DISCLOSURE
This lecture has been adapted from Dr. Michael A. Kahn from Tufts University
Images are take from various sources, including: Dr. Kahn’s original lecture Lectures of Dr. Bruno Jham Oral and Maxillofacial Pathology by Neville and Damm Oral Radiology by White and Pharoah Mosby’s Review NBDE Part 2
Fordyce Granules
Sebaceous glands that occur on the oral mucosa
Yellow plaques/granules
Most common on buccal mucosa and upper lip vermillion
Leukoedema
Intracellular edema of cells More often seen in African Americans Bilateral on buccal mucosa KEY: white area disappears on pulling or stretching the mucosa Normal variant; no treatment required Leukoedema Varices
Located on lip and under the tongue (most common)
Typically seen in elderly Sublingual varices seen in 2/3 of older people
Dilated blue veins
Lip varcies may thrombose and calcify
Geographic Tongue (Erythma Migrans)
Red and white Red = flat central area (atrophy of filiform papillae) White – serpentine border (keratin, cell debris) Moves around; periodically appears Usually asymptomatic, but may cause soreness or burning Geographic Tongue (Erythma Migrans)
Usually no treatment
Steroid rinse if symptomatic (dexamethasone)
Most common on ventral tongue, but can be on other areas Torus Palatinus
Exostosis in the midline of hard palate Torus Mandibularis
Radiographic Findings: may be superimposed over periapical region as radiopaque areas Physiologic Pigmentation (Racial Pigmentation)
More common in darker skinned individuals
Present most of life, but darkens with time
Series of splotchy brown macules Ankyloglossia
Congenital abnormality – short lingual frenum
“Tongue-tied” Cleft Lip and Cleft Palate
Cleft Lip Unilateral (80%) or bilateral (20%) Defect between medial nasal process and maxillary process
Cleft Palate Lack of fusion between palatal shelves Cleft Lip Cleft Palate Cleft Palate
Morsicatio
Chronic mucosa chewing Buccal mucosa = morsicatio buccarum Labial mucosa = morsicatio labiorum Tongue = morsicatio linguarum
White, rough tissue
Above and below occlusal planes White Sponge Nevus
Autosomal dominant genetic mutation of keratin production
Multifocal
Extensive thick, white folds of tissue
No eye involvement White Sponge Nevus
Symmetrical, thickened, white, corrugated/velvety, diffuse plaques.
Bilateral23 in buccal mucosa, but also in ventral tongue, labial/alveolar mucosa, soft palate, floor of mouth Linea Alba
White linear thickening at the level of the occlusal plane 24 Oral Hairy Leukoplakia
White rough plaque on lateral border of tongue
Seen in immunocompromised (commonly HIV+) patients
Caused by Epstein-Barr virus Oral Hairy Leukoplakia
26 Hairy Tongue
Elongation of filiform papillae Treatment: scrape tongue 27 Lichen Planus
Manifests on skin and/or oral mucosa
Middle aged women most often
Skin: purple, polygonal, pruritic papules
Oral – 2 types Reticular: Wickam’s straie – white lacy pattern that does not rub off More common; usually asymptomatic Erosive Painful ulcerations all over the mouth May see remnants of Wickam’s straie Both types: lesions should be multifocal Lichen Planus
Most patients middle-aged adults; 3:2 F:M
Skin features sometimes present Planar Purple Pruritic Polygonal Plaque Papule
29 RETICULAR PATTERN More common form
Multifocal lesions
Wickham’s striae: interlacing white lines
Wax and wane over weeks or months
EROSIVE PATTERN
Less common, but more significant (PAIN)
Central erosion/pseudomembrane with erythema and possibly Wickham’s striae
May present as desquamative gingivitis Lichen Planus
Reticular
Erosive Lichen Planus
Management: Reticular: White lesions are asymptomatic and are not treated If burning occurs, treated with topical corticosteroids Erosive Topical corticosteroids Flare-ups require reapplication of drugs or prophylactic treatment Severe cases require systemic corticoid therapy
32 Nicotinic Stomatitis
Reactive change of hard palate due to heat of smoking Most common with pipe smokers
Red, inflamed minor salivary gland ducts with background leukoplakic change
Not premalignant Nicotinic Stomatitis
34 Red areas are inflamed minor salivary glands CANDIDOSIS (CANDIDIASIS)
Candida albicans: most common oral fungal infection in humans
Opportunistic: seen in people who are immunocompromised, on antibiotics or corticosteroids
2 variations: “Classic” white patches: pseudomembranous candidiasis (thrush) Red variations: Acute erythematous candidosis Chronic erythematous candidosis Denture stomatitis Median rhomboid glossitis
35 Candidosis - White
Pseudomembranous (thrush): “Classic” white patches that rub off leaving red base
Painful Acute Erythematous Candidosis
Generalized pain, burning and erythema Typically follow broad-spectrum antibiotics (“antibiotic sore mouth”)
www.hivdent.org www.washington.edu Chronic Erythematous Candidiasis
Commonly seen in denture wearers, aka denture stomatitis Erythematous areas confined to denture-baring area May cause pain/burning or be asymptomatic Denture stomatitis may not be caused by other things (not candida): poorly fitting dentures, prolonged wearing of denture, poor hygiene
Regezi et al., 2012 Regezi et al., 2012 ANGULAR CHEILITIS Typically occurs with reduced vertical dimension of occlusion, but does not have to be 20% C. albicans alone 60 % combined C. albicans and S. Aureus 20% S. aureus alone
MEDIAN RHOMBOID GLOSSITIS Anterior to the circumvallate papilla “Kissing lesion” on palate may be present
Regezi et al., 2012 Chemical/Physical Burn
Does not represent keratosis; is coagulative necrosis of the surface
White pseudomembrane that rubs off with difficulty
Heat (pizza) or chemical (aspirin) Scarlet Fever
Group A Streptococcus infection
“Strawberry tongue” White strawberry tongue: early; white coating with protruding hyperplastic fungiform papillae Red strawberry tongue: 4-5 days later; white coating is lost
Hemangioma Venous Malformation
HEMANGIOMA - blanches Not present at birth Tumor of infancy that has rapid growth and endothelial cell proliferation Gradual involution VENUS MALFORMATION - blanches Present at birth and persist through life Anomalies of blood vessels without endothelial proliferation
43 Hemangioma Sturge Weber Antiomatosis
Port wine stain (venous malformation)
Meningeal angiomas Convulsive disorders Mental retardation
www.dermatlas.me d.jhmi.edu Submuccosal Hemorrhage
Bruise from minor trauma
DO NOT BLANCH
PETECHIAE = very small hemorrhages into skin, mucosa
ECCHYMOSIS = blood accumulation greater than 2 cm
HEMATOMA = accumulation produces a mass 46 Kaposi’s Sarcoma
Malignancy seen in HIV+ patients
Cause is HHV-8 (human herpes virus 8); not HIV, EBV, CMV, HPV Acquired Melanocytic Nevus (Mole; Nevus)
Controlled proliferation of melanocytes
Junctional type – nevus cells in at junction of epithelium and connective tissue
Compound type – nevus cells in epithelium and connective tissue
Intramucosal type – nevus cells in connective tissue Malignant Melanoma
Can begin as blue-brown macule
May become raised and difficult to distinguish from nevus
Oral melanoma has extremely poor prognosis Heavy Metal Intoxication
Lead
Burton’s line: blue-gray line along gingival margin seen with lead
Traumatic Ulcer
Caused by simple mechanical trauma
Other causes: factitious and iatrogenic
Acute or chronic
Any ulcer lasting for more than 2 weeks without a known cause should be biopsied Aphthous Stomatitis
Cause: unknown, but not infectious
NON-keratinized mucosa
Minor, Major, Herpitiform
Red halo surrounding central yellow/white area
Treatment: Corticosteroids Herpes Simplex
Oral herpes: human herpes virus–1, or 2 HHV-1 and HHV-2 aka herpes simplex (1 or 2) HHV-2 can also infect oral cavity, but HHV-1 more common US incidence estimate of herpes infection is 80-85% Often present as 1-3 mm vesicles that rupture and coalesce to form larger area of ulceration
Specific triggers: Sunlight Tissue injury and inflammation Physical or emotional stress Herpes Simplex
Primary herpes on ➢ Recurrent herpes on keratinized AND non- keratinized tissue only keratinized tissue ➢ Recurs in same location Usually have fever, ➢ No fever, malaise, malaise, lymphadenopathy lymphadenopathy ➢ Prodrome precedes lesions May be subclinical Herpes Treatment
Primary Herpes (within first 3 days of symptoms) Acyclovir suspension Rinse and wallow 5 times daily Children: 15mg/kg; Adults: 200mg Recurrent Herpes RX: Valacyclovir 1 g tablets (Valtrex) Disp: 4 tablets Sig: 2 tablets at onset of symptoms, then 2 tablets 12 hours after first dose Herpes Zoster
Recurrent Varicella (HHV-3) infection
Unilateral distribution on skin and intraorally (follows dermatome) Herpes Zoster (Shingles)
58 Generalized Vesiculoerosive Lesions
Long duration (months): Pemphigus Vulgaris Pemphigoid Erosive Lichen Planus Lupus
Short duration (days): Erythema Multiforme
Short or Long Drug-induced mucositis Nikolsky Sign
Seen in pemphigus vulgaris and mucous membrane pemphigoid
Induction of bullae by lateral pressure 60 or application of air Pemphigus Vulgaris
Autoimmune disease attacking epithelial desmosomes Intraepithelial splitting Generalized ulcerations of skin and/or mucosa Nikolsky sign may be present Demonstrates immunoglobin fluorescence Mucous Membrane Pemphigoid
Autoimmune disease attacking epithelial HEMI-desmosomes Subepithelial splitting Skin, mucosa and EYE involvement Symblepharon formation which may lead to blindness Must be seen by ophthamologist Nikolsky sign may be present Immunoglobin fluorescence present Lupus Erythematosus
Autoimmune disease: women 8-10x more affected
Systemic lupus erythmatosus (SLE) Multisystem disease: heart endocarditis, kidney: renal glomeruli (glomerulonephritis); butterfly rash on face
Chronic cutaneous lupus erythematosus Aka discoid lupus: only skin and oral lesions Erythema Multiforme
Cause: unknown
Predisposing factors: ½ the time preceded by herpes, pneumonia or medications (other ½ no predisposing condition present)
Minor form, Major form (Steven Johnsons) and Toxic Epidermal Necrolysis
KEY FEATURES: ACUTE onset (days) of generalized oral ulcerations Target lesions (not always present) Black crusty lips Erythema Multiforme Crohn’s Disease
Inflammatory bowel disease affecting anywhere from oral cavity to anus Lesions mostly in small intestine May cause rectal bleeding Orally Labial swelling Aphthous-like ulcers Mucosal Tags Granulomatous gingivitis
Epulis Fissuratum (Inflammatory FIBROUS Hyperplasia)
Hyperplastic connective tissue like fibroma
Associated with overextended denture flange Inflammatory PAPILLARY Hyperplasia
Beneath intaglio surface of denture (usually hard palate)
Soft tissue irritation from: Poor fitting dentures Wearing dentures 24h/day
Numerous papillary projections Denture Leaf Fibroma
Occurs on hard palate under a denture Benign Warty Tumors of Squamous Epithelium
Surface is roughened or has multiple finger-like projections (often white)
Associated with human papilloma virus
Papilloma: pedunculated attachment
Verruca vulgaris: sessile attachment
Condyloma: multiple, sessile attachment, sexually transmitted Papilloma
• Rough warty surface or multiple finger like projections
• Pedunculated base Verruca Condyloma Vulgaris
Similar to papilloma but Usually multiple has a sessile base Associated with high Singular risk HPVs: 16,18,31 More common on skin
Case 14 The Five “Ps”
On gingiva, mass differential: Parulis – “gum boil” Pyogenic granuloma Peripheral ossifying fibroma Peripheral giant cell granuloma “Plain” fibroma The Five “Ps” – Red Lesions
Peripheral ossifying fibroma Does not blanch Peripheral giant cell granuloma Red/Purple Blanches Pyogenic granuloma Increased frequency in pregnant women Easily bleeds Blanches The Five “Ps” - Pink
Peripheral ossifying fibroma “Plain” Fibroma Can occur anywhere Not vascular: do not blanch
NOTE: Salivary glands lesions do not occur on gingiva Pleomorphic adenoma, mucoepidermoid carcinoma, etc Other “bumps”
“Peripheral” means on the gingiva only Fibrous Tissue Origin Irritation fibroma/fibroma: occurs anywhere Peripheral ossifying fibroma: gingiva; may or may not blanch Vascular Origin: these will blanch Pyogenic granuloma: occurs anywhere Peripheral giant cell granuloma: gingiva only Neural Origin: occurs anywhere Neurofibroma, schwannoma Traumatic neuroma: only neural one that is painful Granular cell tumor: Most common site: dorsum of tongue May exhibit pseudoepitheliomatous hyperplasia (resembles SCC histologically) Other “bumps”
Muscle Origin Leiomyoma: smooth muscle; occurs anywhere Rhabdomyoma: skeletal muscle; never on gingiva or palate
Fat Origin Lipoma: yellow or pink hue
Unknown Origin Congenital Epulis Present at birth On alveolar ridge 90% females Other “bumps”
Granular Cell Tumor Congenital Epulis Bump commonly on the On alveolar ridge tongue 90% females
Lymphoepithelial Cyst
Occurs in Waldeyer’s ring Floor of mouth Lateral tongue Tonsilar pilar
Well circumscribed welling
Pale, yellow in color Lymphangioma
Lymph-filled superficial vessels
Does not contain blood; does not blanch
Most common location: dorsum of tongue
“Frog-egg” appearance Leukemia
Anemic: reduced red blood cells Fatigue, shortness of breath Leukopenic: reduced white blood cells Increased infections Thrombocytopenic: reduced platelets Prolonged/easy bleeding Oral Findings: Petechiae and pupura of oral mucosa Spontaneous and prolonged gingival bleeding Boggy gingival enlargement and ulcerations Candidosis (decreased immune function) Herpes/Aphthous can happen anywhere (immunocompromised) Leukemia
Lab Test to Order Complete blood count (CBC) White blood count differential Langerhans Cell Disease
Unknown cause; proliferation of Langerhans cells Spectrum of manifestation Eosinophilic granuloma: one or more bone lesions only Hand-Schuler Christionson (Chronic disseminated) Bone lesions, exophthalmos, diabetes insipidus Letterer-Siwe (Acute disseminated) Skin, bone, and internal organs Classic radiographic finding: Scooped out bone Teeth floating in air Langerhans Cell Disease Multiple Myeloma
Mulifocal malignancy of plasma cells Bone pain/fracture common Bence-Jones proteins in urine/serum Well-defined, punched out lesions on radiograph
Cheilitis Glandularis
Mucous minor salivary glands of lips are inflamed Usually lower lip Leads to swelling of lip Inflamed/dilated ducts produce mucopurulent secretions Premalignant condition: risk of squamous cell carcinoma Necrotizing Sialometaplasia Rapid onset
Necrotic/ulceration of tissue due to local ischemia (commonly local anesthesia)
Mimics squamous cell carcinoma so should be biopsied
Self-resolving Mucocele
AKA: mucus retention phenomenon, mucus extravasation phenomenon Severed salivary gland duct leading to mucus deposition in soft tissue Usually caused by trauma, bluish, dome-shaped, and on lower lip History of recurrence (coming and going) Ranula
Mucocele on floor of mouth
Looks like frog belly
Usually blue
Danger of plunging ranula Salivary Gland Tumors
Most common overall: Pleomorphic adenoma Most common benign: Pleomorphic adenoma Most common malignant: Mucoepidermoid carcinoma Most common location: Parotid gland Rule of thumb: The larger the gland, the more likely the tumor is benign; the smaller the gland, the more likely the tumor is malignant Pleomorphic adenoma
Can occur anywhere Canalicular Adenoma
Most commonly in upper lip
Do not confuse with mucocele which is in the lower lip Warthin’s Tumor (Papillary cystadenoma lymphomatosum)
Almost always in parotid
Associated with smoking
Can happen bilaterally (usually not at same time) Sjogren’s Syndrome
Autoimmune disease; not infectious Elderly women Usually have swelling of parotid glands bilaterally Primary SS = Xerostomia, xerophthalmia only Secondary SS = Primary plus a second autoimmune disease (lupus, rheumatoid arthritis)
Leukoplakia
White patch that does not rub off
Clinical term; differential includes: Hyperkeratosis Dysplasia Squamous cell carcinoma
Majority (95%) of cases are hyperkeratosis Erythroplakia Erythroleukplakia (Speckled)
Red patch that does not rub off
Clinical term; differential includes: Dysplasia Squamous cell carcinoma
Much more likely to represent dysplasia or squamous cell carcinoma than leukoplakia (90%) Erythroplakia Erythroleukoplakia Actinic Cheilitis
Common premalignant change of lower lip vermillion Leads to atrophy of vermillion border
Due to long-term or excessive exposure to UV light
Cancer develops in 6-10% of cases Squamous Cell Carcinoma
The most common intra-oral cancer
Cause: gene alterations of oncogenes/tumor suppressor genes
Factors: smoking, drinking, smoking and drinking, HPV, genetic effects
Most common location: lateral border of the tongue and floor of mouth
May present as chronic, nonhealing ulcer, red or white patch, or mass Precursor Lesions to SCC
Disease Malignant Potential
Proliferative Verrucous Leukoplakia ★★★★★★
Nicotine palatinus in reverse smokers ★★★★★
Erythroplakia ★★★★★ Erythroleukoplakia ★★★★ Smooth, thick leukoplakia ★★ Smokeless tobacco keratosis ★ Lichen planus +/- Smooth, thin leukoplakia +/- If a single ulcer shows no sign of healing 14 days after the putative cause is removed, it should be considered malignant until proven otherwise Squamous Cell Carcinoma Verrucous Carcinoma
Low-grade form of squamous cell carcinoma Low tendency to metastasize
Slowly growing with white, rough, warty surface Basal Cell Carcinoma
Painless ulcer on sun exposed face (UV)
Raised rolled border with central area of depression or ulceration
Teleangectasia can be seen on borders
Usually does not metastasize, but locally destructive Squamous Cell Carcinoma vs. Basal Cell Carcinoma
BASAL CELL CARCINOMA • Above the lip-tragus line • Chronic sun exposure • Does NOT appear intra-orally
SQUAMOUS CELL CARCINOMA • Below lip-tragus line • Acute sun damage (sunburn) • Most common intraoral cancer
Alveolar Osteitis
AKA Dry socket
Radiographic exam to rule out root tip or foreign body
Irrigate with warm saline
Avoid curettage
Analgesics and home irrigation Rarefying Osteitis
Non-vital tooth
Radicular cyst, granuloma, abscess
Cannot be differentiated radiographically
All well-defined and radiolucent Condensing Osteitis Sclerosing Osteitis
Non-vital tooth
Area of rarefying osteitis (RL area) surrounded by a diffuse RO border RO area not attached to root PDL is widened or shows rarefying osteitis
Idiopathic Osteosclerosis
NOT INFLAMMATORY
Intrabony counterpart to exostosis
Radiographic features: Radiopaque area that fuses/blends with surrounding trabeculae Not fused with root Not associated with RL area
No treatment Chronic Osteomyelitis
Acute/chronic inflammation away from initial site
Caused by pyogenic organisms: staph, strep
Diffuse (large) area involved; not localized and not well- defined
May have sequestrum: pieces of necrotic bone
Pain common; usually in mandible
Looks like cancer radiographically Chronic osteomyelitis: patchy, ill-defined radiolucency with a moth- eaten appearance. Osteomyelitis with Proliferative Periostitis
Inflammation spreading to periosteum
Periosteum lifted and deposits bone
Young people; mandible
Leads to “onsion-skin” appereance
Dentigerous Cyst
Most common development cyst Most commonly seen with 3rd molars and maxillary canines Radiographic appearance Must be with unerupted tooth Radiolucent area around the crown of the tooth, attached at the CEJ RL area must be greater than 2mm; otherwise it is normal follicle Any size; can be unilocular or multilocular Can push teeth Top differential dx: odontogenic keratocyst, unicystic ameloblastoma Epithelium may transform to ameloblastoma, SCC, mucoepidermoid carcinoma Dentigerous Cyst Lateral Periodontal Cyst
True cyst
75% in premolar-canine area
Teeth can be vital or non- vital Odontogenic Keratocyst
Common cyst with high recurrence rate
Can look like anything, mimics other cysts/tumors Unilocular or multilocular Pericoronal, apical, or lateral position Small or large BUT only in odontogenic areas
Associated with Gorlin Syndrome (nevoid basal cell carcinoma syndrome Odontogenic Keratocyst Calcifying Odontogenic Cyst
Only cyst that may be mixed RL-RO (odontogenic tumors may also be mixed) Mixed = radiolucent with areas of radiopacites
May also be totally RL
Has ghost cells histologically Ameloblastoma
Most common true odontogenic tumor
Age 20-40
Radiographic findings: Always radiolucent Classic “soap bubble” appearance Causes expansion May be unilocular (unicystic ameloblastoma) Most common location is posterior mandible Ameloblastic Fibroma Ameloblastic Fibro-Odontoma
Age <20
Posterior mandible most common location
Precursors to odontoma
Radiographic Findings AF = completely RL AFO = mixed RL/RO (ie, the odontoma part) Ameloblastic Fibroma Ameloblastic Fibro-Odontoma
Both will be under age 20 Ameloblastic Ameloblastic Fibroma Fibro-Odontoma
AFO
Completely RL Mixed RL/RO Odontoma
Develops in first 2 decades of life (doesn’t mean you can’t find one later)
Radiopaque area surrounded by radiolucent rim, surrounded by thin radiopaque line
Compound: identifiable “toothlets”; usually in anterior maxilla
Complex: large unidentifiable mass; posterior mandible Adenomatoid Odonotogenic Tumor RL with snowflake “2/3” Tumor calcifications 2/3 in teenagers 2/3 in females 2/3 in anterior jaws 2/3 in maxilla Often with unerupted tooth
May be radiolucent or mixed Mixed: radiolucent with “snow-flake” calcifications Odontogenic Myxoma
Younger patients, <30
Radiographic: resembles ameloblastoma “Honeycomb” or “tennis racket” apperance Septations at 90 degrees to one another
Nasopalatine Duct Cyst (Incisive Canal Cyst)
Most common developmental non- odontogenic cyst
True cyst
Clinical: may present as palatal swelling
Radiogpraphic: Often has “heart” shaped appearance Nasolabial Cyst
Smooth swelling adjacent to maxillary lateral incisor
Elevation of ala common
Soft tissue involvement only; not in bone (no radiographic changes) Idiopathic Bone Cavity
Other names: Simple bone cyst, Traumatic bone cyst Pseudocyst: represents an empty cavity in bone Do not know why it occurs (not trauma) Radiographic Findings: Usually in mandibular premolar-molar area Superior margin scallops between tooth roots Treatment: spontaneous healing without treatment following exploratory surgery Mucous Retention Pseudocyst (Antral Pseudocyst)
Asymptomatic
Submucosal accumulation of mucus
Non-corticated dome shaped swelling in sinus
No treatment necessary Stafne Defect (Stafne Bone Cyst)
Salivary gland depression in mandible
Asymptomatic
Occurs below the IAC (usually near angle of mandible)
Thickly corticated radiolucent area Osteoma
Benign tumor of bone
Irregularly shaped radiopaque mass
Multiple ones associated with Gardner Syndrome
Osteoma cutis = Osteomas in skin/buccal mucosa/muscle Giant Cell Lesions
All contain giant cells hitologically, so appear identical microscopically; diagnosis is made in correlation with clinical features
Central giant cell granuloma Common in young individuals <30 More common in females Commonly in anterior mandible
Hyperparathyroidism is accompanied by increased serum parathyroid hormone levels.
Cherubism is a familial condition beginning between ages 1-4 years & has large multilocular radiolucent lesions of the posterior regions of jaws bilaterally. Central Giant Cell Granuloma
Females under age 30
Anterior mandible
Commonly see root resorption
Soap bubble and expansion that resembles ameloblastoma Cherubism
Bilateral changes Multilocular, expansile radiolucent lesions Hyperparathyroidsm
Primary: parathyroid gland hyperfunction (usually adenoma)
Secondary: kidney disease
Painful bones, renal stones, abdominal groans, and psychotic moans
May have brown tumor of bone
Radiographic features: Granular (salt and pepper) or “ground glass” bone Loss of lamina dura Spectrum of Cemento-Osseous Dysplasias
Dysplasia, not neoplasm; usually asymptomatic
Found in middle-aged females
Types: Focal cemento-osseous dysplasia: solitary lesion. Most common. Periapical cemental dysplasia: multiple lesions, usually in anterior mandible Florid cemento-osseous dysplasia: multiple, bilateral lesions throughout the jaws
No treatment required Periapical Cemento-Osseous Dysplasia Middle aged African American RL women
Involve mandibular anterior teeth
No treatment necessary Mixed
Radiolucent to Mixed, to Radiopaque (rarely all RO)
RO Focal Cemento-Osseous Dysplasia
Same process; only in one area (not anterior mandible) Florid Cemento-Osseous Dysplasia
Same process; in multiple quadrants (can be anterior mandible plus another area) Fibrous Dysplasia
Genetic cause
Unilateral swelling of the jaw
Painless; early onset; growth stops at age 20
Radiographic appearance “Ground glass” Ill defined borders
Treatment Cosmetic bone remodeling after cessation of growth Fibrous Dysplasia
Remember: young (<20), ground glass, expansion Paget’s Disease of Bone
Abnormal resorption and deposition of bone
Weakened/deformed bone
Older (>40) males (vs. fibrous dysplasia in young)
Findings: Enlargement of jaws/ridges Dentures don’t fig Spaces between teeth Generalized hypercementosis “Cotton wool” radiopaque areas
Has increased risk of osteosarcoma Paget’s Disease of Bone
Extensive Cotton wool hypercementosis appearance Paget’s Disease of Bone
Cotton wool appearance may also be seen in the jaws Melanotic Neuroectodermal Tumor of Infancy
Rapid onset
Increase in vanillylmandelic acid (VMA)
Anterior maxilla
Radiolucent and destructive Osteopetrosis
Defect of osteoclasts
Increased density of bone (skull and jaws) and osteomyelitis
Can have cranial nerve compression (adult) and/or bone fractures (young) Central Neural/Vascular Lesions
Neurofibroma, Schwannoma
Enlargement of canals and/or foramina
Hemangioma – can look like anything Multilocular, unilocular, in any location
Always aspirate radiolucent area prior to biopsy to rule out vascular nature (all lesions) Bone Tumors
Most common primary bone cancer: osteosarcoma
Most common cancer in bone: metastasis Breast, Lung, Thyroid, Kidney, Prostate, Colorectal
Benign growth characteristics: Slow growing, well-defined (may be corticated), push teeth (rather than resorb), expanded/thinned cortex
Malignant growth characteristics Fast growing, poorly defined, non corticated, resorb teeth, perforate bone Numb chin syndrome: parasthesia of the lower lip; ominous sign Osteosarcoma
Age = 20s/30s
Swelling of bone
Loose/displaced teeth
Parsethesia
Radiographic: Poorly defined margins “Sun-ray” appearance Early feature: irregular widening of PDL space Osteosarcoma
Cleidocranial Dysplasia
Multiple unerupted supernumerary teeth
Hypoplasia/aplasia of the clavicles Cleidocranial Dysplasia
Multiple unerupted supernumerary teeth Ectodermal Dysplasia
Hypodontia Teeth are also conical/cone shaped in appearance
Anydrotic type: partial or complete absence of eccrine sweat glands and hair follicles Fine, sparse hair; decreased heat tolerance Multiple Endocrine Neoplasia Syndrome, Type IIB (III)
Oral mucosal neuromas (hamartomas)
Medullary carcinoma of thyroid gland
Pheochromocytoma of adrenal gland Neurofibromatosis, type I (von Ricklinghausen’s disease of skin)
Multiple neurofibromas
Café au lait pigmentations (also seen in fibrous dysplasia)
Axillary freckling
Lisch nodules (eye) Peutz-Jegher Syndrome
Numerous melanotic macules intraorally and periorally
Intestinal polyps that do not become malignant (but at high risk for GI cancer) Gardner Syndrome
Dental anomalies or osteomas Osteomas may block eruption of teeth
Polyps of the colon that become malignant
Epidermoid cysts on the skin Gardner Syndrome Treacher Collins Syndrome (Mandibulofacial Dysostosis) Deformed ears/hearing loss
Coloboma – fissure of lower eyelid
Convex facial profile Downward sloping palpebral fissures Hypoplasia of mandible and malar bones “Bird face” Gorlin Syndrome (Nevoid Basal Cell Carcinoma Syndrome) Most Common Clinical Findings (>50%) Multiple basal cell carcinomas Multiple odontogenic keratocysts Calcified falx cerebri Rib anomalies Palmar plantar pits Ocular Hypertelorism Enlarged head Spina bifida Multiple “Nevoid” basal cell carcinomas
171 172Numerous basal cell carcinomas appearing at a young age Calcification Palmar plant pits of falx cerebri
Basal cell carcinomas Bifid ribs Multiple odontogenic keratocysts (not Gorlin cysts)
Trauma or periapical inflammatory disease of primary tooth leads to enamel defect of developing permanent teeth Root Alterations Hypercementosis: too much cementum, well-defined PDL space; looks like turkey drum Generalized hypercementosis: Paget’s disease Cementoblastoma: large mass of cementum with a radiolucent rim around it; mass appears fused to the root with root resorption Ankylosis: shortened root fused with bone; PDL space lost; occlusal surface apical to other teeth Dens Invaginatus Dens Evaginatus Dens Evaginatus Cusp-like elevation of enamel Most commonly on mandibular premolars May lead to occlusal interference Dens Invaginatus (Dens in dente) Most commonly in permanent maxillary lateral incisors Rare on mandibular or primary teeth Various degrees of severity Post-Developmental Loss of Tooth Structure
Attrition – physiologic wear due to tooth to tooth contact
Abrasion: pathologic wear due to mechanical action of external agent, ie, habits, occupations
Erosion: pathologic wear due to chemicals not involivng bacteria (ie, caries) Chlorinated pools Perimolysis: erosion from gastric regurgitation and GERD
Abfraction: loss of tooth structure from occlusal stresses that create repeated tooth flexure with failure of enamel/dentin Tooth Structure Loss
Attrition Abfraction/Abrasion
Erosion Intrinsic Tooth Stain
Tetracycline: deposition within the dentin Amelogenesis Imperfecta
Hypoplastic: not enough enamel; rough pitted
Hypocalcified: regular thickness at that is soft; easily breaks off/abrades
Hypomature: regular thickness; soft, “snow-capped” Amelogenesis Imperfecta Picket Fence Teeth Dentinogenesis Imperfecta
Translucence of teeth: blue to brown
Bulbous crowns, cervical constriction
Thin, tapered roots
Obliteration of root canals and pulp chamber Amelogenesis Imperfecta vs. Dentinogenesis Imperfecta
Key Findings: Key Findings: Little to no enamel Cervical constriction “Picket fence” Pulpal obliteration appearance “Golf ball on tee” Osteogenesis Imperfecta with Opalescent teeth
Genetic disease that leads to defective collagen
Manifestations: Bones are brittle/fragile: multiple fractures, bowing of legs Blue sclera, hearing loss Opalescent teeth: diffuse blue-brown discoloration Looks the same as dentinogenesis imperfecta clinically Osteogenesis Imperfecta Dentin Dysplasia
Developmental defect of dentin Type I: radicular Rootless teeth Pulpal obliteration Tooth mobility Rarefying osteitis without cause Type II: coronal Enlarged thistle-tube-shaped pulp chambers
Mandibular Fracture
Thick radiolucent line
Overlapping radiopaque lines Progressive Systemic Sclerosis (Scleroderma)
Autoimmune disease
Hardening (sclero-) of the skin (-derma) Trisumus/Limited jaw opening Generalized widening of PDL space Radiation Therapy
Causes cervical caries secondary to inducement of xerostomia
Does not result in pulp necrosis Diffuse Ill-defined Radiolucent Area
Differential (depends on history) Osteomyelitis Radiation induced osteonecrosis Medication-related osteonecrosis of the jaws Bisphosphonates Metastatic Disease Osteosarcoma Diffuse Ill-defined Radiolucent Area
May lead to pathologic fracture Condylar Hyperplasia
Enlarged condyle
Chin deviates away from affected side upon closure
Be careful patient aligned correctly in machine
Radiation Physics
Aluminum filter: blocks low- energy photons (lowers dose to patient)
Tungsten filament: e- cloud
Molybdenum focusing cup
Tungsten focal spot: want small focal spot
Copper stem acts as heat sink Radiation Physics
Step up (high voltage) transformer: increases potential different between cathode and anode
Step down (filament) transformer: decreases voltage to prevent burning filament Radiation Physics
Bremsstrahlung is primary source of x-ray production
Quality of beam: energy of photons
Quantity of beam: number of photons
Factors controlling x-ray beam Kilovoltage: increase in kVp increases quality and quantity Milliamperage and time: increase the quantity of photons Inverse square law: intensity of x-ray beam inversely proportional to square of the distance from source Radiation Biology
Deterministic Effects: Effects occur once threshold is reached After threshold reached, severity proportional to dose Ex: oral mucositis after radiation therapy Stochastic effects Effects may occur independpent of dose; ie, no threshold dose Probability proportional to dose Ex: radiation-induced cancer Nucleus and DNA most sensitive to radiation Cells that are mitotically active and undifferentiated have long mitotic futures (bone marrow, gonads) are more radiosensitive than cells that no longer divide (nerves, muscle) X-Ray Film
Film Composition Emulsion: silver halide grains ( silver bromide) sensitive to radiation/light Base: supports emulsion
Intensifying screen Used in panoramic/cephs Phosphor layer is screen Phosphors emit light when absorb x-rays Light interacts with film Results in less radiation to patient, but decreased resolution Projection Geometry
Image sharpness improved by: Small focal spot Increasing distance between focal spot and object Minimizing distance between object and receptor
Shape distortion Minimized by receptor and long axis of object parallel to each other and both perpendicular to x-ray beam Foreshortening: film is at right angle to x-ray beam, but tooth is not at right angle to x-ray beam Elongation: tooth is at right angle to x-ray beam, but film is not at right angle to x-ray beam Foreshortening Elongation SLOB RULE
SAME LINGUAL, OPPOSITE BUCCAL
Tube moves mesially Tube moves mesially Object moved mesially Object moved distally Same direction = LINGUAL Opposite direction = BUCCAL Film Processing
Latent image: X-rays activate e- that are trapped in sensitivity sites
Steps: 1. Developer: converts exposed silver halide crystals into metallic grains 2. Rinse: stops developer 3. Fixer: dissolves and removes undeveloped silver halide crystals 4. Washing: prevents staining from left over fixer
Kodak GBX-2 safelight filer with 15-W bulb at least 4 feet from working surface
“Penny test” checks for proper safe lighting; penny placed on undeveloped film and then processed to see if image of penny appears Digital Imaging
Detectors: Charge coupled device (CCD) and complementary metal oxide semidconductors (CMOS) Silicon captures x-ray energy as voltage sent to computer Photostimulable phosphor plates (PSP) Plates made of barium fluorohalide with europium Plates capture and store x-ray energy Plates read with laser that releases fluorescence
Contrast resolution: ability to distinguish shades of gray
Spatial resolution: ability to detect edges or close points Film better than CCD/CMOS, better than CCD
Lateral Skull Projection
Main use to display anatomic structures: Anterior mandible Anterior maxilla Orbit Maxillary sinus Submental Vertex
Main use to display anatomic structures: Anterior mandible Condylar head Ethmoid sinus Waters
Main use to display anatomic structures: Zygomatic arch Nasal bones Nasal cavity Frontal Sinus Ethmoid sinus Posterior-Anterior (PA)
Main use to display anatomic structures: Anterior mandible Mandibular body Ramus Coronoid process Condylar neck Ethmoid sinus Reverse Towne
Main use to display anatomic structures: Condylar neck Condylar head
Anatomy
Y line of Ennis (inverted Y) • Superimposition of the floor of nasal cavity and border of maxillary sinus • Marker for maxillary canine d Mandibular Anatomy d
Soft Tissue Structures Soft Tissue Structures