Tuesday February 18 , 2020 Raleigh Wake County Dental Society North Ridge Country Club, Raleigh, NC Bobby M. Collins, DDS, MS Diplomate, Oral and Maxillofacial Pathology In accordance with the policy of the ADA and the North Carolina Dental Society, I declare that I have no proprietary, financial or other personal interest of any nature or kind in any product, service or company that will be discussed or considered during the proposed program. Bobby M. Collins, DDS, MS Even when problem focused - “Doc my tooth hurts” Pause, and do a complete exam (Never treat a stranger) Medical history: review of systems, medications Social history: alcohol, tobacco Explain to the patient that you will address their chief concern, but you need to look around first “so I won’t miss anything” Look, feel, provoke If an abnormality is noted, evaluate: size, color, surface texture, and feel; is it painful / non-painful, numb? Ask about duration, distribution Persistent ulcers of lips, mouth that don’t heal Mass in lip, mouth, or throat >3wk duration White or red areas of ventrolateral tongue, FOM, soft palate/tonsillar complex, BM, alveolar mucosa, gingiva Bleeding, pain, numbness in oral cavity and oropharynx Persistent sore throat, feeling a lump or like something is stuck in throat Pain when chewing or swallowing A change in fit of dentures A change in voice, “hot potato” voice Pain in the ears Lateral neck swelling, cervical lymphadenopathy Ankyloglossia Geographic Tongue Dental lamina cysts Fissured Tongue Retrocuspid Papilla Gingival hyperplasia INFECTIOUS CONDITIONS ULCERATION Herpes Virus Traumatic ulceration (TUGSE) Primary Herpetic Gingivostomatitis Riga-Fede Disease Herpes labialis/oralis Aphthous Ulceration (RAU. RAS) Recurrent herpes Coxsackievirus Herpangina Hand, foot and mouth disease Fungal infection Candidiasis (Perleche) Initial infection with HSV-1, all oropharyngeal sites, erythematous eroded gingiva is common Clustered vesicles break and leave irregular erosions Cervical lymphadenopathy, malaise, inability to eat or drink “Heals” in 7-10 days Generally, lesions are short-lived or self-limiting, occur on keratinized surfaces Complications can arise with contact Scratching – auto-innoculation leads to: Finger (Whitlow), Eye (Ocular), genital lesions And immunocompromise Bell’s palsy (therapy involves tapered steroids and antiviral med (Valtrex)) Herpes encephalitis, meningitis Disease of the very young, very old, very sick Developing immune function, delayed immune response, immune reaction “overwhelmed” Opportunistic infection Immunocompromise, antibiotic use, steroid use Dry mouth (autoimmune, medication induced) Smokers Bactroban (mupirocin) 2% ointment Disp. 15 gm tube Sig. t.i.d. 7-14 days Common in children, a period of immunologic adjustment and a myriad of infections Antigen presentation and lymphocytic hyperplasia are making adjustments Bacterial (Streptococcal) and Viral infections (HSV, EBV, VZV, Influenza, etc) are ubiquitous After age 16, tonsillar enlargement is more worrisome, especially when no clinical illness is evident Riga-Fede disease TUGSE Factitial Injury (insensitivity to pain, metabolic /psychiatric disorder) Blue translucent swelling overlying an erupting tooth that has eroded through its bony crypt, but it hasn’t yet penetrated the gingiva Map like atrophy bordered by filiform papillae in the tongue Waxes, wanes and moves around 10% pts report symptoms – sensitivity to hot spicy or acidic foods Same histologic appearance as psoriasis Hereditary or medication associated thickening of the lamina propria of the gingiva Can over cover the teeth and delay tooth eruption Medications associated with the enlargement include: Calcium channel blockers (Nifedipine), anticonvulsants (Dilantin), and immunomodulatory agents (Cyclosporin) Lip enlargement due to granulomatous disease Can affect both lips simultaneously, or either lip Crohn’s disease, Melkersson-Rosenthal syndrome, Sarcoidosis Melkersson –Rosenthal typically affects maxillary lip Aphthous ulcers Lichen planus/lichenoid Herpes labialis Tonsillar detritic debris Candidiasis Lymphoepithelial cyst Cheek chewing Palatal ecchymosis Pericoronitis Reactive masses Pregnancy gingivitis Squamous papillomas Sexual bruise Geographic tongue Frenal tag/fibroma Transient lingual papillitis • Recurrent aphthous stomatitis (RAS), recurrent aphthous ulcers (RAU) Common, childhood/adolescence onset, F>M RAS affects 5-66%, higher socio-economic groups Recurrent round, or ovoid well-delineated ulcers, erythematous halos, and yellow or gray center Family history is common Not infectious, not contagious Resolution by ~3rd decade Famciclovir (Famvir) 500 mg capsules For Herpes labialis – 1500 mg as a single dose For Zoster – 500 mg q8h, 7 days Valacyclovir HCL (Valtrex) 500 mg For Herpes labialis – 2g twice daily, 12 hours apart For Zoster – 1g t.i.d 7 days Acyclovir (Zovirax) 200mg, 400mg, 800mg Herpes labialis – Take 800 mg onset of symptoms, then 800 mg b.i.d for 3 days Pyogenic Granuloma Peripheral Fibroma Peripheral Ossifying Fibroma Peripheral Giant Cell Granuloma Reactive processes in varied states of connective tissue maturation F>M, psychiatric condition, (control issue) regurgitation after meals Dehydration, nutritional compromise, oral lesions (necrotizing sialometaplasia) Gastric acid causes erosion on palatal and occlusal surfaces of teeth Inflammation around crown of an erupting mandibular tooth, typically a third molar Pain made worse by occlusal trauma from opposing maxillary third molar tooth Pus and blood may emanate from the operculum Treatment: Irrigation with antimicrobial Prescribe Abs – Amoxicillin 500mg t.i.d. Extract opposing tooth and appoint for removal of involved tooth Very addictive, cheaply made, readily available Snorted, smoked, injected Causes dry mouth, parafunctional habits (clenching grinding) Caries result from soft drink consumption to quench thirst Fragmented bone at coronal aspect of erupting tooth The superior aspect of the tooth crypt May be loose, but attached to operculum, or may still be firmly attached to cortical bone of the jaws DNA virus, more than 40 types Spread by skin-to-skin contact, including sex (vaginal, oral, anal, any contact w/ genital area 14 million teenagers infected yearly in US HPV exposure increases with number of sexual partners 75 – 80% sexually active adults have at least one genital HPV infection before age 50 Majority F & M infected with 1 or more HPV types in anogenital area between 15-25 yrs Most infections asymptomatic, particularly in males 10 – 20% of women HPV infection persists Greater chance of developing cervical pre-cancer, and then cancer Progresses to cervical cancer in 20 - 25 years There are low risk HPV associated lesions Common wart (Verruca Vulgaris) HPV 2, 4, 6, 40 Squamous Papilloma HPV 6, 11 Focal Epithelial Hyperplasia (Heck Disease) HPV 13,32 Venereal Warts (Condyloma Acuminatum) HPV 2, 6, 11, 53, 54 - occasionally 16, 18, 31 And High Risk Lesions HPV 16 infection is changing HNSCCa trends Posterior oral cavity (tonsils, tonsillar pillars, crypts, base of tongue), and oropharynx show increase in SCCa incidence rates over last 10 yrs Squamous papilloma HPV 6, 11 – pink or white, exophytic, warty lesions Tongue, lips palate are common sites Verruca vulgaris HPV 2, 4 – pink or white, pebbly surface, collarette Hands, face, lips, anterior tongue May spontaneously resolve Tend to recur Condyloma acuminatum HPV 6, 11 (16, 18), pink or white cauliflower surface Anogenital and oral mucosa (gingiva, tongue, labial mucosa), tend to be multiple Tx – Excision, recur, malignant potential Focal epithelial hyperplasia (Heck’s Disease) HPV 13, 32 – pink white, maculopapular Common in American Indians, Inuits First HPV infection occurs soon after onset of sexual activity HPV infection highest in late teens/early 20s Most infections clear or become undetectable within 1-2 years In 10-20% women infections do not clear Many pre-cancers clear However, pre-cancers can progress to cancer over years to decades Increase in oro-pharyngeal cancer attributable to oro-genital sex Vaccine available, most administered in 9-11 yr olds Cervarix (Bivalent (2vHPV) Types 16, 18 Licensed for use in Females ages 9-25 Discontinued 2016 Gardisil (Quadrivalent (4vHPV)) Types 6, 11, 16, 18 Females and males 9–26 yrs Discontinued 2016 Gardisil 9 (9-valent(9vHPV)) Types 6, 11, 16, 18, 31, 33, 45, 52, 58 Females and males 9–26 yrs (2018 extended to age 45) Dental caries Root caries Gingivitis Periodontitis Xerostomia Candidiasis Acute pseudomembranous (thrush): adherent white plaques that can be wiped off Erythematous (denture stomatitis): red macular lesions, often with a burning sensation Angular cheilitis: erythematous, scaling fissures at the corners of the mouth Oral cancer Head or neck radiation Antihistamines Human immunodeficiency virus Antipsychotics Medication use Anxiolytics Angiotensin-converting enzyme Calcium channel blockers inhibitors Diuretics Alpha and beta blockers Muscle relaxants Analgesics Sedatives Anticholinergics Salivary gland aplasia Antidepressants Sjögren syndrome Antihistamines Smoking > 43,250 new cases/yr in U S, 75% of HNSCCa begin in oral cavity ~8,000 deaths / year Diagnosis relies on patient presentation, physical examination, and biopsy confirmation, so diagnosis is often delayed