibroma and Schwannoma Radiographic – Enlargement of canals and foramina Clinical – Mucolabial.e.Traumatic Bone Cyst  Clinical (Simple Bone Cyst. young adults Diabetes insipidus Exophthalmos Bone lesions 51 – Hand-Schuller-Christian triad Hand-Schuller    Radiographic .. not bone  Histology – Pseudostratified squamous epithelium cystic lining 53 54 9 . 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% .

. BCNS association – Radiolucent. tissue tags above and below the occlusal plane (line alba) Other sites – lip and tongue 59 Odontoma Epidermoid cyst 60 10 . rough. unerupted teeth – Multiple GI (colon) polyps [familial intestinal polyposis] .-> colon carcinoma Clinical – Buccal mucosa site – White. yellowish at times  Radiographic – High recurrence! – Intrabony. posterior mandible but anywhere.Odontogenic Keratocyst Lymphoepithelial Cyst   Clinical Clinical – Commonly on ventral tongue/floor of mouth – Well circumscribed swelling g – Pale.unilocular or multilocular lucencies – Calcification of the falx cerebri 57 58 Cheek Nibbling (Morsicatio Buccarum)  Gardner Syndrome  Clinical – Multiple facial osteomas & skin nodules – Hyperdontia. usually multilocular – M mimic many other May i i h types of lucent cysts and odontogenic tumors including ameloblastoma parakeratin 55 surface 56 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 ..

)..Bell’s Palsy  Clinical – 7th nerve paralysis . intraoral sites excluding gingiva – “Target. gingiva 65 66 11 .-> unilateral lip droop at corner. ulcers of vermilion of lips. bleeding.. vesicles. or bulls-eye lesions” bullsof the hands and feet 63 •Eye (conjunctiva). explosive onset – Triggered by drug or viral infection – Crusted. tongue. etc. iris. genitalia 64 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. mouth (labial mucosa. 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 61 62 Erythema Multiforme  StevensStevens-Johnson syndrome (Erythema Multiforme Major) Clinical – Young adult males – Sudden.

mucus extravastion phenomenon)  Clinical – – – – – – Children and young adults Trauma Lower lip is most common site Vesicle/bulla. depapillated areas of tongue (filiform papillae atrophied) White = keratin. elsewhere on sunsun-exposed face (UV). epithelial cell debris White rubs off with difficulty. Erythema Migrans) Migrans) Clinical – Red and white  Aspirin Burn (Chemical Burn)  Clinical – White = coagulative necrosis of the surface. g telangiectasia  Can be highly destructive if not treated  Usually does not metastasize  (mucus retention phenomenon. 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 69 70 Basal Cell Carcinoma – Clinical Painless ulcer of upper lip.Progressive Systemic Sclerosis (Scleroderma)  Clinical – Demonstrates induration of the soft tissue (mask-like) and (maskgeneralized widening of the PDL space – Trismus 67 68  Benign Migratory Glossitis (Geographic Tongue. assoc. dome-shaped domeBluish often History of recurrence Mucocele 71 72 12 . NOT hyperkeratosis   Red = flat. raised margins  Does NOT occur intraorally  Begins as pearly papule.

phenomenon. 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 “tongue“tongue. mucus retention  Antral Pseudocyst (Mucous Retention Pseudocyst) Clinical – Asymptomatic – No treatment necessary Radiographic – Slight radiopaque... emanating from floor of maxillary sinus Clinical – Floor of mouth swelling Looks like a frog’s belly (Gk ‘ranu’ = frog)  Bluish usually. mucus extravastion phenomenon)  Ranula (mucocele.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 . squamous ameloblastoma. mucoepideromoid carcinoma – Other impacted teeth besides 3rd molars 75 76 Dentigerous Cyst (cont’d)  Radiographic – Pericoronal radiolucency attached at CEJ of unerupted tooth – Radiographic differential diagnoses Ameloblastoma Residual cyst  Odontogenic keratocyst  Odontogenic myxoma   77 78 13 . cell carcinoma. radiopaque domedome-shaped.-> ameloblastoma.

candies.pinpoint bleeding Petechia– Ecchymosis – larger area of involvement – Hematoma – large.g. ulcer mimicking cancer on the tongue) Extravasated Blood  Clinical – spontaneously resolve – Purpura – generalized term – Petechia. phlebolith) Clinical – Incomplete root canal therapy with intermittent sensitivity – Elevated reddish-yellow reddish Clinical evidence of a draining fistula 79 80 Tuberculosis  Clinical – Incidence is increasing worldwide and in the U.S.e. elevated areas 81 82 Allergic Mucositis  Eagle Syndrome  Clinical – Typically due to flavoring agents in toothpastes. yawning.Varices  Parulis (Gum Boil)  Lingual and Lip – Dilated veins .. – Chest radiograph – M spread by infected sputum to oral May db i f t d t t l lesions (e. opening mouth 83 84 14 . 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.blue – Seen typically in the elderly – Lip varices may thrombose and subsequently calcify (i.

. gingival bleeding – Vesicles .. lymphadenopathy ex.-> ulcers throughout the mouth and lips with significant pain – Malaise – Low grade fever – Sore throat. tongue) – Medullary thyroid carcinoma y y – Adrenal pheochromocytoma Example . large intestine and other regions of the GI tract 87 88 Dermoid Cyst  Multiple Endocrine Neoplasia Syndrome.Herpes Zoster  Primary Herpes Gingivostomatitis  Clinical – Crop of vesicles . tongue 85 86 Primary Herpes Gingivostomatitis Crohn’s Disease  Clinical – Granulomatous gingivitis – Aphthous-like ulcers Aphthous– Rectal bleeding  Intestinal skip lesions of small intestine.. – palate.g.. Type IIB (III)  Clinical – Slightly compressible (“doughy”) – Midline distribution usually  Clinical – Multiple mucosal neuromas (e. enlarged marginal gingiva. and to a lesser degree..> ulcers with pain – Striking unilateral distribution on skin and oral l  Clinical – Inflamed.anterior floor of mouth 89 90 15 .

trigger points  Radiographic – Lucent line – Maxillary occlusal film 93 94 Neuritis  Actinic Cheilitis  Clinical – Lip’s 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 95 96 16 .Incisive Canal Cyst (Nasopalatine Duct Cyst)  White Sponge Nevus  Clinical – Most common developmental nonnon-odontogenic cyst – Teeth vital.No eye involvement Often heartheartshaped lucency 91 92 Cleft Palate  Trigeminal Neuralgia  Clinical – Between lateral incisor and canine Clinical – Age of onset typically > 35 years old. midline max – True cyst (epithelial lining) Clinical – A genodermatosis  Autosomal dominant – Often bilateral buccal mucosa. max. other mucosa – Moderately extensive thick. white folds of tissue .

.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. become mixed lucent/opaque and finally mainly opaque Time 101 102 17 ..Cheilitis Glandularis  Clinical – Mucous minor salivary glands of lips are inflamed – Mucus secretions – Premalignant condition . 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 . 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.> squamous cell carcinoma   PostPost-Developmental Loss of Tooth Structure Attrition .. periapical osseous dysplasia)  Clinical – White.asymptomatic  Radiographic – Diagnosed by characteristic findings  Multifocal periapical lucencies which mature over time..

. often asymptomatic Erosive form – On tongue may be mistaken for geographic tongue – Sensitive. individual papules and striae Hyperplastic form . Most likely complication is a secondary osteomyelitis  Radiographic – Radiolucent and radiopaque  Treatment – None necessary after dx 103 104 Lichen Planus  Clinical – Skin and/or oral condition – Middle aged women most often – Skin  Lichen Planus Purple. – dorsum of tongue – White plaques. painful Most common site – Buccal mucosa Ex. .Florid Cemento-osseous Dysplasia Cemento(florid osseous dysplasia)  Florid Osseous Dysplasia Clinical – – – – Multiquadrant FibroFibro-osseous intrabony lesion Hard product produced is avascular so .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. pruritic papules White papules and coalescing papules = Wickam’s striae Does not wipe off – any oral site – Reticular form. polygonal. especially interdental papilla area – Product may be seen on dental radiographs as scattered light opacities 107 108 18 .

Cleidocranial Dysplasia  Clinical – – – – Multiple unerupted supernumerary teeth Retention of primary teeth Delayed eruption of permanent teeth Missing clavicles. frontal bossing. soft and hard tissue – Mobile teeth Radiographic – Intrabony. large head  Neurofibromatosis. inflamed minor salivary gland ducts with background of leukoplakic change – Tobacco use  Pipe smokers – most often  Cigarettes  113 114 19 . type 1 (von Recklinghausen’s disease of skin) Clinical – Multiple neurofibromas (nodules) of the skin and oral cavity (especially tongue) – Café au lait pigmentation (abnormal macules or spots of the skin) p )  Brown macules 109 110 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. destructive – Malignant looking but benign usually  Clinical – Hard palate – Red. lucent.

especially maxillary lateral incisor 119 120 20 . elongated condyle – Chin deviates away from affected side upon y p closure Clinical – Most often found in anterior jaw.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 117 118 Condylar Hyperplasia  Dens-inDens-in-dente (dens invaginatus)  Clinical – Irregular.

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 121 122 (Hypohydrotic) Ectodermal Dysplasia   Epulis Fissuratum  Exhibits hypodontia (anodontia) Hypohidrotic . fluid containing so a vesicle Heavy Metal Systemic Intoxication  Clinical – Lead line  Blue line that parallels free marginal gingiva 125 126 21 .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.

at times. 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.Hemangioma Lymphangioma  Clinical – Lymph-filled superficial vessels Lymph– Most common cause of macroglossia   Clinical – Hamartoma – Red to blue elevated lesions – Blanches. in Paget’s Clinical – Cervical swelling. 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 131 132 22 . 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.

baldish.. HPV virus. individual that progress to AIDS – Etiology  Clinical – Junctional type  Most likely to undergo malignant transformation (i. 137 138 23 . seen in HIV positive malig. ‘nevus’)  Kaposi’s Sarcoma  Clinical – Particular malig. spontaneously resolve in ~ 4 months – Keratin plug in the center of the ulceration Keratoacanthoma 135 136 Xerostomia  Warthin’s tumor (papillary cystadenoma lymphomatosum)  Clinical – Dry mouth (subjective) – Can result in retrograde infection of the salivary glands.Acquired Melanocytic Nevus (common mole’. EBV.e. melanoma) Herpes virus type 8. >> males y. not HIV. 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. HIV EBV. inflamed tongue Clinical – Primary site overwhelmingly is parotid  Not in oral cavity. CMV.

. NOT infectious (e. rheumatoid arthritis 141 142 Proliferative Periostitis (Garre’s)  PeutzPeutz-Jeghers Syndrome  Clinical – Young person. dry mouth = sicca Parotid swelling P tid lli Often other autoimmune diseases – lupus. swelling visible Clinical – Oral and Paraoral   Radiographic – Inferior border of posterior mandible is common site .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 SjÖgren’s Syndrome  Sarcoidosis  Clinical – Bilateral hilar lymphadenopathy (chest x-ray) x– Cutaneous lesions .g. buccal mucosa – Vermilion and skin of lip – Intestinal polyposis 143 144 24 .violaceous – Treatment – corticosteroids Clinical – – – – – Autoimmune disease. herpes) Elderly women Dry eyes.Onion skin pattern (radiographic appearance)  Bands of radiopaque lines that parallel cortical surface Pigmented macules (brown) – Lips. tongue.

tingling lower lip – Onset in late 20s. trabeculae changes. PDL symmetrical widening 145 146 Osteopetrosis  Clinical – Massive overproduction of dense. 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.Osteosarcoma  Clinical – Swift onset of localized pain and swelling. 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 .

spine. – air/water syringe 155 156 26 .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. jaws – Punched-out lucencies Punched153 154 Necrotizing Sialometaplasia  Cervical emphysema  Clinical – Rapid onset – Deep ulceration of the palate (most common site) after i iti l swelling. self-resolving it ) ft initial lli selflf l i Introduction of air into oral soft tissues with resulting sudden painless swelling and crepitance – Ex. pelvic girdle.

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 (cont’d)    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.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. pemphigus and erosive lichen planus 159    Autoimmune diseases more common in women Oncocytoma = parotid swelling (tumor) Gingival hyperplasia – drugs such as cyclosporine. mandible. Most common jaw metastasis site is posterior mandible Onion skin radiograph pattern is also seen in Ewing’s sarcoma Desquamative gingivitis includes pemphigoid. pemphigoid. 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. melanoma. adenocarcinoma osteosarcoma. primary tooth of ant. 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 .

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 (cont’d)     Radiology Facts (cont’d)     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. intermaxillary suture Lingual foramen. inverse square law) Latent period = radiobiology time between exposure and biologic onset of symptoms. genial tubercles Mylohyoid ridge. incisive foramen. not cell exposure and free radical formation Radiograph is rinsed with water to accomplish getting rid of chemicals (not remove emulsion.e. nutrient canals Inverted Y of Ennis Maxillary sinus Tuberosity. 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. articular disc) is an MRI Identify Normal: – – – – – – – Zygomatic process and base. anterior nasal spine. tori. periapical film) 164 Hard palate.Radiology Facts (cont’d)  Radiology Facts (cont’d)    First sign of damage from acute radiation exposure (4 Gy) is erythema Most radioresistant tissue is nerve and muscle cell. the operator should decrease kVp and increase mAs 168 28 .g. diminish silver particles.. 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. hyoid bone.. stylohyoid ligament Radiology Facts (cont’d)    Radiology Facts (cont’d)  Intensifying screens are used to decrease exposure time. nose shadow (ant.

Radiology Facts (cont’d)  Radiology Facts (cont’d)      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 .

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