Oral Pathology - PDF

Oral Pathology Blitz DEVELOPMENTAL CONDITIONS ..................................................................................................................................................... 2 MUCOSAL LESIONS ........................................................................................

Oral Pathology Blitz DEVELOPMENTAL CONDITIONS ..................................................................................................................................................... 2 MUCOSAL LESIONS ........................................................................................................................................................................ 4 REACTIVE ............................................................................................................................................................................................... 4 INFECTIONS ............................................................................................................................................................................................ 5 IMMUNOLOGICAL DISEASES ....................................................................................................................................................................... 7 PREMALIGNANT LESIONS........................................................................................................................................................................... 8 MALIGNANT LESIONS ............................................................................................................................................................................... 8 CONNECTIVE TISSUE ...................................................................................................................................................................... 9 BENIGN TUMORS (REACTIVE)..................................................................................................................................................................... 9 MALIGNANT TUMORS ............................................................................................................................................................................ 10 SALIVARY GLAND DISEASES ......................................................................................................................................................... 11 REACTIVE LESIONS ................................................................................................................................................................................. 11 BENIGN LESIONS ................................................................................................................................................................................... 11 MALIGNANT LESIONS ............................................................................................................................................................................. 12 LYMPHOID NEOPLASMS .............................................................................................................................................................. 12 ODONTOGENIC ............................................................................................................................................................................ 13 CYSTS .................................................................................................................................................................................................. 13 TUMORS .............................................................................................................................................................................................. 14 BONE LESIONS ............................................................................................................................................................................. 15 FIBRO-OSSEOUS LESIONS ........................................................................................................................................................................ 15 GIANT CELL LESIONS .............................................................................................................................................................................. 15 INFLAMMATORY .................................................................................................................................................................................... 16 MALIGNANT LESIONS ............................................................................................................................................................................. 17 HEREDITARY CONDITIONS ........................................................................................................................................................... 18 **These Notes are based on the Mental Dental Pathology Playlist: https://www.youtube.com/watch?v=3zcuZ6U7vQA&list=PLVmK7sDA_arHJZOV12PLjTTZp6FuxxLR1&index=1 1 Developmental Conditions Cleft Lip - Cleft Palate - Lip Pits - Invaginations at the commissures or near the midline of the lip Associated Syndrome: Van der Woude Syndrome: Clefts + Pits Fordyce Granules - Leukoedema - Lingual Thyroid - - Geographic Tongue (Migratory glossitis / Erythema migrans) Fissured Tongue Cherry Angioma Ectopic sebaceous glands Frequently found on buccal mucosa Completely benign White/Grey edematous lesion of the buccal mucosa Very common on buccal mucosa *When lip is stretched, the color goes away* Thyroglossal Duct Cyst Developmental 1/1000 Births Lack of fusion between the medial nasal process and maxillary process (which normally fuse to form the face) 1/2000 births Lack of fusion between the palatal sutures Frequently happens in conjunction with Cleft lip - Thyroid tissue mass at the midline base of the tongue This is where thyroid tissue originates during development, it normally migrates down to the neck/trachea area to form the thyroid gland Located along the embryonic path of thyroid descent Midline neck swelling Located along the embryonic path of thyroid descent Much like the lingual thyroid, only the tissue did not midrate all the way down White ringed lesion surrounding central red islands that migrates over time May be associated with certain foods Occassionally hurts/burns Tx: N/A Fold and furrows in the tongue dorsum Associated syndrome: Melkerson-Rosenthal syndrome: Fissured tongue + Granulomatous cheilitis + Facial paralysis “Mels Bells” -> Melkerson, Bells Palsy “Rosy Red” -> Rosenthal + Red swollen lips Angiomas Tumors of blood vessels or lymph vessels = “Red Mole” Extremely common Completely benign, small tumor of capillaries 2 Hemangioma Lymphangioma Dermoid Cyst Branchial Cyst Oral lymphoepithelial Cyst = Congenital focal proliferation of capillaries Most undergo involution as a child -> If it persists though usually get it surgically removed (mostly for esthetics) = Congenital focal proliferation of lymph vessels Orally its very rare -> Purple spots on the tongue On neck = Cystic hygroma Associated Syndrome: Sturge-Weber Syndrome = Angioma of leptomeninges (Arachnoid and Pia mater) + skin along the trigeminal nerve distribution Cysts Mass in the midline floor of the mouth (if above the mylohyoid) or upper neck ( if below mylohyoid) Contains adnexal structures (hair, sebaceous glands) Doughy consistency -> This is the main distinguishing feature vs a ranula Lateral neck swelling Epithelial cyst within a lymph node of the neck - Stafne Bone Defect (Lingual Bone Defect) Nasopalatine Duct Cyst Globulomaxillary Lesion Traumatic Bone Cyst (Simple Bone Cyst) Epithelial cyst within the lymph nodes of the oral mucosa Commonly Palatal or Lingual tonsils = Radiolucency in the posterior mandible inferior to the IAN canal Very severe lingual concavity = Heart-shaped radiolucency in the nasopalatine canal Caused by cystification of canal remnants Tx: Surgical Excision = Clinical term for any RL between the Max. Canine and Max. Lateral NOT a diagnosis, just a clinical description = Large RL that scallops around tooth roots No epithelial lining (so its like a pseudocyst) Mostly in the mandible of teens and is associated with jaw trauma Tx: Aspirate to diagnose (will usually have blood in them) and monitor 3 Mucosal Lesions Reactive Linea Alba = White line on buccal mucosa In line with the plane of occlusion Focal hyperkeratosis due to chronic friction on mucosa Traumatic Ulcer Chemical Burn Nicotinic Stomatotis Amalgam Tattoo Very Common Erosion = Incomplete break of epithelium Ulcer = Complete break through the epithelium (this is why these are much more painful) Common from: Aspirin (topical application) Hydrogen Peroxide Silver Nitrate Phenol *White sloughing mucosa* = Red dots -> Inflamed minor salivary duct openings on hard palate Only considered pre-malignany if it is related to “reverse smoking” (putting the lit end of a cigarette in your mouth like an idiot) = Traumatic implantation of amalgam particles into mucosa Can see clinically or radiographically Don’t need to biopsy or treat SmokingAssociated Melanosis = Chemicals in tobacco stimulate melanocytes to make more melanin Brown diffuse irregular macules Typically in the anterior gingiva (especially with smokeless tobacco AKA snuff) Tx: Reversed if smoking is stopped Melanotic Macule Hairy Tongue = benign hyperpigmentation in mucous membrane (basically a freckle) Associated syndrome: Peutz-Jeghers Syndrome = Freckles (lips and mouth) + Intestinal polyps = Elongated filiform papillae DentitifriceAssociated Sloughing = Related to SLS (Sodium-lauryl sulfate) Suggest SLS free toothpaste Submucosal Hemorrhage = Extravascular lesions that do not blanch Vascular lesions (hemangiomas, telangiectasias) do blanch Petechiae = 1mm hemorrhages Purpura = slightly large than petechiae Ecchymosis = 1cm or bigger Hematoma = mass of blood within tissue caused by trauma to oral mucosa Tx: Eliminate the cause 4 Infections Herpes Simplex Virus (HSV)` Viral Primary -> pan-oral, self limiting and typically in children Tx: Palliative (symptomatic relief) Remains latent in the Trigeminal Ganglion Recurrent -> Keratinized tissue only Herpes labialis (cold sores, fever blister) = Vermilion border Recurrent intraoral herpes = attached gingiva, hard palate *Reactivation is triggered by stress, sunlight, or immunosuppression* Herpetic whitlow -> Finger lesions Herpes Gladiatorum -> Head (typically in wrestlers) Varicella Zoster Virus (VZV) Tx: Acyclovir in prodromal period (before it activates) Primary -> Varicella (AKA Chickenpox) -> self limiting, childhood Latent in the trigeminal ganglion Recurrent -> Herpes Zoster (AKA Shingles) Associated Syndrome: Ramsay Hunt Syndrome Herpes zoster reactivation in geniculate ganglion affecting CN VII and VIII = Facial paralysis, vertigo, deafness Coxsackie Virus Tx: Acyclovir = Hand-foot-and-mouth disease Herpangina -> Posterior oral cavity (soft palate, throat, tonsils) Measles (Rubeola) = Kolik’s spots (buccal mucosa dot ulcers -> preceds skin rash) Primary Infection -> Self limiting and typically affects kids HPV Papilloma (Wart) - Caused by several HPV strains Benign epithelia pedunculated or sessile proliferations on skin or mucosa - Verucca Vulgaris Common skin wart Condyloma Acuminatum Caused by HPV 6 and 11 Genital wart or from oral sex w/ someone with genital warts Tx: Excision w/ high recurrence Oral Hairy Leukoplakia Focal Epithelial Hyperplasia (Heck’s Disease) Caused by HPV 13 and 32 Multiple small dome-shaped warts on oral mucosa “whole mouth goes to heck” Tx: Excision w/ excellent prognosis Caused by EBV White patch on lateral tongue -> doesn’t wipe off Opportunistic infection -> associated with HIV or Burkitt’s lymphoma Condyloma Acuminatum Heck’s Disease 5 Syphilis Bacterial Infections Caused by Treponema pallidum (spirochete) Primary Lesion -> Chancre Secondary Lesion -> Oral mucous patch, condyloma latum, maculopapular rash Tertiary Lesion -> Gumma, CNS involvement, CV involvement Tuberculosis Congenital Syphilis = Hutchinson’s Triad (notched incisors, mulberry molars, deafness, ocular keratitis) Inhalation of Mycobacterium tuberculosis Oral non-healing chronic ulcers following lung infection Primary -> Ghon complex (inhaled bacteria surrounded by granuloma that undergoes caseating necrosis + infected hilar lymph node draining the first lesion) Secondary -> More widespread lung infection w/ cavitation Miliary -> Systemic spread *HIV Patients are at high risk of progressive disease Gonorrhea Actinomycosis Tx: Multidrug therapy (isoniazid, rifampin, ethambutol) = Caused by Neisseria gonorrhea Rarely has oral manifestations = Caused by Actinomyces israelii (filamentous) -> Not fungal Opportunistic infection, chronic and granulomatous Periapical -> Jaw infections Cervicofacial -> Head and neck infections *Sulfur granules in purulent exudate* Scarlet Fever Tx: Long-term high dose penicillin = Caused by Group A Strep (classically Streptococcus pyogenes) When strep throat becomes systemic Classic sign: Strawberry tongue White-coated tongue w/ red inflamed fungiform papillae Tx: Penicillin Candidiasis (Thrush) Deep Fungal Infections Fungal Pseudomembranous -> White plaque that rubs off to show erythematous mucosa Atrophic -> Red Median rhomboid glossitis -> Loss of lingual papillae Angular cheilitis -> Corner of mouth Tx: Antifungal (-Azole, -Statin) These fungi are typically found geographically in soils Blastomycosis -> US Northeast, spores inhalation Coccidiodomucosis -> US Southwest, Valley Fever Cryptococcosis -> US West Histoplasmosis -> US midwest 6 Immunological Diseases Autoimmune or Hyperimmune responses to either known or unknown stimuli Aphthous Ulcer (Canker Sore) 99% affects non-keratinized tissues Herpes ulcers (recurrent) happens only on keratinized Minor -> Heals without scarring Major (AKA Suttons Disease)-> Heals w/ scarring Associated Syndromes: Behcet’s Syndrome = Multisystem vasculitis causing aphthous ulcers of oral and genital regions and inflammation of eye Erythema Multiforme Tx: Corticosteroids for Behcets, or Salt rinse for minor Often on lips (but can really happen anywhere on the skin or mucosa) Minor -> Herpes simplex hypersensitivity Major (Steven-Johnson Syndrome) -> drug sensitivity Angioedema = Allergic reaction to drug or food contact Characteristic diffuse swelling of the lips (and/or neck and face) Mediated by mast cell release of IgE and Histamines Wegener’s Granulomatosis Tx: Antihistamines = Allergic reaction to inhaled antigen Characteristic sign = Strawberry gingivitis Tx: Corticosteroids (prednisone) and syclophosphamide Lichen Planus T-lymphocytes target and destroy basal keratinocytes Basal zone vacuolization + Sawtooth rete pegs occur secondary to the T-cell mediated destructions Reticular (more common) -> Wickham striae, white and lacy Erosive -> Wickham striae w/ red ulceration Lupus Erythematosus Tx: Corticosteroids Discoid Chronic Type Disc-like lesions on facial skin Oral lesions mimic erosive lichen planus Systemic Acute Type: Multiple organ involvement Characteristic butterfly rash over bridge of nose Because it’s systemic, it involves autoantibodies (can do an ANA test to Dx) Tx: Corticosteroids Scleroderma Pemphigus Vulgaris = Hardening of the skin and connective tissue Restricted opening and uniform widening of the PDL Space = Suprabasilar clefting Autoantibodies against desmisomes Multiple painful ulcers preceded by bullae Positive Nikolsky’s sign -> sloughing of the outer skin layer Tx: Corticosteroids 7 Pemphigoid “O, Old, Ophthamologist” Subbasilar Autoantibodies against Basement membrane Pemphigus = U-bove Pemphigoid = beloiw Pemphigus Pemphigoid Premalignant Lesions - Risk for developing Squamous Cell Carcinoma Leukoplakia *This is a clinical description! NOT a Dx* - White Patch that doesn’t rub off and doesn’t have an obvious clinical Dx Tx: Biopsy mandatory Proliferative Verrucous Leukoplakia Erythroplakia *Also a clinical description* Recurrent and warty May be associated w/ HPV 16 and 18 (highest risk strains for developing cervical cancer) High risk of malignant transformation to SCC or Verrucous Carcinoma *Clinical Description, not a Dx* - Red patch - Higher risk than leukoplakia for becoming malignant (Erythroleukoplakia is the highest risk) Tx: Biopsy mandatory Erythroleukoplakia Actinic Cheilitis Smokeless TobaccoAssociated Lesion *Clinical Description, not a Dx* - Red and white patch - Highest risk for transforming into malignancy Tx: Biopsy mandatory Actinic = Solar ; Cheilitis = Lip inflammation Due to solar damage (UV-B especially) -> UV-Bad White mucosal change in vestibule b/c direct effects of smokeless tobacco and its additives Malignant Lesions - Most cancers = Non-painful, non-healing, indurated ulcers FOM and posterior lateral tongue = #1 and #2 highest risk sites - Cancer Types Carcinoma -> Epithelial origin Sarcoma -> Mesenchymal (CT) origin Leukemia -> Blood Lymphoma -> Lymphatic tissue Cancer Stages Dysplasia = Pre-cancer Carcinoma in situ = All of the epithelial layers are affected Malignant Neoplasm = Cancer (invades past the basement membrane Local invasion -> Connective Tissue Metastasis -> Access to blood or lymph to travel around the body 8 Verrucous Carcinoma (AKA Snuff dippers carcinoma) = Tobacco and HPV 16 and 18 are the causes Slow growing malignancy Tx: Excision Squamous Cell Carcinoma = Caused by oncogene activation or inactivation of tumor suppressor genes ↑ incidence of oropharyngeal SCC associated w/ HPV 16 and 18 5-year survival = 50% Tx: Excision or radiation Basal Cell Carcinoma Oral Melanoma Associated Syndrome: Plummer-Vinson Syndrome: mucosal atrophy + Dysphagia + Iron deficiency anemia + ↑ risk of oral cancer = Caused by sun damage Very rarely metastasizes The least dangerous cancer Tx: Surgery = Malignancy of melanocytes Purplish/blackish lesions High risk sites: Palate and gingiva 5 year survival for skin lesions is > 65%, but <20% for oral lesions ☹ Connective Tissue Benign Tumors (Reactive) = Lumps or bumps Fibroma (Traumatic fibroma, irritation fibroma, hyperplasic scar) Gingival Hyperplasia (VERY commonly tested) = Fibrous hyperplasia of oral mucosa Caused by chronic trauma or irritation Caused by: Calcium Channel Blockers (Nifedipine) Anti-convulsant/epileptic (Dilantin/Phenytoin) Immunosuppressant (Cyclosporin) Tx: Gingivectomy and discontinue drug if possible Denture-induced Fibrous Hyperplasia Traumatic Neuroma Epilus Fissuratum = @ base of vestibule Over-extended flange of the denture causes this Papillary hyperplasia = @ hard palate Caused by poor denture hygiene = Entangled submucosal mass of neural tissue with scar formation Caused by nerve injury Most common at mental foramen Associated Syndrome: Multiple Endocrine Neoplasia (MEN 2B) = Multiple neuromas (NOT Traumatic) + Medullary thyroid cancer + Pheochromocytoma of the adrenal gland “MEN is short for Mental foramen, which is most commonly associated with this lesion” 9 Pyogenic granuloma Nodular Fasciitis Fibromatosis Granular Cell Tumor Schwannoma (Neurilemmoma) Neurofibroma Leiomyoma Rhabdomyoma Lipoma = Hyperplasia of capillaries (causes red colour) Caused by chronic trauma or irritation Very common on the gingiva = Neoplasm of fibroblasts Easy to eradicate and rarely recurs Tx: Surgical Excision = Neoplasm of fibroblasts (again) Difficult to eradicate and often recurs (Opposite of nodular fasciitis) = Neoplasm of Schwann Cells Named because they have granular cytoplasm (histologically) Most common on dorsal tongue Variant found on the gingiva = Congenital Epulis of newborn Pseudoepitheliomatous Hypoplasia (PEH) within this tumor mimics SCC histologically = Neoplasm of Schwann cells Acellular Verocay bodies in Antoni A Tissue, forms a line of scrimmage = Neoplasm of Schwann cells + Fibroblasts Associated Syndrome: Neurofibromatosis Type I (Von Recklinghausen’s disease) = Multiple neurofibromas + multiple skin freckles (Café au lait spots) + Axillary freckles (Crowe’s sign) + Iris freckles (Lisch spots) “Von Frecklinghausen” disease Neurofibromas can transform to neurofibrosarcoma with this disease = Neoplasm of smooth muscle cells = Neoplasm of skeletal muscle cells = Neoplasm of fat cells Most common on buccal mucosa Malignant Tumors - Most are malignant conversion of the benign tumors Look very similar to the benign ones Fibrosarcoma Neurofibrosarcoma (Malignant peripheral nerve sheath tumor) Kaposi’s Sarcoma Leiomyosarcoma Rhabdomyosarcoma Liposarcoma = Malignant proliferation of fibroblasts = Malignant proliferation of Schwann Cells = Malignant proliferation of endothelial cells Caused by HHV8 and most commonly seen as a complication of AIDS Purple lesion = Malignant proliferation of smooth muscles cells = Malignant proliferation of Skeletal muscle cells = Malignant proliferation of fat cells 10 Salivary Gland Diseases Reactive Lesions Mucous Extravasation Phenomenon *Caused by trauma to salivary duct* - NOT necessarily surrounded by epithelium - Mucocele: Common in lower lip. Blockage of duct, typically from trauma - Ranula: when found on FOM Mucous Retention Cyst Necrotizing Sialiometaplasia Tx: Complete excision of the minor gland (and its surrounding glands) = Same as above histologically, however it is a true cyst lined by epithelium Caused by blockage of salivary duct by a sialolith = Rapidly expanding ulcerative lesion Due to ischemic necrosis of minor salivary glands (response to trauma or LA) Tx: Heals on its own in 6-10 weeks. Treat palliatively Sinus Retention Cyst (Antral Pseudocyst) Sarcoidosis = Blockage of glands in the sinus mucosa Tx: None Hyperimmune -> so there are granulomas involved May be triggered by Mycobacteria (same at TB) Primarily a pulmonary disease, but also affects salivary glands and mucosa Causes Xerostomia Associated Syndromes: - Lofgren’s Syndrome = Erythema nodosum + Bilateral hilar lymphadenopathy + arthritis - Heerfordt Syndrome (AKA Uveoparotid Fever) = Anterior uveitis + parotid gland enlargement + Facial nerve Palsy + Fever Sjogren’s Syndrome Tx: Corticosteroids Autoimmune and lymphocyte mediated Affects salivary and tear glands Primary = Keratoconjunctivitis sicca (Dry eyes) + Xerostomia (Dry mouth) Secondary = Primary + another autoimmune disease (usually rheumatoid arthritis) Tx: Symptomatic Benign Lesions Pleomorphic Adenoma Monomorphic Adenoma Warthin’s Tumor **Most common benign salivary gland tumor** Composed of a mixture of cell types (Epithelial and CT) -> hence why it is AKA “Mixed Tumor” Firm rubbery swelling (from small to large) Location: Palate (if minor salivary gland) Ear (if parotid gland) Composed of single cell type Includes: Basal cell adenoma, Canalicular adenoma, myoepithelioma, oncocytic tumor Tx: Surgical Excision Composed of oncocytes + lymphoid cells Oncocyte = epithelial cells w/ excessive mitochondria Location: Parotid of older men 11 Malignant Lesions - All of these are most common on the palate Mucoepidermoid Carcinoma Polymorphous LowGrade Adenocarcinoma (PLGA) Adenoid Cystic Carcinoma **Most common salivary gland malignancy** Composed of mucous and epithelial cells = 2nd most common salivary gland malignancy for minor glands Adeno = gland **Cribiform/Swiss cheese microscopic pattern** 5-year survival is 70%; 15 survival is 10% -> Very lethal Lymphoid Neoplasms - All lymphoid neoplasms are malignant in nature -> Because at this point they have already broken through the basement membrane etc Hodgkin’s Lymphoma **Rare in the oral cavity** Involves Reed-Sternberg cells = Malignant B cells Tx: Chemo +/- Radiation Non-Hodgkin’s Lymphoma (NHL) = Neoplasm of either B or T cells Burkitt’s Lymphoma = Type of B cell NHL w/ bone marrow involvement, swelling, pain, tooth mobility, lip paresthesia, and halted toot development Multiple Myeloma (Plasma Cell myeloma) Tx: Chemo +/- Radiation = Neoplasm of antibody-secreting B cells (plasma cells) - Multiple punched out radiolucencies (usually in the skull) Amyloidosis due to accumulation of complex amyloid proteins that come from antibody light chains Tx: Chemotherapy, poor prognosis though Leukemia = Neoplasm of bone marrow cells (Lymphocytes, NK cells, Granulocytes and megakaryocytes) Classification based on cell lineage (myeloid or lymphoid) and acute vs chronic: ALL -> CML -> AML -> CLL ^In order of age prevalence from young to old “ALL Children Are ChiLL” ALL: Acute Lymphocytic Leukemia CML: Chronic Myelogenous Leukemia AML: Acute Myelogenous Leukemia CLL: Chronic Lymphocytic Leukemia Clinic Signs: Bleeding (Platelets) Fatigue (RBC) Infection (WBC) *Even though we are seeing ↑ production of the bone marrow cells, they are immature and have less function* 12 Odontogenic Cysts Radicular Cyst (Periapical Cyst) **Most common odontogenic Cyst** Epithelial Rests of Malassez (ERM) from the Hertwig’s epithelial Root Sheath (HERS) within pocket of inflammation encapsulate the lesion -> forms cyst Radiographically: RL around the apex of the root of a non-vital tooth Necrotic pulp causes periapical inflammation Acute -> Abscess Chronic -> Granuloma Dentigerous Cyst (Eruption Cyst) Tx: RCT, Apicoectomy or Exo + curettage *Accumulation of fluid between crown and Reduced Enamel Epithelium* Radiographically: RL attached to CEJ of impacted tooth Most common w/ Canines and 3rd molars Lateral Periodontal Cyst Tx: Excision -> but may the source of future odontogenic tumors *Most common in mandibular premolar area* - Always associated with vital tooth - Not centered around the apex Gingival Cyst of the Adult **Soft tissue counterpart of the Lateral Periodontal Cyst** No RL in x-ray because not in the bone Gingival Cyst of the Newborn *Rests of Dental Lamina epithelialize the small lesions* - Bohn’s Nodules = Lateral Palate - Epstein’s Pearls = Midline palate Tx: No tx, will involute as the children age Primordial Cyst *Develops where a tooth would have formed but didnt* - Most common at mandibular 3rd molar area Tx: Complete Removal Keratocystic Odontogenic Tumor (KCOT) **Aggressive and recurrent** Thin corrugated parakeratinized epithelium histologically Fusiform, M-D expansion (not B-L), minimal displacement of teeth or resorption Location: Commonly in Posterior ascending ramus of mand. Associated Syndrome: Gorlin Syndrome (Nevoid Basal Cell Carcinoma, NBCC) = Multiple KCOT, Multiple BCC’s, Calcified Falx Cerebri, Fatal disease Calcifying Odontogenic Cyst (Gorlin Cyst) Tx: Aggressive enucleation *Rare and unpredictable* Involves Ghost Cells: Empty spaces where nucleus was and is filled with keratin. Can undergo calcification w/ little radiodensities present in X-Ray 13 Tumors Ameloblastoma Calcifying Epithelial Odontogenic Tumor (CEOT) (Pindborg Tumor) Adenomatoid Odontogenic Tumor (AOT) Odontogenic Myxoma (Myxofibroma) **Benign, but very aggressive** Location: Posterior mandible Radiographically: Multilocular expansive lesion (Beach ball B-L expansion) with erosion and displacement of roots and cortical bone Tx: Wide excision or resection, high recurrence if you are too conservative Ddx: Ameloblastoma, KCOT, CGCG, COF Radiographically: RL w/ driven snow calcifications (White flecks) Histologically: Amorphous pink amyloid w/ concentric calcifications AKA Liesegang Rings Tx: Surgical excision w/ good prognosis Contains epithelial duct-like spaces + enameloid material Location: Mostly Anterior maxilla over impacted canines Tx: Surgical excision w/ good prognosis Myxomatous CT (pulp-like material w/ minimal collagen) -> Slimy Stroma Radiographically: Messy RL w/ unclear borders and honeycomb/tennis racket pattern Tx: Surgical Excision w/ moderate recurrence Central Odontogenic Fibroma (COF) = Dense collagen w/ strands of epithelial woven within it 2 forms: Central = Occurs within bone, well defined multilocular RL Peripheral = occurs in the gingiva (will not see in radiograph) Cementoblastoma Ameloblastic Fibroma Odontoma = Well circumscribed RO mass Ball of cementum + Cementoblasts that replace the tooth root Connected to the root (surrounded by a PDL space) Tx: Surgical excision and Exo **Occurs mostly in children and teens* Location: Posterior Mandible Contents: Myxomatous CT Tx: Surgical Excision = Opaque lesion composed of dental hard tissues Can block eruption of teeth Compound = Mostly anterior, “Bag of teeth” Complex = Mostly Posterior, conglomerate mass of dental tissue Associated Syndromes: Gardner Syndrome = Multiple odontomas + Intestinal Polyps 14 Bone Lesions Fibro-Osseous Lesions - Typically, more radiopaque, as these lesions are osseous Central Ossifying Fibroma = Fibroblastic stroma in which foci of mineralized products are formed Similar in appearance and behaviour to cementifying fibroma (odontogenic tumor) 3 Types: Central = in bone. Well circumscribed radiolucency with ossification product in the center Peripheral = in soft tissue, so you don’t see the iconic radiographic appearance Juvenile = Aggressive variant, rapid growth, younger patients Fibrous Dysplasia Tx: Surgical Excision **Ground Glass Appearance** “Fiberglass -> “Fibrous + Glass” (memory trick) Usually stops growing after puberty -> but until then it can grow lots and cause major issues Associated Syndrome: McCune-Albright Syndrome = Polyostotic (more than 1 bone) fibrous dysplasia + Cutaneous café au lait spots + endocrine abnormalities Periapical CementoOsseous Dysplasia (PCOD) Tx: Surgical recontouring for cosmetics (typically after puberty) = Reactive process of unknown origin Most common at apices of mandibular anteriors Most common in middle-aged black females Teeth are vital Starts RL -> Progresses to RO (with RL halo) as the lesion matures Tx: None Osteoblastoma Circumscribed Opaque mass of bone and osteoblasts Tx: Surgical Excision Giant Cell Lesions Central Giant Cell Granuloma (CGCG) Aneurysmal Bone Cyst Composition: Fibroblasts and multinucleated giant cells Location: Anterior mandible mostly Types: Central (CGCG): in Bone, RL lesion with thin wispy septations Peripheral: In Soft tissue, Red-purple gingival mass Tx: Excision *Pseudocyst composed of blood-filled spaces* -Fine needle Aspirational Biopsy is what you need to do to determine the Dx Radiographic: Multilocular RL Expansile Location: Posterior mandible favored Tx: Excision 15 Hyperparathyroidism Causes multiple bone lesions that mask as CGCG’s as a result of ↑ ↑ parathyroid hormone Brown Tumor -> Forms due to excess osteoclast activity This ↑ OC activity ↑ the amount of alkaline phosphatase Cherubism Associated Syndrome: Von Recklinghausen’s disease of bone = result of this condition (this is different from von Recklinghausen’s disease/neurofibromatosis) Autosomal Dominant inheritance pattern Characteristic: Symmetrical bilateral swelling from expansile bilateral multilocular radiolucencies (fibrous dysplasia in contrast is asymmetric and unilateral) Stops growing after puberty Langerhans Cell Disease (Idiopathic Histiocytosis) Rare type of cancer Langerhans cells (Histiocytes) normally found in skin as an antigen presenting cells -> can cause damage if they build up in the body Radiographic: Punched out “ice cream scoop” radiolucencies that lead to floating teeth Tx: Excision, radiation and chemo Paget’s Disease = Progressive metabolic disturbance of many bones (spine, femur, skull, jaws) -> causes symmetrical enlargement Usually in adults > 50 years Elevated alkaline phosphatase is found b/c of ↑ bone breakdown As bone expands, dentures and hats become too tight Associated with Hypercementosis Characteristic: Cotton wool appearance Tx: Bisphosphonates and Calcitonin Inflammatory - Most lesions are an extension of either periodontal or periapical inflammation, or trauma Acute Osteomyelitis Causes: Odontogenic infection Trauma Infection/inflammation usually begins the medullary space involving the cancellous bone AND spreads to the cortical bone, periosteum, and soft tissues Symptoms: Deep and intense pain High or intermittent fever Paresthesia or anesthesia of the IAN Tooth is NOT loose (this is caused periodontitis) Yes…this is osteomyelitis in a dog, but it’s good picture of it Tx: Antibiotics 16 Chronic Osteomyelitis *Diffuse mottled radiolucency* Garre’s Osteomyelitis = Chronic osteomyelitis w/ proliferative periosteitis (onion skin) Tx: Antibiotics + debridement of infected area Focal Sclerosing Osteomyelitis (Condensing Osteitis) = Bone sclerosis resulting from low-grade inflammation (like chronic pulpitis) Tx: None, address the cause of inflammation Diffuse Sclerosing Osteomyelitis: Same as focal, but wider scale that may lead to jaw fracture **IV bisphosphonates ↑ risk vs oral** Jaw Pain Exposed necrotic bone BisphosphonateRelated Osteonecrosis of the Jaws (BRONJ) Tx: CHX rinse, antibiotics, conservative surgery Malignant Lesions - Numb lip/paresthesia is the most common symptom associated with malignancy Osteosarcoma = Sarcoma of the jaw where new bone is produced by tumor cells 5-year survival is 25-40% (Pretty deadly) Radiographic: Sunburst pattern of radiopacity Tx: Resection and chemotherapy Chondrosarcoma = Sarcoma of the jaws where new cartilage is produced by tumor cells Same presentation and Tx as the Osteosarcoma Location: More common involving the condyle b/c of its separate cartilaginous origin vs the rest of the jaw Ewing’s Sarcoma = Sarcoma of the long bones involving “round cells” Seldom affects the jaws (because long bones) Affects children mostly Involves swelling Metastatic Carcinoma - Pain, swelling and especially paresthesia Posterior Mandible Ill defined changes are noted Originated somewhere else and metastasized to the jaw: Breast > Lung > Kidney > Colon > Prostate 17 Hereditary Conditions White Sponge Nevus Asymptomatic spongy white lesion on the buccal mucosa -> DOESN’T wipe off Autosomal dominant in heritance Epidermolysis Bullosa Skin and mucosa is fragile and blisters easily Widespread blistering Hereditary Hemorrhagic Telangiectasia (HHT) AKA Olser-Weber-Rendu Syndrome Abnormal capillary formation on skin, mucosa, and viscera Associated w/ iron-deficiency anemia Epistaxis (nose bleeds) is a frequent presenting sign Telangiectasia = red macule or papule from dilated or broken capillaries Cleidocranial Dysplasia (always on NDBE) Ectodermal Dysplasia (Also always tested) Autosomal Dominant Common sign: Missing/poorly developed clavicles -> Shoulders appear hunched in towards the midline Supernumerary teeth Tx: Typically lots of exo’s and the dentures X-linked recessive Common Signs: Missing teeth Hypoplastic hair or nails Osteopetrosis AKA Albergs-Schonberg disease or Marble bone disease Stone Bone -> lack of remodelling and resorption Amelogenesis Imperfecta = Intrinsic alteration of the ENAMEL (dentin and pulp are normal) in both the primary and permanent teeth Autosomal dominant, recessive or x-linked inheritance Tx: Full-coverage crowns for cosmetics Dentinogenesis Imperfecta = intrinsic alteration of DENTIN affecting both primary and permanent teeth Autosomal dominant inheritance Characteristics: Short roots, bell-shaped crowns and obliterated pulps Bulbous crowns in radiographs (b/c constricted DEJ) Blue sclera Tx: Full coverage crowns 18 Dentin Dysplasia = Intrinsic alteration of dentin affecting primary and permanent teeth Autosomal dominants Two Types (Type 1 and Type 2) Characteristics: Chevron pulps and short roots Regional Odontodysplasia **Not good candidates for restoration (short root = poor C;R ratio; Chevron pulps ↑ risk of pulp exposure) = Quadrant of teeth exhibit short roots, open apices, and enlarged pulp chambers Radiographic: Ghost teeth -> Pulps are so huge they make the teeth look almost completed RL (common NDBE term) Tx: Fusion and Gemination Extract affected teeth Fusion 2 Tooth buds merging into 1 tooth Tooth count is 1 less than the normal Gemination 1 root buds into 2 crowns Tooth count is normal 19