Scenarios Ch.16 Flashcards
25 y.o presents to clinic with pain in her mouth. She has lost weight due to lack of eating. She is found to have focal demineralization of the enamel and dentin Condition? Caused by
Dental caries (tooth decay) Acidic metabolites of fermented sugar produced by bacteria
10 y.o presents to clinic with erythema, edema and bleeding of the mouth. Condition Caused by
Gingivitis: soft tissue inflammation Plaque buildup below gum line
30 y.o presents to clinic with complaint that teeth are falling out. Poor oral hygiene is evident. Gram negative bacteria is found Condition Targets Assoc w/ Can lead to
Periodontitis Inflammatory process that affects the supporting structures of the teeth ( periodontal ligament), alveolar bone, and cementum AIDS, leukemia, Crohn’s disease, DM, Down syndrome (since likely to get leukemia) , Sarcoidosis, and syndromes assoc w/ defect in neturophils (Chediak-Higash, agranulocytosis, cyclic neutropenia) Periodontal infections –> systemic disease (infective endocarditis, pulmonary and brain abscess)
20 y.o with recurrent exceedingly painful superficial oral mucosal lesions. Shallow covered with thin exudate and narrow rim of erythema. Has a halo surrounding a yellowish fibronpurulent membrane. Neutrophilic infiltrate conditon Lasts
Aphthous ulcer (canker sore) Resolve 7-10 days
34 y.o presents with nodular mass on the buccal mucosa along the bite line. Smooth pink nodule. Condition Due to Prognosis Tx:
Irritation fibroma (Traumatic fibroma) Reactive proliferation due to repetitive trauma Benign Tx: complete surgical excision
A 34 y.o pregnant women presents to the clinic with a lesion on her gingiva. The lesion is ulcerated and with red-purple tint. The lesion is erythematous, hemorrhagic. The lesion has been rapidly growing Condition Also seen in Prognosis Tx
Pyogenic granuloma (pregnancy tumor) Also seen in young adults and children Benign Options: - regress (pregnancy) - mature into dense fibrous mass - develop into peripheral ossifying fibroma Tx: complete surgical excision
A 47-year-old man sees his dentist for a routine checkup.He states that his gums bleed easily on brushing his teeth. On examination, he is found to have marked gingival recession with erythema, along with extensive plaque and calculus formation over tooth surfaces. Which of the following organisms is most likely to be associated with development of his oral lesions? A Actinobacillus B Candida C Epstein-Barr virus D Herpes simplex virus E Human papillomavirus F Mucor circinelloides
Answer:A Periodontitis becomes more prevalent with age, often secondary to the effects of dental plaque formation driven by oral flora. The gingival recession increases the risk for dental caries. Regular dental cleanings to remove the plaque and regular gentle tooth brushing help to slow the progression of periodontitis. Some periodontitis cases arise in the setting of systemic disease. Candidiasis is seen in immunocompromised individuals and often forms an inflammatory membrane on the tongue. Epstein-Barr virus has been associated with development of hairy leukoplakia. Herpes simplex virus results in vesicles that can rupture and form superficial ulcers on oral mucosa. Human papillomavirus can drive squamous epithelial hyperplasia, dysplasia, and carcinoma. Mucor has broad, nonseptated hyphae and can result in sinusitis, particularly in the setting of ketoacidosis.
A 17-year-old girl notices a small, sensitive, gray-white area forming along the lateral border of her tongue 2 days before the end of her final examinations. On examination by the physician’s assistant, the girl is afebrile. There is a shallow, ulcerated, 0.3-cm lesion with an erythematous rim. No specific therapy is given, and the lesion disappears within 2 weeks. The history shows that the girl does not use tobacco or alcohol. Which of the following is the most probable diagnosis? A Aphthous ulcer B Herpes simplex stomatitis C Leukoplakia D Oral thrush E Sialadenitis
Answer: A An aphthous ulcer is a common lesion that also is known as a canker sore. The lesions are never large, but are annoying and tend to occur during periods of stress. Aphthous ulcers are not infectious; they probably have an autoimmune origin. Herpetic lesions are typically vesicles that can rupture. Leukoplakia appears as white patches of thicker mucosa from hyperkeratosis. It may be a precursor to squamous cell carcinoma in a few cases. The temperance ditty mentioned in the history is a cautionary note for all young people. Oral thrush is a superficial candidal infection that occurs in diabetic, neutropenic, and immunocompromised patients. Inflammation of a salivary gland (sialadenitis), typically a minor salivary gland in the oral cavity, may produce a localized, tender nodule.
A 55-year-old woman notes a nodule while rubbing her tongue on the side of her mouth. On physical examination by her dentist, there is a firm, nontender 0.6-cm nodule covered by pink buccal mucosa at the bite line next to the first molar on the lower right. The lesion is excised and does not recur. What is the most likely diagnosis? A Candidiasis B Fibroma C Leukoplakia D Pyogenic granuloma E Sialadenitis
B Chronic irritation is the most likely cause for an “irritation” fibroma of the buccal mucosa, which is due to connective tissue hyperplasia. Oral thrush from candidiasis produces white-to-gray plaques on the tongue. Leukoplakia is hyperplasia of the squamous epithelium and appears as a white plaque or patch, and can be premalignant. A pyogenic granuloma is a reddish nodule of granulation tissue on the gingiva, and it often ulcerates. A minor salivary gland could become obstructed, producing a mucocele, or become inflamed and tender (sialadenitis).
A 23-year-old primigravida has noticed a rapidly enlarging nodule next to a tooth for the past 16 days. On physical examination there is a 1-cm, soft, reddish, pedunculated mass above a left upper bicuspid. She is advised that the lesion will likely regress. Which of the following pathologic findings is most likely found in this lesion? A Granulation tissue B Lymphoid proliferation C Neutrophilic exudate D Rhabdomyosarcoma E Squamous hyperplasia
A A pyogenic granuloma may begin to enlarge abruptly and increase in size rapidly, which can be alarming, but the process is benign and often regresses, or resolves into fibrous connective tissue. Though there are both acute and chronic inflammatory cells within this granulation tissue, neither predominates. Rhabdomyosarcoma is more likely to be a childhood tumor, and sarcomas in adults are more likely to occur in deep soft tissues. This reddish nodule is not leukoplakia, which is a white plaque from squamous epithelial hyperplasia.
A 25-year-old man notices several 0.3-cm, clear vesicles on his upper lip after a bout of influenza. The vesicles rupture, leaving shallow, painful ulcers that heal over the course of 10 days. Three months later, after a skiing trip, similar vesicles develop, with the same pattern of healing. Which of the following microscopic findings is most likely to be associated with these lesions? A Budding cells with pseudohyphae B Mononuclear inflammatory infiltrates C Neutrophils within abscesses D Squamous epithelial hyperkeratosis E Intranuclear inclusions
E The lesions of herpes simplex virus type 1 (HSV-1), also known as cold sores or fever blisters, are common. Many individuals have been infected with HSV-1, which is latent, and the oral and perianal lesions appear during periods of stress. Recurrence of herpes labialis is the norm. Budding cells with pseudohyphae suggest a candidal infection with oral thrush. A mononuclear infiltrate is nonspecific and can be seen with aphthous ulcers. Atypical lymphocytes are seen with infectious mononucleosis. They may be accompanied by a rash, but do not produce vesicular lesions of the skin. Neutrophilic abscesses suggest bacterial infection. Leukoplakia is marked by hyperkeratosis.
A 35-year-old, HIV-positive man complains that he has had a “bad” taste in his mouth and discoloration of his tongue for the past 6 weeks. On physical examination, there are areas of adherent, yellow-to-gray, circumscribed plaque on the lateral aspects of the tongue. This plaque can be scraped off as a pseudomembrane to show an underlying granular, erythematous base. What is the most likely diagnosis? A Aphthous ulcer B Cheilosis C Hairy leukoplakia D Herpetic stomatitis E Leukoplakia F Oral thrush
F Oral thrush is a common but not life-threatening condition, resulting from oral candidiasis in immunocompromised individuals. The lesion is typically superficial. Microscopic examination shows the typical budding cells and pseudohyphae of Candida. Aphthous ulcers, or canker sores, are very common in young individuals, but can appear at any age; they tend to be recurrent superficial ulcerations. Cheilosis is fissuring or cracking of the mucosa, typically at the corners of the mouth, which may be seen with vitamin B2 (riboflavin) deficiency. Hairy leukoplakia also can be seen with HIV infection, but it is far less common than oral thrush. It occurs from marked hyperkeratosis, forming a rough “hairy” surface, and is related to Epstein-Barr virus infection. Multinucleated cells suggest a herpesvirus infection, which typically has vesicles that ulcerate. Atypical squamous epithelial cells usually arise from areas of oral leukoplakia.
A 42-year-old man has had a constant bad taste in his mouth for the past month. On physical examination there are white fluffy patches on the sides of his tongue. These cannot be scraped off. A biopsy is taken and on microscopic examination shows squamous epithelial hyperkeratosis, parakeratosis, and koilocytosis. Immunohistochemical staining for Epstein- Barr virus (EBV) is positive. Which of the following is the most likely risk factor for his oral lesions? A Chronic alcohol abuse B Diabetes mellitus C HIV infection D Pernicious anemia E Sjögren syndrome
C Oral hairy leukoplakia is seen in immunocompromised persons. It presages AIDS in persons who are HIVpositive. Chronic alcohol and/or tobacco use are associated with oral squamous cell carcinomas. Type 1 diabetes mellitus with ketoacidosis is associated with fungal sinusitis, particularly with mucormycosis. Pernicious anemia from vitamin B12 deficiency is associated with glossitis that is mainly atrophic. Sjögren syndrome leads to inflammation and atrophy of salivary glands leading to xerostomia with atrophy,
A 58-year-old man, a cigar smoker, visited his dentist for a routine dental examination. The dentist noticed lesions with the clinical (A) and histologic (B) appearance shown in the figure. The medical history showed no major medical problems. Which of the following etiologic factors most likely contributed to the development of these lesions? A Chronic sialadenitis B Dental caries C Eating smoked foods D Herpes simplex virus type 1 E Smoking tobacco
E This whitish, well-defined mucosal patch on the tongue has the characteristic appearance of leukoplakia, a premalignant lesion that can give rise to squamous cell carcinoma. Use of tobacco products is implicated in the development of leukoplakia. Chronic alcohol abuse also is implicated, but the association is less strong than with tobacco. Ill-fitting dentures may lead to leukoplakia, but far less commonly than smoking. Infections and inflammation are not recognized risk factors for oral leukoplakia or oral squamous cell cancers. Dental caries is not a risk factor for leukoplakia, unless the affected tooth becomes eroded and misshapen. The type of food eaten has less of a correlation with cancer of the oral cavity than with cancer of the esophagus.
A 51-year-old man from Kolkata has an area of depression in his mouth that has enlarged over the past 7 months. On oral examination, there is a 1.5 × 0.7 cm velvety, erythematous area with focal surface erosion on his left buccal mucosa. The lesion is excised and on microscopic examination there is dysplastic squamous epithelium. Which of the following is the most likely risk factor for developing this lesion? A Candidiasis B Dental malocclusion C Epstein-Barr virus infection D Immunosuppression E Eating hot, spicy food F Tobacco chewing
F Erythroplakia is a premalignant lesion that is more likely to progress to squamous carcinoma than leukoplakia, but the major risk factors are the same: tobacco, alcohol, insufficient fruit intake, and betel nut. Countries of the Indian subcontinent have the highest incidence, accounting for up to 10% of all cancers in those populations. Of the remaining options, dental malocclusion may lead to leukoplakia. The oral infections listed are not premalignant, but may be found with immunosuppression. Dietary fruit tends to mitigate the risk, but spices have no effect either way.
A 49-year-old man has used chewing tobacco and snuff for many years. On physical examination the lesion shown in the figure is seen on the hard palate. It cannot be removed by scraping. A biopsy is performed, and microscopic examination of the lesion shows a thickened squamous mucosa. Four years later, a biopsy specimen of a similar lesion shows carcinoma in situ. Which of the following is the most likely diagnosis? A Oral thrush B Lichen planus C Leukoplakia D Pyogenic granuloma E Xerostomia
C The raised white patches suggest leukoplakia. This is a premalignant condition. Risk factors include tobacco use, particularly tobacco chewing, and chronic irritation. Human papillomavirus infection has been implicated in some lesions. Oral thrush appears most often on the tongue of immunocompromised individuals as a yellowish plaquelike area. Microscopic examination shows budding cells with pseudohyphae characteristic of Candida infection. Lichen planus in the oral cavity usually appears with similar skin lesions; it forms whitish patches that may ulcerate. The lesions have intense submucosal chronic inflammation. A pyogenic granuloma forms a painful gingival nodule of granulation tissue. Xerostomia, or “dry mouth,” is seen in Sjögren syndrome.
A 54-year-old man, a nonsmoker, has a nonhealing ulceration at the base of his tongue on the right side for 2 months. On examination this lesion is 1 cm in diameter with irregular borders. Biopsy of the lesion is performed and microscopic examination shows infiltrating squamous cell carcinoma. Which of the following infectious agents is most likely to be associated with this lesion? A Candida albicans B Herpes simplex virus (HSV) C Human papillomavirus (HPV) D Prevotella intermedia E Group A streptococcus
C Smoking and alcoholism are frequent etiologies for oral squamous cell carcinomas, and mutations in the TP53 gene are often present. However, in nonsmokers, HPV infection may be implicated, along with overexpression of p16. The good news: the oral carcinomas arising with HPV have a better prognosis, though they may be multifocal and recur. The better news: vaccination against HPV may help prevent this disease. Oral candidiasis (thrush) may occur in immunocompromised persons. HSV causes self-limited acute gingivostomatitis (cold sores). The genus Prevotella includes anaerobes that are associated with periodontitis and with buccal infections that become cellulitis (Ludwig angina). Strep throat is an acute exudative pharyngitis that has the immunologic complications of rheumatic heart disease or postinfectious glomerulonephritis.
A 19-year-old woman has noted swelling in the back of her mouth for 2 months. On dental examination, she has an area of swelling in the location of the left third molar. Dental radiographs show a radiolucent unilocular, well-circumscribed cyst surrounding the crown of the unerupted third mandibular molar. The lesion is excised, and on microscopic examination, the cyst is lined by stratified squamous epithelium and surrounded by a chronic inflammatory infiltrate. What is the most likely diagnosis? A Ameloblastoma B Dentigerous cyst C Odontogenic keratocyst D Odontoma E Periapical cyst/granuloma
B A dentigerous cyst typically occurs in young persons when teeth are erupting, particularly molars. It is benign and does not recur following complete excision. Dentigerous cysts originate around the crown of an unerupted tooth, typically the third molar, and are lined by a thin, nonkeratinizing layer of squamous epithelium; they contain a dense chronic inflammatory infiltrate in the stroma. An odontogenic keratocyst that arises from rests of odontogenic epithelium within the jaw and is benign, but can recur if inadequately excised. Ameloblastoma and odontoma are tumors arising from odontogenic epithelium. Odontoma, the most common odontogenic tumor, shows extensive deposition of enamel and dentin. Periapical cysts/granulomas are inflammatory lesions that develop at the apex of teeth as complications of long-standing pulpitis.
A 19-year-old man noted progressive swelling on the left side of his face over the past year. On physical examination, there is painless swelling in the region of the left posterior mandible. Head CT scan shows a circumscribed multilocular cyst of the left mandibular ramus. The lesion is surgically excised with wide bone margins. On microscopic examination, the lesion shows cysts lined by stratified squamous epithelium with a prominent basal layer; no inflammation or granulation tissue is seen. What is the most likely diagnosis? A Ameloblastoma B Dentigerous cyst C Odontogenic keratocyst D Odontoma E Periapical cyst/granuloma
C An odontogenic keratocyst arises from rests of odontogenic epithelium within the jaw. It is benign, but can recur if inadequately excised. Ameloblastoma and odontoma are tumors arising from odontogenic epithelium. Odontoma, the most common odontogenic tumor, shows extensive deposition of enamel and dentin. Dentigerous cysts originate around the crown of an unerupted tooth, typically the third molar, and are lined by a thin, nonkeratinizing layer of squamous epithelium; they contain a dense chronic inflammatory infiltrate in the stroma. Periapical cysts/granulomas are inflammatory lesions that develop at the apex of teeth as complications of long-standing pulpitis.
A 26-year-old man has had difficulty breathing through his nose for 3 years, but this problem has become progressively worse over the past 2 months. Physical examination shows glistening, translucent, polypoid masses filling the nasal cavities. Histologic examination of the excised masses shows respiratory mucosa overlying an edematous stroma with scattered plasma cells and eosinophils. Which of the following laboratory findings is most likely to be present in this patient? A Elevated serum hemoglobin A1c level B Increased serum IgE level C Nuclear staining for Epstein-Barr virus antigens D Positive ANA test result E Tissue culture positive for Staphylococcus aureus
B Inflammatory nasal polyps can be associated with recurrent allergic rhinitis, a form of type I hypersensitivity often called hay fever. Type I hypersensitivity is associated with high IgE levels in the serum. The elevated hemoglobin A1c level indicates diabetes mellitus. Diabetes is not a risk factor for polyp formation, but ketoacidosis can lead to nasopharyngeal mucormycosis. Epstein-Barr virus infection can be found in nasopharyngeal carcinomas. Autoimmune diseases are not associated with nasal polyp formation. Staphylococcus aureus often colonizes the nasal cavity, but it usually does not cause problems.
A 39-year-old woman has been bothered by headache, facial pressure, nasal obstruction with discharge, and diminished taste sensation for the past 6 months. On physical examination there is discomfort on palpation over her left maxillary sinus. No oral lesions are noted. Rhinoscopy shows nasal erythema, marked edema, and purulent discharge. Which of the following complications is most likely to occur in this patient? A Mucocele B Nasopharyngeal carcinoma C Osteomyelitis D Sinonasal papilloma E T-cell lymphoma
C Chronic sinusitis is a common condition and may be punctuated by episodes of acute sinusitis. Lack of smell with nasal cavity inflammation often affects sensation of taste. Once the cycle of inflammation, obstruction, stasis, mucociliary damage, and polymicrobial infection is established it becomes difficult to stop. Increased pressure with inflammation in the sinus can erode into adjacent bone, causing osteomyelitis. A mucocele filled with nonpurulent secretions is more likely to occur in frontal and ethmoid sinuses. Sinusitis is not a risk factor for malignancy. Nasopharyngeal carcinomas are related to Epstein-Barr virus (EBV) infection. T-cell lymphomas typically occur in men and are EBV positive. Papillomas most often occur in men and have an exophytic growth pattern, but those that are endophytic aggressively extend into adjacent soft tissue and bone, making removal difficult.
On December 13, 1799, George Washington, recently retired as first President of the United States, developed a “cold” with mild hoarseness. By the next morning he had difficulty breathing and swallowing, with throat pain. He was treated with the usual therapy of the time: bloodletting. Had vital signs been recorded, they may have shown temperature of 37.8° C, pulse 115/min, respiratory rate 24/min, and blood pressure 90/60 mm Hg. Which of the following organisms most likely caused his illness? A Coronavirus B Corynebacterium diphtheriae C Haemophilus influenzae D Parainfluenza virus E Prevotella intermedia F Group A streptococcus
C George Washington likely succumbed to an acute bacterial epiglottitis, which is now treatable but still life-threatening, particularly in children, in whom it is more common. Medical care has advanced since the year 1799, but it has been little more than a hundred years that medical care has done more good than harm. Haemophilus influenzae may cause inflammation with an abrupt onset of pain and possible airway obstruction, particularly in children. In adults, the airway is typically large enough to preclude marked obstruction. Thus, Washington’s illness was survivable, but the treatments he received at that time in history (bloodletting, purgatives, blistering agents) contributed to his demise. This cautionary tale supports the adage: if you don’t know what you’re doing, then stop. Coronaviruses are best known to cause the common cold. Corynebacterium diphtheriae is the cause of diphtheria, which produces laryngitis with a characteristic dirty gray membrane that may slough and be aspirated. This infection is now rare because of routine childhood immunizations. Another cause for epiglottitis is parainfluenza virus, which has no vaccine, and is best known as the cause for croup in children. The genus Prevotella includes anaerobes that are associated with periodontitis and with buccal infections that become cellulitis (Ludwig angina). Group A streptococci produce a strep throat that is an acute exudative pharyngitis.
A 3-year-old child has had difficulty breathing for the past 24 hours. On physical examination, the child is febrile and has a harsh cough with prominent inspiratory stridor. The lungs are clear on auscultation. An anterior-posterior neck radiograph shows the steeple sign caused by edema producing loss of normal shoulders on the subglottic larynx. The child’s oxygen saturation is normal with pulse oximetry. She improves over the next 3 days while taking nebulized glucocorticoids. Which of the following organisms is the most likely cause of the child’s condition? A Corynebacterium diphtheriae B Epstein-Barr virus C Haemophilus influenzae D Human papillomavirus E Parainfluenza virus F Streptococcus, group A
E The child has croup, a laryngotracheobronchitis that is most often caused by parainfluenza virus. The inflammation may be severe enough to produce airway obstruction. Corynebacterium diphtheriae is the cause of diphtheria, which produces laryngitis with a characteristic dirty gray membrane that may slough and be aspirated. This infection is now rare because of routine childhood immunizations. Epstein- Barr virus may be associated with infectious mononucleosis and produce pharyngitis. Epstein-Barr virus also is associated with nasopharyngeal carcinoma. Haemophilus influenzae may cause an acute bacterial epiglottitis with an abrupt onset of pain and possible airway obstruction. Human papillomavirus is associated with laryngeal papillomatosis. Group A streptococci produce an exudative pharyngitis.
A 9-year-old girl has had a sore throat for the past 2 days. On physical examination there is pharyngeal erythema with yellowish exudates over swollen palatine tonsils. A Gram stain of the exudate shows gram-positive cocci in chains. She is given penicillin therapy. What is the most likely complication prevented by prompt treatment of this girl? A Carditis B Hepatitis C Meningitis D Otitis E Pneumonitis
A She has a group A β-hemolytic streptococcal pharyngitis, and the feared complication is an autoimmune response from molecular mimicry to streptococcal M proteins. Rheumatic fever results 2 to 3 weeks later from formation of antibodies directed at endocardium, epicardium, and/ or myocardium (rheumatic heart disease). Poststreptococcal glomerulonephritis may also occur. The pharyngitis is unlikely to spread elsewhere or produce septicemia. Streptococcus pneumoniae is more likely to produce meningitis, otitis, and pneumonitis. Streptococci are unlikely to involve liver.
A 58-year-old man bothered by increasing hoarseness for almost 6 months now has an episode of hemoptysis. On physical examination, no lesions are noted in the nasal or oral cavity. There is a firm, nontender anterior cervical lymph node. The lesion shown in the figure is identified by endoscopy. The patient undergoes biopsy, followed by laryngectomy and neck dissection. Which of the following etiologic factors most likely played the greatest role in the development of this lesion? A Epstein-Barr virus infection B Human papillomavirus infection C Repeated bouts of aspiration D Smoking tobacco E Type I hypersensitivity
D The figure shows a large, fungating neoplasm that has the typical appearance of a laryngeal squamous cell carcinoma. The most common risk factor is smoking, although chronic alcohol abuse also plays a role; some patients harbor human papillomavirus sequences. Invasive cancers arise from squamous epithelial dysplasias. Epstein-Barr virus infection is associated with nasopharyngeal carcinomas. Aspiration may result in acute inflammation, but not neoplasia. Allergies with type I hypersensitivity may result in transient laryngeal edema, but not neoplasia.
A 57-year-old man notices a lump on the right side of his face that has become larger over the past year. On physical examination, a 3- to 4-cm firm, mobile, painless mass is palpable in the region of the right parotid gland. The oral mucosa appears normal. He does not complain of difficulty in chewing food or talking. The mass is completely excised, and histologic examination shows the findings in the figure. What is the most likely diagnosis? A Mucoepidermoid carcinoma B Non-Hodgkin lymphoma C Pleomorphic adenoma D Sialolithiasis E Sjögren syndrome F Warthin tumor
F Warthin tumor is the second most common salivary gland tumor, and it almost always arises within the parotid gland. These tumors tend to be slow growing. Microscopically there are spaces lined by a double layer of superficial columnar and basal cuboidal epithelial cells that are surrounding a lymphoid stroma. Mucoepidermoid carcinomas are infiltrative and form mucous cysts along with a population of squamoid cells. Non-Hodgkin lymphoma may arise in patients with long-standing Sjögren syndrome. Pleomorphic adenomas are more common than Warthin tumors, but have a microscopic appearance with ductal epithelial cells in a myxoid stroma containing islands of chondroid and bone. Sialolithiasis is usually accompanied by sialadenitis and is quite painful. It may produce some gland enlargement, but usually is not a mass effect. Sjögren syndrome can produce some salivary gland enlargement, but the process is typically bilateral.
