Exam 2 Flashcards

Question

What is the most common/most destructive of the three sinonasal papillomas and where does it usually reside?

Answer 1

* AKA Inverted schneiderian papilloma * **Most common** of the three (up to 75%) * **Greatest potential for destruction & transformation** * 3:1 M\>F * **Lateral nasal wall or sinus** * Significant growth potential * 75% recur after conservative surgery; 15% after aggressive surgery * Up to 25% undergo malignant transformation into squamous cell carcinoma

Answer 2

6-8% 1:100,000 60% occur after a dental procedure, 40% occur spontaneously.

Answer 3

Papules form clusters of fluid-filled vesicles, vesicles rupture and crust within 2 days, heals without scarring in 7-10 days, symptoms are most severe in first 8 hours. Active viral replication is complete within 2 days.

Answer 4

Morsicatio Buccarum * Scientific term for chronic cheek chewing * Morsicatio is from the Latin morsus meaning bite * Name for lesions found elsewhere: * **Morsicatio labiorum (labial mucosa)** * **Morsicatio linguarum (tongue)** * Higher prevalence in those under stress or with psychologic conditions * Typically found bilaterally on the anterior buccal mucosa * Appear as thickened, shredded white areas which may be ulcerated * No treatment is required; not a premalignant condition

Answer 5

* Localized proliferation of sebaceous glands of the skin, and they are almost always umbilicated. * Significant because if its clinical similarity to more serious facial tumors, such as basal cell carcinoma (BCCA)

Answer 6

1. Canalicular adenoma 2. Pleomorphic adenoma 3. Warthin tumor (papillary cystadenoma lymphomatosum) 4. Oncocytoma

Answer 7

* **Clinical staging uses TNM classification; each stage in T has an a (not ulcerated) or b (ulcerated):** * **Each N has an a (microscopic) or a b (macroscopic)** * Key points: * Ulceration is an adverse prognostic indicator for cutaneous melanomas * Ulceration has not been proven to be a prognostic indicator in mucosal melanomas * **Any invasion more than 0.5 mm in oral mucosal melanoma has poor prognosis (The mucosa is the worst for melanoma, but doesn’t happen as often)**

Answer 8

Plummer-Vinson Syndrome

Answer 9

In the Head and Neck region, but no in the mouth.

Answer 10

* Sign of severe immune depression & advanced disease * Rarely occurs in any other form of immune suppression; its presence in the absence of known immunosuppression mandates HIV testing * **Most common EBV-related lesion in AIDS pts** * White mucosal plaque that does not rub off * Usually occur on the lateral border of tongue * Clinical diagnosis can be made * No treatment necessary

Answer 11

* Inhibit osteoclasts * Possibly interfere with angiogenesis * Bisphosphonates are used to: * Slow osseous involvement of cancer * Treat Paget’s disease * Reverse osteoporosis * 2nd generation bisphosphonates are more potent, are termed aminobisphosphonates, and they attack areas of active remodeling, such as the jaw.

Answer 12

Chinese men

Answer 13

* Low-grade malignant neoplasm showing serous acinar differentiation * **Parotid** is the most common site (**85%** of the cases) \> minor glands \> submandibular * Can be Malignant 15% of the time

Answer 14

* **Metastatic spread is largely via lymphatics (Know for test)** * Tends to spread to **ipsilateral cervical lymph nodes** * Nodes will present as: * Firm to stony hard * Painless * Enlarged * Fixed – if the cells have perforated the capsule of the node and invaded into surrounding tissues * Distant metastasis is below the clavicles * Most commonly found in: * Lungs * Liver * Bones

Answer 15

Parotid Gland, then minor, then submandibular, then sublingual.

Answer 16

Adenoid Cystic Carcinoma (although this tumor is mostly (50%) found in minor salivary glands)

Answer 17

Mulloscum Contagiosum * DNA poxvirus * Contains molluscum bodies, aka Henderson-Paterson bodies

Answer 18

Histological

Answer 19

Herpetiform Recurrent Apthous Ulcer * Occurs more commonly in adults * Greatest number of lesions and recurrences of the three clinical variants * Lesions are **1-3 mm in diameter (smallest)** * **Up to 100 ulcerations per occurrence** (Remember that these are similar to herpetic ulcers, but these are on movable mucosa) * Ulcerations heal within 7-10d * Closely spaced recurrences * May have continuous lesions for three years * F\>M * Occurs in adulthood

Answer 20

1. Linear gingival erythema * Linear gingival erythema diagnosis is reserved for gingivitis that doesn’t respond to improved plaque control & has a greater degree of erythema than would expected * Distinguishes from marginal gingivitis * Treat with systemic antifungals 2. Necrotizing ulcerative gingivitis (NUG) * Ulceration & necrosis of interdental papillae with no attachment loss 3. Necrotizing ulcerative periodontitis (NUP) * Ulceration & necrosis with rapidly progressing attachment loss * For NUG and NUP, treat with debridement, antimicrobials, immediate follow-up, long-term maintenance. Necrotizing stomatitis can occur if left untreated.

Answer 21

Intraosseous (Central) Mucoepidermoid Carcinoma * Pathogenesis: * **Ectopic salivary gland tissue that was developmentally entrapped within jaw** * Odontogenic epithelium, mucous metaplasia * Middle age adults, **mand.\> max., molar-ramus region** * Prognosis: 90% survival

Answer 22

5% 1. Persistence over several years 2. Female patient 3. Nonsmoker 4. Oral floor or ventral tongue lesions

Answer 23

Below the waist, mainly through sexual contact. Clinical lesions produced by HSV-1 and HSV-2 are identical.

Answer 24

1. Candidiasis 2. Hairy leukoplakia (EBV) 3. Kaposi’s sarcoma (HHV-8) 4. Non-Hodgkin’s lymphoma 5. Periodontal diseases

Answer 25

1. Oral Hairy Leukoplakia 2. African Burkitt's Lymphona 3. Nasopharyngeal Carcinoma

Answer 26

Grade 1 = Tumors that most closely resemble their parent tissue seem to grow at a lower rate ........ Grade 3 = Tumors that show little resemblance to their parent tissue tend to enlarge rapidly and metastasize early

Answer 27

Abreva or acyclovir cream, and then acyclovir for systemic.

Answer 28

It is a benign tumor formed from glandular structures in epithelial tissue.

Answer 29

1. Cheilitis granulomatosa 2. Facial paralysis 3. Fissured tongue

Answer 30

Major Recurrent Apthous Ulcer * Occurs more in adolescents * **“Sutton’s Disease”** is associated with these, for boards * Larger than minor aphthae * Demonstrate the longest duration per episode when compared to other variants * Measure **1-3 cm** in diameter * Take 2-6 w to heal * May cause scarring * **Number of lesions per episode is 1-10** * **Most commonly** involved: * Labial mucosa * Soft palate * Tonsillar fauces

Answer 31

Leser-Trelat Sign * Sudden appearance of numerous seborrheic keratoses with pruritus has been associated with internal malignancy

Answer 32

1. Multinucleation 2. Acantholysis - separation of the keratinocytes 3. Tzanck cells - free floating epithelial cells in an intraepithelial vesicle, also found with pemphigus vulgaris.

Answer 33

* Results from **UV radiation** * Frequent sunburns and freckling in **childhood** increase risk * Occupational sun exposure and sunburns as an adult are not significant risk factors

Answer 34

Upper Lip (75%)

Answer 35

* T = size of primary local tumor in centimeters * N = Involvement of local lymph nodes * M = Distant metastasis * Best indicators of patient prognosis * Determined by tumor size and extent of metastatic spread (TNM system) * Depending on the T score, the N score, and the M score, you are put into either Stage I, II, III, or IV, with IV being the worst. * Stage TNM Classification I T1 N0 M0 II T2 N0 M0 III T3 N0 M0 OR any T, N1, M0 IV Any M; any T4; any N3

Answer 36

Susuk ## Footnote Thought to: Enhance or preserve beauty Relieve pain Bring success in business Provide protection against harm The majority of those with susuk are Muslim, though Islam prohibits black magic Therefore, individuals may deny placement of susuk even when confronted with evidence Susuk is shaped like a needle; one pointed end and one blunt end Most are silver or gold and are 0.5x0.5 mm Pins vary from one to many and are inserted subcutaneously Orofacial region is the most common place Most patients are middle-aged adults No clinical evidence exists; only found via routine XRAY

Answer 37

* Multifocal neoplasm of vascular endothelial cell origin. * 70% of pts with KS have oral lesions * 20% of pts = oral cavity is primary site of involvement * Most commonly affected: * Hard palate * Gingiva * Tongue * Biopsy is required * **Kaposi's Sarcoma has large dark red and purple mass on palate**

Answer 38

Cervical lymph node metastatis

Answer 39

White Lesions are white because there is something (keratin, microbial colony, scar tissue, necrosis, etc.) blocking the “redness” of the underlying vascular tissue.

Answer 40

Sialadenitis * Infection: * Viral: mumps * Bacterial * Non-infectious causes: * Sjögren syndrome * Sarcoidosis, granulomatous inflammation * Radiation induced * Recent surgery * Allergic reaction * Obstruction of the salivary duct * Mumps (Epidemic Parotitis) * **Paramyxovirus infection primarily affect the salivary glands** * Incidence decreases due to MMR * **Complications: Epididymoorchitis (M), oophoritis, mastitis (F)** * Diganosis based on clinical findings, viral culture, serological tests * Anesthesia Mumps * Rare complication after general anesthesia * **Swelling of parotid or submandibular glands after surgery** * Spontaneously resolving in hours or in a few days

Answer 41

Actinic Lentigo. Ephelis.

Answer 42

Sialolith (Salivary Gland Secretion, Submandibular)

Answer 43

Blue Nevus * Uncommon, **benign proliferation of dermal (or intramucosal) melanocytes** * **Most commonly on the palate – know for test** * Two forms: * Common – 2nd most frequent melanocytic nevus encountered in the oral cavity * Predilection for dorsa of hands and feet, scalp, face * Oral lesions are almost always on the palate * Occurs in children/young adults * Appears clinically as a macule or papule with a blue to blue-black coloration * Less than 1 cm in diameter * Cellular * 50% are seen **on the buttock** * Slow-growing blue-black papule that can reach up to 2 cm in size. * Blue color is due to **Tyndall effect** * Oral lesions must be biopsied to rule out melanoma, because melanoma can be blue and it can be multiple colors, but if it has been there for years, than most likely isn’t melanoma.

Answer 44

1. Floor of mouth 2. Ventral tongue 3. Soft palate

Answer 45

Swiss Cheese

Answer 46

It is VZV/Shingles/Chicken Pox along with all of the symptoms below - * Cutaneous lesions of the external auditory canal * Involvement of ipsilateral face and auditory nerves * Facial paralysis * Hearing deficits * Vertigo

Answer 47

Antral Pseudocysts * Common findings on panoramic XRAYS * Appears as a dome-shaped, slight radiopaque lesion arising from the intact floor of the maxillary sinus * Consists of an exudate (serum, not mucin) that has accumulated under the sinus mucosa and caused a sessile elevation * Present in 2-15% of population * No treatment necessary

Answer 48

Thickened spinous layer

Answer 49

An introral white plaque that does not rub off, and cannot be identified as any well-known entity.

Answer 50

It is a canker sore, it is found exclusively on movable mucosa (if on attached, we would think Herpes Virus/Herpetic Ulcers), and the three clinical variations are Minor (85%), Major (10%), and Herpetiform (5%).

Answer 51

Angiodema * AKA Quincke’s disease * Diffuse edematous swelling of the soft tissues * No pain, but itching and erythema can be present * Most common cause is **mast cell degranulation**, which leads to histamine release * IgE-mediated hypersensitivity reactions * Occurs most commonly on the extremities * Resolves in 1-2 days * Treatment for allergic angioedema is oral antihistamine therapy * IM epinephrine or IV corticosteroids in severe cases * Diffuse involvement of the head and neck can be caused by angiotensin-converting enzyme (ACE) inhibitors * -prils (such as Lisinopril) * Medication for HTN or chronic heart failure * 4x more common in African Americans than Caucasians * **The swelling can look a lot like cheilitis granulomatosis, but cheilitis is usually over the space of weeks and this one is more rapid onset.**

Answer 52

Condyloma Acuminatum * AKA **Venereal wart** * Caused by **HPV** * 2 * **6\* - most common** * **11\* - most common** * **16 – high risk** * **18 – high risk** * **31 – high risk** * 53 * 54 * Considered a sexually transmitted disease Clinically: * Painless * Sessile * Mucosal colored * Well-demarcated * Exophytic * Short, blunted surface projection * Characteristically clustered with other condyloma * Average size is **1 – 1.5 cm** * **Twice as large as papilloma or verruca vulgaris (The larger it is, the more you think Condyloma instead of the other two)**

Answer 53

To distinguish between melanoma and its benign counterpart (melanocytic nevus), the **ABCDE system** has been developed to describe the clinical features of melanoma: * Asymmetry * Border irregularity * Color variation * Diameter greater than 6 mm (roughly the end of an eraser) * Evolving lesions

Answer 54

1. Granulomatous inflammation (Astroid body, multinucleated cells, clumped macrophages) 2. Schaumann bodies (degenerated lysosomes) 3. Asteroid bodies (entrapped collagen fragments) 4. Hamazaki-Wesenberg bodies (large lysosomes)

Answer 55

Above the waist. UV light has been shown to be only thing that can induce lesions experimentally. Clinical presentation of primary infection is called **Gingivostomatitis** in patients younger than 18, and **Pharyngotonsillitis** in patients older than 18.

Answer 56

Trismus and Mucosal Pain

Answer 57

1. Echoviruses 2. Coxsackievirus 3. Poliovirus -Enterovirus diagnoses can be made from clinical manifestations, and the infection is self-limiting.

Answer 58

- Percutaneous exposure = 0.3% - Mucous membrane exposure = 0.09% - Non-intact skin exposure – lower than 0.09% * Risk is reduced by 75% via postprophylaxis with antiretrovirals. Must take within 24h. Must take for 4w.

Answer 59

1. Necrotizing granulomatous lesions of respiratory tract 2. necrotizing glomerulonephritis 3. systemic vasculitis of small arteries and veins

Answer 60

6, 11, 16, 18, and 31

Answer 61

Seborrheic Keratosis * Extremely common skin lesion of older people * **Acquired, benign proliferation of epidermal basal cells** of unknown etiology * **Does not occur in the mouth** * Develop on the skin of the face, trunk, and extremities * Lesions become more prevalent with age * Typically multiple * Start as small, tan to brown macules * Appear “stuck onto” skin * Usually less than 2 cm in diameter * **Dermatosis papulosa nigra** is a form that occurs in 30% of African Americans * AD inheritance * Multiple, 2mm, black papules * Found scattered around the zygomatic and periorbital region * Treatment/prognosis * Seldom removed except for esthetics * No malignant potential * Sudden appearance of numerous seborrheic keratoses with pruritus has been associated with internal malignancy * Called **Leser-Trélat sign**

Answer 62

Pre-malignant, it makes up 85% of oral pre-cancer.

Answer 63

**1. Tobacco** **80%** of patients with leukoplakia smoke Smokeless tobacco = tobacco pouch keratosis **2. Alcohol** Synergistic effect with tobacco **3. Sanguinaria** An herbal extract found in toothpaste or mouth rinses Leukoplakia occurs in the maxillary vestibule or alveolar mucosa of the maxilla 80% of pts with leukoplakic lesions here have a history of using sanguinaria products **4. UV radiation** Causes leukoplakia on the lower lip vermillion **5. Microorganisms** ``` Treponema pallidum (glossitis in 3rd stage syphilis) Candida albicans can colonize the superficial oral mucosa to produce a thick plaque (“candidal hyperplasia”) ``` HPV 16 & 18 has been identified in some leukoplakias **6. Trauma** Not precancerous Not true leukoplakia Examples: nicotine stomatitis & frictional keratosis

Answer 64

* **Multisystem granulomatous disorder of unknown cause** * **African Americans** \>\>\> Caucasians * Variable symptoms at start of disease * Organs most commonly involved * **Lungs** * **Lymph nodes** * Skin * Eyes * Salivary glands * Lymphoid tissue is involved in almost all cases * **90%** will show abnormal chest XRAY * Skin lesions – 25% of pts * Chronic, purple, indurated lesions on H&N termed **lupus pernio** * Scattered, nonspecific, tender, red nodules on lower legs termed erythema nodosum * **Two different syndromes:** * **Lofgren’s syndrome** * **Heerfordt’s syndrome (uveoparotid fever)**

Answer 65

Keratoacanthoma "Self-healing SCCA" * Self-limiting, epithelial proliferation * Patients with **Muir-Torre syndrome** have a hereditary predisposition for multiple lesions * 10% of cases occur on the outer edge of the vermilion border of the lips * Appears as a firm, well-demarcated, painless, sessile, dome-shaped nodule with a central plug of keratin * Three phases: * Growth – Rapidly grows up to 2cm 6w; distinguishes from SCCA * Stationary * **Involution** – within 1 year of onset

Answer 66

* Pilocarpine (Salagen) * Cevimeline (Evoxac)

Answer 67

1. Proliferative verrucous leukoplakia (PVL) 2. Erythroplakia 3. Erythroleukoplakia 4. Leukoplakia

Answer 68

Acquired Melanocytic nevus (AKA Mole) * The acquired melanocytic nevus is a **benign, localized proliferation of cells from the neural crest** * The acquired melanocytic nevus is the **most common of all adult tumors** * Most lesions are above the waist * Intraoral melanocytic nevi are uncommon; 2/3 are found in females * No treatment is necessary unless there is clinical change or found in oral cavity (because we are worried about melanoma)

Answer 69

Submandibular

Answer 70

Togavirus. Has capacity to induce birth defects, including deafness (80%), heart disease, and cataracts. Arthritis is the most common complaint. These are mild, last 3 days. Forcheimer's sign only happens with 20% of patients but they are small, dark-red papules on the palate.

Answer 71

Halo Nevus

Answer 72

1. Lip vermilion 2. Buccal mucosa 3. Gingiva

Answer 73

1. Elevated serum angiotensin-converting enzyme levels 2. Chest XRAY

Answer 74

Verruca Vulgaris (When you see a papilloma on the skin, it is Verruca Vulgaris, but can also be in mouth. Whereas squamous papilloma is only in mouth) * Common wart * Caused by **HPV: 2, 4, 6, 40** * Contagious * Extremely common on the skin * Frequently discovered in **children** * **Skin of hands is most common site** * Clinically: * Painless * Papule or nodule * Papillary projections or a rough, pebbly surface * **Oral lesions are almost always white** * Cutaneous lesions are skin-colored, yellow, or white * Can be pedunculated or sessile * **Maximum size is about 5 mm** * Multiple or clustered lesions are common * Differential diagnosis is same as squamous papilloma * Treatment/prognosis: * Oral lesions are surgically excised * Recurrences are possible * No chance of malignant transformation

Answer 75

Mucocele (Mucus Extravasation Phenomenon) * **Spillage of mucin into the soft tissues due to rupture of a salivary gland duct, usually caused by trauma** * Children and young adults * Most common in the **lower lip (81%)**, **FOM (ranula)**, anterior ventral tongue, buccal mucosa * Treatment: surgical excision, remove with the adjacent minor salivary gland * Submit to pathology * Important clinical distinctions: * Clinical mucoceles of the upper lip are more likely to be a salivary gland tumor * Mucoceles of the retromolar region are distinctly unusual * Most will prove to be mucoepidermoid carcinoma

Answer 76

* AKA Oncocytic schneiderian papilloma * **Most rare** of the three types * Low frequency of HPV (like inverted) * **Occurs on lateral wall** * Treated like inverted papilloma (surgically) * Risk for recurrence and malignant transformation is lower than that of inverted papilloma

Answer 77

Amalgam Tattoo Amalgam can be incorporated into the oral mucosa in several ways: * Previous areas of mucosal abrasion can be contaminated by amalgam dust within the oral fluids * Broken amalgam pieces can fall into extraction sites * Contaminated dental floss can create linear areas of pigmentations * Endodontic retrofill can be left in the soft tissue * High-speed drills can drive fine particles in tissue Amalgam tattoos appear as macules or (rarely) as raised lesions which are blue, black, or gray in color Any mucosal surface can be involved; the most common sites: * **Gingiva & alveolar mucosa** * **Buccal mucosa** **PA XRAYS are usually negative** When metallic fragments are visible on the XRAY, the clinical area of discoloration is large and extends past the size of the fragment To confirm diagnosis, **the clinician can take an XRAY of the affected areas** * **No treatment required if it can be detected via XRAY** * **However, biopsy must be done if not in order to rule out melanoma**

Answer 78

Chemical Injuries * Some patients hold medications within their mouths rather than swallow them, which can be caustic * Aspirin * Bisphosphonates * Two psychoactive drugs (chlorpromazine and promazine) * Other things that can cause mucosal necrosis by patient or dentist misuse: * Tooth-whitening products * **Hydrogen peroxide** * Phenol * Silver nitrate * Certain endodontic materials * Cotton roll

Answer 79

Xerostomia * Subjective sensation of a dry mouth * Common problem and in 25% of older adults * Multiple causes * **Complications:** * Candidiasis * Prone to cervical and root caries * Alteration of taste * **Common Causes for Xerostomia** * Medications * Caffeine/alcohol * Smoking * Radiation therapy to head and neck * Sjögren’s syndrome * Diabetes mellitus * Sarcoidosis * Surgery of salivary glands * **Management of Xerostomia** * Elimination of alcohol, smoking, caffeine consumption * Drug modification, if possible * Sugarless candies, gum * Oral lubricants (mouthwash, gels, spray) * Prescription: **pilocarpine (Salagen), cevimeline (Evoxac)**

Answer 80

Sjogren's Syndrome (Sicca Syndrome)

Answer 81

Treponema Pallidum and Candida Albicans

Answer 82

Smokeless Tobacco Keratosis (Tobacco Pouch Keratosis) * Three types of smokeless tobacco: * Chewing tobacco – men during outdoor activities * **Moist snuff – most popular** * Dry snuff – southern women * Moist snuff’s sales have increased 75% in last 20 years * Use is as high as 25% of men in southern states * Habit is rarely initiated after age 20 * **Most common local change: characteristic, painless loss of gingival tissues in area of tobacco contact** * Gingival recession may be accompanied by destruction of facial surface of alveolar bone * Correlates with quantity of daily use and duration of habit * A brown-black extrinsic tobacco stain on the teeth is common * Halitosis (bad breath) is a frequent finding * **A characteristic white plaque is produced on the mucosa in direct contact – termed smokeless tobacco keratosis** * Appears fissured or rippled * NO: Induration, ulceration, pain * Epithelial dysplasia is uncommon * If present, it’s mild * Treatment is alternating the site of tobacco placement * Habit cessation leads to normal mucosal appearance in 98% of users, usually in 2 weeks * A lesion remaining 6 weeks after habit is stopped requires biopsy

Answer 83

1. Lip vermillion 2. Buccal mucosa 3. Gingiva

Answer 84

1. Verruca vulgaris 2. Condyloma acuminatum 3. Verruciform xanthoma

Answer 85

Oral Melanotic Macule * **Oral counterpart to the ephelis** * Brown asymptomatic macule produced by a focal increased in melanin deposition * **Not dependent on sun exposure** * **Most common site = vermilion zone of the lower lip (labial melanotic macule) (If it is on the lip, call it labial, not oral)** * 80% are solitary * No malignant transformation potential but cannot distinguish clinically from early melanoma; therefore, biopsy is mandatory * **If the histology has pigmentation along the basement membrane of the lesion, then it is a melanotic macule, and not melanoma.**

Answer 86

Granular cell layer; nuclei are lost (Orth-No-Keratosis)

Answer 87

Telangiectatic

Answer 88

Human Herpes Virus facts

Answer 89

Necrotizing Sialometaplasia * Locally destructive inflammatory condition of the salivary glands * Believed to be due to ischemia * **Predisposing factors:** * **Traumatic injuries, dental injections, ill-fitting dentures, upper respiratory infections, adjacent tumors, previous surgery** * **Frequently palate**, unilateral * Non-ulcerated swelling, pain and paresthesia → necrotic tissue sloughs out, ulcer → heal in 5-6 weeks * Mimic malignancy clinically (except too acute onset) and histologically * Biopsy to rule out possible malignancy

Answer 90

1. Buccal Mucosa 2. Retromolar Areas 3. Soft Palate

Answer 91

MRONJ - Medication Related Osteonecrosis of the Jaw. The definition of this is they had current or previous treatment with anti-resorptive or anti-angiogenic agents. Exposed bone that can be probed through an intra or extraoral fistula in the maxillofacial region that has persisted for longer than **8 weeks.**

Answer 92

Lesion on the tip of the nose is a sign, and we worry about permanent blindness. Refer to ophthalmologist if necessary.

Answer 93

Smoker's Melanosis * Nicotine stimulates melanin production * 20% of tobacco smokers have oral pigmentation (3% in nonsmokers) * Most commonly affects anterior facial gingiva * Reverse smokers show changes on hard palate * Cessation of smoking results in gradual disappearance * Biopsy is considered when pigmentation is in unexpected locations or if there are clinical changes

Answer 94

* Up to 5% of HIV-infected pts * Large number have relationship with EBV

Answer 95

* Malignant neoplasm of melanocytic origin * **Arises from a benign melanocytic lesion or de novo from melanocytes within otherwise normal skin or mucosa** * Most develop on the skin, but can develop anywhere melanocytes are present * Damage from UV radiation is a major causative factor * **Chronic sun exposure is not a significant factor; acute sun exposure is** * Risk increases 2-8x with a family hx of disease * Additional risk factors: * Fair complexion * Light hair * Tendency to sunburn easily * History of painful/blistering sunburns in childhood * Personal history of melanoma * Personal history of dysplastic or congenital nevus * **Third most common skin cancer, but accounts for the most deaths** * 1 in 60 will be diagnosed * 90% arise on the skin, 25% of which are H&N * 50% of mucosal melanomas occur in the H&N * Oral cavity * 1 in 3 persons with oral melanoma have a history of a pigmented macule in the region * Sinuses * Mucosal melanoma presents at an advanced state and is more aggressive

Answer 96

1. EBV infection (strongly associated) 2. Vitamin C deficiency 3. Consumption of salt fish with N-nitrosamines 4. +/- tobacco

Answer 97

1. Floor of mouth 2. Ventral tongue 3. Soft palate

Answer 98

Melasma * **Acquired, symmetrical, hormonally-driven hyperpigmentation of the sun-exposed skin of the face - Melanin-Stimulating hormone follow same path as FSH and LH, and is the root of the problem.** * Classically associated with **pregnancy** * **Dark-complexioned women** are more at risk * Clinically presents as bilateral light brown macules which vary in size * Pigmentation can remain faint or darken over time * Difficult to treat * Avoidance of sun or using sunscreen are necessary for clinical management * No risk of malignant transformation

Answer 99

Epidemic Parotitis and it is a disease of exocrine glands, and salivary glands are best known as site of involvement. It is called epididymo-orchitis. 25% of postpubertal males experience this. 25% of first-trimester women will experience spontaneous abortions.

Answer 100

BANS * Interscapular area of the **B**ack * Posterior upper **A**rm * Posterior & lateral **N**eck * **S**calp * Prognosis for oral melanoma is extremely poor * 5-year survival is 15-20% * Younger patients have a better survival than older patients * Patients with amelanotic melanoma have a very poor prognosis * Patients usually die from distant metastases rather from lack of local control

Answer 101

Methamphetamine Use * Powdered stimulant that can be smoked, snorted, injected, or taken orally * Many develop delusions of parasitosis (neurosis that produces the sensation of snakes/insects crawling on or under the skin) * Rampant dental caries occurs * Affects facial smooth and interproximal surfaces first * Due to poor oral hygiene and extreme xerostomia, leading to consumption of sugary and acidic drinks/food * Meth potentiates the sympathomimetic amines for up to 6 hours Use of local anesthetics with epinephrine can lead to: Hypertensive crisis Cerebral vascular accident Myocardial infarction

Answer 102

* Unique form of chronic traumatic ulceration is termed eosinophilic ulceration or TUGSE * **Traumatic Ulcerative Granuloma with Stromal Eosinophilia** * Exhibits a deep pseudoinvasive inflammatory process and is slow to resolve – Looks just like oral cancer on the lips or even the tongue, ask them about it’s history, and see if rest of lips have been sunburned, etc. * Incisional bx (biopsy) is usually curative

Answer 103

* Lip carcinoma is typically treated with **wedge resection** with excellent results * 10% recur * 5-yr survival approaches 100% in lower lip

Answer 104

Both. * Lesions tend to follow the path of the affected nerve and terminate at the midline; pt ususally has accompanying skin lesions – so they usually happen on one half of the palate. * Lesions are 1-4mm, white, opaque vesicles that rupture to form shallow ulcerations

Answer 105

1. Mandibular Vestibule 2. Gingiva

Answer 106

Squamous Papilloma

Answer 107

Pleomorphic Adenoma (Benign Mixed Tumor) * The **most common salivary neoplasm** * It makes up **53-77% of parotid tumors (superficial lobe), 44-68% of submandibular tumors** * Mixture of ductal and myoepithelial cells * Remarkable microscopic diversity accounts for the name * **Palate** is the most common site for minor gland, upper lip, buccal mucosa – **Usually lateral to the midline, and posterior, unlike palatal tori.** * Lesion can grow to grotesque proportions if untreated * Tumor is encapsulated

Answer 108

It is the tendency toward development of multiple mucosal cancers. (Know for Test) * Patients with one carcinoma of the mouth or throat are at an increased risk for an additional SCC * Concurrently (synchronous) * Different time (metachronous)

Answer 109

* Fecal-oral route is major path of transmission * During acute phase, it can be transmitted via saliva or respiratory droplets * Nearly half of reported cases occur in infants younger than 1y * 85% occur in patients younger than 20

Answer 110

1. **Most common site is the tongue** 1. Posterior lateral 2. Ventral 2. Second: floor of mouth 3. Third: soft palate 4. Fourth: Gingiva * Majority of lingual carcinomas are painless, indurated masses or ulcers on the posterior lateral border of the tongue * FOM lesions are most likely to be associated with prior leukoplakia or erythroplakia * Typically located midline, near the frenum * Gingival & alveolar carcinomas are usually painless * Has a propensity to mimic benign lesions or periodontal disease * Of all intraoral SCCA, it is least associated with tobacco use and is more common in females

Answer 111

* Skin rash & oral lesions are associated with flu-like symptoms * Hand & oral lesions are almost always present * Oral lesions arise first & without prodrome * Resemble those of herpangina, but larger and more numerous * Up to 30 lesions; up to 1 cm in diameter * Affect buccal mucosa, labial mucosa, and tongue most commonly * Cutaneous lesions: * Borders of palms & soles * Ventral surfaces & sides of fingers and toes * Erythematous macules that develop central vesicles * Heal without crusting

Answer 112

False. Clinical staging is a better prognostic indicator than histologic grading (Know this for test)

Answer 113

Moderate epithelial dysplasia, which is when alterations are limited to the lower 1/2.

Answer 114

1. Materia Alba 2. White coated tongue 3. Burn (thermal, chemical, cotton roll, etc.) 4. Pseudomembranous candidiasis 5. Sloughing from toothpaste

Answer 115

Paramyxovirus. * Nine-day measles; 3 stages with 3 days * First stage: 3 Cs + fever * Coryza (runny nose) * Cough * Conjunctivitis * First stage also has the most distinctive oral manifestation, Koplik’s spots * Multiple areas of mucosal erythema with numerous, small, blue-white macules (“grains of salt” on a red background) – pretty much necrosis of the epithelial cells * Pathognomonic * Represent foci of epithelial necrosis * Second stage: * Fever continues * Koplik’s spots fade * Maculopapular & erythematous (morbilliform) rash begins * Face first * Downward spread from trunk extremities * Blanches on pressure * Third stage * Fever ends * Rash fades in similar downward progression * Replaced by brown pigmentary staining

Answer 116

Angiodema is pretty sudden onset and cheilitis granulomatosis happens over the course of weeks.

Answer 117

* Red in color due to lack of keratin and epithelial thinness * Allows underlying vasculature to show

Answer 118

A DNA virus

Answer 119

Warthin's Tumor (Papillary Cystadenoma Lymphomatosum) * **Almost exclusively in parotid gland, second (next to pleomorphic adenoma) most common benign parotid tumor, may occur bilaterally** * 60-70 y/o, Male predominance, increasing incidence in female in recent studies * **Smokers have an eightfold greater risk** * Most studies show a decided male predilection, with some early studies demonstrating a male-to-female ratio up to 10:1. * However, more recent investigations show a more balanced sex ratio. Because Warthin tumors have been associated with cigarette smoking, this changing sex ratio may be a reflection of the increased prevalence of smoking in women over the past few decades.

Answer 120

Adenoid Cystic Carcinoma * Minor gland (**50% cases**), palate \> parotid, submandibular gland * **Most common malignant salivary gland tumor of submandibular gland** * Middle age adults, 30 - 60 y/o * **Slow-growing, widely infiltrative, a tendency for perineural spread - poor prognosis because of this, it grows around the nerves** * Pain, facial nerve paralysis * Late recurrence and metastasis * 5 y survival rate: 70% * 20 y survival rate: 20% * **On Histo, it looks like swiss cheese, could be on boards**

Answer 121

Koplik's Spots, and these are associated with Stage 1 of Rubeola (Measles) virus.

Answer 122

Adenoid Cystic Carcinoma

Answer 123

Pleomorphic Adenoma

Answer 124

1. Mucoepidermoid carcinoma 2. Acinic cell adenocarcinoma 3. Adenoid cystic carcinoma 4. Polymorphous low-grade adenocarcinoma (terminal duct adenocarcinoma) 5. Malignant mixed tumor

Answer 125

* Benign, localized proliferations of respiratory mucosa * Three distinct histological patterns: * **Fungiform** * **Inverted** * **Cylindrical cell** * 50% arise from the lateral nasal wall * The rest are from the septum & sinuses * Multiple lesions possible * Etiology is unclear

Answer 126

* Chronic, recurrent immune mediated disease **with oral aphthous-like ulcerations, ocular inflammation, genital ulcers and skin lesions:** * Joint pain is common complaint, Arthralgia, enlarged joints

Answer 127

Erythroplakia

Answer 128

Mitochondria

Answer 129

Verruciform Leukoplakia (85% of time)

Answer 130

Sialolith (Salivary Stones) * Calcifications developed in salivary duct * Often in **submandibular gland**, upper lip, buccal mucosa * **Long and tortuous duct with thick secretions - Submandibular** * Pain or swelling especially at meal time * Radiograph, sialography, ultrasound, CT * TX: gentle massage, increase fluid intake, moist heat, sialogogue, surgery * Etiology is calcification of salivary secretions within the duct system * Anything that slows or inhibits salivary flow thru the duct system may predispose to development of calculi * Mucous plug * Bacterial colonies * Chronic duct blockage phenomena * Normal ductal anatomy (Wharton’s duct) * Xerostomia * Typically are not associated with elevated serum calcium levels

Answer 131

Trigeminal Ganglion

Answer 132

100%. It attacks tissues with rapid turnover, like oral epithelium. Mucositis and Hemorrhage are the two main problems. * Hemorrhage * Secondary to thrombocytopenia (from bone marrow suppression) * Oral petechiae and ecchymosis secondary to minor trauma are the most common presentations * Mucositis * White discoloration from a lack of sufficient desquamation of keratin * Soon followed by a loss of keratin and replacement by atrophic mucosa * Areas of ulceration develop 1. Xerostomia - treatment is topical fluoride and sialogogues. 2. Loss of Taste - usually comes back within 4 months after surgery. 3. Osteoradionecrosis - treat with ABX, debridement, irrigation, removal of diseased bone

Answer 133

Multifocal Epithelial Hyperplasia * AKA **Heck’s disease** * Caused by **HPV 13 & 32** * Clinically: * Appears in childhood * Multiple lesions * Painless * Flattened or rounded papules verrwhich cluster * Can appear **cobblestoned** * **Mucosal colored** * Might have slight papillary surface change * Treatment/Prognosis: * Spontaneously regresses * May perform conservative surgical excision * Risk of recurrence is minimal * No risk of malignant transformation

Answer 134

Traumatic Ulcerations * Acute or chronic trauma can cause surface ulcerations * Most common injuries are on lips, tongue, and buccal mucosa * Injured from dentition * Appears as areas of erythema surrounding a central removable, yellow fibrinopurulent membrane * A rolled white border of hyperkeratosis can develop immediately adjacent to the ulceration * Unique form of chronic traumatic ulceration is termed eosinophilic ulceration or **TUGSE** * **Traumatic Ulcerative Granuloma with Stromal Eosinophilia** * Exhibits a deep pseudoinvasive inflammatory process and is slow to resolve – Looks just like oral cancer on the lips or even the tongue, ask them about it’s history, and see if rest of lips have been sunburned, etc. * Incisional bx (biopsy) is usually curative * **Riga-Fede disease** are chronic ulcerations found under the tongue in infants due to trauma from nursing * Treatment is to remove source of injury if possible * Medications for pain relief – topical analgesics * Biopsy is warranted in cases that do not resolve after 2-4 weeks

Answer 135

* Can reside in salivary gland cells, endothelium, macrophages, and lymphocytes * Almost 90% asymptomatic * Most common symptoms include fever, joint and muscle pain, shivering, etc… * CMV is common in AIDS patients * Most affected individuals have chronic mucosal ulcerations * Histology: “owl eye” cell

Answer 136

Transient Lingual Papillitis * Common oral lesion * Clinical alterations involve variable fungiform papilla (Can involve filiform as well) * Likely represents a hypersensitivity or allergy

Answer 137

1. 1/3 2. 3% 3. 95%

Answer 138

Dermatosis Papulosa Nigra

Answer 139

1. Parotid enlargement 2. Inflammation of eye 3. Facial paralysis 4. Fever

Answer 140

Temovate (0.05% clobetasol proprionate ), use 15 mg

Answer 141

Magic Mouth Wash – **Maalox, Lidocaine, Benadryl**. This soothes and numbs, but doesn’t heal. All three patterns of transient lingual papillitis resolve without therapy.

Answer 142

Sialadenosis (Sialosis)

Answer 143

1. **Tobacco** 2. **Betel Quid** 3. **Alcohol** (1/3 of men with oral SCCA are heavy drinkers compared to 10% of the general population) 4. **Phenolic agents** (Increase risk for workers in the wood industry who are chronically exposed to phenoxyacetic acids) 5. **Radiation** 6. **Iron deficiency** (Iron is required for normal function of the epithelial cells in the upper digestive tract, Pts with severe, chronic forms **Plummer-Vinson syndrome** have an increased risk) 7. **Vitamin-A deficiency** (Produces excessive keratinization) 8. **Syphilis** (Tertiary stage, Dorsal tongue SCCA) 9. **Oncogenic viruses** (HPV 16, 18, 31, 33) 10. **Immunosuppression** 11. **Oncogenes** (Normal genes are proto-oncogenes, Transformed into activated oncogenes via viruses, irradiation, or chemical carcinogens, Once oncogenes are activated, they may stimulate the production of an excessive amount of new genetic material) 12. **Tumor suppressor genes**

Answer 144

Canalicular Adenoma * A type of monomorphic adenoma * Slow growing, painless mass, blue or normal in color, may be multifocal * **Upper lip (75%)**, buccal mucosa, exclusively in minor glands * Only pleomorphic adenoma is found more commonly in the upper lip * \<50 yo = pleomorphic adenoma * \>60 yo = canalicular adenoma

Answer 145

Indirect immunofluorescence detects presence of antineutrophil cytoplasm antibodies (**ANCA**): (Know for test) * Perinuclear (p-ANCA) * Cytoplasmic (c-ANCA) – most useful

Answer 146

1. Acute self-limited viral syndrome 2. Asymptomatic period 3. Final symptomatic period

Answer 147

Basal Cell Carcinoma

Answer 148

Erythroleukoplakia * Red and white intermixed lesions are termed erythroleukoplakia or speckled leukoplakia

Answer 149

Verruciform Xanthoma * Hyperplastic condition which is largely an oral disease of unknown cause (likely trauma) * Characterized by lipid-laden histiocytes (macrophages) in the epithelium * Not associated with any disorder * Clinically: * **Most common on gingiva** * Painless * Sessile (slightly elevated) * Papillary or roughened surface * Mucosal, white, yellow, or red in color * **Smaller than 2 cm** * Can have multiple lesions * **Differential diagnosis is same as squamous papilloma** * Histology is positive for xanthoma cells * **Lipid-laden histiocytes** * Treatment/Prognosis: * Conservative surgical excision * Recurrence is rare * No risk of malignant transformation

Answer 150

Sutton's Disease

Answer 151

- Most common pattern of symptomatic primary HSV infection. 90% are due to HSV-1. - Most cases occur before age 5 - Affected mucosa develops numerous pinhead vesicles. Yellow lesion with red halo. - **Both movable and attached oral mucosa can be affected** - Self-inoculation of fingers, eyes, and genitals can occur. - Leading infectious cause of blindness is Herpes Simplex.

Answer 152

Oral Melanoacanthoma * Acquired pigmentation of the oral mucosa * **Appears to be a reactive process due to trauma** (Can be caused by b**rushing teeth with one side having the tongue scraper** and scraping the oral mucosa) * **Characterized by dendritic melanocytes throughout the epithelium** * Not related to melanoacanthoma of the skin * **Seen almost exclusively in African Americans** * **Buccal mucosa is the most common site of occurrence**

Answer 153

1. Exophytic (mass forming, fungating) 2. Endophytic (invasive, burrowing, ulcerated) 3. Leukoplakic 4. Erythroplakic 5. Erythroleukoplakic

Answer 154

The presence of Paul-Bunnell heterophil antibodies. Most cases resolve in 4-6 weeks.

Answer 155

2, 4, 6, and 40

Answer 156

Sublingual

Answer 157

Ephelis * AKA Freckle * Common hyperpigmented macule of the skin * **Increased melanin production without increase in number of melanocytes** * More prominent in children * More common in light-skinned and light-haired persons * Become more pronounced with sun exposure * Closely associated with history of painful childhood sunburns * Clinically appear as light brown macules in variable numbers * No treatment necessary; sunscreen can prevent new or darkening of lesions

Answer 158

Defined as a red patch that cannot be diagnosed as any other condition

Answer 159

Mucoepidermoid Carcinoma

Answer 160

Shingles, and in the dorsal spinal ganglia

Answer 161

1. Sexual contact 2. Parenteral exposure to blood 3. Transmission from mother to fetus

Answer 162

Submucosal Hemorrhage The picture is from violent coughing. Causes of oral petechiae/purpura/ecchymosis: * Repeated coughing or vomiting * Convulsions * Oral sex * Anticoagulant therapy * Thrombocytopenia * Disseminated intravascular coagulation * Viral infections, especially mono & measles * Appears as a nonblanching zone with a red, purple, blue, or black color No treatment is required if the hemorrhage is not associated with systemic disease The areas should resolve spontaneously

Answer 163

Basal Cell Carcinoma This type in this picture is **Nodular/Noduloulcerative**, which is the most common form. * **Most common** form = nodular (noduloulcerative) (He will not ask us to identify the different types of Basal Cell, but Noduloulcerative is the more common one that he will use to ask us to identify. * Begins as a firm, painless papule * Slowly enlarges and gradually develops a central depression & umbilicated appearance * One or more **telangiectatic** (superficial capillaries) blood vessels are typically seen * Rolled borders are usually present * Metastasis is extremely rare * Other clinicopathologic varieties: * **Pigmented** – same as nodular, but clinically brown or black * **Sclerosing (morpheaform)** – mimics scar tissue; deeply invasive before discovery * **Superficial** – skin of trunk; appear as multiple scaly red patches that somewhat resemble psoriasis * Those associated with nevoid basal cell carcinoma * Treatment depends on size and location of the lesion * Mohs micrographic surgery * Essentially uses frozen-sections to evaluate margins during surgery * 98% cure rate * Recurrence is uncommon with properly treated disease * **Metastasis is exceptionally rare** * Death is usually result of local invasion into vital structures, though it is unusual to have such uncontrollable disease

Answer 164

Actinic Cheilosis * Common premalignant alteration of the lower lip vermilion * Results from long-term exposure to UV light * Outdoor occupation is associated: * Farmer’s lip * Sailor’s lip * Similar to **actinic keratosis** (found on rest of body) in pathophysiologic and biologic behavior * Rare in persons younger than 45 * M:F is 10:1 * Slowly developing; pt is usually not aware of the lesion * Earliest clinical changes: * **Atrophy of the lower lip vermilion border, characterized by a smooth surface and blotchy pale areas** * **Blurring of the margin between the vermilion zone and cutaneous portion of the lip** * As the lesion progresses, scaly areas develop on the drier portions of the vermilion * Further progression leads to ulceration and suggest transformation into SCCA * Changes are irreversible, but patients should be instructed to use lip balms with sunscreens to prevent further damage * If the lesion has any of the following characteristics, it should be submitted for biopsy: * **Induration (firm to the touch)** * **Thickening (leukoplakia)** * **Ulceration** * **10% of such patients will develop SCCA**

Answer 165

Orofacial Granulomatosis * Presentation is variable * Lips are most commonly involved * Labial tissue presents as a nontender, persistent swelling * When lips are only involved, it is termed **cheilitis granulomatosa**

Answer 166

* Primary SS: no other autoimmune disease * Secondary SS: associate with other autoimmune diseases (rheumatoid arthritis, SLE…)

Answer 167

Thickened keratin layer

Answer 168

* Diagnostic Criteria for Primary Sjögren’s Syndrome (2 out of 3)(American College of Rheumatology, 2012) 1. Positive serum anti-SSA and/or anti-SSB (or positive RF and ANA titer ≥1:320) 2. Ocular staining score ≥3 1. Sum of fluorescein staining of cornea (0-6) and lissamine green staining of both nasal and temporal bulbar conjunctiva (0-3) 3. Presence of focal lymphocytic sialadenitis with a focus score ≥1 focus/4mm2 in labial salivary gland biopsy samples

Answer 169

Thermal Burns * Most thermal burns of the oral cavity arise from the ingestion of hot foods or beverages * Typically appear on the palate or posterior buccal mucosa * Appear as zones of erythema and ulceration

Answer 170

* Characterized by: * Sore throat * Fever * Mild headache * 1-5 . to dark-pink nodules on the soft palate or tonsillar pillars * Represent hyperplastic lymphoid aggregates * Resolve within 10d without vesiculation or ulceration

Answer 171

Leukoplakia

Answer 172

* Herpangina * Hand-foot-and-mouth disease * Acute lymphonodular pharyngitis * They all come from Coxsackievirus

Answer 173

1. Buccal mucosa 2. Retromolar areas 3. Soft palate

Answer 174

Ranula * **Mucoceles in floor of mouth, usually lateral to the midline** - A ranula can become a **plunging ranula** by dissecting through the mylohyoid muscle, cause swelling, close off the airway, and kill the patient. This also could be called a dermoid cyst. * **Typically associated with rupture of the sublingual gland duct** * Treatment: * Removal of the feeding sublingual gland and/or marsupialization * Marsupialization (exteriorization) entails removal of theroof of the intraoral lesion

Answer 175

Mast Cell Degranulation, and ACE inhibitors like Lisinopril.

Answer 176

Verrucous Carcinoma * AKA **Snuff Dipper’s cancer – Can look like Cauliflower, has distinct margins, is white** * Low-grade variant of oral SCC * Can be caused by smokeless tobacco * **Most common sites** of involvement: * Mandibular vestibule * Gingiva * Appears as a diffuse, well-demarcated, painless, thick plaque with papillary or verruciform surface projections as well as white and exophytic * Has a **“deceptively benign”** microscopic appearance * Adequate sampling is important because up to **20%** have an SCCA developing within the verrucous carcinoma * 90% disease-free survival

Answer 177

* Herpetic whitlow (herpetic paronychia) is infection of the thumb or fingers * Herpes gladiatorum or scrumpox is a herpetic infection found in wrestlers or rugby players with contaminated abrasions * Herpes barbae is herpes over the bearded region of the face into minor injuries created by daily shaving * Ocular involvement may occur Leading infectious cause of blindness in the United States * Patients with chronic skin conditions may develop diffuse, life-threatening infection . Termed eczema herpeticum or Kaposi’s varicelliform eruption – We don’t need to know these. * Newborns can be affected via infected birth canal (usually HSV-2) 50% mortality without treatment

Answer 178

Minor Recurrent Apthous Ulcer * Occurs in childhood * Pts have the fewest recurrences * Lesions are shorter in duration than other variants * Pts typically have a prodrome * Lesions present as erythematous macule followed by a central yellow-white, removable fibrinopurulent membrane * Ulcerations are **less than 1 cm** * Heal without scaring in 1-2 weeks * **1 to 5 lesions per episode** * Much more painful than they appear

Answer 179

Melanin particles are deep to the surface, so the light reflected back must pass through overlying tissues. Colors with long wavelengths (red/yellow) are more easily absorbed by the tissues; blue has a shorter wavelength and is reflected.

Answer 180

**Upper Lip**, while mucoceles are more common in lower lip. When salivary gland neoplasms are found in lower lip, they are usually more malignant, while upper ones are benign. Salivary gland neoplasms in the **retromolar area are mostly malignant (90%)**

Answer 181

Sialorrhea * Local irritations: ex. aphthous ulcers, ill-fitting dentures * GERD * Rabies, heavy metal poisoning * Medications: lithium, cholinergic agonists * Idiopathic paroxysmal sialorrhea * Drooling: Down syndrome, neurological disorder, ex. cerebral palsy * Treatment of Sialorrhea * Treat the underlying cause * Anticholinergic medications, scopolamine transdermal patch (not for children) * Surgery: relocation of the salivary ducts to tonsillar fossa, tympanic neurectomy

Answer 182

* **80% of pts** with oral SCCA have a history of smoking * **Pipe and cigar smoking** carries a greater oral cancer risk than cigarette smoking * Relative risk (smoker’s risk for oral SCCA compared with that of a nonsmoker) is dose dependent: * 2ppd = 5x increased risk than someone who doesn’t smoke * 4ppd = 17x * Risk increases the longer the person smokes * Greatest risk comes with reverse smoking

Answer 183

Verruciform Xanthona

Answer 184

1. Herpes simplex virus, type 1 (HSV-1 or HHV-1) 2. Herpes simplex virus, type 2 (HSV-2 or HHV-2) 3. Varicella-zoster virus (VZV or HHV-3) 4. Epstein-Barr virus (EBV or HHV-4) 5. Cytomegalovirus (CMV or HHV-5) 6. HHV-6 – not much is known about this. Primary latency resides in CD4 T lymphocytes. 7. HHV-7 - not much is known about this. Primary latency resides in CD4 T lymphocytes. 8. Kaposi’s sarcoma herpesvirus (KSHV or HHV-8)

Answer 185

Exfoliative Cheilitis * Persistent scaling and flaking of the vermilion border * Typically involves both lips * Arises from excessive production and desquamation of superficial keratin * Usually due to chronic injury secondary to habits such as lip licking * Marked female predominance * Treatment is cessation of habit, corticosteroids, psychotherapy, or ruling out other underlying cause (fungus, for example)

Answer 186

* Malignant transformation potential (Most to least) 1. Proliferative verrucous leukoplakia (PVL) 2. Nicotine stomatitis in reverse smokers 3. Erythroplakia 4. Oral submucous fibrosis 5. Erythroleukoplakia 6. Granular leukoplakia 7. Actinic cheilosis

Answer 187

Highly active antiretroviral therapy

Answer 188

Wegner's Granulomatosis Classic Wegener’s granulomatosis: * **Necrotizing granulomatous lesions** of respiratory tract, **necrotizing glomerulonephritis**, and **systemic vasculitis** of small arteries and veins * If untreated, rapid renal involvement develops * Renal involvement is the most common cause of death Limited Wegener’s granulomatosis: * Upper respiratory system, no renal lesions Superficial Wegener’s granulomatosis: * Lesions occur primarily of skin & mucosa Visible lesions may appear as nonspecific ulcerations Oral lesions are characteristic * **Strawberry gingivitis** * Typically an early manifestation * Affected gingiva demonstrate a florid, erythematous, granular hyperplasia Diagnosis - **Indirect immunofluorescence detects presence of antineutrophil cytoplasm antibodies (ANCA): (Know for test)** * **Perinuclear (p-ANCA)** * **Cytoplasmic (c-ANCA) – most useful** Treatment/prognosis for classic disease: **Untreated = 10% two year survival** Steroids are first-line tx; 75% survive 30% relapse Cure can be attained if caught early & appropriately treated

Answer 189

No granular cell layer; nuclei are retained

Answer 190

* Skin rash * 2-6 oral lesions in the posterior mouth * Soft palate * Tonsillar pillars * Begin as red macules * Form fragile vesicles that rapidly ulcerate * Ulcerations are 3m in diameter * Resolve within 10d * Other symptoms: * Sore throat * Fever * Dysphagia

Answer 191

1. Localized One to several fungiform papilla involved They become enlarged and are red or yellow Anterior dorsal tongue Painful 2. Generalized A large percentage of fungiform papilla involved They become enlarged and red Tip & lateral dorsal tongue Very sensitive/painful Associated with fever & lymphadenopathy Can spread among family members (unknown virus?) 3. Diffuse, papulokeratotic variant Large number of affected papilla Appear as elevated, yellow or white papules Asymptomatic

Answer 192

Contact Stomatitis from Cinnamon * Concentrations of flavoring (Cinnamonaldehyde) is 100x that in the natural cinnamon spice * **Lymphocytes** are the cause here, while plasma cell gingivitis can happen with reactions to big red gum but that involves **plasma cells.** * Superficial sloughing can occur (much like that seen in pts using sodium lauryl sulfate-containing toothpastes) (Dr. Trump has this problem) * Localized lesions can appear ulcerated, white, or red

Answer 193

Salivary duct cyst is lined by epithelium, whereas mucocele is lined by granuloma.

Answer 194

* Radical – malignant melanocytes spread horizontally through the basal layer (flat lesion) * Vertical – malignant cells invade underlying connective tissue (tumor)

Answer 195

Lentigo Simplex * **Benign cutaneous melanocytic hyperplasia (increase in number of melanocytes).... while Ephelis is increase in melanin, but not increase in number of melanocytes.** * unknown cause * **Typically occurs on skin not exposed to sunlight** * Happens at any age but most common in children * Appears as macule smaller than 5 mm with uniform brown color; **color intensity does not change with sunlight, similar to Actinic Lentigo** * **Indistinguishable from the nonelevated melanocytic nevus** * Treatment is not required and these lesions do not undergo malignant transformation

Answer 196

* Incidence: **1-6.5 cases/100,000 people** * The **most common** sites: * parotid gland (64-80% of all cases)\> minor glands (9-23%) \> submandibular\> sublingual (\<1%) * **70-90% sublingual neoplasm are malignant.** * **Palate** is the most common site for minor salivary gland neoplasm (50%), especially posterior lateral hard or soft palate

Answer 197

Mucoepidermoid Carcinoma * **It is the most common malignant salivary gland neoplasm for both children and adults** * **More common in Females than in Males** * Affect parotid most often, then minor glands * Palate is most common minor gland site * Treatment depends on location, histopathologic grade, clinical stage * **Prognosis depends on the grade and stage** (**Whereas squamous cell carcinoma is dictated mainly by its clinical stage**) – **So know the difference between Mucoep and SSC.** * **Grading =** * **Low-grade: 90-95% survival** * **High-grade: 30-54% survival**

Answer 198

Squamous Papilloma * Benign proliferation of stratified squamous epithelium * Results in a papillary mass * Caused by human papillomavirus **(HPV)** * DNA virus of the papovavirus subgroup * **Types 6, 11** (We will be tested on these for boards and probably for him * Mode of trasmission is unknown Sites of predilection: * Tongue * Lips * Soft palate Clinically: * Painless * Usually pedunculated (The base is smaller than the top) * Exophytic * Pointed or blunted projections * White, red, or mucosal colored * **Enlarges rapidly to 5 mm, then stabilizes**

Answer 199

* Arises almost exclusively on the **nasal septum** * Treatment is complete surgical excision; recurrence is common (1/3) * Minimal or no risk for malignant transformation

Answer 200

* Target cell = CD4+ helper T lymphocyte * When T-helper cells are destroyed, immune function is lost