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Home , Actinic cheilitis, Amalgam tattoo, Amelogenesis imperfecta, Attrition (dental), Dental fluorosis, Drooling

A.O.C.D. April 25, 2015

Everything you want to know about stuff inside the !!!

GOAL That you will all be Even Greater Giants in the field of oral !!! Oral Dermatology From

Jonathan S. Crane, D.O., F.A.O.C.D. Board-Certified Dermatologist Derm One Dermatology, Wilmington, North Carolina Sampson County Dermatology Residency Program Director Campbell University School of Osteopathic Medicine Dermatology Course Director Pharmaceutical Company Disclosures

Dr. Crane has done research, consulted for, and/or is on the speaker’s bureau for the following:

3M Allergan Candella Laser Company Fujisawa Genentech, Inc. Glaxo Smith Klein

Amongst other companies… Credits

www.uiowa.edu

Oral by John L. Giunta, BS, DMD, MS, Professor of Oral Pathology

Otolaryngology - Houston

Caused by? The stem of the pipe wearing away the lower teeth. - Asymptomatic dark blue-gray macule noted by patient for past 6 months - Not changing since noticed

Amalgam tattoo Iatrogenic caused by traumatic implantation of dental amalgam into soft tissue Most common localized pigmented lesion in the mouth 0.4-0.9% of the US adult population Dark gray or blue, flat macule Located adjacent to a restored No additional treatment is necessary except for cosmetic reasons Laser treatment can be tried www.uiowa.edu

Aphthous

• Ulcer in the center • No diagnostic microscopic findings • Diagnosis is based on the clinical findings and history • Minor and Major forms described Minor Aphthous Ulcers

Most common form www.uiowa.edu Small painful round ulcers 3-6 mm 2-6 can be present Heal w/o scarring 7-12 days Treated with topical steroids, oral steroids, Duke’s Magic , topical immunomodulators, and nicomide Major Aphthous Ulcers Deep painful ulcers 1-2 cm in diameter Last 3-6 weeks May cause scarring 1-5 lesions present at one time

Treatment

•Topical steroids •Intralesional steroid injections •Systemic steroids •Viscous •Dapsone 25-50 mg / day •Colchicine 0.6 mg tid • 300 mg QD then taper Lab investigation: CBC, CMP, G6PD, , Iron, B12 HIV patient with this ulcerated lesion on the lateral . States he doesn’t recall biting it.

• Thalidomide (Thalomid)

• Effective treatment of oral and esophageal aphthous lesions in HIV-infected patients Aphthous • Reserved for severe or -refractory cases In HIV Patient Teratogenic effects

• Rx to appropriate patient  68 year-old male  Wearing away of teeth  Ground down almost to the roots  Orange center is secondary with the yellow dentin surrounding it

Attrition: Erosion by friction • Rapid Onset, slight • painful mouth Ulcers • malodor to her breath • metallic taste • feels the teeth are wedged b/c are swollen • Symptoms of fever & Lymphadenopathy can mimic a viral

The gingival interdental papillae become necrotic and appear cut off Necrotizing Necrotic Tissue acts as a medium For Bacterial infection caused by a fusiform bacillus-spirochete complex plus other oral Gingivostomatitis (ANUG) Triggered by a decrease in the immune response Local debridement of the necrotic material and careful scaling Dental follow-up important! helpful (PCN) 3% Hydrogen peroxide mouthwash May be a sign of AIDS ANUG

Lesions may spread rapidly to involve buccal mucosa, , tongue, and entire respiratory tract

A Severe Form Of ANUG Pearl: Characteristic foul fetid odor is always present 15 year-old with this swelling noted recently by the orthodontist

Pearl: Swellings on the should be respected and make one suspicious

Adenoid cystic carcinoma • tumors can affect the young • Serious lesion • Grow very slowly and invade locally along

Prognosis: relatively good for 10-15 years and very poor at the 20 year follow up when 80+% of patients have died of their

Treatment: -Excision - Possible Radiation - Possible Chemo

Mass on right hard and Ulcerated surface Fixed to surrounding structures

Bulimia is an eating and psychiatric compulsive disorder characterized by episodic binge eating of large volumes of food, followed by purging behavior such as Female new college student presents to your office self-induced vomiting, vigorous You find increased caries and enamel erosion and laxative or diuretic abuse. may Small, purplish-red lesions on the palate take place once enamel is worn down. Swollen lymph nodes and salivary glands , dry lips and around the mouth Broken scleral blood vessels

Provide support and seek psychological assistance Bismuth Line Generalized Pigmentation due to bismuth poisoning.

Patient’s mother treated for while bearing him is pigmented bilaterally 83 Foul breath, notices increased salivation Bi Mild renal insufficiency on Chem 7 208.98038(2) Chronic infection which has associated skin lesions and occasional chronic mouth ulcers

Blastomycosis

• Inhaled spores of dimorphic Blastomyces dermatitidis • Prevalent in Southeastern US and Ohio/Mississippi River Basins and Kentucky • Male to female ratio 6:1 • Oral itraconazole 200-400 mg/day for SIX MONTHS • For more severe cases, IV administered amphotericin B Bechets

• More common in males than in females (8:1) • second or third decade of life • Oral, genital, and ocular lesions • Recurrent aphthous ulcers 3 bouts per year • Plus any two of the following Recurrent genital ulceration Retinal / Skin lesions: E.nodosum, Pseudofolliculitis or Treatment of Bechet’s Syndrome

Mild mouthwash and Colchicine 0.6 mg bid to tid by mouth Dapsone Thalidomide Methotrexate Cyclosporine

Totally normal anatomic finding

Copyright © 1998 John L. Giunta, DMD, MS Circumvallate papillae

The are the largest of the papillae Located at the most posterior dorsal surface forming a V-shape with the point toward the posterior May be exaggerated, rise above the surface to mimic a tumor or tumors. If there were only one swelling in the midline in this region, one could consider lingual thyroid Treatment options include laser destruction, excision or reassurance Congenital ”Cold Sores”

Caused by HSV1 85% adults worldwide are seropositive; 50% with history of orolabial involvement Most cases transmitted during asymptomatic shedding

• Topicals: Penciclovir and Acyclovir are minimally effective • Oral antiviral agents: Valtrex, Famvir, Zovirax • New med sticks inside mouth Sitavig 50 mg Pearl: First outbreak • acylovir single dose should be treated at higher doses and for longer course Angular Chelitis

Dr. Kevin T. Kavanagh, MD

Crusting and cracking at corners of mouth Caused by a yeast organism (C.albicans) Predisposing factors: , overhanging upper , and skin laxity resulting in moist environment, , AIDS, and mucocutaneous Anti-yeast creams and topical steroids commonly used Nystatin for oral/buccal yeast Recurrent cases may require for anatomic causes Restalin and Sculptra helpful Condyloma acuminatum

www.uiowa.edu

Multiple, rough, warty lesions on dorsum of the tongue Oral lesions should be a diagnosis. Common STD in adults 50 % infectivity rate in some populations May predispose toward Rare in mouth, common around genitals/anus Liquid nitrogen for oral lesions works well

Denture trauma

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An ulcer is present on the anterior mandibular alveolar ridge

Refit dentures…. www.uiowa.edu

• CAT Scan or MRI needed • Consider excision Congenital in origin from improper embryonic growth Occurs along cleavage lines Large, compressible well-circumscribed soft tissue enlargement Present in the floor of the mouth Can elevate the tongue

28 year-old male in the military, excellent health Born in the southwest Mottled enamel

• excess, particularly above 1 ppm • Etiology is drinking water and excess tablet ingestion • Affects developing teeth • Starts as whitened spots on the teeth that later become stained • Fluoride substitutes for the calcium content and with less calcium, the teeth are yellowed • A could include imperfecta (genetic enamel disorder) which would have radiographic changes and a hereditary pattern

Exostoses

• Slowly growing nodular growth of dense cortical • Commonly located on maxillary or mandibular buccal alveolar bone, usually in the bicuspid / molar area • Occurs in late teen and early adult years, more common in females than in males • Etiology: Genetic prevalence • TREATMENT: Surgical www.uiowa.edu •A brown macule is present on the vermilion zone of the lower lip •Darkens on sun exposure •NOT a benign Labial melanocytic macule or labial , which do NOT change on sun exposure Ephelides •Ephelides can change with sun exposure •Treatment: Liquid Nitrogen, reassurance, laser () and/or biopsy Diagnosis: • Clinical appearance & family history • Skin bx using transmission electron microscopy or immunofluorescent /antigen mapping. • Rarely genetic testing of KRT5 gene or the KRT14 gene is needed • Autosomal dominant, rarely autosomal recessive www.uiowa.edu • Genetic counseling and prenatal testing are essential in families that have this Epidermolysis bullosa simplex disease in their family lineage

Blister formation after minor trauma to the Management: skin. 4 types described Skin: form: hands, joints, elbows, • Standard non-adherent knees and repetitive trauma areas dressing care for blisters Oral Manifestations: Multiple ulcers of the lips • skin protection and perioral skin. Prevents normal eating and • attention to secondary ensues Most are inherited, rare , infection About 100,000 in the US have EBS (1 in • 20 % aluminum chloride to 500,000 births) palms and soles to reduce Chronic , malnutrition, and growth retardation are common formation • new denture • on the left

Epulis fissuratum

Also referred to as “Inflammatory fibrous ”or “denture hyperplasia” Soft tissue enlargements with a prominent fissure into which the denture flange fits Treatment is to relieve the denture to see if the tissue regresses, if no regression occurs then biopsy needed multiforme Major Ulcers on the gingiva and lower labial mucosa with targetoid lesion on hands

• The major variant is associated with fever, systemic symptoms, and severe oral lesions. • EM major causes include infectious (herpes simplex, echoviruses, pneumoniae, psittacosis, ), drugs, radiation therapy, and other triggers • Considered a hypersensitivity reaction • Treatment involves determining and treating the etiology • If unknown, empiric oral antiviral agents, antibiotics, and corticosteroids (early) may be used • The use of corticosteroids is controversial late in the disease course

Fungiform Papillae

• Young patient noticed spots on his tongue after a date with a new girl • Very prominent pink, circular and dome-shaped

• May or may not have any taste buds in the papillae • Prominent supply • Filiform papillae are the smaller white "hairlike" surrounding structures. • coating making them white Copyright © 1998 John L. Giunta, DMD, MS

56 year-old male Fissured/furrowed tongue Scrotal Tongue or Lingua Plicata

• Seen in Melkersson-Rosenthal syndrome and most patients • Ulceration at the base = true fissure with necrotic debris • Base lined with = furrow  Bacteria accumulate giving malodor • Other than brushing the tongue, there is no treatment • Grooves tend to appear and get deeper or more prominent with age • Must be differentiated from “cobblestone tongue” of syphilis Syphilis

• Tongue findings usually occur in late stages • Findings include: – of base of tongue – Interstitial syphilis of anterior portion of tongue – Tongue may be rigid and stiff with radiating furrows and lack of papillae over affected areas – Surface may be thrown into lobes = cobblestone tongue Result of gummous deposits – Common to have deep furrows covered in leukoplaktic spots where teeth contact tongue may ulcerate Can evolve into cancer Foliate papillae

Normal bilateral structures on the most posterior lateral surface of the tongue Small nodules or vertical folds and grooves composed of lymphoid tissue May contain taste buds In smokers, they may get very red and exaggerated Important to visualize: cancer of the tongue may be found just anterior to them Yellow plaques with a smooth surface

Fordyce granules represent ectopic sebaceous glands and are not pathologic. Another common location are the lips. Fordyce granules Familial epithelial hyperplasia (white sponge )

White epithelial thickening of the left buccal mucosa & mandibular vestibule Mouth, vagina, or rectum involved Progression stops at Autosomal dominant may provide improvement Oral

Dr. Kevin T. Kavanagh, MD

This is a benign lesion in a young patient which can easily be removed as an office procedure

Granular cell tumor

Soft tissue enlargement with an ulcer on the dorsum of the tongue Sessile, painless, somewhat firm, immobile < 1.5 cm. in diameter Most are benign, very rarely malignant Conservative excision is the treatment of choice Less than 7% reoccur Those that reoccur, change in size rapidly, or are > 5 cm should raise grave suspicion Circumscribed soft tissue enlargement on the gingiva

• Developmental abnormality • 5th and 6th decades of life • Uncommon, asymptomatic • Firm, compressible, usually less than 0.5 cm • Dome-like swelling often bluish or blue-gray filled with fluid • Facial gingiva or alveolar mucosa • Mandibular canine-premolar area • Treatment: Excision • Results: Excellent (Benign Migratory ) (Wandering of the Tongue)

Dr. Kevin T. Kavanagh, MD

Benign non-painful Caused by the absence of papilla Glassy patches move around the tongue and change shape Often occurs together with Cause unknown. May be associated with or atopic Treatment: Retin A for 4-6 weeks, corticosteroids for discomfort Avoid brushing tongue

Herpes labialis, recurrent Reactivation of the Lies dormant in the trigeminal Triggering factors (sun, fever, trauma, emotions) proliferate the virus Seeks out peripheral epithelium, forms vesicles that eventually break open Multiple vesicles have coalesced to form a blister or bulla Healing involves a crusting stage and can take weeks

Treatment: Oral antiviral agents Painful, red lesions Recent Dental Visit Smoker

Herpes, Recurrent Intraoral

Not as common as recurrent Virus is triggered to proliferate on the hard, bound down mucosa (not moveable) Can be triggered by trauma Erythema with small, punched out ulcers

Nicotinic stomatitis also present Hand, foot and mouth disease  Young person  Painful oral ulcers of sudden onset  Grouped erythematous

 Accompanying skin lesions can help to establish the diagnosis in such cases www.dental.mu.edu Hand, foot, and mouth disease

Treatment

• No specific treatment needed disease is self- limiting • Use of therapeutic agents to help alleviate pain • Antipyretics reduce fever •  decrease pain

• Childhood disease • Multiple types of coxsackie and echoviruses •Acute onset of fever, , sore •One or more yellow-white vesicles •Anterior faucial pillars, tonsils, uvula or soft palate •Lesions disappear in 5-10 days Hairy Tongue

Dr. Kevin T. Kavanagh, MD

Relatively rare condition which is caused by the elongation of the taste buds Filiform papillae elongate and do not desquamate normally Triggered by smoking, antibiotics, GERD and poor Treatment involves good oral hygiene, brushing of the tongue with Retin A, mouth rinses with Nystatin solution, smoking cessation, etc. Trimming of the elongated papilla may be helpful Left picture is the same patient two months later after improvement in his oral hygiene Lingual

Benign lesion Surgery is difficult Angiography is often needed to outline the feeding vessels and to embolize the hemangioma Laser treatments may be helpful Hemangioma

Diffuse compressible purple enlargement of the right anterior tongue The lesion blanches upon pressure Laser treatment may be considered Hematoma

Purple thickened pigmented lesion Does not blanch upon pressure Present on the left lateral border of the tongue Duration is three weeks Consider biopsy if present for more than one month Herpes zoster

Extensive ulceration of the extending to the midline Caused by varicella virus (chicken pox) reactivation Treatment with high-dose anti-viral agents orally Post-herpetic may occur, especially in older patients When unsure of diagnosis, still treat Oral Mucosal

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Rough, white, asymptomatic patch which does not rub off Located on the mandibular left gingiva and alveolar mucosa

• Always consider biopsy as this may look like • May be associated with hyperkeratosis of palms and soles • Then known as focal palmoplantar and hyperkeratosis syndrome • Treatment: Retinoids may be helpful, consider cessation (, etc.)

Irritation fibroma (polypoid fibrous hyperplasia)

Well-circumscribed dome-shaped soft tissue enlargement of the left buccal mucosa Iron deficiency anemia

Angular , pale colored lips, and smooth bald tongue

Treatment or correction of underlying cause Supplementation with iron

• Anemia's and deficiencies can yield both • Smooth tongue as manifestations • The blue lesion on the lower lip is a dilated or varix

Copyright © 1998 John L. Giunta, DMD, MS

Normal structure that lies just lingual or palatal to the two central incisors Same color as the surrounding tissue or a bit bluish Can be quite exaggerated or tumor like May get traumatized Excise only if symptomatic

Jaffe-Lichtenstein Syndrome (Jaffe Syndrome)

•Syndrome characterized by polyostotic fibrous dysplasia of the skeletal system •Cafe-au-lait spots •Early childhood, multiple, slow-growing, painless expansile bone lesions •Confined to the craniofacial area or throughout the skeleton •May have irregular shaped Café Au Lait Spots on the torso •Disfiguring •increased level of serum alkaline phosphattase •Etiology unknown, possibly genetic •TREATMENT: cosmetic surgery •Prognosis: Good Marquette University School of

Kaposi's Homosexual IV Drug user with circumscribed purple compressible surface lesion on the hard palate The lesion blanches on pressure

Diagnosis: Biopsy Treatment: Intralesional or systemic

Indurated soft tissue enlargement of the right commissure area Fixed to the surface and to underlying muscle Filled with keratin

Solitary, grows rapidly to sizes of 2.5 cm in 3 to 8 weeks Remove by excision or deep scoop biopsy with electrodessication Specimen should be sent to a dermatopathologist as differentiation from squamous cell carcinoma is crucial

Lingual Thyroid

•Very rare •Migration fails and the gland remains in the base of the tongue •Four times more common in females than in males •Asymptomatic midline nodules in the posterior aspect of the tongue • 1 cm (up to 4 cm) • 70% have hypothyroidism 20 year-old presented with "hot potato speech" Difficulty in breathing and swallowing Red fleshy mass at the base of the tongue

• 10% with cretinism (Hypothyroidism during fetal development) Lingual • Normal anatomy, no treatment

Mimics with a white patch Can stretch leukoedema tissue the white essentially disappears Leukoplakia would not disappear Usually bilateral and a hereditary disease, , is similar with wet, shiny looking white lesions White is caused by water within the spinous cells causing the light to reflect back as whitish There is no treatment Lead Poisoning

Generalized pigmentation of gingival margin Worked in a factory smelting for 30 years

Remove oneself from exposure Serial lead levels Consider chelating agents Oral Leukoplakia

• Clinical term defines white patch or plaque attached to oral mucosa • IT IS PRECANCEROUS! • 5% with malignant transformation • Etiologies: Tobacco, , friction, candida, GERD • TREATMENT: Eliminate predisposing factors, Retin A, surgical excision

Dr. Kevin T. Kavanagh, MD

Dr. Kevin T. Kavanagh, MD Chronic, common, inflammatory disease of oral mucosa and skin Skin lesions are polygonal purple pruritic planar papules (PPPPP) Often on the extremities White lace-like pattern on the inside of the Can be caused by a reaction to meds (ß-Blockers, oral hypoglycemics) Can also be associated with other conditions such as C Treatment is with Retin-A®, Accutane®, topical steroids, topical immunomodulators and oral Systemic erythematosus

Ulcers with white hyperkeratotic periphery are present on the right buccal mucosa with this facial rash

• Genetic factors play a role in SLE, • May be a/w anemia, low platelets & WBC • Diagnosis: Skin biopsy for H & E plus IF • LABS: ANA, ssA, ssB, anti-ssDNA and others • Treatment: Corticosteroid administration, Avoid sun, Plaquenil Non-Hodgkin's soft tissue enlargement of the uvula and right soft palate

Diagnosis by biopsy, Staging necessary Treatment: Chemotherapy Linea alba benign hyperkeratosis secondary to mild long-term irritation from the teeth cusps

MEDICATION Atabrine (quinacrine) hydrochloride

Used to treat protozoal & helmintic It can cause diffuse pigmentation on the hard palate in this patient Aspirin

Recent headache Took OTC medication

Desquamative Could be pseudomembranous candidiasis Aspirin is an acid that can burn the tissues if left to contact them Patient dissolved aspirin tablet in her mouth 27 year-old female w/ h/o seizures

Dilantin Hyperplasia

Side reaction causes the to build up yielding a fibrous, non-inflammatory hyperplasia Other drugs that do the same thing are cyclosporine and calcium channel blockers like nifedipine TX: Gingivectomy to remove the overgrowth Otolaryngology Houston Mucormycosis Transmission: Airborne spore inhalation

• 32 year-old juvenile diabetic w/ & DKA • irregularly shaped hyphae of fungal species, including Rhizopus, Rhizomucor, • Absidia, and Basidiobolus • White mucosa of the left hard palate (blanched) and necrotic • easily entered w/ forceps via eroded bone of hard palate • Sinus was full of necrotic brown material • TREATMENT: Surgical debridement and Amphotericin B • Treatment: Surgical Excision

Bechara Y. Ghorayeb, MD

Mucocele of Lower Lip Diffuse thickened darkly pigmented lesion of the mandibular right gingiva and alveolar mucosa • Oral melanoma carries a poor prognosis Persistent nonthickened brown Circular 3 x 3 mm macule flat lesion asymptomatic macule on the with a change in color near the left soft palate midline of lower lip Labial melanotic macule Most common melanotic lesion of the lip is a melanotic macule Pigment confined to basal cells and upper lamina propia Macules are biopsied to prove that they are not a pigmented nevus or a melanoma

Copyright © 1998 John L. Giunta, DMD, MS Enigmatic inflammatory or infectious condition of the dorsum of the tongue Benign, ncommon condition, etiology unknown Prevalence in adults is less than 1% Usually asymptomatic or may cause a slight burning sensation associated with spicy foods The patch of reddened mucosa may be flat or raised; it is usually sharply circumscribed, with a somewhat Bechara Y. Ghorayeb, MD rhomboidal shape. Occasionally, there is a nodular component, or the lesion may be lobulated. The texture may be similar to the surrounding tongue or firm, and Median Rhomboid Glossitis the surface is relatively smooth Biopsy and excise

Red or red-white patch on the midline of the dorsum of the tongue, just anterior to the region of the V of the circumvallate papillae (sulcus terminalis)

Neuroma

Soft tissue enlargement in the mandibular right area The surface of the lesion demonstrates epithelial thickening, probably secondary to trauma from a denture. The lesion is tender to palpation Multiple peripheral nerve bundles in a disorganized pattern separated by dense irregular Necrotizing sialometaplasia

Punctate ulcer on the posterior lateral portion of the hard palate

• Self-limiting benign inflammatory disorder of the salivary gland • Possibly ischemic after vascular infarct • Sudden onset, nodular swelling, that leaves to crater formation • TREATMENT: Spontaneously heals in 4-8 weeks Nicotinic stomatitis

The hard palate is white, rough and nontender The white lesion does not rub off

Specific form of leukoplakia Nicotinic stomatitis is associated with pipe, and cigarette smoking Extra keratin to form at the surface Associated with red, depressed areas corresponding to the inflamed openings of mucous ducts Red dots, representing dilated salivary gland duct orifices, are present in the white plaque TREATMENT: Smoking cessation, Retin-A, biopsy, excision, laser

Oral-Maxillary Fistula

Dr. Kevin T. Kavanagh, MD

Fistula develops between the mouth and the maxillary sinus Can be caused by dental infections or a of surgery Treatment is with a layered surgical closure Oral

•Seen in immunocompromised patients •Test for HIV disease

Characteristic hyperkeratotic, white, non- removable oral hairy leukoplakia lesion

A sessile nodule on the gingiva

Parulis, Parulides (Gum Bois)

Marquette University School of Dentistry

Etiology: Dental infection Occurs at the site where a draining sinus tact reaches the surface.

Treatment antibiotics, oral surgery consult Palatal Rugae

Normal structures Series of ridges composed of dense connective tissue covered by squamous epithelium Mistaken for disease and can be very large Easily be traumatized by rough or hot foods causing erosions and/or ulcerations Papilloma Firm, white, rough, exophytic, pedunculated, nontender soft tissue enlargement is present on the right ventral tongue The enlargement is fixed to the surface mucosa but not to underlying structures Shave excision and electrodessicate base Vulgaris

• with antigen- antibody complexes accumulating at the in the spinous cells of the epithelium Desmognein 3 • Low-power photomicrograph shows a vesicle within the stratified squamous epithelium • Collapsed vesicles and bullae and crusted ulcers are present on the face • DIAGNOSIS: H & E, immunoflourescent stain of biopsy IGG and C3 • TREATMENT: prednisone, immunosuppressants Peridontal (Gingival abscess)

A tender erythematous fluctuant is present facial to the maxillary first and second molars

Treatment: Antibiotics, I & D/Excision, hygiene Peripheral ossifying fibroma A well circumscribed firm nontender soft tissue enlargement is present on the gingiva facial to the mandibular right canine. Probably due to trauma. •DIAGNOSIS: Biopsy and excise lesion

Peripheral giant cell A well circumscribed erythematous soft tissue enlargement is present on the facial gingiva between the maxillary left canine and first premolar. The lesion blanches upon pressure. A small ulceration, probably due to trauma, is present on the surface.

Erythematous gingiva A blast of air is causing the formation of a blister is known as a Nikolsky sign DIAGNOSIS: H & E, IF of biopsy TREATMENT: Prednisone, topical steroids, topical immunomodulators, doxycycline, nicomide

A red compressible rapidly growing well circumscribed soft tissue enlargement of the right anterior tongue Blanches upon pressure White areas are fibrin clots covering ulcerations Treatment is excisional biopsy Tendency to recur pregnant recent growth

Pregnancy tumors pyogenic granuloma

• Swelling, redness & protrusion of the left tonsil • white • slightly displaced uvula • of • bad breath • “hot potato speech”

Quinsy () Quinsy is derived from ancient Greek for dog Treatment: strangling/collar. In 1300, the French used the • Incision and drainage word to describe “a severe ” : qwinaci • broad-spectrum antibiotics = quinsy • pain relief • May need hospitalization for airway protection and IV antibiotics • Next day follow-up if treated outpatient

Dental resident notices dark areas at gingival lines. Asks you for your opinion. You then tell the resident to do plaque scrapings all week.

Normal finding Racial pigmentation No treatment Findings:Same resident one year later •noticesLow bloodgingival pressure pigmentation on a • Weaknessdifferent patient. She diagnoses • High potassium • Lowracial sodiumpigmentation. You see the (Blood/urine)patient, ask some questions and • Lowthe resident cortisol is once again put to • Low plaquealdosterone scraping duty.

Addison’s Disease www.uiowa.edu

• Described by Dr. Thomas Addison in London in 1855. Rare. • Auto-immune complexes against adrenal cortex • cortisol and aldosterone are produced at adrenal cortex • not produced because of the destruction (Primary adrenal • Treatment is insufficiency also called Addison’s Disease). Secondary causes much replacement w/cortisone more common. and florinef or treatment • Cancer mets, fungal infections, CMV/AIDS & hemorrhage of underlying cause • Pigmentation results from excess of ACTH (adrenocorticotrophic • Salt and fluid hormone), one of the normal stimulants of human pigmentation. The others are melanocortins, α-melanocyte stimulating hormone (α -MSH) replacement when ill • Darkening of , nipples, , skin creases, gums, mouth • Avoid dehydration and vaginal lining

Salivary Gland Stone (Sialolith)

Forms in the duct. The left picture shows the duct's papilla in the floor of the mouth, underneath the patient's tongue. This duct drains uphill, is wide a has a mucoid or viscous secretion. 80% of all sialoliths affect major salivary glands and 75% of these are found in the

Treatment consists of excising the stone (if a/w ) or manual manipulation of stone through duct orifice Prevention is with hydration, gland massage and using a few drop of sour lemon juice several times a day to increase salivary flow

Blockage of a salivary gland duct Duct enlarges, forms a sac of saliva Treatment is surgical excision (Herpes Zoster)

• Herpes Zoster Virus (HZV) • Occur years after an individual has had chicken pox • H. Zoster is carried dormant in cell bodies of nerve tissue suppressed by Ab levels • When Ab levels fall the dormant virus emerges & causes lesions to erupt on the skin in which the nerve innervates. • Above corresponds to the lower division of the (V cranial nerve) and the lingual nerve (XII cranial nerve). • TX: Antiviral agents, at least 7 days Schwannoma (Neurilemmoma, Neurinoma, Perineural fibroblastoma) • Benign tumor of ectodermal origin • Derived from schwann cells • Oral cavity is involved in the 2nd or 3rd decade • Often arises from the 8th CN • In a/w in von Recklinghausen's disease • Schwannomatosis, a non- hereditary disease characterized by multiple subcutaneous & On the gingiva, facial to the maxillary intradermal schwannomas together with tumors of internal left first molar organs. A well-circumscribed firm • Antoni type A and B Non-tender soft tissue enlargement Treatment is Excision Squamous Cell Carcinoma

Exposed to appreciable sunshine or UV light Changes c/w w/ blotchy leukoplakia Loss of

• Common cancer of the lower lip Treatment is Excision w/ lip reconstruction Squamous cell carcinoma

Asymptomatic red patch w/ white rough areas is present on the left soft palate Erythematous pebbly plaque, surface lesion Pt unaware of the lesion

Treatment: Surgical Excision, Radiation, Chemotherapy

Tetracycline staining don’t take less than age 8 Stain the teeth different colors, from yellows to tans to greys as in this case.

19 year-old female, father was a missionary physician in South America. Remembers dad gave her medicine to prevent infection when she was 1-8 years old •Must distinguish from dentinogenesis imperfecta Hereditary disease Autosomal dominant Sclerosis of the root canal system, Short roots and bell shaped crowns History and radiographs are important in distinguishing between them Tissue tags

Essentially normal tissues Tags are mistaken for disease May look like a fibroma or other tumor because they are nodular Requires an excisional biopsy if bothersome Tattoo

Thickened gray-black nontender surface lesion present on the right posterior hard palate

Tattoo due to graphite from a pencil implanted in the tissue TREATMENT: Laser Tori

• Exostosis • More common, females over 30 • 20% of adults • Rarely needs treatment • Slowly increases in size • Occasionally removed for denture fit

Torus palatinus

Mandibular tori WWW.GHORAYEB.COM www.entusa.com , Acute Usually caused by gram positive bacteria Streptococcal Pyrogenesis origin poses risk of rheumatic fever (RF) Often multiple different bacteria exist in the tonsillar crypts difficult to culture TX w/ antibiotics to prevent RF & tonsillar abscess formation is advisable also causes acute tonsillitis Myalgias and high fever can assist differentiation from EBV symptoms Rapid tests (rapid strep and MonoSpot) can be helpful They miss up to 15% of cases. History and duration of sx important

Varix

A well circumscribed raised compressible surface lesion is present on the vermilion zone of the lower lip. The lesion blanches upon pressure.

A thrombosed varix does NOT blanch upon pressure TREATMENT: Laser helpful 66 year-old male with a burning tongue

Vitamin B12 deficiency

• Other causes of smooth bald tongue and angular chelitis include iron deficiency anemia, pernicious anemia, and geographic tongue •Can affect up to 15% of patients 65 and older •Acid blocking agents can trigger low levels of B12 from lack of absorption •Measure Vitamin B12 levels (lowered), serum methylmalonic acid and homocysteine levels (elevated), CBC (MCV and Hgb) and peripheral smear •Treatment: Vitamin B replacement, determine cause (malabsoprtion syndromes, nutritional deficiency and other causes) Asymptomatic lesion Small, white Papillary projections on the surface Sessile or broad base

• 30 types spread through sexual contact •Oral HPV least common of STD routes TREATMENTS: • cream •20 percent podophyllin antimitotic soln •0.5 percent podofilox solution •5 percent 5- cream •Trichloroacetic acid (TCA) •freezing () •burning (electrocautery) •laser treatment

Human papilloma virus 79 year-old female Varicosities

Occur in older patients, loss of elasticity in the wall of the veins Mimic a hemangioma in color Lingual veins get tortuous No treatment usually needed •Unilateral sore throat that increases in intensity over several days •Earache on same side •Bad taste and fetid breath

Vincent's of the Tonsil

•Acute necrotizing infection of the pharynx •Fusiform bacilli & spirochetes cause it •Gentian violet-stained smear of the pharyngeal exudate makes diagnosis •Same organisms cause gingivostomatitis (trench mouth)

•Deep well circumscribed unilateral ulcer of one tonsil. •Base of the ulcer is gray and bleeds easily when scraped •Associated submandibular lymphadenopathy •TREATMENT: Penicillin or Clindamycin and surgical debridement

White Sponge Nevus

•Relatively rare, autosomal dominant •Asymptomatic, symmetric, thickened, white, corrugated folded or velvety, diffuse plaques •Buccal mucosa, ventral tongue, labial mucosa, soft palate, alveolar mucosa or floor of the mouth •TREATMENT: No treatment is needed •Prognsos: Good

Xerostomia (Dry Mouth)

Predisposes to fungal/bacterial mucosal infections Angular cheilitis Caries and tooth erosion Inability to express saliva from ductal orifice by gland palpation Need for frequent sips of water or other liquid to keep mouth moist Dry eyes and genital tissues Etiology: ( affect) » Difficulty chewing & swallowing food diuretics, sedatives, hypnotics, , (especially dry foods) antihypertensives, antipsychotics, antidepressants, , and appetite suppressants » Sensation of burning, dryness, or tingling Radiation therapy to head and , salivary gland of the oral mucosa surgery Autoimmune disorders such HIV infections, » Difficulty speaking systemic , rheumatoid , » Dry, glossy atrophic mucosa and Sjogren's Syndrome Endocrine disorders such as diabetes & » Altered taste or diminished taste ability hyperthyroidism » Inflamed, fissured tongue » partial or total papillary atrophy Prognosis: Good » Unilateral or bilateral glandular enlargement

Treatment: Consider stopping offending medication Commercial saliva substitute Fluoride Supplementation Scrupulous dental care is essential

Yellow (Jaundice)

A yellowish staining of the integument, sclerae, and deeper tissues and the excretions with bile pigments, increased in the plasma Spectrum between green and orange is possible Many etiologies: Usually hepatic or metabolic deficiencies

Zygomycosis •Most acute and fulminate fungal infection known •Typically involves the rhino-facial-cranial area, , , skin, or less commonly other organ systems •Associated with acidotic diabetes, starvation, severe , intravenous drug abuse •Other diseases such as leukemia and lymphoma, immunosuppressive therapy, or the use of cytotoxins and corticosteroids, therapy with desferrioxamine •Infecting fungi have a predilection for invading vessels Zygomycosis of the arterial system, causing embolization and caused by Conidiobolus subsequent necrosis of surrounding tissue MANAGEMENT: Early diagnosis, control or reversal of any underlying disease, therapy and aggressive surgical debridement which may have to be repeated until all infected necrotic tissue is removed. DRUG OF CHOICE: Amphotericin B is the drug of choice and full-dose therapy of 1.0 or 1.5 mg/kg/day for 8 to 10 weeks