Diagnostic Detectives: Who is your detective Catching common culprits and alter ego? spotting a mimic in Oral Medicine, Oral Radiology and Oral Pathology

Dr. Kristina Perschbacher Oral Pathology and Oral Medicine Dr. Susanne Perschbacher Oral and Maxillofacial Radiology

You see something Outline

You think you Profiling to catch a culprit You can’t make • know what it sense of it means • Collecting the evidence • Cases • The usual suspects vs. the mimics

You understand it

Profiling to catch a culprit Key questions

• Interrogating the witness • History of abnormality key questions (history of CC) • • symptoms know your witness (medical and • duration social history) • • changes over time • photographic evidence? • attempted treatment • surveying the scene of the “crime” Getting to know your Getting to know your witness witness

• Medical history • Medical history medications (Rx or not) • • allergies, hospitalizations, surgery • oral, topical, injectable, puffer • review of systems • previous use may be important • family history steroids/immunosuppressants, • autoimmune, cancer bisphosphonates, chemotherapy •

Getting to know your Sometimes it is a random witness act of abnormality

• Social history • An incidental finding • age and gender-identity A lesion without specific patient alcohol, tobacco and drug use • • factors • psychiatric disorders

Surveying the scene of Photographic evidence the “crime”

• “selfies” or cell phone pictures • Don’t zone in, look for more clues or • images from referral related “crimes” • sending radiographs • Take a moment to examine the whole scene • Complete clinical exam • Assess radiographs beyond area of interest Collect your evidence

• Clinical examination of the lesion • record all clinical features • Radiologic examination • Additional imaging • Biopsy • Referral

Cases Black/brown spot

• What caught your eye? • Usual suspect • melanotic macule • What is the common culprit (dx) that comes to mind? • physiologic pigmentation • Mimics • things you are familiar with • amalgam tattoo • things you’ve seen before • nevi • Is there any evidence (signs) that • drug induced pigmentation doesn’t fit • melanoma

Single black spot Wart

• Usual suspects • Usual suspect • RO/granuloma • Squamous papilloma • Mimics • Mimics • Cysts • Condyloma • Stafne bone defect • SCC/malignancy • Malignancy Black spots…more than 1 Ulcer

• Usual suspects • Usual Suspects • periapical/periodontal disease • Aphthous ulcer • Traumatic ulcer • Mimics • Mimics • Periapical osseous dysplasia • Herpetic • Mucocutaneous disease (LP/PV/MMP) • Multiple cysts • Oral manifestations of disease • Malignancy • Malignancy (SCCa/Lymphoma/Salivary gland tumor)

White and chunky Red gums

• Usual suspects • Usual suspect • Dense bone island • Gingivitis/Periodontitis • Mimics • Sclerosing osteitis • Lichen Planus • Mimics • Pemphigoid/Pemphigus • Odontoma • Orofacial granulomatosis • Mature periapical osseous dysplasia • Atrophic candidiasis • Primary herpetic gingivostomatitis • Fibrous dysplasia • Malignancy • Osteoblastic malignancy

Floating white spot White patch

• Usual suspect • Usual Suspects • Tonsilloliths • “Leukoplakia” • Mimics • Traumatic or frictional keratosis • Candidiasis • Sialolith • Mimics • Phlebolith • Lichen Planus • Calcinosis cutis • Dysplasia • Foreign bodies • SCCa Cloudy sinus Growth on the gums

• Usual Suspects • Usual suspects • Fibroepithelial polyp • Parulis • Antral pseudocyst • Pyogenic granuloma/peripherial giant cell granuloma • Mimics • Mimics • Peripheral ossifying fibroma Odontogenic lesion • • Gingival cyst of the adult • Malignancy • Foreign body • Malignancy

Test your detective skills!

• Identify your suspects! • give a differential diagnosis for each case