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2014 self-study course two course

The Ohio State University College of is a recognized provider for ADA, CERP, and AGD Fellowship, Mastership and Maintenance credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit house by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.

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ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a 614-292-6737 . RECORD or PRINT THE unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. t o l l f r e e A: Your SMS number can be found in the upper right hand corner of your

1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and, is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses . TWO CREDIT HOURS are issued for available? successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2014-2015 [email protected] biennium totals. . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 GINGIVAL PATHOLOGY 2014 The primary focus of this study centers on abnormal proliferations and course disease processes that can involve the gingiva, either exclusively or as a part of their spectrum. While we are unable to discuss all of these entities, we will two limit the current discussion to some of the more common ones. INTRODUCTION Oral health professionals are given the task of maintaining gingival health. and periodontitis are the most common gingival pathology and, in most cases, remediation can be simply achieved by enforcing vigorous plaque control measures. Considering the extensive knowledge of dentists and Source: www.brown.edu dental hygienists about plaque- related pathology, we are excluding the discussion on gingivitis and in patients older than 50 years of periodontitis in this study. age. Facial gingiva of the mandibular canine and premolar Topics that will be covered in this region is more frequently study include: involved. They appear as small, smooth surfaced, blue swellings • Cysts and Tumors that are primarily asymptomatic. • Reactive Proliferations • Treatment • Infections • Autoimmune Processes Conservative surgical excision is • Pigmented the treatment of choice. • Premalignant and Malignant Recurrence rates are negligible. Processes FIBROMA:

CYSTS AND TUMORS Fibroma is a benign proliferation written by : of fibrous connective tissue identified in areas undergoing amber kiyani, dds A gingival cyst is classified as an chronic irritation or trauma. arising from

remnants of , the band Clinical Features of epithelial tissue which gives way

edited by for developing teeth. It is show no age or sex rachel a. flad, bs considered a soft tissue counterpart predilection. They are commonly of a , due to karen k. daw, mba, cecm identified in the buccal and labial remarking similarity in their mucosa, , and gingiva. histopathologic features. They appear as mucosal colored,

sessile nodules that are firm on Clinical Features palpation. Presence of surface

ulceration may be accompanied Gingival cysts are usually identified by some pain and discomfort. Page 2

Treatment mucosal colored nodules that appear on lingual mandibular attached gingiva of canines. The Conservative surgical excision with submission of lesions are frequently bilateral and are mostly tissue for histopathologic examination is identified in children. They tend to disappear as recommended. the person ages. They show striking clinical and histopathologic similarity to giant cell fibromas. INFLAMMATORY FIBROUS HYPERPLASIA: Treatment Inflammatory fibrous hyperplasia, or denture , are benign proliferations of fibrous The requires conservative surgical excision connective tissue that develop in association with for treatment. The excised giant cell fibroma an ill-fitting dental prosthesis. should be submitted for histopathologic examination to confirm diagnosis. Clinical Features INTRA-OSSESOUS CYSTS AND TUMORS: This process is usually identified in older individuals, and women tend to be more It is not uncommon for intra-osseous cysts and commonly affected. It appears as mucosal colored benign and malignant tumors to erode through folds of hyperplastic tissue that correspond with the cortical bone and appear as soft tissue the ill-fitting flange of the denture. The masses. A radiograph is usually sufficient to hyperplastic tissue is firm and fibrotic on determine an osseous origin. Benign cysts and palpation. While most lesions are primarily tumors tend to exhibit distinct margin, while asymptomatic, occasional reports of pain and malignancies are locally destructive with ill- discomfort may be noted when ulceration is defined margins. present. The size of the lesion can be highly variable, ranging between a few millimeters to the REACTIVE PROLIFERATIONS entire length of the vestibule.

PARULIS: Treatment

Parulis (gum boil) is a collection of granulation Surgical excision of hyperplastic tissue with tissue at the site of the sinus tract opening of a remaking or relining of the dental prosthesis is . recommended. The excised tissue should be submitted for histopathologic examination to rule Clinical Features out any significant pathology mimicking this benign process. Parulides can be seen in patients over a wide age

range. They present as small, red or yellow GIANT CELL FIBROMA: colored nodules on the alveolar or palatal

mucosa. Patients usually report recurrent Giant cell fibroma is a benign fibrous neoplasm episodes of enlargement and compression of the that does not show an association with trauma. . Compression is accompanied by

discharge of foul-tasting pus. Clinical Features

Treatment Giant cell fibromas are more frequently seen in younger patients. A female predilection is noted The offending tooth can be identified by in some studies. Most lesions are identified on the testing the teeth in the vicinity. If pulp testing gingiva, but other sites of occurrence include the does not yield favorable results, insertion of a tongue and the . The lesion appears as a gutta percha point into the sinus tract followed by small, mucosal colored, papillary nodule that can radiographic imaging may aid in identifying the often be mistaken for a squamous papilloma. responsible non-vital tooth. Endodontic

treatment or extraction of the offending tooth Retrocuspid papilla is a name given to small, leads to complete resolution of symptoms. Page 3 PERIPHERAL OSSIFYING FIBROMA: Treatment

Peripheral ossifying fibroma is a common, reactive Surgical removal is the primary treatment. 10- proliferation of fibroblasts that occurs exclusively 15% of the lesions may recur locally. on the gingiva. Despite the similarity in names, this lesion is distinct from a central ossifying PYOGENIC : fibroma; a benign intraosseous neoplasm. Despite the highly suggestive name, pyogenic Clinical Features granuloma has no association with microbial infections. It is a reactive proliferation of The lesion is identified more commonly in women granulation tissue, possibly induced due to low in their 20s. Peripheral ossifying fibroma appears grade irritation or trauma. as a smooth, pink, and sessile nodule. Surface ulceration and erythema are frequently noted. It Clinical Features is relatively smaller in size and rarely enlarge beyond 2 centimeters. The lesion is firm to hard Pyogenic can be seen in patients of in palpation depending on the amount of bone all ages. Some studies have suggested a strong formation. female predilection. Gingiva is the most frequent site of involvement. The lesion may also be Treatment identified on the tongue, , and buccal mucosa. Cutaneous involvement with this process is Conservative surgical excision is the treatment of common. It appears as a red, lobulated growth choice. Histopathologic examination is necessary that is frequently ulcerated, and it tends to bleed in order to establish diagnosis. A small easily on manipulation. The ability of rapid percentage of peripheral ossifying fibromas tend growth in pyogenic granulomas can occasionally to recur. generate concerns about malignancy.

PERIPHERAL GIANT CELL GRANULOMA: Pyogenic granulomas are a frequent finding on the gingiva of pregnant women and may be Similar to peripheral ossifying fibroma, peripheral referred to as a tumor. Hormonal giant cell fibroma is also a reactive proliferation changes are considered an etiological factor in that exclusively involves the gingiva. Some the pathogenesis of this process. These lesions studies have suggested that peripheral giant cell tend to enlarge over the course of the pregnancy. granuloma is the soft tissue counterpart of central Once the child is delivered, remission is usually giant cell granuloma. noted.

Clinical Features

Peripheral giant cell granuloma can be seen in individuals over a wide age range. A female predilection is noted. Lesions tend to occur more commonly in the . They appear as a red- blue, smooth-surfaced, and sessile nodules. Surface ulceration is a common finding. Peripheral giant cell granulomas remain relatively small, rarely exceeding their dimensions by a couple of centimeters. While this lesion does not invade the underlying alveolar bone, it can cause surface resorption leading to a “cupping” defect that can be occasionally identified radiographically. Oral Source: Carl Allen, DDS The Ohio State University College of Dentistry Page 4 Treatment INFECTIONS

Conservative surgical excision with submission of HERPETIC INFECTION: tissue for histopathologic examination is usually the preferred choice of treatment. Recurrence virus has two subtypes, Type I rates are very similar to peripheral ossifying primarily affects the tissues above the diaphragm, fibroma and peripheral giant cell fibromas. while Type II affects the tissues below the Excision of pregnancy tumors should be delayed diaphragm. The discussion in this section will until the baby is delivered. center around Type I. Herpes simplex virus Type I spreads through saliva or contact with active HYPERPLASIA lesions. This virus has the ability to migrate to the sensory ganglion following primary infection and DRUG-RELATED GINGIVAL HYPERPLASIA: cause recurrent infections over subsequent years.

Gingival growth has been known to occur Clinical Features secondary with the use of certain medications: Primary herpetic gingivostomatitis occurs more • Phenytoin- an anti-seizure medication commonly in children. Symptoms include fever, • Cyclosporine- an immunomodulator malaise, lymphadenopathy, anorexia, and • Nifedipine- an antihypertensive drug irritability. Mucosal lesions begin as numerous tiny vesicles that evolve into painful ulcers. These drugs are likely to interfere with the Adjacent lesions can coalesce to form larger collagen remodeling process resulting in excess defects. Any part of the may be accumulation of the protein in tissues. involved. Gingiva appears erythematous and swollen. Fingers, eyes, and the genitals can Clinical Features acquire the virus through self-inoculation. Complete resolution occurs within a week. Gingival hyperplasia associated with medication can be seen over a wide age range. Facial aspects Adult infections are very similar to herpetic of anterior gingiva are more extensively involved. gingivostomatitis except that the mucosal lesions initiates at the interdental tend to occur in the pharyngotonsillar region. papillae and eventually covers the crowns of teeth, either partially or completely. The enlarged Recurrent herpetic infection frequently presents tissue has an irregular appearance and is firm on as or a cold sore. The onset of palpation. If is not effectively blisters may be preceded by a prodromal phase maintained, the hyperplastic gingiva may become characterized by a tingling and burning sensation. erythematous, edematous, and friable. Surface Recurrent lesions may also be identified on the ulceration may also be identified. Edentulous oral mucosa. In such instances, gingiva and the areas are rarely affected. Patients using palate are common sites of involvement. cyclosporine can exhibit hyperplastic growth in Infections in immunocompromised patients tend other oral soft tissues. to be more frequent, severe, and persistent.

Treatment Treatment

Once the drug is identified as the offending agent, The diagnosis can be made on the basis of clinical the patient’s physician is requested to discontinue presentation. Cytology can aid in establishing a the current medication. Significant improvement definitive diagnosis if it is performed within 72 in the condition is seen following cessation of the hours of the onset of lesions. offending drug. To improve esthetics, procedures such as gingivectomy and gingivoplasty may be Use of antivirals, such as acyclovir and valacyclovir, performed. earlier in the course of disease may lead to faster resolution. Supportive treatment such as fluids, Page 5 topical anesthetics and non-steroid anti- process begins as generalized , inflammatory drugs can assist in alleviating edema, and bleeding of the interdental papillae. symptoms. The papillae eventually undergo epithelial necrosis to produce classic punched-out ulcerations. The HERPES ZOSTER: necrosed tissue is covered by an adherent white to gray pseudomembrane. The condition is The varicella zoster virus causes both chickenpox extremely painful and emanates a foul odor. and herpes zoster. The virus becomes latent in the Fever, malaise, and lymphadenopathy may geniculate ganglion following initial infection and accompany the process. has the ability to reactivate in patients in advanced age and immunocompromised states. Treatment

Clinical Features The condition is treated by local debridement and use of topical and systemic antibiotics. Once the Herpes zoster is rarely seen in immunocompetent offending bacteria are killed, regeneration of the individuals under the age of 50. The reactivated gingiva usually occurs. Supportive treatment may virus produces tingling or pain along the course of be necessary if ancillary symptoms are also a single dermatome. Elevated temperature, present. fatigue, and body aches occur before the onset of cutaneous lesions. As the virus travels through the AUTOIMMUNE PROCESSES nerve, the pain intensifies and is followed by the development of pustules along the nerve MUCOUS MEMBRANE : pathway. The lesions do not cross the body’s midline. The pustules rupture to form small ulcers Mucous membrane pemphigoid, also known as and eventually form a yellow colored crust. It cicatricial pemphigoid, is an autoimmune takes 2-3 weeks for complete healing to occur. A blistering disease that primarily affects the oral significant degree of pain may persist up to several mucosa, skin, and conjunctiva. The body produces months following recurrent infection. When the antibodies against the proteins uniting the trigeminal nerve is involved, intraoral lesions may epithelium with the underlying connective tissue be seen. The lesions appear as white vesicles that resulting in blister formation. rupture to form shallow painful ulcers. The course of the disease is very similar to cutaneous lesions. Clinical Features

Treatment The condition is more commonly seen in females

in their 50s and 60s. Oral lesions are seen in a Early treatment with antivirals may limit the course majority of patients affected by this condition. of disease. Supportive treatment with antipyretics They begin as small blisters that eventually rupture and antipruritics is usually beneficial. to form painful ulcers that persist for several

weeks. Intact vesicles are rarely identified. NECROTIZING ULCERATIVE GINGIVITIS: Gingival involvement presents as desquamative

gingivitis characterized by diffuse atrophy and Necrotizing ulcerative gingivitis, also known as ulceration. Conjunctival and cutaneous lesions trench mouth, is a bacterial infection precipitated heal by scarring (cicatrix). If conjunctival lesions by stress, immunosuppression, nutritional are not promptly managed, blindness may result. deficiency, and smoking. The process is linked to a decrease in immune response against pathogenic Diagnosis and Treatment organisms due to stress .

Biopsy of lesional and perilesional tissue is Clinical Features performed for establishing diagnosis. Lesional

tissue is submitted for histopathologic Necrotizing ulcerative gingivitis is seen over a examination, while perilesional tissue should be wide age range. A higher prevalence is noted in submitted for immunofluorescent studies. Once younger individuals in stressful situations. The Page 6 the diagnosis is confirmed, the patient should be Reticular requires no treatment. The referred to an ophthalmologist to rule out eye patient should be reassured and monitored involvement. If no eye involvement is identified, periodically for changes in appearance. Erosive topical corticosteroids are usually sufficient for lichen planus can be controlled by use of potent management. If scarring of conjunctival tissue is topical steroids. noted, systemic therapy becomes mandatory. LICHENIOD MUCOSITIS: LICHEN PLANUS: Lichenoid mucositis is a term used to describe a Lichen planus is an immune-mediated process that specific immune-mediated response of the body may involve the oral and genital mucosa, and the against foreign material, drugs, artificial cinnamon skin. Oral lichen planus is relatively common. The flavoring, and dental amalgam. While the clinical precipitating factor for this condition is currently presentation of these lesions can be quite diverse, not known. It is broadly classified into reticular and they bear a striking resemblance to lichen planus erosive forms. histologically. Posterior buccal mucosa and the tongue are frequently involved with drug-related Clinical Features and contact mucositis. For amalgam reactions, the changes are noted only in the mucosa coming into Lichen planus tends to affect people in their 40s contact with the restoration. and 50s. Women appear to be more frequently affected. Cutaneous lesions present as small, Lichenoid foreign material reaction primarily pruritic, purple colored papules on the wrists, involves the gingiva. It is considered to be an ankles or the base of the spine. The papules abnormal response of mucosa against particles exhibit white, lace-like striation on the surface. originating from dental disks, polishing materials, and dentifrices. It can present itself as isolated, as Reticular lichen planus is relatively more common generalized areas of erythema, or as an ulceration than the erosive form. It presents as symmetrically resembling . A biopsy bilateral, white lace-like striations primarily should be performed and submitted for involving the buccal mucosa. Tongue, palate, and histopathologic examination. It is unlikely to gingiva may also be affected. Most patients are identify the foreign material during unaware of the presence of this condition. histopathologic evaluation. Most cases resolve spontaneously once the foreign material is Erosive lichen planus presents as bilateral, expelled. In chronic symptomatic cases, surgical symmetrical ulceration involving the buccal excision may be the only course of action. mucosa and tongue. Around the margins of the ulceration, erythema and lace-like striation, similar PIGMENTED LESIONS to reticular lichen planus, can be identified. The lesions are extremely painful forcing most patients : to seek help for the condition. Gingival involvement presents as desquamative gingivitis. Occasionally, gingival atrophy and ulceration may Amalgam tattoo is discoloration of the oral mucosa be the only presentation of disease. Identification due to embedded amalgam particles. In most of striation may be difficult in such cases. instances the particles are incorporated following placement or removal of an amalgam restoration. Treatment Clinical Features Diagnosis can usually be made on the basis of clinical appearance. A biopsy of the erosive form Amalgam tattoos are seen in patients over a wide with submission of tissue for histopathologic and age range. Since it is not the preferred choice of immunofluorescent studies, is advised. This restoration material in pediatric patients, the prevents misdiagnosing cases of chronic ulcerative frequency of tattoos identified in this population is and as erosive low. They appear as grey colored macules most lichen planus. Page 7 commonly involving the gingiva. Usually an amalgam restoration can be identified in the vicinity of the lesion. Since amalgam is also employed as a retrograde filling material, sometimes tattooing can be identified on the attached labial gingiva of anterior teeth.

Diagnosis and Treatment

Clinical appearance is usually sufficient for diagnostic purposes and no further intervention is warranted. If the clinician is unsure about the discoloration, radiographs may be helpful in Amalgam Tattoo Source: Amber Kiyani, DDS The Ohio State University identifying amalgam particles in the mucosa. College of Dentistry When no particles are noted, or if the patient has esthetic concerns, conservative surgical excision Clinical Features followed by histopathologic examination should be performed. Smoker’s melanosis occurs more commonly in Caucasians and shows a female predilection. It is MELANOTIC MACULE: presented as diffuse, light brown pigmentation. Anterior facial gingiva is more frequently involved. Melanotic macule is a pigmented lesion that results from focal deposition of melanin in oral soft Diagnosis and Treatment tissues. Some studies have implicated trauma as a potential etiological factor. A history of cigarette smoking or clinical evidence of smoking is sufficient for diagnostic purposes. Clinical Features The pigmentation usually disappears within a few months of smoking cessation. Melanotic macules occur over a wide age range. Lips are the most common site of involvement. : Buccal mucosa, palate, and gingiva may also be involved. They present as well-demarcated brown Melanoma is the malignant tumor of melanocytes. to black macules. They tend to be less than one It is primarily a cutaneous malignancy but can be centimeter in size. identified in the esophagus, small and large bowel, eye, parotid gland, nasopharynx, and the mouth. Treatment Acute damage by ultraviolet radiation is implicated as an etiological factor in cutaneous lesions, The diagnosis of melanotic macule can be made however definitive cause for mucosal lesions is on the clinical presentation. No treatment is currently unknown. Oral are relatively necessary. Dimensions of the lesion should be rare and accounts for less than 1% of all documented at the initial visit. If any changes in melanomas. Oral melanomas tend to be more appearance and size are noted at the follow up aggressive than cutaneous melanomas. visit, an excisional biopsy of the lesion may be mandated. Some patients may also request Clinical Features removal due to esthetic reasons. Oral melanomas occur in older individuals. SMOKER’S MELANOSIS: Maxillary gingiva and the are more commonly involved. The lesion initially presents Smoker’s melanosis is pigmentation of oral tissues as a large, brown to black macule, with irregular in heavy smokers. Melanin is produced as a borders. This macule rapidly evolves into an protective response of oral mucosa against toxic exophytic lesion. Ulceration is a frequent finding. products of cigarette smoke. The tumor is aggressive and can erode into the Page 8 underlying bone creating a radiographically visible vestibule. Cessation of product did not lead to defect. Some lesions may be devoid of resolution. pigmentation and may appear mucosal colored. Such lesions are difficult to diagnose clinically and Treatment are referred to as amelanotic melanoma. If the lesion is small, complete surgical excision Diagnosis extending to normal adjacent tissue is recommended. Larger lesions require incisional Pigmented lesions involving the palate and biopsies. The excised specimen should be alveolar gingiva should always be biopsied. The submitted for histopathologic evaluation. To pathologist may need to perform a series of preserve the integrity of tissue for histopathologic immunohistochemical studies to establish examination, use of lasers should be avoided definitive diagnosis. Surgical excision with wide during excision. Lasers can compromise the tissue margins is the preferred choice of treatment. For sample, making it difficult for the pathologist to deeper lesions, lymph node dissection, radiation, establish diagnosis. Lesions with a diagnosis of and chemotherapy may also be needed. epithelial atypia and mild epithelial dysplasia should be closely monitored at 3 to 6 month PREMALIGNANT AND intervals. If any changes are noted in appearance, texture and size, the lesion should undergo MALIGNANT PROCESSES additional biopsies and the course of treatment should be decided accordingly. Leukoplakias that : are diagnosed to be moderate to severely dysplastic should be either surgically excised or Leukoplakia is a clinical descriptor for white laser ablated completely. Since 30% of all patches, or plaques, in the oral cavity that have leukoplakias can recur, close clinical follow up is distinct margins. While most leukoplakias may recommended for all patients that have represent a premalignant process, definitive leukoplakia surgeries. diagnosis of dysplasia can only be provided once the lesion has been biopsied and has undergone histopathologic examination.

Clinical Features

Leukoplakias are usually seen in patients over the age of 40 and they exhibit a strong male predilection. Use of tobacco products, alcohol and sanguinaria are some of the common etiologic factors associated with this process. Studies have also implicated syphilis and candia as possible etiologies. Leukoplakia Source: Carl Allen, DDS The Ohio State University Most lesions are identified on the , buccal College of Dentistry mucosa, and gingiva. The lesions can have variable appearances; translucent, wrinkled, homogenous, PROLIFERATIVE VERRUCOUS LEUKOPLAKIA: nodular, and speckled. Variations in size is also noted. The lesions are crisply demarcated from the Proliferative verrucous leukoplakia is a condition adjacent normal tissue. characterized by development of multiple leukoplakic lesions in the oral cavity. Women tend Sanguinaria is an herbal extract that was to be more frequently affected. Gingiva is a extensively used in dentifrices in the 1970s. common site of involvement. The leukoplakias Patients that used this product over a period of may evolve to or squamous time developed characteristically thin, white cell carcinoma over a period of years. plaques on the maxillary alveolar gingiva or Page 9 Due to extensive involvement of the mucosa, : complete surgical excision of all leukoplakias is not an option. These patients need to be closely Lymphoma is a lymphoproliferative disorder. It is monitored for changes in size, texture and broadly classified as Hodgkin’s and non- appearances and regularly biopsied. If malignant Hodgkin’s lymphoma. Hodgkin’s lymphoma transformation is suspected, prompt laser ablation primarily affects the lymph nodes, while non- or surgical excision of the area is recommended. Hodgkin’s lymphoma is more frequently identified in extralymphoid tissues. : Clinical Features Squamous cell carcinoma accounts for over 90% of oral malignancies. Cigarette smoking is associated Hodgkin’s lymphoma presents with as the most common cause for this . Other lymphadenopathy commonly involving the etiological factors include smokeless tobacco, betel cervical, axillary, and mediastinal regions. Non- quid, iron deficiency, microbial agents, chemical Hodgkin’s lymphoma is characterized by fever, agents and genetic influences. malaise, night sweats, and weight loss, along with lymphadenopathy. Non-Hodgkin’s lymphoma Clinical Features can occasionally present as an intraoral mass involving the jaws, palate, or gingiva. In some tends to occur in people between 40 instances, the soft tissue swelling may result from and 80 years of age. Men appear to be more malignant cells breaking out of bone. The mass is frequently affected. It can present as a chronic erythematous and can be either smooth surfaced ulceration, an endophytic mass, a fungating tumor, or ulcerated. It tends to have a boggy or as red-white patches. Ulceration, rolled border, consistency. In case of intraosseous involvement, and induration are frequent findings. The surface a ragged radiolucency may be identified. of the tumor is usually irregular and pain may be occasionally noted. The size of the lesions vary Diagnosis and Treatment considerably. The tumor is locally destructive and may erode into the underlying bone to create The diagnosis of lymphoma is established radiographically identifiable changes. through lymph node biopsy, flow cytometry, immunophenotyping, and fluorescence in-situ Gingival lesions show a female predilection and are hybridization studies. If the oral mass is the only not consistently associated with cigarette smoking. presenting symptom, submission of tissue for They develop more commonly in the posterior histopathologic examination and mandibular region and may appear deceptively immunohistochemical studies allows the innocuous. They tend to mimic benign reactive pathologist to render a definitive diagnosis. processes such as inflammatory fibrous hyperplasia and pyogenic granulomas. Local growth LEUKEMIA: eventually results in invasion of the underlying bone and tooth mobility. Leukemia is a hematopoietic malignancy characterized by abnormally increased levels of Diagnosis and Treatment immature leukocytes in bone marrow and blood. It is broadly classified under myeloid and All clinically suspicious lesions should be biopsied lymphocytic types. Acute lymphocytic leukemia and submitted for histopathologic examination. is more common in children and follows an Once the diagnosis is confirmed, the patient is aggressive clinical course. Newer forms of referred to an otolaryngologist. Surgical excision, chemotherapy have significantly improved the radiation, and chemotherapy are the available prognosis for this process. Acute myelogenous treatment options. leukemia primarily affects adults and has unfavorable survival rates despite chemotherapy.

Page 10 Chronic forms of both lymphocytic and myeloid bone by the tumor results in loosening and leukemia are common in adults and run an eventual loss of teeth in the vicinity. indolent course. Diagnosis and Treatment Clinical Features A biopsy is mandated for rapidly enlarging Fever, fatigue, weight loss, oral ulcers, and an masses. The pathologist performs a series of increased frequency of infections are some of the immunohistochemical studies to identify the initial symptoms at presentation. Easy bruising and origin of the tumor. The prognosis for such anemia slowly develop. Extramedullary disease patients is usually poor with palliative treatment may involve the skin, central nervous system and as the only option. the gingiva. The gingiva appears ulcerated, erythematous, and swollen. It is firm on palpation CONCLUSION and can sometimes be green, owing to the high levels of myeloperoxidase in the tissues. This This concludes our review on gingival pathology. presentation is referred to as granulocytic or chloroma. A few important points to remember:

Diagnosis and Treatment • If it is not possible to diagnose a lesion clinically, a biopsy is mandatory. The diagnosis of leukemia is usually made through blood studies and bone marrow examination. If • Tissue from surgical excisions should always be the patient does not have a prior diagnosis of submitted for histopathologic examination. leukemia and presents with gingival involvement, the dentist should perform an incisional biopsy and • Patients with premalignant and malignant submit for histopathologic examination. The lesions should be followed closely. Any pathologist will perform numerous progression in lesional tissue should warrant immunohistochemical studies in order to establish an immediate biopsy. definitive diagnosis. Once the diagnosis of leukemia is confirmed, the patient is referred to a hemeoncologist so chemotherapy can be initiated.

METASTATIC DISEASE:

Metastasis to the oral cavity is relatively rare and accounts for only 1-1.5% of oral malignancies.

Tumors from lung, breast, prostate, kidney and thyroid tend to metastasize to the oral cavity. ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. About 25% of patients are unaware of their primary GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE tumor prior to biopsy of their oral lesion. UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE Clinical Features INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH DIAGNOSTIC AND TEACHING PURPOSES. Metastatic disease of the oral cavity is more HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU commonly seen in individuals between the ages of INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH GASTROINTESTINAL DISEASES. 40-70. Men appear to be more frequently affected than females. In oral soft tissues, 50% of tumors DR. AMBER KIYANI CAN BE CONTACTED occur on the gingiva. The lesions present as AT: [email protected] nodular masses that vary in size considerably. Surface ulceration is a common feature. The lesion exhibits an aggressive growth potential and enlarges rapidly. Destruction of the underlying Page 11 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is June 23, 2014

Peripheral ossifying fibromas frequently enlarge 1 T F beyond two centimeters.

2 T F Excision of pregnancy tumors should be SUBMITcompleted upon detection.

Cutaneous involvement is common with 3 T F pyogenic granuloma.

Cigarette smoking is associated with squamous 4 T F cell carcinoma, leukoplakia, and smoker’s ONLINEmelanosis.

Oral melanomas tend to be more aggressive than 5 T F cutaneous melanomas. d i r e c t o r john r. kalmar, dmd, phd [email protected] Leukoplakias on the maxillary alveolar gingiva 6SUBMIT T F and vestibule have been associated with a s s i s t a n t d i r e c t o r sanguinaria use in the past. karen k. daw, mba, cecm [email protected] Melanotic macules are caused by a specific 7 T F immune-mediated response to artificial channel coordinator cinnamon flavoring. rachel a. flad, bs [email protected]

ONLINEErosive lichen planus is relatively less common 8 T F than reticular lichen planus.

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