CLINICAL ORAL PATHOLOGY PEARLS… Good Stuff Learned Along the Way Idaho State Dental Association 116th Annual Session Coeur d’Alene, ID – July 19, 2012
I. Erythema migrans…geographic tongue + other sites
II. Lateral periodontal cyst / gingival cyst…related?
III. Odontogenic keratocyst…2 types with different behaviors
IV. Keratin vs. cholesterol…different types of cheesy material
V. Buccal bifurcation cyst (paradental cyst)
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VI. Satellite overview of salivary gland tumors
VII. Vesiculobullous lesions…the lichen planus conundrum (More extensive notes on page 4)
VIII. Globulomaxillary cyst…where’s the fissure?
IX. Peculiar mucus retention phenomena
X. Oddball fibromas
XI. Erythroplakia…subtle but deadly
XII. Benign fibro-osseous lesions…primarily focal COD
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XIII. Condensing osteitis vs. idiopathic osteosclerosis
XIV. Smoker’s melanosis…stain from the inside
XV. Minocycline & dark bone
XVI. What’s Your DX??...time permitting
Robert J. Achterberg, DDS, MS InCyte Pathology P.O. Box3405 Spokane, WA 99220-3405 [email protected] (509) 892-2732
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VESICULOBULLOUS LESIONS (IMMUNOBULLOUS)
- Usually one of three possibilities: Lichen planus, BMMP or pemphigus - Desquamative gingivitis…term used for gingival involvement of any of the 3 - Lichen planus = a relatively common mucocutaneous disease that often affects oral mucosa. It is more common than BMMP and much more common than pemphigus - Oral LP seen in two main forms: Reticular (90%) and erosive (10%) - Lichen planus biopsy problems: 1. Characteristic, but not specific histopathologic features 2. Lichenoid drug RX Drugs with lichenoid potential Cardiovascular drugs (ACE inhibitors, beta blockers, thiazide diuretics, antiarrhythmics) Anxiolytics (lorazepam) Hypoglycemics (chlorpropamide, tolbutamide) NSAIDS (ibuprofen, naproxin) Antimalarials (chloroquine, quinidine) Uricosurics (allopurinol) Antimicrobials (streptomycin, tetracyclines, ketoconazole) 3. Lichenoid contact mucositis (cinnamon / mints, etc.) 4. Localized lichenoid amalgam RX 5. Lupus erythematosus 6. Incomplete / no clinical HX 7. BX of ulcerated areas - Immunofluorescence findings = non-specific - TX = usually steroids for symptomatic patients (LP, BMMP & pemphigus) Topical steroid options: Triamcinolone (Kenalog) in Orabase 0.1% in 5g tube – mild cases Fluocinonide (Lidex) 0.05% ointment or gel in 15g, 30g or 60g tubes – mild to severe cases Dexamethasone (Decadron) elixir 0.5mg/5ml in 120ml or 240ml bottle – mild to severe cases Clobetasol (Temovate) 0.05% ointment or gel in 15g, 30g, or 60g tubes – severe cases Halobetasol (Ultravate) 0.05% ointment in 15g or 50g tubes – severe cases Systemic steroid options: Dexamethasone (Decadron) elixir – rinse, swallow by clock regimen Prednisone tabs – 25mg-40mg range initially then taper or Medrol dose pack Tacrolimus ointment Other immunosuppressants / immunomodulators - Periodic BX for any malignant changes is appropriate
- BMMP & pemphigus are both autoimmune diseases with specific histopathologic features - Immunofluorescence findings are specific and diagnostic