OMPR Exam 3

Viral lesions, what is the most common?

Papilloma

What is an HIV associated salivary gland disease?

Parotid lymphoepithelial cysts can uni or usually bilateral enlargement of parotid multiple cysts in parotid, wall is lymphoid, with germinal centers

What are the most common sites for pleomorphic adenoma?

Parotid: 53-75% Submand.: 44-68% minor salivary: 38-43% superficial lobe of parotid gland and palate are MOST COMMON sites (this is the most commonly occurring salivary gland tumor)

What is the most common inflammatory cyst?

Periapical cyst (also known as radicular cyst)

Of the 3 Ps which has the HIGHEST recurrence rate?

Peripheral ossifying fibroma 16%!

In people who are immunocompromised how does herpes simplex present?

can have Recurrent Herpes in atypical regions (moveable mucosa) normally recurrent only on fixed mucosa

How might a rhabdomyosarcoma present? Histo?

can occur in vestibule and can grow into and destroy the maxilla or adjacent bone, very destructive 3 histo types: - *embryonal* (most common!) - alveolar (alveolar air sacs) - anaplastic (rare in kids) need muscle markers to identify (to differentiate from lymphomas and leukemias which present similar on histo)

What is Mumps? cause? affects? transmission? incubation? presentation?

caused by *paramyxovirus* affects primarily *parotid glands* virus transmitted through urine, saliva, or respiratory droplets 2-3 week incubation period fever, headache, malaise and chills ***preauricular pain*** swelling of the salivary glands

What are agranulocytosis/granulocytosis/neutropenia? causes?

cells of granulocyte series (particularly neutrophils) are absent (WBC <200 microliter blood) causes: develops shortly after exposure to drug or chemical (chemo, antibiotics, anticonvulsants, anti inflammatory drugs, anti-thyroid, diuretics, HAART). HIV infection. *Neutrophil count returns to normal in about 10-14 days if drug discontinued*

Who is affected by SS and what causes it?

chronic autoimmune disorder *affects females 80-90%* peak age of onset: 50 years unknown cause primarily involves salivary and lacrimal glands (can involve nasal, vaginal mucosa)

NHL is associated with what diseases: T/F rapidly growing masses occur in lymph node chains

chronic inflammatory disease, sjogren's syndrome, celiac, rheumatoid arthritis, HIV, immunosuppressive tc FALSE. *slow* growing mass in LN chains, can spread to other LN, soft tissue and bone(rare)

What is the classification for SS?

Primary: xerophthalmia and xerostomia ONLY Secondary: xerophthalmia and/or xerostomia associated with another autoimmune disease i.e. rheumatoid arthritis, lupus erythematosus

What is multiple myeloma? prevalence? gender? race?

Proliferation of malignant plasma cells, leads to hypercalcemia, urine Bence-jones proteins, anemia, bony lytic lesions 4/100,000 M > F Af Am affected 2x as whites

What is ossifying fibroma? General points:

classified as a benign neoplasm - considered to be a type of fibre-osseous lesion based on histo - 2 types 1) classic 2) juvenile (seen in younger pts and tend to be more aggressive in nature) - young adults and females most affected - *bony expansion and displacement of teeth seen in many cases* - more common in *mandible*

What's the most common of the 3P lesions?

Pyogenic granuloma (so this would be at the top of your differential!)

Microscopically what is distinctive for Hodgkin's lymphoma?

Reed-Sternberg cell (*owl-eyes*)

What is an autoimmune exocrinopathy that results in dry mouth and eyes that happens slowly over time?

SS progressive loss of secretory function

What group has the HIGHEST prevalence of dry mouth?

SS and head and neck radiation 100%!!

What autoimmune disease makes patients prone to a MALT cell lymphoma?

SS can lead to MALT cell lymphoma! rare

What electrical stimulation is available for pts?

SaliPen - stimulates lingual nerve and causes salivation GenNarino - appliance that fits over teeth and stimulates in area of lingual nerve There is data for the efficacy of these products

What is secondary sjorgrens?

Salivary and/or lacrimal involvement PLUS another CT disease (i.e. lupus, systemic sclerosis, RA etc etc)

What is the ONLY neural lesion that has a capsule?

Schwannoma/neurilemoma easier to treat comes right out

Autoimmune sialadenitis, i.e. SS, what imaging is best?

Sialogram or MRI "*fruit laden branchless tree*" consistent with SS

What are non infectious causes of sialadenitis?

Sjogren syndrome Sarcoidosis

Middle aged female pt CC: I have all these red bumps on the top of my tongue. I think it might be cancer. Pt smokes a pack a day and also has high BP. Pt denies pain and claims "bumps" have been present for a long time clinically: diffuse, dorsal tongue, several bumps reddish/purplish hue next step?

clinical diagnosis!! Lymphangioma if unsure, you can do an incisional biopsy of one of these lesions then leave it alone, high recurrence rate, no malignant transformation

What is hemophilia? 2 types: inheritance: Affects F vs M?

clotting factor deficiency A: Factor VIII deficiency *more common* B: Factor IX deficiency (Christmas disease) X linked recessive inheritance *Males* > Female (carriers) Affected females receive trait from BOTH parents

Cinnamon may cause which can look like what?

contact stomatisis hyperkeratotic areas if on lateral tongue, corrugated lesion on lateral border of tongue (appears similar to EBV oral hairy leukoplakia in immunocompromised individuals) or on buccal can look like morsicatio buccarum

The mucoadhesive agents for salivary hypofunction contain: lasts ____ hours increases what?

contain a lubricating agent and a citrus flavoring agent lasts for 2-4 hours increases subjective and objective measures of dry mouth

What is the best imaging for sialoliths?

conventional radiographs (occlusal radiograph) size 4, place tube head at right angle to film (typically associated with submandibular gland)

What is cyclic neutropenia? oral manifestation? tx?

count falls below 500/ul for 4-5 days every 21 days oral ulcers lasting 3-5 days aphthous like ulcers may also have fever, malaise, cervical lymphadenopathy self limiting palliative tx

What syndrome can be associated with vascular lesions?

Sturge-Weber Angiomatosis

Where intraorally is a rhabdomyoma most common?

TONGUE

T/F SS can have extra glandular manifestations.

TRUE fatigue, lung, kidney, arthralgia, vasculitis, increased risk of lymphoma (MALT type)

T/F Static bone cyst has a male predilection. It can occur bilaterally.

TRUE occur in middle aged and older adults asymptomatic, usually incidental radiographic finding remain stable in size no biopsy or tx necessary in most cases

T/F NHL extra nodal oral site involvement is rare

TRUE 25% of cases if it does occur it can be in: max sinus, nasopharynx, posterior mandible, maxilla, gingiva, floor of mouth, palate, buccal, vestibule it would be a *soft generalized swelling, very vascular, surface RBC, sometimes ulcerated*

T/F There is a statically significant difference in pts with SS and other syndromes vs controls. These patients have thinner saliva which predicts an experience of dryness.

TRUE Gordon Proctor study this is one of the hypotheses about why people feel dry

T/F Tooth loss can cause salivary hypo function

TRUE decreased mastication i.e. tooth loss, soft diet --> salivary hypo function

T/F Benign and malignant tumors of the salivary glands both have similar clinical presentation

TRUE! This is because most malignant are low grade and mimic benign tumors. Note: most malignant salivary gland tumors do NOT show histopath characteristics associated with malignancy

Which thalassemia affects children? Clinically?

Thalassemia Major (severe, onset at infancy) clinically: cheekbones, protrusive premaxilla - "rodent-like" or "chipmunk" face 2 other types: minor (mild, affects adults) intermedia (intermediate)

90% of gingival lesions will be:

The 3 Ps typically occur in interdental papilla (mostly more anterior, can be max or mandibular) they can occur, buccally, lingually, or palatally

66 yr old female pt presents for initial exam stating she wants new partial dentures. Med hx: hypothyroidism and HTN and takes meds. Intra oral: lesion is noted on ventro-lateral tongue Pt denies pain and states this has been present for a while and growing very slowly clinically: lesion looks reddish/purplish hue, large, exophytic palpation: Category of lesions? Differential? Tx?

VASCULAR Differential: hemangioma (prob not a venous malformation which tends to be flatter) YOU DONT KNOW IF ITS CAPILLARY OR CAVERNOUS! Bleeding risk Tx: if not interfering with function, leave it alone observe/monitor, if interfering: refer to OS they can inject sclerosing agent then excise note histo would show: blood vessels with RBCs

Micrscopically: lots of keratin!!, bumpy surface, koilocytes (shrunken nucleus, white halo around them), *binucleated cells, basilar hyperplasia* What is this indicative of?

Verruca vulgaris

What is the second most common benign neoplasm of salivary glands?

Warthins tumor

Can hemangiomas occur centrally in bone?

YES can present as unilocular or multilocular radiolucencies in the maxilla or mandible

T/F Polypharmacy is a risk factor for dry mouth.

Yes, there is a DOSE RESPONSE relationship, number of drugs and flow rate both unstimulated and stimulated flow reduces

What is papillary hyperplasia of the palate?

a form of denture stomatitis, associated with a removable full or partial denture or orthodontic appliance palatal vault is covered by multiple erythematous papillary projections (fibrous CT surfaced by epi), *granular or cobblestone appearance*, erythema is usually due to superinfection with *candida*

What is focal osteoporotic marrow defect? General features?

a large marrow defect that mimics a cystic/neoplastic radiolucency in the jaws - common incidental finding - not associated w/ pathologic process - etiology is unknown - represents a variation of normal anatomy within cancellous bone - does not present with clinical symptoms - commonly seen in *middle aged female adults*

What is a mucocele?

a lesion that forms when a salivary gland duct is severed and the secretion spills into adjacent CT *pseudocyst* not lined by epi presents as a swelling in tissue that may increase and decrease in size location: lower lip most common site, but may form in any area where there are minor salivary glands *fluctuant*

What is Kaposi's Sarcoma? What causes it?

a low grade vascular malignancy caused by HHV-8

What is a simple bone cyst/traumatic bone cyst?

a pathologic cavity in bone that is NOT lined by epithelium may contain fluid or be empty pathogenesis uncertain and controversial, linked to trauma to the bone that is insufficient to cause fracture and results in intra-osseous hematoma age: teenage and young adults almost all cases are in the mandible, usually molar area usually asymptomatic incidental finding, teeth vital radiographic appearance: well circumscribed radiolucency, often "scallops" around the roots of teeth

What is a pseudocyst? 3 that occur in bone?

a pathologic space not lined by epithelium 1. static bone cyst (lingual mandibular salivary gland depression) 2. simple bone cyst 3. aneurysmal bone cyst

What is a parulis?

a proliferation of granulation tissue at the opening of a fistula typically in apical area (not interdental papilla) (be able to differentiate this from a pyogenic granuloma)

Histo of lipoma?

a well delineated tumor composed of mature fat cells

Tx of papillary hyperplasia of the palate?

Treat with antifungal like nystatin ointment in denture base or rinse, cure candida, see whats left, the hyperplasia wont reverse (denture made around it or maybe laser resurfacing needed)

T/F Periapical/Radicular cysts are unilocular T/F Periapical granulomas can sometimes be multilocular

True False BOTH Periapical/Radicular cysts and periapical granulomas are always *unilocular*

T/F Neurofibroma is benign T/F Neurofibroma arises from central nerve tissue

True False - peripheral

T/F The benign fibro-osseous lesions: Fibrous dysplasia, Cemento-osseous dysplasia, Ossifying fibroma are indistinguishable histologically

True all will have fibrous connective tissue surrounded by irregularly shaped bone (Chinese letters in a stroma), thin trabecular bone patterns

What type of hypersensitivity reaction are allergies?

Type 1

What is the oral manifestation of agranulocytosis/neutropenia?

deep, punched out ulcerations of buccal mucosa, gingiva clinically gingival lesions comparable to ANUG

What is relative polycythemia?

dehydration, diuretics, vomiting chronically can increase risk of MI or CVA

Addison's disease clinical manifestation?

diffuse melanin pigmentation described as a bronzing (JFK might have had this) can be confused with racial pigmentation

How does thrombocytopenia purpura present?

direct infection of platelets, clotting issues erythematous areas

What is the most common location of granular cell tumor?

dorsal tongue normally painless and slow growing

What is a periapical cyst? Radiographically? Tx?

epithelial lined cavity involving apex of tooth (epi can be from: rests of malassez, crevicular, max sinus, fistulous tracts) - tooth NONvital, typically asymptomatic - if large pt may exhibit sensitivity, tooth mobility and swelling - *loss of lamina dura in affected area, root resorption possible* Tx: endo or ext of involved teeth, larger lesions may require biopsy w/ endo therapy. Follow up 1-2 yrs. Biopsy if fail to resolve.

What is the aneurysmal bone cyst?

exceedingly rare! a pseudocyst that consists of blood filled spaces and multinucleated giant cells, surrounded by cellular fibrous CT and bone location: usually posterior mandible may produce *rapid expansion* of bone *painful* usually found in people under 30 yrs old radiographic: multilocular, honeycomb, or soap bubble like radiolucency often associated with central giant cell granulomas or fibro-osseous lesions tx: curettage, bone fills in - no need for grafting

What is the treatment for viral soft tissue lesions? Should you perform typing?

excisional biopsy, monitor for recurrence NO typing if there are multiple HPV lesions ensure pt is not medically compromised in some way

Clinical features of irritation fibroma?

exophytic, usually less than 1cm in diameter, location: buccal, tongue, lips, gingiva, color: lighter pink than surrounding mucosa can be sessile OR pedunculated

The GNAS1 gene mutation is seen in:

fibrous dysplasia

How will schwannoma feel upon palpation?

firm

What are the clinical features of an amalgam tattoo?

flat, blueish gray, well defined sometimes radiograph will show radiopacity

What are the most common locations for lymphoepithelial cysts?

floor of mouth, soft palate, and lingual tonsilar area (wherever there is lymphoid tissue)

Preliminary studies show if you dilate salivary ducts and

flush w/ steroids or just NaCl solution, you can loosen mucous plugs and give pts relief this is called *sialdenoscopy* assisted treatment

What is sickle cell anemia?

genetic anemia autosomal recessive reduced O2 carrying capacity RBCs destroy capillaries Spleen traps and destroys abnormal cells --> leads to compensatory *hyperplasia in bone marrow* sick cell crisis: pain (abdomen, muscle, joint) fever, circulatory collapse *dental pain/infection can initiate crisis*

Aplastic anemia oral manifestations?

gingival bleeding gingivitis, perio disease oral candidiasis

What is the MOST common by far of all neurogenic tumors?

granular cell tumor

Sarcoidosis is a ______ disorder with what cause?

granulomatous disorder, multiple systems are involved! unknown cause

Polymorphous low grade adenocarcinoma is:

hard and soft palate most common sites, characteristic microscopic pattern with *single file cord infiltration* (other malignant salivary gland tumor)

What are the locations of minor salivary glands?

hard palate (posterior lateral areas), soft palate, buccal and labial mucosa and vestibule, floor of mouth, ventral tongue

What is thalassemia?

hereditary defect in alpha and beta Hb RBC thin, short life span HYPOchromic & microcytic

How does HIV associated HPV infection present?

herpes papillomatosis

When using sugarless chewing gum when are flow rates high?

high for approximately 10 min until flavor and sweetness leach out, and only the gum base remains. However, gum base alone gives approximately 2-3 times the USR so there is still benefit.

What is lymphoid tissue function and location?

immune response to foreign antigens, viruses, fungi, and bacteria locations: LN of H&N oropharynx

Rituximab seems to preserve salivary gland function but does NOT seem to

improve xerostomia

What is Polycythemia?

increase in the number of circulating red blood cells

What is inflammatory/post traumatic oral pigmentation?

increased melanin production in areas of chronic inflammation (erosive lichen planus, chronic cheek biting)

Recessive type of osteopetrosis is seen in: radiographically?

infants and young children severe form aka infantile or malignant osteoporosis radiographically: - diffuse sclerotic skeleton - delayed tooth eruption - high risk of fractures and osteomyelitis (esp in jaws after extractions)

Where does warthins tumor occur? Imaging?

inferior lobe of the parotid gland, more common in MALES, sometimes bilateral tumors are multiple in 20% of cases Imaging: Med CT scan, well demarcated

What is sialodochitis? Imaging?

inflammation of salivary duct, in chronic type can cause fibrosis and focal obstruction of the duct common in both submandibular and parotid IMAGING: CBCT you'll see: *sausage string* appearance

What is sialography? What are the indications?

inject a non lipid soluble, iodine based agent, radiopaque, into duct of gland, dilate orifice, then inject contrast agent 0.2-1.5ml of contrast agent is enough this fills ductal system, wait 5 min then either: conventional sialogram imaging or CBCT sialogram, wait for 5 min, then re image and evaluate function of gland Indications: suspicious of obstruction, evaluation of infection/inflammation (note acute inflammation is contraindication of sialogram)

What is a thyroglossal tract cyst?

involution failure forms along the tract that the thyroid gland follows in development - from the foramen cecum to its final location in the neck below the hyoid bone occurs in *midline of neck* as painless, fluctuant, movable swelling age: usually 10-20, no sex predilection histo: epithelium varies from stratified squamous to pseudo stratified ciliated columnar, thyroid tissue may be found in the CT wall of the cyst

What are polyostotic conditions?

involving or relating to many bones

Glossitis and angular cheilitis are signs of _____ ______ anemia

iron deficiency anemia

What is plasmacytoma?

isolated lesion with plasma cell proliferation 30% --> to MM over 10 years 50% disseminate within 2-3 years unilocular radiolucency, swelling or bone pain, non tender soft tissue mass *90% occur in head and neck* tx: radiation, better prognosis than MM

The larger the salivary gland the ______ the chance of tumors and _____ chance of malignancy

larger = MORE chance of tumors but LESS chance of malignancy

What are the quantitative hematologic diseases?

leukemia lymphoma multiple myeloma hemophilia thrombocytopenia neutropenia agranulocytosis hemolytic anemia blood loss anemia

What cancer can present with gingival enlargement?

leukemia! pt would need CBC and blood work to confirm (increase in WBC and immature bands)

Histo shows vaculoles, thin fibrous capsule, and surface epithelium, what is this?

lipoma

What is the median mandibular cyst?

location: anterior midline of mandible appears as midline radiolucency b/t or apical to mandibular central incisors bony expansion may be noted pathogenesis: believed to be derived from epithelium entrapped during fusion of halves of mandible controversial: appears that almost all of these midline cysts are of *odontogenic origin* if exists, it is very rare

What is a median palatine (palatal cyst)?

location: more posterior than the incisive canal cyst at midline of palate - well defined, unilocular radiolucency - pathogenesis: a more posterior located nasopalatine cyst vs. a cyst formed from remnants of epi as the left and right palatal processes fuse - clinical swelling of midline hard palate posterior to incisive papilla - occurs in young adults

What is the nasopalatine duct cyst? location? derived from? age? teeth vital or non vital? tx?

location: within the nasopalatine canal derived from the epithelial remnants of the Y shaped embryonal nasapalatine duct that connects the nasal cavities to the oral cavity age: adults, *male predilection* well circumscribed, sometimes *heart shaped* radiolucency b/t #8-9 *teeth are VITAL* its non odontogenic! tx: surgical enucleation, recurrence rare

Acinic cell carcinoma is:

low grade, most common in parotid (other malignant salivary gland tumor)

What is the level of evidence available to support acupuncture as tx for salivary hypofunction?

low quality evidence

Which WBCs are non granulocytes?

lymphocytes (B & T cells) monocytes

Which malignancy is greatly increased in patients with SS?

lymphoma!!

Is SLE manifestation worse in males or females?

males

What are some causes of urticaria?

medications, foods, airborne allergens, physical stimuli (cold weather!)

What is a junctional nevi?

melanocytes cells collect at BM within epithelial layer and CT

What is a compound nevi?

melanocytic cells arranged as both junctional and intramucosal very dark, slightly RAISED!

Folic acid or B12 deficiency can lead to: caused by:

microcytic anemia glossitis often from alcoholism, malabsorption, or medications (trimethoprim, oral contraceptives, anticonvulsants) burning and stinging pain of tongue !!

What is benign lymphoepithelial lesion?

microscopic appearance is identical to SS! usually unilateral adults F > M 85% of cases reported in parotid diffuse swelling of affected gland, asymptomatic or mild discomfort similar salivary gland lesions seen in pts with HIV infection painless, slow growing, requires biopsy

In NHL was in jawbone what would it mimic?

mimics toothaches, leads to extractions and RCTs (always test for vitality even if PARL) typically ill defined radiolucencies and widening of PDL spaces

How is SS diagnosed?

minor salivary gland biopsy (lower lip) see foci of multiple lymphocytes and also need blood work for confirmation radiograph: sialogram reveals "fruit laden branchless tree* schirmer test for eye, below 5mm/5min suggestive of xerophthalamia *0 to 2mm - positive for xerophthalmia*

What are the two main forms of EM?

minor-milder: 1 mucosal site with symmetrical target lesions major-severe: 2 or more mucosal sites in conjunction with widespread lesions In the past Stevens Johnsons and Toxic Epidermal Necrolysis were considered most severe end of erythema multiforme spectrum. Currently, authorities feel these conditions are distinctly different processes with SJS and TEN almost always triggered by drug exposure

Parasympathetic stimulation of salivary glands causes:

more fluid to be formed, more water in saliva

Chronic immunosuppressives in pts with SLE makes them:

more susceptible to infection and development of malignancies

What is normal stimulated salivary flow?

more than 1ml/min is normal

How many medications are xerogenic?

more than 500!! note: SGH is correlated with the *number of drugs taken* regardless of whether these drugs have an established association with dry mouth!

What is a dermoid cyst?

most common in children and young adults, 15% congenital location: most commonly occur in midline of floor of mouth doughy or rubbery mass that frequently retains pitting after application of pressure slow growing, painless histo: cyst lined by orthokeratinized stratified squamous epithelium lumen is filled with keratin fibrous CT cyst wall contained skin adnexal structures

Vascular leiomyoma clinically?

most common of the tumors of muscle (but all are very rare!) when you palpate it should blanch

Which malignant salivary gland tumor can occur in children and in bone?

mucoepidermoid carcinoma

Sublingual and minor glands create ____ secretions ____ unstimulated flow

mucous (viscous) secretions 7-8% unstimulated flow

The submandibular glands create ______ secretion ___% unstimulated volume ___% stimulated volume

mucous/serous secretion (exits through Wharton's duct) 65% unstimulated volume** (this is why pts with radiation feel dry mouth at rest!) 30% of stimulated volume

Peutz-Jeghers syndrome clinical manifestation?

multiple macules on labial mucosa peri oral (macules on nose) and finger tips

What are the clinical features of condylomas?

multiple** pink-ish flat topped bumpy surface

Drugs that can cause a change in salivary flow are typically the drugs that block what receptors?

muscarinic receptors (i.e. anti psychotic agents)

How does a sialolith appear on histo?

must be put in HCl solution to decalcify it/cut debris in the middle with concentric rings of calcification, surface mucosa on top

Young male pt CC: I have a bump on the front of my tongue it is annoying me. Pt claimes it has been present for a while and is slowly increasing in size. He denies pain. clinically: tip of ventral tongue, yellowish hue palpation: firm what category of lesion are you thinking of? next step?

neural! 4 types: granular cell tumor schwannoma neurofibroma neuroma BIOPSY (complete surgical excision)

How do you tell a lipoma from a neurofibroma?

neurofibroma will feel *firm* upon PALPATION lipoma would be soft and doughy

Cyclic neutropenia can lead to what orally? diagnosis? tx?

neutropenic ulcers (without neutrophils!!, no pseudomembrane!!) diagnosis with sequential blood counts (< 500/mm3) tx: antibiotics and G-CSF (granulocyte colony stimulating factor b/c neutrophils are granulocytes)

What is the most common cell in WBC count? List in descending order:

neutrophils (PMNs) neutrophils lymphocytes monocytes eosinophils basophils 1-2%

Histo of compound nevus?

nevus cells in epi and CT

Mammary Analogue Secretory Carcinoma is:

newly recognized, similar microscopic appearance to acidic cell ca/ parotid, labial and buccal mucosa are common sites (other malignant salivary gland tumor)

What is sialadenosis? microscopically?

non inflammatory benign disorder characterized by salivary gland enlargement clinical: slowly evolving swelling of the parotid usually BILATERAL may or may not be accompanied by decreased salivary flow and/or pain microscopic appearance: - hypertrophy of salivary gland acing cells (malnutrition) - acinar atrophy w/ infiltration of fat cells (long standing DM and alcoholism)

What is dominant type osteopetrosis?

not as severe - diagnosed later in life - axial skeleton mainly affected radiographically: - diffuse sclerosis - sclerosis of medullary portion of the mandible - risk of jaw fracture and osteomyelitis post-extraction remain

What are some targeted therapies that may help pts with SS?

not great evidence, still early trials, but these are immune modulated targeted therapies like anti-B cell (rituximab), anti-TNF-alpha (infliximab), etc *strong evidence points to the efficacy of rituximab in management of SS*. Future controlled trials needed for Belimumab and Abatacept. CFZ533 promising alternative. Entanercept and Infliximab not effective.

How does smokers melanosis present?

often female, usually facial mandibular gingiva, possibly reactive change in melanin production due to tobacco components *anterior max or mandibular gingiva* can also occur on palate

What is an oral lesion equivalent to a freckle on skin?

oral melanotic macule

What is strawberry gingivitis? board question

oral presentation of granulomatosis with polyangiitis friable, hemorrhagic, papillary kind of gingiva, ulceration, mucosal nodules, facial paralysis, enlarged major gland from granulomas

What are 2 serious complications of Mumps? Dx? Tx?

orchitis oophoritis (infection of testes and ovaries) can lead to spontaneous abortion in 1st trimester in 25% of infected pregnant females Dx: Mumps IgM or IgG titers tx: palliative for fever and pain

Molluscum contagiosum is:

other lesion associated with HIV infection others include: histoplasmosis, aphthous ulcerations, and oral SCC and persistent generalized lymphadenopathy (75% of people greater than 3 months!!!) warns of progression to AIDS

Plaquenil (hydroxychloroquine) can lead to:

palatal pigmentation

Iron deficiency anemia can lead to what oral manifestations?

pallor *atrophic glossitis* *angular cheilitis*

What are some reasons for unilateral enlargement of the parotid area?

palpable mass: - intrinsic:benign or malignant neoplasm, intra glandular lymph node, hamartoma - external: cysts in the peri-auricular area, extra-parotid tumors, benign lymphoid hyperplasia diffuse swelling: - when no mass present, sialadenitis primary or secondary to ductal obstruction - if not related to the gland: hypertrophy of master muscle, accessory parotid gland, lesions related to TMJ and ramus

What is aplastic anemia? Causes?

pancytopenia bone marrow failure to produce adequate numbers of ALL blood cells from hematopoietic precursors. *life threatening* hematologic disorder - sepsis - bacterial: absent PMNs, fungal immune mediated disease caused by cytotoxic T lymphocytes that target differentiating stem cells - exposure to environmental toxins (benzene) - drugs (chloramphenicol) - viral infections: EBV, HIV, CMV - idiopathic

What are the evidence based recommendations for pts with dry mouth following radiation?

panel recommends *oral pilocarpine* following radiotherapy improves xerostomia. (the improvement may be limited, level of evidence II, grade B). panel recommends use of *parotid sparing IMRT* for prevention of xerostomia (level of evidence II, grade A) panel recommends use of *oral mucosal lubricants/saliva substitutes for short term improvement of xerostomia* (level of evidence II, grade B) panel suggests that the obtained level of sparing by *submandibular salivary gland transfer* might be of clinical significance (level of evidence IV, grade B)

Microscopic: fibrovascular cores, bumpy projections, *koilocytes* are indicative of:

papilloma

Which gland is serous and might have fat?

parotid

What is the most common site for salivary gland tumors?

parotid most common intra oral: junction of hard and soft palate minor gland: palate > labial > buccal upper lip > lower lip

What gland is more radiosensitive? Why?

parotid *because its a serous gland* serous acini are more radiosensitive than mucous acini vs. submandibular or sublingual

In SS what can occur to parotid glands?

parotid enlargment due to lymphocytic infiltrate firm enlargement from persistent inflammation

What is a lymphoepithelial cyst?

pathogenesis: cyst forms from epithelium in a lymph node or within lymphoid tissue location: lymph nodes of the neck, major salivary glands, floor of mouth, posterior lateral tongue, soft palate asymptomatic: yellow or white in color, small most common in young adults histo: cyst lined by stratified squamous epithelium surrounded by lymphoid tissue *common* tx: excisional biopsy or monitor/ruptures on own

What is racial pigmentation?

patients with dark skin color have this, most commonly on *gingiva* diffuse nature, somewhat symmetrical can have pigmentation of *fungiform papillae as well*

Lymphangioma clincally?

pebbly and granular, shiny translucent quality to it (like tapioca looking), frog egg appearance tends to be scattered across dorsal surface of tongue (this is why we normally do incisional biopsy or clinical diagnosis and monitor)

Allergic contact rxns, non mucosal related to topical corticosteroids, cosmetics, creams, moisturizers? Tx?

perioral dematitis erythematous papules/vesicles usually resolves after discontinuation of all products *"zero therapy"*

What is clinically intermediate of the 3 Ps?

peripheral giant cell granuloma (its between pyogenic granuloma and peripheral ossifying fibromas)

What is a side effect of hydroxychloroquine in tx of SLE?

pigmentation (palatal pigmentation shown in class)

Primary vs secondary sjogrens?

primary: SS alone secondary: SS w/ another autoimmune disease

Histo of leiomyosarcoma?

proliferation of cigar shaped smooth muscle cells *enlarged dark cells and atypical mitotic figures*

What is a mucous cyst?

pseudocyst microscopically appears as an epithelial lined cystic structure that is actually a dilated duct (normally sialolith blocks and leads to intraductal mucus aka mucous cyst) *clinically looks like a mucocele (mucocele more common)*

What is the most common pattern of candidiasis in HIV? 2nd most common? Diagnosis? Tx?

pseudomembranous type not diagnostic but does predict aids down the line then erythematous type 2nd most common Diagnosis: cytologic smear Tx: Clotrimazole (pts w/ effective anti-retroviral therapy) Tx: Systemic anti fungal fluconazole (high viral load)

Oral hemangiomas clinically, will look?

purplish/blueish/redish will feel soft and spongy will *BLANCH* with pressure (compresses blood vessels) v impt clinical clue! if hemangioma is cavernous you might feel PULSATILE nature coming from lesion!!!

Clinically how does urticaria present? What is the differential?

raised erythematous lesions have varied sizes acute (<24hrs) and chronic (>6 weeks) differential: - erythema multiforme - morbilliform drug eruption

What is Plummer-Vinson Syndrome:

rare TRIAD: Chronic iron def, dysphagia (esophageal webs), atrophic glossitis Significantly *increased risk of esophageal cancer*

What does a leiomyosarcoma look like clinically?

red, white, ulcerated very uncommon intraorally most common in the uterus

What is anemia: Dx:

reduction in O2 carrying capacity RBC counts, Hg, HCT, red cell indices for dx of type of anemia

What is the common cause of death in SLE?

renal failure (complexes deposited in the kidneys)

What is secondary polycythemia:

response to low O2 environment such as high elevations and smoking (elevation in CO associated with tobacco smoking) increased release of erythropoietin increased production of RBCs

Pt presents with burning tongue, what are next steps?

rule out fungal (mucosal smear) - empirically give antifungals if no improvement with fungal tx then: order CBC w/ diff order Fe, flare, B12 tests R/o pernicious anemia (lack of intrinsic factor that leads to improper absorption of B12) diff: geographic tongue or fissured tongue (taking vitamins B or iron may help these pts too!)

Sympathetic stimulation of salivary glands causes:

saliva to be more protein rich, a little more fluid but not like para

What are some subjective oral symptoms of pts with dry mouth?

saliva: feels foamy, viscous, ropy lips: dry, cracked tongue: burning/pain salivary glands: swollen, painful thirst: fluid intake, keep water at bed side mastication: *dry mouth when eating* (suggests unable to produce even with stimulation), difficulty using a denture dysphagia: *difficulty swallowing without fluids* speech: difficulty speaking (dysphonia) taste: difficulty tasting (dysgeusia) many others

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

salivary hypofunction

Bacterial sialodenitis, what is it? acute vs. chronic? clinical presentation? imaging?

acute: bacterial infection of the terminal acini or parenchyma chronic: extensive swelling and fibrosis, can be a consequence of an untreated acute or associated w/ obstruction of duct clinical: usually unilateral acute: swelling, redness, tenderness, malaise, enlarged lymph node, suppuration chronic: episodic in nature, intermittent swelling, pain when eating, pus may be expressed IMAGING: Chronic type: Sialography (enlargement of structures shown) Acute: Medical CT or MRI for evaluation

Allergic contact stomatitis diagnosis acute vs. chronic?

acute: easier to diagnose due to clearer temporal relationship chronic: eliminate all other causes, perform skin test (directly test oral mucosa-mixture w/ Orabase)

Phase 1 trials of _______ for radiation induced hypofunction show safety and promising initial results

adeno-viral mediated transfer of the aquaporin-1 cDNA

How is cyclic neutropenia diagnosed?

sequential complete blood counts every 2-3 weeks for 8 weeks neutrophil count should be less than 500/ul for 3-5 days during each of at least 3 successive cycles

The parotid creates _____ secretion ___% unstimulated volume ___% stimulated volume

serous (exits through Stenson's duct) 20% unstimulated 50% stimulated

What is Paget's disease?

aka Osteitis Deformans - middle aged and elderly population affected with 2:1 male predominance over age of 65 - the enlarged bones (esp lower body) result in deformation, which lead to *bowing of legs and a "simian-like stance* - pts have elevated levels of *alkaline phosphatase and hydroxyproline in urine* (boards ?!!)

Causes of unilateral enlargement of submandibular area:

sialadenitis primary or secondary to ductal obstruction intrinsic: neoplastic or cystic external: neoplastic, cystic, lympho epithelial lesion

Hair on end on lateral skull radiograph is indicative of:

sickle cell anemia (loss of outer cortical table) also thalassemia

What is the tx for thyroglossal tract cyst?

sistrunk procedure involves removal of cyst, hyoid bone segment, and muscular tissue along tract 10% recurrence rate

Histo of Rhabdomyoma?

skeletal muscle with peripheral nuclei

What is the static bone cyst?

also called Stafne Bone Cyst *not a cyst* no epithelial lining lingual mandibular bone concavity, a depression on the lingual aspect of mandible that contains normal salivary gland tissue radiographic appearance: a well defined, unilocular radiolucency, sclerotic border location: posterior mandible *inferior to the mandibular canal*, can be found in anterior mandible less commonly no tx needed

What is Sjogren's syndrome?

also known as Sicca Syndrome autoimmune disease affecting the salivary and lacrimal glands - results in dry eyes and dry mouth xerophthalmia: decreased tear production xerostomia result: keratoconjunctivitis sicca --> blurry vision diffuse firm enlargement of the major salivary glands *(1/3 to 1/2 pts with SS)*

What is the MOST common oral pigmented lesion by far? What is the rarest oral pigmented lesion?

amalgam tattoo melanoma

What are the 3 qualitative hematologic diseases?

anemia sickle cell anemia thalassemia

Adenocarcinoma NOS is:

any other salivary gland malignancy that doesn't fit a recognized category!!! (other malignant salivary gland tumor)

Clinical features of a lipoma?

appears as a yellowish mass surfaced by thin overlying epithelium often see surface red blood vessels

Why does sialolithiasis arise? pain? palapation? radiographic appearance?

arise from deposition of calcium salts around nidus of debris within the duct lumen episodic pain and swelling during times of increased salivation can be palpated if stone is located toward terminal portion of duct appear as radiopaque mass on radiograph for FOM *occlusal radiograph best*

When do pts experience their worst dry mouth?

at night also winter months are worse

Histo of melanoma:

atypical cells w/ melanin, large nuclei, mitotic activity

The unstimulated flow rate _____ initially when using sugarless chewing gum Even after the flavor agent leaches out, the gum base along gives _____x the unstimulated rate

sky rockets 2-3x so there is still benefit

Clinically what does a rhabdomyoma look like?

slow growing, painless, nodule on tongue what would be at the top of differential for a tongue lesion like this? granular cell tumor

Clinically how does a lipoma feel?

soft and doughy yellow/orange ish color with surface red blood vessels

Severe thrombocytopenia can lead to:

spontaneous gingival bleeding also ecchymosis and hematomas (can be reddish or dark blue, range of colors) (DON'T be confused with hemangioma - these are very superficial and these appear and rupture quickly vs. hemangioma would be present forever!)

What is the stimulated saliva production in ml/day? What is the flow rate mean ml/min? What is the maximum in ml/min?

stimulated 200+ ml/day Flow rate mean 1-2ml/min Max 7ml/min

Which gland is only mucous?

sublingual (also minor salivary glands are mucous as well)

Which gland is mixed (serous/mucous)?

submandibular

Treatment of lipoma?

surgical excision does NOT recur

What is the treatment for neurofibroma?

surgical exision note: malignant transformation (into neurofibrosarcoma) reported but rare

Butterfly rash is associated with: kidneys? heart?

systemic lupus erythematosus *does NOT involve the nasolabial folds* another finding is lupus nephritis (granular, nodular, complexes deposits in kidneys) Libman-Sacks endocarditis (vegetative growths warty looking)

What happens to the filiform papillae overtime if you have dry mouth?

they shorten due to friction, tongue becomes depapillated (more severe sign of dry mouth)

What is the most common intraoral location of Schwannoma/Neurilemoma?

tongue

What are the common sites of neurofibroma orally?

tongue and buccal mucosa

Common location of papilloma?

tongue, lips, soft palate often have long finger like projections not always!, can be keratotic or mucosa colored

T/F Sialometry is difficult to gauge since dependent upon pt's normal baseline

true (because we don't normally have a baseline) *note: low flow rates possible in absence of symptoms (and vice versa)*

T/F Kaposi sarcoma can cause tooth mobility

true! it can burrow through the bone and lead to tooth mobility

Kaposi's sarcoma clinical presentation?

typically involves the skin, multiple flat or raised, purplish/reddish/blueish lesions most common intraoral: *palate and maxillary gingiva* can be flat or raised, single or multiple

Where does mucoepidermoid carcinoma occur in bone?

typically posterior mandible unilocular radiolucency or multi (very rare)

What is the tx for cemento-osseous dysplasia?

typically, no tx is required unless these regions show clinical/radiographic evidence of secondary infection

Clinically Sturge-Weber Angiomatosis can present as:

unilateral port wine stain, one side of face, can be flat or raised in class showed those that show V1 and V2 and then you can see erythema and vascular prolif intraorally along V1 and V2 as well

What is the Challacombe scale?

validated scale of oral dryness, easy scale to use without having to perform sialometry 1-10 (three different colors) 7-10 = severe (check slides for each category)

Microscopic features of peripheral giant cell granuloma?

very cellular, lots of extravasated RBCs, *multi nucleated giant cells*

How will cystic lesions present on imaging? What imaging should be used?

well defined, well demarcated, round, usually homogenous wi some fluid inside it can be intraglandular or extraglandular IMAGING: MRI or Med CT scan

What is sialolithiasis? clinical features?

with = stone sialolith: salivary gland stone - occur in both major and minor glands - often cause obstruction of the duct clinical features: - minor glands: hard yellowish structure in soft tissue - may be visible on radiograph - recurrent swelling (swells during meal time)

What color do neural lesions typically present as?

with yellowish hue (firmer and more solid than a lipoma)

The SUBJECTIVE experience of a dry mouth (i.e. a symptom) is:

xerostomia

Clinical features of SS:

xerostomia: reduction in salivary secretions, mucosa appears dry, fissured and atrophic tongue, increased risk for dental caries, periodontal disease and candidiasis xerophthalmia: blurred vision, itching sensation

What are abnormal flow rates USFR: SFR:

USFR: <0.1-0.2ml/min SFR: <0.5ml/min *thresholds where we categorize someone as having salivary hypofunction*

What is the first manifestation of allergy? What is it caused by?

Urtricaria well defined erythematous papules/plaques which are pruritic Caused by degranulation of mast cell resulting in vasodilation and increased vascular permeability of *SUPERFICIAL blood vessels*

Histo of melanotic macule:

basal cells have melanin pigment granules stays in EPI does not go into CT!

What WBC are granulocytes?

basophils, neutrophils (seg

What is lymphangioma? What is the most frequent intraoral location? Tx?

benign tumor of lymphatic vessels 3 types: capillary, cavernous, or cystic hygroma (largest ones) *tongue* Tx: monitor, surgery if needed, recurrence common

Tx of traumatic bone cyst?

biopsy is necessary surgical exploration and *curettage of bony walls promotes bone regeneration* no further tx necessary monitor progress

How is NHL diagnosed?

biopsy with immunohistochemistry and CBC biopsy will show: proliferation of monoclonal antibodies, lots of mitotic activity, dark nuclei

What is histo of amalgam tattoo?

black round coarse particles overtime diffuses, and dark particles become parallel to collagen fibrils, wrap around blood vessels

What are the clinical manifestations of leukemia? oral manifestations?

bleeding infection fevers, chills malaise weight loss lymphadenopathy gingival enlargements, grow into PDL spaces, displace teeth (asymmetric widening of PDL space with leukemic infiltrate) multifocal bone destruction

Blue nevus appearance? histo:

blue hue *clearing in middle* histo: resembles amalgam tattoo, dendritic melanocytes, serpentine looking, deep into CT

Coarser trabeculae on radiograph are indicative of:

bone marrow hyperplasia sickle cell anemia!! enlarged marrow spaces (more radiolucent)

What is the tx for osteopetrosis?

bone marrow transplant

T/F all 3 "P" lesions usually occur on gingival interdental papillae T/F all are treated the same way

both true tx: since they can look similar clinically, excisional biopsy necessary to determine diagnosis, complete excision and removal of local irritant (SRP)

Lymphoepithelial cyst of the neck is also called a

brachial cleft cyst

Melanocanthoma histo:

branching dendritic melanocytes that push through the epi, makes epi thicker (acanthoma)

Histo of adenoid cystic carcinoma:

"Swiss cheese tumor" cribriform pattern islands of small dark cells perineurial infiltration

What is idiopathic osteo-sclerosis?

"dense bone island" - not associated with any dysplastic, neoplastic, inflammatory or systemic disorder -*common incidental finding* - slow growing, typically stops growing by the time of skeletal maturity - peak prevalence in 3rd decade of life - no tx required, monitoring suggested

How will thalassemia present radiographically?

"hair on end" (lateral ceph) marrow hyperplasia (trabecular large, coarse)

What is Warthin tumor? other name? location? cause? pathogenesis? clinical features? tx?

"papillary cystadenoma lymphomatosum" benign neoplasm that occurs almost exclusively in the parotid gland, cause unknown but linked to EBV and smoking intraoral - extremely rare pathogenesis uncertain (maybe EBV, smoking) clinical: - slow growing painless mass of the *parotid gland* - *UNIQUE FEATURE: occurs bilaterally in 5-17% of cases* - M > W - occurs in older adults tx: surgical excision histo: papilloid projections, lymphoid background, bilayered oncocytic cystic lining

What is the most common benign salivary gland tumor by far?

*Pleomorphic adenoma* (benign mixed tumor)

Analgesics i.e. opioids affect salivary flow by what proposed mechanism?

*central inhibition* inhibit the salivary reflex arc in the CNS by blocking noradrenaline reuptake

Clinical presentations of neurofibromatosis?

*lisch nodules* VERY diagnostic of neurfibromatosis (brown deposits on surface of eyes) (cafe au lait occurs in other conditions)

Where is acute sialadenitis most common? How will it present?

*most common in parotid gland* swollen and *painful* gland, erythematous overlying mucosa/skin, purulent discharge out of Stenson's duct, low grade fever

What Rx meds are available for salivary hypofunction? contraindications? adverse effects?

*muscarinic agonists* stimulate the parasympathetic nervous system *pilocarpine 5-7.5mg tid & qhs* (M1 and M3 agonist) *cevimeline 30mg tid* (more M3 agonist) contraindications: significant cardiovascular, hepatic, renal or respiratory diseases, narrow angle glaucoma AE >10%: sweating, flushing, rhinitis, increased urination, weakness

What are the causes for anemia:

*nutritional* *genetic* *environmental* *organ disease*

Characteristics of oral melanotic macule?

- "freckle" or "ephilis" - occurs at any age in both men and women - most common sites: lower lip most common, buccal mucosa, gingiva, palate - appears as a solitary (15-20% of cases are multiple), well demarcated, *uniformly tan to dark-brown, asymptomatic, round or oval, FLAT "spot"* with a diameter of 7mm or less - lesions generally don't enlarge over time

What is the prognosis of systemic prognosis?

- "limited" has better prognosis than "diffuse" - most pts die from pulmonary involvement 75% 10 yr survival for limited 55% 10 yr survival for diffuse

What is Hodgkin's lymphoma?

- *EBV* associated - B cells - less common than Non-Hodgkin's 1:6 2 main subtypes: - nodular lymphocyte predominant - classical Hodgkin's lymphoma (4 subtypes) Distinctive atypical cell *Reed-Sternberg cell*

What syndromes are associated with Sarcoidosis?

- *Lofgren syndrome*: erythema nodosum, bilateral hilar lymphadenopathy, arthalgia - *Heerfordt syndrome* (uveoparotid fever): parotid enlargement, anterior uveitis, facial paralysis, fever these are specific ways sarcoidosis presents

What are the oral manifestations of multiple myeloma?

- *amyloid deposits* (pinkish/reddish deposits, often involve tongue --> macroglossia) - radiolucencies, mand (posterior body and ramus) > maxilla c/o oral swellings, pain, paraesthesia, dysesthesia tongue, gingiva, lips, skeletal muscle, salivary glands can also have amyloid deposits

What causes dry mouth during anxiety?

- *central inhibition* as a result of connections b/t primary salivary centers and the higher centers of the brain

How is erythema multiforme diagnosed?

- *clinical presentation* - exclusion of other vesiculobullous disorders (i.e. pemphigus vulgaris, mucous membrane pemphigoid) - hemorrhagic lip lesions may mimic paraneoplastic pemphigus - direct immunofluorescence is non specific

Clinical features of Aplastic Anemia:

- *decreased red blood cells* --> severe anemia (fatigue, light headedness, tachycardia, weakness, shortness of breath) - *decreased platelets* (easy brushing, bleeding, epistaxis, gingival hemorrhage) - *decreased white blood cells* (bacterial and fungal infections, fevers)

What are the causes of salivary hypofunction?

- *dehydration*(decrease water intake, increase water loss i.e. DM or emesis) - *medications (Rx & OTC)* - *direct damage to glands* (H&N radiotherapy, chemo [reversible], autoimmune SS, GVHD, HIV) - *decreased mastication* (tooth loss, soft diet) - *conditions affecting the CNS* (depression, anxiety, Alzheimers, Parkinson's, cerebral palsy)

What will you see on histo of neurofibroma?

- *fibrous CT* - serpentine or comma shaped or *s shaped nuclei* - *delicate fibrillar background*

Angioedema: activation of complement define the 2 types

- *hereditary*: reduction of C1 esterase inhibitor or dysfunctional inhibitor - *acquired*: associated with lymphoproliferative dx and autoimmune dx

What are the tumors of muscle?

- *leiomyoma*(benign tumor of smooth muscle) - *vascular leiomyoma* (benign tumor of smooth muscle walls of blood vessels - *rhabdomyoma* (benign tumor of skeletal muscle) - *rhabdomyosarcoma* (malignant tumor of skeletal muscle, *most common soft tissue sarcoma in children, most frequent site is the head and neck*)

How do you diagnose urticaria?

- *look for clinical manifestation* (hives) - *obtain detailed MH* from pt, what have you eaten? what have you been in contact with? insect bites? - *consider food diary*

Oral sarcoidosis lesions, clinically?

- *oral lesion is initial manifestation in 2/3 of pts*: submucosal mass, erythematous macules, granular area, ulceration, normal color, brown-red, violaceous, hyperkeratotic - buccal mucosa, gingiva, lips, tongue, palate - *25% of intraoral reported cases are intraosseous*

What is tx for thrombocytopenia (severe)?

- *platelet transfusion* - *rhEPO* - *DDAVP*: desmopressin hormone, depresses urine output - *Cryoprecipitate*: frozen components of plasma that contain clotting factors and fibrinogen

Radiographic features of Paget's?

- *progressive jaw bone enlargement* - maxilla affected more than mandible - *increased spacing of teeth* skull affected: "cotton wool appearance" and pt complains of head aches and feeling dizzy early: linear pattern of trabeculation middle: hypercementosis (granular appearance) late stage: cotton wool appearance, hypercementosis, spacing of teeth

Histo of schwannoma/neurilemoma?

- *thin fibrous capsule* all the way around - *verocay bodies* very characteristic

What is the tx of sarcoidosis?

- 60% of cases resolve within 2 years - initial diagnosis -> 3-12 mo observation -> active intervention as needed - first line tx: corticosteroids - refractory dx: cytotoxic drugs (methotrexate, azithioprne), TNF blockers, hydroxychloroquine) - *4-10% die of pulmonary, cardiac, or CNS complications*

How is Hodgkin's lymphoma diagnosed?

- CBC - Biopsy (FNA LN), scalpel biopsy

What are the laboratory findings in multiple myeloma?

- CBC: anemia, circulating plasma cells - electrolyte/metabolic panel (creatinine, calcium, and total protein elevated), monoclonal spike (M protein) - urine analysis (Bence jones proteins in urine: fragments of immunoglobulin) - BM bx: % plasma cells - biopsy of radiolucent lesions: plasmacytomas

How is lymphoma treated? SE?

- Chemo and radiation (side effects: mucositis and candidiasis) - BM transplant

What are other causes of oral melanosis other than racial pigmentation?

- Drug induced: poorly understood reaction of melanocytes to particular medications chloroquine (anti-malarial) cyclophosphamide (cancer chemotherapy) amiodarone (cardiac arrhythmia) zidovudine (HIV) minocycline: may affect melanocytes but usually stained bone cortex shows though thin translucent gingiva/mucosa

What will SS lab values be?

- ESR and IgG elevated (non specific signs of inflammation) - Autoantibodies Rh factor (60% of cases) Antinuclear antibodies (ANAs 75% of cases) Anti-SS-B Anti-SS-A (50% of cases)

Angioedema - IgE mediated, causes?

- Hypersensitivity reaction (drugs, foods, plants, dust) - Contact allergic reactions (foods, cosmetics, topical medications, rubber dam) - Physical stimuli (heat, cold, exercise, emotional stress, solar exposure, vibration)

What are some causes of angioedema?

- IgE mediated - drug rxn to ACE inhibitors - hereditary or acquired activation of complement pathway - other (high levels of antigen-antibody complexes and in elevated blood eosinophil counts)

Nevoid Basal Cell Carcinoma Syndrome (Gorlin Syndrome)

- PTCH mutation (autosomal dom) - BCC of skin - odontogenic keratocysts***, multiple and early - intracranial calcifications - rib and vertebral anomalies - palmar and plantar pitting

What rare syndromes are associated with oral melanotic macule? What are they?

- Peutz-Jeghers syndrome (autosomal dom. mutation of a serine-threonine kinase gene which leads to *intestinal polyps not premalignant*, oral and dermal pigmentation and gonadal tumors (Sertoli cell tumors) - Addison's disease (adrenal insufficiency) increased ACTH secretion from the ant. pituitary is associated with MSH (melanocyte stimulating hormone) production, which leads to increased melanin production by melanocytes

What is a primordial cyst?

- RARE, thought to originate from degeneration of enamel organ - occurs in place of tooth, *usually 3rd molars* *no hx of impacted tooth or ext*

What is adenoid cystic carcinoma (cylindroma)? location? age? clinical? prognosis?

- a common and well recognized malignant salivary gland tumor, *palate is most common site* - both major and minor glands (50% minor) age: most common in middle age adults, rare in children slow growing tumor, palate most common, *PAIN* (infiltrates around nerves) *perineural infiltration* tx: surgical excision, often adjuvant radiation prognosis: poor! recurrence common with eventual distant metastasis**

What is monomorphic adenoma? location? age? clinically? tx?

- a group of benign salivary gland tumors that have a more uniform histopathologic pattern than the pleomorphic adenoma - may be major or minor salivary glands location: upper labial mucosa, buccal mucosa 2nd most common ADULTS usually clinically: slow growing, painless mass, with normal overlying mucosa - ulcerated in traumatized tx: surgical excision note histo is *UNIFORM* (much diff than pleomorphic adenoma), *single layered ducts* but a uniform pattern look like bone trabeculae

How will sialadenitis appear on histo?

- acute (neutrophils) or chronic (lymphocytes/macrophages/plasma cells) inflammatory cell infiltrate in the salivary gland chronic form: salivary glands replaced by fibrous connective tissue and fat

What are contraindications of sialogram?

- acute inflammation of salivary gland - known sensitivity to iodine-containing agents, esp previous hx of adverse rxn to contrast media for imaging - anticipated thyroid function tests

What is sialadenitis? Causes?

- acute or chronic inflammation in major or minor salivary glands causes: - obstruction of a salivary gland duct - infection - decreased salivary flow parotid gland = parotitis

What is erythema multiforme? caused? population? clinically?

- acute vesiculobullous, ulcerative mucocutaneous disorder - immunologically mediated - diverse spectrum of presentations "multiforme" - *healthy young adults* in 20-40s - target lesions on skin (may have, not always, target with concentric rings) - prodrome (rare in minor form)

What is a high grade mucoepidermoid carcinoma? clinical? histo? tx? prognosis?

- aggressive malignant tumor - histo shows necrosis, neural invasion, and mitotic activity - generally solid, firm tumor with few cysts and mucous cells tx: surgery plus radiation prognosis: poor

What is plasma cell gingivitis? Tx? Biopsy will show:

- allergen causes mass infiltrate into gingival tissues - diet log to identify allergen, allergy testing Tx: topical steroids Biopsy: proliferation of benign plasma cells

What are the radiographic features of a simple bone cyst? Tx?

- almost exclusively seen in MANDIBLE - periphery varies from well defined corticated to ill defined that blends with surrounding, *radiolucent internal strucure* - shape is often *smooth and curved* - *lesions have propensity to scallop esp. b/t roots* - *grow along bone, DO NOT expand cortical margins* - leaves lamina dura/PDL intact or may obscure their appearance tx: surgical curettage - spontaneous healing reported

What is carcinoma Ex Pleomorphic Adenoma? clinically? tx? prognosis?

- also called Carcinoma ex Pleomorphic adenoma - typical hx of slow growing long-standing PA which suddenly enlarges rapidly, becomes painful or ulcerates tx: wide surgical excision, possible radiation poor prognosis

Tx for sialadenitis:

- antibiotics - rehydration - surgical drainage - surgical removal of the affected gland

What is the tx of angioedema?

- antihistamine/IM epi/IV corticosteroids - intubation and tracheostomy - avoid medications in ACE inhibitor class of drugs - C1 esterase inhibitor concentrate and esterase inhibiting drugs

Tx of urticaria?

- avoid known triggers - antihistamines - corticosteroids

SLE treatment?

- avoid sunlight - NSAIDs (reduce inflammation) - Antimalarial drugs *hydroxychloroquine* (decrease lupus symptoms) - severe/acute episodes - systemic corticosteroids - immunomdulators

Tx of CCLE?

- avoid sunlight - topical corticosteroid - topical calineurin inhibitor - resistant conditions- systemic antimalarials, immunosuppressives

Causes of bilateral enlargement of submandibular area:

- bacterial or viral sialadenitis (rarely mumps) - SS - branchial cleft cyst - submandibular space infection

What are the radiographic features of focal osteoporotic marrow defect?

- because it is a variation of normal anatomy, not a true pathology, periphery varies from well to ill defined - no effect on adjacent osseous and dental structures - if closely associated with teeth *lamina dura and PDL intact* - no tx required, monitoring is suggested or refer to oral radiologist

What is tx of oral melanoacanthoma?

- because of alarming growth rate, *incisional biopsy usually indicated to rule out possibility of melanoma* - once the diagnosis is established, no further tx needed - in several instances, lesions undergo *spontaneous resolution after incisional biopsy*

How does Hodgkin's lymphoma present? clinical features?

- begins in 70-75% cervical/supraclavicular -painless, unresolving - night fevers, malaise *Bimodal* 2 age groups: 15-35 yrs and over 50 *stays confined for LN chains doesn't have extra nodal spread

What are characteristics of neurofibroma?

- benign - arises from peripheral nerve tissue - slow growing, *painless*, vary in size - skin more common than oral mucosa - *may develop centrally in bone* uni or multilocular radiolucency usually posterior mandible

What is oral melanoacanthoma?

- benign and uncommon acquired pigmentation of oral mucosa characterized by dendritic melanocytes dispersed throughout epi - reactive process - seen almost exclusively in *black individuals* shows a *female* predilection and is most common in *3rd-4th decades of life* - buccal mucosa is MOST COMMON site - lesion is *smooth, flat, or slightly raise, and dark-brown to black in color* - often demonstrates a RAPID increase in size and mat reach a diameter of several centimeters within a period of a few weeks!!

What are some causes of BILATERAl enlargement of the parotid areas?

- benign lymphoepithelial lesion - SS - alcoholism - medication (iodine) - warthin's tumor - if painful: related to history of radiation tx or bacterial or viral sialdenitis (mumps)

What are characteristics of Schwannoma/neurilemoma?

- benign neoplasm of Schwann cell origin - uncommon lesion: 28-48% occur in the head and neck - most common in young and middle aged adults - may present with *pain*

What are characteristics of granular cell tumor?

- benign tumor derived from schwann cells - oral cavity is the most common location - vast majority of cases seen on *dorsal tongue* - age: 40-60, rare in children

What are characteristics of hemangiomas?

- benign vascular tumor - rapid growth phase and then gradual involution - more common in *females* than males 3:1 many congenital (born with them) others appear later on in life (in which case they sometimes do not involute) venous malformations present at birth and persist throughout life

Tx for aplastic anemia?

- blood transfusions - immunosuppressive tc - allogeneic stem cell transplant

Why is oral mucosa less sensitive to allergic contact stomatitis?

- brief contact time - saliva dilutes antigen - limited keratinization of mucosa - high vascularity - lower density of langerhans cells and T lymphocytes

What are the oral manifestations of HIV infection?

- candidiasis (sometimes first manifestation) - oral hairy leukoplakia (EBV virus) - kaposi sarcoma (HHV8) - non-hodgkin lymphoma - periodontal disease

What's the histo of hemangioma/venous malformations? Tx?

- capillary and cavernous types this is why as a general dentist NEVER biopsy something vascular you have no idea what kind of bleeding risk is going on Tx: monitor and leave it alone if confident it's vascular and NOT affecting function. If cosmetic issue or affecting function/bleeding send to OS! They might inject a sclerosing agent prior to excision

Histo of granular cell tumor?

- cells with granules - overlying mucosa proliferates, so it looks like there are little islands of epithelium (can be confused for SCC!!)

What is a buccal bifurcation cyst? clinical? radiographic? tx?

- characteristically develops on *buccal of manidbular 1st molars* - age: 5-11 - *swelling, purulent, tender, perio pocket* - well circumscribed unilocular radiolucency, *roots tilt lingually* tx: enucleation of cyst, can response spontaneously, can resolve with daily irrigation of buccal pocket w/ saline/hydrogen peroxide

What is sjogren syndrome?

- chronic, systemic autoimmune disorder - xerostomia and xerophthalmia - keratoconjunctivitis sicca lymphocytes move into salivary and lacrimal glands --> less flow

What tests can be used for SLE diagnosis?

- clinical - microscopic features - DIF - lupus band test (differentiates it from chronic) - serologic test (ANA, anti-dsDNA, anti-Sm) BM zone will have band of immunofluorescence 95% have anti nuclear anitbodies ANA 70% have anti-dsDNA 30% show anti bodies to anti-Sm****** *Anti smith is most specific!!*

How do you diagnose sarcoidosis?

- clinical appearance - radiographic presentations (hilar lymphadenopathy) - histopath appearance (granulomas, maybe shaumann or asteroid bodies) - *elevated ACE levels (60%)* - pulmonary involvement (difficulty breathing due to granulomas) - skin test-Kveim test (no longer performed) - minor salivary gland biopsy/parotid gland biopsy

How is CREST syndrome diagnosed?

- clinical features - lab studies: anti-centromere antibodies

How is angioedema diagnosed?

- clinical presentation - ascertain the antigenic stimulus - evaluate for normal levels of functional C1-INH

How do you diagnose Granulomatosis with polyangiitis?

- clinical presentation - histopath - radiographic eval of chest and sinuses - indirect immunofluorescence for serum antibodies: ANCA=anti neutrophil cytoplasm ic antibodies, *PR3-ANCA (90-95%)*, MPO-ANCA (not as useful since seen in other vasculitides) - *ELISA test for antibodies against PR3*

What is an epidermoid cyst?

- common cyst of the skin, lined by epidermis-like epithelium - often associated with inflamed hair follicle - rarely occurs intra-orally - M > F histo: cyst lined by stratified squamous epi w/ prominent granular cell layer, lumen filled with degenerating orthokeratin - association with Gardner Syndrome yellowish nodule filled with keratin rare

What are other rare causes of angioedema?

- complexes in lupus, viral, and bacterial infections - pts with grossly elevated blood esoinophilia

What is primary cyclic neutropenia? mutation?

- congenital defect in number of neutrophils periodic reduction of neutrophils (q 3 weeks) neutrophils very low for 6 days mutation of *ELA-2* or ELANE gene

What can you do for pts with medication-induced salivary hypofunction?

- coordinate with prescribing physician - reduce drugs with strong anti-cholinergic side effects - reduce redundant drugs (i.e. multiple drugs for same indications) - change to less xerogenic medication - alter dose

Histo of lateral peridontal cyst?

- cyst lining: 1-3 cell layers thick, flattened to cuboidal cells, *plaque like thickenings containing clear cells* - cyst wall: little to no inflammation, may contain odontogenic rests w/ clear cells

Histo of OKC?

- cyst lining: thin, *uniform* layer of stratified squamous epithelium 6-8 cells thick - cyst lumen: may contain *keratinaceous material cheesy material* or clear liquid - cyst wall: devoid of inflammation, satellite cells or odontogenic epi 7-26% cases - *parakeratotic, corrugated surface - flat interface w/ CT no rete ridges - *palisaded prominent basal cell layer* - basilar budding may be present

What is a dentigerous cyst? radiographic key feature? tx?

- cyst that originates from follicle around crown of an unerupted tooth - ALWAYS *associated with an impacted tooth* - *attached at the CEJ* - mandibular 3rd molars most affected - well defined *unilocular radiolucency surrounding crown of an impacted tooth* - *radiolucency should be greater than 3-4mm* tx: surgical excision of tooth with attached lesion

Histo of dentigerous cyst:

- cyst wall: loosely arranged CT wall containing abundant glycosaminoglycan ground substance. Inactive rests of odontogenic epi often present - cyst lining: 2-4 layers flattened epi w/ flat CT interface

Histo of mucocele?

- cyst-like space in soft tissue - lined by compressed granulation tissue (no epi) - lumen filled with mucin, foamy macrophages and inflammatory cells

Histo of Periapical Cyst

- cystic cavity lined by stratified squamous epithelium which may exhibit (exocytosis, spongiosis, hyperplasia, rushton bodies) - cyst lumen: cellular debris and fluid - wall: fibrous CT, inflammatory cells, multinucleated giant cells, cholesterol clefts, hesmosiderin deposits

Tx of NUG and NUP?

- debridement - antimicrobial therapy - pain management - long term maintenance

What factors affect unstimulated flow:

- dehydration - body posture - lighting conditions - circadian/cirannual rhythm (lowest during sleep) - medications - *age is an independent factor for whole saliva and submandibular/sublingual gland secretion (but not parotid)*

What are the radiographic features of cleido-cranial dysplasia?

- delayed closure of cranial sutures radiolucent lines running down the head (failed to close at proper time) - prolonged retention of primary teeth - delayed eruption of permanent teeth - multiple supernumerary teeth - narrow high arched palate - increased prevalence of cleft palate

Clinical implications/bleeding in pts with hemophilia?

- delayed type 3-5 days post surgery - life threatening if severe enough - slow continuous oozing for days

What is the medical management of hemophilia?

- depends on severity, nature of bleed, presence of factor inhibitors (which can lead to *immune rxn vs. transfused factor*) - commercially prepped F complex concentrate - high purity ones are costly (treated to reduce risk of transmitting viruses)

What is a lateral periodontal cyst? clinical? radiographic? tx?

- developmental cyst believed to develop from dental lamina rests - intra bony counterpart of gingival cyst of adult - occurs on lateral aspect of aspect of a tooth root, tooth is *vital*, 75-80% affect *mandibular PM, canine, lateral incisor area* - 5-7th decade radiographic: well defined radiolucency lateral to tooth root, often unilocular, occasionally multilocular tx: *enucleation, recurence low*

What is fibrous dysplasia?

- developmental lesion characterized by substitution of normal bone by poorly organized woven bone and fibrous tissue - *GNAS1 gene* mutation, potential diagnostic adjuvant, not found in normal bone tissue - no gender predilection, typically *pediatric and young adults* - clinically: *can cause bone expansion and asymmetry*, most typical presentation of monostotic fibrous dysplasia is *slow growing painless enlargement* - present a self limiting course, tending to stabilize

What are some clinical characteristics of SS?

- difficulty swallowing - altered taste - difficulty wearing denture - tongue fissured - atrophy of papillae - red and render oral mucosa - lack of salivary cleansing-dental decay

What is the histopath of systemic sclerosis?

- diffuse deposition of dense collagen in normal structures

What is angioedema?

- diffuse edematous swelling of soft tissues, most comonly SC and SM CT - results from vasodilation and increased vascular permability of *DEEPER* blood vessels (this is why you don't see slight raised appearance its more diffuse) not painful

Orofacial granulomatosis tx?

- discover cause - topical or intralesional corticosteroids - other (topical tacrolimus, sulfazalazine, methrotrexate, etc) - some cases resolve spontaneously

Angioedema - ACE inhibitor associated characteristics and tx?

- does NOT respond well to antihistamines - 0.1%-0.2% of those who use ACE inibitors - may be immediate or delayed - *dental procedures may precipitate an attack*

What are some qualitative causes of thrombocytopenia?

- drugs, ASA, NSAIDs, ETOH, Clopidogrel - uremia, dialysis - myeloproliferative D/O - several inherited disorders

Intraorally how can orofacial granulomatosis present?

- edema - ulcers - papules - erythema - pain - fissured tongue - parathesia - taste alterations - "cobblestone" appearance of edematous mucosa (buccal mucosa) - linear hyperplastic folds w/ ulcerations in base (note this is also seen in crohns** so GI workup to rule this out)

What are clinical features of adenomas (benign tumors)?

- encapsulated - freely movable - slow growing - non-tender

Tx of OKC:

- enucleation - curretage - marsupialization - peripheral ostectomy - carnoy's solution - resection - long term follow up significant recurrence *30%*

Cysts of Newborns (3): prevalence? tx?

- episteins pearls: along median palatal raphe - bohns nodules: hard palate near soft palate jxn - gingival cysts: occur on alveolar mucosa *All quite common 65-85% of newborns* small superficial keratin filled cysts clinically: yellowish-white papules often occur in clusters no tx, spontaneously involute

Histo of the nasopalatine canal cyst?

- epithelial lining varies from squamous to respiratory (pseudo stratified ciliated columnar) - CT contains the nerves and blood vessels that are normally found in the area (mucous glands in wall, nerves, and blood vessels)

What will lab values reveal in SS?

- erythrocyte sedimentation rate is high - serum immunoglobulin levels are elevated - positive rheumatoid factor - 75% - antinuclear antibodies present in most cases - two specific anti nuclear antibodies *anti-SS-A and anti-SS-B*

Female pt presents stating "I have a bump on my lower gums" Pt has med hx sig. for T2D and HTN treated with meds She states that the area is sore, difficult to brush properly, and bleeds easily clinically: interdental papilla gingival lesion, facial between 26 and 27, round erythematous next steps? differential? histo showed: giant cells

- excisional biopsy and SRP involved teeth - pyogenic granuloma (most common by far) - peripheral giant cell granuloma - peripheral ossifying fibroma *peripheral giant cell granuloma*

Allergic contact rxns, non mucosal? cause?

- exfoliative cheilitis-dry, scaly, fissured, cracking lips - 25% of cases contact cheilitis - medications, lipsticks, sunscreens, toothpaste, floss, cosmetics can occur from dental implants!

Amalgam tattoo often results due to what procedures?

- extremely common due to past use of amalgam. Often result of material implanted into inflamed gingiva. - secondary to apicoectomy - secondary to prep of amalgam core for crown prep - occasionally visible on radiographs when material is large enough

Histo of Periapical granuloma?

- fibrous and granulation tissue - mixture of: lymphocytes, plasma cells, neutrophils, histiocytes

What is the first clinical sign of granulomatosis with polyangiitis? other signs?

- first signs: *recurrent respiratory infection, cough, or runny nose* - joint pain, weakness, tiredness - *saddle nose deformity* - oral lesions initial presentation in 2% of pts

Radiographic features of idiopathic osteo-sclerosis:

- focused area of increased radiopacity - well-defined area of homogenous radiopacity - "finger-like" projections (normal bone trabecular radiate into the area of dense bone) - more common in mandible - may occur anywhere along the alveolar bone - if present periapically, may obscure lamina dura and/or PDL

List of agents that can cause allergic contact stomatitis?

- foods - food additives - chewing gums - candies - dentrifices - mouthwashes - gloves - rubber dam material - topical anesthetics - restorative metals - acrylic denture materials - dental impression materials - denture adhesive preparations - cinnamon (mainly artificial flavoring)

What is granulomatosis with polyangiitis? cause?

- formerly called "Wegner's" - type of vasculitis of blood vessels - sinuses, trachea, lungs and kidneys - unknown cause - necrotizing granulomas may be seen - mean age = 41 years

Where are minor salivary glands NOT found?

- gingiva and attached alveolar mucosa - mid palatine raphe - anterior hard palate w/ exception of incisive papilla area - dorsal of tongue anterior to circumvallate papillae

What influences saliva composition?

- gland source - flow rate - type/length of sitmulation - circadian rhythms - others: diet, hormonal (pregnancy), exercise, drugs, various diseases, genetics

What is simple in office sialometry?

- graduated plastic tube (>10ml with 0.1ml divisions) - collect after overnight fast or >1.5hrs post prandial - quiet environment unstimulated flow: seated, bow head, swallow, start clock, allow saliva to drip out of mouth for 5 mins, measure flow rate in ml/min stimulated flow (if USFR rate <0.1-0.2ml/min): chew with flavorless gum base (+) or lemon-flavored candy (++), or challenge with pilocarpine (5mg/wait 30 mins) or cevimeline (30mg/wait 90 mins)

Histopath of sarcoidosis:

- granulomatous inflammation - aggregates of epithelioid histiocytes with a rim of lymphocytes (langhans or foreign body type giant cells, *schaumann bodies*, asteroid bodies) - special stains for fungal (GMS) and bacterial (AFB) organisms negative - no polarizable or pigmented foreign material can be detected

MEN syndrome is: type associated with oral cavity? risk of?

- group of rare conditions - autosomal dominant - types 1, 2A, 2B, or 1, 2, 3 *type 2B or 3 associated with oral cavity* - multiple mucosal neuromas - multiple tumors and hyperplasia of endocrine organs - *increased risk of thyroid cancer* characteristic facies: *marfanoid appearance*, thickened eyelids

What are the vascular tumors?

- hemangioma - angiosarcoma - kaposi's sarcoma - lymphangioma - lymphangiosarcoma

What is Gardner's Syndrome?

- hereditary condition by mutation APC on chromosome 5 - autosomal dominant - form of *familial multiple polyposis* where multiple intestinal polyps are formed. these polyps have a strong predilection to undergo malignant transformation that ultimately transform to *ADENOCARCINOMA* - formation of *epidermoid cysts* (non cancerous nu,mps beneath skin) - formation of SC *desmoid tumors* (benign of CT) - increased *prevalence of thyroid carcinoma 100 fold increase in females*

Who does xerostomia affect?

- higher in W vs M - higher in elderly *>30%* - highest in *institutionalized elderly* - higher if med conditions/med use - higher if compromised dental status - Sjogren's syndrome and head and neck radiation (100%)

Orofacial granulomatosis diagnosis?

- histopath - rule out systemic disease and local processes (a strict case definition of OFG requires the exclusion of concomitant systemic granulomatous disease) - consider allergy testing - consider thorough GI evaluation (Crohn disease is often present in younger population)

When working with a dry mouth patient who cannot make saliva in response to stimuli, tx?

- if dehydrated: rehydrate or treat underlying condition (i.e. DM) - salivary substitutes - minimize damage to salivary glands - prevent and tx oral complications (gels have more long lasting lubrication)

Oral consequences of long standing xerostomia?

- increased frequency of caries (*class V and class VI*) - dysarthria - dysphagia - dysgeusia - proclivity toward candidal infection - burning tongue/depapillation - oral mucosal soreness - dry, sore, cracked lips - salivary glands enlargement (various causes)

General clinical features of adenocarcinomas?

- infiltrative - fixed - rapid or slow growth, depending on grade and type of malignant salivary gland tumor - larger, rapidly growing lesions may cause pain and/or paresthesia - ulcerated overlying mucosa

Histopath of granulomatosis with polyangiitis:

- inflammation around blood vessels - histiocytes, lymphocytes, eosinophils and multinucleated giant cells - special stains are negative - no foreign material

What are the characteristics of Subacute Cutaneous Lupus Erythematosus?

- intermediate - skin lesions characterized by photosensitivity - may have oral lesions - arthritis and musculoskeletal problems - may be triggered by medications - tx: stop meds or topical steroids **no kidney or neurological problems *Antibodies to histones, anti nuclear antibodies* USUALLY DRUG INDUCED (CCB and ACE inhibitors)

What is the clinical history of necrotizing sialometaplasia?

- intially appears as a non ulcerated swelling of palate - often associated with pain or paresthesia - within 2-3 weeks, necrotic tissue sloughs off and becomes a crater-like ulcer - no tx, spontaneously resolves within 6-10 weeks "a chunk of the roof of my mouth fell out"

What are radiographic features of Gardner's Syndrome?

- jaw bone osteomas (osteomas: benign tumor of bone - bone forming bone) (can occur in sinuses as well, in class showed - odontomas - supernumerary teeth - impacted teeth - multiple dense bone islands (diffuse radiopacities on pan)

What is the histopathology of SLE?

- keratin thats plugging into hair follicle - patchy inflammatory infiltrate KEY: looks similar to lichen planus with loss of basal cells and inflammatory infiltrate subjacent to the epithelium BUT in BM zone you'll have a thicker membrane with patchy deposits of PAS positive material will need DIF for specific diagnosis

How is SS diagnosed?

- labial salivary gland biopsy - auto antibody tests (look for Anti-SSA** and Anti-SSB) - ocular staining score - schirmer - USFR

How does sarcoidosis of eyes and salivary glands present?

- lacrimal gland keratoconjunctivitis sicca - salivary gland: xerostomia - mimics Sjogren syndrome (so SS on differential)

What is chronic neutropenia? etiology? oral manifestations?

- lasting >6 months - congenital, acquired or idiopathic (ELA2 mutation might be involved) - life threatening - recurrent gingivitis, severe periodontitis starting in early childhood, bone loss, ulceration Tx: G-CSF (Neupogen) at higher doses. Prior to this many died from bacterial sepsis within 1st yr of life

What are the characteristics of Chronic Cutaneous Lupus Erythematosus (CCLE)?

- lesions limited to the skin or mucosa - *discoid lupus erythematosus* (hyper and hypo pigmented lesions) - scaly erythematous patches on sun exposed skin - oral lesions look like erosive lichen planus

What are HIV associated periodontal disease manifestations?

- linear gingival erythema (doesn't respond to plaque control may need CHX) - necrotizing ulcerative gingivitis (punched out, ulceration and necrosis of interdental papillae w/ no perio attachment loss, halitosis) - necrotizing ulcerative periodontitis (gingival ulceration and necrosis associated w/ rapid loss of perio attachment)

What is necrotizing sialometaplasia?

- locally destructive inflammatory condition - salivary gland ischemia - predisposing factors (local trauma, palatal injection of LA, previous surgery) some idiopathic, sometimes bilateral! least common totally benign condition

How does sarcoidosis affect organ systems?

- lungs - lymph nodes (bilateral hilar lymphadenopathy 95% of people w/ sarcoidosis *popcorn like calcifications*) - skin (25% of time) - eyes - salivary glands - other (endocrine, GI, heart, kidney, liver, nervous system, spleen, skeletal)

What are sarcoidosis skin lesions called/presentation?

- lupus pernio (nose, ears, lips and face) erythematous hard violaceous purplish lesions - erythema nodosum (lower legs) diffuse areas of redness somewhat tender

Pts with SS are at higher risk of:

- lymphoma 5-15% - consider benign lymph-epithelial lesions that are truly lymphoma - MALT lymphoma - mucosa associated lymphoid tissue lymphoma

What is cleido-cranial dysplasia?

- malformation syndrome, abnormal or complete loss of clavicle, short stature, frontal/parietal bossing (light bulb shaped head), maxillary hypoplasia, broad base of nose w/ depressed nasal bridge, *delayed eruption* - autosomal dominant - no gender predominance - caused by mutation in RunX2 gene on chromosome 6 *know that this is caused by a genetic mutation* he won't ask gene names

Histo of kaposi's sarcoma?

- malignant proliferation of spindle cells - extravasted RBCs higher power: lots of mitotic activity

How is systemic sclerosis treated?

- management difficult (limited benefit with corticosteroids) - symptomatic management calcium channel blockers to increase peripheral blood flow and to help decrease raynauds ACE inhibitors to tx pulmonary hypertension (lungs scarred over, airways hardened) collapsable dentures hard time with OHI

What is a periapical granuloma? Radiographically? Tx?

- mass of tissue at apex of NONvital tooth ( no response to thermal/electric pulp test) - may arise from PA abscess, may --> periapical cyst - most asymptomatic - *loss of apical lamina dura* *root resorption possible* Tx: Endo or Ext/curretage

What can you do to help pts stimulate saliva?

- masticatory stimuli (harder diet, increase number of meals, sugarless chewing gum) - gustatory stimuli (citric acid) - Rx meds - electronic stimuli - acupunture

What are radiographic features of fibrous dysplasia?

- maxilla 2x > mandible - ill defined borders, blends in with surrounding bone - variable density and orientation of the trabecular patient (radiolucent, radiopaque or a combination) *ground glass appearance* *peau d'orange* *cotton wool* appearance *fingerprint pattern*

What is the oral manifestation of SLE?

- may appear lichenoid or granulomatous - lupus cheilitis - other oral complaints but no direct association: xerostomia, stomatodynia, candidiasis, perio disease, dysgeusia some shallow ulcerations and lesions on palate (often not painful)

What causes the sensation of xerostomia in the ABSENCE of measurable salivary hypofuntion ?

- may be a reduction in baseline sialometry which is still above "normal" - saliva film thickness (palatal glands produce mucous = thickness) - relative contributions by glands (more watery saliva may make pts feel dry) - alterations in sensory perception - mental status/central inhibition

What are the surrounding effects of fibrous dysplasia?

- may have no affect - expansion and thinning of cortical walls - displacement of teeth - one of the few entities that cause *SUPERIOR displacement of the mandibular canal*

What factors affect stimulated saliva flow?

- mechanical stimuli - vomiting - gustatory/olfactory stimuli (acid especially) - gland size *Age is an independent factor for whole saliva (but not for parotid and minor gland secretions)*

What is a blue nevi?

- melanocytes cells are spindle shaped, deeper in the CT, parallel to surface

What is an intramucosal nevi?

- melanocytes nevus cells collect in aggregates within the sub-epithelial CT

What are the oral manifestations of systemic sclerosis?

- microstomia: "purse string" - gingival recession - dysphagia (CT of esophagus becomes hard) - xerostomia (possible secondary sjogrens syndrome)

What is localized scleroderma or morphea?

- milder condition - affects only a solitary patch of skin - "coup de sabre"

What is a low grade mucoepidermoid carcinoma? clinical? histo? tx? prognosis?

- mimics benign neoplasm - contains mucous pools; thus compressible - histologically has abundant mucous cells and prominent cyst formation tx: surgery prognosis: good

What is odontogenic keratocyst? population? clinical? radiographic? tx?

- more aggressive than other cysts - origin from dental lamina rests - 10-40 yrs, male predilection - *posterior mandible and ascending ramus most common* - may or may not cause pain and swelling - *OKCs will grow in an A/P direction before causing bony expansion* - multiple cysts indicate presence of associated syndrome radiographic: well defined radiolucency w/ smooth often sclerotic margins, uni or multilocular, unerupted tooth associated w/ lesion 25-40% of time, root resorption possible - IAN may be displaced towards inferior border of mandible tx: incisional biopsy, see if need enucleation, or resection etc

How does oral granulomatosis present clinically?

- more commonly adults - lips common - non-tender, persistent swelling - Melkersson-Rosenthal syndrome = lip swelling + facial paralysis + fissured tongue - cheilitis granulomatosa = involvement of lips alone remember *this is a diagnosis of exclusion* (rule out systemic disease and local causes)

Characteristics of Mucoepidermoid carcinoma?

- most common salivary gland malignancy - associated w/ both major and minor glands: *parotid most common*, minor glands next most common - broad age range 2nd - 7th decade - *the most common salivary gland tumor in children* clinical: usually slowly enlarging mass *VARIABLE COLORS, more compressible*

Radiographic features of central giant cell granuloma? Tx?

- mostly noted as an incidental finding - occurs most in mandible (from CT to 1st molar region) than maxilla (CI to canine region) - tendency to *cross midline* - well defined margin, may or may not be corticated - internal structure *radiolucent*, may be presence of septae which give it multilocular appearance - lesion has tendency to *expand cortical boundaries, displace, and resorb teeth* Tx: incisional biopsy for dx, followed by complete incision for definitive tx

What is a ranula?

- mucocele like lesion that forms unilaterally on the floor of the mouth - may break through mylohyoid muscle and enter neck space "plunging ranula" - associated with the *ducts of the sublingual and submandibular glands* big and deep blue color if exophytic (sometimes deeper, then can't see blue blue as much)

Histo of mucoepidermoid carcinoma? Tx?

- mucous cells, epithelial islands, cysts tx: is related to grade and location

What is tx of multiple myeloma?

- multidisciplinary appraoch - consult oncology, chemo/XRT - bisphosphonate therapy (BRONJ) - OMFS - mand fixation for fractures prognosis has greatly increased over last 10 years!

Key microscopic features of pyogenic granuloma?

- multiple variously sized blood vessels and inflammatory cells (usually acute neutrophils)

What are characteristics of SLE?

- multisystem: skin/oral, kidneys, cardiac - precise cause is unknown, increase in activity of humoral limb of immune system - women - fever, weight loss, arthritis, fatigue - "flares" most serious type of lupus

How is SLE diagnosed?

- musculoskeletal signs - cutaneous signs - hematologic signs - neurologic signs (seizures, headaches) - cardiopulmonary signs (pericarditis) - renal signs (proteinuria, ESRD)

What is a residual cyst?

- must have history of extraction - well defined unilocular radiolucency histo: lumen, lining, wall v non specific

What is the etiology and treatment for cyclic neutropenia?

- mutation in neutrophil elastase *ELA2 gene* - arrested development of neutrophils in promyelocyte stage in BM - premature apoptosis of myeloid precursor ells frequency 1/1,000,000 *autosomal dominant inheritance* pattern with isolated cases described tx: *G-CSF 30ug/kg* respond in 1-2 weeks. Antibiotics, oral hygiene regimen

Less common oral manifestations of HIV infection?

- mycobacterium tuberculosis - mycobacterium avian intracellulare - melanotic hyperpigmentation - necrotizing ulcerative stomatitis - salivary gland disease (dry mouth, swelling of major glands) - thrombocytopenia purpura - oral ulcerations (NOS) - viral infections: HSV, HPV, VZV

Although biopsy is NOT needed for necrotizing sialometaplasia, what would biopsy reveal?

- necrosis of the salivary glands - salivary gland duct epithelium is replaced by squamous epithelium - appear as islands of squamous epithelium deep in the CT - *can be misdiagnosed as a malignancy*

What are the 4 neural lesions that occur in the oral cavity?

- neuroma - neurofibroma - schwannoma (neurilemoma) - granular cell tumor tend to favor the tongue

What are oral nevus/nevi? prevalence? most common type? location?

- nevi are benign proliferations of nevus cells in the epithelium, CT or both - rare: less than 1% - broadly classified as congenital or acquired - intramucosal nevus (FLAT) >>50%, blue nevi (flat with white clearing)25-36%, junctional and compound nevi account for only 3-6% - location: hard palate 40%, buccal mucosa 20%, other sites: labial mucosa/lip, gingiva. Very rare on tongue/floor of mouth

What is central giant cell granuloma? general features?

- non neoplastic and expansile lesion of unknown etiology - slow growing (may exhibit aggressive behavior) - *common in adolescence/young adults, female predominance* - *painless swelling* histo: primarily fibroblasts, numbers vascular channels, *multinucleated giant cells* and macrophages

Histopath of orofacial granulomatosis?

- non-caseating granulomatous inflammation - granulomas cluster around blood vessels - less discrete granulomas than in sarcoidosis - special stains for fungal and bacterial organisms are negative** this will be on test realize its an diagnosis of exclusion - no polarizable foreign material

What is lymphoid hyperplasia?

- normal response to allergy, infection - increased size of lymphoid tissue: waldeyer's ring (lingual, tubal, adenoid, palatine tonsils) lymphadenopathy

What is an aneurysmal bone cyst? General features? Radiographic?

- not a true cyst - rare, unknown etiology - similar histo/radio to CGCG - blood filled spaces lined by cellular fibrous CT - most common in *first three decades of life* slight female predilection - presents as a swelling *that rapidly grows, pain is occasionally accompanied* RADIOGRAPHIC: - Mandible >> maxillae - ramus is also commonly involved - well defined borders - radiolucent internal structure, septae may be present to give lesion multilocular appearance - *significant expansion of cortical boundaries is a common feature* teeth may be subject to displacement and resorption

Histopath of Erythema Multiforme:

- not pathognomonic - subepithelial or intraepithelial vesiculation may be seen in association with necrotic basal keratinocytes - mixed inflammatory infiltrate (neutrophils lymphocytes and eosinophils) - perivascular orientation of inflammatory infiltrate

What are oral manifestations of polycythemia?

- oral mucosa appears deep red - glossitis - gingiva appears edematous and bleeds easily - consequent "crowding out" of WBCs and platelets and decreases their function (can lead to more *bleeding*)

What are OTC salivary stimulants?

- oramoist - biotene - xylichew - therabreath (*contains spilanthes* can stimulate nerves to produce more saliva)

Female pt CC: I have something growing on my tongue. I am worried about cancer. She denies any sig med hx, she drinks 2-3 glasses of wine per day. Lesion on dorsal tongue. Pt asymptomatic Clinically: lesion on dorsal tongue, fingerlike projections, white hue Differential? Next step? Tx?

- papilloma (by far most common) - verruca vulgaris - condyloma (this one is not likely as its a single lesion whereas condylomas tend to be multiple) Excisional biopsy No HPV typing, prob 6 and 11 but not needed here Histo showed: papillary projections, fibrovascular cores, koilocytes, binucleated cells *PAPILLOMA*

What are the 3 inflammatory odontogenic cysts?

- periapical cyst - residual cyst - buccal bifurcation cyst

What are the indications for MDCT/MRI?

- presence of a mass: tumor, neoplasm, cyst inside or outside the gland

What is peripheral giant cell granuloma? Clinical features?

- probably a reactive lesion, local irritating factors - location: gingiva, usually anterior to the molars - age: most frequent between *40-60 yrs* radiographic features: usually none but superficial destruction of the alveolar bone may occur blueish/purple hue

Histo of hemangioma:

- proliferation of blood vessels

Histo of lymphangioma?

- proliferation of lymphatic and blood vessels with lymph and RBCs - *enlarged lymph vessels are near surface and push surface up into bumps* - *look for lymphatic valves*

Tx of sialolithasis?

- promote passage of the stone (massage, sialogogues, increased fluid intake) - surgical removal

How is multiple myeloma diagnosed?

- radiography - BM biopsy - serum/urine protein electrophoresis - Beta2-microglobulin (amyloid) - quantitative Ig

How does angioedema present clinically?

- rapid onset (resolves in 24-72 hours) - soft, *non tender swelling* which may be diffuse or localized - face, lips, tongue, floor of mouth, pharynx, larynx - may have areas of urtricaria - warning signs: *deep voice, dyspnea, hoarseness* - acute and chronic forms

Clinical presentation of Erythema Multiforme?

- rapidly rupturing vesicles/bullae forming erosions/ulcerations and hemorrhagic encrusted lip lesions, with greyish pseudomembrane - 25-70% of cases have oral involvement - dehydration - lips, labial mucosa, buccal mucosa, tongue

What is systemic sclerosis? cause? number of people? more common in M or F? children or adults?

- rare immune mediated condition - cause not known - dense collagen deposited in tissues - 10-20 persons/million - F > M - adults

Cherubism Clinical Features? tx:

- rare inherited autosomal dominant condition that occurs in early childhood - *bilateral jaw enlargement with "cherubic" appearance* - both jaws affected in posterior regions add notes tx: usually not needed

What is glandular odontogenic cyst? clinical? radiographic? histo? tx?

- rare odontogenic cyst which exhibits features of glandular differentiation w/ epi - clinical: middle aged adults, mandible 85%, anterior may cross midline, may present w/ pain or be asymptomatic, *can show aggressive behavior and recur* radiographic: unilocular or multilocular radiolucency, well defined w/ a sclerotic border histo: *varying epi thickness*, ciliated, mucous cells, *microcysts* ductal structures, plaque like clear ell thickenings tx: enucleation, *30% recurrence rate* may require ressection

What are Stevens Johnson and Toxic Epidermal Necrolysis?

- rare severe blistering disease triggered by drug exposure - *SJS <10% body surface involvement* - *TEN > 30%* - diffuse sloughing of skin and mucosa - Tx: avoid drug - Tx: some investigators have found corticosteroids should be avoided - Tx: pooled human immunoglobin

What is Sturge-Weber Angiomatosis? Characteristics? Tx?

- rare, non hereditary developmental condition - vascular proliferation involving tissues of the brain and face - face: *unilateral distribution* (KEY CLINICAL FEATURE) along one or more segments of the trigeminal nerve (*port wine stain*/nevus flammeus), develop intracranial calcifications (can impinge on cranial nerves and lead to neurological disorders) - intra oral involvement is common Tx: laser useful for oral lesions

Pyogenic granuloma:

- reactive CT hyperplasia, exuberant granulation tissue - response to injury - calculus - misnomer its NOT pyogenic and NOT a true granuloma oftern occurs in pregnant women ("pregnancy tumor") also associated with puberty

Allergic contact stomatitis tx?

- remove the suspected antigen - severe cases: antihistamine (combined w/ a topical anesthetic) - chronic cases: apply topical corticosteroid - recommendations to avoid: mouthwash, gum/mints, cinnamon, excessive salty, spicy, acidic - patch testing

What are the microscopic features of SS?

- replacement of salivary gland tissue by lymphocytes - squamous metaplasia of duct epithelium

What are the causes of gingival enlargement (gingival hyperplasia/hypertrophy)?

- response to chronic inflammation - idiopathic - genetic/inherited (gingival fibromatosis) - drug induced (CCB i.e. nifedipine, phenytoin/dilantin, cyclosporine etc) - hormonal changes (pregnancy/puberty)

Tx for CREST syndrome and prognosis?

- same as systemic sclerosis: NSAIDs, corticosteroids - tx not as aggressive - prognosis better than systemic sclerosis monitor for pulmonary hypertension

What is the cyst of the palatine (incisive) papilla?

- same as the nasopalatine canal cyst but is located in the incisive papilla. - NO evidence on radiograph, the cyst is *in soft tissue of papilla* - NO bony involvement - may have bluish color

How is SS diagnosed?

- schirmer test (place paper on lower eye lid see how far it gets wet) - rose bengal test (place dye on eye to look for corneal damage) - histopath - focal lymphocytic sialadenitis - salivary flow test - parotid sialography (fruit laden branchless tree) - salivary scintigraphy - autoantibodies

What is the tx for Erythema Multiforme?

- self limiting, resolves in a few weeks - symptomatic management, IV rehydration, corticosteroids (topical and oral), antivirals in recurrent cases - avoid causative drug - other second-line systemic therapies

What are the clinical features of congenital epulis? Tx?

- sessile or pedunculated mass, usually found on the anterior gingiva/alveolar mucosa - almost always *occurs in baby girls* - present at birth Tx: surgical excision, does not recur

What is neurofibromatosis? Clinical manifestations?

- several forms, *type 1 most common* - 85-97% cases are inherited autosomal dominant, chromosome 17 - skin nodules - *cafe au lait* pigmentation on skin (flat macules light brown in color on skin) - *lisch nodules* very diagnostic - *malignant transformation in 5% of cases*

Histo of congenital epulis?

- sheets of granular cells - key difference from GCT, there is no PEH at the top, its *flat thin epithelium* will NOT test for neural origin or markers like a granular cell tumor would (peripheral nerve derived)

What is the histopath of CREST?

- similar to systemic sclerosis - may see telangiectatic vessel

How does systemic sclerosis present clinically?

- skin develops a hard texture - Raynaud phenomenon (cold or emotional stress triggers small blood vessels in fingers to constrict) - acroosteolysis (terminal phalanges of finger tips gets resorbed) - flexion contractures - "limited" vs "diffuse" (can lead to organ failure) cutaneous sclerosis

What is a nasolabial (nasoalveolar) cyst?

- soft tissue cyst, no alveolar bone involvement/no evidence on radiograph - location: nasolabial fold area - women 4X as frequently affected as men Age: adults pathogenesis: uncertain, epi possibly derived from nasolacrimal duct histo: epi lining is pseudo stratified ciliary columnar (respiratory)

How is systemic sclerosis diagnosed?

- stiffness of skin - raynaud - biopsy - lab studies (anticentromere antibody or anti-Scl 70 [topoisomerase I])

What is SS tx?

- supportive - artificial tears - artificial saliva, sugarless gum - oral hygiene products w/ lactoperoxidase, lysozyme, lactoferrin (Biotene toothpaste/mouthrinse) - sialogogue - Fl- application - anti fungal for secondary candidiasis

What is tx for SS?

- supportive tx with artificial tears and saliva - daily fluoride application due to increased risk of dental caries - patients have significantly increased risk for lymphoma *up to 40x*!!!!

What is the tx for ossifying fibroma?

- surgical enucleation - wider resection with bone may be necessary in some larger or more clinically aggressive cases

What is the tx of schwannoma/neurilemoma?

- surgical excision - malignant transformation reported but rare

Tx of granular cell tumor?

- surgical excision - rarely recurs

Tx of mucoceles?

- surgical excision - removal of associated minor salivary glands - may recur

What is the Tx of Kaposi's Sarcoma?

- surgical excision, many pts have multiple lesions and require radiation therapy or systemic chemotherapy for multiple non oral lesions

What conditions should you rule out in cases of orofacial granulomatosis?

- systemic disease which may mimic orofacial granulomatosis: crohn, sarcoidosis, tuberculosis - possible local causes to rule out: chronic oral infection, foreign material, allergy

What is the histopath of oral hairy leukoplakia?

- thickened parakeratin - "balloon cells" - nuclear beading (margination of chromatin) sometimes can do immunohisto chemistry to look for EBV

What is the tx for deficiency anemia:

- treat whatever is missing i.e. ferrous sulfate 325 mg TID b/t meals (constipation, add on fiber to diet, green leafy veg) IV doses for absorptive problems: 125 mg in 100ml saline infused over 1 hr folic acid 1 mg PO, 5 mg in malabsorptive dz B12 1mg IM injections weekly for 1-2 months

Tx for oral melanotic macule?

- tx usually not required except for aesthetic considerations - **ALL oral pigmented lesions of recent onset, large size, irregular pigmentation, unknown duration, or recent enlargement should be submitted for microscopic examination note lower lip most common!!

General points on cemento-osseous dysplasia:

- typically asymptomatic, incidental finding - generally, no bony expansion but is not uncommon in the florid type - commonly seen in *middle aged pts*, female predilection. - More common in *black population* and frequently in *asian population*

What is the tx of fibrous dysplasia?

- typically tx is not needed unless there are clinical symptoms or pts present with cosmetic concerns if clinical symptoms are severe - *incisional bone bone biopsy for confirmation and exclusion of other bone tumors* - implants and surgical intervention should be avoided when possible as these areas are void of blood supply

What are some quantitative causes of thrombocytopenia?

- underproduction (viral suppression, HIV), marrow discrepancies, drug induced: chemo

What is orofacial granulomatosis?

- unifying term for a variety of clinical presentations with NON-specific granulomatous inflammation - *idiopathic* - abnormal immune rxn

What are the radiographic features of cemento-osseous dysplasia?

- usually *well defined borders* - early lesions = *radiolucent* as the lesion matures the entity --> *radioopaque* as a result there is an intermediate phase - mature from *center outwards*, there is almost always a *radiolucent rim surrounding the lesion* - typically, periodontal space is intact but may not be visualized

How does sarcoidosis present clinically?

- usually <50 - *females* - *black individuals* - acute: fever, fatigue, anorexia, respiratory symptoms, polyarthritis, vision problems, skin lesions - *chronic course: pulmonary* board question - remission and exacerbation - 20% have NO symptoms

Radiographic features of cherubism?

- usually both jaws affected in posterior regions (ramus of mandible and tuberosity of maxilla) - lesion grows anteriorly - *multilocular radiolucency with multiple internal septations* - *expansion of cortical outlines and enlargement of the jaws* - teeth may be displaced anteriorly

What are the clinical features of pyogenic granuloma?

- usually ulcerated - soft exophytic lesion, either sessile or pedunculated - *deep red to purple in color, bleeds easily* - location: *most common gingiva*, also occurs in other areas of the oral mucosa*** can happen anywhere! size: small to large (mm to cm) develop rapidly then remain static any age!

What is allergic contact stomatitis?

- variable allergic rxn due to *DIRECT* exposure to an allergen - true allergic rxn to dental materials is rare**

What does allergic contact stomatitis look like clinically?

- variable presentation - mild-severe redness, edema, vesicles, erosions, ulcerations - chronic cases-hyperkeratosis may be seen - burning, itching, stinging, tingling - desquamation (showed case in class of several class V restos and upper labial mucosa had redness, vesicles, etc)

What is oral melanoma?

- very rare primary lesion, rare metastatic event - less than 1% of all melanomas - *palate and maxillary gingiva most common sites* - ABCDE rule for melanomas. Asymmetry, borders irregular, color variable, diameter, evolving - prognosis and survival rate greatly improved due to new immunotherapy tx (monoclonal antibodies like ipilimumab)

What are some infectious causes of sialadenitis?

- viral: mumps - bacterial: Staphylococcus aureus *most common* - fungal: candida

What is the composition of saliva?

- water >99% - inorganic ions i.e. bicarbonate, Ca2+, phosphate - organic molecules - macromolecules: proteins

What is a granuloma?

- way of containing infections (i.e. TB, fungal infections) - epithelioid: histiocytes that look like epithelial cells surrounded by multiple lymphocytes if you fall and hit lip, glass in your lip, it can also form a granuloma around the foreign particles

Histo of vascular leiomyoma?

- well circumscribed proliferation of smooth muscle, surrounding a blood vessel *cigar shaped nuclei* sometimes immunohistochemistry for smooth muscle

What is a globulomaxillary cyst?

- well defined, inverted pear shaped radiolucency found ONLY b/t the roots of the *maxillary lateral incisor and cuspid* - pathogenesis is controversial: non odontogenic vs. odontogenic - most agree cyst is odontogenic in origin, periodical or lateral radicular cyst - can cause roots of adjacent teeth to diverge teeth vital and intact tx: surgical enucleation, recurrence low

What are the radiographic features of ossifying fibroma?

- well defined, round lesion - periphery of the lesion is corticated and exhibits a soft tissue capsule - internally, the lesion is homogenously granular and radiopaque - strong tendency to *displace teeth and cortical outlines*

Peripheral Ossifying Fibroma:

- well demarcated, sessile or pedunculated lesion that appears to originate from the gingival interdental papilla - derived from cells of the periodontal ligament - age: children and young adults - sex: females more than males - *recurrence rate 16%*

What might radiographs of systemic sclerosis pt look like?

- widening of PDL - resorption of ramus of the mandible/coronoid/chin/condyle curved angle of ramus

What drugs and medications can cause RBC disorders?

-Carbamazepine - Dapsone - Ibuprofen - Cephalosporins - Penicillins - Tetracycline - Amp B - Antazoline

If pt has low USFR but responds to stimulation, what can you do?

-look for possible causes - restore chewing function - reduce medication-induced salivary hypofunction - salivary stimulation OTC, Rx medications, others - Salivary lubrication - humidification - hydration/prevent dehydration (i.e. avoid alcohol, caffeine) - treat oral consequences

SS prevalence?

0.5% prevalence F:M 9:1

What are the three clinicopathologic forms of lupus erythematosus?

1) systemic lupus erythematosus 2) chronic cutaneous lupus erythematosus 3) subacute cutaneous lupus erythematous 1.5 million in the US affected

When instructing pts to use sugarless chewing gum, tell them they must chew for at least _____ min or more

10 min or more (note: gum use contraindicated in pts with TMJ)

How many baby boomers have xerstomia?

15 million!

How many Gy will cause temporary salivary dysfunction? How many Gy will cause permanent salivary dysfunction? How much Gy does someone with H&N SCC receive?

2 = temporary 26+ Gy will cause permanent damage 60-70 Gy ! Dose and field are critical, IMRT has helped to improve precision

In the US __________ patients have SS __________ survivors of H&N cancer who have had radiation

2 million SS 200,000 head and neck radiation

Leukemias make up __% of all cancers in US. Primarily originate in ____ ______ Characterized by excessive numbers of ____ ______ in circulating blood Classification is based on:

2% bone marrow abnormal WBCs - Acute and chronic - Cell type (myelogenous or lymphocytic) - Maturity of the cells

How many pts in the US have sjogrens? Affects F __: 1 versus males? What age does SS develop?

2-4 million F > M 9 : 1 Age: mid 50s

The average prevalence of xerostomia __%

20%

Stats for malignant neoplasms: ___% parotid tumors ___-__% submandibular tumors ___% sublingual and __-___% minor salivary gland

20% parotid tumors 50-60% submandibular tumors 90% sublingual and 60-75% minor salivary gland

How will sialoliths appear on imaging? What kind of imaging

20-40% not calcified enough to be seen on X-ray (so conventional radiograph of CBCT sometimes not useful), sialogram or sialography better in this case appear as: oval or round shape homogenous radiopacity if radiolucent: sialography intermittent swelling and pain with eating note can cause retrograde infection

Board question, ___% of all tumors are salivary gland neoplasms Approximately ___% in parotid gland, __% in submandibular gland, __% in sublingual and __-__% in minor salivary glands What imaging should be used?

3% of all tumors are salivary gland neoplasms Approximately 80% in parotid gland, 5% in submandibular gland, 1% in sublingual and 10-15% in minor salivary glands most benign or low grade malignancies IMAGING: Med CT or MRI well demarcated mass, can be homogenous or heterogenous

How much factor VIII is needed for normal hemostasis?

30%

___% of plasmacytoma develop into multiple myeloma over 10 years __% of plasmacytomas occur in the head and neck

30% 90%

______ml/day of unstimulated saliva prodction Flow rate mean:

300ml/day *most important for overall oral comfort* Flow rate mean *0.3ml/min*

53 yr old female pt CC: I have a large bump on my gums that is bothering me and moving my teeth around. Med hx: T2D taking metformin she is also a smoker She claims the bump has been slowly increasing in size Differential?

3P lesions, which one is most aggressive? Peripheral ossifying fibroma Histo: will show bone formation high recurrence rate and can move teeth around.

What are the types of Kaposi's Sarcoma?

4 broad types classic: late adult life, italian and jewish men, skin of lower extremities endemic: african form iatrogenic immunosuppression-associated: most often occurs in recipients of organ transplants AIDs related

What % of CCLE will convert to systemic lupus?

5%

When do pts become symptomatic, when factors VIII and IX fall below ___%?

5% mild: 5-30% bleed post surg moderate: 1-5% minor injury, excess severe: <1% spontaneous bleeding

____% of CCLE patients have resolution after several years

50%

What are the triggers of erythema multiforme?

50% of cases precipitating cause is identified *infectious agents*: *herpes simplex virus*, Mycoplasma pneumonia, Adenovirus, Enterovirus, Coccidiomycosis *drugs*: penicillin, cephalosporins, sulphonamides, NSAIDs, phenytoin *other*: foods (benzoates, nitrobenzene), chemicals (perfumes)

The major and minor salivary glands create a total production of ____-____ml/day of saliva

500-600ml

Tx of salivary hypofunction, hydration:

64oz water/day or total weight divided by 2 avoid alcohol/caffeine

20 year survival of SLE?

75%

List percent chance of malignant tumors per gland high to low:

86% sublingual 45% minor glands 30% submandibular 15% parotid

What is 5 year survival of SLE?

95%

Dry mouth may not be perceived until >___% of unstimulated salivary flow is lot.

>50% this suggests there is functional reserve in every system (more than we need)

Quiz question #1 A pt presents with a "growth on the lower gums". The pt claims this appeared a few months ago and is gradually increasing in size. Which of the following are in the differential diagnosis for this lesion? Select all that apply: A. Peripheral giant cell granuloma B. Peripheral ossifying granuloma C. Pyogenic granuloma D. Parulis E. Peripheral ossifying fibroma

A, C, E Peripheral giant cell granuloma Pyogenic granuloma Peripheral ossifying fibroma

A pt presents stating she has a "bump" on her tongue. She denies pain and claims it is slowly increasing in size. The "bump" feels firm upon palpation. A biopsy is performed and characteristic verocay bodies are seen under the microscope. What is the definitive diagnosis? (bump is mucosa colored on dorsal tongue) A. Granular cell tumor B. Schwannoma C. Rhabdomyoma D. Neuroma E. Neurofibroma

A. Schwannoma

Epulis fissuratum Caused by? Location? Clinical features? Tx?

AKA denture induced fibrous hyperplasia, inflammatory hyperplasia cause: ill fitting denture location: vestibule (maxilla or mandible) along the denture border clinical features: arranged in elongated folds of tissue into which the denture flange fits surface ulceration within folds is common composed of dense fibrous CT Tx: surgically excise tissue, denture hygiene, denture reline

What is a neuroma? location? histo?

AKA traumatic neuroma reactive proliferation of nerve tissue after injury, usually extraction or other surgical procedure may be painful (30% of cases) location: *mental foramen area, tongue, lower lip* histo: proliferation of variously sized nerve trunks

Condyloma are often seen in? caused by? associated with? trasmission? location?

AKA venereal wart most often in the genital and anal regions associated with various HPV types transmitted by sexual contact, contagious inoculation to other sites possible location: labial mucosa, palate

Characteristics of congenital epulis?

AKA: congenital epulis of newborn - cells resemble cells of granular cell tumor - cell of origin is not known, *not derived from nerve*

What is chronic hyperplastic pulpitis? location? age? clinical appearance? tx?

AKA: pulp polyp an excessive proliferation of chronically inflamed dental pulp tissue, granulation tissue/fibrous tissue with inflammatory cells. location: teeth with large, open carious lesions, primary or permanent molars *typically primary molars* age: children and young adults clinical appearance: a red or pink nodule of soft tissue protruding from the pulp chamber and fills the entire cavity of the tooth tx: RCT or ext of tooth

Which leukemia is seen in children?

ALL acute lymphocytic leukemia

Leukemia 5 types:

AML (adult) ALL (children) CLL CML Hairy Cell (malignancy of hematopoietic cells)

Which malignant lesion has a tendency to spread to the neurovascular canal?

Adenoid cystic carcinoma use Med CT or MRI to see if extends to brain

Clinical features of Pleomorphic Adenoma "Benign Mixed Tumor": Histo: Tx:

Adults M = F asymptomatic submucosal mass palate > upper lip > buccal mucosa > other sites Histo: *encapsulated*, *double layered duct formation*, epi and myoepi differentiation (*plasmacytoid cells*), no mitosis, variable stroma component: myxoid, chondroid, hyalinized, cellular Tx: surgical excision, occasional recurrences in major glands, *malignant transformation can occur* palpation: FIRM, slow growing, painless

What is the most predictive auto antibody looked for in SS diagnosis?

Anti-SS-A

IV bisphonate therapy can lead to:

BRONJ necrotic bone, destructive radiolucency

Tx for SCC and Thalassemia?

Blood transfusions (depends on severity of disease) Bone marrow transplant

_____ lymphoma is endemic to African countries and is very rare.

Burkitt's

What is CREST syndrome?

C - *calcinosis cutis* (multiple movable subcutaneous calcifications under skin) R - *Raynaud phenomenon* E - *esophageal dysfunction* (incorrect contractions, lack of peristalsis) S - *sclerodactyly* (claw like fingers, stiff, smooth/shiny, due to abnormal collagen deposition) T - *telangiectasia* (pin point bleeding from superficial dilated capillaries, on facial skin or vermillion zone) limited form of scleroderma, F > M, 60s and 70s, signs develop over months to years

Which leukemia is seen in the elderly?

CLL Chronic lymphocytic leukemia

What leukemia is linked to genetic 9:22 translocation (Philadelphia chromosome)?

CML Chronic myelogenous leukemia (affects adults)

What causes irritation fibroma and what is it composed of?

Chronic trauma Composed of dense, scar like, fibrous connective tissue

Micrscopic features: koilocytes, binucleated cells, fibrovascular cores, flat topped broader projection indicative of?

Condyloma **flat topped**

A new pt presents for initial dental exam. Upon intra-oral exam, there is an interesting finding on the right buccal mucosa. The pt denies pain and claims the lesion has been present a long time with minimal change. Which of the following id the MOST LIKELY clinical diagnosis? (lesion looks multinodular, reddish/purplish hue) A. Lymphangioma B. Kaposi Sarcoma C. Peripheral Giant Cell Granuloma D: Hemangioma E: Leiomyoma

D. Hemangioma Note KS wouldnt be slow growing or painless

What is thrombocytopenia? mild? severe?

Decrease in platelets mild: <50,000 severe: < 20,000 under 20,000 = severe thrombocytopenia (will see petechiae in oral cavity) note: normal range is 150-400,000/ml

Gingival Cyst of the adult: derived from? clinical features? tx? histo?

Derived from rests of Serres (dental lamina rests) Predilection for *manidbular canine/premolar area* 60-75% of cases - facial aspect of gingiva or alveolar mucosa - painless - bue-gray or yellow-white in color tx: simple surgical excision histo: thin lining of flattened or cuboidal epithelial cells. Often contains foci of *plaque like thickenings with clear cells*

What is cements-osseous dysplasia?

Dysplastic lesions that are confined to the jaws Periapical - in anterior teeth Focal - posterior teeth Florid - widespread, can cross midline

What conditions are associated with sialadenosis?

ENDOCRINE: - DM - hypothyroidism - pregnancy NUTRITIONAL: - general malnutrition - alcoholism - anorexia nervosa - bulimia NEUROGENIC meds: - psychotropic drugs - sympathomimetic drugs for treating asthma

Oral hairy leukoplakia in HIV pts or sometimes transplant pts is caused by _____ virus It is a sign of _______ ________

Epstein Barr virus sign of severe immunosuppression (corrugated white lesion on lateral border of tongue)

What is an eruption cyst? tx?

Eruption hematoma, soft tissue analogue of dentigerous cyst - children younger than 10 years old - appears translucent, blue, or purple soft tissue mass - *maxillary incior and molar area common* no tx! usually ruptures upon tooth eruption

Tx of all 3 P lesions?

Excisional biopsy and deep SRP of teeth in the area to reduce recurrence

GARDEN-FOREST (Gardner's key features)

F - Familial adenomatous polyposis O - osseous/soft tissue tumors (osteomas, desmoid tumors), RE - retinal hypertrophy ST - supernumerary teeth

T/F There is good evidence that shows sugarless chewing gum increases USFR following long term use

FALSE there is NO good evidence to show this

T/F Multiple myeloma radiolucencies are more common in the maxilla than the mandible.

FALSE more common in mandible! (posterior body and ramus) *punched out radiolucencies* can coalesce and lead to mandible fracture *NON corticated (no white border)*

T/F There is bony expansion associated with cements-osseous dysplasia

FALSE (but sometimes seen in florid type)

Male pt presents stating "I have a bump on my tongue" denies pain and claims bump has been increasing in size slowly. Clinically: mucosa colored, round, exophytic possibly pedunculated histo shows fibrous tissue Tx:

Fibroma Excisional biopsy, look for cause and remove it!! if you don't address etiology it can recur

Tx for Granulomatosis with polyangiitis:

First line: oral prednisone After remission immunosuppressive drugs: methotrexate, cyclosporine, rituximab Tx induces prolonged remission May have relapses can look at PR3 ANCA levels to see how well they are responding

Where is the most common location for sialothiasis and why?

Floor of mouth (twisting pattern, multiple points for stagnation/stone formation)

What is SS histopath?

Focus score = (# of infl. aggregates x 4)/(# of mm2 of sal. gl.) A focus score > = 1 supportive of sjogren greater than 1 is supportive of diagnosis of sjogrens in conjunction w/ other tests

What is the gene for fibrous dysplasia?

GNAS1

Pan with multiple dense bone islands think:

Gardner's Syndrome

Multiple OKC/lesions on pan might be indicative of ______ ______

Gorlin Syndrome (akak Nevoid Basal Cell Carcinoma Syndrome)

What is the most frequent neurogenic tumor?

Granular cell tumor (by far!!) but all of them are relatively rare (neuroma, neurofibroma, schwannoma (neurilemoma), and granular cell tumor are the 4 in this category) note if multiple think of: MEN syndrome, or Neurofibromatosis (von Recklinhausen's disease)

The oral cavity is the most common location of which neural lesion?

Granular cell tumor! (often dorsal tongue!)

What causes Kaposi Sarcoma? Where does it present? diagnosis? tx?

HHV 8 skin and oral mucosa, hard palate, gingiva, tongue (nodular, exophytic erythematous lesions) diagnosis: biopsy tx: typically regresses with immunocompetence

What histocompatibility antigens (HLAs) are associated with SS?

HLA- DRw52 HLAB8 HLA-DR3

Papilloma is caused by what?

HPV typically types 6 and 11 associated with oral lesions

Verruca vulgaris is caused by: common or uncommon? transmission? location? clinically?

HPV usually types 2, 4, 6 very common on skin, much less frequent on oral mucosa contagious self inoculation location: labial mucosa, tongue very white and keratotic!!

Lymphoma 3 types:

Hodgkin's Non-Hodgkin's Burkitt's**fastest growing human tumors**was epidemic to African countries and linked to EBV (malignancy of lymphoid tissue)

Hodgkin lymphoma staging:

I - single LN II - 2 or more LN, same side of diaphragm III - Both sides of diaphragm IV - disseminated extra-lymphatic organs, distant nodal involvement

What is the most common reactive inflammatory lesion?

Irritation fibroma

33 yr old male pt, CC: I have a bump on the inside fo the lower lip, denies pain, claims that the bump has been growing larger slowly clinically: lower lip, can see surface red blood vessels palpation: solid but soft and doughy next steps? what will histo look like?

LIPOMA - excisional biopsy (if you opted for incisional go back and remove the rest) - encapsulated so it will pop out histo: encapsulated, adipocytes vacuoles NO CHANCE of recurrence

What is a benign tumor of mature fat cells?

Lipoma

What tumor floats in a bottle of formalin?

Lipoma!

62 yr old female pt, med hx HTN, hypothyroidism, breast cancer in past. Dentist notes unusual finding on soft palate. yellowish nodule

Lymphoepithelial cyst yellowish nodule, most common on SOFT PALATE area tx: excisional biopsy if you cannot reach it some smaller ones rupture on their own

Which affects the whole body? M1 or M3 receptors?

M1 M3 - more focused on salivary glands

If there are multiple neural lesions what should you think of?

MEN syndrome or Neurofibromatosis (von Recklinhausen's disease)

What is a fibrosarcoma? Tx? Histo? 5 yr survival?

Malignant tumor of fibrous connective tissue malignant tumor of *fibroblasts* SLOW GROWING AND NOT PAINFUL - most common in *young adults and children* Tx: surgical excision, recurrence is common 5 year survival rates range from 40-70% Histo: fibroblasts with dark atypical and pleomorphic cells

What is osteopetrosis?

Marble bone disease 2 types (recessive and dominant) - genetic mutation which is not yet identified - *defect in differentiation and function of osteoclasts* - impaired osteoclast function --> *increased bone mass (impaired remodeling) --> this bone is more fragile and brittle in nature - this bone is also prone to infection --> obliteration of marrow spaces (because of increased bone mass)

What is the most common location for epulis fissuratum?

Maxillary anterior but can occur anywhere

NHL specific to HIV? Tx?

Most cases represent high grade, aggressive B-cell neoplasms More specific to HIV-*primary effusion lymphoma* and *plasmablastic lymphoma* tx: chemo

What is the most common malignant salivary gland tumor?

Mucoepidermoid Carcinoma most commonly parotid gland, the rest are found in the minor glands 5th decade of life

What is the MOST common malignant salivary gland tumor?

Mucoepidermoid carcinoma

What is primary polycythemia? age? prevalence? clinical features? consequences? cause?

Neoplastic proliferation of bone marrow stem cells resulting in abnormally high number of circulating RBCs Age: 40-60 yrs Rare 2.6/100,000 Ashkenazi jews erythema of skin and mucosa, headache, dizziness, pruritus impaired blood flow, thrombi, ischemic episodes, hemorrhage cause unknown

Middle aged AA female pt presents to oral medicine for "bump on front of my tongue" She denies pain and claims that the lesion has been growing slowly. clinically: lesion looks yellowish/white hue on ventral aspect palpation: feels firm category of lesions? next step? differential?

Neural! (not a lipoma because its firm!! and no surface RBCs) Excisional biopsy Differential: - Granular cell tumor - Schwannoma - Neuroma - Neurofibroma the histo showed muscle and granular cells so *Granular cell tumor* no malignant potential or growth so you can just observe if you did incisional

Ventral tongue, yellowish hue, firm nodule, histo shows fibrous serpentine wavy s shaped nuclei in a delicate background. Definitive diagnosis?

Neurofibroma **consider rare possibility of syndrome neurofibromatosis (check for lisch nodules in eye or cafe au lait on skin)

When you have a neurofibroma diagnosis what must you consider?

Neurofibromatosis (von Recklinhausen's disease)

What is more common NHL or Hodgkin's lymphoma?

Non Hodgkin's more common (6:1)

______ lymphoma can lead to enlargement in salivary glands i.e. unilateral parotid enlargement

Non-Hodgkin's lymphoma

What are fibro-osseous lesions? 3 types?

Normal bone is replaced by fibrous CT and newly mineralized products that replace the normal bone architecture 1. Fibrous dysplasia 2. Cemento-osseous dysplasia 3. Ossifying fibroma

What is differentiating between simple bone cyst and OKC?

OKC - show evidence of cortical thinning and/or bony expansion!

What is associated w. Nevoid Basal Cell Carcinoma?

Odontogenic Keratocyst

What is the manifestation of microcytic, hypo chromic anemias (iron def):

PALLOR