Oral Pathology Review Document

Oral and Maxillofacial Pathology
Review for NBDE Part 2
May 2012
Michael A. Kahn, DDS

Professor and Chairman
Thursday, January 19, 2012

Systemic Lupus Erythematosus
! Clinical
– Autoimmune
– Young adult females
– Butterfly rash of face
! Sun exposure worsens it
– Systemic involvement complications
! Heart – endocarditis
! Kidney – renal glomeruli (glomerulonephritis)

Cavernous sinus thrombosis
! Can arise from an infection - - a

subcutaneous abscess of the upper lip or a
intrabony abscess of an anterior maxillary
tooth
– Valveless facial
veins

Ludwig’s angina
! Submandibular space infection

! Most serious complication is edema of
the glottis

Treacher Collins Syndrome
! Has external ear changes

Scarlet fever
! White coating of the tongue that sloughs off

leaving a deep red surface with swollen
hyperplastic fungiform papillae (“strawberry
tongue”)

Fordyce granules
! Ectopic sebaceous glands – yellow

papules/plaques

Turner tooth
! Due to local trauma or infection associated

with the developing tooth bud

Intrinsic tooth stain
! Tetracycline – deposition within the dentin

Recurrent Aphthous Stomatitis
! Clinical
– Moveable mucosa
! Ex. Uvula, labial mucosa
– Recurrent – NOT PRECEDED BY VESICLE
– Associated with certain HLA types
! NOT caused by a virus, bacteria, fungus
– Treatment
! Corticosteroids are often prescribed
– Herpetiform type
! Many small
– Minor and major types
! Very painful
! Size, depth, time to heal (minor 5-10 days)
! Minor – small, shallow ulcer with red halo

Benign Mucous Membrane Pemphigoid
(cicatricial)
! Clinical
– Autoimmune
! Antibody reaction at the
epithelial-connective tissue
interface (BMZ)
! Subepithelial split
– Vesiculoerosive, ulcers
– > women - middle aged
– Skin and eye
– Oral
! Any site: gingiva, soft palate, etc.
! Ulcers, erosions following vesicles, bulla
! Histology
– Subepithelial separation at basement membrane zone

Condyloma Acuminatum
! Clinical
– Venereal wart
– Extensive
– Etiology
! Human papilloma virus (HPV)

Candidiasis –
pseudomembranous
! Clinical
– Opportunistic infection (“yeast”)
! Immature or deficient immune
system
! Antibiotics usage
! Corticosteroids usage
– Hyphae and spores
! May be diagnosed by cytology
smear
– White, wipeable “patch” with red,
underling base; palate and buccal
mucosa are often involved
– “Thrush”
! Newborns and infants

Candidiasis – Chronic
! Median rhomboid glossitis
– Clinical
! Red – atrophy of filiform papillae
! Midline tongue, junction of anterior
2/3 and posterior 1/3 at tuberculum
impar
! Not a developmental disorder as
once thought
! Treatment
– Antifungal agents are sometimes effective, such as nystatin or
clotrimazole
! Denture sore mouth

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

Recurrent (Secondary) Herpes
Simplex
! Clinical
– U.S. incidence estimate of herpes infection is
80-85%
! Most cases are subclinical
! Reactivation from nerve cells of trigeminal ganglion
– Lip
! Skin or vermilion
! Vesicle ruptures - - -> ulcer that heals in 7-10 days
(not present for weeks or months if immunocompetent
person)

Recurrent (Secondary) Herpes
Simplex

Recurrent Herpes Simplex Infection
! Clinical
– HSV Type 1 in humans, most often
– Intraoral
! Hard palate and gingiva = nonmoveable, overlying bone
! Small coalescing shallow ulcers preceded by small vesicles
! Can be subclinical even though person has primary infection
! Usually history of trauma, stress, UV exposure, as triggering
event several days earlier (ex. restorative procedure)
! No history of allergy or chemical burn

Traumatic Neuroma
! Clinical
– Wandering transected nerve with scar tissue
– Painful or tender, firm “lump” or nodule
– Oral site
! Occurs at sites of chronic trauma
! Ex. mandibular alveolar ridge in denture wearer,
especially near mental nerve, denture flange
trauma
! Ex. tongue

Pyogenic 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

Peripheral Giant Cell
Granuloma
! Clinical
– Somewhat similar in appearance to pyogenic
granuloma
– Moderate soft mass
– Often “liver-colored” [brownish purple]
– Distinctive histology
! Multinucleated giant cells
– Limited to alveolar ridge/
gingiva
! Usually anterior to first molar
region

Central Giant Cell Granuloma
! Clinical
– Intrabony
– Same histology as:
! Peripheral giant cell
granuloma
! Brown tumor of hyperpara-
thyroidism
– No effect on saliva production
– Bone destruction secondary to chronic renal
disease

Squamous Papilloma (Papilloma)
! Clinical
– Etiology - epithelium
– White to white-pink usually but can be reddened
– Rough surface (cauliflower)
– Elevated lesion (papule, nodule)
– Common sites
! Facial or lingual gingiva
! Soft or hard palate
! Tongue
– More frequent than some
other “omas”
! Rhabdomyoma
! Leiomyoma
! Lymphangioma

Fibroma
(fibrous nodule, focal fibrous hyperplasia,
traumatic fibroma, irritation fibroma)
! Clinical
– Most common connective tissue tumor
– Reactive, not true tumor
– Hyperplasia; NOT neoplasia,
anaplasia, dysplasia, etc.
– Firm, smooth, pink,
elevated papule/nodule
– Common site is tongue (due to trauma)

Granular Cell Tumor
! Clinical
– Dorsum of tongue #1 site
– Nodule with smooth or papillated surface
– Histology distinct
! Granular cells - cytoplasm
! 50% of time exhibit
pseudoepitheliomatous
hyperplasia
– Resembles squamous cell carcinoma histologically

Leukoplakia
! 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

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
! Initial – incisional biopsy

Squamous Cell Carcinoma
! Clinical
– Lower lip
! Can be preceded by actinic cheilitis
! Firm, indurated ulcer; painless with v. good prognosis
! Submental node is most common lymph node involved by
metastasis
– Most common oral site
! Mid-lateral border of tongue
– Least likely oral site
! Hard palate
– Site with greatest likelihood or risk of developing
squamous cell carcinoma
! Floor of mouth – worse prognosis when lung mets (not size, local
spread or anaplastic cells)
– Metastasis
! Most likely to a lymph node

! Staging vs. Grading
– Stage III has a worse prognosis than I or II
! Radiographic
– When invasive into the alveolar ridge it will
appear poorly defined lucencies without a
reactive sclerotic border

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

Monomorphic Adenoma
(Canalicular Adenoma)
! Clinical
– Most common site
! Upper lip
! > Women
! May be
multinodular
! Asymptomatic
! Do not confuse
with mucocele
of the lower lip

Leukoedema
! Clinical
– Intracellular edema of cells
– More often seen in African-Americans
– Common, bilateral on buccal mucosa
– Diagnostic test chairside
! Pull on buccal mucosa - - - -> disappears or
dissipates
– Normal mucosa variation so no treatment
required

Leukemia
! Clinical/Lab
– Red, swollen (hyperplastic),
boggy, bleeding gingiva
(interdental papilla) with ulcers
– Lab tests ordered
! Complete blood count
! White blood count differential
! Decreased neutrophils
! Leukemic infiltrate leaves blood
and into soft tissue (esp. acute

monocytic type)
– Red macules on skin (purpura =
extravasated blood) & skin infections
– Decreased platelets
– Tired feeling (malaise)
– Anemia (decreased RBCs)

Verrucous Carcinoma
! Clinical
– Very well differentiated
form of squamous cell
carcinoma
– Large, elevated, papillary often
associated with smokeless tobacco
habit
– Most common site is buccal
vestibule
– No tendency to metastasize
! Chief difference from
typical squamous cell carcinoma

Field Cancerization –
! Patient diagnosed and treated for squamous

cell carcinoma of the tongue
! Much more likely to have future premalignant
or malignant lesions anywhere in the oral
cavity
– Ex. – speckled leukoplakia of the floor of mouth
likely to be a second primary lesion
! p53 tumor suppressor gene is most common
associated

Salivary Gland Tumors
! Most common tumor of salivary gland origin is
the pleomorphic adenoma
– Benign
– Most common intraoral site is palate
! Major and minor salivary glands potential sites
– Neoplasm most likely to arise in the parotid
– Neoplasm most likely to arise in the palate
! Adenoid cystic carcinoma
– Characteristic perineural invasion – most likely
! Parotid – facial nerve involvement but no upper lip paresthesia

Physiologic Pigmentation (Racial
Pigmentation)
! Clinical
– Darkens with time; present
most of a person’s lifetime
– African-American patients
! Upper or lower lip vermilion, attached gingiva,
tongue, buccal mucosa
! Series of splotchy brown macules

Lateral Periodontal Cyst
! Clinical
– True cyst (epithelial lining),
not pseudocyst
! Radiographic appearance
– Well circumscribed radioluceny between the
roots of adjacent, erupted, vital teeth (most
commonly seen at mandibular premolars)
– Radiographic differential diagnosis does NOT
include dentigerous cyst (impacted tooth)

Ameloblastoma
! Clinical
– Average age is 34
– Most common in posterior
mandible but anterior mandible
also (can cross midline)
! Radiographic
– Most common true odontogenic tumor
– Multilocular radiolucency
– Superimposed over posterior teeth (> mand.)
– Often associated with impacted tooth
! Histology
– Reverse polarization of the nuclei of the tall, columnar cells
of the periphery

Ameloblastic Fibroma
! Clinical
– Young person
– More often in posterior jaws, esp. mandible
– Slight pain, swelling; not aggressive
– Ameloblastic fibro-odontoma
is similar except for odontoma
component
! Radiographic
– Pure lucency; no
radiopaque component
– AFO – also has radiopaque component (i.e., the
odontoma)
Odontoma
! Clinical – primarily first two decades of life (young persons)
! Radiographic
– Radiopacity with radiolucent rim (= follicle)
! Compound vs. Complex types
– Compound - identifiable toothlets
! > Anterior maxilla
– Complex – unidentifiable mass

! > Posterior of jaws

Adenomatoid Odontogenic
Tumor (AOT)
! Clinical
– Young person (child or teenager)
! Unerupted tooth of the anterior maxilla (#6,
#11)
! Radiographic
– Snow flake calcifications in the radiolucency
surrounding the crown and a portion of the
impacted tooth’s root
Treatment – simple
enucleation

Amelogenesis Imperfecta
! Clinical
– Teeth lack enamel;
– Dentin and cementum
unaffected
– Shapes of root and
crown are normal
! Radiographic
– Enamel is missing
– Pulp chambers and
root canals normal

Dentinogenesis Imperfecta
! Clinical
– Opalescent dentin – blue/gray
– Often associated with osteogenesis
imperfecta
! Blue sclera
! Multiple bone fractures
! Radiographic
– BWXs and PAs demonstrate classic
lack of pulp chambers and root canals
– Bell-shaped crown with constricted
cervical region
Cherubism
! Radiographic
– Multilocular, bilateral
lucencies
! Clinical
– Bilateral jaws
– Young persons
– Jaw expansion - - ceases after childhood

Fibrous Dysplasia
! Clinical
– Unilateral mandibular or maxillary expansion; onset before
puberty; C.C. of “teeth do not fit”
– Painless swelling, usually ceases at age 20
– Root canal therapy will not help since non-infectious
process (i.e., fibro-osseous lesion)
– Café au lait pigmentation
! Polyostotic form – McCune Albright syndrome
! Radiographic
– Ground glass appearance
! Treatment
– After age 20 when stabilized
– Cosmetic bone shaving

Condensing Osteitis
(Sclerosing Osteitis)
! Clinical
– Associated with pulpitis (ex. very carious posterior
mandibular tooth); nonvital tooth
– Associated tooth will test nonvital or signs and
symptoms or tooth destruction will support nonvital
status
! Radiographic
– Periapical opacity so does
NOT mimic a periapical
granuloma radiographically
– Does not connect with root

Idiopathic Osteosclerosis
! Clinical
– No apparent reason including no pulpitis in adjacent
tooth
– No expansion, pain
! Radiographic
– Radiopacity without
peripheral lucent rim
– Not connected to tooth’s
root
! Treatment
– None

Traumatic Bone Cyst
(Simple Bone Cyst; Idiopathic Bone Cavity;
Unicameral Cyst; Hemorrhagic Cyst)
! Clinical
– Undergoes spontaneous healing without
treatment following exploratory surgery
– Pseudocyst
! Radiographic
– Radiolucent with scalloped margins

Paget’s Disease of Bone
! Clinical
– Older age group
– Bilateral maxilla affected
– Involved bone can undergo malignant (sarcomatous)
transformation (i.e., osteosarcoma)
– Cranial nerve deficits as foramen compressed, narrowed
– Does NOT have hyperglobulinemia or premature exfoliation
of primary teeth
! Radiographic
– Cotton wool appearance
– 50% - hypercementosis
! Histology
– Reversal lines with a mosaic pattern

Langerhans Cell Disease
(Histiocytosis X)
! Clinical
– Composed of Langerhans cells,
not histiocytes
– Etiology is still unknown
– Eosinophilic granuloma
! Solitary lesion, young adults
– Hand-Schuller-Christian triad
! Diabetes insipidus
! Exophthalmos
! Bone lesions
! Radiographic
– Tooth “floating in air or space”

Benign vs. Malignant Bone
Involvement
! Clinical
– Ominous malignant sign
! Spontaneous paresthesia of the lower lip
! Radiographic - Benign
– Cortex remains intact – thinned or
expanded

Central Neural Lesions
! Neurofibroma and Schwannoma

! Radiographic
– Enlargement of canals and foramina

Nasolabial Cyst
! Clinical
– Mucolabial, smooth swelling adjacent to a
maxillary lateral incisor
– Soft tissue involvement; not bone
! Histology
– Pseudostratified
squamous epithelium
cystic lining

Lymphoepithelial Cyst
! Clinical
– Commonly on ventral tongue/floor of mouth
– Well circumscribed swelling
– Pale, yellowish at times

Odontogenic Keratocyst
! Clinical
– High recurrence!
– Intrabony, posterior mandible
but anywhere; BCNS association
! Radiographic
– Radiolucent, usually multilocular
– May mimic many other
types of lucent cysts and
odontogenic tumors including
ameloblastoma
parakeratin
surface
Nevoid Basal Cell Carcinoma Syndrome
(Gorlin syndrome; basal cell nevus syndrome)
! Clinical
– Onset is childhood
– Cysts of the jaws =
odontogenic keratocysts
! High recurrence rate
– Basal cell carcinomas
! Face especially
– Bifid rib
! Radiographic
– Keratocysts - unilocular or
multilocular lucencies
– Calcification of the falx cerebri
Cheek Nibbling
(Morsicatio Buccarum)
! Clinical
– Buccal mucosa site
– White, rough, tissue tags
above and below the
occlusal plane (line alba)
Other sites – lip and tongue

Gardner Syndrome
! Clinical
– Multiple facial osteomas &
skin nodules
– Hyperdontia; unerupted teeth
– Multiple GI (colon) polyps [familial intestinal
polyposis] - - - -> colon carcinoma
Epidermoid cyst
Odontoma
Bell’s Palsy
! Clinical
– 7th nerve paralysis - - - -> unilateral lip
droop at corner, inability to close or wink
eyelid
– Last usually less than one month

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

Erythema Multiforme
! Clinical
– Young adult males
– Sudden, explosive onset
– Triggered by drug or viral
infection
– Crusted, bleeding, vesicles,
ulcers of vermilion of lips;
intraoral sites excluding gingiva
– “Target, iris, or bulls-eye lesions”
of the hands and feet

Stevens-Johnson syndrome
(Erythema Multiforme Major)
• Eye (conjunctiva), mouth (labial mucosa,

tongue, etc.), genitalia

Pemphigus Vulgaris
! Clinical/Lab – Vesiculoerosive (oral and skin)

– Demonstrates immunoglobulin fluorescence
intraepithelial (supraepithelial) cementing substance
! Most often immunoglobulin type G (IgG)
– Positive Nikolsky sign
– Common sites – lips, palate, gingiva

Pemphigus Vulgaris

Progressive Systemic Sclerosis
(Scleroderma)
! Clinical
– Demonstrates induration
of the soft tissue (mask-like) and
generalized widening of the PDL space
– Trismus

Benign Migratory Glossitis (Geographic
Tongue, Erythema Migrans)
! Clinical
– Red and white
! Red = flat, depapillated
areas of tongue (filiform
papillae atrophied)
! White = keratin, epithelial
cell debris
– Periodically appears
– Can cause soreness or burning
occasionally
– Treatment
! Corticosteroid rinse (dexamethasone)
– Moves around from day to day
– Dorsum of tongue most often
! Also lateral, ventral surfaces

Aspirin Burn (Chemical Burn)
! Clinical
– White = coagulative necrosis of the surface,
NOT hyperkeratosis
! White rubs off with difficulty, hyperkeratosis does not
wipe off

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

Mucocele
(mucus retention phenomenon, mucus
extravastion phenomenon)
! Clinic
– Children and young adults
– Trauma
– Lower lip is most common site
– Vesicle/bulla, dome-shaped
– Bluish often
– History of recurrence

Ranula (mucocele, mucus retention
phenomenon, mucus extravastion
phenomenon)
! Clinical
– Floor of mouth swelling
! Looks like a frog’s belly (Gk ‘ranu’ = frog)
! Bluish usually; history of recurrence several times
! Mucin will yield viscous aspirate
! Microscopic – histiocytes visible in mucin
MUCIN
GW
MSG

Antral Pseudocyst (Mucous
Retention Pseudocyst)
! Clinical
– Asymptomatic
– No treatment necessary
! Radiographic
– Slight radiopaque,
dome-shaped, emanating
from floor of maxillary sinus

Ankyloglossia
! Congenital abnormality
! “tongue- tied”

Dentigerous Cyst
! Clinical
– Most common site is posterior mandible
– Impacted third molars
– Unicystic ameloblastoma can arise from it
– Malignant transformation of the lining is possible
! Histology
– Epithelial lining - - - -> ameloblastoma, squamous
cell carcinoma, mucoepideromoid carcinoma
– Other impacted teeth besides 3rd molars

Dentigerous Cyst (cont’d)
! Radiographic
– Pericoronal radiolucency attached at CEJ
of unerupted tooth
– Radiographic differential diagnoses
! Ameloblastoma
! Residual cyst
! Odontogenic keratocyst
! Odontogenic myxoma

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

Parulis (Gum Boil)
! Clinical
– Incomplete root canal therapy with
intermittent sensitivity
– Elevated reddish-yellow
! Clinical evidence of a draining fistula

Tuberculosis
! Clinical
– Incidence is increasing worldwide and in the
U.S.
– Chest radiograph
– May spread by infected sputum to oral
lesions (e.g., ulcer mimicking cancer on the
tongue)

Extravasated Blood
! Clinical – spontaneously resolve

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

Allergic Gingivitis
! Clinical
– Typically due to flavoring agents in
toothpastes, candies, and chewing gums
(cinnamon flavoring is a common culprit)

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

Herpes Zoster
! Clinical
– Crop of vesicles - - - > ulcers with pain
– Striking unilateral distribution on skin and
oral
! ex. – palate, tongue

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

Primary Herpes Gingivostomatitis

Crohn’s Disease
! Clinical
– Granulomatous gingivitis
– Aphthous-like ulcers
– Rectal bleeding
! Intestinal skip lesions of small intestine, and
to a lesser degree, large intestine and other
regions of the GI tract

Dermoid Cyst
! Clinical
– Slightly compressible (“doughy”)
– Midline distribution usually
! Example - anterior floor of mouth

Multiple Endocrine Neoplasia
Syndrome, Type IIB (III)
! Clinical
– Multiple mucosal neuromas (e.g., tongue)
– Medullary thyroid carcinoma
– Adrenal pheochromocytoma

Incisive Canal Cyst
(Nasopalatine Duct Cyst)
! Clinical
– Most common developmental
non-odontogenic cyst
– Teeth vital; max. midline
– True cyst (epithelial lining)
Often heart-
shaped
lucency
White Sponge Nevus
! Clinical
– A genodermatosis
! Autosomal dominant
– Often bilateral buccal
mucosa; other mucosa
– Moderately extensive
thick, white folds of tissue
- No eye involvement

Cleft Palate
! Clinical
– Between lateral incisor
and canine
! Radiographic
– Lucent line
– Maxillary occlusal film

Trigeminal Neuralgia
! Clinical
– Age of onset typically > 35 years old; trigger points

Neuritis
! Clinical
– Intense pain for one week duration
– Unilateral
! At forehead and around eye

Actinic Cheilitis
! Clinical
– Lip’s vermilion becomes indistinct
– Great potential for dysplasia to undergo
malignant transformation into squamous cell
carcinoma
! Therefore, a premalignant condition

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

Post-Developmental Loss of Tooth
Structure
! Attrition - physiological
! Abrasion - pathological
– Mechanical wear at
cervical region most typically
– Habits / occupations
! Erosion
– Chemical loss of tooth structure
exclusive of acidogenic theory
of caries
! Chlorinated pools
– Gastric regurgitation and GERD
! Hiatal hernia, bulimia

Structure
Abrasion

Structure
Erosion

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

Periapical Cemento-osseous Dysplasia
(Periapical cemental dysplasia; periapical osseous
dysplasia)
! Clinical
– Middle-aged black women
– Mandibular anterior vital teeth
– No pain or expansion - - asymptomatic
! Radiographic
– Diagnosed by characteristic findings
! Multifocal periapical lucencies which mature over time; become
mixed lucent/opaque and finally mainly opaque
Time

Florid Cemento-osseous Dysplasia
(florid osseous dysplasia)
! Clinical
– Multiquadrant
– Fibro-osseous intrabony lesion
– Hard product produced is avascular so . .
– Most likely complication is a secondary osteomyelitis
! Radiographic
– Radiolucent and radiopaque
! Treatment
– None necessary after dx

Florid Osseous Dysplasia

Lichen Planus
! Clinical
– Skin and/or oral condition
– Middle aged women most often
– Skin
! Purple, polygonal, pruritic papules
– Oral
! White papules and coalescing papules = Wickam’s striae
! Does not wipe off – any oral site
– Reticular form; often asymptomatic
! Erosive form
– On tongue may be mistaken for geographic tongue
– Sensitive, painful
! Most common site
– Buccal mucosa
! Ex. – dorsum of tongue
– White plaques, individual papules and striae
! Hyperplastic form - - plaque-like
– Does not wipe off

Lichen Planus
reticular
cutaneous hyperplastic
Erosive Lichen Planus

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

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

Neurofibromatosis, type 1 (von
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)
! Brown macules

Calcifying Odontogenic Cyst
(Gorlin Cyst)
! Histology
– Ghost cells
– Calcifications

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

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

Auriculotemporal syndrome (Frey
syndrome)
! Clinical
– Often after parotid gland surgery
– Sweating of unilateral facial skin just prior to eating
– Does not affect cranial nerve VI (rather V)
Starch Iodine Test

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

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

Chronic Osteomyelitis
! Radiographic
– Often best seen in lateral oblique
radiographic view
– Radiolucent and radiodense

Condylar Hyperplasia
! Clinical
– Irregular, elongated condyle
– Chin deviates away from affected side upon
closure

Dens-in-dente (dens invaginatus)
! Clinical
– Most often found in anterior jaw, especially
maxillary lateral incisor

Periapical Cyst and Granuloma
! Clinical
– Nonvital tooth, at apex
! Radiographic
– Periapical lucency with thin radiopaque line =
reaction to apical inflammatory disease

Dentin Dysplasia
! Clinical
– Dentin abnormal with
exposure
– Draining fistulas
– Misshapen teeth
! Radiographic
– Type 1 – “rootless” teeth
– Periapical lucencies

(Hypohydrotic) Ectodermal
Dysplasia
! Exhibits hypodontia (anodontia)
! Hypohidrotic - common type
– Lack of skin appendages and hair
– Heat intolerance

Epulis Fissuratum
! Clinical
– Hyperplastic connective tissue like fibroma
– Associated with ill-fitting denture flange
– Treatment does NOT include antibiotic therapy

Gingival Cyst of the Adult
! Clinical
– Soft tissue
– Facial attached gingiva
! Mandibular anterior most often
– Elevated, fluid containing so a vesicle

Heavy Metal Systemic
Intoxication
! Clinical
– Lead line
! Blue line that parallels free marginal gingiva

Hemangioma
! Clinical
– Hamartoma
– Red to blue elevated lesions
– Blanches, compressible
! Histology
– Collection of small or large vessels filled with red blood
cells
Lymphangioma
! Clinical
– Lymph-filled superficial vessels
– Most common cause of macroglossia

Hypercementosis
! Clinical
– Vital mandibular first molar
– Generalized in acromegaly
– Also seen, at times, in Paget’s
! Radiographic
– Radiopacity with intact PDL
– Attached to root surface
cementoblastoma

Infectious Mononucleosis
! Clinical
– Cervical swelling, lateral
– Sore throat
– Teenagers most often
– Positive monospot test
– Epstein-Barr virus association
palatal petechiae

Internal vs. External Tooth
Resorption
! Clinical – pink tooth when crown involved with
internal type
! Radiographic
– Cannot tell difference early in the process
– Round or ovoid radiolucency

Irradiation Therapy
! Clinical
– Causes cervical caries secondary to
inducement of xerostomia
– Does not result in pulp necrosis

Acquired Melanocytic Nevus
(common mole’; ‘nevus’)
! Clinical
– Junctional type
! Most likely to undergo
malignant transformation
(i.e., melanoma)
– Intramucosal type
! Most common oral type
! Called intradermal type on skin
– Compound type

Kaposi’s Sarcoma
! Clinical
– Particular malig. seen in HIV positive
individual that progress to AIDS
– Etiology
! Herpes virus, type 8; not HIV, EBV, CMV, HPV

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

Keratoacanthoma

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

Warthin’s tumor
(papillary cystadenoma lymphomatosum)
! Clinical
– Primary site overwhelmingly is parotid
! Not in oral cavity; >> males

Vitamin C Deficiency
! Clinical
– Scurvy
– Does NOT cause xerostomia

Stafne Defect (salivary gland
depression defect)
! Clinical
– Developmental
– More in males
– Asymptomatic
– Teeth vital
! Radiographic
– Well demarcated lucency found near the angle of
the mandible beneath the
mandibular canal

SjÖgren’s Syndrome
! Clinical
– Autoimmune disease; NOT infectious (e.g., herpes)
– Elderly women
– Dry eyes, dry mouth = sicca
– Parotid swelling
– Often other autoimmune diseases
– lupus, rheumatoid arthritis

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

Proliferative Periostitis
(Garre’s)
! Clinical
– Young person; swelling visible
! Radiographic
– Inferior border of posterior mandible is common site - Onion
skin pattern (radiographic appearance)
! Bands of radiopaque lines that parallel cortical surface

Peutz-Jeghers Syndrome
! Clinical
– Oral and Paraoral
! Pigmented macules (brown)
– Lips, tongue, buccal mucosa
– Vermilion and skin of lip
– Intestinal polyposis

Osteosarcoma
! Clinical
– Swift onset of localized pain
and swelling; tingling lower lip
– Onset in late 20s, early 30s
! Most common primary
malignancy of bone in persons
less than 25-years-old
! Radiographic - early lucency then opacity;
trabeculae changes; PDL symmetrical widening

Osteoporosis
! Clinical
– Decrease in serum estrogen and
calcium
– Older females

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

Osteopetrosis

Osteoma
! Clinical
– Most common site is angle of mandible
! Radiographic
– Well-circumscribed radiopacity

Mandibular Fracture
! Clinical
– Often diagnosed with two radiographs
! Panoramic and occlusal

Mandibular Malignant Ominous
Sign
! Clinical
– Spontaneous paresthesia of the lower lip

Mandibular Torus
! Radiographic
– May be superimposed over periapical region
as radiodensities

Malignant Melanoma
! Clinical
– Most common oral sites
! Hard palate and gingiva

Multiple Myeloma
! Clinical
– Elderly males (high median age)
! Lab Findings
– Bence-Jones proteinuria
– Immunoglobulin spike
! Radiographic
– Multiple bone sites
! Calvaria, spine, pelvic girdle, jaws
– Punched-out lucencies

Necrotizing Sialometaplasia
! Clinical
– Rapid onset
– Deep ulceration of the palate (most common
site) after initial swelling; self-resolving

Cervical emphysema
! Introduction of air into oral soft tissues with

resulting sudden painless swelling and
crepitance
– Ex. – air/water syringe

Odontogenic Myxoma
! Clinical
– Young adult onset
! Radiographic
– Closely resemble ameloblastoma
! Multilocular lucency with soap bubble pattern

Miscellaneous Facts
! Primordial cyst – forms in place of a tooth

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

Miscellaneous Facts
! The parotid gland body is the most likely salivary

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

Miscellaneous Facts (cont’d)
! Autoimmune diseases more common in women

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

Epithelial Dysplasia

Radiology Facts
• X-ray has the shortest wavelength and the

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

Radiology Facts (cont’d)
! First sign of damage from acute radiation

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

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

! Intensifying screens are used to decrease exposure time,
reduce radiation exposure
! 8-bit digital image would have 256 shades of gray
! Complication of radiation treatment in children does NOT
include supernumerary teeth but does include:
– Stunted roots
– Micrognathia
– Condylar hyperplasia
– Malocclusion
! Coin tests
– Used for detection of light leakage

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

! 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
aluminum
! A charged coupled device (CCD) converts x-rays 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

! Collimating an x-ray beam results in an increase

of the penetration of x-ray photons
! Radon is the greatest source of background
radiation on earth
! Basic components of an x-ray cathode ray tube
consists of a filament and a focusing cup
! To change from long scale intensity (low contrast)
to short scale intensity (high contrast) but
maintain image density, the operator should
decrease kVp and increase mAs

! 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

! 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
functions to dissipate heat from the target

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Oral and Maxillofacial Pathology

Review for NBDE Part 2

Michael A. Kahn, DDS

Thursday, January 19, 2012

Thursday, January 19, 2012

! Can arise from an infection - - a

Thursday, January 19, 2012

! Submandibular space infection

Thursday, January 19, 2012

! Has external ear changes

Thursday, January 19, 2012

! White coating of the tongue that sloughs off

Thursday, January 19, 2012

! Ectopic sebaceous glands – yellow

Thursday, January 19, 2012

! Due to local trauma or infection associated

Thursday, January 19, 2012

! Tetracycline – deposition within the dentin

Thursday, January 19, 2012

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Thursday, January 19, 2012

! Denture sore mouth

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! White blood count differential

and into soft tissue (esp. acute

Thursday, January 19, 2012

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! Patient diagnosed and treated for squamous

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– Complex – unidentifiable mass

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