STC Flashcards

Question 1

Q

Irritation Fibromas

Composed of

Etiology

Clinical features ;Color

Location

Treatment

Answer

A

AKA – Fibroma, Traumatic Fibroma
Composed of dense, scar-like, fibrous connective tissue
Occurs as a result of chronic trauma
Clinical Features: Exophytic lesion
Usually less than a centimeter in diameter
Color: lighter pink than surrounding mucosa,the surface can be white sometimes bc it’s rubbing and bumping into other oral structures (like teeth), so they get surface keratinization
Locations: buccal mucosa, tongue, lips, gingiva
Very common; totally benign soft lesion
Treatment: You don’t have to remove them, but the surgical Tx = to excise them bc pts will stop biting them and they’ll heal and stop the irritation

Question 2

Q

What is this clinical finding?

Answer

A

Irritation Fibromas

Question 3

Q

What is this clinical finding?

Answer

A

Irritation Fibromas

Question 4

Q

What is this clinical finding?

Answer

A

Chronic Hyperplastic Pulpitis (pulp polyp)

Question 5

Q

Answer

A

Giant Cell Fibroma

Question 6

Q

Chronic Hyperplastic Pulpitis

What is it?

Location?

Age?

Clinical Appearance?

Treatment?

Answer

A

• AKA: pulp polyp
• An e_xcessive proliferation of chronically inflamed dental pulp tissue_ – granulation tissue/ fibrous tissue with inflammatory cells (like a little fibroma that
occurs from pulp tissue) ( benign soft tissue leasion)
• Location:
• Teeth with large, open carious lesions
• Primary or permanent molars
• Age: Children & young adults
• Clinical Appearance: A red or pink nodule of soft tissue protruding from the
pulp chamber and fills the entire cavity of the tooth
• Treatment: RCT or extraction of tooth

Question 7

Q

Giant Cell Fibroma

Answer

A

Very small form of fibrous tumour that show giant cells
Age: relatively rare in paediatric patients.
Clinically it is presented as a painless, sessile, or pedunculated growth which is usually confused with other fibrous lesions like irritation fibromas or Retrocuspid papilla
Location: Largely occur on lower gingivae and on palate\

Question 8

Q

What are these clinical findings (what is the name of the syndrome or complex?)

Answer

A

Tuberous sclerosis complex

we see A lot of gingival enlargement – is this overgrowth from disease or from seizure medication? Multi organ system involvement

Question 9

Q

What is this clinical finding?

Answer

A

Epulis Fissuratum

Question 10

Q

Cowden Syndrome

Answer

A

(multiple hamartoma and neoplasia syndrome)
• Autosomal dominant disorder affecting multiple organ systems
• Caused by mutations in the phosphatase and tensin homolog gene (PTEN, a tumor suppressor gene)
• Oral and perioral findings include
*multiple papules on the lips and gingivae,**
papillomatosis (benign fibromatosis) of the buccal, palatal, faucial, and oropharyngeal
mucosae often producing a “cobblestone” effect, and the tongue may also present as pebbly or fissured.
• Multiple papillomatous nodules (histologically inverted follicular keratoses or
trichilemmomas) are often present on the perioral, periorbital, and perinasal skin, the pinnae of the ears, and neck.
• These nodules are often accompanied by lipomas, hemangiomas, neuromas, vitiligo, café au lait spots, and acromelanosis .
• A variety of neoplastic changes occur in the organs exhibiting hamartomatous lesions,with an increased rate of breast and thyroid carcinoma and gastrointestinal malignancy.
Squamous cell carcinoma of the tongue and basal cell tumors of the perioral skin have also been reported.
Incredibly rare ( board loves it)

Question 11

Q

What is this clinical finding?

Answer

A

Inflammatory Papillary Hyperplasia of the Palate

Question 12

Q

What is these clinical findings? (what is the name of the syndrome or complex?)

Answer

A

Cowden Syndrome

Very rare!

Question 13

Q

Tuberous sclerosis complex

Answer

A

• is an inherited disorder caused by mutations in the tuberous sclerosis complex (TSC1 or TSC2) genes
• Characterized by seizures and mental retardation associated with hamartomatous glial proliferations and neuronal deformity in the central nervous system.
• Fine wart-like lesions (adenoma sebaceum) occur in a butterfly distribution over the cheeks and forehead, and histologically similar lesions (vascular fibromas) have been described intraorally.
• Characteristic hypoplastic enamel defects (pitted enamel hypoplasia)
occur in 40 to 100% of those affected.
• Rhabdomyoma of the heart and other hamartomas of the kidney,

Question 14

Q

Epulis Fissuratum

AKA

Cause

Location

Clinical presentation

Composed of

Treatment

Answer

A

• AKA: denture-induced fibrous hyperplasia, fibrous inflammatory hyperplasia
• Cause: ill-fitting denture
• Location: vestibule (maxilla or mandible), along the
denture border
•Clinical presentation: Arranged in elongated folds of tissue into which the
denture flange fits; • Surface ulceration within the folds is common
• Composed of dense fibrous connective tissue
• Treatment: surgical excision (scalpel vs CO2 laser -laser is better)
and reline then remake of denture

Question 15

Q

What is the clinical finding?

Answer

A

Pyogenic Granuloma

We can see the corresponding radiograph;

-although the radiograph suggests generalized bone loss, there is a lot of calculus on
the distal of #16 > it makes sense that this is a pyogenic granuloma

Question 16

Q

What is this clinical finding?

Answer

A

Pyogenic Granuloma:

Question 17

Q

Pyogenic Granuloma

Histology

Answer

A

They are filled with blood vessels so they’re very very rich
in vascularization > they tend to bleed easily

Question 18

Q

What is this clinical finding?

Answer

A

A parulis

It is not a pyogenic granuloma

A parulis is a proliferation of granulation tissue at the opening of a sinus tract
When the infection breaks through the alveolar bone and presents itself,
it will sometimes cause this proliferation of granulation tissue

Question 19

Q

Inflammatory Papillary Hyperplasia of the Palate

Majority occur with what disease?

Associated with what?

Clinical appearance

Treatment

Answer

A

Majority occur with denture stomatitis
Associated with a removable full or partial denture or orthodontic
appliance (Something you see in patients who wear denture all the time, don’t take it out, chronic denture wear)
Clinical Appearance: Palatal vault is covered by multiple erythematous papillary projections (fibrous connective tissue surfaced by epithelium) –(papillary but no papilla, instead it’s bumpy and bosselated)
- Granular or cobblestone appearance
- Erythema is usually due to superinfection with candida
Treatment:Treat underlying candidiasis, fix denture. These bumps can be removed, take electrosurgery loop, and scrape off the bumps – heals well

Question 20

Q

What is this clinical finding?

Answer

A

Peripheral Ossifying or Cementifying Fibroma

Lesion in the image is pedunculated – put a periodontal probe on normal gingiva and glide along underneath it, there’s a stalk

Question 21

Q

Peripheral Ossifying Fibroma

Histology

Answer

A

When sessile, when removing it, take scalpel blade and just cut into it
If has a little bone or cementum formation inside it, you can feel the bone with the scalpel

Question 22

Q

What is this clinical finding?

Answer

A

Peripheral Giant Cell Granuloma

Question 23

Q

Peripheral Giant Cell Granuloma

Histology

Answer

A

Giant cells inside the lesion

Question 24

Q

What are the 3P

or 4P?

Answer

A

• Pyogenic granuloma/pregnancy tumor
• Peripheral ossifying**_or_**cementifying fibroma
• Peripheral giant cell granuloma
• Peripheral fibroma (4P)

Memorize these well!

All benign soft tissue lesions

Question 25

Q

Pyogenic Granuloma

What a differential diagonsis to consider if we see it

Answer

A

if it’s on the gingival tissues, take a radiograph
always consider SCC as a differential diagnosis

Question 26

Q

What is this clinical finding?

Answer

A

Inflammatory Gingival Enlargement

Example of someone with true hyperplastic gingivitis
Maybe related to very poor plaque control
In this case, either porcelain or porcelain fused to metal full coverage restorations that have very
bulky margins, and that may play a role for food to pick up

Question 27

Q

Pyogenic Granuloma

What is it?

Etiology

Assossiated with which demographics?

Location?

Treatment?

Answer

A

What is it? Reactive connective tissue hyperplasia - exuberant granulation tissue; Misnomer – not pyogenic and not a true granuloma
Etiology: Response to injury - calculus or overhang restoration
Assosiated with? Often occurs in pregnant women (“pregnancy tumor”), also associated with puberty
Treatment: Excision and removal of irritant (eg calculus, overhanging restorations)

Question 28

Q

What is the Differential diagnosis of gingival enlargement

Answer

A

Acute Myelogenous Leukemia (AML)

Wegener’s Granulomatosis

Kaposi Sarcoma

Plasma Cell Gingivitis

Generalized gingival enlargement – all different cases and diseases

Question 29

Q

How to differentiate Pyogenic Granuloma from the other 2Ps ?

(Peripheral ossifying or cementifying fibroma & Peripheral giant cell granuloma)

Answer

A

They often occur in the gingival, but can occur in multiple areas
- that’s the one thing that distinguishes this from the other 2 P’s: pyogenic granuloma can occur on ANY oral site, most commonly on the gingival tissues

Question 30

Q

What is this clinical finding?

Answer

A

Hereditary Gingivofibromatosis

Question 31

Q

Answer

A

Infantile
Hemangioma

(“strawberry” hemangioma).

Infant with two red, nodular masses on
the posterior scalp and neck

Neville Cr

Question 32

Q

Pyogenic Granuloma

Clinical appearance

Location

Size

Developing rate

Age:

Answer

A

Clinical appearance
Usually ulcerated
Soft exophytic lesion, either sessile or pedunculated
Deep red to purple in color, bleeds easily
Location:
- Most common – gingiva
- Also occurs in other areas of the oral mucosa ( can happen anywhere)
Size: small to large (millimeters to centimeters)
Develop rapidly and then remain static
Age: Any age

Question 33

Q

How to recogonize a capillary Malformation?

Answer

A

When you apply pressure to it, it evacuates the lesion (disappears!), when you pull away, it refills and you see it again – that tells you it’s a vascular lesion

Question 34

Q

What is this clinical finding?

Answer

A

Capillary
Malformation (Low
flow)

Question 35

Q

How to differentiate between

Venous
malformation (low
flow)

from

Arteriovenous or
arteriolar malformations
(High flow)

Answer

A

Venous malformation
(Low flow)
No bruit, non-pulsatile
vs
Arteriovenous or
arteriolar malformations
(High flow)
Bruit and pulsatile

In other word, Venous lesion = Does not have pulse

Histopathologically they look different too

Treatment:

-Don’t biopsy this unless it’s rapidly growing, if it is rapidly growing then suspect ► angiosarcoma? ( unlikely)

-can be surgically treated by oral surgeons -clamping off the blood vessel and dissecting it out, or putting a sclerosis agent

Question 36

Q

What is this clinical finding?

Answer

A

Venous
malformation (low
flow)

Many pts can live with this without treatment

Question 37

Q

What are these clinical findings ( which syndrome or complex is this)?

Answer

A

Osler-Weber-Rendu
Syndrome

Question 38

Q

What are these clinical findings? (What is the syndrome or complex)?

Answer

A

Sturge-Weber
Angiomatosis

Sturge-Weber syndrome

Question 39

Q

What are these clinical findings (What is the syndrome or complex)?

Answer

A

Sturge-Weber
Angiomatosis

Sturge-Weber syndrome

Notice how the vascular malformation is only one side..

Remember: Vascular changes follow trigeminal nerve, so it doesn’t cross midline

Question 40

Q

What is this clinical finding?

Answer

A

Lymphangioma

Question 41

Q

What is this clinical finding?

Answer

A

Cystic Hygroma

a type of Lymphangioma

Question 42

Q

Peripheral Ossifying or Cementifying Fibroma

What is it?

Clinical appearance

Derived from

Age

Sex

Reccurance rate

Treatment

Answer

A

a reactive benign soft tissue lesion
Clinical appearance: Well-demarcated, sessile or pedunculated lesion that appears to originate from the gingival interdental papilla
Derived from: cells of the periodontal ligament
Age: children and young adults
Sex: females more than males
Recurrence rate – about 16%
Treatment: Surgical excision

Question 43

Q

What is this clinical finding?

Answer

A

Neuroma

(Traumatic Neuroma)

Not a benign true neoplasm, it’s reactive lesion
This is an edentulous patient, so resorbed bone, so flange of denture is impinging in the area of mental foramen – develop from repeated trauma
Sometimes have to cut into nerve, peel the neuroma from nerve, careful not to sever nerve

Question 44

Q

What are these clinical findings (Which syndrome or complex)?

Answer

A

Multiple Endocrine
Neoplasia (MEN)
Syndrome

Question 45

Q

What is this clinical finding?

Answer

A

neurofibroma

-it looks like lymphoepithelial cyst, but this is further anterior and not where you would get
lymphoid tissue – so it’s not lymphoepithelial cyst, it’s neurofibroma
Yellow – nerves typically yellow

Question 46

Q

What is this clinical finding?

Answer

A

neurofibroma

Question 47

Q

Peripheral Giant Cell Granuloma

What is it?

Location?

Age?

Clinical appearance:

Radiographic finding?

Answer

A

What is it? Probably a reactive lesion due to local irritating factors (giant cells develop inside the lesion which is a benign soft tissue lesion)
Location: Gingiva, usually anterior to the molars
Age: Most frequently seen between 40-60 years old
Clinical appearance: dusky purple, sessile or pedunculated, smooth-surfaced, dome-shaped papule or nodule. Most lesions are less than 1.5 cm in diameter, though infrequently, may grow as large as 5 cm in greatest dimension
Radiographic Features: Usually none, but superficial destruction of the alveolar bone may occur

Question 48

Q

What are these clinical findings (which syndrome or complex)?

Answer

A

Neurofibromatosis syndrome

von Recklinghausen’s Disease

Lisch nodules on iris, pigmented (eye picture)
Neurofibromatosis in mouth (bottom left picture)
Café au lait (bottom right picture)

Question 49

Q

What is the clinical finding?

Answer

A

Schwannoma/ Neurilemoma

Question 50

Q

What is this clinical finding?

Answer

A

Schwannoma/ Neurilemoma

Question 51

Q

Schwannoma/ Neurilemoma

Histology

Answer

A

Antoni A and Antoni B.

Streaming fascicles of spindle-shaped Schwann cells characterize Antoni A tissue.

These cells
often form a palisaded arrangement around central acellular, eosinophilic areas known as Verocay bodies. Antoni B
tissue is less cellular and less organized; the spindle cells are randomly arranged within a loose, myxomatous stroma.

Question 52

Q

What is this clinical finding?

Answer

A

Granular Cell Tumor

Question 53

Q

What is this clinical finding?

Answer

A

Granular Cell Tumor

Question 54

Q

Granular Cell Tumor

Histology

Answer

A

Has pseudoepitheliomatus hyperplasia of epithelium (seen on left picture)
Characteristic feature are the granular cells on the right picture
Infiltrate down into the muscle layers, that’s when pathologist confirms granular cell tumor

Question 55

Q

Diagnosis and Treatment

of the 3Ps

Answer

A

•Diagnosis: All 3 “P” lesions usually occur on gingival interdental papillae ( however pyogenic granuloma can occur anywhere)
• Since they can look similar clinically, excisional biopsy necessary to
determine diagnosis
• Treatment: complete excision and removal of local irritant (scaling
and root planing)

Question 56

Q

What is this clinical finding?

Answer

A

Congenital Epulis

Question 57

Q

Gingival Enlargement

Etiology

Answer

A

Response to chronic inflammation
Hormonal changes (pregnancy/puberty)
Immune-mediated/plasma cell gingivitis
Drug induced
Genetic/ Inherited

NOTE: Gingival enlargement is not always hyperplastic tissue

Question 58

Q

What is this clinical finding?

Answer

A

Neuroectodermal tumor of infancy

look how they removed it here surgically

is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth.

Question 59

Q

Lipoma

What is it?

Location?

Cliniclly?

Histologically?

Treatment?

Answer

A

What is it: Benign tumor of mature fat cells; Relatively rare
Location:Won’t see on gingival tissue, will see on buccal mucosa, on the tongue, and floor of the mouth
Clinically appears as a yellowish mass surfaced by thin overlying epithelium, When you feel it, it’s soft
Histologically: a well-delineated tumor composed of mature fat cells with a thin capsule
Treatment: surgical excision,does not recur

Question 60

Q

What is this clinical finding?

Answer

A

Lipoma

Usually very orange looking lesion in site where there’s adipose tissue

Very obvious, nothing as orange as lipoma

Question 61

Q

Drug Induced Gingival
Enlargement

What are the famous drugs that are known to cause it?

Answer

A

Phenytoin: (or Dilantin) – the drug that used to be given to every single
person that had seizures
Calcium-channel blockers
- Nifedipine not as prescribed anymore
- Dilitiazem still prescribe
- Amlodipine: is prescribed as one of the first line therapy for hypertension (very commonly prescribed); it doesn’t typically cause gingival overgrowth except in some selected patients, usually
  those with pretty poor oral hygiene
Cyclosporine A (used for for bone marrow transplant, graft vs
host disease, solid organ transplant)
- Cyclosporine is universally recognized as causing gingival hyperplasia
- Cyclosporine is largely replaced with Tacrolimus, which typically doesn’t cause gingival overgrowth
Cyclosporine A is largely replaced with Tacrolimus, which typically doesn’t cause gingival overgrowth
Some drugs have more connective tissue component, others have more epithelial component
Not all identical under the microscope
Cyclosporine provides more epithelial change, Dilantin causes more of a connective tissue change

Question 62

Q

What is this clinical finding?

Answer

A

Vascular leiomyoma

High-power view showing spindle-shaped cells with bluntended
nuclei. Immunohistochemical analysis shows
strong positivity for smooth muscle actin (inset).

Question 63

Q

What is this clinical finding?

Answer

A

Rhabdomyoma

Will see the striated muscle
Differential diagnosis… looks like granular cell tumor – don’t know til you remove it
If patient presents with relatively slow growing tumor like this, will I get incisional biopsy or
excisional biopsy? Hard to say
If confident benign tumor and it’s this size and I don’t think it’s vascular (no pulse, can do
aspiration), feels firm – try to excise it
If it looks different, like you think it’s malignant minor salivary gland neoplasm (won’t find it in this
site, but if it’s on hard palate) – incision?

Question 64

Q

What is this clinical finding?

Answer

A

Leiomyosarcoma

Answer 65

A

What causes it?

Various genes that are implicate (Putative inherited mutations are in the SOS1 or CAMK4 genes.) Linked to both autosomal dominant and recessive patterns of inheritance

How common?

Very rare

what effects on oral cavity?

Sometimes gingival overgrowth will completely obliterate the teeth, grow around entire tooth
Enlargement may be present at birth or may become apparent only with
the eruption of the deciduous or permanent dentitions.
Tooth migration, prolonged retention of the primary dentition, and
diastemata are common, and enlargement may completely cover the
crowns of the teeth, resulting in compromised oral function.

Treatment

Need surgical (usually laser) treatment – just grows back, so have to get it done periodically

Answer 66

A

Rhabdomyosarcoma

In this case, hasn’t broken through epithelium
They don’t all break through

Answer 67

A

When do they appear? They are rarely present at birth, infants are Born with this in place.
Rate of development: the tumor will demonstrate rapid development that occurs at a faster pace than the infant’s overall growth in the first few weeks of life,
Clinical presentation: Either superficial or deeper tumors
- Superficial tumors of the skin appear raised and bosselated with a bright-red color (“strawberry” hemangioma); They are firm and rubbery to palpation, and the blood, cannot be evacuated by applying pressure.
- Deeper tumors may appear only slightly raised with a bluish hue.
- May be left with a pink or magenta macule in site where hemangioma occurred after its involute
Treatment: Typically will involute with time, Some cases don’t involute, so need to be removed
It is a vascular Anomaly

Answer 68

A

Fibrosarcoma

Answer 69

A

a type of vascular anomaly
CMs are commonly known as port wine stains.
They look like a pink, red or purple patch of skin
occur in 1 in 300 newborns.

Answer 70

A

Kaposi Sarcoma

Solitary vascular lesion on hard palate – it was so small so he decided to just excise it in this case^

Answer 71

A

Kaposi Sarcoma

Widespread Kaposi, can see cutaneous lesions
Oral images of this patient: on palate, starts with macule on patient’s left posterior palate –macular stage
Then in becomes proliferative – exophytic nodular stage (seen on patient’s right anterior palate,surrounding canine and some incisors)
Can see engorged blood vessels in area on histology slide

Answer 72

A

Plasmacytoma in Multiple Myeloma

They already had multiple myeloma then developed plasmacytoma
When you biopsy this, it’s filled with plasma cells bc they’re producing the abnormal immunoglobulins, which are the cause of the devastating issues of multiple myeloma

Answer 73

A

Acute myelogenous
leukemiawith
granulocytic
sarcoma

*Complaining of lump inside of her cheek**
*Notsomuch worried about her gingiva**, despite her overgrowth – leukemic infiltrates that got into gingival tissues
*Left buccal mucosa**, kept biting on it, feeling incredibly fatigued though she was always working out
*Oral surgeon biopsied** her buccal mucosa and read by pathologist as pyogenic granuloma
*Physician** sent her for bloodwork, dental school sent her for bloodwork too

Answer 74

A

Lymphoma

Well circumscribed ulceration in area
Associated swelling in periphery
White change in the patient’s left area
Been there for 3 weeks
It’s lymphoma

Answer 75

A

Looks like it could be a salivary gland neoplasm, but it’s not
It was another lymphoma
Manifest in a number of different ways

Answer 76

A

Do you think it’s a fibroma? No. Why?
Fibroma is covered with normal coloring epithelium – sometimes see a little white change on surface or see tiny traumatic ulcer on surface This is not like that, this is completely ulcerated
Not fibroma; fibroma is a chronic bump that patient is aware of
Is it squamous cell carcinoma? Interesting, it is indeed very friable; but no
Sometimes SCC can develop and can be exophytic and don’t have deep invasion, But this is pedunculated, SCC would not be pedunculated
History says there could be some kind of trauma, biting, or nick with bur – not squamous cell
Mucocele? No
Would you typically develop mucocele on lateral border of tongue? No
Not going to be as many mucoceles in this area, but there are the glands of Blandin and Nuhn, so it’s possible to develop on ventral surface of tongue
This bump doesn’t look like a fluid filled bump though, it has surface ulceration, redness ;Mucoceles have intact surface, would not bleed, or be red
Granular cell tumor? No
Granular cell tumor would have normal overlying epithelium (it’s pushing up from underneath)
This does not have normal overlying epithelium
Hemangioma reserved for congenital; not a vascular malformation either
Neurofibroma? No, not the same surface
Salivary gland neoplasms? Possible, there are salivary glands in that area; keep this in differential
The one that this is is pyogenic granuloma: usually red, ulcerated, and bleeds easily

Answer 77

A

AKA

• Hereditary Hemorrhagic Telangiectasia

What is it and its clinical appearance

• disorder of development of the vasculature characterized by telangiectases and
arteriovenous malformations in specific locations. These are essentially endothelial cell issue – get tafted area of abnormal blood vessels multiple different organ systems – causes complications

Type of Herditary and Etiology

•Autosomal dominant with mutations i_n at least five gene_s but mutations in two genes (ENG and ACVRL1/ALK1) cause approximately 85% of cases.

What can it cause?

• Can cause hemorrhage

Location?

often on fingers, lips,tongue, but always look at the fingers!

Answer 78

A

Rare, non-hereditary developmental condition
Vascular proliferation involving tissues of the brain and face
Face: Unilateral distribution along one or more segments of the trigeminal nerve ( unilateral means don’t cross the midline) known as port wine stain/ nevus flammeus – they are deep-purple color.
- Intracranial calcifications; neurological disorders
Intraoral involvement is common

Answer 79

A

What is it?

• Benign tumor of lymphatic vessels
Types

Microcystic
Mixed
Cystic hygroma (macrocystic)

Location

Most frequent extra-oral location: posterior triangle of the neck;
intraoral location: tongue

Treatment:

monitor, surgery if needed, recurrence common

Answer 80

A

AKA

traumatic neuroma

What is it?

Reactive (ie not a true neoplasm) proliferation of nerve tissue after injury, usually extraction or other surgical procedure

Clinical presentation

They are smooth-surfaced, nonulcerated nodules.
May be painful (30% of cases) and sometimes associated with altered nerve sensations that can range from anesthesia to dysesthesia to overt pain

Location

mental foramen area, tongue, lower lip

Answer 81

A

What is it?

Group of rare conditions

Inhertiance type?

Autosomal dominant

Which type is associated with multiple mucosal neruoma?

Type 2B associated with multiple mucosal neuromas (one of the first
visual signs)

What other presentations?
• Marfanoid features
• Multiple tumors and hyperplasias of endocrine organs (ie
pheochromocytoma)

Increase risk of which cancer?

• Increased risk for medullary thyroid cancer (prophylactic thyroidectomy)

Common board questions

Answer 82

A

What is it?

A benign tumor arising from peripheral nerve tissue

Clinical presentation:

Slow growing, painless lesion
Smooth-surfaced, nodular mass that varies in size
Skin more commonly involved than oral mucosa

Location:

Common oral mucosal sites: tongue and buccal mucosa
May develop centrally in bone

Treatment: surgical excision

Malignant transformation reported, but rare

Answer 83

A

Most common form?

Several forms, type I is most common (von Recklinghausen’s Disease)

intheritance type?

• 85-97% of cases inherited as autosomal dominant trait, chromosome 17 (NF1 gene)

Clinical presentations:

Skin nodules (neurofibromas)
Café au lait pigmentation on skin
Lisch nodules very diagnostic (a pigmented hamartomatou in the iris of the eyes)

Malignant transformation

reported in 5% of cases (neurofibrosarcoma)

Answer 84

A

What is it?

• Benign neoplasm of Schwann cell origin
• Uncommon lesion: 28-48% occur in the
head and neck

Age?

• Most common in young and middleaged
adults

Location?

• Most common intraoral location:
tongue

Clinical presentation?

• The solitary schwannoma is a slow-growing, encapsulated
tumor that typically arises in association with a nerve trunk.

• May present with pain

• Treatment

• surgical excision

malignant
transformation

reported, but rare

Answer 85

A

What is it?

Benign tumor derived from
Schwann cells

Location?
• Oral cavity is the most common
location
• Vast majority of cases seen on
dorsal tongue

Clinical presentation?

Typically an asymptomatic sessile nodule that is usually 2 cm or less in size (firm)
The mass is typically pink, but some granular cell tumors appear yellow.
The granular cell tumor is usually solitary, although multiple, separate tumors sometimes occur, especially in black patients.
The lesion often has been noted for many months or years, although sometimes the patient is unaware of its presence.

Age:

40-60, rare in children

Treatment
• Treated by surgical excision (Be careful with excision! no need
to get all of it out, just most of it)
rarely recurs

Answer 86

A

• AKA: Congenital epulis of the newborn
• Cells resemble cells of the granular cell tumor
• Cell of origin is unknown, not derived from nerve
• Clinical features:

Sessile or pedunculated mass, usually found on
*the anterior** gingiva/ alveolar mucosa
Almost always occurs in baby girls
Present at birth

• Treatment:Surgical excision, does not recur

Answer 87

A

Location?

Often occur as soft tissue mass largely in anterior maxilla

Rate of development?

So fast developing that it envelops and moves the teeth

Treatment?

Needs to be surgically excised

Origin?
Thought to be of neuroectodermal source

Clinical presentation?
Pigmented change in tissue

Answer 88

A

Sometimes lipomas can be mixed with fibrous tissue, can be lipofibromous
Two lesions that look almost identical but one is lipoma, one is lipofibroma
Only difference is that one has fibrous tissue in it, no other difference

Answer 89

A

• Leiomyoma
• Benign tumor of smooth muscle
• Vascular Leiomyoma
• Benign tumor of smooth muscle walls of
blood vessels
• Rhabdomyoma
• Benign tumor of skeletal muscle

They are SUPERRR rare
If become malignant, they become leiomyosarcoma or rhabdomyosarcoma – malignant even
more rare

Answer 90

A

a type of rare cancer that grows in the smooth muscles.
So, so rare
Diseases that move rapidly, because they’re malignancies
You might see surface ulcerations, they’re moving so fast, they break through the epithelium

Answer 91

A

is a type of sarcoma.
Rhabdomyosarcoma usually begins in muscles that are attached to bones and that help the body move, but it may begin in many places in the body

Answer 92

A

Sarcoma is cancer of soft tissue (such as muscle), connective tissue (such as tendon or cartilage), or bone.

Answer 93

A

•What is it? Malignant tumor of fibroblasts
• Age? Most common in young adults and
children
• Rate of growth? Slow growing lesion that is usually not
painful (Can be slow growing, can be rapidly growing – different criteria determining high or low grade)
• Treatment: surgical excision, recurrence is common(Aren’t always easy to surgically remove, because already metastasized into other reservoirs, spread into contiguous areas) Aren’t always radiosensitive, don’t always respond to radiation treatment
• 5-year survival rates range from 40-70%

Answer 94

A

• Angiosarcoma

• Malignant tumor of blood vessels

• Lymphangiosarcoma

• Malignant tumor of lymphatic vessels

• Kaposi’s sarcoma

Malignant neoplasm associated with endothelial cells
Seen predominantly in poorly controlled HIV infected patient population (not exclusively)
Elderly people can develop Kaposi

Answer 95

A

Etiology:Caused by HHV-8 (human herpesvirus 8) /part of herpes family

Types:

Classic: late adult life, Italian and Jewish men, skin of lower extremities
Endemic: African form
Iatrogenic immunosuppression-associated: most often occurs in recipients of organ transplants
AIDS-related

Treatment

Surgical excision, radiation therapy or systemic chemotherapy for multiple nonoral lesions, if it gets large, dose-radiation therapy!

Answer 96

A

Presents as soft tissue lesion
It is possible that a patient can present with plasmacytoma that would be the first sign of multiple
myeloma (it would be a rare sign, but it can happen)

Answer 97

A

Lymphoma is a general term for a complex group of heterogeneous lymphoreticular malignancies.
Lymphoma is the sixth most common malignancy and the second most common neoplasm of the head and neck after squamous cell carcinoma and accounts for 50-59% of head and neck neoplasms in children.
They constitute approximately 3-5% of all known malignancies and are generally divided into two morphologically distinct types: Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL).
These malignancies typically arise within the lymphatic tissues and can progress to extranodal disease as in NHL.
Cervical lymph node involvement can be present in any type of lymphoma.
HL extends by means of contiguous nodal spread whereas NHL tends to disseminate hematogenously and is typically a systemic diagnosis.
Within the head and neck, Waldeyer’s ring is the most common site of involvement, accounting for more than half of all extranodal head and neck lymphomas.
Oral involvement by lymphoma may represent a localized disease process but is more often part of a systemic process that secondarily involves the cervical lymph nodes.
Lymphoma arising within the oral cavity accounts for less than 5% of all oral malignancies, and approximately 85% of these lesions involve the pharyngeal tonsil and the palate
Extralymphatic sites include the salivary glands, paranasal sinuses, oral cavity, and larynx.

Answer 98

A

benign tumor
of glandular origin

Answer 99

A

 Encapsulated ‐ distinguishable from surrounding tissues
 Freely movable ‐ not fixed
 Slow growing
 Non tender ‐ patients do not complain of pain

Answer 100

A

 Pleomorphic adenoma aka mixed tumor
 Monomorphic adenomas
o Canalicular adenoma
o Basal cell adenoma
 Warthin tumor (papillary cystadenoma lymphomatosum)

Answer 101

A

This tumor comes in many forms/shapes
Most common salivary gland tumor
Painless, slowly growing, firm mass
Adults (30‐50 years old) ; slight female predilection
Sites:
- 50% to 77% of parotid tumors (most commonly found in parotid-2/3rd to 3/4th of parotid tumors)
- Minor SG: palate>upper lip>buccal mucosa> other site (most common intraoral site is the palate)
Malignant transformation possible in long standing lesions (about 5% cases) ‐> called Ca ex PA

Answer 102

A

PLEOMORPHIC ADENOMA

(MIXED TUMOR)

Answer 103

A

PLEOMORPHIC ADENOMA

Classic presentation: includes swelling in the parotid region

(MIXED TUMOR)

Answer 104

A

PLEOMORPHIC ADENOMA

Palatal presentation: since salivary glands are only in lateral sides of the palate, usually
swellings are in one side and not the midline. Lateral swelling is a clue that you are
looking at a salivary gland lesion (left pics)
On the right pic, it involved midline and crossed over to other side, so there are
exceptions. But more commonly found in lateral side of the palate.

(MIXED TUMOR)

Answer 105

A

PLEOMORPHIC ADENOMA

Upper lip presentation: sometimes swelling can be seen extra orally and intraorally.
Remember the swelling will be movable, not tender, not fixed to underlying structures.

(MIXED TUMOR)

Answer 106

A

Untreated pleomorphic adenoma

slow growing, but can grow to enormous sizes

Answer 107

A

This is a mixed tumor with myxoid component (right) and
fibrous/epithelial component(left)

This type of tumor can produce a lot of different tissues, since the origin is from myoepithelial cells aka plasmacytoid cells, which are pluripotent cells which means they can differentiate into many different lineages of cells such as

Answer 108

A

Canalicular Adenoma

Answer 109

A

Canalicular Adenoma

Mucocele might look this way, but what would make it lower on
differential diagnosis is the location of the swelling. Mucocele is mostly seen on lower lip and this pic shows upper lip. Salivary gland tumors and mucoceles
can have the same clinical presentation, so always do a biopsy for formal histopathology diagnosis.

Answer 110

A

Basaloid appearance of the tumor cells
Primarily parotid lesion
predominantly in women over 50 years of age. It is uncommon in young adults.

 (Basal cells are located in epithelium that is adjacent to interface with the connective tissue and they are separated from the CT by a basement membrane, stem cells of epithelium are located in basal cell layer)
 Basal cells are typically Blue in appearance and cuboidal,

Answer 111

A

Basal Cell Adenoma

Answer 112

A

PAPILLARY
CYSTADENOMA
LYMPHOMATOSUM
(WARTHIN TUMOR)

Answer 113

A

 Most common malignancy of salivary glands
 Most common malignant SG tumor in children

Locations
 Palate, most common intraoral site
 Rare primary intrabony (jaws) tumors
 Most common in parotid
 Minor SG: palate 2nd
Clinical appearance in minor gland: asymptomatic fluctuant swelling; blue or red colored
 Can be mistaken for mucocele
 Histopathology: note the cells growing into adjacent tissue, showing infiltration

Answer 114

A

What is it?

Proliferation of 1 type of cell makes up the tumor.

Types? Includes:
o Canalicular Adenoma
o Basal Cell Adenoma
Treatment for all monomorphic adenomas is surgical excision & diagnosis is done with biopsy

Answer 115

A

MUCOEPIDERMOID
CARCINOMA

Answer 116

A

MUCOEPIDERMOID
CARCINOMA

Request all for biopsies!

Answer 117

A

CENTRAL
MUCOEPIDERMOID
CARCINOMA

Intrabony presentations, may have extraoral swelling depending on the stage
Started as small swelling and progressed rapidly:, need to pick it up early!
Patient recovered, but might need radiation, lost salivary glands, needed reconstruction of palate

Answer 118

A

Almost exclusively in minor SG
Striking predilection for upper lip (>75%)
Nearly always occurs in older adults
Slowly growing, painless mass
One clue for visualization of soft tissue swellings is increased vascularity with blue‐ish tint in the area.

Answer 119

A

ACINIC CELL
ADENOCARCINOMA

Answer 120

A

ACINIC CELL
ADENOCARCINOMA

blue‐ish tint

Answer 121

A

Untreated acinic cell adenocarcinoma

 Because it is slow growing, and a low grade tumor, the
patient is alive and not dead with a tumor this size.
 Similar presentation to pleomorphic adenomas, but there is a lot of ulceration on the surface and prominent vascularization in acinic cell
adenocarcinoma.

Answer 122

A

 High grade salivary gland malignancy ( very bad cancer to get)
 Adults
 Palatal mass; ulcerations
 Spread through perineural invasion ‐ tumor wraps itself around nerves and spreads through perineural spaces
 Grows slowly in the beginning and then picks up speed
 Histology: Duct like proliferation with cystic spaces

Answer 123

A

Adenoid Cystic Carcinoma

Answer 124

A

Adenoid Cystic Carcinoma

Answer 125

A

Adenoid Cystic Carcinoma

Answer 126

A

Swiss cheese appearance, cribriform pattern (full of holes aka cystic spaces)

Answer 127

A

Perineural invasion: nerve nuble in the
center and is wrapped by tumor

Answer 128

A

Polymorphous
Adenocarcinoma

Answer 129

A

Polymorphous
Adenocarcinoma

Answer 130

A

Carcinoma Ex Pleomorphic
Adenoma

Answer 131

A

finger‐like projections, benign, cystic spaces, aggregates oflymphocytes)
Vast majority occur within the parotid gland
Very rare intraorally
Predominantly in men
Typically between 5th and 8th decades
Strong correlation with cigarette smoking
Most common SG tumor to occur bilaterally (bilateral parotid swelling), but can be unilateral
Etiology: Thought to arise within lymph nodes as a result of entrapment of
salivary gland elements early in development
Clinical Features:
- swelling that has more subtle presentation
- Doughy to cystic mass
- In the inferior pole of the gland, adjacent and posterior to the angle of the mandible
Treatment: surgical excision, responds very well to it

Answer 132

A

 Encapsulated, freely movable, not fixed to underlying structure, not tender, patients do not complain of pain, slow growing
 There is one tumor of the ones discussed that does have a risk of malignant transformation (only 5% and will take many, many years) and that is Pleomorphic adenoma

Answer 133

A

 Mucoepidermoid carcinoma
 Acinic cell carcinoma
 Adenoid cystic carcinoma
 Carcinoma ex‐mixed tumor/malignant mixed tumor
 Polymorphous adenocarcinoma

Answer 134

A

 Infiltrative
 Fixed to underlying structures, not moveable
 Rapid or slow growth, depending on grade and type of malignant salivary
gland tumor
 Larger, rapidly growing lesions may cause pain and/or paresthesia
 Ulcerated overlying mucosa

Answer 135

A

What are its compoenents? Mixture of mucus‐producing cells and epidermoid or squamous cells

May arise within jaws from odontogenic epithelium of dentigerous cysts
• More common in the mandible than maxilla
• Molar‐ramus area

Treatment: Usually treated by surgical excision

Prognosis:

• Overall prognosis is fairly good
• 10% of patients die, due to local recurrence or metastasis
 Low‐grade tumors have good prognosis (>90% are cured)
 High‐grade tumors the prognosis is guarded (Only 30% survive)
Therapy by gene?

CRTC1–MAML2, CRTC3‐MAML2 gene fusions (targeted therapy)

Answer 136

A

 Occurs predominantly in major SGs,
 Found in all age groups, peak incidence in 5th and 6th grade
 No gender predilection
 Malignancy with serous acinar differentiation
 Most common in the parotid (since 90% serous acini)
 Variable microscopic appearance
 May even appear encapsulated, since it is SLOW growing
 Better prognosis than salivary gland malignancies

Answer 137

A

Location:

 Approx. 50% occur within the minor SG ‐ palate most common site

Growth rate
 Usually a slowly growing mass

Clinical presentation
 Pain is a common and important early finding, occasionally occurring before there is noticeable swelling (described at annoying pain)
 Tendency to show perineural invasion, corresponds to pain

Treatment
 Excision usually the treatment of choice ‐ but edges of tumor may have perineural invasion and remain undetected ‐ makes tumor dangerous

Prognosis
 5‐year survival rate as high as 70% (maybe 90%)
 By 20 years, only 20% ‐ poor long term prognosis

Answer 138

A

Location:
Almost exclusively in the minor SG
60% on the hard or soft palate
Gender”
2/3rds in females
Appearance:
Tumor cells have deceptively uniform appearance
Growth patterns:
Different growth patterns – polymorphous
Perineural invasion ‐ common ‐ but considered low grade tumor
Treatment: Wide surgical excision; overall prognosis relatively good, with 80% cure rate

Answer 139

A

What is it? (benign tumors that have underwent malignant transformation‐ takes a lot time, 15 to 20 years)

Mean age about 15 years greater than benign counterpart

Growth patterns: Mass present for many years with recent rapid growth with associated pain or ulceration

Treatment: Best treated by wide excision, with local node dissection and radiation

Prognosis: guarded, with 50% local recurrence or metastases and dying Prognosis is case to case scenario, may transform to high grade tumor

Answer 140

A

o Mucocele
o Mucoepidermoid Ca
o Pleomorphic Adenoma

Answer 141

A

o Canalicular Adenoma
o Salivary Duct Cyst*
o Pleomorphic Adenoma

Answer 142

A

o Pleomorphic adenoma
o Warthin’s tumor
o Basal cell adenoma
o Mucoepidermoid ca
o Acinic cell ca
o Adenoid cystic ca
o Ca ex mixed tumor

Answer 143

A

o Pleomorphic adenoma
o Adenoid cystic ca
o Mucoepidermoid ca
o PLGA
o Monomorphic adenoma

Answer 144

A

 Involve both major and minor glands
 Benign and malignant tumors both have similar
clinical presentation
 Most malignant salivary gland tumors do not show histopathologic
characteristics associated with malignancy
 Most occur in adults
 Warthin Tumor seen in parotid, may be bilateral
 Mucoepidermoid carcinoma
o Can occur in children
o May occur centrally in bone

Answer 145

A

Tori are incredibly common, a normal of variant
Part of physical exam is to visualize as well as running index finger over the hard palate every time
Sometimes, torus palatinus is quite small and unnoticeable until you touch it (feel a hard bump and it’s just a bony growth)
Sometimes, they are pedunculated; Sometimes, they get so large they become traumatized; vascular supply on surface can sometimes form ulcerations and even get a little bone exposure.
If patient with history of use of bisphosphonates (bone modifying agents given to women who have osteoporosis or osteopenia and to prevent metastesis for certain cancers), he will remove that dead bone, and it will slowly heal. That’s one of the perils of having an enlarged palatine torus

Answer 146

A

Palatine Torus/Torus Palatinus

Answer 147

A

Palatine Torus/Torus Palatinus

Answer 148

A

Mandibular Torus:
Torus Mandibularis

Answer 149

A

Mandibular Torus:
Torus Mandibularis

Answer 150

A

Buccal Exostoses

Answer 151

A

Sometimes pt’s tori are so large that the sublingual frenum gets stuck underneath
repeated irritation/trauma can create a little white rim on the tori
these tori are rock hard and may grow overtime, but we don’t really understand why people get them

Answer 152

A

Unencapsulated Lymphoid Aggregates

Answer 153

A

Lymphoepithelial
cyst

we see a tiny yellowish cyst. we see the blood vessels on the surface; this is quite characteristic.

Answer 154

A

Unencapsulated
Lymphoid
Aggregates

Post-tonsillectomy

Can even develop these on area of tonsils.
(left pic) Red/salmon is a lymphoid aggregate (unencapsulated lymphoid tissue). This is someone
who had a tonsillectomy , and you can see these
lymphoid aggregates on posterior pharyngeal wall (salmon color).They move around the area.
(right pic) It grew back even in post-tonsillectomy patients.

Answer 155

A

Fordyce Granules

Answer 156

A

Fordyce Granules

Answer 157

A

Sometimes patient develops exostoses (another word for torus).
Can get buccal exostoses, all just bone. Can pick these up on radiograph, the bone is a lot denser.

Why does it happen?

Maybe it’s related to parafunctional habits – but don’t really understand the
basis for the exostosis.
They’re going to be bilateral. If it’s unilateral, we start thinking about other bony diseases

a variant of normal

Answer 158

A

Fimbriated
fold/Plica
semiluminaris

Answer 159

A

Frenal tag

Answer 160

A

the lymphoid aggregates are part of the foliate papillae (they contain some taste buds as well).
This is lymphoid tissue -- when you get a cold or upper respiratory tract infection, sometimes these areas can become hyperplastic in response to infection – can become a little enlarged.
These are usually bilateral.
a variant of normal

Answer 161

A

Sublingual Varices

Answer 162

A

Sublingual Varices

Answer 163

A

Sublingual Varices

Answer 164

A

Circumvallate papillae

Answer 165

A

Parotid Papillia (Stenson duct)

Answer 166

A

Parotid Papillia (Stenson duct)

Answer 167

A

a cystic structure.develops in that area where there are already unencapsulated lymphoid tissue.

This is not normal – Pathologic
Sometimes when you get a cyst in this area – because of lymphoid tissue, you can develop lymphoepithelial cyst – a tiny yellowish cyst. we see the blood vessels on the surface; this is quite characteristic.

Answer 168

A

Linea Alba

Answer 169

A

Leukoedema

Answer 170

A

Occurs on the buccal labial mucosa, retro molar pad and tonsillar area and lips
They are white or yellow ectopic sebaceous glands
They can be present in small or large quantity
Why do we have sebaceous glands in mouth? we dont know, evolutionary advantage? we don’t really understand.
a variant of normal

Answer 171

A

Palatal Rugae

Answer 172

A

Some patients have more obvious fimbriated folds or plica semilunaris in their mouths than others
When you look at the ventral surface of the tongue, you’ll sometimes be able to pick these up.
These are duct opening from a series of salivary glands, minor glands, but they’re a little bit different than other minor glands in the mouth.
They produce more of a viscous type of saliva, and they are the glands of the Blandin and Nuhn
a variant of normal

Answer 173

A

Frenal attachments are thin folds of mucous membrane with enclosed muscle fibers that attach the lips to the alveolar mucosa and underlying periosteum.
Most often, during the oral examination of the patient the dentist gives very little importance to the frenum, for assessing its morpholology and attachment.
Sometimes occur; essentially normal of varient

Answer 174

A

Tortuous dilated vessels (enlarged engourged veins) on the ventral surface of the tongue, and sometimes stretch onto lateral border
Appears bluish purple in color
More prominent with increasing age; we don’t see it in younger pts.
Nothing to be concerned about, a variant of normal

Answer 175

A

Located in the posterior region of the tongue; dividing the body from the base
They are mushroom shaped and arranged in V-shape formation
Although they are usually not apparent in most patients, you may be able to visualize them in some
a variant of normal

Answer 176

A

Located in right and left buccal mucosa at the level of the occlusal plane close to the maxillary first and second molar.
This structure may appear as a small dot or have a prominent pink to red papillae presence.
This is the parotid papilla, and It is the opening of the parotid duct which drains saliva from the parotid gland.

A normal of variant

Answer 177

A

•a white line or keratotic area that present along occlusal plane in some patients

due to some friction In that area. (the buccal mucosa)
It varies in thickness and opacity
Can be seen in some patients who have bruxism
a variant of normal

Answer 178

A

A bluish and white filmy opalescence of the mucosa is observed
In order to differentiate it from other white lesions à gently stretch the patient’s cheek forward and the leukoedema will disappear or partly fade and appears less apparent
It is commonly found in people of color and some smokers.
a variant of normal

Answer 179

A

Raised ridges or folds
Located in the anterior palate on either side of the mid-palatine raphe behind the incisive papilla
They vary in number and size
May increase with age
a variant of normal

Answer 180

A

mucocele/mucous cyst
ranula
necrotizing sialometaplasia
sialolithiasis
sialadentitis

Answer 181

A

• definition: a lesion that forms when a salivary gland duct is severed & secretion spills into the adjacent CT
• a pseudocyst (not lined by epithelium) — mucous builds up in the CT & causes a bump
• clinical features:

swelling in the tissue that may increase & decrease in size
may have a bluish hue, fluctuant on palpation — fluid filled, soft, compressible

• location: lower lip most common site, but may form in any area where there are minor salivary glands

• histologic features:
- a cyst-like space in soft tissue
- lined by compressed granulation tissue
- lumen filled with mucin, foamy macrophages & inflammatory cells
• treatment: surgical excision, removal of associated minor salivary glands
• may recur if don’t remove all associated injured minor salivary glands

Answer 182

A

Mucocele

Answer 183

A

Mucous Cyst

Answer 184

A

Ranula

Notice how it’s unilateral

on the floor of the mouth

Answer 185

A

Ranula

Notice how it’s unilateral*
on the floor of the mouth*

Answer 186

A

• Definition: locally destructive inflammatory condition — looks malignant but is benign
• salivary gland ischemia — “heart attack of the palate”; blood flow is interrupted
• predisposing factors:
- local trauma
- palatal injection of local anesthesia
- previous surgery
- many are idiopathic..
• usually a clinical diagnosis based on history & how fast — palate uncommon for SCC
• clinical features:
- initially appears as a non-ulcerated swelling of the palate
- often associated with pain or paresthesia
- within 2-3 weeks, necrotic tissue sloughs off & becomes a crater-like ulcer
- patient may say: “a chunk of the roof of my mouth fell out”
• histologic features:
- necrosis of the salivary glands — coagulative necrosis (green circles in histology —>)
- salivary gland duct epithelium is replaced by squamous epithelium — appear as islands of squamous epithelium deep in the CT & resembles SCC (arrows in histology —>)
• Treatment: no treatment, spontaneously resolves within 6 to 10 weeks
• irrigating & debriding the area can reintroduce vascularity & help healing

Answer 187

A

Necrotizing Sialometaplasia

Answer 188

A

Definition: lith = stone ;; sialolith: a salivary gland stone

Location: occur in both major & minor salivary glands

• floor of the mouth is most common location (Wharton’s duct is a common place)

• often causes obstruction of the duct

Origin: arise from desposition of calcium salts around nidus of debris within the duct lumen

*clinical features:**- minor glands: hard yellowish structure in soft tissue
may be visible on a radiograph
recurrent swelling (due to the obstruction)
episodic pain & swelling during times of increased salivation
can be palpated if the stone is located toward the terminal portion of the duct
*Radiological features** : may be viewed as a radiopacity on an occlusal x-ray–well defined radiopacity
*Histological features-** concentric rings of calcification, color of it in stain depends on level of calcificatio
*Treatment**: promote passage of stone (massage, sialogogues, increase fluid intake) or surgical removal

Answer 189

A

Sialolithiasis

Answer 190

A

Sialolithiasis

Notice how it can appear radiographically as a well defined radiolucency

Answer 191

A

Sialolithiasis

Answer 192

A

•Definition: a pseudocyst
• microscopicallly appears as an epithelial lined cystic structure that is actually a dilated duct
• clinically you CANNOT tell the difference between a mucocele & mucous cyst
• clinical features:
- same as a mucocele
• histologic features:
- same as mucocele but will see an epithelial lining (but actually a dilated duct)
treatment: same as mucocele; surgical excision

Answer 193

A

Sialadenitis

Acute: parotid papilla purulent discharge

Answer 194

A

Sialadenitis

Chronic: caused fibrosis

Answer 195

A

Mucocele

fluctuant swelling
bluish hue
lower lip most common

Ranula

fluctuant swelling
floor of mouth

Sialolithisis

• major glands: episodic pain &
swelling of affected gland
• minor glands: asymptomatic/
local swelling or tenderness
• if superficial - firm to palpation
& yellowish color

Necrotizing
Sialometaplasia

• initial painful swelling
• later necrotic ulcer
• posterior lateral hard
palate & soft palate

Sialadenitis

• painful swelling of
affected gland
• purulent discharge if
acute infection

Answer 196

A

• Definition: mucocele-like lesion that forms unilaterally on the floor of the mouth
• may break through the mylohyoid muscle & enter neck space = “plunging ranula”
• associated with: the ducts of the sublingual & submandibular glands
• clinical features:
- must be on floor of the mouth for it to be considered a ranula
- big & have deep blue color if exophytic
- sometimes can grow downward/deep & won’t see blue as much
• treatment: surgical excision

Answer 197

A

• definition: acute or chronic inflammation in major or minor salivary glands
• causes:
• obstruction of a salivary gland duct (sialolith)
• infection (mumps [viral], staph aureus [bacterial, most common], candida [fungal])
• decreased salivary flow (Sjogren’s, sarcoidosis)
• parotid gland = parotitis
• clinical features:
- acute: most common in parotid, swollen & painful gland, erythematous & warm overlying mucosa/skin, purulent discharge, low-grade fever
- chronic: caused by recurrent or persistent ductal obstruction, periodic swelling & pain
• histologic features:
- acute or chronic inflammatory cell infiltrate in the salivary gland
- in chronic cases = salivary gland replaced by fibrous CT & fat
- cells: acute = neutrophils ;; chronic = lymphocytes, plasma cells, macrophages
• Treatment: antibiotics, rehydration, surgical drainage, or surgical removal of gland

Answer 198

A

‐ Debacterol (sulfonated phenolics; sulfuric acid solution)
o Chemical cautery
o Label: one time application for 5‐10 seconds
‐ NOT recommended to patients with frequent outbreaks

Answer 199

A

Topical anesthetic agents
o To numb the pain
‐ Surface protective agents/bioadhesives
o Cover the ulcer if small enough
‐ Anti‐inflammatory/immunomodulatory agents
o Applied to ulcer surface (corticosteroids)
‐ Anti‐microbials
o Some evidence that topical tetracycline may help
‐ Chemical/physical cautery Lasers
‐ Over‐the‐counter (OTC) versus prescription (Rx

All essentially do the same thing:
o Numbing agent
o Mucosal covering agent
‐ Bottomline:
o ALL canker sores will heal on their on with time

Answer 200

A

‐ Treatment to reduce pain
‐ vs.
‐ Abortive treatment to reduce healing time
‐ vs.
‐ Suppressive treatment to suppress recurrences
‐ Combination of all

Also Consider

Using Sodium Lauryl Sulfate‐Free Toothpastes
Remove Obvious Possible Causes

Answer 201

A

‐ Treatment to reduce pain

Also Consider

using Sodium Lauryl Sulfate‐Free Toothpastes
Remove Obvious Possible Causes
- ‐ Repair sharp teeth/restorations
- ‐ Remove plaque
- ‐ Optimize lubrication

Answer 202

A

‐ History of RAS
‐ Medical History
o Medications
o Review of Systems
‐ Social History
‐ Dental History
‐ Diet/Nutritional History
‐ Physical Examination
‐ LaboratoryTests

Answer 203

A

‐ Repair sharp teeth/restorations
‐ Remove plaque
‐ Optimize lubrication

Ulcer

Answer 204

A

Behcet’s Disease

‐ Recalcitrant oral ulcers associated with Behcet’s Disease
‐ Later developed genital ulcers and other complications
‐ Image:
o Sores in the labial mucosa have classic aphthae appearance
o Other ulcers are major aphthae:
▪ Larger
▪ Irregular borders
▪ Intense proliferative erythema

Answer 205

A

Behcet’s Disease

‐ Recurrent inflammatory disorder of unknown cause:
o Bacterial?
‐ Affects:
o Middle Eastern Males
o Asian Females
‐ Onset 3rd – 4th decade
‐ HLA‐B51 association

Recurrent aphthous ulcers generally precede other signs:

o Genital/skin/eye lesions & others (arthritis, Gl lesions, CNS symptoms, vascular lesions)
‐ Diagnosis based upon criteria (point system): no laboratory tests

Answer 206

A

Hematinic
Deficiencies

‐ Superficial ulcers
o Not classic aphthous ulcers
‐ Equivocal associations with iron, Vit B1, B2, B6, B12, and folate.
‐ Blood tests are not recommended routinely in all patients with RAS.
‐ Indications for blood work (CBC):
o Older patient with recent RAS history
o Suspicious medical history/review of systems
o Strict vegetarian patients

Answer 207

A

HIV‐Associated
Aphthous

CD4 counts <100 cells/mm3 are predisposed to major RAS
‐ Other sites may be affected:
- o Esophagus
- o Genitals
- o Anus/rectum
‐ We see this less frequently since ART
‐ Diagnosis is important, particularly if no prior history

Answer 208

A

Inflammatory
Bowel Diseases

Specific lesions:
- o Diffuse labial and buccal swelling
- o Cobblestones
- o Other specific lesions
- ▪ Mucosal tags
- ▪ Deep linear ulcerations
- o Mucogingivitis
- o Granulomatous cheilitis
- - Non‐specific lesions:
- o Aphthous ulcerations
- o Pyostomatitis vegetans
- o Dental caries
- o Gingivitis and periodontitis
- o Other non‐specific lesions

Answer 209

A

Transient Lingual
Papillitis

‐ Relatively rare
‐ Canker sore meets fungiform papilla of tongue
- Multiple papilla can become inflamed (above image)
- Very painful
‐ Ulcer Appearance:
- Tiny
- Transient
- On fungiform papilla of tongue
‐ Typically resolves in 7‐10 days

Answer 210

A

Herpetiform aphthous stomatitis

Apppears like herpesvirus but unrelated to it
account for 5% of cases (the least common)

Appearance:

begin as multiple (up to 100) 1- to 3-mm crops of small, painful clusters of ulcers on an erythematous base.
They coalesce to form larger ulcers that last 2 weeks.
A bunch of smaller ulcers that coalesce

Answer 211

A

‐ Minor Recurrent
Aphthous Ulcers
(RAS)‐ Rare Case

o Keratinized
Mucosal
Site

‐ 11‐year‐old boy
‐ Canine is in process of erupting
‐ Canker sore present on his keratinized mucosa (RARE)
o 99% of canker sores occur on NON-KERATINIZED MUCOSA

Answer 212

A

Minor Recurrent
Aphthous Ulcers
(RAS)

aka‐ “Canker Sores”
‐ High prevalence: 5‐25%
‐ Comprises the overwhelming majority of cases
- o 75‐85% of ALL RAS cases
‐ <10 mm in diameter
‐ Ulcer appearance:
- o Shallow
- o Round/Oval Shaped
- o Yellow pseudomembrane
▪ Slightly raised margin
▪ Erythematous Halo
‐ Typically resolves in 7‐10 days
- o *May take longer if in a “high‐traffic” site
‐ No scarring
‐ Recurrence rates vary

Answer 213

A

‐ Hallmarks:
o 1. Central ulceration
o 2. Ring of erythema (erythematous border)
▪ Accentuated in right image

Answer 214

A

‐ Aphthous Ulcer of the tongue

‐ Aphthous ulcers can occur on specialized structures of the mouth

Answer 215

A

Aphthous ulcer (“The
canker sore”)

What would it be like to have a canker sore on your uvula?
o Painful to swallow
‐ The location of the canker sore will predict the symptoms

Answer 216

A

‐ Dexamethasone elixir 0.5mg/5ml (ETOH base) or solution (H20 base)
‐ Indicated for difficult to reach lesions to obtain access to all of them
o Disp:600ml
o Label: swish with 5‐10 ml for 5 minutes up to 0.5mg/5mL 4x/day and
expectorate 00s preservalve.) May be used as suppressive therapy in
selected patients with close surveillance
o Prevent recurrences
‐ May buy an EXTRA DAY of healing time

dr. Kerr prefers the elixir

Answer 217

A

Major Recurrent
Aphthous Ulcers
(RAS)

‐ 10 – 15% of all RAS cases
‐ >10 mm in diameter
‐ Ulcer Appearance:
- o Deeper
- o Irregular borders (usually)
‐ Typically resolves in WEEKS or MONTHS
‐ May be associated with fever or malaise
- o The associated cytokine release can induce a fever
‐ Predilection for the throat
‐ Often DOES leave scarring
‐ Recurrence rates vary

Answer 218

A

‐ Triamcinolone acetonide in Orabase 0.1% (intermediate)
o Disp: 5g tube Dental Past
o Label: apply a thin film over ulcer after meals and bedtime APOTHECON
o Do not use for more than 2 weeks

‐ Fluocinonide gel or ointment 0.05% (Potent)
o Disp: 15g tube
o Label: apply a thin film over
o Do not use for more than 2 weeks
‐ Clobetasol ointment 0.05% (Ultra potent)
o Disp: 15gtube Label: apply a thin film over ulcer bid

Answer 219

A

Topical Treatments
‐ Drug is easily washed away or rubbed off
‐ Topical anesthetics have a short‐lived effect
‐ Often difficult to apply due to location
‐ Cost may be a disincentive to buy OTC
‐ Once ulcers are established, these treatments are not as effective, therefore
abortive treatment early on is preferred

Answer 220

A

‐ Prednisone or systemic steroids were the one systemic treatment that Dr. Kerr
has has success with in practice

o 0.5 mg/kg of Prednisone would be prescribed for about 1 week

o Very successful in patients with frequent outbreaks of multiple canker
sores
‐ In some limited cases Dr. Kerr has seen some success with:
o Colchicine
o Pentoxifylline

Answer 221

A

Homogeneous leukoplakia

○ Thickened leathery, White plaque
○ Well-demarcated, Deepened fissures
○ Non-wipeable white patch

Answer 222

A

Homogeneous leukoplakia.

○ Non-wipeable white patch

Answer 223

A

homogenous leukoplakia

Just
white color

Answer 224

A

Non-homogenous leukoplakia

Nodular leukoplakia ~ Largely white
Verrucous leukoplakia ~ Largely white
Erythroleukoplakia ~ Red and white

Speckled and verrucous leukoplakia have a greater risk for malignant
transformation than the homogeneous form

Answer 225

A

Speckled leukoplakia.

Non-homogenous leukoplakia

Answer 226

A

Hairy Leukoplakia

corrugated white lesion on the lateral tongue.
• It only occurs on the lateral tongue

Answer 227

A

Hairy Leukoplakia

Answer 228

A

Proliferative Verrucous Leukoplakia

Patient with proliferative verrucous leukoplakia but manifesting more as
an erythroplakia in multiple sites than a leukoplakia

Proliferative verrucous leukoplakia has very high risk (49.5% in malignant transformation)
almost 10% risk for malignant transformation every year

Answer 229

A

Proliferative Verrucous Leukoplakia

Location
○ Gingiva (Frequent)
○ Buccal Mucosa
○ Palatal Mucosa

Answer 230

A

Proliferative Verrucous Leukoplakia

Multifocal

Answer 231

A

Oral lichen planus

White lacy appearance, with
a network reticular appearance (Wickham’s striae)
sometimes punctate or plaque‐like lesions predominate

o Wickham’s striae→ very characteris► white wispy changes

Answer 232

A

Oral lichen planus

on the buccal mucosa (most common site

reticular form.

Answer 233

A

Oral lichen planus

slightly more red as you move to the left of the picture
● The white lines have small sunburst effect at the periphery
○ Very very characteristic of lichen planus
○ Will never see this in a leukoplakia

Answer 234

A

Oral lichen planus

Lichen planus of the dorsum of the tongue

this is a hypertrophic form.

Answer 235

A

Etiology

The exact etiology remains unknown. Tobacco, alcohol,
chronic local friction, and Candida albicans are important predisposing
factors. Human papilloma virus (HPV) may also be involved in the
pathogenesis of oral leukoplakia.

Answer 236

A

Biopsy to rule out malignancy
Elimination or discontinuation of predisposing factors,
systemic retinoid compounds.
Smoking cessation (leukoplakias often disappear or become smaller within first year of smoking cessation)
Complete removal with surgical excision, electrocautery, cryosurgery, or laser ablation

Answer 237

A

Lichenoid Reactions

Contact Lesions

a sensitivity in contact with a dental amalgam
▪ When you replace these amalgams, the lichenoid reaction will typically
disappear

Answer 238

A

Oral Lichenoid

Contact lesion

chenoid reaction to dental amalgam and cold: white and erythematous
lesions on the buccal mucosa.

Answer 239

A

Oral Lichenoid Drug
Reaction

Answer 240

A

Oral Lichenoid Drug
Reaction

Answer 241

A

Lichenoid reactions may develop after exposure to a medication for periods of > 1 year
May develop very slowly after the problem is initiated so it can be very challenging to connect the dots

Many different medications that can lead to lichenoid reactions

Beta blockers, ACE inhibitors, Rituxumab etc…
A number of new targeted agents “mabs” and “nibs” can cause lichenoid reactions
In cancer centers, this has become quite a problem because they are taking disease‐modifying drugs

Answer 242

A

Nicotinic Stomatitis

also known as

Smoker’s keratosis

smoker’s palate

the palatal mucosa becomes diffusely gray or white; numerous slightly elevated papules are noted, usually with punctate red centers

Answer 243

A

Nicotinic Stomatitis

These papules represent inflamed minor salivary glands and their ductal orifices.

Answer 244

A

Nicotine Stomatitis.

Answer 245

A

Epstein–Barr virus seems to play an important role in the
pathogenesis.

Answer 246

A

Not required
however, in some cases aciclovir or valaciclovir
can be used with success.
Topical retinoids or podophyllum resin for temporary remission

Answer 247

A

Pseudomembranous candidiasis

on the palate.

usually caused by Candida albicans

Predisposing factors are local

(poor oral hygiene, xerostomia, mucosal
damage, dentures, antibiotic mouthwashes)

Answer 248

A

Geographic tongue/
areata migrans

Multiple, well-demarcated zones of erythema (due to filiform atrophy) surrounded by slightly elevated, yellow-white, serpentine/ scalloped border

annular

serpiginous
atrophic
Fissured

Answer 249

A

Geographic tongue/
areata migrans

Answer 250

A

Geographic tongue/
areata migrans

Answer 251

A

Geographic tongue/
areata migrans

Answer 252

A

Geographic tongue, localized lesion.

Answer 253

A

Fordyce’s granules

on the buccal mucosa.

a normal anatomical variation.

ectopic sebaceous glands of the oral
mucosa.

Answer 254

A

Leukoedema of the buccal mucosa.
Laskaris,

Answer 255

A

White Sponge Nevus

Diffuse, thickened white plaques
of the buccal mucosa

Answer 256

A

White Sponge Nevus

(Canon disease)

Answer 257

A

complete removal: excision, electrocautery, cryosurgery, or laber ablation

Lesions rarely regress despite therapy

Answer 258

A

Verrucous Carcinoma

Early verrucous carcinoma of the buccal mucosa.

Answer 259

A

Verrucous Carcinoma

Large, exophytic, papillary
mass of the maxillary alveolar ridge.

Answer 260

A

Verrucous Carcinoma

Large, exophytic, papillary
mass of the maxillary alveolar ridge.

Answer 261

A

Verrucous Carcinoma

Extensive papillary, white
lesion of the maxillary vestibule

Answer 262

A

Traumatic Erythema /Traumatic Hematoma

on the lower lip.

Answer 263

A

Geographic tongue: well-demarcated red patch on the tongue.

Answer 264

A

Median rhomboid glossitis.

a Chronic hyperplastic, erythematous candidiasis

Answer 265

A

Denture stomatitis.

Answer 266

A

Although the cause is not well known, T cell-mediated autoimmune
phenomena are involved in the pathogenesis of lichen planus.

Answer 267

A

Erythroplakia

of the buccal mucosa

Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 268

A

Erythroplakia of the buccal mucosa.

Answer 269

A

Erythroplakia

of the lateral margin of the tongue.

Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 270

A

Erythroplakia

Firey red Well-demarcated patch or plaque with soft velvety texture

transformed into SCC

Answer 271

A

Incisional biopsy on non-keratinized, non-ulcerated mucosa

○ Asymptomatic → no tx
○ Symptomatic → 0.5mg/ml Dexamethasone Elixir.

Answer 272

A

Erythroplakia.

Well-circumscribed red patch on the
posterior lateral hard and soft palate

Answer 273

A

Erythroplakia.

Erythematous macule on the right
floor of the mouth.

Biopsy–

Turned out to be early invasive squamous cell
carcinoma.

Answer 274

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Smokeless Tobacco–related Gingival Recession.
Extensive recession of the anterior mandibular facial gingiv

Answer 275

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Severe

Answer 276

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Mild. A soft, fissured,
gray-white lesion of the lower labial mucosa located in the area of
chronic snuff placement.

Answer 277

A

Pemphigus Vulgaris.

. Multiple erosions affecting the
marginal gingiva.

Answer 278

A

Pemphigus Vulgaris.

Multiple erosions of the left
buccal mucosa and soft palate.

Answer 279

A

Pemphigus Vulgaris.

Large, irregularly shaped ulcerations
involving the floor of the mouth and ventral tongue.

Answer 280

A

Pemphigus Vulgaris.

Answer 281

A

Hypersensitivity

to

dental restorative materials, amalgam or other metal, composite resins
Foods, oral products
Especially cinnamon
dental plaque accumulation are the most common

Answer 282

A

Insicional biopsy Mandated to distinguish from OLP
○ Biopsy white areas on non-keratinized mucosa NOT ulcerated OR red areas

Treatment Replacement of the restorative material, polishing and
smoothing, and good oral hygiene are recommended.

Topical steroid
treatment for a short time is also helpful.

Answer 283

A

Smoking Cessation.

Nicotine stomatitis is completely reversible, even when it has been present for many decades.
The palate usually returns to normal within 1 to 2 weeks of smoking cessation.

Answer 284

A

The elevated temperature, rather than the tobacco chemicals,
is responsible for this lesion.

Answer 285

A

Generally no treatment is indicated
Reassuring the patient that the condition is completely benign is often all that is necessary.
In case of tenderness or a burning sensation that is so severe –topical corticosteroids, such as fluocinonide or betamethasone gel, may provide relief

Answer 286

A

The exact etiology remains unknown. It may be genetic.

Answer 287

A

Etiology

It is due to increased thickness of the epitheliumand intracellular
edema of the prickle-cell layer.

Treatment

No treatment required

Answer 288

A

Autosomal dominant skin disorder

Etiology:
● This condition is due to a defect in the normal keratinization of the oral mucosa in the 30-member family of keratin filaments, the pair of keratins known as keratin 4 and keratin 13 is specifically expressed in the spinous cell layer of mucosal epithelium.

Answer 289

A

a low-grade variant of squamouscell
carcinoma.

Etiology

Leading theories include

human papillomavirus (HPV) infection
chemical carcinogenesis induced by smoking and chewing tobacco
alcohol consumption
betel nut chewing (oral lesions),
chronic inflammation

Answer 290

A

○ Surgical Excision

○ Radiotherapy

Answer 291

A

No treatment is required.

Answer 292

A

Atrophy of central filiform papillae

Presumably developmental. Candida albicans may also be
involved.

but smokers, people with xerostomia , who use inhalation steroids
and denture wearers are at increased risk

Answer 293

A

Erythroplakia is a high risk for malignant transformation. So, if you
encounter an erythroplakia, it’s probably already a cancer or it’s fast‐tracking
towards a cancer

Answer 294

A

○ Biopsy required for diagnosis

○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal

○ Complete excision

Answer 295

A

typically resolves weeks after cessation

○ if persists 6+weeks -> biopsy to rule out dysplasia + SCC

Answer 296

A

○ Biopsy required for diagnosis

○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal

○ Complete excision

Answer 297

A

Erythroplakia.

Well-circumscribed red patch on the
posterior lateral hard and soft palate

Answer 298

A

Erythroplakia.

Erythematous macule on the right
floor of the mouth.

Biopsy–

Turned out to be early invasive squamous cell
carcinoma.

Answer 299

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Smokeless Tobacco–related Gingival Recession.
Extensive recession of the anterior mandibular facial gingiv

Answer 300

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Severe

Answer 301

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Mild. A soft, fissured,
gray-white lesion of the lower labial mucosa located in the area of
chronic snuff placement.

Answer 302

A

Pemphigus Vulgaris.

. Multiple erosions affecting the
marginal gingiva.

Answer 303

A

Pemphigus Vulgaris.

Multiple erosions of the left
buccal mucosa and soft palate.

Answer 304

A

Pemphigus Vulgaris.

Large, irregularly shaped ulcerations
involving the floor of the mouth and ventral tongue.

Answer 305

A

Pemphigus Vulgaris.

Answer 306

A

Pemphigus vulgaris

● Multiple, chronic, mucocutaneous ulcers
● Many patients also have

● Relatively non‐specific
● Very superficial, only in epithelium
● Occur on any mucosal surface: oral, ocular, nasal, GI, esophageal,
genital

Answer 307

A

Pemphigus vulgaris

PV Lesions can affect
virtually any mucosal
surface (oral, nasal,
ocular, pharyngeal,
esophageal, genital)

Answer 308

A

Pemphigus vulgaris

usually suffer from Desquamative
gingivitis (DG)

More superficial erosion of the marginal gingiva, typically with an
intense erythema and inflammation, and very often in the absence of
local factors that would typically cause a gingivitis

o Hurts to brush their teeth

Immediately look for areas where there are no local factors and look for
inflammation there
o To check the possibility of systemic factors causing local
gingivitis

Answer 309

A

Pemphigus vulgaris

Combination of PV
inflammation and
gingival inflammation
accumulating local
factors can result in
advanced loss of
attachment and tooth
loss

Answer 310

A

Mucous membrane pemphigoid

Answer 311

A

Mucous membrane pemphigoid

SEVERE/HIGH RISK FORMS OF MMP
▪ Ocular
▪ Esophageal

can
result in functional
blindness

Answer 312

A

Mucous membrane pemphigoid

Oral Hygiene: Plaque
related gingival
inflammation
contributing to
continued VB
desquamative
gingivitis

Answer 313

A

Mucous membrane pemphigoid

REMEMBER:

▪ Plaque and calculus can be the consequence of painful MMP lesions
▪ When assessing MMP lesions/desquamative gingivitis, look for areas of intense inflammation WITHOUT local factors as evidence of VB disease

Answer 314

A

take two different sites
○ For H&E, still must be perilesional
○ If you get only ulcer just because the clinician thinks
○ that is the pathology → there is no epithelium!
○ The sample is useless and no diagnosis can be made

Answer 315

A

Actinic cheilitis

(Solar cheilosis)

Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 316

A

Actinic cheilitis

(Solar cheilosis)

Early presetation:

Smooth, blotchy, pale, dry areas

Diffuse, irregular white plaque around line of the lip

Crusted, Scaly

Answer 317

A

typically resolves weeks after cessation

○ if persists 6+weeks -> biopsy to rule out dysplasia + SCC

Answer 318

A

SCC

arising from Actinic Cheilitis

Answer 319

A

Oral Melanoma

a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 320

A

Oral Melanoma

an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 321

A

Oral Melanoma

patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient’s fingers are depicted.)

Answer 322

A

Oral Melanoma

Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 323

A

Amalgam tattoo

This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 324

A

Oral melanoacanthoma.

the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 325

A

Oral melanotic macule

an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 326

A

Oral Melanoma

Answer 327

A

Oral Melanoma

Answer 328

A

Oral Melanoma

Answer 329

A

Traumatic ulcer

caused by sharp or puncturing food stuff

Answer 330

A

Traumatic ulcer

a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 331

A

Traumatic ulcer

Post-anaesthesia traumatic ulcer on lower lip.

Answer 332

A

Traumatic ulcer

Most often on tongue, lips, buccal mucosa

Any sites that may be injured by dentition

Answer 333

A

Traumatic

Granuloma

Answer 334

A

Traumatic

Granuloma

(traumatic ulcertaive granuloma)

Answer 335

A

Traumatic Granuloma

( Traumatic Ulcerative Granuloma)

Answer 336

A

Squamous cell carcinoma

on the buccal mucosa)

Answer 337

A

Erythroplakia and Squamous Cell Carcinoma

Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 338

A

Leukoplakia and Squamous Cell Carcinoma

Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 339

A

Pemphigus vulgaris is not fully understood.

Experts believe that it’s triggered when a person who has a genetic tendency to get this condition comes into contact with an environmental trigger, such as a chemical or a drug.

In some cases, pemphigus vulgaris will go away once the trigger is removed.

Answer 340

A

Graphite tattoo

Most common location on the palate and gingiva

Gray, black, or blue-ish macule

Answer 341

A

Graphite tattoo

Gray, black, or blue-ish macule

Answer 342

A

Treatment has 3 stages:
● Stage 1: Control
○ Suppress inflammation / lesion activity with Systemic Corticosteroid: Remains initial / 1st‐line treatment…
○ Then quickly add steroid‐sparing agents (mycophenolate mofetil) to minimize dose and duration of corticosteroid treatment as well as improve disease control
● Stage 2: Consolidation
○ Reducing auto‐antibody production with the addition of Immunosuppressants
○ Assessed by the lack of development of NEW lesions
● Stage 3. Remission / Maintenance:
○ achieving complete remission of lesion activity OFF medication is the GOAL
○ When lesion activity OFF medications cannot be achieved, principle of MINIMALLY effective therapy is the goal, typically with combination of immunosuppressant medications
○ RITUXIMAB has become the FIRST CHOICE treatment after
○ the consolidation phase to achieve DISEASE REMISSION

● TOPICAL / INJECTABLE CORTICOSTEROID MEDICATIONS
○ o Can be used to help control limited number of lesions resistant to systemic therapy: it treats ONLY the disease
○ outcome (lesions) and not the systemic illness / pathologic antibody production
○ ex:clobetesol 0. 05% , halbetesol 0.05% (most potent)

Answer 343

A

Traumatic ulcer of the tongue.

Answer 344

A

Hemangioma of Infancy

a relatively common benign proliferation of
blood vessels that primarily develops during childhood.

display a rapid growth phase with endothelial
cell proliferation, followed by gradual involution.

Answer 345

A

Hemangioma of Infancy

Answer 346

A

Necrotizing Sialadenometaplasia

we see two ulcers on the palate

Mostly
● Palatal salivary glands
○ Possible for parotid
● 75% of case on posterior palate
● Hard>Soft palate
● 2/3rd are unilateral

Answer 347

A

Mucocutaneous autoimmune disease characterized by sub‐epithelial
blisters (bullae) which ruptures to form large, non‐healing ulcerations

Answer 348

A

Frictional Keratosis.

There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”),
because this area is now edentulous and becomes traumatized
from mastication.

Such frictional keratoses should resolve when the
source of irritation is eliminated and should not be mistaken for true
leukoplakia.

Answer 349

A

Frictional Keratosis

the white surrounding a a traumatic ulcer

Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 350

A

Leukoplakia

Linea alba

Chronic cheek chewing (bite injury)

Candidiasis

Oral Lichen planus

Squamous cell carcinoma

Answer 351

A

Frictional keratosis

on the tongue

Answer 352

A

Trauma from Sharp cusp & ortho appliance
Chronic mechanical irritation (chronic biting)
Masticatory function
Normal hyperplastic response
Dentures/missing teeth

Answer 353

A

Remove the cauative factor that caused the trauma
observe large lesion regularly

excellent prognosis

Answer 354

A

dry‐mouth

patient

a classic example

• Classic fissuring
• depapillation of the tongue papilla
• some white changes on the tongue.

Answer 355

A

dry‐mouth

from radiation

Note the Ropy, frothiness on the palate.

The tissues are red and irritated due to candida infection as well.

Answer 356

A

dry Mouth

Cervical caries related
to radiation.

The patient is a smoker and coffee drinker –> explains the staining

Answer 357

A

dry Mouth

Incisal caries in a
radiation patient:

Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction

Answer 358

A

o Approach is similar to PV – but generally not as aggressive unless
hi‐risk areas ( ocular, esophageal ) where more intense immunosuppression indicated
▪ NON‐immunosuppressive treatments uniquely effective:

*o** Dapsone
*o Tetracycline + nicotinamide**

Answer 359

A

Actinic cheilitis has 2 times of risk for developing SCC of the lip.

SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 360

A

due to chronic ultraviolet light exposure.

Answer 361

A

avoid sun exposure
Laser ablation is preferred for severe actinic cheilitis
surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia
- Lip Shaving” (Vermilionectomy)
can also use cryotherapy, electrodesiccation

It requires long term follow up and prognosis is good if caught early

Answer 362

A

SJÖGREN’S SYNDROME

Autoimmune exocrinopathy

Marked bilateral parotid gland enlargement in a patient with primary Sjögren syndrome

Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive

Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary
glands due to retrograde infections.)

increased risk of lymphoma (MALT type)

Answer 363

A

SJÖGREN’S SYNDROME

Dry Mouth

very severe
cervical disease & very dry lips

Answer 364

A

Depapillated &
Fissured Tongue

SJÖGREN’S SYNDROME

Answer 365

A

a patient
with a
bacterial sialadenitis

who has

SJÖGREN’S SYNDROME

When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 366

A

These patients LOW USFR, no response to stimulation (aka abnormal USFR/SFR)

Rehydrate if dehydrated
Treat underlying conditions (i.e. DM)
Salivary substitutes (glycerin)
Minimize damage to glands from radiation
Prevention of complications & palliative treatment
- Optimal hygiene
- Restore caries
- Smooth sharp edges in oral cavity
- Fluoride therapy
- Antifungals
- Chlorhexidine rinses w/o alcohol
- Sialendoscopy
- Salitron - salivary pacemaker
ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 367

A

Sjögren Syndrome

bilateral enlargement of the submandibular glands
angular cheilitis, dry and cracked lips and fissured and despapilated tongue
severe ocular lesions.

Answer 368

A

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma

Acute sun damage can cause it more than chronic exposure

Answer 369

A

Fair skin

A history of sunburn

Excessive ultraviolet (UV) light exposure.

Living closer to the equator or at a higher elevation

Having many moles or unusual moles

A family history of melanoma

Weakened immune system.

Answer 370

A

Surgical excision
Radiotherapy
Chemotherapy

Answer 371

A

Etiology

typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep.
Chronic mucosal trauma from adjacent teeth
Some adjacent source of irritation

Answer 372

A

Remove cause of irritation

Topical anesthetic or film for pain relief

If there is no obvious cause then ► biopsy

Answer 373

A

HPV + SCC

Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue)

Younger pts, 3:1 Males to females ratio, high socio-eco status

Incidence is decreasing

less aggressive → higher survival rates ( Better than HPV negative SCC)

HPV - SCC

The chief risk factors for oral squamous cell carcinoma are

Smoking (especially > 2 packs/day)

Alcohol use

Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men.

( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva)

mostly men, low socio-economic factors

Incidence is decreasing

Very aggressive → lower survival rates

Answer 374

A

Early stage: Radiation and/or Surgical removal

Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 375

A

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 376

A

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 377

A

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 378

A

Necrotizing Sialadenometaplasia

an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands.

Here it is on the palate

Answer 379

A

The cause is uncertain, although the hypothesis of ischemic
necrosis after vascular infarction seems acceptable.

Answer 380

A

No Treatment Needed

but we need to biopsy to rule out other diseases

Answer 381

A

Xerostomia-related Caries

Or

Dry Mouth

. Extensive cervical caries of
mandibular dentition secondary to radiation-related xerostomia.

Answer 382

A

Xerostomia

The subjective experience of a dry mouth (ie a symptom)

Salivary Hypofunction

The objective measurement of a reduction in salivary flow (a sign)

Answer 383

A

Stimulated Saliva
Production

▪ 200+ ml/day
▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min
o “Normal” range is very wide

Answer 384

A

300 ml/day
▪ Flow rate: mean 0.3 ml/min

Answer 385

A

Dehydration
Medical conditions
Body posture
Lighting conditions
Circadian/circannual rhythm (lowest during)
Medications

Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 386

A

Mechanical stimuli
Vomiting
Gustatory/olfactory stimuli (acid/smell)
Gland size

Age is an independent factor for whole saliva (but not
for parotid and minor gland secretions)

Answer 387

A

Central inhibition as a result of connections between the primary salivary centers and the
higher centers of the brain.

Answer 388

A

May be a reduction in baseline sialometry which is still above “normal.”
- If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.
Saliva film thickness
- Palatal mucous gland secretions?
- Anterior dorsum of tongue?
Relative contributions by glands
- Mucins, proteins?
Alterations in sensory perception?
Mental status/central inhibition?

Answer 389

A

● Dehydration
● Medications (Rx & OTC)

Direct damage to glands
Head and neck radiotherapy
As a result of radiation it’s irreversible damage to the glands
Chemotherapy (reversible)
Autoimmune diseases
Primary vs Secondary Sjögren’s Syndrome, GVHD
HIV disease

● Decreased mastication (tooth loss, soft diet)
● Conditions affecting the CNS:

Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 390

A

Abnormal unstimulated USFR= <0.1–0.2ml/min

Abnormal stiumated SFR = <0.5ml/min

Answer 391

A

Salivary stimulation (OTC) to stimulate their glands
Salivary lubrication ( to improve it)
Humidification ( like a humidifier in the room at night)
Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a
diuretic and lead to dehydration).
Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 392

A

Look for possible causes (major cause will be medications & can dehydration or others)
Restore chewing function (Masticatory issues)
Reduce medication‐induced salivary hypofunction
Prescribe Salivary stimulation OTC, Rx medications, others
Prescribe Salivary lubrication
Humidification ‐use humidifiers
Hydration/prevent dehydration (ie avoid alcohol, caffeine)
Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 393

A

If dehydrated ► rehydrate or treat underlying condition
- People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back.
All we can do is offering Salivary substitutes (sprays, gels, rinses )
For patients with high dose radiation treatment ► makes sure they get the INRT
Minimizing damage to salivary glands ( there are other strategies for that)
Prevention and treatment of oral complications

Answer 394

A

– Muscarinic agonists:
– Pilocarpine 5‐7.5mg tid & qhs (can go as
high as 10mg qid)
– Cevimeline 30mg tid (can go as high as
60mg tid)

Contradicated for : CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma

Pilocarpine affects M1 & M3

side effects (sweating, flushing,
rhinitis, increased urination, weakness and
some experience the shakes. )

Cevimeline affects M3 only

fewer side effects

Answer 395

A

○ Biopsy required for diagnosis

○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal

○ Complete excision

Answer 396

A

Erythroplakia.

Well-circumscribed red patch on the
posterior lateral hard and soft palate

Answer 397

A

Erythroplakia.

Erythematous macule on the right
floor of the mouth.

Biopsy–

Turned out to be early invasive squamous cell
carcinoma.

Answer 398

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Smokeless Tobacco–related Gingival Recession.
Extensive recession of the anterior mandibular facial gingiv

Answer 399

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Severe

Answer 400

A

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS

Tobacco Pouch Keratosis, Mild. A soft, fissured,
gray-white lesion of the lower labial mucosa located in the area of
chronic snuff placement.

Answer 401

A

Pemphigus Vulgaris.

. Multiple erosions affecting the
marginal gingiva.

Answer 402

A

Pemphigus Vulgaris.

Multiple erosions of the left
buccal mucosa and soft palate.

Answer 403

A

Pemphigus Vulgaris.

Large, irregularly shaped ulcerations
involving the floor of the mouth and ventral tongue.

Answer 404

A

Pemphigus Vulgaris.

Answer 405

A

Pemphigus vulgaris

● Multiple, chronic, mucocutaneous ulcers
● Many patients also have

● Relatively non‐specific
● Very superficial, only in epithelium
● Occur on any mucosal surface: oral, ocular, nasal, GI, esophageal,
genital

Answer 406

A

Pemphigus vulgaris

PV Lesions can affect
virtually any mucosal
surface (oral, nasal,
ocular, pharyngeal,
esophageal, genital)

Answer 407

A

Pemphigus vulgaris

usually suffer from Desquamative
gingivitis (DG)

More superficial erosion of the marginal gingiva, typically with an
intense erythema and inflammation, and very often in the absence of
local factors that would typically cause a gingivitis

o Hurts to brush their teeth

Immediately look for areas where there are no local factors and look for
inflammation there
o To check the possibility of systemic factors causing local
gingivitis

Answer 408

A

Pemphigus vulgaris

Combination of PV
inflammation and
gingival inflammation
accumulating local
factors can result in
advanced loss of
attachment and tooth
loss

Answer 409

A

Mucous membrane pemphigoid

Answer 410

A

Mucous membrane pemphigoid

SEVERE/HIGH RISK FORMS OF MMP
▪ Ocular
▪ Esophageal

can
result in functional
blindness

Answer 411

A

Mucous membrane pemphigoid

Oral Hygiene: Plaque
related gingival
inflammation
contributing to
continued VB
desquamative
gingivitis

Answer 412

A

Mucous membrane pemphigoid

REMEMBER:

▪ Plaque and calculus can be the consequence of painful MMP lesions
▪ When assessing MMP lesions/desquamative gingivitis, look for areas of intense inflammation WITHOUT local factors as evidence of VB disease

Answer 413

A

take two different sites
○ For H&E, still must be perilesional
○ If you get only ulcer just because the clinician thinks
○ that is the pathology → there is no epithelium!
○ The sample is useless and no diagnosis can be made

Answer 414

A

Actinic cheilitis

(Solar cheilosis)

Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 415

A

Actinic cheilitis

(Solar cheilosis)

Early presetation:

Smooth, blotchy, pale, dry areas

Diffuse, irregular white plaque around line of the lip

Crusted, Scaly

Answer 416

A

typically resolves weeks after cessation

○ if persists 6+weeks -> biopsy to rule out dysplasia + SCC

Answer 417

A

SCC

arising from Actinic Cheilitis

Answer 418

A

Oral Melanoma

a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 419

A

Oral Melanoma

an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 420

A

Oral Melanoma

patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient’s fingers are depicted.)

Answer 421

A

Oral Melanoma

Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 422

A

Amalgam tattoo

This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 423

A

Oral melanoacanthoma.

the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 424

A

Oral melanotic macule

an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 425

A

Oral Melanoma

Answer 426

A

Oral Melanoma

Answer 427

A

Oral Melanoma

Answer 428

A

Traumatic ulcer

caused by sharp or puncturing food stuff

Answer 429

A

Traumatic ulcer

a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 430

A

Traumatic ulcer

Post-anaesthesia traumatic ulcer on lower lip.

Answer 431

A

Traumatic ulcer

Most often on tongue, lips, buccal mucosa

Any sites that may be injured by dentition

Answer 432

A

Traumatic

Granuloma

Answer 433

A

Traumatic

Granuloma

(traumatic ulcertaive granuloma)

Answer 434

A

Traumatic Granuloma

( Traumatic Ulcerative Granuloma)

Answer 435

A

Squamous cell carcinoma

on the buccal mucosa)

Answer 436

A

Erythroplakia and Squamous Cell Carcinoma

Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 437

A

Leukoplakia and Squamous Cell Carcinoma

Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 438

A

Pemphigus vulgaris is not fully understood.

Experts believe that it’s triggered when a person who has a genetic tendency to get this condition comes into contact with an environmental trigger, such as a chemical or a drug.

In some cases, pemphigus vulgaris will go away once the trigger is removed.

Answer 439

A

Graphite tattoo

Most common location on the palate and gingiva

Gray, black, or blue-ish macule

Answer 440

A

Graphite tattoo

Gray, black, or blue-ish macule

Answer 441

A

Treatment has 3 stages:
● Stage 1: Control
○ Suppress inflammation / lesion activity with Systemic Corticosteroid: Remains initial / 1st‐line treatment…
○ Then quickly add steroid‐sparing agents (mycophenolate mofetil) to minimize dose and duration of corticosteroid treatment as well as improve disease control
● Stage 2: Consolidation
○ Reducing auto‐antibody production with the addition of Immunosuppressants
○ Assessed by the lack of development of NEW lesions
● Stage 3. Remission / Maintenance:
○ achieving complete remission of lesion activity OFF medication is the GOAL
○ When lesion activity OFF medications cannot be achieved, principle of MINIMALLY effective therapy is the goal, typically with combination of immunosuppressant medications
○ RITUXIMAB has become the FIRST CHOICE treatment after
○ the consolidation phase to achieve DISEASE REMISSION

● TOPICAL / INJECTABLE CORTICOSTEROID MEDICATIONS
○ o Can be used to help control limited number of lesions resistant to systemic therapy: it treats ONLY the disease
○ outcome (lesions) and not the systemic illness / pathologic antibody production
○ ex:clobetesol 0. 05% , halbetesol 0.05% (most potent)

Answer 442

A

Traumatic ulcer of the tongue.

Answer 443

A

Hemangioma of Infancy

a relatively common benign proliferation of
blood vessels that primarily develops during childhood.

display a rapid growth phase with endothelial
cell proliferation, followed by gradual involution.

Answer 444

A

Hemangioma of Infancy

Answer 445

A

Necrotizing Sialadenometaplasia

we see two ulcers on the palate

Mostly
● Palatal salivary glands
○ Possible for parotid
● 75% of case on posterior palate
● Hard>Soft palate
● 2/3rd are unilateral

Answer 446

A

Mucocutaneous autoimmune disease characterized by sub‐epithelial
blisters (bullae) which ruptures to form large, non‐healing ulcerations

Answer 447

A

Frictional Keratosis.

There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”),
because this area is now edentulous and becomes traumatized
from mastication.

Such frictional keratoses should resolve when the
source of irritation is eliminated and should not be mistaken for true
leukoplakia.

Answer 448

A

Frictional Keratosis

the white surrounding a a traumatic ulcer

Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 449

A

Leukoplakia

Linea alba

Chronic cheek chewing (bite injury)

Candidiasis

Oral Lichen planus

Squamous cell carcinoma

Answer 450

A

Frictional keratosis

on the tongue

Answer 451

A

Trauma from Sharp cusp & ortho appliance
Chronic mechanical irritation (chronic biting)
Masticatory function
Normal hyperplastic response
Dentures/missing teeth

Answer 452

A

Remove the cauative factor that caused the trauma
observe large lesion regularly

excellent prognosis

Answer 453

A

dry‐mouth

patient

a classic example

• Classic fissuring
• depapillation of the tongue papilla
• some white changes on the tongue.

Answer 454

A

dry‐mouth

from radiation

Note the Ropy, frothiness on the palate.

The tissues are red and irritated due to candida infection as well.

Answer 455

A

dry Mouth

Cervical caries related
to radiation.

The patient is a smoker and coffee drinker –> explains the staining

Answer 456

A

dry Mouth

Incisal caries in a
radiation patient:

Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction

Answer 457

A

o Approach is similar to PV – but generally not as aggressive unless
hi‐risk areas ( ocular, esophageal ) where more intense immunosuppression indicated
▪ NON‐immunosuppressive treatments uniquely effective:

*o** Dapsone
*o Tetracycline + nicotinamide**

Answer 458

A

Actinic cheilitis has 2 times of risk for developing SCC of the lip.

SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 459

A

due to chronic ultraviolet light exposure.

Answer 460

A

avoid sun exposure
Laser ablation is preferred for severe actinic cheilitis
surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia
- Lip Shaving” (Vermilionectomy)
can also use cryotherapy, electrodesiccation

It requires long term follow up and prognosis is good if caught early

Answer 461

A

SJÖGREN’S SYNDROME

Autoimmune exocrinopathy

Marked bilateral parotid gland enlargement in a patient with primary Sjögren syndrome

Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive

Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary
glands due to retrograde infections.)

increased risk of lymphoma (MALT type)

Answer 462

A

SJÖGREN’S SYNDROME

Dry Mouth

very severe
cervical disease & very dry lips

Answer 463

A

Depapillated &
Fissured Tongue

SJÖGREN’S SYNDROME

Answer 464

A

a patient
with a
bacterial sialadenitis

who has

SJÖGREN’S SYNDROME

When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 465

A

These patients LOW USFR, no response to stimulation (aka abnormal USFR/SFR)

Rehydrate if dehydrated
Treat underlying conditions (i.e. DM)
Salivary substitutes (glycerin)
Minimize damage to glands from radiation
Prevention of complications & palliative treatment
- Optimal hygiene
- Restore caries
- Smooth sharp edges in oral cavity
- Fluoride therapy
- Antifungals
- Chlorhexidine rinses w/o alcohol
- Sialendoscopy
- Salitron - salivary pacemaker
ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 466

A

Sjögren Syndrome

bilateral enlargement of the submandibular glands
angular cheilitis, dry and cracked lips and fissured and despapilated tongue
severe ocular lesions.

Answer 467

A

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma

Acute sun damage can cause it more than chronic exposure

Answer 468

A

Fair skin

A history of sunburn

Excessive ultraviolet (UV) light exposure.

Living closer to the equator or at a higher elevation

Having many moles or unusual moles

A family history of melanoma

Weakened immune system.

Answer 469

A

Surgical excision
Radiotherapy
Chemotherapy

Answer 470

A

Etiology

typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep.
Chronic mucosal trauma from adjacent teeth
Some adjacent source of irritation

Answer 471

A

Remove cause of irritation

Topical anesthetic or film for pain relief

If there is no obvious cause then ► biopsy

Answer 472

A

HPV + SCC

Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue)

Younger pts, 3:1 Males to females ratio, high socio-eco status

Incidence is decreasing

less aggressive → higher survival rates ( Better than HPV negative SCC)

HPV - SCC

The chief risk factors for oral squamous cell carcinoma are

Smoking (especially > 2 packs/day)

Alcohol use

Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men.

( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva)

mostly men, low socio-economic factors

Incidence is decreasing

Very aggressive → lower survival rates

Answer 473

A

Early stage: Radiation and/or Surgical removal

Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 474

A

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 475

A

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 476

A

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 477

A

Necrotizing Sialadenometaplasia

an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands.

Here it is on the palate

Answer 478

A

The cause is uncertain, although the hypothesis of ischemic
necrosis after vascular infarction seems acceptable.

Answer 479

A

No Treatment Needed

but we need to biopsy to rule out other diseases

Answer 480

A

Xerostomia-related Caries

Or

Dry Mouth

. Extensive cervical caries of
mandibular dentition secondary to radiation-related xerostomia.

Answer 481

A

Xerostomia

The subjective experience of a dry mouth (ie a symptom)

Salivary Hypofunction

The objective measurement of a reduction in salivary flow (a sign)

Answer 482

A

Stimulated Saliva
Production

▪ 200+ ml/day
▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min
o “Normal” range is very wide

Answer 483

A

300 ml/day
▪ Flow rate: mean 0.3 ml/min

Answer 484

A

Dehydration
Medical conditions
Body posture
Lighting conditions
Circadian/circannual rhythm (lowest during)
Medications

Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 485

A

Mechanical stimuli
Vomiting
Gustatory/olfactory stimuli (acid/smell)
Gland size

Age is an independent factor for whole saliva (but not
for parotid and minor gland secretions)

Answer 486

A

Central inhibition as a result of connections between the primary salivary centers and the
higher centers of the brain.

Answer 487

A

May be a reduction in baseline sialometry which is still above “normal.”
- If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.
Saliva film thickness
- Palatal mucous gland secretions?
- Anterior dorsum of tongue?
Relative contributions by glands
- Mucins, proteins?
Alterations in sensory perception?
Mental status/central inhibition?

Answer 488

A

● Dehydration
● Medications (Rx & OTC)

Direct damage to glands
Head and neck radiotherapy
As a result of radiation it’s irreversible damage to the glands
Chemotherapy (reversible)
Autoimmune diseases
Primary vs Secondary Sjögren’s Syndrome, GVHD
HIV disease

● Decreased mastication (tooth loss, soft diet)
● Conditions affecting the CNS:

Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 489

A

Abnormal unstimulated USFR= <0.1–0.2ml/min

Abnormal stiumated SFR = <0.5ml/min

Answer 490

A

Salivary stimulation (OTC) to stimulate their glands
Salivary lubrication ( to improve it)
Humidification ( like a humidifier in the room at night)
Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a
diuretic and lead to dehydration).
Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 491

A

Look for possible causes (major cause will be medications & can dehydration or others)
Restore chewing function (Masticatory issues)
Reduce medication‐induced salivary hypofunction
Prescribe Salivary stimulation OTC, Rx medications, others
Prescribe Salivary lubrication
Humidification ‐use humidifiers
Hydration/prevent dehydration (ie avoid alcohol, caffeine)
Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 492

A

If dehydrated ► rehydrate or treat underlying condition
- People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back.
All we can do is offering Salivary substitutes (sprays, gels, rinses )
For patients with high dose radiation treatment ► makes sure they get the INRT
Minimizing damage to salivary glands ( there are other strategies for that)
Prevention and treatment of oral complications

Answer 493

A

– Muscarinic agonists:
– Pilocarpine 5‐7.5mg tid & qhs (can go as
high as 10mg qid)
– Cevimeline 30mg tid (can go as high as
60mg tid)

Contradicated for : CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma

Pilocarpine affects M1 & M3

side effects (sweating, flushing,
rhinitis, increased urination, weakness and
some experience the shakes. )

Cevimeline affects M3 only

fewer side effects

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