Images, etiologies, and treatments of most diseases Flashcards

Question 1

Q

What is this radiographic finding?

Answer

A

Periapical Cysts

►Would need to test both teeth for vitality.

Question 2

Q

What is the most common cyst of the jaw?

Answer

A

Periapical Cysts

Question 3

Q

radicular cyst, inflammatory cyst are other names for

Answer

A

Periapical Cysts

Question 4

Q

What is this radiographic finding?

Answer

A

Periapical Cyst

Question 5

Q

What is this radiographic & clinical findings?

Answer

A

Periapical cyst

shows inflammation at site
abscess developed fistula tract thru
soft tissue. Pt will have pain until
pressure is released

Question 6

Q

The wall of which cyst?

Answer

A

Periapical Cyst

Open clear areas = Cholesterol clefts where fat
used to be. Multinucleated cells (purple dots)
trying to break down cholesterol

Question 7

Q

What is this and what is it associated with?

Answer

A

keratin pearl – can be associated w/SCC

Question 8

Q

What are these radiographic findings?

Answer

A

Residual Cysts

Question 9

Q

What is the radiographic finding?

Answer

A

Residual Cyst

Question 10

Q

Periapical Cyst

treatment

Answer

A

endodontic therapy or extraction of involved teeth
larger lesions may require biopsy along with endodontic therapy
lesions which fail to resolve should be biopsied
follow-up at 1-2 years

Question 11

Q

Residual Cyst

Etiology

Answer

A

After tooth extracted, not properly cleaned ► the residual cells of the cyst lining and inflammatory cells continue to proliferate
Has to be at site where tooth was previously removed

Question 12

Q

What is the radiographic finding?

Answer

A

Paradental Cyst

Question 13

Q

What is the radiographic finding?

Answer

A

Paradental Cyst

Question 14

Q

Residual Cyst

Treatment

Answer

A

-Removal

Enucleation if small
Marsupialization if large
Note:*
Enucleation* means: removal of an organ or other mass intact from its supporting tissues

Marsupialization means: surgical technique of cutting a slit into an abscess or cyst to empty its contents and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst or abscess.
Promotes Decompressing and shrinkage.

Question 15

Q

Paradental Cyst

Etiology

Answer

A

Some controversy over this designation
‐ some think they are inflammatory cyst
‐ some think they are developmental cysts
▪ Etiology: remains unclear

Question 16

Q

What is the radiographic finding?

Answer

A

Buccal Bifurcation Cyst

as seen in occlusal radiographs

Question 17

Q

What is the radiographic finding?

Answer

A

Buccal Bifurcation Cyst

as seen in occlusal radiographs

Question 18

Q

Paradental Cyst

Treatment

Answer

A

Extraction of the tooth along with the lesion

Question 19

Q

Buccal Bifurcation Cyst

is similar to what Cyst ?

Answer

A

Similar to a paradental cyst

‐ EXCEPT: location is central on the buccal of mandibular first molars

Question 20

Q

Buccal Bifurcation Cyst

Etiology

Question 21

Q

Buccal Bifurcation Cyst is most commonly seen with eruption of what tooth?

Answer

A

The eruption of the permanent first molar

Question 22

Q

dentigerous cyst or
follicle ?

Answer

A

_dentigerous cys_t
b/c *attachment at CEJ

Question 23

Q

What is the radiographic finding?

Answer

A

Dentigerous Cyst

Question 24

Q

What are these radiographic findings?

Answer

A

dentigerous cyst

Question 25

Q

What are these radiographic findings?

Answer

A

dentigerous cyst

Question 26

Q

What is the radiographic finding?

Answer

A

dentigerous cyst

Question 27

Q

What is this gross finding?

Answer

A

Grossly image of

Dentigerous Cyst

Question 28

Q

Dentigerous Cyst

Treatment

Answer

A

Decompression: Try to open window in the jawand put tube into cyst lumen and have pt irrigate a few times a day for a few weeks ► release pressure and allows bone to grow back ► cyst will shrink
If get rid of whole area surgically► c_an risk_ fracturing the jaw

Question 29

Q

Buccal Bifurcation Cyst
Treatment

Answer

A

▪ Enucleation of cyst; tooth extraction unnecessary
▪ Some cases resolve w/o surgery
▪ Some resolve w/ daily irrigation of buccal pocket with saline/hydrogen peroxide

Question 30

Q

Dentigerous Cyst
also known as ?

Answer

A

Follicular Cyst

Question 31

Q

What is most common type of developmental odontogenic cysts?

20% of all epithelial lined cysts of the jaw

Answer

A

Dentigerous Cyst

Question 32

Q

What is the clinical finding?

Answer

A

Eruption Cyst

Question 33

Q

What is the clinical finding?

Answer

A

Eruption Cyst

Question 34

Q

Dentigerous Cyst

Origin & Etiology

Answer

A

Originates: by the separation of the follicle from the crown of an unerupted tooth

Pathogenesis: accumulation of fluid between the tooth and the reduced enamel epithelium

Question 35

Q

Small Dentigerous Cyst
are hard to differentiate radiographically from —?

Answer

A

enlarged/hyperplastic follicle

Rule of thumb:

If 4‐5mm or more of radiolucency ► dentigerous cyst
If <4mm of radiolucency► can be hyperplastic follicle

Question 36

Q

What is the clinical finding?

Answer

A

Cysts of the Newborn:
Palatal cysts

Question 37

Q

Answer

A

Gingival cyst of the newborn/ Dental lamina cysts/Cysts of the Newborn-gingival

Question 38

Q

Eruption Cyst

Etiology

Answer

A

Results from accumulation of fluid in the follicular space when the tooth has erupted over the alveolar bone *NOT in bone*

Question 39

Q

What is the clinical finding?

Answer

A

Gingival Cyst of the
Adult

Question 40

Q

What is the clinical finding?

Answer

A

Gingival Cyst of the
Adult

Question 41

Q

What is the clinical finding?

Answer

A

Gingival Cyst of the
Adult

notice the bluish hue

Question 42

Q

Eruption Cyst

Treatment

Answer

A

Unless symptomatic, no treatment required, cysts resolve upon eruption of teeth

Question 43

Q

Which is here is

Lateral Periodontal Cyst

Lateral Radicular Cyst

Lateral Odontogenic Kertocyst

Answer

A

Could be differential for lateral Odontogenic keratocyst, except this does not grow in size
Lateral radicular cysts from an accessory canal if tooth is non vital
or it could be Lateral Periodontal Cyst if tooth is vital!

Question 44

Q

What is the radiographical finding?

Answer

A

Lateral Periodontal
Cyst

Question 45

Q

What is the radiographical finding?

Answer

A

Lateral Periodontal
Cyst

Question 46

Q

What is the histological finding?

Answer

A

Lateral Periodontal Cyst

see the alternating
thin to thick epithelium
a characteristic of these cysts

Question 47

Q

What is the histological finding?

Answer

A

Lateral Periodontal Cyst

Question 48

Q

Cysts of the Newborn:
Palatal cysts

Treatment

Answer

A

No treatment is required
‐ Resolve (degenerate or rupture) on their own in a
few months
‐ Once baby eats solid foods, will go away

Question 49

Q

What is the radiographical finding?

Answer

A

Botryoid Odontogenic
Cyst

well circumscribed, between 2 teeth (similar to
lateral odontogenic cyst), multilocular

Question 50

Q

What is the radiographical finding?

Answer

A

Botryoid Odontogenic
Cyst

Question 51

Q

Gingival cyst of the newborn

Treatment

Answer

A

▪ No treatment is necessary

▪ Spontaneously resolve (degenerate or rupture)

Question 52

Q

What is the soft tissue counterpart of the lateral periodontal cyst ?

Answer

A

Gingival Cyst of the Adult

Question 53

Q

What is the radiographical finding?

Answer

A

“Primordial” Cyst

Assuming histologically it is different from OKC

Question 54

Q

Gingival Cyst of the
Adult

has similar histology to which cyst?

Answer

A

lateral periodontal cyst

Question 55

Q

Gingival Cyst of the
Adult

Treatment

Answer

A

simple surgical excision
Unlikely to recur/come back

Question 56

Q

Lateral Periodontal Cyst represents the intrabony counterpart of which cyst?

Answer

A

gingival cyst of the adult?

Question 57

Q

if you see a radilucency Lateral to a teeth

how would you know if it’s

Lateral Periodontal Cyst

or

Lateral Radicular Cyst

or

Lateral OKc

Answer

A

‐ If pulp alive► lateral periodontal cyst or Lateral Okc ( if huge lesion)

‐ If pulp dead► lateral radicular cyst

Question 58

Q

What is the radiographical finding?

Answer

A

Odontogenic
Keratocyst
OKC

Question 59

Q

What is the radiographical finding?

Answer

A

Odontogenic
Keratocyst
OKC

Question 60

Q

What is the radiographical finding?

Answer

A

Odontogenic
Keratocyst
OKC

Question 61

Q

What is the radiographical finding?

Answer

A

Odontogenic
Keratocyst
OKC

Question 62

Q

What is the radiographical finding?

Answer

A

similar to
lateral
periodontal cyst
but is actually
OKC

Question 63

Q

What is the histological finding?

Answer

A

Odontogenic
Keratocyst

Histology

Notice the daughter cysts

Question 64

Q

What is this radiographic finding?

Answer

A

✎A patient who has Nevoid Basal Cell Carcinoma
Syndrome
✎We can see multiple cystics areas and lesions in
the jaws, maxillary and mandible
✎Both 3rd molar displaced in the maxilla because of
the cyst

Answer 64

A

✎Multiple lesions, impacted 3rd molar in mandible
and displaced 3rd molar up into the sinus,
✎These too many lesions hard to manage the issue
with a surgery
✎This large area on the left mandible – good example of why we do
decompression because if you just remove this lesion
and the entire area is left open, this would be an area
risk for fracture

Answer 65

A

✎An example of the pitting that can be seen palmar
and plantar

~ This is a side of a hand
✎This is an early stage of basal carcinoma which
never goes on (like it is aborted)

Answer 66

A

thousands of basal cell carcinoma is developing on the skin

-very difficult to manage with surgery,
~ That’s why they remove
the larger ones, the deeper ones ~ They leave the one
that’s less as an issue until they get to a larger size to
be removed

Answer 67

A

consists of conservative enucleation

Answer 68

A

Botryoid Odontogenic
Cyst

Answer 69

A

shows a grape‐like cluster of small
individual cysts

Answer 70

A

**Calcifying
Odontogenic Cyst (COC)**

in the mandible and you can see it well circumscribed radiolucency
a little bit of blunt root resorption in this area
No calcifications in this one yet ►so this is still unilocular radiolucency

Answer 71

A

Clinical finding for this patient was Obliteration of the vestibule space, because the mandible is showing expansion
radiographically:we see radiolucency going as far as the first molar
This is a mixed radiolucent radiopaque lesion in developing calcifications.
This is an example of Calcifying Odontogenic Cyst (COC)

Answer 72

A

lesion, was actually some other type of cyst
- it is now thought that most of the reported Primordial cysts were actually OKCs

Answer 73

A

Growth and expansion of this lesion due not only to osmotic effects/pressure, but to unusual gene expressions

Answer 74

A

Odontogenic
Keratocyst
OKC

Diagnosis of OKC is based on the characteristic histologic (not
radiographic) findings

Fibrous connective tissue (FCT) containing a pathologic space
lined by stratified squamous epithelium which is 6 to 8 cells in
thickness

Epithelium lining is thin, friable and easily detached from the
FCT, often see lining separated from FCT on histologic section
(thought to be a reason OKCs have a higher risk of recurrence
versus other odontogenic cysts,

Answer 75

A

Expresses Ki‐67 (high rate of cell proliferation)
O_verexpression of Bcl‐2_ (antipoptotic protein)
Overexpression of MMP’s 2 and 9 (thought to allow growth into connective tissue)
Mutation of PTCH, a tumor suppressor gene
- when PTCH is non‐functional → cell proliferation

Answer 76

A

HIGH Recurrence Rate
Benign, but locally aggressive biologic behavior
Solitary OKCs have ~10% recurrence rate with appropriate treatment
_Multiple OKCs hav_e ~ 30% recurrence rate

Answer 77

A

▪ Marsupialization (decompression)
▪ Peripheral ostectomy
‐ Carnoy’s solution
▪ Resection
▪ Medications targeted to PTCH
▪ Long term follow‐up

Answer 78

A

Odontogenic
Keratocyst
OKC

10-25% of cases show satellite or “daughter” cysts in
the connective tissue wall (thought to be another reason
the recurrence rate is so high for OKCs)

Answer 79

A

Basal Cell Nevus or Bifid Rib Syndrome

or

Gorlin syndrome

Answer 80

A

Odontogenic Keratocyst
“OKC”

Answer 81

A

Odontogenic
Keratocyst
OKC

stratified squamous epithelium which is 6 to 8 cells in
thickness

Keratin is noted in the cyst lumen (grossly appears as a
cream colored “cheesy” paste-like substance)

Epithelium lining is thin, friable and easily detached from the
FCT,

Answer 82

A

Autosomal dominant inheritance

Answer 83

A

Mutation of PTCH (tumor suppressor gene)
in the Sonic Hedge Hog pathway

Answer 84

A

■ Prognosis depends on progression of skin tumors

Answer 85

A

✎Surgery (typically MOHS)
✎Sometimes curette them
✎ Radiation therapy (RT) is typically not the first line of therapy with small lesions RT
✎Cryotherapy which means they just use a little liquid nitrogen and freeze them
✎Photodynamic therapy with photosensitizer and topical medications
■ New medication: Vismodegib inhibits sonic hedgehog pathway by binding smoothened (SMO)

suppressive rather than curative cause it seems to work for short time and after ~7-8 months ..may also helps suppress growth of OKC

Answer 86

A

Basal Cell Carcinoma
(BCC)

Answer 87

A

within 5 years of being diagnosed with
BCC►35%-50% of people develop a new skin cancer

Answer 88

A

Ghost cells

They have that sort of polygonal shape or roundish shape with the pink that looks like the cytoplasm, but in
the location where the nucleus would have then, there’s an empty spot

Answer 89

A

■Enucleation with peripheral ostectomy ~ Very similar to odontogenic keratosis
■ Follow up is long term because s_ome of the solid tumors have a more aggressive behavior_

■ Peripheral lesions are treated with excision

Answer 90

A

Calcifying Odontogenic Cyst COC

 Masses of ghosts cells may fuse to form sheets of eosinophilic, amorphous, acellular material within the epithelium
 Calcification within the ghost cells is common and is why radiopacity is seen in radiographs
 if calcifications have not yet formed, lesion will appear radiolucent, not mixed radiolucent/radiopaque
 Areas of FCT adjacent to the epithelium may also show deposition of an eosinophilic material thought to be some sort of odontogenic matrix material (“dentinoid”) formed as a result of the epithelium’s inductive effects
on the adjacent mesenchymal tissue

Answer 91

A

■ Thought to be caused by:

either epithelial remnants of the nasolacrimal duct
or cells left after fusion of the maxillary, medial and lateral nasal processes during development of the midface

Answer 92

A

Surgical Excision via intraoral approach,
usually do not recur ~ very low risk of occurrence

Answer 93

A

Nasolabial Cyst

The lesion here just below the nose and you can tell that it’s sort of raising the edge of the nose slightly

Answer 94

A

Nasolabial Cyst

the lesion raising the edge of the nose slightly

Answer 95

A

we can see the displacement of the root
A teardrop or pear shaped radiolucency between the lateral and the canine
Well circumscribed maybe leaving a little sclerotic edge up here
ended up being in a odontogenic keratocyst (OKC)

Answer 96

A

~ it is kind of a teardrop or pear shaped size

~Little less well differentiated in this particular instance but again unilocular radiolucency between the roots of two teeth

This one ended up being an OKC

Answer 97

A

*A**. It can either be the cyst totally within bone
*B**. It can actually cause widening of the orifice and causing the soft tissue expansion in this way

Answer 98

A

Nasopalatine Duct Cyst

Answer 99

A

Nasopalatine Duct Cyst

✎This person is edentulous
✎ an inverted pear shape
✎The nasal spine is superimposed
on your radiolucency ► a heart shape

Answer 100

A

Nasopalatine Duct Cyst

✎Between the roots of the two teeth, a well circumscribed
radiolucency, not showing any changes to the adjacent structures
✎could be an enlargement of the incisive canal due to variation in size ~ early lesions can be hard to diagnose

Answer 101

A

✎the treatment in such cases: a follow up with another radiograph in six months to see if there’s been any change in size

✎ No surgical intervention until you see the cyst expanding

Answer 102

A

Nasopalatine Duct Cyst

✎Between the roots of the two teeth, a well circumscribed
radiolucency, not showing any changes to the adjacent structures
✎could be an enlargement of the incisive canal due to variation in size ~ early lesions can be hard to diagnose

Answer 103

A

This is showing you the how the
papilla can be enlarged if it’s only
in soft tissue or if there’s a partial
soft tissue partial bone expansion

Nasopalatine Duct Cyst

Answer 104

A

Median Palatine Cyst

Answer 105

A

Remember

Median Mandibular Cyst is a term used to describe a cyst in a anterior mandible not a definitive diagnosis

So, this turned out to be an early ameloblastoma. It wasn’t a cyst

The lesion radiolucency in the anterior mandible and again

Answer 106

A

■ a well-circumscribed unilocular radiolucency on the midline of the anterior hard palate
between and apical to the central incisors
■ The radiolucency often have an oval or inverted pear shape with a sclerotic border
■ Superimposition with the nasal septum can create an appearance of the classic “heart” shape

Answer 107

A

surgical excision
recurrence is rare

Answer 108

A

Surgical Ciliated
Cyst of the Maxilla

In this premolar shot (middle image) you can see a well-circumscribed lesion
✎Because the maxillary sinus is radiolucent, it almost looks like this is radiopaque but it’s not
✎ If you did a CBCT you would see that it’s an empty space within the bone of the maxilla. It’s not actually radiopaque

Answer 109

A

■ Occurs after trauma or sinus surgery (iatrogenic - reactive not neoplastic)

Answer 110

A

after a Caldwell-Luc procedure
sometimes with difficult maxillary extractions

Answer 111

A

you might think that he has an odontogenic infection but he didn’t. You can see that there’s
a pretty significant swelling on the left side of his face

This is a Aneurysmal Bone Cysts

Answer 112

A

Aneurysmal Bone Cyst

you can see that there is kind of a
multilocular radiolucency in this particular area

Answer 113

A

Aneurysmal Bone Cyst

✎ There’s a radiolucency involving the second molar
that’s going as far anterior as the first molar and back
to the third molar
✎ There is a little bit of spiking root resorption and
that’s one of the signs that we associate with
malignancy
✎ It’s a little bit ill-defined ~ hard to say exactly
where it begins and ends

Answer 114

A

Aneurysmal Bone Cyst

✎ It looks like a blood soaked sponge

✎ There’s these open sinusoidal spaces and then fibrous connective tissue surrounding them.

✎The sinusoidal spaces can vary in size; some of them are fairly small and others are large

Answer 115

A

■ Treatment is surgical enucleation and curettage

■ lesions can recur ~ Usually the recurrence is because
you didn’t get the entire thing out the first time around

■ Some surgeons follow enucleation with cryotherapy

■ Irradiation is contraindicated

Answer 116

A

Antral Pseudocyst

a Dome-shape swelling on the floor of the sinus.
They can sometimes be fairly subtle

Antral Pseduocyst are NOT Mucoceles

Mucoceles would have more of meniscus-like
appearancewhere it would come up tothe edge of
the sinus

Answer 117

A

Aneurysmal Bone Cyst

✎ A dome shape swelling on the floor of the sinus that’s associated with some _sort of inflammation of tooth of t_he premolar caused inflammation underneath the apex of the bone (right) and then that leads to accumulation of fluid which causes the sinus lining to elevate off the bone and fill with fluid
✎ After root canal therapy and once the infection gets under control, these will typically resolve on their own

Answer 118

A

Simple Bone Cyst

✎A well-circumscribed with cortication in the body of the
mandible, affecting the posterior aspect (premolars and the molars )

✎Note the scalloping that happens up between the roots. It
doesn’t cause root resorption and actually the lesion will grow up between the roots of the teeth

Answer 119

A

Simple Bone Cyst

A well-circumscribedshowing the scalloping up between the roots of the teeth radiolucency

Answer 120

A

Simple Bone Cyst

✎Big lesion example: It’s going back to the molar area here.

✎You can see that the lesion extends over to the canine on the other side

✎Most lesions are usually in the anterior mandible

Answer 121

A

Etiology ununcertain, theories include:

trauma
ischemic necrosis of medullary space
cystic degeneration of a primary bone lesion

Answer 122

A

exploration and curettage of space to create bleeding. Clot will organize and allow bone repair
Recurrence is rare

Answer 123

A

You can see there’s a little bit of radiolucency.
There happened to actually still be teeth in the area, but
when it was biopsied it showed that it was a
hematopoietic or osteopoietic bone marrow defect

Answer 124

A

■ An asymptomatic focal concavity of the cortical bone on the lingual aspect of the MD

■ A pseudocyst, not a true cyst

Answer 125

A

Etiology unclear
may be hyperplasia of marrow due to need for RBCs or
abnormal regeneration of bone after an extraction or
persistence of fetal marrow

Answer 126

A

Stafne Bone Cyst

This is the classic look.

a well-circumscribed corticated radiolucency
below the inferior alveolar nerve, away from the teeth.
They can be either oval, like this, or round in appearance

Answer 127

A

Stafne Bone Cyst

Less common location

Check if the teeth were vital with vitality test

Get a CBCT in that area
to see what was going on first and then once you saw
the CBCT you’d be able to make the diagnosis.

Answer 128

A

■ Must biopsy to make a definitive diagnosis
■ No further treatment is then necessary

~ You don’t have to remove it; you can just leave it as it is

Answer 129

A

Believed to be developmental in origin, but usually noted only in _adults_

Answer 130

A

lesions in the posterior MD are usually pathognomonic
no further treatment is necessary

Answer 131

A

surgical excision
recurrence is rare

Answer 132

A

Dermoid Cyst

a dome shaped
swellingin the floor of the
mouth.

If these were left long
enough, they could cause issues
with swallowing

Answer 133

A

Dermoid Cyst

✎This is a larger lesion on the floor of the mouth, causing
elevation of the tongue
✎If you let this go/grow, it would be similar to Ludwig’s angina where you would basically eventually obstruct the airway
✎The difference is this is very slow growing while Ludwig’s happens rather quickly. with fever and other symptoms.

Answer 134

A

Dermoid Cyst

This is showing you when they occur below the mylohyoid muscle.
You get an elevation under the chin.
This is a fairly small one but they can get much larger

Answer 135

A

Often occur after _inflammation of a hair follicl_e

Answer 136

A

Epidermoid Cyst

A dome-shaped swelling.

There’s no change in the
overlying skin color, no redness, no pain

Answer 137

A

■ Treatment is excision

■ Recurrence is rare

Answer 138

A

Thyroglossal Duct Cyst

This is NOT a goiter.

It looks like an enlargement of the thyroid, but this ended up being just
a cyst, so they had a thyroglossal duct cyst

Answer 139

A

A developmental cyst that develops from epithelial remnants of a tract which forms when the thyroid anlage descends into the neck from an area that later forms the foramen caecum
Follows a path that goes anterior to the hyoid bone and ends below the thyroid cartilage

Answer 140

A

■ surgical excision

■ recurrence are not uncommon

■ Rare cases of thyroid carcinoma developing in these cysts have been reported

Answer 141

A

Thyroglossal Duct Cyst

Answer 142

A

Branchial Cleft Cyst

a small one in a child.

You can see that
there’s a small cystic lesion here on the neck

Answer 143

A

Branchial Cleft Cyst

Then you can see it in an older person; this is getting
to be maybe 4-5 centimeters at least in size. He left
his for a little bit longer

Answer 144

A

Etiology is disputed

Some think it is from remnants of the branchial cleft
Others think it is cystic change of parotid gland epithelium which became entrapped in a cervical lymph node during development

Answer 145

A

Oral Lymphoepithelial Cyst

A pale dome-shape swelling in the floor of the mouth. because the lesion is so close to the surface; you’re seeing little capillaries of the mucosa lining the lesion

Answer 146

A

surgical excision, recurrence is rare

Answer 147

A

Surgical Excision
Reccurance is Rare

Answer 148

A

Unilocular and unicystic ‐ An example of a unilocular ameloblastoma that is
not associated with an impacted tooth
▪ Is between roots of two teeth, may be confused with lateral
periodontal cyst. Well‐circumscribed radiolucency

Answer 149

A

▪ Typical appearance for ameloblastoma

Multilocular, very well‐circumscribed, associated with impacted tooth.

Can see bowing of inferior aspect of mandible

lateral oblique radiograph.was used here

Answer 150

A

Ameloblastoma

clinically: Have expansion of the buccal plate, obliterating the vestibule in this area.

Radiographically: Root resorption of molar, unilocular radiolucency in mandible

Answer 151

A

Ameloblastoma

Small lesion distal to impacted tooth.
Unilocular radiolucency with elevation of alveolar ridge + some expansion of soft tissue

Answer 152

A

Ameloblastoma

▪ Well‐circumscribed radiolucency with a sclerotic or
corticated margin.

▪ If you had a CBCT, it would probably show you that there
was a thin septa in this area of residual bone trabeculae.

▪ Fracture could be caused by very large cysts.

▪ Resolve by decompressing unless with odontogenic tumor – need to remove the mandible 1cm+ on either side of lesion

Answer 153

A

▪ Over expression of Bcl‐2 (anti‐apoptotic protein)
▪ Expression of fibroblast growth factor (FGF)
▪ Over expression of matrix metalloproteinases (MMPs 9 and 20) – like in OKC, allowing tumor to grow into surrounding area
▪ Surprisingly, no significant increase in Ki‐67 expression (cell
proliferation marker) – ameloblastomas do NOT turn over rapidly

Answer 154

A

▪Left mandible, multilocular radiolucency associated with impacted tooth
▪ It’s well circumscribed, edge may be a little bit sclerotic or corticated
▪ It has displaced an impacted tooth down towards the inferior
aspect of the mandible
▪ Appears to be expanding the cortex of the mandible in areas
▪ There’s blunt resorption of the teeth adjacent (PMs and molar)

Ameloblastoma

Answer 155

A

Conventional/Solid Ameloblastoma

Answer 156

A

Unicystic Ameloblastoma

but could be

Dentigerous Cyst

based on clinical presentation!

So radiograph is not diagonstic

Answer 157

A

Desmoplastic
Ameloblastoma

Spherical growth. Within it, has both radiodense and radiolucent areas (is
mixed radiolucent‐radiopaque)– similar appearance to benign fibro‐osseous lesions.
Well‐circumscribed, corticated.

Answer 158

A

Resection (treatment depends on extent of the lesion and anatomy of involved bone)
Segmental
Composite
Long term (decades) follow up is needed for these patients

Answer 159

A

Peripheral
Ameloblastoma

Answer 160

A

Treatment is typically enucleation and curettage
- Reports of lower rate of recurrence (10‐20%) than conventional ameloblastoma (50‐90%) with similar treatment
- Some recommend decompression prior to surgery
Use of Carnoy’s solution after enucleation- resulted in a recurrence rate lower

Answer 161

A

Calcifying Epithelial Odontogenic Tumor

(CEOT)

Clinically: we see a little expansion on inferior aspect of mandible + lingual too

Radiographically: we see well‐circumscribed, a little corticated/sclerotic edge, impacted tooth
▪ we can see bowing of inferior aspect of mandible
▪ Within areas of radiolucency, see areas of opacity (calcified lesions = classic CEOT)
▪ When smaller► could have looked *unilocular*

Answer 162

A

Calcifying Epithelial Odontogenic Tumor(CEOT)

flecks of calcifications.
Calcifications all around crown is common

Answer 163

A

Calcifying Epithelial Odontogenic Tumor(CEOT)

Multilocular radiolucency with calcifications.
an expansion up to PMs and back to 2nd molar
as well as bowing of mandible.

Answer 164

A

Calcifying Epithelial Odontogenic Tumor(CEOT)

Fewer calcifications here, well‐circumscribed and corticated, impacted tooth.
periosteal reaction causing elevation at the bottom of image!

Answer 165

A

Calcifying Epithelial Odontogenic Tumor(CEOT)

well‐circumscribed radiolucency with calcifications in lower anteriors

Answer 166

A

well‐circumscribed radiolucency at crown of an impacted canine
Hard to tell if attaches at CEJ.

If further down, less likely a dentigerous cyst and more likely AOT, ameloblastoma, or OKC

Answer 167

A

we see calcifications forming, with both radiolucent and radiolucent areas.
▪ Dentingerous cyst, ameloblastoma, and OKC are NO LONGER in the differential diagnosis.

This is clearly AOT

_(_Adenomatoid odontogenic tumor)

Answer 168

A

Adenomatoid odontogenic tumor

(AOT)

Swelling in maxillary vestibule

Answer 169

A

Adenomatoid odontogenic tumor

(AOT)

fibrous capsule of AOT is at least partially encapsulated.

Easy to remove; “popped right out”.

Answer 170

A

Adenomatoid odontogenic tumor

(AOT)

An expansion into lingual area as well as into vestibule

Answer 171

A

Adenomatoid odontogenic tumor

(AOT)

Snowflake‐like calcifications within mixed, well‐circumscribed radiolucency

Answer 172

A

Adenomatoid odontogenic tumor

(AOT)

Teardrop shape / inverted pear between roots of teeth.
Well-circumscribed, corticated margin & snowflake‐like calcifications within

Answer 173

A

In addition to fracture, there is semilunar loss of bone around the molars ► (SOT)

Squamous Odontogenic Tumor

Answer 174

A

SOT

Squamous Odontogenic Tumor

Semilunar loss of bone.
Alveolar bone is gone due to impacted canine that is visible

Answer 175

A

▪ Enucleation _with peripheral ostectom_y
▪ Resection with rim of normal bone
▪ Recurrence rate is ~12%
▪ ~ 2% demonstrate malignant transformation

Answer 176

A

Central odontogenic fibroma (COF)

well‐circumscribed radiolucency posterior to molar

Answer 177

A

Central odontogenic fibroma (COF)

round mass of opacity due to FCT. Ground glass‐like appearance

Answer 178

A

Odontogenic Myxoma

Classic example of enlargement of the mandible caused by multilocular radiolucency.
Enlarged into oral cavity ‐ alveolar ridge elevated

Answer 179

A

Odontogenic Myxoma

Answer 180

A

Clinically: obliteration of vestibule on patient’s left mandible

Radiographically:lesion running from posterior by third molar all the way anterior to canine. Well‐circumscribed, multilocular radiolucency is scalloping up
between teeth, causing some root divergence

Grossly: gelatinous appearance of myxoma makes it hard to remove

After treatment: post‐surgery; had excised all the way to right 2nd PM

This is Odontogenic Myxoma

Answer 181

A

Treatment is usually enucleation
recurrence is rare

Answer 182

A

CEMENTOBLASTOMA
(True Cementoma)

First molar has tumor attached to the root.
Mostly radiopaque but has some less radiodense areas within = classic for cementoblastoma.
Radiolucent halo around region.

Answer 183

A

Cementoblastoma

Grossly continuous growth from tumor to the root of the tooth. Brownish
areas were more vascular.
Histologically: tubular dentin in tooth, attached to mass of tissue with calcifications

Answer 184

A

Treatment is conservative local excision
Recurrence is rare

Answer 185

A

Compound Odontoma

Mature normal appearing pulp, enamel and dentin
Organization like teeth, with enamel surrounding dentin which surrounds pulp ( Well developed rudimentary “tooth” forms)
appear as small tooth‐like structures in the Anterior jaws (esp. MX)

Complex Odontoma

Mature pulp, enamel and dentin
No organization, mass of dentin and enamel matrix and pulp tissue (**Poorly developed mass of calcified deposits)
appear as masses of radiopaque material with
variable densities in the Posterior jaws (esp. MD)

Answer 186

A

Classic appearance of Odontoma

multiple tooth‐like shapes aggregated together
Typically with some sort of radiolucent halo around them

Answer 187

A

Compound Odontoma

little teeth‐like structures blocking canine eruption

Answer 188

A

Complex Odontoma

2‐2.5cm mass overlaying the molar.
radiolucent rim/halo that is mixed, mostly radiopaque

Answer 189

A

Primordial
Odontogenic Tumor
(POT)

unilocular radiolucency

Answer 190

A

Ameloblastic Fibroma
(AF)

1‐3 potential locules, no impacted tooth associated

Answer 191

A

Enucleation with curettage or excision
usually don’t recur

Answer 192

A

Ameloblastic Fibro-odontoma (AFO)

well‐circumscribed radiolucency
corticated edge + calcification

Answer 193

A

Ameloblastic Fibro-odontoma (AFO)

has expansion into oral cavity. Flecks of calcification
in lesion with impacted tooth = odontoma

Answer 194

A

Ameloblastic Fibrosarcoma

in the mandible developed after two years from AF

Answer 195

A

Surgical excision or resection
Because the lesion is not encapsulated and has a gelatinous loose consistency► it is difficult to remove completely
- this is thought to be why myxoma has a fairly high recurrence rate
Maxillary posterior lesions should be treated more aggressively

Answer 196

A

Odontogenic Myxoma

▪ Mimics the histology of dental pulp
▪ Stellate, spindle, and round shaped cells set in a loose myxoid to
lightly collagenized stroma (if abundant mature collagen ‐
fibromyxoma)
▪ Abundant ground substance (mucopolysaccharide extracellular
matrix or GAGs)
▪ Can see residual bone trabeculae and scattered rests of odontogenic
epithelium

Answer 197

A

surgical extraction of the involved tooth with attached tumor
Root amputation (with attached tumor) and endo is an option for smaller lesions
Recurrence is unlikely

Answer 198

A

▪ Simple excision or enucleation
▪ Unlikely to recur

Answer 199

A

conservative excision/enucleation
So far no recurrence

Answer 200

A

Radical surgical excision as the tumor is very aggressive and infiltrative
Prognosis is dependent on complete removal of tumor

Answer 201

A

MOCHA

M odontogenic Myxoma
O Odontogenic keratocyst
C Central giant cell granuloma
H Central Hemangioma
A _A_meloblastoma

Others:

Aneurysmal bone cyst
early CEOT
ameloblastic fibroma AF
central MECa

Answer 202

A

Chondrosarcoma

its consistent widening as opposed to seen in periodontitis and inflammatory disease

Answer 203

A

Chondrosarcoma

Ill defined lesion of anterior maxilla
Areas of radiolucency
Classic area of moth‐eaten look
Circular area of radiolucency with trabecular
pattern
Patient left without surgery, not heeding medical advice

Then patient came back
▪ Someone was willing to do the dentures for her
▪ CC‐ denture was not fitting
▪ Expansion of cortical plate
▪ Hyperkeratotic because of denture rubbing

▪ Still has malignancy
▪ Advise for surgery
▪ Refused again

Then the lesion kept on Lesion still growing
▪ Metastasize to lungs
▪ Admitted to breathing issues
▪ About 5 ½ years from initial dx to
pt passing away

Answer 204

A

Chondrosarcoma

Alveolar process and floor of mouth affected
Limitations of movement of the tongue

Answer 205

A

Can see in the anterior region there’s an
elevation

histology shows it’s not chondrosarcoma

because it contained Cutright lesion

papule or nodule on alveolar ridge

Osseous and/or chondromatous metaplasia within the soft tissue of the gingiva

o Lesion is NOT central in bone or connected to bone
▪ NOT a malignant lesion
o Thought to be reactive metaplasia due to a poorly fitting denture

Answer 206

A

Osteosarcoma

▪ Swelling on left side of face
▪ Difficult opening

Answer 207

A

Osteosarcoma

See something in the operculum
Infection in third molar?

Answer 208

A

Osteosarcoma

AP Plain Film
Most of jaw was missing
Radiolucency affecting entire ramus and condyle

Answer 209

A

Osteosarcoma

Classic sunburst pattern
Fuzzy appearance on outer edges of cortex

Answer 210

A

Osteosarcoma

cloudy bone formation on surface of cortex on facial and lingual aspect

Answer 211

A

Osteosarcoma

a patient with swelling with side of face

Answer 212

A

Osteosarcoma

▪ Lytic lesion
▪ Slightly ill defined
▪ Loss of bone in the inferior aspect of mandible

Answer 213

A

Radical surgical excision on initial treatment
- Maxillectomy/Mandibulectomy
  - If anterior region they remove the entire anterior portion of the jaw
These lesions don’t respond to radiation or chemotherapy
Although used as adjuncts for lesions that can’t be treated surgically
For example a posterior sinus lesion since that is the base of the skull
- These patients have poorer prognosis than those with more accessible sites such as the mandible
Prognosis is poorer than for osteosarcoma (which contrasts with the prognosis in extragnathicsites)
Treatment failure (and mortality) is usually due to uncontrolled local disease not metastasis

Answer 214

A

Since 20% of chondrosarcomas of the jaw are initially misdiagnosed as chondromas ► any diagnosis of chondromain the jaws should be viewed with suspicion
All cartilaginous tumors arising in the jaws should be excised widely
- (>60% of cartilaginous tumors of the jaw recur and ~7% metastasize to the lung and/or bone )

Answer 215

A

Important to distinguish from chondrosarcoma as treatments are different
Osteosarcoma is currently treated with pre-op multi-agent chemotherapy followed by surgery
Radiation therapy alone is insufficient for cure
- Favorable jaw site – MD symphysis
- Worst site – MX sinus
5 year survival is ~ 20% (up to 80% if caught early and treated with radical resection)

Answer 216

A

Langerhans Cell
Disease

Infant with Acute disseminated type
▪ See lesions on head/ear

Answer 217

A

Langerhans Cell
Disease

we see lesions on maxilla

Answer 218

A

Langerhans Cell Disease

▪ Older child
▪ Chronic disseminated form
▪ Alveolar ridge involvement
▪ Lot of bone loss and mobility
▪ Painful to brush

Answer 219

A

Langerhans Cell Disease

Torus and molar involvement

Answer 220

A

Eosinophilic
Granulations

Erythematous area

Answer 221

A

▪ Child with disseminated form of Langerhans cell histiocytosis
▪ Punched out radiolucency in the skull

Answer 222

A

▪ Child with bone loss surround the teeth
▪ Floating teeth

disseminated form

Langerhans cell histiocytosis

Answer 223

A

▪ Floating teeth
▪ Only attached by soft tissue due to extensive bone loss

disseminated form

Langerhans cell histiocytosis

Answer 224

A

Eosinophilic granuloma

Answer 225

A

Etiology unclear
o Demonstration that LCH cells are clonal, along with the recent discovery of activating BRAF mutations in LCH cells, ►strongly suggests that LCH is a neoplastic disease

Answer 226

A

Punched out radiolucency
Lytic radiolucency without cortication

MM

Multiple Myeloma

Answer 227

A

more punched out radiolucency in iliac crest in the image
Bone marrow biopsy usually done in this area since it’s frequently involved

multiple Myeloma

MM

Answer 228

A

Multiple Myeloma

▪ Radiolucency without sclerotic border

▪ Multiple and separated

Answer 229

A

Swelling of gingiva

▪ Plasmacytoma

Answer 230

A

Ewing Sarcoma

▪ Long bone

▪ Large expansion

Answer 231

A

Ewing Sarcoma

an _expansion of tissu_e
Dissolution of bone in that area

Answer 232

A

Metastatic Carcinoma to Jaw Bones

▪ A. Metastatic breast carcinoma surrounding the apical half of the second and third molar roots and extending inferiorly. It has destroyed the inferior border of the mandible.

Answer 233

A

Metastatic Carcinoma to Jaw Bones

B. Bilateral metastatic lesions from the lung destroying the mandibular rami.

Answer 234

A

Metastatic Carcinoma to Jaw Bones

D. Destruction of the left mandibular condyle (arrows) from a thyroid metastatic lesion

Answer 235

A

Metastatic Carcinoma to Jaw Bones

A. Partial panoramic image of prostate metastatic lesions involving the body and ramus; note the sclerotic bone reaction (arrows).

Answer 236

A

Metastatic Carcinoma to Jaw Bones

B. Occlusal image of prostate lesions causing sclerosis and spiculated periosteal reaction (arrows)

Answer 237

A

Metastatic Carcinoma to Jaw Bones

C. Periapical image of a metastatic lesion of breast carcinoma; note the irregular widening of the periodontal membrane spaces and patchy sclerotic bone reaction, especially around the roots of the molars

Answer 238

A

Treatment can include :

chemotherapy with or without Radtiaion Therapy
bone marrow transplant
interferon
antibodies made against tumor cells
thalidomide
Even with treatment, many patients do not survive more than 18‐24 months, however treatment modalities are improving
Older patients are treated less aggressively

Answer 239

A

Combined therapy with multi‐agent chemotherapy, radiation therapy and surgery has led to 40% ‐ 80% survival rates
Gnathic Ewing sarcoma has a lower mortality rate than all other primary sites

Answer 240

A

When it is diagnosed?

● Usually initially diagnosed in adolescents

Etiology?

● Etiology unknown‐ immunologically mediated?
o Theory of being too clean as a child and having a negative response as we grow older since we’re not used to normal bacteria

Prevalence?

● Prevalence increasing, reason unknown

What are the oral implactions?

●Oral lesions can be first sign of disease

Answer 241

A

Current strategies aim for deep and long‐lasting remission, with the goal of preventing complications, such as surgery, and blocking disease progression
Immunosuppressant such as cyclosporine
In more severe cases;
*high dose corticosteroids and**
chemotherapeutics to induce a remission
Nutritional supplements (iron, folate)
- Because they are unable to absorb nutrients
If medical means do not keep patient under control► surgical removal of a portion or all of the intestine
When intestinal symptoms are under control►oral ulcerations resolve

Answer 242

A

Crohn Disease

Patients can also get angular cheilitis
Above the Linear ulceration, can see a flap like structure which is the hyperplastic margin

Answer 243

A

we see the ulceration and hyperplastic tissue surrounding it.

Answer 244

A

Crohn Disease

Nodular appearance of buccal mucosa

Answer 245

A

Crohn Disease

we see more nodules

Answer 246

A

Crohn Disease

Linear granulomatous ulcerations
But they are not the aphthous ulcerations but the more
linear type

Answer 247

A

● Treatment is not well standardized, fairly rare disease and good double blind studies rare
● Can use topical corticosteroids
● Werchniak et al had good results with topical tacrolimus
● Sulfasalazine or Prednisone for GI lesions
● If GI symptoms are under control► oral lesions will resolve

Answer 248

A

Pyostomatitis
Vegetans

Answer 249

A

Pyostomatitis
vegetans

Answer 250

A

Pyostomatitis
vegetans

Snail track
appearance

Answer 251

A

● Use of anti‐inflammatory medications
o Sulfasalazine or Prednisone
● If medical means do not succeed► then removal of part or all of colon

Answer 252

A

Amyloidosis

Nodular “waxy” depositions in skin

deposition on the eyelid

Answer 253

A

Amyloidosis

orange, red, yellow tinge

Answer 254

A

Amyloidosis

Macroglossis and crenation of tongue (indentation near the teeth area)

skin deposits on the comissure,

Answer 255

A

Amyloidosis

macroglossia

Answer 256

A

Amyloidosis

Amyloid deposition on the tongue is amyloid, you have papule and nodule like area, can see the crenation of the tooth

Answer 257

A

Amyloidosis

Submucosal amyloid deposit

Answer 258

A

Amyloidosis

Amyloid deposition with ulceration and petechiae

Answer 259

A

Amyloidosis

▪ different color compared to normal tongue with amyloid

Answer 260

A

Due to chronic inflammatory process
*(osteomyelitis, TB,** sarcoidosis)
Affects liver, kidney, spleen, adrenals but not heart
can affect multiple organs, heart is usually spared

Answer 261

A

o Accumulation of normal protein (beta‐2 microglobulin) in plasma
_o Deposits in bones and joint_s
o Carpal tunnel syndrome, cervical spine pain
o Tongue deposits can have macroglossia

Answer 262

A

Medical work‐up to determine type of amyloidosis
Treat underlying disease when possible
No treatment available for most types
Chemo drugs (Colchicine, Prednisone, Melphalan, Thalidomide, Cyclophosphamide) for multiple myeloma
Serum electrophoresis – monoclonal gammopathy very complicated and time consuming treatment
Renal transplant for dialysis‐associated type
Death due to cardiac failure, arrhythmias or renal failure is not uncommon within a few year of dx

Answer 263

A

Definition

insulin‐dependent diabetes mellitus (IDDM)

Demographics

5‐10% of cases
 Juvenile onset (avg age 14)

Etiology

Autoimmune disease

Thought to be possible viral infection as trigger to Islet cell antibody destruction of beta cells

Answer 264

A

Definition

non‐insulin‐dependent diabetes mellitus (NIDDM)

Demographics

About 90% of cases

Onset in older, obese adults (80‐90%); ketoacidosis is rare

Etiology

Decreased number of insulin receptors or defective receptors
Genetic abnormalities, multifactorial
Growing percent of the US population as well as around the world

Answer 265

A

Insulin injections
Insulin shock‐ if blood glucose falls below 40 mg/dl
Treat with dextrose

Answer 266

A

Dietary modification and weight loss
Oral hypoglycemic agents
- ex. tolbutamide, glyburide, metformin
Drugs may cause a lichenoid drug reaction

Answer 267

A

Most often associated with Type I but may be seen with Type II

Periodontal disease‐ more frequent occurrence, more rapid progression
Poor healing post oral surgery/extractions
Enlargement and erythema of the attached gingiva
Increased risk of infections
Candidiasis
Xerostomia‐ 1/3 of pts complain of dryness
Diabetic Sialadenosis‐ both type I and type II
Mucormycosis‐ in uncontrolled disease and the tissue becomes necrotic because it is not getting any blood supply
Dental Caries
Benign migratory glossitis

Increased prevalence in type I

Answer 268

A

Diabetes Mellitus

Gingivitis = puffy red papillae here between the
central and lateral incisors

Answer 269

A

Diabetes mellitus

Anterior papillae are very puffy and red and fill of pus

Posterior gingiva are very
hyperplastic

Answer 270

A

Hyperplastic gingiva (Gingival Hyperplasia)

Manifestation of different systemic disease such as

diabetes

Crohn’s disease*
anemia*
lymphoma*
vitamin deficiencies*
HIV*

It is also caused by inflammation. It can also be drug-induced, as a side effect of prescribed medications. Common medications that can cause this overgrowth include:

antiseizure drugs
immunosuppressants
calcium channel blockers
drugs used to treat high blood pressure and other heart-related conditions

Answer 271

A

Hyperplastic gingiva (Gingival Hyperplasia)

Manifestation of different systemic disease such as

diabetes

Crohn’s disease*
anemia*
lymphoma*
vitamin deficiencies*
HIV*

Answer 272

A

Diabetes Mellitus

Sialadenosis

Answer 273

A

Diabetes Mellitus

diabetic patient who
developed Mucormycosis

Notice it is causing necrosis in the palate

Answer 274

A

Lichenoid mucositis looks like lichen
planus
-same reticular white pattern, but there are
areas of erosion and some ulceration as
well
-some diabetic medications can lead to this

Answer 275

A

Treatment includes:
- Surgery – complete or partial removal of thyroid gland
- Medications
  - Propylthiouracil and methimazole block normal use of iodine by thyroid gland
- Radioactive iodine 131I
Treatment often results in hypothyroidism

Answer 276

A

Hyperthyroidism

enlargement of the neck
characteristic stare

Answer 277

A

▪ Treatment is thyroid hormone replacement
▪ Prognosis is generally good
▪ If children are not treated in a timely fashion ► permanent CNS damage can occur (mental retardation)

Answer 278

A

hypothyroidism

woman who had
hypothyroidism, lips are thickened, thick creases in the face

Answer 279

A

hypothyroidism,

in child, still has
deciduous teeth even though its an older child

Radiographically we see the teeth have not erupted in the oral cavity

Answer 280

A

Hypothyroidism

Macroglossia and crenation (scalloping)

of the lateral tongue

Answer 281

A

hypothyroidism

Answer 282

A

What happens in Hypothyroidism?

Decreased levels of thyroid hormone

What it is called in children & adults?

cretinism in children
myxedema in adults

How it is diagnosed?

Diagnosed by measuring T4 (free thyroxine) in serum

Answer 283

A

Hyperparathyroidism

in young children

Answer 284

A

bones, stones, and groans (& moans)

Bones – Changes in the bones:
- Subperiosteal resorption of distal phalanges (early in disease)
- Loss of lamina dura around roots (early in disease)
- Loss/blurring of trabecular density in bone with resultant “ground glass” appearance in radiographs
- Brown tumor
Stones – renal calculi (especially with primary disease) due to elevated serum calcium basically kidney stones
Groans – duodenal ulcers
Moans – changes in mental status mild dementia

Answer 285

A

Pseudohypoparathyroidism

pulp chambers are very
elongated

Answer 286

A

Pseudohypoparathyroidism

issues with eruption, no
pulp stones present

Answer 287

A

Hereditary
Hypophosphatemia/vitamin D‐resistant rickets

teeth look fairly
normal, have a draining abscess with ulcers and perilous

Answer 288

A

Hereditary
Hypophosphatemia/vitamin D‐resistant rickets

teeth look fairly
normal, have a draining abscess with ulcers and perilous

Answer 289

A

 Enlarged pulp horns
o Can extend up to DEJ
 Abnormal globular dentin
o Dentin may exhibit clefting
 Enamel clefts
 Bacteria noted in enamel, dentin and pulp
o Pulpal involvement leads to necrosis and development of the periapical pathology

Answer 290

A

uni‐ or multilocular Radiolucency (pelvis, ribs, mandible)
seen with persistent disease
histology of giant cell lesion (like CGCG)

Answer 291

A

It is typically surgical removal of a portion or all of the
parathyroid glands

Answer 292

A

▪ Can be due to inadvertent surgical removal when thyroid gland is excised or to autoimmine destruction.

▪ DiGeorge syndrome (anomaly) and endocrine‐candidiasis syndrome can show this.

Answer 293

A

Oral vitamin D precursor
- vitamin D2 (or ergocalciferol)
Dietary supplements of calcium
Teriparatide (a portion of PTH) injections twice daily

Answer 294

A

Vitamin D and calcium supplements
Serum and urinary calcium are monitored

Answer 295

A

Acromegaly – excess production of growth hormone after closure of the epiphyseal plates

Gigantism – excess production of growth hormone before
closure of the epiphyseal plates

Answer 296

A

Etiology

▪ Usually due to a pituitary adenoma

Answer 297

A

Acromegaly

Answer 298

A

Addison’s Disease

Answer 299

A

Addison’s Disease

Answer 300

A

Pellagra

Deficience in Vitamine B3 (Niacin)

Answer 301

A

Pellagra

Deficience in Vitamine B3 (Niacin)

Dermititis of the skin

Answer 302

A

Pellagra

Deficience in Vitamine B3 (Niacin)

erythema of the tongue

Answer 303

A

Deficiency

pellagra

Classic triad

Dermatitis, Dementia, Diarrhea

Oral symptoms

stomatitis and glossitis

Answer 304

A

Why it is a concern?

Premalignant process
o ↑ incidence of oral and esophageal SCCa

Answer 305

A

PLUMMER‐VINSON
SYNDROME

denuded tongue
and angular chelitis

Answer 306

A

PLUMMER‐VINSON
SYNDROME

Angular chelitis (top) hard to get rid of them

Atrophic Glossitis (bottom) red beefy tongue

Answer 307

A

Treated with iron supplements, extreme cases with blood infusions

Answer 308

A

Pernicious Anemia

glossitis, denuded papillae

Answer 309

A

Pernicious Anemia

denuded tongue and then the papillae is back again after the treatment. You have to get injections for the rest of your life

Answer 310

A

Uremic Stomatitis

Answer 311

A

Treated with iron supplements
Need long term follow up for eval of SCCa

Answer 312

A

Uremic Stomatitis

Before and
After Tx with Dialysis

changes on ventral and lateral side
of the tongue, better outcome after dialysis

Answer 313

A

Reiter’s Syndrome (Reactive arthritis)

This not actually a geogrpahic tongue!

Answer 314

A

Reiter’s Syndrome (Reactive arthritis)

Top: erythema on the palate and
areas of ulceration

Bottom: classic look of geographic
tongue, but it is not geo tongue. They are symptoms of Reiter’s

Answer 315

A

Infective Endocardiatios

Janeway lesions

These are Septic Emboli

Answer 316

A

Hyperparathyroidism

Here we see we see

a granular appearance of the max and mand bone everywhere, it is not localized.
There is a loss of bone density and the loss of definition of cortical bone.
Here we see a loss of definition of lamina dura as well because it is now granular, and is not as clear.

Answer 317

A

Hyperparathyroidism; this is the brown tumor which is sometimes well or ill defined, multi or unilocular radiolucency with granular septation.

If you have a patient that is younger than 15-20 years old that has a central giant cell granuloma ► you have to check that patient for hyperparathyroidism, because it could be a brown tumor.

Answer 318

A

This is another medical CT scan. You see the granular appearance of
the maxilla, skull, and well-defined multilocular radiolucency with
granulation. We call this a brown tumor because it is associated with
hyperparathyroidism.

( systemic endocrine diseases)

Answer 319

A

Hyperparathyroidism

On our intraoral radiographs, we see loss of definition of lamina dura because the bone now has a granular appearance which extends to the lamina dura.

The teeth are usually normal, but there is a loss of lamina
dura around the teeth. These teeth are not mobile.

Answer 320

A

a medical CT scan of a patient with secondary hyperparathyroidism.

We see a lack of cortical bone – no normal cortical bone. Inside the skull

we have a granular appearance, with radiolucent and radiopaque dots, we call this a salt and pepper dots.

This is why we call this a salt and pepper appearance, there is no normal cortical bone.

( systemic endocrine diseases)

Answer 321

A

Type of Anemia?

Megaloblastic Anemia

What difficiency?

Vitamin B₁₂ difficiency

Causes?

Poor absorption of vitamin B12 (extrinsic factor, cobalamin)
These patients lack intrinsic factor, usually due to autoimmune destruction of parietal cells
- Intrinsic factor produced by parietal cells in the stomach is needed for absorption of B12

Answer 322

A

we have 2 Pas of patients

with pseudohypoparathyroidism.

hypoplasia of enamel, tooth material
hypoplastic tooth bud ( hypoplastic means arrested development)
delayed eruption,
external root resorption.

Answer 323

A

monthly IM injections of cyanocobalamin
cannot take B12 orally, you need injections

Answer 324

A

1 – Generalized weakness
2 – Painful tongue
3 – Numbness or tingling of the
extremities

Answer 325

A

▪ Usually clears within a few days after renal dialysis has begun
▪ Mildly acidic mouth rinses seem to clear oral lesions (ex. diluted hydrogen peroxide)
▪ Palliative treatment for pain includes ice chips or a topical anesthetic

Answer 326

A

also known as?

Reactive arthritis

Corrlate with which antigen?

Correlation with HLA B27 (> 70%)

Associated with what?

Typically seen after patient has either a bacterial dysentery or an STD sometimes chlamydia

Answer 327

A

Etiology

Thought to be due to an abnormal immune response to the infection

Answer 328

A

Reiter’s Syndrome

Classic Triad

▪ 1 – Polyarthritis (lasting more than one month)
▪ 2 – Conjunctivitis or uveitis
▪ 3 – Urethritis

Answer 329

A

Hyperparathyroidism

Here we see we see

a granular appearance of the max and mand bone everywhere, it is not localized.
There is a loss of bone density and the loss of definition of cortical bone.
Here we see a loss of definition of lamina dura as well because it is now granular, and is not as clear.

Answer 330

A

Hyperparathyroidism; this is the brown tumor which is sometimes well or ill defined, multi or unilocular radiolucency with granular septation.

If you have a patient that is younger than 15-20 years old that has a central giant cell granuloma ► you have to check that patient for hyperparathyroidism, because it could be a brown tumor.

Answer 331

A

This is another medical CT scan. You see the granular appearance of
the maxilla, skull, and well-defined multilocular radiolucency with
granulation. We call this a brown tumor because it is associated with
hyperparathyroidism.

( systemic endocrine diseases)

Answer 332

A

Hyperparathyroidism

On our intraoral radiographs, we see loss of definition of lamina dura because the bone now has a granular appearance which extends to the lamina dura.

The teeth are usually normal, but there is a loss of lamina
dura around the teeth. These teeth are not mobile.

Answer 333

A

a medical CT scan of a patient with secondary hyperparathyroidism.

We see a lack of cortical bone – no normal cortical bone. Inside the skull

we have a granular appearance, with radiolucent and radiopaque dots, we call this a salt and pepper dots.

This is why we call this a salt and pepper appearance, there is no normal cortical bone.

( systemic endocrine diseases)

Answer 334

A

we have 2 Pas of patients

with pseudohypoparathyroidism.

hypoplasia of enamel, tooth material
hypoplastic tooth bud ( hypoplastic means arrested development)
delayed eruption,
external root resorption.

Answer 335

A

Acromegaly (Hyperpituitarism)

enlargement of the mandibular bone with a high degree of enlargement
a class III appearance
enlargement of sella tursica because of the pituitary gland enlargement

Answer 336

A

• Definition: mucocele-like lesion that forms unilaterally on the floor of the mouth

• associated with: the ducts of the sublingual & submandibular glands
• clinical features:

• treatment: surgical excision

Answer 337

A

Osteoporosis

reduction in bone density,
larger bone marrow spaces.

We need more tests to confirm osteoporosis besides dental radiographs.

Answer 338

A

medical CT scan with a patient with osteopetrosis- very dense. Not a
nice definition of the cortical bone. We see decreased in size of skull
foramina.

Answer 339

A

pt with Osteopetrosis

we see

Hypovascular bones so they are more prone to osteomyelitis. This is a sign of sequestrum which is a sign of osteomyelitis.

Answer 340

A

pt with Osteopetrosis

Generalized increase in bone density, increased trabeculation, loss of large bone marrow spaces.
These patients are more prone to osteomyelitis because they are Hypovascular.
We have to be careful in extractions because they don’t have the same vascularity as other healthy patients have.
We see an onion skin appearance by the white arrow.

Answer 341

A

Ricket / Osteomalacia

hyperplasia or thinning of mineralization of teeth. We
can see hyperplasia of enamel in patients.

Answer 342

A

Renal
Osteodystrophy 1

Presentation is variable. Sometimes you see denser or granular
appearance of bone. You see increase here

but you sometimes will also see loss of definition of lamina dura, sometimes a sclerotic appearance
and trabeculation.

Answer 343

A

Renal
Osteodystrophy 2

sometimes you see:

increase in bone density
loss of definition of lamina
dura and cortical bone

Answer 344

A

What is it?

▪ Generalized decrease in bone mass in which the histologic appearance of bone is normal, it is a metabolic bone diseases (MBD)

Why it happens?

Aging process (postmenopausal women) bone mass usually increases until 30 years of age, and then there is a gradual decrease- about 8% loss in females and 3% loss in males
Nutritional deficiencies
Hormonal imbalance
Inactivity
Corticosteroid or heparin therapy

What the bone are like?

▪ More prone to fracture (distal radius, proximal femur, ribs, and vertebrae)

Answer 345

A

Hypophosphatasia

Answer 346

A

large root canal structures, large root chambers, premature loss of
teeth = hypophosphatasia.

Answer 347

A

Hypophosphatemia

Periapical lesions with radiolucency but no caries on the crown.
There is loss of definition of cortical bone.
On the teeth, you have:
- large pulp chambers
- hypoplasia of enamel and dentin
- periodontal and periapical lesions.

Answer 348

A

Progressive Systemic
Sclerosis
(scleroderma)

sharp areas of resorption in the bones near muscles attached to the
angle of the mandible= masseter and medial pterygoid. You see
resorption at the coronoid process at the attachment of the temporal
bone as well.

Answer 349

A

Progressive Systemic
Sclerosis
(scleroderma)

presence of widening of the PDL space everywhere around the root of the tooth.

Answer 350

A

On a sickle cell anemia patient, you see:

loss of this cortical bone area
the hair-on-end appearance on the skull

Answer 351

A

Sickel Cell Anemia

enlargement of bone marrow spaces, less trabeculation, more
osteoporotic bone. You see periapical pathology associated with teeth
with no obvious reason. You see the radioluscencies around the apex of
the mandibular teeth.

Answer 352

A

Thalassemia

osteopenic bone (loss bone mass and bones get weaker)
radiolucent appearance of bone
thinning of cortical bone around the mandible and maxilla.
Usually there is hypoplasia of the paranasal sinuses.

Answer 353

A

Dwarfism

hypopituitarism*
We see* multiple dental anomalies: hypodontia, radicular fusion, fused roots of left lateral incisor and left canine and impacted permanent teeth.
(from google)*

Answer 354

A

Common factors?

Low levels of tissue-nonspecific alkaline phosphatase
High blood and urinary phosphoethanolamine
Rickets-like skeletal malformations

Dental manfestations?

Premature shedding of primary incisors
Enamel hypoplasia
Enlarged pulp chambers and root canals

Answer 355

A

Treatment for generalized symptoms may involve:

corticosteroids
immunosuppressants, such as methotrexate or Cytoxan
nonsteroidal anti-inflammatory drugs

Depending on your symptoms, treatment can also include:

blood pressure medication
medication to aid breathing
physical therapy
light therapy, such as ultraviolet A1 phototherapy
nitroglycerin ointment to treat localized areas of tightening of the skin

(from google)

Answer 356

A

What is it?

Chronic hemolytic blood disorder

What causes it?

▪ Abnormal hemoglobin, resulting in anemia -> by increasing the production of red blood cells -> requires compensatory hyperplasia of the bone marrow

Answer 357

A

What is it?

Defect in hemoglobin synthesis

What causes it?

RBC with reduced hemoglobin content and short life span

Answer 358

A

Palatine Torus/Torus Palatinus

Answer 359

A

Palatine Torus/Torus Palatinus

Answer 360

A

Mandibular Torus:
Torus Mandibularis

Answer 361

A

Mandibular Torus:
Torus Mandibularis

Answer 362

A

Buccal Exostoses

Answer 363

A

Unencapsulated Lymphoid Aggregates

Answer 364

A

Lymphoepithelial
cyst

we see a tiny yellowish cyst. we see the blood vessels on the surface; this is quite characteristic.

Answer 365

A

Unencapsulated
Lymphoid
Aggregates

Post-tonsillectomy

Can even develop these on area of tonsils.
(left pic) Red/salmon is a lymphoid aggregate (unencapsulated lymphoid tissue). This is someone
who had a tonsillectomy , and you can see these
lymphoid aggregates on posterior pharyngeal wall (salmon color).They move around the area.
(right pic) It grew back even in post-tonsillectomy patients.

Answer 366

A

Fordyce Granules

Answer 367

A

Fordyce Granules

Answer 368

A

Fimbriated
fold/Plica
semiluminaris

Answer 369

A

Frenal tag

Answer 370

A

Sublingual Varices

Answer 371

A

Sublingual Varices

Answer 372

A

Sublingual Varices

Answer 373

A

Circumvallate papillae

Answer 374

A

Parotid Papillia (Stenson duct)

Answer 375

A

Parotid Papillia (Stenson duct)

Answer 376

A

Linea Alba

Answer 377

A

Leukoedema

Answer 378

A

Palatal Rugae

Answer 379

A

AKA – Fibroma, Traumatic Fibroma
Occurs as a result of chronic trauma
Locations: buccal mucosa, tongue, lips, gingiva
Treatment: You don’t have to remove them, but the surgical Tx = to excise them bc pts will stop biting them and they’ll heal and stop the irritation

Answer 380

A

Irritation Fibromas

Answer 381

A

Irritation Fibromas

Answer 382

A

Chronic Hyperplastic Pulpitis (pulp polyp)

Answer 383

A

Giant Cell Fibroma

Answer 384

A

AKA: pulp polyp
An e_xcessive proliferation of chronically inflamed dental pulp tissue_

• Treatment: RCT or extraction of tooth

Answer 385

A

Tuberous sclerosis complex

we see A lot of gingival enlargement – is this overgrowth from disease or from seizure medication? Multi organ system involvement

Answer 386

A

Epulis Fissuratum

Answer 387

A

Inflammatory Papillary Hyperplasia of the Palate

Answer 388

A

Cowden Syndrome

Very rare!

Answer 389

A

AKA: denture-induced fibrous hyperplasia, fibrous inflammatory
Cause: ill-fitting denture

• Treatment: surgical excision (scalpel vs CO2 laser -laser is better)
and reline then remake of denture

Answer 390

A

Pyogenic Granuloma

We can see the corresponding radiograph;

-although the radiograph suggests generalized bone loss, there is a lot of calculus on
the distal of #16 > it makes sense that this is a pyogenic granuloma

Answer 391

A

Pyogenic Granuloma:

Answer 392

A

A parulis

It is not a pyogenic granuloma

A parulis is a proliferation of granulation tissue at the opening of a sinus tract
When the infection breaks through the alveolar bone and presents itself,
it will sometimes cause this proliferation of granulation tissue

Answer 393

A

Majority occur with denture stomatitis
Associated with a removable full or partial denture or orthodontic appliance (Something you see in patients who wear denture all the time, don’t take it out, chronic denture wear)
Treatment:Treat underlying candidiasis, fix denture. These bumps can be removed, take electrosurgery loop, and scrape off the bumps – heals well

Answer 394

A

Peripheral Ossifying or Cementifying Fibroma

Lesion in the image is pedunculated – put a periodontal probe on normal gingiva and glide along underneath it, there’s a stalk

Answer 395

A

Peripheral Giant Cell Granuloma

Answer 396

A

• Pyogenic granuloma/pregnancy tumor
• Peripheral ossifying**_or_**cementifying fibroma
• Peripheral giant cell granuloma
• Peripheral fibroma (4P)

Memorize these well!

All benign soft tissue lesions

Answer 397

A

if it’s on the gingival tissues, take a radiograph
always consider SCC as a differential diagnosis

Answer 398

A

Inflammatory Gingival Enlargement

Example of someone with true hyperplastic gingivitis
Maybe related to very poor plaque control
In this case, either porcelain or porcelain fused to metal full coverage restorations that have very
bulky margins, and that may play a role for food to pick up

Answer 399

A

What is it? Reactive connective tissue hyperplasia - exuberant granulation tissue; Misnomer – not pyogenic and not a true granuloma
Etiology: Response to injury - calculus or overhang restoration
Assosiated with? Often occurs in pregnant women (“pregnancy tumor”), also associated with puberty
Location:
• Most common - gingiva
• Also occurs in other areas of the oral mucosa
Treatment: Excision and removal of irritant (eg calculus, overhanging restorations)

Answer 400

A

Acute Myelogenous Leukemia (AML)

Wegener’s Granulomatosis

Kaposi Sarcoma

Plasma Cell Gingivitis

Generalized gingival enlargement – all different cases and diseases

Answer 401

A

They often occur in the gingival, but can occur in multiple areas
- that’s the one thing that distinguishes this from the other 2 P’s: pyogenic granuloma can occur on ANY oral site, most commonly on the gingival tissues

Answer 402

A

Hereditary Gingivofibromatosis

Answer 403

A

Infantile
Hemangioma

(“strawberry” hemangioma).

Infant with two red, nodular masses on
the posterior scalp and neck

Neville Cr

Answer 404

A

When you apply pressure to it, it evacuates the lesion (disappears!), when you pull away, it refills and you see it again – that tells you it’s a vascular lesion

Answer 405

A

Capillary
Malformation (Low
flow)

Answer 406

A

Venous
malformation (low
flow)

Many pts can live with this without treatment

Answer 407

A

_Osler-Weber-Rendu
Syndrome_

Hereditary hemorrhagic telangiectasia (HHT)

Answer 408

A

Sturge-Weber
Angiomatosis

Sturge-Weber syndrome

Answer 409

A

Sturge-Weber
Angiomatosis

Sturge-Weber syndrome

Notice how the vascular malformation is only one side..

Remember: Vascular changes follow trigeminal nerve, so it doesn’t cross midline

Answer 410

A

Lymphangioma

Answer 411

A

Cystic Hygroma

a type of Lymphangioma

Answer 412

A

a reactive benign soft tissue lesion
Clinical appearance: Well-demarcated, sessile or pedunculated lesion that appears to originate from the gingival interdental papilla
Derived from: cells of the periodontal ligament
Age: children and young adults
Sex: females more than males
Recurrence rate – about 16%
Treatment: Surgical excision

Answer 413

A

Neuroma

(Traumatic Neuroma)

Not a benign true neoplasm, it’s reactive lesion
This is an edentulous patient, so resorbed bone, so flange of denture is impinging in the area of mental foramen – develop from repeated trauma
Sometimes have to cut into nerve, peel the neuroma from nerve, careful not to sever nerve

Answer 414

A

Multiple Endocrine
Neoplasia (MEN)
Syndrome

Answer 415

A

neurofibroma

-it looks like lymphoepithelial cyst, but this is further anterior and not where you would get
lymphoid tissue – so it’s not lymphoepithelial cyst, it’s neurofibroma
Yellow – nerves typically yellow

Answer 416

A

neurofibroma

Answer 417

A

Neurofibromatosis syndrome

von Recklinghausen’s Disease

Lisch nodules on iris, pigmented (eye picture)
Neurofibromatosis in mouth (bottom left picture)
Café au lait (bottom right picture)

Answer 418

A

Schwannoma/ Neurilemoma

Answer 419

A

Schwannoma/ Neurilemoma

Answer 420

A

Granular Cell Tumor

Answer 421

A

Granular Cell Tumor

Answer 422

A

•Diagnosis: All 3 “P” lesions usually occur on gingival interdental papillae ( however pyogenic granuloma can occur anywhere)
• Since they can look similar clinically, excisional biopsy necessary to
determine diagnosis
• Treatment: complete excision and removal of local irritant (scaling
and root planing)

Answer 423

A

Congenital Epulis

Answer 424

A

Response to chronic inflammation
Hormonal changes (pregnancy/puberty)
Immune-mediated/plasma cell gingivitis
Drug induced
Genetic/ Inherited

NOTE: Gingival enlargement is not always hyperplastic tissue

Answer 425

A

Neuroectodermal tumor of infancy

look how they removed it here surgically

is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth.

Answer 426

A

What is it: Benign tumor of mature fat cells; Relatively rare
Histologically: a well-delineated tumor composed of mature fat cells with a thin capsule
Treatment: surgical excision,does not recur

Answer 427

A

Lipoma

Usually very orange looking lesion in site where there’s adipose tissue

Very obvious, nothing as orange as lipoma

Answer 428

A

Phenytoin: (or Dilantin) – the drug that used to be given to every single person that had seizures
Calcium-channel blockers
- Nifedipine not as prescribed anymore
- Dilitiazem still prescribe
- Amlodipine: is prescribed as one of the first line therapy for hypertension (very commonly prescribed); it doesn’t typically cause gingival overgrowth except in some selected patients, usually
  those with pretty poor oral hygiene
Cyclosporine A (used for for bone marrow transplant, graft vs host disease, solid organ transplant)
- Cyclosporine is universally recognized as causing gingival hyperplasia
- Cyclosporine is largely replaced with Tacrolimus, which typically doesn’t cause gingival overgrowth
Some drugs have more connective tissue component, others have more epithelial component
Not all identical under the microscope
Cyclosporine provides more epithelial change, Dilantin causes more of a connective tissue change

Answer 429

A

Vascular leiomyoma

High-power view showing spindle-shaped cells with bluntended
nuclei. Immunohistochemical analysis shows
strong positivity for smooth muscle actin (inset).

Answer 430

A

Rhabdomyoma

Will see the striated muscle
Differential diagnosis… looks like granular cell tumor – don’t know til you remove it
If patient presents with relatively slow growing tumor like this, will I get incisional biopsy or
excisional biopsy? Hard to say
If confident benign tumor and it’s this size and I don’t think it’s vascular (no pulse, can do
aspiration), feels firm – try to excise it
If it looks different, like you think it’s malignant minor salivary gland neoplasm (won’t find it in this
site, but if it’s on hard palate) – incision?

Answer 431

A

Leiomyosarcoma

Answer 432

A

What causes it?

Various genes that are implicate (Putative inherited mutations are in the SOS1 or CAMK4 genes.) Linked to both autosomal dominant and recessive patterns of inheritance

How common?

Very rare

Treatment

Need surgical (usually laser) treatment – just grows back, so have to get it done periodically

Answer 433

A

Rhabdomyosarcoma

In this case, hasn’t broken through epithelium
They don’t all break through

Answer 434

A

When do they appear? They are rarely present at birth, infants are Born with this in place.
Rate of development: the tumor will demonstrate rapid development that occurs at a faster pace than the infant’s overall growth in the first few weeks of life,
Treatment: Typically will involute with time, Some cases don’t involute, so need to be removed
It is a vascular Anomaly

Answer 435

A

Fibrosarcoma

Answer 436

A

Kaposi Sarcoma

Solitary vascular lesion on hard palate – it was so small so he decided to just excise it in this case^

Answer 437

A

Kaposi Sarcoma

Widespread Kaposi, can see cutaneous lesions
Oral images of this patient: on palate, starts with macule on patient’s left posterior palate –macular stage
Then in becomes proliferative – exophytic nodular stage (seen on patient’s right anterior palate,surrounding canine and some incisors)
Can see engorged blood vessels in area on histology slide

Answer 438

A

Plasmacytoma in Multiple Myeloma

They already had multiple myeloma then developed plasmacytoma
When you biopsy this, it’s filled with plasma cells bc they’re producing the abnormal immunoglobulins, which are the cause of the devastating issues of multiple myeloma

Answer 439

A

Acute myelogenous
leukemiawith
granulocytic
sarcoma

*Complaining of lump inside of her cheek**
*Notsomuch worried about her gingiva**, despite her overgrowth – leukemic infiltrates that got into gingival tissues
*Left buccal mucosa**, kept biting on it, feeling incredibly fatigued though she was always working out
*Oral surgeon biopsied** her buccal mucosa and read by pathologist as pyogenic granuloma
*Physician** sent her for bloodwork, dental school sent her for bloodwork too

Answer 440

A

Lymphoma

Well circumscribed ulceration in area
Associated swelling in periphery
White change in the patient’s left area
Been there for 3 weeks
It’s lymphoma

Answer 441

A

Looks like it could be a salivary gland neoplasm, but it’s not
It was another lymphoma
Manifest in a number of different ways

Answer 442

A

Do you think it’s a fibroma? No. Why?
Fibroma is covered with normal coloring epithelium – sometimes see a little white change on surface or see tiny traumatic ulcer on surface This is not like that, this is completely ulcerated
Not fibroma; fibroma is a chronic bump that patient is aware of
Is it squamous cell carcinoma? Interesting, it is indeed very friable; but no
Sometimes SCC can develop and can be exophytic and don’t have deep invasion, But this is pedunculated, SCC would not be pedunculated
History says there could be some kind of trauma, biting, or nick with bur – not squamous cell
Mucocele? No
Would you typically develop mucocele on lateral border of tongue? No
Not going to be as many mucoceles in this area, but there are the glands of Blandin and Nuhn, so it’s possible to develop on ventral surface of tongue
This bump doesn’t look like a fluid filled bump though, it has surface ulceration, redness ;Mucoceles have intact surface, would not bleed, or be red
Granular cell tumor? No
Granular cell tumor would have normal overlying epithelium (it’s pushing up from underneath)
This does not have normal overlying epithelium
Hemangioma reserved for congenital; not a vascular malformation either
Neurofibroma? No, not the same surface
Salivary gland neoplasms? Possible, there are salivary glands in that area; keep this in differential
The one that this is is pyogenic granuloma: usually red, ulcerated, and bleeds easily

Answer 443

A

AKA

• Hereditary Hemorrhagic Telangiectasia

What is it ?

• disorder of development of the vasculature characterized by telangiectases and arteriovenous malformations in specific locations.

Type of Herditary and Etiology

•Autosomal dominant with mutations i_n at least five gene_s but mutations in two genes (ENG and ACVRL1/ALK1) cause approximately 85% of cases.

What can it cause?

• Can cause hemorrhage

Answer 444

A

What is it?

• Benign tumor of lymphatic vessels

Treatment:

monitor, surgery if needed, recurrence common

Answer 445

A

What is it?

Group of rare conditions

Inhertiance type?

Autosomal dominant

Which type is associated with multiple mucosal neruoma?

Type 2B

Increase risk of which cancer?

• Increased risk for medullary thyroid cancer (prophylactic thyroidectomy)

Common board questions

Answer 446

A

What is it?

A benign tumor arising from peripheral nerve tissue

Treatment: surgical excision

Malignant transformation reported, but rare

Answer 447

A

What is it?

• Benign neoplasm of Schwann cell origin
• Uncommon lesion: 28-48% occur in the
head and neck

• Treatment

• surgical excision

malignant
transformation

reported, but rare

Answer 448

A

What is it?

Benign tumor derived from
Schwann cells

Treatment
• Treated by surgical excision (Be careful with excision! no need
to get all of it out, just most of it)
rarely recurs

Answer 449

A

AKA: Congenital epulis of the newborn
Cells resemble cells of the granular cell tumor

• Cell of origin is unknown, not derived from nerve

• Treatment:Surgical excision, does not recur

Answer 450

A

Rate of development?

So fast developing that it envelops and moves the teeth

Treatment?

Needs to be surgically excised

Origin?
Thought to be of neuroectodermal source

Answer 451

A

•What is it? Malignant tumor of fibroblasts
• Age? Most common in young adults and
children
• Rate of growth? Slow growing lesion that is usually not
painful (Can be slow growing, can be rapidly growing – different criteria determining high or low grade)
• Treatment: surgical excision, recurrence is common(Aren’t always easy to surgically remove, because already metastasized into other reservoirs, spread into contiguous areas) Aren’t always radiosensitive, don’t always respond to radiation treatment
• 5-year survival rates range from 40-70%

Answer 452

A

Etiology:Caused by HHV-8 (human herpesvirus 8) /part of herpes family

Treatment

Surgical excision, radiation therapy or systemic chemotherapy for multiple nonoral lesions, if it gets large, dose-radiation therapy!

Answer 453

A

PLEOMORPHIC ADENOMA

(MIXED TUMOR)

Answer 454

A

PLEOMORPHIC ADENOMA

Classic presentation: includes swelling in the parotid region

(MIXED TUMOR)

Answer 455

A

PLEOMORPHIC ADENOMA

Palatal presentation: since salivary glands are only in lateral sides of the palate, usually
swellings are in one side and not the midline. Lateral swelling is a clue that you are
looking at a salivary gland lesion (left pics)
On the right pic, it involved midline and crossed over to other side, so there are
exceptions. But more commonly found in lateral side of the palate.

(MIXED TUMOR)

Answer 456

A

PLEOMORPHIC ADENOMA

Upper lip presentation: sometimes swelling can be seen extra orally and intraorally.
Remember the swelling will be movable, not tender, not fixed to underlying structures.

(MIXED TUMOR)

Answer 457

A

Untreated pleomorphic adenoma

slow growing, but can grow to enormous sizes

Answer 458

A

Canalicular Adenoma

Answer 459

A

Canalicular Adenoma

Mucocele might look this way, but what would make it lower on
differential diagnosis is the location of the swelling. Mucocele is mostly seen on lower lip and this pic shows upper lip. Salivary gland tumors and mucoceles
can have the same clinical presentation, so always do a biopsy for formal histopathology diagnosis.

Answer 460

A

Basal Cell Adenoma

Answer 461

A

PAPILLARY
CYSTADENOMA
LYMPHOMATOSUM
(WARTHIN TUMOR)

Answer 462

A

 Most common malignancy of salivary glands
 Most common malignant SG tumor in children

 Can be mistaken for mucocele

 Histopathology: note the cells growing into adjacent tissue, showing infiltration

Answer 463

A

What is it?

Proliferation of 1 type of cell makes up the tumor.

Types? Includes:
o Canalicular Adenoma
o Basal Cell Adenoma
Treatment for all monomorphic adenomas is surgical excision & diagnosis is done with biopsy

Answer 464

A

MUCOEPIDERMOID
CARCINOMA

Answer 465

A

MUCOEPIDERMOID
CARCINOMA

Request all for biopsies!

Answer 466

A

CENTRAL
MUCOEPIDERMOID
CARCINOMA

Intrabony presentations, may have extraoral swelling depending on the stage
Started as small swelling and progressed rapidly:, need to pick it up early!
Patient recovered, but might need radiation, lost salivary glands, needed reconstruction of palate

Answer 467

A

ACINIC CELL
ADENOCARCINOMA

Answer 468

A

ACINIC CELL
ADENOCARCINOMA

blue‐ish tint

Answer 469

A

Untreated acinic cell adenocarcinoma

 Because it is slow growing, and a low grade tumor, the
patient is alive and not dead with a tumor this size.
 Similar presentation to pleomorphic adenomas, but there is a lot of ulceration on the surface and prominent vascularization in acinic cell
adenocarcinoma.

Answer 470

A

Adenoid Cystic Carcinoma

Answer 471

A

Adenoid Cystic Carcinoma

Answer 472

A

Adenoid Cystic Carcinoma

Answer 473

A

Polymorphous
Adenocarcinoma

Answer 474

A

Polymorphous
Adenocarcinoma

Answer 475

A

Carcinoma Ex Pleomorphic
Adenoma

Answer 476

A

Most common SG tumor to occur bilaterally (bilateral parotid swelling), but can be unilateral
Etiology: Thought to arise within lymph nodes as a result of entrapment ofsalivary gland elements early in development
Strong correlation with cigarette smoking
Treatment: surgical excision, responds very well to it

Answer 477

A

Treatment: Usually treated by surgical excision

Prognosis:

• Overall prognosis is fairly good
• 10% of patients die, due to local recurrence or metastasis
 Low‐grade tumors have good prognosis (>90% are cured)
 High‐grade tumors the prognosis is guarded (Only 30% survive)

Therapy by gene?

CRTC1–MAML2, CRTC3‐MAML2 gene fusions (targeted therapy)

Answer 478

A

Growth rate
 Usually a slowly growing mass

Treatment
 Excision usually the treatment of choice ‐ but edges of tumor may have perineural invasion and remain undetected ‐ makes tumor dangerous

Prognosis
 5‐year survival rate as high as 70% (maybe 90%)
 By 20 years, only 20% ‐ poor long term prognosis

Answer 479

A

Growth patterns:
Different growth patterns – polymorphous
Perineural invasion ‐ common ‐ but considered low grade tumor
Treatment: Wide surgical excision; overall prognosis relatively good, with 80% cure rate

Answer 480

A

What is it? (benign tumors that have underwent malignant transformation‐ takes a lot time, 15 to 20 years)

Growth patterns: Mass present for many years with recent rapid growth with associated pain or ulceration

Treatment: Best treated by wide excision, with local node dissection and radiation

Prognosis: guarded, with 50% local recurrence or metastases and dying Prognosis is case to case scenario, may transform to high grade tumor

Answer 481

A

o Mucocele
o Mucoepidermoid Ca
o Pleomorphic Adenoma

Answer 482

A

o Canalicular Adenoma
o Salivary Duct Cyst*
o Pleomorphic Adenoma

Answer 483

A

o Pleomorphic adenoma
o Warthin’s tumor
o Basal cell adenoma
o Mucoepidermoid ca
o Acinic cell ca
o Adenoid cystic ca
o Ca ex mixed tumor

Answer 484

A

o Pleomorphic adenoma
o Adenoid cystic ca
o Mucoepidermoid ca
o PLGA
o Monomorphic adenoma

Answer 485

A

 Involve both major and minor glands
 Benign and malignant tumors both have similar
clinical presentation
 Most malignant salivary gland tumors do not show histopathologic
characteristics associated with malignancy
 Most occur in adults
 Warthin Tumor seen in parotid, may be bilateral
 Mucoepidermoid carcinoma
o Can occur in children
o May occur centrally in bone

Answer 486

A

• definition: a lesion that forms when a salivary gland duct is severed & secretion spills into the adjacent CT
• a pseudocyst (not lined by epithelium) — mucous builds up in the CT & causes a bump

• treatment: surgical excision, removal of associated minor salivary glands
• may recur if don’t remove all associated injured minor salivary glands

Answer 487

A

Mucocele

Answer 488

A

Mucous Cyst

Answer 489

A

Ranula

Notice how it’s unilateral

on the floor of the mouth

Answer 490

A

Ranula

Notice how it’s unilateral*
on the floor of the mouth*

Answer 491

A

*• Definition:** locally destructive inflammatory condition — looks malignant but is benign
• salivary gland ischemia* — “heart attack of the palate”; blood flow is interrupted

• predisposing factors:
- local trauma
- palatal injection of local anesthesia
- previous surgery
- many are idiopathic..
• usually a clinical diagnosis based on history & how fast — palate uncommon for SCC

Treatment: no treatment, spontaneously resolves within 6 to 10 weeks
irrigating & debriding the area can reintroduce vascularity & help healing

Answer 492

A

Necrotizing Sialometaplasia

Answer 493

A

Definition: lith = stone ;; sialolith: a salivary gland stone

Treatment: promote passage of stone (massage, sialogogues, increase fluid intake) or surgical removal

Answer 494

A

Sialolithiasis

Answer 495

A

Sialolithiasis

Notice how it can appear radiographically as a well defined radioluecency

It doesn’t always appear radioapaque!

Answer 496

A

Sialolithiasis

Answer 497

A

Sialolithiasis

Answer 498

A

Sialolithiasis

A, Minor salivary gland sialolith presenting
as a hard nodule in the upper lip.

B, A soft tissue radiograph of
the same lesion revealed a laminated calcified mass.

Answer 499

A

Definition: a pseudocyst
clinically you CANNOT tell the difference between a mucocele & mucous cyst and histologic features same as mucocele but will see an epithelial linin

treatment: same as mucocele; surgical excision

Answer 500

A

• definition: acute or chronic inflammation in major or minor salivary glands

• causes:
• obstruction of a salivary gland duct (sialolith)
• infection (mumps [viral], staph aureus [bacterial, most common], candida [fungal])
• decreased salivary flow (Sjogren’s, sarcoidosis)
• parotid gland = parotitis

• Treatment: antibiotics, rehydration, surgical drainage, or surgical removal of gland

Answer 501

A

Sialadenitis

Acute: parotid papilla purulent discharge

Answer 502

A

‐ Minor Recurrent
Aphthous Ulcers
(RAS)‐ Rare Case

o Keratinized
Mucosal
Site

‐ 11‐year‐old boy
‐ Canine is in process of erupting
‐ Canker sore present on his keratinized mucosa (RARE)
o 99% of canker sores occur on NON-KERATINIZED MUCOSA

Answer 503

A

Minor Recurrent
Aphthous Ulcers
(RAS)

aka‐ “Canker Sores”
‐ High prevalence: 5‐25%
‐ Comprises the overwhelming majority of cases
- o 75‐85% of ALL RAS cases
‐ <10 mm in diameter
‐ Ulcer appearance:
- o Shallow
- o Round/Oval Shaped
- o Yellow pseudomembrane
▪ Slightly raised margin
▪ Erythematous Halo
‐ Typically resolves in 7‐10 days
- o *May take longer if in a “high‐traffic” site
‐ No scarring
‐ Recurrence rates vary

Answer 504

A

‐ Hallmarks:
o 1. Central ulceration
o 2. Ring of erythema (erythematous border)
▪ Accentuated in right image

Answer 505

A

‐ Aphthous Ulcer of the tongue

‐ Aphthous ulcers can occur on specialized structures of the mouth

Answer 506

A

Aphthous ulcer (“The
canker sore”)

What would it be like to have a canker sore on your uvula?
o Painful to swallow
‐ The location of the canker sore will predict the symptoms

Answer 507

A

‐ Debacterol (sulfonated phenolics; sulfuric acid solution)
o Chemical cautery
o Label: one time application for 5‐10 seconds
‐ NOT recommended to patients with frequent outbreaks

Answer 508

A

‐ Repair sharp teeth/restorations
‐ Remove plaque
‐ Optimize lubrication

Ulcer

Answer 509

A

‐ History of RAS
‐ Medical History
o Medications
o Review of Systems
‐ Social History
‐ Dental History
‐ Diet/Nutritional History
‐ Physical Examination
‐ LaboratoryTests

Answer 510

A

Behcet’s Disease

‐ Recalcitrant oral ulcers associated with Behcet’s Disease
‐ Later developed genital ulcers and other complications
‐ Image:
o Sores in the labial mucosa have classic aphthae appearance
o Other ulcers are major aphthae:
▪ Larger
▪ Irregular borders
▪ Intense proliferative erythema

Answer 511

A

Behcet’s Disease

‐ Recurrent inflammatory disorder of unknown cause:
o Bacterial?
‐ Affects:
o Middle Eastern Males
o Asian Females
‐ Onset 3rd – 4th decade
‐ HLA‐B51 association

Recurrent aphthous ulcers generally precede other signs:

o Genital/skin/eye lesions & others (arthritis, Gl lesions, CNS symptoms, vascular lesions)
‐ Diagnosis based upon criteria (point system): no laboratory tests

Answer 512

A

Hematinic
Deficiencies

‐ Superficial ulcers
o Not classic aphthous ulcers
‐ Equivocal associations with iron, Vit B1, B2, B6, B12, and folate.
‐ Blood tests are not recommended routinely in all patients with RAS.
‐ Indications for blood work (CBC):
o Older patient with recent RAS history
o Suspicious medical history/review of systems
o Strict vegetarian patients

Answer 513

A

HIV‐Associated
Aphthous

CD4 counts <100 cells/mm3 are predisposed to major RAS
‐ Other sites may be affected:
- o Esophagus
- o Genitals
- o Anus/rectum
‐ We see this less frequently since ART
‐ Diagnosis is important, particularly if no prior history

Answer 514

A

Inflammatory
Bowel Diseases

Specific lesions:
- o Diffuse labial and buccal swelling
- o Cobblestones
- o Other specific lesions
- ▪ Mucosal tags
- ▪ Deep linear ulcerations
- o Mucogingivitis
- o Granulomatous cheilitis
- - Non‐specific lesions:
- o Aphthous ulcerations
- o Pyostomatitis vegetans
- o Dental caries
- o Gingivitis and periodontitis
- o Other non‐specific lesions

Answer 515

A

Transient Lingual
Papillitis

‐ Relatively rare
‐ Canker sore meets fungiform papilla of tongue
- Multiple papilla can become inflamed (above image)
- Very painful
‐ Ulcer Appearance:
- Tiny
- Transient
- On fungiform papilla of tongue
‐ Typically resolves in 7‐10 days

Answer 516

A

Herpetiform aphthous stomatitis

Apppears like herpesvirus but unrelated to it
account for 5% of cases (the least common)

Appearance:

begin as multiple (up to 100) 1- to 3-mm crops of small, painful clusters of ulcers on an erythematous base.
They coalesce to form larger ulcers that last 2 weeks.
A bunch of smaller ulcers that coalesce

Answer 517

A

‐ Treatment to reduce pain
‐ vs.
‐ Abortive treatment to reduce healing time
‐ vs.
‐ Suppressive treatment to suppress recurrences
‐ Combination of all

Also Consider

Using Sodium Lauryl Sulfate‐Free Toothpastes
Remove Obvious Possible Causes

Answer 518

A

Sialadenitis

Chronic: caused fibrosis

Answer 519

A

‐ Treatment to reduce pain

Also Consider

using Sodium Lauryl Sulfate‐Free Toothpastes
Remove Obvious Possible Causes
- ‐ Repair sharp teeth/restorations
- ‐ Remove plaque
- ‐ Optimize lubrication

Answer 520

A

Topical anesthetic agents
o To numb the pain
‐ Surface protective agents/bioadhesives
o Cover the ulcer if small enough
‐ Anti‐inflammatory/immunomodulatory agents
o Applied to ulcer surface (corticosteroids)
‐ Anti‐microbials
o Some evidence that topical tetracycline may help
‐ Chemical/physical cautery Lasers
‐ Over‐the‐counter (OTC) versus prescription (Rx

All essentially do the same thing:
o Numbing agent
o Mucosal covering agent
‐ Bottomline:
o ALL canker sores will heal on their on with time

Answer 521

A

Major Recurrent
Aphthous Ulcers
(RAS)

‐ 10 – 15% of all RAS cases
‐ >10 mm in diameter
‐ Ulcer Appearance:
- o Deeper
- o Irregular borders (usually)
‐ Typically resolves in WEEKS or MONTHS
‐ May be associated with fever or malaise
- o The associated cytokine release can induce a fever
‐ Predilection for the throat
‐ Often DOES leave scarring
‐ Recurrence rates vary

Answer 522

A

‐ Dexamethasone elixir 0.5mg/5ml (ETOH base) or solution (H20 base)
‐ Indicated for difficult to reach lesions to obtain access to all of them
o Disp:600ml
o Label: swish with 5‐10 ml for 5 minutes up to 0.5mg/5mL 4x/day and
expectorate 00s preservalve.) May be used as suppressive therapy in
selected patients with close surveillance
o Prevent recurrences
‐ May buy an EXTRA DAY of healing time

dr. Kerr prefers the elixir

Answer 523

A

‐ Triamcinolone acetonide in Orabase 0.1% (intermediate)
o Disp: 5g tube Dental Past
o Label: apply a thin film over ulcer after meals and bedtime APOTHECON
o Do not use for more than 2 weeks

‐ Fluocinonide gel or ointment 0.05% (Potent)
o Disp: 15g tube
o Label: apply a thin film over
o Do not use for more than 2 weeks
‐ Clobetasol ointment 0.05% (Ultra potent)
o Disp: 15gtube Label: apply a thin film over ulcer bid

Answer 524

A

‐ Prednisone or systemic steroids were the one systemic treatment that Dr. Kerr
has has success with in practice

o 0.5 mg/kg of Prednisone would be prescribed for about 1 week

o Very successful in patients with frequent outbreaks of multiple canker
sores
‐ In some limited cases Dr. Kerr has seen some success with:
o Colchicine
o Pentoxifylline

Answer 525

A

Primary infection → Latency → Reactivationn → Recurrent infection

Answer 526

A

Sensory ganglia

Answer 527

A

Sensory ganglia

Answer 528

A

Sensory ganglia (dorsal root ganglia)

Answer 529

A

B‐Lymphocytes

Answer 530

A

Myeloid cells, salivary gland cells, endothelium

Answer 531

A

CD4+ T‐Lymphocytes

Answer 532

A

CD4+ T‐Lymphocytes

Answer 533

A

*B‐lymphocytes (latency)**, **endothelial cells (Kaposi
sarcoma) **

Answer 534

A

○ Acute/Primary Herpetic Gingivostomatitis
○ The easy way to remember where the ulcerations occur?
➢ gingiva and oral cavity

gingivo (=gingiva or fixed keratinized mucosa)

+
stoma (= the movable part of the oral cavity where the CT is
looser, including the labial and buccal mucosa, and the
tongue).

Answer 535

A

two manifestations:

Herpes labialis: occurs on the vermillion border
Intra‐oral herpes: occurs ONLY on the fixed keratinized
mucosa (mucosa that doesn’t move around) MEMORIZE
THIS

Answer 536

A

 Children and young patients

Answer 537

A

HSV‐1: Primary
Infection

it is a raised blister/papule on the
vermilion
The bottom arrow pointing to a mucosal
ulcer w/ tan pseudomembrane.

Answer 538

A

HSV 1- Primary Herpetic
Gingivostomatitis

Ulcer with an erythematous halo (top two arrows). We
also have ulcerations that are irregular in shape on the gingiva
(bottom two arrows).

❏ Clinical Features:

Cervical lymphadenopathy
Chills
Fever
Nausea
Anorexia
Irritability
Sores in mouth
Ulcerations on fixed and movable mucosa
Variable number of lesions
Ulcers coalesce and form larger irregular ulcerations
Gingiva enlarged and painful
Resolution in 5‐7 days

Answer 539

A

HSV‐1: Primary
Infection

pathogensis

❏ Usually young age
❏ Often asymptomatic
❏ Symptomatic = Primary herpetic gingivostomatitis
❏ In adults is usually pharyngotonsillitis (back of throat)
❏ Spread through infected saliva or active lesions
❏ Incubation period = 3‐9 days

These photos represent

gingivostomatitis

multiple irregularly shaped
ulcers present on the fixed and movable mucosa, bilaterally

Answer 540

A

HSV1: primary herpetic gingivostomatitis

there are multiple irregularly shaped
ulcers present on the fixed and movable mucosa –> most likely
diagnosis is primary herpetic gingivostomatitis since the patient has
fever and malaise.

Answer 541

A

❏ Molding
❏ Margination
❏ Multinucleation
❏ Also Tzanck cells

Answer 542

A

HSV‐ Cytology‐
Papanicolaou Stain
(PAP)

Answer 543

A

If you have positive IgM and negative IgG → that means it’s an acute
recent infection.
Then you have to wait 4‐6 weeks
If you do the serology then and get positive IgG and negative IgM → that means the person has the established infection.

Answer 544

A

❏ Supportive/Palliative Treatment
❏ Fluids, nutrition, rest, avoid spreading to others
❏ Avoid touching eyes, genitals
❏ Possible referral to MD if infant is not drinking because of pain
❏ Medications:

Topical anesthetic (OTC vs Rx)
Mucosal coating (OTC)
Analgesic (OTC vs Rx)
Antiviral (Rx)

Answer 545

A

❏ OTC Magic Mouthwash Formulation: helps the person to actually be able to eat bc they have so many ulcerations
○ 1 Part‐ Diphenhydramine/ Benadryl (anticholinergic)
12.5mg/5mL elixir
○ 1 Part‐ Lidocaine (topical anesthetic)
○ 1 Part‐ Magnesium hydroxide/ Maalox (mucosal coating
agent)
○ Disp: 4 oz bottle
○ Label: Rinse with 5mL every 2 hours for 30 sec. then spit
out
❏ Rx‐Topical Anesthetic
○ Lidocaine 2% viscous solution* (viscous lidocaine)
○ Disp: 100mL bottle
○ Label: Rinse with 10 mL for 2 minutes and spit out
*May diminish the gag reflex therefore better suited for older
patients‐ shouldn’t be prescribed to kids. Remember serious sideeffects of seizures and methemoglobinemia in pediatric population.
❏ OTC Analgesic
○ Acetaminophen (Tylenol) OR ibuprofen (NSAID)
suspension/ tablets as directed for body weight
❏ Rx Antivirals
○ Generally only indicated for immunocompromised or
dehydrated patients
○ Limited evidence for other cases‐ see Cochrane Oral Health
Group Review* (*Amended recently)
○ Oral acyclovir suspension (Zovirax) is typically used
○ 15 mg/kg up to adult dose of 200mg
○ Rinse and swallow, 5 times a day for 5‐7 days

Answer 546

A

trigeminal ganglion

Answer 547

A

Prodrome►papules►vesicles►ulcer►crust►heals►no scar

Answer 548

A

recurrent Hsv-1/Recurrent herpes

It is raised
(papule), so it’s in the middle stage

Answer 549

A

Recurrent HSV-1

Punctuate ulceration
erythematous border, irregular shape, fixed mucosa, unilateral

Answer 550

A

Recurrent HSV-1

This is recurrent intraoral herpes. We have
punctate (point‐like) ulcerations which sometimes have clusters of
coalescing ulcers. That’s the words you wanna use
Other features of the ulcers:
○ Erythematous border
○ Irregular shape
○ Fixed mucosa
○ Unilateral

Answer 551

A

Recurrent HSV-1

Bilateral > THIS IS KEY
-differential diagnosis with a Staph infection
that occurs periorally with kids -> impetigo

Answer 552

A

Recurrent HSV-1

Vesicle stage (unilateral)

Answer 553

A

Recurrent HSV-1

crust → later
crust comes off and then
you’ll have
epithelialization
underneath

Answer 554

A

Recurrent HSV-1

papule bc its
raised

Answer 555

A

Recurrent HSV-1

healing stage cause
you might see this one day

Answer 556

A

❏ Clinical‐ if you see punctate ulcers unilaterally on the palate, it is
usually recurrent herpes simplex.
❏ Culture (may take 2 weeks) ‐ takes too long
❏ Tissue biopsy‐ if it wasn’t typical
❏ Cytologic smear‐ the ideal way if you want a definitive diagnosis

Answer 557

A

Atypical recurrent HSV

❏ Immunocompromised host
Atypical recurrent HSV can have this
appearance on the movable mucosa too, not just fixed

Answer 558

A

HSV Associated
Erythema
Multiforme

❏ Skin immune reaction in response to infection

❏HSV implicated in trigger for erythema
multiforme where you get target lesions
and crusted ulcerations on the
lip

❏ need to prescribe :antiviral prophylaxis

Answer 559

A

❏ Depends on severity/frequency
❏ Preventive/suppressive vs episodic/abortive strategies
Two types of treatment:
Preventive/Suppressive: taking antivirals everyday to prevent an outbreak
Episodic: taking antivirals here and there to abort the process; episodic: abortive.
❏ Drugs used:
❏ Antiviral agents
❏ Antiviral‐steroid combination agents
❏ Avoid precipitating factors, like use sunscreens – avoid any triggers

Answer 560

A

❏ the prodrome, prodrome treatment is abortive
**remember this!**

Answer 561

A

Topical like Acyclovir

or Acylovir + steroid combination

There are many OTC topical medications

Answer 562

A

: taking antivirals everyday to prevent those 6 outbreak/year.

There is modest evidence
that systemic acyclovir or
valacyclovir prevents
recurrent herpes labialis

these drugs tend to only affect virally‐altered cells. They don’t
affect the mammalian cells; they’re very safe.

Answer 563

A

❏ Episodic‐Occurring, appearing, or changing at usually irregular
intervals
❏ Abortive‐Tending to cut short the course of a disease
○ Medication has to be taken during Prodrome
○ When the patient feels a burning, itching, and tingling

Answer 564

A

❏ Rx: Acyclovir cream 5% (Zovirax)
Disp: 5g tube
Label: dab on lesion every 2 hours for 4 days
❏ Rx: Penciclovir cream 1% (Denavir)
Disp: 5g tube
Label: dab on lesion every 2 hours for 4 days
❏ Rx: Docosanal cream (Abreva) OTC
Disp: 2g tube
Label: dab on lesion five times per day for 4 days

Acyclovir and Penciclovir
should be taken during
the prodrome stage

❏ Rx: Acyclovir 5%/ hydrocortisone 1% cream (Xerese)
Disp: 5g tube
Label: dab on lesion 5 times a day for 5 days
❏ Rx: Acyclovir buccal tablets (Sitavig) 50mg
Disp: 2 dose pack
Label: apply to canine fossa within 1 hour of symptoms
(single dose)

Answer 565

A

❏ Rx: Valacyclovir 1g tablets
Disp: 4 tabs
Label: 2 tabs stat PO, then again in 12 hours (ie 2 doses)
Given during prodrome.

❏ Rx: Famciclovir 500mg tablets
Disp: 3 tabs
Label: 3 tabs stat PO

Answer 566

A

❏ Primary infection
○ Varicella/ Chicken pox
❏ Secondary infection
○ Zoster/ Shingles
○ May affect oral cavity/ face if reactivation
along distribution of V1/2/3

Answer 567

A

HHV3

Varicella (chickenpox)

It is caused by

Varicella Zoster
Virus Infection

a typical macular, papular, vesicular rash –
it’s bilateral

Answer 568

A

Herpes Zoster/
Shingles

It is affecting the intraoral region
and the maxillary branch.
Picture on the far right looks like recurrent HSV (cluster of coalescing ulcers)
Looking at the picture on the left you can determine it is NOT a recurrent intraoral herpes because we have vesicles that opened up and crusted over on the skin.

VZV histopathology is the same as HSV.

VZV remains latent in the
dorsal root ganglion
travels down the sensory nerves to skin upon reactivation.
❏ The reactivation presents as a painful rash in one or two adjacent
dermatomes that does not cross the midline.
❏ The rash is maculopapular and develops into vesicles.
❏ One complication of zoster is post‐herpetic neuralgia: pain that
persists in the area where the rash once was present.

Answer 569

A

HHV 5

Cytomegalovirus
Infection

Histopathology look like an owl eyes

means the cells are affected- they are nuclear inclusions and cytoplasmic inclusions.

Answer 570

A

HHV 5

Cytomegalovirus
Infection

When a person is immunocompromised, particularly those who’ve had a transplant or HIV+ patients, only these people will present with ulcerations

It’s very hard to identify
based on photo alone

it’s very nonspecific

Answer 571

A

Nasopharyngeal carcinoma
❏ Associated w/ HHV‐4 (EBV)
❏ You might be one of the first people to detect this
cancer – the first sign is the swelling of the lymph
nodes

In this case, these are late stages of the disease.

this photo from google

Answer 572

A

Oral hairy leukoplakia

Epstein‐Barr Virus induced disease
❏ Corrugated white
keratotic lesion
on the lateral
tongue in HIV+ people

Answer 573

A

Infectious mononucleosis

Epstein‐Barr Virus/EBV‐induced disease

The virus spreads through saliva, which is why it’s sometimes called “kissing disease.” Mono occurs most often in teens and young adults. However, you can get it at any age. Symptoms of mono include:

Fever

Sore throat

Swollen lymph glands

when you have salivary transfer, your lymph nodes get swollen
people feel fatigue and fever
they have tonsilitis
can lead to the secretion of white or gray‐ green tonsillar exudate
they can get petechiae on the palate too.

Answer 574

A

Burkitt
Lymphoma

Epstein‐Barr Virus
Infection

Fast growing tumor discovered by Dr. Burkitt
High grade lymphoma B cells‐ Usually affects the jaws of children.
It is the fastest growing tumor/cancer.
There is translocation of c‐myc

Answer 575

A

EBV mucocutaneous ulceration

Very rare

Photos from google

Answer 576

A

Burkitt
Lymphoma

caused by EBV

Answer 577

A

Kaposi sarcoma

HHV 8

Kaposi sarcoma on
the skin:
>1cm
Different color, so
this is called a patch.
Erythematous
patches present on
multiple areas of the
face.

Answer 578

A

Histopathology shows malignant endothelial cells proliferating.
There are tiny spaces. Extravasation of RBCs can be seen

Answer 579

A

Kaposi Sarcoma
(HHV‐8)

Right photo: we see Patch, slightly raised plaque stage
○ This is different from hemangioma because if you press on it, it
doesn’t blanch (where all the blood goes away, and it looks
white)
Left photo: Nodular is when it becomes very exophytic
You need to do a biopsy for this because it looks irregular.

Answer 580

A

6, 11, 16, 18

(condyloma – can be malignant)

Answer 581

A

6 & 11

Answer 582

A

2 & 4

Answer 583

A

16, 18

Answer 584

A

Kaposi sarcoma–associated herpesvirus (KSHV)

❏ Vascular neoplasm of endothelium
❏ Associated with immunosuppression
❏ Usually evolves through 3 stages:
○ Patch►plaque►nodular

More commonly seen in patients with HIV infection.
Treated with topical agents and chemotherapy.

Answer 585

A

▪ LCR: long control region
▪ P97: promoter protein
▪ E1‐E7: early region genes
▪ L1,L2: late region genes

Answer 586

A

Epstein‐Barr Virus
Infection

Latency in lymphocytes

§Infectious mononucleosis
§Oral hairy leukoplakia
§Nasopharyngeal carcinoma
§EBV mucocutaneous ulceration
§Burkitt lymphoma
§Other lymphomas (Hodgkin, post transplant)

Answer 587

A

§Small, non-enveloped icosahedral DNA virus that infects
skin or mucosal cells of humans.
§Circular DNA
§198 types established
§High and low risk types

‐ HIGH risk = CANCER
‐ LOW risk = WARTS

Answer 588

A

**E6 = degrades p53
E7 = inactivates pRb**

E2 = attachment location of Integrated HPV
transcription of E6 + E7
Binding of the viral E7 protein to pRb ► release of E2F and other proteins ► signals for the cell cycle to progress
▪ As long as the E7 protein stays attached to pRb, uncontrolled cell proliferation will continue

HPV E6 protein is:
‐ A ubiquitin ligase
‐ contributes to oncogenesis by attaching ubiquitin molecules to p53 ► making
p53 inactive and subject to proteasomal degradation
▪ Normal function of p53 = to stop cell division + repair damaged DNA so that damaged cells do not reproduce (apoptosis)
▪ When p53 is inactive, cells with changes in the DNA, such as integrated viral DNA, are not repaired ► destabilizes the cell ► increases the risk of malignant transformation

Answer 589

A

▪ Low‐risk types: clear faster, less likely to become persistent
▪ High‐risk types: clear slowly, more likely to become persistent

Answer 590

A

Overall: 6.9% (CI 6.7‐8.3)
▪ Gender: Men (10.1%) > Women (3.6%) – women clear faster

▪ Age: bimodal distribution – 30‐34yo and 60‐64yo (she says 30‐34

In Kerr’s graph shows mid‐20s**

▪ High Risk HPV (3.7%) > Low risk HPV (3.1%)
▪ HPV‐16 infection most prevalent (1% or 2.13 million Americans)
▪ Based on NHANES study w/ oral rinse sampling and PCR

Answer 591

A

HPV 16 = most prevalent

Answer 592

A

Ppl w/ HIV+ and low CD4 T‐cells lvl = higher risk of
HPV
HPV 16+ higher if CD4 <200

Answer 593

A

▪ HPV associated SCCa
‐ Wild type TP53
‐ Low pRb
‐ Increased p16

▪ Tobacco and Alcohol associated SCCa
‐ *Mutated TP53 – mutated by carcinogens in tobacco and alcohol► cancer
‐ pRB overexpression
‐ Decrease p16

Answer 594

A

▪ Squamous papilloma
▪ Verruca vulgaris
▪ Condyloma acuminatum
▪ Focal epithelial hyperplasia
▪ Oral florid papillomatosis

Answer 595

A

SQUAMOUS PAPILLOMA

Benign Oral Low Risk HPV
Lesion

HPV 6+11
“finger‐like projections

The projections are almost feathery
exophytic lesion

Answer 596

A

▪ Benign proliferation of stratified squamous
epithelium resulting ► papillary, verruciform, rugose (ridged or wrinkled) mass
▪ HPV types 6 + 11 – Low risk

▪ **should remove from mouth – but WOULD NOT submit for HPV typing

Answer 597

A

SQUAMOUS PAPILLOMA

Benign Oral Low Risk HPV
Lesion

HPV 6+11
“finger‐like projections

Answer 598

A

Oral Verruca Vulgaris
HPV 2,4,6
Also “finger‐like
projections”

remember it’s contagious

Answer 599

A

▪ HPV 2, and others (1,4,6,7,11,26,27,29,41,57,65,75‐77)
▪ Benign, HPV‐induced focal hyperplasia of stratified squamous epithelium

▪ Contagious – transmitted by direct contact

▪ Soft, painless, usually pedunculated, exophytic lesions w/ numerous fingerlike projections (similar to squamous papilloma)
‐ How to tell the difference? Under microscope

Answer 600

A

Condyloma Acuminatum
(Venereal Wart)
HPV 6,11 – can be
cancerous
Genital warts
“short, blunt, clusters”

Characteristic clustering of multiple lesions

Answer 601

A

(Multifocal) Epithelial
Hyperplasia/Heck’s
Disease

HPV 13,32
“Flat‐top papules”

Answer 602

A

(Multifocal) Epithelial
Hyperplasia/Heck’s
Disease

HPV 13,32
“Flat‐top papules”

Answer 603

A

HPV Types 6, 11 – condyloma can turn cancerous
▪ Virually induced proliferation of stratified squamous epithelium – usually genital or anal mucosa
▪ Contagious – transmitted by direct contact
▪ Incubation period: 1‐3mo
▪ Considered sexually transmitted disease (if corroborated by history)

▪ Characteristic clustering of multiple lesions

Answer 604

A

Oral Florid Papillomatosis

Very characteristic appearance

diffused, in multiple locations
papillary

“Multifocal, papillary lesions”

-if we biopsied these or had these removed for aesthetic regions, we’d
see that the epithelium have become white, long, taller, and bumpy

Answer 605

A

-Since this is a sexually transmitted disease, we need to suspect sexcual child abuse and investigate further!

Answer 606

A

HPV is thought to cause 70% of
oropharyngeal cancers in the US

That’s why we want to know if high risk
HPV– better prognosis

Answer 607

A

▪ Pathologists order it
▪ Only do testing if pathologist sees cancer
No HPV testing on low‐risk HPV lesions (warts)
▪ No medical indication for low‐risk HPV testing b/c
‐ infection NOT associated w/ disease progression
‐ no treatment or therapy change indicated when low‐risk HPV is ID’ed
▪ HPV testing using p16 surrogate on oropharyngeal squamous cell carcinoma (SCC)

Answer 608

A

‐ Usually appear exophytic and papillary
‐ Excision is warranted
‐ Consider possible recurrence

Answer 609

A

▪ Poxvirus

▪ Florid cases seen in immunocompromised persons
▪ Children, young adults

Treatment

‐ Kids can have 6‐9mo and will go away

Answer 610

A

Oral Molluscum
Contagiosum

multiple pink, dome‐shaped, smooth‐surfaced or umbilicated (like belly‐button) papules ‐ with caseous plug

Answer 611

A

‐ Use high power evacuation to prevent transmission
‐ Treatment = controversial
‐ Excision/ablation vs Topical vs Intralesional therapy (or combo)

‐ Consider higher rate of recurrence

Answer 612

A

Measles

*Characterized by Koplik’s spots

salts/grains

Answer 613

A

Excision/Ablation

▪ Scalpel
▪ Carbon dioxide laser – be cautious, don’t know what is burned away
▪ Electrosurgery

Answer 614

A

Hand, foot, and mouth disease

caused by

Coxsackie
Virus

affect children

contagious

The condition is spread by direct contact with saliva or mucus.

Answer 615

A

Herpangina

casued by

Coxsackie
Virus

red macules and vesciles on the soft palate

a sudden viral illness in children.

It causes small blisterlike bumps or sores (ulcers) in the mouth

Answer 616

A

Acute lymphonodular pharyngitis

Caused by

Coxsackie
Virus

Affects children

Nodules on the soft palate.

-distinctive, raised, micronodular lesions occur primarily in the pharynx and related structures and regressed without ulceration.

Answer 617

A

▪ Podophyllin resin
▪ Imiquimod (extra‐oral use only)
▪ Cidofovir
▪ Interferon

Answer 618

A

Rubella

caused by

Family: Togavirus; Genus: Rubivirus

Forchheimer sign (left)
Palatal petechiae (right)

(German Measles)

Answer 619

A

▪ Topical cytotoxic agent which arrests mitosis
▪ Genital warts and other papillomas
▪ Not FDA approved for oral warts
▪ Serious adverse reaction if absorbed systemically
▪ Pregnancy category X

Answer 620

A

▪ Induces cytokines + chemokines w/ resutlant anti‐virl (HPV) effects

Not FDA approved for oral warts

Answer 621

A

Newest is Gardsail 9

against many types

for both men and women

▪ 2 doses recommended for boys/girls age 11‐12 and 6mo later
▪ Recommended for everyone <26yo (MAX)
▪ NOT recommended for 26+yo unless risk for new infections (less benefit since most already exposed)
▪ Virus like particles (VLP) of L1 capsid protein present in vaccine
Results of Vaccination ▪ Drops in infections w/ HPV types that cause most HPV cancers + genital warts in
teen girls, young adult women
▪ Among vaccinated women – cervical precancers dropped by 40%

Answer 622

A

▪ Paramyxovirus
▪ Spread through respiratory droplets

▪ Symptoms: runny nose, red/watery eyes, cough, fever, rash, desquamation of skin

▪ *Characterized by Koplik’s spots
‐ Pathognomonic for measles
‐ Discrete, bluish white punctate mucosal
macules
‐ Surrounded by rim of erythema
‐ Represent foci of epithelial necrosis
‐ Often precedes skin manifestations

▪ Most common location for Koplok’s spots:
Buccal mucosa
‐ Lesions may resemble “grains of salt sprinkled
on erythematous background”

Answer 623

A

-Herpangina‐soft palate, red macules ► fragile vesicles (back of throat)
‐ Hand, foot, and mouth disease – oral lesions more in anterior regions (aphthous‐like), hand/foot (vesicles)
‐ Acute lymphonodular pharyngitis – nodules on the soft palate

▪ Usually seen in children

▪ Self‐limiting

Answer 624

A

▪ Family: Togavirus; Genus: Rubivirus

▪ Respiratory droplets

lymphadenopathy
▪ Rash – maculopapular w/ desquamation

*▪ Forchheimer sign**
*▪ Palatal petechiae**

▪ Congenital rubella syndrome – pandemics in past

▪ Vaccine: MMR – so we barely see this anymore

▪ Diagnosis: by serology

Answer 625

A

Candida Species

● Over 200 species exist

● At least 15 distinct Candida species cause human disease

Answer 626

A

Candida albicans

Answer 627

A

SPORES‐ when they are in this form, they do NOT invade
HYPHAE‐ when they begin their invasion

Answer 628

A

● Superficial and localized‐more common (mild disease)

‐ Intertrigo §Paronychia/Onychomycosis
‐ “Diaper Rash”
‐ Vulvovaginitis
‐ Esophageal Candidiasis §Oral Candidiasis (Candidosis)

● Invasive, disseminated and deep infection‐rare (moderate‐severe)

‐ Affects blood (candidemia‐hospitalized), heart, brain, eyes, bones)

Answer 629

A

Onychomycosis

a type of candidiasis

Answer 630

A

Oral candidiasis

a type of candidiasis

Answer 631

A

Esophageal Candidiasis

a type of candidiasis

Answer 632

A

Vulvovaginitis

a type of candidiasis

Answer 633

A

“Diaper Rash”

a type of candidiasis

Answer 634

A

Intertrigo

a type of candidiasis

Answer 635

A

PSEUDOMEMBRANOUS CANDIDIASIS

UNCONTROLLED
DIABETIC

When you wipe away these plaques, you might
see some Erythematous areas that causes
some of the symptoms that the patient feels

-This is MILD DISEASE

Answer 636

A

*Pseudomembranous Candidiasis‐**
Uncontrolled HIV*

● This can be mistaken with materia alba (this is just food)
‐ Should ask patient if they just ate

● This is MODERATE DISEASE

Answer 637

A

Pseudomembranous Candidiasis

Topical
Corticosteroid Use

Can be brought about from steroid use (steroid inhaler example)
‐ If you don’t rinse your mouth after using steroids, this can happen
■ A proliferation of hyphae

Answer 638

A

PSEUDOMEMBRANOUS CANDIDIASIS

Severe dry mouth

This is severe disease

we would want to use systemic treatments/
intervention

Answer 639

A

Angular Cheilitis

● Erythema, fissuring and scaling at angles of mouth
and commissures of mouth
● Loss of vertical dimension
● Pooling of saliva
● May be mixed bacterial/fungal infection
● Differential diagnosis can be Vit B Deficiency

a subtype of Erythematous
Candidiasis

Answer 640

A

Denture Stomatitis

● Chronic atrophic candidiasis
● Erythema in denture bearing areas of maxilla
● Petechiae may be noted
● Usually, asymptomatic
● Consider denture care/fit/allergy/inadequate curing of acrylic

● This can occur if the patient NEVER takes off their denture

● Inflammatory papillary hyperplasia is associated with condition

● Treatment‐Nystatin applied to intaglio surface of denture and wear denture and patient to remove denture at night

a subtype of Erythematous
Candidiasis

Answer 641

A

Median Rhomboid Glossitis

a subtype of Erythematous
Candidiasis

● “Central Papillary Atrophy”
● Well‐demarcated erythematous zone
● Loss of papillae on midline posterior dorsal tongue
● Usually, asymptomatic
● “Kissing” palatal lesion
‐ Because the tongue and the palate are in contact
with each other
● Can have a diamond shape

Answer 642

A

ATROPHIC CANDIDIASIS

● Erythematous on any mucosal
surface
● “Bald Tongue”
● Typically, painful
● (Chronic multifocal, looks
familiar)

a subtype of Erythematous
Candidiasis

Answer 643

A

C. albicans

Candidal sepsis means that you have the fungal moving around in your body
Life‐threatening event in individual with severely deficient cell
mediated immunity
Most commonly involves urinary tract infection (women/men 4:1)
Very rare

Answer 644

A

HYPERPLASTIC CANDIDIASIS

Answer 645

A

● “Thrush”
● KEY FEATURE: Wipeable white plaques that resemble curdled milk
● Underlying mucosa is erythematous
● Asymptomatic usually
● Mild symptoms: burning, dysgeusia
● Seen in patients with: HIV, broad‐spectrum antibiotics, leukemia,
infants

Answer 646

A

Chronic
Mucocutaneous
Candidiasis

Severe infection of mucosal surfaces, nails, and skin

Answer 647

A

Mucocutaneous
Candidiasis

APECED

Autoimmune
Polyendocrinopathy
Candidiasis
Ectodermal
Dystrophy
Syndrome

Biopsy of the tonuge revealed SCC

Answer 648

A

Oral fluconazole, 100–200mg daily for 7–14 days

● For fluconazole‐refractory disease:
‐ Itraconazole suspension 200 mg once daily OR posaconazole
suspension 400 mg twice daily for 3 days then 400 mg once daily,
for up to 28 days, are recommended

Alternatives for fluconazole‐refractory disease include:
‐ Voriconazole, 200 mg twice daily, OR AmB deoxycholate oral
suspension, 100 mg/mL 4 times daily(strong recommendation;
moderate‐quality evidence).

‐ Intravenous echinocandin (caspofungin: 70‐mg loading dose, then 50 mg daily; micafungin: 100 mg daily; or anidulafungin: 200‐mg loading dose, then 100 mg daily) (weak recommendation;
moderate‐quality evidence). §

Intravenous Amphotericin B deoxycholate, 0.3 mg/kg daily, are
other alternatives for refractory disease (weak recommendation;
moderate‐quality evidence).

Answer 649

A

Clotrimazole troches, 10 mg 5 times daily

or

miconazole mucoadhesive buccal 50 mg tablet applied to the mucosal surface over the canine fossa once daily for 7–14 days
Alternatives for mild disease include nystatin suspension (100 000 u/mL) 4–6 mL swished for >1min then swallow 4 times daily.

Answer 650

A

● Bleach‐1 part bleach to 10 parts water (not for dentures with metallic
clasps)
● Polident (NYU Carries Polident)
● Microwave? ( could be risky, careful not to ruin the denture)

CLEANSERS FOR REMOVABLE PROSTHESIS- you have to use this everynight to avoid denture stomoatits

NYU Carries Polident

Formulation: sodium bicarbonate, citric acid, potassium
monopersulfate, sodium carbonate, sodium carbonate peroxide,
TAED, sodium benzoate, PEG‐180, sodium lauryl sulfate, VP/VA
copolymer, flavor, cellulose gum, FD&C blue 2, blue 1 lake, yellow 5, yellow 5

Answer 651

A

● Clinical Findings:

Red macules or patches
Can be due to multiple things

● Subtypes:

‐ Atrophic Candidiasis (acute‐feels like mouth has been scalded)
‐ Median Rhomboid Glossitis (asymptomatic)
‐ Denture Stomatitis (asymptomatic)
■ HAS THE SHAPE OF THE DENTURE
‐ Chronic multifocal (asymptomatic)
■ THIS HAS BEEN THERE FOR A LONG TIME

Answer 652

A

● Histopathology (H&E and special stain‐GMS)
● Culture
● Serology

as for histology

● Epithelioid macrophages containing histoplasma capsulatum (white arrows)
● Lymphocytes
● Plasma cells

Answer 653

A

Histoplasmosis

● This can be squamous cell carcinoma, shanker, ulcers
‐ Differentials for non healing ulcerations on the lateral tongue
● The white area is called the pseudomembrane

Answer 654

A

● Eastern half of US which extends farther north

● Seen in the wild

Answer 655

A

‐ A: autoimmune
‐ PE: polyendocrinopathy
‐ C: candidiasis
‐ E: ectodermal
‐ D: dystrophy

Chronic Mucocutaneous Candidiasis is also genetic

associted with AIRE gene

Answer 656

A

Blastomycosis

Answer 657

A

● Increased risk of squamous cell carcinoma

Answer 658

A

● Clinical signs
● Therapeutic diagnosis
● Cytologic smear: scrape cells and look at them under the microscope
and stained with PAS stain
● Periodic Acid Schiff Stain (PAS stain)
● KOH float §Biopsy (esp. hyperplastic candidiasis)
● Culture

Answer 659

A

● Polyene‐Nystatin, Amphotericin B (not absorbed; used for deep fungal infections)
● Imidazole‐Clotrimazole, Ketoconazole (GI absorption)
● Triazole‐Fluconazole, Itraconazole, Posaconazole, Echinocandins

Answer 660

A

this is when you keep the fungal infection under control for a
long time

Usually unnecessary in immunocompetent patients
● For patients who have recurrent infections:

‐ For HIV‐infected patients, antiretroviral therapy is strongly
recommended to reduce the incidence of recurrent infections
(strong recommendation; high‐quality evidence).

‐ Fluconazole, 100 mg 3 times weekly, is recommended (strong
recommendation; high‐quality evidence).

● Clotrimazole 10mg troches 1 week out of every month? (no evidence

Answer 661

A

YOU APPLY THE MEDICATION TO THE INTAGLIO PORTION

antifungal medication

(1) Topical Antifungal Agents
‐ Rx. Clotrimazole cream 1% vs OR
‐ Rx. Nystatin‐Triamcinolone Acetonide ointment or cream (why?
To keep the inflammation down)
■ Disp: 15g tube
■ Label: apply to angles of mouth after meals and before
bedtime
(2) Denture adjustment, reline, remake

YOU APPLY THE MEDICATION TO THE INTAGLIO PORTION

Answer 662

A

Histoplasmosis

Answer 663

A

● Histoplasma capsulatum

● Dimorphic (yeast at body temperature and mold in soil)

Answer 664

A

● Endemic in fertile river valleys
‐ Seen in people who spend a lot of time outside; near Ohio and Mississippi rivers

● Bird and bat excrement
● Airborne spores enter lungs through inhalation
● Macrophage ingests fungusàT‐lymphocyte immunity
● Antibodies develop several weeks later
● Macrophages may confine fungus (express disease later)

Answer 665

A

● Acute‐Supportive (analgesics and antipyretics)

● Chronic‐IV lipid preparation of amphotericin B or itraconazole

● Disseminated‐Lipid preparation of amphotericin B (2 weeks or more) followed by daily itraconazole for 6‐18 months

Answer 666

A

● Uncommon fungal infection

● Blastomyces dermatitidis

● Dimorphic

Answer 667

A

● Acute‐ Resembles pneumonia

Answer 668

A

Chronic Resembles tuberculosis

Answer 669

A

● Most cases asymptomatic

● Itraconazole (mild to moderate disease)

● Systemic amphotericin B (severe cases)

● There is a connection with people taking TNF‐alpha inhibitors

Answer 670

A

A deep fungal infecion

causes by:

Paracoccidioidomycosis brasiliensis

Answer 671

A

● Brazil (South America)

● So another name for it is: South American blastomycosis

Answer 672

A

nine‐ringed armadillos

Answer 673

A

Pulmonary infection

Answer 674

A

Paracoccidio Mycosis

looks like the three tail in Naruto lol

Answer 675

A

Paracoccidioidomycosis

looks like strawberry gingiva but it is not

Answer 676

A

●affects the Alveolar mucosa, gingiva and palate lesions with “Mulberry‐like” ulceration (little bumps around it)

● Looks like strawberry gingivitis (differential diagnosis)

Answer 677

A

● Trimethoprim/ sulfamethoxazole (mild‐moderate)

● IV Amphotericin B (severe disease)

Answer 678

A

deep fungal infection that present as Pulmonary infection

Answer 679

A

Valley Fever

Answer 680

A

Coccidioides immitis
Coccidioides posadasii

Answer 681

A

Coccidioidomycosis

Answer 682

A

Dimorphic organism (spores and hyphae)

Answer 683

A

● Mild symptoms‐ no treatment usually

● Amphotericin B (‐ Immunosuppressed ‐ Severe pulmonary infection ‐ Disseminated disease ‐ Pregnant patients ‐ Life‐threatening situation )

● Itraconazole or fluconazole (fewer side effects and complications)

Answer 684

A

●Uncommon

● Cryptococcus neoformans

● Incidence increased due to AIDS epidemic in 1990s

● Pulmonary infection

● Meningitis

Answer 685

A

pigeon excrement (poo)

Answer 686

A

● Pulmonary infection

● Meningitis ( after it spreads from the lungs to the brain. )

Answer 687

A

Mucormycosis‐

arrow refers to ESCHAR‐ always look for this and extreme-Black and necrotic ulcer (

we can see massive tissues destruction

Answer 688

A

Periapical Cysts

Answer 689

A

Mucormycosis‐ CT

Sinus opacificatio

● First thing to do is to find out more about this lesion, how did this patient get this lesion?

Answer 690

A

● Non‐septate hyphae with 90degrees branching

● You see necrosis of tissue in the area because this attacks the blood vessels

Answer 691

A

● Mild case: Fluconazole or Itraconazole

● Cryptococcal meningitis: amphotericin B + other antifungals

Answer 692

A

Infections caused by molds belonging to the order Mucorales
Grow in natural state on decaying organic materials (saprobic‐ recycling)
Spores may be liberated into air and inhaled by humans

Answer 693

A

Aspergillosis

Histopathology includes:

●Branching septate hyphae

● Acute angle branching

● “Fruiting body

Answer 694

A

Aspergillosis

arrow points toward a violaceous‐ purple colour

Answer 695

A

● Surgical debridement (massive tissue destruction)

● High doses of lipid formation of amphotericin B

● Control underlying disease (main one)

● Prosthetic obturation of palatal defects

Answer 696

A

Saprobic (in an environment rich of oxygen)
it caused by Aspergillus flavus and Aspergillus fumigatus

Answer 697

A

Necrotizing Gingivitis (NG)

o No periodontitis features

o SIMILAR APPEARANCE to gonorrhea

▪ Distinguishing characteristic of NG – Fetid Odor

Answer 698

A

Necrotizing Periodontitis (NP)

o Bone loss of the periodontium seen

Answer 699

A

● Aspergilloma‐debridement

● Allergic fungal sinusitis‐debridement and corticosteroid drugs

● Localized invasive‐debridement & voriconazole and amphotericin B

● Disseminated invasive‐consider poor prognosis even with treatment

Answer 700

A

Bacterial infection which presents with a spectrum of lesions

‐ Vary depending upon the localization of lesion and predisposing factors

Answer 701

A

‐ Includes:

o Necrotizing gingivitis (NG):rapidly destructive, non-communicable microbial disease of the gingiva

o Necrotizing periodontitis (NP):apidly progressing disease process that results in the destruction of the periodontium

o Necrotizing stomatitis (NS):When the bacterial infection extends further to OTHER parts of the mouth

o NOMA (extension to skin of face) ▪ Extreme disfigurement due to bacterial infection extending onto the skin of the face

Answer 702

A

Many related factors (Multifactorial etiology):

o Psychological stress

o Immunosuppression

o Smoking

o Local trauma

o Poor nutritional status

o Poor oral hygiene

o Inadequate sleep

Answer 703

A

Necrotizing Periodontal Diseases

o During WW1, soldiers that were fighting in the trenches were under extreme stress

o they commonly developed necrotizing periodontal diseases

Answer 704

A

o Treponema spp.

o Selenomonas spp.

o Fusobacterium spp.

o Prevotella intermedia

o *Also always present in healthy gingiva ▪ so, No, Microbiological testing is NOT used to form a diagnosis

Answer 705

A

o Removal of bacteria (scaling)

o Chlorhexidine rinse

o Antibiotics (fever or signs of systemic illness)

▪ Metronidazole ▪ Penicillin

o Oral hygiene instruction

o Supportive therapy

▪ Rest ▪ Fluids ▪ Soft nutritious diet

o Predisposing (Immunosuppressive)factors

▪ Smoking

▪ HIV?

Answer 706

A

cancrum oris

Answer 707

A

‐ Polymicrobial etiology

‐ Normal flora become pathogenic during immunocompromised states

‐ Key bacteria:

o Fusobacterium necrophorum

o Prevotella intermedium ‐ Other common bacteria:

o Actinomyces pyogenes

o Bacillus cereus

o Bacteroides fragilis

o Fusobacterium nucleatum

o Prevotella melaninogenica

Answer 708

A

‐ Previous necrotizing periodontal disease Poverty

‐ Malnutrition or dehydration

‐ Poor oral hygiene

‐ Poor sanitation

‐ Unsafe drinking water

‐ Proximity to unkempt livestock

‐ Recent illness Malignancy

‐ Immunodeficiency disorder, including AIDS

Answer 709

A

NOMA

This is an aid patient

Figure 2: Extension of infection onto the face

‐ Figure 3: Lost bone and gingiva

‐ Figure 4 & 5 Bone destruction

Answer 710

A

NOMA

Development of NOMA from day 1 to day 15

Answer 711

A

Children

Adults with debilitating disease

Answer 712

A

Impetigo

‐ “Cornflakes glued to Surface” Appearance

o Little papules that can form little vesicles around the mouth

o Vesicles burst open and dry up around the skin of the mouth

‐ Bilateral

Answer 713

A

NOMA

Development of NOMA from day 1 to day 15

Answer 714

A

Erysipelas

Superficial skin infection in immunosuppressed adults

‐ Group A beta‐hemolytic streptococci

‐ Painful ‐ Bright‐red, well‐circumscribed, swollen, indurated (firm) ‐ Warm to touch

‐ Systemic manifestations: o High fever o Swollen lymph nodes

Diagnosis:

Cultures not useful ‐

Treatment: o Penicillin ‐ Complications without treatment

Answer 715

A

o Antibiotics

▪ Penicillin ▪ Metronidazole

o Local wound care

▪ Conservative debridement to avoid iatrogenic tissue damage

o Consider nutrition, hydration and electrolyte imbalances

o May cause significant morbidity

Answer 716

A

Erysipelas

Superficial skin infection in immunosuppressed adults

‐ Group A beta‐hemolytic streptococci

‐ Painful ‐ Bright‐red, well‐circumscribed, swollen, indurated (firm) ‐ Warm to touch

‐ Systemic manifestations: o High fever o Swollen lymph nodes

Diagnosis:

Cultures not useful ‐

Treatment: o Penicillin ‐ Complications without treatment

Answer 717

A

Primary Syphilis

Chancre

at site of inoculation (3 – 90 days later)

‐ Papule ► Ulceration

‐ Most chancres occur in genital area (4% oral

Answer 718

A

Primary Syphilis

Chancre

at site of inoculation (3 – 90 days later)

‐ Papule ► Ulceration

‐ Most chancres occur in genital area (4% oral

Answer 719

A

Secondary Syphilis

‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection

‐ Resolve in 3‐12 weeks

‐ Diffuse maculopapular (flat, raised) rash

o May involve oral cavity ‐ Mucous patches

o Most common on tongue and lip

‐ Condylomata lata

o Resembles viral papillomas

‐ Systemic symptoms

Answer 720

A

Secondary Syphilis ( Rash)

here we see muscus patches (right) and Condylomata lata (left)

‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection

‐ Resolve in 3‐12 weeks

‐ Diffuse maculopapular (flat, raised) rash

o May involve oral cavity ‐ Mucous patches

o Most common on tongue and lip

‐ Condylomata lata

o Resembles viral papillomas

‐ Systemic symptoms

Answer 721

A

Tertiary Syphilis

Gumma

‐ Latent period for 1 ‐ 30 years

‐ 30% of patients develop tertiary syphilis

‐ Serious complications develop:

Vascular system
Central nervous system
Ocular lesions

What is “Gumma”?

o Granulomatous inflammation with tissue destruction
o Common on palate and tongue
o Causes a hole in the palate

Answer 722

A

‐ Caused by:

o Staphylococcus aureus

o Streptococcal pyogenes

Damaged skin allows infection to enter

Usually affects kids

Answer 723

A

Primary Syphilis

Chancre

at site of inoculation (3 – 90 days later)

‐ Papule ► Ulceration

‐ Most chancres occur in genital area (4% oral

Answer 724

A

Congenital Syphilis

‐ Hutchinson Incisors (left image)

‐ Mulberry molars (right image) - not part of the triad

Answer 725

A

Tertiary Syphilis

Gumma

‐ Latent period for 1 ‐ 30 years

‐ 30% of patients develop tertiary syphilis

‐ Serious complications develop:

Vascular system
Central nervous system
Ocular lesions

What is “Gumma”?

o Granulomatous inflammation with tissue destruction
o Common on palate and tongue
o Causes a hole in the palate

Answer 726

A

Secondary Syphilis

Mucous Patch

Answer 727

A

Secondary Syphilis ( Rash)

here we see muscus patches (right) and Condylomata lata (left)

‐ Disseminated lesions are discovered 4 ‐ 10 weeks after initial infection

‐ Resolve in 3‐12 weeks

‐ Diffuse maculopapular (flat, raised) rash

o May involve oral cavity ‐ Mucous patches

o Most common on tongue and lip

‐ Condylomata lata

o Resembles viral papillomas

‐ Systemic symptoms

Answer 728

A

Stage 3 o Granulomatous inflammation o Ulceration may be present ‐ Special stain “Warthin Starry”, highlights corkscrew spirochetes ‐ Immunohistochemical stain

Answer 729

A

Gonorrhea

looks like necrotizing gingivitis (NG) but fetor oris not present

Answer 730

A

Not specific ‐ Stage 1 and 2 similar

o Ulceration

o Hyperplasia (Stage 2)

o Exocytosis of neutrophils into epithelium

Intense Iymphoplasmacytic inflammatory infiltrate in superficial stroma and around deeper vascular channels (blood vessels)

Answer 731

A

Secondary Syphilis

Mucous Patch

Answer 732

A

o Recurrent Herpes Labialis

▪ Resemblance to initial impetigo stages when still unilateral

o Perioral Dermatitis

▪ Triggered by cosmetics and other substances on the skin

o Exfoliative Cheilitis (chapped lips)

Answer 733

A

Diagnosis:

o Presumptive from clinical features

‐ Treatment:

o Topical mupirocin

o Systemic antibiotics

Answer 734

A

‐ Tuberculosis

Answer 735

A

‐ Tuberculosis

Answer 736

A

o Antibiotics

▪ Penicillin ▪ Metronidazole

o Local wound care

▪ Conservative debridement to avoid iatrogenic tissue damage

o Consider nutrition, hydration and electrolyte imbalances

o May cause significant morbidity

Answer 737

A

o Systemic Lupus Erythematosus (SLE)

▪ Due to sparing of nasolabial folds

▪ Butterfly rash in SLE resembles erysipelas

o Cellulitis (dental infection induced):

▪ Tooth infection burrowing through the tissues rather than forming an abscess

o Actinomycosis

Answer 738

A

Chronic infection
caused by spirochete Treponema pallidum

Answer 739

A

Three stages

o Primary (chancre)
o Secondary (rash)
o Tertiary (gumma)

Answer 740

A

TB

Ulceration (tongue ulceration most common)

Answer 741

A

Miliary TB

compared to miliary seeds

Answer 742

A

SCC
Fungal Ulcer
Trumatic Ulcer

Answer 743

A

Differential Diagnosis:

▪ T‐cell Lymphoma
▪ Cocaine abuse
▪ Granulomatosis
▪ Polyangiitis
▪ Mucor

Answer 744

A

‐ Pathognomonic features in Hutchinson triad:

o 1. Hutchinson teeth

o 2. Ocular interstitial keratitis

o 3. Eighth nerve deafness

‐ Other Features:

o High arched palate

o Saddle nose

o Frontal bossing

Clinical changes secondary to fetal infection

Answer 745

A

‐ Pathognomonic features in Hutchinson triad:

o 1. Hutchinson teeth

o 2. Ocular interstitial keratitis

o 3. Eighth nerve deafness

‐ Other Features:

o High arched palate

o Saddle nose

o Frontal bossing

Clinical changes secondary to fetal infection

Answer 746

A

o Single dose of parenteral long‐ acting benzathine penicillin G (primary, secondary, early latent)

o Intramuscular penicillin weekly for three weeks (late latent and tertiary

Answer 747

A

‐ a Sexually transmitted (F>M)

caused by

‐ Neisseria gonorrhoeae

Answer 748

A

‐ Genital area usually‐purulent discharge

‐ Systemic bacteremia (myalgia, arthralgia, polyarthritis, dermatitis)
‐ Pelvic inflammatory disease in women (affects pregnancies)
‐ Gonococcal ophthalmia neonatorum (infection of infant’s eyes)

Answer 749

A

Many cases of resistance with antibiotics
§Cephalosporins

Adults with gonorrhea are treated with antibiotics. Due to emerging strains of drug-resistant Neisseria gonorrhoeae, the Centers for Disease Control and Prevention recommends that uncomplicated gonorrhea be treated with the antibiotic ceftriaxone — given as an injection — with oral azithromycin (Zithromax)

Answer 750

A

Chlamydia trachomatis

Answer 751

A

Reactive arthritis (reiter)
o Can’t see, Can’t Pee, Can’t Climb a Tree

▪ Causes:
● Conjunctivitis
● Urethritis
● Arthritis

Remember: Chlamydia trachomatis coininfect with Neisseria gonorrhoeae

Answer 752

A

Chronic granulomatous infectious disease
Caused by Mycobacterium tuberculosis

§Direct person-to-person spread through airborne droplets

Answer 753

A

Only 5%-10% infections lead to active disease i

Answer 754

A

Leads to disseminated TB (miliary TB)
True, active TB

Answer 755

A

o Single dose of parenteral long‐ acting benzathine penicillin G (primary, secondary, early latent)

o Intramuscular penicillin weekly for three weeks (late latent and tertiary

Answer 756

A

Immunosuppressive medications
Diabetes
Old age
Crowded living conditions
AIDS

Answer 757

A

Only 5%-10% infections lead to active disease i

Answer 758

A

Granulomas

o Epithelioid histiocytes
o Multinucleated giant cells
- ▪ * Langhans giant cells
  - ● Nuclei along the periphery
o Central caseous necrosis

Answer 759

A

Primary Oral TB

Oral Primary TB clinical manifestation is very rare

TB is directly in the epithelial cells.

Person coughs ⇒ organism enters broken skin somewhere in the
oral mucosa ⇒directly causing TB in the mouth
-this person would NOT have any issues in their lungs
-primary TB = infection went directly into their mucosa from another person

Answer 760

A

Primary Oral TB

tongue ulceration

Answer 761

A

o TB
o Deep fungal infections
o Traumatic ulcer
o SCC
o Major Aphthous ulcer

Answer 762

A

o TB‐Test

§Delayed type hypersensitivity (Type 4)
§Checks if developed an immune response to TB
§PPD (purified protein derivative) (what they inject under the skin)
§T cells are attracted by immune system to the skin site
§Lymphokines induce hard raised area with clear margins
§Need to check 48-72 hours later (measure area)

Answer 763

A

Scrofula

Answer 764

A

§Multiagent therapy for active infection to prevent mutation and resistance
§8 week course
§Pyrazinamide
§Isoniazid
§Rifampin
§Ethambutol
§Followed by 16 week course
§Isoniazid
§Rifampin

‐ Chemoprophylaxis
‐ For positive PPD but no active infection

‐ BCG vaccine
o Not used in US due to controversy regarding effectiveness

Answer 765

A

Mycobacterium bovis

Infected milk leads to scrofula

RARE today as milk is pasteurized

Answer 766

A

LEPROSY

Clinical features

*§Bone destruction** ( hole in the palate)
*§Nodular** will become nectortic and then destruction will follow

Answer 767

A

Hansen disease

Answer 768

A

Mycobacterium leprae

Answer 769

A

Actinomycoses

it’s an external Sinus

Answer 770

A

‐ Associated Bacteria:

o Actinomyces israelii
o Actinomyces viscosus

‐ Normal component of oral flora -gram positive anaerobic
bacteria

Answer 771

A

colonies of bacteria (o Actinomyces israelii
o Actinomyces viscosus)

found in suppuration (pus) which means Suppuration (pus) is dead tissue, bacteria, dead white blood cells, and other products of tissue breakdown..

Sulfur granules found in Actinomycoses

yellow in color

Answer 772

A

Cat‐Scratch
Disease

Answer 773

A

o Erysipelas

Answer 774

A

‐ Infectious disease which is seen in lymph nodes

Answer 775

A

‐ Causative organism:
o Bartonella henselae
‐ Previous contact with a cat (scratch or saliva)

Answer 776

A

Cat Scratch Disease

Answer 777

A

‐
o Swellings in the lymph node

o Unilateral swellings of the neck

Answer 778

A

o Self‐limiting (resolves within 4 months)
o Local heat
o Analgesics
o Mechanical removal of suppuration (aspiration)
o May use antibiotics for severe cases
▪ Azithromycin

Answer 779

A

Benign neoplasm

Answer 780

A

a Fibrous dysplasia involving one bone

o Ex: when only the mandible involved or only the maxillae

(Most common type (70%)

Answer 781

A

a Fibrous dysplasia involving more than one bone

Answer 782

A

Polystotic Fibrous dysplasia

Answer 783

A

-a Fibrous dysplasia limited to Skull and Facial Bones...

Answer 784

A

-Fibrous dysplasia with intramuscular myxomas

Answer 785

A

GNAS1 gene mutation in fibrous dysplasia is a potential diagnostic adjuvant, as it is not
found in normal bone tissue (etiolog

Answer 786

A

FD

Radiographically: you have altered trabecular pattern
Clinically: Painless mass slowly growing over time

is is typical
presntation of Fibrous Dysplasia

Answer 787

A

Fibrous Dysplasia

ill‐defined radiolucent/radiopaque/mixed radiolucent‐radiopaque entities that blend with normal bone.
The left side is affected. Left body of the mandible and the ramus.
The cortical outlines have been expanded near the inferior border of the mandible.

Answer 788

A

• Maxillae affected more than mandible
• Ill‐defined borders, blends in with the surrounding bone (not necessary to be corticated)
• Variable density and orientation of the trabecular pattern (radiolucent, radiopaque or a combination)

*• Ground‐glass appearance** (common)
*• Peau d’orange (surface of an orange)** (common)
*• Cotton wool appearance** (common)
*• Fingerprint pattern** ( uncommon pattern)

• Typically the lesionss in the maxillae are more homogenous and radiopaque, whereas they may appear more heterogenous and mixed in the mandible.

*typically you’ll see the ground glass appearnce and Peau d’orange on the maxilla as they are homogenous the cotton wool appearance more commonly found in the mandible since it is heterogenous.

Answer 789

A

Fingerprint pattern

The arrow indicating the inter‐radicular area of this molar. You can see the trabecular
bone has been altered into a fingerprint pattern.
This is a case of localized fibrous dysplasia.

Very uncommon.

Answer 790

A

Cotton wool
appearance

Irregullary shaped and outlined radiopacities blending in with adjacent bone

Answer 791

A

Peau d’orange

surface of an orange – the bone shows a “pitting” appearance.

Answer 792

A

Ground Glass Pattern

it appears granular in nature. (Grainy)

Answer 793

A

Fibrous dysplasia on
the right mandible.

Note the superior displacement of the IAN Canal
This is not odontogenic ( as they are usually above the canal)
Anything below the canal ►think of it as originiating from the bone itself

Answer 794

A

Fibrous Dysplasia in
the left of the
maxillae.

Always compare both side left and right

We see granular/glass appearance of the bone ( blue arrow) and compare it to the contralateral maxillae. The trabucular pattern has changed signficantly.
Also compare the maxillary sinus space. The left maxillary sinus appears radiopaque.
That is because the maxillae has been enlarged to the point where it is pushing the floor of the maxillary sinus superiorly and reducing the total volume of the sinus.
The purple arrows indcate the displaced floor of the maxillary sinus.

Answer 795

A

FD

Note the normal left maxillary sinus and the obliterated space of the right maxillary sinus ( blue arrows).
A ground glass appearing entity (humogenous radiopaque lesion) has obliterated the space secondary to expansion of the right maxilla.
These findings are consistent and quiet common in advanced cases Firbous dysplasia

Answer 796

A

Periapical COD

Green arrow

Simple bone cysts may develop in regions of COD ( periapical or florid type)
So look for areas void of trabucular bone and has scalopping of the lesion.

Red arrow

Answer 797

A

mature Periapical COD

Coronal cross section of the posterior mandible in the region of the premolar

~ mixed radiolucent/radiopaque entity, the center is radiopaque and the periphery is
radiolucent.

Answer 798

A

mature Periapical COD

You can have these lesions in endentulous areas as well.

So this is is an endeulous area, but if there was a tooth here, this would be in the
periapicel region or near it with mixed radiolucent/radiopaque entity  the differential
diagonsis of this area could include Periapical COD.

Answer 799

A

mature Periapical COD

You see a nice radiolucent rim and radiopaque center

 so mixed radiolucent/radiopaque
entity in the periapical region of tooth #31

 most likely diagonsis would be Periapical
COD.

Answer 800

A

A very mature Periapical COD

( purple arrow)
Well‐defined radiopacity in the periapical region.
Sometimes you may or may not be able to differentiate a very thin radiolucent line as in
this case.

you might include ddx of other lesions which might present with
radiopacity in the preapical region
There are certain tests you can do clinically to differentiate too.

or do clinical tests

Answer 801

A

Periapical COD

Sagital cross section of the anterior Mandible.
Mixed radiolucent/radiopaque area (green circle)

Answer 802

A

Early & mature Periapical COD

Preapical radiographs of the anterior mandible of the same patient at different times.

Note the differnece in density between the two radiolecency:
Note the internal structure of the radiopacity is quite radiolucent ( purple arrow)
The Preapical radiographs of the same region taken at a later time shows a more
radiopaque internal structure (pink arrow). This reflect the maturing of the COD lesion.
The lesion with Pink arrow can be described as well‐defined mixed
radiolucent/radiopaque entity. ( because you have radioleucent part and radipaque part)

Answer 803

A

Early Periapical COD

well defined radiolucency surrounding the apeces of these two central

When looking at such cases, it is also imporant to:
1. look at the crowns to look for carious lesions. If there is no restorations or no
evidence of caries, it is likely that these lesions are arising from the bone and not
secondary to pulpal involvement.
2. It also important to look at the PDL and Lamina dura, typically in COD lesions they
should be visisulized and intact ( but because this is a 2D image and this area may
superimpose on this region and obsecure the visulizing of the lamina dura and the
PDL)

what’s the difference between COD and Inflammatory lesion?
COD won’t have effect on the PDL space itself, because it orginates from the bone!
Vitality testing can help us differntiate between inflmmatory lesion and something that happeing inside of the bone.

Answer 804

A

Florid COD

Axial section of the mandible.

Notice mixed radiolucent/radiopaque entity on the patient right side. And on the left the area is more radiopaque centrally and has a thin radioluceny around it.
The arrows indicate well‐defined radiopacities immedietly surrounded by radiolucent rims.
Note that the radiolucent rim on the left side is thin when compared to the lesion on the right. This likely means that the lesion on the left is more mature ( more time has passed for the entity to produce more woven bone).

Answer 805

A

Florid COD

Two periapical radiographs of the left and right posterior mandible of the same patient.

 In this case, note the areas of radiolucency and radiopacity are rather ill defined but widepsread to affect most of the teeth.

Most of the teeth noted here are restored.

 So even if the radiographs suggest a cemento‐osseous process, it is important to keep an eye for these teeth in term of vitality and prevent a periapical infections which would otherwise secondarily infect the altered bone of COD.

Answer 806

A

Florid COD

Multiple regions of COD.
Notice the wide areas of scelortic/radiopaque areas on mandible and also on maxillae

Answer 807

A

Generalized FD

Metabolic bone diseases (hyperparathyroidism) (any disease that incrase trabacular bone density)
Paget’s disease

Localized FD

Osteomyelitis
Osteosarcoma

Answer 808

A

Consultation with an OMFR is advisable. Monitoring of the area is also advised.
Typically treatment is not needed unless there are clinical symptoms or patients present with cosmetic concerns if clinical symptoms are severe
Implants and surgical intervention should be avoided when possible as these areas are void of blood supply

Answer 809

A

Cemento‐ossifying
Fibroma

Note the internal granular appearance of the trabucular bone ( black arrows)
The purple arrows shows the wall of the expanded buccal/facial and lingual cortical plates caused by the neoplastic entity.
This was a confirmed cased of ossifying fibroma* mainly because of two things:
1. siginficant cortical expansion on buccal and lignual side
2. altered trabacular pattern.

ddx of fibrous dysplasia but you should look for a radiolucent rim
if you can and if not, they maybe considered under the same differential diagosnsis.
Note that may help you in differentiating :
 The maxilla is affected more in Fibrous dysplasia
 The mandible is affected more in Ossifying fibroma

Answer 810

A

Cemento‐ossifying
Fibroma

Axial section of the
mandible

The granular radiopacity immediately surrounded by a radiolucent rim ( purple arrow)
Also note the extent of the expansion of the buccal and lingual cortical plates, a feature which is common of ossifying fibroma.
This is more clear radiographically where we see a radiolucent rim surrouding a mixed radiolucent/radiopaque center and there is a siginficant expansion of the buccal and lingual plates. ► very common in ossifying fibroma

Answer 811

A

Cropped Panaromic showing

a case of

Cemento‐ossifying
Fibroma

Appreciate the radiolucent rim indicated by the black arrows.
Also note the internal structure of the trabucular bone and compare it to adjacent unaffected areas. It is more granular and radopaque compared to adjacent areas.
Another important feature to appreciate is the displacement of the anterior teeth (diverging roots)
These features are usually seen in lesions with benign neoplastic characterstics.

Answer 812

A

Well‐defined, round or oval lesion
Periphery of the lesion is corticated and may exhibit a radiolucent periphery (sometimes referred to as a soft tissue capsule)
Internally, the lesion is typically granular or radiopaque but may show variations (mixed radiolucent/radiopaque)
Strong tendency to displace teeth and cortical outlines

Answer 813

A

Cleido-Cranial
Dysplasia

Treatment: For children, facial reconstructive surgery on the bones of the face to reshape the forehead or cheekbones. Spinal fusion procedures to support the spinal column. Lower leg surgery to correct knock knees (knees that bend inward toward the center of the body)

Answer 814

A

Gardner’s Syndrome

Synonym: Familial Multiple Polyposis.

Remember this:

 GarDENse Bone Island.
 GARDEN-FOREST:
 F- Familial adenomatous polyposis.
 O- Osteomas.
 RE- Retinal epithelial hypertropy.
 ST- Supernumerary teeth.

Treatment:

Because people with Gardner’s syndrome have a higher risk of developing colon cancer, treatment is usually aimed at preventing this.

Medications such as an NSAID (sulindac) or a COX2 inhibitor (celecoxib) may be used to help limit the growth of colon polyps.

Treatment also involves close monitoring of the polyps with lower GI tract endoscopy to make sure they do not become malignant (cancerous). Once 20 or more polyps and/or multiple higher risk polyps are found, removal of the colon is recommended in order to prevent colon cancer.

If dental abnormalities are present, treatment may be recommended to correct problems.

Answer 815

A

Osteopetrosis

Osteomyelitis is a complication in patients with osteopetrosis as can be seen in pan image!

Treatment: Bone marrow transplant (to stimulate osteoclast formation).

Answer 816

A

Paget’s disease stages

Early Linear lines: The bone is being resorbed in a very distinct
pattern > linear patterns of trabeculation

Middle -MAY see the “cotton wool” appearance (but this is more
pronounced in the third stage)
-the trabecular pattern may or may not be slightly affected

Late - There is MORE bone deposition -the “cotton wool” appearance
is very very clear in this stage! Also-hypercementosis and spacing of teeth.

Answer 817

A

Paget’s Disease

Also Known As: Osteitis Deformans.

Skeletal disorder involving osteoclasts

Treatment: Osteoporosis drugs (bisphosphonates) are the most common treatment for Paget’s disease of bone

Answer 818

A

Cherubism

Treatment: Usually not needed as the cyst-like lesions fill in with granular bone during adolescence- conservative surgical procedures may follow for cosmetic reasons.

Answer 819

A

Idiopathic
Osteosclerosis

AKA: Dense Bone Island

 Not associated with any dysplastic, neoplastic, inflammatory or systemic disorder.
 Common incidental finding.
 Slow growing, typically stops growing by the time of skeletal maturity.
 Peak prevalence in the third decade of life.
 No treatment required; monitoring is suggested.

Answer 820

A

PCOD

Differentiating factor: Radiolucent zone surrounding the radiopacities of COD lesions. No such radiolucent areas for idiopathic osteosclerosis.
 Important: The root of the tooth #28 appears to be resorbed but is likely not.
Look at the root of #29. These teeth are still undergoing development in a young patient.
 Left is showing dense bone island.
 Right is showing Periapical COD- this is intermediate stage, not fully mature. You should see a radiolucent rim.
 Another more obvious radiographic feature: you see radiolucent areas surrounding in both images, the common feature is: because PCOD and dense bone island do not affect the PDL spaces – you should be able to see the PDL spaces.
 Sometimes it’s not the case. Look for the PDL, look for radiolucent area surrounding possible central radiopacity, idiopathic osteosclerosis can cause resorption; PCOD hasn’t been associated with root resorption.

Answer 821

A

Hypercementosis

 Differentiating Factor: A well-defined radiolucent border that is continuous with the PDL of the tooth, in the case of hypercementosis. This means that whatever is happening is within the confines of the tooth-bearing region. In this case, the
cementum.
 Hypercementosis- Cementum is overraeacting, so there’s enlargement of cementum.
 If cementum is larger, it should be pushing the PDL out (black arrow). So the PDL is enlarged meaning you should be able to see a radiolucent rim around the area. And the radiolucent rim should be continuous with the PDL of the
remaining root structure.

Answer 822

A

Cementoblastoma

 Differentiating Factor: A well-defined radiolucent border that is continuous with the PDL of the tooth, similarly seen in the previous case of hypercementosis.
(sometimes it is difficult to differentiate hypercementosis and cementoblastoma, in this case, the beige arrow indicates the resorbed root surface, which normally occurs in benign neoplastic cases, such as cementoblastoma.
 Cementoblastoma is more of a heterogenous radiopacity- meaning you may see
gaps, like radiolucent voids, in between the areas.
 See radiolucent rim.
 But more common feature include root resorption because it’s a neoplastic condition. It should act like a neoplasms in which it’s destroying some of the root structure.

Answer 823

A

 For condensing osteitis, look for heavily restored or carious teeth. Condensing osteitis typically surrounds the initial rarefying osteitis lesion. The teeth in these cases are non-vital as they represent a condition that is secondary to pulpal necrosis.
 Open necrosis, eventual PDL space widening and then once the infection reaches the bone, you have bone loss.
 Now you have an overreaction or inflammatory reaction surrounding the initial inflammation.

Answer 824

A

Focal Osteoporotic
Marrow Defect

A large marrow defect that may mimic a
cystic/neoplastic radiolucency in the jaw.

common incidental finding

a variation of normal anatomy within trabecular bone.

Answer 825

A

Simple Bone Cyst

Also known as

 1.) Solitary Bone Cyst.
 2.) Traumatic Bone Cyst.
 3.) Idiopathic Bone Cyst.
 4.) Hemorhhagic Bone Cyst.

Remember radiographic feature

tend to Scalop between teeth

 Treatment includes surgical curettage- spontaneous healing has been reported.

Answer 826

A

Sometimes, simple bone cysts should be differentiated from odontogenic keratocysts (OKCs)

Answer 827

A

brown tumor.

Answer 828

A

central giant cell granuloma

CGCG

Answer 829

A

Aneurysmal Bone Cyst

Answer 830

A

Florid COD

 Rarefying osteitis (radiolucent lesions) ( it would differentiate in the more early stages of the COD ( the radiolucent stage)
 Condensing osteitis (considered in the differential when the lesion is more mature and more radiopaque lesions)
 Cementoblastoma ( benign neoplasm of the cementum so we
should be able to see certain features that reflect benign neoplastic lesions )
 Dense bone islands ( a common differential when considering COD)

Answer 831

A

Paget’s disease ( t generalized areas)
Osteomyelitis ( localized area because we have mixed radioluecent/radiopaque areas)

Answer 832

A

Typically, no treatment is required unless these regions show clinical/radiographic evidence of secondary infection
- Ex if patient complain of some pain of that area –> we want to follow up that region
Surgery within the dense bone has a high risk of causing osteomyelitis
Patients should be seen regularlyfor preventive treatment
Want tooth supported rather than tissue supported RPD and CD

Answer 833

A

Surgical excision ( need to send to biopsy in order to confirm the diagosnsis of that)
Wider resection with bone maybe necessary in some larger or more clincally aggressive cases.

Answer 834

A

Leukemia

o Dilantin hyperplasia (drug induced gingival hyperplasia) –
fibrotic looking

o Has to an addition of thromocytopenia

Answer 835

A

Leukomia

o Leukemic infiltrate – have areas of erthema
o Looks like gingival hyperplasia, but in gingivail hyperplasia
you don’t have the same amount of redness. Leukemia has significant hyprotophy of gingivial papilla and areas that look like they have ptechia in them. With gingival
hyperplasia drug induced they are very fibrotic

Answer 836

A

Leukemia

▪ Oral findings include gingival hyperplasia, spontaneous bleeding of gingiva, mucosal ulcerations, candidiasis, recurrent herpetic lesions, etc.
▪ Leukemic infiltrate in soft tissues (ex. gingiva) produces a diffuse,
boggy, nontender swelling that may or may not ulcerate
o most common with myelo‐monocytic types
▪ May create a tumor‐like mass in soft tissue
o granulocytic sarcoma/chloroma (clinically looks green)
▪ mass infiltrate into soft tissue

If you see children and notice they have prominent areas
of redness or red/purple and know the child has decent
oral hygiene, leukemia should be in your differential. Need
to be aware of that cause patients need to be treated in a
fairly quick fashion.

Answer 837

A

Leukemia

Acute and chronic myelo‐monocytic leukemia are the most likely
types of leukemia to exhibit oral manifestations
o Generalized gingival hypertrophy

May create a tumor‐like mass in soft tissue
o granulocytic sarcoma/chloroma (clinically looks green)
▪ mass infiltrate into soft tissue

Answer 838

A

Agranulocytosis

Oral findings:

include multiple ragged ulcerations of the oral mucosa
can mimic recurrent aphthous (but often no erythematous halo)
Gingiva is a common site due -can resemble NUG)

Answer 839

A

Agranulocytosis

Oral findings:

include multiple ragged ulcerations of the oral mucosa
o can mimic recurrent aphthous depending on sites involved
(but often no erythematous halo) – more like neutropenic ulcer
Gingiva is a common site due to the minor trauma caused bymastication (can resemble NUG)

Answer 840

A

Cyclic Neutropenia

o Teeth floating in air

Answer 841

A

Cyclic Neutropenia
▪ Gingiva is most severely affected with periodontal bone loss and
tooth mobility

Answer 842

A

Cyclic Neutropenia

▪ Depending on surface involved, can mimic recurrent aphthous
ulcerations
o Usually do not see erythematous halo that is so typical of
aphthous

Answer 843

A

Cyclic Neutropenia

▪ Oral ulcerations on any mucosal surface exposed to minor trauma (L,T, BM and oropharynx) last 5‐7 days
▪ Depending on surface involved, can mimic recurrent aphthous
ulcerations
o Usually do not see erythematous halo that is so typical of
aphthous
▪ Gingiva is most severely affected with periodontal bone loss and tooth mobility

Answer 844

A

Cyclic Neutropenia

Oral ulcerations on any mucosal surface exposed to minor trauma & can mimic recurrent aphthous ulcerations without the
erythematous halo that is so typical of aphthous
▪ Gingiva is most severely affected with periodontal bone loss and tooth mobility

Answer 845

A

Hematoma

because of THROMBOCYTOPENIA or Trauma

Answer 846

A

Hematoma

because of THROMBOCYTOPENIA orTrauma

Answer 847

A

o hematoma

because of THROMBOCYTOPENIA orTrauma

THROMBOCYTOPENIA:▪ Markedly decreased numbers of circulating blood platelets (severe
cases < 10,000/mm³)

Etiology: Can be from:
o Decreased production (malignancy, drugs)
o Increased destruction (immunologic, drugs)
o Sequestration in the spleen (splenomegaly)

▪ Clinically see spontaneous gingival bleeding, petechiae,
ecchymosis and hematomas
o Clinically see some type of bleeding
▪ Treatment is usually platelet transfusion

Answer 848

A

o hematoma

because of THROMBOCYTOPENIA or Trauma

Answer 849

A

Aplastic Anemia

▪ Failure of the hematopoietic precursor cells to produce adequate
numbers of all types of blood components
▪ Rare, but life threatening
▪ Associated with environmental toxins (benzene), certain drugs
(antibiotic chloramphenicol), or infection with certain viruses
(non‐A, non‐B, non‐C, non‐G hepatitis)
▪ Fanconi’s anemia and dyskeratosis congenita patients have an
increased risk of developing this

Oral signs: are associated with the thrombocytopenia and include
spontaneous gingival hemorrhage, mucosal petechiae, purpura,
and ecchymoses
▪ Nonspecific oral ulcerations (neutropenic ulceration) may also be seen on any mucosal surface, but especially in areas of trauma
(even minor trauma, ex. gingiva)
o Neutropenic = low neutrophils

Answer 850

A

Sickle Cell Anemia

Can see prominent trabeculae left, looks like steps on a ladder

Answer 851

A

Sickle Cell Anemia

Radiographic findings include:

o decreased trabecular pattern in the mandible (due to
increased extramedullary hematopoiesis)

o laddering of inter‐radicular trabeculae
o “hair‐on‐end” appearance of skull films (less prominent
than with thalassemia)

Can see spontaneous pulpal necrosis in the absence of trauma or
caries

Answer 852

A

Beta‐thalassemia

▪ Two defective genes – thalassemia major (Cooley’s anemia,
Mediterranean fever)
o Disease detected when fetal hemoglobin ceases to be
made (~3‐4 months old)
o Extramedullary hematopoiesis cause hepatosplenomegaly,
bone marrow hyperplasia, and lymphadenopathy
o In jaws, painless enlargement of maxilla and mandible
(“chipmunk” facies)
o Skull films show “hair‐on‐end” appearance
o Untreated, patient dies by about one year of age
o Treatment is repeated blood transfusions or bone marrow
transplant

this pt was treated with

Answer 853

A

Macrocytic
(megaloblastic)
Anemias:

▪ Folic acid and B12 deficiencies

Glossitis
Denuded dorsal surface
Burning, stinging pain

Seen in older patients and seen in patients with poor nutrition

Etiology: alcoholism, malabsorption, medications
(trimethoprim, oral contraceptives, anticonvulsants

Answer 854

A

Iron deficiency anemias
Microcytic hypochromic

▪ Atrophic glossitis – tongue has been a little denuded of papilla
▪ Angular cheilitis – white and redness at angle of mouth/
commissure
▪ Plummer‐Vinson Syndrome: type of iron deficiency anemia
o Chronic iron def, dysphagia (esophageal webs), atrophic glossitis.

Significantly increased risk of esophageal cancer (SCC)
More commonly seen in European women
Have difficulty swallowing

Answer 855

A

microcytic,
hypochromic anemias
(iron deficiency):

Pallor

▪ Anemia: reduction in O2 carrying capacity
▪ Diagnosis: RBC counts, Hg, HCT, red cell indices for dx of type of
anemia
▪ Normal upper labial mucosa

▪ Pale lower labial mucosa

Answer 856

A

Aplastic Anemia

One of the main differences between and neutropenic ulcer and an empthis ulcer? Is the red halo, the mucosa surroundingneutropenic ulcer Is pale and not red.
The center of a neutropenic ulcer has granulation tissue with a little bit of white

Answer 857

A

supportive care initially, attempts to stimulate
bone marrow (androgenic steroids), and bone marrow transplants
for severe cases (prognosis is guarded at best)

Answer 858

A

Multiple Myeloma

Elevated M spike in serum ‐ abnormal increase in
immunoglobulin (hyperglobulinemia), most commonly IgG
▪ Reversal of normal albumin/globulin ratio

Answer 859

A

Symptoms

▪ Initial symptoms include non‐specific symptoms of infection malaise, sore throat, swelling, fever, chills, etc.
Oral findings include multiple ragged ulcerations of the oral mucosa, o can mimic recurrent aphthous but no erythematous halo, Gingiva is a common site & can resemble NUG

Treatment

Remove offending drug, numbers should replenish in 10‐14 days
Agranulocytosis secondary to cancer therapy ‐ meticulous oral hygiene, chlorhexidine rinse (non alcohol type) , etc.

Answer 860

A

Non‐Hodgkins Lymphoma (NHL)

o Typically presents with painless lymphadenopathy
(often unilateral)
▪ up to 40% are extranodal
▪ 5‐10% arise in Waldeyer’s ring

▪ Inflamatory or reactive enlarged lymph nodes tend to be

*soft, tender, and movable**
*▪** Lymph nodes associated with malignancy tend to be
*hard/firm, fixed, and non‐tender**

Answer 861

A

Non‐Hodgkins Lymphoma (NHL)

o The most common of the lymphoproliferative diseases
o Uncontrolled proliferation of B or T cell origin derived
from a single cell (or clone)
o Typically presents with painless lymphadenopathy
(often unilateral)
▪ up to 40% are extranodal
▪ 5‐10% arise in Waldeyer’s ring

Answer 862

A

Non‐Hodgkins Lymphoma (NHL)

o The most common of the lymphoproliferative diseases
o Uncontrolled proliferation of B or T cell origin derived
from a single cell (or clone)
o Typically presents with painless lymphadenopathy
(often unilateral)
▪ up to 40% are extranodal
▪ 5‐10% arise in Waldeyer’s ring

Answer 863

A

Adult acute myeloid leukemia (AML)

is a type of cancer in which the bone marrow makes a large number of abnormal blood cells.

We see in these images:
o Hemorrhagic ulcer right vestibule

o Ulcers are deep and can go down to bone

o Ulcers resolved after treatment

Answer 864

A

leukomia

o Multifocal bony destruction
o Widened PDL with leukemic infiltrate

▪ Symmetric widening of PDL space in a patient that doesn’t have that normal vertical bone loss that you associate with periodontal
disease.
▪ If see symmetrical bone loss in PDL space think malignancy, neoplastic
● Lymphomas, leukemias, osteocarcoma, chondro scaroma can
do this

Answer 865

A

leukomia

Cause of infiltrate they has bone loss

Answer 866

A

Leukemia

This is Chloroma, inflitrate gets so dense they look green. On
buccal or lingual mucosa chloroma are more of a
solitary mass, gingival it more diffuses

Answer 867

A

Hodgkins lymphoma

Answer 868

A

Hodgkin Lymphoma

o Begins in lymph nodes
o 70‐75% cervical/supraclavicular
o Painless but unresolving,

o Night fevers/sweats

Answer 869

A

Hodgkin Lymphoma

▪ Cell of origin is unknown
▪ Often begins as a unifocal disease above diaphragm and then
spreads to other sites
▪ Present with painless cervical lymphadenopathy in 60‐80% of
cases

▪ Bimodal ‐ late twenties and after 50 years old

▪ In North America and Europe, EBV positivity has been noted
in over 50 percent of mixed cellularity cases and 10 to 50
percent of nodular sclerosis cases

Answer 870

A

T cell Lymphoma

Less common than B cell lymphomas
▪ One variant associated with palatal perforation
o Old name midline lethal granuloma

Answer 871

A

Burkitt’s Lymphoma

Scattered throughout the lymphocytes are
macrophages containing nuclear debris (tingible body
macrophages)
o Creates a “starry sky” appearance

Answer 872

A

Burkitt’s Lymphoma

North American type (sporadic)
- Typically older children (mean of 11 years)
- Involves abdomen as a mass
- uncommon in the jaws
- No association with EBV
- More localized disease
HIV type
- Adults
- 25% associated with EBV
- GI, marrow and CNS

Teeth floating as shown in the image

Answer 873

A

Low grade B cell (disseminated but slow growing)
- Small lymphocytic, Mantle cell, Marginal zone
- Follicular center (35‐40 % of all B cell lymphomas)
Moderate (aggressive)
- Diffuse B‐cell, Peripheral T‐cell
High Grade B cell (disseminated and rapidly progressive)
- Anaplastic large cell, lymphoblastic
- Large cell (25‐30 % of all B cell lymphomas)
- Burkitt’s
- Immunoblastic (increasingly seen in AIDS)
  - As AIDS patients live longer we see this more
T cell lymphoma (less common than B cell, associated with palatal perforation [midline lethal granuloma]) (in differntial with deep fungal infections/candidiasis, TB, use of cocaine
- Precursor T‐lymphoblastic, T cell chronic lymphocytic,
Hodgkin’s (bimodal ‐ late twenties and after 50 years old)

Answer 874

A

Burkitt’s Lymphoma

African type (endemic)

More common
Peak incidence 3‐8 years of age
Twice as common in males
~95% associated with the Epstein‐Barr virus
North american or non edemic type is not associated
with EBV
~88% under 3 yrs of age have jaw lesions
- Only 25% of those older than 15 do
Typically involves:
- MD, MX, (often affects all 4 quadrants)
- Mandible or maxilla
- Abdomen
grow quickly

Answer 875

A

Multiple Myeloma

Pathological fracture

Answer 876

A

Multiple myeloma

Answer 877

A

Multiple Myloma

Punched out translucency in crest

Answer 878

A

Multiple Myeloma

Monoclonal expansion of malignant plasma cell
▪ Most common in 40‐70 year old (mean 63 yo.)
▪ Present with bone pain (> 70%) and pathologic fractures

Punched out radilucency

Answer 879

A

Plasma Cell Disorders

Clock face nucleaus

Answer 880

A

Plasma cell gingivitis

▪ Allergen causes mass infiltrate into gingival
▪ Benign
▪ Diet log to identify allergen, allergy testing

Answer 881

A

▪ Diet log to identify allergen, allergy testing
▪ Ideally eliminate offending substance
▪ Can manage with topical steroids

Answer 882

A

Plasma cell gingivitis

▪ Allergen causes mass infiltrate into gingival
▪ Benign

Answer 883

A

Multiple Myeloma

Deposition of amyloid in soft tissues
o Can cause macroglossia if tongue is involved

Answer 884

A

Plasmacytoma

▪ Unifocal, monoclonal neoplastic
▪ proliferation of plasma cells

▪ 30% develop into MM over 10 yrs
▪ 50% disseminate w/in 2‐3 yrs
▪ Central Bone lesion
o Unilocular radiolucency
o Swelling or bone pain
o Non‐tender soft tissue mass

▪ 90% occur in Head and neck

Answer 885

A

Multiple Myeloma

Answer 886

A

Cyclic neutropenia
aggressive periodontitist
pamiona fav
burkitts lymphoma
langerhan cell histocytosis

o All these things can occur in children and lead bone
destructions and look like teeth are floating

Answer 887

A

Chemotherapy with or without RT
Bone marrow transplant
interferon
antibodies made against tumor cells, thalidomide, bisphosphonates, corticosteroids, melphalan, etc.
Even with treatment, most patients do not survive more than 18‐24 months
- older patients – better prognosis
- younger patients – more aggressive and worse prognosis
IV bisphosphonate therapy puts patients at increase risk for MRONJ

Answer 888

A

microcytic,
hypochromic anemias
(iron deficiency):

Pallor

▪ Anemia: reduction in O2 carrying capacity
▪ Diagnosis: RBC counts, Hg, HCT, red cell indices for dx of type of
anemia
▪ Normal upper labial mucosa

▪ Pale lower labial mucosa

Answer 889

A

fungal (candidiasis) –> mucosal smear/ Empirically can give antifungals (to figure out if it is candidiasis can do a smear or give antifungal)
If not candidiasis order cbc
▪ Order CBC with diff
▪ Order blood levels on Fe, Folate, B12, zinc
▪ Rule out : diabetic neuropathy
If not candidiasis and blood work didn’t show anything abnormal patient has burning mouth syndrome
▪ TIBC tests to see if theres too much or too little FE in the blood,
measures the bloods capacity to bind fe with transferrin

▪ B12 def can be from pernicious anemia ( Schilling test for
Pernicious Anemia) lack intrinsic factor to allow proper absorption, malnutrition or malabsorption from GI conditions can lead to this as well.

Answer 890

A

Pernicious – “highly injurious or deadly”
▪ Lack of intrinsic factor protein in stomach decreases absorption of
vitamin B12

Etiology is usually the body making antibodies against parietal cells which make intrinsic factor
o Autoimmune disease effecting parietal cells leads to
decreased intrinsic factor

▪ More common in elderly
▪ More common in patients of Northern European and African
decent

This anemia can lead to death

Answer 891

A

▪ Partial thromboplastin time (PTT), prothrombin time (PT), bleeding time (BT) and platelet counts, as well as consultation with physician, should be done prior to any dental treatment
▪ (PT is like INR, Normal INR between 0.8 and 1.2)
▪ Clotting factor replacement therapy (synthetic) given as indicated
▪ Avoid aspirin

Answer 892

A

Beta‐thalassemia

▪ Two defective genes – thalassemia major (Cooley’s anemia,
Mediterranean fever)

Hyperplasia of maxilla, body is trying to make more rbc so bone
marrow enlarges to support space of those red blood cells but rbc
are abnormal so spleen keeps destroying them

Answer 893

A

Sickle cell trait ‐ one allele is affected, only 40‐50% of hemoglobin will be abnormal, no significant clinical manifestations
Sickle cell disease ‐ both alleles affected, close to 100% of hemoglobin is abnormal, significant clinical problems

▪ Abnormal gene confers resistance to malaria, therefore, sickle cell trait is seen most frequently in populations from areas endemic for malaria (Africa, the Mediterranean, and Asia)

Answer 894

A

▪ Increase in the number of circulating red blood cells

Answer 895

A

*of MI or CVA (cerebral vascular accident or
stroke) **

Answer 896

A

▪ Types

Primary polycythemia: polycythemia vera
Secondary polycythemia: response to low O2 environment such as sleep apnea, living in high elevations, smoking
Relative polycythemia
- Dehydration, diuretics, vomiting

Answer 897

A

Secondary
Polycythemia

Oral manifestation

▪ Oral mucosa appears deep red
▪ Glossitis
▪ Gingiva appears edematous and bleeds easily
▪ Consequent “crowding out” of WBCs and platelets may result in
other manifestations

Answer 898

A

▪ Failure of the hematopoietic precursor cells to produce adequate numbers of all types of blood components

▪ Rare, but life threatening

▪ Associated with environmental toxins (benzene), certain drugs
(antibiotic chloramphenicol), or infection with certain viruses
(non‐A, non‐B, non‐C, non‐G hepatitis)

▪ Fanconi’s anemia and dyskeratosis congenita patients have an
increased risk of developing this

Answer 899

A

o Hemophilia A

▪ A patient with only 25% of normal clotting factor VIII levels may function normally, but less than 5% will likely manifest as bruising and bleeding problems

▪ Deep hemorrhage in joints is a major complication resulting in
arthritis, ankylosis and deformity

▪ Oral findings include bleeding (often uncontrolled) upon scaling and root planing, tooth extractions and any oral lacerations
▪ Pesudotumor of hemophilia
o Tissue hemorrhage can result in a submucosal tumor‐like
mass
o Bone hemorrhage can result in intraosseous radiolucency

Answer 900

A

Markedly decreased numbers of circulating blood platelets (severe
cases < 10,000/mm³)

Etiology: Can be from:
o Decreased production (malignancy, drugs)
o Increased destruction (immunologic, drugs)
o Sequestration in the spleen (splenomegaly)

Answer 901

A

▪ Treatment is usually platelet transfusion

Answer 902

A

▪ Clinically see spontaneous gingival bleeding, petechiae,
ecchymosis and hematomas
o Clinically see some type of bleeding

Answer 903

A

Agranulocytosis

Decrease in the number of cells from the granular cell lineage
(neutrophils, eosinophils, basophils, etc.)
o Decreased production or increased destruction

▪ Some cases are idiopathic, most are drug induced
▪ Anticancer chemotherapeutics ‐ inhibit mitotic division and
maturation of hematopoietic stem cells.
▪ In rare cases, agranulocytosis is a congenital syndrome.

▪ Increase risk of infections

Answer 904

A

Probably caused by a combination of environmental and genetic factors
Some leukemias have specific genetic alterations (ex. CML –
Philadelphia chromosome)
- t(9;22)(q34;q11) fusion gene BCR‐ABL1)
  - Translocation of 9 and 22 and fusion gene BCRABL1
Environmental factors include:
- ionizing radiation
- pesticides
- benzene
- viruses (ex. HTLV‐1)

Answer 905

A

▪ Represents several types of malignancies derived from
hematopoietic stem cells

▪ ~ 2.5% of all cancers in USe

Answer 906

A

Divided into acute and chronic, myeloid and lymphoid
o Acute myeloid, chronic myeloid, acute lymphoid, and
chronic lymphoid
▪ Acute leukemia
o Typical course under 6 mos
o Untreated, runs an aggressive course often causing death
▪ Chronic leukemia
o 2‐6 or more years
o More indolent course, although, they too often result in
death
▪ Leukemia, like lymphoma, can cause bone destruction and the
radiographic appearance of “teeth floating in air” in children

Answer 907

A

**▪ Acute myeloid leukemia**
o Adult (and children)

▪ Chronic myeloid leukemia
o Peak 3rd ‐ 5th decade

Answer 908

A

Acute lymphoblastic leukemia (ALL)

Success in treatment of a previously fatal disease

Children age 1‐10 years have higher success with
treatments than teenager do (10‐20yrs)
o And infants (under 1yr) do the worst

Chemotherapy that are given for curing ALL actaully
causes problems when they are older.

Answer 909

A

▪ related to crowding out of normal hematopoietic stem cells in the bone marrow
o ↓ in normal WBC, RBC, and platelets
▪ See fatigue, bleeding, bruising, fevers and infections, etc.

Answer 910

A

Chronic lymphocytic leukemia

o Elderly
o Most common type
o Considered incurable at this time
o unchecked proliferation of B‐cells
o no good treatment

Answer 911

A

Treatment depends on specific type of leukemia, but includes:

multi‐agent chemotherapy (often an initial high dose induction and then a lower maintenance dose)
- And for lymphoma
Bone marrow transplant has been used with limited success

Answer 912

A

▪ Usually a 21 day cycle

o Dx – when count falls below 500/ul for 4‐5 days every 21
days

▪ Patients experience recurrent fever, mallaise, anorexia, cervical
lymphadenopathy, oral ulcerations, etc.

▪ Treatment can be just supportive in mild cases, granulocyte
colony‐stimulating factor for more severe cases

Answer 913

A

Bones most commonly involved include vertebrae and ribs, skull
- 70‐90% will have jaw involvement at some point
Anemia, thrombocytopenia and neutropenia due to
crowding out of normal cells within bone marrow by proliferating malignant cells
50‐60% have Bence‐Jones proteins in urine (light chains, usually kappa)
- Due increased plasma cells ⇒ plasma cells makeantibodies ⇒ antibodies/proteins gets excreted
- Solitary plasmacytoma can be the first sign of multiple myeloma
Radiographically, see punched out radiolucencies (no sclerotic margin) often with an irregular outline

Answer 914

A

▪ Stage I and II – localized disease curable with RT
▪ Stage III and IV – more widespread and treated with chemo
and RT, worse prognosis
▪ Stage determined by sites involved
o Above diaphragm – stage 1 and 2
o Above and Below diaphragm – stage 3 and 4

having it above diaphragm is bette than having it below so stage 1 and 2 are better than stage 3 and 4

Answer 915

A

Midline lethal granuloma (T cell Lymphoma)
deep fungal
malignancy
TB
tertiary syphilis gumma,
cocaine abuse (necrotizing sialometaplasia‐ soft
tissue)

Answer 916

A

▪ Tx: radiation, better prognosis than MM

▪ Solitary better prognosis than disseminated MM

Answer 917

A

Immune cell tumors primarily involving bone marrow and peripheral blood are classified as leukemias
while those of lymph nodes are classified as lymphomas,
however there is often overlap of these entities

Answer 918

A

– environmental

Answer 919

A

o Folic Acid def
o Vit B12 def (pernicious anemia)

Answer 920

A

*menstruation, pregnancy, malabsorption diseases
(eg. Celiac)**

Answer 921

A

– environmental, things like bensin

Answer 922

A

Genetic

Answer 923

A

inflammatory conditions, malignancy
– organ disease

Answer 924

A

low levels of
erythropoietin – organ disease

Answer 925

A

1mg IM injections weekly for 1‐2 months
Monitored for lifetime

Answer 926

A

o 1mg PO, 5mg in malabsorptive disease
o Pregnant women given folic acid to decrease spina bifida
o Can be given IM injections if have malabsorption

Answer 927

A

▪ Ferrous sulfate 325 mg TID between meals
o can cause Constipation
▪ add on fiber to diet, green leafy vegetables
o IV doses for absorptive problems
▪ 125mg in 100ml saline infused over 1 hour

Answer 928

A

▪ A group of disorders of hemoglobin synthesis characterized by
decreased synthesis of either the alpha‐globin or beta‐globin
chains of the hemoglobin molecule

Patients get a microcytic, hypochromic anemia
▪ People with the abnormal gene have a resistance to malaria
▪ People who have the trait rather than the disease are more likely
to live and not die from malaria and spread that gene to their
children
▪ Severity depends on the specific genetic alteration and whether it
is homozygous (severe) or heterozygous (no clinical sign to mild
manifestations)

Answer 929

A

When there are Four defective genes – Hb Bart’s hydrops fetalis
o Lethal in utero or within a few hours of birth
o Not compatible with life

▪ Estimated that 5% of world population carries a variant of Alpha‐thalassemia (over 100 genetic forms)

▪ One defective gene –
o no disease detected
▪ Two defective genes – alpha‐thalassemia trait
o Mild degree of anemia (usually not clinically significant)
▪ Three defective genes – Hb (hemoglobin) H disease
o Hemolytic anemia and splenomegaly

Answer 930

A

Areas with a lot of malaria

Answer 931

A

▪ Genetic disorder of hemoglobin synthesis (one of the
hemoglobinopathies)

▪ Autosomal recessive pattern

▪ Mutation in DNA of thymine for adenine causes alteration of
codon resulting in the substitution of the amino acid valine for
glutamic acid in the beta‐globin chain of hemoglobin

▪ This transformed hemoglobin is prone to molecular aggregation
and polymerization to form a rigid and curved shape (sickle shape)

Answer 932

A

▪ Transcranial Doppler scan used to evaluate blood flow in brain
▪ Hydroxyurea may be used as a therapy
o Induces Hb F formation (doesn’t sickle)
o But can be carcinogenic and teratogenic

Answer 933

A

sickling of the RBCs becomes severe
precipitated by such things as hypoxia, infection,
hypothermia, or dehydration
Symptoms include pain (which may be severe) due to ischemia
and infarction of affected tissues
▪ Long bones, lungs and abdomen are common sites of occurrence for “crises”
▪ Episodes last from 3‐10 days, some patients have monthly crises, some may go a year or more between
▪ May need pre‐medication prior to dental treatment
infections are the most common cause of death in sickle cell
patients (in the US)
▪ Patients also have impaired kidney function and CNS involvement (strokes in 5‐8%, often prior to age of 10)

Answer 934

A

Bleeding disorders associated with a genetic deficiency of any
one of the clotting factors

o Hemophilia A (classic type, most common type )
▪ Factor VIII deficiency
▪ X‐linked recessive
▪ Abnormal PTT
o Hemophilia B (Christmas disease)
▪ Factor IX deficiency,
▪ X‐linked recessive, Abnormal PTT
o Von Willebrand’s disease
▪ Abnormal von Willebrand’s factor, abnormal
platelets
▪ Autosomal dominant
▪ Abnormal BT, abnormal PTT

Answer 935

A

Cyclic Neutropenia

▪ A rare idiopathic disorder characterized by regular periodic
reductions in the neutrophil population

Etiology: Underlying cause is a defect in hematopoietic stem cells in the marrow

▪ Symptoms usually begin in childhood
▪ Most symptoms when neutrophil count is at its lowest point
(nadir), usually lasts 3‐6 days (even when neutrophil counts are at their highest, it’s often lower than normal)
▪ Patients have repeated problems with infections

Oral ulcerations on any mucosal surface exposed to minor trauma & can mimic recurrent aphthous ulcerations without the
erythematous halo that is so typical of aphthous
▪ Gingiva is most severely affected with periodontal bone loss and tooth mobility

Answer 936

A

Homogeneous leukoplakia.

○ Non-wipeable white patch

Answer 937

A

Speckled leukoplakia.

Non-homogenous leukoplakia

Answer 938

A

Homogeneous leukoplakia

○ Thickened leathery, White plaque
○ Well-demarcated, Deepened fissures
○ Non-wipeable white patch

Answer 939

A

Etiology

The exact etiology remains unknown. Tobacco, alcohol,
chronic local friction, and Candida albicans are important predisposing
factors. Human papilloma virus (HPV) may also be involved in the
pathogenesis of oral leukoplakia.

Answer 940

A

Biopsy to rule out malignancy
Elimination or discontinuation of predisposing factors,
systemic retinoid compounds.
Smoking cessation (leukoplakias often disappear or become smaller within first year of smoking cessation)
Complete removal with surgical excision, electrocautery, cryosurgery, or laser ablation

Answer 941

A

Proliferative Verrucous Leukoplakia

Multifocal

Answer 942

A

Hairy Leukoplakia

corrugated white lesion on the lateral tongue.
• It only occurs on the lateral tongue

Answer 943

A

Hairy Leukoplakia

Answer 944

A

Non-homogenous leukoplakia

Nodular leukoplakia ~ Largely white
Verrucous leukoplakia ~ Largely white
Erythroleukoplakia ~ Red and white

Speckled and verrucous leukoplakia have a greater risk for malignant
transformation than the homogeneous form

Answer 945

A

homogenous leukoplakia

Just
white color

Answer 946

A

Oral lichen planus

Lichen planus of the dorsum of the tongue

this is a hypertrophic form.

Answer 947

A

Proliferative Verrucous Leukoplakia

Location
○ Gingiva (Frequent)
○ Buccal Mucosa
○ Palatal Mucosa

Answer 948

A

Proliferative Verrucous Leukoplakia

Patient with proliferative verrucous leukoplakia but manifesting more as
an erythroplakia in multiple sites than a leukoplakia

Proliferative verrucous leukoplakia has very high risk (49.5% in malignant transformation)
almost 10% risk for malignant transformation every year

Answer 949

A

Oral lichen planus

slightly more red as you move to the left of the picture
● The white lines have small sunburst effect at the periphery
○ Very very characteristic of lichen planus
○ Will never see this in a leukoplakia

Answer 950

A

Oral lichen planus

White lacy appearance, with
a network reticular appearance (Wickham’s striae)
sometimes punctate or plaque‐like lesions predominate

o Wickham’s striae→ very characteris► white wispy changes

Answer 951

A

Oral lichen planus

on the buccal mucosa (most common site

reticular form.

Answer 952

A

Not required
however, in some cases aciclovir or valaciclovir
can be used with success.
Topical retinoids or podophyllum resin for temporary remission

Answer 953

A

Epstein–Barr virus seems to play an important role in the
pathogenesis.

Answer 954

A

Oral Lichenoid Drug
Reaction

Answer 955

A

Oral Lichenoid

Contact lesion

chenoid reaction to dental amalgam and cold: white and erythematous
lesions on the buccal mucosa.

Answer 956

A

Lichenoid Reactions

Contact Lesions

a sensitivity in contact with a dental amalgam
▪ When you replace these amalgams, the lichenoid reaction will typically
disappear

Answer 957

A

Oral Lichenoid Drug
Reaction

Answer 958

A

Lichenoid reactions may develop after exposure to a medication for periods of > 1 year
May develop very slowly after the problem is initiated so it can be very challenging to connect the dots

Many different medications that can lead to lichenoid reactions

Beta blockers, ACE inhibitors, Rituxumab etc…
A number of new targeted agents “mabs” and “nibs” can cause lichenoid reactions
In cancer centers, this has become quite a problem because they are taking disease‐modifying drugs

Answer 959

A

Nicotinic Stomatitis

These papules represent inflamed minor salivary glands and their ductal orifices.

Answer 960

A

Nicotinic Stomatitis

also known as

Smoker’s keratosis

smoker’s palate

the palatal mucosa becomes diffusely gray or white; numerous slightly elevated papules are noted, usually with punctate red centers

Answer 961

A

Nicotine Stomatitis.

Answer 962

A

Pseudomembranous candidiasis

on the palate.

usually caused by Candida albicans

Predisposing factors are local

(poor oral hygiene, xerostomia, mucosal
damage, dentures, antibiotic mouthwashes)

Answer 963

A

Geographic tongue, localized lesion.

Answer 964

A

Geographic tongue/
areata migrans

Multiple, well-demarcated zones of erythema (due to filiform atrophy) surrounded by slightly elevated, yellow-white, serpentine/ scalloped border

annular

serpiginous
atrophic
Fissured

Answer 965

A

Geographic tongue/
areata migrans

Answer 966

A

Geographic tongue/
areata migrans

Answer 967

A

Geographic tongue/
areata migrans

Answer 968

A

complete removal: excision, electrocautery, cryosurgery, or laber ablation

Lesions rarely regress despite therapy

Answer 969

A

Fordyce’s granules

on the buccal mucosa.

a normal anatomical variation.

ectopic sebaceous glands of the oral
mucosa.

Answer 970

A

Leukoedema of the buccal mucosa.
Laskaris,

Answer 971

A

White Sponge Nevus

(Canon disease)

Answer 972

A

White Sponge Nevus

Diffuse, thickened white plaques
of the buccal mucosa

Answer 973

A

Verrucous Carcinoma

Extensive papillary, white
lesion of the maxillary vestibule

Answer 974

A

Verrucous Carcinoma

Large, exophytic, papillary
mass of the maxillary alveolar ridge.

Answer 975

A

Traumatic Erythema /Traumatic Hematoma

on the lower lip.

Answer 976

A

Verrucous Carcinoma

Large, exophytic, papillary
mass of the maxillary alveolar ridge.

Answer 977

A

Verrucous Carcinoma

Early verrucous carcinoma of the buccal mucosa.

Answer 978

A

Geographic tongue: well-demarcated red patch on the tongue.

Answer 979

A

Median rhomboid glossitis.

a Chronic hyperplastic, erythematous candidiasis

Answer 980

A

Denture stomatitis.

Answer 981

A

Although the cause is not well known, T cell-mediated autoimmune
phenomena are involved in the pathogenesis of lichen planus.

Answer 982

A

Erythroplakia

of the buccal mucosa

Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 983

A

Erythroplakia of the buccal mucosa.

Answer 984

A

Erythroplakia

of the lateral margin of the tongue.

Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 985

A

Erythroplakia

Firey red Well-demarcated patch or plaque with soft velvety texture

transformed into SCC

Answer 986

A

Incisional biopsy on non-keratinized, non-ulcerated mucosa

○ Asymptomatic → no tx
○ Symptomatic → 0.5mg/ml Dexamethasone Elixir.

Answer 987

A

Erythroplakia.

Erythematous macule on the right
floor of the mouth.

Biopsy–

Turned out to be early invasive squamous cell
carcinoma.

Answer 988

A

Erythroplakia.

Well-circumscribed red patch on the
posterior lateral hard and soft palate

Answer 989

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Mild. A soft, fissured,
gray-white lesion of the lower labial mucosa located in the area of
chronic snuff placement.

Answer 990

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Smokeless Tobacco–related Gingival Recession.
Extensive recession of the anterior mandibular facial gingiv

Answer 991

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Severe

Answer 992

A

Pemphigus vulgaris

usually suffer from Desquamative
gingivitis (DG)

More superficial erosion of the marginal gingiva, typically with an
intense erythema and inflammation, and very often in the absence of
local factors that would typically cause a gingivitis

o Hurts to brush their teeth

Immediately look for areas where there are no local factors and look for
inflammation there
o To check the possibility of systemic factors causing local
gingivitis

Answer 993

A

Pemphigus vulgaris

PV Lesions can affect
virtually any mucosal
surface (oral, nasal,
ocular, pharyngeal,
esophageal, genital)

Answer 994

A

Pemphigus vulgaris

● Multiple, chronic, mucocutaneous ulcers
● Many patients also have

● Relatively non‐specific
● Very superficial, only in epithelium
● Occur on any mucosal surface: oral, ocular, nasal, GI, esophageal,
genital

Answer 995

A

Pemphigus vulgaris

Combination of PV
inflammation and
gingival inflammation
accumulating local
factors can result in
advanced loss of
attachment and tooth
loss

Answer 996

A

Pemphigus Vulgaris.

Multiple erosions of the left
buccal mucosa and soft palate.

Answer 997

A

Pemphigus Vulgaris.

Large, irregularly shaped ulcerations
involving the floor of the mouth and ventral tongue.

Answer 998

A

Pemphigus Vulgaris.

. Multiple erosions affecting the
marginal gingiva.

Answer 999

A

Pemphigus Vulgaris.

Answer 1000

A

Mucous membrane pemphigoid

Oral Hygiene: Plaque
related gingival
inflammation
contributing to
continued VB
desquamative
gingivitis

Answer 1001

A

Mucous membrane pemphigoid

REMEMBER:

▪ Plaque and calculus can be the consequence of painful MMP lesions
▪ When assessing MMP lesions/desquamative gingivitis, look for areas of intense inflammation WITHOUT local factors as evidence of VB disease

Answer 1002

A

Mucous membrane pemphigoid

SEVERE/HIGH RISK FORMS OF MMP
▪ Ocular
▪ Esophageal

can
result in functional
blindness

Answer 1003

A

Mucous membrane pemphigoid

Answer 1004

A

take two different sites
○ For H&E, still must be perilesional
○ If you get only ulcer just because the clinician thinks
○ that is the pathology → there is no epithelium!
○ The sample is useless and no diagnosis can be made

Answer 1005

A

Hypersensitivity

to

dental restorative materials, amalgam or other metal, composite resins
Foods, oral products
Especially cinnamon
dental plaque accumulation are the most common

Answer 1006

A

Insicional biopsy Mandated to distinguish from OLP
○ Biopsy white areas on non-keratinized mucosa NOT ulcerated OR red areas

Treatment Replacement of the restorative material, polishing and
smoothing, and good oral hygiene are recommended.

Topical steroid
treatment for a short time is also helpful.

Answer 1007

A

Smoking Cessation.

Nicotine stomatitis is completely reversible, even when it has been present for many decades.
The palate usually returns to normal within 1 to 2 weeks of smoking cessation.

Answer 1008

A

The elevated temperature, rather than the tobacco chemicals,
is responsible for this lesion.

Answer 1009

A

The exact etiology remains unknown. It may be genetic.

Answer 1010

A

Generally no treatment is indicated
Reassuring the patient that the condition is completely benign is often all that is necessary.
In case of tenderness or a burning sensation that is so severe –topical corticosteroids, such as fluocinonide or betamethasone gel, may provide relief

Answer 1011

A

Etiology

It is due to increased thickness of the epitheliumand intracellular
edema of the prickle-cell layer.

Treatment

No treatment required

Answer 1012

A

Autosomal dominant skin disorder

Etiology:
● This condition is due to a defect in the normal keratinization of the oral mucosa in the 30-member family of keratin filaments, the pair of keratins known as keratin 4 and keratin 13 is specifically expressed in the spinous cell layer of mucosal epithelium.

Answer 1013

A

a low-grade variant of squamouscell
carcinoma.

Etiology

Leading theories include

human papillomavirus (HPV) infection
chemical carcinogenesis induced by smoking and chewing tobacco
alcohol consumption
betel nut chewing (oral lesions),
chronic inflammation

Answer 1014

A

○ Surgical Excision

○ Radiotherapy

Answer 1015

A

Atrophy of central filiform papillae

Presumably developmental. Candida albicans may also be
involved.

but smokers, people with xerostomia , who use inhalation steroids
and denture wearers are at increased risk

Answer 1016

A

No treatment is required.

Answer 1017

A

Erythroplakia is a high risk for malignant transformation. So, if you
encounter an erythroplakia, it’s probably already a cancer or it’s fast‐tracking
towards a cancer

Answer 1018

A

○ Biopsy required for diagnosis

○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal

○ Complete excision

Answer 1019

A

typically resolves weeks after cessation

○ if persists 6+weeks -> biopsy to rule out dysplasia + SCC

Answer 1020

A

Frictional keratosis

on the tongue

Answer 1021

A

Treatment has 3 stages:
● Stage 1: Control
○ Suppress inflammation / lesion activity with Systemic Corticosteroid: Remains initial / 1st‐line treatment…
○ Then quickly add steroid‐sparing agents (mycophenolate mofetil) to minimize dose and duration of corticosteroid treatment as well as improve disease control
● Stage 2: Consolidation
○ Reducing auto‐antibody production with the addition of Immunosuppressants
○ Assessed by the lack of development of NEW lesions
● Stage 3. Remission / Maintenance:
○ achieving complete remission of lesion activity OFF medication is the GOAL
○ When lesion activity OFF medications cannot be achieved, principle of MINIMALLY effective therapy is the goal, typically with combination of immunosuppressant medications
○ RITUXIMAB has become the FIRST CHOICE treatment after
○ the consolidation phase to achieve DISEASE REMISSION

● TOPICAL / INJECTABLE CORTICOSTEROID MEDICATIONS
○ o Can be used to help control limited number of lesions resistant to systemic therapy: it treats ONLY the disease
○ outcome (lesions) and not the systemic illness / pathologic antibody production
○ ex:clobetesol 0. 05% , halbetesol 0.05% (most potent)

Answer 1022

A

Pemphigus vulgaris is not fully understood.

Experts believe that it’s triggered when a person who has a genetic tendency to get this condition comes into contact with an environmental trigger, such as a chemical or a drug.

In some cases, pemphigus vulgaris will go away once the trigger is removed.

Answer 1023

A

Mucocutaneous autoimmune disease characterized by sub‐epithelial
blisters (bullae) which ruptures to form large, non‐healing ulcerations

Answer 1024

A

o Approach is similar to PV – but generally not as aggressive unless
hi‐risk areas ( ocular, esophageal ) where more intense immunosuppression indicated
▪ NON‐immunosuppressive treatments uniquely effective:

*o** Dapsone
*o Tetracycline + nicotinamide**

Answer 1025

A

Option 1: take perilesional sample that has both intact and ulcerated epithelium
○ This is not easily achieved
● Option 2: take two different sites
○ For H&E, still must be perilesional
○ If you get only ulcer just because the clinician thinks
○ that is the pathology → there is no epithelium!
○ The sample is useless and no diagnosis can be made
● Option 3: just collect a large punch of normal non‐ulcerated epithelium and submit for immunofluorescence
○ You will still get product even though it is not ulcerated

Answer 1026

A

Actinic cheilitis

(Solar cheilosis)

Early presetation:

Smooth, blotchy, pale, dry areas

Diffuse, irregular white plaque around line of the lip

Crusted, Scaly

Answer 1027

A

Actinic cheilitis

(Solar cheilosis)

Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 1028

A

Actinic cheilitis has 2 times of risk for developing SCC of the lip.

SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 1029

A

SCC

arising from Actinic Cheilitis

Answer 1030

A

Oral Melanoma

Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 1031

A

Amalgam tattoo

This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 1032

A

Oral Melanoma

a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 1033

A

Oral Melanoma

an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 1034

A

Oral Melanoma

patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient’s fingers are depicted.)

Answer 1035

A

Oral melanoacanthoma.

the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 1036

A

Oral melanotic macule

an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 1037

A

due to chronic ultraviolet light exposure.

Answer 1038

A

avoid sun exposure
Laser ablation is preferred for severe actinic cheilitis
surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia
- Lip Shaving” (Vermilionectomy)
can also use cryotherapy, electrodesiccation

It requires long term follow up and prognosis is good if caught early

Answer 1039

A

Oral Melanoma

Answer 1040

A

Oral Melanoma

Answer 1041

A

Traumatic

Granuloma

(traumatic ulcertaive granuloma)

Answer 1042

A

Oral Melanoma

Answer 1043

A

Traumatic ulcer

Most often on tongue, lips, buccal mucosa

Any sites that may be injured by dentition

Answer 1044

A

Traumatic ulcer

a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 1045

A

Traumatic ulcer

caused by sharp or puncturing food stuff

Answer 1046

A

Traumatic

Granuloma

Answer 1047

A

Traumatic Granuloma

( Traumatic Ulcerative Granuloma)

Answer 1048

A

Squamous cell carcinoma

on the buccal mucosa)

Answer 1049

A

Erythroplakia and Squamous Cell Carcinoma

Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 1050

A

Leukoplakia and Squamous Cell Carcinoma

Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 1051

A

Graphite tattoo

Gray, black, or blue-ish macule

Answer 1052

A

Graphite tattoo

Most common location on the palate and gingiva

Gray, black, or blue-ish macule

Answer 1053

A

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma

Acute sun damage can cause it more than chronic exposure

Answer 1054

A

Fair skin

A history of sunburn

Excessive ultraviolet (UV) light exposure.

Living closer to the equator or at a higher elevation

Having many moles or unusual moles

A family history of melanoma

Weakened immune system.

Answer 1055

A

Surgical excision
Radiotherapy
Chemotherapy

Answer 1056

A

Etiology

typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep.
Chronic mucosal trauma from adjacent teeth
Some adjacent source of irritation

Answer 1057

A

Traumatic ulcer

Post-anaesthesia traumatic ulcer on lower lip.

Answer 1058

A

Remove cause of irritation

Topical anesthetic or film for pain relief

If there is no obvious cause then ► biopsy

Answer 1059

A

HPV + SCC

Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue)

Younger pts, 3:1 Males to females ratio, high socio-eco status

Incidence is decreasing

less aggressive → higher survival rates ( Better than HPV negative SCC)

HPV - SCC

The chief risk factors for oral squamous cell carcinoma are

Smoking (especially > 2 packs/day)

Alcohol use

Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men.

( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva)

mostly men, low socio-economic factors

Incidence is decreasing

Very aggressive → lower survival rates

Answer 1060

A

Early stage: Radiation and/or Surgical removal

Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 1061

A

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 1062

A

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 1063

A

Hemangioma of Infancy

a relatively common benign proliferation of
blood vessels that primarily develops during childhood.

display a rapid growth phase with endothelial
cell proliferation, followed by gradual involution.

Answer 1064

A

Hemangioma of Infancy

Answer 1065

A

Traumatic ulcer of the tongue.

Answer 1066

A

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 1067

A

Necrotizing Sialadenometaplasia

we see two ulcers on the palate

Mostly
● Palatal salivary glands
○ Possible for parotid
● 75% of case on posterior palate
● Hard>Soft palate
● 2/3rd are unilateral

Answer 1068

A

Necrotizing Sialadenometaplasia

an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands.

Here it is on the palate

Answer 1069

A

Xerostomia-related Caries

Or

Dry Mouth

. Extensive cervical caries of
mandibular dentition secondary to radiation-related xerostomia.

Answer 1070

A

The cause is uncertain, although the hypothesis of ischemic
necrosis after vascular infarction seems acceptable.

Answer 1071

A

No Treatment Needed

but we need to biopsy to rule out other diseases

Answer 1072

A

Frictional Keratosis

the white surrounding a a traumatic ulcer

Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 1073

A

Leukoplakia

Linea alba

Chronic cheek chewing (bite injury)

Candidiasis

Oral Lichen planus

Squamous cell carcinoma

Answer 1074

A

Frictional Keratosis.

There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”),
because this area is now edentulous and becomes traumatized
from mastication.

Such frictional keratoses should resolve when the
source of irritation is eliminated and should not be mistaken for true
leukoplakia.

Answer 1075

A

Trauma from Sharp cusp & ortho appliance
Chronic mechanical irritation (chronic biting)
Masticatory function
Normal hyperplastic response
Dentures/missing teeth

Answer 1076

A

Remove the cauative factor that caused the trauma
observe large lesion regularly

excellent prognosis

Answer 1077

A

Xerostomia

The subjective experience of a dry mouth (ie a symptom)

Salivary Hypofunction

The objective measurement of a reduction in salivary flow (a sign)

Answer 1078

A

300 ml/day
▪ Flow rate: mean 0.3 ml/min

Answer 1079

A

Stimulated Saliva
Production

▪ 200+ ml/day
▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min
o “Normal” range is very wide

Answer 1080

A

Dehydration
Medical conditions
Body posture
Lighting conditions
Circadian/circannual rhythm (lowest during)
Medications

Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 1081

A

dry‐mouth

from radiation

Note the Ropy, frothiness on the palate.

The tissues are red and irritated due to candida infection as well.

Answer 1082

A

dry‐mouth

patient

a classic example

• Classic fissuring
• depapillation of the tongue papilla
• some white changes on the tongue.

Answer 1083

A

dry Mouth

Cervical caries related
to radiation.

The patient is a smoker and coffee drinker –> explains the staining

Answer 1084

A

dry Mouth

Incisal caries in a
radiation patient:

Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction

Answer 1085

A

Mechanical stimuli
Vomiting
Gustatory/olfactory stimuli (acid/smell)
Gland size

Age is an independent factor for whole saliva (but not
for parotid and minor gland secretions)

Answer 1086

A

Central inhibition as a result of connections between the primary salivary centers and the
higher centers of the brain.

Answer 1087

A

May be a reduction in baseline sialometry which is still above “normal.”
- If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.
Saliva film thickness
- Palatal mucous gland secretions?
- Anterior dorsum of tongue?
Relative contributions by glands
- Mucins, proteins?
Alterations in sensory perception?
Mental status/central inhibition?

Answer 1088

A

● Dehydration
● Medications (Rx & OTC)

Direct damage to glands
Head and neck radiotherapy
As a result of radiation it’s irreversible damage to the glands
Chemotherapy (reversible)
Autoimmune diseases
Primary vs Secondary Sjögren’s Syndrome, GVHD
HIV disease

● Decreased mastication (tooth loss, soft diet)
● Conditions affecting the CNS:

Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 1089

A

SJÖGREN’S SYNDROME

Dry Mouth

very severe
cervical disease & very dry lips

Answer 1090

A

a patient
with a
bacterial sialadenitis

who has

SJÖGREN’S SYNDROME

When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 1091

A

Depapillated &
Fissured Tongue

SJÖGREN’S SYNDROME

Answer 1092

A

Sjögren Syndrome

bilateral enlargement of the submandibular glands
angular cheilitis, dry and cracked lips and fissured and despapilated tongue
severe ocular lesions.

Answer 1093

A

These patients LOW USFR, no response to stimulation (aka abnormal USFR/SFR)

Rehydrate if dehydrated
Treat underlying conditions (i.e. DM)
Salivary substitutes (glycerin)
Minimize damage to glands from radiation
Prevention of complications & palliative treatment
- Optimal hygiene
- Restore caries
- Smooth sharp edges in oral cavity
- Fluoride therapy
- Antifungals
- Chlorhexidine rinses w/o alcohol
- Sialendoscopy
- Salitron - salivary pacemaker
ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 1094

A

Abnormal unstimulated USFR= <0.1–0.2ml/min

Abnormal stiumated SFR = <0.5ml/min

Answer 1095

A

Salivary stimulation (OTC) to stimulate their glands
Salivary lubrication ( to improve it)
Humidification ( like a humidifier in the room at night)
Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a
diuretic and lead to dehydration).
Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 1096

A

If dehydrated ► rehydrate or treat underlying condition
- People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back.
All we can do is offering Salivary substitutes (sprays, gels, rinses )
For patients with high dose radiation treatment ► makes sure they get the INRT
Minimizing damage to salivary glands ( there are other strategies for that)
Prevention and treatment of oral complications

Answer 1097

A

Look for possible causes (major cause will be medications & can dehydration or others)
Restore chewing function (Masticatory issues)
Reduce medication‐induced salivary hypofunction
Prescribe Salivary stimulation OTC, Rx medications, others
Prescribe Salivary lubrication
Humidification ‐use humidifiers
Hydration/prevent dehydration (ie avoid alcohol, caffeine)
Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 1098

A

– Muscarinic agonists:
– Pilocarpine 5‐7.5mg tid & qhs (can go as
high as 10mg qid)
– Cevimeline 30mg tid (can go as high as
60mg tid)

Contradicated for : CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma

Pilocarpine affects M1 & M3

side effects (sweating, flushing,
rhinitis, increased urination, weakness and
some experience the shakes. )

Cevimeline affects M3 only

fewer side effects

Answer 1099

A

SJÖGREN’S SYNDROME

Autoimmune exocrinopathy

Marked bilateral parotid gland enlargement in a patient with primary Sjögren syndrome

Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive

Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary
glands due to retrograde infections.)

increased risk of lymphoma (MALT type)

Answer 1100

A

Urticaria

Well defined erythematous papules/plaques which are pruritic (itchy)

We’ll see them on the skin ‐ Not found intraorally

Answer 1101

A

Urticaria

(HIVES)

this person was exposed to extreme temperature developed hives (
not really
red but very itchy)
no skin scarring is noted
it goes in about a day

Answer 1102

A

Angioedema

❖ Diffuse edematous swelling of the soft tissues that most commonly
involves the subcutaneous and submucosal connective tissues
❖ Results from local vasodilatation and increased vascular
permeability of DEEPER blood vessels

Answer 1103

A

Angioedema

Answer 1104

A

❖ Medications ► causing rash
❖ Foods ► like peanuts
❖ Airborne allergens ► pollen
❖ Physical stimuli ► ex cold weather

Answer 1105

A

❖Avoid known triggers avoid
the penicillin, any of
the triggers
❖ Antihistamines ( to prevent it
from happening in the first
place)
Corticosteroids (prevents the
inflammatory effect)

Answer 1106

A

Cinnamon Contact
Stomatitis

It can present similar to leukoplakia
So you’d think it is pre‐malignant lesion
But after asking the patients ► you’ll realize they are chewing like 10 cinnamon gums every day.

Answer 1107

A

Allergic Contact
Stomatitis

❖ Mild‐severe redness, edema, vesicles, erosions, ulcerations

❖ Burning, itching, stinging, tingling

●We can’t know what is this right away.

Patients may say it burns, tingles, there could be peeling
(desquamation). We might think it’s a vesiculobullous diseases.
● So these cases require more consulative‐investigative work.

Answer 1108

A

Allergic Contact
Stomatitis‐Clinical

slight vesicales and diffused erythemya
we wouldn’t always know this is Allergic contact stomatitis
This occured due to allumnium chloride on gingival retraction cord.

Answer 1109

A

Exfoliative cheilitis

Allergic Contact
Reactions‐ Non‐
Mucosal

dry, scaly, fissured, cracking lips

This is a mild case that affect the non‐mucosal around the the
skin

Answer 1110

A

Exfoliative Cheilitis

caused by titanium implants and
some mercury in amalgam.

Answer 1111

A

Perioral Dermatitis

Allergic Contact
Reactions‐ Non‐
Mucosal

erythematous
papules/vesicles
– papules ( raised) & vesicles
(actual blisters)

Answer 1112

A

Erythema
Multiforme

Rapidly rupturing vesicles/bullae forming erosions/ulcerations and
hemorrhagic encrusted lip lesions, with greyish pseudomembrane
Fast expansion, ► the skin is just peeling off.

Type 4 hypersensitivity.

Has prodrome phasesudden

Rapid onset, crusted
hemorrhagic swollen
lips, and
desquamative
gingivitis.

Answer 1113

A

Granuloma

This is a granuloma. It’s composed of histeocytes that looks
epithelioid. This is a collection of epithelioid histeocytes

Found in:

TB (They’ll be holding TB inside. But in TB you have caseous necrosis of granuloma.
Deep fungal infections (they holding? fungal organisms)
GRANULOMATOUS DISEASES ( if with Asteroid bodies & Schaumann Bodies)

In these granulomas we don’t know why they are forming.

Answer 1114

A

Orofacial
Granulomatosis

Cheilitis granulomatosa=Involvement of lips alone

Non‐tender, persistent swelling

NEED To BIOPSY to RULE OUT

angioedema

Answer 1115

A

Orofacial
Granulomatosis

Papules, slightly raised areas, fissures, cobblestone appearance

DDx

We could suspect

a traumatic injury

early signs of Crohn’s

Answer 1116

A

Orofacial
Granulomatosis

Answer 1117

A

❖ Discover cause ( we need to find out the cause.)
❖ Topical or intralesional corticosteroids (maybe try steroids)
❖ Other (topical tacrolimus, sulfazalazine, methotrexate, etc)
❖ Some cases resolve spontaneously

(This photo shows a person has puffiness because of granulomas.
Sometimes it goes away on its own. We can use injection steroids on
the lips too.)

Answer 1118

A

Sarcoidosis‐Organ
Systems

❖ Lungs
❖ Lymph Nodes (bilateral hilar
lymphadenopathy)
❖ Skin (25% of time)
❖ Eyes
❖ Salivary Glands
❖ Other (endocrine,
gastrointestinal, heart, kidney, liver, nervous system, spleen, skeletal

Answer 1119

A

Sarcoidosis‐Hilar
Lymph Node
Enlargement

popcorn‐like calcifications in the hilar lymph nodes.

granulomas from
sarcoidosis being inside
.

Answer 1120

A

Sarcoidosis‐Skin
Lesions

Lupus pernio (nose, ears, lips and
face)
‐ when we have these erythematous
indurated, hard on face.

Answer 1121

A

Sarcoidosis

DDX

in the oral cavity. It could be one of the three P’s:
❖ pyogenic granuloma
❖ peripheral ossifying fibroma
❖ peripheral giant cell granuloma.

Answer 1122

A

❖ This is Strawberry gingivitis

Granulomatosis with
Polyangiitis “Wegener’s”

Orally

❖ Ulceration,
❖ Mucosal nodules
❖ Facial paralysis
❖ Enlarged major gland
from granulomas

we need to biopsy, as this also looks like a deep fungal
infection. *

Answer 1123

A

Granulomatosis with
Polyangiitis

Orally

We want to
biopsy to confirm because it Could be contact mucositis.

Answer 1124

A

‐ Cinnamon contact mucositis

This could be oral hairy leukoplakia.
It could be hyperplastic candidiasis
it could be tongue chewing
it could be a leukoplakia.
We’ll know what it is by biopsy and investigate

Answer 1125

A

Urticaria.

Answer 1126

A

Erythema multiforme

Answer 1127

A

* Erythema multiforme

Answer 1128

A

‐ Orofacial granulomatosis.

We make sure there’s no tb, no fungal, no foreign material in the
granulomas

Answer 1129

A

Sarcoidosis

*Erythemous papules (grey circle)
Asteroid bodies ( blue arrow)
Hilar lymph nodes (green circle)

Answer 1130

A

Granulomatosis with polyangiitis

Answer 1131

A

orofacial granulomatosis.

What is
the common way to
describe this?

Cobblestone. This is the classic cobblestone.
Cobblestone and fissuring

DDx: people with Crohn’s with oral manifestations it looks like this
too.

Answer 1132

A

Sarcoidosis

Answer 1133

A

angioedema

Answer 1134

A

Fixed Drug Eruption

–This case has both the skin and oral appearance.

This happened every time this person took NSAIDs that’s not used in
the USA.

A person gets a reaction to a medication they take. It occurs at the
same place each time because there’s some memory T cell at these
sites.

Answer 1135

A

Causes include:
❖ IgE mediated ( most common types are allergy related)

Hypersensitivity reaction
- drugs, foods, plants, dust
Contact allergic reactions
- foods, cosmetics, topical medications, rubber dam
Physical stimuli
- heat, cold, exercise, emotional stress, solar exposure, vibration

❖ Drug reaction to ACE inhibitors

Does not respond well to antihistamines

❖ Hereditary or acquired activation of the complement
pathway
❖ Other (high levels of antigen‐antibody complexes and in
elevated blood eosinophil counts)

Complexes in lupus, viral and bacterial infections
Patients with grossly elevated blood eosinophilia

Answer 1136

A

❖ Antihistamine/IM epinephrine/IV corticosteroids ( typical treatment for allergy)

❖ Intubation and tracheostomy ( if the patient can’t breathe, so we can get air in)

❖ Avoid medications in ACE Inhibitor class of drugs ( for people who has Ace inhibitor induced angieodema)

❖ C1 esterase inhibitor concentrate and esterase inhibiting drugs

Answer 1137

A

Granulomatosis with
Polyangiitis

extra-oral

Joint pain, weakness, tiredness
❖ Known as Saddle nose deformity

❖ First signs may be recurrent
respiratory infection, cough or
runny nose

❖ Oral lesions initial presentation in 2% of patients

Answer 1138

A

First line: oral prednisone
❖ After remission immunosuppressive drugs:
❖ Methotrexate
❖ Cyclosporine
❖ Rituximab
❖ Treatment induces prolonged remission
❖ May have relapses

Answer 1139

A

● pseudomembranous candidiasis
● Mucosal sloughing‐ Allergic Contact Stomatitis
● Food particles

Answer 1140

A

Mucosal sloughing

Allergic Contact Stomatitis

caused by tooth paste (Colagate Total)

white area‐like a film peeling out slowly

Wipeable

could be confused with candidasis

Answer 1141

A

Medications, lipsticks,
sunscreens, toothpaste
floss, cosmetics

Answer 1142

A

Erythema
Multiforme

Acute, vesiculobullous, ulcerative
mucocutaneous disorder

Immunologically mediated

Target lesions on skin (typical board question)

Healthy young adults in 20‐40’s

Answer 1143

A

❖ 50% of cases precipitating cause is identified

Infectious Agents: Herpes simplex virus, Mycoplasma pneumonia, Adenovirus, Enterovirus, Coccidiomycosis
- Most of the time, erythema multiforme is related to a previous infection with herpes simplex virus.
Drugs: Penicillin, Cephalosporins, Sulphonamides, NSAID’s, Phenytoin
Other: Foods (Benzoates, Nitrobenzene), Chemicals (Perfumes)

❖ it’s not an infection, it’s our body reacting to the infectious
organism or pieces of it in a wrong way

Answer 1144

A

Sarcoidosis

discrete clear
granulomas.

2nd

schaumann body in a giant cell (3rd to the right)

Asteroid bodies ( right)

Answer 1145

A

Erythema Multiforme

Focal hemorrhagic crusting of
the lips is seen in conjunction with diffuse shallow ulcerations and
erosions involving this patient’s mandibular labial mucosa

Answer 1146

A

Erythema multiforme

The concentric erythematous
pattern of the cutaneous lesions on the fingers resembles a target or
bull’s-eye.

Answer 1147

A

Sarcoidosis

large red nodule on the lower lip.

Answer 1148

A

Urticaria

developed after bites from an imported fire ant.

Answer 1149

A

Erythema multiforme

multiple erosions on the lips and tongue.

Answer 1150

A

(Granulomatosis with polyangiitis)

formerly Wegener Granulomatosis.

Hyperplastic and hemorrhagic
mucosa of the facial mandibular gingiva on the left side. ((strawberry gingivitis).

Answer 1151

A

❖ Idiopathic

❖ Abnormal immune reaction

❖ in orofacial granulomatosis, people form granulomas and it’s
idiopathic

❖ we don’t know why they’re forming them so that’s an abnormal
immune reaction.

Answer 1152

A

Depends on the case!

❖ 60% of cases resolve within 2 years
❖ Initial diagnosis 3‐12 mo. observationàactive intervention as needed
❖ First line tx: corticosteroids
❖ Refractory dx:

Cytotoxic drugs (methotrexate, azithioprne)
TNF blockers
Hydroxychloroquine

❖ 4‐10% die of pulmonary, cardiac or CNS complications

Answer 1153

A

❖ Granulomatous disorder
❖ Multisystem
❖ Unknown cause

Answer 1154

A

First line: oral prednisone
❖ After remission immunosuppressive drugs:
❖ Methotrexate
❖ Cyclosporine
❖ Rituximab
❖ Treatment induces prolonged remission
❖ May have relapses

Answer 1155

A

erythema multiforme
morbilliform drug eruption

Answer 1156

A

Oral hairy leukoplakia
hyperplastic candidiasis

Answer 1157

A

❖ Foods
❖ Food additives
❖ Chewing gums
❖ Candies
❖ Dentifrices
❖ Mouthwashes
❖ Gloves
❖ Rubber dam material
❖ Topical anaesthetics
❖ Restorative metals
❖ Acrylic denture materials
❖ Dental impression materials
❖ Denture adhesive
preparations
❖ Cinnamon (mainly artificial flavoring)

Answer 1158

A

*❖ Remove the suspected antigen**
*❖** Severe cases‐Antihistamine (combined with a topical anaesthetic) ( because it’s an allergy)
*❖** Chronic cases‐Apply topical corticosteroid

❖ Recommendations to AVOID:

❖ Mouthwash
❖ Gum/mints
❖ Cinnamon
❖ Excessive salty, spicy, acidic

❖ Patch testing (we send them to allergist )

Answer 1159

A

❖Self‐limiting, resolves in a few weeks (It will go away on its own, you just have to manage symptomatically.)

❖Symptomatic management, IV rehydration, corticosteroids (topical and oral), antivirals in recurrent cases (We may use antivirals if they tell us they get cold sores every now and then this means they do have a history of herpes simplex.)

❖ Avoid causative drug (If drug‐related)

❖ Other second‐line systemic therapies (like cyclosporin,
azathioprine and other serious drugs)

❖ Usually not life threatening unless in major form.

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