Systemic Lupus Erythematosus

Oral and Maxillofacial Pathology Review for NBDE Part 2

2010

Clinical
Autoimmune Young adult females Butterfly rash of face
Sun exposure worsens it

Michael A. Kahn, DDS Professor and Chairman Department of Oral and Maxillofacial Pathology Tufts University School of Dental Medicine
1

Systemic involvement complications

Heart endocarditis Kidney renal glomeruli (glomerulonephritis)
2

Cavernous sinus thrombosis

Can arise from an infection - - a subcutaneous abscess of the upper lip or a intrabony abscess of an anterior maxillary tooth t th
Valveless facial veins

Ludwigs angina
Submandibular space infection Most serious complication is edema of the glottis

Ludwig's angina - submandibular space infection --> most serious complication is edema of the glottis

Treacher Collins Syndrome

Has external ear changes

Scarlet fever
White coating of the tongue that sloughs off leaving a deep red surface with swollen hyperplastic fungiform papillae (strawberry tongue) tongue )

strawberry tongue - scarlet fever

Fordyce granules
Ectopic sebaceous glands yellow papules/plaques

Turner tooth
Due to local trauma or infection associated with the developing tooth bud

Turner tooth - due to trauma or infection to primary tooth - causes defect in perm tooth

Intrinsic tooth stain

Tetracycline deposition within the dentin

Recurrent Aphthous Stomatitis

Clinical

Moveable mucosa

Ex. Uvula, labial mucosa

Recurrent NOT PRECEDED BY VESICLE Associated with certain HLA types

NOT caused by a virus, bacteria, fungus Corticosteroids are often prescribed Many small

Treatment

Herpetiform type Minor and major types

Very painful Size, depth, time to heal (minor 55-10 days) Minor small, shallow ulcer with red halo
10

Benign Mucous Membrane Pemphigoid (cicatricial) Clinical

Autoimmune
Antibody reaction at the epithelialepithelial -connective tissue interface (BMZ) Subepithelial split

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

Vesiculoerosive, l ulcers l > women - middle aged Skin and eye Oral
Any site: gingiva, soft palate, etc. Ulcers, erosions following vesicles, bulla

Histology
Subepithelial separation at basement membrane zone
11 12

Candidiasis pseudomembranous
Clinical
Opportunistic infection (yeast)
Immature or deficient immune system Antibiotics usage C ti t id usage Corticosteroids

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

Hyphae and spores

May be diagnosed by cytology smear

White, wipeable patch with red, underling base; palate and buccal mucosa are often involved Thrush
Newborns and infants

Denture sore mouth

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

13

14

Recurrent (Secondary) Herpes Simplex

Clinical
U.S. incidence estimate of herpes infection is 808085%
Most M t cases are subclinical b li i l Reactivation from nerve cells of trigeminal ganglion

Recurrent (Secondary) Herpes Simplex

Lip
Skin or vermilion Vesicle ruptures - - -> ulcer that heals in 77-10 days (not present for weeks or months if immunocompetent person)
15 16

Recurrent Herpes Simplex Infection Clinical

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

Traumatic Neuroma
Clinical
Wandering transected nerve with scar tissue Painful or tender, firm lump or nodule Oral site
O Occurs at t sites it of f chronic h i trauma t Ex. mandibular alveolar ridge in denture wearer, especially near mental nerve, denture flange trauma Ex. tongue

17

18

Pyogenic Granuloma
Clinical
Occur at any age Any location but usually on gingiva Most common is interdental papilla Local reactive growth Irritation Bleeds readily Exophytic Not painful Grows very fast like malignancies Proliferative

Peripheral Giant Cell Granuloma

Clinical
Somewhat similar in appearance to pyogenic granuloma Moderate soft mass Often liverliver-colored [brownish purple] Distinctive histology
Multinucleated giant cells

Limited to alveolar ridge/ gingiva

Usually anterior to first molar region
19 20

Central Giant Cell Granuloma

Clinical
Intrabony Same histology as:
Peripheral giant cell granuloma Brown tumor of hyperpara hyperparathyroidism
No effect on saliva production Bone destruction secondary to chronic renal disease
21

Squamous Papilloma (Papilloma)

Clinical
Etiology - epithelium White to white white-pink usually but can be reddened Rough surface (cauliflower) Elevated lesion (papule, nodule) Common sites
Facial or lingual gingiva Soft or hard palate Tongue

More frequent than some other omas

Rhabdomyoma Leiomyoma Lymphangioma Neurofibroma

22

Fibroma

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

Granular Cell Tumor

Clinical
Most common connective tissue tumor Reactive, Reactive not true tumor Hyperplasia; NOT neoplasia, anaplasia, dysplasia, etc. Firm, smooth, pink, elevated papule/nodule Common site is tongue (due to trauma)
23

Clinical
Dorsum of tongue #1 site Nodule with smooth or papillated surface Histology distinct
Granular cells - cytoplasm 50% of time exhibit pseudoepitheliomatous hyperplasia
Resembles squamous cell carcinoma histologically
24

Leukoplakia

Erythroplakia and Erythroleukoplakia (speckled) Clinical

Red plaque that does not wipe off Studies show that it is likely to have severe dysplasia or worse and undergo malignant transformation to carcinoma Treatment
Initial incisional biopsy

Clinical
White patch that does not wipe off Cytology smear does not help determine specific diagnosis Appropriately managed by biopsy Floor of mouth hyperkeratosis most common site to exhibit dysplasia If two separate areas in persons 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

MidMid -lateral border of tongue

Least likely oral site

Hard palate

Site with greatest likelihood or risk of developing squamous cell carcinoma

Floor of mouth worse prognosis when lung mets (not size, local spread or anaplastic cells)

Metastasis
Most likely to a lymph node

27

28

Squamous Cell Carcinoma

Staging vs. Grading
Stage III has a worse prognosis than I or II

Metastatic Disease to the Jaws

Clinical and Radiographic
Most common site is posterior mandible Does not cause a shift of patients occlusion Usually a poorly defined lucency without sclerotic border

Radiographic
When invasive into the alveolar ridge it will appear poorly defined lucencies without a reactive sclerotic border

29

30

Monomorphic Adenoma (Canalicular Adenoma)

Clinical
Most common site
Upper lip > Women W May be multinodular Asymptomatic Do not confuse with mucocele of the lower lip
31

Leukoedema
Clinical
Intracellular edema of cells More often seen in AfricanAfrican-Americans Common, bilateral on buccal mucosa Diagnostic test chairside
Pull on buccal mucosa - - - -> disappears or dissipates

Normal mucosa variation so no treatment required

32

Leukemia
Clinical/Lab
Red, swollen (hyperplastic), boggy, bleeding gingiva (interdental papilla) with ulcers Lab tests ordered Complete blood count White blood count differential Decreased neutrophils Leukemic infiltrate leaves blood and into soft tissue (esp. acute monocytic type) Red macules on skin ( (purpura purpura = extravasated blood) & skin infections Decreased platelets Tired feeling (malaise) Anemia (decreased RBCs) RBCs)

Verrucous Carcinoma
Clinical
Very well differentiated form of squamous cell carcinoma Large, elevated, papillary often associated with smokeless tobacco habit Most common site is buccal vestibule No tendency to metastasize
33

Chief difference from typical squamous cell carcinoma

34

Field Cancerization Squamous Cell Carcinoma

Patient diagnosed and treated for squamous cell carcinoma of the tongue Much more likely y to have future p premalignant g or malignant lesions anywhere in the oral cavity
Ex. speckled leukoplakia of the floor of mouth likely to be a second primary lesion

Salivary Gland Tumors

Most common tumor of salivary gland origin is the pleomorphic adenoma
Benign Most common intraoral site is p palate

Major and minor salivary glands potential sites

Neoplasm most likely to arise in the parotid Neoplasm most likely to arise in the palate

p53 tumor suppressor gene is most common associated

35

Adenoid cystic carcinoma

Characteristic perineural invasion most likely
Parotid facial nerve involvement but no upper lip paresthesia
36

Physiologic Pigmentation (Racial Pigmentation) Clinical

Darkens with time; present most of a persons person s lifetime African African-American patients
Upper or lower lip vermilion, attached gingiva, tongue, buccal mucosa Series of splotchy brown macules

Lateral Periodontal Cyst

Clinical
True cyst (epithelial lining), not p pseudocyst y

Radiographic appearance
Well circumscribed radioluceny between the roots of adjacent, erupted, vital teeth (most commonly seen at mandibular premolars) Radiographic differential diagnosis does NOT include dentigerous cyst (impacted tooth)
37 38

Ameloblastoma
Clinical
Average age is 34 Most common in posterior mandible but anterior mandible also a so (can (ca cross c oss midline) d e)

Ameloblastic Fibroma

Clinical

Radiographic
Most common true odontogenic tumor Multilocular radiolucency Superimposed over posterior teeth (> mand.) Often associated with impacted tooth
39

Radiographic

Young person More often in posterior jaws, esp. mandible Slight g pain, p , swelling; g; not aggressive gg Ameloblastic fibro fibro-odontoma is similar except for odontoma component

Histology
Reverse polarization of the nuclei of the tall, columnar cells of the periphery

Pure lucency; no radiopaque component AFO also has radiopaque component (i.e., the odontoma) 40

Odontoma
Clinical primarily first two decades of life (young persons) Radiographic Radiopacity with radiolucent rim (= follicle) Compound vs. Complex types Compound - identifiable toothlets > Anterior maxilla Complex unidentifiable mass > Posterior of jaws

Adenomatoid Odontogenic Tumor (AOT)

Clinical
Young person (child or teenager) Unerupted tooth of the anterior maxilla (#6, #11) Snow flake calcifications in the radiolucency surrounding the crown and a portion of the impacted tooths root

Radiographic

Treatment simple enucleation

41 42

Amelogenesis Imperfecta
Clinical
Teeth lack enamel; Dentin and cementum unaffected Shapes of root and crown are normal

Dentinogenesis Imperfecta

Clinical
Opalescent dentin blue/gray Often associated with osteogenesis imperfecta
Blue sclera Multiple bone fractures

Radiographic
Enamel is missing Pulp chambers and root canals normal
43

Radiographic
BWXs and PAs demonstrate classic lack of pulp chambers and root canals Bell Bell-shaped crown with constricted cervical region

44

Cherubism
Radiographic
Multilocular, bilateral lucencies

Fibrous Dysplasia
Clinical
Unilateral mandibular or maxillary expansion; onset before puberty; C.C. of teeth do not fit Painless swelling, usually ceases at age 20 Root canal therapy will not help since nonnon-infectious process (i.e., fibro fibro-osseous lesion) Caf au lait pigmentation
Polyostotic form McCune Albright syndrome

Clinical
Bilateral jaws Young persons Jaw expansion - - ceases after childhood

Radiographic
Ground glass appearance

Treatment
45

After age 20 when stabilized Cosmetic bone shaving

46

Condensing Osteitis
(Sclerosing Osteitis) Clinical
Associated with pulpitis (ex. very carious posterior mandibular tooth); nonvital tooth Associated tooth will test nonvital or signs and symptoms or tooth destruction will support nonvital status

Idiopathic Osteosclerosis
Clinical
No apparent reason including no pulpitis in adjacent tooth No expansion, p , pain p

Radiographic
Periapical opacity so does NOT mimic a periapical granuloma radiographically Does not connect with root

Radiographic
Radiopacity without peripheral lucent rim Not connected to tooths root

Treatment
47

None

48

Traumatic Bone Cyst

elevated level of alkaline phosphatase

jaw fractures, osteomylitis due to bone sclerosis

Pagets Disease of Bone
Clinical
Older age group Bilateral maxilla affected Involved bone can undergo malignant (sarcomatous) transformation (i.e., osteosarcoma) Cranial nerve deficits as foramen compressed, narrowed d Does NOT have hyperglobulinemia or premature exfoliation of primary teeth

Clinical

(Simple Bone Cyst; Idiopathic Bone Cavity; Unicameral Cyst; Hemorrhagic Cyst)

Undergoes spontaneous healing without treatment following exploratory surgery Pseudocyst

Radiographic
Radiolucent with scalloped margins

Radiographic
Cotton wool appearance 50% - hypercementosis

Histology
49

Reversal lines with a mosaic pattern

50

punched lesions/ lucencies around teeth

Langerhans Cell Disease (Histiocytosis X)
Clinical
Composed of Langerhans cells, not histiocytes Etiology is still unknown Eosinophilic granuloma
Solitary lesion, young adults

Benign vs. Malignant Bone Involvement Clinical

Ominous malignant sign
Spontaneous paresthesia of the lower lip

Hand Hand-Schuller Schuller-Christian triad

Diabetes insipidus Exophthalmos Bone lesions

Radiographic - Benign
Cortex remains intact thinned or expanded

Radiographic
Tooth floating in air or space
51 52

Central Neural Lesions

Neurofibroma and Schwannoma Radiographic
Enlargement of canals and foramina

Nasolabial Cyst
Clinical
Mucolabial Mucolabial, , smooth swelling adjacent to a maxillary lateral incisor Soft tissue involvement; not bone

Histology
Pseudostratified squamous epithelium cystic lining
53 54

counterpart of branchial cyst of the neck

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

primordial cyst, associated with impacted tooth

Odontogenic Keratocyst
Clinical
High recurrence! Intrabony, posterior mandible but anywhere; BCNS association Radiolucent, usually multilocular May M mimic i i many other h types of lucent cysts and odontogenic tumors including ameloblastoma

Radiographic

parakeratin
55

surface

56

bifid rib
Nevoid Basal Cell Carcinoma Syndrome (Gorlin syndrome; basal cell nevus syndrome)

multiple OKCs

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

Cheek Nibbling (Morsicatio Buccarum)

Clinical Buccal mucosa site White, rough, tissue tags above and below the occlusal plane (line alba) Other sites lip and tongue

Gardner Syndrome
Clinical
Multiple facial osteomas & skin nodules Hyperdontia; unerupted teeth Multiple GI (colon) polyps [familial intestinal polyposis] - - - -> colon carcinoma

59

Odontoma

Epidermoid cyst

60

10

Bells Palsy
Clinical
7th nerve paralysis - - - -> unilateral lip droop at corner, inability to close or wink eyelid Last usually less than one month

Temporomandibular Dysfunction (TMD)

Clinical
Pain and tenderness of palpated TMJ Deviation of jaw toward painful side upon opening TMJ disc moves anterior and medially due to contraction of the lateral pterygoid muscle Popping and clicking indicate internal derangement with reduction Does not cause dizziness Reduce opening to ~ 45 mm Will get neuritis of VII cranial nerve
61 62

Erythema Multiforme
Clinical
Young adult males Sudden, explosive onset Triggered by drug or viral infection Crusted, bleeding, vesicles, ulcers of vermilion of lips; intraoral sites excluding gingiva Target, iris, or bulls bulls-eye lesions of the hands and feet
63

StevensStevens -Johnson syndrome

(Erythema Multiforme Major)

Eye (conjunctiva), mouth (labial mucosa, tongue, etc.), genitalia

64

Pemphigus Vulgaris
Clinical/Lab Vesiculoerosive (oral and skin) Demonstrates immunoglobulin fluorescence intraepithelial ( (supraepithelial supraepithelial) ) cementing substance
Most often immunoglobulin type G (IgG (IgG) )

Pemphigus Vulgaris

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) Clinical

Red and white
Red = flat, depapillated areas of tongue (filiform papillae atrophied) White = keratin, epithelial cell debris

Aspirin Burn (Chemical Burn)

Clinical
White = coagulative necrosis of the surface, NOT hyperkeratosis
White rubs off with difficulty, hyperkeratosis does not wipe off

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

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

Mucocele

(mucus retention phenomenon, mucus extravastion phenomenon) Clinical

Children and young adults Trauma Lower lip is most common site Vesicle/bulla, dome dome-shaped Bluish often History of recurrence

71

72

12

phenomenon, mucus extravastion phenomenon)

Ranula (mucocele, mucus retention

Antral Pseudocyst (Mucous Retention Pseudocyst)

Clinical Asymptomatic No treatment necessary Radiographic Slight radiopaque, radiopaque domedome -shaped, emanating from floor of maxillary sinus

Clinical
Floor of mouth swelling
Looks like a frogs belly (Gk ranu = frog) Bluish usually; history of recurrence several times Mucin will yield viscous aspirate Microscopic histiocytes visible in mucin
MUCIN GW MSG
73

74

Ankyloglossia
Congenital abnormality tonguetongue - tied

Dentigerous Cyst
Clinical
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 (contd)

Radiographic
Pericoronal radiolucency attached at CEJ of unerupted tooth Radiographic differential diagnoses
Ameloblastoma Residual cyst Odontogenic keratocyst Odontogenic myxoma
77 78

13

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

Parulis (Gum Boil)

Clinical
Incomplete root canal therapy with intermittent sensitivity Elevated reddishreddish-yellow
Clinical evidence of a draining fistula

79

80

Tuberculosis
Clinical
Incidence is increasing worldwide and in the U.S. Chest radiograph May M spread d by b infected i f t d sputum t to t oral l lesions (e.g., ulcer mimicking cancer on the tongue)

Extravasated Blood
Clinical spontaneously resolve
Purpura generalized term Petechia Petechia- pinpoint bleeding Ecchymosis larger area of involvement Hematoma large, elevated areas

81

82

Allergic Mucositis
Clinical
Typically due to flavoring agents in toothpastes, candies, and chewing gums (cinnamon ( i flavoring fl i is i a common culprit) l it)

Eagle Syndrome
Clinical
Elongation and/or calcification of the stylohyoid ligament Head and neck pain is elicited by chewing, yawning, opening mouth
83 84

14

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

Primary Herpes Gingivostomatitis

Clinical
Inflamed, enlarged marginal gingiva; gingival bleeding Vesicles - - - -> ulcers throughout the mouth and lips with significant pain Malaise Low grade fever Sore throat, lymphadenopathy
85 86

Primary Herpes Gingivostomatitis

Crohns Disease
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

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

Multiple Endocrine Neoplasia Syndrome, Type IIB (III) Clinical

Multiple mucosal neuromas (e.g., tongue) Medullary y thyroid y carcinoma Adrenal pheochromocytoma

89

90

15

Incisive Canal Cyst (Nasopalatine Duct Cyst)

Clinical
Most common developmental nonnon -odontogenic cyst Teeth vital; max. max midline True cyst (epithelial lining)

White Sponge Nevus

Clinical
A genodermatosis
Autosomal dominant

Often bilateral buccal mucosa; other mucosa Moderately extensive thick, white folds of tissue - No eye involvement Often heartheartshaped lucency

91

92

Cleft Palate
Clinical
Between lateral incisor and canine

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

Radiographic
Lucent line Maxillary occlusal film

93

94

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

Actinic Cheilitis
Clinical
Lips vermilion becomes indistinct Great potential for dysplasia to undergo malignant transformation into squamous cell carcinoma
Therefore, a premalignant condition

95

96

16

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

Post-Developmental Loss of Tooth PostStructure

Attrition - physiological Abrasion - pathological
Mechanical wear at 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

Hiatal hernia, bulimia

98

Post-Developmental Loss of Tooth PostStructure

Post-Developmental Loss of Tooth PostStructure

Abrasion

Erosion

99

100

Periapical Cemento Cemento-osseous Dysplasia

Oral Hairy Leukoplakia

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

(Periapical cemental dysplasia; periapical osseous dysplasia)

Clinical
MiddleMiddle-aged black women Mandibular anterior vital teeth No pain or expansion - - asymptomatic

Radiographic
Diagnosed by characteristic findings Multifocal periapical lucencies which mature over time; become mixed lucent/opaque and finally mainly opaque

Time

101

102

17

Florid CementoCemento-osseous Dysplasia (florid osseous dysplasia)

Clinical
Multiquadrant FibroFibro -osseous intrabony lesion Hard product produced is avascular so . . Most likely complication is a secondary osteomyelitis

Florid Osseous Dysplasia

Radiographic
Radiolucent and radiopaque

Treatment
None necessary after dx

103

104

Lichen Planus
Clinical
Skin and/or oral condition Middle aged women most often Skin
Purple, polygonal, pruritic papules

Lichen Planus

Oral
White papules and coalescing papules = Wickams striae Does not wipe off any oral site Reticular form; often asymptomatic Erosive form On tongue may be mistaken for geographic tongue Sensitive, painful Most common site Buccal mucosa Ex. dorsum of tongue White plaques, individual papules and striae Hyperplastic form - - plaque plaque-like Does not wipe off

Reticular

105

Cutaneous

Hyperplastic

106

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

Neurofibromatosis, type 1 (von Recklinghausens disease of skin)

Clinical
Multiple neurofibromas (nodules) of the skin and oral cavity (especially tongue) Caf au lait pigmentation (abnormal macules or spots p of the skin) )
Brown macules

109

110

Calcifying Odontogenic Cyst (Gorlin Cyst)

Histology
Ghost cells Calcifications

111

112

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

Melanotic Neuroectodermal Tumor of Infancy

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

113

114

19

Auriculotemporal syndrome (Frey syndrome) Clinical

Often after parotid gland surgery Sweating of unilateral facial skin just prior to eating Does not affect cranial nerve VII (rather V)

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

Starch Iodine Test

115 116

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

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

117

118

Condylar Hyperplasia
Clinical
Irregular, elongated condyle Chin deviates away y from affected side upon p closure

DensDens -in in-dente (dens invaginatus) Clinical

Most often found in anterior jaw, especially maxillary lateral incisor

119

120

20

Periapical Cyst and Granuloma

Clinical
Nonvital tooth, at apex

Dentin Dysplasia
Clinical
Dentin abnormal with exposure Draining fistulas Misshapen teeth

Radiographic
Periapical lucency with thin radiopaque line = reaction to apical inflammatory disease

Radiographic
Type 1 rootless teeth
Periapical lucencies

121

122

(Hypohydrotic) Ectodermal Dysplasia

Exhibits hypodontia (anodontia) Hypohidrotic - common type
Lack of skin appendages and hair Heat intolerance

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

123

124

Gingival Cyst of the Adult

Clinical
Soft tissue Facial attached gingiva Mandibular anterior most often Elevated, fluid containing so a vesicle

Heavy Metal Systemic Intoxication

Clinical
Lead line
Blue line that parallels free marginal gingiva

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 blood cells

127

128

Hypercementosis
Clinical
Vital mandibular first molar Generalized in acromegaly Also seen, at times, in Pagets

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

Radiographic
Radiopacity with intact PDL Attached to root surface

palatal petechiae
Cementoblastoma
129 130

Internal vs. External Tooth Resorption

Clinical pink tooth when crown involved with internal type Radiographic
Cannot tell difference early in the process Round or ovoid radiolucency

Irradiation Therapy
Clinical
Causes cervical caries secondary to inducement of xerostomia Does D not t result lt i in pulp l necrosis i

131

132

22

Acquired Melanocytic Nevus (common mole; nevus)

Clinical
Junctional type
Most likely to undergo malignant transformation (i.e., melanoma)

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

Intramucosal type
Most common oral type Called intradermal type on skin

Compound type
133 134

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

Keratoacanthoma

135

136

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

Warthins tumor
(papillary cystadenoma lymphomatosum)

Clinical
Primary site overwhelmingly is parotid
Not in oral cavity; y; >> males

137

138

23

Vitamin C Deficiency
Clinical
Scurvy Does NOT cause xerostomia

Stafne Defect (salivary gland depression defect)

Clinical
Developmental More in males Asymptomatic Teeth vital

Radiographic
Well demarcated lucency found near the angle of the mandible beneath the mandibular canal
139 140

Sjgrens Syndrome
Clinical
Autoimmune disease; NOT infectious (e.g., herpes) Elderly women Dry eyes, dry mouth = sicca Parotid P tid swelling lli Often other autoimmune diseases lupus, rheumatoid arthritis

Sarcoidosis
Clinical
Bilateral hilar lymphadenopathy (chest xx-ray) Cutaneous lesions - violaceous Treatment corticosteroids

141

142

Proliferative Periostitis (Garres)

Clinical
Young person; swelling visible

PeutzPeutz -Jeghers Syndrome

Clinical
Oral and Paraoral
Pigmented macules (brown)
Lips, tongue, buccal mucosa Vermilion and skin of lip

Radiographic
Inferior border of posterior mandible is common site - Onion skin pattern (radiographic appearance) Bands of radiopaque lines that parallel cortical surface

Intestinal polyposis

143

144

24

Osteosarcoma
Clinical
Swift onset of localized pain and swelling; tingling lower lip Onset in late 20s, early 30s
Most common primary malignancy of bone in persons less than 2525-years years-old

Osteoporosis
Clinical
Decrease in serum estrogen and calcium Older females

Radiographic - early lucency then opacity; trabeculae changes; PDL symmetrical widening

145

146

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

Osteopetrosis

147

148

Osteoma
Clinical
Most common site is angle of mandible

Mandibular Fracture
Clinical
Often diagnosed with two radiographs
Panoramic and occlusal

Radiographic
Well Well-circumscribed radiopacity

149

150

25

Mandibular Malignant Ominous Sign

Clinical
Spontaneous paresthesia of the lower lip

Mandibular Torus
Radiographic
May be superimposed over periapical region as radiodensities

151

152

Malignant Melanoma
Clinical
Most common oral sites
Hard palate and gingiva

Multiple Myeloma
Clinical
Elderly males (high median age)

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
Clinical
Rapid onset Deep ulceration of the palate (most common site) it ) after ft i initial iti l swelling; lli self selflf-resolving l i

Cervical emphysema
Introduction of air into oral soft tissues with resulting sudden painless swelling and crepitance
Ex. air/water syringe

155

156

26

Odontogenic Myxoma
Clinical
Young adult onset

Miscellaneous Facts
Primordial cyst forms in place of a tooth Enamel hypoplasia is a temporary suspension of amelogenesis Fusion one less than normal compliment of teeth; primary tooth of ant. mandible; separate root canals Gemination can be confused with fusion Pleomorphic adenoma (benign mixed tumor) most common salivary gland tumor
158

Radiographic
Closely resemble ameloblastoma
Multilocular lucency with soap bubble pattern

157

Miscellaneous Facts
The parotid gland body is the most likely salivary gland tissue to have a neoplasm Osteoradionecrosis major factor is damage to the vascular supply Prognosis best for sq cell ca of lower lip compared to osteosarcoma, osteosarcoma, melanoma, adenocarcinoma Most common jaw metastasis site is posterior mandible Onion skin radiograph pattern is also seen in Ewings sarcoma Desquamative gingivitis includes pemphigoid, pemphigoid, pemphigus and erosive lichen planus
159

Miscellaneous Facts (contd)

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

Epithelial Dysplasia

Radiology Facts
X-ray has the shortest wavelength and the highest energy; high voltage has the same characteristics When milliamperage is doubled the intensity of an xx-ray beam is doubled Kilovoltage (kVP) primarily controls contrast and is the penetrating characteristic of an x x-ray X-ray penetration is determined by kVP Focal spot size primarily influences resolution
161 162

27

Radiology Facts (contd)

First sign of damage from acute radiation exposure (4 Gy) is erythema Most radioresistant tissue is nerve and muscle cell; most sensitive is hematopoetic Basic shadow casting principle with the paralleling technique does not fulfill the physics requirement of the distance from the object to the recording surface should be as short as possible
163

Radiology Facts (contd)

The density of processed film is not affected by overfixation but is affected by Increase mA Increase exposure time Decreased objectobject-thickness distance Decreased targettarget-object distance B Best i imaging i film fil for f viewing i i internal i l derangement d of f the TMJ (e.g., articular disc) is an MRI Identify Normal:
Zygomatic process and base; intermaxillary suture Lingual foramen; incisive foramen; genial tubercles Mylohyoid ridge; nutrient canals Inverted Y of Ennis Maxillary sinus Tuberosity; hyoid bone; nose shadow (ant. periapical film) 164 Hard palate; tori; anterior nasal spine; stylohyoid ligament

Radiology Facts (contd)

Intensifying screens are used to decrease exposure time, reduce radiation exposure 8-bit digital image would have 256 shades of gray Complication p of radiation treatment in children does NOT include supernumerary teeth but does include:
Stunted roots Micrognathia Condylar hyperplasia Malocclusion
165

Radiology Facts (contd)

Double the distance from the radiation source then the radiation becomes diminished by a factor of 4 (i.e., inverse square law) Latent period = radiobiology time between exposure and biologic onset of symptoms; not cell exposure and free radical formation Radiograph is rinsed with water to accomplish getting rid of chemicals (not remove emulsion, diminish silver particles, remove latent image) Artifact
Bitewing radiograph with a curved dark line through contact points of adjacent crowns = a break in the166 emulsion from film bending

Coin tests
Used for detection of light leakage

Radiology Facts (contd)

A light radiograph is NOT caused by a long process time An MRI is narrow frequency radiation of the electromagnetic spectrum The filter in a dental x x-ray machine is made of aluminum A charged coupled device (CCD) converts xxrays to electrical signals but does NOT result in the same average absorbed dose as conventional radiology (less absorbed dose) Effective dose =comparison of the radiation risk in humans from different radiographic exams and doses/sources
167

Radiology Facts (contd)

Collimating an xx-ray beam results in an x-ray photons increase of the penetration of xRadon is the greatest source of background radiation ad at o o on ea earth t Basic components of an xx-ray cathode ray tube consists of a filament and a focusing cup To change from long scale intensity (low contrast) to short scale intensity (high contrast) but maintain image density, the operator should decrease kVp and increase mAs

168

28

Radiology Facts (contd)

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 (contd)

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 xx-ray tube housing functions to dissipate heat from the target
170

29