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OMF-Path - Systemic Lupus Erythematosus Oral and...

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Unformatted text preview: Systemic Lupus Erythematosus Oral and Maxillofacial Pathology Review Review for NBDE Part 2 ! 2010 2010 – Autoimmune – Young adult females – Butterfly rash of face Michael A. Kahn, DDS Professor and Chairman Department of Oral and Maxillofacial Pathology Tufts University School of Dental Medicine ! Sun exposure worsens it – Systemic involvement complications ! 1 Cavernous sinus thrombosis ! Clinical ! Heart Heart – endocarditis Kidney Kidney – renal glomeruli (glomerulonephritis) (glomerulonephritis) 2 Ludwig’s angina Can Can arise from an infection - - a subcutaneous abscess of the upper lip or a intrabony abscess of an anterior maxillary tooth ! ! Submandibular space infection Most Most serious complication is edema of the glottis the glottis – Valveless facial veins 3 Treacher Collins Syndrome ! 4 Scarlet fever ! Has external ear changes 5 White White coating of the tongue that sloughs off leaving a deep red surface with swollen hyperplastic fungiform papillae (“strawberry tongue tongue”) 6 1 Fordyce Fordyce granules ! Turner tooth Ectopic Ectopic sebaceous glands – yellow yellow papules/plaques papules/plaques ! Due Due to local trauma or infection associated with with the developing tooth bud 7 8 Recurrent Aphthous Stomatitis Intrinsic tooth stain ! Tetracycline Tetracycline – deposition within the dentin ! Clinical – Moveable mucosa ! Ex. Uvula, labial mucosa – Recurrent – NOT PRECEDED BY VESICLE Recurrent – 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) 5Minor Minor – small, shallow ulcer with red halo 9 10 Benign Benign Mucous Membrane Pemphigoid (cicatricial) (cicatricial) ! Condyloma Acuminatum Clinical – Autoimmune ! ! – – – – ! ! Clinical – Venereal wart – Extensive Extensive Vesiculoerosive, ulcers > women - middle aged women Skin and eye Oral ! ! Antibody Antibody reaction at the epithelial-connective epithelial-connective tissue interface interface (BMZ) Subepithelial split – Etiology ! Human papilloma virus (HPV) Any site: gingiva, soft palate, etc. Ulcers, erosions following vesicles, bulla Histology – Subepithelial separation at basement membrane zone 11 12 12 2 Candidiasis Candidiasis – pseudomembranous pseudomembranous ! Candidiasis Chronic Candidiasis – Chronic ! – Clinical Clinical ! – Opportunistic infection (“yeast”) ! ! ! ! Immature Immature or deficient immune system system Antibiotics usage Corticosteroids usage ! – Hyphae and spores ! ! Newborns and infants ! Denture sore mouth – Clinical ! ! 13 ! Recurrent Recurrent (Secondary) Herpes Simplex Simplex ! Red Red – atrophy of filiform papillae Midline Midline tongue, junction of anterior 2/3 and posterior 1/3 at tuberculum impar impar Not Not a developmental disorder as once thought Treatment – Antifungal agents are sometimes effective, such as nystatin Antifungal or or clotrimazole May May be diagnosed by cytology smear smear – White, wipeable “patch” with red, White, underling underling base; palate and buccal mucosa are often involved – “Thrush” ! Median rhomboid glossitis Red Patient Patient does not remove or clean denture – NOT acrylic allergy Tx Tx – rinse mouth and soak denture with antifungal 14 14 Recurrent (Secondary) Herpes Simplex Simplex Clinical – U.S. incidence estimate of herpes infection is 808085% ! ! Most cases are subclinical Reactivation Reactivation from nerve cells of trigeminal ganglion – Lip ! ! Skin or vermilion Vesicle Vesicle ruptures - - -> ulcer that heals in 7-10 days 7-10 (not present for weeks or months if immunocompetent person) 15 Recurrent Herpes Simplex Infection ! 16 Traumatic Neuroma 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 hi UV i event several days earlier (ex. restorative procedure) No history of allergy or chemical burn 17 Clinical – Wandering transected nerve with scar tissue – Painful or tender, firm “lump” or nodule – Oral site Occurs at sites of chronic trauma Ex. Ex. mandibular alveolar ridge in denture wearer, especially near mental nerve, denture flange trauma trauma ! Ex. tongue Ex. ! ! 18 3 Peripheral Peripheral Giant Cell Granuloma Granuloma Pyogenic Granuloma ! Clinical – Occur at any age – Any location but usually on Any gingiva gingiva ! Most common is interdental Most common is interdental papilla papilla – Local reactive growth ! Irritation Irritation – Bleeds readily Bleeds – Exophytic Exophytic – Not painful Not – Grows very fast – like Grows malignancies – Proliferative ! – Somewhat similar in appearance to pyogenic Somewhat granuloma granuloma – Moderate soft mass – Often “liver-colored” [brownish purple] “liver– Distinctive histology Distinctive ! ! Usually Usually anterior to first molar region region 19 20 Squamous Papilloma (Papilloma) ! Clinical – – – – – Clinical – Intrabony – Same histology as: Peripheral giant cell granuloma ! Brown tumor of hyperparahyperparathyroidism Etiology Etiology - epithelium White to white-pink usually but can be reddened whiteRough surface (cauliflower) Elevated lesion (papule, nodule) Common sites ! ! ! ! Facial or lingual gingiva Soft or hard palate Tongue – More frequent than some More other other “omas” – No effect on saliva production No – Bone destruction secondary to chronic renal Bone disease disease ! ! ! 21 ! Fibroma Fibroma Rhabdomyoma Leiomyoma Lymphangioma Neurofibroma 22 Granular Cell Tumor (fibrous nodule, focal fibrous hyperplasia, traumatic traumatic fibroma, irritation fibroma) ! Multinucleated giant cells – Limited to alveolar ridge/ gingiva Central Giant Cell Granuloma ! Clinical Clinical – Most common connective tissue tumor Most – Reactive, not true tumor not true tumor – Hyperplasia; NOT neoplasia, Hyperplasia; anaplasia, anaplasia, dysplasia, etc. – Firm, smooth, pink, Firm, elevated papule/nodule – Common site is tongue (due to trauma) ! Clinical – Dorsum of tongue #1 site of tongue #1 site – Nodule with smooth or papillated surface Nodule – Histology distinct ! ! 23 Granular Granular cells - cytoplasm 50% 50% of time exhibit pseudoepitheliomatous hyperplasia hyperplasia – Resembles squamous cell carcinoma histologically 24 4 Leukoplakia Erythroplakia and and Erythroleukoplakia Erythroleukoplakia (speckled) ! ! Clinical – Red plaque that does not wipe off – Studies show that it is likely to have severe Studies dysplasia or worse and undergo malignant transformation to carcinoma – Treatment Treatment Clinical – White patch that does not wipe off patch that does not wipe off – Cytology smear does not help determine specific Cytology diagnosis diagnosis – Appropriately managed by biopsy – Floor of mouth hyperkeratosis most common site to Floor exhibit exhibit dysplasia – If two separate areas in person’s mouth then both If areas areas should have incisional biopsy ! Initial Initial – incisional biopsy 25 26 26 Squamous Cell Carcinoma ! Clinical – Lower lip ! ! ! Can Can be preceded by actinic cheilitis Firm, Firm, indurated ulcer; painless with v. good prognosis painless with Submental node is most common lymph node involved by node common metastasis metastasis – Most common oral site common oral site ! MidMid-lateral border of tongue – Least likely oral site ! Hard palate – Site with greatest likelihood or risk of developing Site of squamous squamous cell carcinoma ! Floor Floor of mouth – worse prognosis when lung mets (not worse (not size, local spread or anaplastic cells) – Metastasis ! Most likely to a lymph node 27 Squamous Cell Carcinoma ! Metastatic Disease to the Jaws Staging vs. Grading ! 28 Radiographic – Stage III has a worse prognosis than I or II – When invasive into the alveolar ridge it will When appear poorly defined lucencies without appear poorly defined lucencies without a reactive reactive sclerotic border 29 ! Clinical and Radiographic – Most common site is posterior mandible – Does not cause a shift of patient’s occlusion – Usually a poorly defined lucency without Usually poorly defined lucency without sclerotic sclerotic border 30 5 Monomorphic Adenoma (Canalicular Adenoma) ! Leukoedema Clinical ! – Most common site Most ! ! ! ! ! Clinical – Intracellular edema of cells – More often seen in African-Americans often seen in African – Common, bilateral on buccal mucosa – Diagnostic test chairside Diagnostic Upper lip > Women May be multinodular Asymptomatic Do Do not confuse with with mucocele of of the lower lip ! Pull Pull on buccal mucosa - - - -> disappears or disappears dissipates dissipates – Normal mucosa variation so no treatment Normal required required 31 Leukemia ! Verrucous Carcinoma Clinical/Lab – Red, swollen (hyperplastic), Red, boggy, bleeding gingiva (interdental (interdental papilla) with ulcers – Lab tests ordered ! Complete blood count ! White blood count differential blood count differential ! Decreased neutrophils Decreased ! Leukemic infiltrate leaves blood Leukemic and into soft tissue (esp. acute monocytic monocytic type) – Red macules on skin (purpura = Red (purpura extravasated blood) & skin infections – Decreased platelets – Tired feeling (malaise) – Anemia (decreased RBCs) Anemia RBCs) ! ! ! 33 Chief Chief difference from typical squamous cell carcinoma 34 Salivary Salivary Gland Tumors Patient Patient diagnosed and treated for squamous cell cell carcinoma of the tongue Much more likely to have future premalignant Much or or malignant lesions anywhere in the oral cavity ! p53 p53 tumor suppressor gene is most common associated 35 35 Most Most common tumor of salivary gland origin is is the pleomorphic adenoma – Benign – Most common intraoral site is palate ! Major Major and minor salivary glands potential sites sites – Neoplasm most likely to arise in the parotid – Neoplasm most likely to arise in the palate – Ex. – speckled leukoplakia of the floor of mouth Ex. speckled the likely likely to be a second primary lesion ! Clinical – Very well differentiated Very form of squamous cell carcinoma carcinoma – Large, elevated, papillary often associated associated with smokeless tobacco habit habit – Most common site is buccal Most vestibule vestibule – No tendency to metastasize Field Cancerization – Squamous Cell Carcinoma ! 32 ! Adenoid cystic carcinoma – Characteristic perineural invasion – most likely Characteristic most ! Parotid facial Parotid – facial nerve involvement but no upper lip paresthesia paresthesia 36 6 Physiologic Physiologic Pigmentation (Racial Pigmentation) Pigmentation) ! Lateral Periodontal Cyst Clinical ! – Darkens with time; present most of a person’s lifetime of person lifetime – African-American patients African- Clinical – True cyst (epithelial lining), True not pseudocyst not ! Radiographic appearance – Well circumscribed radioluceny between the Well roots of adjacent, erupted, vital teeth (most commonly commonly seen at mandibular premolars) – Radiographic differential diagnosis does NOT Radiographic include include dentigerous cyst (impacted tooth) Upper Upper or lower lip vermilion, attached gingiva, tongue, tongue, buccal mucosa ! Series of splotchy brown macules Series ! 37 38 Ameloblastic Fibroma Ameloblastoma ! Clinical – Average age is 34 – Most common in posterior Most mandible but anterior mandible also (can cross midline) (ca ! 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, Reverse columnar columnar cells of the periphery 39 Odontoma ! ! ! Clinical – – – – Radiographic – – – – ! ! Clinical primarily Clinical – primarily first two decades of life (young persons) persons) Radiographic – Radiopacity with radiolucent rim (= follicle) Compound vs. Complex types – Compound - identifiable toothlets Compound ! > Anterior maxilla – Complex – unidentifiable mass Complex ! > Posterior of jaws Posterior Young person More often in posterior jaws, esp. mandible Slight pain, swelling; not aggressive Ameloblastic fibro-odontoma fibro-odontoma is is similar except for odontoma component Radiographic – Pure lucency; no Pure radiopaque radiopaque component – AFO – also has radiopaque component (i.e., the AFO also odontoma) odontoma) 40 Adenomatoid Odontogenic Tumor Tumor (AOT) ! Clinical – Young person (child or teenager) ! Unerupted tooth of the anterior maxilla (#6, Unerupted #11) #11) ! Radiographic – Snow flake calcifications in the radiolucency Snow surrounding the crown and a portion of the impacted impacted tooth’s root Treatment simple Treatment – simple enucleation enucleation 41 42 7 Dentinogenesis Dentinogenesis Imperfecta Amelogenesis Imperfecta ! Clinical ! – Teeth lack enamel; Teeth – Dentin and cementum Dentin unaffected unaffected – Shapes of root and Shapes crown crown are normal ! Clinical – Opalescent dentin – blue/gray Opalescent – Often associated with osteogenesis Often imperfecta imperfecta Blue sclera Multiple bone fractures ! ! ! Radiographic – Enamel is missing – Pulp chambers and Pulp root canals normal 43 Radiographic – BWXs and PAs demonstrate classic BWXs lack lack of pulp chambers and root canals – Bell-shaped crown with constricted Bell-shaped cervical cervical region 44 Cherubism ! Fibrous Fibrous Dysplasia Radiographic – Multilocular, bilateral lucencies ! ! Clinical – Unilateral mandibular or maxillary expansion; onset mandibular before before puberty; C.C. of “teeth do not fit” – Painless swelling, usually ceases at age 20 Painless – Root canal therapy will not help since non-infectious canal therapy will not help since non infectious process process (i.e., fibro-osseous lesion) fibro– Café au lait pigmentation Café Clinical – Bilateral jaws – Young persons – Jaw expansion - - ceases after childhood Jaw ! Polyostotic Polyostotic form – McCune Albright syndrome ! Radiographic ! Treatment – Ground glass appearance – After age 20 when stabilized – Cosmetic bone shaving 45 46 Condensing Osteitis (Sclerosing Osteitis) ! Idiopathic Osteosclerosis Clinical – Associated with pulpitis (ex. very carious posterior Associated (ex. mandibular tooth); nonvital tooth – Associated tooth will test nonvital or signs and Associated or symptoms or tooth destruction will support nonvital status ! ! Clinical – No apparent reason including no pulpitis in adjacent No tooth tooth – No expansion, pain Radiographic ! – Periapical opacity so does opacity NOT mimic a periapical granuloma granuloma radiographically – Does not connect with root Radiographic – Radiopacity without Radiopacity peripheral peripheral lucent rim – Not connected to tooth’s Not root root ! 47 Treatment – None 48 8 Traumatic Traumatic Bone Cyst Paget’s Disease of Bone (Simple Bone Cyst; Idiopathic Bone Cavity; Unicameral Unicameral Cyst; Hemorrhagic Cyst) ! ! Clinical – Older age group – Bilateral maxilla affected – Involved bone can undergo malignant Involved (sarcomatous) (sarcomatous) transformation (i.e., osteosarcoma) – Cranial nerve deficits as foramen compressed, Cranial narrowed – Does NOT have hyperglobulinemia or premature Does exfoliation exfoliation of primary teeth – Undergoes spontaneous healing without Undergoes treatment treatment following exploratory surgery – Pseudocyst ! Clinical Radiographic – Radiolucent with scalloped margins ! Radiographic – Cotton wool appearance – 50% - hypercementosis 50% hypercementosis ! 49 Langerhans Langerhans Cell Disease (Histiocytosis (Histiocytosis X) ! Histology – Reversal lines with a mosaic pattern Benign Benign vs. Malignant Bone Involvement Clinical – Composed of Langerhans cells, Composed cells, not histiocytes – Etiology is still unknown is still unknown – Eosinophilic granuloma ! Solitary lesion, young adults ! ! ! ! ! Clinical – Ominous malignant sign ! – Hand-Schuller-Christian triad Hand-Schuller! 50 Spontaneous paresthesia of the lower lip Radiographic Benign Radiographic - Benign – Cortex remains intact – thinned or Cortex thinned expanded expanded Diabetes Diabetes insipidus Exophthalmos Bone lesions Radiographic Radiographic – Tooth “floating in air or space” 51 Central Neural Lesions ! ! 52 Nasolabial Cyst Neurofibroma Neurofibroma and Schwannoma Radiographic ! Clinical – Mucolabial, smooth swelling adjacent to a Mucolabial, smooth maxillary maxillary lateral incisor – Soft tissue involvement; not bone – Enlargement of canals and foramina of canals and foramina ! Histology – Pseudostratified squamous squamous epithelium cystic cystic lining 53 54 9 Odontogenic Keratocyst Lymphoepithelial Cyst ! ! – High recurrence! – Intrabony, posterior mandible Intrabony, but anywhere; BCNS association Clinical – Commonly on ventral tongue/floor of mouth – Well circumscribed swelling Well – Pale, yellowish at times Clinical ! Radiographic – Radiolucent, usually multilocular Radiolucent, usually – May mimic many other types of lucent cysts and odontogenic odontogenic tumors including ameloblastoma parakeratin 55 55 56 surface Nevoid Nevoid Basal Cell Carcinoma Syndrome (Gorlin (Gorlin syndrome; basal cell nevus syndrome) ! Clinical Clinical – Onset is childhood – Cysts of the jaws = Cysts odontogenic odontogenic keratocysts ! High Hi h recurrence rate – Basal cell carcinomas Basal ! Face especially – Bifid rib ! Radiographic – Keratocysts - unilocular or Keratocysts unilocular multilocular lucencies – Calcification of the falx cerebri 57 Gardner Syndrome Cheek Cheek Nibbling (Morsicatio (Morsicatio Buccarum) ! 58 ! Clinical – Multiple facial osteomas & Multiple skin nodules – Hyperdontia; unerupted teeth – Multiple GI (colon) polyps [familial intestinal Multiple polyposis] polyposis] - - - -> colon carcinoma Clinical – Buccal mucosa site – White, rough, tissue tags White, above above and below the occlusal occlusal plane (line alba) Other Other sites – lip and tongue 59 59 Odontoma Epidermoid cyst 60 60 10 Bell’s Palsy ! Temporomandibular Temporomandibular Dysfunction Dysfunction (TMD) Clinical – 7th nerve paralysis - - - -> unilateral lip nerve unilateral droop at corner, inability to close or wink eyelid eyelid – Last usually less than one month ! Clinical – Pain and tenderness of palpated TMJ – Deviation of jaw toward painful side upon opening Deviation – TMJ disc moves anterior and medially due to contraction of the TMJ lateral pterygoid muscle lateral pterygoid muscle – Popping and clicking indicate Popping internal derangement with reduction reduction – Does not cause dizziness Does – Reduce opening to ~ 45 mm – Will get neuritis of VII cranial nerve 61 Erythema Multiforme 62 Stevens-Johnson Stevens-Johnson syndrome (Erythema (Erythema Multiforme Major) ! Clinical – Young adult males – Sudden, explosive onset – Triggered by drug or viral Triggered by drug or viral infection infection – Crusted, bleeding, vesicles, Crusted, ulcers of vermilion of lips; intraoral intraoral sites excluding gingiva – “Target, iris, or bulls-eye lesions” bulls-eye of of the hands and feet •Eye (conjunctiva), mouth (labial mucosa, Eye tongue, tongue, etc.), genitalia 63 Pemphigus Vulgaris ! 64 Pemphigus Vulgaris Clinical/Lab Clinical/Lab – Vesiculoerosive (oral and skin) – Demonstrates immunoglobulin fluorescence Demonstrates intraepithelial (supraepithelial) cementing intraepithelial (supraepithelial) cementing substance ! Most often immunoglobulin type G (IgG) (IgG) – Positive Nikolsky sign Positive sign – Common sites – lips, palate, gingiva Common 65 66 11 Progressive Progressive Systemic Sclerosis (Scleroderma) (Scleroderma) ! Clinical – Demonstrates induration Demonstrates of of the soft tissue (mask-like) and (mask-like) generalized widening of the PDL space – Trismus 67 67 ! Benign Benign Migratory Glossitis (Geographic Tongue, Erythema Migrans) Migrans) Clinical Aspirin Burn (Chemical Burn) ! – Red and white Red ! ! 68 Clinical – White = coagulative necrosis of the surface, White of NOT NOT hyperkeratosis Red Red = flat, depapillated areas areas of tongue (filiform papillae papillae atrophied) White White = keratin, epithelial cell cell debris ! White White rubs off with difficulty, hyperkeratosis does not not wipe off – Periodically appears – Can cause soreness or burning Can occasionally occasionally – Treatment Treatment ! Corticosteroid rinse (dexamethasone) (dexamethasone) – Moves around from day to day – Dorsum of tongue most often ! Also lateral, ventral surfaces 69 70 Mucocele Basal Cell Carcinoma (mucus (mucus retention phenomenon, mucus extravastion extravastion phenomenon) ! Clinical – Clinical Painless Painless ulcer of upper lip, elsewhere on sunsun-exposed face (UV); raised margins ! Does NOT occur intraorally ! Begins as pearly papule; assoc. Begins telan telangiectasia ! Can be highly destructive if not treated ! Usually does not metastasize ! – – – – – – 71 Children and young adults Trauma Lower lip is most common site Vesicle/bulla, dome-shaped domeBluish often History of recurrence 72 12 Antral Antral Pseudocyst (Mucous Retention Retention Pseudocyst) Ranula Ranula (mucocele, mucus retention phenomenon, mucus extravastion phenomenon) 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 Microscopic ! Clinical – Asymptomatic – No treatment necessary Radiographic – Slight radiopaque, Slight radiopaque dome-shaped, dome-shaped, emanating from from floor of maxillary sinus MUCIN GW MSG 73 74 Ankyloglossia ! ! Dentigerous Cyst Congenital abnormality “tongue“tongue- tied” ! Clinical – – – – ! Most Most common site is posterior mandible Impacted third molars Unicystic ameloblastoma can arise from it it Malignant transformation of the lining is possible Histology – Epithelial lining - - - -> ameloblastoma, squamous Epithelial ameloblastoma, squamous cell carcinoma, mucoepideromoid carcinoma – Other impacted teeth besides 3rd molars 75 76 77 78 Dentigerous Cyst (cont’d) ! Radiographic – Pericoronal radiolucency attached at CEJ radiolucency of of unerupted tooth – Radiographic differential diagnoses Ameloblastoma Residual cyst ! Odontogenic keratocyst ! Odontogenic myxoma ! ! 13 Varices Varices Parulis (Gum Boil) Lingual and Lip ! Clinical ! – Dilated veins - blue Dilated – Seen typically in the elderly – Lip varices may thrombose and Lip subsequently calcify (i.e. phlebolith) – Incomplete root canal therapy with Incomplete intermittent intermittent sensitivity – Elevated reddish-yellow reddish-yellow ! Clinical Clinical evidence of a draining fistula 79 79 80 80 Tuberculosis ! Extravasated Blood Clinical – Incidence is increasing worldwide and in Incidence the the U.S. – Chest radiograph – May spread by infected sputum to oral lesions (e.g., ulcer mimicking cancer on the the tongue) ! Clinical Clinical – spontaneously resolve – Purpura – generalized term Purpura – Petechia- pinpoint bleeding Petechia– Ecchymosis – larger area of involvement Ecchymosis – Hematoma – large, elevated areas Hematoma large, 81 82 Allergic Allergic Mucositis ! Eagle Syndrome Clinical ! – Typically due to flavoring agents in Typically toothpastes, candies, and chewing gums (cinnamon flavoring is a common culprit) fl Clinical – Elongation and/or Elongation calcification of the stylohyoid ligament – Head and neck pain is Head elicited by chewing, yawning, opening mouth 83 84 84 14 Primary Herpes Gingivostomatitis Gingivostomatitis Herpes Zoster Clinical ! ! – Crop of vesicles - - - > ulcers with pain Crop – Striking unilateral distribution on skin and Striking oral ora ! Clinical – Inflamed, enlarged marginal gingiva; Inflamed, gingival gingival bleeding – Vesicles - - - -> ulcers throughout the Vesicles ulcers mouth mouth and lips with significant pain – Malaise – Low grade fever – Sore throat, lymphadenopathy ex. palate, ex. – palate, tongue 85 Primary Primary Herpes Gingivostomatitis Gingivostomatitis 86 Crohn’s Disease ! Clinical – Granulomatous gingivitis Granulomatous – Aphthous-like ulcers Aphthous– Rectal bleeding ! Intestinal Intestinal skip lesions of small intestine, and to a lesser degree, large intestine and other regions regions of the GI tract 87 Multiple Endocrine Neoplasia Syndrome, Type IIB (III) Dermoid Cyst ! Clinical ! – Slightly compressible (“doughy”) – Midline distribution usually ! 88 Clinical Clinical – Multiple mucosal neuromas (e.g., tongue) – Medullary thyroid carcinoma – Adrenal pheochromocytoma Example anterior Example - anterior floor of mouth 89 90 15 Incisive Incisive Canal Cyst (Nasopalatine (Nasopalatine Duct Cyst) ! White Sponge Nevus Clinical ! – Most common developmental Most nonnon-odontogenic cyst – Teeth vital; max. midline vital; max midline – True cyst (epithelial lining) – A genodermatosis genodermatosis ! 91 92 92 Cleft Palate Trigeminal Trigeminal Neuralgia Clinical ! Clinical – Age of onset typically > 35 years old; trigger points – Between lateral incisor Between and and canine ! Autosomal dominant – Often bilateral buccal Often mucosa; other mucosa – Moderately extensive Moderately thick, thick, white folds of tissue - No eye involvement Often heartheartshaped lucency ! Clinical Radiographic – Lucent line – Maxillary occlusal film Maxillary 93 94 Actinic Cheilitis Neuritis ! ! – Intense pain for one week duration – Unilateral ! Clinical – Lip’s vermilion becomes indistinct – Great potential for dysplasia to undergo Great malignant transformation into squamous cell carcinoma carcinoma Clinical At forehead and around eye ! 95 Therefore, a premalignant condition 96 16 Cheilitis Glandularis ! Post-Developmental Post-Developmental Loss of Tooth Structure Structure Clinical – Mucous minor salivary glands of lips are inflamed – Mucus secretions – Premalignant condition - - - - > squamous cell Premalignant squamous carcinoma carcinoma ! ! Attrition Attrition - physiological Abrasion Abrasion - pathological – Mechanical wear at Mechanical cervical region most typically cervical – Habits / occupations ! Erosion – Chemical loss of tooth structure Chemical exclusive of acidogenic theory of of caries ! Chlorinated pools – Gastric regurgitation and GERD 97 Post-Developmental Post-Developmental Loss of Tooth Structure Structure ! 98 Hiatal Hiatal hernia, bulimia Post-Developmental Post-Developmental Loss of Tooth Structure Structure Erosion Abrasion 99 100 Periapical Cemento-osseous Dysplasia Cemento-osseous (Periapical cemental dysplasia; periapical osseous dysplasia) dysplasia) Oral Hairy Leukoplakia ! ! Clinical – White, rough plaque on lateral border of tongue (#1 White, site) site) – Seen in HIV-positive individuals that are progressing HIV-positive to AIDS to AIDS – Caused by Epstein-Barr virus Epstein- Clinical – Middle-aged black women Middle– Mandibular anterior vital teeth – No pain or expansion - - asymptomatic No ! Radiographic – Diagnosed by characteristic findings by characteristic findings ! Multifocal periapical lucencies which mature over time; Multifocal become become mixed lucent/opaque and finally mainly opaque Time 101 102 17 Florid Cemento-osseous Dysplasia Cemento-osseous (florid (florid osseous dysplasia) ! Florid Osseous Dysplasia Clinical – – – – Multiquadrant FibroFibro-osseous intrabony lesion Hard Hard product produced is avascular so . . Most likely complication is secondary osteomyelitis Most likely complication is a secondary osteomyelitis ! Radiographic ! Treatment – Radiolucent and radiopaque Radiolucent – None necessary after dx None 103 104 Lichen Planus ! Lichen Planus Clinical – Skin and/or oral condition – Middle aged women most often – Skin ! Purple, Purple, polygonal, pruritic papules – Oral ! ! ! ! ! ! White White papules and coalescing papules = Wickam’s striae Does not wipe off any oral site 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 Ex. – dorsum of tongue – White plaques, individual papules and striae White Hyperplastic Hyperplastic form - - plaque-like plaque– Does not wipe off Reticular 105 Cutaneous Hyperplastic 106 Peripheral Ossifying Fibroma Erosive Lichen Planus ! Clinical – Soft tissue lesion, not in bone but makes Soft osteoid/bone – Occurs on gingiva, especially interdental papilla area – Product may be seen on dental radiographs as Product may be seen on dental radiographs as scattered scattered light opacities 107 108 18 Neurofibromatosis, Neurofibromatosis, type 1 (von Recklinghausen’s Recklinghausen’s disease of skin) Cleidocranial Dysplasia ! Clinical – – – – ! Multiple unerupted supernumerary teeth Retention of primary teeth Delayed Delayed eruption of permanent teeth Missing clavicles, frontal bossing, large head Clinical – Multiple neurofibromas (nodules) of the skin and Multiple oral oral cavity (especially tongue) – Café au lait pigmentation (abnormal macules or Café spots of the skin) ! Brown macules 109 110 Calcifying Calcifying Odontogenic Cyst (Gorlin (Gorlin Cyst) ! Histology – Ghost cells – Calcifications 111 112 Melanotic Melanotic Neuroectodermal Tumor Tumor of Infancy Nicotine Stomatitis ! ! Clinical – Hard palate – Red, inflamed minor salivary Red, gland ducts with background of of leukoplakic change – Tobacco use ! Pipe smokers – most often Pipe ! Cigarettes ! 113 113 Clinical – Rapid onset, destructive in newborns – Increase of vanillylmandelic acid (VMA) Increase (VMA) – Anterior maxilla, soft and Anterior hard hard tissue – Mobile teeth Radiographic – Intrabony, lucent, destructive Intrabony, – Malignant looking but Malignant benign benign usually 114 19 Auriculotemporal Auriculotemporal syndrome (Frey syndrome) syndrome) ! Aspiration Clinical – Often after parotid gland surgery – Sweating of unilateral facial skin just prior to eating – Does not affect cranial nerve VII (rather V) not affect cranial nerve VII (rather V) Always Always aspirate an anterior maxillary/mandibular radiolucency prior to to biopsy to rule out vascular nature ! Starch Iodine Test 115 116 Chronic Osteomyelitis Actinomycosis ! ! Radiographic – Often best seen in lateral oblique Often radiographic radiographic view – Radiolucent and radiodense Radiolucent Clinical – Soft tissue swelling (“woody consistency”) Soft with with multiple draining fistulas – “sulfur granules” = colonies of bacterial “sulfur organism organism PMNs 117 Condylar Hyperplasia ! 118 118 Dens-inDens-in-dente (dens invaginatus) Clinical ! – Irregular, elongated condyle – Chin deviates away from affected side upon Chin from closure closure 119 119 Clinical – Most often found in anterior jaw, especially Most maxillary maxillary lateral incisor 120 20 Periapical Cyst and Granuloma ! Dentin Dysplasia Clinical ! Clinical – Dentin abnormal with Dentin exposure exposure – Draining fistulas – Misshapen teeth – Nonvital tooth, at apex ! Radiographic – Periapical lucency with thin radiopaque line = Periapical reaction reaction to apical inflammatory disease ! Radiographic – Type 1 – “rootless” teeth Type – Periapical lucencies Periapical 121 (Hypohydrotic) Ectodermal Dysplasia Dysplasia ! ! 122 Epulis Fissuratum ! Exhibits hypodontia (anodontia) Hypohidrotic common Hypohidrotic - common type Clinical – Hyperplastic connective tissue like fibroma – Associated with ill-fitting denture flange ill– Treatment does NOT include antibiotic therapy – Lack of skin appendages and hair – Heat intolerance intolerance 123 Heavy Heavy Metal Systemic Intoxication Intoxication Gingival Cyst of the Adult ! 124 Clinical – Soft tissue – Facial attached gingiva ! Mandibular anterior most often – Elevated, fluid containing so a vesicle ! Clinical – Lead line ! 125 Blue line that parallels free marginal gingiva 126 21 Hemangioma Lymphangioma ! Clinical – Lymph-filled superficial vessels Lymph– Most common cause of macroglossia Clinical – Hamartoma – Red to blue elevated lesions – Blanches, compressible Histology – Collection of small or large vessels filled with red Collection blood blood cells ! ! 127 128 Hypercementosis ! Infectious Mononucleosis Clinical ! – Vital mandibular first molar – Generalized in acromegaly – Also seen, at times, in Paget’s ! Clinical – Cervical swelling, lateral – Sore throat – Teenagers most often – Positive monospot test – Epstein-Barr virus association Epstein-Barr Radiographic – Radiopacity with intact PDL – Attached to root surface palatal palatal petechiae Cementoblastoma 129 Internal Internal vs. External Tooth Resorption Resorption ! ! 130 Irradiation Therapy Clinical pink Clinical – pink tooth when crown involved with internal internal type Radiographic – Cannot tell difference early in the process – Round or ovoid radiolucency or ovoid radiolucency 131 ! Clinical Clinical – Causes cervical caries secondary to Causes inducement inducement of xerostomia – Does not result in pulp necrosis 132 22 Acquired Acquired Melanocytic Nevus (common (common mole’; ‘nevus’) ! Kaposi’s Sarcoma ! – Particular malig. seen in HIV positive Particular malig. seen individual individual that progress to AIDS – Etiology Clinical – Junctional type ! Clinical Most Most likely to undergo malignant transformation malignant transformation (i.e., (i.e., melanoma) ! Herpes virus type 8; not HIV EBV CMV HPV Herpes virus, type 8; not HIV, EBV, CMV, HPV – Intramucosal type ! ! Most common oral type Called intradermal type on skin – Compound type 133 Keratoacanthoma ! 134 Keratoacanthoma Clinical – Difficult to differentiate from squamous cell Difficult carcinoma carcinoma of the face and lip (and its histology) – Sun-exposed skin Sun– Present for many months; spontaneously resolve in Present ~ 4 months months – Keratin plug in the center of the ulceration 135 Xerostomia ! 136 Warthin’s tumor (papillary cystadenoma lymphomatosum) Clinical Clinical – Dry mouth (subjective) – Can result in retrograde infection of the Can salivary salivary glands; baldish, inflamed tongue 137 ! Clinical – Primary site overwhelmingly is parotid ! Not in oral cavity; >> males 138 23 Stafne Defect (salivary gland depression depression defect) Vitamin C Deficiency ! ! Clinical Clinical – – – – – Scurvy – Does NOT cause xerostomia Does NOT cause xerostomia ! Developmental Developmental More More in males Asymptomatic Asymptomatic Teeth vital Radiographic – Well demarcated lucency found near the angle of Well the mandible beneath the mandibular canal 139 140 Sarcoidosis Sj SjÖgren’s Syndrome ! ! – Bilateral hilar lymphadenopathy (chest x-ray) lymphadenopathy x– Cutaneous lesions - violaceous Cutaneous – Treatment – corticosteroids Treatment Clinical – – – – – Clinical Autoimmune disease; NOT infectious (e.g., herpes) Elderly women Dry eyes, dry mouth = sicca Parotid swelling Often Often other autoimmune diseases – lupus, rheumatoid arthritis 141 142 Proliferative Proliferative Periostitis (Garre’s) (Garre’s) ! PeutzPeutz-Jeghers Syndrome Clinical ! – Young person; swelling visible ! Clinical – Oral and Paraoral Oral Radiographic – Inferior border of posterior mandible is common site - Onion Inferior Onion skin skin pattern (radiographic appearance) ! Bands of radiopaque lines that parallel cortical surface 143 ! Pigmented Pigmented macules (brown) – Lips, tongue, buccal mucosa – Vermilion and skin of lip and skin of lip – Intestinal polyposis Intestinal 144 24 Osteosarcoma ! Clinical Osteoporosis – Swift onset of localized pain Swift and swelling; tingling lower lip – Onset in late 20s, early 30s Onset ! ! ! Most Most common primary malignancy of bone in persons less than 25 less than 25-years-old Clinical – Decrease in serum estrogen and Decrease calcium calcium – Older females Radiographic early Radiographic - early lucency then opacity; trabeculae trabeculae changes; PDL symmetrical widening 145 Osteopetrosis ! 146 Osteopetrosis Clinical – Massive overproduction of dense, nonvital bone of Massive both both jaws – Young persons or adults – Expansion Expansion – Frequent complication ! Secondary osteomyelitis 147 147 Osteoma ! Mandibular Mandibular Fracture Clinical ! 148 Radiographic – Most common site is angle of mandible ! Clinical – Often diagnosed with two radiographs – Well-circumscribed radiopacity circumscribed radiopacity ! 149 Panoramic and occlusal 150 25 Mandibular Mandibular Malignant Ominous Sign Sign ! Mandibular Torus Radiographic Radiographic ! Clinical – May be superimposed over periapical region May as as radiodensities – Spontaneous paresthesia of the lower lip 151 152 Multiple Myeloma Malignant Melanoma ! Clinical ! – Elderly males (high median age) – Most common oral sites ! Clinical ! Hard palate and gingiva Lab Findings – Bence-Jones proteinuria proteinuria – Immunoglobulin spike Immunoglobulin ! Radiographic – Multiple bone sites ! Calvaria, spine, pelvic girdle, jaws – Punched-out lucencies Punched153 Necrotizing Sialometaplasia ! 154 Cervical emphysema Clinical – Rapid onset – Deep ulceration of the palate (most common Deep site) after initial swelling; self-resolving it 155 ! Introduction Introduction of air into oral soft tissues with resulting sudden painless swelling and crepitance crepitance – Ex. – air/water syringe Ex. 156 26 Odontogenic Myxoma ! Miscellaneous Facts Clinical ! ! Radiographic – Closely resemble ameloblastoma resemble ameloblastoma ! Primordial Primordial cyst – forms in place of a tooth Enamel Enamel hypoplasia is a temporary suspension of amelogenesis Fusion one less than normal compliment of Fusion – one less than normal compliment of teeth; primary tooth of ant. mandible; separate root root canals Gemination Gemination – can be confused with fusion Pleomorphic Pleomorphic adenoma (benign mixed tumor) – most common salivary gland tumor ! – Young adult onset ! Multilocular lucency with soap bubble pattern ! ! 157 Miscellaneous Facts ! ! ! ! ! ! 158 Miscellaneous Facts (cont’d) The The parotid gland body is the most likely salivary body gland gland tissue to have a neoplasm Osteoradionecrosis major factor is damage to the major vascular vascular supply Prognosis best for sq cell ca of lower lip compared Prognosis best for sq cell ca of lower lip compared to osteosarcoma, melanoma, adenocarcinoma osteosarcoma, melanoma, Most Most common jaw metastasis site is posterior mandible mandible Onion Onion skin radiograph pattern is also seen in Ewing’s Ewing’s sarcoma Desquamative gingivitis includes pemphigoid, gingivitis pemphigoid, pemphigus and pemphigus and erosive lichen planus ! ! ! ! ! ! Autoimmune diseases more common in women Oncocytoma = parotid swelling (tumor) Gingival Gingival hyperplasia – drugs such as cyclosporine, drugs nifedipine (Procardia phenytoin (Dilantin nifedipine (Procardia®) phenytoin (Dilantin®) Malignant Malignant jaw lesions destroy the cortical plates of bone bone Gingival Gingival condition with no improvement after two months months should be biopsied Dysplasia Dysplasia – abnormal maturation of the epithelium of 159 160 Radiology Facts Epithelial Epithelial Dysplasia • X-ray has the shortest wavelength and the ray highest energy; high voltage has the same characteristics • When milliamperage is doubled the intensity of When milliamperage is doubled the intensity of an xan x-ray beam is doubled ! Kilovoltage (kVP) primarily controls contrast Kilovoltage and and is the penetrating characteristic of an x-ray x! X-ray penetration is determined by kVP ! Focal spot size primarily influences resolution 161 161 162 27 Radiology Facts (cont’d) Radiology Facts (cont’d) ! ! ! ! First First sign of damage from acute radiation exposure (4 Gy) is erythema Most Most radioresistant tissue is nerve and muscle cell; most sensitive is hematopoetic Basic 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 be as short as possible ! ! – – – – – – – 163 163 Radiology Facts (cont’d) ! ! ! ! Stunted roots Micrognathia Condylar hyperplasia Malocclusion 165 165 Radiology Facts (cont’d) ! ! ! ! ! ! ! ! ! Coin tests – Used for detection of light leakage Zygomatic Zygomatic process and base; intermaxillary suture Lingual Lingual foramen; incisive foramen; genial tubercles Mylohyoid ridge; nutrient canals Inverted Y of Ennis Maxillary sinus Tuberosity; hyoid bone; nose shadow (ant. periapical film) 164 Hard palate; tori; anterior nasal spine; stylohyoid ligament Radiology Facts (cont’d) Intensifying Intensifying screens are used to decrease exposure exposure time, reduce radiation exposure 8-bit digital image would have 256 shades of bit gray gray Complication of radiation treatment in children Com does does NOT include supernumerary teeth but does does include: – – – – The The density of processed film is not affected by overfixation overfixation but is affected by – Increase mA – Increase exposure time Increase – Decreased object-thickness distance object– Decreased target-object distance targetBest imaging film for viewing internal derangement of i fil the the TMJ (e.g., articular disc) is an MRI Identify Normal: Double Double the distance from the radiation source then the radiation becomes diminished by a factor factor of 4 (i.e., inverse square law) Latent Latent period = radiobiology time between exposure and biologic onset of symptoms; not exposure and biologic onset of symptoms; not cell cell exposure and free radical formation Radiograph Radiograph is rinsed with water to accomplish getting rid of chemicals (not remove emulsion, diminish diminish silver particles, remove latent image) Artifact – Bitewing radiograph with a curved dark line through Bitewing contact points of adjacent crowns = a break in the166 emulsion emulsion from film bending Radiology Facts (cont’d) A light radiograph is NOT caused by a long light process process time An An MRI is narrow frequency radiation of the electromagnetic electromagnetic spectrum The filter in a dental x-ray machine is made of filter in dental ray machine is made of aluminum aluminum A charged coupled device (CCD) converts xxrays rays to electrical signals but does NOT result in the same average absorbed dose as conventional conventional radiology (less absorbed dose) Effective Effective dose =comparison of the radiation risk in humans from different radiographic exams exams and doses/sources 167 ! ! ! ! Collimating an x-ray beam results in an x-ray xincrease increase of the penetration of x-ray photons Radon Radon is the greatest source of background radiation on earth ea Basic components of an x-ray cathode ray x-ray tube consists of a filament and a focusing cup cup To 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 mAs 168 28 Radiology Facts (cont’d) ! ! ! ! ! Panoramic Panoramic radiograph with one second of movement by patient results in wavy inferior border of the mandible and unsharp image vertically across the the image at that site Major biologic damage from ionizing radiation is Ma primarily due to radiolysis of the water molecules Electrons Electrons flow from cathode to anode with the energy 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 Penumbra – the geometric unsharpness with a fuzzy area surrounding the contours of of the teeth and osseous tissues An An intensifying screen is used with external radiographs to decrease the radiation exposure exposure The oil unit of an x-ray tube housing x-ray functions functions to dissipate heat from the target 170 29 ...
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