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 by Neville and Damm  Oral Radiology by White and Pharoah  Mosby’s Review NBDE Part 2

Fordyce Granules

 Sebaceous glands that occur on the

 Yellow plaques/granules

 Most common on buccal mucosa and upper 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 Varices

 Located on lip and under the (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 (Erythma Migrans)

 Usually no treatment

 Steroid rinse if symptomatic (dexamethasone)

 Most common on ventral tongue, but can be on other areas

 Exostosis in the midline of hard

 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

 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 =  Labial mucosa = morsicatio labiorum  Tongue = morsicatio linguarum

 White, rough tissue

 Above and below occlusal planes

 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

 White rough plaque on lateral border of tongue

 Seen in immunocompromised (commonly HIV+) patients

 Caused by Epstein-Barr virus Oral

26 Hairy Tongue

Elongation of filiform papillae Treatment: scrape tongue 27

 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: 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 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

 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

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 , prolonged wearing of denture, poor hygiene

Regezi et al., 2012 Regezi et al., 2012 ANGULAR 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 ” on palate may be present

Regezi et al., 2012 Chemical/Physical Burn

 Does not represent ; 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 (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

 Cause: unknown, but not infectious

 NON-keratinized mucosa

 Minor, Major, Herpitiform

 Red halo surrounding central yellow/white area

 Treatment: Corticosteroids

 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 ()

58 Generalized Vesiculoerosive Lesions

Long duration (months):  Vulgaris   Erosive Lichen Planus  Lupus

 Short duration (days): 

 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

 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 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

 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”   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  , , 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  : skeletal muscle; never on gingiva or palate

 Fat Origin  Lipoma: yellow or pink hue

 Unknown Origin  Congenital  Present at birth  On alveolar ridge  90% females Other “bumps”

 Granular Cell Tumor   Bump commonly on the  On alveolar ridge tongue  90% females

Lymphoepithelial

 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 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)

 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 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

 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-

 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

 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

 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: , unicystic ameloblastoma  Epithelium may transform to ameloblastoma, SCC, mucoepidermoid carcinoma

 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 /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

 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

 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-

 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

 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,  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 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.

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 ; 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  “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 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

 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 , well-defined PDL space; looks like turkey drum  Generalized hypercementosis: Paget’s disease  : 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 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

– physiologic wear due to tooth to tooth contact

: 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

: loss of tooth structure from occlusal stresses that create repeated tooth flexure with failure of enamel/ Tooth Structure Loss

Attrition Abfraction/Abrasion

Erosion Intrinsic Tooth Stain

 Tetracycline: deposition within the dentin

 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

 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 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