Tuesday February 18 , 2020 Raleigh Wake County Dental Society North Ridge Country Club, Raleigh, NC

Bobby M. Collins, DDS, MS Diplomate, Oral and Maxillofacial Pathology In accordance with the policy of the ADA and the North Carolina Dental Society, I declare that I have no proprietary, financial or other personal interest of any nature or kind in any product, service or company that will be discussed or considered during the proposed program. Bobby M. Collins, DDS, MS  Even when problem focused - “Doc my tooth hurts”  Pause, and do a complete exam (Never treat a stranger)  Medical history: review of systems, medications  Social history: alcohol, tobacco  Explain to the patient that you will address their chief concern, but you need to look around first “so I won’t miss anything”  Look, feel, provoke  If an abnormality is noted, evaluate: size, color, surface texture, and feel; is it painful / non-painful, numb?  Ask about duration, distribution  Persistent ulcers of lips, mouth that don’t heal  Mass in lip, mouth, or throat >3wk duration  White or red areas of ventrolateral tongue, FOM, soft palate/tonsillar complex, BM, alveolar mucosa, gingiva  Bleeding, pain, numbness in oral cavity and oropharynx  Persistent sore throat, feeling a lump or like something is stuck in throat  Pain when chewing or swallowing  A change in fit of dentures  A change in voice, “hot potato” voice  Pain in the ears  Lateral neck swelling, cervical lymphadenopathy

 Ankyloglossia  Geographic Tongue  Dental lamina cysts  Fissured Tongue  Retrocuspid Papilla  Gingival hyperplasia INFECTIOUS CONDITIONS ULCERATION

Herpes Virus  Traumatic ulceration (TUGSE)  Primary Herpetic Gingivostomatitis  Riga-Fede Disease  Herpes labialis/oralis  Aphthous Ulceration (RAU. RAS)  Recurrent herpes Coxsackievirus  Herpangina  Hand, foot and mouth disease Fungal infection  Candidiasis (Perleche)  Initial infection with HSV-1, all oropharyngeal sites, erythematous eroded gingiva is common  Clustered vesicles break and leave irregular erosions  Cervical lymphadenopathy, malaise, inability to eat or drink  “Heals” in 7-10 days  Generally, lesions are short-lived or self-limiting, occur on keratinized surfaces  Complications can arise with contact  Scratching – auto-innoculation leads to:  Finger (Whitlow), Eye (Ocular), genital lesions  And immunocompromise  Bell’s palsy (therapy involves tapered steroids and antiviral med (Valtrex))  Herpes encephalitis, meningitis  Disease of the very young, very old, very sick  Developing immune function, delayed immune response, immune reaction “overwhelmed”  Opportunistic infection  Immunocompromise, antibiotic use, steroid use  Dry mouth (autoimmune, medication induced)  Smokers Bactroban (mupirocin) 2% ointment  Disp. 15 gm tube  Sig. t.i.d. 7-14 days  Common in children, a period of immunologic adjustment and a myriad of infections  Antigen presentation and lymphocytic hyperplasia are making adjustments  Bacterial (Streptococcal) and Viral infections (HSV, EBV, VZV, Influenza, etc) are ubiquitous  After age 16, tonsillar enlargement is more worrisome, especially when no clinical illness is evident  Riga-Fede disease  TUGSE  Factitial Injury (insensitivity to pain, metabolic /psychiatric disorder)  Blue translucent swelling overlying an erupting tooth that has eroded through its bony crypt, but it hasn’t yet penetrated the gingiva  Map like atrophy bordered by filiform papillae in the tongue  Waxes, wanes and moves around  10% pts report symptoms – sensitivity to hot spicy or acidic foods  Same histologic appearance as psoriasis  Hereditary or medication associated thickening of the lamina propria of the gingiva  Can over cover the teeth and delay tooth eruption  Medications associated with the enlargement include: Calcium channel blockers (Nifedipine), anticonvulsants (Dilantin), and immunomodulatory agents (Cyclosporin)  Lip enlargement due to granulomatous disease  Can affect both lips simultaneously, or either lip  Crohn’s disease, Melkersson-Rosenthal syndrome, Sarcoidosis  Melkersson –Rosenthal typically affects maxillary lip

 Aphthous ulcers  Lichen planus/lichenoid  Herpes labialis  Tonsillar detritic debris  Candidiasis  Lymphoepithelial cyst  Cheek chewing  Palatal ecchymosis  Pericoronitis  Reactive masses  Pregnancy gingivitis  Squamous papillomas  Sexual bruise  Geographic tongue  Frenal tag/fibroma  Transient lingual papillitis • Recurrent aphthous stomatitis (RAS), recurrent aphthous ulcers (RAU)  Common, childhood/adolescence onset, F>M  RAS affects 5-66%, higher socio-economic groups  Recurrent round, or ovoid well-delineated ulcers, erythematous halos, and yellow or gray center  Family history is common  Not infectious, not contagious  Resolution by ~3rd decade  Famciclovir (Famvir) 500 mg capsules  For Herpes labialis – 1500 mg as a single dose  For Zoster – 500 mg q8h, 7 days  Valacyclovir HCL (Valtrex) 500 mg  For Herpes labialis – 2g twice daily, 12 hours apart  For Zoster – 1g t.i.d 7 days  Acyclovir (Zovirax) 200mg, 400mg, 800mg  Herpes labialis – Take 800 mg onset of symptoms, then 800 mg b.i.d for 3 days  Pyogenic Granuloma  Peripheral Fibroma  Peripheral Ossifying Fibroma  Peripheral Giant Cell Granuloma

Reactive processes in varied states of connective tissue maturation  F>M, psychiatric condition, (control issue) regurgitation after meals  Dehydration, nutritional compromise, oral lesions (necrotizing sialometaplasia)  Gastric acid causes erosion on palatal and occlusal surfaces of teeth  Inflammation around crown of an erupting mandibular tooth, typically a third molar  Pain made worse by occlusal trauma from opposing maxillary third molar tooth  Pus and blood may emanate from the operculum  Treatment:  Irrigation with antimicrobial  Prescribe Abs – Amoxicillin 500mg t.i.d.  Extract opposing tooth and appoint for removal of involved tooth  Very addictive, cheaply made, readily available  Snorted, smoked, injected  Causes dry mouth, parafunctional habits (clenching grinding)  Caries result from soft drink consumption to quench thirst  Fragmented bone at coronal aspect of erupting tooth  The superior aspect of the tooth crypt  May be loose, but attached to operculum, or may still be firmly attached to cortical bone of the jaws  DNA virus, more than 40 types  Spread by skin-to-skin contact, including sex (vaginal, oral, anal, any contact w/ genital area  14 million teenagers infected yearly in US  HPV exposure increases with number of sexual partners  75 – 80% sexually active adults have at least one genital HPV infection before age 50  Majority F & M infected with 1 or more HPV types in anogenital area between 15-25 yrs  Most infections asymptomatic, particularly in males  10 – 20% of women HPV infection persists  Greater chance of developing cervical pre-cancer, and then cancer  Progresses to cervical cancer in 20 - 25 years  There are low risk HPV associated lesions  Common wart (Verruca Vulgaris)  HPV 2, 4, 6, 40  Squamous Papilloma  HPV 6, 11  Focal Epithelial Hyperplasia (Heck Disease)  HPV 13,32  Venereal Warts (Condyloma Acuminatum)  HPV 2, 6, 11, 53, 54 - occasionally 16, 18, 31  And High Risk Lesions  HPV 16 infection is changing HNSCCa trends  Posterior oral cavity (tonsils, tonsillar pillars, crypts, base of tongue), and oropharynx show increase in SCCa incidence rates over last 10 yrs  Squamous papilloma  HPV 6, 11 – pink or white, exophytic, warty lesions  Tongue, lips palate are common sites  Verruca vulgaris  HPV 2, 4 – pink or white, pebbly surface, collarette  Hands, face, lips, anterior tongue  May spontaneously resolve  Tend to recur  Condyloma acuminatum  HPV 6, 11 (16, 18), pink or white cauliflower surface  Anogenital and oral mucosa (gingiva, tongue, labial mucosa), tend to be multiple  Tx – Excision, recur, malignant potential  Focal epithelial hyperplasia (Heck’s Disease)  HPV 13, 32 – pink white, maculopapular  Common in American Indians, Inuits  First HPV infection occurs soon after onset of sexual activity  HPV infection highest in late teens/early 20s  Most infections clear or become undetectable within 1-2 years  In 10-20% women infections do not clear  Many pre-cancers clear  However, pre-cancers can progress to cancer over years to decades  Increase in oro-pharyngeal cancer attributable to oro-genital sex  Vaccine available, most administered in 9-11 yr olds  Cervarix (Bivalent (2vHPV)  Types 16, 18  Licensed for use in Females ages 9-25  Discontinued 2016  Gardisil (Quadrivalent (4vHPV))  Types 6, 11, 16, 18  Females and males 9–26 yrs  Discontinued 2016  Gardisil 9 (9-valent(9vHPV))  Types 6, 11, 16, 18, 31, 33, 45, 52, 58  Females and males 9–26 yrs (2018 extended to age 45)  Dental caries  Root caries  Gingivitis  Periodontitis  Xerostomia  Candidiasis  Acute pseudomembranous (thrush): adherent white plaques that can be wiped off  Erythematous (denture stomatitis): red macular lesions, often with a burning sensation  Angular cheilitis: erythematous, scaling fissures at the corners of the mouth  Oral cancer  Head or neck radiation  Antihistamines  Human immunodeficiency virus  Antipsychotics  Medication use  Anxiolytics  Angiotensin-converting enzyme  Calcium channel blockers inhibitors  Diuretics  Alpha and beta blockers  Muscle relaxants  Analgesics  Sedatives  Anticholinergics  Salivary gland aplasia  Antidepressants  Sjögren syndrome  Antihistamines  Smoking  > 43,250 new cases/yr in U S, 75% of HNSCCa begin in oral cavity  ~8,000 deaths / year  Diagnosis relies on patient presentation, physical examination, and biopsy confirmation, so diagnosis is often delayed  Survival correlates with stage or extent of tumor  Early diagnosis and early treatment improves prognosis  5yr survival data -overall disease specific survival rate <60%  Survivors often endure major functional, cosmetic, psychological burdens due to inability to speak, swallow, breathe, chew  3 categories:  Carcinomas of oral cavity proper  Tongue, postero-lateral and ventral >30%  FOM, particularly anterior ~15%  Of lip vermilion  Lip <20%  And arising in oropharynx  Soft palate/ tonsillar complex ~15%  Oropharyngeal rates are increasing due to HPV Less common sites:  Gingiva, BM, labial mucosa, hard palate  ~25% pts diagnosed with oral SCCa are non-smokers  But some may live with or associate with smokers  75% oral cancer pts have used some form of tobacco in their lifetimes  Adjunctive devices assist in “thorough” oral cancer screening  The devices include lights of variable wavelength, vital dyes, and tissue collection brushes  They are not a substitute for a systematic, visual inspection with palpation of HNF-IO tissues  A thorough visual and palpation examination of the HNF-IO tissues is always done first  Tissue Reflectance  Light source emits blue-white light, ~440 nm  Microlux/DL, Orascoptic DK, Vizilite, Vizilite plus  1% acetic acid oral rinse (and Tolonium Cl Viz+TBlue)  Abnormal mucosa is “acetowhite”  Autofluorescence  Filtered light source, nml tissue is lime green  Abnormal tissue has decreased autofluorescence (darker)  DOE, Sapphire Plus Lesion Detection, VELscope  Autofluorescence and tissue reflectance  Enhanced oral mucosal examination  Identifi 3000, Oral ID  Liquid-based cytology  Cells collected with a nylon brush  Immersed and spun or twirled in preservative solution  Thin Prep, Surepath  Sample sent to OPL  Machine filters harvested cells from debris  Cells plated as monolayer on glass slide  Exfoliative /Transepithelial cytology  Sampling of red and white lesions by special brush cell collection of full thickness epithelial layer  Oral CDx Brush (Biopsy) test  DOE (Dentlight, Inc)  IDENTIFI (Dentalez Group)  Oral ID  MICROLUX/DL (Addent, Inc)  ORALCDX Brush Test (Oral CDX Laboratories)  Orascoptic DK (Orascoptic Div of Kerr Co.)  Sapphire Plus Lesion Detection (DEN-MAT)  VELSCOPE and VELSCOPE VX (LED Dental,Inc)  VIZILITE and VIZILITE PLUS w/ TBLUE (ZILA)

 Opportunistic infection of the “very young, the very old, and the very sick” and when oral microenvironment has been altered  Typically held in check by oral microflora  Commonly affects:  Denture wearers  Smokers, diabetics, xerostomic (med related)  Patients using steroids  Pts taking oral contraceptives, antibiotics  Superficial mucosal reaction “allergy” to toothpaste ingredients  Mucosa peels like “sunburned skin” with no associated tenderness  Common occurrence with multifunction toothpastes (Whitening, tartar control, antibacterial, etc)  “Gum boil”  Granulation tissue surrounding a sinus tract that may exude pus  Overlie gingiva of severely carious tooth or periodontal infection Antibacterial, mild antifungal  Peridex 0.12%, Periogard 0.12% contain EtOH  Paroex – alcohol free chlorhexidine rinse  Sig. Rinse w/ 15 ml for 30 secs., then expectorate  Do this b.i.d. (AM and qhs)