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JAW/MUCOSA Micrognathia o o Jaw undersized (mand), Mandibulofacial dysostosis (Treacher Collins Syndrome) ▪ Defects of structures from first brachial arch ▪ Auto dom Macrognathia/glossia o o Large jaw Pituitary gigantism (acromegaly) ▪ Uncommon ▪ Due to functional pituitary adenoma Exostoses and...

JAW/MUCOSA Micrognathia o o Jaw undersized (mand), Mandibulofacial dysostosis (Treacher Collins Syndrome) ▪ Defects of structures from first brachial arch ▪ Auto dom Macrognathia/glossia o o Large jaw Pituitary gigantism (acromegaly) ▪ Uncommon ▪ Due to functional pituitary adenoma Exostoses and tori o o Local bony protuberances from cortical plate Benign growths (secondary from stress on bone from teeth) ▪ Buccal, palatal, subpontine exostosis, Torus palatinus and mandibularis o Commissural ▪ Common mucosal invaginations at labial vermillion commissure in ADULTS ▪ Failure of normal fusion of the embryonal maxillary and mandibular processes Paramedian ▪ RARE congenital invag of lower lip ▪ Persistent lateral sulci on embryo mand arch ▪ Bilateral, symmetric, blind sinuses of midline mand labial vermillion ▪ May express salivary secretions ▪ Inherited w/ cleft lip and/or cleft palate (Van der woude syndrome) Lip Pits o Cleft palate o o o One of the most common major congenital human defects Racial variation Considerable range in severity Fordyce Granules o o Sebaceous glands on oral mucosa Multiple yellow papules o o o Buccal mucosa and lateral vermilion of upper lip Asymptomatic (not treatment indicated- clinical appearance characteristic and no biopsy) RARELY may become hyperplastic Ankyloglossia (tongue tie) o o o o Developmental anomaly characterized by a short lingual frenum Limited tongue movement Minor to complete ankyloglossia with fusion of tongue to floor of mouth Treatment often unnecessary, frenotomy/plasty can be done Fissured tongue o o o o Common Numerous grooves/fissures involving the dorsal aspect of tongue STRONG association w/ geographic tongue May be component of Melkersson-Rosenthal Syndrome ▪ Orofacial granulomatosis, facial paralysis, fissured tongue Coated tongue o o o o o Mild thickening of dorsal aspect of tongue Secondary to increased production or decreased desquamation of keratin covering the filiform papillae ▪ Cigs, general debilitation, poor oral hygiene, hyposalivation/dehydration Misdiagnosed as fungal infection Benign w/ no serious sequelae Eliminate predisposing factors and encourage oral hygiene Erythema migrans (geographic tongue) o o o o o COMMON benign condition primary on tongue can be on other sites Unknown etiology Multifocal migratory filiform papillary atrophy, often w/ circumferential yellow-white border Lesion arise quickly, resolve and appear in different area If other mucosal sites involved, tongue almost always affected Median rhomboid glossitis o Originally though to represent a developmental anomaly ▪ More common in adults so theory unlikely ▪ Candidiasis typically seen o o Well-demarcated symmetrical zone of central atrophy of filiform papillae in the dorsal tongue midline anterior to the circumvallate papillae Kissing lesion on palate Lymphoepithelial cyst o o UNCOMMON lesion arising in the lymphoid tissue of Waldeyer ring: ▪ Palatine, lingual tonsils ▪ Pharyngeal adenoids ▪ Accessory aggregates of lymphoid tissue of the floor of the mouth, ventral tongue and soft palate Histopathologic features similar to brachial cleft cyst Tonsillar Concretions o o o o o Convoluted tonsillar crypts plugged with desquamated keratin, foreign material and bacterial microorganisms Compacted contents may calcify Sore throat, irritable cough and halitosis most common complaint Gargling with warm saltwater may assist in exfoliation Superficial calculi can be enucleated or curetted; deeper tonsilloliths may require surgical excision TOOTH ABNORMALITIES Microdontia “microdont” o o Presence of teeth physically smaller than average Isolated forms typically affect ▪ Max lateral incisors (pegs) ▪ Third molars Macrodontia “macrodont” o o o o Presence of teeth physically larger than average Should not be used to describe teeth that have been altered by fusion/gemination Isolated forms often effect incisors and canines, also premol and 3rds Diffuse forms seen in gigantism, otodental syndromes, pineal hyperplasia w/ hyperinsulinism, and hemifacial hyperplasia Taurodont o Enlargement of the body and pulp chamber of a multi-rooted tooth w/ apical displacement of the pulpal floor and bifurcation Gemination “twinning” o o One tooth trying to be two- always count and identify teeth Single enlarged tooth in which the tooth count is normal when the anomalous tooth is counted as one o o Two teeth trying to be one Single enlarged tooth in which the tooth count reveals a missing tooth when the anomalous tooth is counted as one Fusion Dilaceration o Abnormal angulation or sharp bend in a tooth root Talon cusp o o o o Well-delineated additional cusp on the surface of an anterior tooth More common in MAXILLA and in permanent dentition Most contain an associated pulpal extension but this may not be visible radiographically Occurs more frequently in Asian, native American, inuit Dens evaginatus “leong premolar” o o o o o Cusp-like elevation of enamel located in the central groove or lingual ridge of the buccal cusp of premolar or occasionally molar Usually bilateral Usually mandible 50% of cases pulp extends into accessory cusp ▪ Occlusal interference causes wearing/fracture ▪ Pulpal necrosis Common in native americans, Asians, inuit Dens invaginatus “dens in dente” o Deep surface invagination of the crown or root that is lined by enamel Enamel pearl o o o Hemispheric structures composed entirely of enamel or containing underlying dentin and pulp Project from surface of root; though to arise from localized bulging odontoblastic layer Most commonly affect maxillary and mandibular permanent molars Hypercementosis o Non-neoplastic deposition of excessive cementum that is continuous w/ the normal radicular cementum Concrescence o o Union of two fully formed teeth along the root surfaces by cementum May be seen in developmental and post-inflammatory contexts Hypodontia o o Lack of development of one or more teeth Oligodontia ▪ Lack of development of six or more teeth, excluding third molars Ectodermal dysplasia o Group of inherited conditions in which two or more ectodermally derived anatomic structures fail to develop ▪ Skin, hair, nails, teeth, sweat glands Hyperdontia o o Development of an increase number of teeth Called supernumerary teeth Unerupted/impacted teeth o Teeth that cease to erupt before emergence o o Cessation of eruption after emergence Anatomic fusion of cementum or dentin with the alveolar bone Ankylosis Extrinsic stain o Tobacco stain Intrinsic stain o o o o Pulpal necrosis Tetracycline Resoricinol Bile pigment o o Enamel defects secondary to excessive ingestion of fluoride Retention of amelogenin proteins in enamel structure causes foci of hypomineralization Imparts chalky lusterless areas Fluorosis o o o o Zones of yellow to dark brown discoloration “mottled enamel” Enamel hypoplasia characterized by deep irregular brownish pits ▪ Must be bilaterally symmetric ▪ Evidence of excessive fluoride intake Teeth caries resistant Focal enamel hypoplasia “Turner’s tooth” o Enamel defect in permanent dentition caused by trauma or periapical inflammatory disease of the overlying deciduous tooth Chronologic enamel hypoplasia o o Secondary to systemic influences during tooth development such as exanthematous fevers Localization correlates with developmental age of the affected teeth ▪ First 2 years: ant teeth and first molars ▪ 4-5: canines, premolars, and second molars ▪ Bilaterally symmetric horizontal rows of pits or diminished enamel Amelogenesis imperfecta o o o Developmental alterations in the structure of the enamel in the absence of systemic disease Problem may arise in any step of enamel formation ▪ Elaboration of organic matrix ▪ Mineralization of the matrix ▪ Maturation of the enamel Complications of esthetics and function Dentinogenesis imperfecta o o o Hereditary developmental disturbance of dentin in the absence of a systemic disorder Opalescent discoloration, bulbous crowns, cervical constriction, obliteration of pulp canals PPl close to English channel Osteogenesis imperfecta w/ opalescent teeth o o o Osteopenia and bone fragility Mutation in one of two type I collagen genes; major constituent of bone, dentin, sclera, ligaments and skin Bone fractures, long bone and spine deformity, growth impairment, blue sclerae, hearing loss, Wormian bones in the skull, dental altera tions clinically and radiographically identical to dentinogenesis imperfecta Dental Caries o Loss of tooth structure Attrition o Loss of tooth structure secondary to tooth to tooth contact during occlusion and mastication o Loss of tooth structure by a non-bacterial chemical process o Pathologic loss of tooth structure secondary to mechanical action of external agent Erosion Abrasion Abfraction o Loss of tooth structure from occlusal stress creating tooth flexure away from the point of loading External resorption o Common loss of tooth structure accomplished by cells in the periodontal ligament Internal resorption o Uncommon loss of tooth structure accomplished by cells in the dental pulp Periapical Pathosis/Osteonecrosis Periapical abscess o o o o o o o o o o Accumulation of acute inflammatory cells at the apex of a NON-vital tooth Can arise as ▪ Initial periapical pathosis ▪ An acute exacerbation of a chronic periapical inflammatory lesion ▪ The source of infection is usually obvious Symptomatic or asymptomatic Produce tenderness of affected tooth→progresses to intense pain→extreme sensitivity w/percussion→extrusion of tooth→swelling of tissue Doesn’t respond to EPT or cold test Headache, malaise fever and chills may be present Radiographic presentation ▪ Thickening of apical PDL or ill defined radiolucency ▪ Sometimes no alteration are detected Purulent material accumulates within bone Abscess spreads along path of least resistance Purulence may extend through the medullary spaces away from the apical area resulting in OSTEOMYELITIS o o May perforate the cortex spreading diffusely through overlying soft tissue as CELLULITIS Treatment ▪ Drainage and elimination of focal infection ▪ I&D when abscess causes clinical swelling of the bone and soft tissue ▪ NSAIDs for pain ▪ Antibiotics for medically comp patients, pts w/ cellulitis and pts w/ systemic symptoms ▪ Affected bone typically heals after RCT or extraction ▪ Parulis also resolves spontaneously after the offending tooth is treated Parulis (Gum boil) o o o o o From periapical abscess Purulent material accumulates in soft tissue overlying bone→ channelize through the soft tissue→ perforate the surface epi→ drain through intraoral sinus At opening of sinus tract there is a mass of sub acutely inflamed granulation tissue Also can drain through cutaneous sinus Asymptomatic Osteomyelitis o o o o o Acute or chronic inflammatory process in medullary spaces or cortical surfaces of bone that extends away from initial site Majority of case caused by bacterial infection w/ lytic destruction of involved bone and sequestrum formation Arise from odontogenic infection or traumatic fracture Predisposing factors ▪ Chronic systemic diseases, immunocompromised status, disorders associated w/ decreased vascularity of bone Usually in mandible Acute suppurative osteomyelitis o o o o o o Occurs when an acute inflammatory process spreads through the medullary spaces of the bone Duration is less than a month Not enough time for body to react Drainage, exfoliation of sequestrum or involucrum formation can occur Radiograph: unremarkable or ill defined radiolucency Treatment; antibiotic medication and drainage Chronic Suppurative Osteomyelitis o o Defense response leads to production of granulation tissue w/ subsequent formation of dense scar tissue attempting to wall off infected area. Encircled dead space becomes a reservoir of bacteria and antibiotic medications have difficulty reaching the site Develops months after acute process and difficult to manage unless treated aggressively o o o o Swelling, pain, purulent discharge, sequestrum formation Acute exacerbations and periods of decreased pain Radiographs ▪ Patchy rugged ill-defined radiolucency that often contain central radiopaque sequestra Treatment: high dose IV antibiotics and surgical intervention Condensing osteitis o o o o o o o o Bone sclerosis at apex of teeth w/ pulpitis/ pulp necrosis Seen at apex of teeth w/ large carious lesion or large restoration Develops in association w/ an area of inflammation Any age; frequent in children and young adults Radiograph ▪ Localized uniform area of radiodensity at the apex No expansion; no symptoms Mostly involves MD molars and premolars Treatment: resolution of the odontogenic focus infection Proliferative Periostitis o o o o o o o o o Represent a periosteal reaction to the presence of inflammation Most common cause is dental caries with associated periapical inflammatory disease Affected periosteum forms several rows of reactive vital bone that is parallel to each other resulting in expansion of the surface of altered bone COMMON in children and young adults MD premolar, molar area Located along the lower border of the mand or involves buccal cortical plate Radiographs ▪ Parallel radiopaque laminations of bone overlying the cortical surface Histology: parallel rows of reactive woven bone Treatment: extraction or endodontic therapy of the offending tooth; bone remodels to its original state in 6-12 months Periapical Granuloma o o o o o o Mass of chronically inflamed or subacutely inflamed granulation tissue at the apex of a non vital tooth Represents a defensive rxn to the presence of microbial infection in the root canal and spread of toxic products into apical zone Initial phase of periapical inflame disease is acute apical periodontitis which can be symptomatic Acute inflame process evolves into a chronic pattern with formation of granulation tissue; the chronic stage of the disease is usually asymptomatic May arise as the initial periapical pathosis or may develop following a periapical abscess Periapical granulomas are not static ▪ ▪ o Periapical cyst may develop May undergo acute exacerbation redevelopment of symptoms and possible w/ enlargement of associated radiolucency Treatment: ▪ Root canal treatment ▪ Extraction ▪ NSAIDs for symptomatic pts ▪ Antibiotics if swelling/systemic symptoms are present Phoenix abscess o Secondary acute inflame changes within a periapical granuloma Periapical Cyst o o o o o o True epithelium lined cyst formed by stimulation of the epithelium at the apex of a NON vital tooth Source of epithelium is cell rests of Malassez Typically asymptomatic unless acutely inflamed Affected tooth shows negative response to vitality testing Movement and mobility of adjacent teeth are possible Treatment: ▪ Root canal treatment ▪ Extraction ▪ NSAIDs for symptomatic patients ▪ Antibiotics if swelling/systemic symptoms are present Residual Cyst o o o o o Periapical cyst that is not removed at the time of extraction of the tooth Spontaneous resolution can occur following removal of the tooth Cyst at the site of previous tooth extraction Appears as a persistent round to oval radiolucency at the site of previous tooth extraction Treatment: ▪ Thorough curettage; complications UNCOMMON Periapical Scar o o Occurs when bone defect created by periapical lesion heals by formation of dense collagenous tissue instead of forming normal bone Usually occurs when both the buccal and lingual cortical plates have been lost o No further treatment is necessary once the diagnosis is established Chronic Hyperplastic Pulpitis (pulp Polyp) o o o o o o o o Unique pattern of pulpal inflammation Occurs in children/young adults Large pulp exposure Typically involves deciduous or permanent molars Hyperplastic granulation tissue Open apex reduces the likelihood of pulpal necrosis from venous compression Generally asymptomatic Treated by extraction or RCT Bisphosphonate associated osteonecrosis o o o o Bisphosphonates are medications used in management of metabolic bone disease, metastatic disease and malignancy Inhibit osteoclastic resorption of bone Mandibular predominance Altered bone homeostasis can lead to bone osteonecrosis, often secondary to oral surgery or odontogenic infection Development and Ondontogenic Cysts • Cyst is a pathologic cavity that is lined by epithelium Developmental Non-odontogenic cyst Nasopalatine Duct Cyst o o o o o o o o Most COMMON developmental cyst Arises from remnants of the nasopaltine duct 30-50 yrs Male>female Appears as a swelling in the anterior palate Aysmptomatic or pain may be present Well circumscribed radiolucency in the middle of anterior maxilla Treatment: surgical enucleation Median Palatal Cyst o o o o o RARE Develops from epithelium entrapped along the embryonic line of fusion of the lateral palatal shelves of the maxilla Young adults Appears as a swelling of the midline of the hard palate Asymptomatic or painful o o o Well circumscribed radiolucency in the midline of the hard palate; best seen on occlusal radiograph Micro: stratified squamous epithelium or pseudo stratified columnar epi Treatment: surgical removal Nasolabial cyst o o o o o o o o o RARE May arise from epi remnants along the lines of fusion of the maxillary process, medial nasal and lateral nasal processes 30-40 yrs Female>male Appears as a swelling of the upper lip lateral to the mid line Obliteration of the maxillary mucobuccal fold Usually asymptomatic Cyst arises in soft tissues-no radiographic changes seen Treatment: surgical excision Thyroglossal duct cyst o o o o o o o o UNCOMMON Arises from remnants of the thyroglossal duct epi Below 20 yrs Males= females Usually presents as a fluctuant movable swelling in the anterior midline of the neck Occur anywhere from the foramen cecum area of the tongue to the suprasternal notch Painless unless infected Treatment: surgical excision; recurrence is low if aggressively treated; rarely carcinoma can develop Branchial cleft cyst o o o o o Develops from remnants of second branchial arch Young adults 20-40 yrs Presents as swelling in the upper lateral neck along the anterior border of the sternocleidomastoid muscle Painless unless infected Treatment: surgical excision; never recurs; malignant transformation can occur but RARE Lymphoepithelial Cyst o o o UNCOMMON Keratin filled cyst within the lymphoid tissue Any age o o o o o Appears small white or yellow soft tissue mass; firm or soft on palpation Usually asymptomatic Develops in areas of the mouth where lymphoid tissue is present Floor of mouth, ventral and posterior lateral tongue, palatine tonsil, soft palate Treatment: surgical excision; doesn’t recur Dermoid Cyst o o o o o o Uncommon May represent a mild form of teratoma Most common in children and young adults Presents as a flucuant midline swelling in the floor of the mouth ▪ Above geniohyoid muscle= sublingual ▪ Below geniohyoid muscle= submental Painless and slow growing Treatment: surgical excision; recurrence uncommon; malignant transformation is rare Developmental Odontogenic Cyst Eruption Cyst o o o o o o o Soft tissue counterpart of dentigerous cyst Result of separation of the dental follicle from around the crown of the erupting tooth that is within the soft tissues Children younger than 10\Commonly associated with deciduous or permanent incisors and perm 1st molars Soft, translucent swelling in gingival mucosa overlying the crown of the erupting tooth Usually aymptomatic Soft tissue lesion- no radiographic changes Treatment: no treatment needed, spontaneous rupture leads to tooth eruption Dentigerous Cyst o o o o o o MOST COMMON Result of separation of the dental follicle from around the crown of an unerupted tooth Any age; but frequently seen in patients between the age of 10 to 30 yrs Any unerupted tooth; common on impact 3rds Small cyst: asymptomatic Large Cyst: painless expansion o o Radiographically appears as well defined radiolucent lesion associated with the crown of the impacted tooth Treatment: surgical excision; recurrence is rare; neoplastic transformation possible but rare Odontogenic Keratocyst o o o o o o o o o o Common odontogenic cysts Arises from cell rests of dental lamina Any age usually 10-40 yrs Mand>max Small cyst: asymptomatic Large cyst: pain and swelling Gorlin syndrome Well defined unilocular or multilocular radiolucency; radiographically can mimic other odontogenic cysts Treatment: surgical excision; high recurrence rate (25-40%); malignant transformation is rare Micro: ▪ Cysts lining epi is uniform thin (3-7 cell layers) ▪ Surface appears corrugated and parakeratotic ▪ Basal layer is hyperchromatic and palisaded ▪ Artifactual fragmentation of the fragile lining is commonly seen Orthokeratizing Odontogenic Cyst o o o o o o o UNCOMMON Derived from odontogenic epi Young adult Mand>Max Does not denote a specific clinical type but refers to a odontogenic cyst w/ orthokeratinized epi lining Unilocular or multilocular radiolucency Treatment: surgical enucleation and curettage Gingival Cyst of the New Born o o o o o o o o Common lesions Arise from remnants of dental lamina Found in neonates Max alveolus> mand alveolus Appear as multiple small white papules on the alveolar mucosa Present in soft tissues- no radiographic changes Micro: cyst lined by flattened epi Treatment: rupture and disappear spontaneously Gingival cyst of the adult o o o o o o o o o Uncommon lesion Represents soft tissue counterpart of LPC Derieved from rests of serres 40-50 yrs Predilection to occur in the mandibular premolar, canine, lateral incisor area Typically located on the facial gingiva Appear as painless bluish or blue-gray dome shaped swelling Soft tissue lesion- no radiographic changes Treatment: simple surgical excision Lateral Periodontal Cyst o o o o o o o o Uncommon odontogenic cyst Arise of rest of malassez 40-60yrs Predilection to occur in the mand premolar, canine, lateral incisor area Typically occurs along the lateral root surface of a VITAL tooth Asymptomatic, detected on routine radiographic exam Well circumscribed radiolucent area located lateral to the roots of vital teeth Treatment: conservative enucleation; recurrence is unusual Calcifying odontogenic cyst o o o o o o o o Uncommon Any age Max>mand Ant>post Mostly found in incisor canine areas Can be associated w/ unerupted tooth Well defined radiolucency or mixed lucent-opaque lesion Treatment: surgical enucleation; good prognosis Glandular Odontogenic Cyst o o o o o o o o RARE middle aged Mand>max Ant> post Small cyst- asymptomatic Large cysts- expansion/pain Well defined unilocular or multilocular Radiolucency Surgical enucleation and curettage; 30% recur Inflammatory Cysts Buccal Bifurcation Cyst o o o o o o o Uncommon Typically develops on mand 1st premolar May result from inflammation in the follicular tissue during eruption Children 5-13 Pain, swelling, pocket formation and discharge in 1st molar area Radiolucency involving the buccal bifurcation and roots Treatment: enucleation; extraction of the tooth NOT necessary Pseudo Cyst Simple Bone Cyst “Traumatic Bone Cyst” o o o o o o o o o o o o Common Theory is trauma-hemorrhage theory 10-20yrs Male>female Any bone; common in long bones and jaw Typically in mand Asymptomatic; rarely cause painless swelling; associated teeth are vital Empty fluid filled cavity in the bone that is devoid of an epi lining Diagnosis based on clinical radio and surgical findings Radiolucent lesion; superior aspect of cyst shows scalloping between roots of teeth Micro: the defect may be lined with thin fibro vascular connective tissue Treatment: surgical exploration to confirm diagnosis; obliteration of the defect with new bone formation occur following surgical exploration; rarely the lesion can persist or recur Aneurysmal Bone Cyst o o o o o o o RARE Children and young adults Uncertain pathogenesis; may be as a result of disrupted vascular dynamics in a preexisting lesion or when an area of hemorrhage maintains connection to feeder vessel Composed of blood filled spaces lined with fibrous connective tissue Pain and swelling Unilocular or multilocular radiolucent lesion Treatment: enucleation and curettage; appearance at surgery resembles a “blood soaked sponge” Stafne’s Bone Defect o o o Not rare Middle aged Male>females o o o o o Presents as an asymptomatic radiolucency near the angle of mand Represents as a focal concavity of the cortical bone on the lingual surface of the mandible The lingual cortical defect contains salivary gland tissue Diagnosis based on radiographic location and lack of symptoms No treatment necessary Hematopoietic Marrow Defect o o o o o o o o Focus of hematopoietic bone marrow that produces a radiolucency Unknown path Females>males Post mad> max Asymptomatic; no expansion; detected on routine radiographic examination Appears as a radiolucent lesion with ill defined borders and fine central trabeculations Biopsy recommended for definitive diagnosis Treatment: none required Fibro-Osseous Lesions of the Jaws Fibro-osseous lesions of bone o Heterogenous benign disorders in which normal bone is replaced by fibrous connective tissue and mineralized products that resemble lamellar bone, woven bone or cementum. Various entities are recognized, but diagnosis always requires consideration of clinical, radio, and pathologic data Fibrous Dysplasia of bone o o o o o o Fibro-osseous bone disorder that usually arises in childhood and produces poorly circumscribed expansion of one or more bones Affected tissues exhibit a characteristic mutation Maxilla and contiguous craniofacial bones are often affected The disease usually becomes relatively quiescent as skeletal maturity is reached; treatment is conservative, with surgery sometimes indicated for cosmetic improvement Patients exhibit somewhat increase risk of infection and osteaosarcoma at sites of involvement Mutation: ▪ Activating mutations in the subunit of stimulatory G protein have been described that lead to elevation of intracellular adenylyl cyclase, elevated cyclic adenosine monophosphate and expression of the oncogene c-fos ▪ Similar mutations are found in McCune-Albright syndrome, Poly- and monostotic fibrous dysplasia and endocrine adenomas of pituitary, thyroid and testis and in ovarian cysts ▪ o The hypothesis is that this mutation early in embryogenesis results in McCune-Albright Syndrome or polystotic disease, while mutation later results in craniofacial or monostotic fibrous dysplasia Micro: Chinese Characters Ossifying (cementifying) Fibroma o o o Benign bone neoplasm with fibro-osseous microscopic appearance Well circumscribed lucent-opaque lesion, usually involving posterior mandible in adults; asymptomatic expansile May become large; enucleated easily, recurrence uncommon Juvenile aggressive ossifying fibroma o o o o Benign fibro-osseous bone with a propensity for rapid destructive growth and recurrence Affects mostly children, often in maxilla Somewhat circumscribed lucent-opaque lesion producing expansion Difficult surgical management problem Cemento-osseous Dysplasia (cemental Dysplasia) o o o o Group of fibro-osseous lesions limited to alveolar bone; they are generally asymptomatic lucent-opaque foci noted incidentally on dental radiographs Three relatively distinct scenarios are recognized ▪ Focal cemento-osseous dysplasia ▪ Periapical cemento-osseous dysplasia ▪ Florid cemento-osseous dysplasia Histopathology is similar to that seen in cemento-ossifying fibroma; diagnosis depends on correlation of clinical and radiographic information. Biopsy usually not needed Management is usually conservative once diagnosis is made Focal Cemento-osseous dysplsia o o One term for an isolated focus of radiodensity in alveolar bone; often encountered in alveolar ridges of middle age females In absence of symptoms, expansion or displacement of adjacent structures, biopsy is not indicated Periapical Cemento-osseous dysplsia o o o o An asymptomatic fibro-osseous condition that produces lucent-opaque lesions with a predilection for lower anterior teeth of adult black females Very important because of the possibility of misinterpretation; affected teeth are usually health, responding normally to test of pulp vitality Radiographs taken at intervals usually show lucency predominating earlier with lesions becoming progressively opaque over time If teeth appear healthy and respond normally to pulp test, no treatment is indicated Florid Cemento-osseous Dysplasia o o o o Probably constitutes extensive jaw involvement with the same process as periapical cemento-osseous dysplasia Predilection for adult black females, but multiple areas of alveolar bone are affected sites should be avoided Affected areas are prone to dehiscence and infection, so surgery at affected sites should be avoided Preventive dentistry is important to avoid odontogenic or periodontal source of infection Cherubism o o o Autosomal dom condition developing in children that produces swelling and radiolucency in multiple posterior jaw regions. Frequently 2nd and 3rd molars are displaced anteriorly, and a characteristic facies is produced, with chubby cheeks and upturned gaze Management is conservative, since the process is self-limiting when skeletal growth ceases Microscopic findings are variable, with loose fibrous stroma, foci of woven bone, clusters of giant cells and prominent blood vessels Paget’s disease of bone o o o o o o o Chronic, painful bone remodeling disorder affecting one or multiple bones in older adults Characterized by osteoclast hyperactivity and compensatory osteoblastic activity that results in expansion and poor quality bone at affected sites Etiology and path complex Radiographically lucent-opaque “Cotton-wool”; if jaws are affected involved teeth may exhibit hypercementosis During active disease serum alkaline phosphatase is elevated Micro shows large osteoclasts and mosaic bone Can cause osteomyelitis and osteosarcoma Odontogenic tumors • Classification of Odontogenic tumors o Tumors of odontogenic epi only o Tumors of odontogenic epi w/ odontogenic ectomesenchyme o Tumors mainly of odontogenic ectomesenchyme (w/ or w/o odontogenic epi Tumors of Odontogenic Epi Ameloblastoma o o o o o o o o o o o o Most common odontogenic tumor Can arise from rest of dental lamina, developing enamel organ, epi lining of odontogenic cyst or from basal cells of oral mucosa Benign, slow growing, locally invasive tumors 20-60yrs No predilection Mand>max Post>ant Asymptomatic or painless expansion Often associated w/ impacted 3rds Resorption of adjacent tooth roots common Multilocular/unilocular radiolucent lesion (soap bubble or honeycombed appearance) Treatment: marginal resection; progressive infiltration to involve vital structures occasionally seen Unicystic ameloblastoma o o o o o o o o Younger patients, 10to 20 yrs Mand>max Post>ant Small lesions- asymptomatic Large lesions- painless expansion Often associated with the crown of unerupted 3rd molars Well defined unilocular radiolucency Treatment: enucleation and curettage/resection Peripheral Ameloblastoma o o o o o o Uncommon Arises from basal cells of the surface epi or rest of dental lamina Wide age range; mostly middle aged Mand>max Clinically presents as a nodule on post gingiva or alveolar mucosa Treatment: local surgical excision Malignant Ameloblastoma o o o o Any age Metastases to the lung, cervical lymph node, bone No cytologic atypia Poor prognosis Ameloblastic Carcinoma o o Any age; more in older age group Metastases do not necessarily occur o o Cytological features of malignancy Poor prognosis Adenomatoid odontogenic tumor (AOT) o o o o o o o o o 3%-7% of all odontogenic tumors Arises from epi remnants of dental lamina or from the enamel organ epithelium Young patients between 10-19 years of age Anterior maxilla Females>males Asymptomatic/ sometimes causes painless expansion Often involves the crown of an unerupted canine Unilocular radiolucency, may show “snowflake” calcifications Treatment: enucleation, does not recur Calcifying Epithelial Odontogenic Tumor (CEOT) o o o o o o o o Uncommon Arises from remnants of dental lamina or from enamel organ Wide age range, mostly 30-50 yrs Mandible post Painless, slow growing swelling Unilocular/multilocular radiolucency, may contain calcified structures (mixed lucent-opaque) Frequently associated w/ an impacted tooth Treatment: conservative local resection Squamous Odontogenic Tumor (SOT) o o o o o o o o Very rare neoplasm Arises from rest of malassez or dental lamina Wide age range Maxilla=mand Females=males Asymptomatic or clinically presents as gingival nodule with tooth mobility Triangular radiolucent defect lateral to roots Treat with conservative local excision/curettage Clear Cell Odontogenic Tumor o o o o o Rare neoplasm Wide age range; most pateints are older than 50 yrs Mand>max Asymptomatic/ pain and swelling Irregular unilocular or multilocular radiolucency o o o Neoplastic cells have “clear” morphology which resemble glycogen-rich presecretory ameloblasts Aggressive neoplasm with invasion, recurrence, and metastasis Radical surgery Tumors of Odontogenic Epithelium and Odontogenic Ectomesenchyme (mixed odontogenic tumors) Ameloblastic Fibroma o o o o o o o o o True mixed tumor; both epithelial and mesenchymal components are neoplastic Uncommon neoplasm Younger patients; usually 20 yrs Males>females Asymptomatic/swelling of the jaws Predilection for post mand Well defined unilocular or multilocular radiolucency Often associated w/ an unerupted tooth Treatment: conservative surgical excision Ameloblastic Fibro-Odontoma o o o o o o o o Rare Features of ameloblastic fibroma with additional enamel and dentin formation Children, average age 10 years Predilection for post mand Asymptomatic/swelling of the jaws Often associated with unerupted tooth Radiolucent lesion with calcified material within the lesion (mixed lucent-opaque lesion) Treatment: Conservative surgical excision Odontoma o o o o o o o Most common odontogenic tumor Developmental anomaly (hamartoma) Composed of enamel and dentin and varying amounts of odontogenic epithelium and mesenchyme Most patients are younger than 20 Asymptomatic/ rarely expansion of jaws Mixed lucent- opaque lesion Treatment: simple local excision; excellent prognosis Compound odontoma o o Composed of multiple small tooth like structures Ant maxilla Complex odontoma o o Consists of a conglomerate mass of enamel and dentin Post jaw Dentinogenic ghost cell tumor o o o o o Very rare Peripheral or central Central islands of odontogenic epithelium containing ghost cells Dentinoid deposition Calcifications Tumors mainly of odontogenic ectomesenchyme Odontogenic Fibroma o o o o o o o o Uncommon Wide range Females>males Can be associated with unerupted tooth Presents anywhere in the jaws asymptomatic/ bony expansion Unilocular or multilocular radiolucency Root divergence/ root resorption possible Treatment: Curettage; good prognosis Odontogenic Myxoma o o o o o o o Rare Wide age range, mostly young adults Man>max, area of the jaw Asymptomatic or painless expansion Unilocular or multilocular radiolucency Can cause resorption/displacement of teeth Treatment: complete excision Cementoblastoma o o o o o o o o Rare Odontogenic neoplasm of cementoblasts Children and young adults Usually seen in mand post region Pain and swelling present Cortical expansion, cortical erosion, displacement of adjacent teeth Radiopaque mass fused to tooth roots and surrounded by radiolucent rim Treatment: surgical excision of the tooth with the attached mass or root amputation and endodontics Langerhands, Pagets, and Giant cells Lesions Pagets disease of Bone o o o o o o o A chronic, painful bone remodeling disorder affecting one or multiple bones in older adults Characterized by osteoclast hyperactivity and compensatory osteoblastic activity that results in expansion and poor quality bone affected sites Etiology and path are complicated Radiographically lucent-opaque (cotton wool); if jaws are affected involved tooth may exhibit hypercementosis During active disease serum alkaline phosphatase is elevated Defective bone remodeling ▪ Hyperactive osteoclasts, osteoblastic reaction ▪ Enlargement of bones with disorderly bone formation ▪ Cotton wool bone and hypercementosis ▪ Pain and neurologic deficits in head and neck region ▪ Mosaic bone Complications ▪ Osteomyelitis ▪ Osteosarcoma Langerhans Cell Disease o o o o o o Proliferation of cells resembling Langerhans cells of the skin and mucosa Lesions may appear over a wide age range Lytic bone lesions may be found in jaws and/or extragnathic sites; may mimic periapical or periodontal lesions Usually treated with curettage or radiation Immunohistochemical stains ▪ CD1a positive ▪ S-100 positive Coffee bean nuclei Hyperparathyroidism o o o o o Rare in U.S. May be first degree tumor or second degree Vitamin D deficiency Stones, bones and groans On dental X rays, loss of lamina dura and radiolucencies representing giant cell lesions Medical workup shows elevation of serum parathormone Central giant Cell Lesion o o o Uncommon Children are often affected but also adults Swelling, radiolucency, tooth resorption o o o o Clinically/radiographically classified as aggressive or non aggressive for treatment planning purposes Consider hyperparathyroidism Pathogenesis Dysregulated stromal cell proliferation ▪ Recruitment of monocyte precursors of osteoclasts ▪ Promotion of osteoclast development • RANK-RANKL interaction, blocked by Denosumab ▪ Osteoclast maturation and capacity for bone resorption • Blocked by bisphosphonates Simple (traumatic) Bone Cyst o o o o o o o Fairly common; younger patients mainly affected Usually found in mand Asymptomatic lucency, usually incidental finding May “Scallop” around roots of nearby teeth Empty cavity in bone, lacking epithelial lining May resolve spontaneously, or after exploration Pathogenesis unknown Aneurismal Bone Cyst o o o o o o Uncommon Sudden, uncomfortable expansile lucency of bone Young adults; mand>max Upon exploration, clinicians describe “bloody sponge” Histo: variably sized blood filled spaces, foci of giant cells and reactive, woven bone Occasional recurrences after curettage White Lesions Leukoplakia o WHO def ▪ A clinical white patch or plaque that cannot be rubbed or scraped off and cannot be given a specific diagnostic name White lesions o o o o Keratin and rough or thickened epi Coagulated tissue (thermal and chemical burns) Fibrinous exudate (in ulcers) Collections of microorganisms o o o ALWAYS try the surface! ALWAYS try to rub off a white area! Classifications: ▪ Developmental, reactive, infectious, autoimmune, neoplastic Developmental White Sponge Nevus o o o o o o o o Rare genetically determined skin disorder Autosomal dominant inheritance Defect in the normal keratinization Lesion appear at birth/childhood Symmetric, thickened, white diffuse plaques Bilaterally on the buccal mucosa Asymptomatic No treatment necessary Leukoedema o o o o o Common oral mucosal condition Black adults> white adults Diffuse, gray-white, milky, opalescent mucosa Typically occur bilaterally on the buccal mucosa may also appear on the floor of the mouth and palatopharyngeal tissues less visible or disappears when tissue is stretched No treatment necessary Hairy tongue o o o o o Accumulation of keratin on the filiform papillae of the dorsal tongue Increase in keratin production or decrease in keratin desquamation Associated with ▪ Smoking, antibiotic therapy/ general debilitation, poor oral hygiene, radiation Typically asymptomatic No treatment necessary Reactive Frictional Keratosis o o o o o o Very common reactive oral lesion Caused by chronic mechanical irritation Considered to be an hyperplastic response White lesion with roughened keratotic surface Common location- alveolar ridge/retromolar pad Not considered to be precancerous Hyperkeratosis o Thickened layer of keratin o o Parakeratin ▪ No granular cell layer ▪ Nuclei are retained in keratin layer Orthokeratin ▪ Granular cell layer ▪ Nuclei lost in keratin layer Linea Alba o o o o o o Very common lesion Associated with pressure, frictional irritation, trauma from surfaces of teeth Presents as bilateral white line on the buccal mucosa Located at the level of the occlusal plane Present only in dentulous areas No treatment is required Morsicatio o o o o o o Chronic chewing Secondary to chronic nibbling of cheeks (buccarum), labial mucosa (labiorum), or lateral borders of the tongue (linguarum) Females>males; Any age Thick, shredded white areas with occasional erythema and ulceration Most commonly found bilaterally on buccal mucosa No treatment is necessary Tobacco pouch Keratosis o o o o o o o Altered oral mucosa at the sites of tobacco contact Develops after chronic tobacco use Young adult men and in some older men Gray-white plaque; fissured/ rippled surface Malignant transformation potential is low Resolves in 1 to 2 weeks following cessation No treatment unless biopsy shows malignant transformation Oral Submucous Fibrosis o o o o o o o Precancerous condition of the oral mucosa Results in chronic progressive scarring India, Taiwan, China, Southeast Asia Associated with betel quid chewing (paan) Mucosal rigidity due fibroelastic hyperplasia and modification of the superficial connective tissue Trismus, burning sensation to spicy food Buccal mucosa, retromolar pad, soft palate o Treat with intralesional corticosteroids and surgical splitting of fibrous bands Nicotine Stomatitis o o o o o o o White mucosal change of the hard palate Associated with cigar/pipe smoking Not considered to be premalignant Develops in response to heat and not due to tobacco exposure Men older than 45 yrs with long history of tobacco use Diffuse gray-white palate with elevated papules with punctate red centers representing the inflamed salivary gland orifices No treatment is necessary Actinic Cheilitis o o o o o o o Common premalignant alteration of the lower lip vermilion Secondary to UV exposure Affects mainly fair skinned patients Males(>45yrs)> females Blurring of vermilion- skin interface 6-10% of the lesions can progress to Squamous cell carcinoma Mange with sunscreen, biopsy/vermilionectomy Traumatic Ulceration o o o o Acute or chronic trauma to the oral mucosa Variable healing time but usually heals within 2 weeks Erythematous area with central yellow fibrinopurulent membrane surrounded by rolled white hyperkeratotic border Remove source of irritation; biopsy is indicated for chronic ulcers Thermal burns o o o o o o Arise from ingestion of hot foods or beverages Palate, posterior buccal mucosa Resolve w/o treatment Chemical burns Aspirin and other over the counter medication Resolves within 2 weeks Allergic contact stomatitis o o o Allergic contact reactions to food, chewing gum, candies, tooth paste, mouth rinse, dental materials Can be acute or chronic Mucosa can appear erythematous or white and hyperkeratotic o o Identification and removal of the source of allergic contact stomatitis helps to resolve the problem topical anesthetics/ topical corticosteroid Topical anethetics/ topical corticosteroids Infectious Candidiasis o o o Infection with fungal organism Candida albicans Most common oral fungal infection Variety of clinical patterns ▪ Pseudomembranous candidiasis ▪ Erythematous candidiasis ▪ Chronic hyperplastic candidiasis Figure 1: Linchenoid contact reaction to dental resorative material Pseudomembranous Candidiasis o o o o o White plaques resembling curdled milk on the oral mucosa Removable plaques with underlying normal or erythematous mucosa Burning sensation, unpleasant taste Common sites: buccal mucosa, tongue, palate Associated factors; antibiotic therapy, immunosuppression Chronic Hyperplastic Candidiasis o o o o o White patch not removed by scraping Least common Asymptomatic Common site: anterior buccal mucosa May represent candidiasis superimposed on preexisting leukoplakia Red and White Lesions and the Relationship with oral cancer Leukoplakia o o o White plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer Clinical term ▪ Modified after histopathic eval Most common potentially malignant oral lesion with higher risk of malignant transformation with increased follow-up years Leukoedema o o o o Delicate grayish change involving buccal mucosa; disappears on stretching (edema) May be secondary to mild topical injury Remove inciting agent if identified No further management Frictional Keratosis o o Non-keratinized mucosal lesions ▪ Linea alba/morsicatio mucosae oris • Usually not sharply demarcated • Local mild trauma- “nibbling” Keratinized mucosal lesions ▪ Alveolar ridge keratosis (ARK) • White plaque on the alveolar ridge, painless, may be rough; poorly demarcated • Often in the area of previously extracted mand third molar (wisdom tooth) Smokeless tobacco Keratosis o o o o o o o Asymptomatic grey-white opalescent area with parallel ridges where tobacco is placed Likely cause by contact irritation and gradient effect Reversible unless leukoplakia develops Manage by discontinuing habit Counsel patient regarding other adverse effects ▪ Periodontal disease, staining of dentition Cancer risk is 2x; low compared to cigarettes Follow-up Nicotine Stomatitis o o o o o Pebbly, red and white change on palate Caused by heat; typically from pipes, reverse smoking Management via patient education, discontinue habit Reverse smoking may have malignant potential; too few to know Follow-up Candidiasis o o • Pseudomembranous type (thrush); white, curdy plaques that may or may not wipe off Hyperplastic candidiasis; do not wipe off easily ▪ Often associated with muco-cutaneous disease o Treatment ▪ Nystatin, clotrimazole, fluconazole ▪ If necessary, scraping for cytology, biopsy What causes a White Lesion to appear White o Thickened keratin o Thickened epi o Altered epi cells ▪ Keratinocyte edema ▪ Coagulation/degeneration of cells ▪ Epithelial dysplasia ▪ Squamous cell carcinoma o Scar/fibrosis below epi (no surface change) • Potentially malignant/premalignant o Morphologically altered tissue in which cancer is more likely to occur than its apparently normal counterpart Leukoplakia o • • • Localized ▪ Homogenous ▪ Non-homogenous • Verrucous/nodular leukoplakia • Erythroleukoplakia (speckeled leukoplakie) o Proliferative (multi-focal) leukoplakia ▪ Homogenous ▪ Non-homogenous ▪ Verrucous/nodular leukoplakia ▪ Erythroleukoplakia (specked leukoplakia) o Leukoplakia ▪ White, common, 3-17% dysplasia or carcinoma o Speckeled ▪ Red and white, less common, 18-47% dysplasia or carcinoma o Erythroplakia ▪ Red, least common, 90% dysplasia or carcinoma High-Risk sites for Oral Squamous CA o Lateral tongue, ventral tongue, floor of mouth, retromolar trigone, soft palate o 97% cancers in smokers and alcohol consumers ▪ 14.8% floor of mouth ▪ 17.2% ventral and lateral tongue ▪ 30.9% soft palate complex High risk Leukoplakia o Lesioned presence in high risk areas such as the floor of mouth, ventral tongue and soft palate have higher association with dysplasia or carcinoma than other sites o Sharp demarcation at least in parts of the lesion is a worrisome sign o Red, raised or ulcerated component o Patient with exogenous risk factors such as tobacco and alcohol use o Non smoker and unknown etiology of lesion o Non-reversible type o Microscopic atypia Leukoplakia and transformation o Rate of malignant transformation 3-17%: transformation of low-greade dysplasia 5.8yrs, high grade 3.3 yrs o Higher risk of malignant transform in patients over 60, lateral-ventral tongue site, and non-homogenous lesions o Other studies have shown indistinguidable transformation rates amongst mild and severe epithelial dysplasia o Non-dysplastic lesions may transform to cancer; not all dysplastic lesions will transform • • • • • • What is Acceptable risk? o What level of risk of cancer development is acceptable for watching a leukoplakic lesion o Malignant transformation in 3-17% of leukoplkic lesions o If we use very conservative number 3%: 1 in 30 o If we use the higher number 17% 1 in 5 Common myths and misunderstandings regarding pre-malignant and malignant oral lesions o The lesion does not look like cancer o The lesion is not white enough to be cancer o The lesion is too small to be oral cancer o The patient is too young to have oral caner Epithelial Dysplasia o Morphologically altered tissue in which cancer is more likely to occur than its apparently normal counterpart o Or: the sum of various disturbances of epi proliferation as evidence by histopathologic evaluations o Grading and treatment ▪ Mild, moderate, or severe/ carcinoma in situ ▪ No invasion of the underlying connective tissue has occurred ▪ Treat with complete surgical excision Management of Localized Leukoplakia o All dysplastic lesions must be excised, preferably with clear margins o Even if not dysplastic, conservative or narrow excision should be considered, if no clear etiology identified o Wide excision of recurrent lesions Squamous cell carcinoma treatment o Despite advances in surgery and radiotherapy 5 year survival rate unchanged at approx.. 50% o Combination of surgery, radiotherapy and chemotherapy ▪ Altered fractionated radiotherapy ▪ Chemo radiotherapy Proliferative Verrucous Leukoplakia (PVL) o Extensive, irregular white plaques o Involves multiple mucosal sites o Persistent growth, exophytic and verrucous o May lead to dysplasia, squamous cell carcinoma o Female predilection (4:1 versus males) o <50% with tabacco habit o Multifocal lesions, non contiguous o Proliferative leukoplakias transform in 70-100% of cases over time o Homogenous type is rare o Non-homogenous • • • • • ▪ Proliferative verrucous (best known) ▪ Proliferative erythroleukoplakia (may be mistaken for lichen planus) Leukoplakia vs. Proliferative leukoplakia o Localized leukoplakia ▪ Mostly in men ▪ High association w/ cigarette smoking ▪ Single site, usually ventral tongue, floor of mouth ▪ Malignant transformation: 3-16% ▪ Easy to ablate/excise because localized o Proliferative leukoplakia ▪ Mostly in women ▪ Low association w/ smoking ▪ Multifocal ▪ Malignant transformation: 70-100% ▪ Difficult to treat because multi-focal Histopathic findings in Prolifereative leukoplakia o Typically multiple biopsies o Usually early biopsies show benign hyperkeratosis with no evidence of dysplasia o Not reliable- should re-evaluate clinically o Follow closely Erythroplasia o Least common and appears as a well demarcated erythematous area with a velvety texture o Floor of the mouth, tongue and soft palate are common locations o 90% of this change exhibits carcinoma in situ or invasive squamous cell carcinoma at diagnosis Progression o Risk of malignant transformation not completely eliminated by treatment modalities o Lesional progression and malignant transformation may still occur in spite of treatment o Number of lesions prevented from malignant development is unknown o Life-long follow up at routine intervals indicated. Functional categories of disease o Disease recognized; no treatment indicated o Disease recognized; treatment indicated o Disease unrecognized; diagnostic procedure indicated Oral Path Test 2 Mucozal Fragility Diseases Lichen Planus o o o Common chronic immune-mediated condition; adult onset; unknown etiology Most commonly affects buccal mucosa; also involves other sites including tongue and gingiva White striae hallmark; can see ulceration Lichenoid Contact Reactions and Drug Eruptions o o Typically caused by either direct contact of the mucosa with an inciting agent or by a systemic medication Clinical and histopathologic mimic of lichen planus Lupus Erythematosis o o o o SLE = archetypal autoimmune disease Both systemic lupus and discoid (chronic cutaneous) lupus can cause oral lesions Focal lesions involving vestibule and palate with central erythema or ulceration and radiating striae Difficult to distinguish from LP both clinically and histopathologically Graft Versus Host Disease (GVHD) o o o Mainly occurs with allogeneic BMT Affects entire GI system including the oral cavity and also affects the skin and liver Acute and chronic forms of GVHD ▪ No longer classified by number of days post transplant ▪ New classification looks at clinical manifestations Pemphigus Vulgaris o o o o o Uncommon autoimmune disease; incidence increases with age Circulating Ab to keratinocyte surface Ag Epithelial fragility with blister formation Histologically see acantholyis Life threatening if untreated; treat with systemic steroids Mucous Membrane Pemphigoid • • • • • • Autoimmune mucosal fragility disorder; uncommon in patients under age 40 Ab to basement membrane Ag Little circulating Ab in circulation Desquamative gingivitis, blisters, eye involvement Sub-basement membrane split Non life-threatening but may yield blindness Erythema Multiforme • • • • • Hypersensitivity reaction; typically associated with HSV or drug reactions, particularly to antibiotics or analgesics Acute onset, young adults, men>women; often preceded by a prodrome of fever and malaise Self-limiting = 2-6 weeks 50% with skin involvment; targetoid or “bull’s eye” lesions Hemorrhagic crusting of vermilion and intraoral ulcerations, typically lips, buccal mucosa, and tongue Toxic Epidermal Necrolysis (TEN) and Stevens Johnson Syndrome (SJS) • • • • • • TEN and SJS are hypersensitivity reactions like EM but separate clinically and likely separate etiopathogenetically SJS considered less-severe variant of TEN Like EM, both TEN and SJS present with labial crusting, oral bullae/ulcers/erosions Unlike EM SJS typically associated with medication usage or Mycoplasma pneumoniae infection and rarely HSV Skin lesions always present with predominant involvement of the chest Eye and genital involvement in addition to oral lesions Epidermolysis Bullosa • • • • • Inherited mucocutaneous blistering disorder Various dental anomalies may be observed Range in severity from mild to lethal Histopathologically remarkable for clefting either within the epithelium or at the epithelial-connective tissue interface depending on subtype Epidermolysis bullosa aquisita is a non-hereditary condition with IgG antibodies directed against type VII collagen, a component of the anchoring fibrils of the basement membrane Benign Soft Tissue Swellings Tumor Like Lesions Pyogenic granuloma (pregnancy tumor) • • • • • • • • • • Common tumor like growth Tissue response to local irritation or trauma Smooth or lobulated mass, Sessile / pedunculated Surface ulceration, red-purple-pink Fast growing, painless, bleeds easily Predilection for gingiva, may occur elsewhere Any age; common in children and young adults Female predilection Frequently develop in pregnant woman Treatment is conservative surgical excision Peripheral Ossifying Fibroma • • • • • • • Common reactive gingival growth Occurs exclusively on the gingiva Pedunculated / sessile, red / pink Surface ulceration may be present Young adults / Female > Male Maxilla > Mandible / Anterior > Posterior Treatment is local surgical excision Peripheral Giant Cell Granuloma • • • • • • • • • Common tumor like growth Reactive lesion caused by local irritation Soft tissue counterpart of CGCG Exclusively on the gingiva/edentulous alveolar ridge Red or red blue nodular mass Sessile / pedunculated, may be ulcerated Any age, Females > Males, Mand > Max Cupping resorption of underlying bone Local surgical excision Epulis Fissuratum • • • • • • • • Hyperplasia of fibrous connective tissue Associated with the flange of ill fitting denture Single or multiple folds of hyperplastic tissue in the alveolar vestibule Usually firm and fibrous Middle aged / older adults, Females > Males Maxilla = Mandible, Anterior > Posterior Treatment is surgical removal ill fitting denture must be relined or remade Benign Tumors Squamous Papilloma • • • • • • • Common benign proliferation of stratified squamous epithelium Papillary or verruciform mass Often induced by HPV Male=Female; any age; painless; solitary Any site; common sites- tongue, lips, soft palate Usually pedunculated; fingerlike projections Treatment: conservative surgical excision Verruca Vulgaris • • • • • • • • Common wart Benign, virus induced (HPV) Focal hyperplasia of the epithelium Contagious; common lesion of the skin; infrequent in the oral cavity Frequent in children Vermillion border, labial mucosa, anterior tongue Painless mass with papillary projections Treatment: surgical excision Fibroma • • • • • • • Most common tumor Reactive hyperplasia of fibrous connective tissue Nodule; smooth surface; pink Pedunculated / sessile; asymptomatic Male=Female; any age; any site Buccal mucosa, labial mucosa, tongue, gingiva Treatment: conservative surgical excision Lipoma • • • • • • • • • Benign tumor of fat Most common mesenchymal neoplasm Less frequent in the oral cavity Soft smooth surfaced nodule Sessile/pedunculated; asymptomatic; yellow/pink Common sites: buccal mucosa, buccal vestibule tongue, floor of the mouth, lips Age: > 40 yrs, Male=Female Treatment: conservative surgical excision Hemangioma/ Vascular Malformation • • • • • • Benign tumor of blood vessels Structural anomalies of blood vessels Some are present at birth, others arise later May undergo gradual involution or persist throughout life Asymptomatic, may bleed if traumatized Treatment: Sclerotherapy / Surgical excision Infra bony vascular malformation • • • • • • • • • Represent venous or arteriovenous malformation Detected during first 3 decades of life Females > Males; Mandible > Maxilla Asymptomatic or pain/swelling Pulsation on palpation Radiographs: Radiolucent defect-multilocular, ill-defined or well defined radiolucency Needle aspiration before biopsy recommended Risk of severe bleeding Lymphangioma • • • • • • • Benign hamartomatous tumor of lymphatic vessels Predilection for the head and neck region 50% present at birth; 90% develop by 2 years of age Most frequent location-antr2/3rd of tongue Soft swelling, poorly circumscribed, bubbly surface Micro: Composed of dilated lymphatics Treatment: Surgical excision Sturge- Weber Syndrome • • • • • • Rare, non hereditary developmental condition Hamartomatous vascular proliferation Involves tissues of brain and face Port wine stain (dermal capillary vascular malformation of the face; unilateral distribution along the trigeminal nerve) Angiomas affecting cerebral cortex Hyperplastic oral lesions/vascular hyperplasia of the gingiva Neuroma • • • • • • • • Reactive proliferation of neural tissue Result of damage to the nerve Smooth surfaced nodules Any location; common in mental foramen area, tongue, lower lip Trauma, tooth extraction, surgery Any age; common in middle aged adults One third of t