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Introduction to Oral Pathology Introduction to Oral Pathology and Developmental Defectsand Developmental Defects

Michael A. Kahn, DDSMichael A. Kahn, DDSProfessor and ChairmanProfessor and Chairman

Department of Oral and Maxillofacial PathologyDepartment of Oral and Maxillofacial PathologyTufts University School of Dental MedicineTufts University School of Dental Medicine

D2011D2011 -- Lecture #1Lecture #1

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Definition of Oral and Definition of Oral and Maxillofacial PathologyMaxillofacial Pathology

•• The The clinicalclinical specialty of dentistry & specialty of dentistry & pathology which deals with the pathology which deals with the naturenature, , identificationidentification, & , & managementmanagement of of diseases affecting the oral & diseases affecting the oral & maxillofacial regions.maxillofacial regions. It is a clinical It is a clinical science that investigates the science that investigates the causescauses, , processesprocesses, & , & effectseffects of these diseases.of these diseases.

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Definition of Oral and Definition of Oral and Maxillofacial Pathology (contMaxillofacial Pathology (cont’’d)d)

•• The practice of oral & maxillofacial The practice of oral & maxillofacial pathology includes pathology includes researchresearch, , diagnosisdiagnosisof diseases using clinical, radiographic, of diseases using clinical, radiographic, microscopic, biochemical or other microscopic, biochemical or other examinations, & examinations, & management of management of patientspatients..

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Description of Description of SoftSoft Tissue Tissue LesionsLesions

•• Descriptive FeaturesDescriptive FeaturesSiteSiteMorphologyMorphologyColorColorSizeSizeConsistencyConsistency

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Site Site

•• Perioral skinPerioral skin•• LipsLips•• Tongue Tongue •• Floor of mouthFloor of mouth•• GingivaGingiva•• VestibuleVestibule•• Buccal mucosaBuccal mucosa

•• Edentulous alveolar Edentulous alveolar ridgeridge

•• Retromolar padRetromolar pad•• Trigone areaTrigone area•• Hamular notchHamular notch•• Maxillary tuberosityMaxillary tuberosity•• Soft and hard palateSoft and hard palate•• OropharynxOropharynx

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SiteSite

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SiteSite

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Soft Tissue Lesion Morphology Soft Tissue Lesion Morphology --Basic TypesBasic Types

•• ElevatedElevated––AAbove the plane of mucosabove the plane of mucosa

•• DepressedDepressed–– Below the plane of mucosaBelow the plane of mucosa

•• Flat Flat –– Even with the plane of mucosaEven with the plane of mucosa–– Detectable by change in color Detectable by change in color

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Elevated LesionsElevated Lesions

•• Blisterform Blisterform –– contains a body contains a body fluid; fluid; ““blisterblister””––Vesicle Vesicle -- ≤≤ 0.5 cm in diameter0.5 cm in diameter––Bulla Bulla -- > 0.5 cm in diameter> 0.5 cm in diameter––Pustule Pustule –– ≤≤ 0.5 cm and 0.5 cm and > 0.5 cm; > 0.5 cm;

filled with pusfilled with pus

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Elevated LesionsElevated Lesions

•• Nonblisterform Nonblisterform –– no fluidno fluid–– Papule Papule -- ≤≤ 0.5 cm in diameter0.5 cm in diameter–– Nodule Nodule -- > 0.5 cm and > 0.5 cm and ≤≤ 2 cm in 2 cm in

diameterdiameter–– Tumor Tumor -- > 2 cm in diameter > 2 cm in diameter –– Plaque Plaque –– usually > 0.5 cm in diameterusually > 0.5 cm in diameter

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Depressed Lesions Depressed Lesions •• Most are ulcersMost are ulcers

–– Number Number -- single vs. multiplesingle vs. multiple•• Separate vs. coalescingSeparate vs. coalescing

–– Outline Outline -- regular vs. irregular regular vs. irregular –– Margin Margin -- raised vs. smoothraised vs. smooth–– Depth Depth -- superficial vs. deepsuperficial vs. deep

•• ≤≤ 0.3 cm vs. > 0.3 cm0.3 cm vs. > 0.3 cm

–– Diameter Diameter •• ≤≤ 0.5 cm vs. > 0.5 cm 0.5 cm vs. > 0.5 cm

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Depressed LesionsDepressed Lesions

•• Other examples Other examples ––ScarScar––Pit or blind pouchPit or blind pouch

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Flat LesionsFlat Lesions

•• MaculeMacule–– Circumscribed area of abnormal color Circumscribed area of abnormal color

changechange•• Tongue Lesion Tongue Lesion –– special casespecial case

–– Not a macule Not a macule –– Loss of dorsum papillaeLoss of dorsum papillae–– Single or multipleSingle or multiple

•• Irregular or regular outline Irregular or regular outline

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Flat Lesion Flat Lesion –– Tongue Tongue

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ColorColor•• 4 Primary Endogenous 4 Primary Endogenous

PigmentsPigments––Oxyhemoglobin Oxyhemoglobin -- Red Red ––Reduced hemoglobin Reduced hemoglobin -- BlueBlue––Melanin Melanin -- BrownBrown––Carotene Carotene -- YellowYellow

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Color Incidence (%)Color Incidence (%) ––a component of the lesion a component of the lesion

•• RedRed –– 80%80%•• PinkPink –– 50%50%•• WhiteWhite –– 50%50%•• RedRed and and WhiteWhite –– 34%34%•• BlueBlue –– 13%13%•• PurplePurple –– 8%8%•• GrayGray –– 7%7%

• Black –– 7%7%•• BrownBrown –– 5%5%•• TranslucentTranslucent

–– PinkPink–– BlueBlue–– RedRed or or purplepurple

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RedRed•• Intravascular Intravascular

–– Dilation Dilation -- hyperemiahyperemia–– Proliferation Proliferation –– hamartoma, neoplasmhamartoma, neoplasm

•• Extravascular Extravascular –– Purpura (discoloration) Purpura (discoloration) -- maculesmacules

•• Petechia Petechia –– 0.10.1-- 05 cm in diameter 05 cm in diameter •• Ecchymosis Ecchymosis -- > 0.5 cm in diameter > 0.5 cm in diameter •• Hematoma Hematoma -- > 2 cm in diameter> 2 cm in diameter

––Elevated in early stagesElevated in early stages

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SizeSize

•• Expressed as greatest diameter Expressed as greatest diameter in length and widthin length and width

•• Use normal structures as point Use normal structures as point of reference to aid estimateof reference to aid estimate

•• Metric unitsMetric units––Centimeters and fractions thereofCentimeters and fractions thereof

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ConsistencyConsistency

•• Fixed vs. movableFixed vs. movable•• InduratedIndurated•• Firm vs. doughy vs. fluctuant Firm vs. doughy vs. fluctuant

with reboundwith rebound•• CrepitusCrepitus

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Miscellaneous TerminologyMiscellaneous Terminology

•• Ulceration vs. erosionUlceration vs. erosion•• Keratosis Keratosis •• Sessile vs. pedunculatedSessile vs. pedunculated•• Smooth vs. rough Smooth vs. rough

–– Papillary; papillomatousPapillary; papillomatous–– Verrucous; verrucoidVerrucous; verrucoid

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A A sessilesessile 0.5 cm x 0.4 cm yellow vesicle of 0.5 cm x 0.4 cm yellow vesicle of the right anterior floor of mouth the right anterior floor of mouth

approximately 0.2 cm to the right of the approximately 0.2 cm to the right of the lingual frenumlingual frenum

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A 1.0 cm diameter, deep, ovoid ulcer of the right A 1.0 cm diameter, deep, ovoid ulcer of the right posterior hard palate, adjacent to the midline, posterior hard palate, adjacent to the midline, and exhibiting raised, regular nonindurated and exhibiting raised, regular nonindurated

margins margins

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Descriptive TerminologyDescriptive Terminology

•• Know the 34 definitions of handout Know the 34 definitions of handout –– AbrasionAbrasion–– Annular Annular –– AtrophyAtrophy–– ContusionContusion–– CrustCrust–– Etc. Etc.

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•• Radiographic interpretation (analysis) is Radiographic interpretation (analysis) is only one factor in the diagnostic processonly one factor in the diagnostic process

•• Always interpret radiographic findings in Always interpret radiographic findings in conjunction with clinical history and conjunction with clinical history and other informationother information

•• Interpretive methodInterpretive method–– Pattern matching or pattern recognition Pattern matching or pattern recognition

enables creation of a differential diagnosis enables creation of a differential diagnosis

Description of Description of HardHard Tissue LesionsTissue Lesions

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Types of Imaging ExaminedTypes of Imaging Examined

•• PanoramicPanoramic•• PeriapicalPeriapical•• BitewingBitewing•• OcclusalOcclusal•• Computed tomography (cone Computed tomography (cone

beam)beam)

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Radiographic InterpretationRadiographic InterpretationStepsSteps

•• Number of LesionsNumber of Lesions•• Anatomic Anatomic position and extentposition and extent of the of the

abnormalityabnormality•• Internal structureInternal structure of the abnormalityof the abnormality•• PeripheryPeriphery of the abnormality (borders)of the abnormality (borders)•• BehaviorBehavior suggested by the effects on suggested by the effects on

surrounding structuressurrounding structures•• PatientPatient’’s s age, gender and ethnic originage, gender and ethnic origin

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Anatomic Position/ExtentAnatomic Position/Extent

•• Localized vs. Localized vs. generalizedgeneralized

•• Unilateral or bilateralUnilateral or bilateral•• Monostotic or Monostotic or

polyostoticpolyostotic•• Maxilla or mandibleMaxilla or mandible

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Internal StructureInternal Structure

•• DensityDensity–– Completely radiolucentCompletely radiolucent

•• UnilocularUnilocular•• MultilocularMultilocular

–– soapsoap--bubble, tennis racket, bubble, tennis racket, honeycombed, spider webhoneycombed, spider web

–– Mixed radiolucentMixed radiolucent--radiopaqueradiopaque•• Mottled, spherules, flecks, driven snowMottled, spherules, flecks, driven snow

–– Completely radiopaqueCompletely radiopaque•• Homogenous, ground glass, cotton wool Homogenous, ground glass, cotton wool

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Internal Structure Internal Structure

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Multilocular Multilocular -- Honeycomb Honeycomb

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Multilocular Multilocular –– Tennis RacketTennis Racket

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Multilocular Multilocular -- SoapbubbleSoapbubble

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Multilocular Multilocular –– Spider WebSpider Web

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Mixed radiolucent/radiopaque Mixed radiolucent/radiopaque -- Driven SnowDriven Snow

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Complete Radiopaque Complete Radiopaque -- Ground GlassGround Glass

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Periphery (Borders)Periphery (Borders)

•• Well circumscribedWell circumscribed––Hyperostotic, radiolucent rimmingHyperostotic, radiolucent rimming

•• Poorly circumscribedPoorly circumscribed•• ShapeShape

––Round/ovoidRound/ovoid––IrregularIrregular––Pear/inverted pearPear/inverted pear––OthersOthers

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PeripheryPeriphery

Well CircumscribedWell Circumscribed

Narrow Zone of Narrow Zone of TransitionTransition

Poorly CircumscribedPoorly Circumscribed

Wide Zone of Wide Zone of TransitionTransition

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Well CircumscribedWell Circumscribed

•• CorticatedCorticated•• ScleroticSclerotic•• HyperostoticHyperostotic

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Shape Shape

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•• Structures to accessStructures to access–– Teeth, surrounding bone, othersTeeth, surrounding bone, others

•• Behavioral characteristicsBehavioral characteristics–– Effect on teethEffect on teeth

•• Displacement, resorption, PDL, pulp chamberDisplacement, resorption, PDL, pulp chamber–– Effect on cancellous boneEffect on cancellous bone

•• Increased density, remodeling, floatingIncreased density, remodeling, floating--inin--airair–– Effect on cortical boneEffect on cortical bone

•• Intactness, erosion, endosteal scalloping, Intactness, erosion, endosteal scalloping, periosteal reaction, perforation, expansionperiosteal reaction, perforation, expansion

–– Alveolar nerve canalAlveolar nerve canal–– InfiltrationInfiltration

Behavior Suggested by the Effect On Behavior Suggested by the Effect On Adjacent StructuresAdjacent Structures

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Effect on Teeth Effect on Teeth –– Widened PDLWidened PDL

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Effect on Cancellous Bone Effect on Cancellous Bone --FloatingFloating--inin--airair

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Effect on Cortical Bone Effect on Cortical Bone ––Expansion, Perforation Expansion, Perforation

Expansile, Expansile, PerforatedPerforated

Expansile, Not Expansile, Not PerforatedPerforated

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PatientPatient’’s Age, Gender and Ethnic s Age, Gender and Ethnic OriginOrigin

•• Some hard tissue lesions are Some hard tissue lesions are overwhelming in one age, gender, overwhelming in one age, gender, or ethnic groupor ethnic group–– Periapical cemental dysplasia Periapical cemental dysplasia ––

middlemiddle--aged, black, femalesaged, black, females

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Descriptive TerminologyDescriptive Terminology

––Know the 35 definitions of Know the 35 definitions of handouthandout•• Beaten copperBeaten copper•• CorticatedCorticated•• Cotton wool appearanceCotton wool appearance•• CystCyst--like expansionlike expansion•• Driven snow appearanceDriven snow appearance•• Etc. Etc.

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Beaten CopperBeaten Copper

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Cotton Wool AppearanceCotton Wool Appearance

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MothMoth--Eaten Lucencies DescriptorEaten Lucencies Descriptor

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Onion Skin PatternOnion Skin Pattern

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ScallopedScalloped

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Sunburst (Sunray)Sunburst (Sunray)

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Radiographic Patterns of Jaw Radiographic Patterns of Jaw LesionsLesions

•• Radiolucent PatternsRadiolucent Patterns–– Unilocular RL: Pericoronal LocationUnilocular RL: Pericoronal Location–– Unilocular RL: Periapical LocationUnilocular RL: Periapical Location–– Unilocular RL: Other locationsUnilocular RL: Other locations–– Multilocular RLMultilocular RL–– RL: Poorly Defined or Ragged BordersRL: Poorly Defined or Ragged Borders–– RL: Multifocal or GeneralizedRL: Multifocal or Generalized

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Radiolucent PatternsRadiolucent Patterns

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Radiographic Patterns of Jaw Radiographic Patterns of Jaw LesionsLesions

•• Radiopaque PatternsRadiopaque Patterns–– RO: WellRO: Well--Demarcated bordersDemarcated borders–– RO: PoorlyRO: Poorly--Demarcated bordersDemarcated borders–– RO: Multifocal or GeneralizedRO: Multifocal or Generalized

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Radiopaque pattern Radiopaque pattern

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Radiographic Patterns of Jaw Radiographic Patterns of Jaw LesionsLesions

•• Mixed Radiolucent / Radiopaque Mixed Radiolucent / Radiopaque PatternsPatterns–– Mixed RL/RO: WellMixed RL/RO: Well--Demarcated BordersDemarcated Borders–– Mixed RL/RO: Poorly Demarcated BordersMixed RL/RO: Poorly Demarcated Borders–– Mixed RL/RO: Multifocal or GeneralizedMixed RL/RO: Multifocal or Generalized

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Mixed Radiolucent/Radiopaque PatternMixed Radiolucent/Radiopaque Pattern

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Radiographic Patterns of Jaw Radiographic Patterns of Jaw LesionsLesions

•• Unique Radiographic AppearancesUnique Radiographic Appearances–– ““Ground (Frosted) glassGround (Frosted) glass”” RORO–– ““Cotton woolCotton wool”” RORO–– ““SunburstSunburst”” RORO–– ““OnionOnion--skinskin”” RORO–– Soft Tissue ROSoft Tissue RO

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Developmental Developmental DefectsDefects

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Developmental DefectsDevelopmental Defects

•• Classification by tissueClassification by tissue–– MucosaMucosa–– Bone Bone –– TeethTeeth

•• Classification by typeClassification by type–– Developmental cystDevelopmental cyst

•• Classification by incidence Classification by incidence –– Common or rareCommon or rare

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Rare Developmental AnomaliesRare Developmental Anomalies

•• Hemihyperplasia (hemihypertrophy)Hemihyperplasia (hemihypertrophy)•• Progressive hemifacial atrophy Progressive hemifacial atrophy

(Romberg syndrome)(Romberg syndrome)•• Crouzon syndrome (craniofacial Crouzon syndrome (craniofacial

dysostosis)dysostosis)•• Apert syndromeApert syndrome•• TreacherTreacher--Collins syndrome Collins syndrome

(mandibulofacial dysostosis)(mandibulofacial dysostosis)

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HemihyperplasiaHemihyperplasia

•• Body Body –– complexcomplex•• Digit Digit –– simplesimple•• Limb Limb –– segmentalsegmental•• Face Face –– hemifacialhemifacial•• Accentuated with ageAccentuated with age•• Permanent asymmetryPermanent asymmetry•• 20% mental retardation20% mental retardation

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HemihyperplasiaHemihyperplasia

•• Increased incidence of Wilms tumor and Increased incidence of Wilms tumor and hepatoblastomahepatoblastoma

•• MacroglossiaMacroglossia•• Enlarged tooth crownsEnlarged tooth crowns•• Malocclusion Malocclusion –– open biteopen bite•• TreatmentTreatment

–– Surgical bulking after growth ceasesSurgical bulking after growth ceases

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Progressive Hemifacial AtrophyProgressive Hemifacial Atrophy

•• Prior trauma, viral or Prior trauma, viral or Borrelia infection, Borrelia infection, localized localized sclerodermascleroderma

•• Localized to faceLocalized to face–– Dermatome of Dermatome of

trigeminal nervetrigeminal nerve–– Skin becomes Skin becomes

pigmentedpigmented–– Bone hypoplasiaBone hypoplasia–– Linear forehead scar Linear forehead scar

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Coupe de sabreCoupe de sabre

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Hemifacial AtrophyHemifacial Atrophy

•• HistopathologyHistopathology–– Atrophied skin and perivascular Atrophied skin and perivascular

inflammation with endothelial degenerationinflammation with endothelial degeneration•• TreatmentTreatment

–– Reconstructive surgery and orthodontic Reconstructive surgery and orthodontic therapytherapy

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Crouzon SyndromeCrouzon Syndrome(Craniofacial Dysostosis)(Craniofacial Dysostosis)

•• Premature closure of cranial suturesPremature closure of cranial sutures•• Autosomal dominant inheritanceAutosomal dominant inheritance

–– 1 in 25,000 births1 in 25,000 births–– Variable expressivity (multiple symptoms)Variable expressivity (multiple symptoms)

•• Many are spontaneous mutationsMany are spontaneous mutations

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Crouzon SyndromeCrouzon Syndrome

•• Brachycephaly Brachycephaly –– short short headhead

•• Midface hypoplasiaMidface hypoplasia•• HypertelorismHypertelorism•• Shallow orbitsShallow orbits

–– Proptosis leading to impaired Proptosis leading to impaired vision or blindnessvision or blindness

•• Radiograph of skullRadiograph of skullBeaten copper pattern Beaten copper pattern

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Beaten CopperBeaten Copper

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Crouzon SyndromeCrouzon Syndrome

•• TreatmentTreatment–– Surgical correctionSurgical correction

•• Craniectomy to relieve increased Craniectomy to relieve increased intracranial pressureintracranial pressure

•• FrontoFronto--orbital advancement and orbital advancement and midface advancementmidface advancement

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Apert SyndromeApert Syndrome

•• RareRare–– 1 per 100,0001 per 100,000--160,000 160,000

birthsbirths•• Autosomal dominant Autosomal dominant

inheritanceinheritanceFeatures of Crouzon Features of Crouzon syndrome and limb syndrome and limb defectsdefects–– Syndactyly of hands and Syndactyly of hands and

feetfeet•• Mental retardationMental retardation

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Apert SyndromeApert Syndrome

Oral findingsOral findings–– Relative mandibular Relative mandibular

prognathism with prognathism with midface hypoplasiamidface hypoplasia

–– Class III malocclusionClass III malocclusion–– 75% cleft soft palate or 75% cleft soft palate or

uvulauvula–– Gingival thickeningGingival thickening–– Delayed eruptionDelayed eruption

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TreacherTreacher--Collins Syndrome Collins Syndrome (Mandibulofacial Dysostosis)(Mandibulofacial Dysostosis)

•• Defects from first and second branchial Defects from first and second branchial archesarches

•• Autosomal dominant inheritanceAutosomal dominant inheritance•• 60% 60% -- new spontaneous mutationsnew spontaneous mutations•• Variable expressivityVariable expressivity

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TreacherTreacher--Collins SyndromeCollins SyndromeCharacteristic faciesCharacteristic facies–– Narrow, depressed cheeks; Narrow, depressed cheeks;

downward slanting palpebral downward slanting palpebral fissuresfissures

–– Deformed ear pinnaDeformed ear pinna–– Mandible underdeveloped, Mandible underdeveloped,

retruded chinretruded chin–– Hypoplastic coronoid and Hypoplastic coronoid and

condylar processescondylar processes–– Downturned mouth, cleft palate Downturned mouth, cleft palate

(30%)(30%)

•• Hypoplastic or absent parotid Hypoplastic or absent parotid glandgland

•• Infant respiratory difficultiesInfant respiratory difficulties

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Double LipDouble Lip•• Rare anomalyRare anomaly•• Congenital or Congenital or

acquired from acquired from trauma or sucking trauma or sucking habithabit

•• Most common Most common presentation is presentation is redundant upper lipredundant upper lip

•• TreatmentTreatment–– Cosmetic excisionCosmetic excision

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Double Lip Double Lip

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Ascher syndromeAscher syndrome

•• Probably inherited Probably inherited as autosomal as autosomal dominant traitdominant trait–– Double lipDouble lip–– BlepharochalasisBlepharochalasis

•• Recurring Recurring edematous, sagging edematous, sagging eyelids at outer eyelids at outer canthuscanthus

–– 50% have thyroid 50% have thyroid enlargement (goiter)enlargement (goiter)

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Fordyce GranulesFordyce GranulesEctopic sebaceous glands on oral Ectopic sebaceous glands on oral mucosamucosa–– Normal skin Normal skin –– sebum producerssebum producers

•• 80% incidence in adults so a 80% incidence in adults so a ““normal variantnormal variant””–– Rare in childrenRare in children

Site, morphology colorSite, morphology color–– Multiple yellowMultiple yellow--white papules white papules -- -- --> >

plaquesplaques–– Most common on buccal mucosa, Most common on buccal mucosa,

labial mucosa, retromolar arealabial mucosa, retromolar area–– Also genital mucosaAlso genital mucosa

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Fordyce granulesFordyce granules

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Common in AfricanCommon in African--AmericansAmericans–– ~ 90% adults and ~ 50% children~ 90% adults and ~ 50% children–– Another Another ““normal anatomic variantnormal anatomic variant””

•• More severe in smokersMore severe in smokersDiffuse opalescent white mucosal Diffuse opalescent white mucosal surface, folded and wrinkledsurface, folded and wrinkled–– Most commonly found bilaterally on Most commonly found bilaterally on

the buccal mucosathe buccal mucosa–– Whiteness diminishes when mucosa Whiteness diminishes when mucosa

is stretchedis stretched•• HistopathologyHistopathology

–– Intracellular edema, acanthosis, Intracellular edema, acanthosis, vacuolated cellsvacuolated cells

•• TreatmentTreatment–– Observation onlyObservation only

Leukoedema

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Leukoedema

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LeukoedemaLeukoedema

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LeukoedemaLeukoedema•• Clinical differential Clinical differential

diagnosisdiagnosisWhite sponge nevus White sponge nevus (WSN)(WSN)

No eye involvementNo eye involvementHereditary benign Hereditary benign intraepithelial intraepithelial dyskeratosis (HBID)dyskeratosis (HBID)

•• Eye involvementEye involvementNeither WSN or HBID Neither WSN or HBID dissipate upon mucosa dissipate upon mucosa stretching stretching

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White sponge nevus

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MacroglossiaMacroglossia

Congenital CausesCongenital Causes–– Lymphangioma, Lymphangioma,

hemangiomahemangioma–– Down syndromeDown syndrome–– MucopolysaccaridosisMucopolysaccaridosis–– NeurofibromatosisNeurofibromatosis–– Multiple endocrine Multiple endocrine

neoplasia syndromeneoplasia syndrome

Acquired causesAcquired causes–– Edentulous patientsEdentulous patients–– AmyloidosisAmyloidosis–– MyxedemaMyxedema–– AcromegalyAcromegaly–– AngioedemaAngioedema–– Carcinoma and other Carcinoma and other

tumorstumors

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MacroglossiaMacroglossia

•• Pressure of tongue Pressure of tongue against teeth against teeth produces scalloped produces scalloped surface of lateral surface of lateral borderborder–– CrenatedCrenated

•• Open bite, Open bite, prognathismprognathism

•• Speech and airway Speech and airway impairmentimpairment

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Hemangioma

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MacroglossiaMacroglossia•• Smooth surfacedSmooth surfaced

–– HypothyroidismHypothyroidism–– Beckman Wiedemann syndromeBeckman Wiedemann syndrome

•• Papillary (pebbly) surfacePapillary (pebbly) surface–– LymphangiomaLymphangioma–– Down syndromeDown syndromeMultinodular surfaceMultinodular surface–– AmyloidosisAmyloidosis–– NeurofibromatosisNeurofibromatosis–– Multiple endocrine neoplasia syndromeMultiple endocrine neoplasia syndrome

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MacroglossiaMacroglossia

•• TreatmentTreatment–– Determination of etiologyDetermination of etiology–– Reduction glossectomyReduction glossectomy

•• If symptomaticIf symptomatic

–– Chronically edentulous patients may have Chronically edentulous patients may have difficulty with new denturesdifficulty with new dentures

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Reduction glossectomyReduction glossectomy

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Lingual ThyroidLingual Thyroid

•• EtiologyEtiology–– Failure of thyroid gland to Failure of thyroid gland to

descend to neck anterior descend to neck anterior of the tracheaof the trachea

–– Site of invagination and Site of invagination and descent becomes descent becomes foramen cecum of tongueforamen cecum of tongue

•• Females 4:1Females 4:1•• SymptomsSymptoms

–– Dysphagia, hysterical Dysphagia, hysterical globus and dyspnea at globus and dyspnea at puberty, pregnancypuberty, pregnancy

•• 70% have no other 70% have no other thyroid tissuethyroid tissue

•• 1515--30% are hypothyroid30% are hypothyroid

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Lingual ThyroidLingual Thyroid•• Diagnosis by iodine isotope scanDiagnosis by iodine isotope scan•• Biopsy should be avoided due to Biopsy should be avoided due to

hemorrhage complicationhemorrhage complication•• TreatmentTreatment

–– Variable Variable •• None (small lesions)None (small lesions)•• Supplemental hormone therapySupplemental hormone therapy•• Surgical removal or ablation with radioactive Surgical removal or ablation with radioactive

iodine iodine 131131

–– Malignant change 1%Malignant change 1%•• Disproportionately males Disproportionately males •• Suggests prophylactic excisionSuggests prophylactic excision

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Lingual ThyroidLingual Thyroid

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Lingual thyroidLingual thyroid

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Fissured TongueFissured Tongue

•• Relatively common ~ 2Relatively common ~ 2--5%5%

•• Autosomal dominant Autosomal dominant inheritance with inheritance with incomplete penetranceincomplete penetranceMultiple grooves and Multiple grooves and furrows in dorsum furrows in dorsum –– 22--6 mm deep6 mm deep

Associated withAssociated with–– Geographic tongueGeographic tongue–– MelkerssonMelkersson--Rosenthal Rosenthal

syndromesyndrome

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Fissured TongueFissured Tongue

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Fissured TongueFissured Tongue

•• HistopathologyHistopathology–– Rete ridge hyperplasia with loss of Rete ridge hyperplasia with loss of

surface keratinizationsurface keratinization–– Epithelial microEpithelial micro--abscessesabscesses

•• TreatmentTreatment–– Brush tongue grooves to remove food Brush tongue grooves to remove food

debrisdebris

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Hairy TongueHairy Tongue

Keratin accumulation on Keratin accumulation on filiform papillafiliform papilla–– Heavy smokersHeavy smokers–– Secondary to antibioticsSecondary to antibiotics–– Poor hygienePoor hygiene–– DebilitationDebilitation–– MouthwashesMouthwashes–– Oral infectionsOral infections

•• Dorsum, midline, anterior to Dorsum, midline, anterior to circumvallate papillaecircumvallate papillae–– Spares lateral and anterior Spares lateral and anterior

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Hairy TongueHairy Tongue

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Hairy TongueHairy Tongue

•• Typically asymptomaticTypically asymptomatic•• TreatmentTreatment

–– Biopsy unnecessaryBiopsy unnecessary–– Improve oral hygiene and eliminate Improve oral hygiene and eliminate

predisposing factorspredisposing factors

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Varix (varicosities)Varix (varicosities)Abnormally dilated or tortuous Abnormally dilated or tortuous vein (varix)vein (varix)Rare in children, common in Rare in children, common in older adultsolder adults

•• Not associated with Not associated with hypertensionhypertensionSublingual location most Sublingual location most common common

Lip and buccal mucosa next Lip and buccal mucosa next most common sites most common sites

•• BlueBlue--purple asymptomatic purple asymptomatic vesiclesvesicles

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Varix Varix

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VarixVarix

•• May secondarily calcifyMay secondarily calcify–– ThrombusThrombus–– PhlebolithPhlebolith

•• TreatmentTreatment–– Generally not indicatedGenerally not indicated

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ExostosesExostoses

•• Adult incidence Adult incidence -- 1 in 1,0001 in 1,000•• TypesTypes

–– Facial alveolar ridgeFacial alveolar ridge–– Torus palatinus and torus Torus palatinus and torus

mandibularismandibularis–– SubpontineSubpontine

•• Alveolar crestal bone beneath Alveolar crestal bone beneath ponticpontic

•• HistopathologyHistopathology–– Dense lamellar cortical boneDense lamellar cortical bone

•• TreatmentTreatment–– Biopsy unnecessaryBiopsy unnecessary

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ExostosesExostoses

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Torus PalatinusTorus Palatinus

•• Midline, hard palateMidline, hard palate•• Multifactoral causesMultifactoral causes

–– Heredity & local factorsHeredity & local factorsAsymptomaticAsymptomaticSecondarily ulceratedSecondarily ulceratedAsian ancestryAsian ancestryFemale 2:1Female 2:1

•• TreatmentTreatment–– Only if denture Only if denture

fabrication requiresfabrication requires

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Torus PalatinusTorus Palatinus

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Torus PalatinusTorus Palatinus

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Torus PalatinusTorus Palatinus

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Torus MandibularisTorus Mandibularis

90% bilateral90% bilateralLingual mandibleLingual mandible77--10% prevalence in US 10% prevalence in US populationpopulationSlight male predilectionSlight male predilection

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Torus MandibularisTorus Mandibularis

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Torus MandibularisTorus Mandibularis

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Eagle SyndromeEagle Syndrome

•• Anatomic review Anatomic review -- adultsadults–– Stylohyoid ligament connects Stylohyoid ligament connects

styloid process of temporal styloid process of temporal bone to lesser cornu of hyoid bone to lesser cornu of hyoid bonebone

–– Carotid arteries are adjacentCarotid arteries are adjacentElongation of the process or Elongation of the process or mineralization of ligament mineralization of ligament causes impingement causes impingement -- -- -- >>–– Facial pain on swallowing, Facial pain on swallowing,

turning head or openingturning head or opening

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MAKMAK

Eagle SyndromeEagle Syndrome

•• Occurs following Occurs following tonsillectomy in scar tissuetonsillectomy in scar tissueDiagnosisDiagnosis

Panoramic radiographPanoramic radiographPalpation of tonsillar fossa Palpation of tonsillar fossa producing painproducing pain

Affects cranial nerves #5, 7, Affects cranial nerves #5, 7, 9 and 109 and 10

•• TreatmentTreatment–– Steroid injectionSteroid injection–– SurgerySurgery

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Eagle SyndromeEagle Syndrome

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Stafne DefectStafne Defect

Stafne bone cyst; static bone cyst; latent Stafne bone cyst; static bone cyst; latent bone cyst; lingual mandibular salivary gland bone cyst; lingual mandibular salivary gland depressiondepressionDevelopmental defectDevelopmental defect

Lingual concavity of the mandible which most Lingual concavity of the mandible which most often contains normal submandibular glandoften contains normal submandibular gland

Most are unilateralMost are unilateral8080--90% male predilection90% male predilectionAsymptomaticAsymptomatic

MAKMAK

Stafne DefectStafne Defect

•• RadiographicRadiographic–– DiagnosticDiagnostic

Well circumscribed Well circumscribed radiolucency always radiolucency always below the inferior below the inferior alveolar canal alveolar canal Usually corticated Usually corticated borderborder

•• TreatmentTreatment–– NoneNone

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MAKMAK MAKMAK

NonNon--Odontogenic Odontogenic Developmental Cysts Developmental Cysts of the Head and Neckof the Head and Neck

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Palatal Cysts of the NewbornPalatal Cysts of the Newborn•• EpsteinEpstein’’s pearlss pearls

–– Arise from entrapped Arise from entrapped epithelium in line of epithelium in line of palatal fusion palatal fusion

–– Along median palatal Along median palatal raphe and immediate raphe and immediate adjacent areaadjacent area

•• BohnBohn’’s nodules s nodules –– Derived from minor Derived from minor

salivary glandssalivary glands–– Scattered throughout Scattered throughout

hard palatehard palate

MAKMAK

Palatal Cysts of the NewbornPalatal Cysts of the Newborn

•• 65 65 -- 80% incidence80% incidence•• 1 1 -- 3 mm white 3 mm white

papules (vesicles)papules (vesicles)–– KeratinKeratin--filled filled

•• TreatmentTreatment–– None since None since

spontaneously rupture spontaneously rupture within weekswithin weeks

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MAKMAK

Nasolabial CystNasolabial Cyst

Rare soft tissue lesionRare soft tissue lesion–– No radiographic findingsNo radiographic findings

•• Etiology uncertainEtiology uncertain–– Epithelium trapped by fusion of Epithelium trapped by fusion of

maxilla, medial and lateral nasal maxilla, medial and lateral nasal processes ORprocesses OR

–– Epithelium displaced from Epithelium displaced from nasolacrimal ductnasolacrimal duct

Females 3:1; 30 Females 3:1; 30 -- 40 year age 40 year age rangerangeLateral upper lip swelling Lateral upper lip swelling elevating the ala of the nose elevating the ala of the nose and filling maxillary vestibule and filling maxillary vestibule -- ----> nasal obstruction> nasal obstruction

MAKMAK

Nasolabial CystNasolabial Cyst

•• HistopathologyHistopathology–– Cyst lined by Cyst lined by

pseudostratified pseudostratified columnar epithelial columnar epithelial with cilia and mucus with cilia and mucus goblet cellsgoblet cells

•• TreatmentTreatment–– Excision by intraExcision by intra--oral oral

approachapproach–– Recurrence rareRecurrence rare

MAKMAK

Globulomaxillary CystGlobulomaxillary Cyst

Historically the location is Historically the location is always between maxillary always between maxillary lateral incisor and caninelateral incisor and canine

•• Studies have shown not from Studies have shown not from epithelium trapped in fissureepithelium trapped in fissure–– Thus not a true fissural Thus not a true fissural

developmental cystdevelopmental cyst•• Adjacent teeth must be vital Adjacent teeth must be vital

so really . . .so really . . .–– Primordial cyst of aborted Primordial cyst of aborted

supernumerary toothsupernumerary tooth–– Lateral periodontal cystLateral periodontal cyst

•• RadiographicRadiographicWell delineated, inverted, pearWell delineated, inverted, pear--shaped radiolucencyshaped radiolucency

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Globulomaxillary CystGlobulomaxillary Cyst

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Nasopalatine Duct CystNasopalatine Duct Cyst(aka incisive canal cyst)(aka incisive canal cyst)

Most common nonMost common non--odontogenic cyst of the odontogenic cyst of the oral cavityoral cavityEtiologyEtiology

Probably arises from Probably arises from spontaneous cystic spontaneous cystic degeneration of degeneration of remnants of the remnants of the nasopalatine ductsnasopalatine ducts

Male predilectionMale predilectionAnterior palatal swellingAnterior palatal swellingAdjacent teeth are vitalAdjacent teeth are vital

MAKMAK

Nasopalatine Duct CystNasopalatine Duct Cyst

•• RadiographicRadiographicRadiolucency > 6 mm Radiolucency > 6 mm in diameter in diameter (distinguished from (distinguished from normal incisive canal normal incisive canal foramen unless lesion foramen unless lesion is symptomatic)is symptomatic)Round to oval, heartRound to oval, heart--or inverted pearor inverted pear--shapedshaped

–– Root resorption is rareRoot resorption is rare

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Nasopalatine Duct CystNasopalatine Duct Cyst

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Nasopalatine Duct CystNasopalatine Duct Cyst

•• HistopathologyHistopathology–– Epithelium varies from Epithelium varies from

squamous to respiratorysquamous to respiratory–– Nerve, blood vessel and Nerve, blood vessel and

nasal cartilage may be nasal cartilage may be seen in cyst wallseen in cyst wall

•• TreatmentTreatment–– Palatal flap approach for Palatal flap approach for

enucleationenucleation–– Recurrence rareRecurrence rare

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Median Palatal CystMedian Palatal Cyst

•• Rare fissural cyst Rare fissural cyst •• EtiologyEtiology

–– Arises from proliferating epithelium entrapped in Arises from proliferating epithelium entrapped in the fusion line of the lateral or palatal processes of the fusion line of the lateral or palatal processes of the maxillathe maxilla

•• Many radiographic median palatal cysts are Many radiographic median palatal cysts are artifactually distorted nasopalatine duct cystsartifactually distorted nasopalatine duct cysts

MAKMAK

Median Palatal CystMedian Palatal Cyst

•• Young adultsYoung adultsFluctuant swelling midline hard Fluctuant swelling midline hard palatepalate

Clinical enlargement of the palateClinical enlargement of the palateSymptomsSymptoms

Pain or expansion varyPain or expansion varyRadiographicRadiographic–– WellWell--defined radiolucency (2 cm defined radiolucency (2 cm

avg.)avg.)•• HistologyHistology

–– Squamous or respiratory Squamous or respiratory epithelium liningepithelium lining

•• TreatmentTreatment–– EnucleationEnucleation–– Excellent prognosisExcellent prognosis

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Median Palatal CystMedian Palatal Cyst

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Median Mandibular CystMedian Mandibular Cyst•• Questionable existence since Questionable existence since

no justification for fissural no justification for fissural originorigin

•• EtiologyEtiology–– Probably odontogenicProbably odontogenic

•• Periapical cystPeriapical cyst•• Residual cystResidual cyst•• PrimordialPrimordial•• Odontogenic keratocystOdontogenic keratocyst•• Glandular odontogenic cystGlandular odontogenic cyst

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Epidermal CystEpidermal Cyst(epidermoid cyst)(epidermoid cyst)

•• Common on skin but rare in oral Common on skin but rare in oral cavity unless traumatically cavity unless traumatically implantedimplanted

•• Unlike dermoid cyst not an Unlike dermoid cyst not an incomplete variant of teratomaincomplete variant of teratoma

•• Etiology Etiology -- skinskin–– Arises from healing of inflamed hair Arises from healing of inflamed hair

folliclefollicle’’s infundibulum epitheliums infundibulum epithelium–– Acne prone skin of head and neck Acne prone skin of head and neck

areaarea•• May involve lipMay involve lip•• Male predilectionMale predilection•• Associated with GardnerAssociated with Gardner’’s s

syndromesyndrome

MAKMAK

Epidermal CystEpidermal Cyst

•• HistopathologyHistopathology–– KeratinKeratin--filled cystic cavity filled cystic cavity –– Simple or stratified Simple or stratified

squamous lining without squamous lining without skin appendagesskin appendages

•• TreatmentTreatment–– Conservative excisionConservative excision–– Excellent prognosisExcellent prognosis

MAKMAK

Dermoid CystDermoid Cyst•• EtiologyEtiology

–– EctodermEctoderm-- and and mesodermmesoderm--derived derived structuresstructures

•• ClinicalClinicalMidline floor of mouth Midline floor of mouth intraoral swelling intraoral swelling displacing tongue if displacing tongue if above geniohyoid muscleabove geniohyoid muscle

Double chin if below Double chin if below musclemuscle

Mass doughy or rubbery Mass doughy or rubbery in consistencyin consistency

–– Common in young adults, Common in young adults, rare in infantsrare in infants

MAKMAK

Dermoid CystDermoid Cyst

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Dermoid CystDermoid Cyst

•• HistopathologyHistopathology–– Cystic incomplete Cystic incomplete

form of teratoma, form of teratoma, simpler in structuresimpler in structure

–– Does not contain Does not contain tissue from all 3 tissue from all 3 germ layers germ layers

–– Cyst wall contains Cyst wall contains dermal appendagesdermal appendages

MAKMAK

Dermoid CystDermoid Cyst

•• TreatmentTreatment–– Surgical approach based Surgical approach based

on local above or below on local above or below geniohyoid musclegeniohyoid muscle

•• Above Above -- intraoralintraoral•• Below Below -- skinskin

–– Recurrence uncommon Recurrence uncommon following complete removalfollowing complete removal

MAKMAK

Thyroglossal Duct (Tract) CystThyroglossal Duct (Tract) Cyst

•• Review Review -- embryogenesisembryogenesis–– Thyroid gland descends Thyroid gland descends

from primitive foramen from primitive foramen cecum to hyoid bone cecum to hyoid bone location by 7th embryonic location by 7th embryonic weekweek

–– Tract epithelium normally Tract epithelium normally undergoes atrophyundergoes atrophy

–– Persistent remnants are Persistent remnants are the source of the cystthe source of the cyst

MAKMAK

Thyroglossal Duct CystThyroglossal Duct Cyst

Midline swelling Midline swelling anywhere along tract of anywhere along tract of descentdescent

60% 60% -- 80% below the 80% below the hyoid bonehyoid bone

50% occur by age 20 50% occur by age 20 Equal gender incidenceEqual gender incidence

Most < 3 cmMost < 3 cmMay move during May move during swallowing or tongue swallowing or tongue protrusionprotrusion

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Thyroglossal Duct CystThyroglossal Duct Cyst

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Thyroglossal Duct CystThyroglossal Duct Cyst

•• HistopathologyHistopathology–– Lumen lined by stratified Lumen lined by stratified

squamous epithelium squamous epithelium with thyroid tissue in cyst with thyroid tissue in cyst wallwall

•• TreatmentTreatment–– Sistrunk procedure Sistrunk procedure

•• CystectomyCystectomy•• Removal hyoid bone Removal hyoid bone

and generous portion and generous portion of muscle along entire of muscle along entire length of tract akin to length of tract akin to modified neck modified neck dissectiondissection

–– Recurrence 10%Recurrence 10%

MAKMAK

Cervical Lymphoepithelial CystCervical Lymphoepithelial Cyst(aka branchial cleft cyst)(aka branchial cleft cyst)

•• Etiology in disputeEtiology in dispute–– Remnants of branchial clefts or embryonic Remnants of branchial clefts or embryonic

gill apparatus ORgill apparatus OR–– Cystic change in parotid gland epithelium Cystic change in parotid gland epithelium

embryologically entrapped in upper embryologically entrapped in upper cervical lymph nodescervical lymph nodes

MAKMAK

Cervical Lymphoepithelial CystCervical Lymphoepithelial Cyst

Soft, fluctuant mass 1 Soft, fluctuant mass 1 -- 10 10 cm in sizecm in sizeUpper lateral neck on the Upper lateral neck on the anterior border of anterior border of sternocleidomastoid musclesternocleidomastoid muscleYoung adultsYoung adultsPain, if secondarily infectedPain, if secondarily infected

•• Not the multiple Not the multiple lymphoepithelial cysts of the lymphoepithelial cysts of the parotid gland seen in HIV parotid gland seen in HIV patientspatients

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Cervical Lymphoepithelial CystCervical Lymphoepithelial Cyst

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Cervical Lymphoepithelial CystCervical Lymphoepithelial Cyst

•• HistologyHistology–– Cyst lumen lined by squamous Cyst lumen lined by squamous

epitheliumepithelium–– Wall contains typical lymphoid Wall contains typical lymphoid

tissue with germinal centerstissue with germinal centers•• Malignant cases? NoMalignant cases? No

–– Instead metastatic sq cell ca from Instead metastatic sq cell ca from occult primary tumors of the occult primary tumors of the nasopharynx or behind the tonsilsnasopharynx or behind the tonsils

•• TreatmentTreatment–– Surgical removalSurgical removal–– Recurrence almost neverRecurrence almost never

MAKMAK

Oral Lymphoepithelial CystOral Lymphoepithelial Cyst

•• UncommonUncommon•• Young adultsYoung adults

Submucosal mass, Submucosal mass, whitewhite--yellowyellowFloor of mouth most Floor of mouth most oftenoften–– Also ventral and Also ventral and

posterior lateral tongueposterior lateral tongue–– Remainder of Remainder of

WaldheyerWaldheyer’’s ring tissues ring tissueMAKMAK

Oral Lymphoepithelial CystOral Lymphoepithelial Cyst

•• Asymptomatic unless Asymptomatic unless traumatizedtraumatized

•• Smaller in size than cervical Smaller in size than cervical counterpartcounterpart–– < 1 cm< 1 cm

•• Histopathology Histopathology –– Similar to cervical LE cyst Similar to cervical LE cyst

•• TreatmentTreatment–– Conservative surgical excisionConservative surgical excision–– Does not recurDoes not recur