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Oral Pathology Flashcards

1
Q

Define cyst

A

Pathological cavity filled with fluid, semi-fluid or gas freq. lined by epithelium
Never filled with pus

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2
Q

Classification of cysts

A

Epithelial
- odontogenic
- non-odontogenic
Non-Epithelial

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3
Q

Sub classification of odontogenic cysts

A

Inflammatory

  • radicular; apical, lateral
  • residual

Developmental

  • odontogenic keratocyst
  • dentigerous; follicular, eruption
  • lateral periodontal
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4
Q

Sub-classification of non-odontogenic cysts

A

Fissure (developmental)

  • nasopalatine
  • nasolabial
  • median palatine

Soft tissue

  • mucous extravasation
  • mucous retention
  • dermoid
  • lymphoepithelial
  • thyroglossal duct
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5
Q

Non-epithelial cysts

A

Bone

  • simple; solitary, haemorrhagic, traumatic
  • aneurysmal
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6
Q

3 requirements for cyst pathogenesis

A
  1. Epithelial source
  2. Stimuli for cavitation + epithelial proliferation
  3. Mechanism(s) for continued growth + bone resorption
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7
Q

Discuss epithelial source of cysts

A

Inflammatory Cysts
- remnants of Hertwig’s Epithelial Root Sheath
— ensheath’s root dentine
- form epithelial cell rests of Malassez
- throughout PDL, entrapped in periapical granuloma

Dentigerous
- reduced enamel epithelium 
— forms epithelial ‘cover’ for enamel 
— protects enamel during development + eruption 
- split b/w REE + enamel -> cyst

Odontogenic keratocyst
- remnants of dental lamina
— initial buds of oral epithelium
- Glands of Serres

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8
Q

Discuss stimulus for cavitation and epithelial proliferation of cysts

A

Inflammation
- inflammatory cysts usually stim. by inflammation
- site specific: pulp necrosis -> periapical granuloma -> cyst
- PD pocket -> lat. PD inflammatory cyst
- cytokines + growth factors stim. epithelial proliferation
— IL-1+6, TNF, EGF, TGF-beta

Genetic

  • possible genetic defect in tumour suppressor gene
  • odontogenic keratocyst linked to Gorlin’s syndrome
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9
Q

Discuss mechanisms for continued epithelial growth and bone resorption

A

Hydrostatic: inflammatory + dentigerous

  • protein accumulation in cyst
  • wall acts as semi-permeable membrane
  • fluid accumulates in cyst lumen creating +ve pressure in cyst

Bone Resorption

  • cyst releases cytokines stim. bone resorption
  • IL1, TNF, PGE2

Epithelial Growth Factors
- EGF + TGF-beta May cause pronounced epithelial proliferation
- odontogenic keratocyst: pronounced mural growth
— epithelial cells over proliferate
— don’t have lots of expansion

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10
Q

General radiographic presentation of cysts

A

Well defined round/oval radiolucency
- keratocyst: scalloped margin
Usually, well corticated margin (radiopaque)
- except solitary bone cyst
- infection = loss of definition
Shape
- round due to hydrostatic growth
- keratocyst (+ solitary bone) grow through bone cf expand jaw
Locularity
- true (multiple cavities): keratocyst
- large cysts appear multilocular due to ridges in bony wall

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11
Q

General clinical findings of cysts

A 
Swelling
Pain 
Fluctuance 
Eggshell cracking
Tooth displacement/loosening
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12
Q

Clinical + radiographic findings of radicular cyst

A

Clinical

  • S: non-viral tooth, UIs common
  • develop within periapical granuloma (>10mm = cyst)
  • regular growth limited; B expansion late
  • long standing: displacement + loosening

Radiographic

  • unilocular, oval/round
  • well corticated
  • @ apex non-vital tooth
  • continuous w/ lamina dura
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13
Q

Epidemiology + Tx of radicular cyst

A

Epidemiology: 4-5th decade

Most common cyst; 65%

Tx: RCT, XLA

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14
Q

Discuss residual cysts

A

Epithelial odontogenic inflammatory cyst
Derived from rests of Malassez

S: edentulous area; retained radicular cyst post-XLA
Radiographic: well defined, oval/round

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15
Q

Histology of radicular/residual cysts

A

Lumen

  • pale pink serious exudate (white if removed)
  • macrophages, desquamated epithelial
  • inflammatory cells
  • cholesterol clefts + foreign body giant cells (if RF; GP, amalgam)

Epithelial

  • non-keratinised stratified squamous
  • variable thickness, often arcading (hyperplastic rete processes)
  • long-standing: thin, attenuated

Capsule: thick wall fibrous + granulation tissue

Inflammatory infiltrate: acute + chronic cells

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16
Q

Clinical + radiographic findings of dentigerous cysts

A

Clinical
- S: 3s, 8s common
- attached @ CEJ surrounding crown of UE tooth
— confirmed surgically/pathologically (not X-ray)
- envelop crown symmetrically
- late B expansion

Radiographic

  • unilocular, well corticated
  • crown associated lies centrally in cyst
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17
Q

Epidemiology + Tx of dentigerous cysts

A

Epidemiology: 3-4th decade

20% of jaw cysts

Tx: uncover tooth, XLA
- no recurrence

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18
Q

Histology of dentigerous cysts

A

Lumen

  • pink serious exudate
  • cholesterol clefts

Epithelial

  • non-keratinised stratified squamous
  • flat basement membrane
  • thin (2-5 cells), uniform
  • resembles REE

Cyst Wall

  • variably thick
  • blueish myxoid appearance (like dental follicle)

If becomes inflamed, indistinguishable from inflammatory cyst

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19
Q

Clinical + radiographic findings of odontogenic keratocyst

A

Clinical: S: Md; angle, ramus

Radiographic 
- usually multilocular 
- poss. associated w/ UE tooth
- little expansion 
- grows through medullary bone; late B expansion 
— root resorption possible
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20
Q

Epidemiology and Tx of odontogenic kerarocyst

A

Epidemiology: 2-3rd decade

5% jaw cysts

Tx: XLA
- recurrence common due to daughter cysts

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21
Q

Histology of odontogenic keratocyst

A

Lumen: pink, keratin filled

Epithelial 
- para/keratinised corrugated surface 
- flat basement membrane (developmental)
- basal cells
— reverse nuclear polarity (towards lumen)
— darkly staining

Wall: thin, fibrous
Small daughter cysts poss. in wall
- due to epithelial growth grows into marrow spaces
- lots = syndromic

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22
Q

Discuss lateral periodontal cysts

A

Any cyst in lat. PD area
Epithelial: derived from remnants dental lamina

Clinical: lat. roots vital teeth

Radiographic

  • unilocular, well corticated
  • round, small (<1cm)
  • B expansion if v large
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23
Q

Histology of lat. PD cyst

A

Epithelial

  • non-keratinised stratified squamous
  • thin (2-5 cells), not uniform
  • thickened areas for swirled plaques
  • flat basement membrane

Wall

  • thin, fibrous
  • scattered glycogen rich clear cells
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24
Q

Clinical + radiographic findings of nasopalatine cyst

A

Clinical

  • S: midline, ant. Mx; vital UIs
  • size: >6mm
  • asymptomatic

Radiographic

  • unilocular, well corticated
  • round/oval
  • apices of U1s
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25
Q

Histology of nasopalatine cyst

A

Lumen

  • serous exudate
  • variable inflammatory infiltrate

Epithelium

  • non-keratinised stratified squamous
  • ciliated pseudo-stratified respiratory
  • both

Wall

  • fibrous
  • neurovascular bundles
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26
Q

Discuss solitary bone cyst

A

Non-epithelial non-odontogenic cyst
Usually <20y
Aetiology: unknown, poss. trauma

Clinical

  • S: Md body
  • asymptomatic

Radiographic

  • unilocular, well corticated
  • irregular outline; extend b/w roots
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27
Q

Histology of solitary bone cyst

A

Fibrovascular tissue only
Lumen: usually empty

Epithelial: none

Wall: none/thin fibrous

  • occ. giant cells
  • haemosiderin pigment; blood vessels were present
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28
Q

Discuss aneurysmal blood cyst

A

Epidemiology: child, young adult
Aetiology: unknown
Soft tissue lesion; also classified as giant cell lesion
- blood filled cystic spaces

Clinical: S: Md

Radiographic

  • multilocular, well corticated
  • cortical expansion (ballooning)
  • partially cystic, partially solid
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29
Q

Histology of aneurysmal bone cyst

A

Giant cell lesion

Giant cells in hypervascular, hypercellular background
Localised proliferative lesion of vascular tissue w/ giant cells + granulation tissue
Blood filled cystic spaces

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30
Q

Discuss mucous extravasation and retention cysts

A 
Extravasation
- younger
- aetiology: trauma
- S: L lip
- histology 
— lumen: extravasated mucin
— epithelial: none
— wall: granulation tissue 
Retention
- older
- S: L lip less common
- related to duct obstruction 
- histology 
— dilated salivary duct filled w/ mucin 
— has epithelial lining
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31
Q

Discuss lympho-epithelial cyst

A

Epidemiology: late childhood, early adulthood
Epithelial: remnants within lymphoid tissue
- stimuli for proliferation unknown

Clinical

  • unilateral, fluctuant swelling
  • S: lat. neck, ant. sternocleidomastoid

Histology
- attenuated epithelium surrounded by lymphoid stroma

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32
Q

Discuss dermoid cyst

A

Developmental anomaly
Rare
- F=M
- 15-35; may present earlier/later

Clinical: S: midline FoM, above mylohyoid

Histology

  • epithelial: epidermis
  • wall: skin appendages (sebaceous glands, hair follicles)
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33
Q

Discuss thyroglossal cyst

A

Developmental
Occurs when thyroglossal tract left from descent of thyroid doesn’t breakdown

Clinical: S: midline

Histology

  • epithelium: attenuated or respiratory
  • wall: thyroid follicles (req. for Dx)
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34
Q

Briefly describe tooth development

A

Neural crest cells (from ectoderm) migrate + clump beneath oral ectoderm

  • induce formation 1ry epithelial band
  • gives rise to tooth germs

Pre-ameloblast induce odontoblasts

  • form dentine which induce ameloblasts
  • form enamel of crown

Following fragmentation of Hertwig’s root sheath, dentine formation during root development induce cementoblasts

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35
Q

General features of odontogenic tumours

A

Derived: odontogenic epithelium (oral ectoderm) +/- mesenchyme

Neoplasm

  • abnormal/uncontrolled growth/proliferation
  • unrelated to stimuli
  • benign or malignant

Hamartoma

  • developmental malformation
  • normal tissue, incorrect proportion or morphological arrangement

Most odontogenic tumours are benign
- more hard tissue content (mature) = more benign

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36
Q

Classification of odontogenic tumours

A

Epithelium only
Epithelium + mesenchyme +/- hard tissue
Mesenchyme only

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37
Q

Odontogenic epithelium only tumours

A 
Ameloblastoma: benign, v aggressive
Calcifying epithelial: benign 
Squamous: benign 
Clear cell: malignant 
Adenomatoid: enamel, cystic
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38
Q

Odontogenic epithelial + mesenchyme tumours

A

Ameloblastic fibroma: no hard tissue, both epithelium + mesenchyme neoplastic
Calcifying odontogenic cyst: dentine + enamel like material, cystic
Odontoma: all hard tissues formed

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39
Q

Odontogenic mesenchyme only tumours

A

Benign cementoblastoma
Odontogenic fibroma: only mesenchyme neoplastic
Myxoma: destructive potential

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40
Q

Epidemiology, freq., origin + Tx ameloblastoma

A

Benign odontogenic neoplasm

Epidemiology: 20-50y
Freq.: 1% all tumours
Origin: cell rests of enamel organ or dental lamina

Tx

  • surgical removal w/ margin (invasive)
  • long term follow up due to recurrence
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41
Q

Clinical + radiographic findings of ameloblastomas

A

Clinical
- S: Md 80% (angle); Mx 20%
- behaviour: slow growing, locally aggressive
- late Dx + incidental finding as mucosa appears normal
- early: asymptomatic
- late
— expansion of cortical plates, egg shell cracking
— extension into soft tissues
— root resorption, painless
— if left: destruction of Md

Radiographic

  • multilocular ‘soap bubble appearance’
  • well corticated; slow growing, Mx less so
  • round/oval, scalloped edge
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42
Q

Histology of ameloblastoma

A

Solid/cystic/both

Epithelium: resembles ameloblasts

  • tall, columnar
  • reverse nuclear polarity (prominent basal cells)

Follicular

  • epithelial islands
  • filled w/ loose stellate reticulum-like cells
  • some cystic degeneration (not true cyst)

Plexiform

  • interlacing epithelial strands
  • less stellate-like cells
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43
Q

Discuss unilocular ameloblastoma

A

Freq.: 10-15% of ameloblastomas
Radiographic: unilocular
- resembles dentigerous/radicular cyst
Often associated w/ crown UE8

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44
Q

Epidemiology, freq., origin + Tx of calcifying epithelial odontogenic tumours

A

Benign, solid neoplasm

Epidemiology: 20-60
Freq.: rare, 1% of odontogenic tumours
Origin: odontogenic epithelium, poss. cells of stratum intermedia

Tx: surgical excision w/ margin

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45
Q

Clinical + radiographic features of calcifying epithelial odontogenic tumours

A

Clinical
- S: Md body 75% (P/M)
- behaviour: slow growing, locally invasive
— usually small; v. large if undetected
- early: asymptomatic
- late: cortical plate expansion, root resorption

Radiographic

  • uni/multilocular
  • scatter radiopacities; esp. around UE crown
  • often associated w/ UE tooth
  • ill/well defined, irregular/round
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46
Q

Histology of calcifying epithelial odontogenic tumours

A

Epithelial

  • islands
  • pleomorphic, hyperchromatic, prominent nucleoli
  • bizarre atypia
  • no mitosis, no necrosis

Calcifications

  • concentric circles
  • laminated
  • basophilic
  • no pre-dentine layer; abrupt
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47
Q

Epidemiology, freq., origin + Tx ameloblastic fibroma

A

Benign neoplasm

Epidemiology: <20
Freq.: rare;

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48
Q

Clinical + radiographic findings of ameloblastic fibroma

A

Clinical

  • S: Md body 80%
  • behaviour: slow growing
  • asymptomatic
  • B+L expansion w/ tooth displacement
  • 50% associated w/ UE (mistaken for dentigerous)

Radiographic

  • resembles ameloblastoma
  • small: unilocular, smooth, well corticated
  • large: multilocular
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49
Q

Histology of ameloblastic fibroma

A

Similar to ameloblastoma

Epithelial

  • tall, columnar basaolid (ameloblast-like)
  • islands + strands
  • filled w/ stellate-like cells

Hypercellular mesenchyme in connective tissue (fibroma); usually dominant feature
- looks primitive; too many cells for mature cell
No hard tissues

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50
Q

Epidemiology, freq., origin + Tx of adenomatoid odontogenic tumour

A

Benign lesion, epithelium + variable hard tissue

Epidemiology: <30
Freq.: v rare
Origin: odontogenic epithelium

Tx: curettage

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51
Q

Clinical + radiographic findings of adenomatoid odontogenic tumour

A

Clinical

  • S: Mx ant., usually associated w/ UE
  • behaviour: slow growing, locally expansive
  • early: asymptomatic
  • late: root resorption, displacement, bony destruction (expansion)

Radiographic

  • unilocular, round/oval
  • well corticated
  • early: resemble dentigerous cyst, extends apical to CEJ
  • late: small radiopacities within lesion
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52
Q

Histology of adenomatoid odontogenic tumour

A

Solid or cystic
Intra-osseous or extra-osseous (gingival swelling-like)

Epithelium

  • tall, columnar cells resemble ameloblasts
  • from duct-like structures + rosettes (whirls of cells)

Calcifications

  • abrupt, basophilic deposits within epithelium
  • immature enamel, dentine
  • like calcifying epithelial odontogenic tumour
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53
Q

Epidemiology, freq., origin + Tx of calcifying odontogenic cyst

A

Benign cystic tumour; epithelium + hard tissue

Epidemiology: <40
Freq.: rare
Origin: odontogenic epithelium

Tx: enucleation

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54
Q

Clinical + radiographic findings of calcifying odontogenic cyst

A

Clinical

  • S: Md ant. 80%
  • behaviour: slow growing
  • early: asymptomatic
  • late: local expansion

Radiographic

  • unilocular, well corticated
  • occ. associated w/ UE/odontome
  • radiopacities within lesion
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55
Q

Histology of calcifying odontogenic cyst

A

Cystic (majority), some solid
75% intra-osseous

Epithelium

  • tall, columnar, reverse nuclear polarity
  • ameloblast-like
Suprabasal: loose stellate reticulum-like layer
Ghost cells (lack nuclei), may calcify

Calcifications: dysplastic dentine

Resembles ameloblasts, diff. by ghost cells + calcifications

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56
Q

Epidemiology, freq., origin, Tx of odontomes

A

Hamartoma, developmental abnormality (WHO)

Epidemiology: <20
Freq.: most common
Origin: odontogenic epithelium

Tx: XLA

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57
Q

Type of odontome

A

Compound

  • small tooth-like denticles
  • tooth shapes of normal radiodensity

Complex

  • irregular, haphazard mass
  • similar radiopacity to normal
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58
Q

Clinical + radiographic findings of odontomes

A

Clinical

  • S: Mx
  • behaviour: slow growing
  • asymptomatic, delay eruption/impacted
  • local expansion

Radiographic

  • similar radiopacity to normal tissue
  • associated w/ UE/impacted tooth
  • radiolucent line around lesion
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59
Q

Histology of odontome

A

Resemble developing teeth

  • enamel space (white)
  • dentine + pre-dentine
  • pulp tissue

Compound: organised, separated structures
Complex: irregular, haphazard arrangement

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60
Q

Epidemiology, freq., origin, Tx of odontogenic myxoma

A

Benign neoplasm, mesenchymal

Epidemiology: young adult, F>M
Freq.: rare
Origin: mesenchyme (fibroblasts)

Tx: excision

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61
Q

Clinical + radiographic findings of odontogenic myxoma

A

Clinical

  • S: Md (angle) > Mx
  • behaviour: locally invasive + expansive
  • early: asymptomatic
  • late: expansion
Radiographic 
- multi/unilocular
— poss. soap-bubble appearance
- occ. associated w/ UE
- smooth, well defined
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62
Q

Histology of odontogenic myxoma

A

Hypercellular myxoid ground substance

  • contains spindle/stellate cells
  • stellate reticulum-like

Epithelium: scattered rests, not neoplastic

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63
Q

Epidemiology, freq., origin + Tx of benign cementoblastoma

A

Benign neoplasm, mesenchymal

Epidemiology: 10-70; 50% <20
Freq.: rare
Origin: cementoblasts

Tx: excision/enucleation

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64
Q

Clinical + radiographic findings of benign cementoblastoma

A

Clinical

  • S: Md > Mx; P/M
  • behaviour: slow growing
  • local enlargement + expansive
  • root resorption

Radiographic

  • well defined dense mass @ apex
  • radiolucent margin
  • continuous w/ root
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65
Q

Histology of benign cementoblastoma

A 
Cellular cementum 
- attached to root
- resting + reversal lines
— mark changes in growth direction 
— usually indicate fast growing lesion

Fibrous capsule

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66
Q

Histology of alveolar osteitis

A

Dry socket

Excessive acute inflammatory infiltrate

  • lots of neutrophils
  • localised to socket wall

Bacterial aggregates
Irregular necrotic bone

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67
Q

Histology of osteomyelitis

A 
Acute
- acute inflammatory infiltrate 
— densely packed neutrophils form pus
- necrotic bony islands; acellular
— resorbed by osteoclasts

Chronic

  • mixed inflammatory infiltrate
  • fibrosis
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68
Q

Radiographic findings of osteomyelitis

A

Ill defined/poorly corticated; loss of cortication
Mottled/moth eaten appearance
Bony sequestra floating
Mixed radio-density

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69
Q

Histology of ORN

A

Completely acellular bone

  • lacunae empty; lack osteocytes
  • no osteoblasts on periphery

Bacterial aggregates

  • periphery
  • bone marrow spaces

Mixed inflammatory infiltrate
Necrosis
Fibrin

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70
Q

Epidemiology and aetiology of fibrous dysplasia

A

Benign skeletal anomaly
Normal bone replaced by immature disorganised bone + fibrous tissue

Epidemiology

  • children, young adults (bones growing)
  • F>M
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71
Q

Clinical + radiographic findings of fibrous dysplasia

A 
Clinical: depends on bone(s) affected 
- S: Mx > Md
- behaviour: slow growing, self limiting
— stops once bones stop growing 
- facial asymmetry 
- tooth displacement + malocclusion

Radiographic

  • ground-glass appearance
  • ill defined; extends to cortex
  • roots + bone appear continuous (not)
  • loss of lamina dura
  • narrowing of PDL
  • early: radiolucent (fibrous)
  • late; radiopaque (calcified)
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72
Q

Histology of fibrous dysplasia

A

Highly cellular fibrous stroma
Bony islands deposited in fibrous tissue
- immature, woven bone
- no osteoblast rim; secreted by fibroblasts
- irregular, curved, haphazard morphology

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73
Q

Epidemiology, freq. and Tx of cemento-ossifying fibromas

A

Benign neoplasms of jaws + craniofacial skeleton

Epidemiology: 40-59, F>M
Freq.: rare

Tx: excision; recurrence rare

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74
Q

Clinical + radiographic findings of cemento-ossifying fibroma

A 
Clinical 
- S: Md (P/M)
- behaviour: slow growing 
— no malignant transformation 
- B+L expansion 
- painless

Radiographic

  • well corticated
  • mixed radiodensity
  • no fusion b/w roots + bone
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75
Q

Histology of cemento-ossifying

A

Highly cellular fibrous stroma
Pseudo-capsule: reactive bone

Mineralised tissue deposited within stroma

  • reactionary, woven bone
  • lamellar bone
  • cementum-like tissue
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76
Q

Epidemiology of cemento-osseous dysplasia

A

Non-neoplastic fibro-osseous condition affecting alveolar bone

Epidemiology

  • middle aged
  • F
  • Afrocaribbean
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77
Q

Types of cemento-osseous dysplasia

A

PA: PA region, Md, ant.
Focal: single tooth
Florid: multiple sites, multi-Qs
Familial gigantiform cementoma: autosomal dominant, multifocal

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78
Q

Clinical + radiographic findings of cemento-osseous

A

Clinical

  • PA/Focal: asymptomatic, incidental finding
  • Florid: minor bony expansion
  • FGC: bony expansion, facial deformity

Radiographic

  • well defined
  • thin radiolucent rim
  • mixed radiodensity
  • no fusion w/ roots
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79
Q

Mx of cemento-osseous dysplasia

A 
PA/Focal: none, monitor 
Florid: risk osteomyelitis, regular recall 
FGC: surgery 
- risk recurrence 
- 2ry infection
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80
Q

Histology of cemento-osseous dysplasia

A 
High cellular fibrous stroma 
Mineralised deposits 
- woven/lamellar/cementum-like
- haphazard, irregular 
- fuse to from islands 
- many reversal lines
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81
Q

Epidemiology, freq., aetiology + Mx of Paget’s disease

A 
Epidemiology: >40
Freq.: 1.5-8% popn
Aetiology: unknown
- genetic
- environmental: paramyxovirus

Mx: bisphosphonates

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82
Q

Phases of Paget’s disease

A
  1. Osteoclastic: excessive resorption, fibrovascular tissue deposited
  2. Osteoblastic: new bone formation within fibrous tissue
  3. Osteosclerotic: bone coalesces -> dense, sclerotic bone
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83
Q

Clinical presentation of Paget’s disease

A

Jaws rare: Mx > Md

Mx

  • widening of alveolar process
  • palate flattening
  • malocclusion: retroclination UIs, P tipping post.

Md: expansion -> facial deformity

Enlargement
Pathological # (weak)
Deformity of weight bearing bones
Compression of cranial nerves
- deafness 
- visual disturbance 
- vertigo
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84
Q

Radiographic findings of Paget’s disease

A
  1. Radiolucent
  2. Mixed radiodensity, cotton wool appearance, ill defined
  3. Very dense, radiopaque
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85
Q

Dental implications of Paget’s disease

A

Early: highly vascular stroma -> inc. risk post-XLA bleeding
Late: irregular bone + min. vascularity -> inc. risk infection
Hypercementosis: difficult XLA

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86
Q

Histology of Paget’s disease

A

Mosaic pattern
- haphazard, irregular arrangement of bone

Prominent, basophilic reversal lines
Mature: less vascular

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87
Q

Aetiology of cherubism

A

Benign, autosomal dominant disorder of childhood

Aetiology: mutation of binding protein gene

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88
Q

Clinical presentation of cherubism

A

Presents: 2-4y, usually normal @ birth

S: Md > Mx
Behaviour: slow growing, self limiting 
Bilateral, symmetrical expansion 
Facial deformity
- characteristic retracted skin, upwards gaze

Tooth displacement + loosening
Delayed eruption + premature loss

Speech + visual impairments

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89
Q

Radiographic findings + Mx of cherubism

A

Radiographic
- hypercellular + hypervascular fibrous stroma
— replaces bone
— numerous multinucleate osteoclast giant cells
- abundant haemosiderin (b/d of RBC)
- perivascular hyalinisation

Mx
- detect + Tx UE
- OH
- orthognathic: facial deformity + malocclusion 
— once stopped growing
90
Q

Aetiology/types of hyperparathyroidism

A

1ry

  • adenoma (benign tumour) 80%
  • carcinoma (malignancy) 5%
  • idiopathic hyperplasia 15%

2ry: hyperplasia 2ry to renal disease/intestinal malabsorption
3ry: hyperplasia, gland behaves as autonomous adenoma following removal

91
Q

Pathogenesis of hyperparathyroidism

A

Parathyroid glands detect + regulate serum Ca2+ conc.
Excess PTH prod. from adenoma/hyperplasia
Stim. osteoclasts -> Ca2+ mobilised from bone

Ca2+: tubular re-absorption, intestinal absorption
PO4-: renal excretion
PTH: inc.
ALP: inc.

92
Q

Clinical features of hyperparathyroidism

A 
Bone
- brown tumours (giant cell lesions)
- osteoporosis
- joint pain
Renal stones 
GIT irregularity 
Depression
Fatigue, nausea 
Muscle weakness
93
Q

Radiographic findings + Mx of hyperparathyroidism

A

Radiographic

  • well defined
  • variable: radiolucent -> densely sclerotic
  • irregular radiopacities

Mx

  • 1ry: removal
  • 2ry: Tx underlying cause
94
Q

Histology of hyperparathyroidism

A

Similar to cherubism

Hypercellular, hypervascular fibrous stroma
- multinucleate osteoclast giant cells
Haemosiderin
Bony destruction, modular appearance

95
Q

Types of giant cell granuloma

A

Central

Peripheral

96
Q

Epidemiology + Mx of central giant cell granuloma

A

Localised, benign osteolytic lesion of jaws

Epidemiology: F > M

Mx
- curettage 
- intralesional/systemic medication 
— steroid 
— calcitonin 
— interferone
— RANKL inhibitors
97
Q

Clinical + radiographic findings of central

A 
Clinical
- S: Md > Mx, ant.
- behaviour: slow growing, expansile 
- asymptomatic 
- 30% locally aggressive
— pain
— resorption + displacement 
— perforate cortex, involve soft tissue

Radiographic

  • well defined radiolucency
  • advanced: multilocular
98
Q

Histology of central giant cell granuloma

A

Hypercellular, hypervascular fibrovascular stroma
Numerous multinucleate osteoclast giant cells
Haemosiderin

99
Q

Aetiology of peripheral giant cell granuloma

A

Localised reactive proliferation of gingiva/alveolar mucosa

Aetiology

  • 2ry reactive process
  • localised mucoperiosteum/coronal PDL irritation
  • plaque/calculus/overhanging restoration
100
Q

Clinical + radiographic findings, Mx of peripheral giant cell granuloma

A

Clinical

  • S: Md > Mx, gingiva, edentulous ridge
  • sessile/pedunculate soft pink/purple-blue lump
  • smooth/ulcerated/papillomatous surface

Radiographic: no bony invasion (poss. erosion of alveolar bone)

Mx: surgical removal, recurrence low

101
Q

Syndromes that may lead to central giant cell granulomas

A

Neurofibromatosis type 1
Noonan
LEOPARD (noonan w/ lentigines)

102
Q

General features of abscesses

A

Develop @ apices of tooth w/ necrotic/infected RC
May occur in deep PPD along affected tooth
Presents: pain + swelling, poss. discharge
- spread along fascial/muscle planes -> cellulitis, Ludwig’s angina

103
Q

Causes of pulpitis/abscess

A 
Caries
Trauma
#
Deep PPD: lat. +/- accessory canals 
Extension of PA infection from adjacent tooth 
Blood stream (anachoresis)
104
Q

Sequelae of pulpitis

A

Pulpitis -> acute chronic

  • > PA periodontitis -> acute chronic
  • > dento-alveolar abscess PA granuloma
  • > inflammatory dental cyst -> abscess -> distant spread
105
Q

Obligate anaerobes commonly associated w/ pulpitis

A

Gram- rods

  • porphyromonas gingivalis
  • prevotella intermedia
  • fusobacterium nucleatum

Gram+ rods

  • eubacterium
  • lactobacillus
  • actinomyces

Gram+ cocci: peptostreptococci
Gram- cocci: veillonella

106
Q

Facultative anaerobes commonly associated w/ pulpitis

A

Gram+ cocci

  • strep. mitis, oralis, intermedius
  • enterococcus faecalis

Gram- cocci: neisseria

Gram+ rods

  • corynebacterium
  • lactobacillus
107
Q

Tx of pulpitis

A

Debridement: remove necrotic + infected tissue from RC
Antimicrobial: RC dressing, occ. systemic
RCT
Apicoectomy: if infection persists

108
Q

Clinical features of abscesses

A 
Pain: rapid onset
Erythema
Swelling 
Tenderness: TTP, palpation 
Mobility
109
Q

Routes for pus drainage from abscess

A

RC/PDL
Cancellous bone + perforate cortex
Into OC/facial skin through sinus tract

Palate: discrete swelling due to dense mucoperiosteum

110
Q

Mx of periapical abscess

A 
Drainage 
Remove source (RCT)
AB
- req.
— no drainage 
— spread to soft tissues 
— pt febrile 
- amoxicillin 
- metronidazole: failure to respond within 48h
111
Q

What is a periodontal abscess?

A

Abscess caused by acute/ bronco destructive process in periodontium
Results in localised formation of pus communicating w/ OC through PDL and/or periodontal sites
Doesn’t arise from necrotic pulp

112
Q

Classification of periodontal abscesses

A

Gingival: localised soft gingival tissues; margin, interdental papilla
Periodontal: larger, extends apically
Pericoronal: associated gingiva of UE/E tooth (usually periocoronitis)

113
Q

What causes periodontal abscesses to form? Mx?

A

Occlusion or trauma to PPD orifice causing bacteria to become trapped
- infection spread; pocket -> soft tissues

Mx

  • drainage
  • debridement
  • AB: if pyrexia or cellulitis
114
Q

Define abscess

A

Pathological cavity w/ pyogenic membrane + pus filled

115
Q

Local + systemic signs of inflammation

A

Local

  • pain
  • swelling
  • redness
  • heat
  • loss of function
  • lymphadenopathy
Systemic
- fever
- inc. HR
- altered bloods
— Inc.: WBC (PMN), serum protein, ESR
116
Q

Clinical presentation of acute abscess

A

Soft tissue swelling

  • usually B
  • U2/6 P

Pain: poorly localised
- affected tooth painful if post-PA PD

Mobility (post-PD)
X-ray changes: may take few days

117
Q

Tx for acute abscesses

A

Drain pus
Remove cause
- RCT/XLA/incise + drain

118
Q

What can happen if abscesses are left unTx’d?

A

Spontaneous drainage will occur -> chronic abscess

119
Q

Why may an infection to spread? What determines direction of spread?

A

Cause
- host usually maintain balance b/w defence + bacteria
- imbalance -> spread
— opportunistic infection
— inadequate/no Tx
— immunocompromised: cold, fatigue, insomnia

Direction

  • can spread in any direction
  • take path of least resistance
120
Q

Stages of infection/abscess

A

Cellulitis

  • diffuse swelling due to tissue oedema
  • red + shiny
  • firmness depends on amount of fluid
  • spreading in potential connective tissue spaces
  • suppurations @ source, accumulates if unTx’d
Suppurative
- once infection peaked
- pus accumulation @ centre
- position depends on 
— gravity 
— pressure
— heat 
— muscle activity
121
Q

Source of dental infections

A

Odontogenic infections: any dental infectious disease

  • abscess: PA, PD
  • pericoronitis

Less common

  • AUG
  • infected cysts
  • MRONJ/ORN/osteomyelitis
  • fungal infection
  • cancrum oris
122
Q

Potential maxillary spaces for spread of infection

A 
Buccal space: sup. to buccinator
Buccal sulcus: inf. to buccinator 
Palatal
Lat. pharyngeal 
Sinus
Canine fossa
123
Q

Potential mandibular spaces for spread of infection

A 
Sublingual
Submandibular 
Submental
Labial sulcus
Submasseteric
Pytergomandibular 
Lat. pharyngeal 
Peritonsillar
Buccal space
Buccal sulcus
124
Q

Differentiate b/w sublingual + submandibular space

A

Sublingual: sup. to mylohyoid
Submandibular: inf. to mylohyoid

Mylohyoid is lower ant., higher post.
- most post. infection will be sublingual

125
Q

What are the submasseteric and pytergomandibular spaces?

A

Submasseteric: b/w lat. border ramus (lat., post.) + masseter (ant., medial)

Pytergomandibular: b/w medial border ramus (lat., ant.) + medial pterygoid (post., medial’)

126
Q

What are the peritonsillar and lat. pharyngeal spaces?

A

Lat./parapharyngeal

  • b/w carotid sheath (post., lat.) + medial pterygoid (ant., medial)
  • sup. to constrictor

Peritonsillar: inf. to constrictor

127
Q

Differentiate b/w submental + labial sulcus space and buccal space + sulcus in Md

A

Submental

  • chin
  • inf. to mentalis

Labial sulcus: sup. to mentalis

Buccal

  • space: inf. to buccinator
  • sulcus: sup. to buccinator
128
Q

What factors affect the spread of infection?

A

Ability to

  • bacteria: no., virulence
  • failure to drain
  • pt health

Anatomical

  • site
  • drainage site
  • natural barriers
129
Q

Discuss Ludwig’s angina

A

Bilateral submental, submandibular, sublingual infections

Clinical

  • raised, swollen tongue
  • pyrexia
  • dysphagia
  • dyspnoea
  • dysarthria

Tx

  • drainage
  • IV AB
  • poss. tracheostomy for airway
130
Q

Indications urgent referral to hospital is req. for abscess

A 
Rapidly swelling
Pyrexia 
Raised FoM: dysphagia, dysarthria, dyspnoea (Ludwig’s)
Deviated uvula: Ludwig’s
Immunocompromised/DM
Severe trismus
High pulse, raised WBC
Toxic appearance 
Malaise
131
Q

Difference b/w premalignant lesion and condition

A

Lesion: morphologically altered tissue in which cancer more likely cf normal counterpart

Condition: generalised state associated w/ significantly inc. risk developing cancer

132
Q

What is leukoplakia?

A

Pre-malignant lesion characterised by white patches w/ questionable risk having excluded know diseases/disorders w/ no inc. risk

133
Q

Epidemiology + aetiology of leukoplakia

A

Epidemiology

  • middle age, inc. age
  • M>F

Aetiology

  • smoking: 90%
  • idiopathic: 10%
134
Q

Clinical presentation of leukoplakia

A 
White patches 
S
- B mucosa: 25%
- Md gingiva: 20%
- tongue: 10%
- FoM: 10%
135
Q

Discuss the two types of leukoplakia

A

Homogenous: no malignant change

  • uniform flat appearance
  • may have shallow cracks
  • smooth/wrinkled/corrugated surface
  • consistent texture

Non-homogenous: 26% malignant transformation
- predominately white or white/red lesion (erythroleukoplakia)
- irregularly flat/nodular/exophytic
— nodular: raised, rounded, red and/or white excrescences
— exophytic: irregular blunt or sharp projections

136
Q

What is erythroplakia?

A

High risk pre-malignant lesion
Always associated w/ dysplasia/carcinoma

80% malignant transformation

137
Q

Aetiology of erythroplakia

A

Tobacco + smoking

Snus: 60% users get keratoses

  • associated w/ oral epithelial dysplasia
  • rarely dysplastic
  • malignancy: 0-1.2%/10y

Candida albicans: 30% associated

  • chronic hyperplastic candidiasis
  • dysplasia, speckled/nodular = high risk
  • lesion may regress w/ Candida Tx
138
Q

Clinical presentation of erythroplakia

A

Brightly red velvety plaque

Can’t be characterised as any other lesion

139
Q

Oral signs of syphilis

A

1ry: oral chancre (rare, 2% extragenital)

2ry

  • leukoplakia: D tongue
  • condyloma lata
  • mucosal patches
  • ulcers

3ry

  • gumma
  • syphilitic leukoplakia
  • atrophied glossitis
140
Q

Malignancy risk of syphilis

A

2.5% pt have leukoplakia

10% OSCC

141
Q

Clinical presentation of Plummer-Vinson syndrome and associated risk

A 
Clinical 
- Fe anaemia 
— strophic glossitis
— aphthous-like ulcers
— mucosal pallor
— sore tongue 
- post-cricoid oesophageal web 
- dysphagia

Risk factor for OSCC and oesophageal carcinoma

142
Q

Discuss oral submucous fibrosis

A

Pre-malignant condition

Aetiology: Paan/Betel quid chewers

Clinical

  • mucosal fibrosis + marbling
  • trismus
  • leukoplakia
  • staining + attrition

30% develop OSCC

143
Q

Discuss actinic keratosis

A

Aetiology: sunlight damage

Clinical

  • speckled, rough scaly patch
  • obliterates vermillion border
  • lip crusting
  • peri-oral freckles

Risk: 1%/yr SCC
- 60% SCC from AK

144
Q

Cancer risk of LP

A

0.5-2.0%/5yr OSCC

Controversial

145
Q

Define: keratosis, hyperkeratosis, orthokeratosis, parakeratosis

A

Keratosis: keratinisation of epithelium not normally keratinised
Hyperkeratosis: thickening of keratinised layer

Orthokeratosis: flat, anucleate superficial cells w/ homogenous eosinophilic cytoplasm
Parakeratosis: flat, homogenous eosinophilic cells w/ pyknotic nuclei

146
Q

Define: acanthosis, atrophy, atypia, dysplasia

A

Acanthosis

  • inc. no. cells in prickle cell layer
  • inc. epithelial thickness
  • broadening of Rete ridges

Atrophy

  • dec. thickness due to less cells
  • loss of Rete ridges
  • epithelium uniform

Atypia: changes to individual cell

Dysplasia: changes to whole epithelium

147
Q

Features of dysplasia

A 
Nuclear hyperchromatism
Nuclear + cellular pleomorphism 
Inc. nuclear:cytoplasm 
Inc. no. + bizarre mitoses 
Mitosis in prickle layer
Premature keratinisation in prickle layer 
Loss of polarity of basal cells
Loss of cell adherence 
Drop shaped Rete ridges
Loss of epithelial stratification
148
Q

Grading of dysplasia

A

None: epithelium normal
Mild: few epithelial cells in basal layer show atypia
Mod.: atypia in most basal cells + few suprabasal cells
Severe: almost all cells show atypia, basement membrane intact (no invasion)

149
Q

Histology of leukoplakia

A 
Para/hyperkeratosis (clinically white)
Variable: hyperplasia, acanthosis
Atrophy 
Candidal hyphae 
Inflammation 
Poss.: 1/+ dysplasia features
150
Q

Histology of erythroplakia

A

Atrophy (clinically red)
Dysplasia
Inflammation

151
Q

Management of dysplasia

A

Mild: review, advice, biopsy (repeat if req.)
Mod
- small: surgical excision
- large: multiple biopsies, review + monitor, repeat biopsy
Severe: excision

152
Q

Relative freq., incidence, prevalence + death rate of oral cancer in UK

A

Freq.: % all malignancies

  • WW: 10%
  • UK: 1-2%
  • India: 30-50%
  • geographical variation due to aetiological factors

Incidence: new cases / 100000/yr
- UK: 4

Prevalence: cases within popn. @ T
- 0.05-0.1% (1 in 1000)

Mortality: 60% 5yr survival

  • comparable to breast cancer
  • > malignant melanoma, cervical Ca
153
Q

Predisposing factors for oral cancer

A

Elderly M

M:F 3:1

  • lip: 5-20:1
  • tongue: 1:1
  • other: 2:1

Age: 60-70

  • > 50 85%
  • > 40 98%
154
Q

Prognosis of oral cancer

A

Poor prognosis depends on staging

Early: >80% 5 yr
Node involvement: >40%
Distant mets: <20%

155
Q

Aetiology of oral cancer

A 
Tobacco
Alcohol
Diet
Viral infection 
Other infections
156
Q

Discuss tobacco as risk factor for oral Ca

A

Smoking

  • hydrocarbons in cigarettes broken down by salivary enzymes
  • benzopyrene carcinogen of cigarette (tar)
  • 80-90% oral Ca pt long term smokers, 2x risk

Smokeless:
- India, HK, Sri Lanka, SEA: buccal Ca
— association b/w site of betel quid + lesion
— dose T related
— Areca nut: oral submucous fibrosis, Ca not clear
- chewing: nitrosonornicotine (carcinogen)

157
Q

Discuss alcohol as risk factor for oral Ca

A

80-90% oral Ca pt drink

Ethanol: inc. permeability of mucosa to carcinogens
- not carcinogen itself
Contaminants, colourants poss. carcinogenic

158
Q

Discuss how diet can be risk factor for oral Ca

A

Fe2+ deficiency

  • mucosal atrophy -> more susceptible to carcinogen
  • Plummer-Vinson syndrome: Fe2+ deficiency + oesophageal web

VitA

  • req. for normal epithelial differentiation
  • may be factor in neoplasia
  • retinoid Tx can cause remission of white lesions
159
Q

What virus are associated w/ oral Ca? How may viruses cause Ca?

A

Mechanism
- activate cellular oncogenes by
— initiation of mutations OR
— inserting own genome close to oncogene

Associated

  • HPV16/18: oropharyngeal, cervical
  • EBV: nasopharyngeal, Burkitt’s lymphoma
160
Q

What other infections may be involved in oral Ca?

A

Syphilis

  • limited evidence
  • leukoplakia D tongue -> Ca D tongue

Candida

  • associated w/ premalignant white patches
  • leukoplakia w/ Candida more freq. malignant transformation
  • tumour promoter
  • enzymes prod. catalyse: nicotine -> nitrosamines
161
Q

3 factors influence mortality rate of oral Ca

A

Site
Size
Stage

162
Q

Discuss impact of size on oral Ca survival

A

Further ant. better

Lip: 90% 5yr survival
FoM: 45%
Tongue: 40%
B mucosa: 40%

163
Q

Discuss impact of size of tumour on mortality

A

Larger: inc. risk metastases, worse prognosis

Depth invasion worse cf surface size + pattern

Perineural + vascular spread poor prognosis

164
Q

Most common sites for oral Ca

A

Gutter: 80%
Tongue: 30%
FoM: 15%
Retromolar: 15%

165
Q

Regional features of oral Ca

A

Lymphadenopathy

Metastatic deposits cause enlargement
Firm, painless
Fixed if spread beyond capsule

Infected nodes: painful soft/firm, not fixed

166
Q

Local features of oral Ca

A

Leukoplakia
Speckled leukoplakia
Erythroplakia

Ulceration
Fungation (exophytic tumour)
Fixation
Destruction

Painless
Loss of function

167
Q

Ix may be req. for oral Ca

A

Biopsy: fine needle aspirate of lumps
X-ray: bony involvement
CT: soft/hard tissue involvement for staging + Tx plan
MRI: soft tissue, better resolution cf CT
MET: shows ‘hot spots’ of activity, detect occult 1rys

168
Q

Systemic features of oral Ca

A

Weight loss
Cachexia
Symptoms due to distant metastases
- lung: coughing blood, shortness of breath

169
Q

Discuss pathology of oral Ca

A

Epithelial malignancy

Malignant cells invade underlying CT
Spread via lymphatics to regional lymph nodes
- becomes established within node
- replace normal structure
- may spread out of capsule into neck tissue
Rare: vascular spread to distant sites

170
Q

Histology of oral Ca

A

Epithelial island invasion of

  • connective tissue
  • muscle
  • salivary glands
  • bone

Cellular atypia

  • nuclear hyperchromatism
  • nuclear + cellular pleomorphism
  • inc. nuclear:cytoplasm
  • inc. + abnormal mitoses

Inflammatory infiltrate: lymphocytes, plasma cells

171
Q

Principles of Ca surgery

A

Resection

  • remove Ca
  • 1cm clear margin

Reconstruction

  • reshape damaged/destroyed structures
  • skin graft: radial forearm flap, pectoralis major flap
  • microvascular surgery

Rehabilitation

  • speech + language therapist
  • oral competence
  • chewing
  • palatal competence
  • dental rehabilitation: teeth, implants etc
172
Q

How does radiotherapy work?

A

X-ray beams directed at site which cause damage to cells w/ high turnover

173
Q

Adverse affects of radiotherapy

A

Acute

  • mucositis
  • dysgeusia
  • weight loss
  • fatigue

Late: >90d post-Tx

  • xerostomia
  • oedema
  • ORN
  • telangiectasia
  • fibrosis
  • atrophy
174
Q

Difference b/w palliative and curative surgery

A

Palliative

  • doesn’t remove Ca
  • alleviate pain/discomfort
  • improve QoL

Curative

  • removes malignant tissue
  • aims to cure Ca
175
Q

Aetiology + risk factors for acute bacterial sialadenitis

A

Aetiology

  • Strep. pyogenes
  • Staph. aureus

Predisposing

  • red. salivary flow
  • dehydrated
  • immunocompromised
  • acute exacerbation of chronic
176
Q

Clinical features + Mx of acute sialadenitis

A

Clinical

  • S: parotid, submandibular (common), unilateral
  • gland: tender, swelling
  • erythema: skin, mucosa
  • suppurative
  • fever, malaise, trismus
  • lymphadenopathy

Mx

  • antimicrobial: Tx infection
  • target predisposing factor
177
Q

Discuss chronic sialadenitis

A

Non-specific inflammation of gland
Associated w/ red. saliva flow -> low-grade ascending infection

Clinical

  • S: submandibular, unilateral
  • recurrent tenderness + swelling
  • duct orifice: erythema, suppurative (acute exacerbation)
  • early: enlarged
  • late: small, firm, no saliva prod. when massaged

Ix: US, sialography
- determine predisposing: calculus, stricture

178
Q

Histology of sialadenitis

A

Progressive glandular atrophy

  • acinar destruction
  • fibrous replacement
  • ductal ectasia

Inflammatory infiltrate

179
Q

Discuss sialolithiasis

A 
Salivary gland stones 
Predisposing 
- red. saliva flow
- dehydration 
- chronic sialadenitis
- Sjögren’s

Clinical

  • S: submandibular (80-90%)
  • pain + swelling associated w/ meal times

Mx
- Tx acute infection (if present)
- surgical removal
— strategy depends on site

180
Q

Aetiology, epidemiology + Mx of mumps associated sialadenitis

A

Aetiology: paramyxovirus
Epidemiology: childhood usually, any age poss.

Mx
- supportive: hydration, OH, analgesic
- vaccine: 88% effective
— immunity long lasting thus recurrence low

181
Q

Clinical presentation + complications of mumps associated sialadenitis

A

Clinical

  • S: parotid (70% bilateral)
  • prodromal: fever, malaise
  • painful swelling 1/+ glands

Complications

  • orchitis
  • meningoencephalitis
  • pancreatitis
  • arthritis
182
Q

Histology of mumps sialadenitis

A

Dense interstitial lymphoplasmacytic infiltrate
Acinar destruction
Duct dilation

183
Q

Discuss cytomegalic inclusion disease

A

Aetiology: CMV (HHV5)

Clinical

  • asymptomatic
  • neonates, immunocompromised: severe disseminated disease
  • salivary disease usually incidental finding

Histology: viral inclusions in epithelial nucleus + cytoplasm

184
Q

Clinical features of HIV sialadenitis

A

Diffuse cystic enlargement of major salivary glands

S: bilateral 
Gradual, non-tender enlargement 1/+
Cervical lymphadenopathy 
Nasopharyngeal swelling
Xerostomia
185
Q

Histology of HIV sialadenitis

A 
Cystic spaces
- lined by squamous epithelium 
Associated w/ reactive lymphoid stroma 
Florid follicular hyperplasia 
Loss of mantle zones
Lymphoepithelial islands
186
Q

Epidemiology + aetiology of necrotising sialometaplasia

A

Epidemiology: middle age

Aetiology: unknown
- local ischaemia (trauma) -> minor gland infarction

187
Q

Clinical features + Mx of necrotising sialometaplasia

A

Clinical

  • S: hard palate
  • deep crater-like ulcer
  • erythematous edge
  • preceded: indurated swelling
  • mistaken for malignancy

Mx

  • reassure
  • supportive
  • spontaneous resolution: 4-10/52
188
Q

Histology of necrotising sialometaplasia

A 
Mucosal ulceration 
- lobular necrosis minor glands 
Reactive squamous metaplasia 
Ductal hyperplasia 
Mucus extravasation -> inflammation
189
Q

What is sarcoidosis? Clinical features

A

Mutlisystem, systemic granulomatous disorder

Clinical

  • S: parotid (bilateral), minor glands
  • painless, persistent enlargement
  • indurated swellings: gingiva, tongue
  • multiple asymptomatic submucosal nodules
  • xerostomia
190
Q

Mx of sarcoidosis

A

Medications

  • steroids
  • azathioprine
  • methotrexate
  • cyclophosphamide

May remain stable/regress spontaneously/progressively worsen
- mortality: <5%

191
Q

Histology of sarcoidosis

A

Non-necrotising granulomatous inflammation
Hyalinisation
Calcification

192
Q

Aetiology, Mx + histology of tuberculosis

A

Aetiology: mycobacterium tuberculosis

Mx: anti-mycobacterial

Histology: necrotising granulomatous inflammation

193
Q

Clinical features of oral TB

A 
S: parotid
Mycobacterial lymphadenitis 
- peri/intra-parotid lymph node enlargement 
- due to lymphatic drainage 
Painless, discrete nodule(s) in gland 
Deep, punched-out ulcers
- erythema
- swelling
194
Q

Histology of Sjögren’s syndrome

A

Lymphocytic infiltrate
- formation of punctate lymphocytic foci
- peri-acini/ductal/vascular distribution
Exocrine gland atrophy

195
Q

What is Küttner tumour? Epidemiology, risk factors + Mx

A

IgG4-related salivary gland disease
Chronic sclerosing sialadenitis

Benign, fibroinflammatory process affecting submandibular gland in pt w/ IgG4 disease

Epidemiology: >50, M

Mx: surgical excision

196
Q

Clinician features of Kuttner tumour

A

S: submandibular common
Non-tender firm swelling
Mimics neoplasia

197
Q

Histology of Kuttner tumour

A

Dense lymphoplasmacytic infiltrate
Storiform pattern of fibrosis
Obliterative phlebitis

198
Q

Clinical features of pleomorphic adenoma

A

Benign epithelial salivary gland neoplasm

Clinical

  • S: parotid, minor glands
  • behaviour: slow growing
  • asymptomatic
  • smooth, mobile mass
199
Q

Mx + prognosis of pleomorphic adenoma

A

Mx: excision

  • incomplete capsule makes difficult
  • may req. parotidectomy

Prognosis

  • low of complete removal
  • recurrence aggressive
  • malignant transformation: 6%
200
Q

Histology of pleomorphic adenoma

A

Pleomorphism: epithelial, connective tissue

Formation bilayered ducts

  • ductal epithelium: inner layer
  • myo-epithelium: outer layer

Stroma: myxochondroid/myxoid/chondroid + mucin

201
Q

Clinical features of Warthin’s tumour

A

Benign epithelial salivary gland tumour

Clinical

  • S: parotid, peri-parotid lymph nodes
  • behaviour: slow growing
  • asymptomatic, fluctuant swelling
  • multifocal, bilateral
202
Q

Mx + prognosis Warthin’s tumour

A

Mx: excision w/ margin

Prognosis

  • recurrence low (5%): incomplete removal, multifocal
  • malignant transformation: rare
203
Q

Histology of Warthin’s tumour

A

Double layer epithelial cells
Lymphoid stroma
Cystic spaces
Oncocytic columnar cells w/ discontinuous basal cells

204
Q

Epidemiology + clinical features mucoepidermoid carcinoma

A

Epidemiology: <20

Clinical
- S: parotid
— P, submandibular, minor 
- cystic, mimic mucocele 
- soft/firm circumscribed/infiltrative mass
205
Q

Difference b/w low + high grade of mucoepidermoid carcinoma

A

Grading based on epidermal:mucous cells

Low/intermediate

  • less aggressive
  • good prognosis
  • Tx: surgical excision

High Grade

  • aggressive
  • regional metastases
  • Tx: resection +/- neck dissection + post-op radiotherapy
  • 10y survival 25%
206
Q

Histology of mucoepidermoid carcinoma

A

Mucinous, epidermoid + intermediate cells in varying amounts
Solid -> cystic growth pattern
Cysts mucin filled

High grade

  • less mucous cells
  • solid/infiltrative growth
  • perineural spread
  • vascular invasion
  • cytological anaplasia
  • necrosis
207
Q

Discuss adenoid cystic carcinoma

A

Malignant epithelial salivary gland neoplasm

Epidemiology: >50, elderly
Clinical
- S: major glands
— most common submandibular tumour
- behaviour: slow growing, locally invasive 
- painless relentless swelling/mass
- ulceration: skin, mucosa
- numbness/paraesthesia/pain

Mx: excision +/- radiotherapy

Prognosis

  • distant metastases common: >50%
  • 10y survival: 50-70%
208
Q

Histology of adenoid cystic carcinoma

A

Biphasic: ductal epithelial + albuminal myoepithelial
- myoepithelial: basaloid appearance; dark, angulated nucleus + scant cytoplasm

Architecture: cribriform (myoepithelial w/ globules), tubular (tubules) or solid (sheets of basaloid cells)

Acellular basophilic + hyalinised matrix incorporeal into micro-cystic islands
Peri/intraneural spread

High grade

  • solid growth
  • cellular atypia
  • inc. mitoses
  • necrosis
209
Q

Epidemiology + Mx of acinic cell carcinoma

A

Malignant salivary gland neoplasm

Epidemiology: 50, F

Mx

  • excision
  • high grade: neck dissection +/- radiotherapy
210
Q

Clinical features of acinic cell carcinoma

A

S: parotid
Behaviour: slow growing, infiltrative
Solitary, unfixed mass
Poss. multi-nodular +/- fixed

211
Q

Histology of acinic cell carcinoma

A

Usually sheets of neoplastic acinar cells
Non-encapsulated
Pushing or frankly infiltrative
Prominent lymphoid stroma,basophilia

Aggressive: perineural invasion, stromal hyalinisation

212
Q

Indications for salivary gland surgery

A

Overproduction -> drooling
Neoplasia
Obstruction
Trauma -> cyst

213
Q

What is Wilkie’s procedure?

A

Surgical rerouting of parotid and/or subMd ducts

Indicated: overproduction of saliva -> drooling

214
Q

Tx of benign salivary gland tumour

A

Surgical excision

Minor glands: local excision
Superficial parotidectomy
Total parotidectomy; if deep
Extracapsular dissection

215
Q

Discuss parotidectomy; structures + complications

A

Structures

  • CN7
  • great auricular nerve (sensory)
  • retromandibular vein
Complications 
- sensory disturbance 
— CN7: temp 30%, perm 1-3%
- facial hollowing 
- sialocele
- Frey’s syndrome
216
Q

What is Frey’s syndrome?

A

Disorder associated w/ parotid gland and great auricular nerve
Clinical
- erythema + sweating of cheek adjacent to ear
— distribution of great auricular nerve
- usually associated w/ meal times

217
Q

What is extracapsular dissection?

A

Surgical technique for Tx gland tumours aims to preserve CN7
Dissection outside of tumour capsule

Benefits

  • red. CN7 weakness
  • red. Frey’s syndrome

Not suitable for all tumours

218
Q

Discuss Mx of malignant salivary gland tumours

A

Surgical excision w/ wide margin
CN7 preserved if poss.

May req. neck dissection + removal of other structures
- ear, skin, Md

219
Q

Difference b/w mucous extravasation cyst and mucous retention cyst

A

Extravasation

  • damaged duct
  • spillage of mucous into surrounding tissues

Retention

  • duct obstruction/stricture
  • red. mucous secretion from gland
220
Q

Tx for mucocele and ranula

A

Mucocele: excision + closure

Ranula

  • marsupialisation: suture edges open to allowing drainage
  • resection: sublingual/subMd, OE approach
  • sclerotherapy: inject drug to shrink vessel, red. production
221
Q

Tx options for submandibular gland obstruction

A 
Papillotomy
Endoscopic removal 
Duct removal 
Gland removal 
Hilar exploration 
Extracorporeal lithotripsy 
Radiographically assisted basket removal
222
Q

Complications of submandibular gland removal

A

Sensory alteration

  • CN7, Md branch: lip/chin muscles
  • CNV3: lingual branch, sensory ant. 2/3 tongue
  • CN12: muscles of tongue

Sialolithiasis
Scarring

BDS4 (10 decks)

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