Exam 2 Flashcards
Linea Alba
- Typically bilateral
- Located on the buccal mucosa at the level of the occlusal plane
What are the different levels of scoring for T, Primary Tumor Size, for TNM staging, for SCCA?
What is most common site of recurrence for HSV-1?
Vermillion border and adjacent skin of the lips, Recurrent Herpes Labialis, cold sore.
How do you treat Recurrent Apthous Ulcers?
- Minor cases receive no treatment or OTC treatment
- If patient presents with multiple recurrences, many lesions, or intense pain, prescribing a topical corticosteroid is appropriate
- (I use 0.05% clobetasol proprionate (Temovate) (Know This), dispense 15mg, instruct to dry the affected area and apply a thin amount bid (two times a day) prn (as needed); this is a potent steroid so al always re-emphasize that a little goes a long way.
Actinic Lentigo
- Benign brown macule resulting from chronic UV light damage to the skin
- More than 90% of Caucasians older than age 70
- Common on dorsal surface of hands, face, and arms
- Uniformly pigmented tan macules
- Well-demarcated but irregular borders
- No change in color intensity with UV light exposure (unlike ephelis)
- No treatment except for esthetics
- Does not undergo malignant transformation
Salivary Duct Cyst (Mucus Retention Cyst)
- Epithelium-lined cavity that arises from salivary gland tissue – This is lined by epithelium, whereas a mucocele is surrounded by a granuloma, he would have to give us histology.
- Occurs mostly in adults
- Occurs in major and minor glands, can be multiple
- Most often in parotid gland, FOM, buccal mucosa, lips
- Bluish (or normal color) soft fluctuant swelling
- Treatment: Surgical excision
What is the most common location of a blue nevus?
Palate
When they develop in the oropharyngeal area, where does SCCA usually form?
- They develop on the soft palate or tonsillar area
- Have same appearance as SCCs located more anteriorly, but pt is usually unaware of its presence
- Therefore when it is discovered, there are more likely to be metastasis
- 80% of posterior oropharyngeal wall lesions have metastasized or extensively involved surrounding structures at the time of diagnosis
HIV/AIDS and Candidiasis: how common and how do you treat it?
Present in 1/3 of HIV pts and 90% of AIDS pts. Treatment is difficult – skip nystatin & prescribe topical clotrimazole. Use systemic fluconazole if patient is really bad.
What is the proper name for a Birthmark? What is a common feature of a large Birthmark, and what percent chance does it have of transforming into melanoma?
Congenital Melanocytic Nevis
- A common feature in the large type is hypertrichosis (excess hair)
- Up to 15% of large congenital nevi may undergo malignant transformation into melanoma
What are Sjogren’s Syndrome patients at increased risk for? And at what multiplication?
- Increased risk for lymphoma (40x), marginal zone lymphoma (MALT lymphoma)
What are the three characteristics associated with Lofgren’s syndrome?
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Arthralgia
Where are recurrent herpes simplex intraoral lesions almost always found?
On Keratinized bound mucosa (palate, attached gingiva). They can have a central yellowish area of ulceration with a red halo.
What are the symptoms of Mono?
-With mono, you get fatigue, malaise, anorexia, and prodrome happens 2w before fever. For classical infection fever reaches up to 104, and 90% get lymphadenopathy. Oral lesions include tonsillar enlargement, 25% get petechiae on hard palate, and you can get NUG.
What is the most common disease resulting from EBV exposure?
Infectious Mononucleosis.
In what three lcoations is 90% of Leukoplakia with dysplasia or carcinoma found?
- Lip vermilion
- Lateral/ventral tongue
- Floor of mouth
What is the name of the syndrome involved with Keratoacanthoma?
Muir-Torre Syndrome
Nicotine Stomatitis
- White keratotic change on the palate
- Due to heat (long-term hot beverage use can cause the same clinical changes)
- Not premalignant
-
Reverse smoking:
- Lit end is held in mouth
- Significant potential for malignant transformation, requires biopsy
- Most commonly found in white males, older than age 45
- Long-term exposure to heat
- Diffusely gray or white palate
- Numerous, slightly elevated papules are present; typically have punctate red centers
- Represent inflamed minor salivary glands and their ductal orifices
- May appear like “dried mud”
- Completely reversible
- Palate returns to normal within 2 weeks of habit cessation
Polymorphous Low-grade Adenocarcinoma (Terminal Duct Carcinoma)
- Almost exclusively occurs in minor salivary glands
- Hard and soft palate (65% cases)> upper lip, buccal mucosa
- F>M, older adults
- Exhibit different growth patterns histologically
Cheilitis Glandularis
- Swelling and eversion of the lower lip as a result of hypertrophy and inflammation of the minor salivary glands. – The way to differentiate from actinic cheilosis is cheilitis glandularis goes deeper into the mouth and has weeping secretions.
- Cause unknown, possible due to sun damage, tobacco, syphilis, poor hygiene, heredity
- Clinical presentation:
- Swelling and pain, typically of the lower lip
- Eversion of the lip
- Red dots indicate duct orifices
- “Weeping” mucopurulent secretions often are seen
- Middle aged to older males
- Histo: chronic sialadenitis and ductal dilation
Oral Submucous Fibrosis
- Chronic, progressive, scarring, high-risk precancerous condition of the oral mucosa
-
Linked to chronic placement of betel quid or paan
-
Quid:
- Areca nut (from a palm tree)
- Slaked lime
- Betel leaf
- +/- tobacco
- +/- sweeteners
-
Quid:
- Seen primarily in the Indiana subcontinent, but 600 million people worldwide use it regularly
- Slaked lime releases alkaloids from the areca nut
- Results in euphoria
- Users typically use 16-24h/day
- Can purchase ingredients in the US; they have a higher concentration of areca nut and cause lesions more rapidly than conventional
- Characterized by mucosal rigidity
- A few pts developed disease after only a few contacts with areca nut
- First chief complaint = trismus and mucosal pain from eating spicy foods
-
Most commonly affected sites:
- Buccal mucosa
- Retromolar areas
- Soft palate
- Surface is typically white
- Lesion does NOT regress with habit cessation
- Frequent follow-up is mandatory
- 10% undergo malignant transformation
What is the main difference between Ephelis and Actinic Lentigo?
With Ephelis, there IS change in color intensity with more UV light exposure, with Actinic Lentigo, there IS NOT a change in color intensity with more UV light exposure.
We we are concerned about malignancy with Leukoplakia, what type of screening techniques should be avoided?
Noninvasive screening techniques like brush biopsy and cytologic testing. Biopsy is mandatory, taken from most severe looking areas of involvement.
Electrical Burns
- 5% of all burn admissions to hospitals are electrical burns to the oral cavity
- Two types:
- Contact
- Arc
- Contact burns require a good ground and involve electrical current passing through the body from the point of contact to the ground site
- Electric current can cause cardiopulmonary arrest and may be fatal
- Most electrical burns affecting the oral cavity are the arc type
- Saliva acts as a conducting medium and an electrical arc flows between the electrical source and the mouth
- Most cases result from chewing on the female end of an extension cord or biting a live wire
- Most electrical burns occur in kids younger than age 5 and affect the lip
- Burn appears as a painless, charred, yellow area that doesn’t bleed
- Edema develops within a few hours
- On the 4th day, the area becomes necrotic and begins to slough (may bleed profusely)
What is the most common/most destructive of the three sinonasal papillomas and where does it usually reside?
- 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
What is the prevalence of osteonecrosis of the jaw in patients taking IV bisphosphonates? Oral bisphosphonates?
6-8%
1:100,000
60% occur after a dental procedure, 40% occur spontaneously.
What is the timeline for the small erythematous papules with Herpes?
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.
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
What is sebacious hyperplasia, and why can it be clinically significant?
- 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)
What are the main four benign salivary gland neoplasms?
- Canalicular adenoma
- Pleomorphic adenoma
- Warthin tumor (papillary cystadenoma lymphomatosum)
- Oncocytoma
How does the TNM classification differ for Melanoma, when compared to SCCA?
- 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)
What is the name of the syndrome associated with Iron Defiency, making someone more susceptible to SCCA?
Plummer-Vinson Syndrome
Where are 80% of Basal Cell Carcinomas found?
In the Head and Neck region, but no in the mouth.
HIV/AIDS and Oral Hairy Leukoplakia: what is it?
- 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
In terms of Minor Salivary Glands, what are the percentages of Benign vs. Malignant salivary gland neoplasms in
- Minor glands
- Upper lip
- Lower lip
- Palate
- Tongue
- Cheek
- Retromolar Pad
What do bisphosphonates do?
- 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.
In what population is Nasopharyngeal carcinoma most prevalent?
Chinese men
What is Acinic Cell Adenocarcinoma, and where is it most commonly found?
- 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
When SCCA metastasizes, how does it spread?
- 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
What is the most common site of salivary gland neoplasms, in general?
Parotid Gland, then minor, then submandibular, then sublingual.
What is the most common malignant salivary gland neoplasm of the submandibular salivary gland?
Adenoid Cystic Carcinoma (although this tumor is mostly (50%) found in minor salivary glands)
True Erythroplakias are never completely benign. True or False?
True
Mulloscum Contagiosum
- DNA poxvirus
- Contains molluscum bodies, aka Henderson-Paterson bodies
Does SCCA grading refer to clinical or histological assessments?
Histological
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
HIV/AIDS and Periodontal Disease: what are the three atypical patterns associated with HIV?
- 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
- Necrotizing ulcerative gingivitis (NUG)
* Ulceration & necrosis of interdental papillae with no attachment loss - 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.
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
What percentage of Leukoplakias end up becoming Squamous Cell Carcinomas, and what four things increase the risk of Leukoplakia turning cancerous?
5%
- Persistence over several years
- Female patient
- Nonsmoker
- Oral floor or ventral tongue lesions
HSV-2
Below the waist, mainly through sexual contact. Clinical lesions produced by HSV-1 and HSV-2 are identical.
What are the five oral manifestations most strongly associated with an HIV infection?
- Candidiasis
- Hairy leukoplakia (EBV)
- Kaposi’s sarcoma (HHV-8)
- Non-Hodgkin’s lymphoma
- Periodontal diseases
What are 3 other lesions that demonstrate EBV?
- Oral Hairy Leukoplakia
- African Burkitt’s Lymphona
- Nasopharyngeal Carcinoma
What is the difference between a Grade I, II, or III histological grading of SCCA? Which has the worse prognosis?
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
How to treat recurrent herpes labialis, both locally and systemically?
Abreva or acyclovir cream, and then acyclovir for systemic.
What is an adenoma?
It is a benign tumor formed from glandular structures in epithelial tissue.
What are the three characteristics of Melkersson-Rosenthal syndrome?
- Cheilitis granulomatosa
- Facial paralysis
- Fissured tongue
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
Leser-Trelat Sign
- Sudden appearance of numerous seborrheic keratoses with pruritus has been associated with internal malignancy
What are the three main histopathologic features of HSV?
- Multinucleation
- Acantholysis - separation of the keratinocytes
- Tzanck cells - free floating epithelial cells in an intraepithelial vesicle, also found with pemphigus vulgaris.
What causes Basal Cell Carcinoma?
- 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
Where is most common for Canalicular Adenoma?
Upper Lip (75%)
In regards to SCCA, what does the TNM system stand for and what does it help with?
- 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
What is the name of the magical charm that is common in Southeast Asia?
Susuk
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
HIV/AIDS and Kaposi’s Sarcoma: what is it?
- 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
What are the different levels of scoring for Regional Node Involvement, N, for TNM staging for SCCA?
What is the first sign of nasopharyngeal carcinoma in half of patients?
Cervical lymph node metastatis
What makes lesions white?
White Lesions are white because there is something (keratin, microbial colony, scar tissue, necrosis, etc.) blocking the “redness” of the underlying vascular tissue.
In terms of Major Salivary Glands, what are the percentages of Benign vs. Malignant salivary gland neoplasms in each location?
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
Which skin lesion has no change in color with more UV light exposure? Which one DOES?
Actinic Lentigo. Ephelis.
Sialolith (Salivary Gland Secretion, Submandibular)
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.
- Common – 2nd most frequent melanocytic nevus encountered in the oral cavity
- 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.
What are the three most common locations of Erythroplakia?
- Floor of mouth
- Ventral tongue
- Soft palate
What type of food does the Adenoid Cystic Carcinoma look like on histology?
Swiss Cheese
What is Ramsay Hunt Syndrome?
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
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
Definition of Acanthosis:
Thickened spinous layer
What is the definition of Leukoplakia, word for word?
An introral white plaque that does not rub off, and cannot be identified as any well-known entity.
What is a Recurrent Apthous Ulcer? Where is it found? And what are the three Clinical Variations?
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%).
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.
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)
How do you distinguish between Melanoma and its benign counterpart, Melanocytic Nevus?
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
What are the four histological features of Sarcoidosis?
- Granulomatous inflammation (Astroid body, multinucleated cells, clumped macrophages)
- Schaumann bodies (degenerated lysosomes)
- Asteroid bodies (entrapped collagen fragments)
- Hamazaki-Wesenberg bodies (large lysosomes)
HSV-1
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.
What is the first chief complaint from Quid and Oral Submucous Fibrosis?
Trismus and Mucosal Pain
If you see a fever with a rash, should you think viral or bacterial infection?
Viral
What three groups are enteroviruses classified into?
- Echoviruses
- Coxsackievirus
- Poliovirus
-Enterovirus diagnoses can be made from clinical manifestations, and the infection is self-limiting.
What is the risk of getting HIV infection after exposure to blood?
- 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.
What are the three things associated with Classic Wegener’s Granulomatosis?
- Necrotizing granulomatous lesions of respiratory tract
- necrotizing glomerulonephritis
- systemic vasculitis of small arteries and veins
Which HPV viruses cause Condyloma Acuminatum?
6, 11, 16, 18, and 31
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
Is leukoplakie considered pre-malignant, or malignant?
Pre-malignant, it makes up 85% of oral pre-cancer.
Is Chickenpox the primary or secondary infection of VZV?
Primary
What are the six main things that can cause Leukoplakia?
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
What is Sarcoidosis? And what are the two different syndromes associated with it?
- 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)
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
What are the two main prescription drugs used for Xerostomia?
- Pilocarpine (Salagen)
- Cevimeline (Evoxac)
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)
Halo Nevus
What are the different levels of scoring for Involvement by Distant Metastases, M, for TNM staging, for SCCA?
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
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
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
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
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)
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
- Gingival recession may be accompanied by destruction of facial surface of alveolar bone
- 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
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.
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
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
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
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
Squamous Papilloma
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
In regards to Minor, Major, and Herpetiform Recurrent Apthous Ulcers, what are the size, healing time, scarring, lesions per episode, and recurrences of each of them?
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.
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
Koplik’s Spots, and these are associated with Stage 1 of Rubeola (Measles) virus.
Erythroplakia
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
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
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
-
Traumatic Ulcerative Granuloma with Stromal Eosinophilia
- 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
Transient Lingual Papillitis
- Common oral lesion
- Clinical alterations involve variable fungiform papilla (Can involve filiform as well)
- Likely represents a hypersensitivity or allergy
Dermatosis Papulosa Nigra
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
- Only pleomorphic adenoma is found more commonly in the upper lip
What are the most common benign and malignant salivary gland neoplasms for both children and adults?
Erythroleukoplakia
- Red and white intermixed lesions are termed erythroleukoplakia or speckled leukoplakia
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
Oral Melanoacanthoma
- Acquired pigmentation of the oral mucosa
- Appears to be a reactive process due to trauma (Can be caused by brushing 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
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
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
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
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
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
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
Leukoplakia
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
- Removal of the feeding sublingual gland and/or marsupialization
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
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
Melanoma
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)
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
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
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
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
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
Melanoma
