Oral and Maxillofacial Pathology

Review for NBDE Part 2

May 2007





Michael A. Kahn, DDS
Professor and Chairman
Department of Oral and Maxillofacial Pathology
Tufts University School of Dental Medicine
Systemic Lupus Erythematosus
Clinical
Autoimmune
Young adult females
Butterfly rash of face
Sun exposure worsens it
Systemic involvement complications
Heart endocarditis
Kidney renal glomeruli (glomerulonephritis)
Cavernous sinus thrombosis
Can arise from an infection - - a
subcutaneous abscess of the upper lip or a
intrabony abscess of an anterior maxillary
tooth
Valveless facial
veins

Ludwigs angina
Submandibular space infection
Most serious complication is edema of
the glottis
Treacher Collins Syndrome
Has external ear changes
Scarlet fever
White coating of the tongue that sloughs off
leaving a deep red surface with swollen
hyperplastic fungiform papillae (strawberry
tongue)
Fordyce granules
Ectopic sebaceous glands yellow
papules/plaques
Turner tooth
Due to local trauma or infection associated
with the developing tooth bud
Intrinsic tooth stain
Tetracycline deposition within the dentin
Recurrent Aphthous Stomatitis
Clinical
Moveable mucosa
Ex. Uvula, labial mucosa
Recurrent NOT PRECEDED BY VESICLE
Associated with certain HLA types
NOT caused by a virus, bacteria, fungus
Treatment
Corticosteroids are often prescribed
Herpetiform type
Many small
Minor and major types
Very painful
Size, depth, time to heal (minor 5-10 days)
Minor small, shallow ulcer with red halo


Benign Mucous Membrane Pemphigoid
(cicatricial)
Clinical
Autoimmune
Antibody reaction at the
epithelial-connective tissue
interface (BMZ)
Subepithelial split
Vesiculoerosive, ulcers
> women - middle aged
Skin and eye
Oral
Any site: gingiva, soft palate, etc.
Ulcers, erosions following vesicles, bulla
Histology
Subepithelial separation at basement membrane zone
Condyloma Acuminatum
Clinical
Venereal wart
Extensive

Etiology
Human papilloma virus (HPV)
Candidiasis
pseudomembranous
Clinical
Opportunistic infection (yeast)
Immature or deficient immune
system
Antibiotics usage
Corticosteroids usage
Hyphae and spores
May be diagnosed by cytology
smear
White, wipeable patch with red,
underling base; palate and buccal
mucosa are often involved
Thrush
Newborns and infants
Candidiasis Chronic
Median rhomboid glossitis
Clinical
Red atrophy of filiform papillae
Midline tongue, junction of anterior
2/3 and posterior 1/3 at tuberculum
impar
Not a developmental disorder as
once thought
Treatment
Antifungal agents are sometimes effective, such as nystatin
or clotrimazole
Denture sore mouth
Clinical
Red
Patient does not remove
or clean denture NOT acrylic allergy
Tx rinse mouth and soak denture with antifungal

Recurrent (Secondary) Herpes
Simplex
Clinical
U.S. incidence estimate of herpes infection is 80-
85%
Most cases are subclinical
Reactivation from nerve cells of trigeminal ganglion
Lip
Skin or vermilion
Vesicle ruptures - - -> ulcer that heals in 7-10 days
(not present for weeks or months if immunocompetent
person)
Recurrent (Secondary) Herpes
Simplex
Recurrent Herpes Simplex Infection
Clinical
HSV Type 1 in humans, most often
Intraoral
Hard palate and gingiva = nonmoveable, overlying bone
Small coalescing shallow ulcers preceded by small vesicles
Can be subclinical even though person has primary infection
Usually history of trauma, stress, UV exposure, as triggering
event several days earlier (ex. restorative procedure)
No history of allergy or chemical burn

Traumatic Neuroma
Clinical
Wandering transected nerve with scar tissue
Painful or tender, firm lump or nodule
Oral site
Occurs at sites of chronic trauma
Ex. mandibular alveolar ridge in denture
wearer, especially near mental nerve,
denture flange trauma
Ex. tongue

Pyogenic Granuloma
Clinical
Occur at any age
Any location but usually on
gingiva
Most common is interdental
papilla
Local reactive growth
Irritation
Bleeds readily
Exophytic
Not painful
Grows very fast like
malignancies
Proliferative
Peripheral Giant Cell
Granuloma
Clinical
Somewhat similar in appearance to pyogenic
granuloma
Moderate soft mass
Often liver-colored [brownish purple]
Distinctive histology
Multinucleated giant cells
Limited to alveolar ridge/
gingiva
Usually anterior to first molar
region


Central Giant Cell Granuloma
Clinical
Intrabony
Same histology as:
Peripheral giant cell
granuloma
Brown tumor of hyperpara-
thyroidism
No effect on saliva production
Bone destruction secondary to chronic renal
disease
Squamous Papilloma (Papilloma)
Clinical
Etiology - epithelium
White to white-pink usually but can be reddened
Rough surface (cauliflower)
Elevated lesion (papule, nodule)
Common sites
Facial or lingual gingiva
Soft or hard palate
Tongue
More frequent than some
other omas
Rhabdomyoma
Leiomyoma
Lymphangioma
Neurofibroma

Fibroma
(fibrous nodule, focal fibrous hyperplasia,
traumatic fibroma, irritation fibroma)
Clinical
Most common connective tissue tumor
Reactive, not true tumor
Hyperplasia; NOT neoplasia,
anaplasia, dysplasia, etc.
Firm, smooth, pink,
elevated papule/nodule
Common site is tongue (due to trauma)

Granular Cell Tumor
Clinical
Dorsum of tongue #1 site
Nodule with smooth or papillated surface
Histology distinct
Granular cells - cytoplasm
50% of time exhibit
pseudoepitheliomatous
hyperplasia
Resembles squamous cell carcinoma histologically
Leukoplakia
Clinical
White patch that does not wipe off
Cytology smear does not help determine specific
diagnosis
Appropriately managed by biopsy
Floor of mouth hyperkeratosis most common site to
exhibit dysplasia
If two separate areas in persons mouth then both
areas should have incisional biopsy
Erythroplakia and
Erythroleukoplakia (speckled)
Clinical
Red plaque that does not wipe off
Studies show that it is likely to have severe
dysplasia or worse and undergo malignant
transformation to carcinoma
Treatment
Initial incisional biopsy
Squamous Cell Carcinoma
Clinical
Lower lip
Can be preceded by actinic cheilitis
Firm, indurated ulcer; painless with v. good prognosis
Submental node is most common lymph node involved by
metastasis
Most common oral site
Mid-lateral border of tongue
Least likely oral site
Hard palate
Site with greatest likelihood or risk of developing
squamous cell carcinoma
Floor of mouth worse prognosis when lung mets (not
size, local spread or anaplastic cells)
Metastasis
Most likely to a lymph node

Squamous Cell Carcinoma
Staging vs. Grading
Stage III has a worse prognosis than I or II
Radiographic
When invasive into the alveolar ridge it will
appear poorly defined lucencies without a
reactive sclerotic border
Metastatic Disease to the Jaws
Clinical and Radiographic
Most common site is posterior mandible
Does not cause a shift of patients occlusion
Usually a poorly defined lucency without
sclerotic border
Monomorphic Adenoma
(Canalicular Adenoma)
Clinical
Most common site
Upper lip
> Women
May be
multinodular
Asymptomatic
Do not confuse
with mucocele
of the lower lip
Leukoedema
Clinical
Intracellular edema of cells
More often seen in African-Americans
Common, bilateral on buccal mucosa
Diagnostic test chairside
Pull on buccal mucosa - - - -> disappears or
dissipates
Normal mucosa variation so no treatment
required

Leukemia
Clinical/Lab
Red, swollen (hyperplastic),
boggy, bleeding gingiva
(interdental papilla) with ulcers
Lab tests ordered
Complete blood count
White blood count differential
Decreased neutrophils
Leukemic infiltrate leaves blood
and into soft tissue (esp. acute
monocytic type)
Red macules on skin (purpura =
extravasated blood) & skin infections
Decreased platelets
Tired feeling (malaise)
Anemia (decreased RBCs)
Verrucous Carcinoma
Clinical
Very well differentiated
form of squamous cell
carcinoma
Large, elevated, papillary often
associated with smokeless tobacco
habit
Most common site is buccal
vestibule
No tendency to metastasize
Chief difference from
typical squamous cell carcinoma
Field Cancerization
Squamous Cell Carcinoma
Patient diagnosed and treated for squamous
cell carcinoma of the tongue
Much more likely to have future premalignant
or malignant lesions anywhere in the oral
cavity
Ex. speckled leukoplakia of the floor of mouth
likely to be a second primary lesion
p53 tumor suppressor gene is most common
associated
Salivary Gland Tumors
Most common tumor of salivary gland origin
is the pleomorphic adenoma
Benign
Most common intraoral site is palate
Major and minor salivary glands potential
sites
Neoplasm most likely to arise in the parotid
Neoplasm most likely to arise in the palate
Adenoid cystic carcinoma
Characteristic perineural invasion most likely
Parotid facial nerve involvement but no upper lip
paresthesia
Physiologic Pigmentation (Racial
Pigmentation)
Clinical
Darkens with time; present
most of a persons lifetime
African-American patients
Upper or lower lip vermilion, attached gingiva,
tongue, buccal mucosa
Series of splotchy brown macules
Lateral Periodontal Cyst
Clinical
True cyst (epithelial lining),
not pseudocyst
Radiographic appearance
Well circumscribed radioluceny between the
roots of adjacent, erupted, vital teeth (most
commonly seen at mandibular premolars)
Radiographic differential diagnosis does NOT
include dentigerous cyst (impacted tooth)


Ameloblastoma
Clinical
Average age is 34
Most common in posterior
mandible but anterior mandible
also (can cross midline)
Radiographic
Most common true odontogenic tumor
Multilocular radiolucency
Superimposed over posterior teeth (> mand.)
Often associated with impacted tooth
Histology
Reverse polarization of the nuclei of the tall,
columnar cells of the periphery
Ameloblastic Fibroma
Clinical
Young person
More often in posterior jaws, esp. mandible
Slight pain, swelling; not aggressive
Ameloblastic fibro-odontoma
is similar except for odontoma
component
Radiographic
Pure lucency; no
radiopaque component
AFO also has radiopaque component (i.e., the
odontoma)

Odontoma
Clinical primarily first two decades of life (young
persons)
Radiographic
Radiopacity with radiolucent rim (= follicle)
Compound vs. Complex types
Compound - identifiable toothlets
> Anterior maxilla
Complex unidentifiable mass
> Posterior of jaws
Adenomatoid Odontogenic
Tumor (AOT)
Clinical
Young person (child or teenager)
Unerupted tooth of the anterior maxilla (#6,
#11)
Radiographic
Snow flake calcifications in the radiolucency
surrounding the crown and a portion of the
impacted tooths root
Treatment simple
enucleation
Amelogenesis Imperfecta
Clinical
Teeth lack enamel;
Dentin and cementum
unaffected
Shapes of root and
crown are normal
Radiographic
Enamel is missing
Pulp chambers and
root canals normal
Dentinogenesis Imperfecta
Clinical
Opalescent dentin blue/gray
Often associated with osteogenesis
imperfecta
Blue sclera
Multiple bone fractures
Radiographic
BWXs and PAs demonstrate classic
lack of pulp chambers and root canals
Bell-shaped crown with constricted
cervical region

Cherubism
Radiographic
Multilocular, bilateral
lucencies
Clinical
Bilateral jaws
Young persons
Jaw expansion - - ceases after childhood
Fibrous Dysplasia
Clinical
Unilateral mandibular or maxillary expansion; onset
before puberty; C.C. of teeth do not fit
Painless swelling, usually ceases at age 20
Root canal therapy will not help since non-infectious
process (i.e., fibro-osseous lesion)
Caf au lait pigmentation
Polyostotic form McCune Albright syndrome
Radiographic
Ground glass appearance
Treatment
After age 20 when stabilized
Cosmetic bone shaving


Condensing Osteitis
(Sclerosing Osteitis)
Clinical
Associated with pulpitis (ex. very carious posterior
mandibular tooth); nonvital tooth
Associated tooth will test nonvital or signs and
symptoms or tooth destruction will support nonvital
status
Radiographic
Periapical opacity so does
NOT mimic a periapical
granuloma radiographically
Does not connect with root
Idiopathic Osteosclerosis
Clinical
No apparent reason including no pulpitis in adjacent
tooth
No expansion, pain
Radiographic
Radiopacity without
peripheral lucent rim
Not connected to tooths
root
Treatment
None


Traumatic Bone Cyst
(Simple Bone Cyst; Idiopathic Bone Cavity;
Unicameral Cyst; Hemorrhagic Cyst)
Clinical
Undergoes spontaneous healing without
treatment following exploratory surgery
Pseudocyst
Radiographic
Radiolucent with scalloped margins
Pagets Disease of Bone
Clinical
Older age group
Bilateral maxilla affected
Involved bone can undergo malignant
(sarcomatous) transformation (i.e., osteosarcoma)
Cranial nerve deficits as foramen compressed,
narrowed
Does NOT have hyperglobulinemia or premature
exfoliation of primary teeth
Radiographic
Cotton wool appearance
50% - hypercementosis
Histology
Reversal lines with a mosaic pattern

Langerhans Cell Disease
(Histiocytosis X)
Clinical
Composed of Langerhans cells,
not histiocytes
Etiology is still unknown
TQ Eosinophilic granuloma
Solitary lesion, young adults
Hand-Schuller-Christian triad
Diabetes insipidus
Exophthalmos
Bone lesions
Radiographic
Tooth floating in air or space
Benign vs. Malignant Bone
Involvement
Clinical
Ominous malignant sign
Spontaneous paresthesia of the lower lip
Radiographic - Benign
Cortex remains intact thinned or
expanded


Central Neural Lesions
Neurofibroma and Schwannoma
Radiographic
Enlargement of canals and foramina

Nasolabial Cyst
Clinical
Mucolabial, smooth swelling adjacent to a
maxillary lateral incisor
Soft tissue involvement; not bone
Histology
Pseudostratified
squamous epithelium
cystic lining
Lymphoepithelial Cyst
Clinical
Commonly on ventral tongue/floor of mouth
Well circumscribed swelling
Pale, yellowish at times
Odontogenic Keratocyst
Clinical
High recurrence!
Intrabony, posterior mandible
but anywhere; BCNS association
Radiographic
Radiolucent, usually multilocular
May mimic many other
types of lucent cysts and
odontogenic tumors including
ameloblastoma
parakeratin
surface
Nevoid Basal Cell Carcinoma Syndrome
(Gorlin syndrome; basal cell nevus syndrome)
Clinical
Onset is childhood
Cysts of the jaws =
odontogenic keratocysts
High recurrence rate
Basal cell carcinomas
Face especially
Bifid rib
Radiographic
Keratocysts - unilocular or
multilocular lucencies
Calcification of the falx cerebri
Cheek Nibbling
(Morsicatio Buccarum)
Clinical
Buccal mucosa site
White, rough, tissue tags
above and below the
occlusal plane (line alba)

Other sites lip and tongue

Gardner Syndrome
Clinical
Multiple facial osteomas &
skin nodules
Hyperdontia; unerupted teeth
Multiple GI (colon) polyps [familial intestinal
polyposis] - - - -> colon carcinoma
Epidermoid cyst
Odontoma
Bells Palsy
Clinical
7
th
nerve paralysis - - - -> unilateral lip
droop at corner, inability to close or wink
eyelid
Last usually less than one month
Temporomandibular
Dysfunction (TMD)
Clinical
Pain and tenderness of palpated TMJ
Deviation of jaw toward painful side upon opening
TMJ disc moves anterior and medially due to contraction of the
lateral pterygoid muscle
Popping and clicking indicate
internal derangement with
reduction
Does not cause dizziness
Reduce opening to ~ 45 mm
Will get neuritis of VII cranial
nerve

Erythema Multiforme
Clinical
Young adult males
Sudden, explosive onset
Triggered by drug or viral
infection
Crusted, bleeding, vesicles,
ulcers of vermilion of lips;
intraoral sites excluding gingiva
Target, iris, or bulls-eye lesions
of the hands and feet
Stevens-Johnson syndrome
(Erythema Multiforme Major)
Eye (conjunctiva), mouth (labial mucosa,
tongue, etc.), genitalia
Clinical/Lab Vesiculoerosive (oral and skin)
Demonstrates immunoglobulin fluorescence
intraepithelial (supraepithelial) cementing substance
Most often immunoglobulin type G (IgG)
Positive Nikolsky sign
Common sites lips, palate, gingiva
Pemphigus Vulgaris

Pemphigus Vulgaris
Progressive Systemic Sclerosis
(Scleroderma)
Clinical
Demonstrates induration
of the soft tissue (mask-like) and
generalized widening of the PDL space
Trismus
Benign Migratory Glossitis (Geographic
Tongue, Erythema Migrans)
Clinical
Red and white
Red = flat, depapillated
areas of tongue (filiform
papillae atrophied)
White = keratin, epithelial
cell debris
Periodically appears
Can cause soreness or burning
occasionally
Treatment
Corticosteroid rinse (dexamethasone)
Moves around from day to day
Dorsum of tongue most often
Also lateral, ventral surfaces
Aspirin Burn (Chemical Burn)
Clinical
White = coagulative necrosis of the surface,
NOT hyperkeratosis
White rubs off with difficulty, hyperkeratosis does
not wipe off

Basal Cell Carcinoma
Clinical
Painless ulcer of upper lip, elsewhere on
sun-exposed face (UV); raised margins
Does NOT occur intraorally
Begins as pearly papule; assoc.
telangiectasia
Can be highly destructive if not treated
Usually does not metastasize
Mucocele
(mucus retention phenomenon, mucus
extravastion phenomenon)
Clinic
Children and young adults
Trauma
Lower lip is most common site
Vesicle/bulla, dome-shaped
Bluish often
History of recurrence
Ranula (mucocele, mucus retention
phenomenon, mucus extravastion
phenomenon)
Clinical
Floor of mouth swelling
Looks like a frogs belly (Gk ranu = frog)
Bluish usually; history of recurrence several times
Mucin will yield viscous aspirate
Microscopic histiocytes visible in mucin
MSG
MUCIN
GW
Antral Pseudocyst (Mucous
Retention Pseudocyst)
Clinical
Asymptomatic
No treatment necessary
Radiographic
Slight radiopaque,
dome-shaped, emanating
from floor of maxillary sinus
Ankyloglossia
Congenital abnormality
tongue- tied
Dentigerous Cyst
Clinical
Most common site is posterior mandible
Impacted third molars
Unicystic ameloblastoma can arise from it
Malignant transformation of the lining is possible
Histology
Epithelial lining - - - -> ameloblastoma, squamous
cell carcinoma, mucoepideromoid carcinoma
Other impacted teeth besides 3
rd
molars

Dentigerous Cyst (contd)
Radiographic
Pericoronal radiolucency attached at CEJ
of unerupted tooth
Radiographic differential diagnoses
Ameloblastoma
Residual cyst
Odontogenic keratocyst
Odontogenic myxoma

Varices
Lingual and Lip
Dilated veins - blue
Seen typically in the elderly
Lip varices may thrombose and
subsequently calcify (i.e. phlebolith)
Parulis (Gum Boil)
Clinical
Incomplete root canal therapy with
intermittent sensitivity
Elevated reddish-yellow
Clinical evidence of a draining fistula
Tuberculosis
Clinical
Incidence is increasing worldwide and in
the U.S.
Chest radiograph
May spread by infected sputum to oral
lesions (e.g., ulcer mimicking cancer on
the tongue)
Extravasated Blood
Clinical spontaneously resolve
Purpura generalized term
Petechia- pinpoint bleeding
Ecchymosis larger area of involvement
Hematoma large, elevated areas
Allergic Gingivitis
Clinical
Typically due to flavoring agents in
toothpastes, candies, and chewing gums
(cinnamon flavoring is a common culprit)
Eagle Syndrome
Clinical
Elongation and/or
calcification of the
stylohyoid ligament
Head and neck pain is
elicited by chewing,
yawning, opening mouth
Herpes Zoster
Clinical
Crop of vesicles - - - > ulcers with pain
Striking unilateral distribution on skin and
oral
ex. palate, tongue
Primary Herpes
Gingivostomatitis
Clinical
Inflamed, enlarged marginal gingiva;
gingival bleeding
Vesicles - - - -> ulcers throughout the
mouth and lips with significant pain
Malaise
Low grade fever
Sore throat, lymphadenopathy
Primary Herpes
Gingivostomatitis
Crohns Disease
Clinical
Granulomatous gingivitis
Aphthous-like ulcers
Rectal bleeding
Intestinal skip lesions of small intestine, and
to a lesser degree, large intestine and other
regions of the GI tract
Dermoid Cyst
Clinical
Slightly compressible (doughy)
Midline distribution usually
Example - anterior floor of mouth
Multiple Endocrine Neoplasia
Syndrome, Type IIB (III)
Clinical
Multiple mucosal neuromas (e.g., tongue)
Medullary thyroid carcinoma
Adrenal pheochromocytoma
Incisive Canal Cyst
(Nasopalatine Duct Cyst)
Clinical
Most common developmental
non-odontogenic cyst
Teeth vital; max. midline
True cyst (epithelial lining)
Often heart-
shaped lucency
White Sponge Nevus
Clinical
A genodermatosis
Autosomal dominant
Often bilateral buccal
mucosa; other mucosa
Moderately extensive
thick, white folds of tissue
- No eye involvement

Cleft Palate
Clinical
Between lateral incisor
and canine
Radiographic
Lucent line
Maxillary occlusal film
Trigeminal Neuralgia
Clinical
Age of onset typically > 35 years old; trigger points
Neuritis
Clinical
Intense pain for one week duration
Unilateral
At forehead and around eye
Actinic Cheilitis
Clinical
Lips vermilion becomes indistinct
Great potential for dysplasia to undergo
malignant transformation into squamous cell
carcinoma
Therefore, a premalignant condition
Cheilitis Glandularis
Clinical
Mucous minor salivary glands of lips are inflamed
Mucus secretions
Premalignant condition - - - - > squamous cell
carcinoma
Post-Developmental Loss of Tooth
Structure
Attrition - physiological
Abrasion - pathological
Mechanical wear at
cervical region most typically
Habits / occupations
Erosion
Chemical loss of tooth structure
exclusive of acidogenic theory
of caries
Chlorinated pools
Gastric regurgitation and GERD
Hiatal hernia, bulimia
Post-Developmental Loss of Tooth
Structure
Abrasion
Post-Developmental Loss of Tooth
Structure
Erosion
Oral Hairy Leukoplakia
Clinical
White, rough plaque on lateral border of tongue (#1
site)
Seen in HIV-positive individuals that are progressing
to AIDS
Caused by Epstein-Barr virus
Periapical Cemento-osseous Dysplasia
(Periapical cemental dysplasia; periapical osseous
dysplasia)
Clinical
Middle-aged black women
Mandibular anterior vital teeth
No pain or expansion - - asymptomatic
Radiographic
Diagnosed by characteristic findings
Multifocal periapical lucencies which mature over time;
become mixed lucent/opaque and finally mainly opaque

Time
Florid Cemento-osseous Dysplasia
(florid osseous dysplasia)
Clinical
Multiquadrant
Fibro-osseous intrabony lesion
Hard product produced is avascular so . .
Most likely complication is a secondary osteomyelitis
Radiographic
Radiolucent and radiopaque
Treatment
None necessary after dx


Florid Osseous Dysplasia
Lichen Planus
Clinical
Skin and/or oral condition
Middle aged women most often
Skin
Purple, polygonal, pruritic, papules
Oral
White papules and coalescing papules = Wickams striae
Does not wipe off any oral site
Reticular form; often asymptomatic
Erosive form
TEST On tongue may be mistaken for geographic
tongue
Sensitive, painful
Most common site
Buccal mucosa
Ex. dorsum of tongue
White plaques, individual papules and striae
Hyperplastic form - - plaque-like
Does not wipe off

Lichen Planus
hyperplastic
cutaneous
reticular
Erosive Lichen Planus
Peripheral Ossifying Fibroma
Clinical
Soft tissue lesion, not in bone but makes
osteoid/bone
Occurs on gingiva, especially interdental papilla area
Product may be seen on dental radiographs as
scattered light opacities


Cleidocranial Dysplasia
Clinical
Multiple unerupted supernumerary teeth
Retention of primary teeth
Delayed eruption of permanent teeth
Missing clavicles, frontal bossing, large head
Neurofibromatosis, type 1 (von
Recklinghausens disease of skin)
Clinical
Multiple neurofibromas (nodules) of the skin and
oral cavity (especially tongue)
Caf au lait pigmentation (abnormal macules or
spots of the skin)
Brown macules
Calcifying Odontogenic Cyst
(Gorlin Cyst)
Histology
Ghost cells
Calcifications
Nicotine Stomatitis
Clinical
Hard palate
Red, inflamed minor salivary
gland ducts with background
of leukoplakic change
Tobacco use
Pipe smokers most often
Cigarettes
Melanotic Neuroectodermal
Tumor of Infancy
Clinical
Rapid onset, destructive in newborns
Increase of vanillylmandelic acid (VMA)
Anterior maxilla, soft and
hard tissue
Mobile teeth
Radiographic
Intrabony, lucent, destructive
Malignant looking but
benign usually

Auriculotemporal syndrome (Frey
syndrome)
Clinical
Often after parotid gland surgery
Sweating of unilateral facial skin just prior to eating
Does not affect cranial nerve VI (rather V)
Starch Iodine Test
Aspiration
Always aspirate an anterior
maxillary/mandibular radiolucency prior
to biopsy to rule out vascular nature
Actinomycosis
Clinical
Soft tissue swelling (woody consistency)
with multiple draining fistulas
sulfur granules = colonies of bacterial
organism
PMNs
Chronic Osteomyelitis
Radiographic
Often best seen in lateral oblique
radiographic view
Radiolucent and radiodense
Condylar Hyperplasia
Clinical
Irregular, elongated condyle
Chin deviates away from affected side upon
closure
Dens-in-dente (dens invaginatus)
Clinical
Most often found in anterior jaw, especially
maxillary lateral incisor
Periapical Cyst and Granuloma
Clinical
Nonvital tooth, at apex
Radiographic
Periapical lucency with thin radiopaque line =
reaction to apical inflammatory disease
Dentin Dysplasia
Clinical
Dentin abnormal with
exposure
Draining fistulas
Misshapen teeth
Radiographic
Type 1 rootless teeth
Periapical lucencies

(Hypohydrotic) Ectodermal
Dysplasia

Exhibits hypodontia (anodontia)
Hypohidrotic - common type
Lack of skin appendages and hair
Heat intolerance
Epulis Fissuratum
Clinical
Hyperplastic connective tissue like fibroma
Associated with ill-fitting denture flange
Treatment does NOT include antibiotic therapy
Gingival Cyst of the Adult
Clinical
Soft tissue
Facial attached gingiva
Mandibular anterior most often
Elevated, fluid containing so a vesicle

Heavy Metal Systemic
Intoxication
Clinical
Lead line
Blue line that parallels free marginal gingiva
Hemangioma
Clinical
Hamartoma
Red to blue elevated lesions
Blanches, compressible
Histology
Collection of small or large vessels filled with red
blood cells

Lymphangioma
Clinical
Lymph-filled superficial vessels
Most common cause of macroglossia
Hypercementosis
Clinical
Vital mandibular first molar
Generalized in acromegaly
Also seen, at times, in Pagets
Radiographic
Radiopacity with intact PDL
Attached to root surface
cementoblastoma
Infectious Mononucleosis
Clinical
Cervical swelling, lateral
Sore throat
Teenagers most often
Positive monospot test
Epstein-Barr virus association
palatal petechiae
Internal vs. External Tooth
Resorption
Clinical pink tooth when crown involved with
internal type
Radiographic
Cannot tell difference early in the process
Round or ovoid radiolucency
Irradiation Therapy
Clinical
Causes cervical caries secondary to
inducement of xerostomia
Does not result in pulp necrosis
Acquired Melanocytic Nevus
(common mole; nevus)
Clinical
Junctional type
Most likely to undergo
malignant transformation
(i.e., melanoma)

Intramucosal type
Most common oral type
Called intradermal type on skin

Compound type


Kaposis Sarcoma
Clinical
Particular malig. seen in HIV positive
individual that progress to AIDS
Etiology
Herpes virus, type 8; not HIV, EBV, CMV, HPV

Keratoacanthoma
Clinical
Difficult to differentiate from squamous cell
carcinoma of the face and lip (and its histology)
Sun-exposed skin
Present for many months; spontaneously resolve in
~ 4 months
Keratin plug in the center of the ulceration
Keratoacanthoma
Xerostomia
Clinical
Dry mouth (subjective)
Can result in retrograde infection of the
salivary glands; baldish, inflamed tongue
Warthins tumor
(papillary cystadenoma lymphomatosum)
Clinical
Primary site overwhelmingly is parotid
Not in oral cavity; >> males
Vitamin C Deficiency
Clinical
Scurvy
Does NOT cause xerostomia
Stafne Defect (salivary gland
depression defect)
Clinical
Developmental
More in males
Asymptomatic
Teeth vital
Radiographic
Well demarcated lucency found near the angle of
the mandible beneath the
mandibular canal
Sjgrens Syndrome
Clinical
Autoimmune disease; NOT infectious (e.g., herpes)
Elderly women
Dry eyes, dry mouth = sicca
Parotid swelling
Often other autoimmune diseases
lupus, rheumatoid arthritis

Sarcoidosis
Clinical
Bilateral hilar lymphadenopathy (chest x-ray)
Cutaneous lesions - violaceous
Treatment corticosteroids

Proliferative Periostitis
(Garres)
Clinical
Young person; swelling visible
Radiographic
Inferior border of posterior mandible is common site - Onion
skin pattern (radiographic appearance)
Bands of radiopaque lines that parallel cortical surface

Peutz-Jeghers Syndrome
Clinical
Oral and Paraoral
Pigmented macules (brown)
Lips, tongue, buccal mucosa
Vermilion and skin of lip
Intestinal polyposis
Osteosarcoma
Clinical
Swift onset of localized pain
and swelling; tingling lower lip
Onset in late 20s, early 30s
Most common primary
malignancy of bone in persons
less than 25-years-old
Radiographic - early lucency then opacity;
trabeculae changes; PDL symmetrical widening
Osteoporosis
Clinical
Decrease in serum estrogen and
calcium
Older females
Osteopetrosis
Clinical
Massive overproduction of dense, nonvital bone of
both jaws
Young persons or adults
Expansion
Frequent complication
Secondary osteomyelitis
Osteopetrosis
Osteoma
Clinical
Most common site is angle of mandible
Radiographic
Well-circumscribed radiopacity


Mandibular Fracture
Clinical
Often diagnosed with two radiographs
Panoramic and occlusal
Mandibular Malignant Ominous
Sign
Clinical
Spontaneous paresthesia of the lower lip
Mandibular Torus
Radiographic
May be superimposed over periapical region
as radiodensities
Malignant Melanoma
Clinical
Most common oral sites
Hard palate and gingiva
Multiple Myeloma
Clinical
Elderly males (high median age)
Lab Findings
Bence-Jones proteinuria
Immunoglobulin spike
Radiographic
Multiple bone sites
Calvaria, spine, pelvic girdle, jaws
Punched-out lucencies
Necrotizing Sialometaplasia
Clinical
Rapid onset
Deep ulceration of the palate (most common
site) after initial swelling; self-resolving
Cervical emphysema
Introduction of air into oral soft tissues with
resulting sudden painless swelling and
crepitance
Ex. air/water syringe
Odontogenic Myxoma
Clinical
Young adult onset
Radiographic
Closely resemble ameloblastoma
Multilocular lucency with soap bubble pattern
Miscellaneous Facts
Primordial cyst forms in place of a tooth
Enamel hypoplasia is a temporary suspension
of amelogenesis
Fusion one less than normal compliment of
teeth; primary tooth of ant. mandible; separate
root canals
Gemination can be confused with fusion
Pleomorphic adenoma (benign mixed tumor)
most common salivary gland tumor

Miscellaneous Facts
The parotid gland body is the most likely salivary
gland tissue to have a neoplasm
Osteoradionecrosis major factor is damage to
the vascular supply
Prognosis best for sq cell ca of lower lip compared
to osteosarcoma, melanoma, adenocarcinoma
Most common jaw metastasis site is posterior
mandible
Onion skin radiograph pattern is also seen in
Ewings sarcoma
Desquamative gingivitis includes
pemphigoid, pemphigus and erosive lichen
planus ON THE TEST


Miscellaneous Facts (contd)
Autoimmune diseases more common in women
Oncocytoma = parotid swelling (tumor)
Gingival hyperplasia drugs such as cyclosporine,
nifedipine (Procardia

) phenytoin (Dilantin

)
Malignant jaw lesions destroy the cortical plates of
bone
Gingival condition with no improvement after two
months should be biopsied
Dysplasia abnormal maturation of the epithelium

Epithelial Dysplasia
Radiology Facts
X-ray has the shortest wavelength and the
highest energy; high voltage has the same
characteristics
When milliamperage is doubled the intensity of
an x-ray beam is doubled
Kilovoltage (kVP) primarily controls contrast
and is the penetrating characteristic of an x-ray
X-ray penetration is determined by kVP on test
Focal spot size primarily influences resolution


Radiology Facts (contd)
First sign of damage from acute radiation
exposure (4 Gy) is erythema
Most radioresistant tissue is nerve and
muscle cell; most sensitive is hematopoetic
Basic shadow casting principle with the
paralleling technique does not fulfill the
physics requirement of the distance from
the object to the recording surface should
be as short as possible

Radiology Facts (contd)
The density of processed film is not affected by
overfixation but is affected by
Increase mA
Increase exposure time
Decreased object-thickness distance
Decreased target-object distance
Best imaging film for viewing internal derangement of
the TMJ (e.g., articular disc) is an MRI
Identify Normal:
Zygomatic process and base; intermaxillary suture
Lingual foramen; incisive foramen; genial tubercles
Mylohyoid ridge; nutrient canals
Inverted Y of Ennis
Maxillary sinus
Tuberosity; hyoid bone; nose shadow (ant. periapical film)
Hard palate; tori; anterior nasal spine; stylohyoid ligament


Radiology Facts (contd)
Intensifying screens are used to decrease
exposure time, reduce radiation exposure
8-bit digital image would have 256 shades of
gray
Complication of radiation treatment in children
does NOT include supernumerary teeth but
does include:
Stunted roots
Micrognathia
Condylar hyperplasia
Malocclusion
Coin tests
Used for detection of light leakage
Radiology Facts (contd)
Double the distance from the radiation source
then the radiation becomes diminished by a
factor of 4 (i.e., inverse square law)
Latent period = radiobiology time between
exposure and biologic onset of symptoms;
not cell exposure and free radical formation
Radiograph is rinsed with water to accomplish
getting rid of chemicals (not remove emulsion,
diminish silver particles, remove latent image)
Artifact
Bitewing radiograph with a curved dark line through
contact points of adjacent crowns = a break in the
emulsion from film bending
Radiology Facts (contd)
A light radiograph is NOT caused by a long
process time
An MRI is narrow frequency radiation of the
electromagnetic spectrum
The filter in a dental x-ray machine is made of
aluminum
A charged coupled device (CCD) converts x-
rays to electrical signals but does NOT result in
the same average absorbed dose as
conventional radiology (less absorbed dose)
Effective dose =comparison of the radiation
risk in humans from different radiographic
exams and doses/sources
Radiology Facts (contd)
Collimating an x-ray beam results in an
increase of the penetration of x-ray photons
Radon is the greatest source of background
radiation on earth
Basic components of an x-ray cathode ray
tube consists of a filament and a focusing
cup
To change from long scale intensity (low
contrast) to short scale intensity (high
contrast) but maintain image density, the
operator should decrease kVp and increase
mAs


Radiology Facts (contd)
Panoramic radiograph with one second of
movement by patient results in wavy inferior border
of the mandible and unsharp image vertically across
the image at that site
Major biologic damage from ionizing radiation is
primarily due to radiolysis of the water molecules
Electrons flow from cathode to anode with the
energy converted to heat
Recognize MRI and CT films
Recognize technical errors
Incorrect beam centering (cone cut)
Blurring due to patient movement
Radiology Facts (contd)
Penumbra the geometric unsharpness
with a fuzzy area surrounding the contours
of the teeth and osseous tissues
An intensifying screen is used with external
radiographs to decrease the radiation
exposure
The oil unit of an x-ray tube housing
functions to dissipate heat from the target


Penumbra