Images for Final Flashcards
Idiopathic Osteosclerosis
Erythroleukoplakia
Dentigerous Cyst
Aphthous stomatitis
Minor, Major, Herpetiform aphthous ulcers
Pyogenic Granuloma
Idiopathic Osteosclerosis
Inflammatory Fibrous Hyperplasia
- Tumor-like hyperplasia of fibrous connective tissue
- Epulis Fissuratum is the name given for inflammatory fibrous hyperplasia in association with the flange of an ill-fitting denture
- Usually develops on the facial aspect of the alveolar ridge
- Treatment is surgical removal and remake the denture
Denture Stomatitis
Tramautic Ulcer - Riga-Fede disease
Stafne Defect
(Lingual mandibular salivary gland depression, it is one of the only things we see that happens below the inferior alveolar canal, cysts tumors (which this isn’t) rarely go beneath the canal, Has a corticated rim on the x-ray)
Amalgam Tattoo
Mucous Membrane Pemphigoid
-
May also be termed cicatricial pemphigoid; cicatrix means scar
- Twice as common as pemphigus
- Avg age is 55; F:M 2:1
-
Oral lesions begin as vesicles or bullae which eventually rupture and leave ulcerated mucosa
- Intraoral blisters may be seen clinically (unlike with pemphigus); an intraoral blood blister is virtually pathognomonic
- Unlike other lesions in this disease, oral lesions usually don’t scar
-
Most significant complication is the ocular involvement (up to 25%)
- Earliest change can be detected via slit-lamp examination by an ophthalmologist
- As disease progresses, conjunctiva become inflamed and eroded; attempts at healing lead to scarring
-
Adhesions, called symblepharons, result
- Scarring can turn the eyelids inward (entropion), which causes the eyelashes to rub against the cornea
- Scarring can close opening of lacrimal glands
- After all this happens, the cornea produces keratin as a protective mechanism
- Keratin is opaque; this leads to blindness
- Blindness can also occur by the upper and lower eyelids scarring together
- Histopathologic features:
- Autoantibodies are directed against the basement membrane, leading to a subepithelial split (interepithelial)
- Direct immunofluorescence (DIF) shows C3 and IgG along the basement membrane
- Treatment:
- First part of treatment is to refer to an ophthalmologist, regardless of if the patient has symptoms
- Topical corticosteroids are used first; if they are unsuccessful, systemic agents may be used
Condensing Osteitis
Peripheral giant cell granuloma
With epithelium
Periapical cyst
histo know the def. saw tooth rete pegs (lichen planus)
Inflammatory Papillary Hyperplasia
Squamous Papilloma
Tonsilloliths
When the tonsillar crypts become filled with desquamated keratin and foreign material. Can be colonized with Actinomyces species. Only termed tonsillolith when it undergoes dystrophic calcification. No treatment unelss symptomatic, gargle salt water if you want.
Lymphoepithelial Cyst
(These are lymphoid aggregates most commonly found on floor of mouth, ventral tongue, and soft palate)
- Waldeyer’s ring (palatine tonsils, lingual tonsils, pharyngeal adenoids)
Lipoma
Condensing Osteitis
Geographic Tongue
Linea Alba
Florid Cemento-Osseous Dysplasia
Erythroleukoplakia
desmosomes, pemphigus vulgaris(histo picture)
Desquamative Gingivitis
Lichen Planus
Pemphigoid
Pemphigus
Hypersensitivity Reaction
Smoker’s Melanosis
Sialolith
Lichen Planus (Wickhan’s Striae)
Recurrent Herpes
Major Recurrent Aphthous Ulcer
Minor Recurrent Aphthous Ulcer
Tobacco Pouch Keratosis
Fibroma
Periapical Granuloma
(The most common periapical pathosis. Mass of inflamed granulation tissue at the apex of a nonvital tooth. Phoenix abscess= secondary acute inflammatory changes within a periapical granuloma. Plasma cells and lymphocytes = granuloma. Histology has mixed with like a spider web)
White Coated Tongue
Periapical Abscess
(If the histology is all blue with a bunch of cells, probably an abscess. Accumulation of acute inflammatory cells at the apex of a nonvital tooth)
Desquamative Gingivitis
(Used to describe gingival epithelium that spontaneously sloughs or can be removed with minor manipulation. The five different differentials of Desquamative Gingivitis are:
1) Lichen Planus
2) Mucous membrane pemphigoid
3) Pemphigus Vulgaris
4) Systemic Lupus Erythematosis
5) Hypersensitivity
Morsicatio
Buccarum, Labiorum, Linguarum
Drug-related Gingival Hyperplasia
Traumatic ulcer
Ameloblastic fibro-odontoma
Sialolith
Drug-Related Gingival Overgrowth
Abnormal growth of gingival tissues secondary to use of systemic medication:
Cyclosporine (transplant therapy) ~25%
Phenytoin (anticonvulsant) ~50% (meaning half of patients with Phenytoin get this)
Nifedipine (calcium channel blocker) ~25
Cementoblastoma
- Odontogenic neoplasm of cementoblasts
- 75% arise in the mandible, almost always in the molar/premolar region - know this
- Typically only affect permanent teeth
- 75% occur before age 30 - don’t need to know
- Pain and swelling are present in 2/3
- Via XRAY:
- RO mass that is fused to one or more tooth roots – Can look very similar to cemento-osseus dysplasia, but this fact highlighted is a hint that this is the better answer.
- Outline of the root or roots is usually obscured
- Surrounded by a thin RL rim
- Treatment is surgical extraction of the tooth with the calcified mass – it will keep growing because it is a neoplasm, so we take it out.
Antral Pseudocysts
- Common findings on panoramic XRAYS
- Appears as a dome-shaped, slight radiopaque lesion arising from the intact floor of the maxillary sinus
- Consists of an exudate (serum, not mucin) that has accumulated under the sinus mucosa and caused a sessile elevation
- Present in 2-15% of population
- No treatment necessary
Inflammatory Papillary Hyperplasia
Varicosities
Leukoedema
Periapical Abscess
Mucocele
Leukoplakia
Labial Melanotic Macule
Mucocele
Traumatic bone cyst
Peripheral Ossifying Fibroma
Leukoplakia
Sialolith
Ameloblastic Fibroma
- True mixed tumor - both epithelial and mesenchymal tissues are neoplastic – everything up to this point has been epithelial
- Occur in younger patients – usually before age 20
- Small tumors are asymptomatic; larger ones cause painless swelling
- 70% are located in the posterior mandible
- Via XRAY:
- Can be unilocular or multilocular
- Margins are well-defined and sclerotic
- 75% are associated with an unerupted tooth
- Conservative initial therapy seems appropriate; recurrences require more aggressive surgery
- 50% of the ameloblastic fibrosarcomas develop in the setting of a recurrent ameloblastic fibroma
Central Giant Cell Granuloma
- The histology is a cellular, vascular stroma with prominent multinucleated giant cells (Without the history or the radiograph, this image looks like other things, like a peripheral giant cell granuloma)
Erythroleukoplakia
Peripheral Ossifying Fibroma
Differ: dentigours cyst, okc, ameloblastoma central giant cell,
Primary Herpetic Gingivostomatitis
Morsicatio Labiorum
Nasopalatine duct cyst
Amalgam Tattoo
Amalgam Tattoo
Recurrent Herpes
Pyogenic Granuloma
- Not a true granuloma, but is a reactive lesion to local irritation or trauma (poor oral hygiene)
- May exhibit rapid growth
- Striking predilection for gingiva (75%), followed by lips, tongue and buccal mucosa
- Most common in children and young adults
- Smooth or lobulated mass that is typically pedunculated
- Surface is characteristically ulcerated and lesion bleeds easily
- Young lesions appear red; older lesions are more collagenized and pink
- Female predilection
- Frequently occurs in pregnant women, most commonly in the 1st trimester
-
a.k.a pregnancy tumor or granuloma gravidarum
- Some regress after pregnancy
- Treatment is surgical excision
- For gingival lesions, the excision should extend to periosteum and adjacent teeth scaled
- Lesions occasionally recur
- For lesions developing during pregnancy, defer treatment unless functional or esthetic problems develop
Fibroma
Nasopalatine Duct Cyst
Lymphoepithelial Cyst
Oral Melanotic Macule
Buccal Exostoses
Florid Cemento-Osseous Dysplasia
- Multiple focal involvement not limited to the anterior mandible
- Pts may just have lesions in the post jaws, but many patients have lesions throughout
- 90% are female; 90% are African American
- Occurs in middle-aged or older adults
- Marked tendency to be bilateral and symmetrical
- May be completely asymptomatic
- Via XRAY, lesions demonstrate an identical pattern of maturation noted in the other two forms:
- Initially, lesions are predominantly radiolucent
- Over time become mixed RL-RO
- End-stage lesions are predominantly radiopaque with a thin peripheral RL rim
- Involvement is unrelated to presence or absence of teeth
Erythroleukoplakia
Papilloma
Periapical Cemento-osseous dysplasia
Papilloma
With mixed inflammatory cells
Periapical granuloma
Eruption cyst
Odontoma (Complex)
- Most common odontogenic tumor
- Considered the late-stage of ameloblastic fibroma
- Considered to be developmental anomalies (hamartomas) rather than true neoplasms
- Divided into compound and complex types
- Compound – Composed of multiple, small, toothlike structures
- Complex- Conglomerate mass of enamel and dentin; bears no anatomic resemblance of a tooth
- Ave age – 15
- Completely asymptomatic
- Relatively small and discovered via XRAY when films are taken to determine the reason for failure of tooth eruption
- Usually associated with an unerupted tooth
- Compound is more common in anterior maxilla; complex is more common in the molar regions – he won’t ask us this.
- Compound odontoma, via XRAY:
- Appears as a collection of toothlike structures of varying size and shape
- Surrounded by a narrow RL zone
- Complex odontoma, via XRAY:
- Calcified mass with the radiodensity of a tooth
- Surrounded by a narrow, RL rim
- XRAY findings are usually diagnostic
- Odontomas are treated by simple local excision with an excellent prognosis
Denture Stomatitis
Odontoma- compound
Condensing Osteitis
Lymphoepithelial Cyst
Palatal Exostoses. They develop from the lingual aspect of the maxillary tuberosity.
Recurrent Herpes Labialis
Lymphoepithelial cyst
Ameloblastoma
“Honeycombed” appearance
- The typical radiographic feature is a multilocular radiolucency
- The lesion is described in one of two ways:
- “Soap bubble” – when the RL loculations are large
- “Honeycombed” – when the loculations are small
- **Buccal and lingual cortical expansion is frequently present**
- The lesion is described in one of two ways:
- Mixed so there is 4 things:
- COC
- CEOT
- AOT
- AFO
Primary Herpetic Gingivostomatitis
Tobacco Pouch Keratosis
Dentigerous Cyst
- Cyst that originates by separation of the follicle from around the crown of an unerupted tooth
- Apparently develops by accumulation of fluid between the reduced enamel epithelium and the tooth crown – If the space is more than 3 mm, than there is fluid in there and the cyst will grow. The lining is stratified squamous epithelium.
- Most common developmental cyst
- Encloses the crown of the unerupted tooth and is attached at the CEJ
-
Most often involve mandibular 3rd molars
- Rarely involve unerupted deciduous teeth
- Most frequently found in patients ages 10-30
- Completely asymptomatic & discovered on routine XRAY
- Usually do not, but can grow to considerable size & expand bone, cause facial asymmetry, etc.
- That’s why they must be removed (that and to rule out other cysts like OKC)
- Via XRAY:
- Unilocular radiolucency associated with crown of unerupted tooth
- Well-defined and usually sclerotic border
- Treatment is enucleation of the cyst together with the unerupted tooth
- Large examples may be treated by marsupialization
- Prognosis is excellent and recurrence is rare
Tramautic Ulcer
Focal Cemento-Osseous Dysplasia
- Exhibits a single sight of involvement
- 90% occur in females
-
Average age is 40 – middle-aged – this is the main age fact that we need to know for the test, no other ones
- On your boards, this is more common in Caucasians. However, for your professional life, realize that is due to a population bias of the survey; it is actually more common in African Americans.
- Most common place is posterior mandible
- Asymptomatic
- Lesions are smaller than 1.5 cm
- Via XRAY:
- Vary from completely radiolucent to densely radiopaque
- Lesions will have a thin radiolucent rim
- Differentiates from idiopathic osteosclerosis & condensing osteitis
- Most commonly, there is a mixed RL-RO pattern
- Lesion is usually well defined
Leukoplakia
Leukoplakia
Leukoplakia
Eruption Cyst
-
Soft tissue analogue of the dentigerous cyst – know this
- Develops as a result of separation of the dental follicle from around the crown of an erupting tooth
- Occurs within the soft tissues overlying the alveolar bone
- Appears as a soft, translucent swelling in the gingival mucosa overlying the crown of an erupting tooth
- Usually seen in children younger than 10
- Surface trauma may result blood to accumulate in the cystic fluid, which imparts a blue or purple color
- Called eruption hematomas
- Treatment may not be required
- Cyst usually ruptures spontaneously
- If this doesn’t occur, excision of the roof of the cyst permits eruption of the tooth
Geographic Tongue
Central giant cell granuloma
Stafne Defect
Smokeless Tobacco Keratosis (Tobacco Pouch Keratosis)
- Three types of smokeless tobacco:
- Chewing tobacco – men during outdoor activities
- Moist snuff – most popular
- Dry snuff – southern women
- Moist snuff’s sales have increased 75% in last 20 years
- Use is as high as 25% of men in southern states
- Habit is rarely initiated after age 20
-
Most common local change: characteristic, painless loss of gingival tissues in area of tobacco contact
- Gingival recession may be accompanied by destruction of facial surface of alveolar bone
- Correlates with quantity of daily use and duration of habit
- Gingival recession may be accompanied by destruction of facial surface of alveolar bone
- A brown-black extrinsic tobacco stain on the teeth is common
- Halitosis (bad breath) is a frequent finding
- A characteristic white plaque is produced on the mucosa in direct contact – termed smokeless tobacco keratosis
- Appears fissured or rippled
- NO: Induration, ulceration, pain
- Epithelial dysplasia is uncommon
- If present, it’s mild
- Treatment is alternating the site of tobacco placement
- Habit cessation leads to normal mucosal appearance in 98% of users, usually in 2 weeks
- A lesion remaining 6 weeks after habit is stopped requires biopsy
Denture Stomatitis
Recurrent Herpes Labialis
Tonsilolith
Erythroplakia
Ameloblastoma
Nasopalatine Duct Cyst
Lipoma
Parulis
Lymphoid Hyperplasia (Lingual Tonsil)
Condensing osteitis
Eruption cyst
Plasma Cell Gingivitis
Distinctive pattern of gingival inflammation
Most cases related to hypersensitivity (Big Red chewing gum from the cinnamon aldehyde)
Patients usually experience a rapid onset of sore mouth
Lymphoepithelial Cyst
Lichen Planus
Lipoma
Pyogenic granuloma
Ameloblastoma, OKC, central giant cell granuloma ( multi. Radiolucencys=OKC) gorlin syndrome!!
Periapical Cyst
(Inflammatory stimulation of epithelium in the area (Rests of Malassez), Can be found on side of the root – Lateral apical periodontal cyst. Cyst remains following extraction of the tooth – Residual apical periodontal cyst. The histology has white areas with epithelium around it)
OKC (tooth displaced)
Central giant cell granuloma, OKC, ameloblastoma. (if impacted tooth include dentigerous cyst)
Black/brown hairy tongue
Stafne defect
below mandibular canal
Inflammatory Papillary Hyperplasia
Eruption Cyst
Lymphoid Hyperplasia (Lingual Tonsil)
Orthokeratinized Odontogenic Cyst
- An odontogenic cysts with orthokeratinized lining and NO basal palisading
- Remember, OKC has parakeratin and a palisaded basal layer – Also, the granular cell layer is present in orthokeratinized, but not in parakeratinized, so it is found here, but not in odontogenic keratocyst.
- Occur in young adults
- 2:1 M:F
-
Most common in the posterior mandible – most of these occur in the posterior mandible, so I would remember the ones that DON’T occur in the posterior mandible.
- Typically unilocular
- Usually appear radiographically as a dentigerous cyst around a third molar
- Rarely recur after enucleation with curettage (around 2%)
Linea Alba
- Typically bilateral
- Located on the buccal mucosa at the level of the occlusal plane
Fordyce Granules
(Ectopic sebaceous glands, without the hair follicle, common in 80% of population)
Odontogenic Keratocyst
- Two most important things:
- 30% recurrence rate –They can come back more often, unlike the dentigerous cyst.
- Associated with a syndrome
- Arises from cell rests of the dental lamina
-
WHO has reclassified this lesion as the “keratocystic odontogenic tumor” (KOT) – Boards might use this name now.
- While this new terminology is being increasingly accepted and taught, most clinicians will refer to this lesion as an OKC
- Your boards will probably say KOT, so you need to know both
- Most cases are diagnosed between ages 10-40
- Posterior mandible is the most common location
- **Tend to grow in an anterior-posterior direction**
- OKC is also associated with displacing a tooth way up near the orbit
- Doesn’t cause bone expansion
- Via XRAY:
- Smaller lesions: well-defined, unilocular RL with corticated margins
- Larger lesions: Multilocular
- An unerupted tooth is involved in 1/3 of cases
- Typically does not resorb roots of adjacent teeth
-
Histopathology: - Know these characteristics
- Thin, friable wall
- Epithelial lining is a uniform 6-8 layers thick
- Basal cell (dark blue) layer shows palisading (standing up like soldiers) & is hyperchromatic
- Epithelium is surfaced by wavy or “corrugated” parakeratin (has nuclei)
- May have small satellite cysts away from primary lesion – “daughter cysts” – another reason why recurrence rate is higher.
- Biopsy is required for diagnosis
- Most lesions are treated with enucleation and curettage
- Complete removal is often difficult due to the friable nature of the cyst wall
- Recurrence is 30% and may happen 10 or more years after surgery (long-term follow-up required) – This is the main one we worry about recurring.
- If a patient age 20 or younger has an OKC, he or she should be further evaluated to rule out Gorlin syndrome
Lichen Planus
Pseudomembranous Candidiasis
Angular Cheilitis
Pyogenic Granuloma
Calcifying Epithelial Odontogenic Tumor
- **AKA Pindborg Tumor**
- Occurs around age 40
- M=F; md>mx; posterior>anterior
- Most common presenting sign is a painless, slow-growing swelling
- Via XRAY:
- Unilocular or multilocular
- Unilocular is more common in the maxilla
- Margins are typically scalloped & well-defined; may be corticated or ill-defined
- Frequently associated with an impacted tooth (most often a mandibular molar)
- Contains calcified structures of varying size and density
- Some believe the calcifications are prominent around the crown in a “driven-snow” pattern
- Occurs in 10%
- Unilocular or multilocular
- Histopathologic features: - know these histologic features, we won’t need to identify them though.
- Nuclear pleomorphism & atypia
- They secrete amyloid-like extracellular material; positive for Congo red, which exhibits an apple-green birefringence when viewed under polarized light
- Calcifications with concentric rings form in the amyloid-like areas (Liesegang rings)
- Conservative local resection with a narrow rim of bone is the treatment of choice
- Recurrence rate is 15%; highest with curettage as treatment
- Prognosis is typically good, but rare lesions can exhibit aggressive or malignant behavior
Fordyce Granules
Calcifying Odontogenic Cyst
- AKA Gorlin Cyst
- The WHO reclassified this entity to be calcifying cystic odontogenic tumor, but most clinicians refer to this entity as a Gorlin cyst
- 65% are found in the incisor-canine areas; mx=md
- Average age of pt is 35
- 20% are associated with odontomas
- XRAY features:
- Unilocular, well-defined radiolucency
- Radiopaque structures are seen within the RL in 50%
- 1/3 are associated with an unerupted tooth (usually canine)
- Histopathologic features:
- Has ghost cells, which can calcify
- Rare recurrences have been reported after enucleation
- Prognosis is good
Lichen Planus
- Common, chronic dermatologic disease that can affect the oral mucosa
- May be due to medications, amalgam, etc. – this is better known as “lichenoid mucositis”
- Patients are middle-aged adults; F>M
- Approximately 1% of the population is affected
-
Skin lesions are the 4 Ps:
- Purple
- Pruritus - itchy
- Polygonal
-
Papules – slightly raised
- Skin lesions itch, but the patient doesn’t usually scratch because they will hurt
- The skin papules will also have a thin, lacelike network of white lines termed Wickham’s striae
- There are two forms of oral lesions:
- Reticular
- Erosive
-
Lichen planus – Reticular – In most cases it is bilateral and that is a clue it is not leukoplakia
- Much more common than erosive form
- Asymptomatic
- Involves the posterior buccal mucosa bilaterally, seen as Wickham’s striae
- If it occurs on the tongue, the lesions will be plaque-like
- Lesions tend to wax and wane
- Lichen planus - Erosive
- Patients are symptomatic
- Lesions are atrophic, erythematous areas with a central ulceration
- Periphery is usually bordered by fine, white, radiating striae
-
If confined to the gingiva, it is termed desquamative gingivitis (differentials to desquamative gingivitis are pemphigus, pemphigoid, lichen planus, and hypersensitivity like Big Red)
- Becomes indistinguishable from pemphigus & pemphigoid, which may also be limited to the gingiva
- Drug-induced LP lesions are typically found on the lower lip as non-healing ulcers
- Histopathologic features:
- Pointed, “saw-toothed” rete ridges
- Destruction of the basal layer
- Band-like infiltrate of lymphocytes subjacent to the epithelium
- Degenerating keratinocytes within the epithelium (termed Civatte bodies)
- Deposition of fibrinogen at the basement membrane via DIF
-
No biopsy is needed if the lesions are:
-
Bilateral AND asymptomatic
- This is consistent with a clinical diagnosis of reticular oral lichen planus; no treatment is necessary
-
Bilateral AND asymptomatic
- Biopsy is indicated if the lesions are symptomatic or asymmetric
- Oral topical corticosteroids are used for treatment
- A few extra tidbits to help your patients:
- 28% of women with ELP have vaginal lesions
- Lesions can be induced with the following:
- S – Stress
- T – Trauma
- A – Advil (any NSAIDs, acetaminophen is ok)
Y – Yeast
Odontoma (compound)
Racial Pigmentation
Erythema Migrans
- AKA Geographic tongue (but if on locations other than tongue, called erythema migrans)
- AKA Benign migratory glossitis
- Common condition primarily affecting the tongue
- Affects up to 3% of the population
- F:M 2:1
- May be related to psoriasis
- Characteristically, the lesions appear on the anterior 2/3 of the dorsal tongue
- Concentrated on the tip & lateral borders
- May appear in other places but will have the serpentine border which helps with identification
- The lesions begin as multiple, small white patches which develop central erythematous atrophic zones and enlarge into well-demarcated zones of erythema
- These areas are surrounded at least partially by a slightly elevated, yellow-white, serpentine or scalloped border
- The lesions will heal in one area and then develop in a different area
- There is an association with fissured tongue
- Most patients are asymptomatic but may experience burning when eating spicy foods
- No treatment necessary for asymptomatic erythema migrans
- No biopsy required, It is a clinical diagnosis
- Patients should be assured they have a benign condition
If patients are symptomatic, topical corticosteroids are appropriate
Lateral Periodontal Cyst
- Developmental odontogenic cyst which typically occurs along the lateral root surface
- Arises from rests of dental lamina
- Intrabony counterpart of the gingival cyst of the adult (so the gingival cyst of the adult is the soft tissue counterpart)
- Found in pts ages 40-60
- Striking predilection to occur in the mandibular premolar-canine-lateral incisor area – know this for sure
- Teeth are vital
- Via XRAY, it appears as a well-circumscribed RL
- Occasionally, the lesion may appear polycystic
-
These are termed botryoid odontogenic cysts – Just know this definition, it is a Lateral Periodontal Cyst that is multilocular.
- Botroid means “grapelike”
- Usually appear multilocular via XRAY
- Represents a variant of the LPC
-
These are termed botryoid odontogenic cysts – Just know this definition, it is a Lateral Periodontal Cyst that is multilocular.
- Occasionally, the lesion may appear polycystic
- Conservative enucleation is treatment
- Recurrence and/or malignant transformation is exceedingly rare
Tramautic Bone Cyst
With Neutrophils
Abscess
Lateral Periodontal Cyst
Lichen Planus (erosive)
Sialolith
Fordyce granules
Glandular Odontogenic Cyst
- Developmental cyst with glandular and/or salivary gland features
- The most recently named Odontogenic Cyst
- Second most common to cross midline, next to central giant cell granuloma, if a tooth is involved, assume GOC rather than CGCG
- Avg age = 50
-
75% of cases occur in the mandible
- Predilection for anterior jaws – know this
- Size can vary from small to very large
- XRAY:
- Either unilocular or multilocular radiolucency
- Well-defined margins
- Sclerotic rim
- Treatment is enucleation or curettage
- 30% will recur – The other one with 30% recurrence rate is odontogenic keratocyst
- Multilocular lesions are more likely to recur than unilocular lesions
- Therefore, en bloc resection is used at times
Ranula
- Mucoceles in floor of mouth, usually lateral to the midline - A ranula can become a plunging ranula by dissecting through the mylohyoid muscle, cause swelling, close off the airway, and kill the patient. This also could be called a dermoid cyst.
- Typically associated with rupture of the sublingual gland duct
- Treatment:
- Removal of the feeding sublingual gland and/or marsupialization
- Marsupialization (exteriorization) entails removal of theroof of the intraoral lesion
- Removal of the feeding sublingual gland and/or marsupialization
Stafne Defect
Angular Cheilitis
Pseudomembranous Candidiasis
Central Giant Cell Granuloma
- Considered a nonneoplastic lesion
- Some demonstrate aggressive behavior
- Most cases occur before age 30; F>M; Md>Mx
- **More common in the anterior jaw; frequently cross the midline** - know this (the most common two things that cross the midline are this one and glandular odontogenic cyst)
- Most are asymptomatic & discovered during routine XRAY or due to painless bone expansion
- A minority of cases are aggressive & associated with pain, paresthesia, & perforation of the cortical plate
- XRAY:
- Not diagnostic
- Radiolucent lesions which may be multilocular or unilocular
- Typically well-delineated (different from corticated)
- Noncorticated margins (usually slow growing ones have corticated rims, but this picture above is more aggressive and not slow so it corticated)
-
The histopathology is identical to a brown tumor of hyperparathyroidism (so patients MUST be evaluated for this condition) and lesions of cherubism.
- Histology is a cellular, vascular stroma with prominent multinucleated giant cells (Without the history of the radiograph, this image on the right looks like other things, like a peripheral giant cell granuloma)
-
Treatment is curettage with a recurrence of 20% - if small enough
- Likelihood of recurrence is greater in young patients
- Most recurrent lesions respond to further curettage
- New treatments are used with aggressive tumors, such as injections of corticosteroids – if large
- Long term prognosis is good; there is no risk for metastasis
Parulis
Inflammatory papillary hyperplasia
Pyogenic Granuloma
Peripheral Ossifying Fibroma
- Occurs exclusively on the gingiva – Usually tissue colored
- Appears as a nodular mass, usually originating from the dental papilla
- Average age is 15 (teenagers and young adults 10-19)
- 2/3 occur in females
- 50% of cases occur in the incisor-cuspid region
- Treatment is excision down to periosteum and scale adjacent teeth
- 15% recur (usually because the base of the lesion was not removed)
Inflammatory Papillary Hyperplasia (IPH)
- Reactive tissue growth that develops under a denture
- Condition is related to:
- Ill-fitting denture
- Poor denture hygiene
- Wearing denture 24h a day
- 20% of patients who continuously wear their denture have IPH
- Typically occurs on the hard palate
- Asymptomatic, erythematous tissue with a pebbly or papillary surface
- Most patients also have a Candidal infection
- For very early lesions, removal of the denture may allow healing
- Condition may show improvement after antifungal therapy
- For more advanced lesions, treatment is surgical removal
Lateral periodontal cyst
premolar-canine-lateral incisor area
Leukoedema
Stretch that thang
Torus Mandibularis
Periapical Granuloma, Cyst, or Abscess
Idiopathic Osteosclerosis
Eruption Cyst
Traumatic Ulcerations
- Acute or chronic trauma can cause surface ulcerations
- Most common injuries are on lips, tongue, and buccal mucosa
- Injured from dentition
- Appears as areas of erythema surrounding a central removable, yellow fibrinopurulent membrane
- A rolled white border of hyperkeratosis can develop immediately adjacent to the ulceration
- Unique form of chronic traumatic ulceration is termed eosinophilic ulceration or TUGSE
-
Traumatic Ulcerative Granuloma with Stromal Eosinophilia
- Exhibits a deep pseudoinvasive inflammatory process and is slow to resolve – Looks just like oral cancer on the lips or even the tongue, ask them about it’s history, and see if rest of lips have been sunburned, etc.
- Incisional bx (biopsy) is usually curative
-
Traumatic Ulcerative Granuloma with Stromal Eosinophilia
- Riga-Fede disease are chronic ulcerations found under the tongue in infants due to trauma from nursing
- Treatment is to remove source of injury if possible
- Medications for pain relief – topical analgesics
- Biopsy is warranted in cases that do not resolve after 2-4 weeks
OKC (know histo!) easy cheese
Recurrent herpes
Periapical Cemento-Osseous Dysplasia
- Involves the periapical region of the anterior mandible
- Multiple foci are usually present
- 90% are female; 70% in African Americans
- Average age = 40 – same thing, middle-aged women
- Teeth are invariably vital
- Asymptomatic and discovered when XRAYs are taken for other reasons
- Early lesions are circumscribed areas of RL involving the apex of a tooth – this lesion looks identical to that of a periapical granuloma or cyst
- Lesions “mature” over time to have a mixed RL-RO appearance
-
End-stage lesions are densely RO with a RL rim
- The PDL will be intact; the lesion will NOT fuse to the tooth
- Each lesion is self-limiting and progressive growth does not occur
Papilloma
Tobacco Pouch Keratosis
Nasopalatine Duct Cyst
With hard tissue histo
Peripheral ossifying fibroma
Dentigerous Cyst
Smoker’s melanosis
Nasopalatine Duct Cyst
Drug-Related Gingival Hyperplasia
Squamous Papilloma
- Benign proliferation of stratified squamous epithelium
- Results in a papillary mass
- Caused by human papillomavirus (HPV)
- DNA virus of the papovavirus subgroup
- Types 6, 11 (We will be tested on these for boards and probably for him
- Mode of trasmission is unknown
Sites of predilection:
- Tongue
- Lips
- Soft palate
Clinically:
- Painless
- Usually pedunculated (The base is smaller than the top)
- Exophytic
- Pointed or blunted projections
- White, red, or mucosal colored
- Enlarges rapidly to 5 mm, then stabilizes
Central Giant Cell Granuloma
Odontoma (Complex)
Lateral periodontal cyst ( botryoid-grapelike)
Papilloma
Erythroleukoplakia
- Red and white intermixed lesions are termed erythroleukoplakia or speckled leukoplakia
Abscess (periapical)
Odontogenic Keratocyst
- Adenomatoid odontogenic tumor
- AOT
- CEOT
- COC
- AFO
periapical cement-osseaus dysplasia (middle age female, A.A> caucasains) except focal.
Epulis Fissuratum
Varicosities
Tonsilolith
Parulis
White Coated Tongue
Varicosities
Pseudomembranous Candidiasis
Palatal Tori
Parulis
Torus/exostosis
buccal and palatal exostosis
torus palatinus
Sialolith (Salivary Stones)
- Calcifications developed in salivary duct
- Often in submandibular gland, upper lip, buccal mucosa
- Long and tortuous duct with thick secretions - Submandibular
- Pain or swelling especially at meal time
- Radiograph, sialography, ultrasound, CT
- TX: gentle massage, increase fluid intake, moist heat, sialogogue, surgery
- Etiology is calcification of salivary secretions within the duct system
- Anything that slows or inhibits salivary flow thru the duct system may predispose to development of calculi
- Mucous plug
- Bacterial colonies
- Chronic duct blockage phenomena
- Normal ductal anatomy (Wharton’s duct)
- Xerostomia
- Typically are not associated with elevated serum calcium levels
Adenomatoid Odontogenic Tumor
- Occurs in young patients, ages 10-20
- Very uncommon in patients over the age of 30
- *Striking tendency to occur in the anterior jaws
- *Mx>Md
- *F:M 2:1
- Most are relatively small; may also rarely occur peripherally
- **Asymptomatic and discovered during XRAY to determine why a tooth hasn’t erupted**
-
*In 75% of cases, the tumor is a circumscribed, unilocular RL involving the crown of an unerupted tooth*
- Most often a canine tooth – helps distinguish it from the other differentials like dentigerous cyst.
- RL often extends apically past the CEJ; this can help differentiate from dentigerous cyst
- Lesion may contain fine, snowflake calcifications via XRAY – can also help differentiate from dentigerous cyst – so mostly radiolucent, but some calcifications, so the differentials for this combination are adenomatoid odontogenic tumor, calcifying odontogenic cyst, and calcifying epithelial odontogenic tumor. (AFO is also differentials, next page down, also, desmoplastic amelofibroma)
- If around impacted canine, it would be AOT
- Unilocular radiolucency in between canine and premolar roots, lateral periodontal cyst.
- If it is a 10 year old child (you can tell from teeth), posterior mandible, impacted tooth, mixed radiolucency and radiopaque, then AFO is the answer.
- Lesion may also develop as a well-defined, unilocular RL between roots
- Tumor has a thick, fibrous capsule that makes enucleation easy
- Recurrence doesn’t occur; lesion is completely benign & aggressive behavior has not been documented
- Prognosis is good
Peripheral Giant Cell Granuloma
Hypersensitivity Reaction
Leukoedema
Sialolith (Salivary Gland Secretion, Submandibular)
Tonsilloliths
Amalgam tattoo
Minor Recurrent Apthous Ulcer
- Occurs in childhood
- Pts have the fewest recurrences
- Lesions are shorter in duration than other variants
- Pts typically have a prodrome
- Lesions present as erythematous macule followed by a central yellow-white, removable fibrinopurulent membrane
- Ulcerations are less than 1 cm
- Heal without scaring in 1-2 weeks
- 1 to 5 lesions per episode
- Much more painful than they appear
Fibroma
Linea Alba
Geographic Tongue
(Remember that it is called erythema migrans when it is not found on the tongue, and might end up looking like leukoedema, often patients with fissured tongue are affected, usually doesn’t, but may burn or hurt)
Denture Stomatitis
- “Chronic atrophic candidiasis”
- Localized to denture-bearing areas of a maxillary removable denture
- Striking clinical appearance, but asymptomatic
- Pt wears denture continuously
- Denture harbors most of the organism
- Remember to treat both the soft tissues and the denture (recurrence)
Racial pigmentation
Idiopathic osteosclerosis
Oral Melanotic Macule
Antral Pseudocyst
Mucocele (Mucus Extravasation Phenomenon)
- Spillage of mucin into the soft tissues due to rupture of a salivary gland duct, usually caused by trauma
- Children and young adults
- Most common in the lower lip (81%), FOM (ranula), anterior ventral tongue, buccal mucosa
- Treatment: surgical excision, remove with the adjacent minor salivary gland
- Submit to pathology
- Important clinical distinctions:
- Clinical mucoceles of the upper lip are more likely to be a salivary gland tumor
- Mucoceles of the retromolar region are distinctly unusual
- Most will prove to be mucoepidermoid carcinoma
Antral Pseudocyst
Major Recurrent Apthous Ulcer
- Occurs more in adolescents
- “Sutton’s Disease” is associated with these, for boards
- Larger than minor aphthae
- Demonstrate the longest duration per episode when compared to other variants
- Measure 1-3 cm in diameter
- Take 2-6 w to heal
- May cause scarring
- Number of lesions per episode is 1-10
-
Most commonly involved:
- Labial mucosa
- Soft palate
- Tonsillar fauces
Florid cement osseus dysplasia
Mucous Membrane Pemphigoid
Lymphoepithelial Cyst
Focal Cemento-osseous dysplasia
Torus Palatinus. Occur in the midline of the hard palate.
Residual Cyst
Traumatic Bone Cyst
- Also known as simple bone cyst
- Benign, empty or fluid filled cavity within bone
- **“Cyst” is a misnomer because the lesion does not have an epithelial lining** - know this
- Trauma-hemorrhage theory is the most widely accepted etiology:
- Trauma to the bone which is insufficient to cause a fracture results in intraosseous hematoma
- If the hematoma does not undergo organization & repair, it may liquefy and result in a defect
- Majority of simple bone cysts are found in long bones
- In the jaws, they are found in pts aged 10-20
- Almost exclusively found in mandible
- Asymptomatic; 20% have a swelling
- XRAY:
- Well-delineated
- Radiolucent
- Margins can be ill- or well-defined
- **When several teeth are involved, the defect shows domelike projections that scallop between the roots; this feature is highly suggestive** - know this
- Teeth are vital
- Radiographic features are suggestive but not diagnostic
- Surgical exploration is necessary
- Little or no tissue will be obtained, so the diagnosis is made with the clinical & radiographic features together with surgical findings
- During surgery, the wall of the cavity should be curetted to rule out thin-walled lesions
- Surgical exploration is curative; there will rapid obliteration of the defect by new bone formation
- Periodic XRAYs should be taken until complete resolution has occurred; the prognosis is excellent
Odontogenic keratocyst
CEOT
Melanotic macule
Oral
Labial
Nasopalatine Duct Cyst
(Most common non-odontogenic cyst of oral cavity. 6mm diameter is upper limit of normal size for incisive foramen. Biopsy is mandatory because the lesion cannot be diagnosed radiographically. It would be called cysts of the incisive papilla if it rested just in the soft tissue, without bony involvement)
Herpetiform Recurrent Aphthous Ulcer
Morsicatio Linguarum
Idiopathic Osteosclerosis
Lichen Planus
Labial Melanotic Macule
Tobacco Pouch Keratosis
Lichen Planus
Peripheral Ossifying Fibroma
Oral Melanotic Macule
- Oral counterpart to the ephelis
- Brown asymptomatic macule produced by a focal increased in melanin deposition
- Not dependent on sun exposure
- Most common site = vermilion zone of the lower lip (labial melanotic macule) (If it is on the lip, call it labial, not oral)
- 80% are solitary
- No malignant transformation potential but cannot distinguish clinically from early melanoma; therefore, biopsy is mandatory
- If the histology has pigmentation along the basement membrane of the lesion, then it is a melanotic macule, and not melanoma.
Fordyce Granules
Mucocele
Amalgam Tattoo
Amalgam can be incorporated into the oral mucosa in several ways:
- Previous areas of mucosal abrasion can be contaminated by amalgam dust within the oral fluids
- Broken amalgam pieces can fall into extraction sites
- Contaminated dental floss can create linear areas of pigmentations
- Endodontic retrofill can be left in the soft tissue
- High-speed drills can drive fine particles in tissue
Amalgam tattoos appear as macules or (rarely) as raised lesions which are blue, black, or gray in color
Any mucosal surface can be involved; the most common sites:
- Gingiva & alveolar mucosa
- Buccal mucosa
PA XRAYS are usually negative
When metallic fragments are visible on the XRAY, the clinical area of discoloration is large and extends past the size of the fragment
To confirm diagnosis, the clinician can take an XRAY of the affected areas
- No treatment required if it can be detected via XRAY
- However, biopsy must be done if not in order to rule out melanoma
Leukoedema
Idiopathic Osteosclerosis
-
Focal area of increased radiodensity that is of unknown cause and cannot be attributed to anything else
- Do not confuse with condensing osteitis, which is associated with an infection – the clue for condensing osteitis is that the tooth will have deep caries or a deep filling/root canal, because it is associated with an infection. If virgin tooth with no caries, then not condensing osteitis.
- Do not confuse with focal cemento-osseous dysplasia, which will have a radiolucent rim
- Do not confuse with cementoblastoma, which will be fused with the tooth
- Affects approximately 5% of Americans
- Most cases arise in teenage years and remain static
- Invariably asymptomatic
- No cortical expansion
- 90% in the mandible
- Via XRAY:
- Well-defined, round or elliptical, radiopaque
- Usually associated with root apex, 20% aren’t
- Vary from 3mm to 2cm in greatest diameter
- A radiolucent rim does NOT surround the lesion
- Diagnosis can be made based on history, clinical features, and radiographic findings
- Biopsy is considered only if there are symptoms, continued growth, or cortical expansion
- If lesion is discovered during adolescence, periodic XRAYs are prudent until the area stabilizes; after that, no treatment is necessary
Pemphigus Vulgaris
Lichen Planus (erosive)
Pseudomembranous Candidiasis
What are the different levels of scoring for T, Primary Tumor Size, for TNM staging, for SCCA?
Erythema Migrans
Geographic Tongue
Epulis fissuratum
Ameloblastoma (reverse polarity, apical vacuolization and palisading)
Lateral Periodontal Cyst
Angular Cheilitis
Condensing Osteitis
Localized area of bone sclerosis associated with apices of teeth with pulpitis (The bone tries to get hard and form bone and become more radiopaque to get rid of the infection and protect itself). Association with inflammation is critical in diagnosis (radiographically identical to idiopathic osteosclerosis).
XRAY changes:
Increased RO adjacent to tooth apex that has a thickened PDL or apical inflammatory lesion
No RL border (distinguishes from focal cemento-osseous dysplasia)
Not separated from apex (distinguishes from idiopathic osteosclerosis)
No clinical expansion of bone
85% regress after odontogenic infection is eliminated
Residual areas are termed bone scars
Mandibular Tori
- Desquamtive gingivitis:
- Pemphigus
- Mucus membrane pemphigo
- Lichen Planus
Lymphoid Hyperplasia
- Enlargement of lymphoid tissue
- Typically due to infection
- May affect the lymph nodes, Waldeyer’s ring, or aggregates of lymphoid tissue scattered throughout the oral cavity
- Aggregates of lymphoid tissue are most commonly seen:
- Oropharynx
- Soft palate
- Lateral tongue
- Floor of mouth
- With acute infections, the lymphoid hyperplasia (tonsillar) appears as enlarged, tender, soft, freely movable nodules
- Chronic infection (tonsillar) produce enlarged, nontender, firm, freely movable nodules
- Chronic hyperplastic lymph nodes may be difficult to distinguish clinically from lymphoma
- Tonsillar size is variable from patient to patient
- Lymphoid tissue is usually more prominent in younger patients; peaking around age 20, then decreasing in size
-
If large tonsils are symmetrical and asymptomatic, it is likely they are normal for that particular patient
- Tonsillar asymmetry is a potentially serious sign that should be further evaluated to rule out a metastatic tumor or lymphoma
- Intraoral lesions appear as discrete, nontender, submucosal swellings
- May be normal in color or yellow
- If lesions appear on the posterior lateral tongue, they are usually bilateral
- Biopsy is usually necessary to establish diagnosis
Once diagnosis is confirmed, no treatment is required
Ameloblastoma
“Resorption of Roots is Common”
- “Soap bubble” – when the RL loculations are large
- “Honeycombed” – when the loculations are small
- **Buccal and lingual cortical expansion is frequently present**
Gingival Cyst of the Adult
- **Represents the soft tissue counterpart of the lateral periodontal cyst** - know this
- Derived from rests of dental lamina (rests of Serres)
- Striking predilection to occur in the mandibular canine & premolar area
- Most commonly found in pts age 40-50
- Invariably located on the facial gingiva or alveolar mucosa
- Painless, dome-like swellings which are less than 5mm
- May be blue in color
- Surgical excision with is sufficient treatment
Leukoplakia
Mucocele
Ameloblastoma
Lipoma
- Benign tumor of fat
- By far the most common mesenchymal (non-epithelial, so soft tissue) neoplasm – Know this, but more common on the trunk
- More common in obese patients, but the metabolism is independent of normal body fat
- Appear as soft, smooth-surfaced nodular masses
- Lesion may be yellow or mucosal-colored or white
- 50% occur in the buccal mucosa
- Most patients are older than age 40
- Float in formalin (helps with diagnosis)
- Surgical excision is curative
Tobacco Pouch Keratosis
Herpetiform Recurrent Apthous Ulcer
- Occurs more commonly in adults
- Greatest number of lesions and recurrences of the three clinical variants
- Lesions are 1-3 mm in diameter (smallest)
- Up to 100 ulcerations per occurrence (Remember that these are similar to herpetic ulcers, but these are on movable mucosa)
- Ulcerations heal within 7-10d
- Closely spaced recurrences
- May have continuous lesions for three years
- F>M
- Occurs in adulthood
Sialolith
Odontogenic Keratocyst
Antral pseudocyst
Black Hairy Tongue
Lipoma
Concrescence
(Union of two adjacent teeth by cementum alone without confluence of underlying dentin.)
Central Giant Cell Granuloma
Calcifying odontogenic cyst
Black Hairy Tongue
Pemphigus
- The term ‘pemphigus’ represents four related diseases
- Pemphigus vulgaris
- Pemphigus vegetans
- Pemphigus erythematosus
- Pemphigus foliaceus
- Our discussion is limited to pemphigus vulgaris, the most common of the disorders and affects the oral mucosa
-
Oral lesions are the first sign of the disease and the last to resolve with therapy
- “First to show, last to go”
-
Autoantibodies are directed against the desmosomes
- Desmosomes bond epithelial cells to each other
- Therefore, there is a split within the epithelium (intraepithelial split)
- Initial manifestations will affect the oral mucosa in adults, around age 50
- M=F
- Patients complain of oral pain and will exhibit multiple erosions throughout on intraoral examination
- Patients rarely report vesicle or bulla formation intraorally
- Likely due to early rupture because of the thin roof of the blisters
- Skin lesions are flaccid vesicles and bullae that rupture quickly and leave an ulceration
- Skin lesions are the most complicated involvement
- Without treatment, the oral & cutaneous lesions are progressive
- A characteristic feature is a positive Nikolsky sign: Bulla can be induced on normal-appearing skin if firm lateral pressure is exerted
- Histopathologic features:
- Cells of the epithelium “fall apart” – termed acantholysis
- The loose cells are rounded and termed Tzanck cells, which can be useful in diagnosis
- Remember, the Tzanck cells aren’t exclusive to pemphigus vulgaris – this is also a histopathologic feature of herpes
- Direct immunofluorescence (DIF) is positive for C3 and IgG within the epithelium
- Indirect immunofluorescence (IIF) correlates with disease activity
- Before the development of corticosteroids, 90% died due to infection and electrolyte imbalances
- Today, treatment is to send to a dermatologist, who will administer systemic corticosteroids
- This is often in combo with other immunosuppressive drugs
- 75% will have disease resolution in 10 years
- 15% will remain on steroids throughout life
- 10% succumb to disease, often due to complications of long-term steroid use
- Hailey-Hailey Disease has “test-tube” like ridges, and it is also called Familial Pemphagus
Pyogenic Granuloma
Smoker’s Melanosis
Ameloblastic Fibro-Odontoma
- Histologically appears similar to ameloblastic fibroma, except it also has enamel and dentin
- We believe that these tumors start as an ameloblastic fibroma, become ameloblastic fibro-odontomas, and then just become odontomas.
- Avg age is 10
- Occurs in the posterior jaws
- Small lesions are asymptomatic; large lesions are associated with a painless swelling
- Via XRAY:
- Well-circumscribed unilocular radiolucency
- Contains varying amounts of calcified material
- Typically associated with an unerupted tooth
- Treated with conservative curettage with rare recurrence
Primary herpetic gingivostomatitis
Residual Cyst
Primary Herpetic Gingivostomatitis
Torus Mandibularis. Develop along lingual aspect of mandible.
Eruption Cyst
Denture Stomatitis
Lichen Planus
Pseudomembranous Candidiasis
- Best recognized form
- Thrush
- Cottage cheese white plaques
- Can remove with gauze
- If underlying mucosa bleeds, more likely of lichen planus occuring as well
- Can happen from antibiotics, immunocompromised, asthma inhalers
Erythroleukoplakia
Erythema Migrans
Calcifying epithelial odontogenic tumor (CEOT)
Pinborg Tumor
Turner’s Hypoplasia
(Enamel defects seen in permanent teeth caused by periapical inflammatory disease of the overlying deciduous tooth, limited to one tooth. Turner’s Tooth. Most commonly seen in the permanent bicuspids because of their relationship to the overlying deciduous molars)
Traumatic bone cyst (simple bone cyst)
Most often with the canine
Adenomatoid odontogenic tumor
Morsicatio Buccarum
Morsicatio Buccarum
- Scientific term for chronic cheek chewing
- Morsicatio is from the Latin morsus meaning bite
- Name for lesions found elsewhere:
- Morsicatio labiorum (labial mucosa)
- Morsicatio linguarum (tongue)
- Higher prevalence in those under stress or with psychologic conditions
- Typically found bilaterally on the anterior buccal mucosa
- Appear as thickened, shredded white areas which may be ulcerated
- No treatment is required; not a premalignant condition
Smoker’s Melanosis
- Nicotine stimulates melanin production
- 20% of tobacco smokers have oral pigmentation (3% in nonsmokers)
- Most commonly affects anterior facial gingiva
- Reverse smokers show changes on hard palate
- Cessation of smoking results in gradual disappearance
- Biopsy is considered when pigmentation is in unexpected locations or if there are clinical changes
central giant cell granuloma,, ameloblastoma, OKC ( glandular odontogenic?) (know differ)
Dentigerous cyst
Ameloblastoma
- Most common clinically significant odontogenic tumor – because of its recurrence rate, but odontoma is the most common odontogenic tumor in general.
- Tumors of odontogenic epithelial origin
-
Three different types – board question:
- Conventional solid or multicystic – 85% - This is multilocular, has the worst prognosis
- Unicystic – 15%
- Peripheral – 1%
- Equal prevalence in the 3rd – 7th decade
- No sex predilection
- 85% occur in the mandible, usually the molar-ascending ramus area – board question
- Tumor is asymptomatic; smaller lesions are detected only during routine XRAY
- If there is a clinical sign, it’s most often a painless swelling
- If untreated, can grow to grotesque proportions – even then, pain & paresthesia are uncommon
- Ameloblastoma
- The typical radiographic feature is a multilocular radiolucency
- The lesion is described in one of two ways:
- “Soap bubble” – when the RL loculations are large
- “Honeycombed” – when the loculations are small
- **Buccal and lingual cortical expansion is frequently present**
- Resorption of roots is common
- An unerupted tooth may be associated with the defect
- The lesion is described in one of two ways:
- Six patterns: - we do not need to know these patterns
- Follicular – most common
- Plexiform – 2nd most common
- Acanthomatous – has keratin
- Granular cell
- Basal cell – very rare
- Desmoplastic – see below
-
The desmoplastic ameloblastoma does not share features with the other forms:
- Predilection for the anterior maxilla
-
May be mixed radiolucent-radiopaque – similar to calcifying odontogenic cyst
- Due to osseous metaplasia
- Histopathologic features:
- **Palisading**, hyperchromatic basal layer – odontogenic keratocyst also has hyperchromatic
- **Reverse polarity** - nucleus is on opposite side of where it usually is
- You also have a red, white, and blue layer sequence on histology
- The three differentials for a multilocular (really any locular) radiolucency around an impacted tooth are dentigerous cyst, odontogenic keratocyst, ameloblastoma, central giant cell granuloma. And if you see root resorption, you would think ameloblastoma. If it is unilocular, most likely a dentigerous cyst (especially if with a tooth), then OKC, then eruption cyst.
- And if it crosses the midline, then glandular odontogenic cyst, CGCG, OKC, and ameloblastoma are the biggest, but if tooth is involved, CGCG drops to bottom of list.
- Apical vacuolization
- Patients with conventional solid or multicystic ameloblastomas are treated in a variety of ways, from simple enucleation & curettage to en bloc resection
- Ameloblastomas infiltrate between cancellous bone at lesion periphery
- In early stages, bone resorption cannot be seen via radiograph
- Curettage have recurrence rates anywhere from 50 – 90%
- Recurrence takes years
- Marginal resection is the most widely used treatment; recurrence rate is 15%
- Some surgeons take 1.5 cm margins beyond what is visible radiographically
Leukoplakia
Tramautic Ulcer
Residual cyst
site of extraction
Drug-related gingival hyperplasia
Mandibular Tori
Leukoedema
(Noticeable in African Americans, if you stretch the skin and it disappears, then it is most likely leukoedema, if not, then most likely leukoplakia, lichen planus, or erythema migrans (which is geographic tongue not found on the tongue))
- Dentigeour
- Dentigerous cyst
- OKC
- Ameloblastoma
Lymphoid Hyperplasia (Lingual Tonsil)
Cementoblastoma
Lingual tonsil
Lymphoid hyperplasia
Florid Cemento-osseous dysplasia
