Oral Cavity

Question 1

Histology of Oral Cavity

Answer 1

Squamous Epithelium, Focally Keratinized

Question 2

Pulp Chamber

Answer 2

Has nerve, pain receptors, capillaries, lymphatics, CT

When pulp is exposed to microbes, get inflammatory response

Question 3

Cementum

Answer 3

Hydroxyapatite and collage at root
Anchors periodontal ligament to alveolar bone
Avascular

Question 4

Periodontal ligament

Answer 4

“Multipotential cells”

Provides nutrients & vascularity for cementoblasts

Question 5

Bacterial Succession

Answer 5

1st colonizers: S. mutans
2nd colonizers: Prevotella intermedia, Porphyromonas gingivalis
3rd colonizers: Actinomycetem comitans

Question 6

Plaque and Micros

Answer 6

Micros that form the biofilm are mainly Strep mutans and anaerobes.
ECM contains proteins, long chain polysaccharides, and lipids

Question 7

Dental Caries Pathologies

Answer 7

1. Absorption of proteins + biofilm
2. Secondary colonizers attach to primary colonizers
3. Cells divid + form biofilm that hardens in 48hrs

Plaque+Lactic acid +Low pH –> dissolve Ca Phosphate of enamel

Question 8

Caries Risk Factors

Answer 8

Sugar, processed foods, Xerostomia, meds, Sjogrens

Systemic risk of sepsis from flossing and brushing

Question 9

Caries Complications

Answer 9

Fistula, Periosteal abscess, Radicular cyst
Cavernous sinus thrombosis
- internal carotid aa can become thrombosed and infected
- abducens n can be affected
- presents w/swollen eye, lateral gaze palsy, horizontal diplopia, headache
Ludwig’s angina - compromise airway

Question 10

Gingiva & Periodontium

Answer 10

Plaque deposits beneath the gum line - gingivitis
Inflammation of gingiva is usually due to poor oral hygiene
Erythema, edema, bleeding, change in contour, soft tissue damage

Question 11

Periodontitis

Answer 11

Can be due to poor oral hygiene due to genetics, diabetes, smoking, Ehlers-Dantos
Healthy periodontium - facultative gram positive organisms
Active periodontium w/plaque - anaerobic & microaerophilic gram negative flora
Adult periodontitis - Actinobacillus most common

Question 12

Periodontal Disease

Answer 12

Mild - 1-3mm of attachment loss
Moderate - 4-5mm of loss
Severe - > 6mm of loss

Affects cementum, periodontal ligament and alveolar bone leading to loss of tooth

Question 13

Periodontitis: Component of Systemic disease

Answer 13

Acquired immunodeficiency syndrome (AIDS)
Leukemia
Diabetes mellitus
Sarcoidosis
Congenital
   - Kostmann’s Disease =
      Severe Congenital
       Neutropenia, deficient
       defensins and LL-37
   - Chediak-Higashi syndrome
agranulocytosis,cyclic neutropenia

Question 14

Periodontitis: May cause Systemic disease

Answer 14

Infective endocarditis
Pulmonary abscess
Brain abscess
Adverse pregnancy outcome

Question 15

Aphthous ulcer “canker sore”

Answer 15

Painful ulceration of oral cavity mucosa.
Occur primarily in young adult
Not contagious
Very common aged 12-25 W>>M
Uncommon after 45
Rare assoc w/celiac or IBD

Question 16

Initial HSV-1 Infection - Two Patterns

Answer 16

90% age 2 to 4 yr; asymptomatic or mild, transient orofacial blisters

10% Acute Herpetic Gingivostomatitis numerous variable-size mucosal ulcers

Question 17

Oral Candidiasis

Answer 17

~50 % healthy adults have Candida albicans in oral cavity

Risk for oral candidiasis: immunosuppressed (HIV, chemoRx, ect.) or newborn infants

Lesions: white, cheesy, “velvety”, easily scraped away with little or no bleeding

Question 18

Oral Hairy Leukoplakia

Answer 18

Two Factors: Immune Suppression (80% have HIV-1) + Epstein-Barr Virus (EBV)
Resembles ‘thrush’, but doesn’t scrape off
May be first sign of HIV
“balloon cells”

Question 19

(Black) Hairy Tongue

Answer 19

Condition of defective desquamation of the filiform papillae.
Basic defect in hairy tongue is a hypertrophy of filiform papillae on the dorsal surface of the tongue
Factors are numerous and include tobacco use and coffee or tea drinking

Question 20

Irritation Fibroma

Answer 20

Occur on tongue or buccal mucosa - bite line
Result of repetitive trauma
Reactive fibroblastic tissue
Treated by surgical excision

Question 21

Pyogenic Granuloma

Answer 21

Occur gingiva, tongue
Common in pregnancy (pregnancy tumor) and in children, young adults
Exuberant, Reactive granulation tissue

Question 22

Cancer of the Oral Cavity

Answer 22

95% are Squamous Cell Carcinomas; 5% are Adenocarcinomas of Salivary Glands

Oral Cavity…Usually Tobacco and Alcohol
- India-chewing betel quid & paan
- Subcategory < 40 yo…tongue…no risk factors
Oral Pharynx…70% HPV(usually Type 16)

Question 23

Leukoplakia = White Patch/Plaque

Answer 23

Cannot be scraped off; due to increased keratin

1. Hyperkeratosis alone is NOT a premalignant change
2. But, 5 - 25% leukoplakia do contain premalignant findings
3. Biopsy is needed to evaluate if premalignant changes present

Question 24

Erythroplakia = Red Patch

Answer 24

Less common than leukoplakia, but more ominous …
represents highly vascular eroded mucosa …”
~ 90% have dysplasia or CIS, some have invasive SCC

Question 25

Oral Cavity/Oral Pharynx Squamous Cell Carcinoma

Answer 25

Invasive infiltrating squamous carcinoma with numerous “keratin pearls” and nests of malignant squamous cells.

Question 26

Staging and Treatment of Oral Cavity/Oral Pharynx SCC

Answer 26

Stage I -- 2cm, 4cm or spread to one [3cm, spread to other tissues, or mets Treatment: Stage I-II: Wide local excision or RT Stage III-IV: Excision + RT +/- chemo HPV assoc tumors have better prognosis

Question 27

Mump (Infectious Parotitis)

Answer 27

Acute onset of bilateral tender, self-limited swelling of parotid or other salivary glands lasting 2+ days Major complication: Testicular inflammation (orchitis) occurs ~40% of postpubertal males. Sequela may be sterility

Question 28

Sjögren Syndrome

Answer 28

9:1 F:M ratio; two peaks age of onset: Mid-20's & Mid-50's. ``` Mild disease (75%): Dry eyes and mouth (Sicca [dryness] syndrome) Dry mouth (Xerostomia) ``` ``` Severe disease (25%): Above, plus florid salivary gland enlargement, adenopathy Extraglandular manifestations (vaginal dryness, joints) Risk of non-Hodgkin's lymphoma (~5%) ```

Question 29

Sjögren Syndrome Dx

Answer 29

Antibodies - SS-A (Ro); SS-B (La) Biopsy of lip minor salivary gland to get diagnosis Defects of tubular function, including renal tubular acidosis, uricosuria, and phosphaturia, are often seen and are associated histologically with tubulointerstitial nephritis

Question 30

Mucocele (mucous retention cyst)

Answer 30

Most common lesion of salivary glands - may get bigger with meals Cause: Blockage or rupture of minor salivary gland duct; leads to saliva blockage, pooling and distension. Most frequent site is lower lip due to trauma

Question 31

Sialolithiasis

Answer 31

May result from blockage terminal portion of salivary duct by food particle [nidus] and subsequent enlargement of the nidus via aggregation of inspissated, dehydrated mucous Common Location: submandibular; also in sublingual and parotid

Question 32

Bacterial Sialadenitis

Answer 32

1. Duct obstruction leads to stasis…unilateral 2. Stasis leads to bacterial infection, commonly Staph aureus and Strep viridans 3. Bacteria cause acute inflammation (necrosis, suppuration abscess formation) 4. Acute process continues leading to chronic inflammation that then causes gland destruction and fibrosis (scarring)

Question 33

Pleomorphic Adenoma (Mixed Tumor)

Answer 33

50% all salivary gland tumors and 70% of benign neoplasms Location: 60% - parotid, 40% - submandibular/sublingual; rare - in minor salivary glands. Painless, slow growing, mobile, discrete masses Termed “Mixed Tumor” because both epithelial and mesenchymal (myxoid - cartilage) elements - neoplasm arises from multipotential basal myoepithelial cells Carcinoma in pleomorphic adenoma: In 5-yrs , 2% develop carcinoma. In 15-yrs period, 10% of unresected pleomorphic adenomas will develop cancer.

Question 34

Warthin Tumor (Papillary Cystadenoma Lymphomatosum)

Answer 34

5 - 10% of all salivary tumors parotid, M>F, 50s-60s, smokers [possibly not even a neoplasm!] Double layer of tall eosinophilic epithelial cells over a lymphoid stroma Second most common salivary gland neoplasm

Question 35

Malignant Tumors of the Salivary GlandsMucoepidermoid Carcinoma

Answer 35

Parotid is the predominant site [Parotid contains ~75% salivary tissue mass] Slow-growing, but relentless: difficult to excise and treat Grade most important prognostically Low-grade: locally aggressive, rarely metastasizes >95% 5-yr and 10 year survival High-grade: Invasive, frequent metastasis <50% 5-yr survival pink squamous cells -“epidermoid” Mucin secreting

Question 36

Adenoid Cystic Carcinoma

Answer 36

Difficult to Treat “Perineural invasion” Tumor spreads via peripheral nerves with numerous “skip” or non-contiguous tumor extensions 50% mets to bone, liver, and brain, sometimes decades after attempted removal. 5-year survival rate 60% to 70%, it drops to about 30% at 10 years and 15% at 15 years. Neoplasms arising in the minor salivary glands have poorer prognosis than those that arise in parotid glands.