Systemic Lupus Erythematosus

Oral and Maxillofacial Pathology

Review for NBDE Part 2
! Clinical
2010
– Autoimmune
– Young adult females
– Butterfly rash of face
Michael A. Kahn, DDS ! Sun exposure worsens it
Professor and Chairman
Department of Oral and Maxillofacial Pathology
– Systemic involvement complications
Tufts University School of Dental Medicine ! Heart – endocarditis
1
! Kidney – renal glomeruli (glomerulonephritis) 2

limit sun exposure

***psoriosis is better with sun exposure***

Cavernous sinus thrombosis Ludwig’s angina

! Can arise from an infection - - a ! Submandibular space infection

subcutaneous abscess of the upper lip or a
! Most serious complication is edema of
intrabony abscess of an anterior maxillary
tooth
t th the glottis
– Valveless facial
veins

3 4

Treacher Collins Syndrome Scarlet fever

! White coating of the tongue that sloughs off

! Has external ear changes
leaving a deep red surface with swollen
hyperplastic fungiform papillae (“strawberry
tongue”))
tongue

5 6

1
 Fordyce granules Turner tooth

! Ectopic sebaceous glands – yellow ! Due to local trauma or infection associated

papules/plaques with the developing tooth bud

7 8

Recurrent Aphthous Stomatitis

Intrinsic tooth stain

! Tetracycline – deposition within the dentin

! Clinical
– Moveable mucosa
! Ex. Uvula, labial mucosa
– Recurrent – NOT PRECEDED BY VESICLE
– Associated with certain HLA types
! NOT caused by a virus, bacteria, fungus
– Treatment
! Corticosteroids are often prescribed
– Herpetiform type
! Many small
– Minor and major types
! Very painful
! Size, depth, time to heal (minor 5-
5-10 days)
! Minor – small, shallow ulcer with red halo
9 10

Benign Mucous Membrane Pemphigoid

(cicatricial)
Condyloma Acuminatum
! Clinical
– Autoimmune
! Antibody reaction at the ! Clinical
epithelial--connective tissue
epithelial
interface (BMZ)
– Venereal wart
! Subepithelial split – Extensive
– Vesiculoerosive,
l ulcers
l
– > women - middle aged
– Skin and eye – Etiology
– Oral ! Human papilloma virus (HPV)
! Any site: gingiva, soft palate, etc.
! Ulcers, erosions following vesicles, bulla
! Histology
– Subepithelial separation at basement membrane zone
11 12

2
 Candidiasis – Candidiasis – Chronic
pseudomembranous ! Median rhomboid glossitis
– Clinical
! Clinical ! Red – atrophy of filiform papillae
– Opportunistic infection (“yeast”) ! Midline tongue, junction of anterior
! Immature or deficient immune 2/3 and posterior 1/3 at tuberculum
system impar
! Antibiotics usage ! Not a developmental disorder as
! C ti t id usage
Corticosteroids once thought
– Hyphae and spores ! Treatment
! May be diagnosed by cytology – Antifungal agents are sometimes effective, such as nystatin
or clotrimazole
smear
– White, wipeable “patch” with red, ! Denture sore mouth
underling base; palate and buccal – Clinical
Red
mucosa are often involved !
! Patient does not remove
– “Thrush” or clean denture – NOT acrylic allergy
13 14
! Newborns and infants ! Tx – rinse mouth and soak denture with antifungal

Recurrent (Secondary) Herpes Recurrent (Secondary) Herpes

Simplex Simplex
! Clinical
– U.S. incidence estimate of herpes infection is 80-
80-
85%
! Most
M t cases are subclinical
b li i l
! Reactivation from nerve cells of trigeminal ganglion
– Lip
! Skin or vermilion
! Vesicle ruptures - - -> ulcer that heals in 7-
7-10 days
(not present for weeks or months if immunocompetent
person)

15 16

Recurrent Herpes Simplex Infection Traumatic Neuroma

! Clinical
– HSV Type 1 in humans, most often ! Clinical
– Intraoral – Wandering transected nerve with scar tissue
! Hard palate and gingiva = nonmoveable, overlying bone
! Small coalescing shallow ulcers preceded by small vesicles
– Painful or tender, firm “lump” or nodule
! Can be subclinical even though person has primary infection – Oral site
! U
Usually
ll history
hi t off trauma,
t stress,
t UV exposure, as triggering
ti i ! O
Occurs att sites
it off chronic
h i trauma
t
event several days earlier (ex. restorative procedure) ! Ex. mandibular alveolar ridge in denture wearer,
! No history of allergy or chemical burn especially near mental nerve, denture flange
trauma
! Ex. tongue

17 18

3
 Pyogenic Granuloma Peripheral Giant Cell
Granuloma
! Clinical ! Clinical
– Occur at any age
– Somewhat similar in appearance to pyogenic
– Any location but usually on granuloma
gingiva
! Most common is interdental
– Moderate soft mass
papilla – Often “liver
“liver--colored” [brownish purple]
– Local reactive growth – Distinctive histology
! Irritation ! Multinucleated giant cells
– Bleeds readily – Limited to alveolar ridge/
– Exophytic
gingiva
– Not painful
! Usually anterior to first molar
– Grows very fast – like
region
malignancies
– Proliferative 19 20

Squamous Papilloma (Papilloma)

Central Giant Cell Granuloma
! Clinical
– Etiology - epithelium
! Clinical – White to white-
white-pink usually but can be reddened
– Rough surface (cauliflower)
– Intrabony
– Elevated lesion (papule, nodule)
– Same histology as: – Common sites
! Peripheral giant cell ! Facial or lingual gingiva
granuloma ! Soft or hard palate
! Brown tumor of hyperpara
hyperpara-- ! Tongue
thyroidism – More frequent than some
– No effect on saliva production other “omas”
– Bone destruction secondary to chronic renal ! Rhabdomyoma
disease ! Leiomyoma
! Lymphangioma
21
! Neurofibroma 22

Fibroma Granular Cell Tumor

(fibrous nodule, focal fibrous hyperplasia,
traumatic fibroma, irritation fibroma)

! Clinical
– Most common connective tissue tumor ! Clinical
– Reactive,
Reactive not true tumor – Dorsum of tongue #1 site
– Hyperplasia; NOT neoplasia, – Nodule with smooth or papillated surface
anaplasia, dysplasia, etc. – Histology distinct
– Firm, smooth, pink, ! Granular cells - cytoplasm
! 50% of time exhibit
elevated papule/nodule pseudoepitheliomatous
– Common site is tongue (due to trauma) hyperplasia
– Resembles squamous cell carcinoma histologically
23 24

4
Leukoplakia Erythroplakia and
Erythroleukoplakia (speckled)
! Clinical
– Red plaque that does not wipe off
– Studies show that it is likely to have severe
! Clinical dysplasia or worse and undergo malignant
– White patch that does not wipe off transformation to carcinoma
– Cytology smear does not help determine specific
diagnosis – Treatment
– Appropriately managed by biopsy ! Initial – incisional biopsy
– Floor of mouth hyperkeratosis most common site to
exhibit dysplasia
– If two separate areas in person’s mouth then both
areas should have incisional biopsy
25 26

Squamous Cell Carcinoma

! Clinical
– Lower lip
! Can be preceded by actinic cheilitis
! Firm, indurated ulcer; painless with v. good prognosis
! Submental node is most common lymph node involved by
metastasis
– Most common oral site
! Mid--lateral border of tongue
Mid
– Least likely oral site
! Hard palate
– Site with greatest likelihood or risk of developing
squamous cell carcinoma
! Floor of mouth – worse prognosis when lung mets (not
size, local spread or anaplastic cells)
– Metastasis 27 28

! Most likely to a lymph node

Squamous Cell Carcinoma

Metastatic Disease to the Jaws
! Staging vs. Grading
– Stage III has a worse prognosis than I or II ! Clinical and Radiographic
! Radiographic – Most common site is posterior mandible
– When invasive into the alveolar ridge it will – Does not cause a shift of patient’s occlusion
appear poorly defined lucencies without a – Usually a poorly defined lucency without
sclerotic border
reactive sclerotic border

29 30

5
 Monomorphic Adenoma
(Canalicular Adenoma) Leukoedema
! Clinical ! Clinical
– Most common site
– Intracellular edema of cells
! Upper lip
! > Women
W – More often seen in African-
African-Americans
! May be – Common, bilateral on buccal mucosa
multinodular – Diagnostic test chairside
! Asymptomatic
! Pull on buccal mucosa - - - -> disappears or
Do not confuse
!
dissipates
with mucocele
of the lower lip
– Normal mucosa variation so no treatment
required
31 32

Leukemia Verrucous Carcinoma

! Clinical/Lab
– Red, swollen (hyperplastic),
boggy, bleeding gingiva ! Clinical
(interdental papilla) with ulcers
– Very well differentiated
– Lab tests ordered
! Complete blood count
form of squamous cell
! White blood count differential carcinoma
! Decreased neutrophils – Large, elevated, papillary often
! Leukemic infiltrate leaves blood associated with smokeless tobacco
and into soft tissue (esp. acute
habit
monocytic type)
– Red macules on skin (purpura
(purpura = – Most common site is buccal
extravasated blood) & skin infections vestibule
– Decreased platelets – No tendency to metastasize
– Tired feeling (malaise) ! Chief difference from
33 34
– Anemia (decreased RBCs)RBCs) typical squamous cell carcinoma

Field Cancerization –
Squamous Cell Carcinoma Salivary Gland Tumors
! Most common tumor of salivary gland origin
! Patient diagnosed and treated for squamous is the pleomorphic adenoma
cell carcinoma of the tongue – Benign
! Much more likelyy to have future premalignant
p g – Most common intraoral site is p
palate
or malignant lesions anywhere in the oral ! Major and minor salivary glands potential
cavity sites
– Ex. – speckled leukoplakia of the floor of mouth – Neoplasm most likely to arise in the parotid
likely to be a second primary lesion – Neoplasm most likely to arise in the palate
! p53 tumor suppressor gene is most common ! Adenoid cystic carcinoma
associated – Characteristic perineural invasion – most likely
! Parotid – facial nerve involvement but no upper lip
35
paresthesia 36

6
 Physiologic Pigmentation (Racial
Pigmentation) Lateral Periodontal Cyst

! Clinical ! Clinical
– Darkens with time; present – True cyst (epithelial lining),
most of a person
person’ss lifetime not p
pseudocyst
y
– African
African--American patients ! Radiographic appearance
! Upper or lower lip vermilion, attached gingiva, – Well circumscribed radioluceny between the
tongue, buccal mucosa roots of adjacent, erupted, vital teeth (most
! Series of splotchy brown macules
commonly seen at mandibular premolars)
– Radiographic differential diagnosis does NOT
include dentigerous cyst (impacted tooth)
37 38

Ameloblastic Fibroma
Ameloblastoma
! Clinical
– Average age is 34 ! Clinical
– Most common in posterior – Young person
mandible but anterior mandible – More often in posterior jaws, esp. mandible
also
a so (can
(ca cross
c oss midline)
d e) – Slight
g p pain,, swelling;
g; not aggressive
gg
! Radiographic – Ameloblastic fibro-
fibro-odontoma
is similar except for odontoma
– Most common true odontogenic tumor
component
– Multilocular radiolucency
! Radiographic
– Superimposed over posterior teeth (> mand.)
– Pure lucency; no
– Often associated with impacted tooth
radiopaque component
! Histology – AFO – also has radiopaque component (i.e., the
– Reverse polarization of the nuclei of the tall, 39
odontoma) 40

columnar cells of the periphery

Odontoma
Adenomatoid Odontogenic
Clinical – primarily first two decades of life (young
!
persons) Tumor (AOT)
Radiographic
!
! Clinical
– Radiopacity with radiolucent rim (= follicle) – Young person (child or teenager)
! Compound vs. Complex types ! Unerupted tooth of the anterior maxilla (#6,
– Compound - identifiable toothlets #11)
! > Anterior maxilla ! Radiographic
– Complex – unidentifiable mass – Snow flake calcifications in the radiolucency
surrounding the crown and a portion of the
! > Posterior of jaws impacted tooth’s root
Treatment – simple
enucleation

41 42

7
 Dentinogenesis Imperfecta
Amelogenesis Imperfecta

! Clinical ! Clinical
– Teeth lack enamel; – Opalescent dentin – blue/gray
– Dentin and cementum – Often associated with osteogenesis
unaffected imperfecta
– Shapes of root and ! Blue sclera
crown are normal ! Multiple bone fractures

! Radiographic ! Radiographic
– Enamel is missing – BWXs and PAs demonstrate classic
– Pulp chambers and lack of pulp chambers and root canals
root canals normal – Bell
Bell--shaped crown with constricted
43
cervical region 44

Cherubism
! Radiographic Fibrous Dysplasia
– Multilocular, bilateral ! Clinical
lucencies – Unilateral mandibular or maxillary expansion; onset
before puberty; C.C. of “teeth do not fit”
! Clinical
– Painless swelling, usually ceases at age 20
– Bilateral jaws
– Root canal therapy will not help since non-
non-infectious
– Young persons process (i.e., fibro-
fibro-osseous lesion)
– Jaw expansion - - ceases after childhood – Café au lait pigmentation
! Polyostotic form – McCune Albright syndrome
! Radiographic
– Ground glass appearance
! Treatment
– After age 20 when stabilized
45 46
– Cosmetic bone shaving

Condensing Osteitis
(Sclerosing Osteitis)
Idiopathic Osteosclerosis
! Clinical
– Associated with pulpitis (ex. very carious posterior
mandibular tooth); nonvital tooth ! Clinical
– Associated tooth will test nonvital or signs and – No apparent reason including no pulpitis in adjacent
symptoms or tooth destruction will support nonvital tooth
status – No expansion,
p , pain
p
! Radiographic ! Radiographic
– Periapical opacity so does – Radiopacity without
NOT mimic a periapical peripheral lucent rim
granuloma radiographically – Not connected to tooth’s
– Does not connect with root root
! Treatment
47 – None 48

8
 Traumatic Bone Cyst Paget’s Disease of Bone
(Simple Bone Cyst; Idiopathic Bone Cavity;
Unicameral Cyst; Hemorrhagic Cyst)
! Clinical
! Clinical – Older age group
– Undergoes spontaneous healing without – Bilateral maxilla affected
treatment following exploratory surgery – Involved bone can undergo malignant
(sarcomatous) transformation (i.e., osteosarcoma)
– Pseudocyst
– Cranial nerve deficits as foramen compressed,
! Radiographic narrowed d
– Radiolucent with scalloped margins – Does NOT have hyperglobulinemia or premature
exfoliation of primary teeth
! Radiographic
– Cotton wool appearance
– 50% - hypercementosis
! Histology
49
– Reversal lines with a mosaic pattern 50

Langerhans Cell Disease Benign vs. Malignant Bone

(Histiocytosis X) Involvement

! Clinical
– Composed of Langerhans cells, ! Clinical
not histiocytes
– Ominous malignant sign
– Etiology is still unknown
! Spontaneous paresthesia of the lower lip
– Eosinophilic granuloma
! Solitary lesion, young adults ! Radiographic - Benign
– Hand
Hand--Schuller
Schuller--Christian triad
! Diabetes insipidus
– Cortex remains intact – thinned or
! Exophthalmos expanded
! Bone lesions
! Radiographic
– Tooth “floating in air or space” 51 52

Central Neural Lesions Nasolabial Cyst

! Neurofibroma and Schwannoma ! Clinical

! Radiographic – Mucolabial
Mucolabial,, smooth swelling adjacent to a
maxillary lateral incisor
– Enlargement of canals and foramina – Soft tissue involvement; not bone
! Histology
– Pseudostratified
squamous epithelium
cystic lining

53 54

9
 Odontogenic Keratocyst
Lymphoepithelial Cyst ! Clinical
– High recurrence!
– Intrabony, posterior mandible
! Clinical but anywhere; BCNS association
– Commonly on ventral tongue/floor of mouth ! Radiographic
– Well circumscribed swelling
g – Radiolucent, usually multilocular
– May
M mimici i many other
h
– Pale, yellowish at times types of lucent cysts and
odontogenic tumors including
ameloblastoma

parakeratin
55 56
surface

Nevoid Basal Cell Carcinoma Syndrome

(Gorlin syndrome; basal cell nevus syndrome)

! Clinical
– Onset is childhood
– Cysts of the jaws =
odontogenic keratocysts
! Hi h recurrence rate
High t
– Basal cell carcinomas
! Face especially
– Bifid rib
! Radiographic
– Keratocysts - unilocular or
multilocular lucencies
– Calcification of the falx cerebri 57 58

Gardner Syndrome
Cheek Nibbling
(Morsicatio Buccarum) ! Clinical
– Multiple facial osteomas &
! Clinical skin nodules
– Buccal mucosa site – Hyperdontia; unerupted teeth
– White, rough, tissue tags – Multiple GI (colon) polyps [familial intestinal
above and below the polyposis] - - - -> colon carcinoma
occlusal plane (line alba)

Other sites – lip and tongue

59 60
Epidermoid cyst
Odontoma

10
 Bell’s Palsy Temporomandibular
! Clinical Dysfunction (TMD)
– 7th nerve paralysis - - - -> unilateral lip ! Clinical
droop at corner, inability to close or wink – Pain and tenderness of palpated TMJ
eyelid – Deviation of jaw toward painful side upon opening
– TMJ disc moves anterior and medially due to contraction of the
– Last usually less than one month lateral pterygoid muscle
– Popping and clicking indicate
internal derangement with
reduction
– Does not cause dizziness
– Reduce opening to ~ 45 mm
– Will get neuritis of VII cranial
nerve

61 62

Erythema Multiforme Stevens--Johnson syndrome

Stevens
(Erythema Multiforme Major)
! Clinical
– Young adult males
– Sudden, explosive onset
– Triggered by drug or viral
infection
– Crusted, bleeding, vesicles,
ulcers of vermilion of lips;
intraoral sites excluding gingiva
– “Target, iris, or bulls
bulls--eye lesions”
of the hands and feet •Eye (conjunctiva), mouth (labial mucosa,
tongue, etc.), genitalia
63 64

Pemphigus Vulgaris Pemphigus Vulgaris

! Clinical/Lab – Vesiculoerosive (oral and skin)
– Demonstrates immunoglobulin fluorescence
intraepithelial ((supraepithelial
supraepithelial)) cementing substance
! Most often immunoglobulin type G ((IgG
IgG))
– Positive Nikolsky sign
– Common sites – lips, palate, gingiva

65 66

11
 Progressive Systemic Sclerosis
(Scleroderma)
! Clinical
– Demonstrates induration
of the soft tissue (mask-
(mask-like) and
generalized widening of the PDL space
– Trismus

67 68

Benign Migratory Glossitis (Geographic

Tongue, Erythema Migrans)
Migrans) Aspirin Burn (Chemical Burn)
! Clinical ! Clinical
– Red and white
! Red = flat, depapillated – White = coagulative necrosis of the surface,
areas of tongue (filiform NOT hyperkeratosis
papillae atrophied)
! White rubs off with difficulty, hyperkeratosis does
! White = keratin, epithelial
not wipe off
cell debris
– Periodically appears
– Can cause soreness or burning
occasionally
– Treatment
! Corticosteroid rinse (dexamethasone
(dexamethasone))
– Moves around from day to day
– Dorsum of tongue most often
! Also lateral, ventral surfaces 69 70

Basal Cell Carcinoma Mucocele

(mucus retention phenomenon, mucus
– Clinical
extravastion phenomenon)
! Painless ulcer of upper lip, elsewhere on
! Clinical
sun--exposed face (UV); raised margins
sun
! Does NOT occur intraorally
– Children and young adults
! Begins as pearly papule; assoc.
– Trauma
g
telangiectasia – Lower lip is most common site
! Can be highly destructive if not treated – Vesicle/bulla, dome-
dome-shaped
! Usually does not metastasize – Bluish often
– History of recurrence

71 72

12
 Ranula (mucocele, mucus retention Antral Pseudocyst (Mucous
phenomenon, mucus extravastion Retention Pseudocyst)
phenomenon) ! Clinical
! Clinical – Asymptomatic
– No treatment necessary
– Floor of mouth swelling
! Radiographic
! Looks like a frog’s belly (Gk ‘ranu’ = frog)
– Slight radiopaque,
radiopaque
! Bluish usually; history of recurrence several times
dome--shaped, emanating
dome
! Mucin will yield viscous aspirate
from floor of maxillary sinus
! Microscopic – histiocytes visible in mucin

MUCIN

GW

MSG 73 74

Ankyloglossia Dentigerous Cyst

! Congenital abnormality ! Clinical

! “tongue-- tied”
“tongue – Most common site is posterior mandible
– Impacted third molars
– U i ti ameloblastoma
Unicystic l bl t can arise
i from
f it
– Malignant transformation of the lining is possible
! Histology
– Epithelial lining - - - -> ameloblastoma,
ameloblastoma, squamous
cell carcinoma, mucoepideromoid carcinoma
– Other impacted teeth besides 3rd molars
75 76

Dentigerous Cyst (cont’d)

! Radiographic
– Pericoronal radiolucency attached at CEJ
of unerupted tooth
– Radiographic differential diagnoses
! Ameloblastoma
! Residual cyst
! Odontogenic keratocyst

! Odontogenic myxoma

77 78

13
Varices Parulis (Gum Boil)
! Lingual and Lip ! Clinical
– Dilated veins - blue – Incomplete root canal therapy with
– Seen typically in the elderly intermittent sensitivity
– Lip varices may thrombose and – Elevated reddish-
reddish-yellow
subsequently calcify (i.e. phlebolith) ! Clinical evidence of a draining fistula

79 80

Tuberculosis
Extravasated Blood
! Clinical
– Incidence is increasing worldwide and in ! Clinical – spontaneously resolve
the U.S.
– Purpura – generalized term
– Chest radiograph
– Petechia
Petechia-- pinpoint bleeding
– May
M spread d by
b iinfected
f t d sputum
t tto orall
– Ecchymosis – larger area of involvement
lesions (e.g., ulcer mimicking cancer on
the tongue) – Hematoma – large, elevated areas

81 82

Allergic Mucositis Eagle Syndrome

! Clinical ! Clinical
– Typically due to flavoring agents in – Elongation and/or
toothpastes, candies, and chewing gums calcification of the
(cinnamon
( i flavoring
fl i isi a common culprit)
l it) stylohyoid ligament
– Head and neck pain is
elicited by chewing,
yawning, opening mouth

83 84

14
 Primary Herpes
Herpes Zoster
Gingivostomatitis
! Clinical ! Clinical
– Crop of vesicles - - - > ulcers with pain – Inflamed, enlarged marginal gingiva;
– Striking unilateral distribution on skin and gingival bleeding
orall – Vesicles - - - -> ulcers throughout the
! ex. – palate, tongue mouth and lips with significant pain
– Malaise
– Low grade fever
– Sore throat, lymphadenopathy

85 86

Primary Herpes
Crohn’s Disease
Gingivostomatitis
! Clinical
– Granulomatous gingivitis
– Aphthous
Aphthous--like ulcers
– Rectal bleeding
! Intestinal skip lesions of small intestine, and
to a lesser degree, large intestine and other
regions of the GI tract

87 88

Multiple Endocrine Neoplasia

Dermoid Cyst Syndrome, Type IIB (III)

! Clinical ! Clinical
– Slightly compressible (“doughy”) – Multiple mucosal neuromas (e.g., tongue)
– Midline distribution usually – Medullaryy thyroid
y carcinoma
! Example - anterior floor of mouth – Adrenal pheochromocytoma

89 90

15
 Incisive Canal Cyst
(Nasopalatine Duct Cyst) White Sponge Nevus
! Clinical ! Clinical
– Most common developmental – A genodermatosis
non--odontogenic cyst
non ! Autosomal dominant
– Teeth vital; max.
max midline – Often bilateral buccal
– True cyst (epithelial lining) mucosa; other mucosa
– Moderately extensive
thick, white folds of tissue
- No eye involvement

Often heart-
heart-
shaped lucency 91 92

Cleft Palate Trigeminal Neuralgia

! Clinical ! Clinical
– Between lateral incisor – Age of onset typically > 35 years old; trigger points

and canine
! Radiographic
– Lucent line
– Maxillary occlusal film

93 94

Neuritis Actinic Cheilitis

! Clinical
! Clinical – Lip’s vermilion becomes indistinct
– Intense pain for one week duration – Great potential for dysplasia to undergo
malignant transformation into squamous cell
– Unilateral
carcinoma
! At forehead and around eye
! Therefore, a premalignant condition

95 96

16
Cheilitis Glandularis Post-Developmental Loss of Tooth
Post-
Structure
! Clinical
– Mucous minor salivary glands of lips are inflamed ! Attrition - physiological
– Mucus secretions ! Abrasion - pathological
– Premalignant condition - - - - > squamous cell – Mechanical wear at
carcinoma cervical region
g most typically
yp y
– Habits / occupations
! Erosion
– Chemical loss of tooth structure
exclusive of acidogenic theory
of caries
! Chlorinated pools
– Gastric regurgitation and GERD
97 98
! Hiatal hernia, bulimia

Post-Developmental Loss of Tooth

Post- Post-Developmental Loss of Tooth
Post-
Structure Structure

Erosion
Abrasion

99 100

Periapical Cemento-
Cemento-osseous Dysplasia
(Periapical cemental dysplasia; periapical osseous
Oral Hairy Leukoplakia dysplasia)
! Clinical
! Clinical – Middle-
Middle-aged black women
– White, rough plaque on lateral border of tongue (#1 – Mandibular anterior vital teeth
site) – No pain or expansion - - asymptomatic
– Seen in HIV-
HIV-positive individuals that are progressing ! Radiographic
to AIDS – Diagnosed by characteristic findings
! Multifocal periapical lucencies which mature over time;
– Caused by Epstein-
Epstein-Barr virus
become mixed lucent/opaque and finally mainly opaque

Time

101 102

17
 Florid Cemento-
Cemento-osseous Dysplasia
(florid osseous dysplasia) Florid Osseous Dysplasia
! Clinical
– Multiquadrant
– Fibro--osseous intrabony lesion
Fibro
– Hard product produced is avascular so . .
– Most likely complication is a secondary osteomyelitis
! Radiographic
– Radiolucent and radiopaque
! Treatment
– None necessary after dx

103 104

Lichen Planus
Lichen Planus
! Clinical
– Skin and/or oral condition
– Middle aged women most often
– Skin
! Purple, polygonal, pruritic papules
– Oral
! White papules and coalescing papules = Wickam’s striae
! Does not wipe off – any oral site
– Reticular form; often asymptomatic Reticular
! Erosive form
– On tongue may be mistaken for geographic tongue
– Sensitive, painful
! Most common site
– Buccal mucosa
! Ex. – dorsum of tongue
– White plaques, individual papules and striae
! Hyperplastic form - - plaque-
plaque-like
105 106
– Does not wipe off Cutaneous Hyperplastic

Erosive Lichen Planus Peripheral Ossifying Fibroma

! Clinical
– Soft tissue lesion, not in bone but makes
osteoid/bone
– Occurs on gingiva, especially interdental papilla area
– Product may be seen on dental radiographs as
scattered light opacities

107 108

18
 Cleidocranial Dysplasia Neurofibromatosis, type 1 (von
Recklinghausen’s disease of skin)
! Clinical
– Multiple unerupted supernumerary teeth ! Clinical
– Retention of primary teeth – Multiple neurofibromas (nodules) of the skin and
oral cavity (especially tongue)
– Delayed eruption of permanent teeth
– Café au lait pigmentation (abnormal macules or
– Missing clavicles, frontal bossing, large head
spots
p of the skin))
! Brown macules

109 110

Calcifying Odontogenic Cyst

(Gorlin Cyst)

! Histology
– Ghost cells
– Calcifications

111 112

Melanotic Neuroectodermal
Tumor of Infancy
Nicotine Stomatitis
! Clinical
– Rapid onset, destructive in newborns
! Clinical
– Increase of vanillylmandelic acid ((VMA
VMA))
– Hard palate – Anterior maxilla, soft and
– Red, inflamed minor salivary hard tissue
gland ducts with background – Mobile teeth
of leukoplakic change ! Radiographic
– Tobacco use – Intrabony, lucent, destructive
! Pipe smokers – most often – Malignant looking but
! Cigarettes benign usually

113 114

19
Auriculotemporal syndrome (Frey
syndrome) Aspiration
! Clinical ! Always aspirate an anterior
– Often after parotid gland surgery
maxillary/mandibular radiolucency prior
– Sweating of unilateral facial skin just prior to eating
to biopsy to rule out vascular nature
– Does not affect cranial nerve VII (rather V)

Starch Iodine Test

115 116

Chronic Osteomyelitis
Actinomycosis
! Radiographic
! Clinical – Often best seen in lateral oblique
radiographic view
– Soft tissue swelling (“woody consistency”)
with multiple draining fistulas – Radiolucent and radiodense
– “sulfur granules” = colonies of bacterial
organism
PMNs

117 118

Condylar Hyperplasia Dens--in

Dens in--dente (dens invaginatus)

! Clinical ! Clinical
– Irregular, elongated condyle – Most often found in anterior jaw, especially
– Chin deviates awayy from affected side upon
p maxillary lateral incisor
closure

119 120

20
Periapical Cyst and Granuloma
Dentin Dysplasia

! Clinical ! Clinical
– Dentin abnormal with
– Nonvital tooth, at apex
exposure
! Radiographic – Draining fistulas
– Periapical lucency with thin radiopaque line = – Misshapen teeth
reaction to apical inflammatory disease ! Radiographic
– Type 1 – “rootless” teeth
– Periapical lucencies

121 122

(Hypohydrotic) Ectodermal Epulis Fissuratum

Dysplasia
! Clinical
! Exhibits hypodontia (anodontia) – Hyperplastic connective tissue like fibroma
! Hypohidrotic - common type – Associated with ill-
ill-fitting denture flange
– Lack of skin appendages and hair – Treatment does NOT include antibiotic therapy
– Heat intolerance

123 124

Gingival Cyst of the Adult Heavy Metal Systemic

! Clinical Intoxication
– Soft tissue
– Facial attached gingiva ! Clinical
! Mandibular anterior most often – Lead line
– Elevated, fluid containing so a vesicle ! Blue line that parallels free marginal gingiva

125 126

21
 Hemangioma
Lymphangioma
! Clinical
– Lymph
Lymph--filled superficial vessels
– Most common cause of macroglossia

! Clinical
– Hamartoma
– Red to blue elevated lesions
– Blanches, compressible
! Histology
– Collection of small or large vessels filled with red 127 128
blood cells

Hypercementosis Infectious Mononucleosis

! Clinical
– Vital mandibular first molar
! Clinical
– Generalized in acromegaly – Cervical swelling, lateral
– Also seen, at times, in Paget’s – Sore throat
! Radiographic – Teenagers most often
– Radiopacity with intact PDL – Positive monospot test
– Attached to root surface – Epstein
Epstein--Barr virus association

palatal petechiae

Cementoblastoma
129 130

Internal vs. External Tooth

Resorption Irradiation Therapy
! Clinical – pink tooth when crown involved with
internal type ! Clinical
! Radiographic – Causes cervical caries secondary to
– Cannot tell difference early in the process inducement of xerostomia
– Round or ovoid radiolucency – Does
D nott result
lt iin pulp
l necrosis
i

131 132

22
 Acquired Melanocytic Nevus Kaposi’s Sarcoma
(common mole’; ‘nevus’)
! Clinical
! Clinical – Particular malig.
malig. seen in HIV positive
– Junctional type individual that progress to AIDS
! Most likely to undergo – Etiology
malignant transformation
! Herpes virus
virus, type 8; not HIV,
HIV EBV
EBV,, CMV
CMV,, HPV
(i.e., melanoma)

– Intramucosal type
! Most common oral type
! Called intradermal type on skin

– Compound type
133 134

Keratoacanthoma
Keratoacanthoma
! Clinical
– Difficult to differentiate from squamous cell
carcinoma of the face and lip (and its histology)
– Sun
Sun--exposed skin
– Present for many months; spontaneously resolve in
~ 4 months
– Keratin plug in the center of the ulceration

135 136

Xerostomia Warthin’s tumor

! Clinical (papillary cystadenoma lymphomatosum)

– Dry mouth (subjective) ! Clinical

– Can result in retrograde infection of the – Primary site overwhelmingly is parotid
salivary glands; baldish, inflamed tongue
! Not in oral cavity;
y; >> males

137 138

23
 Stafne Defect (salivary gland
Vitamin C Deficiency depression defect)

! Clinical
! Clinical
– Developmental
– Scurvy – More in males
– Does NOT cause xerostomia – Asymptomatic
– Teeth vital
! Radiographic
– Well demarcated lucency found near the angle of
the mandible beneath the
mandibular canal

139 140

Sarcoidosis
SjÖgren’s Syndrome ! Clinical
! Clinical – Bilateral hilar lymphadenopathy (chest x-
x-ray)
– Autoimmune disease; NOT infectious (e.g., herpes) – Cutaneous lesions - violaceous
– Elderly women – Treatment – corticosteroids
– Dry eyes, dry mouth = sicca
– Parotid
P tid swelling
lli
– Often other autoimmune diseases
– lupus, rheumatoid arthritis

141 142

Proliferative Periostitis
(Garre’s) Peutz--Jeghers Syndrome
Peutz
! Clinical ! Clinical
– Young person; swelling visible
– Oral and Paraoral
! Radiographic
– Inferior border of posterior mandible is common site - Onion ! Pigmented macules (brown)
skin pattern (radiographic appearance) – Lips, tongue, buccal mucosa
! Bands of radiopaque lines that parallel cortical surface
– Vermilion and skin of lip
– Intestinal polyposis

143 144

24
Osteosarcoma
Clinical
!
– Swift onset of localized pain
Osteoporosis
and swelling; tingling lower lip
– Onset in late 20s, early 30s ! Clinical
! Most common primary
malignancy of bone in persons – Decrease in serum estrogen and
less than 25
25--years
years--old calcium
! Radiographic - early lucency then opacity;
– Older females
trabeculae changes; PDL symmetrical widening

145 146

Osteopetrosis
! Clinical
Osteopetrosis
– Massive overproduction of dense, nonvital bone of
both jaws
– Young persons or adults
– Expansion
– Frequent complication
! Secondary osteomyelitis

147 148

Osteoma Mandibular Fracture

! Clinical
– Most common site is angle of mandible ! Clinical
! Radiographic – Often diagnosed with two radiographs
– Well
Well--circumscribed radiopacity ! Panoramic and occlusal

149 150

25
Mandibular Malignant Ominous
Mandibular Torus
Sign
! Radiographic
! Clinical
– May be superimposed over periapical region
– Spontaneous paresthesia of the lower lip
as radiodensities

151 152

Multiple Myeloma
Malignant Melanoma

! Clinical ! Clinical
– Elderly males (high median age)
– Most common oral sites
! Hard palate and gingiva ! Lab Findings
– Bence
Bence--Jones proteinuria
– Immunoglobulin spike
! Radiographic
– Multiple bone sites
! Calvaria, spine, pelvic girdle, jaws
– Punched
Punched--out lucencies

153 154

Necrotizing Sialometaplasia Cervical emphysema

! Clinical ! Introduction of air into oral soft tissues with

– Rapid onset resulting sudden painless swelling and
– Deep ulceration of the palate (most common crepitance
site)
it ) after
ft initial
i iti l swelling;
lli self
self-
lf-resolving
l i – Ex. – air/water syringe

155 156

26
 Odontogenic Myxoma Miscellaneous Facts
! Clinical
! Primordial cyst – forms in place of a tooth
– Young adult onset
! Enamel hypoplasia is a temporary suspension
! Radiographic of amelogenesis
– Closely resemble ameloblastoma ! Fusion – one less than normal compliment of
! Multilocular lucency with soap bubble pattern teeth; primary tooth of ant. mandible; separate
root canals
! Gemination – can be confused with fusion
! Pleomorphic adenoma (benign mixed tumor) –
most common salivary gland tumor

157 158

Miscellaneous Facts Miscellaneous Facts (cont’d)

! The parotid gland body is the most likely salivary ! Autoimmune diseases more common in women
gland tissue to have a neoplasm
! Osteoradionecrosis major factor is damage to the ! Oncocytoma = parotid swelling (tumor)
vascular supply ! Gingival hyperplasia – drugs such as cyclosporine,
! Prognosis best for sq cell ca of lower lip compared nifedipine (Procardia®) phenytoin (Dilantin®)
to osteosarcoma,
osteosarcoma, melanoma, adenocarcinoma ! Malignant jaw lesions destroy the cortical plates of
! Most common jaw metastasis site is posterior bone
mandible
! Onion skin radiograph pattern is also seen in ! Gingival condition with no improvement after two
Ewing’s sarcoma months should be biopsied
! Desquamative gingivitis includes pemphigoid
pemphigoid,, ! Dysplasia – abnormal maturation of the epithelium
pemphigus and erosive lichen planus
159 160

Radiology Facts
Epithelial Dysplasia
• X-ray has the shortest wavelength and the
highest energy; high voltage has the same
characteristics
• When milliamperage is doubled the intensity of
an x-
x-ray beam is doubled
! Kilovoltage (kVP) primarily controls contrast
and is the penetrating characteristic of an x-
x-ray
! X-ray penetration is determined by kVP
! Focal spot size primarily influences resolution

161 162

27
 Radiology Facts (cont’d)
Radiology Facts (cont’d) ! The density of processed film is not affected by
overfixation but is affected by
– Increase mA
! First sign of damage from acute radiation – Increase exposure time
exposure (4 Gy) is erythema – Decreased object-
object-thickness distance
! Most radioresistant tissue is nerve and – Decreased target-
target-object distance
muscle cell; most sensitive is hematopoetic ! B
Best iimaging
i film
fil for
f viewing
i i internal
i l derangement
d off
the TMJ (e.g., articular disc) is an MRI
! Basic shadow casting principle with the ! Identify Normal:
paralleling technique does not fulfill the – Zygomatic process and base; intermaxillary suture
physics requirement of the distance from – Lingual foramen; incisive foramen; genial tubercles
– Mylohyoid ridge; nutrient canals
the object to the recording surface should
– Inverted Y of Ennis
be as short as possible – Maxillary sinus
163 – Tuberosity; hyoid bone; nose shadow (ant. periapical film)164

– Hard palate; tori; anterior nasal spine; stylohyoid ligament

Radiology Facts (cont’d) Radiology Facts (cont’d)

! Intensifying screens are used to decrease
exposure time, reduce radiation exposure ! Double the distance from the radiation source
then the radiation becomes diminished by a
! 8-bit digital image would have 256 shades of factor of 4 (i.e., inverse square law)
gray
! Latent period = radiobiology time between
! Complication
p of radiation treatment in children exposure and biologic onset of symptoms; not
does NOT include supernumerary teeth but cell exposure and free radical formation
does include:
! Radiograph is rinsed with water to accomplish
– Stunted roots
getting rid of chemicals (not remove emulsion,
– Micrognathia
diminish silver particles, remove latent image)
– Condylar hyperplasia
– Malocclusion
! Artifact
– Bitewing radiograph with a curved dark line through
! Coin tests contact points of adjacent crowns = a break in the166
165
– Used for detection of light leakage emulsion from film bending

Radiology Facts (cont’d)

Radiology Facts (cont’d)
! A light radiograph is NOT caused by a long
process time ! Collimating an x-
x-ray beam results in an
! An MRI is narrow frequency radiation of the increase of the penetration of x-
x-ray photons
electromagnetic spectrum ! Radon is the greatest source of background
! The filter in a dental x-
x-ray machine is made of radiation
ad at o oon ea
earth
t
aluminum ! Basic components of an x- x-ray cathode ray
! A charged coupled device (CCD) converts x- x- tube consists of a filament and a focusing
rays to electrical signals but does NOT result in cup
the same average absorbed dose as ! To change from long scale intensity (low
conventional radiology (less absorbed dose) contrast) to short scale intensity (high
! Effective dose =comparison of the radiation contrast) but maintain image density, the
risk in humans from different radiographic 167
operator should decrease kVp and increase 168

exams and doses/sources mAs

28
 Radiology Facts (cont’d)
Radiology Facts (cont’d)
! Panoramic radiograph with one second of ! Penumbra – the geometric unsharpness
movement by patient results in wavy inferior border
of the mandible and unsharp image vertically across with a fuzzy area surrounding the contours
the image at that site of the teeth and osseous tissues
! Major biologic damage from ionizing radiation is ! An intensifying screen is used with external
primarily due to radiolysis of the water molecules
radiographs to decrease the radiation
! Electrons flow from cathode to anode with the
energy converted to heat exposure
! Recognize MRI and CT films ! The oil unit of an x-
x-ray tube housing
! Recognize technical errors functions to dissipate heat from the target
– Incorrect beam centering (“cone cut”)
– Blurring due to patient movement 169 170

29