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
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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
Scarlet fever
White coating of the tongue that sloughs off leaving a deep red surface with swollen hyperplastic fungiform papillae (strawberry tongue) tongue )
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
Clinical
Moveable mucosa
Treatment
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
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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
White, wipeable patch with red, underling base; palate and buccal mucosa are often involved Thrush
Newborns and infants
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Lip
Skin or vermilion Vesicle ruptures - - -> ulcer that heals in 77-10 days (not present for weeks or months if immunocompetent person)
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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
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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
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Fibroma
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)
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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
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Leukoplakia
Clinical
White patch that does not wipe off Cytology smear does not help determine specific diagnosis Appropriately managed by biopsy Floor of mouth hyperkeratosis most common site to exhibit dysplasia If two separate areas in persons mouth then both areas should have incisional biopsy
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Metastasis
Most likely to a lymph node
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Radiographic
When invasive into the alveolar ridge it will appear poorly defined lucencies without a reactive sclerotic border
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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
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
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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)
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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
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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
Radiographic
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
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Radiographic
BWXs and PAs demonstrate classic lack of pulp chambers and root canals Bell Bell-shaped crown with constricted cervical region
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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
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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
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None
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Clinical
(Simple Bone Cyst; Idiopathic Bone Cavity; Unicameral Cyst; Hemorrhagic Cyst)
Radiographic
Radiolucent with scalloped margins
Radiographic
Cotton wool appearance 50% - hypercementosis
Histology
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Radiographic - Benign
Cortex remains intact thinned or expanded
Radiographic
Tooth floating in air or space
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Nasolabial Cyst
Clinical
Mucolabial Mucolabial, , smooth swelling adjacent to a maxillary lateral incisor Soft tissue involvement; not bone
Histology
Pseudostratified squamous epithelium cystic lining
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Radiographic
parakeratin
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surface
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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
Bifid rib
Radiographic
Keratocysts - unilocular or multilocular lucencies Calcification of the falx cerebri
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Gardner Syndrome
Clinical
Multiple facial osteomas & skin nodules Hyperdontia; unerupted teeth Multiple GI (colon) polyps [familial intestinal polyposis] - - - -> colon carcinoma
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Odontoma
Epidermoid cyst
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Bells Palsy
Clinical
7th nerve paralysis - - - -> unilateral lip droop at corner, inability to close or wink eyelid Last usually less than one month
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
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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
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Mucocele
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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
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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
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Varices
Lingual and Lip
Dilated veins - blue Seen typically in the elderly Lip varices may thrombose and subsequently calcify (i.e. phlebolith)
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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
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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
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Herpes Zoster
Clinical
Crop of vesicles - - - > ulcers with pain Striking unilateral distribution on skin and oral l
ex. palate, tongue
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
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Dermoid Cyst
Clinical
Slightly compressible (doughy) Midline distribution usually
Example - anterior floor of mouth
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Often bilateral buccal mucosa; other mucosa Moderately extensive thick, white folds of tissue - No eye involvement Often heartheartshaped lucency
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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
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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
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Cheilitis Glandularis
Clinical
Mucous minor salivary glands of lips are inflamed Mucus secretions Premalignant condition - - - - > squamous cell carcinoma
Erosion
Chemical loss of tooth structure exclusive of acidogenic theory of caries
Chlorinated pools
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Abrasion
Erosion
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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
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Radiographic
Radiolucent and radiopaque
Treatment
None necessary after dx
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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
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Cutaneous
Hyperplastic
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Cleidocranial Dysplasia
Clinical
Multiple unerupted supernumerary teeth Retention of primary teeth Delayed eruption of permanent teeth Missing clavicles, frontal bossing, large head
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Nicotine Stomatitis
Clinical
Hard palate Red, inflamed minor salivary gland ducts with background of leukoplakic change Tobacco use Pipe smokers most often Cigarettes
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Aspiration
Always aspirate an anterior maxillary/mandibular radiolucency prior to biopsy to rule out vascular nature
Actinomycosis
Clinical
Soft tissue swelling (woody consistency) with multiple draining fistulas sulfur granules = colonies of bacterial organism
PMNs
Chronic Osteomyelitis
Radiographic
Often best seen in lateral oblique radiographic view Radiolucent and radiodense
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Condylar Hyperplasia
Clinical
Irregular, elongated condyle Chin deviates away y from affected side upon p closure
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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
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Epulis Fissuratum
Clinical
Hyperplastic connective tissue like fibroma Associated with illill-fitting denture flange Treatment does NOT include antibiotic therapy
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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
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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
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Irradiation Therapy
Clinical
Causes cervical caries secondary to inducement of xerostomia Does D not t result lt i in pulp l necrosis i
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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
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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
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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
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Vitamin C Deficiency
Clinical
Scurvy Does NOT cause xerostomia
Radiographic
Well demarcated lucency found near the angle of the mandible beneath the mandibular canal
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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
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Radiographic
Inferior border of posterior mandible is common site - Onion skin pattern (radiographic appearance) Bands of radiopaque lines that parallel cortical surface
Intestinal polyposis
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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
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Osteopetrosis
Clinical
Massive overproduction of dense, nonvital bone of both jaws Young persons or adults Expansion Frequent complication Secondary osteomyelitis
Osteopetrosis
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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
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Mandibular Torus
Radiographic
May be superimposed over periapical region as radiodensities
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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
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
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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
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Radiographic
Closely resemble ameloblastoma
Multilocular lucency with soap bubble pattern
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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
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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
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Coin tests
Used for detection of light leakage
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