ORAL PATHOLOGY

Important Tables
University question
CRANIOFACIAL DYOSTOSIS
Also called Cruzon syndrome(mcq)
Autosomal dominant craniofacial disorder
Characterized by the premature closure of cranial
bone sutures (craniosynostosis)
MUTATION: fibroblast growth factor(mcq)
Hypoplastic Maxilla • Short upper lip • Widely
spaced eyes (hypertelorism) • Shallow orbits,
protruding eyeballs (ocular proptosis) • Poor
vision and hearing deficits • Short head
(brachycephaly) • Calcified stylohyoid ligaments •
Dental arch width is reduced • Crowding of the
maxillary teeth • Unilateral or bilateral posterior
crossbite
The skull typically exhibits increased digital
markings (beaten metal pattern) (mcq)
MANDIBULOFACIAL DYOSTOSIS
Also called Treacher Collin syndrome
Autosomal dominant
An autosomal dominant disorder characterized by the
abnormal development of structures derived from
the first and second branchial arches
GENE: long arm of chromosome 5 (5q32-q33).
Zygomas are hypoplastic, resulting in depressed
cheeks. • Downward-sloping lower eyelids • Notched
lower eyelid (coloboma) • The ears exhibit a spectrum
of abnormalities, including hypoplastic ear lobes,
malformed pinnae, absent ear canals, and defective
middle-ear structures with varying degrees of hearing
loss. • The mandible exhibits condylar and coronoid
hypoplasia’s as a retruded chin
Absent

As uhs exam
Ossifying fibroma Cemento osseous Fibrous Dysplasia
dysplasia
Clinical features mandible posterior Periapical ---- Nonexpansile Mono ostotic (MFD)—no
to the canines and Nonsymptomatic gender predilection
only occasionally in Anterior mandible Juvenile MFD
the maxilla and Middle-aged women
Vital teeth
Adult MFD
other locations. It
Focal—posterior mandible Poly ostotic (PFD)--
occurs twice as
Florid ---involves multipe females
often in women and
primarily in the 20- quadrants Buccal /lingual cortical
to 30-year age expansion
group. The lesion is MFD..maxilla>>mandible
usually painless and PFD…craniofacial bones,
grows slowly, femur, tibia, pelvis,
exhibiting marked
buccal and lingual
bony expansion
Radiographic early stages the Periapical & focal--- EARLY LESIONS Radiolucent
features lesions are small completely radiolucent to becoming radiopaque as
and usually densely radiopaque with a more bone
completely thin peripheral radiolucent formation occurs
radiolucent As rim. MATURE LESIONS
they enlarge, Florid-- Mixed lucent and Orange peel (peau
increased amounts opaque lesions d'orange) appearance
of irregularly “Cotton ball” appearance Ground glass appearance
shaped
radiopacities

appear within the

radiolucent area. In
the later, more
mature stage, the
radiopaque
structures enlarge
and coalesce, often
forming a nearly
radiopaque lesion
with a thin rim of
radiolucency
separating it from
the surrounding
normal bone
Histopathological composed of osteolytic stage consists Initially: cellular connective
features cellular fibrous primarily of cellular tissue that has replaced the
connective tissue, connective tissue replacing normal trabeculae and
frequently in a the normal trabecular bone marrow.
whorled pattern. with calcified structures Mixed stage: irregular
Spherical cementoblastic stage has islands of metaplastic bone
amorphous the same connective tissue emerge from the fibrous
calcifications component, but displays a tissue background. ----
(cementicles) are mixture of spherical CHINESE LETTER
often present and calcifications and irregularly APPEARANCE
randomly shaped deposits of osteoid Arise by metaplasia and are
distributed ---- and mineralized bone. not surrounded by plump
Demonstrate These calcified and appositional osteoblasts T
peripheral brush mineralized structures are lesional bone fuses directly
borders that blend surrounded by osteoblasts to normal bone at the
into the adjacent containing osteocytes periphery of the lesion so,
connective tissue matured stage is composed no capsule or line of
Irregularly shaped almost entirely of coalesced demarcation is present
calcified structures spherical calcifications and Eventually the bony
containing sclerotic mineralized bone component predominates
osteocytes and a with little connective tissue. the lesion with much of the
wide zone of bone and collagen matrix
osteoid and developing a lamellar
rimming of pattern
osteoblasts . A thin
outer zone of
fibrous connective
tissue is usually
present, separating
the fibroosseous
tissue from the
surrounding normal
bone

As uhs exam
RADIOGRAPHIC FEATURES
EWING SARCOMA bone appears “moth-eaten,”
simulating an osteomyelitis with
indistinct margins. The
periosteum often has a lamellar
layering, referred to as an
“onionskin” reaction.
HISTOPATHOLOGICAL FEATURES
Individual cells may be of two types:
(1) small and round, with darkly
staining nuclei and a visibly delineated
cytoplasm, and (2) larger, with a finely
granular nucleus and a faint ill-defined
cytoplasm. Both cell types are
undifferentiated cells.
 OSTEOSARCOMA The “classic” sunburst or sun ray contain normal or abnormal osteoid or
appearance bone that is closely associated with the
Codman’s triangle, a triangular malignant connective tissue cells to
distinguish them from other forms of
elevation of the periosteum
sarcoma
Symmetrical widening of the
periodontal ligament space
around a tooth or several teeth.
“Spiking” resorption of roots as
a result of the tapered
narrowing of the root

CHONDROSARCOMA appears as an expansile well-differentiated and resemble a

“motheaten” radiolucent area benign cartilaginous lesion or they may
with indistinct boundaries be anaplastic, composed of spindled
cells with little evidence of cartilage
containing flecks or blotchy
formation. Most lesions exhibit a
radiopacities combination of abnormal cartilage
Widening of PDL surrounded by neoplastic cells
Sunburst app when penetrates
cortices
• A patient presented to the oral and maxillofacial clinic with a painless mass on the left
retromolar area. Histopathology revealed sarcomatous spindle cells and 10-12 mitosis per hpf.
Give the differential diagnosis along with Immunohistochemistry

Spindle cell sarcoma IHC

Fibrosarcoma Vimentin
Leiomyosarcoma Desmin,Smooth muscle actin
Rhabdomyosarcoma Desmin.myoglobin
Malignant peripheral nerve sheath tumor S100

Angiosarcoma/Kaposi sarcoma CD34 & CD 31

As UHS exam
RADIOGRAPIC FEATURES HISTOPATHALOGICAL FEATURES
Acute suppurative Little radiographic changes unless The bone shows a loss of the osteocytes from their
OM the disease has developed for 1-2 lacunae,
week, an ill-defined radiolucency, peripheral resorption, and bacterial colonization
Individual trabeculae become The periphery of the bone and the haversian
fuzzy and indistinct------MOTH canals contain necrotic debris and an acute
EATEN APPEARENCE inflammatory infiltrate consisting of
polymorphonuclear leukocytes.
Chronic Suppurative A patchy, ragged, Soft tissue component consists of chronically or
OM and ill-defined subacutely inflamed fibrous connective tissue
radiolucency that filling the intertrabecular areas of the bone
often contains Scattered sequestra and pockets of abscess
central formation are seen
radiopaque
sequestra
Focal Sclerosing OM Localized, usually uniform zone of
increased radiodensity-- Adjacent
to the apex of a tooth ---Exhibits a
thickened periodontal ligament
space
Diffuse Sclerosing Diffuse, patchy sclerosis of bone
OM (cotton wool appearance)---May be
extensive or bilateral
Chronic OM with multiple thin layers of new bone,
Proliferative referred to as an “onion skin”
periostitis appearance. The trabecular bone
will also exhibit the characteristic
diffuse mottling of a chronic
osteomyelitis
Dense bony trabeculae with little interstitial
marrow, Empty lacunae
Multiple reversal lines giving pagetoid appearance
Connective tissue between trabeculae is fibrotic and
infilterated by small number of lymphocytes
Dense, irregular bony trabeculae, some of which are
bordered by an active layer of osteoblasts
Focal areas of osteoclastic activity
May show mosaic pattern
The soft tissue is fibrous with small capillaries &
focal collections of lymphocytes and plasma cells If
the adjacent inflammatory process extends into the
sclerotic bone, then necrosis often occurs. The
necrotic bone separates from the adjacent vital
tissue and becomes surrounded by subacutely
inflamed granulation tissue. Secondary bacterial
colonization often is visible.
Parallel rows of highly cellular and reactive woven
bone in which the individual trabeculae are
frequently oriented perpendicular to the surface.
The trabeculae sometimes form an interconnecting
meshwork of bone or are scattered more widely,
resembling the pattern seen in immature fibrous
dysplasia
Between the cellular trabeculae, relatively
uninflamed fibrous connective tissue is evident.
 AMELOGENESIS DENTINOGENESIS DENTINE DYSPLASIA
IMPERFECTA IMPERFECTA
CLINICAL HYPOPLASTIC TYPE I (ass with Type I (radicular DD): All teeth in
FEATURES Generalized or localized Osteogenesis both dentitions are affected. The color
• Pitted - • imperfecta), Type II of the teeth is usually within the
Smooth - • Rough - (Hereditary oplascent normal range
teeth). Type III Type II (Coronal DD): Both the
• The enamel is
(Brandywine type) primary and permanent dentitions are
thinner than normal in affected.
focal or Clinical features: In all
three subtypes of DI, Clinically the deciduous teeth exhibit a
generalized areas bluish-gray, brownish, or yellowish
HYPOMINERALIZED teeth of both dentitions color and have the same translucent,
Enamel matrix is laid are affected with opalescent appearance that is seen in
down appropriately but variable clinical DI.
no significant appearances. The teeth the permanent teeth have a normal
mineralization occurs. are opalescent with the clinical appearance.
The enamel is of normal color ranging from
thickness but softer than bluish-gray to brown
normal and can be to yellowish. The
easily removed with a dentin is abnormally
blunt instrument soft, providing
Opaque white to inadequate structural
yellow-brown, support to the
• soft rough overlying enamel.
enamel surface, ---- Although the enamel is
Wear off easily normal, it fractures or
• dental chips away easily,
sensitivity and open bite exposing the occlusal
common and incisal dentin The
HYPOMATURATION exposed soft dentin
TYPE often undergoes rapid
The enamel is of normal and severe functional
thickness but not of attrition.
normal hardness and
translucency enamel can
be pierced with the
point of a dental
explorer with firm
pressure and can be
chipped away from the
underlying normal
dentin; mildest form of
the hypomaturation type
---enamel of normal
hardness and has white
opaque flecks in the
incisal areas of the teeth
(snow-capped teeth)
RADIOGRAPHIC In the smooth
FEATURES hypoplastic type, the
enamel layer is
conspicuously thin and
its radiodensity is greater
than the adjacent dentin;
in the hypocalcified type,
the enamel layer appears
wispy or absent and is
usually less radiodense
than the adjacent dentin;
in the hypomaturation
type, the radiodensity of
the enamel is almost
equal to that of normal
dentin.
The teeth in DI DD 1: roots of the teeth are usually
subtypes I and II are short, blunt, bulged, conic, or absent.
similar and exhibit characteristic W-shaped roots. -
bulb-shaped crowns deciduous dentition, -----total
with constricted obliteration of the pulpal chambers and
cementoenamel canals. permanent teeth ------pulpal
junctions and thin obliteration; OR , thin crescent shaped
roots.Depending on the or chevron-shaped remnants of the pulp
age of the patient, the chambers are often present. Periapical
teeth will exhibit radiolucencies --abscesses,
varying stages of granulomas, or cysts may be present in
obliteration of the pulp the absence of dental caries
chambers and pulp DD2: deciduous teeth of DD type II
canals The cementum, exhibit obliterated pulpal chambers
periodontal ligament, and canals that are similar to those
and supporting
 alveolar bone appear seen in DD type I and in DI. pulpal
normal. The teeth in obliteration roots of the deciduous
DI type III may be and permanent dentitions are of
similar to those seen in normal shape and length.
types I and II, or they pulp chambers in the permanent teeth
may exhibit extremely are -----a thistle or flame shape to the
large pulpal chambers root portion of the pulp.
surrounded by a thin Pulpal calcifications (pulp stones) -
shell of dentin. coronal pulp chambers and the root
pulp canals are narrowed

A radiograph of the lower incisors revealed a single radiolucent lesion at the apex of a tooth.

A. What is differential diagnosis? Periapical cyst…. Periapical cyst, granuloma, periapical cemento osseous
dysplaisa

B. Compare the histopathological features

PERIAPICAL CYST
LINING : • cyst is lined by stratified squamous
epithelium, which may demonstrate exocytosis,
spongiosis, or hyperplasia • scattered mucous cells or
areas of ciliated pseudostratified columnar epithelium
may be noted. Lining epithelium may demonstrate
linear or arch-shaped calcifications known as Rushton
bodies
LUMEN: cyst lumen -------fluid and cellular debris. •
Dystrophic calcification, cholesterol clefts with
multinucleated giant cells, red blood cells, and areas of
hemosiderin pigmentation may be present in the lumen,
wall, or both. • The wall of the cyst consists of dense
fibrous connective tissue, often with an inflammatory
infiltrate containing lymphocytes variably intermixed
with neutrophils, plasma cells, histiocytes, and (rarely)
mast cells and eosinophils. • walls of inflammatory
cysts will contain scattered hyaline bodies ---These
bodies appear as small circumscribed pools of
eosinophilic material that exhibits a corrugated
periphery of condensed collagen often surrounded by
lymphocytes and multinucleated giant cells
PERIAPICAL GRANULOMA
Periapical granulomas consist of inflamed granulation
tissue surrounded by a fibrous connective tissue wall. •
Granulation tissue-----dense lymphocytic infiltrate that
is intermixed frequently with neutrophils, plasma cells,
histiocytes, and, less frequently, mast cells and
eosinophils. When numerous plasma cells are present,
1. scattered eosinophilic globules of gamma globulin
(Russell bodies) may be seen. 2. clusters of lightly
basophilic particles (pyronine bodies) also may be
present in association with the plasmacytic infiltrate.
Epithelial rests of Malassez may be identified within
the granulation tissue. • Collections of cholesterol
clefts, with associated multinucleated giant cells and
areas of red blood cell extravasation with hemosiderin
pigmentation, may be present

What is Stephan curve give its significance?

DEFINITION: A mathematical model used to determine the impact of ingested foods on the pH of dental plaque
and subsequent caries formation. Decalcification of teeth occurs when the pH in the oral cavity is less than 5.5.
SIGNIGICANCE:The significance of a Stephan curve shows that the plaque pH curve will drop a lot and quickly
after the consumption of fermentable carbohydrates. And then it will drop below what we call a critical pH, in which
case the demineralization of the tooth enamel minerals will occur.
FACTORS AFFECTING CURVE:
• The time taken for these changes to occur varies between individuals and also varies according to the nature
of the challenge.
• The initial sharp drop depends upon the speed with which plaque microbes are able to metabolise sugar.
Large molecules, like starch for example, diffuse into the plaque more slowly and take longer to be broken
down resulting in a less steep drop in pH.

As uhs exam
Den’s Invaginatus Den’s Evaginatus

Definition: Deep enamel-lined pit that extends for Definition: characterized by a cusp like supernumerary focal
varying depths into the underlying dentin enamel protrusion on the occlusal or lingual surface of the crown
Pathogenesis: Invagination is an end result of a speedy
and aggressive proliferation of a part of inner enamel
epithelium invading the dental papilla
Synonym: Also called as “Tooth in tooth”
Site: Maxillary lateral incisors
Pathogenesis: caused by abnormal proliferation of the inner
enamel epithelium into the Stellate reticulum
Synonym: “TUBERCULATE CUSP” or “ACCESSORY
TUBERCLE” OR “LEONG’S PREMOLAR
Site: Primarily affects premolar teeth

Dilated odontoma: the deep invagination results in a Dilated odontoma: No

bulbous expansion of the affected root, a form that has
been termed a dilated odontoma
Composition: The base of the pit or deep invagination is Composition: Tubercles have an enamel layer covering a dentin
composed of a thin, often defective layer of enamel and core containing a thin extension of pulp
dentin

LESIONS INTERNAL RESORPTION EXTERNAL RESORPTION

DEFINITION A form of tooth loss that begins within
the pulpal chambers of intact teeth,
destroying dentin as it extends outward
in a uniform pattern toward the tooth
surfaces. Most
A loss of tooth structure that begins on the
outer surface and extends inward toward
the pulp.

CAUSE • Idiopathic • Idiopathic

• Caries exposure
• Pulpal treatments
• Chronic Inflammation
• Hairline fractures
• Traumatic
• Inflammatory or neoplastic
• Cyst
• Long duration impacted teeth.
• Overly aggressive orthodontic
movement of the teeth at an earlier
time.
• Excessive traumatic occlusion.
• Transplanted and re-implanted teeth.

PATHOGENESIS • Occurs as a result of activation of • Release of chemical mediators

osteoclast or dentinoclasts on • Increased vascularity
internal surfaces of root & crown. • Increased pressure

PROGRESSION • Inside-out • Outside-in

SITE • Any tooth involved • • On an erupted tooth, lesions begin in
Mostly single tooth. the cervical areas.
• Crown of anterior • Mid root area, because of traumatic
incisors (MCQs) incident
• At the apex because of an encroaching
inflammatory or neoplastic lesion.
• Apical resorption of multiple teeth
because of excessive traumatic
occlusion.

• In re-implanted teeth are non-vital

and have no surrounding viable
PDL, resorbed and replaced by bone.
S/S • • Asymptomatic • Pulp is necrotic
The lesion first detected by the
appearance of a pink spot beneath
• the enamel surface
Pulp is vital
RADIOGRAPH • • Distinctive • Apex shortened, flattened or blunted.
It usually consists of a fusiform Margins of lesions are ragged and
enlargement of the pulpal chamber • irregular.
of one or more teeth that appears in Lesion may be superimposed over
either the crown or root • the canal
• pulpal chambers Canal that is superimposed can be
Margins of lesion are sharp, smooth • followed all the way to the apex,
• and clearly defined. unaltered.
Lesions may be symmetrical or Outline of the canal is normal.
• eccentric. •
Canals not present in the area of
lesion and not followed
•
Outline of the canal is distorted
HISTOPATHOLOGY • In intact teeth; the pulpal tissue in • Osteoclasts border the affected
the area of the resorption reveals a dentine or enamel.
loose connective tissue with • Inflammatory changes may be
increased vascularity and few superimposed if the pulp chamber
inflammatory cells. has been opened by destruction of its
• If associated with caries exposure, walls.
pulpal treatments, or hairline • Irregular repair with bone or
fractures, the pulpal tissues will cementum may take place
contain a granulation tissue that is
densely infiltrated with acute and
chronic inflammatory cells.
• Reversal lines may be seen in
adjacent hard tissue.

As Uhs Exam 2022

Wegners granulomatosis EXTRANODAL NK/T-CELL LYMPHOMA,

NASAL-TYPE (ANGIOCENTRIC T-CELL
LYMPHOMA; MIDLINE LETHAL
GRANULOMA)
definition
Wegener granulomatosis (WG) is an ssive, nonrelenting destruction of the midline
uncommon disease consisting of an structures of the palate and nasal fossa
inflammatory granulomatous process
characterized by severe vasculitis and
necrosis involving mainly the upper and lower
respiratory system and kidneys.

Clinical features
granulomatous hyperplastic gingivitis that
appears to originate in the interdental
papilla. Such lesions are deep red, nodular,
and friable and have been referred to as
“strawberry gingivitis,” ulcers and
perforations of the palate and swelling
and desquamation of the lips.
Observed in adults. initial signs and
symptoms -----localized to the nasal region
and include nasal stuffiness or epistaxis.
Pain may accompany the nasal symptoms.
Swelling of the soft palate or posterior hard
palate
may precede the formation of a deep,
necrotic ulceration, which usually occupies a
midline position. -----ulceration enlarges and
destroys the palatal tissues,
which typically creates an oronasal fistula

Histopathology
the tissues feature a prominent vasculitis a mixed infiltrate of a variety of inflammatory
with zones of necrosis and fibrinoid deposits cells, often arranged around blood vessels
in a general background of granulomas. (angiocentric)
Eosinophils and multinucleated giant cells are Necrosis is often present in some areas of the
commonly encountered. lesion, secondary to infiltration of the blood
vessels by the tumor cells.
Large, angular, lymphocytic cells with an
atypical appearance are usually identified as a
component of the cellular infiltrate
Investigation
CT chest /Xray chest Biopsy
Tissue biopsy Immunohistochemistry…T cell markers
Lab test: C ANCA (high levels of positive
antineutrophil cytoplasmic antibody ) Urine
analysis…hematuria or proteinuria
As uhs exam