Oral Path Final deck Flashcards
Define Hamartoma…
Disorganized overgrowth of normal tissue in its normal location
Define Choristoma…
Growth of normal tissue in an abnormal location
Define Neoplasm…
Growth of abnormal tissue, may be either benign or malignant
What are some characteristics of a Benign lesion?
-Bilateral -Rapid onset (ulceration, soft tissue swelling) -Pain -Growth around native structures - Slow expansion (osseous) - Smooth root resorption
What are some characteristics of malignant lesion?
- Unilateral - Chronic, persistent (ulceration) - Absence of pain/presence of paresthesia - Invasion/destruction of native structures - Cortex destruction - Spiking root resorption
Define Adenoma…
Usually a benign neoplasm: Pleomorphic adenoma, oncocytoma
Define Carcinoma…
- Malignant neoplasm derived from epithelial cells - Surface (skin, mucosal): Basal cell carcinoma - Glandular: Adenocarcinoma
Define Sarcoma…
Malignant neoplasm derived from cells of mesodermal origin: Liposarcoma, fibrosarcoma
Define Metastasis…
- Spread of disease from one part of the body to another - Tumor implants are discontinuous with the primary tumor
What are the 4 differentials for the gum bump differential?
- Fibroma 2. Pyogenic Granuloma (Lobular Capillary Hemangioma) 3. Peripheral Ossifying Fibroma 4. Peripheral Giant Cell Granuloma POF AND PGCG OCCUR ONLY ON THE GINGIVA!
What are the 4 Human Papilloma Virus Differential?
- Squamous Papilloma 2. Verruca Vulgaris 3. Condyloma Acuminata (High risk types 16 & 18) 4. Heck’s Disease (Multifocal Epithlial Hyperplasia)
What is the differential list for Multilocular Radiolucent Lesions?
MACHO! M: Myxoma A: Ameloblastoma C: Central Giant Cell Lesion H: Hemangioma (Vascular Malformation) O: Odontogenic Keratocyst Also may be included: - Dentigerous Cyst - Glandular Odontogenic Cyst
What is the differential for Mixed Radiolucent/Radiopaque Differential Diagnosis?
- Adenomatoid Odontogenic Tumor - Calcifying Odontogenic Cyst - Ameloblastic Fibro-Odontoma - Calcifying Epithelial Odontogenic Tumor - Ossifying Fibroma - Fibrous Dysplasia - Desmoplastic Ameloblastoma
Define Odontogenic Cyst…
Cysts lined by odontogenic epithlium
Which odontogenic cysts are inflammatory? Can you name 3?
- Periapical (radicular) cyst 2. Residual periapical (radicular) cyst 3. Buccal bifurcation cyst
Which odontogenic cysts are developmental…there’s a lot!
- Dentigerous Cyst 2. Eruption Cyst 3. Odontogenic Keratocyst 4. Orthokeratinized Odontogenic Cyst 5. Gingival (alveolar) cyst of the newborn 6. Gingival Cyst of the Adult 7. Lateral Periodontal Cyst 8. Calcifying Odontogenic Cyst 9. Glandular Odontogenic Cyst
What are the 4 tumors of Odontogenic Epithelium?
- Ameloblastoma 2. Adenomatoid Odontogenic Tumor 3. Calcifying Epithelial Odontogenic Tumor 4. Squamous Odontogenic Tumor
What are some Mesenchymal Odontogenic Tumors? Can you name 3?
- Odontogenic Myxoma 2. Central Odontogenic Fibroma 3. Cementoblastoma
What are some mixed epithelial/mesenchymal odontogenic tumors?
- Ameloblastic Fibroma 2. Fibroodontoma 3. Odontoma (considered a hamartoma)
Define Leukoplakia…
White patch that cannot be wiped off, clinical descriptions, not a diagnosis
Define Erythroplakia…
- Red patch or plaque-like lesion that cannot be clinically or pathologically diagnosed as any other condition - Often represents malignant change: Up to 90% of erythroplakic lesions represent severe epithelial dysplasia, carcinoma in situ, or SCCa
Define Erythroleukoplakia…
- AKA speckled leukoplakia - Frequently dysplasia or carcinoma in situ on biopsy
Sharply demarcated leukoplakia is concerning for…
Dysplasia!
What percentage of erythropakic lesions represent severe epithelial dysplasia, carcinoma in situ, or squamous cell carcinoma?
90%!
What is the evolution of Proliferative Verrucous Leukoplakia look like?
- Characterized by multiple, persistent, keratotic plaques that over time progress to SCC - Verrucous hyperplasia leads to… - Verrucous Carcinoma that leads to… - Invasive squamous cell carcinoma - Lesions rarely regress dispite therapy
Define Dysplasia…
- Abnormal tissue development - Rapid cell turn over - Immature epithelial cells, lack of maturation - Can be mild, moderate, or severe (thirds of epithelium)
What is Squamous Cell Carcinoma in situ…
- Dysplastic change involving the full-thickness of epithelium - Latin (in site) - Not extending beyond the focus or level of origin - No invasion by definition
Oral Squamous Cell Carcinoma is most commonly found in these 2 locations…
- Tongue: posterior lateral most common 2. Floor of mouth (midline near frenum) Most likely location intraorally (versus oropharynx) to demonstrate early metastasis to cervical lymph nodes. Leukoplakia in this area also has a higher chance of containing dysplasia/carcinoma
What is the vitality of teeth associated with buccal bifurcation cysts?
Vital
What is the tx for buccal bifurcation cyst
curettage, do not ext
What is the most common dev odontogenic cyst
dentigerous
What teeth are dent cysts most commonly associated with
impacted thirds and impacted canines
If an impacted tooth has a pericoronal radiolucency greater that ??? mm you should be concerned about more serious entities
3mm
Whats the tx for dentigerous cysts
Ext and send tissue to pathology
What is an eruption cyst
overlying soft tissue impacted tooth, may appear blue or red
What is the treatment for an eruption cyst
none, usually spontaneously resolve.
What are some details concerning OKC growth and expansion
May grow large and cause expansion but more often tracks up the mandible ramps if in Max can grow into sinuses
What is the tx for OKCs
Must be completely removed, high recurrence rate with curettage (30%) can do peripheral osteotomy or marsupialization to shrink cyst prior to surgery
What are multiple OKCs suggestive of
Nevoid Basal Cell Carcinoma Syndrome
How do orthokeratinized Odontogenic Cysts compare to OKs
Histologically similar not usually as large associated with thirds recurrence rate with curettage low (2%)
Are gingival cysts of the newborn common
yes
Tx for gingival cysts of the newborn
none, spontaneously resolve by 3 months
Lat periodontal cyst facts
Associated with vital teeth bone window with simple enucleation usually curative
where are lat periodontal cysts most likely to occur
Man canine/premolar area (similar to gingival cyst of the adult)
Where are calcifying odontogenic cysts usually found
Max=man, often in the anterior
Which ddx do Calcifying Odontogenic Cysts fall under
Mixed, can be multilocular
Whats an interesting histologic feature of Calcifying Odontogenic cysts
Ghost cell formation
Tx for Calcifying odontogenic cyst
Enucleates easily (peels out of bone), low recurrence rate
Glandular odontogenic cyst locations
Propensity for mandible, premolar incisor region, crosses midline
Tx for glandular odontogenic cyst
can be aggressive so resection may be necessary
What can glandular odontogenic cysts be misdiagnosed as
intraossseous mucoepidermoid carcinoma
Where do nasopalatine duct cyst appear
ant max midline, either palatal or facial of 8/9 (teeth vital)
Tx for nasopalatine duct cyst
simple curettage
What is a nasolabial cyst
soft tissue cyst in the nasolabial fold that elevates ala.
What is the nasolabial cyst remnants of
Nasolacrimal duct
What gender is more likely to have nasolabial cyst
females
Tx for nasolabial cyst
surgical excision
Tx for developmental inclusion cyst of the neonate
none, resolve spontaneously
Types of dev inclusion cysts of the newborn
Epstein pearl and john nodules
Where can a thyroglossal duct cyst be found
Midline of the new, anywhere from the foramen cecum (base of tongue) down to thyroid usually attached to hyoid bone and moves when pt swallows
What is the tx for Thyroglossal duct cyst
Sistrunk procedure:rem cyst and involved portion of hyoid bone
Where can a branchial cleft cyst be found
Lateral neck common, but can be anywhere from ear down to clavicle along SCM.
What does branchial cleft cyst appear as in histology
Lymphoepithelia cyst
Epidermal inclusion cysts are filled with what
keratin-stinky. its can complain of periodic smelly drainage if cyst is continuous with skin surface
How many germ cell layers does an epidermal inclusion cyst have
1
Multiple Epidermal inclusion cysts are consistent with
Gardner syndrome
Where are dermoid cysts found
midline of body, often floor of mouth or inner cants of the eye
How many germ layers are in a dermoid cyst
2, epidermoid and mesodermal
describe look and location of oral lymphoepithelial cyst
yellowish module, 1 cm on lateral posterior tongue or tonsillar area, soft palate.
What is an oral lymphoepithelial cyst
ectopic tonsillar/lymphoid tissue
Tx for oral lymphoepithelial cyst
Simple excision
Tx for ameloblastoma
Agressive and must be completely rem with resection of up to 1 cm into clear margins
common location of ameloblastoma
can occur anywhere but post man most common
What is the only clincally relevant histologic subtype of ameloblastoma
Desmoplastic ameloblastoma
where is desmoplastic ameloblastoma often found
Ant Maxilla
What is a desmoplastic ameloblastoma similar to radiographically
benign fibre-osseous lesion, ground glass
What is the text book presentation of adenomatoid odontogenic tumor
2/3: ant max, female, young, impacted canine
Tx for Adenomatoid odontogenic tumor
usually shells out of bone in large pieces, if completely removed no recurrence
Where are calcifying epithelial odontogenic tumors most likely found
post mandible
What do CEOTs produce histologically and radiographically
Amyloid like material concentric calcifications called leisegang rings
tx of Calcifying epithelial odontogenic tumors
conservative excision with low recurrence rates
Where can you find central odontogenic fibromas
Ant Max, post man
What is the classical presentation of central odontogenic fibroma in max
Palatal notch
Tx for central odontogenic fibroma
enucleation, low recurrence
Central odontogenic fibroma radiographically presents as
RL but can have RO flecks
What radiographic feature defines odontogenic myxoma
thin separations at right angles to each other. thin wispy septations
Tx for odntogenic myxoma
Resection difficult as they grow large with a jelly like consistency with myxoid fingers into surrounding bone that isn’t visible on imaging, conservative resection needed
Who is most likely to have cementoblastoma
young adults,kids
where are cementoblastomas most commonly found
post man
Clinical presentation of cementoblastoma
painful and expansile
What happens to teeth associated with cementoblastomas
must be ext
radiographic presentation of cementoblastoma
RO, or mixed with RL rim, attached to tooth roots
Odontomas are an example of
harmartoma
What are the types of odontoma
compound complex
Compound odontomas def
still has three separate layers, usually ant max
Complex odontoma
unrecognizable as tooth, usually in posterior
what demographic is common for ameloblastic fibroma/fibro-odontoma
Kids in 1st or second decades. Any mixed or RL session ddx in kid should include this
growth facts about Ameloblastic fibroma/fibro odontoma
grow large, can displace teeth
tx for ameloblastic fibroma/fibro-odontoma
conservative excision, may need resection if recurs
Which locations have SCCs that are p16+
Soft palate, oropharynx larynx, base of tongue
What does p16+ indicate
a specific mutated pathway that may be HPV induced.
what are features of p16+ tumors
more aggressive respond better to therapy
What common variants of SCC are found in the soft palate/oropharynx/larynx/base of tongue
Non keratinizing SCC and basaxoid SCC
Tradition risk factors (smoking alcohol) are least associated with SCC in this intramural site
gingiva
Which gender is more likely to have SCC on gingiva
females
What is verrucous carcinoma
A less aggressive less invasive variant of SCC
Do verrucous carcinoma metastasize
no, if does likely represents transformation to conventional SCC
what are the three major salivary glands
parotid, submandibular, sublingual
what do myoepithelial cells do
contract to assist in expulsion of glad secretory product
what are features of the parotid
serous two lobes separated by facial nerve empties into stepsons duct contains lymph nodes lateral to facial nerve
Submandibular gland
80/20 serous/mucinous whitens duct 3-6 lymph nodes adjacent to gland
Sublingual gland
mucinous
Where do mucoceles not occur
upper lip
What happens to a mucocele during salivation
likely to expand
Mucocele tx
if excised take surrounding minor glands too to decrease chance of recurrence
what is a ranula
mucocele on the floor of the moth that may grow large.
what are some ddx of ranula
dermoid cyst, cystic hygroma
Where are sialoliths most likely to be found
submandibular gland in the tortuous whartons duct, but can be found in parotid and minor glands
What are possible causes of sialadentitis
stone blockage autoimmune (IgG4 chronic sclerosis sialadentitis) sjogren syndrome
Describe necrotizing sialometaplasia
chronic non healing ulcer that can grow large but often quicker onset than SCC, often on the palate biopsy often incites resolution
Necrotizing sialometaplasia can mimic
mucous, and SCC
what is the most common location of saliva gland neoplasia
parotid followed by minor salivary glands
Bengin v malignant stats in parotid
bening 2x malignant
benign v malignant stats in submandibular
benign more common
benign v malignant stats in sublingual
neoplasms less common but when present usually malignant
Where are minor salivary gland neoplasms most likely
palate followed by lips
benign v malignant stats in minor salivary glands
malignant more likely (palate 50/50)
Aggressiveness of salivary gland malignancies
may be slow and not very agressive
What are concerning clinical features of salivary gland neoplasms
facial nerve paresthesia or paralysis, ulceration
what is the most common benign salivary gland neoplasm
pleomorphic adenoma
most common malignant salivary gland neoplasm
mucoepidermoid carcinoma
Location of pleomorphic adenoma
Parotid, then minor glands
Demographics of a warthin tumor pt
older male, smoker
where do warthin tumors present
parotid, often bilaterally though not necessarily at the same time
Canalicular adenoma are found where
75% in upper lip, other in ant buccal mucosa. may be multi factorial
Mucoepidermoid carcinoma are found where
anyloction but the parotid and palate more common
clinical features of mucoep
bluish nodule that may be ulcerated.
what stain is used to highlight mucous cell in mucoep
mucicarmine special stain
three grades of much ep
low intermediate high
DDX in the palate
necrotizing sialometaplasia, MEC, SCC
where does acidic cell carcinoma present most commonly
parotid
where is adenoid cystic carcinoma found most
minor glands, palat and sinonasal
Who typically gets adenoid cystic carcinoma
middle age, 40’s, male
how would you describe the growth and metastasis of adenoid cystic carcinoma
slow relentless growth with metastases along skip lesions along nerves. difficult to resect
What other treatments needed for neoplasms
neck dissection, chemo, radiation dependent on lymph node mets, and on grade of umor
what is freys syndrome
damage to auriculptemporal branch of facial nerve during parotid surgery resulting in gustatory sweating
Multiple osteomas are seen in..
Gardners syndrome
Where are osteopath primarily distributed
craniofacially
Are tori/exostosis osteomas
no, they are developmental/reactive
what is the etiology of condensing osteitis
reactive bone sclerosis due to inflammation of a usually non vital tooth, can regress following resolution of imflammation
facts about idiopathic osteosclerosis
vital teeth, no def etiology
what is the typical patient for osteoporotic marrow defects
middle aged female
likely site of osteoporotic marrow defect
body of man, can be site of prev ext
what is usually found when entering a marrow deffect
normal bone marrow
predilections of idiopathic bone cavity
young, man, male, maybe trauma
Findings upon entering an idiopathic bone cavity
nothing, bleeding incited usually causes healing
radiologic finding of idiopathic bone cavity
scallops around tooth roots
where are aneurysmal bone cysts more commonly found
long bones
growth of ABCs
rapid expansion and can be aggressive
predilections of ABCs
young females
Types of ABCs
primary and secondary
primary ABCs are associated with
neoplastic genetic mutation
secondary ABCs association
another entity such as central giant cell lesion
most common sites to metastasize to bone
BLT with a Kosher pickle breast, lungs, thyroid, kidney, and prostate
most common form of bone malignancy
bone mets
where are osteosarcomas most commonly found
long bones: proximal tibia/distal femur in pubescent boys
Gnathic osteosarcoma demographics
average 35 yo
what are the radiographic hallmarks of osteosarcoma
asymmetric widening of pal bone formation in soft tissue bone formation above alveolar crest spiking root resorption sun burst only in 25% of cases
what is the tx for osteosarcoma
radical resection
Which type of benign fibro osseous lesion is reactive
cemento osseous dysplasia
which type of benign fibroosseous lesion is neoplastic
ossifying fibroma
which type of benign fiber osseous lesion is developmental
fibrous dysplasia
whats the requirement to call COD florid
at least two quadrants are affected
whats the concern for COD in edentulous pts
the masses sequester and create opportunity for infections
tx for central ossifying fibroma
neoplastic with unlimited growth potential so needs to be completely removed
where are central ossifying fibromas most likely found
mandible
what is a hallmark radiographic feature of central ossifying fibroma
downward bowing of the inferior border of the mandible
what is different about juvenile active ossifying fibroma
more aggressive rapid growth thats more common in Max.can also occur in the ethmoid bones and other craniofacial bones
what gene is responsible for fibrous dysplasia
GNAS1 gene mutation
types of fibrous dysplasia
monostotic, polysotic, syndromic polystotic may just affect craniofacial bones
what syndromes are associated with fibrous dysplasia
mccune albright FD, café au lait pigmentations (coast of Maine), endocrinopathies) jaffe lichtenstein FD, café au lait pigmentations
tx of Fibrous dysplasia
Growth often continues through adolescence, then slows/stops in adulthood. Lesions may need to be debulked periodically.
central giant cell lesions share same histology with…
Cherubism, hyperparathyroidism, ABCs
Whats cherubism
Kids, multiple quadrants of CGCL; often resolve in adulthood, sometimes not.
Hyperparathyroidism
Stones: nephroliathiasis Bones Subperiosteal resorption of the phalanges of the index & middle fingers Loss of lamina dura around teeth “Ground glass” appearance of bone Brown tumor: identical to central giant cell lesion microscopically Usually affect mandible, clavicle, ribs, & pelvis UL/ML RL Severe form: osteitis fibrosa cystica (central degeneration & fibrosis) If secondary to renal dz ⇒ renal osteodystrophy Groans: secondary to duodenal ulcers Moans (psychic): mental status changes (lethargy, confusion, dementia)
What types of skin pathology are Benign, not pre-malignant?
- Solar Lentigo
- Seborrheic Keratosis
What is this?
Solar Lentigo
What is this?
Seborrheic Keratosis
What is this?
Basal Cell Carcinoma
- Pearly papule
- Rolled borders and telangiectasias
- Most common cancer
- It does NOT occur intraorally or on mucosa
- Strictly a skin cancer
- Doesn’t tend to matastasize
What is this?
Is it pre-malignant?
- Actinic Keratosis
- Yes!
What is this?
Is it pre-malignant?
- Actinic Keratosis
- Yes!
What is this?
- Squamous Cell Carcinoma
- Can Metastasize
What 2 skins lesions are Pre-malignant?
- Actinic Keratosis
- Cheilitis
What is this?
Subungual Melanoma
Oral melanoma can be…
Amelanotic
What 2 entities are often a result of chronic, long-term exposure to sun?
BCC & SCC
What are the A, B, C, D, E’s of melanoma?
- Assymetry
- Border
- Color
- Diameter
- Evolution
What is wegners granulomatosis
autoimmune disorder of unknown etiology resulting in systemic vasculitis and necrotizinf granulomatous lesions of the respiratory tract
What is the most characteristic oral manifestation of wegeners granulomatosis
Strawberry gingivitis florid granular hyperplasia (bumpy hemorrhagic and friable) reported boine destruction and tooth mobility
What are you looking for in indirect immunoflourescence for Wegener
c-ANCA clasic anti neutrophil cytoplastic antibodies diffuse cytoplasmic staining pattern
IN Wegner what are you looking for with ELISA (Enzyme linked immunosorbent assay
ID antibodies against proteinase 3 confirms positive indirect immunoflourescence
What are the halmarks of hyperparathyroidism
Stones bones groans moans brown tumor
In hyperparathyroidism what does Stones mean
Kidney stones metastatic calcification within other soft tissue: blood vessel walls sclera, dura, subcutaneous
In hyperparathyroidism what does bones mean
subperiosteal resorption of phalanges loss of lamina dura around tooth roos alterations of bony trabecular pattern (ground glass)
What is a brown tumor
Name derived from gross apearance due to hemorrhage and hemosiderin well delineated, uni or multilocular radiolucencies mandible clavicles pelvis ribs histology is identical to central giant cell lesion
What is osteitis fibrosa cystica
central fibrosis/degredation of brown tumors
What is renal osteodystrophy
end stage renal disease with striking jaw enlargement ground glass appearance can cause secondary hyperparathyroidism
Whats the def of amyloidosis
a heterogenous group of conditions characterized by the deposition of an extracellular proteinaceous substance (amyloid)
How is amyloidosis classified
organ limited systemic
what is an amyloid nodule
solitary asymptomatic submucosal deposit composed of aggregates of immunoglobulin light chains focal collections of monoclonal plasma cells may be responsible not associated with systemic alteration this type is RARE in oral soft tissues
amyloidosis and multiple myeloma
shared in 15-20% of cases
Symptoms of systemic amyloidosis
inisital non specific skin lesions then smooth surfaced firm waxy papules/plaques on eyelid retroauricular region, neck, lips Macroglossia difuse or nodular enlargement of tongue (may be ulcerated) Xerostomia and xerophtalmia if amyloid deposits in the lacrimal and salivary glands
What organ system is associated with systemic amyloidosis
end stage renal disease/dialysis
what is direct immunofluorescence
a way to stain tissues to search for antibodies by making them flourese. used to detect auto immune disease
how do you take a biopsy for immunoflouresence
• Submit half in Michel’s solution – ammonium sulfate solution; transport medium, not a fixative like formalin; allows for “fresh” tissue
what are good terms for intramural changes due to vesiculobullous conditions
desquamative gingivitis and desquamative mucosa
where is separation in pemphigus vulgaris
intraepithelial. the antibodies attack desmosomes
what is the positive nikolsky sign and what does it indicate
– Formation of bullae on previously unaffected skin after application of firm, lateral pressure – Characteristic of pemphigus vulgaris
what is usually the first sign of hemp vulgarisms
• Initial presentation may be oral lesions; 50% of patients have oral lesions 1 year or more before onset of skin lesions
what are the results of immunoflourecence in pemp vulgarisms
direct and indirect usually positive between epithelial cells. Indirect can also be used to asses tx
how do you tx temp vulgaris
Systemic corticosteroids (prednisone) • Combined with other immunosuppressive drugs (steroid sparing): azothioprine • High initial dosing schedule, followed by low maintenance doses for long-term control With corticosteroids, 5% to 10% mortality remains, often from long-term steroid use
what is cicatricial pemphigoid
• Autoimmune • Antibodies directed against components of the epithelial basement membrane (subepithelial splitting) • More common than pemphigus, better prognosis cicatrix means scar
what sites are usually affected by cicatricial pemphigoid
Oral lesions found in most patients, other sites often found as well (conjunctival, nasal, esophageal, vaginal, laryngeal) • Gingival involvement – desquamative gingivitis, also seen in other conditions
what is symblepharon
consequence of cicatricial pemphigoid Adhesion between bulbar and palpebral conjunctivae • Subconjunctival fibrosis – early change • Conjunctiva becomes inflamed and eroded • Repeated healing leads to scarring b/w bulbar and palpebral conjunctiva
in cicatricial pemphigoid where does separation usually occur
between the basement membrane and basal layer of epithelium
what is the usual immunoflouresent results with cicatricial pemphigod
• Direct immunofluorescence – Continuous linear band along basement membrane zone – 90% of patients – IgG, C3, possibly IgA and IgM • Indirect immunofluorescence – Only 5% of patients
Cicatricial Pemphigoid Treatment
• Immediately refer to an ophthalmologist • Treatment is varied, individual – Topical agents (if only oral lesions are present) – Systemic agents: corticosteroids plus other immunosuppressives (cyclophosphamide), dapsone, minocycline or niacinamide make sure ophthalmologist i involved
what are the two types of lichen planus
reticular and eosive
what are the immunoflouresent results of oral lichen planus
Direct is non specific. positive for fibrinogen along the basal layer
when do you treat oral lichen planus
when it is symptomatic
what is the tx for oral lichen planus
if concomitant candida present give 2 weeks of anti fungal. f LP still around give topical corticosteroids Lydex gel. if LP still present be concerned for dsplasia
What are the types of erythema multiforme
Minor, major TEN
Describe presentation of EM minor
target lesions of skin
what usually is the trigger of EM minor
secondary HSV
describe presentation of EM major
stevens johnson syndrome often in sick pt. Hemorrhagic crusting of lips. Dehydration
What is common trigger of EM major
usually medication, often a relatively common one such as tylenol
What is TEN
toxic epidermal necrolysis. its lose skin and must be treated like burn patients. no steroids as they are prone to infection
which form of candidiasis is associated tiwh invasion of tissues
hyphen form (yeast form is innocuous)
What factors determined clinical evidence of infection
• Host immune status • Oral environment • C. albicans strain
what are the four clinical patterns of candidiasis
• Pseudomembranous • Erythematous • Chronic hyperplastic • Mucocutaneous
PSEUDOMEMBRANOUS CANDIDIASIS
• Best recognized form of candidiasis • Aka “thrush” • White mucosal plaques (cottage cheese) • Plaques can be removed, usually revealing red, irritated tissue
Where are the most common sites for pseudomembranous candida
• Most common sites are buccal mucosa, dorsum of tongue, and palate
what are symptoms of pseudomembranous candidiasis
Symptoms may include mild chronic burning, bad taste (salty, bitter), “blisters”
What are the predisposing factors for candidiasis
Pre-disposing factors • Recent history of broad spectrum antibiotic • Immune dysfunction (HIV, leukemia) • Infants (underdeveloped immune system
what are the subtypes of erythematous candida
• Acute atrophic candidiasis • Median rhomboid glossitis • Chronic multifocal candidiasis • Angular cheilitis • Denture stomatitis
Acute atrophic candidiasis
• “Antibiotic sore mouth” – recent course of broad spectrum antibiotics • Burning, scalded sensation • Red, bald tongue due to diffuse loss of filiform papillae
Median rhomboid glossitis
• Aka central papillary atrophy • Found in adults, consistently associated with c. albicans • Well-outlined erythema in midline of posterior dorsal tongue • Loss of filiform papillae; may be smooth or lobulated • Often asymptomatic, may resolve with antifungal therapy
Chronic multifocal candidiasis
Involvement of dorsal tongue as well as other areas, usually junction of hard and soft palate (“kissing lesion”) and corners of the mouth
Angular cheilitis
• Red, fissured, scaling lesions at the mouth corners • Common patient: older, with reduced vertical dimension
what bacteria is usually connected with angular chelitis
s. aureus
Cheilocandidiasis
type of angular chelitis Involvement of perioral region, often due to lip or thumb sucking
Denture stomatitis
• Aka chronic atrophic candidiasis • Denture-bearing areas under maxillary removable prosthesis • The fungus shows very little invasion into tissue, and lesion is usually asymptomatic • Heavier fungal colonization on denture than tissue
CHRONIC HYPERPLASTIC CANDIDIASIS
• Aka candidal leukoplakia • White patch cannot be removed by rubbing • May represent secondary candidal infection of a leukoplakic lesion
location of chronic hyper plastic candidiasis and description
• Usually located on anterior buccal mucosa • May be speckled red and white • Hyphae are present • Diagnosis is confirmed by lesion resolution after antifungal therapy
MUCOCUTANEOUS CANDIDIASIS
• Seen within a rare group of immune disorders, usually sporadic or autosomal recessive • Candidiasis of mouth, nails, skin, etc from a young age • Thick white, foul-smelling plaques cannot be rubbed off, but can be controlled throughout life by anti-fungals
which candida may be associated with iron deficiency anemia
MUCOCUTANEOUS CANDIDIASIS
Endocrine-candidiasis syndrome:
• Hypothyroidism • Hypoparathyroidism • Hypoadrenocorticism (Addison’s) • Diabetes mellitus
CANDIDIASIS DIAGNOSIS • Combination of?
Clinical presentation • Exfoliative cytology • Biopsy • Level of response to anti-fungal treatment
CANDIDIASIS TREATMENT • Mucosal Tissue:
• Mycelex troches, 5x/day for 10 days. One in morning, then 30 minutes after each meal, and one more before bed.
treatment for candida on Complete dentures:
• 1 cup of water plus 1 teaspoon bleach, soak denture overnight
tx of candida on partials
• NO bleach. Use Nystatin elixir, 480 mL; place cup in refrigerator and instruct the patient to drop FPD’s in cup each night
whats a typical patient history who has melanoacanthoma
Rapid onset and growth Buccal mucosa most common site • Dark-brown or black pigmentation • Flat or slightly raised Predilection for black females • 3rd to 4th decades
Whats the etiology of melanoacanthoma
unknown. its considered a reactive lesion
how do you tx melanoacanthoma
• Incisional biopsy to confirm diagnosis • No further treatment is necessary • May spontaneously regress due to biopsy
what are the types of nevi
intramucosal, compound junctional
whats a intramucosal nevi
nevus found in the epithelial tissues
what is a compound nevus
found in epidermis and dermis
what is a junctional nevus
one found in-between epithelial and dermal tissues
where due blue nevi tend to occur orally
on the palate,
why are blue nevi blue
tyndall effect (physics) the cells tend to be deeper in the connective tissue and epithelial tissue above it reflect the blue light.
what are two examples of large congenital blue nevi
nevus of ito, nevus of ota
Whats pout nether syndrome
intestinal polyposis and perioral freckling
what are varix
abnormally dilated vessel with a torturous course
what is classic presentation of superficial lymphangioma
midline posterior tongue typical frogs egg vesicles
what is epulis granulomatosa
Hyperplastic growth of granulation tissue arising in an extraction socket
what should you do before biopsy of a suspected hemangioma
aspirate for lots of blood
what is common tx for congenital hemangiomas
often spontaneously resolve toward adult hood but some do require surgical intervention
what is the hallmark of storage weber syndrome
Nevus flammeus (port wine stain): along 1 or more segments of the trigeminal nerve
what can oral storage weber mimic
pyogenic granuloma
what is the ideal tx for peripheral osseous fibroma and peripheral giant cell granuloma
excise down to periosteum, then sc/rp to remove inciting irritant
what are names of benign peripheral nerve sheath tumors
schwannoma, neurofibroma, traumatic neuroma, palisaded encapsulated neuroma
which is the most common benign peripheral nerve sheath tumors
neurofibroma
where are the most common spots for neurofibroma
tongue and buccal of mandible
how common are oral schwanoma
not only 25% occur in head and neck
which nerve sheath tumor are usually painful
traumatic neuroma
where are most palisaded encapsulated neuromas found
nose and cheek 90%
what are bilateral commissural mucosal neuromas characteristic of
MEN 2B
why is a MEN2B dx important early
100% of its present with medullary thyroid carcinoma by age 30.
What is Mycobacteria?
Any mycobacteria other than tuberculosis and leprosy is considered “atypical mycobacerium”
What is this?
Cervico Actinomycosis
- Woody induratino to soft tissue
- Bacteria burrow straight through hard and soft tissue (direct extension)
- Often create a draining sinus tract extraorally
- Can mimic malignancy
- Part of normal flora (tonsils, intraoral); sulfur granules
What is this?
Median Rhomboid Glossitis
- Central Papillary Atrophy
- Often associated with/caused by candida
What is this?
“Kissing” Lesions
Chronic Multifocal Candidiasis
- Lesions of posterior tongue and soft palate
- Especially in patiens who chronically use steroid inhaler
What is this?
Angular Cheilitis
Often caused by candida
What is this?
Denture Stomatitis
Much heavier fungal colonization on denture than tissue; treat the denture
What is this?
Aspergillus
- Can present as allergic fungal sinusitis
- Mycetoma (fungal ball in sinus); or as
- Angioinvasive sinus disease in immunocompromised patients
What is this?
Mycormycosis
- Zygomycosis
- Angioinvasive fungal sinusitis
- Immunocompromised patients
- Be wary of paltal ulcerations in uncontrolled diabetics, patient undergoing chemo, etc
- Rapidly progressive tissue necrosis
What is Candidiasis?
- Dimorphic fungus (yeast and hyphal forms)
- Usually superficial infection
- Can be invasive in immnocompromised patients
What is this?
Laryngeal Papillomatosis
- Caused by HPV 16 and 18
- Juvenile or adult
- Can choke off airway
- Condylomas, with risk for malignant transformation
- Periodic debulding, sent to pathology to monitor for dysplasia/carcinoma
What is HHV-8 associated with?
Kaposi’s Sarcoma
What are two well known types of high risk types of HPV?
16 and 18
Culprit in many oropharyngeal SCC cases
HSV I is typically …
Oral
HSV 2 is typically…
Genital
HHV - 3 is…
Varicella-Zoster (chicken pox/shingles)
What is HHV-4?
Epstein-Barr Virus
- Mononucleosis
- Hodgkin Lymphoma
- Undifferentiated Naspharyngeal Carcinoma
- Oral Hairy Leukoplakia
What is HHV-5?
Cytomegalovirus
- CMV Infection
- Seen in immunodeficiency or congenitally
How does HSV-1 typically present?
- Tends to occur in kids
- low-grade fever and mild crusting/bleeding of intraoral/perioral area
How does HSV 1 typically present in an adult?
- Tends to be located more posteriorly with severe pharyngitis and high fever
What causes cold sores?
HSV-1, which does NOT cause apthous
What are some common manifestations of Nevoid Basal Cell Carcinoma?
- Multiple OKC’s
- Basal Cell Carcinomas at a young age
- Palmar/plantar pits
- Kyphoscoliosis
- Bifid ribs
- Calcified falx cerebri
- PTCH tumor suppressor gene mutation, chromosome 9
What is this?
Gardner Syndrome
- Supernumary teeth
- Multiple Osteomas
- Epidermal Inclusion Cysts
- Desmoid Tumors
- Colon Polyps with high rate of malignant transformation
- Buys patients prophylactic colectomy by age 30.
- APC gene mutation, chromosom 5
What is this?
McCune - Albright Syndrome
- Polyostotic Fibrous Dysplasia
- Multiple endocrinopathies (especially early-onset menses in females)
- Cafe au lait pigmentations (coast of Maine)
- Hocket stick deformity to femur
- GNAS1 gene mutation
What is this?
Treacher - Collins Syndrome
- Normal intelligence
- Hypoplastic Zygomas
- Conductive Hearing loss (missing external ear)
- Retruded chin
- Coloboma
- Spontaneous mutation in the proband (first person with mutation), then syndrome becomes worse in each successive generation
What is this?
Crouzon Syndrome
- Normal intelligence
- Proptosis
- Mid-face hypoplasia
- High arched palate
- Beaten copper skull films
What is this?
Apert Syndrome
- Similar to Crouzon Syndrome
- Plus Syndactyly and mental deficiency
What is this?
Neurofirbromatosis I
- Multiple neurofibromas (bag of worms)
- Can be extremely large
- Can undergo malignant transformation
- Cafe au laid pigmentations (coast of California)
- Axillary freckling;
- Lisch nodules of eye
What is this?
Multiple Endocrine Neoplasia, Type 2B
- Multiple mucosal neuromas; bilateral commissural neuromas in a kiddo is virtually diagnostic. Don’t miss this!
- Marfanoid body habitus (tall and thin, long arm length); long thin face.
- Almost guaranteed to have medullay carcinoma of thyroid; prophylactic thyroidectomy at young age recommended
- Pheochromocytomas of adrenal cortex. Hypertensive issues
What are some objective criteria for Sjogren Syndrome?
- Histologic evidence of lymphoplasmacytic inflammatin within salivary gland parenchyma
- Decreased salivary and/or eye secretions measured by Lashley cups or Rose-Bengal or Schirmer test;
- Positive serology for antibodies against SS-A (Ro) and SS-B (La).
- Also increased risk for lymphoma (MALT lymphoma)
When you have bilateral acoutic neuromas, you may have…
Neurofibromatosis 2
