ORAL DIAGNOSIS Pathology and Diagnosis pt 1 Flashcards
what percent of cleft lips are unilateral, and what percent are bilateral?
80% unilateral, 20% bilateral
cleft lips are caused by a defect between the ___ process and ___ process
medial nasal process and maxillary process
what is the occurrence of cleft lip?
1/1000 births, but varies with race
cleft palates result from a lack of fusions between ___
palatal shelves
what is the occurrence of cleft palate?
1/2000 births
what percent of patients affected by cleft lip/palate have cleft lip only, cleft palate only, and both?
- cleft lip only 25%
- cleft palate only 25%
- cleft lip and palate 50%
___ are invaginations at the commissures or near the midline
lip pits
what are fordyce granules? where are they commonly seen?
- ectopic sebaceous glands
- buccal mucosa or lip
___ is a bilateral opacification of the buccal mucosa
leukoedema
is leukoedema common? what is the clinical significance?
- common
- no significance
what are the causes of macroglossia?
- congenital hyperplasia/hypertrophy
- tumors (lymphangioma, vascular malformation, neurofibroma, multiple granular cell tumors, salivary gland tumors, endocrine abnormality)
- acromegaly, cretinism
- infections obstructing lymphatics
- beckwith-wiedemann syndrome
- exophthalmos, gigantism
- amyloidosis
what is lingual thyroid? what part of the tongue is it located?
thyroid tissue mass located at the midline tongue base
what is lingual thyroid caused by?
- incomplete descent of thyroid anlage
- may be patients only thyroid
thyroglossal tract cyst is a ___ swelling secondary to ___
- midline neck swelling
- cystic change of remnants of thyroid tissue
thyroglossal tract cysts are located along the ___ of thyroid descent
embryonic path
what are two other names for geographic tongue?
benign migratory glossitis and erythema migrans
geographic tongue is common and affects ___% of the population
2%
what is the cause of geographic tongue?
unknown
how does geographic tongue appear?
white annular lesions surrounding atrophic red central zones that migrate with time
is geographic tongue symptomatic?
occasionally (mild pain or burning)
what is the treatment for geographic tongue?
none necessary
fissured tongue is common and affects ___% of the population
3%
is fissured tongue symptomatic?
usually not
fissured tongue is a component of melkersson-rosenthal syndrome. what are the other two components?
granulomatous cheilitis and facial paralysis
what are the two types of hemangiomas?
congenital and vascular malformation
describe congenital hemangiomas
- focal proliferation of capillaries
- most lesions undergo involution
- persistent lesions are excised
describe hemangiomas that result from vascular malformations
- persistent malformation of capillaries, veins, and arteries
- exhibits a thrill (palpate a pulse) and bruit (hear a pulse)
what is sturge-weber syndrome?
- type of vascular malformation (hemangioma)
- aka encephalotrigeminal angiomatosis
- lesions involve skin along one of the branches of the trigeminal nerve
- the leptomeninges of the cerebral cortex may be involved by the malformations, leading to mental retardation and seizures
___ is a congenital focal proliferation of lymphatic channels
lymphangioma
when a lymphangioma occurs in the neck, it is termed ___
hygroma colli
exostoses are excessive ___ bone growth of unknown cause
cortical
what are the types of exostoses?
buccal exostoses, torus palatinus, torus mandibularis
___ is a developmental soft tissue cyst that presents as a mass in the midline floor of the mouth if above the mylohyoid muscle, or in upper neck if below mylohyoid muscle
dermoid cyst
___ is a developmental soft tissue epithelial cyst within the lymph nodes of the neck
branchial cyst
___ is a developmental soft tissue cyst within lymphoid tissue that is the oral counterpart of the branchial cyst of the neck
oral lymphoepithelial cyst
where are oral lymphoepithelial cysts commonly found?
soft palate, oral floor, or lateral tongue
a stafne (static) defect is a diagnostic radiolucency of the mandible secondary to ___
invagination of the lingual surface of the jaw
where are stafne defects typically located?
posterior mandible below the mandibular canal
a nasopalatine duct (canal) cyst is a lucency, often heart shaped, in the nasopalatine canal. what is it caused by?
cystification of nasopalatine duct remnants
a ___ is a clinical term denoting any pathologic radiolucency between the maxillary cuspid and the lateral incisor
globulomaxillary lesion
why is histopathologic analysis required for the definitive diagnosis of a globulomaxillary lesion?
it is present between the maxillary cuspid and lateral incisor, and many other lesions occur in this location and therefore radiolucency in this location represents a wide array of inflammatory lesions, odontogenic cysts and tumors, and nonodontogenic bone diseases
___ is a radiolucent dead space (no epithelial lining) in the mandible of teenagers
traumatic (simple) bone cyst
are traumatic bone cysts associated with trauma?
some, but not all
___ is a lucency in the jaw that contains hematopoietic bone marrow, often in an extraction site
focal osteoporotic marrow defect
___ is a common white lesion caused by chronic friction on mucosa
focal (frictional) hyperkeratosis
how is focal (frictional) hyperkeratosis differentiated from idiopathic leukoplakia?
the cause of focal hyperkeratosis is known
___ is a type of frictional hyperkeratosis that appears as a linear white line in the buccal mucosa
linea alba
traumatic ulcers are very common. chronic ulcers mimic ___ and ___
oral cancer and chronic infectious ulcers
chemical burns usually manifest as ___
ulcers
chemical burns may be caused by what?
aspirin, hydrogen peroxide, silver nitrate, phenol, or other agents
___ is a white change in the palate caused by smoking
nicotine stomatitis
what are the red dots in the white lesions of nicotine stomatitis?
inflamed salivary duct orifices
is nicotine stomatitis considered premalignant?
not unless it is related to reverse smoking
___ is caused by the traumatic implantation of amalgam particles into mucosa
amalgam tattoo
what is the most common oral pigmented lesion?
amalgam tattoo
___ is caused by a chemical in tobacco smoke that stimulates melanin production
smoking-associated melanosis
is smoking-associated melanosis reversible?
yes, if smoking is discontinued
where is smoking-associated melanosis typically seen?
anterior gingiva
___ is the most common melanotic lesion
melanotic macule
what is melanotic macule caused by?
may be postinflammatory, syndrome-associated (primarily peutz-jeghers syndrome [freckles and benign intestinal polyps]), or idiopathic
what are the most common causes of drug-induced pigmentation?
- minocycline
- chloroquine
- cyclophosphamide
- azidothymidine (zidovudine)
what is hairy tongue?
elongation of filiform papillae (cosmetic significance only)
what are the causes of hairy tongue?
extended use of antibiotics, corticosteroids, and hydrogen peroxide
what is dentifrice-associated slough?
superficial chemical burn of buccal mucosa caused by some dentifrices
oral infections are ___, ___, or ___ in nature
viral, bacterial, or fungal
what are the most commonly encountered infections caused by (either viral, bacterial, or fungal)?
viral, usually herpes simplex virus
clinical presentations of viral infections depends on viral type. how do the following typically present:
herpes, HPV, epstein-barr (EBV)
- herpes = mucosal ulceration preceded by vesicles
- HPV induces a verruciform (warty) lesion
- EBV causes a white lesion (hairy leukoplakia)
most bacterial and fungal infections manifest as ___
chronic ulcers
the fungus candida albicans can cause either ___ or ___ lesions
white or red
primary HSV infections are predominantly in what population?
children
HSV infections are severe in which population?
immunocompromised patients
secondary disease of HSV infections is ___ and is triggered by ___
- reactivating of latent virus in the trigeminal ganglion
- sunlight, stress, or immunosuppression
HSV lesion on the finger is called ___
herpetic whitlow
in HSV infections, ___ in epithelial cells are diagnostic when taken in clinical context
intranuclear viral inclusions
what is varicella (chickenpox)?
- self limiting childhood disease caused by varicella-zoster virus (VZV)
- oral lesions are uncommon
which disease represents reactivation of latent VZV?
herpes zoster
the latent varicella zoster virus is believed to reside where?
the dorsal root and trigeminal ganglia
hand foot and mouth disease and herpangina are infections caused by which virus?
coxsackievirus
are coxsackievirus infections self limiting? what population do they affect?
self limiting childhood systemic infections, usually endemic
what are the typical lesion sites for hand foot and mouth disease? what about herpangina?
- hand foot and mouth disease…guess…….hands, feet, and mouth
- herpangina = posterior oral cavity
measles are also called ___
rubeola
___ is a self-limiting childhood systemic infection caused by measles virus
measles (rubeola)
what are the presenting signs of measles?
fever, malaise, and skin rash
in measles (rubeola), what precedes the skin rash?
punctuate buccal mucosa ulcers (koplik’s spots)
what are the 3 HPV infections?
- papillomas
- condyloma acuminatum (genital warts)
- focal epithelial hyperplasia (heck’s disease)
describe papillomas
- benign epithelial proliferations (pedunculated or sessile) of little significance
- most, if not all, caused by HPV
- include verruca vulgaris (wart), which are more prevalent in HIV positive patients
describe condyloma acuminatum (genital warts)
- caused by HPV 6 and 11
- oral lesions acquired by oral-genital contact
- broad-based verruciform lesion
describe focal epithelial hyperplasia (heck’s disease)
- most common in certain ethnic groups (native americans, inuits, and central americans)
- multiple, small, dome-shaped warts on oral mucosa
- caused by HPV 13 and 32
hairy leukoplakia is a result of which virus?
epstein barr
describe hairy leukoplakia
- opportunistic infection resulting in white patch or patches of the lateral tongue
- almost all associated with HIV (may be a pre-AIDS sign)
- occurrence is decreasing with use of new AIDS drugs
T or F:
hairy leukoplakia is frequently seen in normal healthy patients
- false
- almost all cases are associated with HIV
- infrequently seen in patients with other immunosuppressed states
how is hairy leukoplakia diagnosed?
biopsy specimen showing intranuclear viral inclusions
what are the malignancies associated with EBV?
- burkitt’s lymphoma and nasopharyngeal carcinoma
- EBV has an etiologic role in these two malignancies
what are the oral complications of AIDS?
- herpes simplex and herpes zoster
- EBV-associated hairy leukoplakia
- cytomegalovirus
- HPV associated warts
- tuberculosis
- histoplasmosis
- candidiasis
- neoplasms
- kaposi’s sarcoma (HHV 8)
- high grade lymphomas
- severe aphthous ulcers
- xerostomia
- gingivitis and periodontal disease
why are acute bacterial infections uncommon in oral mucosa?
- owing to the protective effects (immunologic and physical) that saliva provides the stratified squamous epithelium lining the mouth
- chronic bacterial infections are also uncommon, probably for the same reasons
what type of bacterial infections can sometimes appear in the oral mucosa after deep trauma or surgery?
- acute pustular staphylococcal infections
- treated with appropriate antibiotics and surgical techniques
syphilis is a bacterial infections caused by contact with patients infected with which bacteria?
treponema pallidum
what are the primary, secondary, and tertiary lesions of syphilis?
- primary lesion is a chancre
- secondary lesions are oral mucous patches, condyloma latum, and maculopapular rash
- tertiary lesions are gummas, and have central nervous system involvement, and cardiovascular involvement
congenital syphilis is an in utero infection that causes ___
hutchinson’s triad (notched incisors, deafness, and ocular keratitis)
tuberculosis is a bacterial infection caused by inhalation of which bacteria?
mycobacterium tuberculosis
in tuberculosis infections, how do oral lesions present?
- nonhealing chronic ulcers
- appear after lung infection
why is the incidence of tuberculosis increasing?
overcrowding, debilitation, and AIDS
tuberculosis causes caseating granulomas with ___ cells
multinucleated giant cells (langerhan’s giant cells)
how is tuberculosis treated?
multidrug therapy (isoniazid, rifampin, and ethambutol
gonorrhea is a sexually transmitted disease caused by ___
neisseria gonorrhoeae
what is the oral manifestation of gonorrhea?
oral pharyngitis (rarely seen)
actinomycosis is caused by which opportunistic bacterium found in the oral flora of many patients?
actinomyces israelii
in patients with actinomycosis, ___ may follow dental surgery
chronic jaw infection
in patients with actinomycosis, head and neck infections are called ___
cervicofacial actinomycosis
how is actinomycosis treated?
long-term, high-dose penicillin
scarlet fever is a systemic infection caused by some strains of which bacteria?
group A streptococci
what are the manifestations of scarlet fever?
- strep throat (pharyngitis, fever, and malaise)
- rash caused by erythrogenic toxin
- strawberry tongue (white coated tongue with red, inflamed fungiform papillae)
how is scarlet fever treated?
penicillin to prevent complications of rheumatic fever
what are considered “deep” fungi?
histoplasmosis, coccidioidomycosis, blastomycosis, and cryptococcosis
histoplasmosis is endemic to ___, and coccidioidomycosis is endemic to ___
- US midwest
- US west (san joaquin valley fever)
deep fungal infections of the lung may lead to what oral manifestations?
- oral chronic granulomatous ulcers secondary to oral implantation of microorganisms
- oral lesions must be differentiated from oral cancer and chronic traumatic ulcers
what are opportunistic fungi?
- candidiasis (thrush, moniliasis)
- aspergillosis, mucormycosis, rhizopus
candidiasis is caused by ___
c. albicans (part of normal flora)
candidiasis is a predisposing factor for ___
fungal overgrowth
how do acute and chronic candidiasis lesions present?
- acute lesions are white, which represent the fungal colonies growing in mucosa (removal leaves raw, bleeding surface)
- chronic lesions are erythematous
what are the specific types of chronic candidiasis?
denture sore mouth, angular cheilitis, and median rhomboid glossitis
what is are the treatment options for candidiasis?
- topical treatment: nystatin, clotrimazole
- systemic treatment: fluconazole, itraconazole, caspofungin
what are the predisposing factors for candidiasis?
immune deficiency, endocrine abnormality, diabetes mellitus, pregnancy, hypoparathyroidism, hypoadrenalism, stress, prolonged antibiotic therapy, prolonged corticosteroid therapy, chemotherapy for malignancies, xerostomia, poor oral hygiene
aspergillosis, mucormycosis, and rhizopus are infections caused by organisms that are found throughout the ___
environment
which patients are at risk of aspergillosis, mucormycosis, and/or rhizopus?
patients who are medically debilitated or immunocompromised
how do aspergillosis, mucormycosis, and rhizopus lesions of the head and neck present?
appear as destructive ulcerations in the paranasal sinuses or nasal cavity
how are aspergillosis, mucormycosis, and rhizopus infections treated?
intense antifungal therapy is indicated, along with controlling the contributing condition
describe aphthous ulcers
- recurrent painful ulcers (not preceded by vesicles)
- unknown cause, probably related to focal immune defect
- appear on nonkeratinized oral mucosa (unattached)
- may be seen in association with some systemic diseases
what are the 3 types of aphthous ulcers?
minor, major, herpetiform
describe minor aphthous ulcers
- one to several painful oval ulcers <0.5cm
- most common type
- duration of 7-10 days
describe major aphthous ulcers
- up to 10 deep crateriform ulcers >0.5cm
- very painful and may be debilitating
- may take several weeks to heal
describe herpetiform aphthous ulcers
- recurrent crops of minor aphthae
- painful, take 1-2 weeks to heal
- may be found on any mucosal surface
- same cause as other aphthae (not viral)
___ is a multisystem disease believed to represent immune dysfunction in which vasculitis is a prominent feature
behcet’s syndrome
what are the features of behcet’s syndrome?
- oral and genital aphthous-type ulcers
- conjunctivitis
- uveitis (inflammation of the layers of the eye)
- arthritis
- headache
- other CNS manifestations
how is behcet’s syndrome treated?
corticosteroids and other immunosuppressive drugs
erythema multiforme is a self limiting ___ reaction that affects skin or mucosa or both
hypersensitivity
erythema multiforme minor is associated with ___
secondary herpes simplex hypersensitivity
erythema multiforme major is also called ___, and is often triggered by ___
- stevens-johnson syndrome
- often triggered by drugs
oral lesions that result from drug reactions and contact allergies include ___
vesicular, ulcerative, erythematous, and lichenoid
acquired angioedema is a specific type of ___
allergic reaction
acquired angioedema is precipitated by ___ and mediated by ___
- drugs or food (shellfish, nuts)
- mast cell release of IgE
acquired angioedema results in characteristic ___
soft, diffuse swelling of lips, neck, or face
hereditary angioedema is a rare form of acquired angioedema that is a ___ trait
autosomal dominant
what is wegener’s granulomatosis?
destructive granulomatous lesions with necrotizing vasculitis of unknown cause
wegener’s granulomatosis affects ___
upper respiratory tract, lungs, and kidneys
what is the diagnosis of wegener’s granulomatosis based on?
biopsy and demonstration of antineutrophil cytoplasmic antibodies
how is wegener’s granulomatosis treated?
- cyclophosphamide and corticosteroids or rituximab
- prognosis is good
midline granuloma is a destructive necrotizing midfacial phenomenon that clinically mimics lesions of ___
wegener’s granylomatosis
most midline granuloma cases represent ___
peripheral T-cell lymphomas of the upper respiratory tract or mouth (perforation of the hard palate may be seen)
how is midline granuloma treated?
- radiation
- good prognosis when treated early
lichen planus is a common mucocutaneous disease that affects ___% of adults
1-2%
what is lichen planus caused by?
- T lymphocytes target and destroy basal keratinocytes
- reason for this immunologically mediated phenomenon is unknown
describe the microscopy of lichen planus
- hyperkeratosis
- lymphocytes infiltrate at epithelial-connective tissue interface
- basal zone vacuolation secondary to basal keratinocyte destruction
- epithelium may exhibit a “saw tooth” pattern as it remodels after basal cell damage
describe the oral lesions of lichen planus
bilateral on the buccal mucosa, although tongue and gingival lesions exhibit white (hyperkeratotic) lines
what are the clinical types of lichen planus?
- reticular: lesions consist of interlacing lines (wickham’s striae)
- erosive: same presentation as reticular, but ulceration also present
- erythematous or atrophic: lesions predominantly red
- plaque: lesions predominantly plaque-like
describe the cutaneous lesions of lichen planus
- characteristically purple puritic papules on lower legs and arms
- respond to corticosteroids
- erosive form may have slightly increased risk for malignant change
lupus erythematosus is an autoimmune disease that occurs in either ___ or ___ forms
discoid or systemic
describe the discoid (chronic) form of lupus erythematosus
- affects skin (especially face and scalp) or oral mucosa (buccal mucosa, gingiva, vermillion)
- usually affects middle aged adults, especially women
- lesions are erythematous; oral lesions mimic erosive lichen planus
- no systemic signs or symptoms; rarely progresses to systemic form
how is discoid lupus erythematosus treated?
corticosteroids and other drugs
describe the systemic (acute) type of lupus erythematosus
- multiple organ involvement (heart, kidney, joints, skin, oral)
- classic sign: butterfly rash over bridge of the nose
- autoantibodies directed against nuclear and cytoplasmic antigens
how is systemic lupus erythematosus treated?
corticosteroids and other immunosuppressive drugs
___ is an autoimmune, multiorgan disease of adults, especially women, in which fibrosis of tissues eventually leads to organ dysfunction
scleroderma
scleroderma may occur concomitantly with other autoimmune diseases, such as ___
lupus erythematosus, rheumatoid arthritis, dermatomyositis, and sjogren’s syndrome
describe the cutaneous changes seen in scleroderma patients
induration and rigidity, atrophy, and telangiectasias
describe the oral changes seen in scleroderma patients
restriction of orifice, uniform widening of periodontal membrane, and bony resorption of posterior margin of the mandibular ramus
___ is an autoimmune, mucocutaneous disease in which antibodies are directed against desmosomal protein (desmoglein 3)
pemphigus vulgaris
how does pemphigus vulgaris manifest?
multiple, painful ulcers preceded by bullae that form within the epithelium
what is a positive nikolsky’s sign? what immunologic disease is it sometimes present with?
- formation of blister with rubbing or pressure
- pemphigus vulgaris and mucous membrane pemphigoid
in pemphigus vulgaris, how often do oral lesions precede skin lesions?
about half the time
what can happen if pemphigus vulgaris is untreated?
it runs a progressive clinical course and may be fatal if untreated
how is pemphigus vulgaris treated?
systemic corticosteroids or other immunosuppressive drugs
___ is a persistent, autoimmune disease of mucous membranes in which antibodies are directed against basement membrane antigens (laminin 5, BP180)
mucous membrane pemphigoid
what patient population does mucous membrane pemphigoid affect?
older adults, typically >50 years old
how does mucous membrane pemphigoid present?
multiple, painful ulcers preceded by bullae that form below the epithelium at the basement membrane
where are mucous membrane pemphigoid lesions commonly found?
may be found in any region, especially and sometimes exclusively in the attached gingiva
if untreated, what can ocular lesions associated with mucous membrane pemphigoid lead to?
blindness
what is the management for mucous membrane pemphigoid?
corticosteroids
patients with idiopathic leukoplakia, proliferative verrucous leukoplakia, erythroplakia, actinic cheilitis, oral submucous fibrosis, and smokeless tobacco-associated white lesions are at risk for the development of ___
squamous cell carcinoma
___ is a white or opaque oral mucosa lesion that does not rub off and is not clinically diagnostic for any other white lesion
idiopathic leukoplakia
what is the cause of idiopathic leukoplakia? what age population does it affect?
- cause is unknown, although tobacco and alcohol may be contributing factors
- biopsy is mandatory because diagnosis cannot be made clinically
- > 40 years old
what percent of benign idiopathic leukoplakia lesions transform to squamous cell carcinoma?
5-15%
what is the treatment for idiopathic leukoplakia? is recurrence common?
- excision
- recurrence is common
what are the high risk sites for malignant transformation of idiopathic leukoplakia?
floor of mouth and tongue
what are the different stages of idiopathic leukoplakia?
- hyperkeratosis 80%
- dysplasia 12%
- in situ carcinoma 3%
- squamous cell carcinoma 5%
proliferative verrucous leukoplakia is a high-risk form of ___, with an unknown cause, although some are associated with which forms of HPV?
- leukoplakia
- 16 and 18
describe proliferative verrucous leukoplakia lesions
- recurrent or persistent and usually multiple
- may start with a flat profile but progress to broad-based, wartlike (verruciform) lesions
proliferative verrucous leukoplakia has a high risk of malignant transformation to ___ or ___
verrucous carcinoma or squamous cell carcinoma
___ is a high-risk, idiopathic red patch of mucosa with an unknown cause, although some are tobacco related
erythroplakia (erythroplasia)
most erythroplakia lesions represent ___ or ___
dysplasia or malignancy
is erythroplakia more or less common than idiopathic leukoplakia?
much less common
is a biopsy mandatory for erythroplakia?
yes
erythroplakia usually occurs in what age population?
50-70 years old
what are the high risk sites for erythroplakia?
floor of mouth, tongue, retromolar area
describe the microscopy of erythroplakia
- mild to moderate dysplasia 10%
- severe dysplasia/carcinoma in situ 40%
- squamous cell carcinoma 50%
what is the cause of actinic (solar) cheilitis?
ultraviolet light, especially UVB, 2900-3200nm
describe the presentation/progression of actinic (solar) cheilitis
- the lower lip shows epithelial atrophy and focal keratosis
- upper lip is minimally affected because it is more protected from UV light
- the junction of the vermillion and skin becomes indistinct
- may progress to squamous cell carcinoma
oral submucous fibrosis is irreversible mucosal change thought to be due to hypersensitivity to ___, especially ___
dietary substances, especially betel nut
describe the presentation/progression of oral submucous fibrosis
- mucosa becomes opaque secondary to submucosal scarring
- may progress to squamous cell carcinoma
why is smokeless tobacco-associated white lesion not idiopathic leukoplakia?
- because the cause is known (white mucosal change from direct effects of smokeless tobacco and additives) and the lesion is clinically diagnostic
- however, it could be classified under a more generic designation of leukoplakia or white patch
where are smokeless tobacco-associated white lesions located?
labial and buccal vestibules where tobacco is held
smokeless tobacco-associated white lesions may cause ___. is malignant transformation common?
- focal periodontal destruction, tooth abrasion, or hypertension
- malignant transformation is rare
melanomas manifest as abnormally pigmented surface lesions that start at the junction of the ___ and ___
epithelium and submucosa
___ is a well-differentiated, slow growing form of carcinoma that infrequently metastasizes and exhibits a broad-based verruciform architecture
verrucous carcinoma
what are the etiological factors of verrucous carcinoma?
tobacco and/or HPV 16 and 18
how is verrucous carcinoma treated?
- surgical excision
- good prognosis
squamous cell carcinoma is caused by ___
mutation, amplification, or inactivation of oncogenes and tumor suppressor genes
what are some causes of genetic alterations seen in squamous cell carcinoma?
tobacco and heredity
there is an increased incidence of oropharyngeal (including tonsillar) squamous cell carcinoma, many of which are associated with detection of ___
oncogenic HPV infection (HPV 16 a d 18)
patients with ___ syndrome are at an increased risk of oral cancer
plummer-vinson syndrome (mucosal atrophy, dysphagia, and iron-deficiency anemia)
what are the clinical features of squamous cell carcinoma?
- may manifest as chronic, nonhealing ulcer, red or white patch, or mass
- most commonly seen in posterior-lateral tongue and floor of mouth
what is the prognosis based on for patients with squamous cell carcinoma?
- clinical stage is more important than microscopic classification in determining prognosis
- stage I (<2cm) is good
- stage II (2-4cm) and no neck disease is fair
- stage III and IV metastasis found in neck is poor
- overall 5-year survival is 45-50%; with neck metastasis, 25%
what is the treatment for squamous cell carcinoma?
- surgical excision of primary
- neck dissection with positive nodes or large primary lesion
- radiotherapy
- combination surgery and radiotherapy
- radiotherapy combined with chemotherapy
what is the most common skin cancer?
basal cell carcinoma
describe basal cell carcinoma
- low-grade, rarely metastasizes
- usually in sun-damaged skin; rare in mucosa
how does basal cell carcinoma manifest?
nonhealing, indurated chronic ulcer
how is basal cell carcinoma treated? what is the prognosis?
- surgery
- very excellent prognosis
oral melanoma is a malignancy of ___
melanocytes
what are the high risk sites for oral melanoma?
palate and gingiva
what population is oral melanoma more common in?
almost always in adults; rarely in children
what are the survival rates for oral melanoma?
- oral mucosa lesions 5-year survival rate is <20%
- skin lesions 5-year survival rate is >65%
some oral melanoma lesions have prolonged ___ phase preceding vertical (invasive) growth
in situ
connective tissue tumors manifest as ___. overlying epithelium is generally intact, unless ___
- masses (lumps or bumps) within the submucosa
- ulceration occurs because of trauma to the lesion
what are the two groups of benign connective tissue tumors?
reactive or neoplastic
what are the types of benign fibrous reactive connective tissue lesions?
peripheral fibroma, generalized gingival hyperplasia, focal fibrous hyperplasia, denture-induced fibrous hyperplasia
what is a peripheral fibroma?
- fibrous reactive connective tissue lesion
- fibrous hyperplasia of the gingiva
- caused by trauma or chronic irritation
what is generalized gingival hyperplasia?
- fibrous reactive connective tissue lesion
- fibrous hyperplasia caused by local factors and modified by systemic conditions
what are the drugs that can contribute to generalized gingival hyperplasia?
- phenytoin (dilantin) for seizures
- cyclosporine (immunosuppressant)
- nifedipine (calcium channel blocker)
what is focal fibrous hyperplasia?
- fibrous reactive connective tissue lesion
- fibrous hyperplasia or oral mucosa
- caused by chronic trauma or chronic irritation
focal fibrous hyperplasia is also called ___
traumatic fibroma, irritation fibroma, and hyperplastic scar
what is denture-induced fibrous hyperplasia?
- fibrous reactive connective tissue lesion
- fibrous hyperplasia associated with ill-fitting dentures
- usually seen in anterior labial vestibules
- no malignant potential
what is papillary hyperplasia (palatal papillomatosis) of the palate?
another type of fibrous hyperplasia associated with ill-fitting dentures
what is a traumatic neuroma?
- neural reactive connective tissue lesion
- entangled submucosal mass of neural tissue and scar
- caused by injury to nerve
- most commonly seen at mental foramen in oral cavity
what is a pyogenic granuloma?
- vascular reactive connective tissue lesion
- hyperplasia of capillaries and fibroblasts
- caused by trauma or chronic irritation
- common in gingiva but can be seen anywhere there is mucosal (or skin) trauma
what are the types of neoplastic benign connective tissue lesions?
- fibrous = nodular fasciitis and fibromatosis
- neural = granular cell tumor, schwannoma (neurilemoma), neurofibroma, mucosal neuromas of multiple endocrine neoplasia 2B
- muscle = leiomyoma and rhabdomyoma
- fat = lipoma
describe nodular fasciitis
- fibrous neoplastic connective tissue lesion
- rare submucosal proliferation of fibroblasts
- reactive lesion that exhibits rapid growth
- treated with surgical excision, rare recurrence
describe fibromatosis
- fibrous neoplastic connective tissue lesion
- although benign, this troublesome fibroblastic neoplasm is locally aggressive and infiltrative
- difficult to eradicate and often recurs
- behavior similar to low-grade fibrosarcoma
describe granular cell tumor
- neural neoplastic connective tissue lesion
- benign, nonrecurring submucosal neoplasm of schwann’s cells
- tumor cells have granular or grainy cytoplasm
- overlying epithelium may exhibit pseudoepitheliomatous hyperplasia (microscopically mimics carcinoma)
what location are granular cell tumors most common?
tongue
describe the infant counterpart of granular cell tumors
- congenital granular cell tumor (congenital epulis)
- occurs on gingiva only as pedunculated mass
- no pseudoepitheliomatous hyperplasia
- surgical excision, no recurrence
describe a schwannoma
- neural neoplastic connective tissue lesion
- aka neurilemoma
- benign neoplasm of schwann’s cells
- any site, tongue favored
- solitary; not syndrome-related
describe a neurofibroma
- neural neoplastic connective tissue lesion
- benign neoplasm of schwann’s cells and perineural fibroblasts
- any site, especially tongue and buccal mucosa
- solitary to simple
- syndrome of neurofibromatosis 1
what is syndrome of neurofibromatosis 1?
- multiple neurofibromas
- six of more cafe au lait macules (each >1.5 cm diameter)
- axillary freckling (crowe’s sign) and iris freckling (lisch spots)
- malignant transformation of neurofibromas occurs in 5-15% of patients
describe mucosal neuromas of multiple endocrine neoplasia 2B
- neural neoplastic connective tissue lesion
- autosomal dominant inheritance
what are the syndrome components of mucosal neuromas of multiple endocrine neoplasia 2B?
- oral mucosal neuromas (hamartomas)
- medullary carcinoma of the thyroid
- pheochromocytoma of the adrenal gland
what is a leiomyoma?
- neoplastic connective tissue lesion
- rare, benign neoplasm of smooth muscle origin
what is a rhabdomyoma?
- neoplastic connective tissue lesion
- very rare, benign neoplasm of skeletal muscle origin
what is a lipoma?
- neoplastic connective tissue lesion
- uncommon benign neoplasm of fat cell origin
- buccal mucosa is characteristic site
what is a fibrosarcoma?
rare sarcoma (malignant) showing microscopic evidence of fibroblast differentiation
what is a neurosarcoma?
- malignant peripheral nerve sheath tumor
- rare sarcoma showing microscopic evidence of neural differentiation
- may arise from preexisting neurofibroma or de novo (no preexisting lesion)
what is kaposi’s sarcoma?
- malignant vascular proliferation of endothelial cells
- HHV 8 has etiologic role
- most commonly seen as a complication of AIDS; incidence markedly reduced by new antiretroviral therapies
- may also be seen as endemic african type or classic mediterranean type
what is a leiomyosarcoma?
rare sarcoma (malignant) showing microscopic evidence of smooth muscle differentiation
what is a rhabdomyosarcoma?
rare sarcoma (malignant) showing microscopic evidence of skeletal muscle differentiation
what is a liposarcoma?
rare sarcoma (malignant) showing microscopic evidence of fat cell differentiation
___ is a recurring submucosal nodule of saliva (often bluish in color) resulting from escape from duct of salivary gland
mucous extravasation phenomenon
what are mucous extravasation phenomena caused by?
traumatic severance of salivary excretory duct
where are mucous extravasation phenomena common?
lower lip (rare in upper lip) and buccal mucosa
do mucous extravasation phenomena recur?
not if the contributing gland is removed
___ is a submucosal nodule (often bluish in color) resulting from blockage of salivary duct by a salivary stone (sialolith)
mucous retention cyst
where are mucous retention cysts most common?
floor of mouth, palate, buccal mucosa, and upper lip (rare in lower lip)
a mucous retention cyst is known as a ___ when occurring in the floor of the mouth
ranula
___ is a chronic ulcer of the palate secondary to ischemic necrosis of palatal salivary glands
necrotizing sialometaplasia
necrotizing sialometaplasia is believed to be triggered by ___
trauma, surgery, or local anesthesia
what is the treatment for necrotizing sialometaplasia?
heals in 6-10 weeks without treatment
necrotizing sialometaplasia mimics ___ clinically and microscopically
carcinoma (squamous metaplasia of ducts)
___ is a common insignificant incidental finding in a panoramic image that may represent blockage of the sinus salivary gland or focal fluid accumulation of sinus mucosa
maxillary sinus retention cyst (pseudocyst)
what is the treatment for maxillary sinus retention cyst (pseudocyst)
lesions are asymptomatic and require no treatment
what are the potential causes of infectious sialadenitis (salivary gland infections)?
- acute or chronic
- viral or bacterial
describe infectious sialadenitis due to viral infections
- mumps is an acute viral infection usually of the parotid glands
- cytomegalovirus infections are chronic and may be seen in immunosuppressed patients or (rarely) in infants via transplacental infection
describe infectious sialadenitis due to bacterial infections
- bacterial infections usually occur when salivary flow is reduced or impeded, especially in major glands, allowing bacterial overgrowth
- staphylococci and streptococci are the usual infecting agents
___ is a chronic granulomatous disease of unknown cause, although bacteria (possibly mycobacteria) are suspected
sarcoidosis
sarcoidosis is primarily a ___ disease
pulmonary disease, although many other organs may be affected, including salivary glands and mucosa
in sarcoidosis, ___ cause organ nodularity and loss of parenchyma
granulomas (macrophage infiltrates)
how is sarcoidosis diagnosed?
- biopsy, radiographic studies, and laboratory tests
- serum chemistry for hypercalcemia and elevated angiotensin-converting enzyme
- chest films for pulmonary involvement
- radiographs for bone involvement
how is sarcoidosis treated?
corticosteroids and other immunomodulating drugs
bilateral parotid enlargement is associated with several ___ and ___ conditions. how do they feel to palpation?
- systemic and metabolic
- soft
what are the metabolic conditions associated with bilateral parotid enlargement?
chronic alcoholism, dietary deficiencies, obesity, diabetes mellitus, hypertension, hyperlipidemia, and sjogren’s syndrome
___ is a chronic lymphocyte-mediated autoimmune disease affecting exocrine glands and other organ systems
sjogren’s syndrome
primary sjogren’s syndrome consists of ___ and ___
keratoconjunctivitis sicca (dry eyes) and xerostomia
secondary sjogren’s syndrome consists of ___ in addition to ___
dry eyes and mouth in addition to another autoimmune disease, often rheumatoid arthritis
how is sjogren’s syndrome diagnosed?
- assessment of salivary function (usually labial salivary gland biopsy)
- assessment of decrease in lacrimal function (schirmer test)
- laboratory tests for autoantibodies (rheumatoid factor, antinuclear antibodies, sjogren’s syndrome A and B)
what is the cause and treatment of sjogren’s syndrome?
- cause is unknown
- symptoms are treated
patients with sjogren’s syndrome are at risk for ___
lymphoma
what are the dental complications of sjogren’s syndrome?
cervical caries associated with xerostomia
what is the most common benign salivary gland tumor (major and minor glands)
mixed tumor (pleomorphic adenoma)
mixed tumor (pleomorphic adenomas) are a mixture of more than one cell type (___) in many patterns (___)
- epithelial and connective tissue elements
- pleomorphic
what is the most common site for mixed tumor (pleomorphic adenoma) minor gland lesions?
palate
do mixed tumors (pleomorphic adenomas) recur?
occasional recurrence associated with incomplete or poorly formed tumor capsule
___ are benign salivary tumors composed of a single cell type
monomorphic adenomas
what are the types of monomorphic adenomas?
basal cell adenoma, canalicular adenoma, myoepitheliomas, and oncocytic tumors (oncocytes stain bright pink because of abundant mitochondrial proteins)
how are monomorphic adenomas treated?
surgical excision with infrequent recurrences
___ is an oncocytic tumor that also contains lymphoid tissue
warthin’s tumor
what location and population is warthin’s tumor most commonly found?
- parotid of older men
- occasionally bilateral
what is the most common salivary malignancy in both minor and major glands?
mucoepidermoid carcinoma
what is the most common intraoral site for mucoepidermoid carcinoma?
palate
mucoepidermoid carcinoma is composed of what cell types?
mucous and epithelial cells
describe metastasis of mucoepidermoid carcinoma
- microscopic low grade lesions rarely metastasize and have excellent prognosis
- microscopic high grade lesions frequently metastasize and have a fair prognosis
___ is the second most common salivary gland malignancy (rare in major glands)
polymorphous low grade adenocarcinoma
what is the most common site for polymorphous low grade adenocarcinoma?
palate
what is the treatment and prognosis for polymorphous low grade adenocarcinoma?
low grade malignancy has a good prognosis after surgical excision
adenoid cystic carcinoma is a ___ salivary malignancy and the ___ is the most common site
- high grade
- palate
what is the microscopic pattern of adenoid cystic carcinoma?
cribriform or “swiss cheese” microscopic pattern
adenoid cystic carcinomas can spread through ___ spaces
perineural
what is the 5-year survival rate for adenoid cystic carcinoma?
- 70%
- 15 year survival rate is 10%
all lymphoid neoplasms are ___
malignant
hodgkin’s lymphoma is characterized by ___ cells
- reed-sternberg cells
- rare in the oral cavity
non hodgkins lymphoma is a malignancy of one of the cells making up lymphoid tissue. the microscopic classification of the various types of lymphomas currently follows the ___ classification
revised european-american lymphoma classification
most lymphomas are ___ cell type
- B-cell type
- T-cell lymphomas are very rare in the mouth
lymphoma behavior patterns range from indolent to highly aggressive. most head and neck tumors start in ___ or in ___. most common intraoral sites are ___.
- lymph nodes or in mucosa-assocaited lymphoid tissues (MALT)
- tonsils and palate
bone involvement, especially in Burkitt’s lymphoma, often results in ___
swelling, pain, tooth mobility, and lip parasthesia
AIDS-associated lymphomas are typically high-grade ___-cell tumors
B-cell
what is the treatment for lymphomas?
- dependent on lymphoma classification and stage
- radiation is used for localized disease
- chemotherapy is used for extensive disease
- chemoradiotherapy is also used
- some indolent low-grade lymphomas, known to respond poorly to therapeutic regimens, are not treated
___ represents a monoclonal neoplastic expansion of immunoglobulin-secreting B cells (plasma cells) in what could be termed a monoclonal gammopathy
multiple myeloma or plasma cell myeloma
what are the radiographic characteristics of multiple myeloma (plasma cell myeloma)?
multiple punched out bone lucencies (solitary plasmacytoma invariably becomes multiple myeloma) in patients older than 50 years
some of the clinical features of ___ include abnormal immunoglobulin protein peak (M protein) on serum electrophoresis and urinary monoclonal light chains (bence-jones protein)
multiple myeloma (plasma cell myeloma)
what are the signs and symptoms of multiple myeloma?
- pain, swelling, and numbness
- anemia, bleeding, infection, and fracture associated with extensive marrow involvement
how is multiple myeloma treated? prognosis?
- chemotherapy
- poor prognosis
a form of amyloidosis occurs in ___% of patients with multiple myelosis
10%
amyloidosis that occurs in 10% of patients with multiple myelosis is due to what?
formation of complex proteins in which immunoglobulin light chains are precursors
amyoloidosis that occurs in patients with multiple myelosis results in amyloid protein that is deposited in various organs and can leads to organ dysfunction. which organs are commonly affected?
kidney, heart, GI tract, liver, and spleen
how do amyloid proteins (amyloidosis) present microscopically?
amyloid proteins react with Congo red stain producing a green birefringence in polarized light
secondary amyloidosis can develop in patients with ___
chronic diseases such as rheumatoid arthritis, chronic osteomyelitis, and chronic renal failure
single organ or localized amyloidosis may be seen where in the mouth?
tongue
