Systemic Lupus Erythematosus

Oral and Maxillofacial Pathology

Review for NBDE Part 2

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

Cavernous sinus thrombosis

Clinical

Heart endocarditis
Kidney renal glomeruli (glomerulonephritis)

Ludwigs angina

Can arise from an infection - - a

subcutaneous abscess of the upper lip or a
intrabony abscess of an anterior maxillary
tooth
t th

Submandibular space infection

Most serious complication is edema of
the glottis

Valveless facial
veins

Treacher Collins Syndrome

Scarlet fever

Has external ear changes

White coating of the tongue that sloughs off

leaving a deep red surface with swollen
hyperplastic fungiform papillae (strawberry
tongue))
tongue

Fordyce granules

Turner tooth

Ectopic sebaceous glands yellow

papules/plaques

Due to local trauma or infection associated

with the developing tooth bud

Recurrent Aphthous Stomatitis

Intrinsic tooth stain

Tetracycline deposition within the dentin

Clinical

Moveable mucosa

Ex. Uvula, labial mucosa

Recurrent NOT PRECEDED BY VESICLE

Associated with certain HLA types

NOT caused by a virus, bacteria, fungus

Treatment

Corticosteroids are often prescribed

Herpetiform type

Many small

Minor and major types

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

10

Benign Mucous Membrane Pemphigoid

(cicatricial)

Condyloma Acuminatum

Clinical
Autoimmune

Clinical
Venereal wart
Extensive

Vesiculoerosive,
l
ulcers
l
> women - middle aged
Skin and eye
Oral

Antibody reaction at the

epithelial--connective tissue
epithelial
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

Candidiasis
pseudomembranous

Candidiasis Chronic

Clinical

Clinical

Opportunistic infection (yeast)

Immature or deficient immune

system
Antibiotics usage
C ti t id usage
Corticosteroids

Hyphae and spores

Newborns and infants

Denture sore mouth

Clinical

13

Recurrent (Secondary) Herpes

Simplex

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

May be diagnosed by cytology

smear

White, wipeable patch with red,

underling base; palate and buccal
mucosa are often involved
Thrush

Median rhomboid glossitis

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

14

Recurrent (Secondary) Herpes

Simplex

Clinical
U.S. incidence estimate of herpes infection is 80
80-85%

Most
M t cases are subclinical
b li i l
Reactivation from nerve cells of trigeminal ganglion

Lip

Skin or vermilion
Vesicle ruptures - - -> ulcer that heals in 7
7--10 days
(not present for weeks or months if immunocompetent
person)
15

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
U
Usually
ll history
hi t
off trauma,
t
stress,
t
UV exposure, as triggering
ti
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
O
Occurs
att sites
it off chronic
h i trauma
t
Ex. mandibular alveolar ridge in denture wearer,
especially near mental nerve, denture flange
trauma
Ex. tongue

18

Peripheral Giant Cell

Granuloma

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

Somewhat similar in appearance to pyogenic

granuloma
Moderate soft mass
Often liverliver-colored [brownish purple]
Distinctive histology

Usually anterior to first molar

region

19

20

Squamous Papilloma (Papilloma)

Clinical

Clinical
Intrabony
Same histology as:
Peripheral giant cell
granuloma
Brown tumor of hyperpara
hyperpara-thyroidism

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

No effect on saliva production

Bone destruction secondary to chronic renal
disease

21

Fibroma

Rhabdomyoma
Leiomyoma
Lymphangioma
Neurofibroma

22

Granular Cell Tumor

(fibrous nodule, focal fibrous hyperplasia,

traumatic fibroma, irritation fibroma)

Multinucleated giant cells

Limited to alveolar ridge/

gingiva

Central Giant Cell Granuloma

Clinical

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)

Clinical
Dorsum of tongue #1 site
Nodule with smooth or papillated surface
Histology distinct

23

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

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

Initial incisional biopsy

25

26

Squamous Cell Carcinoma

Clinical
Lower lip

Can be preceded by actinic cheilitis

Firm, indurated ulcer; painless with v. good prognosis
Submental node is most common lymph node involved by
metastasis

Most common oral site

Mid--lateral border of tongue

Mid

Least likely oral site

Hard palate

Site with greatest likelihood or risk of developing

squamous cell carcinoma

Floor of mouth worse prognosis when lung mets (not

size, local spread or anaplastic cells)

Metastasis

Most likely to a lymph node

27

Squamous Cell Carcinoma

Staging vs. Grading

Radiographic

28

Metastatic Disease to the Jaws

Stage III has a worse prognosis than I or II

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

29

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

30

Monomorphic Adenoma
(Canalicular Adenoma)

Leukoedema

Clinical

Most common site

Clinical
Intracellular edema of cells
More often seen in AfricanAfrican-Americans
Common, bilateral on buccal mucosa
Diagnostic test chairside

Upper lip
> Women
W
May be
multinodular
Asymptomatic
Do not confuse
with mucocele
of the lower lip

Pull on buccal mucosa - - - -> disappears or

dissipates

Normal mucosa variation so no treatment

required
31

Leukemia

Verrucous Carcinoma

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)

33

Chief difference from

typical squamous cell carcinoma

34

Salivary Gland Tumors

Patient diagnosed and treated for squamous

cell carcinoma of the tongue
Much more likelyy to have future p
premalignant
g
or malignant lesions anywhere in the oral
cavity

p53 tumor suppressor gene is most common

associated
35

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

Ex. speckled leukoplakia of the floor of mouth

likely to be a second primary lesion

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

Field Cancerization
Squamous Cell Carcinoma

32

Adenoid cystic carcinoma

Characteristic perineural invasion most likely

Parotid facial nerve involvement but no upper lip

paresthesia

36

Physiologic Pigmentation (Racial

Pigmentation)

Lateral Periodontal Cyst

Clinical

Darkens with time; present

most of a person
personss lifetime
African
African--American patients

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)

Upper or lower lip vermilion, attached gingiva,

tongue, buccal mucosa
Series of splotchy brown macules

37

38

Ameloblastic Fibroma

Ameloblastoma

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

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,
columnar cells of the periphery

39

Odontoma

Clinical

Radiographic

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

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

Radiographic

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

Adenomatoid Odontogenic
Tumor (AOT)

Clinical
Young person (child or teenager)
Unerupted tooth of the anterior maxilla (#6,
#11)

Radiographic

Snow flake calcifications in the radiolucency

surrounding the crown and a portion of the
impacted tooths root

Treatment simple
enucleation
41

42

Dentinogenesis Imperfecta

Amelogenesis Imperfecta

Clinical

Teeth lack enamel;

Dentin and cementum
unaffected
Shapes of root and
crown are normal

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

Fibrous Dysplasia

Radiographic
Multilocular, bilateral
lucencies

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 non
non--infectious
process (i.e., fibro
fibro--osseous lesion)
Caf au lait pigmentation

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

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
mandibular tooth); nonvital tooth
Associated tooth will test nonvital or signs and
symptoms or tooth destruction will support nonvital
status

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

47

Treatment
None

48

Traumatic Bone Cyst

Pagets Disease of Bone

(Simple Bone Cyst; Idiopathic Bone Cavity;

Unicameral Cyst; Hemorrhagic Cyst)

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

Undergoes spontaneous healing without

treatment following exploratory surgery
Pseudocyst

Clinical

Radiographic
Radiolucent with scalloped margins

Radiographic
Cotton wool appearance
50% - hypercementosis

49

Langerhans Cell Disease

(Histiocytosis X)

Reversal lines with a mosaic pattern

Composed of Langerhans cells,

not histiocytes
Etiology is still unknown
Eosinophilic granuloma

Solitary lesion, young adults

Clinical
Ominous malignant sign

Hand
Hand--Schuller
Schuller--Christian triad

50

Benign vs. Malignant Bone

Involvement

Clinical

Histology

Spontaneous paresthesia of the lower lip

Radiographic - Benign
Cortex remains intact thinned or
expanded

Diabetes insipidus
Exophthalmos
Bone lesions

Radiographic
Tooth floating in air or space

51

Central Neural Lesions

52

Nasolabial Cyst

Neurofibroma and Schwannoma

Radiographic

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

Enlargement of canals and foramina

Histology
Pseudostratified
squamous epithelium
cystic lining

53

54

Odontogenic Keratocyst
Lymphoepithelial Cyst

High recurrence!
Intrabony, posterior mandible
but anywhere; BCNS association

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

Clinical

Radiographic

Radiolucent, usually multilocular

May
M mimic
i i many other
h
types of lucent cysts and
odontogenic tumors including
ameloblastoma

parakeratin
55

56

surface

Nevoid Basal Cell Carcinoma Syndrome

(Gorlin syndrome; basal cell nevus syndrome)

Clinical
Onset is childhood
Cysts of the jaws =
odontogenic keratocysts

Hi h recurrence rate
High
t

Basal cell carcinomas

Face especially

Bifid rib

Radiographic
Keratocysts - unilocular or
multilocular lucencies
Calcification of the falx cerebri

57

Gardner Syndrome

Cheek Nibbling
(Morsicatio Buccarum)

58

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

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

59

Odontoma

Epidermoid cyst

60

10

Bells Palsy

Temporomandibular
Dysfunction (TMD)

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

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

Erythema Multiforme

62

Stevens--Johnson syndrome
Stevens
(Erythema Multiforme Major)

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

Eye (conjunctiva), mouth (labial mucosa,

tongue, etc.), genitalia
63

Pemphigus Vulgaris

64

Pemphigus Vulgaris

Clinical/Lab Vesiculoerosive (oral and skin)

Demonstrates immunoglobulin fluorescence
intraepithelial ((supraepithelial
supraepithelial)) cementing substance

Most often immunoglobulin type G (IgG

(IgG))

Positive Nikolsky sign

Common sites lips, palate, gingiva

65

66

11

Progressive Systemic Sclerosis

(Scleroderma)

Clinical
Demonstrates induration
of the soft tissue (mask(mask-like) and
generalized widening of the PDL space
Trismus

67

Benign Migratory Glossitis (Geographic

Tongue, Erythema Migrans)
Migrans)
Clinical

Aspirin Burn (Chemical Burn)

Red and white

68

Clinical
White = coagulative necrosis of the surface,
NOT hyperkeratosis

Red = flat, depapillated

areas of tongue (filiform
papillae atrophied)
White = keratin, epithelial
cell debris

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

Mucocele

Basal Cell Carcinoma

(mucus retention phenomenon, mucus

extravastion phenomenon)
Clinical

Clinical
Painless ulcer of upper lip, elsewhere on
sun--exposed face (UV); raised margins
sun
Does NOT occur intraorally
Begins as pearly papule; assoc.
g
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
dome--shaped
Bluish often
History of recurrence

72

12

Antral Pseudocyst (Mucous

Retention Pseudocyst)

Ranula (mucocele, mucus retention

phenomenon, mucus extravastion

phenomenon)

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

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

MUCIN
GW
MSG

73

74

Ankyloglossia

Dentigerous Cyst

Congenital abnormality
tongue-- tied
tongue

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

77

78

Dentigerous Cyst (contd)

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

13

Varices

Parulis (Gum Boil)

Lingual and Lip

Clinical

Dilated veins - blue

Seen typically in the elderly
Lip varices may thrombose and
subsequently calcify (i.e. phlebolith)

Incomplete root canal therapy with

intermittent sensitivity
Elevated reddishreddish-yellow

Clinical evidence of a draining fistula

79

80

Tuberculosis

Extravasated Blood

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 orall
lesions (e.g., ulcer mimicking cancer on
the tongue)

Clinical spontaneously resolve

Purpura generalized term
Petechia
Petechia-- pinpoint bleeding
Ecchymosis larger area of involvement
Hematoma large, elevated areas

81

82

Allergic Mucositis

Eagle Syndrome

Clinical

Typically due to flavoring agents in

toothpastes, candies, and chewing gums
(cinnamon
( i
flavoring
fl
i is
i a common culprit)
l it)

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

83

84

14

Primary Herpes
Gingivostomatitis

Herpes Zoster
Clinical

Crop of vesicles - - - > ulcers with pain

Striking unilateral distribution on skin and
orall

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

ex. palate, tongue

85

Primary Herpes
Gingivostomatitis

86

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

Multiple Endocrine Neoplasia

Syndrome, Type IIB (III)

Dermoid Cyst

Clinical

Slightly compressible (doughy)

Midline distribution usually

88

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

Example - anterior floor of mouth

89

90

15

Incisive Canal Cyst

(Nasopalatine Duct Cyst)

White Sponge Nevus

Clinical

Most common developmental

non--odontogenic cyst
non
Teeth vital; max.
max midline
True cyst (epithelial lining)

A genodermatosis

91

92

Cleft Palate

Trigeminal Neuralgia

Clinical

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

Between lateral incisor

and canine

Autosomal dominant

Often bilateral buccal

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

Clinical

Radiographic
Lucent line
Maxillary occlusal film

93

94

Actinic Cheilitis

Neuritis

Intense pain for one week duration

Unilateral

Clinical
Lips vermilion becomes indistinct
Great potential for dysplasia to undergo
malignant transformation into squamous cell
carcinoma

Clinical

At forehead and around eye

95

Therefore, a premalignant condition

96

16

Cheilitis Glandularis

Post-Developmental Loss of Tooth

PostStructure

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

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

Post-Developmental Loss of Tooth

PostStructure

98

Hiatal hernia, bulimia

Post-Developmental Loss of Tooth

PostStructure

Erosion

Abrasion

99

100

Periapical Cemento
Cemento--osseous Dysplasia
(Periapical cemental dysplasia; periapical 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

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)

Florid Osseous Dysplasia

Clinical

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

Radiographic

Treatment

Radiolucent and radiopaque

None necessary after dx

103

104

Lichen Planus

Lichen Planus

Clinical
Skin and/or oral condition
Middle aged women most often
Skin

Purple, polygonal, pruritic papules

Oral

White papules and coalescing papules = 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

Peripheral Ossifying Fibroma

Erosive Lichen Planus

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

Neurofibromatosis, type 1 (von

Recklinghausens disease of skin)

Cleidocranial Dysplasia

Clinical

Multiple unerupted supernumerary teeth

Retention of primary teeth
Delayed eruption of permanent teeth
Missing clavicles, frontal bossing, large head

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

Melanotic Neuroectodermal
Tumor of Infancy

Nicotine Stomatitis

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

113

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

114

19

Auriculotemporal syndrome (Frey

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)

Always aspirate an anterior

maxillary/mandibular radiolucency prior
to biopsy to rule out vascular nature

Starch Iodine Test

115

116

Chronic Osteomyelitis

Actinomycosis

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

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

117

Condylar Hyperplasia

118

Dens--in
Dens
in--dente (dens invaginatus)

Clinical

Irregular, elongated condyle

Chin deviates awayy from affected side upon
p
closure

119

Clinical
Most often found in anterior jaw, especially
maxillary lateral incisor

120

20

Periapical Cyst and Granuloma

Dentin Dysplasia

Clinical

Clinical
Dentin abnormal with
exposure
Draining fistulas
Misshapen teeth

Nonvital tooth, at apex

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

Radiographic
Type 1 rootless teeth
Periapical lucencies

121

(Hypohydrotic) Ectodermal
Dysplasia

122

Epulis Fissuratum

Exhibits hypodontia (anodontia)

Hypohidrotic - common type

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

Lack of skin appendages and hair

Heat intolerance

123

Heavy Metal Systemic

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
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

Infectious Mononucleosis

Clinical

Vital mandibular first molar

Generalized in acromegaly
Also seen, at times, in Pagets

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

Internal vs. External Tooth

Resorption

130

Irradiation Therapy

Clinical pink tooth when crown involved with

internal type
Radiographic
Cannot tell difference early in the process
Round or ovoid radiolucency

131

Clinical
Causes cervical caries secondary to
inducement of xerostomia
Does
D
nott result
lt iin pulp
l necrosis
i

132

22

Acquired Melanocytic Nevus

(common mole; nevus)

Kaposis Sarcoma

Particular malig.
malig. seen in HIV positive
individual that progress to AIDS
Etiology

Clinical
Junctional type

Clinical

Most likely to undergo

malignant transformation
(i.e., melanoma)

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

Keratoacanthoma

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

135

Xerostomia

136

Warthins tumor
(papillary cystadenoma lymphomatosum)

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

137

Clinical
Primary site overwhelmingly is parotid

Not in oral cavity;

y; >> males

138

23

Stafne Defect (salivary gland

depression defect)

Vitamin C Deficiency

Clinical

Clinical

Scurvy
Does NOT cause xerostomia

Developmental
More in males
Asymptomatic
Teeth vital

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

139

140

Sarcoidosis

Sjgrens Syndrome

Bilateral hilar lymphadenopathy (chest xx-ray)

Cutaneous lesions - violaceous
Treatment corticosteroids

Clinical

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

141

142

Proliferative Periostitis
(Garres)

Peutz--Jeghers Syndrome
Peutz

Clinical

Young person; swelling visible

Clinical
Oral and Paraoral

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

143

Pigmented macules (brown)

Lips, tongue, buccal mucosa
Vermilion and skin of lip

Intestinal polyposis

144

24

Osteosarcoma

Clinical

Osteoporosis

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

Clinical
Decrease in serum estrogen and
calcium
Older females

Radiographic - early lucency then opacity;

trabeculae changes; PDL symmetrical widening

145

Osteopetrosis

146

Osteopetrosis

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

147

Osteoma

Clinical

Radiographic

148

Mandibular Fracture

Most common site is angle of mandible

Clinical
Often diagnosed with two radiographs

Well
Well--circumscribed radiopacity

149

Panoramic and occlusal

150

25

Mandibular Malignant Ominous

Sign

Mandibular Torus
Radiographic

Clinical

May be superimposed over periapical region

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
Bence--Jones proteinuria
Immunoglobulin spike

Radiographic
Multiple bone sites

Calvaria, spine, pelvic girdle, jaws

Punched
Punched--out lucencies
153

Necrotizing Sialometaplasia

154

Cervical emphysema

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

155

Introduction of air into oral soft tissues with

resulting sudden painless swelling and
crepitance
Ex. air/water syringe

156

26

Odontogenic Myxoma

Miscellaneous Facts

Clinical

Radiographic
Closely resemble ameloblastoma

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

Young adult onset

Multilocular lucency with soap bubble pattern

157

Miscellaneous Facts

158

Miscellaneous Facts (contd)

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

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

159

160

Radiology Facts

Epithelial Dysplasia

X-ray has the shortest wavelength and the

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

162

27

Radiology Facts (contd)

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)

Stunted roots
Micrognathia
Condylar hyperplasia
Malocclusion
165

Radiology Facts (contd)

Coin tests
Used for detection of light leakage

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:

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
iimaging
i film
fil for
f viewing
i i internal
i
l derangement
d
off
the TMJ (e.g., articular disc) is an MRI
Identify Normal:

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

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 xx--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

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