Clinical'Principles'of'Pa/ent'

Evalua/on'
Midterm'Review'
 Test'Responsibili/es'
•  Differen/al'Diagnosis:'list'3'maximum'
•  Clinical'Diagnosis:'list'most'likely'
•  Defini/ve'Diagnosis:'should'be'able'to'tell'for'
sure'

•  No'histology'at'all'
 Case'1'Introduc/on'
•  An'asymptoma/c'42'year'old'white'female'
comes'to'your'office'for'rou/ne'dental'care.''
During'your'radiographic'exam,'you'find'a'1'
cm'radiolucency'at'the'apex'of'the'right'
maxillary'central'incisor'
Case'1'Visual'
 Case'1'Ques/ons'
•  What'clinical'test'is'indicated'to'determine'the'nature'of'the'
pathologic'process?'
–  Thermal'and/or'Electronic'pulp'test'to'determine'vitality'
•  Vital'
•  NonSvital'
–  Look'for'reasons'of'nonSvitality'on'tooth'(ie:'large'caries,'crown,'etc)'
•  In'an'asymptoma/c'(nonSvital'tooth)'pa/ent,'what'two'condi/ons'
would'this'most'likely'represent?'
–  Periapical'cyst'
–  Periapical'granuloma'
•  In'a'symptoma/c'(nonSvital'tooth)'pt…'
–  Periapical'abscess'
•  How'would'you'treat'this'lesion?'
–  nsRCT'(“best”'due'to'high'success'rate'and'anterior'esthe/cs)'
–  EXT'!'implant'
 Case'2'Introduc/on'
•  JF,'a'17'year'old'white'female,'complained'of'
dull'pain'associated'with'her'le_'anterior'
maxilla.''Radiographs'revealed'a'large'
radiolucency'at'the'apex'of'her'maxillary'le_'
lateral'incisor'
Case'2'Visual'
 Case'2'Ques/ons'
•  2'Ways'to'devitalize'a'tooth'
–  Trauma'
–  Caries'
•  Radiographic'differences'between'granuloma'and'cyst'
–  None'
•  Differen/al'diagnosis?'
–  Periapical'Granuloma'
–  Periapical'Cyst'
–  Periapical'Abscess'
•  Microscopic'diagnosis'
–  Periapical'Granuloma'
•  Treatment'
–  nsRCT'
–  EXT'!'Implant'
•  Curebe'during'extrac/on'to'remove'granula/on'/ssue'or'cyst'
 Case'3'Introduc/on'
•  A'38'year'old'Vietnamese'male'was'in'for'a'
rou/ne'checkSup.''Radiographic'examina/on'
reveals'a'well'circumscribed'radiolucency'
between'the'mandibular'right'cuspid'and'
central'incisor.''The'lateral'incisor'was'missing.'
Case'3'Visual'
 Case'3'Ques/ons'
•  What'does'the'radiopacity'in'the'lesion’s'margin'represent'and'what'does'it'tell'
you'about'the'growth'characteris/cs'of'the'pathologic'process?'
–  Features:'symmetrical,'cor/cated'(ie:'lucent'w/'radiopaque'bony'halo)'
–  This'is'slow'growth'!'benign'lesion'
•  Differen/al'diagnosis?'
–  Residual'Periodontal'Cyst'
–  Cementossifying'fibroma'
–  Any'benign'lucent'tumor'
•  Ameloblastoma,'Adenomatoid'Odontogenic'Tumor,'Pindborg'Tumor,'Gorlyn'Cyst,'Glandular'
Odontogenic'Cyst,'Giant'Cell'Granuloma,'Primordial'Cyst'(only'if'pt'never'developed'a'tooth)'
•  How'would'you'establish'a'diagnosis'in'the'case?'
–  Biopsy'
•  Microscopic'diagnosis'
–  Residual'periodontal'cyst'
•  Lumen'in'nonSkera/nized'SSE,'Inflammatory'cells'are'present'
•  Management'
–  Curebe,'refer'to'OMS'
 Case'4'Introduc/on'
•  A'32'year'old'AfricanSAmerican'male'
complained'of'divergence'of'his'maxillary'
central'incisors.''Radiographs'were'taken'and'
showed'a'large'well'circumscribed'
radiolucency'between'the'roots'of'the'
involved'teeth'
Case'4'Visual'
Case'4'Visual'
Case'4'Visual'
 Case'4'Ques/ons'
•  Features'of'Radiograph'
–  Moving'teeth'!'benign'
•  Differen/al'Diagnosis?'
–  Nasopala/ne'Duct'(aka:'Incisive'Canal)'Cyst'
•  Most'common'
–  Any'PA'pathology'(ie:'PA'cyst/granuloma/abscess)'
–  Median'Palatal'Cyst'
•  Usually'more'posterior'
•  Not'common'
–  Central'Giant'Cell'Granuloma'
•  What'clinical'test'could'be'used'to'help'dis/nguish'between'these'two'most'likely'choices?'
–  Pulp'Vitality'
•  How'would'the'results'of'your'clinical'test'in'number'2'alter'treatment?'
–  If'vital'!'eliminate'any'PA'pathology'
•  Dis/nguish'between'developmental'and'inflammatory'cysts'
–  Inflammatory'cysts'are'associated'with'PA'disease'
•  Microscopic'diagnosis'
–  Nasopala/ne'Duct'(aka:'Incisive'Canal)'Cyst'
•  Treatement'
–  Enuclea/on' or exicision
 Case'5'Introduc/on'
•  A'62'year'old'white'female'comes'to'your'
office'complaining'of'pain'and'paresthesia'of'
her'le_'mandible.'Radiographs'reveal'a'poorly'
circumscribed'lucency'of'her'mandibular'
midbody.''There'was'also'so_'/ssue'swelling'
of'her'edentulous'alveolar'ridge'distal'to'the'
second'premolar'
Case'5'Visual'

So_'Tissue'
Radiopacity'
 Case'5'Ques/ons'
•  Radiographic'Benign'vs.'Malignant'
–  Malignant'
•  No'cor/ca/on'
•  Paresthesia'
•  Root'resorp/on'
•  Asymmetric'
•  Differen/al'diagnosis'
–  Metasta/c'Tumor'
–  Mul/ple'Myeloma'
–  Osteosarcoma'
–  Chondrosarcoma'
–  Acute'Osteomyeli/s'
•  Very'rare'in'developed'countries'with'good'an/bio/cs'
•  If'you'see'pus'!'must'be'bacterial'infec/on'
•  Of'what'significance,'if'any,'is'the'paresthesia?'
–  Most'likely'malignant'since'benign'tumors'don’t'o_en'affect'the'nerve'
•  What'is'the'most'common'malignancy'affec/ng'the'jaws'
–  Metasta/c'Tumor'
•  Women'metastasize'from'breast'cancer'
•  Men'metastasize'from'lung'cancer'
•  ¼'of'people'don’t'realize'they'have'cancer'
•  Microscopic'diagnosis'
–  Metasta/c'Tumor'
 Case'6'Introduc/on'
•  This'42'year'old'white'male'had'a'radiographic'
survey'prior'to'construc/on'of'par/al'
dentures.''Radiographs'reveal'an'impacted'
third'molar'with'a'large'radiolucency'around'
its'crown.''The'tooth'had'been'displaced'to'
the'inferior'border'of'the'mandible'
Case'6'Visual'
 Case'6'Ques/ons'
•  Benign'vs'Malignant'
–  Benign'!'tooth'displacement,'symmetrical,'cor/ca/on'
•  What'is'the'significance'of'pericoronal'
–  Almost'guarantees'us'that'we'have'odontogenic'pathology'
•  Differen/al'diagnosis:'(well'circumscribed'periocoronal'radiolucency!'odontogenic'cysts'and'
tumors)'
–  Den/gerous'Cyst'
–  OKC'
–  Ameloblas/c'Fibroma'
•  Age'range'for'AF'is'teenage/young'adult'
–  Glandular'Odontogenic'Cyst'
–  Gorlin'Cyst'
–  Ameloblastoma'
–  Odontogenic'Myxoma'
–  Pindborg'(aka:'CEOT)'
•  Provisional'clinical'diagnosis'
–  Den/gerous'Cyst'(90%'likely)'
•  Why'is'it'important'to'have'this'/ssue'examined'histologically?'
–  The'pathology'could'be'an'OKC'
•  Microscopic'diagnosis'
–  Den/gerous'Cyst'
 Case'7'Introduc/on'
•  A'46'year'old'black'male'was'found'to'have'a'
well'defined'3cm'radiolucency'around'the'
crown'of'his'impacted'mandibular'le_'third'
molar.''The'pa/ent'was'asymptoma/c.'
Case'7'Visual'
 Case'7'Ques/ons'
•  Radiographic'analysis'
–  Radiolucent'lesion'
–  Cor/cated'borders'
–  Abached'to'crown'
•  Differen/al'
–  OKC'
–  Den/gerous'Cyst'
–  Ameloblastoma'
–  AOT'
–  Gorlin'Cyst'
•  Provisional'clinical'diagnosis'
•  Upon'entering'the'bone,'you'find'a'cys/c'lesion.''The'cyst'separates'easily'from'the'surrounding'
bone'and'is'therefore'enucleated.''You'open'the'cyst'to'examine'its'luminal'surface'and'find'a'small'
nodule'within'the'cyst'wall.''Name'three'things'this'nodule'could'represent.'
–  Neoplasm'
•  SCC'from'epi'in'cyst'wall'
•  Ameloblastoma'
•  Mucoepidermoid'Carcinoma'
•  Microscopic'diagnosis'
–  Ameloblastoma'
•  How'should'this'lesion'be'managed?'
–  Surgically'remove'cyst'and'1S2cm'of'bone'around'cyst'to'prevent'recurrence'
 Case'8'Introduc/on'
•  A'14'year'old'white'male'is'referred'to'your'
office'for'the'diagnosis'of'an'asymptoma/c'
radiolucency'of'his'right'posterior'mandible.''
There'was'no'swelling'or'tenderness'in'the'
region.''The'teeth'in'the'region'tested'vital.''
The'radiolucency'was'from'the'second'
premolar'to'second'molar'and'extended'up'
between'the'roots'of'the'teeth.'
Case'8'Visual'
 Case'8'Ques/ons'
•  Differen/al'diagnosis'
–  Trauma/c'bone'cyst'
–  Ameloblastoma'
–  OKC'
–  Central'Giant'Cell'Granuloma'
•  Provisional'clinical'diagnosis'
–  Trauma/c'Bone'Cyst'
•  What'radiographic'feature'is'highly'sugges/ve'of'this'condi/on?'
–  Scalloping'of'lesion'between'roots'
•  You'decide'to'biopsy'the'lesion.''Upon'entering'the'bony'cavity,'you'find'a'
small'amount'of'seroSsanguinous'fluid'but'no'evidence'of'a'cys/c'lining?'
–  Sugges/ve'of'trauma/c'bone'cyst'
•  Treatment'
–  Curebe'cavity'!'bleeding'!'bone'fills'in'cavity'
 Case'9'Introduc/on'
•  A'small'discrete'well'circumscribed'
radiolucency'is'found'midway'between'the'
roots'of'the'mandibular'cuspid'and'lateral'
incisor'on'this'37'year'old'white'male.''The'
pa/ent'was'asymptoma/c'and'unaware'of'the'
lesion.'
Case'9'Visual'
 Case'9'Ques/ons'
•  Radiographic'analysis'
–  Well'circumscribed,'symmetrical,'not'displacing'teeth'
•  Differen/al'diagnosis'
–  Lateral'periodontal'cyst'
–  Lateral'radicular'cyst'
–  Central'giant'cell'granuloma'
–  Gorlin'cyst'
•  How'would'you'establish'a'diagnosis?'
–  Test'for'vitality'
•  Vital'!'lateral'periodontal'cyst'(developmental'cyst)'
•  NonSvital'!'lateral'radicular'cyst'(inflammatory'cyst'from'lateral'canal)'
•  Microscopic'diagnosis'
–  Lateral'periodontal'cyst'
•  How'would'you'describe'the'growth'poten/al'of'this'lesion?'
–  Slow'and'limited'growth'
–  Demographic'of'LPC:'canine/premolar'region'in'mandible,'50sS70s'
 Case'10'Introduc/on'
•  A'17'year'old'white'female'complained'of'
discomfort'and'slight'swelling'of'her'le_'
mandible.''Panorex'radiograph'revealed'a'
mul/Slocular'radiolucency'extending'from'the'
le_'third'molar'to'the'right'first'premolar.'
Case'10'Visual'
 Case'10'Ques/ons'
•  Radiographic'analysis'
–  Large'mul/locular'radiolucency'
•  Differen/al'diagnosis'
–  Most'likely'
•  OKC'
•  Ameloblastoma'
•  Central'Giant'Cell'Granuloma'
–  Not'as'likely'
•  Gorlin'Cyst'
•  Odontogenic'Myxoma'
•  Ameloblas/c'Fibroma'
•  Microscopic'diagnosis'
–  OKC'
•  Kera/nzed'epithelium'
•  What'is'the'recurrence'rate'for'this'lesion?'
–  30%'
•  Lining'is'smooth'and'not'abached'to'CT'very'well'!'hard'to'curebe'out;'satellite'cells'
 Case'11'Introduc/on'
•  A'white'17'year'old'male'was'referred'to'an'
oral'surgeon'for'removal'of'his'impacted'third'
molars.''Radiographs'revealed'a'1cm'x'2cm'
radiolucency'around'the'crown'of'his'lower'
right'third'molar.'
Case'11'Visual'
 Case'11'Ques/ons'
•  Radiographic'analysis'
–  Well'defined'unilocular'surrounding'crown'of'tooth'with'cor/cated'border'
•  Differen/al'diagnosis'
–  More'likely'
•  Den/gerous'cyst'
•  Ameloblastoma'
•  OKC'
–  Unlikely'
•  Gorlin'Cyst'
•  Ameloblas/c'fibroma'
•  AOT:'loca/on'is'not'very'good;'usually'anterior'maxilla'
•  Provisional'clinical'diagnosis'
–  Den/gerous'cyst'
•  Due'to'loca/on:'cyst'is'abached'to'crown'of'impacted'tooth'at'CEJ'
•  Microscopic'diagnosis'
–  OKC'
•  List'three'significant'clinical'features'that'characterized'this'lesion.'
–  High'recurrence'rate'
–  Aggressive'
–  Small'%'are'associated'with'Nevoid'Basal'Cell'Syndrome'(aka:'Bifid'Rib'Symdrome)'!'mul/ple'OKCs'
•  Calcifica/on'of'falx'cerebri,'100s'of'basal'cell'carcinomas,'bifid'ribs'
 Case'12'Introduc/on'
•  A'38'year'old'male'experienced'pain'and'
swelling'of'his'le_'posterior'mandible.''
Radiographic'examina/on'revealed'a'
mul/locular,'expansile,'radiolucency'
containing'a'molar'tooth'at'its'posterior'
border'
Case'12'Visual'
 Case'12'Ques/ons'
•  Differen/al'diagnosis'
–  3'Most'Common'Mul/locular'Radiolucencies'
•  OKC'
•  Ameloblastoma'
•  Central'Giant'Cell'Granuloma'
–  Less'common'
•  Interosseous'Mucoepidermoid'Carcinoma'
–  Only'one'of'this'differen/al'diagnosis'that'is'malignant'
•  Ameloblas/c'Fibroma'
–  Usually'limited'to'kids'!'not'likely'here'
•  Pindborg'Tumor'(aka:'Calcifying'Epithelial'Odontogenic'Tumor)'
–  PT'='driven'snow'!'Not'likely'here'unless'this'is'super'early'lesion'
•  Microscopic'diagnosis'
–  Ameloblastoma'
•  How'is'the'tumor'best'treated?''How'would'you'handle'this'par/cular'case?'
–  Aggressive'curebage'
•  Recurrence'rate'of'50%'
–  Could'also'do'block'resec/on'if'it'is'large'like'this'case'
 Case'13'Introduc/on'
•  This'34'year'old'female'complained'of'selling'
of'the'body'of'her'le_'mandible.''Radiographs'
of'the'area'showed'an'expansile'lucency'
containing'numerous'fine'opaque'bony'
trabecula/ons.'
Case'13'Visual'
 Case'13'Ques/ons'
Differen/al'diagnosis'
–  Ameloblastoma'
–  Central'Giant'Cell'Granuloma'
–  Odontogenic'Myxoma'
–  Pindborg'Tumor'(aka:'CEOT)'
–  Ossifying'Fibroma'
Note'all'the'above'are'benign'neoplasms'
•  Provisional'clinical'diagnosis'
–  Odontogenic'Myxoma'
•  Has'residual'bony'trabecuale'
•  Microscopic'diagnosis'
–  Odontogenic'Myxoma'
•  What'is'the'preferred'treatment'for'this'lesion?'
–  Marginal'Resec/on'
 Case'14'Introduc/on'
•  An'18'year'old'AfricanSAmerican'female'came'
to'your'office'complaining'that'her'lower'front'
teeth'“seemed'to'be'moving”.''There'was'
some'tenderness'to'percussion'and'slight'
labial'expansion'was'noted.''Your'panorex'
radiograph'revealed'a'large'unilocular'
radiolucency'from'the'mandibular'right'first'
premolar'to'the'mandibular'le_'first'premolar.'
Case'14'Visual'
 Case'14'Ques/ons'
•  Differen/al'diagnosis'
–  Central'Giant'Cell'Granuloma'
–  Not'Likely'
•  Langerhan’s'Cell'Disease:'Classically'See'floa/ng'teeth'
•  Trauma/c'Bone'Cyst:'Would'not'move'teeth'
•  Ameloblastoma:'Usually'more'posterior'
•  Keratocyst:'Usually'more'posterior'
•  Provisional'clinical'diagnosis'
–  Central'Giant'Cell'Granuloma'
•  Crosses'the'midline;'Anterior'loca/on;'Females,'<30yrs,'Expanding'Radiolucency'
•  Microscopic'diagnosis'
–  CGCG'
•  Is'this'a'reac/ve'or'neoplas/c'process?'
–  Reac/ve'(we'don’t'know'what'it'is'reac/ve'to'though)'
•  With'these'histological'features,'what'other'pathologic'condi/on'must'be'ruled'out'clinically?'
–  Hyperparathyroidism'(looks'iden/cal'to'CGCG'histologically)'
•  Excess'PTH'!'excess'CA2+'
•  “Bones,'Stones,'and'Intes/nal'Groans”'
•  50S60'
•  Treatment'
–  Currebage'
 Case'15'Introduc/on'
•  A'43'year'old'AfricanSAmerican'female'
presents'for'rou/ne'dental'care.''In'evalua/ng'
her'radiographic'survey,'you'find'two'small'
radiolucencies'at'the'apices'of'her'mandibular'
central'incisors.'
Case'15'Visual'
 Case'15'Ques/ons'
•  Differen/al'diagnosis'
–  Vital'!'Periapical'Cementosseous'Dysplasia'(PCOD)'
•  Anterior'Mandible:'PA'CoD'
•  Isolated'single'tooth:'Focal'CoD'
•  Generalized:'Florid'CoD'
–  NonSvital'!'PA'Granuloma/Cyst/Abscess'
•  Provisional'clinical'diagnosis'
–  PA'Cementosseous'Dysplasia'
•  AA'female,'40S45'yr,'painless,'<1cm,'anterior'mandible'
•  How'would'you'establish'a'diagnosis'in'this'case?'
–  Pulp'test'!'vital'!'PCOD'
•  How'should'this'condi/on'be'treated?'
–  Nothing'(no'biopsy),'just'watch'and'document'
–  3'stages:'lucent'!'mixed'!'opaque'(selfSlimi/ng'once'it'becomes'
opaque)'
 Case'16'Introduc/on'
•  A'44'year'old'male'experienced'pain'and'
progressive'swelling'of'his'le_'mandible'for'6'
months.''Radiographs'revealed'a'large'mixed'
radiolucentSradiopaque'lesion'with'expansion'
of'the'inferior'border'of'the'mandible.'
Case'16'Visual'
 Case'16'Ques/ons'
•  Differen/al'diagnosis'
–  Cementossifying'Fibroma'
–  Pindborg'Tumor'(aka:'Calcifying'Epithelial'Odontogenic'Tumor)'
–  Gorlan'Cyst'(aka:'Calcifying'Odontogenic'Cyst)'
–  Ameloblas/c'FibroSOdontoma'
•  Mixed'stage'of'ameloblastoma'
•  Usually'kid'!'not'likely'
–  Cementoblastoma'
•  Not'ankylosed'to'tooth'though'!'not'likely'
–  Osteoblastoma'
•  Not'CementoSosseous'dysplasia'due'to'expansion'
•  Microscopic'diagnosis'
–  Pindborg'Tumor'
•  How'would'you'compare'the'growth'poten/al'of'this'neoplasm'with'an'
ameloblastoma?'
–  Less'growth'
–  Curebe'!'small'recurrence'(15%)'
 Case'17'Introduc/on'
•  A'63'year'old'female'presented'with'pain'in'
her'right'maxilla'of'approximately'2'months'
dura/on.''Clinically'there'was'an'area'of'
exposed'bone'approximately'2S3cm.''
Radiographically'an'area'of'illSdefined''opacity'
was'seen'in'the'right'maxilla.''Significant'in'
her'medical'history'was'a'diagnosis'of'mul/ple'
myeloma.''She'had'received'a'course'of'
chemotherapy'and'was'taking'intravenous'
ZOMETA'(Zolendroic'Acid)'
Case'17'Visual'
Case'17'Visual'
 Case'17'Ques/ons'
•  What'is'the'most'likely'cause'of'the'osteonecrosis?'
–  Surgery'(rarely'occur'spontaneously)'
•  What'is'the'suggested'mechanism'of'ac/on'of'Zometa?'
–  Inhibited'osteoclast'breakdown'of'bone'
•  What'is'the'half'life'of'these'drugs'in'bone?'
–  IV:'10'years'
•  Discuss'risk'with'the'intravenous'drugs'versus'those'orally'
administered'
–  Oral:'lower'dose'!'only'1:100k'
–  IV:'1:100'pts'will'get'osteonecrosis'due'to'higher'dose'
•  Discuss'management'of'this'pa/ent'
–  No'treatment'is'available'!'Preven/on'is'key'
–  Locally'debride'if'there'is'ac/ve'infec/on'and'give'an/bio/cs'
 Case'18'Introduc/on'
•  A'34'year'old'white'male'is'a'new'pa/ent'in'
your'prac/ce.''He'is'asymptoma/c'but'in'
rou/ne'radiographs,'you'discover'a'roughly'
4S5mm'radiopacity'disal'to'#18.''There'is'no'
expansion.'
Case'18'Visual'
 Case'18'Ques/ons'
•  What'clinical'test'is'indicated'to'further'evaluate'this'lesion?'
–  Vitality'tes/ng'
•  Differen/al'diagnosis'
–  NonSvital'!'condensing'ostei/s'
–  Vital'!'Odontoma'
•  Benign'cementoblastoma:'radiopaque'w/'lucent'halo'(capsule),'fused'to'root'
•  Focal'Cementosseos'Dysplasia:'lucency' condensing osteitis
•  Ideopathic'osteosclerosis'
•  Provisional'clinical'diagnosis'
–  Ideopathic'osteosclerosis'
•  Bc'en/rely'radiopaque'with'no'halo'
•  Assuming'your'provisional'diagnosis'is'correct,'how'would'you'
expect'this'lesion'to'behave?'
–  Self'limi/ng'w/'no'expansion'or'pain'
–  Do'NOT'biopsy'!'would'devitalize'tooth'
would not biopsy CoD or ideopathic oscteosclerosis
 Case'19'Introduc/on'
•  This'26'year'old'AfricanSAmerican'female'
developed'a'radiolucent'lesion'in'the'body'of'her'
le_'mandible'about'a'year'ago.''Her'den/st'
provisionally'diagnosed'the'condi/on'as'
periapical'infec/on'and'extracted'the'posterior'
teeth.''The'lesion'con/nued'to'grow,'producing'
clinical'expansion'of'her'buccal'cortex.''Being'
dissa/sfied'with'her'current'therapy,'she'comes'
to'you.''Your'exam'confirms'the'buccal'swelling'
and'radiographs'reveal'an'expansile'radiolucency'
containing'mul/ple'foci'of'opacifica/on.'
Case'19'Visual'
Case'19'Visual'
 Case'19'Ques/ons'
•  Differen/al'diagnosis'
–  Cemento'Ossifying'Fibroma' Benign - symmetrical, well circumscribed
–  Gorlin'Cyst' CoD- doesn’t have charac. of expansion
–  Ameloblas/c'FibroSodontoma'
–  Pindborg'(aka:'CEOT)'
•  Your'pa/ent'wants'to'know'if'her'teeth'were'
correctly'extracted'
–  No,'but'tell'pt'that'you'don’t'know'what'happened'
back'then'
•  Microscopic'diagnosis'
–  Cemento'Ossifying'Fibroma'
 Case'20'Introduc/on'
•  A'17'year'old'white'male'developed'pain'in'his'
right'posterior'mandible.''Radiographs'
revealed'a'predominantly'2cm'radiopaque'
mass'abached'to'the'distal'root'of'the'
mandibular'first'molar.''The'mass'was'
surrounded'by'a'thin'radiolucent'zone.'
Case'20'Visual'
 Case'20'Ques/ons'
•  Differen/al'diagnosis'
–  Condensing'ostei/s'
•  Tooth'is'vital'!'not'likely'
–  Benign'Cementoblastoma'
–  Focal'Cementoosseous'dysplasia'
•  Provisional'clinical'diagnosis'
–  Benign'Cementoblastoma'
•  Pain,'swelling,'abached'to'root,'posterior'mandible'(esp'1M)'
•  What'would'your'provisional'diagnosis'be'for'a'similar'lesion'if'the'
tooth'was'nonvital?'
•  How'would'you'manage'this'case?'
–  Ext' Oral surgery - surgical extraction
•  Microscopic'diagnosis'
–  Benign'cementoblastoma'
 Case'21'Introduc/on'
•  On'rou/ne'radiographic'examina/on'of'this'15'
year'old'white'male,'you'find'a'well'
circumscribed'radiolucency'between'his'
maxillary'right'cuspid'and'first'bicuspid.''The'
inferior'half'of'the'lesion'contains'opaci/es'
resembling'toothSlike'structures.'
Case'21'Visual'
 ****On TEST, kinda look like unerupted teeth, little tooth like structures

Case'21'Ques/ons'
•  Provisional'clinical'diagnosis'
–  Compound'Odontoma' only make it when teeth developing
•  Teeth'“pound”'food'!'“toothlike”'odontomas'are''
com”pound”'where'complex'are'globs'that'don’t'look'like'teeth'
•  Microscopic'diagnosis'
–  Compound'Odontoma'
•  What'anatomic'structure'does'the'radiolucency'around'this'lesion'
represent'and'how'does'it'relate'to'treatment'and'prognosis?'
–  Lucency'is'follicle'
–  Tx'='extrac/on'
–  Prognosis'='good'
•  How'would'you'describe'the'growth'poten/al'of'this'lesion?'
–  Low'growth'poten/al'
 Case'22'Introduc/on'
•  A'22'year'old'Hispanic'female'comes'to'your'
office'for'rou/ne'dental'care.''A'radiographic'
survey'discloses'a'large'radiopaque'mass'
overlying'the'crown'of'an'impacted'posterior'
tooth.'
Case'22'Visual'
 Case'22'Ques/ons'
•  Differen/al'diagnosis'
–  Complex'odontoma'
–  Osteoid'Osteoma'
–  Ameloblas/c'FibroSodontoma' “developing odontoma”

•  Classically'is'mixed'lucent/opaque'
•  If'you'don’t'tx'Ameloblas/c'Fibroma'!'get'
Ameloblas/c'FibroSodontoma'!'then'get'Odontoma'
•  Provisional'clinical'diagnosis'
–  Complex'Odontoma' Tx: Extraction
 Case'23'Introduc/on'
•  On'rou/ne'radiographic'examina/on,'this'52'
year'old'black'female'was'found'to'have'
mul/ple'globular'opaci/es'throughout'both'
maxilla'and'mandible.'
Case'23'Visual'
 Case'23'Ques/ons'
•  Differen/al'diagnosis'
–  Florid'Cementosseous'Dysplasia'
–  Cleidocranial'Dysplasia'
–  Paget’s'Disease' “cotton tufts radiographically” increased alk phosphate in blood
–  Gardner’s'Syndrome' osteomas
–  Gigan/form'Cementoma' inherited
•  What'addi/onal'clinical'history'or'laboratory'values'might'be'helpful'in'ruling'out'
condi/ons'listed'in'#1?'
–  Cleidocranial'Dysplasia'='mul/ple'supernumerary'teeth'
–  Paget’s'='increased'Alkaline'Phosphatase'
–  Gardner’s'Syndrome'='intes/nal'polyps'that'progress'to'cancer,'gene/cs'are'AD'
–  Gigan/form'Cementoma'='extremely'rare'AD'disease'
•  Would'you'biopsy'this'pa/ent?'
–  No'
•  Diagnosis'
–  Florid'CementoSOsseous'Dysplasia:'asymptoma/c,'middle'aged'AA'female,'
•  How'should'this'condi/on'be'managed?'
–  No'ac/on'needed'except'documenta/on'
 Case'24'Introduc/on'
•  A'57'year'old'female'presented'complaining'of'
a'“painful'mouth”.''Clinical'examina/on'
revealed'mul/ple,'irregular'whi/sh'plaques'
mixed'with'areas'of'erythema.'
Case'24'Visual'
 Case'24'Ques/ons'
•  Differen/al'diagnosis'
–  Candidiasis:'if'it'wipes'off'!'can'clinically'diagnose'as'Pseudomembranous'Candidiasis'
–  Burn:'normally'would'not'be'this'widespread'
–  Systema/c'Lupus'Erythematosus:'would'see'buberfly'rashes'on'face;'lesion'would'not'rub'off'
–  Lichen'Planus:'would'see'a'pabern'w/'network'of'white'stria'
–  Erythema'Mul/form:'would'see'more'destruc/on'and'ulcera/on'of'/ssue;'also'is'very'rapid'progression'
•  How'would'you'establish'a'diagnosis?'
–  Try'to'wipe'off'lesion'!'if'wipeable'!'pseudomembranous'candidiasis'
•  What'is'meant'by'opportunis/c'infec/on?'
–  Infec/on'by'a'member'of'the'standard'oral'flora'that'is'kept'in'check'under'normal'condi/ons'
•  Name'some'predisposing'factors:'all'are'immunosuppression'
–  An/bio/cs'
–  Steroids'Medica/ons'
–  HIV+'
–  Diabetes'
–  Infec/on'
•  Why'is'this'lesion'white?'
–  Necro/c'cells'of'the'epithelium'trapped'in'the'hyphae'of'candidae'
•  How'would'you'manage'this'pa/ent?'
–  Topical'An/fungal'(ie:'Nysta/n'Oral'Rinse'or'Clotrimazole)'
 Case'25'Introduc/on'
•  A'25'year'old'white'male'presented'with'a'
“toothache”'of'his'right'posterior'mandible.''
Clinical'examina/on'revealed'a'badly'decayed'
and'broken'down'mandibular'right'first'molar.''
In'addi/on,'however,'there'was'a'large'
irregular'white'plaque'of'his'right'buccal'
mucosa.'
Case'25'Visual'
 Case'25'Ques/ons'
•  Differen/al'
–  Chemical'burn'
–  Leukoplakia'
–  Fric/onal'Keratosis'
–  Candidiasis'
•  Is'there'anything'clinically'and/or'historically'that'could'be'pursued'in'order'to'
establish'a'diagnosis?'
–  Talk'to'pa/ent'about''
–  Try'to'wipe'off'
•  Wipes'off'!'severe'burn'or'pseudomembranous'candidiasis'
•  Does'NOT'wipe'off'!'light'burn'or'hyperplas/c'candidiasis'(usually'seen'on'tongue)'
•  How'would'you'establish'a'diagnosis'in'this'case?'
–  Ask'if'pa/ent'placed'aspirin'in'the'area'
•  Why'is'the'lesion'white?'
–  Necrosis'of'epithelial'cells'
•  How'would'you'treat'this'pa/ent?'
–  Tx'toothache'(RCT'or'EXT)'!'allow'10S14'days'for'burn'to'heal'
–  Tell'pa/ent'to'swallow'aspirin'
 Case'26'Introduc/on'
•  A'62'year'old'white'female'presented'with'a'
1cm'white'plaque'on'the'le_'lateral'border'of'
her'tongue.'This'lesion'did'not'wipe'off.'
Case'26'Visual'
 Case'26'Ques/ons'
•  List'a'clinical'differen/al'diagnosis'
–  Leukoplakia'
–  Candidiasis'(hyperplas/c'since'it'does'not'rub'off)'
–  Fric/onal'Keratosis'
–  Squamous'Cell'Carcinoma'
•  What'is'the'most'common'cause'of'hyperkerato/c'lesions'
in'the'mouth?'
–  Sharp/Broken'Cusp'Tips'
•  Why'are'hyperkerato/c'lesions'of'the'oral'cavity'white?'
–  Increased'kera/n'that'is'hydrated'by'saliva'
•  Is'this'a'“highSrisk”'site'for'intraoral'carcinoma?'
–  Yes'
Case'26'Post'Op'
 Case'27'Introduc/on'
•  A'27'year'old'male'had'asymptoma/c'whi/sh'
papules'of'his'buccal'mucosae.''He'was'
unaware'of'their'presence.'
Case'27'Visual'
 Case'27'Ques/ons'
•  Based'on'the'clinical'appearance'and'distribu/on'of'the'lesions,'name'four'condi/ons'that'this'
pa/ent'might'have.'
–  Lichen'Planus:'asymptoma/c,'very'common'(0.5S2.0'%'of'all'pa/ents'will'have'LP'in'life/me)'
–  Candidiasis'
–  Leukoedema'
–  Cheek'Bi/ng'(aka:'Morsica/o'buccarum)'
–  Fordyce'Granules'
–  Sebaceous'Hyperplasia'
•  Many'of'the'condi/ons'listed'above'can'be'ruled'out'by'clinical'history'and/or'simple'clinical'tests.''
Specifically,'how'could'you'rule'out'some'of'the'condi/ons'without'biopsy?'
–  Candidiasis:'would'be'symptoma/c'
–  Leukoedema:'usually'in'AA,'more'diffuse'and'plaque'like','if'you'stretch'/ssue'!'color'goes'away'
–  Cheek'Bi/ng:'would'be'anatomically'confined'to'the'occlusal'plane'
–  Fordyce'Granules:'would'be'more'yellow'
–  Sebaceous'Hyperplasia:'would'be'more'yellow'
•  Microscopic'diagnosis'
–  Lichen'Planus'(papular'form)'
•  Name'the'four'clinical'variants'of'this'disease'
–  Re/cular,'Papular,'Erosive,'Pigmented,'Bullous,'Plaque'
•  What'percentage'of'pa/ents'with'this'disease'have'skin'lesions?'
–  10%'
•  How'would'you'treat'this'pa/ent?'
–  Usually'mild'!'no'tx'
–  If'severe'!'steroid'immunosuppressant'bc'it'is'autoimmune'disease'
 Re/cular'Lichen'Planus:'
Will'Be'On'Midterm'and'Final'
Don’t'put'cheek'chewing'or'white'sponge'Nevus'
 Case'28'Introduc/on'
•  A'29'year'old'white'male'came'in'for'rou/ng'
dental'care.''Examina/on'revealed'that'his'
buccal'mucosae'were'covered'with'extensive'
white'plaques.''He'stated'the'condi/on'was'
asymptoma/c'and'had'been'present'as'long'
as'he'could'remember.'
Case'28'Visual'
Case'28'Visual'
Case'28'Visual'
 Case'28'Ques/ons'
•  Provisional'clinical'diagnosis'
–  White'Sponge'Nevus:'most'common;'asymptoma/c;'presents'as'long'
as'pt'can'remember'
–  Other'Genokeratoses'
•  Benign'Intraepithelial'Dyskeratosis'
•  Leukoedema'
•  DarierSWhite'Disease'
•  Pachyonychia'Congenital'
•  Dyskeratosis'Congenital'('
•  What'clinical'informa/on'could'help'to'establish'the'diagnosis?'
–  Family'history'(AD'gene/c)'
–  Early'presenta/on'in'life'
–  Asymptoma/c'
•  Treatment'
–  None'
 Case'29'Introduc/on'
•  A'59'year'old'white'male'is'referred'to'your'
office'for'rou/ne'dental'care.''During'your'so_'
/ssue'exam'you'discovered'a'white'lesion'
about'1cm'in'the'floor'of'his'mouth.''The'
pa/ent'was'unaware'of'its'presence.'
Case'29'Visual'
 Case'29'Ques/ons'
•  What'condi/ons'can'produce'a'similar'clinical'appearance'(ie:'differen/al)?'
–  Leukoplakia' (white plaque that doesn’t rub off, no clinical charac. that diagnoses)
–  Plaque'form'of'Lichen'Planus:'usually'not'isolated;'and'usually'on'buccal'mucosa'
–  Squamous'Cell'Carcinoma'(Early):'if'firm'underneath'!'more'likely'
–  Fric/onal'Keratosis:'loca/on'(floor'of'mouth)'makes'this'unlikely'
–  Hyperplas/c'Candidiasis:'usually'on'tongue'or'commisure'of'mouth'
•  What'would'you'call'this'lesion'clinically?'
–  Leukoplakia'because'you'can’t'diagnose'clinically'and'it'doesn’t'rub'off'!'technically'
premalignant' (biopsy)
•  Overall,'what'do'most'(80%)'leukoplakias'represent'histologically?'
–  Hyperkeratosis'withOUT'dysplasia'
–  20%'are'dysplas/c'
•  Increased'chance'of'dysplasia'if'you'see:'redness,'ulcera/on,'or'disease'is'in'a'high'risk'loca/on'
•  Specifically,'does'the'anatomic'site'in'this'case'change'that'figure'(ques/on'3)?'
–  Yes,'floor'of'mouth'site'increases'cancer'risk'(about'50%)' high risk sites: lateral ventral tongue, FOM, lower lip
•  Microscopic'diagnosis'
–  Severe'Epithelial'Dysplasia'!'remove'and'follow'up'due'to'future'high'risk'of'cancer'
•  If'the'microscopic'diagnosis'was'hyperparakeratosis,'what'does'that'mean'in'terms'
of'treatment,'follow'up,'and'malignant'poten/al?'
–  Treatment:'follow'up'and'rebiopsy'if'lesion'thickens,'ulcerates,'reddens,'etc'
–  S/il'premalignant'
 Case'30'Introduc/on'
•  A'68'year'old'white'female'presented'with'a'
1cm'x'3cm'white'plaque'on'the'le_'posterior'
lateral'border'of'her'tongue.''She'stated'that'
the'area'was'painful'and'occasionally'burned,'
especially'when'ea/ng'spicy'foods.'
Case'30'Visual'
 Case'30'Ques/ons'
•  What'is'your'clinical'differen/al'diagnosis?'
–  Squamous'Cell'Carcinoma:'no'firmness'to'palpa/on'!'not'likely'but's/ll'possible'
–  Candidiasis:'usually'not'isolated,'rarely'ulcerated'
–  Chemical'burn:'this'pa/ent'did'not'report'the'use'of'any'chemical'agents'
–  Lichen'planus'(ulcera/ve):'would'be'bilateral,'more'likely'on'buccal'mucosa'
–  Leukoplakia:'by'defini/on'since'nothing'above'is'likely'
•  In'the'event'that'the'lesion'cannot'be'diagnosed'as'a'specific'disease'clinically,'what'would'you'call'this'lesion'
clinically?'
–  Leukoplakia'
•  Is'this'lesion'homogenous'and'why'is'that'important?'
–  NonShomogenous'(redness,'ulcera/on,'“pebbley”)'!'more'likely'to'be'cancerous'
•  Microscopic'diagnosis'
–  MildSModerate'Epithelial'Dysplasia'
•  Name'five'cytologic'features'of'epithelial'dysplasia'
–  Pleomorphism'(cells'of'unequal'shape)'
–  Anisocytosis'(cells'of'unequal'size)'
–  Hyperchroma/sm'(excessive'pigmenta/on)'
–  Presence'of'mito/c'figures'(an'unusual'number'of'cells'which'are'currently'dividing)'
•  What'is'the'significance'of'a'diagnosis'of'epithelial'dysplasia'to'your'pa/ent'and'how'should'it'be'managed'
clinically?'
–  Treat'via'remove'or'laser'abla/on'
•  If'the'microscopic'diagnosis'was'hyperparakeratosis,'what'does'that'mean'in'terms'of'treatment,'follow'up,'and'
malignant'poten/al?'
–  Same'as'previous'case,'follow'up'but'
 Case'31'Introduc/on'
•  A'66'year'old'male'complains'of'the'unsightly'
appearance'of'his'lower'lip.''The'lesion'does'
not'rub'off.'
Case'31'Visual'
 Case'31'Ques/ons'
•  In'terms'of'e/ology,'what'is'the'first'ques/on'you'
would'ask'this'pa/ent?'
–  Do'you'have'a'history'of'long'term'sun'exposure?'
•  Provisional'clinical'diagnosis'
–  Ac/nic'Keratosis'(aka:'Solar'Keratosis)'
•  What'clinical'features'present'led'you'to'your'diagnosis'
in'#2?'
–  Fair'skinned,'loss'of'defini/on'of'vermillion'border,'
ulcera/on'with'white'scaly'border,'erythematous,'white'
pigmenta/on'change'
•  What'is'the'next'step'in'management?'
–  Biopsy'!'if'dysplas/c'!'vermillionectomy'
 Case'32'Introduc/on'
•  A'72'year'old'white'male'presented'to'your'
office'for'the'fabrica/on'of'new'dentures.''
During'your'so_'/ssue'exam,'you'find'a'small'
1'cm'white'plaque'on'the'le_'posterior'lateral'
border'of'his'tongue'at'the'junc/on'with'the'
floor'of'his'mouth.'
Case'32'Visual'
 Case'32'Ques/ons'
•  What'is'your'clinical'differen/al'diagnosis?' #1 oral cancer=post lateral tongue
–  SCC'
–  Lichen'Planus:'nothing'seen'on'cheek'!'unlikely'
–  Leukoplakia'
–  Fric/onal'Keratosis:'pt'doesn’t'have'teeth'!'unlikely'
–  Candidiasis:'small'plaque'!'highly'unlikely''
•  What'is'the'most'serious'condi/on'that'can'present'as'a'white'plaque?'
–  SCC'
•  Clinical'diagnosis'
–  Leukoplakia'(need'to'diagnose'SCC'from'histology)'
•  Microscopic'diagnosis'
–  Invasive'SCC'
•  Describe'5'histological'features'of'squamous'cell'carcinoma'
–  Same'as'epithelial'dysplasia' (case 30)
•  What'are'the'clinical'and'histological'differences'between'carcinomaSinSsitu'and'
invasive'carcinoma?'
–  InSSitu:'dysplasia'has'not'le_'the'epithelium'
–  Invasive:'dysplasia'has'invaded'CT'underneath'epithelium'

2/13 Test Ends Here

 Case'33'Introduc/on'
•  A'31'year'old'white'male'comes'in'for'rou/ne'
dental'care.'You'discover'mul/ple'areas'of'
mild'erosion'on'dorsal'and'lateral'borders'of'
his'tongue.'Many'of'the'areas'are'bordered'by'
dis/nct'white'lines.'The'pt'is'asymptoma/c'
and'unaware'of'the'condi/on.''
Case'33'Visual'
Case'33'Visual'
Case'33'Visual'
Case'33'Addi/onal'Example'
 Case'33'Ques/ons'
•  Provisional'Clinical'Dx''
–  Erythema+Migrans+(aka:+Geographic+Tongue;+Benign+Migratory+Glossi<s)+'
–  Candida''
•  Would'not'get'really'well'defined'scalloped'borders'with'red'interiors'
–  Lichen'planus'
•  Raised'white'borders'
•  Usually'symptoma/c'if'redness'is'no/ced'
–  Reiter’s'syndrome'
•  Rare'form'of'arthri/s'(immune'mediated),'would'have'UTI’s'and'skin'lesions'
•  Is'this'condi/on'always'asymptoma/c,'and'is'it'always'confined'to'the'tongue?''
–  No,'some'people'complain'about'burning'sensa/on'
–  No,'can'occur'elsewhere'(in'that'case'is'known'as'Erythema'Migrans)'
•  How'would'you'establish'a'dx?''
–  No'biopsy'unless'pt'is'worried'about'malignancy'
–  Ask'pa/ents'
•  How'long'have'you'had'it?'
•  Observe'and'see'if'it'changes'pabern'
•  How'would'you'treat'this'pa/ent?''
–  If'asymptoma/c'!'watch''
–  If'symptoma/c'!'cor/costeroid'rinses,'an/Sinflammatory'compound''
 Case'34'Introduc/on'
•  On'rou/ne'clinical'ex'of'this'24'yo'male,'you'
find'an'asymptoma/c,'reddened'area'on'the'
posterior'midSdorsal'surface'of'his'tongue.''
Case'34'Visual'
Case'34'Visual'
 Case'34'Ques/ons'
•  Provisional'clinical'dx''
–  Median+Rhomboidal+Glossi<s+
–  Erythematous'Candidiasis'
–  Erythroplakia'
•  Red'plaque'that'is'technically'preSmaligant'
•  Do'you'need'to'biopsy'this'area'in'order'to'establish'a'defini/ve'dx?''
–  No,'pabern'specific''
•  What'has'recently'been'implicated'in'the'e/ology'of'this'condi/on?''
–  Candida'
•  Can'culture'but'a'smear'is'easier'to'confirm'dx'
•  Tx'PRN:'
–  Nysta/n'OS'
–  Clotrimazole'(MYCELEX)'
–  Azoles'(KetoconS,'FluconS,'Itracon)'
 Case'35'Introduc/on'
•  This'46'y.o.'white'female'had'a'painful'and'
burning'mouth.'Clinical'examina/on'revealed'
mul/ple'red,'eroded'areas'bilaterally'on'her'
buccal'mucosa.''
Case'35'Visual'
Case'35'Visual'
 Case'35'Ques/ons'
•  Differen/al'dx''
–  Ulcerated+Lichen+planus+
•  B+Nikolsky'sign'
•  White'stria/ons'
•  Ulcera/ons'possible'
•  Types'
–  Re/cular:'usually'white'lines'
–  Ulcerated'
•  Immune'Mediated'
•  Ideopathic'
–  Pemphigoid'
•  +'Nikolsky'sign'
•  Tissue'sloughing'
–  Pemphigus'Vulgaris'
•  +Nikolsky'sign'
•  Skin'lesion'
•  How'would'you'tx'this'pt?''
–  Tx'w/'high'potency'cor/costeroid'(esp'LIDEX),'topical'1st'then'systemic''
•  10%'skin'lesion'–'purple,'periodic,'papules'(raised'lesion)'
Addi/onal'Ulcerated'Lichen'Planus'
Addi/onal'Ulcerated'Lichen'Planus'
 Case'36'Introduc/on'
•  This'17'yo'white'female'comes'to'your'office'
for'the'dx'of'a'condi/on'of'her'lower'lip.'For'a'
couple'days'her'lip'has'been'red'and'eroded.'
She'states'her'lip'burns'and'that'the'condi/on'
was'of'fairly'rapid'onset.'The'lip'is'also'slightly'
swollen.''
Case'36''Visual'
 Case'36'Ques/ons'
•  Differen/al'dx''
–  Chemical'burn'or'injury''
–  Herpes'Simplex'Virus'
•  Ask'if'she'has'had'before,'fever'blisters,'can'get'bilateral''
–  Erythema'mul/forme'
•  Is'usually'not'limited'to'lip'
•  Usually'get'hemorragic/blitering'lesions'on'vermillion'border'
•  Usually'is'acute'onset'
•  Allergic'reac/on'(hypersensi/vity)'to'medicine'or'infec/on''
–  Allergic+rxn+
•  Rapid'onset'
•  How'would'you'establish'a'dx''
–  Ask'about'pt'hx,'see'if'there'are'any'new'local'causes'(ie:'cinnamaldehyde'from'new'
toothpaste)'
•  The'rapid'onset'and'local'nature'of'rx'should'make'you'consider'what'in'terms'of'
e/ology?''
–  Allergy'–'self'limi/ng,'remove'allergen'and'will'clear'4S5'days'
–  Acute'onset'could'be'Erythema'Mul/forme'too,'but'not'likely'in'this'case'
 Case'37'Introduc/on'
•  A'62'yo'male'was'being'tx'for'periodon//s'by'
his'local'den/st.'The'/ssues'were'responding'
poorly'to'local'measures'and'pt'was'referred'
to'a'periodon/st.'Clinical'examina/on'
revealed'mul/ple'red'areas'of'erosion'
involving'both'mandibular'and'maxillary'
gingiva.'Radiographs'revealed'bone'loss'in'
these'as'well'as'other'areas.'
Case'37'Visual'
Case'37'Visual'
Case'37'Visual'
Case'37'Visual'
Case'37'Visual'
 Case'37'Ques/ons'
•  Differen/al'dx''
–  Histoplasmosis+
•  Air'borne'space'inflamma/on'
•  Is'a'deep'fungal'infec/on'that'starts'in'the'lungs'
•  Regional'preference'toward'Mississippi'River/Ohio'River'Valley'
–  Lichen'Planus'(specificially'Desquama/ve'Gingivi/s)'
–  Perio'disease'
•  Specifically'ANUG'(possibly'from'HIV)'
–  Autoimmune'diseseases'
•  Pemphigus'Vulgaris'
•  Pemphigoid'Vulgaris'
•  How'would'you'establish'a'dx'in'this'case?'
–  Biopsy'site'
•  How'do'you'tx?'
–  Refer'to'PCP'for'Systemic'An/fugal'
 Case'38'Introduc/on'
•  This'47'year'old'female'presented'w/'painful'
gingiva.'Clinical'examina/on'revealed'mul/ple'
areas'of'desquama/on'of'her'abached'
gingiva.'The'epithelium'of'the'gingiva'could'be'
removed'w/'slight'finger'pressure.''
Case'38'Visual'
Case'38'Visual'
Case'38'Visual'
 Case'38'Ques/ons'
•  Define'Chronic'Desquama/ve'Gingivi/s''
–  Gingival'epithelium'can'be'removed'under'light'pressure'(aka:'posi/ve'Nikolsky’s'Sign)'
–  Not'a'dx'clinical'descrip/ve'term''
•  List'4'condi/ons'that'can'produce'this'clinical'pabern'of'involvement''
–  Lichen'Planus''
–  Benign+Mucous+Membrane+Pemphigoid+'
–  Pemphigus'vulgaris''
–  Allergy'(ie:'cinnamon)'
–  Chronic'Ulcera/ve'Stoma//s'(rare)'
•  What'precau/ons'must'be'taken'in'obtaining'a'biopsy'specimen?''
–  Need'2'Biopsies'
•  Normal:'Stain'normally'(ie:'H&E)'!'place'in'formalin'
•  Immunofluorescence:'Stain'to'look'for'Ab!'place'in'Michele’s'solu/on'
•  Microscopic'dx'
–  See'An/bodies'located'at'basement'membrane''
•  What'addi/onal'test'can'be'performed'to'confirm'this'dx?''
–  Nikolsky'sign'
•  Posi/ve:'Pemphigus'or'Pemphogoid'
•  Nega/ve:'Lichen'
–  immunofluoresence'test'
•  Posi/ve:'Pemphigus''or'pemphigoid'
 Case'39'Introduc/on'
•  64'y/o'white'female'complained'of'a'burning'
sensa/on'of'her'right'posteroSlateral'so_'
palate'and'tonsilar'pilar.'Clinical'examina/on'
of'the'area'revealed'a'large,'irregular'
reddened'area.''
Case'39'Visual'
 Case'39'Ques/ons'
•  List'any'number'of'condi/ons'can'present'as'red'lesions'of'oral'mucosa.''
–  Erythroplakia'
–  Denture'stoma//s'
•  Usually'more'generalized'than'this'and'always'under'the'denture'
–  Burns'(either'thermal'or'chemical)'
–  Allergic'(usually'for'isolated)'–'Strep.'Infec/on'
–  SCC'
–  Pemphigus'
•  Usually'not'isolated'
–  Candidiasis'
•  Usually'not'isolated'(has'mul/ple'lesions'and'more'widespread)'
–  The'“3'Dermatoses”'(aka:'involve'the'skin)'
•  Lichen'Planus'
•  Pemphigus'
•  Pemphigoid'
–  Strep'Mutans'
•  Usually'involves'the'whole'throat'
•  What'would'you'call'this'lesion'clinically?'
–  Erythroplakia''
•  in'general,'would'your'clinical'suspicion'be'higher'for'a'red'or'white'lesion'for'which'you'can'find'no'apparent'
cause?''
–  Erythroplakia'is'preSmalignant'and'has'up'100%'dysplasia'rates'!'need'to'biopsy'
•  Microscopic'dx''
–  Severe'dysplasia'in'this'case!'likely'to'be'maliganant'!'need'to'excise'lesion'to'tx'
 Case'40'Introduc/on'
•  68'yo'white'female'had'a'chief'complaint'of'a'
burning'maxilla.'Upon'removing'her'dentures,'
the'denture'bearing'/ssues'of'the'maxilla'
appeared'red.''
Case'40'Visual'
 Case'40'Ques/ons'
•  Differen/al'dx'
–  Denture'stoma//s'(aka:'Chronic'Atrophic'Candidiasis)'
•  Occurs'bc'pt'is'not'taking'upper'denture'out'at'night'
–  Erythrooplakia'
–  Lupus''
–  Toxic'rxn'due'to'uncured'monomer''
•  Not'an'allergy!'
•  Provisional'clinical'dx'
–  Denture+stoma<<s+'
•  How'would'you'establish'a'dx'in'this'case?''
–  Don’t'need'to'do'anything'
•  You'could'theore/cally'do'a'smear'test'!'but'you'can'easily'get'false'nega/ves'
–  Will'never'get'this'on'the'mandible'
•  How'can'this'condi/on'best'be'prevented'and/or'treated?''
–  Tell'pt'to'take'denture'out'at'night'(Pt'educa/on)'
–  Nysta/n'
•  Oral'rinse'and'cover'the'denture'
•  Candida'is'part'of'the'normal'flora'in'almost'100%'of'pa/ents'
–  Is'an'opportunis/c'infec/on'(ie:'has'very'low'virulance'normally)'
 Case'41'Introduc/on'
•  This'42'yo'Hispanic'male'comes'to'your'office'
complaining'of'burning'and'sloughing'oral'
mucosae.'Clinical'examina/on'reveal'mul/ple'
areas'of'desquama/on'throughout'the'oral'
cavity''
Case'41'Visual'
Case'41'Visual'
Case'41'Visual'
 Case'41'Ques/ons'
•  Differen/al'dx''
–  Lichen'planus''
•  Usually'will'have'stria'
–  Erythema'Mul/forme'(aka:'StevenSJohnson'Syndrome'when'certain'condi/ons'are'met)'
•  Usually'will'be'acute'
–  Pemphigoid+'
–  Pemphigus+'
–  Lupus'
–  Less'likely:'Candidiasis,'Chemical'burn,'Erythroplakia'
•  How'would'you'establish'a'dx?''
–  Ask'when'did'it'start?'
•  EM'is'acute,'others'are'usually'chronic'
–  Look'for'skin'lesions'
•  No'skin'lesions'!'not'lupus'
–  Look'for'striae'and'perform'Nikolsky'Test'
•  Striae'and'Nega/ve'Nikolsky'!'lichen'planus'
•  No'striae'and'posi/ve'nikolsky'!'pemphigus'or'pemphigoid'!'need'to'biopsy'
•  Microscopic'dx'
–  Need'to'do'immunofluorescence'test'(send'in'Michele’s'soln)'
–  Pemphigus'
•  How'should'this'pt'be'treated?'
–  Refer'to'dermatologist'bc'disease'is'life'threatening'if'untreated'
–  Tx:'Cor/costeroids'
•  Is'this'condi/on'ever'totally'confined'to'the'oral'cavity?'
–  No,'it'is'a'skin'dx'
 Case'42'Introduc/on'
•  62'y/o'white'female'is'referred'to'your'office'
for'evalua/on'of'a'speckled'red'and'white'
lesion'of'her'le_'posterior'buccal'mucosa.'The'
lesion'has'been'present'“for'years”'and'is'
sporadically'symptoma/c.'The'pt'had'an'
intraoral'carcinoma'of'her'right'Mandibular'
alveolar'ridge'treated'8'years'previously.'Her'
physician'is'trea/ng'her'le_'cheek'for'lichen'
planus.''
Case'42'Visual'
 Case'42'Ques/ons'
•  Differen/al'dx''
–  ErythroBleukoplakia+
–  Lichen'Planus'
•  Usually'has'no'stria/ons'and'has'mul/ple'lesions/bilateral'
–  Candidiasis'
•  Pseudomembranous'would'rub'off'
–  Allergy'
•  Ask'if'they'are'using'anything'new'
•  Usually'is'bilateral'
–  SCC'
–  Chemical'burn''
•  Do'you'feel'a'biopsy'is'indicated?''
–  Yes,'previous'cancer'(10S40%'get'2nd'intraoral'cancer'!'high'risk)''
•  Microscopic'dx'
–  Carcinoma'in'situ'!'laser'abla/on'(old'days'you'would'excise'and'skin'gra_)'
 Case'43'Introduc/on'
•  This'16'yo'male'presented'for'rou/ne'dental'
care.'During'your'so_'/ssue'examina/on,'you'
no/ced'bilateral'white'and'red'areas'of'his'
buccal'mucosa.''
Case'43'Visual'
 Case'43'Ques/ons'
•  Differen/al'dx''
–  Candidiasis'
•  Usually'will'wipe'off,'plaque'form'won’t'get'this'big'
–  Lichen'planus'
•  Plaque'form'would'not'be'this'big'
–  Cheek+bi<ng+(aka:+Morsica<o+Buccarum)'
–  White'sponge'nevus'
•  Family'will'have'history'because'it'is'autosomal'dominant'trait'
•  Would'extend'up'into'the'buccal'ves/bule'
•  How'would'you'establish'a'dx?'
–  Ask'if'pt'is'bi/ng'cheeks'
–  Look'at'anatomic'extent'of'damage,'pt'cannot'chew'into'ves/bule'
•  Final'dx'
–  Cheek'bi/ng''
•  Is'this'condi/on'premaligant?'
–  No''
 Case'44'Introduc/on'
•  14'yo'African'American'male'comes'to'your'
office'in'acute'distress.'He'relates'that'within'
the'past'24'hours,'he'has'developed'a'severe'
“rash”'over'much'of'his'body'and'mouth.'You'
observe'numerous'cutaneous'macules'and'
erosions'and'ulcera/ons'of'his'oral'cavity.'His'
lips'are'ulcerated'and'crusted.'He'has'severe'
pain'and'can'not'eat.'In'addi/on,'the'pt'states'
that'he'was'taking'sulfonamides'for'urinary'
tract'infec/on''
Case'44'Visual'
Case'44'Visual'
Case'44'Visual'
Case'44'Visual'
Case'44'Visual'
Case'44'Visual'
 Case'44'Ques/ons'
•  Provisional'clinical'dx''
–  Erythema+mul<forme'
•  Usually'not'febrile'
•  Rash'on'palms'and'soles'
–  Systemic'Allergy'
•  Will'see'immediately'(<24hrs)'
•  Will'also'see'skin'rash,'ur/caria,'and'hives'
–  Primary'Herpes'Infec/on'
•  Would'never'get'lesions'on'forehead,'trunk,'palms,'and/or'soles'
•  Only'slightly'periSoral'in'nature'
•  How'would'you'establish'a'dx'in'this'case?''
–  Lesions'are'widespread'!'not'herpes'
•  Ask'for'hx'of'new'medicines,'esp'sulfonomides'
–  If'lesions'were'confined'to'the'mouth'!'Ask'for'hx'of'fever,'if'posi/ve'consider'herpes'
•  Is'this'ever'a'lifeS'threatening'condi/on?'
–  Yes'(StevenSJohnson'Syndrome)'
•  How'would'you'treat'this'pt?''
–  Discon/nue'sulfonamides'and'give'high'dose'systemic'cor/costeroids'
•  Pt'will'respond'drama/cally'within'24S48'hours'
 Case'45'Introduc/on'
•  41'year'old'white'female'complained'of'an'
erosive'condi/on'of'her'mouth'and'skin.'
Clinical'examina/on'revealed'whi/sh'plaques'
w/'red'eroded'areas'bilaterally'on'her'buccal'
mucosa.'In'addi/on,'she'had'mul/ple'
erythematous'areas'on'her'skin'which'were'
especially'prominent'across'the'bridge'of'her'
nose.'She'has'a'S'nikolsky'sign''
Case'45'Visual'
Case'45'Visual'
Case'45'Visual'
 Case'45'Ques/ons'
•  Diff.'dx''
–  Lupus+
•  Buberfly'rash'due'to'sun'exposure'
•  Lesions'look'like'lichen'planus'
–  Lichen'planus'
•  Usually'will'get'small'red/purple'papules'and'arms'
–  Erythroleukoplakia'
•  Is'premalignant'
–  Pemphigus'
•  Will'usually'get'blistering/ulcera/ons'
•  Worse'than'pemphigoid'
–  Pemphigoid''
•  Usually'localized'to'gingiva'
•  Will'usually'get'blistering/ulcera/ons'
•  What'are'the'two'forms'of'this'disease'and'how'do'you'dis/nguish'between'them?''
–  Discod'(aka:'Chronic'Cutaneous'Lupus)'
•  Skin'and'oral'mucosa'lesions'only'
–  Systemic'
•  Skin'and'oral'mucosa'lesions'
•  Arthri/c'joints'and'internal'organs'disease'(kidney'failure'–'cause'of'death,'get'vegeta/on'on'heart'
valves)''
 Case'46'Introduc/on'
•  This'28'y/o'African'American'female'
presented'for'rou/ne'dental'care.'You'find'
mul/ple'areas'of'pigmenta/on,'confined'
mostly'to'the'facial'abached'gingiva.''
Case'46'Visual'
 Case'46'Ques/ons'
•  Clinical'dx'
–  Racial+pigmenta<on+
•  Generalized'pigmenta/on'of'the'gingiva'
•  Other'possibili/es'that'cause'generalized'
pigmenta/on'
–  Smoker’s'melinosis'
–  Addison’s'
–  Pregnancy'
–  An/Smalarial'and'Lupus'medica/ons'
•  How'would'you'treat'this'pt?'
–  Nothing''
 Case'47'Introduc/on'
•  This'14'yo'male'was'concered'because'of'
unsightly'pigmented'spots'on'his'lips'and'
buccal'mucosa.''
Case'47'Visual'
Case'47'Visual'
 Case'47'Ques/ons'
•  Differen/al'dx''
–  Thrombocytopenic'purpura'
•  Not'limited'to'musoca/lips,'drugs'or'meds)'
•  Looks'more'reddish/purple'
–  Melanomic'macules'
•  Usually'is'isolated'(<3'spots)'
–  PutzBJaeger+syndrome+
–  Smoker’s'melanomas'
•  'Borders'would'be'irregular'
–  Addison’s'
•  Would'have'bronzing'instead'of'freckles'
–  Neurofibromatosis'
•  Get'freckles'in'armpits'and'CaféSau=Lait'spots'
•  What'clinical'informa/on'might'help'in'this'case'is'establishing'the'dx?''
–  Ask'about'family'hx'(AD'trait)'
–  Pts'get'intes/nal'polyps'!'Ask'about'bowel'problems'due'to'obstruc/on'
–  Ask'how'long'been'present'
•  Dx'
–  PutzBJaeger+refer'to'MD'for'further'tests,'do'not'biopsy'
•  Why'is'dx'significant?'
–  Pt'is'more'likely'to'get'adenocarcinoma'of'the'intes/n'and'other'cancers'
 Case'48'Introduc/on'
•  On'clinical'examina/on'of'this'28'year'old'
white'male,'you'find'a'small,'slightly'raised'
pigmented'lesion'of'le_'buccal'mucosa.'He'
was'unaware'of'its'presence.''
Case'48'Visual'
 Case'48'Ques/ons'
•  Differen/al'dx''
–  Amalgam'taboo''
•  Needs'to'have'an'amalgam'close'by'
•  Is'usually'flat'
–  Malignant'melanoma'
•  Is'asymetrical,'not'uniform'in'color,'with'irregular'borders,'usually'large'5S6mm''
–  Nevus+
•  Usually'raised'
•  Rare'intraorally'
–  Melano/c'Macule'
•  Usually'flat''
–  Venus'Haemangioma'
•  in'general,'should'pigmented'lesion'of'oral'cavity'be'removed?''
–  Yes'–'biopsy''
•  Is'there'any'chance'this'lesion'could'have'become'malignant'if'not'excised?''
–  Not'likely'
•  Physical'irrita/on'could'cause'progression'to'malignancy'
 Case'49'Introduc/on'
•  This'39'y/o'white'male'said'that'he'no/ced'a'
small'pigmented'spot'on'his'lower'lip.'Over'
the'next'six'months'the'lesion'increased'to'
include'almost'half'vermilion'border.'The'
lesion'was'mostly'flat'and'contained'no'
palpable'nodules.''
Case'49'Visual'
 Case'49'Ques/ons'
•  Diff.'dx''
–  Malignant+melanoma+(Superficial+spreading+subtype)+
•  70%'of'all'melanomas'
–  Smoker’s'melanoma'
•  Would'be'on'gingiva'or'palate''
–  Addison'dx'
•  Would'have'skin'bronzing,'no'energy,'nausea/vomi/ng''
–  Hematoma'
•  Would'be'in'1st'5'yrs'of'life''
•  Provisional'clinical'dx'
–  Melanoma'
•  Assymetry'
•  Borders'are'irregular'
•  Color'varia/ons'
•  Diameter'is'greater'than'6mm'
•  Evolu/on:'changes'over'/me'
•  What'is'meant'by'radial'growth'phase'and'what'clinical'significance'does'it'have?'
–  You'laterally'and'spread'through'epithelium''
•  What'causes'melanoma?'
–  ExtraSorally:'acute'sun'damage'
–  Intraorally:'random'malignancy'of'melanocytes'
•  Intra'oral'melanoma'has'very'poor'5'year'survival'rate'of'20%'or'so'
 Case'50'Introduc/on'
•  52'y/o'male'was'referred'to'your'office'in'a'
state'of'panic.'He'had'just'been'seen'by'a'local'
ENT'physician'and'told'he'might'have'
melanoma.'Clinical'exam'reveals'a'1'cm'bluish'
pigmented'areas'of'his'right'buccal'mucosa.''
Case'50'Visual'
 Case'50'Ques/ons'
•  Differen/al'dx'
–  Amalgam+taPoo+
–  Hematoma'
–  Melanoma'
•  Look'for'the'ABCDE’s'
–  Blue'Nevus'
•  Usually'occur'on'the'palate'
•  Not'very'common'
•  Provisional'clinical'dx'
–  Amalgam+taPoo+
•  Is'there'anything'you'can'do'clinically'to'help'establish'that'dx?''
–  Lesion'is'in'buccal'mucosa'directly'adjacent'to'a'large'amalgam'
–  XSray'to'see'if'you'can'see'a'radiopacity'
•  What'would'you'tell'this'pt'and'how'would'you'manage'this'case?''
–  You'can'biopsy'if'the'pa/ent'desires'to'rule'out'melanoma'
–  Tell'them'it'will'not'go'away'w/'/me''
 Case'51'Introduc/on'
•  This'52'y/o'male'had'a'small,'slightly'elevated'
bluish'nodule'on'the'vermilion'border'of'his'
upper'lip.'The'pt'said'the'lesion'was'
asymptoma/c'but'did'not'know'how'long'it'
had'been'present.''
Case'51'Visual'
 Case'51'Ques/ons'
•  Diff.'dx''
–  Nevus'
•  Usually'in'the'palate'
–  Hematoma'
•  Usually'in'children'1S5'yo'
•  Usually'is'>'4S5mm'
•  Usually'is'not'elevated'
•  Hematoma'will'not'blanch'on'diascapy'
–  Varices+
•  Commonly'occurs'in'older'people'(50+'y/o)'
•  Small,'single'vesicle'
•  Commonly'sublingual'
•  Can'do'a'glass'slide'diascapy'to'see'if'lesion'blanches'
–  Melanoma''
•  Doesn’t'have'ABCDE’s'
–  Foreign'body'rxn'
•  Not'common''
•  Provisional'clinical'dx''
–  Varices'
•  Tx'
–  None'needed,'only'for'esthe/c'reasons'
 Case'52'Introduc/on'
•  This'22'year'old'white'male'comes'to'your'
office'complaining'of'a'sore'on'the'side'of'his'
tongue.'Clinical'examina/on'reveals'a'2'cm'
area'of'ulcera/on.'The'area'is'firm'but'
extremely'painful'when'you'try'to'palpate'it.'
The'pt'also'has'several'small,'tender'but'
enlarged'lymph'nodes'on'that'side.''
Case'52'Visual'
 Case'52'Ques/ons'
•  Differen/al'dx''
–  Trauma/c'ulcer'
•  Ask'the'pa/ent'if'they'have'a'sharp'cusp'or'broke'a'piece'off'of'their'tooth'recently'
•  Ulcer='total'loss'of'epithlium'
–  SCC'
•  Good'loca/on'on'posteriorSlateral'border'of'tongue'
•  Usually'older'people'
•  Usually'asymptoma/c'
•  Usually'has'fixed,'non'tender'lymph'nodes'
–  Apthous'ulcer'(aka:'Cancer'sore)'
•  Usually'has'a'red'border'and'is'on'abached'gingiva'
•  Provisional'clinical'dx'
–  Apthous'ulcer/trauma/c'ulcer''
•  How'would'you'establish'a'defini/ve'dx'in'this'case?'
–  Ask'about'pt'history'
•  Periodic'ulcers,'absence'of'injury'!'apthous'ulcer'
•  Final'dx'
–  Trauma<c+ulcer+'
•  The'most'common'cause'of'intraoral'ulcera/on'is:'
–  Trauma–'!'remove'irritant'and'it'will'heal'
–  Nothing'therapeu/c'is'needed'to'heal''
•  Why'are'ulcers'tan'clinically?'
–  Fibrin'coats'surface'of'ulcer'to'protect'wound'during'healing''
 Case'53'Introduc/on'
•  The'26'year'white'male'developed'mul/ple'
erosions'and'ulcera/ons'of'his'oral'mucosa'
over'the'past'3'weeks.'He'was'aSfebrile'and'
had'no'skin'lesions.''
Case'53'Visual'
Case'53'Visual'
Case'53'Visual'
 Case'53'Ques/ons'
•  Differen/al'dx''
–  Pemphigoid'
•  +'nikolsky’s'sign'(which'this'pa/ent'has)'
–  Pemphigus+
•  +'nikolsky’s'sign'(which'this'pa/ent'has)'
–  Lichen'planus'
•  Would'have'S'nikolsky’s'sign'and'white'stria'
–  Erythema'mul/forme'
•  Would'also'have'skin'lesions'that'look'like'bullseye'targets'
–  Primary'herpes'
•  Acute'stage'is'usually'over'by'3'weeks'
–  Vulgus'vulgarins'–'vesicles''
•  Microscopic'dx''
–  Suspect'autoimmune'!'do'immunofluroscence'test'!'send'in'michelle’s'solu/on'
–  Pemphigus+vulgaris+
•  With'the'ins/tu/on'of'therapy,'do'you'feel'this'pt'will'go'on'to'develop'cutaneous'dx?''
–  He#did#not#answer#this#
•  Tx'
–  High'dose'systemic'cor/costeroids'(prednisone'2S5'mg)''
•  Is'this'dx'poten/ally'fatal?'
–  Yes'
 Case'54'Introduc/on'
•  An'86'year'old'white'female'complained'of'
loose'teeth.'Clinical'examina/on'revealed'a'
poor'state'of'oral'hygiene'w/'calculus'on'many'
of'the'teeth.'The'/ssues'were'inflamed'and'
edematous.'The'/ssues'were'especially'bad'in'
the'le_'mandibular'cuspidSpremolar'area'
where'there'were'also'erosions'and'
ulcera/ons.'She'had'swelling'in'the'marginal'
gingiva'in'all'areas'of'mouth.''
Case'54'Visual'
 Case'54'Ques/ons'
•  Differen/al'dx''
–  SCC'
•  This'is'not'a'common'loca/on'
–  Pemphigoid'
•  Usually'get'mul/ple'ulcera/ons'
–  Pemphigus'
•  Usually'get'mul/ple'ulcera/ons'
–  Deep'fungal'infec/on'(specifically'Histoplasmosis)'
•  Most'common'deep'fungal'infec/on'in'Texas'
–  Perio'dx'
•  Decreased'likelihood'the'further'you'get'from'the'marginal'gingiva'
•  Provisional'clinical'dx'
–  'SCC+'
•  Microscopic'dx'
–  Pleomorphic,'migrant'cells'!'early'SCC''
•  Gingival'SCC'
–  Looks'like'perio'dz'!'diagnosed'later'than'normal'
–  Gingiva'overlays'bone'!'quicker'bone'invasion'!'lowers'prognosis''
 Case'55'Introduc/on'
•  This'68'year'old'farmer'developed'an'
ulcera/on'on'the'skin'below'his'le_'eye.'The'
lesion'was'umbilicated,'with'a'central'
ulcerated'depression'and'rolled'elevated'
borders.'He'stated'the'lesion'had'been'
present'for'a'couple'years''
Case'55'Visual'
 Case'55'Ques/ons'
•  Differen/al'dx''
–  Basal'cell'carcinoma'
•  98%'of'skin'cancers'are'BSCs'!'extremely'common'(1M/year)'
•  Good'loca/on'due'to'UV'radia/on'from'sun'exposure'as'a'farmer'
•  Doesn’t'occur'in'mouth'
–  SCC'
–  Deep'fungal'Infec/on'
•  Provisional'clinical'dx'
–  Basal+cell+carcinoma+
•  How'can'this'lesion'be'successfully'treated?'
–  Good'prognosis''
–  Refer'to'OMS,'plas/c'surgeon,'or'dermatologist''
 Case'56'Introduc/on'
•  This'22'year'old'AfricanSAmerican'male'
presented'w/'chief'complaint'of'an'ulcer'on'
his'tongue.'Clinical'examina/on'revealed'a'
small,'slightly'elevated'ulcer'on'the'midS
dorsum'of'his'tongue.'The'lesion'had'been'
present'for'one'week,'no'trauma''
Case'56'Visual'
 Case'56'Ques/ons'
•  Differen/al'dx''
–  SCC'
•  Incredibly'rare'to'get'SCC'on'dorsal'tongue'
•  Usually'are'older'when'you'get'SCC'
•  Usually'last'longer'than'a'few'weeks'
–  Trauma/c'ulcer'
•  Harder'to'trauma/ze'dorsal'tongue'
–  Primary+Syphilis+Chancre'
–  Deep'fungal'infec/on'(ie:'Histoplasmosis)'
•  Could'be,'but'not'likely'
–  Apthous'ulcer'
•  Usually'don’t'occur'on'dorsal'tongue'
•  How'would'you'confirm'your'clinical'suspicion?''
–  Do'RPR'(rapid'plasma'reagin)'test'which'is'super'sensi/ve,'but'not'specific'!'if'posi/ve'then'do'FTASAb'test'
of'blood'
–  Ask'pt'if'sexually'transmibed'dz''
•  Name'the'3'lesions'that'characterize'the'3'clinical'stages'of'this'dx''
–  Chancre:'primary'ulcera/on'in'the'mouth'that'lasts'4S6'weeks'
–  Mucous'patches:'skin'and'mucosa'rash'from'2ndary'stage'
–  Gumma:'Gramuloma/inflamma/on/necrosis,'but'not'seen'anymore'
•  Tx'
–  Penicillin''
 Case'57'Introduc/on'
•  This'20'year'old'male'was'experiencing'
considerable'pain'because'of'an'ulcera/on'on'
lateral'and'ventral'surfaces'of'his'tongue.'The'
lesion'had'started'as'a'small'break'in'the'
tongue'mucosa'and'had'slowly'enlarged'over'
a'period'of'several'weeks.'He'related'that'he'
had'experienced'night'sweats'and'had'lost'
weight.'(systemic'problem)''
Case'57'Visual'
 Case'57'Ques/ons'
•  Differen/al'dx''
–  SCC'(age'make'highly'unlikely)''
–  Phys/chemicaltrauma''
–  Syphilis'(infec/on,'chancre)''
–  Hodgkin’s'(lymphoma'–'night'sweats/'weight'lose'(char),'palpate'lesions'–rare'
in'oral'cavity)''
–  Tuberculosis+(rare,'from'bacteria'own'pulmonary'dz'–'night'sweats)''
•  How'would'you'manage'this'case'in'order'to'arrive'at'a'dx?''
–  Chest'xSray,'hx'
–  Signs/symptoms:'chestpain/cough'
–  BiopsyS'lesion''
•  What'is'meant'by'granulomatous'inflamma/on?''
–  Inflamma/on'in'TB'–'necrosis'
–  Pabern'(round)'
–  Foreign'body'causes'this'type'of'rxn'
–  Spec.'stains'to'see'if'organism'in'/ssue''
 Case'58'Introduc/on'
•  This'42'year'old'white'female'developed'
“blisters”'of'her'hard'palate'over'the'last'
couple'days.'She'now'has'mul/ple'small'ulcers'
of'her'hard'palate.'Cluster'pabern''
Case'58'Visual'
 Case'58'Ques/ons'
•  Differen/al'dx''
–  Herpes:'pabern'
–  Herpes'labialis'
–  Necro/c'skin'lesion'
–  VaricellaSzoster'S'unilateral'shingles,'lesion'on'face'(lesion'follows'CN'V)'
–  Burn'(phy/chem.)'not'that'pabern''
•  What'dx'technique'short'of'biopsy'might'help'establish'the'dx''
–  Herpes'simplex'–'viral'cluster'pabern'
–  Intraora'leffects'!'palate'and'mas/catory'mucosa'(Kera/nized'/ssue)''
•  In'what'ways'are'these'lesions'different'from'aphthous'ulcers?''
–  Apthous'ulcers'are'on'nonSkera/nized'/ssue''
•  Final'dx'
–  Herpes+simplex+'
•  Tx'
–  An/Sviral,'self'limi/ng''
 Case'59'Introduc/on'
•  This'4th'year'dental'student'developed'a'small'
cluster'of'vesicles'on'the'vermilion'border'of'
his'lower'lip.'The'night'before,'he'stated'that'
his'lip'itched.'Having'cut'all'of'his'oral'path'
labs,'he'had'no'idea'what'these'were.''
Case'59'Visual'
 Case'59'Ques/ons'
•  Provisional'clinical'dx''
–  Herpes'simplex'
•  What'is'e/ology'and'pathogenesis'of'this'
condi/on?'
–  HSV'
•  You'have'a'cut'on'your'finger.'What'precau/ons'
should'you'take'in'examining'this'pt?'
–  Wear'gloves'to'prevent'bloodborne'transfer'of'HSV'
•  Discuss'tx'
–  An/virals'
 Case'60'Introduc/on'
•  This'66'year'old'white'male'had'a'chief'
complaint'of'mul/ple'oral'mucosal'
ulcera/ons.'They'were'most'prominent'along'
the'lower'labial'and'buccal'mucosa.'The'pt'
was'febrile'and'reported'that'his'physician'
had'placed'him'on'chloramphenicol'about'a'
week'prior'to'this'outbreak.''
Case'60'Visual'
Case'60'Visual'
 Case'60'Ques/ons'
•  Differen/al'dx''
–  Aplas/c'amenia'(low'RBC,WBC,'neutrophils)''
–  Apthous'ulcer''
–  Erythema'mul/forme'(rxn'to'drugs,'have'skin'lesion,'no'fever,'effects'
vermillion'border'of'lower'lip)''
–  Beschet’s'(intraoral'ulcera/ons,'lots'of'erythema,'genial'ulcera/on)''
–  Allergy''
•  Would'any'lab'tests'help'to'determine'or'rule'out'any'specific'dx?''
–  WBC'count,'CBC''
•  What'is'the'normal'white'cell'count'in'peripheral'blood?''
–  5,000'to'10,000'
–  neutrophil'–'45S75%'or'1800'to'4500'(decrease'1,000'infec/on)''
•  Final'dx'
–  Aplas<c+anemia+'
•  How'should'this'pt'be'treated?'
–  Hospitalized'un/l'beber''
 Case'61'Introduc/on'
•  A'25'year'old'white'female'presents'to'your'
office'complaining'of'pain'in'her'le_'cheek.'
Clinical'examina/on'reveals'a'1'cm'ulcera/on'
of'posterior'buccal'mucosa.'The'ulcer'had'a'
white'surface'and'was'surrounded'by'an'
erythematous'border.'She'stated'the'lesion'
had'been'present'for'4'days.''
Case'61'Visual'
 Case'61'Ques/ons'
•  Differen/al'dx''
–  Apthous'ulcer''
–  Trauma/c'ulcer''
–  Prostoma//s'vegitans'(oral'manifesta/on'of'inflammatory'bowl'dz,'mul/ple'
ulcers)''
•  Provisional'clinical'dx''
–  Trauma/c'ulcer'
–  Trauma'(ie:'she'bit'her'check)'
–  Apthous'ulcer'–'don’t'have'trauma/c'experience,'recurring''
•  Final'dx'
–  Apthous+ulcer+–'nonSkerat.'/ssue,'most'common'oral'dx'in'world,'Buccal'
mucosa'and'cheek'
•  Tx'
–  Topical'Lydex'or'fluocinonide'(increase'poten/al'cor/costeroids)''
–  Have'to'tx'when'cells'are'geng'ac/ve'(aka:'prodrome'stage)'
 Case'62'Introduc/on'
•  A'parents'of'this'14'year'old'boy'bring'their'
son'to'your'office'because'of'the'unsightly'
appearance'of'his'guns.'Clinical'examina/on'
reveals'a'generalized'overgrowth'of'his'
gingival'/ssues.'The'growth'is'firm'to'
palpa/on''
Case'62'Visual'
 Case'62'Ques/ons'
•  Differen/al'dx''
–  Drug+related+gingivi<s+
•  An/Sconvulsivants'(ie:'Phenytoin'(DILANTIN))'
–  Can'prevent'hyperplasia'with'me/culous'oral'hygiene'
•  Ca+'channel'blockers'for'HTN'(ie:'Nifedepine,'Amlodipine)'
•  Cyclosporine'to'immunosuppress'post'transplant'pa/ents'
–  Leukemia'
•  Bone'marrow'cancer'
–  Gingival'Fibromatosis'
•  Is'hereditary'disease'!'ask'about'family'history'
–  Aplas/c'Anemia'
–  Hyperplas/c'Gingivi/s'
•  Rare'
•  Occurs'due'to'hormonal'changes'during'pregnancy'and'puberty'or'inflama/on'due'to'plaque'(would'look'more'
erythematous)'
•  Provisional'dx''
–  Drug+related+gingival+hyperplasia'
•  How'would'you'est.'a'dx?''
–  Ask'about'drug,'oral'hygiene,'no'biopsy'needed'
–  Can'do'gingivectomy'
•  How'would'you'advise'or'treat'this'pt?''
–  Me/culous'oral'hygiene''
 Case'63'Introduc/on'
•  A'79'year'old'white'female'had'her'remaining'
teeth'removed'in'December'for'fabrica/on'of'
complete'dentures.'She'was'lost'to'follow'up'
during'the'holiday'but'returned'in'mid'
January.'At'that'/me'she'was'found'to'have'a'
2'cm'yellowish'red'mass'growing'from'an'
extrac/on'socket'of'her'le_'posterior'
mandible.'She'is'currently'being'treated'for'
gastric'carcinoma.''
Case'63'Visual'
Case'63'Visual'
 Case'63'Ques/ons'
•  Differen/al'dx''
–  Peripheral'Giant'Cell'Granuloma'
–  Pyogenic'Granuloma'
–  Peripheral'Ossifying'Fibroma'
•  Arise'from'PDL'!'Almost'never'see'them'in'edentulous'areas'bc'PDL'is'gone'
–  Central'giant'cell'granuloma'
•  Would'have'pain'
–  SCC'
•  Not'a'good'loca/on'
–  Metastasis'to'oral'cavity'
•  Only'metastasize'to'so_'/ssue'1/3'of'the'/me'and'produces'pain'
•  Radiographs'would'not'show'healing/infill'of'bone'
•  Provisional'clinical'dx''
–  Pyogenic+granuloma+!+ulcera/ve'granula/on'/ssue'from'leaving'
bone/tooth'fragments'in'the'socket'
 Case'64'Introduc/on'
•  This'19'year'old'AA'male'work'up'one'morning'
w/'a'raise'lump'of'his'lower'labial'mucosa.'He'
stated'that'prior'to'coming'in,'the'lesion'
seemed'to'change'size,'going'up'and'down.'
The'lesion'was'1'cm,'so_'and'compressible''
Case'64'Visual'
 Case'64'Ques/ons'
•  Differen/al'dx''
–  Mucocele+
•  Most'common'in'lower'lip'(areas'where'trauma'happens'easily)'
•  Is'so_/compressible'and'arises'quickly'
•  Duct'swells'with'saliva'due'to'trauma/severing'salivary'duct'
•  Doesn’t'have'an'epithelial'lining'!'is'not'a'true'cyst'
–  Salivary'Gland'Tumor'
•  Usually'is'turgid'and'more'slowly'growing'
–  Salivary'Duct'Cyst''
•  Less'common'
•  Provisional'Clinical'Diagnosis'
–  Mucocele'
•  Microscopic'dx'
–  Mucocele'
•  To'prevent'recurrence'
–  Excision'of'salivary'gland'
 Case'65'Introduc/on'
•  This'68'year'old'female'requested'removal'of'
a'bump'on'her'cheek'because'she'occasionally'
bit'it.'Your'examina/on'revealed'a'1S1'1⁄2'cm'
firm'nodule'in'the'right'buccal'mucosa.'The'
lesion'was'sessile'and'mucosa'overlying'the'
lesion'was'normal'color.''
Case'65'Visual'
 Case'65'Ques/ons'
•  Differen/al'dx''
–  Fibroma'
•  Most'common'
–  Neurofibroma'
–  Lipoma'
–  Lyomyoma'
•  Provisional'clinical'dx''
–  Trauma<c+fibroma+'
•  Dis/nguish'b/t'tumor'and'neoplasm'
–  Tumor'='swelling'
–  Neoplasm'='uncontrolled,'autonomous,'new'growth'of'cells'
•  Tx'
–  Will'not'resolve'by'itself'
–  Can'excise/biopsy'if'the'fibroma'is'causing'discomfort'from'bi/ng'or'if'pt'
wants'to'rule'out'malignancy''
 Case'66'Introduc/on'
•  This'22'year'old'white'male'comes'in'for'his'
first'dental'appointment.'During'your'so_'
/ssue'exam,'you'no/ce'a'small'nodular'
eleva/on'on'the'right'posterior'lateral'border'
of'his'tongue'back'toward'the'base.''
Case'66''Visual'
 Case'66'Ques/ons'
•  Differen/al'dx''
–  Trauma/c'fibroma'
–  Lipoma'
–  Lyomyoma'
–  Lingual+tonsil+
•  Overgrowth'of'lymphoid'/ssue'
•  How'would'you'tx'this'pt?'
–  Watch'
–  Look'@'other'side'
•  Bilaterally'symmetrical'!'normal'
•  NotSbilaterally'symmetrical''!'can'biopsy'to'rule'out'malignancy'
 Case'67'Introduc/on'
•  This'57'year'old'white'male'was'found'to'have'
a'2'cm'raised,'reddish'lesion'of'the'le_'lateral'
border'of'his'tongue.'He'stated'the'lesion'has'
been'present'for'“some'/me.”''
Case'67'Visual'
 Case'67'Ques/ons'
•  Diff.'dx''
–  Hematoma'
•  Would'have'a'more'recent'onset'
•  Trauma'causes'blood'swelling'
•  Would'have'resorbed'by'now'
–  Hemangioma+
•  Is'a'benign'BV'tumor'
•  Usually'occurs'in'children,'then'go'away'
–  In'this'case,'it'occurred'in'an'adult'
•  Can'do'diascopy'to'confirm'blood'vessel'
•  Is'a'developmental'overgrowth,'not'a'neoplasm'
–  Kaposi’s'sarcoma'
•  Would'have'HIV+'
–  SCC'
•  Good'loca/on'but'SCC'is'rarely'pigmented'!'would'only'get'½'credit'
•  What'lesion'is'considered'when'a'pt'presents'w/'an'intraoral'vascular'lesion?'
–  Med.'Hx:'make'sure'not'+'for'HIV''
•  Provisional'dx'
–  Hemangioma'
•  Treatment'
–  Excision'if'pt'is'at'risk'for'bi/ng'lesion'and'bleeding'
 Case'68'Introduc/on'
•  This'14'year'old'white'female'presented'w/'a'
localized'overgrowth'of'her'gingiva.'A'4x5'cm'
mass,'w/'surface'ulcera/on'was'seen'on'
anterior'right'maxilla.'The'lesion'was'painless'
and'had'been'present'a'couple'weeks.''
Case'68''Visual'
 Case'68'Ques/ons'
•  95%'of'all'localized'growths'on'gingiva'will'be'one'of'four'lesions.'What'are'they?''
–  Peripheral+Giant+Cell+Granuloma'
•  Deep'purple'color'
–  Pyogenic'Granuloma'
•  Usually'compressible,'hemorrhagic,'and'light'red/pink'in'color'
•  Usually'ulcerated'
•  Can'be'hormonally'triggered'
–  Peripheral'Fibroma'
•  Pale,'not'usually'ulcera/ve'
–  Odontogenic'Fibroma'(aka:'Ossifying'Fibroma)'
•  'PDL'derived'
•  Normal'pink'colored'/ssue'
•  What'is'the'nature'of'all'these'lesions?'
–  These'lesions'are'reac/ve'to'irrita/on/trauma'from'calculus,'overhangs,'etc'
•  What'should'you'be'par/cularly'cognizant'of'when'removing'them?'
–  When'taking'out'the'lesion,'go'down'to'bone'because'some'of'these'might'arise'from'
periosteum'cells'
–  Remove'the'source:'Calculus,'Overhanging'margins'
–  Can'reSoccur'about'10%'of'the'/me'due'to'incomplete'removal'of'source'or'incomplete'
dissec/on'to'bone''
 Case'69'Introduc/on'
•  One'of'your'pt,'returns'on'recall'exam'a_er'
two'years.'A_er'removing'her'dentures,'you'
no/ce'that'her'hard'palate'is'erythematous'
and'has'mul/ple'small'pebbly'eleva/ons.''
Case'69'Visual'
 Case'69'Ques/ons'
•  Diff.'dx''
–  Inflammatory+Papillary+Hyperplasia+
•  Caused'by'ill'fing'dentures'
•  Has'a'pebbly/bumpy'area'
•  Usually'occurs'on'palate,'but'can'be''
–  Denture'Stoma//s'(aka:'Chronic'Atrophic'Candidiasis)'
•  Caused'by'wearing'dentures'24/7,'poor'OH'
•  Denture'fit'is'fine'
–  Erythroplakia'
•  Tx'
–  Don’t'biopsy,'remove'denture'and'see'if'it'resolves'
–  If'it'does,'reline'denture'to'make'it'fit'and'give'OHI'on'how'
to'clean'
 Case'70'Introduc/on'
•  This'58'y/o'white'female'was'referred'to'your'
office'for'fabrica/on'of'new'dentures.'You'
no/ce'that'along'the'facial'borders'of'the'
lower'denture'there'are'large'folds'of'firm'
/ssue.''
Case'70'Visual'
Case'70'Visual'
 Case'70'Ques/ons'
•  Diff'dx''
–  Epulis'fissuratum'
–  Peripheral'Granuloma'
–  Pyogenic'Granuloma'
•  Provisional'dx''
–  Epulis+fissuratum+
•  Are'folds'in'mucosa'due'to'irrita/on'where'borders'are'over'
extended'on'alveolar'bone'resorp/on''
•  Tx'
–  Reline'denture/remake'
–  Surgical'excision'of'/ssue'folds''
 Case'71'Introduc/on'
•  This'26'y/o'white'female'had'a'white,'
exophy/c'papillary'lesion'on'the'right'dorsal'
surface'of'her'tongue.'The'lesion'was'
pedunculated'and'the'pt'stated'it'had'been'
present'for'several'months.''
Case'71'Visual'
 Case'71'Ques/ons'
•  Diff.'dx'(4'Lesions'Caused'by'HPV)'
–  Squamous+Papilloma+
•  Common'epithelial.'prolifera/on'
•  Benign''
–  Veruca'Vulgaris'(aka:'Common'Wart)'
•  Rare'in'mouth'
•  Common'with'children'
–  Condyloma'Acuminatum'
•  Sessile,'pink,'warts,'STD,'mul/ple'lesions''
–  Focal'Epithelial'Hyperplasia'(aka:'Heck’s'Disease)'
•  'Usually'occurs'as'mul/ple'white/pink'lesions'in'kids'
•  Tx'
–  Biopsy'and'removal''
 Case'72'Introduc/on'
•  A'67'y/o'female'developed'a'crusted'lesion'of'
le_'side'of'her'lower'lip'about'a'year'ago.'She'
stated'that'she'thought'her'lip'was'white'in'
that'area'previously.'The'lesion'had'con/nued'
to'expand.'It'is'now'a'1'1⁄2'cm'ulcerated'
nodule.'On'palpa/on,'it'is'firm'and'fixed'to'
surrounding'/ssue.''
Case'72'Visual'
 Case'72'Ques/ons'
•  Diff.'dx''
–  SCC+
•  Previous'white'lesion,'nodule'fixed'and'ulcerated,'most'common'cancer'in'lower'lip''
–  Keratoacanthoma'(KA)'
•  Like'a'SCC,'but'benign'
•  Not'preceded'by'white'lesion,'6m'to'1'year'go'away''
–  Ac/nic'keratosis'(AK)'
•  No'nodule'under'
•  Only'about'10%'of'AK'progress'to'SCC''
–  Merkel'Cell'Carcinoma'
•  Aggressive'malignancy'on'lips,'usually'skin,'comes'from'neuro.'cells''
•  With'what'e/ologic'factor'is'this'lesion'linked''
–  Skin'cancer'–'gene/c'damage'of'chronic'sun'exposure''
•  What'is'the'precursor'for'this'lesion?'
–  Ac/nic'Keratosis:'white'lesion'
•  Tx'
–  Biopsy'(OMS)'!'excision'
–  Good'prognosis'since'it'is'not'intraoral'
•  Most'common'cancer'in'upper'lips'
–  Basal'Cell'Carcinoma'
 Case'73'Introduc/on'
•  A'63'y/o'alcoholic'is'seen'in'a'screening'clinic'
run'by'the'state'department'of'health.'
Examina/on'reveals'a'5'cm'mass'of'le_'lateral'
border'of'his'tongue.'Although'the'mass'is'
predominately'exophy/c,'it'is'fixed'to'the'
deeper'musculature'of'the'tongue.'The'
surface'is'ulcerated'and'necro/c.''
Case'73'Visual'
 Case'73'Ques/ons'
•  Differen/al'Diagnosis'
–  SCC'
–  Deep'Fungal'Infec/on'(Mucomycosis)'
–  Melanoma'
–  Infec/ons'(TB/Syphilis)'
•  Provisional'dx''
–  SCC+
•  Posterior'lateral'border'tongue'#1'site'
•  Most'common'cancer'in'mouth'
•  Occurs'in'sites'exposed'to'carcinogens'(ie:'sites'where'saliva'pools)''
•  Is'this'an'early'or'advanced'lesion,'and'what'would'you'consider'reasonable'
prognosis'for'this'pt?'
–  Advanced'due'to'perineural/perivascular'involvement'!'poor'prognosis''
•  Tx'
–  Biopsy,'surgical'excision'
–  Neck'dissec/on'of'ipsilateral'lymph'nodes'to'make'sure'cancer'hasn’t'metastasized'
–  Radia/on/chemo'therapy''
 Case'74'Introduc/on'
•  A'56'y/o'white'F'developed'a'whi/sh,'
exophy/c,'papillary'growth'of'the'abached'
gingiva'around'a'lower'PM.'The'lesion'had'
been'present'for'about'a'year,'but'was'not'
painful.'She'thought'that'it'seemed'to'be'
geng'larger.''She'also'reported'that'she'
occasionally'dipped'a'lible'snuff'for'the'past'
48'years.''
Case'74''Visual'
 Case'74'Ques/ons'
•  Diff.'dx''
–  SCC'
–  Leukoplakia''
–  Verrucous+carcinoma+
•  Unique'to'spit'tobacco'
•  Pebbly'surface,'non'painful'
•  A'type'of'low'grade'SCC'that'rarely'metastasizes'but'can'be'
locally'aggressive'
–  PseudoSepitheliomatous'hyperplasia'
•  Tx'
–  Excision'(bc'about'10%'transform'into'SCC)'
 Case'75'Introduc/on'
•  A'53yo'AfricanSamerican'male'comes'in'for'
rou/ne'dental'care.'During'so_'/ssue'
examina/on'you'find'a'slightly'raised,'1cm'
mass'in'the'substance'of'right'lateral'border'of'
his'tongue.'The'lesion'is'firm'and'somewhat'
fixed'to'surrounding'structures.'The'surface'
mucosa'is'of'normal'color'but'shows'the'loss'
of'papillae.'He'was'unaware'of'the'lesion'and'
therefore'doesn’t'know'how'long'it'had'been'
present.''
Case'75'Visual'
Case'75'Visual'
 Case'75'Ques/ons'
•  Diff'dx'(Benign'Symmetrical'Mesenchymal'Tumors)'
–  Fibroma'
•  Fibrous'Connec/ve'Tissue'
–  Lipoma'
•  Fat'
–  Granular+Cell+Tumor+(aka:+Pseudoepithelomatous+Hyperplasia)+
•  Occurs'40%'of'the'/me'on'the'tongue'
•  May'come'from'neural'sheath'cells'
–  Neurofibroma'
•  Nerve'sheath'and'other'cells'
–  Schwannoma'(aka:'Neurolemoma)'
•  Nerve'sheath'cells'only'
–  Leiomyoma'
•  Smooth'muscle'
–  Rhabdomyoma'
•  Striated'muscle'
•  Treatment'
–  All'benign'mesenchymal'tumors'are'excised'!'biopsy'!'if''
 Case'76'Introduc/on'
•  A'9'yo'male'presented'w/'massive'10'cm'mass'
of'right'maxillary'mucobuccal'fold.'The'lesion'
had'grown'rapidly'over'the'past'4'weeks.''
Case'76'Visual'
 Case'76'Ques/ons'
•  Differen/al'dx'(is'malignancies'due'to'size'and'rapid'onset)'
–  Sarcomas'
•  Types'of'sarcomas:'bone'(osteoS),'car/lage'(chondroS),'fibrous'/ssue'
(fibroS)'muscle'(rhabdoS'or'leiomyo),'fat'(lipoS)'
•  Very'rare'(<1%'of'all'cancers)'because'most'carcinogens'contact'
epithelium'first'
–  Carcinoma'
•  Neoplasm'from'epithelium'
•  Specifically'could'be'a'adenocarcinoma'(from''
•  Provisional'dx'
–  Sarcoma'
•  Microscopic'dx'
–  Rhadomyosarcoma+'
 Case'77'Introduc/on'
•  A'36'y/o'male'developed'a'sessile,'smooth'
surface'1'1⁄2'cm'mass'of'his'right'buccal'
mucosa.'The'overlying'mucosa'was'intact'and'
lesion'appeared'well'circumscribed.'He'said'it'
had'been'present'about'6'months.''
Case'77'Visual'
 Case'77'Ques/ons'
•  Diff'dx'(mesenchymal'tumors)'
–  Fibroma'
•  Common'loca/on'due'occlusal'trauma'
–  Lipoma'
–  Neurofibroma+
•  Presents'with'CaféSAuSLait'spots'and'family'history'due'
to'AD'inheritance'
•  Microscopic'dx'
–  Excisional'biopsy'!'Neurofibroma'
 Case'78'Introduc/on'
•  A'27'y/o'African'American'male'had'a'
painless,'freely'movable'1.5S2'cm'nodule'in'his'
upper'lip.'He'stated'that'although'the'lesion'
was'slowly'growing,'it'had'been'present'about'
8'months.''
Case'78'Visual'
 Case'78'Ques/ons'
•  Diff.'dx'(Mesenchymal'Benign'Tumors'and'1'Epithelium'Tumor)'
–  Fibroma,'Lipoma,'etc'
–  Adenoma'
•  Arises'from'epithelium'
•  Name'for'a'benign'(Soma)'salivary'gland'(adenoS)'tumor'
•  Character'of'tumor'that'make'you'think'it'is'benign'
–  Freely'movable'!'not'diving'into'deeper'/ssues'
–  Encapuslated''
•  Microscopic'dx'
–  Neurolemoma+(aka:+Schwanoma)'
•  Tx'
–  Excisional'biopsy'via'enuclea/on'!'dx'histologically'to'make'sure'it'is'
benign'
–  Good'prognosis'
 Case'79'Introduc/on'
•  A'15'y/o'white'female'had'no/ced'a'bump'in'
the'roof'of'her'mouth'for'about'a'month.'
Clinical'examina/on'revealed'a'firm'1'–'1.5'cm'
submucosal'mass'in'posterior'lateral'hard'
palate'on'the'right.'The'overlying'mucosa'was'
intact.''
Case'79'Visual'
 Case'79'Ques/ons'
•  Diff'dx'()'
–  Abscess'
•  Would'usually'be'painful'
•  Would'usually'be'fluctuant'
•  Need'to'take'XSray'to'rule'out'for'sure'
–  All'the'Benign'Mesenchymal'Neoplasms'(fibroma,'etc)'
–  Adenoma+
•  Most'likely'loca/on'for'minor'salivary'gland'tumor'is'lateral'hard'palate'
•  This'is'the'only'epithelial'tumor'that'presents'as'a'mesenchymal'tumor'
–  Adenocarcinoma'
•  Malignancies'have'to'start'small,'but'would'grow'bigger'
•  Prov.'Dx'
–  Salivary'gland'tumor'(aka:'Adenoma)''
•  Micro'dx'
–  Pleomorphic'adenoma''
•  Tx'
–  Incisional'biopsy'
 Case'80'Introduc/on'
•  A'56'y/o'female'developed'a'rapidly'growing'
mass'of'her'right'posterior'lateral'hard'palate.'
The'lesion'was'about'4'cm'in'diamater,'
ulcerated,'and'painful.'Been'present'for'
several'months.''
Case'80'Visual'
 Case'80'Ques/ons'
•  Differen/al'dx''
–  Adenoma'
•  Benign'Salivary'Gland'Tumor'
–  Adenocarcinoma+
•  Malignant'salivary'gland'tumor'
–  SCC'
•  Not'common'loca/on'
–  Very'rare'
•  Lymphoma'
•  Sarcoma'
•  Provisional'clinical'dx'
–  Adenocarcinoma+
•  Microscopic'Diagnosis'
–  Adenoid+Cys<c+Carcinoma+(Is+a+type+of+adenocarcinoma)+
•  What'is'prognosis'for'this'dx'in'long'term?'
–  Short'term:'very'good'
–  Long'term:'terrible'
•  What'is'factor'accounts'for'poor'prognosis'
–  This'carcinoma'classically'grows'along'nerves'!'surgeons'can’t'tell'how'far'they'have'grown'!'usually'don’t'
resect'all'of'the'carcinoma'!'will'have'late'reccurance''