What are the most common locations for lymphoepithelial cysts?
floor of mouth, soft palate, and lingual tonsilar area (wherever there is lymphoid tissue)
What are the causes for anemia:
nutritional
genetic
environmental
organ disease
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 manifestation of microcytic, hypo chromic anemias (iron def):
PALLOR
Iron deficiency anemia can lead to what oral manifestations?
pallor
atrophic glossitis
angular cheilitis
What is Plummer-Vinson Syndrome:
rare
TRIAD: Chronic iron def, dysphagia (esophageal webs), atrophic glossitis
Significantly
increased risk of esophageal cancer
Glossitis and angular cheilitis are signs of _____ ______ anemia
iron deficiency anemia
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 !!
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 t
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
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 colla
Hair on end on lateral skull radiograph is indicative of:
sickle cell anemia
(loss of outer cortical table)
also thalassemia
Coarser trabeculae on radiograph are indicative of:
bone marrow hyperplasia
sickle cell anemia!!
enlarged marrow spaces (more radiolucent)
What is thalassemia?
hereditary defect in alpha and beta Hb
RBC thin, short life span
HYPOchromic & microcytic
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)
How will thalassemia present radiographically?
hair on end" (lateral ceph)
marrow hyperplasia (trabecular large, coarse)
Tx for SCC and Thalassemia?
Blood transfusions (depends on severity of disease)
Bone marrow transplant
What is Polycythemia?
increase in the number of circulating red blood cells
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 epi
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
What is relative polycythemia?
dehydration, diuretics, vomiting
chronically can increase risk of MI or CVA
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 drugs and medications can cause RBC disorders?
-Carbamazepine
- Dapsone
- Ibuprofen
- Cephalosporins
- Penicillins
- Tetracycline
- Amp B
- Antazoline
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
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 are some qualitative causes of thrombocytopenia?
- drugs, ASA, NSAIDs, ETOH, Clopidogrel
- uremia, dialysis
- myeloproliferative D/O
- several inherited disorders
What are some quantitative causes of thrombocytopenia?
- underproduction (viral suppression, HIV), marrow discrepancies, drug induced: chemo
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
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
How much factor VIII is needed for normal hemostasis?
30%
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
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 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 t
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 infec
Aplastic anemia oral manifestations?
gingival bleeding
gingivitis, perio disease
oral candidiasis
Tx for aplastic anemia?
- blood transfusions
- immunosuppressive tc
- allogeneic stem cell transplant
What WBC are granulocytes?
basophils, neutrophils (seg
Which WBCs are non granulocytes?
lymphocytes (B & T cells)
monocytes
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 i
What is the oral manifestation of agranulocytosis/neutropenia?
deep, punched out ulcerations of buccal mucosa, gingiva
clinically gingival lesions comparable to ANUG
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
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
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-
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 th
What is lymphoid tissue function and location?
immune response to foreign antigens, viruses, fungi, and bacteria
locations: LN of H&N
oropharynx
What is lymphoid hyperplasia?
- normal response to allergy, infection
- increased size of lymphoid tissue: waldeyer's ring (lingual, tubal, adenoid, palatine tonsils) lymphadenopathy
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)
Leukemia 5 types:
AML (adult)
ALL (children)
CLL
CML
Hairy Cell
(malignancy of hematopoietic cells)
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
Which leukemia is seen in children?
ALL
acute lymphocytic leukemia
What leukemia is linked to genetic 9:22 translocation (Philadelphia chromosome)?
CML
Chronic myelogenous leukemia
(affects adults)
Which leukemia is seen in the elderly?
CLL
Chronic lymphocytic leukemia
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
_____ lymphoma is endemic to African countries and is very rare.
Burkitt's
______ lymphoma can lead to enlargement in salivary glands i.e. unilateral parotid enlargement
Non-Hodgkin's lymphoma
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)
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
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 NHL diagnosed?
biopsy with immunohistochemistry and
CBC
biopsy will show: proliferation of monoclonal antibodies, lots of mitotic activity, dark nuclei
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
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 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
Microscopically what is distinctive for Hodgkin's lymphoma?
Reed-Sternberg cell (
owl-eyes
)
What is more common NHL or Hodgkin's lymphoma?
Non Hodgkin's more common (6:1)
How is Hodgkin's lymphoma diagnosed?
- CBC
- Biopsy (FNA LN), scalpel biopsy
How is lymphoma treated? SE?
- Chemo and radiation (side effects: mucositis and candidiasis)
- BM transplant
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 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
How is multiple myeloma diagnosed?
- radiography
- BM biopsy
- serum/urine protein electrophoresis
- Beta2-microglobulin (amyloid)
- quantitative Ig
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 ca
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)
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
- b
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!
IV bisphonate therapy can lead to:
BRONJ
necrotic bone, destructive radiolucency
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
___% of plasmacytoma develop into multiple myeloma over 10 years
__% of plasmacytomas occur in the head and neck
30%
90%
Which gland is mixed (serous/mucous)?
submandibular
Which gland is serous and might have fat?
parotid
Which gland is only mucous?
sublingual
(also minor salivary glands are mucous as well)
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
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 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 a
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
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)
Tx of mucoceles?
- surgical excision
- removal of associated minor salivary glands
- may recur
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 exophyti
What does a plunging ranula look like extra orally?
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
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
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 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 (swell
Where is the most common location for sialothiasis and why?
Floor of mouth (twisting pattern, multiple points for stagnation/stone formation)
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
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
Tx of sialolithasis?
- promote passage of the stone (massage, sialogogues, increased fluid intake)
- surgical removal
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 are some infectious causes of sialadenitis?
- viral: mumps
- bacterial: Staphylococcus aureus
most common
- fungal: candida
What are non infectious causes of sialadenitis?
Sjogren syndrome
Sarcoidosis
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
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
Tx for sialadenitis:
- antibiotics
- rehydration
- surgical drainage
- surgical removal of the affected gland
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 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
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 enlargemen
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)
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
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 the microscopic features of SS?
- replacement of salivary gland tissue by lymphocytes
- squamous metaplasia of duct epithelium
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 - po
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
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
!!!!
Which malignancy is greatly increased in patients with SS?
lymphoma!!
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 gr
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 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
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
The larger the salivary gland the ______ the chance of tumors and _____ chance of malignancy
larger = MORE chance of tumors but LESS chance of malignancy
List percent chance of malignant tumors per gland high to low:
86% sublingual
45% minor glands
30% submandibular
15% 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 are clinical features of adenomas (benign tumors)?
- encapsulated
- freely movable
- slow growing
- non-tender
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
What is the most common benign salivary gland tumor by far?
Pleomorphic adenoma
(benign mixed tumor)
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)
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, chondroi
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 gr
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
What is the MOST common malignant salivary gland tumor?
Mucoepidermoid carcinoma
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 enlargi
Histo of mucoepidermoid carcinoma?
Tx?
- mucous cells, epithelial islands, cysts
tx: is related to grade and location
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 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
Where does mucoepidermoid carcinoma occur in bone?
typically posterior mandible
unilocular radiolucency or multi (very rare)
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 ne
Histo of adenoid cystic carcinoma:
Swiss cheese tumor"
cribriform pattern
islands of small dark cells
perineurial infiltration
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
Acinic cell carcinoma is:
low grade, most common in parotid
(other malignant salivary gland tumor)
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)
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)
Adenocarcinoma NOS is:
any other salivary gland malignancy that doesn't fit a recognized category!!!
(other malignant salivary gland tumor)
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 malignant salivary gland tumor can occur in children and in bone?
mucoepidermoid carcinoma
The SUBJECTIVE experience of a dry mouth (i.e. a symptom) is:
xerostomia
The objective measurement of a reduction in salivary flow (a sign) is:
salivary hypofunction
The average prevalence of xerostomia __%
20%
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%)
What group has the HIGHEST prevalence of dry mouth?
SS and head and neck radiation
100%!!
In the US
__________ patients have SS
__________ survivors of H&N cancer who have had radiation
2 million SS
200,000 head and neck radiation
How many baby boomers have xerstomia?
15 million!
The major and minor salivary glands create a total production of ____-____ml/day of saliva
500-600ml
What is the composition of saliva?
- water >99%
- inorganic ions i.e. bicarbonate, Ca2+, phosphate
- organic molecules
- macromolecules: proteins
What influences saliva composition?
- gland source
- flow rate
- type/length of sitmulation
- circadian rhythms
- others: diet, hormonal (pregnancy), exercise, drugs, various diseases, genetics
______ml/day of unstimulated saliva prodction
Flow rate mean:
300ml/day
most important for overall oral comfort
Flow rate mean
0.3ml/min
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)
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)
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
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)
The parotid creates _____ secretion
___% unstimulated volume
___% stimulated volume
serous (exits through Stenson's duct)
20% unstimulated
50% stimulated
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
Sublingual and minor glands create ____ secretions
____ unstimulated flow
mucous (viscous) secretions
7-8% unstimulated flow
When do pts experience their worst dry mouth?
at night
also winter months are worse
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 usi
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)
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 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
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)
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
Parasympathetic stimulation of salivary glands causes:
more fluid to be formed, more water in saliva
Sympathetic stimulation of salivary glands causes:
saliva to be more protein rich, a little more fluid but not like para
Drugs that can cause a change in salivary flow are typically the drugs that block what receptors?
muscarinic receptors
(i.e. anti psychotic agents)
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
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
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
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 a
T/F Tooth loss can cause salivary hypo function
TRUE
decreased mastication i.e. tooth loss, soft diet --> salivary hypo function
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!
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
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
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
What gland is more radiosensitive? Why?
parotid
because its a serous gland
serous acini are more radiosensitive than mucous acini
vs. submandibular or sublingual
What is an autoimmune exocrinopathy that results in dry mouth and eyes that happens slowly over time?
SS
progressive loss of secretory function
What autoimmune disease makes patients prone to a MALT cell lymphoma?
SS can lead to MALT cell lymphoma!
rare
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
T/F SS can have extra glandular manifestations.
TRUE
fatigue, lung, kidney, arthralgia, vasculitis, increased risk of lymphoma (MALT type)
What is secondary sjorgrens?
Salivary and/or lacrimal involvement PLUS another CT disease (i.e. lupus, systemic sclerosis, RA etc etc)
How is SS diagnosed?
- labial salivary gland biopsy
- auto antibody tests (look for Anti-SSA** and Anti-SSB)
- ocular staining score
- schirmer
- USFR
What is the most predictive auto antibody looked for in SS diagnosis?
Anti-SS-A
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 ca
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
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
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 OTC salivary stimulants?
- oramoist
- biotene
- xylichew
- therabreath (
contains spilanthes
can stimulate nerves to produce more saliva)
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
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.
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
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)
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 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 gl
Which affects the whole body? M1 or M3 receptors?
M1
M3 - more focused on salivary glands
Tx of salivary hypofunction, hydration:
64oz water/day or total weight divided by 2
avoid alcohol/caffeine
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 the level of evidence available to support acupuncture as tx for salivary hypofunction?
low quality evidence
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)
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
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 nee
Rituximab seems to preserve salivary gland function but does NOT seem to
improve xerostomia
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
Phase 1 trials of _______ for radiation induced hypofunction show safety and promising initial results
adeno-viral mediated transfer of the aquaporin-1 cDNA
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
radioluc
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 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 fu
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 radic
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
controversia
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
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 pseu
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
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 orthokerat
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
Lymphoepithelial cyst of the neck is also called a
brachial cleft cyst
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, n
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
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 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, scl
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
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
Tx of traumatic bone cyst?
biopsy is necessary
surgical exploration and
curettage of bony walls promotes bone regeneration
no further tx necessary
monitor progress
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 3
What are the 3 inflammatory odontogenic cysts?
- periapical cyst
- residual cyst
- buccal bifurcation cyst
What is the most common inflammatory cyst?
Periapical cyst (also known as radicular cyst)
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
Histo of Periapical granuloma?
- fibrous and granulation tissue
- mixture of: lymphocytes, plasma cells, neutrophils, histiocytes
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
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
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,
What is a residual cyst?
- must have history of extraction
- well defined unilocular radiolucency
histo: lumen, lining, wall v non specific
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 wit
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 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
-
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
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
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 ofte
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 linin
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 d
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
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: unil
What is associated w. Nevoid Basal Cell Carcinoma?
Odontogenic Keratocyst
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 expa
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
- *pa
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 o
Tx of OKC:
- enucleation
- curretage
- marsupialization
- peripheral ostectomy
- carnoy's solution
- resection
- long term follow up significant recurrence
30%
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
Multiple OKC/lesions on pan might be indicative of ______ ______
Gorlin Syndrome (akak Nevoid Basal Cell Carcinoma Syndrome)
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)
Causes of unilateral enlargement of submandibular area:
sialadenitis primary or secondary to ductal obstruction
intrinsic: neoplastic or cystic
external: neoplastic, cystic, lympho epithelial lesion
Causes of bilateral enlargement of submandibular area:
- bacterial or viral sialadenitis (rarely mumps)
- SS
- branchial cleft cyst
- submandibular space infection
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 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 sialo
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 are the indications for MDCT/MRI?
- presence of a mass: tumor, neoplasm, cyst inside or outside the 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
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, mal
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
Autoimmune sialadenitis, i.e. SS, what imaging is best?
Sialogram or MRI
"
fruit laden branchless tree
" consistent with SS
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
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 hom
What is the second most common benign neoplasm of salivary glands?
Warthins tumor
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
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
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
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
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
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 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 y
The GNAS1 gene mutation is seen in:
fibrous dysplasia
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
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 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 sh
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
T/F There is bony expansion associated with cements-osseous dysplasia
FALSE
(but sometimes seen in florid type)
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 are the quantitative hematologic diseases?
leukemia
lymphoma
multiple myeloma
hemophilia
thrombocytopenia
neutropenia
agranulocytosis
hemolytic anemia
blood loss anemia
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
- typi
What is the tx for cemento-osseous dysplasia?
typically, no tx is required unless these regions show clinical/radiographic evidence of secondary infection
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
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
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 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 re
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 pres
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 wi
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
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
What is differentiating between simple bone cyst and OKC?
OKC - show evidence of cortical thinning and/or bony expansion!
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,
multinucleate
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 pr
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 occasi
What are polyostotic conditions?
involving or relating to many bones
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 predomi
What is the gene for fibrous dysplasia?
GNAS1
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
- increas
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 tran
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)
Pan with multiple dense bone islands think:
Gardner's Syndrome
GARDEN-FOREST (Gardner's key features)
F - Familial adenomatous polyposis
O - osseous/soft tissue tumors (osteomas, desmoid tumors),
RE - retinal hypertrophy
ST - supernumerary teeth
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
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)
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 is the tx for osteopetrosis?
bone marrow transplant
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 o
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
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
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 ma
What is the most common cell in WBC count?
List in descending order:
neutrophils (PMNs)
neutrophils
lymphocytes
monocytes
eosinophils
basophils 1-2%
What are the 3 qualitative hematologic diseases?
anemia
sickle cell anemia
thalassemia