Oral path photos Flashcards
Odontogenic Myxoma
o Radiographic feature: thin septations at right angles to each other. Thin, wispy septations.
o Can grow large; resection is difficult as tumor is jelly-like and may send myxoid fingers into surrounding bone, not visible on imaging.
o Conservative resection necessary.
Oral Melanotic Macule
- 2:1 female predilection
- tan to brown round macule, usually solitary
- tx not required, biopsy if unknown etiology
Ranula
- Mucocele on floor of mouth
- plunging = dissecting through mylohyoid. May grow large.
- DDx
- Dermoid cyst is in ddx,
- Cystic Hygroma (neck lymphangioma).
Hemangioma (Arterio-venous Malformation)
- Multilocular RL ddx (if intraosseous).
- Aspirate prior to biopsy
- Congenital hemangiomas often spontaneous resolve toward adulthood
Erythema Multiforme
- Probably autoimmune; 50% pts had other infx
-
EM Minor: Target lesions of skin, assoc w/ HSV
- Mostly male, 20s-30s, self-limiting (2-6 wks)
- 20% recurrence, irreg lesions necrose/ulcer
-
EM Major: (Stevens-Johnsons Syndrome)
- Sick Patients, trigger often a med, 5M/yr
-
Toxic Epidermal Necrolysis (TEN)
- Old pts, tx in burn unit, sloughing of skin
Osteosarcoma
Freq in long bones: proximal tibia/distal femur, in pubescent boys. Gnathic osteosarcs = older age, average 35. X-ray hallmarks of osteosarcoma: asymm widening of PDL space; bone formation in soft tissue; bone formation above the alveolar crest. Spiking root resorption; irregular, ill-defined borders; may be RL to Mixed to RO; “Sun-burst” only in 25% of jaw osteosarcs. Radical resection is only effective tx.
Veruccous Carcinoma
- A less aggressive, less invasive variant of conventional SCC.
- Exhibits a prominent papillary, exophytic growth pattern.
- Does not metastasize; if metastatic, likely represents transformation to conventional SCC.
Eruption Cyst
o Overlying soft-tissue impacted tooth, may clinically appear blue or red.
o Usually, spontaneous resolution with subsequent eruption of the tooth, no need to make an incision.
Wegeners Granulomatosus
- “Saddle Nose,” affects Respiratory/Renal Systems
- Oral Manifestation = “Strawberry Gingiva”
- before renal involvement
- florid, granular hyperplasia (bumpy, hemorrhagic, and friable)
- bone destruction and tooth mobility
Central Giant Cell Granuloma
- Multilocular RL ddx; some may be aggressive.
- Can be associated with aneurysmal bone cyst
- Same histology seen in Cherubism; Brown Tumors of hyperparathyroidism.
Macule
- A circumscribed flat area, up to 1.0 cm in diameter
- Perceptibly different color from surrounding tissue
Papule
- A circumscribed, solid elevation in skin or mucosa
Buccal Bifurcation Cyst
Be familiar with typical clinical presentation
- associated tooth is vital
- tx with curettage
- DO NOT extract tooth.
McCune-Albright Syndrome
- Polyostotic Fibrous Dysplasia
- Cafe-au-lait (Coast of Maine)
- Endocrinopathies (early menses in Females)
- Hockey Stick deformity to Femur
Squamous Papilloma
- HPV subtypes 6 & 11 found in 50% of squamous papillomas
- tongue, lips; most common soft tissue mass of soft palate
- cauliflower appearance, finger-like projections
- Papilloma Ddx= Squamous Papilloma, Verruca Vulgaris, Condyloma Acuminata, Heck’s Disease
HSV-1
- Cold sores…not the same as Canker sores/apthae
- Typically initially presents in Kids, crusting mouth, low fever
- Rarely initial presentation in adults, high fever, pharnyx
Erythema Multiforme
Probably autoimmune; 50% pts had other infx
EM Minor: Target lesions of skin, assoc w/ HSV
- Mostly male, 20s-30s, self-limiting (2-6 wks)
- 20% recurrence, irreg lesions necrose/ulcer
EM Major: (Stevens-Johnsons Syndrome)
- Sick Patients, trigger often a med, 5M/yr
Toxic Epidermal Necrolysis (TEN)
- Old pts, tx in burn unit, sloughing of skin
Osteoma
- Benign neoplasm; multiple seen in Gardner’s syndrome.
- Primarily craniofacial distribution.
Amelanotic Melanoma
- 20% of oral melanomas are non-pigmented
- Oral are of the Acral Lentiginous variety
- Rarely ulcerate
Epulis Granulomatosum
- histologically identical to pyogenic granuloma
- occurs within the socket of a recently extracted tooth
- hyperplastic growth of granulation tissue
Fibrous Dysplasia
Developmental; post-zygotic mutation of GNAS1 gene. Monostotic (late mutation), Polyostotic (intermediate mutation), Syndromic (early mutation).
- Polyostotic may affect just craniofacial bones.
- “Ground glass” radiopaque appearance to bone expansion. Ill-defined borders.
- Syndromes:
- McCune-Albright (FD, café au lait pigmentations (coast of Maine), endocrinopathies)
- Jaffe-Lichtenstein (FD, café au lait pigmentations).
- Growth often continues through adolescence, then slows/stops in adulthood. Lesions may need to be debulked periodically.
Cherubism
- presents in Kids
- multiple quadrants of CGCL
- often resolves in adulthood, sometimes not.
Thyroglossal Duct Cyst
o Midline of neck, anywhere from foramen cecum (base of tongue) down to thyroid.
o Usually attached to hyoid bone; cyst moves when patient swallows.
o Surgical procedure is Sistrunk procedure: remove cyst and involved portion of hyoid bone.
Epstein Barr
- HHV-4
Oral Melanoacanthoma
- Rapid onset and growth
- Buccal mucosa most common site
- Dark-brown or black pigmentation
- Flat or slightly raised
- Biopsy tends to incite resolution.
- Considered reactive, but etiology unknown.
- Black Females 20s/30s most common
Actinic Lentigo (Liver spots)
- not considered premalignant (no cytologic atypia)
- UV damaged skin
- Common in people with light skin (90% of whites over 70 years); Rare under 40 years
- well-demarcated, irregular borders
- usually multiple, may coalesce (to form into one)
- no treatment required (cosmetic)
Neurofibroma
- most common BPNST
- most percutaneous including facial skin; oral lesions less common
- young adults, M=F
- tongue & buccal; mandible
- soft painless nodule; unencapsulated bundles of spindle cells
- Multiple: concern for neurofibromatosis
Angular Chelitis
- usually related to candidiasis, but may have other cutaneous bacterial microfloral admixed
- redness, cracking of corners of the mouth
- often waxes and wanes
- may require topical or systemic antifungal therapy
Mucoepidermoid Carcinoma
- Malignant. Most common malignant salivary gland neoplasm.
- Any location; parotid and palate more common.
- Bluish nodule, may be ulcerated.
- Mucicarmine special stain highlights mucous cells histologically.
- Graded: low, intermediate, high grades.
- DDX in the palate: necrotizing sialometaplasia, MEC, SCC.
Giant Cell Fibroma
Hemangioma
COC with Ghost Cells
o Maxillary = mandible; often anterior.
o Mixed RL/RO ddx; can sometimes appear multilocular RL.
o On histology: ghost cell formation.
o Usually enucleates fairly easily (peels out of bone); low recurrence rate.
Cicatricial Pemphigoid
- Cicatricial means “scarring”
- Pemphigoid is between epithelium & Base Mem
- less deadly
- detectable with Direct Immunofluoresence 90% of the time
- Symblepheron: conjunctival adhesion bulbar/palpebral
- blocks eye ducts, overproduces keratin
Residual Periapical Cyst
- Radiographically appears as an oval or round lucency within the alveolar ridge at the site of a previous tooth extraction.
- Histology is similar to the periapical cyst…
- The clinical history and radiographic description that you provide are necessary to diagnose this
Peripheral Ossifying fibroma
- Part of Gum Bump Differential
- Peripheral Ossifying Fibroma
- Peripheral Giant Cell Granuloma
- Pyogenic Granuloma
- Fibroma
Mixed Tumor
Central Ossifying Fibroma
- neoplastic, unlimited growth potential, needs to be completely removed if possible.
- More common in mandible, slow growth typically.
- Downward bowing of the inferior border of the mandible is a radiographic feature of large OF’s.
- Juvenile active ossifying fibroma (JAOF or just active OF): more aggressive, rapid growth, more common in maxilla, younger patients. Can occur in ethmoid bone, other craniofacial bones.
Crouzon’s Syndrome
- Premature closing of cranial sutures.
- Normal intelligence.
- Proptosis (shallow orbits, bulging eyes appearance),
- mid-face hypoplasia, high arched palate.
- Beaten copper skull films.
Epidermoid Cyst
o Extremely common dermal cyst, along continuum of epidermoid cyst – dermoid cyst – teratoma. EIC has only 1 germ cell layer (epidermal)
o Filled with keratin – stinky. Patients may complain of periodic smelly “drainage”, if in continuity with skin surface.
o Multiple EICs can be seen in patients with Gardner Syndrome.
Neurofibroma
- most common BPNST
- most percutaneous including facial skin; oral lesions less common
- young adults, M=F
- tongue & buccal; mandible
- soft painless nodule; unencapsulated bundles of spindle cells
- Multiple: concern for neurofibromatosis
Epulis Granulomatosum
- histologically identical to pyogenic granuloma
- occurs within the socket of a recently extracted tooth
- hyperplastic growth of granulation tissue
Seborrheic Keratosis
- acquired, benign proliferation of epidermal cells
- very common; correlated w/ sun exposure
- “stuck-on rasin” or “stuck-on burnt cornflake”
- many are not pigmented
- No treatment required
- Multiple seborrheic keratosis with pruritis (itching)
- Leser-Trelat sign - indication of internal malignancy
Florid Cemento Osseous Dysplasia
- Predilection for Afr-Amer females, 30-50 years old
- Multiple quadrants involved
- Usually no symptoms or expansion
- Radiogrpahic: Lobular, irregular ROs with RL areas
- Pattern similar to PCOD & Focal COD
- 50% are associated with idiopathic bone cavities
- Treatment: usually not necessary
- Maintain oral health to avoid extraction/dentures
- Exposure of sclerotic masses to oral cavity may cause chronic osteomyelitis
Gingival Cyst of the Adult
- Considered the soft tissue counterpart to the lateral periodontal cyst
- 60% - 70% of cases occur in the mandibular canine and premolar area, on the facial gingiva or alveolar mucosa; maxillary cysts may also be found in the incisor region
- Patients are usually in the 5th to 6th decades
Verruca Vulgaris
- HPV types 2, 4, 6, or 40 are found in almost every lesion
- contagious, may spread via auto-inoculation
- tx must include base of the lesion
- HPV Differential
- Verruca Vulgaris
- Condyloma Acuminata
- Heck’s Disease
- Squamous Papilloma
Sturge-Weber Syndrome
- Related to CN V
- Port Wine stain of skin
- may include buccal mucosa
Sialolithiasis
- Most common in submandibular gland (tortuous Wharton’s duct), but also seen in parotid, minor glands.
- the condition that forms a “Sialolith”
Central Ossifying Fibroma
- neoplastic, unlimited growth potential, needs to be completely removed if possible.
o More common in mandible, slow growth typically.
o Downward bowing of the inferior border of the mandible is a radiographic feature of large OF’s.
o Juvenile active ossifying fibroma (JAOF or just active OF): more aggressive, rapid growth, more common in maxilla, younger patients. Can occur in ethmoid bone, other craniofacial bones.
Epidermoid Cyst
o Extremely common dermal cyst, along continuum of epidermoid cyst – dermoid cyst – teratoma. EIC has only 1 germ cell layer (epidermal)
o Filled with keratin – stinky. Patients may complain of periodic smelly “drainage”, if in continuity with skin surface.
o Multiple EICs can be seen in patients with Gardner Syndrome.
Calcifying Epithelial Odontogenic Tumor
o Most often posterior mandible.
o Mixed RL/RO ddx; often presents with central dense calcification, often around crown of an impacted tooth, then more radiolucent toward periphery.
o Produces amyloid-like material (histology) and concentric calcifications called Leisegang rings.
o Conservative excision, lower recurrence rate.
Oral Melanoacanthoma
- Rapid onset and growth
- Buccal mucosa most common site
- Dark-brown or black pigmentation
- Flat or slightly raised
- Biopsy tends to incite resolution.
- Considered reactive, but etiology unknown.
- Black Females 20s/30s most common
Necrotizing Sialometaplasia
- Chronic, non-healing ulcer, can grow large, but often comes on relatively quickly (compared to SCC). Often located on palate.
- Clinical and histologic ddx includes Mucoepidermoid Carcinoma and SCC. Ischemic necrosis? Biopsy often incites resolution.
Salivary gland neoplasia, general trends:
o Parotid is most common location, followed by mainor glands.
o Neoplasia in parotid is twice as likely to be benign; still more likely to be benign than malignant in submandibular gland; but in sublingual gland, neoplasia is less common, but much more likely to be malignant than benign.
o In minor glands, palate is most common location, followed by lips. All in all, neoplasia in minor glands is more likely to be malignant than benign (50/50 on palate).
o Even malignancies may be slow growing and not very aggressive.
o Concerning clinical features include facial nerve paresthesia or paralysis; ulceration.
o Most common benign salivary gland neoplasm: pleomorphic adenoma. Most common malignant salivary gland neoplasm: mucoepidermoid carcinoma (at SAMMC, it seems to be adenoid cystic carcinoma).
Recurrent HSV1
Pemphigus Vulgaris
- Splits epithelium up from itself
- Positive Nikolsky Sign (sloughing of tissue)
- 60-80% die if untreated
Osteoma
- Benign neoplasm
- multiple seen in Gardner’s syndrome.
- Primarily craniofacial distribution
Warthin Tumor
- Benign; typical patient is older male, smoker.
- Warthin tumor primarily occurs in the parotid, often bilaterally, although not necessarily at the same time.
Gorlin Syndrome
- AKA Nevoid Basal Cell Carcinoma Syndrome
- Mandibular prognathism
- numerous basal cell carcinomas (frequent head and neck region)
- 65% palmar and plantar pits
- 60-75% of patients have skeletal abnormalities: bifid ribs, spina bifida, etc.
Central Giant Cell Lesion
- Multilocular RL; some may be aggressive.
- Can be associated with aneurysmal bone cyst features.
- Same histology seen in cherubism; brown tumors of hyperparathyroidism.
Adenoid Cystic Carcinoma
- Malignant. Minor glands more common; palate, also sinonasal. Middle age, 40’s and male common. Slow, relentless growth, pain and paresthesia can be seen. This tumor spreads via skip lesions along nerves. Difficult to resect; eventually results in distant metastases (lung).
- All salivary gland neoplasms need to be completely excised due to propensity for unlimited local growth.
- Additional treatment modalities (neck dissection for lymph node metastases, chemo, radiation) is dependent on lymph node mets, and on grade of tumor (high grade, poorly differentiated).
- Frey’s syndrome: damage to auriculotemporal branch of facial nerve during parotid surgery: gustatory sweating (sweating of facial skin during salivation).
Lupus Vulgaris
- mucocutaneous lesions of secondary tuberculosis
- Mycobacterium
Herpetiform Apthous
Crouzon’s Syndrome
- Premature closing of cranial sutures.
- Normal intelligence.
- Proptosis (shallow orbits, bulging eyes appearance),
- mid-face hypoplasia, high arched palate.
- Beaten copper skull films.
Actinic Keratosis
- precancerous skin growth-squamous carcinoma
- ill-defined, scaly plaques < 1 cm in diameter
- tan, red or skin colored
- related to cumulative lifetime sun exposure
- more common on sun-exposed sites in fair-skinned elderly
- face, neck, forearms, & dorsal hands
- excess keratin build-up may cause cutaneous horn
- same as in squamous cell carcinomaestimated: progress to malignancy in 5-20% (10%)
Cervical Facial Actinomycosis
- Woody induration 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
OKC
o On multilocular radiolucent ddx.
o May grow large and cause expansion, but more often tracks up ramus of mandible.
o Maxillary OKC’s can grow into maxillary sinuses.
o Must be completely removed; high recurrence rate with curettage about 30%). Can do peripheral ostectomy or marsupialization to shrink cyst prior to excision/resection.
o Multiple OKC’s are highly suggestive of Nevoid Basal Cell Carcinoma Syndrome (aka Gorlin Syndrome).
Gorlin Syndrome
Ameloblastic Fibroma
- Kiddo tumor, 1st-2nd decades common.
- Should be on the ddx for RL lesion in a kid, or mixed RL/RO in a kid.
- Can grow large, displace teeth.
- Conservative excision; recurrences may require resection.
Central Ossifying Fibroma
- neoplastic, unlimited growth potential, needs to be completely removed if possible.
o More common in mandible, slow growth typically.
o Downward bowing of the inferior border of the mandible is a radiographic feature of large OF’s.
o Juvenile active ossifying fibroma (JAOF or just active OF): more aggressive, rapid growth, more common in maxilla, younger patients. Can occur in ethmoid bone, other craniofacial bones.
Oral Melanoacanthoma
- Rapid onset and growth
- Buccal mucosa most common site
- Dark-brown or black pigmentation
- Flat or slightly raised
- Biopsy tends to incite resolution.
- Considered reactive, but etiology unknown.
- Black Females 20s/30s most common
Oral Melanotic Macule
- 2:1 female predilection
- tan to brown round macule, usually solitary
- treatment is not required
- biopsies recommended for most oral presentations of etiology is unknown
- may be watch this clinical history and presentation is not concerning
COC-Calcifying Odontogenic Cyst
o Maxillary = mandible; often anterior.
o Mixed RL/RO ddx; can sometimes appear multilocular RL.
o On histology: ghost cell formation.
o Usually enucleates fairly easily (peels out of bone); low recurrence rate.
Multiple Mucosal Neuromas
- Diagnositic for Multiple Endocrine Neoplasia in kids
Hemangioma (Arterio-venous Malformation)
- Multilocular RL ddx (if intraosseous).
- Aspirate prior to biopsy
- Congenital hemangiomas often spontaneous resolve toward adulthood
Canalicular Adenoma
- Benign. 75% are found in the upper lip; half of remainder in anterior buccal mucosa.
- Should be at the top of the ddx for a submucosal nodule of the upper lip.
- May be multifocal
- (Mucoceoles don’t exist on Upper Lip)
Adenomatoid Odontogenic Tumor
o 2/3rds tumor: Anterior, maxilla, female, young, impacted canine
o Included in the mixed RL/RO ddx.
o Usually shells out of bone in large pieces, easily. If removed completely, no recurrence.
Ameloblastic Fibroodontoma
o Kiddo tumor, 1st-2nd decades common. Should be on the ddx for RL lesion in a kid, or mixed RL/RO in a kid.
o Can grow large, displace teeth.
o Conservative excision; recurrences may require resection.
AOT
o 2/3rds tumor: Anterior, maxilla, female, young, impacted canine
o Included in the mixed RL/RO ddx.
o Usually shells out of bone in large pieces, easily. If removed completely, no recurrence.
Lupus Vulgaris
- mucocutaneous lesions of secondary tuberculosis
- Mycobacterium
Crouzon’s Syndrome
- Premature closing of cranial sutures.
- Normal intelligence.
- Proptosis (shallow orbits, bulging eyes appearance),
- mid-face hypoplasia, high arched palate.
- Beaten copper skull films.
Amyloidosis
- deposition of an extracellular proteinaceous substance known as amyloid…waxy
- Can be caused by end stage Renal Disease
- associated with Multiple Myeloma
Probably Treacher-Collins Syndrome
Denture Stomatitis
Mixed Tumor
Multiple Myeloma
- “Punched-out radiolucency”. Neoplastic proliferation of plasma cells (the end differentiation of B-cells.) May produce amyloid.
Epidermoid Cyst
o Extremely common dermal cyst, along continuum of epidermoid cyst – dermoid cyst – teratoma. EIC has only 1 germ cell layer (epidermal)
o Filled with keratin – stinky. Patients may complain of periodic smelly “drainage”, if in continuity with skin surface.
o Multiple EICs can be seen in patients with Gardner Syndrome.
Goriln’s Syndrome
- AKA Nevoid Basal Cell Carcinoma Syndrome
- Mandibular prognathism
- numerous basal cell carcinomas (frequent head and neck region)
- 65% palmar and plantar pits
- 60-75% of patients have skeletal abnormalities: bifid ribs, spina bifida, etc.
Botryoid odontogenic cyst
- 5th-6th decade of life, 75-80% occur in mandibular premolar-canine-lateral incisor areas
- Usually well-circumscribed lucency lateral to vital tooth
- polycystic (grapelike) multilocular appearance
- Type of lateral periodontal cyst
Actinic Keratosis
- precancerous skin growth-squamous carcinoma
- ill-defined, scaly plaques < 1 cm in diameter
- tan, red or skin colored
- related to cumulative lifetime sun exposure
- more common on sun-exposed sites in fair-skinned elderly
- face, neck, forearms, & dorsal hands
- excess keratin build-up may cause cutaneous horn
fibroma
COC
o Maxillary = mandible; often anterior.
o Mixed RL/RO ddx; can sometimes appear multilocular RL.
o On histology: ghost cell formation.
o Usually enucleates fairly easily (peels out of bone); low recurrence rate.
Multiple Mucosal Neuromas
- characteristic of MEN 2b syndrome
- Thyroidectomy by age 30 to prevent cancer
Lipoma
Acinic Cell Adenocarcinoma
- Malignant, mostly found in parotid
- Commonly found at SAMMC
Actinic Chelitis
- typically associated with candidiasis
Condyloma Acuminata
- HPV 16 and 18 - higher risk for SCC (anogenital)
- Watch where you put your tongue!!
Basal cell carcinoma
- most common cancer
- from sun exposure (cumulative)
- if in young person, look for Gorlins aka Nevoid Basal Cell Carcinoma Syndrome
Cementoblastoma
o Young adults, kids; more common in posterior mandible.
o Often painful, expansile. Neoplastic, must be removed.
o RO, or mixed RL/RO, with RL rim. Attached to tooth root(s).
o Associated teeth need to be extracted.
Ameloblastic Fibroma
o Kiddo tumor, 1st-2nd decades common. Should be on the ddx for RL lesion in a kid, or mixed RL/RO in a kid.
o Can grow large, displace teeth.
o Conservative excision; recurrences may require resection.
Nasal Palatine Duct Cyst
o Anterior maxillary midline, can present either to the facial or palatal to teeth 8/9.
o Heart-shaped radiolucency, associated teeth are vital.
o Simple curettage usually curative.
Ossifying Fibroma
- Adults - age 20-40, mean 32 years
- No sex or racial predilection
- 80% in mandible
- Radiolucent to opaque with a lucent rim
- BOWING OF INFERIOR BORDER OF MANDIBLE
- NEOPLASTIC - completely excise, curettage, or en bloc for more aggressive tumors
- A few cases have been identified with mutations in the tumor suppressor gene HRPT2
- Associated with a rare condition: HYPERPARATHYROIDISM - JAW-JAW TUMOR SYNDROME. Characterized by parathyroid adenoma or carcinoma, ossifying fibromas of the jaws, renal cysts, and Wilm’s tumors (specific kind of malignant kidney tumor usually seen in small kids.)
OKC
o On multilocular radiolucent ddx.
o May grow large and cause expansion, but more often tracks up ramus of mandible.
o Maxillary OKC’s can grow into maxillary sinuses.
o Must be completely removed; high recurrence rate with curettage about 30%). Can do peripheral ostectomy or marsupialization to shrink cyst prior to excision/resection.
o Multiple OKC’s are highly suggestive of Nevoid Basal Cell Carcinoma Syndrome.
palisaded encapsulated neuroma
basal cell carcinoma
cervical facial actinomycosis
hsv 1
Ameloblastoma
o Benign neoplastic, can be aggressive. Must be completely removed, often requires resection of up to 1 cm clear margins.
o Can occur anywhere, but posterior mandible common.
o Included in the multilocular radiolucent ddx.
o Several histologic sub-types; desmoplastic ameloblastoma is the only clinically relevant sub-type.
o Desmoplastic ameloblastoma: More common in anterior maxilla; radiographically similar to a benign fibro-osseous lesion (BFOL), ground glass, than to multilocular RL. May be considered more aggressive.
amyloidosis
Ameloblastic Fibroodontoma
o Kiddo tumor, 1st-2nd decades common. Should be on the ddx for RL lesion in a kid, or mixed RL/RO in a kid.
o Can grow large, displace teeth.
o Conservative excision; recurrences may require resection.