STC Flashcards

Question

**Pyogenic Granuloma** What a differential diagonsis to consider if we see it

Answer 1

- if it’s on the gingival tissues, take a radiograph - always consider **SCC** as a differential diagnosis

Answer 2

Inflammatory Gingival Enlargement Example of someone with true hyperplastic gingivitis Maybe related to very poor plaque control In this case, either porcelain or porcelain fused to metal full coverage restorations that have very bulky margins, and that may play a role for food to pick up

Answer 3

* **What is it?** Reactive connective tissue hyperplasia - exuberant granulation tissue; Misnomer – not pyogenic and not a true granuloma * **Etiology:** Response to injury - calculus or overhang restoration * **Assosiated with**? Often occurs in **pregnant women (“pregnancy tumor”)**, also associated with **puberty** * **Treatment**: Excision and removal of irritant (eg calculus, overhanging restorations)

Answer 4

Acute Myelogenous Leukemia (AML) Wegener’s Granulomatosis Kaposi Sarcoma Plasma Cell Gingivitis **Generalized gingival enlargement – all different cases and diseases**

Answer 5

* They often occur in the gingival, but can occur in multiple areas * that’s the one thing that distinguishes this from the other 2 P’s: pyogenic granuloma can occur on ANY oral site, most commonly on the gingival tissues

Answer 6

Hereditary Gingivofibromatosis

Answer 7

**Infantile Hemangioma** **(“strawberry” hemangioma).** Infant with two red, nodular masses on the posterior scalp and neck *Neville Cr*

Answer 8

* **Clinical appearance** * Usually **ulcerated** * Soft exophytic lesion, either **sessile or pedunculated** * **Deep red to purple in color, bleeds easily** * **Location:** * **Most common – *gingiva*** * Also occurs in **other areas of the oral mucosa ( can happen anywhere)** * **Size**: small to large (millimeters to centimeters) * **Develop** rapidly and then remain static * **Age**: Any age

Answer 9

When you apply pressure to it, it evacuates the lesion (disappears!), when you pull away, it refills and you see it again – that tells you it’s a vascular lesion

Answer 10

**Capillary Malformation (Low flow)**

Answer 11

Venous malformation (Low flow) **No bruit, non-pulsatile** vs Arteriovenous or arteriolar malformations (High flow) **Bruit and pulsatile** **In other word, Venous lesion = Does not have pulse** **Histopathologically they look different too** **Treatment:** **-**Don't biopsy this unless it's rapidly growing, if it is rapidly growing then suspect ► *angiosarcoma*? ( unlikely) -can be surgically treated by oral surgeons -clamping off the blood vessel and dissecting it out, or putting a sclerosis agent

Answer 12

Venous malformation (low flow) *Many pts can live with this without treatment*

Answer 13

Osler-Weber-Rendu Syndrome

Answer 14

Sturge-Weber Angiomatosis Sturge-Weber syndrome

Answer 15

**Sturge-Weber Angiomatosis** **Sturge-Weber syndrome** Notice how the vascular malformation is only one side.. Remember: Vascular changes follow trigeminal nerve, so it doesn’t cross midline

Answer 16

**Lymphangioma**

Answer 17

**Cystic Hygroma** a type of Lymphangioma

Answer 18

* a reactive benign soft tissue lesion * **Clinical appearance:** Well-demarcated, sessile or pedunculated lesion that appears to originate from _the gingival interdental papilla_ * **Derived from:** cells of the periodontal ligament * **Age**: children and young adults * **Sex**: females more than males * **Recurrence rate** – about 16% * **Treatment**: Surgical excision

Answer 19

**Neuroma** **(Traumatic Neuroma)** Not a benign true neoplasm, it’s reactive lesion This is an edentulous patient, so resorbed bone, so flange of denture is impinging in the area of mental foramen – develop from repeated trauma Sometimes have to cut into nerve, peel the neuroma from nerve, careful not to sever nerve

Answer 20

Multiple Endocrine Neoplasia (MEN) Syndrome

Answer 21

neurofibroma -it looks like **lymphoepithelial cyst,** but this is further anterior and not where you would get lymphoid tissue – so it’s not lymphoepithelial cyst, it’s neurofibroma Yellow – nerves typically yellow

Answer 22

neurofibroma

Answer 23

* **What is it?** Probably a reactive lesion due to local irritating factors (giant cells develop inside the lesion which is a benign soft tissue lesion) * **Location**: _Gingiva_, usually anterior to the molars * **Age:** Most frequently seen between 40-60 years old * **Clinical appearance:** dusky purple, sessile or pedunculated, smooth-surfaced, dome-shaped papule or nodule. Most lesions are less than 1.5 cm in diameter, though infrequently, may grow as large as 5 cm in greatest dimension * **Radiographic Features:** Usually none, but superficial destruction of the alveolar bone may occur

Answer 24

**Neurofibromatosis syndrome** **von Recklinghausen’s Disease** * Lisch nodules on iris, pigmented (eye picture) * Neurofibromatosis in mouth (bottom left picture) * Café au lait (bottom right picture)

Answer 25

Schwannoma/ Neurilemoma

Answer 26

Schwannoma/ Neurilemoma

Answer 27

**Antoni A and Antoni B.** Streaming fascicles of spindle-shaped Schwann cells characterize Antoni A tissue. These cells often form a palisaded arrangement around central acellular, eosinophilic areas known as **Verocay bodies.** Antoni B tissue is less cellular and less organized; the spindle cells are randomly arranged within a loose, myxomatous stroma.

Answer 28

Granular Cell Tumor

Answer 29

Granular Cell Tumor

Answer 30

Has pseudoepitheliomatus hyperplasia of epithelium (seen on left picture) Characteristic feature are the granular cells on the right picture Infiltrate down into the muscle layers, that’s when pathologist confirms granular cell tumor

Answer 31

•**Diagnosis**: All 3 “P” lesions usually occur on gingival interdental papillae ( however pyogenic granuloma can occur anywhere) • Since they can look similar clinically, **excisional biopsy necessary to determine diagnosis** • **Treatment**: complete excision and removal of local irritant (scaling and root planing)

Answer 32

**Congenital Epulis**

Answer 33

- Response to chronic inflammation - Hormonal changes (pregnancy/puberty) - Immune-mediated/plasma cell gingivitis - Drug induced - Genetic/ Inherited NOTE: Gingival enlargement is not always ***hyperplastic tissue***

Answer 34

Neuroectodermal tumor of infancy look how they removed it here surgically *is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth.*

Answer 35

* **What is it:** Benign tumor of mature fat cells; Relatively rare * **Location:**Won’t see on gingival tissue, will see _on buccal mucosa, on the tongue, and floor of the mouth_ * **Clinically** appears as _a yellowish mass_ surfaced by thin overlying epithelium, When you feel it, it’s soft * **Histologically**: a well-delineated tumor composed of mature fat cells with a thin capsule * **Treatment**: surgical excision,does not recur

Answer 36

**Lipoma** Usually very orange looking lesion in site where there’s adipose tissue Very obvious, nothing as orange as lipoma

Answer 37

* **Phenytoin**: (or Dilantin) – the drug that used to be given to every single * person that had seizures * Calcium-channel blockers * Nifedipine *not as prescribed anymore* * Dilitiazem still prescribe * Amlodipine: is prescribed as one of the first line therapy for hypertension (very commonly prescribed); it doesn’t typically cause gingival overgrowth except in some selected patients, usually those with pretty poor oral hygiene * Cyclosporine A (used for for bone marrow transplant, graft vs host disease, solid organ transplant) * **Cyclosporine is universally recognized as causing gingival hyperplasia** * **Cyclosporine** is largely replaced with **Tacrolimus**, which typically doesn’t cause gingival overgrowth * Cyclosporine A is largely replaced with Tacrolimus, which typically doesn’t cause gingival overgrowth Some drugs have more connective tissue component, others have more epithelial component Not all identical under the microscope * Cyclosporine provides more epithelial change, Dilantin causes more of a connective tissue change

Answer 38

**Vascular leiomyoma** **High-power view showing spindle-shaped cells with bluntended nuclei. Immunohistochemical analysis shows strong positivity for smooth muscle actin (inset).**

Answer 39

**Rhabdomyoma** ## Footnote Will see the striated muscle Differential diagnosis… looks like granular cell tumor – don’t know til you remove it If patient presents with relatively slow growing tumor like this, will I get incisional biopsy or excisional biopsy? Hard to say If confident benign tumor and it’s this size and I don’t think it’s vascular (no pulse, can do aspiration), feels firm – try to excise it If it looks different, like you think it’s malignant minor salivary gland neoplasm (won’t find it in this site, but if it’s on hard palate) – incision?

Answer 40

**Leiomyosarcoma**

Answer 41

**What causes it?** * Various genes that are implicate (Putative inherited mutations are in the SOS1 or CAMK4 genes.) Linked to both autosomal dominant and recessive patterns of inheritance **How common?** * Very rare **what effects on oral cavity?** * Sometimes gingival overgrowth will completely obliterate the teeth, grow around entire tooth * Enlargement may be present at birth or may become apparent only with the eruption of the deciduous or permanent dentitions. * Tooth migration, prolonged retention of the primary dentition, and diastemata are common, and enlargement may completely cover the crowns of the teeth, resulting in compromised oral function. **Treatment** * Need surgical (usually laser) treatment – just grows back, so have to get it done periodically

Answer 42

Rhabdomyosarcoma In this case, hasn’t broken through epithelium They don’t all break through

Answer 43

* **_When do they appear?_** They are rarely present at birth, infants are Born with this in place. * **Rate of development:** the tumor will demonstrate rapid development that occurs at a faster pace than the infant’s overall growth in the first few weeks of life, * **Clinical presentation:** Either superficial or deeper tumors * Superficial tumors of the skin appear raised and bosselated with a bright-red color (“strawberry” hemangioma); They are firm and rubbery to palpation, and the blood, cannot be evacuated by applying pressure. * Deeper tumors may appear only slightly raised with a bluish hue. * May be left with a _pink or magenta macule_ in site where hemangioma occurred after its involute * **Treatment:** Typically will involute with time, Some cases don’t involute, so need to be removed * *It is a vascular Anomaly*

Answer 44

**Fibrosarcoma**

Answer 45

* a type of vascular anomaly * CMs are commonly known as port wine stains. * They look like a pink, red or purple patch of skin * occur in 1 in 300 newborns.

Answer 46

**Kaposi Sarcoma** Solitary vascular lesion on hard palate – it was so small so he decided to just excise it in this case^

Answer 47

**Kaposi Sarcoma** * Widespread Kaposi, can see cutaneous lesions * Oral images of this patient: on palate, starts with macule on patient’s left posterior palate –macular stage * Then in becomes proliferative – exophytic nodular stage (seen on patient’s right anterior palate,surrounding canine and some incisors) * Can see engorged blood vessels in area on histology slide

Answer 48

**Plasmacytoma in Multiple Myeloma** * They already had **multiple myeloma** then developed plasmacytoma * When you biopsy this, **it’s filled with plasma cells** bc they’re producing the abnormal immunoglobulins, which are the cause of the devastating issues of multiple myeloma

Answer 49

**Acute myelogenous leukemia***with* **granulocytic sarcoma** ## Footnote * *Complaining of lump inside of her cheek** * *Notsomuch worried about her gingiva**, despite her overgrowth – leukemic infiltrates that got into gingival tissues * *Left buccal mucosa**, kept biting on it, feeling incredibly fatigued though she was always working out * *Oral surgeon biopsied** her buccal mucosa and read by pathologist as pyogenic granuloma * *Physician** sent her for bloodwork, dental school sent her for bloodwork too

Answer 50

Lymphoma * Well circumscribed ulceration in area * Associated swelling in periphery * White change in the patient’s left area * Been there for 3 weeks * It’s lymphoma

Answer 51

Looks like it could be a salivary gland neoplasm, but it’s not It was another **lymphoma** Manifest in a number of different ways

Answer 52

**Do you think it’s a fibroma? No. Why?** Fibroma is covered with normal coloring epithelium – sometimes see a little white change on surface or see tiny traumatic ulcer on surface This is not like that, this is completely ulcerated Not fibroma; fibroma is a chronic bump that patient is aware of **Is it squamous cell carcinoma? Interesting, it is indeed very friable; but no** Sometimes SCC can develop and can be exophytic and don’t have deep invasion, But this is pedunculated, SCC would not be pedunculated History says there could be some kind of trauma, biting, or nick with bur – not squamous cell **Mucocele? No** Would you typically develop mucocele on lateral border of tongue? No Not going to be as many mucoceles in this area, but there are the glands of Blandin and Nuhn, so it’s possible to develop on ventral surface of tongue This bump doesn’t look like a fluid filled bump though, it has surface ulceration, redness ;Mucoceles have intact surface, would not bleed, or be red **Granular cell tumor? No** Granular cell tumor would have normal overlying epithelium (it’s pushing up from underneath) This does not have normal overlying epithelium **Hemangioma reserved for congenita**l; not a vascular malformation either **Neurofibroma? No, not the same surface** **Salivary gland neoplasms? Possible**, there are salivary glands in that area; keep this in differential The one that this is is **pyogenic granuloma**: usually red, ulcerated, and bleeds easily

Answer 53

**AKA** • _Hereditary Hemorrhagic Telangiectasia_ **What is it and its clinical appearance** • _disorder of development of the vasculature_ characterized by **telangiectases** and **arteriovenous malformations** in specific locations. These are essentially endothelial cell issue – get tafted area of abnormal blood vessels multiple different organ systems – causes complications **Type of Herditary and Etiology** •Autosomal dominant with mutations i_n at least five gene_s but mutations in two **genes (ENG and ACVRL1/ALK1)** cause approximately 85% of cases. **What can it cause?** • Can cause hemorrhage **Location?** often on fingers, lips,tongue, but always look at the fingers!

Answer 54

* Rare, non-hereditary developmental condition * **Vascular proliferation** involving tissues of the brain and face * Face: **Unilateral** distribution along one or more segments of the trigeminal nerve ( unilateral means don't cross the midline) known as **port wine stain/ nevus flammeus --** they are deep-purple color. * **Intracranial calcifications**; **neurological disorders** * **Intraoral involvement** _is common_

Answer 55

**What is it?** • Benign tumor of lymphatic vessels **Types** * Microcystic * Mixed * Cystic hygroma (macrocystic) **Location** * Most frequent extra-oral location: **posterior triangle of the nec**k; * intraoral location: **tongue** **Treatment**: monitor, surgery if needed, _recurrence common_

Answer 56

**AKA** * _traumatic neuroma_ **What is it?** * Reactive (ie not a true neoplasm) proliferation of nerve tissue after injury, usually extraction or other surgical procedure **Clinical presentation** * They are smooth-surfaced, nonulcerated nodules. * May be painful (30% of cases) and sometimes associated with altered nerve sensations that can range from anesthesia to dysesthesia to overt pain **Location** * mental foramen area, tongue, lower lip

Answer 57

***_What is it?_*** Group of rare conditions ***_Inhertiance type?_*** Autosomal dominant ***_Which type is associated with multiple mucosal neruoma?_*** **Type 2B associated with multiple mucosal neuromas (one of the first visual signs)** ***_What other presentations?_*** • Marfanoid features • Multiple tumors and hyperplasias of endocrine organs (ie pheochromocytoma) *_Increase risk of which cancer?_* **•** Increased risk for **medullary thyroid cancer (prophylactic thyroidectomy)** *_Common board questions_*

Answer 58

**What is it?** * A benign tumor arising from peripheral nerve tissue **Clinical presentation:** * Slow growing, painless lesion * Smooth-surfaced, nodular mass that varies in size * Skin more commonly involved than oral mucosa Location: * **Common oral mucosal sites:** tongue and buccal mucosa * May develop _centrally in bone_ **Treatment**: surgical excision **Malignant transformation** _reported, but rare_

Answer 59

_Most common form?_ Several forms, **type I** is **most common (von Recklinghausen’s Disease)** _intheritance type?_ • 85-97% of cases inherited as _autosomal dominant trait,_ c**hromosome 17 (NF1 gene)** **Clinical presentations:** * **Skin nodules** **(neurofibromas)** * **Café au lait** pigmentation on skin * **Lisch nodules** very diagnostic (a pigmented hamartomatou in the iris of the eyes) **Malignant transformation** * reported in 5% of cases (**neurofibrosarcoma**)

Answer 60

**What is it?** • Benign neoplasm of Schwann cell origin • Uncommon lesion: 28-48% occur in the head and neck **Age?** • Most common in young and middleaged adults **Location?** • Most common intraoral location: tongue **Clinical presentation?** • The **solitary** schwannoma is a slow-growing, encapsulated tumor that typically arises in association with a nerve trunk. • May present with pain **• Treatment** • surgical excision **malignant transformation** reported, but rare

Answer 61

**What is it?** Benign tumor derived from Schwann cells **Location?** • Oral cavity is the most common location • Vast majority of cases seen on dorsal tongue **Clinical presentation?** * Typically an **asymptomatic sessile nodule that is usually 2 cm or less in size (firm)** * The mass is typically **pink,** but some granular cell tumors appear **yellow**. * The granular cell tumor is usually solitary, although multiple, separate tumors sometimes occur, especially in black patients. * The lesion often has been noted for many months or years, although sometimes the patient is unaware of its presence. **Age**: 40-60, rare in children **Treatment** • Treated by surgical excision (Be careful with excision! no need to get all of it out, just most of it) rarely recurs

Answer 62

• **AKA**: Congenital epulis of the newborn • **Cells resemble** cells of the granular cell tumor **• Cell of origin** is unknown, not derived from nerve **• Clinical features:** * Sessile or pedunculated mass, usually found on * *the anterior** **gingiva/ alveolar mucosa** * Almost always occurs in baby girls * Present at birth **• Treatment:**Surgical excision, does not recur

Answer 63

**Location?** Often occur as soft tissue mass largely in _anterior maxilla_ **Rate of development?** So fast developing that it envelops and moves the teeth **Treatment?** Needs to be surgically excised **Origin?** Thought to be of **neuroectodermal source** **Clinical presentation?** Pigmented change in tissue

Answer 64

* Sometimes lipomas can be mixed with fibrous tissue, can be **lipofibromous** * Two lesions that look almost identical but one is **lipoma**, one is **lipofibroma** * Only difference is that **one has fibrous tissue in it, no other difference**

Answer 65

• **Leiomyoma** • Benign tumor of smooth muscle **• Vascular Leiomyoma** • Benign tumor of smooth muscle walls of blood vessels **• Rhabdomyoma** • Benign tumor of skeletal muscle They are SUPERRR rare If become malignant, they become leiomyosarcoma or rhabdomyosarcoma – malignant even more rare

Answer 66

* a type of rare cancer that grows in the smooth muscles. * So, so rare * Diseases that move rapidly, because they’re malignancies * You might see surface ulcerations, they’re moving so fast, they break through the epithelium

Answer 67

* is a type of sarcoma. * **Rhabdomyosarcoma** usually begins in muscles that are attached to bones and that help the body move, but it may begin in many places in the body

Answer 68

Sarcoma is cancer of soft tissue (such as muscle), connective tissue (such as tendon or cartilage), or bone.

Answer 69

**•What is it?** Malignant tumor of fibroblasts • **Age?** Most common in young adults and children • **Rate of growth?** Slow growing lesion that is usually not painful (Can be slow growing, can be rapidly growing – different criteria determining high or low grade) • **Treatment**: surgical excision, recurrence is common(Aren’t always easy to surgically remove, because already metastasized into other reservoirs, spread into contiguous areas) Aren’t always radiosensitive, don’t always respond to radiation treatment • 5-year **survival rates** range from 40-70%

Answer 70

**• Angiosarcoma** • Malignant tumor of blood vessels **• Lymphangiosarcoma** • Malignant tumor of lymphatic vessels **• Kaposi’s sarcoma** * Malignant neoplasm associated with endothelial cells * Seen predominantly in poorly controlled HIV infected patient population (not exclusively) * Elderly people can develop Kaposi

Answer 71

**Etiology**:Caused by **HHV-8 (human herpesvirus 8) /***part of herpes family* **Types:** * **Classic:** late adult life, Italian and Jewish men, skin of lower extremities * **Endemic:** African form * **Iatrogenic immunosuppression-associated:** most often occurs in recipients of organ transplants * **AIDS-related** **Treatment** * Surgical excision, radiation therapy or systemic chemotherapy for multiple nonoral lesions, if it gets large, dose-radiation therapy!

Answer 72

Presents as soft tissue lesion It is possible that a patient can present with plasmacytoma that would be the first sign of multiple myeloma (it would be a rare sign, but it can happen)

Answer 73

* **Lymphoma** is a general term for a complex group of heterogeneous lymphoreticular malignancies. * **Lymphoma** is the _sixth most common malignancy_ and the **second most common neoplasm of the head and neck after squamous cell carcinoma** and **accounts for 50-59% of head and neck neoplasms in children.** * They constitute approximately 3-5% of all known malignancies and are generally divided into two morphologically distinct types: **Hodgkin’s lymphoma (HL)** and **non-Hodgkin’s lymphoma (NHL).** * These malignancies typically **arise within the lymphatic tissues and can progress to extranodal disease as in NHL.** * **Cervical lymph node involvement can be present in any type of lymphoma**. * HL extends by means of contiguous nodal spread whereas NHL tends to disseminate hematogenously and is typically a systemic diagnosis. * Within the head and neck, **Waldeyer’s ring** is the most common site of involvement, accounting for more than half of all extranodal head and neck lymphomas. * **Oral involvement by lymphoma** may represent _a localized disease process_ but is _more often part of a systemic process that secondarily involves the cervical lymph nodes._ * **Lymphoma** arising within the oral cavity accounts for less than 5% of all oral malignancies, and **approximately 85% of these lesions involve the pharyngeal tonsil** and the **palate** * Extralymphatic sites include the **salivary glands, paranasal sinuses, oral cavity, and larynx.**

Answer 74

benign tumor of glandular origin

Answer 75

 Encapsulated ‐ distinguishable from surrounding tissues  Freely movable ‐ not fixed  Slow growing  Non tender ‐ patients do not complain of pain

Answer 76

 **Pleomorphic adenoma** aka mixed tumor  **Monomorphic adenoma**s o **Canalicular adenoma** o **Basal cell adenoma**  **Warthin tumor** (papillary cystadenoma lymphomatosum)

Answer 77

* This tumor comes in many forms/shapes * **Most common salivary gland tumor** * **Painless, slowly growing, firm mass** * Adults (30‐50 years old) ; slight female predilection * Sites: * 50% to 77% of **parotid tumors** (most commonly found in parotid-2/3rd to 3/4th of parotid tumors) * Minor SG: **palate\>upper lip\>buccal mucosa\>** other site (most common intraoral site is the **palate**) * Malignant transformation possible in long standing lesions (about 5% cases) ‐\> called Ca ex PA

Answer 78

PLEOMORPHIC ADENOMA | (MIXED TUMOR)

Answer 79

PLEOMORPHIC ADENOMA Classic presentation: includes swelling in the parotid region | (MIXED TUMOR)

Answer 80

PLEOMORPHIC ADENOMA **Palatal presentation**: since salivary glands are only in lateral sides of the palate, **usually swellings are in one side and not the midline.** Lateral swelling is a clue that you are looking at a salivary gland lesion (left pics) On the right pic, it involved midline and crossed over to other side, so there are exceptions. But more commonly found in lateral side of the palate. | (MIXED TUMOR)

Answer 81

PLEOMORPHIC ADENOMA * Upper lip presentation: sometimes swelling can be seen extra orally and intraorally. * Remember the swelling will be movable, not tender, not fixed to underlying structures. | (MIXED TUMOR)

Answer 82

**Untreated pleomorphic adenoma** slow growing, but can grow to enormous sizes

Answer 83

This is a **mixed tumor** with myxoid component (right) and fibrous/epithelial component(left) This type of tumor can produce a lot of different tissues, since the origin is from myoepithelial cells aka plasmacytoid cells, which are pluripotent cells which means they can differentiate into many different lineages of cells such as

Answer 84

Canalicular Adenoma

Answer 85

**Canalicular Adenoma** * ***Mucocele*** might look this way, but what would make it lower on * differential diagnosis is the location of the swelling. Mucocele is mostly seen on lower lip and this pic shows upper lip. Salivary gland tumors and mucoceles * can have the same clinical presentation, so always do a biopsy for formal histopathology diagnosis.

Answer 86

* **Basaloid appearance of the tumor cells** * **Primarily parotid lesion** * **predominantly in women over 50 years of age**. It is uncommon in young adults.  (Basal cells are located in epithelium that is adjacent to interface with the connective tissue and they are separated from the CT by a basement membrane, stem cells of epithelium are located in basal cell layer)  Basal cells are typically Blue in appearance and cuboidal,

Answer 87

**Basal Cell Adenoma**

Answer 88

PAPILLARY CYSTADENOMA LYMPHOMATOSUM (WARTHIN TUMOR)

Answer 89

** Most common malignancy of salivary glands  Most common malignant SG tumor in children** **Locations**  **Palate**, most common intraoral site  Rare primary intrabony (jaws) tumors  Most common in **parotid**  **Minor SG: palate 2nd** **Clinical appearance in minor gland:** asymptomatic fluctuant swelling; blue or red colored ** Can be mistaken for mucocele**  **Histopathology**: note the cells growing into adjacent tissue, showing infiltration

Answer 90

**What is it?** Proliferation of 1 type of cell makes up the tumor. **Types? Includes:** o Canalicular Adenoma o Basal Cell Adenoma **Treatment** for all monomorphic adenomas is surgical excision & diagnosis is done with biopsy

Answer 91

MUCOEPIDERMOID CARCINOMA

Answer 92

MUCOEPIDERMOID CARCINOMA ## Footnote *Request all for biopsies!*

Answer 93

**CENTRAL MUCOEPIDERMOID CARCINOMA** * _Intrabony presentations_, may have extraoral swelling depending on the stage * Started as small swelling and progressed rapidly:, need to pick it up early! * Patient recovered, but might need radiation, lost salivary glands, needed reconstruction of palate

Answer 94

* Almost exclusively in **minor SG** * Striking predilection for **upper lip (\>75%)** * Nearly always occurs in **older adults** * **Slowly growing, painless mass** * One clue for visualization of soft tissue swellings is increased vascularity with **blue‐ish tint in the area.**

Answer 95

**ACINIC CELL ADENOCARCINOMA**

Answer 96

ACINIC CELL ADENOCARCINOMA blue‐ish tint

Answer 97

Untreated acinic cell adenocarcinoma ## Footnote  Because it is slow growing, and a low grade tumor, the patient is alive and not dead with a tumor this size.  Similar presentation to pleomorphic adenomas, but there is a lot of ulceration on the surface and prominent vascularization in acinic cell adenocarcinoma.

Answer 98

 **High grade salivary gland malignancy** ( very bad cancer to get)  Adults  **Palatal mass; ulcerations**  Spread through **perineural invasion** ‐ tumor wraps itself around nerves and spreads through perineural spaces  **Grows slowly in the beginning and then picks up speed**  **Histology**: Duct like proliferation with cystic spaces

Answer 99

Adenoid Cystic Carcinoma

Answer 100

Adenoid Cystic Carcinoma

Answer 101

Adenoid Cystic Carcinoma

Answer 102

Swiss cheese appearance, cribriform pattern (full of holes aka cystic spaces)

Answer 103

Perineural invasion: nerve nuble in the center and is wrapped by tumor

Answer 104

Polymorphous Adenocarcinoma

Answer 105

Polymorphous Adenocarcinoma

Answer 106

Carcinoma Ex Pleomorphic Adenoma

Answer 107

* **finger‐like projections, benign, cystic spaces, aggregates of****lymphocytes)** * Vast majority occur within **the parotid gland** * Very rare intraorally * **Predominantly in men** * Typically between **5th and 8th decades** * _Strong correlation with cigarette smoking_ * **Most common SG tumor to occur bilaterally** (bilateral parotid swelling), but can be unilateral * **Etiology:** Thought to arise within lymph nodes as a result of entrapment of * salivary gland elements early in development * **Clinical Features:** * **swelling that has** more subtle presentation * **Doughy to cystic mass** * In the inferior pole of the gland, adjacent and posterior to the angle of the mandible * **Treatment**: surgical excision, responds very well to it

Answer 108

 **Encapsulated, freely movable, not fixed to underlying structure, not tender, patients do not complain of pain, slow growing**  There is one tumor of the ones discussed that does have a risk of malignant transformation (only 5% and will take many, many years) and that is **Pleomorphic adenoma**

Answer 109

 Mucoepidermoid carcinoma  Acinic cell carcinoma  Adenoid cystic carcinoma  Carcinoma ex‐mixed tumor/malignant mixed tumor  Polymorphous adenocarcinoma

Answer 110

 Infiltrative  Fixed to underlying structures, not moveable  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

Answer 111

**What are its compoenents?** Mixture of mucus‐producing cells and epidermoid or squamous cells May arise **within jaws** from odontogenic epithelium of dentigerous cysts • More common in the **mandible** than maxilla **• Molar‐ramus area** **Treatment**: Usually treated by surgical excision **Prognosis:** • Overall prognosis is _fairly good_ • 10% of patients die, due to local recurrence or metastasis  Low‐grade tumors have good prognosis (\>90% are cured)  High‐grade tumors the prognosis is guarded (Only 30% survive) **Therapy by gene?** *CRTC1–MAML2, CRTC3‐MAML2* gene fusions (targeted therapy)

Answer 112

*  Occurs **predominantly in major SGs,** *  Found in **all age group**s, peak incidence in 5th and 6th grade *  **No gender predilection** *  _Malignancy with serous acinar differentiation_ *  **Most common in the parotid** (since 90% serous acini) *  Variable microscopic appearance *  May even appear **encapsulated**, since it is SLOW growing *  **Better prognosis than salivary gland malignancies**

Answer 113

**Location**:  Approx. 50% occur within the minor SG ‐ palate most common site **Growth rate**  Usually a slowly growing mass **Clinical presentation**  Pain is a common and important early finding, occasionally occurring before there is noticeable swelling (described at annoying pain)  Tendency to show perineural invasion, corresponds to pain **Treatment**  Excision usually the treatment of choice ‐ but edges of tumor may have perineural invasion and remain undetected ‐ makes tumor dangerous **Prognosis**  5‐year survival rate as high as 70% (maybe 90%)  By 20 years, only 20% ‐ poor long term prognosis

Answer 114

* **Location:** * Almost exclusively in the **minor SG** * **60%** on the hard or **soft palate** * **Gender"** * *2/3rds in **females*** * **Appearance**: * Tumor cells have _deceptively uniform appearance_ * **Growth patterns:** * Different growth patterns – polymorphous * _Perineural invasion ‐ common_ ‐ but considered low grade tumor * **Treatment**: Wide surgical excision; overall prognosis relatively good, with 80% cure rate

Answer 115

**What is it?** (benign tumors that have underwent malignant transformation‐ takes a lot time, 15 to 20 years) **Mean age** about 15 years greater than benign counterpart **Growth patterns:** Mass present for many years with recent rapid growth with associated pain or ulceration **Treatment**: Best treated by wide excision, with local node dissection and radiation **Prognosis:** guarded, with 50% local recurrence or metastases and dying Prognosis is case to case scenario, may transform to high grade tumor

Answer 116

**o Mucocele o Mucoepidermoid Ca o Pleomorphic Adenoma**

Answer 117

**o Canalicular Adenoma o Salivary Duct Cyst\* o Pleomorphic Adenoma**

Answer 118

**o Pleomorphic adenoma o Warthin’s tumor o Basal cell adenoma o Mucoepidermoid ca o Acinic cell ca o Adenoid cystic ca o Ca ex mixed tumor**

Answer 119

**o Pleomorphic adenoma o Adenoid cystic ca o Mucoepidermoid ca o PLGA o Monomorphic adenoma**

Answer 120

 Involve both major and minor glands ** Benign and malignant tumors both have similar clinical presentation**  Most malignant salivary gland tumors do not show histopathologic characteristics associated with malignancy  Most occur in adults  Warthin Tumor seen in parotid, may be bilateral ** Mucoepidermoid carcinoma** o Can occur in children o May occur centrally in bone

Answer 121

* Tori are incredibly common, a normal of variant * Part of physical exam is to visualize as well as running index finger over the hard palate every time * Sometimes, torus palatinus is quite small and unnoticeable until you touch it (feel a hard bump and it’s just a bony growth) * Sometimes, they are pedunculated; Sometimes, they get so large they become traumatized; vascular supply on surface can sometimes form ulcerations and even get a little bone exposure. * If patient with history of use of bisphosphonates (bone modifying agents given to women who have osteoporosis or osteopenia and to prevent metastesis for certain cancers), he will remove that dead bone, and it will slowly heal. That’s one of the perils of having an enlarged palatine torus

Answer 122

Palatine Torus/Torus Palatinus

Answer 123

Palatine Torus/Torus Palatinus

Answer 124

Mandibular Torus: Torus Mandibularis

Answer 125

Mandibular Torus: Torus Mandibularis

Answer 126

Buccal Exostoses

Answer 127

- Sometimes pt’s tori are so large that the sublingual frenum gets stuck underneath - repeated irritation/trauma can create a little white rim on the tori - these tori are rock hard and may grow overtime, but we don’t really understand why people get them

Answer 128

Unencapsulated Lymphoid Aggregates

Answer 129

Lymphoepithelial cyst we see a tiny yellowish cyst. we see the blood vessels on the surface; this is quite characteristic.

Answer 130

**Unencapsulated Lymphoid Aggregates** **Post-tonsillectomy** Can even develop these on area of tonsils. (left pic) Red/salmon is a lymphoid aggregate (unencapsulated lymphoid tissue). This is someone who had a tonsillectomy , and you can see these lymphoid aggregates on posterior pharyngeal wall (salmon color).They move around the area. (right pic) It grew back even in post-tonsillectomy patients.

Answer 131

Fordyce Granules

Answer 132

Fordyce Granules

Answer 133

* Sometimes patient develops **exostoses** (another word for **torus**). * Can get buccal exostoses, all just bone. Can pick these up on radiograph, the _bone is a lot denser._ **Why does it happen?** * Maybe it’s related to parafunctional habits – but don’t really understand the * basis for the exostosis. * They’re going to be **bilateral**. If it’s unilateral, we start thinking about other bony diseases *a variant of normal*

Answer 134

**Fimbriated fold/Plica semiluminaris**

Answer 135

**Frenal tag**

Answer 136

* the lymphoid aggregates _are part of the foliate papillae_ (they contain some taste buds as well). * **This is lymphoid tissue -**- when you get a cold or upper respiratory tract infection, sometimes these areas can become **hyperplastic** _in response to infection_ – **can become** **a little enlarged.** * These are usually **bilateral.** * *a variant of normal*

Answer 137

Sublingual Varices

Answer 138

Sublingual Varices

Answer 139

Sublingual Varices

Answer 140

Circumvallate papillae

Answer 141

Parotid Papillia (Stenson duct)

Answer 142

Parotid Papillia (Stenson duct)

Answer 143

a cystic structure.develops in that area where there are already _unencapsulated lymphoid tissue._ **This is not normal – Pathologic** Sometimes when you get a cyst in this area -- because of lymphoid tissue, you can develop lymphoepithelial cyst – **a tiny yellowish cyst**. we see the blood vessels on the surface; this is quite characteristic.

Answer 144

Linea Alba

Answer 145

Leukoedema

Answer 146

* Occurs on the buccal labial mucosa, retro molar pad and tonsillar area and lips * They are white or yellow **ectopic sebaceous glands** * They can be present in small or large quantity * Why do we have sebaceous glands in mouth? we dont know, evolutionary advantage? we don’t really understand. * a variant of normal

Answer 147

Palatal Rugae

Answer 148

* Some patients have *_more obvious_* **fimbriated folds or plica semilunaris** in their mouths than others * When you look at the **ventral surface of the tongue**, you’ll sometimes be able to pick these up. * These are **duct opening from a series of salivary glands, minor glands,** but they’re a little bit different than other minor glands in the mouth. * They produce more of a **viscous type of saliva**, and they are **the glands of the Blandin and Nuhn** * a variant of normal

Answer 149

* Frenal attachments are **thin folds of mucous membrane with enclosed muscle fibers that attach the lips to the alveolar mucosa and underlying periosteum.** * Most often, during the oral examination of the patient the dentist gives very little importance to the frenum, for assessing its morpholology and attachment. * Sometimes occur; essentially normal of varient

Answer 150

* Tortuous dilated vessels (enlarged engourged veins) on the ventral surface of the tongue, and sometimes stretch onto lateral border * Appears bluish purple in color * More prominent with increasing age; we don't see it in younger pts. * Nothing to be concerned about, a variant of normal

Answer 151

* Located in the **posterior region of the tongue**; dividing the body from the base * They are mushroom shaped and arranged in V-shape formation * Although they are usually not apparent in most patients, you may be able to visualize them in some * a variant of normal

Answer 152

* **Located in right and left buccal mucosa** at the level of the occlusal plane close to the maxillary first and second molar. * This structure may appear a**s a small dot or have a prominent pink to red papillae presence.** * This is the **parotid papilla**, and It is the opening of the parotid duct which drains saliva from the parotid gland. *A normal of variant*

Answer 153

•a white line or keratotic area that present along occlusal plane in some patients * due to some friction In that area. (the buccal mucosa) * It varies in thickness and opacity * Can be seen in some patients who have bruxism * a variant of normal

Answer 154

* A bluish and white filmy opalescence of the mucosa is observed * In order to differentiate it from other white lesions à gently stretch the patient’s cheek forward and the leukoedema will disappear or partly fade and appears less apparent * It is commonly found in people of color and some smokers. * a variant of normal

Answer 155

* Raised ridges or folds * Located in the anterior palate on either side of the mid-palatine raphe behind the incisive papilla * They vary in number and size * May increase with age * a variant of normal

Answer 156

* mucocele/mucous cyst * ranula * necrotizing sialometaplasia * sialolithiasis * sialadentitis

Answer 157

**• definition:** a lesion that forms when a salivary gland duct is severed & secretion spills into the adjacent CT • **a pseudocyst** (not lined by epithelium) — mucous builds up in the CT & causes a bump **• clinical features:** * swelling in the tissue that may increase & decrease in size * may have a bluish hue, fluctuant on palpation — fluid filled, soft, compressible **•** **location**: _lower lip most common site_, but may form in any area where there are minor salivary glands **• histologic features:** - a cyst-like space in soft tissue - lined by compressed granulation tissue - lumen filled with mucin, foamy macrophages & inflammatory cells **• treatment:** surgical excision, removal of associated minor salivary glands • may recur if don’t remove all associated injured minor salivary glands

Answer 158

**Mucocele**

Answer 159

**Mucous Cyst**

Answer 160

**Ranula** Notice how it's unilateral on the floor of the mouth

Answer 161

Ranula * Notice how it's unilateral* * on the floor of the mouth*

Answer 162

**• Definition:** locally destructive inflammatory condition — looks malignant but is _benign_ *• salivary gland ischemia* — “heart attack of the palate”; blood flow is interrupted **• predisposing factors:** - local trauma - palatal injection of local anesthesia - previous surgery - many are idiopathic.. • usually a clinical diagnosis based on history & how fast — palate uncommon for SCC **• clinical features:** - initially appears as a non-ulcerated swelling of the palate - often associated with pain or paresthesia - within 2-3 weeks, necrotic tissue sloughs off & becomes a crater-like ulcer - patient may say: “a chunk of the roof of my mouth fell out” **• histologic features:** - necrosis of the salivary glands — coagulative necrosis (green circles in histology —\>) - *salivary gland duct epithelium* is replaced by **squamous epithelium** — appear as islands of squamous epithelium deep in the CT & **resembles SCC** (arrows in histology —\>) • **Treatment**: no treatment, spontaneously resolves within 6 to 10 weeks • _irrigating & debriding the area_ can reintroduce vascularity & help healing

Answer 163

Necrotizing Sialometaplasia

Answer 164

**Definition:** lith = stone ;; sialolith: a salivary gland stone **Location:** occur in both major & minor salivary glands • floor of the mouth is most common location (Wharton’s duct is a common place) *• often causes obstruction of the duct* **Origin:** arise from _desposition of calcium salts around nidus of debris within the duct lumen_ * *clinical features:**- minor glands: hard yellowish structure in soft tissue - may be visible on a radiograph - recurrent swelling (due to the obstruction) - episodic pain & swelling during times of increased salivation - can be palpated if the stone is located toward the terminal portion of the duct * *Radiological features** : may be viewed as a radiopacity on an occlusal x-ray--well defined radiopacity * *Histological features-** concentric rings of calcification, color of it in stain depends on level of calcificatio * *Treatment**: promote passage of stone (massage, sialogogues, increase fluid intake) or surgical removal

Answer 165

Sialolithiasis

Answer 166

**Sialolithiasis** Notice how it can appear radiographically as a well defined radiolucency

Answer 167

**Sialolithiasis**

Answer 168

•_Definition:_ a pseudocyst • microscopicallly appears as an epithelial lined cystic structure that is actually a dilated duct • **clinically you CANNOT tell the difference between a mucocele & mucous cyst** **• clinical features:** - same as a mucocele **• histologic features:** - same as mucocele but will see an epithelial lining (but actually a dilated duct) **treatment**: same as mucocele; surgical excision

Answer 169

**Sialadenitis** Acute: parotid papilla purulent discharge

Answer 170

Sialadenitis Chronic: caused fibrosis

Answer 171

**Mucocele** * fluctuant swelling * bluish hue * lower lip most common **Ranula** * fluctuant swelling * floor of mouth **Sialolithisis** • major glands: episodic pain & swelling of affected gland • minor glands: asymptomatic/ local swelling or tenderness • if superficial - firm to palpation & yellowish color **Necrotizing Sialometaplasia** • initial painful swelling • later necrotic ulcer • posterior lateral hard palate & soft palate **Sialadenitis** • painful swelling of affected gland • purulent discharge if acute infection

Answer 172

• **Definition**: mucocele-like lesion that forms unilaterally on the floor of the mouth • may break through the mylohyoid muscle & enter neck space = *“plunging ranula”* • **associated with:** the _ducts of the sublingual & submandibular glands_ **• clinical features:** - must be _on floor of the mouth_ for it to be considered a ***ranula*** - big & have deep blue color if exophytic - sometimes can grow downward/deep & won’t see blue as much **• treatment**: surgical excision

Answer 173

• **definition**: acute or chronic _inflammation in major or minor salivary glands_ **• causes:** • obstruction of a salivary gland duct (sialolith) • infection (mumps [viral], staph aureus [bacterial, most common], candida [fungal]) • decreased salivary flow (Sjogren’s, sarcoidosis) • parotid gland = parotitis **• clinical features:** **- acute:** most common in parotid, swollen & painful gland, erythematous & warm overlying mucosa/skin, purulent discharge, low-grade fever **-** **chronic**: caused by recurrent or persistent ductal obstruction, periodic swelling & pain **• histologic features:** - acute or chronic inflammatory cell infiltrate in the salivary gland - in chronic cases = salivary gland replaced by fibrous CT & fat - **cells: acute = neutrophils** ;; **chronic = lymphocytes, plasma cells, macrophages** **• Treatment:** antibiotics, rehydration, surgical drainage, or surgical removal of gland

Answer 174

**‐ Debacterol** (sulfonated phenolics; sulfuric acid solution) **o Chemical cautery** o Label: one time application for 5‐10 seconds ‐ NOT recommended to patients with frequent outbreaks

Answer 175

**Topical anesthetic agents** o To numb the pain **‐ Surface protective agents/bioadhesives** o Cover the ulcer if small enough **‐ Anti‐inflammatory/immunomodulatory agents** o Applied to ulcer surface (corticosteroids) **‐ Anti‐microbials** o Some evidence that topical tetracycline may help **‐ Chemical/physical cautery Lasers** ‐ Over‐the‐counter (OTC) versus prescription (Rx **All essentially do the same thing:** o Numbing agent o Mucosal covering agent ‐ Bottomline: **o ALL canker sores will heal on their on with time**

Answer 176

**‐ Treatment to reduce pain ‐ vs. ‐ Abortive treatment to reduce healing time ‐ vs. ‐ Suppressive treatment to suppress recurrences ‐ Combination of all** Also Consider * Using Sodium Lauryl Sulfate‐Free Toothpastes * Remove Obvious Possible Causes

Answer 177

**‐ Treatment to reduce pain** Also Consider * using Sodium Lauryl Sulfate‐Free Toothpastes * Remove Obvious Possible Causes * ‐ Repair sharp teeth/restorations * ‐ Remove plaque * ‐ Optimize lubrication

Answer 178

‐ History of RAS ‐ Medical History o Medications o Review of Systems ‐ Social History ‐ Dental History ‐ Diet/Nutritional History ‐ Physical Examination ‐ LaboratoryTests

Answer 179

‐ Repair sharp teeth/restorations ‐ Remove plaque ‐ Optimize lubrication Ulcer

Answer 180

**Behcet’s Disease** ‐ Recalcitrant oral ulcers associated with Behcet’s Disease ‐ Later developed genital ulcers and other complications ‐ Image: o Sores in the labial mucosa have classic aphthae appearance o Other ulcers are major aphthae: ▪ Larger ▪ Irregular borders ▪ Intense proliferative erythema

Answer 181

**Behcet’s Disease** ‐ Recurrent inflammatory disorder of unknown cause: o Bacterial? ‐ Affects: o Middle Eastern Males o Asian Females ‐ Onset 3rd – 4th decade ‐ HLA‐B51 association Recurrent aphthous ulcers generally precede other signs: o Genital/skin/eye lesions & others (arthritis, Gl lesions, CNS symptoms, vascular lesions) ‐ Diagnosis based upon criteria (point system): no laboratory tests

Answer 182

**Hematinic Deficiencies** ## Footnote **‐ Superficial ulcers** o Not classic aphthous ulcers ‐ Equivocal associations with iron, Vit B1, B2, B6, B12, and folate. ‐ Blood tests are not recommended routinely in all patients with RAS. ‐ Indications for blood work (CBC): o Older patient with recent RAS history o Suspicious medical history/review of systems **o Strict vegetarian patients**

Answer 183

**HIV‐Associated Aphthous** * CD4 counts \<100 cells/mm3 are predisposed to major RAS * ‐ Other sites may be affected: * o Esophagus * o Genitals * o Anus/rectum * ‐ We see this **less frequently since ART** * ‐ Diagnosis is important, particularly if no prior history

Answer 184

**Inflammatory Bowel Diseases** * **Specific lesions:** * o Diffuse labial and buccal swelling * o Cobblestones * o Other specific lesions * ▪ Mucosal tags * ▪ Deep linear ulcerations * o Mucogingivitis * o Granulomatous cheilitis * * **Non‐specific lesions:** * o Aphthous ulcerations * o Pyostomatitis vegetans * o Dental caries * o Gingivitis and periodontitis * o Other non‐specific lesions

Answer 185

**Transient Lingual Papillitis** * ‐ Relatively rare * ‐ Canker sore meets **fungiform papilla** of tongue * Multiple papilla can become inflamed (above image) * **Very painful** * ‐ Ulcer Appearance: * Tiny * Transient * On fungiform papilla of tongue * **‐ Typically resolves in 7‐10 days**

Answer 186

**Herpetiform aphthous stomatitis** * Apppears like **herpesvirus but unrelated to it** * account for **5% of cases (**the least common) **Appearance**: * begin as multiple (up to 100) 1- to 3-mm crops of small, painful clusters of ulcers on an erythematous base. * They coalesce to form larger ulcers that last 2 weeks. * *A bunch of smaller ulcers that coalesce*

Answer 187

**‐ Minor Recurrent Aphthous Ulcers (RAS)‐ Rare Case** _o Keratinized Mucosal Site_ ‐ 11‐year‐old boy ‐ Canine is in process of erupting ‐ Canker sore present on his keratinized mucosa (RARE) **o 99% of canker sores occur on NON-KERATINIZED MUCOSA**

Answer 188

**Minor Recurrent Aphthous Ulcers (RAS)** * **aka‐ “Canker Sores”** * ‐ High prevalence: 5‐25% * ‐ Comprises the overwhelming majority of cases * o 75‐85% of ALL RAS cases * **‐ \<10 mm in diameter** * ‐ Ulcer appearance: * **o Shallow** * **o Round/Oval Shaped** * **o Yellow pseudomembrane** * ▪ Slightly raised margin * ▪ Erythematous Halo * **‐ Typically resolves in 7‐10 days** * o \*May take longer if in a “high‐traffic” site * **‐ No scarring** * ‐ Recurrence rates vary

Answer 189

**‐ Hallmarks:** o 1. Central ulceration o 2. Ring of erythema (erythematous border) ▪ Accentuated in right image

Answer 190

**‐ Aphthous Ulcer of the tongue** ‐ Aphthous ulcers can occur on specialized structures of the mouth

Answer 191

``` Aphthous ulcer (“The canker sore”) ``` What would it be like to have a canker sore on your uvula? o Painful to swallow ‐ The location of the canker sore will predict the symptoms

Answer 192

**‐ Dexamethasone elixir 0.5mg/5ml (ETOH base) or solution (H20 base)** ‐ Indicated for difficult to reach lesions to obtain access to all of them o Disp:600ml o Label: swish with 5‐10 ml for 5 minutes up to 0.5mg/5mL 4x/day and expectorate 00s preservalve.) May be used as suppressive therapy in selected patients with close surveillance o Prevent recurrences ‐ May buy an EXTRA DAY of healing time _dr. Kerr prefers the elixir_

Answer 193

**Major Recurrent Aphthous Ulcers (RAS)** * ‐ 10 – 15% of all RAS cases * **‐ \>10 mm in diameter** * ‐ Ulcer Appearance: * **o Deeper** * **o Irregular borders (usually)** * ‐ **Typically resolves in WEEKS or MONTHS** * ‐ May be associated with fever or malaise * o The associated cytokine release can induce a fever * ‐ Predilection for the throat * **‐ Often DOES leave scarring** * ‐ Recurrence rates vary

Answer 194

**‐ Triamcinolone acetonide** in Orabase 0.1% (intermediate) o Disp: 5g tube Dental Past o Label: apply a thin film over ulcer after meals and bedtime APOTHECON o Do not use for more than 2 weeks **‐ Fluocinonide gel or ointment** 0.05% (Potent) o Disp: 15g tube o Label: apply a thin film over o Do not use for more than 2 weeks ‐ Clobetasol ointment 0.05% (Ultra potent) o Disp: 15gtube Label: apply a thin film over ulcer bid

Answer 195

Topical Treatments ‐ Drug is easily washed away or rubbed off ‐ Topical anesthetics have a short‐lived effect ‐ Often difficult to apply due to location ‐ Cost may be a disincentive to buy OTC ‐ Once ulcers are established, these treatments are not as effective, therefore abortive treatment early on is preferred

Answer 196

**‐ Prednisone or systemic steroids were the one systemic treatment that Dr. Kerr has has success with in practice** **o 0.5 mg/kg of Prednisone would be prescribed for about 1 week** o Very successful in patients with frequent outbreaks of multiple canker sores ‐ In some limited cases Dr. Kerr has seen some success with: o Colchicine o Pentoxifylline

Answer 197

**Homogeneous leukoplakia** ○ Thickened leathery, White plaque ○ Well-demarcated, Deepened fissures ○ Non-wipeable white patch

Answer 198

Homogeneous leukoplakia. *○ Non-wipeable white patch*

Answer 199

**homogenous leukoplakia** Just white color

Answer 200

**Non-homogenous leukoplakia** Nodular leukoplakia ~ Largely white Verrucous leukoplakia ~ Largely white Erythroleukoplakia ~ Red and white Speckled and verrucous leukoplakia have a greater risk for malignant transformation than the homogeneous form

Answer 201

**Speckled leukoplakia.** **Non-homogenous leukoplakia**

Answer 202

**Hairy Leukoplakia** corrugated white lesion on the lateral tongue. **• It only occurs on the lateral tongue**

Answer 203

**Hairy Leukoplakia**

Answer 204

**Proliferative Verrucous Leukoplakia** Patient with proliferative verrucous leukoplakia but manifesting more as an erythroplakia in multiple sites than a leukoplakia **Proliferative verrucous leukoplakia has very high risk (49.5% in malignant transformation)** almost 10% risk for malignant transformation every year

Answer 205

**Proliferative Verrucous Leukoplakia** **Location** ○ Gingiva (Frequent) ○ Buccal Mucosa ○ Palatal Mucosa

Answer 206

**Proliferative Verrucous Leukoplakia** Multifocal

Answer 207

**Oral lichen planus** White lacy appearance, with a network reticular appearance (Wickham’s striae) sometimes punctate or plaque‐like lesions predominate o **Wickham’s striae**→ very characteris► white wispy changes

Answer 208

**Oral lichen planus** on the buccal mucosa (most common site reticular form.

Answer 209

Oral lichen planus slightly more **red** as you move to the left of the picture ● The white lines have small sunburst effect at the periphery ○ Very very characteristic of lichen planus ○ Will never see this in a leukoplakia

Answer 210

**Oral lichen planus** Lichen planus of the dorsum of the tongue this is a hypertrophic form.

Answer 211

**Etiology** The exact etiology remains unknown. Tobacco, alcohol, chronic local friction, and Candida albicans are important predisposing factors. Human papilloma virus (HPV) may also be involved in the pathogenesis of oral leukoplakia.

Answer 212

* Biopsy to rule out malignancy * Elimination or discontinuation of predisposing factors, * systemic retinoid compounds. * Smoking cessation (leukoplakias often disappear or become smaller within first year of smoking cessation) * Complete removal with surgical excision, electrocautery, cryosurgery, or laser ablation

Answer 213

**Lichenoid Reactions** **Contact Lesions** a sensitivity in contact with a **dental amalgam** ▪ When you replace these amalgams, the lichenoid reaction will typically disappear

Answer 214

**Oral Lichenoid** **Contact lesion** chenoid reaction to dental amalgam and cold: white and erythematous lesions on the buccal mucosa.

Answer 215

Oral Lichenoid Drug Reaction

Answer 216

Oral Lichenoid Drug Reaction

Answer 217

* Lichenoid reactions may develop after exposure to a medication for periods of \> 1 year * May develop very slowly after the problem is initiated so it can be very challenging to connect the dots **Many different medications that can lead to lichenoid reactions** * Beta blockers, ACE inhibitors, Rituxumab etc… * A number of new targeted agents “mabs” and “nibs” can cause lichenoid reactions * In cancer centers, this has become quite a problem because they are taking disease‐modifying drugs

Answer 218

**Nicotinic Stomatitis** also known as Smoker’s keratosis smoker’s palate * the palatal mucosa becomes diffusely gray or white; numerous slightly elevated papules are noted, usually with punctate red centers

Answer 219

**Nicotinic Stomatitis** These papules represent _inflamed minor salivary glands_ and their ductal orifices.

Answer 220

Nicotine Stomatitis.

Answer 221

Epstein–Barr virus seems to play an important role in the pathogenesis.

Answer 222

* Not required * however, in some cases aciclovir or valaciclovir * can be used with success. * Topical retinoids or podophyllum resin for temporary remission

Answer 223

**Pseudomembranous candidiasis** on the palate. usually caused by Candida albicans Predisposing factors are local (poor oral hygiene, xerostomia, mucosal damage, dentures, antibiotic mouthwashes)

Answer 224

Geographic tongue/ areata migrans Multiple, well-demarcated zones of erythema (due to filiform atrophy) surrounded by slightly elevated, yellow-white, serpentine/ scalloped border annular - serpiginous - atrophic - Fissured

Answer 225

Geographic tongue/ areata migrans

Answer 226

Geographic tongue/ areata migrans

Answer 227

Geographic tongue/ areata migrans

Answer 228

Geographic tongue, localized lesion.

Answer 229

**Fordyce’s granules** on the buccal mucosa. a normal anatomical variation. ectopic sebaceous glands of the oral mucosa.

Answer 230

Leukoedema of the buccal mucosa. Laskaris,

Answer 231

White Sponge Nevus Diffuse, thickened white plaques of the buccal mucosa

Answer 232

White Sponge Nevus | (Canon disease)

Answer 233

complete removal: excision, electrocautery, cryosurgery, or laber ablation ## Footnote *Lesions rarely regress despite therapy*

Answer 234

**Verrucous Carcinoma** Early verrucous carcinoma of the buccal mucosa.

Answer 235

**Verrucous Carcinoma** Large, exophytic, papillary mass of the maxillary alveolar ridge.

Answer 236

**Verrucous Carcinoma** Large, exophytic, papillary mass of the maxillary alveolar ridge.

Answer 237

Verrucous Carcinoma Extensive papillary, white lesion of the maxillary vestibule

Answer 238

Traumatic Erythema /Traumatic Hematoma on the lower lip.

Answer 239

Geographic tongue: well-demarcated red patch on the tongue.

Answer 240

Median rhomboid glossitis. a Chronic hyperplastic, erythematous candidiasis

Answer 241

Denture stomatitis.

Answer 242

Although the cause is not well known, T cell-mediated autoimmune phenomena are involved in the pathogenesis of lichen planus.

Answer 243

**Erythroplakia** of the buccal mucosa Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 244

Erythroplakia of the buccal mucosa.

Answer 245

**Erythroplakia** of the lateral margin of the tongue. Well-demarcated erythematous patch or plaque with soft velvety texture

Answer 246

Erythroplakia Firey red Well-demarcated patch or plaque with soft velvety texture transformed into SCC

Answer 247

* Incisional biopsy on non-keratinized, non-ulcerated mucosa ○ Asymptomatic → no tx ○ Symptomatic → 0.5mg/ml Dexamethasone Elixir.

Answer 248

Erythroplakia. Well-circumscribed red patch on the posterior lateral hard and soft palate

Answer 249

Erythroplakia. Erythematous macule on the right floor of the mouth. Biopsy-- Turned out to be early invasive squamous cell carcinoma.

Answer 250

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Smokeless Tobacco–related Gingival Recession. Extensive recession of the anterior mandibular facial gingiv

Answer 251

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Severe

Answer 252

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Mild. A soft, fissured, gray-white lesion of the lower labial mucosa located in the area of chronic snuff placement.

Answer 253

**Pemphigus Vulgaris.** . Multiple erosions affecting the marginal gingiva.

Answer 254

**Pemphigus Vulgaris.** Multiple erosions of the left buccal mucosa and soft palate.

Answer 255

**Pemphigus Vulgaris.** Large, irregularly shaped ulcerations involving the floor of the mouth and ventral tongue.

Answer 256

**Pemphigus Vulgaris.**

Answer 257

**Hypersensitivity** to * dental restorative materials, amalgam or other metal, composite resins * Foods, oral products * Especially cinnamon * dental plaque accumulation are the most common

Answer 258

**Insicional biopsy Mandated to distinguish from OLP** ○ Biopsy white areas on non-keratinized mucosa NOT ulcerated OR red areas Treatment Replacement of the restorative material, polishing and smoothing, and good oral hygiene are recommended. Topical steroid treatment for a short time is also helpful.

Answer 259

Smoking Cessation. * Nicotine stomatitis is completely reversible, even when it has been present for many decades. * The palate usually returns to normal within 1 to 2 weeks of smoking cessation.

Answer 260

The elevated temperature, rather than the tobacco chemicals, is responsible for this lesion.

Answer 261

* Generally no treatment is indicated * Reassuring the patient that the condition is completely benign is often all that is necessary. * In case of tenderness or a burning sensation that is so severe --topical corticosteroids, such as fluocinonide or betamethasone gel, may provide relief

Answer 262

The exact etiology remains unknown. It may be genetic.

Answer 263

Etiology It is due to increased thickness of the epitheliumand intracellular edema of the prickle-cell layer. Treatment No treatment required

Answer 264

**Autosomal dominant skin disorder** Etiology: ● This condition is due to a defect in the normal keratinization of the oral mucosa in the 30-member family of keratin filaments, the pair of keratins known as **keratin 4 and keratin 13** is specifically expressed in the spinous cell layer of mucosal epithelium.

Answer 265

a low-grade variant of squamouscell carcinoma. Etiology Leading theories include * human papillomavirus (HPV) infection * chemical carcinogenesis induced by smoking and chewing tobacco * alcohol consumption * betel nut chewing (oral lesions), * chronic inflammation

Answer 266

○ Surgical Excision ○ Radiotherapy

Answer 267

No treatment is required.

Answer 268

**Atrophy of central filiform papillae** Presumably developmental. Candida albicans may also be involved. but smokers, people with xerostomia , who use inhalation steroids and denture wearers are **at increased risk**

Answer 269

Erythroplakia is a high risk for malignant transformation. So, if you encounter an erythroplakia, it's probably already a cancer or it's fast‐tracking towards a cancer

Answer 270

○ Biopsy required for diagnosis ○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal ○ Complete excision

Answer 271

typically resolves weeks after cessation ○ if persists 6+weeks -\> biopsy to rule out dysplasia + SCC

Answer 272

○ Biopsy required for diagnosis ○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal ○ Complete excision

Answer 273

Erythroplakia. Well-circumscribed red patch on the posterior lateral hard and soft palate

Answer 274

Erythroplakia. Erythematous macule on the right floor of the mouth. Biopsy-- Turned out to be early invasive squamous cell carcinoma.

Answer 275

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Smokeless Tobacco–related Gingival Recession. Extensive recession of the anterior mandibular facial gingiv

Answer 276

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Severe

Answer 277

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Mild. A soft, fissured, gray-white lesion of the lower labial mucosa located in the area of chronic snuff placement.

Answer 278

**Pemphigus Vulgaris.** . Multiple erosions affecting the marginal gingiva.

Answer 279

**Pemphigus Vulgaris.** Multiple erosions of the left buccal mucosa and soft palate.

Answer 280

**Pemphigus Vulgaris.** Large, irregularly shaped ulcerations involving the floor of the mouth and ventral tongue.

Answer 281

**Pemphigus Vulgaris.**

Answer 282

**Pemphigus vulgaris** ● Multiple, chronic, mucocutaneous ulcers ● Many patients also have ● Relatively non‐specific ● Very superficial, only in epithelium ● Occur on any mucosal surface: oral, ocular, nasal, GI, esophageal, genital

Answer 283

**Pemphigus vulgaris** PV Lesions can affect virtually any mucosal surface (oral, nasal, ocular, pharyngeal, esophageal, genital)

Answer 284

**Pemphigus vulgaris** **usually suffer from Desquamative gingivitis (DG)** More superficial erosion of the marginal gingiva, typically with an intense erythema and inflammation, and very often in the absence of local factors that would typically cause a gingivitis o Hurts to brush their teeth Immediately look for areas where there are no local factors and look for inflammation there o To check the possibility of systemic factors causing local gingivitis

Answer 285

**Pemphigus vulgaris** Combination of PV inflammation and gingival inflammation accumulating local factors can result in advanced loss of attachment and tooth loss

Answer 286

Mucous membrane pemphigoid

Answer 287

Mucous membrane pemphigoid SEVERE/HIGH RISK FORMS OF MMP ▪ Ocular ▪ Esophageal can result in functional blindness

Answer 288

Mucous membrane pemphigoid Oral Hygiene: Plaque related gingival inflammation contributing to continued VB desquamative gingivitis

Answer 289

Mucous membrane pemphigoid REMEMBER: ▪ Plaque and calculus can be the consequence of painful MMP lesions ▪ When assessing MMP lesions/desquamative gingivitis, look for areas of intense inflammation WITHOUT local factors as evidence of VB disease

Answer 290

take two different sites ○ For H&E, still must be perilesional ○ If you get only ulcer just because the clinician thinks ○ that is the pathology → there is no epithelium! ○ The sample is useless and no diagnosis can be made

Answer 291

Actinic cheilitis (Solar cheilosis) Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 292

Actinic cheilitis (Solar cheilosis) Early presetation: Smooth, blotchy, pale, dry areas Diffuse, irregular white plaque around line of the lip Crusted, Scaly ****

Answer 293

typically resolves weeks after cessation ○ if persists 6+weeks -\> biopsy to rule out dysplasia + SCC

Answer 294

**_SCC_** arising from **Actinic Cheilitis**

Answer 295

**Oral Melanoma** a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 296

**Oral Melanoma** an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 297

**Oral Melanoma** patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient's fingers are depicted.)

Answer 298

**Oral Melanoma** Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 299

Amalgam tattoo This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 300

Oral melanoacanthoma. the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 301

**Oral melanotic macule** an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 302

Oral Melanoma

Answer 303

Oral Melanoma

Answer 304

Oral Melanoma

Answer 305

Traumatic ulcer caused by sharp or puncturing food stuff

Answer 306

Traumatic ulcer a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 307

Traumatic ulcer Post-anaesthesia traumatic ulcer on lower lip.

Answer 308

Traumatic ulcer Most often on tongue, lips, buccal mucosa Any sites that may be injured by dentition

Answer 309

Traumatic Granuloma

Answer 310

Traumatic Granuloma (traumatic ulcertaive granuloma)

Answer 311

**Traumatic Granuloma** | ( Traumatic Ulcerative Granuloma)

Answer 312

Squamous cell carcinoma on the buccal mucosa)

Answer 313

**Erythroplakia and Squamous Cell Carcinoma** Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 314

Leukoplakia and Squamous Cell Carcinoma Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 315

Pemphigus vulgaris is not fully understood. Experts believe that it's triggered when a person who has a genetic tendency to get this condition comes into contact with an environmental trigger, such as a chemical or a drug. In some cases, pemphigus vulgaris will go away once the trigger is removed.

Answer 316

**Graphite tattoo** Most common location on the palate and gingiva Gray, black, or blue-ish macule

Answer 317

**Graphite tattoo** Gray, black, or blue-ish macule

Answer 318

Treatment has 3 stages: **● Stage 1: Control** ○ Suppress inflammation / lesion activity with Systemic **Corticosteroid: Remains initial / 1st‐line treatment…** ○ Then quickly add steroid‐sparing agents (mycophenolate mofetil) to minimize dose and duration of corticosteroid treatment as well as improve disease control **● Stage 2: Consolidation** ○ Reducing auto‐antibody production with the addition of Immunosuppressants ○ Assessed by the lack of development of NEW lesions **● Stage 3. Remission / Maintenance:** ○ achieving complete remission of lesion activity OFF medication is the GOAL ○ When lesion activity OFF medications cannot be achieved, principle of MINIMALLY effective therapy is the goal, typically with combination of immunosuppressant medications **○ RITUXIMAB has become the FIRST CHOICE treatment after ○ the consolidation phase to achieve DISEASE REMISSION** _● TOPICAL / INJECTABLE CORTICOSTEROID MEDICATIONS_ ○ o Can be used to help control limited number of lesions resistant to systemic therapy: it treats ONLY the disease ○ outcome (lesions) and not the systemic illness / pathologic antibody production **○ ex:clobetesol 0. 05% , halbetesol 0.05% (most potent)**

Answer 319

Traumatic ulcer of the tongue.

Answer 320

**Hemangioma of Infancy** a relatively common benign proliferation of blood vessels that primarily develops during childhood. display a rapid growth phase with endothelial cell proliferation, followed by gradual involution.

Answer 321

Hemangioma of Infancy

Answer 322

**Necrotizing Sialadenometaplasia** *we see two ulcers on the palate* *Mostly ● Palatal salivary glands ○ Possible for parotid ● 75% of case on posterior palate ● Hard\>Soft palate ● 2/3rd are unilateral*

Answer 323

Mucocutaneous autoimmune disease characterized by sub‐epithelial blisters (bullae) which ruptures to form large, non‐healing ulcerations

Answer 324

**Frictional Keratosis.** There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”), because this area is now edentulous and becomes traumatized from mastication. **Such frictional keratoses should resolve when the source of irritation is eliminated and should not be mistaken for true leukoplakia.**

Answer 325

**Frictional Keratosis** **the white surrounding a a traumatic ulcer** Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 326

Leukoplakia Linea alba Chronic cheek chewing (bite injury) Candidiasis Oral Lichen planus Squamous cell carcinoma

Answer 327

Frictional keratosis on the tongue

Answer 328

* Trauma from Sharp cusp & ortho appliance * Chronic mechanical irritation (chronic biting) * Masticatory function * Normal hyperplastic response * Dentures/missing teeth

Answer 329

* Remove the cauative factor that caused the trauma * observe large lesion regularly excellent prognosis

Answer 330

**dry‐mouth** patient a classic example **• Classic fissuring • depapillation of the tongue papilla • some white changes on the tongue.**

Answer 331

**dry‐mouth** from radiation Note the Ropy, frothiness on the palate. - The tissues are red and irritated due to candida infection as well.

Answer 332

**dry Mouth** Cervical caries related to radiation. The patient is a smoker and coffee drinker --\> explains the staining

Answer 333

dry Mouth Incisal caries in a radiation patient: **Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction**

Answer 334

o Approach is similar to PV – but generally not as aggressive unless hi‐risk areas ( ocular, esophageal ) where more intense immunosuppression indicated ▪ NON‐immunosuppressive treatments uniquely effective: * *o** **Dapsone** * *o Tetracycline + nicotinamide**

Answer 335

Actinic cheilitis has **2 times** of risk for developing SCC of the lip. SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 336

due to chronic ultraviolet light exposure.

Answer 337

* avoid sun exposure * Laser ablation is preferred for severe actinic cheilitis * surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia * Lip Shaving” (Vermilionectomy) * can also use cryotherapy, electrodesiccation It requires long term follow up and **prognosis is good if caught early**

Answer 338

**SJÖGREN’S SYNDROME** Autoimmune exocrinopathy Marked bilateral parotid gland enlargement in a patient with primary Sjögren syndrome Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary glands due to retrograde infections.) **increased risk of lymphoma (MALT type)**

Answer 339

**SJÖGREN’S SYNDROME** _Dry Mouth_ very severe cervical disease & very dry lips

Answer 340

Depapillated & Fissured Tongue ## Footnote **SJÖGREN’S SYNDROME**

Answer 341

a patient with a **_bacterial sialadenitis_** who has **_SJÖGREN’S SYNDROME_** When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 342

These patients **LOW USFR, no response to stimulation (aka abnormal USFR/SFR)** * Rehydrate if dehydrated * Treat underlying conditions (i.e. DM) * Salivary substitutes (glycerin) * Minimize damage to glands from radiation * Prevention of complications & palliative treatment * Optimal hygiene * Restore caries * Smooth sharp edges in oral cavity * Fluoride therapy * Antifungals * Chlorhexidine rinses w/o alcohol * Sialendoscopy * Salitron - salivary pacemaker * ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 343

**Sjögren Syndrome** * bilateral enlargement of the submandibular glands * angular cheilitis, dry and cracked lips and fissured and despapilated tongue * severe ocular lesions.

Answer 344

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma **Acute sun damage** can cause it more than chronic exposure

Answer 345

Fair skin A history of sunburn Excessive ultraviolet (UV) light exposure. Living closer to the equator or at a higher elevation Having many moles or unusual moles A family history of melanoma Weakened immune system.

Answer 346

* Surgical excision * Radiotherapy * Chemotherapy

Answer 347

**Etiology** * typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep. * Chronic mucosal trauma from adjacent teeth * Some adjacent source of irritation

Answer 348

**Remove cause of irritation** Topical anesthetic or film for pain relief If there is no obvious cause then ► **biopsy**

Answer 349

**HPV + SCC** Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue) Younger pts, 3:1 Males to females ratio, high socio-eco status Incidence is decreasing less aggressive → higher survival rates ( Better than HPV negative SCC) **HPV - SCC** The chief risk factors for oral squamous cell carcinoma are Smoking (especially \> 2 packs/day) Alcohol use Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men. ( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva) mostly men, low socio-economic factors Incidence is decreasing Very aggressive → lower survival rates

Answer 350

Early stage: Radiation and/or Surgical removal Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 351

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 352

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 353

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 354

Necrotizing Sialadenometaplasia an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands. *Here it is on the palate*

Answer 355

*The cause is uncertain, although the hypothesis of ischemic necrosis after vascular infarction seems acceptable.*

Answer 356

No Treatment Needed but we need to biopsy to rule out other diseases

Answer 357

**Xerostomia-related Caries** **Or** **Dry Mouth** . Extensive cervical caries of mandibular dentition secondary to radiation-related xerostomia.

Answer 358

**Xerostomia** The subjective experience of a dry mouth (ie a symptom) **Salivary Hypofunction** The objective measurement of a reduction in salivary flow (a sign)

Answer 359

**Stimulated Saliva Production** **▪ 200+ ml/day ▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min** o “Normal” range is very wide

Answer 360

**300 ml/day ▪ Flow rate: mean 0.3 ml/min**

Answer 361

* **Dehydration** * **Medical conditions** * **Body posture** * **Lighting conditions** * **Circadian/circannual rhythm (lowest during)** * **Medications** Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 362

* **Mechanical stimuli** * **Vomiting** * **Gustatory/olfactory stimuli (acid/smell)** * **Gland size** Age is an independent factor for whole saliva (but not for parotid and minor gland secretions)

Answer 363

Central inhibition as a result of connections between the primary salivary centers and the higher centers of the brain.

Answer 364

* **May be a reduction in baseline sialometry which is still above “normal.”** * *If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.* * **Saliva film thickness** * *Palatal mucous gland secretions?* * *Anterior dorsum of tongue?* * **Relative contributions by glands** * Mucins, proteins? * **Alterations in sensory perception?** * **Mental status/central inhibition?**

Answer 365

**● Dehydration ● Medications (Rx & OTC)** * *Direct damage to glands* * *Head and neck radiotherapy* * *As a result of radiation it’s irreversible damage to the glands* * *Chemotherapy (reversible)* * *Autoimmune diseases* * *Primary vs Secondary Sjögren’s Syndrome, GVHD* * *HIV disease* **● Decreased mastication (tooth loss, soft diet) ● Conditions affecting the CNS:** * Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 366

**Abnormal unstimulated USFR= \<0.1–0.2ml/min** **Abnormal stiumated SFR = \<0.5ml/min**

Answer 367

* Salivary stimulation (OTC) to stimulate their glands * Salivary lubrication ( to improve it) * Humidification ( like a humidifier in the room at night) * Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a * diuretic and lead to dehydration). * Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 368

* Look for possible causes (major cause will be medications & can dehydration or others) * Restore chewing function (Masticatory issues) * Reduce medication‐induced salivary hypofunction * Prescribe Salivary stimulation OTC, Rx medications, others * Prescribe Salivary lubrication * Humidification ‐use humidifiers * Hydration/prevent dehydration (ie avoid alcohol, caffeine) * Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 369

* If dehydrated ► rehydrate or treat underlying condition * People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back. * All we can do is offering Salivary substitutes (sprays, gels, rinses ) * For patients with high dose radiation treatment ► makes sure they get the INRT * Minimizing damage to salivary glands ( there are other strategies for that) * Prevention and treatment of oral complications

Answer 370

– Muscarinic agonists: – **Pilocarpine** 5‐7.5mg tid & qhs (can go as high as 10mg qid) – **Cevimeline** 30mg tid (can go as high as 60mg tid) _Contradicated for_ : **CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma** **Pilocarpine affects M1 & M3** _side effects_ (sweating, flushing, rhinitis, increased urination, weakness and some experience the shakes. ) **Cevimeline affects M3 only** fewer side effects

Answer 371

○ Biopsy required for diagnosis ○ If a source of irritation can be identified and removed, biopsy may be delayed for 2 weeks to allow lesion to heal ○ Complete excision

Answer 372

Erythroplakia. Well-circumscribed red patch on the posterior lateral hard and soft palate

Answer 373

Erythroplakia. Erythematous macule on the right floor of the mouth. Biopsy-- Turned out to be early invasive squamous cell carcinoma.

Answer 374

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Smokeless Tobacco–related Gingival Recession. Extensive recession of the anterior mandibular facial gingiv

Answer 375

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Severe

Answer 376

Smokeless tobacco keratosis/TOBACCO POUCH KERATOSIS Tobacco Pouch Keratosis, Mild. A soft, fissured, gray-white lesion of the lower labial mucosa located in the area of chronic snuff placement.

Answer 377

**Pemphigus Vulgaris.** . Multiple erosions affecting the marginal gingiva.

Answer 378

**Pemphigus Vulgaris.** Multiple erosions of the left buccal mucosa and soft palate.

Answer 379

**Pemphigus Vulgaris.** Large, irregularly shaped ulcerations involving the floor of the mouth and ventral tongue.

Answer 380

**Pemphigus Vulgaris.**

Answer 381

**Pemphigus vulgaris** ● Multiple, chronic, mucocutaneous ulcers ● Many patients also have ● Relatively non‐specific ● Very superficial, only in epithelium ● Occur on any mucosal surface: oral, ocular, nasal, GI, esophageal, genital

Answer 382

**Pemphigus vulgaris** PV Lesions can affect virtually any mucosal surface (oral, nasal, ocular, pharyngeal, esophageal, genital)

Answer 383

**Pemphigus vulgaris** **usually suffer from Desquamative gingivitis (DG)** More superficial erosion of the marginal gingiva, typically with an intense erythema and inflammation, and very often in the absence of local factors that would typically cause a gingivitis o Hurts to brush their teeth Immediately look for areas where there are no local factors and look for inflammation there o To check the possibility of systemic factors causing local gingivitis

Answer 384

**Pemphigus vulgaris** Combination of PV inflammation and gingival inflammation accumulating local factors can result in advanced loss of attachment and tooth loss

Answer 385

Mucous membrane pemphigoid

Answer 386

Mucous membrane pemphigoid SEVERE/HIGH RISK FORMS OF MMP ▪ Ocular ▪ Esophageal can result in functional blindness

Answer 387

Mucous membrane pemphigoid Oral Hygiene: Plaque related gingival inflammation contributing to continued VB desquamative gingivitis

Answer 388

Mucous membrane pemphigoid REMEMBER: ▪ Plaque and calculus can be the consequence of painful MMP lesions ▪ When assessing MMP lesions/desquamative gingivitis, look for areas of intense inflammation WITHOUT local factors as evidence of VB disease

Answer 389

take two different sites ○ For H&E, still must be perilesional ○ If you get only ulcer just because the clinician thinks ○ that is the pathology → there is no epithelium! ○ The sample is useless and no diagnosis can be made

Answer 390

Actinic cheilitis (Solar cheilosis) Typical presentation of angular cheilitis with erythema, crusting and mild fissuring of the angles of the mouth bilaterally.

Answer 391

Actinic cheilitis (Solar cheilosis) Early presetation: Smooth, blotchy, pale, dry areas Diffuse, irregular white plaque around line of the lip Crusted, Scaly ****

Answer 392

typically resolves weeks after cessation ○ if persists 6+weeks -\> biopsy to rule out dysplasia + SCC

Answer 393

**_SCC_** arising from **Actinic Cheilitis**

Answer 394

**Oral Melanoma** a highly malignant neoplasia, arising from melanocytes, the cells that produce the brownish pigment melanin.

Answer 395

**Oral Melanoma** an ulcerated, blue-black, slightly elevated lesion in the edentulous, posterior right maxilla. The lesion extends across the residual alveolar ridge onto the palate and onto the facial aspect of the ridge.

Answer 396

**Oral Melanoma** patient with extensive, black-pigmented and irregularly bordered macule in the maxillary labial mucosa and midline facial gingiva, (teeth 8 and 9). (The patient's fingers are depicted.)

Answer 397

**Oral Melanoma** Large, blue-black, irregularly bordered lesion on the upper lip of a male Japanese patient. The diagnosis is oral melanoma.

Answer 398

Amalgam tattoo This image depicts two diffusely bordered, dark gray macules in the left posterior buccal mucosa adjacent to molar teeth that have been restored. .

Answer 399

Oral melanoacanthoma. the buccal mucosa of a middle-aged, black woman with a brown-black, irregularly bordered macule that arose suddenly. The patient was unaware of its presence.

Answer 400

**Oral melanotic macule** an irregularly shaped, tan-brown macule on the left hard palate in an edentulous patient.

Answer 401

Oral Melanoma

Answer 402

Oral Melanoma

Answer 403

Oral Melanoma

Answer 404

Traumatic ulcer caused by sharp or puncturing food stuff

Answer 405

Traumatic ulcer a chronic ulcer on the left posterior lateral border of the tongue caused by lingually tilted mandibular 3rd molar. Note central ulceration with peripheral keratosis

Answer 406

Traumatic ulcer Post-anaesthesia traumatic ulcer on lower lip.

Answer 407

Traumatic ulcer Most often on tongue, lips, buccal mucosa Any sites that may be injured by dentition

Answer 408

Traumatic Granuloma

Answer 409

Traumatic Granuloma (traumatic ulcertaive granuloma)

Answer 410

**Traumatic Granuloma** | ( Traumatic Ulcerative Granuloma)

Answer 411

Squamous cell carcinoma on the buccal mucosa)

Answer 412

**Erythroplakia and Squamous Cell Carcinoma** Erythroplakia is a general term for red, flat, or eroded velvety lesions that develop in the mouth. In this image, an exophytic squamous cell carcinoma on the tongue is surrounded by a margin of erythroplakia

Answer 413

Leukoplakia and Squamous Cell Carcinoma Leukoplakia is a general term for white hyperkeratotic plaques that develop in the mouth. About 80% are benign. However, in this image, squamous cell carcinoma is present in one of the leukoplakic lesions on the ventral surface of the tongue (arrow).

Answer 414

Pemphigus vulgaris is not fully understood. Experts believe that it's triggered when a person who has a genetic tendency to get this condition comes into contact with an environmental trigger, such as a chemical or a drug. In some cases, pemphigus vulgaris will go away once the trigger is removed.

Answer 415

**Graphite tattoo** Most common location on the palate and gingiva Gray, black, or blue-ish macule

Answer 416

**Graphite tattoo** Gray, black, or blue-ish macule

Answer 417

Treatment has 3 stages: **● Stage 1: Control** ○ Suppress inflammation / lesion activity with Systemic **Corticosteroid: Remains initial / 1st‐line treatment…** ○ Then quickly add steroid‐sparing agents (mycophenolate mofetil) to minimize dose and duration of corticosteroid treatment as well as improve disease control **● Stage 2: Consolidation** ○ Reducing auto‐antibody production with the addition of Immunosuppressants ○ Assessed by the lack of development of NEW lesions **● Stage 3. Remission / Maintenance:** ○ achieving complete remission of lesion activity OFF medication is the GOAL ○ When lesion activity OFF medications cannot be achieved, principle of MINIMALLY effective therapy is the goal, typically with combination of immunosuppressant medications **○ RITUXIMAB has become the FIRST CHOICE treatment after ○ the consolidation phase to achieve DISEASE REMISSION** _● TOPICAL / INJECTABLE CORTICOSTEROID MEDICATIONS_ ○ o Can be used to help control limited number of lesions resistant to systemic therapy: it treats ONLY the disease ○ outcome (lesions) and not the systemic illness / pathologic antibody production **○ ex:clobetesol 0. 05% , halbetesol 0.05% (most potent)**

Answer 418

Traumatic ulcer of the tongue.

Answer 419

**Hemangioma of Infancy** a relatively common benign proliferation of blood vessels that primarily develops during childhood. display a rapid growth phase with endothelial cell proliferation, followed by gradual involution.

Answer 420

Hemangioma of Infancy

Answer 421

**Necrotizing Sialadenometaplasia** *we see two ulcers on the palate* *Mostly ● Palatal salivary glands ○ Possible for parotid ● 75% of case on posterior palate ● Hard\>Soft palate ● 2/3rd are unilateral*

Answer 422

Mucocutaneous autoimmune disease characterized by sub‐epithelial blisters (bullae) which ruptures to form large, non‐healing ulcerations

Answer 423

**Frictional Keratosis.** There is a rough, hyperkeratotic change to the posterior mandibular alveolar ridge (“alveolar ridge keratosis”), because this area is now edentulous and becomes traumatized from mastication. **Such frictional keratoses should resolve when the source of irritation is eliminated and should not be mistaken for true leukoplakia.**

Answer 424

**Frictional Keratosis** **the white surrounding a a traumatic ulcer** Symptomatic traumatic ulceration of the left mid-ventral tongue associated with a sharp left lower molar. The ulcer has flat edges and is surrounded by an area of frictional keratosis.

Answer 425

Leukoplakia Linea alba Chronic cheek chewing (bite injury) Candidiasis Oral Lichen planus Squamous cell carcinoma

Answer 426

Frictional keratosis on the tongue

Answer 427

* Trauma from Sharp cusp & ortho appliance * Chronic mechanical irritation (chronic biting) * Masticatory function * Normal hyperplastic response * Dentures/missing teeth

Answer 428

* Remove the cauative factor that caused the trauma * observe large lesion regularly excellent prognosis

Answer 429

**dry‐mouth** patient a classic example **• Classic fissuring • depapillation of the tongue papilla • some white changes on the tongue.**

Answer 430

**dry‐mouth** from radiation Note the Ropy, frothiness on the palate. - The tissues are red and irritated due to candida infection as well.

Answer 431

**dry Mouth** Cervical caries related to radiation. The patient is a smoker and coffee drinker --\> explains the staining

Answer 432

dry Mouth Incisal caries in a radiation patient: **Incisal caries is a sure sign of severe dry mouth/ significant salivary gland hypofunction**

Answer 433

o Approach is similar to PV – but generally not as aggressive unless hi‐risk areas ( ocular, esophageal ) where more intense immunosuppression indicated ▪ NON‐immunosuppressive treatments uniquely effective: * *o** **Dapsone** * *o Tetracycline + nicotinamide**

Answer 434

Actinic cheilitis has **2 times** of risk for developing SCC of the lip. SCC on the lips is 11 times as likely to metastasize compared to SCC found on other parts of the body

Answer 435

due to chronic ultraviolet light exposure.

Answer 436

* avoid sun exposure * Laser ablation is preferred for severe actinic cheilitis * surgical excision is recommended for severe actinic cheilitis with evidence of high-grade dysplasia * Lip Shaving” (Vermilionectomy) * can also use cryotherapy, electrodesiccation It requires long term follow up and **prognosis is good if caught early**

Answer 437

**SJÖGREN’S SYNDROME** Autoimmune exocrinopathy Marked bilateral parotid gland enlargement in a patient with primary Sjögren syndrome Dry mouth and eyes resulting from a chronic progressive loss of secretory function (Slowly but surely, the salivary glands and/or lacrimal glands (some cases are more lacrimal & less salivary or vice versa); slow & progressive Patients with Sjogren’s can have bilateral salivary gland enlargement (parotid) (Sometimes we may see a unilateral enlargement of the salivary glands due to retrograde infections.) **increased risk of lymphoma (MALT type)**

Answer 438

**SJÖGREN’S SYNDROME** _Dry Mouth_ very severe cervical disease & very dry lips

Answer 439

Depapillated & Fissured Tongue ## Footnote **SJÖGREN’S SYNDROME**

Answer 440

a patient with a **_bacterial sialadenitis_** who has **_SJÖGREN’S SYNDROME_** When we examine such patients and ”milk” the gland ► you actually see a purulent drainage from the gland itself.

Answer 441

These patients **LOW USFR, no response to stimulation (aka abnormal USFR/SFR)** * Rehydrate if dehydrated * Treat underlying conditions (i.e. DM) * Salivary substitutes (glycerin) * Minimize damage to glands from radiation * Prevention of complications & palliative treatment * Optimal hygiene * Restore caries * Smooth sharp edges in oral cavity * Fluoride therapy * Antifungals * Chlorhexidine rinses w/o alcohol * Sialendoscopy * Salitron - salivary pacemaker * ALTENS (acupuncture like transcutaneous electrical nerve stimulation)

Answer 442

**Sjögren Syndrome** * bilateral enlargement of the submandibular glands * angular cheilitis, dry and cracked lips and fissured and despapilated tongue * severe ocular lesions.

Answer 443

Unknown. Ultraviolet radiation is an important causative factor for skin melanoma **Acute sun damage** can cause it more than chronic exposure

Answer 444

Fair skin A history of sunburn Excessive ultraviolet (UV) light exposure. Living closer to the equator or at a higher elevation Having many moles or unusual moles A family history of melanoma Weakened immune system.

Answer 445

* Surgical excision * Radiotherapy * Chemotherapy

Answer 446

**Etiology** * typically caused by trauma. In more than half the cases, the patient does not recall traumatizing the area although this may have occurred during sleep. * Chronic mucosal trauma from adjacent teeth * Some adjacent source of irritation

Answer 447

**Remove cause of irritation** Topical anesthetic or film for pain relief If there is no obvious cause then ► **biopsy**

Answer 448

**HPV + SCC** Area affected: ( Oropharynx cancers largely involved tonsils, . Posterior 3rd of the Tongue) Younger pts, 3:1 Males to females ratio, high socio-eco status Incidence is decreasing less aggressive → higher survival rates ( Better than HPV negative SCC) **HPV - SCC** The chief risk factors for oral squamous cell carcinoma are Smoking (especially \> 2 packs/day) Alcohol use Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men. ( this affects these ares : the tongue, floor of mouth, buccal mucosa, or gingiva) mostly men, low socio-economic factors Incidence is decreasing Very aggressive → lower survival rates

Answer 449

Early stage: Radiation and/or Surgical removal Late stage : combination of surgery, radiation therapy, or chemotherapy

Answer 450

If patient is concerned for cosmetic reasons ► then removal of lesion with autogenous graft

Answer 451

result from pencil lead that is traumatically implanted, usually during the elementary school years

Answer 452

○ Because most hemangiomas of infancy undergo involution, management often consists of “watchful neglect.”

Answer 453

Necrotizing Sialadenometaplasia an uncommon, usually self-limiting, benign inflammatory disorder of the salivary glands. *Here it is on the palate*

Answer 454

*The cause is uncertain, although the hypothesis of ischemic necrosis after vascular infarction seems acceptable.*

Answer 455

No Treatment Needed but we need to biopsy to rule out other diseases

Answer 456

**Xerostomia-related Caries** **Or** **Dry Mouth** . Extensive cervical caries of mandibular dentition secondary to radiation-related xerostomia.

Answer 457

**Xerostomia** The subjective experience of a dry mouth (ie a symptom) **Salivary Hypofunction** The objective measurement of a reduction in salivary flow (a sign)

Answer 458

**Stimulated Saliva Production** **▪ 200+ ml/day ▪ Flow rate: mean 1-2 ml/min, maximum 7 ml/min** o “Normal” range is very wide

Answer 459

**300 ml/day ▪ Flow rate: mean 0.3 ml/min**

Answer 460

* **Dehydration** * **Medical conditions** * **Body posture** * **Lighting conditions** * **Circadian/circannual rhythm (lowest during)** * **Medications** Age is an independent factor for whole saliva andsubmandibular/sublingual gland secretion (but notparotid).

Answer 461

* **Mechanical stimuli** * **Vomiting** * **Gustatory/olfactory stimuli (acid/smell)** * **Gland size** Age is an independent factor for whole saliva (but not for parotid and minor gland secretions)

Answer 462

Central inhibition as a result of connections between the primary salivary centers and the higher centers of the brain.

Answer 463

* **May be a reduction in baseline sialometry which is still above “normal.”** * *If they get a decrease in the salivary flow, they still may be in the normal range, but for them the experience is that they have got dry mouth.* * **Saliva film thickness** * *Palatal mucous gland secretions?* * *Anterior dorsum of tongue?* * **Relative contributions by glands** * Mucins, proteins? * **Alterations in sensory perception?** * **Mental status/central inhibition?**

Answer 464

**● Dehydration ● Medications (Rx & OTC)** * *Direct damage to glands* * *Head and neck radiotherapy* * *As a result of radiation it’s irreversible damage to the glands* * *Chemotherapy (reversible)* * *Autoimmune diseases* * *Primary vs Secondary Sjögren’s Syndrome, GVHD* * *HIV disease* **● Decreased mastication (tooth loss, soft diet) ● Conditions affecting the CNS:** * Psychologic disorders (depression/anxiety?), Alzheimer’s, Parkinson’s, Cerebral palsy

Answer 465

**Abnormal unstimulated USFR= \<0.1–0.2ml/min** **Abnormal stiumated SFR = \<0.5ml/min**

Answer 466

* Salivary stimulation (OTC) to stimulate their glands * Salivary lubrication ( to improve it) * Humidification ( like a humidifier in the room at night) * Hydration/prevent dehydration (ie avoid alcohol, caffeine both will act as a * diuretic and lead to dehydration). * Monitor closely to rule out emerging disease ( to see whether they are developing Sjogren’s or something else 􀀀 we want to follow them over time)

Answer 467

* Look for possible causes (major cause will be medications & can dehydration or others) * Restore chewing function (Masticatory issues) * Reduce medication‐induced salivary hypofunction * Prescribe Salivary stimulation OTC, Rx medications, others * Prescribe Salivary lubrication * Humidification ‐use humidifiers * Hydration/prevent dehydration (ie avoid alcohol, caffeine) * Treat oral consequences (such as candidiasis treated with an antifungal or caries with management of caries).

Answer 468

* If dehydrated ► rehydrate or treat underlying condition * People with uncontrolled diabetes, once you control the diabetes‐ their flow comes back. * All we can do is offering Salivary substitutes (sprays, gels, rinses ) * For patients with high dose radiation treatment ► makes sure they get the INRT * Minimizing damage to salivary glands ( there are other strategies for that) * Prevention and treatment of oral complications

Answer 469

– Muscarinic agonists: – **Pilocarpine** 5‐7.5mg tid & qhs (can go as high as 10mg qid) – **Cevimeline** 30mg tid (can go as high as 60mg tid) _Contradicated for_ : **CV disease, hepatic, renal or respiratory diseases or narrow angle glaucoma** **Pilocarpine affects M1 & M3** _side effects_ (sweating, flushing, rhinitis, increased urination, weakness and some experience the shakes. ) **Cevimeline affects M3 only** fewer side effects

STC Flashcards

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