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170 Cards in this Set
- Front
- Back
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White lesions
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Leukoplakia/Dysplasia
Hereditary Reactive Infectious Miscellaneous Ex. Trauma |
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White color results from
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Hyperkeratosis - Thickened surface keratin
Acanthosis - Thickened spinous layer |
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Leukoplakia types
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Mild or thin
Homogeneous or thick Granular or nodular Verrucous or Verruciform |
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Leukoedema
Characteristics Histology Treatment |
Characteristics
- Seen more commonly in blacks which is explained by presence of background pigmentation for easy visualization. - Diffuse grayish-white on buccal mucosa bilaterally - Do not rub off but disappears when cheek is retracted Histology - Acanthosis - Cell vacuolization of the spinous layer - Pyknotic nuclei - Parakeratinized Treatment - Not pre-malignant - No treatment required |
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White sponge Nevus
Characteristics Clinical appearance Mimic Histology Treatment |
Characteristics
- aka Cannon's disease or Familial white folded dysplasia - Autosomal dominant and appears in early childhood due to mutation in Keratin 4 and/or 13 genes - Usually asymptomatic patients Clinical Appearance - Symmetric thickened plaques on buccal mucosa - Does NOT disappear when stretch like Leukoedema Mimick - Leukoedema and Hereditary Benign Intraepithelial Dyskeratosis. HBID Histology - HyperParaKeratosis - Acanthosis and Spongiosis(Intraellular Edema) - Eosinophilic condensation in the perinuclear region of superficial epithelial cells Treatment - Not Pre-malignant - No treatment required |
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Hereditary Benign Intraepithelial Dyskeratosis HBID
Characteristics Clinical appearance Mimick Histology Treatment |
Characteristics
- aka Witkop-Von Sallmann Syndrome - Autosomal Dominant trait of a tri-racial isolate from North Carolina. White Black and Native american Clinical Appearance - Affects Buccal mucosa, floor of mough, and lateral tongue - Ocular lesions develop early in life as thick opaque gelatinous plaques next to cornea. Very itchy and more prominent in spring. May go blind Mimick - Leukoedema - White Sponge Nevus Histology - Marked acanthosis - Parakeratosis - Dyskeratosis throughout upper spinous layer - Cell within a cell phenomenon Treatment - Refer to an Opthalmologist for surgery - Oral lesions are benign and need no treatment |
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Darier's Disease
Characteristics Mechanism Clinical Histology Treatment |
Characteristics
- Keratosis Follicularis, Dyskeratosis Follicularis - Striking skin involvement with subtle oral lesions Mechanism - Disorganization of Desmosomes due to mutation in calcium channel pump Clinical - Erythematous and Puritic Papules on trunk and scalp - Buildup of keratin gives rough texture to skin and smells during summer - Nails show longitudinal lines, ridges and painful splits - Asymptomatic oral papules that can confluent and give cobblestone appearance on hard palate and alveolar mucosa Histology - Dyskeratosis: Corpus Ronds or grains - Suprabasilar clefting and acantholysis - Test tubed rete pegs Treatment - Minimize exposure to hot environments - Keratolytic agents for mild cases, Systemic retinoids for severe cases - Not pre-malignant |
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Focal Acantholytic Dyskeratosis
Characteristics Clinical Treatment |
Characteristics
- Solitary lesion that occurs on skin and mucosa - Cause is unknown but has same histology as Darier's disease Clinical - Appears as asymptomatic umbilicated papule - Intraoral lesions are pink or white and found on keratinized mucosa Treatment - Excision |
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Xeroderma Pigmentosum
Mechanism Clinical |
Mechanism
- Autosomal recessive defect in excision/repair mechanism of DNA - UV light leads to mutations and 1000-4000 times greater risks of skin cancer Clinical - Marked tendency to sunburn as infants - Actinic keratosis develops in young childhood which can rapidly progress to SCC - May see subnormal intelligence associated with Consanguineous parents - Tongue carcinoma seen on dorsal tip of tongue which is spared by SCC of tongue |
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Geographic Tongue
Characteristics Clinical Mimic Histology Treatment |
Characteristics
- aka. Erythema Migrans and Benign migratory glossitis - Common benign condition affecting the tongue - Twice as common in females. Clinical - Typically anterior 2/3 of tongue on tip and lateral borders - Multiple well-demarcated zones of erythema surrounded by slightly elevated yellowish-white serpentine border - Erythema due to loss of filiform papillae and inflammation Mimic - Can be seen on other oral mucosal sites - Called Stomatitis areata migrans or Ectopic geographic tongue Histology - Munro Abscesses: Collections of neutrophils within epithelium - Test tube rete pegs like Darier's - Similar histology with Psoriasiform Mucositis. Geographic tongue occurs more frequently in patients with psoriasis Treatment - Benign process and no treatment unless symptomatic - Topical corticosteroids in extreme cases |
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Hereditary white lesions (7)
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Leukoedema
White sponge nevus Hereditary Benign Intraepithelial Dyskeratosis Darier's disease Focal Acantholysis Dysplasia Xeroderma pigmentosum Geograpic tongue |
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Focal Frictional Keratosis
Characteristics |
Characteristics
- Linea alba on bilateral buccal mucosa restricted to dentulous areas |
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Chronic Cheek Biting or Sucking
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Morsicatio Buccarum
- Ragged mucosal surface |
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Smokeless Tobacco Keratosis
Clinical Histology Treatment |
Clinical
- Painless loss of gingival and periodontal tissues in area of tobacco contact - PREMALIGNANT grey-white plaque. More for Snuff users - Mucosa appears fissured when tobacco is not in place Histology - Hyperkeratotic and acanthotic epithelium - Parakeratin CHEVRONS - Deposition of an acellular amorphous eosinophilic material within the subajacent connective tissue above the salivary glands Treatment - 4x greater oral cancer risk than non-users but is still lower than with Cigarettes - Should return to normal once stopped - Lesions remaining after a month should be biopsied to rule out dysplasia |
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Betel Quid
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Combination of Areca nut and slaked lime with tobacco wrapped in betel leaf
- Can cause Oral Submucous Fibrosis which is a High risk pre-cancerous condition - Risk DOES NOT regress with cessation of use |
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Reverse Smoking
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- Pronounced keratosis and Premalignant lesions
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Nicotine Stomatitis
Characteristics Clinical Histology |
Characteristics
- Develops in response to chemicals and heat in smoke - Similar changes as long-term use of extremely hot beverages - NOT-premalignant Clinical - Numerous slightly elevated papules that may appear cobblestone like Darier's and Cowden's syndrome - Papules represent inflamed minor salivary duct orifices Histology - Squamous metaplasia of excretory ducts - Inflammatory exudate within duct lumina |
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Actinic Keratosis & Cheilosis
Characteristics Histology Treatment |
Characteristics
- aka Solar keratosis - Pre-Malignant caused by UV light. 13-25% malignant transformation - May form a "Horn" Characteristics - Pre-malignant lesion of the lower lip vermillion with 6-10% Premalignant transformation - 10:1 Male predilection over 45yrs - Vermillion appears atrophic and blend in with skin Histology - By definition, epithelial dysplasia is seen - Teardrop shaped rete-pegs - Sun damaged collagen appears basophilic Treatment - Cutaneous: Cryotherapy, topical 5-Flourouracil, or surgery - Lip: Should be encouraged to use sunscreen, and severe cases get vermillonectomy/Lip shave - Areas of ulceration, induration, or leukoplakia on lip should be submitted to rule out carcinoma |
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Uremic Stomatitis
Mechanism Clinical Treatment |
Mechanism
- Uncommon complication of renal failure - Urease in oral flora degrades urea in saliva to liberate ammonia Clinical - Abrupt onset of painful white plaques or crusts usually on buccal mucosa, tongue, and floor of mouth - May detect odor or ammonia or urine on breath Treatment - Clears in a few days after dialysis - Dilute H2O2 works |
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Palifermin
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Keratinocyte growth factor used to prevent oral mucosal injury
- White tongues are commonly seen and reflects transient protective mucosal thickening |
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Viadent Leukoplakia
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Seen on masillary buccal gingiva. Unusual spot
- Associated with use of Viadent or other products contaning Sanguinaria |
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Candidiasis
Characteristics Clinical Types Treatment |
Characteristics
- aka Moniliasis - Dimorphic fungi. Yeast is innocuous by hyphal form associated with invasion of host. - Part of normal flora in 30-50% Clinical - Increased risk with poor immune status, and xerostomia, corticosteroids, and broad spec antibiotics - Do cytologic smear to confirm. Types - Pseudomembraneous (Thrush): Removable white plaques with burning sensation - Hyperplastic: Non-Removable white plaques - Erythematous: Red macule, burning - Central papillary atrophy: Red asymptomatic area on dorsal tongue - Angular Cheilitis: Red fissured labial commissures - Chronic atrophic(Denture candidiasis): Red asymptomatic area under a denture base. - Mucocutaneous: White plaques like hyperplastic. Rare sporatic or inherited idiopathic - Endocrine-Candidiasis syndromes: Rare endocrine disorder such as hypothyroidism, hypoparathyroidism, and diabetes mellitus developing after candidiasis. Treatment - Polyene agents: Nystatin, Amphotericin B - Imidazoles, Triazole, Others |
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Oral Hairy Leukoplakia
Characteristics Clinical Histology |
Characteristics
- Thought to be caused by EBV - Positive correlation with depletion of peripheral CD4 cells Clinical - Vertical streaks often noted in areas of leukoplakia, can appear shaggy. - Almost Exclusively in lateral border of tongue Histology - Chromatin Beading in nucleus as chromatin becomes displaced to periphery |
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Squamous Papilloma
Characteristics Histology Treatment |
Characteristics
- Sessile lesion with finger-like projections - Thought to be induced by HPV 6 or 11 Histology - Much like clinical presentation with numerous papillary or finger-like projections - Core of lesion consists of vascular fibrous connective tissue - May see viral cytopathic changes Treatment - Surgical Excision |
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Viral cytopathic effect
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Common in most HPV lesions and includes
- Koilocytes: Enlarged nuclei with Hyperchromasia - Binucleated cells - Mitosoid bodies |
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Juvenile Laryngeal Papillomatosis
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Progressive papillomas presenting with hoarseness
- Can lead to death by asphyxiation |
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Verruca Vulgaris
Characteristics Clinical Histololgy |
Characteristics
- Most frequently papillary lesion on skin of hands - Difficult to differentiate from squamous papilloma if found in oral cavity Clinical - Contagious lesions and thought to transfer by putting fingers into mouth - Occurs on vermillion border, labial mucosa, and anterior tongue Histology - Hyperkeratotic SSE - Papillary lesions with rete ridges that converge towards center of lesion - HPV viral cytopathic effects |
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Condyloma Acuminatum
Characteristics Clinical Histology Treatment |
Characteristics
- HPV 2,6,11 - Oral lesions are secondary to oral-genital contact - Labial mucosa, Soft palate, and Lingual Frenum are the most common intraoral sites Clinical - Similar to papillomas but larger in size and clustered - May be an indicator of sexual abuse of diagnosed in young children - Genital lesions are often high risk types 16 and 18, associated with later development of SCCa Histology - Broad based rete pegs with more blunted epithelial projections compared to papillomas and verrucae - Show Viral cytopathic effect Treatment - *Do not laser due to spread via airborne particles. - Best to excise all lesions at the same time - Podophyllin is antimitotic and has not been FDA approved for oral use. Doctor has to apply in office |
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Focal Epithelial Hyperplasia
Characteristics Histology Treatment |
Characteristics
- aka Heck's disease - Viral HPV 13 and 32 induced proliferation of oral SSE - Multiple flattened papules with normal mucosal color Histology - Thickening extending upwards, not down into connective tissue. Same level rete pegs - Viral Changes like Koilocytes, Mitosoid bodies, and binucleated cells Treatment - Spontaneously regresses after a few months/years - Conservative surgical excision if needed and risk of recurrence is minimal |
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Cowden's Syndrome
Characteristics Clinical |
Characteristics
- aka Multiple Hamartoma Syndrome - Inherited autosomal dominant due to mutation on PTEN gene on chromosome 10 Clinical - May appear cobblestone like Darier's disease and Nicotine stomatitis. - Increased fibrous hamartomas of GI tract - Increased Thyroid adenoma or Adenocarcinoma, and increased risk of Breast cancer in females - Skin lesions of trichilemmomas |
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Lichen Planus
Characteristics Clinical Types Histology Treatment |
Characteristics
- Common dermatologic disease sometimes with mucosal involvement Clinical - Seen more in females and middle aged patients - Oral lesions seen in 1-2% of population - Red/Purple pruritic papules on flexor surfaces of extremities Types 1) Reticular Lichen Planus: More common and asymptomatic. Interlacing white lines called Wickham's striae for a net-like pattern. 2) Erosive Lichen Planus: Itching or burning. Can cause desquamative gingivitis. Looks like Pemphigoid and Pemphigus. Histology - Saw toothed Rete pegs - Dense band of subepithelial T cell infiltration - Hydropic degeneration of basal cell layer - Similar to lichenoid drug, amalgam reactions, lupus erythematous, chronic ulcerative stomatitis, and mucosal reaction to CINAMMON Treatment - Reticular LP: No treatment. May have superimposed candidiasis - Erosive LP: Topical steroid applied for no more than 2 wks |
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Lupus Erythematosus
Characteristics Types Histology Diagnosis Treatment |
Characteristics
- Immune modulated - Most common type of collagen vascular or connective tissue disorders. Types - Systemic LE - Chronic Cutaneous LE - Subacute Cutaneous LE Histology - Hyperkeratosis and alternating atrophy and thickening of spinous layer with subepithelial lymphocytic infiltrate. In both LP and LE - Unlike LP, LE also has perivascular infiltrate deeper in CT and material at the basement membrane Diagnosis - Immunoflourescence will reliably distinguish between Lichen planus and CCLE - CCLE has IgM, IgG, and C3 at basement membrane zone. If seen in non-lesional tissue, this would be a positive Lupus band test. - LP would have shaggy band of fibrinogen at basement membrane zone Treatment - Avoid sunlight - NSAIDS with anti-malarial drug for mild - Systemic corticosteroids for more severe - Topical steroids, anti-malarial, and thalidomide for resistant CCLE. |
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SLE
Characteristics Clinical Lab Findings |
Characteristics
- Increase in activity of B cells in conjunction with abnormal T cells - Difficult to diagnose in early stages due to nonspecific symptoms - Rash over malar area of nose - 50% with kidney involvement and/or Libman-Sacks endocarditis. - 75% survival rate 15yrs after initial presentation Clinical - 5-25% have oral lesion - May look lichenoid - May see Lupus Cheilitis with involvement of vermilion zone on lower lip Labs - 95% positive for Anti-nuclear antibody test. Nonspecific also seen in other autoimmune diseases. - 70% have DS DNA antibodies. More specific - 30% have antibodies to Sm, a protein complexed with small nuclear RNA. Very specific for SLE |
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CCLE
Characteristics Clinical |
Characteristics
- Limited to skin and mucosa - Skin lesions are Discoid lupus erythematosus - Healing results in atrophy with scarring and hypo or hyperpigmentation of area. Clinical - Appear identical to Erosive LP. However, in LP, you won't see skin lesions. |
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CCLE
Characteristics Clinical |
Characteristics
- Limited to skin and mucosa - Skin lesions are Discoid lupus erythematosus - Healing results in atrophy with scarring and hypo or hyperpigmentation of area. Clinical - Appear identical to Erosive LP. However, in LP, you won't see skin lesions. |
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Leukoplakia
Characteristics Clinical |
Characteristics
- Considered pre-malignant but only 5%-25% of all biopsies have dysplasia or frank invasive carcinoma. - 4% have malignant transformation potential of 4% - Most common chronic lesion and most common pre-malignancy of oral mucosa Clinical - 70% in 40yr old males - When seen on lip vermillion, tongue, and floor of mouth, greater than 90% would show dysplasia or carcinoma. |
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Dysplasia Histology
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- Bulbous and teardrop-shaped rete ridges
- Loss of polarity - Keratin or epithelial pearls. Dyskeratosis - Loss of cellular cohesion. Acantholysis - Enlarged nuclei with prominent nucleoli - Pleomorphism and Hyperchromaticity - Increase in mitotic activity - Abnormal mitotic figures |
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Combination of both Leukoplakia and Erythroplakia
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Speckled Leukoplakia
Erythroleukoplakia |
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Leukoplakia
Characteristics Color |
Clinical term used to describe a white patch or plaque that can't be characterized as any other disease
- Most common chronic lesion and premalignancy of oral mucosa - Must exclude all other possible causes such as Lichen planus, Candidiasis, Frictional keratosis, Leukoedema, etc - Considered a premalignant lesion 5-25% have dysplasia or invasive carcinoma with 4% malignant transformation potential White color from: - Hyperkeratosis: Thickened surface keratin - Acanthosis: Thickened spinous layer |
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Leukoplakia types
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Mild or thin - Translucent flat or non-palpable
Homogeneous or thick-Opaque, flat, well-defined Granular or nodular leukoplakia - Red and white, raised and rough Verrucous or verruciform Leukoplakia - White raised finger like projections |
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Proliferative Verrucous Leukoplakia
Characteristics Histology |
Characteristics
- Strong Female predilection 4x - Begins as simple flat leukoplakia but grows to become exophytic and verrucous - Exhibits persistent growth even after treatment - over 70% develop dysplasia and carcinoma dispite therapy Histology - Hyperkeratosis and acanthosis - Chronic inflammatory infiltrate - Verrucous lesions have papillary projections and broad blunted rete pegs |
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Dysplasia histology
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Teardrop rete pegs
Enlarged nuclei Increased mitotic activity Abnormal mitotic figures Acantholysis Dyskeratosis: Keratin or epithelial pearls |
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Dysplasia
Grading Clinical Treatment |
Mild - Limited to Basilar 1/3
Moderate - up to midpoint of spinous layer Severe - Above midpoint Carcinoma in situ - Full thickness changes. Clinical - Dysplasia can skip areas and different areas can have different grades of dysplasia - So take biopsy from thickest area of leukoplakia or mixed are of erythro-leukoplakia - 36% risk for dysplasia becoming a Carcinoma Treatment - Discontinue all irritants such as smoking or alcohol including listering - Topical treatment with Accutane or 5-FU |
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Bowen's disease
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Squamous cell Carcinoma in Situ
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Erythroplakia
Characteristics Clinical D/D Diagnosis Treatment |
Characteristics
- Less common than Leukoplakia but all true erythroplakias demonstrate significant dysplasia or carcinoma Clinica - Male > Female - Peak age is late 60's early 70's - Most common in floor of mouth, tongue, and soft palate D/D - Allergic or drug induced Mucositis - Atrophic / erythematous candidiasis - Ecchymosis - Vascular lesions - Psoriasis Diagnosis - Use Toludine Blue to identify areas to be biopsied. Can also stain ulcerations so be careful - Visilite and VELscope, but can only be used as adjuncts. Treatment - Red lesions in high risk areas should be viewed with suspicion and biopsied - If diagnosis is dysplasia, lesions should be removed entirely if possible - Long term followup is needed because recurrence is common |
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Keratoacanthoma
Characteristics Clinical Types Histology |
Characteristics
- Self-limiting epithelial proliferation that arises from infundibulum of hair folliflces - Seen after 45 - 95% appear on sun exposed skin and 8% occur on the outer edge of the vermilion border Clinical - Firm nontender dome shaped nodules with a central umbilication that is filled with keratin - Rapid enlargement to 1-2cm and then stabilizes - Most spontaneously regress in 6-12 wks - Frequently has a *Depressed Scar Types - Muir-Torre syndrome: GI carcinoma and sebaceous tumors - Ferguson-Smith type: Appears early in life and may not involute - Grzybowski type - Associated with internal malignancy. Hundreds of Keratoacanthomas on skin and upper GI system. Histology - Overall PATTERN of growth is more diagnostic than individual cells - Central crater-form with overlying lip |
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Signs and Symptoms of Oral Cancer
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Early
- Persistent red and/or white patch - Non healing ulcer - Progressive swelling or enlargement Late - Indurated area - Paresthesia - Airway obstruction - Chronic earache |
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Oral Cancer
Characteristics Incidence Non-smokers Etiology Risk factors |
Characteristics
- More prevalent in males 2:1 - Most are over 40yrs - Most common sites is floor of mouth, ventral/lateral tongue, Soft palate/Faucial pillars Incidence - Middle age: Black males have highest incidence - Elderly: White males have highest incidence - In India, oral cancer is most common form of cancer Affected non smokers - Tend to be female - Have intraoral carcinoma - Be younger at diagnosis - Demonstrate mutations of p53 gene or other tumor suppressors Etiology - Multifactorial with no single clearly defined cause. Extrinsic and Intrinsic factors - Loss of cell cycle control leading to increased proliferation and decreased apoptosis - Increased motility allowing invasion into tissue and blood vessels and lymphatics Risk factors Tobacco - 3-13x increased risk of oral cancer. 4x risk with smokeless tobacco. Alcohol - Not proven to cause oral cancer by itself, but combination with smoking increases risk to 15x over nonsmoker/nondrinker - Iron deficiency - Atrophy of lingual papilla leads to smooth red tongue. Patients often have angular cheilitis and koilomychia. Plummer-Vinson or Patterson-Kelly syndrome. HPV infection - HPV 16&18 Koilocytic dysplasia Genetic - Oncogenes ras myc c-erbB. Tumor supressors p53, pRb, and E--cadherin. Radiation - Decreases imuune reactivity and produces abnormalities in chromosomes. UV-B is greater risk factor than UV-A Oral Submucous fibrosis - Premalignant condition that presents with mucosal rigidity and pallor. Risk doesn't regress with cessation of use |
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Oral cancer Appearance and Clinical by site
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Appear
- Exophytic: Mass forming, fungating, papillary - Endophytic: Invasive, burrowing, ulcerated - Leukoplakic, Erythroplakic, Erythroleukoplakic - May present with moth eaten radiolucency with ragged margins Tongue>Floor of mouth>SP>Gingiva>Buccal mucosa>Lingual mucosa>Hard Palate Tongue - Most common site on ventral and posterior lateral - Presents as painless indurated mass or ulceration in 2/3 of cases - Site most common in young patients and nonsmoking females Floor of mouth - Most common on midline near frenum - Most likely site for oral cancer to arise from existing leukoplakia or erythroplakia - Most often associated with a second primary malignancy of upper aerodigestive tract Soft Palate/Oropharynx - Patients often unaware of lesions on soft palate or oropharynx - 80% of tumors present with cervical and distant metastases at the time of diagnosis - Initial symptom is often dysphagia Gingiva - Seen on keratinized mucosa of posterior mandibular ridge - Least associated with tobacco smoking - Site with greatest predilection for females Lip - Seen in fair skinned patients with chronic exposure to the sun such as outdoor occupations - 90% on the lower lip - Appear as slowly growing crusted, nontender, indurated ulcerations |
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D/D for a non-healing ulceration
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SCC
Traumatic ulcer Burns Infections Cocaine abuse Lymphoma |
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Squamous Cell Carcinoma
Histology Treatment Metastasis |
Histology
- Surface epithelium shows dysplasia with transition to infiltrating tumor - Tumor cells have abundant eosinophilic cytoplasm, hyperchromatic nucleoli, cellular pleomorphism, abnormal mitotic figures - Dyskeratosis and keratin pearl formation - Increased nuclear-cytoplasmic ratio - May see perineural, intravascular and lymphatic invasion. Oral SCC often spreads to lung - Often see chronic inflammatory infiltrate of lymphocytes, plasma cells, and eosinophils Treatment - Intraoral lesions get radical excision, radiation, or combination - No chemotherapy has improved patient survival - Lip vermillion lesions treated with surgery with 100% 5yr survival. Except upper lip which is 58% Metastasis - Not an early event. Occurs due to delays in treatment - Node with metastatic lesion is usually stone hard, nontender, fixed and enlarged - Usually to lung, liver, bone |
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Grade and Staging. Survival rates
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Grade - degree of differentiation and subjectively differentiated
Staging - Stage at diagnosis is the most predictive factor of prognosis for SCC - Tumor size - Spread of regional Nodes - Metastasis 5 Year survival rates Stage 1 - 85% Stage 2 - 66% Stage 3 - 41% Stage 4 - 9% |
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Lymph node drainage of mouth
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Lower lip and FOM - Submental nodes which can go to deep cervical or submandibular
Posterior mouth - Superior jugular and digastric nodes Oropharynx - Jugulodigastric or retropharyngeal nodes |
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Field cancerization
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One carcinoma of upper aerodigestive tract leads to increased risk for second primary
- Continued smoking 36% - Decreased smoking 18% - Quit smoking 7% |
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Verrucous Carcinoma
Characteristics Clinical Histology Treatment |
Characteristics
- Low grade variant of SCC - Slowly growing exophytic tumor with superficial invasion and extremely low incidence - Can be locally destructive of bone and soft tissues - Associated with smokeless tobacco Clinical - Most frequently seen on buccal mucosa and alveolar ridge - Diffuse, well-demarcated, painless, thick plaque with papillary projections Histology - Deceptively benign - Wide elongated rete pegs with broad bases that appear to push into connective tissue - Abundant parakeratin plugging between surface projections - Normal epithelial maturation with no significant degree of cellular atypia - Must see endophytic growth* Treatment - Need good biopsy because 20% have a concurrent SCC - Surgical excision without neck dissection due to low incidence of metastasis - Treatment failure usually due to missed conventional SCC |
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Nasopharyngeal carcinoma
Characteristics Clinical WHO classification Treatment Prognosis |
Characteristics
- Arises from lining epithelium of nasopharynx - Incidence is high in china - Associated with EBV Clinical - First sign in 60% of cases is an enlarged cervical lymph node posterior to SCM muscle which is unusual compared to other carcinomas of H&N - Usually occurs on lateral nasopharyngeal walls - 50% have hearing loss and serous otitis media from obstructed eustachian tube WHO classification - SCC (Keratinizing) - Nonkeratinizing carcinoma - Undifferentiated carcinoma. Regaud pattern: Nests and cords separate from inflammation, Schmincke pattern: Inflammatory infiltrate permeates cell nests and may be confused with lymphoma - Nonkeratinizing and undifferentiated types have a well established association with EBV - **EBV association and pattern of undifferentiated type has no significance** Treatment - Radiation with chemo - Keratinizing type does not respond well to radiation Prognosis - 5yr survival is 100% for stage 1 but decreases to 35% for stage 4 - High clinical stage, male sex, bony invasion of skull base, and paralysis of cranial nerves are associated with poor prognosis - Patients under 20 have a better outcome |
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Oral manifestations of HSV and antibodies
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Primary herpetic gingivostomatitis
Recurrent HSV infection - Antibodies to HSV1 decreases the chances of infection with HSV2 and vice versa |
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Primary herpetic Gingivostomatitis
Characteristics Clinical Diagnosis Treatment |
Characteristics
- Only 1% manifests to gingivostomatitis usually between 6 months and 5yrs of age - Most cases are subacute - Both keratinized and nonkeratinized mucosa 60-70% of population are affected Clinical - Abrupt onset of symptoms - Acute gingivitis WITHOUT necrosis of interdental papillae - Crops of vesicles that rupture in 24hrs and coalesce into ulcerations - Heals without scarring within 12-18days Diagnosis - Established with a cytologic smear or viral culture - See Tzank cells like in VZV, Pemphigus, and CMV - See viral cytopathic effect. Balloon degeneration and Nuclear molding Treatment - Antipyretics, but NOT asprin - Topical anesthesia - Acyclovir is NOT indicated in healthy patients because it has little effect on established lesions. May be used in immunocompromised lesions |
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Secondary HSV infection
Characteristics Clinical Diagnosis & Treatment |
Characteristics
- Occurs in 20% of population - Most commonly on vermillion border and adjacent skin - Oral cavity lesions occur on fixed, keratinized mucosa such as hard palate and gingiva Clinical - Prodromal stage 6-24hrs before eruptions - Crops of painful vesicles appear, ulcerate, and then coalesce and crust on lip - Heals in 7-10days without scarring - Lesions percipitated by sunlight, trauma, hormonal changes, and illness Diagnosis and Treatment - Use cytologic smear or viral culture for Tzank cells - Treat with acyclovir as soon ans prodromal signs begin. Apply every 30 min for first 8 hours and then QID for 2 days - Or take systemic antiviral as soon as prodromal signs begin - Studies show 1gram of lysine per day decreases the frequency of recurrent episodes |
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Clinical D/D of Herpes Simplex
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- Herpes Zoster, Chicken pox
- Coxsackie: Herpangina on soft palate, Hand Food Mouth is anywhere in mouth - Recurrent aphthous - Erythema Multiforme - Traumatic ulcerations |
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Secondary Varicella Zoster
Characteristics Treatment |
Characteristics
- aka Shingles - Can present as toothache Treatment - Keep rash dry and clean - Avoid topical antibiotics - Keep rash covered if possible - Alert physician if rash worsens or they have fever which can indicate superinfection - Acyclovir, Famciclovir, and Valacyclovir are approved by FDA to treat zoster. All are nucleoside analogues that inhibit viral replication. |
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Mucous Membrane Diseases
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Aphthous lesions
Vesiculobullous lesions/Desquamative gingivitis - Erosive lichen planus - Benign mucours membrane Pemphigoid - Pemphigus vulgaris - Erythema Multiforme |
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Recurrent Aphthous Stomatitis
Characteristics Forms Clinical Etiology |
Characteristics
- Chronic Ulcerative disease affecting 20% of population or 50% of college students Forms - Minor: Canker sores - Major: Sutton's disease, PMNR - Herpetiform ulcerations Clinical - Females are more commonly affected - Appears to be a polygenic inheritance pattern - 3 factors: Primary immuneodysregulation, Decrease of mucosal barrier, Increase in antigenic exposure Etiology - Mucosal destruction represents a T-cell mediated immune dysregulation - Decreased CD4 to CD8 ratio - Activated T cells aggregate in the connective tissue at periphery of aphthous ulcers |
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Minor Aphthous
Characteristics Clinical Histology Treatment |
Characteristics
- Most common type - Usually shows up in childhood - Usually 1-2 painful ulcers less than 1cm - Occurs on non-keratinized moveable mucosa - Fewest recurrences with shortest duration vs other two Clinical - Stats as erythematous macule and develops into an ulceration. No vesicle - Well delineated grayish-white ulcer with erythematous halo - Heals without scarring in 7-10days Histology - CT exhibits increased vascularity and a mixed inflammatory infiltrate. PMN's, Langerhans cells, and histiocytes Treatment - Rule out any systemic disorder associated with aphthous-like ulcers - Treat with topical steroids if necessary |
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Sutton's disease
Characteristics Treatment |
Major aphthous, aka PMNR
Characteristics - Less common but more severe - Multiple >1cm ulcerations - Deeper ulcerations also on non-keratinized mucosa - Takes 6wks to 3months to heal - Also heals without scarring - Frequently invovles soft palate/Faucial pillao complex and labial mucosa - Usually occurs after puberty vs Childhood for Minor Treatment - Treat with initial course of systemic steroids and then maintenance with topical steroids if possible - Steroid resistant patients respond to 10wk course of acyclovir - *Surgical removal is Inappropriate |
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Herpetiform Ulcerations
Characteristics Treatment |
An Aphthous ulcer
Characteristics - Uncommon - Presents as painful crops of 20-100 Small ulcerations - Lack of vesicle stage so it differs from herpetic infection - Usually nonkeratinized, but MAY occur on keratinized. So can be confused with recurrent HSV - Adulthood onset Treatment - Don't prescribe steroids until you're sure lesions aren't due to herpes - Tetracycline rinse 125mg/5cc soak 2x2 gauze and hold it over area. If regresses, its aphthous, if they don't then its herpes - If true aphthous, responds dramatically to topical steroids |
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Systemic disorders associated with RAS
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Behcet's syndrome - Ocular and orogenital lesions with oral lesions being first sign. Middle east and Japaenese heritage
PFAPA syndrome - Periodic Fever, Aphthous, Pharyngitis, Cervical Adenitis MAGIC syndrome - Mouth and Genital ulcers with Inflammed cartilage Celiac disease - Males>females. Gluten sensitivity causes ulcers in any part of GI tract. Associated with skin lesions Cyclic neutropenia - Periodic ulceration due to decreased ability to fight infection Inflammatory bowel disease - Crohn's disease and Ulcerative colitis Immunocompromised - HIV and transplant patients Helicobacter Pylori |
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Graft vs Host disease
Characteristics Types Clinical |
Characteristics
- Seen mainly with allogenic bone marrow transplants - Milder disease when younger, cord blood, and females Acute - Within a few weeks of transplant 50% of the time - Skin lesions from mild rash to sloughing similar to toxic epidermal necrolysis Chronic - Continuation of acute disease or one that develops 100 days after transplant - Expected 30-65% of time - Mimics autoimmune conditions like SLE and Sjogren's - May mimic lichen planus or systemic sclerosis Clinical - Oral lesions seen 30-75% of acute disease and 80% of chronic disease - Involves everything in mouth but spares Gingiva - Resembles erosive lichen planus with erosion or ulceration and white striae reticular pattern - May have mucositis and xerostomia is common |
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Desquamative Gingivitis
Definition Clinical Diagnosis |
Clinical term used to describe oral lesion that is usually one of four
- Erosive lichen planus/ Lichenoid drug reactions(Mucositis) - Pemphigus vulgaris - Benign mucous membrane pemphigoid - Erythema Multiforme (less freuqently) Clinical - Affects free and attached gingiva - Diffuse and markedly erythematous gingiva - Found in peri-menopausal females - Associated with sensitivity to spicy foods - Treated when symptomatic - Precise diagnosis is made via biopsy |
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Erosive Lichen Planus
Characteristics Histology Immunoflourescence Treatment |
Characteristics
- Not as common as reticular - Atrophic erythematous area often with central ulceration - Can be confined to gingiva - Has a small risk 2% of dysplastic transformation or carcinoma. No risk with reticular form Histology - Shows dense band of subepithelial lymphocytic infiltrate with "Saw Toothed" rete pegs and destruction of basal cell layer Immunoflourescence - Antibodies bind fibrinogen - Non specific and reveals shaggy deposition if antibodies at basement membrane Treatment - Treat with topical corticosteroids or tetracycline and niacinamide or protopic. |
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Lichenoid Mucositis
Characteristics Histology Treatment |
Characteristics
- Similar histologically and clinically to Lichen planus. Can be white or red, with or without striae - However, more likely to be unilateral than Lichen planus - Can be caused by systemic medications such as NSAID's, anti-hypertensives - Cinnamon products can also cause this Histology - Resembles Lichen planus but show more mixed inflammatory infiltrate and a deeper perivascular infiltrate unseen with Lichen Planus Treatment - Topical steroids, or tetracycline and niacinamide or protopic. |
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Chronic Ulcerative Stomatitis
Characteristics Treatment |
Characteristics
- May present as desquamative gingivitis - Also looks clinically and histologically similar to Lichen planus as Lichenoid mucositis. - Circulating antibodies against nuclei of their own Stratified Squamous epithelium. ANAs - Not responsive to corticosteroids - Antimalarial drug Hydroxychloroquine has been used successfully |
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Erythema Multiforme
Characteristics Clinical Forms Histology |
Characteristics
- Vesiculo-ulcerative disease thought to be reactive in nature - Many are idiopathic, but can be secondary to herpes, Mycoplasma pneumoniae, drug reaction, underlying malignancy Clinical - Acute onset and can be explosive - More common in young males 20-30 - Nonspecific prodromal symptoms such as malaise, fever, cough 1wk prior to outbreak. Prodrome more often seen in infection cases rather than drug induced. - 20% have recurrent episodes but usually self limiting Forms - Minor - Major - Stevens-Johnson syndrome - Severe - Toxic epidermal necrolysis or Lyell's disease Histology - Tissue underneath epithelium break down forming bullas that comes off and forms an ulcer |
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Minor Erythema Multiforme
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- Erythematous mucosal patches undergo necrosis and evolve into large shallow EROSIONS and ULCERATIONS
- Oral mucosa involved in SYMMETRICAL MANNER by irregular painful erosions - Lip involvement may be severe with HEMORRHAGIC crusted lesions - Entire PERIMETER of tongue is usually affected with sparing of gingiva and hard palate |
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Major Erythema Multiforme
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- Usually triggered by drug
- Need either ocular or genital mocosal involvement for diagnosis to be made - 2-10% Mortality rate*** |
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Toxic Epidermal Necrolysis
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- Almost always triggered by drug exposure
- More common in older women compared to young males for minor and major - Diffuse sloughing due to increased apoptosis of epithelial cells - Managed like burn patients with 35% mortality rate |
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Direct vs Indirect Immunoflourescence
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Direct: Forzen section of patient's tissue is placed on slide and incubated with anti-human Ab tagged with flourecene
Indirect - Frozen section of tissue similar to human oral mucosa such as monkey esophagus is incubated with patient's serum. Then incubate with anti-human antibody tagged with flourecene and view with ultraviolet microscope |
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Pemphigus Types
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Types
- Pemphigus Vulgaris: Most common - Pemphigus Vegetans: Rare and may have oral lesions - Pemphigus erythematous: Skin lesions only - Pemphigus Foliaceous: Skin lesions only - Paraneoplastic pemphigus: Pemphigus like oral lesions associated with malignancy |
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Pemphigus Vulgaris
Characteristics Clinical Histology Diagnosis Treatment |
Characteristics
- Potentially life threatening skin and mucous membrane disease - Oral lesions are first to show and last to go - More common in 50yr old Jews Clinical - Most common oral sites are buccal mucosa, palate and gingiva - Bullae or vesicles are rarely identified due to early rupture of thin friable blister roof. Often ulcerated - >50% have oral lesions before skin lesions so early treatment may prevent skin lesions - Positive Nikolsky sign seen in PV aand BMMP. Induce Bullae by applying firm lateral pressure on normal mucosa Histology - Epithelium shows suprabasilar cleavage - Leaves basal cell attached forming row of tombstones - Acantholysis - Rounded Tzank cells can be seen Diagnosis - IgGs directed against Desmoglein-3 of desmosomes - Should be confirmed with direct immunoflourescence showing chicken wire pattern - Indirect is also positive 80-90% of the time - Must take biopsy with a piece of perilesional tissue to see interface between epithelium and CT to make diagnosis Treatment - Refer patient to vesiculobullous clinic - Given systemic steroids and chemotherapeutic/immunosupressive drugs with many side effects. |
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Potential side effects of systemic Corticosteroids
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- Diabetes Mellitus
- Adrenal suppression - Weight gain - Osteoporosis |
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Hailey-Hailey disease
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aka Chronic benign familial pemphigus
- Rare genetic condition with erosive skin lesions. - Oral lesions uncommon |
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Pyostomatitis Vegetans
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- Appear clinically similar to pemphigus vegetans
- Oral lesions are seen in association with ulcerative colitis or Crohn's - Intraoral lesions appear as snail track serpentine pustules on erythematous mucosa |
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Benign Mucous Membrane Pemphigoid
Characteristics Clinical Histology Diagnosis Pathogenesis Treatment |
aka Cicatricial(Scarring) Pemphigoid
Characteristics - Looks similar to pemphigus vulgaris but twice as common - Autoantibodies produced against one or more components of basement membrane Clinical - Twice as common in older females - Most patients have oral lesions - Other sites include conjunctiva, nasal, vaginal, and esophageal mucosa as well as skin - *Frequently find vesicles or bullae compared to pemphigus because the cleavage is subepithelial - Many patients have ocular lesions that heal with scarring forming adhesions caled Symblepharons. Should be referred to ophthalmologist Histology - Epithelium shows sub-basilar cleavage forming subepithelial blisters - Should confirm with direct immunoflourescence which shows linear band at basement membrane - Primarily IgG and C3. May see IgA and IgM as well Diagnosis - Immunoreactants bind to antigens in hemidesmosomes - BPAG1, BPAG2, and sometimes Laminin5 in area of Lamina Lucida -*** Low circulating auto-antibodies. So CANNOT use indirect method Pathogenesis - Deposition of Igs in BM leads to complement activation - In combination with mast cell degranulation generates chemotactic factors that induces Neutrophil migration - Release of proteolytic enzymes by neutrophils causes blister formation Treatment - If oral lesions apply potent topical corticosteroids and then taper dose. May reappear if treatment is discontinued - Systemic treatment: Tetracycline with Niacinamide which can cause flushing Dapsone but can get blood dyscrasias Systemic steroids in combo with immunosupressive drugs if above two are unsuccessful |
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Symblepharon
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Adhesions of scarring from ocular lesions found in Benign Mucous Membrane Pemphigoid
- Should refer to ophthalmologist even if patient has no ocular lesions |
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Epidermolysis Bullosa Acquisita
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- Clinically and histologically similar to BMMP and Linear IgA with subepithelial cleavage
- Autoabtibodies to Type 7 collagen which is part of anchoring fibrils connecting epithelium to CT - Must diagnose with special technique called SALT SPLIT SKIN which is incubation perilesional biopsy in concentrated salt solution to form a bulla - *Shows IgG deposited on floor of bulla compared to IgG deposited on Roof of bulla |
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Linear IgA
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- Bullous dermatosis clinically and histologically similar to BMMP and EBA with subepithelial cleavage
- Involves skin and oral, and ocular mucosa - Need immunoflourescence to differentiate from BMMP and see linear deposit of IgA at BM zone |
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Traumatic Ulceration
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- See erythematous center(Granulation tissue) with hyperkeratotic border due to chronic minor trauma
- Compared to Aphthous which has a white fibrinous center with erythematous border - Heals within 2 wks of trauma is discontinued |
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Riga-Fede disease
Characteristics Treatment |
Characteristics
- Sublingual ulcerations in infants secondary to chronic mucosal trauma from adjacent primary teeth - Between 1wk and 1yr - Most common in anterior ventral tongue - Histology same as for traumatic ulceration. Erythematous center of granulation tissue with hyperkeratotic border. Treatment - Exo of anterior primary teeth is not recommended but would lead to resolution - Grinding incisal mamelons - Coverage of teeth with mough guard - Discontinue nursing |
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Pigmented Oral Macules
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All oral pigmented macules of the following should be surgically sampled and submitted for biopsy
- Recent onset - Recent enlargement - Unknown duration - Irregular pigmentation |
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Physiologic pigmentation
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- Symmetric, Diffuse, Macular pigmentation involving gingiva and buccal mucosa
- Usually seen in patients with dark skin - Due to increase in Melanin production. NOT increase in malanocytes in epithelium |
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Oral Melanotic Macule
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Well demarcated Flat brown mucosal discoloration
- Increase in melanin deposition AND an *increase in melanocytes in the basal cell layer - Not dependent on sun exposure - Vermillion border is most common site with avg of 7mm - Not considered premalignant but can mimic melignant melanoma - Biopsy is recommended |
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Addison's disease
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Primary Adrenocortical insufficiency
- Decreased cortisol production causes increase in ACTH and MSH - Leads to Diffuse Pigmentation of skin - See multiple oral melanotic macules and Ephelides(Freckles) |
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Peutz-Jegher's syndrome
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- Inherited autosomal dominant disorder characterized by oral and peri-oral Ephelides and oral Melanotic macules
- Multiple polyps found in small intestines thought to be Hamartomas. Less risk compared to those of Gardner |
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Smokers Melanosis
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- Component in cigarette smokes that stimulates increased melanin production. *Not increase in melanocytes
- More common in females especially those on oral contraceptives. Thought to be due to female hormones. - Most common site is anterior labial attached gingiva - Intensity of pigmentation is directly proportional to pack years |
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Melanoacanthoma
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- Benign acquired pigmented macule characterized by dendritic melanocytes dispersed throughout the epithelium
- Seen almost exclusively in black patients and thought to be a reactive lesion - Lesions show a rapid increase in size and can reach several centimeters in a few weeks - Biopsy to rule out melanoma - Not treatment necessary |
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Melanocytic Nevi
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- Benign proliferations of cells originating from Neural Crest. Not melanocytes
- Nevus is a term for congenital or developmental malformation of skin or mucosa |
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Nevus cells
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Type A - Epithelioid: Round to oval cells with moderate amounts of cytoplasm and uniform round nuclei
- Type B - Lymphocytic like: Less cytoplasm and pigment. - Type C - Spindle shaped: Signs of maturation and neurotization. More elongated and spindled Theques - Small round aggregates of type A or B *- Unlike melanocytes. Nevus cells are NOT dendritic |
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Evolution of Nevi
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Junctional - Sharply demarcated Macule. Theques located at junction of epithelium and CT
Compound - Slightly elevated soft smooth papule with theques at junction of epithelium and within CT Intramucosal/Intradermal - Gradual loss of pigmentation, more elevate, more papillary surface and hair growth. Nevus totally within CT |
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Cafe Au Lait Spots
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McCune Albright Syndrome
- Polyostotic Fibrous dysplasia with Endocrine dysfunction - Associated with Gs alpha gene - Irregular outline of cafe-au-lait spots Neurofibromatosis Type I - aka Von Recklinghausen's disease - Multiple neurofibromas - Associated with Neurofibromin gene - Cafe-au-lait spots with a more smooth outline and axillary frecking (Crowe's sign) |
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ABCD of Melanomas
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Asymmetry
Border irregularity Color Variegation Diameter of greater than 6mm |
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Melanoma (General)
Clinical Types |
Clinical
- 3rd most common form of skin cancer. Also most deadly - 25% arise in head and neck - 2-8times higher risk of relative has history of melanoma - Primary oral melanomas are rare Clinicopathologic Types - Lentigo maligna - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma Directional Growth patterns - Radial - Vertical |
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Oral Melanoma
Characteristics Sites Pronosis Histology Treatment |
Characteristics
- Very rare and 1% of all melanomas - Metastatic lesions are more common than primary. Thought to arise de Novo and not within a nevus or melanotic macule - More often in old aged men - Incidence has remained stable unlike cutaneous melanoma which has been increasing Sites - Metastatic: Mandible, tongue, buccal mucosa - Primary: Palate and Maxillary gingiva Prognosis - Median survival for oral melanoma is less than 2 years - Thickness or volume is most reliable prognostic indicator vs depth of invasion used for cutaneous tumors - If regional lymph nodes are positive then 5yr survival is 16% vs 40% for negative nodes Histology - Asymmetrical - Increased number of melanocytes. Normally 1 per 10 basal keratinocytes - Melanocytes show Nuclear atypia(Enlargement, presence of nucleoli) and increased mitotic activyt - Pagetoid spread of melanocytes. Upward migration Treatment - Surgical removal with node ID and removal - Prognosis is poor in all cases except in situ cases - Requires life-long followup |
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Focal Argyrosis
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Most common pigmentation in oral cavity
- Amalgam Tattoo |
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Heavy metal pigmentation
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- Lead shows a dark line at gingival margin due to reaction with sulfur dioxide produced by bacteria
- Bismuth in peptobismol can lead to black tongue |
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Medication pigmentation
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- Minocycline causes black discoloration of bone which shows through the soft tissue as a grey pigmentation
- Malarial drugs, Cyclophosphomide, and AZT can cause pigmentations |
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Ephelis
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- Freckle associated with sun exposure due to increased melanin in basal layer.
- No increase in number of melanocytes - Not pre-malignant |
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Seborrheic Keratosis
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- Benign proliferation of epidermal basal cells appears raised
- Positive correlation with sun exposure. - Not pre-malignant |
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Actinic Lentigo
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- aka Age or Liver spots
- Brown flat Macules resulting from chronic sun exposure seen in more than 90% of caucasians over 65. - Not pre-malignant |
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Melasma
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Symmetric hyperpigmentation seen with pregnancy and use of oral contraceptives
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Black Hairy Tongue
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- Asymptomatic Hyperkeratosis and elogation of Filiform Papillae
- Chromogenic bacteria and yeast make RBC pigments of porphyrin that makes tongue black - May also see black tongue with bismuth use but does NOT shot elongation of filiform papillae |
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Soft tissue Emphysema
Characteristics D/D |
aka Cervicofacial Emphysema
- Most often after surgical procedure using high speed handpiece - Crackling upon palation - Leads to airway obstruction and air in potential spaces and mediastinum D/D - Odontogenic infection - Angioedema - Hematoma |
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Bell's Palsy
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- Acute unilateral paralysis
- More in sping and fall - Middle age adults most common - May be triggered by cold, infections, extraction, trauma or ischemia to facial nerve - May have residual loss of muscle tone - Currently, use of antiviral and corticosteroids is in favor |
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Recurrence of Bell's Palsy
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Melkerson-Rosenthal Syndrome
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Lyme's disease
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May show palsy that mimics signs of Bell's Palsy
- Good practice to get Lyme titer for patients with facial palsy |
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Tic Douloureux
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- Most common type of trigeminal Neuralgia
- More common in Females of 6-7th decade - Thought to be caused by compression of trigeminal nerve and focal demyelination caused by blood vessles |
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Neuralgia
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- Paroxysmal or constant pain presenting as sharp, stabbing, itching or burning in distribution of nerve
- Does not cross to opposite side but some may be bilateral - Can treat with surgery to relieve compression or medication |
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Frey's syndrome
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Gustatory sweating
- Parasympathetic nerves that stimulate salavary glands connect with sweat glands - Seen after trauma to nerve - Treatment is with Botulinum toxin injection |
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Meth Mouth
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Meth induces:
- Bruxism - Acidity which erodes enamel - Xerostomia - Decrease in hygiene - Increase craving for high carbs - Vasoconstriction of vessels in periodontium which won't recover causing necrosis - Smooth surfaces often involved - Most damage seen when drug is ingested or smoked |
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Asplenic
Characteristics Treatment |
Characteristics
- Spleen filters erythrocytes and also produces Opsonins - Properdin and Tuftsin are opsonins that protect against bacteria such as Pneumococci - Children are 10 times more likely to develop sepsis after splenectomy Treatment - Patients should be immunized against Pneumococci, H.Influenzae, and Neisseria Meningitidis - Antimicrobial prophylaxis could be indicated before dental procedures |
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Burning and Painful tongue
Characteristics Diagnosis Treatment |
Glossopyrosis and Glossodynia
- BMS or Burning mouth syndrome is diagnosed when there is no underlying systemic disorder - Most often in post menopausal females. Often begins after a dental treatment - Increased taste sensation Diagnosis - Vitamin B-12 deficiency - Diabetes Mellitus - GERD - Hypothyroidism - Esterogen deficiency - AIDS - Also rule out candidiasis Treatment - Palliative: Biotene products, or Sugarless sucking candy - Capsaicin: Diluted tabasco - Tricyclic Antidepressants at a dose less than for depression treatment |
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Impetigo
Characteristics Clinical |
Characteristics
- Strep pyogenes or Staph Aureus - Endemic in young children and associated with poor hygiene, crowded conditions and hot climates Clinical - Vesicles rupture to leave thick amber crusts - Longer lasting bullae leave thin light brown crusts - Pruritis and lymphadenopathy but not systemic symptoms like fever - May mimic herpes simplex or exfoliative cheilitis |
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Erysipelas
Characteristics Clinical |
Characteristics
- Superficial skin infection usually associated with Strep pyogenes - May be misdiagnosed as cellulitis due to dental infection - Most cases in winter or spring Clinical - Seen in young, elderly, or debilitated patients - Often seen on face, cheeks, butterfly-like similar to SLE - Abscess, gangrene, thrombophlebitis, Toxic shock syndrome may occur if left untreated |
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Scarlet Fever
Characteristics Clinical |
Characteristics
- Systemic infection with Strep pyogenes - Begins as streptococcal pharyngotonsilitis in children 3-12 - Toxins attack blood vessels and produces characteristic skin rash Clinical - White strawberry tongue in days 1-2 because fungiform papillae shows through white coating - Red strawberry tongue in days 4-5 because coating sloughs revealing erythematous dorsal surface - Fever develops around day 2 - Cutaneous rash with skin desquamation - Pastia's lines: Transverse streaks in skin folds due to capillary fragility |
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Diphtheria
Characteristics Clinical Treatment |
Characteristics
- Exotoxin causing necrosis and organism feeds off dead tissue and spreads. Predominantly mucosa - Humans are only reservoir Clinical - Oropharyngeal exodate begins on one tonsil but eventually covers both tonsils, uvula, soft palate, and parts of pharynx with pseudomembrane - Tonsillar involvement can be significant and lead to bull neck - Exotoxin may cause myocarditis and neurologic involvement causing soft palate paralysis Treatment - Confirm diagnosis with culture from beneath pseudomembrane - Treat with antitoxin and antibiotics |
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Syphilis
Characteristics Phases Clinical Diagnosis |
Characteristics
- Troponema Pallidum - Spreads through sexual contact Primary - Chancre at site of innoculation - Oral lesions on lips, tongue, palate, gingiva, or tonsils and appear as painless ulcerations or vascular proliferations. Mimics pyogenic granuloma Secondary - Disseminated disease 4-10wks after infection - Lymphadenopathy, headache, fever, musculoskeletal pain - White Oral mucous patches in 30% of patients resembling Leukoplakia - Diffuse erythematous maculopapular rash **- Condyloma Lata: Resemble vira papillomas **- Lues Maligna: Explosive widespread infection in immunocompromised patients Tertiary - Gummas: Focal granulomatous inflammation producing significant destruction including perforation of palate - Intersitial glossitis due to contracture of lingual musculature after healing of gummas - Luetic glossitis: Diffuse atrophy of dorsal papillae - CV: Ascending aortic aneurysm, left ventricular hypertrophy, CHF - VNS: Psychosis and dementia Congenital - Hutchinson's triad - Hutchinson's incisors and mulberry molars - Ocular interstitial keratitis - 8th nerve deafness - Rhagades: Cracks or fissures around mouth Diagnosis - Dark field microscope or special stains - Should be confirmed with specific immunoflourescent antibody staining or serologic testing - FTA-ABS, and TPHA are specific and highly sensitive. VDRL and RPR is not specific and not highly sensitive. |
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Noma Characteristics
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aka Cancrum Oris and Gangrenous stomatitis
Characteristics - Rapidly progressive infection caused by normal flora that become pathogenic during periods of immune compromise - Commonly Fusobacterium Necrophorum, F. Nucleatum, and P. Intermedia, - Begins as ANUG and extends to soft tissues - Can see Noma Neonatorum in babies within 1st month |
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Actinomyces
Clinical Histology Treatment |
Clinical
Gram positive BACTERIAL infection - Usually Actinomyces Israelii which is a part of normal oral flora - 55% of cases seen in cervicofacial region - Enters through area of trauma such as tooth infection - Does not spread through normal fascial planes or normal lymphatic and vascular routes - Spreads via Direct extension through tissue. Lymph nodes only become involved if they are in the direct path. - Suppurative Sulfur granules that represent colonies - May form sinus tract to skin surface often over mandibular angle - Present with "Wooden" indurated areas of fibrosis and central abscess Histology - Club shaped filamentous organisms surrounded by a sea of neutrophils Treatment - Penicillin or Tetracycline for 6wks to 12months |
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Bartonella Henselae
Characteristics Histology Treatment |
Characteristics
- Cat-Scratch Disease - Most common cause of Chronic regional lymphadenopathy in children - Scratches on face often lead to submandibular lymphadenopathy and may mimic odontogenic infections Histology - Granulomatous inflammatory response in lymph nodes with characteristic "Stellate" Abscess Treatment - Self limiting and resolves in 4 months - Antibiotics for severe or prolonged cases |
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Oculoglandular Syndrome of Parinaud
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- Usually a result of Cat-Scratch Disease. Rare
- Primary lesion adjacent to the eye resulting in a conjunctival granuloma in association with preauricular lymphadenopathy |
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Bacillary Angiomatosis
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- Seen in AIDS patients
- Also caused by Bartonella Henselae - Characterized by painful subcutaneous vascular proliferation - Clinically resembles Kaposi's Sarcoma |
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Varicella-Zoster Virus
Clinical |
Clinical
- Spreads through air droplets or direct contact - 90% have primary infection before 15 - Most primary cases are symptomatic unlike HSV - Lesions progress through stages of erythema, vesicle, pustule, and crust or scab. Described as dewdrops on a rose petal - Lesions at all stages present on skin vs smallpox which has lesions all at the same stage at the same time. - Lesions erupt for 4 days and patient is infectious 2 days before the rash until all lesions have crusted - Oral lesions are usually painless and often on palate or buccal mucosa |
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Herpes zoster with no vesicles
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Zoster Sine Herpete
- Severe pain in abscence of vesicles |
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Ramsay Hunt syndrome
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Complication of facial Zoster
- Facial paralysis - Vertigo - Hearing loss |
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Infectious Mononucleosis
Characteristics Diagnosis Treatment |
Characteristics
- EBV virus - Spread by intimate contact and most symptomatic infections are in young adults - Lymphoid enlargement, Tonsillar enlargement, Palatal petechiae, ANUG Diagnosis - Paul-Bunnel Heterophil antibody is found in 90% of cases. Mono-Spot test is based on this Treatment - Self limiting in 4-6wks |
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Cytomegalovirus
Characteristics Clinical Histology Treatment |
Characteristics
- Virus remains latent in endothelium, macrophages, lymphocytes, and salivary glands - Primary infection is usually sub-clinical - May be seen in neonates or immunocompromised Clinical Neonates: - Encephalitis leading to mental and motor deficits, hepatosplenomegaly, and thrombocytopenia - Diffuse enamel hypoplasia and hypomaturation is seen in 40% Clinical Immunocompromised: - Most common cause of blindness in HIV patients - Most common life-threatening infection in HIV patients - Oral lesions seen as chronic ulcerations Histology - Intracytoplasmic and Intranuclear inclusion bodies. Owl eye cells - Salivary duct epithelium may show similar changes Treatment - Gangcyclovir |
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Enteroviruses
Members Characteristics |
Cosakie A, B
Poliovirus Echovirus Enterovirus - Most infections occur in infants and children - Most are subacute or asymptomatic |
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Coxsackie viruses
Clinical Diseases |
Types
Herpangina - Coxsackie A1-6,8,10,22 HFM disease - A16 Acute lymphonodular pharyngitis - A10 Clinical - Most cases in summer and fall - Oral fecal route of transmission Herpangina Types 1-6,8,10,22 - Most cases are subacute or mild - Small number of oral lesions develop on POSTERIOR mouth - Lesions progress to red macules to vesicles to ulcers that heal without scarring HFM disease - A16 - Skin rash and oral lesions with flu like symptoms - Oral lesions on buccal and labial mucosa, and tongue. Not confined to posterior mouth like herpangina - Begin as erythematous macules that develop vesicles which rupture to form ulcerations that heal without scarring. Acute lymphonodular pharyngitis - Sore throat fever and mild headaches - Yellow to dark pink nodules on soft palate and tonsillar pillar that represent hyperplastic lymphoid aggregates |
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Measles
Characteristics Clinical |
aka Rubeola
Characteristics - Infection caused by paramyxovirus - Usually occurs in spring Clinical - Starts on face and moves down to trunk and extremities. Resolves in 1 wk - Koplik spots are present: Small bluish white macules representing focal epithelial necrosis |
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German Measles
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aka Rubella
- Mild infection caused by a togavirus - Classic triad of Deafness, Heart disease, and Cataracts. Deafness usually >80% and bilateral - Normally asymptomatic - Most common complication is arthritis which increases in frequency with increased age - Forchheimer sign in 20% of cases: Small discrete dark red papules on soft palate. Only lasts 12-14 hours after skin rash |
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Aspergillosis
Characteristics Clinical Histology Treatment |
Characteristics
- Second most common opportunistic fungal infection - Spores found in soil, water, or decaying material that becomes inhaled by host Clinical - Extent of damage depends on immune status - Can form Aspergilloma which is a low grade infection in maxillary sinus - Once reaches blood stream, can involves CNS, eyes, skin, liver, or GI tract Histology - Organism shows branching at Acute Angles - Small vessel occlusion and associated ischemic necrosis of tissue is seen Treatment - Debriedment and systemic antifungals - Only 1/3 of immunocompromised patients survive |
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Zygomycosis
Characteristics Clinical Diagnosis Treatment Prognosis |
Characteristics
- Includes Absidia Mucor, Rhizomucor, Rhizopus - Spores found in decaying material and inhaled by human host - Seen frequently in uncontrolled diabetes mellitus and immunocompromised patients Clinical - Can have Rhinocerebral Zygomycosis which presents with cranial nerve involvement and facial paralysis - Maxillary sinus involvement can lead to bone destruction and palatal perforation Diagnosis - Biopsy reveals large branching nonseptate hyphae at 90Degrees - Has affinity for small vessels and resultant tissue necrosis Treatment - Radical surgical debridement and systemic amphotericin B Prognosis - Poor and progression to cranial vault may lead to lethargy, blindness, seizures, and eventual death |
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Histoplasmosis
Characteristics Forms Histology |
Characteristics
- Most common systemic fungal infection in the US - Dimorphic fungus - Found in humid areas with soil enriched by bird or bat excrement - Endemic to regions drained by ohio and mississippi rivers - Spores are inhaled and grow in lungs - Disease may be expressed years later if patient becomes immune compromised Forms Acute Histoplasmosis - Self limited pulmonary infection - Symptoms mimic influenza Chronic Histoplasmosis - Usually elderly and immunosupressed patients - Clinically similar to tuberculosis showing lung infiltrates and cavitations Disseminated form - Least common. Spread to extrapulmonary sites - Oral lesions present as solitary non-healing ulcerations on tongue, palate or buccal mucosa. - May mimic Squamous Cell Carcinoma with indurated rolled margins Histology - Biopsy shows macriphages containing numerous yeasts |
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Blastomycosis
Characteristics Clinical Histology |
Characteristics
- Less common than Histoplasmosis - Much more common in Males 9:1 Clinical - Acute form: Symptoms similar to pneumonia - Chronic form: May mimic tuberculosis but without calcifications unlike TB and Histoplasmosis - May have oral lesions with ulcerations with irregular indurated margins mimicking Squamous cell carcinoma both clinically and histologically Histology - Mixture of acute and granulomatous inflammation - Surface epithelium may demonstrate pseudoepitheliomatous hyperplasia (PEH) - Have a characteristic doubly refractile cell wall. Birefringent. |
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Paracoccidiodomycosis
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Characteristics
- Distinct male predilection 25:1 possibly due to female hormone protection - Most are subclinical but oral lesions may present as mulberry like ulcerations usually on attached mucosa - Also may demonstrate PEH |
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Coccidiodomycosis
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Characteristics
- Saprophytic organism found in Alkaline, Semiarid, Desert soil of southwestern US and mexico - Peak incidence in winter months with occasional hypersensitivity reaction - Valley fever - Mimics TB Histology - Large spherule organism containing numerous endospores - |
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Cryptococcosis
Characteristics Histology |
Characteristics
- Cryptococcus neoformans grows as a yeast in both soil and tissue - Most common life threatening fungal infection in AIDS patients and rarely affects healthy patients - Often found in Pigeon Droppings - Presents as nonhealing crater-like ulcerations Histology - Chronic granulomatous reaction - Organism is a round to ovoid yeast surrounded by a clear halo that represents the capsule. - Mucopolysaccharide capsule stains mucicarmine positive |
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Toxoplasmosis
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Protozoal infection caused by Toxoplasma Gondii
- Devastating for fetus or immunocompromised patient - May lead to necrotizing encephalitis, pneumonia, and myositis, or myocarditis - Cats are the definitive host - Can cross placenta causing blindness, mental retardation, and delayed psychomotor development |
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Granuloma
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Focal area of granulomatous inflammation with aggregation of epithelioid macrophages surrounded by mononuclear leukocytes
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Tuberculosis
Characteristics Clinical |
Characteristics
- Only active disease is treated which is about 5-10% of infected patients - Secondary TB clasically involves the apex Clinical - Weight loss, fever, malaise, Night Sweats - Miliary TB is diffuse dissemination through the vascular system - Involvement of Skin is called Lupus Vulgaris - Cervical Lymphadenopathy is most common finding in head and neck - Oral lesions present as nonhealing painless ulcerations |
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Lupus Vulgaris
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Skin involvement of TB infection
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Scrofula
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Seen with ingestion of unpasteurized milk causing Mycobacterium Bovis infection
- Cervical lymphadenopathy that have fistulas to skin and calcified nodes |
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Hansen's disease
Characteristics Types Clinical Histology |
aka Leprosy
Characteristics - Low infectivity and requires cool host body temp for survival - Exact route of transmission is unclear Types Tuberculoid leprosy (Paucibacillary)- Positive lepromin test because host has high immune reaction. No organisms on biopsy Lepromatous leprosy (Multibacillary) - Reduced cell mediated immune response. See organisms on biopsy and no response to lepromin test Clinical - Long incubation - Active disease progresses slowly through stages of invasion, proliferation, ulceration and resolution with fibrosis - Hair in affected area is lost - Collapse of nasal bridge is pathognomonic - Can see loss of uvula and fixation of Soft palate - Infection of lip can result in Macrocheilia - Maxillary involvement in children can lead to enamel hypoplasia and short tapered roots - Pink tooth of mummery - Perforation of palate - Facial paralysis Histology - Tuberculoid type has well formed granulomas with few organisms - Lepromatous type shows sheets of langerhans cells with histiocytes filled with organisms - A type of Acid Fast called Fite Stain is used |
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Sarcoidosis
Characteristics Clinical Histology Diagnosis Treatment |
Characteristics
- Multisystem granulomatous disorder - Usually affects Blacks between 20-40 - 20% have no symptoms but chest xray may see bilateral hilar lymphadenopathy - See Lupus Pernio which is pathognomic for sarcoidosis Clinical Acute Sarcoidosis - Lofgren's syndrome: Erythema Nodosum, Bilateral hilar lymphadenopathy, and Arthralgia - Heerfordt's syndrome: Parotid enlargement, Facial paralysis, and fever - 1/4 of all intraoral cases are central in bone with ill-defined radiolucency with no expansion Histology - Non-caseating granulomas - See Schaumann bodies and Asteroid bodies. Basophilic and Eosinophilic inclusions - Stains for organisms are negative Diagnosis - Elevated ACE is supportive of diagnosis - Kveim test Human sarcoid tissue was injected intradermally to look for granulomatous reaction Treatment - 60% of patients resolve spontaneously within 2 years - Can treat with corticosteroids - 4-10% die of pulmonary, cardiac, or CNS complications |
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Crohn's Disease
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Characteristics
- Inflammatory and immunologically mediated condition - Primarily affects distal small intestine but can be seen anywhere along GI tract - 30% of cases oral lesions precede intestinal lesions Clinical - Abdominal cramping, pain, diarrhea and nausea - Oral findings show diffuse or nodular swelling of oral and perioral tissues - Cobblestone mucosal appearance - Deep linear granulomatous ulcerations - Recurrent Aphthous like ulcerations can be seen Histology - See non-necrotizing granulomatous inflammation in submucosal CT |
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Orofacial Granulomatosis
Characteristics Clinical Histology |
Characteristics
- Etiology is probably abnormal immune response - Diagnosis of exclusion. Rule out systemic diseases and local processes - Most common site is nontender persistent swelling of lips - Intraorally, can occur on tongue, gingiva, mucobuccal fold Clinical - Melkersson-Rosenthal Syndrome: Macrocheilia, Facial paralysis, and fissured tongue - Cheilitis granulomatosa: Only lip swelling Histology - Special stains are negative for organisms and no foreign material is found - Granulomas are seen clustered around blood vessels |
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Wegener's Granulomatosis
Characteristics Clinical Histology Diagnosis Treatment |
Characteristics
- Disease of abnormal immune response - Respiratory necrotizing granulomas, necrotizing glomerulonephritis and systemic vasculitis - Purulent nasal drainage, chronic sinus pain, and nasal ulceration - Can get destruction on nasal septum causing saddle nose deformity - Renal involvement usually comes late but is the most frequent cause of death Clinical - Strawberry gingivitis usually only on buccal of attached gingiva - Gingiva has a florid and granular hyperplasia with short papillary projections that are friable and hemorrhagic Histology - Prominent eosinophils centered around blood vessels causing vasculitis - Leukocytoclastic vasculitis - See Pseudoepithelial hyperplasia PEH Diagnosis - Indirect immunoflourescence of serum Antibody against cytoplasmic components of neutrophils. Either Perinuclear p-ANCA or Cytoplasmic c-ANCA Treatment - Cyclophosphamide and prednisone |
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Foreign body reactions
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- Histologically see chronic granulomatous reaction in connective tissue
- See either pigmented or polarized material in CT or macrophages/giant cells - Special stains are negative for organisms |
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TNM system
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T1 - 2cm or less
T2 - Between 2-4cm T3 - Greater than 4cm T4 - Invades adjacent structures N1 - Single ipsilateral node 3cm or less N2 - Multiple nodes no more than 6 N3 - More than 6cm M0 M1 Stage 1: T1 Stage 2: T2 Stage 3: T3 or any N1 Stage 4: T4 or any N2,N3, or M1 |
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Small solid elevated lesion smaller than 0.5cm
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Papule
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Occupies a large surface area in comparison with its height above skin level
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Plaque
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A surface markedly different in appearance or character from what is around it
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Patch
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Palpaple Solid Lesions Differs in depth of involvement
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Nodule
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Rounded or flat topped papule or plaque that disappears within hours
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Wheals
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Circumscribed elevated lesion that contains fluid
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Vesicle - Thin walls are so thin that they are translucent
Bulla - Vesicle greater 0.5cm |
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Moist circumscribed depressed lesion that results from loss of epidermis
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Erosion - Epidermis only
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Circumscribed raised lesion that contains purulent exudate. Composed of leukocytes with or without cellular debries
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Pustules
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Destruction of epidermis and dermis
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Ulcer
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Circumscribed hardening or induration in the skin
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Sclerosis
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Abnormal shedding or accumulation of stratum corneum
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Scaling
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Hardened deposits from dried serum, blood, or purulent exudate
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Crusts
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