Oral Path Final deck Flashcards
1
Q
Define Hamartoma…
A
Disorganized overgrowth of normal tissue in its normal location
2
Q
Define Choristoma…
A
Growth of normal tissue in an abnormal location
3
Q
Define Neoplasm…
A
Growth of abnormal tissue, may be either benign or malignant
4
Q
What are some characteristics of a Benign lesion?
A
-Bilateral -Rapid onset (ulceration, soft tissue swelling) -Pain -Growth around native structures - Slow expansion (osseous) - Smooth root resorption
5
Q
What are some characteristics of malignant lesion?
A
- Unilateral - Chronic, persistent (ulceration) - Absence of pain/presence of paresthesia - Invasion/destruction of native structures - Cortex destruction - Spiking root resorption
6
Q
Define Adenoma…
A
Usually a benign neoplasm: Pleomorphic adenoma, oncocytoma
7
Q
Define Carcinoma…
A
- Malignant neoplasm derived from epithelial cells - Surface (skin, mucosal): Basal cell carcinoma - Glandular: Adenocarcinoma
8
Q
Define Sarcoma…
A
Malignant neoplasm derived from cells of mesodermal origin: Liposarcoma, fibrosarcoma
9
Q
Define Metastasis…
A
- Spread of disease from one part of the body to another - Tumor implants are discontinuous with the primary tumor
10
Q
What are the 4 differentials for the gum bump differential?
A
- Fibroma 2. Pyogenic Granuloma (Lobular Capillary Hemangioma) 3. Peripheral Ossifying Fibroma 4. Peripheral Giant Cell Granuloma POF AND PGCG OCCUR ONLY ON THE GINGIVA!
11
Q
What are the 4 Human Papilloma Virus Differential?
A
- Squamous Papilloma 2. Verruca Vulgaris 3. Condyloma Acuminata (High risk types 16 & 18) 4. Heck’s Disease (Multifocal Epithlial Hyperplasia)
12
Q
What is the differential list for Multilocular Radiolucent Lesions?
A
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
13
Q
What is the differential for Mixed Radiolucent/Radiopaque Differential Diagnosis?
A
- Adenomatoid Odontogenic Tumor - Calcifying Odontogenic Cyst - Ameloblastic Fibro-Odontoma - Calcifying Epithelial Odontogenic Tumor - Ossifying Fibroma - Fibrous Dysplasia - Desmoplastic Ameloblastoma
14
Q
Define Odontogenic Cyst…
A
Cysts lined by odontogenic epithlium
15
Q
Which odontogenic cysts are inflammatory? Can you name 3?
A
- Periapical (radicular) cyst 2. Residual periapical (radicular) cyst 3. Buccal bifurcation cyst
16
Q
Which odontogenic cysts are developmental…there’s a lot!
A
- 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
17
Q
What are the 4 tumors of Odontogenic Epithelium?
A
- Ameloblastoma 2. Adenomatoid Odontogenic Tumor 3. Calcifying Epithelial Odontogenic Tumor 4. Squamous Odontogenic Tumor
18
Q
What are some Mesenchymal Odontogenic Tumors? Can you name 3?
A
- Odontogenic Myxoma 2. Central Odontogenic Fibroma 3. Cementoblastoma
19
Q
What are some mixed epithelial/mesenchymal odontogenic tumors?
A
- Ameloblastic Fibroma 2. Fibroodontoma 3. Odontoma (considered a hamartoma)
20
Q
Define Leukoplakia…
A
White patch that cannot be wiped off, clinical descriptions, not a diagnosis
21
Q
Define Erythroplakia…
A
- 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
22
Q
Define Erythroleukoplakia…
A
- AKA speckled leukoplakia - Frequently dysplasia or carcinoma in situ on biopsy
23
Q
Sharply demarcated leukoplakia is concerning for…
A
Dysplasia!
24
Q
What percentage of erythropakic lesions represent severe epithelial dysplasia, carcinoma in situ, or squamous cell carcinoma?
A
90%!
25
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
26
Define Dysplasia...
- Abnormal tissue development - Rapid cell turn over - Immature epithelial cells, lack of maturation - Can be mild, moderate, or severe (thirds of epithelium)
27
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
28
Oral Squamous Cell Carcinoma is most commonly found in these 2 locations...
1. 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
29
What is the vitality of teeth associated with buccal bifurcation cysts?
Vital
30
What is the tx for buccal bifurcation cyst
curettage, do not ext
31
What is the most common dev odontogenic cyst
dentigerous
32
What teeth are dent cysts most commonly associated with
impacted thirds and impacted canines
33
If an impacted tooth has a pericoronal radiolucency greater that ??? mm you should be concerned about more serious entities
3mm
34
Whats the tx for dentigerous cysts
Ext and send tissue to pathology
35
What is an eruption cyst
overlying soft tissue impacted tooth, may appear blue or red
36
What is the treatment for an eruption cyst
none, usually spontaneously resolve.
37
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
38
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
39
What are multiple OKCs suggestive of
Nevoid Basal Cell Carcinoma Syndrome
40
How do orthokeratinized Odontogenic Cysts compare to OKs
Histologically similar not usually as large associated with thirds recurrence rate with curettage low (2%)
41
Are gingival cysts of the newborn common
yes
42
Tx for gingival cysts of the newborn
none, spontaneously resolve by 3 months
43
Lat periodontal cyst facts
Associated with vital teeth bone window with simple enucleation usually curative
44
where are lat periodontal cysts most likely to occur
Man canine/premolar area (similar to gingival cyst of the adult)
45
Where are calcifying odontogenic cysts usually found
Max=man, often in the anterior
46
Which ddx do Calcifying Odontogenic Cysts fall under
Mixed, can be multilocular
47
Whats an interesting histologic feature of Calcifying Odontogenic cysts
Ghost cell formation
48
Tx for Calcifying odontogenic cyst
Enucleates easily (peels out of bone), low recurrence rate
49
Glandular odontogenic cyst locations
Propensity for mandible, premolar incisor region, crosses midline
50
Tx for glandular odontogenic cyst
can be aggressive so resection may be necessary
51
What can glandular odontogenic cysts be misdiagnosed as
intraossseous mucoepidermoid carcinoma
52
Where do nasopalatine duct cyst appear
ant max midline, either palatal or facial of 8/9 (teeth vital)
53
Tx for nasopalatine duct cyst
simple curettage
54
What is a nasolabial cyst
soft tissue cyst in the nasolabial fold that elevates ala.
55
What is the nasolabial cyst remnants of
Nasolacrimal duct
56
What gender is more likely to have nasolabial cyst
females
57
Tx for nasolabial cyst
surgical excision
58
Tx for developmental inclusion cyst of the neonate
none, resolve spontaneously
59
Types of dev inclusion cysts of the newborn
Epstein pearl and john nodules
60
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
61
What is the tx for Thyroglossal duct cyst
Sistrunk procedure:rem cyst and involved portion of hyoid bone
62
Where can a branchial cleft cyst be found
Lateral neck common, but can be anywhere from ear down to clavicle along SCM.
63
What does branchial cleft cyst appear as in histology
Lymphoepithelia cyst
64
Epidermal inclusion cysts are filled with what
keratin-stinky. its can complain of periodic smelly drainage if cyst is continuous with skin surface
65
How many germ cell layers does an epidermal inclusion cyst have
1
66
Multiple Epidermal inclusion cysts are consistent with
Gardner syndrome
67
Where are dermoid cysts found
midline of body, often floor of mouth or inner cants of the eye
68
How many germ layers are in a dermoid cyst
2, epidermoid and mesodermal
69
describe look and location of oral lymphoepithelial cyst
yellowish module, 1 cm on lateral posterior tongue or tonsillar area, soft palate.
70
What is an oral lymphoepithelial cyst
ectopic tonsillar/lymphoid tissue
71
Tx for oral lymphoepithelial cyst
Simple excision
72
Tx for ameloblastoma
Agressive and must be completely rem with resection of up to 1 cm into clear margins
73
common location of ameloblastoma
can occur anywhere but post man most common
74
What is the only clincally relevant histologic subtype of ameloblastoma
Desmoplastic ameloblastoma
75
where is desmoplastic ameloblastoma often found
Ant Maxilla
76
What is a desmoplastic ameloblastoma similar to radiographically
benign fibre-osseous lesion, ground glass
77
What is the text book presentation of adenomatoid odontogenic tumor
2/3: ant max, female, young, impacted canine
78
Tx for Adenomatoid odontogenic tumor
usually shells out of bone in large pieces, if completely removed no recurrence
79
Where are calcifying epithelial odontogenic tumors most likely found
post mandible
80
What do CEOTs produce histologically and radiographically
Amyloid like material concentric calcifications called leisegang rings
81
tx of Calcifying epithelial odontogenic tumors
conservative excision with low recurrence rates
82
Where can you find central odontogenic fibromas
Ant Max, post man
83
What is the classical presentation of central odontogenic fibroma in max
Palatal notch
84
Tx for central odontogenic fibroma
enucleation, low recurrence
85
Central odontogenic fibroma radiographically presents as
RL but can have RO flecks
86
What radiographic feature defines odontogenic myxoma
thin separations at right angles to each other. thin wispy septations
87
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
88
Who is most likely to have cementoblastoma
young adults,kids
89
where are cementoblastomas most commonly found
post man
90
Clinical presentation of cementoblastoma
painful and expansile
91
What happens to teeth associated with cementoblastomas
must be ext
92
radiographic presentation of cementoblastoma
RO, or mixed with RL rim, attached to tooth roots
93
Odontomas are an example of
harmartoma
94
What are the types of odontoma
compound complex
95
Compound odontomas def
still has three separate layers, usually ant max
96
Complex odontoma
unrecognizable as tooth, usually in posterior
97
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
98
growth facts about Ameloblastic fibroma/fibro odontoma
grow large, can displace teeth
99
tx for ameloblastic fibroma/fibro-odontoma
conservative excision, may need resection if recurs
100
Which locations have SCCs that are p16+
Soft palate, oropharynx larynx, base of tongue
101
What does p16+ indicate
a specific mutated pathway that may be HPV induced.
102
what are features of p16+ tumors
more aggressive respond better to therapy
103
What common variants of SCC are found in the soft palate/oropharynx/larynx/base of tongue
Non keratinizing SCC and basaxoid SCC
104
Tradition risk factors (smoking alcohol) are least associated with SCC in this intramural site
gingiva
105
Which gender is more likely to have SCC on gingiva
females
106
What is verrucous carcinoma
A less aggressive less invasive variant of SCC
107
Do verrucous carcinoma metastasize
no, if does likely represents transformation to conventional SCC
108
what are the three major salivary glands
parotid, submandibular, sublingual
109
what do myoepithelial cells do
contract to assist in expulsion of glad secretory product
110
what are features of the parotid
serous two lobes separated by facial nerve empties into stepsons duct contains lymph nodes lateral to facial nerve
111
Submandibular gland
80/20 serous/mucinous whitens duct 3-6 lymph nodes adjacent to gland
112
Sublingual gland
mucinous
113
Where do mucoceles not occur
upper lip
114
What happens to a mucocele during salivation
likely to expand
115
Mucocele tx
if excised take surrounding minor glands too to decrease chance of recurrence
116
what is a ranula
mucocele on the floor of the moth that may grow large.
117
what are some ddx of ranula
dermoid cyst, cystic hygroma
118
Where are sialoliths most likely to be found
submandibular gland in the tortuous whartons duct, but can be found in parotid and minor glands
119
What are possible causes of sialadentitis
stone blockage autoimmune (IgG4 chronic sclerosis sialadentitis) sjogren syndrome
120
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
121
Necrotizing sialometaplasia can mimic
mucous, and SCC
122
what is the most common location of saliva gland neoplasia
parotid followed by minor salivary glands
123
Bengin v malignant stats in parotid
bening 2x malignant
124
benign v malignant stats in submandibular
benign more common
125
benign v malignant stats in sublingual
neoplasms less common but when present usually malignant
126
Where are minor salivary gland neoplasms most likely
palate followed by lips
127
benign v malignant stats in minor salivary glands
malignant more likely (palate 50/50)
128
Aggressiveness of salivary gland malignancies
may be slow and not very agressive
129
What are concerning clinical features of salivary gland neoplasms
facial nerve paresthesia or paralysis, ulceration
130
what is the most common benign salivary gland neoplasm
pleomorphic adenoma
131
most common malignant salivary gland neoplasm
mucoepidermoid carcinoma
132
Location of pleomorphic adenoma
Parotid, then minor glands
133
Demographics of a warthin tumor pt
older male, smoker
134
where do warthin tumors present
parotid, often bilaterally though not necessarily at the same time
135
Canalicular adenoma are found where
75% in upper lip, other in ant buccal mucosa. may be multi factorial
136
Mucoepidermoid carcinoma are found where
anyloction but the parotid and palate more common
137
clinical features of mucoep
bluish nodule that may be ulcerated.
138
what stain is used to highlight mucous cell in mucoep
mucicarmine special stain
139
three grades of much ep
low intermediate high
140
DDX in the palate
necrotizing sialometaplasia, MEC, SCC
141
where does acidic cell carcinoma present most commonly
parotid
142
where is adenoid cystic carcinoma found most
minor glands, palat and sinonasal
143
Who typically gets adenoid cystic carcinoma
middle age, 40's, male
144
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
145
What other treatments needed for neoplasms
neck dissection, chemo, radiation dependent on lymph node mets, and on grade of umor
146
what is freys syndrome
damage to auriculptemporal branch of facial nerve during parotid surgery resulting in gustatory sweating
147
Multiple osteomas are seen in..
Gardners syndrome
148
Where are osteopath primarily distributed
craniofacially
149
Are tori/exostosis osteomas
no, they are developmental/reactive
150
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
151
facts about idiopathic osteosclerosis
vital teeth, no def etiology
152
what is the typical patient for osteoporotic marrow defects
middle aged female
153
likely site of osteoporotic marrow defect
body of man, can be site of prev ext
154
what is usually found when entering a marrow deffect
normal bone marrow
155
predilections of idiopathic bone cavity
young, man, male, maybe trauma
156
Findings upon entering an idiopathic bone cavity
nothing, bleeding incited usually causes healing
157
radiologic finding of idiopathic bone cavity
scallops around tooth roots
158
where are aneurysmal bone cysts more commonly found
long bones
159
growth of ABCs
rapid expansion and can be aggressive
160
predilections of ABCs
young females
161
Types of ABCs
primary and secondary
162
primary ABCs are associated with
neoplastic genetic mutation
163
secondary ABCs association
another entity such as central giant cell lesion
164
most common sites to metastasize to bone
BLT with a Kosher pickle breast, lungs, thyroid, kidney, and prostate
165
most common form of bone malignancy
bone mets
166
where are osteosarcomas most commonly found
long bones: proximal tibia/distal femur in pubescent boys
167
Gnathic osteosarcoma demographics
average 35 yo
168
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
169
what is the tx for osteosarcoma
radical resection
170
Which type of benign fibro osseous lesion is reactive
cemento osseous dysplasia
171
which type of benign fibroosseous lesion is neoplastic
ossifying fibroma
172
which type of benign fiber osseous lesion is developmental
fibrous dysplasia
173
whats the requirement to call COD florid
at least two quadrants are affected
174
whats the concern for COD in edentulous pts
the masses sequester and create opportunity for infections
175
tx for central ossifying fibroma
neoplastic with unlimited growth potential so needs to be completely removed
176
where are central ossifying fibromas most likely found
mandible
177
what is a hallmark radiographic feature of central ossifying fibroma
downward bowing of the inferior border of the mandible
178
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
179
what gene is responsible for fibrous dysplasia
GNAS1 gene mutation
180
types of fibrous dysplasia
monostotic, polysotic, syndromic polystotic may just affect craniofacial bones
181
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
182
tx of Fibrous dysplasia
Growth often continues through adolescence, then slows/stops in adulthood. Lesions may need to be debulked periodically.
183
central giant cell lesions share same histology with...
Cherubism, hyperparathyroidism, ABCs
184
Whats cherubism
Kids, multiple quadrants of CGCL; often resolve in adulthood, sometimes not.
185
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)
186
What types of skin pathology are Benign, not pre-malignant?
* Solar Lentigo
* Seborrheic Keratosis
187
What is this?
Solar Lentigo
188
What is this?
Seborrheic Keratosis
190
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
191
What is this?
Is it pre-malignant?
* Actinic Keratosis
* Yes!
192
What is this?
Is it pre-malignant?
* Actinic Keratosis
* Yes!
193
What is this?
* Squamous Cell Carcinoma
* Can Metastasize
195
What 2 skins lesions are Pre-malignant?
* Actinic Keratosis
* Cheilitis
196
What is this?
Subungual Melanoma
197
Oral melanoma can be...
Amelanotic
202
What 2 entities are often a result of chronic, long-term exposure to sun?
BCC & SCC
203
What are the A, B, C, D, E's of melanoma?
* Assymetry
* Border
* Color
* Diameter
* Evolution
204
What is wegners granulomatosis
autoimmune disorder of unknown etiology resulting in systemic vasculitis and necrotizinf granulomatous lesions of the respiratory tract
205
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
206
What are you looking for in indirect immunoflourescence for Wegener
c-ANCA clasic anti neutrophil cytoplastic antibodies diffuse cytoplasmic staining pattern
207
IN Wegner what are you looking for with ELISA (Enzyme linked immunosorbent assay
ID antibodies against proteinase 3 confirms positive indirect immunoflourescence
208
What are the halmarks of hyperparathyroidism
Stones bones groans moans brown tumor
209
In hyperparathyroidism what does Stones mean
Kidney stones metastatic calcification within other soft tissue: blood vessel walls sclera, dura, subcutaneous
210
In hyperparathyroidism what does bones mean
subperiosteal resorption of phalanges loss of lamina dura around tooth roos alterations of bony trabecular pattern (ground glass)
211
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
212
What is osteitis fibrosa cystica
central fibrosis/degredation of brown tumors
213
What is renal osteodystrophy
end stage renal disease with striking jaw enlargement ground glass appearance can cause secondary hyperparathyroidism
214
Whats the def of amyloidosis
a heterogenous group of conditions characterized by the deposition of an extracellular proteinaceous substance (amyloid)
215
How is amyloidosis classified
organ limited systemic
216
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
217
amyloidosis and multiple myeloma
shared in 15-20% of cases
218
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
219
What organ system is associated with systemic amyloidosis
end stage renal disease/dialysis
220
what is direct immunofluorescence
a way to stain tissues to search for antibodies by making them flourese. used to detect auto immune disease
221
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
222
what are good terms for intramural changes due to vesiculobullous conditions
desquamative gingivitis and desquamative mucosa
223
where is separation in pemphigus vulgaris
intraepithelial. the antibodies attack desmosomes
224
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
225
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
226
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
227
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
228
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
229
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
230
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
231
in cicatricial pemphigoid where does separation usually occur
between the basement membrane and basal layer of epithelium
232
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
233
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
234
what are the two types of lichen planus
reticular and eosive
235
what are the immunoflouresent results of oral lichen planus
Direct is non specific. positive for fibrinogen along the basal layer
236
when do you treat oral lichen planus
when it is symptomatic
237
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
238
What are the types of erythema multiforme
Minor, major TEN
239
Describe presentation of EM minor
target lesions of skin
240
what usually is the trigger of EM minor
secondary HSV
241
describe presentation of EM major
stevens johnson syndrome often in sick pt. Hemorrhagic crusting of lips. Dehydration
242
What is common trigger of EM major
usually medication, often a relatively common one such as tylenol
243
What is TEN
toxic epidermal necrolysis. its lose skin and must be treated like burn patients. no steroids as they are prone to infection
244
which form of candidiasis is associated tiwh invasion of tissues
hyphen form (yeast form is innocuous)
245
What factors determined clinical evidence of infection
• Host immune status • Oral environment • C. albicans strain
246
what are the four clinical patterns of candidiasis
• Pseudomembranous • Erythematous • Chronic hyperplastic • Mucocutaneous
247
PSEUDOMEMBRANOUS CANDIDIASIS
• Best recognized form of candidiasis • Aka “thrush” • White mucosal plaques (cottage cheese) • Plaques can be removed, usually revealing red, irritated tissue
248
Where are the most common sites for pseudomembranous candida
• Most common sites are buccal mucosa, dorsum of tongue, and palate
249
what are symptoms of pseudomembranous candidiasis
Symptoms may include mild chronic burning, bad taste (salty, bitter), “blisters”
250
What are the predisposing factors for candidiasis
Pre-disposing factors • Recent history of broad spectrum antibiotic • Immune dysfunction (HIV, leukemia) • Infants (underdeveloped immune system
251
what are the subtypes of erythematous candida
• Acute atrophic candidiasis • Median rhomboid glossitis • Chronic multifocal candidiasis • Angular cheilitis • Denture stomatitis
252
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
253
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
254
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
255
Angular cheilitis
• Red, fissured, scaling lesions at the mouth corners • Common patient: older, with reduced vertical dimension
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what bacteria is usually connected with angular chelitis
s. aureus
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Cheilocandidiasis
type of angular chelitis Involvement of perioral region, often due to lip or thumb sucking
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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
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CHRONIC HYPERPLASTIC CANDIDIASIS
• Aka candidal leukoplakia • White patch cannot be removed by rubbing • May represent secondary candidal infection of a leukoplakic lesion
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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
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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
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which candida may be associated with iron deficiency anemia
MUCOCUTANEOUS CANDIDIASIS
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Endocrine-candidiasis syndrome:
• Hypothyroidism • Hypoparathyroidism • Hypoadrenocorticism (Addison’s) • Diabetes mellitus
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CANDIDIASIS DIAGNOSIS • Combination of?
Clinical presentation • Exfoliative cytology • Biopsy • Level of response to anti-fungal treatment
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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.
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treatment for candida on Complete dentures:
• 1 cup of water plus 1 teaspoon bleach, soak denture overnight
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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
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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
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Whats the etiology of melanoacanthoma
unknown. its considered a reactive lesion
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how do you tx melanoacanthoma
• Incisional biopsy to confirm diagnosis • No further treatment is necessary • May spontaneously regress due to biopsy
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what are the types of nevi
intramucosal, compound junctional
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whats a intramucosal nevi
nevus found in the epithelial tissues
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what is a compound nevus
found in epidermis and dermis
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what is a junctional nevus
one found in-between epithelial and dermal tissues
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where due blue nevi tend to occur orally
on the palate,
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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.
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what are two examples of large congenital blue nevi
nevus of ito, nevus of ota
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Whats pout nether syndrome
intestinal polyposis and perioral freckling
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what are varix
abnormally dilated vessel with a torturous course
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what is classic presentation of superficial lymphangioma
midline posterior tongue typical frogs egg vesicles
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what is epulis granulomatosa
Hyperplastic growth of granulation tissue arising in an extraction socket
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what should you do before biopsy of a suspected hemangioma
aspirate for lots of blood
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what is common tx for congenital hemangiomas
often spontaneously resolve toward adult hood but some do require surgical intervention
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what is the hallmark of storage weber syndrome
Nevus flammeus (port wine stain): along 1 or more segments of the trigeminal nerve
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what can oral storage weber mimic
pyogenic granuloma
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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
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what are names of benign peripheral nerve sheath tumors
schwannoma, neurofibroma, traumatic neuroma, palisaded encapsulated neuroma
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which is the most common benign peripheral nerve sheath tumors
neurofibroma
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where are the most common spots for neurofibroma
tongue and buccal of mandible
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how common are oral schwanoma
not only 25% occur in head and neck
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which nerve sheath tumor are usually painful
traumatic neuroma
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where are most palisaded encapsulated neuromas found
nose and cheek 90%
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what are bilateral commissural mucosal neuromas characteristic of
MEN 2B
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why is a MEN2B dx important early
100% of its present with medullary thyroid carcinoma by age 30.
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What is Mycobacteria?
Any mycobacteria other than tuberculosis and leprosy is considered "atypical mycobacerium"
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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
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What is this?
Median Rhomboid Glossitis
* Central Papillary Atrophy
* Often associated with/caused by candida
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What is this?
"Kissing" Lesions
Chronic Multifocal Candidiasis
* Lesions of posterior tongue and soft palate
* Especially in patiens who chronically use steroid inhaler
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What is this?
Angular Cheilitis
Often caused by candida
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What is this?
Denture Stomatitis
Much heavier fungal colonization on denture than tissue; treat the denture
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What is this?
Aspergillus
* Can present as allergic fungal sinusitis
* Mycetoma (fungal ball in sinus); or as
* _Angioinvasive sinus disease in immunocompromised patients_
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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
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What is Candidiasis?
* Dimorphic fungus (yeast and hyphal forms)
* Usually superficial infection
* Can be invasive in immnocompromised patients
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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
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What is HHV-8 associated with?
Kaposi's Sarcoma
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What are two well known types of high risk types of HPV?
16 and 18
Culprit in many oropharyngeal SCC cases
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HSV I is typically ...
Oral
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HSV 2 is typically...
Genital
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HHV - 3 is...
Varicella-Zoster (chicken pox/shingles)
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What is HHV-4?
Epstein-Barr Virus
* Mononucleosis
* Hodgkin Lymphoma
* Undifferentiated Naspharyngeal Carcinoma
* Oral Hairy Leukoplakia
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What is HHV-5?
Cytomegalovirus
* CMV Infection
* Seen in immunodeficiency or congenitally
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How does HSV-1 typically present?
* Tends to occur in kids
* low-grade fever and mild crusting/bleeding of intraoral/perioral area
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How does HSV 1 typically present in an adult?
* Tends to be located more posteriorly with severe pharyngitis and high fever
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What causes cold sores?
HSV-1, which does NOT cause apthous
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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
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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
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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
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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
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What is this?
Crouzon Syndrome
* Normal intelligence
* Proptosis
* Mid-face hypoplasia
* High arched palate
* Beaten copper skull films
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What is this?
Apert Syndrome
* Similar to Crouzon Syndrome
* Plus Syndactyly and mental deficiency
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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
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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
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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)
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When you have bilateral acoutic neuromas, you may have...
Neurofibromatosis 2
