Systemic Lupus Erythematosus

Oral and Maxillofacial Pathology

Review for NBDE Part 2
Clinical
2010
– Autoimmune
– Young adult females
– Butterfly rash of face
Michael A. Kahn, DDS Sun exposure worsens it
Professor and Chairman
Department of Oral and Maxillofacial Pathology
– Systemic involvement complications
Tufts University School of Dental Medicine Heart – endocarditis
1
Kidney – renal glomeruli (glomerulonephritis) 2

Cavernous sinus thrombosis Ludwig’s angina

Can arise from an infection - - a Submandibular space infection

subcutaneous abscess of the upper lip or a
Most serious complication is edema of
intrabony abscess of an anterior maxillary
tooth
t th the glottis
– Valveless facial
veins

3 4

Treacher Collins Syndrome Scarlet fever

White coating of the tongue that sloughs off

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

5 6

1
Fordyce granules Turner tooth

Ectopic sebaceous glands – yellow Due to local trauma or infection associated

papules/plaques with the developing tooth bud

7 8

Recurrent Aphthous Stomatitis

Intrinsic tooth stain

Tetracycline – deposition within the dentin

Clinical
– Moveable mucosa
Ex. Uvula, labial mucosa
– Recurrent – NOT PRECEDED BY VESICLE
– Associated with certain HLA types
NOT caused by a virus, bacteria, fungus
– Treatment
Corticosteroids are often prescribed
– Herpetiform type
Many small
– Minor and major types
Very painful
Size, depth, time to heal (minor 5-
5 - 10 days)
Minor – small, shallow ulcer with red halo
9 10

Benign Mucous Membrane Pemphigoid

(cicatricial)
Condyloma Acuminatum
Clinical
– Autoimmune
Antibody reaction at the Clinical
epithelial--connective tissue
epithelial
interface (BMZ)
– Venereal wart
Subepithelial split – Extensive
– Vesiculoerosive,
l ulcers
l
– > women - middle aged
– Skin and eye – Etiology
– Oral Human papilloma virus (HPV)
Any site: gingiva, soft palate, etc.
Ulcers, erosions following vesicles, bulla
Histology
– Subepithelial separation at basement membrane zone
11 12

2
 Candidiasis – Candidiasis – Chronic
pseudomembranous Median rhomboid glossitis
– Clinical
Clinical Red – atrophy of filiform papillae
– Opportunistic infection (“yeast”) Midline tongue, junction of anterior
Immature or deficient immune 2/3 and posterior 1/3 at tuberculum
system impar
Antibiotics usage Not a developmental disorder as
C ti t id usage
Corticosteroids once thought
– Hyphae and spores Treatment
May be diagnosed by cytology – Antifungal agents are sometimes effective, such as nystatin
or clotrimazole
smear
– White, wipeable “patch” with red, Denture sore mouth
underling base; palate and buccal – Clinical
Red
mucosa are often involved
Patient does not remove
– “Thrush” or clean denture – NOT acrylic allergy
13 14
Newborns and infants Tx – rinse mouth and soak denture with antifungal

Recurrent (Secondary) Herpes Recurrent (Secondary) Herpes

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

15 16

Recurrent Herpes Simplex Infection Traumatic Neuroma

Clinical
– HSV Type 1 in humans, most often Clinical
– Intraoral – Wandering transected nerve with scar tissue
Hard palate and gingiva = nonmoveable, overlying bone
Small coalescing shallow ulcers preceded by small vesicles
– Painful or tender, firm “lump” or nodule
Can be subclinical even though person has primary infection – Oral site
U
Usually
ll history
hi t off trauma,
t stress,
t UV exposure, as triggering
ti i O
Occurs att sites
it off chronic
h i trauma
t
event several days earlier (ex. restorative procedure) Ex. mandibular alveolar ridge in denture wearer,
No history of allergy or chemical burn especially near mental nerve, denture flange
trauma
Ex. tongue

17 18

3
Pyogenic Granuloma Peripheral Giant Cell
Granuloma
Clinical Clinical
– Occur at any age
– Somewhat similar in appearance to pyogenic
– Any location but usually on granuloma
gingiva
Most common is interdental
– Moderate soft mass
papilla – Often “liver-
“liver- colored” [brownish purple]
– Local reactive growth – Distinctive histology
Irritation Multinucleated giant cells
– Bleeds readily – Limited to alveolar ridge/
– Exophytic
gingiva
– Not painful
Usually anterior to first molar
– Grows very fast – like
region
malignancies
– Proliferative 19 20

Squamous Papilloma (Papilloma)

Central Giant Cell Granuloma
Clinical
– Etiology - epithelium
Clinical – White to white
white-- pink usually but can be reddened
– Rough surface (cauliflower)
– Intrabony
– Elevated lesion (papule, nodule)
– Same histology as: – Common sites
Peripheral giant cell Facial or lingual gingiva
granuloma Soft or hard palate
Brown tumor of hyperpara
hyperpara-- Tongue
thyroidism – More frequent than some
– No effect on saliva production other “omas”
– Bone destruction secondary to chronic renal Rhabdomyoma
disease Leiomyoma
Lymphangioma
21
Neurofibroma 22

Fibroma Granular Cell Tumor

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

Clinical
– Most common connective tissue tumor Clinical
– Reactive,
Reactive not true tumor – Dorsum of tongue # 1 site
– Hyperplasia; NOT neoplasia, – Nodule with smooth or papillated surface
anaplasia, dysplasia, etc. – Histology distinct
– Firm, smooth, pink, Granular cells - cytoplasm
50% of time exhibit
elevated papule/nodule pseudoepitheliomatous
– Common site is tongue (due to trauma) hyperplasia
– Resembles squamous cell carcinoma histologically
23 24

4
Leukoplakia Erythroplakia and
Erythroleukoplakia (speckled)
Clinical
– Red plaque that does not wipe off
– Studies show that it is likely to have severe
Clinical dysplasia or worse and undergo malignant
– White patch that does not wipe off transformation to carcinoma
– Cytology smear does not help determine specific
diagnosis – Treatment
– Appropriately managed by biopsy Initial – incisional biopsy
– Floor of mouth hyperkeratosis most common site to
exhibit dysplasia
– If two separate areas in person’s mouth then both
areas should have incisional biopsy
25 26

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
Mid
– 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 27 28

Most likely to a lymph node

Squamous Cell Carcinoma

Metastatic Disease to the Jaws
Staging vs. Grading
– Stage III has a worse prognosis than I or II Clinical and Radiographic
Radiographic – Most common site is posterior mandible
– When invasive into the alveolar ridge it will – Does not cause a shift of patient’s occlusion
appear poorly defined lucencies without a – Usually a poorly defined lucency without
sclerotic border
reactive sclerotic border

29 30

5
Monomorphic Adenoma
(Canalicular Adenoma) Leukoedema
Clinical Clinical
– Most common site
– Intracellular edema of cells
Upper lip
> Women
W – More often seen in African-
African -Americans
May be – Common, bilateral on buccal mucosa
multinodular – Diagnostic test chairside
Asymptomatic
Pull on buccal mucosa - - - - > disappears or
Do not confuse
dissipates
with mucocele
of the lower lip
– Normal mucosa variation so no treatment
required
31 32

Leukemia Verrucous Carcinoma

Clinical/Lab
– Red, swollen (hyperplastic),
boggy, bleeding gingiva Clinical
(interdental papilla) with ulcers
– Very well differentiated
– Lab tests ordered
Complete blood count form of squamous cell
White blood count differential carcinoma
Decreased neutrophils – Large, elevated, papillary often
Leukemic infiltrate leaves blood associated with smokeless tobacco
and into soft tissue (esp. acute
habit
monocytic type)
– Red macules on skin (purpura
( purpura = – Most common site is buccal
extravasated blood) & skin infections vestibule
– Decreased platelets – No tendency to metastasize
– Tired feeling (malaise) Chief difference from
33 34
– Anemia (decreased RBCs)RBCs) typical squamous cell carcinoma

Field Cancerization –
Squamous Cell Carcinoma Salivary Gland Tumors
Most common tumor of salivary gland origin
Patient diagnosed and treated for squamous is the pleomorphic adenoma
cell carcinoma of the tongue – Benign
Much more likelyy to have future p
premalignant
g – Most common intraoral site is p
palate
or malignant lesions anywhere in the oral Major and minor salivary glands potential
cavity sites
– Ex. – speckled leukoplakia of the floor of mouth – Neoplasm most likely to arise in the parotid
likely to be a second primary lesion – Neoplasm most likely to arise in the palate
p53 tumor suppressor gene is most common Adenoid cystic carcinoma
associated – Characteristic perineural invasion – most likely
Parotid – facial nerve involvement but no upper lip
35
paresthesia 36

6
Physiologic Pigmentation (Racial
Pigmentation) Lateral Periodontal Cyst

Clinical Clinical
– Darkens with time; present – True cyst (epithelial lining),
most of a person
person’ss lifetime not p
pseudocyst
y
– African
African--American patients Radiographic appearance
Upper or lower lip vermilion, attached gingiva, – Well circumscribed radioluceny between the
tongue, buccal mucosa roots of adjacent, erupted, vital teeth (most
Series of splotchy brown macules commonly seen at mandibular premolars)
– Radiographic differential diagnosis does NOT
include dentigerous cyst (impacted tooth)
37 38

Ameloblastic Fibroma
Ameloblastoma
Clinical
– Average age is 34 Clinical
– Most common in posterior – Young person
mandible but anterior mandible – More often in posterior jaws, esp. mandible
also
a so (ca
(can ccross
oss midline)
d e) – Slight
g pain,
p , swelling; g; not aggressive
gg
Radiographic – Ameloblastic fibro
fibro--odontoma
is similar except for odontoma
– Most common true odontogenic tumor
component
– Multilocular radiolucency
Radiographic
– Superimposed over posterior teeth ( > mand.)
– Pure lucency; no
– Often associated with impacted tooth
radiopaque component
Histology – AFO – also has radiopaque component (i.e., the
– Reverse polarization of the nuclei of the tall, 39
odontoma) 40

columnar cells of the periphery

Odontoma
Adenomatoid Odontogenic
Clinical – primarily first two decades of life (young
persons) Tumor (AOT)
Radiographic
Clinical
– Radiopacity with radiolucent rim ( = follicle) – Young person (child or teenager)
Compound vs. Complex types Unerupted tooth of the anterior maxilla ( # 6,
– Compound - identifiable toothlets # 11)
> Anterior maxilla Radiographic
– Complex – unidentifiable mass – Snow flake calcifications in the radiolucency
surrounding the crown and a portion of the
> Posterior of jaws impacted tooth’s root
Treatment – simple
enucleation

41 42

7
 Dentinogenesis Imperfecta
Amelogenesis Imperfecta

Clinical Clinical
– Teeth lack enamel; – Opalescent dentin – blue/gray
– Dentin and cementum – Often associated with osteogenesis
unaffected imperfecta
– Shapes of root and Blue sclera
crown are normal Multiple bone fractures

Radiographic Radiographic
– Enamel is missing – BWXs and PAs demonstrate classic
– Pulp chambers and lack of pulp chambers and root canals
root canals normal – Bell
Bell--shaped crown with constricted
43
cervical region 44

Cherubism
Radiographic Fibrous Dysplasia
– Multilocular, bilateral Clinical
lucencies – Unilateral mandibular or maxillary expansion; onset
before puberty; C.C. of “teeth do not fit”
Clinical
– Painless swelling, usually ceases at age 20
– Bilateral jaws
– Root canal therapy will not help since non
non-- infectious
– Young persons process (i.e., fibro
fibro-- osseous lesion)
– Jaw expansion - - ceases after childhood – Café au lait pigmentation
Polyostotic form – McCune Albright syndrome
Radiographic
– Ground glass appearance
Treatment
– After age 20 when stabilized
45 46
– Cosmetic bone shaving

Condensing Osteitis
(Sclerosing Osteitis)
Idiopathic Osteosclerosis
Clinical
– Associated with pulpitis (ex. very carious posterior
mandibular tooth); nonvital tooth Clinical
– Associated tooth will test nonvital or signs and – No apparent reason including no pulpitis in adjacent
symptoms or tooth destruction will support nonvital tooth
status – No expansion,
p , pain
p
Radiographic Radiographic
– Periapical opacity so does – Radiopacity without
NOT mimic a periapical peripheral lucent rim
granuloma radiographically – Not connected to tooth’s
– Does not connect with root root
Treatment
47 – None 48

8
 Traumatic Bone Cyst Paget’s Disease of Bone
(Simple Bone Cyst; Idiopathic Bone Cavity;
Unicameral Cyst; Hemorrhagic Cyst)
Clinical
Clinical – Older age group
– Undergoes spontaneous healing without – Bilateral maxilla affected
treatment following exploratory surgery – Involved bone can undergo malignant
(sarcomatous) transformation (i.e., osteosarcoma)
– Pseudocyst
– Cranial nerve deficits as foramen compressed,
Radiographic narrowed d
– Radiolucent with scalloped margins – Does NOT have hyperglobulinemia or premature
exfoliation of primary teeth
Radiographic
– Cotton wool appearance
– 50% - hypercementosis
Histology
49
– Reversal lines with a mosaic pattern 50

Langerhans Cell Disease Benign vs. Malignant Bone

(Histiocytosis X) Involvement

Clinical
– Composed of Langerhans cells, Clinical
not histiocytes
– Ominous malignant sign
– Etiology is still unknown
Spontaneous paresthesia of the lower lip
– Eosinophilic granuloma
Solitary lesion, young adults Radiographic - Benign
– Hand
Hand--Schuller
Schuller-- Christian triad
Diabetes insipidus
– Cortex remains intact – thinned or
Exophthalmos expanded
Bone lesions
Radiographic
– Tooth “floating in air or space” 51 52

Central Neural Lesions Nasolabial Cyst

Neurofibroma and Schwannoma Clinical

Radiographic – Mucolabial
Mucolabial,, smooth swelling adjacent to a
maxillary lateral incisor
– Enlargement of canals and foramina – Soft tissue involvement; not bone
Histology
– Pseudostratified
squamous epithelium
cystic lining

53 54

9
 Odontogenic Keratocyst
Lymphoepithelial Cyst Clinical
– High recurrence!
– Intrabony, posterior mandible
Clinical but anywhere; BCNS association
– Commonly on ventral tongue/floor of mouth Radiographic
– Well circumscribed swelling
g – Radiolucent, usually multilocular
– May
M mimic
i i many otherh
– Pale, yellowish at times types of lucent cysts and
odontogenic tumors including
ameloblastoma

parakeratin
55 56
surface

Nevoid Basal Cell Carcinoma Syndrome

(Gorlin syndrome; basal cell nevus syndrome)

Clinical
– Onset is childhood
– Cysts of the jaws =
odontogenic keratocysts
Hi h recurrence rate
High t
– Basal cell carcinomas
Face especially
– Bifid rib
Radiographic
– Keratocysts - unilocular or
multilocular lucencies
– Calcification of the falx cerebri 57 58

Gardner Syndrome
Cheek Nibbling
(Morsicatio Buccarum) Clinical
– Multiple facial osteomas &
Clinical skin nodules
– Buccal mucosa site – Hyperdontia; unerupted teeth
– White, rough, tissue tags – Multiple GI (colon) polyps [familial intestinal
above and below the polyposis] - - - - > colon carcinoma
occlusal plane (line alba)

Other sites – lip and tongue

59 60
Epidermoid cyst
Odontoma

10
 Bell’s Palsy Temporomandibular
Clinical Dysfunction (TMD)
– 7 th nerve paralysis - - - - > unilateral lip Clinical
droop at corner, inability to close or wink – Pain and tenderness of palpated TMJ
eyelid – Deviation of jaw toward painful side upon opening
– TMJ disc moves anterior and medially due to contraction of the
– Last usually less than one month lateral pterygoid muscle
– Popping and clicking indicate
internal derangement with
reduction
– Does not cause dizziness
– Reduce opening to ~ 45 mm
– Will get neuritis of VII cranial
nerve

61 62

Erythema Multiforme Stevens-- Johnson syndrome

Stevens
(Erythema Multiforme Major)
Clinical
– Young adult males
– Sudden, explosive onset
– Triggered by drug or viral
infection
– Crusted, bleeding, vesicles,
ulcers of vermilion of lips;
intraoral sites excluding gingiva
– “Target, iris, or bulls
bulls-- eye lesions”
of the hands and feet •Eye (conjunctiva), mouth (labial mucosa,
tongue, etc.), genitalia
63 64

Pemphigus Vulgaris Pemphigus Vulgaris

Clinical/Lab – Vesiculoerosive (oral and skin)
– Demonstrates immunoglobulin fluorescence
intraepithelial ((supraepithelial
supraepithelial)) cementing substance
Most often immunoglobulin type G (IgG
( IgG))
– Positive Nikolsky sign
– Common sites – lips, palate, gingiva

65 66

11
 Progressive Systemic Sclerosis
(Scleroderma)
Clinical
– Demonstrates induration
of the soft tissue (mask-
(mask - like) and
generalized widening of the PDL space
– Trismus

67 68

Benign Migratory Glossitis (Geographic

Tongue, Erythema Migrans)
Migrans ) Aspirin Burn (Chemical Burn)
Clinical Clinical
– Red and white
Red = flat, depapillated – White = coagulative necrosis of the surface,
areas of tongue (filiform NOT hyperkeratosis
papillae atrophied)
White rubs off with difficulty, hyperkeratosis does
White = keratin, epithelial
not wipe off
cell debris
– Periodically appears
– Can cause soreness or burning
occasionally
– Treatment
Corticosteroid rinse (dexamethasone
( dexamethasone))
– Moves around from day to day
– Dorsum of tongue most often
Also lateral, ventral surfaces 69 70

Basal Cell Carcinoma Mucocele

(mucus retention phenomenon, mucus
– Clinical
extravastion phenomenon)
Painless ulcer of upper lip, elsewhere on
sun-- exposed face (UV); raised margins
sun Clinical
Does NOT occur intraorally – Children and young adults
Begins as pearly papule; assoc. – Trauma
g
telangiectasia – Lower lip is most common site
Can be highly destructive if not treated – Vesicle/bulla, dome
dome--shaped
Usually does not metastasize – Bluish often
– History of recurrence

71 72

12
 Ranula (mucocele, mucus retention Antral Pseudocyst (Mucous
phenomenon, mucus extravastion Retention Pseudocyst)
phenomenon) Clinical
Clinical – Asymptomatic
– No treatment necessary
– Floor of mouth swelling
Radiographic
Looks like a frog’s belly (Gk ‘ranu’ = frog)
– Slight radiopaque,
radiopaque
Bluish usually; history of recurrence several times
dome--shaped, emanating
dome
Mucin will yield viscous aspirate
from floor of maxillary sinus
Microscopic – histiocytes visible in mucin

MUCIN

GW

MSG 73 74

Ankyloglossia Dentigerous Cyst

Congenital abnormality Clinical

“tongue-- tied”
“tongue – Most common site is posterior mandible
– Impacted third molars
– U i ti ameloblastoma
Unicystic l bl t can arise
i from
f it
– Malignant transformation of the lining is possible
Histology
– Epithelial lining - - - - > ameloblastoma,
ameloblastoma , squamous
cell carcinoma, mucoepideromoid carcinoma
– Other impacted teeth besides 3rd molars
75 76

Dentigerous Cyst (cont’d)

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

77 78

13
Varices Parulis (Gum Boil)
Lingual and Lip Clinical
– Dilated veins - blue – Incomplete root canal therapy with
– Seen typically in the elderly intermittent sensitivity
– Lip varices may thrombose and – Elevated reddish-
reddish - yellow
subsequently calcify (i.e. phlebolith) Clinical evidence of a draining fistula

79 80

Tuberculosis
Extravasated Blood
Clinical
– Incidence is increasing worldwide and in Clinical – spontaneously resolve
the U.S.
– Purpura – generalized term
– Chest radiograph
– Petechia
Petechia-- pinpoint bleeding
– May
M spread d by
b infected
i f t d sputum
t to
t orall
– Ecchymosis – larger area of involvement
lesions (e.g., ulcer mimicking cancer on
the tongue) – Hematoma – large, elevated areas

81 82

Allergic Mucositis Eagle Syndrome

Clinical Clinical
– Typically due to flavoring agents in – Elongation and/or
toothpastes, candies, and chewing gums calcification of the
(cinnamon
( i flavoring
fl i isi a common culprit)
l it) stylohyoid ligament
– Head and neck pain is
elicited by chewing,
yawning, opening mouth

83 84

14
 Primary Herpes
Herpes Zoster
Gingivostomatitis
Clinical Clinical
– Crop of vesicles - - - > ulcers with pain – Inflamed, enlarged marginal gingiva;
– Striking unilateral distribution on skin and gingival bleeding
orall – Vesicles - - - - > ulcers throughout the
ex. – palate, tongue mouth and lips with significant pain
– Malaise
– Low grade fever
– Sore throat, lymphadenopathy

85 86

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

87 88

Multiple Endocrine Neoplasia

Dermoid Cyst Syndrome, Type I IB ( I I I )

Clinical Clinical
– Slightly compressible (“doughy”) – Multiple mucosal neuromas (e.g., tongue)
– Midline distribution usually – Medullaryy thyroid
y carcinoma
Example - anterior floor of mouth – Adrenal pheochromocytoma

89 90

15
 Incisive Canal Cyst
(Nasopalatine Duct Cyst) White Sponge Nevus
Clinical Clinical
– Most common developmental – A genodermatosis
non-- odontogenic cyst
non Autosomal dominant
– Teeth vital; max.
max midline – Often bilateral buccal
– True cyst (epithelial lining) mucosa; other mucosa
– Moderately extensive
thick, white folds of tissue
- No eye involvement

Often heart-
heart -
shaped lucency 91 92

Cleft Palate Trigeminal Neuralgia

Clinical Clinical
– Between lateral incisor – Age of onset typically > 35 years old; trigger points

and canine
Radiographic
– Lucent line
– Maxillary occlusal film

93 94

Neuritis Actinic Cheilitis

Clinical
Clinical – Lip’s vermilion becomes indistinct
– Intense pain for one week duration – Great potential for dysplasia to undergo
malignant transformation into squamous cell
– Unilateral
carcinoma
At forehead and around eye
Therefore, a premalignant condition

95 96

16
Cheilitis Glandularis Post-- Developmental Loss of Tooth
Post
Structure
Clinical
– Mucous minor salivary glands of lips are inflamed Attrition - physiological
– Mucus secretions Abrasion - pathological
– Premalignant condition - - - - > squamous cell – Mechanical wear at
carcinoma cervical region
g most typically
yp y
– Habits / occupations
Erosion
– Chemical loss of tooth structure
exclusive of acidogenic theory
of caries
Chlorinated pools
– Gastric regurgitation and GERD
97 98
Hiatal hernia, bulimia

Post-- Developmental Loss of Tooth

Post Post-- Developmental Loss of Tooth
Post
Structure Structure

Erosion
Abrasion

99 100

Periapical Cemento
Cemento-- osseous Dysplasia
(Periapical cemental dysplasia; periapical osseous
Oral Hairy Leukoplakia dysplasia)
Clinical
Clinical – Middle-
Middle - aged black women
– White, rough plaque on lateral border of tongue ( # 1 – Mandibular anterior vital teeth
site) – No pain or expansion - - asymptomatic
– Seen in HIV-
HIV- positive individuals that are progressing Radiographic
to AIDS – Diagnosed by characteristic findings
– Caused by Epstein
Epstein--Barr virus Multifocal periapical lucencies which mature over time;
become mixed lucent/opaque and finally mainly opaque

Time

101 102

17
 Florid Cemento-
Cemento - osseous Dysplasia
(florid osseous dysplasia) Florid Osseous Dysplasia
Clinical
– Multiquadrant
– Fibro-- osseous intrabony lesion
Fibro
– Hard product produced is avascular so . .
– Most likely complication is a secondary osteomyelitis
Radiographic
– Radiolucent and radiopaque
Treatment
– None necessary after dx

103 104

Lichen Planus
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 Reticular
Erosive form
– On tongue may be mistaken for geographic tongue
– Sensitive, painful
Most common site
– Buccal mucosa
Ex. – dorsum of tongue
– White plaques, individual papules and striae
Hyperplastic form - - plaque
plaque--like
105 106
– Does not wipe off 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

107 108

18
 Cleidocranial Dysplasia Neurofibromatosis, type 1 (von
Recklinghausen’s disease of skin)
Clinical
– Multiple unerupted supernumerary teeth Clinical
– Retention of primary teeth – Multiple neurofibromas (nodules) of the skin and
oral cavity (especially tongue)
– Delayed eruption of permanent teeth
– Café au lait pigmentation (abnormal macules or
– Missing clavicles, frontal bossing, large head
spots
p of the skin))
Brown macules

109 110

Calcifying Odontogenic Cyst

(Gorlin Cyst)

Histology
– Ghost cells
– Calcifications

111 112

Melanotic Neuroectodermal
Tumor of Infancy
Nicotine Stomatitis
Clinical
– Rapid onset, destructive in newborns
Clinical
– Increase of vanillylmandelic acid ((VMA
VMA))
– Hard palate – Anterior maxilla, soft and
– Red, inflamed minor salivary hard tissue
gland ducts with background – Mobile teeth
of leukoplakic change Radiographic
– Tobacco use – Intrabony, lucent, destructive
Pipe smokers – most often – Malignant looking but
Cigarettes benign usually

113 114

19
Auriculotemporal syndrome (Frey
syndrome) Aspiration
Clinical Always aspirate an anterior
– Often after parotid gland surgery
maxillary/mandibular radiolucency prior
– Sweating of unilateral facial skin just prior to eating
to biopsy to rule out vascular nature
– Does not affect cranial nerve VII (rather V)

Starch Iodine Test

115 116

Chronic Osteomyelitis
Actinomycosis
Radiographic
Clinical – Often best seen in lateral oblique
radiographic view
– Soft tissue swelling (“woody consistency”)
with multiple draining fistulas – Radiolucent and radiodense
– “sulfur granules” = colonies of bacterial
organism
PMNs

117 118

Condylar Hyperplasia Dens-- in

Dens in-- dente (dens invaginatus)

Clinical Clinical
– Irregular, elongated condyle – Most often found in anterior jaw, especially
– Chin deviates awayy from affected side upon
p maxillary lateral incisor
closure

119 120

20
Periapical Cyst and Granuloma
Dentin Dysplasia

Clinical Clinical
– Dentin abnormal with
– Nonvital tooth, at apex
exposure
Radiographic – Draining fistulas
– Periapical lucency with thin radiopaque line = – Misshapen teeth
reaction to apical inflammatory disease Radiographic
– Type 1 – “rootless” teeth
– Periapical lucencies

121 122

(Hypohydrotic) Ectodermal Epulis Fissuratum

Dysplasia
Clinical
Exhibits hypodontia (anodontia) – Hyperplastic connective tissue like fibroma
Hypohidrotic - common type – Associated with ill-
ill - fitting denture flange
– Lack of skin appendages and hair – Treatment does NOT include antibiotic therapy
– Heat intolerance

123 124

Gingival Cyst of the Adult Heavy Metal Systemic

Clinical Intoxication
– Soft tissue
– Facial attached gingiva Clinical
Mandibular anterior most often – Lead line
– Elevated, fluid containing so a vesicle Blue line that parallels free marginal gingiva

125 126

21
 Hemangioma
Lymphangioma
Clinical
– Lymph
Lymph-- filled superficial vessels
– Most common cause of macroglossia

Clinical
– Hamartoma
– Red to blue elevated lesions
– Blanches, compressible
Histology
– Collection of small or large vessels filled with red 127 128
blood cells

Hypercementosis Infectious Mononucleosis

Clinical
– Vital mandibular first molar
Clinical
– Generalized in acromegaly – Cervical swelling, lateral
– Also seen, at times, in Paget’s – Sore throat
Radiographic – Teenagers most often
– Radiopacity with intact PDL – Positive monospot test
– Attached to root surface – Epstein
Epstein--Barr virus association

palatal petechiae

Cementoblastoma
129 130

Internal vs. External Tooth

Resorption Irradiation Therapy
Clinical – pink tooth when crown involved with
internal type Clinical
Radiographic – Causes cervical caries secondary to
– Cannot tell difference early in the process inducement of xerostomia
– Round or ovoid radiolucency – Does
D nott result
lt iin pulp
l necrosis
i

131 132

22
Acquired Melanocytic Nevus Kaposi’s Sarcoma
(common mole’; ‘nevus’)
Clinical
Clinical – Particular malig.
malig . seen in HIV positive
– Junctional type individual that progress to AIDS
Most likely to undergo – Etiology
malignant transformation
Herpes virus
virus, type 8; not HIV,
HIV EBV
EBV,, CMV
CMV,, HPV
(i.e., melanoma)

– Intramucosal type
Most common oral type
Called intradermal type on skin

– Compound type
133 134

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

135 136

Xerostomia Warthin’s tumor

Clinical (papillary cystadenoma lymphomatosum)

– Dry mouth (subjective) Clinical

– Can result in retrograde infection of the – Primary site overwhelmingly is parotid
salivary glands; baldish, inflamed tongue
Not in oral cavity;
y; > > males

137 138

23
 Stafne Defect (salivary gland
Vitamin C Deficiency depression defect)

Clinical
Clinical
– Developmental
– Scurvy – More in males
– Does NOT cause xerostomia – Asymptomatic
– Teeth vital
Radiographic
– Well demarcated lucency found near the angle of
the mandible beneath the
mandibular canal

139 140

Sarcoidosis
Sj Ögren’s Syndrome Clinical
Clinical – Bilateral hilar lymphadenopathy (chest x-
x-ray)
– Autoimmune disease; NOT infectious (e.g., herpes) – Cutaneous lesions - violaceous
– Elderly women – Treatment – corticosteroids
– Dry eyes, dry mouth = sicca
– Parotid
P tid swelling
lli
– Often other autoimmune diseases
– lupus, rheumatoid arthritis

141 142

Proliferative Periostitis
(Garre’s) Peutz-- Jeghers Syndrome
Peutz
Clinical Clinical
– Young person; swelling visible
– Oral and Paraoral
Radiographic
– Inferior border of posterior mandible is common site - Onion Pigmented macules (brown)
skin pattern (radiographic appearance ) – Lips, tongue, buccal mucosa
Bands of radiopaque lines that parallel cortical surface – Vermilion and skin of lip
– Intestinal polyposis

143 144

24
Osteosarcoma
Clinical
– Swift onset of localized pain
Osteoporosis
and swelling; tingling lower lip
– Onset in late 20s, early 30s Clinical
Most common primary
malignancy of bone in persons – Decrease in serum estrogen and
less than 25-
25- years
years--old calcium
Radiographic - early lucency then opacity;
– Older females
trabeculae changes; PDL symmetrical widening

145 146

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

147 148

Osteoma Mandibular Fracture

Clinical
– Most common site is angle of mandible Clinical
Radiographic – Often diagnosed with two radiographs
– Well
Well-- circumscribed radiopacity Panoramic and occlusal

149 150

25
Mandibular Malignant Ominous
Mandibular Torus
Sign
Radiographic
Clinical
– May be superimposed over periapical region
– Spontaneous paresthesia of the lower lip
as radiodensities

151 152

Multiple Myeloma
Malignant Melanoma

Clinical Clinical
– Elderly males (high median age)
– Most common oral sites
Hard palate and gingiva Lab Findings
– Bence
Bence--Jones proteinuria
– Immunoglobulin spike
Radiographic
– Multiple bone sites
Calvaria, spine, pelvic girdle, jaws
– Punched
Punched-- out lucencies

153 154

Necrotizing Sialometaplasia Cervical emphysema

Clinical Introduction of air into oral soft tissues with

– Rapid onset resulting sudden painless swelling and
– Deep ulceration of the palate (most common crepitance
site)
it ) after
ft iinitial
iti l swelling;
lli self
self-
lf -resolving
l i – Ex. – air/water syringe

155 156

26
 Odontogenic Myxoma Miscellaneous Facts
Clinical
Primordial cyst – forms in place of a tooth
– Young adult onset
Enamel hypoplasia is a temporary suspension
Radiographic of amelogenesis
– Closely resemble ameloblastoma Fusion – one less than normal compliment of
Multilocular lucency with soap bubble pattern 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

157 158

Miscellaneous Facts Miscellaneous Facts (cont’d)

The parotid gland body is the most likely salivary
gland tissue to have a neoplasm
Osteoradionecrosis major factor is damage to the
vascular supply
Prognosis best for sq cell ca of lower lip compared
to osteosarcoma,
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,
pemphigoid ,
pemphigus and erosive lichen planus
159
Autoimmune diseases more common in women
Oncocytoma = parotid swelling (tumor)
Gingival hyperplasia – drugs such as cyclosporine,
nifedipine (Procardia ® ) phenytoin (Dilantin ® )
Malignant jaw lesions destroy the cortical plates of
bone
Gingival condition with no improvement after two
months should be biopsied
Dysplasia – abnormal maturation of the epithelium
160

Radiology Facts
Epithelial Dysplasia
• 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-
x-ray beam is doubled
Kilovoltage (kVP) primarily controls contrast
and is the penetrating characteristic of an xx--ray
X-ray penetration is determined by kVP
Focal spot size primarily influences resolution

161 162

27
 Radiology Facts (cont’d)
Radiology Facts (cont’d) The density of processed film is not affected by
overfixation but is affected by
– Increase mA
First sign of damage from acute radiation – Increase exposure time
exposure (4 Gy) is erythema – Decreased object-
object - thickness distance
Most radioresistant tissue is nerve and – Decreased target-
target - object distance
muscle cell; most sensitive is hematopoetic B
Best iimaging
i film
fil for
f viewing
i i internal
i l derangement
d off
the TMJ (e.g., articular disc) is an MRI
Basic shadow casting principle with the Identify Normal:
paralleling technique does not fulfill the – Zygomatic process and base; intermaxillary suture
physics requirement of the distance from – Lingual foramen; incisive foramen; genial tubercles
– Mylohyoid ridge; nutrient canals
the object to the recording surface should
– Inverted Y of Ennis
be as short as possible – Maxillary sinus
163 – Tuberosity; hyoid bone; nose shadow (ant. periapical film)164

– Hard palate; tori; anterior nasal spine; stylohyoid ligament

Radiology Facts (cont’d) Radiology Facts (cont’d)

Intensifying screens are used to decrease
exposure time, reduce radiation exposure Double the distance from the radiation source
then the radiation becomes diminished by a
8 - bit digital image would have 256 shades of factor of 4 (i.e., inverse square law)
gray
Latent period = radiobiology time between
Complication
p of radiation treatment in children exposure and biologic onset of symptoms; not
does NOT include supernumerary teeth but cell exposure and free radical formation
does include:
Radiograph is rinsed with water to accomplish
– Stunted roots
getting rid of chemicals (not remove emulsion,
– Micrognathia
diminish silver particles, remove latent image)
– Condylar hyperplasia
– Malocclusion
Artifact
– Bitewing radiograph with a curved dark line through
Coin tests contact points of adjacent crowns = a break in the166
165
– Used for detection of light leakage emulsion from film bending

Radiology Facts (cont’d)

Radiology Facts (cont’d)
A light radiograph is NOT caused by a long
process time Collimating an x-
x-ray beam results in an
An MRI is narrow frequency radiation of the increase of the penetration of x-
x-ray photons
electromagnetic spectrum Radon is the greatest source of background
The filter in a dental xx--ray machine is made of radiation
ad at o oon ea
earth
t
aluminum Basic components of an x- x-ray cathode ray
A charged coupled device (CCD) converts x- x- tube consists of a filament and a focusing
rays to electrical signals but does NOT result in cup
the same average absorbed dose as To change from long scale intensity (low
conventional radiology (less absorbed dose) contrast) to short scale intensity (high
Effective dose = comparison of the radiation contrast) but maintain image density, the
risk in humans from different radiographic 167
operator should decrease kVp and increase 168

exams and doses/sources mAs

28

Radiology Facts (cont’d)
Panoramic radiograph with one second of
movement by patient results in wavy inferior border
of the mandible and unsharp image vertically across
the image at that site
Major biologic damage from ionizing radiation is
primarily due to radiolysis of the water molecules
Electrons flow from cathode to anode with the
energy converted to heat
Recognize MRI and CT films
Recognize technical errors
– Incorrect beam centering (“cone cut”)
– Blurring due to patient movement 169
Radiology Facts (cont’d)
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-
x-ray tube housing
functions to dissipate heat from the target
170

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